犬・猫の呼吸器臨床研究会

診療基準研究班の報告(2019.3.22 更新 計18)

「城下幸仁. 犬・猫の呼吸器を診る(1) 呼吸器の基礎と体系、診断の過程. SA Medicine2017;19:63-74.」の内容を検証します。とくに、症状のスコア化、血液ガス分析、検査実施方法の標準化についての文献レビュー

咳の臨床グレーディング

獣医学領域の文献

Canonne AM, Bolen G, Peeters D, et al. Long-term follow-up in dogs with idiopathic eosinophilic bronchopneumopathy treated with inhaled steroid therapy. J Small Anim Pract 2016;57:537-542. (PDFあり)

ステロイド吸入治療を試みた犬の特発性好酸球性気管支肺症の長期followup研究

BACKGROUND: Treatment of canine idiopathic eosinophilic bronchopneumopathy mainly consists of long-term oral corticosteroid therapy. To avoid side effects, inhaled steroid therapy has been increasingly used but long-term clinical response and potential side effects are sparsely described. OBJECTIVES: Description of clinical response and side effects with long-term fluticasone in dogs with eosinophilic bronchopneumopathy. METHODS: Case series of dogs with eosinophilic bronchopneumopathy and treated with fluticasone monotherapy for at least 6 months. Clinical response and side effects assessed by physical examination, standardised questionnaire and ACTH (corticotropin) stimulation test. RESULTS: Eight dogs were treated for between 6 months and 5 years. Cough initially improved in all dogs; two dogs remained free of clinical signs, three were well controlled, but three showed severe relapse. Pituitary-adrenal axis inhibition occurred in two dogs treated with fluticasone monotherapy for more than 2 years; only one dog had clinical signs of iatrogenic hyperadrenocorticism. CLINICAL SIGNIFICANCE: Fluticasone monotherapy allows initial improvement or remission in the majority of dogs but long-term treatment fails to resolve the cough in some individuals. In addition, such therapy may induce pituitary-adrenal axis inhibition. Prospective larger and randomised studies including both fluticasone and orally-treated dogs are needed to define the optimal treatment.

フルチカゾン吸入単独でも特発性好酸球性気管支肺症の初期治療には効果が見込める。しかし長期投与では再発する症例もある。本研究で臨床徴候の評価として咳の有無を基準にしている。咳の重症度の目安は記載されていないが、軽度、中等度、重度と記載されている。咳を10回/日以上の頻度で発症する症例を重度と記載している(兵庫ペット医療センター東灘病院 谷口哲也-2019.3.4)。


Grobman M, Reinero C. Investigation of Neurokinin-1 Receptor Antagonism as a Novel Treatment for Chronic Bronchitis in Dogs. J Vet Intern Med 2016;30:847-852.

doi: 10.1111/jvim.13935. Epub 2016 Mar 20.

犬の慢性気管支炎に対する新しい治療薬としてのニューロキニンレセプター拮抗薬の効果について

BACKGROUND: Canine chronic bronchitis (CCB) results in cough lasting >/=2 months and airway inflammation. Adverse effects include risk of secondary infection associated with lifelong corticosteroid administration and prompt investigation into alternative therapies. Neurogenic pathways mediated by tachykinins that bind neurokinin (NK) 1 receptors may induce cough and airway inflammation. Maropitant, a NK-1 receptor antagonist, has been advocated for treatment of CCB based on anecdotal improvement, but without scientific evidence. HYPOTHESIS/OBJECTIVES: Maropitant will blunt clinical signs and airway inflammation associated with CCB. ANIMALS: Client-owned dogs (n = 8) with cough >2 months, thoracic radiographic evidence of airway disease and sterile airway inflammation (>7% non-degenerate neutrophils, >7% eosinophils or both) on bronchoalveolar lavage (BAL) enrolled. METHODS: Maropitant (2 mg/kg) administered q48h for 14 days. Study endpoints included client perception of clinical signs (surveys at baseline and 14 days, and visual analogue scale [VAS] at baseline, 7, and 14 days), and BAL % neutrophils and eosinophils (baseline and 14 days). One-way repeated measures ANOVA (VAS) and Wilcoxon-signed rank-sum tests (BAL cells, cough frequency) used with P < .05 considered significant. RESULTS: Maropitant significantly decreased cough frequency (P < .001) and VAS scores (P = .005). No differences in BAL % neutrophils or % eosinophils noted with treatment (P = .279 and P = .382, respectively). CONCLUSIONS AND CLINICAL IMPORTANCE: Preliminary results suggest that although maropitant may have antitussive properties leading to perceived clinical improvement, its failure to diminish airway inflammation makes it unsuitable for treatment of CCB. Future studies could evaluate maropitant as a cough suppressant for other respiratory disorders in dogs.

