Hi everybody and welcome to this evening's webinar in which we're going to focus on the cat that presents to you in an acute dysneic crisis. We'll all unfortunately have come across these cases. They do happen all too frequently, and as you will be well aware, these cats are a real emergency situation because they're dysne combined with their fear, can.

Rapidly lead them to spiral down hill and sometimes you can find yourself feeling that really whatever is causing the problem and whatever you try to do the cat seems to get worse and worse and unfortunately you can end up with a fatal outcome. So really what I wanted to do this evening is to try and outline for you an approach to managing these cases in the emergency setting. Which we've developed over the years in our practise, and we have found it to be a very practical and accessible way to approach these cases to get an understanding of what's causing their problem, but also to institute good effective emergency management in a way that doesn't contribute to the problem getting worse.

And I think one of the key principles that we need to be aware of with the cat that presents with acute dyspnea is that we really need to minimise their stress, handle them as gently as we can, really handle them as little as we can while still giving them good supportive treatment and assessing their immediate treatment needs so that hopefully we can make some treatment decisions that will improve their situation. But without necessarily doing a lot of detailed, hands-on investigations which at this particular moment may be more than the cat can cope with. So gentle handling, prompt supportive treatment.

And a rapid assessment of just what might be the underlying cause of the dysne to guide treatment. And I'm going to obviously talk to you a little bit more about what's involved in that rapid assessment and just how much we can get by looking at the cat by doing some very basic assessments in order to guide our treatment plan. Gentle handling is absolutely key, and with at all times with these cases we have to take what we call a hands-off approach, so we touch the cat as little as possible.

We restrain the cat as minimally as we can and really just try to allow it to settle in a in a position and a, a situation that it feels as comfortable as we can. Prompt supportive treatment is going to be really the same no matter what the cause of the dyspnea. So we need to get the cat into a safe and comfortable environment where it can rest.

We need to provide additional oxygen again in a way that's not stressful for the cat. And I would strongly recommend always giving these cats at the time of arrival in your practise an injection of butterphenol, which can be given IM. It's well tolerated.

It's not a painful injection to deliver. It's a good anti-anxiety. It does also have some pain relief properties, but the main purpose of using it in this emergency situation.

It is to reduce the cat's anxiety, reduce the cat's stress levels, adrenaline, cortisol, and so on, and allow it to cope better with the situation it finds itself in. And then we're gonna do a rapid hands-off assessment which is going to involve speaking with the owner to get an idea of the background history and a very brief and basic physical examination, but again with the emphasis on a hands-off approach and minimal restraint. So if we think about what might be going on in these cats that present acutely dysneic, perhaps with open mouth breathing, the pictures that you've seen so far of cats in this state have that very characteristic position.

They're keeping themselves quite straight. They're resting in sternal recumbency with their paws a little bit widespread, usually their head a little bit down, their neck a little bit outstretched, and very often they will be open mouth breathing which in a cat, unless it's overheated, is always going to be a sign of significant respiratory distress. And really the differential list at this stage in terms of common things that are likely to be going on is quite restricted, and I think if you keep what I call the big four causes in your mind as you approach this cat.

Hopefully I can show you that it's relatively straightforward in most cases to decide which category the cat falls into and thus allow you to give it appropriate immediate emergency treatment, stabilise the situation before going on to do any more detailed investigations. So as you see here, the big four causes are going to be pleural effusion from whatever underlying disease. Pulmonary edoema, usually due to congestive heart failure, so-called asthma or chronic bronchial disease, so a lower airway disease.

And of course trauma if cats have fallen from a height or have been hit by a car or attacked by a dog or one of the various ways in which they get themselves into trouble, but hopefully from the clinical history and the basic examination of the cat, it will be fairly evident if there has been a trauma significant enough to cause this level of dyspnea. So those are what I would call the big four. What we should not forget is that of course there are other causes of dyspnea, and we do need to be aware that cats are very stress susceptible.

If they are in pain, if they are significantly stressed, if they've become overheated because of being in an overheated environment, then of course they can pant and look dysneic. If we have a cat with anaemia, they can certainly have increased respiratory effort and tachypnia because of the lack of oxygen carrying capacity. Laryngeal disease is rare in cats, certainly much less common in cats than some breeds of dog, but it does happen.

And we should be on the lookout for it. They can get bronchopneumonia. It can be severe enough to cause dysne, although it would be unusual for it to cause the real acute dysnea, crisis that we are thinking about until or unless the cat is also in pain and stressed and has other factors coming on top.

So of course we need to be aware of those other conditions, but if we apply the principles that I've just outlined of gentle handling, immediate supportive treatment, and a basic physical examination, that will be equally appropriate for any of those conditions, and it should those should rapidly settle, and it should become more clear that you're dealing with one of those less common situations. So in terms of the immediate approach, when the cat first presents and when they arrive in that dystonic state, they are really on a knife edge, and we do need to act quickly and appropriately to minimise their stress, to get some appropriate. Go in in order to stop the situation from spiralling out of control.

