Mechanical ventilation in foals with botulism: 9 cases (1989-2002)

"Shaker foal" disease, toxicoinfectious botulism of foals, was 1st described as a clinical entity in 1967. The reported mortality rate was 90%, with death occurring within 24-72 hours of the onset of the characteristic clinical signs. The mortality rate decreased when equine-origin botulism antitoxin became available; however, a certain percentage of foals continued to die of respiratory failure. Mechanical ventilation is an important part of the treatment of infant botulism and is essential to the survival of many affected infants. We report a retrospective study of 9 foals with toxicoinfectious botulism where early mechanical ventilation was employed as part of the treatment. Foals receiving mechanical ventilation were progressively acidemic and had increased PaCO2 tensions before mechanical ventilation. These arterial blood gas abnormalities were ameliorated with mechanical ventilation. One foal was euthanized for economic reasons; survival in treated foals was 87.5%. Mechanical ventilation of foals with botulism and respiratory failure appears to be an effective therapy.     

Developments in management of the newborn foal in respiratory distress 2: Treatment

New developments in therapy for foals in respiratory distress are discussed. Therapy is based on preservation of the foal's life by maintenance of a patent airway, resuscitation with fluids and warmth, provision of humidified oxygen to raise the fractional concentration of inspired oxygen sufficient to avoid hypoxia and provision of ventilatory support when hypercapnia becomes critical. Ventilatory support described includes assisted and controlled ventilation, positive end expiratory pressure, continuous positive airway pressure and intermittent mandatory ventilation. The aims of these techniques are discussed together with their associated indications, disadvantages and complications. Secondary therapy includes coupage, airway hygiene, drug therapy and stress management. Knowledge of equine neonatology is limited in comparison with human neonatology. More information in basic physiology and pharmacology relating to equine neonatology is needed and the efficacy of various modes of therapy must be evaluated.     

Botulism in foals less than 6 months of age: 30 cases (1989-2002)

Botulism has been recognized as a clinical entity in foals since the 1960s. Also known as "Shaker foal" disease, the toxicoinfectious form of botulism affects foals, with the highest incidence in the United States seen in Kentucky and the mid-Atlantic region. The disease is characterized by progressive muscular weakness caused by the action of botulism neurotoxin at cholinergic neuromuscular junctions. Increased number of episodes and duration of recumbency, muscular trembling, and dysphagia are seen in affected foals. Left untreated, the disease can be rapidly fatal, with death occuring secondary to respiratory muscle paralysis within 24 to 72 hours of the onset of clinical signs. Very mildly affected foals can survive with minimal treatment Despite advances made in treatment of these foals, including administration of botulism antitoxin early in the course of the disease, there is still an impression that the disease carries a high mortality rate. The purpose of this study was to evaluate outcome in 30 foals <6 months of age diagnosed with botulism between 1989 and 2002 at the George D. Widener Large Animal Hospital, New Bolton Center. Two foals were euthanized for economic reasons early in the disease course, and I died while being treated. Survival of treated cases was greater than 96%. Approximately 50% of the cases required oxygen therapy, whereas 30% required mechanical ventilation. All foals, excepting 1 mildly affected foal, received botulism antitoxin. Mean duration of hospitalization was 14 days. With appropriate treatment, foals with botulism have a high survival rate.     

Resuscitation and emergency management for neonatal foals.

Early intervention can dramatically alter outcome in foals. Cardio-pulmonary cerebral resuscitation can be successful and clinically worthwhile when applied to foals that arrest as part of the birthing process. Readily available equipment and an ordered plan starting with addressing the respiratory system (airway and breathing) followed by the circulatory system (circulation and drugs) are the keys to success. Hypoglycemia is common in foals that are not nursing and in septic foals. Support of serum glucose can be an important emergency treatment. Respiratory support with oxygen therapy should be considered in all foals following resuscitation and dystocia. Other foals that are likely to benefit from oxygen are those that are dyspneic, cyanotic, meconium-stained after birth,or recumbent. Emergency therapies, applied correctly, are expected to result in decreased mortality and morbidity.     

