Dec 09 Quiz: Dyspnoea in a puppy - Discussion + Answers

Re: Dec 09 Quiz: Dyspnoea in a puppy - Discussion

Virginia Campbell — Sat, 26 Dec 2009 19:39:57 GMT

Thanks very much for this case, esp the add-ons (radiographs, video of pup, microscopy video).

Re: Dec 09 Quiz: Dyspnoea in a puppy - Discussion

Mike Martin — Wed, 23 Dec 2009 13:16:32 GMT

WHAT I WOULD NOT DO

[quote user="Mike Martin"] Need to screen for heart disease, therefore ECG and/or echocardiography [/quote]

We had ruled out heart failure early in the discussion. No murmur. Wrong distribution for cardiogenic pulmonary oedema.

[quote user="Mike Martin"] To avoid GA perform a FNA, under gentle sedation and local, and get a sample for cytology [/quote]

I did this in my early (younger) years. Hmm, lost a few from pneumothorax, or ended up be hospitalised with chest drains and loads of explanations to owners that are hard to explain or bill for. So I've not done this for a long time, but I'd be happy to hear others experiences....?

[quote user="Mike Martin"] Another option to avoid GA, perform a trans-tracheal washing, to get a sample for cytology [/quote]

Another one I did in my early years. Whilst the technique is viable in relaxed dogs, I found it very difficult in dogs with dyspnoea. I found it very hard to restrain a dyspnoeic dog long enough to get the needle in the trachea, pass a catheter and perform a flush. Even then, it was mainly a tracheal wash rather than a proper BAL, so often unrewarding with a low yield. However maybe I've not seen it done well and it might work for others.

[quote user="Mike Martin"] Get on and treat: antibiotics at a high dose
Get on and treat: furosemide [/quote]

Wrong distribution for infection, so I was not concerned about this.

And it wasn't heart failure or non-cardiogenic oedema, so no need for frusemide.

Anyway, those were my thoughts. Others may have had different experiences and/or opinions, which would be interesting to share on this forum.

Re: Dec 09 Quiz: Dyspnoea in a puppy - Discussion

Mike Martin — Wed, 23 Dec 2009 13:02:34 GMT

UPDATE

So, this is what I did (I'm not saying this right). But I'm also a believer that "proof is in the pudding". The pup is alive and well, and having given the owner a guarded prognosis, they're now very happy.

Answer 1. [quote user="Mike Martin"] Have a look at some faeces (+saline) mixed on a glass slide under the microscope in search of wriggling larvae.

[/quote]

I do this regularly when I suspect lungworm. If its a severe case, like this one, then there is likely to be a lot of larvae per gram of faeces. I take a spot from a thermometer with a drop of saline and look under low power. Because they are alive and wrigglying, they're easy to spot. It took me a good 2-3 minutes to find the first one and then found 3 shortly after. But, diagnosis made. Here's an example. Faeces was then also sent for ID to Liverpool.

So what if I didn't see any? Well, I was pretty convinced by the characteristic lung pattern in this young dog, so lungworm was my top differential.

[quote user="Hannah Wynne Richards"] Practitioners pragmatic approach Antibiotics 50 mgs/kg fenbendazole daily for 1 week also preds as dead A vasorum more antigenic than live reasses Saves danger of GA in high risk case Be prepared to change tack if gets worse

Wynne

ps Academics probably throwing their hands up in horror as treatment without definitive diagnosis, but in the real world the aim is to cure the patient, not demonstrate what a clever -clogs you are!!!!!!!!!!!!!!!!!!!!!!!

[/quote]

I laughed and laughed. I agree.

Answer 2 [quote user="Mike Martin"] Get on and treat: worm with either Panacur, Advocate or Milbemax

[/quote]

So I have used Panacur since my days working in Cornwall, gosh 20 years now. I dose inversely proportional to severity. So in this case I used only 20mg/kg FBZ. I've not used Milbemax or Advocate on severe cases. So I've no experience. Can you titrate a small dose with these drugs? Unlike others, I do not routinely give steroids at the same time. However if this pup was to deteriorate, in response to the medication, I would stop the FBZ and inject with dex for a day or two. Then, when better, re-start the FBZ.

