Hello. Welcome to this webinar, webinar. Always lovely to, to work for this team, as you know, I've given a few, webinars for them.
The topic of today, feline pneumonia. Now, I know you don't see it every day, but We see it, you see it, and sometimes it can be, ah, what am I gonna do with this? And certainly, I really wanted to underline, some of the infectious causes because we're now recognising them much more frequently.
And because of that, we've actually got something to Specifically treat. And that's really important because otherwise you're kind of flying blind. So I really want to, to bring out how we can get the best of those diagnostics.
So this lecture is just about the causes and how you work these cases up. And, Dawn and the webinar vet team have allowed me another lecture where we're going to talk about treating these guys, separately. All right.
So, you're gonna have to wait for that. So sorry to make you wait, but there's so much new stuff. I wanted to make sure that you got it.
All right. OK. So let's share slides.
OK. So, feline pneumonia. And some great slides as well.
There's a lovely one from Conor O'Hallorhan. I think it's really important to start by understanding, as always, cats are different to dogs. They're lesser species.
I didn't say that out loud. And certainly, what makes them cough and what causes dyspnea is quite different. Well, the dyspnea actually is pretty similar.
Coughing is not. So with cats, they will cough with upper respiratory tract disease because you have post-nasal drip. Lovely phrase.
So, you know, you've got inflammation of the, the nasopharynx nasopharynx, and you get inflammation of your edoema of your larynx, and you're gonna get, it's not dripping down onto your larynx, that's gonna make you cough. So upperspiric tract disease will definitely make you cough. A disease of the trachea and the first couple of bifurcations of the bronchi.
We'll do it too, but only the first couple. So here's a great image made for me by Brian Matha, who I work with. Sorry, there should be a T in there.
Sorry, Brian. So coughing from here, all the way down the larynx, just to the first couple of bifurcations. All right.
So you Cats do not cough when they've got disease around the majority of the lungs. That's really important. They don't cough with mediastinal disease or plural disease either.
And so this is a great picture. This is, mediastinal, lymphoma of the cat. This is an 18 month old, Siamese.
I'm sure some of you have seen this. That's this little cat's heart completely pushed back and squished. It's a bit of lung.
Oh, do you, maybe I can find you a better pointer. Let's see. Pointer options.
Yeah, there you go. There's the heart, squished lungs, and then, the, that's higher lymph nodes, but this is all this huge mass, and you can see the trachea is completely crushed against the underside of the vertebrae. And this cat wasn't coughing.
These cats get dyspnea and they get regurgitation. And so that's because the, the dorsal ligament of the cat's trachea is much, much firmer than the dog. It doesn't collapse, because it doesn't collapse, it doesn't actually trigger the cough receptors inside it.
And that is important. So, there was one. The paper that came out not too long ago, and they found 20% of cats with what they was, general practise paper.
So it was a great paper because it had big numbers, but it was limited by not having complete diagnostics. And they felt that about 20% of the cats with heart disease were coughing. And my argument would be, actually, we need to look further if we've got a cat with heart disease and coughing because there's something else happening.
And it could be pulmonary edoema that has actually got high enough up the bronchi to start causing coughing. That might be what's happening, but it's got to be really bad before you're gonna get that, and that's important to know. So it's a little picture at the top, spelled properly this time.
We need to think about the type of dysmia, whether it's inspiratory or expiratory. So is the difficulty on in breath, which obviously if you've got a face full of snot, it's very difficult to breathe in and obviously likely to have nasal discharge, although not always, and you're quite likely to have a cough. With lower respiratory, and by this, the lower respiratory when we talk about lower respiratory tract disease, it's, it's very misleading because it can make people think, oh, that includes alveoli and the the lower airways.
It doesn't. Lower spiritual tract disease is trachea and the first few bifurcations. All right?
So it's, it's a bit misleading and that's gonna cause ex-spiritual dyspnea, so problems with the out breath, OK, out rather than in. And obviously, quite like to cause coughing. Alveolar and plural, this is inspiratory again.
So, it's just the lungs cannot expand properly. And with pneumonia, it's often they simply can't expand. So we're not gonna see snots.
Very rare to see, coughing. You've got to get whatever the, the grotten gubbins in the, the periphery that's causing the pneumonia. That has got to move up.
It's got to move up from here. To actually trigger the, the cough receptors higher up. And obviously non-respiratory diseases tachypnea generally rather than dyspnea, although I'm gonna make one comment about that in a minute.
And that is metabolic acidosis. So these are all different things on this page that can cause tachypnea. But it's not this near, unless, of course, you get, that's a bit misleading, isn't it, cardiovascular disease, congestive failure, yeah, it does start becoming OK.
I think I'll take that one out. We can fighter for that whenever we want to. Certainly, anaemia is the, the classic, and I'll show you a video of that that, Craig Barney has shared with me.
Increased abdomen, this lass is actually, giving birth, so that's a bit misleading, but she is dysneic. This poor cat, very old picture, severe abdominal distention, also some pleural fluid, and she has mouth breathing. This little cat from from Ross has been shot, a 12 ball pepper, and the analgesia wasn't good enough and that cat was dyspnea at that point.
And this is Strobe, a cat that myself and Sarah Canney and Andy Sparks have all treated over time. He's a hypokalemic myopathy in a, a, a Burmese. And because his lungs, he didn't have enough potassium in his blood, he couldn't breathe properly.
So very, very, fast, shallow breathing. It can look restrictive, and we want to come back to that. But if you've got low potassium, then it can be a little bit misleading.
And certainly metabolic acidosis, so diabetic ketoacidosis, they get a real Oh breath, like they, they're blowing off all the CO2 and, and that's important to, to recognise that we've been misled. I know a lot of people have been misled where it's a cat that, for example, has been a chronic diabetic. Other way around chronic asthmatic, that's on steroids.
And so you know it's an an asthmatic cat and then it presents in a respiratory crisis and you think, oh, this will be it's asthma again, but actually it's now in DKA because of all the steroids. So it's only when you open the oxygen chamber and you get the wa of the ketones, if you can smell them, then then you recognise it. So it's important to to remember these potential causes.
