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Top 10 Mistakes to Avoid in Dyspneic Patients
Justine A. Lee, DVM, DACVECC, DABT CEO, VetGirl
Garret Pachtinger, VMD, DACVECC COO, VetGirl
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Thanks to today’s SPONSOR!
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Introduction
Justine A. Lee, DVM, DACVECC, DABT
CEO, VetGirl
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Introduction
Garret Pachtinger, VMD, DACVECC
COO, VetGirl
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VetGirl… on the go! ! The tech-saavy way to get CE credit!
! Subscription-based podcast service offering RACE-approved CE for $99/year
! VetGirl ELITE includes 12 hours of webinars
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Who likes seeing dyspenic patients?
Photo courtesy of Vicki Campbell, DVM, DACVA, DACVECC
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Classic orthopnea
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English bulldog
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Goals of the Talk
! Not knowing what a TFAST is
! Taking chest radiographs in dyspneic cats
! Not feeling comfortable performing a thoracocentesis
! Not smelling cats more
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Goals of the Talk ! Not being able to interpret a pulse oximetry
reading
! Being scared to control the airway
! Assuming it is congestive heart failure (CHF) if the HR is < 150-160 bpm
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Goals of the Talk
! Underutilizing your patient’s signalment to guide your therapy
! Not understanding oxygen content (CaO2):
When to give oxygen vs. blood products
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Goals of the Talk
! Not knowing what ARDS or ALI are ! Not using inhalers more frequently
! How to give oxygen!
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Mistake #1: Not Knowing What a TFAST Is
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FAST Exam
! Focused Assessment with Sonography for Trauma
! New standard of care, human ER
! 2-minute test
! Helps pay off your ultrasound machine
! Evidence of free abdominal fluid: look in 4 areas
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FAST Locations
§ Caudal to xiphoid process § On midline over bladder § Over most gravity-dependent area § Right and left flank
Figure courtesy of Boysen SR from IVECCS proceedings 2006.
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TFAST: Thoracic Focused Assessment with Sonography for Trauma
! Use the FAST exam for the chest ! Pleural effusion ! Pneumothorax
! Etch-a-sketch™ ! The “Glide” sign (no pneumothorax!) J
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Not Knowing What a TFAST Is
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Mistake #2: Taking Chest Radiographs in Dyspneic Cats
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Taking Chest Radiographs in Dyspneic Cats
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Mistake #3: Not Feeling Comfortable Performing a Thoracocentesis
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Thoracocentesis ! Supplies:
! 20 cc syringe ! 3 way stopcock ! 16-22 ga. needle or butterfly catheter ! Extension setting ! Empty bowl ! +/- sedation
! Butorphanol: 0.2-0.8 mg/kg IM or IV ! Diazepam: 0.1-0.25 mg/kg IV
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The exceptions to the “benign thoracocentesis?”
! Siamese cats ! Chronic cats:
! Chylothorax ! Asthma
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Mistake #4: Not Smelling Cats More
! Siamese cats ! Acutely dyspneic ! Asthma ! Smoke smell ! Essential oil smell? ! www.Fritzthebrave.com
f_coughing-cat.wmv
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Mistake #5: Not being able to correlate a pulse oximetry reading well
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Pulse oximetry
! Limitations ! Excessive movement ! Pigmentation ! Jaundice ! Hypothermia ! Nail polish ! Extraneous light ! Decreased perfusion
! Accuracy? ! ALWAYS perform
arterial blood gas if concerned
! Matching HR ! Good wave ! VBG + pulse ox = ABG
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Pulse ox 100% until it’s dead/pulseless
! Recognize limitations ! Anesthetized patients
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Relying on your pulse oximeter under general anesthesia
! You should expect the PO2 to be higher with O2 supplementation. Multiple by 5 to get your expected PaO2. ! i.e., FiO2 of 21% X 5 = expected PaO2 of 105 ! i.e., FiO2 of 40% X 5 = expected PaO2 of 200 ! i.e., FiO2 of 60% X 5 = expected PaO2 of 300 ! i.e., FiO2 of 100% X 5 = expected PaO2 of 500
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Mistake #6: Being Scared to Control the Airway
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If Severe Dyspnea or Peri-arrest: Control the Airway!
