So, I've got a few cases that I'm going to go through with you, there are a few questions to, to answer as we go through, so, keep, keep alert and, and, come in and do those questions because once you're committed, you're more likely to learn something than if you just think, well, I probably knew that, anyway, so you've got to commit yourself on some of these, questions. So the first question is a first case rather is a Cairn terrier, 1 year old female inti called Clara, and Clara, was presented, 2 days prior to referral with lethargy and scleral hemorrhrrhage. She was taken to her primary vet, who suspected, rodenticide.
Intoxication, treated her with vitamin K. The owners though declined further investigation to confirm rodenticide, intoxication, and, to cut a story short, there was a progressive deterioration over the next few days, and then she was referred. So when she was referred on clinical examination, she had bilateral scleral haemorrhages that you can see in those pictures below, petechiation and ecchymotic haemorrhages, that the more you clipped her hair, the more you found out, particularly over her ventral abdomen and later aspect of her thorax.
Routine, haematology and biochemistry was, the biochemistry was fairly unremarkable. Haematology showed that there was a, moderate to neutrophilia of 36.8, a lymphocytosis, a monocytosis, and a moderate anaemia with a PCV of 0.22.
Thrombocytopenia was also present at 48 times 109, which is in the area where you might expect some enhanced bleeding, but not usually spontaneous bleeding associated with just the deficiency of platelets. Because of the low platelet count, she was a coagulation profile was performed, this was basically unremarkable, but the fibrinogen was noted to be low, D-dimers were mildly increased, suggesting early disseminated intravascular coagulation. So in her investigation, we wanted to know really whether there was any evidence of internal bleeding, so she had chest and abdominal radiographs and and an ultrasound examination of her abdomen.
And I'm going to show you the chest radiographs, so this is the right lateral chest radiograph from Clara. This is the left lateral, and we know that it's the left lateral because the left crust of the diaphragm has moved cranially, and has the gas-filled fundus just behind it. Remember the lower, recumbent area of the abdomen is the area that will push on the diaphragm moving that crura forwards.
Dorsa ventral was taken in addition, and this is the dorsa ventral radiograph. So I'm going to ask you what, lung pattern predominates. I'll just go back through those radiographs, there's the dorsa ventral.
There's the left lateral. And there's the right lateral. So just look through those and decide what is the predominant.
Pulmonary pattern. Is it bronchial, is it vascular? Is it a localised alveolar pattern, a nodular interstitial pattern, or an unstructured interstitial pattern?
Anthony, have you got the polling? . I'm not sure they've been .
Set up Mike, so, did you send those across, have we got other ones that we can get set up? Yes, I sent them to Pam with a list of the slide numbers where there was a polling question. Right, let me go and, find out in the background because it looks like they're not on unless I'm making a mistake.
So give me a second in the background and we'll see how we get on. Sorry about that, Mike. Shall I carry on then?
Yeah, please. OK. So, Whichever you chose, the right answer is actually a vascular pattern.
And that's a fairly unusual pattern, but one that is, quite important both for cardiac disease, and for, some, respiratory diseases. And if we look at the cranial lung lobes in the right lateral, here you can see above the bronchus is the cranial lobe artery, below the bronchus is the cranial lobe vein. And it's really the artery that is much more prominent than normal and it extends right out to the periphery.
Normally it should taper down to quite a small diameter by the time it gets towards the periphery, of the, the lungs. So, we can see that the, pulmonary arteries are enlarged. And yet some of them seem to be truncated, so here's a pulmonary artery that's coming down on the other cranial lung lobe, and it seems to abruptly stop, towards the periphery.
We look in the caudal area, again, we can see that the arteries are above the bronchus, and the veins are below the bronchus, and the arteries are much more prominent, than the pulmonary veins as they go out into the lungs. And again, there's some increased capacity around those vessels, some of that. It's Giving a rather interstitial pattern towards the underneath, but it's all really associated mostly, with the, vascular pattern, and when you see, end on, you can see that there are round, tubes going, through the three dimensional structure, so it's definitely a vascular pattern.
On the left lateral. Again, we can see that there's quite a lot of vascular pattern coming right the way down towards the periphery, maybe even a little bit of an air bronchogram down here because there might be some fluid within the alveoli, very distally, but really still quite a prominent, arterial pattern compared to the venous pattern. And on the dorsoventral again, we can see these arteries, the arteries on the dorsoventral are lateral to the bronchus, the veins are medial to the bronchus, so this is a pulmonary artery coming into the right, caudal lobe, and again you can see that it's quite prominent.
