Acute respiratory distress syndrome in dogs and cats: a review of clinical findings and pathophysiology

Objective: To review the clinical and pathophysiologic aspects of acute respiratory distress syndrome (ARDS) in dogs and cats. Data sources: Data from human and veterinary literature were reviewed through Medline and CAB as well as manual search of references listed in articles pertaining to acute lung injury (ALI)/ARDS. Human data synthesis: Since the term ARDS was first coined in 1967, there has been a abundance of literature pertaining to this devastating syndrome in human medicine. More complete understanding of the complex interactions between inflammatory cells, soluble mediators (e.g., tumor necrosis factor, interleukin (IL)‐6, IL‐8, platelet activating factor) and the clinical patient has provided for timely recognition and mechanistically based protective strategies decreasing morbidity and mortality in human patients with ARDS. Veterinary data synthesis: Although little is known, ARDS is becoming a more commonly recognized sequela in small animals. Initial case reports and retrospective studies have provided basic clinical characterization of ARDS in dogs and cats. Additionally, information from experimental models has expanded our understanding of the inflammatory mechanisms involved. It appears that the inflammatory processes and pathologic changes associated with ARDS are similar in dogs, cats, and humans. Conclusions: Unfortunately, current mortality rates for ARDS in small animals are close to 100%. As our capability to treat patients with advanced life‐threatening disease increases, it is vital that we develop a familiarity with the pathogenesis of ARDS. Understanding the complex inflammatory interactions is essential for determining effective preventative and management strategies as well as designing novel therapies for veterinary patients.     

Suggested Strategies for Ventilatory Management of Veterinary Patients with Acute Respiratory Distress Syndrome

Objective: To review the current recommendations and guidelines for mechanical ventilation in humans and in animals with acute respiratory distress syndrome.
Human data synthesis: Acute respiratory distress syndrome (ARDS) in humans in defined as an acute onset of bilateral, diffuse infiltrates on thoracic radiographs that are not the result of heart disease and a significant oxygenation impairment. These patients require mechanical ventilation. Research has shown that further pulmonary damage can occur as a result of mechanical ventilation. Various alveolar recruitment maneuvers and a low tidal volume with increased positive end expiratory pressure (PEEP) have been associated with an increased survival.
Veterinary dat synthesis: Two veterinary reports have characterized ARDS in dogs using human criteria. There are no prospective veterinary studies using recruitment that ventilator-induced lung injury (VILI) occurs in dogs, sheep, and rats.
Conclusion: Recruitment maneuvers in conjunction with low tidal volumes and PEEP keep the alveoli open for gas exchange and decrease VILI. Prospective veterinary research in needed to determine if these maneuvers and recommendation can be applied to veterinary patients.     

Acute lung injury and acute respiratory distress syndromes in veterinary medicine: consensus definitions: The Dorothy Russell Havemeyer Working Group on ALI and ARDS in Veterinary Medicine

Background: As veterinary medicine has become more sophisticated, with greater numbers of veterinary patients receiving intensive care, more patients with an acute respiratory distress (ARDS)‐like syndrome have been recognized. Methods: A consensus definition meeting was held for the purpose of developing veterinary‐specific definitions for acute lung injury (ALI) and ARDS. Results/conclusions: Three clinically based definitions for acute lung injury and acute respiratory distress‐like syndromes occurring in veterinary patients were described. Neonatal equine respiratory distress syndrome (NERDS) was defined separately due to the specific requirement for primary developmental surfactant dysfunction and lack of an inflammatory component. Five diagnostic criteria categories were established for Veterinary ALI/ARDS (Vet ALI/ARDS) with 4 required and a fifth highly recommended criteria. A strong consensus was reached that onset of respiratory distress must have been acute and that known risk factors must be present. Additional criteria included evidence of pulmonary capillary leak with no evidence of increased pulmonary capillary pressure, evidence of inefficient gas exchange and, finally, evidence of inflammation. Some features of ALI/ARDS in the neonatal horse were recognized as unique, therefore, equine neonatal ALI/ARDS (EqNALI/EqNARDS) was similarly defined but with a graded gas exchange inefficiency table to allow for normal developmental changes in gas exchange. Use of these definitions in planning prospective studies of these problems in veterinary patients should allow for more direct comparisons of studies and clinical trials, with a larger goal of improving outcome in veterinary patients.     

