the following is a medical media production from
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Okay
well ladies and gentlemen,
this is uh sort of uh maybe
not such a scientific topic
or talk.
It's on viral infections,
Lower respiratory tract infections
in Children.
That's kind of fancy for a chest cold
and I find that the biggest
problem with the
residents as they come on the pediatric service,
this doesn't occur in july because you don't
have this,
you know what happens?
The kids go back to school in september
october and they go
into the school which is the world's biggest Petri
dishes I think.
And everything grows
fine in all the rooms.
It gets about october and I mean they're
coughing in their hack and I got diarrhea and you know and it
comes home and and you get it or you give it
to them and so forth.
It's the usual fall and winter
cold stuff and they're all going to come into the clinics
and to the emergency rooms for
assessment of the of
their lower respiratory tract infection.
And you're gonna see a whole bunch of things on the X ray.
Now,
you see your basic decision will
be it's not gonna be yours.
You just kid yourself,
it's yours.
Does he get antibiotics or does he not get
antibiotics?
Because he'll get antibiotics?
And if in doubt find a red ear?
Yes,
the pediatricians ask him if in
doubt the ear is always a little red
enough to give them a little something penicillin,
right and so forth.
And then they get better.
And uh and you never really do know and I
don't know if this stuff really has that much
practical significance because what I'm going to show you here
isn't going to alter the practice of
the fallen winter chest cold very much.
But I'm hoping that it will give you a better understanding
of what we see on the run kilograms now on
this first slide,
which I've concocted
and we can dim these lights here now,
if you look up here,
it says viral,
lower respiratory tract infections and we're not gonna talk about
specific viruses.
I'm not gonna tell you that.
I can tell respiratory syncytial virus
from,
you know,
something else and so forth.
They all kind of look the same and they're around all the time.
Some are more this year,
some are more than next year.
Adenovirus always kind of bad.
That will give you some angry looking things.
Mycoplasma sort of a cousin to viruses
around and stuff like that.
But I'm not going to go into detail into any of these with
the exception of mycoplasma.
The rest of them,
however,
do not usually give you low bar
pneumonia like configurations.
They'll give you something that looks like low bar pneumonia.
But I'm going to point out to you later.
Hopefully that it's really not a pneumonitis,
but for orientation,
let's look at this.
You can have set of
basic four basic patterns.
We're going to deal with the one right here,
which is your most common one.
This is what I call a chest cold.
Now in the old days
when I was a kid,
this was good for about three days from
school right here.
Of course it wasn't so good because you
had junk put on your chest,
you know,
has to have stuff called thermo jean,
which I don't know if they still make that boy,
If you sweat into that stuff,
it's gonna be thermogenesis.
Alright.
Uh And then you have to go to the burn hospital
and get your skin burns treated for the but was
supposed to apply constant heat to your
congested chest.
I think it did.
It used to be not as vicious and awful
looking as a mustard plaster and then you'd
have all kinds of medicines you see to take care of this
cold and and I remember one,
so I'm not going to give the brand name,
but I don't remember,
but it was just totally ugly.
I mean you're cold could just disappear like that if you knew you
had to take that kind of medicine and so forth.
So that's really the most of it.
This is what comes into the clinics and emergency room,
just plain old chest cold in the adult.
You don't see anything with that to speak of.
And this is one of the orientations you have to make when you get
it in kids,
you see what amounts to acute
bronchitis.
You see what amounts to chronic sort of bronchial
problems,
like in an asthmatic,
you can pick out an asthmatic and a chest film and a child just like
that.
Once you get used to what you're looking for,
basically,
you're looking at a bronchitis,
we'll examine it in more detail later on,
but this is the most common pattern.
It's para Hyler para bronchial,
at least that's what we term it.
A lot of people turn it that way para heiler,
because that's where you see most of the change and perry
bronchial,
because your inflammation is perry
bronchial,
this leads to thickening of the bronchi and
you may see that on x rays,
if you move in this direction,
if you move in this direction,
you will pick up interstitial
patterns of Perrin,
camel,
infiltrate or el Villar patterns and
that's about as far as I'm gonna get to that,
because I am no expert in
interstitial and El Villar and then
guarantee you right now,
I'm never going to become an expert in
interstitial and El Villar,
but I'm gonna put it there because some of the stuff does
look interstitial,
you know,
and others looks L Villa and this is what I want to
talk about a little later on about just exactly
what's pneumonia and what isn't pneumonia.
