Hello and good evening, everyone, and thank you very, very much for joining us for this month's monthly nurse webinar. So tonight's presentation is on aspiration pneumonia and will be presented by Katie grey. Katie is currently appointed as senior Emergency and critical care nurse at the Royal Veterinary College, where she's been since late 2012.

Katie's favourite cases are those who are critically unwell in the ICU, especially septic patients and those on mechanical ventilation. Katie spent 3 years on the BSAVA Metropolitan Committee. She has written several articles for the venue publications and regularly speaks to vets and nurses on emergency and critical care topics.

She achieved her PG certificate in veterinary education at the RVC in 2020 and is studying towards a diploma in therapeutic integrative counselling. In her spare time, Katie enjoys spending time with her two spaniels, a Flo and Martha, a cat, Hendrix, and gardening with her ducks. So if anyone has any questions for Katie, if you could pop them in the Q&A box at the bottom, and we'll get to them at the end.

So, over to you, Katie. Thank you very much and thanks everyone for joining us. So yeah, this evening we're gonna be talking about aspiration pneumonia and how we can look after our veterinary patients.

So looking at some learning outcomes, hopefully after this evening's talk, you will understand the different types of pneumonia that we might see in veterinary practise. We'll go through the patients that will have an increased risk of contracting aspiration pneumonia, such as our brachycephalic patients. We're also gonna talk about diagnosing aspiration pneumonia and then going through the different treatments that are required by those patients, and then we're gonna finally talk about how best to nurse them.

So firstly, what is pneumonia? So pneumonia is just inflammation of the lung tissue which is normally caused by infection. And your alveoli, if you can remember your physiology, just fill up with fluid, and sometimes this fluid can be purulent.

Aspiration pneumonia and pneumonias in general can be both primary or secondary disease, and that just means that it is the first condition that that patient has presented with, or it's a condition that that patient has contracted secondary to something else, so like another underlying pathology that's making them unwell. It's possible to get pneumonia from an infectious cause such as kennel cough, and it's also possible that a patient might develop a pyothorax from a pneumonia, if that is severe enough. We can see pneumonias both virally and also bacterial, and it's also possible that patients will acquire pneumonias whilst they're with us in hospital for various reasons.

Some of that might be acquired under general anaesthesia, and some of them may acquire it while they're being ventilated, so we can see a ventilator acquired pneumonia as well. So obviously this evening we're gonna focus on aspiration pneumonia, and this is when fluid that has been brought up from the patient through either coughing or vomiting or regurgitating is then inhaled and unfortunately causes the infection in those lungs. It happens a lot, obviously, with our recumbent patients because they're not able to position themselves in a good way in order to keep that airway safe.

And we'll go through some of the different patients that are obviously at an increased risk of that, but those do include geriatric, obese, and brachycephalics. We talked a little bit just then about how we can see these patients acquire it in hospital. We have done some studies on this, and some of the veterinary studies and literature do show that up to 26% of aspiration pneumonia cases in veterinary hospitals have acquired that after having a general anaesthetic in the preceding sort of few days.

Aspiration pneumonia also is typically bacterial and that's obviously because if you think about those gastric contents coming up that is obviously dirty and there's gonna be lots of bacteria in that, so we do see bacterial aspiration pneumonia, most commonly. So now that we've been through those quickly, those different types of pneumonia, we're gonna go through our increased risk patients. So firstly, our brachycephalics, and we are all seeing and obviously this huge increase in demand for brachycephalic pets, and so we're seeing a lot more pugs and bulldogs.

Some of our big breeds of dogs as well are Do Bordeaux and our mastiff, we're seeing a lot more brachycephalic mastiffs as well. And so, And also not forgetting our cats, our little Persian cats. They're also becoming much more popular.

And I think because of this, we're also now going to see sort of a rise in aspiration pneumonia patients, unfortunately just due to their poor confirmation. So it's something I think we're all going to get much more used to seeing on a day to day basis. And this is because most brachycephalics, that we'll see in hospital will suffer from a degree of brachycephalic obstructive airway syndrome, which we'll discuss on the next slide.

They'll also commonly have hiatal hernias, many, many other congenital abnormalities, and because of that, they are a huge risk of aspiration pneumonia, both in a primary sense and also secondary to having any of those other problems, that they might present with. Once they've also been in the hospital, they're also more likely to have several more complications, whether that be associated with their pneumonia or associated with something else. So brachyphallic obstructive airway syndrome typically consists of four sort of things that will tick off our list.

So the first being stenotic nares. And as you can see in this patient here on the right hand side, these nares are barely even in existence. There's basically no.

Air flow through there at all. They also will typically have an elongated and a thickened soft palate. They'll have short nasal cavities, and we all can see that with these patients, you know, they don't have a very long nose at all, in comparison with our, docio and mesocephalic, .

