Downloaded 69 times
![higher in the active control group (4%) compared to mg/kg orally. The effect was still present 8 hours the average voluntary consumption was 84.2%.
the Vetmedin group (1%). after dosing. There was a delay between peak blood
levels of pimobendan and active metabolite and the Animal Safety: In a laboratory study, Vetmedin
Adverse reactions/new clinical findings were seen in maximum physiologic response (peak LV dP/dtmax). chewable tablets were administered to 6 healthy
NADA 141-273, Approved by FDA both treatment groups and were potentially related Blood levels of pimobendan and active metabolite Beagles per treatment group at 0 (control), 1, 3, and
to CHF, the therapy of CHF, or both. The following began to drop before maximum contractility was seen. 5 times the recommended dosage for 6 months. See
Vetmedin ® adverse reactions/new clinical findings are listed
according to body system and are not in order of
Repeated oral administration of pimobendan did not
result in evidence of tachyphylaxis (decreased positive
Table 3 for cardiac pathology results. The cardiac
pathology/histopathology noted in the 3X and 5X dose
(pimobendan) Chewable Tablets prevalence: CHF death, sudden death, chordae groups is typical of positive inotropic and vasodilator
inotropic effect) or drug accumulation (increased
Cardiac drug for oral use in dogs only tendineae rupture, left atrial tear, arrhythmias overall, positive inotropic effect). Laboratory studies indicate drug toxicity in normal dog hearts, and is associated
tachycardia, syncope, weak pulses, irregular pulses, that the positive inotropic effect of pimobendan may with exaggerated hemodynamic responses to these
Caution: Federal law restricts this drug to use by increased pulmonary edema, dyspnea, increased drugs. None of the dogs developed signs of heart
or on the order of a licensed veterinarian. be attenuated by the concurrent use of a ß-adrenergic
respiratory rate, coughing, gagging, pleural effusion, blocker or a calcium channel blocker. failure and there was no mortality.
Description: Vetmedin (pimobendan) is supplied as ascites, hepatic congestion, decreased appetite,
vomiting, diarrhea, melena, weight loss, lethargy, Effectiveness: In a double-masked, multi-site, 56-day Table 3: Incidence of Cardiac Pathology/
oblong half-scored chewable tablets containing 1.25, Histopathology in the Six-month Safety Study
2.5 or 5 mg pimobendan per tablet. Pimobendan, depression, weakness, collapse, shaking, trembling, field study, 355 dogs with modified NYHA Class II,
a benzimidazole-pyridazinone derivative, is a non- ataxia, seizures, restlessness, agitation, pruritus, III, or IV CHF due to AVVI or DCM were randomly
increased water consumption, increased urination, assigned to either the active control (enalapril maleate) Severe left ventricular One 3X and
sympathomimetic, non-glycoside inotropic drug hypertrophy with two 5X dogsa
with vasodilatative properties. Pimobendan exerts urinary accidents, azotemia, dehydration, abnormal or the Vetmedin (pimobendan) treatment group. Of multifocal subendocardial
a stimulatory myocardial effect by a dual mechanism serum electrolyte, protein, and glucose values, mild the 355 dogs, 52% were male and 48% were female; ischemic lesions
of action consisting of an increase in calcium increases in serum hepatic enzyme levels, and mildly 72% were diagnosed with AVVI and 28% were
sensitivity of cardiac myofilaments and inhibition of decreased platelet counts. diagnosed with DCM; 34% had Class II, 47% had Moderate to marked Three 5X dogs
phosphodiesterase (Type III). Pimobendan exhibits Class III, and 19% had Class IV CHF. Dogs ranged myxomatous thickening
See Table 1 for mortality due to CHF (including in age and weight from 1 to 17 years and 3.3 to of the mitral valves
vasodilating activity by inhibiting phosphodiesterase euthanasia, natural death, and sudden death) and for
III activity. The chemical name of pimobendan 191 lb, respectively. The most common breeds were
the development of new arrhythmias (not present in a mixed breed, Doberman Pinscher, Cocker Spaniel, Myxomatous thickening One 3X and
is 4,5-dihydro-6-[2-(4-methoxyphenyl)-1H- dog prior to beginning study treatments) by treatment of the chordae tendineae two 5X dogs
benzimidazole-5-yl]-5-methyl-3(2H)-pyridazinone. Miniature/Toy Poodle, Maltese, Chihuahua, Miniature
group and type of heart disease (AVVI or DCM) in the Schnauzer, Dachshund, and Cavalier King Charles
The structural formula of pimobendan is: 56-day field study. Spaniel. The 180 dogs (130 AVVI, 50 DCM) in the Endocardial thickening One 1X, two 3X,
of the left ventricular and two 5X dogs
Table 1: CHF Death and New Arrhythmias in the active control group received enalapril maleate outflow tract
56-Day Field Study (0.5 mg/kg once or twice daily), and all but 2 received
furosemide. Per protocol, all dogs with DCM in the Left atrial endocardial One 3X and
Vetmedin® Active Control active control group received digoxin. The 175 dogs thickening (jet lesions) one 5X dog
Group Group (126 AVVI, 49 DCM) in the Vetmedin group received in 2 of the dogs that
pimobendan (0.5 mg/kg/day divided into 2 portions developed murmurs of
that were not necessarily equal, and the portions were mitral valve insufficiency
14.3% 14.4%
Indications: Vetmedin (pimobendan) is indicated for n=175 n=180 administered approximately 12 hours apart), and all
the management of the signs of mild, moderate, or but 4 received furosemide. Digoxin was optional for Granulomatous One 3X dog
severe (modified NYHA Class IIa, IIIb, or IV c) congestive 9 of 126 dogs 16 of 130 treating supraventricular tachyarrhythmia in either
inflammatory lesion in the
heart failure in dogs due to atrioventricular valvular Dogs that died right atrial myocardium
with AVVI dogs with treatment group, as was the addition of a ß-adrenergic
insufficiency (AVVI) or dilated cardiomyopathy (DCM). due to CHF
AVVI blocker if digoxin was ineffective in controlling heart a
Vetmedin is indicated for use with concurrent therapy Most of the gross and histopathologic findings
rate. After initial treatment at the clinic on Day 1, dog occurred in these three dogs
for congestive heart failure (e.g., furosemide, etc.) as 16 of 49 dogs 10 of 50 dogs owners were to administer the assigned product and
appropriate on a case-by-case basis. with DCM with DCM
concurrent medications for up to 56±4 days. Murmurs of mitral valve insufficiency were detected in
a
A dog with modified New York Heart Association one 3X (Day 65) and two 5X dogs (Days 135 and 163).
39.4% 45.0% The determination of effectiveness (treatment success) These murmurs (grades II-III of VI) were not associated
(NYHA) Class II heart failure has fatigue, shortness n=175 n=180 for each case was based on improvement in at
of breath, coughing, etc. apparent when ordinary with clinical signs.
least 2 of the 3 following primary variables: modified
exercise is exceeded. Dogs that 45 of 126 59 of 130 NYHA classification, pulmonary edema score by a Indirect blood pressure was unaffected by Vetmedin
b developed new dogs with dogs with masked veterinary radiologist, and the investigator’s at the label dose (1X). Mean diastolic blood pressure
A dog with modified NYHA Class III heart failure is arrhythmiasa AVVI AVVI
comfortable at rest, but exercise capacity is minimal. overall clinical effectiveness score (based on physical was decreased in the 3X group (74 mmHg) compared
examination, radiography, electrocardiography, and to the control group (82 mmHg). Mean systolic blood
c
A dog with modified NYHA Class IV heart failure has 24 of 49 dogs 22 of 50 dogs
with DCM with DCM clinical pathology). Attitude, pleural effusion, coughing, pressure was decreased in the 5X group (117 mmHg)
no capacity for exercise and disabling clinical signs activity level, furosemide dosage change, cardiac compared to the control group (124 mmHg). None of
are present even at rest. a size, body weight, survival, and owner observations the dogs had clinical signs of hypotension.
New arrhythmias included supraventricular
Dosage and Administration: Vetmedin should be were secondary evaluations contributing information On 24-hour Holter monitoring, mean heart rate
premature beats and tachycardia, atrial fibrillation,
administered orally at a total daily dose of 0.23 mg/lb supportive to product effectiveness and safety. Based was increased in the 5X group (101 beats/min)
atrioventricular block, sinus bradycardia, ventricular
(0.5 mg/kg) body weight, using a suitable combination on protocol compliance and individual case integrity, compared to the control group (94 beats/min). Not
premature beats and tachycardia, and bundle
of whole or half tablets. The total daily dose should 265 cases (134 Vetmedin, 131 active control) were counting escape beats, the 3X and 5X groups had
branch block
be divided into 2 portions that are not necessarily evaluated for treatment success on Day 29. See Table slightly higher numbers of isolated ventricular ectopic
equal, and the portions should be administered Following the 56-day masked field study, 137 dogs 2 for effectiveness results. complexes (VEs). The maximum number of non-
approximately 12 hours apart (i.e., morning and in the Vetmedin group were allowed to continue on Table 2: Effectiveness Results for the escape VEs recorded either at baseline or in a control
evening). The tablets are scored and the calculated Vetmedin in an open-label extended-use study without 56-Day Field Study group dog was 4 VEs/24 hours. At either Week 4 or
dosage should be provided to the nearest half tablet restrictions on concurrent therapy. The adverse Week 20, three 3X group dogs had maximums of 33,
increment. reactions/new clinical findings in the extended-use Active Control 13, and 10 VEs/24 hours, and two 5X group dogs had
Vetmedin®
Contraindications: Vetmedin should not be given in study were consistent with those reported in the Group Group maximums of 22 and 9 VEs/24 hours. One 1X group
cases of hypertrophic cardiomyopathy, aortic stenosis, 56-day study, with the following exception: One dog with no VEs at baseline had 6 VEs/24 hours
or any other clinical condition where an augmentation dog in the extended-use study developed acute 80.7% 76.3% at Week 4 and again at Week 20. Second-degree
of cardiac output is inappropriate for functional or cholestatic liver failure after 140 days on Vetmedin n=134 n=131 atrioventricular heart block was recorded in one 3X
anatomical reasons. and furosemide. group dog at Weeks 4 and 20, and in one dog from
Treatment 88 of 101 77 of 100 each of the 1X and 5X groups at Week 20. None of
Warnings: Only for use in dogs with clinical evidence In foreign post-approval drug experience reporting, the Success on dogs with dogs with the dogs had clinical signs associated with these
of heart failure. At 3 and 5 times the recommended following additional suspected adverse reactions were Day 29 AVVI AVVI electrocardiogram changes.
dosage, administered over a 6-month period of time, reported in dogs treated with a capsule formulation
pimobendan caused an exaggerated hemodynamic of pimobendan: hemorrhage, petechia, anemia, 20 of 33 dogs 23 of 31 dogs Treatment was associated with small differences
response in the normal dog heart, which was hyperactivity, excited behavior, erythema, rash, with DCM with DCM in mean platelet counts (decreased in the 3X and
associated with cardiac pathology (See Animal drooling, constipation, and diabetes mellitus. 1X groups), potassium (increased in the 5X group),
71.1% 67.2% glucose (decreased in the 1X and 3X groups), and
Safety). To report suspected adverse reactions, to obtain a n=113 n=110 maximum blood glucose in glucose curves (increased
Human Warnings: Not for use in humans. Keep this Material Safety Data Sheet, or for technical assistance in the 5X group). All individual values for these
call 1-866-638-2226. Treatment
and all medications out of reach of children. Consult a 66 of 85 dogs 56 of 85 dogs variables were within the normal range. Three 1X and
Success on
with AVVI with AVVI
physician in case of accidental ingestion by humans. Clinical Pharmacology: Pimobendan is oxidatively Day 56 one 5X group dogs had mild elevations of alkaline
demethylated to a pharmacologically active metabolite 13 of 28 dogs 17 of 25 dogs
phosphatase (less than two times normal). Loose
Precautions: The safety of Vetmedin has not been stools and vomiting were infrequent and self-limiting.
established in dogs with asymptomatic heart disease which is then conjugated with sulfate or glucuronic with DCM with DCM
or in heart failure caused by etiologies other than acid and excreted mainly via feces. The mean extent Storage Information: Store at controlled room
AVVI or DCM. The safe use of Vetmedin has not been of protein binding of pimobendan and the active No increase in temperature 59-86°F (15-30°C).
evaluated in dogs younger than 6 months of age, metabolite in dog plasma is >90%. Following a single furosemide
78.3% 68.6%
oral administration of 0.25 mg/kg Vetmedin tablets dose between How Supplied:
dogs with congenital heart defects, dogs with diabetes n=130 n=126
the maximal mean (± 1 SD) plasma concentrations Day 1 and Vetmedin® (pimobendan) Chewable Tablets:
mellitus or other serious metabolic diseases, dogs Day 29
used for breeding, or pregnant or lactating bitches. (Cmax) of pimobendan and the active metabolite were Available at 1.25, 2.5 or 5 mg oblong half-scored
3.09 (0.76) ng/mL and 3.66 (1.21) ng/mL, respectively. At the end of the 56-day study, dogs in the Vetmedin chewable tablets – 50 tablets per bottle.
Adverse Reactions: Clinical findings/adverse Individual dog Cmax values for pimobendan and the group were enrolled in an unmasked field study
reactions were recorded in a 56-day field study of active metabolite were observed 1 to 4 hours post- Manufactured by:
to monitor safety under extended use, without MEDA Manufacturing GmbH
dogs with congestive heart failure (CHF) due to AVVI dose (mean: 2 and 3 hours, respectively). The total restrictions on concurrent medications.
(256 dogs) or DCM (99 dogs). Dogs were treated body clearance of pimobendan was approximately Cologne, Germany
with either Vetmedin (175 dogs) or the active control 90 mL/min/kg, and the terminal elimination half-lives Vetmedin was used safely in dogs concurrently Manufactured for:
enalapril maleate (180 dogs). Dogs in both treatment of pimobendan and the active metabolite were receiving furosemide, digoxin, enalapril, atenolol, Boehringer Ingelheim Vetmedica, Inc.
groups received additional background cardiac approximately 0.5 hours and 2 hours, respectively. spironolactone, nitroglycerin, hydralazine, diltiazem, St. Joseph, MO 64506 U.S.A.
therapy (See Effectiveness for details and the Plasma levels of pimobendan and active metabolite antiparasitic products (including heartworm 1-866-638-2226
difference in digoxin administration between treatment were below quantifiable levels by 4 and 8 hours after prevention), antibiotics (metronidazole, cephalexin,
groups). oral administration, respectively. The steady-state amoxicillin-clavulanate, fluoroquinolones), topical VETMEDIN is a registered trademark of
volume of distribution of pimobendan is 2.6 L/kg ophthalmic and otic products, famotidine, theophylline, Boehringer Ingelheim Vetmedica GmbH,
The Vetmedin group had the following prevalence indicating that the drug is readily distributed into levothyroxine sodium, diphenhydramine, hydrocodone, licensed to Boehringer Ingelheim Vetmedica, Inc.
(percent of dogs with at least one occurrence) of tissues. Food decreased the bioavailability of an metoclopramide, and butorphanol, and in dogs on
common adverse reactions/new clinical findings (not © 2009 Boehringer Ingelheim Vetmedica, Inc.
aqueous solution of pimobendan, but the effect of sodium-restricted diets.
present in a dog prior to beginning study treatments): food on the absorption of pimobendan from Vetmedin Code 448011, 448111, 448211
poor appetite (38%), lethargy (33%), diarrhea (30%), Palatability: In a laboratory study, the palatability of Revised 06/2007
tablets is unknown.
dyspnea (29%), azotemia (14%), weakness and ataxia Vetmedin was evaluated in 20 adult female Beagle
(13%), pleural effusion (10%), syncope (9%), cough In normal dogs instrumented with left ventricular (LV) dogs offered doses twice daily for 14 days. Ninety
(7%), sudden death (6%), ascites (6%), and heart pressure transducers, pimobendan increased LV percent (18 of 20 dogs) voluntarily consumed more
murmur (3%). Prevalence was similar in the active dP/dtmax (a measure of contractility of the heart) than 70% of the 28 tablets offered. Including two dogs
control group. The prevalence of renal failure was in a dose dependent manner between 0.1 and 0.5 that consumed only 4 and 7% of the tablets offered,](https://image.slidesharecdn.com/pv0509-091029165850-phpapp02/85/Pv0509-6-320.jpg)
![Editorial
COLUMN EDITOR
COLUMN EDITOR Craig E. Griffin, DVM, DACVD
Animal Dermatology Clinic, San Diego, California
COLUMN EDITOR
COLUMN EDITOR Wayne S. Rosenkrantz, DVM, DACVD
Animal Dermatology Clinic, Tustin, California
Dr. Yu (shown here with his dogs
[from left to right] Timmy, Joey,
and Bitsy) is associate professor
Overview of Flea Allergy Dermatitis of dermatology at The University
of Guelph Ontario Veterinary
College in Canada.
❯❯ Andrea Lam, DVM ❯❯ Anthony Yu, DVM, MS, DACVDa
University of California Davis Veterinary Medical Teaching Hospital University of Guelph Ontario Veterinary College
F lea allergy dermatitis, or flea-bite hypersensitivity, is the
most common small animal dermatologic condition.1–3
In some regions of the world, it is the most commonly seen
sources. The larvae feed on adult flea feces
(partially digested blood) in the environment.
Within 5 to 11 days, a larva undergoes two sep-
arate molting stages before forming a pupa.
canine disease. This disease does not exist in locations that The pupal stage is the most resilient of all
are inhospitable to fleas, such as those at elevations above stages because the cocoon is highly resistant
to desiccation. It also has a sticky surface that
1500 ft or with low humidity (e.g., the desert).
helps to prevent premature removal from the
Although there are more than 2000 docu- environment and that accumulates dust and
mented species and subspecies of fleas, the other household particulates to provide pro-
cat flea (Ctenocephalides felis felis) is the spe- tection. On average, the pupal stage lasts 8 to
cies most frequently found infesting dogs, cats, 9 days; however, fleas can pupate for up to 6
and all caged pets in North America. months if the environmental conditions are not
ideal for emergence. Only with proper environ-
Flea Facts mental stimuli, such as an increase in carbon
The life cycle of the flea ranges from as few dioxide, warmth, physical pressure, and vibra-
as 12 to as many as 190 days, with an average tion, will an adult flea emerge from its cocoon.
of 21 days. The time needed for development After emerging from the cocoon, adult fleas
At a Glance depends heavily on environmental conditions, search for an appropriate host. Adult fleas are
particularly temperature and humidity. The opti- attracted to light and tend to migrate upward
Flea Facts
Page 220 mal environment is a low-altitude geographic toward surfaces where contact with an appropri-
location, a temperature of 75°F (23.8°C), and a ate host is more likely. Once a host is found, feed-
Pathogenesis
Page 220
relative humidity of 78%. ing and mating take place within 8 to 24 hours.
An adult flea takes its first blood meal from Female fleas can consume 15 times their body
Diagnosis a host within minutes of contact. Female fleas weight in blood per day. Adult fleas act as obligate,
Page 222
lay their first egg 24 to 36 hours after this permanent ectoparasites, preferring to remain on
Treatment blood meal. Flea eggs are smooth and slick. a host rather than in the environment.
Page 223
Only 30% of eggs remain on the haircoat; the
Flea Control remainder fall off the host into the environ- Pathogenesis
Products ment. Hatching takes place within 1 to 10 days, Flea saliva contains histamine-like compounds,
Page 224 again depending on humidity and tempera- proteolytic enzymes, and anticoagulants. These
ture. A single female flea can lay 1000 eggs proteins are released into the host during
within 30 days, and most average 2000 eggs feeding and can act as inflammatory or anti-
❯❯ Wayne S. Rosenkrantz, ❯❯ Craig E. Griffin, DVM,
during their life. genic stimuli in sensitive animals. Various
Although eggs can hatch anywhere in the immunologic responses are provoked, includ- WEB
environment, development of the larvae that ing immediate and delayed hypersensitivity EXCLUSIVE
a
Dr. Yu discloses that he emerge from the eggs must take place off the reactions,4 late-phase IgE-mediated responses,
has received financial sup- host because mammalian body temperatures and cutaneous basophil hypersensitivity reac- An extended version of
port from Greer Laborato-
DVM, DACVD DACVD
are too high for survival. Larvae are highly sen- tions.5 Dogs with atopic dermatitis appear to this article is available on
ries, Iams, Novartis Animal
Health, and Pfizer Animal sitive to heat and desiccation and therefore tend be predisposed to the development of flea CompendiumVet.com.
Health. to move downward and away from direct light allergy dermatitis.6,7
220 Compendium: Continuing Education for Veterinarians® | May 2009 | CompendiumVet.com CompendiumVet.com | May 2009 | Compendium: Continuing Education for Veterinarians® 221
Animal Dermatology Clinic Animal Dermatology Clinic
Tustin, California San Diego, California New dermatology series begins on page 220.
Applied Dermatology
S
kin and ear diseases are the most common be written or coauthored by diplomates or residents
problems that veterinarians deal with in of the American College of Veterinary Dermatology,
practice on a daily basis. Because many of who will present evidence-based approaches to
these cases are secondary to genetic causes, cure common dermatologic conditions. This new col-
is often not possible, and management becomes umn will appear quarterly. Occasionally, recog-
the mainstay of therapy. Fortunately, many nized dermatology experts will contribute their
advances in diagnostics and therapeutics have individual approaches to specific problems as
been made in the field of veterinary dermatology, online supplements to this series; the first of these
and pet owners are demanding a higher level articles, “A Practical Approach to Diagnosing and
Managing Ear Disease in Dogs,” by Paul Bloom,
The new dermatology series will provide DVM, DACVD, DABVP (Canine and Feline), will be
published on CompendiumVet.com this month.
practical, easy-to-use techniques for the We hope that this new column will provide
valuable information on how specialists approach
diagnosis and treatment of many common
and manage common skin and ear diseases and
canine and feline ear and skin diseases. will help keep you updated on new diagnostic
and therapeutic options so you can better han-
of care and are often willing to allow advanced dle these often frustrating cases in your clinical
diagnostic testing and therapy. To be able to offer practice.
your clients this higher quality of medicine, it is
imperative to stay current on the latest options
available to manage these chronic and sometimes SHARE YOUR COMMENTS
frustrating cases. Have something to say about this
To help you in this effort, the new Compendium editorial or topic? Let us know:
dermatology series, Applied Dermatology, will pro-
E-MAIL editor@CompendiumVet.com
vide practical, easy-to-use techniques for the diag-
nosis and treatment of many common canine and FAX 800-556-3288
feline ear and skin diseases. The articles in this new
series, which debuts on page 220 of this issue, will
CompendiumVet.com | May 2009 | Compendium: Continuing Education for Veterinarians® 211](https://image.slidesharecdn.com/pv0509-091029165850-phpapp02/85/Pv0509-13-320.jpg)
![FREE
CE Laryngeal Paralysis in Dogs
BOX 1
Unless the examiner is aware of the phase
Anesthetic Regimens for of respiration, it is easy to mistake paradoxical
Diagnosing Laryngeal movement of the larynx for active abduction.
Lack of arytenoid cartilage abduction during
Paralysis in Dogs inspiration narrows the rima glottidis, increas-
ing resistance to airflow. Rapid, forceful inspira-
Preoxygenate for 3 to 5 minutes before tion creates negative pressure within the larynx,
induction. which pulls the flaccid arytenoid cartilages
medially, worsening the obstruction.27 The car-
Thiopental (12–16 mg/kg IV to effect) tilages are forcefully separated by airflow as the
Propofol (4.5–7 mg/kg IV slowly to effect) animal exhales. Therefore, dogs with laryngeal
and doxapram (1 mg/kg IV) paralysis and paradoxical motion have inward
Acepromazine (0.2 mg/kg IM) and butor- movement of the arytenoid cartilages on inspi-
phanol (0.4 mg/kg IM) 20 minutes before
ration and outward, passive movement of the
mask induction with isoflurane
cartilages during expiration. Intubation may be
required in some patients with severe paradox-
ical motion and resultant hypoxia.23
examined under a light plane of anesthesia
induced by mask inhalation of isoflurane.21 In Medical Management
QuickNotes animals in which laryngeal function has been Dogs that present with acute cyanosis or in col-
depressed by sedatives and opioids, doxapram lapse require emergency treatment. Supplemen-
In dogs with
(1 mg/kg) can be administered intravenously tal oxygen should be provided to help alleviate
laryngeal paraly-
to stimulate respiration23 (BOX 1). hypoxia. An intravenous catheter should be
sis, paradoxical Although a portable laryngoscope can be placed for administration of fluid and medica-
movement can be used to visualize the rima glottidis, retraction tions. Severely dyspneic or anxious dogs may
mistaken for active of the tongue and pressure on the epiglot- require sedation with acepromazine (0.005 to
arytenoid abduction tis with the laryngoscope blade may affect 0.02 mg/kg IV) and butorphanol (0.2 to 0.4 mg/
during laryngeal laryngeal function. Therefore, many clinicians kg IV) or other sedatives. If laryngeal edema is
examination. prefer to use a transoral video endoscope. suspected, an antiinflammatory dose of a gluco-
Laryngeal paralysis has also been diagnosed corticoid such as dexamethasone (0.1 to 0.5 mg/
with transnasal laryngoscopy and laryngeal kg) or prednisolone sodium succinate (0.5 to
ultrasound.24,25 1 mg/kg) can be administered intravenously.
If possible, blood oxygen saturation should Dogs that are significantly hyperthermic (≥106°F
be monitored with a pulse oximeter during [41°C]) are treated with sedatives, IV fluids, cool
laryngoscopy to ensure that the hemoglobin water baths, and fans. The rectal temperature
saturation remains ≥95%.26 Flow-by oxygen should be monitored continuously until it has
can be administered by attaching flexible tub- stabilized within a normal range and external
ing from an oxygen source to the blade of cooling has been discontinued. Dogs that are
the laryngoscope or to the insufflation port cyanotic, severely dyspneic, or hypoxic (SpO2
of the video endoscope to reduce the risk of <95%) despite supplemental oxygen therapy
hypoxia. During laryngeal examination, laryn- may require intubation and light anesthesia until
geal motion should be correlated with the laryngeal swelling resolves. If an intubation
phase of respiration. It is helpful to have an period of several hours or longer is expected,
assistant call out when each inspiration and a tracheostomy tube should be placed to avoid
VIDEO expiration occurs. In normal dogs, the rima exacerbation of laryngeal swelling from the
glottidis remains open at rest, closes slightly endotracheal tube and prolonged periods of
during expiration, and opens widely during anesthesia.28 It is possible for severe cases to
inspiration. Inability of the arytenoid carti- progress to respiratory muscle fatigue, which
To see videos of lages to abduct during inspiration is diagnostic may require mechanical ventilation.29 There is
normal and paralyzed
for laryngeal paralysis. In questionable cases, no reliable bedside measurement for detection
laryngeal abduction,
please visit
doxapram is administered intravenously.23 Res- of respiratory muscle fatigue; the diagnosis is
CompendiumVet.com. piration is usually stimulated within 8 seconds based on changes in breathing patterns, such as
after administration. inward movement of the abdomen during inspi-
216 Compendium: Continuing Education for Veterinarians® | May 2009 | CompendiumVet.com](https://image.slidesharecdn.com/pv0509-091029165850-phpapp02/85/Pv0509-18-320.jpg)
![Dr. Yu (shown here with his dogs
[from left to right] Timmy, Joey,
and Bitsy) is associate professor
of dermatology at The University
of Guelph Ontario Veterinary
College in Canada.
WEB
EXCLUSIVE
An extended version of
this article is available on
CompendiumVet.com.
