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1974;54;442PediatricsPeyton A. Eggleston, Byron H. Ward, William E. Pierson and C. Warren Bierman

Radiographic Abnormalities in Acute Asthma in Children

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442 PEDIATRICS Vol. 54 No. 4 October 1974

Peyton A. Eggleston, M.D., Byron H. Ward, M.D., William E. Pierson, M.D., and

C. Warren Bierman, M.D.

From the Department of Pediatrics, University of Virginia School of Medicine, Chaslottesvilk;

Department of Radiology and Cardiopulmonary Department,Children’s Orthopedic Hospital and Medical Center, Seattle; and Division of Allergy,

University of Washington School of Medicine, Seattle

ABSTRACT. To determine the incidence of radiographic

abnormalities in acute asthma of children and adolescents,

and to examine the contribution of the chest x-ray to their

care, 515 asthma admissions were reviewed. Of these, 479had admission chest films, 22.3% of which were abnormal.

Significant perihilar infiltrates were the most frequent ab-normality seen; atelectasis, especially of the right middle

lobe, was the next most frequent. Pneumomediastinum was

also a common finding. Both pneumomediastinum and in-filtrates were strikingly age-dependent: 15.5% over 10 years

old had pneumomediastinum; none under 2 years old had

this complication; infiltrates occurred in nearly 25% of younger

children but in only 8.3% over 10 years old. Since pul-monary complications substantially alter therapeutic man-

agement, a chest x-ray should be part of the initial evalu-ation of any child hospitalized with acute asthma. Pediatrics,

54 :442, 1974, ASTHMA, X-RAYS, ATELECTASIS, PNEUMONIA,

PNEUMOMEDIASTINUM.

The contribution of a chest radiograph to theevaluation of a child hospitalized for acute asthmais often questioned, especially when the child is not

severely ill. The greater availability of spriometry,

blood gases and other methods to evaluate patho-

physiologic changes has resulted in therapy based

increasingly on these tests. The individual physician

caring for a child with asthma may well ask: “Since

a chest x-ray contributes so little, why get one with-

out a specific indication?”

Twenty years ago Royle1 reviewed chest radio-

grams in asthmatic adults and children in an out-

patient department and found 21% with some ab-

normality other than hyperinflation. Richards and

Patrick’ found that 31% of children hospitalized forasthma had radiographic evidence of pneumonia;

Dworetsky and Philson3 reported a 21% incidence

of pneumonia in chest x-rays of children admitted

to the New York Hospital. These studies, which

provide some, albeit sparse information are the

only reported evaluations on the contribution of

chest x-rays to the management of the child hospi-

talized with asthma. Certain complications havereceived individual attention: pneumomediastinum,

pneumothorax47 and recurrent right middle lobe48 New methods of therapy of acute

severe asthma may produce their own complica-

29, 10 This study was undertaken to review

information gained from the routine chest film in

children hospitalized for acute asthma, and to

evaluate the clinical relevance of this information.

METHODSAll admissions to Children’s Orthopedic Hospital

and Medical Center, Seattle, Washington, for

asthma and asthmatic bronchitis from January 1,

1967, to December 31, 1969, were studied; each

admission was considered a separate episode.

Asthma was diagnosed according to the AmericanThoracic Society criteria�; asthmatic bronchitis was

included in this definition. Children with asthma

hospitalized for other reasons were excluded.Data were recorded regarding age, sex, race,

admitting date, length of stay in hospital, severity

of illness and therapy. Severity of illness was based

on the physician’s initial evaluation as “mild,” “mod-

erate” or “severe,” confirmed with vital signs, nurs-

( Received July 16; revision accepted for publication Decem-

ber 10, 1973.)

Supported in part by Public Health Service training grant5-TOl-AlOOll from the National Institute of Allergy and

Infectious Diseases.

ADDRESS FOR REPRINTS: (P.A.E.) Department ofPediatrics, University of Virginia School of Medicine, Char-

lottesville, Virginia 22901.

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z0

04

0

z

AGE IN YEARS

TABLE I

AGE AT ADMISSION

ARTICLES 443

ing observations, spirometry and arterial blood

gases, when available.

