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Pleural Effusion in the Cat: A Practical Approach to Determining Aetiology

Article · September 2010

DOI: 10.1016/j.jfms.2010.07.013 · Source: PubMed

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R E V I E W / Pleural effusion in cats

It is important not to focus on fluid analysis in isolation.

While properties of the fluid may be diagnostic in cases of pyothorax, neoplasia and FIP,
in other cases they must be interpreted together with other clinical information.

TABLE 1 Classification of pleural fluid based on total protein (TP) processes including congestive heart failure
concentration and total nucleated cell count (TNCC)10 (CHF), neoplasia and trauma; in cats, however,
they are commonly idiopathic.11 Using total
Classification TP g/l TNCC/l Comments protein (TP) and total nucleated cell count
Transudate <25 <1000 Uncommon in cats. Rule out: (TNCC), chylous effusions may be classified as
✜ CHF modified transudates or as exudates.12
✜ Hypoalbuminaemia More useful clinically are the gross character-
✜ Fluid overload
istics, triglyceride and cholesterol concentra-
Modified 25–35 500–10,000 Least specific. Differentials ranked tions of fluid and serum, and the presence of
transudate according to clinical criteria and gross chylomicrons. On cytology small lymphocytes
characteristics of fluid to guide
investigation predominate initially but neutrophil and mono-
cyte counts increase over time.11 The results of
Exudate >30 >5000 May be subclassified as septic, fluid analysis are useful only in as much as they
non-septic, chylous*, neoplastic.
Rule out: elucidate the underlying disease process. It is
✜ FIP important to appreciate their value and limita-
✜ Infection tions (discussed later). In cases of pyothorax,
✜ Neoplasia
neoplasia and feline infectious peritonitis (FIP),
*Chylous effusions may have TP/TNCC of a modified transudate or an exudate. fluid characteristics may be diagnostic, whereas
They are defined in cats (and dogs) as effusions with a triglyceride concentration of determining that the fluid is a modified transu-
>100 mg/dl (>1.12 mmol/l)6. CHF = congestive heart failure
date is non-specific and must be interpreted in
the light of other clinical data.

TABLE 2 Clinical features of common causes of pleural effusion in cats

Underlying aetiology Signalment
or disease process
Pyothorax/ Usually young (mean 4–6
infectious pleuritis years)
Any age or breed can be
affected
Right and/or left Any age or breed,
congestive heart depending on the
failure underlying cardiac disease
Effusive FIP 70% <1 year old. Increased
risk in some breeding lines
and in entire cats
Common in mixed-breed cats
Neoplasia Bronchopulmonary and
thymoma: usually >10 years
Mediastinal lymphoma:
young Siamese breed cats
Idiopathic Any age, any breed,
chylothorax Siamese may have
increased risk
FIP = feline infectious peritonitis, TP = total protein, TNCC = total nucleated cell count
History
Variable
Mean duration of signs 1–2 weeks
May present acutely
Dyspnoea, cough
Lethargy, reduced appetite,
weight loss
Previous upper respiratory tract
infection (25%)
Variable, depends on aetiology
of heart disease. With secondary
cardiomyopathies (eg, thyrotoxic)
may see signs of primary disease
Recent multicat environment
and/or stressor (neutering,
rehoming). Non-specific lethargy,
reduced appetite, weight loss.
Abdominal distension
Variable, non-specific, cough,
dyspnoea
Cough, dyspnoea
Physical findings not related Fluid characteristics
to pleural effusion
Pyrexia, dehydration, poor Exudate
body condition
If sepsis: hypoglycaemia,
hypothermia, jaundice,
bradycardia
Congenital: may have small Variable:
stature transudate,
Tachycardia, murmur, gallop, modified transudate,
arrhythmia, jugular distension/ chylous
pulse, cyanosis,
ascites/hepatomegaly
May have no other signs of
cardiovascular dysfunction
Pyrexia, poor body condition, High protein (>35 g/l),
peritoneal effusion, ocular low cellular (<5000/µl)
changes, neurological signs
Distant metastases (digits, Variable: modified
eyes, skeletal muscle) transudate, exudate,
Poor body condition chylous
Decreased thoracic
compressibility
Paraneoplastic syndromes
None Fluid triglyceride >100
mg/dl (1.12 mmol/l)
TP and TNCC of
modified transudate
or exudate

