Step 1: Recognise the Signs. Disclaimer of CONFLICT of INTEREST. HANDS OFF! How to recognise the cardiac patient 18/03/2013. Cardiac! Respiratory!

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1 Disclaimer of CONFLICT of INTEREST I DO NOT have any direct or indirect financial interest in promoting, advertising or recommending any pharmaceutical products HANDS OFF! How to recognise the cardiac patient Dr Luca Ferasin DVM PhD CertVC PGCert(HE) DipECVIM-CA (Cardiology) GPCert(B&PS) MRCVS European and RCVS Recognised Specialist in Veterinary Cardiology Companies cited in these lectures HAVE NOT provided any bibliographic or promotional material to be used in this presentation Companies cited in these lectures HAVE NOT previewed, suggested or influenced the scientific content of this presentation Cardiac! Respiratory! Step 1: Recognise the Signs 1

2 Stridors Stridors Stenotic nares Laryngeal Paralysis Bibo, 12y MN X-breed 6-month history of coughing Systolic grade III/VI heart murmur with PMI=LA Currently on furosemide and benazepril Luna 13y FN Chihuahua 1-year history of coughing Systolic grade IV/VI heart murmur with PMI=LA Currently on furosemide, benazepril, pimobendan, digoxin 2

3 Coughing Aaaahhhh my dog keeps coughing!! Cough: What s in the name? Cough: Why should we bother? When cough becomes persistent, it may interfere with: Breathing Eating/Drinking Sleeping (Dog) Sleeping (Owner) (more rarely: syncope, incontinence, muscle ache, fatigue) 3

4 Cough: the Reflex (Chang, AB. Pediatric Pulmonology 1999, 28:59 70) 4

5 Voluntary Control of Cough Cerebral Cortex Placebo Effect Sensation of Irritation + - Endogenous Opioids Exogenous Opioids Vagus nerve Airway irritation Respiratory Area of Brainstem Modified from: Ravi & Kappagoda (1990) News PhysiolSci 5: 95-9 Respiratory Muscles Cough Phases (several skeletal mm involved) Plasticity of Cough Inspiration Near-maximal inspiration Compression Closure for 200 ms Intrapleural and intra-alveolar pressure 300 mmhg Expulsion Airflow ~ 30 m/s Dynamic collapse bronchial tree ( pressure gradients) Relaxation Resume functional residual capacity 5

6 Tracheal palpation How can I stopo coughing if this idiot is trying to strangulate me?!! Cough Reflex Expiratory Reflex Explosive Cough 6

7 Cough: most common causes in people Expiratory Reflex Cough Reflex Cigarette Smoking Acute Respiratory Tract Infection Allergy Chronic Bronchitis and Bronchiectasis Post-nasal drip syndrome (PNDS) Gastro-Oesophageal Reflux ACE inhibitors No Reflex Chronic Bronchitis Commonly observed in dogs, especially middleage or old dogs of the small breeds Post-nasal drip syndrome (PNDS) No coughing receptors in the pharynx Commonly observed in dogs but poorly described Mostly associated with rhinosinusitis Excessive swallowing, coughing and sneezing 7

8 Gastro-oesophageal reflux activation of oesophageal sensory receptors responsive to acid or due to reflux of gastric contents irritating the larynx ACE inhibitors 20% human patients on ACE inhibitors develop a dry cough, sometimes severe enough to require discontinuation of the drug. (Eur Respir J 1993; 6:576) Cough as a side-effect of ACEi is not recognised as being ACEi-related or is symptomatically treated with antitussive agents instead of ACEi substitution (Br J Clin Pharmacol Feb;69:200) ACE Bradykinin breakdown Bradykinin Arachidonic Acid Inflammation Nitric Oxide Drinking/Eating-induced coughing associated with swallowing impairment or, less commonly, bronchoesophageal fistula Cigarette Smoking 8

9 The Cardinal Signs of Heart Failure Why do Dogs with Cardiac Disease Cough? (Merck s Medical Manual) Exercise Intolerance Dyspnoea (Merck s Veterinary Manual) Cough Dyspnoea Cough: Cardiac causes? Pulmonary interstitial / alveolar transudate Described only in Veterinary Textbooks Described primarily in Dogs Attributed to: Pulmonary oedema Bronchial mucosa oedema Dorsal elevation and compression of the trachea Dorsal elevation and compression of the left main stem bronchus 9

10 Oedema of the bronchial mucosa? In dogs, blood from the extra-pulmonary bronchi drains into the left azygos vein From: The Bronchial Circulation by John Butler ; Pub Informa Healthcare; 1 ed Dorsal elevation and airway compression Dorsal elevation and airway compression 10

