Effect of sodium cromoglycate on light racehorses with elevated metachromatic cell numbers on bronchoalveolar lavage and reduced exercise tolerance

Towards personalized medicine for the treatment of equine asthma

Although horses with asthma share similar clinical signs, the heterogeneity of the disease in terms of severity, triggering factors, inflammatory profile, and pathological features has hindered our ability to define biologically distinct subgroups. The recognition of phenotypes and endotypes could enable the development of precision medicine, including personalized, targeted therapy, to benefit affected horses. While in its infancy in horses, this review outlines the phenotypes of equine asthma and discusses how knowledge gained from targeted therapy in human medicine can be applied to evaluate the potential opportunities for personalized medicine in equine asthma and to suggest avenues for research to advance this emerging field.

Efficacy of dexamethasone, salbutamol, and reduced respirable particulate concentration on aerobic capacity in horses with smoke-induced mild asthma

Background

Mild asthma in horses decreases racing performance and impairs gas exchange. The efficacy of treatment on performance is unknown.

Hypothesis

Treatment targeting lung inflammation improves V˙O₂peak in horses with mild asthma.

Animals

Thoroughbred polo horses (n = 12) with smoke‐induced mild asthma. Horses were exposed to increased ambient particulate matter (35.51 μg/m³ [PM_2.5]; day mean, centrally measured) from day −33 to 0, from bushfire smoke (natural model).

Methods

Prospective, randomized, placebo‐controlled, double‐blinded clinical trial. All horses completed 3 V˙O₂peak tests, measuring aerobic and anaerobic variables: day 0 ‐baseline; day 16 ‐after dexamethasone (20 mg IM q24h; DEX, n = 6) or saline treatment (SALINE, n = 6), under improved ambient PM_2.5 concentrations (7.04 μg/m³); day 17‐15‐30mins after inhaled salbutamol (1500 μg). Bronchoalveolar lavage and mucus scoring were performed on day −8 and day 20. Linear mixed effects models were used to examine the effects of timepoint and treatment group on BAL differential cell counts, mucus scores, aerobic and anaerobic variables.

Results

Horses’ mucus scores improved significantly from day −8 to 20 by 1.27 ± .38 (P = .01). There was a significant increase in V˙O₂peak of 15.5 ± 4.0 mL(min.kg)⁻¹ from day 0 to 17 (P = .002), representing an average (mean) increase in V˙O₂peak of 13.2%. There was no difference in V˙O₂peak between treatment groups (SALINE versus DEX) at any timepoint.

Conclusions and Clinical Importance

This study highlighted the key role of improved air quality on functionally important airway inflammation. Evidence provided is central to increasing owner compliance regarding improved air quality for the treatment and prevention of mild asthma.

Effect of Dexamethasone and Fluticasone on Airway Hyperresponsiveness in Horses With Inflammatory Airway Disease

Background

Airway hyperresponsiveness (AWHR), expressed as hypersensitivity (PC₇₅R_L) or hyperreactivity (slope of the histamine dose‐response curve), is a feature of inflammatory airway disease (IAD) or mild equine asthma in horses. Glucocorticoids are used empirically to treat IAD.

Objectives

To determine whether dexamethasone (DEX) (0.05 mg/kg IM q24h) and inhaled fluticasone (FLUT) (3,000 μg q12h) administered by inhalation are effective in decreasing AWHR, lung inflammation, and clinical signs in horses with IAD.

Methods

A randomized crossover study design was used. Eight horses with IAD were assigned to a treatment group with either DEX or FLUT. Measured outcomes included lung mechanics during bronchoprovocative challenges, bronchoalveolar lavage fluid (BALF) cytology, and scoring of clinical signs during exercise.

Results

Dexamethasone and FLUT abolished the increase in R_L by 75% at any histamine bronchoprovocative dose in all horses after the first week of treatment. However, after 2 weeks of FLUT treatment, 1 horse redeveloped hypersensitivity. There was a significant decrease in the number of lymphocytes after treatment with both DEX and FLUT (P = .039 for both) but no significant differences in other BALF cell types or total cell counts (P > .05). There was no difference in the scoring of the clinical signs during each treatment and washout period (P > .05).

