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FELINE ASTHMA
Diagnosis and Treatment
Philip Padrid, RN, DVM
Asthma in human beings is a chronic inflammatory disease within
the lower airways (bronchi and bronchioles) that causes cough, wheeze,
and exercise intolerance. These clinical signs are the result of a decrease
in airflow through airways that are narrowed from excessive mucus
secretion, airway wall edema, and bronchoconstriction. "Feline asthma"
is a remarkably similar condition that has been recognized in the veteri-
nary literature since at least 1906, when HilF described cats with in-
creased airway mucus, airway inflammation, and the clinical signs of
labored breathing and wheezing.
DIAGNOSIS
There are no clinical signs or laboratory tests available in routine
veterinary clinical practice that are pathognomonic for asthma in cats.
The tests we can perform are most valuable to exclude other common
causes of (acute) dyspnea, wheeze, and cough, including chronic bron-
chitis, heart failure, pneumonia, pulmonary malignancy, respiratory par-
asitism, and inhaled foreign bodies. Fortunately, except for chronic bron-
chitis, these other disorders do not routinely cause clinical signs similar
to asthma in an otherwise healthy cat. As a result, we can usually make
the correct diagnosis of feline asthma if we examine only a few clinical
signs and radiographic findings, including:
From the Section of Pulmonary/Critical Care Medicine, University of Chicago, Chicago,
Illinois; and the Veterinary Centers of America, Los Angeles, California
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1280 PADRID
1. There is a history of sudden onset of labored breathing that is
quickly relieved (usually) with some combination of oxygen,
bronchodilators, and steroids.
2. In some cases, however, the only clinical problem is a chronic
cough. Cats with chronic bronchitis have the clinical symptom of
daily cough, and this can mimic feline asthma. Fortunately, cats
with chronic bronchitis should be treated similarly as cats with
asthma (daily, mild or moderate [see classification scheme be-
low]). As a result, the distinction between chronic bronchitis and
asthma is not always critical.
3. The most important radiographic finding is bronchial wall thick-
ening. These changes are usually described as "doughnuts" and
"tramlines." Air trapping may be assumed if there is flattening
of the diaphragm and the dorsal crus of the diaphragm is near
intercostal space 12 to 13 on multiple views of the thorax. This is
a less common but significant finding.
4. When airway cytology is available, cats with asthma usually
have evidence of airway inflammation, including large numbers
of eosinophils recovered from tracheobronchial secretions. This
is not specific for asthma, however, as many healthy cats also
have large numbers of eosinophils within their respiratory tract. 19
In contrast, the neutrophil is the predominant inflammatory cell
in tracheobronchial secretions from cats with chronic bronchitis.
These clinical and laboratory findings are also found in human
asthma. Histologic fe9-tures of feline asthma, including hyperplasia and
hypertrophy of the mucus-secreting apparatus, airway smooth muscle
thickening, and epithelial erosion associated with an eosinophilic infil-
trate, also closely parallel the human condition (Fig. 1). Finally, "airway
hyper-reactivity," a defining feature of human asthma, has recently been
demonstrated in cats with clinical signs of asthma. 3 Thus, cats do get
asthma in the same way as we understand this disorder in human be-
ings.
Although the clinical signs of asthma may seem straightforward,
the classification of the disease has not been as clear. Even in human
respiratory medicine, it has historically been easier to recognize the
clinical signs of asthma than it has been to precisely define the condition.
Thus, the purpose of this article is to (1) review our current under-
standing of the pathophysiology of asthma in cats; (2) suggest a straight-
forward and clinically oriented classification scheme for diagnosing and
treating cats with asthma; and (3) introduce the practical use of inhaled
medications to treat asthmatic cats with mild, moderate, or severe dis-
ease.
PATHOPHYSIOLOGY OF ASTHMA IN CATS
Although there are many potential causes of asthma, the airways
respond to inhaled irritants or immunologic stimuli in a limited number
of ways:
FELINE ASTHMA 1281
Figure 1. Naturally occurring feline asthma. Medium-sized bronchus from a 9-year-old
Siamese Cat with a 4-year history of cough and wheeze. Note the invagination of airway
mucus from bronchoconstriction, luminal exudate, thickened smooth muscle, and hypertro-
phied submucosal glands. (From Padrid P: Feline asthma: Pathophysiology and treatment.
