Hello everyone, it's Anthony Chadwick from the webinar vet welcoming you to another of our evening webinars. We're very fortunate today to have Chris Gomeron on the line who is going to be talking about the use of ultrasound for plural and lung ultrasound. Chris is a Belgian vet.

He qualified from Khent University, and then followed up with a residency in internal medicine. He's a specialist in emergency and critical care and also has a PhD in the topic was systemic inflammation, the effects on the cardiovascular system. He's the past president of the European Veterinary Emergency and Critical Care Society, and he also co-founded the animal blood bank for Benelux.

Really excited to to listen to Chris's talk today, which has been made possible to make it free of charge for all of you listening, thanks to the very kind sponsorship of Butterfly. And we do have David Rousso on the call who will be joining us at the end to help with any questions we might have on this fabulous new technology. Chris, it's over to you.

Thank you very much, Anthony. Hi, everybody. I'm currently in my office in Liege, Belgium.

So, it's still the, the old school type of webinars in which I'm located somewhere and I'm actually looking at my computer screen and I'm completely blinded, so it's almost like a research setting here. Who am I talking to? But I'm very excited to actually be able to talk about, plural and lung ultrasound.

So, yes, first, full disclosure, I am not an imager. If you now want to leave this webinar, this is the moment to, run for it. I'm an internist.

I'm an ECC specialist, and I'm married to a general practitioner. I always say that people always laugh because I very often start talking about what I see in my wife's practise. But I think that is one of the things that drives me most, and the research that I do and the things that I like to work on here at the university, it has always been the aim to try to provide general practitioners with better means to more efficiently take care of your patients.

So that is what really drives me and I always tell my friends that I'm the, the hobbyist in our family, because I work at university and I can have fun doing research and trying to make your lives better. So, David will keep track of any questions that might be there. Feel free to type them and then I'd be very happy to come and go back to them at the end.

I'm notoriously known for not really prepping any notes on my slides. I always say that out loud as well cause I prepare my own slides. Don't worry, those are my slides.

This is what I would like to talk about, but I also want to be able to just Be passionate about what I'm talking and in the end, if you've got questions, go ahead. I don't have to be anywhere else anymore today. So we will see how things are going.

So that's one of my headshot pictures. There are way too many around on the internet. But as I'm one of the past.

Presidents of the European Society of Emergency and Critical Care, I want to start by saying that we have now actually started the Veterinary Emergency and Critical Care Ultrasound Interest Group, which is supported by the College and the Society in Europe of Emergency and Critical Care. And our goals are exactly to promote the use of point of ultrasound. So, hey, this is what I'm doing right now.

We try to advance the knowledge and the competency of vets to perform veterinary point of care ultrasound and we would also like to standardise training programmes. Student's curricula to make sure that we are teaching this the right way. So, you can see how thrilled I must be to be able to talk about this because it's something I'm really, really passionate about.

I really think that point of care ultrasound changes the way we approach our patients. And so I'm an ultra geek and I'm one of this little bunch of geeks who are the, the founding members of this interest group. So we've got Laura Cole who's our president, Maxim Kombernac, who's the vice president, Andrea Armininii, who is our secretary, and then Serron Boysen and myself, we are founding members, .

So we don't have that much to do. And we've played it very well. We can just be supportive.

But we also really like to do research, spread the world, the word, and travel around the world to try and teach this to people. In the meanwhile, I don't work in a fancy place in the UK, in Canada, in the US or anywhere else. I work in Belgium, where we also see dyspneic patients like this little doggy, of which I could have shown you a lot of pictures of his plural and lung ultrasound.

And we have quite a busy hospital. I think we see roughly 4500 emergencies which are mainly referred a year. And that means that I can't start any presentation without showing you the entire team of people we have, which, as it's university is composed by a lot of young, motivated and passionate veterinarians.

We are now 2 specialists, 4 specialists in training, 5 ECC interns, and 5 nurses. For those who work in the Anglo-Saxon regions, yes, we have very low numbers of nurses. We have high numbers of students.

That is one of the biggest fears in our everyday life, but we won't have a debate on the psychological consequences of that. We're here to learn about how actually, point of care ultrasound has changed the way we work at the university because that's one of the things I quite often encounter when I speak with former students or I meet old friends. I think a lot of veterinarians think that time at university stood still.

And so did you think we still train what you have been taught when you were a student? Things really changed quite rapidly in university as well, despite what the general opinion might be for many people. And so, point of care ultrasound has got a lot of different applications.

So this is just a little diagram to tell you all of the choices of topics I could have had to talk to you about part of ultrasound because it is to our humble opinion, very important for initial triage, initial diagnostics, or unstable patients. It is really helpful to guide your treatment in certain circumstances. It allows you to monitor the evolution of patients and it allows you to even screen for complications which may occur.

And this is not just a graph and something that we say to try to convince you while we don't do it. I'm one floor above our ICU in which currently there are 12 ICU patients and we have been using point of care ultrasound for all of the 4 things that I've just been talking about. Whether it was the possible appearance.

Of free fluid in the abdomen on the dog who had a nearly perforating ulcer, where it was to treat a pericardial tamponade and quickly perform pericardial, pericardiocentesis, where it was just to monitor the fluid status of patients. All of those things are things we do on a daily and regular basis. So, And of course, I think the first question that I should try to answer when I do this talk is why did I choose to talk about plural and lung ultrasound?

Especially because Anthony told you that actually my PhD research was more on cardiac function. And now I decide not to talk about volume status, or cardiac function, which are things that I like a lot as well. It's because I honestly think this is one of the biggest game changers for general practitioners.

I think it is more difficult for me to convince you to buy into the idea that with an ultrasound device, you could also assess volume status, fluid tolerance with all of its flaws, nothing is perfect in my life. Besides certain things that I will not disclose, but I think plural and lung ultrasound is actually one of the things that I should be able to convince you over a webinar on why you should do it. And I would start by saying that if you think about the dyspneic patients, Most of you will clearly recognise the patient to be dysphic, but many practitioners will feel an urge to perform medical imaging.

And what I've been taught as well when I was a student, was that in many of those patients, we were going to take thoracic X-rays rather rapidly. And that is because humans are visual beings. I'll go back to the pericardial tympana.

If you think about what you've been taught as a student in your courses, it said you could have pulses paradoxes, you could have decreased heart sounds, you could have distended jugular veins, but all of those things are actually quite rare. The most common clinical finding on a dog with pericardial tamponade in its history. I vomiting.

67% of those patients vomit. Everything else is less frequent. So what you want as a diagnosis, typically, is to be able to see the Tompona with an ultrasound.

That is the thing that will always convince you because now you've diagnosed it. And we are visual creatures and it is what reassures us most of the time. So this is what I used to do when I was just finishing my university degree.

We took radiographs, chest radiographs in lateral recury. And so to the right, I accept it's a bit of a small print, but I just wanted to make you read this little piece of the abstract right here that actually says that when you have patients who are in sternal recurpancy, they have higher PAO2s. They have better oxygenation than when they are in lateral recurancy.

And that is undoubtedly true for your dyspneic patients. Almost all of them will feel better when they can be internal recurancy. Yet, we've been used to Moving them around to the X-ray machine, putting them in lateral rectomy because we wanted to see what was going on.