CompendiumVet.com | May 2009 | Compendium: Continuing Education for Veterinarians® 221](https://image.slidesharecdn.com/pv0509-091029165850-phpapp02/85/Pv0509-23-320.jpg)
![FREE
CE Pneumothorax
37. Ludwig L. Surgical emergencies of the respiratory system. Vet lung. In: Cunningham JG, ed. Textbook of Veterinary Physiology.
Clin North Am Small Anim Pract 2000;30:531-553. 3rd ed. Philadelphia: Saunders; 2002:468-478.
38. Groblinger K, Lorinson D, Wiskocil L. Spontaneous pneu- 47. Tillson D. Thoracostomy tubes. Part 1. Compend Contin Educ
mothorax caused by bullae pulmonales in four huskies [abstract]. Pract Vet 1997;19:1258-1266.
Vet Surg 2001;30:304. 48. Tillson D. Thoracostomy tubes. Part 2. Compend Contin Educ
39. Au JJ, Weisman DL, Stefanacci JD, et al. Use of computed Pract Vet 1997;19:1331-1337.
tomography for evaluation of lung lesions associated with spon- 49. Salci H, Kennerman E, Celemli N, et al. Use of a heimlich flut-
taneous pneumothorax in dogs: 12 cases (1999-2002). JAVMA ter valve in a dogs with spontaneous pneumothorax. Aust Vet Pract
2006;228(5):733-737. 2005;35:47-51.
40. Bowman D. Helminths. In: Bowman D, ed. Georgi’s Parasitol- 50. Jerram RM, Fossum TW, Berridge BR, et al. The efficacy of me-
ogy for Veterinarians. 8th ed. St. Louis: Saunders; 2003:115-243. chanical abrasion and talc slurry as methods of pleurodesis in nor-
41. Carr DH, Pride NB. Computed tomography in pre-operative as- mal dogs. Vet Surg 1999;28:322-332.
sessment of bullous emphysema. Clin Radiol 1984;35:43-45. 51. Dupre GP, Corlouer JP, Bouvy B. Thoracoscopic pericardecto-
42. Sihoe ADL, Yim APC, Lee TW, et al. Can CT scanning be used my performed without pulmonary exclusion in 9 dogs. Vet Surg
to select patients with unilateral primary spontaneous pnemothorax 2001;30:21-27.
for bilateral surgery? Chest 2001;118:380-383. 52. Garcia F, Prandi D, Pena T, et al. Examination of the thoracic cavity
43. Mittlehner W, Friedrich M, Dissman W. Value of computed to- and lung lobectomy by means of thoracoscopy in dogs. Can Vet J
mography in the detection of bullae and blebs in patients with pri- 1998;39:285-290.
mary spontaneous pneumothorax. Respiration 1992;59:221-227. 53. De Rycke LM, Gielen IM, Van Ryssen B. Thoracoscopic anatomy
44. Yasufuku K, Takashi O, Fujisawa T. The effectiveness of thin- of dogs positioned in lateral recumbency. JAAHA 2001;37:543-548.
section computed tomography in diagnosing bullous lesions in 54. Champion JK, McKernan JB. Bilateral thoracoscopic stapled
patients with spontanous pneumothorax. Nihon Kokyuki Gakkai volume reduction for bullous vs diffuse emphysema. Surg Endosc
Zasshi 1999;37:953-957. 1998;12:338-341.
45. Crisp M. Critical care techniques. In: Birchard SR, Scherding 55. Delaunois L, El Khawad C. Medical thoracoscopy in the manage-
R, eds. Saunders Manual of Small Animal Practice. Philadelphia: ment of pneumothorax. Monaldi Arch Chest Dis 1998;53:148-150.
Saunders; 2000:25. 56. Sampietro R. Videothoracoscopic treatment of bullous lung
46. Robinson N. Overview of respiratory function; ventilation of the disease: indications and techniques. Int Surg 1996;81:333-335.
3 CE
CREDITS CE TEST 2 This article qualifies for 3 contact hours of continuing education credit from the Auburn University College of Veterinary
Medicine. Subscribers may take individual CE tests online and get real-time scores at CompendiumVet.com. Those who wish to apply this
credit to fulfill state relicensure requirements should consult their respective state authorities regarding the applicability of this program.
1. Iatrogenic pneumothorax secondary to intu- 5. Which breed has been shown to have 8. Which of the following is an indication
bation in cats has not been associated with a greater incidence of spontaneous for placement of a thoracostomy tube?
a. overinflation of the cuff. pneumothorax? a. Negative pressure can be obtained
b. turning the patient without disconnect- a. golden retriever by thoracocentesis.
ing the tube. b. Siberian husky b. More than 2 mL/kg of air is aspirated
c. tracheal injury from a stylet. c. Chihuahua over 12 hours.
d. laryngospasm. d. shih tzu c. Only one thoracocentesis procedure
is required to alleviate respiratory
2. Pneumothorax is classified as a(n) 6. Which is not a typical radiographic distress.
_________ disorder of the lung. feature of pneumothorax? d. Tension pneumothorax is present.
a. obstructive a. cardiac elevation from the sternum
b. restrictive on the lateral recumbent projection 9. Which statement about thoracoscopy is
c. vascular b. atelectasis or partial atelectasis true?
d. parenchymal c. loss of the vascular pattern adjacent a. It results in less morbidity and mortal-
to the chest wall ity for lung lobectomy than median
3. Which of the following is the most com- d. air bronchograms sternotomy.
mon cause of pneumothorax? b. It cannot be used as a diagnostic tool.
a. tracheal tears secondary to intubation 7. Which statement is true regarding c. It does not allow sufficient visualization
b. thoracic trauma the use of CT in diagnosing of thoracic structures.
c. bullous emphysema pneumothorax? d. It has not been attempted in animals
d. pulmonary neoplasia a. It is not helpful. with pneumothorax.
b. It is more accurate than radiography
4. The most common cause of spontaneous in the diagnosis of underlying lesions 10. Which type of pneumothorax routinely
pneumothorax is causing spontaneous pneumothorax. requires surgery for correction?
a. bullous emphysema. c. It should be used to diagnose traumatic a. closed traumatic
b. parasitic cysts. pneumothorax. b. closed spontaneous
c. pulmonary neoplasia. d. It is used in human medicine to c. open traumatic
d. grass awn migration. diagnose traumatic pneumothorax. d. iatrogenic
242 Compendium: Continuing Education for Veterinarians® | May 2009 | CompendiumVet.com](https://image.slidesharecdn.com/pv0509-091029165850-phpapp02/85/Pv0509-44-320.jpg)
![Letters
Clinical Snapshot
Pruritus in a Great Dane Particularly intriguing or difficult cases
Case Presentation #1
❯❯ Karen A. Moriello, DVM, DACVD, University of Wisconsin-Madison
TO LEARN MORE
I would like to apologize to readers for an unin- This Great Dane (A) was one of 12
dogs in a kennel, all of which had had
intense pruritus for 1 year. The owners
border collies and seven cats in addi-
tion to these dogs. What are the treat-
ment options for this kennel of dogs?
Clinical Snapshot presents illustrated
case histories and challenges you to
answer the questions posed. This case
reported that the other dogs looked 3. A similarly named condition occurs is part of the series of Self-Assessment
Colour Review books on multiple topics
tentional error in the March 2009 Clinical Snap-
similar and that all the dogs were los- in cats. What is the cause, and what
ing weight and were irritable with the treatment can be used for this from Manson Publishing Ltd., London,
available from Blackwell Publishing
owners and each other. Close examina- condition?
Professional.
tion of the skin revealed a generalized SEE PAGE 114 FOR ANSWERS AND EXPLANATIONS.
papular eruption without evidence of For more information or to obtain any of the
A
pustules or epidermal collarettes. Any books in the series, call 800-862-6657
shot, “Pruritus in a Great Dane,” in which I stated manipulation of the skin triggered an
intense episode of self-mutilation. All
the dogs were currently vaccinated and
received monthly heartworm medica-
B
or visit BlackwellProfessional.com
tion and monthly spot-on flea control.
The owners reported no lesions or dis-
that “the manufacturer reported [selamectin] to comfort after handling the dogs. Flea
combings were negative. Skin scrap-
ings revealed the organism shown (B).
1. What is the diagnosis?
2. The owners of the kennel have three
be effective in 70% of cases” when discussing INTERCEPTOR Flavor Tabs are palatable and most often will be consumed by the dog or cat when offered by the owner.
As an alternative, the dual-purpose tablet may be offered in food or administered as other tablet medications. Watch the dog
or cat closely following dosing to be sure the entire dose has been consumed. If it is not entirely consumed, redose once with
the full recommended dose as soon as possible.
treatment for canine scabies. This statement was
INTERCEPTOR Flavor Tabs must be administered monthly, preferably on the same date each month. The first dose should be
administered within one month of the dog or cat’s first exposure to mosquitoes and monthly thereafter until the end of the
mosquito season. If a dose is missed and a 30-day interval between dosing is exceeded, administer INTERCEPTOR Flavor
NADA 140-915, Approved by FDA Tabs immediately and resume the monthly dosing schedule.
INTERCEPTOR® (milbemycin oxime) Flavor Tabs® for Dogs and Cats
If INTERCEPTOR Flavor Tabs replace diethylcarbamazine (DEC) for heartworm prevention in dogs, the first dose must be
Brief Summary—For full product information see product insert.
given within 30 days after the last dose of DEC.
er
Caution: Federal (USA) law restricts this drug to use by or on the order of a licensed veterinarian.
Warnings: Not for human use. Keep this and all drugs out of the reach of children.
an f children.
Indications and Usage: INTERCEPTOR Flavor Tabs for dogs are indicated for use in the prevention of heartworm disease
Precautions:
caused by Dirofilaria immitis, the control of adult Ancylostoma caninum (hookworm), and the removal and control of adult
Dogs: Do not use in puppies less than four weeks of age and less than two pounds of body weight. Prior to initiation of the
pies r weeks f age
an incorrect extrapolation of information on
Toxocara canis and Toxascaris leonina (roundworms) and Trichuris vulpis (whipworm) infections in dogs and in puppies
INTERCEPTOR Flavor Tabs treatment program, dogs should be tested for existing heartworm infections. Infected dogs
abs
four weeks of age or greater and two pounds body weight or greater. INTERCEPTOR Flavor Tabs are indicated for use
should be treated to remove adult heartworms and microfilariae prior to initiating treatment with INTERCEPTOR Flavor Tabs.
move
in the prevention of heartworm disease caused by Dirofilaria immitis, and the removal of adult Ancylostoma tubaeforme
Mild, transient hypersensitivity reactions manifested as labored respiration, vomiting, salivation, and lethargy may occur
nsitivity
(hookworm) and Toxocara cati (roundworm) in cats and kittens six weeks of age or greater and 1.5 lbs. body weight or
after treatment of dogs carrying a high number of circulating microfilariae.
greater.
Dosage and Administration:
Clinical Snapshot
Cats: Do not use in kittens less than six weeks of age or less than 1.5 lbs. body weight. Safety in heartworm positive cats has
ns
not been established. Safety in breeding, pregnant, and lactating queens and breeding toms has not been established.
afety
Dogs: INTERCEPTOR Flavor Tabs for Dogs are given orally, once a month, at the recommended minimum dosage rate of
0.23 mg milbemycin oxime per pound of body weight (0.5 mg/kg). Adverse Reactions: The following adverse reactions have been reported following the use of INTERCEPTOR in dogs:
depression/lethargy, vomiting, ataxia, anorexia, diarrhea, convulsions, weakness, and hypersalivation.
miting,
Recommended Dosage Schedule for Dogs
Body Weight INTERCEPTOR Flavor Tabs Answers and Explanations Case Presentation #1 A B
studies conducted by the manufacturer. I would
Efficacy:
2–10 lbs. One tablet (2.3 mg) Dogs: INTERCEPTOR Flavor Tabs eliminate the tissue stage of heartworm larvae and the adult stage of hookworm
11–25 lbs. One tablet (5.75 mg) ( Ancylostoma caninum),, roundworms ( Toxocara canis, Toxascaris leonina ), and whipworm ( Trichuris vulpis ) infestations
a s
26–50 lbs. One tablet (11.5 mg) when administered orally according to the recommended dosage PAGE 104 FOR CASE PRESENTATION.
y according SEE schedule.
51–100 lbs. One tablet (23.0 mg)
ity (e.g., tremors, salivation)
Cats: INTERCEPTOR Flavor Tabs for Cats eliminate the tissue stage of heartworm larvae and hookworm (Ancylostoma
avor
Dogs over 100 lbs. are provided the appropriate combination of tablets. Scabies infestation. The organism 1.
tubaeforme ) and roundworm ( Toxocara catii ) infections when administered orally according to the recommended
dworm within 24 hours, I administer
dosage schedule.
Cats: INTERCEPTOR Flavor Tabs for Cats are given orally, once a month, at the recommended minimum dosage rate of is a Sarcoptes egg. One mite or egg
For technical assistance or to report suspected adverse events, call 1-800-332-2761.
a full treatment dose of 200
0.9 mg milbemycin oxime per pound of body weight (2.0 mg/kg).
Recommended Dosage Schedule for Cats
is diagnostic for scabies. Definitive
vartis
Manufactured for: Novartis Animal Health US, Inc. μg/kg PO the next day.
like to correct this statement and comment on
Body Weight INTERCEPTOR Flavor Tabs eensboro,
Greensboro, NC 27408, USA
evidence of a scabies infestation Herding breeds of dogs,
1.5–6 lbs. One tablet (5.75 mg) ©2008 Novartis Animal Health US, Inc.
6.1–12 lbs. One tablet (11.5 mg) (eggs or mites) is not always found, especially collies, are known to 3. Canine scabies is not considered con-
12.1–25 lbs. One tablet (23.0 mg) INTERCEPTOR and Flavor Tabs are registered trademarks of Novartis AG.
r f Novartis
Cats over 25 lbs. are provided the appropriate combination of tablets. NAH/INT-FT/BS/5
even in “classic cases.” Most dogs
06/08
be sensitive to ivermectin. Thus, tagious to cats. However, Sarcoptes
with scabies are diagnosed based this drug is best avoided in collies. mites have been reported in a small
on response to treatment; therefore, Dogs sensitive to ivermectin can number of cats with severe debilita-
104 Compendium: Continuing Education for Veterinarians® | March 2009 | CompendiumVet.com mVet.com if scabies is suspected, it should be often tolerate milbemycin oxime tion and in pruritic cats in England.
my current use of selamectin. treated accordingly.
2. Scabies mites can live for a short
period of time off the host. The
kennel facilities should be thor-
at 3 mg/kg PO weekly for 3 to 6
weeks. Lime sulfur dips are also
an effective therapy. Doramectin at
0.2 mg/kg SC or IM has also been
There may be some geographic varia-
tion with respect to contagion to
cats. These cats do not need to be
treated. True “feline scabies” is caused
oughly cleaned with high-pressure reported to be effective. Finally, by Notoedres cati, a contagious mange
water, scrubbed with detergent, and two applications of selamectin or mite. In contrast to canine scabies mites,
Selamectin has been found to be the stratum corneum and coat, which sprayed with an environmental par-
asiticidal agent. All dogs in contact
with these Great Danes should be
fipronil at 30-day intervals may be
effective. Selamectin is licensed
for the treatment of scabies, and
N. cati is easily found in large numbers
on skin scrapings. Lesions occur on
the head, feet, and perineum. This
treated for scabies. Lime sulfur dips the manufacturer reported it to be infestation can cause large amounts
highly effective against Sarcoptes mite is one reason that medicated bathing is
once weekly for 6 weeks or amitraz effective in 70% of cases. Fipronil of crust; cats should be sedated, the
dips every 2 weeks for 6 weeks are is not licensed for scabies treat- haircoat clipped, and the cats bathed
effective topical therapies. Lime sul- ment but has been found to be to remove the contaminated crusts
fur can be combined with ivermec- effective. It is important to remem- before treatment. Because cats are
tin therapy. Ivermectin (200 μg/kg ber that no treatment is 100% effi- extremely sensitive to parasiticidal
infestations in dogs. Large field stud- often very beneficial for these patients. PO or SC) every 2 weeks for 6 weeks
is also an effective treatment. I use
a test dose of 100 μg/kg PO in all
cacious in all patients. If scabies is
suspected and the patient does not
respond, retreatment with a differ-
agents, lime sulfur and ivermectin are
the most commonly used treatments.
Affected cats, and all animals in con-
dogs. If there are no adverse effects ent therapy should be performed tact with them, should be treated for
ies with naturally occurring Sarcoptes Because selamectin has a wide spec- consistent with ivermectin sensitiv- before scabies is ruled out.
Letters
at least 6 weeks.
Call for Papers
infestations in dogs have reported post- trum of activity, I routinely recommend
CONTINUED FROM PAGE 113 Editor’s note: Thank you to
Toxicology. Philadelphia: Williams and the attentive readers who
Wilkins; 1996:317-328. pointed out the difference
Are you involved in research? 2. Gaynor AR, Dhupa N. Acute ethyl-
between these articles and to
ene glycol intoxication. Part II. Compend
Contin Educ Pract Vet 1999;21(12):1124- the authors for their clarifica-
treatment efficacy of 93% to 95% after year-round use of selamectin in hunt- Veterinary Therapeutics: Research in Applied
Veterinary Medicine® is a quarterly journal dedicated
to rapid publication.
1133.
3. Dorman DC, Dye JA. Chemical tox-
icities. In: Ettinger SJ, Feldman EC, eds.
Textbook of Veterinary Internal Medicine.
tion. As in many aspects of
veterinary medicine, differ-
ent recommendations exist
We invite the submission of clinical and laboratory 6th ed. St. Louis: Elsevier Saunders;
based on clinical experience
research manuscripts in small animal, large animal, 2005:257-258.
one dose and 100% after two doses. It is ing dogs and in dogs that frequent dog and comparative medicine, including pathophysiology,
diagnosis, treatment, and prognosis. Prospective,
retrospective, and corroborative studies are all
4. Richardson JA, Welch SL, Gwaltney-
Brant SM, et al. Metaldehyde toxicoses
in dogs. Compend Contin Educ Pract Vet
2003;25(5):376-380.
and patient presentation ver-
sus laboratory chemistry, and
different references reflect
welcome. Submitted articles are scheduled to be 5. Mull RL. Metaldehyde poisoning. In: these variations. Awareness
published 90 to 120 days after acceptance. Kirk RW, ed. Current Veterinary Therapy:
important to remember that part of the parks, “play groups” or “day care,” or Contact Cheryl Hobbs, 800-426-9119, ext 52408,
or email chobbs@vetlearn.com.
Small Animal Practice VIII. London: WB
Saunders; 1983:106-107.
6. Tilley LP, Smith FWK Jr. The 5-Min-
ute Veterinary Consult: Canine and Feline.
of both laboratory and clini-
cal data is useful when deter-
mining the most appropriate
treatment for an individual
It’s not just therapeutics! 2nd ed. Philadelphia: Lippincott Williams
& Wilkins;2000:958-959. patient.
pathogenesis of the pruritus of scabies is agility and training classes. 114 Compendium: Continuing Education for Veterinarians® | March 2009 | CompendiumVet.com
hypersensitivity to mites, dead or alive. Karen A. Moriello, DVM, DACVD
Dogs can be mite free but still pruritic Clinical Professor of Dermatology
until mite proteins have been shed from University of Wisconsin-Madison
Call for Papers
Are you involved in research?
Veterinary Therapeutics: Research in Applied Veterinary
Medicine® is a quarterly journal dedicated to rapid publication.
We invite the submission of clinical and laboratory research
manuscripts in small animal, large animal, and comparative
medicine, including pathophysiology, diagnosis, treatment,
and prognosis. Prospective, retrospective, and corrobora-
tive studies are all welcome. Submitted articles are sched-
uled to be published 90 to 120 days after acceptance.
Contact Cheryl Hobbs, 800-426-9119,
ext 52408, or e-mail chobbs@vetlearn.com.
It’s not just therapeutics!
