Neonatal CXR/AXR Analysis - B/O Kalpana, SNCU, 15-Jul-2026

Lines & Tubes

Chest Findings

• Lung volumes: Low-to-moderate - consistent with a sick neonate on respiratory support
• Left lung: Patchy reticulogranular (ground-glass) opacity with air bronchograms
• Right lung: Relatively better aerated, mild diffuse haziness
• Heart size: Normal for age; cardiomediastinal silhouette not widened
• No pneumothorax, no pneumomediastinum

1. Respiratory Distress Syndrome (RDS) / Hyaline Membrane Disease - especially if preterm
2. Transient Tachypnea of the Newborn (TTN) - if term/near-term
3. Neonatal pneumonia / aspiration cannot be excluded

Abdominal Findings

• Bowel gas: Present throughout small and large bowel - gas has reached the bowel, which is a normal/reassuring finding (no obstruction)
• No pneumatosis intestinalis (no bowel wall gas - NEC is not suggested at this time)
• No free air (no pneumoperitoneum)
• No portal venous gas
• Mild non-specific bowel distension in the left hemiabdomen - watch clinically

Skeletal

• Ribs, clavicles, spine, pelvis, proximal femora: Normal mineralization, no fractures, no vertebral anomalies

Summary & Recommendations for Residents

Note: This is a radiological interpretation for educational and clinical support purposes. Final clinical decisions must be made by the treating team in the context of full clinical assessment.

Revised Diagnosis: Left-sided CDH with Rightward Mediastinal Shift

• Left hemithorax filled with gas-filled bowel loops (not lung parenchyma - this was misread as haziness)
• Heart and mediastinum pushed to the RIGHT by mass effect from herniated abdominal contents
• Paucity of abdominal bowel gas (bowel is in the chest, not the abdomen)
• Left Bochdalek hernia - the most common type (85% of CDH is left-sided)

CDH: What Residents Must Know

Pathophysiology

• Failure of fusion of the pleuroperitoneal folds (by 9 weeks gestation) → diaphragmatic defect
• Bochdalek hernia (posterolateral) = 70-75% of CDH; left-sided in 85%
• Herniated bowel/stomach/liver compresses the developing lung → pulmonary hypoplasia (bilateral, ipsilateral worse)
• Abnormal pulmonary vascular smooth muscle → Persistent Pulmonary Hypertension of the Newborn (PPHN)
• Survival: 65-90% in modern high-volume centers

Classic Clinical Signs

• Scaphoid abdomen (bowel is in the chest)
• Diminished breath sounds on left, +/- bowel sounds audible in chest
• Displaced heart tones to the right
• Respiratory distress: grunting, cyanosis, retractions from birth
• Pre/post-ductal SpO2 difference (right-to-left shunting)

X-Ray Findings (This Film)

Immediate SNCU Management

1. Airway - DO NOT BAG-MASK VENTILATE

• Bag-mask ventilation inflates the herniated bowel further, worsening compression
• Immediate intubation (ETT) if not already done

2. Gastric Decompression

• Large-bore NG/OG tube insertion and continuous suction - decompresses herniated stomach/bowel to reduce mass effect

3. Respiratory Support ("Gentilation" - Gentle Ventilation)

• Permissive hypercapnia (allow PaCO2 45-60 mmHg)
• Peak inspiratory pressure <25 cmH2O to minimize barotrauma
• Rate 40-60/min, low PEEP
• Goal: preductal SpO2 >85%, not 100% - avoid hyperoxia-induced vasoconstriction
• High-frequency oscillatory ventilation (HFOV) if conventional ventilation fails

4. Pulmonary Hypertension Management

• Inhaled Nitric Oxide (iNO): 20 ppm - pulmonary vasodilator of choice
• Milrinone, sildenafil, PGI2 (prostacyclin) as adjuncts
• Avoid acidosis, hypothermia, pain/agitation (all worsen PPHN)
• ECMO if refractory hypoxemia (pre-ductal SpO2 <85% on maximal therapy)

5. Hemodynamic Support

• UAC/UVC (already in place - good positioning confirmed)
• Dopamine/dobutamine for systemic hypotension
• Avoid excessive fluids

6. Investigations

• ABG (preductal = right radial; postductal = lower limb) - assess shunting
• Echo - assess cardiac anatomy (associated CHD in ~30%), PPHN severity, ductal shunting
• Karyotype/genetics screen (associated chromosomal anomalies in 10-20%)

Surgery: NOT Immediate

"Optimal timing of CDH repair focuses on aggressive treatment of pulmonary hypertension first. Surgery is delayed until the infant is hemodynamically stable." - Sabiston Textbook of Surgery

• Delay repair until PPHN is treated and the baby is stable (often 24-72 hours or longer)
• Approach: Subcostal laparotomy (open) or laparoscopic/thoracoscopic repair
• Defect repair: Primary closure if possible; prosthetic patch (Gore-Tex/Vicryl) for large defects
• Ipsilateral chest drain NOT placed routinely post-op (mediastinum slowly re-centers)

Prognosis Factors

X-Ray Brief: CDH (B/O Kalpana, 15-Jul-2026)

Findings

• Left hemithorax: Gas-filled bowel loops (herniated abdominal contents)
• Mediastinum/Heart: Shifted to the RIGHT
• Left diaphragm: Not visualized
• Abdominal gas: Markedly reduced (bowel is in the chest)
• UAC: T8-T9 - satisfactory high position
• UVC: At IVC-RA junction - acceptable

Impression

Immediate Actions

1. Intubate - no bag-mask ventilation
2. OG/NG tube on continuous suction
3. Gentle ventilation - PIP <25, permissive hypercapnia
4. iNO for PPHN
5. Echo - rule out CHD, assess PPHN
6. Surgery deferred - stabilize first

Lines Present on This X-Ray

What This Means Clinically

• My earlier mention of a UVC was incorrect - apologies for the error
• Only a UAC is in situ
• This baby likely needs a UVC inserted urgently for:
  • Central venous access for fluids/medications
  • Prostaglandin E1 if duct-dependent lesion suspected
  • iNO drug delivery and monitoring
  • Vasopressors if PPHN deteriorates

How to Identify UAC vs UVC on X-Ray

1. UVC Tip at T11-T12 — Is It Acceptable?

2. OG Tube in CDH — Is It Correct?

Normal baby:    OG tip → stomach → LEFT UPPER QUADRANT of ABDOMEN

CDH baby:       OG tip → stomach → LEFT HEMITHORAX (stomach herniated into chest)
                                    ↑
                         THIS IS WHAT YOU SEE HERE ✅

Why OG is Mandatory in CDH:

• The herniated stomach fills with air → further compresses the lung
• OG on continuous suction deflates the stomach → reduces mass effect → improves ventilation
• Critical: without OG suction, every breath the baby takes pumps more air into the intrathoracic stomach/bowel

Summary for the Team