Pulmonary abscesses due to possible aspiration during surgery

Discussion in 'Health & General Care' started by PiddlePod, Sep 6, 2019.

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  1. Sep 6, 2019 #1

    PiddlePod

    PiddlePod

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    Hello all,

    Our precious guy Beans (just turned 2 on June 4th) has been dealing with ongoing respiratory issues since having a polypoid polyp removed from his ear canal back in December 2018. We had a biopsy done on the polyp prior to the surgery and unfortunately it became infected a week later, likely from him sticking his dirty little toes in his ear... We first thought the polyp was growing because during the two weeks following the biopsy it was suddenly and very clearly visible in the canal when it originally couldn't be seen w/o peering deep inside the ear... but it turned out that it was actually infected and this wasn't discovered until he was in endoscopic surgery. The exotics vet noted that pus had come out of the polyp when he resected it and he flushed the canal immediately with saline before removing the polyp at the stem via cauterization. The polyp has not grown back but instead we have been dealing with respiratory issues since the surgery in Dec 2018.
    Immediately following the surgery once Beans had woken up he had extreme labored breathing which was thought to be a symptom of pain but he also had congestion/wheezing and in addition to pain meds I immediately put him on doxy/baytril. About 10 days later he worsened and I rushed him back to the vet...lots of x-rays and it appeared he had a possible partial collapse on his left side in the lower lobe (IMO indictive of aspiration)..

    Long story short we placed him on a doxy/baytril/azithromycin combo plus lasix that day. He seemed to partially improve after about two weeks on that combo then declined some around 3 weeks after starting the combo and I pushed for nebulizing injectable enrofloxicin/Albuterol and 3% hypertonic saline for 14 days. We ended up up extending the this to over a month of nebulizing along with the combo of oral meds, the addition of nebulizing seemed to have helped but it took some time...fast forward to April 2019 after stopping the nebulizing but continuing the azithromycin/doxy and adding oral baytril, Beans' lungs looked "OK" in x-rays and he improved significantly in regards to his respiratory rate with no suspicious lung sounds...but he still had some pretty crappy breathing that would come and go, likely from scarring(??)... He had 3.5 months of good lungs and breathing up until mid July 2019 although he had several follow up vet visits to monitor his improvement. FYI he has also been evaluated about 5 times for possible CHF/heart issues (via x-rays etc) and it has been confirmed that his symptoms are not heart related and he does not have CHF. There are also no CHF or heart issues with his brother and I've checked w/ the breeder and the rest of his siblings are free of heart defects as well.

    So, his breathing suddenly turned for the worse again on July 19 2019 and after a visit to the vet the x-ray showed "polkadot" spots on the left lung with some on the right including the consolidation that was seen/similar in his two x-rays in December 2018 and early January 2019, but somewhat worse. Beans has been on azithromycin/doxy/baytril and lasix for about 6 or 7 months and was still on the combo during the July 2019 visit.

    He was placed on a different combo of doxy/azithromycin/clavamox on July 19 with prednisolone every other day and seemed to have some improvement in about 5 days but about two weeks ago on about August 31 2019, he became worse (very similar to when he exibited symptoms in Dec 2018). We added in the nebulization with enrofloxicin/Albuterol/3% saline and today is day 6...he seems to be responding to the treatment (he is still on oral azithromycin/doxy/clavamox) but it isn't as significant of a recovery like it was back when we first added the nebulizing, but we are continuing it for another two weeks, including the oral antibiotic combo, lasix (3x daily) and Pred every other day likely for life. He still has some labored breathing (it has improved some), occasional "whooping" in the chest and some congested sounds mostly in the left lung.. Aside from this he is active and seems very happy,has lots of energy, plays with us and his brother, has a great appetite and is enjoying life.

    I'm asking for any thoughts on his current treatment and/or guidance on trying different drug combos or thoughts on what this could possibly be... I'm pretty certain this is related to some infected material aspirating into his lungs during the surgery and that we have been dealing with abscesses in the lungs due to this...but I'm not a doctor and I can't say for certain that this is the cause and his exotics vet had denied the possibility. He believes it is myco related which it could be as well..

    Thank you so much for taking the time to read through this and for any help or advice you all may be able to offer!
     
