Radiology in paediatric non-traumatic thoracic emergencies

Abstract

Non-traumatic thoracic emergencies in children are very frequent, and they usually present with breathing difficulties. Associated symptoms may be feeding or swallowing problems or less specific general symptoms such as fever, sepsis or chest pain. The emergencies always require a rapid diagnosis to establish a medical or surgical intervention plan, and radiological imaging often plays a key role. Correct interpretation of the radiological findings is of great importance in diagnosing and monitoring the illness and in avoiding serious complications. Plain radiography with fluoroscopy still remains the most important and frequently used tool to gain information on acute pulmonary problems. Ultrasound is the first choice for the detection and treatment of simple and complicated pleural effusions. Cross-sectional techniques such as multidetector computed tomography (MDCT) and magnetic resonance imaging (MRI) are mainly used to study pulmonary/mediastinal masses and congenital abnormalities of the great vessels and the lungs. This article will discuss the choice of imaging technique, the urgency of radiological management and the imaging characteristics of acquired and congenital causes of non-traumatic thoracic emergencies. They represent common conditions involving the respiratory tract, chest wall and the oesophagus, as well as the less frequent causes such as tumours and manifestations of congenital malformations.

Fig. 1

a–d Pneumothorax. a Tension pneumothorax in a premature baby on the right side with a mediastinal shift to the left and compression of the left lung. b Anteroposterior and c lateral view of pneumomediastinum with air around the thymus—the “angel wing sign”—and bilateral basal pneumothorax in a term baby with respiratory problems. d A 7-year-old girl with pneumothorax on the right side and air leak into the mediastinum and subcutaneous tissue on the neck and axillae bilaterally

Fig. 2

A neonate with respiratory syncytial (RS) virus infection. Chest radiography shows hyperinflation with air trapping and atelectasis

Fig. 3

a–c A 1-year-old boy with a viral infection and severe breathing problems. a Chest radiography findings raised the suspicion of the narrowing of the distal trachea. b Axial CT and c volume-rendering reconstruction reveal an aberrant right upper bronchus and a long distal tracheal stenosis caused by complete cartilage rings

Fig. 4

a, b Congenital diaphragmatic hernia (CDH). a Antenatally diagnosed CDH in a neonate where chest radiography immediately after birth reveals opacity of the left thorax, mediastinal shift and the nasogastric tube directed into the left thorax. b A neonate presenting with respiratory distress on the fifth day of life. CDH with air-filled structures in the left thorax causing mediastinal shift to the right. The nasogastric tube is in the ventricle in a normal sub-diaphragmatic position

Fig. 5

Chest radiography of a 3-year-old girl reveals a generalised hyperinflation with bilateral perihilar linear opacities

Fig. 6

Chest radiography of a 9-year-old boy. Lobar opacity without volume reduction in the right upper lobe

Fig. 7

a–c A boy, 6 years of age, presenting with high fever and cough. a Chest radiography with consolidation of the left lower lobe. There is a typical ipsilateral scoliosis and a pleural effusion with medial convexity indicating a loculated effusion. b Ultrasound confirms the presence of an effusion with fibrinous septations traversing the pleural space. c Axial contrast-enhanced CT shows the pleural effusion and enhancing parietal pleura (white arrow)

Fig. 8

a–d Cavitary necrosis in a neonate with Ebsteins anomaly and complications in the postoperative period after heart surgery. a Chest radiography shows a longstanding opacity of the entire left lung with gradual development of a large air bubble in the lower part. There were clinical signs of bacterial infection. b Ultrasound reveals a round, well-circumscribed, sub-pleural lesion containing air and fluid. c Contrast-enhanced CT in an axial plane shows an air fluid level and no enhancement of the peripheral rim and adjacent lung. d Chest radiography after ultrasound-guided drainage of the necrosis and bronchopleural fistula

Fig. 9

Foreign body aspiration in a 2-year-old girl with a 2-week history of coughing and wheezing. Chest radiography shows obstructive emphysema of the left lung with a mediastinal shift supporting the suspicion of a foreign body in the left main bronchus. A walnut fragment was removed during bronchoscopy

Fig. 10

a–c Foreign body in a 3-year-old girl with a 9-month history of coughing. a Chest radiography in the anteroposterior view and b the lateral view shows an open safety pin in the right main bronchus. c Removal of the pin with a snare during bronchography

Fig. 11

a, b Foreign body in 1-year-old baby with acute wheezing. a Chest radiography with b the lateral view reveals a screw in the proximal part of the oesophagus and minor linear opacities in the lower part of the right lung

Fig. 12

a, b Congenital lobar emphysema in a term baby. a At day 1 of life the chest radiography is normal. b Three days later there are increasing respiratory problems, and radiography shows emphysema in the left upper lobe compressing the lower lobe and the right lung

Fig. 13

a–d Vascular ring in a boy, 10 years of age, presenting with acute stridor when playing football. a Chest radiography with upper GI series, the anteroposterior view and b the lateral view shows a typical dorsal impression in the oesophagus suspected to be a vascular ring. c CTA, axial plane and d VR show a right-sided aortic arch with tracheal and oesophageal compression by a remaining fibrous ligament and a diverticulum of Kommerell (arrow)

Fig. 14

a–c Boy, 11 years of age, with a 2-month history of cough, weight loss and lymph nodes in the neck. a Chest radiography shows a large mediastinal mass affecting the apex of the right hemithorax with severe tracheal compression. b Coronal plane of a contrast-enhanced CT with a better delineation of the tumour and airway compression of both main bronchi. c The corresponding coronal fluoro-deoxy-glucose (FDG) PET-CT, with pathological uptake of FDG of active disease extending up to the right side of the neck