11/13/2024
Every now and then someone comes along who reminds this old Veterinarian of why I need to keep on keepin’ on. These are their stories:
Here is the second installment. If you missed Chapter 1: Louis, go here.
https://www.facebook.com/BodegaBayVeterinary/posts/pfbid0oHQbYJ6MoHznD3G2B4Rgvbcxn8Xkq766eW1g8u1fn7ddAESbzwUihGZge1RiqaoQl
Chapter 2: Jimmy
That’s not his real name, of course, and no, he’s not the late night TV host. He is rather boyish and charming, however, and would probably be quite popular telling jokes at 11:30.
Jimmy is a doggie of a certain age. He doesn’t qualify as "old," exactly, but he’s not a Spring chicken either. Yeah, little Jimmy has a few miles on him. He’s got a few problems, but his general health is, well, generally pretty good.
Or, it was.
Jimmy has had a mild but naggingly persistent cough for a while now. A dry airway cough is fairly common among small breed dogs, and Jimmy does have a heart murmur, so his heart is a little bit larger than normal, but it’s not like he’s in heart failure or anything. Many smaller dogs develop degenerative changes in their large airways as they age.
There are a series of C-shaped cartilage rings that support the trachea and bigger bronchi. These rings act like springs and keep the airways from collapsing. There are some pretty big pressure changes between inhalation and exhalation and the airways require a certain amount of flex to maintain effective air flow. As these little guys age, the cartilage rings have a tendency to lose their springiness, which results in narrowing of the airway.
Sometimes, the loss of flexibility is so extreme that the trachea actually collapses and becomes so narrow that it’s all but impossible to move enough air in and out. When this happens it’s ever so annoying.
To make things worse, an enlarged heart tends to push the trachea upwards inside the chest, squeeing the airway tube against the spine and making airway collapse even worse. Under the wrong conditions, like during heavy exercise or when attempting to pant away excessive body heat, tracheal and bronchial collapse can be life threatening. Animals have been known to suffer heat prostration, and will sometimes die, as a direct result of airway collapse. Even those mild cases promote chronic bronchitis and frequent coughing. Of course, the act of coughing puts that much more stress on the airway cartilages, which makes the whole problem worse.
So it was easy for everyone to think that Jimmy was just another little doggie with a big heart and lousy airway cartilage. I believed it. It was the obvious thing, and I have to say, the theory that Jimmy’s cough was caused by this very problem was really a pretty good one, except that it wasn’t true.
And so, it came to pass that Jimmy’s cough became suddenly much much worse one night, and he was in severe distress. He was taken to the emergency hospital, where he was X-rayed and diagnosed with lobar pneumonia (fluid in the air spaces of a lung lobe). After a couple of days in an oxygen cage, a whole lot of treatment, and $7,000, Jimmy recovered and got to go home.
But his cough never went away, and Jimmy’s doggie Mom had only so many $7,000 stacks of cash lying around. When Jimmy continued showing signs of lung disease (along with airway disease), his life was in danger. This was due as much to his disease as Mom’s inability to (ahem) cough up the money required to care for him.
And so, Jimmy found himself on my exam table. Now, there are lots of little dogs with mild airway disease and most of them get along pretty well with little or no trouble. Only a few need more than basic care.
But this problem was different. Jimmy had pneumonia. Who does that? On top of it all, Jimmy had lobar pneumonia. The very presence of pneumonia didn’t make a lot of sense in someone who was just supposed to have airway disease, but lobar pneumonia implies that Jimmy had inhaled something into his lung tissue. So really, Jimmy didn’t have lobar pneumonia so much as aspiration pneumonia. Or actually, if you need to put a point on it, Jimmy had BOTH.
And that’s the thing: Bronchitis and airway collapse are one thing, but pneumonia, much less lobar pneumonia, much, much less aspiration pneumonia… Well, they are (like Jimmy) very different animals. This whole thing didn’t fit together in a sensible way.
And besides, Jimmy’s X-rays showed that his big heart wasn’t THAT big, and his great big, dilated trachea appeared anything but collapsed. Sure, he had lobar pneumonia, but even though he was struggling for breath when his X-rays were taken, he just wasn’t showing the kind of airway narrowing that everyone quite reasonably expected he should have.
Jimmy has a secret. What is it?
OK. What have we got? Aspiration pneumonia, chronic bronchitis without much airway collapse, and the whole thing started with a chronic, low grade mystery cough in a middle aged, small breed dog with sub-clinical cardiac valvular disease. What’s your diagnosis?
Hint: What did Jimmy inhale?
Remember, his problem showed up at NIGHT. He seemed fine the day before. That’s key. Sherlock Holmes said, "When you have eliminated the impossible, whatever remains, HOWEVER IMPROBABLE, must be the truth."
***SPOILER ALERT!**THE ANSWER IMMEDIATELY FOLLOWS!***
When you think it over, it becomes clear that Jimmy never had an airway problem at all, at least, not in the beginning. Jimmy’s problem was much more mundane, simple even.
Jimmy, like so many middle aged males, suffers from gastro-esophageal reflux. Every night as he slept, stomach acid would creep up his esophagus and he would inhale the fumes. Stomach acid is extremely powerful, and the fumes alone were enough to irritate his airway linings. THAT was the cause of his cough. Then, one night, the acid rose a little higher, and he inhaled some. It didn’t take much, but that small amount went down his airway and dropped into a lung lobe, and P**F! Jimmy had lobar pneumonia (that nearly killed him).
And now? We started Jimmy on an antacid (similar to Prilosec®). When he had another, less severe episode of aspiration, we added a pro-motility drug to help his esophagus contain the acid down in his stomach, where it belongs. Jimmy was started on the old folks meal schedule to ensure that his stomach is completely empty by bedtime.
And Jimmy is OK. Since we got him dialed in, there have been no repetitions of his aspiration event. His cough is fading as his long-abused airways slowly heal. So far, so good.
As Holmes also said, “As a rule, the more bizarre a thing is, the less mysterious it proves to be.”
Dr. Michael Trapani