  2. Sep 6, 2019 #2

    Rocket99

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    Hi Piddle,

    So I read your entire history of Beans. Here are my thoughts, but be aware I am not a vet, and these are just my opinions and experienced thoughts, and I'm sure SQ or lilspaz68 might have more in depth info. Anyway, I am not sure that the lung issue was caused by an infection aspiration from during sedation, although it most likely was caused from him being unstable and distressed, with resulting immune system deficiencies. Surgery, and the accompanying anesthesia, is very stressful on rats, with quite a high fatality rate, as I'm sure you know. Considering all pet rats have Myco, the respiratory infection, the chances of it being exasperated by the immense stress from surgery, as well as the drop in immune function, is greatly increased. So I'm thinking that Beans just had a debilitating flare up, and with Myco, these flare ups can cause permanent lung damage, especially if the rat is older and has had a significant progression of the disease, which, many rats do anyway. Considering the age of Beans now, you will likely be treating him for the rest of his life, with ever increasing powerful drugs. It seems to me that you did, and are doing, an incredible job with his treatment. Hopefully, there will be more posts with encouraging words of wisdom, unfortunately I must say that you probably have a more extensive knowledge of Beans history and treatment than anyone else other than maybe your vet. Unless someone knows of more radical treatments, and there are some, then you might just want to stick to what works best with minor adjustments to see what he might respond to better. Personally, I would be careful of drastic changes, or at least do your homework and research them extensively, basically because if something goes wrong, and it ends badly, you will forever blame your actions and second guess yourself. Beans is 2+ years old now, a survivor of a serious surgery and illness, and has serious lung impairments, you might want to rethink things, and consider just trying to keep him as healthy as possible, but more importantly, as comfortable as possible, I mean, he IS an older gent. He is between the ages of 2 and 3, and you know that he has had a fantastic life with you, and I pray he is able to enjoy his remaining time healthy enough for it to be as close to as possible. My best to you and Beans, I hope you find what you're looking for, but while you're looking, don't forget to spend every second you can enjoying his remaining time with him and not "for" him, so to speak. Please don't take this wrong, I'm just trying to help you avoid not seeing the forest through the trees. My best ❤️.
     
  3. Sep 6, 2019 #3

    PiddlePod

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    Hi Rocket,

    Thank you so much for replying. I've been wondering the same regarding myco and all of this resulting from immune impairment due to stress of surgery...I've gone back and forth between this and aspiration but it's so difficult really know... Beans is a rat whom has never had respiratory issues, not even a sneeze prior to the surgery, which is what concerned me the most but again...every rat has myco and he may have been doing a great job at hiding it up until the surgery.

    No worries, I take no offense! Thank you for your honesty...I absolutely understand about his age... it's easy to forget how old he and his brother are sometimes especially when they are just as energetic and silly as they were as babies. ❤️ I know that what he is dealing with isn't curable but I just want to make sure I am doing everything I am able to for this little guy. :)
     
  4. Sep 7, 2019 #4

    lilspaz68

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    It sounds like he may have pulmonary abscesses but most times these run in families showing up after 18 months. The rat starts to lose weight and the chest starts to feel harder with little give as these abscesses fill up the lungs and garden. They often seem like they have COPD. I have found a zithro combo most effective antibiotic-wise, with just a hypertonic saline nebulization to help the healthy lung tissue. Once the rat starts to lose serious weight and their abdomen starts getting tucked up like a greyhound I add a steroid to help open up their airways. PA is a sad progressive condition and you just try to keep the rat comfortable as long as possible.
     
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  5. Sep 7, 2019 #5

    PiddlePod

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    Hi Lilspaz,

    Thank you for responding!

    It sounds like we're going about his treatment the right way having the oral Zithro, hypertonic saline, etc which gives me peace of mind. Have you any experience with azithromycin suspension for inhalation/nebulization? I read about it being used for people with cystic fibrosis and pneumonia. I plan to discuss it with the vet at our next follow up to see if it may be an option, but I have no idea what the cost would be for something like that considering it is a speciality drug. Any thoughts?
     
  6. Sep 18, 2019 #6

    PiddlePod

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    Hey All--

    Just wanted to give an update on our little Beanzu. He is doing as well as he can be considering the issues, both known and unknown (pulmonary abscesses due to the above-mentioned possibilities, prior atelectasis and currently lung consolidation and congestion) that I've been trying to manage under the guidance of his exotics vet. Beans is still being nebulized (enrofloxicin/3% hypertonic saline and Albuterol twice a day) along with his oral med combo (doxy/clavamox/azithromycin, Lasix daily and prednisolone every other day). I've seen some slight to very noticable improvement that comes and goes which I understand is common w/ PA -- some days his breathing and congestion/consolidation seems improved and others he is wheezy and a little whoopy. The left side is and has always been worse since his surgery (symptoms started an hour after his infected ear polyp surgery), sometimes it sounds like there is less air passing in and out of the left lung likely due to the heavier consolidation in the lung on that side. But, Beans is still alert, seems happy and is eating and enjoying his life so far. He and his brother have been sleepier/lazier but I attribute that to being older gents (2 years and 3 months old).

