Bonzo has a cough.. Flashcards
What are the differentials of the upper airway (nose,larynx, phrynx) for coughing (4)
- *Degenerative**: Laryngeal paralysisleading to secondary aspiration pneumonia
- *Neoplastic**: masses of the pharynx or larynx typically cause more stertor, stridor, dyspnoea or retching than a cough but some owners may present these to you as a “cough”.
- *Inflammation/infection**: You might see a dry retching cough again from infection or severe inflammation in this area, but again a true cough would be unusual.
- *Trauma:** A stick injury to this location may again cause gagging but not a true cough.
What are the differentials of the trachea for coughing (5)
The trachea is a common site of origin for coughing which is typically paroxysmal, dry and non-productive - it may be described in many cases as being like a goose honk.
- *Degenerative**: Tracheal collapse is a common cause of a dry, retching cough in small breed and some larger breed dogs.
- *Anomalous**: Ciliary dyskinesia is rare but possible as a differential.
- *Neoplastic:** Tracheal masses are really rare but could well make an animal cough if they compress the lumen.
- *Infectious/inflammatory**: There are several bacterial, viral and parasitic ones which go in here including Bordetella bronchoseptica, Canine parainfluenza virus, and Oslerus osleri - look on WikiVet for more information about these.
- *Trauma**: tracheal traumas such as ruptures and avulsions may cause a cough but more commonly cause dyspnoea and emphysema. Foreign bodies in the airway can certainly cause a cough however.
What are the differentials of the bronchi and bronchioles for coughing
There are cough sensors all the way down here so any pathology in this site could lead to a cough which is triggered by material in the airways, compression from externally or a collapse of the bronichi.
The differential list is far too long to go to in any detail here but you can look these up if you’ve not heard of them. It should include: bronchial collapse; inhaled foreign material eg plant material or food or toxins such as smoke; chronic inflammation (bronchitis); feline bronchial disease (asthma, allergic); bronchial tumours; bronchiectasis; parasites; fungal and protozoal diseases; eosinophillic infiltration; lung lobe torsion.
What are the differentials of the tracheo-bronchial lymphadenopathy for coughing
Big lymph nodes compressing the trachea arise most typically from neoplasia or infection (bacterial, fungal, viral, protozoal) within the thorax and cause a cough by compressing the main stem bronchi.
What are the differentials of the alveoli for coughing
It is not thought that there are many cough receptors in the alveoli so whilst alveolar disease is definitiely associated with coughing, it may be more from the disease process affecting the local bronchi and bronchioles instead of as a direct mechanism.
Alveolar fluid can be a transudate, modified transudate, exudate or blood or rarely aspirated material such as barium or lipid. Infiltrative disease can on occasion have this appearance too. Left sided heart disease is the first one that many people think of as causing an alveolar pattern on radiographs but pneumonia, coagulopathies and tumours can all cause fluid filling of the alveoli too. There are also some odd causes of non-cardiogenic oedema, but these are typically very dyspnoeic animals rather than having a cough, probably due to the lack of bronchiole involvement.
Why is pleural disease rarely on the differentials for coughing??
Pleuraldisease is a rare cause of coughing - it much more commonly leads to shallow breathing and dyspnoea so should not really be on your differential list.
Why are the rib not an area on the differential list for coughing?
Rib masses and fractures are much more likely to cause dyspnoea than a cough due to space occupation in the case of masses, lung laceration and pneumothorax in the case of rib fractures or from a flail chest if there are multiple fractures. Rib disease should therefore not be on your list for common causes of coughing.
Why is the mediastinum not an area high up on the differential list for a cough?
Mediastinal disease is a rare cause of a cough unless it leads to tracheal or bronchial compression so should not be high up on your list. It much more commonly causes dyspnoea from direct space occupation or by generating a pleural effusion.
Why may the heart cause a cough?
A tented left atrium leading to tracheal elevation and compression is a common differential for a cough in cardiac patients. More generalised cardiomegally may also have the same effect.
Why may the oesophagus cause a cough?
Rare, but oesophageal disease can lead to a cough. Megaoesophagus is a high risk factor for aspiration pneumonia which will cause a cough, and very occasionally oeophageal rupture, typically from foreign bodies, can cause a cough.
