Received: 27 November 2018 Revised: 29 April 2019 Accepted: 10 May 2019

DOI: 10.1111/vec.13021

ORIGINAL STUDY

Diagnosis of pulmonary contusions with point-of-care lung

ultrasonography and thoracic radiography compared to
thoracic computed tomography in dogs with motor vehicle
trauma: 29 cases (2017-2018)

Samuel A. Dicker DVM, DACVECC1 Gregory R. Lisciandro DVM, DABVP, DACVECC2

Susan M. Newell DVM, MS, DACVR1 Justine A. Johnson DVM, DACVECC1

1
Ocean State Veterinary Specialists, East
Greenwich, RI Abstract
2
Hill Country Veterinary Specialists, Objective: To determine the accuracy of lung ultrasound (LUS) using the Veterinary
Spicewood, TX
Bedside Lung Ultrasound Examination (VetBLUE) protocol and 3-view thoracic radio-
Correspondence graphs (TXR) compared to thoracic computed tomography (TCT) for diagnosing the
Dr. Samuel A. Dicker, Veterinary Emergency
presence and quantification of pulmonary contusions (PC).
& Referral Group, 196 4th Ave, Brooklyn, NY
11217. Design: Prospective cohort study conducted from February 2017 to June 2018.
Email: dicker.sam@gmail.com
Setting: Private emergency and referral center.
Animals: Thirty-two dogs having sustained motor vehicle trauma were consecutively
enrolled. Three dogs were excluded from statistical analysis. All dogs survived to hos-
pital discharge.
Interventions: Within 24 hours of sustaining trauma, dogs had LUS, TXR, and TCT per-
formed. Using the VetBLUE protocol, LUS PC were scored according to the presence
and number of B-lines and C-lines, indicating extravascular lung water. Thoracic radio-
graphs and TCT were scored for PC in a similar topographical pattern to the VetBLUE
protocol. Lung ultrasound and TXR were compared to “gold standard” TCT for the pres-
ence and quantification of PC.
Measurements and Main Results: On TCT, 21 of 29 (72.4%) dogs were positive and 8 of
29 (27.6%) dogs were negative for PC. When LUS was compared to TCT, 19 of 21 dogs
were positive for PC (90.5% sensitivity) and 7 of 8 dogs were negative (87.5% speci-
ficity) for PC. LUS PC score correlated strongly with TCT PC score (R = 0.8, P < 0.001).
When TXR was compared to TCT, 14 of 21 dogs were positive for PC (66.7% sensitiv-
ity) and 7 of 8 dogs were negative (87.5% specificity) for PC. TXR PC score correlated
strongly with TCT PC score (R = 0.74, P < 0.001).
Conclusions: In this population of dogs with motor vehicle trauma, LUS had high sensi-
tivity for diagnosis of PC when compared to “gold standard” TCT. LUS provides reliable
diagnosis of PC after trauma. More patients with PC were identified with LUS than with

Abbreviations: LUS, lung ultrasound; PC, pulmonary contusions; TCT, thoracic computed tomography; TXR, thoracic radiographs; VetBLUE, Veterinary Bedside Lung Ultrasound Examination

© Veterinary Emergency and Critical Care Society 2020

638 wileyonlinelibrary.com/journal/vec J Vet Emerg Crit Care. 2020;30:638–646.

DICKER ET AL .
TXR, and additional studies are warranted to determine whether this increased sensi-
tivity is statistically significant.
KEYWORDS
blunt force trauma, canine, pneumothorax, ultrasound
1 INTRODUCTION
Pulmonary contusions (PC) occur commonly in dogs, cats, and people
that have sustained blunt force trauma.1–6 In dogs, severity of PC on
thoracic radiographs (TXR) has been directly correlated with oxygen
supplementation duration and hospitalization time.1 In people, sever-
ity of PC on thoracic computed tomography (TCT) is highly predictive
of the need for mechanical ventilation and the development of acute
respiratory distress syndrome (ARDS).2,3,7 Despite high prevalence in
the bluntly traumatized patient, PC may be initially underdiagnosed.