And hopefully these videos are going to play. What do I need to do? Oh, do I need to?
Oh, that's a pain if I have to change back. There you go. So.
So ignore the, the sound. I apologise. I should have turned it off.
6.3 lactate is what she just said, which clearly is not good. It should be less than 2, and you could see a very rapid breathing at its tachychnia in this case.
So major differentials. Obviously, bronchopulmonary disease is a real biggie. So this is the, the asthma, chronic bronchitis, eventually emphysema, COPD type picture.
These two images are pretty useful. Whoopsie, lost my pointer. This is why me looking professional falls down.
Hopefully you can see this point because I'm gonna go back to the, you know. I'll get slicker, I promise. So this is normal lung.
And you can see here is proper alveoli lung, and then here where a bronchial got a little bit of, cartilage, but not much and normal respiratory, epithelium. This little cat died in status asthmaticus. This is the alveolar lung, and you can see it is completely solid.
And the epithelia, it's just awful and just shedding all over the place. So all of these obviously feline asthma it's going to be associated with the xenopils, but the others don't have to be. What you've got in all of them is a real sensitivity, inflammation of the tracheal bronchial epithelium, hyper responsiveness to any kind of airway challenge could be the cold, could be an infection.
What you then get is, broncho constriction. And I think it's press on floor, but please correct me if I've got my things wrong, and that is that the amount of reduced flow in a tube, whether it's a blood vessel or airways, for, well, it's basically for a very small amount of reduction, you've got something like sixteenfold, loss of airflow. Physics, physicians, you'll, you'll, you'll hate me for that, but basically, even a small amount in the reduction of the diameter of that tube, a very significant reduction of air flow.
And the big problem is the increased airway secretion because you can give drugs like rebutyin and that can counter the constriction, but you've still got all this airway secretion if you've had an asthmatic response to whatever they're responsive to. And initially this is reversible, but unfortunately, with time, it becomes chronic damage and irreversible. The differentials for chronic bronchopulmonary disease are the the chronic bronchopneumonias as a classic, and a lot of these are infectious.
So parasitic, please don't underestimate toxo, sorry, toxoplasma go. So this is our standard toxoplasma. But if a cat is eating rodents, we've got a beautiful Burmese here who's eating a slug, which is just revolting.
Toxo is gonna be slugs, snails, but particularly birds and mice, and obviously the lung worms, sorry, I'm, I'm having a funny morning today, aren't I? Slugs and snails is a strong and citrusis and, what I still think of as capillary aerophila, and obviously all of these guys are birds and and mices. Yeah, we need to remember them.
I think that's, I'm really gonna emphasise the lung worms because I don't think in Britain we tend to think about them. Very, very common in on the continent where you've got roloronullus Bravera as well. They are here.
I've, I've published a few papers on these, and this was a pathology case, that, Oliver Coldrick or what was CTDS then. And this is what he could see in the the path. This was the radiograph that went with it.
So you've got a very flat diaphragm and kind of a very, very diffuse, interstitial to alveola type pattern. And this was a cat that unfortunately did eat, slugs and snails, and say this is a euolus Aophilus cat. So we do see them and we've certainly seen a struggletrus, and we've seen this killing kittens as as young as you kind of like 14 weeks old, which means it's it's actually coming from mom, and that wasn't in the books before.
So don't forget the parasitics, and of course they're easily dealt with, you know, it's well, we'll come back to that in the next one, you know, the treatments. But actually I will say just in case you miss it, the 3 licence treatment for these guys is Broadline, Advocate and Profender, the, the, the licenced products. Viral herpes and choleia are obviously two big ones, and they do not just cause upper respiratory.
They most certainly cause low respiratory as well. Oddly enough, feline coronavirus, yeah, the feline coronavirus. It can cause FIP of the lungs.
It's not common, but it does occur. And certainly when cats are first infected with feline coronavirus, it can be a respiratory tract problem before it goes into the gut. I should call it cowpox, but that's daft because it doesn't come from cows.
It comes from voles. But pox absolutely can do this. That's seasonal, particularly in the autumn and winter.
Avian flu, thankfully, we haven't got a pandemic of that at the moment, but it does come around every now and again. And COVID, the, human coronavirus that of course, came from, from bats, etc. Then, that, unfortunately can infect cats.
It can cause clinical disease with respiratory and GI signs, and it has killed some cats and cats can actually, pass it on, but only in a household where there are humans passing it on all over the place, so they don't make a significant effect on that. Bacterial, pneumonia, obviously very common, and you're gonna think of pasturella, but actually, that's not anywhere near as common as mycoplasma. I'm going to show that to you.
Bella bronchoceptica, so, kennel cough for the dog. This is, I always describe it as a bit of a tarty bacteria because it really doesn't mind which mammalian species it likes. It does, atrophic rhinitis in the pig.
It affects, rabbits, it affects, people. Actually, most of these here are zoonoses, and I'm gonna come back to that for a second as well. Strep Canis, absolutely, it doesn't stay in its own host, it jumps to ours.
As for the day anyway. Strepzoe. So obviously that's gonna come from horses, so it will be a cat that lives in the stables or has access to stables.
E. Coli, absolutely, particularly immunosuppressed cats. Iseria, oddly enough, is not a particularly unusual, pneumonia.
We get peripheral pneumonias particularly associated with bacteria from, from the mouth, and then they go through and cause pyothorax. So, Pythorax is most typically caused by the bacteria from the teeth. It's actually dental, you know, subgingival bacteria.
You say it goes through the lungs, causes a little bit of say subplural pneumonia, and because they are . Anaerobic, they don't like oxygen, so they head through the lungs and then go to the plural space where there isn't any oxygen. We see salmonella causing pneumonia as well, which is pretty rude.
And I think you all know that I deal with a lot of mycobacteria, and Britain is the mycobacterial capital of, certainly the TB capital of the world, and we get a lot of myco packs as well. But we'll talk about some of those next time. So look at some of these here.
