The use of equine surfactant and positive pressure ventilation to treat a premature alpaca cria with severe hypoventilation and hypercapnia

A 5-hour-old, premature alpaca cria was presented with failure to nurse, weakness, hypoglycemia, hypercapnia, and respiratory distress. The cria was treated with 3 doses of fresh, crude equine surfactant, positive pressure ventilation, and supplemental intranasal oxygen. Recovery to discharge was uneventful, and the cria regained apparently normal respiratory function. Three years after hospital discharge, the alpaca was a healthy adult.     

Treatment of a dog with severe baclofen intoxication using hemodialysis and mechanical ventilation

Objective: This case report describes the successful management of a dog with coma and respiratory depression due to severe baclofen intoxication. Case summary: A Doberman Pinscher mixed breed dog ingested 500 mg (20 mg/kg) of baclofen. Signs of severe intoxication included coma and profound respiratory muscle weakness. The dog was supported with positive pressure ventilation and treated with one session of hemodialysis. Weaning from the ventilator was achieved within 4 hours of hemodialysis, and recovery from coma occurred over the following 12–36 hours. The dog regained full neurologic function and was normal at discharge following 3 days of hospitalization. New or unique information provide: Severe central nervous system depression and respiratory depression due to baclofen intoxication can be life threatening. In addition to other supportive care, hemodialysis may hasten recovery and ventilatory support may be essential to achieve a positive outcome. With successful treatment, toxicity can be decreased and the associated life‐threatening central nervous system and ventilatory depression can resolve. Prognosis for return of normal function is excellent.     

Severe seizures associated with traumatic brain injury managed by controlled hypothermia,pharmacologic coma,and mechanical ventilation in a dog

Objective – To describe the management and outcome of a dog presenting with intractable seizures associated with traumatic brain injury. Case Summary – A spayed female Wheaten Terrier was presented to an emergency clinic with neurologic deficits (modified Glasgow coma scale of 10) shortly after a road traffic accident. Seizures were uncontrolled despite aggressive pharmacologic intervention. Controlled hypothermia to achieve a rectal temperature of 33–35°C (91.4–95°F) was initiated as a protective measure to reduce intracranial pressure and cerebral metabolic rate, and to assist with seizure control. Intubation and mechanical ventilation were required to protect the airway and manage hypercapnia associated with hypoventilation. The patient went on to make a full recovery, although behavioral changes were noted by the owners for an 8‐week period following injury. New or Unique Information Provided – To the author's knowledge, this is the first instance of therapeutic hypothermia reported in the veterinary literature. A short review of this treatment modality is provided.     

Balanced anesthesia and ventilation strategies for an alpaca (Lama pacos) with an increased anesthetic-risk

We report the use of a balanced anesthetic technique in a three-year-old, female Huacaya alpaca with an increased anesthetic risk that underwent an extensive dental surgery. Anesthesia was provided with an infusion of midazolam, fentanyl, S-ketamine and low concentrations of isoflurane in oxygen. The mandibular alveolar nerve was desensitized with a lidocaine-bupivacaine combination. The alpaca showed signs of hypoxemia fifteen minutes after anesthesia induction and arterial blood gases confirmed severe venous admixture. Application of positive end expiratory pressure (PEEP) of 6-9 cm H2O improved the arterial oxygenation. Other cardiopulmonary variables remained within the normal range. At the end of surgery, sarmazenil was administered to antagonize the effects of midazolam and emergence from anesthesia was smooth and uneventful. Flunixine meglumine and a transdermal delivery system for fentanyl were administered for post-operative analgesia. This method of balanced anesthesia allowed for an adequate anesthetic plane and a safe recovery, however, special ventilation strategies (PEEP) had to be applied.     

Causes of respiratory failure.

