Respiratory CVT Flashcards
What are the 2 forms that oxygen is carried in the blood?
- Dissolved in arterial blood (responsible for diffusion pressure driving oxygen to tissue)
- 97% attached to hemoglobin
What are the 2 most important factors influencing amount of O2 in blood?
- Amount/concentration of hemoglobin in blood
2. % of Hb that is saturated with oxygen (SaO2)
What are 5 conditions that oxygen should be supplemented?
- Hypoxemia (SaO2 < 90%)
- Hypotension (< 18)
- Respiratory Distress (RR>24)
Under what conditions are SaO2 and PaO2 within normal limits, but tissue hypoxia present?
Low cardiac output, anemia, failure of tissues to use oxygen
In these situations mixed venous oxygen (PvO2) better measure of tissue oxygenation
What is the gold standard for determining if oxygen supplementaion is needed?
Arterial PO2; Needed if <80mmHg
What does a venous PO2 value indicate?
Influenced by amount of oxygen in arterial blood, tissue perfusion, uptake of oxygen (oxygen extraction ratio)
If < 30mmHg = Low arterial oxygen OR high oxygen extraction ratio
What does a PEEP valve do to pulmonary capacity?
PEEP (positive end-expiratory pressure) valve = increases pulmonary functional residual capacity = Decreased work of breathing
Recommended when there is a V/Q mismatch (pulmonary edema, hemorrhage, or parenchymal dz)
Leaves air in the lungs a little longer = increasing time for gas exchange
Aimed at 5-10 mmHg (since 15 mmHg = Barotrauma!)
Name 7 ways that oxygen can be supplemented.
- Blow By
- Oxygen Hood
- Oxygen Collar
- Nasal Cannula
- Nasal Catheters (nasal, nasopharyngeal, or nasotracheal)
- Transtracheal catheters
- Oxygen Cages
What are the 3 methods to assess supplemental oxygen effectiveness?
- Clinical Evaluation (CS, lactate, ECG/Echo)
2. Pulse Oximetry (Bad if 65 mmHg)
What does pulse oximetry measure?
Peak oxygen saturation of Hb in capillary blood
What does a PaO2 with oxygen supplementation less than 65mmHg indicate?
Right to left shunt OR pulmonary dysfunction; Others (pneumothorax, severe hypovolemic shock, cardiogenic shock, obstructive airway disease)
What is CPAP?
Continuous positive airway pressure: Maintaining pressure above atmospheric pressure throughout respiratory cycle
What is a side effect of using PEEP?
Increased intrathroacic pressure = decreased venous return to heart and increase in dead space
What is a hyperbaric pressure?
Pressures higher than sea level
Why is the administration of high concentrations of oxygen bad?
Can result in oxygen toxicity - which can cause further lung injury
What are guidelines for ventilation?
- Failure of Gas Exchange:
PaCO2 above 50 mmHg
PaO2 will not rise above 50 mmHg with test of 100% O2 or cannot be maintained with FiO2 0.6 or less - Need to assess the work of breathing in each patient = respiratory muscle exhaustion
What are the 2 classifications of patients that benefit from mechanical ventilation?
- Primary pulmonary diseases (lung-injured patients) = Noncardiogenic and cardiogenic pulmonary edema, pneumonia, pulmonary contusions, ALI, ARDS, Airway obstruction, smoke inhalation
- Neuromuscular Apparatus Failure (nonlung-injured patients) = polyradiculoneuritis
(coonhound paralysis), myasthenia gravis, tick paralysis, botulism, tetanus,
cranial cervical spinal cord lesions, brain injury, anesthetic complication, drug overdose, postcardiopulmonary resuscitation, respiratory muscle exhaustion caused by high work of breathing, diaphragmatic herniation, and chest wall trauma
What are the 5 main causes of hypoxemia?
- Alveolar hypoventilation
- V/Q Mismatch
- Shunt
- Low Insipired FiO2 (high altitudes)
- Diffusion Impairment
What is the most common cause of hypoxemia?
V/Q Mismatch
What are the two ways that ventilators are cycled?
- Volume-cycle (good for healthy lungs)
2. Pressure-cycle (good for injured lungs, but lots of variation in tidal volume delivered)
What are the 3 types of patient breaths in a ventilator?