コメント:慢性気管支炎と診断した犬に対してマロピタント (2mg/kg EOD)の投薬を実施した。咳の重症度は87.5%の症例で減少、咳の頻度は75%の症例で減少した。VASは治療開始より2週間後より有意に減少した。しかしBALF中の好中球数と好酸球数に減少はみられなかった。本研究で咳の評価を主観的評価として飼い主への問診で咳の頻度、重症度が増えた/減った/不変の3つに分類している。客観的評価として咳の頻度(1日あたりで1週間の平均値)とVASを用いた評価法を使用している(兵庫ペット医療センター東灘病院 谷口哲也-2019.3.4)。


Trzil JE, Masseau I, Webb TL, et al. Long-term evaluation of mesenchymal stem cell therapy in a feline model of chronic allergic asthma. Clin Exp Allergy 2014;44:1546-1557.

doi: 10.1111/cea.12411.

猫喘息モデルへの脂肪組織由来幹細胞(MSCs)の静脈内投与後の長期観察について

BACKGROUND: Mesenchymal stem cells (MSCs) decrease airway eosinophilia, airway hyperresponsiveness (AHR), and remodelling in murine models of acutely induced asthma. We hypothesized that MSCs would diminish these hallmark features in a chronic feline asthma model. OBJECTIVE: To document effects of allogeneic, adipose-derived MSCs on airway inflammation, AHR, and remodelling over time and investigate mechanisms by which MSCs alter local and systemic immunologic responses in chronic experimental feline allergic asthma. METHODS: Cats with chronic, experimentally induced asthma received six intravenous infusions of MSCs (0.36-2.5 x 10E7 MSCs/infusion) or placebo bimonthly at the time of study enrollment. Cats were evaluated at baseline and longitudinally for 1 year. Outcome measures included: bronchoalveolar lavage fluid cytology to assess airway eosinophilia, pulmonary mechanics and clinical scoring to assess AHR, and thoracic computed tomographic (CT) scans to assess structural changes (airway remodelling). CT scans were evaluated using a scoring system for lung attenuation (LA) and bronchial wall thickening (BWT). To assess mechanisms of MSC action, immunologic assays including allergen-specific IgE, cellular IL-10 production, and allergen-specific lymphocyte proliferation were performed. RESULTS: There were no differences between treatment groups or over time with respect to airway eosinophilia or AHR. However, significantly lower LA and BWT scores were noted in CT images of MSC-treated animals compared to placebo-treated cats at month 8 of the study (LA P = 0.0311; BWT P = 0.0489). No differences were noted between groups in the immunologic assays. CONCLUSIONS AND CLINICAL RELEVANCE: When administered after development of chronic allergic feline asthma, MSCs failed to reduce airway inflammation and AHR. However, repeated administration of MSCs at the start of study did reduce computed tomographic measures of airway remodelling by month 8, although the effect was not sustained at month 12. Further study of MSC therapy including repeated MSC administration is warranted to assess impact on remodelling in chronic asthma.

コメント: 猫喘息モデルへの脂肪組織由来幹細胞(MSCs)の静脈内投与による治療反応をみた研究論文。CT, BAL, 臨床徴候によって効果を客観的かつ主観的に評価した結果、MSCsは気道過敏性や好酸球増加症を改善させることはできなかったが、気道のリモデリングは8ヶ月間は減少させられた。しかしより長期(12ヶ月)のリモデリング抑制させることはできなかった。この文献で治療効果を呼吸数、異常呼吸音、咳嗽の有無、臨床徴候発現までの期間、臨床徴候の重症度によって細かくスコアリングしている。VASによる評価もされているが、咳嗽の重症度までは評価されていない(兵庫ペット医療センター東灘病院 谷口哲也-2019.3.4)。


人医領域の文献

Morice AH, Fontana GA, Belvisi MG, et al. ERS guidelines on the assessment of cough. Eur Respir J 2007;29:1256-1276.

doi:10.1183/09031936.00101006

咳嗽評価におけるERSガイドライン

Cough

1) All basic scientific articles should refer to cough as a three-phase motor act. For the purposes of acoustic recordings in clinical studies, however, cough should be described as a forced expulsive manoeuvre or manoeuvres against a closed glottis that are associated with a characteristic sound or sounds.

2) All scientific articles should include a clear definition of what the authors have used as their definition of cough.

Capsaicin and citric acid inhalation cough challenge

1) The methodology for the performance inhalation cough challenge should be standardised so as to facilitate universal interpretation and comparison of data generated by different laboratories.

2) Comprehensive normal ranges need to be developed using the standardised methodology advocated in the present document.

3) The single-breath concentration‒response method using a flow-limited dosimeter is recommended for most experimental protocols.

4) Both C2 and C5 should be recorded.

5) Since there is wide inter-individual variation, cough challenge data have no intrinsic significance, but may usefully be used to follow change in cough reflex sensitivity in an individual.

Cough induced by inhalation of aqueous solutions

1) Aerosolised aqueous solutions represent useful experimental tool in cough research.

2) The cough challenge with ultrasonic distilled water (fog) is difficult to standardise since it is highly dependent upon nebuliser output.

3) Consideration should be given to potential adverse events, such as bronchoconstriction and cross-infection.

