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com

EQUINE PRACTICE Bronchoalveolar lavage is easy

to perform in general practice
and should be carried out when
a complete evaluation of the
lower respiratory tract is
required

RAO and IAD: respiratory disease

in horses revisited KATE ALLEN AND SAMANTHA FRANKLIN

RESPIRATORY disease continues to be a major problem for horse owners and trainers worldwide. Lower
airway inflammation is now recognised in a range of animals, from aged ponies to young racehorses.
This article discusses recent developments in the definitions and understanding of recurrent airway
obstruction (RAO) and inflammatory airway disease (IAD). For both conditions, it describes the clinical
signs, diagnosis and treatment. A more comprehensive discussion of therapeutic options was provided
in an earlier article in In Practice (Durham 2001).

RECURRENT AIRWAY OBSTRUCTION severity progresses, the cough becomes more frequent
Kate Allen qualified
from Liverpool in and severely affected horses will have paroxysmal bouts
2002. She spent RAO is an inflammatory obstructive airway disease of coughing. Horses are typically afebrile, but have a pro-
a year in mixed
practice, before that usually becomes apparent in middle-aged and older gressively elevated respiratory rate and varying amounts of
undertaking a horses. Once it is clinically evident, the susceptibility to mucopurulent nasal discharge. In severe cases, signs of res-
one-year equine
internship at Bristol. disease persists for the life of the horse; however, if suc- piratory distress (eg, flaring of the nostrils, audible wheez-
She is currently cessfully managed, horses can remain in remission with ing at the nostrils and obvious abdominal expiratory effort)
the clinical scholar
in equine sports
normal pulmonary function. are apparent at rest. Horses that are markedly dyspnoeic
medicine and may not maintain body condition due to increased energy
internal medicine CLINICAL SIGNS expenditure caused by the increased work of breathing.
at Bristol.
Generally, the first clinical signs reported by an owner are In chronic severe cases, a ‘heave’ line may develop due to
occasional coughing and exercise intolerance. As disease hypertrophy of the external abdominal oblique muscle.

Equine lower airway disease – terms and definitions

For years, the term chronic obstructive pulmonary dis-
ease (COPD) was used to describe any accumulation of
neutrophils and mucus in the airways in the absence
Samantha Franklin of active infection (eg, both the mature horse with
qualified from Bristol severe heaves and the younger animal with reduced
in 1995. After four
years in practice, she
performance, increased airway neutrophils and
returned to Bristol mucus). However, in recent years, a number of inter-
to complete a PhD national workshops have been held to clarify the
in dynamic upper
airway disorders definitions of equine lower airway disease.
of the horse. She In 2000, one such workshop on equine chronic
currently runs
the equine sports airway disease highlighted the fact that the term
medicine referral equine COPD was used widely and often inappro-
centre at Bristol.
priately to describe horses with airway inflamma-
tion. Human COPD is a progressive disease with lit-
tle reversibility that is usually related to smoking.
In contrast, the equine disease is characterised by
In Practice (2007) reversible airway narrowing due to bronchospasm
29, 76-82
and, therefore, it more closely resembles human
asthma. As a result it was decided to eliminate the
term ‘COPD’ and recommend the term ‘heaves’
or ‘recurrent airway obstruction (RAO)’ instead
(Robinson 2001).
The syndrome of lower airway disease, particular-
ly in young horses, was referred to as ‘inflammatory
airway disease (IAD)’ and, in 2002, a workshop was
set up with the aim of better defining it (Hoffman
and others 2003).
In an attempt to differentiate between RAO
and IAD, it is important to bear in mind the
current accepted definitions (see box on the
right). However, at present, the definition of IAD
covers a broad range of clinical disease and future
research is likely to identify subsets with varying
aetiologies.

