Tracheal collapse or not?

RE: Tracheal collapse or not?

David Mills — Thu, 28 Jan 2016 00:29:14 GMT

Update on the case.

Started preds and tmps for 10 days. Mild cough only now, generally very much improved. So likely is teach collapse/bronchitis.

RE: Tracheal collapse or not?

mariette asselbergs — Wed, 27 Jan 2016 21:35:51 GMT

Just to say that I have just read through this whole discussion and it is a wonderful supplement to the JSAP article! Picked up some nice tricks (the oral torbugesic).

Thanks everybody who contributed! This is the Vetsurgeon forum at its best. (for me that is)

Mariette

RE: Tracheal collapse or not?

Anthony Todd — Wed, 27 Jan 2016 00:32:03 GMT

[quote user="Virginia Campbell"]Didn't they get fat then? I find this the main bummer with long term pred use in micro dogs[/quote]

Not that I noticed, but they were always on either a single shot or perhaps tablets for a couple of days which stopped the cough, repeated if necessary; never continuously, and certainly never long term.

As an aside there's this http://emedicine.medscape.com/article/426003-overview which talks about congenital tracheomalacia etc in children, and cartilage degeneration.

RE: Tracheal collapse or not?

Virginia Campbell — Wed, 27 Jan 2016 00:00:21 GMT

[quote user="Anthony Todd"]the theoretical and nonsensical side effects which, with sensible use, we never saw[/quote]

Didn't they get fat then? I find this the main bummer with long term pred use in micro dogs, even though we use it at as low a dose and frequency as possible, with management control (harness not collar etc) and beg and plead with the owners to reduce the rations and not let them get fat. Or fatter than they already are.

RE: Tracheal collapse or not?

Rob Loxley — Tue, 26 Jan 2016 21:14:23 GMT

[quote user="Anthony Todd"]As someone who has never seen, let alone diagnosed one of these[/quote]

you certainly seem to have a lot to say about them?!

RE: Tracheal collapse or not?

Anthony Todd — Wed, 20 Jan 2016 17:29:24 GMT

[quote user="Thomas Johnson"]If it was just listed for the tablet formulation they wouldn't be able to transfer it to the injectable form without testing the injectable form to see if it worked as well.[/quote]

Yes you're right, just the tablet form for cough; injectable is for analgesia and premed, and pages of it...

I suppose if you used the injectable orally, oh, I can't be doing with it.....

RE: Tracheal collapse or not?

Thomas Johnson — Wed, 20 Jan 2016 10:30:25 GMT

[quote user="Anthony Todd"]

[quote user="Thomas Johnson"]They would have to have trials showing that their product (Torbugesic injection) was effective as a cough suppressant, they wouldn't be allowed to use data from trials of the active ingredient in another formulation[/quote]

Yes, I realise that but, in that case why is it in the printed NOAH in 2009, including tablet form, [unless they didn't have to do the trials then or the regs have changed]?

Wouldn't the "indications" just carry on from NOAH 2009?

[/quote]

Was the it listed as a cough suppressant in both the tablet (Torbutrol) and injectable (Torbugesic) formulations. If it was just listed for the tablet formulation they wouldn't be able to transfer it to the injectable form without testing the injectable form to see if it worked as well.

RE: Tracheal collapse or not?

Anthony Todd — Wed, 20 Jan 2016 10:21:33 GMT

Yes, I realise that but, in that case why is it in the printed NOAH in 2009, including tablet form, [unless they didn't have to do the trials then or the regs have changed]?

Wouldn't the "indications" just carry on from NOAH 2009?

RE: Tracheal collapse or not?

Thomas Johnson — Wed, 20 Jan 2016 09:13:59 GMT

[quote user="Anthony Todd"]

[quote user="Anthony Dennison"]

From the BSAVA Formulary:

"Potent antitussive agent...."

[/quote]

Sorry Anthony it's mentioned for Torbutrol [NOAH 2009] and in tablet form and "For the relief of acute or chronic non-productive cough associated with.... etc."

But not now, in the on-line compendium???!!!

"Curiouser and curiouser" said Alice.

Hate to get into a damages claim when an over-sedated yorkie, with a cough, fell down the stairs, even if you had informed the client and got the form signed.

I wonder why they don't mention it now [not being sarcastic, just interested]

[/quote]

They would have to have trials showing that their product (Torbugesic injection) was effective as a cough suppressant, they wouldn't be allowed to use data from trials of the active ingredient in another formulation in their license application. It seems unlikely that they would try and license an injectable product for long-term use for this sort of condition.