Cough monitors

1)No cough monitor is currently the gold standard.

2) Monitors should be developed that are ambulatory, are capable of being digitally processed and permit prolonged (24-h) recording.

3) There is little to commend any particular method of quantifying cough over any other.

Assessment of quality of life of patients with chronic cough

1) Cough can have profound effects on health status, which can be assessed by coughspecific health status questionnaires.

2) Cough visual analogue scale (VAS, 0‒100 mm) should be used to assess cough severity in patients with chronic cough.

3) Patients with chronic cough should be assessed with cough-specific quality-of-life questionnaires in clinical studies.

Animal models of cough

1) The most useful animal model of cough is the conscious guinea pig.

2) Both sound and airflow should be used to define a cough event.

Design and conduct of clinical trials of antitussive drugs

1) The experimental model in which antitussive drugs are tested depends greatly upon the mode of action of the agent.

2) Normal volunteer studies should be designed in the knowledge that a large placebo effect is likely.

3) In acute cough, parallel group studies are required.

4) In chronic cough, the patient population studied should be defined by a diagnostic test.

コメント:咳は健康状態に重大な影響を与える可能性があり、これはLCQ、CQLQ、CCIQといった咳に特異的なQOL問診票によって評価する。慢性咳嗽患者の咳の重症度を評価するには、咳の視覚的アナログスケール(VAS、0~100 mm)を使用する。慢性咳嗽患者においてはVASは非常に反応性が高く、咳に特異的なQOLと関連している。しかし客観的に咳の頻度との関連を評価することはできない(兵庫ペット医療センター東灘病院谷口哲也-2019.3.4)


Spinou A, Birring SS. An update on measurement and monitoring of cough: what are the important study endpoints? J Thorac Dis 2014;6:S728-734.

doi: 10.3978/j.issn.2072-1439.2014.10.08.

咳嗽の評価法とモニタリングのアップデート:研究での重要ポイントはどこか?

Considerable progress has been achieved in the development of tools that assess cough. The visual analogue scale (VAS) for cough severity is widely used in clinical practice because it’s simple and practical. The Leicester cough questionnaire (LCQ) and the cough-specific quality of life questionnaire (CQLQ) are the most widely used health status questionnaires for adults with chronic cough. They are well validated for assessing the impact of cough. Cough can be assessed objectively with challenge tests that measure the sensitivity of the cough reflex. Cough challenge tests are better used to determine the mechanism of action of therapy, rather than efficacy. Cough frequency monitoring, the preferred tool to objectively assess cough, is increasingly being used as primary end-points in clinical trials. The most widely used cough monitors are the Leicester cough monitor (LCM) and VitaloJak. They are ambulatory devices that consist of a microphone and recording device. Cough frequency monitors do not reflect the intensity or the impact of cough; hence their relationship with subjective measures of cough is weak. Cough should therefore be assessed with a combination of subjective and objective tools. There is a paucity of studies that have investigated the minimal important difference of cough frequency monitors, rendering further investigations needed.

コメント:咳嗽評価方法のMID(the minimal important difference、臨床的に有意な最小検出較差)を検討した。VASのMIDは急性咳嗽では17mm、慢性咳嗽におけるVASのMIDは研究されていない。LCQにおいて急性および慢性咳のMIDはそれぞれ2.0および1.3である。CQLQは慢性咳嗽で13である。咳の頻度評価は咳の客観的評価のためのゴールドスタンダードと見なされており、急性の咳嗽では、咳の頻度のMIDは54%の減少と報告されている(兵庫ペット医療センター東灘病院 谷口哲也-2019.3.4)。


 

呼吸困難のスコア化、客観評価法


掲載準備中


運動不耐性のスコア化、客観評価法


掲載準備中


聴診音の機序や疾患との関連


掲載準備中


 

獣医療における動脈血ガス分析の適用について

一般

Shiroshita Y, Tanaka R, Shibazaki A, et al. Retrospective study of clinical complications occurring after arterial punctures in 111 dogs. Vet Rec 2000;146:16-19.

犬の動脈穿刺111例に対する合併症について

The clinical complications occurring after 111 dogs had undergone arterial punctures were reviewed in relation to the dogs’ breed, bodyweight, age, sex and underlying diseases. Seven of the dogs had moderate to extensive ecchymoses, which were significantly more common in dogs under 3.5 kg in bodyweight and in dogs with disorders of the cardiovascular system.

コメント:7/111例で軽度から広範な皮内出血が生じたが全身状態に影響を与えなかった。この合併症は、体重3.5kg以下、心血管障害を有する犬で有意に生じやすかったが、10-14日で問題なく消失した(犬・猫の呼吸器科 城下-2018.11.28)。


城下幸仁:特集 血液ガス 「血液ガスとは-その理論と重要性」、InfoVets 3(8), 11-16, 2000

コメント:臨床血液ガスについてコンパクトにまとめております(犬・猫の呼吸器科 城下-2018.11.28)。


城下幸仁, 山根義久. 外来患犬に行われた動脈血血液ガス分析176例. 日本獣医学会131回講演要旨集 2001:150.