Oops sorry about that. Patients and so they have sort of limited airflow through that as well. And then that space that they do have unfortunately is filled with the most enormous tongue.

So, they're really sort of in a bad state when it comes to their airway. They also, because of this, have increased negative pressure. So in each breath, this negative pressure will cause them to have an increased chance of regurgitating and vomiting, and that's why we see a lot of these patients have regurgitating or vomiting post anaesthetic or post anything else really.

They get it as secondary to a lot of different complications, in veterinary practise. Due to that, they have reduced capacity to recover from GA, or any other procedure that we typically do. And overall they have a decreased morbidity and mortality as well.

So they're just a really tricky patient to look after. The other high risk categories that we might see are at two ends of the scale. We'll have our geriatric patients who are quite likely to be recumbent or just at least have difficulty mobilising if they have osteoarthritis, etc.

And they might also be more prone to other illnesses. They could have slower reflexes, more comorbidities, and if we're thinking about our, sort of like our older Labradors, that present with our laryngeal paralysis, you know, those kind of cases are also at increased risk of contracting aspiration pneumonia. And on the other end of the spectrum we have our neonates, so, patients that might require assisted feeding, especially if they've been at home, and a member of the public has been trying to feed them.

We see a lot of cases of aspiration pneumonia through goodwill and having to, having to Feed them through a syringe. These patients are recumbent, you know, they're not up and mobilising, as an older patient would be. And also these patients might have a congenital abnormality such as cleft palate, which again would further increase the likelihood of them having aspiration pneumonia.

We could also see patients with some neurological disorders, patients that are seizuring, that kind of thing. Patients who may have an immune disorder as well are at increased risk of aspiration pneumonia, contracting infection, due to the, the drugs that they might be receiving, and patients that might have had inadequate vaccination or a parasitic infection which then could cause a secondary bacterial infection as well. We should also be thinking about patients at increased risk with a tracheostomy tube in hospital, and patients with megaesophagus have been shown to represent over 25% of our veterinary patients with aspiration pneumonia.

So we're just gonna go through now how aspiration pneumonia is diagnosed in practise. The first thing that we're probably going to do is have a physical exam of these patients when they come into us. And initially we might think that because this is an infection, that all of these patients are going to be pyreexic, but actually, more than half of these pneumonia patients are afebrile, so it's not something that we can rely on in terms of, well, it's definitely, you know, got aspiration pneumonia if it's pyreexic.

Lots of patients that will present with pneumonia have a soft cough, although cats like to be difficult, so they tend to not present with a soft cough. We'll expect to see a lot of canine patients with a mild dyspnea, but cats, again, sometimes will just show no respiratory signs whatsoever until they're really, really late in that disease process. The more common signs that these patients will present with frustratingly are these waxing and waning, sort of lethargies and inappetents, things that really you can't associate with anything in particular, sort of a general unwellness, but we could see patients presenting with a nasal discharge that might be purulent.

And a lot of patients will have a predisposing disorder that we've just discussed. So it has been shown in studies that about half, half of dogs that present to us will have a concurrent disorder alongside it as well. Because of this waxing and waning sort of physiology that they've got, they might have an acute weight loss, and their mentation is important to observe sort of when they arrive.

But again, this can be really, really difficult to judge because some patients will arrive wagging their tail, absolutely happy as Larry, have no clue that they're sick, and some of them again later on in the disease process might actually be obtunded testsuperus. We would expect most of our aspiration pneumonia patients to at least be a little bit kipnik, and that does go for cats and dogs. They might have an increased respiratory effort, so we might just be seeing a little bit of an abdominal component to their breathing.

Some patients will present to us with a cough, and this could be moist or dry. We will sometimes do a tracheal pinch, just as you would do in a kennel cough, patient, but this again is inconclusive really when we're talking about pneumonias. And then the most important part of our physical exam really for a patient coming in with any sort of respiratory disease process will be our aussultation of, of the lungs.

And 90% of dogs will have an increased breath sounds, crackles or wheezes on aussultation. And although that's not specific to aspiration pneumonia, and that's not something that our vets can diagnose aspiration pneumonia off, if those sounds tend to be more cranioventral areas, then that is more likely for aspiration pneumonia just because that's the area that is most affected by, by when these patients aspirate. Obviously we want to be speaking to these owners and just seeing if we can get a really full history.

We're seeing a lot of patients coming in now from other countries, and lots of European imports which might have come over with sort of different parasitic controls that maybe aren't up to date. We to be checking their vaccine histories in case they might have distemper because we have seen a few cases of that, and I think that's gonna be more common. And so just so that we know not only really for that patient, but also considering our other patients in the hospital, making sure we've got really good barrier nursing protocols in place for these guys.