Conclusions and Clinical Importance

Both DEX and FLUT treatments significantly inhibit airway hypersensitivity and hyperreactivity in horses with IAD. There are no significant effects on the clinical signs or the number of inflammatory cells (except lymphocytes) in BALF. The treatments have no residual effect 3 weeks after discontinuation.

Pulmonary Remodeling in Equine Asthma: What Do We Know about Mediators of Inflammation in the Horse?

Equine inflammatory airway disease (IAD) and recurrent airway obstruction (RAO) represent a spectrum of chronic inflammatory disease of the airways in horses resembling human asthma in many aspects. Therefore, both are now described as severity grades of equine asthma. Increasing evidence in horses and humans suggests that local pulmonary inflammation is influenced by systemic inflammatory processes and the other way around. Inflammation, coagulation, and fibrinolysis as well as extracellular remodeling show close interactions. Cytology of bronchoalveolar lavage fluid and tracheal wash is commonly used to evaluate the severity of local inflammation in the lung. Other mediators of inflammation, like interleukins involved in the chemotaxis of neutrophils, have been studied. Chronic obstructive pneumopathies lead to remodeling of bronchial walls and lung parenchyma, ultimately causing fibrosis. Matrix metalloproteinases (MMPs) are discussed as the most important proteolytic enzymes during remodeling in human medicine and increasing evidence exists for the horse as well. A systemic involvement has been shown for severe equine asthma by increased acute phase proteins like serum amyloid A and haptoglobin in peripheral blood during exacerbation. Studies focusing on these and further possible inflammatory markers for chronic respiratory disease in the horse are discussed in this review of the literature.

Inflammatory Airway Disease of Horses--Revised Consensus Statement

The purpose of this manuscript is to revise and update the previous consensus statement on inflammatory airway disease (IAD) in horses. Since 2007, a large number of scientific articles have been published on the topic and these new findings have led to a significant evolution of our understanding of IAD.

Respiratory diseases and their effects on respiratory function and exercise capacity

Given that aerobic metabolism is the predominant energy pathway for most sports, the respiratory system can be a rate-limiting factor in the exercise capacity of fit and healthy horses. Consequently, respiratory diseases, even in mild forms, are potentially deleterious to any athletic performance. The functional impairment associated with a respiratory condition depends on the degree of severity of the disease and the equestrian discipline involved. Respiratory abnormalities generally result in an increase in respiratory impedance and work of breathing and a reduced level of ventilation that can be detected objectively by deterioration in breathing mechanics and arterial blood gas tensions and/or lactataemia. The overall prevalence of airway diseases is comparatively high in equine athletes and may affect the upper airways, lower airways or both. Diseases of the airways have been associated with a wide variety of anatomical and/or inflammatory conditions. In some instances, the diagnosis is challenging because conditions can be subclinical in horses at rest and become clinically relevant only during exercise. In such cases, an exercise test may be warranted in the evaluation of the patient. The design of the exercise test is critical to inducing the clinical signs of the problem and establishing an accurate diagnosis. Additional diagnostic techniques, such as airway sampling, can be valuable in the diagnosis of subclinical lower airway problems that have the capacity to impair performance. As all these techniques become more widely used in practice, they should inevitably enhance veterinarians' diagnostic capabilities and improve their assessment of treatment effectiveness and the long-term management of equine athletes.

Laboratory findings in respiratory fluids of the poorly-performing horse

Any disorder impairing a performance horse's ability to ventilate its lungs and exchange oxygen compromises exercise performance in any discipline. Since bronchoalveolar lavage was described in horses in the early 1980s, laboratory evaluation of respiratory fluids, along with clinical and functional assessment of the respiratory system, has become a relevant step in the diagnosis of respiratory disease affecting performance. The aim of this review is to provide objective information to assist clinicians in interpreting laboratory findings by (1) summarising published cytological references values in both clinically healthy horses and those with various airway diseases, (2) assessing the influence of physiological circumstances, such as exercise, on the cytological evaluation, (3) discussing the relationship between cytological and microbiological analyses, clinical signs and respiratory function, and (4) suggesting how this latter relationship may affect performance.