    Also for those interested, I've discussed switching the enrofloxicin for nebulization for tobramycin solution for nebulization after speaking with his vet about successful treatment with this antibiotic via nebulization in human patients with cystic fibrosis and COPD in that it helps repair some lung damage but does a good job of preventing additional damage as well as the anti-inflammatory properties and it's effectiveness on lung infections such as PA. The treatment with tobramycin is mostly palliative but has been shown to improve quality of life and lung function, lessening or completely eliminating the need for other airway treatments and emergency inhaler treatments in human patients. We also discussed kinase inhibitors like pirfenidone (Esbriet) that are nebulized as a solution and are indicated for patients with cystic fibrosis and idiopathic pulmonary fibrosis in that it preserves and improves lung function as well as reduces lung decline... clearly for palliative care. For those interested in the clinical findings, in human patients Esbriet improved lung function and lung filling capacity by 15-20% and reduced lung damage and prevented further lung damage 48%. Of course this all may not have the same improvement or benefit in rats but Beans' exotics vet and I are still discussing both the tobramycin and Esbriet and the vet has reached out to the manufacturer (Genentech) for more information on Esbriet dosages and of course cost...but I wanted to share in case someone else was interested in learning more about these two treatments or if they may have had any experience with them in rats or in their own medical care. I will share what I find out once we've investigated further and if we decide to try the tobramycin and/or Esbriet (depending on cost of the Esbriet..) I will follow up with the treatment protocol and any improvement that we observe with Beans for those interested.

    I understand that Beans is up there in age and some folks might believe this isn't worth pursuing due to time/cost or that it to may be considered excessive to try off label meds like the ones I mentioned but I have always tried to do what is best for Beans and only for Beans..so I will keep trying making the best decisions for him in regards to his care with his quality of life as a priority so that he maintains that quality of life with the possibility of improving it during the time that he has with us.❤️ I figure that if he has to be nebulized for the remainder of his life why not try some other nebulized meds if there is the possibility that they may improve or at least maintain his lung function/quality of life, strictly from a palliative care position since this isn't curative.

    Looking forward to hearing thoughts, suggestions or other experiences with PA and related lung issues from the group. Hopefully folks will post and share experiences or thoughts on the two new meds. ❤️ Thanks in advance and lots of scritches and kisses to everyone's ratties!❤️
     
  7. Sep 21, 2019 #7

    jorats

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    This is very interesting! And I hope you do keep us updated with any results for sure.
    I good long time ago, I used to nebulize my rats. With my vet, we decided to try it more so as a preventative. I can't say for certain if it's worked. My rats did live longer and have less respiratory issues but then so did my later crew once I changed their feeding habit and food.
     
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  8. Sep 21, 2019 #8

    PiddlePod

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    Hey Jorats! I'm still working the numbers here.... TOBI (tobramycin for inhalation) is a head spinning $7670 for 280ml but they do have 60ml bottles for about $1600 all w/o insurance. The vet is looking at dosages which may put the cost at a less head spinning amount of $380 which is doable especially if it will last for a couple of months of treatment. I don't even want to mention what the Esbriet cost is because it is insane w/o insurance but I've been talking to a researcher at Genentech and there is a possibility that they may consider working out a solution for us so that it isn't an incredible amount of money while still being able to provide a theraputic benefit. I am pretty sure it helped to sway them a bit when I attached a couple of pictures of Beans when I followed up on my inquiry w/ Genentech and they were amoured by his cuteness lol...but I'll have to see how all of this actually plays out. I'm semi hopeful but I've kept in mind that they are a huge pharmaceutical company and no matter how much the researchers loved Beans and seemed willing to help, the bottom line for them is of course $$$.

    So, anyway so far we've been continuing the nebs with enrofloxicin but we have changed the protocol to once a day in the evening since yesterday. We're hoping that we can maintain him on once a day as opposed to twice a day since Beans isn't a huge fan of being nebulized.

