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Approach to Respiratory Distress in Dogs & Cats

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Approach to Respiratory Distress in Dogs & Cats APPROACH TO RESPIRATORY DISTRESS Peer Reviewed Approach to Respiratory Distress in Dogs & Cats Claire R. Sharp, BSc, BVMS (Hons), MS, CMAVA, Diplomate ACVECC Tufts University Managing dogs and cats in respiratory distress Cooling Measures is a multifaceted effort that involves stabilizing Animals with upper airway obstruction, such patients prior to determining a defi nitive diagnosis. as those with laryngeal paralysis, may become Fortunately, respiratory distress—no matter what hyperthermic due to the increased work of the cause—requires somewhat standardized breathing. Because of the airway obstruction, these interventions during initial stabilization. animals are unable to effectively pant, resulting in inability to thermoregulate and dissipate heat. As INITIAL STABILIZATION such, cooling hyperthermic patients in respiratory One of the benefits of initial stabilization is that distress is an important component of initial it provides the practitioner time to consider stabilization, and can be accomplished by: Minimizing the appropriate diagnostic and subsequent • Administering room temperature IV fluids Stress • Covering the patient with wet towels therapeutic approach. Dogs and cats with • Putting a fan on the patient respiratory distress Oxygen Supplementation • Applying alcohol to the axilla, inguinal area, and feet. are often fragile and Initial stabilization of a patient in respiratory Active cooling should stop once the patient’s can decompensate distress generally involves provision of oxygen temperature reaches 103°F to avoid precipitating rapidly. Initial hypothermia. evaluation should be supplementation, with or without patient sedation. performed rapidly, • The most common type of oxygen Thoracocentesis with minimal stress supplementation provided is use of an oxygen Initial stabilization may also include thoracocentesis, if to the patient. cage with a high fraction of inspired oxygen (FiO ) Often, one of the 2 severe respiratory distress is secondary to pleural space (eg, 40%–60%); a face mask or flow-by oxygen best fi rst steps is disease, such as pneumothorax or pleural effusion. from a hose can also be used. to place the animal • In more extreme cases, animals in respiratory distress in an oxygen cage INITIAL DIAGNOSTIC APPROACH and allow it to relax, may require emergency intubation, higher FiO (eg, 2 Diagnostic approach to a patient in respiratory considering it has 100%), and provision of positive pressure ventilation distress should consider the patient’s signalment and usually been through in order to provide adequate respiratory stabilization. history as well as the broad anatomic differential a stressful car • Particularly in cases of upper airway obstruction, ride and changed diagnoses of dyspnea (Table 1, page 54). the practitioner may need to ensure a patent environments (home airway by intubation or tracheostomy (if oral to car to clinic) that Signalment can exacerbate intubation is not possible). Clues in the patient’s signalment are common. distress. For example: Sedation • Upper airway obstruction due to Sedation with careful monitoring and, if necessary, brachycephalic airway disease is a common intubation and ventilation can be extremely useful in cause of respiratory distress in brachycephalic animals that have become anxious due to hypoxemia dogs, such as English bulldogs. and/or hypercapnia. In some patients, especially • Cardiogenic pulmonary edema is a common cause dogs with upper airway obstruction, stabilization of respiratory distress in small breed dogs with may require sedating the animal by administering chronic valvular disease (eg, mitral endocardiosis), some form of anesthetic induction agent; then such as Cavalier King Charles spaniels. clearing the oral cavity of obstructing material (eg, • Lower airway obstruction associated with asthma is secretions or foreign material in a choking animal) a common cause of respiratory distress in cats, with prior to intubation or tracheostomy. certain breeds, such as the Siamese, overrepresented. tvpjournal.com | November/December 2015 | TODAY’S VETERINARY PRACTICE 53 Peer Reviewed APPROACH TO RESPIRATORY DISTRESS History and the potential for cardiogenic pulmonary edema History can also be extremely useful; for example: or pleural effusion. • History of blunt trauma (eg, hit by a car) should In general, breathing patterns help narrow the list prompt concern for pulmonary contusions, of differential diagnoses (Table 1). For example, pneumothorax, diaphragmatic hernia, or flail chest. upper airway obstruction is associated with inspiratory • In cats, a history of cough is consistent with dyspnea and an externally audible noise. In contrast, asthma, while