And then kind of the most important question really when speaking to any owners is to ask when was that patient last normal? Because I think as an owner, they can get a bit confused with, clinical signs and when things started to go a little bit wrong. They first started to worry about them, but if you can ask a an owner, when was the last time that your cat or dog was completely normal, they tend to to have a date in mind for that, which just gives you a really good idea about how long this pet might have been unwell for.

So the next part will obviously be our imaging. So once these patients have been admitted into the hospital, we'll take some images, first of which will probably be some radiographs, we might also do an ultrasound scan, and then sometimes, but not that commonly, we could put these patients in a CT or an MRI scanner, but it's not normally necessary. And when we're looking at our radiographs, we want to do 3 views, so making sure we're taking both sides of the lateral and DV and looking out for alveolar opacities, consolidation and interstitial patterns.

And then in aspiration pneumonia, you'll often see that it's the right middle lung lobe that's affected and the ventral part of other loads, again because of the way that patient has aspirated and has been lying. And moving on to our point of care ultrasound scans, these are obviously very non-invasive. We can do this with the patients sort of stood on the table or on the floor with their calmest on the floor, and they're quite cheap to run and they just give us a really good idea of what's going on in this patient.

And when our vets are scanning the the dogs and the cats, just kind of knowing a little bit more about what you're looking at is just really helpful and also just makes lives more interesting. And so when we are having a look at the scan of the thorax, you'll typically see this image here and what we're looking for here is obviously these black lines that go vertically down. They're just the the shadowing of the ribs.

So that's a completely normal line to see. The other lines that we want to look at are A lines, and again these are completely normal, and these are just kind of like horizontal white lines that go along sort of this way, and they just indicate normal lung tissue. And then you might have heard people talking about bee lines, and these are sort of white shadowy lines that again go vertically, and they indicate some kind of lung pathology.

So whilst they're not indicative indicative of anything in particular, they do tell us that something abnormal is going on within that lung field. And then the next thing that we look at with our thoracic ultrasound is looking for a glide sign. And this isn't specific to aspiration pneumonia, but this is what we use in order to rule out a pneumothorax.

And a glide sign is just looking at this bright white line here, and every time this patients Breathing, you should see this white line sliding across. And that's the lung tissue with the pleura, just meeting there. So, obviously, a lack of that line, would indicate that that lung tissue isn't meeting that pleura, visceral pleura.

So you, you might have a gap there, which would indicate a pneumothorax. So once you've done our imaging, we'll move on to doing a little bit of blood work. Typically we might send off a full CBC and biochemistry to the lab, and what we'd be looking for there would be a neutropenia or a neutrophilia with a left shift, and this would just indicate systemic inflammation.

Other bloods that our vets might consider sending off to the lab would include some biomarkers. And you may have heard of CRP or you might test for that really regularly in your practise. It's quite non-specific, but C-reactive protein just monitors trends of inflammation in a patient and can provide really good prognostic information if we do it often enough.

It's used really regularly in the human field to measure inflammation and prognosis, and I think it is becoming much more common in our veterinary patients as well. The most helpful blood work that we can do with patients with pneumonia is an arterial blood gas, and this is so that we can monitor trends in partial pressures of oxygen and carbon dioxide, and we can do this quite quickly and regularly. So therefore we can see how our interventions might be helping the patient.

So if we've got a patient and we take an arterial blood gas sort of soon after admission, and we start oxygen therapy, for example, we can then take another blood gas later on that day and see if that oxygen therapy is doing enough to support that patient through it or whether we need to make any further interventions there. When we have a patient with aspiration pneumonia, it's really common that they'll be hypoxemic or hypocapnic. They'll have an increased alveolar arterial gradient, and I'll speak a little bit more about that calculation later.

It's less common to see a hypercapnia that's an increased CO2. But if you do see that on these patients, it suggests that that patient's becoming quite tired, really fatiguing, and maybe we need to be thinking about how we can support them better. So then, in order to diagnose which bacteria we've got present, we're obviously gonna have to take some samples and so our vets will have a decision to make about how to do that.

Some of the things that we might look at are tracheal washes, and there's two ways of doing that. So we've got our endotracheal wash, which is obviously down the endotrareal tube, and we've got a transtrareal wash which is just through the skin into the trachea, as you can see in these photos. They prefer to do endotracheal washes in smaller patients because it is really minimally invasive.

But in dogs, a trans tracheal wash is as sensitive as doing a lung aspirator or a BAL to diagnose pneumonia. And the way that that works is you have the patient normally a little bit sedated, so maybe some butrophenol or something, just to keep them really calm, and then just a little clip patch over the trachea, really good scrub, obviously you prep that. And then using an IV catheter normally.

