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X-Rays Michael R. Jackson. Neonatal Chest Radiography Michael R. Jackson RRT-NPS CPFT Brigham & Women’s Hospital, Boston, MA Diligent Study.

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Presentation on theme: "X-Rays Michael R. Jackson. Neonatal Chest Radiography Michael R. Jackson RRT-NPS CPFT Brigham & Women’s Hospital, Boston, MA Diligent Study."— Presentation transcript:

1 X-Rays Michael R. Jackson

2 Neonatal Chest Radiography Michael R. Jackson RRT-NPS CPFT Brigham & Women’s Hospital, Boston, MA Diligent Study

3 Neonatal Chest Radiography Michael R. Jackson RRT-NPS CPFT Brigham & Women’s Hospital, Boston, MA Diligent Study

4 Neonatal Chest Radiography Michael R. Jackson RRT-NPS CPFT Brigham & Women’s Hospital, Boston, MA Diligent Study

5 Neonatl Chest Radiography Michael R. Jackson RRT-NPS CPFT Brigham & Women’s Hospital, Boston, MA Diligent Study

6 ANATOMY Location Size & Placement Lungs Heart Thymus Vessels Chest wall

7 LUNGLUNG

8 HEARTHEART Half the lateral diameter Plumper in newborns

9 THYMUSTHYMUS

10 CHESTCHEST

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12 Method

13 Quality Improvement in Radiography in a Neonatal Intensive Care Unit Linda Loovere, MD, FRCPC, Elaine M Boyle, MB,ChB, MSc, Susan Blatz, RN, PhD, Marion Bowslaugh, M.R.T.(R), ACR, Marilyn Kereliuk, M.R.T.(R), Bosco Paes, MBBS, FRCPC E D Dougeni. Dose and image quality optimization in neonatal radiography. Br J of Radiol. 2007;80: Europen Commission. European guidelines on Quality Criteria for Diagnostic Radiographic Images in Pediatrics. EUR 1996;16261:1-71. Key factors in the optimization of paediatric X-ray practice J V Cook, MRCP, FRCR1, J C Kyriou, BSc, MSc2, A Pettet, DCR, DMU2, M C Fitzgerald, BSc, MSc2, K Shah, DCR, DMU1 and S M Pablot, FRCR1 (n=3000)

14 0/100% MD Orders 0/100% Daily plan 5/97% Eq change Q 48 hrs 20/93% Suture 7 days 36/99% FiO2 SaO2 0/100% Reason For Trach 0/100% Teaching Aids? 98/100% Manual Bed 100% 80% 60% 40% 20% 0%

15 Correct Position Detail Good Obscured Area <0.001 Area as Requested Minimal Artifacts <0.001 Minimal Rotation Centered anatomy Not wanted <0.001 * 100% 80% 60% 40% 20% 0% Shield Correct <0.001 * Soboleski D, Unnecessary irradiation to non-thoracic structures during pediatric chest radiography, Pediatr Radiol. 36, 2006;36: /9997/10039/899/9778/9777/9792/9698/5458/79 The ratio of radiation exposure to non-thoracic structures increases as the age of the patient decreases.

16 Chest Wall Tissues indicate nutrition Congenital rib & spine changes Spine & sternum intact on lateral view Diaphragm Outlines intact – positive silhouette sign Domes in normal position? Pleura Sharp costophrenic angles Pneumothorax? Fissures in normal position? Ctd…

17 Identification – Name date Technique – View appropriate & complete Patient position (upright, supine) markers placed clavicles centered AP PA Lateral, oblique, decubitus – tube angulation Ventilatory phase (insp., exp., forced exp.) R oblique Technical qualities (eg. Lordotic film) Penetration Visualize dorsal inter-vertebral disk spaces Serial consistency? Artifact (e.g. motion) Canalization of airways

18 Mediastinum – sail & wave sign In normal position? Heart large (thymus effect in kids) Aortic arch on left? Clear heart borders? Major airways normal? Hila & Pulmonary Vessels Normal hila size & position? Vessels normal caliber & definition? Lung Densities? Air bronchogram? Positive silhouette (homogeneous tissue) sign? Area behind heart normal? Kerley lines – thickened interlobular septa Spine sign Hyperaeration or atelectasis

19 Systematic Analysis 1.Bones, soft tissue, diaphragm a. Bones (configuration, breaks, notches, destruction) b. Soft tissue (amount, breast tissue, masses, SQ air, adipose) c. Diaphragm (position, shape, angles, subdiaphragmatic abnormalities?) 2. 4 PS a.Plastic b.Pump c.Pleura d.Parenchyma

