0:00

This is an example of a chest

0:02

and abdominal radiograph of a premature baby in the nicu.

0:06

While I will discuss some specific findings such

0:09

as the chest opacities in a later section,

0:12

I do wanna point out a few things right now.

0:14

First, you might notice that this baby is being

0:18

held in place

0:20

by an adult hand here at the bottom of the image.

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And if you were to zoom on your own computer so

0:26

that your hand matches the size of

0:30

that adult's hand zoom in

0:32

or out, you'll get a good sense for

0:34

how small this baby really is.

0:36

And that is important

0:38

because it helps us realize

0:40

that when we talk about some things that you might be used

0:42

to, like support lines

0:44

and tubes, you need to take into account

0:47

how tiny this patient really is.

0:48

If you're gonna make recommendations about

0:50

adjusting those lines of tubes.

0:52

For example, we can see

0:54

that this patient has an endotracheal tube

0:56

and we see that the tip is overlying the mid thoracic

0:59

trachea, whereas in older patients,

1:02

if this tube was too high or too low,

1:05

or even if it's in the place that you would expect

1:08

frequently, we describe the tip of the tube

1:10

as a measurement based on how close it is to the Karina

1:13

in a baby of this size.

1:15

However, the baby could just move its chin

1:18

around a little bit, and

1:19

that's gonna make the tube seem like it's gonna move up

1:22

or down quite a bit, just

1:23

because relative to the size of the baby,

1:26

that movement can be several centimeters.

1:29

So when we're looking at these chest radiographs

1:32

of NICU babies, we don't usually give any measurements

1:35

unless it needs to be retracted or advanced.

1:38

Instead, we just ensure that the tip of

1:41

that tube is somewhere

1:42

between the thoracic inlet and the Karina.

1:45

My personal preference is to describe the tip

1:47

as overlying the upper, mid, or lower thoracic trachea,

1:51

and that is sufficient for these patients.

1:54

Again, you don't need to actually measure the tip

1:56

because if you were to take a radiograph five seconds later,

2:00

if the baby just tilts their chin up,

2:02

that tube might be in a seemingly

2:04

completely different place.

2:06

So that's one major difference

2:08

to think about with NICU babies.

2:10

Otherwise, when we look at these films,

2:13

we're really gonna use the same search pattern

2:15

that you're gonna use for any other patient

2:17

who has a chest x-ray.

2:18

So if you prefer to use the A, B, C, D, E method,

2:22

meaning look at the airway B, breathing

2:25

or lungs, C, cardiac, D, diaphragm, E extra,

2:30

you still do that In this case,

2:32

whatever is your normal search pattern, you still do here.

2:35

Yes, a lot of these structures will look a little different

2:38

from what you're used to, but they're still there.

2:40

So I realized that these posterior ribs might look quite a

2:43

bit thinner than you're used to, but they're still ribs.

2:46

In pediatrics, I often actually count the ribs to make sure

2:50

that there are 12, uh,

2:52

and I pay attention to make sure

2:54

that there are no vertebral anomalies,

2:56

because in some of these babies, especially if they're

2:58

Born, born with some sort of genetic syndrome,

3:00

they might have some sort of segmentation or fusion anomaly.

3:04

But again, whatever is your normal search pattern,

3:06

go ahead and keep up with that.

3:08

You'll also want to remember

3:09

that on these tiny little babies, sometimes a lot

3:12

of their anatomy ends up within the field of view.

3:15

So in this particular patient, we can see most

3:18

of the upper extremities as well.

3:20

So make sure not to forget to look at all

3:22

of those structures and familiarize yourself

3:24

with these structures when they have

3:27

a little bit of a different look.

3:28

In pediatrics, for example, in this baby,

3:31

the proximal humeral head epiphysis is not yet ossified.

3:35

We see the metaphysis.

3:36

And so in your mind's eye, you should know

3:39

that the cartilaginous humeral head is here

3:42

and here as a baby gets older, you'll start

3:45

to see ossification centers form

3:47

and eventually it will fuse with the rest of the bone.