694 JFMS CLINICAL PRACTICE


TABLE 3 Summary of published case series of feline pleural effusion
demonstrating the major underlying aetiologies and disease processes
Date Number of FIP CHF
collected cases with (% of total) (% of total)
(and published definitive
source) diagnosis
2002–039 19 5 47
8 65 25 23
1989–92
7 63 13 14
1987–95
1975–775 54 4 17
1972–744 64 10 44
FIP = feline infectious peritonitis, CHF = congestive heart failure
Aetiology
Fortunately, the list of common causes of a
moderate to large volume pleural effusion in
the cat is relatively short. While incidence data
are not available, FIP, CHF, pyothorax and
neoplasia together accounted for 88–100% of
265 cases with a confirmed aetiology (Table
3).4–9 In two studies, 9/19 cats (12.5% of total)
and 3/7 cats (15% of total) were defined as
having idiopathic chylothorax where an
aetiology could not be determined despite
investigation.6,7
CHF
Pleural effusion can result from left and/or
right CHF causing a transudate, a modified
transudate or a chylous effusion. Increased
ventricular diastolic pressure results in
increased capillary hydrostatic pressure in the
systemic and/or pulmonary circulation. The
visceral pleura drain into the pulmonary
veins in both cats and dogs but pleural effu-
sion from left CHF (LHF) seems to be more
common in cats than dogs.1,13 As parietal pleu-
ral veins drain into the systemic venous cir-
cuit, right CHF (RHF) may also cause pleural
effusion. RHF is a fairly common cause of
chylothorax in the cat.6,14,15 Chylothorax in
this setting presumably results from increased
pressure in the major lymphatics as the
thoracic duct terminates in the left external
jugular veins or jugulosubclavian angle.
Diverse underlying cardiac problems can
result in heart failure. In cats heart failure is
often due to diastolic dysfunction.13 Common
cardiomyopathies (hypertrophic, restrictive,
unclassified, thyrotoxic) should be ruled out
first. While cardiac signs are common in
hyperthyroid cats (eg, tachycardia, murmur,
gallop), earlier diagnosis has resulted in a
decrease in the frequency of CHF in cats with
thyrotoxicosis.16,17 One study reported a
significant decline in the prevalence of
CHF in hyperthyroid cats from 12% in 1983 to
2% in 1993.16
R E V I E W / Pleural effusion in cats
Pyothorax Neoplasia % of total due
(% of total) (% of total) to FIP, CHF,
pyothorax or
neoplasia combined
11 26 100
12 34 94
24 37 88
17 61 99
4 34 92
Fortunately, the list of common causes
of a moderate to large volume pleural effusion
in the cat is relatively short.
Neoplasia
Mediastinal, bronchopulmonary or primary
pleural neoplasia may cause pleural effusion
with the characteristics of a modified transu-
date, an exudate or a chylous effusion. In
published case series, 26–61% of feline pleural
effusions were associated with neoplasia
(Table 3). Mediastinal lymphoma accounted
for the majority of neoplasia-associated
pleural effusions (60–79%) reported in cats
between 1972 and 1995.4,5,7,8 Although the
prevalence of feline leukaemia virus (FeLV)
associated mediastinal lymphoma has
declined with that of FeLV, an increased risk of
developing mediastinal lymphoma has been
documented in young cats of the Siamese
breed group, independent of their FeLV status
(Table 2).18 Other neoplastic and non-neoplas-
tic mediastinal masses such as thymoma,
thymolipoma, thymic hyperplasia and devel-
opmental anomalies should be considered
where mediastinal lesions are identified.19–21
Definitive diagnosis of mediastinal lesions is
essential to determine prognosis and guide
treatment options. In addition to fluid produc-
tion, mediastinal lesions may cause dyspnoea
due to a space-occupying mass effect.
Regardless, they are included here because
they often occur concurrently, presentation and
diagnostics are similar and it can be difficult to
differentiate a mass from fluid using radiology
alone. Primary and, less commonly, secondary
bronchopulmonary carcinoma makes up the
bulk of the other neoplasms. Primary pleural
neoplasia is rarely reported in the cat.22
Infectious pleuritis
Infectious pleuritis is caused by obligate and
facultative anaerobes of oropharyngeal origin
in more than 80% of cases, resulting in accu-
JFMS CLINICAL PRACTICE 695
R E V I E W / Pleural effusion in cats

TABLE 4 Assessment of respiratory patterns in dyspnoeic cats

Pleural Extrathoracic Intrathoracic large Bronchial disease Pulmonary

space disease airway disease airway disease (trachea/ parenchymal disease
mainstem bronchi)
Dyspnoea Inspiratory Inspiratory Expiratory Expiratory Inspiratory ± expiratory

Audible respiratory No Stridor or ± Expiratory ± Expiratory No

noise stertor wheeze/cough wheeze/cough

Thoracic No ↑ Breath sounds ↑ Breath sounds Expiratory wheeze/ ↑ Breath sounds;

auscultatory noise ↓ breath sounds (referred upper airway (referred upper airway ↑ breath sounds ± crackles ± wheezes
noise) noise) ± crackles

Respiratory rate Rapid Normal to Normal to Rapid Rapid

mildly increased mildly increased
Respiratory pattern Restrictive Obstructive Obstructive Mixed Restrictive or mixed

mulation of a purulent exudate (pyothorax). A restrictive (rapid, shallow) respiratory pattern

Parapneumonic spread of infection following with increased inspiratory effort is typical of pleural
colonisation of lung tissue by oropharyngeal
flora seems to be the most frequent cause of space disease – but not pathognomonic.
feline pyothorax.23

FIP puted tomography (CT) angiography.2 Even so,

The effusive form of FIP is associated with 15–20% of pleural effusions in humans remain
widespread vasculitis. Subsequent exudation undiagnosed even after pleural biopsy.33
of high protein effusion can occur in peri-
toneal, pleural or pericardial cavities. Recognising pleural
space disease
Other
Other documented causes of pleural fluid Observation
accumulation in the cat include trauma, coag- Observation of the respiratory pattern in a
ulopathy, peritoneopericardial diaphragmatic dyspnoeic patient is the first step in localising
hernia, uraemia, pulmonary thromboem- the problem. The respiratory rate and depth,
bolism, lung lobe torsion, possible extension the phase of respiration that is laboured
from a perinephric pseudocyst, pancreatitis, (inspiratory, expiratory or both), the presence
glomerulonephropathies and Aelurostongylus or absence of audible respiratory noise
abstrusus infection.2,7,8,24–29 Trauma, which can (stridor, stertor, wheeze) and the presence or
result in effusion secondarily to haemorrhage, absence of respiratory noises on auscultation
diaphragmatic hernia, thoracic duct rupture (referred large airway sounds, breath sounds,
or, rarely, urinothorax,7 was the underlying wheezes, crackles) should be noted (Table 4).
cause in 8% of cases in one study.30 Although Cats with significant pleural space disease
heartworm disease is often listed as a possible adopt a sternal position with abducted
aetiology in the cat, evidence that pleural elbows. A restrictive (rapid, shallow) respira-
effusion occurs as a consequence of natural tory pattern with increased inspiratory effort
infection in this species is limited.31,32 is typical (see video 1, doi:10.1016/j.jfms.2010.
07.013). Once air is inhaled, it can be exhaled
Undetermined without any impediment or obstruction. A
A practical classification to
In some cases the aetiology direct the clinical investigation subtle increase in inspiratory excursions may
may remain elusive because A clinically useful classification for pleural be easier to discern when the cat is viewed
the mechanism is recog- effusion in the cat is presented in Table 2. from above. An increased respiratory rate and
nised as being idiopathic Based on this, the quality of data collection from decreased inspiratory volume minimises res-
a minimally invasive examination can be maximised
(for chylothorax) or and differential diagnoses ranked for the patient.
piratory effort in non-compliant lungs.
because of lack of access This directs the clinical investigation and facilitates Therefore, restrictive respiratory patterns can
to advanced diagnostic expedient identification of the underlying aetiology so be seen in cats with pulmonary parenchymal
techniques. Pulmonary that owners can be informed regarding management pathology (eg, pulmonary oedema, pneumo-
options and the prognosis for their pet.
thromboembolism is a nia) and with disorders of the chest wall,
common cause of pleural diaphragm, peritoneal cavity or peripheral
effusion in humans but has nerves (Table 4).
been documented infrequent- Upper respiratory tract (URT) obstruction is
ly as a cause in the cat where the other major cause of inspiratory dysp-
there is limited availability of com- noea. In this case respiration is usually slow

696 JFMS CLINICAL PRACTICE

 R E V I E W / Pleural effusion in cats

Breath sounds are decreased or absent with pleural space disease.