So before we spend a lot of time talking to the owner about the background and trying to examine the cat, certainly before we think about running any blood tests or doing any imaging, we're gonna admit the cat, get it into a safe, comfortable cage environment with minimal handling. Never ever lying them on their side or restraining them on their side for any of the procedures that we may need to do. Providing them with oxygen and as I say, we would in our practise absolutely first line we would give them a dose of butterphenol given I am so that we don't have to handle them, but it acts quickly.

It's an effective anti-anxiety and it will have some analgesic properties, but we should of course also be aware. That they may need more effective analgesia and in fact if we assess on our immediate admission that they have, for example, had a traumatic event, been hit by a car or bitten by a dog or whatever it is, then actually we may not givebuterphenol, we may give methadone or morphine instead. Or sometimes what can be a very useful combination is a combination of buttorphenol and buprenorphine.

Those two things can be given at the same time, even in the same syringe, so it's a single IM injection. The nice thing about it is that the butterphenol works on very quickly, but in terms of its analgesia effect, it doesn't last very long, probably not more than an hour or so. However, buprenorphine, given I am, is quite slow to take effect, so it wouldn't be an ideal first choice in the acute situation.

But if the butterphennol works on quickly and the buprenorphine starts to work as the butterphenol is wearing off, so as the butterphenol is coming off the receptors, the buprenorphine is going on. That can be a very effective, safe, well tolerated, combination. So if we think the cat has a source of acute pain, then yes, we'll give a stronger opioid.

So the butterphennol, as I say, is really as an anxiolytic and anti-anxiety rather than necessarily primarily as an analgesic. I would be cautious about using nonsteroidals in these cases until we have a better understanding of what's going on, but if it's a young and healthy cat and you know that it's had a trauma, then a nonsteroidal might be a very appropriate addition to the opioid. So those immediate treatments are going to apply whatever the underlying cause of the dyspnea, and will certainly do no harm whatever the underlying cause.

Then we want to also try to supplement the oxygen that the cat has in its inspired air. That's actually not necessarily so straightforward to do as it is to say. I think the best way to deliver the oxygen in a cat that does not need to be handled is in some form of oxygen incubator.

You can see here the one we have in our practise. It's a nice clear sided, soft, collapsible cage so it can be stored elsewhere if needs be and got out when needed. It has a heat pad in the bottom of it, which is nice, and you can see we've padded it out with a lot of extra blankets to keep the cat as comfy as we can.

It's important that you can see in so that you can see the cat, although there's a, there's a balance and a trade-off there because the cat doesn't want to feel too exposed to the world. So we very often cover three sides with a towel and just leave one side open for us to be able to view the cat. It's low stress because once the cat is in there it can be left alone.

It can find its own comfortable position and it feels reasonably secure, especially if you put some of its own bedding in with it. But some cats are still scared by being controlled and restricted to that environment, and if you do activate the heat pad and the cat is panting and it is a reasonably warm day, you can actually rapidly get a cat who overheats in there. It can get quite humid.

You can go from a situation where the cat is, is panting because it's dysneic. You give it appropriate treatment and it would stop panting, except that it is now overheating and so it continues to pant and you can feel that your treatment is not working. So just be aware.

That they are in a little greenhouse in there, and it can get quite warm. So just be on the lookout for that. But on the whole, that's probably the most reliable way to effectively increase the oxygen in the cat's inspired air.

If you don't have an incubator or for longer term use or if the cat is overheating, then you can try and manufacture a kind of oxygen cage from a normal cat cat kennel. If you have glass fronted perspex fronted cages, then they lend themselves well. If you have the more traditional wire fronted cage, as in this picture, you can literally just wrap the cage door in cling film to provide some sort of barrier to the oxygen if I diffusing out, although of course there are gaps all round, so it's a little bit questionable just how much additional oxygen will actually stay in the environment.

And we should be aware that whether we're using an oxygen incubator or an oxygen cage, any time you actually open the door of the cage to handle the cat, examine the cat, move the cat, all of the oxygen will rapidly diffuse out, and you will be back to room air oxygen levels. So again, minimal handling, minimal opening of the cage, and again we have to just question just how effective these methods are, but they probably do have some value. If you do have the cat in an oxygen cage, then of course there is a bit more space for it to have bedding, litter tray, food, water, and so on, so more appropriate for cats that need support in the longer term.

Another way to deliver oxygen when the cat is not restricted to a cage or carrier is to use so-called flow by oxygen, which literally means holding, holding the, the source of oxygen close to the cat's nose, allowing the cat to breathe the air mixed with the enriched oxygen that's coming out of the the tube. It is probably reasonably effective if you, if the cat will tolerate you keeping the tube very close to its nose. You will obviously need to move with the cat as the cat moves around.

I wouldn't try and hold the cat's head still because that again is going to be stressful. Most cats will fight against that. Of course it's very labour intensive.

You need someone literally sitting by the cat holding the the tube near its nose. But it is a good way to provide a bit of additional oxygen if the cat needs to be out of the cage or incubator while you perform other procedures or give it other treatments. What I would avoid at all costs really is trying to deliver oxygen via a face mask.

It's, it's too stressful for the cat to have that held over its face. It must have a, it must feel a little suffocating. You need to hold the cat.

