Canine Spontaneous Pneumothorax

I am going to depart from this blog's theme and style to post, in detail, about my dog's spontaneous pneumothorax. After it happened, the nerdy scientist in me immediately started doing research online, only to discover there is not a lot of information on this condition in dogs out there in cyberspace. A lot of websites have the same information cut and pasted from somewhere else. Human websites are available, but not necessarily helpful. As her surgeon told me, a lot of things they can do in  human patients, they cannot do in dogs. The two legitimate veterinary journal abstracts published online dealt with 12 and 64 dogs respectively. I can assure you as a scientist that, even together, these do not equal a statistically valid sample upon which to base any kind of inferences. So I add here my experience. It may be anecdotal, but it may help someone else if they ever have to research this terrifying incident after it happens to their dog.

There is no medical advice offered herein. Your experience of canine spontaneous pneumothorax will depend on a number of parameters, not the least of which is your dog and his or her general health and the cause of their pneumothorax. This is simply offered to present one dog's experience. It may help you to formulate some of the questions you have for your vet. Remember, you are responsible for your dog, and you have every right to ask as many questions as you want, and to have your dog treated by the vet you want. Be proactive in your pet's care as you would with your own health. 

On Wednesday, 1 December, 2010, my 9 year 10 month old spayed female Samoyed had a spontaneous pneumothorax, or in plain language, somehow blew a hole in her lung that started leaking air into her pleural cavity. When I left for work at 6:30 a.m, she was fine; had her breakfast, got her daily eye drop (a hang over from eye surgery she had to undergo at age 2), did her business, was completely normal. My mother, who thankfully was visiting for the holidays and therefore was able to provide the sequence of events, reported that at around 8:00 a.m, she became very restless and started pacing and would not settle down. Online symptoms of a pneumothorax are lethargy, vomiting, etc., but she evinced none of these, just restlessness, pacing, and a refusal to sit or lay down. My mother thought at first that she needed to go out, but she did nothing once outside, just continued pacing. She was reluctant to lay down or sit down or put pressure on her chest.

This went on for several hours, and my mother got increasingly worried. She looked for evidence that the dog had eaten something that was stuck or making her sick, but found nothing. She looked outside for anything that might be unusual--nothing. Unfortunately, I am a field scientist and I happened to be working that day out in the field, about 50-60 miles from town.  Mom called my cell phone at 2:21 p.m. to tell me about the dog, but I didn't get the call. Even if I had, without my vehicle, I couldn't have left the field without somehow convincing the rest of the team to call the day short. We left the field at 3:18 p.m., and arrived back at the office just before 5 p.m. Mom called again while I was driving home. Regardless, I still feel guilty at not checking my phone for messages or missed calls.

My first thought and fear was that she had bloated, as the symptoms--restlessness, pacing, refusal to put any weight on her stomach/abdomen--sounded like that. As soon as I got into the house, I examined her stomach, but it had neither the tightness nor the sound of a bloated stomach. Then I looked at her tongue and saw that it was blue, and knew immediately that she was having breathing difficulties. I put her in the car, and she started coughing and gasping. Each pant would end in a gasp for air.

At 5:00 p.m., the vet specialty hospital is a good 45-60 minutes from my home through rush hour traffic, so I took her to the emergency clinic literally around the corner. They x-rayed her and immediately told me it was a spontaneous pneumothorax, which was easily seen on the radiographs even by a lay person. Then the emergency room doctor told me something very scary; she pointed to a spot on the film and called it a lesion, and added her suspicion that the pneumothorax had been caused by neoplasia/cancer (although other causes, such as valley fever and bullous emphysema, were a possibility).

Of course, my heart sank and I got all queasy, wondering if I was going to have another animal with cancer. And the doctor didn't reassure me that she could either heal naturally or have surgery to resolve the pneumothorax--I had to find that out for myself online. I went home, cried hysterically, and wondered if I'd lose my dog to this. She had been leaking air probably for almost 9 hours.

An hour later the emergency room called to say that they had immediately removed 2 liters of air from her by needle, and would continue to draw air from her. If needed, they would put a tube in her to facilitate air removal (this had been discussed while I was there). A later call reported that they had taken another liter of air (so 3 liters in total) from her, and inserted a tube into her lung. If she did not stop leaking air after 3 or 5 days, she would have to have surgery to remove that affected portion of her lung.