There are many causes of respiratory failure in veterinary patients. Assessment of oxygenation is imperative for the diagnosis and monitoring of these patients. Oxygen therapy should be instituted when hypoxemia is diagnosed to prevent tissue hypoxia, end-organ damage, and death. Methods of administering oxygen include commercial oxygen cages, mask oxygen, nasal cannulation (for dogs), and intubation. Mechanical ventilation is an option in many referral hospitals for patients who are severely hypoxemic and are not responding to inspired oxygen concentrations achieved with other methods of oxygen administration. One rule of thumb used to assess need for mechanical ventilation is a PaO2 of less than 50 mm Hg despite aggressive oxygen therapy, or a PaCO2 of greater than 50 mm Hg despite treatment for causes of hypoventilation. A mechanical ventilator has the ability to vary the FiO2 by increments of one, from 21% to 100% (0.21-1) oxygen in inspired gas. Positive end-expiratory pressure (PEEP) is also available on most ventilators. PEEP allows the alveoli to remain open on expiration, allowing gas exchange to occur in both inspiration and expiration. PEEP also helps diseased alveoli to inflate, increasing the available surface area for gas exchange and improving arterial blood oxygen tension. Because patients requiring mechanical ventilation have severe respiratory failure that did not respond to conventional oxygen therapy, the prognosis is guarded for most of these patients unless ventilation is instituted due to primary hypoventilation and lung parenchyma is normal. Hypoxemia caused by respiratory failure is a common problem in small animal veterinary patients. Assessment of blood oxygenation and continual monitoring of respiratory rate and effort are essential in management of these patients. Oxygen therapy should be instituted if hypoxemia is diagnosed. The prognosis depends on the underlying disease process and response to treatment with an enriched oxygen environment.     

Weaning from mechanical ventilation

Patients that require positive pressure ventilation to maintain sufficient alveolar ventilation or pulmonary gas exchange may eventually reach a point in the course of their care wherein mechanical ventilation is no longer necessary. This process of transferring the work of breathing from the ventilator back to the patient is referred to as ventilator weaning. The term "ventilator weaning" may be used to refer to all methods by which this transfer of workload may be accomplished. In many patients, particularly those with short-lasting or readily correctable causes of respiratory insufficiency (e.g., general anesthesia), the discontinuation of positive pressure ventilation may be easily achieved. Indeed, in patients awakening from general anesthesia, the axiom "awake enough to blink, awake enough to breath" may prove to be a sufficient guideline. However, in those patients requiring long-term mechanical ventilatory support, the process can prove to be both frustrating and exceptionally challenging. It is of crucial importance to identify those patients that may be successfully weaned because of both the financial impact of prolonged intensive care unit hospitalization and the risks imposed on the patient by the process of positive pressure ventilation. To be able to predict which patients may be ready to be weaned from the ventilator requires an understanding of the balance between the work of breathing (ventilatory load) and the ability of the patient's respiratory pump to meet those needs (ventilatory capacity). The management of patients experiencing difficulty during the weaning process requires that the clinician recognize imbalances between ventilatory load and capacity and to correct these imbalances once identified.     

Successful use of short‐term mechanical ventilation to manage respiratory failure secondary to profound hypokalemia in a cat with hyperaldosteronism

Objective – To report successful management of respiratory failure due to severe hypokalemia in a cat with hyperaldosteronism, including short‐term mechanical ventilation strategies and aspects of medical and surgical treatment. Case Summary – A cat presented with bilateral pelvic limb weakness that rapidly progressed to tetraparesis and respiratory muscle failure. Point‐of‐care testing revealed severe hypokalemia (1.9 mmol/L) and mild azotemia. Initial management included endotracheal intubation, mechanical ventilation, and aggressive potassium supplementation. Spironolactone was started due to a high index of suspicion for hyperaldosteronism. A right adrenal mass visualized during abdominal ultrasonographic examination and a serum aldosterone level greater than 3329 pmol/L confirmed the diagnosis. The cat made a full recovery following surgical removal of a right adrenal adenoma. New or Unique Information Provided – We report successful management of respiratory failure in a cat with hyperaldosteronism using short‐term mechanical ventilation. Respiratory failure due to severe hypokalemia should be considered a complication of hyperaldosteronism in cats and may require mechanical ventilation. However, full recovery is possible.     

