Successful treatment of acute respiratory failure following hypertensive crisis in a dog with presumed pheochromocytoma or paraganglioma

Background

Acute respiratory failure has been reported as one of the manifestations of hypertensive crisis in pheochromocytoma in human medicine. In dogs, no reports have been described as acute respiratory failure following hypertensive crisis. Here, we report the clinical presentation, course, and treatment of acute respiratory failure following the hypertensive crisis in a dog with presumed pheochromocytoma or paraganglioma.

Case Description

A 12-year-old neutered male toy poodle was referred for the diagnostic evaluation of a right adrenal gland mass. The dog suddenly exhibited severe dyspnea with abnormal hypertension (systolic blood pressure >200 mmHg) 15 minutes after recovery from the anesthesia for the computed tomography (CT) examination. Pulmonary CT and ultrasonography findings suggested acute onset of severe pulmonary edema. Pulmonary edema was treated with mechanical ventilation (pressure-support ventilation with continuous positive airway pressure) and negative fluid balance after the administration of furosemide. Weaning from mechanical ventilation was successful 24 hours after the onset of respiratory failure. Finally, the dog was discharged 3 days after weaning from ventilation without complications.

Conclusion

This report outlines a case of acute respiratory failure following a hypertensive crisis requiring mechanical ventilatory management in a dog. The onset and progression of pulmonary edema were extremely rapid. However, improvement in pulmonary edema was also rapid. Hemodynamic stability, in addition to prompt diagnosis and aggressive therapeutic intervention, including mechanical ventilation, may have contributed to the good prognosis of pulmonary edema following hypertensive crisis in a dog, which we attribute to a catecholamine storm.

Use of a novel surgical approach for treatment of complete bilateral membranous choanal atresia in an alpaca cria

CASE DESCRIPTION A 4-hour-old 6.3-kg (13.9-lb) female alpaca cria was evaluated because of severe respiratory distress and difficulty nursing since birth. CLINICAL FINDINGS The cria had open-mouth breathing and cyanotic membranes, with no airflow evident from either nostril. Supplemental oxygen was delivered, and the patient was anesthetized and intubated orotracheally; a CT evaluation of the head confirmed bilateral membranous obstruction of the nasal cavities, consistent with complete bilateral choanal atresia. TREATMENT AND OUTCOME Choanal atresia was treated with an endoscopically assisted balloon-dilation technique, and temporary tracheostomy was performed. Stenosis recurred, requiring revision of the repair and intranasal stent placement 3 days after the first surgery. The tracheostomy tube was removed the next day. Complications during hospitalization included mucoid obstruction of the tracheostomy tube, granulation tissue development in the trachea near the tracheostomy site, mucoid stent obstruction, aspiration pneumonia, and presumed partial failure of passive transfer of immunity. The stents were removed 2 weeks after admission, and the cria was discharged 3 days later. The owner was advised that the animal should not be bred. At last follow-up 3 years later, the alpaca was doing well. CLINICAL RELEVANCE Surgical treatment with a balloon-dilation technique and placement of nasal stents with endoscopic guidance were curative in this neonatal alpaca with bilateral membranous choanal atresia. Computed tomography was useful to determine the nature of the atresia and aid surgical planning. Because a genetic component is likely, owners should be advised to prevent affected animals from breeding.

Compressive Myelopathy due to Intervertebral Disk Extrusion in a Llama (Lama Glama)

A 12-year-old intact female llama was euthanized following acute onset of spastic tetraparesis and recumbency with inability to rise. Postmortem examination revealed caudal cervical spinal cord compression due to a mass within the ventral spinal canal arising from the C6–C7 intervertebral disk space and attached to an irregularly thickened annulus fibrosis. On histopathologic examination, the mass was composed of amorphous acellular basophilic to amphophilic material admixed with irregularly arranged collagen bundles. The amorphous material was metachromatic and contained multiple small foci of markedly vacuolated round cells, characteristic of origin from the nucleus pulposus. Severe necrosis of all white matter tracts with astrocytic reaction was present in the overlying spinal cord segment. Ascending and descending Wallerian degeneration and dissecting interstitial astrogliosis were present within white matter tracts above and below the lesion, respectively. The diagnosis was compressive myelopathy due to chronic extrusion of the nucleus pulposus of the C6–C7 inter-vertebral disk. To the authors' knowledge, this is the first report of intervertebral disk disease in a camelid.

Primary mycoplasma pneumonia associated with reversible respiratory failure in a cat

A young adult cat was evaluated for respiratory failure. Diagnostic testing, including computed tomography and culture, documented a primary Mycoplasma species pneumonia. The cat was treated aggressively with supportive care, including mechanical ventilation and appropriate antibiotics including doxycycline, and made a complete recovery. This is a unique case in respect of the severity of the Mycoplasma species pneumonia as well as the cat's recovery from severe lung injury.

Indications, management, and outcome of long-term positive-pressure ventilation in dogs and cats: 148 cases (1990-2001)

OBJECTIVE

To determine outcome of positive-pressure ventilation (PPV) for 24 hours or longer and identify factors associated with successful weaning from PPV and survival to hospital discharge in dogs and cats.

DESIGN

Retrospective case series.

ANIMALS

124 dogs and 24 cats that received PPV for 24 hours or longer.

PROCEDURES

Medical records were reviewed for signalment, primary diagnosis, reason for initiating PPV, measures of oxygenation and ventilation before and during PPV, ventilator settings, complications, duration of PPV, and outcome. Animals were categorized into 1 of 3 groups on the basis of the reason for PPV.