- Controlled breaths (set interval)
- Assisted Breaths (patient can start it, ventilator finished it)
- Spontaneous breaths (patient taking own breaths)
What is sensitivity of the ventilator?
Sensitivity - responsiveness of the ventilator to patient efforts to initiate breathing (assisted or spontaneous breaths)
What are the breath delivery mode of the ventilator?
- A/C Mode: (Assist/Control) No spontanous breaths allowed (patients with poor respiratory drive)
- SIMV Mode: (Synchronized intermittent mandatory ventilation): allows both mechanical and spontaneous breaths to be delivered according to patient demand
- SPONT mode (spontaneous): the ventilator delivers no mandatory mechanical breaths. All breaths are spontaneous = Prewean mode
What are 4 ways that PEEP can improve ventilation?
- increase in the functional residual capacity
- alveolar recruitment
- improved V/Q matching
- redistribution of the extravascular lung water
What are 2 types of ventilator induced lung injury?
- High pressures and use of high tidal volumes = Damage capillaries
- Opening and closing of alveoli = Shear stress!
What is the trade-off of lung protective strategies for ventilation?
Hypoventilation (PaCO2 - 70-80 mmHg) permitted
Which type of patients are harder to keep sedate when using a ventilator?
lung-injured patients typically are more difficult to control because of high ventilatory
drive from hypercarbia or hypoxemia
What is a potential cardiovascular cost of ventilation?
Declining cardiac output and resultant decreasing oxygen delivery = Eventually it outweighs the benefit of increasing arterial oxygen content
What is a potential sequela of ventilation?
Ventilator associated pneumonia (pathogenesis: colonization of the aerodigestive tract with pathogenic microbes early in the course of hospitalization and aspiration of the contaminated secretions)
When would nasal discharge cytology be useful?
Eucoleus [Capillaria] boehmi parasitic ova
What 2 bacteria can result in rhinitis in dogs as pure isolates?
Bordetella bronchiseptica or Pasteurella multocida (both are very rare; pneumonia may be present)
What are the most common causes of rhinitis in dogs, excluding nasal FB and dental dz)?
- Neoplasia
- Idiopathic chronic (lymphoplasmacytic) rhinitis
- Fungal rhinitis
Name the dog nasal mite and nasal nematode.
Nasal mites: Pneumonyssus caninum
Nasal Nematode: Eucoleus [Capillaria] boehmi
What is the most common cause of fungal rhinitis in dogs? Name 3 others as well.
Aspergillus fumigatus is the most common cause of fungal rhinitis in dogs. occasionally Penicillium spp., Rhinosporidium seeberi, and very rarely Cryptococcus neoformansin dogs
Which nasal fungal infection results in granulomatous masses in the rostral nasal cavity that need to be surgically removed?
Rhinosporidium seeberi
Name the 2 breeds that are predisposed to nasal Aspergillus.
GSH and Rotties
Name the signalment of dogs with nasal Aspergillus.
young to middle-aged dolichocephalic dogs
How is nasal Aspergillus diagnosed?
- Visualization of fungal plaques on nasal mucosa
2. Demonstration of branching septate hyphae on cytologic or histologic samples
Why are nasal cultures misleading for a diagnosis of Aspergillus?
Cultures of nasal discharge may be misleading in that 30% to 40% of cultures from normal dogs
and those with nasal neoplasia can yield Aspergillus or Penicillium spp
What type of treatment is most effective for nasal Aspergillus?
Topical therapy is more effective than orally administered antifungal agents
- Topical therapy with clotrimazole has become the treatment of choice: As many as 90% of patients may be cured with a single procedure, although some dogs require a second procedure 3 weeks later.
- Topical application of enilconazole through surgically placed catheters into the frontal sinuses and nasal chambers has a success rate as high as 90%
- Combination of clotrimazole irrigation and depot therapy: 86% of dogs with nasal aspergillosis or penicilliosis established a cure from infection
- Oral antifungals only good if cribiform plate compromised and topical antifungals cannot be used (itraconazole, terbinafine, fluconazole, adn voriconazole)
What is the etiology of lymphoplasmacytic rhinitis in dogs?
Unknown; potential for aeroallergen, reaction of commensal fungi, etc??
