21/04/2021

The coughing dog – Heart or Lungs?

Yolanda Martinez Pereira LdaVet CertVC DipECVIM-CA(Cardiology) SFHEA MRCVS

Friday 11th June 2021, 1:30 -2:20 pm

Sponsored by

Speaker Disclosure

The coughing dog: Heart or Lungs?

Yolanda Martinez Pereira

FINAL DISCLOSURE:
No relevant financial exists

UNLABELED/UNAPPROVED USES DISCLOSURE:

None

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Learning outcomes

1. List the key findings of cardiac and respiratory disease during physical examination

2. Formulate a differential diagnosis list for coughing

3. List the main diagnostic tests available to investigate coughing

Agenda

INTRODUCTION
1) Anatomy
2) Respiratory physiology

DIFFERENTIAL DIAGNOSIS
1) Coughing

HISTORY AND PHYSICAL EXAMINATION

1) Cardiovascular and respiratory systems

DIAGNOSTIC PLAN

Introduction – respiratory anatomy

Nasal LOWER AIRWAYS

cavity Nasopharynx
Nares
Oropharynx Larynx

intrathoracic trachea
Cervical trachea
Bronchi
Bronchiols,
alveolae,
Heart intersitium
UPPER AIRWAYS

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Introduction – respiratory physiology

RESPIRATORY FUNCTION
• AIR PASSAGE
SUPPLY O2 TO TISSUES
1) Pharynx – larynx DISPOSE CO2
2) Trachea FUNCTIONS
3) Bronchi (1os, 2os, 3os) VENTILATION
4) Bronchiole, terminal bronchiole DIFFUSION (O2 + CO2)
TRANSPORT GAS - blood, tissues
• PULMONARY PARENCHYMA REGULATION RESPIRATION
1) Respiratory bronchiole
2) Alveolae
3) Interstitium
• Vessels
• Nervous fibers
• Cellular components: fibroblasts, mastocytes, etc
• Extracellular matrix

Introduction – respiratory physiology

AIRWAY PASSAGES
• RESPIRATORY AIRWAYS – specialised tissue

Cartilage
Smooth muscle
Low resistance
Mucous glands (Goblet cells,
submucosal glands)
Protective mucous layer
Ciliated epithelium
Constant ciliary movement
Nasal passages
Filtration
Warming
Humidification
Nasal epithelium – cilia – caudal movement
Traqueal, bronchial epithelium – cilia - cranial movement
Pediatric respiratory medicine. Taussing. Mosby Elsevier, 2nd Ed, 2008

RESPIRATORY UNIT

Respiratory bronchiole
Alveolar duct
Atria
Alveoli – pneumocytes I (95%),
II (surfactant, repair cells)
Very thin walls
Covered by extense net of
capillaries– “sheet of blood”
Pulmonary “membrane” (0.2-0.6 µm)
http://www.alpha1health.com/images/content_assets/respitorywork.jpg
Surfactant layer
Alveolar epithelium
Basal membrane of alveolar
epithelium
Interstitial space
Basal membrane of capillary
endothelium
Capillary endothelium

Pediatric respiratory medicine. Taussing. Mosby Elsevier, 2 nd Ed, 2008

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http://fau.pearlashes.com/anatomy/Chapter 36

http://www.pdh-odp.co.uk/images/Diffusion%20of%20Gases.jpg

RESPIRATORY MEMBRANE

Pediatric respiratory medicine. Taussing. Mosby Elsevier, 2nd Ed, 2008

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Respiratory physiology – defence mechanisms

• EXLCUSION of particles/infectious agents

• Mucociliary escalator system
• Particle deposition – size
• Closure of larynx – C fiber R
• Coughing reflex
• Bronchoconstriction
• Increased mucus production
• ELIMINATION of particles/infectious agents
• Alveolar fagocytosis (alveolar, interstitial and intravascular macrophages and neutrophils)
• Pulmonary lymphatics & lymphoid tissue (LN & BALT)