So this pup was given a dose and kept in for monitoring (in case I had to go to my next option). He did not deteriorate. The next day, he was slightly but significantly better. Less dyspnoea, happier. Eating. I gave him his next dose. By the following afternoon, I was convinced he was moving in the recovery direction and let him stay at home (which was local to me, otherwise, I might have waited another day or two).

So what would I have done if he did not improve? Hmm.

Option 3. [quote user="Mike Martin"] GA for bronchoscopy; see what the airway fluid is (ie. pus, blood, oedema), get a sample for cytology (results in probably 24 hours)

[/quote]

This would have been my next step and I had preped the owner for this option. Its always a bit scary giving a GA to a dyspnoeic dog, the receovery is the hard stage (going from 100% O2, back to room air). But generally speaking, I'm always amazed how my level of worry exceeds reality. GA is often not as risky as one might think, well in my experience anyway. So whilst I saw no point in taking that risk until my other options had been tried, I was happy to go this route if needed. I would then have seen what sort of fluid was in the airways. In these cases, often it is a purulent discharge. I'd have performed a BAL, and prepared spun sediment unto slides to post for cytology. But I'd also have made wet preps and looked under the microscope.

So a happy outcome (of course I would not have posted a case that did not live). The lungworm ID came back a week later as Angiostrongylus vasorum.

There's way too much advertising about lungworm at present, and my case does not help. However I felt this was a good case to highlight a logical approach, using experience to assess the clinical presentation, reading and interpreting the vet's radiographs and a pragmatic approach to case management.

Re: Dec 09 Quiz: Dyspnoea in a puppy - Discussion

Mike Martin — Fri, 18 Dec 2009 09:29:34 GMT

[quote user="Arlo Guthrie"]

OK, we are now closing this thread, and finishing with a multi-choice question for you to answer. Click here.

[/quote]

Any more votes?

Re: Dec 09 Quiz: Dyspnoea in a puppy - Discussion

Arlo Guthrie — Wed, 16 Dec 2009 14:52:28 GMT

OK, we are now closing this thread, and finishing with a multi-choice question for you to answer. Click here.

Re: Dec 09 Quiz: Dyspnoea in a puppy - Discussion

Helen Bowes — Wed, 16 Dec 2009 09:52:20 GMT

Definately an in house faecal float for eggs or larvae

If no time to wait for clotting screen to come back you could do something like a BMBT to access if bleeding disorder problem.

Re: Dec 09 Quiz: Dyspnoea in a puppy - Discussion

Mike Martin — Tue, 15 Dec 2009 17:16:10 GMT

[quote user="Catherine Canakis"]

QUICK QUESTION which would help if ever I get a dyspneic dog which needs XR's:

1) What did you use as a sedative in this dog to take the radiograph (low dose ACP & Opiod? Some avoid midazolam given it's unpredictability)

2) What dose per kg did you use?

[/quote]

The radiographs were taken by the primary vet and from their record it says: ACP 0.02mg/kg + butorphanol 0.02mg/kg iv. I saw the dog only a few hours later, and I would have said that the sedation had not been excessive. In my own hands, I would have used the same drugs in this case - here's a link to 'our current sedation regime'. but at 1/4 the dose. In other cases, it depends upon the severity of the dyspnoea. Some we would x-ray through an anesthetic chamber (box) while giving oxygen.

Re: Dec 09 Quiz: Dyspnoea in a puppy - Discussion

Clive Ansell — Mon, 14 Dec 2009 17:22:45 GMT

I think next I may consider;

Faecal analysis to look for larvae.

Clotting studies if not already done, and reexamine mm for signs of haemorrage

Transtracheal bronchioalveolar lavage, if patient cooperative enough under local anaesthesia.

Possible percutaneous trans thoracic biopsy to try a get a sample of parencymal tissue, although given that the radiographic changes are patchy getting a Representative sample may be difficult. This carries risks of course; pneumothorax and puncture of pulmonary vessels. may be possible if patient collapsed or cooperative with local anaesthesia. Not sure whether to use a FNA or biopsy needle though. FNA safer, but less likely to get Representative I guess. May be far more risky than GA?

