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PAPER Aetiology and outcome in 90 cats presenting with dyspnoea in a referral population OBJECTIVES: Dyspnoea is an unspecific severe presenting sign, which can be life threatening and requires prompt treatment. Dyspnoeic cats often have significant underlying disease. Underlying aetiologies in cats that presented with dyspnoea were reviewed, and associations with patient signalment and outcome were investigated. METHODS: The case records of 90 dyspnoeic cats were retrospectively reviewed and sep
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  PAPER 466  Journal of Small Animal Practice ã Vol 50 ã September 2009 ã © 2009 British Small Animal Veterinary Association    Aetiology and outcome in 90 catspresenting with dyspnoea in a referralpopulation INTRODUCTION Dyspnoea is defined as laboured or dif-ficult breathing and is a common reasonfor the emergency presentation of felinepatients in veterinary medicine. Early clinical signs may be difficult for ownersto appreciate until the signs have becomesevere. Therefore, dyspnoeic cats are fre-quently presented as acute emergencies.Investigations to discover the underly-ing aetiology must be balanced with thestatus of the cat (Tseng and Waddell2000) as stress can be detrimental in thesepatients. Frequently supportive treatmentand stabilisation of the patient is neces-sary before further investigations can beundertaken.Feline dyspnoea can be due to up-per airway disease, lower airway disease,pulmonary parenchymal disease, pleuraldisease, mediastinal disease, cardiac dis-eases, thoracic damage and extra-thoracicdiseases. Upper airway disease includesstenotic nares, rhinitis, nasal neoplasia,laryngeal disease and tracheal lesions(Schachter and Norris 2000, Jakubiak and others 2005). Lower airway diseasesinclude extraluminal airway compression,foreign bodies, chronic bronchitis/asthmaand smoke inhalation (Corcoran and oth-ers 1995, Foster and others 2004). Pul-monary parenchymal disorders includebronchopneumonia, aspiration pneumo-nia, non-cardiogenic pulmonary oedema,intrapulmonary haemorrhage, pulmonary thromboembolism and pulmonary neo-plasia (Ohn and others 2004, Schermer-horn and others 2004, Grandi and others2005). Pleural diseases, most commonly pleural effusions, have a variety of aeti-ologies, including infectious [for example,feline coronavirus infection or feline in-fectious peritonitis (FIP), bacterial pyo-thorax], neoplastic or cardiac. Mediastinaldisease includes neoplasia, toxins (for ex-ample, paraquat and warfarin poisoning)and infections. Common neoplastic causesare lymphoma and thymoma (Patnaik andothers 2003, Jakubiak and others 2005).Cardiac disease includes acquired disease(particularly the cardiomyopathies such ashypertrophic, dilated, restrictive, unclassi-fied and arrhythmogenic right ventricularprimary forms, and secondary cardiomy-opathies) and congenital cardiac diseases(Ferasin and others 2003, Chetboul andothers 2006, Schrope and Kelch 2007).Dyspnoea in cardiac disease is usually as-sociated with pulmonary oedema or pleu-ral effusion. However, congenital right toleft shunting cardiac defects may resultin dyspnoea due to chronic hypoxaemia.Thoracic damage can result in dyspnoeafrom pleural effusion, pneumothorax, dia-phragmatic hernia, pulmonary contusions O BJECTIVES :Dyspnoea is an unspecific severe presenting sign, whichcan be life threatening and requires prompt treatment. Dyspnoeiccats often have significant underlying disease. Underlying aetiologiesin cats that presented with dyspnoea were reviewed, and associa-tions with patient signalment and outcome were investigated.M ETHODS :The case records of 90 dyspnoeic cats were retrospectivelyreviewed and separated into different groups depending on aetiol-ogy (cardiac, respiratory, neoplastic and trauma). Duration of clinicalsigns, presentation, hospitalisation length and survival were analysed.R ESULTS :Cardiac (38 per cent), respiratory (32 per cent) andneoplastic (20 per cent) diseases were common causes of felinedyspnoea. Cats with respiratory causes had longer duration of clinical signs (P<0 ¥ 001) before presentation. Cats with neoplasiawere significantly older (P<0 ¥ 001). No significant difference inrespiratory rates was present between the groups (P=0 ¥ 154). Highheart rates (P<0 ¥ 001) and abnormalities on cardiac auscultationwere more likely in the cardiac group.C LINICAL S IGNIFICANCE :Frequent causes of dyspnoea in cats werecardiac disease followed by respiratory causes and neoplasticconditions. Heart rate on presentation and presence of heartmurmurs or gallops are useful to identify cardiac causes. Improvedproportion surviving was found in the respiratory group (P=0 ¥ 027),whereas cats with neoplasia had the worst outcome. S. S WIFT , J. D UKES -M C E WAN , S.F ONFARA , J. F. L OUREIRO   AND  R. B URROW Journal of Small Animal Practice  (2009) 50 , 466–473DOI: 10.1111/j.1748-5827.2009.00767.xAccepted: 26 March 2009 University of Liverpool Small Animal TeachingHospital, Leahurst, Chester High Road, Neston,Wirral CH64 7TES Swift’s current address is Rutland House Re-ferrals, Abbotsfield Road, St Helens WA9 4HUJ.F. Loureiro’s current address is Royal (Dick)School of Veterinary Studies, Division of Veteri-nary Clinical Sciences, The University of Edin-burgh, Hospital for Small Animals, Easter BushVeterinary Centre, Roslin, Midlothian, EH25 9RG     Journal of Small Animal Practice ã Vol 50 ã September 2009 ã © 2009 British Small Animal Veterinary Association 467  Aetiology and outcome in 90 cats with dyspnoea   or rib fractures. Extra-thoracic diseasesinclude anaemia or heatstroke (Luis Fuen-tes 1998, Martin and Corcoran 2006).The diseases listed cause dyspnoea viaobstruction of airways, restriction of lungparenchyma, parenchymal impairment,pulmonary oedema, pleural effusion, ven-tilation–perfusion mismatch and haema-tological disorders.To the authors’ knowledge, this is thefirst study of feline dyspnoea as a present-ing sign. Other studies examine specificconditions and comment on the frequen-cy of dyspnoea as a presenting sign in thatcondition. The objective of the study wasto investigate frequent aetiologies in catspresented with dyspnoea and whether age,presentation as emergency or routine re-ferral, duration of clinical signs and respi-ratory or heart rates on admission had aneffect on predicting survival. MATERIALS AND METHODS The medical records of all cats referredto University of Liverpool Small AnimalTeaching Hospital (LUSATH) between January 2003 and December 2007 weresearched for “dyspnoea” using a databasesoftware program (Animalcare tools). Cats were eligible for inclusion into this retro-spective study if they were identified to bedyspnoeic on initial presentation, assessedby the referring veterinary surgeon or cli-nician who initially assessed the case atLUSATH, and in which case records werecomplete. A total of 90 cats were identi-fied and their records were reviewed forsignalment (breed, age and sex), presenta-tion as emergency or routine consultation,duration of clinical signs before consulta-tion according to the owner, respiratory rate on admission, length of hospitalisa-tion at LUSATH, underlying aetiology and outcome.Depending on underlying cause of dyspnoea, cats were separated into fourmajor groups: (i) cardiac, (ii) respiratory,(iii) neoplastic and (iv) traumatic. Withinthese categories, further subdivisions weremade.i. Cardiac cases included cats with con-genital heart disease (aortic stenosis, cortriatriatum sinister, tricuspid dysplasia,pericardio-peritoneal diaphragmatichernia) and acquired diseases, includ-ing hypertrophic cardiomyopathy (HCM), hypertrophic obstructivecardiomyopathy (HOCM), unclassi-fied cardiomyopathy (UCM), restric-tive cardiomyopathy (RCM), dilatedcardiomyopathy (DCM) and arrhyth-mogenic right ventricular cardiomy-opathy (ARVC) as defined previously (Ferasin and others 2003) and onecase of secondary cardiomyopathy dueto thyrotoxicosis.ii. Respiratory