Approach to the patient in respiratory distress

Respiratory distress is a very common presenting complaint in emergency practice. It is essential that the clinician rapidly determine the underlying cause of the clinical signs using physical examination findings and nonstressful diagnostic tests. Oxygen therapy will often stabilize a patient, allowing for a more complete physical examination and diagnostics, including thoracocentesis, thoracic radiographs, and blood collection for laboratory analysis. The disease processes that cause respiratory distress can be grouped according to anatomic location: the airways, pulmonary parenchyma, pleural space, or thoracic wall. The choice of diagnostic and therapeutic techniques will be dependent on the suspected anatomic origin of disease. Techniques useful in diagnosing airway disorders include oral examination, cervical and thoracic radiographs, fluoroscopy, and bronchoscopy. Therapeutic techniques include intubation and tracheostomy. For parenchymal disease, thoracic radiographs, echocardiography, ultrasound of the thorax, and transtracheal or endotracheal wash can be useful. When the disease process is in the pleural space, thoracocentesis can be both diagnostic and therapeutic. Chest tube placement may be necessary for continuous removal of air or fluid from the pleural space. Monitoring of the respiratory patient can involve serial physical examination, pulse oximetry, and arterial blood gas analysis. It is essential to minimize stress on patients with respiratory distress because decompensation can occur easily, leading to respiratory arrest.     

RADIOGRAPHIC ASPECTS OF INFLAMMATORY LUNG DISEASE IN THE HORSE

The radiographic appearances of inflammatory lung disease in the horse are presented under three major morphologic categories: (a) parenchymal diseases, (b) airway diseases, (c) pleural diseases. Under the category of inflammatory parenchymal disorders, pneumonias of bacterial, viral, mycotic, parasitic, and immunologic origins are discussed. Airway disorders described included bronchitis, bronchiolitis, bronchiectasis, and emphysema. Pleural effusion as well as less common manifestations of pleural disease, are also discussed.     

Evaluation of respiratory parameters at presentation as clinical indicators of the respiratory localization in dogs and cats with respiratory distress

Objective ? To describe clinical respiratory parameters in cats and dogs with respiratory distress and identify associations between respiratory signs at presentation and localization of the disease with particular evaluation between the synchrony of abdominal and chest wall movements as a clinical indicators for pleural space disease. Design ? Prospective observational clinical study. Setting ? Emergency service in a university veterinary teaching hospital. Animals ? Cats and dogs with respiratory distress presented to the emergency service between April 2008 and July 2009. Interventions ? None. Measurements and Main Results ? The following parameters were systematically determined at time of admission: respiratory rate, heart rate, temperature, type of breathing, movement of the thoracic and abdominal wall during inspiration, presence of stridor, presence and type of dyspnea, and results of thoracic auscultation. Abdominal and chest wall movement was categorized as synchronous, asynchronous, or inverse. Diagnostic test results, diagnosis, and outcome were subsequently recorded. Based on the final diagnoses, animals were assigned to 1 or more of the following groups regarding the anatomical localization of the respiratory distress: upper airways, lower airways, lung parenchyma, pleural space, thoracic wall, nonrespiratory causes, and normal animals. One hundred and seventy‐six animals (103 cats and 73 dogs) were evaluated. Inspiratory dyspnea was associated with upper airway disease in dogs and expiratory dyspnea with lower airway disease in cats. Respiratory noises were significantly associated and highly sensitive and specific for upper airway disease. An asynchronous or inverse breathing pattern and decreased lung auscultation results were significantly associated with pleural space disease in both dogs and cats (P<0.001). The combination is highly sensitive (99%) but not very specific (45%). Fast and shallow breathing was not associated with pleural space disease. Increased or moist pulmonary auscultation findings were associated with parenchymal lung disease. Conclusions ? Cats and dogs with pleural space disease can be identified by an asynchronous or inverse breathing pattern in combination with decreased lung sounds on auscultation.     