But if you go in this direction,
in other words,
if you start picking up garbage in the peripheral lung
fields,
chances are you have a sicker kid,
especially if they're younger and the young infants
with this kind of pattern or that kind of pattern,
chances are they'll come in the hospital.
Okay?
And then if you go the other way,
you have a very clear looking chest,
usually an infant.
Almost always an infant.
Young infant peaks,
you know,
for six months and so forth.
That's bronchiolitis,
a big clinical picture with it.
Not much to see on the x rays.
And this means when you head out that way,
chances are you have a sicker kid on your
hands.
So this is sort of the spectrum bronchiolitis all the
way to parental infiltrates.
But by and large,
most of them are gonna fit right down here.
What you're sort of regular chess co what does it look like?
Well,
you've heard the phrase that at an apathy is
common with childhood pneumonias.
I would like you to rephrase that and say at an
apathy is common with childhood
lower respiratory tract infections
because that's what you have here.
This is para hablar para bronchial.
Mostly at an apathy though.
Here's at an apathy here and here and a little
prominence of the bronco vascular markings.
If you're lucky on some of these kids you'll see the bronc
ion and they look cuffed just like an
assistant,
just like an asthmatic.
Now usually there's an element of air trapping
here and because of that you have an
over a rated chest in many of these Children
and in a lot of ways they overlap with
asthmatics and of course asthmatics pick up these viral
things and that's what will bring them in.
I mentioned that to you not so that you bind,
bind it tightly together but so that you'll
appreciate that asthmatics get these
problems very frequently and they get
superimposed viral lower respiratory tract
infection on their chronic picture of
over oration and the end result radio graphically it
looks awfully similar but what you have
is para hablar para bronchial prominence of the
bronchial markings although it may be hard to separate them
out.
Certainly at an apathy which is usually bilateral like
this,
Here's another one with more Adan apathy
and more para hablar para bronchial
infiltrate with over aeration.
Now you know you can start thinking well
what are other things of retinopathy?
This is the most common cause of bilateral
heiler Adan apathy in the pediatric age group and
that's just a viral lower respiratory tract infection.
And in another two or three weeks all the clinics and emergency
rooms will be full of kids with this kind
of pattern.
If the regular viruses comes through,
If swine comes through,
I don't know what what it looked like.
But on lateral this is where you look for holler at
an apathy,
right where it should be right in the highland regions and
if you can't make up your mind on the frontal view,
look at the lateral view and see if you have a big blob of stuff over
here,
Then you have some retinopathy.
It don't make too much difference.
But that's the most common pattern
of viral lower respiratory tract infection.
And in a normal patient you notice you don't have
that wad of inflammatory tissue there.
Now in some of these patients you don't have as much at
an apathy but you have more of the para holler pair,
bronchial infiltrate and over aeration.
Now why do you need to become familiar with this?
I'll tell you why.
See this kid comes in and he's coughing and
hacking away and he's got a runny nose
and he may be Crew P.
And the clinician listens
to the chest.
I mean they're all kind of noises.
If you still believe in Wronki and riles and all that
stuff,
they're better hurt all the time after.
You see the chest X ray very often
my biggest regret is I probably never
will hear whispering back to relic.
We always thought that would be nice to
hear.
But I think I'm gonna hear
that.
I don't find that
I'm very good with the stethoscope anymore.
But uh they'll you know,
they'll get the chest X ray and so forth.
But many times they listen beforehand.
I mean they'll hear all kind of stuff.
They'll heal decreased air entry here and
decreased air entry up there and then they'll come up
and I'll show you a couple of things that you and they and everybody will
misinterpret for pneumonia.
Everybody will be happy but they're not hearing
pneumonia per se.
They're hearing the effects of para holler.
Pierre bronchial inflammatory disease will end
as I'll show you later on,
a lot of airway disturbance at Alexis's
emphysema changing patterns wrong.
I you get them to cough,
it changes and stuff like that and you'll never
correlate and that's the real sum total of this.
You'll never correlate what they hear with what you
see.
If you really,
if you if you don't appreciate that this is a widespread
problem that changes and it changes because you have
secretions and junk in the end of
bronchial in the tubes.
So when they come down and say I got decreased air entry
in the right lower lobe.
Don't say that's a pneumonia in the right lower lobe.