They will introduce that styler into the trachea, take the styler out and instil some saline and draw that back out, and then they'll send that off to the lab. And the reason I've got oral swabs here with a question mark is that I think sometimes these are still used in terms of diagnosing which bacteria are present in order to choose an antibiotic, but, taking a swab from a mouth, you know, you're always gonna get lots of bacteria. Cats, cats and dogs' mouths are quite dirty, so it's not a very clear cut diagnosing tool.

We also could have these patients considered for a bronchoalveolar lavage, so a BAL. And the reason that our vets might want to do this would be to obtain a larger sample than a transtracheal wash, which they could send off for bacterial culture and sensitivity. However, this does need your patient to be a little bit more stable.

It obviously requires a general anaesthetic to do, and there have been studies to show that there is a small decrease in lung function sort of shortly after the BAL has been performed. So it's not something that we would do in our most critical patients. We'd have to wait until they're a little bit more stable.

In humans, they use BALs to diagnose between pneumonia and pneumonitis, but we do not tend to differentiate between those and our veterinary patients, we just tend to treat them all the same. So now we're just gonna talk about some treatment options available. So the first thing that we think of when we've got this infection will be our antibiotics.

And they should always be based on a culture test. So, gone are the days where I think we would just give antibiotics, off the shelf, without really thinking about it. We obviously want to Be promoting sensible use of antibiotics.

And so taking those samples first is really important. And then once that's been done, we could start broad spectrum antibiotics in order to cover sort of the widest range of bacteria until we've got those results back. It is also possible that our vets might want to look at cytology of those washes in-house, and that could provide us some answers while we're waiting on the lab results as well.

If the patient is worsening and they've been started on broad spectrum antibiotics such as amoxicabb or . Absolutely mind blank. Mic lab, then, we could see that other antimicrobials introduced and repeat airway sampling done.

And it's interesting to see that actually some antibiotics will work much more effectively in respiratory patients than others. So our cephalosporins and penicillins actually have really poor penetration, unless there's a huge amount of inflammation present. Whereas our fluoroquinolones will actually, penetrate and reach therapeutic levels much more quickly in bronchial secretions.

And so those actually might have a more favourable opinion, for our vets over the cephalosporins. The next drug of choice we might want to look at could be antiemetics. As we talked about previously, many of these patients will have regurgitation or vomiting signs because they might have a concurrent disease process.

That might be why they've already got this aspiration pneumonia in the first place. And so we want to try and prevent them from regurgitating or vomiting further or just feeling sick. So, we would consider to start a metoclopramide continuous rate infusion.

We tend to do that over bolusing, because it just provides a more therapeutic level, obviously throughout the 24 hour period, and that we use to promote gastric emptying. Mirropotin is the first line antiemetic that we would go for, and we can use this in a variety of ways. So we can give it IV if our patient's sick enough, because it can be a bit stingy to give subcut, and we'll give that once a day to try and prevent them from vomiting.

However, if they are really feeling really poorly and they're still vomiting or feeling nauseous through that, then we could consider introducing on Dansetron, and this can be given twice a day, and we'd also look at giving omeprazole to these patients twice a day too. And moving on to our fluid therapy, lots of these patients may have been anorexic for a while or hypoorexic, and they might have been quite poorly for a few days. So these patients will often require at least some intravenous fluid therapy.

Once we've taken our blood samples, we might have seen that these patients have electrolyte abnormalities, and so we can always supplement our fluids with some potassium or glucose if it's required, which is just a really nice way of trying to correct some of those. We could also consider nutrition as well. So parentinal nutrition is something that, we probably don't do enough in our veterinary patients, but it is quite readily available to us.

I do think it's quite expensive, so that's probably a limiting factor. But if we're thinking that these patients actually haven't eaten for a few days before they come into us and maybe we're looking at them and they're not going to eat for a while, it is something to consider, at least while we're discussing maybe placements of feeding tubes and things. So moving on now to our oxygenation assessment, which is probably our most important thing when we're talking about pneumonia.

We want to assess the partial pressure of oxygen in the blood gas, and it needs to be an arterial sample. There is no point in looking at that on a venous sample at all. A partial pressure of oxygen should always be above 95 millimetres of mercury in a healthy patient, and under 90 just indicates it's a hypoxemia.

And to give you some kind of idea about what that looks like in, in our veterinary patients, that would be equal to about an SPO2 of 95% or less in a patient on a pulse ox. So it is quite easy, I think, with pulse oximeters to not really believe the numbers. They're obviously not the most reliable piece of equipment that we have.

But just So if you are trusting a waveform and you're using that to follow trends, that just knowing that an SPA 2 of 95 or less is, is hypoxic, and is important to watch. And a severe hypoxemia, so talking about less than 60, is actually equal to 90% on a pulse oximeter. So, below 90, really, we were very, very worried about our patients.