CT features of pleural masses and nodules

Pleural space masses and nodules are rarely described on computed tomography (CT) in veterinary medicine and have only been described in patients with neoplasia. Our purpose was to describe the CT findings and diagnoses in seven patients with pleural masses and nodules. Two patients had broad-based, plaque-like pleural masses, both of which were due to neoplasia (primary pleural carcinoma, metastatic thymoma). Two patients had well-defined pleural nodules and nodular pleural thickening, one of which had mesothelial hypertrophy, and another of which had metastatic hemangiosarcoma. Three patients had ill-defined pleural nodules to nodular pleural thickening, one of which had metastatic pulmonary carcinoma, while the other two had bacterial infection with mesothelial proliferation (n = 2), fibrinous pleuritis (n = 1), and severe mediastinal pleuritis/mediastinitis (n = 2). Five of the seven patients had focal, multifocal or diffuse smooth, and/or irregular pleural thickening. Five of seven patients had pleural effusion, and postcontrast CT was useful in several patients for delineating the pleural lesions from the effusion. All patients except one had additional lesions identified on CT besides those in the pleural space. CT is useful in identifying and characterizing pleural space lesions and could be used to guide further diagnostic procedures such as thoracoscopy or exploratory thoracotomy. Both neoplastic and nonneoplastic diseases should be considered in the differential diagnoses for pleural space masses and nodules found on CT.     

Diagnosing disorders of the equine oesophagus

Most disorders of the equine cervical oesophagus present with a similar range of clinical signs, resulting from acute, chronic or recurrent impediment to the transit of ingesta and saliva. These include profuse frothy nasal discharge and dysphagia with gagging and coughing. Rupture of the cervical oesophagus is characterised by a painful ventral swelling at the affected site with crepitus, cellulitis and potential drainage of necrotic material. Disorders of the thoracic and abdominal segments of the oesophagus are less well recognised and clinical signs are more insidious in onset. Catastrophic damage to the thoracic oesophagus may occur without previous signs of obstruction. Pyrexia, tachycardia, tachypnoea and vague colic signs may be the first manifestations of perforation of the thoracic oesophagus, resulting from a progressive septic pleural effusion. Rupture of the thoracic oesophagus should be a differential in any horse presenting with an unexplained pleural effusion and ruled out by careful endoscopic examination.     

Feline pyothorax: a retrospective study of 27 cases in Australia

Pyothorax was diagnosed in 27 cats between 1983 and 2002. In 21 (78%) of the cases, pleural fluid culture and/or cytology was consistent with a mixed anaerobic bacterial infection of oropharyngeal origin. In six cases (22%), infection was caused by unusual pathogens or pathogens of non-oropharyngeal origin, including a Mycoplasma species, Cryptococcus gattii, Escherichia coli, Salmonella typhimurium and Staphylococcus aureus. The overall mortality rate was 22%. Treatment was successful in 18 of 19 cases (95%) where closed thoracostomy tubes were inserted. One case resolved only after thoracotomy. Actinomyces species were isolated in three cases and in contrast to dogs where thoracotomy is recommended, they were resolved with tube thoracostomy. Mechanical complications occurred in 58% of the cats with indwelling chest tubes. Probable mechanisms of pleural space infection were identified in 18 cats (67%) including haematogenous infection (n=1), direct inoculation of bacteria into the pleural space (n=1), intrathoracic oesophageal rupture (n=1) and parapneumonic extension of infection (n=15; 56%). Of the latter, perioperative aspiration was suspected in two cats, parasitic migration in two and antecedent upper respiratory tract infection was implicated in seven. Parapneumonic spread of infection after colonisation and invasion of lung tissue by oropharyngeal flora appears to be the most frequent cause of feline anaerobic polymicrobial pyothorax and contests the widespread belief that direct inoculation of pleural cavity by bite wounds is more common.     

Pleural effusions and diseases of the pleura

There are four factors that govern fluid movement to or from the pleural space: hydrostatic pressure, colloid osmotic pressure, filtration coefficient, and lymphatic function. When any of these factors are altered, fluid accumulates within the pleural space. Congestive heart failure, pancreatitis, neoplasia, hypoalbuminemia, and pulmonary thromboembolism can evoke pleural effusions by altering normal fluid transport mechanisms. This approach to pleural effusion helps to explain fluid accumulation. Chylothorax, hemothorax, and empyema are also covered in the article.     