Successful treatment of acute respiratory distress syndrome in 2 dogs

Acute respiratory distress syndrome (ARDS) was diagnosed in 2 dogs with acute dyspnea. Short-term positive pressure ventilation and intense critical and nursing care were provided. Both dogs improved and were discharged. Few reports describe successful recovery from ARDS. Due to advances in positive pressure ventilation and improvement in the supportive care of critically ill veterinary patients, the prognosis for ARDS may improve.     

Noninvasive ventilation in cats

Objective – The primary objective of this study was to assess the feasibility of noninvasive mechanical ventilation (NIV) in cats. The secondary objective was to determine whether cardiovascular parameters and anesthetic drug requirements associated with noninvasive ventilation differ from those associated with invasive ventilation. Design – Randomized, cross‐over design. Setting – A research laboratory in a veterinary teaching hospital. Animals – Eight healthy adult cats, 3 intact females and 5 intact males, weighing between 3 and 6 kg, were used. Interventions – Each cat was randomly assigned to NIV via nasal mask, or invasive ventilation using an endotracheal tube. Mechanical ventilation was performed for 6 hours. Anesthesia was provided using continuous infusions of propofol and butorphanol. After a minimum 9‐day washout period, the procedure was repeated using the alternate ventilation interface. Measurements and Main Results – Cardiovascular parameters (heart rate, rectal temperature, direct arterial blood pressure), arterial blood gases, drug requirements, sedation score, and ventilation parameters, were monitored throughout the procedures. These values were evaluated using ANCOVA for repeated measures. All cats were effectively ventilated using NIV. There were no significant differences in cardiovascular parameters, drug requirements, or sedation scores between groups. Although PaCO₂ values did not differ, PaO₂ values were significantly higher in the invasively ventilated group. Inspiratory tidal volumes were similar between groups, whereas expiratory tidal volumes were significantly lower in the NIV group. Inspiratory pressures were significantly higher in the NIV group. Respiratory frequency was significantly higher in the invasively ventilated group. Conclusions – NIV of cats is possible. However, currently it does not confer any cardiovascular benefit over invasive ventilation and drug requirements are similar. Use of a correctly fitted mask is essential for successful NIV as air leaks account for the observed discrepancy between inspiratory and expiratory volumes. Further investigation into this modality is warranted.     

Cardiorespiratory and blood gas alterations during laparoscopic surgery for intra-uterine artificial insemination in dogs

Cardiorespiratory and blood gas alterations were evaluated in 6 healthy dogs that underwent a laparoscopic procedure using isoflurane anesthesia and carbon dioxide (CO(2)) pneumoperitoneum for 30 min. Heart rate, respiratory rate, body temperature, venous blood pH, partial pressure of CO(2) and oxygen, oxygen saturation, total carbon dioxide (TCO(2)) and bicarbonate were monitored. Significant alterations were hypercapnia, hypoventilation, and respiratory acidosis.     

Cardiopulmonary effects of halothane anesthesia in cats

The cardiopulmonary effects of 2 planes of halothane anesthesia (halothane end-tidal concentrations of 1.78% [light anesthesia] and 2.75% [deep anesthesia]) and 2 ventilatory modes (spontaneous ventilation [SV] or mechanically controlled ventilation [CV]) were studied in 8 cats. Anesthesia was induced and maintained with halothane in O2 only, and each cat was administered each treatment according to a Latin square design. Cardiac output, arterial blood pressure, pulmonary arterial pressure, heart rate, respiratory frequency, and PaO2, PaCO2, and pH were measured during each treatment. Stroke volume, cardiac index, and total peripheral resistance were calculated. A probability value of less than 5% was accepted as significant. In the cats, cardiac output, cardiac index, and stroke volume were reduced by deep anesthesia and CV, although only the reduction attributable to CV was significant. Systemic arterial pressure was significantly reduced by use of deep anesthesia and CV. Respiratory frequency was significantly lower during CV than during SV. Arterial PO2 was significantly decreased at the deeper plan of anesthesia, compared with the lighter plane. At the deeper plane of anesthesia, arterial PCO2 and pulmonary arterial pressure were significantly lower during CV than during SV. The deeper plane of halothane anesthesia depressed cardiopulmonary function in these cats, resulting in hypotension and considerable hypercapnia. Compared with SV, CV significantly reduced circulatory variables and should be used with care in cats. Arterial blood pressure was judged to be more useful for assessing anesthetic depth than was heart rate or respiratory frequency.     

