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Inspiratory Stridor On Pug

by ericahawker - May 10, 2009

Okay, so I am really stumped on this new patient. I have a client that brought in her 9 yr old MN pug for a alternative med consult. I really want to help this dog out, but not sure where to start.

In Dec 08 owner noticed louder breathing and saw some discharge in the ears. He was treated at another clinic with Tresaderm and antihistamines. Chest/neck films were normal. No improvement with breathing on meds, but dog had a severe rxn to tresaderm with bilateral hematomas and swollen canals. So, they put him on pred and then had to place drains in the pinnae to help the hematomas resolve. Dog has never had any breathing or ear probs before this. Last on meds at end of January 09.

Ears finally improved on pred, but he was hyper, ravenous and had increased urination on pred. However, the ears still have proliferative tissue in the canal which is calcified.

On exam he was BAR, had mild stenotic nares, inspiratory resp stridor that I feel based on auscultation is localized to the upper resp tract. Ears--no erythema, mild brown exudate but unable to place otoscope in ears. Ear cytology--TNTC yeast in right, 1+ yeast in left. Mild tartar. Mild nasal hyperkeratosis, no nasal discharge and normal air flow in both nostrils. Pulse is deep and wiry. Tongue is pink and raw on the right.

Eats crayons and diapers occasionally. Diet--Iams low fat dry. Drinks good amt water, but grazes on food. Lies in the sun and hates snow/rain. Sleeps in dog bed. Enjoys walks. Formed, brown BMs unless he gets into something and then they are soft. Urinates 2-3 times per day.

So, Steve I know you said the side effects you see from the drugs are symptoms of the patient itself. Based on that I would say he is hot and excess. Yet with the other history like hating the cold/snow I would say he is cold and mildly damp. All I have done so far is recommend a grain-free, high protein diet (owner unable to home-cook and not interested in raw) and put him on Conofite SID for ears.

The formula I am considering is San Ren Tang.
I am looking at Yin tonics byt

by ericahawker

May 10, 2009

Oops, disregard that last sentence on my original post.

by naturevet

May 11, 2009

Hi Erica,

Once again, a nice analysis. Either we're both right or we'll both go down in flames together. The aural hematomas and the response to pred both indicate a very hot animal. Chinese medicine says the Yang rises to the ears. Too much Yang can create bleeding, since the exuberant Yang is 'driving the Blood out of the vessels'. From a western standpoint, the aggravation by pred and the severe inflammatory response both indicate a dog with significant oxidative stress and inflammatory tendencies, undoubtedly fueled by the diet. Diet change is thus a step in the right direction. The chilliness you're seeing is actually quite common with Spleen deficient Damp Heat animals, so although you thought it was out of keeping with the rest of the case, it actually fits.

The two formulas I'd consider are Si Miao San or San Ren Tang, as you suggested. Si Miao San has more antioxidant and anti-inflammatory influence, as well as higher specific activity against metabolic syndrome and inflammation. San Ren Tang has the greater reputation for drying up excess mucosal secretions and saliva. So once again, we have a toss up. I guess, on the assumption this is more about tissue swelling than exudation, that Si Miao San might be the place to start, given it's more potent, and given the overt reactions you've seen so far.

I hope that helps. Let us know how it goes!

Steve

by ericahawker

May 28, 2009

Saw Winston back today. No change in inspiratory stridor. I did notice a small amt clear nasal discharge and nasal hyperkeratosis. Ear infecton resolved. Owner did mention that he is slightly more energetic and still has a good appetite. Just recently changed to Wellness core diet in the past week.

He still licks the carpet and owner did describe episodes where she thought he was going to vomit but did not.

On exam, pink tongue--raw area has resolved from initial exam. Pulses noted to be moderate in strength and depth, slightly stronger on right.

I started him on Si Miao San--1/2 tab BID 2 weeks ago. Should I try San Ren Tang instead?
I did send him home with some chlorpheniramine to see if it would help with the congestion.

Thanks!

by naturevet

May 28, 2009

Hi Erica,

Given the deeper pulse, SRT may be a better choice. But now he's on SMS let's see what happens! The two formulas are quite close, so there's bound to be a little improvement if we're on the right track.

Thanks for the update! Looking forward to the next one!

Steve

by ericahawker

May 28, 2009

Saw Winston back today. No change in inspiratory stridor. I did notice a small amt clear nasal discharge and nasal hyperkeratosis. Ear infecton resolved. Owner did mention that he is slightly more energetic and still has a good appetite. Just recently changed to Wellness core diet in the past week.

He still licks the carpet and owner did describe episodes where she thought he was going to vomit but did not.

On exam, pink tongue--raw area has resolved from initial exam. Pulses noted to be moderate in strength and depth, slightly stronger on right.

I started him on Si Miao San--1/2 tab BID 2 weeks ago. Should I try San Ren Tang instead?
I did send him home with some chlorpheniramine to see if it would help with the congestion.

Thanks!

by ericahawker

May 28, 2009

So should I increase the dose or the frequency or just keep him on 1/2 tab BID and recheck again in 2 weeks?

Erica

by naturevet

May 28, 2009

Oh, sorry, I misunderstood. Okay, I'd start on SRT as well, and continue the SMS. I'd then recheck in a couple of weeks.

S

by ericahawker

May 28, 2009

Why would you do them both together? Are they synergistic when used together? And then start SRT BID also? How do you know if you should increase the dose of the current formula or add on another one?

I know lots of questions, but I this is one of my first cases that I followed up on and I am a bit confused.

Erica

by ericahawker

June 16, 2009

Just thought I would give an update.

Saw Winston again today--no improvement with inspiratory stridor.
At last visit I added on SRT to SMS and also prescribed chlorpheniramine.

I think he may have a structural abnormality such as elongated soft palate because nares are normal and he is not obese or congested. Ears look good. Tongue is pink and pulses are deep and wiry.

Owner is okay with knowing she has tried everything. I told her to finish the SMS and SRT. Any other suggestions?

by naturevet

June 16, 2009

My last two ideas are:
1. Blood stasis in the upper burner - this could be why he had the hematomas. In addition, it can create the sense of pulmonary congestion and mild breathlessness that could accentuate stridor. Xue Fu Zhu Yu Tang would be the formula to use if you suspected this diagnosis.

2. Kidney deficiency - this diagnosis would be more relevant if it was worse after exertion, or if you were wondering if he had laryngeal paralysis. Lately we've had some success in laryngeal paralysis using Kidney formulas. You could safely try Ba Wei Di Huang Wan (Rehmannia Eight) here. Often, Kidney deficient dogs will experience some improvement on prednisone.

Hopefully one of those two ideas will work. Good luck and hang in there!

S

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