All the radiographs that I show you in the dorsoventral or ventra dorsal projection. Will have the right hand side of the body to the left-hand side of the screen, and it's always good to look at images the same way round as with the, laterals where the head will be to the left hand side of your screen and the tail will be to the right-hand side of your screen. Well, those of you who realised that it was a vascular pattern probably thought what could the cause be when there's changes just within the pulmonary artery, and, and really that would be that there is a possibility of, heartworm disease, which in the UK would tend to be angiostrongylus vazorum, and indeed cholera was positive.
For the angular strongum, Strongylus visorum antigen test, she was also positive, by the faecal, faecal, Berman test, and the, larvae could be seen, and they have a very typical, little hook on the end of their tail, which, means that you can identify them, quite, clearly. I just thought it was worthwhile talking about why you get that abrupt change to the to the arteries, and that's because there's a thromboembolic disease occurring with the parasite, and this is a 5 year old Bernese mountain dog, that was negative on the antigen test, was negative on the faecal, Berman test and also on a, a bronchoalveolar lavage, but what we could see was the arteries came down and abruptly terminated. this dog was actually treated, for angiostrongylus because we were concerned about that, but she had a massive thromboembolic shower and actually died in a postmortem, we confirmed.
That there were, larvae present within those, thrombi, so don't be put off, by a negative, antigen test or even a negative, Berman's test on faecal or on bronchoalvular vage. You should still, if you suspect, treat these animals with a suitable parasiticide. OK, case two is a bichon frise, 9-year-old male neutered called Oscar, and Oscar has a chronic history of coughing going back over 2 years.
More recently, that, cough had become, slightly softer and more moist, and there were episodes of, dyspnea, present when, she became, he became, coughing and wanted to exploit some material. Anyway, on, clinical examination, he was bright, alert, and responsive. His respiratory rate was 28 breaths per minute, but with some increased, expiratory effort.
There was audible wheezing when he was stressed, with adventitious lung sounds audible in the middle third of the thorax bilaterally. There was no cardiac murmur present, . These are the radiographs, so again we have the right lateral which of course tends to show the left side of the lung because in a right lateral position, the right lung lobes deflate and the left lung lobes slightly overinflate so they show up lesions within the left lung better on the right lateral.
And on a left lateral, the reverse happens, so we're really looking at the right. Lung field, and it's important to understand the differences between these two lateral views because, if you're looking at pulmonary disease, you really need to look at both the lateral projections, as well as the dorsoventral projection. And this is the dorsal ventral projection, from this dog.
So there's a lateral radiograph of his cervical area, a cough could be elicited from palpation of the trachea, which was similar to the cough that the owner reported as being the most predominant, in this case. So what I want you to answer if if you can, or at least in your own mind, is this tracheal collapse? Is there a bronchial pattern?
Is there a vascular pattern? Is there a nodular interstitial pattern or an unstructured interstitial pattern, and is there a localised alveolar pattern? So you can only answer one and you want to choose the lung pattern that is most severe, so bronchial to interstitial to alveolar would increase the severity of the disease process.
We're, we're back on track again, Mike, we've we've got them all up to date, so apologies for that. No problem, no problem. Just give people a few more seconds to vote.
Jonathan Pycock, who's a, equine repro vet, Mike was, was accusing people of being lurkers and not actually answering, so he was getting quite, shirty with people if they didn't put an answer in. So I, I don't know if you can, if you can just sort of cajole a bit more because we didn't have everybody voting there. I must admit I, I can't vote.
But I do try and have a go at it because, it does make it a bit more fun. Usually I, I, I get it right sometimes and get it wrong sometimes, so, you learn more from when you get it wrong, don't you? Yeah, I don't think it matters whether you get it right or wrong because when you get it wrong, you're probably likely to learn what was right and remember what was right about it.
If you get it right, then that's also satisfying that you got the right answer. I will, I'll shout out what we've got here, Mike. We've got 5% of people thinking tracheal collapse.
We've got 55% same bronchial pattern, 9% saying vascular. 18% saying nodular interstitial, 14% saying unstructured interstitial, and nobody said localised alveola. OK, well, the majority got the right answer.
