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Proceedings of the 33rd World Small

Animal Veterinary Congress
Dublin, Ireland - 2008

Next WSAVA Congress :

Reprinted in IVIS with the permission of the Congress Organizers

 Reprinted in IVIS with the permission of the Congress Organizers
WSAVA / FECAVA World Small Animal Congress
27 Vet Nurse Stream
5 S teps - dyspnoea
Kate Hopper BVSc(Hons), MVSc, DACVECC
Dept Veterinary Surgery & Radiology, Room 2112, Tupper Hall, University of California, Davis,
Davis CA 95616, USA
Dyspnoea or respiratory distress
is a common emergency problem
characterized by an increased
respiratory rate and effort. Animals
are often uncomfortable and
restless; they may extend their neck
and have increased respiratory noise.
The respiratory distress patient is
one of the most challenging patients
to manage as they often cannot
tolerate diagnostic tests and can require treatment
without knowledge of a definitive diagnosis.
1. Triage
Triage means ‘to sort’ and describes the process in
which patients are prioritized in order of their disease
severity so that the sickest animals are treated first.
Any patient arriving at the veterinary hospital for an
acute complaint should be immediately evaluated by the
triage nurse. This evaluation is based on the ‘ABCs’ and
includes assessment of the animals breathing rate and
effort and the perfusion parameters (mucous membrane
colour, capillary refill time, heart rate, pulse quality and
extremity temperature). Patients with any abnormality
of concern on this examination, active bleeding or
seizures should be transported to the treatment area
immediately for further assessment and treatment. The
respiratory distress patient will be evident by increased
respiratory rate, exaggerated respiratory effort and/
or excessive respiratory noise. These patients should
be transported to the treatment area immediately and
oxygen therapy started.
2. Oxygen, oxygen, oxygen
There are few if any adverse affects associated with short
term oxygen therapy and all respiratory distress patients
should be given the benefit of supplemental oxygen
until they are adequately stabilized. Initially a high
fraction of inspired oxygen (FIO2) is given to maximise
the benefit to the patient, this can be reduced once
effective monitoring of an animal’s ability to oxygenate
is established. Oxygen therapy requires a source of
oxygen, either a dedicated tank, an in wall system or via
an anaesthetic machine.
Flow by
The simplest way to administer oxygen is by directing
oxygen gas flow towards the patient’s mouth and nose
(flow-by), either via a Bain’s circuit or a face mask. A
face mask may allow administration of higher FIO2 than
Proceedings of the 33rd World Small Animal Veterinary Congress 2008 - Dublin, Ireland
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simple flow-by but close fitting masks may prevent
adequate loss of carbon dioxide (CO2) and heat. Flow-by
oxygen requires flow rates of 100-200 ml/kg/min and
may deliver anything from 30% to 60% FIO2.
Elizabethan collar
An Elizabethan collar with an oxygen source taped inside
and covered with plastic wrap (e.g. Glad wrap®) is a
cheap, readily available method in which reasonably high
levels of oxygen can be administered. It is important to
make a window in the top of the plastic wrap to prevent
accumulation of heat and CO2. It is difficult to control the
FIO2 in this situation and some animals with respiratory
distress will not tolerate the placement of the collar.
Nasal oxygen catheter
A nasal oxygen catheter is generally well accepted by most
patients and will supply an FIO2 of ~ 40% with an oxygen
flow rate of 100-200 ml/kg/min. It is advantageous
in that patient assessment and management can be
performed without interruption to the oxygen therapy.
Disadvantages include nasal mucosal irritation and it is
impossible to determine the actual FIO2 being given. In
order to reduce nasal irritation the administered oxygen
should first pass through a bubble humidifier and local
anaesthetic should be administered as required.
Oxygen cage
An oxygen cage allows administration of a known FIO2
to patients in a low stress, non-invasive manner. It is an
excellent way to provide oxygen therapy and is essential
for many cats. It uses a lot of oxygen and the cages are
expensive to purchase. Large dogs may quickly overheat
in an oxygen cage and must be monitored closely. A
temporary oxygen cage can be made by covering the
front of a normal cage with plastic or placing an entire
cat carrier inside a plastic bag. Accumulation of carbon
dioxide and heat can easily occur in these situations
so adequate ventilation and monitoring is essential.
Second hand human neonatal humidicribs can often be
purchased cheaply and can be excellent oxygen cages for
cats and small dogs.
3. Patient evaluation
Evaluation of the respiratory distress patient may be
limited depending on the animal’s tolerance to handling.
A physical examination including auscultation of the
chest is ideal when possible. Thoracic radiographs
are often diagnostic in respiratory distress patients
but frequently cannot be taken initially as holding
a respiratory distress patient down for radiographs
can have fatal consequences. Another diagnostic test
21-07-2008 11:24:49
 Reprinted in IVIS with the permission of the Congress Organizers
considered in the emergency room is thoracocentesis
- if fluid or air is aspirated from the pleural space it is
diagnostic. The maximal volume of air or fluid should be