RESULTS

Group 1 patients received PPV for inadequate oxygenation (67 dogs and 6 cats), group 2 for inadequate ventilation (46 dogs and 16 cats), and group 3 for inadequate oxygenation and ventilation (11 dogs and 2 cats). Of the group 1 animals, 36% (26/73) were weaned from PPV and 22% (16/73) survived to hospital discharge. In group 2, 50% (31/62) were weaned from PPV and 39% (24/62) survived to hospital discharge. In group 3, 3 of 13 were weaned from PPV and 1 of 13 survived to hospital discharge. Likelihood of successful weaning and survival to hospital discharge were significantly higher for group 2 animals, and cats had a significantly lower likelihood of successful weaning from PPV, compared with dogs. Median duration of PPV was 48 hours (range, 24 to 356 hours) and was not associated with outcome.

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggested that long-term PPV is practical and successful in dogs and cats.

Severe bronchoconstriction after bronchoalveolar lavage in a dog with eosinophilic airway disease

Bronchoalveolar lavage (BAL) is considered to be a safe procedure in humans and other animals. However, in some instances, potentially life-threatening complications can arise. In this clinical report, a dog with eosinophilic airway disease that underwent a BAL and subsequently became profoundly dyspneic during the recovery period is described. The dyspnea was severe enough to warrant mechanical ventilation for almost 24 hours. Several anti-inflammatory and bronchodilatory medications were also used. The dog was successfully weaned off the ventilator and made a full recovery. On the basis of radiographic findings and clinical response to treatment, we believe the dog had acute exacerbation of eosinophilic airway disease and severe bronchoconstriction secondary to the BAL. Caution should be exercised when performing a BAL if there is suspicion of a reactive airway disease.

Indications for and outcome of positive-pressure ventilation in cats: 53 cases (1993-2002)

OBJECTIVE

To determine indications for and outcomes of positive-pressure ventilation (PPV) in cats, document ventilator management, and identify factors associated with outcome.

DESIGN

Retrospective study.

ANIMALS

53 cats that underwent PPV.

PROCEDURE

Information on signalment, history, concurrent diseases, clinical findings, results of venous blood gas analyses and clinicopathologic testing, treatment, ventilator settings, and outcome was retrieved from the medical records. Data for cats that survived were compared with data for cats that died or were euthanatized while undergoing PPV RESULTS: PPV was initiated for management of respiratory failure (36 cats [68%]), cardiac arrest (9 [17%]), neurologic impairment (6 [11%]), and nonresponsive hypotension (2 [4%]). Eight cats (15%) survived, 19 (36%) died, and 26 (49%) were euthanatized while undergoing PPV. Cats that survived had a longer duration of ventilation than did those that died or were euthanatized and had a significantly higher incidence of ventilator-associated pneumonia. Signalment and ventilator settings were not associated with outcome. Cats that had no clinical evidence of pulmonary disease but required PPV because of primary neurologic disease had a higher survival rate (2/6) than did cats that required PPV because of respiratory failure (5/36), cardiac arrest (1/9), or nonresponsive hypotension (0/2).

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggest that the survival rate for cats requiring PPV may be lower than reported survival rates for dogs. Death was attributable to progressive respiratory failure, non-responsive hypotension, kidney failure, or neurologic impairment.

Approach to the patient with respiratory distress

Respiratory emergencies are common presentations to emergency clinicians. Appropriate assessment and timely interventions may be crucial in the stabilization of dyspneic patients. The emergency clinician should be fully prepared and equipped to correctly ascertain and treat the most likely cause of respiratory compromise of a patient. Based on history, signalment, clinical presentation, and brief physical examination findings, the clinician should be able to formulate a plan of action to relieve respiratory distress and communicate with the owner about the diagnostic and therapeutic strategies and overall prognosis of the patient. Prompt recognition of the underlying respiratory disease and complete familiarity with emergency diagnostic and therapeutic procedures can lead to the successful management of many emergency respiratory patients.

Fatal paraquat poisoning in seven Portland, Oregon, dogs

Paraquat is one of the few broad-spectrum herbicides available in the US; however, it is extremely toxic to companion animals when ingested. Despite its restricted use status, poisoning of dogs and cats remains relatively common. This clinical report documents a series of chronologically and geographically related cases of presumed malicious and fatal sub-acute paraquat poisoning in 7 dogs in Portland, OR. All animals developed acute gastrointestinal disturbance, renal compromise and insidiously progressive respiratory failure. Hyperlipasemia and moderate hypertension were notable featured in 5/7 cases. Trace levels of paraquat were demonstrated in the urine of 4/7 animals by gas-liquid chromatography/mass spectroscopy. Diagnosis in the remaining 3 cases was made through a combination of history or exposure, clinical signs and their progression, and pulmonary and renal histopathology.

