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Lung Expansion in the Diagnosis of Lung Disease

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Lung Expansion in the Diagnosis of Lung Disease Lung Expansion in the Diagnosis of Lung Disease Kevin Winegardner, DVM Peter V. Scrivani, DVM Robin D. Gleed, BVSc, MRCVS Cornell University Ithaca, New York ABSTRACT: The most common abnormality detected during thoracic radiography of patients with lung disease is increased opacity of the lungs. Although sensitive for lung disease, this finding alone is not specific for the cause of lung disease. Other conditions that increase lung opacity include technical complications and extrapulmonary lesions that compress the lung. Therefore, other radiographic signs are used to make a more definitive diagnosis. The size of the abnormally opaque lung lobe can be helpful in differentiating lung disease from other conditions. If the lung is normal to large in size, it is considered expanded . This situation always indicates disease. If the lung is small, it is considered incompletely expanded. This finding indicates pulmonary, thoracic wall, or pleural space disease or a technical complication. Common terms that are used to describe the volume of expanded or incompletely expanded lungs include infiltration, consolidation, collapse, and atelectasis . Although they are used as radiographic diagnoses, these terms should not be considered an end- point analysis, and other radiographic signs must be sought to make a more definitive diagnosis. he radiographic opacity of normal lungs is but often is not specific for the cause of pul - the result of a balance between air-filled monary disease. More specific tests for pul - Tspaces and pulmonary blood vessels . Other monary disease rely on recognizing patterns of lung structures (e.g., bronchial walls, interstitium) increased opacity and other radiographic signs. are generally too small to be seen when normal. One of the most important signs , in combination During disease, the opacity of the lungs is fre - with altered opacity , is the size of the affected quently altered. Therefore, it is important to be lung. When a lung lobe is normal or increased in able to recognize the normal opacity of the lungs size, it is described as expanded . Infiltrated and because abnormal opacity is a consolidated are other terms that are used to sign of lung disease. In veteri - describe this appearance. When the lung lobe is nary medicine, most pul - decreased in size, it is described as incompletely •Take CE tests monary diseases produce an expanded . The terms collapsed and atelectatic are • See full-text articles increased opacity of the lungs also used to describe this appearance. CompendiumVet.com (i.e., they appear more white), Although commonly used in veterinary medi - which is a significant finding cine, these other terms are sometimes controver - September 2008 479 COMPENDIUM 480 Lung Expansion in the Diagnosis of Lung Disease Figure 1. Interstitial versus alveolar pattern. An example of a diffuse interstitial pattern, also called a An example of a diffuse alveolar pattern, also called a diffuse air -space diffuse air -space pattern , in a lateral thoracic radiograph pattern, in a lateral thoracic radiograph from a middle -aged cat with from a geriatric cat with tachypnea. In the lungs, there is a severe respiratory distress. In the lungs, there is a severe, diffuse increase moderate, diffuse increase in soft tissue opacity that in soft tissue opacity that is worse centrally, completely obscures partially silhouettes with pulmonary blood vessel margins. pulmonary blood vessel margins and adjacent heart margins, and creates The differential diagnosis for this lesion is broad; in this air bronchograms. The differential diagnosis for this lesion distribution is case , the lung pattern was due to left congestive cardiac also broad; however, the lung pattern in this case was also due to left failure secondary to hypertrophic cardiomyopathy. congestive cardiac failure secondary to hypertrophic cardiomyopathy. sial because they may be mistakenly used as an end-point preference; we use atelectasis in this article. When a analysis that does not sufficiently describe all the available neonate lung that never fully expanded is described, the radiographic information. Rather, they should be consid - term anectasis (also called primary atelectasis ) is used . This ered radiographic diagnoses that prompt the clinician to situation is considered separate from atelectasis because make a differential diagnosis. Therefore, we emphasize it indicates that the lung never expanded after birth, not that differentiating whether the lung is expanded is only that it expanded and subsequently collapsed. 