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APPROACH TO RESPIRATORY DISTRESS Peer Reviewed

Approach to Respiratory Distress


in Dogs & Cats
Claire R. Sharp, BSc, BVMS (Hons), MS, CMAVA, Diplomate ACVECC
Tufts University

Managing dogs and cats in respiratory distress Cooling Measures


is a multifaceted effort that involves stabilizing Animals with upper airway obstruction, such
patients prior to determining a definitive diagnosis. as those with laryngeal paralysis, may become
Fortunately, respiratory distressno matter what hyperthermic due to the increased work of
the causerequires somewhat standardized breathing. Because of the airway obstruction, these
interventions during initial stabilization. animals are unable to effectively pant, resulting in
inability to thermoregulate and dissipate heat. As
INITIAL STABILIZATION such, cooling hyperthermic patients in respiratory
One of the benefits of initial stabilization is that distress is an important component of initial
it provides the practitioner time to consider stabilization, and can be accomplished by: Minimizing
the appropriate diagnostic and subsequent Administering room temperature IV fluids Stress
therapeutic approach. Covering the patient with wet towels
Dogs and cats with
Putting a fan on the patient
respiratory distress
Oxygen Supplementation Applying alcohol to the axilla, inguinal area, and feet. are often fragile and
Initial stabilization of a patient in respiratory Active cooling should stop once the patients can decompensate
distress generally involves provision of oxygen temperature reaches 103F to avoid precipitating rapidly. Initial
hypothermia. evaluation should be
supplementation, with or without patient sedation.
performed rapidly,
The most common type of oxygen with minimal stress
Thoracocentesis
supplementation provided is use of an oxygen to the patient.
Initial stabilization may also include thoracocentesis, if
cage with a high fraction of inspired oxygen (FiO2) Often, one of the
severe respiratory distress is secondary to pleural space
(eg, 40%60%); a face mask or flow-by oxygen best first steps is
disease, such as pneumothorax or pleural effusion. to place the animal
from a hose can also be used.
In more extreme cases, animals in respiratory distress in an oxygen cage
INITIAL DIAGNOSTIC APPROACH and allow it to relax,
may require emergency intubation, higher FiO2 (eg,
Diagnostic approach to a patient in respiratory considering it has
100%), and provision of positive pressure ventilation usually been through
distress should consider the patients signalment and
in order to provide adequate respiratory stabilization. a stressful car
history as well as the broad anatomic differential
Particularly in cases of upper airway obstruction, diagnoses of dyspnea (Table 1, page 54). ride and changed
the practitioner may need to ensure a patent environments (home
airway by intubation or tracheostomy (if oral to car to clinic) that
Signalment can exacerbate
intubation is not possible). Clues in the patients signalment are common. distress.
For example:
Sedation Upper airway obstruction due to
Sedation with careful monitoring and, if necessary, brachycephalic airway disease is a common
intubation and ventilation can be extremely useful in cause of respiratory distress in brachycephalic
animals that have become anxious due to hypoxemia dogs, such as English bulldogs.
and/or hypercapnia. In some patients, especially Cardiogenic pulmonary edema is a common cause
dogs with upper airway obstruction, stabilization of respiratory distress in small breed dogs with
may require sedating the animal by administering chronic valvular disease (eg, mitral endocardiosis),
some form of anesthetic induction agent; then such as Cavalier King Charles spaniels.
clearing the oral cavity of obstructing material (eg, Lower airway obstruction associated with asthma is
secretions or foreign material in a choking animal) a common cause of respiratory distress in cats, with
prior to intubation or tracheostomy. certain breeds, such as the Siamese, overrepresented.