76 In Practice ● FEBRUARY 20 07
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PATHOPHYSIOLOGY
Most evidence suggests that RAO is a specific pulmonary
hypersensitivity to inhaled antigens (eg, hay dust, moulds,
spores, forage mites, endotoxins and inorganic compo-
nents) from feeds and bedding that results in marked air-
way inflammation in susceptible horses. The identification
of allergen-specific immunoglobulin E (IgE) in broncho-
alveolar lavage (BAL) fluid and sera of some affected hors-
es supports the involvement of a late phase IgE-mediated
hypersensitivity. However, it has recently been suggested
that RAO may result from a non-specific inflammatory
response to inhaled pro-inflammatory agents. Horses with
RAO appear to have an exaggerated inflammatory response
to environmental conditions that might only cause mild
inflammation in ‘normal’ horses. There is some evidence
that genetic factors play a role in RAO.
Accumulation of mucus and neutrophils in the airway
lumen and concurrent bronchospasm produce airway
obstruction. Furthermore, inflammatory changes within
the airway wall occur both acutely, with the development
of oedema, and chronically due to airway wall remodel-
ling, which involves mucus metaplasia, smooth muscle
hypertrophy, peribronchial inflammation and fibrosis.
DIAGNOSIS
A presumptive diagnosis may be made on the basis of the
history and clinical examination. Characteristic ‘crackles’
and ‘wheezes’ may be auscultated from the trachea to the
peripheral lung fields. In mildly affected horses, the use of
a rebreathing bag may aid auscultation of abnormal lung
sounds, but it is inappropriate to perform this technique in
dyspnoeic horses. Routine haematology and biochemistry
are usually within normal limits. Excessive mucopurulent
tracheal secretions are evident on endoscopy, and fluids
obtained from tracheal wash (TW) and BAL are charac-
terised by a marked neutrophilia. BAL should not be per-
formed if the horse is markedly dyspnoeic and should be
postponed until the dyspnoea is controlled. Reduction of
respiratory distress after the administration of a bronchodi-
lator confirms the presence of bronchospasm. This ‘test’ is
best performed using intravenous atropine. Radiographs
are recommended in animals that do not respond to treat- Many horses benefit from corticosteroid administration
ment as anticipated, as they are useful to rule out other early in the course of the disease in conjunction with bron-
types of lung disease and, in some cases, may show evi- chodilators, as this will address the underlying inflammation
Recurrent airway obstruction
■ Affects middle-aged and older horses (ie, >seven years)
■ Signs include obstructive airway disease, cough and increased respi-
ratory rate and expiratory effort
■ Recurrent episodes of disease
■ Disease is reversible, at least in part, with changes in environment or
the use of bronchodilators
■ Accumulations of tracheal mucus
■ Increased proportions of neutrophils are found in TW and BAL fluids
Inflammatory airway disease
■ Affects horses of any age
■ Clinical signs are vague and limited, possibly including poor perform-
ance, cough and nasal discharge
■ Accumulations of tracheal mucus
■ Increased proportions of inflammatory cells (predominantly neu-
trophils) are found in TW and BAL fluids
In Practice ● FEBRUARY 20 07
dence of irreversible lung
pathology such as bron- Summer pasture-associated
chiectasis. There is little obstructive pulmonary disease
evidence to support the use
Summer pasture-associated obstructive pulmonary
of serum and intradermal
disease (SPAOPD) is a syndrome recognised in hors-
allergy testing in the diag-
es at pasture in the summer months. It is clinically
nosis of RAO.
indistinguishable from RAO, but horses frequently
have more severe airway inflammation. It is likely
TREATMENT AND to be a pulmonary hypersensitivity to inhaled aller-
PREVENTION gens, such as moulds on grasses and possibly pol-
The mainstays of treatment
lens. Affected horses often require stabling during
and prevention of RAO are
the summer months, or moving to alternative pas-
environmental control, the
ture. Air hygiene in the stable environment must
use of bronchodilators to
also be addressed as some horses suffer from both
reduce respiratory distress
SPAOPD and RAO. Many horses will require addi-
and the administration of
tional medical treatment, as described for RAO.
corticosteroids to reduce
inflammation.
Environmental control
Environmental control is important in all stages of the
disease and, as reported by many studies, may in itself
result in clinical and functional improvement. Owners
need to appreciate that environmental management is at
least as important as medical treatment, and they should
be made aware that even a brief exposure to dust is suffi-
cient to induce inflammation in horses with RAO, which
may take days or weeks to resolve.
Bronchodilators
Bronchodilators are used to counteract the bronchospasm
and thereby relieve some of the respiratory distress expe-
rienced by horses with RAO. Although a large part of the
airway obstruction may be due to bronchospasm, some
obstruction of the airway may remain, despite maximal
bronchodilation, due to the mucus accumulation and
inflammatory changes in the airway wall. It is important
to understand that bronchodilators do not treat the under-
lying inflammation.
Corticosteroids
as well as bronchospasm. Cortico-
steroids can be administered sys-
temically using intravenous or oral
preparations, or by inhalation. (The
association between corticosteroids
and laminitis should be discussed
with the owner.)
The advantage of inhaled cor-
ticosteroids is that they are admin-
istered directly to the respiratory
tract; therefore, the required ther-
apeutic dose is lower, resulting
in less systemic absorption and
hence less risk of side effects. The
pulmonary distribution of inhaled
corticosteroids is poor during
severe airway obstruction, so this
method of administration should
only be used after an improve-
ment in lung function has been
achieved with systemic cortico-
steroids and/or bronchodilators.
Continued on page 80
77
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Tracheal wash and bronchoalveolar lavage

