Lung Lung PatternsPatterns - Nc State Universityradfileshare.cvm.ncsu.edu/PRINT/2011/Week 9...

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Lung Lung PatternsPatterns

VMB 960

3/7/2011

Abnormal Lung Pattern Abnormal Lung Pattern ClassificationClassification

Alveolar

Interstitial

BronchialBronchial

Vascular (covered with heart lecture)

Mixed

NormalNormalMay be the MOST DIFFICULT pattern

to diagnose!

The ability to see vessels, bronchi and some interstitial markings is NORMALg

Although “technically” not a pattern, determination of ‘normal’ is obviously critical

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NormalNormal

Broad range of normal depending on:Age of the animal

Conformation of the animal

Phase of respiration

Be clear if you mean “radiographically normal” or “clinically normal”

Does a normal lung pattern mean an absence of lung pathology? NO!!

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Alveolar Lung PatternAlveolar Lung Pattern

Flooding of alveoli withFlooding of alveoli with

‘blood, pus or water’ ‘blood, pus or water’

Hallmark sign of alveolar lung disease is theHallmark sign of alveolar lung disease is the

Alveolar Pattern

Air Bronchogram

Increased soft tissue

opacity in alveolar space, gas remains

in bronchi

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Normal

Air bronchograms

Alveolar PatternAlveolar PatternRadiographic SignsIncreased soft tissue opacity (can be intense)“Air bronchogram”

– Does NOT have to be present– If present alveolar patternp p

Loss of visualization of the vesselsCannot see bronchial walls

Special CircumstancesLobar signAtelectasis/collapse

L Lat VD

L Lat

VD

R lat

Note change in lesion conspicuity between left and right lateral views

R Lat

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Lobar sign

R lat

L lat

Alveolar PatternAlveolar Pattern

There are two DIFFERENT mechanisms that can result in an alveolar pattern

CONSOLIDATION– Fluid or cells in the alveoli (blood, pus, water)

ATELECTASIS– Collapse of the alveoli

Both result in an increase in soft tissue opacity in the alveolar space


CONSOLIDATION Fluid and/or cells in the

alveoli No mediastinal shift

ATELECTASIS Collapse of the alveoli

(loss of air in alveoli)

M di ti l hift No mediastinal shift Lung lobe “normal” size Not necessarily

associated with pleural disease

Mediastinal shift

Lung lobe decreased in size

Often associated with pleural disease– Pneumothorax

– Pleural effusion

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Mediastinal shiftMediastinal shift No shiftNo shift

Alveolar Pulmonary PatternConsolidation vs. Atelectasis

Consolidation Atelectasis


General Causes of Alveolar lung General Causes of Alveolar lung diseasedisease

Atelectasis eg: recumbencyAtelectasis eg: recumbency

Edema eg: LH failure

Hemorrhage eg: coagulopathy

Inflammatory exudates eg: pneumonia

Infiltrate eg: PIE

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Most common cause of generalized Most common cause of generalized alveolar lung disease isalveolar lung disease is

Pulmonary EdemaPulmonary EdemaPulmonary EdemaPulmonary Edema

Increased Hydrostatic Pressure

Reduced Oncotic pressure

Increased Capillary Permeability


Focal alveolar lung diseaseFocal alveolar lung disease

Multiple causes

Differential diagnosis prioritizationDifferential diagnosis prioritization influenced by distribution and intensity of change

Accurate history important in ranking differentials


Important ‘distribution patterns’Important ‘distribution patterns’

Generalized perm/hydro/onc

Cranioventral pneumoniaCranioventral pneumonia

Perihilar hydrostatic

Caudodorsal perm/hydro/onc

Focal nonspecific

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Pattern Distribution – Aspiration pneumonia

Cranioventral lung lobes

Right middle lung lobe most commonLook for summation sign over the cardiac silhouetteLook for summation sign over the cardiac silhouette

on left lateral view!

Usually intensity of opacification is

most severe with inhalation pneumonia

Alveolar PatternAlveolar PatternPattern Distribution – Pulmonary EdemaCardiogenic

– Perihilar – Can become generalized

Non-cardiogenic (or neurogenic)Non cardiogenic (or neurogenic)– Caudodorsal lung fields– Can become generalized

Caudodorsal lung fields generally most affected

Remember that distribution can change as disease progresses or resolves.

Alveolar PatternNon-cardiogenic Edema

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Interstitial PatternsInterstitial Patterns

UnstructuredUnstructured StructuredStructured

Interstitial PatternsInterstitial PatternsUnstructuredUnstructured

Patient factors•Ageing changes•Inflammatory processes•Infiltrative processes•Vasogenic factors

Technical factors•Under exposure•Expiratory radiograph•Obesity

Usually generalized / diffuseUsually generalized / diffuse

Unstructured Interstitial Unstructured Interstitial PatternPattern

Technical factorsImportant that thoracic radiographs are made

on PEAK INSPIRATIONE i t fil tif t ll– Expiratory films may artifactually cause or enhance an unstructured interstitial pattern

Other factors that may cause an APPARENTunstructured interstitial pattern– Respiratory motion– Obesity– Underexposure

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Expiration Inspiration

Expiration Inspiration Inspiration vs Expiration

Same dog, same views. Note difference in degree of soft tissue

lung opacity!