Where there is effusion, the reduction in breath sounds is often more
pronounced ventrally, and a fluid line may be appreciated.

and deep (obstructive) and accompanied by
other URT signs such as stertor or stridor
(see video 2, doi:10.1016/j.jfms.2010.07.013).
Auscultation
Auscultation helps to distinguish pleural
space disease from pulmonary parenchymal
disease when there is a restrictive pattern.
Breath sounds are decreased or absent with
pleural space disease. Differential diagnoses
then include pleural effusion, pneumothorax,
intrathoracic mass or diaphragmatic hernia.
Where there is effusion, the reduction in
breath sounds is often more pronounced
ventrally and a fluid line may be appreciated
on auscultation or percussion. Concurrent
pulmonary oedema may contribute to the
dyspnoea in LHF and result in auscultable
crackles dorsally. Pleural effusion or peri-
cardial effusion can cause muffled heart
sounds. An intrathoracic mass or focal
accumulation of fluid can displace the cardiac
apex beat. With diaphragmatic hernia, borbo-
rygmi may be auscultated in the thorax.
In contrast, pulmonary parenchymal dis-
eases severe enough to cause restrictive respi-
ration are characterised by increased lung
sounds, crackles or wheezes on auscultation.
Auscultation over the trachea and larynx
should be performed routinely to differentiate
sounds referable to URT obstruction from
sounds emanating from the LRT.
Percussion
Thoracic percussion is more difficult to per-
form in cats than dogs because of their small
stature. If tolerated, it can be a useful diagnos-
tic tool. Percussion is performed by firmly
tapping one or two fingers placed against an
intercostal space and comparing the reso-
nance of the sound produced at several differ-
ent locations over the thorax bilaterally. A
more resonant sound dorsally (‘drum-like’)
provides evidence for pneumothorax. A less
resonant or dull sound ventrally provides evi-
dence for loss of pulmonary aeration.

Confirming pleural space disease

The presence of pleural effusion can be rapidly and non-

invasively confirmed with either a single dorsoventral (DV)
radiographic view or thoracic ultrasonography. Maintaining the
patient in sternal recumbency avoids positional atelectasis and
requires minimal restraint. A single DV view will confirm pleural
space disease and differentiate between pleural effusion,
pneumothorax or diaphragmatic hernia. The increased oxygen
demand associated with additional restraint for symmetric posi-
tioning is not usually justified prior to thoracocentesis as signifi-
cant pleural space disease will be apparent, even from slightly
rotated views. Horizontal beam (lateral) views with the cat in a
standing position similarly require minimal restraint.
The radiographic signs of pleural effusion are listed below.34
Unilateral effusion should raise the index of suspicion for
pyothorax or chylothorax.11,23
Thoracic ultrasonography is similarly useful for confirming a
moderate to large volume pleural effusion, diaphragmatic hernia
and, in the hands of a skilled operator, pneumothorax.35

Radiographic signs of pleural effusion

✜ Interlobar fissure lines
✜ Rounding of the lung margins at the costophrenic angles
✜ Retraction of the lobar borders from the thoracic wall
✜ Widening of the mediastinum
✜ Scalloping of the lung margins at the sternal border
✜ Effacing of cardiac silhouette (silhouette sign)
✜ Dorsal displacement of the trachea A dorsoventral radiographic view rapidly confirms moderate
to large volume pleural effusion and requires minimal restraint

JFMS CLINICAL PRACTICE 697

R E V I E W / Pleural effusion in cats

Approach to the dyspnoeic cat Cats showing clinical signs of pleural space
with pleural effusion
disease have significantly compromised
The priorities for the clinician managing a cat respiration and are at risk of respiratory failure.
with pleural effusion are discussed in the fol-
lowing sections beginning, first and foremost,
with stabilisation of the patient. Thereafter,
data obtained from signalment, history and 10
100

physical examination is used to rank the list of

common differentials. This ranking is further 80
80

Haemoglobin
informed by the gross characteristics of fluid
60
obtained at thoracocentesis. 60

Stabilisation 40
40

It is not unusual for dyspnoea to be subtle or 20

20

absent prior to arrival at the clinic. As pleural

fluid accumulates the haemoglobin saturation 20
2 4400
40 60
60 80
80 100
10 P o2
Po
falls gradually (Fig 1). Combined with
Arterial partial pressure of oxygen
reduced activity, this allows the cat to Arterial
Arterial p
partial
artial p
pressure
r e s s u r e of
o f oxyge
oxyge
compensate initially. When the arterial partial FIG 1 Oxygen dissociation curve (see text for explanation)36
pressure of oxygen (PaO2) falls below 60

✜ Reduce oxygen requirements Placing the patient in a cool,
quiet environment and minimising handling will reduce
oxygen demand.
✜ Supplemental oxygen Options for short term oxygen
delivery to the dyspnoeic cat include oxygen chamber, mask
and flow-by (see below). The method that is best tolerated
by the patient should be used. Struggling must be avoided.
An oxygen chamber is a useful way to deliver oxygen
without the need for restraint. These chambers are available
commercially (Buster ICU Cage, DLC Australia) or can be
constructed from perspex. Some cats will tolerate a mask
held against the face, especially if the rubber gasket has
been removed. Flow-by oxygen is best tolerated but least
effective.37 Use of intranasal catheters should be avoided in
conscious dyspnoeic cats as, even with local anaesthesia,
placement is usually resented. Intranasal catheters are,
however, useful for delivery of humidified oxygen after
stabilisation (eg, anaesthetic recovery following indwelling
thoracic drain placement).
Stabilisation techniques
✜ Intravenous access This should be achieved at the earliest
opportunity.
✜ Light sedation Dyspnoeic cats may benefit from light
sedation (eg, acepromazine with one or morphine,
methadone or butorphanol) to reduce anxiety.
Cats in respiratory distress may panic when handled.
✜ Therapeutic thoracocentesis Usually this is carried out
after imaging. However, where the suspicion for pleural
effusion is high and the dyspnoea is severe, unguided
needle thoracocentesis can be life-saving and the risk of
causing significant harm is minimal.
✜ Monitoring Respiratory rate and depth should be monitored
so that changes can be readily appreciated. The utility of pulse
oximetry is limited in conscious cats by movement and failure to
tolerate the probe. Pigmented skin, severe anaemia and reduced
peripheral perfusion are other potential sources of error.38
✜ Ventilation Where hypoventilation cannot be controlled
by other means, the clinician should be prepared to
anaesthetise, intubate and ventilate the patient.

