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July 2020
A Peer-Reviewed Journal | cliniciansbrief.com
KITTEN
DEVELOPMENTAL
IN THIS ISSUE
STAGES
Developmental
Stages of Puppies
Hemoabdomen:
Management Algorithm
Top 5 Passive Cervical
Flexion Causes
Feline Asthma Review
Differential Diagnoses:
Thrombocytosis
Volume 18 Number 7
THE OFFICIAL CLINICAL PRACTICE JOURNAL OF THE WSAVA
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July 2020 cliniciansbrief.com 1
From Clinician’s Brief
on Social Media
WE ASKED …
I will never forget my What is the largest number of pets you have had
first case of at a single time?
______________________.
“I currently have 5 cats, 1 (large) dog, and 8 chickens. The chickens are living in my
“Marijuana toxicity!”—Leslie H house because they are still young.”—Jen M
“Maggots; I love watching others’ first “I once had 16 small rescue dogs.”—Heidi S
time with them as well.”—Noah L “My personal count is 11 indoor cats, plus a litter of 7 rescued kittens that had to be
“Hypoadrenocorticism. The dog came in bottle-fed, so 18 total cats, 4 dogs, 1 snake, 2 fish, and 1 boyfriend with his 2 little
little more than dead. I was able to draw boys. I do not know how I managed.”—Gen L
blood, place a catheter, give medica- “I foster cats, so, including fosters, the most I have had at a single time was 26 cats
tions, and stabilize her on my own. It was and 7 dogs. I do not count the farm animals, as they were outside, but there were
like she came back to life.”—Maggie Q 11 chickens, 2 ducks, and 1 horse.”—Karen D
“Chocolate poisoning in a diabetic “Currently, I have 6 dogs, 2 cats, 1 ball python, 1 betta fish, and a scorpion that had
dachshund on Christmas day. The poor surprise babies, making a total of 20 scorpions!”—Brittany B
thing did not make it.”—Dawn S
“Right now, I have 9 indoor cats, 6 dogs, 1 potbellied pig, 6 parrots, 17 bunnies,
“Burns. It was winter and a heat bulb in 11 guinea pigs, 2 degus, 8 chinchillas, 7 hamsters, 3 rats, 1 bearded dragon, 1
the dog house, which was more like an leopard gecko, 1 veiled chameleon, 1 tenrec, 7 African pygmy hedgehogs, and
outdoor shed/run area where the dogs 2 sugar gliders—almost all rescues—as well as 1 tropical fish tank and 3 marine
slept, fell over. ”—Jacey E fish tanks.”—Jacqeulene S
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July 2020 cliniciansbrief.com 3
OUR
AUTHORS
JULIE ALLEN, BVMS, MS, MRCVS, DACVIM (SAIM), DACVP, is a former clinical
assistant professor of clinical pathology at Cornell University. She earned her veter-
inary degree from University of Glasgow and her MS from Iowa State University,
where she completed a rotating internship in small animal medicine and surgery
and a residency in small animal internal medicine. She also completed a residency
in clinical pathology at North Carolina State University. Dr. Allen focuses on
cachexia/anorexia, endocrinology, and hepatobiliary and pancreatic disease and
has committed her career to improving the diagnosis of disease.
differential diagnosis page 27
SARAH E. CUDNEY, DVM, is a senior emergency medicine and critical care resident
at Cummings School of Veterinary Medicine at Tufts University. She earned her
DVM from Cornell University and completed a rotating internship at Angell
Memorial Animal Hospital in Boston, Massachusetts. Her interests are in trauma,
point-of-care ultrasonography, mechanical ventilations, and zoo and exotic animal
critical care.
management tree page 28
ELLEN M. LINDELL, VMD, DACVB, is the president of the American College of Veter-
inary Behaviorists. Her behavior specialty practice is based in New York and Con-
necticut. Dr. Lindell is a member of the Fear Free Advisory Panel, a certified Fear
Free professional, and an approved Fear Free speaker. She is also a behavior consul-
tant for Veterinary Information Network and has lectured extensively. Dr. Lindell
has written chapters for several publications, including the BSAVA Manual of Canine
and Feline Behavior, Blackwell’s 5-Minute Veterinary Consult, the newly updated Black-
well’s 5-Minute Consult: Canine and Feline Behavior, and Decoding Your Dog.
consult the expert page 10
consult the expert page 30
LAURA A. NAFE, DVM, MS, DACVIM (SAIM), is an assistant professor of small
animal internal medicine at Oklahoma State University. She earned her DVM from
University of Missouri, where she also completed a residency in small animal
internal medicine. Dr. Nafe also completed a rotating internship in small animal
medicine and surgery at North Carolina State University. Her clinical and research
interests include respiratory, vector-borne, and immune-mediated disease.
consult the expert page 17
4 cliniciansbrief.com July 2020
every
pet
ELIZABETH A. ROZANSKI, DVM, DACVIM
(Small Animal), DACVECC, is an associate
professor of emergency medicine and criti-
cal care at Cummings School of Veterinary
Help your favorite
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her DVM from University of Illinois and
completed an internship at University of RECEIVE A
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management tree page 28
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MARK TROXEL, DVM, DACVIM (Neurol-
ogy), is a neurologist and neurosurgeon at
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IN THIS
ISSUE
ON THE COVER
CONSULT THE EXPERT
Developmental
Stages of Kittens
Ellen M. Lindell, VMD,
DACVB
30
PG
10 CONSULT THE EXPERT
Developmental
Stages of Puppies
27 DIFFERENTIAL DIAGNOSIS
Thrombocytosis
Julie Allen, BVMS, MS, MRCVS,
Ellen M. Lindell, VMD, DACVB DACVIM (SAIM), DACVP
17 CONSULT THE EXPERT
Feline Asthma
Laura A. Nafe, DVM, MS, DACVIM
28 MANAGEMENT TREE
Hemoabdomen
Elizabeth A. Rozanski, DVM, DACVIM
(SAIM) (Small Animal), DACVECC
Sarah E. Cudney, DVM
61 TOP 5
Top 5 Causes of Passive
Cervical Flexion
Mark Troxel, DVM, DACVIM
(Neurology)
July 2020 cliniciansbrief.com 7
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23 SYMPOSIUM CAPSULES
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04 OUR
AUTHORS
37 FROM PAGE TO PATIENT
Tips and techniques from
59 CLINICIAN’S BRIEF ONLINE
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July 2020 cliniciansbrief.com 9DEPARTMENT h CATEGORY h PEER REVIEWED
PANCREATIC
CONSULT THE EXPERT
DEVELOPMENTAL
BIOPSY
STAGES OF PUPPIES
Ron Ofri, DVM, PhD, DECVO
Ellen M.