She was in the emergency room 5 days, on a tube until Sunday morning. She stopped leaking air sometime between 3:00 p.m. and 8:00 p.m. on Friday, two of the times at which I called for updates and asked if she was still leaking, so the time is bracketed accurately even if I don't know exactly when she stopped (so at least 50 hours, perhaps 55 hours total of air leaking). She was improving the whole time, eating well, alert, and very loving (as is her nature). In order to keep her quiet so the tube was not endangered, I didn't visit her (in fact, I wasn't even given the option until Saturday, when the doctor cautioned that I knew my dog, and if she was going to get excited, it would be best not to visit. I know my dog--she would not only get excited, she would want to leave, so as hard as it was not to be able to see her in person, I stayed away). On Saturday, the doctor told me she might be the one in a million dog who heals naturally, and she did. On Sunday morning, the tube was removed, but she needed to be observed until Tuesday, when they had made an appointment for her to see a surgeon at another hospital. This was the same hospital where she had had her eye surgery with the then only canine opthomology department in the city, but I had never heard of this surgeon. I called her vets to ask them their opinion of which surgeon she should see.

Over the 4 and half days she was in the hospital, she had 7 x-rays taken to determine if the pneumothorax was resolving itself. No other emergency room doctor with whom I spoke over that time ever mentioned that lesion identified by the first doctor. The surgeon did not see anything that was a lesion. I now believe that it was the lung folded on itself or some other perturbation of tissue, perhaps even the initial rupture spot.

I had been in touch with both her regular vet (who has taken care of her since she was 11.5 weeks) and her acupuncture vet (who also practices Western medicine in a holistic approach). Her holistic vet knew of the named surgeon, but had had no personal experience with her and recommended that if she need surgery, it be done by a different surgeon, Dr. Boulay. On Monday, when I was able to speak with her regular vet, he insisted she be released that morning and sent to a different veterinary hospital in town, where the best veterinary surgeon in town practiced. This was Dr. Boulay, the same surgeon her holistic vet had named. (My years of pet ownership meant I had heard of him, but had never had to use him before, so I was already aware of his reputation before this all happened.) My regular vet called over to the hospital (luckily, he and the surgeon are very good friends, and in fact, my vet attended the surgeon's wedding last year in Hawaii and had offered the surgeon space in his own hospital for a year while his new offices were being built; thank God for personal favors), and made arrangements for her to be admitted and for Dr. Boulay specifically to see her (there are two other surgeons in the practice).

Monday morning was the first time I had seen my dog since Wednesday night. She was so tired of the hospital and so eager to go home that she made a beeline straight past me to the door. She had been shaved almost completely around the middle for the tube. I carefully drove her over to the vet specialty hospital owned by the surgeon. I timed it--45 minutes during the middle of the morning (post rush hour). They examined her, did another x-ray to compare with the series taken at the other hospital, and decided to keep her overnight in order to do a CT scan the next day (the radiologist worked Tuesday to Friday). It was very hard to leave her again, but I knew she was in the best possible hands.

FYI, when they brought her back from the x-ray they had taken the large bandage off, and I found a just starting to embed itself tick on her non-tubed side, which could only have come from the other hospital. You can imagine how disgusted I was; and yes, I did call the other hospital and tell them of this.

The three surgeons at the vet specialty center disagreed on the immediate next course of action; Dr. Boulay, the surgeon in charge of her case, wanted to do the CT scan right away; Dr. Shields was concerned that the anesthesia required would cause the newly formed seal to burst, causing another pneumothorax; and Dr. Gores appears to have been the mediator, as well as insisting that I be told they disagreed so that it was my decision on which course of action we took. Ultimately, Dr. Boulay agreed to wait two weeks for the CT scan to allow maximum internal healing. I was instructed to keep her quiet at home.

It wasn't until the following Sunday, Dec. 12, almost 2 weeks after the incident and 5 days after she was released from the hospital, that she started to behave like her normal self. That day, also, a huge bruise became visible around the staples where the tube had been (these needed to be left in 2 weeks, and were to be removed when she had the CT scan). Almost 4 weeks later, the bruise is still visible, although with her fur starting to grow back, it's difficult to tell how dark it remains.

The CT scan was taken two weeks later, on Dec. 21, and I picked her up at 5 o'clock that evening. I was supposed to meet then with the surgeon, but he had to go into a "complicated" surgery until 7 p.m., and knowing how things can run longer than planned, I made arrangements to meet with him on Thursday morning before the hospital was open to go over the scan. A CT scan requires that the dog be anesthetized, and the scan takes about 15 minutes. I had expected her to bounce back from such a short anaesthetic pretty quickly, but at almost 10 years old, she is the equivalent of a 55-year-old human, and she was groggy and not herself until well into the next morning. But she was relieved to be home, and I was relieved to have her home.