Respiratory secretions and cells that accumu-
late in the lower trachea are likely to be a
collection of all secretions that have derived
not just from the trachea but also from the
more distal airways. In contrast, BAL samples
are taken from a specific, more peripheral
lung segment. There are important differ-
ences between cytological findings in normal
TW and BAL fluids, indicating that the popu-
lation of cells within the trachea is not truly
representative of the lower airways. When
comparing the two techniques lung inflam-
mation may be underdiagnosed if only one
method is used in isolation. TW is frequently
the procedure of choice in a clinical setting
due to the more invasive nature of BAL and
the requirement for sedation. However, BAL
cytology may be more relevant when consid-
ering any potential effects on performance
as it samples the site of gas exchange.
Most horses tolerate endoscopy well, but
sedation will facilitate endoscopy in horses
with inflamed or hypersensitive airways. A
visual assessment of the trachea, carina and
bronchi should be performed. In cases of
RAO, it is not uncommon to see blunting of
the carina due to oedema and remodelling.

(left) A sharp carina and wide

bronchi are seen in normal
horses and often horses with
IAD. (right) A thickened carina
and narrowed bronchi due to
airway wall inflammation are
typical findings in cases of
chronic RAO

Grading of mucus accumulation

Mucus accumulation in the trachea is observed in most horses with RAO and IAD. Mucus quantity should be graded and a 0 (none) to
5 (extreme) scale is recommended. Excessive mucus (>2) has been associated with poor performance in racehorses and other sport
horses.

Grade 1 Grade 2 Grade 3 Grade 4 Grade 5

Little Moderate Marked Large Extreme
Small blobs Large blobs Stream forming Pool forming Profuse

Tracheal wash
Performing a TW transendoscopically has largely replaced
the transtracheal method as it is less invasive and has fewer
side effects. The endoscope is passed into the trachea and
10 to 30 ml of prewarmed sterile (0·9 per cent) saline or
phosphate-buffered saline is introduced at the mid-tracheal
level via a catheter passed through the biopsy portal of the
endoscope. Ideally, a guarded catheter system should be
used when submitting the sample for culture to avoid con-
tamination. If these systems are not available, plugging the
tip of a polythene catheter with a small amount of sterile (left) Polythene catheter
protruding from the biopsy
agar prior to use will help to reduce the risk of commensal channel of an endoscope
bacterial contamination. Once introduced, the saline col- while performing a tracheal
wash. (right) Turbid tracheal
lects at the tracheal ‘sump’ at the thoracic inlet from where wash from a horse with RAO,
it can be aspirated. showing excessive mucus