The diagnosis and management of snakebite in dogs--a southern African perspective

Cases of snakebite envenomation are frequently presented to veterinary practitioners in southern Africa. Despite this, no published guidelines exist on how this medical emergency should be managed. Southern African snake venoms can be classified into 3 main types based on the main mechanism of venom action and clinical presentation. A polyvalent antivenom is manufactured in South Africa and contains antibodies against the most important southern African snake venoms. The cytotoxic venoms are represented mainly by the puff-adder (Bitis arietans), Mozambique spitting cobra (Naja mossabica), black-necked spitting cobra (Naja nigricollis) (in the Western Cape and Namibia) and the stiletto snake (Atractaspis bibronii). These venoms may cause dramatic local swelling, high morbidity and low mortality and infrequently require the use of antivenom for survival (the only cytotoxic venoms used to prepare the antivenom are the puff-adder and Mozambique spitting cobra). The neurotoxic venoms (represented chiefly by the non-spitting cobras and mambas) cause high mortality due to rapid onset of paresis and require antivenom and mechanical ventilatory support which is life-saving. The boomslang (Dispholidus typus) and the vine snake (coagulopathic venom) rarely bite humans but dogs may be bitten more frequently. These venoms cause a consumption coagulopathy and successful treatment of boomslang bites requires the use of snake species-specific monovalent antivenom. There is no antivenom available for treating vine snake (Thelotornis capensis), berg adder (Bitis atropos), night adder (Causus spp.), stiletto snake and other lesser adder bites. There are some important differences between the way snakebites are managed in humans and dogs.

Myxedema coma leading to respiratory depression in a dog

A 10-year-old, intact male, cocker spaniel was presented with hypothermia, without shivering, and progressive stupor leading to coma. Myxedema coma, potentially precipitated by diuretic therapy, was tentatively diagnosed and treatment initiated, but progressive respiratory depression led to the decision to euthanize. Postmortem findings supported the diagnosis of myxedema coma.

Nodular immunocyte-derived (AL) amyloidosis in the trachea of a dog

A 7-year-old castrated male Miniature Schnauzer was examined because of labored breathing and episodes of respiratory distress that progressed to collapse. On cervical radiographs, a focal soft tissue mass in the caudal cervical portion of the trachea was observed, and during tracheoscopy, a 1 x 1 cm, pedunculated, multinodular, pink, intraluminal mass extending from the dorsal tracheal membrane and obstructing approximately 80% of the tracheal lumen was seen. Tracheal resection and anastomosis was performed to remove the mass, and the dog recovered without complications. On histologic examination, the mass consisted of a large accumulation of homogeneous, faintly fibrillar eosinophilic material admixed with a predominantly plasma cell infiltrate; examination of sections stained with thioflavin T and Congo red stain confirmed that the eosinophilic material was amyloid. A diagnosis of nodular, immunocyte-derived (AL) amyloidosis was made. Seventeen months after surgery, the dog had a relapse of respiratory distress because of an extramedullary plasmacytoma involving the trachea.

Thoracic high-resolution computed tomography in the diagnosis of metastatic carcinoma

Three dogs were presented for investigation of recurrent pyrexia of unknown origin, chronic vomiting and respiratory distress, respectively. One dog was markedly underweight and the other two were cachexic. Physical examination and initial diagnostic tests failed to establish the underlying cause of the presenting signs. Thoracic radiographs were within normal limits for the age of the dog. In each case there was a high index of suspicion for an occult neoplastic process in view of the profound unexplained weight loss present. High-resolution computed tomography (HRCT) of the thorax was performed. The lung fields were divided into three zones for analysis and a novel classification scheme was used to describe the HRCT findings in each zone. Postmortem examination and histopathology confirmed the presence of an infiltrating metastatic carcinoma in all three cases. The HRCT changes correlated closely with the pathological findings. The authors conclude that HRCT of the lung should be considered for pulmonary metastatic screening in the dog and introduce a classification system for HRCT findings, based on terminology used in human medicine.

Pneumonia in a Paso-Fino mare

A 5-year-old Paso-Fino mare was presented for severe respiratory distress. The mare had foaled 2 months prior to presentation. The horse was in poor body condition with a dull hair coat. A mild fever was noted during physical examination and increased bronchovesicular sounds were auscultated. Thoracic radiographs showed an interstitial pattern and an alveolar infiltrate with distinct air bronchograms. Moderate purulent inflammation with increased mucus was observed in tracheal wash fluid, but no infectious agents were identified. A bronchoalveolar lavage (BAL) contained a large amount of mucus and reactive mononuclear phagocytes with variable numbers of intracellular fungal organisms morphologically consistent with Pneumocystis carinii. The mare had undetectable levels of immunoglobulin M (IgM) and decreased IgG levels in the serum. Immunophenotyping revealed decreased expression of major histocompatibility complex (MHC) class II molecules. Moderate to marked hyperplasia of type II epithelial cells was present throughout histologic sections of lung, but the fungal organisms were not observed. A culture system has not been developed for diagnosis of P carinii infection. Instead, diagnosis of P carinii pneumonia is achieved by microscopic identification of characteristic morphologic features of the pathogen. Cytologic examination of BAL fluid is the preferred method used to diagnose human infection with P carinii. In humans, the diagnostic sensitivity of cytology is significantly higher than the sensitivity of histopathologic examination of lung biopsies. The difference in sensitivity between BAL cytology and lung histopathology may also apply to the diagnosis of P carinii pneumonia in horses.

Mechanical ventilation in foals with botulism: 9 cases (1989-2002)

"Shaker foal" disease, toxicoinfectious botulism of foals, was 1st described as a clinical entity in 1967. The reported mortality rate was 90%, with death occurring within 24-72 hours of the onset of the characteristic clinical signs. The mortality rate decreased when equine-origin botulism antitoxin became available; however, a certain percentage of foals continued to die of respiratory failure. Mechanical ventilation is an important part of the treatment of infant botulism and is essential to the survival of many affected infants. We report a retrospective study of 9 foals with toxicoinfectious botulism where early mechanical ventilation was employed as part of the treatment. Foals receiving mechanical ventilation were progressively acidemic and had increased PaCO2 tensions before mechanical ventilation. These arterial blood gas abnormalities were ameliorated with mechanical ventilation. One foal was euthanized for economic reasons; survival in treated foals was 87.5%. Mechanical ventilation of foals with botulism and respiratory failure appears to be an effective therapy.

