lung patterns: are they overemphasized? · aeration: atelectasis is bad lungs always look worse in...
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Lung Patterns: Are They Overemphasized?
Donald E Thrall, DVM, PhD
Ross University
School of Veterinary Medicine
Basseterre, St. Kitts
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Donald E Thrall, DVM, PhD
Ross University
School of Veterinary Medicine
Basseterre, St. Kitts
Lung Patterns: They Are Overemphasized?
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Lung Radiology Pattern Recognition is taught widely
Alveolar
Bronchial
Interstitial
Structured vs Unstructured
Is Pattern Recognition the best system?
Fail to consider normal vs. abnormal
Few diseases involve one compartment
Can’t make diagnosis from radiograph
For beginners (and maybe intermediates), too confusing
Confession…even radiologists argue about patterns
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Can It Be Simplified?
Is the radiograph normal?
Yes, it is abnormal
Is the airspace involved?
Is airway sampling
indicated?
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“Abnormal” usually means increased opacity
Radiographic technique (analog) Inadequate film blackness
Improper contrast
Aeration: Atelectasis is bad Lungs always look worse in lateral
views
Sedation leads to atelectasis
Habitus: Overlying tissue increases opacity in image Athletic breed?
Obese?
These non-pathologic entities lead to increased lung
opacity, and a false diagnosis of abnormal
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Correct Too Light
115136
Too Dark
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Effect of Ventilation
MRN141252
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Effect of Body Condition
146766
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Lateral vs. VD/DV
114627
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Lateral VD
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Effect of recumbency
93447
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Normal Disease adds to normal lung opacity
Normal will vary from practice to
practice
114529
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Lung Disease
Patterns
Alveolar
Bronchial
Interstitial
Structured
Unstructured
An Alternate
Airway
Non-Airway
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Why An Alternate? Pattern recognition overwhelmes inexperienced
interpreters
Become too focused on trying to assess the pattern
Lose sight of patient’s problem
Keep it simple
Can’t make diagnosis from radiographs regardless of
system
A key point is whether the airspaces are involved
Airway vs. non-airway will indicate usefulness of
transtracheal aspirate or bronchoalveolar lavage
Can still use distribution of lesions to help with
diagnosis
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Airway Disease Radiographic Signs
Air Bronchogram
Intense lung disease
Not a mass
Rings and Trams
Many patients will have a
cough or wheeze…but not
always
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Air Bronchogram
Air in lung, but
not bronchi,
displaced by fluid
or cells
More common in
dogs than cats
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Air Bronchograms Not an Air
Bronchogram
101840
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Intense Lung Disease
Alveolar disease
Indistinct margins
Lung mass
Distinct margins
110996
174205
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Pulmonary edema, cat; no air bronchograms
Note intensity
of lung
opacification
per unit area
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Rings and Tram Lines
Appearance
Circular opacities with lucent
centers
Parallel non-tapering lines
Some ring opacities are
normal
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Classic ring and tram pattern
Not Intense/Unit Area
115583
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Classic ring and tram pattern
Not Intense/Unit Area
115329
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Is the interstitium involved?
It doesn’t matter…there
clearly are abnormal
airways and a TTA or BAL
may be very useful in
narrowing the list of
ruleouts
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Definitely airway, but likely other compartment(s) as well
What is it?
Infection Pulmonary Edema Metastasis
Can’t make these diagnoses
from radiographs. Consider
history and signalment. TTA
or BAL likely to yield
diagnosis if clinically
indicated to perform.
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The Process
Normal or abnormal
Assess signalment and history
Start out by assessing airways
Less stringent pattern
recognition may facilitate next
diagnostic step
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Labrador, 13y
Cough for one month
Sputum occasionally blood-
tinged
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107830
This is confusing, but the airways are involved!
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TTA??
YES
Carcinoma
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Fel, DSH, 10y
History of anemia
Increased respiratory sounds
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A153182
TTA?
Doubtful
Post: FIP
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The End