Bluntly traumatized dogs and cats with PC may not have external or
auscultation physical exam findings suggestive of thoracic injury.4 Con-
ventional thoracic radiographic identification of PC in people often
lags behind clinical signs or fails entirely to demonstrate PC.5,8,9
is a cross-sectional imaging modality and has been accepted as the
“gold standard” for diagnosis of PC in people.3,5,6,8–10 In an experi-
mental model of canine PC, TCT identified PC in 100% of patients.5
In veterinary patients, thoracic radiography and TCT require move-
ment of the potentially unstable trauma patient to the radiology suite.
Moreover, TCT is further limited by equipment availability and owner
finances.
Lung ultrasound (LUS) has been documented to be an effective
and safe imaging modality for the rapid diagnosis of common types
of thoracic pathology in animals and people. LUS relies on ultrasono-
graphic artifacts to diagnose normal lung or increased extravascu-
lar lung water (B-lines and C-lines) at the pulmonary-pleural surface,
previously described elsewhere.6,9–24 , Multiple human trauma stud-
ies have demonstrated that LUS has high sensitivity when compared
to “gold standard” TCT for detecting PC.6,10 , In Soldati et al, LUS was
94.6% sensitive and 96.1% specific for identifying PC when compared
to TCT, and TXR were 27% sensitive and 100% specific for PC.10
Hyacinthe et al concluded that LUS exceeded TXR and TCT when
diagnosing PC when the ultrasonographer was an experienced emer-
gency physician.6 A recent study of dogs that sustained trauma docu-
mented that 100% of the dogs with PC identified on TXR had alveolar-
interstitial syndrome on LUS (B-lines and C-lines) most consistent with
PC.25
In this study, dogs had LUS, standard 3-view TXR, and TCT imag-
ing modalities acquired in a 30-minute time frame within 24 hours of
sustaining motor vehicle trauma. The study hypotheses were: (1) LUS
would have high sensitivity for diagnosis of PC compared to TCT; (2)
LUS would correctly identify more dogs as positive for PC than TXR
when compared to TCT; (3) LUS PC score would correlate to TCT PC
639
score; and (4) interobserver agreement would be high for interpreta-
tion of LUS B-lines and C-lines.
2 MATERIALS AND METHODS
Dogs that had sustained motor vehicle trauma within 24 hours of
presentation to a 24-hour veterinary specialty emergency hospital
between February 2017 and June 2018 were prospectively enrolled
in the study. Dogs were excluded from the study if they had previous
known respiratory disease. All owners provided informed written con-
sent for the study, and the study was granted institutional approval.
Parameters, including patient age, sex, breed, weight, heart rate, res-
TCT piratory rate, and body temperature, were obtained at triage. All dogs
were treated at the discretion of the attending emergency clinician.
If pneumothorax or pleural effusion was suspected based on physical
exam findings or initial imaging (including LUS or TXR, but not TCT)
ordered by the emergency clinician (separate from study images) and
were contributing to respiratory distress, therapeutic thoracocentesis
was performed.
The LUS, TXR, and TCT studies were all acquired in a 30-minute time
frame within 24 hours of the dog sustaining trauma. All LUS examina-
tions were performed by 1 investigator, an Emergency & Critical Care
resident (SD), who completed an 8-hour training session in point-of-
care ultrasonography taught by another investigator (GL) with signifi-
cant experience in point-of-care ultrasonography.14–17,20–23,29–31 LUS
examinations were performed using a single ultrasound machine* and a
curvilinear probe† (10.2-4.2 MHz) and used the VetBLUE protocol first
described by Lisciandro et al.15 In brief, the protocol consists of 4 bilat-
erally applied thoracic acoustic windows (8 total acoustic windows),
referred to as the caudo-dorsal lung region (Cd), the perihilar lung
region (Ph), the middle lung region (Md), and the cranial lung region
(Cr). Dogs were positioned in standing or sternal recumbency to avoid
atelectasis (Figure 1). Hair was not clipped, 70% isopropyl alcohol was
applied (sterile ultrasound gel was substituted if cutaneous wounds
were present), and the fur was parted to the skin at each acoustic
window. The ultrasound probe marker was directed cranially, and the
probe was placed between 2 ribs, yielding a “gator sign.” The ultrasound
probe was placed at a single intercostal space at each acoustic window.