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History and the potential for cardiogenic pulmonary edema


History can also be extremely useful; for example: or pleural effusion.
History of blunt trauma (eg, hit by a car) should In general, breathing patterns help narrow the list
prompt concern for pulmonary contusions, of differential diagnoses (Table 1). For example,
pneumothorax, diaphragmatic hernia, or flail chest. upper airway obstruction is associated with inspiratory
In cats, a history of cough is consistent with dyspnea and an externally audible noise. In contrast,
asthma, while in dogs, a cough might suggest lower airway obstruction tends to be associated with
tracheobronchial disease, interstitial lung disease, expiratory dyspnea and wheeze, with the wheeze
or pulmonary edema. generally just audible on thoracic auscultation with a
stethoscope, rather than externally audible.
Physical Examination
Examining a patient with respiratory distress Diagnostic Tests
should involve: Extensive diagnostics should not be performed until
1. Initial observation: Consider breathing pattern, the patient has been stabilized as much as possible, a
presence of externally audible noise with breathing, brief physical examination has been performed, and
any signs of trauma, or abdominal distension the practitioner has localized the disease to the most
2. Lung auscultation: likely anatomic location (Table 1). Diagnostic tests
Increased adventitial lung sounds (eg, crackles, may subsequently involve:
wheezes, harsh lung sounds) are associated with Blood analysis: Screening blood tests, blood gases
lower airway and pulmonary parenchymal disease Imaging: Thoracic ultrasound, including focused
Decreased lung sounds, in an animal with assessment with sonography for trauma, triage, and
respiratory distress, are associated with pleural tracking (tFAST); thoracic radiographs; thoracic
space disease. computed tomography (CT); or echocardiography
3. Cardiac auscultation: A murmur, gallop, or other Respiratory fluid analysis: Bronchoalveolar
arrhythmia may indicate underlying cardiac disease lavage, thoracocentesis

Categories of Dogs and cats with respiratory distress can be classified into 8 disease categories, some of which are
associated with distinct breathing patterns observed during physical examination.1,2 These categories
Respiratory include both primary respiratory diseases and secondary causes of respiratory difficulty. Diagnostic
approach is determined by the category of disease causing respiratory distress.
Disease
Table 1.
Anatomic Classification: Causes of Respiratory Distress
DISEASE EXAMPLES BREATHING PATTERN
CATEGORY
1. Upper Airway Brachycephalic airway disease Inspiratory dyspnea
Obstruction Laryngeal paralysis Externally audible noise (eg, stertor, stridor)
2. Lower Airway Asthma Expiratory dyspnea
Obstruction Wheeze (audible with stethoscope)
3. Pulmonary Pneumonia Not consistent; may be rapid, shallow, or
Parenchymal Disease Interstitial lung disease both, and have both inspiratory and expira-
Pulmonary edema tory components
Pulmonary contusions
4. Vascular Pulmonary thromboembolism Not specific
5. Pleural Space Disease Pneumothorax Inspiratory dyspnea, rapid shallow breathing,
Pleural effusion or generalized paradoxical breathing
Reduced lung sounds on auscultation
6. Flail Chest Focal paradoxical breathing
7. Abdominal Distension Ascites Inspiratory dyspnea
Organomegaly
8. Look-alike Diseases Not specific

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Approach to Respiratory Distress Peer Reviewed

