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This is Pediatrics case number three and the diagnosis

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we're considering is lung disease of prematurity.

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And for this case, I would

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like us to not just think about a static moment in time,

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but I want to think about the progression of the disease over

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time because this really is a disease that changes and

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evolves in the impact it has on the

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child. So we're starting here with a newborn chest radiograph

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and you can see that a

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little bit of work has already been done. So you can see

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that the patients got an esophageal

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gastric tube coming down the midline and they've got an

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umbilical venous catheter coming up from below and

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those are standard but they also tell us that the patient is

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Not well, there's something going on here. And the

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second thing I want you to focus on is the

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appearance of the lungs. They're not quite clear. And

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at the same time if I asked you to point to

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the one area of abnormality, it'd be

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difficult and that's because they're diffusely abnormal throughout

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the right and the left lung we're seeing

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a kind of hazy opacification.

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That is not a specific finding but it is

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a problem and you really need to know some clinical context

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for the patient to narrow your differential. So what

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do we know about this patient? Well, we know that

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they're ill they have these lines and tubes. We know

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that they're not

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Definitely term or post term because if

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they were going to have signs of

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being term or post-term, we would expect to see

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ossification of the humeral heads of

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the shoulders and you can see that I've circled there there's no

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bone. So it's all cartilage at this point. So that

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doesn't prove that the patient can't

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be at term but it's suggestive that

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this might be a preterm birth. And

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so what we're looking at is a diffuse

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haziness of the lungs. Could it be infection? Yes,

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could it be just fluid

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maybe the patient was a precipitous delivery of

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cesarean delivery didn't have time to squeeze all of

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the fluid out of their airways. Yes, but it

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also could be the effects of prematurity. So we're gonna need to

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watch over time what happens with

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this patient because it's really going to direct our

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differential and as you know newborns with respiratory distress

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are getting x-rays.

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Every day if not multiple times a day. So I'm

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going to just pull up.

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The next point in time and that

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is this image here, which was obtained at

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one month of life and things have

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progressed. The first thing we notice is

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that the patient has now an

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endotracheal tube and you can see the

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tip of the endotracheal tube right here. This is a patient in

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respiratory failure things aren't getting better. Things are

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getting worse. What's the next thing that we notice now? We

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have an umbilical venous catheter coming up from Below.

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We also have an increase in the

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course appearance of the lungs. So

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although there are still diffuse opacities

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in the lungs.

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We're seeing them become a little bit more reticular. I

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don't know if you can make out some of these lines that

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are crisscrossing throughout but you're

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seeing all of these little dot dash lines throughout

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the image now, I've made a mess of my

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image, but what's happened is the septations in

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between the Airways the interlobular pulmonary SEPTA

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Have become thickened and coarsened and we've developed some scarring.

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And this is because we're trying to help these patients.

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This is a patient born prematurely. We

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still even at one month of life don't see any

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ossification of the humeral head. So we're certain now.

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This is a premature patient.

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And they didn't have sufficient surfactant to develop

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the alveoli when they were born. They were just born too soon.

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And so what's happened is the lungs didn't pop

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open. We're using a ventilator maybe a jet ventilator

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a force air in really fast, but these lungs are like tissue paper

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and if you take blasts of air it a tissue paper

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sculpture, you're gonna rip the tissue you're gonna tear it you're gonna damage

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it and so in our attempt to save these patients, we

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also cause damage to their lungs we're starting to see the effects of

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that and one month of life is right around the time we start saying

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not only is this prematurity lung disease

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of prematurity, but they've developed findings of chronic lung disease

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of prematurity. It's been more than a month and now

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I'm gonna step us ahead even further in time and this

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is four months of life and what you

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can see is an even further delineation of

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those reticular opacities, so

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you can see the lines Criss Crossing throughout the lungs. They've

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become more permanent more visible more refined

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we can also see that the lungs are hyper.

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Banded and that's because we're working really hard

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to get every ounce of ventilation and respiration out

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of these lungs but a lot of the lungs are damaged and scarred

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and aren't working properly. So we're really trying hard. This

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patient is progressed and they're still intubated.

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There's the endotracheal tube. They've now got a

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pick because they can keep their umbilical

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catheter that long

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and what's happened is there are little areas of

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atelectasis throughout the lungs because the lungs never fully

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open to the extent that they ought because of all

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of that scarring and these are patients who are especially at risk for

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barot trauma. So you need to look for pneumothorax pneumonia Steinem.

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You need to look for air that's dissected into

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the interstitution which we call pulmonary interstitial emphysema.

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Those are all things very common in this

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age group that need to be addressed by adjusting the ventilator settings.