1–3 one step in the overall process of making a radiographic The term unstructured interstitial pattern has been used diagnosis. We also emphasize the need to understand the to describe lungs that have increased opacity without terminology used. complete effacement of pulmonary blood vessel margins. Unstructured interstitial pattern has also been used to TERMINOLOGY AND DEFINITIONS describe lungs that are reduced in size (i.e., atelectatic) Infiltration is the migration of gas, fluid , or cells into a due to incomplete inhalation or to partial lung collapse substance, cell , or tissue. 1,2 Examples include deep s oft caused by pleural fluid .5 However , the term interstitial tissue emphysema secondary to a tracheal tear and the pattern has classically indicated that there is infiltration accumulation of white blood cells in the prostate in of fluid or cells into the non –air-containing elements of response to infection. Consolidation can be considered the lung. 5 Infiltration does not occur during incomplete solidification of tissue and is applied especially to inflam - inhalation or partial lung collapse; therefore, the term matory induration of a normally aerated lung by cellular interstitial pattern is misleading in these cases because it exudates in the pulmonary alveoli; this process occurs in does not precisely represent the underlying pathogenesis. pneumonia, lung infarct, neoplastic infiltration , and other Other descriptions of atelectasis use the term alveolar conditions. 1–4 Both terms are used to describe the patho - pattern .5–7 This description is more appropriate because logic process that is suspected to be present when a lung an alveolar pattern is produced when a portion of the of normal or increased size has increased radiographic lung contains less than the normal volume of air due to opacity. Atelectasis is a decrease in, or complete loss of, air either the collapse of or infiltration (cells or fluid) into in the lung with resultant decreased volume of the ini - the alveolar air spaces. 5–7 In our experience, interstitial tially expanded lung. 1–4 The terms atelectasis and collapse pattern and alveolar pattern have been used to describe are used synonymously and often according to personal differences in severity of reduced lung size . COMPENDIUM September 2008 Lung Expansion in the Diagnosis of Lung Disease 481 Another reported descriptor used for lungs with increased opacity is air-space pattern .5 This term may be preferable because it can be modified to denote severity. For example, a mild air-space pattern would correspond with the use of interstitial pattern to denote less severe disease with partial obscuring of the pulmonary blood vessels , and a severe air-space pattern would correspond with the classic use of alveolar pattern to describe dis - ease in which the pulmonary blood vessels are completely obscured (Figure 1) . Alterna - tively, the lung may be described as having Figure 2. Orthogonal thoracic radiographs of a 6-year-old, spayed, increased opacity that is further character - mixed-breed dog that was admitted for lethargy, pyrexia, and ized by the use of other descriptors (e .g., dis - hemoptysis. The right middle lung lobe has a severe increase in opacity that silhouettes with pulmonary blood vessels and summates with the heart. Air tribution, lung size, air bronchograms, bronchograms and a lobar sign with adjacent lung lobes are also present. The silhouetting of blood vessels, lines , and rings) lung lobe is mildly increased in size, resulting in left displacement of the heart. to convey radiographic abnormalities with no These radiographic signs indicate a pattern of consolidation. mention of pattern. THE EXPANDED LUNG Consolidation or infiltration is recognized radiographically when a lung that is normal or increased in size has a relatively homoge - nous soft tissue opacity characterized by effacement of pulmonary blood vessels and , sometimes , air bronchograms (Figure 2). Consolidation or infiltration always produces an air-space pattern because there is infiltra - tion of the alveoli by fluid, cells , or both. Nor - mal or increased lung size is detected by knowing the normal extent of lung lobes and identifying bulging pleural surfaces or dis - Figure 3. Orthogonal thoracic radiographs of a 12-year-old neutered placement of structures (mediastinum, heart, malamute that was admitted for dental cleaning. During the dental procedure, adjacent unaffected lung) away from the patient ventilation became difficult , and thoracic radiography was performed to affected lung lobe (i.e., mass effect). Although identify the possible cause. During radiography, the dog was under general anesthesia the term consolidation may imply that the lung and positive-pressure ventilation was used. Several radiographic signs are visible: reduced size and increased opacity of the left caudal lung lobe, crowding and is solid, the diseases that produce consolida - reorienting of pulmonary blood vessels,
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