Re: Dec 09 Quiz: Dyspnoea in a puppy - Discussion

Richard Carter — Mon, 14 Dec 2009 12:16:05 GMT

had a pup that chewed and burst a ventolin asthma pump in its mouth that produced an xray very similar to this but the dyspnoea was immediate (along with spectacular tachycardia) and i.v cortisone saved the day.... so i.v abs (pen/clav), metronidozole p/o followed by i.v dexadresson to try ease some resp distress - the purists will say we haven't a diagnosis yet but have to agree with Hannah - need to help the dog survive long enough to try make a dx even if it is later or not at all

Re: Dec 09 Quiz: Dyspnoea in a puppy - Discussion

Laurence Webb — Mon, 14 Dec 2009 11:12:56 GMT

You can do a faecal smear - if the dog is shedding lungworm larvae then they produce several thousand per gram of faeces. Although shedding can be intermittent if you find lots of larvae you've got a diagnosis

Re: Dec 09 Quiz: Dyspnoea in a puppy - Discussion

Mike Martin — Mon, 14 Dec 2009 09:20:51 GMT

UPDATE

An alveolar pattern is due to the presence of fluid or cellular infiltrate within the air space of alveoli, or collapse (atelectasis) of the alveoli. The fluid is commonly either, oedema, blood or pus.

Differentials are:

artifact (atelectasis associated with a previous lateral recumbency)
bronchopneumonia (inhalation, bacterial, FB, eosinophilic)
haemorrhage
contusion
cardiogenic and non-cardiogenic pulmonary oedema
lung torsion
protozoal pneumonitis
thromboembolism
adult respiratory distress syndrome
neoplasia

A textbook list is often too big, and includes the weird and rare and thus not overly helpful. The distribution of the lung pathology is often more useful for me.

atelectasis - usually one side only, often middle lobe, with mediastinal shift
bronchopneumonia
    inhalation of food is often ventral
    FB pneumonia is often one of the caudal lobes only
    bacterial - primary bacterial.....I've never seen (usuallly secondary to above)
    eosinophilic - widespread, often a bronchial pattern , occasionally patchy
haemorrhage - depends upon cause
contusion - localised to affected injury site
non-cardiogenic pulmonary oedema - more intense alveolar pattern, not so patchy
lung torsion - localised to affected lobe, may have pleural effusion
protozoal pneumonitis - rare
thromboembolism - uncommon
adult respiratory distress syndrome - rare
neoplasia - in every differential list!

So to run thro everyones differentials. For me, its not bacterial because of the distribution. Its not a FB beause it should be localised. Its not non-cardiogenic oedema (the alveolar component is not intense enough and just too patchy.

The pathology dominates the caudal lung lobes and is patchy - so I'm thinking, eosinophilic (+/- parasitic), but maybe patchy haemorrhage.

So next diagnostic step. I know some of you want to get in there with a scope - so did I. But before (or if) we do, are you comfortable with giving this puppy a GA. Is there any other diagnostic step we could do before committing to that? And something that is quicker than waiting for Baermann that will take 2-4 days - I'm not sure the pup will survival that long, in which case GA may be the lesser of two evils.

Link to quiz

Re: Dec 09 Quiz: Dyspnoea in a puppy - Discussion

Catherine Canakis — Sat, 12 Dec 2009 13:25:58 GMT

I completely agree with Anna Ellams.....IV antibiotics until culture results are known... etc.

I've heard that Enrofloxacin & TMP sulphonamides can also be effective.

I remember a case at University where a dog had pneumonia & he was treated using a "FOUR QUADRANT" ANTIBIOTIC regime. WOULD ANYONE KNOW what would be included (I think it was Clav pot amoxicillin, Enrofloxaxin & Metronidazole). Along with mist therapy followed by coupage, he fully recovered.

Re: Dec 09 Quiz: Dyspnoea in a puppy - Discussion

Catherine Canakis — Sat, 12 Dec 2009 12:51:04 GMT

I am joining in just now!! Definatively forced expiratiratory phase based on the video which would suggest lower airway pathology. Air bronchograms very visible in the radiograph with multiple fluffy & poorly marginated increased opacities.

