WEBVTT 00:00.000 --> 00:30.000 position:50% align:top line:0% *This machine-generated transcript may have errors. If remediation or a manually-generated transcript is needed, please contact NLM Support at https://support.nlm.nih.gov.* 00:01.750 --> 00:04.650 the following is a medical media production from 00:04.650 --> 00:06.650 WR AMC Tv. 00:09.040 --> 00:09.250 Okay 00:18.140 --> 00:19.230 well ladies and gentlemen, 00:19.230 --> 00:22.140 this is uh sort of uh maybe 00:22.140 --> 00:24.830 not such a scientific topic 00:24.840 --> 00:26.090 or talk. 00:26.100 --> 00:28.610 It's on viral infections, 00:28.610 --> 00:30.760 Lower respiratory tract infections 00:31.500 --> 00:32.390 in Children. 00:32.390 --> 00:35.060 That's kind of fancy for a chest cold 00:35.540 --> 00:38.380 and I find that the biggest 00:38.380 --> 00:40.650 problem with the 00:41.140 --> 00:43.740 residents as they come on the pediatric service, 00:43.790 --> 00:46.750 this doesn't occur in july because you don't 00:46.750 --> 00:47.320 have this, 00:47.840 --> 00:48.770 you know what happens? 00:48.930 --> 00:51.510 The kids go back to school in september 00:51.510 --> 00:54.340 october and they go 00:54.340 --> 00:57.020 into the school which is the world's biggest Petri 00:57.020 --> 00:58.020 dishes I think. 00:58.280 --> 01:01.020 And everything grows 01:01.020 --> 01:02.700 fine in all the rooms. 01:02.700 --> 01:05.300 It gets about october and I mean they're 01:05.300 --> 01:08.050 coughing in their hack and I got diarrhea and you know and it 01:08.050 --> 01:10.950 comes home and and you get it or you give it 01:10.950 --> 01:11.960 to them and so forth. 01:11.960 --> 01:14.600 It's the usual fall and winter 01:14.800 --> 01:17.570 cold stuff and they're all going to come into the clinics 01:17.730 --> 01:20.000 and to the emergency rooms for 01:20.000 --> 01:22.950 assessment of the of 01:22.950 --> 01:25.610 their lower respiratory tract infection. 01:25.970 --> 01:28.960 And you're gonna see a whole bunch of things on the X ray. 01:28.960 --> 01:29.270 Now, 01:29.280 --> 01:32.210 you see your basic decision will 01:32.210 --> 01:34.930 be it's not gonna be yours. 01:34.930 --> 01:35.840 You just kid yourself, 01:35.840 --> 01:36.230 it's yours. 01:36.240 --> 01:38.520 Does he get antibiotics or does he not get 01:38.520 --> 01:39.310 antibiotics? 01:39.310 --> 01:41.120 Because he'll get antibiotics? 01:41.740 --> 01:43.970 And if in doubt find a red ear? 01:44.070 --> 01:44.820 Yes, 01:44.820 --> 01:47.540 the pediatricians ask him if in 01:47.540 --> 01:50.260 doubt the ear is always a little red 01:50.940 --> 01:53.710 enough to give them a little something penicillin, 01:53.710 --> 01:55.480 right and so forth. 01:55.490 --> 01:57.360 And then they get better. 01:57.740 --> 02:00.570 And uh and you never really do know and I 02:00.570 --> 02:03.460 don't know if this stuff really has that much 02:03.460 --> 02:06.390 practical significance because what I'm going to show you here 02:06.390 --> 02:09.030 isn't going to alter the practice of 02:09.030 --> 02:11.660 the fallen winter chest cold very much. 02:11.670 --> 02:14.400 But I'm hoping that it will give you a better understanding 02:14.490 --> 02:17.340 of what we see on the run kilograms now on 02:17.340 --> 02:18.460 this first slide, 02:18.840 --> 02:20.250 which I've concocted 02:21.540 --> 02:23.630 and we can dim these lights here now, 02:23.730 --> 02:25.390 if you look up here, 02:25.390 --> 02:26.230 it says viral, 02:26.230 --> 02:29.170 lower respiratory tract infections and we're not gonna talk about 02:29.170 --> 02:30.250 specific viruses. 02:30.250 --> 02:31.180 I'm not gonna tell you that. 02:31.180 --> 02:33.940 I can tell respiratory syncytial virus 02:33.940 --> 02:34.280 from, 02:34.280 --> 02:34.550 you know, 02:34.550 --> 02:36.060 something else and so forth. 02:36.440 --> 02:39.210 They all kind of look the same and they're around all the time. 02:39.210 --> 02:40.280 Some are more this year, 02:40.280 --> 02:41.560 some are more than next year. 02:41.940 --> 02:44.080 Adenovirus always kind of bad. 02:44.090 --> 02:45.990 That will give you some angry looking things. 02:46.260 --> 02:48.910 Mycoplasma sort of a cousin to viruses 02:48.910 --> 02:50.470 around and stuff like that. 02:50.600 --> 02:53.600 But I'm not going to go into detail into any of these with 02:53.600 --> 02:55.650 the exception of mycoplasma. 02:55.660 --> 02:56.510 The rest of them, 02:56.510 --> 02:57.290 however, 02:57.490 --> 03:00.150 do not usually give you low bar 03:00.150 --> 03:02.350 pneumonia like configurations. 03:02.740 --> 03:05.300 They'll give you something that looks like low bar pneumonia. 03:05.300 --> 03:06.840 But I'm going to point out to you later. 03:06.840 --> 03:09.820 Hopefully that it's really not a pneumonitis, 03:09.910 --> 03:11.440 but for orientation, 03:11.440 --> 03:12.340 let's look at this. 03:12.350 --> 03:14.970 You can have set of 03:14.970 --> 03:16.650 basic four basic patterns. 03:16.920 --> 03:18.440 We're going to deal with the one right here, 03:18.440 --> 03:19.790 which is your most common one. 03:20.010 --> 03:21.460 This is what I call a chest cold. 03:21.840 --> 03:23.250 Now in the old days 03:24.640 --> 03:25.660 when I was a kid, 03:26.330 --> 03:29.310 this was good for about three days from 03:29.310 --> 03:31.250 school right here. 03:31.640 --> 03:34.450 Of course it wasn't so good because you 03:34.450 --> 03:36.270 had junk put on your chest, 03:36.270 --> 03:36.660 you know, 03:37.040 --> 03:38.750 has to have stuff called thermo jean, 03:39.240 --> 03:41.840 which I don't know if they still make that boy, 03:41.840 --> 03:43.560 If you sweat into that stuff, 03:43.940 --> 03:45.240 it's gonna be thermogenesis. 