20 Illusions Skin folds Rotation from desired posture

21 HELIUM_NEON LIGHT

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23 Features of Digital Image Display American College of Radiology Standards for Teleradiology 2006 Bright high resolution (1023 lines/60Hz) monitor Gray scales maximized –6 bits = 64 gray 8 bits = 256 gray 12 bits = 4,096 gray low reflections & controlled ambient light Accurate choice of patient, demographics & image sequence Adjust window, zoom, pan & rotation – maintain viewer orientation Assess linear measurements & Hounsfield units for CT Image compression ration, cropping, Matrix size & Bit depth display

24 Contrast Brightness

25 msrcol.org 1,023 lines/60 Hz monitor Digital Reduced rad exposure Edge enhancement Magnification Windowing capable

26 ETTUBEETTUBE

27 Leone TA, Rich W, Finer NN, Neonatal Intubation Success of Pediatric Trainees, J Pediatr 2005;146: Preferred number of experiences to achieve competency is 45. Opportunities have diminished since we stopped intubating active meconium babies. Rates of Intubation Success

28 Depth of insertion Weight (kg)(cm from upper lip) * Predicted Tube Location in Trachea Tip-to-lip measurement © 2000 AAP/AHA

29 The fulcrum for movement of this lever arm is the upper cervical spine. Fulcrum for movement of this lever arm is the upper cervical spine Vocal Cord Vocal Cord Epiglottis Thy. Cartilage Epiglottis FLEXION NEUTRAL EXTENSION Rost, J R, Effect of neck position on endotracheal tube location in low birth weight infants, Pediatric Pulmonology Volume 27, Issue 3, Pages Published Online: 21 May 1999

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32 90 degree airway entrance Blue line of ETT superior

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37 RDS TTN Pneumonia Pulm Edema Atelectasis Severe BPD PIE Grainy Streaky Patchy Fluffy Hazy Bubbly Dotty

38 SDPIEBPD ratlung

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46 23 YEAR OLD MALE IN RESPIRATORY DISTRESS WITH LATE SEQUELAE OF BPD OF INFANCY Jeannine Busick M.S. RRT., Steve Morrison RRT-NPS RPFT, Truman Read RRT, Michael R. Jackson RRT-NPS CPFT, Paul F. Nuccio, RRT, FAARC. Department of Respiratory Care, Brigham and Women’s Hospital, Boston, Massachusetts. Introduction: Late pulmonary sequelae of bronchopulmonary dysplasia (BPD) may underlie disease processes that we care for in adulthood. Case Summary: This 23-year-old male, a former NICU patient from 1983, re-presented and was admitted to our medical ICU with significant shortness of breath. Initially, he was managed on BIPAP; however, worsening respiratory status, specifically severe hypoxemia, required intubation and mechanical ventilation. Despite antibiotics, systemic steroids, anticoagulation, diuretics, and nitirc oxide, his oxygenation Discussion: Late pulmonary sequelae of BPD in adolescents and young adults may include airway obstruction, hyper-reactivity, and hyperinflation. In this case the patient has evidence of a significant obstructive airway component, as evidenced by pulmonary function testing prior to this most recent admission and emphysematous changes evident from CT. Additionally, he has a history of hyper-reactive airways. Although, no single element of this patient’s medical history can be demonstrated to stem directly from his BPD in infancy, the conglomeration of diagnoses and repeated lung injuries are illustrative of a potential course of pulmonary sequelae following BPD of infancy. remained mechanically ventilated for 59 days. On day 28 he developed sepsis and perihilar infiltrates. Set pressures never exceeded 23 cm H2O with sustained PEEP of 4 cm H2O. The patient was discharged after 191 days on 1/8 lpm O2 and Alupent. Childhood health history includes: BPD, six pneumonias during early childhood, severe persistent asthma, obesity, and ADD. Environmental history includes: 16 years of second hand smoke exposure, smoking ¼ pack year, work installing sheet metal ductwork and insulation. status remained tenuous and ETCO2 remained elevated. Tests for alpha-1-antitrypsin and lung cultures were negative. Radiographic chest imagery revealed diffuse scattered interstitial markings manifest on CT. Lung biopsy findings were consistent with known sequelae and remodeling of bronchopulmonary dysplasia. PMH: This patient was born at 28 weeks gestation weighing 650 g. He had mild respiratory distress syndrome and was. extubated on day 2; on day 10 he was re-intubated for apnea and

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