Bleeders - facts- fiction - future - treatment - of exercise-induced haemorrhages

By Dr. David Marlin

We are now approaching half a century since Bob Cook pioneered the use of the flexible fibreoptic endoscope, which allowed examination of the respiratory tract in the conscious horse. One of the important outcomes of this technique was that it opened the door to the study of “bleeding” or exercise-induced pulmonary hemorrhage (EIPH).

But nearly 50 years on the irony is perhaps that whilst we have become good at describing the prevalence of EIPH and some of the factors that appear to increase the severity of EIPH within individual horses, we still lack a clear understanding of the condition and how to manage it.

I use the term manage rather than treat or prevent as our knowledge of EIPH must show us that EIPH cannot be stopped entirely; it is a consequence of intense exercise. The other irony is that in the past 50 years, by far the majority of research into the management of EIPH has focused on the use of the diuretic furosemide. Whilst we have good evidence from controlled studies that furosemide reduces the severity of EIPH on a single occasion, we still lack good evidence to suggest that furosemide is effective when used repeatedly during training and or racing; and there is also evidence to the contrary. Let’s review some basic facts about EIPH, which should not be contentious.

• EIPH is the appearance of blood in the airways associated with exercise.

• EIPH occurs as a result of moderate to intense exercise. In fact, EIPH has been found after trotting when deep lung wash (bronchoalveolar lavage or BAL) is done after exercise.

• EIPH most often involves the smallest blood vessels (capillaries) but can sometimes and less commonly be due to the rupture of larger blood vessels.

• The smallest blood vessels are extremely thin. Around 1/100th the thickness of a human hair. But this extremely thin membrane is also what allows racehorses such as Thoroughbreds, Standardbreds and Arabs to use oxygen at such a high rate and is a major reason for their athleticism.

• EIPH is a progressive condition. The chance of seeing blood in the trachea after exercise increases with time in racing.

• EIPH is variable over time, even when horses are scoped after the same type of work.

• If you ‘scope a horse after three gallops in a row, you can expect to see blood in the trachea on at least one occasion.

• EIPH damage to the lungs starts at the back and top, and over time moves forward and down and is approximately symmetrical.

• Following EIPH the lung becomes fibrotic (as scar tissue), stiffer and does not work as well. The iron from the blood is combined with protein and stored permanently in the lung tissue where it can cause inflammation.

• High blood pressure within the lung is a contributing factor in EIPH. Horses with higher blood pressure appear to suffer worse EIPH.

• There is also evidence that upper airway resistance and breathing pattern can play a role in EIPH.

• Airway inflammation and poor air quality may increase the severity of EIPH within individual horses.

• Increasing severity of EIPH appears to have an increasing negative effect on performance.

• Visible bleeding (epistaxis) has a very clear and marked negative effect on performance. In order to make progress in the management of EIPH (i.e., to minimize the severity of EIPH in each individual), there are certain steps that trainers can take based on the information we have to date. These include:

• Ensuring good air quality in stables • Regular respiratory examination and treatment of airway inflammation • Reduced intensity of training during periods of treatment for moderate to severe airway inflammation

• Extended periods of rest and light work with a slower return to work for horses following viral infection

• Addressing anything that increases upper airway resistance (e.g., roaring, gurgling)

• Avoiding intense work in cold weather

• Avoiding extremes of going

• Limiting number of training days in race preparation and increasing interval between races.

FUTURE OPPORTUNITIES IN UNDERSTANDING AND MANAGING EIPH

We have to accept EIPH as a normal consequence of intense exercise in horses. Our aim should be to reduce the severity to a minimum in each individual horse. However, there are areas in which we still need a much greater scientific understanding.

What actually causes the capillaries to leak or rupture?

If you ask any vet, scientist or informed trainer what is the cause of EIPH, they will give the phrase “pulmonary capillary stress-failure”. But this is simply a description of what happens—NOT an explanation or a mechanism. EIPH and pulmonary capillary stress-failure are both descriptions of what’s happening. We know high blood pressure makes the capillaries stiff. But what makes them actually rupture? A balloon filled with water may be distended and under a lot of stress. But a pin prick will actually make it burst. The pin is the cause.

Assessing EIPH

At present the most common way to assess the severity of EIPH in horses in training and racing is by ‘scoping 30-40 minutes after exercise and scoring the amount of blood in the trachea. This is a crude method, and when we see a horse that has a score of 1 after one gallop and a 3 after the next gallop, we don’t know whether this is due to differences in how quickly the blood has moved from the periphery of the lung into the trachea or due to a true difference in the amount of bleeding. We know our ‘scoping scores vary from gallop to gallop; we just don’t know why.BAL (deep lung wash) is not the answer either. It will pick up blood when there is none to be seen in the trachea (i.e., it’s a more sensitive technique), but with BAL we are looking atrelatively small areas of the lung. What we need is a technique that will allow us to image the whole lung and map the blood that is in the airways and not in the blood vessels so we can assess volume and distribution of hemorrhage.

Furosemide is not the answer

A number of well-conducted and well-written scientific studies have shown conclusively that furosemide is effective in reducing the severity of EIPH in individual horses when used ONE time! We lack convincing studies that prove furosemide works as well when used one to two times a week for two to three months. In fact, several studies suggest that furosemide becomes less effective with regular use, such as the return to previous performance of horses after initial racing and improved performance on furosemide. In human medicine, repetitive administration of furosemide induces short-term (braking phenomenon, acute diuretic resistance) and longterm (chronic diuretic resistance) tolerance (i.e., if you give the same dose repeatedly, the body becomes tolerant and you get less and less urine production). A study in horses from Michigan State University in 2017 showed horses develop tolerance to furosemide. Why, when we have had nearly 50 years of research into EIPH with more published studies devoted to furosemide than any other aspect, do we still not know if furosemide is effective when used on a regular basis?