Obviously you need to restrain the cat's head quite, quite carefully to keep the mask on, and for most cats, the increase in stress, the increase in oxygen demand in the tissues because of the stress is going to outweigh the benefit of the oxygen that you're delivering. So flow by is, is good. Oxygen incubator is, is good and really again, anything to avoid building up stress and increasing the heart rate, increasing the blood pressure, increasing the tissue oxygen demand.

So there he is. There's our cat in his incubator with a clear side so that we can see him. He's got some of his own bedding in there to try and make him feel comfortable.

You can see that his pupils are quite dilated because he's had buterphenol, and we've just let him rest. And then we need to think about where we go from here because you have a cat in distress. You have an owner who's very worried about their cat.

You have a situation which you know is serious and could get worse. The cat is looking at you in a stressed way, and there is a lot of pressure on you to act quickly, to do something, to intervene, to relieve this cat's distress. And so the temptation is to is is to make some quick decisions to try and do some further diagnostics, to try and get in with treatment quickly, but I think there is a, a, a good rationale at this moment from actually just taking a step back, taking a deep breath, fighting the urge to rush in to try and help, and rather than taking a don't just stand there, do something approach, we might turn that on its head and say don't just do something.

Stand there, stand there. Look at the cat, assess the cat, consider the history. Take a moment to really make sure that the something that you are going to do is actually going to be well judged and of benefit to the cat.

So take a step back, take a pause, and do what I call a rapid basic assessment. From the history of the owner, we may be able to identify whether this is genuinely an acute condition that has truly just come on today or in the last few hours or actually as is so common, whether this is actually a chronic disease which has now progressed to a point at which the cat is exhibiting signs has started to become distressed and then spiralled into that downward, slope. Owners will very often not have recognised earlier signs of disease, but we know that cats are the masters of disguise.

They're very good at hiding the gradual onset of chronic problems until they cannot hide it any more. And so we very frequently see that acute on chronic presentation. So a discussion with the owners about the history of the cat and the recent behaviours at home.

Has there been any weight loss? Has the cat been quieter than usual? Have there been any other associated signs?

Or is it genuinely something that's come on very acutely which would make you think more about trauma, toxin, electric shock, those, those sorts of things? And then again, with hands off, so we're not handling the cat, we're literally just watching it. We can get quite a long way by assessing the respiratory pattern, looking at whether there is increased effort.

And or increased rates if there is increased effort, is it on the inspiratory phase or the expiratory phase? And is there any audible noise coming from the cat? This is not listening with a stethoscope.

This is literally just listening with your ears. And if there is noise, when in the cycle, so is it inspiratory or expiratory, and where is it coming from? Is it coming from the nose?

Is it coming from the laryngeal or nasopharynx area? Is it coming from the chest as a, as a genuine lower respiratory wheeze? And then with most cats once they've had butterphenol and a chance to rest in the oxygen environment, you will be able to do a basic physical examination.

But again, if the cat is getting stressed, you need to stop and let it relax and get some further treatment into it based on whatever information you have been able to glean. So there he is again, our cat in his incubator and reminding ourselves that we broadly speaking at this stage have, I'm gonna say 5 reasonably common causes of respiratory distress. Up at the top we've got trauma, hopefully again, history and physical examination is gonna give us an idea about that.

We've already mentioned pulmonary edoema, pleural effusion, chronic bronchial disease as common causes of dyspnea in cats, part of the big four, and then I've added that 5th 1 of upper respiratory disease because it can cause significant respiratory distress, especially if it's nasopharyngeal or nasal. But generally with upper respiratory problems it will be quite apparent from your physical examination from listening to the noise that the cat's making, you'll be able to establish that this is an upper respiratory issue, so that one again, usually you can identify pretty quickly. So again, here's another cat.

This is an example of another cat that's presented with dysnea. You can see the shiny, surface tells us he's in that oxygen incubator and we're just looking at his respiratory pattern, looking at the respiratory distress. And I would say at this stage, let's, let's just try and keep it simple.

We've got in our mind, those four main causes trauma, pulmonary edoema, pleural effusion, lower airway disease. And you could ask when I, when I say at the top of this slide, what's the question, you could say, well, that's, that's the question, what's the what what's causing the cat's disease. But actually, really and truly, in the emergency clinic situation, I think the question is a bit more basic than that.

Really what we need to know is what do I need to do for this cat in order to alleviate its problem. And I would say therefore that the options that we are considering are, is there something to drain? Is there blood or fluid or air in this cat's chest that we need to remove.

Bluntly, do I use rosemide because the cat's got congestive heart failure, or do I use corticosteroid because the cat has got lower airway disease asthma? And really, I would say that's those are the questions that are running through our mind at this point. Keep those in mind when you're examining the cat, and I think we can answer those questions with some very basic assessments.

So looking at the respiratory pattern, I've alluded to the fact that we can often get a lot of information just by looking at whether the cat has effortful breathing or not, and if there is effort, whether it is on inspiration or expiration. So here's the, the cat that we actually have already seen in the incubator, he's now out on the table, and we watch his respiratory effort, and I hope you can see that in this case, the effort that he's making is on inspiration. You can see that by watching his ribs and seeing that the effort is on inspiration.

It's a kind of upward movement of the ribs in the effortful phase and then a quick, sharp relaxation on the expiratory phase. If you look at his face, you can also see that the muscles around his nose and his muzzle also are pulling and contracting as he breathes in, and then he relaxes as he breathes out. So this is a classic inspiratory effort pattern.