Hebrew Lindell,
University VMD, DACVB
of Jerusalem
Rehovot, Israel
Veterinary Behavior Consultations
New York & Connecticut
10 cliniciansbrief.com January 2016MA
any
ntemortem
dog owners
diagnosis
have certain
of
expectations
pancreatic regarding
disease is athe
behavioral
challenge.
traits
Histopathol-
of an ideal
canine
ogy companion.
remains the Most
gold standard
prefer their
of
dogdto
iagnosis
be friendly,
for pancreatic neopla-
affectionate, and
responsive. When these Pancreatic
sia and pancreatitis.
1
behavioral
expectations are notamet
biopsy provides or undesirable
definitive diag-
behaviors occur,
nosis of the risk for
pancreatitis, a dog being
assuming a
relinquished or euthanized
representative sample is increases.2,3
Theobtained.
human–animal bond
An open may weaken as
or laparo-
owners wait
scopic for puppies
approach can to
be “outgrow”
made to
undesirable behaviors.
collect samples.
September 2015 cliniciansbrief.com 11CONSULT THE EXPERT h BEHAVIOR h PEER REVIEWED
The veterinary healthcare team plays an important nication (eg, growling) and interactions (eg, play)
role in ensuring puppies mature into well-behaved are first observed during this period. Puppies
dogs. With an understanding of normal develop- become more aware of their environment and are
ment, clinicians can be a primary source for able to eliminate without maternal stimulation.
providing appropriate guidance to owners during Because puppies can move further from the
the 4 developmental stages of dogs to help prevent nesting area, this is an ideal time to introduce
undesirable behaviors. an appropriate elimination substrate.
The 4 Developmental Stages Socialization Stage
Behavioral development is integrated with physical Socialization refers to the process of developing
maturation and development of the nervous appropriate social behaviors toward conspecifics.
system. Puppy development is divided into 4 stages: In practice, “socialization” is applied more broadly
neonatal, transitional, socialization, and juvenile.4 to include the development of social behaviors
However, these stages are not rigidly fixed; toward any species and the process of adjustment
different breeds may develop at different rates,5 to relevant environmental stimuli.
and environmental factors can affect genetic
expression. Prenatal conditions (eg, diet and A sensitive period is considered a phase in which
health of the dam) can influence puppy develop- external stimuli are particularly likely to have a
ment. Research in other species has shown that long-term effect on development. Preferences are
the offspring of mothers subjected to stressful acquired more readily during this period.13 The
handling are more sensitive to stressors.6,7 How- sensitive period of socialization in puppies begins
ever, these 4 periods continue to be useful reference at 3 weeks of age and lasts until 12 to 14 weeks of
points for discussions of puppy development. age.8,9,12 Puppies that have not been socialized
during this time have a tendency to react fearfully
Neonatal Stage to novel humans or situations.4
The neonatal stage ranges from birth to ≈2 weeks
of age; eyes are not yet open, and ear canals are Controlled exposure to humans during the social-
closed, so puppies experience the world mainly ization period is crucial. Even small amounts of
through touch and olfaction.8,9 handling can result in beneficial effects. In one
study, puppies not handled until 7 weeks of age
Despite an immature nervous system, neonates were more hesitant to approach humans than
respond to their environment. In a study, puppies were puppies handled at 3 to 5 weeks of age.14
that received more maternal care during this Puppies not handled until 14 weeks of age
period scored higher for social and physical remained persistently fearful and resistant to
engagement as adults than those raised by less handling.14
attentive mothers.10 In another study, puppies
gently handled by humans starting at 3 days of Negative experiences during the sensitive period
age were calmer and more confident at 8 weeks of can also have a profound impact on behavioral
age as compared with controls.11 Foster families development. Abrupt weaning, particularly when
and breeders should be advised to introduce soft paired with sudden separation from littermates,
handling of puppies as early as possible. may have long-term consequences on behavior.
Puppies removed from the dam and litter prior to
Transitional Stage 6 weeks of age have been shown to be more fearful
The transitional stage lasts ≈7 days (range, ≈14-21 and have exhibited more undesirable behaviors as
days of age).8,12 Eyes and ears begin to function, adults as compared with puppies that remain with
and muscle coordination improves. Social commu- the litter through 8 weeks of age.15,16
12 cliniciansbrief.com July 2020Juvenile Stage Healthy puppies of any age can begin to visit new
The juvenile stage represents the time from the end places at least twice a week. Owners should take
of the socialization period to sexual maturity. Sex- care to avoid locations frequented by dogs of
ual behavior is generally observed at ≈6 months of unknown health and vaccination status. The
age, although it may be delayed in large and giant puppy should be allowed to explore at its own
breeds.9 comfortable pace. Bringing treats and toys can
make the experience more pleasant, but if the
Dogs remain behaviorally immature even after they puppy becomes too frightened to play or take a
have reached sexual maturity. Large-breed dogs snack, the session should be ended.
may not mature socially until they are 18 months
of age or older.8 Because behavior problems are The puppy should be introduced to a variety of
frequently reported during this period, adolescent humans, beginning with quiet adults. Children
behavioral well-care visits should be encouraged. that are old enough to be quiet and gentle with
dogs should then be introduced. Puppies can be
Designing a Socialization Program carefully socialized with healthy puppies and adult
It is never too early to start socializing a puppy, dogs that are known to be gentle with puppies.
