Common Respiratory Cases Flashcards
1
Q
What does cough with tracheal palpation mean?
A
- Elicits a cough due to any disease below the thoracic inlet
2
Q
Diseases of the airways below the thoracic inlet
A
- Chronic obstructive pulmonary disease (canine chronic bronchitis)
- Allergic bronchitis (feline asthma)
- Infectious bronchitis
- Airway collapse or compression or obstruction due to foreign body
- Peribronchial to interstitial fibrosis
3
Q
Diagnostic tests for lower airway disease
A
- Thoracic radiographs
- Bronchoscopy
- Bronchial lavage
- Cytology
- CBC
- Fecal
- Culture and sensitivity
4
Q
What can airway wash rule out?
A
- Infectious agents
- Neoplasia
- Parasites
- Direct specific therapy
5
Q
Types of airway wash
A
- Bronchoalveolar lavage +/- bronchial brush
- Trans-tracheal wash
- She prefers bronchoalveolar lavage
6
Q
What does cytology from a bronchoalveolar lavage look like for canine obstructive pulmonary disease?
A
- High neutrophilic component
- +/- High macrophage component
- ALWAYS SUBMIT CULTURES
7
Q
What is canine chronic bronchitis or canine COPD?
A
- Long-term airway inflammation, typically some component of irreversible changes
8
Q
Typical findings of canine COPD
A
- Mixed inflammatory cell infiltrates (neutrophils +/- macrophages))
- Ciliary dysfunction
- Glandular and epithelial hyperplasia
- Excessive mucus production
- Bronchiectasis
- Airway thickening
9
Q
Type A COPD characteristics
A
- Minimal to no coughing until late in the course (more like emphysema)
10
Q
Type B COPD characteristics
A
- Chronic coughing
- Predominates in the large airways
11
Q
Which form of COPD is more common?
A
- COPD Type B
12
Q
Who gets canine chronic bronchitis?
A
- Middle-aged, older small and toy breeds of dogs
- NOTE: THIS IS THE SAME signalment for mitral regurgitation
13
Q
Characteristics of the canine chronic bronchitis cough
A
- Loud, resonant, and classically has terminal gag
- Owners may not appreciate the productive cough due to swallowing
- Often may cough MORE at night or first thing in the morning after being recumbent due to settling of airway secretions
14
Q
Common comorbidities with canine chronic bronchitis
A
- Collapsing trachea
- Bronchiectasis
- Pulmonary hypertension
- Infectious agents (Bordetella and Mycoplasma spp especially) - may need to put on secondary doxycycline
15
Q
Incidence of K9 bronchitis, allergic bronchitis, and infectious bronchitis
A
K9 bronchitis: most common airway disease of small dogs
Allergic bronchitis: more in cats
Infectious bronchitis: more common in young animals or multi animals (kennel cough)
16
Q
Cytology of k9 chronic bronchitis
A
- Chronic irritant with mixed inflammation
- Possible 2° opportunistic infections
17
Q
Cytology of allergic bronchitis
A
- Eosinophilic component
- Allergic sensitization to allergen
18
Q
Etiology of infectious bronchitis in dogs
A
- CA adenovirus 2 +/- parainfluenza +/- Bordetella
19
Q
Etiology of infectious bronchitis in cats
A
- Herpesvirus
- Calicivirus
- Bordetella
- Mycoplasma
20
Q
Clinical scenario of K9 chronic bronchitis
A
- Coughing (typical bronchitis, type B)
- Non-coughing types (emphysema like, type A)
21
Q
Clinical scenario of allergic bronchitis in cats
A
- Acute or chronic
- Can be a component of a chronic bronchitis disorder
22
Q
Clinical scenario of infectious bronchitis
A
- Sudden onset, self limiting usually
- Can complicate another airway disorder (to left)
23
Q
What are the mainstays of therapy for chronic bronchitis (broad categories)
A
- Bronchodilators
- Corticosteroids
- Combos
24
Q
Which oral bronchodilators are used for treatment of chronic bronchitis?
A
- Methylxanthines like theophylline (mucociliary apparatus and mucolytic effects)
- Beta 2 stimulants (Terbutaline)
25
Which inhaled bronchodilators are used for treatment of chronic bronchitis?
