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Managing the dyspnoeic emergency patient

Ava Firth and Amanda Boag

Ava Firth has been working in emergency and critical care since 1986. Originally from the USA, she has held positions in both academic and private emergency practice in the USA, Australia and the UK. She is currently a clinical training specialist with Vets Now, based at its Nottingham clinic.

Correct and rapid management of respiratory emergencies is demanded of almost every veterinary practitioner. A structured, logical approach to the dyspnoeic patient will maximise the chance of a successful outcome. This article looks at initial treatment of respiratory emergencies as well as respiratory diseases of the lower and upper airway and thoracic cage.

Amanda Boag graduated from Cambridge University in 1998. She undertook further clinical training at the Royal Veterinary College and the University of Pennsylvania and is board certied in both Internal Medicine and Emergency and Critical Care. In September 2008, she took up the post of clinical director at Vets Now where she has responsibility for clinical standards and training. She acts as a veterinary consultant for the Pet Blood Bank and the Veterinary Poisons Information Service and is currently president of the European Society of Emergency and Critical Care.

A PaTIENT in respiratory distress affords the practitioner very little margin for error or hesitation. Fortunately, the majority of dyspnoeic patients respond well to oxygen therapy and a few key management strategies. These techniques allow the veterinary surgeon to alleviate life-threatening distress and allow time for definitive diagnostics and treatments to be accomplished. All veterinary practice staff, including receptionists, should be trained to recognise the signs of dysp noea. Postural manifestations of dyspnoea such as open-mouth breathing, an extended neck, abducted elbows and an anxious facial expression may be seen. Some patients will appear distressed by the respiratory effort whereas others may seem behaviourally normal; the second group commonly have a more insidious onset to their respiratory signs.

All patients with severe hypoxaemia should have their activity restricted. Any potentially stressful procedures, such as catheter placement or radiography, should be carried out cautiously and incrementally, while providing supplemental oxygen and allowing time for recovery between steps. When working with dyspnoeic patients, one should always be prepared for emergency intubation. This includes assembly of the appropriate equipment, including a good light source, which should be kept ready for use when the patient is stabilised.

Patient positioning
Patient position can significantly affect arterial oxygen concentration. Putting the animal in sternal recumbency is a simple but effective way of increasing oxygenation.

Provide oxygen
It is never wrong to administer oxygen and it should be the first therapy given to any dyspnoeic patient. Oxygen supplementation can be provided by a variety of methods. An oxygen source and non-rebreathing anaesthetic circuit plus or minus a face mask are all that are necessary to provide immediate oxygen to almost any patient for the first 15 to 30 minutes. The oxygen source can be from an anaesthetic machine, from a single cylinder with a regulator or from a piped gas supply. Flow-by oxygen can be administered simply by holding the open end of the breathing circuit in front of the patients nose or mouth. A flow rate between three and 15 litres/minute is recommended, depending on the size of the patient. The efficacy of this is minimal, however, and it is only a short-term solution until other strategies can be put in place. If tolerated by the patient, a mask is the next step, to focus the flow of oxygen towards the patients face. If a mask is used, the rubber diaphragm should be removed from around the edge to allow exhalation of carbon dioxide (Fig 1). Nasal prongs made for humans come in adult and paediatric sizes, and are an inexpensive, non-invasive way of providing supplemental oxygen to most sizes of dogs. Unfortunately, the prongs are too big for cats noses. The prongs are gently inserted into the nostrils and the loop is then secured over the back of the head,

Initial treatment
Minimise stress
Minimising stress is vital in the dyspnoeic patient. Animals with severe hypoxaemia should have their movement limited in order to maintain sufficient oxygenation. Any increase in non-essential tissue oxygen consumption, such as that caused by struggling against a restraint, may precipitate cardiorespiratory arrest.

doi:10.1136/inp.e7376

Fig 1: An oxygen mask. The rubber rim should be removed when in use to support dyspnoeic patients

