Hello guys. We're going to be doing a talk this morning on respiratory emergencies, and looking forward to sharing it with you. To introduce myself just briefly, then, my name's Jackie Seymour, and I'm currently an RCBS Advanced Practitioner in ECC and work with Vets Now, and also have links to the regional Northeast Territory of BVA.

And today we're going to be looking at respiratory emergencies. Now, people either love or hate these. The biggest challenge is that essentially, it's, it's one of the major body systems affected.

So when we talk about major body systems, we're talking about respiratory, we're talking about cardiovascular, and we're talking about neurological parameters. And obviously, they do affect respiratory, but you can also have more than one affected because you can also get your cardiovascular or your neurological causes as well for these guys. The challenge we have with a major body system that's affected is it is essential for life, and the respiratory system, in particular, is very prone to acute decompensations and fatigue if it has to struggle for a little while.

This can make them either exciting or stressful, certainly very stressful for the patients. And the chances are, whatever area of practise you work in, you are gonna see these ones from time to time, and that can mean that you're either better or worse prepared when they do come in. The good thing is that there are several key concepts that can make it much easier to approach them effectively and ensure that we get the best patient outcome and best team and client experience.

So, even though we'll often have a limited history, we'll have very different treatments depending on the underlying cause, and we'll often have limited planning time to try and work those out as to what's going on and what's going to be best, we can actually do really, really well on these. So the learning outcomes that we're looking for are ideally by the end of this session, in 30 minutes. We're gonna understand that these are inherently unstable.

Most of us would already be quite happy with that concept. We're going to recognise that actually, in order to work with that and not against it, going for a non-invasive approach, we're able, so potentially a thoracic point of care ultrasound or TOcus rather than a series of X-rays. Sometimes looking at therapeutic trial benefits of trying medication and seeing the response from that can actually be really beneficial.

We want to appreciate that there's value and limitations for each of the options we can use to help stabilise. Oxygen is, is very benign. It doesn't tend to cause any problems for them, but equally, it won't stabilise a pleural effusion, as well as being able to actually use thoracentesis to tap that chest.

Likewise, thoracocentesis can be a diagnosis and treatment in one. Whereas when you're just looking at it from the point of view of A scan or an X-ray, you might get your diagnosis, but you might not be able to actually then use that directly to stabilise the patient. Communication as in anything in veterinary medicine is massively important, so we want to be able to communicate rapidly with the owners.

We've got a limited time frame, but we also want to do it effectively so that we've got informed consent and we've got the best history and details that we can. And we want to quickly assess and stabilise our patient with the minimum stress for both our patient, our client, and our team. So, first off, I thought actually, in order to start approaching this.

And see where you are with it. It's useful to think about different respiratory emergencies. And how they differ from other emergency presentations, you see.

So if you've got a pen and paper, you've got your phone or tablet, then if you just pause and just write down a couple of quick words and phrases on what's your first thought on hearing that these guys are on their way, when somebody says, Oh, there's a breathing difficulty coming down. What do you think? And if part of your thought is, God, I hope it isn't, or I hope I don't have to, what is it?

What's the biggest fear? What is the one bit that you're really hoping you don't have to do? Is a tracheostomy.

Is it a thoracic ultrasound. And when they come through the door, what do you try and focus on first? What is your number one priority with these guys?

Is it setting up the oxygen tent? Is it trying to get a scan? Is it trying to get your hands off them as quickly as you put them on them?

And how do you handle your clients? If you're in a rush, does it affect your communication? Do you handle them differently?

Do you use a different tone when you're trying to get that quick information than you might if it was maybe a patient with something like a foreign body that you can take a little bit more time over on the initial stabilisation. I'm just thinking how that changes for it. And think about your team as well, cause you'll have differences in your team as well, depending on their experience levels and their roles.

So if any of you are listening to this together, it's a good time to just put it on pause and have a quick chat. And just recognise that you've got different stresses, cause that can help to. Piece together why things sometimes do unravel and different people have different priorities, and one person's trying to reassure the owner, one person's trying to set up the oxygen, one person's trying to examine the pet.

And recognising if you actively alter your behaviour for respiratory cases and how. That's really, really helpful to then understanding your own inherent treatment aims. What's your comfort zone?