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- 4. May 2009 Vol 31(5) CompendiumVet.com | Peer Reviewed | Listed in MEDLINE EDITORIAL BOARD Anesthesia Internal Medicine Nora S. Matthews, DVM, DACVA Dana G. Allen, DVM, MSc, DACVIM AMERICAN Texas A&M University Ontario Veterinary College BOARD OF Cardiology Internal Medicine and Emergency/ VETERINARY Bruce Keene, DVM, MSc, DACVIM Critical Care PRACTITIONERS North Carolina State University Alison R. Gaynor, DVM, DACVIM (Internal Medicine), DACVECC (ABVP) REVIEW Clinical Chemistry, Hematology, North Grafton, Massachusetts BOARD and Urinalysis Betsy Welles, DVM, PhD, DACVP Nephrology Kurt Blaicher, DVM, DABVP Auburn University Catherine E. Langston, DVM, ACVIM (Canine/Feline) Dentistry Animal Medical Center Plainfield Animal Hospital Gary B. Beard, DVM, DAVDC New York, New York Plainfield, New Jersey Auburn University Neurology Canine and Feline Medicine EDITOR IN CHIEF R. Michael Peak, DVM, DAVDC Curtis W. Dewey, DVM, MS, DACVIM The Pet Dentist—Tampa Bay Veterinary (Neurology), DACVS Eric Chafetz, DVM, DABVP Douglass K. Macintire, Cornell University Hospital for Animals Dentistry (Canine/Feline) DVM, MS, DACVIM, DACVECC Largo, Florida Vienna Animal Hospital Oncology Department of Clinical Sciences Emergency/Critical Care and Ann E. Hohenhaus, DVM, DACVIM Vienna, Virginia College of Veterinary Medicine Respiratory Medicine (Oncology and Internal Medicine) Canine and Feline Medicine Auburn University, AL 36849 Lesley King, MVB, MRCVS, DACVECC, Animal Medical Center DACVIM New York, New York Henry E. Childers, DVM, University of Pennsylvania DABVP (Canine/Feline) Gregory K. Ogilvie, DVM, DACVIM Endocrinology and Metabolic Disorders (Internal Medicine, Oncology), Cranston Animal Hospital Marie E. Kerl, DVM, ACVIM, ACVECC DECVIM-CA (Oncology) Cranston, Rhode Island University of Missouri-Columbia CVS Angel Care Cancer Center Canine and Feline Medicine EXECUTIVE Epidemiology and Special Care Foundation for Companion Animals ADVISORY Philip H. Kass, DVM, MPVM, MS, PhD, Carlsbad, California David E. Harling, DVM, BOARD DACVPM DABVP (Canine/Feline), University of California, Davis Ophthalmology DACVO MEMBERS David A. Wilkie, DVM, MS, DACVO Reidsville Veterinary Hospital Exotics Avian The Ohio State University Reidsville, North Carolina Behavior Canine and Feline Medicine, Thomas N. Tully, Jr, DVM, MS, DABVP Parasitology Sharon L. Crowell-Davis, (Avian), ECAMS Ophthalmology Byron L. Blagburn, MS, PhD DVM, PhD, DACVB Louisiana State University Auburn University The University of Georgia Jeffrey Katuna, DVM, DABVP Reptiles David S. Lindsay, PhD Douglas R. Mader, MS, DVM, DABVP (DC) Wellesley-Natick Veterinary Virginia Polytechnic Institute Hospital Dermatology Marathon Veterinary Hospital and State University Craig E. Griffin, DVM, Marathon, Florida Natick, Massachusetts DACVD Pharmacology Canine and Feline Medicine Small Mammals Animal Dermatology Clinic Katrina L. Mealey, DVM, PhD, DACVIM, Karen Rosenthal, DVM, MS, DABVP DACVCP Robert J. Neunzig, DVM, San Diego, California (Avian) Washington State University University of Pennsylvania DABVP (Canine/Feline) Rehabilitation and Physical Therapy The Pet Hospital Wayne S. Rosenkrantz, Feline Medicine Bessemer City, North Carolina Darryl Millis, MS, DVM, DACVS DVM, DACVD Michael R. Lappin, DVM, PhD, University of Tennessee Canine and Feline Medicine Animal Dermatology Clinic DACVIM (Internal Medicine) Colorado State University Tustin, California Surgery Compendium is a Margie Scherk, DVM, DABVP Philipp Mayhew, BVM&S, MRCVS, (Feline Medicine) DACVS refereed journal. Articles Nutrition Cats Only Veterinary Clinic Columbia River Veterinary Specialists published herein have Kathryn E. Michel, DVM, Vancouver, British Columbia Vancouver, Washington MS, DACVN been reviewed by at least University of Pennsylvania Gastroenterology C. Thomas Nelson, DVM two academic experts on Debra L. Zoran, DVM, MS, PhD, Animal Medical Center the respective topic and DACVIM (Internal Medicine) Anniston, Alabama Surgery Texas A&M University by an ABVP practitioner. Elizabeth M. Hardie, Toxicology Infectious Disease Tina Wismer, DVM, DABVT, DABT Any statements, claims, or product DVM, PhD, DACVS Derek P. Burney, PhD, DVM ASPCA National Animal Poison Control endorsements made in Compendium North Carolina State Gulf Coast Veterinary Specialists Center are solely the opinions of our authors and advertisers and do not necessarily University Houston, Texas Urbana, Illinois reflect the views of the Publisher or Editorial Board. 202 CompendiumVet.com m
- 5. The secret toa longer life in dogs with heart failure. The QUEST study provides new evidence that Vetmedin® (pimobendan) extends life for dogs with congestive heart failure (CHF). In a study of unprecedented magnitude, dogs with CHF due to mitral valve disease who were treated with VETMEDIN* lived virtually twice as long as those on an ACE inhibitor.1 This hard evidence from the QUEST study supports using VETMEDIN as first-line therapy in all dogs with symptomatic CHF. News like this should make your clients jump for joy as well. *The study used VETMEDIN Capsules. In the US, only chewable tablets are licensed. Both capsules and chewable tablets contain the same pharmaceutical ingredient, pimobendan, and are considered equivalent for clinical use. Bioequivalence, however, has not been established. Visit www.questtrial.com for additional study details, and visit www.vetmedin-us.com for more information about VETMEDIN. Important safety information: VETMEDIN should not be given in case of hypertrophic cardiomyopathy, aortic stenosis, or any other clinical condition where an augmentation of cardiac output is inappropriate for functional or anatomical reasons. The safety of VETMEDIN has not been established in dogs with asymptomatic heart disease or in heart failure caused by other etiologies other than atrioventricular valvular insufficiency or dilated cardiomyopathy. Use only in dogs with clinical evidence of heart failure. The most common side effects reported in field studies were poor appetite, lethargy, diarrhea, dyspnea, azotemia, weakness, and ataxia. If side effects should occur, pet owners should contact their veterinarian. Please refer to the package insert for complete product information or visit www.vetmedin-us.com. Reference: 1. Häggström J et al. Effect of pimobendan or benazepril hydrochloride on survival times in dogs with congestive heart failure caused by naturally occurring myxomatous mitral valve disease: The QUEST study. J Vet Intern Med. 2008;22:1124–1135. VETMEDIN is a registered trademark of Boehringer Ingelheim Vetmedica GmbH, licensed to Boehringer Ingelheim Vetmedica, Inc. © 2009 Boehringer Ingelheim Vetmedica, Inc. VET0209003 See Page 204 for Product Information Summary
- 6. higher in theactive control group (4%) compared to mg/kg orally. The effect was still present 8 hours the average voluntary consumption was 84.2%. the Vetmedin group (1%). after dosing. There was a delay between peak blood levels of pimobendan and active metabolite and the Animal Safety: In a laboratory study, Vetmedin Adverse reactions/new clinical findings were seen in maximum physiologic response (peak LV dP/dtmax). chewable tablets were administered to 6 healthy NADA 141-273, Approved by FDA both treatment groups and were potentially related Blood levels of pimobendan and active metabolite Beagles per treatment group at 0 (control), 1, 3, and to CHF, the therapy of CHF, or both. The following began to drop before maximum contractility was seen. 5 times the recommended dosage for 6 months. See Vetmedin ® adverse reactions/new clinical findings are listed according to body system and are not in order of Repeated oral administration of pimobendan did not result in evidence of tachyphylaxis (decreased positive Table 3 for cardiac pathology results. The cardiac pathology/histopathology noted in the 3X and 5X dose (pimobendan) Chewable Tablets prevalence: CHF death, sudden death, chordae groups is typical of positive inotropic and vasodilator inotropic effect) or drug accumulation (increased Cardiac drug for oral use in dogs only tendineae rupture, left atrial tear, arrhythmias overall, positive inotropic effect). Laboratory studies indicate drug toxicity in normal dog hearts, and is associated tachycardia, syncope, weak pulses, irregular pulses, that the positive inotropic effect of pimobendan may with exaggerated hemodynamic responses to these Caution: Federal law restricts this drug to use by increased pulmonary edema, dyspnea, increased drugs. None of the dogs developed signs of heart or on the order of a licensed veterinarian. be attenuated by the concurrent use of a ß-adrenergic respiratory rate, coughing, gagging, pleural effusion, blocker or a calcium channel blocker. failure and there was no mortality. Description: Vetmedin (pimobendan) is supplied as ascites, hepatic congestion, decreased appetite, vomiting, diarrhea, melena, weight loss, lethargy, Effectiveness: In a double-masked, multi-site, 56-day Table 3: Incidence of Cardiac Pathology/ oblong half-scored chewable tablets containing 1.25, Histopathology in the Six-month Safety Study 2.5 or 5 mg pimobendan per tablet. Pimobendan, depression, weakness, collapse, shaking, trembling, field study, 355 dogs with modified NYHA Class II, a benzimidazole-pyridazinone derivative, is a non- ataxia, seizures, restlessness, agitation, pruritus, III, or IV CHF due to AVVI or DCM were randomly increased water consumption, increased urination, assigned to either the active control (enalapril maleate) Severe left ventricular One 3X and sympathomimetic, non-glycoside inotropic drug hypertrophy with two 5X dogsa with vasodilatative properties. Pimobendan exerts urinary accidents, azotemia, dehydration, abnormal or the Vetmedin (pimobendan) treatment group. Of multifocal subendocardial a stimulatory myocardial effect by a dual mechanism serum electrolyte, protein, and glucose values, mild the 355 dogs, 52% were male and 48% were female; ischemic lesions of action consisting of an increase in calcium increases in serum hepatic enzyme levels, and mildly 72% were diagnosed with AVVI and 28% were sensitivity of cardiac myofilaments and inhibition of decreased platelet counts. diagnosed with DCM; 34% had Class II, 47% had Moderate to marked Three 5X dogs phosphodiesterase (Type III). Pimobendan exhibits Class III, and 19% had Class IV CHF. Dogs ranged myxomatous thickening See Table 1 for mortality due to CHF (including in age and weight from 1 to 17 years and 3.3 to of the mitral valves vasodilating activity by inhibiting phosphodiesterase euthanasia, natural death, and sudden death) and for III activity. The chemical name of pimobendan 191 lb, respectively. The most common breeds were the development of new arrhythmias (not present in a mixed breed, Doberman Pinscher, Cocker Spaniel, Myxomatous thickening One 3X and is 4,5-dihydro-6-[2-(4-methoxyphenyl)-1H- dog prior to beginning study treatments) by treatment of the chordae tendineae two 5X dogs benzimidazole-5-yl]-5-methyl-3(2H)-pyridazinone. Miniature/Toy Poodle, Maltese, Chihuahua, Miniature group and type of heart disease (AVVI or DCM) in the Schnauzer, Dachshund, and Cavalier King Charles The structural formula of pimobendan is: 56-day field study. Spaniel. The 180 dogs (130 AVVI, 50 DCM) in the Endocardial thickening One 1X, two 3X, of the left ventricular and two 5X dogs Table 1: CHF Death and New Arrhythmias in the active control group received enalapril maleate outflow tract 56-Day Field Study (0.5 mg/kg once or twice daily), and all but 2 received furosemide. Per protocol, all dogs with DCM in the Left atrial endocardial One 3X and Vetmedin® Active Control active control group received digoxin. The 175 dogs thickening (jet lesions) one 5X dog Group Group (126 AVVI, 49 DCM) in the Vetmedin group received in 2 of the dogs that pimobendan (0.5 mg/kg/day divided into 2 portions developed murmurs of that were not necessarily equal, and the portions were mitral valve insufficiency 14.3% 14.4% Indications: Vetmedin (pimobendan) is indicated for n=175 n=180 administered approximately 12 hours apart), and all the management of the signs of mild, moderate, or but 4 received furosemide. Digoxin was optional for Granulomatous One 3X dog severe (modified NYHA Class IIa, IIIb, or IV c) congestive 9 of 126 dogs 16 of 130 treating supraventricular tachyarrhythmia in either inflammatory lesion in the heart failure in dogs due to atrioventricular valvular Dogs that died right atrial myocardium with AVVI dogs with treatment group, as was the addition of a ß-adrenergic insufficiency (AVVI) or dilated cardiomyopathy (DCM). due to CHF AVVI blocker if digoxin was ineffective in controlling heart a Vetmedin is indicated for use with concurrent therapy Most of the gross and histopathologic findings rate. After initial treatment at the clinic on Day 1, dog occurred in these three dogs for congestive heart failure (e.g., furosemide, etc.) as 16 of 49 dogs 10 of 50 dogs owners were to administer the assigned product and appropriate on a case-by-case basis. with DCM with DCM concurrent medications for up to 56±4 days. Murmurs of mitral valve insufficiency were detected in a A dog with modified New York Heart Association one 3X (Day 65) and two 5X dogs (Days 135 and 163). 39.4% 45.0% The determination of effectiveness (treatment success) These murmurs (grades II-III of VI) were not associated (NYHA) Class II heart failure has fatigue, shortness n=175 n=180 for each case was based on improvement in at of breath, coughing, etc. apparent when ordinary with clinical signs. least 2 of the 3 following primary variables: modified exercise is exceeded. Dogs that 45 of 126 59 of 130 NYHA classification, pulmonary edema score by a Indirect blood pressure was unaffected by Vetmedin b developed new dogs with dogs with masked veterinary radiologist, and the investigator’s at the label dose (1X). Mean diastolic blood pressure A dog with modified NYHA Class III heart failure is arrhythmiasa AVVI AVVI comfortable at rest, but exercise capacity is minimal. overall clinical effectiveness score (based on physical was decreased in the 3X group (74 mmHg) compared examination, radiography, electrocardiography, and to the control group (82 mmHg). Mean systolic blood c A dog with modified NYHA Class IV heart failure has 24 of 49 dogs 22 of 50 dogs with DCM with DCM clinical pathology). Attitude, pleural effusion, coughing, pressure was decreased in the 5X group (117 mmHg) no capacity for exercise and disabling clinical signs activity level, furosemide dosage change, cardiac compared to the control group (124 mmHg). None of are present even at rest. a size, body weight, survival, and owner observations the dogs had clinical signs of hypotension. New arrhythmias included supraventricular Dosage and Administration: Vetmedin should be were secondary evaluations contributing information On 24-hour Holter monitoring, mean heart rate premature beats and tachycardia, atrial fibrillation, administered orally at a total daily dose of 0.23 mg/lb supportive to product effectiveness and safety. Based was increased in the 5X group (101 beats/min) atrioventricular block, sinus bradycardia, ventricular (0.5 mg/kg) body weight, using a suitable combination on protocol compliance and individual case integrity, compared to the control group (94 beats/min). Not premature beats and tachycardia, and bundle of whole or half tablets. The total daily dose should 265 cases (134 Vetmedin, 131 active control) were counting escape beats, the 3X and 5X groups had branch block be divided into 2 portions that are not necessarily evaluated for treatment success on Day 29. See Table slightly higher numbers of isolated ventricular ectopic equal, and the portions should be administered Following the 56-day masked field study, 137 dogs 2 for effectiveness results. complexes (VEs). The maximum number of non- approximately 12 hours apart (i.e., morning and in the Vetmedin group were allowed to continue on Table 2: Effectiveness Results for the escape VEs recorded either at baseline or in a control evening). The tablets are scored and the calculated Vetmedin in an open-label extended-use study without 56-Day Field Study group dog was 4 VEs/24 hours. At either Week 4 or dosage should be provided to the nearest half tablet restrictions on concurrent therapy. The adverse Week 20, three 3X group dogs had maximums of 33, increment. reactions/new clinical findings in the extended-use Active Control 13, and 10 VEs/24 hours, and two 5X group dogs had Vetmedin® Contraindications: Vetmedin should not be given in study were consistent with those reported in the Group Group maximums of 22 and 9 VEs/24 hours. One 1X group cases of hypertrophic cardiomyopathy, aortic stenosis, 56-day study, with the following exception: One dog with no VEs at baseline had 6 VEs/24 hours or any other clinical condition where an augmentation dog in the extended-use study developed acute 80.7% 76.3% at Week 4 and again at Week 20. Second-degree of cardiac output is inappropriate for functional or cholestatic liver failure after 140 days on Vetmedin n=134 n=131 atrioventricular heart block was recorded in one 3X anatomical reasons. and furosemide. group dog at Weeks 4 and 20, and in one dog from Treatment 88 of 101 77 of 100 each of the 1X and 5X groups at Week 20. None of Warnings: Only for use in dogs with clinical evidence In foreign post-approval drug experience reporting, the Success on dogs with dogs with the dogs had clinical signs associated with these of heart failure. At 3 and 5 times the recommended following additional suspected adverse reactions were Day 29 AVVI AVVI electrocardiogram changes. dosage, administered over a 6-month period of time, reported in dogs treated with a capsule formulation pimobendan caused an exaggerated hemodynamic of pimobendan: hemorrhage, petechia, anemia, 20 of 33 dogs 23 of 31 dogs Treatment was associated with small differences response in the normal dog heart, which was hyperactivity, excited behavior, erythema, rash, with DCM with DCM in mean platelet counts (decreased in the 3X and associated with cardiac pathology (See Animal drooling, constipation, and diabetes mellitus. 1X groups), potassium (increased in the 5X group), 71.1% 67.2% glucose (decreased in the 1X and 3X groups), and Safety). To report suspected adverse reactions, to obtain a n=113 n=110 maximum blood glucose in glucose curves (increased Human Warnings: Not for use in humans. Keep this Material Safety Data Sheet, or for technical assistance in the 5X group). All individual values for these call 1-866-638-2226. Treatment and all medications out of reach of children. Consult a 66 of 85 dogs 56 of 85 dogs variables were within the normal range. Three 1X and Success on with AVVI with AVVI physician in case of accidental ingestion by humans. Clinical Pharmacology: Pimobendan is oxidatively Day 56 one 5X group dogs had mild elevations of alkaline demethylated to a pharmacologically active metabolite 13 of 28 dogs 17 of 25 dogs phosphatase (less than two times normal). Loose Precautions: The safety of Vetmedin has not been stools and vomiting were infrequent and self-limiting. established in dogs with asymptomatic heart disease which is then conjugated with sulfate or glucuronic with DCM with DCM or in heart failure caused by etiologies other than acid and excreted mainly via feces. The mean extent Storage Information: Store at controlled room AVVI or DCM. The safe use of Vetmedin has not been of protein binding of pimobendan and the active No increase in temperature 59-86°F (15-30°C). evaluated in dogs younger than 6 months of age, metabolite in dog plasma is >90%. Following a single furosemide 78.3% 68.6% oral administration of 0.25 mg/kg Vetmedin tablets dose between How Supplied: dogs with congenital heart defects, dogs with diabetes n=130 n=126 the maximal mean (± 1 SD) plasma concentrations Day 1 and Vetmedin® (pimobendan) Chewable Tablets: mellitus or other serious metabolic diseases, dogs Day 29 used for breeding, or pregnant or lactating bitches. (Cmax) of pimobendan and the active metabolite were Available at 1.25, 2.5 or 5 mg oblong half-scored 3.09 (0.76) ng/mL and 3.66 (1.21) ng/mL, respectively. At the end of the 56-day study, dogs in the Vetmedin chewable tablets – 50 tablets per bottle. Adverse Reactions: Clinical findings/adverse Individual dog Cmax values for pimobendan and the group were enrolled in an unmasked field study reactions were recorded in a 56-day field study of active metabolite were observed 1 to 4 hours post- Manufactured by: to monitor safety under extended use, without MEDA Manufacturing GmbH dogs with congestive heart failure (CHF) due to AVVI dose (mean: 2 and 3 hours, respectively). The total restrictions on concurrent medications. (256 dogs) or DCM (99 dogs). Dogs were treated body clearance of pimobendan was approximately Cologne, Germany with either Vetmedin (175 dogs) or the active control 90 mL/min/kg, and the terminal elimination half-lives Vetmedin was used safely in dogs concurrently Manufactured for: enalapril maleate (180 dogs). Dogs in both treatment of pimobendan and the active metabolite were receiving furosemide, digoxin, enalapril, atenolol, Boehringer Ingelheim Vetmedica, Inc. groups received additional background cardiac approximately 0.5 hours and 2 hours, respectively. spironolactone, nitroglycerin, hydralazine, diltiazem, St. Joseph, MO 64506 U.S.A. therapy (See Effectiveness for details and the Plasma levels of pimobendan and active metabolite antiparasitic products (including heartworm 1-866-638-2226 difference in digoxin administration between treatment were below quantifiable levels by 4 and 8 hours after prevention), antibiotics (metronidazole, cephalexin, groups). oral administration, respectively. The steady-state amoxicillin-clavulanate, fluoroquinolones), topical VETMEDIN is a registered trademark of volume of distribution of pimobendan is 2.6 L/kg ophthalmic and otic products, famotidine, theophylline, Boehringer Ingelheim Vetmedica GmbH, The Vetmedin group had the following prevalence indicating that the drug is readily distributed into levothyroxine sodium, diphenhydramine, hydrocodone, licensed to Boehringer Ingelheim Vetmedica, Inc. (percent of dogs with at least one occurrence) of tissues. Food decreased the bioavailability of an metoclopramide, and butorphanol, and in dogs on common adverse reactions/new clinical findings (not © 2009 Boehringer Ingelheim Vetmedica, Inc. aqueous solution of pimobendan, but the effect of sodium-restricted diets. present in a dog prior to beginning study treatments): food on the absorption of pimobendan from Vetmedin Code 448011, 448111, 448211 poor appetite (38%), lethargy (33%), diarrhea (30%), Palatability: In a laboratory study, the palatability of Revised 06/2007 tablets is unknown. dyspnea (29%), azotemia (14%), weakness and ataxia Vetmedin was evaluated in 20 adult female Beagle (13%), pleural effusion (10%), syncope (9%), cough In normal dogs instrumented with left ventricular (LV) dogs offered doses twice daily for 14 days. Ninety (7%), sudden death (6%), ascites (6%), and heart pressure transducers, pimobendan increased LV percent (18 of 20 dogs) voluntarily consumed more murmur (3%). Prevalence was similar in the active dP/dtmax (a measure of contractility of the heart) than 70% of the 28 tablets offered. Including two dogs control group. The prevalence of renal failure was in a dose dependent manner between 0.1 and 0.5 that consumed only 4 and 7% of the tablets offered,
- 7. E Each CE article is accredited for 3 contact hours by CE A Auburn University College of Veterinary Medicine. May 2009 Vol 31(5) Features 212 Laryngeal Paralysis in Dogs FREE CompendiumVet.com | Peer Reviewed | Listed in MEDLINE ❯❯ Ralph P. Millard and Karen M. Tobias Laryngeal paralysis can CE 220 Applied Dermatology NEW cause progressive upper SERIES airway obstruction and Overview of Flea Allergy Dermatitis ultimately death, usu- ❯❯ Andrea Lam and Anthony Yu ally in older, large-breed A new quarterly column debuts this month dogs. Videos of normal with a quick guide to the diagnosis and man- and paralyzed laryngeal agement of flea allergy dermatitis in general abduction are available at practice. An extended version of this article, CompendiumVet.com. with details of available flea-control products, is available at CompendiumVet.com. 232 Pneumothorax ❯❯ Karl C. Maritato, José A. Colón, and David H. Kergosien Pneumothorax is classified according to type and causative mechanism. Information on sig- nalment, diagnostic evaluation, and treatment is given for each type, along with the basic steps of thoracocentesis and thoracostomy tube p placement. FREE CE Departments 208 Clinical Snapshot Poor Haircoat Clinical in a Persian Snapshot ❯❯ Jeff Ruth PAGE 208 211 Editorial: Applied Dermatology Cover image © 2009 Peter Olson Photography ❯❯ Wayne S. Rosenkrantz and Craig E. Griffin 245 Product Forum On the Cover 226 CompendiumVet.com Dr. Anthony Yu performs a dermatologic 246 Index to Advertisers examination on Joey, a Parson Russell terrier 230 Abstract Thoughts ❯❯ Joseph Harari 246 Market Showcase mix, at Ontario Veterinary College in Guelph, Ontario, Canada. 243 Letters 246 Classified Advertising 244 Research Recap 248 Reading Room * 2009 PERQ/HCI FOCUS® Veterinary Study of Total Com- Selected abstract from Guidelines for Euthanasia panion Animal Veterinarians, in comparison to ratings Veterinary Therapeutics of Nondomestic Animals for each publication, by that publication’s readers. Compendium: Continuing Education for Veterinarians® 205
- 8. Canadian News Veterinary CancerCentre Opens Therapy Dogs Trained T he St. John Ambulance Company T he Western Veterinary Specialist and Emergency Centre in downtown Calgary, Alberta, opened its new Can- ulated radiation therapy capabilities that allow radiation to be targeted specifically at tumor cells, sparing normal tissues. of Comox Valley, Vancouver Island, British Columbia, has 10 new therapy dog teams, bringing the total to 34 active cer Centre Tuesday, April 14. The centre, The Western Veterinary Specialist teams. The addition of these new teams which has been in development since and Emer gency Centre treats more makes the St. John Ambulance Therapy 2006, will use cutting-edge technology, than 8000 companion animal patients Dog Branch the largest on Vancouver previously unavailable in Canada, to annually at its Island. treat pets with cancer. 30,000-square- The therapy dogs serve as surro- The Cancer Centre is equipped with foot facility. gate pets for people who are no lon- a linear accelerator with intensity mod- ger able to have animals of their own. Before entering the program, the dogs are tested against national standards for OVC Pet Trust Funds $232,500 temperament and obedience for work in seniors’ facilities. Volunteers commit in Companion Animal Research to a minimum of 1 hour per week. T he donor-supported OVC Pet Trust the needs and expectations of pet own- SPREAD YOUR GOOD NEWS has funded 19 research projects at the ers whose animals are receiving cancer Canadian News Ontario Veterinary College (OVC). The care at the OVC. Another will study the c/o Veterinary Learning Systems projects were chosen in a fall 2008 com- use of laser lithotripsy (the treatment 780 Township Line Road petition. Species to be studied include of choice in humans) to pulverize kid- Yardley, PA 19067 USA , companion animals such as cats, dogs, ney and ureteral stones in vitro in dogs. E-MAIL editor@CompendiumVet.com parrots, and veiled chameleons. Other areas of research funded by the FAX 800-556-3288 The chosen projects cover a wide Pet Trust include hematology, cardiol- WEB CompendiumVet.com range of topics. One project will explore ogy, and infectious disease topics. Coming Events July 16 September 9 October 13 Ontario Veterinary Medical Association: Calgary Academy of Veterinary Medicine: Toronto Academy of Veterinary Medicine: Career Planning for Associate Ophthalmology Early Resuscitation and Stabilization of the Veterinarians & Potential Clara Christie Theatre, Health Sciences Emergency Patient Practice Owners University of Calgary, Alberta Dave and Buster’s Ontario Veterinary Medical Association This seminar will offer 1.5 hours of scientific Toronto, Ontario Milton, Ontario CE and will be presented by Dr. Cheryl Cullen. This seminar will focus on practical This course presents the benefits and Phone 403-863-7160 emergency management using case downsides of owning a practice as well as E-mail info@cavm.ab.ca examples. It will offer 5.5 CE credits. the practical aspects of practice ownership. Web www.cavm.ab.ca/ce_calendar.html Phone 800-670-1702 Web https://www.ovma.info/Meetings/ Web www.tavm.org September 15 August 8–13 Toronto Academy of Veterinary Medicine: October 18 World Association for the Advancement Update on Clinical Gastroenterology Calgary Academy of Veterinary Medicine: of Veterinary Parasitology: Dave and Buster’s Hematology 22nd International Conference Toronto, Ontario Clara Christie Theatre, Health Sciences Calgary, Alberta This seminar will provide an update on University of Calgary, Alberta This conference will discuss current issues GI disorders of cats and dogs, with an This seminar will offer 6 hours of scientific CE in parasitology, with a theme of “One emphasis on diagnosis and treatment. and will be presented by Dr. Marjorie Brooks. World One Health: Parasites in a Changing It will offer 5.5 CE credits. Phone 403-863-7160 Environment.” Phone 800-670-1702 E-mail info@cavm.ab.ca Web www.waavp2009.com Web www.tavm.org Web www.cavm.ab.ca/ce_calendar.html 206 Compendium: Continuing Education for Veterinarians® | May 2009 | CompendiumVet.com
- 9. . . .trust me! . . . you’ll be fine! My patients rely on me every day. And I rely on Baytril®. Because when it comes to infections, it’s on my side – an effective partner I can count on. Federal (U.S.A.) law restricts this drug to use by or on the order of a licensed veterinarian. In animal safety studies, isolated incidences of vomition and inappetence were reported. © 2009 Bayer HealthCare LLC, Animal Health Division, Shawnee Mission, Kansas 66201. Bayer, the Bayer Cross, Baytril and Right the first time are registered trademarks of Bayer. B090123n See Page 208 for Product Information Summary
- 10. Clinical Snapshot Particularlyintriguing or difficult cases Case Presentation #1 ❯❯ Jeff Ruth, DVM, DABVP (Canine/Feline) Bissonnet/Southampton Veterinary Clinic Houston, Texas A 3-year-old intact male Persian cat presented with chronic, greasy skin of the tail and an unkempt haircoat (A). Prior unsuccessful attempts to treat the cat included systemic antibiotics (cefpodoxime 6.25 mg/kg PO q24h for 14 days) and antibacterial shampoo (4% chlorhexidine every 14 days for 3 months). A 2 × 6–cm focal zone of seborrhea oleosa, yellow crusting, and alopecia affected the proximal third of the tail (B). Additional abnormalities included mild medial canthal entropion of the left eye and resultant obstruction of nasolacrimal tear drainage. A 1. Given the history and clinical signs, what is the most likely cause of the lesion? 2. What ancillary tests should be performed? 3. What are the recommended treat- ment and the prognosis for this cat? SEE PAGE 210 FOR ANSWERS AND EXPLANATIONS. B 208 Compendium: Continuing Education for Veterinarians® | May 2009 | CompendiumVet.com