Diagnostic challenges: Equine thoracic neoplasia

The diagnosis of thoracic neoplasia in the horse can be difficult due to the nonspecific nature of the clinical signs and their overlap with other pulmonary diseases. Haematological and serum biochemical evaluation, thoracic ultrasonography, radiography, endoscopic examination, and, where appropriate, thoracocentesis and pleural fluid cytology may all be helpful in reaching a diagnosis. Granular cell tumours are the most frequently reported primary pulmonary tumours of horses. They occur as single or multiple masses adjacent to bronchi and bronchioles, and the mass typically extends into the airway, resulting in partial or complete occlusion of the lumen. Thymic tumours are classified as benign or metastatic, based on evidence of tissue invasiveness, even though they uniformly appear benign histologically. These tumours are derived from epithelial reticular cells of the thymus and are rare in horses. Other primary thoracic neoplasms originate from various pulmonary tissues and are primarily reported as single case reports: pulmonary and bronchial carcinoma and adenocarcinoma, bronchogenic squamous cell carcinoma, bronchial myxoma, pulmonary chondrosarcoma, pulmonary leiomyosarcoma and pleuropulmonary blastoma. Clinical signs of these primary pulmonary neoplasms are dependent on the tumour type and location, but commonly include chronic cough, weight loss, anorexia, fever and respiratory difficulty; ventral oedema, pleural effusion and epistaxis are also frequently observed. Mesothelioma is a rare primary pleural tumour arising from the mesothelium of the pleura, pericardium and peritoneum. The clinical presentation in horses includes weight loss, respiratory difficulty and large volume pleural effusion. The tumour appears ultrasonographically as multiple small nodules on a thick serosal surface and pleural biopsy is diagnostic. Lymphoma is the most common haematopoietic neoplasm in horses, which can present with 4 main manifestations of lesions: mediastinal, multicentric, alimentary and cutaneous. Common clinical features include chronic weight loss, lethargy, anorexia, subcutaneous oedema, lymphadenopathy, colic, bleeding tendency and diarrhoea. Coughing and laboured respiratory effort are often apparent in individuals suffering from mediastinal masses. In such instances, pleural effusion may result in severe pulmonary atelectasis and pulmonary function is significantly compromised. Haemangiosarcoma is the second most common metastatic thoracic neoplasm in horses. Disseminated haemangiosarcoma is aggressive and rapidly progressive. The clinical presentation often includes tachypnoea, pale or icteric mucous membranes, respiratory distress, epistaxis, and subcutaneous, cutaneous or intramuscular masses. Other tumour types that metastasise to the thoracic cavity include adenocarcinoma, squamous cell carcinoma, fibrosarcoma, metastatic melanoma, mastocytoma and undifferentiated sarcoma. The clinical features of these tumours are generally nonspecific and often relate more to the primary site of tumour formation.     

Palliative intracavitary carboplatin therapy in a cat with suspected pleural mesothelioma

A 12-year-old neutered male oriental shorthair cat was referred to the Animal Health Trust for investigation of pleural effusion. Ultrasonography revealed marked irregular thickening of the pleural surface of the cranial and caudal mediastinum. Cytological examination of the pleural fluid and fine needle aspirates of the thickened pleura suggested a diagnosis of mesothelioma. Following complete drainage of the thoracic cavity under ultrasound guidance, 180 mg/m2 carboplatin diluted in 60 ml sterile water was infused into the pleural space (30 ml in each hemithorax). This resulted in complete resolution of clinical signs for 34 days (having required thoracocentesis on four occasions in the preceding 4 weeks). The procedure was repeated using 200 mg/m2 carboplatin, and there was a further 20-day period where the cat was free of clinical signs. Further treatment was declined and the cat was euthanased 120 days after initial presentation. This is the first report of successful palliative chemotherapy for suspected feline mesothelioma and suggests that intracavitary carboplatin could be considered in tumours affecting the pleural cavity.     

Broncho-oesophageal fistula in two dogs

Two clinical cases of broncho-oesophageal fistula in the dog are presented. While both cases illustrate the value of oesophagoscopy as a diagnostic tool, one case depicts the complications which may be associated with positive contrast oesophagography. These two cases support previous observations that broncho-oesophageal fistulae are frequently of foreign body aetiology and usually extend from the caudal oesophagus, via the pleural space, to the caudal or middle right lung lobes.     

Evaluation of small-bore wire-guided chest drains for management of pleural space disease

O bjectives : To evaluate the efficacy and practicality of a small-bore wire-guided chest drain for management of pleural space disease in dogs and cats.
M aterials and M ethods : A 14 gauge chest drain was placed using a modified Seldinger technique in animals requiring ongoing management of pleural space disease. A questionnaire was used immediately after placement to collect data regarding the ease of placement, reliability and function of the drain.
R esults : Twenty animals were enrolled in which 29 drains were placed. The most common pleural space disease encountered was pyothorax (10 of 20). Sixteen animals required sedation for placement, and 25 of 29 chest drains were inserted at the first attempt. Most drains were placed in less than 10 minutes. The median length of time of catheter use was three days. Few complications were noted during the insertion and throughout the use of the drains. Clinicians rated drain placement as "easy" in 27 of 29 times and the drain function as "good" in 24 of 29 times.
C linical S ignificance : Small-bore wire-guided chest drains are an effective alternative to larger gauge drains. Only minor complications were seen during insertion of the chest drains, and their performance was deemed satisfactory in most cases.     

