Pyothorax on a budget

Re: Pyothorax on a budget

Michael Woodhouse — Tue, 11 Feb 2014 23:17:29 GMT

Sounds promising.

Re: Pyothorax on a budget

Birte Toft — Tue, 11 Feb 2014 23:13:57 GMT

[quote user="Michael Woodhouse"]

How's the moggy?

[/quote]

Looking good so far! Breathing slightly less laboured, the chest sounds pretty good on percussion and auscultation. Brighter and eating well, and he is now watching telly again, which the owner reckons is a good sign. I think the owner has accepted that he didn't "just need a wormer", but I'm still not convinced she will carry on antibiotics as prescribed.

Re: Pyothorax on a budget

Michael Woodhouse — Mon, 10 Feb 2014 22:30:05 GMT

How's the moggy?

Re: Pyothorax on a budget

Anthony Todd — Fri, 07 Feb 2014 21:20:37 GMT

[quote user="Birte Toft"]To be honest, given the financial constraints in this particular case, if the cat had been blue and gasping I doubt we would have done more than a diagnostic aspirate and euthanasia. OOH treatment here is not particularly affordable.[/quote]

See my previous reply above.

Cat relieved, diagnosis probably confirmed in most cases; cat probably better in minutes [except for a chest tumour or chylothorax, FIP?] and some others I've forgotten and probably at the same or less cost than your diagnostic aspirate [assuming the sample was sent off?]

Re: Pyothorax on a budget

Anthony Todd — Fri, 07 Feb 2014 21:14:21 GMT

[quote user="Evelyn Barbour-Hill"]A quick conscious Xray (hand-held – ooh!) confirms you have fluid in the chest[/quote]

So does a chest tap!

You can then proceed to remove it all, sample it and inject some ABs, having confirmed by SG that it is not a transudate or lymph [white milk] or blood [red].

Send the clear low SG ones off for cytology too......

All in a few minutes.

You can watch the cat go from blue to pink before your very eyes, and stop open mouthed breathing and start smiling.

Done it loads of times

Re: Pyothorax on a budget

Birte Toft — Fri, 07 Feb 2014 20:14:11 GMT

[quote user="Anthony Todd"]

I really wonder whether Xrays etc give you any critical information and definitely can kill, by the stress and dyspnoea, [killed one of my referred cats.]

Don't turn them on their backs!!

A quick chest tap, in a consult, with the emphasis on minimal stress for the cat,both sides and, if you like, C&S of the fluid, gives you all the info you need, and getting rid of the fluid, whatever it may be turns a blue, gasping cat into a pink normal one.

Is this dinosaureal?

It's certainly not off topic.....

[/quote]

To be honest, given the financial constraints in this particular case, if the cat had been blue and gasping I doubt we would have done more than a diagnostic aspirate and euthanasia. OOH treatment here is not particularly affordable.

Re: Pyothorax on a budget

Evelyn Barbour-Hill — Fri, 07 Feb 2014 19:49:42 GMT

[quote user="Anthony Todd"]

I really wonder whether Xrays etc give you any critical information and definitely can kill, by the stress and dyspnoea, [killed one of my referred cats.]

Don't turn them on their backs!!

[/quote]

A quick conscious Xray (hand-held – ooh!) confirms you have fluid in the chest rather than something solid or something else. True, sometimes the cat's life is on a knife-edge and just that holding it still for a second can tip it into death.

Re: Pyothorax on a budget

Anthony Todd — Fri, 07 Feb 2014 19:24:32 GMT

[quote user="Evelyn Barbour-Hill"] In fact I was always relieved when I saw pus, as opposed to any clear fluid, on the first trial thoracocentesis.[/quote]

Then a quick SG and you knew what you were dealing with within minutes.

Dinosours used to rool!

Re: Pyothorax on a budget

Anthony Todd — Fri, 07 Feb 2014 19:18:49 GMT

[quote user="Birte Toft"] radiographs[/quote]

"I'm not disputing that the more modern more elaborate techniques can improve the prognosis."

I really wonder whether Xrays etc give you any critical information and definitely can kill, by the stress and dyspnoea, [killed one of my referred cats.]

Don't turn them on their backs!!

Is this dinosaureal?

It's certainly not off topic.....

Re: Pyothorax on a budget

Anthony Todd — Fri, 07 Feb 2014 19:06:37 GMT

"I'm not disputing that the more modern more elaborate techniques can improve the prognosis."

