Diseases of the lungs and thorax

Question 1

UL of the thorax:

• indications (favourable situations)

Answer 1

• pleural fluid
• superficial localization
• Not contact with lungs
• contact with the thoracic wall
• contact with the diaphragm
• contact with the heart

Question 2

UL of the thorax

• unfavourable situations

Answer 2

• deep localization
• lung artifact
• rib artifact

Question 3

History and clinical sign of the mediastial disease

Answer 3

• History
• trauma, foreig body ingestion, invasive diagnostic/therapeutic procedures (trachea, esophagus, cervical region)
• Clinical signs:
• dysphagia, regurgitation, cough, Horner´s syndrome
• Physical examination:
• poor compressibility of the cranial thorax
• peripheral lymphadeopathy, PU/PD, weight loss

Question 4

Diagnostic evaluation of the mediastinum

Answer 4

• not easily accessible (location)
• Survey radiography: LL and DV/VD
• normal is difficult to evaluate (lack of contrasting tissue densities)
• increased size (fat, inflammation, hemorrhage, edema, thymoma)
• pneumomediastinum (visualization of aorta, esophagus)
• UL
• Mediastinal masses (thymoma), FNA
• CT:
• most detailed analysis
• but: anaesthesia, mass or collpased lung lobe?

Question 5

Diseases of the mediuastinum

Answer 5

• mediastinitis
• mediastinal neoplasia
• pneumomediastinum

Question 6

Mediastinitis

• Causes, clinical signs

Answer 6

• Acute, chronic: underlying disease
• Causes:
• tracheal-, esophageal perforation
• infection (pleural space, lung, pericardium)
• Clinical signs:
• Head and neck edema, tachypnea (pain), dyspnea, cough, regurgitation, fever, voice change (recurrent laryngeal nerve)

Question 7

Mediastinitis

• diagnosis, treatment

Answer 7

• Physical examination: decreased lung sounds
• Radiography:
• Focal or diffuse widening, PTX, pneumomediastinum, pleural effusion
• Treatment:
• antibiotics
• perforation of trachea, esophagus
• surgical resection of mediastinal masses
• pyothrax (thoracostomy tube placement)

Question 8

Mediastinal neoplasia

• origin, clinical signs, physical examination

Answer 8

• origin:
• lumphoma, thyoma, chemodectoma, esophagus, trachea
• Clinical signs:
• Tachypnea,
• neck-, head-, forelimb edema
• regurgitation, PU/PD, Horners syndrome
• Physical examination:
• dislocation of the heart, compressibility of the cranial thorax decreases (cats)
• dyspnea (mass, pleural effusion)
• dull areas on percussion of chest

Question 9

Disorders of the pleural cavity and mediastinum

• sign, diagnosis

Answer 9

Pleural or mediastinal mass (neoplasm, abscess, lymph node)

• Signs:
• +/- edema of the forelimbs (if the vena cava is compressed)
• +/- thoracal wall thickening (osteoma or osteosarcoma from the thoracic wall)
• asymetric breathing movements and sound or circumscribed dullness
• cardiac dislocation
• cat: thorax is not to be compressed!
• Diagnosis:
• Radiography
• thoracal ultrsonography
• puncture or biopsy
• Blood count, punctate cytology or histology of biopsy sample
• diagnostic thoracotomy, thoracoscopy)

Question 10

Symptoms of Unilateral mesothelioma in dog

Answer 10

• asymetric thorax
• The respiratoric movements wew asymatric as well
• in addition, unilateral dullness was detected by thoracic percussion

Question 11

what can cause Pneumomediastinum

Answer 11

Pneumomediastinum: presence of air within the mediastinum

• secondary to:
• Trauma of the neck, subcutaneous emphysema
• rupture of the airways (bronchitis, pneumonia, transtracheal aspiration, tracheostomy, trauma)
• Esophageal rupture
• Normal communication:
• between the neck, mediastinum retroperitoneal region of the abdomen

Question 12

Pneumomediastinum

• clinical signs, what do you see on x-ray, treatment

Answer 12

• Clinical signs:
• Tachypnea, dyspnea (PTX),
• regurgitation (esophageal rupture),
• emphysema of the neck
• Radiography:
• air within ght neck region and within the mediastinum
• Pneumomediastinum, PTX, pneumoperitoneum
• Treatment:
• Sponteneous recovery
• PTX (chest tubing?)
• Underlying disease (esophageal, tracheal rupture)

Question 13

Diseases of the pleural space

Answer 13

• pleural effusion
• pleural mass
• pneumothorax
• diaphragmatic hernia

Question 14

Diagnostic aspects and clinical sign of pleural effusion (PE)

Answer 14

• Clinical signs and physical examination:
• inspiratory type dyspnea with delayed expiration
  
  • either pleural disorder or stenosis cranial from the thoracic inlet (laryngeal paralysis, bronchial collapse etc.)
• tachypnoe, open mouth breahing, cyanosis
• percussion: horizontal dullness (ALWAYS in case of fluid), Diernhofer-traingle will disappear
• Auscultation: bronchial sounds above and zero sound under the fluid
• thoracocentesis:
• cytology, culture, biochemistry, blood count

Question 15

Pleural effusion

• types of fluid that can be found

Answer 15

Transudate (true), modified transudate, exudate (protein, cell count)

• Hydrothorax:
• hypoalbuminemia
• congestive heart failure: mainly in cats
• diaphragmatic hernia, portal hypertension
• Pyothorax:
• FIP, pleuritis exsudativa
• Chylothorax
• Hemothorax:
• coagulopathy; dicumarol poisoning, hemophilia
• trauma
• thoracic neoplasm (haemangiosarcoma), thymus apoplexia (dog)

