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Ask Dr. Michael Salkin Your Own Question
Dr. Michael Salkin
Dr. Michael Salkin, Veterinarian
Category: Dog
Satisfied Customers: 24397
Experience:  University of California at Davis graduate veterinarian with 44 years of experience
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My dog is in the emergency hospital in an oxygen cage and has

Customer Question

My dog is in the emergency hospital in an oxygen cage and has been for almost 3 days now. He has pneumonia. He is having difficulty breathing. I just found out he coughed up some blood and foamy fluid. The doctor said that by itself is not too concerning but if his breathing gets worse there may not be much we can do. He was diagnosed with Vasculits a few months ago and had a terrible reaction to anesthesia when he had his teeth cleaned a couple of months ago, so we can't sedate him to get a sample of the fluid. I just don't know if there is anything to be done. Is it normal to cough up blood? Is it normal to still be needing an oxygen cage after 3 days? Is there anything else that can be done?
Submitted: 1 year ago.
Category: Dog
Expert:  Dr. Michael Salkin replied 1 year ago.
I'm sorry that your question wasn't answered in a timely manner. No, hemoptysis is never normal. Please see this thorough review of hemoptysis taken from Clinical Veterinary Advisor, 3rd Ed., Cote', 2015
Hemoptysis
Definition
Expectoration of blood, bloody mucus, or bloody fluid, originating from the lower respiratory tract. Uncommon, but always indicates a serious medical condition.
Epidemiology
Species, Age, Sex
Dogs and cats of any age and either sex
Genetics and Breed Predisposition
Numerous, based on underlying cause (e.g., von Willebrand disease: Doberman pinscher, Shetland sheepdog, and many others)
Risk Factors
Breed predisposition to bleeding disorders
Exposure to anticoagulant rodenticide
Off leash or roaming behavior (trauma, infectious disease)
Residence in or travel to an endemic region (infectious disease)
Neoplasia more common in older patients
Predisposition to pulmonary thromboembolism (e.g., immune-mediated hemolytic anemia [IMHA], neoplasia, heartworm disease, hyperadrenocorticism, heart disease)
Contagion and Zoonosis
Systemic fungal infections (risk of common-source infection)
Clinical Presentation
History, Chief Complaint
Coughing up blood or blood-tinged foam, fluid, or mucus
Regurgitation of blood, hematemesis or melena: animal may swallow blood rather than expectorate
Bloody nasal discharge (can be confused with epistaxis)
Tachypnea, dyspnea, exercise intolerance
Lethargy, weakness, collapse
Underlying coagulopathy: historical or current bleeding diathesis
Underlying pulmonary disease: history of heart murmur +/− congestive heart failure (CHF), chronic cough, neoplasia, heartworm disease, etc.
Physical Exam Findings
Physical exam: special attention to cardiovascular and respiratory systems
Cardiac auscultation
Heart murmur: consider CHF but heart murmur can also be incidental finding
Tachycardia: CHF, shock, pain, etc.
Muffled heart sounds: pericardial effusion, dilated cardiomyopathy, pleural effusion, mass effect, etc.
Pulmonary auscultation
Crackles: pulmonary edema (CHF, noncardiogenic), exudate within airways (mucus, blood, pneumonia), pulmonary fibrosis
Wheezes: bronchoconstriction (asthma, exudate, fluid), airway obstruction (intraluminal mass or foreign body, extraluminal compression)
Decreased lung sounds: pleural effusion, pneumothorax, mass effect, diaphragmatic hernia
Fundic exam: retinal hemorrhage (coagulopathy), chorioretinitis (infectious disease), bilateral uveitis (coagulopathy/intraocular hemorrhage, infectious disease, neoplasia)
Oral exam: bleeding mass, trauma, gingival bleeding, etc.
Coagulopathy: possibly petechiae, ecchymoses, epistaxis, hematomas, hematochezia, melena, hematuria, scleral or retinal hemorrhage, hemorrhagic effusions
Etiology and Pathophysiology
Coagulopathy (thrombocytopenia, coagulation factor deficiency, thrombocytopathia): bleeding into airways
Pulmonary tumor, granuloma, abscess, lung lobe torsion: direct hemorrhage or erosion of local blood vessels
Trauma: contusions, rib fractures, etc.
Pulmonary edema: expectoration of blood-tinged fluid
Bacterial pneumonia, chronic bronchitis, parasitism, eosinophilic bronchopneumopathy, foreign body, etc.: irritation or bleeding of mucosal airway surface
Pulmonary thromboembolism, pulmonary hypertension, arteriovenous fistula: abnormal shunting of blood (uncommon)
Diagnosis
Diagnostic Overview
Diagnostic investigation is focused on identification of the underlying cause. Minimum database should include patient history, physical exam, complete blood count, serum biochemical profile, urinalysis, three-view thoracic radiographs, and coagulation profile (e.g., prothrombin and partial thromboplastin times [PT/PTT] and/or activated clotting time [ACT]).
Differential Diagnosis
For additional differential information, see table.