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The coughing reflex is a respiratory defence mechanism

RECEPTORS of the tracheobronchial tree Neuroepithelial bodies –

• Larynx, trachea and larger bronchi involved in hypoxia-induced
bronchoconstriction?
• Slow-adapting bronchial stretch R (breathing)
• Rapidly-adapting irritant stretch R (coughing + bronchoconstriction, increased mucus production, laryngeal
closure)
• Smaller bronchi Respond to endogenous mediators (histaminE, Ach,
PG, bradykinin) and cause apnea + tachypnoea (no
• Bronchial C-fiber R coughing), also mucus production,
• Alveoli bronchocosntriction, laryngeal constriction,
bradycardia…
• Pulmonary C-fiber R Activated by pneumonia, pulm congestion/oedema.,
• C-fibers (unmyelinated axons) PTE

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The coughing reflex – easy to identify?

• Deep inspiration
• Closure of glottis
• Forcible contraction of expiratory muscles
• Raise in pleural cavity pressure
• Sudden opening of glottis
• Expulsion of air (+ particles) through larynx
• High speed (H 160 Km/h)
REVERSE SNEEZING,
GAGGING, RETCHING,
HAIR BALL !

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Why coughing in cardiac disease?

• Coughing is a defence mechanism of the airways

• Cardiomegaly (LAE) activates receptors – coughing

• Pulmonary oedema and pulmonary venous congestion activates receptors - tachypnoea

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Coughing
Oropharyngeal disorders Inflammation Trauma and irritants
(tonsillitis,pharyngitis) Congenital/ conformation
Neoplasia abnormalities
Foreign bodies
Upper airway disorders Inflammation (laryngitis, Laryngeal paralysis
tracheitis) Tracheal collapse
Neoplasia Tracheal hypoplasia
Trauma Tracheal stenosis
Foreign bodies and irritants Extramural tracheal compression
Tracheal parasites
Pulmonary parenchymal disease Pneumonia Pulmonary oedema (cardiogenic
Abscessation and non cardiogenic)
Neoplasia Pulmonary fibrosis
Pulmonary infiltrate with Irritant gas inhalation
eosinophils
Mediastinal and thoracic wall Pleuritis neoplasia
disease Pleural effusions
Cardiac disease Left sided congestive heart failure (left atrial enlargement and
pulmonary oedema)

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Inspiratory dyspnoea
Nostrils Stenotic nares
Fungal rhinitis
Nasal plane masses

Nasal Foreign bodies Rhinitis and accumulation of nasal

Cavity Space occupying lesions (masses) secretions

Larynx Elongated soft palate Laryngeal paralysis

Pharynx Nasopharyngeal polyps Laryngeal oedema
Nasopharyngeal stenosis Everted laryngeal saccules
Layngeal and pharyngeal masses Laryngeal laceration/trauma

Cervical Tracheal collapse Intraluminal occupying lesions (mass)

trachea Tracheobronchitis Tracheal foreign body
Tracheal parasites Extraluminal compression

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Expiratory dyspnoea
OBSTRUCTIVE RESTRICTIVE
Thoracic trachea Bronchial Tree Pleural Cavity Pulmonary Abdominal Metabolic
parenchyma distension causes
Tracheal collapse Bronchitis Pleural effusions Oedema Ascitis Anaemia
Tracheobronchitis Bronchoconstriction Pneumothorax Inflammation Organomegaly Metabolic
Tracheal parasites (asthma) Diaphragmatic (pneumonia) Pregnancy acidosis
Intraluminal space Intraluminal space hernia Fibrosis Obesity
occupying lesion occupying lesions Chest wall Neoplasia Neoplasia
(mass) Extraluminal tumours Haemorrhage GDV
Tracheal foreign compression /contusion
body (cardiomegaly, Embolisation
Extraluminal neoplasia, LN) (PTE)
compresssion

