Drs. Potter and Richardson are interested in education and Pediatric Emergency Medicine. Follow along with the EMGuideWire.com team and Dr. Michael Gibbs as they post these educational, self-guided radiology slides on Pediatric Emergency Medicine Radiology Topics including: • Recurrent pneumothorax • Parapneumonic effusion • Pediatric ARDS • Septic pulmonary emboli • RUl Pneumonia • GSW with pulmonary hemorrhage

1. Pediatric Chest X-Rays Of The Month
Nikki Richardson MD & Jennifer Potter MD
Department of Emergency Medicine
Carolinas Medical Center & Levine Children’s Hospital
Michael Gibbs MD, Faculty Editor
Chest X-Ray Mastery Project
May 2020

2. Disclosures
 This ongoing chest X-ray interpretation series is proudly sponsored by the
Emergency Medicine Residency Program at Carolinas Medical Center.
 The goal is to promote widespread mastery of CXR interpretation.
 There is no personal health information [PHI] within, and ages have been
changed to protect patient confidentiality.

3. Process
 Many are providing cases and these slides are shared with all contributors.
 Contributors from many CMC departments, and now… Tanzania and Brazil.
 Cases submitted this week will be distributed monthly.
 When reviewing the presentation, the 1st image will show a chest X-ray
without identifiers and the 2nd image will reveal the diagnosis.

4. Normal CXR
For Your
Reference

5. HPI: 3-year-old previously
healthy male presented with
respiratory distress in the
setting fever and cough.
Pulmonary exam showed tight
lungs, decreased movement to
bases and increased work of
breathing with diffuse
retractions and tachypnea.

6. HPI: 3-year-old previously
healthy male presented with
respiratory distress in the
setting fever and cough.
Pulmonary exam showed tight
lungs, decreased movement to
bases and increased work of
breathing with diffuse
retractions and tachypnea.
Pneumomediastinum
Dx: Pneumomediastinum due to
viral bronchiolitis

7. Pneumothorax
Dx: Spontaneous Pneumothorax
HPI: Late preterm newborn
with respiratory
distress/grunting at 20min of
life treated with CPAP

8. Mediastinal Shift
Dx: Tension Pneumothorax
Attempted needle
decompression, subsequently
patient developed hypoxia to
89%, bradycardia, and
worsening tachypnea. Repeat
CXR shows…
Worsening Pneumothorax

9. Proceeded to pigtail
thoracostomy
Resolution of Pneumothorax

10. HPI: 4-year-old female
admitted for MRSA sepsis with
ARDS from hip septic arthritis
and osteomyelitis. Patient
intubated and on oscillator
with acute episode of
desaturation which persisted
despite bagging. Vital signs:
HR: 118
BP: 70/42
SpO2 on 100% FiO2: 61%

11. HPI: 4-year-old female
admitted for MRSA sepsis with
ARDS from hip septic arthritis
and osteomyelitis. Patient
intubated and on oscillator
with acute episode of
desaturation.
Mediastinal Shift
Left Sided Pneumothorax
Dx: Tension Pneumothorax
Deep Sulcus Sign

12. Spontaneous
Pneumothorax• Etiology:
• May be primary or secondary
• 94% occur in patients >10yrs old, 80% in males
• Presentation:
• Presentation is often delayed
• Most patients presents with acute onset chest pain or shortness of breath
• Activities which increase intrathoracic pressure increase symptoms
• Diagnosis:
• Ultrasound: ~90% sensitive (may be higher based on operator)
• Supine CXR: ~50% sensitive
• Erect CXR: has increased sensitivity (~90%)
• Management: 100% O2 therapy is recommended for PTX less than 15-20%
Dotson K, Timm N, Gittelman M. Is Spontaneous Pneumothorax Really a Pediatric Problem? A National Perspective. Pediatric Emer Care 2012; 28(4): 340-344.
Dotson K, Johnson LH. Pediatric Spontaneous Pneumothorax. Pediatric Emer Care 2012; 28(7): 715-723.
From: Pediatric EM
Morsels™