- 11. Month-long flea protection in a chewable tablet Fast-acting Convenient Family-friendly Doesn’t wash off • Starts killing fleas in 30 minutes • 100% effective within 4 hours in a controlled laboratory study • Approved by the FDA and available by prescription only To learn more about Comfortis®, see your Lilly representative or distributor representative, call 1 (888) LillyPet or visit www.comfortis4dogs.com The most common adverse reaction recorded during clinical trials was vomiting. Other adverse reactions were decreased appetite, lethargy or decreased activity, diarrhea, cough, increased thirst, vocalization, increased appetite, redness of the skin, hyperactivity and excessive salivation. For product label, including important safety information, see page 210. ©2009 Eli Lilly and Company CF00305 010109
- 12. Clinical Snapshot Answers andExplanations Case Presentation #1 A B SEE PAGE 208 FOR CASE PRESENTATION. 1. Feline tail gland hyperplasia (FTGH). 3. Treatment goals are to minimize The tail gland, or supracaudal gland, the accumulation of seborrheic is a dense accumulation of seba- oil produced by the glands and ceous glands located on the dorsal to address secondary skin infec- surface of the tail in cats and dogs. tions. The influence of androgens Hyperplasia of the sebaceous glands is poorly understood, and cas- and resultant sebum overproduction tration is unlikely to completely induces focal clinical signs that may resolve the condition. The use of include a greasy haircoat, hyperpig- keratolytic and keratoplastic sham- mentation, furunculosis, alopecia, poos (e.g., sulfur 2% and salicylic and comedones in the region of the acid 2% q36h for 4 weeks, then tail gland. FTGH, or stud tail, is a weekly) or degreasing agents (e.g., disease of young cats of either sex, benzoyl peroxide 2.5% q36h for altered or intact. 4 weeks, then weekly) is recom- mended. Systemic antiseborrheic 2. Skin cytology should be conducted agents used in veterinary medicine to detect secondary bacterial pyo- include synthetic retinoids such as derma or Malassezia infection, isotretinoin and etretinate. While which may complicate the disease. these agents may have benefit in Dermatophyte culture and skin refractory cases, their use carries scrapings for Demodex spp are also a greater risk of adverse effects. warranted. Seborrheic dermatitis Clients should be prepared to also necessitates the identification invest time in regular grooming and strict control of fleas and other to minimize the largely cosmetic ectoparasites. clinical signs of this disease. With A variety of primary and sec- attention to routine care, the prog- ondary keratinization defects have nosis for FTGH is favorable. characteristics that can mimic FTGH. Among these are gener- alized primary seborrhea, allergic dermatitis, neoplasia (carcinoma in Recommended Reading g situ or cutaneous lymphoma), and Guaguère E, Prélaud P. A Practical zoonotic infectious disease (pythiosis, Guide to Feline Dermatology. Paris: phaeohyphomycosis). If the signs are Merial; 1999. not localized to the region of the tail Scott DW, Miller WH, Griffin CE. gland, or if the initial workup fails Keratinization defects. In: Scott DW, to elucidate a cause, biopsy for his- Miller WH, Griffin CE, eds. Muller topathology and culture is indicated. and Kirk’s Small Animal Dermatol- Histopathology in cases of FTGH ogy. 6th ed. Philadelphia: WB Saun- demonstrates the characteristic hyper- ders; 2001:1046-1048. plasia of regional sebaceous glands. 210 Compendium: Continuing Education for Veterinarians® | May 2009 | CompendiumVet.com
- 13. Editorial COLUMN EDITOR COLUMN EDITOR Craig E. Griffin, DVM, DACVD Animal Dermatology Clinic, San Diego, California COLUMN EDITOR COLUMN EDITOR Wayne S. Rosenkrantz, DVM, DACVD Animal Dermatology Clinic, Tustin, California Dr. Yu (shown here with his dogs [from left to right] Timmy, Joey, and Bitsy) is associate professor Overview of Flea Allergy Dermatitis of dermatology at The University of Guelph Ontario Veterinary College in Canada. ❯❯ Andrea Lam, DVM ❯❯ Anthony Yu, DVM, MS, DACVDa University of California Davis Veterinary Medical Teaching Hospital University of Guelph Ontario Veterinary College F lea allergy dermatitis, or flea-bite hypersensitivity, is the most common small animal dermatologic condition.1–3 In some regions of the world, it is the most commonly seen sources. The larvae feed on adult flea feces (partially digested blood) in the environment. Within 5 to 11 days, a larva undergoes two sep- arate molting stages before forming a pupa. canine disease. This disease does not exist in locations that The pupal stage is the most resilient of all are inhospitable to fleas, such as those at elevations above stages because the cocoon is highly resistant to desiccation. It also has a sticky surface that 1500 ft or with low humidity (e.g., the desert). helps to prevent premature removal from the Although there are more than 2000 docu- environment and that accumulates dust and mented species and subspecies of fleas, the other household particulates to provide pro- cat flea (Ctenocephalides felis felis) is the spe- tection. On average, the pupal stage lasts 8 to cies most frequently found infesting dogs, cats, 9 days; however, fleas can pupate for up to 6 and all caged pets in North America. months if the environmental conditions are not ideal for emergence. Only with proper environ- Flea Facts mental stimuli, such as an increase in carbon The life cycle of the flea ranges from as few dioxide, warmth, physical pressure, and vibra- as 12 to as many as 190 days, with an average tion, will an adult flea emerge from its cocoon. of 21 days. The time needed for development After emerging from the cocoon, adult fleas At a Glance depends heavily on environmental conditions, search for an appropriate host. Adult fleas are particularly temperature and humidity. The opti- attracted to light and tend to migrate upward Flea Facts Page 220 mal environment is a low-altitude geographic toward surfaces where contact with an appropri- location, a temperature of 75°F (23.8°C), and a ate host is more likely. Once a host is found, feed- Pathogenesis Page 220 relative humidity of 78%. ing and mating take place within 8 to 24 hours. An adult flea takes its first blood meal from Female fleas can consume 15 times their body Diagnosis a host within minutes of contact. Female fleas weight in blood per day. Adult fleas act as obligate, Page 222 lay their first egg 24 to 36 hours after this permanent ectoparasites, preferring to remain on Treatment blood meal. Flea eggs are smooth and slick. a host rather than in the environment. Page 223 Only 30% of eggs remain on the haircoat; the Flea Control remainder fall off the host into the environ- Pathogenesis Products ment. Hatching takes place within 1 to 10 days, Flea saliva contains histamine-like compounds, Page 224 again depending on humidity and tempera- proteolytic enzymes, and anticoagulants. These ture. A single female flea can lay 1000 eggs proteins are released into the host during within 30 days, and most average 2000 eggs feeding and can act as inflammatory or anti- ❯❯ Wayne S. Rosenkrantz, ❯❯ Craig E. Griffin, DVM, during their life. genic stimuli in sensitive animals. Various Although eggs can hatch anywhere in the immunologic responses are provoked, includ- WEB environment, development of the larvae that ing immediate and delayed hypersensitivity EXCLUSIVE a Dr. Yu discloses that he emerge from the eggs must take place off the reactions,4 late-phase IgE-mediated responses, has received financial sup- host because mammalian body temperatures and cutaneous basophil hypersensitivity reac- An extended version of port from Greer Laborato- DVM, DACVD DACVD are too high for survival. Larvae are highly sen- tions.5 Dogs with atopic dermatitis appear to this article is available on ries, Iams, Novartis Animal Health, and Pfizer Animal sitive to heat and desiccation and therefore tend be predisposed to the development of flea CompendiumVet.com. Health. to move downward and away from direct light allergy dermatitis.6,7 220 Compendium: Continuing Education for Veterinarians® | May 2009 | CompendiumVet.com CompendiumVet.com | May 2009 | Compendium: Continuing Education for Veterinarians® 221 Animal Dermatology Clinic Animal Dermatology Clinic Tustin, California San Diego, California New dermatology series begins on page 220. Applied Dermatology S kin and ear diseases are the most common be written or coauthored by diplomates or residents problems that veterinarians deal with in of the American College of Veterinary Dermatology, practice on a daily basis. Because many of who will present evidence-based approaches to these cases are secondary to genetic causes, cure common dermatologic conditions. This new col- is often not possible, and management becomes umn will appear quarterly. Occasionally, recog- the mainstay of therapy. Fortunately, many nized dermatology experts will contribute their advances in diagnostics and therapeutics have individual approaches to specific problems as been made in the field of veterinary dermatology, online supplements to this series; the first of these and pet owners are demanding a higher level articles, “A Practical Approach to Diagnosing and Managing Ear Disease in Dogs,” by Paul Bloom, The new dermatology series will provide DVM, DACVD, DABVP (Canine and Feline), will be published on CompendiumVet.com this month. practical, easy-to-use techniques for the We hope that this new column will provide valuable information on how specialists approach diagnosis and treatment of many common and manage common skin and ear diseases and canine and feline ear and skin diseases. will help keep you updated on new diagnostic and therapeutic options so you can better han- of care and are often willing to allow advanced dle these often frustrating cases in your clinical diagnostic testing and therapy. To be able to offer practice. your clients this higher quality of medicine, it is imperative to stay current on the latest options available to manage these chronic and sometimes SHARE YOUR COMMENTS frustrating cases. Have something to say about this To help you in this effort, the new Compendium editorial or topic? Let us know: dermatology series, Applied Dermatology, will pro- E-MAIL editor@CompendiumVet.com vide practical, easy-to-use techniques for the diag- nosis and treatment of many common canine and FAX 800-556-3288 feline ear and skin diseases. The articles in this new series, which debuts on page 220 of this issue, will CompendiumVet.com | May 2009 | Compendium: Continuing Education for Veterinarians® 211
- 14. 3 CE CREDITS CE Article 1 Laryngeal Paralysis in Dogs ❯❯ Ralph P. Millard, DVM Abstract: Laryngeal paralysis is a common cause of upper airway obstruction in large-breed dogs. ❯❯ Karen M. Tobias, DVM, Although congenital forms have been reported, the disease is usually an acquired condition in older MS, DACVS dogs. Clinical signs include voice change, inspiratory stridor, and dyspnea. Laryngeal paralysis is ❯❯ University of Tennessee diagnosed by observing the absence of arytenoid abduction during laryngeal examination under a light plane of anesthesia. The most common method of surgical treatment is unilateral arytenoid lateralization. Most dogs experience significant improvement in respiration following surgery; however, they have an increased risk of aspiration pneumonia for the remainder of their lives. L aryngeal paralysis is a well-recog- laryngeal paralysis displayed neurogenic nized disease of large-breed dogs atrophy of the cranial tibial muscle and that results in upper airway obstruc- axonal degeneration of the peroneal nerve tion and dyspnea. The condition results in all cases, regardless of whether the from dysfunction of the caudal laryngeal dogs had signs of peripheral neuropathy.8 nerves, which are the terminations of Within 2 years after diagnosis of laryn- the recurrent laryngeal nerves. The cau- geal paralysis, clinical signs of general- dal laryngeal nerves provide innervation ized lower motor neuron disease were to all the muscles of the larynx except the cricothyroideus muscle. Dysfunction FIGURE 1 of these nerves results in the loss of arytenoid abduction by the cricoarytenoi- deus dorsalis muscle and the inability to actively constrict the glottis or relax the At a Glance vocal folds1 (FIGURES 1 AND 2). Etiology Etiology Page 212 Laryngeal paralysis can be congenital or Signalment and Clinical acquired. A hereditary form has been Signs described in Bouvier des Flandres, dal- Page 213 matians, rottweilers, and Siberian huskies Diagnosis and is usually reported in dogs younger Page 213 than 1 year.2–5 Acquired laryngeal paraly- Medical Management sis may result from trauma or iatrogenic Page 216 injury to the recurrent laryngeal nerve (e.g., during thyroidectomy) or compres- Surgical Treatment Page 217 sion of the recurrent laryngeal nerve by a cranial mediastinal or cervical mass.6 More commonly, however, laryngeal paral- ysis is classified as idiopathic in older dogs. Although the underlying etiology is Cranial view of a dissected canine unknown, idiopathic laryngeal paralysis larynx. (a) Corniculate process of arytenoid is most likely part of a generalized periph- cartilage, (b) cuneiform process of arytenoid eral neuropathy.7 In one recent study, cartilage, (c) epiglottis, (d) vocal fold, (e) laryn- muscle and peripheral nerve biopsy sam- geal ventricles, (f) cricoid cartilage, (g) muscu- ples obtained from 11 dogs with acquired lar process of arytenoid cartilage. 212 Compendium: Continuing Education for Veterinarians® | May 2009 | CompendiumVet.com
- 15. FREE Laryngeal Paralysis in Dogs CE present in all dogs in the study. 8 Although FIGURE 2 laryngeal paralysis has been reported in dogs with hypothyroidism, the association between the two conditions is unknown.9,10 Myasthenia gravis has also been suggested as a cause of laryngeal paralysis in dogs.11 Signalment and Clinical Signs Laryngeal paralysis is most commonly reported in older, large-breed dogs, especially Labrador retrievers.9,12–14 The average age at the time of presentation is approximately 10 years.9,12,14 Males are affected more frequently than females.12–14 Clinical signs progress as laryn- geal dysfunction becomes more severe. Early in the disease process, owners may notice a voice change, inspiratory stridor, and exercise intolerance. Owners may initially believe that Lateral view of a dissected canine larynx. (a) Thyroid cartilage, (b) cricoid the dog’s reluctance to move is simply a sign cartilage, (c) hyoid apparatus, (d) epiglottis, (e) corniculate process of arytenoid of aging. Dysphagia can also occur, possibly cartilage. in association with peripheral neuropathy.9,14 Owners may also report vomiting; however, could contribute to exercise intolerance. A they may actually be seeing regurgitation from complete neurologic examination should be concurrent esophageal disease or gagging and performed to evaluate for signs of polyneu- retching from a soft palate that has elongated ropathy, such as decreased postural reactions, as a result of inspiratory dyspnea. Once the deficits in spinal reflexes, and cranial nerve laryngeal muscles are paralyzed bilaterally, abnormalities.7 dogs may develop severe dyspnea, cyanosis, A rectal temperature should be obtained, and syncope. Exercise, obesity, excitement, and all dogs should be evaluated for sys- and increased ambient temperature can exac- temic signs of heatstroke, such as petechial QuickNotes erbate clinical signs, leading to an emergency hemorrhages associated with disseminated presentation.9 Affected dogs may develop intravascular coagulation, excessive panting, Acquired laryngeal pneumonia or pulmonary edema, which can collapse, hyperemic mucous membranes, and paralysis may be contribute to respiratory distress. Inability abnormalities in mentation, regardless of body associated with a to constrict the glottis properly during swal- temperature at time of presentation.17,18 The generalized periph- lowing, regurgitation, or vomiting increases primary means of heat loss in dogs is evapo- eral neuropathy. the risk of aspiration. Pulmonary edema can ration while panting. Dogs affected by acute develop in cases of upper airway obstruction signs of laryngeal paralysis are more suscepti- as a result of changes in intrathoracic pressure ble to hyperthermia due to a lack of heat dissi- and hypoxia, which cause increased perme- pation through an obstructed respiratory tract. ability of alveolar capillary membranes.15,16 Heatstroke from sustained hyperthermia can progress to multiorgan failure and death.17,18 Diagnosis If the body temperature is ≥106°F (41°C) or If an affected dog is stable, it should undergo systemic signs of heatstroke are evident, addi- a thorough physical examination. The thorax tional diagnostics (e.g., coagulation panels, should be auscultated for evidence of pneumo- immediate evaluation of glucose and elec- nia or pulmonary edema, such as harsh crack- trolytes) and supportive treatment should be les, wheezes, or rales, and for cardiac murmurs instituted. or arrhythmias. Arterial pulses should be pal- Complete blood count and serum biochem- pated for rate, rhythm, symmetry, and strength istry profile results are typically normal unless to assess for cardiovascular abnormalities that concurrent diseases are present. In dogs with CompendiumVet.com | May 2009 | Compendium: Continuing Education for Veterinarians® 213
- 16. FREE CE Laryngeal Paralysisin Dogs peripheral weakness, exercise intolerance, mega- of aspiration largely outweighs the diagnostic esophagus, or other signs of generalized poly- benefits of contrast esophagography; there- neuropathy, free thyroxine and endogenous fore, this procedure is not performed routinely thyroid-stimulating hormone concentrations are in dogs with laryngeal paralysis. measured to rule out hypothyroidism, and ace- Laryngeal paralysis is most commonly tylcholine receptor antibody titers are measured diagnosed with transoral laryngoscopy under to rule out myasthenia gravis.7,19 The association a light plane of anesthesia. Excessive admin- of laryngeal paralysis with hypothyroidism or istration of any anesthetic can inhibit laryn- myasthenia gravis is unclear, however, as medi- geal motion; however, some drugs may reduce cal treatment for either of these conditions is arytenoid abduction under a light plane of unlikely to restore laryngeal nerve function. anesthesia. In a comparison of seven different Thoracic radiography is important for rul- anesthetic protocols,21 acepromazine plus thi- ing out other causes of dyspnea and exercise opental, acepromazine plus propofol, and ket- intolerance and for determining whether con- amine plus diazepam resulted in no laryngeal current conditions are present in dogs with motion in 67%, 50%, and 50% of normal dogs, laryngeal paralysis. The lung fields should be respectively. Thiopental and propofol as single assessed for evidence of aspiration pneumonia agents inhibit laryngeal motion less than these and noncardiogenic pulmonary edema, which drug combinations.21,22 However, compared can occur with upper airway obstruction. Dogs with propofol, thiopental as a single agent QuickNotes with laryngeal paralysis from polyneuropathy results in significantly more arytenoid motion or neuromuscular junction disease such as during inspiration and is therefore preferred Every dog sus- myasthenia gravis may develop megaesopha- for evaluation of laryngeal function.21,22 Often, pected of having gus, which significantly increases the likeli- dogs receive acepromazine when they present laryngeal paralysis hood of aspiration pneumonia11,12 (FIGURE 3). with anxiety and respiratory distress. In the should undergo tho- A contrast esophagram with videofluoroscopy comparison study, laryngeal function was evi- racic radiography. may be required to make a definitive diagno- dent in all normal dogs that received acepro- sis of decreased esophageal motility.20 The risk mazine and butorphanol sedation and were FIGURE 3 Thoracic Radiographs. A B Thoracic radiographs of a dog with megaesophagus and aspiration pneumonia. Note the borders of a dilated, air-filled esophagus (arrowheads) and air bronchograms (arrows). (A) Ventrodorsal view. (B) Right lateral view. 214 Compendium: Continuing Education for Veterinarians® | May 2009 | CompendiumVet.com
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- 18. FREE CE Laryngeal Paralysisin Dogs BOX 1 Unless the examiner is aware of the phase Anesthetic Regimens for of respiration, it is easy to mistake paradoxical Diagnosing Laryngeal movement of the larynx for active abduction. Lack of arytenoid cartilage abduction during Paralysis in Dogs inspiration narrows the rima glottidis, increas- ing resistance to airflow. Rapid, forceful inspira- Preoxygenate for 3 to 5 minutes before tion creates negative pressure within the larynx, induction. which pulls the flaccid arytenoid cartilages medially, worsening the obstruction.27 The car- Thiopental (12–16 mg/kg IV to effect) tilages are forcefully separated by airflow as the Propofol (4.5–7 mg/kg IV slowly to effect) animal exhales. Therefore, dogs with laryngeal and doxapram (1 mg/kg IV) paralysis and paradoxical motion have inward Acepromazine (0.2 mg/kg IM) and butor- movement of the arytenoid cartilages on inspi- phanol (0.4 mg/kg IM) 20 minutes before ration and outward, passive movement of the mask induction with isoflurane cartilages during expiration. Intubation may be required in some patients with severe paradox- ical motion and resultant hypoxia.23 examined under a light plane of anesthesia induced by mask inhalation of isoflurane.21 In Medical Management QuickNotes animals in which laryngeal function has been Dogs that present with acute cyanosis or in col- depressed by sedatives and opioids, doxapram lapse require emergency treatment. Supplemen- In dogs with (1 mg/kg) can be administered intravenously tal oxygen should be provided to help alleviate laryngeal paraly- to stimulate respiration23 (BOX 1). hypoxia. An intravenous catheter should be sis, paradoxical Although a portable laryngoscope can be placed for administration of fluid and medica- movement can be used to visualize the rima glottidis, retraction tions. Severely dyspneic or anxious dogs may mistaken for active of the tongue and pressure on the epiglot- require sedation with acepromazine (0.005 to arytenoid abduction tis with the laryngoscope blade may affect 0.02 mg/kg IV) and butorphanol (0.2 to 0.4 mg/ during laryngeal laryngeal function. Therefore, many clinicians kg IV) or other sedatives. If laryngeal edema is examination. prefer to use a transoral video endoscope. suspected, an antiinflammatory dose of a gluco- Laryngeal paralysis has also been diagnosed corticoid such as dexamethasone (0.1 to 0.5 mg/ with transnasal laryngoscopy and laryngeal kg) or prednisolone sodium succinate (0.5 to ultrasound.24,25 1 mg/kg) can be administered intravenously. If possible, blood oxygen saturation should Dogs that are significantly hyperthermic (≥106°F be monitored with a pulse oximeter during [41°C]) are treated with sedatives, IV fluids, cool laryngoscopy to ensure that the hemoglobin water baths, and fans. The rectal temperature saturation remains ≥95%.26 Flow-by oxygen should be monitored continuously until it has can be administered by attaching flexible tub- stabilized within a normal range and external ing from an oxygen source to the blade of cooling has been discontinued. Dogs that are the laryngoscope or to the insufflation port cyanotic, severely dyspneic, or hypoxic (SpO2 of the video endoscope to reduce the risk of <95%) despite supplemental oxygen therapy hypoxia. During laryngeal examination, laryn- may require intubation and light anesthesia until geal motion should be correlated with the laryngeal swelling resolves. If an intubation phase of respiration. It is helpful to have an period of several hours or longer is expected, assistant call out when each inspiration and a tracheostomy tube should be placed to avoid VIDEO expiration occurs. In normal dogs, the rima exacerbation of laryngeal swelling from the glottidis remains open at rest, closes slightly endotracheal tube and prolonged periods of during expiration, and opens widely during anesthesia.28 It is possible for severe cases to inspiration. Inability of the arytenoid carti- progress to respiratory muscle fatigue, which To see videos of lages to abduct during inspiration is diagnostic may require mechanical ventilation.29 There is normal and paralyzed for laryngeal paralysis. In questionable cases, no reliable bedside measurement for detection laryngeal abduction, please visit doxapram is administered intravenously.23 Res- of respiratory muscle fatigue; the diagnosis is CompendiumVet.com. piration is usually stimulated within 8 seconds based on changes in breathing patterns, such as after administration. inward movement of the abdomen during inspi- 216 Compendium: Continuing Education for Veterinarians® | May 2009 | CompendiumVet.com
- 19. FREE Laryngeal Paralysis in Dogs CE ration, uncoordinated alterations between rib- FIGURE 4 cage and abdominal movements, and increased PaCO2 on blood gas analysis.29 Dogs that have mild clinical signs or are asymptomatic at rest may be managed con- servatively by reducing stress, excitement, and exposure to high ambient temperatures and with weight loss as needed. Owners should be informed that laryngeal paralysis is usually progressive and that many dogs require surgery as clinical signs become more severe or qual- ity of life is affected. Surgical Treatment The goal of surgery is to enlarge the size of the rima glottidis to decrease resistance to airflow during inspiration. Surgical techniques include unilateral arytenoid lateralization (UAL), partial arytenoidectomy, vocal fold resection, castel- Dorsolateral view of a dissected canine larynx. (a) Muscular process of arytenoid cartilage, (b) cricoid cartilage, (c) thyroid cartilage, (solid line) suture lated laryngofissure, and muscle–nerve pedi- 30–32 placement for cricoarytenoid lateralization, (broken line) suture placement for cle transposition. Some dogs may require thyroarytenoid lateralization. concurrent soft palate resection because pro- longed negative airway pressure can increase tilage during inspiration33 (FIGURES 4 AND 5). soft palate length and thickness. Castellated Active abduction of the arytenoid with the laryngofissure is rarely performed, and mus- suture is not required to reduce laryngeal air- cle–nerve pedicle transposition has not been way resistance.34,35 If the soft palate is elongated, evaluated in dogs with spontaneous laryngeal it is resected before recovery from anesthesia. paralysis; therefore, these procedures are not Bilateral arytenoid lateralization increases the described in this article. risk of postoperative complications and respira- In animals undergoing vocal fold resec- tory-related death and is not recommended.11 tion for laryngeal paralysis, the vocal fold and Complications are reported in 10% to 28% process are removed unilaterally or bilaterally. of dogs that undergo UAL (BOX 2) and include QuickNotes The procedure is often performed transorally aspiration pneumonia (8% to 33%), coughing with scissors. If bilateral vocal cordectomy is and gagging (16%), suture failure or return of Administration of performed, the ventral 1 to 2 mm of the vocal clinical signs (4% to 8%), gastric dilatation– doxapram during fold should be left in place to reduce the risk volvulus (4%), respiratory distress (2% to 4%), laryngeal exami- of scar formation and subsequent glottal steno- and sudden death (3%).12,14,36 Aspiration pneu- nation facilitates sis. Partial arytenoidectomy involves unilateral monia may occur shortly after surgery or at differentiation of resection of the corniculate process of the laryngeal paraly- arytenoid cartilage. This procedure can also be BOX 2 performed through a transoral approach with sis from drug- cup biopsy forceps and may be combined with Complications of Unilateral induced laryngeal 12 a vocal fold resection. In one study, complica- Arytenoid Lateralization dysfunction. tions were reported in 40% of dogs undergo- ing unilateral laryngectomy (arytenoidectomy, Aspiration pneumonia vocal cordectomy, or a combination of both) Coughing/gagging for treatment of laryngeal paralysis, and 30% of Surgical repair failure the dogs died from respiratory-related causes. UAL is the most commonly performed pro- Respiratory distress cedure for laryngeal paralysis.12,14 With this Gastric dilatation–volvulus technique, a suture is placed between the Seroma formation arytenoid and cricoid or thyroid cartilages to Sudden death prevent inward motion of the arytenoid car- CompendiumVet.com | May 2009 | Compendium: Continuing Education for Veterinarians® 217