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Taking a history to differentiate cardiac vs

respiratory disease
• MARIN COMPLAINTS:
CARDIAC OR RESPIRATORY?
• COUGHING
• Sneezing
• Reverse sneezing
• Nasal/ocular discharge
• Decreased exercise tolerance
• Abnormal “respiratory noise”
• Abnormal breathing pattern
• Breathless
• Increased panting
• Collapse
• Respiratory distress
• Cyanosis

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Taking a history – key points

1) IDENTIFY PRIMARY PROBLEMS

• Duration, severity (progressively worse? Improving? Intermittent?), response to previous
treatment
2) BACKGROUND
• Vaccination, worming (when? Product? Other pets?), exercise, environment
(garden/slugs/foxes/smokers/rural), other pets, travelling, family, previous illnesses
(neoplasia? RTA? Pneumonia?)
3) DETAILED INFORMATION OF MAIN PROBLEM/S
4) OTHER BODY SYSTEMS
More than 10 minutes…

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Taking a history – the importance of the details

• How often? URT noise

• For how long? • Nasal estertor
• Triggers? • Laryngeal stridor
• Changes in barking?
• Progression?
• Coughing when eating/driking?
• Productive?
• Snoring?
• Tussive syncope?
LRT noise
• Timing?
• Wheezes
• Retching/gagging, sneezing/reverse…
• Ronchi

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Physical examination

OBSERVATION EXAMINATION

• Count the resting respiratory rate • General examination – head to toes

• Evaluate the breathing pattern • Specific cardiorespiratory examination
• Emergency? – O2 supplementation • Mucous membranes
• Body condition – out of 9 • Chest palpation
• Cardiac cachexia • Chest percussion
• Obesity – ventilation! • Chest auscultation
• Coughing? Sneezing? • Pulses
• Nasal depigmentation?

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OBESITY

CACHEXIA

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Physical examination

PALPATION PERCUSSION
• Apex beat • Easy to perform, cheap!
• Displaced?
• Muffled?
• Useful if pleural effusion
• Air • Pleural line
• Masses • Increased resonance if pneumothorax
• Pneumonia
• Effusion (pericardial/pleural)
• Decreased resonance
• Fluid
• Heart rate and rhythm? Thrill?
• respiratory arrhythmia? • Masses
• Pain? • Pneumonia
• Cardiomegaly
• Asymmetries?

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MEDIASTINAL MASS – APEX

BEAT DISPLACED L and D

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CHEST PALPATION

CARDIOMEGALY – caudal
displacement of apex beat
ARRHYTHMIA – fast AF

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CHEST PERCUSION

PLEURAL EFFUSION – fluid line

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Auscultation

CARDIAC LUNG
• Rate • Respiratory rate
• Rhythm • D <20
• C <40
• Murmurs?
• Grade (I-VI) • Four quadrant
• Timing (S, D, T&F, C) • Abnormal respiratory sounds
• PMI • Inspirator/expiratory wheezes
• Character (ejection, regurgitant) • Ronchi
• Muffled? • Inspiratory crackles
• Fine
• Other abnormal sounds? • Coarse
• Split S2
• Tracheal/laryngeal auscultation

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Ao

PA
Apex beat
MV

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GRADE DESCRIPTION PRACTICAL Lungvall JSAP

2014

I Very quiet, difficult to hear (quiet room) MILD SOFT

II Very quiet but can be heard when in the

right position

III Can be heard immediately but is not MODERATE MODERATE SUBJECTIVE BUT
louder than heart sounds (S1-S2) USEFUL! – DON’T
FORGET TO PALPATE
IV Easy to hear, louder than S2-S2 but no LOUD THE CHEST!!
thrill

V Can’t miss! Palpable thrill LOUD THRILLING

VI Can’t miss! Palpable thrill and can hear

even when separating stethoscope from
chest wall!