Waltham Focus 9:17-22, 1999; with permission.)
1. Airway epithelium may thicken (hypertrophy), evolve to a differ-
ent structure (metaplastic change), or simply become damaged
(erode or ulcerate).
2. The structures responsible for producing mucus (goblet cells and
submucosal glands) may enlarge and produce excessive amounts
of a particularly thick form of mucus.
3. Bronchial smooth muscle often spasms and may become hyper-
trophied.
These changes are associated with cellular infiltration of the bronchial
mucosa and submucosa, and this tissue m ay also become edematous.
The resulting clinical signs of cough, wheeze, difficulty in breathing,
and decreased exercise capacity are due to airway narrowing (and air-
flow reduction) from excessive mucus secretions, airway edem a, airway
narrowing from cellular infiltrates, and airway smooth muscle constric-
tion. Cough may also result from stimulation of inflamed and contracted
cough mechanoreceptors located in airway epithelium. This is an im-
portant concept, because even a small degree of airway narrowing can
produce dramatic changes in clinical signs. For example, a 50% reduction
in the radius of an airway results in a 16-fold reduction in the amount
1282 PADRID
Figure 2. Effect of airway size on air flow. A, Normal-sized airway. B, Asthmatic airway, in
which the airway is partially obstructed (50%) with mucus and cellular debris. This obstruc-
tion results in a 16-fold reduction in air flow through that airway. (From Padrid P: Feline
asthma: Pathophysiology and treatment. Waltham Focus 9:17-22, 1999; with permission.)
of air that flows through that airway (Fig. 2). It is easy to imagine why
any movement that requires an increase in the depth of breathing such
as chasing a mouse is tremendously altered if there is a 16-fold decrease
in the amount of air that comes into the lungs during normal respiration.
The important take-home message is that small changes in airway size
result in dramatic changes in airflow through that airway. The clinical
implications of this finding are twofold. First, relatively small amounts
of mucus or bronchoconstriction can partially occlude airways and cause
a dramatic fall in airflow. Conversely, therapy that results in relatively
small increases in airway size may cause a dramatic improvement in
clinical signs.
An important advance in our understanding of this relation between
airway structure and function is the recent discovery that human asth-
matic airways are chronically inflamed whether or not the patient is
symptomatic (this has not been confirmed in cats). It has also been
recognized for some time that eosinophils seem to play a primary role
in chronic asthmatic airway inflammation in human beings and cats.
Highly charged cationic proteins within eosinophil granules are released
into airways and cause epithelial disruption and sloughing. Additionally,
these granular proteins can make airway smooth muscle more " twitchy"
and prone to contraction after exposure to low levels of stimulation
(airway hyper-reactivity). 6• zo
Eosinophil-T Lymphocyte Interactions
The pathogenesis of asthmatic airway hyper-reactivity is complex.
Recent studies suggest that the interaction between activated T lympho-
FELINE ASTHMA 1283
cytes and eosinophils within airways may play a particularly important
role in the generation of eosinophilic airway inflammation and airway
hyper-reactivity in human asthma. Cytokines, including interleukin-5
secreted from the T-helper-2 subset of activated CD4 + T cells, promote
eosinophil survival, activation, and recruitment into airways. 5 Recent
experimental studies using transgenic and "knockout" mice to overex-
press or delete activated T lymphocytes or T cell-specific cytokine prod-
ucts in antigen-challenged mice continue to support the role of activated
T lymphocytes and eosinophils in the development of asthmatic airway
inflammation. 11' 17
WHAT DO WE KNOW ABOUT CATS WITH ASTHMA?