The real advantage of the computer age and PMSs, and particularly vetsurgeon.org for vets now [er, and the NHS.....] is that with a touch of a few buttons you can call up all the PYOTHORAX cases for the last X years and find out whether those on drug A did better than drug B; mortality rates, whether chest drains or one drain did better etc. etc.

We just drained them and injected our favourite antibiotic of the time, continued a course of the same, and saw them back.

Trouble is, if I said "almost all did fine" I would really have no idea at all, and my opinion would be based on a hazy, rose-tinted view after one client gave me a bottle of scotch and, before computers, I'd be totally sure of my opinion!

We have now got evidence based medicine not experience based medicine.

I'd be happy to collate the data if it's in ExCel [can't do Access]

Re: Pyothorax on a budget

Evelyn Barbour-Hill — Fri, 07 Feb 2014 18:42:15 GMT

[quote user="Thomas Johnson"]

The last one I saw with limited funds for treatment I injected metronidazole into the pleural space after draining the pyothorax, there's a dose in the BSAVA formulary. I also put it on oral antibiotics, can't remember which sorry, and it made a full recovery.

[/quote]

Not criticising you at all, Thomas, indeed that is what I used to do, but I am sure that it has now been demonstrated (no, I can't quote chapter and verse) that there is no benefit to be gained by putting antibacterial into the pleural space – the full dose of metronidazole injected subcutaneously is fine.

I'm not disputing that the more modern more elaborate techniques can improve the prognosis. I'd just say that in past years I have successfully treated many many cases (no, I'm not claiming 100% success) with: a single thoracocentesis and suction session (usually involving 2 to 4, possibly more, punctures, and easily lasting an hour or two); three to five days metronidazole by s.c. injection; and five days antibiotic (usually clavulanate/amoxycillin) by intramuscular injection. Sometimes the thoracocentesis might need to be repeated once or twice, and occasionally we needed an oesophagostomy tube for nourishment, but not often. In fact I was always relieved when I saw pus, as opposed to any clear fluid, on the first trial thoracocentesis.

Re: Pyothorax on a budget

David Mills — Fri, 07 Feb 2014 18:38:37 GMT

[quote user="Neil Wheadon"]

How do you treat them as a charity David?

Interestingly, I've just done a search through the PDSA records and 2 of the last 3 were euthanased shortly after diagnosis

Neil

[/quote]

At each charity I've been at (Blue Cross, RSPCA, other smaller ones), we've always used chest drains (unilateral) with a proviso that if they were still in after 7 days (and they were still working) they'd be PTS'd. I've seen about 10 over the last 3 years and they've all made it with this approach. Not sure what the PDSA procedure is. I've seen one managed with repeated centeses which didn't make it.

I think the problem is that in a pyothroax you've got ongoing pus production, often very thick accumulation, which necessitates usually TID draining (+/- lavage), whereas with e.g. pleural effusion due to CHF you can generally prevent further fluid formation meaning it's normally a one-stop shop centesis. That, and you're essentially racing against time before the pleura fibrose - this may well be underestimated in cats as they're non-athletic so suboptimal respiratory function is not always obvious.

Re: Pyothorax on a budget

David Mills — Fri, 07 Feb 2014 18:25:42 GMT

[quote user="Robin Grimmer"]

I wonder if convenia would be any good for these? Not cheap but solves the problem of compliance.

[/quote]

Seems to help in Amur tigers:

http://www.ncbi.nlm.nih.gov/pubmed/22779255

(1.3L!)

...and different cavity in lions:

http://www.ncbi.nlm.nih.gov/pubmed/23082542

Re: Pyothorax on a budget

Birte Toft — Fri, 07 Feb 2014 17:07:16 GMT

Rucksack cat and its owner did turn up today, if only to pay for yesterday's consult and inform us that we had exceeded the treatment budget. The cat was a bit brighter today, and the dyspnoea had definitely improved. Drainage has definitely helped, but I would have liked to have got more fluid off it. We did repeat thoracocentesis and radiographs free of charge, a strategy that has backfired badly in the past when clients end up at another practice OOH, so we're crossing our fingers for improvement over the weekend.