cases were subdivided intoinfectious, non-infectious and devel-opmental causes. Infectious causesincluded upper and lower respiratory tract infections, pyothorax and theeffusive form of FIP. Non-infectiouscauses included feline asthma/chronicbronchial disease, laryngeal paralysis,tracheal foreign body, tracheal steno-sis, reverse sneezing, nasopharyngealpolyp and pulmonary thromboembo-lism. Developmental causes includedpalatine cyst, congenital diaphrag-matic hernia and epiglottic tethering.iii. The neoplastic group consisted of cas-es where the presence of neoplasia orresulting pleural/abdominal effusion was responsible for the dyspnoea.iv. The trauma group was composedof patients where traumatic injury  was evident either on history and/orclinical examination or on ancillary diagnostic tests (for example, radiog-raphy).In one case presenting with dyspnoeano underlying cause was found, and thecat improved spontaneously with oxygentherapy, without further dyspnoeic epi-sodes. This case was excluded from furtheranalysis. Cats with more than one condi-tion were placed into the group most like-ly to be causing the dyspnoea.Examination of all cats included physi-cal examination, routine haematology andbiochemistry and thoracic radiography.Supportive treatment was commenced inunstable cats, and other diagnostic testsonly carried out once stable. Diagnosticand therapeutic thoracocentesis were car-ried out in cats suspected of having a pleu-ral effusion. Six lead electrocardiography,Doppler-derived systolic blood pressuremeasurement and Doppler echocardiogra-phy were performed in patients suspectedor known to have cardiac disease. In ad-dition, a T4 assay was performed in casessuspected of having acquired heart disease.Bronchoscopy and broncho-alveolar lavage(BAL) were performed in dyspnoeic cases where a respiratory cause was suspectedonce these cases were stable enough to tol-erate anaesthesia. In cases with a suspectedinfectious cause for pleural effusion, fluidcytology, bacteriological culture and felinecoronavirus serology were performed. Incases with an accessible thoracic mass, fineneedle aspirates were obtained and sub-mitted for cytological analysis.For the population as a whole, and within the main categories, descriptivestatistics were carried out using commer-cial statistical analysis software (Excel; Mi-crosoft, Sigmastat v2 ⋅ 03; SPSS Inc.). Forcontinuous variables, comparison betweengroups was made using one-way analysis of variance (ANOVA) when data were nor-mally distributed, with multiple pair-wisetesting using the Tukey test, or Kruskal- Wallis ANOVA on ranks where non-nor-mal distribution of data was evident, withmultiple comparisons using the Dunn’smethod. The pair-wise comparisons(Tukey or Dunn’s) were only performed if a statistically significant ANOVA or Krus-kal-Wallis ANOVA result was attained. If only two groups were being compared,the unpaired two-tailed Student’s t  test was used, or the Mann-Whitney U test when data were not normally distributed.For categorical variables, comparison be-tween groups was made after construct-ing contingency tables using chi-squaredtest or Fisher’s exact test. Demographicsof the LUSATH Feline Hospital Popula-tion were compared with the dyspnoeicpopulation. In analysing the numbers of pedigree cats, all breeds were grouped andcompared with all non-pedigree cats (do-mestic short or longhaired; DSH, DLH).In investigating any differences betweenage when comparing the age of the dys-pnoeic population with the hospital popu-lation, ages were grouped as <2 years, 2 to5 years, 6 to 10 years, 11 to 15 years and>16 years. Neutered cats were includedin their gender group, to compare totalnumbers of males and females, becausevery few entire cats were present in the  S. Swift and others  468  Journal of Small Animal Practice ã Vol 50 ã September 2009 ã © 2009 British Small Animal Veterinary Association   dyspnoeic population. Statistical signifi-cance was accepted as P<0 ⋅ 05. RESULTS