Hazy/amorphous increase in

soft tissue opacityThe result of :– The result of : Fluid and/or cells in the interstitial space

Fibrosis in the interstitial space– Chronic inflammation

– Normal ageing change

Diffuse Unstructured Interstitial Pattern - LSA

Normal

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Interstitial Lung Disease Interstitial Lung Disease (LSA)(LSA)


Peribronchial enhancement

The ability to see the bronchi “better”

because of an increase in opacity of thebecause of an increase in opacity of the

interstitium

– adventitial border of bronchus is ill-defined and bronchus appears thick

Peribronchial enhancement Normal

Note some bronchi have thick “fuzzy” border, this suggests surrounding interstitial disease.

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Overlap of Patterns

A severe unstructured interstitial pattern may mimic a mild alveolar patternmay mimic a mild alveolar pattern– Sometimes cannot distinguish between the

two patterns

– If in doubt identify the pattern as alveolar - being most severe

Interstitial PatternsInterstitial PatternsStructuredStructured

Cavitary•Abscess / cyst•Necrotic tumor•Parasitic

Non-cavitary•Extrathoracic•Fake out•Tumor 1 or 2•Granuloma

Focal or generalizedFocal or generalized

Interstitial PatternsInterstitial PatternsStructured Structured -- NonNon--cavitarycavitary

Focal or generalized – Nodular

Metastatic lung disease

Primary lung mass

Pulmonary osseous metaplasia

Granuloma fungal, eosinophilic, FB

Abscess

Fluid filled bulla

– Miliary Fungal – Blastomycosis

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Nodules - metastasis

Pulmonary Osseous MetaplasiaPulmonary Osseous Metaplasia

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Intense MiliaryIntense Miliary

–– with coalescencewith coalescence

Structured / Nodular InterstitialStructured / Nodular Interstitial

Radiographic appearanceCircumscribed lesions of various opacity, size

and number in the interstitial space of the lung

May be single or multipleMay be CAVITARY or NON-CAVITARY

– CAVITARY = CONTAINS GAS OPACITY– NON-CAVITARY = NO GAS OPACITY

Can have cavitary and non-cavitary lesions in the same patient

Structured or Nodular Structured or Nodular InterstitialInterstitial

Where are the nodules?The nodules are located in the interstitial

spaceTh i t titi l t i thThe interstitial space contains the:

– Vessels– Bronchi– Nerves– Lymphatics

The nodules are between or invade the structures of the interstitial space

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Structured / Nodular InterstitialStructured / Nodular InterstitialEnd-on Vessel Located near other

vessels Same size or smaller

than associated l it di l l

Pulmonary Nodule Does not have to be

near vessels Can be any size Random in location

longitudinal vessels Tend to follow a patternMay be near a

bronchus Typically well-defined

smooth marginsMay have a “tail”More opaque than

expected for size

Does not have to be near a bronchus

Margins may be smooth or irregular

No “tail”

Structured / Nodular InterstitialStructured / Nodular Interstitial

Pulmonary Nodule or Something on Skin?

Ectoparasites (ticks), skin masses, nipples etc can mimic a pulmonary noduleetc. can mimic a pulmonary nodule

Structures on the surface often more opaque than expected due to air/soft tissue interface

Place radiopaque marker on “lesion” to determine location

Extrathoracic “Nodule”

Note large nipples on lateral view

“Perfect” alignment of “nodules” of the same size should be a clue that these structures may not be pulmonary.

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Cavitary Structured Interstitial Pulmonary PatternHematocoele (Blood-filled bulla)

Horizontal beam radiograph - note the fluid lines in the pulmonary masses.

Structured Interstitial – cavitary

Bronchial PatternBronchial Pattern

Radiographic appearanceIncreased visualization of the bronchi

Typically most difficult pattern for students to recognize

Must look for normally visualized pulmonary structures– Bronchi– Vessels

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Bronchial PatternBronchial PatternRadiographic FindingsIncrease in size of bronchiApparent increase in number of bronchi

– Due to increase in size of bronchi

Loss of taperBronchial walls become parallel– Bronchial walls become parallel

Bronchial wall thickening– Can be difficult to distinguish from peribronchial

enhancement

Special CircumstancesBronchial mineralization

– Can be a normal aging change If only finding, probably do NOT have a bronchial

pattern

Bronchial PatternBronchial Pattern

Radiographic FindingsIncrease in size is RELATIVELook in the periphery of the lung fields

– Look for end on bronchi– Should have a lucent center

Look VERY closely!Although identified as large, the bronchi are

still very small!– Especially in CATS!!!

