X-rays have become a very important tool in managing newborns with lung disease. This is true because of their ability to give view of the effect of various disease processes on the internal body structures. When interpreting x-rays, keep in mind that the disease itself is not seen rather, the radiograph is a visual confirmation of the presence or absence of a disease process. The physical alterations resulting from a disease are seen on the chest film.
It can usually be expected that a chest film of a newborn or pediatric patient is obtained as an anterior posterior view (AP) rather than a posterior anterior view (PA). It is a best practice for practitioners to always confirm the position of film before evaluating structure changes, because each view reveals internal structures differently and can cause a misdiagnosis.
Evaluation of the Film
- Check the patient identification stamp, date and time, for accurate assessment of the patientâ€™s current problems, it is important to use the most recent film for disease process comparison.
- You should next orient the film so that the patientâ€™s right side is on your left. This is often marked by an x-ray technician before the procedure, but always check the anatomy yourself. Look for landmarks such as heart monitor leads placement, and chest tube sites. The heart should be centered but slightly to the left. If a stomach bubble is present, it should be on your right as you look at the film.
- Check the position of the patient on the film. The patient should be relatively straight on the film, and not rotated to either side. Rotation will alter the heart size and cover areas you may need to see. The clavicles should be examined for symmetry. The peripheral ribs should be turned downward, and not flat or turning upward. A rotated chest film may give you the impression of an enlarged heart or shifted trachea.
Determination of Inspiration and Expiration
- The next step is to determine if the film was exposed during inspiration or expiration. On an inspiratory film, the diaphragm should be at or below the 9th rib. Overdistention or hyperinflation of the lungs will show the diaphragm near the or below the 10th rib. A radiograph taken during expiration will show the diaphragm at the 6th or 7th rib.
Examination of the Diaphragm
- Examine the shape of the diaphragm. It should be dome-shaped on both sides, with the right diaphragm usually being one rib higher than the left. This is caused by the liver pushing the diaphragm upward. Air trapping and hyperaeration will cause the diaphragms to become flat.
Examination of the Abdomen
- The presence of a stomach bubble help to orient the film. A large air bubble in the stomach and excessive air in the bowel are indicative of gastric distention. Excessive distention in the stomach can decrease the ventilation of the infant by pressing upward against the diaphragm.
Examination of the Cardiac Silhouette
- The cardiac silhouette is extremely variable in size and should be less than 60% of the thoracic width.
Examination of the Hilum
- The hilum is the area where the trachea splits and enters both lungs. Of special concern in this area is the amount of vascularity that is visible.
Examination of the Respiratory Tract
- Trachea â€“ Visualize the larynx and follow it to the carina. The trachea often deviates slightly to the right, but should be located near the center of the spinal column. A trachea that is deviated significantly may indicate the presence of atelectasis or a pneumothorax.
- Endotracheal Tube â€“ If the patient is intubated, check the location of the tip of the endotracheal tube. The tip of the tube should be halfway between the carina and the clavicles.
- Mainstem bronchus â€“ Now follow the trachea past the carina to the mainstem bronchi. The right bronchus may appear as an extension of the trachea, whereas the left angles off at almost a 90-degree angle.
- Lung fields â€“ Examine the lung fields. Generally speaking, the lung tissue should be expanded with air, if taken during inspiration, and thus appear dark on the film. Lungs that appear whiter are either under expanded or are involved in some type of disease process that is making them atelectatic.
Respiratory Distress Syndrome
Respiratory Distress Syndrome (RDS), also called hyaline membrane disease (HMD), is the primary cause of respiratory disorders in the neonate. The etiology of RDS is well understood. It is known that the underlying etiology in the neonate is a deficiency of surfactant production. Although many factors contribute to this deficiency, the main contributor is prematurity of the pulmonary system.
The clinical manifestations of RDS usually begin at birth, or shortly thereafter. The patient has a respiratory rate above 60 breaths per minute, indicating some degree of respiratory difficulty. The patient then begins grunting, so named because of the sound created by the infant exhaling against a partially closed glottis. This obstruction of exhalation causes a back pressure in the alveoli, resulting in an increased FRC. This is an attempt by the neonate to combat the effects of volume loss in the stiffening lungs. It can be thought of as a natural positive end expiratory pressure (PEEP) in the airways.
The neonate with RDS will also begin to show chest retractions as the disease worsens. With ever stiffening lungs, the infant must generate greater and greater negative pressures to open the alveoli. The increased negative thoracic pressure causes the spaces between the ribs and at the top and bottom of the thoracic cage to be pulled inward. This inward movement of the skin is called a retraction. Another sign of worsening distress is the flaring of the external nares of the nose. This is an attempt by the neonate to get more gas into the lungs by widening the airway passage. In most cases, the symptoms of RDS gradually worsen for the first 48 to 72 hours followed by stabilization and a slow recovery period. Stabilization of the disease is often associated with the onset of diuresis.
Radiographic findings in RDS are quite characteristic. Fine reticulogranular patterns, alveoli with increased tissue and water densities surrounding small areas of aerated alveoli, are found in both lung fields. This is commonly called a ground glass or a frosted glass appearance. Both lungs appear as opaque white density, reflecting the lack of lung aeration and expansion.
The ideal treatment for RDS would be to prevent it from occurring. The administration of glucocorticoids to the mother, if done at least two days before delivery, has been shown to promote fetal lung and surfactant development. No discussion of treating RDS would be complete without examining the use of surfactant replacement therapy, we will learn more about surfactant during the course.
For this assignment, write a paper of at least 500 words that discuss:
1. The four steps to stabilizing a neonatal patient. Include how to recognize and treat signs of respiratory distress syndrome. Also, include the equipment used in the treatment of an infant with respiratory distress syndrome.
2. Explain the characteristics of an infant with an Apgar score of 8, and what actions would you take?
3. Explain the characteristics of an infant with an Apgar score of 4, and what actions would you take?
Provide your answer in 500 words or more. You must submit the assignment in IWG format including two peer reviewed references.