And I'm gonna try to convince you that doing point of care ultrasound, according to the plus protocol or if you want to do another, another protocol, you can allow the dog to stay in sternal recomposing, remain in its cage where it's receiving treatment, and where it's in a common and stressless environment. And you can come up with probably most of the things you want to know. Because, and this is just based on human medicine, born of care ultrasound has been demonstrated to be really sensitive and specific compared to X-rays to detect pleural effusion of pneumothorax.

It's been demonstrated to be very sensitive to detect pulmonary confusion, and it's been demonstrated that it's useful to detect cardiogenic edoema, pneumonia, or thromboembolism. So, almost all of the things that you would want to see with your X-ray, I'm gonna try to tell you, you can also see that with an ultrasound. I'll already say once more that if at the end of this webinar you're not convinced, but you want to try, I've reached my goal.

Go ahead and start trying it. Just ask yourself, what if from now on, I try to do one of the ultrasound without any stress to the patient and it's perfect position to breathe, and I'll just check. And I'll write on a piece of paper what I think it has, and when I'm still uncertain and I'm quite sure the dog can handle the x-rays or the cat can handle the x-rays and the transport, I'll first do that and I'll start comparing.

And then probably you're gonna figure out that after a year from now, perhaps you're gonna say, I've checked it with ultrasound. I don't need the X-rays anymore. And I'm now at a university where We still take X-rays.

And I'm just saying it out loud because we do research. So I need to be able to demonstrate that we've got ultrasound findings, we've done X-rays, and honestly, most of the time, I wouldn't have bothered taking the X-rays. And very often, we will only do them the next day or two days later when the dog is more stable, the cat is more stable, and there's no risk associated with the X-rays anymore.

Quite sure we've already saved a couple of lives just by changing that habit at our institution. So that's the first thing you should take home. Now, of course, Sir and Boris and Sir Shaloop, and I, yeah, myself, we actually also written this little book on plural space and lung ultrasound, which is supposed to help general practitioners or residents to understand what we think they should look look for when they do plural and lung ultrasound and how to look for it.

And so it really focuses on the plural space and the lungs. Now, I've put lungs in between hyphens because you won't be able to see much of the lungs most of the time. Before you get disappointed, this is actually what makes it so simple and which allows me, being not an imager, to be quite convinced that I can explain you what you need to be looking for.

So, Let's try to convince you furthermore. If we say point of care ultrasound, first basic rule, it's never going to be a complete ultrasound. Our goal will never be to look for the entire pleural space and the entire lung surface to know every little detail that is ongoing there.

We are also not specialists. I've just told you that. We won't clip the entire chest.

We will just part the fur, steal a little bit of the skin, apply alcohol or gel there, and then Try to assess what we can see there. We don't master our device, perhaps to the level that an imager would, and I would like to be able to do the basic things. Just remember, higher frequencies is for superficial things, lower frequencies.

For deeper things, you want to always maximise your window to not be distracted by anything else and have the best possible view of what you're trying to assess and go from this point on in a step-wise manner. You are more than free to take your time and say, OK, this week, I'm starting to get convinced that I can do this. And then you add on things that you are comfortable that you can assess.

And every time we are learning something, that means you need to be able to recognise normal. Think of your veterinary studies. You started with a lot of normalcy, and then when you know what normal looks like, then you can start to recognise the abnormal.

So, we will all promote a standardised approach. Try to put your probe in a transverse orientation, so it actually is perpendicular to the flow of the ribs. If these are my ribs, you put it perpendicular to them, so this direction.

Whenever you do that, you should try to put your probe. Usually, we're gonna use a microconvex probe in between two ribs, and you're not going to see a lot. That's what we will see quite often, but it is true, you won't see a lot.

You will see a rib head, another rib head, and underneath them, you will see a plural line, which is very hyper-echolic line. So it's more hyper-echolic than everything else that's there. And then you might see some a lines, which are just actually repeat artefacts from this line.

The only thing you will see because ribs are bone, so there's just an acoustic shadow here, and here there's just a chest wall. Not the most complicated image in the world, something I would say I'm comfortable assessing. So, in a schematic way, you should recognise what we call as a bet sign.

It's been named after somebody who said it looked like the underneath of a bet. I don't really see that quite often in life. But you could say bone air thorax, BAT bet sign, probably makes more sense to me.

You will see those A lines, which are those repeat lines, and you might recognise a glide sign, which you don't see on the still image because you would need some movement. And the glide sign, if you check here, look for those ribheads and that hyperechoic line underneath is actually moving with respiration. Now, you can see that this is not a perfect still.

People are already moving around it because that will be part of your plural and lung ultrasound protocol that you're actually travelling to a certain place. And whenever you are in doubt, you stop it and you assess and your question is, do I see a glide sign, yes? It's an important thing because it's actually the parietal and visceral pleura that are sliding over each other as the patient is breathing.

Another thing that you will be trying to recognise while you're walking through the chest is what we call the curtain sign. And so on this image here, I'll take the laser pointer again. This line is actually the curtain.

Here you have the hyperchoic line of the plural space. These are all the artefacts generated by the fact that your ultrasound beam is hitting somewhere, and behind it you actually have got abdominal content. So here you do have an image, much more complicated to interpret and thank God, not what we're aiming for.

We're assessing the thoracic cavity. So this is your curtain sign. It means you're now.

At the front here in between the thoracic cavity and the abdominal cavity. The relevance of that, I'm gonna try to explain in a couple of minutes because it's part of why we want to do a plural and lung ultrasound protocol. That is the normalcy you need to recognise to then afterwards be aware of what abnormal looks like.

So things that are abnormal, and I'm gonna glance over some and I'm gonna spend more time over others, are an absent glide sign, so there's no moving with respiration. The lung point, I'll come back to that later. An abnormal curtain sign probably sounds completely unclear.

I will again try to address that later, which are all things that you could associate with the pneumothorax. You will learn how to look for pleural effusion. Of course, very important and abnormal.

If you see that in any patient, it is a concern. And we will try to explain what bee lines are and what the lung consolidations are, which are both different forms of a zone in which there's decreased amounts of air in the lung. So, what are all those things?

That's what you're here to learn, I hope. Again, why a plus protocol and not another protocol? Because I could imagine that you've heard about other terms like the Ramache for quadrant approach, that blue, TFAST, sliding protocols.

There are all different protocols to assess the thoracic cavity. Don't have time to go into the details of all. I will try to explain why I would be a strong advocate of this type of protocol.

And why this is what I want you to do and what I teach to our residents, our interns, and our students. So, whenever you are working in practise, we will always tell you that you need to ask the right question to come up with the right answer. So that means that I think for every patient that you ever encounter in practise, you should try to define the question as precise as possible.

And so, the question you're asking, do I think this patient has got a pneumothorax? Do I think this patient has got a pleural effusion? Do I think this patient has got cardiogenic pulmonary edoema?

They should all allow me to do something different because I also want to have the best complimentary exam that allows me to have the best likelihood to have an accurate answer. So that is one of the reasons why I like this plus protocol because I'm gonna try and convince you to do something slightly different, depending on the questions you're asking. Most of the other protocols, they always do the same thing.