Evaluation of a combination of xylazine, ketamine, and halothane for anesthesia in llamas

Anesthesia induced by use of a combination of xylazine, ketamine, and halothane, under conditions of spontaneous and mechanically controlled ventilation, was evaluated in 5 llamas positioned in dorsal recumbency. Using chronically implanted catheters, systemic arterial blood pressure, pulmonary arterial pressure, right atrial pressure, heart rate and rhythm, cardiac output, blood pH and gas tensions, body temperature, and respiratory rate were measured before anesthesia induction (baseline), throughout the anesthetic period, and for 1 hour into the recovery period. During anesthesia, llamas undergoing spontaneous ventilation developed hypercapnia and respiratory acidosis. Cardiovascular function was decreased during both types of ventilation. The combination of xylazine, ketamine, and halothane in various doses and 2 ventilation procedures (spontaneous and controlled) provided a reliable method for general anesthesia in llamas, but marked cardiovascular depression developed during anesthesia maintenance with halothane. Spontaneous ventilation resulted in potentially clinically important respiratory acidosis.     

Clinical use of positive-pressure ventilation in the horse

Positive-pressure ventilation is used to provide improved ventilatory support during anesthesia in the horse. Because of the horse's size and the physiologic changes it undergoes during anesthesia, however, the use of positive-pressure ventilation does not always provide the improvement seen in smaller species. Careful attention to respiratory rate, inspiratory pressure, and I:E ratio minimizes the negative aspect of IPPV on the cardiovascular system. The goal of future ventilatory techniques will be to improve oxygenation without cardiovascular compromise and to do so at a reasonable cost to the client.     

Effects of desflurane and mode of ventilation on cardiovascular and respiratory functions and clinicopathologic variables in horses

OBJECTIVE: To quantitate the effects of desflurane and mode of ventilation on cardiovascular and respiratory functions and identify changes in selected clinicopathologic variables and serum fluoride values associated with desflurane anesthesia in horses. ANIMALS: 6 healthy adult horses. PROCEDURE: Horses were anesthetized on 2 occasions: first, to determine the minimum alveolar concentration (MAC) of desflurane in O2 and second, to characterize cardiopulmonary and clinicopathologic responses to 1X, 1.5X, and 1.75X desflurane MAC during both controlled and spontaneous ventilation. RESULTS: Mean +/- SEM MAC of desflurane in horses was 8.06 +/- 0.41 %; inhalation of desflurane did not appear to cause airway irritation. During spontaneous ventilation, mean PaCO2 was 69 mm Hg. Arterial blood pressure, stroke volume, and cardiac output decreased as the dose of desflurane increased. Conditions of intermittent positive pressure ventilation and eucapnia resulted in further cardiovascular depression. Horses recovered quickly from anesthesia with little transient or no clinicopathologic evidence of adverse effects. Serum fluoride concentration before and after administration of desflurane was below the limit of detection of 0.05 ppm (2.63microM/L). CONCLUSIONS AND CLINICAL RELEVANCE: Results indicate that desflurane, like other inhalation anesthetics, causes profound hypoventilation in horses. The magnitude of cardiovascular depression is related to dose and mode of ventilation; cardiovascular depression is less severe at doses of 1X to 1.5X MAC, compared with known effects of other inhalation anesthetics under similar conditions. Desflurane is not metabolized to an important degree and does not appear to prominently influence renal function or hepatic cellular integrity or function.     

Anesthetic equipment fault leading to hypercapnia in a cat

Spontaneous ventilation during positive pressure ventilation was observed in a 4-year-old DSH cat maintained under general anesthesia with isoflurane delivered with a nonrebreathing system. This was accompanied by an increase in heart rate and blood pressure. On investigation, neither an inadequate plane of anesthesia, nor hypoxemia, nor hyperthermia was present. The nonrebreathing system was replaced and the hypercapnia resolved. A defect in the inner fresh gas delivery tube of the Bain system was identified. A simple and quick test is described which can be performed to verify the integrity of the inner tube of the Bain breathing circuit.     