The ultrasound probe was tilted dorsally and ventrally to optimize visu-
alization of the pulmonary-pleural line and record the maximum num-
ber of B-lines (Figure 1) or C-lines (Figure 2) at each acoustic window.
Depth was adjusted to 3 to 7 cm. A video clip at each VetBLUE acoustic
640
F I G U R E 1 Illustration depicting the Veterinary Bedside Lung
Ultrasound Examination (VetBLUE). The patient may be in sternal
recumbency or standing. The ultrasound probe is held horizontally at 4
sites on each hemithorax and video images are recorded. Below the
illustration, still B-mode images with corresponding illustrations
depict normal LUS with no B-lines (image A, left) compared to
abnormal LUS with B-lines (image B, right). With permission from
Ward JL, Lisciandro GR, Keene BW, et al. Accuracy of point-of-care
lung ultrasonography for the diagnosis of cardiogenic pulmonary
edema in dogs and cats with acute dyspnea. J Am Vet Med Assoc.
2017;250(6):666-675
F I G U R E 2 B-mode ultrasound image of C-lines, defined as areas
of hypoechoic lung that cause an irregular pulmonary-pleural line and
indicate the presence of lung consolidation. The dashed arrows
indicate the pulmonary-parietal pleural interface. The solid arrows
indicate the subpleural-based consolidation known as C-lines, also
referred to as a “shred sign.”
window with a duration of at least 3 seconds with 39 to 47 frames per
second was saved to an on-site server and was converted to an audio
video interleave (AVI) file for post-hoc analysis. If no pleural “glide sign”
was identified by the ultrasonographer, pneumothorax was suspected
and therapeutic thoracocentesis was performed to visualize the lung
parenchyma. The video clips were then recorded. If subcutaneous
DICKER ET AL .
emphysema hindered visualization of the pulmonary-pleural interface,
the patient was excluded from the study. Post-hoc, each video clip was
visually assessed for B- and C-lines. Acoustic windows were scored
as 0, 1, 2, 3, > 3, or confluent (also known as infinity, where individual
B-lines could not be discerned) B-lines, and for the presence of C-lines.
After scoring, each acoustic window was converted to a numerical
value for statistical analysis as follows: 0 B-lines = 0, 1 B-line = 1, 2
B-lines = 2, 3 B-lines = 3, > 3 B-lines = 4, confluent B-lines = 5, and
C-lines = 6. If any C-lines were seen at that respective acoustic window
regardless of numbers of B-lines, a score of 6 was given. The highest
possible score could be 48 (8 acoustic windows × maximum score of
6). This novel scoring system allowed for an objective measurement
for evaluating the quantity of B- and C-lines associated with PC using
the VetBLUE protocol. Each acoustic window was graded post-hoc
by 2 investigators (SD & GL), who were both blinded to the patient’s
respective TXR and TCT images, as well as each other’s findings.
Because 1 investigator had more experience interpreting LUS images
and was also blinded to all knowledge of each clinical case (GL), this
investigator’s findings were used in statistical analyses. The 2 investi-
gators’ findings were then compared for interobserver agreement. A
dog was considered positive for PC if a total of >3 B-lines or if any C-
lines were identified because dogs with radiographically normal lungs
may have up to 3 B-lines and because C-lines are not seen in normal
lung.15
Immediately after LUS, standard 3-view TXR were obtained. Imme-
diately after TXR, dogs were transported to the CT imaging suite,
sedated, and placed in sternal recumbency. If the patient was deemed
unstable for sedation or transport to the radiology suite, the study
was aborted. Due to concern of positive pressure ventilation worsen-
ing potential closed pneumothorax, dogs were not intubated or admin-
istered inhalant anesthesia. Dogs were provided flow-by oxygen, eye
covers, and cotton ear buds. Sedation protocols were modified based
on patient cardiovascular stability, pain level assessment, and tem-
perament. All dogs were administered either fentanyl‡ (5 µg/kg, IV)
or methadone§ (0.2 mg/kg, IV). In addition, some dogs received IV
propofol** titrated to effect, acepromazine†† (0.01–0.02 mg/kg, IV) or
dexmedetomidine‡‡ (5 µg/kg, IV). Thoracic CT was then performed
with the following parameters: 1.0-second tube rotation, 1.5 pitch,
120 kVp, 200 mA.§§,*** Transverse slices (2–5 mm thick) were acquired
and reformatted for transverse images. Intravenous contrast was not
administered. If motion artifact hampered TCT image interpretation,
the TCT study was repeated. Post-hoc, TXR, and TCT were evaluated
by the board-certified radiologist (SN), who was blinded to each dog’s
respective LUS. Because abnormalities present on TXR were likely to
be present on TCT but unlikely vice versa, the radiologist first scored
the dog’s TXR and then scored the dog’s TCT. Thoracic radiographs
and TCT were evaluated in a topographical pattern similar to the Vet-
BLUE protocol, with 4 sites (Cd, Ph, Md, and Cr) evaluated per hemitho-
rax, totaling 8 scored sites per dog (Figure 3). PC scoring for TXR and
TCT at each site was as follows: no evidence of PC = 0, interstitial pat-
tern = 1, or alveolar pattern = 2. The highest possible score for both
TXR and TCT could be 16 (8 radiographic or CT sites × maximum score
of 2). Dogs were considered positive for PC if any interstitial or alveolar
DICKER ET AL .
