Respiratory tract cases

Question 1

Case 1, Billy
Make a problem list.

Answer 1

cough

increased resp sounds and clicking on expiration

overweight

Question 2

Case 1, Billy
Make a differential diagnosis list.

Answer 2

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.

Question 3

Case 1, Billy
Make a diagnostic plan.

Answer 3

xrays with cervical trachea in

bloods: hematology, CRP at minimum
+ arterial blood gases

analyze fecal sample: both flotation and Baermann

bronchoscopy + BAL

Question 4

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?

Answer 4

D. Something else, what? tracheal collapse

Question 5

Case 1, Billy
* Bronchoalveolar lavage cytology normal and no bacterial growth

What is your diagnosis?
How do you treat Billy?

Answer 5

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

Question 6

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.”

Answer 6

B. Don’t remove the blood. It will be absorbed!

If there’s no dyspnea then don’t remove.

Question 7

Case 3, Nana.

Make a problem list!

Answer 7

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

Question 8

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

Answer 8

D. Mild bronchointerstitial pattern

Question 9

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.

Answer 9

B. Doxycycline 5mg/kg BID for 2 weeks

in case its tracheobronchitis with bordetella bronchiseptica

Question 10

Case 4, Evi.
Make a problem list!

Answer 10

4th floor fall
Respiratory rate 70/min
heart rate 250/min
Breathing shallowly and mouth open
absent lungs sounds on auscultation

Question 11

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

Answer 11

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.

Question 12

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

Answer 12

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.

Question 13

Case 5, Mica.
What do you think about these arterial blood gas findings?

Answer 13

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

Question 14

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

Answer 14

B. eosinophils (black arrow), neutrophils (red), alveolar macrophages (greenn)

Question 15

What is your opinion about the bronchoalveolar lavage fluid analysis?

Answer 15

highly cellular
suspiciously low macrophage number
neutrophilia
eosinophilia
lymphopenia

Question 16

Case 5, Mica
What is your diagnosis?

Answer 16

Eosinophilic bronchopneumopathy

Question 17

Case 5, Mica
Are there still some examinations you should do before starting treatment?

Answer 17

BALF culture to rule out bacterial infection?

fecal flotation + baermann to rule out parasites

Question 18

Case 5, Mica
How do you treat this disorder?

Answer 18

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.

Question 19

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).

Answer 19

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.

Question 20

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!

Answer 20

pleural effusion likely due to undiagnosed heart disease, or neoplasia that we can’t discern due to fluid.

Question 21

Case 7, Rambo.
What is the type of this effusion fluid?

Answer 21

Non-septic inflammatory effusion/ exudate

Question 22

Case 7, Rambo.
What is the first disease in your differential diagnosis list?

Answer 22

FIP,
neoplasia,
chronic chylothorax,
chronic lung lobe torsion,
fungal effusion

Question 23

Case 8, Milli
Make a problem list.

Answer 23

Acute onset of dyspnea
Tachypnea,
expiratory dyspnea,

murmur 2/6,
tachycardia

Maybe crackles on auscultation and a little bit of wheezing?

Question 24

Case 8, Milli

Make a differential diagnosis list.

Answer 24

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

Question 25

Case 8, Milli

What is your diagnostic plan?

Answer 25

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

Question 26

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?

Answer 26

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

Question 27

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

Answer 27

A. Feline inflammatory lower airway disease

(can lead to emphysema)

Question 28

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

Answer 28

C. Bronchodilator and fast-acting corticosteroid

Question 29

Case 9, Zeus

Make a differential diagnosis list (the most likely diagnosis first).

Answer 29

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)

Question 30

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.

Answer 30

a. Rhinoscopy in ideal world but in real world,

c. Treatment trial for nasal mites. (stronghold-selamectin (6 weeks) or milbemycin (1 month))

Question 31

most common cause of leftsided heart failure in dogs

Answer 31

myxomatous mitral valve disease

Question 32

cardiogenic pulmonary edema due to congestive heart failure is NOT a reason for chronic cough.
Why?

Answer 32

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.

Question 33

hemoglobin saturation under anesthesia

Answer 33

should be 1 hundo %

Question 34

thoracocentesis site

Answer 34

7th-9th intercostal space, cranial border of rib

Question 35

feline bacterial pneumonia

Answer 35

xrays may show basically any abnormal pattern.

Question 36

severe canine pleural effusion auscultation. what do you hear?

Answer 36

muffled

Question 37

How do you differentiate feline asthma and feline chronic bronchitis using bloods, xrays and signs?

Answer 37

you don’t

they’re both inflammatory and indistinguishable

Question 38

pleural effusion versus pulmonary edema and left or right heart failure in dogs vs cats

Answer 38

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.

Question 39

cat needs oral corticosteroids for asthma. what do you prescribe?

Answer 39

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.