Respiratory tract cases Flashcards
Case 1, Billy
Make a problem list.
cough
increased resp sounds and clicking on expiration
overweight
Case 1, Billy
Make a differential diagnosis list.
tracheal collapse
canine infectious respiratory disease
complex
AB resistant bacterial tracheobronchitis / pneumonia
pulmonary neoplasia
heart disease
heart worm / lung worm
chronic bronchitis
Eosinophilic bronchopneumopathy
Canine idiopathic pulmonary fibrosis
etc.
Case 1, Billy
Make a diagnostic plan.
xrays with cervical trachea in
bloods: hematology, CRP at minimum
+ arterial blood gases
analyze fecal sample: both flotation and Baermann
bronchoscopy + BAL
Case 1, Billy
What do you see in thoracic radiographs?
A. Alveolar opacity in the right middle lung lobe
B. Increased bronchial opacity and moderate cardiomegaly
C. Mild pleural effusion
D. Something else, what?
D. Something else, what? tracheal collapse
Case 1, Billy
* Bronchoalveolar lavage cytology normal and no bacterial growth
What is your diagnosis?
How do you treat Billy?
What is your diagnosis?
75% grade III tracheal collapse & bronchomalacia
How do you treat Billy?
Y-harness, weight loss
Oral prednisolone for short courses only, fluticasone inhalation for long-term. 0.5 mg/kg BID 1 week then taper off.
theophylline - though no effect on large airways but reduces smaller-airway spasm which lowers intrathoracic pressure and the tendency of larger airways to collapse.
intratracheal stent if owner is willing
Case 2, consultation call from a colleague.
He asks:
”The dog has been in an accident and has bled quite a lot blood to pleural cavity. It is doing pretty ok at the moment.
How much blood should I remove from the pleural cavity? The dog weighs 20kg.”
B. Don’t remove the blood. It will be absorbed!
If there’s no dyspnea then don’t remove.
Case 3, Nana.
Make a problem list!
sneezing and nasal discharge (that resolved with AB)
mild fever
6 week cough
heart rate 138/min - tachy
increased breathing sounds on auscultation
CRP 28 mg/l
Case 3, Nana
What do you see in the radiographs?
A. Mild alveolar pattern
B. Mild pleural effusion
C. Mild vascular pattern
D. Mild bronchointerstitial pattern
D. Mild bronchointerstitial pattern
Case 3, Nana
* You suggest bronchoscopy with BAL but the owner denies it.
How do you treat Nana and why?
A. Corticosteroid treatment trial with oral prednisolone, antibiotics were tried already!
B. Doxycycline for 2 weeks
C. Inhaled fluticasone and inhaled bronchodilator
D. Follow up, no other treatment, maybe a cough suppressant if the owner is bothered by the cough.
B. Doxycycline 5mg/kg BID for 2 weeks
in case its tracheobronchitis with bordetella bronchiseptica
Case 4, Evi.
Make a problem list!
4th floor fall
Respiratory rate 70/min
heart rate 250/min
Breathing shallowly and mouth open
absent lungs sounds on auscultation
Case 4, Evi
In addition to giving the cat oxygen and sedating it slightly with butorphanol, what else should you do and why?
A. The cat is having bronchoconstriction, give fast acting corticosteroids and bronchodilator
B. Take radiographs of the lung otherwise you don’t know how to proceed
C. Perform thoracocentesis in case the cat has pneumothorax
D. Perform thoracic ultrasound to see if there is free gas in pleural cavity
C. Perform thoracocentesis in case the cat has pneumothorax
or
D. Perform thoracic ultrasound to see if there is free gas in pleural cavity
you can choose which to start with, no harm is usually done by just tapping the chest first thing.
Case 5, Mica.
What do you see in the radiographs?
A. Alveolar opacity
B. Bronchial opacity
C. Bronchiectasis and ground glass opacity
D. Cardiomegaly and vascular pattern
B. Bronchial opacity
you know the opacity ventral to the heart is fat because it doesn’t obscure the ventral cardiac silhouette and is a slightly different density than soft tissue. fluid would be the same density as soft tissue.
Case 5, Mica.
What do you think about these arterial blood gas findings?
mild hypoxemia
mildly increased alveolar arterial oxygen gradient (Normal <15-20 mmHg)
increased base excess (Alactic base excess (ABE)) indicating buffering/compensation has happened despite PaCO2 being WNL
Bronchoalveolar lavage fluid cytology.
What do you see?
A. degenerated neutrophils, intracellular
bacteria
B. eosinophils, neutrophils, alveolar
macrophages
C. plasma cells, epithelial cells, eosinophils
D. neutrophils, lymphocytes, basophils
B. eosinophils (black arrow), neutrophils (red), alveolar macrophages (greenn)
What is your opinion about the bronchoalveolar lavage fluid analysis?
highly cellular
suspiciously low macrophage number
neutrophilia
eosinophilia
lymphopenia
Case 5, Mica
What is your diagnosis?
Eosinophilic bronchopneumopathy
Case 5, Mica
Are there still some examinations you should do before starting treatment?
BALF culture to rule out bacterial infection?
fecal flotation + baermann to rule out parasites
Case 5, Mica
How do you treat this disorder?
doxycycline treatment trial if owner doesn’t pursue further diagnostics
but if bronchoscopy is done, tx with Corticosteroids.
◦ Usually start with an immunosuppressive dosage, then taper down.
◦ Inhaled fluticasone is good for longer term management with less side effects but it isn’t enough in all dogs. Some may need PO as well.