Pneumonia in weanlings

Lower respiratory tract infection is common in weanling- and suckling-aged animals. Increased susceptibility to disease in this age group can result from a delay in the establishment of a competent immune system and environmental factors, such as overcrowding, shipping, and sales. S zooepidemicus and R equi are the two most common bacterial isolates. S equi is primarily a disease of the lymph nodes and upper respiratory tract. Viral agents can compromise the natural defense mechanisms of the respiratory tract, resulting in secondary bacterial infections. The acute respiratory distress syndrome is one of unknown etiology and high mortality.

Successful management of long-term general anesthesia in rabbits used as an animal model of human disease

The rabbit represents a popular animal model for basic science research, but projects requiring anesthesia and endotracheal intubation represent a technical challenge because of the difficulty in accessing the animal's airway and sensitivity to common anesthetic agents. We hypothesized that transoral intubation under direct visualization with guidewire assistance would improve airway access success and reduce perioperative mortality in the rabbit. Of the 39 New Zealand White rabbits that had passive inhalation anesthesia and were intubated using wire-guided assistance under direct laryngeal visualization, 33 were intubated using a flexible wire after the rigid guide had resulted in airway injury in three of the first six rabbits. Animals were then maintained under general anesthesia during a 4- to 5-h procedure. At the completion of the procedure, animals were recovered from anesthesia and extubated. All 39 animals were successfully intubated, mostly on the first attempt. There were two animal deaths, both in the first six animals; one death was a direct result of laryngeal injury from the rigid wire guide initially used. One additional animal in the first six had pulmonary difficulty after an airway injury but recovered and was successfully used in the experiment. Two animals developed gastric distention during anesthesia, which was alleviated with placement of an orogastric tube without adverse sequelae. No animals developed problems with oxygenation during the experiment, but over half (52.8%) had end-tidal CO2 (ETCO2) above 45 mmHg at least once during the surgery, and 13 rabbits were above this level for longer than 1 h. An average of 18 min elapsed between withdrawal of anesthesia and the time when spontaneous respirations and chewing movements returned. Animals then could be safely extubated. There was no correlation between high perioperative ETCO2 and time to recovery from anesthesia (P = 0.18, r = 0.23).

Molecular biological characterization of equine surfactant protein A

In the following, we describe the isolation and sequencing of the equine surfactant protein A (Sp-A) as found in both the cDNA and the genomic DNA. We found a length of the cDNA sequence of 747 bp (base pairs), in translation into amino acids of 248. Compared with the known molecular biological facts about Sp-A in other species, the cDNA sequence obtained showed highest homology with that of sheep (85.01%). The genomic DNA of equine Sp-A, as in other species, includes three introns. There were no hints for the existence of two different Sp-A genes. These results should form the basis for a better understanding of respiratory failure in foals and adult horses, and also lead to further studies on this item.

Causes of respiratory failure

There are many causes of respiratory failure in veterinary patients. Assessment of oxygenation is imperative for the diagnosis and monitoring of these patients. Oxygen therapy should be instituted when hypoxemia is diagnosed to prevent tissue hypoxia, end-organ damage, and death. Methods of administering oxygen include commercial oxygen cages, mask oxygen, nasal cannulation (for dogs), and intubation. Mechanical ventilation is an option in many referral hospitals for patients who are severely hypoxemic and are not responding to inspired oxygen concentrations achieved with other methods of oxygen administration. One rule of thumb used to assess need for mechanical ventilation is a PaO2 of less than 50 mm Hg despite aggressive oxygen therapy, or a PaCO2 of greater than 50 mm Hg despite treatment for causes of hypoventilation. A mechanical ventilator has the ability to vary the FiO2 by increments of one, from 21% to 100% (0.21-1) oxygen in inspired gas. Positive end-expiratory pressure (PEEP) is also available on most ventilators. PEEP allows the alveoli to remain open on expiration, allowing gas exchange to occur in both inspiration and expiration. PEEP also helps diseased alveoli to inflate, increasing the available surface area for gas exchange and improving arterial blood oxygen tension. Because patients requiring mechanical ventilation have severe respiratory failure that did not respond to conventional oxygen therapy, the prognosis is guarded for most of these patients unless ventilation is instituted due to primary hypoventilation and lung parenchyma is normal. Hypoxemia caused by respiratory failure is a common problem in small animal veterinary patients. Assessment of blood oxygenation and continual monitoring of respiratory rate and effort are essential in management of these patients. Oxygen therapy should be instituted if hypoxemia is diagnosed. The prognosis depends on the underlying disease process and response to treatment with an enriched oxygen environment.

Respiratory muscle fatigue

The contribution of respiratory muscle fatigue to the development of ventilatory failure has been the subject of considerable interest and has stimulated much research. Experimental studies in dogs have shown respiratory muscle fatigue to be a cause of ventilatory failure in both cardiogenic and septic shock models. In clinical conditions resulting in acute or chronic hypercapnia, respiratory muscle fatigue is believed to occur; however, the specific role of fatigue has been difficult to prove.

