67 | 5 key considerations to manage chronic rhinitis confidently as a vet nurse

PodcastRespiratory
Written By Laura Jones

In this episode, I want to chat to you about a very common, very frustrating, and, in my opinion a very under-appreciated condition - chronic rhinitis.

 

Chronic rhinitis is one of those conditions that can easily fly under the radar - we often think a lot about nursing our cat ‘flu cats for example, but there are many patients who suffer from chronic nasal disease that can significantly impact quality of life.

Think of it as the nasal equivalent of IBD - often misunderstood, sometimes not easy to spot, frustrating to manage and with the potential to make our patients VERY miserable.

There’s quite a bit we can do to support these patients long term, and to do that well, we first need to understand what chronic rhinitis is, how it affects our patients, and how we treat it.

Ok, let’s dive in - what IS chronic rhinitis?

Chronic rhinitis is an incredibly frustrating condition to both diagnose and treat. It’s defined as rhinitis or rhinosinusitis that persists for longer than one month without signs of systemic disease.

It’s most commonly diagnosed in cats, though we can see it in dogs, too. It can be seen in patients of any age - it’s reported in patients as young as 6 months and cats as old as 20 years!

These patients are usually described as ‘always being a bit sniffly’ and have long-standing clinical signs such as sneezing, stertor, nasal congestion and nasal discharge, which can be serous, mucoid, haemorrhagic or mucopurulent (with mucopurulent discharge indicating a likely secondary bacterial infection). Some patients will also present with gagging or upper respiratory coughing.

And whilst we don’t know what specifically causes chronic rhinitis in most cases, there are a few causes we need to be aware of.

Chronic rhinitis remains a poorly understood condition. There are lots of suspected factors in its development, including:

  • Environmental factors (eg cigarette smoke, cleaning products, air fresheners, dust)

  • Allergens

  • Immune-mediated factors

  • Previous viral infection (particularly in cats, as we chatted about in episode 66).

Regardless of the cause, the impact on our patients is the same.

They present with chronic upper respiratory stertor, reduced airflow and discharge, potentially leading to waxing and waning changes in appetite, energy and activity levels, and quality of life.

And whilst this is a frustrating condition to diagnose and manage, it is possible to do so successfully with client support and education - something we’re really good at as veterinary nurses and technicians.

Ok, so that’s what chronic rhinitis is, and the patients we see it in. How do we diagnose it?

I mentioned that I think of chronic rhinitis as the nasal equivalent to IBD, and that’s because we diagnose it similarly - by ruling out other diseases affecting that area and taking samples to confirm the presence of inflammation.

Chronic rhinitis is an idiopathic disease. When we have an idiopathic disease, the only way we can confirm it is via diagnosis of exclusion. This means we need to confirm the absence of any other primary nasal disease before saying our patient has chronic rhinitis.

So, our diagnostic approach is very similar to other nasal disorders. We’re likely to

Perform diagnostic imaging of the head (ideally, CT since this provides us with the most information - unless you’re looking for something very obvious, X-ray will be of limited value)

Test for infectious diseases (e.g. feline herpesvirus-1, feline calicivirus, canine adenovirus, bordetella, mycoplasma)

Perform a rhinoscopy (to look for foreign bodies, evidence of fungal infection, or neoplasia)

Take biopsies and submit these for histology and culture (either bacterial culture, fungal culture, or both). These biopsies should be collected blindly (i.e. not through an endoscope biopsy channel, using larger forceps) where possible, since they’ll result in larger biopsies - unless, of course, you’re worried about a specific area of the nose and need to collect guided samples.

What other tests do we need to perform?

Like we discussed in episode 65, rhinoscopy and nasal sampling carries a high risk of bleeding. If you’ve ever had a nosebleed you’ll know how hard it can be to stop - and that inflamed, irritated and sore tissue our nasal disease patients have can be even more likely to bleed.

This means we need to check our patient’s haemostatic status - i.e. how well they can stop haemorrhage - before we go anywhere near that nose. As a minimum, check your patient has enough platelets (and if you’re dealing with a high-risk patient, a buccal mucosal bleeding time to check platelet function might be worth it too). If there’s any worries, you might also need to check their coagulation times (aPTT and PT) and ensure these are normal before proceeding.

FeLV/FIV status should also be checked for cats if not already known.

Aside from this, the rest of our testing is for anaesthetic safety purposes - if they’ve not had routine bloodwork recently you might want to consider a pre-anaesthetic biochemistry panel, for example, depending on your patient’s age and ASA status.

Those biopsies we sent? There’s a good chance they’ll come back with evidence of inflammation.