Airway examination: Upper airway examination, Clinical Signs


tracheobronchoscopy Characteristic signs in patients with an upper airway
Drug trials: Such as bronchodilators, diuretics, obstruction include inspiratory distress and an
and corticosteroids. externally audible noise associated with breathing (eg,
stertor, stridor). Tracheal disease is usually associated
UPPER AIRWAY OBSTRUCTION with a cough.
Etiology
Upper respiratory tract obstruction involves a Initial Stabilization
mechanical or functional obstruction of the upper Initial stabilization and therapy may involve:
(large) airways (ie, the pharynx, larynx, or trachea). Oxygen administration/securing an airway:
Nasal disorders are not considered in this article as Generally administered by face mask (if tolerated),
the animal should always be able to open its mouth flow-by oxygen, or oxygen cage, with intubation
and breathe, preventing the development of dyspnea or tracheostomy performed if needed
even if the nasal cavity is obstructed. Sedation: Achieved with anxiolytic drugs, such
Specific causes of upper airway obstruction include: as acepromazine or dexmedetomidine, or sedative
Naso-oropharyngeal disorders, including polyps analgesics, such as butorphanol (Table 2)
(especially in cats), masses, and foreign bodies Cooling: Many dogs with upper airway
Severe head trauma that results in bone fractures obstructions become hyperthermic due to inability
(especially nasal, jaw, and palatine fractures) and to dissipate heat through their upper airways;
associated hemorrhage and swelling the goal is to reduce body temperature to at least
Laryngeal disorders, including laryngeal 103F, while avoiding hypothermia
paralysis, laryngeal collapse, laryngeal masses (eg, Corticosteroids: Breathing against an obstruction
neoplasia, abscesses, granulomas), and laryngeal can result in marked edema of the upper airway
inflammation soft tissue; therefore, anti-inflammatory doses of
Tracheal diseases, including tracheal collapse, tracheal corticosteroids (eg, dexamethasone SP, 0.15 mg/kg
foreign body, tracheal stenosis, stricture, tracheal tear, IV single dose or Q 24 H) can be considered.
or tracheal mass (either intra- or extraluminal)
Brachycephalic airway disease, which involves Diagnostic Approach
a combination of primary and secondary anatomic Once the patient is stable, diagnostic tests can be pursued.
abnormalities of the upper airways, including Upper airway examination. Examination is
stenotic nares, an elongated soft palate, everted performed after preoxygenation under sedation. At
laryngeal saccules, laryngeal edema and/or collapse its most basic, examination may involve inspection
and, in some breeds (eg, English bulldog), a of the oropharynx and larynx with a laryngoscope;
hypoplastic trachea. in patients with suspected tracheal disease, it

In dogs, reasonable choices for sedation are


butorphanol, acepromazine, or dexmedetomidine,
however, it can produce undesirable effects,
such as bradycardia and hypotension.
Sedation for
while butorphanol is the drug of choice in cats. Regardless of the chosen drug, in potentially Patients in
Choice of drug(s) used for sedation/anxiolysis unstable patients, lower doses are given initially
should be based on the individual drugs and later increased as needed and tolerated by Respiratory
properties, and relative risks versus benefits for the
patient. For example:
the patient.
Distress
Butorphanol is a very safe and effective drug Table 2.
at recommended doses; however, it is relatively Patients in Respiratory Distress:
short acting (often only 12 hours) and cannot Sedative Drug Dosages
easily be reversed.
SEDATIVE DRUG DOSE RANGE
Acepromazine is also very effective; however,
it may be more likely to produce undesirable Butorphanol 0.10.4 mg/kg IM or
effects, such as hypotension; has a long duration IV Q 14 H, as needed
of action (46+ hours); and cannot be reversed. Acepromazine 0.0050.05 mg/kg IM or
Dexmedetomidine has the desirable quality IV Q 48 H, as needed
of being reversible (with atipamezole) and
Dexmedetomidine 0.010.1 mg/kg/H IV CRI
titratable (given a short duration of action);

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Peer Reviewed Approach to Respiratory Distress