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Bronchoalveolar lavage
BAL is routinely performed under sedation.
The addition of butorphanol into the seda-
tion protocol may be of benefit due to its
antitussive properties. This procedure can
be performed with either a 1·8 to 2 m endo-
scope or a proprietary BAL catheter:
■ The advantage of an endoscope is that
one piece of equipment can be used to
perform both TW and BAL. It also allows
a specific bronchus to be selected for BAL
collection;
■ The advantage of a BAL catheter is its
smaller diameter and longer length, which
enables more distal airways to be sampled.
After performing a TW, it is optional to
infuse 30 ml of (0·2 per cent) lidocaine solu-
tion at the level of the carina, which may
help to reduce coughing during the BAL pro-
cedure. If using a BAL catheter, this is passed
blindly into the trachea. Extending the neck
aids passage into the trachea and, once in the
trachea, the catheter is passed with very little
resistance. A smooth procedure will help to
reduce oropharyngeal contamination. How-
ever, as the tube is extremely flexible, the
catheter can inadvertently be passed into the
oesophagus and possibly become retroverted
underneath the soft palate or passed down
the other side of the nasal septum!
Horses rarely cough until the catheter/
endoscope is at the level of the bronchi. The
catheter/endoscope is passed until it becomes
‘wedged’ (ie, resistance is detected with
gentle attempts to pass it any further). If
a BAL catheter is used, the cuff is gently
inflated with air (~5 ml). Horses may cough
excessively while the ‘wedge’ is performed,
but this usually ceases once the saline is
introduced. Approximately 250 to 500 ml
of sterile (0·9 per cent) saline or phosphate-
buffered saline is introduced and then
immediately recovered by manual aspiration
with 60 ml syringes. More than 50 per cent
of the instilled volume should be retrieved
and a frothy sample (indicating surfactant)
confirms that a bronchoalveolar rather than
bronchial sample has been obtained. If only
air is retrieved, it is likely that an insuffi-
(above) Proprietary BAL catheter (eg, Cook
cient ‘wedge’ was obtained. If no fluid/air Veterinary Products) with cuff inflated.
is obtained, the end of the catheter/endo- (below) Typical BAL samples showing frothy
surfactant layer
scope is likely to be positioned against the
airway wall. In this case, rotating the endo-
scope or releasing some air from the cuff
of the catheter and withdrawing it by 1 cm
may aid fluid retrieval. At the end of the
procedure, the cuff is deflated and the cath-
eter/endoscope is withdrawn.
Sample analysis
Both the TW and BAL samples should be
submitted for cytology. Evaluation of the
severity of disease is generally based on the
proportions of inflammatory cells and the
total cell count. a single organism is more likely to indicate
TW yields greater numbers of positive true infection while scanty mixed growth
bacterial cultures compared with BAL. This is less likely to be of clinical significance.
may represent the normal bacterial flora Positive bacterial cultures are more common
of the conducting airways, true infection, in younger horses, those that cough and
impaired mucociliary clearance or contamina- those with tracheal exudates. Quantitative
tion during the sampling procedure. Culture culture may assist interpretation: >103 colony
results should be interpreted in the light of forming units/ml suggests that bacteria are
clinical signs and cytology. A pure growth of contributing to the disease process.

Cytological examination
RAO and IAD are characterised by neu-
trophilic airway inflammation, in contrast
to the airway eosinophilia seen in cases of
human asthma.
Tracheal wash
The main disadvantage of TWs is the wide
variation in the percentage of inflamma-
tory cells derived from apparently healthy
horses. Macrophages are the most abun-
dant inflammatory cell type in normal
horses (~45 per cent). Lymphocytes tend
to be present in lower numbers (~5 per
cent). The majority of normal horses have
<20 per cent neutrophils in TWs and there
is a strong correlation between a higher
proportion of neutrophils (>20 per cent)
and respiratory signs. Eosinophils and mast
cells are present only in very low numbers
(<1 per cent) in normal horses. Epithelial
cells are also observed in variable numbers
(~30 per cent).
Bronchoalveolar lavage
The advantage of BAL samples is that
there is a smaller variation in appar-
ently normal horses. The majority of cells
are macrophages (~60 per cent) and
lymphocytes (~35 per cent). Normal
horses are observed to have <5 per
cent neutrophils and only very low
numbers of mast cells (<2 per cent),
eosinophils (<0·1 per cent) and epithelial
cells.