and, as long as the puppy remains calm and not
fearful, it is never too late to begin. The owner’s For some puppies, even mild stimuli may seem
goals should be considered when customizing a overwhelming. The socialization plan for these
socialization program, and stimuli relevant to puppies should be modified accordingly. If fear is
their puppy’s future should be introduced. profound or persistent, a more in-depth behavioral
Continues h
THE 4 DEVELOPMENTAL STAGES
NEONATAL STAGE TRANSITIONAL STAGE SOCIALIZATION STAGE JUVENILE STAGE
The neonatal stage ranges from The transitional stage The sensitive period of The juvenile stage represents the
birth to ≈2 weeks of age. lasts ≈7 days (range, socialization in puppies begins at time from the end of the
≈14-21 days of age).8,12 3 weeks of age and lasts until socialization period to sexual
12 to 14 weeks of age.8,9,12 maturity. Sexual behavior is
generally observed at ≈6 months
of age, although it may be
delayed in large and giant
breeds.9
July 2020 cliniciansbrief.com 13CONSULT THE EXPERT h BEHAVIOR h PEER REVIEWED
treatment plan should be discussed with the owner, It is important to be aware that puppies do not
and referral to a boarded veterinary behaviorist is complete vaccinations until they are 12 to 16 weeks
never premature. Repeated exposure in the face of of age. However, a survey-based study found that
profound fear can lead to sensitization and may not the risk for a puppy contracting canine parvovirus
be reversible. at a socialization class is low,18 and inadequate
behavioral inoculation may result in rehoming.
Puppy Socialization Classes Evaluating enrollment requirements for local
Puppy socialization classes are an opportunity puppy classes may be beneficial in minimizing
for puppies to learn how to behave calmly around this risk. An instructor who requires initial vacci-
humans and dogs. Puppies that attend socialization nations and veterinary health certificates is ideal.
classes are less likely to be rehomed than puppies The classes should be well-run so that puppies are
that do not attend similar classes.17 not overwhelmed or frightened.
The First Veterinary Visit
History
A brief behavioral history should be obtained for
POLL all puppies. Owners should be asked about any
Do you offer puppy socialization classes at concerns they are experiencing with their puppy.
your clinic? Handouts should be provided to pet owners to
help them manage normal but undesirable behav-
A. Yes iors (eg, mouthing, house soiling, destructive
B. No behavior, barking). Such behaviors typically do
C. Not yet, but we are planning to in not resolve on their own and may often escalate if
the future. owners attempt inappropriate techniques based
on their own research.
Scan the QR code to submit your answer and see the
other responses! The poll is located at the bottom of
Physical & Behavioral Examination
the article.
Puppies are usually presented for initial examina-
Using QR codes from your mobile tions while in their sensitive period for socializa-
device is easy and quick! tion. Positive and negative experiences have a
Simply focus your phone’s camera on profound impact on future behavior. Puppies that
the QR code as if taking a picture (but don’t click!). experience positive veterinary visits are more likely
A notification banner will pop up at the top of your to become cooperative patients that can receive
screen; tap the banner to view the linked content. good healthcare for years to come.
Both physical and behavioral observations should
be included in the patient’s medical record. Normal
puppies will explore the room and relax during the
physical examination,19 whereas fearful puppies
A survey-based study need special attention to assure a positive experi-
found that the risk for a ence; some may require behavioral therapy.
puppy contracting canine Behavior Monitoring
parvovirus at a socialization Clinicians should follow up with owners to ensure
they remain committed to providing excellent
class is low.18 socialization opportunities for their puppy. As
14 cliniciansbrief.com July 2020puppies mature, new behavioral concerns often improves the puppy’s ability to accept excellent
develop. A plan should be developed to provide medical care, and helps create a strong clinician–
behavioral check-ups every 4 to 6 months until owner–patient relationship. n
social maturity is reached.
Conclusion RELATED ARTICLE
Clinicians are in a unique position to positively For a related article, please see
affect the social development of puppies. Early, Developmental Stages of Kittens
accurate behavioral advice increases the strength on page 30.
of the bond between the owner and the puppy,
References
1. King T, Marston LC, Bennett PC. Describing the ideal Australian com- D, eds. BSAVA Manual of Canine and Feline Behavioural Medicine. 2nd
panion dog. Appl Anim Behavior Sci. 2009;120(1-2):84-93. ed. St. Louis, MO: Saunders Elsevier; 2013:122-161.
2. Patronek GJ, Glickman LT, Beck AM, McCabe GP, Ecker C. Risk factors 13. Bateson P. How do sensitive periods arise and what are they for? Anim
for relinquishment of cats to an animal shelter. J Am Vet Med Assoc. Behav. 1979;27(2):470-486.
1996;209(3):582-588. 14. Friedman DG, King JA, Elliot O. Critical period in the social develop-
3. Salman MD, Hutchinson JM, Ruch-Gaille R, Kogan LR. Behavioral ment of dogs. Science. 1961;133(3457):1016-1017.
reasons for relinquishment of dogs and cats to 12 shelters. J Appl Anim 15. Pierantoni L, Albertini M, Pirrone F. Prevalence of owner-reported
Welf Sci. 2000;3(2):93-106. behaviours in dogs separated from the litter at two different ages.
4. Scott JP, Fuller JL. Genetics and the Social Behavior of the Dog. Chi- Vet Rec. 2011;169(18):468.
cago, IL: The University of Chicago Press; 1965. 16. Slabbert JM, Rasa OA. The effect of early separation from the mother
5. Morrow M, Ottobre J, Ottobre A, et al. Breed-dependent differences in on pups in bonding to humans and pup health. J S Afr Vet Assoc.
the onset of fear-related avoidance behavior in puppies. J Vet Behav. 1993;64(1):4-8.
2015;10(4):286-294. 17. Duxbury MM, Jackson JA, Line SW, Anderson RK. Evaluation of associ-
6. Champagne FA. Epigenetic mechanisms and the transgenerational ation between retention in the home and attendance at puppy social-
effects of maternal care. Front Neuroendocrinol. 2008;29(3):386-397. ization classes. J Am Vet Med Assoc. 2003;223(1):61-66.