Cardiopulmonary cerebral resuscitation in neonatal foals

Cardiovascular or pulmonary system failure in neonatal foals requires rapid recognition and initiation of cardiopulmonary cerebral resuscitation (CPCR). Foals may require resuscitation immediately after birth or after arrest from progression of a disease process such as severe sepsis or septic shock. Initial treatment is aimed at establishing an airway and providing ventilation. Circulation is provided by closed-chest compressions. Circulatory access is important to provide intravenous fluid and pharmacologic therapy for cardiovascular support. Ventricular fibrillation and pulseless ventricular tachycardia are arrhythmias not commonly recognized with arrest in foals, whereas asystole and cardiovascular collapse are frequently encountered. Training of personnel, preparation of supplies, and organization during CPCR is essential to a successful outcome.Most of the information used for CPCR in neonatal foals is derived from human medical research and clinical medicine. As new advances are made in human neonatal and pediatric CPCR, many of these treatments and techniques can be applied to foals. This article reviews currently available CPCR guidelines in foals and highlights new perspectives in human medicine that may be applicable to foals.     

Cardiopulmonary effects of xylazine sedation in the foal

Six healthy foals underwent instrumentation for measurement of the cardiopulmonary effects of sedation with 1.1 mg/kg bodyweight xylazine hydrochloride given intravenously. Responses to xylazine in foals at 10 and 28 days of age were not significantly different. Foals became sedate and markedly ataxic, and four of the six foals became recumbent. Heart rate decreased significantly but no arrhythmias were detected. Arterial blood pressure increased initially and then fell significantly below pre-injection values. Changes in respiratory airflow, upper airway obstruction and respiratory noise were noted in the initial 20 mins of sedation, after which respiratory rate fell, tidal volume increased, and minute volume decreased gradually. Arterial blood gas tensions and pH did not change significantly during the 120 mins following xylazine administration. Control studies showed no significant changes. All foals recovered uneventfully.     

High-frequency jet ventilation in a neonatal foal

High-frequency jet ventilation was performed on a premature foal for respiratory difficulty attributable to in utero-acquired pneumonia. The procedure involves delivery of compressed gas through a small-bore cannula at frequencies up to 400 cycles/min. Ventilation settings of drive pressure, frequency, and FIO2 were varied to optimize PaO2 and PaCO2 values. The foal was ventilated with this equipment for 14 hours. Evidence of a favorable response to this method of ventilation was observed in the form of improvement in arterial blood gas values as well as the foal's attitude and degree of respiratory effort. High-frequency jet ventilation appears to be a useful method of ventilation for respiratory disease in neonatal foals; however, there remains no clear-cut advantage over conventional positive-pressure ventilation.     

Successful ventilatory management of post‐anesthetic airway collapse and hypoxemia in a dog

Abstract Objective: To report a life‐threatening complication (airway collapse) associated with a common procedure (anesthesia) and to describe its successful management. Case Summary: A dog without pre‐existing signs of respiratory disease developed hypoxemia and severe atelectasis in the post‐anesthetic recovery period and was demonstrated, by bronchoscopic examination, to have severe airway collapse. Mechanical ventilation was used to re‐expand collapsed lung units and to prevent re‐collapse. A ventilation strategy designed to minimize airway and alveolar trauma was used. The dog was successfully weaned from the ventilator and made a full recovery. Unique Information Provided: Acute, severe hypoxemia due to airway collapse occurred in the post‐operative period in a dog with no signs of pre‐existing respiratory disease. The dog was successfully managed with short‐term mechanical ventilation. High frequency jet ventilation was used for a diagnostic bronchoscopy.     

Respiratory studies in foals from birth to seven days old

Respiratory measurements and blood-gas and acid-base values are reported in nine term induced foals. Measurements were performed at 2, 15, 30 and 60 mins, 4, 12, 24 and 48 h, and four and seven days after birth. Minute respiratory volume was significantly lower at birth than values from 12 h old. Tidal volume peaked at 60 mins old, while respiration rate decreased significantly at 15 mins after birth. Oxygen consumption was high at birth and decreased to its lowest values at 24 and 48 h. The respiratory exchange ratio and ventilatory equivalent showed few significant changes to seven days, as did the minute alveolar ventilation and physiological deadspace. The blood-gas and acid-base values indicated that the foals rapidly establish adequate pulmonary ventilation within minutes of birth, and that those values changed little from 12 h to seven days after birth. Body position had a significant effect on arterial oxygen tension with Pao₂ values in lateral recumbency being, on average, 14 mmHg lower than when the foals were standing.     