It's probably the most common that we see. It generally indicates that there is plural space disease. Something is preventing the lungs from expanding, so the cat is having to make a big effort to try to drag air in.

And most commonly that's due to pleural effusion or to pneumothorax. You will see significant increase in inspiratory effort also with upper respiratory disease, laryngeal or. Nasal disease, but in both those cases there will tend to be an audible noise that you can hear again, not with your stethoscope, just with your ears, an audible noise that will help you to identify that you're dealing with upper respiratory.

So big increase in inspiratory effort, but with no audible noise is generally plural space disease. I've got an example here now of another cat, and this cat is also showing significant inspiratory effort, but this is an example of a cat with laryngeal disease, and I hope when I play the video you'll be able to hear the classic noise it makes. You'll hear it obviously you'll be much more used to picking up laryngeal noise in dogs than cats, but the principle is the same.

Just be aware and have it on your agenda. So you can see again a big inspiratory effort. Inspiratory effort, the effort is in an upward direction.

Look at the chest, look at the head. Everything is being pulled up in the effort phase, and then the down phase, the, the relaxation, the, the expiratory phase is the down phase, and that's the relaxed phase. Sometimes it helps to actually breathe with the cat and and model what the cat is doing yourself.

You might feel a bit foolish doing it at the time, but actually it can be very helpful if you do, if you, if you copy the cat. And move with it, then you can rapidly identify that increase in inspiratory effort and the upward movement. The other pattern that we do see quite commonly is what is sometimes described as a restrictive pattern.

In this case, what we're gonna see is that the cat's breathing is quite rapid, so it's tachypneic, but we don't have that big increase in effort. So there's quite a symmetric, it's quite a symmetric pattern in terms of the inspiratory phase and the expiratory phase. So it's rapid, shallow, symmetric breathing, and this would be typical of an interstitial disease, a a a a an alveolar disease, pulmonary edoema, or interstitial pneumonia.

So watching this little cat here's a different cat to the previous black and white cat. I think you can see that the cat is breathing quite quickly. Sorry, the video's just stopping a bit, but the cat is breathing quite rapidly.

But we've got an even inspiratory and expiratory phase and no big increase in effort. This poor little cat is very immobile because unfortunately, it's suffered an aortic thromboembolism. It's had, therefore methadone because it's, that's an acutely painful condition, so it's somewhat sedated on that.

It also has pulmonary edoema because of congestive heart failure, which unfortunately is a common combination in those cats when they present with thromboembolism, but he's a nice, I hope, example of that restrictive pattern, shallow, symmetric, inspiratory, and expiratory phases. OK, and then the, the third pattern that that you should be aware of and keep an eye out for is the, is the situation in which it is actually the expiratory phase which is effortful. Now, this is less common, I would say, sometimes more difficult to recognise, but it is an indication of lower airway disease.

Sometimes there will be expiratory noise at the same time. Often there will be history of cough when you talk to the owner, and often when you listen with your stethoscope, you will hear expiratory noise and expiratory wheeze. So here's a little video of a cat exhibiting expiratory effort.

Expiry is the down phase, so you can see there and there. And there that the effort for prolonged phase of respiration is the expiratory phase. Again looking at the cat's face, you can see that as well.

And in this case, if you look at the abdomen, you can see that the abdomen is actually contracting during the expiratory phase to try and push the air, push the diaphragm and push the air. Out, so it's the expiratory phase, the down phase, looking at the ribs, the down phase that is the effortful prolonged phase, and that would be typical of lower airway disease, so chronic bronchial disease or so-called asthma. So just by looking at the cat and looking at its breathing, we can actually go quite a long way to categorise the, the, the type of problem that the cat has.

But of course, we can also add a little bit extra from again, a brief minimally handling physical examination. Most of these cats will have their mouths open so you can assess whether they have good. Membrane colour, whether they are pale, it's rare, but whether they are cyanotic or even have the sort of chocolate coloured membranes from something like a paracetamol poisoning but again that would be much less common than the kinds of conditions we've talked about so far.

But you should be able to get a good look at the mucous membranes just by watching the cat as it breathes and as it pants. If it will let you and once it again has been in the oxygen environment and has had some butterphenol or more powerful analgesia if you assess it to need it, then hopefully you can just slide a stethoscope gently onto the rib cage to have a listen to the lungs and listen for either inspiratory or expiratory noise or listen for loss of noise, muffling of the lung sounds if there is fluid or air between you and the lungs. Obviously air will tend to be towards the top of the chest, dorsally fluid will tend to be at the bottom of the chest, so ventrally, and so again, even even you can go beyond just that there is something and get an idea of whether it is bilateral or whether it is fluid or whether it is air just from your physical exam.

And you can listen to the heart if the cat will allow you and, and, and there isn't too much fluid between you and the heart. You can hear the heart sounds. The majority of these cats will be tachycardic because of the stress that they're under, and we can't use that as an indicator of cardiac involvement.

Murmurs, heart murmurs also, as we know unfortunately are not the most reliable indicator of cardiac disease. The louder the murmur, the more likely it is that it does indicate some form of heart problem. But as we know, many cats with very significant heart disease will not have a murmur at all.