7. Braastad BO, Osadchuk LV, Lund G, Bakken M. Effects of prenatal han- 18. Stepita ME, Bain MJ, Kass PH. Frequency of CPV infection in vacci-
dling stress on adrenal weight and behavior in novel situations in blue nated puppies that attended puppy socialization classes. J Am Anim
fox cubs Alopex lagopus. Appl Anim Behav Sci. 1998;57(1-2):157-169. Hosp Assoc. 2013;49(2):95-100.
8. Houpt KA. Development of behavior. In: Houpt KA. Domestic Animal 19. Godbout M, Frank D. Persistence of puppy behaviors and signs of anxi-
Behavior for Veterinarians and Animal Scientists. 6th ed. Ames, IA: ety during adulthood. J Vet Behav. 2011;6(1):92.
Wiley-Blackwell; 2018:163-190.
9. Serpell J, Duffy D, Jagoe JA. Becoming a dog: early experience and
the development of behavior. In: Serpell J, ed. The Domestic Dog: Its
Suggested Reading
Evolution, Behavior and Interactions with People. 2nd ed. Cambridge, Fear Free. Fear Free: taking the “pet” out of “petrified.” Fear Free website.
UK: Cambridge University Press; 2017:93-117. https://fearfreepets.com. Accessed May 12, 2020.
10. Foyer P, Wilsson E, Jensen P. Levels of maternal care in dogs affect Seksel K. Preventing behavior problems in puppies and kittens. Vet Clin
adult offspring temperament. Sci Rep. 2016;6:19253. North Am Small Animal Practice. 2008;38(5):971-982.
11. Gazzano A, Mariti C, Notari L, Sighieri C, McBride A. Effects of early Yin S. Perfect Puppy in 7 Days. Davis, CA: Cattle Dog publishing; 2011.
gentling and early environment on emotional development of pup- Zulch H, Mills D. Life Skills for Puppies: Laying the Foundation for a Loving,
pies. Appl Anim Behav Sci. 2008;110(3-4):294-304. Lasting Relationship. Hubble and Hattie Publishing; 2012.
12. Overall K. Normal canine behavior and ontogeny. In: Horwitz D, Mills
July 2020 cliniciansbrief.com 15CONSULT THE EXPERT h RESPIRATORY MEDICINE h PEER REVIEWED
Feline
Asthma
Laura A. Nafe, DVM, MS,
DACVIM (SAIM)
Oklahoma State University
dF
IGURE 1 Ventrodorsal thoracic radiograph of an asthmatic
cat demonstrating a diffuse bronchial pattern and collapse of
the right middle lung lobe, which developed secondary to
mucus accumulation and resulted in atelectasis
Feline asthma is a lower airway disease that Hallmark clinical features of asthma include bronchoc-
onstriction, airway edema, airway eosinophilia, and
affects 1% to 5% of cats,1 most commonly excessive mucus production. The combination of these
young to middle-aged cats.1 Although median features can result in cough, tachypnea, and/or expira-
age on diagnosis has been reported to be 4 tory dyspnea.1,3 Compounding airway edema, smooth
muscle bronchoconstriction, and mucus hypersecretion
to 5 years, most cats with asthma experience
can result in airflow limitation, which can be at least
clinical signs earlier in life.1 Classified as partially reversible with bronchodilator therapy. If left
an allergic disease, feline asthma is the untreated, chronic airway inflammation can result in
irreversible airway remodeling.
result of a type-1 hypersensitivity to specific
aeroallergens.2 This immune response results
Clinical Signs
in cytokine release and elaboration that can Clinical signs associated with feline asthma include
ultimately cause pathologic airway changes. cough, tachypnea, open-mouth breathing, and/or
July 2020 cliniciansbrief.com 17CONSULT THE EXPERT h RESPIRATORY MEDICINE h PEER REVIEWED
respiratory distress, typically characterized by a and antibody testing), imaging (eg, thoracic radi-
prolonged expiratory phase of respiration and ography, thoracic ultrasonography, CT, bronchos-
abdominal push. Some patients may have only one copy, echocardiography), airway sampling, and
of these clinical signs, whereas others may have additional diagnostic testing (eg, airway cytology)
both a chronic cough and intermittent exacerba- to rule out other causes of eosinophilic airway
tions resulting in respiratory distress with expira- inflammation.
tory effort.3 Accordingly, clinical signs can be
episodic and vary in severity, from a mild, intermit- Physical examination may be normal or may
tent cough to life-threatening dyspnea (ie, status reveal tachypnea, inducible cough on tracheal
asthmaticus). Pet owners may struggle to identify a palpation, and/or abnormalities on thoracic aus-
true cough and may be confused with “vomiting cultation (eg, increased bronchovesicular sounds,
hairballs” without production of a hairball. expiratory wheezes). Classic radiographic findings
include a diffuse bronchial or bronchointerstitial
Diagnosis pattern, hyperinflation due to air trapping, and/or
Definitive diagnosis of feline asthma can be collapse of the right middle lung lobe due to mucus
challenging due to clinical features that overlap plug obstruction (Figure 1, previous page).3,4
with various other cardiopulmonary conditions, Because ≈20% of asthmatic cats have normal tho-
including chronic bronchitis, heartworm- racic radiographs, asthma should remain on the
associated respiratory disease, and pulmonary differential list for any cat with respiratory dis-
parasitic disease. Diagnosis can be facilitated tress and normal thoracic radiographs.5 In addi-
through a combination of consistent historical tion, a bronchial or bronchointerstitial pattern is
information, clinical signs (ie, cough and/or respi- also the predominant pulmonary pattern seen in
ratory distress), physical examination, laboratory cats with chronic bronchitis and/or heartworm-
data (eg, CBC, serum chemistry profile, fecal flota- associated respiratory disease, making it challeng-
tion and analysis, urinalysis, heartworm antigen ing to differentiate these conditions from asthma
via only physical examination and radiography.