Acute respiratory distress syndrome.

Several combination therapies have been described throughout this article: in all likelihood, it is combination therapy that will allow improved survival of ARDS patients. As medicine moves into the future, clinical trials evaluating the efficacy of therapies for ARDS will be performed. In human critical care medicine, a large forward step was taken when ALI and ARDS were clearly defined. Unfortunately. as good as the definition is, ALI and ARDS occur secondary to many different underlying pathologic processes,perhaps obscuring the benefits of certain therapies for ARDS based on the underlying condition, for example, trauma versus sepsis. Selection of patients entering any ARDS trial is crucial: not only must those patients meet the strict definition of ARDS but the underlying disease process should be clearly identified. Identification of patients suffering from different disease processes before the onset of ARDS will allow for stratification of outcomes according to the intervention and the underlying pathology--comparing apples to apples and not to oranges. We are in a unique position in veterinary medicine. Although frequently financially limited by our clients, we have the opportunity to achieve several goals. First, we need to clearly define what constitutes ALI and ARDS in veterinary medicine. Do we want to rely on the human definitions? Probably not; however, as a group, we need to determine what we will accept as definitions. For example, we may not be able perform right heart catheterizations on all our patients to meet the wedge pressure requirement of human beings of less than 18 mm Hg. Do we agree that a PAOP of less than 18 mmHg is appropriate for animals, and is it appropriate for all animals? Will we accept another measure, for example, pulmonary artery diameter increases with echocardiographic evidence of acceptable left heart function? What is acceptable left heart function? As veterinarians, what do we consider to be hypoxemia? Is it the same in all species that we work with? What do we define as acute onset? Most human ARDS cases occur while patients are in hospital being treated for other problems, whereas many of our patients present already in respiratory distress. If we are unable to ventilate patients for economic or practical reasons, what do we use as the equivalent of the Pao2/Flo, ratio'? Reliance on the pathologist is not reasonable, because many disease processes can look similar to ARDS under the microscope. If anything, ALI and ARDS are clinical diagnoses. It is time for veterinarians to reach a consensus on the definition for ALI and ARDS in our patients.Only when we have a consensus of definition can rational prospective clinical trials of therapies be designed.     

Prevalence and patterns of self-reported animal-related injury among veterinarians in metropolitan Kampala

To establish the prevalence, patterns and risk factors of animal-related injuries among veterinarians, self-administered questionnaires were given to 60 veterinarians practicing in metropolitan Kampala. The prevalence of animal-related injuries in metropolitan Kampala was 72% (95%CI, 57~84). Some veterinarians (34%) suffered multiple injuries with a mean and median of 2.1 and 2.0 injuries per veterinarian, respectively. Of a total of 70 self-reported animal related injuries, cattle accounted for 72%, cats for 25%, dogs for 23%, self inoculation for 15% and birds for 13%. Injuries associated with poultry did not require hospital treatment. The upper limb was the most the frequently (68%) injured anatomical body part of veterinarians, and vaccination of animals (25%) was the major activity associated with injury. Animal-related injuries are common among practicing veterinarians in metropolitan Kampala; however, they did not differ significantly based on the veterinarian''s gender, experience or risk awareness.     

Veterinarian injuries associated with bovine TB testing livestock in Michigan, 2001

Testing all the cattle in an entire state with a uniform procedure for each animal affords an opportunity to relate human injury data to a known number of animals handled while carrying out a standardized procedure. Our objective was to describe the type and incidence density of injuries associated with TB-testing a large number of cattle herds, and to delineate the various factors associated with the risk of injury. A survey was mailed to all veterinarians (N = 259) who had completed at least five official bovine TB (bTB) herd tests in Michigan in 2001. We collected data regarding basic demographics and health status, work experience, veterinary specialty, and practice information. Each veterinarian was also requested to complete a separate injury questionnaire for each injury received while TB testing livestock in 2001. Accurate addresses were found for 247 eligible veterinarians, 175 (71%) of whom returned the survey. Thirty-six veterinarians reported a total of 53 injuries (10 major, 12 minor and 31 self-treated). Hands (29%) and legs (21%) were the anatomic locations most frequently injured, with sprains/strains (30%) and abrasion/contusion (30%) the most common types of injuries sustained. The overall incidence density of injuries was 1.9 per 10,000 animals tested. Female gender (RR = 3.3), being employed by the government (RR = 4.5), and smoking (RR = 6.0) were significantly associated with a higher rate of injury. Significant colliniearities were found between some risk factors associated with an increased rate of injury and participants thought 81% of their injuries could have been prevented. These results are explained by the administrative structure of the bTB testing program in Michigan, and the changing demographics of the veterinary workforce.     