Many cats who have normal heart function, but other problems will have a heart murmur, so it can certainly be caused by stress and tachycardia. Very common in a cat that's anaemic and so on. So a murmur, if it's a very loud murmur, it will increase your index of suspicion of cardiac disease as the cause of the cat's dyspnea, but it's not a very reliable finding.

What is more reliable, less common but more reliable. It is if you hear a gallop rhythm. So that 3 beats instead of 2, this lovely picture of a gorgeous horse galloping with quite a relaxing sound when you just listen.

Not so relaxing if that is the cardiac sound. So a gallop rhythm generally is an indicator of heart disease. And likewise in a cat dysrhythmia, most cats should have a very regular heart rhythm.

They don't even really get that, sinus arrhythmia that that dogs and people get because the chest is relatively small. So if you do detect a dysrhythmia. Then again that tends to be more of a reliable indication of, of heart disease.

So you can get a certain amount listening to the heart, but unfortunately, as I say, tachycardia and heart murmur will be present in a lot of these cases and doesn't necessarily indicate heart disease as the cause of the dyspnea. Some cats will also, comfortably allow you to do thoracic percussion. I think it's a little bit more tricky to, to, to listen and to interpret in cats and dogs again just because of their small size.

But if the cat will sit reasonably still and allow you to do it, it can give you increased information about whether there is fluid or perhaps a large mass, in the chest causing muffling and and dulling of the percussive sound. So this is a video just demonstrating the the technique for thoracic percussion. Keep your finger of your non-dominant hand flat against the rib cage, and then using the finger of your other hand, tap quite sharply on a knuckle, so you want to be right on the knuckle of your finger so that the bone transmits the sound waves straight through your finger and onto the chest.

And if you listen over an area with air under it, you will get a nice hollow sound. If you listen over an area that has muscle or heart or fluid or mass, you will get a much duller sound. It's worth practising this technique on normal cats so that you get used to doing it.

It can be done very quickly. It's not too distressing for the cat, but of course it does require the cat to sit reasonably still, and if they are not wanting to sit still, I would not force the issue in order to, to do the percussion. But it may be something you can do and give you a little bit extra information.

Because the more information we get, the better decisions we can take. It may be from your initial investigation and and assessment you already have a strong idea of what's going on. But if not, then I think if you have an ultrasound machine in your practise and are able to get it to the cat without stressing the cat too much, we tend to bring the machine to the cat rather than the cat to the machine again to allow us to, to, to have a look with minimal handling.

Then actually a a very speedy and minimal handling chest ultrasound can give you a lot of extra information, but what we're not trying to do here is do a full and complete examination of the heart and or the lungs. This is not the time for a detailed thoracic ultrasound. This is very much a quick idea to get a rough look at what's going on in the chest and rule in or out some of our major differentials.

So again, minimal handling, let the cat stay upright. Do not restrain a dysneate cat in lateral, so don't try and lie it down in order to do a heart scan. Just let the cat sit.

I would have, I would suggest that you don't try and clip the fur unless you have robust but silent clippers. Clipping can again be quite stressful for the cat, so you can just soak a small window of, of, of fur with water and then spirit. Use plenty of gel, part part the fur, use plenty of gel, and then you can get a reasonable image with minimal distress and stress to the cat.

And you only need a a a a a a low resolution image if you like. So of course you would get a much better image if you clip and prepare, but this is perhaps not the moment for that because really what we're looking for is, is there plural fluid? Is there a large media sinal mass?

Are there perhaps abdominal organs in the thorax or the pericardium if the cat has a diaphragmatic hernia or a pericardio peritoneal diaphragmatic hernia? Is there an enlarged left atrium which would give us the lead on the fact that the cat's problem relates to congestive heart failure? And those four very straightforward things can be identified, as I say, on a brief examination with the cat internal, even if you're not a very experienced ultrasonographer.

So pleural fluid generally will be very evident as obviously dark black fluid with the lungs floating around in it, and, and obviously you'll see the heart beating within it, but generally pleural effusion, ultrasound is very good at picking it up. It's usually pretty easy to to determine that there is fluid. Then you can drain the fluid, and then once the cat has had the fluid drained and is recovering, you can do a much more detailed assessment to work out what the fluid is and why it's there.

Likewise, if you find the heart and then move your probe forward, if there is a significant sized mediastinal mass, it will be very evident that there is no lung tissue cranial to the heart, that you have a soft tissue mass that is not expanding and contracting as the cat tries to breathe in and out. Abdominal organs in the area can be quite confusing if you're not expecting them to be there or not you know, haven't really thought thought about seeing them, but if you do have them on your differential list, you'll generally be able to identify liver or intestinal intestinal structures if they're there. And then the enlarged left atrium, now if you're not an experienced cardiac ultrasonographer, it can be a bit daunting to be looking for an enlarged left atrium.

But actually, if the cat has significant dysa because of congestive heart failure, it often will have a very big left atrium. So even if you are not able to get detailed measurements, and you probably won't be able to get an idealised view of the, the heart in order to get an an exact ratio. Very often the disparity between the aorta and the left atrium is so significant that if you are have looked at a reasonable number of of hearts of, of more normal cats, you can identify that enlarged left atrium.