Which is good. It provides a degree of certainty. I always do this in a specific way, but it will be a compromise regarding the sensitivity and specificity if you ask me.

It's very little detail regarding scientific evidence, but I will try to convince you that if you use fixed positions, that means you're gonna compromise with your accuracy of your diagnostic test. And of course, that technique will depend on whether you have fixed positions, yes or no. So, in the plus protocol, you will not start with fixed sites.

You will use landmarks, which means you will try to define what the boundaries of that thoracic cavity are. You will understand where you are with your probe, and you'll dare to move around. So it might be slightly more complicated, but it is as complicated as in a wet lab, we can teach every veterinarian or student to do it within half an hour.

Can't be rocket science. It is something that you master quite rapidly. And so it will be a comprehensive procedure.

We want you to think about what you think is ongoing. So, Chris, put your money where your mouth is. What do you mean?

Well, a dyspic patient enters through your practise. We will always tell you it starts with signalment history, assessing whether it's inspirri or expert dyspnea, auscultating those patients. All of these things remain incredibly important.

And at the same time, you have this thoracic cavity and you're wondering, well, where do I have to look? What are the points? Can I just always put my probe on the same point and it will be good enough?

I would argue it isn't. I would tell you, well, take different scenarios. Based on everything we just discussed, you think this patient might have neal thorax.

If your patient is in internal recumbency, air is going to go up in the thoracic cavity and so you want to dare to go with your probe to the most sensitive spot. So you see the arrow going from the starting point to where we're going to travel to go from a safe spot where probably there will be a normal view and trying to track abnormalities as we increase the sensitivity to find even small cases of pneumothorax. Inversely, if you think your patient has got pleural effusion, we'll do a same similar starting point.

We'll again, go for the curtain sign, which means we now identify the caudal boundary, and now we'll go ventrally and go into those lower pockets where actually that fluid should be sitting. You can see that there are quite weird errors there. We'll come back to that again later on what we can do to even do a maximal attempt to have best sensitivity.

Similarly, if you have a typical patient with aspiration pneumonia and you think it should be the right ventral lobes, sometimes the left ventral lobes, we're gonna use the same itinerary as when we're looking for pleural effusion just to be sure we've checked the most sensitive sites to find significant changes. Finally, sometimes you just have a patient who you think has got some prankable disease. It might even be diffuse primal disease and you want to cover a certain amount of space.

Well, we just have this little S bend that you go and do on both sides of the chest, all of the things I just said, you always do both sides of the chest. When you think about it, here you would start at the same starting point. You would go up to the higher starting point of the S arrow, and then you just make your S arrow with the second and final part is what you did for your pleural effusion.

So it isn't that much more and you can perfectly do this when you think this might be diffuse prancable disease. So, in doing this, we think we have a good compromise regarding the speed at which we should obtain the information. We think we increase the sensitivity to be able to find even mild cases, and you as a veterinarian should actually really know the boundaries, not only the boundaries of what you're able to interpret, but also, OK, where is the most dorsal point of the thoracic cavity?

What is the most caudal region of the thoracic cavity? What is the ventral aspect of the thoracic cavity? And so now that you know where you're at, you probably also are a better ultratographer of the thoracic cavity.

So we think it's a win-win. So, we promised that we would definitely go into the chimal regions, but I think we always need to start with the basics because what can you see regarding the plural space and what can you learn in case of a neat thorax or, or pleural effusion. I think it also is relevant for you to have an idea.

So, if you have a patient that you suspect to have a pneumothorax, there are actually multiple things that you could do that allow you to diagnose it and a couple of things that will allow you to say it doesn't have a pneumothorax based on point of care ultrasound. Again, if you look at this little illustration on the left, we would start on the middle level of the thoracic cavity right behind the scapula. That should be a very safe spot if you've got a pneumothorax.

If you still have a pneumothorax in that region, it must be a really, really, really severe one. And I'll come back to how you probably can suspect that in that situation. I've shown you what a glide sign looks like, that little movement of the plural line.

At the level of the hyperechoic first line under those ribs. And with every inspiration, you should actually see something simmering in it as those two sheets of pleura are actually going one over the other. If you don't see a glide sign, good chance it's got a pneumothorax.

If you recognise a lung point, you know it's got a pneumothorax. You've got an abnormal curtin sign, you know it's got a pneumothorax. A lot of things that will tell you it does have a pneumothorax.

There are also things that allow you to rule it out. If you see a glide sign, there's no pneumothorax at that level. More importantly, if you see bee lines or consolidases, you know the patient should not have a pneumothorax.

And I think that is a sentence that is very often forgotten by people who start to use point of ultrasound to diagnose a pneumothorax. 90% of your clinical cases suspected to have a pneumothorax are trauma cases. So if you think about it, it should never look like healthy lung.

Either you are going to see pleural effusion, which is gonna be rather easy to recognise, you should see beelines or consolidations due to the bruising to the pulmonary contusions. You could even have a diaphragmatic hernia and see organs, but if it all looks like perfectly normal. And the only question I have is, do I actually see a glide sign?

Yes or no? Probably, you should just remember that it's none of the other things. It should be a pneumothorax.

And if you think your patient is dying rather than spending 10 minutes to look for a lung point or an abnormal curtin sign, we will always advocate to just perform a thoracentesis and check whether you get free air, yes or no. That said, Of course, position is incredibly important. If your patient after a trauma is presented in a lateral recompy and you think it's got a pneumothorax, you should always think air is going up.

So don't head for that most card of dorsal spot, but just check where the highest point of the thoracic cavity at that point is because that's where the air should accumulate. That being said, let's try to just go over those typical findings once more in abnormals. So, On the left, you see a still image of a patient who's got a normal air-filled lung and you recognise, I hope, what is normal, the bed sign.

You see those ribs with the rib shadows, you see the hyperchoic line and the repeat signals of those a lines. Normal healthy lung. Unfortunately, on the right.

That is a plumores. And what you see are just the same things. You see two ribheads, the rib shadows, the hyperechoic line, and repeated a lines.

So on a still image, there's no way you can make the differentiation between perfectly healthy lung and neumothorax. However, this is what we call a glide sign. So if you see this lung sliding here, which once more, I'll try to just point out at this height, this is your pleural line and this is the patient breathing out, breathing and breathing out.

Reading and and so you can actually see some movement there with every breath the patient is taking. So you know those two pleural seeds are in contact. This patient does not have a pneumothorax at this level of his thoracic cavity.

Super important to clearly feel comfortable identifying this, not always easy, but when you see it, you're actually almost perfectly convinced there's no pneumothorax at this level. You've seen lung sliding, there is contact. If you lose it, it is a sign of a present pneumothorax, and what is the lung point is actually the transition in between those two things.

So if you look at the proposition here on the left of my screen, it is actually on the thoracic cavity on the level where the lung loses its contact with the thoracic cage. So if the patient breathes in, those lungs will expand and you will see some lungs sliding appearing. As you can see on the single loop on the right, the patient is gonna breathe in right now.

You can see the hyperchoic line passing by. The patient breathes out. It disappears once more.

So this is exactly where you lose contact. And now you know everything above this lung point is pneumothorax. Everything underneath it is still lung in touch, in contact with the thoracic wall.

