Case of the month - April 2015

Spot the obvious problem!  Air is supposed to be in your lungs within your chest - not leaking out into your surrounding tissues.  Read on to see how Dennis managed to survive this despite being 15 years old!

Dennis is a very sociable 15 year old Burmese cat and loves his cuddles. He has been living with two conditions for some time.  The first is a condition called chronic rhinitis. This is an inflammatory process which causes Dennis to have a constant stuffed up nose. This must be hard for Dennis to have a constant snotty nose but he doesn’t seem to mind and certainly doesn't stop him purring! His second condition is Diabetes Mellitus. This is where his blood sugar is too high due to his pancreas being no longer able to produce insulin.  Treatment of his diabetes consists of twice daily injections of insulin. Both his chronic rhinitis and diabetes are well managed and Dennis leads a very happy, normal life.

One morning Dennis’ mum rang to say Dennis was having severe problems breathing. Breathing difficulties in cats are always an urgent issue so instructions were given to bring Dennis to the surgery straight away. On presentation, Dennis had laboured, paradoxical breathing. This describes the chest moving in an opposite way to the normal movements of inspiration and expiration of the lungs. There was also a small spot of blood on his coat and air building up underneath his skin which suggested some type of trauma.

On further investigation with X-rays it was found that Dennis had fractured a rib and in doing so had punctured a lung.  This was allowing air to leak from his lung into the chest cavity and then out under the damaged skin and muscle.  This is a condition called pneumothorax.

This air build up prevents the lungs from expanding properly to bring air into the body and can be a life threatening situation. A pneumothorax occurs when a defect in either the lungs causes air from the lungs to enter this space or if a defect in the chest wall allows air to enter from outside the body. You can see Dennis' breathing in this video below and how his rib cage is moving and then the bulge in the body wall as air escapes!

Video of Dennis showing paradoxical breathing otherwise known as flail chest.

A pneumothorax most commonly occurs with trauma(road traffic accident, fall from a height). However, it can also occur when lung pathology is present causing the an area of lung to burst or in an asthmatic cat which is struggling to breath and their ribs break. In Dennis' case it appears to have been unknown trauma.

Dennis was treated by draining the air out of the cavity surrounding his lungs and pain relief and antibiotic cover. Sometimes, after draining the air out of the chest the leaking hole which caused the problem will self seal given 24-48 hours of rest.   Below is a picture after the chest had been drained.  You can see in the radiograph below the chest cavity has a more grey appearnce generally and the heart has dropped back down into a more normal position allowing Dennis to be much more comfortable and be able to take deep breaths.  

However, in Dennis' case the air around his lungs started to re-appear and the air underneath his skin on the chest wall was still present. This suggested that Dennis’ lung defect was not sealing and he was still leaking air into the cavity around his lungs. As his body was not repairing on it’s own it was decided he may need an operation to repair the defects to his chest.

Dennis was referred to Fitzpatrick Referrals to have advanced imaging in the form of a CT scan to identify the exact location of the defect so the appropriate surgical treatment could be performed. It was found that he had a very large hole in the muscle which made up his chest wall. His lung also had a damaged area due to a puncture from his broken rib but this hole had healed on its own.

You can see a couple of the 3D images here - clearly showing his fractured rib and how much free air was inside his chest cavity
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Surgery was performed to remove his fractured rib and have the muscles surrounding his chest stitched back together to prevent further air from entering the space surrounding his lungs. After the surgery he had a drain left in his chest to ensure all air was removed and the lungs could work properly. Dennis was discharged a few days after his operation as he was eating and recovering very well. He has continued pain relief at home and made a full recovery. His fractured rib was sent for further analysis and thankfully showed that this was just a 'normal' fracture with no sign of cancer or infection in the bone.

Throughout all of this Dennis was the most amazing patient!  Very happy with his pain relief - you can hear him purring away on the video.  Straight after surgery he was eating and home the next day!  Thankfully despite his age he was also a very quick healer.

As  you can see here he has an impressive scar to show off to his friends but amazingly he is back to his old tricks and should have no long lasting issues which seems incredible now he is missing one rib!