So these are quite basic things which again hopefully even with only a moderate amount of ultrasound experience, you can reliably identify and they will allow you to move on to appropriate treatment without stressing the cat further. It takes a little more experience, but you can also identify fluid interfaces, air fluid interfaces within the lungs which produce this characteristic appearance called B lines. These are these bright white lines.

Some people describe them as being like search lights, going through the night sky. They emanate from. The interface as say between air and fluid, and they reverberate right down through the entire ultrasound view.

So you, you, you know, you'll see them quite characteristically. They they will move as the cat is breathing, but you see these bright white lines like like spotlights through the night sky. And if you see those, that is an indication of wet lung, usually because of pulmonary edoema, although it could be because of haemorrhage or, or I guess it could be because of bronch pneumonia, but most commonly it will be because of edoema and again most commonly that will be because of congestive heart failure.

Sometimes it can also be useful to consider running a pro BNP test if you are still not sure whether the cat may or may not have heart failure. If you've already seen a large left atrium or if there is fluid that you can drain, then you may not be going straight to this test, but it can be a useful test if you are trying to decide is this cat that's in respiratory distress? Does it have congestive heart failure, or does it not?

Clearly this isn't the time to be sending out a sample and waiting two days for the result to come back, so this is going to be, the in-house, cageside snap test. And the interpretation essentially is that in a dysneat cat, if you get a positive result on your test, and of course you only get a yes no, it's the, the in-house test is not a quantitative test, but if you do get an abnormal result, it is quite likely that the cat has congestive heart failure. There will be some false positives, but it's quite likely to be congestive heart failure.

Probably more usefully if you get a normal result, it's really pretty unlikely that the cat has congestive heart failure. So there's a lot of overlap between normal and abnormal with this test, which which limits its use as a screening test, but in the cat with acute dyspnea. Again, positive result, quite likely it means it is heart failure.

Normal result makes it very unlikely that it's congestive heart failure, and we should be looking elsewhere for evidence of other issues. You can run this test on effusion as well as blood, which is very useful because taking a blood sample in an acutely dysneneate cat can be quite stressful for the cat and indeed for you. So whereas getting a sample of effusion may be much more straightforward and of course may be high on your plan in terms of immediate treatment of the cat.

So if there is a fusion, you want to drain it anyway, you can then use a bit of a sample to run your snap test if the sample looks like, a pleural effusion from congestive heart failure, so a, a pale yellow, relatively clear fluid. If you are taking a blood sample because there is no effusion, then again, if you have not already given it, give butterphenol as an anti-anxiety, and local anaesthetic cream can be very helpful again in reducing the cat's discomfort and distress and allowing you to get the blood sample with absolutely minimal handling. But use a generous amount of local anaesthetic cream and give it plenty.

Time to work 20 minutes or so again with the cat just resting in an oxygen environment and I, as I alluded to earlier on, a blood sample may not be your first priority with these cases. Your respiratory assessment, your basic ultrasound, your effusion sampling, if you, if there is effusion might be much higher up your priority list. So just consider whether it's really justified to stress the cat in that way.

So back we come to to our cat, and our main differentials again, trauma, hopefully we can identify fairly straightforwardly. Upper respiratory, we can identify through the inspiratory but upper respiratory noise that the cat's making. Pleural effusion will have that inspiratory effort pattern.

Chronic bronchial disease will have an expiratory effort pattern. Pulmonary edoema will have a rapid, shallow but symmetric breathing pattern. And then we've talked about other, basic ultrasound can also help you, particularly with pleural effusion.

An IE snap test might help you to identify whether there's congestive heart failure causing pulmonary edoema or pleural effusion. But what if we're still not sure, cause it's all very well me sitting here and telling you that you can get all this wonderful information just by looking at the cat and showing you a video and telling you what you're seeing, but it's not the same when you're on your own, maybe in the middle of the night or maybe in the middle of a busy surgery. There's a lot going on.

You've got to make a decision. You've got to decide what treatment you're going to give this cat. It isn't always straightforward.

So sometimes it's tempting to think, well, what, what can I, what, what can I do that covers all bases? Shall I, shall I, can, can I already pick a specific treatment for the pathology I suspect is there, or actually, can I cover all bases? Can I give the cat maybe both diuretic and corticosteroid?

And then once it's better I can worry about what the problem was. Sometimes that may actually be a rational thing to do if you really are not sure. But let's think about these specific treatment options and and their pros and cons.

So thoracic, thoracocentesis absolutely appropriate if there is pleural effusion or pneumothorax. If it's pleural effusion, it will get you a diagnostic sample, but it will also, of course, alleviate a lot of the cat's distress. .

And there is nothing wrong if you strongly suspect that there is pneumothorax or pleural effusion from your physical examination. There is nothing wrong with doing a diagnostic tap to establish whether there is or is not fluid or air. If you do not have an ultrasound machine to hand, then a trial tap is a perfectly reasonable thing to do.

If you do that and you get free fluid or air, happy days, you've done the right thing in removing that fluid or air, you will immediately improve the cat's situation. You can help it will help to stabilise the cat, and then you can go on to consider what caused the problem. But what if, what if we misinterpreted and actually there is no free fluid or air?