All that is is para hablar para bronchial
and next five minutes it can change and be
up here what they're hearing,
decreased air entry.
Well getting back to this first pattern.
This is uh less at an apathy and
more uh of the paranormal appear bronchial
infiltrate.
Now when you get out into Perenco will infiltrate,
It can look like this which you can call
whatever you want.
I'll just say it's paranormal.
Most of the time when you have this much involvement,
you have a sicker kid.
Although that's not always true.
You'll be surprised at how ugly the chest can
look and how healthy the kid can be.
I mean,
so it's not a 1-1 rule.
Generally speaking though,
the more you have,
the more you have in your parent comma,
the sick of the kid and this is just going in the
direction of a sicker kid and if they're younger they're
sicker.
Now,
this is really one of the only reasons I want to bring up this kind
of ratty looking interstitial
pattern,
does it kind of look to you like it might be congested,
I mean passively congested in this
particular case and maybe I have another one here.
How about that one?
Is a little kind of hazy now,
that's what you really call,
what do you call it?
The Shaggy heart of prosthesis.
But it isn't prosthesis.
I mean I don't even know what this is.
This is regular virus running through because shaggy
heart just means a lot of para hablar para
bronchial infiltrate with some interstitial
extent extension into the parent comma.
With this if you like interstitial pattern it
gives you a hazy,
fuzzy looking cardiac silhouette.
It happens to occur in parenthesis not every time by
the way,
normal chest is perfectly all right with prosthesis it
happens with viruses very commonly and that's the
most common cause of a shaggy heart is some
viral lower respiratory tract infection.
Notice over oration it's over
aeration,
that's really the most significant thing on this film.
But this is the reason that you
will have asked of you by the
clinician,
the pediatrician,
how do you tell pneumonia from congestion
on the X ray?
Because you could say this could be congestion.
Well basically if you have a big heart
and the thing looks congested then you have cardiac
disease.
If it looks congested and your heart's not big and you've
got a lot of over aeration you've got a
viral lower respiratory tract infection with
this interstitial if you like pattern
and the clinical presentation will be different.
But on a purely run cartographic basis it is this kind
of film and perhaps this kind of
film that prompts want to ask the
radiologist.
How can you tell that this isn't
congestion and that this is infiltrate.
Well sometimes it's impossible.
But if you notice there is no cardio Meagley here.
And if you know that this could be a pattern
of viral interstitial infiltration which
this is what we're dealing with here then you can say,
well that's the way I tell.
But in some cases that's impossible.
But it is this pattern,
one of the parent camo patterns that leads to
that question.
And really,
you know what the answer to that question is.
He sit and read a bunch of films and then congestion looks
like congestion and pneumonia looks like pneumonia,
but don't say it to them because then they won't come
back and they'll think you give them a smart answer.
But that's really true.
That's the way you do a lot of radiology.
Now we're going to go the other way.
Not much in the lungs,
but a lot of over aeration.
And this is a fairly specific clinical picture.
These kids do not move air,
their young infants,
their young infants,
often it's respiratory sensational virus that does
this.
But others can do it.
And they have profound air trapping.
You notice all of them had air trapping,
but here you have profound air trapping
and the old business of not moving the diaphragmatic leaflets
their way flat.
Look at the famous is separated off the heart.
Here you have profound air trapping.
But in my experience,
most of the time,
nothing in the chest,
very little,
very little in the chest in the way of
infiltrates.
Oh,
you'll see other things in the chest.
But I hope to convince you that they're not really
areas of pneumonitis.
This is bronchiolitis for the most part and
over a distended chest.
An infant who is very
distressed cyanotic and it's not
moving air because of profound air trapping.
Okay,
and I think here is the lateral view with an over distant
little light film.
So it doesn't bring the hyper loosen c of the
lungs out very well.
Okay,
so those are the basic patterns we've gone from the
standard para hollopeter bronco without an apathy,
moved into the parent camo patterns and then moved to
the bronchiolitis without a lot in the chest in the
lungs rather,
but a lot of over aeration.
Now two things that are always over called
for pneumonitis and I and I find that the first thing I have
to do,
like I'm gonna have to do as soon as I get back to
Galveston here in another two or three weeks,
these kids will be coming through the
the clinics in the emergency room is teach the
resident to subtract
what he's learned for adult in adult.
And it's true,
this is a good sign.
This is dr Felson silhouette sign here.
