CHAPTER 74 — Lung Lobe Torsion 559
99. Guterbock WM, Levine ND: Coccidia and intestinal nematodes of
east central Illinois cats, JAVMA 170:1411-1413, 1977.
100. Beelitz P, Gobel E, Gothe R: Fauna and incidence of endoparasites
in kittens and their mothers from different husbandry situations
in south Germany, Tierarztl Prax 20:297-300, 1992.
101. Campbell BG, Little MD: Identification of the eggs of a nematode
(Eucoleus boehmi) from the nasal mucosa of North American
dogs, JAVMA 198:1520-1523, 1991.
102. Evinger JV, Kazacos KR, Cantwell HD: Ivermectin for treatment of
nasal capillariasis in a dog, JAVMA 186:174-175, 1985.
103. Endres WA: Levamisole in treatment of Capillaria aerophilla in a
cat (a case report), Vet Med Small Anim Clin 71:1553, 1976.
104. Corwin RM, Pratt SE, McCurdy HD: Anthelmintic effect of febantel/
praziquantel paste in dogs and cats, Am J Vet Res 45:154-155, 1984.
105. Herman LH, Helland DR: Paragonimiasis in a cat, JAVMA
149:753-757, 1966.
106. Pechman RD Jr.: Pulmonary paragonimiasis in dogs and cats: A
review, J Small Anim Pract 21:87-95, 1980.
107. Hoover EA, Dubey JP: Pathogenesis of experimental pulmonary
paragonimiasis in cats, Am J Vet Res 39:1827-1832, 1978.
108. Dubey JP, Stromberg PC, Toussant MJ et al: Induced paragonimia-
sis in cats: Clinical signs and diagnosis, JAVMA 173:734-742, 1978.
109. Stromberg PC, Dubey JP: The life cycle of Paragonimus kellicotti
in cats, J Parasitol 64:998-1002, 1978.
CHAPTER 74
Lung Lobe Torsion
Prudence J. Neath
Definition
Lung lobe torsion is a rare condition; details of only 47
dogs 1-12 and 7 cats 13-15 have been reported in the veteri-
nary literature. The torsion occurs when the lung lobe
rotates about its bronchovascular pedicle and is unable
to return to its normal position. The thin-walled vein col-
lapses easily, whereas the more muscular arterial wall
continues to allow bloodflow into the lung. Severe con-
gestion occurs, and consolidation develops as fluid
moves into the interstitial tissue and airways. Eventually
pleural effusion almost always occurs as fluid moves
into the pleural cavity, although rare patients without
pleural effusion have been anecdotally seen.
Etiology
The cause of lung lobe torsion in humans and animals
has been the subject of debate. The primary event asso-
ciated with pulmonary torsion in humans is reported to
be surgical trauma: a recent literature review found that
36 cases occurred following thoracic surgery, whereas 5
110. Weina PJ, England DM: The American lung fluke, Paragonimus
kellicotti, in a cat model, J Parasitol 76:568-572, 1990.
111. Kirkpatrick CE, Shelly EA: Paragonimiasis in a dog: Treatment
with praziquantel, JAVMA 187:75-76, 1985.
112. Pechman RD: The radiographic features of pulmonary paragonimi-
asis in the dog and cat, J Am Vet Radiol Soc (17):182-191, 1976.
113. Bowman DD, Frongillo MK, Johnson RC et al: Evaluation of praz-
iquantel for treatment of experimentally induced paragonimiasis
in dogs and cats, Am J Vet Res 52:68-71, 1991.
114. Dubey JP, Miller TB, Sharma SP: Fenbendazole for treatment of
Paragonimus kellicotti infection in dogs, JAVMA 174:835-837,
1979.
115. Dubey JP, Hoover EA, Stromberg PC et al: Albendazole therapy
for experimentally induced Paragonimus kellicotti infection in
cats, Am J Vet Res 39:1027-1031, 1978.