【目的および方法】小動物臨床において動脈血血液ガス分析はいまだルーチン化されていない。そこで、その臨床応用への有用性を評価するため、過去6年間に外来患犬に行われた全ての動脈血血液ガス分析結果およびその診療記録を調査し、i)正常犬の値、ii)患犬の基礎疾患、iii)各種酸塩基平衡障害の頻度、iv)低酸素血症の頻度、について検討した。動脈血血液ガス分析:大腿動脈を経皮的に穿刺してサンプル採取し、pH、PCO2、PO2、[HCO3-]、およびBase Excessについて、37℃で測定した。血液ガス分析装置にはOPTI 1(AVL)を用いた。

【結果】 総計176例が得られた(体重1.3-29.2kg、年齢0.3-16歳、雄74:雌102、疾患あり150/臨床的に正常26、無麻酔room air下164/酸素吸入下12)。i)無麻酔room air下の正常犬20例の平均値±2SDは、pH 7.406±0.057、PCO2 34.7±7.2 mm Hg、PO2 96.3±16.3 mm Hg、[HCO3-] 21.3±3.8 mmol/L、Base Excess -2.5±3.7 mmol/Lだった。ii) 基礎疾患で多かったのは呼吸器系(40例)、心血管系(25例)、泌尿器系(14例)だった。 iii)疾患犬150例中66例[44.0%]から何らかの酸塩基平衡障害を検出でき、順に、呼吸性アシドーシス26例[17.3%]、代謝性アルカローシス 20例[13.3%]、代謝性アシドーシス13例[8.7%]、呼吸性アルカローシス7例[4.7%]であった。iv) 疾患犬で無麻酔room air下140例中42例[30.1%]から低酸素血症を発見でき、順に、重度(PO2<40)4例[2.9%]、中等度(40-49.9)4例[2.9%] 、軽度(50-59.9)6例[4.3%] 、ごく軽度(60-79.8)28例[20.0%]であった。

【総括】動脈血血液ガス分析は、日常診療でルーチン化すれば種々の疾患犬の酸塩基平衡障害および低酸素血症を的確に診断でき、臨床的に有用である。

コメント:体温補正しない正常値を示しました(犬・猫の呼吸器科 城下-2018.11.28)。


城下幸仁. 血液ガスで肺機能を考える. 第26回動物臨床医学会年次大会プロシーディングno.2 2005:13-17.

コメント:換気血流比不均等について述べています(犬・猫の呼吸器科 城下-2018.11.28)


城下幸仁. 体液異常に挑む(原因の見極めと治療) 血液ガス・酸塩基平衡異常. 動物臨床医学会年次大会プロシーディング 2012;33回:322-326.

コメント:酸塩基平衡の基本的な考え方について述べています(犬・猫の呼吸器科 城下-2018.11.28)。


末梢血静脈血の適応限界

城下幸仁, 山根義久. 犬の末梢静脈血の血液ガス分析値の臨床応用への適応限界について. 動物臨床医学 2004;13:61-65.

犬における末梢静脈血の血液ガス分析値の臨床応用への適応限界を提示するため、連続した61例の循環動態が維持された外来患犬より続けて採取した動脈血と末梢静脈血サンプルを用い、両者の血液ガス分析値を比較した。末梢静脈血は、安静時に横臥で駆血をせず、シリンジ内に空泡を混入せずに採取された。そのサンプルは、動脈血のpH,炭酸ガス分圧(Pco2)、重炭酸塩濃度([HCO3]),塩基過剰(Base Excess、以下B.E.)値とかなりの相関を示したが(R2 = 0.56 – 0.79)、pHで動脈血値より有意に低く、Pco2で有意に高く、Po2で有意に低く、[HCO3]で有意に高い値を示した。B.E.値は動脈血値と有意差なく臨床的にも差がないと考えられた。末梢静脈血のB.E.値は臨床目的に動脈血値と代用可能である。末梢静脈血サンプルの血液ガス分析値は、B.E.を除き、動脈血のおおよその値を推測するにすぎず動脈血値に代用できない。

コメント:末梢静脈血の血液ガスサンプルは、採血時手技に気を払う必要があり、実質利用できるのは外頸静脈のみで、それでも動脈血値に臨床的に代用できる値は Base  Excessのみです(犬・猫の呼吸器科 城下−2018.11.28)。
動脈血化末梢静脈血の評価

Shiroshita Y, Yamane Y. Assessment of arterialization of peripheral venous blood in well-perfused dogs: 2012 ACVIM Forum Abstructs (oral presentation) in New Orleans, LA. J Vet Intern Med 2012;26:822.

