CONSULT THE EXPERT  h  RESPIRATORY MEDICINE   h  PEER REVIEWED

Feline
Asthma
Laura A. Nafe, DVM, MS,
DACVIM (SAIM)
Oklahoma State University

dF
 IGURE 1 Ventrodorsal thoracic radiograph of an asthmatic
cat demonstrating a diffuse bronchial pattern and collapse of
the right middle lung lobe, which developed secondary to
mucus accumulation and resulted in atelectasis

Feline asthma is a lower airway disease that Hallmark clinical features of asthma include bronchoc-
onstriction, airway edema, airway eosinophilia, and
affects 1% to 5% of cats,1 most commonly excessive mucus production. The combination of these
young to middle-aged cats.1 Although median features can result in cough, tachypnea, and/or expira-
age on diagnosis has been reported to be 4 tory dyspnea.1,3 Compounding airway edema, smooth
muscle bronchoconstriction, and mucus hypersecretion
to 5 years, most cats with asthma experience
can result in airflow limitation, which can be at least
clinical signs earlier in life.1 Classified as partially reversible with bronchodilator therapy. If left
an allergic disease, feline asthma is the untreated, chronic airway inflammation can result in
irreversible airway remodeling.
result of a type-1 hypersensitivity to specific
aeroallergens.2 This immune response results
Clinical Signs
in cytokine release and elaboration that can Clinical signs associated with feline asthma include
ultimately cause pathologic airway changes. cough, tachypnea, open-mouth breathing, and/or

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CONSULT THE EXPERT  h  RESPIRATORY MEDICINE   h  PEER REVIEWED

respiratory distress, typically characterized by a and antibody testing), imaging (eg, thoracic radi-
prolonged expiratory phase of respiration and ography, thoracic ultrasonography, CT, bronchos-
abdominal push. Some patients may have only one copy, echocardiography), airway sampling, and
of these clinical signs, whereas others may have additional diagnostic testing (eg, airway cytology)
both a chronic cough and intermittent exacerba- to rule out other causes of eosinophilic airway
tions resulting in respiratory distress with expira- inflammation.
tory effort.3 Accordingly, clinical signs can be
episodic and vary in severity, from a mild, intermit- Physical examination may be normal or may
tent cough to life-threatening dyspnea (ie, status reveal tachypnea, inducible cough on tracheal
asthmaticus). Pet owners may struggle to identify a palpation, and/or abnormalities on thoracic aus-
true cough and may be confused with “vomiting cultation (eg, increased bronchovesicular sounds,
hairballs” without production of a hairball. expiratory wheezes). Classic radiographic findings
include a diffuse bronchial or bronchointerstitial
Diagnosis pattern, hyperinflation due to air trapping, and/or
Definitive diagnosis of feline asthma can be collapse of the right middle lung lobe due to mucus
challenging due to clinical features that overlap plug obstruction (Figure 1, previous page).3,4
with various other cardiopulmonary conditions, Because ≈20% of asthmatic cats have normal tho-
including chronic bronchitis, heartworm- racic radiographs, asthma should remain on the
associated respiratory disease, and pulmonary differential list for any cat with respiratory dis-
parasitic disease. Diagnosis can be facilitated tress and normal thoracic radiographs.5 In addi-
through a combination of consistent historical tion, a bronchial or bronchointerstitial pattern is
information, clinical signs (ie, cough and/or respi- also the predominant pulmonary pattern seen in
ratory distress), physical examination, laboratory cats with chronic bronchitis and/or heartworm-
data (eg, CBC, serum chemistry profile, fecal flota- associated respiratory disease, making it challeng-
tion and analysis, urinalysis, heartworm antigen ing to differentiate these conditions from asthma
via only physical examination and radiography.