So this is a perfect diagnosis of now I'm certain this patient does have a pneumothorax. Not always easy to see. Sometimes that lung point can be hiding underneath the ribs, so sometimes you need to slide a little bit up and down, one rip forward, one rib caudally, but if you see it, you now know 100% certain this is a pneumothorax.

There's also one other way to diagnose the pneumataction to be certain it is there. Based on a small set of case series that was reported by Cern Boyce and Jan Tina and myself. If you look very carefully, I was so attentive that I've missed my own last name when we submitted it.

Sometimes we don't pay attention, not important, but it is what we call abnormal curtain signs. I've just shown you those two illustrations, just so you know that they are called the asynchronous skeleton sign, and we are using the accordion because actually what you see is as the thoracic cavity expands, the intestines or the abdominal content seems to move cranial, so you got this accordion-like movement. And the other one is what you call the kabu sign because you would suddenly see whoop, organs appearing in the middle.

And then on two sides, you see a curtain sign. So if you see either of those two things while you're going over the curtain sign which is supposed to just be the transition in between the thoracic cavity and abdominal cavity, this appears to be diagnostic for a pneumothorax. If you get the hang of identifying those things, you will start to feel comfortable that it must be of pneumothorax, and until now, Knock on wood, we've always had the impression that our diagnosis was right.

If we see it, it is there. It is slightly more complicated. I would need to spend more time again to show you a couple of synalos to explain you the rationality before you would feel comfortable, but again, not rocket science in the sense that if we train our interns, I've had a year where the day after the training, an intern came up and said, I saw an abnormal curtain sign, where I was a bit blay thinking like, yeah, well, you're just overconfident.

It's gonna be too fast. It's probably something else. No, he had recorded in loop.

He showed it to me, perfect abnormal character sign, basically with the pneumothorax. He proved me wrong. This is something you can really learn within a day, recognise it with confidence, and we now have training protocols for our interns in which we try to track them, and actually 80 to 90% of interns are confident after a month in their internship to recognise the pneumothoraxs based on abnormal cur sign.

So, again, if you start to follow this training, you follow lecture on it, I'm quite sure you'll be able to recognise them as well. As I already said, if you are looking for pleural effusion, it should sink in the thoracic cavity. So now we're gonna go from a starting point to the curtain sign, and then we're gonna follow that curtain ventrally.

And of course, your diaphragm moves cranially so sometimes again, you need to jump a rib until you come into this pericardial diaphragmatic site in which ideally you should be able to see the heart on one side, the liver on the other. And a little little triangle of plural line in the middle. And this, that's where the magic happens.

You're gonna try to increase your sensitivity by moving your probe from perpendicular to longitudinal parallel to ribs. And now at this level, you jump one rip perinal at a time, looking for a small amounts of pleural effusion. The severely dyspic patient due to pleural effusion, you will not struggle to identify it.

The one who's developing it after trauma, you'll be happy to even see small amounts, knowing that probably shit is about to hit the fan. So it should be able to help you to even diagnose small quantities of hematterra, biothorax, scallathorax, modified transcates, pure transcates. Not for these type of patients in which you see large quantities, more for this type of patient and when there's a very, very small quantity.

So, Doctor Boysen once made an illustration which I can use, so I'll demonstrate it for you. Must have taken a lot of time. What you see on the left is a thoracic cage.

It is schematic, and the probe is perpendicular to the ribs. The yellow line is where you're looking with your probe. This is what you're assessing if your probe is in a perpendicular position.

The red line is where there's a little amount of fluid. So you can imagine that you should tilt your probe fairly to exactly the right direction to not hit air because as soon as you hit air, you can't see underneath it, but still see that red line. It's a nearly impossible.

If you were just to turn a parallel, now you're looking at this entire region. So yes, now you have a very little chance you see that most ventral blue line of the yellow zone, that one is not hitting air and you still see some fluids. So suddenly you could see it.

So on the right, on the screen. You see a plural light. And if you look at that plural line, it's nice and hyperchoic.

There's no free fluid to be seen. If I were to turn my probe, you could see that where the hyperchoic line ends. There's a very small pocket of fluid here.

It's tiny. It's not going to be significant and clinically relevant at this point in time. It could be the beginning of something important.

So, if you want to detect that little amount of fluid that's sitting there where the blue line is, you need to learn how to turn your probe. And so this is the entire y loop in which we're now looking transverse. Now we turn the probe, bam, as you go in transverse, suddenly you see the little pocket of fluid sitting in this area and sitting in that area.

So it allows you to detect even small quantities of free fluid, which is an amazing find. And so, Yes, we've seen trauma patients who were having pleural fluid accumulating that we could identify more rapidly after trauma thanks to this technique. We've diagnosed patients with carcinomatosis thanks to this technique.

So I'm convinced that it allows you to detect smaller quantities. Dare to shift your probe from perpendicular to parallel, and then you slide every intercostal spacecraly to check the entire ventral area of the thorax to even identify small quantities. So that's what I wanted to say regarding pneumothorax and pleural effusion.

Now, whatever is left, I can spend on explaining on the pulmonary parenchyma, which I actually think is even the cooler thing to just explain the sweetness of point of care ultrasound. So, we know that air is the other enemy of ultrasound rates. We had bone, doesn't like it.

Air is the other one. So what you see on the left is actually a schematic or probe that is placed on the skin. And the yellow arrow is what your ultrasound wave would do.

It goes through those layers of tissue and as soon as it touches the pleural line, it bounces back. And then you get a repeat signal which will create those lines. But you will only assess those 1st 2 millimetres.

Of the lung surface. There's nothing you're seeing underneath. It's an illusion to say, I see the lung when it's healthy, you only see the outside.

The cool thing is what happens if the amount of air decreases. And so this is just a SpongeBob illustration that you've seen 50 times around, but the lung is a sponge. And this little illustration already directly tells you the biggest ways on how the amount of air could decrease.

Your sponge could be collapsed at the lectosis, or you could have too much fluid in there. You could also have too much tissue in there. SpongeBob isn't doing that, but one of those things is explaining why air decreases and if air decreases, you start to see artefacts.

You see these vertical white lines, which are called bee lines. You can see one in a healthy patient. The more regions you would scan, the higher the likelihood you would find 1 or 2 in a healthy patients.

It's been reported in between 10 to 30%, depending on how many regions were scanned in healthy patients. So to see one, You can ignore it. To see 5, like this illustration is always abnormal.

More than 3 is definitely abnormal, and these be lines are very hyperchoic lines. They all arise from that plural line. Again, if I use my pointer, this is your plural line.

They start there. They don't start proximal to your probe, they start on the plural line. They will go through those air lines.

They will extend to the far field which would typically set at 4 to 6 centimetres, and the most interesting part, they will move with respiration. As I told you about that glide sign, they're supposed to follow the glide sign. So you will see them shifting with that plural glide in and out of your image.

So typical filing on bee lines is that you will see them moving through your field. Super important. Now, the interesting part is if you see them, It means the amount of air in your lung in that region has decreased.

Interesting finding. It means there's some pathology there. Second thing, even if you only see one, it is something in that lung.

So now you know that at that level, the lung is in contact with the thoracic wall. So you can't have a pneumothorax at that level if you see a bee line. It's ruled out because there's contact.