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Just Because the Gums Are Pink…
! Arterial vs. venous blood gas analysis ! Normal:
! paO2 80–100 mmHg ! paCO2 30–35 mmHg
! “50:50” rule
! Pulse oximetry
! SpO2 95-100% à normal ! SpO2 < 93% à needs O2
! SpO2 < 90% à horrible!
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Being Scared to Control the Airway
! PROS: ! Controls airway ! Allows one to do
advanced diagnostics in a calm, controlled manner
! CONS: ! Requires sedation
! Risks ! Requires preparation
for positive-pressure ventilation (PPV)
! Expense ! Labor intensive ! Lung disease à
pneumothorax?
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Being Scared to Control the Airway
! When to do it: ! Respiratory fatigue ! Pending respiratory
arrest ! Agonal ! Severe hemoptysis
! When not to do it: ! Not prepared ! For routine laceration
repair in HBC ! Possible
pneumothorax ! Owner?
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MAP
SVR
CO
SV
HR
preload
contractility
afterload
Mistake #7: Assuming it is CHF if the HR is < 150–160 bpm (canine)
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Mistake #7: Assuming it is congestive heart failure (CHF) if the HR is < 150–160 bpm (canine)
! Body’s goal: oxygen delivery
! Increase HR to increase cardiac output (CO)
Cardiac output
Stroke volume
Heart rate
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Assuming it is CHF if the HR is < 150–160 bpm (canine)
! With most heart failure, good contractility until
failure ! Exception: dilated cardiomyopathy (DCM)
! If HR < 160, likely not CHF!
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Mistake #8: Underutilizing your Patient’s Signalment to Guide Your Therapy
! Sex ! Age ! Weight ! Breed ! Presenting complaint
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Underutilizing your Patient’s Signalment to Guide Your Therapy
! Sex: ! Male cats –> HCM (hypertrophic cardiomyopathy) ! DCM (dilated cardiomyopathy) à 73% male dogs
! Age: ! 2 years old à HCM
! Weight: ! DCM à > 15 kg
! Breed: ! DCM à Dobermans ! HCM à Maine coon ! HCM à Ragdolls (UK)
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Underutilizing Your Patient’s Signalment to Guide Your Therapy
! Doberman, 8-year-old MC ! 3-week history of exercise intolerance ! PC:
! Cyanotic ! Coughing ! Crackles all fields ! 1/6 heart murmur ! HR 180 ! T: 36.8ºC (98.2ºF) ! RR: 100
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Underutilizing Your Patient’s Signalment to Guide Your Therapy
! 2-year-old MC Maine Coon cat ! 1-day history of open-mouth breathing, 10-day
history of ↑ RR/RE ! PC:
! Open-mouth breathing ! Dull lung sounds ! T 37.1ºC (98.8ºF) ! HR 200 ! RR 100 ! Muffled heart sounds ! No heart murmur
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Underutilizing Your Patient’s Signalment to Guide Your Therapy
! Diagnostic plan? ! Shave, TFAST ! Thoracocentesis ! Post-tap chest radiographs ! Evaluate heart size ! Cytology ! Echocardiography
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Underutilizing Your Patient’s Signalment to Guide Your Therapy
! 9-year-old FS Westie ! History:
! Chronic cough X 2 months ! Exercise intolerance X 2 months ! Heartworm (–)
! PC: ! Severe tachypnea ! Cyanotic mm ! Inspiratory crackles ! T 38.8ºC (101.8ºF) ! HR 120; 1/VI murmur? ! Pulse quality good ! RR 100
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Underutilizing Your Patient’s Signalment to Guide Your Therapy
! 12-year-old miniature poodle, MC
! History: ! DDX with heart murmur 3 years ago ! No treatment ! Chronic cough X 2 years with excitement
(“honking” cough)
! Current meds: ! Enalapril X 3 years ! Hydrocodone X 2 years as needed
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Underutilizing Your Patient’s Signalment to Guide Your Therapy
! PC: ! Progressive tachypnea X 3 days ! Tachypneic and dyspneic ! T 37.9ºC (100.3ºF) ! HR: 170 ! RR panting ! Fine crackles
! Diagnostics: ! Furosemide 2-4 mg/kg IM or IV trial, q 15 minutes until RR improved! ! Oxygen therapy ! Echocardiography
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Mistake #9: Not Understanding Oxygen Content (CaO2): When to Give Oxygen vs. Blood Products
! Buffy, 7 yo Cocker with IMHA ! PCV of 9%
! Does she need blood or oxygen?