Supplemental oxygen delivery techniques

Oxygen chamber Mask delivery Flow-by

698 JFMS CLINICAL PRACTICE

 R E V I E W / Pleural effusion in cats

Signalment – an aid to
mmHg, haemoglobin saturation ranking common differentials A previous history of upper respi-
falls precipitously.36 This point Signalment data cannot be used to exclude an ratory tract infection in a young
aetiology but may assist in ranking the common differ-
will be reached gradually as the cat would raise suspicion for
entials (Table 2).
underlying disease progress- ✜ In young cats, effusive FIP, mediastinal lymphoma and pyothorax pyothorax.23 Recent history
es – however, an acute are likely, whereas the median age for developing bronchopulmonary of a multicat environment
increase in oxygen neoplasia, thymoma and decompensated thyrotoxic cardiomyopathy is 11–13 and/or a stressor, such as
demand, such as that years.39–41 Approximately 70% of FIP cases occur in cats less than 1 year of age.42 neutering or rehoming,
✜ An increased risk of developing FIP has been demonstrated in purebred and
associated with handling, in entire cats and there is evidence of heritability in some lines.42,43
However, FIP is
in a young cat would
can precipitate decom- often diagnosed in domestic crossbreeds, and older cats may sometimes be affected. increase suspicion for
pensation. By the time ✜ Cats of the Siamese breed are overrepresented for both mediastinal lymphoma FIP.42 Owners of cats
patients with pleural (young cats) and chylothorax.11,18,44 >8 years old should
effusion show signs of ✜ Familial cardiomyopathies have been identified in many breeds, including the be questioned about
Maine Coon, Ragdoll, British and American Shorthair, Bengal, Sphynx, Norwegian
respiratory distress Forest and Siberian.45 Less information is available regarding breed predispositions signs related to hyper-
(open-mouth breathing, for other types of cardiac disease. The Chartreux breed has been identified as thyroidism such as
agitation, vocalisation, being overrepresented for tricuspid dysplasia.46 polyphagia, weight loss,
extension of the neck, fail- ✜ While congenital aetiologies are more likely in young cats, cats with polyuria, polydipsia and
congenital, heritable and acquired cardiac disease can develop heart failure
ure to maintain sternal at any age.
gastrointestinal signs.
positioning) little reserve ✜ Some acquired cardiac problems are age-related (eg, thyrotoxic Oesophageal signs includ-
remains. cardiomyopathy). ing dysphagia, regurgitation
Thus cats showing clinical and ptyalism may reflect com-
signs of pleural space disease pression of the oesophagus from
have significantly compromised res- an intrathoracic mass. Haemothorax
piration and are at risk of respiratory would be less likely in cats without out-
failure. This reinforces the importance of door access or exposure to anticoagulant
triage at reception. All cats should be rodenticides. There is conflicting data regarding
observed on arrival. Where respiratory dis- whether pyothorax is more common in outdoor
tress is noted or suspected, immediate stabili- or indoor cats.7,49
sation is indicated. The choice of the various
techniques (see box on page 698), and order in Clinical examination
which they are carried out, depends on assess-
ment of the individual patient. The importance of gentle handling of cats in
Dependent on the underlying disease respiratory distress cannot be overempha-
process, other considerations for patient sta- sised. Struggling must be avoided. Some tests,
bilisation include identification and correction such as rectal temperature, may need to wait
of hypothermia, hypotension, hypoglycaemia, until the patient is stable. Nonetheless, useful
and fluid and electrolyte imbalances. information can be gained non-invasively to
help rank the common aetiologies.
History
Examination of the cardiovascular system
Historical abnormalities may relate to the Mucous membranes should be examined for
presence of the pleural effusion and/or the colour and capillary refill time. Jugular veins
underlying disease. Non-specific signs such as can be evaluated for distension and pulsation,
reduced appetite, weight loss or lethargy are with the cat sitting or standing. The neck
common.7,11,23 Dyspnoea is noted in 60–80% of should be moderately extended and the over-
cases and coughing in up to 30% of cats with lying hair wetted or clipped. The jugular veins
chylothorax and pyothorax.7,11,47 Coughing are not distended in healthy cats. Distension
may be associated with the presence of effu- occurs due to increased systemic venous pres-
sion or it may be related to the aetiology sure or venous occlusion between the jugular
(eg, concurrent bronchopulmonary infection vein and the right heart.
or neoplasia, or airway compression from a Normal jugular venous pulsation does not
cranial mediastinal mass). Coughing due to ascend higher than a third of the way up the
cardiac disease is not as commonly recognised neck in healthy cats. Jugular pulses must be
in cats as dogs, but it can occur.48 It is the differentiated from carotid artery pulsations,
authors’ experience that owners may not which may be transmitted through adjacent
recognise coughing in cats, but rather attrib- soft tissues in thin or agitated cats. A true
ute this sign to ‘hairballs’ or dry retching. jugular pulse will disappear if the jugular vein
Careful questioning is required. is occluded below the level of the visible

Normal jugular venous pulsation does not ascend higher than a third
of the way up the neck in healthy cats.