You are looking at the lung, which is then should be in contact. So, That's the side finding going back to the pneumatics. What you're thinking about now when we talk about brachial disease, an increased amount of these beelines indicates decreased air.

So, another schematic in which there are more to decide with the typical presentation as it looked in the clinical setting. So here you have all of these beelines in this patient. And then I'll show you a little video.

If you allow me, there you see our little patient where you see those beelines arising here. On the other side of the rib had more beelines. So in this patient, if you look, you see a lot of like stroboscope like white.

Artefacts going all the way down to your field in this region. So yes, that's clearly one, that's another one, another one, another one. There's at least 4 there.

This is an abnormal region. There's something wrong with the pulmonary parenchyma in this patient in this region. Simple observation based just on lung ultrasound.

Now, that is when there is a significant amount of air that has disappeared. Now, what if that even gets worse? So suddenly on the right, you see you get a more distorted view and everything looks abnormal, and if you exaggerate it even further, you could actually see a consolidated lung.

Suddenly, you would start to see lung tissue. So in the schematic on the left, you have some. Lung that is visible and that's consolidated, so really becomes tissue that's apparent.

And the distal border actually gets this jagged appearance very often with hyperchoic lines. And that's what we call the shred sign, like a piece of shredded paper. So that is where suddenly there's again more air, and as there's more air, you start to no longer see things.

So this is a true still frame of a patient who here in this region has got a consolidated lung. This is the distal jagged border, that's your red sign. And so these are all artefacts, reverberation artefacts, because of this increased air, suddenly going tissue air interface, creating a ring down artefact.

So, constellated lung, not completely going through the entire lung and only showing a little piece of it. So, gonna try to remove the laser pointer again. And here, a moving in loop in which on the higher proximal part.

This region here, this is your shred. This is the hyperchoic border, those are the ring down artefacts. So this is a region with severely decreased amounts of air.

In that region, there's very little air that actually remained in the lung, creating you to show a true tissue-like appearance. Again, everything can get worse. You can have your entire lung lobe that would actually have such a severely decreased amount of air that you seem to be able to look through it.

So if it's translober, we also call that lung hepatization. You, your beam goes through from one side to the other. So here you have the still frame of that patient and you might recognise those hyperchoic dots.

Those are actually bronchi, which contains small amounts of air still and they give that hyperechoic appearance. And so you know that that is actually a lung lobe and on the other side is the liver. So this is completely consolidated lung lobe showing this image.

To summarise all of that, So, take your time to absorb this. If you start at the level of the left image, you've got a normal healthy lung. It's composed for 85 to 90% of air.

It's got a perfectly normal image. You've got your ribheads, you've got your a lines, you've got your hyperchoic line of the pleura. If you decrease the amount of air, you go to 60 to 85% of air, you start to see those bee lights.

As that decreases further, and let's say only half of your lung is still air, you will see all of those be lines start to coalesce. That actually is pretty hard because now everything seems right. You might think you've messed up your game.

If you, of course, compared with normal areas, things will return to much more easy to interpret, but this might actually be more complicated because everything's abnormal. Things return to a more easy point when you go to less than 10% of air and you start to see red signs. And so you see regions where you recognise tissue and then this hyper called jagged line and the ring down artefacts underneath it, a typical shred sign.

And if you have a truly consolidated lung, it almost looks like a liver, and you're very happy to see some air in some bronchi or some fluid in some bronchi to know this has to be the lung. And so there's a transition in between slightly affected to severely affected barranoma. If you memorise this slide only, you should have a good feeling of what you might detect when you're looking at these patients.

No The disappointment is it just like an X-ray. On an X-ray, you might, might see I have an alveolar initial pattern. But what is causing it?

Is it atleticis? Is it an increased amount of fluid? Is it an increased amount of tissue like in lung fibrosis?

Well, that actually is very difficult to see and what you will use its history, signalment, findings, breed. Whether it's focal or diffuse, whether it's uni or bilateral, whether it's cranial, ventral or quato dorsal, you will have to use exactly the same pointers you're using with every other type of imaging that is easily readily available for you as a practitioner. So you're not doing this because there will suddenly be like this fluid text on your screen saying, oh, I'm one bleeding.

That's not what will happen. You will have to say, OK, in this region, I've got abnormalities in a 12 year old cavalier with a heart murmur. I see diffused findings.

Hmm, that looks like it's gonna be cardiogenic pulmonary edoema due to left-sided congestive heart failure. Classic things will become very easily apparent. So indeed, that research has been performed, and so this is an awesome paper by Rademacher in which they did a lung ultrasound in dogs with or without cardiogenic pulmonary edoema.

What did the study find? That you can see beelines in normal dogs, yes, even 1/3 of dogs using a 4 quadrant techniques where they only looked at fixed sites on the thoracic cavity, had some beelines, but all dogs with cardiogenic pulmonary edoema had a large amount of beelines. Moreover, in severe cases, they became almost coalescent.

Just like we said, it becomes really diffused. What is not in this paper, but what is our true belief is that in typical cases of cardiogenic pulmonary edoema, you will see a very thin plural line still and no signs of a spread of consolidation. So they get diffuse increases of some air in the lungs.

We don't typically see consolidations in those patients. We don't see a really thick plural line. And it's a very diffused process.

You will see those increased bee lines over almost all of the regions of the thoracic cavity. So, these are illustrations from that paper just to illustrate that those things are really seen also in those researches. So you see on the left the patient with one beeline.

That's normal. It doesn't mean anything. The patient in the middle has got at least 12345 bee lines and the patient on the right has got coalescent beelines.

So it will become more and more severe as the patient has got a higher amount of fluid in his lungs, so when he's more symptomatic. No consolidations, a very diffuse pattern. I want you to remember that, and I want you to try and compare that.

The next, disease, which is aspiration pneumonia. So this is from our group at Liz University on which we've published a couple of publications on aspiration pneumonia. And so the idea was that we should be able to identify aspiration pneumonia using point of care ultrasound.

What better way to compare it with chest radiographs? We've also done CRPs on those. And my hope, because it's hidden missing research was that we could use point of care ultrasound to more rapidly discontinue antibiotic treatments, as was said in the introduction.

I was raised to be an internist during my residency. One of the frustrating things that I remember from my Ettinger was aspiration pneumonia. You're supposed to give antibiotics at least until 2 weeks after normalisation of thoracic radiographs.

I don't know how many amongst you have seen a patient on a controlled visit after 3 weeks, after 6 weeks, and after 9 weeks with a specialist. In imaging, still see something abnormal. Patients normal, everything's normal, temperature is normal, but according to the consensus, I was supposed to continue to give antibiotics.

So I was looking for something better and I was actually hoping point of ultrasound would be the ideal thing. More readily available, no exposure to radiations, life would be simple. I'll be honest, that's not really what we found.

The best correlation with clinical appraisal by the owner was actually C-reactive protein concentrations and when we stopped antibiotics, as soon as CRP normalised, we didn't see any relapse. So probably, you can definitely stop when CRP normalises. Now, it's only 17 patients.

I'm not saying it will be through 100%. Again, nothing is perfect, but following your CRPs should allow you to more rapidly discontinue antibiotics. Now, this lecture was not on CRP.