DDX:

Differentials of alveoloar pattern (excluding cardiogenic causes) would include:

Bacterial pneumonia, Aspiration pneumonia (which can be diffuse), Atelectasis, Immune mediated -> Allergies, Pulmonary eosinophilic infiltrate 2ry to Parasitic pneumonia, inhaled allergen, FB, (but blood eosinophils were normal).

Allergies, Toxins, Electric shock (Post-ictal & Uremia are other differentials but are highly unlikely given history).

Although the dog was wormed, we cannot exclude parasites: The dog may not have really taken all the worming tablets ---could have spat one out. Alternatively, the dog may have been exposed to lungworm prior to being wormed. Or the dog may not have been really "fully wormed" at purchase (however, the breeder was a vet & I would be very surprised & disappointed if that were the case)

My next step would be to perform a BAL in attempt to yeild diagnostic material.

QUICK QUESTION which would help if ever I get a dyspneic dog which needs XR's:

1) What did you use as a sedative in this dog to take the radiograph (low dose ACP & Opiod? Some avoid midazolam given it's unpredictability)

2) What dose per kg did you use?

Re: Dec 09 Quiz: Dyspnoea in a puppy - Discussion

Mike Martin — Thu, 10 Dec 2009 12:44:04 GMT

UPDATE

There has been an interesting range of differentials......

[quote] Mostly alveolar + bronchograms.
High heart rate, thus might be heart
Changes are too widespread for FB
Alveolar with interstitial, fluffy bits in patches in periphery (not hilar, so not cardiogenic oedema)
Heart looks normal.
Pneumonia
Mediastinal disease
Respiratory, not cardiac
[/quote]

So to progress the discussion a bit. We had ruled out Upper airway obstruction on the clincial presentation, ie. absence of distinct inspiratory dyspnoea. (I have a movie example of this if there is interest).

Next category to consider is heart. Well IF this puppy was in heart failure (ie. pulmonary oedema) then it needs to have a congenital defect to cause left sided congestive heart failure, such as: mitral dysplasia, patent ductus arteriosus (PDA), ventricular septal defect. All these defects would produce a significant murmur - but none was found.

Then on the radiographs. Difficult to really see the heart, due to the lung pathology, but the carina is not particularly pushed upwards, which it should be with left atrial enlargment. But the DV was useful, as the heart is fairly well seen. And on this view it looks fairly normal. Importantly, there is not enlargement of the left atrial body (bulge between the two caudal lobe bronchi) nor the left auricle (bulge at 3 o'clock). Another thing I tend to look for is a prominent vascular pattern to support heart failure, but the vessels are hard to see on both films.

So that leaves my third category: chest disease (pulm path, pleural space). There have been a number of good interpretation, this is one example....

[quote user="Anna Ellams"] Difficult to see cardiac silhouette clearly so would struggle with accurate VHS. There are air bronchograms visible starting centrally and extending to distal tip caudal lungs.There are patchy fluffy opacities throughout the lungfields that obscure the vascular pattern: I would say this was an alveolar pattern. The lungs fill the chest cavity which excludes pleural space disease. Again, diff to see clear cardiac silhouette but the heart seems to occupy 1/2- 2/3rd the width of the chest cavity and therefore does not seem enlarged. The fluffy opacities are more marked in the caudal R lung lobes. They do extend to the cranial lobes as well [/quote]

So what causes an alveolar pattern, and thus what are the differentials at this stage?

Re: Dec 09 Quiz: Dyspnoea in a puppy - Discussion

Mike Martin — Thu, 10 Dec 2009 12:09:20 GMT

[quote user="Laurence Webb"] The buffy coat profile graph hasn't come out well and I'd question the sample quality. From my limited knowledge of the graphs I'd suspect that there were small clots in the sample (producing the small bumps in the DNA trace) which would have rendered both the red and white cell readings as unreliable. [/quote]

I agree. I didn't feel there was anything wonderfully useful from this blood sample. But does warrant a repeat haematology and cytologist to look at the smear. Even then, for me the key clues are in the clinical and radiographs.