Bronchoscopy may be used in asthmatic cats to
evaluate airway structure and collect bronchoalve-
Because ≈20% of asthmatic olar lavage fluid (BALF) for cytology, culture and
susceptibility testing, and Mycoplasma spp PCR
cats have normal thoracic testing. Alternatively, blind bronchoalveolar
radiographs, asthma lavage may also be performed in cats that show
diffuse radiographic changes. Clinicians should
should remain on the be cautious when interpreting BALF culture and
Mycoplasma spp PCR results in combination with
differential list for any cat BALF cytology results, as airways (especially the
with respiratory distress trachea) are not sterile and the presence of bacte-
ria or Mycoplasma spp does not equate to active
and normal thoracic infection.6
radiographs.5
Bronchoscopy findings are often nonspecific in
asthmatic patients and may include excessive
mucus accumulation, airway hyperemia, and/or
epithelial irregularities.1 Eosinophilic airway
BALF = bronchoalveolar lavage fluid inflammation is characteristic of but not specific to
18 cliniciansbrief.com July 2020asthma (Figure 2), as parasitic disease commonly heart murmur or gallop rhythm and perform cage-
results in airway eosinophilia. Historically, eosino- side thoracic ultrasonography to assess for pleural
philic airway inflammation has been defined as effusion and/or pulmonary edema (eg, presence of
>17% eosinophils present in BALF; however, recent B lines). If other causes of respiratory distress are
evidence suggests that >5% eosinophils is consid- not evident on initial evaluation, intervention
ered abnormal in feline BALF.7,8 Clinicians should with a bronchodilator for possible asthma may be
evaluate BALF eosinophil percentage in light of warranted.
clinical signs and concurrent conditions associated
with eosinophilia (eg, allergic skin disease). Most Management of chronic feline asthma is aimed at
asthmatic cats typically have significant BALF reducing airway inflammation and preventing or
eosinophilia; some can have lower eosinophil and reducing airflow-limiting bronchoconstriction.1
higher neutrophil numbers, particularly in chronic Reduced inflammation is best achieved by minimiz-
asthma cases. A heartworm antigen and antibody ing exposure to aeroallergens and environmental
test, fecal flotation, and Baermann test should be irritants (eg, aerosols, dust) and administration of
performed in all cases. In addition, the author com- oral glucocorticoids (eg, prednisolone). Minimiz-
monly institutes empiric antiparasitic treatment, ing environmental allergens is best achieved by
even if results are negative. reducing exposure to known allergens (eg, elimi-
nating outdoor access), cleaning bedding and other
Treatment & Management surfaces in the household frequented by the cat,
Management of feline asthma consists of both and using an air filter to improve air quality. Oral
acute and chronic treatment strategies. Clinicians glucocorticoid (prednisolone) therapy should be
and owners should understand that asthma is not initiated at a dose of 1-2 mg/kg/day. The dose may
a condition that can be cured; lifelong environ- be tapered by 25% to 50% every 2 to 4 weeks
mental and medical management are necessary. depending on clinical response. The goal is to
taper steroids to the lowest effective dose.
Cats presented in status asthmaticus require acute
management consisting of supplemental oxygen, Continues h
stress reduction and minimal handling, and bron-
chodilator therapy (eg, inhaled albuterol [via
metered dose inhaler], injectable terbutaline). In
the author’s clinical experience, injectable terbu-
taline is preferred over inhaled albuterol in the
emergency setting, as cats in respiratory distress
typically may not inspire deeply enough to appro-
priately deliver inhaled medication to the lower
airways. Identifying an expiratory respiratory pat-
tern can be suggestive of bronchoconstriction and
may lead the clinician to implement early inter-
vention with bronchodilator therapy. Expiratory
respiratory patterns are characterized by an
abdominal push during exhalation. If an obvious
expiratory pattern is not identified, evaluation for
other causes of respiratory distress (eg, pleural
effusion, congestive heart failure) should be per-
d FIGURE 2 BALF cytology from a cat demonstrating a predominance of
formed prior to empiric treatment with a broncho- eosinophils (arrows), which is characteristic of feline asthma. Image
dilator. Clinicians should evaluate patients for a courtesy of Dr. Susan Fielder, Oklahoma State University
July 2020 cliniciansbrief.com 19CONSULT THE EXPERT h RESPIRATORY MEDICINE h PEER REVIEWED
Inhalant Therapy S-enantiomer; however, racemic albuterol can be
Some cats can be transitioned to receiving only used at home by owners for rescue as needed.11
inhaled steroid therapy (eg, fluticasone) to mini- Oral terbutaline or theophylline may also be used
mize the systemic adverse effects of oral glucocorti- for chronic bronchodilator therapy. Although
coids and maintained on inhaled glucocorticoids many patients may need bronchodilator therapy
alone for long-term management.9 It is important to initially, once airway inflammation is controlled
overlap the inhaled steroid with oral glucocorticoid with glucocorticoid therapy, many can be weaned
therapy, as it is believed that inhaled glucocorti- off bronchodilators long-term and managed as
coids require ≈2 weeks to achieve full clinical effect. needed. In addition, feline asthma should never
Although the author frequently initiates inhaled be managed with bronchodilator therapy alone,
fluticasone at a dose of 110 μg every 12 hours, a as bronchodilators will not address airway
study evaluating inhaled fluticasone in cats with inflammation, which is an integral component
experimentally induced asthma found that airway of controlling asthma.
eosinophilia was controlled with a variety of doses,
including 44 μg, 110 μg, and 220 μg, administered Additional Therapeutic Options
every 12 hours.9 The efficacy of lower-dose flutica- Various other therapeutic drugs (ie, cyprohepta-
sone has not been evaluated in cats with naturally dine, cetirizine, nebulized lidocaine, maropitant)
occurring asthma. In cats with concurrent condi- have been investigated for management of experi-
tions in which systemic glucocorticoids are contra- mentally induced asthma in cats12-14; although
indicated (eg, congestive heart failure, diabetes some show promise in reducing airflow limitation,
mellitus), inhaled glucocorticoid therapy and/or none have been shown to be effective as monother-
oral cyclosporine may be considered.9,10 apy for management of feline asthma. As a result,
these other therapeutics can be considered as
Bronchodilator Therapy adjunctive treatments along with glucocorticoids.
