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228
a
M. Köstenberger et al.
11.9.7 Cardiac Tumours
Primary tumours of heart—rare in infants and children, most of them benign:
• Rhabdomyoma: homogenous, echo-bright mass(es) in both ventricles and highly
associated with tuberous sclerosis.
• Fibroma: predominantly single intramuscular tumour of LV.
• Myxoma: globular and heterogenous tumours, usually attached to atrial septum.
When tumour found:
• Exact evaluation of entire heart—to rule out multiple lesions.
• Evaluation of haemodynamic consequences (e.g. congestive heart failure or
valve obstruction).
• Evaluate for systemic condition; sometimes additional imaging needed.
11.10 Modern Approaches, Peri-interventional
andPostoperatrive Applications
There are quite a few applications, e.g.,
• Pericardial effusion with haemodynamic relevance with requirement of ultra-
sound guided puncture of the PE in the ICU (see Fig.11.22).
Most common operative procedure in paediatric cardiology ASD closure (direct
suture or patch repair):
• Perioperative TEE in the operation room: look for cardiac function, PE, ow pat-
terns at TR level, residual shunt at interatrial structures.
b
Fig. 11.22 (a) Pericardial effusion with tamponade—apical four-chamber view. Signicant com-
pression of heart by anechoic surrounding pericardial uid (—). LV left ventricle, LA left atrium,
RV right ventricle, RA right atrium. (b) Subcostal view (favoured in perioperative setting) shows
massive circular pericardial effusion (PE) with haemodynamic compromise. (c) Impressive
improvement after ultrasound guided puncture; minimal residual PE seen (arrows)
c
11 Basics ofPaediatric Echocardiography
• Postoperative TTE in the ICU: look for LV and RV systolic function, PE, resid-
ual shunt at interatrial structures.
229
11.11 Complementing Investigations
11.11.1 Cardiac Catheterisation andAngiography
Diagnostic cardiac catheterisation with angiography may be indicated if:
• Exact haemodynamic evaluation essential (shunt volume, pulmonary artery pres-
sure/pulmonary vascular resistance, etc.).
• Echocardiographic assessment of morphology (e.g. lung perfusion, coronary
anatomy) not satisfying.
• In most cases of congenital heart disease, preoperative echocardiography suf-
cient—diagnostic catheterisation usually not needed.
• Today role has changed: approximately 50% of cardiac catheterisations in chil-
dren are therapeutic interventional procedures.
11.11.2 Cardiac MRI andCT
• Have become more important during the last two decades.
• Can provide additional morphologic and functional information.
• Can provide more detailed topographic relation to other intrathoracic structures.
• 3D reconstruction helpful in preoperative evaluation of complex anatomy.
• Carefully select indications, particularly for CT (radiation burden, challenging
anatomic size and heart rate, etc.).
11.12 When toDo What
11.12.1 Imaging inTypical Clinical Scenarios
11.12.1.1 Typical Orientating Examination
Particularly in newborns and infants in emergency situation or in (N)ICU.
For example, echocardiographic differential diagnosis of a cyanotic newborn,
echocardiographic evaluation of critically ill child.
• Most relevant malformations easily depictable.
• Always include apical four-chamber view and view at IVC entrance to RA in
every US of upper abdomen.
• Include transabdominal/apical heart view during eFAST or eRUSH in ER
(e.g. pericardial effusion, poor contractility) (see Chap. 5).
230
M. Köstenberger et al.
• Typical course of basic orienting investigation and minimal requirements for ori-
enting assessment.
– Start with apical and/or subcostal four-chamber view.
– Continue through parasternal long and short axis.
– End with suprasternal view of the aorta.
11.12.1.2 Typical Clinical Queries
• Child with murmur: clinical examination and echocardiography.
• Child with cyanosis: clinical examination and echocardiography.
• Child with syncope: clinical examination, exact history; echocardiography only
necessary in case of pathologic ECG or murmur.
• Child with chest/heart pain and sensations: clinical examination, ECG and
echocardiography.
Note
Cardiac reasons for chest pain rare in children.
11.12.2 Trauma andEmergency
In chest trauma—orientating four-chamber view often sufcient:
• Assess global ventricular function.
• Rule out pericardial effusion.
• Severe trauma = indication for ce-CT(A).
Ultrasound oftheChest
12
MichaelRiccabona
12.1 Requisites
12.1.1 Transducers
Chest Wall
High-resolution linear arrays, plenty of US gel (stand-off pad sometimes helpful).
Deeper Structures
Sector and curved linear arrays—small surface helpful to properly insonate through
intercostal space for sufcient penetration into deeper structures.
Frequency depends on age and depth of targeted structure.
12.1.2 Positioning
Depends on area of interest: prone, supine, decubitus.
• For jugular access extend head and neck, potentially put pillow below shoulders.
