PULMONARY IMAGING:

GETTING THE MOST INFORMATION FROM THORACIC RADIOGRAPHS

Peter Scrivani, DVM, DACVR
Cornell University College of Veterinary Medicine, Ithaca, NY

Outline

• Pulmonary anatomy
• Selecting the imaging examination
• Principles of radiographic interpretation
The incompletely expanded lung
Pulmonary Imaging
•
Break
• The fully expanded lung
• Summary

Peter V. Scrivani, DVM

Assistant Professor, Department of Clinical Sciences

Pulmonary Anatomy

• 2 lungs
– Left
– Right
• 2 “lung fields”
– Cranioventral
– Caudodorsal

Pulmonary Anatomy Dog: Left lung

Gross Anatomy Gross Anatomy

• 6 lung lobes • Trachea

– Right cranial – Principal bronchi
– Right middle • Lobar bronchi
– Right caudal – Segmental bronchi
» Bronchi
– Accessory
• Bronchioles
– Left caudal
– Left cranial
• Cranial part
• Caudal part

• Bronchopulmonary segments

226111 187515 LLAT RLAT

1
 Gross Anatomy Artery, Bronchus, Vein

Artery, bronchus, vein

Veterinary Radiology & Ultrasonography 2012;53(1):1-10.

Histologic Anatomy Histologic Anatomy

Conducting Zone Respiratory Zone

Veterinary Radiology & Ultrasonography 2012;53(1):1-10.

Radiographic Localization of Lung Disease Gross & Histologic Anatomy

• Lung
– Lobe
• Bronchopulmonary segment
–Secondary pulmonary lobule
»Pulmonary acinus
• Primary pulmonary lobule
• Alveolus
• Wall (interstitial pattern)
• Bronchovascular bundle (conducting zone)
• Pulmonary parenchyma (respiratory zone) • Space (alveolar pattern)
• Pulmonary blood vessels

2
 Gross & Histologic Anatomy Gross & Histologic Anatomy

• Lung • Lung
– Lobe – Lobe
• Bronchopulmonary segment • Bronchopulmonary segment
–Secondary pulmonary lobule –Secondary pulmonary lobule
»Pulmonary acinus Imaging limit »Pulmonary acinus Imaging limit

• Primary pulmonary lobule • Primary pulmonary lobule
• Alveolus • Alveolus
• Wall (interstitial pattern) • Wall (interstitial pattern)
• Space (alveolar pattern) • Space (alveolar pattern)

Anatomic Organization of the Lung Anatomic Organization of the Lung

Computed tomography of the lung, A pattern approach, 2007, Springer Computed tomography of the lung, A pattern approach, 2007, Springer

Anatomic Organization of the Lung Pulmonary Interstitium

Connective Tissue

Computed tomography of the lung, A pattern approach, 2007, Springer Computed tomography of the lung, A pattern approach, 2007, Springer

3
 Pulmonary Interstitium Pulmonary Interstitium
Connective Tissue Connective Tissue

1. Subpleural space, bronchopulmonary segments, 1. Subpleural space, bronchopulmonary segments,

secondary pulmonary lobules, & pulmonary acini secondary pulmonary lobules, & pulmonary acini
2. Originate at hilum, surrounds bronchovascular 2. Originate at hilum, surrounds bronchovascular
structures & alveoli structures & alveoli
3. Between the alveoli and capillaries (alveolar wall) 3. Between the alveoli and capillaries (alveolar wall)

Computed tomography of the lung, A pattern approach, 2007, Springer Computed tomography of the lung, A pattern approach, 2007, Springer

Bovine & Canine Lungs

Selecting the Examination

Selecting the Examination “Up” lung

• Orthogonal-view thoracic radiography

– RLAT and DV Cardiac cases
– LLAT and VD Respiratory cases
– Other combinations
• 1-view thoracic radiography L
• 3-view thoracic radiography
• Thoracic CT

In small-animals, see lung lesions best in the “up” lung R

Other lesions best when placed close to the detector 195681

4
 LLAT & RLAT DV & VD

221686 191703

DV & VD

Principles of Interpretation

192308 Pleural fluid

Principles of Radiographic Interpretation Breed Conformation

• Assuming proper
– Examination
– Positioning
– Exposure
– No superimposition
of collar, wet hair, etc.