Although coughing and wheezing cats have been identified by
owners and veterinarians for more than 90 years, it is only in the last 5
years that we have begun to study the disorder in earnest. Doctors at
the University of Illinois School of Veterinary Medicine have identified
pulmonary function abnormalities in cats with signs of chronic lower
airway inflammation. Some of these cats have increased lung resistance
that resolves after treatment with terbutaline (a !32 agonist), indicating
the presence of reversible bronchoconstriction in these patients. 3' 12 Addi-
tionally, some of these cats experience dramatic bronchoconstriction after
exposure to low levels of methacholine, a drug that has minimal effects
on pulmonary function when used in equivalent doses in nonasthmatic
cats. This is an important finding as the first demonstration of spontane-
ous and naturally occurring airway hyper-reactivity in a nonhuman
species. Even more recently, Hoffman and associates8 at Tufts School of
Veterinary Medicine have validated the use of the Buxco noninvasive
plethysmograph (Buxco Electronics, Sharon, CT) to study pulmonary
function in awake nonrestrained cats. Use of this device may greatly
speed the generation of knowledge regarding pulmonary function in
asthmatic cats and lead to objective means of evaluating current and
future drug therapies for these patients,
HOW SHOULD WE CLASSIFY CATS WITH ASTHMA?
In veterinary medicine, feline asthma has been referred to as feline
lower airway disease, feline allergic asthma, extrinsic asthma, feline
allergic bronchitis, chronic obstructive pulmonary disease, eosinophilic
bronchitis, acute allergic bronchitis, chronic bronchitis, and immune-
mediated airway disease. 2' 3, 12, 13, 15, 16 These multiple definitions of asthma
in cats reflect a widespread confusion in the veterinary community
regarding respiratory disease in general and respiratory disease in cats
in particular. This confusion, in turn, has inhibited the development of
generally accepted rational standards of care for feline asthma. What
follows is an attempt to clarify the notion of feline asthma by simplifying
1284 PADRID
the way we classify cats with this disease and proposing a standard of
treatment for these animals.
Obviously, the clinician should be reasonably certain of the diagno-
sis. Once the diagnosis is made, the first step is to determine if the
clinical signs are intermittent or if they occur daily. If symptoms occur
daily, the next step is to decide if the clinical signs are mild, moderate,
or severe.
1. Mild symptoms: In these cases, the symptoms do not affect the
way in which the cat conducts its business (quality of life). In
these cases, between "attacks/' the cat eats, drinks, and plays as
if nothing is wrong.
2. Moderate symptoms: In these cases, the asthmatic condition
sometimes affects the way the cat conducts its business (e.g., it
may tire easily, it may wake up at night coughing). Symptoms
are not constant, and the cat does not have obvious difficulty
when breathing at rest most times of the day.
3. Severe symptoms: In these cases, the asthmatic condition is con-
tinual and clearly limits the eat's ability to conduct its business.
These cats are not comfortable at rest, and the symptoms occur
for most of each day.
In summary, to classify cats with asthma, we take the following
steps: (1) determine if the signs are intermittent or daily, and (2) deter-
mine the severity of daily symptoms. These two steps are the beginning
of a rational treatment plan.
HOW SHOULD WE TREAT CATS WITH ASTHMA?
The primary signs of asthma include cough and wheeze, and these
signs are frequently caused by airway smooth muscle contraction. It is
tempting to treat these signs of asthma by using bronchodilators to
reverse the airway smooth muscle spasm, and, in fact, this is the logical
treatment for cats with intermittent symptoms. It is critically important
to remember that human (feline?) asthmatic airways show evidence of
chronic ongoing inflammation whether or not the patient is symptom-
atic. As a result, for cats with daily symptoms, treatment strategies are
most successful if they are directed toward decreasing the underlying
inflammatory component of the disease.
Corticosteroids are the most effective long-term treatment of feline
asthma. Corticosteroids have many beneficial effects in this setting,
including inhibiting the synthesis of genes for cytokines that are im-
portant in generating airway inflammation. Nevertheless, the side effects
of chronic high-dose oral steroid treatment in cats are well known
and include pancreatitis, insulin resistance (diabetes), and significant
behavioral changes in addition to polyuria, cystitis, and inappropriate
urination. Fortunately, inhaled steroids are now available that do not
FELINE AS1HMA 1285
cause systemic side effects, and this treatment has greatly enhanced our
ability to successfully treat cats with asthma.