116. Johnson KE, Kazacos KR, Blevins WE et al: Albendazole for treat-
ment of Paragonimus kellicotti infection in two cats, JAVMA
178:483-485, 1981.
117. Kazacos KR, Bright RM, Johnson KE et al: Cuterebra spp. as a
cause of pharyngeal myiasis in cats, J Am Anim Hosp Assoc 16:
773-776, 1980.
118. Wolf AM: Cuterebra larva in the nasal passage of a kitten, Feline
Practice 9:25-26, 1979.
cases followed blunt trauma and 4 cases occurred spon-
taneously.16 It has been proposed that deflation of the
lung and division of the pulmonary ligaments during
surgery may predispose to the development of lung lobe
torsion in humans.17-19 The situation in dogs and cats is
less clear. It has been proposed that a combination of
lung consolidation or atelectasis (caused by pleural effu-
sion, pneumothorax, trauma, pneumonia, or manipula-
tion during surgery), with increased air or fluid around
the lobe, may predispose it to rotate about its axis.2,3,6,7
However, presumed spontaneous lung lobe torsion has
been identified in dogs and cats in which no predispos-
ing factors were discovered.2,8,12,13 Pleural effusion asso-
ciated with the spontaneous cases may be a manifesta-
tion of the vascular and lymphatic obstruction rather
than a predisposing factor.8,12
Historical Findings and Clinical Signs
Lung lobe torsion occurs more commonly in large, deep-
chested dogs, particularly Afghan hounds.1-12 Afghan
hounds are reported to be 133 times more likely to develop
560 PART FIVE — Disorders of the Respiratory Tract: D. Pulmonary Parenchyma

lung lobe torsion than other breeds.12 Occurrence in cats

and small breeds of dog has been reported less often.2,12-15
Clinical history usually includes progressive dyspnea;
coughing; depression; and, in some instances, anorexia,
vomiting, and diarrhea.1-15 There may be a previous history
of respiratory disease or trauma.1-7,9-15 On physical exami-
nation, the predominant abnormalities are respiratory
signs with dyspnea, coughing, and dull cardiopulmonary
sounds on thoracic auscultation. Pyrexia, depression,
vomiting, or cardiovascular instability are noted in some
instances.1-15

Differential Diagnosis
Atelectasis, pneumonia, neoplasia, pulmonary contu-
sion, pulmonary thromboembolism, diaphragmatic her-
nia, hemothorax, and pyothorax should also be consid-
ered in animals with these signs.
Figure 74-1. Lateral thoracic radiograph of a dog with torsion
of the right middle lung lobe, following thoracocentesis to remove
the pleural effusion. Note the consolidated lung lobe and abnor-
mal path of the bronchus.

Diagnostic Tests
Thoracocentesis is performed to relieve dyspnea and al-
low fluid analysis. The fluid is often hemorrhagic, but
may be clear; serosanguineous; or chylous, with a
milky-white appearance with a triglyceride content
greater than that of serum. Cytological examination typ-
ically reveals an inflammatory cell population with high
numbers of neutrophils, lymphocytes, and often erythro-
cytes and a few modified mesothelial cells.12 The fluid
analysis can become more complicated if an underlying
disease is also present. Bacteria are occasionally cul-
tured from the pleural effusion, but pyothorax is
rare.2,6,12,13 Bacteria identified include Pseudomonas spp.,
Enterococcus spp., Proteus spp., Staphylococcus spp.,
Enterobacter spp., and Serratia spp.12 The complete
blood count often reveals neutrophilia and, occasionally,
anemia; biochemistry results reveal inconsistent changes Figure 74-2. Thoracic ultrasound showing obstructed hilus of a
that may be caused by the underlying disease process torsed lung lobe, filled with fluid.