may involve tracheobronchoscopy with a flexible Chronic bronchitis. Lower airway disease
bronchoscope or endoscope. in cats may also be associated with neutrophilic
When evaluating laryngeal function as part of an inflammation (often referred to as chronic
upper airway examination: bronchitis), or a combination of both eosinophilic
Take care to minimize the level of anesthesia to and neutrophilic inflammation.3 In dogs,
preserve laryngeal function as best as possible bronchomalaciaseen in severe, end-stage, chronic
Consider using the respiratory stimulant bronchitiscan also cause lower airway obstruction.
doxapram HCl (0.51.1 mg/kg IV) to stimulate
laryngeal motion Clinical Signs
Carefully observe inspiration versus expiration to Characteristic signs in an animal with lower airway
ensure that the larynx is abducting (increasing the obstruction usually include expiratory distress and,
aperture of the rima glottis) on inspiration (rather sometimes, an expiratory grunt or push. These patients
than on expiration as might occur with paradoxical may have an expiratory wheeze on thoracic auscultation
motion in patients with laryngeal paralysis). and, less commonly, an externally audible wheeze.
Cervical and thoracic radiographs are useful for
patients with laryngeal or tracheal disease to detect Initial Stabilization
masses and collapse. Initial stabilization and therapy usually involve:
Fluoroscopy is useful for detecting dynamic Oxygen supplementation: See recommendations
upper airway collapse that may not be visible on in the Initial Stabilization section (page 53)
standard radiographs. Bronchodilator trial: Options for an acute
bronchodilator trial include either:
Management Inhaled albuterol (1 or 2 puffs from a metered
Definitive management for upper respiratory tract dose inhaler with a spacer)
obstruction is extremely varied, depending on the Single dose of terbutaline (0.01 mg/kg IM or SC).3
definitive diagnosis, and beyond the scope of this review. Bronchodilator therapy often results in rapid
improvement in these patients (eg, within 515 minutes).
LOWER AIRWAY OBSTRUCTION
Etiology Diagnostic Approach
Lower airway obstruction is associated with a Once the patient is stable, the diagnostic approach
narrowed bronchial lumen, which can be caused by usually involves:3
varied pathophysiologic processes, including: Thoracic radiographs: Lower airway disease
Bronchial inflammation with edema and hyperemia is classically associated with a bronchial
of bronchial mucosa or bronchointerstitial pattern on thoracic
Bronchospasm radiographs. Additonally, air trapping in cats with
Bronchomalacia asthma may result in pulmonary hyperinflation
Mucus accumulation and a flattened diaphragm.
Acute anaphylactic reaction (uncommon). Lower airway cytology: Eosinophilic
In all of these conditions, the bronchial lumen inflammation (> 17% eosinophils) is characteristic
tends to close early during expiration, while it is of feline asthma, while neutrophilic inflammation
opened by radial traction from the lungs during is evident in dogs and cats with chronic bronchitis.
inhalation. Therefore, expiratory dyspnea is a Heartworm testing (ideally both antigen
hallmark of lower airway obstruction. and antibody tests): Determines if heartworm
associated respiratory disease is present in cats.
Specific Diseases Baermann fecal test: Evaluates for lungworm
Feline asthma and chronic bronchitis in dogs and disease.
cats are associated with accumulation of mucus in the
lower airways that contributes to obstruction. Management
Feline asthma. The classic disease in cats that Treatment of lower airway disease may involve
causes lower airway obstruction is feline asthma, bronchodilators, corticosteroids and, potentially,
the hallmarks of which are eosinophilic airway deworming in cats.4 See Treatment of Feline
inflammation, reversible bronchoconstriction and, Lower Airway Disease (March/April 2014),
ultimately, airway remodeling.3 available at tvpjournal.com.

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Approach to Respiratory Distress Peer Reviewed