FIGURE 3 Ventrodorsal (a) and right lateral thoracic (b) radiographs depicting anatomic sites corresponding to each VetBLUE acoustic window
pattern was identified (cumulative score was >0). If atelectasis was sus-
pected based upon the anatomic location and was a gravity-dependent
site yielding an interstitial or alveolar pattern, the site was scored as
negative for PC (scored as 0) at the radiologist’s discretion. A limita-
tion of LUS is the inability to detect lesions deep to the pulmonary-
parietal pleural interface. As such, at each site on TCT that was scored
positive for PC, the radiologist recorded if the PC at that specific site
did or did not come into contact with the pulmonary-parietal pleural
surface.
3 STATISTICAL ANALYSES
Statistical analyses were performed using statistical software.***
Descriptive statistics were performed on the results of total score for
each test (LUS, TXR, and TCT) by the SAS Proc Means procedure. Sen-
sitivity and specificity were estimated for each of the 2 tests (LUS
and TXR) compared to the reference method (TCT). Sensitivity and
specificity are proportions of true positive and true negative findings
among the positive and negative test results, respectively. The sensi-
tivities of LUS-TCT and TXR-TCT were compared with a Fisher’s exact
test. The SAS Proc Reg procedure was used to compute the Pearson
product-moment correlation coefficient (R-value) between LUS-TCT
and TXR-TCT. The following criteria were used for assessing strength
of correlation: R greater than 0.70 with a P-value of ≤ 0.05 indicated
a strong linear relationship, R between 0.50 and 0.69 a moderate lin-
ear relationship, R of 0.30 to 0.49 a weak linear relationship, and
R < 0.30 a poor linear relationship. The Kappa statistic was calcu-
lated by means of SAS Proc Freq to assess agreement between LUS-
TCT and TXR-TCT. A Kappa statistic greater than or equal to 0.81 was
deemed to have good correlation, between 0.61 and 0.80 was charac-
terized as substantial correlation, between 0.41 and 0.60 was moder-
ate correlation, and <0.20 was deemed to indicate poor correlation.
641
Normality was assessed by means of a normal probability plot and a
histogram.
4 RESULTS
Three dogs were excluded from statistical analyses. One dog had
severe subcutaneous emphysema over the thoracic wall and fractures
of the left 4th and 5th ribs. When the ultrasonographer placed the
ultrasound probe on the thorax, the pulmonary-parietal pleural inter-
face could not be seen due to air reverberation artifact from subcuta-
neous emphysema, resulting in an incomplete LUS study and exclusion
of this dog from statistical analysis. Two dogs had severe hemorrhagic
pleural effusion. One dog with severe pleural effusion had all 3 imaging
modalities performed. On LUS, this dog had both B- and C-lines deep
to the pleural effusion. The TXR and TCT revealed pleural effusion, and
the TCT had both interstitial and alveolar patterns deep to the pleu-
ral effusion. The other dog had only LUS performed, which revealed
severe pleural effusion with B- and C-lines deep to the pleural effusion.
Because pressure atelectasis from pleural effusion caused the appear-
ance of increased extravascular lung water on all imaging modalities,
this precluded accurate diagnosis of PC, and these dogs were excluded
from statistical analyses.