RE: Tracheal collapse or not?

Anthony Todd — Wed, 20 Jan 2016 01:12:47 GMT

[quote user="Catriona MacIntyre"]FLIP SAKE! SIDE EFFECTS???? FREAKIN WIRED TO THE MOON! [/quote]

Yes, I've got a friend who was on pred for Crohns and had noticeable effects when he went from just 5mg to 2.5mg per day, really had to be tapered off slowly, and he had mood swings too.

Only side effect we noticed was polydipsis/polyuria in westies on even low doses and sometimes incontinence in old spayed bitches. Didn't seem to be dose related either.

I've always said do your diagnostics but concurrently give steroidal symptomatic relief and only give the steroids as necessary, not continuously, which most just don't do......

I never found codeine, even in the high "forte" form ever stopped a cough but a shot of steroids always did, never tried Torbutrol.

RE: Tracheal collapse or not?

Catriona MacIntyre — Tue, 19 Jan 2016 21:15:05 GMT

[quote user="Kate Richardson"]I agree corticosteroids seem to have been given a bad name, but personally I think they're one of the most useful drugs we have on the shelf, used sensibly as you say. Sometimes I feel some vets have more fear of corticosteroids than the owner does. Blame the universities?[/quote]

I think there is more than a little truth in that Kate. I certainly came out of university convinced that I would rarely use them at all (sheesh - soon changed that!) I do remember really struggling with a letter of complaint from an ex client.

I had spent time and funds working up a dermatology case (not allergy testing, but scrapes, etc) as I had been trained to do, but the owners got impatient and went to a neighbouring practice... who prescribed prednisolone at a cost of about £2.50 and it underwent a dramatic improvement - so why hadn't I done that in the first place! Refund was demanded.

Now at almost 15 years qualified, I am much more relaxed, but have been a bit jolted by my own experience of having been prescribed a 5 day course of 40mg pred per day.

FLIP SAKE! SIDE EFFECTS???? FREAKIN WIRED TO THE MOON! 14hours sleep in 5 nights combined with full time work and a chest infection has seriously made me worry about side effects. I don't think cats and dogs are as severely affected... but it made me think! :)

ETA - I did used to use Torbutrol for cough suppression, but now usually use codeine. Can't get hold of co-phenotrope at all at the minute.

RE: Tracheal collapse or not?

John Flynn — Tue, 19 Jan 2016 20:33:24 GMT

[quote user="Kate Richardson"]I haven't used the injection orally, but may try it now (thankyou John Flynn but John mentions very small doses, so sedation I presume is much less of an issue, if at all? What doses do you use John Flynn[/quote]

I'm a regular vet, so my case-load ain't that high, but for what it's worth:

Ultimately, titrate to effect. Dose required for anti-tussive effects much lower than that required for sedation (though some owners have reported sedation suggesting either that they are dosing in manner that leads to transmucosal absorption such as squirting in mouth or that the supposed high first-pass metabolism by liver when given by GI route is actually rather variable; if dosing last thing at night to stop the dog honking cough all night while sleeping on owner's bed, then I think a little sedative effect is often a bonus should it occur!)

I think I initially started at 0.5mg/kg dosed GI tract, but I think all dogs have had effect on fraction of this with owners reducing to lowest effective dose. You can start lower and climb instead if you prefer. GI preferred to transmucosal/injection by me as slower absorption with lower peak levels etc gives longer anti-tussive effect I reckon.

RE: Tracheal collapse or not?

Kate Richardson — Tue, 19 Jan 2016 20:20:01 GMT

[quote user="Anthony Todd"]Nope , if animals got better I never followed them up, difficult to get them back when they're fine, but perhaps things have changed 'cos steroids never cure anything, there's got to be another invasive test to do....[/quote]

Playing devils' advocate here somewhat- is it possible you never saw them back in some cases because the course of steroids resolved the cough but then it recurred, which the owners interpreted as 'the vet didn't cure my dog' and they went to see someone else? Honestly am not being derogatory- it happens to all of us (no matter how long you spend explain you can't cure their dog, but you can manage it.....)?

