Wk 10 - Respiratory pt1 + 2 (Exam and Coughing)

History questions

• SHEDC

  • S - _______________

  • H- _______________

  • E - _______________

  • D - _______________

  • C - _______________

signalment; health; environment; diet; complaint

Hands-on exam

• airway _______________

• sinus/thoracic _______________

• _______________ palpation

• auscultation

  • bronchovesicular vs adventitial sounds

• don’t forget to _______________ the animal

patency; percussion; laryngeal/tracheal; rest

Abnormal resp sounds

• abnormal UPPER airway sounds

  • _______________

  • _______________

  • _______________

stertor; stridor; tracheal rattle

Abnormal resp sounds

• abnormal LOWER airway sounds

  • _______________

  • _______________

  • _______________

  • absent lung sounds

crackles; wheezes; pleural friction rubs

Abnormal LOWER airway sounds

• absent lung sounds

  • dorsally = possible _______________

  • ventrally = possible _______________

pneumothorax; pleural effusion

Rebreathing exam

• encourages _______________ through rebreathing of expired CO2

• enhances detection of abnormal lung sounds

• Goal = _______________

deep breaths; localize resp disease

Rebreathing exams

• Focus on:

  • how well patient tolerated exam

    • normal = deeper breaths but NO _______________ and NO _______________

  • quality of lung sounds

    • normal = _______________

  • how well/quickly patient recovered

    • normal = _______________ deep breaths after removal of bag with NO _______________

distress; cough; clear (bronchovescicular); 3-5

Rebreathing exam - tips

• don’t _______________

  • let horse get used to bag

• keep bag AWAY from _______________

• continue auscultating _______________

rush in; nostrils; after bag is removed (will take deeper breaths)

Resp diagnostics

• bloodwork (CBC, Chem)

• upper airway sampling

  • _______________ swab

  • _______________ wash or swab (NPW/NPS)

  • _______________ lavage

• imaging

  • rads, US, endoscopy

• lower airway sampling

  • _______________ lavage

  • _______________ wash

• fluid/tissue sampling

  • thoracocentesis

  • lung Bx, FNA, biopsy mass, etc

nasal; nasopharyngeal; guttoral pouch; bronchoalveolar; trans tracheal

Bloodwork

• CBC

  • may be non-specific

• Chem

  • _______________

• blood gas

  • venous

    • _______________ assessment of pulmonary function

    • PvO2, PvCO2, SvO2, pH, HCO3-, lactate

  • arterial

    • _______________ assessment of pulmonary function

    • PaO2, PaCO2, SvO2, FIO2, A-a gradient, pH, HCO3-, lactate

• pathogen-specific testing

serum amyloid A (SAA); indirect; direct

What upper airway sampling method is the most sensitive?

nasopharyngeal wash (covers more surface area)

Upper airway sampling

• _______________ = enemy of _______________ and _______________

debris; PCR; culture

Upper airway sampling

• tips

  • _______________ swabs preferred over _______________

  • wipe outer nares of any _______________ before sampling

  • aim “_______________” in nostril

  • if grossly dirty (brown), get a new sample

synthetic; cotton; debris; central and ventral

Thoracic US

• most field vets wont be able to take rads

• normal lung

  • filled with air → _______________

• can only see as far as the _______________ when scanning healthy lungs

• can “see” into _______________ tissue (i.e. _______________ lung)

dirty shadow; pleural surface; non-aerated; consolidated

Thoracic US

• helpful for _______________ lung disease

  • _______________ lung disease

  • _______________ disease

diffuse; peripheral; pleural

Thoracic US Exam

• typically work caudal to cranial and scan dorsal to ventral in each rib space

• _______________ artifacts = _______________

  • sheets or coalescing = suggestive of _______________

comet tail; pleural irregularities; pulmonary edema

Thoracic rads

• portable/field machine for ______________ ONLY

• in-house generator needed for ______________

foals/minis; adults

What lung is usually affected by resp infection?

