Exam 5 Flashcards

Question

Feline Nasopharyngeal polyps

Answer 1

C/S -Stertor, obstructive breathing pattern, mucopurulent nasal discharge. -If present in ear canal, can cause head tilt, nystagmus, Horner's syndrome -Benign growths that occur in young cats and kittens -Often attached to base of eustachian tube 1. Primary treatment: surgical excision 2. short course of antibiotics and prednisone

Answer 2

-Older animals >8 years -Dolicocephalic breeds -Most tumors malignant (80-90%) -Locally invasive -Metastases rare (later stages to LN and lung) Types Epithelial (carcinomas) **Adenocarcinoma (most common in dogs) ** -Squamous cell carcinoma -Undifferentiated carcinoma Mesenchymal (sarcomas) -Chondrosarcoma -Fibrosarcoma -Undifferentiated sarcoma Discrete round cell -Lymphoma (most common in cats) -Squamous most common in nasal planum white cats. -Transmissible general tumor (rare) -Mast cell tumor (rare) C/S -Nasal discharge (unilateral to bilateral) -Sneezing -Nasofacial deformities -Exophthalmia (or exophthalmia) -Stertor -Open-mouthed breathing -Oral deformity -Dysphagia -CNS signs Dx -Rads: nasal turbinate destruction, soft tissue opacity, bone lysis (frontal vomer), deviation of vomer bone. -Rhinoscopy with Biopsy -Blind nasal biopsy -Rhinotomy, turbinectomy -Definitive dx requires histopathology

Answer 3

-Evaluate local lymph nodes -Thoracic radiographs Tx -Radiation therapy = 12-16 months -Palliative vs. curative = 3-6 mts Survival factors -Adenocarcinomas, sarcomas longer -Undifferentiated and SCC, shorter -Clinical stage: metastasis to lungs, shorter -Extensive local invasion, shorter -Cats tolerate and respond better than dogs

Answer 4

-Not well validated in dogs and cats -hypersensitivity response to airborne allergens C/S -Sneezing, serous nasal discharge may progress to mucopurulent -May worsen with exposure to perfume, smoke, etc Dx -History and clinical presentation -Rads may show increased soft tissue density Tx -control allergens -antihistamines -corticosteroids

Answer 5

Feline chronic rhino sinusitis -Diagnosis of exclusion -Chronic mucoid or mucopurulent discharge for mts or years -Sneezing and nasal discharge most consistent signs -Typically bilateral +/- hemorrhage -Chronic inflammation leads to turbinate destruction -Chronic management necessary -supportive therapy similar to URI -Nasal/sinus flush may help temporarily -Antibiotics secondary infections Canine Lymphoplasmacytic Rhinitis -Diagnosis of exclusion -unknown etiology -No association with CAV-2, parainfluenza, Chlamydophila or Bartonella. -C/S and cytology similar to feline chronic rhinitis -Tx: prednisone, antibiotics for secondary infections, higher immunosuppressive doses -unresponsive in both dogs and cats

Answer 6

Laryngeal and Pharyngeal disease

Answer 7

-Hallmark signs regardless of etiology are respiratory distress and stridor (high pitch wheezing sound on inspiration due to upper airway obstruction) **Gagging and coughing may be present** -Voice change is indicative of laryngeal disease (dysphonia) but not consistent finding -Airway obstruction with laryngeal disease causes profound respiratory distress (often acutely) -Initially patients limit their own physical activity -Crisis if animal overheats, respiratory effort increases -Paradoxical motion: soft tissues are pulled into airway during inspiration due to increased negative pressure, which causes the tissue to become more inflamed and edematous -Respiratory rate is normal to slightly elevated (30-40 bpm) which is abnormal for level of distress -Inspiration is prolonged and labored -Expiration is more passive but tissue edema can cause dynamic obstruction during expiration May be associated with aspiration pneumonia -Cough -Lathergy -Anorexia -Fever -Tachypnea -Abnormal lung sounds Ddx -Laryngeal paralysis (large dogs not cats) -Obstructive neoplasia -Obstructive laryngitis -Laryngeal collapse -Web formation -Trauma -Foreign body -Extraluminal mass -Acute laryngitis

Answer 8

**Stertor, gagging, coughing, reverse sneezing and dysphagia are more common clinical signs** Ddx -Brachycephalic airway syndrome -Elongated soft palate -Nasopharyngeal polyp -Foreign body -Neoplasia -Abscess -Granuloma -Extraluminal mass -Nasopharyngeal stenosis Diagnostics -Rads for identifying radio dense foreign, bony changes, some masses -Not as useful for dynamic disease: laryngeal paralysis, collapsing airways -Fluoroscopy: most useful for dynamic disease in which observation of abnormal motion is necessary for diagnosis . Increased exposure to radiation -Bronchoscope: non-invasive option -CT/ MRI -Laryngoscopy/pharungoscopy : useful for direct visual examination of tissues and movement -Be prepared for more definitive immediate treatment of airway obstruction when scoping