And what's your resilience under pressure going to be like? If you know your pinch points and what's going to cause a problem, it gives you an idea in advance of which areas you personally need to focus and target. So what do we notice?

The key differences people tend to realise are the uncertainty. They don't really like the fact that there could be different diagnosis possibilities. There could be different levels of stability, and these patients can decompensate really, really quickly.

We don't want to make an error. We don't want to destabilise our patients, and we don't want to get the diagnosis wrong. And we want to act quickly.

We've got that time pressure, but equally, we don't want to overly stress the patient, we don't want to dive in. Too much. The attention to detail.

Is a real key difference in, in, in respiratory cases in terms of what you can get, and it sounds a bit ridiculous looking at detail when it's an urgent case, but actually, it's really essential because small changes in your clinical exam or the owner's history. Can give you really important clues regarding the differentials, regarding how close that patient is to decompensation, and those can be massively helpful for you, for then piecing together the pieces very, very quickly. So it actually can save you time to have that attention to detail.

And the potential outcomes and resilience of both the patients and your team with these guys that actually. People do get twitchy about a very distate count because there is a very real risk of crash. Could go into full cardiopulmonary arrest.

They're sometimes perceived poor outcomes, you know, the end stage cardiac failure ones are really difficult and really, really sad to treat sometimes. And there's also frustration at limited interventions if you like to diagnose your respiratory pathology with a nice series of X-rays and you're not comfortable with your ultrasound techniques. And actually, the fact that you're going to struggle to get an X-ray in some of these guys safely and sensibly in your time period, that can be really difficult and put people out of their comfort zones.

So as with anything, the first thing in these cases is getting your communication right. If you can get this right, it makes your case flow easier. And it's being aware for the INS this may be a sudden stressful change for them.

They've got a previously healthy pet in a lot of cases, even a, even a bulldog puppy, they may feel it's a previously healthy pet. And. They suddenly got a breathing difficulty.

Now, even if it's a mild breathing difficulty, and we're not very excited, if they're coming down to the vets for a breathing difficulty, they're worried. It's never a good visit for them. And when they come down, they're still wanting to have the basic niceties to build that relationship and build that trust from the first time they see you.

So, when it comes in, your first thought is likely to be the patient. But actually, if you can just take a moment, pause, breathe, compose yourself. And recognise that the client still needs to know who you are, see that you've got the sympathy for their pet, and let them know what's happening.

And because they're stressed, because they're upset, because they may not know what's happened, they may not have had any previous indications as to how their day was going to go, then signposting for them. So what are they, what are you going to do? Where's the pet going?

When will you be back? When will you be contacting them? What should they do now?

And this is where using your other team members can be really, really useful. So that they can help to actually stream this process for you. Even if you need to grab the cat and run, there's somebody there on backup who can actually direct the client back to their car, check their telephone number, and we'll call them as soon as we've had a chance to assess them.

Obviously, the cup of tea in the listening ear is a bit of a challenge at the moment in COVID, but it is very much a case of if we're able to back up that communication for them and, and start to build that relationship, start to gain that history as quickly as possible and as sensitively as possible, that will make it much easier. Likewise, closed loop communication, not only with their clients, making sure that we are repeating and checking back with what they've said, but also with our teams, because these are the patients where we sometimes do race them straight in and put them in an oxygen kennel. And we want to make sure that the team are aware that they've come through the back.

We want to make sure that our team are aware what medications we've given, what interventions they've given when these patients were last checked, who's responsible for keeping an eye on them. And just make sure that they don't risk slipping through the gap in any aspects of their treatment because they do sometimes sneak in quite quickly with one team member. When it comes to the clinical challenges, Then this is where they get exciting.

And generally with these guys, the best tip I can give is, find something life-threatening. In this case, the breathing may well be it. Start your stabilisation, and then start returning back.

Once you've done that initial bit of your exam or stabilisation for that question you want answered, that bit you want to address, then come back for the secondary exam, secondary questions, and start to think again from there so that you're almost doing it in a little step by step process. Because we need to understand that respiratory patients often aren't suitable for the standard diagnostic paths. They're usually unstable in at least one of the major body systems, as we said.

Definitely respiratory, but can also be cardiovascular or neurological too. These guys may not cope with standard sedation and GA protocols without stabilising them first. And there can be a bit of variation that sometimes.