- Albuterol (shorter acting/rescue) Beta 2 stimulant
| - Combivent (albuterol/ipratropium combo that is longer acting Beta 2 stimulant)
26
Corticosteroids used for chronic bronchitis
- Fluticasone (inhaled steroid)
27
Combination drugs for chronic bronchitis
- Advair (fluticasone/salmeterol)
| - Symbicort (Budesonide/formoterol)
28
Additional treatment strategies for canine bronchitis
- Weight loss
- Environment
- Cough suppressants
- Antibiotics
- Antiprostaglandins
- Emergency therapy as needed
29
Purpose of weight loss in treatment for chronic bronchitis
- Increase lung compliance and volume
30
Things to look at for environment for chronic bronchitis
- Possible allergens
| - Smoking
31
Cough suppressants to use for chronic bronchitis
- Hycodan
- Butorphanol
- Lomotil
32
ANtibiotics used for chronic bronchitis secondary infections
- Doxycycline for Bordetella and Mycoplasma
| - Base on cultures
33
Antiprostaglandins that can be used for chronic bronchitis
- COX-2 inhibitors
34
Emergency therapy for chronic bronchitis
- Epinephrine
- Atropine
- Albuterol inhaler
- Oxygen therapy
35
What two devices can be used for inhaling aerosolized drugs?
- Aerokat for local therapy
- Can also use a giant Ziploc bag
- Either way, animals need training to use an inhaler device
36
Prognosis for type B chronic bronchitis
- Good for control, no cure
37
Prognosis for type A chronic bronchitis
- Guarded to poor, often advanced at the time of diagnosis
38
Typical presentation, observation, and physical exam for cat with asthma
- Alert
- Open mouth breathing when examined
- Elevated respiratory right
- Prolonged inspiratory pull
- Can hear wheezing, harsh sounds on inspiration
- Cough elicited by tracheal palpation
39
What is the most appropriate test to look at with the airways with a coughing cat?
- Thoracic radiograph
40
Do cats generally cough with heart failure?
- Nope, that's mostly dogs
41
Appearance of thoracic radiographs in a cat with asthma
- Fine honeycomb type pattern
| - Some evidence of railroad tracks and donuts
42
Cytology with feline allergic bronchitis
- Often an eosinophilic component
| - TTW or BAL
43
Pathophysiology of allergic bronchitis/feline asthma
- Re-exposure releases mediators (histamine, kinins, eosinophilic chemotactic factor)
- Bronchioconstriction occurs
44
Chronic bronchoconstriction characteristics with feline asthma
- Primarily coughing
| - Inspiratory effort and noise
45
Acute bronchoconstriction
- Status asthmaticus
- Tachypnea, dyspnea
- Inspiratory and expiratory effort (+/- abdominal push) if end-terminal bronchioles are affected
46
Key therapy for allergic bronchitis
1. Bronchodilators
2. Corticosteroids (this is even more important with cats, as they are often steroid dependent)
3. Combos
47
Examples of bronchodilators for allergic bronchitis that are oral
- Methylxanthines (theophylline)
| - Beta 2 stimulant
48
Inhaled bronchodilators for allergic bronchitis
- Albuterol (shorter acting/rescue Beta 2 stimulant)
| - Combivent which is albuterol and ipratropium (longer acting)
49
Inhaled corticosteroids for cats
- Fluticasone
50
Combos for allergic bronchitis
- Same as before
- Fluticasone/salmeterol
- Budesonide/formoterol
51
Prognosis for feline asthma
- Good for control, no cure
- Identifying environmental allergens is difficult
- Long term steroid use can be challenging, so consider inhaled
52
Where is the disease:
Coughing >1 year, esp with activity
- No ∆ in behavior or appetite
- G 2/6 systolic murmur, left apex
- Wheezes on inspiration heard with a scope
- Airway disease
| - Radiograph the chest
53
What is tracheal collapse?
- Flattening of tracheal rings and/or redundant dorsal trachealis membrane
54
Who gets tracheal collapse?
- Toy and small breed
55
Classic sound of the cough of a dog with tracheal collapse
- Goose honk +/- terminal gag
56
Concurrent diseases that are common with tracheal collapse
- Mitral valve regurgitation
| - Chronic bronchitis
57
Radiographic appearance of collapsing trachea
- Collapse in cervical or thoracic region
58
Managing bronchial collapse
- Weight loss**
- Avoid using a collar/leash (use a harness)
- Cough suppressants may be used in severe cases of coughing fits
- Treat concurrent conditions
- Severe cases may require surgery to stent the airway open
- Prognosis for medical management is reasonably good; for cure is poor
59
What is one of the most important aspects of managing bronchial collapse?