Pulmonary intravascular macrophages and endotoxin-induced pulmonary pathophysiology in horses

Endotoxemia causes significant mortality and morbidity in horses. The mechanisms underlying this complex pathophysiology remain unclear. Therefore, effective tools to treat endotoxemia in horses are lacking. Furthermore, the multifactorial and multiorgan pathophysiology of equine endotoxemia has not been fully addressed, especially the lung injury associated with endotoxemia. Within the context of the broader picture of endotoxemia and lung injury, we offer a perspective on the roles of pulmonary intravascular macrophages in endotoxin-induced lung inflammation in horses.     

When to neuter dogs and cats: a survey of New York state veterinarians' practices and beliefs

Practicing veterinarians in small-animal or mixed-animal practice in New York state were surveyed about their beliefs and practices regarding the age at which dogs and cats should be neutered and their attitudes toward early neutering (at 4 months of age or younger). The majority of veterinarians routinely recommended neutering for all client animals (70.6%) and supported the routine neutering of shelter animals before adoption (90.3%). More veterinarians in this study reported at least one perceived benefit (91.3%) for early neutering than reported at least one perceived risk (84.4%). Veterinarians with experience neutering early were less likely to believe that the procedure was associated with one or more risks.     

Blue-green algae toxicosis in five dairy cows

Five Holstein cows developed a sudden clinical syndrome of ataxia, muscle tremors, recumbency, and bloody diarrhea. The pond where these cows obtained water contained a near pure culture of Microcystis aeruginosa, a toxic blue-green algae. All cows affected were treated with activated charcoal, procaine penicillin, glucose, and calcium and magnesium gluconate. All 5 cows were clinically normal ten days later. Many practicing veterinarians regard blue-green algae toxicosis as a rare syndrome that results in rapid death for consuming animals; however, this toxicosis may be common and not lethal. Because no diagnostic test is available for blue-green algae toxicosis, this condition rarely is diagnosed.     

Perioperative use of analgesics in dogs and cats by Canadian veterinarians in 2001

A random sample of 652 Canadian veterinarians was surveyed to determine perioperative use of analgesics in dogs and cats following common surgeries. The response rate was 57.8%. With the exception of taildocking in puppies, at least 85% of animals received preincisional analgesics, and 30% to 98.1% received postincisional analgesics. A similar survey was conducted in 1994; since then, analgesic usage has increased markedly, as have ratings of the pain caused by different surgeries. In 2001 most veterinarians (62%) used at least 2 classes of analgesic perioperatively. However, strong opioids, local anesthetics, and alpha-2 agonists were underused, and there was an overreliance on weak opioids (butorphanol, meperidine). Up to 12% of veterinarians did not use any analgesics. Nationally, this may have affected many animals monthly; for example, approximately 6000 dogs or cats undergoing ovariohysterectomy. Continuing education (provincial level) and review articles were considered effective ways to inform veterinarians about optimal analgesic practices.     

Suspected adverse drug reactions in 2004

We received 62 reports of suspected adverse events (SARs) for the year 2004. Their number and repartition according to affected animals and active substances were comparable with the previous year. The distributors or manufacturers submitted most of the declarations, but the proportion submitted by practicing veterinarians is slowly growing. 72% of the declarations dealt with adverse reactions in small animals (cats and dogs), followed by cattle and horses. Antiparasitics, anti-inflammatory drugs and immunologicals were the most frequently mentioned therapeutic classes, which are listed here according to the international ATCvet classification. A report from abroad about a fatality following injection of an antibiotic preparation for cattle prompted Swissmedic to review the security of this medication also sold on the Swiss market. It was decided to modify the package insert to warn about the danger of inadvertent self-injection in humans, to reduce the risk of similar accidents in Switzerland. We hope that the pharmacovigilance system will enjoy an increasing awareness by the practicing veterinarians.     