A full general anaesthetic. Might give you full rapid airway control, which could actually be a huge benefit compared to sedation. Likewise, a sedation may actually still, if it's light enough, allow them to try and compensate for themselves.

Without knocking out their full airway drive. So you have to be prepared for what your intervention is likely to do. And what the benefit is likely to be for it.

And it might be that actually the X-rays can be done 2 days later. And we can get the information we need on the clinical exam or on the ultrasound. We need to bear in mind that we may not actually get.

The results. Before we actually have to start planning the treatment. So, we might want a full culture and sensitivity of what organisms might be growing in that chest for pneumonia, but we might not be able to get those in the time period that we want while we're having to make the decision.

So we may have to make some decisions and then come back to it. Likewise, thoracentesis, we might have to do it as diagnosis and treatment because if the patient isn't. Able to tolerate an ultrasound, and we decided that rather than do the ultrasound and then try thoracentesis, we're just going to try it out and see if we've actually got something we can drain there.

And it's bearing in mind that these tests can be higher risk because you've overstressed patient, then even a clinical exam, trying to take a temperature and restrain a very stressed dysmic cat can actually push them over the edge. And certainly things like trying to quickly put them on the table for just a quick X-ray with some sandbags. Again, you're running that risk that what they might tolerate nice and normally in other presentations for respiratory emergencies.

That may not work. So what can we do? We can work with what we've got, and we can use the lightest test first.

The lightest test may well be. The history. It may well be what we can get from an observation or clinical exam, looking at the respiratory pattern.

It might well be assultation, it might well be an ultrasound. It might well be doing some bloods and seeing what we've got on there. You'll see in this picture, this patient isn't actually on oxygen, and there's something red going into the line.

This patient presented for breathing difficulties and actually had a PCV of 8%. And so we obviously we had a bit of a cardiovascular decompensation in there that was contributing to why the patient looked like a breathing difficulty. So for him actually, his, his blood test was was a very important test for him more so than trying to get X-rays of his chest.

Considering the GA and sedation benefit, again, like I said. Midazolamketamine is a really, really good light sedation choice that I really like. But actually, with some of these guys, I'll actually want to induce them with propofol and take full airway control quite quickly, because I don't feel that's actually, they're that far off decompensation.

I don't feel they're that far off fatiguing, and that sedation might just sort of knock them down a little bit. It might stress them. It might be a little bit trippy for them.

And actually, we might not get the results that we want, whereas if we use roperol, I can get full airway control. And there's no stress, there's no worry in terms of that patient for themselves. Options for combined diagnosis and treatment, the classic one we talk about is tlacocentesis, because you can tap the chest and find out if you've got an effusion, and if you have, you can drain it.

Knowing where your three-way taps are in advance is a very good option. And prioritising your least invasive versus your most useful. So sometimes you will go for a more invasive.

Thoracocentesis is more invasive than oxygen therapy, but it's of more benefit for pleural effusion. You'd use the oxygen therapy first, but if you just did that for 24 hours, you wouldn't get the same results as if you did your oxygen therapy for the 1st 10 minutes, and then actually identified the effusion and tapped it. And being aware of the recovery guidelines.

The recovery guidelines are the evidence-based CPCR guidelines. They are, it sounds really pessimistic to put them in here, but these guys do have a risk of arrest. So if you've already got a prepared crash box, if you've already got a team who are prepared for CPCR situations, your chance of getting these guys back, because some of these causes will be reversible.

And actually, Really, really beneficial, and knowing in yourself that if the worst happens and this patient crashes, you've actually got a reasonable chance of success. That's brilliant, that's massively, massively helpful for improving your comfort levels going into these guys. We want to approach each parameter assessed for the maximum benefit.

Use our tests to their full advantage. So, as full a clinical exam as possible. It might be that we do decide that areas like taking the temperature are not actually useful at that point.

But if you can get a quick check of pulses, if you can get a quick assultation of the chest wall and the oxygen tent, these things are all really, really useful. What to sample and how much? Are we doing blood tests?

If we are, how are we going to obtain them? Are we going to go for a venous sample, or are we going to go for an arterial sample, and what are the pros and cons of each? The arterial sample will give you better information on your blood gases.

