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Peribronchial Cuffing Rather Than Consolidation Pneumonia Or Not? P-CXR

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Peribronchial Cuffing Rather Than Consolidation Pneumonia Or Not? P-CXR 21.04.23 KSEM spring conference: Pediatric images, what we have to focus on P-CXR Essential viewpoints for pediatrics in ED1 Ajou Univ. School of Medicine Department of emergency medicine Jung Heon Kim P-CXR I have nothing to disclose .“Normal” chest AP .Pneumonia or not? .Appendix .Take-home message P-CXR Am I normal? “Normal” chest AP P-CXR My residents: “What (the hell) is normal chest AP?” The answer is… It is inherently difficult… Check expiration & rotation Why? Young kids (<4 y): poor cooperation when taking pictures “Normal” chest AP P-CXR . AP view: trapezoid thorax & horizontal ribs . Small-looking lungs - CT ratio: 60%–65% (false cardiomegaly) - Elevated diaphragm . False (+) findings - Thymus: look like mediastinal mass - Trachea: slightly Rt-deviated - Air bronchogram: bronchial branching around hilum . Lat view (optional): retrosternal “white” “Normal” chest AP P-CXR Check expiration & rotation Findings Expiration Diaphragm at 8th post rib or higher (cf, 6th ant. rib) Under-aerated (“whitish lung”) & Rt-deviated trachea Triangular hemi-thorax (ribs: oblique > horizontal) “Larger”-looking heart & thymus Rotation T-spinous proc is midway between 2 med ends of clavicles “Normal” chest AP P-CXR Expiration WIN! vs 8 8 th Diaphragm at slightly higher than 8 post rib ( Diaphragm at 9th post rib (5th ant rib) 4th ant rib) More trapezoid hemi-thorax Triangular hemi-thorax & larger heart “Normal” chest AP P-CXR Rotation WIN! vs Diaphragm at 8th post rib (6th ant rib) Diaphragm at 8th post rib (5th ant rib) Triangular hemi-thorax Trapezoid hemi-thorax T-spinous proc is Lt-deviated T-spinous proc is midway P-CXR Pneumonia or not? P-CXR This CXR indicates pneumonia? Many EPs The expectation is… expect… May be… Going in wrong direction… consolidation? Lower resp tract infection (LRTI = bron chiolitis + pneumonia) is clinically more acceptable We should find… Air trapping + peribronchial cuffing rather than consolidation Pneumonia or not? P-CXR ↓ Alveoli & pores of Kohn Radiology 2005;236:22–9 Virus » bacteria → Airways & alveoli are ↓ Consolidation continuous in small thorax Available from: https://www.pathologyoutlines.com /topic/lungnontumorinfectionsgener al.html Airway > alveoli Obstruction (↑expiration) → atelectasis LRTI shows ↑ Airway resistance (ie, Wall thickening inflammatory airway disease) Lancet 2017;389:211–24 ↓ Consolidation Pneumonia or not? P-CXR ↑ Airway obstruction Air trapping Young kids’ airways… (±atelectasis) + • ↓ Size peribronchial cuffing • ↑ Compliance ↑ Exp. obstruction But, their alveoli… • ↓ Alveolar surface area • ↓ Pore of Kohn ↓ Parenchymal lesion ↓ Consolidation 8.6% Most LRTI look air trapping + peribronchial cuffing Clin Pediatr (Phila) 2005;44:427-35 Pneumonia or not? P-CXR . Air trapping Retention of excess air in all or part of the lung, especially during expirati on, either as a result of complete or partial airway obstruction or as a result of local ab normalities in pulmonary compliance. It may also sometimes be observed in normal in dividuals . Peribronchial cuffing Haziness or increased density around the walls of a bronchus or large bronchiole seen end-on, both on X-ray & CT. It may either represent bronchial wall thickening or fluid around bronchi due to lymphatic congestion (may be preferred t o “peribronchial infiltration”) Available from: radiopaedia.org