Severe diaphragmatic necrosis in 4 horses with degenerative myopathy

Severe diaphragmatic necrosis occurred in horses with degenerative myopathy due to polysaccharide storage myopathy (n = 2), nutritional myopathy (n = 1), and vasculitis (n = 1). Blood gas analysis performed in 1 horse indicated development of respiratory acidosis. Respiratory muscle necrosis can be severe in horses with degenerative myopathy and can lead to respiratory failure.

Glycogen branching enzyme deficiency in quarter horse foals

Seven related Quarter Horse foals that died by 7 weeks of age were examined for glycogen branching enzyme (GBE) deficiency. Clinical signs varied from stillbirth, transient flexural limb deformities, seizures, and respiratory or cardiac failure to persistent recumbency. Leukopenia (5 of 5 foals) as well as high serum creatine kinase (CK; 5 of 5), aspartate transaminase (AST; 4 of 4), and gamma glutamyl transferase (GGT; 5 of 5) activities were present in most foals, and intermittent hypoglycemia was present in 2 foals. Gross postmortem lesions were minor, except for pulmonary edema in 2 foals. Muscle, heart, or liver samples from the foals contained abnormal periodic acid Schiff's (PAS)-positive globular or crystalline intracellular inclusions in amounts proportional to the foal's age at death. Accumulation of an unbranched polysaccharide in tissues was suggested by a shift in the iodine absorption spectra of polysaccharide isolated from the liver and muscle of affected foals. Skeletal muscle total polysaccharide concentrations were reduced by 30%, but liver and cardiac muscle glycogen concentrations were normal. Several glycolytic enzyme activities were normal, whereas GBE activity was virtually absent in cardiac and skeletal muscle, as well as in liver and peripheral blood cells of affected foals. GBE activities in peripheral blood cells of dams of affected foals and several of their half-siblings or full siblings were approximately 50% of controls. GBE protein in liver determined by Western blot was markedly reduced to absent in affected foals, and in a half-sibling of an affected foal, it was approximately one-half the amount of normal controls. Pedigree analysis also supported an autosomal recessive mode of inheritance. The affected foals have at least 2,600 half-siblings. Consequently, GBE deficiency may be a common cause of neonatal mortality in Quarter Horses that is obscured by the variety of clinical signs that resemble other equine neonatal diseases.

Dissecting aneurysm of the carotid artery as a cause of respiratory distress in adult cattle

A two-and-a-half-year-old Friesian cow and a five-year-old Charolais cow developed severe respiratory distress and palpable swellings to the left of the larynx as a result of a dissecting aneurysm of the common carotid artery. Neither cow responded to medical treatment. The underlying pathogenesis of the condition was uncertain, but direct trauma to the carotid artery was a possible contributory factor. Aneurysms of the common carotid artery should be considered when swelling occurs in the region of the larynx or when respiratory distress is due to laryngeal compression.

Acute respiratory failure caused by leukaemic infiltration of the lung of a dog

A seven-year-old crossbred male dog with a suspected leukaemic condition was referred for investigation and treatment. A bone marrow aspirate revealed an acute myeloid leukaemia. Combination chemotherapy was administered and the dog initially improved, but 18 days after the initiation of therapy its body condition deteriorated and the animal developed acute respiratory distress. On postmortem examination, extensive leukaemic pulmonary infiltrates were evident.

Fatal pulmonary fat embolism during humeral fracture repair in a cat

An 11-month-old cat was referred following a road traffic accident with non-weightbearing forelimb lameness and tachypnoea. A diaphragmatic rupture was repaired two days after trauma. Six days post trauma, a further operation was performed to repair the fractured humerus. As an intramedullary pin was advanced into the bone to achieve stabilisation, acute respiratory arrest occurred. Manual extrathoracic cardiopulmonary resuscitation was immediately instigated, but the cat did not recover. Postmortem examination identified a high degree of embolic fat occluding pulmonary capillaries. A massive embolic shower was established as the cause of death.

Strategies for mechanical ventilation

With the advancement of veterinary critical care medicine, an increasing number of veterinary patients are being supported with positive-pressure ventilation. Animals with potentially reversible ventilatory failure (PaCO2 > 60 mmHg) caused by neuromuscular disease or pulmonary parenchymal disease or with pulmonary parenchymal disease causing hypoxemia (PaO2 < 60) despite supplemental oxygen are candidates for ventilatory support. The equation of motion for the respiratory system is defined and is used to describe the potential interactions between the patient and the ventilator. Commonly used modes of ventilation are described in terms of control and phase variables. The intent of this report is to aid clinicians in choosing an optimal ventilatory strategy for each patient that will best achieve the desired physiologic goals with minimal detrimental side effects.

Weaning from mechanical ventilation

Patients that require positive pressure ventilation to maintain sufficient alveolar ventilation or pulmonary gas exchange may eventually reach a point in the course of their care wherein mechanical ventilation is no longer necessary. This process of transferring the work of breathing from the ventilator back to the patient is referred to as ventilator weaning. The term "ventilator weaning" may be used to refer to all methods by which this transfer of workload may be accomplished. In many patients, particularly those with short-lasting or readily correctable causes of respiratory insufficiency (e.g., general anesthesia), the discontinuation of positive pressure ventilation may be easily achieved. Indeed, in patients awakening from general anesthesia, the axiom "awake enough to blink, awake enough to breath" may prove to be a sufficient guideline. However, in those patients requiring long-term mechanical ventilatory support, the process can prove to be both frustrating and exceptionally challenging. It is of crucial importance to identify those patients that may be successfully weaned because of both the financial impact of prolonged intensive care unit hospitalization and the risks imposed on the patient by the process of positive pressure ventilation. To be able to predict which patients may be ready to be weaned from the ventilator requires an understanding of the balance between the work of breathing (ventilatory load) and the ability of the patient's respiratory pump to meet those needs (ventilatory capacity). The management of patients experiencing difficulty during the weaning process requires that the clinician recognize imbalances between ventilatory load and capacity and to correct these imbalances once identified.