IMAGING DIAGNOSIS: ACUTE LUNG INJURY FOLLOWING MASSIVE BEE ENVENOMATION IN A DOG

A 5-year-old neutered male mixed breed dog presented for increased respiratory effort after being stung by over 100 bees and developing anaphylactic shock. Given the history, clinical signs and thoracic radiographic findings of a mild bilateral interstitial pattern, acute lung injury/acute respiratory distress syndrome (ALI/ARDS) was suspected. Further testing was performed to support this diagnosis. On computed tomographic images, there was a diffuse bilateral opacification of the lungs, with preservation of bronchial and vascular margins. Pulmonary function testing indicated decreased pulmonary compliance, decreased diffusion capacity and decreased functional residual capacity. These results supported the diagnosis of ALI/ARDS secondary to bee sting envenomation and development of anaphylactic shock. After 8 days of treatment with oxygen, steroids, antibiotics, and bronchodilators the dog improved. This case demonstrates the usefulness of computed tomography and pulmonary function testing in the diagnosis of ALI/ARDS.     

The increasing risk of Lyme disease in Canada

There is an increasing risk of Lyme disease in Canada due to range expansion of the tick vector, Ixodes scapularis. The objectives of this article are to i) raise public awareness with the help of veterinarians on the emerging and expanding risk of Lyme disease across Canada, ii) review the key clinical features of Lyme disease in dogs, and iii) provide recommendations for veterinarians on the management of Lyme disease in dogs.     

Emerging Ferret Diseases

There are a number of newly described and emerging disease syndromes affecting the domestic ferret, and the purpose of this article is to make veterinarians aware of these diseases. A recently described systemic coronavirus infection appears to be a variant of the ferret enteric coronavirus and is currently termed “ferret infectious peritonitis.” Disseminated immunopathologic myositis, aplastic anemia/bone marrow aplasia, acute hemorrhagic syndrome, and oral ulcerations are also described, although the exact etiologies for these diseases have yet to be determined. There appears to be at least 2 important amino acid metabolism deficiencies in ferrets: hindlimb weakness in older ferrets (L-carnitine) and cysteine urolithiasis. Ferrets have recently been found to be susceptible to H1N1 influenza, so knowledge regarding this zoonotic disease is essential for veterinarians working with these animals. A novel Mycoplasma spp. has also recently been identified in ferrets with chronic respiratory problems that originated from one breeding colony. Because these diseases are still being investigated, practitioners who treat a ferret patient exhibiting clinical signs consistent with any of the conditions mentioned are encouraged to contact people who are knowledgeable of that particular illness.     

Application of risk assessment and management principles to the extralabel use of drugs in food-producing animals

A risk assessment of the food safety implications of drugs used in food-producing animals is an essential component of the regulatory approval process for products containing these drugs. This ensures that there is negligible risk to human health if these drugs are used according to the instructions that appear on the approved label. A relative paucity of approved products for veterinary species; however, forces veterinarians worldwide to use drugs in an extralabel manner to treat disease and alleviate suffering in animals. In food-producing animals, this may result in residues that are potentially harmful to the human consumer. This review describes how risk assessment principles can be extended to evaluate the risks posed by different classes of extralabel drug use. Risk management practices in the United States and Europe are summarized and contrasted to illustrate the application of these principles.     

Pet poultry training for veterinary practitioners

Keeping backyard poultry in urban areas is a burgeoning trend in the United States. As such, we believe urban pet poultry owners are increasingly likely to seek veterinary services from urban companion-animal practitioners. Traditionally, poultry species have been classified as production animals. Most small-animal practitioners have limited experience or knowledge of these species and hesitate to accept these animals at their practices. We developed a one-day course to train veterinarians in pet poultry (as opposed to commercial poultry) medicine. The course covers poultry examination, diseases, and treatments and provides an introduction to poultry breeds and behavior and the basics of nutrition and husbandry. We believe this type of continuing education program is important for veterinarians because they are often on the front line of human public health issues. In addition, courses of this type increase the number of veterinarians trained to spot serious avian diseases, including foreign diseases and diseases with zoonotic potential. Most important, veterinarians with this training develop the knowledge to contribute to the health and well-being of pet poultry along with their clients' other companion animals.     