PULMONARY PARENCHYMAL DISEASE receiving broad spectrum empiric antibiotics as


Etiology soon as possible.7
Pulmonary parenchymal diseases affect the terminal
and respiratory bronchioles, interstitium, alveoli, Diagnostic Approach
and vasculature. These diseases include pneumonia, Once the patient is stable, if cardiogenic pulmonary
pulmonary edema, interstitial lung disease, pulmonary edema is suspected, firstline diagnostics should include:
neoplasia, and others. Examples of pulmonary Thoracic radiographs
parenchymal diseases are listed in Table 3. Echocardiography.
When it is unclear whether the etiology is primary
Clinical Signs cardiac versus primary respiratory disease, other
Characteristic signs in an animal with pulmonary diagnostics can be performed, including:
parenchymal disease often include abnormally loud Measurement of serum NT-pBNP (aminoterminal
breathing sounds on thoracic auscultation, such as pro B-type natriuretic peptide)a biomarker
harsh lung sounds, crackles, and wheezes. Patients associated with atrial stretch, which is increased
with cardiogenic pulmonary edema may also have in dogs and cats with clinically significant heart
obvious cardiac abnormalities on auscultation, such disease; in cats, this test can be performed in a
as a murmur or arrhythmia.5 point-of-care fashion but, in dogs, is only available
Animals with infectious causes of pulmonary as a reference laboratory test at this time.
parenchymal disease (eg, pneumonia) may have a Airway cytology (depending on radiographic
fever; however, fever has only been reported in about abnormalities identified).
8 of dogs and of cats with pneumonia, making it Further diagnostics for interstitial lung disease
an unreliable abnormality.6 may include:
Thoracic CT
Initial Stabilization Lung biopsy.
Initial stabilization and therapy usually involve: If a solitary lung mass is identified close to the chest
Oxygen supplementation: See recommendations wall, percutaneous fine needle aspiration or biopsy
in the Initial Stabilization section (page 53) may be an ideal diagnostic modality. Additionally,
Diuretic: Depending on index of suspicion for surgical removal via lung lobectomy may be both
cardiogenic pulmonary edema, a furosemide trial dose diagnostic and therapeutic.
may be administered (typically, 24 mg/kg IV, IM)
Antibiotics: If there is a high index of suspicion Management
for pneumonia (eg, history of vomiting, Treatment for pulmonary parenchymal diseases depends
regurgitation, fever), the patient should begin entirely on the underlying disease. However, regardless
of the underlying cause, judicious fluid therapy is usually
Table 3. appropriate to prevent exacerbation of extravascular
Classification & Examples of Pulmonary lung water and potential diffusion impairment.
Parenchymal Diseases Intravenous fluid therapy is generally absolutely
CLASSIFICATION EXAMPLES contraindicated in animals with heart failure; rather,
diuretic therapy is a mainstay of treatment.
Pneumonia Infectious (viral, bacterial,
parasitic, fungal)
Specific therapeutic approaches include:
Aspiration Cardiogenic pulmonary edema: Diuretic therapy
and other cardiac drugs
Pulmonary edema Cardiogenic
Noncardiogenic Microbial pneumonia: Antimicrobial
administration and supportive care; adjunct
Interstitial lung Idiopathic pulmonary
diseases fibrosis therapies, such as nebulization and coupage,
Eosinophilic bronchopneu- may be considered. Empirical antimicrobial drug
mopathy choices depend somewhat on patient stability.
Heartworm disease
Animals that present in respiratory distress
Pulmonary neoplasia Primary generally warrant broad spectrum coverage with
Metastatic
parenterally administered antibiotics, such as:
Traumatic pulmonary Pulmonary contusions Monotherapy with a potentiated
parenchymal injury
aminopenicillin, such as ampicillin + sulbactam

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Peer Reviewed Approach to Respiratory Distress