13. Spontaneous
Pneumothorax
Dotson K, Timm N, Gittelman M. Is Spontaneous Pneumothorax Really a Pediatric Problem? A National Perspective. Pediatric Emer Care 2012; 28(4): 340-344.
Dotson K, Johnson LH. Pediatric Spontaneous Pneumothorax. Pediatric Emer Care 2012; 28(7): 715-723.
Secondary Spontaneous Pneumothorax
Chronic Lung Pathology
Asthma
Cystic Fibrosis
Emphysema
Connective Tissue Disorder
Marfan Syndrome
Ehlers-Danlos Syndrome
Lupus
Infection
Malignancy
Foreign Body
Congenital Malformation
Catamenial (associated with menses)
From: Pediatric EM
Morsels™

14. HPI: 13-year-old previously
healthy female presented for
evaluation of intermittent
chest tightness x 1 month with
three days of cough.
Respiratory rate 22, SpO2 97%
on room air but speaking in 2-
3-word sentences
Dx: Spontaneous Pneumothorax

15. Pigtail tube thoracostomy
preformed resulting in
resolution of pneumothorax
and improvement of symptoms

16. Patients spontaneous pneumothorax thought to be secondary to apical
blebs. Underwent bilateral apical blebectomy with mechanical
pleurodesis after recovery from her initial PTX
But that’s not the end of her
story….

17. Patient returned 2 years later
with shortness of breath and
cough without shortness of
breath. SpO2 100% on room air,
heart rate 109
Dx: Recurrent Pneumothorax

18. Pigtail chest tube thoracostomy
performed, post-procedural
CXR shows…
Dx: Small Apical Pneumothorax

19. During hospitalization, patient
developed recurrent subjective
SOB during CT scan which
showed…
Dx: Recurrent Pneumothorax

20. Patient returned from CT scan
and chest tube reconnected to
wall suction. Patient in no
respiratory distress and
endorsing improvement of her
shortness of breath.
Dx: Resolution of
Pneumothorax

21. Patient underwent R video assisted thoracoscopic surgery with
bulbectomy, pleurectomy and pleurodesis during this hospitalization.
But that’s not the end of her
story….

22. Patient returned 1 month later
with recurrent shortness of
breath and right sided chest
pain. Patient in no respiratory
distress. SpO2 100% on room
air with mild tachypnea and
tachycardia.
Dx: Recurrent Pneumothorax

23. Patient had another pigtail thoracostomy preformed and was admitted
for recurrent pneumothorax. She underwent talc pleurodesis and was
seen by genetics for evaluation for possible connective tissue disorder
given recurrent pneumothoraces.
But that’s not the end of her
story….

24. Patient returned 6 months later
after acute onset of L upper
back pain and shortness of
breath when bending over. She
was again noted to be mildly
tachycardic and tachypnea, but
breathing comfortably with
SpO2 100% on room air
Dx: Left Sided Pneumothorax
Given the patient was breathing
comfortably on room air without
vital sign abnormality she was
discharged home.

25. Patient returned 1 year later
with recurrent shortness of
breath and left sided chest
pain. Patient again in no
respiratory distress. SpO2 100%
on room air with mild
tachypnea and tachycardia.
Dx: Recurrent Left
Pneumothorax

26. Admitted for observation.
Repeat CXR 1 day later showed
increase in size of PTX and thus
she underwent thoracoscopy,
lysis of pleural adhesions,
apical blebectomy and creation
of pleural tent
Dx: Recurrent Left
Pneumothorax

27. Patient discharged in stable condition approximately 6 days after her
surgery.
But that’s not the end of her
story….

28. Patient represented 2 days
after discharge with recurrent
shortness of breath and left
sided chest pain. Again vital
signs stable other than mild
tachycardia.
Dx: Recurrent Left
Pneumothorax

29. Patient admitted to the surgical service for observation and underwent
tube thoracostomy for her recurrent L sided pneumothorax. Chest tube
removed on hospital day 3 and discharged home in stable condition
But that’s not the end of her
story….

30. Patient represented 1 month
later with left sided chest pain.
Vital signs all within normal
limits.
Dx: Recurrent Left
Pneumothorax
Last but not least…

31. Patient admitted to the surgical service for observation and underwent
repeat CXR with resolution of pneumothorax and discharge in stable
condition the next day
She continues to have no known etiology for her recurrent
pneumothoraces.