Answer 9

-Ideally performed with flexible laryngoscope, resulting in the least distortion of the laryngeal structures -Can be performed by direct visualization through oral cavity using a blade laryngoscope -Short acting injectable agent (e.g., propofol) to produce light plane anesthesia -Maintain spontaneous deep respirations -Arytenoid movement is enhanced by administering IV do pram by increasing respiratory rate and effort -With laryngeal paralysis, one or both sides do not abduct sufficiently with inspiration -Flow-by-oxygen should be administered during the exam -Have endotracheal tube available in case your patient has paradoxical motion, laryngeal collapse or recovering -Don't do this exam if you are not ready to deal with potential respiratory problems upon recovery

Answer 10

Dog-brachycephalic syndrome due to elongated soft palate -Cat-nasopharyngeal polyp

Answer 11

Laryngeal and pharyngeal disorders

Answer 12

-Failure of the arytenoid cartilages to abduct during inspiration -Creates an upper airway obstruction -Abductor muscles are innervated by the right and left **Recurrent laryngeal nerves** -Dogs most commonly affected Causes -Idiopathic -Ventral cervical lesions -Trauma to nerves: direct, inflammation, fibrosis -Neoplasia -Anterior thoracic lesion: neoplasia, trauma, port-operative -Polyneuropathy and Polymyopathy: idiopathic, immune mediated -Endocrinopathy: hypothyroidism -Other systemic disorder: toxicity -Congenital disease -Myasthenia Gravis Etiology -Idiopathic LP is part of generalized neuromuscular or polyneuropathy complex -Polyneuropathies have been associated with immune-mediated disease, endocrinopathies, other systemic disorders **Congenital LP: Bouvier des Flandres, Siberian Huskies, Bull Terriers** -LP-polyneuropathy complex reported in Dalmations, Rottweilers and Great Pyrenees **Labrador Retrievers** -Damage to the laryngeal nerves of larynx can lead to LP

Answer 13

C/S -Any age, any breed -Most common in older, larger-breed dogs -Hallmark signs of respiratory distress and stridor -Vocal change may be noted by owner -Stridorous breathing dog may turn blue **Often acute respiratory crisis** requires emergency intervention -Often present with a history of gagging or coughing, especially when drinking or eating Diagnosis -Further workup should be continued to rule out underlying disease -Evaluate for concurrent pulmonary disease, such as aspiration pneumonia -Rule out pharyngeal and esophageal dysmotility and megaesophagus Treatment -Emergency management of airway obstruction -Sedation acepromazine, butorphanol or morphine (nothing by mouth because it can get trapped in the trachea) -Provide cool, oxygen rich environment -Evaluate for surgical management once stable **Arytenoid lateralization ("tie-back") unilateral or bilateral, not if megaesophagus ** -Increase diameter of airflow but not so large to encourage aspiration Medical management -When surgery is not an option, it can be attempted -+/- corticosteroids to reduce inflammation -Weight management -Exercise/heat restriction -Walkin in harness vs. collar Prognosis -Fair to good -Aspiration pneumonia is most common complication -Guarded prognosis for generalized neuromuscular disease or/and megaesophagus

Answer 14

C/S -Vomiting and regurgitation -Concurrent with GI disease -Increased intrathoracic pressure created with increased inspiratory effort Anatomic abnormalities 1. Stenotic nares (cats have them too) 2. Elongated soft palate 3. Hypoplastic trachea (Bulldogs) 4. Everted laryngeal saccules: close to the vocal cords, get edematous and affect the airway space

Answer 15

C/S -Caused by impaired airflow through the upper airways -Increased intrathoracic pressure -Loud upper airway noise associated with obstruction: inspiratory phase STERTOR, SNORING -Cyanosis, syncope -GI signs of vomiting and regurgitation Dx -Based on breed, clinical presentation -Cervical and thoracic radiographs to evaluate structure, secondary disease -Visual exam of oropharynx/larynx via scoping Tx -Enhance passage or air through limited airways -Minimize stress factors: limit exercise, cool ambient temperature, weight control -Surgical correction of abnormalities: excise excessive soft palate and everted laryngeal saccules, correct stenotic nares -Perform procedures early (particularly stenotic nares) at 3-4 months age before clinical signs develop

Answer 16

-Uncommon in dogs and cats -Carcinomas: SCC, undifferentiated, adenocarcinoma -Lymphoma most common in cats -Melanoma -Mast cell tumor -Benign neoplasia C/S -Consistent with upper airway disease: noisy respiration, stridor, increased inspiratory efforts, change in voice -Mass lesions can cause dysphagia, aspiration pneumonia, palpable mass Dx -Diagnostic imaging: rads, CT/MRI, laryngoscopy -FNA and biopsy for histopath -Staging disease once diagnosed with malignant neoplasia: local LNs evaluation, thoracic radiographs Tx -Depends on tumor type -Surgical excision, laryngectomy with permanent tracheostomy -Radiation therapy -Chemotherapy: e.g., lymphoma -NSAIDS: Cox-2 inhibition can slow progression