227238—Boxer 203368—Chihuahua

5
 Age-related Changes & Body Condition Principles of Radiographic Interpretation

• Classic pattern approach

– Interstitial pattern
– Alveolar pattern
– Bronchial pattern
– Vascular pattern
– Mixed pattern

206192

Principles of Radiographic Interpretation Principles of Radiographic Interpretation

• Pulmonary patterns are a combination of signs • Pulmonary patterns are a combination of signs
– Degree of lung expansion – Degree of lung expansion
– The opacity of the lung • Reduced, normal, or increased
– Appearance of increased opacity – The opacity of the lung
– Macroscopic distribution of altered opacity • Increased or decreased
– Additional signs – Appearance of increased opacity
• Alveolar, interstitial, bronchial, vascular
– Macroscopic distribution of altered opacity
• Cranioventral, diffuse, lobar, focal, etc
– Additional signs

Principles of Radiographic Interpretation

• Pulmonary patterns are a combination of signs

– Degree of lung expansion
• Reduced, normal, or increased
– The opacity of the lung
• Increased or decreased
– Appearance of increased opacity
• Alveolar, interstitial, bronchial, vascular
– Macroscopic distribution of altered opacity Incomplete Lung Expansion
• Cranioventral, diffuse, lobar, focal, etc
– Additional signs

6
 Incomplete Lung Expansion Incomplete Lung Expansion

• Often considered as only

a technical complication
– Obscure pathology
– Spurious pathology
• Cardiomegaly
• Increased lung opacity

Exhalation Exhalation Inhalation

224972 224972

Incomplete Lung Expansion Signs of Incomplete Lung Expansion

• Commonly due to normal exhalation • Decreased lung size • Compensatory hyperinflation

• Increased opacity • Bronchial rearrangement
• Can be a component of the disease process • Lobar sign • Cardiac rotation
– Reduced or absent gas exchange • Crowding of ribs • Displacement of diaphragm
– Clue to the underlying pathology • Air bronchogram sign • Rounded pulmonary margins
• Positive silhouette sign • Displacement of pleural fissures
• Poorly defined margins of vessels • Changed location of abnormal
• Mediastinal shift (toward collapse) structures
• Crowding and reorientation of
pulmonary blood vessels

Textbook of Veterinary Diagnostic Radiology, 3rd Ed.

Signs of Incomplete Lung Expansion Incomplete Lung Expansion

• Anectasis
– Lungs never expanded
• Atelectasis
– Lungs previously expanded then collapsed
• Collapse
– Same as atelectasis, but often used when more severe
– Less severity may be indicated by “partial collapse”

191582 9-year-old, MC, Weimaraner

7
 Atelectasis or Collapse Relaxation Atelectasis

• Related to physiology of lung expansion • Lung does not expand due to the unopposed
– Elasticity tendency for lung to collapse due to elasticity
– Compliance – Exhalation
– Airway patency – Pleural fluid
– Surface tension – 100% oxygen
– Pneumothorax
– Shallow breathing
– Gravity dependent
– Space-occupying lesion

Relaxation Atelectasis Relaxation Atelectasis

0.6-year-old, M,
Siberian husky

5-year-old, FS,
mixed-breed dog

176633 165188 186202 11-year-old, FS, mixed-breed dog

Obstructive Atelectasis Obstructive Atelectasis

• Lung not expanded due to absorption of L

alveolar gas without replacement due to

airway obstruction
– Infectious bronchitis or pneumonia
– Mucous plugging (eg, asthma)
– Ciliary dyskinesia
– Foreign body R
– Neoplasm

186808 13-year-old, FS, DSH Cat

8
 Obstructive Atelectasis Obstructive Atelectasis

Basal cell carcinoma

186808 13-year-old, FS, DSH Cat 11-year-old, MC, DLH Cat

5-year-old, M, Labrador Retriever 5-year-old, M, Labrador Retriever

with Chronic Coughing with Chronic Coughing

Compare lung expansion on both laterals

220061 Compare lung expansion on both laterals 220061

Bronchial Foreign Bodies Feline Asthma

• Visible foreign body

• No radiographic sign
• Obstructive atelectasis
– Chronic
– Complete obstruction
• Obstructive emphysema
– Acute
– Partial obstruction
Cat found dead in cage
Tracheal foreign body (kibble)