JFMS CLINICAL PRACTICE 699

R E V I E W / Pleural effusion in cats

Clinical findings that make cardiogenic causes of pleural effusion more likely include
a murmur, gallop, arrhythmia, crackles dorsally, jugular distension and jugular pulsation.

pulse; pulsation will continue if it is being volaemia. The cat should be examined for
transmitted from the carotid artery (see video signs of trauma and haemorrhage at other
3, doi:10.1016/j.jfms.2010.07.013). Jugular distension sites. The thyroid lobes should be palpated
and pulsation occur with RHF.48,50 Large routinely. Cranial mediastinal mass lesions
volume, non-cardiogenic pleural effusions can may cause reduced compressibility of the
raise central venous pressure and cause jugu- anterior rib cage and may be palpable at the
lar distension but not pulsation.51 Similarly thoracic inlet.52,55 Paraneoplastic syndromes
occlusion of right heart inflow from a medi- associated with intrathoracic mass lesions
astinal mass lesion can cause jugular venous include myasthenia gravis, exfoliative der-
distension that may be accompanied by facial, matitis and polymyositis.19 Pulmonary carci-
neck and forelimb oedema.52 noma in cats has a propensity to metastasise
Changes in cardiac rate, rhythm and heart widely to unusual locations including the
sounds should be assessed carefully. In one eyes, digits and skeletal muscles.56 Cats with
study, the majority of cats with dyspnoea from intrathoracic lesions may present with lame-
cardiac disease had an abnormality on cardiac ness due to digital metastases or hypertrophic
auscultation.53 Increased heart rate and the osteopathy. In young cats, FIP is a major dif-
presence of a murmur or gallop sound can be ferential and signs potentially referable to this
useful indicators of cardiogenic causes of pleu- problem should be noted including abdomi-
ral effusion. However, the possibility that the nal effusion, ocular changes (eg, uveitis, kerat-
cat has structural cardiac disease but is not in ic precipitates) and neurological signs.
heart failure – that is, the pleural effusion is Gentle abdominal palpation and assessment
non-cardiogenic – should also be considered. It for a fluid wave may be possible. Simul-
is important to note that the absence of a mur- taneous peritoneal and pleural effusion can
mur does not rule out cardiac disease. In one occur with systemic disease processes or fol-
study, the sensitivity and specificity of the pres- lowing extension from one cavity to the other.
ence of a heart murmur for diagnosing cardio- In the cat, double effusion increases suspicion
myopathy were 31% and 87%, respectively.54 for FIP, RHF, neoplasia, haemorrhage, sys-
Clinical examination findings that make temic inflammation or infection, nephrotic
cardiogenic causes of pleural effusion more syndrome and ruptured diaphragm. Of cats
likely include a murmur, gallop, arrhythmia, with effusive FIP, 62% have peritoneal effu-
crackles dorsally, jugular distension and jugu- sion, 17% have pleural effusion and 21% have
lar pulsation. double effusions.42 Extension of pyothorax
into the abdominal cavity is rare.57
Examination of other body systems Glomerulonephropathies are a rare cause
Poor body condition score is a non-specific of pleural effusion and affected cats typically
indicator of underlying debilitating disease in show other signs of nephrotic syndrome
cases that are not trauma or toxin-associated. including ascites and subcutaneous oedema.
Pyrexia may be a feature of FIP, pyothorax or
neoplasia. Hypothermia may indicate sepsis
in cases of pyothorax, especially if there is Data obtained from signalment, history
also bradycardia and hypoglycaemia. Hypo- and physical examination can be used to
thermia in conjunction with tachycardia and
pale mucous membranes may indicate hypo- rank the list of common differentials.
This ranking is further informed by the gross
characteristics of fluid obtained at thoracocentesis.
Thoracocentesis
Thoracocentesis is both a diagnostic and therapeutic procedure pared aseptically. With the bevel facing the chest, the needle is
and is often tolerated without sedation or local anaesthesia. passed slowly into the thoracic cavity, cranial to the costo-
Ultrasound guidance is chondral junction at the
useful but not essential. As much pleural fluid as can easily be obtained seventh or eighth inter-
A 21 or 23 gauge costal space. Negative
butterfly needle, exten- to improve respiration should be removed. pressure is applied to the
sion tubing and a three- syringe and sufficient
way tap are attached to a 20 ml syringe. The cat is positioned pleural fluid as required for diagnostic sampling and/or thera-
in sternal recumbency and the chest wall is clipped and pre- peutic purposes is collected.

700 JFMS CLINICAL PRACTICE

 R E V I E W / Pleural effusion in cats

Gross characteristics of pleural effusion

Pyothorax fluid before (left) Chylous pleural Serosanguineous Transudate FIP effusion. (inset) Note the viscosity
and after (right) centrifugation effusion effusion

Fluid analysis – value and centrifugation because the opacity is due to

limitations lipid rather than cells or debris. The TP and
TNCC lead to classification as a modified tran-
Fluid analysis is variably useful in determin- sudate or an exudate. Lipid in chylous effu-
ing aetiology and the results must be inter- sions artefactually increases protein estimation
preted in the light of clinical data. Samples when determined by refractometry. In addition
collected in EDTA and plain tubes, and direct to small lymphocytes or neutrophils and lipid-
smears should be submitted for TNCC, laden macrophages, refractile lipid droplets
TP, differential cell count and cytology. (chylomicrons) are often seen on cytology. In
Additional testing will be directed by clinical chylous effusions the pleural fluid triglyceride
data and gross evaluation of the fluid. content is greater than the serum triglyceride
concentration, while the pleural fluid choles-
Malodorous effusions terol level is less than or equal to serum choles-
A foul smell is a very useful indicator of terol. If only pleural fluid is available then
anaerobic infection, which is typical in over triglyceride >100 mg/dl (>1.12 mmol/l) con-
80% of pyothorax cases.23 The fluid is usually firms chylothorax.6 The investigation should
opaque and creamy but can be pink, green- be directed to rule out known causes of chy-
tinged or sanguineous, and flocculent materi- lothorax in the cat – principally CHF, neoplasia
al is often present. Aerobic and anaerobic cul- and trauma.11 It should be expected that many
ture and cytology, including Gram staining, is cases of chylothorax in the cat will be consid-
indicated. Fluid associated with infection typ- ered idiopathic despite investigation.
ically has a high protein content (>30 g/l) and Pseudochylous effusions resemble chylous
TNCC (>7000/μl), with neutrophils predomi- effusions grossly and may not clear after cen-
nating (>85% of TNCC), and is classified as an trifugation, but do not contain chyle. They are
exudate. Commercial anaerobic specimen col- associated with chronic pleural disease and
lectors are available (eg, Vacutainer Anaerobic have a higher cholesterol content than serum,
Specimen Collector, BD Biosciences). Where while the pleural fluid triglyceride level is less
frank pus is aspirated, other tests are not than or equal to the serum triglyceride. It is
necessary. Lack of odour does not rule out an thought that cholesterol enters the pleural
infectious cause; 20% of cases of infectious space during acute pleural inflammation and
pleuritis, particularly in kittens, are caused accumulates within pleural fluid over time
by unusual bacterial, fungal or protozoal because of a change in lipoprotein binding
pathogens.23 Cytology and culture will assist characteristics that impedes transfer out of the
in identifying these causes. Systemic toxoplas- pleural space.3 Pseudochylous effusions seem
mosis can be associated with a large volume to be rare in cats.44
pleural effusion in the cat.58
Serosanguineous effusions
Milky effusions Where fluids appear bloody, the clinician
Opaque and milky or pink fluids should be must differentiate between frank haemor-
centrifuged. Chylous fluids form a cream layer rhage into the pleural space (haemothorax),
upon standing but do not become clear after and blood contamination of an effusion with a

