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This is a chest radiograph of a newborn

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who was born at 25 weeks gestational age.

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As you can see here on the chest radiographs.

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In addition to the support devices, we see diffuse, hazy

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and granular opacities throughout both lungs.

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When discussing opacities in a neonatal chest X-ray,

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the terms hazy

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and granular tend to have a very specific meaning.

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When you say those words, they're basically buzzwords

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for respiratory distress syndrome

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or surfactant deficiency disease.

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And the way I like to think about it,

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when I look at these radiographs

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and I look at these opacities, to me, they remind me

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of a smudged pencil eraser look.

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That is if you took a dull pencil

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and colored in the lungs in the coloring book,

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and then you take that same pencil

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with a poor quality eraser and try to erase it

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and it gets all smudgy.

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That's the effect I think

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of when I look at these respiratory distress

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or surfactant deficiency disease chest radiographs.

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In this particular case, we can see

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that both the diaphragmatic

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and cardio mediastinal margins are partially obscured due

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to the pulmonary opacities.

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So this is what I would call the a moderate to severe case

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of respiratory distress syndrome

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or surfactant deficiency disease.

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Oftentimes in my own reports,

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I'll actually call it an SDD

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for surfactant deficiency syndrome

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or respiratory distress syndrome hyphen pattern.

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So I'll say this has an SDD pattern

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because as we'll talk about a little bit later,

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this same pattern can be seen

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with another entity, neonatal pneumonia.

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So from radiographs,

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we don't always know if we're looking at SDD

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or neonatal pneumonia,

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but the clinicians will know that

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this is a chest radiograph of that same patient.

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Three hours later you can see

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that the patient has an endotracheal.

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Two patients who have surfactant deficiency syndrome

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or respiratory distress syndrome will receive exogenous

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surfactant and oftentimes they will improve quite a bit.

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As we could see here, we still see

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that pencil smudge eraser look a little bit those hazy

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and granular opacities,

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but substantially improved from the original radiograph.

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One thing to be aware of is that sometimes

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after surfactant treatment is initiated,

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the patient's radiographs actually get

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worse before they get better.

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So that's something to expect as well.

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The next patient is a patient born at 26

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weeks gestational age,

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and you can see similarly we have those hazy

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and granular pulmonary opacities throughout both lungs,

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but it's a little bit more asymmetric

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and that's not uncommon as well.

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We can see that it has a fairly uniform look in the right

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lung, but a little bit more

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of a heterogeneous look in the left lung.

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And that can happen particularly

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as the hours and days progress.

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And there are areas of micro atelectasis scattered

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throughout the long and they

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Can improve or worsen over time.

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And so you can have what we sometimes call shifting

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atelectasis, where some areas look better aerated

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and other areas look worse over time.

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And the last patient I will show you here is a baby

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that was born at 35 weeks gestation.

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You can see that the patient is rotated to their left.

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I'll give you a little trick here.

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In babies, it can be a little bit more difficult sometimes

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to determine if they are rotated to one side

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or the other based on their clavicles as we often do

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with older patients.

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So what you can do is you can hold your hands in front

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of you like this or your thumbs or facing your face

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and your other fingers are facing outwards.

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And that simulates looking at the clavicles

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and ribs where your thumbs are like the patient clavicles

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and your fingers are like the patient's posterior ribs.

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And then if you turn your hands one way or the other

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and look at which ones which fingers look

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for shortened versus which ones look lengthened,

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that'll tell you which direction the patient is rotated.

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So in this case, if you hold your hands in front

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of your face and you turn your hands towards your right

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or the patient left, those right fingers,

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which are the patient's left ribs,

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look longer than the other side.

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And that's what we see in this patient.

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So you can see these left ribs look longer than the right

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lip ribs, so this patient is rotated to their left.

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In this particular case, I would say that these hazy

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and granular opacities are on the milder side compared

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to our other two patients.

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So this is what I would describe as a more mild SDD pattern.