Treatment needed for several months.
Case 6, pug show.
What do you do? Remember, you are in a dog show, not in a hospital (but you have your medical bag with basic medication and equipment with you).
Keep it in calm, quiet and shady place.
No more walking or running.
Check its temperature, active cooling if needed. Wet the coat. Stop cooling when it gets to 39.5’C.
A drop of butorphanol IM to calm its breathing rate.
Give an IM dose of dexamethasone (dogs don’t have reversible bronchoconstriction so bronchodilators won’t work) to ease the inflammation.
IV fluids would be beneficial but may not be feasible in the dog show setting.
Case 7, Rambo.
You manage to take one lateral thoracic radiograph before the cat gets mad at you. What do you see?
Write your answer, no clues given!
pleural effusion likely due to undiagnosed heart disease, or neoplasia that we can’t discern due to fluid.
Case 7, Rambo.
What is the type of this effusion fluid?
Non-septic inflammatory effusion/ exudate
Case 7, Rambo.
What is the first disease in your differential diagnosis list?
FIP,
neoplasia,
chronic chylothorax,
chronic lung lobe torsion,
fungal effusion
Case 8, Milli
Make a problem list.
Acute onset of dyspnea
Tachypnea,
expiratory dyspnea,
murmur 2/6,
tachycardia
Maybe crackles on auscultation and a little bit of wheezing?
Case 8, Milli
Make a differential diagnosis list.
Feline inflammatory lower airway disease/
feline asthma
heart disease
aspiration pneumonia
bacterial pneumonia
mycoplasmal pneumonia
neoplasia
parasites e.g. lungworm
pleural space disease like idiopathic pulmonary fibrosis
Case 8, Milli
What is your diagnostic plan?
take hematology, SAA and proBNP
arterial blood gases are tricky in cats because they’re so small, even harder in dyspneic patients.
fecal sample
chest xrays
tfAST and later, echocardiography
Case 8, Milli
- You give oxygen and sedate the cat with butorphanol.
Although the cat is dyspneic, you decide to take a radiograph.
What do you see?
diffuse bronchial pattern
increased opacity, atelectasis right middle lung lobe (typical spot because anatomically this lung lobe’s bronchus is lowest)
emphysema: lungs are a bit too dark and overinflated. big for a cat.
gastric aerophagia
Case 8, Milli
What is the most likely diagnosis?
A. Feline inflammatory lower airway disease
B. Bacterial pneumonia, it can look like anything on radiographs!
C. Upper airway obstruction causing air trapping in the lung
D. Cardiomyopathy and cardiogenic edema
A. Feline inflammatory lower airway disease
(can lead to emphysema)
Case 8, Milli
How would you treat Milli’s respiratory emergency?
A. Furosemide, iv fluids and broad-spectrum antibiotics
B. You should perform a thoracocentesis
C. Bronchodilator and fast-acting corticosteroid
D. Bronchodilator, fast-acting corticosteroids, antibiotic and furosemide
C. Bronchodilator and fast-acting corticosteroid
Case 9, Zeus
Make a differential diagnosis list (the most likely diagnosis first).
Canine infectious respiratory disease
complex?
Canine lymphoplasmacytic rhinitis
nasal foreign body
nasal mites
nasal neoplasia
oronasal fistula
aspergillosis
Canine distemper virus (prob not cause vaccinated)
Case 9, Zeus
* How would you proceed?
a. Rhinoscopy
b. Computed tomography
c. Treatment trial for nasal mites.
d. Treatment trial with intranasal saline drops.
e. Treatment trial with inhaled corticosteroids.
f. Treatment trial with antibiotics.
a. Rhinoscopy in ideal world but in real world,
c. Treatment trial for nasal mites. (stronghold-selamectin (6 weeks) or milbemycin (1 month))
most common cause of leftsided heart failure in dogs
myxomatous mitral valve disease
cardiogenic pulmonary edema due to congestive heart failure is NOT a reason for chronic cough.
Why?
no cough receptors in alveoli.
when edema is severe and finally reaches bronchi, then cough starts.
so, fulminant congestive heart failure with cardiogenic edema can cause cough!
cardiomegaly can cause irritation by pressing on the bronchi and thus can cause cough but usually dogs with big hearts also have concurrent lower airway disease like bronchomalacia or bronchitis which contribute to cough.
hemoglobin saturation under anesthesia
should be 1 hundo %
thoracocentesis site
7th-9th intercostal space, cranial border of rib
feline bacterial pneumonia
xrays may show basically any abnormal pattern.
severe canine pleural effusion auscultation. what do you hear?
muffled
How do you differentiate feline asthma and feline chronic bronchitis using bloods, xrays and signs?
you don’t
they’re both inflammatory and indistinguishable
pleural effusion versus pulmonary edema and left or right heart failure in dogs vs cats
Cats: Pleural effusion from both left- and right-sided heart failure; pulmonary edema mostly from left-sided heart failure.
Dogs: Pleural effusion primarily from right-sided heart failure form blood backing up into systemic circulation; pulmonary edema from left-sided heart failure from blood backing up into the lungs.
cat needs oral corticosteroids for asthma. what do you prescribe?
prednisolone
(NOT predniSONE)
differences in their metabolism and how effectively they can be used by the cat’s body.
Prednisone must be metabolized by the liver into its active form, prednisolone, to exert its therapeutic effects.
This conversion occurs efficiently in humans and dogs, but cats have a reduced ability to convert prednisone into prednisolone. Therefore, prescribing prednisone may result in less effective treatment due to incomplete conversion.