Disease association and clinical assessment of feline pericardial effusion

Records were reviewed from 83 cases to determine the main causes and clinical significance of feline pericardial effusion. The most common causes included hypertrophic cardiomyopathy with congestive heart failure, neoplasia, and systemic infection. Most cases had concurrent or secondary pleural effusion or pulmonary edema, with clinical signs of respiratory disease. However, several cases appeared to be affected solely by pericardial effusion rather than pulmonary pathology. Feline pericardial effusion remains an infrequent diagnosis, but its clinical relevance and association with severe cardiac and extracardiac disease warrant diagnostic evaluation.     

Management of pleural effusion secondary to metastatic adenocarcinoma in a dog

A 4-year-old spayed Collie-type dog was evaluated for pleural effusion secondary to metastatic adenocarcinoma with no identifiable primary tumor. For 48 weeks, chemotherapy and thoracentesis palliated clinical signs associated with pleural effusion. At week 49, 5 mCi of chronic phosphate P32 (32P) suspension was injected into the right pleural space. Pleural effusion was not detected for 14 weeks after 32P administration (week 63). In week 64, 32P suspension was readministered by injecting 7.5 mCi into the right hemithorax and 2.5 mCi into the left. Pleural effusion was again detected 3 weeks later (week 67), and the dog was treated with additional chemotherapy. Death, at week 72, was caused by disseminated intravascular coagulopathy.     

Hematopoietic Neoplasias in Horses: Myeloproliferative and Lymphoproliferative Disorders

Leukemia, i.e., the neoplasia of one or more cell lines of the bone marrow, although less common than in other species, it is also reported in horses. Leukemia can be classified according to the affected cells (myeloproliferative or lymphoproliferative disorders), evolution of clinical signs (acute or chronic) and the presence or lack of abnormal cells in peripheral blood (leukemic, subleukemic and aleukemic leukemia). The main myeloproliferative disorders in horses are malignant histiocytosis and myeloid leukemia, the latter being classified as monocytic and myelomonocytic, granulocytic, primary erythrocytosis or polycythemia vera and megakaryocytic leukemia. The most common lymphoproliferative disorders in horses are lymphoid leukemia, plasma cell or multiple myeloma and lymphoma. Lymphoma is the most common hematopoietic neoplasia in horses and usually involves lymphoid organs, without leukemia, although bone marrow may be affected after metastasis. Lymphoma could be classified according to the organs involved and four main clinical categories have been established: generalized-multicentric, alimentary-gastrointestinal, mediastinal-thymic-thoracic and cutaneous. The clinical signs, hematological and clinical pathological findings, results of bone marrow aspirates, involvement of other organs, prognosis and treatment, if applicable, are presented for each type of neoplasia. This paper aims to provide a guide for equine practitioners when approaching to clinical cases with suspicion of hematopoietic neoplasia.     

Radiographic, computed tomographic, and ultrasonographic findings with migrating intrathoracic grass awns in dogs and cats.

The purpose of this study was to describe the clinical, radiographic, and computed tomographic findings in dogs and cats with migrating intrathoracic grass awns. Thirty-five dogs and five cats with visual confirmation of a grass awn following surgery, endoscopy or necropsy, and histology were assessed. The medical records and all diagnostic imaging studies were reviewed retrospectively. Labrador Retrievers or English Pointers < 5 years of age, with a history of coughing and hyperthermia, were the most common presentations. Seventeen animals had an inflammatory leukogram of which 14 had a left shift or toxic neutrophils. Radiographs were performed in 38 animals and computed tomography (CT) in 14. Thoracic radiographs were characterized by focal pulmonary interstitial to alveolar opacities (n = 26) that occurred most commonly in the caudal (n = 19) or accessory lobes (n = 8). Additional findings included pneumothorax (n = 9), pleural effusion (n = 8), and pleural thickening (n = 7). Pulmonary opacities identified on radiographs correlated to areas of pneumonia and foreign body location. CT findings included focal interstitial to alveolar pulmonary opacities (n = 12) most commonly in the right caudal lung lobe (n = 9), pleural thickening (n = 11), mildly enlarged intrathoracic lymph nodes (n = 10), soft tissue tracking (n = 7) with enhancing margins (n = 4), pneumothorax (n = 6), pleural effusion (n = 4), and foreign body visualization (n = 4). Histologic diagnoses included pulmonary and mediastinal granulomas or abscesses, bronchopneumonia, and pleuritis. Migrating intrathoracic grass awns should be considered as a differential diagnosis in coughing, febrile animals with focal interstitial to alveolar pulmonary opacities, pleural effusion, pleural thickening, and/or pneumothorax on radiographs or CT.     