Question 16

Pyothorax/pleuritis

• caused by

Answer 16

• obligate anaerobes, Actinomyces, Nocardia spp.
• Penetrating thoracic wounds, migratory foreign material (grass awns), hematogenous metastasis (lung

Question 17

Pyothorax/pleuritis

• diagnosis, therapy

Answer 17

• Dignosis: cytology, culture
• Therapy:
• thoracocentesis, chest tubing, thoracic lavage
• antiobiotics (in case om culture correction), analgetics
• surgery (lobectomy, foreign body?)
• NEVER give Ab before doing pleurocyntesis

Question 18

Exudative pleuritis

• etiology

Answer 18

• Anaerobe bacteria: e.g Actinomyces
• Nocardia asteroides spp. canis:
• both in dogs and cats, mainly via skin injuries (rarely aerogenic or enteral infection), reddish-brown, turbulent grits-like exudate; honey (peritonitis can also occur)
• Thoracic traumas, wandering foreign bodies, esophageal perforation, haematogenous spread
• FIP:
• in cats, (honey-(resin-)like, viscous exudate (++ fibrinogen and glubulin)
• more commonly peritonitis, or can be in body cavities

Question 19

Exudative pleuritis

• diagnosis, treatment

Answer 19

• diagnosis:
• Total protein (FIP: > 35 G/l, globulin > 50%
• FIT test (questionable result)
• cytology, bacterial culture
• Treatment:
• thoracocentesis, drainage, lavage
• antibacterial drugs, analgesic
• surgery (lobectomy, removal of foreign body)

Question 20

Chylothorax

• causes, diagnosis, therapy

Answer 20

Lymphatic vessels –> thoracic duct –> cranial venaa cava

• causes:
• decreased lymphatic drainage
• diagnosis:
• thoracocentesis, cytology,
• truglyceride fluid: pleural fluid > blood plasma; lymphangiography (contrast into the spleen or ln. nodes, mostly used before surgery)
• therapy:
• thoracocentesis, underlying cause, low-fat dieet, surgery

Question 21

Reasons for chylothorax

Answer 21

• congenital:
• congential weakenss of the lymphatic vessels (lymphangiectasia)
• idiopathic
• non-traumatic (disturbed lymphatic drainage)
• right sided cardiac failure
• compression of the thoracic duct: tumor, inflammatory adhesion

Question 22

Classifications of Pneumothorax

Answer 22

Air accumulation on the pleural spcae (pneumomediastinum)

• Classification:
• Traumatic PTX - most common:
  
  • blunt trauma, penetrating injuries
• Spontaneous PTX
  
  • Idiopathic: large, deep-chested dogs (huskies!)
  • Secondary rupture of airways (bullae?, inflammation?)
• Simple/complicated/tensioned
• Open/closed

Question 23

Pneumothorax

• clinical signs

Answer 23

• acute inspiratory dyspnea
• cyanosis
• decreased lung and heart sounds
• decreased respiratory sounds
• increased resonance
• underlying disease (wounds, rib fractures, coughing)
• high tympanic sounds in percussion!

Question 24

Pneumothorax

• diagnosis, treatment

Answer 24

• Diagnosis
• thoracocentesis
• Radiography is obligatory!
  
  • 3 typical findings on x-rays: Heart elevevated from the sternum. The respiratory organs can be seen very obvious due to the contrast effect of the air. Compression on the lung
• treatment:
• thoracocentesis/chest tubing
• cage rest, oxygen
• surgery (open chest wound, airway leaking)
• control radiography

Question 25

Pneumothorax - radiographic differential diagnosis

Answer 25

- "microcardia" due to dehydration: Addison disease, parvovirus enteritis - Improper recumbency positioning during laterolateral radiography

Question 26

Pneumothorax - treatment in case of simple/complicated, tension, open/closed, trauma/spontaneous

Answer 26

- Simple: thoracocentesis +/- - Complicated: repeated accumulation of air --\> thoracic drainage catheter - Tension: rapid decline in cardiopulmonary status and death if not recognized and treated immediatly! * tear in the lung or chest wall that creates a flap valve - Open/closed - Trauma/spontaneous: PTX (ruptured emphysema, neoplasia, abscess esophageal tears/foreign bodies, heartworm)

Question 27

Causes of Traumatic pneumothorax

Answer 27

* pneumothorax (open/closed/tension) * rib fracture * airway obstruction * pulmonary contusion/hemothorax/cardiac temponade/diaphragmatic hernia * hypovolemic shock

Question 28

Treatment of open chest wound in PTX

Answer 28

1. close the wound as quick as possible 2. thoracocentesis/thoracostomy tube 3. antibiotics 4. if the patient is stable, the open chest wound can be surgically explored, lavaged and definitively corrected 5. radiographs after stabilisation

Question 29

Classifications of Diaphragmatic hernia

Answer 29

Abdominal contents enter the thoracic cavity - Classification * Pleuroperitoneal (can be congenital( / Peritoneopericardial (PPDH) * Traumatic \> congential (PPDHH \> hiatal hernia)

Question 30

Diaphragmatic hernia - clinical signs

Answer 30

* mixed or insiratory type dyspnea * shock, stomack distension * dullness, asymmetric rspiratory noises * cyanosis, arrythmia * Not possible to diagnose based on physical examination, you need x-ray!

Question 31

Diaphragmatic hernia - diagnosis. treatment

Answer 31

- Diagnosis: * radiography, UL * Barium sukphate given before x-ray * Cave! * thoracocentesis: can be blood-tinged fluid (need UL so you dont puncture the liver!) - treatment: * surgery!