32. Recurrent PTX
• Recurrence rates in the pediatric population is estimated at
approximately 61%
• Management of recurrent PTX is controversial and often at the
discretion of the managing surgical service
• In a retrospective study of patients with primary spontaneous
pneumothorax, 92 patients required thoroscopic surgery1
• Surgical indications included failed non-operative management (32.7%),
recurrent ipsilateral PTX (36.4%)
• Bulla was identified in 91.8% of cases
• Authors concluded that early thoracoscopic mechanical pleurodesis and
stapled bullectomy after thoracostomy tube insertion could be offered as a
primary option for management of large PSP in pediatric population, since
most of these patients had bulla identified as the culprit of the disease.
• Another retrospective study analyzed the 36 patients admitted for
spontaneous pneumothorax2
• VATS was preformed in 14 of these patients for persistent air leak (57%) and
recurrent pneumothorax (43%)
• Patients undergoing surgery had longer hospitalizations, but lower recurrence
rates
• Authors concluded that VATS is successful, efficient, and safe method of
treatment for spontaneous pneumothorax, due to its significantly lower rate
of recurrence in comparison with chest tube insertion.
1. Yeung F, et al. “Surgical Intervention for Primary Spontaneous Pneumothorax in Pediatric Population: When and Why?”. Journal of Laparoendosc Adv Surg Tech 2017;27(8):841-844
2. Pogorelic Z, et al. “Management of the Pediatric Spontaneous Pneumothorax: The Role of Video Assisted Thoracoscopic Surgery. J Laparoendosc Adv Surg Tech 2020

33. HPI: 2-month-old previously
healthy male presented to the
emergency department in
respiratory distress. Noted to
have increased work of
breathing with hypoxia,
requiring 10L by HFNC to
maintain oxygen saturations
Rightward shift of mediastinal
structures
Extensive left sided airspace
opacity
Dx: Consolidation vs atelectasis
vs large pleural effusion

34. What can we use in this unstable patient to further classify the airspace
opacity?
Ultrasound!!!

35. HPI: 2-month-old previously healthy male presented to the
emergency department in respiratory distress with left sided
consolidation on CXR. Ultrasound used to further differentiate.
Spleen
Diaphragm
Lung tissue
floating in fluid
Dx: Pleural Effusion

36. HPI: 2-month-old previously
healthy male presented to the
emergency department in
respiratory distress. Noted to
have a large left pleural
effusion. Chest tube placed
with exudative pleural effusion.
Patchy consolidation on L with
resolution of L pleural effusion
Dx: Parapneumonic effusion

37. Pediatric Chest Tube Recommendations
• Consider what is it you have to drain
• Acute blood or air can easily be drained with a pigtail
catheter
• If it is expected to be viscous, you may need a small
caliber thoracostomy tube, however Chien-Heng found no
difference between drainage and hospitalization days
when using a pigtail catheter versus thoracostomy tube
for drainage of parapneumonic effusion1
• Be nice – anesthetize and sedate if needed
• Be safe – Use a flexible tipped guidewire and US for
guidance
• Aim high – above 6th intercostal space
1. Lin, Chien-Heng, et al. “Comparison of Pigtail Catheter with Chest Tube for
Drainage of Parapneumonic Effusion in Children.” Pediatrics and
Neonatology, U.S. National Library of Medicine, Dec. 2011,
www.ncbi.nlm.nih.gov/pubmed/22192262.
Pediatric EM Morsles – PigTail Catheter

38. HPI: 11-month-old previously
healthy female presented with
respiratory distress in the
setting of RSV bronchiolitis
progressive to septic shock,
ARDS and pulmonary
hemorrhage. CXR upon
admission to our facility.