All chest films taken during hospitalization werereexamined by a pediatric radiologist (B.H.W.)

without reference to the child’s hospital course.

Radiograms taken on five admissions were not avail-

able at the time of this study so only the original

interpretation was included in the data.

Any extrapulmonary air not found in the pleural

space was designated a pneumomediastinum. An

attempt was made to differentiate atelectasis from

pneumonitis : an infiltrate with apparent loss of

volume whose distribution corresponded to a lobe

or bronchopulmonary segment, or which shifted

location or resolved suddenly in subsequent x-rays,

was called atelectasis. When differentiation was fin-

possible or when the densities were clearly associ-

ated with bronchovascular structure, the nonspecific

term “radiodensity” was used. Infiltrate applies as

a general term to any pulmonary shadow seen. Any

reticulated shadow with the characteristics of pneu-

monitis was called interstitial pneumonitis.

The chi-square method was used for statistical

analysis.

PATIENTSThere were 515 admissions among 325 patients

during the three years; roentgenograms were taken

during 479 admissions. Those not x-rayed were

usually older children with mild asthma; they have

been excluded from further analysis.

The admissions included in this study are repre-

sentative of those seen in any large metropolitan

hospital. Besides serving as a major referral center

for the Pacific Northwest (it is the only children’s

hospital in the state with a combination of pediatric

house staff and readily accessible pediatric inten-

sive care nursing, blood gas analysis and mechanical

ventilation ) Children’s Orthopedic Hospital pro-vides primary care for a large population in the

Seattle-King County area. The 515 patient-admis-

sions included here almost equal the number of

admissions for asthma to the pediatric units of the

14 other Seattle hospitals during the three years.

Fic. 1. Age distribution of admissions. Age at admission

ranges from 1 month to 19 years with a median of 3.8years. The cross-hatched area represents the number of

females represented in each admission age group; the dis-proportionate number of males represented in younger ad-

missions is not present in older admissions.

There was such a broad age distribution ( Fig. 1)

that it was necessary to analyze all admissions in six

age groups (Table I). Two hundred and eighty-nine

admissions were male ( 56. 1% ) . Fifty-two percent

of admissions in all age groups were only mildly ill.

Treatment varied greatly: 17 patients received

no medications during their admission; others re-

ceived the intensive treatment described by Pierson

et al.” Two hundred and sixty-seven patients re-ceived antibiotics. Only one child required assisted

ventilation.

RESULTSIncidence of Abnormal Chest X-rays

One hundred and twelve of the 479 admission

chest films showed some abnormality other thanhyperinilation (23.3%). Sixteen children had only a

pneumomediastinum, 86 had infiltrates only and

10 had both pneumomediastinum and infiltrate

( Fig. 2 ) . There were no episodes of pneumothorax.

There was no signfficant correlation betweenseverity of illness and pulmonary infiltrates but

INCIDENCE BY AGE

Age (yr) 2 2-3.9 4-5.9 6-7.9 8-9.9 10+No. of admissions I 1 1 149 78 46 38 93

No. with chest x-rays 108 143 71 43 30 84

Pneumomediastinum* 0 4(2.8%) 3(4.2%) 3(7%) 3(10%) 13(15.5%)

Inflitratet 24(22.2%) 33(23.1%) 20(27.2%) 8(18.6%) 4(13.3%) 7(8.3%)

ox2=29.2, p<.O0l.

tx2=1O.O, p=.O5.



INCIDENCE BY SEvERIT�’

51 Admissions

PNEUMONITIS

pneumomediastinum was associated with more Se-

vere disease (Table II ). Although both complica-

tions, pneumomediastinum and infiltrate, tended tooccur more frequently in girls (pneumomedi-

astinum 53.8%, infiltrates 56.3%), neither percentage

differed statistically from the proportion of females

(43.8%) in the entire group.