Demographic profile of the veterinary profession in New Zealand, 1985

The demographic characteristics of the veterinary profession in New Zealand are examined using information supplied by registered veterinarians to the Veterinary Surgeons Board in their applications for annual practising certificates in 1985. Comparisons are made with the veterinary professions in other similar countries, and with the medical and paramedical professions in New Zealand. In 1985 1308 registered veterinarians were working in New Zealand and 304 were overseas, whereas in 1976 the equivalent figures were 748 and 182. This represents an increase of 73% in the number of registered veterinarians in the last 10 years. Eighteen percent of veterinarians were female. The mean age of veterinarians was 38 years, but females in the profession were on average much younger (32 years) than males (42 years). Clinical practice provides employment for 70% of veterinarians: of these 59% work principally with farm animals and 41% with non-farm animals. The remaining veterinarians are employed by Government (22%), University (5%) and Industry (3%). The current demographic structure of the profession has been markedly influenced by the opening of New Zealand's only veterinary school at Massey University in 1963. Differences from other medical professional populations in New Zealand and overseas principally reflect the marked change in the number and sex ratio of graduates entering the veterinary profession since that time. It will take about another twenty years before the population reaches a stable age and sex structure, assuming that current graduation patterns persist throughout that period. Because the structure of the population is changing, considerable caution is needed in predicting future employment trends from data for a single year.     

Demographic profile of the veterinary profession in New Zealand, 1985

The demographic characteristics of the veterinary profession in New Zealand are examined using information supplied by registered veterinarians to the Veterinary Surgeons Board in their applications for annual practising certificates in 1985. Comparisons are made with the veterinary professions in other similar countries, and with the medical and paramedical professions in New Zealand. In 1985 1308 registered veterinarians were working in New Zealand and 304 were overseas, whereas in 1976 the equivalent figures were 748 and 182. This represents an increase of 73% in the number of registered veterinarians in the last 10 years. Eighteen percent of veterinarians were female. The mean age of veterinarians was 38 years, but females in the profession were on average much younger (32 years) than males (42 years). Clinical practice provides employment for 70% of veterinarians: of these 59% work principally with farm animals and 41% with non-farm animals. The remaining veterinarians are employed by Government (22%), University (5%) and Industry (3%). The current demographic structure of the profession has been markedly influenced by the opening of New Zealand's only veterinary school at Massey University in 1963. Differences from other medical professional populations in New Zealand and overseas principally reflect the marked change in the number and sex ratio of graduates entering the veterinary profession since that time. It will take about another twenty years before the population reaches a stable age and sex structure, assuming that current graduation patterns persist throughout that period. Because the structure of the population is changing, considerable caution is needed in predicting future employment trends from data for a single year.     

Biosecurity of veterinary practices.

Hospitalization of sick animals tremendously increases their risk of acquiring infections as this congregates animals that are most likely to be shedding infectious agents with animals that often have enhanced susceptibility. In order to provide the best veterinary care possible, veterinarians have an underlying responsibility to minimize the risk of additional harm that might unintentionally befall a patient because of their interventions. This includes minimizing the risk of exposing patients to infectious agents. It is therefore incumbent upon veterinarians to actively manage the risk of nosocomial infections. Nosocomial infections in veterinary hospitals are not solely a patient-care concern; the spread of infectious agents can also significantly impact normal hospital operations, revenue, client confidence, public image, and can even affect the morale of hospital personnel. In some cases nosocomial agents can also be zoonotic. This paper discusses the need for biosecurity programs in veterinary practices, and describes a practical approach for developing biosecurity practices that are tailored to individual facilities.     

A short review of transmissible spongiform encephalopathies, and guidelines for managing risks associated with chronic wasting disease in captive cervids in zoos.

The transmissible spongiform encephalopathies (TSEs) represent an emerging group of diseases that have been labeled as "prion diseases" because of the recent characterization of the infectious agent. TSEs are caused by prions, which induce neurodegenerative fatal diseases in humans and animals. Some TSEs (scrapie and kuru), have existed in both animals and humans for a very long time, whereas others such as bovine spongiform encephalopathy and variant Creutzfeld-Jakob disease have either recently emerged or are more thoroughly described and recognized. It is obvious that the medical community will be forced to consider these diseases in humans and animals for the future. This article offers a short review of the TSEs of immediate concern to zoo and wildlife veterinarians and wildlife biologists and suggests risk management strategies for the prevention of these diseases, with special focus on chronic wasting disease of cervids in North America.