This is a marked bronchial pattern, and if we, go back and look at the, the radiographs, I just get them. What we can see is that you can see bronchial walls coming down these fine lines, and what you realise is that, of course, these bronchial walls have a much greater diameter than the trachea. They are partially mineralized, which makes them more clearly defined, but this shows that there's distention of the bronchial bronchi.
Ect as is a saccular bronchiectasis extending down through the lungs. A close up here shows you the difference in the diameter of the trachea to the diameter of the cranial lobe, bronchus, the middle lobe bronchus, and the caudal lobe, bronchi. So, .
Those of you who chose a bronchial pattern, were, were certainly correct. On the left lateral, you've got exactly the same, this massive, widening and distention, of the bronchial lum. Coming out, in all the lung lobes.
Occasionally this condition will only affect one lung lobe, but here we can see that it, affects them all. The cranial lung lobes here. The middle lung lobe here and the caudal lung lobe on both sides, the cranial, lung lobe on the left side, of course, having its cranial component and its caudal component, all of which are involved in this process.
And what happens with this saccular dilation of the bronchi is that the mucociliary carpet fails. So particulate matter and bacteria accumulate within the secretions, the secretions aren't swept up on the mucociliary carpet and then coughed up, so there's a chronic inflammatory response. That occurs within the lungs, giving rise, of course, to the sign of coughing, and also, of course, wheezing and, and, and dyspnea if there's lower, yeah, respiratory tract involvement.
A close up there of the bronchi. Now I included the lateral view of the chest, this is a small breed dog and obviously tracheal claapse can occur in small breed dogs, and what we need to understand. About tracheal collapse, of course, is that it is a dynamic, process, so we may not see evidence of tracheal collapse on all, radiographs.
If we take the radiograph during inspiration, then the tracheal. Lumen in the cervical area will tend to collapse, whereas if we take it during expiration, then the tracheal lumen will tend to dilate. Sometimes to a larger diameter than you would normally identify as being the diameter of the trachea.
The opposite occurs in the thorax, so on inspiration. Then the trachea will tend to dilate, and if we want to see collapse of the intrathoracic and bronchi, then we want to take it during expiration. So although we always try to take our radiograph.
During inspiration to get the best diagnostic information, we may on occasions take them during exploration to get additional information that we wouldn't otherwise be able to identify. Well this dog went for broncho bronchoscopy and bronchoalveolar lavage to confirm the changes, samples were taken and this is the sample from the bronchoalveol lavage, it's a sort of yellowy green colour, it's often rich in, in eosinophils, although, this isn't associated generally with, parasitic disease but more allergic disease, and the dog was treated with antibiosis to, reduce, the infection that was cultured from, the, stagnant mucus, inhaled fluticasone, to, Reduce the bronchial spasm associated with the allergic response, steam inhalation and nebulization to keep this inspassated material, fluid so that the animal could try and cough it up even though the mucociliary carpet was not working, properly, and coupage, following the steam inhalation and nebulization. To encourage expectoration, and the, removal, of this, material.
OK, case three is a, a basset hound called Basil, a 7 year old male, neutered basset hound, and he was, Basil was presented with a 1 month history of coughing. Occasionally that cough would bring up mucus, which was flecked with blood, not pure blood, that he was bringing up, but just mucus that had, some blood staining within it. There'd been no response to oxy doxycycline or to immunocloprid and moxidectin thinking of treating angiostrongylus or other parasitic diseases.
And Basil started to develop reduced exercise tolerance with an increased, respiratory, effort. On clinical examination, it was quite clear there were decreased or to absent lung sounds across the entire right lung field with wheezes and crackles present on the left side, of the chest. Haematology showed a marked eosinophilia, 27.2 times 10 9th of really quite marked, eosinophil count in this case.
So we were interested by the eosinophil count because when we saw the radiographs and because he was mildly dyspneic, we take a dorsoventral radiograph first, to see whether or not there might be fluid or whether he might resent. Lying on one side or the other because of pathology within the lungs, obviously they, if he walks in, then, then taking a dorsoventral is going to be the least stressful to him. So in dyspneic animals, we tend to start off with the dorsoventral, we don't do the ventral dorsal because if there is free flu.