Severe Bronchial Pattern

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Bronchial Bronchial

BronchiectasisBronchiectasisnote airway collapse on expirationnote airway collapse on expiration

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Lung Patterns Case Discussions

3/8/2011

Lung Model using Adobe PhotoshopLung Model using Adobe Photoshop

Case Discussions Case Discussions

Things we will cover Things we will cover

Case 1Case 1

1 year old German Shepherd 707221 year old German Shepherd 70722

Female spayed Female spayed

Febrile and dyspnea Febrile and dyspnea

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L R

Case 1 Findings Case 1 Findings

There is soft tissue opacification with air bronchograms There is soft tissue opacification with air bronchograms in the right middle lung lobe, caudal part of the right in the right middle lung lobe, caudal part of the right cranialcranial lung lobe and to a lesser degree of the caudal lung lobe and to a lesser degree of the caudal portion of the left cranial lung lobe. portion of the left cranial lung lobe.

The heart and pulmonary vessels are small consistent The heart and pulmonary vessels are small consistent with hypovolemia possibly due to dehydration. with hypovolemia possibly due to dehydration.

What are the most likely differentials for this pattern?What are the most likely differentials for this pattern?

Case 2Case 2

12 year old Labrador Retriever 12 year old Labrador Retriever 6793367933

Male castrateMale castrate

Chronic progressive paraparesisChronic progressive paraparesis

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There is a moderate diffuse bronchial There is a moderate diffuse bronchial (bronchointerstitial)(bronchointerstitial) lung pattern with thickening and lung pattern with thickening and mineralization of bronchial walls.mineralization of bronchial walls.

Ple ral fiss re lines are presentPle ral fiss re lines are present probably aprobably a Pleural fissure lines are present Pleural fissure lines are present –– probably a probably a manifestation of pleural fibrosis. manifestation of pleural fibrosis.

Changes are consistent with chronic Changes are consistent with chronic inflammatory airway disease. inflammatory airway disease.

Bronchial Bronchial -- another example another example

Case 3Case 3

2 year old Chinese Crested 2 year old Chinese Crested 5116751167

Male Male

Rescued from a garage fire. Severe dyspneaRescued from a garage fire. Severe dyspnea

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Extensive air bronchograms are present Extensive air bronchograms are present throughout the lung parenchyma, indicating a throughout the lung parenchyma, indicating a diffuse, intense alveolar pattern. diffuse, intense alveolar pattern.

In light of the history p lmonary edemaIn light of the history p lmonary edema In light of the history, pulmonary edema In light of the history, pulmonary edema secondary to smoke inhalation is the most likely secondary to smoke inhalation is the most likely diagnosis.diagnosis.

Case 4Case 4

10 year old Golden Retriever 8690610 year old Golden Retriever 86906

Male Male

Osteosarcoma Osteosarcoma –– distal femur distal femur

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Multiple variablyMultiple variably--sized soft tissue pulmonary nodules sized soft tissue pulmonary nodules are present throughout the lungs. are present throughout the lungs.

Cardiovascular structures appear within normal limits. Cardiovascular structures appear within normal limits. Ca d ovascu a st uctu es appea w t o a ts.Ca d ovascu a st uctu es appea w t o a ts.

This pattern is typical of metastatic lung disease.This pattern is typical of metastatic lung disease.

What are other differentials for a nodular interstitial What are other differentials for a nodular interstitial pattern? pattern?

Case 5Case 5

5 year old Cocker Spaniel 5 year old Cocker Spaniel 6655866558

Constipation and tachypneaConstipation and tachypnea

Constipation thought due to pelvic canal mass Constipation thought due to pelvic canal mass

What are the radiographic findings? What are the radiographic findings?

What are the most likely differentials? What are the most likely differentials?

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A soft tissue opacity is superimposed over the A soft tissue opacity is superimposed over the carina with apparent ventral deviation of the carina with apparent ventral deviation of the principal bronchi. This finding is consistent with principal bronchi. This finding is consistent with tracheobronchial lymphomegalytracheobronchial lymphomegalytracheobronchial lymphomegaly. tracheobronchial lymphomegaly.

There is a fine reticular interstitial pattern, most There is a fine reticular interstitial pattern, most pronounced in the caudodorsal lung fields. pronounced in the caudodorsal lung fields.

An infiltrative disease as with Lymphoma or a An infiltrative disease as with Lymphoma or a fungal infection should be considered. fungal infection should be considered.

Case 6Case 6

10 year old German Shepherd 10 year old German Shepherd 8462384623

Male castrateMale castrate

Intermittent cough Intermittent cough

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An alveolar pattern is present in the caudal part of the An alveolar pattern is present in the caudal part of the left cranial lung lobe.left cranial lung lobe.

A patchy alveolar pattern is also present in the right A patchy alveolar pattern is also present in the right cranial lung lobe.cranial lung lobe.gg

The cardiovascular structures are within normal The cardiovascular structures are within normal limits.limits.

Dorsal deviation of the trachea is likely a manifestation Dorsal deviation of the trachea is likely a manifestation of head position.of head position.

What are the most likely differentials for this pattern?What are the most likely differentials for this pattern?

Lung Lung PatternsPatterns - Nc State Universityradfileshare.cvm.ncsu.edu/PRINT/2011/Week 9...

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