Pneumonia or not? P-CXR Definitions of ped radiological findings (Bull World Health Organ 2005;83:353-9) Pneumonia or not? P-CXR Radiology 2005;236:22–9 vs th Flat diaphragm at lower than 8 post rib Normal chest AP Peribronchial cuffing on both lungs No definite consolidation Pneumonia or not? P-CXR 1 y/M, 1-d fever, cough, & dyspnea 1 y/M, 4-d cough 1-d fever, RR 34 + RR 30, SpO2 93% + neb albuterol retraction Flat diaphragm at 9th post rib Flat diaphragm at 9th post rib Peribronchial cuffing on both lungs Peribronchial cuffing on both lungs No definite consolidation No definite consolidation Rhinovirus (+) RSV (+) Pneumonia or not? P-CXR . Air trapping Retention of excess air in all or part of the lung, especially during ex piration, either as a result of complete or partial airway obstruction or as a result o f local abnormalities in pulmonary compliance. It may also sometimes be observe d in normal individuals . Peribronchial cuffing Haziness or increased density around the walls of a bronc hus or large bronchiole seen end-on, both on X-ray & CT. It may either represent bronchial wall thickening or fluid around bronchi due to lymphatic congestion (may be preferred to “peribronchial infiltration”) Available from: radiopaedia.org Pneumonia or not? P-CXR . 2011 IDSA pneumonia guidelines: “Routine CXR are not necessary for t he confirmation of suspected CAP in patients well enough to be treated in the outpatient settings (after evaluation in the office, clinic or ED) (Clin Inf ect Dis 2011;53:e25-76).” . 2014 AAP bronchiolitis guidelines: “Current evidence does not support r outine CXR in children with bronchiolitis (Pediatrics 2014;134:e1474-502).” . No evidence of a substantial impact on outcomes of kids <6 y with pneumonia (Lancet 1998;351:404-8) . Radiologists: “Radiology residents have often expressed to us their frus tration & confusion when attempting to interpret CXRs of infants (Radiology 20 05;236:22–9).” Comment: Do not expect much on CXR. Find subtle signs of LRTI! P-CXR Thymus vs. mediastinal mass Round pneumonia Foreign body aspiration Myocarditis COVID-19 Appendix P-CXR Normal Sail sign Thymus looks as a large, dense, ant mediastinal mass until 6-12 y Sharp inferior edge (eg, sail sign) & no obstruction of adjacent organs DDx: lobar pneumonia, heart failure, & mediastinal tumor Tintinalli’s 9th ed, p. 818 Appendix P-CXR 6 y/M, cough, fever, sore throat, rash dyspnea T cell-ALL Appendix P-CXR Round pneumonia Tintinalli says, “Younger children can also present with round pneumonia, a sharply defined co nsolidation often found in posterior lower lobe, classi cally from pneumococcal infection.” Tintinalli’s 9th ed, p. 819 Appendix P-CXR 19 mo/M, Nut ingestion → cough/dyspnea Unilateral air trapping Peanut in Lt sup lobar bronchus Appendix P-CXR 3 y/M, abd pain, seizure, & pallor → 2 y/M, 2-d fever → seizure → arrest HR 50 Myocarditis, recovered in 3 d Myocarditis, expired in same day Appendix P-CXR Nonspecific! 90% of CXR showed abnormalities. Peribronchial cuffing was most common (86.3%), followed by GGOs (50%). Eur J Radiol 2020;131:109236 21.04.23 KSEM spring conference: Pediatric images, what we have to focus on P-CXR Essential viewpoints for pediatrics in ED1 . In young kids with LRTI, CXR is not sensitive & specific, thus not routin e (Do not expect much…). First, check true chest AP (expiration & rotation). Second, check the presence of LRTI using air trapping + peribronchial c uffing rather than consolidation. Learn something on a case-by-case fashion (eg, mediastinal mass). .
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