It's on point of care ultrasound. So what is the interesting part of what we saw on point of care ultrasound? A very frightening graphic, but in the end, it summarises it all.

So allow me to explain what you're supposed to see when you're looking at these little tables with coloured circles. So, these are just very easy representations of what each test read looked on on these patients on average. As you can see on the left, you've got an index.

T0 is when they were included, 17 patients. You've got 13 patients at the first control visit and only 6 remaining at the second control visit. That's a bit of a shame.

But the interesting finding is that you have the left-sided thoracic radiograph and the right-sided Thoracic radiograph throughout those three different time zones, which each chest radiograph divided the 9 zones. Those are the 9 little boxes in each table. So, you have the left-sided aspect of a Jurassic radiograph, 9 little boxes.

The bigger the circle. The higher the percentile of abnormalities that were seen on those patients. The bluer the circle, the more severe the lesions were in those patients with very, very white going to just increase beelines to dark blue being severe consolidations.

So, if you just see for yourself, you can see that in the first set of tables, G0, on the left and on the right, there are very dark blue circles in the bottom three boxes. You see consolidations in your patients when they have an aspiration pneumonia. Even more often on the right than on the left, which is not surprising, the distribution coincides with finding a radiographs and so you will see consolidations in those ventral lung lobes surrounded by regions with increased beelines.

Which is quite logical, severe inflammation, aspiration, those lungs are completely filled. There's no more air. Inflammation around it, but not that aspirated, you see increased amount of beelines.

We've seen patients in which you can almost perfectly see that it's a single lung lobe that was aspirated. So you have a consolidated lung lobe and then you see that line in between two lungs and the next one is completely healthy. You can really appreciate that with point of care ultrasound and to find consolidations in your ventral lung lobes in a dog with cuff or hyperthermia is extremely suggestive of an aspiration pneumonia.

That is what I think is of incredible value because now you don't need to take X-rays anymore. And I'm a firm believer of that because this study was performed in newly presented aspiration cases. I work in an emergency critical care setting and in critical care, aspiration is one of the typical complications in dull patients, and it's not typically in those ventral lung lobes because they might be in lateral recumbency.

And so we will sometimes suddenly have a patient that was hospitalised in ICU deteriorating, presenting with hyperthermia, and now suddenly we have a consolidation on the region where it was actually recumbent. That is strongly suggested that he's doing aspiration pneumonia if you ask me, still need to publish that one, but I think it's something interesting to just consider. So in aspiration pneumonia, you would have consolidations surrounded by beelines in a very regional pattern and in a healthy dog that just aspirated because he vomited, typically, cranial ventral lung lobes.

So those are two extremes of the spectrum. This, of course, asks for some case examples to convince you of what we could see. So I'm just gonna show you what we've seen in the last week and a half.

I think it's always best to not take the case that I've seen 5 years ago and say, oh, that was interesting. This is everyday ICU life. So this is Gabba, a very Sweet cats presented for a pyrex.

And what you will see here, I will take my laser pointer again, is that you have your dia pericardial diaphragmatic window and this is actually your angle where you would hope to see some lung, but just behind the heart in front of the liver and the diaphragm and you see a lot of pleural effusion here. There's even some fibrine strands in there and if you scan more cranially, you even see some pleural effusion there. So this is a dog, a cat who had a pyothorax, placed a drain and treated it.

Same day, an accident never occurs all by itself. This is oval European short hair, and this one, if you check very carefully, here's there's some pleural effusion there. It's gone now.

If you look maybe a little bit here, but there's clearly some pleural effusion there around the heart again. This then is the lung. Interesting thing, I'm just gonna try to pause my video for a second.

Is that if you look at this video, If we go towards there, those lungs, do you see that there's bee lines there? So although there's only a very small amount of pleural effusion in that region, there are beelines suggesting that there's more than just pleural effusion and lectosis because of the very small amount of pleural effusion. I don't think that's gonna be the reason why we see those beelines.

There seems to be another reason why there's decreased air. In the lungs of this cat and this cat had a cardiac pathology and so probably this was an just an expression of its congestive heart disease. So once more, this is gain, large amounts of pleural effusion around the heart in the ventral regions, you can see and appreciate the heart there.

If you go to oval, much smaller amounts of pleural effusion at the same time, you see there's an increased amount of beelines in this kitty cat. Again, based on the fact that ICB lines, I cannot promise you this is cardiogenic pulmonary edoema. No, I can just say it's decreased air and then I can start to hypothesise based on everything else I know on why I would have decreased air in that region.

This is Sammy, a 12-year-old male neutered mixed breed dog who was presented for sudden dysputia. He had a history of coughing, exercise intolerance, a great 3 out of 6 systolic murmur, was tachypnic at 50 breaths per minute, and had crackles and ausculta. If I would have shown you a cavalier, I don't think you would have been surprised to say that, oh, this sounds like congestive heart disease.

It's just the fact that it's a mixed breed. But you look at the pulmonary paoma of Sami and you see increased amounts of beelines almost everywhere in this patient. Now, honestly, I don't work 24 hours a day, so this is the next day morning after furosemide.

And you can make those beelines disappear quite rapidly with diuretics. So this was the area where I could still easily identify 4 beelines. The same loops of the day before taken by my colleague were not properly stored.

Very sound piece of advice for your practise. Please all learn how to store your images because you'll definitely regret it when people don't. And the typical modern thing to do is to take your hands, your smartphone, and start to film your screen and then everything moves and nothing is in focus and everybody gets upset and nobody wants to share them, please don't.

Learn how to store your images. Ever? I know aspiration pneumonia in a cat, it can also occur.

So just look at what you can see in our little ivory. We have this clear shred here. So this is a consolidation with jagged appearance, and then you have those ring down artefacts around it, bee lines around it in a very focal pattern.

In a two year old cat that actually was seen vomiting. After it had tricobizoach, which I'm probably pronouncing horribly, so her ball, much easier to say. Final case that I really want to share with you, because whenever I'm telling you something is fantastic, I have to end by telling you that.

Only things that you master properly will work decently. Everything depends on you. So this is Lola, a 10 year old female spade Texan presented for diabetic ketoacidosis, who actually was fine on clinical exam, was still drinking but was reported to be anorectic.

I had a great 3 out of 6 systolic murmur, was tachycardic at a heart rate of 140 to 160 beats per minute, and that was the thing that bothered me. The dog did not have abdominal discomfort, didn't have any respiratory signs, as far as I could tell, didn't have any crackles and auscultation. I just had this dex sound.

Well actually when we say diabetic ketoacidosis had a pH of 7.35, so it was nearly normal. OK, PCO2 was slightly low, so there was some mentrual compensation.

But I mean, it was a disappointing diabetic ketoacidosis patient. It was way too good. It's standing upright.

It's still drinking without vomiting. It's just slightly anorectic. But why is it so tachycardic?

It's got a heart rate of 140 to 160. It doesn't make sense. It's an old dog, small breed.

It's got a great 3 out of 6 systolic murmur. So, what I asked my intern to do is to do horn of ultrasound of the thoracic cavity, including the heart, to check for the left atriumti aortic ratio and see whether there was presence of be lines. When I came back into the ICU and I asked what the results were, the answer was, well, I think the left atrium is enlarged.