194119 Collapsed & hyperinflated lung lobes

9
 Cicatrizing Atelectasis Compliance

• Lungs do not increase in volume under normal • Relationship between volume & pressure
respiration due to reduced compliance
– Chronic immune-mediated lung disease
Volume
– Chronic idiopathic fibrosis
– Radiation pneumonitis
– Chronic pneumonia

Pressure

Cicatrizing Atelectasis Pulmonary Fibrosis

14-year-old, MC, West Highland White terrier

144037 with chronic idiopathic pulmonary fibrosis 140648 Unspecified age, FS, mixed-breed dog

Restrictive Pleuritis Adhesive Atelectasis

• Lungs do not expand due to lumen surfaces of

alveoli sticking from surfactant abnormality
– Neonatal respiratory distress syndrome
– Acute respiratory distress syndrome
– Pulmonary thrombosis

Surfactants (surface active agents) are compounds that

lower the surface tension between two liquids or between a
liquid and solid. Surfactants may act as detergents, wetting
agents, emulsifiers, foaming agents, and dispersants.

226429 VD LLAT RLAT 1-month

10
 Adhesive Atelectasis Ventilation and Perfusion

• Goal is to match ventilation of air (V) with the

perfusion of blood flow (Q) to the lung
– Ventilation perfusion quotient (V/Q) is the amount of
air that is breathed in and perfused into the blood
• V/Q affected by
– Gravity
– Normal physiology
– Disease

Pre-mature, F, Thoroughbred horse

Lung Zones Gravity Affects V/Q

1 V>Q

2 V=Q

8-year-old, F, Golden Retriever 4-year-old, F, Saanan Goat

Atelectasis Blood Pooling

3 V<Q

223822 217161 878375

Gravity Affects V/Q Physiologic Regulation of V/Q

• Zone 1: V>Q • Normal breathing = tidal breath

– Hypotension – Half of the alveoli are normally collapsed
– Hyperexpanded alveoli • Improve V/Q across lung zones
• Zone 2: V=Q – Take a deep breath
– Normotensive – Hypoxic vasoconstriction
– Normally expanded • The alveoli that are not well ventilate stimulate
• Zone 3: V<Q arteriole vasoconstriction to those alveoli and
increases blood flow to the rest of the lung
– Hypertension – Reduces size of Zone 3
– Collapsed alveoli – Increases size of Zone 2

11
 Hypoxic Vasoconstriction Hypoxic Vasoconstriction

• Normal Lungs 1 V>Q

– Only well ventilated alveoli receive blood flow
– Poorly ventilated alveoli are not perfused

Lung Zone
2 V=Q

3 V<Q

215746 223822

Hypoxic Vasoconstriction Atelectasis

• Pulmonary Inflammation
– Increased vasodilation
• Perfusion to non-ventilated lung
• V/Q mismatch

V<Q • Can be a technical complication

Decreased oxygen saturation
• Can cause decreased V/Q
“Functional R-L shunt”
– An important component of the disease process
due to reduced gas exchange
– A source of “shunt” in anesthetized patients
• Hypoxic vasoconstriction ineffective in anesthesia
215746 219400

Atelectasis as a Diagnostic Clue

• Indicator of lung disease and process

• Differentiating types of atelectasis
– Not always possible
– Regional vs diffuse
– Acute vs chronic

The Fully Expanded Lung

12
 Importance of Lung Size The Fully Expanded Lung

Altered Lung Opacity • The opacity of the lung

• Appearance of increased opacity
Reduced Size Normal-to-Increased Size
• Macroscopic distribution of altered opacity
Technical
Complication Disease Disease

Incidental PPV

Obscured Pathology

Misidentified Pathology

Lung Opacity Decreased Lung Opacity

• Decreased
• Normal
• Increased

Congenital lobar emphysema

Courtesy of Dr. Anthony Fischetti

Hypovolemia Appearance of Increased Lung Opacity

• Classic description
– Interstitial pattern
– Alveolar pattern
– Bronchial pattern
– Vascular pattern
– Mixed pattern

163034

13
 Appearance of Increased Lung Opacity Appearance of Increased Lung Opacity

• Classic description • Variable terminology • Classic description • Variable terminology