Twenty-nine dogs were included in statistical analysis. Breeds rep-
resented included mixed breed dog (n = 11), Labrador Retriever (n = 5),
Yorkshire Terrier (n = 2), and 1 of each of the following: Australian
Shepherd, Bernese Mountain Dog, Border Collie, Brittany Spaniel,
Chihuahua, Coonhound, German Shepherd Dog, Golden Retriever,
Poodle, Shih Tzu, and Siberian Husky. The mean body weight of study
dogs was 20.0 kg (± 11.3 kg, SD). The mean age of study dogs was 3.3
years (± 3.0 y, SD) with a range of 5 months to 14 years. The study
population consisted of 7 intact male dogs, 8 neutered male dogs, 6
intact female dogs, and 8 neutered female dogs. All dogs recovered
642
from sedation unremarkably and had no appreciable adverse events
attributable to the protocol. All dogs survived to hospital discharge.
On TCT, 21 of 29 (72.4%) dogs were positive and 8 of 29 (27.6%)
dogs were negative for PC. Of the 21 dogs positive for PC on TCT,
21 of 21 (100%) had PC in at least 1 VetBLUE site that touched
the pulmonary-parietal pleural surface. Of the total 232 graded sites
among 29 total dogs (8 sites per dog), 86 of 232 (37.1%) sites were pos-
itive for PC on TCT, and 79 of 86 (91.9%) positively scored sites touched
the pulmonary-parietal pleural surface. Mild motion artifact was noted
on some TCT image slices that did not hamper the radiologist’s inter-
pretation of images. No TCT studies were repeated due to excessive
motion artifact.
On LUS, 20 of 29 (69.0%) dogs were scored positive and 9 of 29
(31.0%) dogs were scored negative for PC. Four dogs had LUS PC
scores >0 and ≤3 (including 3 dogs with an LUS PC score of 1, and 1
dog with an LUS PC score of 3). A 1-year-old female Shih Tzu had 1
B-line at the left Ph, 1 B-line at the right Ph, and a suspected single
hypoechoic, round nodule that cast 1 B-line was identified in the left
Cr (totaling an LUS PC score of 3); this dog was negative for PC on
TXR and TCT. When LUS was compared to TCT, 19 of 21 dogs were
positive for PC (90.5% sensitivity) and 7 of 8 dogs were negative
(87.5% specificity) for PC. LUS PC score correlated strongly with TCT
PC score (R = 0.8, P < 0.001). Agreement for diagnosing PC between
LUS and TCT was substantial (Kappa = 0.75).
On TXR, 15 of 29 (51.7%) dogs were scored positive and 14
of 29 (48.3%) dogs were scored negative for PC. When TXR was
compared to TCT, 14 of 21 dogs were positive for PC (66.7%
sensitivity) and 7 of 8 dogs were negative (87.5% specificity) for
PC. Thoracic radiographs PC score correlated strongly with TCT
PC score (R = 0.74, P < 0.001). Agreement for diagnosing PC
between TXR and TCT was moderate (Kappa = 0.44). The differ-
ence in sensitivities for diagnosis of PC between LUS compared to
TCT, and TXR compared to TCT were not statistically significant
(P = 0.13).
For all 29 dogs, total LUS PC score ranged from 0 to 24 with a mean
of 7 (±6.38 SD) and a median of 5. Of the 20 of 29 dogs scored positive
for PC on LUS, total LUS PC score ranged from 4 to 24 with a mean of
9.9 (±5.64 SD) and a median of 9.5. A novel scoring system was used
for grading PC on TCT and TXR. For all 29 dogs, total TCT PC score
ranged from 0 to 13 with a mean of 4.31 (± 3.92 SD) and median of 4.
Of the 21 of 29 dogs scored positive for PC on TCT, total TCT PC score
ranged from 1 to 13 with a mean of 5.95 (± 3.39 SD) and median of
5. For all 29 dogs, total TXR PC score ranged from 0 to 7 with a mean
of 1.48 (± 2.06 SD) and a median of 1. Of the 15 of 29 dogs scored
positive for PC on TXR, total TXR PC score ranged from 1 to 7 with a
mean of 2.87 (±2.06 SD).