Specifically lymphoplasmacytic inflammation - causing lymphoplasmacytic rhinitis or LPR. This means that lymphocytes and plasma cells (which are antibody-producing cells that develop from lymphocytes) have infiltrated the nasal tissue, and it’s a hallmark finding in chronic rhinitis.

Secondary bacterial infection is also common, which is why we’ll submit a biopsy for fresh tissue culture too.

And then once you’ve got a diagnosis, it’s time to think about treatment and nursing care.

Unsurprisingly, chronic rhinitis is frustrating to treat. There’s no cure, and instead our treatment is supportive, minimising inflammation and improving clinical signs and quality of life as much as possible.

Some patients will be mostly normal and have very mild signs, and others will have frequent infections or persistant signs that significantly impact their quality of life - so our treatment, and supportive nursing care, is tailored to the individual.

Common treatments include antibiotics and anti-inflammatories.

Secondary bacterial infection is common, and antibiotics are often prescribed. Antibiotics with good nasal penetration and that are effective against mycoplasma - such as doxycycline - are often used, depending on culture and sensitivity results.

If anti-inflammatories are needed, either a non-steroidal anti-inflammatory or a glucocorticoid is used. The use of glucocorticoids can be controversial, particularly in cats, as we want to avoid long-term systemic glucocorticoids where possible (since they can cause diabetes mellitus). Inhaled versions, such as fluticasone, are sometimes used as an alternative.

What else can we do to support these patients?

Inhaled therapies with nebulisation can be really helpful for these patients - both in the clinic and at home. This will help to loosen those nasal secretions and ease congestion.

In severe cases, patients may need periodic nasal flush procedures to clear their accumulated mucous and discharge. These patients are admitted, anaesthetised, and their nose copiously flushed with saline. Throat packs are periodically checked and changed throughout the procedure, and when they are clear of discharge, the procedure is stopped.

So we know there’s not much we can do to ‘fix’ these patients - but how can we help them as nurses?

Here are my top five considerations when caring for chronic rhinitis cases:

1: Cleaning and clearing over everything else.

Yes, cleaning nasal discharge seems basic. No, it isn’t a fancy nursing intervention - but it is fundamental to these patients feeling better. Nebulising the patient to loosen up those secretions, and then removing that loosened discharge will make them feel SO much happier, less congested, and more likely to eat.

2: Don’t underestimate the impact on appetite and hydration.

In severe cases, these patients will be really congested and this can have a significant impact on their hydration and their voluntary appetite. Once they’re comfortable, clean and nebulised there’s a good chance they’ll eat well themselves - especially if you’re offering something palatable, lappable and warmed to enhance the smell. But if not, you might need to consider appetite stimulants.

3: Provide thorough client education and support.

These patients have lifelong disease, and most of their management will be at home - so client support and education is crucial. And lucky for us, it’s also where we’re best! Chat to the client about nebulisation, reducing environmental allergens, monitoring, appetite support and when to bring the patient in for flushes, if needed.

4: Protect your patient against aspiration.

Anaesthetising your patient for a nasal flush? You’ll need to protect them from aspiration. Make sure you intubate them with a cuffed ET tube (yes, even for cats) inflated to an appropriate pressure, place throat packs, and check and change these regularly.

5: Monitor for bleeding and intervene where needed.

Scoping or biopsying your patient? There’s a chance they’ll have epistaxis either during the procedure or in recovery. In most cases the bleeding is minimal and self-limiting, though there are some cases where we run into issues. If you need, drugs like topical or systemic tranexamic acid can be used, and adrenaline-dipped cotton buds can be carefully placed in the nose (in an anaesthetised patient).

There you have it - my top 5 considerations to care for chronic rhinitis patients confidently as a vet nurse or technician. To recap, chronic rhinitis is a frustrating, poorly understood condition with lots of potential causes, including immune-mediated and environmental factors, allergies and previous viral infection. 

These patients have ongoing nasal inflammation, diagnosed by sampling the nose for histology and culture. Treatment is mostly supportive, alongside the use of antibiotics and anti-inflammatories when needed. And when nursing these patients, we need to prioritise nutrition and hydration, cleaning and nebulising, client education, monitoring and more.

Did you enjoy this episode? If so, I’d love to hear what you think. Take a screenshot and tag me on Instagram (@vetinternalmedicinenursing) so I can give you a shout-out and share it with a colleague who’d find it helpful!

Thanks for learning with me this week, and I’ll see you next time!

References and Further Reading

Laura Jones
Next

66 | How to nurse your cat ‘flu patients like a pro: the vet nurse’s guide to feline respiratory disease complex