Radiographic scoring lacks predictive value in inflammatory airway disease

REASONS FOR PERFORMING STUDY

Diagnosis of inflammatory airway disease (IAD) currently rests upon the results of bronchoalveolar lavage (BAL) cytology, lung function testing and histamine bronchoprovocation (HBP), none of which provides direct information about structural change in the lung.

HYPOTHESIS

That thoracic radiography might better portray structural change in the lungs and therefore offer a good clinical assessment of IAD.

METHODS

A radiographic scoring system was developed to assess the extent of bronchial and interstitial pattern on thoracic radiographs in the dorsocaudal, dorsocranial and caudoventral regions in 16 control horses and 33 horses with IAD. Mean scores were compared to ascertain whether thoracic radiographs could distinguish between the 2 groups. In order to determine whether independent observers reliably scored radiographs similarly, an inter-rater reliability score was employed for each radiographic observation. Correlations between radiographic scores, BAL cytology, lung function testing using the forced oscillatory technique and HBP were examined.

RESULTS

Inter-rater reliability was only moderate. Radiographic scoring demonstrated no differences between the 2 groups. There were no correlations among BAL cytology, lung function testing, HBP and radiographic scores.

CONCLUSIONS AND POTENTIAL RELEVANCE

Thoracic radiographs are a low-yield diagnostic modality in horses with a clinical history compatible with IAD. In the absence of clinical evidence of more extensive, infectious disease, thoracic radiographs neither refine nor improve diagnosis of IAD, but increase diagnostic costs.

Comparison of tracheal aspirates and bronchoalveolar lavage in racehorses 1. Evaluation of cytological stains and the percentage of mast cells and eosinophils

OBJECTIVE

To compare a fast Romanowsky cytological stain (Diff-Quik) and Leishman's stain for the detection of mast cells in samples from the lower airways of racehorses, and to compare the proportion of mast cells and eosinophils in the total inflammatory cells in tracheal aspirate (TA) with those in paired bronchoalveolar lavage (BAL) samples.

DESIGN

Retrospective case series of 48 young Thoroughbred and Standardbred racehorses.

PROCEDURE

Fifty-one paired TA and BAL samples were collected after treadmill exercise from 48 horses with poor racing performance. Two slides were prepared from each sample; one was stained with Diff-Quik stain and the other with Leishman's stain. Differential cell counts of eosinophils and mast cells were recorded from each slide. Comparison of the suitability of the stains for the detection of mast cells, and comparisons of eosinophil and mast cell percentages in TA and BAL samples were analysed using the non-parametric Wilcoxon matched pairs test.

RESULTS

Percentages of mast cells were significantly higher in Leishman than in Diff-Quik stained slides in both TA (P = 0.03) and BAL samples (P < 0.0001). Mast cell percentages were significantly higher in BAL than in TA samples using Leishman's stain (P < 0.0001). There was no significant difference in eosinophil percentages between TA and BAL samples (P = 0.07).

CONCLUSIONS

Fast Romanowsky type stains (for example Diff-Quik) are not appropriate for the detection of mast cells in samples from the equine lower respiratory tract. Therefore, a metachromatic stain that reliably identifies mast cells (for example Leishman's) should be used if evaluation of mast cells in lower respiratory tract is undertaken. Mast cells are predominantly found in the distal small airways and alveoli sampled with a BAL. In contrast, eosinophils appear to be evenly distributed in the lower respiratory tract. However, high percentages of eosinophils are occasionally found only in TA samples. We recommend that both a TA and BAL be used for the evaluation of eosinophils and mast cells within the equine lower respiratory tract.

Equine respiratory pharmacology

Differentiation of diseases of the equine respiratory tract is based on history, clinical signs, auscultation, endoscopy, imaging, and sampling of airway exudate. Upper respiratory therapies include surgical correction of airway obstructions; flushing of localized abscesses (strangles), guttural pouch disease, or sinusitis; and oral or parenteral antibiotic and anti-inflammatory therapy if deemed necessary. Pneumonia usually is treated with antimicrobials, anti-inflammatories, and bronchodilators. Pleural drainage is indicated if significant pleural effusion is present. The most commonly used therapies for early inflammatory and chronic allergic obstructive conditions include bronchodilators and anti-inflammatories. Acute respiratory distress, particularly acute pulmonary edema, is treated with diuretics (usually furosemide), intranasal oxygen, bronchodilators, corticosteroids, and alleviation of the underlying cause. Furosemide also had been used in North America as a race-day preventative for exercise-induced pulmonary hemorrhage (EIPH), but recent data have shown that furosemide may be a performance-enhancing agent itself.

