1/13/2014. Proper Radiographs. Proper Radiographs. A Review of Pulmonary Patterns

Transcription

1 Live Webinar A Review of Pulmonary Patterns Sofija R. Liles, DVM, DACVR Proper Radiographs Which views? One lateral plus ventrodorsal (at least) Left lateral is best for thorax Three views for full metastatic check 2 Proper Radiographs Right vs. Left Lateral Thorax Left Right 3 1

2 Proper Radiographs Which views? Pathology needs to be on the upside of the patient Atelectasis will mask any lesions in the down lung Applies for VD/DV and left vs. right laterals 4 Proper Radiographs Correct positioning according to pathology 5 Proper Radiographs DV vs. VD (pathology needs to be UP) DV VD 6 2

3 Proper Radiographs Right vs. Left (pathology on up side) RT LT 7 Proper Radiographs Exposure Want to assess fine details of lungs Higher kvp and lower mas best On VD should be able to just make out spine through cardiac silhouette Adjust settings according to each patient Fat, gas, fluid, alveolar disease 8 Accurate Interpretation Systematic approach Pulmonary Patterns Cardiovascular Structures Mediastinum Musculoskeletal Structures 9 3

4 Accurate Interpretation Normal vs. Abnormal Distribution Clinical signs Breed, age, sex Concurrent thoracic changes Does the entire picture fit? 10 Pulmonary Patterns Alveolar Bronchial Interstitial Nodular or structured Unstructured Combination patterns Mineralization within pulmonary parenchyma Vascular (not really pulmonary) 11 Alveoli full of fluid Blood (contusions, coagulopathy) Pus (aspiration pneumonia, hematogenous pneumonia) Water (heart failure, vasculitis, noncardiogenic edema) Atelectic lung lobes Neoplasia (bronchogenic carcinoma and metastatic in cats) 12 4

5 Signs Air bronchograms Silhouetting sign Lobar sign 13 Air Bronchograms 14 Silhouette Sign 15 5

6 Lobar Sign 16 Location, location, location Right middle lung lobe/ventral (aspiration) Ruminants Right Cranial Lung (tracheal bronchus) Caudodorsal (noncardiogenic) Right caudal lung lobe/perihilar? (cardiogenic edema) Patchy distribution (hemorrhage) Concurrent cardiac shift (atelectasis) 17 Pneumonia (Bacterial) 18 6

7 Pneumonia (Bacterial) 19 Noncardiogenic Pulmonary Edema 20 Cardiogenic Edema 21 7

8 Cardiogenic Edema 22 Edema? 23 Cardiogenic Edema DCM 24 8

9 Bronchogenic Carcinoma/Metastatic Disease Cats 25 Atelectasis Cardiac Shift 26 Warfarin Toxicity 27 9

10 Warfarin Toxicity 28 Concurrent thoracic changes Vessels, heart, esophagus, fractured ribs, trachea, larynx, etc. Breed/History Murmur, coughing, vomiting, rodenticide toxicity, IMHA, HBC, head trauma, etc. 29 Bronchial Disease Signs Doughnuts Railroad tracks Peribronchial cuffing Digital imaging advancement 30 10

11 Bronchial Disease 31 Bronchial Disease Most often diffuse, but can be lobar Often times combined with interstitial disease Severity, is there bronchiectasis present? Breeds West Highland white terriers 32 Bronchial Disease Differentials Chronic inflammation (bronchitis) Parasitic (aelurostrongylosis) Peribronchial cuffing: Early edema Bronchopneumonia Pulmonary eosinophilic infiltrates (may have nodules) 33 11

12 Bronchiectasis 34 Bronchial Disease Pulmonary Eosinophilic Infiltrates 35 Bronchial Disease Other things to look for Pulmonary hyperinflation or air trapping Tenting of diaphragm from chronic increased respiratory effort 36 12

13 Bronchial Disease 37 Structured/Nodular Signs Solitary nodules present (mass or small nodules) Cavitated Non-cavitated Unstructured Signs Hazy increased opacity to lungs (does not cause silhouetting) 38 Structured/Nodular Single noncavitated Small in size Metastatic nodule Granuloma Abscess Large in size Primary pulmonary carcinoma (caudal lungs) Granuloma Abscess 39 13

14 Structured/Nodular Single and Cavitated Primary pulmonary carcinoma (large) Metastatic disease (secretory tumors) Abscess Granuloma (parasitic disease) Fluid-filled bulla Cyst 40 Structured/Nodular Multiple small in size Metastatic disease (can be cavitated) Granulomas (fungal disease) Abscesses Multiple large in size or variable sizes Primary pulmonary neoplasia Malignant Histiocytosis Fungal Disease Lymphomatoid Granulomatosis Metastatic disease 41 Structured 42 14

15 Primary Pulmonary Carcinoma 43 Bullae 44 Unstructured Distribution variable Hazy appearance to lungs Remember freshman histology /alveoli.htm 45 15

16 Unstructured Things that may enhance interstitial pattern Age of patient Expiration Sedation Exposure Anesthesia Lateral vs. Ventrodorsal 46 Expiratory vs. Inspiratory Radiographs 47 Unstructured 48 16

17 Unstructured 49 Unstructured 50 Differentials Diffuse Artifact (digital) Old lungs Lymphoma Pneumonitis Viral Parasitic Metabolic Inhalant Toxic Disease in Transition Early edema Bronchopneumonia Hemorrhage Localized Partial lung collapse Hemorrhage (early) PTE Bronchial FB Diseases in Transition i Edema Bronchopneumonia Hemorrhage Pulmonary Parasites Textbook of Veterinary Diagnostic Radiology, Donald E Thrall, fourth edition 51 17

18 Combination Patterns Alveolar plus Nodular Interstitial Fungal disease (small nodules) Malignant Histiocytosis Lymphomatoid Granulomatosis Abscesses? Bronchointerstitial Chronic allergic lung disease Pulmonary Fibrosis 52 Combination Patterns Malignant Histiocytosis 53 Mineralization of Lungs Typically dystrophic Age related changes/idiopathic Pulmonary osseous metaplasia Chronic allergic lung disease Previous abscess Previous parasitic disease Thromboembolic disease Cushing s Syndrome Hypothyroid dogs with vascular mineralization Chronic uremia Neoplasia Not commonly seen 54 18

19 Pulmonary Mineralization Pulmonary Osseous Metaplasia 55 Vascular Mineralization 56 Pulmonary Mineralization Aortic Bulb Mineralization 57 19

20 Recap Decide which pulmonary pattern is present Distribution Look at concurrent pathology (heart, vessels, esophagus, abdomen, etc.) Make your differentials Does this fit with the clinic picture? What further tests might be needed to prove or disprove findings? 58 Still Confused? Send your radiographs to a radiologist. 59 Thank you for attending today s webinar: A Review of Pulmonary Patterns Sofija R. Liles, DVM, DACVR For a complete list of educational events, visit us online at idexxlearningcenter.com

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