What is on your differential list for this clinical exam of a bulldog? (4)
Bonzo appears bright and alert in your room, He appears to have increased effort to breathe, mainly on inspiration but he has a bit of abdominal effort on expiration too. He is not breathing more shallowly than normal.
Nose: Bonzo has a bilateral mucopurulent nasal discharge which his owners hadn’t noticed - he licks it away pretty quickly once it has appeared. He has bilaterally symmetrical airflow, no nasal planum depigmentation and no evidence of nasal pain on palpation.
Mouth: Examining the mouth of a bulldog is often unrewarding because they are pretty tricky to restrain and have relatively huge tongues for their brachycephalic heads. You can see that Bonzo’s colour is pink with a capillary refil time of less than two seconds but that is all you can see.
Upper airway auscultation and palpation: It’s really important to listen over the larynx and trachea of all animals but especially important in brachycephalic breeds because they often have very loud sounds generated by their long soft palates. Bonzo does indeed have a lot of noise up here, mainly stertorous inspiratory sounds from his palate. You cannot elicit a cough on tracheal pinch.
Thoracic auscultation: Now you know what noise is coming from Bonzo’s upper respiratory tract, you can try to subtract this from his lower airway auscultation. Bonzo has now had enough of having his mouth held shut so you have to listen between bouts of panting. He has marked sinus arrhythmia and and a heart rate of 86bpm with no apparent murmurs. His respiratory rate is difficult to count accurately but you think it is about 40 breaths a minute. You percuss his thorax and listen to his lung fields. He’s a really hard dog to examine but you wonder if he sounds more dull over the right ventral side of his thorax. Palpation of his ribs and neck is unremarkable.
Abdominal palpation: Always do a full clinical examination on any animal; whilst it seems Bonzo may just have a lung problem, you may be missing something else significant if you don’t look and there is that history of some abdominal signs too. Bonzo is tense on abdominal palpation but you don’t think you can feel anything remarkable and he doesn’t seem painful.
Temperature: Bonzo has recently been treated for dermatitis around his tailhead due to his corkscrew tail, so is particularly displeased when you try to take his temperature but you get there eventually. Bonzo’s rectal temperature was 39.7C. The faeces on the thermometer look unremarkable.
- Bronchitits
- Bacterial or viral pneumonia
- Aspiration pneumonia
- Inhaled FB
So Bonzo’s nasal discharge, the pyrexia, moist cough and the reduced lung sounds on the right make an infectious lung disease more likely than many of the other differential diagnoses on the list, though remember that not every dog reads the text book.
What are the option next?
Home: I wouldn’t with a pyrexic bulldog, we’ll come on to more of why in a bit. Try again.
Trial treat: If his owners can’t afford anything else, if he is well in himself and they are fully aware of the potential differentials and that Bonzo really would benefit from more investigation then you could do this but I wouldn’t have it as a top option and might add in other things too.
Bloods: This is sensible as you can assess Bonzo for concurrent disease, check his neutrophil count etc..
Radiography: This is a very sensible option as it’s the best way of starting to localise where his cough is coming from if you think you’ve limited it to being a lung problem.
BAL: I would image first as he may not need this or may not be stable enough for this proceedure.
Blood gas: There would be nothing wrong with doing this and it would provide valuable information on his oxygenation status but I wouldn’t have it on my initial priority list yet.
What is your diagnosis?
Alveolar pattern in right middle lung lobe
What is highlighted?
Tracheo-bronchial lymphadenopathy
Not that clear but I think the lymph nodes are big in this area, which would not be surprising with the pathology elsewhere.
What is highlighted?.
Air bronchograms
These are the air bronchograms associated with this lung lobe.
What is highlighted?.
Right middle lung lobe consolidation
There is a marked alveolar pattern overlying the heart with visible air bronchograms. This is the right middle lung lobe which can be affected by pneumonia including secondary to aspiration. You can also get lung lobe torsions here in some breeds of dog, and collapse of the right middle lobe is not uncommon in cats with asthma so it’s a good place to have a close look at.