OK, these two can't go to people, but pox can, avian flu can. COVID will have come from them. Pasturerella, yep, there's a few people who've been put into hospital, from pasturerella.
It's pretty hard to catch, but you can. Mycoplasma Mycoplasma fillers put me in hospital with pneumonia and flu, pleurisy, that hurt like heck, caught it from a cat in ICU. We both ended up with the same thing.
It was really quite funny. Borella most certainly can affect people. So care when you're using those doggy vaccines if you need to check.
If you're using them, you need to check that the owner isn't at all immunosuppressed, particularly when you're administering them to the dog in the room, but actually the dog going home as well, because of course they're going to, to, to shed that. Strepzo, zoonotic E. Coli can be niceeria can be salmonella most definitely is, and mycobact can be as well.
So whenever you're dealing with pneumonia cases, you need to be thinking about potential zoonotic disease, protect yourself. And then we've got inhalation, food, lipid, smoke, obviously. And toxic.
The two biggies, I would say, I, I've put uremia in there, but actually, pancreatitis would be much, much the commonest that I see. And that's because the pancreatitis causes inflammation of the pancreas, obviously, you get leakage of digestive enzymes into the blood. Yeah, not good.
Pro-inflammatory cytokines into the blood, etc. Causes vasculitis. And in cats of vasculitis particularly shows up in the lung where you can get pulmonary edoema or pleural fluid.
And we have quite a few cats that are referred to us for respiratory cases, and they actually turn out to be, pancreatitis. If you're using potassium bromide, well, you really shouldn't be in the cat because a third of them will get a fatal eenophilic pneumonitis. You don't want to do that.
Other things, obviously neoplasia is a very, unusual one. This is a, hemangiosar, obviously, lymphoma or a mammary carcinoma or metastatic, other metastatic carcinoma would be far more common. Foreign bodies, we do see this is a snail, you can see caught in the bifurcation.
That was a real creature to get out. I don't know how it got in there. What did the cat do, yawn for 20 minutes?
Pulmonary edoema, which obviously can be cardiogenic or not, and I've already mentioned pancreatitis, pulmonary contusion, secondary to kitten crush or RTAs would be the biggie. Pulmonary thromboembolism, something we're not good at recognising, but I think it's probably more common than we'll probably think about it and hypertension, they're all in there. And then obviously, you need to be thinking about potential pulmonary thoracic effusions and thoracic damage because it could be that they're happening too.
So while this talk is about the respiratory tract disease, you know, if you've got thoracic effusion, so for example, FIP, this is a little FIP cat. I just drew that out of his lung out of his plural space and took the photograph and then realised it's a pretty sad photo, isn't it? Giving a bit of a death sentence.
But so that can, FIP can go through the lungs as well. So you get a mixed pattern. Obviously, pyothorax can be pneumonia as well.
So most of these others, not so much, but certainly a ruptured diaphragm, then that's likely to have pulmonary, contusions as well. Same with chest wall damage, RTA pulmonary contusions. And the diagnosis, we all know, we start with the signalment and we work all the way through, depending on what resources we have.
This is the one thing I really want to highlight. And that is that while you're sat watching this, then probably less than 5% of the oxygen you're breathing in is actually being used for your muscles of respiration, for the act of breathing. But by the time a cat becomes dysneic or a human for that matter, it's gonna be more than 50% of the oxygen breathing in is being directly used for respiration.
And you can see how a cat can very quickly become critical, just just not enough for the for the brain as well. So signalment, well, age obviously might help if you've got a kitten and it's just been stood on. Well, that's a kitten crush.
Congenital things more likely to be in babies, obviously flat-chestedness, etc. Infectious disease is much more common in youngsters. So we've got, yeah.
This is where you're gonna see your infections, and there's a lovely crusty nose. Concurrent upper respiratory tract or when you see upper respiratory tract disease, be thinking about concurrent lower respiratory tract disease as well, because particularly flu, for all its causes, they can all go down into the lungs. So don't forget that.
Age by way of a middle-aged oriental cat like this little Siamese, then asthma, chronic bronchopulmonary disease are very likely. So the pattern can be useful. If you've got a seasonal pattern, so worse, for example, in the summer.
Now, it could be that it's an allergic problem, so it's the cat is asthmatic to pollens, for example. It could be that the cat is eating lung worm because that's when you're going to get, you know, if they're hunting more, that's when you're gonna have problems with getting eating lung worm along with the everything else they're eating their their slugs and snails and and mice and birds. If they're worse at night, that is more likely to be dust mite allergies, because they're obviously on the bed, maybe the heating's on, etc.
And that can give you a seasonality as well, because if they're allergic to dust mites, etc. They're gonna be worse in the autumn winter when the house is locked up and the heating's on than during the summer when the heating's off and the doors and windows are open. The environment, most certainly, if you've got really it's really irritant to the airways are very dusty, etc.
Then that's obviously gonna be something you need to find out when you're doing the history. Associated cough, what's it like? Is it, is it wet?
Is it not? And whether or not it's productive. Now, for a cat, a productive cough, they don't do like dogs and footballers where they go.
And then stick something up. Cats are much more polite. They swallow.
So to determine whether a cat's cough is productive, and hence whether there's a lot of fluid down there, more likely pneumonia, it's does the cat swallow after coughing. All right? And then progression from previous.
So did the cat have upper respiratory tract disease and, and is it now It's kind of progressed from there. So that sort of thing can be very helpful. If every time it gets given antibiotics, it gets better and then comes back, then you're expecting to see some kind of infection, but is it a secondary problem has to be the question.
Next, really important character of breathing. OK. Is it inspiratory or is it expiratory?
So we've discussed that inspiratory is upper respiratory. It is, the it is pleural disease, thoracic wall, and it is pneumonia, whereas exspiratory is trachea and the first few bifurcations. Restrictive, so short shallow breaths goes along with inspiratory.
So you just can't get the lungs inflated, so it's little and often breathing, as opposed to obstructive, is much more likely to be trachea or the first few bifurcations. So let's make this video. It's a shame I have to switch out of the Huawei pointer options, there we go.