Conventional versus high-flow oxygen therapy in dogs with lower airway injury

Dogs with lower airway pathology that present in respiratory distress often receive oxygen therapy as the first line of treatment regardless of the underlying cause. Conventional “low-flow” systems deliver oxygen with a maximum flow rate of 15 L/minute. Traditionally, when an animal’s respiratory status does not improve with conventional oxygen therapy and treatments for underlying disease, options might be limited to either intubation and mechanical ventilation or humane euthanasia. High-flow oxygen therapy (HFOT) has been gaining popularity in veterinary medicine as an alternative route of oxygen supplementation for animals that require support beyond conventional therapy. High-flow oxygen therapy can supply a mixture of air and oxygen via a heated and humidified circuit. It is user friendly and can be used in an environment in which mechanical ventilation is unavailable.This review article is written for emergency doctors and general practitioners who lack access to mechanical ventilation. This article briefly reviews pertinent respiratory physiology, traditional oxygen supplementation techniques, the physiology of HFOT, and the limited evidence available in veterinary medicine regarding the use of HFOT, its applications, and limitations. Guidelines for the use of HFOT are suggested and HFOT is compared to conventional therapy.     

Developments in management of the newborn foal in respiratory distress 1: Evaluation

Developments in evaluation of newborn foals with respiratory distress are discussed. Major causes of respiratory distress are outlined and discussed in terms of the similar respiratory signs exhibited by foals with this clinical syndrome. History, physical examination, clinical pathology, chest radiography and blood gas analyses are discussed as important elements of the evaluation of the condition of these foals. Foals with respiratory disease are grouped into three major categories on the basis of clinical signs and arterial blood gas profiles. The evaluation of foals with respiratory distress is designed not only to reach an accurate diagnosis of the aetiology but also to define the foal's need for respiratory support.     

Clinical and prognostic significance of radiographic pattern, distribution, and severity of thoracic radiographic changes in neonatal foals

A total of 207 thoracic radiographs obtained from 128 foals were evaluated to assess the impact of pulmonary radiographic pattern, distribution, and severity of pulmonary changes on short-term survival of neonatal foals. The association between selected clinical variables and the radiographic manifestation of neonatal respiratory disease was also investigated. The evaluation of interstitial and alveolar-interstitial radiographic patterns within the caudodorsal, caudoventral, and cranioventral lung regions proved to be highly reliable between viewers in the study. A diagnosis of systemic inflammatory response syndrome was related to increased pulmonary infiltrates within the caudodorsal lung region. Dyspneic foals had more extensive pulmonary infiltrates within the cranioventral lung, advanced respiratory disease, and lower survival rates. A fibrinogen concentration >400 mg/dL was associated with increased cranioventral radiographic abnormalities. In addition, tachypnea most consistently related to diffuse (caudodorsal, caudoventral, and cranioventral) pulmonary changes. Neutropenia, milk reflux from the nares, upper airway pathology, abnormal respiratory sounds, failure of transfer of passive immunity (IgG concentration <400 mg/dL), immaturity, or fever, however, were not related to radiographic pattern, distribution, or severity of radiographic changes. Sixty-five percent of foals with radiographic pulmonary disease were discharged alive from our referral hospital. Concurrent caudodorsal and caudoventral radiographic disease was most frequently observed in this foal population. Increased caudodorsal radiographic scores retained statistical significance as a prognostic indicator for nonsurvival in a multiple stepwise logistic regression analysis.     

Comparison of the effects of caffeine and doxapram on respiratory and cardiovascular function in foals with induced respiratory acidosis