循環動態が維持された犬における末梢静脈血の動脈血化の評価

Multiple arterial blood gas samples are essential for monitoring a patient during perioperative and critical care. In small animals, an indwelling arterial cannula is usually used for multiple blood gas sampling, although it may cause massive hematoma from rupture of the artery. In well-perfused humans, blood obtained from a superficial hand vein after heating the hands in hot water for several minutes has been reported as an appropriate substitute for arterial samples for the measurement of pH, PCO2, and lactate. The heated-hand technique is referred to as arterialization. Multiple blood gas samples can be obtained more easily and safely with this technique than with an indwelling arterial cannula. This study aimed to ascertain if arterialized venous blood samples can replace arterial blood gas sampling in well-perfused dogs.

Blood samples from the femoral artery (A), cephalic vein (CV), and saphenous vein (SV) were simultaneously collected from 8 lightly anesthetized dogs under conditions of experimentally induced metabolic acidosis, metabolic alkalosis, respiratory acidosis, and respiratory alkalosis in each dog. Samples were analyzed for pH, PCO2, PO2, [HCO3−], and base excess for each acid–base status. Metabolic acidosis was induced by continuous infusion of 0.6 M NH4Cl in 5% dextrose, and metabolic alkalosis was induced by administration of 1 M sodium bicarbonate solution. Respiratory acid–base disturbances were induced by mechanical ventilation. The forepaw and hindpaw were continuously heated at 37oC to arterialize CV and SV. Mean arterial pressure was maintained at more than 80 mm Hg. Statistical analysis was performed using MANOVA and linear regression. Bland–Altman plots were used to assess the degree of agreement between the blood gas values of A and arterialized CV or SV. P < 0.05 was considered statistically significant.

pH, [HCO3−], and base excess values in arterialized CV and SV exhibited no significant differences from those in A, high correlations with those in A (coefficient of determination, r2 = 0.93–0.99), and a clinically approximate agreement with those in A, respectively. PO2 values under all acid-base statuses in arterialized CV and SV were significantly lower than those in A (P < 0.01) and not correlated with those in A (r2 = 0.51–0.75), respectively. PCO2 values under metabolic acidosis in arterialized CV and SV were significantly higher than those in A [CV, 38.7 ± 2.6; SV, 37.5 ± 2.6; A, 33.2 ± 3.0 (mean ± SD) mm Hg; P < 0.01]. However, PCO2 in arterialized SV was closely correlated with that in A under both metabolic and respiratory acid–base disturbances (r2 = 0.93 and 0.99, respectively). It also demonstrated clinically acceptable agreement with that in A. In conclusion, arterialized SV blood samples can replace arterial blood gas samples for the measurement of pH, PCO2, [HCO3−], and base excess in well-perfused dogs for clinical purposes.

コメント:循環動態が安定した犬において後肢趾端部を37°に保温した環境下でのサフエナ静脈血サンプルは、動脈血のpH, PCO2, [HCO3−], Base Excess値に臨床的に代用可能である(犬・猫の呼吸器科 城下−2018.11.28)
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X線検査の実施方法の標準化


掲載準備中


 

透視検査の有用性と標準化


掲載準備中


胸部CT検査の所見と疾患関連について


Panopoulos I, Auriemma E, Specchi S, et al. 64-multidetector CT anatomical assessment of the feline bronchial and pulmonary vascular structures. J Feline Med Surg 2018;8:1098612X18807778.

OBJECTIVES: The aim of the study was to provide a detailed anatomical study of the feline bronchial and vascular structures by using CT angiography (CTA). METHODS: Adult cats with no respiratory clinical signs were enrolled in a CTA protocol to provide an anatomical study of the thorax. The dimensions, number of branches and branching pattern (monopodial vs dichotomic) of both bronchial and pulmonary vascular structures were evaluated under positive inspiration apnoea. A linear generalised estimating equations analysis (Spearman’s rho) was used to identify statistical correlation between tracheal diameter, age and body weight of the cats. RESULTS: Fourteen cats met the inclusion criteria. The pulmonary arteries had larger diameters than the pulmonary veins, and the pulmonary veins had larger diameters than the bronchial structures. A higher number of segmental bronchial and pulmonary vascular branches was observed in the left caudal lung lobe than in the other lobes. The monopodial branching pattern of both bronchial and pulmonary vascular structures was predominant in all cats of our study (100%) in cranial, caudal and right middle lung lobes, while a dichotomic branching pattern of the bronchial and pulmonary vascular structures of the accessory lung lobe was seen in 13 cats (93%). Thirteen cats (93%) had three pulmonary vein ostia, and one cat (7%) also presented with an additional left intermediate pulmonary vein ostium. Variation in the number of segmental pulmonary vein branches was noted in the right caudal lung lobe. There was no statistical correlation between tracheal diameter, age and weight. CONCLUSIONS AND RELEVANCE: Architecture of the feline bronchovascularr structures belongs to a mixed type of monopodial and dichotomic branching pattern. In cats, the pulmonary venous drainage system predominately presents three pulmonary vein ostia. Variations in the type of formation and the number of branches of the pulmonary venous drainage system were noted.

