COMMON PATHOLOGICAL FINDINGS IN PEDIATRICS CHEST RADIOGRAPHS

The aim of this research project is to define among all the pediatrics chest disorders which of them is a common finding in pediatrics chest radiographs at University of Nigeria Teaching Hospital, (UNTH) Ituku-ozalla,Enugu state.

     This research is a retrospective study which documented the possible chest diseases,common chest pathology of the pediatrics and gender distribution of chest diseases from pediatrics chest radiographs.

The study investigated all cases of pediatrics chest examination done from January 2011 to December 2012.A total of 102 patients were studied retrospectively.The result showed that out of 102 radiographs studied,82 radiographs were presented with pathologies while 20 radiographs were of no pathology.Out of 82 radiographs with pathologies male has frequency [n=33,42.24%] while female has frequency of [n=49,59.75%].

It was discovered that pneumonia [n=39,38,24%] has the highest frequency.Bronchopneumonia [n=25,64%] of all pneumonia disorders is more prevalent.

TABLE 1.Age distribution of pediatrics chest cases………………………………38

TABLE.2.Relative distribution of gender age groups 

of pediatrics chest case………………………………………………………………39

TABLE.3.Relative distribution of gender age groups

 with pathologic findings and without pathologic findings on radiographs……….40.

TABLE .4.Pediatrics chest radiographic findings……………………………………41.

TABLE .5.Relative prevalence of all types of pneumonia 

in pediatrics chest radiographs………………………………………………………42.

Title page……………………………………………………………………………......i

Approval page…………………………………………………………………………ii

Certification………………………………………………………………………………..iii

Dedication……………………………………………………………………………iv

Acknowledgement……………………………………………………………………v

List of tables…………………………………………………………………………vi.

Table of contents……………………………………………………………………vii

Abstract………………………………………………………………………………viii

CHAPTER ONE:Introduction

1.1. Statement of problem…………………………………………………………....7

1.2. General objective………………………………………………………………..8

1.3. Specific objective………………………………………………………………..8

1.4. Significance of study…………………………………………………………….8

1.5. Scope of the study………………………………………………………………….9

1.6. Literature review…………………………………………………………………..9

1.6.1. Common findings and diagnosis in plain chest radiograph…………………….16

2.0 CHAPTER TWO: Theoretical Background

2.1. Radiography………………………………………………………………………27

2.1.1. Radiographs………………………………………………………………….…27

2.1.2. Image production in radiography……………………………………………….28

2.1.3. Chest radiography……………………………………………………………….29

2.1.3.1. Common pathologies identified in chest radiographs………………………….29

2.1.3.2. Regions where chest x-rays may identify problems……………………………30

2.1.5. Additional views and other associated findings…………………………………...33

2.1.6. Limitations of  chest radiography………………………………………………….33

3.0 CHAPTER THREE:RESEARCH METHODOLOGY

3.1 Research design……………………………………………………………………….35

3.2 Area of study………………………………………………………………………….35

3.3 Target population……………………………………………………………………..35

3.4 Inclusion criteria………………………………………………………………………35

3.5 Exclusion criteria………………………………………………………………………36

3.6 Sampling procedure……………………………………………………………………36

3.7 Samples Size…………………………………………………………………………..36

3.8 Procedure for data collection………………………………………………………….36

3.9 Method of data analysis……………………………………………………………….37

4.0 CHAPTER FOUR: PRESENTATION OF TABLES

Table1: Age Distribution of Pediatric Chest Cases……………………………………….38

Table 2: Relative Distribution of Gender Age Group of Pediatric Chest Disorders……..39

Table 3: Relative Distribution of Gender Age Groups with Pathologic Findings and without Pathologic Finding on Radiographs………………………………………………………..40

Table 4: Pediatric Chest Radiographic Findings……………………………………………41

Table 5: Prevalence of all types of Pneumonia in Pediatric Chest………………………….42.

5.0 CHAPTER FIVE: DISCUSSION, CONCLUSION AND RECOMMENDATION

5.1 Discussion………………………………………………………………………………..43

5.2 Conclusion……………………………………………………………………………….44

5.3 Recommendation…………………………………………………………………………45

5.5 Difficulties………………………………………………………………………………..45

5.6 Areas of further study……………………………………………………………………46

5.7 Reference………………………………………………………………………………….47

Chest radiography of pediatrics is becoming a common radiographic examination being undertaken for intensive pediatrics care in various x-ray departments these days. In Nigeria, from time people begin to wonder the likely factors that are responsible for this. Radiography has an important role in the investigation of pediatrics chest, mainly in the diagnosis of thoracic pathologies and other conditions that are indirectly affecting the thoracic structures. Chest radiography is the primary imaging study to confirm the diagnosis of pneumonia using a well-centered, appropriately, penetrated,

anterior posterior chest radiography in the pediatrics. Although, other views may be warranted to clarify anatomic relationships and air-fluid levels1. Chest radiography in determination of pneumonia needs the radiographers and the radiologists to pay attention to the following: Costophrenic angles, pleural spaces and surfaces, diaphragmatic margins, cardiothymic silhouette, pulmonary vasculature, right major fissures, air bronchograms overlying the cardiac shadow, lung expansion and patterns of aeration1.The use of ionizing radiation in the diagnosis and treatment of the pediatrics pathologies has been questioned over the years due to the possible occurrence of radiation-induced diseases in the pediatrics receiving treatment and undergoing radio-investigation.