Pulmonary eosinophilia associated with increased airway responsiveness in young racing horses

Horses are known to acquire small airway disease (SAD), an allergen-induced naturally occurring syndrome of reversible obstructive lung disease accompanied by airway hyperresponsiveness and increased inflammatory cell numbers on bronchoalveolar lavage (BAL). This disorder has received scant attention in young racehorses. The purpose of the present report was to examine the effect of BAL eosinophilia in young racehorses on clinical examination, BAL, hematology, airway responsiveness, and on pulmonary function at rest and after a standardized exercise challenge. Five (3 males, 2 females; age 2.6 +/- 0.9 years) with a history of respiratory compromise and BAL eosinophil differential count > 5% and 6 controls (4 males, 2 females; age 3.5 +/- 1.0 years) training and performing to expectation with normal BAL cell differential (eosinophils < 1%) were studied. Respiratory system clinical examination was performed and expressed as a clinical score. Arterial blood gas measurements, CBC, and pulmonary function testing were performed at rest. Pulmonary mechanics measurements were repeated 1 hour and 20 hours after a standardized treadmill exercise challenge. Incremental histamine inhalation challenge was performed and the concentration of histamine effecting a 35% decrease in dynamic compliance (PC35CDyn) was determined. Significant differences were noted between and controls with regard to clinical score (P = .01), blood eosinophils (P = .04), BAL cell count (P = .04), BAL macrophage differential (P = .04), PC35CDyn (P = .008), and tidal volume and respiratory rate at 20 hours following exercise challenge (P = .05). We conclude that pulmonary eosinophilia and airway hyperresponsiveness are manifest in some young horses without overt airway obstruction at rest. We speculate that these may be early events in the natural progression of heaves.

Inhaled medications and bronchodilator usage in the horse

The advantages of aerosol medications include the direct, topical application to the target organ (airways); rapid effect; and low systemic availability. There are now more efficient methods for aerosol delivery that facilitate the use of increasingly sophisticated aerosol drugs. This article reviews the principles of aerosol deposition and the pharmacology of current medications.

Small airway disease as a vanguard for chronic obstructive pulmonary disease

Equine allergic small airway disease is a highly prevalent respiratory condition among the stabled horse population. With the assistance of new diagnostic tools such as bronchoalveolar lavage, the condition can be recognized in young performing horses. The pathophysiological and clinical features resemble an earlier stage of chronic obstructive pulmonary disease as determined by the appearance of specific inflammatory cells. Although environmental management is paramount in controlling the disease, proper selective therapeutic regimens are as important to reduce the concurrent inflammation and to reduce exacerbations of the disease.

Immune therapy in respiratory disease

Pharmacologic manipulation of pulmonary immunity plays an important role in primary and adjunct therapy for equine respiratory disease. Frequent exposure to respiratory viral pathogens, strenuous exercise, long distance transport, and inhalation of harmful substances destroy various aspects of the pulmonary defense system and predispose performance horses to development of infectious and noninfectious respiratory disease. Pulmonary immunity may be bolstered by nonspecific immunostimulants to combat primary or secondary immunodeficiency. State of the art technology improves active and passive-specific immunity for prevention of common infectious respiratory diseases in horses. Immuno-suppressive therapy can attenuate hyperreactive pulmonary immune responses in horses with allergic airway disease.

Lower respiratory tract disease

Lower respiratory tract disease is an important source of poor performance and exercise intolerance in racehorses and middle-aged sport horses. Horses that perform high-intensity exercise are predisposed to development of infectious and noninfectious respiratory disease. Diagnostic aids for investigation of lower respiratory tract disease include thorough thoracic auscultation with rebreathing, endoscopic examination, bronchoalveolar lavage (BAL), and thoracic radiographic examination. The therapeutic approach for horses with lower respiratory tract diseases often can be directed by cytologic evaluation of BAL fluid. Conservative management techniques may reduce the risk or severity of respiratory disease in horses performing high-intensity exercise.