Answer 17

Lower respiratory tract Trachea Bronchi Bronchioles Alveoli Interstitium Vasculature of lungs

Answer 18

C/S Cough -Productive vs. non-productive -Intensity: loud, harsh, paroxysmal, soft -Temporal associations: time of day, activity Productive Cough -Moist sound heard during cough -Mucus, exudate, edema fluid, or blood from airways into oral cavity -Commonly caused by inflammation, infectious disease, or heart failure Non-productive cough -"Dry cough" -Mostly associated with airway disease such as collapsing trachea **Goose honking = collapsing trachea** Exercise Intolerance -Restricts itself from too much activity -Mild tachypnea and subtly decreased activity - exercise intolerance and Dyspnea at rest -Often present in overt (and "sudden") distress -Orthopnic: extended neck

Answer 19

Evaluating -Resting respiratory rate: upper limit 20-30 -Mucous membrane color: pallor (acute hypoxemia), cyanosis (severe hypoxemia) -Breathing pattern: rate, depth, inspiratory and expiratory efforts, audible sounds Inspiratory -Pulmonary disease primarily but also CHF -Extrathoracic disease: collapsing trachea, laryngeal paralysis Expiratory -Intrathoracic airways Dyspnea: difficult or labored respiration

Answer 20

Initial evaluation -PE: complete systemic physical. Thoracic evaluation -Radiographs -Blood work: CBC Auscultation -Bronchial: most prominent in central area of lungs; tubular sounds over large airways -Vesicular: most prominent in peripheral lung fields; "breeze blowing through leaves" Abnormal lung (breath) sounds -Decreased lungs sounds (pleural effusion, pneumothorax, mass lesions) -Increased or harsh lung sounds, crackles, wheezes Radiographs -Most helpful tool for intrathoracic disease Dx -Right and left lateral increase sensitivity -Minimum 2 views: RL and VD -Dorsoventral views are taken to highlight dorsal pulmonary arteries, and to lessen stress in the dyspneic patient -Horizontal views to evaluate pleural effusion or cavitary lesions **Peak Inspiration** -Short exposure time -Cervical radiographs to evaluate trachea and upper airway structures, if clinical signs suggest -Vascular pattern: characterized by an increased or decreased in size of the artery or vein -Bronchial pattern: characterized by "donuts and tram lines" -Alveolar pattern: characterized by air bronchograms and lobar signs -Interstitial pattern: characterized Structured (nodular) unstructured (diffuse) or a combination in an increase in lung opacity -Pleural effusion:

Answer 21

-Lung lobe consolidation - entire lobe is soft tissue opacity -Atelectasis -Cavitary lesions: abnormal air accumulation in the lung (e.g., bullae) -Lung torsion

Answer 22

-Angiography: used to confirm pulmonary thromboembolism -Ultrasonography: used to evaluate pulmonary mass lesions and guide collection of FNA samples -CT/MRI: masses, metastatic disease, PTE, pneumonias, etc -Nuclear imaging: used to diagnosis ciliary dyskinesia, pulmonary perfusion and ventilation -Parasitology: direct observation, Blood tests, Cytology analysis of fluid or respiratory samples, Fecal flotation. -Serology: fungal pulmonary disease: histoplasmosis, blastomycoses, coccidioidomycosis. Toxoplamosis, cryptococcus, heart worm disease. Tracheal wash -Transtracheal wash technique, transoral (endotracheal) technique Broncoalveolar lavage -Bronchoscopic -Nonbronchoscopic Transthoracic lung aspiration -Ultrasound guided FNA of pulmonary parenchyma -Potential complications include pneumothorax, hemothorax, and pulmonary hemorrhage -Can be utilized for masses near body wall and diffuse interstitial lung disease Bronchoscopy -Evaluation of major airways -Bronchio-alveolar lavage (BAL) put sterile fluid in -Technique of choice for always foreign body removal

Answer 23

1. Cough 2. Exercise intolerance 3. Respiratory distress

Answer 24

Transoral/endotracheal wash

Answer 25

Common diseases of Trachea and Bronchi -Canine infectious tracheobronchitis (ITB) -Canine chronic bronchitis -Feline bronchitis -Tracheobronchomalacia or collapsing trachea -Allergic bronchitis -Parasitic - Oslerus osleri in young dogs