Risk of adverse effects in pneumonic foals treated with erythromycin versus other antibiotics: 143 cases (1986-1996)

OBJECTIVE

To determine whether foals with pneumonia that were treated with erythromycin, alone or in combination with rifampin or gentamicin, had a higher risk of developing adverse effects, compared with foals treated with trimethoprim-sulfamethoxazole (TMS), penicillin G procaine (PGP), or a combination of TMS and PGP (control foals).

DESIGN

Retrospective study.

ANIMALS

143 foals < 240 days old.

PROCEDURE

Information on age, sex, breed, primary drug treatment, total days of treatment with the primary drug, and whether the foal developed diarrhea, hyperthermia, or respiratory distress was obtained from the medical records. Relative risk (RR) and attributable risk (AR) were calculated to compare risk of adverse reactions between foals treated with erythromycin and control foals.

RESULTS

Only 3 (4.3%) control foals developed diarrhea; none developed hyperthermia or respiratory distress. Foals treated with erythromycin had an 8-fold risk (RR, 8.3) of developing diarrhea, compared with control foals, and increased risks of hyperthermia (AR, 25%) and respiratory distress (AR, 15%).

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggest that use of erythromycin to treat foals with pneumonia was associated with an increased risk of diarrhea, hyperthermia, and respiratory distress, compared with use of TMS or PGP.

Approach to the patient in respiratory distress

Respiratory distress is a very common presenting complaint in emergency practice. It is essential that the clinician rapidly determine the underlying cause of the clinical signs using physical examination findings and nonstressful diagnostic tests. Oxygen therapy will often stabilize a patient, allowing for a more complete physical examination and diagnostics, including thoracocentesis, thoracic radiographs, and blood collection for laboratory analysis. The disease processes that cause respiratory distress can be grouped according to anatomic location: the airways, pulmonary parenchyma, pleural space, or thoracic wall. The choice of diagnostic and therapeutic techniques will be dependent on the suspected anatomic origin of disease. Techniques useful in diagnosing airway disorders include oral examination, cervical and thoracic radiographs, fluoroscopy, and bronchoscopy. Therapeutic techniques include intubation and tracheostomy. For parenchymal disease, thoracic radiographs, echocardiography, ultrasound of the thorax, and transtracheal or endotracheal wash can be useful. When the disease process is in the pleural space, thoracocentesis can be both diagnostic and therapeutic. Chest tube placement may be necessary for continuous removal of air or fluid from the pleural space. Monitoring of the respiratory patient can involve serial physical examination, pulse oximetry, and arterial blood gas analysis. It is essential to minimize stress on patients with respiratory distress because decompensation can occur easily, leading to respiratory arrest.

Postoperative management of the emergency surgery small animal patient

Hypovolemia, hypothermia, and hypotension are common postoperative findings that predispose the critically ill patient to secondary complications. This patient population is especially vulnerable to sepsis, hypoxia, and immune dysfunction. Careful monitoring is essential for early recognition of potentially life-threatening physiologic derangements. Early and aggressive intervention may help minimize systemic insult before it progresses to acute respiratory distress syndrome, acute renal failure, disseminated intravascular coagulation, or multiple organ failure.

A krimpsiekte-like syndrome in small stock poisoned by Ornithogalum toxicarium Archer & Archer

Krimpsiekte (the syndrome associated with chronic cardiac glycoside poisoning) was purportedly induced by Ornithlogalum toxicarium in the Karas mountains area of Keetmanshoop, Namibia. This chinkerinchee species was previously linked to a condition known as 'kwylbek' krimpsiekte in small stock in the Beaufort West district of the Western Cape Province, South Africa. In a dosing trial, respiratory distress, tachycardia and sternal recumbency were observed in 2 sheep drenched with fresh plant material. A fluorescence polarisation immunoassay (FPIA) detected the presence of a substance that cross-reacted with digoxin antibodies in some of the plant material collected at Keetmanshoop and Beaufort West. This is the first time that apparent cardiac glycoside poisoning was induced by a southern African chinkerinchee species. The presence of the cardiac glycoside-like substance in O. toxicarium requires further chemical verification.

Respiratory failure attributable to moxidectin intoxication in a dog

A 5-month-old 22-kg (48.4-lb) sexually intact male Collie was examined after ingesting a moxidectin-containing deworming medication. The dog was comatose and had respiratory arrest after progressively worsening lethargy, ataxia, and seizures. Exposure was confirmed by isolation of moxidectin from a biopsy specimen of adipose tissue, using liquid chromatography-mass spectroscopy methods. Treatment included use of intermittent positive-pressure ventilation, activated charcoal and cathartic administered enterally, nutrients administered via nasogastric tube, and intensive supportive care. The dog was weaned from a ventilator on day 6 after ingestion and was discharged on day 10. The dog was considered clinically normal during examination 24 days after ingestion. On the basis of the dog reported here and toxicologic data provided by the manufacturer of the deworming product, some Collies may have increased susceptibility to products containing high doses of moxidectin.

