Episode 6A - Bonus Episode! Deep Dive into Dyspnoea, PART 1

1.The GP hook

A practical ECC walkthrough for GP teams: the oxygen‑first, hands‑off approach to dyspnoea, reading the room, stabilisation without overhandling, and the chest POCUS views that distinguish wet lung, pleural effusion and pericardial effusion — fast.

A practical ECC walkthrough for GP teams: the oxygen‑first, hands‑off approach to dyspnoea, reading the room, stabilisation without overhandling, and the chest POCUS views that distinguish wet lung, pleural effusion and pericardial effusion — fast.

This Part 1 covers the first 10 minutes and the POCUS that helps. Part 2 (already released) picks up with pneumothorax signs, basic echo impressions, differentials and treatment direction.

Clinical disclaimer

• What follows is practical, experience‑based guidance from emergency clinicians. It’s not a protocol. Always confirm drug choices, doses, routes and complex procedures against current evidence, your practice formulary and local SOPs before acting.

2.The first 10 seconds: don’t panic, get consent, get oxygen

Monday‑Morning Move

If a dyspnoeic case is en route, turn the oxygen on to the kennel/tent early so it’s primed when they arrive.

• Panic isn’t a plan. Most dyspnoeic patients will do better if you reduce their stress level first.
• Use a clear 10‑second owner line: “I don’t like this breathing. I’d like to pop Charlie into oxygen while we talk and take a closer look — is that OK?”
• Cats/small dogs: oxygen kennel or tent is ideal. It takes time for the enclosure to fill, so have oxygen running before the patient has been in it for long.
• Medium/large dogs: flow‑by near the nares or nasal prongs (if tolerated) are often best. Masks are frequently poorly tolerated when an animal is distressed. Avoid improvised “bags” or head‑covers that increase stress, heat and CO2 retention.

3.ABCs first — hands off unless you must

• Airway, breathing, circulation — check in that order.
• If apnoeic: confirm pulse/heartbeat immediately. No pulse = start CPR. Pulse present but not breathing = secure airway and provide ventilation — that pulse will not last without ventilation.
• Quick oropharyngeal check only if safe (big dogs can bite). Obvious obstructions should be removed if reachable without putting anyone at risk.
• If the patient is collapsed/unresponsive and unreactive, a fuller exam and urgent access (IV/IO) are appropriate — you won’t worsen them by acting quickly.

4.Early reads from a distance

• Mucous membranes: quick visual inspection — blue, white, bright red, or pink? You can often see tongue/gums from across the room in a panting dog.
• Watch rate, pattern and audible noise from outside the kennel:
• Loud audible respiratory noise without a stethoscope pushes toward upper airway disease (brachycephalic issues, laryngeal pathology).
• Paradoxical breathing (chest moving inwards on inspiration while abdomen moves outwards) strongly suggests pleural space disease.
• Hindlimb non‑weightbearing in a dyspnoeic cat: weigh up saddle thrombus versus trauma (history and external clues help).
• Get a respiratory rate early — it’s a concrete figure to compare later.

5.Analgesia vs anxiolysis — calm the patient, safely

Common trap

Distress‑panting is not the same as true dyspnoea. A hit‑by‑car cat may pant hard from stress and look much better 30–45 minutes after analgesia and oxygen. Buy time with oxygen and calm, then reassess.

• Many dyspnoeic patients breathe better once calmer. Single‑agent anxiolysis/analgesia is commonly used to reduce stress‑related respiratory effort.
• In painful trauma cases, choose an opioid analgesic appropriate for the situation and route. In non‑traumatic, primarily distressed patients, a lighter opioid or sedative can be helpful to decrease agitation and improve breathing.
• Clinicians have different preferences and routes (IM versus IV) can affect behaviour (e.g. transient panting with some agents given IV). Always confirm your drug, dose and route against local guidance and check monitoring capabilities before giving sedatives/analgesics.
• Practical note (experiential): clinicians commonly give a pragmatic IM dose when weight is unknown to avoid prolonged handling and distress — but this is an experienced clinician choice and should not substitute for following local protocols.

6.Temperature matters — don’t forget it

• Measure and recheck temperature early. Oxygen kennels can get hot; hypothermic trauma cats and heat‑loaded brachycephalics both occur.
• Actively cool dogs that are clearly hyperthermic using practical measures (clip, water, fans) and stop active cooling once the patient reaches a safer temperature range per your practice guidelines. Avoid covering with wet towels that trap heat.
• For hypothermic trauma patients, avoid over‑warmth too quickly — follow local hypothermia protocols.
• Note: approaches to cooling vary and much of the discussion in this episode was experiential rather than evidence definitive.