right ventral lung

Endoscopy

• ______________ scope used for UPPER airway

• ______________ scope used to see past ______________

1m; 1.5m; tracheal bifurcation

Lower airway sampling

• Bronchoalveolar lavage

  • procedure: ______________ passed up nostrils to trachea

• trans tracheal wash

  • procedure: incision made over ______________ trachea, ______________ inserted, catheter passed to ______________

tube; mid ventral; trocar; thoracic inlet

Lower airway sampling

• BAL

  • wedges in bronchus

  • ______________ml saline injected and aspirated

  • ______________ procedure

• TTW

  • ______________ml of saline injected and aspirated

  • ______________ procedure

250-300; non-sterile; 15-30; sterile

Lower airway sampling

• BAL

  • lab submissions

    • ______________

    • ______________

• TTW

  • lab submissions

    • ______________

    • ______________ (exception = ______________)

cytology; EHV-5 PCR;

cytology AND culture; organism-specific PCR; EHV-5

Lower airway sampling

• BAL

  • primary disease rule out:

    • ______________

• TTW

  • primary disease rule out:

    • ______________

equine asthma; bacT pneumonia

T/F: You can do a trans tracheal wash through an endoscope

True

What is a normal neutrophil count for trans tracheal wash?

<5%

What do you think this horse has?

exercise induced pulmonary hemorrhage (EPH - macrophages + RBC)

What do you think this horse has?

pleuropneumonia (fibrin present; ALWAYS do TTW)

Tissue sampling

• ______________ = more commonly done

• Indicated for:

  • ______________

  • ______________

lung biopsy; atypical interstitial pneumonia; superficial pulmonary masses

Tissue sampling

• Indicated for:

  • atypical interstitial pneumonias

    • ______________, ______________, ______________

  • superficial pulmonary masses

EMPF (equine multinodular pulmonary fibrosis); silicosis; toxins

Tissue sampling

• primary risks

  • ______________

  • ______________

  • ______________

hemorrhage; pneumothorax; sudden death

What triggers a cough:

• mechanical

  • tracheal ______________

  • ______________

  • ______________ accumulation

  • inhaled particles

  • ______________ airway compression

compression; bronchoconstriction; mucous; intra or extramural

What triggers a cough:

• mechanical

  • intra or extramural airway compression

    • ______________

    • decreased pulmonary ______________ (______________ or ______________)

mass; compliance; fibrosis; pleural effusion

What triggers a cough:

• chemical

  • inert dust:

    • irritant ______________

    • ______________

  • biological mediators

    • ______________

    • ______________

gases; carbon; histamine; prostaglandin

What triggers a cough:

• others

  • exposure to ______________ or ______________

  • infectious diseases

  • ______________

cold; hot air; epithelial sloughing

Where can a cough be localized to:

• nasal passages

• ______________

• ______________

• pharynx

• trachea

• ______________

• ______________

sinus; guttoral pouch; bronchioles; alveoli

Coughing - Diagnostics

• Bloodwork

  • CBC

  • blood gas

  • serology

    • ______________

    • ______________

    • ______________

  • PCR

  • blood cultures

Strep equi equi; Corynebacterium pseudotuberculosis; C. immitis (Coccidioidomycosis)

Coughing - diagnostics

• imaging

  • US

    • ______________

    • ______________

    • ______________

  • rads

    • ______________

    • ______________

    • ______________

  • endoscopy

    • guttoral pouch

    • upper and lower airway

cardiac; thoracic; throatlatch/SMLN; skull; neck; thorax

Coughing - diagnostics

• airway sampling

  • nasal swab

    • ______________

    • ______________

  • nasopharyngeal wash/swab

    • ______________

    • ______________

  • BAL

    • ______________

  • TTW

    • ______________

    • ______________

culture; PCR;

culture; PCR;

cytology;

cytology; culture

Coughing - diagnostics

• thoracocentesis

  • ______________

  • ______________

• lung biopsy

  • histopath

  • ______________

  • ______________

cytology; culture; PCR; culture

Upper vs lower airway coughing

• Upper - CS

  • ______________

  • ______________

  • airflow from ______________

unilateral nasal discharge; stridor; only 1 nostril

Upper vs lower airway coughing

• lower - CS

  • ______________

  • ______________

  • ______________

  • ______________

pleurodynia; crackles; wheezes; pleural friction rub

Baseline auscultation is often ______________ for detecting lung pathology

• how can we improve this?