– Interstitial pattern – Interstitial – Interstitial pattern – Bronchial
– Alveolar pattern • Unstructured – Alveolar pattern • Bronchointerstitial
– Bronchial pattern • Structured – Bronchial pattern • Peribronchial
– Vascular pattern – Nodular – Vascular pattern – Vascular
– Reticular
– Mixed pattern – Mixed pattern • Bronchovascular
– Alveolar
• Alveolointerstitial
• Airspace

Disease of Pulmonary Blood Vessels Disease of the Pulmonary Parenchyma

• Vascular pattern • Classic description

– Pulmonary artery enlargement – Interstitial pattern
– Pulmonary venous congestion Clear glass
– Alveolar pattern Ground glass
– Pulmonary over-perfusion
Opaque glass

Patent Ductus Arteriosus

Respiratory Zone
203393

Disease of the Pulmonary Parenchyma Disease of the Pulmonary Parenchyma

212701 204095 193750

Fully aerated Partially aerated Void of air

Interstitial Alveolar Groundglass opacity Consolidated
Ground-glass opacity* Consolidated*

Relates to the ability to see the pulmonary blood vessels

Fleischner Society: Glossary of Terms for Thoracic Imaging

Radiology 2008;246(3):697-722. *Terms apply to incompletely and fully inflated lungs In all 3 examples, the lungs are fully expanded

14
 Disease of the Pulmonary Parenchyma Disease of the Pulmonary Parenchyma

Atelectasis

Mass

Ground-glass opacity Consolidated

Relates to the ability to see the pulmonary blood vessels

227765 201539 221546

Consolidated Lung Groundglass Opacity vs. Consolidation

(Pulmonary Blood Vessels Obscured)

• Due to differences in lung density

– Important for patient management
Without air bronchograms – Defined by how much air is displaced from lungs
• Filling the alveolar spaces with fluid or cells
• Filling the alveolar walls with fluid or cells
• Partial or complete collapse
• Increased blood flow
With air bronchograms

224090

Air Is Displaced From The Lungs By Air Is Displaced From The Lungs By
Attenuation of the voxel or X-ray path Attenuation of the voxel or X-ray path

A B C

D E F

A. Normal lung D. Thick interstitium A. Normal lung D. Thick interstitium

B. Atelectasis E. Filled alveoli B. Atelectasis E. Filled alveoli
C. Hyperemia F. Thick alveolar wall & filled alveolar space C. Hyperemia F. Thick alveolar wall & filled alveolar space

15
 Acute Respiratory Distress Syndrome Lung Inflammation

• Lung inflammation can cause acute lung injury (ALI) • Inhaled

– Burns
– Infections
– Chemicals
• Hematogenous spread
of inflammatory mediators
– Ischemic gut
– Infection elsewhere

218700 Lung is “first stop” for inflammation elsewhere in the body

Lung Inflammation Pulmonary Pathophysiology

• Acute respiratory failure • Acute respiratory failure

• Chronic respiratory failure – Leaky capillaries & vasodilation
• Pulmonary edema
– Decreased diffusion/hypoxia
– Flooding of alveoli
• V/Q mismatch (R-L shunt)
– Decreased surfactant
• Decreased compliance
• Chronic respiratory failure
– Fibrosis
• Decreased diffusion
• Decreased compliance

Pulmonary Pathophysiology Pulmonary Pathophysiology

• Acute respiratory failure • Acute respiratory failure

– Leaky capillaries & vasodilation – Leaky capillaries & vasodilation
• Pulmonary edema • Pulmonary edema
– Decreased diffusion/hypoxia – Decreased diffusion/hypoxia
– Flooding of alveoli – Flooding of alveoli
• V/Q mismatch (R-L shunt) • V/Q mismatch (R-L shunt)
– Decreased surfactant – Decreased surfactant
• Decreased compliance • Decreased compliance
• Chronic respiratory failure • Chronic respiratory failure
– Fibrosis – Fibrosis
• Decreased diffusion • Decreased diffusion
• Decreased compliance • Decreased compliance
Neutrophil influx damages
Type II pneumocytes