- 20. FREE CE Laryngeal Paralysisin Dogs FIGURE 5 agus, and neurologic disease.12 In one study, five of six dogs that developed megaesopha- gus in conjunction with aspiration pneumonia died.12 Because polyneuropathy is suspected as an underlying etiology for laryngeal paralysis, affected dogs should be monitored frequently for evidence of neuromuscular weakness and esophageal dysfunction. The associa- tion between temporary tracheostomy tube placement and increased postoperative com- plications should be interpreted with caution because dogs that require tracheostomy tubes are likely to be in critical condition. Clinicians should not hesitate to place a tracheostomy tube in animals with severe inspiratory dyspnea. Despite complications, approximately 90% of dogs have a reduction in respiratory signs and improved exercise tolerance after UAL. Lateral view of a dissected canine larynx. (a) Muscular process of Most owners report an improvement in qual- arytenoid cartilage, (b) cricoid cartilage, (c) cricothyroid articulation, (d) thyroid ity of life and are satisfied with their decision cartilage retracted laterally, (e) articulation of thyroid cartilage and thyrohyoid bone, (solid line) suture placement for cricoarytenoid lateralization. to go to surgery.12,14 any time for the remainder of the dog’s life. Conclusion The use of metoclopramide reduces the risk of Laryngeal paralysis is a common cause of upper perioperative aspiration pneumonia.36 airway obstruction in older, large-breed dogs Median survival times after UAL range from and is likely associated with a generalized poly- QuickNotes 1 to 5 years, with approximately 14% of dogs neuropathy in most animals. Surgical therapy dying from diseases related to the respiratory is frequently indicated, and UAL is currently Aspiration pneu- tract.12,14 Factors associated with a higher rate the recommended treatment. Respiratory signs monia is the most of complications or death include increasing significantly improve in most patients after sur- common complica- age, placement of a temporary tracheostomy gery; however, postoperative complication rates tion after surgery for tube, and presence of concurrent respiratory can be high, and patients have a lifelong risk of laryngeal paralysis. tract abnormalities, postoperative megaesoph- developing respiratory tract disease. References 1. Evans HE, Kitchell RL. Cranial nerves and cutaneous innervation of 10. Jaggy A, Oliver JE, Ferguson DC, et al. Neurological manifestations the head. In: Evans HE, ed. Miller’s Anatomy of the Dog. Philadelphia: of hypothyroidism: a retrospective study of 29 dogs. J Vet Intern Med WB Saunders; 1993:953-987. 1994;8:328-336. 2. Venker-van Haagen AJ, Bouw J, Hartman W. Hereditary trans- 11. Dewey CW, Bailey CS, Shelton GD, et al. Clinical forms of acquired mission of laryngeal paralysis in Bouviers. JAAHA 1981;17:75-76. myasthenia gravis in dogs: 25 cases (1988-1995). J Vet Intern Med 3. Braund KG, Shores A, Cochrane S, et al. Laryngeal paralysis-polyneu- 1997;11:50-57. ropathy complex in young dalmatians. Am J Vet Res 1994; 55:534-542. 12. MacPhail CM, Monnet E. Outcome of and postoperative compli- 4. Mahony OM, Knowles KE, Braund KG, et al. Laryngeal paraly- cations in dogs undergoing surgical treatment of laryngeal paraly- sis-polyneuropathy complex in young rottweilers. J Vet Intern Med sis: 140 cases (1985-1998). JAVMA 2001;218:1949-1956. 1998;12:330-337. 13. Snelling SR, Edwards GA. A retrospective study of unilateral 5. Polizopoulou ZS, Koutinas AF, Papadopoulos GC, et al. Juve- arytenoid lateralisation in the treatment of laryngeal paralysis in 100 nile laryngeal paralysis in three Siberian husky x Alaskan malamute dogs (1992-2000). Aust Vet J 2003;81:464-468. puppies. Vet Rec 2003;153:624-627. 14. Hammel SP, Hottinger HA, Novo RE. Postoperative results of uni- 6. Klein MK, Powers BE, Withrow SJ, et al. Treatment of thyroid lateral arytenoid lateralization for treatment of idiopathic laryngeal pa- carcinoma in dogs by surgical resection alone: 20 cases (1981- ralysis in dogs: 39 cases (1996-2002). JAVMA 2006;228:1215-1220. 1989). JAVMA 1995;206:1007-1009. 15. Algren JT, Price RD, Buchino JJ, et al. Pulmonary edema asso- 7. Jeffery ND, Talbot CE, Smith PM, et al. Acquired idiopathic la- ciated with upper airway obstruction in dogs. Pediatr Emerg Care ryngeal paralysis as a prominent feature of generalised neuromus- 1993;9:332-337. cular disease in 39 dogs. Vet Rec 2006;158:17. 16. John PJ, Mahashur AA. Pulmonary oedema associated with air- 8. Thieman KM, Krahwinkel DJ, Shelton D, et al. Laryngeal paraly- way obstruction. Can J Anaesth 1991;38:139-140. sis: part of a generalized polyneuropathy syndrome in older dogs. 17. Bruchim Y, Klement E, Saragusty J, et al. Heat stroke in dogs: a ret- Vet Surg 2007;36:E26. rospective study of 54 cases (1999-2004) and analysis of risk factors 9. Burbidge HM. A review of laryngeal paralysis in dogs. Br Vet J for death. J Vet Intern Med 2006;20:38-46. 1995;151:71-82. 18. Flournoy WS, Macintire DK, Wohl JS. Heatstroke in dogs: clini- 218 Compendium: Continuing Education for Veterinarians® | May 2009 | CompendiumVet.com
- 21. FREE Laryngeal Paralysis in Dogs CE cal signs, treatment, prognosis, and prevention. Compend Contin 28. Bishop MJ, Hibbard AJ, Fink BR, et al. Laryngeal injury in a Educ Pract Vet 2003;25:422-431. dog model of prolonged endotracheal intubation. Anesthesiology 19. Shelton GD. Myasthenia gravis and disorders of neuromuscular trans- 1985;62:770-773. mission. Vet Clin North Am Small Anim Pract 2002;32:189-206, vii. 29. Barton L. Respiratory muscle fatigue. Vet Clin North Am Small 20. Washabau RJ, Hall JA. Diagnosis and management of gastroin- Anim Pract 2002;32:1059-1071, vi. testinal motility disorders in dogs and cats. Compend Contin Educ 30. Greenfield CL, Walshaw R, Kumar K, et al. Neuromuscular pedicle graft Pract Vet 1997;19:721-737. for restoration of arytenoid abductor function in dogs with experimentally 21. Jackson AM, Tobias K, Long C, et al. Effects of various anes- induced laryngeal hemiplegia. Am J Vet Res 1988;49:1360-1366. thetic agents on laryngeal motion during laryngoscopy in normal 31. Toth A, Szucs A, Harasztosi C, et al. Intrinsic laryngeal muscle dogs. Vet Surg 2004;33:102-106. reinnervation with nerve-muscle pedicle. Otolaryngol Head Neck 22. Gross ME, Dodam JR, Pope ER, et al. A comparison of thiopen- Surg 2005;132:701-706. tal, propofol, and diazepam-ketamine anesthesia for evaluation of 32. Fulton IC, Stick JA, Derksen FJ. Laryngeal reinnervation in the laryngeal function in dogs premedicated with butorphanol-glycopy- horse. Vet Clin North Am Equine Pract 2003;19:189-208, viii. rrolate. JAAHA 2002;38:503-506. 33. Mathews KG, Roe S, Stebbins M, et al. Biomechanical evalu- 23. Tobias KM, Jackson AM, Harvey RC. Effects of doxapram HCl ation of suture pullout from canine arytenoid cartilages: effects of on laryngeal function of normal dogs and dogs with naturally oc- hole diameter, suture configuration, suture size, and distraction curring laryngeal paralysis. Vet Anaesth Analg 2004;31:258-263. rate. Vet Surg 2004;33:191-199. 24. Radlinsky MG, Mason DE, Hodgson D. Transnasal laryngoscopy for 34. Bureau S, Monnet E. Effects of suture tension and surgical ap- the diagnosis of laryngeal paralysis in dogs. JAAHA 2004;40:211-215. proach during unilateral arytenoid lateralization on the rima glottidis 25. Rudorf H, Barr FJ, Lane JG. The role of ultrasound in the assessment in the canine larynx. Vet Surg 2002;31:589-595. of laryngeal paralysis in the dog. Vet Radiol Ultrasound 2001;42:338-343. 35. Greenberg MJ, Bureau S, Monnet E. Effects of suture tension 26. Proulx J. Respiratory monitoring: arterial blood gas analysis, during unilateral cricoarytenoid lateralization on canine laryngeal pulse oximetry, and end-tidal carbon dioxide analysis. Clin Tech resistance in vitro. Vet Surg 2007;36:526-532. Small Anim Pract 1999;14:227-230. 36. Greenberg MJ, Reems MR, Monnet E. Use of perioperative me- 27. Smith MM. Diagnosing laryngeal paralysis. JAAHA 2000;36:383- toclopramide in dogs undergoing surgical treatment of laryngeal 384. paralysis: 43 cases (1999-2006). Vet Surg 2007;36:E11. 3 CE CREDITS CE TEST 1 This article qualifies for 3 contact hours of continuing education credit from the Auburn University College of Veterinary Medicine. Subscribers may take individual CE tests online and get real-time scores at CompendiumVet.com. Those who wish to apply this credit to fulfill state relicensure requirements should consult their respective state authorities regarding the applicability of this program. 1. The most common cause of acquired 5. Which anesthetic protocol decreases 8. Which factor is associated with a higher laryngeal paralysis is laryngeal function in at least 50% of rate of complications or death after UAL a. hypothyroidism. normal dogs? in dogs with laryngeal paralysis? b. myasthenia gravis. a. acepromazine/thiopental a. young age c. trauma. b. acepromazine/propofol b. obesity d. idiopathic. c. ketamine/diazepam c. the need to place a temporary d. all of the above tracheostomy tube 2. The muscle responsible for abduction d. perioperative metoclopramide of the arytenoid cartilages during 6. Regarding partial laryngectomy, which inspiration is the ___________ muscle. statement is true? 9. Which statement is true? a. cricoarytenoideus dorsalis a. In dogs undergoing bilateral vocal cor- a. Shortening an elongated soft palate b. cricoarytenoideus lateralis dectomy, the entire vocal fold should be increases the risk of postoperative aspi- c. thyropharyngeus removed. ration after arytenoid lateralization. d. arytenoideus transversus b. Partial arytenoidectomy is performed b. During UAL, the arytenoid cartilage by removing the corniculate process of should be maximally abducted with 3. Laryngeal paralysis has been identified the arytenoid cartilage. sutures to enlarge the glottic opening. as a congenital condition in c. Complications are reported in 10% of c. Bilateral arytenoid lateralization a. Labrador retrievers. dogs undergoing unilateral partial laryn- increases the risk of postoperative b. Great Danes. gectomy for laryngeal paralysis. complications and respiratory-related c. Afghan hounds. d. Approximately 5% of dogs undergoing death. d. Bouvier des Flandres. unilateral partial laryngectomy die from d. The risk of aspiration pneumonia signifi- respiratory-related diseases. cantly decreases 1 year after UAL. 4. Which is an early sign of laryngeal paralysis? 7. The most common complication after 10. Approximately ___________ of dogs expe- a. syncope unilateral arytenoid lateralization is rience improvement in upper airway b. cardiac murmur a. respiratory distress. resistance and exercise tolerance fol- c. voice change b. aspiration pneumonia. lowing arytenoid lateralization. d. cyanosis c. seroma formation. a. 30% c. 75% d. suture failure. b. 50% d. 90% CompendiumVet.com | May 2009 | Compendium: Continuing Education for Veterinarians® 219
- 22. COLUMN EDITOR COLUMN EDITOR Craig E. Griffin, DVM, DACVD Animal Dermatology Clinic, San Diego, California COLUMN EDITOR COLUMN EDITOR Wayne S. Rosenkrantz, DVM, DACVD Animal Dermatology Clinic, Tustin, California Overview of Flea Allergy Dermatitis ❯❯ Andrea Lam, DVM ❯❯ Anthony Yu, DVM, MS, DACVDa University of California Davis Veterinary Medical Teaching Hospital University of Guelph Ontario Veterinary College F lea allergy dermatitis, or flea-bite hypersensitivity, is the most common small animal dermatologic condition.1–3 In some regions of the world, it is the most commonly seen sources. The larvae feed on adult flea feces (partially digested blood) in the environment. Within 5 to 11 days, a larva undergoes two sep- arate molting stages before forming a pupa. canine disease. This disease does not exist in locations that The pupal stage is the most resilient of all are inhospitable to fleas, such as those at elevations above stages because the cocoon is highly resistant to desiccation. It also has a sticky surface that 1500 ft or with low humidity (e.g., the desert). helps to prevent premature removal from the Although there are more than 2000 docu- environment and that accumulates dust and mented species and subspecies of fleas, the other household particulates to provide pro- cat flea (Ctenocephalides felis felis) is the spe- tection. On average, the pupal stage lasts 8 to cies most frequently found infesting dogs, cats, 9 days; however, fleas can pupate for up to 6 and all caged pets in North America. months if the environmental conditions are not ideal for emergence. Only with proper environ- Flea Facts mental stimuli, such as an increase in carbon The life cycle of the flea ranges from as few dioxide, warmth, physical pressure, and vibra- as 12 to as many as 190 days, with an average tion, will an adult flea emerge from its cocoon. of 21 days. The time needed for development After emerging from the cocoon, adult fleas At a Glance depends heavily on environmental conditions, search for an appropriate host. Adult fleas are particularly temperature and humidity. The opti- attracted to light and tend to migrate upward Flea Facts Page 220 mal environment is a low-altitude geographic toward surfaces where contact with an appropri- location, a temperature of 75°F (23.8°C), and a ate host is more likely. Once a host is found, feed- Pathogenesis Page 220 relative humidity of 78%. ing and mating take place within 8 to 24 hours. An adult flea takes its first blood meal from Female fleas can consume 15 times their body Diagnosis a host within minutes of contact. Female fleas weight in blood per day. Adult fleas act as obligate, Page 222 lay their first egg 24 to 36 hours after this permanent ectoparasites, preferring to remain on Treatment blood meal. Flea eggs are smooth and slick. a host rather than in the environment. Page 223 Only 30% of eggs remain on the haircoat; the Flea Control remainder fall off the host into the environ- Pathogenesis Products ment. Hatching takes place within 1 to 10 days, Flea saliva contains histamine-like compounds, Page 224 again depending on humidity and tempera- proteolytic enzymes, and anticoagulants. These ture. A single female flea can lay 1000 eggs proteins are released into the host during within 30 days, and most average 2000 eggs feeding and can act as inflammatory or anti- during their life. genic stimuli in sensitive animals. Various Although eggs can hatch anywhere in the immunologic responses are provoked, includ- environment, development of the larvae that ing immediate and delayed hypersensitivity a Dr. Yu discloses that he emerge from the eggs must take place off the reactions,4 late-phase IgE-mediated responses, has received financial sup- host because mammalian body temperatures and cutaneous basophil hypersensitivity reac- port from Greer Laborato- are too high for survival. Larvae are highly sen- tions.5 Dogs with atopic dermatitis appear to ries, Iams, Novartis Animal Health, and Pfizer Animal sitive to heat and desiccation and therefore tend be predisposed to the development of flea Health. to move downward and away from direct light allergy dermatitis.6,7 220 Compendium: Continuing Education for Veterinarians® | May 2009 | CompendiumVet.com
- 23. Dr. Yu (shownhere with his dogs [from left to right] Timmy, Joey, and Bitsy) is associate professor of dermatology at The University of Guelph Ontario Veterinary College in Canada. WEB EXCLUSIVE An extended version of this article is available on CompendiumVet.com. CompendiumVet.com | May 2009 | Compendium: Continuing Education for Veterinarians® 221
- 24. FIGURE 1 FIGURE 2 Typical distribution pattern of flea allergy dermatitis A fibropruritic nodule, a benign hyperplastic reaction to severe affecting the caudodorsolumbar region and caudal thighs (caudal flea allergy dermatitis, on a dog. to the “waistline”). Diagnosis haircoat; hyperpigmentation; and/or lichenifi- History and physical examination findings are cation may be observed affecting the dorsal the keys to making an appropriate diagnosis lumbosacral region, tail base, caudomedial QuickNotes of flea allergy dermatitis. There is no breed thighs, inguinal region, and umbilical fold.1 or sex predilection, and flea allergy dermatitis Other physical examination findings include History and physical can develop in animals of any age. Patients papules or encrusted papules, crusting, scal- examination find- may exhibit seasonal or year-round pruritus, ing, and, occasionally, fibropruritic nodules ings are the keys to depending on their geographic location. The (FIGURE 2) in association with affected areas. making an appropri- owner may report an increase in pruritus fol- Secondary superficial to deep pyodermas are ate diagnosis of flea lowing the introduction of a new pet or a visit common (FIGURE 3). Close examination of the allergy dermatitis. to a boarding or grooming facility. skin and haircoat using a flea comb may reveal Often, clinical signs manifest on the cau- flea dirt or adult fleas (FIGURE 4). Some pets dal aspect of the animal, especially in dogs may even exhibit clinical anemia as a result (FIGURE 1). Evidence of self-induced alopecia; of severe flea infestation (FIGURE 5). Pets that erythema; pyotraumatic dermatitis; dull, coarse are fastidious groomers can ingest adult fleas FIGURE 3 FIGURE 4 “Hot spot” or acute moist traumatic dermatitis. One of the Flea comb. This is a useful tool to demonstrate fleas and flea dirt common underlying etiologies of this condition is flea allergy or to clients who are in denial about the presence of fleas on their pet. flea-bite hypersensitivity. 222 Compendium: Continuing Education for Veterinarians® | May 2009 | CompendiumVet.com
- 25. carrying the tapewormDipylidium caninum (IGRs) or insect development inhibitors (IDIs), and may have segments of D. caninum in should be used as a long-term management their feces. program to effectively eradicate infestation Clinical manifestations of flea allergy der- while minimizing potential drug resistance. matitis in cats can include miliary dermati- If the environment is heavily burdened with tis, eosinophilic granulomas or plaques, or various stages of fleas, environmental con- self-induced alopecia without active lesions trol is also warranted. Vibrations from a (FIGURE 6). Affected areas may include the vacuum cleaner help stimulate emergence of dorsum, inguinal region, caudomedial thighs, the adult flea from the impervious pupa and, head, and neck. hence, increase the likelihood of effective A lack of fleas or flea dirt is commonly reported environmental ectoparasiticide control. One by owners and should not override a diagnosis to two applications of a synthetic pyrethroid of flea allergy dermatitis if clinical suspicion is or fipronil as an environmental spray every 7 high. Intradermal skin testing with flea allergen days should be sufficient, although the addi- may reveal wheal formation with immediate and tion of a household IGR such as methoprene delayed hypersensitivity. Serum in vitro testing for or pyriproxyfen and/or sodium polyborate in flea-specific IgE has variable accuracy and does carpeted areas would produce the best results not identify animals with delayed hypersensitiv- in the house. To avoid any potential adverse ity reactions. Histopathology is nonspecific and reactions, it is best to remove pets from the reveals a superficial perivascular inflammation, treated environment until the products have often containing eosinophils—a pattern that can dried; therefore environmental treatment is QuickNotes be seen in other hypersensitivity reactions. often done in stages. Professionally licensed exterminators should be considered for yards A lack of fleas or Treatment and households that are heavily infested. flea dirt should not Based on current knowledge of flea biology, All blankets, bedding, and rugs that are override a diagno- topical or systemic flea adulticide therapy may favored by the affected pet should be laun- sis of flea allergy be the only management required to establish dered. All carpeted areas and furniture that dermatitis if clinical adequate control over flea infestations. Many can house preadult fleas should be vacuumed, suspicion is high. prescription flea control products are currently and the vacuum bag should be disposed of available (TABLE 1). Ideally, integrated pest immediately. All household pets should be management, including the use of flea adul- prevented access to flea-dense areas, such as ticides along with insect growth regulators porches, garages, and crawl spaces. Contact FIGURE 5 Severe flea infestation. Fleas on a dog before treatment. When the dog was bathed, the water turned red from the extreme amount of flea dirt in the haircoat. CompendiumVet.com | May 2009 | Compendium: Continuing Education for Veterinarians® 223
- 26. TABLE 1 Flea ControlProducts Approved by the US Environmental Protection Agency and/or the US Food and Drug Administrationa Product (Manufacturer) Active Flea Control Species and Minimum Age Dosage/Administration Mode of Action Ingredientsb Program/Sentinel Lufenuron Dogs: 4 weeks Monthly oral; also injectable Inhibitor of chitin biosynthesis (Novartis Animal Health) q6mo feline product Cats: 6 weeks Frontline Plus Fipronil Dogs: 8 weeks Monthly spot-on Fipronil: GABA-gated chloride channel (Merial) antagonist S-Methoprene Cats: 8 weeks S-methoprene: Juvenile hormone analogue (IGR) Advantage Imidacloprid Dogs: 7 weeks Monthly spot-on; can be used Nicotinic acetylcholine-receptor (Bayer Animal Health) weekly antagonist Cats: 8 weeks Advantage Multi Imidacloprid Dogs: 7 weeks Monthly spot-on Nicotinic acetylcholine-receptor (Bayer Animal Health) antagonist Cats: 9 weeks (do not use canine product on cats) K9 Advantix Imidacloprid Dogs: 7 weeks Monthly spot-on Nicotinic acetylcholine-receptor (Bayer Animal Health) antagonist Permethrin Permethrin: Sodium channel modulator Revolution Selamectin Dogs: 8 weeks Monthly spot-on Chloride channel activator (Pfizer Animal Health) Cats: 8 weeks ProMeris for dogs Metaflumizone Dogs: 8 weeks Monthly spot-on Voltage-dependent sodium channel (Fort Dodge Animal blocker Health) ProMeris for cats Metaflumizone Cats: 8 weeks Monthly spot-on Voltage-dependent sodium channel (Fort Dodge Animal blocker Health) Comfortis Spinosad Dogs: 14 weeks Monthly chewable tablet Nicotinic acetylcholine-receptor (Eli Lilly) agonist (spinosyn) Capstar Nitenpyram Dogs: 4 weeks and 2+ lb One tablet prn or daily/EOD Nicotinic acetylcholine-receptor (Novartis Animal Health) antagonist Cats: 4 weeks and 2+ lb Vectra 3D for Dogsc Dinotefuran Dogs: 7 weeks Monthly spot-on Dinotefuran: Nicotinic acetylcholine- (Summit VetPharm) receptor antagonist Permethrin Permethrin: Sodium channel Pyriproxyfen modulator Pyriproxyfen: Juvenile hormone analogue (IGR) Vectra for Cats & Kittens Dinotefuran Cats: 8 weeks Monthly spot-on Dinotefuran: Nicotinic acetylcholine- (Summit VetPharm) receptor antagonist Pyriproxyfen Pyriproxyfen: Juvenile hormone analogue (IGR) a Adapted with permission from Mark Grossman and Carol Foil, Veterinary Information Network 2008. For the complete chart, visit www.vin.com/Link.plx?ID=37277. (EOD = every other day; prn = as needed) b Ingredients active against other parasites not listed. c This chart reflects the latest revision by VIN in September 2008. Please note that the following product has since become available: Vectra for Dogs and Puppies. 224 Compendium: Continuing Education for Veterinarians® | May 2009 | CompendiumVet.com
- 27. FIGURE 6 Common reaction patterns associated with underlying flea allergic dermatitis in cats. QuickNotes Topical or systemic flea adulticide therapy may be Miliary dermatitis of the dorsum. Self-induced alopecia of the ventral abdomen. the only manage- ment required to establish adequate with feral cats, wildlife, and other unknown therapies. Antihistamines and essential fatty control over flea neighborhood animals should be prevented. acids are not effective in flea-allergic patients. infestations. Eliminating all secondary bacterial and Finally, all animals in the household must Malassezia infections provides short-term relief be treated with ectoparasiticide therapy to pre- of pruritus. Shampoo therapy and short courses vent reestablishment of flea populations and of oral corticosteroids are good adjunctive perpetuation of disease. References 1. Scott DW, Miller WH, Griffin CE. Skin immune system and aller- sensitivity in the dog. Vet Pathol 1985;22:78-81. gic skin disorders. In: Scott DW, Miller WH, Griffin CE, eds. Muller 5. Halliwell RE, Preston JF, Nesbitt JG. Aspects of the immuno- and Kirk’s Small Animal Dermatology. 6th ed. Philadelphia: WB pathogenesis of flea allergy dermatitis in dogs. Vet Immunol Im- Saunders; 2001:543-666. munopathol 1987;17:483-494. 2. Cole LK. Fleas and flea allergy dermatitis. 6th Proc World Congr 6. Kwocka KW. Fleas and related disease. Vet Clin North Am Small Vet Dermatol 2008:119-125. Anim Pract 1987;17:1235-1262. 3. Dryden MW. Flea and tick control in the 21st century: challeng- 7. Reedy LM, Miller WH. In: Reedy LM, Miller WH, eds. Aller- es and opportunities. Vet Dermatol 2008;19(suppl 1):12. gic Skin Diseases of Dogs and Cats. Philadelphia: WB Saunders: 4. Gross TL, Halliwell RE. Lesions of experimental flea bite hyper- 1989:171-187. APPLIED Otitis externa is another common, often frustrating, DERMATOLOGY dermatologic condition. Visit CompendiumVet.com for one expert’s approach to canine otitis externa, “A WEB Practical Approach to Diagnosing and Managing Ear EXCLUSIVE Disease in Dogs,” by Paul Bloom, DVM, DACVD, DAVBP (Canine and Feline). CompendiumVet.com | May 2009 | Compendium: Continuing Education for Veterinarians® 225
- 28. May 2009 Vol 31(5) WEB EXCLUSIVES CE ARTICLES WEB-EXCLUSIVE ARTICLES WEB- EXCLUSIVE ❯❯ Feline Nonregenerative Anemia ❯❯ A Practical Approach to Diagnosing VIDEOS ❯❯ Carrie White and Nyssa Reine and Managing Ear Disease in Dogs Anemia in cats is not a diagnosis but rather a ❯❯ Paul Bloom sign of an underlying disease. The diagnostic In a supplement to the new Applied work-up for an anemic patient is often extensive. Dermatology series, Dr. Bloom describes the If nonregenerative anemia is identified, a number many factors that cause and perpetuate canine of tests may be required to determine its cause, otitis externa and presents his approach to including a close examination of the patient’s treating these often frustrating cases. blood and bone marrow. Although there are standard supportive measures for anemic cats, ❯❯ Overview of Flea Allergy Dermatitis ❯❯ Laryngeal Paralysis specific therapies can be implemented for cer- ❯❯ Andrea Lam and Anthony Yu Videos tain etiologies of nonregenerative anemia. Part This expanded version of the Applied The article “Laryngeal one of this article addresses the pathophysiol- Paralysis in Dogs,” by Dermatology article published in this issue ogy and etiologies of nonregenerative anemia in includes information on currently available Drs. Ralph P. Millard and cats; part two provides an overview of diagnosis flea-control products. Karen M. Tobias in this issue, discusses the use and treatment. of endoscopy to help diagnose this condition. ❯❯ Arterial and Venous Blood Gases NEWS BITES Two endoscopic videos ❯❯ Ricardo Irizarry and Adam Reiss of normal and paralyzed ❯❯ Professor Links Gum Diseases and Blood gas analysis is frequently requested as laryngeal abduction help part of the point-of-care testing for emergency or Heart Problems in Dogs illustrate the concept. critical care patients presenting with metabolic ❯❯ Mucosal Muscarinic Receptors or respiratory abnormalities. With the advent of Enhance Bladder Activity in Cats portable units, information regarding a patient’s with Feline Interstitial Cystitis acid–base balance and ventilation and oxy- genation status can be rapidly obtained. In two ❯❯ Veterinarians Required to Prevent related articles, Drs. Irizarry and Reiss provide Identity Theft information on arterial and venous blood gas analysis with the goal of helping clinicians ❯❯ Feline Diet Study Triggers Nervous integrate such data in their case management. System Repair Discovery E-NEWSLETTER ❯❯ COMPENDIUM EXTRA, a monthly e-newsletter, provides Web-exclusive articles and news as well as a preview of this month’s journal. Sign up at CompendiumVet.com. CONTACT US ❯❯ E-mail your questions, suggestions, corrections, or letters to the editor: editor@CompendiumVet.com 226 Compendium
- 29. Looking for newteam members? Reach over 56,800 total qualified subscribers1 — plus the virtually unlimited Internet audience — with your classified ad in COMPENDIUM. Reserve your space today! Toll-free: 800-920-1695 Email: CompendiumClassifieds@vetlearn.com Web: www.VetClassifieds.com/placeanad Fax: 201-231-6373 SPECIAL OFFER Buy 2 Ads, Get 1 FREE!* 1 Source: December 2008 BPA Statement. *Restrictions apply; call or see website for details. Limited time offer valid for new/renewing classified advertising orders placed in or prior to August 2009 issue only. Indicate promo code 1E0405 to receive free ad placement. OCTOBER 12–15, 2009 Atlantic City Convention Center Atlantic Coast Veterinary Conference Offering the best value in veterinary continuing education — plus the excitement of Atlantic City! Check out everything that's included in your registration fee: • WORLD CLASS CE in a relaxed, smoke-free environment, • We provide over 330 hours of stimulating education in an featuring more than 40 of the foremost veterinary speakers environment that emphasizes the entire veterinary team across the United States • 23 RACE approved Continuing Education credits • Breakfast and lunch included Tuesday, Wednesday & Thursday • Wet labs for veterinarians: Ultrasound, Rigid Endoscopy, Ear • “Ask The Professor” Lunch Sessions Therapeutics, Stifle Procedures, Tibial Tuberosity Advancement, • Proceedings on-line (pre-conference) and provided on CD-ROM and more! (also available in printed version) • Wet labs for technicians: Animal Behavior, Canine CPR, Dental • Access to over 200 of the leading suppliers of veterinary goods Radiography, Clinical Chemistry, Instrument Care, and more! and services will be exhibited Wet Lab Space is Limited! Be sure to register early! www.acvc.org 390 Amwell Road, Suite 403, Hillsborough, NJ 08844 p 908.359.1184 | f 908.450.1340 | e info@acvc.org
- 30. DERMDIGEST Treating Dermatology Cases: The Secrets to Success Joel Sailor, DVM Town & Country Veterinary Clinic Starke, Florida In today’s tight economy, there is tendency to assume that people don’t want or need our services. The last time I checked though, conditions such as atopy, diabetes, renal disease, and hypothyroidism were completely unaffected by the financial state of domestic or A step-by-step foreign markets. Family is often the one thing people find solace in during tough financial times. For my clients, this includes both two-legged and four-legged family members. As a practitioner, I am encouraged by the devotion clients continue to display toward their pets. approach It is tempting to try to take shortcuts in an effort to save money when doing diagnostic work-ups on patients, but this is not what our clients want. They certainly want to spend that includes as little money as possible, but not at the expense of their pet’s health. Take It Step by Step the entire To avoid unnecessary procedures in making the correct diagnosis and identifying the appropriate treatment, a step-by-step approach that includes the entire practice team is helpful. The purpose is not to remove the doctor from the process but rather to give him or practice team her a platform from which to excel. The example I would use is beef Wellington. This is a well-known and often signature dish for many chefs, but all have put their own spin on the entrée while maintaining the integrity of the dish. In terms of allergic patients, we would is helpful. like the owners to recognize our efforts in creating an expertly crafted dermatologic work-up and treatment plan. I believe a practice succeeds or fails as a team. Therefore, it is necessary that all doctors and staff members follow a well-conceived and well-written protocol. This is easier for smaller practices but shouldn’t be difficult in larger practices if we can check our pride at the door when creating protocols for the team. Protocols can be developed based on both current literature and consultations with a dermatology specialist. For all “skin cases” seen at my practice, we generally begin with a conversation with clients about the complexity of dermatologic disease. This starts with the receptionist and is repeated by the technician and doctor. The initial history is taken by the technician using a scripted survey questionnaire and is then expanded based on questions asked by the attending doctor. An important step in avoiding misdiagnosis is to establish a minimal test database that is used for every patient. For first-time evaluations, we perform a three-slide cytology panel that consists of an ear swab, skin scrape, and adhesive tape preparation of affected areas. These samples can be collected by the technician or doctor depending on the experience of the staff. Tiffany Carty, one of our technicians, puts it best: “Being able to get and process cytology samples for our skin cases not only speeds our diagnostic process, it also helps me feel like an integral part of the medical team.” We then address any existing parasites or infections. Depending on the severity of the pruritus, we may prescribe antihistamines and a corticosteroid to ameliorate the itching and prevent further skin damage. This information has not been peer reviewed and does not necessarily reflect the opinions of, nor constitute or imply endorsement or recommendation by, the Publisher or Editorial Board. The Publisher is not responsible for any data, opinions, or statements provided herein.