03:45.240 --> 03:45.650 Alright. 03:45.660 --> 03:48.520 Uh And then you have to go to the burn hospital 03:48.520 --> 03:51.420 and get your skin burns treated for the but was 03:51.420 --> 03:53.870 supposed to apply constant heat to your 03:53.870 --> 03:55.140 congested chest. 03:55.350 --> 03:55.980 I think it did. 03:55.980 --> 03:58.710 It used to be not as vicious and awful 03:58.710 --> 04:01.600 looking as a mustard plaster and then you'd 04:01.600 --> 04:04.180 have all kinds of medicines you see to take care of this 04:04.180 --> 04:06.810 cold and and I remember one, 04:06.820 --> 04:08.250 so I'm not going to give the brand name, 04:08.250 --> 04:08.970 but I don't remember, 04:08.970 --> 04:10.750 but it was just totally ugly. 04:11.140 --> 04:14.000 I mean you're cold could just disappear like that if you knew you 04:14.000 --> 04:16.780 had to take that kind of medicine and so forth. 04:16.780 --> 04:18.830 So that's really the most of it. 04:18.840 --> 04:21.580 This is what comes into the clinics and emergency room, 04:21.580 --> 04:24.550 just plain old chest cold in the adult. 04:25.640 --> 04:27.620 You don't see anything with that to speak of. 04:27.760 --> 04:30.710 And this is one of the orientations you have to make when you get 04:30.710 --> 04:31.430 it in kids, 04:31.450 --> 04:34.190 you see what amounts to acute 04:34.200 --> 04:35.060 bronchitis. 04:36.140 --> 04:38.650 You see what amounts to chronic sort of bronchial 04:38.650 --> 04:39.150 problems, 04:39.150 --> 04:40.160 like in an asthmatic, 04:40.160 --> 04:43.010 you can pick out an asthmatic and a chest film and a child just like 04:43.010 --> 04:43.240 that. 04:43.240 --> 04:45.640 Once you get used to what you're looking for, 04:45.920 --> 04:46.960 basically, 04:46.960 --> 04:48.200 you're looking at a bronchitis, 04:48.200 --> 04:50.230 we'll examine it in more detail later on, 04:50.230 --> 04:51.980 but this is the most common pattern. 04:51.980 --> 04:54.730 It's para Hyler para bronchial, 04:54.890 --> 04:56.230 at least that's what we term it. 04:56.230 --> 04:58.360 A lot of people turn it that way para heiler, 04:58.360 --> 05:00.940 because that's where you see most of the change and perry 05:00.940 --> 05:01.530 bronchial, 05:01.530 --> 05:04.000 because your inflammation is perry 05:04.000 --> 05:04.680 bronchial, 05:04.800 --> 05:07.700 this leads to thickening of the bronchi and 05:07.700 --> 05:09.000 you may see that on x rays, 05:09.010 --> 05:10.900 if you move in this direction, 05:11.840 --> 05:13.450 if you move in this direction, 05:13.610 --> 05:16.040 you will pick up interstitial 05:16.040 --> 05:18.000 patterns of Perrin, 05:18.000 --> 05:18.300 camel, 05:18.300 --> 05:21.300 infiltrate or el Villar patterns and 05:21.300 --> 05:23.280 that's about as far as I'm gonna get to that, 05:23.280 --> 05:25.480 because I am no expert in 05:25.480 --> 05:28.150 interstitial and El Villar and then 05:28.150 --> 05:29.260 guarantee you right now, 05:29.270 --> 05:31.600 I'm never going to become an expert in 05:31.600 --> 05:33.310 interstitial and El Villar, 05:33.310 --> 05:35.750 but I'm gonna put it there because some of the stuff does 05:35.750 --> 05:37.500 look interstitial, 05:37.500 --> 05:38.020 you know, 05:38.020 --> 05:40.560 and others looks L Villa and this is what I want to 05:40.740 --> 05:43.590 talk about a little later on about just exactly 05:43.590 --> 05:45.500 what's pneumonia and what isn't pneumonia. 05:45.500 --> 05:47.800 But if you go in this direction, 05:47.800 --> 05:48.660 in other words, 05:48.880 --> 05:51.550 if you start picking up garbage in the peripheral lung 05:51.550 --> 05:52.040 fields, 05:52.070 --> 05:53.960 chances are you have a sicker kid, 05:54.210 --> 05:57.040 especially if they're younger and the young infants 05:57.040 --> 05:59.120 with this kind of pattern or that kind of pattern, 05:59.130 --> 06:01.560 chances are they'll come in the hospital. 06:01.670 --> 06:02.190 Okay? 06:02.200 --> 06:03.910 And then if you go the other way, 06:03.910 --> 06:05.950 you have a very clear looking chest, 06:06.340 --> 06:07.560 usually an infant. 06:08.240 --> 06:09.530 Almost always an infant. 06:09.530 --> 06:11.120 Young infant peaks, 06:11.130 --> 06:11.740 you know, 06:11.750 --> 06:13.760 for six months and so forth. 06:13.760 --> 06:15.040 That's bronchiolitis, 06:15.270 --> 06:17.360 a big clinical picture with it. 06:17.840 --> 06:19.890 Not much to see on the x rays. 06:19.900 --> 06:22.330 And this means when you head out that way, 06:22.350 --> 06:25.170 chances are you have a sicker kid on your 06:25.170 --> 06:25.520 hands. 06:25.520 --> 06:28.450 So this is sort of the spectrum bronchiolitis all the 06:28.450 --> 06:30.050 way to parental infiltrates. 06:30.090 --> 06:31.200 But by and large, 06:31.200 --> 06:33.210 most of them are gonna fit right down here. 06:33.220 --> 06:36.040 What you're sort of regular chess co what does it look like? 06:36.050 --> 06:36.560 Well, 06:36.840 --> 06:39.710 you've heard the phrase that at an apathy is 06:39.710 --> 06:42.490 common with childhood pneumonias. 