Is it harmful to do a trial thoracocentesis tap? Well, actually it shouldn't be if the cat is reasonably well restrained or partially sedated by its butterphenol, . And then as long as the needle is not flailing around in the chest, then actually if you put the needle in you do not get anything out you withdraw the needle, then you will not do any harm.

Yes, it does require a bit of restraint. It's a little bit uncomfortable for the cat, so it's not ideal, you know, we'd rather avoid it, but if you are considering that the cat, if you suspect that the cat does have pleural effusion or pneumothorax and you have a reasonable index of suspicion, I don't think it's at all wrong to go ahead and try, try to see whether you can draw any off. You go carefully, you will not do any significant harm.

Other options, of course, if we know that there's pulmonary edoema or we suspect pulmonary edoema, we have that, that, that, that shallow rapid symmetric breathing pattern, then we would certainly want to come in with some furosemide. Delivery of the dose depends a little bit on the cat. If you have IV access, then of course you can give it IV, and if you do give it IV, you may choose to give it a low dose frequently.

But it can be stressful for the cat to have an IV cannula placed, so it may well be that you do not at this stage have IV access, in which case, of course, it can be given IM. We would hope to see a reasonable improvement within even an hour or so, and we can then top up as necessary if we are getting a good response. Glycerol tri nitrate ointment, I think, is, is rarely used these days.

If you have it, then it can be useful in the emergency situation. It's quite a powerful vasodilator, so it does drop blood pressure, but it does help to reabsorb pulmonary edoema. It only has quite short term effect, but it rubbed into the ear, it's very easy to, to deliver.

And again, analgesia if you have not already done it, because pulmonary edoema is a painful condition and we should manage that pain as well as trying to manage the edoema. So if we have assessed that the cat has pulmonary edoema, maybe we've seen a large left atrium on ultrasound and we have that shallow. Symmetric restrictive breathing pattern absolutely we'll get in with some rosemide again, what if we've misinterpreted or what if we're just not sure and we just give the give fruzamide because it might have pulmonary edoema if we are correct and it has congestive heart failure again, happy days, we've done the right thing, the cat's situation should start to improve.

But we should be aware that it's not a completely benign treatment. It, it does cause dehydration. That's essentially how it works.

What if we have misinterpreted and the cat actually had lower airway disease or bronchopneumonia or trauma or shock or hypothermia or one of those other conditions and we go in and give it rosemide? Well, it's probably not the worst thing in the world that you could do. But if we are essentially inducing dehydration, then we will reduce peripheral perfusion, and that cannot help any cat to, to recover.

It will also increase the viscosity of inflammatory exudates, and if this cat has actually lower airway disease and it's bronchial mucosa and it's, it has bronchial mucus and we dehydrate it and make that bronchial mucus more sticky, then we may actually make the cat significantly worse rather than better. So I don't think it's wrong to give it if you strongly suspect congestive heart failure, but I don't think we should be using it as a blanket first line treatment for all cats that present with dysne, even though for a reasonable proportion of them it will be the right choice. Again, that basic assessment, which may or may not include a basic ultrasound scan, but looking at the cat.

And looking at the breathing pattern and using the, the physical findings that you do have available to you, I hope will help you to narrow down those cases that are more likely to benefit from the rosemide. So if the cat does have chronic bronchial disease, and again, that's gonna be an expiratory effortful breathing pattern, there will usually be wheezing, there will usually be a history of cough, then in that circumstance, we would want to treat the cat with a. Of bronchodilator and corticosteroid, bronchodilator to open up the constricted airways, corticosteroid to reduce the inflammation, reduce the mucus production, which is clogging up those airways.

I would advocate giving those medications by IM injection in the first instance. You can, of course, give the corticosteroid IV if you have IV access, but again, as I've said, you may not have a cannula in place at this stage with this cat. So if you assess the cat to have chronic bronchial disease or lower airway disease, then an injection of tebutyle would be the injectable, .

Bronchodilator of choice and dexamethasone, short acting but quick acting in anti-inflammatory doses in order to start to control the inflammation. Some people say, well, what about in the inhaled route? Is that not a safer and quicker way to deliver these drugs, and it can be very effective.

And if the cat is known to have asthma and is already being treated via inhaled, the inhaled root, then, then absolutely it may be appropriate certainly for owners at home to be aware of the indications and the approach to giving additional doses of either salbutamol as a bronchodilator. And or fluticasone as a steroid, but if the cat has not been acclimatised to a face mask in the past, then again placing its a face mask on it and trying to deliver these drugs effectively by the inhalation route in the emergency situation. I think is probably not necessarily the best approach, and it may not deliver the drugs as reliably as the IM injectable route.

So for me this would be something for owners to do at home if they have a cat acclimatised to an inhaler, but not necessarily something we would be using in the emergency situation. So again, if we, if we take the view that we believe the cat to have lower airway disease from our physical assessment and we give that treatment, may we do harm? Well, again, if the cat does have lower airway disease, both corticosteroid and bronchodilators will be a very appropriate treatment and usually will result in an alleviation of the dyspnea really very quickly.

So absolutely the right thing to do. But again if we have not done as careful an assessment as we perhaps might have done if we do take a view that we just give them straight away anyway. And the cat actually has heart disease, which of course is quite common.

