Pediatric CXR:

Neonatal Respiratory Distress

Faculty of Medicine
MAHSA University

DR ZALEHA ABD MANAF

Neonatal Respiratory Distress
 Chest radiograph (CXR)
• CXR review is a key competency for medical students, junior
doctors and other allied health professionals.
• Systematic method for chest x-ray review:
– A: airways
– B: breathing (the lungs and pleural spaces)
– C: circulation (cardiomediastinal contour)
– D: disability (bones - especially fractures)
– E: everything else, e.g. pneumoperitoneum
 Interpreting CXR

lity
Clin Q ua
cor ical e
rela ag
tion Im

Anatomy &
Pathology
 Key History
What was the gestational age of the baby
at birth?
• Preemie by definition: < 34 weeks

How old is the baby?

• Hours, days, weeks after birth
Causes of Neonatal Respiratory Distress
Premature: RDS
Medical condition
Term: TTN, MAS,
Neonatal respiratory neonatal pneumonia
distress
CDH
Surgical condition CCAM
CLE, etc
bone & soft tissue*

Complications of NICU Catheters, lines and tubes placement

support apparatus Barotrauma- air leaks
Five Causes of Neonatal Respiratory Distress
1. Transient Tachypnea of the Newborn. TTN
2. Respiratory Distress Syndrome. RDS
(Hyaline Membrane Disease. HMD)
3. Meconium Aspiration Syndrome. MAS
4. Neonatal Pneumonia.
5. Bronchopulmonary Dysplasia. PBD
 Role of Neonatal CXR
Premature: RDS
Medial condition:
bilateral
Term: TTN, MAS,
Neonatal respiratory neonatal pneumonia
distress
CDH
Surgical condition:
CCAM
unilateral
CLE, etc
bone & soft tissue*

Assessment of NICU Catheters, lines and tubes placement

support apparatus Monitor lung inflation (HFOV)
Barotrauma- air leaks
Respiratory Distress Syndrome
(RDS)
 Respiratory Distress Syndrome (RDS)
General Considerations
• RDS most common cause in premature infants
• Lack of sufficient surfactant production
• ↑ pressure to keep alveoli open;
• ↓ lung compliance

Predisposed:
• premature infants < 34 weeks
• Caesarean-section
• Second-born twins
• Infants of diabetic mothers
 Respiratory Distress Syndrome (RDS)
Clinical Findings:
• Symptoms present in first 2 hours of life
• Symptoms that begin > 8 hrs are not due to RDS
• May ↑ in severity from 24 - 48 hours
• Then, gradual improvement > 48-72hours
 Respiratory Distress Syndrome (RDS)
Imaging Findings:
• Typically, diffuse “ground-glass” or
finely granular appearance
• Bilateral and symmetrical distribution +/- unilateral
• Air bronchograms are common
• Especially extending peripherally
• Hypoaeration in non-ventilated lungs
• Hyperinflation excludes RDS
Respiratory Distress Syndrome (RDS)
Respiratory Distress Syndrome (RDS)
Respiratory Distress Syndrome (RDS)
“Pseudoclearing” of RDS Due to
Greater Distension of Bronchioles and Alveolar Ducts
 Patent ductus arteriosus
Murmur, high pulse pressure
 Respiratory Distress Syndrome (RDS)
Disease Treatment:

• Surfactant administered via ETT.

• Positive end-expiratory pressure (PEEP).
• Continuous positive airway pressure (CPAP).
• High Frequency Ventilation (HFV).
• Oxygen and diuretics.
 Respiratory Distress Syndrome (RDS)
Disease Prognosis
• In the past, almost all infants died of RDS by 72 hrs.
Therefore, complications were rare

• With assisted ventilation, recovery >90%

All that follows represent complications
of treatment, rather than of the disease
 Respiratory Distress Syndrome (RDS)
• Complications of Treatment: Air Leaks
 Respiratory Distress Syndrome (RDS)

• Complications of Treatment:
Pulmonary interstitial emphysema
 Respiratory Distress Syndrome (RDS)

• Complications of Treatment:
Pulmonary interstitial emphysema
 Respiratory Distress Syndrome (RDS)
Complications of Treatment:

Pneumothorax
 Respiratory Distress Syndrome (RDS)
Complications of
Treatment:

Pneumopericardium
 Respiratory Distress Syndrome (RDS)
Complications of
Treatment:

Pneumoperitoneum
 sudden respiratory
IRDS p/ surfactant D1 decompensation and bloody
endotracheal aspirates
Bronchopulmonary Dysplasia
(BPD)

Chronic Respiratory
Insufficiency of the Premature
 Bronchopulmonary Dysplasia (BPD)
• BPD refers to late pathological lung changes that develop
several weeks later in infants on prolonged ventilation
• It occurs from a paradoxical combination of hypoxia and
oxygen toxicity
• BPD remains a major complication of prematurity resulting
in significant mortality and morbidity
 Bronchopulmonary Dysplasia (BPD)
• There is initial capillary wall damage, interstitial fluid seepage
and pulmonary oedema which is followed by loss of ciliated
epithelium and bronchiolar mucosal necrosis.
• Areas of both hyper expansion and atelectasis are seen.
• Rarely occurs in infants > 1250 g and in
infants born after 30 weeks gestation
 Bronchopulmonary Dysplasia (BPD)