JFMS CLINICAL PRACTICE 701

R E V I E W / Pleural effusion in cats
Distinguishing cardiogenic, neoplastic and atypical infectious effusions
Fluid cytology is useful for diagnosing neoplasia.
Hirschberger and others demonstrated that cytology
had a sensitivity of 61% and specificity of 100% for
detecting neoplasia in body cavity effusions, includ-
ing 65 feline pleural effusions, where diagnosis was
confirmed.8 These authors report a NPV of 90% and
a PPV of 100% for cytology for diagnosing malignant
feline effusions. A caveat to this is that reactive
mesothelial cells may be confused with neoplastic
cells by those less experienced in cytology.
There is limited information on the use of other
pleural fluid markers to determine aetiology in feline
cases. One study showed elevated fibronectin levels
to be useful for discriminating between cardiogenic
and neoplastic effusions and as a negative predictor
of neoplasia in the cat.62 LDH is a marker of pleural
inflammation and elevations in this enzyme are used
to differentiate exudates from transudates in human
medicine, but not to further subdivide exudates.3 In a
study by Zoia and others, an absolute cut-off of 226
IU/l for pleural fluid LDH could be used to differenti-
ate neoplastic from cardiogenic pleural effusions in
different aetiology (haemorrhagic effusion).
Fluid can appear bloody with a haematocrit
of <5%,3 whereas haemothorax is variably
defined as fluid with a haematocrit of at least
25%, or 50% of the peripheral blood haemat-
ocrit.3,59 Where haemorrhage has been present
for more than 1 h no platelets will be seen on
pleural fluid smears and the blood will be
defibrinated so it will not clot in a plain tube.
Causes of haemothorax include trauma, anti-
coagulant rodenticide intoxication and neo-
plasia. History and physical examination data
may support one of these aetiologies. Cats
with acute haemorrhage into the pleural space
sufficient to restrict respiration should present
with obvious signs of hypovolaemia (pale
mucous membranes, weak pulses, tachycar-
dia, hypothermia).
Translucent effusions
Where the fluid is clear or yellow, a TP estima-
tion should be obtained cage-side. The protein
scale on handheld refractometers is inaccurate
at <25 g/l; tables are available to convert the
urine specific gravity (USG) reading for the
sample to the protein concentration between
10 and 25 g/l.12 Low protein fluids are uncom-
mon in cats and have few differentials.9,29 If
the protein concentration falls into the transu-
date range (<25 g/l) then serum albumin
should be measured. If serum albumin is >15
g/l then pleural effusion due to decreased
plasma oncotic pressure can be ruled out.
Fluid overload can easily be ruled out from
702 JFMS CLINICAL PRACTICE
14/15 feline cases, with cardiogenic effusions having
lower values.9 LDH concentrations are usually >300
IU/l in FIP effusions.42 The measurement of LDH, glu-
cose and pH has been advocated to help identify
septic effusions; LDH is typically >200 IU/l, pH is )6.9
and glucose is usually <1.7 mmol/l (30 mg/dl, 0.3 g/l)
and lower than a concurrent blood glucose measure-
ment.2 This is not usually necessary for diagnosing
pyothorax but may have utility for unusual
infections. The same source suggests that canine
and feline neoplastic effusions typically have a nor-
mal or high pH (>7.4), low neutrophil count (<30%)
and low glucose (0.5–4.5 mmol/l).2 Accurate pH
measurement is often not available as it requires
anaerobic collection into a heparinised syringe and
immediate analysis using a blood gas machine or
hand-held analyser.63 Pleural fluid pH is most useful
as a prognostic marker in human parapneumonic
effusions.3
Studies that validate these and other potential
markers for determining aetiology and prognosis in
veterinary medicine would be welcomed.
the history. CHF remains the major differen-
tial diagnosis and echocardiography is the
most useful test here.
For translucent, yellow effusions with a
protein content >30 g/l, FIP is a major differ-
ential. The effusion associated with FIP is
typically viscous (evaluated by expelling the
fluid from a syringe, see page 701), froths on
agitation due to its high protein content, and
clots on standing. While the protein content is
consistent with an exudate, the TNCC,
comprising neutrophils and macrophages, is
low, consistent with a modified (<5000
cells/μl) or pure (<1000/μl) transudate.60 The
single most useful test for ruling in FIP as a
cause of pleural effusion is the use of
immunofluorescence to detect feline corona-
virus (FeCoV) antigen in macrophages.61 This
test has a positive predictive value (PPV) of
100%. It is less useful for ruling out infection,
with a negative predictive value (NPV) of
57%. A negative result may occur in a cat with
FIP if there are low numbers of macrophages
or if epitope masking by patient antibody
occurs. Rivalta’s test can be used (PPV 86%,
NPV 97%) where immunofluorescence is not
available, or to support a negative finding on
immunofluorescence.61 This test identifies
exudates based on their ability to retain their
shape in a dilute acetic acid solution. Where
less invasive tests are inconclusive, and a
definitive diagnosis is required, immunohis-
tochemistry of tissue biopsies can be used to
confirm FIP.
 R E V I E W / Pleural effusion in cats

Post-drainage chest radiographs, including lateral views, should be obtained

to detect abnormalities that may have been effaced by fluid or obscured by atelectasis.

