Mouth Breathing Moggies - Cedarmount Vets · •Chronic bacterial rhinitis – if non-surgical...
Transcript of Mouth Breathing Moggies - Cedarmount Vets · •Chronic bacterial rhinitis – if non-surgical...
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Cedarmount Veterinary Clinic, Bangor
Mouth Breathing Moggies
Craig Reilly BVM&S CertSAM MRCVS
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Cedarmount Veterinary Clinic, Bangor
• Assessment
• Initial Presumptive Diagnosis?
• Review Causes of Dyspnoea and Therapy
in acute cases
• Chronic management?
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Initial assessment • Signalment and history
• Observation of demeanour and breathing pattern
• Clinical examination ?delay until stabilised?
• Auscultate chest (murmur/gallop/airway sounds)
• Beware normal heart rate!
Cedarmount Veterinary Clinic, Bangor
Courtesy: ICU, Vet. Clinical Medicine, Madras Veterinary College, Chennai- 600
007, Tamil nadu, India
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Significance of breathing pattern
Cedarmount Veterinary Clinic, Bangor
Loud airways
Inspiratory Stridor
Expiratory stridor
URT
Pharynx/larynx
Intrathoracic
trachea / bronchi
Rapid shallow breaths Lung parenchyma
Short choppy breaths (chest and
abdomen moving in opposite
directions)Pleural space
Short inspiration, prolonged
expirationSmall airway
Stenotic nares
Naso-
pharyngeal
polyp
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Parenchymal Lung Disease
(rapid shallow breaths)
Cedarmount Veterinary Clinic, Bangor
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Pleural Space disease (short choppy breaths progressing to paradoxical
respiration: abdomen and chest moving in opposite
directions)
Cedarmount Veterinary Clinic, Bangor
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Lower
airway
disease Short
inspiration,
prolonged
expiration
Cedarmount Veterinary Clinic, Bangor
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Mediastinal mass
(expiratory stridor)
Cedarmount Veterinary Clinic, Bangor
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It`s not always easy to tell!
Cedarmount Veterinary Clinic, Bangor
Cyanosis: O2 deoxyhaemoglobin
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..much easier in slow motion! ..when sedated
…or slow replay
using technology –
new iphone5s
SloMo (fantastic
for lameness)
Cedarmount Veterinary Clinic, Bangor
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In Severe Respiratory Distress?
• Avoid further stressing the cat
• Oxygen (won`t do harm: but virtually ineffective in anaemia)
• Delay investigation until stabilised if possible +/- sedation
Cedarmount Veterinary Clinic, Bangor
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Slightly more high tech….
Cedarmount Veterinary Clinic, Bangor
Buster O2 tent (£)
(Care – overheating!!)
Shorline O2
Door (££?) (remember need
piped/portable O2)
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Fine needle aspirate
Cedarmount Veterinary Clinic, Bangor
•Air
•Transudate
•Modified transudate
•Exudate
•Chyle/pseudochyle
•Cells from abdominal organs
•Blood
•Pulmonary oedema fluid (well
oxygenated)
6th-8th intercostal
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Practice laboratory • Diagnosis in <5 mins
• More accurate prognosis/therapy
• Specialist confirmation?
Cedarmount Veterinary Clinic, Bangor
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Radiography and ultrasonography
• Sedation (personal preference and familiarity)
• vital to have anaesthetic machine ready in case of respiratory failure
Cedarmount Veterinary Clinic, Bangor
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Causes of Dyspnoea Don’t focus solely on respiratory system!!
Cedarmount Veterinary Clinic, Bangor
Methaemoglobinaemia
Oxidative damage to
haemoglobin
• Paracetamol • Chemotherapy
• Local anaesthetic
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Blue is the new black? Congenital
methaemoglobinaemia?
Cedarmount Veterinary Clinic, Bangor
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Non-respiratory Causes of Dyspnoea
• Methaemoglobinaemia
• Anaemia – acute only
• Congestive Heart failure?
– Rate (beware!)
– Gallop rhythm
– Murmur (significance in dyspnoea?)
– LA size?
Cedarmount Veterinary Clinic, Bangor
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Cardiology for medics!
LA is
usually
enlarged if
there is a
cardiac
cause of
dyspnoea!