3:50

Let's look at another patient. Here is a baby who's not

3:54

premature, but is an infant.

3:57

And again, it might look a little bit different from

3:59

what you're used to, but you use the same exact pattern.

4:02

So if you want to start with the airway,

4:03

we'll look at the airway, then you're gonna look at the

4:06

lungs, then you're gonna look at the heart

4:07

and the mediastinal structures, et cetera.

4:10

In this particular patient, you may notice

4:12

that the trachea appears to be bowed to the right,

4:15

and that's actually normal in this patient.

4:17

And I will discuss that in more detail

4:20

in the large airway section later on.

4:24

Similarly, you might notice

4:25

that there's soft tissue prominence in the upper

4:28

mediastinum, superior to the heart,

4:30

and that is a normal thymus.

4:31

I will also discuss that a little bit later on

4:34

in this introductory section.

4:36

Let's look at another patient. This is a different infant.

4:39

This one is one day old,

4:41

and we have two views, both a frontal and a lateral,

4:44

and sometimes it can be a little bit challenging to

4:48

evaluate whether the cardiac silhouette might be normal

4:51

or abnormal in a baby for a couple different reasons.

4:55

One is that

4:57

because babies can't follow directions, they might happen

5:00

to be in the expiratory phase

5:02

of respiration when the image is obtained.

5:04

If that happens, the lung volumes can be low

5:07

and the cardiac silhouette might appear to be large,

5:10

relatively large, given the low lung volumes.

5:14

Additionally, in this patient,

5:16

the image is somewhat lordotic,

5:18

and so we're the X-ray beam is going up somewhat like this.

5:21

And then so we see the domes

5:23

or the diaphragms here taking up some of that thoracic space

5:26

and making the lungs look smaller.

5:28

We can confirm this on the lateral, and we look here

5:30

and we see that the anterior diaphragms are obviously more

5:34

superior than the posterior diaphragm.

5:36

So you can imagine with a lordotic view,

5:38

looking up this way, that can make

5:40

the lung volumes look smaller.

5:42

Additionally, in our babies,

5:44

we almost always are obtaining our frontal radiographs in

5:47

the AP view as opposed to the PA view

5:49

that is the anterior posterior rather than the

5:51

posterior anterior view.

5:54

And as we all know, when we do that, sometimes

5:56

We can artificially make the cardiac silhouette look

5:59

larger because the beam is closer to the heart.

6:04

However, the same rules apply.

6:05

We're still gonna look at the airway,

6:07

we're still gonna look at the lungs.

6:09

We just take into account the fact

6:10

that there might be positional

6:11

or technique reasons for them to look like low lung volumes.

6:14

In this case, we're still gonna look at the mediastinal

6:17

structures and the cardiac silhouette.

6:19

Again, taking into account those potential technical

6:22

considerations, et cetera.

6:25

Finally, I'll show you radiographs of a patient who's older,

6:28

an adolescent or young teenager,

6:30

and at this point, most likely

6:33

these structures are starting to look more familiar.

6:36

So as we head into hood,

6:39

these structures look more like those of an adult

6:41

and you might be more comfortable with them,

6:43

but just as the same with the other radiographs,

6:45

we're gonna follow the same pattern.

6:47

We're gonna look at the airway,

6:48

we're gonna look at the lungs, et cetera, et cetera.

6:51

I wanna point out that although in this patient we can't see

6:54

the humeral heads because they're not in the field of view.

6:58

We do see them in some of our other patients.

7:00

So as I mentioned with the NICU baby,

7:02

we don't see the humeral head epiphyses,

7:04

but in this older infant,

7:06

we can see little ossification centers starting to form

7:09

and like I mentioned, as the patient rows that will enlarge

7:13

and eventually fuse with the rest of the humerus.

7:16

And so the, those are the sorts of things

7:18

that you can look out for and pay attention

7:19

to when you're looking at pediatric patients

7:22

of various ages.