Coagulopathy
Thrombocytopenia
Immune-mediated destruction (primary/idiopathic vs. secondary)
Infection (ehrlichiosis, babesiosis, hemotropic mycoplasmosis, Rocky Mountain spotted fever, leishmaniasis, borreliosis, dirofilariasis, cytauxzoonosis, distemper virus, parvovirus, feline leukemia virus, feline immunodeficiency virus, feline infectious peritonitis)
Decreased bone marrow production
Other: disseminated intravascular coagulation (DIC), splenic sequestration, vasculitis
Coagulation factor deficiency:
Anticoagulant rodenticide toxicosis
Congenital factor deficiency (e.g., hemophilia A or B)
Other: severe liver disease, disseminated intravascular coagulation
Thrombocytopathia:
von Willebrand disease
Other: drug-induced (e.g., aspirin/nonsteroidal antiinflammatory drugs), hyperglobulinemia, DIC, uremia, thrombasthenia, thrombopathia
Pulmonary disease
Neoplasia (primary or metastatic): hemangiosarcoma, adenocarcinoma, squamous cell carcinoma, primary tracheal neoplasia
Fungal pneumonia: blastomycosis, histoplasmosis, coccidioidomycosis
Bacterial pneumonia or pulmonary abscess (including nocardiosis)
Parasitic infection: Paragonimus kellicotti, Eucoleus aerophilus (formerly Capillaria aerophila), Aelurostrongylus abstrusus, Filaroides hirthi
Lung lobe torsion
Foreign body
Bronchiectasis
Chronic bronchitis
Eosinophilic bronchopneumopathy (eosinophilic pneumonia/pulmonary infiltrates with eosinophils)
Pulmonary hypertension
Pulmonary thromboembolism
Cardiovascular disease
CHF
Heartworm infection
Arteriovenous fistula
Other
Trauma
Iatrogenic: complication of bronchoalveolar lavage, transtracheal wash, lung aspirate or biopsy, etc.
Initial Database
Quick assessment tests
Packed cell volume/total solids, blood gas analysis (if available), blood glucose, manual exam of peripheral blood smear (including platelet estimate), activated clotting time
Complete blood count
Serum biochemistry profile
Coagulation testing
Prothrombin and partial thromboplastin times
Activated clotting time
Urinalysis
Three-view thoracic radiographs
Advanced or Confirmatory Testing
Platelet function testing (buccal mucosal bleeding time, platelet function analysis [e.g., PFA-100], von Willebrand factor analysis) for suspected bleeding disorder despite normal platelet count and coagulation profile
Screening tests for infectious disease (antibody titers, ELISA, PCR)
Blood gas analysis to confirm and monitor severe hypoxemia if suspected
Thoracic CT scan: potentially more sensitive for parenchymal disease than thoracic radiographs
Echocardiogram
Neoplasia (hemangiosarcoma), endocarditis, pulmonary artery hypertension
Sedated oropharyngeal exam
Bronchoscopy
Visually examine lower airways, remove foreign bodies, bronchoalveolar lavage (cytologic evaluation, culture).
Fine-needle aspirate or biopsy of pulmonary mass(es)
Fecal testing for parasitic infection: fecal flotation, Baermann technique
Treatment
Treatment Overview
Ensure patient is hemodynamically stable.
Minimize stress and anxiety so as not to exacerbate dyspnea.
Handle carefully and avoid invasive procedures (including jugular vein blood sampling and cystocentesis) until coagulation status is known.
Acute General Treatment
Ensure patency and adequacy of patient airway. Endotracheal intubation may be required.
Oxygen supplementation
Volume resuscitation with intravenous crystalloid or colloid fluids
Whole blood or packed red blood cell transfusion
Sedation to ease breathing in anxious or stressed patients
Withdraw any medications that can predispose to coagulopathy and avoid drugs with antiplatelet properties.
Mechanical ventilatory support could be required.
Vitamin K1 treatment +/− plasma transfusion for anticoagulant rodenticide toxicity
Chronic Treatment
Nature and efficacy of chronic/specific treatment depends on the underlying cause.
Possible Complications
Hypovolemia and/or anemia due to hemorrhage
Airway obstruction
Dyspnea
Respiratory failure and/or physical exhaustion due to work of breathing requiring mechanical ventilation
Death
Recommended Monitoring
Vital parameters including systemic blood pressure
Packed cell volume/total solids or hematocrit
Arterial blood gas and/or pulse oximetry
Serial thoracic radiographs
Prognosis & Outcome
Ranges from excellent to poor depending on the underlying cause
Pearls & Considerations
Comments
Take appropriate measures to stabilize patient before diagnostic investigation.
In the author's experience, bleeding disorders (namely thrombocytopenia or anticoagulant rodenticide toxicosis), neoplasia (primary or metastatic, specifically hemangiosarcoma), and fungal pneumonia are the more common differential diagnoses in canine patients. This will vary with patient population, geography, etc.
The top two differential diagnoses for a dog with hemoptysis and a miliary interstitial pulmonary radiographic pattern are fungal disease and neoplasia. If the patient seems clinically very ill, either is possible, but if the patient seems well, neoplasia is more likely.
If both hemorrhagic nasal discharge and cough are present, diagnostic evaluation must consider differential diagnoses for epistaxis and hemoptysis.
As you can see there are many possible etiologies for hemoptysis and all are very serious. He'll continue to need an oxygen cage as long as his p02 - oxygen saturation in his blood as measured by a pulse oximeter - is too low.
Please respond with further questions or concerns if you wish.