[quote user="Anthony Todd"]Steroids were regarded as sensible therapy for these sort of cases, animals just got better which, way back then, most owners regarded to be the object of the attendance, and nobody seemed to query the theoretical and nonsensical side effects which, with sensible use, we never saw. Vets felt the same; if the animal got better, no side effects [except Westies that really really got polydipsia, if you gave them too much....] then job done.[/quote]

I agree corticosteroids seem to have been given a bad name, but personally I think they're one of the most useful drugs we have on the shelf, used sensibly as you say. Sometimes I feel some vets have more fear of corticosteroids than the owner does. Blame the universities? There are a lot of very good alternatives for long term use (off tangent here a bit apologies) or combination of alternative therapies (thinking skin here mainly) but these are often time consuming not to mention expensive. And the only thing holding some owner's back from giving their dog some relief sometimes is the vet, so I understand where you are coming from. So I believe in using corticosteroids where appropriate but also in discussing alternatives where indicated and coming to a decision with the owner about what is the best option for theit pet, them as carers and their wallet.

[quote user="Anthony Todd"]Sometimes, and usually, relieving the symptoms [and eliminating the cause if possible,] is all you have to do. Exact diagnosis is only necessary, and only sometimes, as an aid to relieving the symptoms and not the end in itself![/quote]

Absolutely. Relieving the symptoms is the most important thing, but sometimes a diagnosis is necessary to do this in the most effective way. So we do agree on somethings! I think you will find most vets agree with this. No point doing further tests if it ain't going to change what you are going to do.

RE: Tracheal collapse or not?

Anthony Todd — Tue, 19 Jan 2016 19:27:52 GMT

[quote user="Kate Richardson"]

Did you really never see chronic coughing dogs or weren't Yorkies invented back in the day?

[/quote]

Yes, I had a big breeder of small yorkies who kept them in cupboards in her kitchen....

And I don't recall chronic coughing dogs unless we had actually diagnosed the reason and. AFAIK it wasn't tracheal defects, hence my query re inheritance.

We went from psychotic cockers [won Crufts] to lethal Alsatians [won Crufts] to Staffies/american pitbulls [American TV] etc. etc.

Sorry, missed out lovable, mad, dalmatians [the Crufts winner used to leap onto the consult table!! From the consult door......]

[quote user="Kate Richardson"]Or did you put them all on corticosteroids and they improved, so no further follow up?[/quote]

Nope , if animals got better I never followed them up, difficult to get them back when they're fine, but perhaps things have changed 'cos steroids never cure anything, there's got to be another invasive test to do....

Steroids were regarded as sensible therapy for these sort of cases, animals just got better which, way back then, most owners regarded to be the object of the attendance, and nobody seemed to query the theoretical and nonsensical side effects which, with sensible use, we never saw. Vets felt the same; if the animal got better, no side effects [except Westies that really really got polydipsia, if you gave them too much....] then job done.

[quote user="Kate Richardson"]Pinching the trachea will elicit a reaction/cough if the trachea is inflamed, but will not differentiate cause.[/quote]

No, I meant by squeezing the trachea you got some impression of a non-continuous circle, ie the circumference has a break in it, as opposed to squeezing, say, anaesthetic circle tubing, with it's integrity.

Sometimes, and usually, relieving the symptoms [and eliminating the cause if possible,] is all you have to do. Exact diagnosis is only necessary, and only sometimes, as an aid to relieving the symptoms and not the end in itself!

RE: Tracheal collapse or not?

Anthony Dennison — Tue, 19 Jan 2016 16:00:39 GMT

Well, in the latest JSAP there's an article on canine tracheal collapse. That's good timing. Anthony, if you want a copy, PM me and I'll see if I can email you a pdf of the article

RE: Tracheal collapse or not?

Kate Richardson — Tue, 19 Jan 2016 15:28:48 GMT

[quote user="Anthony Todd"]

[quote user="Anthony Dennison"]

From the BSAVA Formulary:

"Potent antitussive agent...."

[/quote]

Sorry Anthony it's mentioned for Torbutrol [NOAH 2009] and in tablet form and "For the relief of acute or chronic non-productive cough associated with.... etc."

But not now, in the on-line compendium???!!!

"Curiouser and curiouser" said Alice.

Hate to get into a damages claim when an over-sedated yorkie, with a cough, fell down the stairs, even if you had informed the client and got the form signed.

I wonder why they don't mention it now [not being sarcastic, just interested]

[/quote]

It is probably not mentioned now in Noah as Torbutrol is the trade name for the active ingredient butorphanol and tablets are no longer available, only the injectable butorphanol (Torbugesic, there may be other trade names/manufacturers?)

I haven't used the injection orally, but may try it now (thankyou John Flynn but John mentions very small doses, so sedation I presume is much less of an issue, if at all? What doses do you use John Flynn It's also a pretty poor sedative on it's own, usually used in combination with ACP or medetomidine for sedation.