OBJECTIVE: To determine and compare the effects of caffeine and doxapram on cardiorespiratory variables in foals during isoflurane-induced respiratory acidosis. ANIMALS: 6 clinically normal foals (1 to 3 days old). PROCEDURES: At intervals of > or = 24 hours, foals received each of 3 IV treatments while in a steady state of hypercapnia induced by isoflurane anesthesia (mean +/- SD, 1.4 +/- 0.3% endtidal isoflurane concentration). After assessment of baseline cardiorespiratory variables, a low dose of the treatment was administered and variables were reassessed; a high dose was then administered, and variables were again assessed. Sequential low- and high-dose treatments included doxapram (loading dose of 0.5 mg/kg, followed by a 20-minute infusion at 0.03 mg/kg/min and then 0.08 mg/kg/min), caffeine (5 mg/kg and 10 mg/kg), and saline (0.9% NaCl) solution (equivalent volumes). RESULTS: Administration of doxapram at both infusion rates resulted in a significant increase in respiratory rate, minute ventilation, arterial blood pH, PaO(2), and arterial blood pressure. These variables were also significantly higher during doxapram administration than during caffeine or saline solution administration. There was a significant dose-dependent decrease in PaCO(2) and arterial bicarbonate concentration during doxapram treatment. In contrast, PaCO(2) increased from baseline values after administration of saline solution or caffeine. The PaCO(2) value was significantly lower during doxapram treatment than it was during caffeine or saline solution treatment. CONCLUSIONS AND CLINICAL RELEVANCE: Results indicated that doxapram restored ventilation in a dose-dependent manner in neonatal foals with isoflurane-induced hypercapnia. The effects of caffeine on respiratory function were indistinguishable from those of saline solution.     

Respiratory mechanics in Standardbred horses with sub-clinical inflammatory airway disease and poor athletic performance

The aim of this study was to investigate and quantify respiratory mechanical dysfunctions in Standardbred horses with both poor performance and bronchoalveolar lavage fluid cytology characteristic of inflammatory airway disease (IAD). A control group of healthy Standardbred horses was compared. Respiratory mechanics and breathing pattern were examined at rest and during hyperventilation induced using a rebreathing method. At rest, respiratory mechanics and breathing pattern were superimposable in both groups. In IAD horses, rebreathing increased ventilation, with larger tidal volumes and lower respiratory frequencies. During hyperventilation, IAD animals showed frequency-dependent dynamic lung compliance, and had greater viscous lung resistance and rate of dynamic work of breathing. As IAD alters pulmonary mechanics, the ventilatory load increases and horses requiring significantly higher energy for breathing may suffer restrictions in their athletic performance. This rebreathing method permits early evaluation of respiratory mechanical dysfunction in poorly performing horses with sub-clinical IAD.     

Acute lung injury/acute respiratory distress syndrome in 15 foals

REASONS FOR PERFORMING STUDY: Few reports exist in the veterinary medical literature describing clinical and pathological findings resembling conditions described as (ALI) and acute respiratory distress syndrome (ARDS) in man. OBJECTIVES: To document history, clinical, laboratory and diagnostic findings, treatment and outcome of foals age 1-12 months diagnosed with ALI/ARDS at a referral hospital. METHODS: Medical records, including radiographic, cytological, microbiological, serological and post mortem findings, were reviewed in a retrospective manner to identify foals with acute onset of respiratory distress, a partial pressure of arterial oxygen (PaO2) to fraction of oxygen in inspired gases (FiO2) ratio of < or = 300 mmHg, pulmonary infiltrates on thoracic radiographs or post mortem findings consistent with ALI/ARDS. RESULTS: Fifteen foals age 1.5-8 months were included in the study. Seven foals had previously been treated for respiratory disease, and all foals developed acute respiratory distress <48 h prior to presentation. Findings on presentation included tachycardia and tachypnoea in all foals, with fever recorded in 8 cases. Eight cases met the criteria for ALI and 7 for ARDS. Radiographic findings demonstrated diffuse bronchointerstitial pattern with focal to coalescing alveolar radiopacities. An aetiological agent was identified in foals ante mortem (n = 6) and post mortem (n = 4). All foals were treated with intranasal oxygen and antimicrobial drugs; 13 received corticosteroids. Nine patients survived, 4 died due to respiratory failure and 2 were subjected to euthanasia in a moribund state. Follow-up was available for 7 foals; all performed as well as age mates or siblings, and one was racing successfully. CONCLUSIONS: A condition closely meeting the human criteria for ALI/ARDS exists in foals age 1-12 months and may be identical to previously described acute bronchointerstitial pneumonia in young horses. POTENTIAL RELEVANCE: ALI/ARDS should be suspected in foals with acute severe respiratory distress and hypoxaemia that is minimally responsive to intranasal oxygen therapy. Treatment with systemic corticosteroids, intranasal oxygen and antimicrobials may be beneficial in foals with clinical signs compatible with ALI/ARDS.     