Re: Dec 09 Quiz: Dyspnoea in a puppy - Discussion

Richard Carter — Wed, 09 Dec 2009 13:23:12 GMT

[quote user="Anna Ellams"]

NB: raised calcium on bloods likely related to slight elevation of Alb.

[/quote]

also young immature dog done on adult profile

Re: Dec 09 Quiz: Dyspnoea in a puppy - Discussion

Nuno Pereira — Tue, 08 Dec 2009 17:58:42 GMT

I think mixed pattern, alveolar + interstitial. definitely air bronchograms and peri-bronchial regions more affected.

I tried to measure heart size roughly on my pc screen and looks within normal range (9.5 +- 0.5 vertebrae).

Bloods are highly suspicious of infection (high globulins, granulocytosis) and i'm not sure what to make of a slightly high Ca value (too young for hyperparathyroid i think and i sure hope too young for neoplasia as well...)

I'm saying its not cardiac in origin but respiratory, so my ddx list would be start with infecctious (parasitical/bacterial/viral/fungal). Dont know what it was dewormed with, but it doesnt make any difference, angyostrongylus is still very likely and fits very well in here so it'll be my main ddx. I'd like to remember anything congenital or hereditary related to the breed but i can't, so next i'll say some other underlying systemic/hematogenous condition even though i cant specify what, then unlikely things like foreign bodies and finish with neoplastic.

Because the endoscopy and BAL + anaesthetic can kill the puppy, id hospitalize him, put him on iv antibiotics and fenbendazol for a few days, monitor very closely for thrombotic events or coagulopathy and if i'm completely wrong and this doesnt work, then give in and propofol the dog into a BAL for cytology and culture. In the meanwhile some blood cultures might be a good idea(?).

Re: Dec 09 Quiz: Dyspnoea in a puppy - Discussion

Hannah Wynne Richards — Tue, 08 Dec 2009 17:51:36 GMT

Practitioners pragmatic approach Antibiotics 50 mgs/kg fenbendazole daily for 1 week also preds as dead A vasorum more antigenic than live reasses Saves danger of GA in high risk case Be prepared to change tack if gets worse

Wynne

Re: Dec 09 Quiz: Dyspnoea in a puppy - Discussion

Anna Ellams — Tue, 08 Dec 2009 17:41:15 GMT

NB: raised calcium on bloods likely related to slight elevation of Alb.

Re: Dec 09 Quiz: Dyspnoea in a puppy - Discussion

Anna Ellams — Tue, 08 Dec 2009 17:39:36 GMT

Stage 2:

radiograph interpretation then:

Lateral:

Good exposure, some rotation of the thorax. Difficult to see cardiac silhouette clearly so would struggle with accurate VHS. Still the trachea curves dorsally in the cranial thorax and the carina could also be said to be dorsally placed which might suggest cardiomegaly though I suspect it's just positioning?...

There are air bronchograms visible starting centrally and extending to distal tip caudal lungs.There are patchy fluffy opacities throughout the lungfields that obscure the vascular pattern:

I would say this was an alveolar pattern.

The lungs fill the chest cavity which excludes pleural space disease.

The DV / VD:

Similar comments re the exposure and positioning. Again, diff to see clear cardiac silhouette but the heart seems to occupy 1/2- 2/3rd the width of the chest cavity and therefore does not seem enlarged.

The fluffy opacities are more marked in the caudal R lung lobes. They do extend to the cranial lobes as well though i think the increased soft tissue density radio-opacity there is exacerbated by overlying muscles.

So, differntials for diffuse alveolar pattern + an attempt at preference for suspected cause:

A) Pneumonia:

Bronchopneumonia - viral: KC, (distemper but surely not as been vaccinated and no other clin signs); possibly parasitic: lungworm; + 2ndary bacterial infection on top of both of those;

Aspiration pneumonia - distribution of lesions doesn't fit though? Don't they tend to be more cranioventral? and localised if something like FB:

B) Cardiogenic oedema - not convinced this is cardiac at all.; Non-cardiogenic oedema (smoke inhalation, paraquat poisoning?, other inhaled irritant)

C) Haemorrhage - coagulopathy but unusal presentation for ratbait / immune-mediated...