Just, well, I can't see what I'm doing, . There you go. I'm having trouble with this.
Oh dear, that's a problem. I take it it won't do it like that, will it? OK.
I want it to play. I've got to somehow. Place a pointed pen highlighter.
Can I just do that? Mm, sorry guys. That's why I was gonna put video in.
Why can't it just allow me? I just click on, ah, OK, that's what you do. So this is a very obstructive pattern, all right?
So he's really making a lot of effort. Not only that, it's not just effort. He's got paradoxical breathing.
His chest and his abdomen are out of sync. That's a cat that is really critical. All right.
Well, his head doesn't look too stressed, his chest most certainly is. And as I always say to the students, there are 5 ways to do the primary thoracic examination. First, look and listen.
I want to know what pattern of breathing it is. I want to know if you can hear anything, any squeaks, any striders, stors, etc. That might say this is laryngeal, this is, above the larynx, anything like that.
Then you can touch the cat and it's palpation. You're feeling, where is the apex beat because if it's been pushed cordially, it has to be a mass. All right?
You must have a mediasty mass if the apex beat is pushed back. But then what does it feel like? You know, is it for a faint, is it, can you feel it, you know, an obvious, murmur just with your fingers, you know, which would tell you you've got really severe heart disease?
Have you got broken ribs, etc. Then gently compress. If when you compress the cat goes, that's pain, in which case, don't go on to to percuss.
But with the compression, you want to know, is it normal, which means you need to compress cats normally to know what is normal. And, kittens are obviously very squishy, whereas elderly cats have got mineralization of the costochondrals, fat cats have got obesity that reduces compression, because that can really help you. And then percussion, which is what I'm doing in the first picture, obviously, before we were doing, a bear below the elbows and all that sort of stuff.
I, I just percuss two fingers or one finger on my, onto the other finger. And you can really get good at this. It's just practise.
It's not 100% correct, but certainly, if you've got a lot of extra air in there, you will hear the increased resonance, which is gonna be a pneumothorax or asthma type condition with Air trapping. So you know what, the radiograph's gonna have a, a, a what it's gonna look like if you combine that with, wheezes, wheezes and air that goes right to the last rib, you're gonna have a flat diaphragm and bronchial type changes. Whereas if it's very flat and dull, more likely that you've got fluid or a mass in there.
So it really is, something worth doing because so often cats are purring, which can mean that using a stethoscope is limited. Then go on to your, your stethoscope, and my, my little hint here is when you're listening to elderly cats, listen over the sternum because the heart flops down. And you can often hear much more loudly, murmurs, etc.
At the, the sternum. A few things in, I should say that was Kerry Simpson who gave them to me before she was, Kerry Thorpe. So this is Kerry Thorpe, now, brilliant lady and collaborator.
So if the heart is not happy, you're gonna have membrane changes, and apex beat. Jugular pulses. Looking for jugular pulses is really important.
This is only a mile this is after the blood sample's been done and it was one of my training ACA spotted this. See him? OK.
That is a jugular pulse. If you've got a jugular pulse, it usually, not 100%, but it usually indicates that the cat's gonna become congestive. So if you can get an echo or at least do an LAAO, then that would be really good.
Hopefully, the next picture should, there we go. This is, that one was one of mine. This one's one of Kerry's, this one's stunning.
Yeah, if anyone missed this jucular pulse, you need to be blind and this cat's got so congestive that she's actually dripping transcate from her nose. Clear float from her nose. So, do have a look for jugular pulses.
If you've got, if you're not sure, then get someone to go behind the cat and gently squeeze the cat's liver because that's gonna put the blood from the liver into the vasculature of the chest of the car. Can't, can't handle it. You will then see the jugular pulse go from the where it is at the base of the the trachea, base of the thoracic and right up to the corner of the jaw and then you know, OK, this cat has got congestive problems.
So matched pulses, etc. Obviously, I really use the, the, the pulses on the, the tops of the pores are my favourite ones to use because cats don't tend to like you reaching for their, for their inner thigh. Can you blame them?
A few other things I've thrown in about heart. I am not a cardiologist, so please don't take these as cardiology rules. These are internal medic rules when I need to call a cardiologist.
So obviously, we've got potential dyspnea. I see where my point is gone. Come on, pointer, come back.
There you go. . Claudia?
Murmurs not very sensitive. OK. So some of these studies have shown that in this one, quite a few cats, and all the cats, 65%, had a murmur.
But, and the murmurs tend to get worse with age and worse with hypertension. OK. Gallops definitely are something to worry about.
A murmur, certainly if it's a grade 3 or higher, then they worry me, or if it's new or if it's gone. If I've got an elderly cat that used to have a murmur, I expect them to have a grade 2. They've got stiff hearts.
And it disappears, that worries me because it could mean that the, the angular ring has actually, the, the base of the heart is now so big, the murmur's gone. So, whereas a gallop is always a worry. You've got some kind of myocardial disease, even if it's not primary cardiac, it could be secondary to whatever else is going on, hyperthyroidism or anaemia, but both of those can cause heart failure, so we need to worry about them.
Obviously arrhythmias, etc. Sinus arrhythmia does occur in the cat, unusual in the clinic because they've got too much, a catacclaine drive and a drink, but if they've got severe respiratory disease, in fact, particularly upper respiratory is when you'll start seeing it. One study said if you got tachypnea above 80 beats per minute, it was more likely.
Pulselessness, obviously. Hypothermia came out in that study as well. And so they did see coughs, or it's 25%, not 20%, but I do question whether there were other diseases missed because I explained why they, there shouldn't be one.
And a lot of cats with heart disease, no clinical signs at all. And I've thrown in blood pressure and you're gonna say, why have you thrown in blood pressure? Is that useful?
Yes, it is. This was a study Gary and I did years ago when she was still a resident of a long time ago. And these were all the cats going into, our ICU then.
And we used it as a negative as a prognostic indicator, a negative one. And actually, the cutoff was 124, systolic on Doppler, which isn't the most useful. So we now just use 100.