Note For standardised assessment and measurement of pleural effusions stan-
dardised upright positioning (sitting) helpful—also improves comparability with
chest radiographs.
M. Riccabona (*)
Department of Radiology, Division of Pediatric Radiology, Medical University Graz
and University Hospital Graz, Graz, Austria
e-mail: michael.riccabona@medunigraz.at
© Springer Nature Switzerland AG 2020
M. Riccabona (ed.), Pediatric Ultrasound,
https://doi.org/10.1007/978-3-030-47910-7_12
231
232
M. Riccabona
12.1.3 Indications
• Pleural and pericardial effusions.
• Equivocal opacities on plain lm
– e.g. tumour, malformation, cyst, pneumonia and effusion.
• Diaphragm and diaphragmatic motion.
• Pathology of chest wall (soft tissue, cartilage, breasts, etc.).
• Assessment of mediastinal structures
– Particularly thymus, central vessels.
• Echocardiography addressed separately (see respective chapter).
12.1.4 How toPerform Chest US
For large vessels: typical cardiologic planes:
• Jugular, parasternal and intercostal access.
For other chest areas:
• Upper abdomen with transdiaphragmatic access through liver and spleen,
• Subxiphoid access,
• Jugular access,
• Intercostal access.
Note In neonates and infants, ossication of chest wall is not completed—access
achievable through cartilaginous parts of sternum and ribs.
Documentation: Basic minimum documentation of all scanned areas is advisable, even if normal. If lesion or pathology, image in longitudinal and axial sections:
• Additional sections should be obtained if necessary and with pathology.
• Try to document all relevant structures with some neighbouring reference
structure.
• Proper labelling, potentially using pictograms, is extremely helpful.
Even if only chest US is requested, orienting overview of cardiac structures
Note
or potential effusion (and upper abdominal “sonoscope”—brief survey of particularly upper abdomen) is helpful. Detailed course of investigation depends on individual query.
For the new “lung ultrasound” (LUS) technique based on assessing artefacts to
then draw conclusion on an underlying lung condition a different approach is used:
mapping entire chest from anterior and posterior, sliding transducer up and down
into all intercostal spaces in axial/transverse orientation to observe lung surface and
detect any pathology, particularly pneumothorax, consolidation or uid—complemented by coronal or sagittal views (Fig.12.1).
bc
12 Ultrasound oftheChest
233
a
Fig. 12.1 Schematic drawing for LUS transducer position during standardised course of examination; (a) ventral, (b) dorsal, (c) in neonates (transvers from suprasternal over transsternal to
xiphoid, and sagittal/coronal from axillary line to parasternal on both sides)
For this (as well as for standardised assessment of pleural effusions) an upright
sitting position is helpful in older children—to be able to easily reach all spaces;
in newborn the posterior parts are usually skipped (as all for this age group relevant questions in the NICU can usually be sufciently seen and assessed from
ventral in the laying baby, and posterior parts are prone to atelectasis because of
the yet immature lung histology which may cause additional confusion).
In (e)FAST or (e)RUSH the transducer often is positioned not axially as described
above, but sagittally in a paramedian section of the upper chest (see respective
chapter).
Note As in a well aerated lung all sound is reected at the lung surface, a high rela-
tive sound energy is deposited at this point of total reection. Thus US related side
effects may occur causing, e.g. rupture of small vessels—therefore only use the
lowest diagnostically necessary output gain to avoid harm, set focus properly, avoid
harmonic imaging and observe MI/TI.
12.2 Normal Findings
12.2.1 Chest Wall
Below typical multilayer structures of skin and subcutaneous tissue, large chest and
intercostal muscles seen.
Ribs seen as echogenic surfaces with shadowing in ossied parts, hypoechoic in
cartilaginous aspects:
• Continuity of ribs/sternum easy to follow, subtle alterations depictable—
helpful for diagnosis of fractures/ssures,—to be differentiated from physi-
ologic gaps such as additional ossication centres, syndesmoses or
synchondroses.
234
Below chest wall:
• Echogenic surface—reverberation echoes caused by air-lled lungs.
• In more medial position—cardiac and mediastinal structures.
M. Riccabona
12.2.2 Breast
Breast appearance varies with age, depending on hormonal status:
• Neonatally breast tissue seen, may appear large, eventually regresses.
• In (pre)puberty breast tissue increases, typical change in echotexture.
• Eventually typical adult breast US features.
Note Some minimal breast tissue even in male neonates physiologic; thereafter, no
breast tissue should be seen at any stage of development in boys.
12.2.3 Pleural Space
Usually pleural space not accessible by US.
Visualisation of both pleural sheets only achieved by high-resolution linear
arrays if some effusion present.
Note The two pleural surfaces move independently from each other.