And earlier I did mention the AA gradient. So this is the difference between the partial pressure of oxygen in the alveoli and the actual partial pressure in the artery. And it's just useful again for following the trend in a patient with respiratory problems.

Over time you'd hope that that AA gradient would improve, and if you're interested in that calculation, it, is in one of the references at the end, so I can point that out for you. Another calculation that we do quite regularly is working out our PF ratio. And in order to do that, we would divide our oxygen number that we're getting on that AR gas sample by the inspired oxygen as a decimal place.

So if that patient was on room air, it would be 0.21, or if that patient was on 50% inspired or 100% inspired, it would be as a decimal. And a value of 20 to 300 would indicate a severe respiratory problem.

And as that number gets gets lower, it is worse for that patient. So under 200 is an acutely life threatening acute respiratory distress syndrome. So you would again, you would do this really regularly with these patients on oxygen supplementation and just checking that that number is improving and not worsening.

So moving on to our oxygen therapy, we're quite lucky, we have a lot of different avenues to go down when we're thinking about how we can supplement oxygen in veterinary medicine. The first one that we tend to think about when emergencies arrive might be some flow by, just some supplemental oxygen, just to keep them a little bit happier while we work things out. And then that would move on to our nasal prongs, which again we can get quite cheaply, and they're just really useful as long as we're making sure we're humidifying the air that we're sending down them.

Nasal cannula is kind of the next escalation there, as seen in this lovely little cocker spaniel. So we can place those either in a single nostril or bilaterally depending on the patient and and sort of how they're doing. One of our least invasive oxygen therapies would be our oxygen kennels, and so actually they're they're an absolutely brilliant investment into veterinary practise, because we can pop a patient in there.

They're very calm, they're quiet areas to be in, and we can give them quite a lot of oxygen into those. Oxygen hoods have been around for a while and I think they've been quite popular in some areas of Europe. So I have seen them in a couple of times in the UK now, as well, and I think that that's something that's definitely going to be explored further.

We also are able to give high flow oxygen therapy, which is kind of a more positive pressure ventilation therapy, and I'll go through that machine in just a second. And then if these patients really aren't doing very well, we want to consider intubating them. We might want to do IPPV and if these patients really aren't doing well, then we might even consider mechanical ventilation.

So without oxygen therapy, you wanna start off with the lowest invasiveness because you want these patients to be as calm as possible. And if that, it means popping them in an oxygen kennel or popping some oxygen prongs on and that really is enough to keep them happy, then that's brilliant. In order to know how they're doing, we tend to look at their clinical response to intervention first, but also monitor their PAO2.

So, taking an arterial sample isn't, pain free. So in a lot of stressy patients, it's not possible for us. So even just putting them in the oxygen kennel or onto the oxygen, whichever method we've chosen, looking at them clinically, so watching their respiratory rate and respiratory effort and their demeanour, we can kind of see if that's doing enough for them, without kind of looking at all the numbers all the time.

If this patient isn't doing as well as we hoped, we would escalate the oxygen therapy as necessary. Oxygen prongs can deliver up to 40% oxygen. Oxygen cannula can deliver up to 60% if they're bilaterally placed, and an oxygen kennel can deliver up to 80%.

High flow and mechanical ventilation can give us up to 100% inspired oxygen, and so these are really invaluable for our sickest patients. And patient stress is a huge factor, so we really only want to do as much as that patient's going to tolerate because it's completely counterproductive to force them into something. It will just make them feel much, much worse, and it will definitely worsen their clinical response.

Some patients will tolerate much sort of more invasive oxygen therapies than others, even if they have the same sort of disease process and physiology. And this is our high flow oxygen machine. So this is the best photo I could get of it, sorry.

But basically, if you can see here, we have a compressor here at the bottom, and this is the oxygen machine here. We have piped oxygen from the wall. And then there's a single use canister which sits in the middle here.

Using water for inhalation, water for inhalation runs through that canister. There's a really wide bore tubing now that runs all the way to the patient. And this is so that this, Oxygen and air that's being delivered is fully humidified until it literally reaches the patient.

So they have specialised nasal prongs that are just much shorter, so that everything that's delivered is really, really humid. And the reason for that is. Because this is positive pressure ventilation.

So the number here on the left hand side is how many litres a minute we're giving. The number on the right is our inspired oxygen, and the number at the bottom in red here is the temperature, which this is humidified to. So that's normally about body temperature.

So the litres per minute can actually go really, really high. And actually when this is put on high for these patients, it really can be quite uncomfortable if the patients aren't aren't sick enough. So sometimes in some places they will sedate some patients in order for them to tolerate it.