rather than the effects of lung lobe torsion.7,8,10,11-15
Details of thoracic radiographs are often obscured by
pleural effusion; removal of the fluid by thoracocentesis ultrasound has been used more often in recent years to
will reveal one or more consolidated lung lobes.1-15 The confirm consolidation of the lung lobe/s and may illus-
finding of severe consolidation of one particular lung trate filling of the bronchi with fluid (Figure 74-2).12
lobe, with relative normality of the other lung lobes, The most commonly affected lobe is the thin, narrow,
should raise suspicion of a lung lobe torsion. Horizontal right middle lung lobe, but the left cranial lobe is af-
beam radiographs may allow the lung lobes to be seen fected almost as often.1-15 Although the left cranial lung
more clearly.2 Radiographic changes are variable depend- lobe is larger than the right middle lobe, neither of these
ing on the duration of the torsion, the volume of pleural lobes has extensive attachments to the surrounding
fluid, and whether underlying disease is present. Air structures and this may predispose them to torsion.
bronchograms or air alveolograms are often seen within Torsion of any other lung lobe is also possible.
the affected lobe, but this air usually disperses within a
few days as it is replaced by blood or fluid.2,6,8,11,12
Abnormal bronchial positioning consistent with torsion is Management and Monitoring
sometimes seen (Figure 74-1).6,12,13
Positive-contrast bronchography has been used to MEDICAL STABILIZATION
demonstrate the obstructed orifice of the twisted
bronchus.2 Fiberoptic bronchoscopy may also demon- Surgical excision of the affected lobe is required, but sta-
strate bronchial occlusion; the bronchial mucosa at the bilizing treatment is often needed before surgery. Pleural
site of the obstruction may appear edematous.5 Thoracic effusion should be removed by needle thoracocentesis to

Figure 74-3. Intraoperative appearance of lung lobe torsion.
Note the dark, consolidated lung lobe and twisted hilus.
alleviate dyspnea. Placement of chest tube/s may be re-
quired if the effusion rapidly recurs. Oxygen therapy
should be provided via a mask, nasal catheter, or oxygen
cage. Fluid resuscitation is required in many cases, and
fluid therapy should be provided throughout surgery.
Appropriate intravenous antibiotics should be adminis-
tered, especially if there is evidence of concurrent pneu-
monia or bacteria in the pleural effusion.
SURGICAL TREATMENT
Exploration of the thorax is performed via a lateral thora-
cotomy at the fifth intercostal space on the affected side.
Care should be taken when entering the thorax because
adhesions may have formed between the lung and the
thoracic wall. Most twisted lung lobes appear dark, con-
solidated, friable, and may be necrotic (Figure 74-3). The
bronchovascular pedicle should be carefully clamped to
prevent release of cytokines into the circulation if the lobe
is untwisted during removal. The lobe should always be
removed, even if reinflation seems possible. The bron-
chovascular pedicle can be ligated and divided either by
hand or by use of a stapling device. Identification of vas-
cular structures during manual ligation may be aided by
de-rotation of the lung lobe, but this is rarely required
when a stapling device is used. Biopsies of any abnormal
tissue should be obtained (e.g., a mediastinal mass or a
mass in the affected lung lobe). If chylothorax is present
at the time of surgery, thoracic duct ligation and peri-
cardiectomy should be performed at the time of the initial
lung lobe resection. This is particularly important in the
case of Afghan hounds, in which the chylothorax is likely
to persist following lung lobectomy alone. The position
and inflation of the remaining lung lobes should be as-
sessed, and a chest tube placed before closing the thorax.
POSTOPERATIVE CARE
Oxygen therapy may be required postoperatively and can
be administered by mask, by nasal catheter, or by place-
CHAPTER 74 — Lung Lobe Torsion 561
ment in an oxygen cage. Appropriate antibiotics should
be continued postoperatively until results of bacterial cul-
tures have returned. Analgesia should be provided; par-
enteral administration of opioids can be supplemented by
administration of intrapleural bupivacaine. Drainage of
chest tubes should be continued at regular intervals until
less than 5 ml/kg/day of fluid is being produced. Fluid
intake and output should be monitored, and fluid therapy
administered as needed.