Normal cytology
TW: <20% neutrophils
BAL: <5% neutrophils

(left) Normal BAL sample showing

macrophages, lymphocytes and an
epithelial cell. (right) BAL sample
showing neutrophilic inflammation.
Both samples stained with modified
Wright’s stain

In Practice ● FEBRUARY 20 07 79
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In mild to moderate cases, systemic corticosteroids may
not be required and inhaled corticosteroids may be used
from the outset. Ideally, inhaled corticosteroids should
be administered after inhaled bronchodilators to improve
their penetration to the lower airways.
In the majority of cases, medical treatment should be
considered a short-term measure while environmental
improvements are instituted.
INFLAMMATORY AIRWAY DISEASE
Classically, IAD is used to describe lower airway inflam-
mation in young racehorses as a result of bacterial infec-
tion (reportedly up to 80 per cent of racehorses are affected
at some point in the first year of training). However, non-
infectious IAD is now being recognised in horses of all
ages and disciplines. It is reported that up to 70 per cent
of stabled sport horses may be affected. In non-racehorses,
IAD is often diagnosed at an older age and animals appear
to have more obvious clinical signs of respiratory disease.
The true effect of IAD on athletic performance is
currently unclear. Anecdotal reports suggest that the
syndrome has a detrimental effect on athletic perform-
ance through impairment of lung function. Indeed, many
horses undergoing investigation for poor performance
have evidence of IAD. However, it has been suggested
that, in fact, most stabled horses have some evidence of
lower airway inflammation and that this may not always
result in clinical signs.
Few studies have investigated the physiological
effects of IAD. In one study, submaximal exercise failed
to induce obvious differences in gas exchange in horses
with IAD versus healthy horses. In contrast, others have
found a more pronounced exercise-induced hypoxaemia
in horses with IAD compared with healthy controls.
Also, airway resistance has been shown to be mildly
increased in horses with IAD, suggesting a degree of air-
way obstruction, although not to the same extent as that
seen in horses with RAO. It is likely that the extent to
which IAD affects performance will depend on the type
of exercise horses are expected to perform. In horses
performing maximal exercise (eg, racehorses), any pul-
monary dysfunction is likely to be apparent at an earlier
stage than in horses performing less strenuous exercise.
CLINICAL SIGNS
Horses show no systemic signs of illness and no obvious
respiratory distress at rest, but have evidence of airway
inflammation, including increased tracheal mucus and
inflammatory cells within the airways. In many cases,
the only indication of disease will be reduced exercise
tolerance or poor high speed performance. Some horses
may have prolonged recovery times, and show excessive
blowing post-exercise, an occasional cough or a small
amount of nasal discharge.
AETIOPATHOGENESIS
The underlying aetiopathogenesis of IAD is unclear. It is
likely that multiple factors are involved and infectious,
environmental and immunological causes have been
proposed.
Little evidence exists to support respiratory viral
infections as a primary cause of IAD, but they do cause
alterations in the normal respiratory defence mechanisms
and can exacerbate airway hyperresponsiveness. This can
80
predispose a horse to increased sensitivity to bacteria,
dusts, moulds, pollens and other irritants.
The role of bacteria in the aetiology of IAD in young
horses has been well documented. Streptococcus zoo-
epidemicus, Actinobacillus/Pasteurella species, Strepto-
coccus pneumoniae and Mycoplasma species have
been associated with IAD in young racehorses in the
UK. However, the role of bacteria remains controversial
as infection in older racehorses and sports horses, for
example, is considerably less common.
The potential role of environmental agents in the
aetiopathogenesis of IAD has been investigated more
recently. Inhalation of a variety of airborne particle
agents (particularly exposure to high concentrations of
respirable endotoxins) has been proposed to cause IAD.
DIAGNOSIS
The limitations of clinical examinations in the diagnosis
of low grade IAD cannot be overemphasised. Detection
of abnormal lung sounds, despite the use of a rebreath-
ing bag, is rare. Routine haematology and biochemistry
are often unremarkable. Thus, it is likely that the preva-
lence of IAD is underestimated.
The hallmark of IAD is mucopurulent tracheal exu-
dates containing increased proportions of inflammatory
cells, so endoscopy, TW and BAL are the mainstays of
diagnosis. Most horses with IAD have increased propor-
tions of neutrophils in airway secretions. However, there
appear to be subsets of the disease, with horses having
increased proportions of mast cells and/or eosinophils. It
has been reported that, as the disease process progresses,
the cellularity may change, suggesting that the varying
‘subsets’ may be different stages of the same disease.
TREATMENT
The aim of treatment is to reduce airway inflammation.
At present, it appears likely that the cause of the inflam-
mation may differ between individuals. Therefore, thera-
peutic recommendations may vary and should be based
on the results of both TW and BAL cytological evalua-
tion, and culture and sensitivity tests. Most cases will be
treated with antibiotics, anti-inflammatory drugs and/or