Answer 26

Pathophysiology -Viruses, bacteria, and mycoplasma (any or all) -Most commonly parainfluenza virus, adenovirus with Bordetella bronchiseptica -Highly contagious from aerosol or direct contact (rarely fomites) Signalment/history -Young, unvaccinated dog -Boarding, parks, etc, exposure C/S -Loud, goose-honk cough -Cough often productive, foamy, clear liquid -Post-tussive gagging is common +/- Mucopurulent ocular and nasal discharge, sneezing Physical examination -Uncomplicated cases - tracheal sensitivity, normal lung sounds, generally self-limiting -Complicated cases - fever, crackles or wheezes, anorexia, can progress to bronchopneumonia -10-14 days resolution usually Diagnosis -Uncomplicated cases - empirical (experienced based) -Complicated cases: CBC, chest radiographs (remember contagious), +/- tracheal wash with cytology and culture -Highly contagious - coughing dogs should wait in the owner's vehicle until the exam, avoid exposing other patients Treatment -Uncomplicated: typically self limiting, 10-14 days resolution -Anti-tussives (butorphanol, hydrocodone, tramadol) +/- anti-inflammatory doses of corticosteroids +/- antibiotics - empiric choices (doxycycline, amoxicillin: clavulanic acid, trimethoprim sulfa, enrofloxacin) -Mycoplasma and Bordetella - Doxycycline -Complicated: antibiotics, culture of tracheal wash fluid is best -Nebulization of antibiotics (GENTAMICIN) most effective -Supportive care including maintaining hydration, corticosteroids, courage and nebulization Prevention -Vaccine not 100% effective -Bordetella whiten 5 days -intranasal Parainfluenza and Bordetella within 5 days -CAV-2 and Bordetella Parenteral within 14 days

Answer 27

-Chronic, persistent cough of 2 or more consecutive months in duration without other disease processes -Fibrosis, epithelial hyperplasia, glandular hypertrophy and inflammatory infiltrates -Inflammation initiated by infection, allergy, inhaled irritants or toxins Signalment -Middle aged to older -Small breed -Terrier, Poodle, Crocker Spaniels -Cough progresses slowly over months to years -Complications: bordetella, mycoplasma, pulmonary hypertension, bronchiectasis Diagnosis -History, C/S -Radiographs: bronchial to bronchointerstitial pattern -BAL: neutrophilic to mixed inflammatory cells, increased mucus -Bronchoscopy if necessary Treatment -Symptomatic management -Avoid exacerbating factors (e.g., smoke, allergens, perfume) -Keep secretions moist and moving -Control weight -Glucocorticoids decrease inflammation -Treat secondary infections culture and sensitivity TTW -Bronchodilators: aminophylline, theophylline, terbutaline, albuterol

Answer 28

-Feline airways are highly reactive and prone to bronchoconstriction -Common signs of bronchitis in cats: cough, wheeze, respiratory distress -Idiopathic bronchitis is a disease of exclusion -Young and middle aged Ddx -Allergic bronchitis -Heartworm disease -Pulmonary parasites -Bacterial bronchitis -Mycoplasma bronchitis -Toxoplasmosis -Carcinoma -Aspiration pneumonia C/S -Coughing -Intermittent respiratory distress "vomiting hair ball" 1. Bronchial asthma: reversible, bronchoconstriction, eosinophils 2. Acute bronchitis: reversible airway inflammation <3 mts, increase neutrophils 3. Chronic bronchitis: irreversible >3mts 4. Emphysema destruction of bronchiolar and alveolar walls similar to COPD Dx -History, clinical presentation -PE, don't escalate stress in dyspneic cat -CBC -Heartworm test and other blood work as indicated -Fecal testing -Thoracic radiographs (bronchial pattern) -Cytology from TTW or BAL Emergency -Stabilization with oxygen -Bronchodilators (terbutaline SC) rapid-acting -Glucocorticoids (dexmethasone SP, Solu-Medrol, IV, SC or IM) -Administer albuterol by face mask, multi dose inhaler (MDI), if additional doses needed - Aerokat -Place in cool, oxygen-rich environment Chronic -Glucocorticoids - oral prednisolone -Inhaled glucocorticoids - Fluticasone delivered MDI -Bronchodilators may be needed long term

Answer 29

Pathophy -Dorsoventral collapse of airway upon inhalation -Intrathoracic, extra thoracic, and/or mainstream bronchi involvement -Self-perpetuating Signalment -Middle aged to older toy and small breed dogs C/S -Dry, non-productive cough -Worsens with excitement/exercise -Occasionally associated with post-jussive gagging/retching -Increased inspiratory effort with extra thoracic -Increased expiratory effort with intrathoracic -May present in dyspneic crisis -Tracheal sensitivity common Dx -Radiographs -Fluoroscopy -Tracheobronchoscopy - best -Tracheal wash may be help in ruling out other diseases Tx -Combination often needed -Stable patient: bronchodilators (theophylline, terbutaline, albuterol), anti-inflammatories corticosteroids, antitussives (butorphanol, hydrocodone) -Weight loss -Avoid environmental triggers (fragrances) Dyspneic collapsing trachea patient -Oxygen -Anxiolytics (acepromazine, butorphanol, diazepam) -Nebulization -Corticosteroids -Surgical placement of stents

Answer 30

-Intraluminal foreign body/mass/neoplasia -Lymph node -Thymoma -Parasites: Oslerus Osleri granulomatous nodule near carina -Trauma: subcutaneous emphysema, pneumomediastinum HBC, traumatic venipuncture