Fluid, in the pleural space that will quickly redistribute to the dorsal area when we lie the animals on their back, it will collapse, the lung lobes that are the only aerated parts, so you can really compromise the the respiratory reserve of an animal with, pleural fluid by moving it around too much, so don't struggle with them. Anyway, this is the radiograph of the dorsoventral view. We then thought it was safe enough to do a right and left lateral, this is the right lateral looking at the aerated left lung lobes.
And this is the left lateral looking at the right lung fields. So what we want to know now is whether there was a bronchial pattern, a vascular pattern, a localised alveolar pattern, a nodular interstitial pattern, or an unstructured interstitial pattern. And I'll let people er vote my, can you hear me OK cos I've taken my headset off.
No, I can take, I can hear you very well, thank you. OK, thank you. Just give people a few more.
Seconds to vote. Be brave Yes, commit, commit, that's the most important thing. Yeah, so we've got a few more voting, which is great.
We've got 3% same bronchial, 3% same vascular. 41% saying localised alveola, 38% saying nodular interstitial, and 16 saying unstructured institial. OK, very good, because there's definitely a nodular component to it, but there is also a localised alveolar component, and, if you get, two, types of, lung pattern, then the most severe is the one that you should concentrate your differential diagnosis on because that is likely to lead you to the, cause.
Now, let's go through the, radiographs again, so. What we can see on the dorsoventral is undoubtedly a area of consolidation, so you could think that that was a nodular interstitial pattern, there's certainly some areas of it which seem to be sort of rounded that we wouldn't normally, identify. Also on the left side, we can see these changes around here now.
What we should also realise, of course, is that the trachea is coming through here, so this may be a tracheal bronchial lymph node that's quite enlarged, at the bifurcation of the trachea. Remember there are 3 trachea bronchial lymph nodes, on either side of the terminal trachea and between the main stem bronchi, just above the left atrium. But those of you who said that there was a localised alveolar pattern were also correct, because here, and we can see that in this close-up view, we can see an air bronchogram coming down.
Going towards the periphery, and of course an air bronchogram is the cardinal feature of an alveolar pattern. There's some smaller air bronchograms over here, and the start of some air bronchograms over on the left side, so this lung pattern appears to be slightly more generalised than just that area in the right caudal lung lobe that is so consolidated. In fact, when we look around the bronchi in these areas, we can see that there's also what we call a bronchial pattern because we can see the walls of these bronchi are much thicker than normal, and on end on we can see these sort of, American style doughnuts with an air-filled hole in the centre as it comes towards us in this two-dimensional view of a three dimensional structure.
In the right lateral view, so looking mostly at the left lung fields, we can see that the bronchial pattern is really quite marked in these cranial lung lobes, less so but becoming more alveolar in the middle, lung lobe and the caudal lung feels quite dense. And then on the left lateral, looking more at the right side, of course, we've got this large area of consolidation with some rounded areas that could look like a nodular interstitial pattern, but also this swelling around the bifurcation which is probably associated with Enlarged tracheal bronchial lymph nodes. So if you have consolidated lung, of course you can see into it with ultrasound, and you should always remember that because it's quite useful to get some quick samples from the lung, which would avoid often having to anaesthetize the animal to, to do a bronchoalveal lavage if the animal is, perhaps, quite dyspneic and, anaesthesia would be perhaps considered to be, perhaps more dangerous.
So what we see with the ultrasound, of course, if it's normal lung, we don't see anything apart from perhaps a gliding sign of speckles of hyperintensity close to the chest wall of the lung moving up and down, during inspiration, but now we can see right into it, we can see the heart beating in real time, but we can see this dense area. Of lung, some of it looking round, and, hypoechoic, others looking, more, hypoechoic around it. All of that is abnormal tissue, and if you see that, then taking a fine needle aspiration of that, once you've checked that it's not, vascular and particularly not the heart, then the secret to getting good, aspirates.
Is to be very quick. Use a very fine needle, a 23 gauge needle, go through with ultrasound guidance or blindly if it's a large area, go into the lung, suck a few times, come out of the lung. Don't leave the needle in there for a long period of time because the needle will just cut through the lung and you've got a much greater chance then of ending up with a, a, a pneumothorax that might require drainage.