コメント:CTを用いた正常猫の気管支樹と肺循環を評価した。猫においては気管支樹がMonopodial branching patternなのかDichotomic branching patternの報告はなく、犬はmonopodialで人はdichotomicと言われている。猫は副葉以外は犬と同様で主にmonopodialであった。これはガス交換に何らかの影響を与える可能性が示されており今後の研究課題となる。また肺動脈は気管支よりもわずかに大きく、肺動脈は肺静脈よりも大きかった (兵庫ペット医療センター東灘病院 谷口哲也-2019.3.22)。


 

呼吸器疾患罹患動物のQOLの定義


掲載準備中


 

各呼吸器疾患の診断基準や治療法について


猫の気管支疾患/猫喘息

Nafe LA, Leach SB. Treatment of feline asthma with ciclosporin in a cat with diabetes mellitus and congestive heart failure. J Feline Med Surg 2015;17:1073-1076. (PDFあり)

糖尿病およびうっ血性心不全を合併した猫喘息症例に対し、シクロスポリン投与で治療した1例

A 5-year-old domestic shorthair cat that had been previously diagnosed with diabetes mellitus was presented for episodes of coughing and respiratory distress. Diagnostic testing revealed congestive heart failure secondary to hypertrophic cardiomyopathy and concurrent asthma. All clinical signs and eosinophilic airway inflammation resolved with oral ciclosporin while the cat was concurrently receiving medications for treatment of heart failure (furosemide and enalapril). Ciclosporin should be considered for treatment of feline asthma in patients with concurrent diseases (eg, diabetes mellitus, severe heart disease) that may contraindicate use of oral glucocorticoid therapy.

コメント:猫喘息症例の導入期にシクロスポリンを用い初期症状安定化に成功した症例報告。シクロスポリンは4mg/kg PO 1日2回にて開始し、ただちに咳や呼吸困難は改善した(犬・猫の呼吸器科 城下幸仁-2019.3.8)


Padrid PA, Cozzi P, Leff AR. Cyclosporine A inhibits airway reactivity and remodeling after chronic antigen challenge in cats. Am J Respir Crit Care Med 1996;154:1812-1818.

シクロスポリンAは猫において、慢性抗原刺激後の気道過敏性とリモデルングを抑制する

We determined the effect of cyclosporine A (CSA) on airway reactivity and remodeling after chronic antigen challenge in Ascaris suum (AA)-sensitized cats. CSA efficacy was demonstrated by inhibition of interleukin-2 (IL-2) production from phytohemagglutinin (PHA)-stimulated peripheral blood mononuclear (PBMN) cells. Twenty-four hours after the first AA exposure, cats not receiving cyclosporine (CsA-) demonstrated airway hyperresponsiveness (AHR) to acetycholine (approximately 1.0 log increase in PD200 versus baseline; p < 0.01), and a 13-fold increase in eosinophils in bronchoalveolar lavage fluid (BALF) (p < 0.01). AHR persisted (approximately 1.5 log increase in PD200 p < 0.001 versus baseline), and BALF eosinophilia was unchanged in CsA-cats 72 h after final AA challenge. The percent of normodense BALF eosinophils also decreased substantially in CsA-cats (p < 0.05). Necropsy specimens from CsA-cats demonstrated: (1) increased smooth-muscle thickness; (2) goblet cell and submucosal gland hypertrophy and hyperplasia; and (3) epithelial erosion with eosinophilic infiltration. There was no significant change in AHR, BALF, eosinophilia, or histology after chronic AA challenge in Csa-treated cats. These data suggest that CsA inhibits products of immune cells necessary for the development of AHR, airway inflammation, and airway wall remodeling caused by immune-sensitization in this model of atopic asthma.

コメント:(現在調査中 犬・猫の呼吸器科 城下幸仁−2019.3.8)



喉頭麻痺

掲載準備中


 

呼吸器診療に関するその他の有用な情報


Branter E, Weisse C, Berent A. Tracheal malformations in Yorkshire Terriors: 2012 ACVIM Forum Abstructs. J Vet Intern Med 2012;26:820-821.

ヨークシャー・テリアにおける気管の限局性「W」型変形

Tracheal collapse is a syndrome describing various forms of functionally narrowed tracheal lumens. Focal tracheal cartilage malformations in Yorkshire Terriers is a previously unclassified manifestation of this syndrome.

The purpose of this study was to describe the clinical signs, diagnostic findings, and short-term outcome following endolumi- nal tracheal stenting for this unique population. Medical records were reviewed of all dogs presenting to the Animal Medical Cen¬ter Interventional Radiology Service with a diagnosis of tracheal malformation. Clinical signs including dyspnea, honking/raspy breathing, and coughing were each serially classified by the owner on a scale of 0-10 (absent to continuous). Outcomes and compli¬cations were reported.

Thirteen dogs, all Yorkshire Terriers, were identified to have non-traditional cartilage malformations of the trachea. Thoracic radiographs found focal collapse at the thoracic inlet in all dogs. All dogs had tracheal stent placement. Tracheoscopy was per- formed in 11/13 dogs and all of these had evidence of shaped tracheal rings. Median pre-stent coughing score was 2 (0-10), post¬-stent was 2 (0-2), median pre-stent honking score was 6.5 (0-10) and post-stent was 0 in all, median pre-stent dyspnea was 5 (2-10) and post-stent was 0 (0-2). Complications occurred in 5/13; 2 stent fractures not requiring intervention and 3 tissue ingrowth (1 resolved with prednisone, 2 required stent placement).