removed from the pleural space in this situation making
this both a diagnostic and therapeutic procedure. Often
response to therapy is the only diagnostic tool available.
Drugs such as diuretics for suspected congestive heart
failure or bronchodilators for suspected asthma may be
given and the patient’s response is evaluated.
4. Possible causes and
5. Specific treatment
The causes of respiratory distress can be divided into
eight broad categories. By evaluation of the history,
clinical signs and limited diagnostic tests the most likely
cause(s) of respiratory distress can be determined and
the specific treatment can be provided.
Upper airway disease
Upper airway obstructions will cause increased
respiratory noise and effort, usually associated with
inspiration. Complete upper airway obstructions will
be associated with an absence of respiratory noise and
marked respiratory efforts which will quickly progress to
respiratory arrest. Causes of obstruction include foreign
bodies, neoplasia, laryngeal paralysis, laryngeal edema,
inflammatory lesions, abscesses, tracheal collapse and
brachycephalic syndrome. Diagnosis of an upper airway
problem is based on the clinical signs and response to
treatment.
Treatment is based on oxygen therapy and reducing the
degree of respiratory effort. Patients with upper airway
disease have fewer difficulties if they will breathe slow
and shallow breaths. If the temperature is elevated
the animal should be actively cooled with water and
fans. Sedation with low doses of acepromazine and/or
butorphanol is often beneficial. If the animal is in severe
distress, cyanotic etc., rapid induction of anesthesia
and securing the airway with orotracheal intubation is
indicated. If intubation is unsuccessful an emergency
tracheostomy will be required.
Lower airway disease
Lower airway disease causes wheezes and respiratory
distress on exhalation. Lower airway disease is most
commonly due to bronchoconstriction, often of an
allergic nature such as feline asthma. The wheezing
may be audible on initial evaluation or it may require
auscultation. If the disease process is chronic there may
be visible bronchial changes on radiographs but in acute
disease radiographs may be normal. Treatment includes
oxygen therapy and bronchodilators. If allergic disease is
suspected corticosteroids are indicated.
Pulmonary parenchymal disease
Pulmonary parenchymal disease describes disease of the
lung tissue itself and can be due to trauma (pulmonary
Proceedings of the 33rd World Small Animal Veterinary Congress 2008 - Dublin, Ireland
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Vet Nurse Stream 27
contusions), hemorrhage, infection, oedema, neoplasia or
inflammatory disease. All these diseases result in variable
degrees of alveolar fluid accumulation and alveolar
collapse. Clinically patients will have respiratory distress;
auscultation may reveal increased breath sounds and
moist crackles or may be normal. Diagnosis is confirmed
with thoracic radiographs where pulmonary infiltrates
will be present. Treatment is always oxygen therapy and
specific therapy for the primary disease if there is any.
Pleural space disease
Accumulation of air, fluid or soft tissue in the pleural
space prevents lung expansion, this reduces tidal volume
and predisposes to atelectasis. Animals with pleural
space disease may present with acute respiratory
signs or they may have a history of chronic progressive
respiratory disease. Auscultation may be abnormal,
fluid and soft tissue accumulations will dampen lung
sounds making them difficult to hear. When there is
fluid accumulation the loss of lung sounds is most
distinct ventrally. Thoracic radiographs are diagnostic but
thoracocentesis can be both therapeutic and diagnostic
and should be performed immediately in any patient
with severe respiratory distress suspected of having
pleural space disease. If thoracocentesis cannot fully
empty the pleural space or repeated thoracocentesis is
required, chest drains may need to be placed.
Chest wall disease
Chest wall defects are primarily the result of trauma and
are clearly evident at the time of physical examination.
These include rib fractures and open chest wounds.
Emergency therapy for these problems includes
oxygen therapy, thoracocentesis to ensure the pleural
space is empty, analgesia and in some cases surgical
intervention.
Pulmonary thromboembolism
Blood clots can lodge in the pulmonary blood vessels and
cause acute respiratory distress. This is called pulmonary
thromboembolism (PTE). Dyspnoea and hypoxemia in a
patient with normal thoracic radiographs is suggestive
of PTE. Definitive diagnosis is extremely challenging and
it is commonly assumed but not proven. Diagnosis of
PTE is only likely in patients which have an underlying
disease that may make them prone to forming abnormal
blood clots. Such diseases include immune mediated
haemolytic anemia, heart disease, neoplasia and protein
losing kidney disease. In mild to moderate cases oxygen
therapy and anticoagulant treatment to prevent further
blood clot formation is recommended. In cases of severe
respiratory distress and/or cardiovascular compromise
blood clot lysis with tissue plasminogen activator or
streptokinase is indicated. This therapy is associated with
a significant risk of hemorrhage.
Abdominal distension
Abdominal distension causes anterior displacement
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WSAVA / FECAVA World Small Animal Congress