- 31. Sponsored by NovartisAnimal Health US, Inc., maker of Atopica Brief Summary: For full product information see product insert. Caution: Federal (USA) law restricts this drug to use by or on the order of a licensed veterinarian. Description: ATOPICA (cyclosporine capsules, USP) MODIFIED is an oral form of cyclosporine that immediately forms a microemulsion in an aqueous environment. Consider Product Turns When Indications and Usage: ATOPICA is indicated for the control of atopic dermatitis in dogs weighing at least 4 lbs body weight. Pricing Dermatology Products Dosage and Administration: The initial daily dose of ATOPICA is 5 mg/kg/day (3.3- 6.7 mg/kg/day) as a single daily dose for 30 days. Following this initial daily treatment A rapidly turning product is one that is purchased repeatedly by the same client. Com- period, the dose of ATOPICA may be tapered by decreasing the frequency of dosing to every other day or two times a week, until a minimum frequency is reached which pared with products such as heartworm preventives, which are purchased once or twice will maintain the desired therapeutic effect. ATOPICA should be given at least one hour before or two hours after a meal. If a dose is missed, the next dose should be a year, rapidly turning products provide income all year long. Thus, the markup on administered (without doubling) as soon as possible, but dosing should be no more these products can be lower and still result in a higher net profit by year’s end. frequent than once daily. See Product Insert for dosing chart. Contraindications: ATOPICA is contraindicated for use in dogs with a history of neoplasia. A recheck in 1 month is a must. We repeat the history, focusing on any changes WARNINGS: ATOPICA (cyclosporine) is a potent systemic immunosuppressant that may increase the susceptibility to infection and the development of neoplasia. since the last visit. At this visit, we move toward addressing the allergies present, Human Warnings: Not for human use. Keep this and all drugs out of reach of children. For use only in dogs. starting with a discussion of the long-term solutions available for the life-long Precautions: Gastrointestinal problems and gingival hyperplasia may occur at the issue of allergies. At this stage we will begin a course of ATOPICA® (cyclosporine initial recommended dose. ATOPICA should be used with caution with drugs that affect the P-450 enzyme system. Simultaneous administration of ATOPICA with drugs that capsules, USP) MODIFIED in patients with suspected atopy, and any residual suppress the P-450 enzyme system, such as ketoconazole, may lead to increased plasma levels of cyclosporine. infections—the most frequent cause for failure with ATOPICA therapy—are The safety and effectiveness of ATOPICA has not been established in dogs less than 6 addressed. We commonly employ a nontraditional markup for ATOPICA because months of age or less than 4 lbs body weight. ATOPICA is not for use in breeding dogs, pregnant or lactating bitches. it is a rapidly turning inventory item in our practice, similar to pet food. This Since the effect of cyclosporine use on dogs with compromised renal function has not been studied ATOPICA should be used with caution in dogs with renal insufficiency. keeps the product affordable for clients while still creating tremendous profit for There have been reports of convulsions in human adult and pediatric patients receiving the practice. We also market any rebates available at the time. cyclosporine, particularly in combination with high dose methylprednisolone. Killed vaccines are recommended for dogs receiving ATOPICA because the impact of Patients are again rechecked in 1 month to reassess treatment. If they are cyclosporine on the immune response to modified live vaccines is unknown. As with any immunomodulation regimen, exacerbation of sub-clinical neoplastic conditions may doing well, we continue with the therapy; if not, we will switch to a food trial. occur. Any changes in treatment are based on the patient’s history since the previous Adverse Reactions: A total of 265 dogs were included in the field study safety analysis. One hundred and eleven (111) dogs were treated with placebo for the first 30 visit. We continue this process until management of the symptoms is achieved. days. For the remainder of the study, all dogs received ATOPICA capsules. Four dogs withdrew from the study after vomiting. One dog each withdrew from the study after diarrhea; vomiting, diarrhea and pruritus; vomiting, depression and lethargy; lethargy, Prevent Personal Bias anorexia and hepatitis; gingival hyperplasia, lethargy, polyuria/polydipsia and soft stool; seizure; sebaceous cyst; pruritus; erythema; or otitis externa respectively. Part of our success is not allowing any personal bias about cost enter our Vomiting (30.9%) and diarrhea (20.0%) were the most common adverse reactions occurring during the study. In most cases, signs spontaneously resolved with continued discussions with clients. We automatically assume they want the best for their pet dosing. In other cases, temporary dose modifications (brief interruption in dosing, divided dosing, or administration with a small amount of food) were employed to and would prefer to avoid long-term use of corticosteroids. Clients are looking for resolve signs. answers to their pets’ problems. I am certain that those who are hesitant to follow Persistent otitis externa (6.8%), urinary tract infections (3.8%), anorexia (3.0%), gingival hyperplasia (2.3%), lymphadenopathy (2.3%) and lethargy (2.3%) were the our recommendations are picking up on my inadvertent projection of bias about next most frequent adverse events observed. Gingival hyperplasia regressed with dose tapering. Owners of four dogs reported seizures while dogs were receiving ATOPICA. In the cost. When I am more confident in my recommendation, compliance usually one dog, seizures were the result of a brain tumor diagnosed one month into the study. Another dog experienced seizures before and after the study. follows. Of course, there are clients who cannot afford our recommended The following clinical signs were reported in less than 2% of dogs treated with ATOPICA treatment plan, but it is our part to recommend and theirs to let us know their in the field study: constipation, flatulence, Clostridial organisms in the feces, nausea, regurgitation, polyuria/polydipsia, strong urine odor, proteinuria, pruritus, erythema/ limitations. So we always make our best recommendation first; if that is not flushed appearance, pyoderma, sebaceous adenitis, crusty dermatitis, excessive shedding, coarse coat, alopecia, papillomas, histiocytoma, granulomatous mass or within their budget, then and only then do we offer a second-best option. lesion, cutaneous cyst, epulis, benign epithelial tumor, multiple hemangioma, raised nodule on pinna, seizure, shaking/trembling, hind limb twitch, panting, depression, * * * irritability, hyperactivity, quieter, increased light sensitivity, reluctance to go outside, weight loss, hepatitis. I have purposely left out specific details about our protocol because your Clinical Pathology Changes: During the study, some dogs experienced changes in clinical chemistry parameters while receiving ATOPICA, as follows: elevated creatinine (7.8%), team needs to create its own protocol to be successful. The main points I can’t hyperglobulinemia (6.4%), hyperphosphatemia (5.3%), hyperproteinemia (3.4%), hypercholesterolemia (2.6%), hypoalbuminemia (2.3%), hypocalcemia (2.3%) and emphasize enough are to (1) standardize how you handle these cases, (2) price elevated BUN (2.3%). your treatments realistically for both the client and the practice, and (3) Post-approval Experience: Neoplasms have been reported in dogs taking ATOPICA, including reports of prevent personal bias from dictating what you recommend to your clients. lymphosarcoma and mast cell tumor. It is unknown if these were preexisting or developed de novo while on ATOPICA. In post-approval drug experience reporting the following additional adverse reactions As with all drugs, side effects may occur. In a field study, the most common side have been associated with ATOPICA administration in dogs: vomiting, diarrhea, depression/lethargy, anorexia, pruritus, liver enzyme elevations, trembling, convulsions, effects were gastrointestinal signs. Gingival hyperplasia and papillomas may polydipsia, polyuria, weight loss, hyperactivity, nervousness, neoplasia. also occur during the initial dosing phase. ATOPICA is a systemic immunosup- To report suspected adverse reactions or for technical assistance, call 1-800-332-2761. pressant that may increase the susceptibility to infection. ATOPICA is not for use Manufactured for: Novartis Animal Health US, Inc. in reproducing dogs or dogs with a history of neoplasia. Greensboro, NC 27408, USA NADA 141-218, Approved by FDA ©2008 Novartis Animal Health US, Inc. ATOPICA is a registered trademark of Novartis AG. NAH/ATO-GC/BS/5 07/08 ATO09DIGEST1
- 32. Abstract Thoughts Offeringa brief look at the latest important research presented in the international veterinary literature. Idiopathic Inflammation of Epidural Fat in Dachshunds Aikawa T, Yoshigae Y, Kanazono S. Epidural idiopathic sterile pyogranulomatous inflammation causing spinal cord compressive injury in five miniature dachshunds. Vet Surg 2008;37:594-601. Column Editor ABSTR ACT This retrospective study from a veterinary medical cen- ❯❯ Joseph Harari, MS, DVM, DACVS ter in Tokyo describes the clinicopathologic features of idiopathic sterile Veterinary Surgical Specialists pyogranulomatous inflammation of epidural fat causing spinal cord com- Spokane, Washington pression in five mature miniature dachshunds. During the time interval of the study (2000–2006), 515 miniature dachshunds were surgically treated for thoracolumbar disk disease. Three of the five dogs identified as hav- ing idiopathic sterile pyogranulomatous inflammation of epidural fat were ambulatory and had chronic paraspinal pain; the other two dogs were acutely paraparetic/paraplegic and nonambulatory. No abnormalities were detected on hematologic profile tests. Three dogs had received predniso- lone therapy for 1 to 5 months before admission. Myelography indicated focal or multifocal extradural spinal compression in the thoracolumbar region in all five dogs. Hemilaminectomy revealed a compressive, easily removable mass of epidural fat characterized histologically as pyogranu- lomatous inflammatory steatitis. Microbial culture of the surgical specimen was conducted for two dogs and yielded no bacterial growth. All dogs recovered well from surgery and were ambulatory within 1 to 18 days. Improved neurologic status was noted for a median of 17 months after surgery. Two dogs had other pyogranulomatous lesions after surgery, and four dogs received postoperative prednisolone therapy. COM MEN TA RY Intervertebral disk disease in dachshunds is a common clinical scenario for small animal practitioners. Dogs can present with variable neurologic signs, and diagnostic imaging is critical in estab- TO LEARN MORE lishing a diagnosis. The results of this study should alert clinicians to the possibility of a compressive thoracolumbar spinal lesion in dachshunds that is not an intervertebral disk-related lesion. Although myelography pro- Take CE tests vided significant diagnostic information about the location of the lesion, it Access full-text articles would be interesting to know in future studies if cerebrospinal fluid analy- Watch videos sis or magnetic resonance imaging would be beneficial in the work-up of these cases. It appears that surgical decompression and histologic evalua- You can find these at tion of excised tissue were critical in recovery and the fi nal diagnosis. It is CompendiumVet.com interesting to note the systemic involvement of pyogranulomatous disease in some of the dogs and the inconclusive effects of corticosteroids. 230 Compendium: Continuing Education for Veterinarians® | May 2009 | CompendiumVet.com
- 33. Exceeding client expectations “ No matter you are such ahave been in thisin the human–animal bond. to know that how long you trusted partner profession, it’s always humbling Knowing that my clients can access their Pet Portal® to find good medical advice, review their pet’s medical records, and receive medication reminders allows me to consistently meet their needs — and exceed their expectations — even when I have no extra time. Vetstreet ensures client satisfaction and compliance without additional work for me or my staff. ” Gary Edlin, DVM Owner, East Louisville Animal Hospital Louisville, KY Easy to set up and easy to use, Vetstreet® is a powerful practice communication and management tool that keeps you in touch with your clients via Pet Portals. To discover how Vetstreet can help you increase client satisfaction, build compliance, and enhance your bottom line, visit Vetstreet.com, call toll-free 888-799-8387 or email info@vetstreet.com. , Vetstreet and Pet Portal are registered trademarks of VetInsite.com, Inc.
- 34. 3 CE CREDITS CE Article 2 Pneumothorax ❯❯ Karl C. Maritato, DVM Abstract: Pneumothorax may be classified as open or closed and as traumatic, spontaneous, or MedVet Medical and Cancer iatrogenic. The most common cause of pneumothorax is thoracic trauma. Spontaneous pneu- Center for Pets Worthington, Ohio mothorax is often a result of bullous emphysema, and iatrogenic pneumothorax is an important complication of procedures involving the thoracic cavity. Most animals present with tachypnea, ❯❯ José A. Colón, DVM ❯❯ David H. Kergosien, MS, tachycardia, respiratory distress, and anxiety. Radiography and thoracocentesis are useful diag- DVM, DACVS nostic aids. Traumatic and iatrogenic pneumothorax are commonly treated with thoracocentesis ❯❯ Louisiana Veterinary Referral or thoracostomy tube placement. Spontaneous pneumothorax usually requires surgical resection Center of the affected lobe(s). The prognosis for traumatic pneumothorax is excellent if there are no other Mandeville, Louisiana life-threatening injuries; for spontaneous pneumothorax, the prognosis depends on the underlying cause and method of treatment. The prognosis for iatrogenic pneumothorax is considered good. P neumothorax is classified as open results from a penetrating thoracic injury or closed and according to the such as a stab, gunshot, or bite wound. causative mechanism. Open pneu- mothorax results from a penetrating tho- Spontaneous racic injury that permits entry of air into Spontaneous pneumothorax is not the At a Glance the chest, while closed pneumothorax is the accumulation of air originating from result of traumatic injury and is classified as closed. Spontaneous pneumothorax is less Causative Mechanisms the respiratory system within the pleural common than traumatic pneumothorax,1,7–10 Page 232 space. In some cases, the air may come Effects from both sources (e.g., severe thoracic BOX 1 Page 234 bite wounds with lung punctures). Types and Causes of Signalment Page 234 Causative Mechanisms Pneumothorax Pneumothorax is classified as traumatic, History Page 234 spontaneous, or iatrogenic according to Traumatic its cause1 (BOX 1). Physical Examination ❯ Open: Stab, gunshot, bite wounds Page 235 ❯ Closed: Impact (inflicted by person Traumatic or car) Diagnostic Evaluation Traumatic pneumothorax is the most com- Page 235 Spontaneous mon form of pneumothorax in dogs.1–6 ❯ Cavitary lung lesions: Bullae/blebs, Treatment Traumatic pneumothorax can be open cysts, abscesses/granulomas, Page 236 or closed1; however, it is usually closed.2 pneumatoceles, parasitic cysts Postoperative Thoracotomy Closed traumatic pneumothorax is often (Paragonimus spp) and Monitoring the result of blunt trauma (e.g., automo- ❯ Grass awns/porcupine quills Page 240 bile accident). When the chest is com- ❯ Pneumonia pressed against a closed glottis, the ❯ Dirofilaria immitis Prognosis Page 240 bronchial tree or lung parenchyma can ❯ Neoplasia rupture with resultant air leakage into ❯ Feline asthma the pleural space.3,4 If a large airway is Iatrogenic injured, pneumomediastinum may be ❯ Thoracic fine-needle aspiration present.5,6 Fractured ribs can lacerate lung ❯ Tracheal intubation lobes, resulting in closed traumatic pneu- ❯ Mechanical ventilation mothorax.3 Open traumatic pneumothorax 232 Compendium: Continuing Education for Veterinarians® | May 2009 | CompendiumVet.com
- 35. FREE Pneumothorax CE has several different etiologies, and is classified rapid closure of parenchymal–pleural fistulas.32 as primary (no obvious clinical evidence of pul- Iatrogenic pneumothorax has rarely been monary disease) or secondary (obvious clinical associated with tracheal rupture due to intu- evidence of pulmonary disease).4,11,12 The most bation in cats if the pressure is high enough common cause of spontaneous pneumothorax to rupture the mediastinum33 (FIGURE 2). The is the rupture of pulmonary blebs or bullae most common cause of tracheal rupture is (bullous emphysema).1,7,8,10,12,13 Pulmonary blebs overinflation of the endotracheal tube cuff5; result from air that has accumulated within other causes include rotation of the animal the visceral pleura.12,14,15 Bullae are the result of without disconnection from the anesthesia destruction, dilation, and convergence of con- machine tubing, traumatic intubation with a tiguous alveoli14,15 secondary to obstruction of the small airways13 and are found within the FIGURE 1 lung parenchyma. Blebs most commonly arise at the apex of the lung lobes13 (FIGURE 1). In cases of single lung lobe involvement, the right middle lung lobe is overrepresented.16 Rupture of the bullae and blebs is thought to be due to obstruction of the small airways. Courtesy of John V. Mauterer, DVM, DACVS Blebs and bullae belong to a class of pul- monary lesions known as cavitary lung lesions.17 Other cavitary lung lesions that may result in secondary spontaneous pneumotho- rax include pneumatoceles, abscesses, cystic bronchiectasis, and parasitic cysts. Other causes of secondary spontaneous pneumothorax are grass awn migration, por- cupine quill migration, pneumonia, chronic granulomatous infections, Dirofilaria immitis infections, and neoplasia.7,8,10,13,16,18–27 Seven cats Intraoperative photograph of a pulmonary bleb. Note that the bleb is at with small airway disease secondary to feline the apex of the lung lobe. lower airway disease (asthma) were reported to have closed spontaneous pneumothorax.28,29 FIGURE 2 Asthma can predispose cats to increased alveo- lar pressure and emphysema resulting in spon- taneous pneumothorax. 29 Congenital lobar emphysema secondary to bronchial cartilage hypoplasia and bronchiectasis has also been reported in the literature as a cause of sponta- neous pneumothorax.22,23,30 Because bilateral involvement is common and tension pneumothorax can result, sponta- neous pneumothorax should be considered a serious, life-threatening disease.7 Iatrogenic Thoracic fine-needle aspiration is a common cause of closed iatrogenic pneumothorax.1,12,31 Chronic effusions such as chylothorax, pyotho- rax, and malignant pleural effusions increase the Radiograph of a cat with iatrogenic pneumothorax, pneumomediasti- risk of pneumothorax after thoracic aspiration. num, and subcutaneous emphysema (arrow) as a result of tracheal Chronic effusions often result in fibrosing pleu- tear after tracheal intubation. The single arrowhead indicates cardiac silhou- ritis, which leads to the persistence rather than ette elevation. The double arrowhead indicates lung lobe atelectasis. CompendiumVet.com | May 2009 | Compendium: Continuing Education for Veterinarians® 233
- 36. FREE CE Pneumothorax stylet, and removal of the tube without defla- causing collapse of the lungs and great veins.11 tion of the cuff.33 Tracheoscopy is considered The patient rapidly deteriorates4,11,37 and dies. the method of choice for documenting tra- Radiographs should never be used for diagnosis cheal tears.5 in animals with tension pneumothorax because Positive end-expiratory pressure mechani- the associated delay and stress may result in the cal ventilation can lead to barotrauma and death of the patient. iatrogenic pneumothorax, especially in ani- mals with pulmonary parenchymal disease Signalment requiring high pressure. Jugular venipuncture Traumatic causing tracheal laceration and the lateral sur- Traumatic pneumothorax is most common gical approach to the thoracolumbar vertebrae in young, intact male dogs because they are are other reported causes of iatrogenic pneu- more apt to wander and be hit by cars.2,8 mothorax in cats and dogs, respectively.3 Spontaneous Effects Primary spontaneous pneumothorax is most Bilateral pneumothorax is the most common common in deep-chested, large-breed dogs.1,12,13 condition1,7,12,13,34 because air diffuses through Studies have shown that Siberian huskies the thin mediastinum.4 Pneumothorax is con- have a significantly greater incidence of pri- sidered a restrictive disorder of the lung.11 A mary spontaneous pneumothorax than other QuickNotes decrease in the lung’s compliance due to extra- breeds.1,38 Animals of any age can develop Pneumothorax can pulmonary air is the primary defect.31 When pneumonia or become infected with respira- air enters the pleural space, the negative pres- tory parasites or heartworms. Older animals result from trau- sure of the pleural space is diminished, allow- are more likely to develop pneumothorax sec- matic, spontaneous, ing the lung’s inherent elastic recoil to result ondary to neoplasia of the lungs. or iatrogenic causes. in collapse (atelectasis). Atelectasis leads to a ventilation/perfusion mismatch.11,35 This can Iatrogenic lead to arterial hypoxemia, which in turn may Iatrogenic pneumothorax can occur in any result in myocardial dysfunction, lactic aci- animal undergoing thoracic surgery, anesthe- dosis, and ultimately death if not corrected.35 sia, or mechanical ventilation. Hypercapnia due to hypoventilation magnifies acidosis.36 History When the lungs collapse, the tidal volume Traumatic is reduced, prompting tachypnea in an attempt Patients with traumatic pneumothorax usually to maintain the minute ventilation. 35 Local present with an obvious history of trauma, evi- hypoxia induces vasoconstriction of pulmo- dence of trauma, or a history consistent with nary vessels, diverting blood flow to ventilated trauma, such as, “came home breathing hard.” areas. Vasoconstriction, combined with collapse of blood vessels due to atelectasis, eventually Spontaneous leads to pulmonary hypertension and increased The most common historical complaints from work for the right side of the heart.35 owners of animals presenting with spontane- Tension pneumothorax is the most severe ous pneumothorax include difficulty breath- form of pneumothorax. It can result from blunt ing, anorexia, tachypnea, coughing, and or penetrating thoracic trauma or from spontane- vomiting.1,4,12,39 Lethargy, fever, cyanosis, gag- ous pneumothorax.7 In this form of pneumotho- ging, exercise intolerance, and collapse are rax, thoracic injuries or pulmonary lesions act less commonly reported signs.1 In one study,1 as one-way valves, allowing air into the pleu- the median duration of clinical signs before ral space during inspiration and preventing presentation to a veterinary hospital in dogs expulsion during expiration. A slight increase with spontaneous pneumothorax was 3 days in pressure in the pleural cavity results in a sig- (range: 0 to 28 days); in another study,39 it was nificant decrease in venous return. Blood pools 1 day (range: 1 hour to 3.5 days). in capacitance vessels, and shock results. The continued accumulation of air quickly results Iatrogenic in supraatmospheric pressure within the thorax, Animals with iatrogenic pneumothorax have a 234 Compendium: Continuing Education for Veterinarians® | May 2009 | CompendiumVet.com
- 37. FREE Pneumothorax CE recent history of thoracic aspiration, tracheal cent, air-filled pleural space created as the lungs intubation, anesthesia, or other procedures retract from the parietal pleura (FIGURE 3). As related to the thoracic cavity. the lungs collapse, the vascular pattern of the lungs no longer extends to the chest wall as it Physical Examination does in a healthy animal. Traumatic Animals with traumatic pneumothorax often Traumatic have other injuries associated with the trauma In animals with traumatic pneumothorax, other (e.g., lacerations, scrapes, bruises, fractures). injuries are common, and the patient and the radio- Animals with open pneumothorax secondary graphs should be evaluated carefully for occult or to penetration of the thoracic cavity may have subtle injuries. Diaphragmatic hernia, hemotho- an obvious wound, such as a “sucking tho- rax, rib and vertebral fractures, and pulmonary racic wound” (a large open wound that allows contusions are common concurrent injuries. the influx of air into the chest during inspira- tion).4 In other cases, the wound may not be Spontaneous immediately visible. This is particularly true In animals with spontaneous pneumothorax, for thoracic bite wounds. radiographs should be evaluated for potential underlying causes of pneumothorax. Pneumonia, Spontaneous abscesses, granulomas, neoplasia, and changes Tachypnea, tachycardia, respiratory distress, and secondary to heartworm disease (e.g., tortuous QuickNotes anxiety are common findings during the physi- vessels, enlarged pulmonary arteries) should be Consequences of cal examination of animals with pneumotho- excluded. The presence of bullae or blebs may pneumothorax may rax. Shallow, rapid breaths with an abdominal be difficult to appreciate; however, these lesions component (restrictive breathing pattern) may are occasionally visible (FIGURE 4). In studies of include tachypnea, be noted.1,4 Auscultation of the chest reveals dogs with spontaneous pneumothorax, radio- hypoxemia, tachy- muffled heart and lung sounds dorsally.3,4 graphic bullae have been detected in 4% to 31% cardia, and, if left of cases.1,7,12,39 untreated, cardio- Iatrogenic vascular collapse Subcutaneous emphysema may be present in Iatrogenic and death. cats with concomitant pneumomediastinum Animals with tracheal tears may have subcu- and pneumothorax secondary to tracheal tears taneous emphysema and pneumomediasti- after intubation33 (FIGURE 2). num,5,33 which is noted by the visualization of the cranial vena cava, aorta, and esopha- Diagnostic Evaluation FIGURE 3 Laboratory Evaluation Complete blood count and biochemical pro- file results are usually normal, nonspecific, or related to concomitant disease.12,39 Blood gas analysis may document hypoxemia as well as respiratory acidosis due to hypoventila- tion and hypercapnia.36 In animals with pneu- mothorax secondary to heartworm disease, results of occult heartworm tests are posi- tive. Paragonimus infections can be identified using Baermann sedimentation fecal examina- Courtesy of Dr. Mauterer tion18,40 or transtracheal aspiration.18 Radiography Animals in severe distress should undergo tho- racocentesis before radiography. Lateral tho- racic radiographs show elevation of the cardiac silhouette from the sternum. Atelectatic lung Radiograph showing severe pneumothorax. Note cardiac silhouette eleva- lobes are radiopaque in contrast to the radiolu- tion (bracket) and lung lobe atelectasis (arrowhead). CompendiumVet.com | May 2009 | Compendium: Continuing Education for Veterinarians® 235
- 38. FREE CE Pneumothorax gus (normally not visible in healthy animals; Thoracocentesis carries the risk of lacerat- FIGURE 2). In animals that develop pneu- ing or puncturing a lung lobe, which results mothorax after thoracocentesis, rounded lung in iatrogenic pneumothorax; however, proper margins, consistent with chronic effusion, may technique, caution, and recognition of at-risk be seen (FIGURE 5). patients can minimize these complications.45 Computed Tomography Treatment Computed tomography (CT) is routinely used Supplemental Oxygen in people for the diagnosis of bullae and blebs Because atelectasis and ventilation/perfusion because it is considered more sensitive than radi- mismatch can lead to hypoxia, animals with ography.41 The accuracy of lesion identification pneumothorax may benefit from supplemental using CT in humans has been shown to range oxygen.35 Oxygen therapy may also be benefi- from 88% to 91.8%.42–44 One study39 comparing cial because these animals may have respira- the accuracy of radiography and CT for bullae tory and metabolic acidosis and hypercapnia.36 and bleb identification in dogs with spontaneous In animals with closed pneumothorax, oxy- pneumothorax found radiography to be accurate gen therapy can hasten the resolution of the in 16% of cases and CT to be accurate in 80% pneumothorax. The full physiology behind QuickNotes of cases. The authors of this study suggested that this mechanism is beyond the scope of this CT was a better diagnostic tool than radiography article; however, it is based on differences in Radiographs readily for the identification of lung lesions associated partial pressures of blood gases. The extrapul- depict pneumotho- with spontaneous pneumothorax.39 However, in monary air of pneumothorax contains mainly rax; however, the many veterinary patients, a CT scan is not per- nitrogen and oxygen (~21%) and other minor underlying cause formed preoperatively because the findings may constituents. The partial pressure of oxygen may not be evident not change the surgical approach and because in the blood is approximately 100 mm Hg at on plain-film radio- of the additional costs. sea level and normal barometric pressure (760 graphs. Computed mm Hg).46 When the oxygen content of the air tomography may Thoracocentesis delivered to an animal is higher than 21%, the Thoracocentesis is beneficial in that it may partial pressure in the blood increases. This be useful in some be both diagnostic and therapeutic (BOX 2). causes a decrease in the partial pressure of cases. Often, radiography is conducted before thora- other gases in the blood (e.g., nitrogen), which cocentesis. However, thoracocentesis may be in turn creates a pressure gradient for these performed in a rapidly deteriorating patient gases to diffuse from the pneumothorax into without prior radiography.4,45 the blood and eventually out of the system through respiration. Oxygen can be delivered FIGURE 4 by mask, nasal cannula, or cage/tank. It is important to minimize stress in these animals; therefore, for fractious or excited patients, an oxygen cage may be the best option. Thoracocentesis In animals with traumatic, closed pneumotho- rax, thoracocentesis can be curative, and recurrence is uncommon.4,37,45 Thoracocentesis should restore negative pressure within the thoracic cavity. If negative pressure cannot be reached, >10 mL/kg of air is aspirated within Courtesy of Dr. Mauterer a 12-hour period, or repeated aspiration is required to alleviate respiratory distress, chest tube placement should be considered.2,8,47 Open chest wounds should be covered imme- diately with a sterile, occlusive dressing to prevent further equilibration with atmospheric Radiograph of a pulmonary bulla (arrowhead). pressure and allow effective aspiration of air. 236 Compendium: Continuing Education for Veterinarians® | May 2009 | CompendiumVet.com