- Weight loss
- Many dogs will palliate with weight loss alone
- Reduces intrathoracic pressures, increases lung compliance and volume, decreases compression of fat
60
Cough suppressants for treatment of tracheal collapse
- Can be used in severe cases but caution is advised as cough suppressants may predispose already compromised airways to opportunistic infections
61
Where is the disease process:
- 2 year old DSH
- Obtained from shelter as a kitten
- "Breathing problem" for about 4 months
- Progressively worse
- Eating and drinking normally
- Upper airways
- Can be heard without stethoscope
- Over the nasopharyngeal area
62
Possibly ways to diagnose an upper airway problem in a kitty
- Sedated oropharyngeal exam
| - CT
63
Who gets nasopharyngeal polyps?
- Usually young cats
64
What are nasopharyngeal polyps?
- Secondary to chronic mid-ear inflammation
- Non-cancerous growth
- Space occupying lesion
- Surgical removal
- Sometimes bulla osteotomy
65
Nasopharyngeal polyps prognosis
- Can recur
| - Usually good once removed
66
Where is the disease process:
- 10 year old Brittany
- Anorexia and vomiting for 3 days
- Acute onset respiratory distress and soft cough
- HR 140, RR 66
- Crackles, late inspiration and expiration
- Parenchymal disease
| - Not as much worried about heart disease because not tachypneic enough
67
Differentials for parenchymal disease
- Pneumonia (bacterial, viral, parasitic, aspiration)
- Pulmonary edema (cardiogenic vs non-cardiogenic)
- Small bronchial diseases (terminal airways)
- Pulmonary parenchymal diseases (parasitic, fungal, neoplasia)
68
Non-cardiogenic causes of edema
- ARDS
| - Electrocution
69
Diagnostic plan for suspected parenchymal disease
- Thoracic radiographs
70
Appearance of alveolar disease on radiograph
- Alveolar pattern (very dense interstitial)
- Assess heart for any evidence of congestive heart failure as well
- Severely might see an air bronchogram
71
Which lung region is most likely to be affected with aspiration pneumonia?
- Cranioventral alveolar pattern generally
| - Right cranial lung lobe is the most impacted
72
Air bronchogram
- Airways are "flooded" which highlights the open airway
73
Definition of aspiration pneumonia
- Inhalation of food, fluid, +/- bacteria
74
What are risk factors for aspiration pneumonia?
- Anything that can alter laryngeal-pharyngeal function
- Neuromuscular disease
- Megaesophagus, chronic reflux, chronic vomiting
- Anesthesia or depressed mental states (why we do NPO and blow up the cough)
- Accidental tubing
75
Treatment for aspiration pneumonia (acute fulminate or chronic insidious)
- Oxygen therapy
- Bronchodilators
- Antibiotics based on cultures (they can aspirate the area)
- Shock therapy if fulminate or septic
- Prevent further aspiration
76
Fluids with aspiration pneumonia and shock
- Be cautious
| - There is lung/capillary injury and worsening edema
77
Where is the disease?
- Coughing for 1 week, progressive
- Decreased appetite/activity
- Decreased G4/6 systolic murmur, left apex
- End-inspiratory and expiratory crackles (RR =66)
- HR is 220 BPM
- Parenchyma
| - Take thoracic radiographs
78
Hallmarks of left heart congestive heart failure on thoracic radiographs
- congested pulmonary veins
- Left sided heart enlargement
- Hilar region interstitial pattern
79
Treatment options for endocardiosis and secondary pulmonary edema
1. Diuretics (furosemide)
2. ACE inhibitor (Enalapril)
3. Pimobendan
4. +/- Spironolactone, other vasodilators like amlodipine
80
Where is the disease process?
- 11 year old Lhasa apso with history of mitral regurgitation
- On enalapril as a prophylactic
- Bout of pancreatitis
- 2 days later, acute respiratory distress
- HR 160, RR 80
- Increased expiratory effort
- Crackles, late inspiration and expiration
- Parenchymal disease
- COULD BE HEART FAILURE or something else too
- Thoracic radiographs
81
Radiographs of a dog with ARDS
- Generalized parenchymal opacity
| - Not hilar specific
82
Treatment for dog that is very sick, with generalized increased lung opacity, and history of heart disease?
- Treat as heart failure in addition to the lung disease
- They weren't convinced that he had venous congestion
- Gave positive inotropes
- Oxygen therapy
- Furosemide
83
Cytology of non-cardiogenic pulmonary edema
- mild inflammation
- High protein fluid
- Edema protein:serum protein ratio (~80%)
84
Non-cardiogenic pulmonary edema protein: serum protein ratio compared to CHF
- 80% compared to <50% in CHF
- Non-cardiogenic edema fluid is protein rich due to a capillary permeability issue
- CHF is protein poor due to a hydrostatic pressure issue
85
What is acute respiratory distress syndrome or non-cardiogenic edema?