Histopathological Findings
A small sample of the resected lung lobe should be sub-
mitted for bacterial culture, and the remainder of the lobe
submitted for histopathological examination. Histological
abnormalities caused by lung lobe torsion usually in-
clude hemorrhagic fluid within the bronchi, thrombosis
of venous channels, infiltration by plasma cells and lym-
phocytes, and necrosis.1,12,18 Histopathological examina-
tion may also reveal underlying disease that may have
precipitated the lung lobe torsion (e.g., neoplasia or
pneumonia).2,9,12,15
Outcome and Prognosis
Prognosis for animals with lung lobe torsion is fair to
poor depending on whether there is underlying disease
and what breed is affected.1-15 If the pleural effusion has
been caused by neoplasia, the long-term prognosis is
guarded, depending on the type of neoplasm.12,13 The
majority of animals with spontaneous uncomplicated
lung lobe torsion will have a successful outcome.*
Hemorrhagic effusion that is not associated with under-
lying thoracic disease will usually resolve within 3 to 7
days postoperatively. Death of these patients, if it occurs,
is often related to systemic inflammation as a result of
cytokine release from necrotic lung tissue, which may
result in the acute respiratory distress syndrome or car-
diovascular collapse.
Chylothorax has often been reported in association
with lung lobe torsion, and it is unclear whether it is a
cause or a consequence of the torsion.† Chylothorax is
thought to develop after disruption or impedance of the
thoracic duct or thoracic lymphatics, resulting in lym-
phangiectasia.20 Inciting causes include trauma, neopla-
sia, fungal infection, heartworm disease, and diaphrag-
matic hernia, but in many cases chylothorax is
idiopathic.20-22 Chylothorax has been diagnosed at the
same time as lung lobe torsion,7,10,12,14 but has also been
reported to develop following surgery to correct lung
lobe torsion.2,6,12 Chylothorax resolves within 7 days of
lung lobe resection in most cases, without any require-
ment to perform a thoracic duct ligation or pericardiec-
tomy.2,12 Persistent chylothorax that fails to resolve after
lung lobe resection is a particular problem in Afghan
*References 1, 5, 8, 12, 13, and 15.
†References 2, 6, 7, 10, 12, and 14.
562 PART FIVE — Disorders of the Respiratory Tract: D. Pulmonary Parenchyma
hounds; 92% (all but one) of the persistent canine cases
in the literature were Afghan hounds.2,6,7,10,12
Because Afghan hounds are overrepresented in reports
of chylothorax secondary to lymphangiectasia,20 it has
been proposed that their thoracic lymphatic system has a
lower tolerance for insults of any kind, increasing their
likelihood of developing chylothorax in association with
lung lobe torsion.12 Eight of 14 Afghan hounds in the lit-
erature developed chylothorax in association with their
lung lobe torsion.2,6,7,10,12 The prognosis for chylothorax in
that breed is poor, with only 17% of dogs surviving to
6 months.20 Chylothorax associated with lung lobe torsion
has only been reported in 1 cat.14 Although the prognosis
for cats with chylothorax is poor, this feline case had a
successful outcome following thoracic duct ligation.14,23
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CHAPTER 75
Respiratory Toxicology
Lori S. Waddell • Robert Poppenga
T oxicant-induced damage to the respiratory tract can
occur via inhalation of a toxicant or, in many cases, via
the blood following oral, intravenous, or dermal expo-
sure. The respiratory system can be the primary target of
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Each step of the respiratory process can be affected by
toxicants. Toxicants can affect respiratory drive by di-
rectly suppressing or stimulating the respiratory center,
by altering the response of chemoreceptors to changes in
PCO2, or by increasing metabolic demands because of ag-
itation or fever.1 For example, opioids depress respiration
by decreasing responsiveness of chemoreceptors to CO2