Imaging Findings
• Coarse, irregular, rope-like, linear densities
• Represents atelectasis or fibrosis
• Lucent, cyst-like foci
• Hyperexpanded areas of air-trapping
• Hyperaeration of the lungs
Bronchopulmonary Dysplasia (BPD)
Bronchopulmonary Dysplasia (BPD)
 Bronchopulmonary Dysplasia (BPD)

atelectasis
 Bronchopulmonary Dysplasia (BPD)
Complications:

• Sudden infant death

• Pulmonary arterial hypertension
• Increased risk of pulmonary infection
• Development of asthma (hyperactive airway
diseasse)
 Transient Tachypnea
of the Newborn
TTN

Neonatal Retained Fluid Syndrome

 Transient Tachypnea of the Newborn
TTN
• Most common cause of neonatal respiratory
distress in full-term
• Usually full-term or slightly preterm
• Some delivered by C-section; some
precipitous labor
• Mild respiratory distress immediately after birth
• Improve within several hours
 Transient Tachypnea
of the Newborn TTN
Imaging Findings:

• Hyperinflation of the lungs

• Fluid in the fissures
• Laminar effusions
• Fuzzy vessels
Transient Tachypnea of the Newborn
TTN
Transient Tachypnea of the Newborn
TTN
 Transient Tachypnea of the Newborn
TTN
Treatment:

• Oxygen
• Maintenance of body temperature
• Improvement most often occurs in < 24 hrs
Meconium Aspiration Syndrome
MAS
 Meconium Aspiration Syndrome (MAS)
Pathogenesis:

• Meconium in amniotic fluid of 20% of

pregnancies
• Meconium products produce bronchial
obstruction and air-trapping
• Chemical pneumonitis
 Meconium Aspiration Syndrome (MAS)
Clinical Findings:

• Post-mature
• Severe respiratory distress almost immediately
• Respiratory distress more severe than TTN
 Meconium Aspiration Syndrome (MAS)
Imaging Findings:
• Diffuse “ropey” densities (similar to BPD)
• Patchy areas of atelectasis and emphysema from air-trapping
• Hyperinflation of lungs
• Spontaneous pneumothorax and pneumomediastinum
• Small pleural effusions (20%)
• No air bronchograms
• Clearing usually quick if mostly water; days-weeks if
mostly meconium
Meconium Aspiration Syndrome (MAS)
Meconium Aspiration Syndrome (MAS)
 Meconium Aspiration Syndrome (MAS)
Treatment:
• Supportive
• Antibiotics and oxygen
• ECMO can be used

Complications:
• Pulmonary hypertension → R→L shunting
• Cyanosis
• Anoxic brain damage
Neonatal Pneumonia
 Neonatal Pneumonia
Etiology
Intrauterine infection or during delivery
Most are bacterial in origin

• Group B Beta nonhemolytic Strep used

to be most common
• Now E. Coli in preemies
 Neonatal Pneumonia
Clinical Findings:

• Temperature instability.
• Marked respiratory distress
• Tachypnoea
• Metabolic acidosis
• Septicaemia and shock
 Neonatal Pneumonia
Imaging Findings:

• Perihilar streaky pattern may resemble TTN

• Patchy airspace disease
• Diffuse, relatively homogeneous
infiltrates resembling ground-glass pattern of HMD
• Occasionally pleural effusion may occur
 Neonatal Pneumonia
Imaging Findings
• Lobar consolidation from infection is
unusual in a newborn
• Group B Strep looks most like RDS
• Term infant with findings of “RDS”
should be considered to have
pneumonia until proven otherwise
Neonatal Pneumonia
 Neonatal Pneumonia
Treatment:

• Appropriate antibiotic
• Oxygen
• Fluid support as needed
Hyper-inflated lung →exclude RDS
 ??????

Decide which of those 5 diseases is

depicted on each of the following 5
chest radiographs
 Image 1

34 week preemie 6 weeks post-partum

Broncho-pulmonary Dysplasia
 Image 1

34 week preemie 6 weeks post-partum

 Image 2

Term infant with respiratory distress; birth

 Image 2

Term infant with respiratory distress; birth

Term→ not RDS

At birth→ not BPD, Not N
Pneum.

MAS, TTN
Lung Edema?
Air Bronchogarm? –ve .

Transient Tachypnea of the Newborn

 Image 3
36 week preemie with respiratory distress; birth
 Image 3
36 week preemie with respiratory distress; birth

Primee→ RDS, TTN

1-hypo or Hyperinflated Lung→
Hpo→ RDS
2-Lung edema→ -ve

Respiratory distress syndrome

 Image 4

Term infant with respiratory distress; birth

 Image 4

Term infant with respiratory distress; birth

Term → not HMD
At birth not pneumo
→TTN,MAS.

1-Air bronchogram→-
ve—> MAS.
2-ropey Densities→
MAS
3- Fissure edema-ve→
not TTN

Meconium Aspiration Syndrome

 Image 5

Term infant with severe respiratory distress; Day

2
 Image 5

Term infant with severe respiratory distress; Day

2
Term → not HMD
Day 2→ most probably
N pneumo
tempreture

Neonatal Pneumonia
More cases ???
More cases
More cases
Congenital diaphragmatic hernia (CDH)
More cases
 More cases

Aspyxiating thoracic dystrophy Osteogenesis Imperfecta

Thank
You
ACKNOWLEDGEMENT:
DR. MUNA MOHAMMED HUSSEIN