27 Vet Nurse Stream

of the diaphragm leading to respiratory compromise. References

Common causes of severe abdominal distension include 1. King LG. Textbook of respiratory disease in dogs and cats. WB
gastric dilation volvulus, heavy pregnancy, ascites Saunders, St Louis 2004
and intra-abdominal masses. Significant abdominal 2. Macintire DK, Drobatz KJ, Haskins SC and Saxon WD. Small animal
distension in a patient with respiratory distress should emergency and critical care medicine. Lippincott Williams &
be decompressed as far as possible. In cases of severe Wilkins, Baltimore 2005
abdominal distension pulmonary atelectasis can occur. 3. Marino PL, The ICU Book, 2nd Ed. Williams & Wilkins, Baltimore
‘Look-alikes’ 1998
There are several causes of increased respiratory 4. West JB, Respiratory Physiology, The Essentials. 6th Ed. Lippincott
rate and/or effort that are due to stimulation of the Williams & Wilkins, Baltimore 2000
central respiratory center in animals with no primary 5. Hackett TB. Tachypnea and hypoxemia. In: Silverstein DC, Hopper
respiratory tract disease. These patients will have normal K, eds. Small animal critical care medicine. Saunders, St Louis,
oxygenation and no abnormalities on auscultation or 2009, p37
thoracic radiographs. They require no treatment of their 6. Mazaferro EM. Oxygen therapy. In: Silverstein DC, Hopper K, eds.
respiratory signs but may benefit from treatment of Small animal critical care medicine. Saunders, St Louis, 2009, p78
their primary disease process.
Many brain diseases can cause stimulation of the
medullary respiratory center. Diseases such as neoplasia,
inflammatory brain disease and trauma can all lead
to respiratory changes. These patients usually have
other signs of brain disease such as obtundation, cranial
nerve defects and behavioral changes. They may also
have abnormal respiratory patterns such as apneustic
breathing and Cheyne Stokes breathing.
Hyperthermia is also a potent stimulus of respiratory
rate and effort, especially in dogs. Hyperthermia is the
consequence of high ambient temperatures and/or
exertion and should be differentiated from fever. Fever
describes an elevation in body temperature due to
endogenous pyrogens and will not trigger increases
in respiratory rate and effort. Measurement of body
temperature in animals with respiratory distress is very
important. Hyperthermia may be the primary cause or a
contributor to increased respiratory rate and effort and
cooling will tend to improve these clinical signs.
Drugs such as opioids will directly stimulate the
central respiratory centre producing rapid panting. On
examination these animals will have a normal or lower
than normal body temperature and a normal or higher
than normal PCO2.
Metabolic acidosis will also stimulate increases in
respiratory rate and depth of breathing in an effort to
lower PCO2 and return pH towards normal.

Proceedings of the 33rd World Small Animal Veterinary Congress 2008 - Dublin, Ireland
678 | WSAVA / FECAVA Programme 2008

653-690 27 Vet Nurse Stream.indd 678 21-07-2008 11:24:50