An understanding of the infant chest radiography requires a review of how embryology, anatomy, physiology, pathology, immunology and the physics of fluid mechanics influence its appearance, this knowledge is critical in the interpretation of the infant chest radiograph2. Going with the embryological and anatomical descriptions of infant chest, it is believed that all  generations of airways have developed by the time the fetus reaches 16th week of gestational age2. There are about 22 generation of airways depending on how the last generation is counted and where the count is performed2. Near the lungs hila, there may be as few as 10 generations of airway before the gas-exchange unite-the respiratory bronchioles and alveolar sac are reached in the lungs periphery. There may be as many as 25 generations of airways before the gas-exchange units are reached2.. As the child grows and becomes an adult the airways grow in length and diameter but not in number.2. The alveoli, the gas-exchange units, develop after the airways. They start proliferating about 29weeks of gestational age. By the 40th week of gestation, there are approximately 20million alveoli in the new born lung.Although the precise number is debated. The mature lungs contain approximately 300 million alveoli. That number is reached at about 8years of age. The alveoli then increases in size, and then the lining gets progressively thinner. 

Chest radiography often is a necessary preliminary study and is the most commonly used requested study for a child complaining of chest pain. Its availability, low cost, and lower radiation exposure compared with all other imaging modalities makes it a preliminary procedure of choice for thoracic pathologies and other conditions that affect indirectly the chest. Chest radiography is 42-72% accurate in predicting the etiology of a case of

pneumonia. In a study of 168 children with pneumonia, 2 radiologists who independently evaluated all chest radiographs were unable to distinguish whether the agent involved was bacterial, viral, or unidentified. Chest radiography is indicated in an infant or toddler who present with fever and any of the following conditions. Tachypnea, nasal flaring, retractions, grunting, rales, decreased breath sounds, and respiratory distress; while in older children and adolescents, the diagnosis of pneumonia is often based on clinical presentation.  Chest radiography is a commonly requested examination for both in-patients and out-patients that have varieties of intra and extra-thoracic complaints. The intra-thoracic complaint can include pathologies affecting the lungs and their accessory structures, meditational pathologies, cardiopathies, and so many other conditions which are predominantly associated with adults.

Immunopathologically, growing children are exposed to many infectious organisms and need to develop immunity to them. The average adult inhales more than 9000liter of air per day, the infant, much less. A multitude of organisms enter the airways along with this inspired air. The organisms that infect the respiratory track in infancy are usually viral. The most severe diseases in the lower respiratory track are caused by Para influenza viruses and the respiratory syncytial virus. These are also among the most common organisms to infect the infant respiratory system. Adult has some immunity to most of these organisms because they were exposed to them as children and developed immunity against them. Although adults may be infected and transmit these viruses to others they usually become no more than mildly ill. Infants have not yet developed immunity against so many diseases. Thoracic diseases are common chemical problems in children and often require the use of imaging in order to diagnose and aid in the treatment of the problem3.

In so many related studies such as Radiologia brasilera1; normal findings on chest x-rays of neonates. The purpose of this study is to describe the normal findings of the newborn chest radiography. It is deduced from this study that a change in fetal circulation contributes to an increase in cardiac size, skin folds and variation in thymic silhouette may may simulate disease.

In another related study performed by Julie Ryu, MD2

How many chest x-rays are enough? When should order. The study was aimed at assessing the number of chest x-rays that are enough and when to order for imaging studies and  which studies should be done? Every test has its risks as well as its benefit. I would only order a test if the result will change my clinical decision or management, and the same is true of x-ray studies. It is usually more common to order imaging studies during initial evaluation of a patient which chronic respiratory symptoms. 

Davies3, H. et al diagnosis of the lower respiratory infections in young children. Forty chest radiographs of infants younger than 6 age admitted with lower respiratory track infection to a tertiary care pediatric hospital were independently reviewed on two separate occasions by three pediatric radiologists blinded to the patient’s clinical diagnoses.

In his conclusions, he wrote that clinicians basing the diagnosis of lower respiratory infections in young infants on radiographic diagnosis should be aware that there is variation in intra observer and inter observer agreement among radiologists on the radiographic features used for diagnosis. There is also variation in how specific radiologic features are used in interpreting the radiogram. However, the cardinal finding of consolidation for the diagnosis of the pneumonia appears to be highly reliable.

Steven M. Salbot et.al4 in his prospective study of the pediatric chest pain, in this study all children who were admitted to the emergency department with chest pain were evaluated prospectively. Patients with ill-defined chest pain had ECGs and echocardiograms performed. A total of 407 children were evaluated the most common cause of the pain were idiopathic (21% 1 and musculoskeletal 15%) cardiac problems were found in 4% chest pain was acute (of 48hours’ duration) in 43% and chronic (of 6 months’ duration) in 7% pain caused 30% of children to stay out of school and 31% to awaken from sleep. Chest wall tenderness was the most common abnormality. ECGs were obtained in 47%; results of 31/197 ECGs abnormality were related to the diagnosis Echocardiogram were obtained in 34%, result of 17/139 were abnormal (12/15, showed mitral value prolapsed. Young children older than 12years of age are more likely to have psychogenic pain. The description and location of the pain and the patient’s sex are not related to the diagnosis. Non-organic disease is related to a family history of heart disease or chest pain or having chronic pain organic disease is related to pain of acute onset, abnormal physical examination results, pain that awakens the child from sleep, and the presence of fever. Laboratory test are rarely helpful in evaluating children with chest pain. Chest pain children are usually benign. Psychogenic pain and idiopathic pain are less common than previously believed.

D. Demetrius Zukin5 et al. correlation of pulmonary signs and symptoms with chest radiographs in the pediatrics age group. In this study one hundred and five pediatric emergency department patients were studied finding on the physical examination were predictive of abnormalities seen on chest radiography.Pulmonary alveolar proteins is congenital lymph angiectasia, and idiopathic pulmonary hemosiderosis all healthy.

In his conclusion, he stated that a high proportion of pediatric interstitial lung diseases can be diagnosed on thin-section CT then on chest radiograph.