  • ______________

• consider signalment, timing/quality, PE to help localize

insensitive; rebreathing exam

Infectious cough

• PE

  • ______________

  • ______________ nasal discharge

  • ______________

  • run a ______________

FEVER; purulent; enlarged SMLN (submandibular LN); CBC

What is the first thing you should do if you suspect a horse has an infectious cough?

ISOLATE (don’t wait)

Cough - Workup

• age matters - Ex: coughing TB gelding

  • 3m

    • ______________

  • 3yr

    • if healthy: ______________

    • if sick: ______________

  • 15yr

    • ______________

rhodococus equi pneumonia;

lymphoid pharyngitis; shipping fever;

equine asthma

Lymphoid pharyngitis

• common cause of cough in ______________ horses

• pathophysio

  • ______________ secondary to

    • ______________ resp diseases

    • ______________

1-3yr (young); lymphoid hyperplasia; infectious (often viral); local irritant

Lymphoid pharyngitis

• 2 forms

  • ______________

    • will also have ______________

  • ______________

acute; nasal discharge; chronic

Lymphoid pharyngitis

• PE

  • usually look ______________

• Diagnostics

  • ______________

  • ______________

healthy; upper resp endoscopy; nasopharyngeal swab/wash

Lymphoid pharyngitis - Tx

• mostly ______________

• ± ______________

• ± ______________

• ± ______________

symptomatic; systemic anti-inflam; topical anti-inflam; topical Abx

Equine (pleuro) pneumonia

• aka “______________”

• rare, spontaneous disease

• occurs in ______________ horses

• usually requires 1 or more ______________ and/or breakdown in ______________ mechanisms

shipping fever; adult; risk factors; protective

Equine (pleuro) pneumonia

• risk factors

  • ______________

  • ______________

  • ______________

  • poor ______________

  • ______________

  • ______________

  • recent/current ______________ infection

travel; exercise (strenuous); stress; ventilation; GA; choke; viral URT

Equine (pleuro) pneumonia

• risk factors

  • travel

    • ______________

    • ______________

  • strenuous exercise

    • esp in ______________

long distances; head elevated; young TB racehorses

Equine (pleuro) pneumonia

• protective mechanisms

  • ______________

  • ______________

  • ______________

  • ______________

COUGH; mucociliary escalator; gravity; local immune cells

Equine (pleuro) pneumonia

• pathogens involved

  • ______________ / ______________ / ______________ bacT

  • often ______________

commensal; opportunistic; environmental; polymicrobial

Equine (pleuro) pneumonia

• most common pathogen = ______________

• others:

  • ______________ (Actinobacillus, Pasteurella, E. coli, Klebsiella pneumonia, etc)

  • ______________ (Bacteroides fragilis, Fusobacterium, Peptostreptococcus, Clostridium)

Strep equi zooepidemicus (G+); G- aerobes; anaerobes

Equine (pleuro) pneumonia

• CS

  • fever, lethargy, cough

  • ______________

  • ______________

  • ______________

tachypnea; nasal discharge; crackles or wheezes

Equine (pleuro) pneumonia

• signs suggestive of this

  • ______________

  • ______________

  • ______________ on the thorax above which lung sounds can be heard

pleurodynia; pleural friction rub; horizontal line

Equine (pleuro) pneumonia - Dx

• if overtly abnormal lung sounds, DO NOT do a ______________

• CBC

  • mild to severe ______________

• increased ______________

• rads or US first?: ______________

• BAL or TTW?: ______________

rebreathing exam; inc WBC; SAA; US; TTW

Why do you want to do a TTW instead of a BAL for a patient with (pleuro) pneumonia?