Answer 31

Pulmonary parenchyma disease Viral Pneumonia Bacterial pneumonia Aspiration pneumonia Fungal pneumonia Pulmonary parasites Eosinophilic lung disease Idiopathic interstitial pneumonia Pulmonary neoplasia Pulmonary hypertension Pulmonary thromboembolism Pulmonary edema

Answer 32

1. Canine Influenza virus (H3N8 - equine, H3N2 - avian) -Incubation 2-4 days = most contagious NO c/s -7-10 decreased shedding of virus C/S -Coughing, nasal discharge most common -High fever and pneumonia >serious -No Tx = >mortality Dx -History, exposure -PCR testing (within 4 days) canine respiratory panels. -Acute and convalescent serology Tx -Primarily supportive -Vaccination based on risk -Prevent exposure 2. Canine Adenovirus-1 and 2 3. Canine Parainfluenza 4. Canine Distemper 5. Feline Calicivirus (rare)

Answer 33

-Aspiration pneumonia -Hematogenous route spread -Immunocompromised animals -Underlying respiratory disorder (ciliary dyskinesia, chronic bronchitis) -Not contagious Bordetella - Puppies Adults - E. coli, Pasteurella, Bordetella, Streptococcus, Staphylococcus, Klebsiella, Enterococcus, and Pseudomonas -Anaerobes present in mixed infections where lung lobe consolidation is present C/S -Lethargic, pyrexia, anorexia -Tachypnea to dyspnea -Increased respiratory phase/effort (inspiration most notable) -Soft, productive cough -Nasal discharge -Crackles or increased bronchovesicular sounds -Pale or cyanotic mucous membranes Dx -Radiographs -Patchy interstitial and alveolar patterns most common -Consolidation of lung lobe -Pleural fissure lines, lobar signs **Cranioventral distribution common with aspiration pneumonia** -Caudal or diffuse distribution common with marked interstitial involvement hematogenous bacterial pneumonia -CBC - inflammatory leukogram, with left shift -Blood gas/pulse oximetry <90% -BAL or TTW culture -Misc: fecal flotation, serum chem, UA, HWT Tx -Oxygen - SpO2 <90% = cage or nasal canula -Loosen secretions, vaporization, nebulization and or courage -Antimicrobial therapy -Antimicrobial: culture of septum, BAL, or TTW. Non-responsice to empirical treatment, chronicity, minimize costs -Bronchodilators -Physiotherapy: turn animal every 2 hrs if recumbent -Mild exercise to promote coughing

Answer 34

-Bacterial pneumonias are primary underlying cause -Begins as inflammatory process -CV distribution -Predisposition: Megaesophagus, GI disease, aggressive force feeding, laryngeal paralysis, anesthesia induced regurgitation/reflux

Answer 35

Canine -Blastomycosis and coccidioidomycosis most common: skin lesions, draining -Histoplasmosis possible Feline -Histoplasmosis and cryptococcosis most common: chronic nasal discharge -Blastomycosis and coccidioidomycosis possible C/S -More chronic -Weight loss -Cyclic fever -Lymphadenopathy -Blastomycosis: skin lesions, bone, ocular -Coccidioidomycosis: bone, joint, CNS -Histoplasmosis: diarrhea in dogs Dx -Radiographs: similar to neoplasia pattern -Diffuse military or nodular pattern -May occasionally see pleural effusion (chronic) and "mass" lesions

Answer 36

Dx -Serology -Urine antigen test 94% sensitivity -CBC, Chem, UA - nonspecific findings: normochromic, normocytic anemia, leukopenia, leukocytosis, hyperglobulinemia, proteinuria -Cytology: really important -Skin lesions - Blasto; nasal cavity swabs -FNA of lungs and/or LNs -FNA or spleen, liver, affected organs -TTW or BAL Tx -Systemic antifungals **Itraconazole** -Fluconazole -Ketocanazole -Prednisone - control inflammation -Supportive -60-90 days often 6 mts or longer -Treat 2 months past resolution of signs -High change of recurrence

Answer 37

Paragonimus kellicotti - Small fluke, snail and crayfish -Geographically limited -More common in cats vs. dogs C/S -Asymptomatic or allergic bronchitis -Occasional pneumothorax - bullae -Radiographic lesion - single or multiple solid or cavitary lesions Tx -Fenbendazole Aelustrongylus abstrusus -Cats only -Snails/bird intermediate host -Asymptomatic commonly -Young cats: bronchitis Dx -Larvae in fecal Baermann float or in airway specimens Tx -Fenbendazole

Answer 38

Capillary aerophila -Dogs and cats -Small nematode beneath epithelial surfaces of airways -Usually asymptomatic -May show allergic bronchitis Dx -Radiographs signs of bronchial or bronchointerstitial pattern Tx -Fenbendazole

Answer 39

-Primary pulmonary tumors: carcinoma. Malignant - begin as single mass lesion -Surgical lobectomy beneficial if caught early -Metastatic pulmonary tumors: extensive capillary network allows blood-borne neoplastic cells to deposit within lungs -May present as multi-nodular, single nodule, or mass