Re: Pyothorax on a budget

Tim Charlesworth — Fri, 07 Feb 2014 15:57:01 GMT

These cats can do very well as has been said but they can also go downhill very quickly, succumbing to systemic inflammatory reactions/sepsis. Most cases are thought to be due to parapneumonic spread (aot the dogs with migratory FBs). If its a low volume effusion then there's nothing wrong with simple drainage, flushing (if possible) may be helfpul but the cat will prob need 4-6 weeks of ab's. Amoxiclav on its own is normally good enough but backing it up with metronidazole is fair enough esp if can't do cultures etc. If you scan it, look out for compartmentalisation which could prevent simple drainage being effective.

Good luck, if the owner can't treat the cat for whatever reason and the cat doesn't improve soon then PTS would be reasonable (esp given risk of recurrence etc)

Tim

Re: Pyothorax on a budget

Thomas Johnson — Fri, 07 Feb 2014 09:40:24 GMT

Re: Pyothorax on a budget

Gillian Mostyn — Fri, 07 Feb 2014 08:27:47 GMT

[quote user="Birte Toft"]Vets aren't allowed to dispense meds here, bloody nuisance, I'll have to check pharmacy prices before prescribing,[/quote]

And we think we have it tough!

Re: Pyothorax on a budget

Birte Toft — Fri, 07 Feb 2014 00:14:46 GMT

Thanks, all. Maybe I'm being too gloomy. I think the cat has been ill for some time, and I'm not at all convinced that the owner grasps the severity of the situation, so compliance is likely to be an issue.

We kept a sample for c&s, but that money will probably be better spent on antibiotics. Vets aren't allowed to dispense meds here, bloody nuisance, I'll have to check pharmacy prices before prescribing, but antirobe may be a reasonable option.

I did find a case report online about pyothorax in a tiger successfully treated with convenia, clindamycin and marbofloxacin...

Re: Pyothorax on a budget

Robin Grimmer — Thu, 06 Feb 2014 23:43:35 GMT

I wonder if convenia would be any good for these? Not cheap but solves the problem of compliance.

Re: Pyothorax on a budget

Neil Wheadon — Thu, 06 Feb 2014 23:31:34 GMT

[quote user="David Mills"]The prognosis is good enough as long as the cat is symptom-free enough[/quote]

How do you treat them as a charity David?

Interestingly, I've just done a search through the PDSA records and 2 of the last 3 were euthanased shortly after diagnosis

Neil

Re: Pyothorax on a budget

Evelyn Barbour-Hill — Thu, 06 Feb 2014 23:01:27 GMT

[quote user="David Mills"]

[quote user="Evelyn Barbour-Hill"]the prognosis is good enough.[/quote]

The prognosis is good enough as long as the cat is symptom-free enough. Otherwise PTS. The consequences of chronic pyothorax are simply awful

[/quote]

Quite true.

I meant, the chances of making a full recovery are good enough.

Re: Pyothorax on a budget

David Mills — Thu, 06 Feb 2014 22:57:09 GMT

[quote user="Evelyn Barbour-Hill"]the prognosis is good enough.[/quote]

The prognosis is good enough as long as the cat is symptom-free enough. Otherwise PTS. The consequences of chronic pyothorax are simply awful

Re: Pyothorax on a budget

Neil Wheadon — Thu, 06 Feb 2014 22:47:49 GMT

A retrospective study of 27 cats in 2005, suggested that 76% were bilateral and that 78% had an anaerobic infection, so gives you an idea what you are dealing with

I spoke to the PDSA a few weeks ago about these and they said they had good success with 50mg Flagyl BID and Amox/Clav 50mg BID

I've had good success with antirobe in the past

Therefore where there's life there's hope

Good Luck

Neil

Re: Pyothorax on a budget

Stephen Courtney — Thu, 06 Feb 2014 22:39:05 GMT

the real issue is going to be making sure this cat gets the antibiotics properly and for long enough. compliance is essential. i would make sure you take care to explain everything carefully, and document that explanation and give a guarded prognosis, but i agree with Evelyn, it is not impossible that the cat could do well.

Re: Pyothorax on a budget

Evelyn Barbour-Hill — Thu, 06 Feb 2014 22:29:00 GMT

[quote user="Birte Toft"]Our plan is to drain as much as we can, cover with antibiotics and hope for the best, but I'm in two minds whether we should just recommend euthanasia as I am really unsure of how much follow-up this cat is going to get. Any thoughts on success rates?[/quote]

I take it you drained as much as you could tonight?

If you suck out as much as you possibly can in one initial session, and employ suitable antibiotics – or suitable antibacterials, to be precise – the prognosis is good enough.