Treatment
Treatment of BE can be quite challenging, given the fact that these patients have impaired ability to eliminate bronchial secretions from the lower respiratory tract. Most cases of BE are associated with persistent coughing and refractory chronic bacterial lung infections.
Many patients with BE will require prolonged courses of antibiotics but given the rising incidence of antibiotic resistance; it is incumbent to use antibiotics judiciously. Thus, antibiotic selection in the case of a chronic disease like BE, that requires prolonged antibiotic cover, should always be based on culture and sensitivity. Ideally, first-line antibiotics such as amoxicillin, first-generation cephalosporins and sulphonamides should be used. The main challenge of antibiotic therapy is monitoring therapy and titrating treatment according to the severity of the disease. Repeat sampling of lung fluid is not routinely performed, and thus there are currently no objective parameters to measure the progress ofpatients with BE. Resultantly, the monitoring is typically clinical, and thus demonstrating improved level of comfort and reduction in the frequency of coughing, if present is typically the way in which progress is monitored. Follow up radiographs/CT can be performed, especially where deterioration is observed, and serve to assess the development of complications such as worsening bronchopneumonia or development of inspissated areas of infection or abscesses that may require surgical removal. In general, surgery is not indicated and the majority of cases are managed medically. Adjunctive therapies such as nebulization, humidification of air, reduction of aero-pollutants (such as cigarette smoke) coupage, and mucolytic therapy are often also prescribed in order to improve clearance of mucus from the airways. Currently there are no evidence-based recommendations supporting the use of any particular therapeutic interventions, however, the use of these treatment methodologies is intuitively reasonable.Wherever possible the underlying disease process should be managed.
In the case of allergic/immune mediated inflammatory diseases this may include circumspect use of glucocorticoids (GCs) but needs to be carefully considered and the risk/benefit ratio needs to be discussed with the client. In the case of a florid bacterial pneumonia, the use of GCs particularly higher doses may be contraindicated, and thus are probably best reserved for when the patient is more stable, and the infection is under control. In cases where the underlying etiology is likely due to chronic inflammatory diseases such as chronic bronchitis a short course of steroids may be of benefit. A sensible approach may be to start with a dose of 0.5-1 mg/kg once daily for 5-7 days, and if an improvement is noted the dose can be tapered to effect over a number of weeks, and reduced to the lowest effective dose. Alternatively, the author has found that inhaled GCs (fluticasone, budesonide) are also sometimes effective, and in some cases can be used alone, or may reduce the required amount of oral prednisolone required to control the clinical signs. Inhaled GCs are particularly helpful in cases were systemic GCs are inappropriate such as in patients with diabetes mellitus or hyperadrenocorticism. The author will normally advise that the owner obtains a humidifier and if possible a nebulizer. Humidifiers are helpful in dry and dusty climates, and can be placed near to where the pet sleeps, and anecdotally seem to improve the comfort level of the patient. Coupage also appears to be of some benefit. Certain owners can be shown how to perform this, or alterna-
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