11 Courtesy of Dr Enrico Bottero PULMONARY OEDEMA CARDIOMEGALY AIRWAY DISEASE 11

12 Mitral Regurgitation and Cough Mitral Regurgitation and CHF Cough No Cough Dyspnoea 0% No Dyspnoea 44% 56% 100% Ferasin et al JVIM 2013 Ferasin et al JVIM 2013 UNIVARIATE ANALYSIS MULTIVARIATE ANALYSIS Odds Ratio NS Odds Ratio NS NS NS NS NS

13 P = P = Odds Ratio 6 4 AOR Absence of Airway Dx Presence of Airway Dx Age (Years) Normal LA size Increased LA size Normal LA size Increased LA size Furosemide: the big confounder anti-inflammatory effect (inhibition of production and release of cytokines interleukin (IL)-6, IL-8, and TNF-α, improving the sensitivity of target cells to endogenous glucocorticosteroids 1 In adults and children with asthma, furosemide exerts a protective effect against bronchoconstriction 2 activation of stretch receptors and inhibition of irritant receptors resulting in inhibition of cough 3 Häggström et al., J Vet Intern Med 2008;22:1124 1) Prandota J. American Journal of Therapeutics. 2002; 9:317 2) Journal of Veterinary Emergency and Critical Care. 2008, 18:26 3) Sudo et al. Am Journal Respiratory Critical Care Medicine. 2000; 162:971 13

14 Self-improvement: another big confounder Tachypnoea/Dyspnoea If you cough because of a cold and you take drugs you will improve in approximately 1 week If you cough because of a cold and you DON T take drugs...you will improve in approximately 7 days! Polypnoea Tachypnoea/Dyspnoea Laboured and often fast breathing unpleasant or uncomfortable sensation unusual position to improve breathing anxiety The experience of dyspnoea likely results from a complex interaction between: chemoreceptor stimulation mechanical abnormalities in breathing perception of those abnormalities by the CNS 14

15 Sleeping Respiratory Rate (SRR) Tachypnoea Lung Fibrosis Dyspnoea Orthopnoea Congestive Heart Failure Congestive Heart Failure 15

16 Breathing pattern Localisation Differential diagnosis Prolonged inspiration Normal resp rate Stridors Dynamic Upper airway obstruction Normal resp rate with noise Fixed upper airway on inspiration and expiration obstruction Normal resp rate with cough, Intrathoracic trachea or wheezes, rhonchi lower airway disease. Prolonged expiration Rapid resp rate with pulmonary crackles Rapid resp rate with quiet breath sounds Pulmonary parenchymal disease Pleural disease Nasopharyngeal polyp Inflammatory laryngitis Tracheal obstruction (neoplasia, FB) Asthma Chronic bronchitis Mass lesion affecting intrathoracic airways Pneumonia Pulmonary contusions Neoplasia Pulmonary thromboembolism Pulmonary oedema Pleural effusions Pulmonary oedema Neoplasia Pyothorax FIP Chylothorax Haemothorax Pneumothorax Diaphragmatic hernia Anxiety Stress Dyspnoea 16

17 Pallor IMHA Cyanosis Exercise Intolerance Tetralogy Fallot Usually based on Owner s perception Available tests for more objective evaluation 17

18 Pre-treatment 1-week treatment 4 week treatment Ascites Pre-treat 1-w eek Pre-treat 1-w eek Rest Level 1 Level 2 Level 3 Recovery 0 Rest Level 1 Level 2 Level 3 Recovery Pre-treat 1-w eek w eek Pre-treat 1-w eek Rest Level 1 Level 2 Level 3 Recovery Rest Level 1 Level 2 Level 3 Recovery Right-sided heart failure 18

19 Syncope sudden, unexpected, and unprovoked loss of consciousness loss of postural control, unresponsiveness transient (seconds), spontaneous recovery Inappetance/Weight Loss/ Growth Failure Paresis/paralysis Hindlimb paresis/paralysis Arterial Thromboembolism Reversed PDA Arterial Thromboembolism 19

20 History Signalment Species Breed Age Gender Origin Age Breed Congenital ± failure to grow Respiratory infections non-vaccinated animals Neoplasia AV valve pathologies Cardiomyopathy Lung fibrosis Laryngeal paralysis Hyperthyroidism Systemic hypertension 20

21 General Impression Evaluation of respiratory movements Evaluation of respiratory movements General Impression 21

22 General Impression Interview Questionnaire How to open a question (e.g. coughing=yes)? how long coughing has been present? whether it began suddenly? if it has changed recently? what factors influence it (eg, cold air, barking, posture, eating or drinking, time of day)? whether it is associated with sputum production (often noticed by the owner as swallowing after coughing ) or other symptoms 22

23 Nutritional condition thin or even emaciated > cardiac cachexia obesity > may exacerbate coughing associated with respiratory diseases. Body condition/ appearance enlarged abdomen and inadequate gait > ascites? Coat dull > dehydration symmetrical alopecia > Hypothyroidism and hyperadrenocorticism Behaviour dyspnoea or tachycardias > anxiety History Mental Status Chronic cardio-respiratory disease > lethargy 23