If a cat's got a Doppler systolic blood pressure of less than 100, The prognosis is not good. That can actually be very useful when particular funds are limited. And the case is divided very neatly into two groups, and that was, they were cardiac.
Some of them it wasn't obvious to start with because it had furosemide. But once we gave them fluids, it became obvious and it was like, oh yeah, this is cardiac. The rest were sepsis, pancreatitis, GI type cases.
So, you know, that, that really is a, a useful thing if you've got low blood pressure to start with, the prognosis, it's not so good. And then look for the clinical signs, but this is in. Really highlighted for a reason.
40% of fatal pneumonia had no clinical signs relating to the respiratory tract that the vets noticed. 40% cats are so good at hiding pneumonia. So if you've got a cat that's anorexic, hyperexic.
Lethargic. Be thinking, could this be pneumonia? You know, you always have that on your differential list.
Obviously, you're gonna check out all of these bits the whole physical exam here we've got an FIP with a swollen abdomen, cystic, and he's depressed. This little guy with Gallo, it's purple nose, halei, we've got a tongue that's all ulcerated, feeling for a large thyroid and this old lady. This, little guy, no, yeah, it was a little guy, no, it was a little girl, sorry, she had corners and lung mass.
FIP again, definitely look in the eyes if this is a young pedigree and look at the nails, could it have been an RTA. Other things to look for. These are some pox cases, and they do occur in Britain, tend to be in autumn time, virulent calllei, you're gonna have edoema of the ears and the face.
Virulent callici, we've got obvious vasculitis. Hypertension, which might be associated with heart disease. Here this should say Sheila Crispin's picture, my apologies.
Sorry, Sheila. We've got an aneurysm, we've got haemorrhage, we've got a hyperreflective bit, that very bright bit in the middle, very unhappy looking retina. Crypto lumpy, third eyelid, mycobacteria.
That's a TB doesn't look like it, does it? So, you know, really good physical exam, you need to look at the whole cat. Just put in as a chronic bronchopulmonary disease, so these are the chronic asthma type ones.
Often there's a history of previous flu. It's often seasonal because it's allergic, and findings can vary between really severe, you know, wheezes and crackles, sometimes, you know, a real barrel chest because it's been going on so long and they've got, airway trapping, or it could be unremarkable, which is not very helpful, is it? So, what can we do?
Next bit of diagnosis. So we've done our history, and we've done our physical and I, I, I don't, you know, I spend a lot of time on that because it's so important. Earsinophils might be up with asthma, lung worm.
Could be the cats got fleas. High calcium could be because of some cancers, could be because of TB. If you haven't got echo, then the troponins or pro BNP would be good to do.
Serology tends to be done after the fact when you think you might have a problem. Looking for Long faecal exam, but again, mostly, we don't bother. Bacterial swabs.
You can do culture. Make sure the lab knows what you want to culture for, and that should be bacteria and fungi. You do occasionally find fungi in cat's lungs in this country, not often.
And when you do, and your, sorry, aspergillosis, occasionally, candida of all things. Respiratory screening? Absolutely.
But what we're using more and more are just a plain swab for PCR. The one I like is what used to be called CTDS, and it's now called the VETP Path group, and it's got more than the Idex because both have got herpes, calei, Bella, and Mycoplasma elli. But this one, so it's a vetath group has got mycoplasma Gattii as well.
Those two are both really important. We'll talk about those more in the next one. Both have, chlamydia, but the, that path one has got, obstrusis, a lung one as well.
So that's really useful. If you've got a skin mass, biopsy it, chop it in half, put half in formalin, and then the other half in a sterile pot and freeze it. Even if it's a tiny mass, freeze them.
Because if the histopath comes back something weird, you've got some more tissue that you can investigate. And I just put this here as an aid memoir, the respiratory mycoplasmas, we will talk about these, OK? Mycoplasma, mycobacteria are different, very easy to confuse.
But the mycoplasmas are the ones without a cell wall, and these are very, very common in cat respiratory tract disease. They're present in 15 to 20% of all lower respiratory tract cases. That is a lot.
The major ones are elus, gatii, and filiinutum. If you're thinking about the re the the blood ones, the hemaplasmas, that's hemophilus, whereas this is yus, hemomutum as opposed to filimutum, and then urensis. So it's just they're the names of the blood ones, they're the names of the major respiratory ones.
And I think this is important. I put this in, because this is now something that's done so routinely. So this is, thoracic, point of care ultrasound, so, thoracic pocus.
I know it's a dog. Sorry about that. But it, it correlates well.
You hold, if you've got an ultrasound probe, and I know most of you will have access to one, and I know a lot of you have started to do this now, . Get my pointer back there you go. Actually, I'm gonna have to put the other pointer on because I think you're gonna need to see it.
There you go. Hold the pointer horizontally. OK.
So both sides the same, and you have these 4 sides, 1234. I'll go through them on the next slide. So there's the proper species, and we've got 44 sites on each side, the quarter dorsal.
The perihila. The Middle And the cranial, OK? On both sides.
The, and this is what you see. On a normal cat, you get these dark lines. So this is where the probe is.
These are a lines, these slightly brighter lines. This is pleural, where the pleura, the, the visceral and the parietal pleura run along each other. But that's their a lines and you can see they become less obvious as you go down.
You're really looking at them right near the the the the surface. The asterisks, these are the intercostal spaces. These are the ribs, all right.
So Cat in respiratory distress, you start seeing bee lions. Greg Brown's, he's a, he's one of our brilliant students and then interns and then resident, and now we've kept him, as a, as a lecturer because he is just brilliant. We're not letting anyone ever have it.
He's all ours. And he, I said, how do you describe these best? And he said, oh, like light coming in through, in through water.
If you're swimming underwater, then this is lines of, of sunlight coming through, and I like that. So, you shouldn't have more than 3. You can see and, and of course, left is right and right is left because we like confusing things.
So this in the cranial part of this, scan, there are 4. So it's just about OK, but when we go to the caudal area, it's just wall to wall, . I said it the wrong way around.