Cedarmount Veterinary Clinic, Bangor
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Clinical signs and left atrial size in cats
with cardiovascular disease in general
practice
S. Smith1,
J. Dukes-McEwan2
Article first published online: 19 NOV 2011
DOI: 10.1111/j.1748-5827.2011.01143.x
© 2011 British Small Animal Veterinary
Association
Issue
Journal of Small Animal Practice
Volume 53, Issue 1, pages 27–33, January
2012
Cedarmount Veterinary Clinic, Bangor
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CHF (classification of HCM?)
Cedarmount Veterinary Clinic, Bangor
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Echocardiography
Cedarmount Veterinary Clinic, Bangor
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Cedarmount Veterinary Clinic, Bangor
• Lateral: 2/3rds height, 2 rib spaces wide (or VHS 7-8)
• Dorsoventral: 2/3rds width
Heart Size
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Cedarmount Veterinary Clinic, Bangor
Cardiomegaly and pulmonary congestion
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Cedarmount Veterinary Clinic, Bangor
Pulmonary oedema due to CHF can be
anywhere in the lung (cf canine hilar oedema)
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Cedarmount Veterinary Clinic, Bangor
..sometimes it’s
pretty obviously
cardiac…!
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URT Causes of Dyspnoea
• Stenotic nares (part of Brachycephalic Syndrome) –
– Surgical correction very rewarding as frequently no soft palate or laryngeal complications (cf. dogs!!)
• Nasal Pathology (FB/Flu/Bordetella/Chronic Rhinitis/Mycoplasma/tumour/trauma‘Flu/Acute Rhinitis/trauma/neoplasia/ Crytococcosis/Chronic bacterial rhinitis/Mycoplasma??/LP Rhinitis/FB
Cedarmount Veterinary Clinic, Bangor
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Nasal Imaging
• Don’t forget basics – teeth - palpate hard
palate and nasal bones – and image sinuses
too!!
• Xrays
• Rhinoscopy
• CT
• MRI
Cedarmount Veterinary Clinic, Bangor
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Tips for radiography
4 options each with
advantages and
disavantages
• Whole skull
• Intraoral cassette
• Intraoral film
• Dental Film!! – best
by far!
Cedarmount Veterinary Clinic, Bangor
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Intraoral film (processing issues!!)
Cedarmount Veterinary Clinic, Bangor
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Cedarmount Veterinary Clinic, Bangor
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Conventional Intraoral film
v Dental Imaging No
contest!!
Cedarmount Veterinary Clinic, Bangor
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Nasopharyngeal Causes of Dyspnoea
• Pharyngitis/trauma/neoplasia
• Chronic bacterial rhinitis/Mycoplasma??/FB (grass blade!)
• Retroflex bronchoscope, or rigid rhinoscope by left entry pharyngotomy
• Nasopharyngeal stenosis or Polyp (can cure!)
• Nasal Lymphoma – beware renal!
Cedarmount Veterinary Clinic, Bangor
Rhinoscope
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Respiratory Causes of Dyspnoea
• Larynx (audible wheezing!)
Allergy/polyps/neoplasia/trauma/paralysis :very resistant to anti-inflammatory therapy – many referral centres refuse feline laryngeal surgery!!
• Trachea FB/Flu/Bordetella/Aleurostrongylus/ tumour/trauma/external pressure (endotracheal tube cuff insufflation!)
Cedarmount Veterinary Clinic, Bangor
Cystoscope
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Respiratory Causes of Dyspnoea
Chest wall trauma or congenital malformation
Cedarmount Veterinary Clinic, Bangor
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Cedarmount Veterinary Clinic, Bangor
Pneumothorax and atelectasis
Trauma/Primary Lung Pathology
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Respiratory Causes of Dyspnoea
• Bronchi (Feline Airway Disease/chronic bronchitis/ asthma/Aleurostrongylus)
• Lungs (oedema incl non-
cardiac),trauma, neoplasia,bronchopneumonia)
• Thoracic cavity (effusions
(incl. wet FIP)/pneumothorax/ruptured diaphragm/ mediastinal disease/neoplasia/ pneumomediastinum)
Cedarmount Veterinary Clinic, Bangor
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Cedarmount Veterinary Clinic, Bangor
Tracheal elevation: Cats aren’t small dogs
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Cedarmount Veterinary Clinic, Bangor
Thymoma +/- paraneoplastic dz
• Myasthenia gravis
• Exfoliative Dermatitis
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Cedarmount Veterinary Clinic, Bangor
Unusual exudate associated with thoracic lymphoma
Never forget FeLV FIV Coronavirus!