Bronchoscopy may be used in asthmatic cats to

evaluate airway structure and collect bronchoalve-

Because ≈20% of asthmatic olar lavage fluid (BALF) for cytology, culture and
susceptibility testing, and Mycoplasma spp PCR
cats have normal thoracic testing. Alternatively, blind bronchoalveolar

radiographs, asthma lavage may also be performed in cats that show

diffuse radiographic changes. Clinicians should
should remain on the be cautious when interpreting BALF culture and
Mycoplasma spp PCR results in combination with
differential list for any cat BALF cytology results, as airways (especially the
with respiratory distress trachea) are not sterile and the presence of bacte-
ria or Mycoplasma spp does not equate to active
and normal thoracic infection.6
radiographs.5
Bronchoscopy findings are often nonspecific in
asthmatic patients and may include excessive
mucus accumulation, airway hyperemia, and/or
epithelial irregularities.1 Eosinophilic airway
BALF = bronchoalveolar lavage fluid inflammation is characteristic of but not specific to

18    cliniciansbrief.com    July 2020

asthma (Figure 2), as parasitic disease commonly heart murmur or gallop rhythm and perform cage-
results in airway eosinophilia. Historically, eosino- side thoracic ultrasonography to assess for pleural
philic airway inflammation has been defined as effusion and/or pulmonary edema (eg, presence of
>17% eosinophils present in BALF; however, recent B lines). If other causes of respiratory distress are
evidence suggests that >5% eosinophils is consid- not evident on initial evaluation, intervention
ered abnormal in feline BALF.7,8 Clinicians should with a bronchodilator for possible asthma may be
evaluate BALF eosinophil percentage in light of warranted.
clinical signs and concurrent conditions associated
with eosinophilia (eg, allergic skin disease). Most Management of chronic feline asthma is aimed at
asthmatic cats typically have significant BALF reducing airway inflammation and preventing or
eosinophilia; some can have lower eosinophil and reducing airflow-limiting bronchoconstriction.1
higher neutrophil numbers, particularly in chronic Reduced inflammation is best achieved by minimiz-
asthma cases. A heartworm antigen and antibody ing exposure to aeroallergens and environmental
test, fecal flotation, and Baermann test should be irritants (eg, aerosols, dust) and administration of
performed in all cases. In addition, the author com- oral glucocorticoids (eg, prednisolone). Minimiz-
monly institutes empiric antiparasitic treatment, ing environmental allergens is best achieved by
even if results are negative. reducing exposure to known allergens (eg, elimi-
nating outdoor access), cleaning bedding and other
Treatment & Management surfaces in the household frequented by the cat,
Management of feline asthma consists of both and using an air filter to improve air quality. Oral
acute and chronic treatment strategies. Clinicians glucocorticoid (prednisolone) therapy should be
and owners should understand that asthma is not initiated at a dose of 1-2 mg/kg/day. The dose may
a condition that can be cured; lifelong environ- be tapered by 25% to 50% every 2 to 4 weeks
mental and medical management are necessary. depending on clinical response. The goal is to
taper steroids to the lowest effective dose.
Cats presented in status asthmaticus require acute
management consisting of supplemental oxygen, Continues h
stress reduction and minimal handling, and bron-
chodilator therapy (eg, inhaled albuterol [via
metered dose inhaler], injectable terbutaline). In
the author’s clinical experience, injectable terbu-
taline is preferred over inhaled albuterol in the
emergency setting, as cats in respiratory distress
typically may not inspire deeply enough to appro-
priately deliver inhaled medication to the lower
airways. Identifying an expiratory respiratory pat-
tern can be suggestive of bronchoconstriction and
may lead the clinician to implement early inter-
vention with bronchodilator therapy. Expiratory
respiratory patterns are characterized by an
abdominal push during exhalation. If an obvious
expiratory pattern is not identified, evaluation for
other causes of respiratory distress (eg, pleural
effusion, congestive heart failure) should be per-
d FIGURE 2 BALF cytology from a cat demonstrating a predominance of
formed prior to empiric treatment with a broncho- eosinophils (arrows), which is characteristic of feline asthma. Image
dilator. Clinicians should evaluate patients for a courtesy of Dr. Susan Fielder, Oklahoma State University