    I'm a nerd when it comes to researching and I came across a lot of documentation on the veterinary use of F10 SC for nebulizing in addition to nebulizing enrofloxicin for small animals. Has anyone had experience with this??? I looked into his F10n SC stuff and it is some sort of veterinary disinfectant o_O Our exotics vet never mentioned this stuff to us before and considering it's a disinfectant I'm hesitant to ask him about it. Out of curiosity has anyone had experience with F10 as a nebulizing additive or ever heard of it being used?

    I'll update further on the other two meds once we figure out if using them is an option and won't bankrupt me haha. :eek:

    Thanks again!!
     
  9. Sep 21, 2019 #9

    PiddlePod

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    Ah yes! I was looking through old posts and read some about you nebulizing w/ enrofloxicin for prevention. I wish I would have known this a long time ago because I probably would have done the same thing. This lung stuff is a real bummer. I would have thought that by now there would have been more options for our fur babies when it comes to this sort of thing. But our exotics vet made a good point, most of the information and data out there for rats and treatment options are based on documentation/experience in a research/laboratory setting...I hope that as rats become more appreciated and accepted as companion animals that over time there will be more interest in researching better treatments and options when it comes to mycoplasmosis and all the other crud that our little potatoes have to deal with.♥️
     
  10. Oct 29, 2019 #10

    PiddlePod

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    Hey all, just dropping in for a Beans update. Unfortunately the experimental drugs turned out to be around $2800 for a 60 day supply of the tobramycin for inhalation and $4900 for a 30 day supply of the Esbriet LOL. :eek::(

    I've kept Beans on the injectable baytril/Albuterol/3% saline nebulizing (two days on for nebs twice a day and one day off, repeat) along with oral Lasix (3xs daily)/doxy/azithromycin/clavamox combo, plus prednisolone every other day (2xs) and finally found a mix to mask the theophylline (2x daily). Regardless of all of these meds he's plateaued and at times it seems like he is getting worse...his breathing is more labored lately with an increase in his respiratory rate...he hasn't had any open mouth breathing/gasping but that doesn't mean that he isn't having any less trouble breathing. He's alert and has lots of energy, enjoys his treats and playtime but at 2.5 years old he and his brother are a little lazier/sleepier lately, so he and his brother are climbing up there in age.

    I plan on calling the vet tomorrow to ask again if we can try gentamicin to nebulize. The vets have been very conservative in some of his treatment options and ive had push back when asking to try the gentmicin in the past but I'm hoping that they will be more receptive to giving it a try this time since I feel like we are running out of options and Beans is likely just going to get worse on the current treatment protocol. :( The vets are concerned about the side effects of gentamicin and every time I ask to try it, I'm told that it can cause all kinds of neurological issues and acute kidney failure/injury. I understand the risks and I've researched it as a treatment, so it is a matter of convincing the exotics vets to sign off on it and just get started on it to see if it makes a difference.

    Has anyone had any experience with nebulizing gentamicin and have you found it to be successful for treating/stabilizing PAs? Any advice is appreciated!! I feel like time may be running out for my little guy but as long as he is happy and wants to keep going, I'm willing to try something else to see if it could be more beneficial to him than the current treatment protocol.

    Please share your thoughts and experiences even if they aren't related to gentamicin. Any ideas are welcome!
    Thank you in advance!!:)
     
  11. Nov 1, 2019 #11

    Rocket99

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    Wow. Just wow. Maybe it's time to discontinue all treatment and let the poor guy live his life until it's his time. Must be a miserable existence like that, for both of you.
     
  12. Nov 1, 2019 #12

    PiddlePod

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    I wouldn't agree that our existence is miserable, not at all. I don't have any issue with researching treatments or making sure that Beans is given veterinary treatment. He would not have made it this long into his life if I had listened to advice like that and gave up on treating him and giving him the best quality of life I can. He's a very happy rat, loves to come out for playtime, loves to cuddle and is loved by myself and my husband very much. At no point in caring for any of our rats did we ever feel like it was a miserable existence for neither us or any of our rats. Beans spends 15 minutes twice a day being nebulized and the remaining 23.5 hours are enjoyable for him. If you don't like or if you disagree with the lengths that I've gone for my rat, then you do not have to read my posts. I did not appreciate the tone and your comment was incredibly rude and unwanted.
     
    Last edited: Nov 1, 2019
  13. Nov 4, 2019 #13

    Kermit&Pickles.Mom

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    I have nothing to advice. Only to say your poor little baby. Sending love and light
     
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  14. Nov 7, 2019 #14

    PiddlePod

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    Thank you Pickles' Mom!! I appreciate the well wishes for my little guy ❤️❤️
     

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