It seems to be enlarged compared to normal, and yes, I do have beelines present. So that's where you think it's left-sided congestive heart failure. Yes.

I was a bit surprised because I asked like why is my dog actually tachycardic? Yeah, because it's heart's not functioning properly. OK.

There's another dog lying 2 cages further down the road, which is a cavalier, which is a stage D refractory patient. He's not that tachycardic as this dog was standing up. Did you really have diffused beelines everywhere?

Well, I wouldn't say diffused. OK, you wouldn't say diffuse? Show me the Cyloop.

So this is the sin loop of this dog, of what she had stored. And so it might be subtle, but if you look here, You can see that there's a small consolidation there. Now, it's not really visible.

You can see the coalescing beelines. You see it's around the heart. There it is.

There's a small consolidation here at the top of your screen. See, there it is. That's the one.

That's not normal. I just told you that cardiogenic pulmonary edoema, you don't really see consolidation. It's the ventral part of my little dog.

So, I'm certainly thinking maybe this DK did vomit once. Maybe this was aspiration pneumonia, would or aspiration-induced lung injury. I don't have any hyperthermia.

I agree, could be aspiration-induced lung injury. So, we are now at the point in time where I'm actually quite confident about my diagnosis. But we have a little little funding that we can do for our own didactic experiences.

So this one is paid on me. I asked the owners whether we could and so if you look at this patient, yes, he does have a very nice pattern compatible with an aspiration pneumonia exactly in the region where we saw that little consolidation and those coalescent bee lines. All these regions were normal.

No bee lines here, so it wasn't diffused, it was regional. There was a consolidation. And so if you want to see cardiogenic pulmonary edoema, it's very simple to misinterpret findings.

One of the reasons why I want you to do a full plus protocol and not just stick to standard views because I think if you don't ask the proper question, you risk have poor interpretation. If you have poor interpretation, you've got misdiagnosis, if you've got misdiagnosis, it will lead to mistreatment or maltreatment and you'll have complications. So that's what we want to avoid.

So, this is And we This diagrams or where you have to look, what are the things you want to answer, just to avoid that you have a structured approach and you will consider all the options and not just be focused blindly on what you would want to see, cause I think it is one of the key things that will make you a better veterinarian to have a structured stepwise approach. And so, I hope that this hour on hocus pocus will convince you to try and practise point of care ultrasound in your clinic. If you've already done it, that you've got some points on things that we think you should do in a certain type of way to get some structure and some reassurance that you can do it.

As I already said in the beginning, dare to do it. While you're stabilising those patients, just have a crack, write down on a piece of paper what you think it should have, store your sy looks in the right way, and then when the patient is definitely stable enough to have the X-rays in the beginning. Go ahead, find more certainty for yourself, repeating those and then getting positive affirmation that you can do this.

And I just want to make sure that I thank the entire team of ECC at my university because my young colleagues have also stored some of those images. They are seeing all of those patients while I'm mostly giving advice together with my partner in crime, other Chris Christopher Kennedy. I really want to thank the team who has launched the Vecus interest group together with me.

We really need to be grateful to the society and the College of Veterinary critical care in Europe for supporting us to dare to do all of this. Then of course, other partners in crime, SERS and CERN, with who I am of a lot of fun. I actually was with CERN in the Champaign region two weeks ago.

So this is one of the pictures taken because even the best can get completely lost at certain times when they don't know where they are. I wasn't really crying. I'll.

It was just making a pretty face, but just be aware that it's all about having fun while we're working on developing point of care ultrasound. And if ever you have any questions regarding the point of care ultrasound, let me say that there also is a Facebook page. This is coming from the man who does not have social media.

But I know there's a European point of care ultrasound interest group Facebook page on which more than 1000 people actually share their sy loops. So it's a fantastic resource to just share yoursy loops and get feedback. I sometimes appear under the name of my wife, to just give some feedback.

I know our colleagues from VAA are all there to sometimes help and develop this. And if there are any questions, I'll really be happy to try and answer them. I hope you've enjoyed this little session and I'm looking forward to seeing what your questions are.

Chris, that was fantastic. Thank you so much. And of course thank you butterfly for making it possible.

The technology here is just fabulous. I love this whole concept of point of care ultrasound, you know, the fact that you've got the probe in your pocket, that you can get it out, that you can use it, you know, at the time of the consultation is massive. I remember in my practise, it would take about 5 very strong men to wheel my ultrasound machine.

Into wherever I needed to put it because it was so big, it was a human style ultrasound and the quality of the images is just excellent. So Chris, thank you so much for that. We always work on the principle at Webinar that that if you learn one thing from a webinar, it's worth going on it and there's been more than one today, so that's been really, really excellent.

Thank you so much. As I said before, we've got David also joining us, David Rousseau from Butterfly, who will be happy to sort of ask answer any technical questions on the probe and on the, the the kind of programme and everything, won't you, David? Yeah, absolutely.

Thank you, Anthony, and thank you, Chris. That was an excellent presentation. There were a couple of questions that came across that sort of, probably I'll, I'll have you answer them because I'm gonna sound biassed if it's me, but there were questions about actually using the butterfly, and I actually responded to someone that I, that some of your sign clips.

We're definitely a butterfly because there's a little blue be there, but, equipment specifications when you're using point of of, excuse me, point of care ultrasound, do you have any particular piece of equipment that you like and . Yeah, for collecting videos and and images. Yes, .

So, again, not an imager. I'll give you my history. I think that's probably the, the best way to, to convince you of how much I also believe in point of ultrasound.

Started with a small device that was not portable but on a little tabletop, then had a second one because after half a year, I wanted one in emergency critical care. Different supplier, one additional probe. I start with one microconvex and a microconvex and linear, .

Went on to have 3 devices. Now we got a 4 device which is purely for research and the cardio-oriented things that we do, who's got 3 linear 3 phase ray probes on it. There's a new one coming because we're doing research on the assessment of the, the veins, the peripheral veins in our critical care patients for which I got a hockey stick.

And we're at the point that we're considering to have one for each intern which should be completely portable. So I think the only honest correct answer is it depends on where you're at and what you want to do. Do you want a very versatile piece of equipment that will allow you to do the basics and to work in a single room, or do you also want to use an ambulatory and to go somewhere?

How portable should it be? How many people go actually into that single room? Because I'll give you a good example.

All of these devices, which are so portable in university, you're a bit scared because there's like 200 people passing by every day and you want them to be at a fixed position. So then they need to be somebody's machine. Because if I would have my single machine that's in ISU I'm quite sure that half of the year it's not there.

It needs to be somebody's personal machine. And so I think there's a huge evolution in what point of your ultrasound devices will look like. I will give you my, my own idea of what the future will look like.

If you go back to the very first stethoscope, it was a very big and clumsy wooden thing. I don't know whether you've ever seen the images of the first stethoscope. And then students now all have a stethoscope, quite often a cheap starting device, and then I know that a lot of students get a fancy one when they graduate because that's what they always wanted because they love cardio.

I think that before the time I'll retire. We'll probably see that most students will have a small portable point of care ultraso device. I really think that's what's going to happen because we're gonna say that it is an invaluable piece of equipment to see your patients asking specific questions.