I'm sorry, I'm having one of those mornings, but thankfully, I've made good notes on the side, so that if you read it and don't listen to me, it'll be better. So, cranial is caudal and ca is cranial. I know.
I'm not good at left and right, so it's no wonder I messed these things up. These are infinite. You can see you can't see individual ones.
Here you can see individual lines still. Whereas this poor cat, it's just a disaster. They're, you know, wall to wall.
So cat D, absolutely infinite beelines. This cat is in really severe respiratory disease. Whereas we get to E and you can start seeing this pleural fluid in here, the blackness, and again in F we can see a lot of different big patches.
So air, You know, I I'll show you air in a second. But this is what you should see. So when people talk about a lines, they're up, it's the plural up here, and then they just get horizontal down there, whereas your B lines shadow out from the surface.
And that's the easiest way of remembering them. And obviously, if you see a lot of dark stuff, then it's fluid. If it's very clear dark stuff, then it's more likely to be a transitate.
If it is very thick, goopy, swirly stuff, it's more likely to be pussy. And then from the right middle sight, you can look at your LAAO and that'll tell you whether your cat is likely to be in congestive. So, so these, because it's just this is done in ICU, which is why Craig has all the fabulous videos.
So beelines inter interface between fluid and air, and yeah, sunlight beams viewed underwater. Isn't that lovely? Increased number of lines means you've got less air and your lungs are more solid, whether they are solid because of congestive, or whether they're solid because of pneumonia, or whether they're solid because of a mass.
It doesn't tell you. So it could be fluid, as I've listed all of those, it could be to pneumonia. If it is ventral, then aspiration pneumonia is more likely, particularly in the dog, cat's aspiration and you can go pretty much anywhere.
I don't understand why, but it can. And obviously, if you've got them everywhere, then congestive failure is more likely. And this is a really useful one.
You're not gonna have to take the, the, the cat or the dog anywhere from wherever you do your ICU. You work, you don't need to take them to to X-ray or that sort of so it's safer. And there's a little video of his.
And you can see just wall to wall bee lines, absolutely lovely. Oh, how is it I set that one to play? And these ones are set to play much more sensible.
So glide glides. Is the pleura and then the A lines, so that's an A line which has got a glide sign. And this you can see is wall to wall bee lines, we can't see any of this.
I'm sorry, guys. I'm, I really am having a morning. Now, this one, I this is we, we never radiograph these, we never do anything with these.
This is very much more of a, ICU one. It's like I've got the hatch picture that from him cause I've never generated that picture myself. I generate the bee lines, no trouble.
This is a pneumothorax. OK. So you can't see the lung and they call this a bar barcode sign, which kind of says what it does, doesn't it?
And it's all air, so you, you see it as not black. Black is fluid, white is air. And it's really interesting.
It's really been in the last 5 years maybe, that this has come in before then use of ultrasound was limited in the thoracic investigation was limited to just looking for fluid. And now it's so much more useful. And, you know, more and more of us have an ultrasound that's easy to use.
And this is so much safer for the patient than trying to take a radiograph, which you might have to lay the cat down, which is just such a risky thing to do. So much, much better to use your ultrasound. He, we've got, one of his patients with pleural fluid.
Hopefully it'll play. No, it's not gonna play, so I've got to switch out. Point I think I just went to that, didn't I, pointer options.
I went back to that. You can see She's really in a, in a bad way. From above.
Interestingly, she's got quite an almost obstructive pattern, and yet she is a pleural fluid, which shows that the patterns are not cast in stone, and it is really useful always to include, real cases. But a cat like that that's in that respiratory, you do not want a radiograph like that because the risk is unless you radiograph her in that position, she's gonna die while you do it. Whereas if you can put the probe on her.
You can see all of this fluid. There's a heart, and that was, and it's a shorty, . Heart, obviously, and then all this fluid and transitate is likely to be an echoic, so no echoes, whereas thick cellular, it's gonna be pus.
Now this image, when he sent me these ones, I nearly had a Yeah, heart attack, because this really worries me because I do all the infectious diseases, and I'm really clued on those and I worry about them. And this is past being poured down a sink that could be causing an aerosol. So I prefer they're collected into a closed collection, but obviously, I see you as busy.
And you can see they are pouring that very gently. They're trying not to splash, etc. And when they're gonna pour water in, they actually do it by filling up this container and gently flushing it down, trying to do everything other than create an aerosol.
But please be thinking about that. This is a lesser species. It's a dog, but you can see this poor, poor dog.
His heart is barely moving. And obviously that is something you can see, it's not an echo. This is just, it's it's using the same ultrasound machine, so it's not getting the proper positions, but that tells you this animal's heart is really in a very poor systolic function.
And then you have the LA, I can't say LAAO taken from the the so it's left atrial to aortic ratio, taken from the right hand side and you generate the Mercedes Benz sign. And you want the, I know this, it's the machine flips them. So here, that's the 8 o'clock here, that's the 8 o'clock.
And yeah, I know it doesn't help that the machine flips. But what you're trying to do is look at the aorta to the aortic left atrial ratio, aorta to you go across there. So you're cutting across there and obviously the aorta.
Should be about the same size as the left atri. As the left atria gets bigger, you've got congestive and if it gets, the ratio gets greater than 1.6, then you're in trouble.
And you can see you're saying you drew it across there. All right. It's across there.
So, Ultrasound of the chest, really, really helpful. Loss of a lines with the pneumothorax, and then you might see, that, barcode sign. You can see this is a great one from, Richard Malick.
This is tissue. This is actually a mycobacterial infection. He's got a mycobacteria mass in wrapping around his heart.
Not Richard's case. And then bee lines, we've talked about this is consolidation or con or congestive failure. It's liquid to solid.
And when it gets really solid like this, and it's, we call this hepatoid pneumonia, and I always say, if you've got hepatoid pneumonia, so it looks like liver. You've got two options. Either it is liver, in which case you've got a ruptured diaphragm and needs surgery, or you've got a very solid lung.