Inhaled Medications
Corticosteroids and bronchodilators can now be given effectively by
inhalation to cats with asthma (Table 1). Both classes of drugs are
available as metered dose inhalers (MDis) (Fig. 3) for human patients
with asthma. Proper use of an MDI requires the patient to coordinate
inhaling with the actuation of the device, and this has proven to be
surprisingly difficult for most patients. This is also not realistic for
infants and young children. An alternative was developed to allow
these individuals to use the MDis without the need to coordinate their
breathing. Thus, the MDI is used in conjunction with a "spacer" de-
signed for use in infants and small children and a face mask specifically
made for cats. The spacer is a plastic chamber the size of a cardboard
Table 1. DRUGS AVAILABLE AS METERED DOSE INHALERS, USED WITH SPACERS
AND FACE MASKS TO TREAT DOGS AND CATS WITH RESPIRATORY DISEASE*
Drug Class Drug Name Indication Important Points
Bronchodilator (~-2 Albuterol (Ventolin, Immediate relief of Effect is short-lived
agonist) Proventil) bronchoconstriction (<4 h)
Pirbuterol (Maxair) Immediate relief of Not studied in
bronchoconstriction dogs and cats
Bitolterol (To malate) Immediate relief of Not studied in
bronchoconstriction dogs and cats
Salmeterol (Serevent) Long-term (12 h) Takes > 1 h to take
control of effect
bronchoconstriction
Anticholinergic Ipratropium bromide Additive Not studied in
(Atrovent) bronchodilation dogs and cats
with ~-2 agonists
Anti-inflammatory Fluticasone Long-term control of Takes 10-14 days
corticosteroid propionate inflammation to reach peak
(Flovent) effects
Flunisolide Long-term control of Not studied in
(AeroBid) inflammation dogs and cats
Budesonide Long-term control of Not studied in
(Pulmocort) inflammation dogs and cats
Beclomethasone Long-term control of Not studied in
dipropionate inflammation dogs and cats
(Beclovent,
Vanceril)
Mechanisms Cromolyn sodium Long-term control of Not studied in
unclear (inhibits (Intal) inflammation dogs and cats
mast cell
degranulation)
Nedocromil sodium Long-term control of Not studied in
(Tilade) inflammation dogs and cats
*See text for specific indications.
1286 PADRlD
Figure 3. Metered dose inhaler (MDI) used to treat respiratory disease in human beings.
This device requires a coordinated effort by the patient to inhale immediately after actuation
of the device and is not suitable, by itself, for use in animals.
FELINE ASTHMA 1287
Figure 4. A, The spacer device connected to an MDI. B, The spacer connected to an MDI
and a self-sealing mask commonly used for induction of anesthesia. The spacer acts as a
reservoir for the inhaled medication, so that the animal breathes the drug into its airways
whenever it breathes through the face mask.
1288 PADRID
Figure 5. The attachment on the spacer for the face mask has been removed to show the
thin rubber gasket that acts as a one-way valve. On inspiration the gasket moves toward
the mouth and opens, allowing the medication within the spacer to be inhaled. The gasket
closes on exhalation, preventing the medication from escaping.
inner roll of toilet paper. The MDI fits into one end of the spacer, and
the other end of the spacer has an attachment for the face mask (Fig. 4).
The end of the spacer that connects with the face mask has an inner
rubber gasket that acts as a one-way valve so that the medication within
the spacer can only leave the spacer during an inhalation (Fig. 5).
The client first attaches the MDI and the face mask to the spacer
and then actuates (presses) the MDI twice to fill the spacer with medica-
tion. The client then places the face mask gently over the eat's mouth
and nose. The cat is allowed to breath in and out 7 to 10 times with the
mask in place, and the treatment is completed.
Specific Treatment for Cats with Asthma
Treatment of Feline Asthma if Symptoms Are Intermittent
(Do Not Occur Daily)
In these cases, I prescribe an albuterol inhaler with instructions to
use "as needed." The assumption in these cases is that cats with symp-
FELINE ASTHMA 1289
toms that do not occur daily do not have significant chronic ongoing
inflammation that requires daily anti-inflammatory therapy. When acute
signs do occur (e.g., cough, wheeze, difficulty in breathing), they can
usually be effectively and quickly treated with the inhaled bronchodila-
tor. If signs become more frequent, the cat should be re-evaluated to
determine if more aggressive treatment should be initiated (see next
step).