- 39. FREE Pneumothorax CE BOX 2 Basic Steps of Thoracocentesis 1. Restrain the animal appropriately in make additional small holes in the catheter either sternal or lateral recumbency. that are about one-third the diameter of With the patient in lateral recumbency, the catheter. the 7th to 9th intercostal space at the 5. Gently insert the needle through the skin, level of the costochondral junction is an subcutaneous tissue, fascia, and intercos- appropriate location for thoracocentesis.4 tal muscles cranial to the rib to avoid the In standing or sternal animals, the same intercostal vessels and nerves, which lie just intercostal spaces can be used; however, caudal to the ribs. Aspirate while the needle needle placement should be in the dorsal is being advanced to allow appreciation of two-thirds to one-third of the thorax.4 the proper depth.4 A gentle “pop” may be felt 2. Clip and aseptically prepare the 7th to as entry into the pleural cavity is achieved. 9th intercostal space. 6. Turn the needle so that the bevel is facing 3. A local anesthetic block of the area is medially and the needle is against the rib encouraged.4 cage to reduce the risk of lung laceration. QuickNotes 4. In small dogs and cats, a butterfly 7. Aspirate and quantitate the amount of air catheter (19 to 23 gauge) connected to a removed from the pleural cavity. Traumatic and three-way stopcock may be used for aspi- 8. Once negative pressure is achieved, be iatrogenic pneu- ration.44 In larger dogs or obese animals, sure not to aspirate while removing the mothorax are com- a large-bore over-the-needle catheter needle/catheter from the pleural cavity. monly treated by connected to an extension set, three-way 9. If no air is aspirated, redirect, tap a dif- thoracocentesis stopcock, and syringe may be used44 ferent site, or stop if the animal is no longer (FIGURE A). A #11 blade can be used to clinically dyspneic.44 or tube thoracos- tomy; spontaneous FIGURE A pneumothorax often requires exploratory thoracotomy or thoracoscopy for resection. Photograph showing proper needle placement and technique for thoracocentesis. CompendiumVet.com | May 2009 | Compendium: Continuing Education for Veterinarians® 237
- 40. FREE CE Pneumothorax Tube Thoracostomy quantification of the air accumulating within Thoracostomy tube placement is indicated the chest. When the tube is not being used, a when reaccumulation of air in the pleural hemostat, C-clamp, or commercially available space is too rapid or severe to be controlled plastic clamp can be placed over the tube to by thoracocentesis, thoracocentesis is per- prevent aspiration of air into the tube.48 formed more than three times in a 24-hour Continuous closed-suction drainage is indi- period, or severe or tension pneumothorax is cated when air accumulation is very rapid and present.1,7,8,10,47,48 Placement of a thoracostomy intermittent suction is not effective in achiev- tube allows air to be removed intermittently ing negative pressure. Continuous suction or continuously, as necessary. BOX 3 briefly is based on the underwater suction system. describes tube placement and maintenance. Commercially available continuous-suction This procedure has been more fully described units include the Pleur-Evac (Teleflex Medical, elsewhere.47,48 Research Triangle Park, NC). These systems Intermittent drainage is usually sufficient require constant monitoring (because patients if the amount of air accumulating is not life- can easily remove or damage the tubes) and threatening or very rapid. This method allows do not allow quantification of the air removed BOX 3 Basic Steps of Thoracostomy Tube Placement The tubes should be flexible but firm and resis- The appropriate size of the tube is determined tant to collapse.47 Polyvinyl thoracic drainage by the size of the mainstem bronchus on tubes with stylets to assist with placement are radiographs.45,47 Commercial tubes come with commercially available (Argyle, Sherwood Medi- preplaced holes; however, additional holes can cal) (FIGURE A). Red rubber feeding tubes may be added to achieve a total of three to five holes, cause tissue reaction but may be used if other which is sufficient for drainage. Many commer- commercial tubes are unavailable and long-term cial tubes also have an incorporated longitudinal placement is not anticipated.2 radiopaque marker to allow visualization of the tube on radiographs. If additional holes are FIGURE A placed, the last hole should be on the ra- diopaque marker line to allow assessment of the tube’s placement within the thoracic cavity. The tube is generally placed with the animal under general anesthesia. If the animal’s status precludes general anesthesia, local intercostal nerve blocks that include the parietal pleura may be used.45,47 The lateral thorax is clipped and prepared asep- tically before tube placement. For medium and large dogs: 1. Make a small stab incision in the skin in the dorsal one-third of the thorax at the 10th to 12th intercostal spaces. 2. Make a tunnel in the subcutaneous tissue three to four intercostal spaces cranially using Instruments needed for place- the tube with the stylet. If using a red rubber ment of a thoracostomy tube. (A) Thoracostomy tube. catheter or a tube without a stylet, use a pair (B) 5-in-1 (Christmas tree) adapter. of large hemostatic forceps to create the tun- (C) Three-way stopcock. nel and advance the tube.48 (D) Surgical (cerclage) wire. 3. Rotate the tube perpendicular to the thoracic wall. 238 Compendium: Continuing Education for Veterinarians® | May 2009 | CompendiumVet.com
- 41. FREE Pneumothorax CE from the thoracic cavity. Some clinicians pre- ment of spontaneous pneumothorax second- fer these systems because they can maintain ary to infective pleuropneumonia using only a lung inflation, which may facilitate healing. thoracostomy tube with a Heimlich valve. Heimlich valves are designed to use the Thoracostomy tubes can be removed when pressure generated by expiration to expel air production is absent for 24 to 48 hours. pleural air while preventing air from entering These tubes may cause a small amount of the pleural cavity during inspiration. These effusion (2 to 4 mL/kg/day), which resolves devices should only be used in medium- to when the tube is removed.4,2,45,48 The tube is large-breed dogs because small dogs and cats removed with steady traction and the site cov- may not produce enough pressure on expira- ered with an occlusive bandage for 6 to 24 tion to expel the air.4,47 They should not be hours; the incision is allowed to heal by sec- used in patients with pleural effusion because ond intention.48 the valve will fill and seal, preventing air Treatment of spontaneous pneumothorax expulsion.47 If a Heimlich valve is oriented by thoracocentesis or thoracostomy tube alone incorrectly, iatrogenic tension pneumothorax is usually insufficient because recurrence is results. Salci et al49 reported successful treat- common.1,7,8,10,12,50 4. With one quick, brisk thrust, pass the tube (or FIGURE B hemostat) through the intercostal musculature into the thoracic cavity. However, use caution, as too brisk an entry into the thoracic cavity may cause inadvertent damage to thoracic organs. Also, as for thoracocentesis, be care- ful to avoid the large intercostal vessels and nerves just caudal to the ribs. 5. Once penetration is achieved, lay the tube parallel to the spine, advance it slightly, and remove the stylet, passing the tube cranially and ventrally into the cranial pleural space. 6. Obtain a radiograph to ensure proper place- ment of the tube in the cranioventral pleural space to approximately the level of the second Radiograph showing proper placement of a thoracostomy tube. rib48 (FIGURE B). 7. Place a purse-string suture at the entry site into the thoracic cavity to prevent leakage of For small dogs, puppies, and cats, in which the air or fluid into the subcutaneous tissue.48 chest is too compressible for any technique 8. Suture the tube to the skin using a Chinese that requires force, or to avoid having to thrust finger-trap suture pattern or variation thereof.48 the tube into the thorax in larger dogs, use the 9. Attach the tubing to a three-way stopcock, following technique: either directly or with a five-in-one (Christmas 1. After proper preparation of the area, pull the tree) adapter. skin forward to the appropriate space.48 10. Secure the tubing to the stopcock with surgi- 2. Make the skin incision, followed by dissection cal wire to allow intermittent drainage. down through the chest wall.48 11. Cover the tube entry with a few gauze sponges im- 3. Insert the tube in an open fashion or use it to pregnated with a small amount of iodine ointment, gently penetrate the inner intercostal layer.48 followed by a soft, padded bandage or tubular 4. Allow the skin to retract to its normal position, stockinet over the chest to protect the tube. resulting in subcutaneous tunneling of the 12. Apply an Elizabethan collar to prevent prema- tube.48 ture pulling by the animal. 5. Follow steps 6 through 12 above. CompendiumVet.com | May 2009 | Compendium: Continuing Education for Veterinarians® 239
- 42. FREE CE Pneumothorax FIGURE5 spontaneous pneumothorax was successfully Courtesy of Elizabeth Rozanski, DVM, DACVECC, DACVIM diagnosed and treated in three dogs using thoracoscopy, with no evidence of recurrence at 18 to 29 months after surgery. Lung lobec- tomy or biopsy can be performed with less morbidity and mortality using thoracoscopy.52 Minimally invasive surgery is associated with decreased morbidity, less pain, shorter hospi- talization, and a quicker recovery.34,54–56 The experience of the operator is a large variable in the outcome of this procedure. Postoperative Thoracotomy and Monitoring After surgery, patients should be monitored closely for pain, respiratory distress, tachyp- Radiograph of a cat with chronic pleural effusion and pneumothorax secondary to fine-needle aspiration. nea, hypoventilation, and recurrence of pneu- mothorax. The thoracostomy tube should be aspirated every hour for the first 4 to 6 hours postoperatively until negative pressure is Surgical Intervention achieved. Aspiration can then be conducted Traumatic every 4 to 6 hours. In almost all cases, there Surgery is rarely needed to correct traumatic should be little or no ongoing air production. pneumothorax. Thoracocentesis or thoracos- When negative pressure has been maintained tomy is usually sufficient to allow pulmonary for approximately 24 to 48 hours, the thora- healing in 3 to 5 days, and mild pneumotho- costomy tube can be removed. Some sero- rax may require only monitoring.3,37 However, sanguineous discharge may be present while surgery may be indicated to repair open chest the tube is in the chest (approximately 2 to 4 wounds or other wounds related to the trauma. mL/kg/day).48 This will resolve once the tube is removed. If the animal shows any signs Spontaneous of respiratory distress or tachypnea, thoracic Spontaneous pneumothorax is considered a radiography should be conducted to assess for surgical disease because dogs rarely respond pleural effusion, recurrence of pneumothorax, to conservative therapy alone. A lateral or atelectasis, or any other potential lesion. median approach may be used. Median sterno- Postoperative pain is an important consid- tomy is the procedure of choice for exploration eration in animals undergoing surgical explo- of the thorax1,7,8 because it allows visualization ration of the thoracic cavity. Intercostal nerve of both hemithoraces, which facilitates loca- blocks, interpleural regional anesthesia, con- tion of the air leak. Details of this and other tinuous-rate infusion of drugs such as fentanyl surgical techniques have been published in or other opioid analgesics, and NSAIDs are various surgical texts. all viable options to decrease the morbidity associated with these procedures. Appropriate Iatrogenic dosages of these agents have been published Thoracocentesis or thoracostomy tube place- in anesthesia/analgesia texts. ment is usually sufficient for treatment of iatro- genic pneumothorax; however, if conservative Prognosis therapy is unsuccessful, surgery is indicated.3 Traumatic The prognosis for animals with traumatic pneu- Thoracoscopy mothorax is considered excellent12 if there are Thoracoscopy can be used therapeutically and no other life-threatening injuries. as a diagnostic tool if radiography and CT cannot localize a lesion.34,51,52 All structures Spontaneous within the thorax can be sufficiently observed The prognosis for spontaneous pneumothorax using thoracoscopy.34,51,53 In a 2003 study,40 depends on the method of treatment. Surgery 240 Compendium: Continuing Education for Veterinarians® | May 2009 | CompendiumVet.com
- 43. FREE Pneumothorax CE is considered the treatment of choice for spon- Conclusion taneous pneumothorax, with recurrence rates A basic understanding of normal respiratory of 0% to 25% versus 50% to 100% with conser- anatomy and physiology is important in under- vative therapy alone.1,7,10,12 Surgery may also be standing the pathophysiologic effects of pneu- more economical than thoracostomy or thora- mothorax. Early recognition of the clinical signs cocentesis when long-term hospitalization and of pneumothorax is important, especially in care costs are calculated.7 animals with tension pneumothorax, which can cause rapid deterioration and death. A thorough Iatrogenic understanding of lifesaving procedures such as The prognosis for animals with iatrogenic thoracocentesis and thoracostomy tube place- pneumothorax is fair to good. Most animals ment is invaluable. Most animals with traumatic can be treated conservatively.3 In animals with pneumothorax do well with conservative therapy pneumothorax resulting from diagnostic pro- alone, whereas animals with spontaneous pneu- cedures to the thoracic cavity or mechanical mothorax frequently require surgical intervention ventilation, the ultimate prognosis depends on for complete resolution. Iatrogenic pneumotho- the underlying disease. rax can usually be treated conservatively. References 1. Puerto DA, Brockman DJ, Linquist C, et al. Surgical and nonsurgical mothorax and focal peritonitis in a dog due to migration of an in- management of and selected risk factors for spontaneous pneumotho- haled grass awn. Vet Radiol Ultrasound 2004;45(2):136-138. rax in dogs: 64 cases (1986-1999). JAVMA 2002;220(11):1670-1674. 20. Smith JW, Scott-Moncrieff C, Rivers BJ. Pneumothorax second- 2. Monnet E. Pleura and pleural space. In: Slatter D, ed. Textbook of ary to Dirofilaria immitis infection in two cats. JAVMA 1998;213(1): Small Animal Surgery. 3rd ed. Philadelphia: Saunders; 2003:387-405. 91-93. 3. Brockman DJ, Puerto DA. Pneumomediastinum and pneu- 21. Berson JL, Rendano VT, Hoffer RE. Recurrent pneumothorax mothorax. In: King L, ed. Textbook of Respiratory Diseases of Dogs secondary to ruptured pulmonary blebs: a case report. JAAHA and Cats. Philadelphia: Saunders; 2003:616-624. 1979;15:707-711. 4. Fossum TW. Surgery of the lower respiratory system. In: Fos- 22. Herrtage ME, Clarke DD. Congenital lobar emphysema in two sum TW, ed. Small Animal Surgery. 2nd ed. St. Louis: Mosby; dogs. J Small Anim Pract 1985;26:453-464. 2002:788-820. 23. Tennant BJ, Haywood S. Congenital bullous emphysema in a 5. Hardie EM, Spodnick GJ, Gilson SD, et al. Tracheal rupture in dog: a case report. J Small Anim Pract 1987;28:109-116. cats: 16 cases (1983-1998). JAVMA 1999;214(4):508-512. 24. Busch DS, Noxon JO. Pneumothorax in a dog infected with 6. Johnson-Neitman JL, Huber ML, Amann JF. What is your diag- Dirofilaria immitis. JAVMA 1992;201(12):1893. nosis? JAVMA 2006;229(3):359-360. 25. Forrester SD, Fossom TW, Miller MW. Pneumothorax in a dog 7. Holtsinger RH, Beale BS, Bellah JR, et al. Spontaneous pneu- with a pulmonary abscess and suspected infective endocarditis. mothorax in the dog: a retrospective analysis of 21 cases. JAAHA JAVMA 1992;200(3):351-354. 1993;29:195-210. 26. Saheki Y, Ishitani R. Acute fatal pneumothorax in canine dirofi- 8. Yoshioka MM. Management of spontaneous pneumothorax in lariasis. Jpn J Vet Sci 1981;43:315-328. twelve dogs. JAAHA 1982;18:57-62. 27. Dallman MJ, Martin RA, Roth L. Pneumothorax as the prima- 9. Tamas PM, Paddleford RR, Krahwinkel DJ. Thoracic trauma in ry problem in two cases of bronchoalveolar carcinoma in the dog. dogs and cats presented for limb fractures. JAAHA 1985;21:161-166. JAAHA 1988;24:710-714. 10. Valentine A, Smeak D, Allen D et al. Spontaneous pnuemotho- 28. White HL, Rozanski EA, Tidwell AS, et al. Spontaneous rax in dogs. Compend Contin Educ Pract Vet 1996;18(1):53-62. pneumothorax in two cats with small airway disease. JAVMA 11. Tucker A. Respiratory pathophysiology. In: Slatter D, ed. Text- 2003;222(11):1573-1575. book of Small Animal Surgery. 3rd ed. Philadelphia: Saunders; 29. Cooper ES, Syring RS, King LG. Pneumothorax in cats with 2003:781-797. a clinical diagnosis of feline asthma: 5 cases (1990-2000). J Vet 12. Lipscomb VJ, Hardie RJ, Dubielzig RR. Spontaneous pnemotho- Emerg Crit Care 2003;13(2):95-101. rax caused by pulmonary blebs and bullae in 12 dogs. JAAHA 2003; 30. Matsumoto H, Kakehata T, Hyodo T, et al. Surgical correction of con- 39:435-445. genital lobar emphysema in a dog. J Vet Med Sci 2004;66(2):217-219. 13. Kramek BA, Caywood DD, O’Brien TD. Bullous emphysema and 31. Cherniak RM. Respiration in Health and Disease. Philadelphia: recurrent pneumothorax in the dog. JAVMA 1985;186(9):971-974. Saunders; 1972. 14. Nelson AW, Monnet E. Lungs. In: Slatter D, ed. Textbook of Small 32. Heidecker J, Huggins JT, Sahn SA, et al. Pathophysiology of Animal Surgery. 3rd ed. Philadelphia: Saunders; 2003:880. pneumothorax following ultrasound-guided thoracocentesis. Chest 15. Murphy DM, Fishman AP. Bullous disease of the lung. In: Fish- 2006;130(4):1173-1184. man A, Elias J, Fishman J, et al. Fishman’s Pulmonary Disease and 33. Mitchell SL, McCarthy R, Rudloff E, et al. Tracheal rupture as- Disorders. New York: McGraw-Hill; 2008:913-930. sociated with intubation in cats: 20 cases (1996-1998). JAVMA 16. Stogdale L, O’Connor CD, Williams MC, et al. Recurrent pneu- 2000;216(10):1592-1595. mothorax associated with a pulmonary emphysematous bulla in 34. Brissot HN, Dupre GP, Bouvy BM, et al. Thoracoscopic treatment a dog: surgical correction and proposed pathogenesis. Can Vet J of bullous emphysema in 3 dogs. Vet Surg 2003;32:524-529. 1982;23(10):281-287. 35. Bennett RA, Orton EC, Tucker A, et al. Cardiopulmonary chang- 17. Anderson GI. Pulmonary cavitary lesions in the dog: a review of es in conscious dogs with induced progressive pneumothorax. Am seven cases. JAAHA 1987;23:89-94. J Vet Res 1989;50(2):280-284. 18. Rochat MC, Cowell RL, Tyler RD, et al. Paragonimiasis in dogs 36. Willard T. Blood gases. In: Willard T, Turnwald GH, eds. Small and cats. Compend Contin Educ Pract Vet 1990;12(8):1093-1098. Animal Clinical Diagnosis by Laboratory Methods. 3rd ed. Philadel- 19. Hopper BJ, Lester NV, Irwin PJ, et al. Imaging diagnosis: pneu- phia: Saunders; 1999:93-107. CompendiumVet.com | May 2009 | Compendium: Continuing Education for Veterinarians® 241
- 44. FREE CE Pneumothorax 37. Ludwig L. Surgical emergencies of the respiratory system. Vet lung. In: Cunningham JG, ed. Textbook of Veterinary Physiology. Clin North Am Small Anim Pract 2000;30:531-553. 3rd ed. Philadelphia: Saunders; 2002:468-478. 38. Groblinger K, Lorinson D, Wiskocil L. Spontaneous pneu- 47. Tillson D. Thoracostomy tubes. Part 1. Compend Contin Educ mothorax caused by bullae pulmonales in four huskies [abstract]. Pract Vet 1997;19:1258-1266. Vet Surg 2001;30:304. 48. Tillson D. Thoracostomy tubes. Part 2. Compend Contin Educ 39. Au JJ, Weisman DL, Stefanacci JD, et al. Use of computed Pract Vet 1997;19:1331-1337. tomography for evaluation of lung lesions associated with spon- 49. Salci H, Kennerman E, Celemli N, et al. Use of a heimlich flut- taneous pneumothorax in dogs: 12 cases (1999-2002). JAVMA ter valve in a dogs with spontaneous pneumothorax. Aust Vet Pract 2006;228(5):733-737. 2005;35:47-51. 40. Bowman D. Helminths. In: Bowman D, ed. Georgi’s Parasitol- 50. Jerram RM, Fossum TW, Berridge BR, et al. The efficacy of me- ogy for Veterinarians. 8th ed. St. Louis: Saunders; 2003:115-243. chanical abrasion and talc slurry as methods of pleurodesis in nor- 41. Carr DH, Pride NB. Computed tomography in pre-operative as- mal dogs. Vet Surg 1999;28:322-332. sessment of bullous emphysema. Clin Radiol 1984;35:43-45. 51. Dupre GP, Corlouer JP, Bouvy B. Thoracoscopic pericardecto- 42. Sihoe ADL, Yim APC, Lee TW, et al. Can CT scanning be used my performed without pulmonary exclusion in 9 dogs. Vet Surg to select patients with unilateral primary spontaneous pnemothorax 2001;30:21-27. for bilateral surgery? Chest 2001;118:380-383. 52. Garcia F, Prandi D, Pena T, et al. Examination of the thoracic cavity 43. Mittlehner W, Friedrich M, Dissman W. Value of computed to- and lung lobectomy by means of thoracoscopy in dogs. Can Vet J mography in the detection of bullae and blebs in patients with pri- 1998;39:285-290. mary spontaneous pneumothorax. Respiration 1992;59:221-227. 53. De Rycke LM, Gielen IM, Van Ryssen B. Thoracoscopic anatomy 44. Yasufuku K, Takashi O, Fujisawa T. The effectiveness of thin- of dogs positioned in lateral recumbency. JAAHA 2001;37:543-548. section computed tomography in diagnosing bullous lesions in 54. Champion JK, McKernan JB. Bilateral thoracoscopic stapled patients with spontanous pneumothorax. Nihon Kokyuki Gakkai volume reduction for bullous vs diffuse emphysema. Surg Endosc Zasshi 1999;37:953-957. 1998;12:338-341. 45. Crisp M. Critical care techniques. In: Birchard SR, Scherding 55. Delaunois L, El Khawad C. Medical thoracoscopy in the manage- R, eds. Saunders Manual of Small Animal Practice. Philadelphia: ment of pneumothorax. Monaldi Arch Chest Dis 1998;53:148-150. Saunders; 2000:25. 56. Sampietro R. Videothoracoscopic treatment of bullous lung 46. Robinson N. Overview of respiratory function; ventilation of the disease: indications and techniques. Int Surg 1996;81:333-335. 3 CE CREDITS CE TEST 2 This article qualifies for 3 contact hours of continuing education credit from the Auburn University College of Veterinary Medicine. Subscribers may take individual CE tests online and get real-time scores at CompendiumVet.com. Those who wish to apply this credit to fulfill state relicensure requirements should consult their respective state authorities regarding the applicability of this program. 1. Iatrogenic pneumothorax secondary to intu- 5. Which breed has been shown to have 8. Which of the following is an indication bation in cats has not been associated with a greater incidence of spontaneous for placement of a thoracostomy tube? a. overinflation of the cuff. pneumothorax? a. Negative pressure can be obtained b. turning the patient without disconnect- a. golden retriever by thoracocentesis. ing the tube. b. Siberian husky b. More than 2 mL/kg of air is aspirated c. tracheal injury from a stylet. c. Chihuahua over 12 hours. d. laryngospasm. d. shih tzu c. Only one thoracocentesis procedure is required to alleviate respiratory 2. Pneumothorax is classified as a(n) 6. Which is not a typical radiographic distress. _________ disorder of the lung. feature of pneumothorax? d. Tension pneumothorax is present. a. obstructive a. cardiac elevation from the sternum b. restrictive on the lateral recumbent projection 9. Which statement about thoracoscopy is c. vascular b. atelectasis or partial atelectasis true? d. parenchymal c. loss of the vascular pattern adjacent a. It results in less morbidity and mortal- to the chest wall ity for lung lobectomy than median 3. Which of the following is the most com- d. air bronchograms sternotomy. mon cause of pneumothorax? b. It cannot be used as a diagnostic tool. a. tracheal tears secondary to intubation 7. Which statement is true regarding c. It does not allow sufficient visualization b. thoracic trauma the use of CT in diagnosing of thoracic structures. c. bullous emphysema pneumothorax? d. It has not been attempted in animals d. pulmonary neoplasia a. It is not helpful. with pneumothorax. b. It is more accurate than radiography 4. The most common cause of spontaneous in the diagnosis of underlying lesions 10. Which type of pneumothorax routinely pneumothorax is causing spontaneous pneumothorax. requires surgery for correction? a. bullous emphysema. c. It should be used to diagnose traumatic a. closed traumatic b. parasitic cysts. pneumothorax. b. closed spontaneous c. pulmonary neoplasia. d. It is used in human medicine to c. open traumatic d. grass awn migration. diagnose traumatic pneumothorax. d. iatrogenic 242 Compendium: Continuing Education for Veterinarians® | May 2009 | CompendiumVet.com