A subset of Yorkshire Terriers exists with a unique form of the tracheal collapse syndrome that can be identified pre-operatively and is treated in similar ways with expected outcomes and complications similar to those reported with other forms tracheal collapse.

Tracheal collapse is a syndrome describing various forms of functionally narrowed tracheal lumens. Focal tracheal cartilage malformations in Yorkshire Terriers is a previously unclassified manifestation of this syndrome.

The purpose of this study was to describe the clinical signs, diagnostic findings, and short-term outcome following endolumi- nal tracheal stenting for this unique population. Medical records were reviewed of all dogs presenting to the Animal Medical Center Interventional Radiology Service with a diagnosis of tracheal malformation. Clinical signs including dyspnea, honking/raspy breathing, and coughing were each serially classified by the owner on a scale of 0-10 (absent to continuous). Outcomes and compli¬cations were reported.

Thirteen dogs, all Yorkshire Terriers, were identified to have non-traditional cartilage malformations of the trachea. Thoracic radiographs found focal collapse at the thoracic inlet in all dogs. All dogs had tracheal stent placement. Tracheoscopy was per- formed in 11/13 dogs and all of these had evidence of shaped tracheal rings. Median pre-stent coughing score was 2 (0-10), post-stent was 2 (0-2), median pre-stent honking score was 6.5 (0-10) and post-stent was 0 in all, median pre-stent dyspnea was 5 (2-10) and post-stent was 0 (0-2). Complications occurred in 5/13; 2 stent fractures not requiring intervention and 3 tissue ingrowth (1 resolved with prednisone, 2 required stent placement).

A subset of Yorkshire Terriers exists with a unique form of the tracheal collapse syndrome that can be identified pre-operatively and is treated in similar ways with expected outcomes and complications similar to those reported with other forms tracheal collapse.

コメント:ヨークシャーテリアには従来の気管虚脱とは異なる気管変形があるようだ。胸郭前口部気管の気管軟骨輪部中央が「W」字型に変形する。13例のヨークシャーテリアでこのタイプの気管狭窄が認められ、飼い主主観のスコア評価にて、咳は比較的軽度、喘鳴や呼吸困難は強かった。気管内ステント設置で対処可能であり、術後の同スコア評価にて咳も喘鳴もほぼ消失した。5/13例で術後合併症あり、2例はステント破損したが処置不要、3例はステント内肉芽組織形成で1例はプレドニゾロンで治癒;2例は再ステント設置した(犬・猫の呼吸器科 城下-2018.12.5)。


細菌性呼吸器疾患、分離菌、抗菌剤の選択について

Lappin MR, Blondeau J, Boothe D, et al. Antimicrobial use Guidelines for Treatment of Respiratory Tract Disease in Dogs and Cats: Antimicrobial Guidelines Working Group of the International Society for Companion Animal Infectious Diseases. J Vet Intern Med 2017;31:279-294.     doi: 10.1111/jvim.14627

犬と猫の気道疾患治療における抗菌剤使用のガイドライン-コンパニオンアニマル感染性疾患のための国際学会の抗菌剤ガイドライン作成委員会による

Respiratory tract disease can be associated with primary or secondary bacterial infections in dogs and cats and is a common reason for use and potential misuse, improper use, and overuse of antimicrobials. There is a lack of comprehensive treatment guidelines such as those that are available for human medicine. Accordingly, the International Society for Companion Animal Infectious Diseases convened a Working Group of clinical microbiologists, pharmacologists, and internists to share experiences, examine scientific data, review clinical trials, and develop these guidelines to assist veterinarians in making antimicrobial treatment choices for use in the management of bacterial respiratory diseases in dogs and cats.

コメント:ISCAIDによる細菌性呼吸器疾患の治療ガイドラインを提唱したもの。現在の獣医療において抗菌薬の使用についてのガイドラインについて明記したものはなく、経験的な使用とそれに伴う耐性菌の出現が問題となっている。この論文では猫上部気道感染症(URTD)、犬呼吸器複合感染症(CIRDC)、細菌性気管支炎、細菌性肺炎、膿胸についての定義と治療のガイドラインが明記されている(兵庫ペット医療センター東灘病院 谷口哲也-2019.3.11)。


Proulx A, Hume DZ, Drobatz KJ, et al. In vitro bacterial isolate susceptibility to empirically selected antimicrobials in 111 dogs with bacterial pneumonia. J Vet Emerg Crit Care (San Antonio) 2014;24:194-200.   (PDFあり)