If this is obliterated,
you think there's something going on there now,
it just so happens that this is the most
common pseudo positive silhouette sign in
childhood.
Now it'll happen normally in a slightly Lord
attic film and you may have just vessels,
you may have perry bronchial disease
one way or another,
it's gonna rub this out well before you jump on that as
pneumonia.
Remember most of the time,
if you think it's in the middle lobe,
it ought to be in the middle lobe and there's nothing there.
Okay.
So if you get,
I don't know,
this is sort of a standard for our emergency room,
Lord attic chest.
When you,
when you learn things,
you have to learn one criteria for daytime and one for
night time because nighttime chances are,
you'll get a lord chest,
you know,
and if you look here,
you'll say,
well maybe there's something there,
maybe there's something there,
you know,
be careful and especially over
here if you think there's something,
they're always look at the lateral,
make sure there's nothing because if you
think you have a silhouette sign positive like this
and there is something on the
lateral view in the middle of you can see it there,
then you have something that's at electric,
There's pneumonia and so forth.
That is the most over called
pneumonia,
pseudo pneumonia in childhood is right along the right
cardiac border.
And all it is is para hablar para bronchial
infiltrate with the Lord arctic chest or a poor
inspiration.
And the second most common place is the
pulmonary arteries drifting back here,
especially,
I mean it must be awfully easy to hear something in the lung basis.
You know how it is and so forth.
And they're making noises all over the place and once your
attention is focused to this,
they'll pick this up and say there's the infiltrate.
Well,
first of all,
they don't come in this linear fashion very
often.
And the second thing,
if you know that there are vessels heading back there that tend
to look like that,
you'll say,
well,
just a minute,
you know,
we ought to find this on frontal view and lateral view.
I think you have nothing but para holler,
para bronchial infiltrate.
Okay,
so there are two areas that are constantly over
called for a pneumonitis with viral lower
respiratory tract infection.
Now,
a couple of complicating pictures,
this is para hablar para bronchial,
right,
But what are we doing with this?
And what's this?
And what's this now?
I'll guarantee you,
I'll guarantee you that this will be called
pneumonia.
This is nothing more than what we saw.
To begin with.
This is para hablar para bronco.
And you know what these are.
These are areas of segmental add
Alexis's and when they speak round in an a
northerly fashion and their linear,
triangular it's add Alexis's and
it has nothing to do with that patient's
condition.
This is probably not causing him a whole lot of trouble,
you know what's causing him trouble.
His pair of Tyler perry bronchial infiltrates with over
aeration.
This is incidental due to mucus plugging or
secretions plugging up the bronchi and they'll come
and go so you don't want to misinterpret that.
And I mention it to you because you see you'll get a
chest film like this and you'll say yeah that kid must be
sick and you know he's sitting there,
he looks miserable,
he's got a runny nose,
he's got a little fever,
he's coughing and hacking deathly sick though
and you'll go back there and you'll say gosh you got to be real
sick,
you know,
and so forth.
This stuff.
This is not a good pattern
for viral lower respiratory
tract consolidations.
It just doesn't occur very often.
It just doesn't it?
Oh it will.
I'm not saying it doesn't occur at all.
But when you see this start saying to yourself,
I wonder if these areas just represent
areas of add electricity is of ad
Alexis's.
No.
To demonstrate this on a grocer
fashion.
Here's a patient with a viral lower respiratory tract
infection and what are we going to call this?
Well,
I'll show you what it is because these three slides,
I'm going to show you here are taken are films that are taken
in less than I think 36 hours
less than that apart,
maybe less than 24 hours apart.
This would have been called,
I'm sure a pneumonia Except,
you know,
less than 12 hours it's gone.
That's at Alexis's you see what's creeping up over
here.
I mean is this another pneumonia?
You see less than 36 hours,
this is gone.
This is a dialect is the same patient.
This is a dialectics is fleeting once the right
upper lobe and now the entire left lung
here is a dialectic because mucus
plugs are very
common in viral lower respiratory tract
infection.
And they will they will cause you concern
and they will cause you to misinterpret films.
Now,
here's an excellent example.
What is the most significant finding in
this infant?
Not this hazy density over here
and not this over here,
but the over aeration.
This infant has bronchiolitis.
This is what brings the infant into the hospital.
This is why he's overrated.
This is not pneumonia and neither
is that those are areas of Ad Alexis is now you
notice this is the compressed wedge like
configuration of right middle lobe add
Alexis's and this was really
treated as a pneumonia.