Ninety cats referred to LUSATH between2003 and 2007 were presented with dys-pnoea. Of these 58 per cent presented asemergencies. Comparing the dyspnoeicpopulation with the hospital populationshowed no significant differences in gen-der or the proportions of non-pedigree versus  pedigree cats. However, the dys-pnoeic population was significantly older(median 6 ⋅ 1 years, ranging from 4 monthsto 18 years) than the hospital population(median 5 years; P<0 ⋅ 001).The most frequent diagnosis was cardi-ac disease (n=34, 37 ⋅ 7 per cent), followedby respiratory (n=29, 32 ⋅ 2 per cent), neo-plastic (n=18, 20 ⋅ 0 per cent) and traumat-ic (n=8, 8 ⋅ 9 per cent) conditions. Table 1gives the summary data for each group. Causes of dyspnoea Cardiac  Thirty-four cats [23 male (oneentire) and 11 female (one entire)] werediagnosed with cardiac causes; 28 cats hadacquired heart disease, four had congeni-tal heart disease and in two cats presented with congestive heart failure no diagnosis was achieved. One died before further in-vestigations were obtained and one washyperthyroid and responded to symptom-atic treatment. Details of the animals arelisted in Table 2.Most cats with acquired heart diseases were diagnosed with HCM/HOCM(n=16) and UCM (n=8; table 2). Of theHCM/HOCM cases, 13 had radiographicevidence of pulmonary oedema, two hadpleural effusions and one had both. Five of the eight cats with UCM had pleural effu-sions, two had pulmonary oedema and onehad both. Both cats with RCM presented with pleural effusions. Thyrotoxicosis, acause of secondary cardiomyopathy, wasseen in two other cats, one with UCMand one with RCM. In neither case didthe heart muscle disease improve despitegood control of thyroid hormone levels.There was no significant differencein respiratory rate (P=0 ⋅ 375), heart rate(P=0 ⋅ 485), presence of heart murmur(P=0 ⋅ 273) or diastolic gallops (P=0 ⋅ 239)documented on presentation, dura-tion of clinical signs before presentation(P=0 ⋅ 462), or on length of hospitalisa-tion (P=0 ⋅ 439), between the cardiac sub-groups. A total of 87 per cent of cats withHCM/HOCM survived to be discharged,compared with 54 per cent of cats withnon-hypertrophic forms of cardiomy-opathy (grouped), which was significant(P<0 ⋅ 001). Respiratory The respiratory group (n=29) was subdi-vided into infectious, non-infectious anddevelopmental causes of dyspnoea. Within the infectious subgroup (n=10),there were three cases of the effusive formof FIP, four cases of pyothorax, two up-per respiratory tract infections (URTI)and one lower respiratory tract infection(LRTI). All three cases of FIP were inBengals. Two DSH, one Siamese and oneoriental presented with pyothorax. Two of these were male. Bacteriological cultureshowed a variety of organisms including Pasteurella (most common), Bacteroides  , Prevotella and mixed anaerobes. Upper re-spiratory tract infection was identified inone Burmese and one Burmilla, and thecase of LRTI was  Mycoplasma broncho- pneumoniae  infection in a Russian blue. Within the infectious group, there werefive female neutered cats, four male neu-tered cats and one male entire. Within the non-infectious subgroup(n=16), conditions recorded includedfeline asthma/chronic bronchial disease(n=7), laryngeal paralysis (n=3), with onecase each of tracheal foreign body, trachealstenosis, reverse sneezing, nasopharyngealpolyp, rhinitis in which infectious causeshad been actively excluded and one caseof pulmonary thromboembolism in a cat with diarrhoea and hypoalbuminaemia.There were five DSH, one DLH and oneBurmese affected by feline asthma/chron-ic bronchial disease, four were neuteredmales and three neutered females (fn).The mean (sd) age of the asthma/bron-chial disease was 5 ⋅ 43 (3 ⋅ 41) years. Twoof the cats with laryngeal paralysis wereelderly neutered males (one 18-year-oldDSH with iatrogenic paralysis follow-ing thyroidectomy surgery, and one 15-year-old DSH with idiopathic disease). A four-year-old fn Burmese had idiopathiclaryngeal paralysis.There