2025 – PAGE 436 – PULMONOLOGY

HIGH-YIELD CHEST X-RAY FINDINGS AND PEARLS

PULMONARY VASCULAR CONGESTION

Pulmonary vascular congestion can be noted on chest X-rays of children with transposition of the great arteries/vessels (TOGA), truncus arteriosus, total anomalous pulmonary venous return (TAPVR), and left ventricular outflow tract obstruction (LVOT).

PATCHY AREAS OF DIFFUSE ATELECTASIS

If patchy areas of diffuse atelectasis are noted on a newborn’s X-ray and it shows focal air trapping and increased lung volumes, pick meconium aspiration.

• (DOUBLE TAKE) MECONIUM ASPIRATION SYNDROME (MAS): Meconium is rarely passed in utero before 34 weeks. Do not intubate and suction reflexively if there is Meconium Stained Amniotic Fluid (MSAF). Suctioning has not proven to provide any benefit. Intubation should be reserved for those showing signs and symptoms related to respiratory distress (labored breathing, hypoxia and bradycardia). Newborns showing evidence of respiratory distress within 15 minutes of birth, or those with APGAR scores of < 8, are at greatest risk for developing Meconium Aspiration Syndrome(MAS) requiring ventilatory support. The most common complication of MAS is persistent pulmonary hypertension. Vigorous newborns with APGAR scores > 9 rarely require ventilatory support (warm, dry and stimulate if needed).

FLUID IN HORIZONTAL FISSURE

If fluid in the horizontal fissure is noted in a newborn with tachypnea, pick transient tachypnea of newborn. The chest X-ray should also have appropriate expansion/inflation. If it shows under-inflation, then either the X-ray needs to be repeated, or this is not the diagnosis.

UNDERINFLATED CHEST X-RAY

A chest X-ray showing underinflation, ground glass findings, and air bronchograms is either respiratory distress syndrome or congenital Group B Streptococcus (GBS) pneumonia.

PEARL: Do NOT look at the WBC to help you differentiate between RDS and GBS pneumonia. It is very unreliable in the newborn. Look instead at the ratio of bands to neutrophils. If it’s > 0.2, that is more suggestive of GBS.

DIFFUSE OPACITIES WITH CYSTIC AREAS

If diffuse opacities with cystic areas are noted in a preemie or infant, consider bronchopulmonary dysplasia (BPD) from prolonged oxygenation or barotrauma. Treat with diuretics and monitor for electrolyte abnormalities associated with diuretic use. Some of these kids can end up having poor neurologic development.