12.2.4 Diaphragm
Seen as un-/hypoechoic muscular structure—particularly at origin and insertion.
Majority of diaphragm usually only indirectly visible—by aerated lung surface:
• Movement/shape of diaphragm assessed using this pseudosurface.
• With pleural effusion, even smaller parts of diaphragm visible.
• Documentation of diaphragmatic motion: M-mode, video clip (Fig.12.2).
12.2.5 Lung
Normal lung is aerated and only seen indirectly by surface (echogenic structure with
reverberation echoes that changes with respiration).
• Parts beyond aerated lung surface not visualised.
12 Ultrasound oftheChest
Fig. 12.2 Diaphragm and diaphragmatic motion: (a) Normal diaphragmatic respiratory motion
on M-mode—the echogenic border represents air-lled base of lung, not diaphragm itself, the
inhomogeneous spots are minimal peripheral atelectatic areas. (b) No diaphragmatic motion, conspicuously documented by M-mode displaying a straight line, after surgery and postoperative
pleural effusion in diaphragmatic palsy. (c) M-mode under ventilation therapy: M-mode trace
reects effect of mechanical ventilation and not patients’ own respiratory motion
235
Note As soon as US can penetrate lung tissue, some pathology must be expected
(e.g. atelectasis, consolidation, effusion, other non-aerated space-occupying
process).
Respiratory motion of lung surface used (“sliding sign”) to differentiate normal
aerated lung from pneumothorax, where no motion of reecting surface/air space
can be noted.
• Also seen in air-lled bronchogenic cysts and severe obstructive hyperination
(“air trapping”).
• Documentation by video clip or M-mode.
Basal parts of lungs best seen by transabdominal access:
• Should be part of any standard abdominal US (as effusion, atelectasis and pneu-
monia may cause abdominal complains, particularly in young children).
The physiologic artefact when US meets surface (pleura) of well aerated lung
causes the “A-lines” (reverberation artefact) and is used in more modern approach
to lung US; some inhomogeneous peripheral ventilation however is often present in
particularly young children who are prone to have some mild dystelectasis due to
the still immature and different microscopic lung architecture that favours collapse
of small peripheral lung/airways/alveoli and may cause some “B-lines” (“comet
tail”, “ring down”—see respective dedicated entry and Table12.1) which—if only
a few—are still considered normal.
Note
Particularly with the new LUS application there is a strong dependency on
device and settings; these artefacts may look quite different or be even obscured
when using harmonic imaging or strong compounding.
236
M. Riccabona
Table 12.1 Table of common signs on LUS—with background explanation and some image
examples in alphabetical order
A-line Horizontal lines,
move with
respiration
Normal nding; the
m-mode trace
demonstrates
respiratory motion by
undulating lines
Airbronchogram
=
Sonopneumobronchogram
B-line Vertical lines,
Barcode sign = stratosphere sign M-mode in
Line-like series of
echogenic dots,
may undulate with
respiration,
represent residual
air bubbles in
otherwise
insufcient
ventilated bronchus
arising from pleural
line, spread
downwards,
well- dened, reach
edge of image,
erase A-lines, move
with breathing
Coalescent B-lines = white lung, e.g. in
Typical for pneumonia,
may be in dystelectasis
In various conditions,
some may be normal,
otherwise “alveolointerstitial syndrome”
neonatal (I)RDS
pneumothorax
indicating lack of
motion by straight
A-lines without
undulating motion
Bat sign On longitudinal
lung section, best
seen with (micro-)
curved array—
caused by rib
shadow
Normal nding
12 Ultrasound oftheChest
Table 12.1 (continued)
Comet tail Smaller reections
just below pleural
line, gradually
disappear
sometimes grouped
and very echogenic
237
= ring-down artefact,
mild form of “B-lines”
Lung rockets = severe
focal coalescent B-lines
Consolidation Area of non-
ventilated lung,
with liver-like
appearance, may
contain
sonobronchogram
May be solitary or
patchy and
multifocal
If small/irregular,
subpleural may
give appearance of
spared areas in an
inhomogenously
ventilated lung
Lung point Transition from
ventilated lung to
air without
respiratory sliding
Double lung point
Term sometimes
used for transition
from different lung
US appearances/
sonographic
patterns
Pneumonia, atelectasis,
multiple also in
meconium aspiration
syndrome (MAS) or
bronchopulmonary
dysplasia (BPD)
Any condition with a
patchy distribution
(BPD, MAD,
dystlelectasis
broncho-pneumonia/
inammatory, etc.)
Typically seen in
pneumothorax, but
respect DDx and
pitfalls
Typically seen in
transient tachypnea of
the newborn (TTN)
Lung pulse Pulsations
replacing lung
sliding,
(transmission of
cardiac motion onto
pleural line)
Particularly seen in
pneumothorax
(continued)