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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

  • 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 differentials6
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 differentials7
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 differentials8
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 like9
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 like13
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 differentials16
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 further17
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 like18
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