06:42.630 --> 06:45.330 I would like you to rephrase that and say at an 06:45.330 --> 06:47.630 apathy is common with childhood 06:47.750 --> 06:50.690 lower respiratory tract infections 06:50.700 --> 06:52.700 because that's what you have here. 06:52.840 --> 06:55.180 This is para hablar para bronchial. 06:55.250 --> 06:56.950 Mostly at an apathy though. 06:56.960 --> 06:59.800 Here's at an apathy here and here and a little 06:59.800 --> 07:01.990 prominence of the bronco vascular markings. 07:01.990 --> 07:04.670 If you're lucky on some of these kids you'll see the bronc 07:04.670 --> 07:07.140 ion and they look cuffed just like an 07:07.140 --> 07:07.710 assistant, 07:08.000 --> 07:09.490 just like an asthmatic. 07:09.610 --> 07:12.490 Now usually there's an element of air trapping 07:12.490 --> 07:15.410 here and because of that you have an 07:15.420 --> 07:18.300 over a rated chest in many of these Children 07:18.340 --> 07:21.340 and in a lot of ways they overlap with 07:21.350 --> 07:24.190 asthmatics and of course asthmatics pick up these viral 07:24.190 --> 07:26.370 things and that's what will bring them in. 07:26.460 --> 07:28.790 I mentioned that to you not so that you bind, 07:28.800 --> 07:31.550 bind it tightly together but so that you'll 07:31.550 --> 07:33.790 appreciate that asthmatics get these 07:33.790 --> 07:36.180 problems very frequently and they get 07:36.180 --> 07:39.040 superimposed viral lower respiratory tract 07:39.050 --> 07:41.780 infection on their chronic picture of 07:41.790 --> 07:44.480 over oration and the end result radio graphically it 07:44.480 --> 07:47.410 looks awfully similar but what you have 07:47.410 --> 07:50.120 is para hablar para bronchial prominence of the 07:50.140 --> 07:53.030 bronchial markings although it may be hard to separate them 07:53.030 --> 07:53.350 out. 07:53.560 --> 07:56.550 Certainly at an apathy which is usually bilateral like 07:56.550 --> 07:56.950 this, 07:57.940 --> 08:00.700 Here's another one with more Adan apathy 08:00.710 --> 08:03.420 and more para hablar para bronchial 08:03.430 --> 08:05.640 infiltrate with over aeration. 08:05.750 --> 08:08.640 Now you know you can start thinking well 08:08.640 --> 08:10.330 what are other things of retinopathy? 08:10.330 --> 08:13.180 This is the most common cause of bilateral 08:13.180 --> 08:16.070 heiler Adan apathy in the pediatric age group and 08:16.070 --> 08:19.070 that's just a viral lower respiratory tract infection. 08:19.070 --> 08:22.020 And in another two or three weeks all the clinics and emergency 08:22.020 --> 08:24.970 rooms will be full of kids with this kind 08:24.970 --> 08:25.550 of pattern. 08:25.940 --> 08:27.970 If the regular viruses comes through, 08:27.970 --> 08:29.420 If swine comes through, 08:29.430 --> 08:31.210 I don't know what what it looked like. 08:31.220 --> 08:34.180 But on lateral this is where you look for holler at 08:34.180 --> 08:35.040 an apathy, 08:35.200 --> 08:38.160 right where it should be right in the highland regions and 08:38.230 --> 08:41.090 if you can't make up your mind on the frontal view, 08:41.260 --> 08:44.140 look at the lateral view and see if you have a big blob of stuff over 08:44.140 --> 08:44.450 here, 08:44.640 --> 08:46.420 Then you have some retinopathy. 08:46.420 --> 08:47.650 It don't make too much difference. 08:47.650 --> 08:50.530 But that's the most common pattern 08:50.620 --> 08:53.610 of viral lower respiratory tract infection. 08:53.690 --> 08:56.260 And in a normal patient you notice you don't have 08:56.640 --> 08:59.490 that wad of inflammatory tissue there. 09:01.140 --> 09:04.030 Now in some of these patients you don't have as much at 09:04.030 --> 09:06.890 an apathy but you have more of the para holler pair, 09:06.890 --> 09:09.860 bronchial infiltrate and over aeration. 09:09.870 --> 09:12.540 Now why do you need to become familiar with this? 09:12.550 --> 09:13.560 I'll tell you why. 09:14.940 --> 09:17.570 See this kid comes in and he's coughing and 09:17.570 --> 09:20.500 hacking away and he's got a runny nose 09:20.510 --> 09:21.960 and he may be Crew P. 09:22.540 --> 09:25.440 And the clinician listens 09:25.440 --> 09:26.290 to the chest. 09:26.450 --> 09:28.070 I mean they're all kind of noises. 09:28.540 --> 09:31.190 If you still believe in Wronki and riles and all that 09:31.190 --> 09:31.560 stuff, 09:31.940 --> 09:33.720 they're better hurt all the time after. 09:33.720 --> 09:36.290 You see the chest X ray very often 09:36.670 --> 09:39.490 my biggest regret is I probably never 09:39.490 --> 09:41.810 will hear whispering back to relic. 09:41.810 --> 09:43.860 We always thought that would be nice to 09:43.860 --> 09:45.050 hear. 09:45.540 --> 09:48.400 But I think I'm gonna hear 09:48.400 --> 09:48.760 that. 09:49.140 --> 09:52.090 I don't find that 09:52.090 --> 09:54.020 I'm very good with the stethoscope anymore. 09:54.020 --> 09:56.320 But uh they'll you know, 09:56.320 --> 09:57.980 they'll get the chest X ray and so forth. 09:57.980 --> 10:00.750 But many times they listen beforehand. 10:00.960 --> 10:02.600 I mean they'll hear all kind of stuff. 10:02.610 --> 10:05.610 They'll heal decreased air entry here and 10:05.610 --> 10:08.600 decreased air entry up there and then they'll come up 10:08.610 --> 10:11.490 and I'll show you a couple of things that you and they and everybody will 10:11.490 --> 10:13.000 misinterpret for pneumonia. 10:13.080 --> 10:15.950 Everybody will be happy but they're not hearing 10:15.950 --> 10:17.140 pneumonia per se. 10:17.140 --> 10:19.320 They're hearing the effects of para holler. 