Thanks Andrew for your comments, and appreciation of the difference between GP practice and referral practice

[quote user="Anthony Todd"]As someone who has never seen, let alone diagnosed one of these, but has not [AKAIK] had chronic coughing dogs I wonder if you can diagnose it by palpation and/or pressure on the trachea. Does the trachea sort of fold within itself or can it only be diagnosed by a cough and an Xray, 'scope, etc?[/quote]

You couldn't diagnose it on palpation as it is a dynamic condition as I understand it; changes in intra thoracic pressure in inspiration and expiration cause the collapse. Pinching the trachea will elicit a reaction/cough if the trachea is inflamed, but will not differentiate cause.

Did you really never see chronic coughing dogs or weren't Yorkies invented back in the day?

Or did you put them all on corticosteroids and they improved, so no further follow up?

But I agree, I haven't seen many in 20 years. But we don't have a lot of Yorkies on our books

RE: Tracheal collapse or not?

Anthony Todd — Tue, 19 Jan 2016 14:09:42 GMT

[quote user="Andrew Kent"]So it would be great to hear the experiences of these cases from a front line point of view as that is likely much more reflective of most cases![/quote]

As someone who has never seen, let alone diagnosed one of these, but has not [AKAIK] had chronic coughing dogs I wonder if you can diagnose it by palpation and/or pressure on the trachea. Does the trachea sort of fold within itself or can it only be diagnosed by a cough and an Xray, 'scope, etc?

I don't recall anyone in the practice diagnosing one hence my "inherited" query.

RE: Tracheal collapse or not?

John Flynn — Tue, 19 Jan 2016 14:06:04 GMT

[quote user="Andrew Kent"]

[quote user="Anthony Todd"]In this age of meticulous and pedantic following of regulation is the product legally allowed to be used as a cough suppressant? [/quote]

I don't think there are any licensed cough-suppressants so anything we use would be off-licence and require appropriate consent.

[/quote]

In Ireland we are very old-fashioned and just use medicines if we think they work!

Google tells me that there is a licensed veterinary medicine in UK for the indication of: "symptomatic relief ... coughs and minor infections in dogs and cats" if that is somehow relevant to UK-based practitioners.

RE: Tracheal collapse or not?

Anthony Todd — Tue, 19 Jan 2016 11:46:12 GMT

[quote user="Anthony Dennison"]

From the BSAVA Formulary:

"Potent antitussive agent...."

[/quote]

Sorry Anthony it's mentioned for Torbutrol [NOAH 2009] and in tablet form and "For the relief of acute or chronic non-productive cough associated with.... etc."

But not now, in the on-line compendium???!!!

"Curiouser and curiouser" said Alice.

Hate to get into a damages claim when an over-sedated yorkie, with a cough, fell down the stairs, even if you had informed the client and got the form signed.

I wonder why they don't mention it now [not being sarcastic, just interested]

RE: Tracheal collapse or not?

Anthony Dennison — Tue, 19 Jan 2016 11:10:53 GMT

[quote user="Anthony Todd"]

I don't think there are any licensed cough-suppressants so anything we use would be off-licence and require appropriate consent.

In this age of pernickity regulation conformity...........

[/quote]

Get the clients to sign an off licence form, explain that although it isn't licensed for this use, it is licensed for use in dogs and cats, lots of people use it this way and there are large amounts of anecdotal evidence to show it is effective.

If I offered someone a medication that would stop their dog making annoying sounds, I'm sure they'd be happy as to whatever it was

RE: Tracheal collapse or not?

Anthony Todd — Tue, 19 Jan 2016 10:18:16 GMT

[quote user="Anthony Dennison"]From the BSAVA Formulary:[/quote] etc.

but from Andy:

I don't think there are any licensed cough-suppressants so anything we use would be off-licence and require appropriate consent.

In this age of pernickity regulation conformity...........

Back in the day if you mentioned something was "not licensed" the owner would think it was poisonous, addictive and dangerous, despite anything said..... and blame it for any incident for the next 10 years.

[someone once told a cat owner it had been given a lepto booster by mistake and the trouble.....]

RE: Tracheal collapse or not?

Anthony Todd — Tue, 19 Jan 2016 10:04:43 GMT

[quote user="Anthony Dennison"]

From the BSAVA Formulary:

'Potent antitussive agent indicated for the relief of acute or chronic non-productive cough associated with tracheobronchitis, tracheitis, tonsillitis or laryngitis resulting from inflammatory conditions of the upper respiratory tract.'

[/quote]

Fair enough, but why don't the manufacturers mention it??

RE: Tracheal collapse or not?

Andrew Kent — Tue, 19 Jan 2016 09:42:32 GMT

What a great discussion - I think this is one of those areas in which there are multiple 'right' ways to proceed and everybody probably does it slightly differently.