were three cats with develop-mental defects. One had a congenital dia-phragmatic hernia, one a palatine cyst andone had congenital epiglotic tethering.These were all British shorthaired (BSH)cats, one female entire, two male neuteredand under two years of age.Cats with non-infectious causes of dys-pnoea were significantly older than theinfectious or the developmental group(P=0 ⋅ 03). The mean age of the non-infec-tious group was 6 ⋅ 0 years. The mean ageof the infectious group was 1 ⋅ 9 years.The duration of clinical signs in thedevelopmental and non-infectious groups(median 60 days for both) was signifi-cantly longer than the infectious group(median 7 ⋅ 5 days; P=0 ⋅ 002). The lengthof hospitalisation was significantly longerfor the infectious group (median 7 days)compared with developmental (median 3days) and non-infectious causes (median2 days; P=0 ⋅ 009). There was no signifi-cant difference in proportion survivingto discharge between the three respiratory groups (P=0 ⋅ 275). Neoplasia Eighteen cats (eight male, 10 female, allneutered) were diagnosed with neoplasia.Breeds included 13 DSH and individualcats of the following breeds: BSH, Siamese,Persian, MC and a Norwegian Forest cat.The most common diagnosis was lym-phoma (six of the 12 cases in which a de-finitive diagnosis was made; 50 per cent).Of these, three had thymic lymphoma,two had tracheal or laryngeal involvementand one had nasal lymphoma. Individualcases were seen of thymoma, bronchogen-ic carcinoma, heart base tumour, trachealtumour of epithelial srcin, squamous cellcarcinoma and nasal adenocarcinoma. Insix cases, the tumour type was not identi-fied in life, and post-mortem examination was declined by the owners. Four of thesix lymphoma cats survived to dischargecompared with only two of the 10 cats with other forms of neoplasia, which sug-gested improved survival for lymphoma versus  other neoplasms, although this didnot achieve significance (P=0 ⋅ 107). All thecats with neoplasia were negative for Fe-line Leukaemia virus (FeLV).   Journal of Small Animal Practice ã Vol 50 ã September 2009 ã © 2009 British Small Animal Veterinary Association 469  Aetiology and outcome in 90 cats with dyspnoea   Trauma Eight cats (five male, three female, all neu-tered) experienced trauma as a cause of their dyspnoea. Four cats were involvedin RTAs. Injuries suffered included pneu-mothorax (n=2), diaphragmatic rupture(n=1) and tracheal avulsion (n=1). Onecat was presented with tracheal avulsionof uncertain cause. One cat suffered a la-ryngeal avulsion after being attacked by adog and one had gun shot wounds withpleural haemorrhage. One cat had an iat-rogenic pneumothorax following attemptsat thoracocentesis, although subsequentreview of radiographs suggested pulmo-nary oedema (data of this case not includ-ed in other categories, as cause of pulmo-nary oedema was not ascertained and thecat’s signs spontaneously resolved). Comparison between groups There was a significant difference in agebetween the groups (P<0 ⋅ 001), with cats with neoplasia being significantly olderthan cats in the other three groups (Table1; Fig 1). Although there were more malesthan females with cardiac disease, with bal-anced sex distribution in the other groups,this did not achieve statistical significance(P=0 ⋅ 398). More pedigree cats than non-pedigree seemed to present with infectiousrespiratory disease. However, no significantdifferences comparing the proportions of non-pedigree to pedigree cats were evident within and between groups (P=0 ⋅ 087).The duration of clinical signs be-fore referral (P<0 ⋅ 001) and presentationas emergency or routine consultation(P<0 ⋅ 001) differed between the aetiologi-cal groups (Table 1). Cats with respira-tory or neoplastic causes of their dys-pnoea had a significantly longer periodof clinical signs before presentation thanthose with cardiac disease or trauma (Fig2). All cats presented with trauma and 74per cent of the cardiac cases were emer-gencies compared with only 32 per