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Flashcards in Lecture 3 Deck (25):
1

Dyspnea present?

1. Severity
- Oxygen dependent?
2. Localization
- Inspiratory vs. expiratory vs. restrictive
- Upper airway, lower airway, parenchymal, thoracic wall, neurologic, abdominal (or not dyspnea...)

2

Cough mechanism

PROTECTIVE!!
- works w/ mucociliary apparatus
- both are less effective w/ disease!

NOTE: the trachea and large airways have the most "cough receptors"

3

Coughing

Coughing is a non-specific clinical sign ==> an accurate medical history is critical!
- acute vs chronic, static vs worsening, associations (ie. after exercise), productive vs. non-productive, other systemic signs

4

Potential coughing triggers

1. owner is a smoker
2. perfume/air fresheners
3. dusty kitty litter
4. house construction

Especially dig for some of these if patient has a cough history w/ no systemic disease or sign of infectious pneumonia

5

Coughing patient?

Consider any environmental exposure
- boarding/grooming?
- obtained from shelter?
- outdoors? travel history?
- walks? dog parks?
- show? agility competitor?
- heartworm prevention?
- other sick/coughing animals at home?

6

Physical exam components of coughing patient

1. Tracheal and cervical palpation
2. Nasal discharge (nasal discharge w/ lots of drainage ==> drainage may irritate the trachea and cause cough)
3. Changes in weight
4. Skin lesions
5. Cardiac abnormalities
6. Lymphadenopathy
7. Fundic examinations (ocular lesions may be seen w/ fungal and neoplastic disease)
8. Rectal examination

7

Characteristics of a non-productive cough

1. Usually loud, harsh, and paroxysmal
- "Goose-honk"
2. Most commonly associated with:
- Upper airway disease (trachea and mainstem bronchi)

8

Productive cough

1. Expectoration of sputum
- Fluid/mucus/debris from the LOWER AIRWAYS (not much mucous/fluid is produced in upper airway)
2. Most commonly associated with:
- Lower airway disease
- Pulmonary parenchymal disease

NOTE: productive cough yielding a foamy expectorant: foamy is associated w/ edema or heart failure
NOTE 2: Are they coughing and then just swallowing? Are they swallowing their "productive cough"???

9

Productive cough characteristics

1. Typically softer in volume ("huff")
2. Less likely to be "paroxysmal"
3. May be difficult to appreciate
- Swallows sputum
- Owner perceives as vomiting
Terminal retch = NOT productive typically

10

Cats coughing?

Coughing in cats is RARE
- When present should pursue aggressively!!
1. Most common cause of coughing in cats is LOWER AIRWAY DISEASE (asthma)
- Pleural space disease (rare)
- Tracheal disease (uncommon)

11

Cardiogenic Cough

1. Implies congestive heart failure... usually
- Pulmonary edema

NOTE: Which abnormal breath sound should you be able to auscultate during your exam w/ cardiogenic cough?
- CRACKLES.

CHF: significant mitral valve disease ==> may lead to enlarged Left Atria ==> may compress mainstem bronchi ==> may see an upper airway non-productive cough (unless CHF is so severe there is pulmonary edema)

12

Cardiogenic Cough

1. Cough classically worse at night
2. Typically exhibit concurrent exercise intolerance at rest
3. May have auscultation abnormality (ie. murmur)
4. Perihilar edema on radiographs
- Furosemide responsive

13

Non-cardiogenic cough

1. Upper (large) airway
2. Lower (small) airway
3. Parenchymal
4. Pleural Space

14

Upper Airway Cough: infectious

Infectious (tend to be honking, loud, non-productive)
- Infectious tracheobronchitis
- Parasitic (Oslerus osleri - filaroides) => K9 lungworm
- Hilar lymph node enlargement (squishes carina; Fungal disease - especially histoplasmosis)

NOTE: upper airway coughs tend to be non-productive

15

Upper airway cough: non-infectious

Non-infectious
- Tracheal collapse
- Compressive masses (mural or extra-mural)
- Foreign bodies

16

Lower Airway Cough

1. Inflammatory airway disease
- K9 chronic bronchitis
- Feline lower airway disease
- Eosinophilic bronchopneumopathy
2. Smoke/chemical irritant inhalation

17

Parenchymal Disease Cough: infectious

Infectious
- Bacterial
- Fungal disease (blastomyces, histoplasma, coccidioides)
- Heartworm infection
- Parasitic (Aleurostrongylus -cats, Filaroides hirthi -K9, Paragonimus -lung fluke)
- Toxoplasma (more common in cats)

18

Parenchymal disease cough: non-infectious

Noninfectious
1. Neoplasia
- Primary (caudal lung lobes)
- Metastatic (multiple nodules)
2. Lung lobe torsion (concurrent pleural effusion)
3. Non-cardiogenic pulmonary edema (strangulation and electrocution are the top 2 causes)

19

Diagnostic Plan: 1st tier tests

Common "first tier" tests
1. CBC (look for inflammatory change)
2. Thoracic radiographs (if stridor, stertor, goose-honk we're thinking possible extra-thoracic so may want cervical rads)
3. Fecal exam (float, sediment, Baermann)
4. Heartworm testing
5. Cytology (skin lesions, nasal discharge, lymph nodes)

20

Diagnostic Plan: 2nd tier tests

Second tier testing
1. cardiac evaluation
2. chem panel (helps if there's systemic disease - like fungal - may have infiltrated liver and increased enzymes)
3. Urinalysis (fungal antigen titers)
4. AIRWAY SAMPLING (TTW, ETW, BAL)
5. Advanced imaging (fluoroscopy, CT)
6. Lung aspirate/biopsy
7. Bronchoscopy/thoracotomy

21

Transtracheal and endotracheal wash

1. When there is diffuse disease! (ie. bronchitis)
2. instill 0.5-1.0 ml/kg per aliquot (repeat 2-3 times)
3. catheter usually goes to the level of the carina (may go deeper w/ ETW)
4. Recovered saline wash sample submitted for cytology and culture

NOTE: patient must be able to cough ==> consider when choosing anesthetic/sedative drugs

22

Bronchoalveolar Lavage (BAL)

BAL:
- LOCALIZED disease
1. At least to 1 hemi-thorax (ie. right-sided aspiration pneumonia)
2. Sample taken via guidance of bronchoscope - scope lodged in lower airway
3. can take localized samples and can get greater volume yields
4. patient may be oxygen-dependent until the patient coughs the saline up

23

Empiric antibiotic therapy possible?

1. Limited to 1 course (failure = airway sampling necessary)
2. Discontinue 1-2 weeks before sampling airways, if possible
3. Informed client consent (may complicate future diagnosis/tx if unsuccessful)

24

Antitussives

1. Opioids
- Butorphanol (torbugesic)
- Hydrocodone (combined w/ anticholinergic)
- Loperamide (Imodium)
- Diphenoxylate (also combined w/ anticholinergic)

2. Opioid derivative
- Dextromethorphan (OTC)

SIDE EFFECTS expected: sedation, constipation

25

Points to Ponder!

1. Cough is a PROTECTIVE MECHANISM
- am I treating the patient or the owner? Is the cough interfering w/ quality of life in a big way?
- what are my top differentials?
- Collapsing trachea? Bronchitis?

Relative CONTRAINDICATIONS:
- Productive cough
- Infectious disease present