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behind the ears. A piece of tape across the bridge of the nose helps to keep the tubing in place (Fig 2). For those patients that will tolerate them, nasal prongs can be a useful means of medium term oxygen supplementation Oxygen cages may be useful for very small patients and those that cannot tolerate any restraint whatsoever. Their use is often limited by lack of availability, especially for larger patients. Moreover, oxygen cages are inefficient and prevent frequent examination of the patient. A small cage that measures only 50 cm 50 cm 40 cm has a volume of 100 litres, and it will take a minimum of 10 minutes to achieve adequate oxygen levels if flow rates are 10 litres/minute. Finally, accumulation of carbon dioxide and increases in temperature and humidity can limit the usefulness of some cages. After the initial 15 to 30 minutes, nasal oxygen catheters are the most economical and efficient way to provide oxygen supplementation for a longer period of time. Placing them requires only topical anaesthetic; sedation is not usually required (Box 1). The simplest source of oxygen in an emergency is the anaesthetic machine, but it is worth planning how to deliver oxygen in your practice independently of the anaesthetic machine for an extended period of time. An old anaesthetic machine without a vaporiser can be used to provide an oxygen flowmeter. If oxygen is supplied as piped gas, then a separate oxygen flowmeter can be purchased at an economical price. Variable diameter flexible tubing is also remarkably economical and can be purchased in 50 metre rolls, which allows customisation of the connections and use whatever length is required. Humidification of the oxygen source should be provided when nasal prongs or nasal catheters are used in the medium to long term, as oxygen is quite drying to the nasal passages. Disposable humidification chambers are available and are quite economical. obvious. With severe inspiratory effort of any cause, a paradoxical or asynchronous pattern may develop where the abdomen moves in while the thoracic wall moves outwards. This occurs when the intercostal muscle contractions moving the ribs up and out on inspiration are powerful enough to pull the diaphragm forwards and Fig 2: Dog wearing nasal prongs with a tape bridge hence the abdomen in. Common causes of asynchronous breathing include upper airway obstruction, non-compliant (stiff) lungs with a variety of parenchymal diseases, severe chronic pleural effusion and diaphragmatic rupture/paralysis; it is also associated with chest wall damage in cats (Sigrist and others 2011). Physical examination of the dyspnoeic patient focuses on two things sound and movement. Look carefully at the expansion of the rib cage and whether there is any abdominal movement. Then, even before auscultation, listen for audible noises while doing a visual assessment of the patients respiratory effort. Decide whether any noises heard coincide with inspiration or expiration. There are characteristic noises associated with an abnormality of each major anatomical region; these regions are the upper airway, lower airway, parenchyma or pleural space. Most upper airway obstructions nares, pharynx, larynx, trachea are characterised by inspiratory stridor (a high-pitched, whistling musical sound) or stertor (a low-pitched snoring sound), and an open mouth on inspiration. The exception to this rule is a complete obstruction of the larynx or trachea, such as that caused by a ball these patients are literally gasping for breath, but make no noise. Urgent intervention is required for these patients. Careful and patient auscultation is the next step in localising airway lesions and should be used to discriminate between lower airway, parenchymal and pleural space disease. Lower airway problems, typified by feline asthma, result in a high-pitched expiratory wheeze. Parenchymal problems, such as pneumonia or pulmonary oedema, will create harsh breath sounds and possibly crackles. Pleural space lesions will result in reduced lung sounds for the amount of breathing effort and decreased variation between inspiratory and expiratory breath sounds. If pleural space disease is present, auscultation can also help the clinician to decide whether it is an accumulation of fluid, air or soft tissue. If the pleural space is filled with air, then lung sounds will tend to be dull or absent dorsally. With pleural fluid, sounds will be duller or absent ventrally and sounds may be harsher dorsally, resulting in a reversal of the normal distribution of lung sounds. With soft tissue, sounds will be dull in specific areas reflecting the distribution of the soft tissue. Percussion may also be useful, with pneumothorax being associated with hyper-resonance. After localising the problem to an anatomical region,
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Examine the patient and localise the problem

All emergency patients should be triaged and examined in a systematic manner, which includes evaluation of the respiratory system. The goal of initial physical examination in the dyspnoeic patient is to localise the problem anatomically within the respiratory tract. It is important to be able to localise the primary respiratory problem rapidly, based solely on physical examination and auscultation, because the anatomical location has important implications for treatment and diagnostic strategies. Radiographs are more appropriately used to define the extent and specific nature of the problem, rather than to provide the primary anatomical location. The first step in localising airway lesions is to understand how the anatomical regions act in concert to create what we see as a respiratory pattern. It is then possible to predict how a lesion in a given anatomical region will change the pattern of respiratory excursion. In normal patients, the thorax and abdomen move together and in the same direction, that is, both the rib cage and the abdomen will expand outwards on inspiration. This is called a synchronous pattern. Normal cats and dogs have a respiratory rate of 15 to 25 breaths per minute with only a small amount of thoracic and even less abdominal movement. As respiratory effort increases, thoracic and abdominal wall movement become more