When scoring each VetBLUE acoustic window video clip for num-
bers of B- and C-lines, the 2 observers (SD & GL) agreed on 213 of
232 (91.8%) video clips. Of the 19 of 232 (8.2%) discordant video clip
findings, the 2 observers disagreed by a factor of 1 scoring point 15 of
19 (78.9%) times.
DICKER ET AL .
5 DISCUSSION
This study suggests that LUS is highly sensitive for identifying PC when
compared to TCT as the “gold standard.” PC scores on LUS correlated
well with TCT. These findings emulate similar studies on human blunt
trauma patients.6,10 These results suggest that the veterinarian should
utilize LUS as a part of triage of the trauma patient, allowing for rapid
point-of-care diagnosis of PC without the immediate need for TXR. Fur-
thermore, TXR failed to identify PC in 7 of 21 (33.3%) of dogs deter-
mined to be positive for PC on TCT (Figures 4 and 5). The diagnostic
utility of TXR or TCT for identifying other trauma pathology, such as
skeletal fractures and diaphragmatic hernia, is not replaced by LUS and
should still be considered once the patient is deemed stable.
One dog had severe subcutaneous emphysema over the thoracic
wall and fractures of the left 4th and 5th ribs. In LUS of people, sub-
cutaneous emphysema has been documented to preclude “visualiza-
tion of underlying structures.”10 In dogs, the presence of subcutaneous
emphysema is generally surmountable with application of gentle ultra-
sound probe pressure to displace the subcutaneous emphysema.17 In
the patient described, additional ultrasound probe pressure was not
applied due to rib fractures and concern for patient discomfort.
Thoracic CT is considered the “gold standard” in human medicine
for diagnosis of PC.3,5,6,8–10 However, this may not be the case for vet-
erinary patients. Human patients undergoing TCT may be conscious,
spontaneously ventilating, and may be asked to remain motionless.
Veterinary patients may require sedation or anesthesia for TCT, and
breath-holding patient directives are not possible. Lack of positive
pressure ventilation or positive end-expiratory pressure may have led
to varying degrees of lung atelectasis.27 In this study’s sedated patient
population, the radiologist occasionally had difficulty discerning
between atelectatic lung and true PC. This discrepancy was most often
present in the cranioventral and middle lung fields in patients in sternal
recumbency. If atelectasis was suspected, PC could not be confirmed.
Therefore, TCT may not represent the gold standard for diagnosis of
PC in nonintubated animals under sedation. Furthermore, recumbency
has been shown to play a role in location of atelectasis in gravity-
dependent regions of anesthetized animals on TCT.27,28 Atelectasis
may also be a limitation to LUS diagnosis of PC. Atelectasis has been
proposed as a cause of B- or C-lines in people and sedated and anes-
thetized dogs.12,29,30 It is unknown how nonpathologic lung atelectasis
would behave in thoracic trauma cases with variable degrees of
ventilation from thoracic injury, thus further study is required.
Because ultrasound travels poorly through aerated lung, LUS is only
capable of identifying lung abnormalities at the pulmonary-parietal
pleural interface. Thus, PC that does not reach the pulmonary-pleural
surface at a particular acoustic window is unlikely to be identified
by LUS (Figures 4 and 6). Of the sites scored positive on TCT, 7 of
86 (8.1%) of these sites did not touch the pulmonary-pleural surface.
In this respect, TCT is superior to LUS for identification of PC. This
may have accounted for TCT having a higher sensitivity than LUS
for diagnosing PC; however, all 21 patients that were positive for PC
DICKER ET AL . 643

F I G U R E 4 Images from a 1-year-old female Australian Shepherd that was positive for PC only on TCT. (a) Lung ultrasound image at the left Cd
VetBLUE acoustic window indicating no B- or C-lines. (b) Ventrodorsal thoracic radiograph with no evidence of PC. (c) Thoracic CT image of PC in
the right caudal lung lobe (solid arrows). This image serves as an example of PC not visible with LUS due to the central location of lung pathology.