犬の細菌性肺炎111例から分離された細菌の経験的抗菌剤に対する薬剤感受性

OBJECTIVES: To determine the proportion of airway bacterial isolates resistant to both empirically selected and recently administered antimicrobials, and to assess the impact of inappropriate initial empiric antimicrobials selection on length of hospital stay and survival to discharge in dogs with bacterial pneumonia. DESIGN: Retrospective study. SETTING: University veterinary teaching hospital. ANIMALS: One hundred and eleven dogs with a clinical diagnosis of bacterial pneumonia that had aerobic bacterial culture and susceptibility testing performed from a tracheal wash sample. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: Overall, 26% (29/111) of the dogs had at least 1 bacterial isolate that was resistant to empirically selected antimicrobials. In dogs with a history of antimicrobial administration within the preceding 4 weeks, a high incidence (57.4%, 31/54) of in vitro bacterial resistance to those antimicrobials was found: 64.7% (11/17) in the community-acquired pneumonia group, 55.2% (16/29) in the aspiration pneumonia group, and 50.0% (4/8) in the other causes of bacterial pneumonia group. No statistically significant association was found between bacterial isolate resistance to empirically selected antimicrobials and length of hospital stay or mortality. CONCLUSIONS: The high proportion of in vitro airway bacterial resistance to empiric antimicrobials would suggest that airway sampling for bacterial culture and susceptibility testing may be helpful in guiding antimicrobial therapy and recently administered antimicrobials should be avoided when empirically selecting antimicrobials. Although no relationship was found between inappropriate initial empiric antimicrobial selection and length of hospital stay or mortality, future prospective studies using standardized airway-sampling techniques, treatment modalities, and stratification of disease severity based on objective values, such as arterial blood gas analysis in all dogs with pneumonia, would be needed to determine if a clinical effect of in vitro bacterial resistance to empirically administered antimicrobials truly exists or not.

コメント:細菌性肺炎と診断された犬111頭の気管支肺胞洗浄液の細菌学的検査の結果。一般的な肺炎はBordetella bronchisepticaの分離が多かった。吸入性肺炎とその他の肺炎ではEscherichia coli、Klebsiella sp.、Streptococcus sp.、Staphylococcus sp.の分離が多かった。全体では26%の犬が耐性菌を持っており、過去4週以内に抗菌薬の投薬を受けている犬は57.4%の割合で耐性菌を持っていた。どの抗菌薬が無効/有効かの記載はない。耐性菌の有無で入院期間と死亡率に有意差はなかった(兵庫ペット医療センター東灘病院 谷口哲也-2019.3.11)。


Epstein SE, Mellema MS, Hopper K. Airway microbial culture and susceptibility patterns in dogs and cats with respiratory disease of varying severity. J Vet Emerg Crit Care (San Antonio) 2010;20:587-594. (PDFあり)

重症度の異なる犬と猫の呼吸器疾患における気道内サンプルの細菌学検査のパターン

OBJECTIVE: To compare airway microbiological culture and susceptibility results in 2 groups of dogs and cats: 1 with respiratory failure requiring positive pressure ventilation (PPV) and 1 with respiratory disease. DESIGN: Retrospective study. SETTING: University teaching hospital. ANIMALS: Fifty-two dogs and cats requiring PPV that had an airway microbiologic culture submitted from October 1, 2003 to October 31, 2008 were included. One hundred and four airway microbiologic cultures from dogs and cats with respiratory disease not requiring PPV were randomly sampled for comparison. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patients with respiratory failure were more likely to have a gram-negative enteric isolate identified (P<0.001), while patients with respiratory disease were more likely to have a gram-negative nonenteric isolate (P<0.001) or anaerobic isolate (P<0.001) identified. Aerobic bacterial isolates from patients with respiratory failure were less likely to be susceptible to ampicillin (P=0.006), amoxicillin/clavulonate (P<0.001), chloramphenicol (P=0.004), enrofloxacin (P<0.001), ticarcillin/clavulonate (P=0.004), and the combination of ampicillin with enrofloxacin (P<0.001) than were aerobic bacterial isolates from patients with respiratory disease. CONCLUSIONS: Canine and feline patients with respiratory failure severe enough to require PPV exhibit a different pattern of bacterial isolates cultured from their airways when compared with isolates from patients with respiratory disease that has not resulted in ventilator dependence. These isolates are more likely to be resistant to commonly used antimicrobials/antimicrobial combinations than patients in the respiratory disease group. These findings suggest that in canine and feline patients with infectious lower respiratory tract disease, consideration of the severity of the pulmonary insult may allow for better prediction of likely isolates and their antimicrobial susceptibilities. Further prospective studies with a standardized collection technique are warranted.

コメント:犬および猫について人工呼吸器を必要とする呼吸不全群53症例と呼吸器疾患群104症例の気道サンプル培養を実施した際の耐性菌について評価した。呼吸不全群ではアミカシンとイムペネムに対する感受性は良好であった。呼吸器疾患群と比較して呼吸不全群ではエンロフロキサシンとアンピシリンの併用は耐性がある可能性が高かった(兵庫ペット医療センター東灘病院 谷口哲也-2019.3.11)。