Infiltrates

Ninety-six admission radiographs (20.0%) demon-strated pulmonary infiltrates. Children under 6

years of age had a signfficantly higher incidence, as

noted in Table I. Pneumonia, atelectasis and “radio-

densities” occurred randomly ( Fig. 3) and usually

6 Admissions

479 ADMISSIONS WITH CHEST X-RAYS

1 1 Admissions

RADI ODE NSITIES

5 Admissions

TABLE II ATELECTASIS

444 ACUTE ASTHMA IN CHILDREN

Number

of

Admis-

sions

Number

With

A-ra)’S

Infiltrate Pneumomedias-

tznum

Mild 268 238 41(17.2%) 4(1.7%)

Moderate 214 210 46(21.9%) 17(8.1%)

Severe

Total

33 31 9(29.0%) 5(16.1%)

515 479 96(20.0%)

�‘=2.5p>.05

26(5.4%)

x2=16.8p<.OOl

FIG. 2. Incidence of abnormalities in children with roentgeno-graphs taken during admission. Eighty-six ( 18%) had infil-trates only, 16 (3.3%) had pneumomediastinum only, and

10 (2.1%) had both infiltrates and pneumomediastinum.

INTERSTITAL PNEUMONITIS

PERIHILAR INFILTRATE ONLY-28 Admissions

Fic. 3. Distribution of various types of infiltrates. Twenty-eight x-rays demonstrated perthilar interstitial pneumonitis

only; 58 others had perihilar interstitial pneumonia as well

as some other infiltrate. The small numbers in each loberepresent the number of times that particular lobe was in-volved with each type of abnormality, while the larger

numbers to the side of the lung outlines represent the total

number of admission radiographs involved with a particulartype of infiltrate. In most x-rays multiple lobes were involvedwith various types of infiltrates. See text for definition of

various x-ray abnormalities.



ARTICLES 445

FIG. 4. The characteristic distribution of mediastinal emphy-

sema in younger children. Besides irregular streaks of anterior

mediastinal air seen in the lateral view ( see arrows ) , theleft pulmonary artery, left mainstem bronchus and perihilar

nodes are outlined by air. Note that although extrapulmonar�

air is widely distributed in the chest, none is found in the

neck or axillae. There is an associated atelectasis of the

anterior segment of the left lower lobe and lingula as well

as moderately extensive perihilar interstitial pneumonia.

involved multiple lobes. Eighty-six chest films

(89.8% of those with infiltrates of any type ) showedperihilar interstitial infiltrates varying in severity

from increased bronchovascular markings to shaggy,

diffuse peribronchial pneumonia. Atelectasis of all

or part of a lobe was the next most common corn-

plication, occurring on 51 admissions; the right

middle lobe became atelectatic most frequently.

Infiltrates recurred, but the rate of recurrence

was not large. Although 41 children hospitalized

three or more times for acute asthma during the

three-year period, accounting for 39.5% of 479 ad-

missions, no child had more than three admissionscomplicated by infiltrate. In all, 14 children had

recurrent atelectasis, usually involving different

lobes on each admission. Three girls and a 2-year-

old boy had recurrent right middle lobe atelectasis.

One of the three girls underwent right middle

lobectomy when she was 63� years old, after several

years of chronic and persistent atelectasis of thelobe. A 10-year-old boy had two episodes of leftlower lobe interstitial pneumonitis, once accom-

panied by diffusely dissecting pnuemomediastinum.

Pneumomediastinum

Not only did the incidence of pneumomediasti-

num increase significantly with age ( see Table I)

but the pattern of distribution of air varied in

different ages as well. Three of the seven children

admitted when less than 6 years old had perihilar,

anterior and superior mediastinal emphysema with-

out dissection into the neck and axilla. Only one

older child, a girl 10 years old, had air confined to

this pattern. This is the same pattern characteristic-

ally seen in neonates and infants,�’ � although noneof the younger children in this series were as des-

perately ill as the neonates who developed medi-

astinal emphysema. Pneumomediastinum in olderchildren was almost invariably associated with

cervical and axillary subcutaneous emphysema.

Typical examples of the patterns seen in younger

and older children are shown in Figures 4 and 5.