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Box 1: Nasal oxygen catheter placement

Soft, pliable tubes (usually silicone) should be used to provide the maximum amount of comfort for your patient. The diameter and length of the tube required varies; adult cats and small dogs will generally require a 5 Fr diameter tube, mediumsized dogs will generally take an 8 Fr, and large dogs will take a 10 Fr. A length of 25 cm is sufcient for almost all patients. If correctly positioned, the nasal oxygen catheter will enter the nostril, travel through the ventral meatus of the sinus and exit the choana, where the tip will sit on top of the soft palate. Oxygen will then be supplied to the nasopharynx. Accessing the ventral meatus requires accurate positioning of the patient, your hand and the tube. The dorsal meatus is also accessible from the nares, but does not connect with the nasopharynx so cannot be used for oxygen supplementation. Although some authors recommend inserting the catheter only to the level of the carnassial tooth or medial canthus of the eye, this depth of positioning is often insufcient to prevent the patient from sneezing out the catheter. Advance the catheter to the level of the lateral canthus instead. Equipment list 5-10 Fr soft, closed-end tube (15 to 25 cm long) KY Jelly (Johnson & Johnson) Local anaesthetic 2 ml syringe Elastoplast (two pieces of 5 cm each) 20 g hypodermic needle One or two pieces of nylon (20 cm long) Superglue Marker pen Patient positioning The patient can be restrained in either sternal or lateral recumbency. If the patient is conscious, you will need an assistant to hold the patient and restrain the head. Topical anaesthesia Topical anaesthesia is required for tube placement; there are several options: Proxymetacaine (topical ophthalmic) drops Local anaesthetic laryngeal sprays (eg, Intubeaze, Dechra) Lidocaine (0.5-1 ml 20 per cent lidocaine) drawn into syringe and expelled into nostril Regardless of anaesthetic used, it must be applied a sufcient time before placing the tube to be effective (typically ve to 10 minutes). Placement (1) Measure the tube from the tip of the nostril to the lateral canthus. Then make a buttery tape tab with a piece of the Elastoplast and place it around the catheter at this point, so that the front edge of the tape tab will sit at the edge of the patients nostril (a). (2) Lubricate the tube tip. (3) Grasp the top of the patients muzzle and head with your nondominant hand. Place your fingers across the muzzle and your thumb on the tip of the nose, pushing the nasal planum slightly upwards (b). This will give you a rm grip on the patients muzzle even if the dog is panting. This manoeuvre will also help to open up the ventral meatus.

(4) With your dominant hand, hold the tip of the catheter as if throwing darts. Aim the catheter ventrally, at about a 60 degree angle and medially (as if trying to hit the angle of the mandible on the opposite side) (c).

(5) Push the catheter firmly into the ventral meatus a few cm at a time, letting go of the catheter quickly after each advance. It should feed smoothly (d).

(6) If the tube will not advance after the rst few centimetres, it may be in the dorsal meatus. Pull the tube back to just inside the nares, redirect it more ventrally and advance it again. (7) Advance the tube to its premarked position at the level of the patients lateral canthus (e). The tip of the tube will be sitting on top of the soft palate.

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Securing and dressing (8) The tube must be secured immediately as it exits the nostril (that is, before the haired skin starts). It should then be laid either along the side of the patients muzzle or up the bridge of the nose between the eyes; either is acceptable dependent on the patients conformation and comfort (f).

The tube should be secured on at least two additional sites (j). No matter what technique is used to secure the tube, a Buster collar should be placed on the patient.

(9) There are two methods of securing the tube, both of which use tape butteries: Cyanoacrylate (tissue) glue: place a small dot of glue onto the tape buttery and press rmly onto the patients skin or hair. Warning: tissue glue may leave a permanent bald patch, so use with caution in show animals and animals with very short hair (g). Suture: use nylon to suture the tape butterfly to the skin. Two sutures should be placed per buttery. The suture can be placed either using nylon with a swaged on needle or by placing a hypodermic needle through the skin and buttery and then passing a piece of suture through the needle (h). The needle is then removed before the suture is tied by hand. Make sure that the first suture is as close as possible to the edge of the nostril (i). This is essential to keep the tube from slipping backwards out of the nose.