10:19.320 --> 10:22.260 Pierre bronchial inflammatory disease will end 10:22.350 --> 10:23.780 as I'll show you later on, 10:23.790 --> 10:26.790 a lot of airway disturbance at Alexis's 10:26.790 --> 10:29.320 emphysema changing patterns wrong. 10:29.320 --> 10:30.790 I you get them to cough, 10:30.790 --> 10:33.440 it changes and stuff like that and you'll never 10:33.440 --> 10:35.970 correlate and that's the real sum total of this. 10:35.980 --> 10:38.900 You'll never correlate what they hear with what you 10:38.900 --> 10:39.320 see. 10:39.940 --> 10:40.800 If you really, 10:40.810 --> 10:43.670 if you if you don't appreciate that this is a widespread 10:43.670 --> 10:46.620 problem that changes and it changes because you have 10:46.630 --> 10:49.290 secretions and junk in the end of 10:49.290 --> 10:50.950 bronchial in the tubes. 10:51.440 --> 10:54.410 So when they come down and say I got decreased air entry 10:54.410 --> 10:55.090 in the right lower lobe. 10:55.090 --> 10:57.160 Don't say that's a pneumonia in the right lower lobe. 10:57.540 --> 10:59.860 All that is is para hablar para bronchial 10:59.920 --> 11:02.890 and next five minutes it can change and be 11:02.890 --> 11:04.400 up here what they're hearing, 11:04.400 --> 11:05.650 decreased air entry. 11:05.680 --> 11:07.970 Well getting back to this first pattern. 11:07.970 --> 11:10.690 This is uh less at an apathy and 11:10.700 --> 11:13.500 more uh of the paranormal appear bronchial 11:13.500 --> 11:14.160 infiltrate. 11:14.940 --> 11:17.160 Now when you get out into Perenco will infiltrate, 11:17.940 --> 11:20.770 It can look like this which you can call 11:20.770 --> 11:21.630 whatever you want. 11:21.650 --> 11:23.380 I'll just say it's paranormal. 11:23.750 --> 11:26.230 Most of the time when you have this much involvement, 11:26.230 --> 11:27.180 you have a sicker kid. 11:27.180 --> 11:28.740 Although that's not always true. 11:28.740 --> 11:31.550 You'll be surprised at how ugly the chest can 11:31.550 --> 11:33.910 look and how healthy the kid can be. 11:33.910 --> 11:34.160 I mean, 11:34.160 --> 11:36.060 so it's not a 1-1 rule. 11:36.240 --> 11:37.580 Generally speaking though, 11:37.590 --> 11:38.760 the more you have, 11:39.040 --> 11:40.950 the more you have in your parent comma, 11:41.010 --> 11:43.610 the sick of the kid and this is just going in the 11:43.610 --> 11:46.360 direction of a sicker kid and if they're younger they're 11:46.360 --> 11:46.700 sicker. 11:46.700 --> 11:47.350 Now, 11:48.030 --> 11:50.940 this is really one of the only reasons I want to bring up this kind 11:50.940 --> 11:53.590 of ratty looking interstitial 11:53.590 --> 11:54.090 pattern, 11:54.100 --> 11:56.980 does it kind of look to you like it might be congested, 11:56.980 --> 11:59.550 I mean passively congested in this 11:59.550 --> 12:02.480 particular case and maybe I have another one here. 12:02.480 --> 12:03.170 How about that one? 12:03.170 --> 12:05.190 Is a little kind of hazy now, 12:05.190 --> 12:06.700 that's what you really call, 12:06.710 --> 12:07.700 what do you call it? 12:07.700 --> 12:09.560 The Shaggy heart of prosthesis. 12:10.440 --> 12:11.770 But it isn't prosthesis. 12:12.440 --> 12:13.940 I mean I don't even know what this is. 12:13.940 --> 12:16.840 This is regular virus running through because shaggy 12:16.840 --> 12:19.410 heart just means a lot of para hablar para 12:19.410 --> 12:21.980 bronchial infiltrate with some interstitial 12:21.980 --> 12:24.000 extent extension into the parent comma. 12:24.000 --> 12:26.910 With this if you like interstitial pattern it 12:26.910 --> 12:27.730 gives you a hazy, 12:27.730 --> 12:29.560 fuzzy looking cardiac silhouette. 12:29.640 --> 12:32.560 It happens to occur in parenthesis not every time by 12:32.560 --> 12:32.880 the way, 12:32.880 --> 12:35.790 normal chest is perfectly all right with prosthesis it 12:35.790 --> 12:38.750 happens with viruses very commonly and that's the 12:38.750 --> 12:41.320 most common cause of a shaggy heart is some 12:41.330 --> 12:44.070 viral lower respiratory tract infection. 12:44.080 --> 12:46.700 Notice over oration it's over 12:46.700 --> 12:47.180 aeration, 12:47.180 --> 12:49.980 that's really the most significant thing on this film. 12:50.010 --> 12:52.840 But this is the reason that you 12:52.840 --> 12:55.630 will have asked of you by the 12:55.630 --> 12:56.290 clinician, 12:56.600 --> 12:57.590 the pediatrician, 12:58.140 --> 13:00.450 how do you tell pneumonia from congestion 13:00.940 --> 13:01.790 on the X ray? 13:01.790 --> 13:04.100 Because you could say this could be congestion. 13:04.100 --> 13:07.060 Well basically if you have a big heart 13:07.640 --> 13:10.220 and the thing looks congested then you have cardiac 13:10.220 --> 13:10.720 disease. 13:10.720 --> 13:13.650 If it looks congested and your heart's not big and you've 13:13.650 --> 13:16.060 got a lot of over aeration you've got a 13:16.070 --> 13:18.810 viral lower respiratory tract infection with 13:18.810 --> 13:21.640 this interstitial if you like pattern 13:21.780 --> 13:23.910 and the clinical presentation will be different. 13:23.920 --> 13:26.910 But on a purely run cartographic basis it is this kind 13:26.910 --> 13:29.590 of film and perhaps this kind of 13:29.590 --> 13:32.260 film that prompts want to ask the 13:32.260 --> 13:32.910 radiologist. 13:32.920 --> 13:35.110 How can you tell that this isn't 13:35.120 --> 13:37.430 congestion and that this is infiltrate. 13:37.440 --> 13:39.620 Well sometimes it's impossible. 