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Veterinary Specialists Of South Florida Presents…

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Veterinary Specialists Of South Florida Presents…

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  1. Veterinary Specialists Of South Florida Presents…

  2. Near Drowning and Noncardiogenic Pulmonary Edema VETERINARY SPECIALISTS OF SOUTH FLORIDA Tyler Foreman, DVM

  3. “Luke” • 2.5 year old MN American Bulldog • Presented with increased RR/RE • Became acutely dyspnic after playing in the ocean • Owner described Luke “biting” at the waves • He had two episodes of vomiting and diarrhea shortly after leaving the beach

  4. Physical Exam • 5% dehyrdated • MM light pink to pale and slightly tacky • Increased to harsh bronchovesicular sounds in all lung fields • RR = 132 • SpO2 = 81% on room air

  5. Diagnostics • Stress leukogram • HCT = 50.5 • TP = 8.4 • K+ = 3.2 (range from 3.8 – 5.3) • Radiographs

  6. Radiographs

  7. Normal Alveolar Fluid Physiology • Collodial oncotic pressure (COP)and hydrostatic pressures interact to create a mild negative fluid pressure in the interstitial tissues. • Lymphatic drainage primarily responsible for removing excess fluid • Low normal hydrostatic pressures • Surfactant within the alveoli • Can withstand 20-40 mmHg hydrostatic pressure without leaking into the alveolus

  8. Pathophysiology • 3 Main Causes of Pulmonary Edema • Increased hydrostatic pressure • Increased capillary permeability • Mixed • Initial fluid accumulation on capillary side opposite gas exchange • Eventually, fluid moves into alveolus, altering ventilation • Acts as diffusion barrier to gas exchange • Increases vascular resistence • End result is hypoxemia

  9. Noncardiogenic Pulmonary Edema • Definition – Fluid accumulation in the pulmonary interstitium and alveoli caused by a disorder other than congestion resulting from heart disease.

  10. Typically a result of increased capillary permeability • Can also result from impaired lymphatic drainage (neoplasia, lymphangitis) • Decreased plasma oncotic pressure is rarely a cause of pulmonary edema

  11. Near Drowning • Both a form of noncardiogenic pulmonary edema and an aspiration event • Usually small volumes aspirated • Dilutes surfactant • Collapses avleoli • Decreases lung compliance • Salt water increases fluid flux into alveoli due to hypertonicity

  12. Clinical Signs/PE Findings • Respiratory Distress • Tachypnea • Cough • Expectoration of fluid • Crackles may be ausculted at varying times and places • Cyanosis

  13. Risk Factors/Underlying Conditions: Noncardiogenic Edema • Upper airway obstruction • Laryngeal paralysis, foreign body, mass, brachycephalic, etc. • Systemic Inflammatory response syndrome (SIRS) or Acute Respiratory Distress syndrome (ARDS) • Sepsis, pancreatitis, pneumonia, severe tissue trauma, Immune-mediated disease, metastatic neoplasia • Systemic vasculitis • Pulmonary Thromboembolism • Ventilator-associated lung injury • Volatile hydrocarbons • Cisplatin in cats • Recent history of being in water

  14. Diagnosis • R/O Heart Disease first • Thoracic Radiographs • CBC/Chem • Hunt for causes of underlying disease

  15. Therapy • Oxygen therapy • Positive pressure ventilation • Thoracocentesis if pleural effusion present • Medical Management • Furosemide • Decreases pulmonary hydrostatic pressure • Increases COP secondary to hemoconcentration • Evidence that it acts as a vasodilator and bronchodilator

  16. Therapy Continued • Vasodilators (Nitroprusside, Nitroglycerin) • More for use in cardiogenic edema • Decrease afterload and preload • Beta-2 agonists (Terbutaline) • Increase cAMP which increases fluid reabsorption from the alveolar space • Fluid Therapy • Generally avoided • Use with caution if necessary • Sedatives, if patient is overtly anxious

  17. Luke’s Therapy • Furosemide CRI • 0.2-0.4 mg/kg/hr • Best administered as a CRI for 6 hours • Oxygen therapy • 40% O2 overnight • Weaned off in the morning after RR/RE had stabilized • IV Fluids • Started at ¾ maintenance • Increased to 1.0x maintenance • Added 30 mEq/L KCl

  18. Initial Radiographs

  19. Outcome • Luke dramatically improved overnight • Went home the next day

  20. Summary • Important to first R/O Cardiogenic Edema • Determine origin of Noncardiogenic edema • Treat underlying cause and symptoms • Noncardiogenic edema does not usually respond as well to therapy as cardiogenic edema

  21. We would like to thank you for your continued support and referrals.

  22. References • Noncardiogenic Pulmonary Edema. Clinical Veterinary Advisor. Pg 913-914 • Pulmonary Edema. Small Animal Critical Care Medicine. Pg 82-84 • Noncardiogenic Pulmonary Edema. Textbook of Veterinary Internal Medicine. pg 1240 • Near Drowning. Textbook of Veterinary Internal Medicine. pg 1260-1261 • http://www.pathologyatlas.ro/pathology_atlas_imagini/pulmonary_edema_detail.jpg • Chest. 2007 Apr;131(4):964-71 • Schweiz Arch Tierheilkd. 2010 Jul;152(7):311-7 • Anesthesiology. 2010 Jul;113(1):104-15