16
 Pulmonary Pathophysiology It is Understandable

• Acute respiratory failure • Why lung patterns are

– Leaky capillaries & vasodilation commonly thought to refer to
• Pulmonary edema the microscopic localization of
– Decreased diffusion/hypoxia
lung lesions
– Flooding of alveoli
• V/Q mismatch (R-L shunt) – Interstitial pattern
– Decreased surfactant – Alveolar pattern
• Decreased compliance • However, the appearances
• Chronic respiratory failure relates to severity of air
– Fibrosis displacement and not the
• Decreased diffusion underlying cause of disease
• Decreased compliance

Compare, For Example Compare, For Example

• Left congestive heart failure causes

increased hydrostatic pressure
– Interstitial pattern
• Leaky capillaries & vasodilation
– Alveolar pattern
• Flooding of alveoli

201757 Metastatic mammary adenocarcinoma Carcinoma 201539

Disease of the Pulmonary Parenchyma Disease of the Bronchovascular Bundle

• Groundglass opacity or interstitial pattern • Classic description

– Affected lungs are partially aerated – Bronchial pattern
• Consolidation or alveolar pattern
– Affected lungs are void of air

Normal
What the pathologist calls “interstitial disease” is different
from what a radiologist calls an “interstitial pattern.” Suter & Lord

174941

17
 Disease of the Bronchovascular Bundle Bronchovascular Pattern

• Classic description • Bronchovascular bundle

– Bronchial pattern – Bronchi
– Arteries
– Veins Bronchovascular
– Lymphatic vessels
• Bronchiolovascular bundle
– Bronchioles
– Arterioles
– Venules
– Lymphatic vessels

Conducting Zone
Differentiate bronchovascular disease from an air bronchogram (parenchymal disease) Normal

Bronchovascular Pattern Blastomycosis

214640 217042 10-year-old, FS, German Shepherd

Bronchiectasis Bronchiectasis

202189 206507 183162 6-weeks later lung and bronchus are better aerated

18
 Some Take-Home Messages Some Take-Home Messages

• The appearances of increase opacity differentiates • Different appearances of parenchymal disease

– Bronchovascular diseases is determined by the ability to see the margins of
– Parenchymal diseases the pulmonary blood vessels
– Nodular diseases – This is helpful for determining disease severity
and not forming the differential diagnosis

Some Take-Home Messages Forming the Differential Diagnosis

• Interstitial pattern or groundglass opacity • Lung lobe size

indicates that the lungs are partially aerated • Opacity of the lung
– Not that disease is necessarily localized to interstitium • Appearance of increased opacity
• Alveolar pattern or consolidation indicates • Macroscopic distribution / shape of lesions
that the lungs are void of air
• Additional signs
– Not that disease is necessarily localized to the
alveolus
• Bronchial or bronchovascular pattern indicates
that disease is centered in or around the
bronchial wall

Macroscopic Distribution of Lung Disease Macroscopic Distribution of Lung Disease

• Cranioventral • Bronchocentric • Cranioventral

• Caudodorsal • Peripheral • Caudodorsal-to-diffuse
• Diffuse • Central • Focal
• Lobar • Secondary pulmonary lobule • Multifocal
• Locally extensive – Centrilobular
– Panlobular • Patchy/asymmetric
– “sublobar”
• Focal – Perilobular
• Multifocal
• Patchy/asymmetric

19
 Cranioventral & Caudodorsal Distributions Cranioventral Parenchymal Disease

• Pneumonia
– Aspiration
– Bronchopneumonia
• Hemorrhage
• Neoplasm
• Lung lobe torsion

215570

Caudodorsal-to-Diffuse Parenchymal Disease Example of Diffuse Distribution

• Cardiogenic pulmonary edema

• Non-cardiogenic pulmonary edema
– Upper airway obstruction
– Toxin inhalation
– ALI (SIRS/ARDS)
– Near drowning
– Neurogenic
– Vasculitis
– DIC
• Lymphoma

161844 218301

Diffuse Parenchymal vs. Generalized-Random Diffuse Bronchovascular Disease

• All causes of bronchitis

– Allergic
– Infectious
– Immune mediated
• Lymphatic spread of tumor
• Early pulmonary edema

Normal Generalized random Diffuse

20
 Diffuse Bronchovascular Disease Bronchocentric Distribution

• Bronchocentric
– Involves the pulmonary parenchyma around the
bronchovascular bundle