centof respiratory cases. Cats presenting withinfectious causes of pleural effusion hadlonger hospital stays than other cats, butcomparison between groups showed nosignificant difference in hospitalisationtime (P=0 ⋅ 079; Table 1). Clinical examination results There was no significant difference inrespiratory rate recorded on admissionbetween groups (P=0 ⋅ 154). However, FIG 1. The age distribution of the dyspnoeic cats in the different categories. The boxes define the25th and 75th percentiles, with the median indicated. The whiskers delineate the 10th and 90thpercentiles, with outliers indicated as points. There was a significant difference in age betweengroups (P<0 ⋅ 001). Statistically different pair-wise differences showed that the neoplasia group aresignificantly older than the other three groups (P<0 ⋅ 05) (*) Age distribution of the dyspnoeic population in the different groups    A  g  e   (  y  e  a  r  s   ) 02468101214161820CardiacRespiratoryNeoplasiaTrauma****    T  a   b   l  e   1 .   D  a   t  a  a   b  o  u   t   t   h  e   d   i   f   f  e  r  e  n   t  a  e   t   i  o   l  o   g   i  c  a   l   g  r  o  u  p  s  o   f   d  y  s  p  n  o  e   i  c  c  a   t  s    C  a  u  s  e   N  u  m   b  e  r   A  g  e   i  n  y  e  a  r  s ,  m  e  a  n   (  s   d   )   D  u  r  a   t   i  o  n  o   f  c   l   i  n   i  c  a   l  s   i  g  n  s   b  e   f  o  r  e  p  r  e  s  e  n   t  a  -   t   i  o  n   (   d  a  y  s   ) ,  m  e   d   i  a  n   (   2   5   t  o   7   5  p  e  r  c  e  n   t   i   l  e  s   )   L  e  n  g   t   h  o   f   h  o  s  p   i  -   t  a   l   i  s  a   t   i  o  n   i  n   d  a  y  s ,  m  e   d   i  a  n   (   2   5   t  o   7   5  p  e  r  c  e  n   t   i   l  e  s   )   R  e  s  p   i  r  a   t  o  r  y  r  a   t  e  o  n  a   d  m   i  s  s   i  o  n   i  n   b  r  e  a   t   h  s  p  e  r  m   i  n  u   t  e ,  m  e  a  n   (  s   d   )   E  m  e  r  g  e  n  c  y  r  e  -   f  e  r  r  a   l   (  p  e  r  c  e  n   t  o   f  c  a  s  e  s   )   S  u  r  v   i  v  a   l   t  o   d   i  s  c   h  a  r  g  e   (  p  e  r  c  e  n   t   )   H  e  a  r   t  r  a   t  e  p  e  r  m   i  n  u   t  e   (  m  e  a  n        ±    s   d   )   P  r  e  s  e  n  c  e  o   f   h  e  a  r   t  m  u  r  m  u  r   P  r  e  s  e  n  c  e  o   f   d   i  a  s   t  o   l   i  c  g  a   l   l  o  p    C  a  r   d   i  a  c   3   4   6    ⋅    4   0   (   4    ⋅    0   )   7   (   3   t  o   2   8   )   2   (   1   t  o   4   )   5   1    ⋅    9   6   (   2   3    ⋅    7   )   7   4   6   7    ⋅    6   2   0   3    ⋅    6   ±   3   3    ⋅    3   1   5   /   2   3   1   0   /   2   3   R  e  s  p   i  r  a   t  o  r  y   2   9   4    ⋅    0   6   (   4    ⋅    4   )   1   7    ⋅    5   (   1   1   t  o   9   0   )   3   (   2   t  o   7   )   4   0    ⋅    0   0   (   1   7    ⋅    6   )   3   2   7   5    ⋅    9   1   6   1    ⋅    8   ±   3   6    ⋅    6   6   /   2   2   2   /   2   2   N  e  o  p   l  a  s   t   i  c   1   8   1   0    ⋅    1   7   (   3    ⋅    3   )   2   1   (   1   3   t  o   6   0   )   3   (   2   t  o   5    ⋅    5   )   4   5    ⋅    5   3   (   1   8    ⋅    2   )   4   7   3   3    ⋅    3   1   4   6    ⋅    8   ±   1   8    ⋅    1   0   /   6   0   /   6   T  r  a  u  m  a   t   i  c   8   3    ⋅    8   3   (   4    ⋅    1   )   2    ⋅    5   (   1   t  o   1   2   )   4   (   2   t  o   8    ⋅    5   )   3   8    ⋅    6   7   (   1   6    ⋅    1   )   1   0   0   6   2    ⋅    5   1   6   0    ⋅    0   ±   3   3    ⋅    7   0   /   5   0   /   5   P  <   0    ⋅    0   0   1   P  <   0    ⋅    0   0   1   P  =   0    ⋅    0   7   9  n  s   P  =   0    ⋅    1   5   4 ,  n  s   P  <   0    ⋅    0   0   1   P  =   0    ⋅    0   2   7   P  <   0    ⋅    0   0   1   P  =   0    ⋅    0   0   0   2   P  =   0    ⋅    0   0   9   s   d   S   t  a  n   d  a  r   d   d  e  v   i  a   t   i  o  n ,  n  s   N  o   t  s   i  g  n   i   fi  c  a  n   t 
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