Anyway, the fine needle aspirates of this case showed a marked a number of eosinophils, so that goes along with the eosinophilia that was present in the peripheral smear, but look at those eosinophils, if, if you haven't seen eosinophils then this is the sm, this is the smear to teach you what eosinophils look like. Now I will show you the CT, the reason we did a CT was this dog is older than most, to get an eosinophilic, pulmonary, disease or bronchopneumopathy, as it's now called, and we wanted to be sure that there wasn't actually a, mass underlying, this, this disease. So what we can see and what you'll notice in the next few slides is that this is quite a dorsal reconstruction, and we're looking at this one, this will not change throughout the next 3 slides.
We've got some aerated lung cranially, we've got a fairly aerated lung. On the left hand side, but with these very, dense bronchial walls, so those of you who put a bronchial pattern, yes, there is a bronchial pattern, perhaps not the most predominant pattern or the most serious pattern, and some of the bronchi are actually blocked with, with mucus and detritus. So on the right lung field, particularly the right caudal lobe, again you can see this massive thickening of the bronchial walls, but also consolidation within the lung losing its normal appearance and and air-filled areas.
Going more ventrally, then this does become more solid, there are a few gas shadows, this is where the fine needle aspirate was, was taken. You can now see that tracheobronchial lymph node, here and here, this one just merges between . The, the bronchi, so without contrast, it wouldn't be possible to identify that as a, a structure on its own, and then, more ventrally you can see how, how, consolidated these ventral, lobes are on the right-hand side, but also the start of some, consolidation also occurring on the left side.
So we were convinced that there wasn't a, a, a mass within the lung, that it was all eosinophils and particularly, the granulomatous form of, the, pulmonary infiltrate with the eosinophil, eosinophils or eosinophilic bronchopneumopathy, the granulomatous form doesn't always respond, to treatment, but it's always worth trying because sometimes you can get a fairly spectacular, resolution. And so we put Basil onto prednisolone, cyclosporine. We were still concerned that there might be some underlying parasitic involvement, so fembendazole was used to resolve anything that was remaining there that we couldn't detect.
Otherwise, the coughing stopped fairly quickly, breathing improved within 2 days, and we rechecked, Basil at 3 weeks, and these are the radiographs. Taken at 3 weeks, so quite a lot of clearing now, of the lungs, a lot more aeration, still some resolving, change, so, a lot of improvement, some alveolar change still occurring here in the right, called lung lobe, this is the left lateral view, remember, so, a good response really. And Basil went on for another 88 months, before developing, a tumour somewhere else in the body and, and that didn't, go so well.
So case 4, case 4 is a domestic short-haired cat, of unknown age, female. She was a stray cat that was found collapsed and shocked, on the side of the road, unable to stand. She had severe dyspnea, a pneumothorax was diagnosed and the thoracic drain was inserted, but there was a continuous leak, from the, lung, so she, was referred into us for, management.
So here she is with the chest strain in place, the lung lobes were fully expanded because we were sucking out air as soon as it formed, but this is the dorsoventral. View, remember, as I said, in a dyspneic animal we'd always take the dorsoventral view first and, assess that before deciding whether it was safe enough to go and take the, two lateral views. Because we've got the lung lobes pretty much fully expanded, maybe this lung lobe isn't quite fully expanded, but.
We were able to take the lateral views, and that shows that they're not, the lung lobes are not fully expanded or released weren't fully expanded, in this particular position. The animal's now, anaesthetized. So what I want you to tell me from this is, is there a pneumothorax?
Is there a pneumo mediastinum? Is there pulmonary haemorrhage and contusion, a ruptured diaphragm, or a fractured spine, and which of those radiological signs is the most relevant clinically? Mike, do you want to put it back onto the radiograph again just so people can, yeah, I, I will try, there we are.
Hopefully people can see that I don't, yeah, that looks. So there's the dorsa ventral. And there's the lateral.
Remember there's no naming and shaming if you get the wrong answer, just commit yourself to one and then we'll see whether that's right or wrong. We've had those who are gonna vote have voted, we've got 45% saying pneumothorax. 23% say pneumo mediastinum.
And then 23% saying pulmonary haemorrhage and contusion, and we've got 5% thinking there's a ruptured diaphragm and 5% thinking there's a, a fractured spine. OK. Well, let's, let's have a look then at, So on the dorsoventral.
We can see that, the chest drain is in place on the right-hand side. We can see, there are some changes within the lung lobes, particularly, on the left side, some infiltrate within the lung. That's probably considering that this animal's most likely had a road traffic accident, pulmonary haemorrhage and contusion, present here, present around here.