less fluid given and can send for culture

When would you want to do a thoracocentesis in a patient with (pleuro) pneumonia?

evidence of pleural fluid on US

Pleuropneumonia - Progression

• starts as ______________

• left untreated (or treated inappropriately) → pleura becomes ______________ → ______________

bronchopneumonia; inflamed; pleuropneumonia

Pleuropneumonia - Progression

1. ______________ stage

2. ______________ stage

3. ______________ stage

exudative; fibrinopurulent; organization

Pleuropneumonia - Progression

• exudative stage

  • pleural fluid is initially ______________

• fibrinopurulent stage

  • neut/bacT → ______________

• organization stage

  • ______________ migrate and produce the ______________ that encases the lung

sterile; fibrin deposit; fibroblasts; pleural peel

(Pleuro) pneumonia - Tx

• ______________

• ______________

• if significant pleural fluid present → ______________

• supportive care

ABx; anti-inflammatories; DRAIN IT

(pleuro) pneunmonia - Tx

• ABx

  • NEVER give ______________

  • if sedated with ______________, DO NOT give ______________

IV doxycycline; a2 agonist; IV TMS

Foal cough - DDx

• <30d old

  • ______________

  • ______________

• 1-6 months

  • ______________

dysphagia; pneumonia; Rhodococcus equi pneumonia

Foal cough - DDx

• <30d old

  • dysphagia

    • congenital upper airway defect

    • ______________

    • ______________

  • pneumonia

    • in utero infection (______________ or ______________)

    • secondary to ______________

    • ______________ spread

pharyngeal paresis; HIE/NMS; EHV-1; EAV; aspiration; hematogenous

Rhodococcus equi

• severe problem in breeding farms

• bacT classification

  • Gram ______________

  • ______________ bacT

    • grows in ______________

    • virulence - associated ______________

positive cocci; intracellular; macrophages; protein A (VapA)

Rhodococcus equi

• route of infection: ______________

• shed in ______________ of adults and foals

• mostly affects foals

• ______________ and ______________ diseases

inhaled; feces; pulmonary; extra-pulmonary

Rhodococcus equi - Manifestations

• ______________ = most common form

  • causes ______________ disease

  • will see ______________ with ______________

pulmonary; subclinical; suppurative bronchopneumonia; absessation

Rhodococcus equi - manifestations

• extrapulmonary

  • ______________

  • ulcerative ______________

  • ______________

  • ______________

  • ______________

abdominal abscess; enterocolitis/thyphlitis; osteomyelitis; polysynovitis; uveitis

When to suspect R. equi pneumonia

• patient is a ______________

• CS of ______________ disease

• cytologic evidence of ______________

• evidence of ______________ on imaging (rads or US)

foal; lower resp; airway inflammation; bronchopneumonia

How to test for R. equi:

• ______________

  • ± vapA PCR

• ______________

  • ± vapA PCR

• ______________

  • ± vapA PCR

• ______________

nasal swab culture; TTW culture; fecal culture; vapA PCR

R. equi - when to treat

• clinical cases with appropriate diagnostics performed

• Treating subclinical foals based on:

  • evidence of inflammation on ______________

    • NOT very sensitive

  • increased ______________ or ______________

    • NOT sensitive or specific

  • ______________ of lung on US

    • based on amount

CBC; fibrinogen; SAA; consolidation

What cumulative amount of consolidation do you need to see on US to treat subclinical R. equi?

>8-10cm

R. equi - Tx

• classic Tx

  • ______________ (______________, ______________ or ______________) + ______________

macrolide; azithromycin; clarithromycin; erythromycin; rifampin

R. equi - Tx

• side effects

  • macrolide - ______________ (esp for mare), ______________

  • rifampin - ______________

colitis; hyperthermia; urine discoloration

R. equi - prevention

• NO ______________

• regular screening of foals on ______________ farms

• decrease mare/foal stocking density??

• admin ______________ on ______________ farms**

Vx; endemic; R. equi plasma; endemic