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Chronic Cough In A Dog

by sara.baldey - November 14, 2018 View Case Report

Hi Steve,

Apologies for the long history below...

I have recently been seeing an old dog for chronic coughing. "Brodie" is a 15 year, male, neutered Jack Russell Terrier X. Brodie has a history of chronic coughing since 2015. He has been managed with fluticasone delivered by aerodog spacer, twice a day. The cough is normally dry but sometimes becomes moist. When this happens he is typically placed onto antibiotics by the regular Vet, which immediately improves the cough. Other symptoms include shortness of breath and wheezing, particularly when he is moving around or anxious.
Brodie had laryngeal tie back surgery performed a few years ago and also has a heart murmur, which has previously been evaluated by a Veterinary Cardiac Specialist. The owner monitors the resting respiratory rate diligently and this is always less than 30bpm.
Photos (quality of images received were not great) of thoracic radiographs recently taken by the regular Vet indicate tracheal collapse, small amount of pleural fluid, suspected broncho-interstitial pattern and VHS = 11.

I first saw Brodie on 25/10/18. Brodie is an overweight geriatric. His symptoms get worse in hot weather and prefers cool areas to rest. His eyes were red and his head was warm to touch. The abdominal flanks and hypochondrial region were tense. His tongue was purple and pulses were so weak they were almost absent. (Unfortunately I cant recall what his back shu points and alarm points were like). I performed an acupuncture treatment and started him on Xue Fu Zhu Yu Tang.

I next saw Brodie a week later on 1/11/18. The owner reported that Brodie had significantly improved since starting the herbs. He was
breathing better, had improved energy and cognition. He also seemed stronger when walking and less short of breath. His tongue was dark pink/red and purplish, with no coat. The pulses were almost absent, again. I performed another acupuncture treatment and continued the XFZYT.

I saw Brodie the following week on 9/11/18. This time the owners went away for a long weekend where the weather was warmer and humid, and Brodie seemed worse in this weather. The coughing was still reduced but Brodie was wheezing a lot. The owner showed me videos of this. This time Brodie seemed a bit tense over his flanks again, and his eyes were red and and his head was warm to touch. The tongue was dark pink and purple, with no coat and some tacky white saliva. Again, the pulse was almost absent. I performed another acupuncture treatment and continued the XFZYT.

I am due to see Brodie again tomorrow. However, I spoke to the owner on the phone today. It sounds like Brodie developed a mild to moderate form of idiopathic geriatric vestibular disease 2 days ago, and is showing slow and steady signs of improvement. I advised that he be checked out by his regular Vet (the owner lives a long way from our practice and I wasn't at work today) and I will see him tomorrow as planned.

Here in Melbourne we are in the midst of Spring, and I believe the geriatric vestibular disease may be caused by the "unrestrained" movement of Yang to the exterior. (In such an old dog, can this be due to an underlying Yin deficiency?). I was wondering if I should consider the use of Ban Xia Zhu Tian Ma Tang or Chai Hu Jia Long Gu Mu Li Tang or Xiao Chai Hu Tang? Would any of these be appropriate to use alongside the XFZYT? Or is there a better approach?

Many thanks for taking the time to read this! As always, I am very grateful for any thoughts and advice you have to offer.

Kind regards,
Sara.

by naturevet

November 15, 2018

Hi Sara,

I think you're bang on the money with your idea of suggesting CHJLGMLT. The worsening in hot weather suggests possible trouble internalizing Yang, as does the weak pulse (due to secondary Source Qi deficiency). Since a harmonious Shao Yang is required to both move Blood (outwardly from the Lungs) as well as move Lung Qi and Yang internally, we commonly use it in pulmonary decongesting protocols. The history of vestibular syndrome and collapsing trachea pretty much assures you it will help. I'd get it started. It will also mobilize fluid trapped in the Upper Burner for descent to and through the Kidneys

Let us know how it goes!

Steve

Chai Hu Jia Long Gu Mu Li Tang

by sara.baldey

November 15, 2018

Hi Steve,

Thank you so much for your advice. I really appreciate it. I will use the CHJLGMLT along with the XFZYT. I will let you know how he goes!