The distribution of mediastinal and subcutaneous

air also appeared to be related to the severity of

illness ( Fig. 6 ) . In more severe attacks air was

confined to the inferior mediastinum while axillary

air was seen in mild to moderately severe attacks.The data were inadequate to decide whether the

relationship was pathophysiologically important orwhether the relationship was coincidental.

The most common x-ray manifestation of medi-

astinal emphysema, and usually the earliest, wasthin streaks of air around the roots of the great

vessels and the mainstem bronchi. Air usually ap-

peared first on the left side, and dissected up the

left side of the great vessels in perivascular areo-

lar tissues.

Recurrences, again, were not common; no child

had more than three admissions complicated by

1)netlmomediastinum. Of the three who developeda pneumomediastinum during three admissions, two

had chronic steroid-dependent asthma. Two older

children developed pneumomediastinum following

delivery of adrenergic aerosol by a positive pressure

device ( IPPB ) . One had a prior x-ray showing no

mediastinal air ( Fig. 5 ) ; the other had no prior

x-ray. Both boys complained of anterior chest pain

after IPPB treatment and experienced a marked

increase in wheezing and anxiety.

DISCUSSION

The remarkably high incidence of pneumomedi-

astinum was unexpected, although it has been pre-

viously suggestedb 14 that this is an under-reported

complication of acute asthma. On the other hand,

the 20% incidence of infiltrates in admission chest

films is similar to that found in earlier studiesl3, 15;

and it emphasizes the need for radiographic exam-

ination of every child hospitalized with acute

asthma. The higher incidence of abnormal chest




FIG. 5. This 15-year-old boy had chronic, severe asthma re-

quiring low dose prednisorie therapy for control and was

admitted in status asthmaticus. The upper two x-rays, taken

on admission, show extreme hyperinfiation with “tenting”

of the diaphragmatic costal insertions and herniated lung

anteriorly and posteriorly minimally increased. Bronchovas-cular markings such as this were not included in the stalls-

tics unless they were felt to be significantly increased from

those seen prior to admission. The radiolucent area, ap-

parently air, outlining the left cardiac border is an optical

illusion produced by the abutment of areas of varying

radiodensity; it can be made to disappear by masking allof the radiograph except this area. The lower x-rays were

taken following delivery of an adrenergic aerosol by IPPB,

when a pneumomediastinum had developed. Air has dis-

sected widely within the thorax and subcutaneously, in the

pattern typically seen in older children.



NECK

DISTRIBUTION OF AIR

IN CASES WITH MEDIASTINUM

I �

PERIBRONCHIAL I � N.S.

LEFTPERIBRONCHIAL

ALLPNEUMOMEDIASTINUM

I I10 15

# ADMISSIONS

ARTICLES 447

AXILLA [ � p<.oo1

NOT IN AXILLA � � p�_ .01INFERIOR ______________

INFERIOR ______________________MEDIASTINUM � � p .01>05

MEDIASTINUM I � N.S.ANTERIOR

MEDIASTINUM I � N.S.SUPERIOR

[ %�1�%1��

l_5

I I20 25

FIG. 6. Severity of illness related to distribution of medias-

tinal and subcutaneous air. The unmarked areas represent

mildly ill children, the cross-hatched represent moderately

ill and the solid areas severely ill. Pneumomediastinum, ingeneral, was associated with significantly more severe disease

( p < .001 > .05). Most admissions with pneumomediasti-

num had air in multiple locations.

films in children less than five years of age, con-

firming the findings of Richards et al.,1� deserves

even more emphasis; this is the age group most

vulnerable to sudden respiratory failure and

death.2’ 16

Many reasons are given for not x-raying a par-

ticular child hospitalized for acute asthma. First,

the child may have had a normal film earlier in thecourse of the attack; considering the rapidity with

which atelectasis may develop and clear, this is an un-

tenable excuse unless the previous examination was

just prior to admission. Other times the child may

not seem severely ill; although the severity of the

attack may be statistically helpful in predicting

whether or not a child has a pneumomediastinum,

there is no such relationship between severity and

infiltrates. The reason most frequently given for not

obtaining a chest film is that the treatment of the

attack will be little influenced by the results of the

radiograph; yet 67.7% of the admissions with in-

filtrates found in chest films in this series were

given antibiotics.