13:39.620 --> 13:42.270 But if you notice there is no cardio Meagley here. 13:42.300 --> 13:45.270 And if you know that this could be a pattern 13:45.300 --> 13:48.120 of viral interstitial infiltration which 13:48.120 --> 13:50.780 this is what we're dealing with here then you can say, 13:50.780 --> 13:52.270 well that's the way I tell. 13:52.340 --> 13:54.270 But in some cases that's impossible. 13:54.270 --> 13:55.620 But it is this pattern, 13:55.630 --> 13:58.550 one of the parent camo patterns that leads to 13:58.550 --> 13:59.360 that question. 13:59.840 --> 14:00.550 And really, 14:00.550 --> 14:02.260 you know what the answer to that question is. 14:03.940 --> 14:06.830 He sit and read a bunch of films and then congestion looks 14:06.830 --> 14:09.780 like congestion and pneumonia looks like pneumonia, 14:10.010 --> 14:12.920 but don't say it to them because then they won't come 14:12.920 --> 14:15.500 back and they'll think you give them a smart answer. 14:15.500 --> 14:16.470 But that's really true. 14:16.470 --> 14:18.270 That's the way you do a lot of radiology. 14:18.680 --> 14:20.410 Now we're going to go the other way. 14:20.600 --> 14:22.150 Not much in the lungs, 14:23.140 --> 14:24.790 but a lot of over aeration. 14:24.790 --> 14:27.270 And this is a fairly specific clinical picture. 14:27.560 --> 14:29.680 These kids do not move air, 14:29.890 --> 14:31.060 their young infants, 14:31.060 --> 14:32.080 their young infants, 14:32.090 --> 14:35.070 often it's respiratory sensational virus that does 14:35.070 --> 14:35.300 this. 14:35.300 --> 14:36.490 But others can do it. 14:36.660 --> 14:38.930 And they have profound air trapping. 14:38.930 --> 14:40.730 You notice all of them had air trapping, 14:40.730 --> 14:43.450 but here you have profound air trapping 14:43.640 --> 14:46.540 and the old business of not moving the diaphragmatic leaflets 14:46.540 --> 14:47.250 their way flat. 14:47.250 --> 14:49.350 Look at the famous is separated off the heart. 14:49.350 --> 14:51.970 Here you have profound air trapping. 14:52.040 --> 14:54.080 But in my experience, 14:54.130 --> 14:55.430 most of the time, 14:55.660 --> 14:57.050 nothing in the chest, 14:57.540 --> 14:58.330 very little, 14:58.340 --> 15:00.590 very little in the chest in the way of 15:00.600 --> 15:01.480 infiltrates. 15:01.900 --> 15:02.190 Oh, 15:02.190 --> 15:03.770 you'll see other things in the chest. 15:03.770 --> 15:06.060 But I hope to convince you that they're not really 15:06.220 --> 15:08.020 areas of pneumonitis. 15:08.340 --> 15:11.290 This is bronchiolitis for the most part and 15:11.300 --> 15:12.860 over a distended chest. 15:13.240 --> 15:14.840 An infant who is very 15:15.080 --> 15:17.840 distressed cyanotic and it's not 15:17.840 --> 15:20.790 moving air because of profound air trapping. 15:20.940 --> 15:21.550 Okay, 15:21.790 --> 15:24.710 and I think here is the lateral view with an over distant 15:24.710 --> 15:25.590 little light film. 15:25.590 --> 15:28.280 So it doesn't bring the hyper loosen c of the 15:28.280 --> 15:29.360 lungs out very well. 15:30.440 --> 15:30.900 Okay, 15:30.900 --> 15:33.460 so those are the basic patterns we've gone from the 15:33.460 --> 15:36.360 standard para hollopeter bronco without an apathy, 15:36.390 --> 15:39.330 moved into the parent camo patterns and then moved to 15:39.330 --> 15:42.070 the bronchiolitis without a lot in the chest in the 15:42.070 --> 15:42.810 lungs rather, 15:42.830 --> 15:44.460 but a lot of over aeration. 15:44.750 --> 15:47.570 Now two things that are always over called 15:47.570 --> 15:50.540 for pneumonitis and I and I find that the first thing I have 15:50.540 --> 15:50.940 to do, 15:50.940 --> 15:53.570 like I'm gonna have to do as soon as I get back to 15:53.570 --> 15:55.550 Galveston here in another two or three weeks, 15:55.550 --> 15:58.090 these kids will be coming through the 15:58.200 --> 16:00.800 the clinics in the emergency room is teach the 16:00.800 --> 16:03.060 resident to subtract 16:03.840 --> 16:06.480 what he's learned for adult in adult. 16:06.550 --> 16:07.170 And it's true, 16:07.170 --> 16:08.250 this is a good sign. 16:08.550 --> 16:10.890 This is dr Felson silhouette sign here. 16:10.900 --> 16:12.180 If this is obliterated, 16:12.260 --> 16:14.800 you think there's something going on there now, 16:14.810 --> 16:17.600 it just so happens that this is the most 16:17.600 --> 16:20.540 common pseudo positive silhouette sign in 16:20.540 --> 16:21.300 childhood. 16:21.550 --> 16:24.300 Now it'll happen normally in a slightly Lord 16:24.300 --> 16:26.880 attic film and you may have just vessels, 16:26.880 --> 16:29.600 you may have perry bronchial disease 16:29.610 --> 16:30.710 one way or another, 16:30.710 --> 16:33.490 it's gonna rub this out well before you jump on that as 16:33.490 --> 16:34.230 pneumonia. 16:34.350 --> 16:36.080 Remember most of the time, 16:36.080 --> 16:37.840 if you think it's in the middle lobe, 16:37.850 --> 16:40.440 it ought to be in the middle lobe and there's nothing there. 16:40.450 --> 16:41.010 Okay. 16:41.110 --> 16:42.570 So if you get, 16:43.240 --> 16:43.680 I don't know, 16:43.680 --> 16:46.510 this is sort of a standard for our emergency room, 16:46.510 --> 16:47.570 Lord attic chest. 