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Not Understanding Oxygen Content (CaO2): When to Give Oxygen vs. Blood Products
! Buffy, 7 yo Cocker with IMHA ! PCV of 9%
! CaO2= Hb X 1.34 X SaO2 + (0.003 X paO2)
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Mistake #10: Not Knowing What ALI and ARDS Are
! ALI: Acute Lung Injury
! ARDS: Acute respiratory distress syndrome
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Mistake #10: Not Knowing What ALI and ARDS Are
Photos courtesy Dr. Monica Clare, DACVECC
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Not Knowing What ALI and ARDS Are
Photo courtesy Dr. Monica Clare, DACVECC
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Acute Lung Injury (ALI)
American-European Consensus Conference definition: (1994)
1. Acute onset in nature 2. Pulmonary artery occlusion pressure < 18 mmHg
or lack of LA hypertension 3. Hypoxemia with a PaO2/FiO2 ratio < 300 mmHg 4. Radiographic evidence of bilateral infiltrates
Bernard GR, Artigas A, Brigham KL, et al. The American-European Consensus Conference on ARDS. Definitions, mechanisms, relevant outcomes, and clinical trial coordination. Am J Respir Crit Care Med.Care Med 1994;149:818-824.
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Causes for ALI
! Prolonged hypotension ! Aspiration of gastric
contents ! Sepsis ! Trauma ! Pancreatitis ! Neurogenic pulmonary
edema
! Cirrhosis ! Toxic inhalation ! Lung resection ! Multiple transfusions
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Treatment
! Conservative fluids
! Symptomatic and supportive
! Removing inciting nidus
! Turf!
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Mistake #11: Not Using Inhalers More Frequently
! Mainstay of emergency treatment: humans ! Acute asthmatic attacks ! COPD ! Cystic fibrosis ! Anaphylaxis ! Pneumonia
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Benefits: Inhaled Medications
! Quick therapeutic response ! Increase time to patient comfort ! Decrease hospitalization time
! Fewer systemic side effects ! Glucocorticoids
! Option for chronic therapy
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Aerokat, Aerodawg, AeroHippus®
! Metered-dose inhaler (MDI) with spacer and small face mask
! Trudell Medical International, Canada
! http://www.trudellmed.com/animal-health/aerodawg
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Use of inhaled medication to treat respiratory diseases in small animals
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Use of Valved Holding Chambers with Inhalers
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AeroKat* Feline Aerosol Chamber
Universal backpiece – can be used with all Metered Dose Inhalers
Anti-Static Chamber – provides consistent aerosol delivery and can be used right out of package (cloudy appearance)
Valve - Low resistance valves ideal for cats (low inspiratory flow)
Baffle - breaks down particles to smaller size resulting in decreased oropharyngeal deposition Two attachable facemasks
designed specifically for felines (accommodate all breeds and sizes of cats)
Flow-Vu* Indicator – moves with respiration and provides caregiver assurance that inhalation is performed correctly.