Chronic bronchodilator therapy is not necessary Immunotherapy and mesenchymal stem cell ther-
in all cats with asthma and is only recommended apy have shown promise as future novel therapeu-
in patients that have signs associated with bron- tics and warrant further investigation both in cats
choconstriction (eg, respiratory distress, episodic that have experimental and naturally occurring
tachypnea). Inhaled racemic albuterol should not asthma.15,16
be used for chronic management of bronchocon-
striction due to the proinflammatory effects of the Prognosis & Prevention
Prognosis for feline asthma is typically good with
prompt diagnosis and appropriate management.
Status asthmaticus, however, is a potentially
life-threatening manifestation of asthma in cats,
Prognosis for feline especially if not recognized and treated appropri-
ately in the emergency setting. Prevention is chal-
asthma is typically good lenging, as it is impossible to truly prevent the onset
with prompt diagnosis and of an allergic condition like asthma. Prevention
and/or reduction of clinical signs can be achieved
appropriate management. through avoidance of known aeroallergens.
Clinical Follow-Up & Monitoring
Follow-up evaluation is necessary for successful
chronic management of cats with asthma. Clini-
cians should decide whether to reduce a steroid
20 cliniciansbrief.com July 2020dose based on clinical signs, physical examination,
thoracic radiography, and, occasionally, resolution
of airway eosinophilia. Long-term management of POLL
feline asthma is aimed at lowering glucocorticoid
doses to the lowest effective dose that controls clini- Approximately what percentage of your
cal signs and airway inflammation. Some patients feline asthma patients are maintained on
may be transitioned to inhaled glucocorticoid ther- inhaled glucocorticoids?
apy (eg, fluticasone) using a space chamber to aid A. 100%
drug delivery. Patients started on bronchodilator B. 75% to 99%
therapy can often be tapered off once airway C. 50% to 74%
inflammation is controlled. D. 25% to 49%
E. 1% to 24%
Feline asthma patients are generally responsive to F. I do not use inhaled glucocorticoids for
treatment with a glucocorticoid ± bronchodilator. my feline asthma patients.
In feline respiratory patients unresponsive to stan-
dard asthma therapy, the diagnosis should be Scan the QR code to submit your answer and see
reconsidered and further diagnostics pursued. n the other responses! The poll is located at the
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References
1. Trzil JE. Feline asthma: diagnostic and treatment update. Vet Clin J Feline Med Surg. 2010;12(2):91-96.
North Am Small Anim Pract. 2020;50(2):375-391. 10. Nafe LA, Leach SB. Treatment of feline asthma with ciclosporin in a
2. Reinero CR. Advances in the understanding of pathogenesis, and cat with diabetes mellitus and congestive heart failure. J Feline Med
diagnostics and therapeutics for feline allergic asthma. Vet J. Surg. 2015;17(12):1073-1076.
2011;190(1):28-33. 11. Reinero CR, Delgado C, Spinka C, DeClue AE, Dhand R. Enantiomer-
3. Corcoran BM, Foster DJ, Fuentes VL. Feline asthma syndrome: a specific effects of albuterol on airway inflammation in healthy and
retrospective study of the clinical presentation in 29 cats. J Small asthmatic cats. Int Arch Allergy Immunol. 2009;150(1):43-50.
Anim Pract. 1995;36(11):481-488. 12. Grobman M, Graham A, Outi H, Dodam JR, Reinero CR. Chronic
4. Foster SF, Allan GS, Martin P, Robertson ID, Malik R. Twenty-five neurokinin-1 receptor antagonism fails to ameliorate clinical
cases of feline bronchial disease (1995-2000). J Feline Med Surg. signs, airway hyper-responsiveness or airway eosinophilia in
2004;6(3):181-188. an experimental model of feline asthma. J Feline Med Surg.
5. Adamama-Moraitou KK, Patsikas MN, Koutinas AF. Feline lower 2016;18(4):273-279.
airway disease: a retrospective study of 22 naturally occurring cases 13. Nafe LA, Guntur VP, Dodam JR, Lee-Fowler TM, Cohn LA, Reinero
from Greece. J Feline Med Surg. 2004;6(4):227-233. CR. Nebulized lidocaine blunts airway hyper-responsiveness in
6. Schulz BS, Richter P, Weber K, et al. Detection of feline Mycoplasma experimental feline asthma. J Feline Med Surg. 2013;15(8):712-716.
species in cats with feline asthma and chronic bronchitis. J Feline 14. Schooley EK, McGee Turner JB, Jiji RD, Spinka CM, Reinero CR.
Med Surg. 2014;16(12):943-949. Effects of cyproheptadine and cetirizine on eosinophilic airway
7. Hawkins EC, DeNicola DB, Kuehn NF. Bronchoalveolar lavage in the inflammation in cats with experimentally induced asthma. Am J Vet
evaluation of pulmonary disease in the dog and cat. State of the art. Res. 2007;68(11):1265-1271.
J Vet Intern Med. 1990;4(5):267-274. 15. Reinero CR, Byerly JR, Berghaus RD, et al. Rush immunotherapy
8. Shibly S, Klang A, Galler A, et al. Architecture and inflammatory in an experimental model of feline allergic asthma. Vet Immunol
cell composition of the feline lung with special consideration of Immunopathol. 2006;110(1-2):141-153.
eosinophil counts. J Comp Pathol. 2014;150(4):408-415. 16. Trzil JE, Masseau I, Webb TL, et al. Long-term evaluation of
9. Cohn LA, DeClue AE, Cohen RL, Reinero CR. Effects of fluticasone mesenchymal stem cell therapy in a feline model of chronic allergic
propionate dosage in an experimental model of feline asthma. asthma. Clin Exp Allergy. 2014;44(12):1546-1557.
July 2020 cliniciansbrief.com 21Hygiene Options?
In Veterinary Dentistry?
iM3 offers a range of products designed to keep the dental work
environment cleaner & safer for staff and patients.