THORACIC RADIOGRAPHY IN THE NEONATAL FOAL: A PRELIMINARY REPORT

Thoracic radiographs from 22 neonatal foals were reviewed to investigate the radiographic appearance of the thorax in normal, immature, and septicemic foals, and in foals with neonatal respiratory distress syndrome. The size and radiographic appearance of intrathoracic structures and abnormal lung opacities were evaluated. The craniocaudal and apicobasilar dimensions of the heart were 5.6–6.3 and 6.7–7.8 times the length of a midthoracic vetebral body, respectively, in normal, immature and septicemic foals. Apicobasilar measurements were greater (8.0–8.7) in the foals with respiratory distress syndrome. Normal foals had clear lung fields within 12 hours of birth. A more marked interstitial pattern was observed in immature and septicemic foals compared to normals. Diffuse air–space (alveolar) pattern with air bronchograms was seen in foals with respiratory distress syndrome. It was concluded from this series that thoracic radiographs taken 24–48 hours after birth may aid differentiation of normal foals, septicemic or immature foals, and foals with respiratory distress syndrome.     

Airway responses to histamine aerosol in clinically normal foods.

OBJECTIVE: To describe the spectrum of nonspecific airway reactivity in a group of clinically normal foals. ANIMALS: 12 clinically normal mixed-breed foals, 48 to 92 days old, without history of clinical lung disease. PROCEDURE: Nonspecific airway reactivity was determined by measuring the extent of changes in dynamic compliance during nebulization of incrementally increasing concentrations of histamine aerosol. Degree of airway reactivity was expressed as the dose of histamine that evoked a decrease in dynamic compliance (Cdyn) to 65% of the after saline nebulization value (PC65Cdyn) or increase in pulmonary resistance (R(L)) to 135% of baseline (PC135R(L)). RESULTS: In all foals, it was possible to induce a decrease in Cdyn in dose-dependent manner to < or = 65% of baseline. Response of foals in terms of R(L) was more erratic, and, in 1 foal, R(L) decreased after histamine exposure. Mean+/-SD PC65Cdyn was 5.43+/-1.74 (range, 0.77 to 19.56) mg/ml, and mean PC135R(L) was 3.34+/-1.52 (range, -0.749 to 17.35) mg/ml. Body weight was not correlated to baseline Cdyn, R(L), PC65Cdyn, or PC135R(L). CONCLUSIONS AND CLINICAL RELEVANCE: Clinically normal foals had a wide range of airway reactivity, which may contribute to variation in clinical responses of foals to otherwise similar stimuli, such as infection, inflammation, and challenge exposure with environmental irritants.     

Respiratory stridor associated with polymyopathy suspected to be hyperkalemic periodic paralysis in four quarter horse foals.

Four Quarter Horse foals ranging in age from 6 days to 2 months were determined to have upper airway stridor secondary to polymyopathy suspected to be hyperkalemic periodic paralysis. Electromyography revealed spontaneous muscle activity in all muscles examined. Electromyographic findings were similar in the dams of 3 foals (No. 1, 3 and 4). Hyperkalemia was found in foals 1 and 4. Endoscopically, the upper airway stridor in foals 1 and 3 was confirmed to be attributable to laryngeal and pharyngeal collapse or spasm. Foals 1, 2, and 3 were treated with acetazolamide. Foal 4 was not treated, at the owner's request. Foals 2 and 3 improved with treatment, foal 4's condition was static, and foal 1 required a tracheostomy and laryngeal surgery to manage its upper airway stridor.     

Effect of hyperimmune plasma on the severity of pneumonia caused by Rhodococcus equi in experimentally infected foals

This study evaluated the prophylactic effectiveness of hyperimmune plasma (HIP) as an aid in the prevention of pneumonia caused by experimental infection with Rhodococcus equi. Thirty neonatal foals were administered R. equi HIP or saline at 2 days of age and were infected with virulent R. equi at 7 days. All foals developed signs or symptoms of respiratory disease. Radiographic scores on day 28 and neutrophil concentrations on day 49 were significantly greater in control foals, and time to respiratory effort score of 2 or higher was significantly shorter for control foals. Three foals, all in the principal group, died or were euthanized before the end of the study, but there was no significant difference in mortality between groups. VapA titers were significantly greater in principal foals. Administration of R. equi HIP decreased the severity of radiographic lesions and prolonged time to increased respiratory effort due to R. equi-induced pneumonia.