Ljungvall, JSAP 2014. “Murmur intensity in small breed dogs with MMVD reflects disease severity”

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Differential diagnosis – Left base systolic

• Aortic stenosis
• Pulmonic stenosis
• PDA
• Ejection murmur
• Innocent
• Anaemia
PDA continuous
murmur, often
causes LA
enlargement and
CHF

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Differential diagnosis – Left apical systolic

• Mitral regurgitation
• Myxomatous mitral valve disease (MMVD)
• Mitral Valve Dysplasia (MVD)
• Dilated Cardiomyopathy (DCM) - mild

Left atrial
enlargement
LCHF

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Differential diagnosis – Right systolic

• Tricuspid regurgitation
• Tricuspid valve dysplasia (TVD)
• Pulmonary hypertension (PH) with TR

• Ventricular Septal Defect (VSD)

Chronic parenchymal lung

disease can cause
pulmonary hypertension –
cor pulmonale

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Other clues to cardiac disease

• Femoral pulses
• Weak, pulsus paradoxus, pulsus alternans, pulse
deficits, hyperdynamic (PDA, AI)
• Jugular distension/pulsation
• Hepatojugular reflux
• Abdominal effusion

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Summary key findings from physical examination

CARDIAC RESPIRATORY
• Sinus tachycardia • Sinus arrhythmia
• MMVD – loud L apical murmur • Abnormal respiratory sounds
• Crackles
• DCM – murmur not always there • Wheezes
• Effusion – muffled! • Ronchi
• URT noise
• Others – abdominal fluid thrill, jugular • Laryngeal stridor
pulsation, abnormal pulses, arrhythmia
• Chronic presentation
• Gradual worsening • FB – acute onset
• BCS – cardiac cachexia • BCS

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Diagnostic approach in dogs with coughing

• Blood tests (GHP, BGA)

• Faecal tests
• Thoracic imaging
• Radiography, ultrasonography
• Fluoroscopy/CT
• Endoscopy
• Laryngoscopy
• Bronchoscopy
• Cytology/histopathology
• Tracheal wash
• BAL
• FNA/lung biopsy

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COUGHING

History and Physical Examination

Heart disease more likely Respiratory disease more

likely

I DON’T KNOW! • Thoracic xrays

• Thoracic xrays
• Echocardiography • Laryngoscopy
• ECG • Bronchoscopy
• Blood pressure • BAL/tracheal wash
• Holter • Fecal analysis/worming
• NT-proBNP • CT
• cTnI
• Thoracic xrays • Fluoroscopy
• Bloods • POCUS
• Urine • Lung FNA/biopsy
• LA/Ao • Bloods
• Lung US
• Response to tx?

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How can blood tests help me?

• Routine haematology
• Leukocytosis (neutrophilia)
• Pneumonia
• Eosinophilia
• PIE, parasites
• Polycythaemia
• Chronic hypoxia
• Serum biochemistry
• In case cardiac meds needed…

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Is BGA needed?
PaO2: • A-a gradient: information about V/Q match
• 5 x FiO2 (100 mmHg at room air, 500 mmHg on an intubated patient on
100% O2) PAO2 = FIO2 (PB + PH2O) – PaCO2/RQ
• Normal 80-110 mmHg
• PB: barometric pressure
• Hypoxaemia <80 mmHg
• Severe hypoxaemia <60 mmHg • PH2O: water vapour pressure
• Lethal hypoxaemia <40 mmHg
• RQ: respiratory quotient
• PaO2:FiO2
• Normal 480 • FIO2: fractional inspired O2
• Severe lung disease <300
• ARDS <200
PaCO2 PAO2 = 150 – 1.1 x PaCO2
• Normal 35-45 mmHg
• Hypercapnia >45 – hypoventilation • At room air at sea level with RQ 0.9
• Ariway obstruction
• Depression respiratory centre
• Neuromuscular disease PAO2 – PaO2
• Restrictive defect (pneumothorax, effusion)
• Respiratory muscle fatigue
• Normal is <15
• Hypocapnia <35 – hyperventilation
• Pain/fear/stress • Increased if pulmonary function is compromised (>30
•
•
Neurological disease
Hyperthermia
significant impairement)
•
•
Metabolic acidosis (compensation)
Marked hypoxaemia
• Normal if hypoxaemia is caused by hypoventilation

