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Pulmonary patterns. What does it all mean?. Mike Ackerley. Overview. What are they? What do they look like? What are the differentials for each? What can I do to diagnose it further?. What are they?. Interstitial Alveolar Bronchial Mixed. What do they look like?.

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Pulmonary patterns

Pulmonary patterns

What does it all mean?

Mike Ackerley


Overview
Overview

  • What are they?

  • What do they look like?

  • What are the differentials for each?

  • What can I do to diagnose it further?


What are they
What are they?

  • Interstitial

  • Alveolar

  • Bronchial

  • Mixed


What do they look like
What do they look like?

  • Interstitial a.k.a “busy” lungs: smudging or blurring of the outline of structures.

    Stuff scattered in the outside garbage bag.

    • Structured

      • Nodules - < 3 cm (if you can see them they’re at least 4 – 5 mm)

      • Masses - > 3 cm

      • Differentiate nodules from end on vessels.

        • Less numerous

        • End on vessels more opaque, and smaller in diameter

        • Adjacent to bronchus & have connected “tail” b/c part of vessel projects laterally

    • Unstructured

      • Fluid (non-cardiogenic edema)

      • Cells (pneumonia – bacterial, fungal, viral)

      • Scar tissue (contusions)

      • Age

      • Artifact?


What are the differentials
What are the differentials?

  • Structured (Nodules/Masses)

    • Mineralization:osteomas (large breed dog, not significant)

    • Solitary (can be cavitary or solid): Perihilar region or caudal lung lobes

      • Tumor

        • Adenocarcinoma

        • Bronchogenic carcinoma

        • SCC

        • Malignant histiocytosis (Rotties, Goldens, and Bernese)

      • Abscesses (Can’t tell difference from tumor)

      • Granuloma

      • Hematoma

      • Fulid filled cyst or bullae


What are the differentials1
What are the differentials?

  • Structured (Nodules/Masses)

    • Multiple:

      • Metastatic tumors

      • Fungal granulomas

      • Parasitic granulomas (Aleurosyrongylus – Feline lung worm)

      • Abscessation

      • Lymphoma

      • Malignant hystiocytosis

      • Lymphoid granulomatosis

    • Miliary (remember what the seeds look like):

      • Lymphoma

      • Fungal pneumonia

      • Hematogenous bacterial pneumonia

      • Metastatic thyroid, haemangiosarcoma or mammary carcinoma


What are the differentials2
What are the differentials?

  • Unstructured

    • Artifact (MOST COMMON)

      • Underexposure/development: film too “light”

      • Expiratory radiograph

      • Obese animals

      • Forelimbs not pulled forward (musculature in way)

    • Age: lungs less elastic (scarring)

    • Pneumonia (cells)

      • Bacterial (MOST COMMON) right middle lung lobe

      • Fungal: common blasto, crypto, histio, coccidiomycoses

      • Viral: distemper – caudodorsal distribution


What are the differentials3
What are the differentials?

  • Unstructured

    • Cardiogenic edema (fluid): precedes alveolar pattern

    • Non-cardiogenic edema: usually caudodorsal

      • Near drowning

      • Epilespy, seizure

      • Electric cord bite

      • Head trauma

    • Hemorrhage/contusions: DIC, anticoagulant poisoning

    • Neoplasia: Lymphoma, metastatic (hemangio/adenocarcinoma)

    • Allergic

    • Parasitic: Heartworm or lungworms


What do they look like1
What do they look like?

  • Alveolar pattern: Alveoli are filled with blood, pus, edema, etc.

    Stuff in the inner garbage bag!!!!!

    • Air bronchograms – just b/c they’re not there doesn’t mean it’s not alveolar (hard to see in cats)

    • Lobar sign – alveolar pattern extends to the border of normal lung lobe

    • Difficult to see heart margins, diaphragm, bronchial walls, or pulmonary vasculature.


What are differentials
What are differentials?

  • Consolidation (alveoli infiltrated)

    • Pneumonia

      • Aspiration usually right middle

      • Bronchopneumonia usually cranioventral

    • Edema (Caudal lung lobes in dog, variable in cat)

      • Cardiogenic – LHF

      • Non-Cardiogenic – upper airway obstruction (including brachycephalics and lar. Par), electrocution, seizures, allergic, near drowning and blood transfusions.

    • Hemorrhage – usually asymmetrical

    • Neoplasia

  • Atelectasis (alveoli collapsed): look for mediastinal shift towards affected lung, only see bronchograms with moderate to severe collapse

    • Anesthesia

    • Pleural effusion

    • Pneumothorax

    • Asthma

    • Lung lobe torsion – usually right middle lung lobe


Remember dr ps abcs
Remember Dr. Ps ABCs

A = Atelectasis, Anesthesia

B = Bronchopneumonia, Bacterial pneumonia

C = Contusion, Cancer

D = Dirofilaria

E = Edema (Cardiogenic and Non)

F = Bronchial Foreign Body (caudal lobes)

G = Granulomatous (Fungal)

H = Hemorrhage


What can i do to diagnose it further
What can I do to diagnose it further?

  • History & PE big help

    • Signalment, Trauma, anesthesia, previously dx heart dz or murmur ausculted?

  • Diuretic – If it is edema you will see significant change if you re-radiograph in ~ 12 hours. If it is hemorrhage or bronchopneumonia will see no change

  • TTW or BAL – determine what type of fluid and culture for possible bronchopneumonia


What do they look like2
What do they look like?

  • Bronchial Pattern: Increased visibility of the bronchial wall due to thickening or mineralization. May see change in size and shape of the lumen.

    Stuff along the wall of the white balloon.

    • Donuts (end on)

    • Railroad tracks (longitudinal)


What are differentials1
What are differentials?

  • Bronchial Mineralization

    • AGE: Insignificant in older and chondrodystrophic dogs

    • Calcification of peribronchial mucus glands in cats

    • Hyperadrenocorticism or long term corticosteroid use

  • Bronchial Thickening

    • Chronic bronchitis: older animals

    • Feline asthma

    • PIE – Pulmonary Infiltrate with eosinophilia

    • Parasites (aelurostrongylosis)

    • Neoplasia: Lymphoma, bronchogenic adenocarcinoma


What can i do to diagnose it further1
What can I do to diagnose it further?

  • TTW or BAL

    • Cytology to determine what type of cells are present (eosinophils, neoplastic?)


What do they look like3
What do they look like?

  • Mixed:

    • Variable – depends on what process is dominating

      • Bronchointerstitial pattern most common

      • Alveolar and interstitial patterns are sometimes hard to evaluate and often co-exist


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