Connecting to oxygen (10) Connect the catheter to an oxygen source, using bubbler humidier if available. A combination of a couple of endotracheal adapters and an intravenous extension set can be used to connect the patient to an anaesthetic machine as an oxygen source (k). Oxygen ow rates of 50 to 100 ml/kg are usual. If you can hear hissing, then the flow rates are too high. Label the tube DO NOT INJECT.

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the clinician may then provide appropriate interventions for the patient in severe distress. Examples of these interventions might be immediate thoracocentesis for a pneumothorax or transtracheal oxygen for a pharyngeal foreign body. If the patients circumstances are less critical then the clinician faces the usual process of defining the problem more precisely and establishing a diagnosis. Common emergency problems are outlined below, categorised by anatomical region. accounts for the vast majority of patients presenting with signs of laryngeal obstruction, other causes are possible. They should be considered more likely if the signalment or history is atypical, or if the patient has clinical signs consistent with a fixed as opposed to dynamic laryngeal obstruction. The neck should be palpated for evidence of laryngeal, perilaryngeal or tracheal masses. Radiographs of the larynx, trachea and thorax should be taken after the initial dyspnoea is resolved and while maintaining oxygen supplementation. Penetrating foreign bodies, such as sticks, may not have remained in the airway but can cause perilaryngeal tissue swelling and effective laryngeal obstruction. Anticoagulant rodenticides may also cause bleeding in the airway or mediastinum, which can present similarly to laryngeal obstruction. A coagulopathy should be ruled out before performing a tracheostomy. Cats develop laryngeal disease much less commonly than dogs, but inflammatory conditions such as granulomatous laryngitis (Costello and others 2001), and neoplastic processes such as lymphoma, have been reported. Histology is required for a definitive diagnosis as gross appearance is unreliable. Some patients with laryngeal oedema can benefit from anti-inflammatory doses of corticosteroids such as dexamethasone 0.3 mg/kg intravenously every 12 hours. However, steroids are not a definitive solution and the clinician should be confident that there is no infectious or neoplastic process present before administering corticosteroids.

Upper airway disease

The most common upper airway diseases seen in non-brachycephalic dogs are laryngeal paralysis in large breeds and collapsing trachea in small breeds. However, other differentials (eg, foreign bodies or neo plasia) should always be considered. Nasopharyngeal polyps are a common cause of upper airway obstruction in the cat.

Laryngeal paralysis
The development of laryngeal paralysis is usually insidious but often aggravated by an exercise episode or the onset of warm weather with resultant heat stress. Sedation with acepromazine (0.005 to 0.05 mg/kg intravenously or intramuscularly to effect) is indicated if the patient is otherwise stable with no cardiovascular disease or hypovolaemia. Other sedation protocols should be considered for patients with cardiovascular instability or other concurrent disease that stops the use of acepromazine. Patients with an acute crisis are also frequently hyperthermic and active cooling measures (eg, use of a fan or cooled intravenous fluids) may be required. A nasal or nasotracheal oxygen catheter can be used to supplement oxygen in mildly affected patients. Placing a nasotracheal catheter requires a short period of general anaesthesia, during which thecatheter is placed through the nose, through the arytenoids and into the trachea to the level of the thoracic inlet. Providing oxygen through this catheter then bypasses the laryngeal obstruction and will often keep the patient comfortable. This technique is most useful in mild cases where appropriate surgical expertise to allow definitive treatment is not available for 12 to 24 hours. A transtracheal catheter can also be placed, using a 14 or 16 gauge intravenous catheter, to facilitate entry. However, the rate of flow of oxygen that is possible though this catheter is generally insufficient to support large dogs. Severe cases may require a period of general anaesthesia and endotracheal intubation. Administering general anaesthesia allows examination of the laryngeal function and breaks the cycle of patient distress and hyperthermia. In severely affected patients, who cannot be extubated successfully, a temporary tracheostomy can be performed until such time that definitive surgical intervention is possible. The majority of dogs with laryngeal paralysis will, however, stabilise with additional oxygen, sedation and cooling, allowing the definitive surgical pro cedure to be performed on an elective basis.