It's obviously still much less invasive than a mechanical ventilation and therefore much cheaper, but some patients will tolerate it really well and some patients won't. And so. There it's a, it's a brilliant machine and it's really useful to have in veterinary practise, but it's worth knowing that it it is it's not benign either.

And then once our patients really aren't doing as well as we'd hoped, they will be escalated to mechanical ventilation. So if our patients are doing worse in terms of their hypoxemia, so we will measure our our arterial blood gas and seeing what those numbers are doing. But also if these patients are progressively getting more tired or fatigued or they're really stressed and we can't get on top of that, then for patient welfare, we'll decide to do this.

We will look at trending arterial oxygen samples to indicate what we would do, and we would look at ventilating patients with an arterial partial pressure of under 60. Unfortunately, due to the disease and the severity of the aspiration pneumonia in these patients, they have quite a poor prognosis on the ventilator, when you compare other patients on the ventilator that are on for non-respiratory diseases. And again, mechanical ventilation is not a benign procedure, so there's huge risks associated with it.

We we have to inform our owners that there is a risk of developing a pneumothorax because of the pressure that the ventilator might use. There could be some alveolar rupture. It might be that there could be endothelial damage of the lining of the lung tissue.

We might see the ventilator associated pneumonia. So we do try and keep everything as sterile as possible. All of the procedures that we do on these patients are completely sterile, and we bury a nurse them really, really well, but it's still a risk that they might, come off these ventilators or, or end up with, two different types of pneumonia.

However, it is worth doing and in acute respiratory distress syndrome in people, but also in dogs, it has been shown to be hugely useful and will increase our survival to discharge rates as well with patients with aspiration pneumonia. So now we've gone through and we've looked at the treatment, we'll have a look now on how we can nurse these patients. So as a nurse, we want to be as prepared as possible.

I would always have a suction machine nearby if you've got a patient who has been recumbent and maybe regurgitating or vomiting, and we're worried about pneumonia. Any patient that's in the hospital and we're worried about aspiration pneumonia, we want to make sure we're we're doing all of our techniques as aseptically as possible. So placing our tubes, lines and drains really cleanly.

You want to have good monitoring equipment on standby, make sure that you're writing really good clear notes on the patient's documents and making sure that the lines of communication between yourself and your nursing colleagues and also your veterinary colleagues, are really clear and open so you can share ideas and really know when things are going well or, or if things aren't going as well, because with patients with pneumonia, things can change quite rapidly. Our patient handling is really important, and any handling of any patient with pneumonia or any respiratory distress should be completely minimal. Sedation should always be considered and sometimes butrophenol is enough just to take the edge off these patients in order to facilitate something as simple as an IV catheter placement, if they've just been admitted, or maybe some imaging.

As nurses, we are advocates for our patients. And so just a reminder that imaging is never more important than oxygen therapy. I think sometimes with these patients we might get carried away, especially if they've come in and they've got acute respiratory distress.

understandably, we want to be able to rule out. Anything that we can fix more quickly, such as a pneumothorax or a pleural effusion. But it is not worth sort of forcing a cat or a dog to lie down on an X-ray table if they are in respiratory distress, because it will just make them worse.

So, giving them a touch of sedation is always the way forward. And we always want to have that IV access in case there's any deterioration or if they rest on us. So, just some bunil to take the edge off, just sometimes really helps.

And we've talked a lot about arterial sampling, so I just thought we'd go through the procedure for doing this. And in our cats and dogs we would use our dorsal pedal or our femoral artery most commonly. As with the venous sample, you want to clip the area that you're going to go really well with clean and sharp blades so there's no nicks to the skin.

And then you want to prepare the area with a chlorhex and alcohol swab as you would a vein, but the difference being is you don't want to scrub because that artery might go into spasm and it would be really difficult to take the sample. So just gently wiping it is absolutely sufficient. You want to feel for the pulse with your index and middle fingers, and then with your finger still on that pulse, using an arterial syringe or a 1 mil syringe, you can use a very small needle and insert that needle at a 45 degree angle and watch that hub closely for flashback.

Once you've hit the artery, the artery will fill your syringe. So we normally pre-draw the syringe back to the amount that we're going to need for the machine that we're using, and the artery will fill the syringe, so we don't pull on the artery at all. Once that syringe is full, we'll cap the syringe and apply pressure dressing to the site and go and quickly run our sample.

And then we might take some samples from catheters. So if we're looking at our oxygen, we obviously want to use our artery. But actually if we're looking at maybe our CO2, we can take that and reliably look at that from a venous sample.

So we might take some samples from catheters that we've got in these patients, and I just wanted to highlight the differences between taking a sample from a venous catheter and taking a sample from an arterial catheter. So with a venous catheter, you want to pause any fluids that you've got and you want to clean that port really thoroughly. And then using saline, you might flush between 0.5 mL to 2 mLs of saline into the line depending on your patients size and their sort of fluid ability.