Should a pneumomediastinum or pneumothorax

be recognized, therapy must be altered. Administra-

tion of adrenergic aerosols by positive pressure

devices ( IPPB ) is contraindicated.17 Some feelmechanical ventilation should not be used in pa-

tients with pneumomediastinum or pneumothorax2;

othersls consider these complications one indication

for treating patients in respiratory failure with

methods other than positive pressure ventilation,

such as intravenous isoproterenol.1#{176} Certainly anyphysician treating an asthmatic child with IPPB

should first obtain a chest film. The following case

illustrates problems that may develop when this

is not done.

A 6-2/12-year-old boy with chronic steroid-dependent

asthma was admitted in moderate severe respiratory distressafter three days of progressively severe wheezing. He was

treated with intravenous aminophyllin, oral diazepam andprednisone, and epinephrine aerosol. The first two IPPB

treatments produced some relief, but following the third,

he became severely dyspneic and anxious and subcutaneous

crepitus was detected. A chest film, the first taken duringthis admission, revealed extensive mediastinal and subcu-

taneous emphysema.

The chest x-ray is the most sensitive and reliable

method of detecting pulmonary complications in

FIG. 7. The roentgenogram of this 5-year-old boy demon-

strates the radiopaque line produced by apposition of

pleural surfaces anteriorly ( upper arrows ) and posteriorlyin cases with marked hyperinfiation. Similar lines, thoughless apparent, may be seen in normals. Minimal perihilar

infiltrates are present and there is no pneumomediastinum.




asthma and should be given the same priority as awhite blood cell count, temperature or physical

examination in evaluating a child hospitalized for

asthma. A signfficant leukocytosis may be stimu-

lated by adrenaline administered prior to admis-

sion.’9 Fever may be suppressed by corticosteroid

therapy and some fever may be associated with an

uncomplicated asthma attack. In the series ofRichards et al.9 83% of the patients with radiogra-

phic evidence of infection and 72% of those without

had white blood cell counts above 10,000/cu mm;likewise 83% of those infected and 60% of those with-

out infection had temperatures greater than 38 C.

Even subcutaneous air, if minimal and scattered

among enlarged nodes, may be overlooked on physi-

cal examination; 10 of the 26 cases of pneumomedi-astinum in the present series were not appreciated

at the time of admission.

A pneumomediastinum may be overlooked if thechest x-ray is not carefully examined. Several pat-

tems of minimal involvement were seen: pulmonaryvessels and bronchi may be seen “end-on” with a

rim of air in a “target” configuration; irregular

lucent areas may be scattered in the hilum and

superior mediastinum, especially in the lateral pro-

jections; a radio-dense line of dissected pleura may

parallel aorta, esophagus and heart; and small ac-

cumulations may be seen along the carotid sheath

and strap muscles in the neck and around axillary

vessels and nodes.

Many lucencies may be confused with pneumome-diastinum. The abutment of two varying radiodensi-

ties, the heart and lungs, may produce an optical

illusion of a sharp radiolucent line outlining theheart. It disappears when all of the x-ray is masked,

except a portion of the heart border. Hyperinfiatedlung herniating anteriorly and posteriorly to the

heart (as in Fig. 5) mimicks a large pneumomediasti-

num. This may be differentiated from a true pneu-

momediastinum by its homogeneous rounded ap-pearance and by finding other signs of extreme

hyperinflation such as inverted diaphragms with“tented” costal insertions or readily apparent, sharpvertical shadows superior and inferior to the heart

on frontal x-rays where pleural surfaces coapt be-tween heart, esophagus and aorta (see Fig. 7).

Much confusion can be avoided if it is remembered

that mediastinal air is found in areolar tissues

and almost always appears as irregular bubbles

and streaks.