Additional tests examination is useful to detect ascites and

enlargement of the caudal vena cava and
Imaging hepatic veins. Where pericardial effusion is
Post-drainage chest radiographs, including detected concurrently with pleural effusion it
lateral views, should be obtained to detect is likely to be a consequence of the same
abnormalities that may have been effaced underlying disease process, such as CHF, FIP
by fluid or obscured by atelectasis. The or neoplasia, rather than a cause of the pleural
pulmonary parenchyma and vasculature, effusion, since pericardial effusion rarely
cardiac silhouette and mediastinum should be causes tamponade in cats.65
evaluated. The presence of restrictive pleural The lung fields should be inspected for evi-
disease should be noted. The vertebral heart dence of underlying disease consistent with
score should be determined.64 Enlargement CHF, neoplasia and abscessation. Radio-
of the cardiac silhouette usually indicates graphic signs of pulmonary oedema in the cat
cardiomegaly but pericardial effusion or rare are variable. They include interstitial or alveo-
disorders such as pericardioperitoneal lar opacities in the perihilar area, dorsocaudal
diaphragmatic hernia should be considered. lung fields, more focally caudal to the heart or
Echocardiographic examination will rapidly unevenly distributed throughout the lung
distinguish between these possibilities and is fields. Patchy infiltrates from pulmonary
the diagnostic modality of choice to rule out oedema can be difficult to differentiate from
decompensated cardiac disease. Ascribing other lung diseases including neoplasia
significance to subtle echocardiographic (primary and metastatic) and infection.66–68
changes can be challenging. The atria dilate in Rounding of the borders of the lung lobes is
response to both pressure and volume over- consistent with pleural fibrosis seen with
load. Although there are exceptions, if the long-standing or irritant effusions. Fibrosing
atria are not enlarged, then CHF as a cause pleuritis is a cause of persistent dyspnoea
of pleural effusion is ruled out. Where RHF after pleural fluid drainage.
is suspected a cursory abdominal ultrasound Diagnosing mediastinal mass lesions, which

Investigative approach to pleural effusion

Suspected Stabilise Imaging to Clinical data Rank major differential Fluid characteristics
pleural confirm ✜ Signalment diagnoses (DDx) ✜ Gross
effusion (screen for ✜ History ✜ CHF ✜ TP
abdominal ✜ Physical ✜ FIP ✜ TNCC
fluid if using examination ✜ Neoplasia
ultrasound) ✜ Pyothorax
✜ Idiopathic chylothorax
✜ Other

Tests for confirming definitive diagnosis

Re-rank
Major DDx Diagnostic test Alternative/additional tests major DDx

CHF Echocardiography Serum pro-brain natriuretic peptide, review post-drainage radiographs, vertebral heart score

FIP Immunofluorescence Other tests on fluid: Rivalta’s test, lactate dehydrogenase (LDH), cytology.
of fluid for FeCoV Immunochemistry of tissue biopsies
Neoplasia Cytology of fluid Review post-drainage radiographs, thoracic ultrasound/CT

Pyothorax Anaerobic and aerobic Review post-drainage radiographs

culture, cytology

Idiopathic Confirm chylous effusion Rule out other causes: CHF, neoplasia, trauma, diaphragmatic hernia
chylothorax (triglyceride >100 mg/dl),
cytology
Other Guided by clinical data Consider packed cell volume, cytology, culture and sensitivity testing,
and fluid characteristics echocardiography, immunofluorescence for FeCoV, triglyceride concentration
(theoretically possible to not look chylous), LDH, glucose, thoracic CT, thoracoscopy

JFMS CLINICAL PRACTICE 703

R E V I E W / Pleural effusion in cats

are often accompanied by pleural effusion, can
be challenging using radiography alone since
mass lesions may be effaced by fluid. On a later-
al view, dorsal displacement of the trachea and
caudal displacement of the carina (which nor-
mally sits at intercostal space 6 in the cat) can
occur with large volume effusion, cardiomegaly
or a cranial mediastinal mass. On a DV or ven-
trodorsal (VD) view in healthy cats the width of
the mediastinum is usually less than twice the
width of the spine.52 DV or VD projections are
more useful than lateral views to differentiate
mediastinal mass lesions from pulmonary
masses. Cranial mediastinal masses displace the
carina and lungs caudally and can cause lateral
deviation of mediastinal structures.
Ultrasonographic evaluation of non-cardiac
intrathoracic structures and guided fine-
needle aspiration (FNA) biopsy or core biopsy
are useful for identifying neoplasia, pul-
monary abscessation, benign mass lesions and
diaphragmatic hernia.69 Pleural fluid provides
an acoustic window, enhancing visualisation.
The presence of concurrent peritoneal effusion
should be investigated. Peripheral, focal, non-
aerated pulmonary lesions are suitable for
ultrasound-guided FNA biopsy. In one study
of 56 feline and canine patients in which this
procedure was performed no complications
were noted and the sensitivity of this
technique for diagnosis was 91%.69 Although
more limited in availability, thoracic CT is an
excellent modality to detect, characterise and
evaluate the extent of intrathoracic nodules or
masses.70 Similarly, CT-guided FNA biopsy
or core biopsy, thoracoscopic biopsy or
exploratory thoracotomy may be indicated.71
The most common complications associated
with CT-guided or ultrasound-guided core
biopsy are pneumothorax and haemorrhage.
Serum testing
Routine haematology, biochemistry, urinalysis
and retrovirus testing are likely to be relatively
low yield in determining the underlying
disease process compared with analysis of the
effusion, but form part of the minimum data-
base to guide patient management and should