Equine developmental dental disorders

The true prevalence of developmental dental disorders in horses is unknown, but from a clinical perspective, dental dysplasia of varying degrees of severity appears to be far more common than developmental abnormalities of tooth numbers. The latter includes the presence of increased numbers of teeth (supernumerary teeth), which in turn appears more prevalent than reduced numbers of teeth (hypodontia or anodontia). This clinical commentary briefly reviews all three types of developmental dental disorders from a clinical viewpoint.     

IMAGING DIAGNOSIS—DORSAL MEDIASTINAL T‐CELL LYMPHOMA IN AN ALPACA

A 14‐year‐old male alpaca had refractory pleural effusion. The cause of the effusion was not apparent either radiographically or sonographically, or following a pleural fluid cytologic examination. Using computed tomographic (CT) examination, a dorsal paravertebral mass was identified and similar masses were found in the cranial mediastinum, retroperitoneal space, and adjacent to the hepatic entry of the portal vein. The histopathologic diagnosis was multicentric T‐cell lymphoma. CT examination may prove to be a valuable imaging modality in the localization and staging of neoplasia in new world camelids.     

PLEURAL FLUID MOVEMENT

The present study was an attempt to illustrate the differences between ventrodorsal (VD) and dorsoventral (DV) radiographs that result from the movement of free pleural fluid. A volume of 25 ml/kg of normal saline was introduced into the pleural space of a normal dog, and radiographs of the thorax were produced in ventral and dorsal recumbency using a vertical (overhead) x-ray beam and a laterally directed horizontal x-ray beam. On the DV projection (ventral recumbency) the heart, cranial mediastinum, cranial lung lobes, and the ventral aspect of the diaphragm were submersed in fluid, which resulted in the loss of radiographically detectable borders. On the VD projection (dorsal recumbency) radiographic visualization of these structures was improved due to movement of the free pleural fluid away from them, toward the dependent caudodorsal aspect of the thorax. Radiographs of three dogs with spontaneous pleural effusion are presented to illustrate the differences in radiographic appearance of the thorax with pleural effusion when radiographed in DV and VD projections. The movement of fluid to the dorsocaudal thoracic cavity in dorsal recumbency caused lesions that were obscured on the DV projection to be revealed on the VD projection. the authors therefore recommend the use of the VD projection of the thorax in patients with pleural fluid when clinical status permits.     

Calcium homeostasis in thyroid disease in dogs and cats.

Hyperthyroidism is the most common endocrine disorder of cats, and hypothyroidism is the most common endocrine disorder of dogs. Little is known regarding the effects of hyperthyroidism, hypothyroidism, or treatment of these disorders on calcium metabolism in the dog or cat, however, especially any potential effects on bone. With better diagnostic tools, better treatments, and increased longevity of pets, the clinical impact of thyroid disorders on calcium metabolism and bone may be uncovered.     

Endoscopic sealing of a chronic bronchopleural fistula using acrylate co-monomer glue

A bronchopleural fistula (BPF) consists of a direct communication between the bronchial tree and the pleural space, which can develop secondary to (pleuro) pneumonia. Thoracotomy has been reported as a viable treatment option in cases of nonresponsive pleuropneumonia, pleural abscess formation and necrotising pneumonia. The presence of a BPF can delay and even prevent healing of the thoracotomy site, with clinical signs of coughing and putrid purulent nasal discharge often seen. In this case report, we describe the diagnosis and localisation of a bronchopleural fistula using retrograde instillation of methylene blue through the thoracotomy site, followed by the successful closure of the BPF using endoscopic application of acrylate co-monomer glue (Glubran 2^®).