the following is a medical media production from 

WR AMC Tv.

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.