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Is BGA needed? – conscious pulsoxymetry

• Non-invasive method
• Assessment of oxyhaemoglobin content of perfused tissues – estimate of SaO2
• Relies on detection of light absorption during arterial pulsations compared to the background (veins,
tissue..)
• Needs a perfused tissue

Practicalities:
- If in tongue – needs moistening
- probe may need repositioning
(decreased perfusion due to pressure)
- may not work in pigmented dogs
- movement!

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Pulsoxymetry does not replace BGA but can be helpful

• Useful if hypoxia oxyHb

• Can rapidly assess response to O2 dissociation
• Can be performed conscious (PE) curve is sigmoid!
• Check HR matches!
• Useful if very high saturation obtained!

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Thoracic radiography is priceless!

• Need to remember your thoracic anatomy!

• Allows you to diagnose CHF
• LAE
• Congested PL vessels
• Lung pattern
• VHS – cardiomegaly
• Lung patterns
• Lung masses

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R Cr
Left Cranial
(Cr)

R Md Left cranial
(Cd)

R Cd

Left
caudal

R Acc

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Sometimes you need advance imaging

• Pleural effusion
• Lung masses
• Intrathoracic masses
• Complex pneumonia
• Interstitial lung disease
• Complex cardiac disease
• AngioCT
• Dynamic airway obstruction
• Fluoroscopy

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When cardiac disease is suspected

• Echocardiography
• POCUS

• LA/Ao >1.5
• Effusion (PE, PleuE)
• Heart base tumour
• Lung US – B lines

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When respiratory disease is suspected

• GA required
• Laryngoscopy
• Bronchoscopy
• BAL
• Bronchoscopy guided
• Blind

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Airway cytology

TRACHEAL WASH BAL

• Samples from trachea and primary bronchi • Samples from alveolae and small airways
• Cytology • Cytology
• Culture
• Culture
• Technique
• Transtracheal • Technique
• Sedation not required • Bronchoscopic
• Coughing reflex present • Non-bronchoscopic
• Endotracheal
• Anaesthesia required • Safe procedure, minor side-effects
• Coughing reflex not present • bronchospasm
• Safe procedure, minor side-effects • More sensitive than tracheal wash
• Less sensitive than BAL • Training and equipment
• Especial training or equipment not required?

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Summary key findings from diagnostic tests

CARDIAC RESPIRATORY
Radiographs Radiographs
• Cardiac silhouette • Lung pattern
• Cardiomegaly • Bronchial
• LAE • Interstitial
• Pulmonary congestion • Masses
• Lung pattern If respiratory work up required – GA
Thoracic US
• Laryngeal function
• LA/Ao
• Bronchoscopy
• Effusion (PE, PleurE)
• BAL
• Lung US

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COUGHING

History and Physical Examination

Heart disease more likely Respiratory disease more

likely

I DON’T KNOW! • Thoracic xrays

• Thoracic xrays
• Echocardiography • Laryngoscopy
• ECG • Bronchoscopy
• Blood pressure • BAL/tracheal wash
• Holter • Fecal analysis/worming
• NT-proBNP • CT
• cTnI
• Thoracic xrays • Fluoroscopy
• Bloods • POCUS
• Urine • Lung FNA/biopsy
• LA/Ao • Bloods
• Lung US
• Response to tx?

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Questions? Thank you to our Sponsor

Yolanda Martinez Pereira LdaVet CertVC

DipECVIM_CA(Cardiology) SFHEA MRCVS
Hospital for Small Animals, R(D)SVS, University of
Edinburgh
Yolanda.Martinez@ed.ac.uk

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