Treatment of Feline Asthma if Symptoms Occur Daily
Mild Daily Symptoms. These cats have daily symptoms but in
between the coughing and wheezing, they are generally unaffected by
their disorder. For these cats, I prescribe 220 f..Lg of Flovent twice daily. I
also prescribe an albuterol inhaler as needed for those times when
symptoms are particularly troublesome. Because inhaled Flovent takes
about 7 to 10 days before its maximum effect is seen, these cats continue
to be symptomatic for an additional week or so. Clients should be
supported through this period and encouraged that their pet is going to
begin to improve after the first week of therapy.
Moderate Daily Symptoms. These cats have daily symptoms that
have a negative effect on their quality of life, but their cough, wheeze,
or dyspnea is not constant. For these cases, I prescribe 220 f..Lg of Flovent
twice daily and albuterol as needed. I also prescribe 1 mg/kg of predni-
sone administered orally twice daily for 5 days and then daily for 5
additional days. After 10 days of combined oral and inhaled steroids,
the cat has generally shown great improvement, and the oral prednisone
can be discontinued without taper. Oral prednisone is used in this
setting because significant daily symptoms suggest the presence of a
more aggressive inflammatory component that should be more aggres-
sively treated.
Severe Daily Symptoms. These cats are symptomatic and uncom-
fortable at rest and require aggressive early management. I begin with
2 mg/kg of dexamethasone administered intravenously and inhaled
albuterol every 30 minutes for up to 4 hours. This frequency of albuterol
treatment generally does not cause side effects or might cause slight
muscle tremor. These cats are also given 40% to 100% oxygen either by
nasal cannula or oxygen cage. Once these patients are stabilized (their
symptoms are dramatically improved), they can be discharged with 220
f..Lg of Flovent administered twice daily and albuterol administered four
times daily as needed. Some of these cats with severe symptoms may
also require intermittent lower doses of oral prednisone, but this is
tailored for the individual patient.
ADDITIONAL TREATMENTS
Antibiotics
There is no objective evidence that bacterial infections play a sig-
nificant role in the cause or continuation of feline asthma. Similarly,
1290 PADRID
there is little objective evidence that antibiotic therapy has any effect on
the duration or intensity of signs displayed by the cat with asthma. 1' 3, 19
It is important to remember that the clinical signs of asthma frequently
wax and wane in severity as well as in frequency of occurrence. There
are anecdotal reports describing the therapeutic effect of antibiotics in
controlling asthmatic symptoms; however, the author believes that these
reports are consistent with the "waxing and waning" nature of the
symptoms in nontreated cases.
A positive culture result obtained from a tracheobronchial wash
does not necessarily demonstrate a clinically significant airway infection
and should not automatically prompt the clinician to start antibiotic
therapy. Remember, there is a revolving population of commensal bacte-
ria that live in the respiratory tract in cats and other species, and these
organisms are not disease-producing. 3, 19
In general, antibiotics are rarely indicated for cats with asthma and
are appropriate only when there is good evidence of superimposed
airway infection. A true infection may be assumed if the positive culture
was obtained after growing the organisms in culture without using an
enrichment broth such as thioglycolate. (Your reference laboratory can
tell you if enrichment broth was used or if your samples were subcul-
tured.) This is because the concentration of aerobic bacteria recovered
from the airways of healthy cats rarely exceeds 5 X 103 organisms per
milliliter. In contrast, growth of a single organism recovered without the
use of enrichment broth implies more than 105 organisms per milliliter,
and this is consistent with an "infected" airway. 3' 19 Antibiotic therapy is
then based on sensitivity data. Prophylactic or long-term antibiotic ther-
apy is not indicated unless there is documentation of a chronic airway
infection. Documented chronic airway infection is extraordinarily un-
common in feline asthma.