39. HPI: 11-month-old previously
healthy female presented with
respiratory distress in the
setting of RSV bronchiolitis
progressive to septic shock,
ARDS and pulmonary
hemorrhage. CXR upon
admission to our facility.
RUL opacification consistent
with pulmonary hemorrhage
Extensive bilateral ground glass
opacities
Small, bilateral pleural effusions

40. Patient developed worsening
respiratory distress with SpO2
in the 80s while on 100% FiO2
with hypotension requiring
pressor support and decision
was made to proceed with
ECMO. CXR obtained at the
time of ECMO cannulation.
Extensive bilateral pulmonary
opacities

41. Pediatric ARDS: Definition
Cheifetz, IM. “Pediatric ARDS”. Resp Care. 2017;62(6):718-731

42. Pediatric ARDS: Management Basics
Cheifetz, IM. “Pediatric ARDS”. Resp Care. 2017;62(6):718-731
• Tidal Volume:
• 3– 6 mL/kg predicted body weight for patients with poor respiratory system compliance
• 5–8 mL/kg ideal body weight (physiologic range) for patients with better preserved respiratory
compliance
• Plateau Pressure: 28 cm H2O, allowing for slightly higher plateau pressures (29 –32 cm
H2O) for patients with increased chest wall elastance
• PEEP: Titrate to avoid alveolar collapse at end expiration
• moderately elevated levels of PEEP (10 – 15 cm H2O) should be titrated in patients with severe
PARDS to the observed oxygenation and hemodynamic response
• PEEP levels > 15 cm H2O may be needed for severe PARDS with attention paid to limiting the
peak airway pressure
• Recruitment Strategies: No convincing data. Recommend Careful recruitment
maneuvers by slow, incremental and decremental PEEP steps in an attempt to improve
severe oxygenation failure
• Gas Exchange
• Permissive hypoxemia
• Mild PARDS with PEEP <10 cm H2O, the SpO2 goal should generally be 92–97%.
• Severe PARDS with PEEP >10 cm H2O, SpO2 of 88 –92% “should be considered” after PEEP has been
optimized with recommendation to monitor central venous saturation when SpO2 <92%
• Permissive hypercapnia with goal pH 7.15 – 7.30

43. Pediatric ARDS: Management with HFOV
1. Cheifetz, IM. “Pediatric ARDS”. Resp Care. 2017;62(6):718-731
2. Young D, Lamb SE, Shah S, MacKenzie I, Tunnicliffe W, Lall R, et al. High-frequency oscillation for acute respiratory distress syndrome. N Engl J Med 2013;368(9):806-813
3. Ferguson ND, Cook DJ, Guyatt GH, Mehta S, Hand L, Austin P, et al. High-frequency oscillation in early acute respiratory distress syndrome. N Engl J Med 2013;368(9):795-805
4. Bateman ST, Borasino S, Asaro LA, Cheifetz IM, Diane S, Wypij D, Curley MAQ, RESTORE Study Investigators. Early high frequency oscillatory ventilation in pediatric acute respiratory failure: a propensity score analysis. Am J Respir
Crit Care Med 2016;193(5):495-503
• High-Frequency Oscillatory Ventilation (HFOV) theoretically provides a
lung-protective ventilation strategy by preventing atelectrauma and
maintaining airway recruitment via a constant applied airway pressure
and preventing volutrauma by avoiding alveolar overdistention via the
delivery of VT less than anatomic dead space
• Two adult RCTs have evaluated the differences between HFOV and lung-
protective conventional ventilation in adults with early moderate to
severe ARDS.
• OSCAR: no significant difference in all cause 30d mortality and in-hospital
mortality between HFOV and control group2
• OSCILLATE studied early use of HFOV in patients with high initial mean airway
pressure to promote lung recruitment and found an increase in mortality with
HFOV as compared with the lung-protective conventional group3
• There are no pediatric RCTs
• Bateman et al published a secondary propensity score analysis of the
353 subjects enrolled in the RESTORE study who were managed with
HFOV and found early application of HFOV was associated with
significantly longer duration of mechanical ventilation and greater use
of sedation and pharmacologic paralysis, but no mortality association
was note4
• Recommendation: HFOV should be considered as an alternative
ventilatory mode for those patients with moderate-to-severe PARDS in
whom plateau airway pressures exceed 28 cm H2O in the absence of
clinical evidence of reduced chest-wall compliance