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Cedarmount Veterinary Clinic, Bangor
Diaphragmatic hernia (hepatocytes on FNA left thorax)
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Feline Asthma/chronic airway disease
• Air entrapment
• Tram-lines and doughnuts
• Consolidation of right middle lung lobe (cf aletectasis)
• Many asthmatics have normal radiographs!
• BAL to confirm
Cedarmount Veterinary Clinic, Bangor
R L
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Air entrapment – radiograph
interpretation?
Cedarmount Veterinary Clinic, Bangor
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No-one would argue with…..
Cedarmount Veterinary Clinic, Bangor
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Tramlines and doughnuts!
Cedarmount Veterinary Clinic, Bangor
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Care with over-
magnification!
Cedarmount Veterinary Clinic, Bangor
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Why is right middle lobe so
susceptible to consolidation?
Cedarmount Veterinary Clinic, Bangor
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Cedarmount Veterinary Clinic, Bangor
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Bronchoalveolar lavage in the cat
• Sterile urinary catheter (pre-measured) introduced into lung via endotracheal tube
• three doses of 5-10 ml sterile saline
• chest coupage before each re-aspiration
• first wash usually not recovered
• second wash for culture
• final wash for cytology
(froth reflects presence of surfactant)
Cedarmount Veterinary Clinic, Bangor
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Cedarmount Veterinary Clinic, Bangor
Airway cytology
Bacteria in PMN`s
Lungworm larvae
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Cedarmount Veterinary Clinic, Bangor
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Cedarmount Veterinary Clinic, Bangor
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Cedarmount Veterinary Clinic, Bangor
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Cedarmount Veterinary Clinic, Bangor
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Cedarmount Veterinary Clinic, Bangor
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Cedarmount Veterinary Clinic, Bangor
Pulmonary neoplasia confirmed on BAL
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Cedarmount Veterinary Clinic, Bangor
Lung Digit
syndrome
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Cedarmount Veterinary Clinic, Bangor
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Cedarmount Veterinary Clinic, Bangor
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Cedarmount Veterinary Clinic, Bangor
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Cedarmount Veterinary Clinic, Bangor
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Therapy for Feline Asthma • Lifestyle changes
• Fenbendazole 50mg/kg sid 5dd/Milbemax/Advocate???
• Dexamethasone 0.2-2.2 mg/kg then Prednisolone 1 mg/kg bid 5dd and taper slowly
• Theophylline (Corvental-D) 100mg/cat sid
• (Terbutaline 0.01 mg/kg s/cut or 1/8 to 1/4 2.5mg tablet bid PO)
Cedarmount Veterinary Clinic, Bangor
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Inhalers - you can`t be serious!
Older Protocol
• Albuterol (one dose as needed - up to every 30 mins)
• Fluticasone 250mg - one puff bid daily (+/- oral pred)
• ?? Beclamethasone
Cedarmount Veterinary Clinic, Bangor
(Intractable cases: Consider addition of cyproheptadine (1mg/kg PO bid/tid))
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Cedarmount Veterinary Clinic, Bangor
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Cedarmount Veterinary Clinic, Bangor
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Strategies for management long
term infections
• Mycoplasma – Ronaxan 5mg/kg BID
• Chronic bacterial rhinitis – if non-surgical
control can be partially achieved with 1/3rd
of a 250mg capsule of Zithromax every
3dd, often combined with therapeutic nasal
flushes
Cedarmount Veterinary Clinic, Bangor
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It must be Beer o’clock!!!
Cedarmount Veterinary Clinic, Bangor
[email protected] 91271364 (w) 07817877137 (mob)
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Cedarmount Veterinary Clinic, Bangor
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Cedarmount Veterinary Clinic, Bangor
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Cedarmount Veterinary Clinic, Bangor
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Reference material
• Pyothorax management http://veterinarycalendar.dvm360.com/avhc/Medicine/Pyothorax
-Medical-treatment-surgical-treatment-or-
/ArticleStandard/Article/detail/587154
• Asthma http://www.felineasthma.org/links/gunn-moore.htm
• Dyspnoea management tables http://inpractice.bmj.com/content/15/6/301.full.pdf+html?sid=04
abfbec-091b-43b7-ae6c-6a44506faabc
• FIP http://www.dr-addie.com/
Cedarmount Veterinary Clinic, Bangor