bronchodilators, and avoidance of environmental irri-
tants. The following general points should be noted:
■ Air hygiene improvements should be performed in all
cases as non-specific airway hyperresponsiveness accom-
panies many inflammatory airway diseases. The airways
can become extremely sensitive to any airborne irritant;
■ The results of culture and sensitivity testing are like-
ly to dictate the use of antibiotics. In areas of the UK
where a high population of young horses are in con-
tact, the likelihood of a bacterial component is higher.
Anecdotally, the use of antibiotics in young horses in
training has proven successful in treating IAD;
■ If there is no evidence of significant numbers of spe-
cific bacteria, the use of antibiotics may be less benefi-
cial, and these cases usually benefit from environmental
management, and the administration of inhaled or oral
corticosteroids;
■ Mast cell stabilising drugs (eg, sodium cromolyn)
have potential benefits in mast cell rich IAD;
■ Although horses with IAD do not have overt evidence
of bronchoconstriction on clinical examination, meas-
urements of lung function have demonstrated airway
hyperreactivity. Therefore, the additional use of bron-
chodilators may be warranted in some cases.
In Practice ● FEBRUARY 20 07
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Environmental control
The most logical way to treat airway inflam-
mation involves reducing or eliminating
dust exposure. The stable environment is
recognised as a source of respiratory aller-
gens and irritants with potentially high lev-
els of organic dust, fungi and their spores,
bacterial endotoxins and ammonia. The
principal sources of dust are hay and bed-
ding. The levels of these environmental pol-
lutants vary considerably between stables,
depending on the management regimens
employed and the amount of ventilation.
Airborne particulate material from feeds
and bedding are increased by the horse’s
movements so that the concentration of
dusts is higher within a 30 cm radius of
the horse’s nostrils. In most instances, dust
levels in this so-called ‘breathing zone’ are
vastly greater than those in the remainder
of the stable.
Pasture and stabling
Keeping the horse at pasture with a shel-
ter against adverse weather conditions and
no supplementary hay feeding is the ideal
way of eliminating dust exposure in RAO-
susceptible animals. Improvement of clinical
signs in many horses with RAO occurs after
five to seven days. It is essential to realise
that some susceptible horses are extremely
sensitive and a few minutes’ contact with
hay may be sufficient to induce clinical
signs. For horses susceptible to RAO, expo-
sure to hay for seven hours has been shown
to induce bronchial hyperresponsiveness
that lasted for three days. Therefore, turn-
out during the day and stabling at night
will not be sufficient to relieve inflamma-
tion. In susceptible horses, even bringing
the animal in for grooming or transport,
for example, may be sufficient to produce
airway inflammation. However, for practical
reasons, many horses are stabled indoors.
The dust levels in the stable can be reduced
by decreasing the dust content of food and
bedding, increasing ventilation, or a combi-
nation of the two.
Forage
Hay is a major source of inhaled particles in
a horse’s breathing zone. Regardless of the
quality of the hay, high loads of respirable
particles are present. However, the high-
est loads are seen in hay that has heated, is
very dusty and has obvious mould. Soaking
hay does reduce the respirable dust chal-
lenge, but this may not be to a level
low enough to resolve the symptoms of
RAO. Soaking does not remove mould
and fungal spores but it does reduce the
amount of dust aerosol (provided the hay
does not dry out while being fed). Exclusion
of hay is justified as haylage is consider-
ably lower in dust. The use of alfalfa pel-
lets instead of forage may be an option in
some horses, as these can contain fewer
allergens than haylage. This is not suitable
in all cases as complete lack of long fibre in
the diet may result in abnormal behaviour
patterns.
Concentrates
The respirable dust challenge from concen-
trates may be reduced by feeding molassed
or dampened concentrates. Rolled grains
are particularly high in respirable dusts.
Bedding
Bedding is an important source of respir-
able particles. The most popular alternative
to straw is shavings. However, it is important
that these are dust-extracted shavings. Some
commercially available shavings have high-
er levels of respirable particles than good
quality straw. Rubber matting, cardboard
and shredded paper are excellent dust-free
alternatives to straw and shavings. Deep lit-
ter systems should not be used, regardless of
the bedding type, as these develop high lev-
els of fungal and mould contamination. The
horse should be removed from the stable
during and immediately after mucking out.
Surrounding environment
Ideally, adjacent stables should be man-
aged similarly. However, if this is not pos-
sible, changing the management of one
stable can still have significant benefits.
The stable should not be in close proximity
to the storage of hay, straw and manure.
Ventilation
Adequate ventilation is essential to remove
airborne respirable particles and noxious
gases, and the simplest way to achieve this
is to provide an air outlet at the back of
the stable. However, ventilation alone does
not fully remove the dust challenge from
the breathing zone and the other manage-
ment changes described above must also
be implemented.