44. Pediatric ARDS: Adjunct Treatments
Cheifetz, IM. “Pediatric ARDS”. Resp Care. 2017;62(6):718-731
• Other adjunctive treatments which may be considered
in select patient populations but whose routine use is
not recommended include:
• Corticosteroids
• iNO
• Prone positioning
• Exogenous surfactant
• Neuromuscular blockage

45. HPI: 11-year-old previously
healthy male presented to the
emergency department for
evaluation of L hip septic
arthritis. Patient was taken to
the OR by orthopedics.
Postoperatively he was noted
to be progressively more
hypotensive. CXR obtained:

46. HPI: 11-year-old previously
healthy male presented to the
emergency department for
evaluation of L hip septic
arthritis. Patient was taken to
the OR by orthopedics.
Postoperatively he was noted
to be progressively more
hypotensive.
Bilateral nodular patchy airspace
opacities

47. What’s the Differential?
DDx Bilateral Airspace Opacities
Infection
Bacterial
Fungal
Viral
Fluid Pulmonary Edema
Blood
Pulmonary Contusion
Pulmonary hemorrhage
Autoimmune
Goodpasture Syndrome
Granulomatosis with
Polyangitis
Sarcoidosis
Emboli
DDx Nodular Opacities
Infection
Bacterial (TB)
Fungal (Aspergillus, PJP)
Autoimmune
Goodpasture Syndrome
Granulomatosis with Polyangitis
Sarcoidosis
Emboli Septic Pulmonary Emboli
Malignancy
Pulmonary metastasis
Bronchoalveolar Carcinoma
Pulmonary Lymphoma
Karposi Sarcoma

48. To further narrow down the
differential, CT obtained
Dx: Septic Pulmonary Emboli
Extensive nodular, peribronchial
airspace opacities throughout
both lungs, some of which
demonstrate central cavitation

49. HPI: 4-year-old previously
healthy female presented to
the Emergency Department for
evaluation of five days of fever,
cough, nausea/vomiting.
Vital signs:
HR 170s
BP: 120/63
RR: 55
SpO2: 91%

50. HPI: 4-year-old previously
healthy female presented to
the Emergency Department for
evaluation of five days of fever,
cough, nausea/vomiting
Bilateral patchy airspace
opacities
Dx: ARDS

51. HPI: 6-month-old ex 25wk
premie with chronic lung
disease of prematurity
presented to the Emergency
Department for evaluation of
cough and increasing oxygen
requirements after
hospitalization 2 weeks prior
for viral URI. Vital signs:
HR 180s
BP: 115/89
RR: 52
SpO2: 98% on 0.25L
(on 0.15L at home)

52. HPI: 6-month-old ex 25wk
premie presented to the
Emergency Department for
evaluation of cough and
increasing oxygen
requirements
Bilateral perihilar patchy
airspace opacities
RUL Consolidation
Dx: Viral bronchiolitis with
superimposed RUL PNA

53. Unfortunately, the patient
became progressively more
hypoxic with increased work of
breathing despite significant
HFNC support and the decision
was made to proceed with
intubation. Post intubation CXR
ETT terminates 8mm below
carina
Dx: R Mainstem Intubation
Left lobe atelectasis

54. HPI: 3-year-old male with no
significant past medical history
presented to the emergency
department for evaluation of
GSW to the neck. Vital signs:
HR 180s
BP: 60/40
RR: 22
GCS: 7-8

55. HPI: 3-year-old male with no
significant past medical history
presented to the emergency
department for evaluation of
GSW to the neck. Vital signs:
HR 180s
BP: 60/40
RR: 22
GCS: 7-8

56. HPI: 3-year-old male with no
significant past medical history
presented to the emergency
department for evaluation of
GSW to the neck. Vital signs:
HR 180s
BP: 60/40
RR: 22
GCS: 7-8
Dx: GSW to right chest with
resultant rib fractures and
pulmonary hemorrhage
Right 1st and 2nd posterior rib
fractures
RUL consolidation consistent
with pulmonary hemorrhage

57. Summary Of This Month’s Diagnoses
• Recurrent pneumothorax
• Parapneumonic effusion
• Pediatric ARDS
• Septic pulmonary emboli
• RUL pneumonia
• GSW with pulmonary hemorrhage