Kind regards,
Sara.

by sara.baldey

February 3, 2019

Hi Steve,

Last year, Brodie made a swift recovery from his episode of idiopathic geriatric vestibular disease. In the lead up to Christmas, Brodie was doing really well on XFZYT and CHJLGMLT. He was breathing very well and had improved level of activity. The owner was very happy.

I have seen Brodie a few times already this year. Over the last fortnight, Brodie has seemed to have slightly deteriorated with his breathing. He has some mild shortness of breath, and some wheezing (mostly in the morning). His hindlegs have become stiffer and weaker also. His abdomen has also subjectively appeared a bit more distended - though he has gained a little weight. He is still eating very well. He seems to get particularly worse in hot (+/- humid) weather. The weather here in Melbourne has been very variable over the last few weeks - very hot and dry, to cool, to wet...and back again, then repeat!

On his most recent visit, I was not able to feel Brodie's left pulse and the right pulse is very weak. The tongue was dark pink with some purple, no coat, with a wet, clear drip from tip of tongue.
Back shu points that elicited a response were BL17, BL22. Alarm points that elicited a response were LIV14, CV17. (On the two visits previous to this I was also getting a combined response over BL17, BL18, BL22, GB25).

I am wondering if I should change the CHJLGMLT to XCHT?, to address a possible TBO. Or does this seem a little silly, as the CHJLGMLT should already by beneficial for such a problem? I was also wondering if BWDHW was a worthwhile option to consider? I would really appreciate your thoughts and advice, please.

Kind regards,
Sara.

by naturevet

February 3, 2019

Hi Sara,

Such a weak pulse can suggest Source Qi or Yang deficiency; deep penetration of a Dampness and Phlegm pathogen; and Blood deficiency. Did any one or two of the points you list make a big difference to the pulse. I wasn't clear based on your description? That information can help steer us. One thing's for sure. The pulse is so deep now that you don't need to worry about internalizing Yang using CHJLGMLT, so you can stop that.

Blood deficiency can potentially be ruled out just because you've been working on Blood so long. That doesn't mean we should stop, since we don't want to destabilize him further, but it may suggest we should look elsewhere for ideas.

Kidney Yang deficiency would be expected to create weakness in the morning and a dog that felt generally better in the afternoon. You don't mention coughing, which it could cause, but it does fit with the hind limb weakness

Source Qi deficiency can be aggravated any time Yin and Yang are naturally separated, both morning and evening. It can cause weakness, too, and would potentially create a worsening during hot weather. In that instance, Yang would mobilize Blood, but with minimal Qi reserves to steer it, it would stagnate, weakening the pulse. Intuitively, I suspect that is what is going on, although the dog should probably receive a thorough cardiac work up to make sure there aren't pharmaceuticals that could have him feeling better quickly, such as diuretics. I presume that tree has been barked up, though.

Assuming that's the case, I'd wonder if the next step is Bu Yang Huan Wu Tang, perhaps in tandem with Liu Jun Zi Tang. The pulse is technically generated by Wei Qi, which naturally wanes as Source Qi declines. BYHWT also moves Blood, so XFZYT can be potentially stopped, in case three formulas seems like too much to use

Hopefully that helps you out. Let us know how it goes. You should hopefully see improvements in a few weeks

Steve

by sara.baldey

February 5, 2019

Hi Steve,

Many thanks for your helpful insights!! I am due to see Brodie again later this week and your reply gives me plenty to follow up on. I will keep you updated.

Thanks again,
Sara.

by naturevet

February 5, 2019

Thanks, Sara.

Meanwhile, thanks so much for the thoughtful Christmas gift. I really appreciate it!

Have a good rest of your week!

Steve

by sara.baldey

February 6, 2019

Hi Steve,

Glad you got it! Just something to say thank you for your time and for sharing your knowledge with Veterinarians like me. And for making Curedcases possible! It makes a huge difference to us, and our patients.