Brachycephalic airway obstructive syndrome

Brachycephalic airway obstructive syndrome (BAOS) is a combination of anatomical abnormalities common in brachycephalic breeds, including stenotic nares, elongated soft palate, everted laryngeal saccules and hypoplastic trachea. These structural abnormalities result in the characteristic stertor commonly heard. Even very young two to three month old brachycephalic animals may have significant anatomical abnormalities and clinical signs. Emergency management consists of sedation and oxygen supplementation, by whatever means tolerated by the patient, followed by prompt referral to a surgeon for definitive treatment.

Tracheal collapse
Tracheal collapse is a progressive disease in which the cartilage rings of the trachea lose their structural integrity. Toy breeds, especially Yorkshire terriers, are commonly affected. Tracheal collapse can be intrathoracic, extrathoracic or both. Plain lateral radiographs can sometimes be helpful in documenting the condition, but fluoroscopy and/or endoscopy provides definitive diagnosis. The extrathoracic trachea collapses during inspiration, and the intrathoracic trachea and mainstem bronchi collapse during expiration. Initial emergency management is similar to other causes of upper airway obstruction such as oxygen supplementation, reduction of stress and sedation/anxiolysis. Drugs used in the medium- to longterm medical management of the disease may also be introduced, including bronchodilators such as terb utaline or salbutamol, low doses of anti-inflammatory drugs such as prednisolone, and cough suppressants such as codeine. Owners need to be informed that this

Other causes of laryngeal oedema and laryngeal obstruction

Although idiopathic or congenital laryngeal paralysis

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condition can be managed but is unlikely to be cured. Overweight patients should be put on a strict weight loss plan. Possible environmental allergens or secondhand smoke should be investigated and removed. Invasive management options (eg, surgery or stenting) are available, although the prognosis is variable because of the wide range of dysfunction.

Pulmonary oedema
Pulmonary oedema has a variety of causes in both the dog and cat. Radiographs are helpful in characterising its distribution. Pulmonary oedema secondary to cardiac disease has a characteristic perihilar distribution in dogs, but can be patchy and diffuse in cats. Dogs with cardiogenic pulmonary oedema are very likely to have an auscultable murmur or significant arrhythmia. Most, but not all, cats will have either a murmur or a gallop rhythm if cardiac disease is the cause of pulmonary oedema. Cardiac ultrasound can be used even in an emergency setting to assess the left ventricular wall thickness, contractility and the left atrial:aortic root ratio (Barr 2007). Initial medical management of pulmonary oedema secondary to congestive heart failure consists principally of diuretics, such as furosemide 2 to 4 mg/kg intravenously every two to four hours. Severely affected cases may benefit from other drug therapies especially positive inotropes, such as pimobendan or dobutamine. However, decisions on the appropriateness of these drugs requires a good understanding of the nature of the underlying cardiac disease and is beyond the scope of this article. Non-cardiogenic causes of pulmonary oedema in emergency patients include seizures, head trauma, electrocution and secondary to upper airway obstruction. Typically, non-cardiogenic pulmonary oedema and dyspnoea will develop in the hour following the inciting cause, although a delay of up to 12 hours is possible. Radiographs can show either an alveolar or interstitial pattern, with the dorsocaudal lung fields usually being the first and worst affected. Regardless of the aetiology of pulmonary oedema, oxygen supplementation is used to support the patient while medical management takes effect. Some patients require positive pressure ventilation due to the severity of the oedema.