Case notes
A 14-year-old female neutered domestic shorthair
was presented with acute-onset dyspnoea.
The cat had become progressively inappetent
R Eover
VIEW / title
the previous 2 months and had lost weight.
On the morning of presentation she refused all food
and the owner noticed that she was ‘breathing up’.
Physical examination Major abnormalities were poor body
condition (body condition score 1/5), tachypnoea (respiratory
rate 60/min) with increased inspiratory effort and increased
respiratory excursions. On thoracic auscultation heart sounds
were muffled but harsh lung sounds were heard over the dorsal
lung fields bilaterally. The heart rate and pulse rate were 175
bpm. Rectal temperature was 38.2oC. The femoral pulse was
of normal amplitude. There was no jugular venous distension
or pulsation. The thyroid lobes were not palpable. Abdominal
palpation was unremarkable.
✜ CASE WORK-UP
Preliminary assessment Tachypnoea with increased
inspiratory effort and muffled heart sounds is suggestive of
pleural space disease. The harsh lung sounds dorsally suggest
concurrent pulmonary parenchymal disease. Pericardial effusion
was considered unlikely because of the lack of jugular venous
distension/pulsation and normal femoral pulse amplitude.
A restrictive respiratory pattern, as seen with pleural space
disease, is characterised by rapid, shallow respiration.
The respiratory excursions in this patient were quite deep
and more suggestive of a mixed respiratory pattern.
Thoracic ultrasonographic screening was planned after
stabilisation with supplemental oxygen. The cat was placed in
an oxygen chamber on admission and monitoring of respiratory
rate and depth at 5 min intervals was commenced. Pleural
effusion was confirmed on thoracic ultrasound.
Thoracocentesis was performed and yielded 150 ml of
non-odorous, moderately cloudy, straw-coloured fluid.
Respiratory rate and effort were reduced, but the patient
remained dyspnoeic (see video 4, doi:10.1016/j.jfms.2010.07.013,
post-thoracocentesis, respiratory rate 44 bpm).
Ranking of differential diagnoses The information gained
so far can be used to rank the common causes of feline pleural
effusion (see Table 2, page 694). A neoplastic or cardiogenic
effusion is most likely. Effusive FIP is possible because of the gross
characteristics of the fluid, but is uncommon in cats of this age.
Atypical infection remains a possibility. Although, theoretically,
prolonged fasting may reduce the lipid content of a chylous effusion
such as to alter the gross characteristics, this is very unlikely.
Given the age of the cat, primary bronchopulmonary neoplasia,
metastatic neoplasia and thymoma should be considered. Possible
cardiogenic causes include primary or secondary cardiomyopathies
or decompensated congenital heart disease. Cardiogenic causes
were ranked after neoplastic causes because of the absence of
signs such as tachycardia, murmur, gallop and jugular venous
distension, together with the poor body condition.
What next? Post-drainage thoracic radiographs are essential.
Depending on the findings, echocardiography may be indicated
to rule out CHF.
Fluid analysis should be carried out including cell count and
differential, protein content and cytological analysis. Other
parameters that would be useful to measure to differentiate
CHF from neoplasia include LDH, pH and NT-proBNP.
A complete blood count, feline immunodeficiency (FIV)/
FeLV tests, serum biochemistry profile and urinalysis are also
indicated to look for markers of systemic disease.

704 JFMS CLINICAL PRACTICE

 R E V I E W / Pleural effusion in cats

be carried out once the cat is stable. Other tests,
including total serum T4 and Dirofilaria immitis
antigen and antibody detection, may be indi-
cated depending on the case. An exciting recent
development is the validation of circulating
natriuretic peptide levels to differentiate
between cardiac and non-cardiac causes of
respiratory distress in cats. N-terminal pro-
brain natriuretic peptide (NT-proBNP) has
been shown to have sensitivity and specificity
of around 90% for detecting myocardial dis-
ease in this setting.72,73

Case notes (continued)

✜ RESULTS
Radiographic findings and
interpretation Three-view
post-drainage thoracic
radiographs from this cat are
shown on the right. Hyperinflated
lung lobes with obvious pleural
margins suggest emphysema or
air-trapping, possibly associated
with chronic pleuritis. There are
three homogeneous 2–3 cm
diameter pulmonary nodules. A
diffuse bronchointerstitial pattern
throughout the lungs indicates
more extensive pulmonary
infiltrative disease. Small pockets
of residual pleural fluid are also
evident. The sternal abnormality
may be congenital, traumatic or
possibly secondary to chronic
dyspnoea.
These findings are most
supportive of a neoplastic aetiology. Differential diagnoses
include primary or metastatic pulmonary neoplasia, although
the size of the pulmonary nodules is more suggestive of anisocytosis and feature a high nuclear:cytoplasmic ratio.
primary pulmonary neoplasia. An inflammatory process There is marked anisocytosis and anisokaryosis. Nuclei are
(eg, mycotic granuloma, FIP, toxoplasmosis, atypical bacteria) round, oval or indented. Nucleoli are large. Cytoplasm
is possible, but less likely. varies from scant to moderate in volume, is deep grey and
sometimes vacuolated. Mitotic figures, binucleate and
Haematology and biochemistry Results unremarkable. multinucleate cells are common. Abnormally large nuclei/cells
The total plasma protein was 75 g/l (reference intervals 59–78 are scattered throughout. Neutrophils and macrophages are
g/l) and serum albumin was 31 (reference intervals 19–38 g/l). present in the background.

Smear/cytospin There are numerous epithelial-like clusters

of rounded mononuclear cells that display marked

Fluid analysis results

Fluid type Thoracic fluid

Description Moderately cloudy, straw-coloured

Total protein 42 g/l

Nucleated cells 4000 x106/l
Erythrocytes 10,000 x106/l

Viscosity Not apparent

✜ DIAGNOSIS AND OUTCOME

The findings are consistent with a neoplastic effusion of epithelial origin. Exfoliating carcinoma cells appear to be present,
the main differential being a pulmonary carcinoma.
Because of the poor prognosis the cat was euthanased. Post-mortem examination was permitted and the resultant
histopathological diagnosis was pulmonary carcinoma.

JFMS CLINICAL PRACTICE 705

R E V I E W / Pleural effusion in cats

KEY POINTS
✜ Observation and auscultation of the dyspnoeic patient with pleural space disease is usually
sufficient to localise the problem. Imaging confirms pleural effusion.
✜ Assessment for respiratory compromise, stabilisation and monitoring are crucial to a good outcome.
✜ Congestive heart failure (CHF), feline infectious peritonitis (FIP), neoplasia, pyothorax and idiopathic
chylothorax account for most cases. Other causes are reported uncommonly.
✜ Signalment, history and data obtained from a minimally invasive physical examination are useful to rank differential
diagnoses.
✜ Appropriate laboratory testing of fluid obtained from diagnostic thoracocentesis is guided by clinical data and the
gross characteristics of the fluid.
✜ Results of fluid analysis may be diagnostic for pyothorax, neoplasia and FIP. In other cases they inform the diagnostic
investigation of the patient.

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