199892 Feline Asthma

Bronchocentric Differential Diagnosis Lobar/Sublobar Distributions

• Inflammatory
• Neoplasm

205295

Lobar Parenchymal Disease Sublobar Parenchymal Disease

• Pneumonia • Pneumonia
– Aspiration – Aspiration
– Bronchopneumonia – Bronchopneumonia
• Hemorrhage • Hemorrhage
• Neoplasm • Neoplasm
• Lung lobe torsion

187357 187862

21
 Aspiration Pneumonia Focal Distribution
Left Cranial Lobe (Caudal Part)

• Focal
– Milliary (<1 mm)
– Nodule (<3 cm)
– Mass (>3 cm)

Locally extensive

LLAT RLAT

201498

Focal/Multifocal Differential Diagnosis Ossifying Pulmonary Metaplasia

• C.H.A.N.G.
Cyst
Hematoma
Abscess
Neoplasm
Granuloma

202324 218657 209110

Patchy Distributions Patchy/Asymmetric Distribution

• Does not conform to other distributions

1 lesion multiple lesions

Trauma
177263

22
 Patchy/Asymmetric Parenchymal Disease Central & Peripheral Distributions

• Trauma • Central lung (hilar)

• Infection • Central lobe
• Neoplasia • Peripheral lung
• Hemorrhage • Peripheral lobe
• Inflammation

Rodenticide toxicity
212351

Hilar Secondary Pulmonary Lobule Distributions

A. Centrilobular
B. Panlobular
C. Perilobular

224932 1-day apart; possible resuscitation trauma

Perilobular & Centrilobular Distributions Mixed Pattern

• Use cautiously
– Often there is a mix, but we conclude the most severe
• Not the same as an asymmetric distribution

Perilobular Centrilobular
May appear nodular

197843

23
 Hemangiosarcoma Additional Signs

• Pulmonary
– Bullae
– Cavitary
– Mineralization
• Non-pulmonary
– Pleural fluid
– Heart enlargement
– Lymph node enlargement

226447 8-year-old, FS, German Shepherd 177238

Lung Lobe Torsion Pulmonary Adenocarcinoma

188929 225950 12-year-old, MC, DSH

Pulmonary Thromboembolism

Summary

192827 6-year-old, FS, Labrador retriever

24
 Key Points
Summary
• Pulmonary imaging interpretation
• Pulmonary anatomy – Anatomy
– Pathophysiology
• Selecting the imaging examination
– Physical principles of imaging modalities
• Principles of radiographic interpretation
• Pulmonary patterns are a combination of signs
• The incompletely expanded lung – Degree of lung expansion
• The fully expanded lung – The opacity of the lung
• Summary – Appearance of increased opacity
– Macroscopic distribution of altered opacity
– Additional signs

Lung Expansion & Opacity Appearance

• Size • Opacity • Bronchovascular disease

– Small – Decreased • Parenchymal disease
– Normal – Normal • Nodular disease
– Enlarged – Increased
• Vascular disease

Appearance Appearance

• Bronchovascular disease • Bronchovascular disease

– Conducting zone • Parenchymal disease
• Parenchymal disease – Groundglass opacity
– Respiratory zone – Consolidation How much gas is displaced
Atelectasis from the lungs
• Nodular disease –
– Collapse
• Vascular disease
• Nodular disease
– Milliary
– Nodule
– Mass
• Vascular disease

25
 Distribution Quantify Disease Severity

• Cranioventral • Normal • Normal

• Caudodorsal • Questionable • Small
• Diffuse • Mild • Medium
• Lobar • Moderate • Large
• Sublobar/locally extensive • Severe
• Focal
• Multifocal
• Patchy/asymmetric
• Secondary pulmonary lobule

Putting It Together Pulmonary Pattern Interpretation

• Severe, cranioventral, lung consolidation • Definitive diagnosis

• Large, focal, lung mass • Differential diagnoses
• Large, focal, cavitary lung mass • No diagnosis possible
• Moderate, generalized random, nodules
• Moderate, diffuse, atelectasis
• Mild, diffuse, groundglass pattern
• Mild, diffuse, bronchovascular pattern

Severity, distribution, appearance

26