16:47.830 --> 16:48.520 When you, 16:48.520 --> 16:49.330 when you learn things, 16:49.330 --> 16:52.240 you have to learn one criteria for daytime and one for 16:52.240 --> 16:54.640 night time because nighttime chances are, 16:54.640 --> 16:56.060 you'll get a lord chest, 16:56.060 --> 16:56.440 you know, 16:56.580 --> 16:57.850 and if you look here, 16:57.850 --> 16:58.210 you'll say, 16:58.210 --> 16:59.580 well maybe there's something there, 16:59.580 --> 17:00.700 maybe there's something there, 17:00.700 --> 17:01.030 you know, 17:01.040 --> 17:03.560 be careful and especially over 17:03.560 --> 17:05.380 here if you think there's something, 17:05.380 --> 17:06.930 they're always look at the lateral, 17:06.930 --> 17:09.870 make sure there's nothing because if you 17:09.870 --> 17:12.630 think you have a silhouette sign positive like this 17:13.140 --> 17:15.960 and there is something on the 17:15.960 --> 17:18.460 lateral view in the middle of you can see it there, 17:18.520 --> 17:20.350 then you have something that's at electric, 17:20.350 --> 17:21.910 There's pneumonia and so forth. 17:21.920 --> 17:23.860 That is the most over called 17:24.340 --> 17:25.270 pneumonia, 17:25.740 --> 17:28.420 pseudo pneumonia in childhood is right along the right 17:28.420 --> 17:29.420 cardiac border. 17:29.630 --> 17:32.100 And all it is is para hablar para bronchial 17:32.100 --> 17:35.080 infiltrate with the Lord arctic chest or a poor 17:35.090 --> 17:35.880 inspiration. 17:36.030 --> 17:38.750 And the second most common place is the 17:38.750 --> 17:40.950 pulmonary arteries drifting back here, 17:41.640 --> 17:42.450 especially, 17:42.610 --> 17:45.540 I mean it must be awfully easy to hear something in the lung basis. 17:45.540 --> 17:46.850 You know how it is and so forth. 17:46.850 --> 17:49.640 And they're making noises all over the place and once your 17:49.640 --> 17:50.940 attention is focused to this, 17:51.170 --> 17:53.480 they'll pick this up and say there's the infiltrate. 17:53.750 --> 17:54.140 Well, 17:54.150 --> 17:54.870 first of all, 17:54.870 --> 17:57.470 they don't come in this linear fashion very 17:57.470 --> 17:57.960 often. 17:57.960 --> 17:58.680 And the second thing, 17:58.680 --> 18:01.620 if you know that there are vessels heading back there that tend 18:01.620 --> 18:02.430 to look like that, 18:02.430 --> 18:02.710 you'll say, 18:02.710 --> 18:02.860 well, 18:02.860 --> 18:03.410 just a minute, 18:03.410 --> 18:03.660 you know, 18:03.660 --> 18:06.520 we ought to find this on frontal view and lateral view. 18:06.680 --> 18:08.710 I think you have nothing but para holler, 18:08.960 --> 18:10.870 para bronchial infiltrate. 18:10.870 --> 18:11.130 Okay, 18:11.130 --> 18:14.130 so there are two areas that are constantly over 18:14.130 --> 18:16.740 called for a pneumonitis with viral lower 18:16.740 --> 18:18.290 respiratory tract infection. 18:18.590 --> 18:19.060 Now, 18:19.640 --> 18:21.760 a couple of complicating pictures, 18:22.030 --> 18:23.770 this is para hablar para bronchial, 18:23.770 --> 18:24.120 right, 18:24.540 --> 18:26.020 But what are we doing with this? 18:26.640 --> 18:27.610 And what's this? 18:28.020 --> 18:29.680 And what's this now? 18:29.690 --> 18:30.800 I'll guarantee you, 18:31.110 --> 18:33.770 I'll guarantee you that this will be called 18:33.780 --> 18:34.550 pneumonia. 18:35.040 --> 18:36.760 This is nothing more than what we saw. 18:36.760 --> 18:37.420 To begin with. 18:37.430 --> 18:39.270 This is para hablar para bronco. 18:39.280 --> 18:40.580 And you know what these are. 18:40.880 --> 18:43.240 These are areas of segmental add 18:43.240 --> 18:45.990 Alexis's and when they speak round in an a 18:45.990 --> 18:47.810 northerly fashion and their linear, 18:47.810 --> 18:50.770 triangular it's add Alexis's and 18:50.770 --> 18:53.220 it has nothing to do with that patient's 18:53.220 --> 18:53.790 condition. 18:54.240 --> 18:56.570 This is probably not causing him a whole lot of trouble, 18:56.570 --> 18:57.720 you know what's causing him trouble. 18:57.730 --> 19:00.550 His pair of Tyler perry bronchial infiltrates with over 19:00.550 --> 19:01.170 aeration. 19:01.540 --> 19:04.420 This is incidental due to mucus plugging or 19:04.420 --> 19:07.300 secretions plugging up the bronchi and they'll come 19:07.300 --> 19:09.430 and go so you don't want to misinterpret that. 19:09.430 --> 19:12.260 And I mention it to you because you see you'll get a 19:12.260 --> 19:14.860 chest film like this and you'll say yeah that kid must be 19:14.860 --> 19:16.570 sick and you know he's sitting there, 19:16.570 --> 19:17.490 he looks miserable, 19:17.490 --> 19:18.500 he's got a runny nose, 19:18.500 --> 19:19.500 he's got a little fever, 19:19.500 --> 19:22.450 he's coughing and hacking deathly sick though 19:23.140 --> 19:25.810 and you'll go back there and you'll say gosh you got to be real 19:25.810 --> 19:26.230 sick, 19:26.230 --> 19:26.520 you know, 19:26.520 --> 19:27.070 and so forth. 19:27.080 --> 19:27.850 This stuff. 19:29.120 --> 19:31.290 This is not a good pattern 19:31.740 --> 19:34.540 for viral lower respiratory 19:34.540 --> 19:36.020 tract consolidations. 19:36.020 --> 19:37.800 It just doesn't occur very often. 19:37.800 --> 19:38.650 It just doesn't it? 19:38.660 --> 19:39.310 Oh it will. 19:39.310 --> 19:40.860 I'm not saying it doesn't occur at all. 19:41.240 --> 19:43.690 But when you see this start saying to yourself, 19:43.690 --> 19:46.560 I wonder if these areas just represent 19:46.570 --> 19:49.270 areas of add electricity is of ad 19:49.270 --> 19:50.100 Alexis's. 19:50.640 --> 19:51.170 No. 19:52.640 --> 19:55.260 To demonstrate this on a grocer 19:55.260 --> 19:55.840 fashion. 