- Aucte pulmonary edema (non-cardiogenic) secondary to lung injury and increased capillary/tissue permeability
86
What causes ARDS?
- Often idiopathic
| - Can occur secondary to electrocution too
87
Predisposing causes of ARDS
- Sepsis
- Drug reaction
- Pancreatitis - Aspiration
- Inhalant injury
- Major trauma or surgery
88
Prognosis for ARDS
- Poor in general
89
Treatment for ARDS
- Treat underlying condition if known
- O2 therapy is essential
- Maintain low-normal circulatory volume with cautious fluid therapy
- Steroids are of unconfirmed benefit
- Diuretics may be helpful initially, but are of no benefit in latter phases of ARDS (>5-7 days)
- Nitric oxide as an endogenous mediator of vascular smooth muscle relaxation under investigation
90
O2 therapy for ARDS
- Intubation and mechanical ventilation
| - Positive end-expiratory pressure (PEEP) methods are ideal
91
Why is it important to maintain low-normal circulatory volume in ARDS?
- Leaky capillaries
92
What can you look at the estimate hydration status with ARDS?
- Serial measures of arterial blood pressure, PCV, total protein, electrolytes, renal enzymes
93
Where is the disease:
- 12 year old DSH
- Presents abnormal breathing and weight loss
- Indoor only; mostly routine vaccines
- HR 160; RR 60
- Quiet lung sounds
- Lung parenchymal disease
| - Do chest radiographs
94
Pleural effusion appearance on radiographs
- Retracted lung edge
- Scalloped, ventral fluid
- Overall white (fluid) opacity
95
What are the four causes of pleural effusion?
1. Increased hydrostatic pressure in the capillaries
2. Decreased oncotic pressure (hypoalbuminemia; <1.5 mg/dL)
3. Increased capillary permeability
4. Impaired lymphatic drainage (granulomatous disease and cancer)
96
Are pleural effusions usually unilateral or bilateral in dogs and cats?
- Bilateral generally
| - Mediastinum of dog and cat is fenestrated or incomplete
97
What type of disease process is suggested with a unilateral pleural effusion in a dog or cat?
- Inflammatory focus almost always
- Infectious, neoplastic, granulomatous disease
- The fenestration may be plugged up
98
Management of severe pleural effusion (severe respiratory distress; fragile)
- Oxygen therapy and thoracocentesis should be performed initially before additional diagnostics
- Thoracocentesis is invasive, but benefit outweighs the small chance of complications
99
Management of mild, stable pleural effusion (stable condition)
- Present in stable condition
| - May have chest radiographs taken to confirm presence of pleural effusion before thoracocentesis
100
How to categorize the pleural effusion?
- Measure protein concentration
- Total cell count
- Cytologic analysis may reveal a specific diagnosis or assist in directing next diagnostic steps
101
Fluid aspiration tips
- Small volumes just require needle and syringe (+ sterile prep)
- For larger volume, sterile prep, syringe, butterfly catheter, and 3-way stopcock
- Sedate cats
- Can use radiographs or count rib spaces
102
Pure transudate
- Protein <2.5 g/dL
| - Cells <1000/µL
103
Rule outs for pure transudate
- Hypoalbuminemia
| - PLN, PLE
104
Exudate
Protein >3 g/dL
| Cells >5000/µL
105
Exudate major categories
- Non-septic
- Septic
- Hemorrhagic
- Chylous
106
Modified transudate
Protein <3.5 g/dL
| Cell <5000/µL
107
Rule outs for modified transduate
- Right sided congestive heart failure
- Diaphragmatic hernia
- Neoplasia
- Lung lobe torsion
108
Causes of right sided heart failure
- Pulmonary hypertension
- Tricuspid regurgitation
- Pericardial effusion or restriction
- Cardiomyopathy (dilated or hypertrophic)
109
Non-septic exudate rule-outs
- Neoplasia
- Fungal infection
- Chronic chylothorax (very irritating)
- FIP
- Chronic lung lobe torsion
110
Septic exudate rule-outs
- Penetrating chest wound
- FOreign body inhalation
- Ruptured esophagus
- Ruptured pulmonary abscess or abscessed tumor
- Hematogenous bacterial infection
111
Hemorrhagic exudate rule-outs
- Neoplasia
- Coagulopathy
- Trauma
- Lung lobe torsion
112
Chylous exudate rule-outs
- Neoplasia
- Heartworm disease
- Hypertrophic cardiomyopathy
- Lung lobe torsion
- Diaphragmatic hernia