But we also feel that the lungs aren't fully expanded, and that of course is, shown also in the lateral view. Now those of you who thought that there was a ruptured diaphragm, you can actually see the diaphragmatic shadow coming around here, so there's no disruption of the diaphragm there and certainly no disruption of the diaphragm on the lateral view here because it's highlighted by air within the pleural space. So, those of you who put pneumo, thorax were correct, those that put, pulmonary contusion and haemorrhage, were also correct.
There isn't really much evidence of a pneumo mediastinum. We can't see. Particularly clearly the mediastinal structures, so the aorta, the zygous vein, the cranial media the cranial vena cava, or the both walls of the trachea.
So I don't think pneumo mediastinum is right, and I don't think that diaphragmatic hernia is right. But the person that or the people that saw that there was a fracture to the spine, hopefully had seen this area here because this, of course, is clinically significant, particularly as the cat, was brought in in a non-ambulatory, State because this may be spinal shock, but it may also be that the cat, has had much more trauma to the thoracic, thoracic spine and the spinal cord, at the time of the injury, cos it doesn't look as though it's, That collapsed at the moment, but clearly, there's discontinuity of the ventral border, of this thoracic vertebrae, and there's a sort of what looks like a triangle of bone from the end plate that is moved up into the canal. Well, this, cat had a, a, a CT to see whether or not we should be doing anything about the continuous, leakage, and, and what you can see is, of course, that there is some pulmonary, haemorrhage and contusion within the lung tissue.
There is, some now some subcutaneous emphysema which was associated really with this, thoracic drain, on the right-hand side, and there is some, pneumo, pneumothorax present, but there's also a traumatic bulla. We didn't see that or didn't identify that on the radiographs. This one is obviously, intact, further back, it's, considerably larger in size, but it may be that the, pneumothorax was associated with a bulla that had ruptured, and actually by keeping the Lungs fully inflated by continuous drainage, then the lungs sealed, so no further action was taken at that point.
But of course the fractured spine. Is a, a significant, finding. There's a large chunk.
This is just a sagittal reconstruction of the, CT showing that, triangle of bone really pushing up. This is in the midline, really pushing up into the spinal cord, so that may be a permanent damage. So the changes that we saw subcutaneous emphysema, there was a pneumo medias sign that was present on the, on the CT.
I didn't perhaps, point that out so well, but you can see it, down here. Yeah, now that may have occurred when the, subcutaneous emphysema, arose because that can go into the thoracic inlet. It wasn't particularly evident on the radiographs as I outlined.
Pneumothorax, pulmonary contusion, pulmonary bulla, which again wasn't really evident from the thoracic radiographs, and of course the thoracic vertebral fracture. So case five is a Shih Tzzu, 7 year old female neutered called Molly. She had a sudden onset of dyspnea.
And these are the radiographs taken in the dorsoventral projection. Now, hopefully you can all see that there's a a marked pneumothorax present. The lung lobes are really quite collapsed.
So, what I want you to say is, what is the most clinically, relevant, piece of information that you can get from the radiographs? Is there pulmonary emphysema? A pneumothorax, a tension pneumothorax or fractured ribs.
We've got the polling question. Mike, I'm not sure That we've put that one and we haven't got this one on, on the list. OK, don't worry.
Sorry. No, don't worry. So what I would really want you to notice is that this is a tension pneumothorax.
Now a tension pneumothorax occurs when the pressure, In the pleural space builds up dramatically, usually with a one-way valve, so you, during inspiration air comes out into the pleural space, and it can't get back into the lungs during expiration, so there is a. Rapid deterioration, in the breathing and a rapid collapse of the lung lobes, that's why the lung lobes are really so small and consolidated here, and the thorax is so, enlarged and rounded. And the importance of that is that all you need to do in this case is to put a needle into the chest and you will at least equilibrate the pressure to atmospheric pressure and those lung lobes will come up until you can get a chest drain in and then drain off the .
Excess fluid, so tension pneumothorax, really something that you should be able to recognise, both clinically from the rapid deterioration, but also from the radiographs with the massive amount of air and the over distension of the of the thoracic volume with the collapse of the lung lobes. So a chest drain was put in. We've now got the radiographs and you can see that there still a bit of leakage coming from the lungs as we've not been able to remove all the air from the pleural space, but as we've cleared the lungs a little bit, we've got this structure here, this is a right lateral, so that's probably in the left cranial lung lobe that has a solid air component and then a less solid component.