Is EIPH really blood?…

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Australian EIPH report - new research on the impact of EIPH from an Australian perspective but with worldwide implications

By Guy Lester and Ellie Crispe

Exercise-induced pulmonary hemorrhage (EIPH) is a common disease of racehorses. The precise cause of EIPH is yet to be fully determined, but a well-accepted theory is that lung blood vessels rupture in response to the extremely high blood pressure and low airway pressure experienced during strenuous exercise. The barrier that separates the airway from the blood vessels is ultra-thin to facilitate the efficient exchange of gases, but this predisposes to breakage. The condition is most frequently described in Thoroughbred and Standardbred racehorses, but it has also been identified in racing Appaloosas and Quarter Horses, as well as horses involved in other high-intensity athletic activities, including showjumpers, 3-day eventers, barrel racers, steeplechasers and polo horses.

EIPH is not unique to horses and has been reported in human athletes, as well as racing greyhounds and camels. Our group at Murdoch University in Perth, Australia has had an interest in EIPH, which has led to three recent publications in the Equine Veterinary Journal.1-3

How common is EIPH?

Blood from both nostrils—also known as epistaxis—is the most obvious manifestation of EIPH and occurs between 1.5 and 8.4/1000 race starts, varying with racing jurisdiction. Epistaxis represents a severe manifestation of EIPH, and basing surveys on its presence vastly underestimates the true prevalence of lung hemorrhage. There are several techniques used to diagnose EIPH, but endoscopy of the trachea 30-120 minutes after racing or galloping is a common and reliable method. Occurrence and severity of pulmonary hemorrhage is typically graded using a 0-4 scale. Using endoscopy, we reported a prevalence of EIPH post-race in Australian Thoroughbreds racing on turf tracks of around 55%, with most positive horses having low to moderate volumes of blood in the trachea. EIPH is less common if horses are examined after trialing and reduced further if examined after track gallops. The prevalence of EIPH increases when horses are examined on multiple occasions after racing; and in fact, all horses in our research population that had seven monitored race-starts experienced EIPH on at least one occasion.

What is the effect of EIPH on race-day performance?

It is generally considered that EIPH has a negative impact on racing performance, but evidence for this assertion is surprisingly lacking. We performed 3,794 post-race endoscopy exams on over 1,500 Australian horses and reported that inferior race-day performance was limited to horses with severe EIPH (grades 3 and 4); this reflected only 6.3% of all examinations. Horses with the highest grades of EIPH (grade 4) were less likely to finish in the first three, finished further from the winner, were less likely to collect race earnings, were slower over the final stages of the race, and were more likely to be overtaken by other competitors in the home straight than horses without EIPH. Interestingly, horses with EIPH grade 1 or 2 were more likely to overtake others in the home straight, compared to horses without EIPH (grade 0). It is highly unlikely that low-grade EIPH (grade 1 or 2) confers an athletic advantage; a plausible explanation is that horses that are ridden competitively to the finish are functioning at their maximal physiological limit, compared to horses that are eased up and overtaken during the finishing stages of the race because they are not in prize contention or are affected by interference in the home straight. Another interesting finding was that horses with moderate to severe EIPH (grades 3 or 4) raced the early and mid-sections of the race faster than horses without EIPH. It is possible that these horses reach the breaking threshold of the small lung blood vessels at an earlier stage in the race compared to horses that start the race slower, compounding the severity thereafter. A study of barrel racing horses reported that horses with the most severe grade of EIPH were faster than horses without EIPH, a finding which may also reflect this rapid acceleration increasing the risk of EIPH. It may be wise for trainers to instruct jockeys riding horses with a history of moderate to severe EIPH to refrain from racing in this manner.  

What is the effect of a one-off diagnosis of EIPH over a horse’s career?

A pattern of increasing endoscopic EIPH severity over a racehorse’s career is suspected but has not been proven. Another Australian research group examined 744 Thoroughbreds post-race with endoscopy, looked back 12 years later and compared EIPH score to their career performance. There was no association between any grade of EIPH and career duration, lifetime earnings, or the number of wins or places. These observations led to the conclusion that a one-off diagnosis of EIPH is an unreliable predictor of overall career performance.

Is EIPH a progressive disease?

EIPH is typically described as a progressive disease, but again, evidence is lacking. In our Australian Thoroughbred population, EIPH scores were often erratic from one race start to the next, especially as the EIPH severity increases. We were able to identify factors which were associated with change in EIPH score from one race start to another and which might help manage horses that are prone to EIPH. Increasing the number of days between races was associated with a transition from a higher to a lower grade of EIPH and racing in cooler weather was associated with a transition from a lower to a higher EIPH grade at the next observation. There are also likely to be unmeasured intra-horse and race factors that could also account for the variation in EIPH scores from one race start to another. Although in individual horses, EIPH severity can differ from race to race, from a population perspective, we concluded that EIPH is a mildly progressive condition.

What are the risk factors for EIPH?

Several investigators have found an association between temperature and EIPH. Cold weather on race day increases the chances of diagnosing EIPH and increases the chances of diagnosing more severe grades of EIPH. Furthermore, for horses that previously had no or only mild EIPH, racing in colder weather was more likely to be associated with a worsening of EIPH grade at the next observation. The reason that EIPH worsens with cold weather is unknown, but this phenomenon could mimic cold-induced pulmonary hypertension reported in other species. It may reflect the ambient temperature during training rather than specifically the temperature at the time of the race. Avoiding cold weather during training or racing may reduce the risk of EIPH in horses with a history of moderate to severe EIPH.

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Does bleeding affect performance? Results of a ten year study

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Do bleeders breed bleeders?

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Sid Fernando (25 July 2011 - Issue 21)