You would draw back on that same port to at least double the volume that you've just flushed in, and that's to avoid having a contaminated sample in the machine. You could save that syringe and keep that sterile, use a fresh to take your sample and then put that previous syringe, which has got that blood and saline back into the patient, and flush that line and then restart your fluids. Taking a sample from an arterial line, if you're lucky enough to have one in your patient, is very, very similar.

So you would stop your measurement of your IVP. You'd flush gently between the same amount, so 0.5 to 2 mLs of saline into the artery, depending on the size of your patient, and then very, very gently draw back to at least double that volume again and keep that syringe.

You then want to take a new syringe, draw back to your predetermined mark and let the artery fill that syringe. And then you want to give that blood and saline back to the patient, but it's really important that you put that back into a vein and not into the artery, and then flush that with saline and restart your IVP. So then also our SPO2 monitoring.

And again, I've already mentioned, you know, sometimes these aren't the most reliable machines. So making sure that if we are using one of these that we are happy that the heart rate is matching the heart rate of the patient and that you've got a good wave form and that it seems really consistent. And I think once you're happy with that, that you can have a look at that number and monitor the trends.

We tend to try and use this on the tongue, that's where it's most useful in our veterinary patients, but we can also use this on the ears or in the interdigital skin or inguinal skin. And as well as having these clips that obviously we use most commonly with our patients with SPO2s, you can also get little disposable ends that are like, they're like plasters that you can use to wrap around maybe a patient's pinna, or in an inguinal area as well, and those can be quite useful. And then attaching our multiparameter monitors to our patients.

So these are becoming much more common in practise, and they're really invaluable to us as nurses. So we obviously want to make sure, looking at our patient, we're definitely observing them with our eyes and our ears, and there's nothing more more important and more accurate than that. But using these multi-parameter monitors, it can just give us a really good indication if something changes.

Quickly, because these patients are not always nursed 1 to 1. We have very busy practises. I think especially at the moment, we're all very busy.

And so it's likely that we're gonna be nursing far more patients than this one patient with pneumonia. And so, by putting a multi-parameter monitor on it, we can just see if the heart rate suddenly drops or the respirate changes, or we have a blood pressure change. We can obviously look at this, monitor and assess a number of different things.

So we look at the heart rate and rhythm, we can look at blood pressure, both invasive or non-invasive. We can put our respiratory rate on there, which can give us a really good sort of eyes view of that. We can look at our SPO2 can also be monitored on here, and also our temperatures as well.

And we can use these on both recumbent patients and patients that are up and about. They might just be a little bit more annoying if they start pulling off their ECG pads, but they are, they are able to be used on a on a variety of patients. And again, we want to be recording these on the hospital sheets and following trends because trends are our most important tool.

The next thing that we want to make sure that all of our patients are getting is some good physiotherapy. And it's really important to introduce that as soon as possible in our patients stay. On average, dogs will stay in intensive care with aspiration pneumonia for about 3 to 6 days.

So that's nearly a week. And actually, if they're recumbent or if they're elderly, they can lose muscle tone really, really quickly. And if that happens, we've not been doing our physiotherapy, then actually we can really prolong their hospital stay before they're up and about and able to go home.

And so by doing some efLage and petrisage and some passive range of movement, we can increase that mobilisation and get them home a little bit quicker. And then thinking as well about our respiratory physiotherapy. So the aims of respiratory physiotherapy is to clear up any secretions.

We want to improve gaseous exchange. We want to increase the lung volume and reduce respiratory efforts. We want to improve exercise tolerance and then prevent any further complications.

Techniques that we might use to do all of that would be to keep our patients really hydrated. So whether that be that they're eating and then they're drinking and they're up and about, that's great, or whether that just be that we're using appropriate fluid therapy. We wanna humidify any oxygen that we're delivering to them.

So if oxygen's being given via nasal prongs, that should be definitely attached to humidifier. Patients in oxygen kennels should definitely have humidified oxygen in there as well. And we, if it's available to us.

Could nebulize these patients as well. And now, little nebulizers, we can get, very, very small nebulizers that are really quiet and very, well tolerated by cats and dogs. And so those are really a useful tool to have a sort of a bedside for our aspiration pneumonia patients.

Other techniques that we might use could be positioning, so making sure that our patients are in a sternal position as best as possible, even just for their front end, so that they're able to expand both of their lungs really fully. If you think about that patient being put into a lateral position, you're going to quickly have that lung on the bottom side collapse and not be very much used to that patient. And if they're already struggling with their, with their lung capacity, and sort of having diseased lungs, then actually you want them to have as much lung tissue functioning as possible.