What is the signalment of patients that get lymphoplasmacytic rhinitis in dogs?
Young to middle-aged dolichocephalic and mesaticephalic large-breed dogs
Which breed is particularly affected with LP rhinitis in dogs?
Dachshunds
What are treatment options for LP rhinits in dogs?
Steroids and antihistamines RARELY work
Need immunomodulating antibiotic (doxy or azithromycin) + NSAID (piroxicam) = Needed at least 6 months, but likley longterm
What percent of chronic nasal disease in dogs is from nasal neoplasia?
About 1/3 of all dogs with chronic nasal disease
About 2/3 of these are tumors of epithelial origin (mets to LNs and lungs = Rare, late in dz)
What is the treatment of choice for nasal tumors in dogs?
Radiation therapy
Median Survival: 16.5-23 months, about 1 year in 54-60% of dogs with nasal neoplasia
NOT cryosurgery or chemo (cisplatin, same as no tx given)
Nasal polyps are rare in dogs, but with cancer has been seen on resection of polypous tissue?
Low-grade fibrosarcoma
Which breed gets hyperplastic rhinitis?
Irish Wolfhounds
Which feline virus has been suggested as a cause (but not proven) in feline chronic rhinosinusitis?
Feline herpesvirus type 1 (FHV-1)
Can feline chronic rhinosinusitis have unilateral nasal signs?
Yes!
How is feline chronic rhinosinusitis diagnosed?
It is a diagnosis of exclusion = Bx is required to differentiate from other causes
Does rhinoscopic appearance of mucosa predict amount of inflammation present in cats with chronic rhinitis?
NO! Rhinoscopic appearance does not predict the presence or absence of substantial inflammation
Since feline rhinitis can have secondary bacterial infections caused by aerobic, anarobic, and Mycoplasma felis, which antibiotics may be considered?
Doxycycline
Topical Gentamicin (if Bordetella considered)
Azithromycin
Penicllin-like ones = BAD (do not get Mycoplasma, since they lack cell walls)
Enrofloxacin
Clindamycin (esp if bone involved)
How does lysine work for viral infections?
Lysine: an amino acid that competes with arginine for use by the viral machinery in replication
What are the common congenital and acquired abnormalities seen with Brachycephalic Upper Airway syndrome in dogs?
Congenital: stenotic nares; shortening, widening, and flattening of the nasal cavity and pharynx; elongation, thickening, and flaccidity of
the soft palate; and decreased glottic size (+/- hypoplastic trachea)
Acquired: From increased respiratory effort = edema and further thickening of the soft palate, eversion of the laryngeal saccules,
edema of the pharyngeal and laryngeal mucosa, enlargement of the tonsils, and progressive laryngeal dysfunction ending with complete laryngeal collapse
Name 5 breeds that are most commonly affected by Brachycephalic Upper Airway Syndrome in dogs?
English bulldog, pug, Boston terrier, chow-chow, Pekingese, Shih Tzu and shar-pei
What is the most common CS of Brachycephalic Upper Airway Syndrome in dogs?
Progressively worsening inspiratory dyspnea (+/- stridor)
What are the most common nasopharyngeal disease in cats?
Cryptococcosis (dependent on location), nasopharyngeal polyps, neoplasia, and foreign bodies
What are the most common nasopharyngeal disease in dogs?
Inflammation, neoplasia, foreign bodies, nasal mites (Pneumonyssoides caninum) or congenital abnormalities
What types of CS are specific to nasopharyngeal disease?
Stertor Reverse sneezing (dogs)
What type of neurologic CS are possible in animals with nasopharyngeal disease?
Central nervous signs - if extension of fungus or neoplasia into brain
Vestibular disease - if extension into tympanic bulla, opening of eustachian tube
Horner’s Syndrome (cats) - with invovlement of tympanie bullae
Facial Nerve Dysfunction too (facial assymmetry and absent palpebral reflex)
Why is it important to determine if stertor vs stridor is present?
differentiate stertor (a snoring-type noise arising from the nasopharynx or pharynx, see effect of opening mouth with stertor) from stridor (a high-pitched noise arising from disturbance of air flow through the larynx or trachea)
What serologic test can be used for Cryptococcus spp?
Positive latex cryptococcal antigen agglutination test titer (can be measured for treatment response too)
Name 2 nasopharyngeal parasites.