For more suggestions on how to A chlorhexidine rinse, single-use consumables,
make your dental suite safer, and sterilizable cart attachments are just a few
email us at info@im3usa.com of the innovations to keep you and your patients
or call 800-664-6348 safe. In addition, iM3 Advantage LED high-speed
hand pieces can help reduce the likelihood of
cross-contamination between patients.SYMPOSIUM CAPSULES
SYMPOSIUM
CAPSULES
My Patient Has are usually contraindicated in patients with
cardiac disease due to severe vasoconstriction
2019 International a Heart Murmur; and reflex bradycardia. Combining an opioid
and benzodiazepine is typically safe in seda-
Veterinary Emergency
& Critical Care Society
Can I Sedate or tion protocols, and the drugs work synergisti-
Anesthetize? cally. Alfaxalone is safe in smaller doses (eg, 1-2
mg/kg IV or IM) as part of a sedation protocol
or to prolong sedation after administration
September 6-10, 2019 of another sedative combination. Likewise,
Washington, DC ketamine at 1-2 mg/kg can be useful for pro-
It can be difficult to determine the pathology
underlying a heart murmur and whether that longing sedation. Both can be administered in
pathology is significant enough to warrant a patients with or without heart murmurs.
delay or special drug protocol for sedation or
anesthesia. Thoracic radiography can pro- Propofol, alfaxalone, and a combination of
vide insights into cardiac disease through ketamine with a benzodiazepine are gener-
assessment of heart size (especially the left ally safe for induction, especially when used
atrium), pulmonary vessel size, and presence with appropriate premedications. Analgesics,
of pulmonary edema. as well as locoregional anesthesia, decrease
the amount of inhalant anesthetic needed,
Opioids, benzodiazepines, ketamine, and tra- thereby minimizing adverse effects. Inhalant
zodone do not significantly impact the cardio- induction is contraindicated in patients due
vascular system and are generally considered to increased stress, which can result in tachy-
safe in animals. Fentanyl and other potent opi- cardia that may compromise cardiac output.
oids may induce vagally mediated bradycar- Preoxygenation may help prevent or limit
dia, and meperidine and morphine can cause tissue hypoxia. The total amount of IV fluid
histamine release, leading to hypotension. administered during anesthesia or sedation
In cats with cardiomyopathy, ketamine may should be limited (unless indicated as part of
cause catecholamine-associated tachycardia treatment), particularly in patients with left
that can decrease cardiac output. α2 agonists atrial enlargement.—Brainard BM
SAVE THE DATE
2020 International
Veterinary Emergency
& Critical Care Society
September 12-16, 2020
St. Louis, Missouri
July 2020 cliniciansbrief.com 23SYMPOSIUM CAPSULES
The Cons with immunity and coagulation. New
research has identified the ESL, which
integrity rather than on intravascular
colloid osmotic pressure. Circulating
of Colloids: is a fragile semipermeable layer, as the
main barrier controlling vascular fluid
intravascular volume is smaller than
previously thought, so IV fluid bolus vol-
How to Feel and macromolecule shifts; intravascular umes may be safely reduced, possibly
Comfortable colloid osmotic pressure plays a lesser
role than previously believed. Albumin
further protecting the ESL.
Not Using is vital to the integrity and selective per-
meability of the ESL; however, subphysi-
Colloids may cause harm when used in
place of a balanced crystalloid solution;
Colloids ologic concentrations may be adequate, however, patients with systemic inflam-
and it is becoming increasingly evident matory response syndrome unrespon-
that focus should be on providing suf- sive to crystalloids may still respond to
Colloid therapy has recognized risks; ficient albumin for maintaining ESL colloid therapy.—Hughes D
new data on transvascular fluid move-
ment involving the glycocalyx and endo-
thelial surface layer (ESL) have provided
further support for limiting colloid use. Circulating intravascular volume is smaller
Colloids are extravasated into the inter-
stitium faster than previously thought. than previously thought, so IV fluid bolus
In some tissue, colloid molecules can
persist for long periods, potentially
volumes may be safely reduced, possibly
causing tissue damage and interference further protecting the ESL.
Use & Misuse was then used in a prospective fixed-
order crossover clinical trial comparing
yet been studied in epileptic cats,
and its clinical efficacy is unknown. In
of Transdermal transdermal and oral phenobarbital
in 9 epileptic cats. A dose of 9 mg/kg
addition, the use of extended-release
levetiracetam was evaluated in 9
& Extended- every 12 hours resulted in poor correla- healthy cats weighing ≥11 lb (5 kg).
Release tion between transdermal dosage and
serum phenobarbital concentrations,
Cats were given extended-release
levetiracetam at 500 mg (≈100 mg/
Anticonvulsant requiring more dosage adjustments
than oral administration; however, 6
kg) once daily for 10 days. Serum
concentrations measured above the
Drugs in Cats out of 9 owners preferred transdermal minimum human therapeutic range,
over oral administration. and patients had few adverse effects;
however, serum therapeutic ranges
Transdermal levetiracetam at 60 mg/kg have yet to be established in cats or
Difficulties in giving an epileptic cat every 8 hours was also investigated in dogs with epilepsy. Clinicians should
oral medication multiple times a day 8 healthy cats using the same trans- exercise caution when prescribing this
can lead to suboptimal serum pheno- dermal carrier molecule as was used in medication for cats, stay aware of the
barbital concentrations. In this study, the transdermal phenobarbital study. gap in clinical efficacy studies, and be
2 transdermal phenobarbital formu- After 7 days, serum concentrations were able to communicate this information
lations in healthy cats were evaluated above the minimum human therapeutic to owners when discussing novel
and demonstrated adequate absorp- range at all time points; however, anticonvulsant treatment.—Barnes
tion. The owner-preferred formulation transdermal levetiracetam has not Heller HL
24 cliniciansbrief.com July 2020Difficult Vascular landmark placement, but veterinary
studies are lacking.
Venous cutdown is typically used
as a last resort. Contraindications
Access Because the IO space can be considered
for this method include trauma to
the site, infection in the area being
continuous with and equivalent to the catheterized, and coagulopathies.