19:55.850 --> 19:58.420 Here's a patient with a viral lower respiratory tract 19:58.420 --> 20:00.710 infection and what are we going to call this? 20:00.960 --> 20:01.250 Well, 20:01.250 --> 20:03.720 I'll show you what it is because these three slides, 20:03.720 --> 20:06.720 I'm going to show you here are taken are films that are taken 20:06.720 --> 20:09.630 in less than I think 36 hours 20:09.630 --> 20:10.560 less than that apart, 20:10.570 --> 20:12.950 maybe less than 24 hours apart. 20:13.240 --> 20:14.250 This would have been called, 20:14.250 --> 20:16.580 I'm sure a pneumonia Except, 20:16.580 --> 20:16.790 you know, 20:16.790 --> 20:18.500 less than 12 hours it's gone. 20:19.240 --> 20:21.940 That's at Alexis's you see what's creeping up over 20:21.940 --> 20:22.370 here. 20:22.380 --> 20:23.910 I mean is this another pneumonia? 20:23.920 --> 20:26.250 You see less than 36 hours, 20:26.250 --> 20:27.060 this is gone. 20:27.440 --> 20:29.400 This is a dialect is the same patient. 20:29.400 --> 20:32.200 This is a dialectics is fleeting once the right 20:32.200 --> 20:34.890 upper lobe and now the entire left lung 20:34.890 --> 20:37.720 here is a dialectic because mucus 20:37.720 --> 20:40.470 plugs are very 20:40.470 --> 20:43.430 common in viral lower respiratory tract 20:43.440 --> 20:44.120 infection. 20:44.140 --> 20:46.930 And they will they will cause you concern 20:46.940 --> 20:49.200 and they will cause you to misinterpret films. 20:49.210 --> 20:49.590 Now, 20:49.600 --> 20:50.940 here's an excellent example. 20:50.950 --> 20:53.740 What is the most significant finding in 20:53.740 --> 20:54.600 this infant? 20:54.990 --> 20:57.750 Not this hazy density over here 20:57.760 --> 20:59.170 and not this over here, 20:59.240 --> 21:00.560 but the over aeration. 21:01.140 --> 21:03.170 This infant has bronchiolitis. 21:03.390 --> 21:06.360 This is what brings the infant into the hospital. 21:06.520 --> 21:08.280 This is why he's overrated. 21:08.510 --> 21:11.470 This is not pneumonia and neither 21:11.470 --> 21:14.430 is that those are areas of Ad Alexis is now you 21:14.430 --> 21:16.550 notice this is the compressed wedge like 21:16.560 --> 21:19.020 configuration of right middle lobe add 21:19.020 --> 21:21.540 Alexis's and this was really 21:21.540 --> 21:23.110 treated as a pneumonia. 21:23.110 --> 21:24.440 The kid got antibiotics. 21:24.440 --> 21:25.670 I mean he didn't need them. 21:26.040 --> 21:27.430 He had a viral lower. 21:27.430 --> 21:28.950 I could tell you that he didn't need him. 21:29.440 --> 21:30.720 What I argue strongly. 21:30.720 --> 21:31.390 Of course not. 21:31.390 --> 21:34.260 I mean that's not my business to decide whether he 21:34.260 --> 21:35.750 needs antibiotics, 21:35.750 --> 21:37.490 but he did not need him. 21:37.500 --> 21:40.490 What he needed to be in hospital and be treated for bronchiolitis, 21:40.490 --> 21:42.160 which he was being treated for. 21:42.740 --> 21:45.660 He happened to get antibiotics incidentally for 21:45.660 --> 21:45.830 that. 21:45.830 --> 21:47.040 So it distracted them. 21:47.050 --> 21:48.120 Here's another one, 21:48.540 --> 21:51.470 add electricity here and some here with 21:51.470 --> 21:54.440 relative good aeration of the middle lobe. 21:54.450 --> 21:57.240 The big problem here is the bronchiolitis 21:57.250 --> 22:00.100 pair of holler para bronchial picture in this infant. 22:00.100 --> 22:03.100 This is extra and with one lobe down 22:03.100 --> 22:03.410 like that, 22:03.410 --> 22:05.790 it's probably causing him some extra impairment. 22:05.800 --> 22:07.730 Here's another one you see, 22:07.730 --> 22:09.610 here's a funny configuration of, 22:09.830 --> 22:11.460 of upper lobe at Alexis's, 22:11.460 --> 22:14.450 here's the minor fisher and this was most difficult to 22:14.460 --> 22:15.210 demonstrate with. 22:15.220 --> 22:16.490 This was not fluid. 22:16.490 --> 22:18.020 We thought it was fluid to begin with. 22:18.020 --> 22:20.440 It was not eventually it disappeared. 22:20.490 --> 22:22.740 But this distracted everybody. 22:22.810 --> 22:24.850 But really look at the over aeration, 22:24.860 --> 22:27.100 this infant had bronchiolitis. 22:27.100 --> 22:28.150 It's a bad film there, 22:28.150 --> 22:30.820 but it does demonstrate how this can distract Now. 22:30.820 --> 22:32.430 Look how he's overrated here. 22:32.720 --> 22:35.440 This is the rest of the right lung herniated way over here, 22:35.740 --> 22:36.780 marked air trapping, 22:36.780 --> 22:38.690 that's what was causing his difficulty. 22:38.740 --> 22:39.860 And here's another one. 22:40.540 --> 22:43.520 This patient was given antibiotics and he was just he was 22:43.520 --> 22:46.160 in the age group to have have himself covered 22:46.420 --> 22:47.520 for Hemophilus 22:48.840 --> 22:51.780 And I think he got ampicillin or something like that for 22:51.780 --> 22:52.220 this. 22:52.310 --> 22:53.100 And I would, 22:53.110 --> 22:53.700 you know, 22:53.700 --> 22:55.480 I'd have to say that looks like a pneumonia. 22:55.480 --> 22:56.260 I'm not telling you that. 22:56.260 --> 22:56.950 I'm so smart. 22:56.950 --> 22:59.200 I can tell that electricity from pneumonia. 22:59.200 --> 23:01.920 But I just want to show you that if less than 23:01.920 --> 23:04.390 24 hours later it looks this 23:04.400 --> 23:07.080 improved you get 23:07.080 --> 23:09.770 yourself a patent on that antibiotic because it is 23:09.770 --> 23:10.560 terrific. 