[quote user="Anthony Todd"]Do any dogs have this tracheal defect and never cough, ever?[/quote]

Yes absolutely - in mild cases it can be incidental, but it is often progressive so coughing may come later.

[quote user="Anthony Todd"]In this age of meticulous and pedantic following of regulation is the product legally allowed to be used as a cough suppressant? [/quote]

I don't think there are any licensed cough-suppressants so anything we use would be off-licence and require appropriate consent.

[quote user="Anthony Todd"]

Am I right in thinking the dog would need a GA to get the mandatory sample and culture before deciding. or not [if nothing significant grew] to give A/Bs?

I think many owners of an ageing JRT or yorkie might demur at a GA to decide which A/B to use should a pathogen be found.

[/quote]

Ok so it would be very rare that I would scope these dogs just to get a sample for culture. I routinely use bronchoscopy for diagnosis, grading of the collapse and at the same time get my sample for culture and cytology. I agree that a GA just for culture may be overkill (there are some times when we do that but, at least initially, this is part of the investigation).

[quote user="Anthony Todd"]When these cases have been sampled someone should be able to give an opinion of the %age that grew a pathogen[/quote]

So the percentage that grow something is reasonably high, but the significance of that (if its a tracheal sample) is questionable. My caseload is very different as many of the cases that I see referred will have already had antibiotics and therefore may have a higher rate of resistance etc - so my experiences are probably not reflective of the results obtained when this is done as a primary procedure.

[quote user="Kate Richardson"]

Are anti-inflammatory doses appropriate for this condition?

Are inhaled corticosteroids of any benefit?

What would others do?

[/quote]

So, for what its worth, my approach is as follows:

-for cases in which I am satisfied that there is tracheal collapse but no evidence of lower airway disease I do not routinely use antibiotics - I use cough suppression and then add steroids if needed. But I do like to see cytologically that there is no evidence of significant infection.

In terms of steroid choice - inhaled is my preference because dogs get fat on steroids and fat dogs have worse airway disease. But there are significant cost implications to inhaled steroids and, in some dogs, they are not as effective as oral so I do regularly use oral pred (either initially or long-term) in these cases.

In terms of doses yes I would go anti-inflammatory as well. The only time I use higher doses is in dogs with stents who get tissue reaction around the stent - they commonly need higher doses.

Avoidance of airborne irritants, weight loss and a harness are all crucial to success as well.

Lower airway disease is an entirely different kettle of fish - those dogs usually do get antibiotics as they have failure of mucous clearance and so infection is common either as a primary or secondary event. Again I will usually have sampled those dogs because I want a cytological diagnosis so I have a culture, but I often use doxycycline for the spectrum that I want plus the possible immunomodulating activity.

But my caseload is definitely not typical of first opinion cases and I fully accept that the cases that I see are usually the ones that haven't got better with symptomatic treatment so there is an expectation for me to do more than send them away with antibiotics and steroids - people go for referral because they want a diagnosis.

So it would be great to hear the experiences of these cases from a front line point of view as that is likely much more reflective of most cases!

Andy

RE: Tracheal collapse or not?

Anthony Dennison — Tue, 19 Jan 2016 09:12:27 GMT

[quote user="Anthony Todd"]

Butorphanol seems to be an analgesic and I think no manufacturer mentions its anti-tussive qualities; according to NOAH it's only a sedative, and by injection.

In this age of meticulous and pedantic following of regulation is the product legally allowed to be used as a cough suppressant?

[/quote]

From the BSAVA Formulary:

RE: Tracheal collapse or not?

Anthony Todd — Mon, 18 Jan 2016 23:39:18 GMT

[quote user="Kate Richardson"]The hard question to answer is what do you do[/quote]

I agree, [and not trying to be facetious]

A few further thoughts to be demolished.

Am I right in thinking the dog would need a GA to get the mandatory sample and culture before deciding. or not [if nothing significant grew] to give A/Bs?

I think many owners of an ageing JRT or yorkie might demur at a GA to decide which A/B to use should a pathogen be found.

When these cases have been sampled someone should be able to give an opinion of the %age that grew a pathogen. [I'll bet that amoxycillin comes up as a suitable A/B

Butorphanol seems to be an analgesic and I think no manufacturer mentions its anti-tussive qualities; according to NOAH it's only a sedative, and by injection.

In this age of meticulous and pedantic following of regulation is the product legally allowed to be used as a cough suppressant?

Do any dogs have this tracheal defect and never cough, ever?