And we were interested in that because of the age of the dog, so we carried out a CT to see whether that should be. Significant, and what you can see is that there's a solid mass, with a, a bulla around it, and that bulla is probably the bulla that has ruptured since most of the pneumothorax was in that, area of, of the lung. No other areas of the lung were affected, no nodules were seen, just this one, area.
And this was a pulmonary carcinoma with a bullar formation, removal of that left cranial lung lobe was curative in both the pneumothorax and also in the tumour formation. These, don't usually spread providing the, there's no evidence of spread at the time of surgery. OK, case 6, it is a Maine Coon, 2 year old male neuter called Butch Cassidy.
And Butch Cassidy had a fairly traumatic, time because, 2 weeks, previously he'd been involved in some, a trauma, presumed anyway because he had a right femoral, neck, head and neck excision following a, a, a fracture of the right femoral neck. However, all of that recovered really well, he was starting to walk and move around, well, but the owners noticed that, in the last few days that, he has, was developing a swelling around his neck and chest, and, that swelling quickly spread all over the body and down his legs. He was fairly dull and depressed by the time he came to us with this massive subcutaneous emphysema over the neck, and back and all his legs.
Breathing was more audible, but there was no coughing, there was swelling, that spread down his back and his legs. No pain over his hip, no evidence of any, problems with the operation site, and he was able to bear weight, on that, leg that had been operated on. So a chest radiograph was taken.
This is the chest, radiograph, and you can see the subcutaneous emphysema, hopefully quite well. You've got the thorax in there as well. This is the dorsa ventral view.
And the question that I would like you to answer, slightly oblique view, to, Look and see. Is would you insert a chest drain, yes or no. So it seems quite a simple question really, but it's quite an important question as we'll see.
We've got like 15% would insert one but 85% wouldn't. Excellent. So the 85% of you are certainly correct.
In fact, if you inserted a chest drain, you would be very likely to, introduce air into the pleural space and the lungs would go down and you'd probably have then quite some difficulty in keeping the, lungs, up because all of this gas is actually subcutaneous. Around the neck, around the legs, around the body, but actually when you look at the lung in any detail at all, you can see that the lung markings come right out towards that chest wall, and that apart from some overlying structures that sort of change that, opacity, there's nothing to suggest that there is any free air, in the pleural space. However, because the subcutaneous emphysema, is, present, that can get into the cranial aspect of the thorax, and you will see that there is a pneumo mediastinum, you can see gas coming down along the line of the aorta, here and also in the cranial, mediastinal structures there.
And so what we can see on the lateral is we can see the aorta much more clearly than we would expect to see. We can see the oesophagus coming through the thorax with gas around it. We can see both walls of the trachea very clearly.
We can. See the left subclavian and brachocephalic trunk as they come off the aorta, and we can see the cranial vena cava coming through into the the chest. So a pneumo mediastin is certainly present along with this, subcutaneous emphysema.
But nothing else. So then the question is, well, why has this cat got such marked, subcutaneous emphysema, and, a pneumo mediastinum, and we can note that the air started around the neck area. We can see trachea coming up here, and then we kind of lose it.
And so there's some change in the trachea here, normally it should come into the larynx, which would be around here, but we don't really see that connection. If we oblique it, we can see at least that the ventral border of the trachea comes into the larynx, but the dorsal wall of the trachea doesn't seem to be present. So we consider that the rupture to the trachea was the most likely cause for the subcutaneous emphysema.
We scoped the animal and confirmed that there was a tear in the dorsal ligament of the trachea, and, and this is the surgery, so here the surgical site, this is in the neck, we can see a hole in the dorsal Ligament of the trachea, the dorsal membrane, into the lumen, you can see how long it is, it's quite an extensive, area of the dorsal ligament. In That has been too rigid in that when it's placed, it can damage the dorsal ligament of the trachea, and then that dorsal ligament will slowly close and and rupture, and that's what's happened in this case, associated with that massive production of subcutaneous air. So I hope you've enjoyed those cases.
If you have, you're welcome to come back for the abdominal session, in an hour's time, but I'm happy to answer any questions that you might have, at this stage.