And they're kind of a list of the classic things that can do it, severe herpes, Calei, pox, like put COVID in there, . All the bacteria we've been talking about, definitely toxo goes in there, fulminant neoplasia, lung lobe torsion, although it tends to have fluid with it, and pulmonary emboli, as it gets worse, we'll do that too. It's really useful using the ultrasound because you see you've got a mass, stick a needle in it.
So you got fluid, stick a needle in that, suck it out as much as possible. Yeah, and this is a, this is a PO case that FNA and you've got these little pox factories and cytologist can literally look at that and go, this is a case of pox, so you can get your diagnosis really quickly, which is good. This is a mycoplasma pneumonia, where you can see there's very little, airway left.
This is, the mouse trap which I'll show you in a second, and it's just a great picture because you've got really solid lung. You can go in there and stick a needle, no risk at all for minimal risk. So, radiographs, if you were lucky enough to have CT and you can generate, you've got a mouse trap, this is great.
It's circular because it then gives no shadows. This was my little cat who was blind, hence the big pupils. It's an oxygen box as well as getting advanced imaging.
It's great. Make sure it's tied down the it's closed properly. This was one of my patients making an exit.
If you haven't got this, which obviously most practises haven't got, then it's radiographs. If you can prop this up like this, then this is far less risky to the cat. If you have got pleural fluid or severe, pneumonia, putting the cat onto their side or their back is often fatal.
So be really, really careful. And just some images to show you these are not always the easiest to interpret. Here, we've got classic ch chronic bronchopulmonary disease, so we can see air trapping, all this is extra air, lots of space between the heart and the diaphragm, very flat diaphragm, and they often have collapse of the middle lung lobe, which is what you're seeing there, that kind of very marked line.
That's a plural line there. And you can see diffuse bronchial kind of bronchial type pattern. This is a lymphoma case that's actually trying to do a lot to look similar.
You've got for a flat diaphragm and just it's more of an interstitial pattern, very hazy. This is a pneumonia, and you can see this is really very similar to chronic bronchopulmonary, flat diaphragm, collapsed middle lung lobe. We think the middle lung lobe goes down because the bronchus is so narrow.
It just collapses very quickly. And you've got a bronchial bronchial interstitial pattern. This is an FIP to show you FIP can cause pulmonary changes.
Again, a flat diaphragm, collapsed middle lung lobe, and a bronchial to bronchial interstitial pattern. So it shows you the imaging is rarely passingnemonic. This is a mycoback, but they can look very like whatever they like really, but these are classically interstitial because we think it goes from the cutaneous lesions to the But to the cat's chest hematogeneously, hence hence a interstitial pattern.
Lung worm, they can look all at what they like as well, tend to be patchy, patchy diffuse, they can get mineralization, as can mycobacks. Both of these can cause high calcium. I didn't mention lung worm high calcium earlier and I should have done.
You can see we're starting to get a bit of mineralization up here. So sometimes you see verminous mineralization with lung worm where it kind of looks wriggly like a lung worm. And then these two, I love these two pictures.
This, these are asthma cases, very flat diaphragm in both. But in this one, we've got a marked, bronchial pattern that just jumps out at you. And this one, you know, it's still a severely dysneate cat, and yet the, the lungs, lobes and cells look reasonably clear, and yet this cat is clearly having major problems breathing.
Look how flat her diaphragm is. Thoracic effusions, so we, hopefully, we're not gonna be seeing pictures of lots of effusions anymore because we should pick that up on the thoracic pocus, lifted heart, elevated trachea, and the coral lung lobes leafing away from the, from cord dorsally. And you can see the same here.
And when you're looking at, hopefully, it's, this is a VD, It doesn't always happen that way. You can see, it's, it's quarterly, you really get to see what you're looking at. Generally, it just looks hazy and you go, why can't I see anything?
And you're looking at the leafing quarterly. Try to look at the vessels, see if there's any indication that this is, yeah, look at vessel size again to see whether or not this is cardiac. I wanted to put these pictures, and this is the same cat.
These are radiographs that were sent to me by, by Amy Tro. And she said, What do you think of this case? And I went, Oh, it's a generalised, diffuse, yeah, interstitial type pattern, I think.
But there's definitely some highlighting of airways as well. And then this is the CT we generated. And what you quite often see is that they go, below the, so subplural.
And isn't that beautiful? Really around the the, the major airways. So around the major airways and then diffuse and you get these little patches, they can be really quite beautiful.
tree and bud, I, I put this in, and this is often mycoplasma, but, but not always. This was not a thing we recognised until fairly recently when this fabulous paper came out. And this is when you do CT and it looks like trees in bud.
And there's often mineralization of some of the material. When you look at the radiographs, it's really hard to, it's you've got mineralized patches and you've got kind of a diffuse. Nodular.
It looks diffuse nodular, I think you'd agree with me. But actually when it really makes you worry about TB, but then you look at it here and it's actually, it's, it's a bronchiolla pattern. Right, this is tree and bud and it's bronchioles.
It can be caused by anything that causes bronchiolar disease. Remember, disease at this level in the cat is not going to cause coughing. It's got to get further up the tree to cause coughing, which is why it can't cough out this rubbish.
And you've got mineralization of the macrophages that are trying desperately to get rid of the rubbish. And then that leaves us to collection of samples, because ultimately the images will help but say nothing is painnemonic. So tracheal washes, we don't tend to do in cats.
mucosal brushing years since I did those, the cytology was just rubbish. We're gonna go through bowel, which obviously I hope some of you do, but it's definitely a practise tool. And obviously, we all know how to stick a needle and aspirate, pleural fluid.
If you see a mass, then, that's actually a CT guided one cause I, we needed to go right beside the spinal cord. So a spinal column, so it was like, it's all a bit close, so I asked the images to. Catch that one for me.
Things you might see looking down, this is in the trachea, this is a lymphoma mass, that's a a fine catheter to supply oxygen. Kenya. Borella tends to be much pussier than mycoplasma.