The CT scan revealed that both of her lungs are full of bullous emphysema, or little blisters that form on the lung (both inside and outside). I counted at least a dozen, ranging from pinpricks to 1.0 and 1.5 cm bullae on her left lung. Scarily, she has an enormous bulla that measures approximately 4.5 by 6 + cm across on the outside of her right lung. These bullae are three-dimensional spheres full of air that can form in the honeycomb interior surface of the lung. No one knows why they form. The CT showed no indication that she had ever had valley fever, a fungal infection endemic to humans and dogs here in the desert (it's caused by fingal spores we inhale and that cause lesions on the lungs, which are visible on an x-ray) and which I had thought may have caused this. The CT scan also showed absolutely no signs of lung cancer (or cancer elsewhere in her upper body; I do not know if a full body scan was done, or just a scan of her thorax as we concentrated on looking at her lungs on the computer).  The surgeon spent 45 minutes repeatedly moving the imagery up and down her lungs. Unfortunately, she has about a dozen (at least) bullae in both her lungs, so surgical removal of the affected lobe or lobes is impossible.There would not be enough intact lung left for her to survive. He went on to say that bullous emphysema is very frustrating for vets, because they don't know what causes it. Although his practice sees quite a few dogs with this in their lungs, they only see 2-3 spontaneous pnuemothorax patients every year. Although the Web suggests that large-chested dogs and possibly northern breeds are susceptible, he was not sure, and said that at his practice, they had seen this in German shephards more than in other dogs, for what that might suggest. However, his hospital is one of only two in the city that has a CT scanner, so it remains unclear to me how common this condition is, how often and in what kinds of dogs it occurs, does this practice see more because they have to ability to do so (bullous emphysema is not visible on an x-ray), etc. There are so many parameters that are involved and about which there is no or little information.

If she has another pneumothorax, it will likely be this large bulla that erupts. The surgeon, who has been practicing at least 25-30 years, said he had never seen a bulla this large. Her holistic vet had told me that if she has another incident, they will have to do surgery. I asked him what was now the option if she has another spontaneous pneumothorax, and he said "what we just did: insert a needle to remove the air, and if necessary, a tube." He went on to say that he prefers not to use the tube unless necessary (and outlined what those necessary situations were) and to let the dog heal on its own.

This last was reassuring, since my big fear, having seen the CT scan and realizing the extent of the bullae in her, was what would happen if she had this again. I flatly asked him if she would die, and he said no. I asked him what would happen if the large bulla burst, as opposed to a smaller one; would the rate of air loss be faster and would she therefore get sicker, faster. He said the rate of air loss depended on her respiration rate, which would not change regardless of the size of the bulla that burst; I found this reassuring, too, in a way. We have no way of knowing the size of the bulla that burst, but we at least know how many hours it appears it took for her to get comprised in her breathing.

Dr. Boulay said that it may have been something as innocuous as a sneeze that caused the initial rupture. He also told me both lungs had had a leak, which no one told me before. He pointed out a lot of scar tissue that has formed on her left lung and said that was where he suspected the initial leak appeared. He is hoping her mediastinum, a membrane between the two lungs, has also been scarred by this as it would then form a a barrier that would allow one lung to be unaffected if the other should develop a leak. He also discussed a pleurodesis, where they create a slurry and glue the lung to the cavity wall so there is no way for a bulla to erupt through the lung wall, but he is cautious of doing this and wants to do some research. He also said he is going to contact various other vets around the country, including Dr. Foss, a soft tissue surgery specialist, to see if they have ever had a patient with multiple scattered bullae that precluded surgery, or if anyone has ever seen such a massive bulla as hers (he said it was the size of a plum; but what is the size of a dog lung?).

It is possible that another bulla may burst, and it may be tomorrow or in two years, or it may never happen again. We will live on tenterhooks now, wondering. She can no longer jog or run or do any activity that will cause her to want to bring in large amounts of air quickly into her lungs. Not a problem as I hate to run and jog and she never did these anyway, but it does mean that dog park visits will no longer happen as she liked to chase balls and other dogs, and I don't want to risk it. He said I could begin exercising her normally, but to take it slow (we literally walked only around the block until yesterday, when I increased it to two blocks). He also cleared her to resume her Pet Therapy Program visits at the hospital when she's ready. Although seeing her in her funny shaved appearance might actually be a good thing for some kids, I don't want her to do anything that requires long walks for a while yet. She cannot undergo any procedure requiring anesthesia unless it is critical. And as the hospital has all kinds of specialists associated with it, if she does require it, it will be done there where Dr. Boulay can keep an eye on her at all times.

I still fear this is a death sentence, even though it doesn't appear to be so and Dr. Boulay said they can do the same thing again should she have another pneumothorax. I still fear leaving her alone. Today I left her alone for an hour and a half and was anxious the whole while. She acts normally sometimes and other times is a little quiet or depressed. The weather has been a bit damp, and it may be that her arthritis is bothering her. It may be that she feels the cold a little more than normally without one-third of her coat. It may be that certain movements cause a twinge in her lungs, or pull the muscles the tube went through, or something like that. I still watch her breathing, and check to make sure she's breathing every few hours. I still check her gums and tongue a lot. We're both not quite over this yet. I am still scared. I will be for a long time.