- 45. Letters Clinical Snapshot Pruritus in a Great Dane Particularly intriguing or difficult cases Case Presentation #1 ❯❯ Karen A. Moriello, DVM, DACVD, University of Wisconsin-Madison TO LEARN MORE I would like to apologize to readers for an unin- This Great Dane (A) was one of 12 dogs in a kennel, all of which had had intense pruritus for 1 year. The owners border collies and seven cats in addi- tion to these dogs. What are the treat- ment options for this kennel of dogs? Clinical Snapshot presents illustrated case histories and challenges you to answer the questions posed. This case reported that the other dogs looked 3. A similarly named condition occurs is part of the series of Self-Assessment Colour Review books on multiple topics tentional error in the March 2009 Clinical Snap- similar and that all the dogs were los- in cats. What is the cause, and what ing weight and were irritable with the treatment can be used for this from Manson Publishing Ltd., London, available from Blackwell Publishing owners and each other. Close examina- condition? Professional. tion of the skin revealed a generalized SEE PAGE 114 FOR ANSWERS AND EXPLANATIONS. papular eruption without evidence of For more information or to obtain any of the A pustules or epidermal collarettes. Any books in the series, call 800-862-6657 shot, “Pruritus in a Great Dane,” in which I stated manipulation of the skin triggered an intense episode of self-mutilation. All the dogs were currently vaccinated and received monthly heartworm medica- B or visit BlackwellProfessional.com tion and monthly spot-on flea control. The owners reported no lesions or dis- that “the manufacturer reported [selamectin] to comfort after handling the dogs. Flea combings were negative. Skin scrap- ings revealed the organism shown (B). 1. What is the diagnosis? 2. The owners of the kennel have three be effective in 70% of cases” when discussing INTERCEPTOR Flavor Tabs are palatable and most often will be consumed by the dog or cat when offered by the owner. As an alternative, the dual-purpose tablet may be offered in food or administered as other tablet medications. Watch the dog or cat closely following dosing to be sure the entire dose has been consumed. If it is not entirely consumed, redose once with the full recommended dose as soon as possible. treatment for canine scabies. This statement was INTERCEPTOR Flavor Tabs must be administered monthly, preferably on the same date each month. The first dose should be administered within one month of the dog or cat’s first exposure to mosquitoes and monthly thereafter until the end of the mosquito season. If a dose is missed and a 30-day interval between dosing is exceeded, administer INTERCEPTOR Flavor NADA 140-915, Approved by FDA Tabs immediately and resume the monthly dosing schedule. INTERCEPTOR® (milbemycin oxime) Flavor Tabs® for Dogs and Cats If INTERCEPTOR Flavor Tabs replace diethylcarbamazine (DEC) for heartworm prevention in dogs, the first dose must be Brief Summary—For full product information see product insert. given within 30 days after the last dose of DEC. er Caution: Federal (USA) law restricts this drug to use by or on the order of a licensed veterinarian. Warnings: Not for human use. Keep this and all drugs out of the reach of children. an f children. Indications and Usage: INTERCEPTOR Flavor Tabs for dogs are indicated for use in the prevention of heartworm disease Precautions: caused by Dirofilaria immitis, the control of adult Ancylostoma caninum (hookworm), and the removal and control of adult Dogs: Do not use in puppies less than four weeks of age and less than two pounds of body weight. Prior to initiation of the pies r weeks f age an incorrect extrapolation of information on Toxocara canis and Toxascaris leonina (roundworms) and Trichuris vulpis (whipworm) infections in dogs and in puppies INTERCEPTOR Flavor Tabs treatment program, dogs should be tested for existing heartworm infections. Infected dogs abs four weeks of age or greater and two pounds body weight or greater. INTERCEPTOR Flavor Tabs are indicated for use should be treated to remove adult heartworms and microfilariae prior to initiating treatment with INTERCEPTOR Flavor Tabs. move in the prevention of heartworm disease caused by Dirofilaria immitis, and the removal of adult Ancylostoma tubaeforme Mild, transient hypersensitivity reactions manifested as labored respiration, vomiting, salivation, and lethargy may occur nsitivity (hookworm) and Toxocara cati (roundworm) in cats and kittens six weeks of age or greater and 1.5 lbs. body weight or after treatment of dogs carrying a high number of circulating microfilariae. greater. Dosage and Administration: Clinical Snapshot Cats: Do not use in kittens less than six weeks of age or less than 1.5 lbs. body weight. Safety in heartworm positive cats has ns not been established. Safety in breeding, pregnant, and lactating queens and breeding toms has not been established. afety Dogs: INTERCEPTOR Flavor Tabs for Dogs are given orally, once a month, at the recommended minimum dosage rate of 0.23 mg milbemycin oxime per pound of body weight (0.5 mg/kg). Adverse Reactions: The following adverse reactions have been reported following the use of INTERCEPTOR in dogs: depression/lethargy, vomiting, ataxia, anorexia, diarrhea, convulsions, weakness, and hypersalivation. miting, Recommended Dosage Schedule for Dogs Body Weight INTERCEPTOR Flavor Tabs Answers and Explanations Case Presentation #1 A B studies conducted by the manufacturer. I would Efficacy: 2–10 lbs. One tablet (2.3 mg) Dogs: INTERCEPTOR Flavor Tabs eliminate the tissue stage of heartworm larvae and the adult stage of hookworm 11–25 lbs. One tablet (5.75 mg) ( Ancylostoma caninum),, roundworms ( Toxocara canis, Toxascaris leonina ), and whipworm ( Trichuris vulpis ) infestations a s 26–50 lbs. One tablet (11.5 mg) when administered orally according to the recommended dosage PAGE 104 FOR CASE PRESENTATION. y according SEE schedule. 51–100 lbs. One tablet (23.0 mg) ity (e.g., tremors, salivation) Cats: INTERCEPTOR Flavor Tabs for Cats eliminate the tissue stage of heartworm larvae and hookworm (Ancylostoma avor Dogs over 100 lbs. are provided the appropriate combination of tablets. Scabies infestation. The organism 1. tubaeforme ) and roundworm ( Toxocara catii ) infections when administered orally according to the recommended dworm within 24 hours, I administer dosage schedule. Cats: INTERCEPTOR Flavor Tabs for Cats are given orally, once a month, at the recommended minimum dosage rate of is a Sarcoptes egg. One mite or egg For technical assistance or to report suspected adverse events, call 1-800-332-2761. a full treatment dose of 200 0.9 mg milbemycin oxime per pound of body weight (2.0 mg/kg). Recommended Dosage Schedule for Cats is diagnostic for scabies. Definitive vartis Manufactured for: Novartis Animal Health US, Inc. μg/kg PO the next day. like to correct this statement and comment on Body Weight INTERCEPTOR Flavor Tabs eensboro, Greensboro, NC 27408, USA evidence of a scabies infestation Herding breeds of dogs, 1.5–6 lbs. One tablet (5.75 mg) ©2008 Novartis Animal Health US, Inc. 6.1–12 lbs. One tablet (11.5 mg) (eggs or mites) is not always found, especially collies, are known to 3. Canine scabies is not considered con- 12.1–25 lbs. One tablet (23.0 mg) INTERCEPTOR and Flavor Tabs are registered trademarks of Novartis AG. r f Novartis Cats over 25 lbs. are provided the appropriate combination of tablets. NAH/INT-FT/BS/5 even in “classic cases.” Most dogs 06/08 be sensitive to ivermectin. Thus, tagious to cats. However, Sarcoptes with scabies are diagnosed based this drug is best avoided in collies. mites have been reported in a small on response to treatment; therefore, Dogs sensitive to ivermectin can number of cats with severe debilita- 104 Compendium: Continuing Education for Veterinarians® | March 2009 | CompendiumVet.com mVet.com if scabies is suspected, it should be often tolerate milbemycin oxime tion and in pruritic cats in England. my current use of selamectin. treated accordingly. 2. Scabies mites can live for a short period of time off the host. The kennel facilities should be thor- at 3 mg/kg PO weekly for 3 to 6 weeks. Lime sulfur dips are also an effective therapy. Doramectin at 0.2 mg/kg SC or IM has also been There may be some geographic varia- tion with respect to contagion to cats. These cats do not need to be treated. True “feline scabies” is caused oughly cleaned with high-pressure reported to be effective. Finally, by Notoedres cati, a contagious mange water, scrubbed with detergent, and two applications of selamectin or mite. In contrast to canine scabies mites, Selamectin has been found to be the stratum corneum and coat, which sprayed with an environmental par- asiticidal agent. All dogs in contact with these Great Danes should be fipronil at 30-day intervals may be effective. Selamectin is licensed for the treatment of scabies, and N. cati is easily found in large numbers on skin scrapings. Lesions occur on the head, feet, and perineum. This treated for scabies. Lime sulfur dips the manufacturer reported it to be infestation can cause large amounts highly effective against Sarcoptes mite is one reason that medicated bathing is once weekly for 6 weeks or amitraz effective in 70% of cases. Fipronil of crust; cats should be sedated, the dips every 2 weeks for 6 weeks are is not licensed for scabies treat- haircoat clipped, and the cats bathed effective topical therapies. Lime sul- ment but has been found to be to remove the contaminated crusts fur can be combined with ivermec- effective. It is important to remem- before treatment. Because cats are tin therapy. Ivermectin (200 μg/kg ber that no treatment is 100% effi- extremely sensitive to parasiticidal infestations in dogs. Large field stud- often very beneficial for these patients. PO or SC) every 2 weeks for 6 weeks is also an effective treatment. I use a test dose of 100 μg/kg PO in all cacious in all patients. If scabies is suspected and the patient does not respond, retreatment with a differ- agents, lime sulfur and ivermectin are the most commonly used treatments. Affected cats, and all animals in con- dogs. If there are no adverse effects ent therapy should be performed tact with them, should be treated for ies with naturally occurring Sarcoptes Because selamectin has a wide spec- consistent with ivermectin sensitiv- before scabies is ruled out. Letters at least 6 weeks. Call for Papers infestations in dogs have reported post- trum of activity, I routinely recommend CONTINUED FROM PAGE 113 Editor’s note: Thank you to Toxicology. Philadelphia: Williams and the attentive readers who Wilkins; 1996:317-328. pointed out the difference Are you involved in research? 2. Gaynor AR, Dhupa N. Acute ethyl- between these articles and to ene glycol intoxication. Part II. Compend Contin Educ Pract Vet 1999;21(12):1124- the authors for their clarifica- treatment efficacy of 93% to 95% after year-round use of selamectin in hunt- Veterinary Therapeutics: Research in Applied Veterinary Medicine® is a quarterly journal dedicated to rapid publication. 1133. 3. Dorman DC, Dye JA. Chemical tox- icities. In: Ettinger SJ, Feldman EC, eds. Textbook of Veterinary Internal Medicine. tion. As in many aspects of veterinary medicine, differ- ent recommendations exist We invite the submission of clinical and laboratory 6th ed. St. Louis: Elsevier Saunders; based on clinical experience research manuscripts in small animal, large animal, 2005:257-258. one dose and 100% after two doses. It is ing dogs and in dogs that frequent dog and comparative medicine, including pathophysiology, diagnosis, treatment, and prognosis. Prospective, retrospective, and corroborative studies are all 4. Richardson JA, Welch SL, Gwaltney- Brant SM, et al. Metaldehyde toxicoses in dogs. Compend Contin Educ Pract Vet 2003;25(5):376-380. and patient presentation ver- sus laboratory chemistry, and different references reflect welcome. Submitted articles are scheduled to be 5. Mull RL. Metaldehyde poisoning. In: these variations. Awareness published 90 to 120 days after acceptance. Kirk RW, ed. Current Veterinary Therapy: important to remember that part of the parks, “play groups” or “day care,” or Contact Cheryl Hobbs, 800-426-9119, ext 52408, or email chobbs@vetlearn.com. Small Animal Practice VIII. London: WB Saunders; 1983:106-107. 6. Tilley LP, Smith FWK Jr. The 5-Min- ute Veterinary Consult: Canine and Feline. of both laboratory and clini- cal data is useful when deter- mining the most appropriate treatment for an individual It’s not just therapeutics! 2nd ed. Philadelphia: Lippincott Williams & Wilkins;2000:958-959. patient. pathogenesis of the pruritus of scabies is agility and training classes. 114 Compendium: Continuing Education for Veterinarians® | March 2009 | CompendiumVet.com hypersensitivity to mites, dead or alive. Karen A. Moriello, DVM, DACVD Dogs can be mite free but still pruritic Clinical Professor of Dermatology until mite proteins have been shed from University of Wisconsin-Madison Call for Papers Are you involved in research? Veterinary Therapeutics: Research in Applied Veterinary Medicine® is a quarterly journal dedicated to rapid publication. We invite the submission of clinical and laboratory research manuscripts in small animal, large animal, and comparative medicine, including pathophysiology, diagnosis, treatment, and prognosis. Prospective, retrospective, and corrobora- tive studies are all welcome. Submitted articles are sched- uled to be published 90 to 120 days after acceptance. Contact Cheryl Hobbs, 800-426-9119, ext 52408, or e-mail chobbs@vetlearn.com. It’s not just therapeutics! CompendiumVet.com | May 2009 | Compendium: Continuing Education for Veterinarians® 243
- 46. Research Recap Selectedabstract from Veterinary Therapeutics Sensitivity of serum markers for pancreatitis in dogs with macroscopic evidence of pancreatitis Steiner JM, Newman SJ, Xenoulis PG, et al. Vet Ther 2008;9(4):263-273. Pancreatitis is recognized as an important and This is the first report of a direct comparison common problem in dogs, but diagnosis can of the sensitivity of these and other more be challenging. Recently, new assays for the traditional serum markers for the diagnosis measurement of trypsin-α1-proteinase inhibi- of canine pancreatitis in a subset of dogs tor complexes and canine pancreatic lipase with this disease (i.e., dogs with both mac- immunoreactivity (cPLI and Spec cPL) have roscopic and microscopic changes charac- been developed and analytically validated. teristic of pancreatitis). Serum cPLI and Spec cPL concentrations showed the highest sensitivity for the diag- TO nosis of pancreatitis in this LEARN MORE group of patients. Further stud- F From th the ies will be required to compare For more Veterinary Therapeutics the specificity of these serum Winter 2008 issue abstracts, visit the archives at VeterinaryTherapeutics.com markers and thus determine their clinical utility. THIS USER- FRIENDLY, EASY-TO-FOLLOW RESOURCE LETS YOU “GET IT RIGHT” EVERY TIME. Order today at VLSstore.com or call 800-426-9119 Publisher of Compendium Equine *US orders only. Contact info@vetlearn.com for other pricing. 244 Compendium: Continuing Education for Veterinarians® | May 2009 | CompendiumVet.com EQ7IPE
- 47. Product Forum Lancing Device Ophthalmoscope The AlphaTRAK lancing device is Keeler Instruments has developed the first now available in the AlphaTRAK digital indirect ophthalmoscope for veteri- Blood Glucose Monitoring System nary ophthalmology. The Digital Vantage- Kit. The lancing device uses spring-loaded action to pierce the skin, Plus LED has an integrated digital camera creating a reliable way of acquiring capillary blood for testing. Alpha- that can capture both video and still TRAK offers a convenient alternative to needles and venous blood images. The long-life LED improves sampling for clients and pet owners. image clarity. Abbott Animal Health Keeler Instruments | 610-353-4350 | www.keelerusa.com 888-299-7416 | www.alphatrakmeter.com Vector-Borne Disease Panel Heart Failure Drug IDEXX Reference Laboratories has announced several new panels for Vetmedin (pimobendan) has been approved by the FDA to treat con- vector-borne diseases. The new tests combine IDEXX serology testing gestive heart failure (CHF) in dogs. Boehringer Ingelheim Vetmedica, and real-time polymerase chain reaction testing, making diagnosis more Inc., is manufacturing this drug, the first new agent approved to treat accurate and cost-effective. Vector-borne disease panels should be used CHF in dogs in more than a decade. Available by prescription only, primarily for patients with clinical signs consistent with a vector-borne Vetmedin is a chewable tablet that is administered twice daily. It can illness; however, they can also be used to identify patients with a sub- be used concurrently with other cardiac medications. clinical vector-borne infection or to monitor therapy for previously diag- Boehringer Ingelheim Vetmedica, Inc. nosed patients. 800-325-9167 | www.bi-vetmedica.com IDEXX Reference Laboratories | 888-433-9987 | www.idexx.com Oral Dispensers Eye Drops EPS has added a new product to its PetVisionPro Lubricating Eye Drops are line of dispensing products. EPS designed to alleviate most common cat- Oral Dispensers are latex free and aracts in dogs and cats by disaggregat- can be capped with standard or ing the glycated proteins that trigger the wagon-wheel tips. They show grad- degeneration of the normal protein uations in both milliliters and frac- structure of the lens fibers in incipient tionated teaspoon measurements. and immature cataracts. The eye drops The dispensers are available in four also provide a high level of corneal lubri- sizes and two colors, clear or ultraviolet-inhibiting amber. cation and add amino acids, which help EPS, Inc. | 800-523-8966 | www.medidose.com form new proteins. Ader Enterprises | 858-792-3410 | www.aderent.com Anti-Lick Products Anti-Lick Strips discourage Dryer pets from licking, biting, or Andis Comfort Dry is a new dryer designed chewing injuries or skin con- to be less damaging to the coats and skin ditions. The strips come in of pets. The new dryer has three heat set- three varieties, Prevent, Pro, tings and two air speeds and is nearly 20% quieter and Pro C, and are made than traditional dryers, with an average decibel level from all-natural ingredients, such as cayenne pepper and clove oil. of 71. There is also a cool air setting for less damaging Pro C is designed exclusively for in-clinic use and has a more drying. The 1875-watt dryer also has a stand aggressive adhesive. with five different positions. Nurtured Pets | 877-738-7771 | www.nurturedpets.com Andis | 800-558-9441 | www.andis.com The product information presented here is provided by the manufacturers and does not reflect endorsement by Compendium. CompendiumVet.com | May 2009 | Compendium: Continuing Education for Veterinarians® 245
- 48. MARKET SHOWCASE CLASSIFIEDS Northgate VETERINARIANS WANTED GLASS DOORS Veterinary Supply, the makers of EXCEPTIONAL CALIFORNIA – Incredible opportunity, great lifestyle. Ultra Cage and Econocage, DISCOUNTS Make over $125K/year—work a flexible schedule. No after-hours, no emergencies, no night calls, no on-call re- now offers choice of glass door in Market Showcase sponsibility. Work in close proximity to LA, Palm Springs, Big Bear, and coastal living in a fully equipped, progres- or rod gates. Available in standard and now available! sive, multi-doctor small animal practice that cares about you. We offer compensation packages with perks. APPLY custom sizes. NOW — there’s no limit to your earning potential! Contact Steven Butchko, DVM: 5488 Mission Blvd., Riverside, CA 4140 Redwood Highway 92509; phone 951-686-2242; fax 951-686-7681. San Rafael, CA 94903 Call today to lock in savings 1-888-DOGCAGE FAX (415) 499-5738 for the entire year. NORTH CAROLINA – Well-established, 24-hour, AAHA- accredited small animal hospital in central North Carolina www.northgatevetsupply.com needs an emergency/critical care veterinarian and an as- sociate veterinarian. Located only hours from the moun- tains and coastlines, our busy, progressive, and expand- Need Techs? ing five-doctor practice is fully equipped and staffed by 25 highly motivated veterinarians, technicians, and lay Support Staff? staff. Established more than 27 years, our hospital has an excellent client base and strong emphasis on qual- ity care. Work in a great practice environment with an excellent opportunity for career development. Competitive salary and benefits include 401(k), profit sharing, CE, and insurance. Experience preferred. Send resume to Dr. Karl B. Milliren, 303 National Highway, Thomasville, NC 27360; email tvh303@cs.com; fax 336-475-0140. TEXAS Associate Veterinarian Full-time position for enthusiastic individual with excellent work ethic. Busy small animal clinic located in thriving West Texas has full diagnostic and surgical capabilities, including ultrasound, Fast. Easy. Inexpensive. endoscopy, and neurosurgery. Contact Lisa Siebert to place your ad today. All interested applicants welcome. WhereTechsConnect.com Call 432-332-5782. is your answer! Call 215-589-9457 or email lsiebert@vetlearn.com. VIRGINIA – Small animal practice in Shenandoah Valley seeks full-time associate. Spacious, newly remod- Index to Advertisers eled small animal hospital with in-house laboratory with For free information about products advertised in this issue, e-mail the product names to productinfo@compendiumvet.com. IDEXX Vet Test and QVC machine. Emergency clinic 20 minutes away. Great location to live, beautiful country, Company Product Page fishing, camping, great outdoors. Seventy-five minutes Atlantic Coast Veterinary Conference 2009 Conference 227 from District of Columbia. Excellent compensation and Bayer Animal Health Baytril 207, 208 benefits. Must be client-oriented; equine experience a plus. Contact Shenandoah Animal Hospital, PO Box 503, Boehringer Ingelheim Vetmedica Vetmedin 203, 204 Woodstock, VA 22664; fax 540-459-4998; phone 540- Companion Animal Parasite Council Road Show Inside front cover (US only) 459-2930, ask for Paula Cooper. Eli Lilly and Company Comfortis 209, 210 Hill’s Pet Nutrition PetFitness VetSync Inside front cover (Canada only) PRACTICES FOR SALE IDEXX Laboratories, Inc. Real Time Care Back cover TEXAS – For sale: AAHA-accredited small animal and ex- otics practice specializing in diagnostic medicine and laser Northgate Veterinary Supply Glass cage doors and rod gates 246 surgery, established in 1982. Located in university area of Novartis Animal Health CEforVetsandTechs.com Inside back cover Houston; excellent demographics. Grossed $860,000 in 2008 — great growth potential for 2009. Equipped with Derm Digest 228–229 computer technology and in-house diagnostic equipment, Summit VetPharm Vectra 215 including ultrasound and digital x-ray. Highly motivated, cer- tified staff; many with college degrees. Interactive, custom- Veterinary Learning Systems A Guide to Equine Joint Injection 244 designed website. Business and real estate package; asking CE Center 206 (US only) $1,599,000 — financing available. Call 713-446-3399 or email vetdoc81@hotmail.com for your appointment. Veterinary Therapeutics 243 Vetstreet Pet Portal Service 231 For classified advertising information, WhereTechsConnect.com Job Marketplace 246 call Liese Dixon at 800-920-1695. Looking for new team members? Buy 2 Ads, Get 1 FREE!* * *See Page 227 for details. 246 Compendium: Continuing Education for Veterinarians® | May 2009 | CompendiumVet.com
- 49. CLASSIFIEDS ORDER FORM PleasePlace My Ad In: ® The Complete Journal for the Veterinary Health Care Team for ____________ issue(s) for ____________ issue(s) for ____________ issue(s) for ____________ issue(s) Pricing, Discounts, and Options* New Ad Placement Price per word $2.20 Available Discounts Single ad in multiple issues (e.g., one ad placed in Veterinary Forum for 2 issues). 10% off Single ad in multiple journals (e.g., one ad placed in Veterinary Forum and Compendium for one issue each). 15% off Single ad in multiple journals for multiple months (e.g., one ad placed in Veterinary Forum and Compendium for two issues each). 20% off Advertising Options ❏ Early Internet Exposure — Place your ad on VetClassifieds.com up to 30 days before your first issue release. (one-time cost) $30 ❏ Instant Internet Exposure —Your ad appears on VetClassifieds.com up to 7 weeks before your first issue release. (one-time cost) $45 ❏ Confidential Forwarding Service — Direct inquiries to our attention; we send them to you via mail, fax, or email. (one-time cost) $40 ❏ Deluxe Package — Add a box border and bold contact information. Choose from six styles (see below). $50 ❏ Premium Package — Deluxe Package plus your clinic/company logo (email as high-resolution tiff, jpeg, or eps file). $100 Deluxe/Premium Package Style Sample (circle letter) A B C D E F Payment VISA MasterCard American Express Call for details regarding check or money order payments. Credit Card Number Expiration Date ____________ / ____________ Contact Name _______________________________________________________ Contact Phone ( ) ________________________________________ Clinic/Company _____________________________________________________________________________________________________________________ Address ____________________________________________________________________________________________________________________________ City__________________________________________________________________ State _____________ Zip _______________________________________ Telephone ( ) ____________________________________________________ Fax ( )___________________________________________________ Cardholder Name ________________________________________________________________________ Billing Zip ________________________________ Authorized Signature________________________________________________________________________________________________________________ Mail or fax completed order form and your ad to: Email your ad and clinic/company information to: information Veterinary Learning Systems, Classified Advertising, VetForumClassifieds@vetlearn.com; CompendiumClassifieds@vetlearn.com; 780Township Line Road, Yardley, PA 19067 • Fax 201-231-6373 CompendiumEquineClassifieds@vetlearn.com; VetTechClassifieds@vetlearn.com *All ads are subject to a 40-word minimum charge and may be edited for grammar and style. All ads are posted on VetClassifieds.com on the first day of the issue month at no charge; all other advertising options incur an additional charge. Discounts are not applicable to first ad placement. Limit one discount per ad, barring promotional specials. All ads received after deadline will be printed in the next available issue(s). No cancellation after deadline. Include complete billing information with all orders. DO NOT mail check or money order payments with your ad; call for detailed instructions first. DO NOT email credit card information; mail or fax your payment information or use our secure Internet server at VetClassifieds.com. NEED MORE INFORMATION? Contact Liese Dixon, Classified Advertising Specialist, at 800-920-1695 (toll-free). Visit www.VetClassifieds.com to browse ads or place your order
- 50. Reading Room* A CCOR DING TO T H E FOR E WOR D by Bernard E. Rollin, PhD (Department of Philo- sophy, Colorado State University, Fort Collins), this publication is an outgrowth of the social-ethical approach to wild animal welfare that has emerged over the past few decades. Dr. Rollin cites the “privi- lege” of maintaining nondomestic animals in captiv- ity, in wildlife reserves, and as research subjects and notes the attendant responsibility of providing taxon-specific recommen- providing them with euthanasia as dations. There are separate chapters needed. To this end, the professional on invertebrates, fish, amphibians, In this book, zoologic and wildlife communities reptiles, birds, monotremes, marsupials, the professional have gathered in this book the best bats, nonhuman primates, rodents, procedures for euthanizing these marine mammals, carnivores, hoof- zoologic and wildlife animals with minimal fear and pain. stock, swine, and megavertebrates. This book is the result of close Multiple methods are outlined in all communities have collaboration among the American cases, including inhaled and injected Association of Zoo Veterinarians, the chemicals and physical approaches. gathered the best American Association of Wildlife Where applicable, in-the-field recom- Veterinarians, the American Board of mendations are also cited. Informa- procedures for Veterinary Toxicology, the American tion is summarized in tables for College of Zoological Medicine, the larger animal groups (e.g., inver- euthanizing Association of Avian Veterinarians, the tebrates, fish). The chapters are short Association of Reptilian and Amphib- and free of undue theoretical dis- nondomestic animals ian Veterinarians, the Canadian Associ- cussion and are thus useful for quick ation of Zoo and Wildlife Veterinarians, reference. The third section of the with minimal fear and the Wildlife Disease Association. book summarizes methods of euthan- These contributors acknowledge a num- asia for wild and exotic vertebrates, and pain. ber of limitations with regard to their consisting of a master table that recommendations, noting that they do presents and classifies methods as Title: Guidelines for Euthanasia of not reflect the only acceptable means recommended, conditionally accept- Nondomestic Animals of euthanasia. Certain methods may able, or unacceptable, with concise Editor: Charlotte Kirk Baer not be applicable because of the con- comments as appropriate. straints of managing free-ranging This book would be a great asset Publisher: American Association of Zoo wild life or because of the need to for any medical professional deal- Veterinarians obtain samples for pathologic analy- ing with nondomestic animals and Year: 2006 sis and disease control in a popula- is designed for ease of use in what Pages: 111 tion. The authors point out that in will often be an emergency situation. some settings, it may not be feasible Despite its bare-bones pragmatism, it to meet the high standards of eutha- is guided by philosophical principles TO LEARN MORE nasia for domestic animals but that in and a clear ethical code throughout. all cases, life should be terminated As Dr. Rollin notes, this publication “as humanely and rapidly as possible.” represents only “the beginning of an The first part of the book addresses ongoing quest for procedures that For further information about this general concerns, such as criteria for mitigate pain and distress and provide book or to order a copy, visit humane euthanasia, physiology, and for a humane termination of life for aazv.org. regulatory issues. The second part species other than those commonly comprises the majority of the text, defined as domestic animals.” 248 Compendium: Continuing Education for Veterinarians® | May 2009 | CompendiumVet.com *Written by Patricia L. Van Horn, a free- lance writer in Long Branch, New Jersey.
- 51. Welcome to CE F O RV E T S A N D T E C H S . C O M Your Newest Source for FREE Dermatology and Parasitology CE CEforVETS.com is now CEforVetsandTechs.com—Your resource of choice for learning the most current approaches for diagnosing and treating challenging dermatology and parasitology cases. > Free, accredited CE by the > Updated content most renowned authorities in > Easier navigation dermatology and parasitology > Links to select articles > Cytology gallery from Compendium® and > Reference library Veterinary Forum® Visit often and watch the site grow and expand as new courses and other content are added. Supported by an educational grant from Novartis Animal Health US, Inc. Courses meet the requirements for 1 hour of continuing education credit in jurisdictions which recognize AAVSB’s RACE approval; however, participants should be aware that some boards have limitations on the number of hours accepted in certain categories and/or restrictions on certain methods of delivery of continuing education.
- 52. Real. Time. Care.TM ©2009 IDEXX Laboratories, Inc. All rights reserved. All ®/TM marks are owned by IDEXX Laboratories, Inc. or its affiliates in the United States and/or other countries. 8336-00 Positive Real-time care lets you give your clients what they expect: answers now. Your ability to handle cases efficiently and outcomes thoroughly, with confidence and empathy, sets you apart. For them, that makes all the difference. That’s real-time care. That’s IDEXX in-house diagnostics. regardless of results Learn more—join us for this live Webinar: Exceeding Client Expectations in a Tough Economy at www.idexx.com/ihd IDEXX In-House Diagnostics IDEXX VetLab® Analyzers | IDEXX SNAP® Immunoassay Tests | IDEXX Digital Imaging