Comparison of laboratory test results before and after surgical removal of heartworms in dogs with vena caval syndrome

OBJECTIVE

To compare results of laboratory tests in dogs with vena caval syndrome before and after surgical removal of heartworms.

DESIGN

Longitudinal uncontrolled clinical trial.

ANIMALS

51 dogs with vena caval syndrome.

PROCEDURE

Heartworms were removed from the area of the tricuspid valve and pulmonary arteries via venotomy and by use of flexible alligator forceps. Blood samples were obtained before and 10 days after removal of heartworms. Red and white blood cell counts were determined, using an automated cell counter. Biochemical tests were performed, using a dry chemical method.

RESULTS

45 dogs survived the procedure, and 6 died or were euthanatized after surgical treatment. After surgery, RBC count and total protein, albumin, calcium, and sodium concentrations increased, and total bilirubin, ammonia, BUN, creatinine, uric acid, and potassium concentrations decreased in dogs that survived. Creatine kinase, L-lactate dehydrogenase, and amylase activities decreased, whereas alkaline phosphatase and gamma-glutamyltransferase activities and total cholesterol concentration increased. Alanine transaminase activity decreased in 27 dogs but increased in 3 dogs. Changes in test results in dogs that did not survive. Significant differences were found in RBC count, gamma-glutamyltransferase activity, and total protein, total cholesterol, BUN, and total bilirubin concentrations before and after removal of heartworms.

CLINICAL IMPLICATIONS

Hepatic and renal functions improve rapidly after surgical removal of heartworms, presumably because general and pulmonary circulation is normalized. However, cholestasis may develop, and dogs that survive may need additional treatment to preserve hepatic function.

Complications of balloon catheterization associated with aberrant cerebral arterial anatomy in a horse with guttural pouch mycosis

A 3-year-old Quarter Horse gelding was treated for left guttural pouch mycosis by ligation and balloon catheterization of the left internal carotid artery. Catheter advancement was shorter (10 cm) than the normally reported distance (13-15 cm), but was observed endoscopically during placement as it coursed within the internal carotid artery through the guttural pouch. The horse developed a persistently abnormal respiratory pattern after catheter placement, failed to gain consciousness, developed pulmonary edema, and died 5.5 hours postoperatively. Postmortem examination revealed an aberrant left internal carotid arterial course with location of the embolectomy catheter at the junction of the basilar and caudal cerebellar arteries. Brainstem neuronal necrosis and alveolar and interstitial pulmonary edema were identified on histological examination. Angiography may be used to identify aberrant branching patterns. Failure to identify and occlude aberrant branches may result in fatal epistaxis and Brainstem lesions.

Associations between physical examination, laboratory, and radiographic findings and outcome and subsequent racing performance of foals with Rhodococcus equi infection: 115 cases (1984-1992)

OBJECTIVE

To determine whether physical examination, laboratory, or radiographic abnormalities in foals with Rhodococcus equi infection were associated with survival, ability to race at least once after recovery, or, for foals that survived and went on to race, subsequent racing performance.

DESIGN

Retrospective study.

ANIMALS

49 Thoroughbreds and 66 Standardbreds admitted to 1 of 6 veterinary teaching hospitals between 1984 and 1992 in which R equi infection was positively diagnosed.

PROCEDURE

Results of physical examination, laboratory testing, and thoracic radiography were reviewed. Indices of racing performance were obtained for foals that recovered and eventually raced and compared with values for the US racing population.

RESULTS

83 (72%) foals survived. Foals that did not survive were more likely to have extreme tachycardia (heart rate > 100 beats/min), be in respiratory distress, and have severe radiographic abnormalities on thoracic radiographs at the time of initial examination than were foals that survived. Clinicopathologic abnormalities were not associated with whether foals did or did not survive. Forty-five of the 83 surviving foals (54%) eventually raced at least once, but none of the factors examined was associated with whether foals went on to race. Racing performance of foals that raced as adults was not significantly different from that of the US racing population.

CLINICAL IMPLICATIONS

R equi infection in foals is associated with a decreased chance of racing as an adult; however, foals that eventually go on to race perform comparably to the US racing population.

Acute fulminating myasthenia gravis in five dogs

Acute fulminating myasthenia gravis (MG) was diagnosed in 5 dogs. Acute fulminating generalized MG in dogs is characterized by sudden onset of megaesophagus and frequent regurgitation of large volumes of fluid. Generalized muscle weakness can worsen and lead to recumbency within days. Despite appropriate supportive care, weakness is not alleviated by rest. Respiratory failure caused by aspiration pneumonia and loss of strength in muscles involved with respiration is a common cause of death. In dogs with acute onset of regurgitation, MG should be considered as a differential diagnosis. Clinicians should be aware of the risk of rapid progression to quadriparesis if aspiration pneumonia develops.

Surfactant protein-B and lung function in surfactant-treated preterm lambs

We asked if the amount of SP-B (range 37-410 micrograms/ml) in surfactants used to treat preterm lambs at 123 days of gestation correlated with postnatal lung function or the SP-B content of surfactant recovered by alveolar washes after 10 h ventilation. Ventilation was initiated using a low tidal volume strategy to minimize early lung injury. There were small increases in compliance for the lambs treated with surfactants containing more than 37 micrograms/ml SP-B and an increased lung volume for lambs treated with a surfactant containing 385 micrograms/ml/ml relative to the surfactant containing 37 micrograms/ml SP-B. The amount of SP-B in the surfactant used for treatment correlated linearly with the amount of SP-B in the surfactant recovered from the lambs (r = 0.95, p < 0.001). Albumin leak from the vasculature to the airspace was low as was total protein in alveolar washes, indicating minimal lung injury. The SP-B content of surfactant (from 37 to 410 micrograms/ml) had minimal effects on postnatal lung function over a 10-hour study period in lambs ventilated in a manner to minimize lung injury.