Lower airway disease

The lower airway is defined as the region from the carina to the alveoli. Diseases of this region are an uncommon cause of dyspnoea in small animals, with the exception of feline allergic airway disease. Feline allergic airway disease is a common cause of dyspnoea in cats, and can be quite spectacular in presentation. Some owners will report that the cat has been retching, coughing or vomiting. These patients may present with tachypnoea, open-mouth breathing, and laboured respiratory effort. The cat may appear to be gasping for breath, leading one to think initially that it is an inspiratory problem. However, closer examination will reveal pronounced expiratory effort, thus localising the problem to the lower airway. Auscultation will usually reveal a char acteristic expiratory wheeze. Radiographic findings are often non-specific but may show a bronchial pattern. Emergency treatment consists of oxygen supplementation, dexamethasone 0.2 mg/kg intravenously/intramuscularly, and a bronchodilator such as terbutaline 0.1 mg/kg intramuscularly/subcutaneously or intramuscularly. Some improvement should be seen within 30 to 60 minutes. The use of inhaled bronchodilators and corticosteroids is becoming more common and works well in some cats as part of a long-term management plan. However, unless the cat is familiar with this route of administration, it may simply increase stress during an acute dyspnoeic episode. Cases of feline allergic airway disease are quite likely to recur and are potentially fatal if appropriate long-term medical management is not started. It is therefore important to explain to the client that, even if the acute episode resolves rapidly, a full diagnostic work-up and long-term management plan should be pursued. The AeroKat chamber (Trudell Medical, www.aerokat.com) provides a method of adapting human inhalant medications to a mask delivery system that is well tolerated by most cats after an initial acclimatisation period. Videos on YouTube can help educate the owners: one shows a cat having a characteristic asthma attack (www.youtube.com/ watch?v=vkebV2tv_cs&feature=related); another shows a cat being administered inhalant medication using an AeroKat chamber (www.youtube.com/watch? v=chvRhvDgeS8&feature=related).

Pulmonary contusions
Pulmonary contusions are a common problem in trauma patients and occur when blood accumulates in the alveoli following blunt chest trauma. Intravenous fluid therapy in patients with pulmonary contusions needs to be conservative, with the aim of restoring perfusion while minimising the risk of increased pulmonary hydrostatic pressure with consequent worsening of contusions. Nasal oxygen supplementation is often useful in mild-to-moderate cases. Prognosis in these cases is good although they may require oxygen support for two to three days. Severe cases may require long-term ventilation; even if this is available, prognosis is guarded to grave. It is important to realise when treating these patients and counselling owners that it is common for patients with pulmonary contusions to deteriorate in the first six to 12 hours before they start to improve.

Parenchymal disease
Parenchymal disease (disease of the alveoli and/or pulmonary interstitium) is characterised by an inspiratory or mixed breathing pattern. On auscultation, pulmo nary noises are generally louder than expected for the degree of breathing effort. Crackles may be heard and are more common as the disease worsens. There are a large number of differential diagnoses for the patient with parenchymal disease; some of the common ones seen in emergency patients are discussed briefly below.

Pneumonia
Viral, bacterial, parasitic and even fungal pneumonia may all be causes of parenchymal disease in patients presenting with dyspnoea. Aspiration of gastric contents is a common causes of bacterial pneumonia, especially in dogs, and should be considered in any dog that becomes dyspnoeic following vomiting or dysphagia. Radiographs show that the changes are variable, with the right middle lung lobe being most commonly
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affected (Kogan and others 2008). Ideally, samples for cytology and culture are obtained from the lungs before starting therapy. A transtracheal wash is an effective way of obtaining these samples in conscious or sedated emergency patients. Successful treatment relies on diagnosis of the underlying infectious agent. In the emergency situation, oxygen supplementation should be used to alleviate the signs of dyspnoea. Fluid therapy should be used cautiously to avoid sudden increases in pulmonary hydrostatic pressure that may worsen pulmonary fluid extravasation. Empirical treatment for likely infectious agents should be started pending results of diagnostic tests. Parasitic pneumonia (most commonly angiostrongylosis in UK) may be diagnosed by faecal smear or a Baermanns test.
Table 1: Causes of pleural space disease Substance present in pleural space Air Tissue Blood Key differential diagnoses Trauma Idiopathic (eg, bulla rupture) Diaphragmatic rupture Neoplasia Coagulopathy (eg, rodenticide toxicity) Trauma (rare to cause dyspnoea) Severe hypoproteinaemia Congestive heart failure Vasculitis Congestive heart failure Lung lobe torsion Idiopathic chylothorax Bacterial infection (pyothorax) Neoplasia Feline infectious peritonitis

Transudate (uncommon) Modified transudate Chylothorax/ pseudochylous effusion Exudate

Pleural space disease

Pleural space lesions typically cause the patient to develop a characteristic pattern of rapid, shallow breathing regardless of what is actually filling the pleural space. Numerous aetiologies are possible (Table 1). The approach to all patients where pleural space is possible or suspected based on signalment, history and observation of the breathing pattern is similar. (1) Confirm suspicion by the finding of dull lung sounds on auscultation; (2) diagnostic/therapeutic thoracocentesis; (3) radiographs; and (4) definitive drainage if necessary. Importantly, thoracocentesis should precede radiographs in patients displaying respiratory distress and can be life-saving as well as diagnostic. Optimal management of pyothorax cases is debated but generally requires an indwelling chest drain for successful resolution (Johnson and others 2007; Barrs and others 2005; Rooney and others 2002). However, other causes of pleural space disease can usually be managed by intermittent thoracocentesis, coupled with medical therapy, to reduce the speed of fluid accumulation.

times have a complete mediastinum that necessitates bilateral chest drains. The use of small-bore, wireguided chest drains has recently been evaluated and is encouraged (Valtolina and others 2009).