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.     

Strategies for mechanical ventilation

With the advancement of veterinary critical care medicine, an increasing number of veterinary patients are being supported with positive-pressure ventilation. Animals with potentially reversible ventilatory failure (PaCO2 > 60 mmHg) caused by neuromuscular disease or pulmonary parenchymal disease or with pulmonary parenchymal disease causing hypoxemia (PaO2 < 60) despite supplemental oxygen are candidates for ventilatory support. The equation of motion for the respiratory system is defined and is used to describe the potential interactions between the patient and the ventilator. Commonly used modes of ventilation are described in terms of control and phase variables. The intent of this report is to aid clinicians in choosing an optimal ventilatory strategy for each patient that will best achieve the desired physiologic goals with minimal detrimental side effects.     

Hemodynamic effects of carbon dioxide during intermittent positive-pressure ventilation in horses

The hemodynamic effects of high arterial carbon dioxide pressure (PaCO2) during anesthesia in horses were studied. Eight horses were anesthetized with xylazine, guaifenesin, and thiamylal, and were maintained with halothane in oxygen (end-tidal halothane concentration = 1.15%). Baseline data were collected while the horses were breathing spontaneously; then the horses were subjected to intermittent positive-pressure ventilation, and data were collected during normocapnia (PaCO2, 35 to 45 mm of Hg), moderate hypercapnia (PaCO2, 60 to 70 mm of Hg), and severe hypercapnia (PaCO2, 75 to 85 mm of Hg). Hypercapnia was induced by adding carbon dioxide to the inspired gas mixture. Moderate and severe hypercapnia were associated with significant (P less than 0.05) increases in aortic blood pressure, left ventricular systolic pressure, cardiac output, stroke volume, maximal rate of increase and decrease in left ventricular pressure (positive and negative dP/dtmax, respectively), and median arterial blood flow, and decreased time constant for ventricular relaxation. These hemodynamic changes were accompanied by increased plasma epinephrine and norepinephrine concentrations. Administration of the beta-blocking drug, propranolol hydrochloride, markedly depressed the response to hypercapnia. This study confirmed that in horses, hypercapnia is associated with augmentation of cardiovascular function.     

Tracheal gas isufflation-aided mechanical ventilation during carbon dioxide-induced pneumoperitoneum in rabbits

Despite numerous benefits of laparoscopic procedures, the serious hypercapnia and respiratory acidosis in hypercapnic patients with decreased pulmonary compliance during carbon dioxide-induced pneumoperitoneum (CDP) may be developed. Tracheal gas insufflation (TGI) has been shown to be a useful adjunct to controlled mechanical hypoventilation. This study was undertaken to identify whether TGI superimposed on controlled mechanical ventilation (CMV) improve ventilatory efficiency during CDP in rabbits. Sixteen paralyzed and anesthetized rabbits were used. The animals were assigned to two groups-CMV group: CMV alone; TGI group: CMV superimposed by TGI with flow rate of 2L/min. The animals were insufflated to intra-abdominal pressure of 8 mmHg with CO2 gas. Then, tidal volume (V(T)) was changed to maintain the set peak inspiratory pressure (PIP) value, while other ventilatory settings were kept constant. The set PIP value corresponding to 30, 60, and 90 min after the start of peritoneal insufflation of CO2 were 15, 22, and 25 cm H2O, respectively. During CDP with TGI, PaCO2 decreased significantly (p<0.01) from CMV without TGI of 82.1 +/- 14.1 to 47.5 +/- 5.5, 58.1 +/- 9.9 to 40.0 +/- 4.6, 47.1 +/- 9.4 to 32.7 +/- 5.1 mmHg at PIP of 15, 22, and 25 cm H2O, respectively. The inspired V(T) decreased significantly (p<0.05) from CMV without TGI of 18.4 +/- 3.9 to 12.8 +/- 2.8 ml at PIP of 15 cm H2O. TGI superimposed on CMV is more effective than CMV alone in enhancing ventilatory efficiency during CDP in rabbits.