Kind regards,
Sara.

by sara.baldey

February 20, 2019

Hi Steve,

Just a quick update on Brodie.
When I saw Brodie last week, the owner reported that he had been quite well during the week. His respiratory symptoms were under control, though he was still weak in the hindlimbs. I did forget that Brodie does have an occasional harsh cough that is consistent with tracheal collapse (sorry!).

When I examined him the pulses were weak and deep, with the left pulse almost absent. When assessing surrogate pulses the LU and KID pulses were particularly weak.
The tongue was dark pink with a slight touch of purple.
Back shu points that elicited a response were: BL17 (mild), BL22, BL18/19
Alarm points were ok.
During the acupuncture treatment I noted that BL17 and BL23 made a definite improvement in the pulse.

We have stopped the CHJLGMLT. We are continuing the XFZYT, and have also started BYHWT and LJZT.
I am seeing Brodie again this week, and will keep you updated with his progress.

Kind regards,
Sara.

by naturevet

February 20, 2019

Excellent, thanks so much, Sara!

You really do seem to be a skilled practitioner

Steve

by sara.baldey

March 4, 2019

Hi Steve,

I have another update on Brodie.

As mentioned in my previous post, Brodie stayed on XFZYT and started BYHWT and LJZT (on 14/02/19).

I saw Brodie again the following week (on 21/02/19). The owner reported that Brodie seemed a bit weaker on the new herbs and that he also seemed to have increased gut sounds. He also had an incident where he was "found lying on his side with a blocked nose", from which he recovered fine. Vitals were normal, thoracic auscultation was normal, as were thoracic radiographs performed on the day, and was scheduled for an echocardiogram the following week.

On 25/02/19 the owner took Brodie to the animal emergency centre as he was incredibly flat and had developed a mucoid nasal discharge. He was diagnosed with suspected aspiration pneumonia following regurgitation. (Brodie had a laryngeal tie back surgery with his previous Vets a few years ago). The owner stopped the herbs at this point.

I saw Brodie on 28/02/19. In just a few days he had definitely improved on the antibiotics instituted by the emergency vet, but was still naturally lethargic and inappetant. He is continuing his medications and the only formula I suggested the owner continue is XFZYT, if she can get it into Brodie. I will see Brodie again later this week.

My concern is that one of the herbal formulas (BYHWT or LJZT) has caused a digestive upset and lead to the regurgitation and aspiration pneumonia - an unfortunate sequela of his laryngeal tie back surgery a few years ago. Though I am not sure which one? (I also feel so awful about this! Though the owner is still happy to come and see me and have Brodie in my care). I also feel that I should have transitioned Brodie more slowly onto the new herbs - rookie error.

Brodie was doing well on XFZYT and CHJLGMLT prior to all of this. I read that CHJLGMLT can be used in pneumonia, do you think this would be helpful to him? Though a part of me wants him to make a full recovery from the pneumonia before I tweak his herbs again. I have lost my confidence.

As always, your insights and advice would be greatly appreciated, please.

Kind regards,
Sara.

by naturevet

March 5, 2019

Hi Sara,

Laryngeal paralysis and pneumonia are both major indicators for a Shao Yang fomrula like CHJLGMLT. If he was doing well on it, I'd resume it. Or even Xiao Chai Hu Tang, but a late summer onset of disease suggests CHJLGMLT may be more helpful. If the latter is indicated, the pulse will be superficial and either bounding, or at least full and toneless, and will improve with GB point tonification. If XCHT is indicated, the pulse will still feel deep, and will respond to GB point sedation

I don't think it was a new formula that was the problem. Maybe the withdrawal of one that was helping more than we thought. It was my fault, looking back, that you discontinued it so rapidly, so feel free to blame me when you talk to your client.

Fingers crossed he gets back to normal, and goes on to do even better

by sara.baldey

March 5, 2019

Hi Steve,

Thank you so much for your swift reply.

When I next see Brodie I will check the pulse and see how it responds to the stimulation of GB points.

Please know that at no point has the owner expressed any dismay over what has happened to Brodie. She remains a very satisfied and loyal client. Your insights and advice are invaluable, to me, my clients and my patients. I will always take full responsibility for whatever happens and never pin any blame on you. Thanks for the back up.

Kind regards,
Sara.

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