SPECULATIONSPeribronchial interstitial infiltrates, which usually

clear quickly, were found in 18% of admission chest

x-rays, and have been noted in earlier tu�

Mifier et al.2#{176}speculated that they were caused by

“allergic bronchopneumonia.” A similar though

more widespread process was reported by Felson2#{176}in adults with asthma; the only autopsy demon-

strated diffuse suppurative bronchiolitis and peri-

bronchial pneumonia. Viral infections are generally

felt to be the most common cause of hospitalization

for asthma and it is more likely that these pen-

bronchial infiltrates are nelated to a viral infectionthat precipitated the attacks. Indeed, McIntosh

et al.22 found evidence of viral infection during 42%

of all wheezing episodes in a group of children.The marked increased incidence of mediastinal

emphysema found in older admissions is difficult to

explain. In animal lungs23’24 pneumomediastinum

develops when increased intnapulmonary pressure

and alveolar hyperexpansion combine to decrease

local blood flow and interstitial support, allowing

air to escape and dissect pnoximally along vessels.

Compensatory hypeninflation secondary to atelec-

tasis is an important pathogenic factor in younger

but not in older children; our observation that four

of six children less than 5 years old who developedpneumomediastinum had lobar atelectasis while

only one older child had this association confirms614 impressions and supports this concept.

Older patients are able to generate much higher

intrathoracic pressures with severe bronchial ob-

struction, and because their respiratory rates are

generally lower than younger patients, these pres-

sures are maintained over longer periods. This fac-

tor, together with generalized hypeninflation, could

be responsible for their susceptibility to mediastinal

emphysema. In support of this explanation, wefound that all five of the severely ill patients with

pneumomediastinum (Table II ) and 12 of the 17

moderately ill patients were over 4 years old.Chronic structural damage from chronic asthma

or adrenocorticosteroid therapy is an unlikely ex-

planation for the increased incidence in olderasthmatics for two reasons. Ffrst, Tooley et al.25

demonstrated that any abnormal pulmonary physi-

ology found in children with chronic severe asthma

could be completely reversed by therapy. Secondly,if this explanation is followed to its logical conclu-

sipn, pneumomediastinum would occur more andmore commonly as the asthmatic child became anasthmatic adult, and it would be a common compli-

cation of adult asthma. This, obviously, is not the

case.

CONCLUSIONSA chest radiograph does contribute, significantly,

to the initial appraisal of children with acute un-

responsive asthma. Since one out of four chest filmswill be abnormal, and since the complications foundmust be considered in planning subsequent therapy,



ARTICLES 449

the chest radiograph should be included as a rou-

tine part of the admission examination. Without it,

not only may unnecessary complications be pro-

duced by therapy, as in the case report above, but

significant complications may go untreated. Indeed,

the only pediatric death from asthma in Seattle dur-

ing the three years of this study occurred at another

hospital when a 3-year-old boy died with acute

asthma and an undiagnosed bilateral pneumothorax.

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1. Royle, H.: X-ray appearance in asthma: A study of

200 cases. Brit. Med. J., 1:577, 1952.2. Richards, W., and Patrick, J. R.: Death from asthma

in children. Amer. J. Dis. Child., 110:4, 1965.3. Dworetsky, M., and Philson, A. D.: Review of asthmatic

patients hospitalized in the Pavilion Service of theNew York Hospital from 1948 to 1965 with em-

phasis on mortality rate. J. Allerg., 41: 181, 1968.4. Wittig, H. J., and Chang, C. H.: Right middle lobe

atelectasis in childhood asthma. J. Allerg., 39:245,

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T. J., and Hensel, A. E., Jr.: Mediastinal and sub-cutaneous emphysema complicating atopic asthma

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ACKNOWLEDGMENTWe would like to express our gratitude to Margaret A.

Ohlson, Ph.D., for her invaluable help in organizing a large

amount of data into a coherent statement, and to David E.

Woodrum, M.D., and Paul P. VanArsdel, M.D., who re-viewed the manuscript and gave much editorial help.



1974;54;442PediatricsPeyton A. Eggleston, Byron H. Ward, William E. Pierson and C. Warren Bierman


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Online ISSN: 1098-4275.Copyright © 1974 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007.has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it



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