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Indications for Use
! Cats ! Respiratory distress due to allergic bronchial
disease ! Bronchodilators ! Corticosteroids: combine with parenteral use
! Dogs ! Chronic bronchitis, pulmonary fibrosis ! Anaphylaxis ! Pneumonia ?
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! Albuterol (β-agonist) ! Bronchodilation ! Toxicity in dogs when chewed!
! Fluticasone proprionate (Flovent®) ! 220 mcg inhaler, chamber inhaler system ! Controls airway inflammation ! BID dosing, taper to SID to EOD
Inhaled Medications
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However…
! If severe lung disease, must use systemic prednisolone first to treat underlying disease!
! Rescue therapy: inhaler therapy!
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Mistake #12: Not Administering Oxygen Efficiently
! Face mask ! Flow by ! Hood/E-collar ! Intranasal ! Intra-tracheal ! Oxygen cage ! Tracheostomy tube ! Endotracheal tube (ETT) ! Positive pressure ventilation (PPV)
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Approximate FiO2
O2 therapy FiO2 PaO2 (mmHg)
Room air 0.21 (21%) 80–100
Oxygen cage 0.4–1 150–500
Nasal cannulas* 0.4–0.6 150–300
Intubation 1 (100%) 500
*Dependent on O2 flow in L/min
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Delivering Supplemental Oxygen to Dogs and Cats
B: Dr. Tim Crowe ,Table 1, DVM NEWSMAGAZINE, Oct 2009.
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Oxygen Therapy: Flow By or Face Mask
! PROS: ! Easy access to patient ! “Hands on” ! Can achieve high FiO2
! FiO2 = 0.25-0.45 @ 6-8 L/min ! FiO2= 0.7-0.8 @ 8-12 L/min
! CONS: ! Can be stressful ! Face mask intolerant ! Oxygenating the room
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Oxygen Therapy: Hood/E-collar ! PROS:
! May be well tolerated ! FiO2= 0.3-0.4 @ 0.2-0.5 L/min
! CONS: ! Hot, ↑CO2? ! High delivery rate ! Inconsistent oxygen level ! Needs 24-hour
supervision to make sure no suffocation!
Photo courtesy of Dr. Tim Crowe
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Oxygen Therapy: Intranasal
! Excellent patient accessibility ! Stressful placement ! Usually well tolerated ! FiO2= 0.40-0.60
! @50–100 mL/kg unilateral vs. bilateral
Photo courtesy of Dr. L Powell, DACVECC
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Oxygen Therapy: Tracheostomy
! PROS: ! Similar advantages as
ETT ! Well tolerated in awake
patients ! Bypasses upper airway ! 100% FiO2 at 0.2 L/kg/min
! CONS: ! Invasive! ! Placement requires
anesthesia ! Controlled
environment
! Nursing care! Aseptic!
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Oxygen Therapy: Endotracheal Tube
! PROS: ! Allows maximal
control ! Low pressure, high
volume cuff ! Bypasses upper
airway obstruction ! 100% FiO2
! CONS: ! Requires sedation ! Intensive care ! Tracheal necrosis
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Positive Pressure Ventilation (PPV)
! Ventilator ! Anesthesia Ventilator ! Anesthesia Machine ! Baine’s Circuit ! Ambu Bag
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So how do I give oxygen?
• Needs 24 hour care
• Use the safest modality for the patient
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Conclusion
! Utilize TFAST more ! Limit chest radiographs to post-thoracocentesis ! Thoracocentesis à life-saving! ! Clues to diagnosis: signalment, HR ! Knowing when to give blood vs. oxygen
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Who likes seeing dyspenic patients?
Photo courtesy of Vicki Campbell, DVM, DACVA, DACVECC
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@VetGirlOnTheRun VetGirlOnTheRun
Questions?
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Thanks to today’s SPONSOR!
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