(3050 mg/kg IV Q 6 H) or on radiographs (ie, a patient in


ticarcillin + clavulanate (50 mg/ severe respiratory distress with
kg IV Q 6 H) minimal abnormalities on thoracic
Dual therapy with a beta-lactam radiographs)
antimicrobial (eg, ampicillin, Demonstration of focal hypolucency
3050 mg/kg IV Q 6 H) and or vessel truncation
enrofloxacin (5 mg/kg IV Q 24 H Evidence of main pulmonary artery
in cats; 1020 mg/kg IV Q 24 H and/or right heart enlargement due
in dogs) to pulmonary hypertension, a result
Other antibiotic choices may also of significant PTE.
be appropriate but are beyond the Echocardiography is also a useful
scope of this article. diagnostic modality in cases of
Interstitial lung disease: These suspected PTE as it can document
conditions are challenging to treat; pulmonary hypertension that often
some are steroid responsive occurs secondary to PTE; detect
Pulmonary neoplasia: right-sided cardiomegaly and main
Management depends on type, pulmonary artery dilation; and may
location, and whether neoplasia is allow visualization of a thrombus in
primary versus metastatic; surgery, the main pulmonary artery.
chemotherapy, and radiation therapy Advanced imaging, such as CT
are all considerations. angiography or, less commonly, a
ventilation/perfusion lung scan with
PULMONARY nuclear scintigraphy, are required to
THROMBOEMBOLISM confirm the diagnosis.8,9
FIGURE. Thoracic radiograph demonstrating
focal hypolucency in the right middle and Etiology
caudal lung lobes associated with pulmonary \Causes of PTE are the same as Stabilization & Management
thromboembolism; main pulmonary artery for any thromboembolic disease Stabilization involves oxygen
enlargement is also evident. Courtesy Dr. essentially abnormalities in Virchows supplementation, and treatment
Carol Reinero triad, which include abnormalities requires anticoagulant drugs as well
of blood flow (turbulence or as addressing the underlying disease.
stasis), endothelial damage, and Therapies that can be used include:
hypercoagulability. Anticoagulants (unfractionated
With PTE, it is critical to identify or low-molecular-weight heparin)
and treat the underlying disease and/or antiplatelet drugs (eg,
if it is not immediately apparent, clopidogrel) reduce risk of further
so as to reduce the risk of further thrombus formation. Although the
thromboembolic events. Theoretically, ideal antithrombotic strategy for
Table 4. any systemic inflammatory state can dogs and cats with PTE is unknown,
Diseases & Conditions That Predispose result in a systemic pro-coagulant state it is reasonable to combine low-
Veterinary Patients to Hypercoagulability that predisposes the patient to PTE. molecular-weight heparin (eg,
DISEASES Table 4 lists diseases and conditions dalteparin, 150 U/kg SC Q 12 H)
Cardiac disease known to predispose veterinary with clopidogrel (approximately 2
Disseminated intravascular coagulation patients to hypercoagulability.8 mg/kg PO Q 24 H in dogs; 18.75
Heartworm disease mg/day in cats). Dalteparin dosing
Hyperadrenocorticism
Clinical Signs & Diagnostic should ideally be monitored by
Immune-mediated hemolytic anemia
Neoplasia Approach assessment of anti-Xa activity.
Protein-losing enteropathy Diagnosis of PTE can be challenging. Thrombolytic therapies, such as
Protein-losing nephropathy While thoracic radiographs may be tissue plasminogen activator (tPA),
Sepsis
normal, indications of PTE include can also be administered; however,
CONDITIONS (Figure): systemic administration of tPA is
Exogenous corticosteroid administration Degree of respiratory distress limited by adverse effects.
Indwelling IV catheters
out of proportion with changes Sildenafil is often beneficial

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APPROACH TO RESPIRATORY DISTRESS Peer Reviewed

for reducing moderate to severe pulmonary Concurrent injuries, such as pulmonary contusions
hypertension if documented on echocardiography. and pneumothorax, are common in dogs with flail
chest and are generally the cause of respiratory
PLEURAL SPACE DISEASE compromise, rather than the flail chest itself.
Etiology
Pleural space disease refers to abnormal Clinical Signs & Diagnostic Approach
accumulations within the pleural space that impair Flail chest is usually visually obvious on examination,
lung expansion on inhalation. These accumulations but radiographs are indicated to confirm the nature
can be associated with fluid (ie, pleural effusion), of the rib fractures and allow assessment of severity of
air (ie, pneumothorax), masses, or organs (ie, the underlying pulmonary parenchymal damage. Rib
diaphragmatic hernia). fractures are extremely painful and may cause rapid,
shallow breathing because big chest excursions cause
Clinical Signs more pain than little breaths.
Animals with pleural space disease may have:
Inspiratory distress Stabilization & Management
Rapid shallow breathing Management of flail chest is often supportive; the
Paradoxical breathing pattern in which the chest following should be provided:
falls on inspiration and the abdomen expands Oxygen supplementation, given the high
rather than the chest rising with inspiration likelihood of underlying pulmonary contusions
Decreased lung sounds on thoracic auscultation. Appropriate analgesia:
Usually in the form of systemic analgesia
Diagnostic Approach (eg, pure mu-opioid agonists, such as
Thoracic imaging is the mainstay of diagnosis. hydromorphone or fentanyl) local nerve
In unstable patients, point-of-care ultrasound is blocks
particularly useful to confirm the presence of pleural Intercostal nerve blocks can be performed in
fluid or air.10 Radiographs can also confirm diagnosis dogs using 0.5% bupivacaine, with a total of 1
but ideally, in unstable patients, thoracocentesis to 4 mg/kg divided between sites
(see Stabilization & Management) should be If local anesthetic nerve blocks are used in cats,
performed after ultrasound and prior to radiographs. dose reduction to prevent toxicity is important;
If ultrasound is not available, thoracocentesis should generally, the total local anesthetic dose should
be performed based on clinical suspicion, in order to not exceed 0.2 to 0.5 mg/kg in cats; particular
stabilize the patient prior to obtaining radiographs. care should be taken to avoid inadvertent IV
administration
Diaphragmatic
Stabilization & Management Although use of nonsteroidal anti-inflammatory
In patients with pleural effusion or pneumothorax, drugs (NSAIDS) should be avoided in the Hernia:
therapeutic thoracocentesis should result in initial stabilization and management of trauma emergency
immediate improvement. Pleural fluid can then patients, NSAIDs can be considered later in Management
be submitted for analysis/cytology and, in cases the course of hospitalization once the patient is
Patients with
of pyothorax, bacterial culture (both aerobic and hemodynamically stable. diaphragmatic
anaerobic culture). Additional supportive care may include: hernia usually
Once therapeutic thoracocentesis has been Patient positioning in lateral recumbency, with have a history of
performed, the next step is addressing the underlying the flail segment facing downwards trauma; either
disease. Specific discussion of treatment of underlying Bandaging the chest to reduce movement of the acute, or at some
time in the past.
diseases is beyond the scope of this article. flail segment, although, extreme care must be taken
Surgery via a ventral
to avoid further impeding inspiration. midline laparotomy
FLAIL CHEST Surgery is not indicated unless penetrating thoracic to replace the
Etiology wounds are present, in which case an exploratory abdominal contents
Flail chest refers to destabilization of a portion of the thoracotomy should be performed. Assuming unilateral in the abdomen
rib cage, which occurs if there are rib fractures in 2 penetrating thoracic wounds, a lateral thoracotomy is and repair the
performed to allow visualization of the affected thorax, torn diaphragm is
different locations (proximal and distal) on the same
indicated as soon
rib(s). This condition often affects multiple ribs (at a lung lobectomy if necessary, and thoracic lavage, prior
as possible.
least 2 consecutive ribs), creating a flail segment.11 to closure with placement of a chest tube.

