What does it all mean?

Mike Ackerley

OverviewWhat 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 AlveolarBronchialMixed

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 laterallyUnstructured

Fluid (non-cardiogenic edema) Cells (pneumonia – bacterial, fungal, viral) Scar tissue (contusions) Age Artifact?

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 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 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 differentials?Unstructured

Cardiogenic edema (fluid): precedes alveolar patternNon-cardiogenic edema: usually caudodorsal

Near drowning Epilespy, seizure Electric cord bite Head trauma

Hemorrhage/contusions: DIC, anticoagulant poisoning

Neoplasia: Lymphoma, metastatic (hemangio/adenocarcinoma)

AllergicParasitic: Heartworm or lungworms

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?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 collapseAnesthesia Pleural effusionPneumothoraxAsthmaLung lobe torsion – usually right middle lung lobe

Remember Dr. Ps ABCsA = Atelectasis, AnesthesiaB = Bronchopneumonia, Bacterial pneumoniaC = Contusion, Cancer D = DirofilariaE = Edema (Cardiogenic and Non)F = Bronchial Foreign Body (caudal lobes)G = Granulomatous (Fungal)H = Hemorrhage

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 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 differentials?Bronchial Mineralization

AGE: Insignificant in older and chondrodystrophic dogs

Calcification of peribronchial mucus glands in catsHyperadrenocorticism or long term corticosteroid

use

Bronchial ThickeningChronic bronchitis: older animalsFeline asthmaPIE – Pulmonary Infiltrate with eosinophiliaParasites (aelurostrongylosis)Neoplasia: Lymphoma, bronchogenic

adenocarcinoma

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 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