Examination of the respiratory tract patient Flashcards
Anamnesis:
▪ Localization of the problem
▪ Specific questions for the respiratory tract
To which part of the respiratory tract
does this problem localize?
gagging,
coughing,
wheezing, having
a weird sound
there is something in it’s throat,
it cannot breath,
it is vomiting whitish mucus,
the stomach is moving when it is
breathing
Use the signs to try and figure this out.
Localizing the problem to the Nasal cavity may include the following signs: (6)
Nasal discharge,
sneezing,
pain of the muzzle,
rubbing and licking the muzzle,
soft cough or gagging (post-nasal drip)
Localizing the problem to the upper resp. tract (nasopharynx, pharynx, larynx,
cervical trachea) may include the following signs: (8+)
Snoring,
stertor, stridor,
reverse sneezing,
voice change,
exercise intolerance,
heat intolerance,
dyspnea, cough
NB Inspiratory difficulty
Diseases of the cervical trachea cause
problems in ?, diseases of the
intrathoracic trachea in ?.
Diseases of the cervical trachea cause
problems in inspiration, diseases of the
intrathoracic trachea in expiration.
Localizing the problem to the Lower respiratory tract (intrathoracic trachea, bronchi, pulmonary parenchyma) may include the following signs: (6+)
Cough,
abdominal push in breathing,
occasionally shallow breathing and tachypnea,
prolonged exhalation,
exercise intolerance,
dyspnea
NB Expiratory difficulty
Inspiratory difficulty vs Expiratory difficulty
Area of localization?
Inspiratory difficulty due to Upper respiratory tract issue (nasopharynx, pharynx, larynx, cervical trachea).
Expiratory difficulty due to lower respiratory tract issue (intrathoracic trachea, bronchi, pulmonary parenchyma).
Localizing the problem to the pleural space may include the following signs: (3)
Asynchronous breathing,
tachypnea
NB Restrictive breathing difficulty
Specifying questions for respiratory anamnesis.
▪ Acute or chronic?
▪ Stable or progressive?
▪ Signs of systemic illness, fever?
Cough?
▪ Vomiting vs. coughing
▪ Nonproductive or productive?
Cough is common in dogs, less common in cats. Cats always need further workup.
Are the symptoms related to rest,
exercise or excitement?
Cough during the night or after rest indicates Mucus in the airways. Not necessarily a cardiac problem!
Dry cough when excited - if a Small breed dog - tracheal collapse?
Respiratory distress worse when exercising -> Inspiratory noise – laryngeal paralysis?
Exercise intolerance is Difficult to notice in cats! Disease needs to be severe enough to affect gas exchange.
If prev tx - WHICH antibiotics were used?/ Which DOSE corticosteroids were given?
Allergic/inflammatory Differential
diagnoses for cough. (6)
◦ Feline asthma/bronchitis
◦ Chronic bronchitis (dogs)
◦ Eosinophilic bronchopneumopathy (dogs)
◦ Laryngitis
◦ Rhinitis
◦ Tonsillitis
Cardiovascular Differential
diagnoses for cough. (4)
◦ Cardiogenic pulmonary edema
◦ Cardiomegaly
◦ Pulmonary embolism
◦ Pericardial effusion
Infectious Differential
diagnoses for cough. (4)
◦ Tracheobronchitis (bacterial, viral)
◦ Pneumonia (bacterial, viral, fungal, protozoal)
◦ Pulmonary abscess
◦ Parasitic infection (pulmonary parasites, larval migration, heart worm, Angiostrongylus vasorum)
Degenerative Differential
diagnoses for cough. (4)
◦ Tracheal collapse (dogs)
◦ Bronchomalacia
◦ Bronchiectasis
◦ Laryngeal paralysis
Neoplastic Differential
diagnoses for cough. (2)
◦ Primary or metastatic (larynx, trachea,
mediastinum, lung)
Non-categorized/Other Differential
diagnoses for cough. (4+)
◦ Interstitial lung diseases
◦ Foreign body
◦ Near-drowning
◦ Near-strangulation
◦ Lung lobe torsion
◦ Dysphagia
◦ Gastroesophageal reflux
◦ Noncardiogenic pulmonary edema
◦ Pulmonary contusion
◦ Pleural effusion
Physical examination in respiratory patients.
Look and listen before touching!
Recognize dyspneic patients
▪ Tachypnea > 30/min
▪ Changed respiratory pattern
▪ Open-mouth breathing
▪ Standing posture with extended neck and
abducted elbows.
▪ Cyanosis
NB Normal color of mucous membranes does NOT rule out severe respiratory disease!
Noisy breathing, stridor, stertor localizes to…
the upper resp tract / inspiratory problem
Abnormal auscultation, crackles, rhonchi,
wheezes localizes to…
the lower resp tract / exspiratory problem
Asynchronous breathing, shallow, fast localizes to…
Pleural space disease / restrictive problem
May include Muffled heart
and lung sounds.
Describe auscultation of breathing sounds.
Standing animal, all areas of the chest
▪ No panting, no purring
Normal breath sounds arise from
trachea and bronchi
▪ Heard better on inspiration
No audible breath sounds?
▪ Fat cat?
▪ Pleural disease!
What is Tracheal sensitivity?
Part of your clinical exam of a resp. patient, Hold the trachea between your thumb and index finger, press slightly.
◦ Dogs with increased tracheal sensitivity start coughing. Is not specific to any disease!