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identified based on a complete history, physical


TABLE 5.
examination, and screening laboratory tests. Thoracic
Intra-abdominal Pathology That Results in
radiographs can help definitively rule out underlying
Significant Abdominal Distension
respiratory disease.
Abdominal masses Since the increased respiratory effort associated
Ascites with these conditions is not usually oxygen
Gastric dilatation +/- volvulus
responsive, management is aimed at treating the
Hepatomegaly
underlying disease.
Late-term pregnancy
Splenomegaly
IN SUMMARY
The mainstays of management of a patient in
ABDOMINAL DISTENSION respiratory distress are:
Etiology 1. Initial stabilization, including oxygen
Significant abdominal enlargement (Table 5) can supplementation and potentially sedation
result in respiratory distress because it impedes 2. Characterization of the breathing pattern to
thoracic expansion during inspiration. Dyspnea is localize the disease
rarely a presenting sign, but tachypnea is common in 3. Systematic approach to diagnostics and therapy
these patients. based on identifying the anatomic location of the
cause of respiratory distress.
Clinical Signs & Diagnostic Approach
Respiratory distress due to abdominal distension CT = computed tomography; FiO2 = fraction
is usually visually obvious. Abdominal palpation of inspired oxygen; NSAID = nonsteroidal
and imaging (ie, abdominal radiographs and/or anti-inflammatory drug; PTE = pulmonary
ultrasound) can help determine the underlying cause. thromboembolism

Stabilization & Management References


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CLAIRE R. SHARP computed tomography pulmonary angiography and point-of-
Claire R. Sharp, BSc, BVMS (Hons), MS, CMAVA, Diplomate ACVECC, care tests for pulmonary thromboembolism diagnosis in dogs.
is senior lecturer at Murdoch University in Perth, Western Australia, and J Small Anim Pract 2014; 55:190-197.
adjunct assistant professor at Tufts Cummings School of Veterinary 10. Lisciandro GR. Abdominal and thoracic focused assessment
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University, and an internship and residency in small animal emergency 11. Olsen D, Renberg W, Perrett J, et al. Clinical management of
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