23:11.040 --> 23:13.910 This is just a little bit of that electricity is that is 23:13.910 --> 23:15.090 slowly clearing up. 23:15.090 --> 23:17.730 You see the only point I really would like to 23:17.730 --> 23:19.150 make and this will be the last, 23:19.150 --> 23:20.300 this is a short session. 23:20.590 --> 23:23.580 The only point I'd like to make out of that is that what's 23:23.580 --> 23:26.480 going to happen and you'll never understand it unless you appreciate 23:26.480 --> 23:26.630 it. 23:26.640 --> 23:29.570 What's going to happen is that the clinician is gonna come 23:29.570 --> 23:32.200 with all kind of a skull territory findings 23:32.640 --> 23:35.580 and you're either going to match that up with him or you're not gonna 23:35.580 --> 23:38.520 match it or you may come up with a bunch of 23:38.520 --> 23:41.490 chest film findings that he can't explain. 23:41.490 --> 23:43.810 I mean they may look like the worst chest you've ever seen. 23:43.810 --> 23:45.170 He said well he's not that sick. 23:45.540 --> 23:48.330 Remember that had electricity secondary 23:48.330 --> 23:49.970 to end a bronchial obstruction, 23:49.970 --> 23:50.750 mucus plugs, 23:50.750 --> 23:52.990 usually secretions very common. 23:53.000 --> 23:54.030 Very common. 23:54.040 --> 23:56.970 And of practical consideration is this last case. 23:56.980 --> 23:58.270 Here's an infant. 23:58.640 --> 24:01.540 Now here's that Alexis ist and here's that 24:01.540 --> 24:02.510 electricity is right, 24:02.740 --> 24:05.580 there's a lower lobe and the right 24:05.580 --> 24:06.100 upper lobe. 24:06.110 --> 24:08.790 What you have to decide here is 24:08.790 --> 24:11.410 this at electricity or is this compressive that 24:11.410 --> 24:14.350 electricity is secondary to the right middle lobe 24:14.360 --> 24:15.600 being over distended. 24:15.690 --> 24:18.230 And you see when we finally finished with this 24:18.230 --> 24:18.720 patient, 24:18.730 --> 24:21.690 what it turns out is that he has right middle lobe 24:21.700 --> 24:24.460 emphysema and it is classic for right middle 24:24.460 --> 24:25.450 lobe emphysema. 24:25.910 --> 24:27.960 This is very good and it's often missed. 24:28.340 --> 24:30.710 Now is this congenital or is this 24:30.710 --> 24:31.360 acquired? 24:32.140 --> 24:33.670 You say to yourself, 24:34.040 --> 24:35.330 If this is congenital, 24:35.330 --> 24:36.950 right middle lobe emphysema, 24:37.540 --> 24:38.610 then why is this long? 24:38.610 --> 24:39.670 So what we're aerated, 24:40.340 --> 24:43.240 I mean did this kid come in because somebody found 24:43.240 --> 24:43.490 no, 24:43.490 --> 24:45.390 this kid came in because he had a runny nose, 24:45.390 --> 24:46.110 He was coughing, 24:46.110 --> 24:48.530 he had all kind of finding and you got this chest film. 24:48.530 --> 24:49.220 You know what he's got, 24:49.220 --> 24:50.770 he's got bronchiolitis if you like. 24:50.780 --> 24:53.750 Para hablar para bronchial infiltrates drifting into the 24:53.750 --> 24:54.580 bronchiolitis. 24:54.670 --> 24:56.060 That's why he was sick. 24:56.940 --> 24:59.820 Obviously this right lung is even more compromised in the 24:59.820 --> 25:02.540 left because this is an electronic that saddle ecstatic 25:02.550 --> 25:05.320 and this is right middle lobe and dr Schaffner a number of 25:05.320 --> 25:07.900 years ago had an article on aeration, 25:07.900 --> 25:10.390 disturbances in pediatric 25:10.400 --> 25:13.350 uh in the pediatric age group associated 25:13.350 --> 25:15.890 with acute respiratory tract infections. 25:15.890 --> 25:16.950 And there he said, 25:17.440 --> 25:20.170 just drag your heels and 25:20.170 --> 25:22.880 don't have this low removed 25:22.890 --> 25:24.880 because less than a week later, 25:24.890 --> 25:26.650 when everything settles down, 25:26.690 --> 25:29.330 there's nothing wrong over here that was transient, 25:29.330 --> 25:32.100 right middle lobe emphysema due to 25:32.110 --> 25:33.350 a mucus plug. 25:33.740 --> 25:36.510 So we can have the slides off and just have the 25:36.510 --> 25:39.360 lights on here for a minute and I'll summarize that for 25:39.360 --> 25:39.570 you. 25:39.670 --> 25:41.870 I'm not sure that this is gonna be the greatest 25:41.880 --> 25:44.590 impact on the treatment of Children with viral 25:44.590 --> 25:46.630 lower respiratory tract infections. 25:46.690 --> 25:49.600 But I'm hoping that it will help you understand what you're 25:49.600 --> 25:50.850 looking at the X rays. 25:51.070 --> 25:53.680 And so when you have a situation where the 25:53.690 --> 25:56.100 the pediatrician comes in and said, 25:56.240 --> 25:59.090 I hear things in the left lower lobe and you 25:59.090 --> 26:00.030 don't find him there, 26:00.030 --> 26:02.640 you will have a sensible explanation for 26:02.640 --> 26:05.170 him or her as to why 26:06.140 --> 26:09.060 he sees it or hears that she hears it 26:09.070 --> 26:11.050 and you don't see it on the X rays. 26:11.210 --> 26:14.150 And only when you understand what's going on with viral 26:14.150 --> 26:15.910 lower respiratory tract infections. 26:15.920 --> 26:18.480 Will you really render a sensible 26:18.480 --> 26:19.770 interpretation of the films? 26:19.780 --> 26:22.770 Otherwise you know what you'll do you say? 26:23.240 --> 26:24.460 Do you want a pneumonia? 26:24.840 --> 26:25.210 Yeah. 26:25.220 --> 26:25.580 Okay. 26:25.580 --> 26:26.610 You got a pneumonia? 26:26.730 --> 26:27.360 Okay. 26:27.370 --> 26:27.860 Thank you. 26:34.440 --> 26:37.050 A medical media production from WR 26:37.050 --> 26:38.270 AMC TV.