Examination of the nose.
Nasal discharge, sneezing, reverse sneezing, open mouth breathing, stertor, stridor, conjunctivitis?
Palpate the head and muzzle
◦ Look for Symmetry, pain, masses, enlarged lymph nodes?
Investigate the skin and mucous membranes
◦ Look for Ulceration, depigmentation?
Examination of the nose.
Check air flow through both nostrils
Examine teeth and gums
Hematology in resp. patients
Do Complete blood count, differential cell counts. You May see Left-shift, leukocytosis, leukopenia.
If above normal, bacterial pneumonia still possible.
Eosinophilia may indicate Eosinophilic lung diseases, parasites.
Acute phase proteins in resp. patients
▪ Serum C-reactive protein (CRP) in dogs
▪ Serum amyloid A (SAA) in cats
NB A Normal SAA does not rule out chronic bacterial pneumonia.
Serum biochemistry in resp. patients
▪ Do Depending on the case.
▪ Do in Animals with severe or chronic disease or old age.
▪ IDEXX Snapp proBNP in cats if suspicion of
heart failure.
Parasitological testing types in resp. patients (3)
Fecal examination for parasites
▪ Intermittent shedding – take a 3-day sample.
Flotation for parasite eggs
▪ Toxocara spp., Toxascaris spp.,
Eucoleus aerophilus
Baermann sedimentation for larvae
▪ Aerulostrongulus abstrusus (feline lungworm),
Filaroides spp. (Oslerus osleri),
Crenosoma vulpis (fox lungworm),
Angiostrongylus vasorum
(French heartworm)
Estimating lung function.
Endoscopy and sampling of the respiratory
tract: options for scoping? (5)
Bronchoscopy
Bronchoalveolar lavage
Transtracheal wash
Rhinoscopy
Laryngoscopy
Bronchoscopy =
endoscopy of the trachea and bronchi.
Visual Inspection of the structure and mucosal surface of trachea and bronchi.
Sampling by bronchoalveolar lavage or bronchial biopsy.
Indications:
- Acute severe disease when no cause can be identified
- Chronic diseases of the lower respiratory tract
- Foreign body removal
Requires general anesthesia.
Cats more prone to complications!
Describe Bronchoscopy - anesthesia. (4)
Suitable anesthetic protocol for patient with respiratory problems!
Preoxygenation via face mask prior to anesthesia.
Premedication of cats with terbutaline!
- 0.01mg/kg sc 30min prior to scoping
IV-anesthesia, inhalation in bigger dogs.
Careful monitoring!
BAL =
What is it?
Bronchoalveolar lavage
Diagnostic technique for sampling
from the alveoli and small airways.
Sterile saline instilled through
bronchoscope and retrieved back for
analysis.
- Bacterial culture
- Cytological analysis
- Total cell count and differential cell counts
Bronchoalveolar lavage fluid neutrophilia indicating Infection, chronic bronchitis,
pulmonary fibrosis yms.
Bronchoalveolar lavage fluid eosinophilia indicating Eosinophilic bronchopneumopathy (dogs),
asthma (cats), parasitic infection yms.
Describe BAL – bacterial culture (3)
Lower respiratory tract is not sterile!
Quantitative bacterial culture,
aerobic and anaerobic.
Antibiotic sensitivity testing
Describe Blind bronchoalveolar lavage
In cats and small dogs in which bronchoscope is too big.
Animal intubated in general anesthesia.
Insert a small catheter through the endotracheal tube, instill a small amount of sterile 0.9% saline, aspirate back.
What’s this?
Transtracheal wash
To obtain respiratory sample from major airways in medium and large sized dogs (>10kg).
Does not require general anesthesia.
For animals in which sample is needed but general anesthesia is not possible.
Rhinoscopy =
Describe it.
endoscopy of the nose
Visualization and sampling of the nasal cavities and nasopharynx.
Indications
- Nasal discharge, congestion, pain, stertor, epistaxis, sneezing, reverse
sneezing, lack of air flow from nostrils, facial asymmetry, depigmentation or ulceration of nostrils
Requires general anesthesia
After CT scanning
Contraindicated in animals with hemostatic disorders!
Describe nasal biopsies via rhinoscopy.
Rhinoscopy guided or blindly taken
Alligator forceps, biopsy forceps.
Check hemosthasis before biopsy!
Prior to biopsy, measure the instrument
to the medial canthus of the eye. Advance no further!
Place the biopsy to formalin and send to
histopathological evaluation. Bacterial culture rarely useful.
Describe Nasal flush.
Removal of secretions, fungal plaques, foreign bodies.
Bacterial culture of flush sample might be helpful in some cases.
Bacterial culture from nasal swab is not recommended.
- Animal in sternal recumbency
- Flush sterile saline through the nose while pressing the contralateral nostril
- If cribriform plate is damaged, perform a retrograde flush
Laryngoscopy =
Describe it.
endoscopy of the larynx
Visualization of larynx, evaluation of laryngeal anatomy and function.
Indications
- Voice change, stridor, stertor, increased inspiratory effort, prolonged inspiration, exercise intolerance, coughing after eating or drinking.
Fast and technically easy procedure
Light anesthesia!
Laryngoscope with a light source or endoscope
- How many lobes does the right lung have?
a) One
b) Three
c) Two
d) Four
d) Four
- How many lobes does the left lung have?
a) one
b) Three
c) Two
d) Four
c) Two