Pneumonyssoides caninum - found in nasal cavity, nasopharynx, and frontal sinus worldwide Cuterebra larvea (cats) - Watch for hypersensitivity rxn to hemolymph
Describe the etiology of nasopharyngeal polyps in cats.
Unknown: Congenital defect, chronic inflammation of middle ear or eustachian tube, or viral upper respiratory infection
What is the difference in location of nasophyarngeal polyps in cats vs dogs?
Cats: Eustachian tube or middle ear
Dogs: Caudal Nasal Turbinates (from chronic rhinitis)
What are the recommended treatment options for cats with nasopharyngeal polyps?
Traction/avulsion good first option in cats with no bullae involvement (not all cats will develop involvement of the bullae). Transient Horner’s syndrome is likely; recommended reduced reccurence if anti-inflammatory steroids given after removal
Ventral Bullae Osterotomy
What is nasopharyngeal stenosis?
Stricture formation may occur in both cats and dogs following chronic inflammation (infectious diseases, surgery, or other trauma (reflux) or as a congenital abnormality (choanal atresia)
What breed has Nasopharyngeal stenosis resulting from abnormally thickened
palatopharyngeal muscles has also been reported?
dachshunds
What is cystic Rathke’s cleft?
Embryonic pituitary development proceeds abnormally, resulting in a progressively expansile cystic lesion within the sphenoid bone
May or may not be assoicated with congenital dwarfism
Why do some nasal tumors in dogs respond to piroxicam?
81% of canine nasal tumors have been shown to express cyclooxygenase-2 (COX-2)
(Kleiter et al, 2004), and a recent small case series demonstrated that the treatment with oral piroxicam (a
COX-2 inhibitor) in conjunction with alternating doses of doxorubicin and carboplatin was efficacious and well tolerated (Langova et al., 2004)
What are the 2 main factors that need to be present to develop tracheal collapse?
- Primary cartilage abnormality = Weakness of tracheal rings
- Secondary factors capable of initiating progression to the symptomatic state
What is the primary defect responsible for intrinsic weakness of tracheal rings?
Reduction in the glycoprotein and glycosaminoglycan content of the hyaline cartilage of the tracheal rings = Reduced capacity of cartilage to retain water
Name potential factors that can contribute to clinical syndrome of tracheal collapse?
- Cardiomegaly
- Pulmonary Edema
- Respiratory Infection
- Upper Airway Obstruction
- Chronic Bronchitis
- Allergic Tracheobronchitis
- Inhaled irritants (smoke)
- Cervical trauma
- Obseity
- Tracheal intubation
- HAC
When does collapse of cervical tracheal segment occur in?
Inspiration, decreased pressure within the trachea
When does collapse of the thoracic portion of trachea occur in?
Expiration, increased intrathoracic pressure
What creates the cycle of tracheal collapse?
• Once clinical signs are apparent, the syndrome is perpetuated by the cycle of chronic inflammation of the tracheal mucosa, which precipitates cough and in turn is exacerbated by the cough
○ Persistent inflammation of the tracheal mucosa leads to a loss of epithelium = fibrinous membrane formation = squamous metaplasia with polypoid proliferation evident in advanced cases
○ Population of ciliated cells is reduced significantly by the metaplastic changes in the mucosa, and the hyperplastic subepithelial glands secrete increasingly viscid mucus = normal ciliary function is replaced progressively by cough as the major tracheobronchial clearing mechanism
○ Once the condition becomes symptomatic, the changes in the dorsal membrane and cartilage are believed to progress beyond those of the original anatomic abnormality
What is the most common signalment for tracheal collapse?
Small/toy-breed dogs (mild, intermittent “honking” cough to severe resp distress/obstruction); more common in older (all ages affected)
Toy and miniature breeds = Yorkies, Mini Poodles, Chichuahua, Pomeranians
What percentage of dogs with tracheal collapse are affected by 6 months of age?
25%
Do severity of clinical signs related directly to the severity of anatomic changes with tracheal collapse?
NO!
What is the gold standard for diagnosing tracheal collapse?
Endoscopy - Tracheoscopy
What other organ system has been identified to be dysfunctional in many dogs with tracheal collapse?
Hepatic dysfunction