Answer 40

>30 mmHg (normal 25/10 mmHg) pulmonary arterial pressure -Cardiac disease: CHF, L to R shunts -Increased pulmonary vascular resistance: pulmonary thromboembolism, heartworm disease -Chronic pulmonary parenchymal disease -Pulmonary fibrosis, chronic bronchitis C/S -Exercise intolerance -Weakness -Syncope -Respiratory distress -Physical examination may reveal a loud split S2 heart sound Dx -Radiographic signs of right-sided cardiomegaly, prominent main pulmonary artery Tx -Aggressively treat underlying disease -If no underlying disease: Sidenafil citrate (viagra), Pimobendan

Answer 41

-Emboli lodge in the low-pressure vascular system of lungs -First pass for systemic venous thrombi and right ventricle **Acute respiratory distress** can be fatal -Causes hemorrhage, edema, bronchoconstriction, decreased blood flow -Blood clot formation associated with venous status, turbulent blood flow, endothelial damage, hyper coagulation -Emboli can also consist of bacteria, parasites, neoplasia or fat C/S -Acute respiratory distress -Cardiovascular shock and sudden death -Early diagnosis: milder dyspnea and tachypnea (chronic) Dx -Easy to overlook -Based on suspected clinical signs -Thoracic radiographs (no changes in early stage) -Arterial blood gas-hypoxemia -Echocardiography -Bloodwork **Difenitive = spiral CT angiography, selective angiography (gold standard), nuclear perfusion scan** -Poor response to oxygen supplementation is supportive of PTE Tx -Aggressive supportive care, oxygen -Treat underlying cause -Eliminate/control predisposing factors -Fibrinolytic agent use not as well established as in human medicine -Useful agents may include low molecular weight heparin, aspirin or clopidogrel (Plavix)

Answer 42

-Mechanisms of edema include decreased plasma oncotic pressure, vascular overload, lymphatic obstruction, and increased vascular permeability -Edema initially accumulates in the interstitium, moving rapidly to the alveoli -Respiratory function is compromised by atelectasis, compression of alveoli and decreased surfactant concentration Dx -Rads: early changes = interstitial pattern -Progress to alveolar pattern Tx -Activity restriction, minimize stress -Hypoxemia treated with oxygen supplementation -Bronchodilators (methylxanthine) -Furosemide: not if hypovolemic -Correct underlying cause -Cardiogenic edema, over hydration, low oncotic pressure - colloids, plasma. Vascular permeability - difficult to treat, look for underlying cause

Answer 43

Pleural and Mediastinal Disease

Answer 44

-Accumulation of fluid (pleural effusion) -Accumulation of air (pneumothorax and pneumomediastinum) -Respiratory dysfunction is associated with interference with normal lung expansion -Exercise intolerance - overt respiratory distress -Abdominal effort may be increased -Increased inspiratory effort -Paradoxical movement of abdomen inwards during inspiration -In cats with mediastinal masses, decreased compliance of chest wall in cranial thorax Radiography -Pleura is not normally visible on radiographs -Individual lung lobes are not distinguished -Abnormalities include pleural thickening, pleural effusion and pneumothorax -Pleural thickening produces pleural fissure lines ~ 50-100 ml fluid

Answer 45

1. Transudates <2.5-3.0 g/dl protein <500-100/microL nucleated cells -Primary macrophages, lymphocytes, mesothelial cells -Increased hydrostatic pressure: Right CHF, pericardial disease -Decreased plasma oncotic pressure: hypoalbuminemia <1g/dl -Lymphatic obstruction: neoplasia, diaphragmatic hernias 2. Modified transudates -3.5 g/dL protein content 5000/microL nucleated cell count -Neutrophils and mononuclear cells -Chronic diaphragmatic hernias 3. Exudates -High protein > 3g/dl ->5000/microL nucleated cells Nonseptic exudate: neutrophils (non degenerate), macrophages, eosinophils, lymphocytes, no organisms -Ddx: FIP, neoplasia, chronic diaphragmatic hernia, lung lober torsion, resolving septic exudates Septic >50000-100000/microL nucleated cells -Neutrophils (degenerate), organisms seen -Ddx: pyothorax, spontaneous, penetrating wound, foreign bodies, extension of bacterial pneumonia. 4. Chylous effusions -Milky white and turbid due to Chylomicrons -May be blood tinged -Rarely: clear.colorless >2.5 g/dl protein 400-10000/microL nucleated cells -Lymphocytes -Confirmation: triglycerides in fluid and serum higher than in pleural fluid -Ddx: leaking from thoracic duct due to idiopathic, congenital, secondary, pericardial disease, lung lobe torsion, heartworm disease, or diaphragmatic hernia 5. Hemorrhagic effusions -Grossly red >3 mg/dl protein >100/microL nucleated cells -Erythrophagocytosis, inflammatory response, do not clot, and PCV lower than peripheral blood. -Associated with trauma, coagulopathies, neoplasia (hemangiosarcoma), lung lobe torsion -Activated clotting time and platelet count should be initially performed, followed by additional clotting tests as needed 6. Neoplastic effusion -Can result in most effusion types **Lymphoma is the only neoplasia reliably identified in neoplastic effusion** -Difficult to establish diagnosis based on cytology -Inflammation causes metaplastic changes in mesothelial cells, which are hard to distinguish from neoplastic cells