Total PC scores for this patient were LUS 1, TXR 0, and TCT 7

FIGURE 5 Images from a 1-year-old male Chihuahua mix that was positive for PC on LUS and TCT, but not on TXR. (a) Lung ultrasound image
at the right Cd Vet BLUE acoustic window with >3 B-lines. (b) Ventrodorsal thoracic radiograph with no evidence of PC. The black circle indicates
where the ultrasound probe would contact the thorax at the right Cd Vet BLUE acoustic window. (c) Thoracic CT image of PC (solid arrows) in the
right caudal lung lobe that touch the pulmonary-pleural surface (dashed arrow). Total PC scores for this patient were LUS 4, TXR 0, and TCT 1

F I G U R E 6 Images from a 2-year-old male neutered Chihuahua mix that was positive for PC on all imaging modalities. (a) Lung ultrasound
image at the right Md Vet BLUE acoustic window with C-lines (dashed arrows) and confluent B-lines originating from the pulmonary-parietal
pleural interface (solid arrows). (b) Ventrodorsal thoracic radiograph (combined with lateral radiographs, not shown) scored as positive for PC with
an interstitial pattern in the left Cd and right Md sites as well as an alveolar pattern in the left Md site (black circle). (c) Thoracic CT image of PC in
both the left and right lungs. Certain PC (solid arrows) touch the pulmonary-parietal pleural surface and other PC are more central (dashed
arrows); the latter are not visible with LUS. Total PC scores for this patient were LUS 24, TXR 4, and TCT 12
644
on TCT had at least 1 site of PC extending to the pulmonary-pleural
surface, indicating that LUS would likely identify PC in those patients.
Pneumothorax, depending on severity, precludes visualization of
the lung parenchyma by LUS and renders it impossible to assess for PC
at those respective thoracic acoustic windows with this imaging modal-
ity. Therefore, the clinician’s proper identification of pneumothorax via
LUS is of utmost importance as to not confuse lack of B- or C-lines with
normal lung. Correct ultrasonographic identification of pneumotho-
rax varies with ultrasonographer experience and study protocol.17,31,32
This study primarily focused on diagnosis of PC and did not address the
ability of LUS to identify pneumothorax.
Two patients were falsely negative for PC on LUS compared to TCT.
The precise reason why LUS did not identify these 2 dogs with PC
may only be speculated. One explanation is that the VetBLUE proto-
col is a point-of-care LUS technique designed to rapidly provide the
clinician with information concerning 4 bilaterally applied acoustic win-
dows. Thus, if the lung surface pathology is not present at these respec-
tive acoustic windows, then PC would be unidentified. Other LUS tech-
niques describe a “sliding” protocol, where the ultrasound probe is slid
in a dorsal-ventral direction between intercostal spaces.19,24,25 In the-
ory, a sliding protocol allows for a more complete assessment of all
possible lung acoustic windows and may have detected the missed PC.
However, certain sliding protocols require clipping fur, and a sliding
protocol may be more time consuming, which may be detrimental to
the critical trauma patient. A second explanation is that lung atelecta-
sis may have developed during the time interval between LUS and TCT.
Dependent atelectasis develops rapidly in sedated recumbent dogs,
and the degree of atelectasis worsens if patients are supplemented
with oxygen.33
A 1-year-old female Shih Tzu had a suspected single nodule iden-
tified on LUS at the left Cr VetBLUE acoustic window, which cast 1
B-line; this dog’s total LUS PC score was 3 (ie, negative for PC on
LUS), and the dog was negative for PC on TXR and TCT. The signif-
icance of the suspected nodule is unknown, and subpleural consol-
idation could not be entirely ruled out. The suspected nodule may
reflect previous thoracic pathology. The radiology report did not indi-
cate any nodules or consolidation in this lung region but indicated a
mild diffuse bronchial pattern identified on both TXR and TCT. It is
possible that this dog had previously undocumented lung disease and
that the nodule-associated B-line was recorded as a false positive for
PC. This result may further emphasize the high sensitivity of LUS for
lung surface pathology over TCT, and although this study’s criterion
for being positive on LUS was a total of >3 B-lines or the presence
of C-lines, PC also could not be entirely ruled out in this patient. Fur-
thermore, LUS may be more sensitive than TCT for diagnosis of PC
at the pulmonary-pleural surface, similar to the results in Hyacinthe
et al.6
Previous studies in dogs may have refrained from using TCT as
an imaging modality in patients with thoracic trauma due to the
potential for cardiovascular instability and perceived need for general
anesthesia. While the authors of this study delayed sedation for TCT
if the patient was deemed unstable, all patients were sedated and
recovered from sedation in the ICU without incident. Many patients
DICKER ET AL .
tolerated TCT with minimal sedation, often with opioids alone. In a
recent study of trauma in 13 dogs and 2 cats, whole body CTs were
performed with sedation within 2.5 hours of hospital presentation with
no reported complications.32 As CT technology continues to improve
and as imaging times are shortened, acquiring CT images using mild
sedation may become a useful imaging modality in more veterinary
practices.