SUMMARY
RAO and IAD are both disorders characterised by
increased mucus and inflammatory cells in respira-
tory secretions. Horses with RAO tend to have obvious
clinical signs and evidence of airway obstruction at rest.
In contrast, horses with IAD frequently have no obvi-
ous clinical signs at rest, and may only show reduced
performance. It is currently unclear as to whether
IAD and RAO represent two separate clinical
disorders or whether they are a continuum of airway
inflammation.
Certainly, at the two ends of the spectrum, diag-
nosis is relatively straightforward, but there is a
‘grey area’ between the two disease syndromes where
diagnosis becomes more difficult. For example, does
an older horse with poor performance, increased
tracheal mucus and occasional cough have mild
RAO or IAD? At present, the answer to this ques-
tion may be largely academic as the treatment of the
two conditions is similar. This is, however, an area
that requires further research in order to improve
our understanding of the relationship between these
conditions.
Acknowledgements
The authors would like to thank Tim Brazil for his advice in editing the draft manuscript, and
Henry Tremaine and Mark Pinches for providing the photographs used in this article.
References and further reading
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cytology analyses in racehorses with respiratory disease. Equine Veterinary Journal 30 (Suppl), 77-82
COUETIL, L. L., ROSENTHAL, F. S., DENICOLA, D. & CHILCOAT, C. D. (2001) Clinical signs,
evaluation of bronchoalveolar lavage fluid, and assessment of pulmonary function in horses with
inflammatory respiratory disease. American Journal of Veterinary Research 62, 538-545
DURHAM, A. (2001) Update on therapeutics for obstructive pulmonary diseases in horses.
In Practice 23, 474-481
FAIRBAIRN, S. M., LEES, P., PAGE, C. P. & CUNNINGHAM, F. M. (1993) Duration of antigen-induced
hyperresponsiveness in horses with allergic respiratory disease and possible links with early airway
obstruction. Journal of Veterinary Pharmacology and Therapeutics 16, 469-476
GERBER, V., STRAUB, R., MARTI, E., HAUPTMAN, J., HERHOLZ, C., KING, M., IMHOF, A., TAHON,
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RAO and IAD: respiratory disease in horses

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Kate Allen and Samantha Franklin

In Practice 2007 29: 76-85

doi: 10.1136/inpract.29.2.76

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