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CONSULT THE EXPERT  h  RESPIRATORY MEDICINE   h  PEER REVIEWED

Inhalant Therapy S-enantiomer; however, racemic albuterol can be

Some cats can be transitioned to receiving only used at home by owners for rescue as needed.11
inhaled steroid therapy (eg, fluticasone) to mini- Oral terbutaline or theophylline may also be used
mize the systemic adverse effects of oral glucocorti- for chronic bronchodilator therapy. Although
coids and maintained on inhaled glucocorticoids many patients may need bronchodilator therapy
alone for long-term management.9 It is important to initially, once airway inflammation is controlled
overlap the inhaled steroid with oral glucocorticoid with glucocorticoid therapy, many can be weaned
therapy, as it is believed that inhaled glucocorti- off bronchodilators long-term and managed as
coids require ≈2 weeks to achieve full clinical effect. needed. In addition, feline asthma should never
Although the author frequently initiates inhaled be managed with bronchodilator therapy alone,
fluticasone at a dose of 110 μg every 12 hours, a as bronchodilators will not address airway
study evaluating inhaled fluticasone in cats with inflammation, which is an integral component
experimentally induced asthma found that airway of controlling asthma.
eosinophilia was controlled with a variety of doses,
including 44 μg, 110 μg, and 220 μg, administered Additional Therapeutic Options
every 12 hours.9 The efficacy of lower-dose flutica- Various other therapeutic drugs (ie, cyprohepta-
sone has not been evaluated in cats with naturally dine, cetirizine, nebulized lidocaine, maropitant)
occurring asthma. In cats with concurrent condi- have been investigated for management of experi-
tions in which systemic glucocorticoids are contra- mentally induced asthma in cats12-14; although
indicated (eg, congestive heart failure, diabetes some show promise in reducing airflow limitation,
mellitus), inhaled glucocorticoid therapy and/or none have been shown to be effective as monother-
oral cyclosporine may be considered.9,10 apy for management of feline asthma. As a result,
these other therapeutics can be considered as
Bronchodilator Therapy adjunctive treatments along with glucocorticoids.
Chronic bronchodilator therapy is not necessary Immunotherapy and mesenchymal stem cell ther-
in all cats with asthma and is only recommended apy have shown promise as future novel therapeu-
in patients that have signs associated with bron- tics and warrant further investigation both in cats
choconstriction (eg, respiratory distress, episodic that have experimental and naturally occurring
tachypnea). Inhaled racemic albuterol should not asthma.15,16
be used for chronic management of bronchocon-
striction due to the proinflammatory effects of the Prognosis & Prevention
Prognosis for feline asthma is typically good with
prompt diagnosis and appropriate management.
Status asthmaticus, however, is a potentially
life-threatening manifestation of asthma in cats,
Prognosis for feline especially if not recognized and treated appropri-
ately in the emergency setting. Prevention is chal-
asthma is typically good lenging, as it is impossible to truly prevent the onset
with prompt diagnosis and of an allergic condition like asthma. Prevention
and/or reduction of clinical signs can be achieved
appropriate management. through avoidance of known aeroallergens.

Clinical Follow-Up & Monitoring

Follow-up evaluation is necessary for successful
chronic management of cats with asthma. Clini-
cians should decide whether to reduce a steroid

20    cliniciansbrief.com    July 2020

dose based on clinical signs, physical examination,
thoracic radiography, and, occasionally, resolution
of airway eosinophilia. Long-term management of POLL
feline asthma is aimed at lowering glucocorticoid
doses to the lowest effective dose that controls clini- Approximately what percentage of your
cal signs and airway inflammation. Some patients feline asthma patients are maintained on
may be transitioned to inhaled glucocorticoid ther- inhaled glucocorticoids?
apy (eg, fluticasone) using a space chamber to aid A. 100%
drug delivery. Patients started on bronchodilator B. 75% to 99%
therapy can often be tapered off once airway C. 50% to 74%
inflammation is controlled. D. 25% to 49%
E. 1% to 24%
Feline asthma patients are generally responsive to F. I do not use inhaled glucocorticoids for
treatment with a glucocorticoid ± bronchodilator. my feline asthma patients.
In feline respiratory patients unresponsive to stan-
dard asthma therapy, the diagnosis should be Scan the QR code to submit your answer and see
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