Multiple limitations were identified in this study. Although LUS cor-
rectly identified PC in more dogs than TXR when compared to TCT,
the difference in sensitivities between LUS compared to TCT, and TXR
compared to TCT were not statistically significant; this may be due to
type II error. Additional studies with larger numbers of dogs are needed
to determine if LUS is significantly more sensitive than TXR for diagno-
sis of PC.
The ultrasonographer (SD) was not blinded to any initial imaging or
therapeutics (such as centesis) performed by the attending emergency
clinicians prior to study image acquisition (no TCTs were performed
prior to study image acquisition). This may have biased the ultrasono-
grapher when performing LUS. However, a different investigator (GL)
was blinded to all aspects of the clinical case, and this investigator’s LUS
PC scores were used for statistical analyses.
Increased numbers of B-lines are not pathognomonic for PC and
may indicate increased extravascular lung water of varying etiologies
including acute or chronic conditions.12 Chronic lung disease, such as
pulmonary fibrosis, is more common in older dogs.34 The mean age of
the study population was 3.3 years (±3.0 y, SD). Dogs were excluded
from this study if they had previous known respiratory disease.
Although LUS serves as an excellent screening tool for lung surface
pathology in traumatized dogs, it may be used as complimentary to TXR
and TCT, especially in older dogs and in those dogs with known lung dis-
ease because LUS surface pathology does not necessarily indicate PC.
The PC scoring systems for LUS, TXR, and TCT were newly devel-
oped for this study. Additional studies are needed to determine the
clinical utility of these LUS, TXR, and TCT PC scores.
In conclusion, LUS had high sensitivity when compared to TCT for
diagnosis of PC in this population of predominantly young dogs with
motor vehicle trauma. LUS provides reliable diagnosis of PC after
trauma in dogs without pre-existing lung disease. Additional studies are
needed to determine the clinical utility of PC scores.
ORCID
Samuel A. Dicker DVM, DACVECC https://orcid.org/0000-0002-
2662-7907
Gregory R. Lisciandro DVM, DABVP, DACVECC https://orcid.org/
0000-0001-6266-3430
Notes
*
Toshiba Xario XG iStyle, Minato, Tokyo, Japan.
†
Toshiba 11MC4 convex curvilinear ultrasound probe, Minato, Tokyo,
Japan.
‡
Fentanyl citrate injection, USP, West-Ward. Eatontown, NJ.
§
Methadone hydrochloride injection, USP, Mylan, Rockford, IL.
**
Propofol injectable emulsion, Hospira, Lake Forest, IL.
††
Acepromazine maleate injection USP, VetOne, Boise, ID.
DICKER ET AL .
‡‡
Dexmedetomidine hydrochloride, Dechra, Northwich, UK.
§§
General Electric Medical Systems HiSpeed FX/i Series 6.03, Boston, MA.
***
Statistical Analysis Software, version 9.4, SAS Institute Inc, Cary, NC.
CONFLICTS OF INTEREST
Drs. Dicker, Newell, and Johnson declare no conflicts of interest.
Dr. Lisciandro is the president of the International Point-of-Care
Ultrasound Society (IVPOCUS), a non-profit society, and FASTVet.com,
a privately owned for-profit ultrasound education company.
ACKNOWLEDGMENTS
The authors extend our gratitude to Joe Hauptman, DVM, MS, DACVS
for statistical analysis, Amy Cardwell, LVT, Jessica Weber, LVT, VTS
(Neurology), and Timothy Roddick for TCT acquisition, and the emer-
gency veterinarians and technicians of Ocean State Veterinary Special-
ists for their diligent help treating and enrolling patients in the study.
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