So just keeping them upright and internal as best you can. Sometimes we might think about doing a little bit of coupage and also hyperinflation. So that would just mean extended sort of inhalations and extended exhalations in these patients in order to increase their lung volume.

And whilst in human medicine they can obviously ask a patient to hold breath hold, sort of on the inhalation and expiration. We can't do that with our dogs and cats. So this is really only possible along with the suctioning with patients who are anaesthetized and possibly on ventilation.

And the best thing that we can do for aspiration opponents in terms of physiotherapy is really to get them up and about as soon as possible. So, this guy was on the ventilator for a few days for his pneumonia, and he, is obviously huge. He was about 60 kg.

He developed some pretty severe edoema in his front legs as well, which I'm not sure you can appreciate on these. Photos. But he was, very, very poorly for a long time.

And so when we wanted him to be up and coughing and moving about, he really was struggling a lot. And because of his general size, we also were just struggling to get him up and about and doing this physiotherapy, and getting him coughing. So, in order to help, we enlisted our, mechanical hoist.

And so once we got him up, we would do this for maybe a few minutes every few hours, get him up in this hoist. And you can see in this first photo, he wasn't always that excited about doing it, and he didn't look like he was putting in much effort, but it did sort of get easier for him, and it would just make him cough a lot and really produce, the mucus and sort of get it all moving, which was really good. And sort of after maybe half a day of doing this to a day, he actually started trying to walk and and sort of went for little trips up and down the corridor in it, to the point where he was doing really well and he went home.

So really getting them up and moving them about is probably the best physiotherapy we can do. And then just general nursing care. So we want to think about TLC.

Obviously these patients have been really poorly for a long time, so we want to just give them as much care as possible. We want to think about oral care, especially if they're not eating and drinking or or if they're recumbent. So, if tolerated, we might just dampen some swabs, maybe with some diluted chlorhexidine and just sort of give their their teeth a good rinse, and all in their lip folds or anything like that.

Keep them as clean as possible. We want to think about eye care, so making sure that we're flashing their eyes regularly and and using sufficient lubrication. The last thing we want is to be sending these French bulldogs home with canneal ulceration as a complication of this.

We want to monitor any ins and outs, so urinary management really important. And whether that be through a urinary catheter that we can monitor their urine output, or even just if they're on vet beds and we're appropriately managing them that way, that's fine. And then obviously knowing our calculations.

So whether that be our calculations we've discussed, in terms of our oxygen demands, or, or our drug calculations, making sure that we are happy that we're, understanding and comfortable with those. So that's it really. So, this evening we've obviously talked about the different types of pneumonia that we see, the predispositions that our veterinary patients might have for requiring aspiration pneumonia, how we diagnose and treat it, and we've gone through a little bit of the nursing care.

So if you've got any questions, I'm happy to ask so. Well, Kasey, thank, thank you very much for that really, really informative talk. I really enjoyed that.

And just kind of seeing like the different, different, things that you, well, different answer but obviously similar things that you guys do compared to a lot of the hospitals. So if anyone else does have any questions, if you would like to pop them into the question and answer box, and then we can, we can put them over to Katie. So I'll give you a few minutes to do that.

So Kasey, in the when you are using the nebulizer or humidifying for or oxygen therapy, what do you use to humidify? Is it just you just use sterile saline or water for injection? Did I hear you say water for inhalation or is that, is that something different?

Yeah, so we have a few different types of things that we use depending on what we are doing for the patients who are going on to oxygen prongs. So we have oxygen ports sort of throughout ICU and we actually buy in now some pre-prepared bubble humidifiers which just contain a saline solution. And previous to that we were getting bubble humidifiers that we would fill up with saline.

So that's So we'd use for those. In the oxygen kennels, they require it to be, water for inhalation. I think because of the saline crystallising in the machine rather than anything to do with the patient.

So water for inhalation is just, a sterile solution that we order, alongside our other fluids, through the same company. And we use that water for inhalation. So, yeah, we use it for oxygen kennels, the high flow machine, and also our mechanical ventilation humidifier as well.

OK, I've never come across the water for inhalation. I feel like that's something I'm going to need to go and investigate when I get back to work tomorrow. So, we've had no questions.

So I think you've clearly you've gone through everything very informatively, and I would, well, yeah, 100%, I would agree there. So I would, so I think we will call it an evening and let everyone and yourself get back to having a little cup of tea and a little rest before you go, get off to bed and prepare for tomorrow. So I would just like to thank everyone for, attending this evening.

I'd like to thank Helen from the web and our vet for doing all the stuff in the background for us. And I'd like to thank Katie again for a really, really informative talk. And, yeah, I really, really enjoyed it.

So I hope everyone has a lovely evening. And yeah, hope to see you all again on another webinar soon. Take care.

Bye.