7.The quick focused exam (once they’ve settled)

• Auscultate heart and lungs when safe:
• Dorsal silence with audible effort can indicate pneumothorax.
• Ventral muffling suggests pleural effusion.
• Muffled cardiac sounds may indicate pericardial effusion.
• Murmurs in cats are not decisive — interpret in the context of history and other findings.
• Neuro basics: mentation, ability to move all limbs, and any clear focal deficits (e.g. signs of thromboembolism in cats).
• If safe, a quick look in the mouth for obstruction or pooled fluid.

8.The first decent history — after stabilisation

• Key quick history points: onset (minutes/hours/days), cough history, trauma/exertion, recent visits/meds, known cardiac disease, and any previous similar episodes.
• Three high‑yield questions: 1) “Has anything like this happened before?” 2) “Any coughing, even months ago?” 3) “Any known heart issues?”

9.Thoracic POCUS — the hands‑off test that helps you choose

Clinical pearl

Cranioventral B‑lines → think aspiration or focal pneumonia. Caudodorsal B‑lines → cardiogenic oedema. Unilateral/localised → contusion or focal pathology.

• T‑POCUS answers a few binary questions quickly and changes plans fast. The chest is more forgiving than the abdomen for point‑of‑care scans.
• Let the animal choose position — sternal or standing in an oxygen kennel is often best.
• Prep: part the fur with spirit or use ample gel. If equipment restrictions exist, gel inside a glove over the probe can be a workaround.
• Typical scan points:
• Cats/small dogs: two dorsal points per side and one ventral field behind the elbow.
• Bigger dogs: add mid‑thoracic and extra ventral points as tolerated.
• A‑lines vs B‑lines (how to spot wet lung):
• Normal: bright pleural line and horizontal reverberation artefacts (A‑lines). No vertical laser‑like artefacts should reach the bottom of the screen.
• B‑lines: bright, vertical “comet‑tail” lines that move with respiration and extend to the bottom of the screen. Three or more in a field is clinically meaningful for interstitial/alveolar fluid (pulmonary oedema, contusion, pneumonia). Distribution gives diagnostic clues.

10.Pleural effusion on POCUS — often clearer than radiographs in unstable patients

• Ultrasound signs: pleural line sits deeper; anechoic/hypoechoic fluid above it; floating fibrin or membranes; triangular pockets between organs.
• Scan ventrally along the thoracic floor toward the diaphragm/liver notch to detect caudoventral pools.
• In unstable dyspnoeic patients, ultrasound first is usually safer and faster than lateral radiographs; avoid forcing a lateral rads position if it will decompensate the patient.
• If strongly suspicious and scanning is equivocal, prepare for thoracocentesis — the tap is both diagnostic and therapeutic.
• Thoracocentesis comments (experience‑based):
• Know your equipment pros/cons (butterfly needles vs catheters). Technique and vigilance are more important than the specific kit.
• One experienced tip: insert perpendicularly to the chest wall initially, then rotate to lie the bevel more parallel to the wall — this can reduce lung trauma as the lung re‑expands. This is an individual clinician technique and should be practiced under supervision.

11.Pericardial effusion: what it looks like and first decisions

• Classic US appearance: a beating heart floating in a black sac — often a sick, collapsing patient.
• Differentiate pleural vs pericardial fluid by tracking caudoventrally and looking for triangular collections (pleural) versus a round sac enveloping the heart (pericardial). Subxiphoid views and panning can help.
• If tapping pericardial effusion:
• Consider a catheter so you can leave it in if needed; even draining a small volume often relieves tamponade.
• Save fluid samples in plain and EDTA tubes if possible for cytology/culture — very helpful at referral.
• Prognosis notes (experience): not all pericardial effusions are neoplastic; breed and presentation matter. Giant breeds often have idiopathic effusions and may do well with surgical options. Rare infectious or foreign‑body causes can resolve with appropriate treatment.

12.What’s next (Part 2)

• Pneumothorax signs on POCUS (glide sign, lung point), quick cardiac impressions (contractility, LA:Ao eyeball), refining differentials and initial treatment pathways.

13.Take‑home points

Final note

The win with dyspnoea is nearly always early: oxygen, reduce stress, one or two decisive moves, and a POCUS that answers “wet lung?”, “pleural?” or “pericardial?” in minutes. Part 2 turns those answers into differentials and practical next steps.

• Oxygen first, stress last. A quick owner consent and hands‑off oxygenation buy time.
• ABCs trump everything. If they’re not breathing, act. If collapsed and unreactive, examine and secure access.
• Use opioids judiciously to settle dyspnoeic patients and choose full analgesia for obvious trauma — verify agents and doses against your practice formulary.
• Temperature matters — measure early and address hyper‑ or hypo‑thermia per local guidance.
• Thoracic POCUS changes plans fast. Learn to spot B‑lines, pleural effusion and pericardial effusion from sternal/standing positions.
• Ultrasound first whenever possible in unstable chests. If you suspect pleural space disease and scanning is unclear, a careful, monitored tap is often diagnostic and therapeutic.

Bonus material

Bonus material – managing hyperthermia in brachycephalics