Question Details
Pulmonary Congestion In A Dog
by sophiek - November 2, 2023    View Case Report
HI Steve,

Dudley is a 12.5 year old ME Shih. Tzu

Acute onset cough and collapse 9/10/23. Coughing fit brought up phlegm and blood. Treated with cough suppressants, antibiotics (Amoxyclav) and nasal oxygen at emergency centre, cardiac murmur also noted.
Went home with amoxyclav antibiotics and vetmedin, much improved.

Deteriorated from 21/10/23 despite continuing on medication.
Repeat emergency centre visit suspected tracheal collapse and he was sent home.Regular veterinarian then advised to stop antibiotics and Vetmedin in case an adverse reaction to these medications.

26/10/23 readmitted to emergency centre after further deterioration, struggling to breathe. Treated with IV antibiotics and nasal oxygen with good response.Radiographs show pulmonary congestion, not consistent with aspiration pneumonia.
Possible ddx include;
atypical bacterial infection, resistant infection or parasites
pulmonary hypertension
inflammatory lung disease with unusual lack of cough in history
cancerous infiltration of lungs (brochiogenic carcinoma, metastatic disease from elsewhere)
Returned home on Clinacin, Doxycycline, Prednisolone and Cerenia
Cerenia has been stopped due to inappetence / sedation on this medication. Owners also noted when given Vetmedin previously that he seemed wobbly on this.

Although he has a significant heart murmur (not present on check up 2 months ago), the specialist does not think the pulmonary congestion is pulmonary oedema related to congestive cardiac failure.

He has idiopathic epilepsy currently controlled with Pexion, Phenobarbitone and CBD.
He also has IBD and regularly has watery diarrhoea and inappetence.

Grade 5/6 murmur, no arrhythmia, slight tachycardia
Increased lung sounds generalised, tachypnoea, dyspnoea. No cough in consult. Weight loss. Prednisolone has improved appetite but he is hot. Antibiotics - good response. Vetmedin - adverse reaction.
Tongue pale and lavender/blue
Pulse fine, slippery, superficial

My TCVM diagnosis is Damp Heat with Spleen Qi Deficiency, Lung Phlegm, Stasis in Upper Burner, Kidney Qi Deficiency, Heart Qi Deficiency, Global Qi Deficiency and Shao Yang Disharmony.

I started him on CHJLGMLT - I was also thinking about Voltrex, as this might be more anti-inflammatory for his airways? But thought CHJLGMLT fitted more for seizures, pulmonary congestion, the slippery pulse.
I also started LJZT as a general Qi tonic / Spleen Qi tonic

I am wondering about using XFZYT - I think it fits biomedically for possible pulmonary hypertension, support cardiac function, possible lung neoplasia BUT I am concerned this doesn't really address Lung Phlegm / Dampness, and could exacerbate this? Would Tan Yu Tang be more suitable - would this still support cardiac function at all?
Are there any other formulas that address Lung Phlegm?

Also, I think I read somewhere that an adverse reaction to pimobendan could indicate BZYQT, but I don't know why - what is the reasoning behind this?

Thanks so much for your help - I'm finding this a complicated case!
by naturevet
November 2, 2023
I'm actually wondering, Sophie, if you need to start with a Spleen or Kidney tonic like Rehmannia Eight. The tongue says 'tonify and remove Stasis' while the pulse says drain or internalize and tonify. Sometimes Kidney deficient animals can have purplish tongues, because of the internal Cold making them prone to Stasis. Internal cold fits with the worsening on antibiotics and the loss of appetite.
Although Rehmannia Eight in its initially published form fits this, you can hedge your bets by adding in Six Gentlemen and/or Wei Ling Tang. The worsening in spring is consistent with Damp

Other differentials include Wei Qi deficiency, which can present similarly, and Blood deficiency. Blood tonics should be used with caution if things are wet looking, so I'd hold off on XFZYT for a bit. Shao Yang disharmony is a consideration, too.

I guess see what you've accomplished with your current protocol. At the very least, LJZT seems apropos. Wei Ling Tang potentially. Rehmannia 8, too. You could use all three at once. Without a toned deeper pulse, I'd be cautious using XFZYT in this dog, though. I guess my last thought is something like Zhen Wu Tang (True Warrior Combination) if you do start to suspect outright pulmonary edema from CHF.

I don't suppose that helped you much, but if in doubt, you could use those first three formulas together

by sophiek
November 3, 2023
Thanks for your reply Steve.

"Dudley" actually responded well to the antibiotics, at least initially (great for a week before deteriorating, then good again on a change of antibiotics) - does this change the possible TCM diagnosis from Internal Cold?

He did have an adverse reaction to Pimobendan - does this indicate anything from a TCVM perspective?

Thank you!
by naturevet
November 3, 2023
Hi Sophie,

In that case, maybe try a Wei Qi tonic like Bu Zhong Yi Qi Tang. Add 12g Gui Zhi and 15g Bai Shao to help expel any Wind Cold and warm the upper burner.

As to what Pimobendan can do from a Chinese medical perspective, I basically have to interpret the exact adverse events. If the collapse seen earlier was Pimobendan-induced, then BZYQT can indeed be the antidote

Let me know how things go!

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