Pneumothorax
Most, but not all, pneumothorax patients have a history of trauma. Signs of cardiovascular instability (shock) may be present if a tension pneumothorax has occurred. However, this is rare. Thoracocentesis should be performed as soon as there is a suspicion of a pneumothorax. Radiographs should be taken once the pneumothorax has been drained to ascertain if there is any concurrent pathology in the pulmonary parenchyma or ventilatory apparatus. The effectiveness of thoracocentesis can be determined principally by an improvement in the signs of dyspnoea and confirmed by radiography. If the pneumothorax redevelops over a short timeframe, an indwelling chest drain may need to be placed. The decision to place a chest drain should be made on an individual patient basis; however, the need to perform three thoracocentesis procedures to manage the dyspnoea over a short time frame (hours), suggests that a chest drain may be required. Open pneumothorax occurs rarely but can be very dramatic. These patients have a wound that creates an open communication between the exterior and the pleural space; some patients present with remarkably mild signs whereas others present in respiratory arrest. To stabilize the patient, the wound should immediately be covered with a water-soluble gel, such as KY Jelly (Johnson & Johnson), and an occlusive dressing providing a temporary airtight seal. The pleural space should then be evacuated by needle thoracocentesis. In severe cases, the patient may need to be anaesthetised, intubated and ventilated to allow this. A chest tube may then be inserted on the same side of the thorax, and the animal stabilised for definitive surgical treatment.

Pleural effusion
Pleural effusion may occur secondary to a large number of underlying diagnoses (Table 1). Respiratory signs are usually a result of restriction of expansion of the lungs resulting in small, rapid respirations. Effusions are typically bilateral but may be unilateral. If pleural effusion is suspected in an animal with severe respiratory distress, thoracocentesis is often diagnostic and therapeutic. The total protein of the fluid should be measured to establish whether it is a transudate, modified transudate or exudate, and a fluid sample should be examined microscopically.

Pyothorax
Pyothorax is a relatively common cause of pleural effusion especially in young, outdoor cats. These cats should be managed with thoracocentesis for the first 12 to 24 hours, while intravenous fluids and broad spectrum, intravenous antibiotics are used to stabilise any systemic signs. Definitive resolution of a pyotho rax is rarely achieved without placement of an indwelling chest drain. After placing a chest drain on one side, care should be taken to check that both sides of the chest are responding to drainage, because cats some-

Thoracic cage
Rib fractures
Rib fractures are often associated with pulmonary

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Dyspnoeic cats a special challenge

Dyspnoeic cats present many challenges, most importantly in their requirements for smooth handling and a quiet, quick approach. Cats have little reserve once they are overtly dyspnoeic and may not survive if they are treated in the same manner as a dog. Under normal circumstances, the respiratory excursion of a cat is barely perceptible. Therefore, any cat with visibly obvious respiratory effort should be handled carefully and presumed hypoxic until proven otherwise. Preoxygenation is very helpful even before physical examination, and certainly should be done before any procedures are undertaken. An oxygen cage can be very helpful in this regard and oxygen cages suitable for cats are more readily available than those for dogs. Radiographs should only be taken after the cat has had preoxygenation. Diagnostic and therapeutic thoracocentesis should be done before radiographs if pleural space disease is suspected on the basis of physical examination. Radiography of a dyspnoeic cat warrants careful preparation and an extra pair of hands to minimise the usual fuss of measuring and positioning. There are three very common causes of dyspnoea in a cat: feline allergic airway disease (FAAD), pulmonary oedema secondary to cardiac disease, and pleural effusion secondary to a variety of causes. Emergency management of these conditions is discussed in the main body of this article. Patients with pleural space disease and FAAD typically respond rapidly to emergency management. For patients with pulmonary oedema secondary to cardiac disease, long-term oxygen supplementation may be required and can be administered in an oxygen cage or with a nasal oxygen catheter (Fig 3).