The kid got antibiotics.
I mean he didn't need them.
He had a viral lower.
I could tell you that he didn't need him.
What I argue strongly.
Of course not.
I mean that's not my business to decide whether he
needs antibiotics,
but he did not need him.
What he needed to be in hospital and be treated for bronchiolitis,
which he was being treated for.
He happened to get antibiotics incidentally for
that.
So it distracted them.
Here's another one,
add electricity here and some here with
relative good aeration of the middle lobe.
The big problem here is the bronchiolitis
pair of holler para bronchial picture in this infant.
This is extra and with one lobe down
like that,
it's probably causing him some extra impairment.
Here's another one you see,
here's a funny configuration of,
of upper lobe at Alexis's,
here's the minor fisher and this was most difficult to
demonstrate with.
This was not fluid.
We thought it was fluid to begin with.
It was not eventually it disappeared.
But this distracted everybody.
But really look at the over aeration,
this infant had bronchiolitis.
It's a bad film there,
but it does demonstrate how this can distract Now.
Look how he's overrated here.
This is the rest of the right lung herniated way over here,
marked air trapping,
that's what was causing his difficulty.
And here's another one.
This patient was given antibiotics and he was just he was
in the age group to have have himself covered
for Hemophilus
And I think he got ampicillin or something like that for
this.
And I would,
you know,
I'd have to say that looks like a pneumonia.
I'm not telling you that.
I'm so smart.
I can tell that electricity from pneumonia.
But I just want to show you that if less than
24 hours later it looks this
improved you get
yourself a patent on that antibiotic because it is
terrific.
This is just a little bit of that electricity is that is
slowly clearing up.
You see the only point I really would like to
make and this will be the last,
this is a short session.
The only point I'd like to make out of that is that what's
going to happen and you'll never understand it unless you appreciate
it.
What's going to happen is that the clinician is gonna come
with all kind of a skull territory findings
and you're either going to match that up with him or you're not gonna
match it or you may come up with a bunch of
chest film findings that he can't explain.
I mean they may look like the worst chest you've ever seen.
He said well he's not that sick.
Remember that had electricity secondary
to end a bronchial obstruction,
mucus plugs,
usually secretions very common.
Very common.
And of practical consideration is this last case.
Here's an infant.
Now here's that Alexis ist and here's that
electricity is right,
there's a lower lobe and the right
upper lobe.
What you have to decide here is
this at electricity or is this compressive that
electricity is secondary to the right middle lobe
being over distended.
And you see when we finally finished with this
patient,
what it turns out is that he has right middle lobe
emphysema and it is classic for right middle
lobe emphysema.
This is very good and it's often missed.
Now is this congenital or is this
acquired?
You say to yourself,
If this is congenital,
right middle lobe emphysema,
then why is this long?
So what we're aerated,
I mean did this kid come in because somebody found
no,
this kid came in because he had a runny nose,
He was coughing,
he had all kind of finding and you got this chest film.
You know what he's got,
he's got bronchiolitis if you like.
Para hablar para bronchial infiltrates drifting into the
bronchiolitis.
That's why he was sick.
Obviously this right lung is even more compromised in the
left because this is an electronic that saddle ecstatic
and this is right middle lobe and dr Schaffner a number of
years ago had an article on aeration,
disturbances in pediatric
uh in the pediatric age group associated
with acute respiratory tract infections.
And there he said,
just drag your heels and
don't have this low removed
because less than a week later,
when everything settles down,
there's nothing wrong over here that was transient,
right middle lobe emphysema due to
a mucus plug.
So we can have the slides off and just have the
lights on here for a minute and I'll summarize that for
you.
I'm not sure that this is gonna be the greatest
impact on the treatment of Children with viral
lower respiratory tract infections.
But I'm hoping that it will help you understand what you're
looking at the X rays.
And so when you have a situation where the
the pediatrician comes in and said,
I hear things in the left lower lobe and you
don't find him there,
you will have a sensible explanation for
him or her as to why
he sees it or hears that she hears it
and you don't see it on the X rays.
And only when you understand what's going on with viral
lower respiratory tract infections.
Will you really render a sensible
interpretation of the films?
Otherwise you know what you'll do you say?
Do you want a pneumonia?
Yeah.
Okay.
You got a pneumonia?
Okay.
Thank you.
A medical media production from WR
AMC TV.