Answer 46

-Tension pneumothorax develops if air leaks through functional "one-way valve" lesion in the lungs -Extrathoracic entry can occur after thoracic well trauma, iatrogenically through a chest tube, or during abdominal surgery if diaphragm is not intact Of Pulmonary origin -Blunt chest wall trauma -Rupture of cavitary lung lesions (cysts, bullae, blebs, necrotic neoplastic tissue, abscesses, etc)

Answer 47

-Inspiratory distress due to displacement of lung tissue or secondary to pleural fluid accumulation -Primary differential: Neoplasia (lymphoma common in cats) -Thymoma, thyroid carcinoma, parathyroid carcinoma, and chemodectoma -Non-neoplastic masses: abscesses, granulomas, hematomas, and cysts

Answer 48

-Rapid -Minimally invasive assessment of pleural space for fluid or air

Answer 49

-More sensitive than rads for assessing the thorax -Useful for evaluating extent of masses -Increases likelihood of finding cavitary lesion in spontaneous pneumothorax

Answer 50

-Indicated for collection of fluid or air from pleural space in the dog or cat -Possible complications: lung laceration, hemothoraz, iatrogenic pyothorax **7th intercostal space, 2/3rd distance from constochondral junction to spine** -Aseptic technique -Sternal or lateral recumbency Chest Tube -Indicated for tx of pyothorax and accumulating pneumothorax -Burrowed SQ from 10th intercostal space to 7th intercostal space

Answer 51

Disorders of Pleural Cavity - Feline

Answer 52

-Septic: most idiopathic origin in cats -Can result from penetrating wounds, foreign bodies, migrating plant material, intrathoracic esophageal tears (usually foreign body) C/S -Tachypnea -Decreased lung sounds -Increased abdominal effort with inhalation -Fever, lethargy -Acute or chronic -Asynchronous lung sounds -Systemic inflammatory response syndrome, septic shock Dx -Thoracic rads -Cytology of pleural fluid, aerobic and anaerobic cultures, Gram staining (filamentous gram +) -Most bilateral in cats -Possible mass lesions, pleural fibrosis, or lung lobe torsion -Pre and post thoracocentesis rads Tx -Antibiotic -Drainage of pleural space and supportive care -Empirical choice of antibiotics initially -Anaerobes and Pasteurella: amoxicillin/clavulonic acid PO, or ampicillin/sublactam IV -Anaerobes: Clindamycin, metronidazole -Add gram negative coverage: Fluoroquinolone or amino glycoside -4-6 weeks antibiotics Lavage pleural space -Daily with 10ml/kg warm saline, slowly infuse, patient rolled on side to side gently -Heparin to fluid can decrease fibrin formation -Obtain thoracic radiographs every 24-48 hours -Discontinue when volume decreases to <2ml/kg/day -Cytology resolution of infection Thoracotomy -Indicated in animals not responding to medical therapy -Suspected nidus of infection or foreign bodies

Answer 53

Lung Lobe torsion

Answer 54

-Congenital -Traumatic (surgical or HBC) -HF in cats, diaphragmatic hernia -Non-traumatic - neoplasia, cardiomyopathy, pericardial disease, heartworm disease, lung lobe torsion, diaphragmatic hernia, systemic lymphagectasia -Idiopathic **Originates from thoracic duct, gets dumped into jugular vein. Chyle contains triglycerides, lymphocytes, protein and fast-soluble vitamins** Breeds -Afghan hounds, Shiba Inu, Siamese, Himalayan cats C/S -Lethargy -Anorexia -Weight loss -Exercise intolerance Dx -Thoracic radiographs -Evaluation of effusion (cells and triglycerides) -Peripheral lymphopenia and panhypoproteinemia may be present -Evaluate for underlying disease Tx -Resolve underlying disease -Medical management: intermittent thoracocentesis (every 2 weeks) -Low fat diet -Administer RUTIN - Benzopyrone drug that decreases protein content of the effusion (promoting resorption of the fluid) -Surgical ligation of the thoracic duct if not resolved within 3-4 months -Peuroperitoneal or pleurovenous shunts may be utilized if all else fails -50-80% response to surgical therapy

Answer 55

GOLDEN RETRIEVER -Rupture of cavitary lesions leads to spontaneous pneumothorax -Occurs more often in dogs than cats -Leads to rapid, profound respiratory distress following rupture if tension pneumothorax develops Pulmonary Blebs < 1 cm Pulmonary Bullae >1cm Cavitary lesions -Paragonimus infection -Necrotic neoplasia -PTE -Abscesses and granulomas -Congenital -Idiopathic -Traumatic -Chronic always disease -Bullae Tx -Thoracocentesis -Medical treatment successful for Paragonimus (Fenbendazole) -Most others surgical excision required