The relation of ventilatory failure to pulmonary, respiratory muscle and central nervous system disturbances in calves with an experimentally produced pneumonia

To explore the pathophysiology of respiratory failure in an experimental pneumonia, a Pasteurella haemolytica broth culture was injected intratracheally into 12 calves, which were then studied over a period of 10 h. Measurements were made of inspired minute ventilation (VE), ventilatory pattern [inspiratory time (TI), expiratory time (TE), respiratory rate (RR) and tidal volume (VT)], transdiaphragmatic pressure (Pdi), occlusion pressure at the airway opening 100 milliseconds after onset of inspiration (Pawo100ms), arterial blood gas tensions and pH and recorded diaphragmatic electromyogram (EMGdi) and rectal temperature (Tr). On and after the third hour after inoculation, the animals varied in respect of clinical signs, Tr, RR, VE, Pawo100ms/EMGdi, and arterial gases and pH. In benign cases, diminished alertness, laboured respiration and fall of arterial oxygen pressure (PaO2) worsened up to 7 h after inoculation, but then progressively improved, VE being maintained at approximately 150% baseline throughout the study (10 h). Neither arterial carbon dioxide pressure (PaCO2) nor pH was altered. Moderate cases resembled benign cases in respect of laboured respiration, VE, PaO2 and PaCO2; however, pH was at first maintained at preinoculation levels, but declined thereafter. In severe cases, the animals were drowsy between hours 3 and 7, and became comatose between hours 8 and 10; in contrast to both benign and moderate cases: (1) RR was reduced by hour 5, (2) there was no trend towards recovery of PaO2 and pH, (3) VE, Pdi, Pawo100ms and Pawo100ms/EMGdi were severely decreased, and (4) PaCO2 increased. These results suggest that pneumonia does not alter ventilatory neuromuscular pump function in calves, unless concomitant cardiovascular collapse occurs. It is not clear whether fatal ventilatory failure is caused mainly by deterioration in ventilatory muscle fibre processes or structures, altered central nervous system adjustment of ventilatory timing, or cardiovascular dysfunction. However, inspiratory pressures fall when excitation to the diaphragm is still growing, which suggests peripheral respiratory muscle fatigue.

Tracheal resection and anastomosis for an intratracheal chondroma in a ball python

A 9-year-old female ball python was evaluated for lethargy and respiratory compromise. Radiographic and endoscopic examination revealed a 1-cm intratracheal mass occluding the tracheal lumen. A partial tracheal resection and anastomosis was performed to remove the mass. On histologic examination, the mass was determined to be an intratracheal chondroma. Eosinophilic cytoplasmic inclusions observed within the tissue were calcium deposits. Electron microscopy was used to differentiate these from viral inclusion bodies often associated with neoplasms in reptiles. Endoscopic evaluation of the trachea 5 weeks after surgery revealed complete healing and minimal stenosis at the surgery site. Indications of tumor regrowth were not evident. Clinical signs of recurrence of respiratory compromise had not been observed 9 months after surgery.

The impact of the 1993 Braer oil spill on grey seals in Shetland

Signs of acute respiratory distress were reported in moulting grey seals (Halichoerus grypus) hauled out on Lady's Holm, Shetland, following the Braer oil spill in January, 1993. Behavioural observations carried out between 16 January and 13 February 1993 showed that the proportion of animals exhibiting a discharge of nasal mucus was significantly higher than the proportion at a control site in the north (Papa Stour). The proportion of animals affected on Lady's Holm increased for up to one month following the spill. However, the time lag between exposure and peak response was approximately 30 days, longer than may be expected for an acute effect. The proportion of non-specific signs of respiratory distress in unexposed Shetland seals was assessed from observations made between 16 January and 25 January 1994. Symptoms similar to those seen in 1993 were also reported during this period, but the proportion of affected animals was higher in 1993. Symptoms were not observed at a grey seal moult site on the east coast of England in March 1993 and 1994. Grey seals moulting in Shetland during the time of the oil spill may have been acutely affected by exposure to hydrocarbons, but without sufficient baseline data on the occurrence of respiratory distress in grey seals it is difficult to determine the proportion attributable to other causes.

Pulmonary function changes induced by three regimens of bronchodilating agents in calves with acute respiratory distress syndrome

Two aerosolised bronchodilators, one sympathomimetic and one parasympatholytic, were tested either alone or in combination for their ability to improve the pulmonary function of double-muscled calves suffering from acute respiratory distress syndrome. In control animals treated with 0.9 per cent saline the parameters of pulmonary function and signs of clinical distress did not change significantly within the hour following the first treatment. Among the other animals, both at one hour and seven days after the first treatment, the most clinical improvement was observed in the animals treated with both bronchodilators and the least in the animals treated with clenbuterol hydrochloride. One hour after the first treatment the respiratory system compliance of the animals treated with ipratropium bromide and the arterial oxygen tension of the animals treated with both bronchodilators were significantly enhanced. After seven days the resistive parameters, the rectal temperature and the respiratory rate were also significantly improved in the animals treated with ipratropium bromide or both bronchodilators whereas only the respiratory rate and rectal temperature were significantly reduced in the animals treated with clenbuterol hydrochloride.