Then corticosteroids, well, unfortunately, corticosteroids can precipitate congestive heart failure in in cats that have occult heart disease and certainly would not be an ideal treatment for a cat who is actually in the throes of an episode of pulmonary edoema. Because of the, the additional fluid retention, so again, it may unfortunately either make things worse or counteract if you're using this sort of dual approach of give it everything. It may counteract some of the effect of the rosemide that you're giving.

Likewise, bronchodilators generally will be very well tolerated, but potential side effects are indeed tachycardia and hypotension, which is an acceptable risk in a cat with lower airway disease. But of course in a cat that did not have lower airway disease and actually had heart disease would not be such a good thing. So I do think that it is worth doing that basic assessment.

Interpreting your findings with care and trying to direct your treatment in a more specific way based on that basic assessment. And if you're really not sure, if you've looked at the respiratory pattern, if you've maybe tried to do a basic ultrasound or maybe you don't have access to ultrasound, you've done perhaps a trial tap and you have not got any fluid or air and you really feel that you need an X-ray. Then Fair enough, fair enough, that that that can happen, you know, I'm not, I'm not going to say it will never happen, but you'll notice that I have been talking some time now before advocating or mentioning thoracic X-rays because I believe that they have less of a role to play in this emergency situation.

Than the other investigations I've discussed, and if you do need to take a chest X-ray, then again minimal restraint. And never in lateral don't lie these dysneate cats down in lateral recumbency. It's very stressful for them if there is fluid or air, as it redistributes, it can crush new areas of lung that were previously well aerated, and it can absolutely tip the cat over the edge and be the thing that precipitates its final crisis, which clearly is a situation none of us wants to find ourselves in.

So how do we take a reasonable chest X-ray in a stressed cat with minimal restraint and not in lateral recumbency, you might ask? Well, there's another, there's a very technical piece of equipment here which you can use to help you in this situation. A little cardboard box, cardboard box that is about the same width as a cat.

Cats like to be in enclosed spaces, particularly if they find themselves in a veterinary environment when they are dysic and stressed and really just want to get away from everybody and be left alone. So if you place the box on your X-ray cassette under your X-ray beam, get it all collimated, and then offer the cat the box, very often they will creep into the box. You can see on the left hand picture that we've cut a little slit out of the back of the box so that the cat can see out and and it may encourage the cat to go into the box if there is a bit of light coming in from the end, but you can see from the two pictures in the centre and on the right hand side that some cats just turn themselves round anyway, but nevertheless, you can see that the cat is actually restrained in a reasonably straight manner.

And if the box is on top of the X-ray cassette, then the cat is reasonably centred on the X-ray cassette, allowing you to take a picture without holding the cat, so you're not, contravening any radiation protection, regulations, and you are not handling the cat. The cat feels reasonably, relaxed. It will not be a perfect picture.

It will be this kind of a picture. It's not ideal. It's not gonna win you any prizes in a radio in a radiography competition, but actually it is enough to tell you whether there is whether there are fractured ribs, whether there's a pneumothorax, whether there is pleural effusion, whether there is a very enlarged heart, whether there is a big mediastinal mass.

So if you are not in a position to do that basic ultrasound scan, which I would argue can give you more information more safely. Then a very straightforward rough and ready ventro dorsal X-ray can be useful, but at dorsoventral, I'm sorry, dorsoventral x-ray, don't lie the cat on its side. Certainly don't lie the cat on its back and maybe use something like that cardboard box as a as a a a a means of restraint that is much less stressful than sandbags or handling.

But please don't take an X-ray like this. So this is a cat with very significant pleural effusion operating on a very small percentage of its natural lung capacity. And if we lie that cat down on its side and restrain it in that way, I'm afraid, as I say, that really can be the thing that tips it over the edge and precipitates a terminal, deterioration.

We don't want to find ourselves in that situation. There are other ways that we can assess this cat, and we should be able to recognise that level of pleural effusion from our physical examination, our respiratory assessment, and, as I say, if you have it, a basic, ultrasound scan. OK.

So, we've covered quite a lot of ground. I hope it's been helpful. I hope I've been able to show you that in these cases, these cats that come in, they are in a genuine emergency situation.

But with very simple approaches and and very safe approaches, we can go a long way to stabilising the cat and directing our initial emergency management in order to alleviate the crisis so that we can then get the cat into a position where we can do maybe some subsequent investigations as necessary to more fully understand the background to the problem. So gentle handling that hands-off approach and minimal restraint, prompt supportive treatment with cage rest and oxygen. And then your rapid physical assessment and clinical assessment through talking to the owner about the history, basic physical examination, and if you can, a brief thoracic ultrasound.

And I've alluded again to the value in these cases, but actually in in all cases of using butterphenol as a very safe, very rapid acting anti-anxiety medication which does have some analgesic properties, but in this circumstance it's all about reducing stress to reduce the oxygen demand for the cat and allow it to respond better to the emergency treatment that you give. OK, so I hope that that's been helpful. I hope there's been a few pointers and maybe tips and tricks that are new to you that you can perhaps take back to your practises and that will stand you in good stead when next you have to manage one of these cats.

OK, thank you very much indeed.