Answer 56

Compare triglyceride concentration Evaluate cytology with Diff-Quick stain and a gram stain Cervical mass TFAST and check out chest tube and pericardial sites

Answer 57

Emergency Management of Respiratory Distress and Oxygen Supplementation

Answer 58

C/S -Orthopnea (shortness of breath) -Exaggerated abdominal movement -Cats with notable chest movement or open mouth breathing are seriously compromised -Cyanosis = severe hypoxemia -Pallor = acute hypoxemia -Extended neck breathing, open mouth, adduction of elbows: orthopnea secondary to CHF Dx -Perform a rapid PE -Breathing pattern, auscultation, mm color, pulses, perfusion -Localize where the problem is Upper airway: stridor, storting Lower airway: expiratory difficulty, crackles, wheezes Pulmonary parenchyma Pulmonary interstitial or pleural disease Emergency Management -Treat for shock: circulatory support, appropriate fluid therapy, balance electrolytes, etc. -Triad of emergency 1. Decrease stress (sedation, anxiolytic) 2. Place in cool environment 3. Supplement with oxygen to maintain PaO2 > 60 mmHg

Answer 59

PaO2: 85-100 mmHg PaCo2 : 35-45 mmHg HCO3: 21-27 mmol/l pH: 7.35-7.45 -Pulse oximetry: estimates arterial oxygen by measuring hemoglobin saturation -Arterial blood gas measures both oxygen and CO2: dorsal pedal artery (medium to large dogs). Pre-heparinized syringes and process according to laboratory instructions --Cage-side point of care machines (e.g., IStat with blood gas cartridges)

Answer 60

Metabolic Acidosis -pH: decreased -PCO2: decreased -HCO3: decreased -Hyperventilation - compensatory Metabolic Alkalosis -pH: Increased -PCO2: Increased -HCO3: increased -Hypoventilation - compensatory Respiratory Acidosis -pH: decreased -PCO2: increased -HCO3: increased -Compensatory renal increased HCO3 resorption Respiratory Alkalosis -pH: Increased -PCO2: Decreased -HCO3: decreased -Compensatory decreased renal HCO3 resorption Acid-base status Primary Hypoventilation -Increased PCO2, respiratory acidosis Primary hyperventilation -Decreased PCO2, respiratory alkalosis Metabolic acidosis -Decreased HCO3, drives respiratory hyperventilation (secondary) and decreased PaCO2. Metabolic alkalosis -Increased HCO3, drives respiratory hypoventilation (secondary) and increases PCO2

Answer 61

PaO2: pressure of oxygen dissolved in arterial blood SaO2: Oxygen saturation of hemoglobin is dependent on PaO2. Clinically measured by pulse oximetry When PaO2 > 80 mmHg = SaO2 ~100% Hypoxemia/Oxygen -Hypoventilation -V/Q (ventilation/perfusion) mismatch in the lung -Diffusion abnormality -Hypercapnia occurs with hypoxemia -V and Q must be matched for blood to be fully oxygenated upon leaving the lung -Poor ventilation occurs in most pulmonary diseases, ex edema, alveolar collapse, small airway obstruction (bronchitis) -Poor ventilated lungs with normal blood flow have low V/Q -A high V/Q ration is associated with pulmonary thromboembolism

Answer 62

-Monitors saturation of blood -Estimation of arterial oxyhemoglobin saturation by transmitting light through tissues -SpO2 is the difference between light absorption during pulsation (arterial) and background absorption (venous blood, tissue, bone) -Continuous, immediate, noninvasive estimation of oxygen

Answer 63

Artifact -Probe falls off or poorly positioned -Dry tongue -Fluorescent lighting -Tissue thickness too great -Pigmented tissue -Electrical interference (electrocautery) -Must record a pulse that matches animal's

Answer 64

-Indicated if needed to maintain PaO2 >60 mmHg -Indicated in every patient with respiratory distress or labored breathing -Cyanosis -If not responsive to supplemental 100% oxygen, ventilation is the next step -Oxygen masks - useful for short term supplementation -Oxygen hoods -Nasal catheters - long term supplementation -Endotracheal tubes - requires anesthesia -Oxygen cages -Patients requiring supplemental O2 need to be monitored closely Every 2 hrs get RR, HR, respiratory effort, MM color, and SpO2 Make sure that a bubble humidifier is connected to the oxygen for long term supplementation

Answer 65

-Decrease the retention of CO2 and increase oxygenation -Referral - labor intensive -Recommended if patient PaCO2 >60 mmHg -Positive pressure ventilation recommended for ARDS patients -Potential detrimental effects of PPV - decreased venous return to the heart, systemic hypertension, decreased lung compliance

Exam 5 Flashcards

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