Not using your ultrasound probe thinking you need to see the entire patient, but you will, I think, learn to say, OK, it's a this patient and you think it's a pneumothorax, start doing this. But even in consultations, not only in emergency. So I think the future is going to be portable personal devices.

I think, of course. There's compromises to be made. If I want to do excellent cardio work, I will better have a perfectly designated phase array in different frequencies allowing me to do perfect things that are high end.

But it depends on what you want to achieve yourself. And what I see, I'll always refer to my wife's practise. She started with a small one-ro machine.

You start to get better at what you're doing. You want to expand your capacities, you want to have your Your machine grow with you and to be able to do more and more things. So I think that's the, the honest answer.

It's so personal dependent. What are your goals, what do you want to achieve. But I will say that for point of care ultrasound, and then I'll shut up because that was a long answer.

. I think most of the time when you start, any decent probe that's microconvex or not too big and linear should allow you to do everything that is plus in 99% of patients easily. Thanks, Chris, we've had. The survey put up in the chat as well.

So if people want to fill in the survey, and obviously if you want to know more about butterfly and what they can offer in the perspective of point of care ultrasound, then obviously they can get in contact with you and let you know more about the piece of kit. Obviously it's also be lovely to know where people are listening from. I just noticed before that Maria said thank you from Ukraine, thoughts with you there, Maria.

I know it's a difficult time at the moment, so. Let us know where you're listening in from as well. I had a, I had a question, Chris, when you're actually doing the ultrasound of the chest, do you clip the chest or can you just do it over the head?

What sort of contact do you need? So, we, we almost never, ever, ever clip them for anything that's point of care ultrasound, especially the chest. I've never had to.

You can just part the fur and so. When you do this plus protocol, I, what I very often see where people when we do the wet lab struggle is that they lift their probe and then start parting this for 2 minutes further and then put alcohol there again and place their probe there once more in a dog or a cat, if you start just behind the front leg, just think about the placement of a thoracic drain. We pull.

And I will bring it back. And actually, you can almost go everywhere just by having your probe nicely, firmly positioned against the thoracic cage. It's not going to collapse.

It's a rib cage. You can just wander around without ever having to raise your probe most of the time. So it is very easily doable without any clipping.

You can choose to just use alcohol in itself. Another corner if you do it with alcohol, some people tend to rub up and down. Because I think they think when they do it with gel and clip patients, that's how they typically start.

But if you do that just after you've parted the fur and you've placed alcohol there, the entire point of placing alcohol there is to lose all air. If you then rub your XT then making another little layer of hairs in which there's air there. So, don't do it, just part the fur, alkyl there and sink your probe into the skin.

Thanks, Chris. And people are also asking about recording. It's always good to go back over, especially some of the very subtle changes that Chris was showing.

So the recording should be up within the next 24 to 48 hours, and we will send you out an email and feel free to share with friends as well if if you feel that it would be of interest to any of your colleagues. Chris, Amy has a question, he said, she said, sorry, . I find the shred sign confusing as I think it looks like fluid, although irregular.

How do I differentiate pleural effusion from a shred sign, please? That is an excellent question. I think I can go back, right, if I use my arrows.

So let me go back to the diagrams because they should allow you to see it nice and easy. So, Let's take this one, which, of course, not gonna say this is too easy to be true. But if you take the one on the left, I'm gonna say it's quite hard because you only see something that you could say, how am I quite sure that this is not a fusion.

And I agree, it's not an easy one to say. The one thing that's gonna give it away is hyperechoic lines like the one you have here or points. If you take this one, of course, it's so irregular.

You have this border that is nice and hyperechoic. And look again, you've got these little hyperchoic dots and marks. Those are actually small amounts of air that are still there.

And so every time you have this transition from different egogenicities, air fluid, you get those hyperechoic signals. So if you get pleural effusion, You are, and of course, much less likely to have it. That's the annoying part.

If you have a high cellularity pleural effusion due to a pyothorax, you could have some signs of hyperachardiogenicity, but you would typically not see linear lines or a little round. So if you see that, you see, this is perfectly hypoecho echoic, it's a small amount of acellular fluid. So there's no hint.

Of any hyperechoic stuff there that looks like it's a line or that it's a nice circular structure. And if you see those things, you will be more convinced that you know this truly is a consolidation. I hope that answers Amy's question, which was absolutely excellent.

Today, today, so too late, we have a cat with a severely chronic pyothorax. In which we performed complete thoracic ultrasound by a specialist in imaging. Because it's not really responding to medical treatment and we had exactly that discussion.

Are we looking at very cellular pleural fluid or is that already part of the lung? Not always easy to tell. So excellent question.

Chris, we obviously part of the problem with webinars is that you never hear that this tumultuous applause at the end of the webinar, but I just wanted to inform you, people have been listening and Innes said, I'm from Belgium, knowing Chris as an inspiring teacher, I just had to be here. So that's from from Innis and Norbert listening in from the UK said thank you for this very good course. Hugo Chukwu from Nigeria said thank you for the session.

Philip from South Africa said thank you very much. Excellent good evenings from South Africa. So lots of positive comments coming in.

I know it sometimes you feel like you're in a bubble. I've also just had . Ross saying thanks from Calgary in Alberta, so people listening in from from all over.

That's super nice to hear. Thanks for the compliments. Right, let's see if there's any more questions.

Have you got any comments, David? I have no other comments, Anthony, that I've come across, my Q&A pod. Yeah, I'm just trying to, I can't see anything else here.

We've got somebody listening in from San Diego, beautiful city, so . Welcome to to you in San Diego and CA die in Oman. So people listening in from all over.

And Chris, you know, I really enjoyed the session. It just shows how versatile this is because you never really think about using ultrasound on lungs, or at least I don't. I'm a simple dermatologist, so it's been great to get that insight as to how much you can do and .

Just looking forward to learning more, I think as this tool develops and we begin to get better and better at it, and I, I absolutely agree, from my perspective of dermatology, taking samples, looking at them under the microscope was the way that I got better at things. So it really is practise makes perfect, isn't it? Yeah, don't be afraid to try it.

The good part is there's no, there's normally no harm. I will give you that as a, a last little pointer if anybody's got a defibrillator when I just said, just for the first and spray alcohol on it. The only thing that is really incompatible with point of ultrasound that way is defibrillation, but I think that makes sense.

So, that is the, the biggest complication described with point of ultrasound. If you compare with anything else, it is the safest thing you can actually do as a complementary exam because you can do it where the patient is receiving its treatment, where you can think, where you can do everything else. And so there's no harm in trying and just record your syna loops and start comparing.

And I'm quite sure you will really change your habits. Fantastic. And then we've got Kay, a new graduate who says, and this has helped me loads, performing pocus, but a lot more confident with abdomen.

This has helped me identify abnormalities and hopefully I can practise this soon. Well, thank you Kay. Chris, thank you so much for a fantastic webinar.

Obviously also David, thank you so much for making it possible. It's a fabulous tool. I'm sure it's gonna really revolutionise the way that we do veterinary medicine as more and more people take it up.

But thank you so much for making this training possible today. It was my pleasure, really. Take care everyone, good night and we'll see you on the webinar very soon.

Bye bye.