Fig 3: Nasal oxygen catheter in a cat

contusions or lacerations of intercostal blood vessels. Although pain, pneumo/haemothorax and inadequate movement of the affected segment of the chest wall all contribute to decreased ventilation and hypoxia, often it is the concurrent pulmonary contusions which impair oxygenation to the greatest degree. Rib fractures are generally managed conservatively with oxygen supplementation and analgesia. Systemic opioids are generally required but intercostal nerve blocks can also be considered to reduce pain and may improve ventilatory efforts.

Summary
Dyspnoeic patients are some of the most fragile patients that veterinary surgeons have to stabilise and treat. The list of possible causes for dyspnoea is long; however, the emergency approach to these patients can be simplified. All dyspnoeic patients will benefit from oxygen support and minimisation of stress. A thorough and insightful physical examination should then be used to localise the problem anatomically within the respiratory tract with further stabilisation measures targeted towards that location. Definitive diagnostic procedures should be delayed until stabilisation has been performed.
References
BARR, F. (2007) Imaging techniques in the critical patient. In: BSAVA Manual of Canine and Feline Emergency and Critical Care, 2nd edn. Eds L. G. King, A. K. Boag. BSAVA Publications BARRS, V. R., ALLAN, G. S., MARTIN, P., BEATTY, J. A. & MALIK, R. (2005) Feline pyothorax: a retrospective study of 27 cases in Australia. Journal of Feline Medicine and Surgery 7, 211-222 COSTELLO, M. F., KEITH, D., HENDRICK, M. & KING, L. (2001) Acute upper airway obstruction due to inflammatory laryngeal disease in 5 cats. Journal of Veterinary Emergency and Critical Care 11, 205-210 JOHNSON, M. S. & Martin, M. W. (2007) Successful medical treatment of 15 dogs with pyothorax. Journal of Small Animal Practice 48, 12-16 KOGAN, D. A., JOHNSON, L. R., JANDREY, K. E. & POLLARD, R. E. (2008) Clinical, clinicopatholgic, and radiographic findings in dogs with aspiration pneumonia: 88 cases (2004-2006). Journal of the American Veterinary Medical Association 233, 1742-1747 ROONEY, M. B. & MONNET, E. (2002) Medical and surgical treatment of pyothorax in dogs: 26 cases (1991-2001). Journal of the American Veterinary Medicial Association 221, 86-92 SIGRIST, N. E., ADAMIK, K. N., DOHERR, M. G. & SPRENG, D. E. (2011) Evaluation of respiratory parameters at presentation as clinical indicators of the respiratory localization in dogs and cats with respiratory distress. Journal of Veterinary Emergency and Critical Care 21, 13-23 VALTOLINA, C. & ADAMANTOS, S. (2009) Evaluation of small-bore wire-guided chest drains for management of pleural space disease. Journal of Small Animal Practice 50, 290-297

Flail chest
The term flail chest is used to describe an area of multiple fractured ribs. The disconnected area of chest wall may be seen moving in the opposite direction to the remainder of the thoracic cage with each inspiration. Although various fixation methods have been described historically, treatment is conservative and consists of good analgesia (use of a -receptor opioid agonist, such as morphine, is probably required), time and oxygen supplementation as necessary. External fixation is rarely required.

Diaphragmatic rupture
Diaphragmatic rupture with herniation of abdominal contents may create an asynchronous respiratory pattern. This respiratory pattern is also created by more diffuse problems that affect the function of the diaphragm and thoracic musculature, such as various myopathies, neuropathies and metabolic disorders. Chest or abdominal pain may also cause a reduced respiratory excursion and so may result in the same expiratory/ abdominal pattern. Radiographs are typically helpful in the diagnosis of diaphragmatic rupture. If radiographs are inconclusive, ultrasound may help to identify structural abnormalities. Immediate management of diaphragmatic hernias consists of oxygen administration and associated supportive care. Definitive management requires surgical repair of the hernia and continuous positive-pressure ventilation while under anaesthesia.

In Practice November/December 2012 | Volume 34 | 564-571

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Managing the dyspnoeic emergency Patient

Ava Firth and Amanda Boag In Practice 2012 34: 564-571

doi: 10.1136/inp.e7376

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