D) PIE / other inflam cell infiltrate ...

Looking at the bloods provided : those globulins and inflam leukogram would go with bronchopneumonia / aspiration pneumonia ; HCT would probably exclude haemorrhage; lack of eosinophilia does not rule out parasitic issue nor PIE

So, stage 3:

Ideally i would do baermanns combined 3 days faecal analysis, and BAL though might end up just doing non-bronchoscopic lung wash depending on resp distress of patient / how brave i was feeling. A scope might reveal a FB but then again, might not if i was not in the right place / unable to get that far down.

The samples obtained would be sent off for cytology and culture . IN the mean time I would change atbs to something like intravenous potentiated amoxycillin tid which has reasonable lung tissue penetration though doens't cross the bronchus well... and i might start panacur at 50mgs/kg po for next 28days ; Iv fluids and other supportive therapy eg: steaming and bisolvon might also help clear some mucus

repeat rads in 2-3 days to check whether things were worsening or not in there.

Re: Dec 09 Quiz: Dyspnoea in a puppy - Discussion

Clive Ansell — Tue, 08 Dec 2009 09:55:48 GMT

Increased radiodensity of lung parencyhma, with both alveolar and bronchial patterns affecting mainly middle and caudal areas, more so in Hilar region but not confined too.

The heart is not clearly defined, but it can be seen ventrally on lateral view, which suggests it is of normal size and shape. can see part of aortic arch, but not vena cava.

My feeling is this is respiratory, not cardiac.

Ddx for increased radiodensity include infiltration with; oedema, exudate, blood, cellular debris. The granulocytosis would indicate infection and/or inflammation.

My differential list at this stage would be: bacterial/parasitic/fungal pneumonia either primary or secondary to inhalation of poison, toxic or irritant material, or food from vomiting or regurgitation; coagulopathy;pulmonary embolism;

Next step bronchoscopy and a transtracheal wash for me.

Re: Dec 09 Quiz: Dyspnoea in a puppy - Discussion

Richard Carter — Tue, 08 Dec 2009 09:50:14 GMT

I.v antibiotics based on blds, evaluate stability for scope/ tracheal flush

FNA thoracocentesis - if purulent scope oesophagus for tears; if lymphocytes, cry

Re: Dec 09 Quiz: Dyspnoea in a puppy - Discussion

Richard Carter — Tue, 08 Dec 2009 09:21:05 GMT

On lateral x-ray would have said pneumonia, but on DV looks mediastinal with clear lobes??? Time to refer...

Re: Dec 09 Quiz: Dyspnoea in a puppy - Discussion

Utlendigur — Mon, 07 Dec 2009 23:34:35 GMT

I too would say alveolar pattern with some interstitial. Heart size looks normal to me (VHS about 9.5-10). The fluffy bits seem to be spread in patches through the lung fields including peripheral (rather than hilar as I would expect with pulmonary oedema). Evidence of inflammation on bloods (WBC, gran, TP, glob), also mild thrombocytopenia and mild hypercalcaemia (but relatively normal when corrected for albumin) - but not sure of reliability of sample (and haven't used Vettest). Would probably be considering DDX of parasitic/bacterial pneumonia, pulmonary haemorrhage, PIE. Would probably send off full blood count to lab to recheck (+/- clotting profile), faecal sample for worms. Wouldn't fancy risking GA so no endoscopy or BAL. Continue antibiotics and ?start fenbendazole while waiting, possibly bronchodilator and steroid if dyspnoea worsening

Re: Dec 09 Quiz: Dyspnoea in a puppy - Discussion

Laurence Webb — Mon, 07 Dec 2009 23:09:34 GMT

I realise that the bloods are not very helpful in this case, especialy given the #'s on the QBC

The buffy coat profile graph hasn't come out well and I'd question the sample quality. From my limited knowledge of the graphs I'd suspect that there were small clots in the sample (producing the small bumps in the DNA trace) which would have rendered both the red and white cell readings as unreliable.

I was suspecting an inhaled FB but seeing the X-rays I'm not convinced - the changes are mostly in the right lung but are a little too widespread . Wouldn't mind scoping it if the dog's stable enough.