Asthma doesn't necessarily give you much in between asthmatic episodes, very obvious blood blood vessels, some erythema. This one's one of Nico van Israel's, yeah. Can I say, this is a very expensive way to worm a cat, taking them out one at a time.
You really should have treated for one worm before we get to this point. Have we been caught out? Well, clearly we have this photographic evidence.
So let's finish up with talking about bronchialveolar age. I wish I could ask how many of you do it. We can talk about this in the questions, afterwards, if you have any questions.
So I put the cat in a sternal unless the radiographs tell me that one side of the lung is affected. If just one side is affected, you want to lay the cat on that side. All right?
You want to keep the oxygenating side, the one that's working on the top. But generally it's pretty diffuse. Please pre-med with tebutyin because what you don't want is to trigger an asthma attack.
When you trigger an asthma attack, say you're gonna get the broncho constriction, which I talked about earlier, and the rosants law of sixteen-fold reduction in in air flow. But you're also gonna get production of mucus. And while tebutylin will reverse the bronchi constriction, it doesn't clear all the snot that just filled up your poor cat's chest.
So, try not to trigger it, particularly if you think it might be an asthma case, but in any case, because it's just so easy with cats, you know what they're like, that's so easy, the larynx, spasms, the nasopharynx spasms. I've seen that a couple of times. That's quite scary.
Actually more than a couple of times. And obviously, the, the lower airway can spasm. So let's give a tebutyline, pre-med.
The reason you want to give it pre-med as well is because if you can give it sub Q, then you're not gonna get anywhere as near tachycardia as you're gonna get with this drug. Opens airways and speeds up the heart. Cat's internal, there we go.
Obviously, I'd prefer none of us were using these spring loaded gags because that can cause blindness and and and death, which is, as the residents say, definitely suboptimal. And then pick your fine catheter of choice. This was a Portex one that we used to be able to get hold of and now that it's rubbish.
So I use a dog urinary catheter, either the, I think they're 8 or is it 6 or 8. It's the yellow one or the orange one, depending on the size of my cat. Pass it through the ET tube.
If you've got an endoscope and you can do it endoscopically by, as you can see in this image down here wedging that in, then, OK, do that. The problem is that in cats, the bronchoscope is the same diameter as the trachea. So the cat has no oxygen while you're doing this.
So your anaesthetist tends to get quite twitchy. So we'll do it if, when, you know, we can do it and we're quick unless it's a very small cat. And we always use one of these, which joins onto the endoscope.
I'm sorry, yeah, you put that onto the endoscope and you get the fluid sucking back and it's very gentle suction. To be honest, I use this, even if I'm not using the bronchoscope, I can attach this onto the end of the dog urinary catheter. And it's just a lovely gentle suction, much less trauma.
So, pre-med. Sterile ET tube, gently wedge your doggy urinary catheter into place. And then draw up, before you do that, draw up 45 mil syringes, each with 3 mLs of saline in it.
That is because when you tip that. Syringe, so you then wanna, you've got your 3 mLs of saline, then pull back, so you've got 3 mLs of saline and 2 mLs of air. Because when you turn it upside down and put it into the urinary catheter that's in the, the cat's airway, you're gonna have the fluid closest to the cat and then air behind it.
Because if you don't, then you're gonna flush fluid into the cat's airway and it's all sitting in the tube. Which is useless. So you need the air to flush the the saline into the cat's airway, and you're aiming to fill up the the lower airway, the little bronchus, terminal bronchus that you've picked.
So you first flush that in and then gently coupage the cats and make cup shapes of your hands and coupage so that agitates this so that alveoli macrophages and clearly it falls into it. You can try and suck back the first syringe. There's almost nothing there.
So then you put another syringe in coupage. Gently start back and you repeat that however many times you need. Normally, you only need 3.
There's a big cat, you might need 4. Then you're gonna get a lovely harvest which is frothy, which means you've got surfactant and cloudy because you've got cells and mucus, which is great. And then think about what you're gonna do with it.
You want aerobic and anaerobic and fungal culture, ideally, Definitely you want at least standard bacterial and fungal culture, if they can't do anaerobic. If you're looking for your mycoplasma like culture, you might need transport media. Well you definitely need to ask them so that they set it up for you.
So that's what you're gonna Fend off. PCR is actually, yes, we'd always send for culture. We send for bacterial and fungal culture is one tube.
So we, we get that. Let me go back on. To see.
So we've got our lovely harvest here. We divide it into three pots. One is Depending if it's got a post, then you want EDTA or some kind of self preservative for cytology, standard plane for routine bacterial and fungal culture, and another plane which goes for PCR.
It is the same PCR that I mentioned earlier, that goes to the VETPath group, which checks for all of those different potential pathogens. And make slides too, and look at them. Because if what you've got, as you can see here, loads of neutrophils and red blood cells.
And if you look closely, you've got toxic nuts in there and you can see intracellular bacteria as well, then you've got pneumonia. Whereas this one, we've got loads of Xinopils and mucus strands. This is a a chronic bronchopulmonary.
This is an asthmatic cat. And this cat has got nontoxic newts, and we've got some little runs of epithelia. You can see the respiratory epithelia.
They've got a basal nucleus and fluffy. They've got little villa, really pretty. This is chronic bronchopulmonary disease.
So make slides yourself and check them. Try to make time. I know it's really hard, but if you can try to do that.
So you can then compare them to what the lab tells you so that you then have one on a Friday and go actually, I know that this is an asthma case. So hopefully guys, that was useful for you. A little bit of a whistle stop tour because I put in all the poker stuff because I felt you couldn't not have it.
. We will be able to take any questions you like, and then with the next one, which Dawn will be able to tell you that the date for the next one, we will have cases will be completely case-based, and we will talk about treatment. So I hope that was useful.
Thank you as always, to the webinar vet for organising these webinars. They're just great. And obviously, as always, as well, thank you to the dick.
. Because, you know, they're, they're such a good place to work. But most of all, it's thank you to you guys because you guys are taking time out from what I know is really frantic, very difficult time to spend just over an hour. Oops, .
Looking at cat respiratory disease, low respiratory disease. So thank you very much. OK.