There is a possible exception to these statements. Mycoplasma species
have been isolated from the airway of as many as 25% of cats with signs
of lower airway disease. 16 In contrast, Mycoplasma species are not cul-
tured from the airway of healthy cats. For this reason, and because
Mycoplasma species have the potential to cause significant structural
damage to airway epithelium, it may be prudent to treat any cat with a
Mycoplasma-positive airway culture with an appropriate antibiotic. 4
Cyproheptadine
Cyproheptadine is an antihistamine and antiserotonin compound
that has been used in feline medicine to increase appetite. Our laboratory
demonstrated that mast cells within feline airways contain serotonin
and that serotonin can cause smooth muscle constriction within feline
airways. These studies were performed with isolated lung tissue in vitro
and were intended to encourage further studies in vivo to determine the
effectiveness (or lack of effectiveness) of cyproheptadine in cats with
asthma. 18 Although there have been many anecdotal reports that cypro-
FELINE ASTHMA 1291
heptadine is sometimes helpful in these cases, the author does not
routinely prescribe this drug for these cats.
Antileukotriene (or Receptor) Drugs
There has been a great deal of recent interest in drugs that block
production of leukotrienes (LTC.v LTD4 ) or ligation of these molecules to
their receptor(s). In general, these drugs have limited but significant
effectiveness in treating some human asthmatics with moderate to severe
disease. 9• 10 Leukotrienes increase mucus production, induce cellular
edema, and promote airway smooth muscle constriction in human be-
ings and other species, so it is reasonable to think that antileukotriene
drugs might have a role in the therapy of feline asthma. Perhaps it is
not surprising that Zyflo, Accolate, and Singulair have all been used to
treat cats with asthma even though there are no safety or efficacy studies
of these drugs in the feline species. We have found that LTE.v the
metabolic product of LTC 4 and LTD4 metabolism, is found in increased
amounts in urine of cats with asthma but not in normal cats or cats with
nonasthmatic disorders such as kidney failure or pancreatitis. We have
also found similar increases in prostaglandins (PGF 2., PGI2 ) and throm-
boxane A 2 (TXA 2 ) in bronchoalveolar lavage fluid of cats with experi-
mentally induced asthma (unpublished studies). This suggests that leu-
kotrienes and other products of the arachadonic acid cascade are
manufactured in increased amounts in cats with asthma. Interestingly, a
more recent study by Mellema et aP 4 did not support our finding but
instead found no increase in urinary LTE 4 in 20 cats with signs of lower
airway disease. Additionally, direct instillation of LTC4 into the airways
of normal cats has no adverse effect on feline airway structure or
function.
It is probable that increased leukotriene production, like prostaglan-
din production, is a clinically nonsignificant byproduct of the general
inflammation in asthma. There are no current data that suggest that
antileukotriene drugs have an important role in the treatment of cats
with asthma. Most importantly, the author strongly believes that correct
diagnosis and aggressive therapy of cats with asthma as outlined in this
article minimize the need to explore untested and variably effective
human drugs in these feline patients.
SUMMARY AND CONCLUSIONS
Human asthma is not a curable disease, although spontaneous
resolution is common in adult asthmatics who developed asthma in
childhood. We do not know if this is true or not for cats with asthma.
We do know that some cats may be only mildly and intermittently
symptomatic and that others may suffer life-threatening illness. An
important new development in our understanding of this disease is the
occurrence of airway inflammation even when patients are symptom-
1292 PADRID
free. It is therefore crucial that we direct our therapeutic attention toward
the underlying chronic inflammation that causes the acute clinical signs
of cough, wheeze, and increased respiratory effort. Client education is
also critical so that our clients develop realistic expectations of the
effectiveness of these treatments for their pets.
A great deal still needs to be learned regarding the pathogenesis of
feline asthma and the optimal approach( es) to treating cats with this
sometimes debilitating and potentially fatal respiratory syndrome. There
is great hope and anticipation that ongoing research can bring new
treatments for human and feline asthmatics alike.
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Address reprint requests to
Philip Padrid, RN, DVM
University of Chicago
Section of Pulmonary/Critical Care Medicine
MC 1030
Attn: Animal Resources Center
5841 South Maryland Avenue
Chicago, IL 60637
e-mail: ppadrid@[Link]