IV space, IO catheters are ideal in unsta- Complications are relatively rare, and
There are several options for achieving ble patients with poor hemodynamic catheter removal within 12 to 24 hours
successful vascular access in cases in status or patients too small to easily is recommended.—Boysen S
which landmark-based IV catheter place- place an IV catheter. In older patients, a
ment has failed. In stable patients, ultra- manual or automated IO device or bone
sound-guided IV catheter placement can marrow biopsy needle can be used to
be used; in unstable patients, intraos- penetrate the bony cortex. In younger
seous (IO) catheters and venous cut- patients with a softer cortex, regular Most fluids
downs are preferred. Ultrasound-guided 18-g to 25-g hypodermic needles ± a
catheter placement is recommended if manual IO device or 18-g to 22-g spinal and medications
cases are complicated by hematomas,
if there is difficulty finding landmarks,
needles can be used. Contraindications
to IO catheters include patients with a
given IV can
in the presence of edema or obesity, compromised or fractured target limb, also be given IO.
and/or if blind catheter placement fails acute infection at the insertion site,
after 3 attempts. Studies in humans and/or previous orthopedic surgery
show higher success rates, faster time with hardware at the insertion site.
to placement, and lower complication Most fluids and medications given IV
rates with this method than with blind/ can also be given IO.
Management of is preferred for contaminated wounds,
although secondary healing via granula-
repaired using standard reconstruction
techniques; resection and anastomosis
Cervical Bite tion may be the only alternative. can be performed in patients with signif-
icant damage. Approximately 25% of the
Wounds Patients with cervical bite wounds can trachea can be safely resected without
have airway trauma, which should be significant compromise. One or both
suspected with SC emphysema, signifi- jugular veins can be ligated or occluded
cant hemorrhage, and/or swelling in the to control hemorrhage. Dogs—not cats—
The intricate anatomy and number of pharyngeal area. Radiography may help can tolerate bilateral occlusion or liga-
vital structures in the cervical region can localize the injury. Patients with ongoing tion of the carotid arteries. A temporary
make treatment for injuries to this area bleeding, respiratory distress, and/or tracheostomy and/or gastrostomy tube
complex. Normal recommendations deep tissue plane disruption require sur- may be indicated.
for bite wound management—includ- gical exploration to evaluate for injury
ing exploration, debridement, flushing, to the trachea, esophagus, and deeper Spinal trauma from bite wounds should
bandaging, and surgical repair as indi- structures. Laryngeal function should be treated as with any spinal cord injury;
cated—should be used. Systemic anti- be assessed on anesthetic induction in additional complications (eg, soft tissue
biotic therapy should be used promptly, patients with severe cervical injury or in damage, vertebral fracture, bacterial
preferably within 3 hours of injury, to cases in which there is preoperative evi- contamination) must be addressed.
address potential bacteria (eg, Pasteu- dence of inspiratory stridor. Care should
rella spp, Staphylococcus spp, Strepto- be taken not to damage the vagosym- Although there is a wide range of mor-
coccus spp) in the wound. Contraindica- pathetic trunk or recurrent laryngeal tality rates for cervical injuries, with
tions to primary wound closure include nerves. appropriate treatment, prognosis can be
tension, infection, and/or questionable excellent.—Taney K n
tissue viability. Delayed primary closure Tracheal damage can be surgically
July 2020 cliniciansbrief.com 25FINDEVENTHE DOSE
IF YOU CAN’T
FIND THE BOOK
Check contraindications, drug
interactions, and more from any device
With peer-reviewed drug information, a built-in conversion calculator, drug
information sheets for pet owners, and more, Plumb’s Veterinary Drugs has you
covered—wherever veterinary practice takes you.
Get started at plumbsveterinarydrugs.comDIFFERENTIAL DIAGNOSIS h INTERNAL MEDICINE h PEER REVIEWED
Thrombocytosis
Julie Allen, BVMS, MS, MRCVS, DACVIM (SAIM), DACVP
FOR MORE Following are differential References
Find more Differential Athanasiou LV, Polizopoulou ZS, Papavasileiou EG,
Diagnosis lists in diagnoses for patients presented Mpairamoglou EL, Kantere MC, Rousou XA. Magnitude
of reactive thrombocytosis and associated clinical
upcoming issues of with thrombocytosis. conditions in dogs. Vet Rec. 2017;181(10):267.
Clinician’s Brief and on Koprivnikar J, Kessler CM. Thrombocytosis: essential
thrombocythemia and reactive causes. In: Kitchens CS,
cliniciansbrief.com Drug-induced response (eg, to vincristine,
h Kessler CM, Konkle BA, eds. Consultative Hemostasis
and Thrombosis. 3rd ed. Philadelphia, PA: Elsevier
epinephrine, possibly a glucocorticoid) Saunders; 2013:298-323.
Iron deficiency
h Kuku I, Kaya E, Yologlu S, Gokdeniz R, Baydin A. Platelet
counts in adults with iron deficiency anemia. Platelets.
Physiologic reaction
h 2009;20(6):401-405.
• T o epinephrine (eg, due to trauma, exer- Rizzo F, Tappin SW, Tasker S. Thrombocytosis in cats: a
retrospective study of 51 cases (2000-2005). J Feline
cise, or excitement) Med Surg. 2007;9(4):319-325.
• Postsplenectomy Tefferi A, Barbui T. Polycythemia vera and essential
thrombocythemia: 2019 update on diagnosis,
h Primary thrombocytosis risk-stratification and management. Am J Hematol.
• Acute megakaryocytic leukemia 2019;94(1):133-143.
van der Meer W, MacKenzie MA, Dinnissen JWB, de Keijzer
• Chronic myeloproliferative disease MH. Pseudoplatelets: a retrospective study of their
–Chronic basophilic leukemia incidence and interference with platelet counting. J Clin
Pathol. 2003;56(10):772-774.
–Chronic myeloid leukemia Vo QT, Thompson DF. A review and assessment of
–Essential thrombocythemia drug-induced thrombocytosis. Ann Pharmacother.
2019;53(5):523-536.
–Other myelodysplastic/
myeloproliferative neoplasm
–Polycythemia vera
–Primary myelofibrosis
h Pseudothrombocytosis
• R BC ghosts or fragments, fragile
leukocytes, microorganisms, or lipemia
h Reactive thrombocytosis
• H ematopoietic/nonhematopoietic
neoplasia
• Hyperadrenocorticism
• Infection
• I nflammation (eg, immune-mediated
or hepatobiliary disease)
• Postsplenectomy
• Rebound from thrombocytopenia
• Trauma n
July 2020 cliniciansbrief.com 27You can also read