in dogs, a cough might suggest lower airway obstruction tends to be associated with tracheobronchial disease, interstitial lung disease, expiratory dyspnea and wheeze, with the wheeze or pulmonary edema. generally just audible on thoracic auscultation with a stethoscope, rather than externally audible. Physical Examination Examining a patient with respiratory distress Diagnostic Tests should involve: Extensive diagnostics should not be performed until 1. Initial observation: Consider breathing pattern, the patient has been stabilized as much as possible, a presence of externally audible noise with breathing, brief physical examination has been performed, and any signs of trauma, or abdominal distension the practitioner has localized the disease to the most 2. Lung auscultation: likely anatomic location (Table 1). Diagnostic tests » Increased adventitial lung sounds (eg, crackles, may subsequently involve: wheezes, harsh lung sounds) are associated with • Blood analysis: Screening blood tests, blood gases lower airway and pulmonary parenchymal disease • Imaging: Thoracic ultrasound, including focused » Decreased lung sounds, in an animal with assessment with sonography for trauma, triage, and respiratory distress, are associated with pleural tracking (tFAST); thoracic radiographs; thoracic space disease. computed tomography (CT); or echocardiography 3. Cardiac auscultation: A murmur, gallop, or other • Respiratory fluid analysis: Bronchoalveolar arrhythmia may indicate underlying cardiac disease lavage, thoracocentesis Dogs and cats with respiratory distress can be classified into 8 disease categories, some of which are Categories of associated with distinct breathing patterns observed during physical examination.1,2 These categories Respiratory include both primary respiratory diseases and secondary causes of respiratory difficulty. Diagnostic approach is determined by the category of disease causing respiratory distress. Disease TABLE 1. Anatomic Classification: Causes of Respiratory Distress DISEASE EXAMPLES BREATHING PATTERN CATEGORY 1. Upper Airway • Brachycephalic airway disease • Inspiratory dyspnea Obstruction • Laryngeal paralysis • Externally audible noise (eg, stertor, stridor) 2. Lower Airway • Asthma • Expiratory dyspnea Obstruction • Wheeze (audible with stethoscope) 3. Pulmonary • Pneumonia • Not consistent; may be rapid, shallow, or Parenchymal Disease • Interstitial lung disease both, and have both inspiratory and expira- • Pulmonary edema tory components • Pulmonary contusions 4. Vascular • Pulmonary thromboembolism • Not specific 5. Pleural Space Disease • Pneumothorax • Inspiratory dyspnea, rapid shallow breathing, • Pleural effusion or generalized paradoxical breathing • Reduced lung sounds on auscultation 6. Flail Chest • Focal paradoxical breathing 7. Abdominal Distension • Ascites • Inspiratory dyspnea • Organomegaly 8. Look-alike Diseases • Not specific 54 TODAY’s VeTERINARY PRACTICE | November/December 2015 | tvpjournal.com APPROACH TO RESPIRATORY DISTRESS Peer Reviewed • Airway examination: Upper airway examination, Clinical Signs tracheobronchoscopy Characteristic signs in patients with an upper airway • Drug trials: Such as bronchodilators, diuretics, obstruction include inspiratory distress and an and corticosteroids. externally audible noise associated with breathing (eg, stertor, stridor). Tracheal disease is usually associated UPPER AIRWAY OBSTRUCTION with a cough. Etiology Upper respiratory tract obstruction involves a Initial Stabilization mechanical or functional obstruction of the upper Initial stabilization and therapy may involve: (large) airways (ie, the pharynx, larynx, or trachea). • Oxygen administration/securing an airway: Nasal disorders are not considered in this article as Generally administered by face mask (if tolerated), the animal should always be able to open its mouth flow-by oxygen, or oxygen cage, with intubation and breathe, preventing the development of dyspnea or tracheostomy performed if needed even if the nasal cavity is obstructed. • Sedation: Achieved with anxiolytic drugs, such Specific causes of upper airway obstruction include: as acepromazine or dexmedetomidine, or sedative • Naso-oropharyngeal disorders, including polyps analgesics, such as butorphanol (Table 2) (especially in cats), masses, and foreign bodies • Cooling: Many dogs with upper airway • Severe head trauma that results in bone fractures obstructions become hyperthermic due to inability (especially nasal, jaw, and palatine fractures) and to dissipate heat through their upper airways; associated hemorrhage and swelling the goal is to reduce body temperature to at least • Laryngeal disorders, including laryngeal 103°F, while avoiding hypothermia paralysis, laryngeal collapse, laryngeal masses (eg, • Corticosteroids: Breathing against an obstruction neoplasia,
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