But it's also going to be a bit more challenging to try and obtain. I just me cat trying to hang on to it for an arterial sample may not actually be that practical. Likewise, if we want to tap in a fusion.

If it's a hematur right we might only want to tap off just the minimum we need. In order to stabilise the dysmia. If it's a pioothorax, we might want to tap off as much as we possibly can and repeat the process and look at putting in drains to enable regular flushing.

So there's gonna be variation depending on what's going on with these guys, and that's where these two questions are really helpful. What is your essential question or concern at that time? What is it?

That is your, your burning thing, what do you want to know? Is it, has he got a fusion? Is it?

Why is his breathing so shallow? And then the second question is, what will this intervention achieve? And that's where we're again, looking at what is the, what's the value?

Offset against the risks, what is the benefit of this intervention? And it might be that actually taking a temperature at the moment is not going to give us any further information. That is going to realistically influence our treatment plan.

I'm pretty sure this guy is cardiac. Or alternatively it might be that actually no I I really want. This assultation because I want to know which area of the lung fields we've got the problems in.

I really, it's worth it to try and just get a stethoscope on the side of this patient. And so you should always have those questions in your mind of what is it you're trying to answer, and will the intervention you're about to do answer that for you. And like we say, the minimally invasive diagnostics can often give us quite a lot of information in these guys.

So my picture down there, you'll see is a rather beautiful one of a pneumothorax. There, it's, it's wonderful. It's, it's very diagnostic.

I, I really like it. Would I rather that there wasn't a picture of a beautiful X-ray pneumothorax? Yes, absolutely.

Because that potentially could have been picked up by listening to him on a careful assultation, to give a suspicion that actually things, things are a bit muffled in there. That could have been picked up on a diagnostic thoracchocentesis tap, which would have provided diagnosis and treatment at the same time. It could have been picked up on a point of care ultrasound of his chest.

And those would have been less invasive than that X-ray. We got away with it in this one, but certainly, I'd much rather we were using other less risky procedures to get the same answer. So using your history, using your clinical exam, considering ultrasound versus X-rays, Considering laycentesis.

And if we are looking at other tests like arterial sampling like bronchialveolar lavage. It's asking yourself, what are they going to gain for us, and planning them in. And it might be that those are then performed a little bit further down the initial stabilisation.

Because actually, the risks in the initial presentation in the heat of the moment. Are not going to be worth the benefit, but they would be really useful information to have when we're a little bit more confident of our patient. There is quite a lot you can do just armed with your eyes and a stethoscope in respiratory emergencies.

It's almost a system that you can see from the outside, which makes it a little bit easier. So it can be really helpful to have a quick reference table like this one. Just up in your prep room, in your favourite notebook.

So you've got a quick, easy option for the respiratory pattern, when he's sitting in his oxygen kennel just chilling for his 1st 10 minutes and you're looking at him from a foot away. Quite often you'll be able to pick out the respiratory pattern just from that. And that'll give you a hint as to which particular area of the respiratory system you might be looking at.

When you can get your stethoscope inside that little oxygen tent up alongside him in the kennel, I actually have a little listen to. Again, it's gonna give you quite good indications of what's going on. And sometimes we listen.

And we come away with conclusions and information and sometimes we listen and then we move on to the next test. We really, really advise you. That with respiratory emergencies, the most you can get out of your assultation.

The better, because it's, it's a true non-invasive test. It can be done alongside your oxygen, it can be done alongside doing a thoracic ultrasound, and actually, it'll quite often give you some hints. Why do we want the hints?

We want the hints because we want, obviously, a diagnosis treatment is great because it can then be more specific and more sensitive. But we need to offset it against a live patient too. So we want to be looking at the upper airway, lower airway, pulmonary parenchyma, little space, chest warm diaphragm, neurological disease.

We're looking at all of these and considering them when the patient first comes in, but then we want to narrow them down. Because what we get to will give us different treatments, actually, we might well find that. We've only managed to narrow it down partially to a particular level, so to an upper airway, to a lower airway.

And actually, if we've managed to get to those. Then we've got quite a lot of different treatment options, we've got quite a lot of different tests that we might actually then consider and move on to. And if you can get partially there, that gives you a huge, huge advantage because you can actually sit there and, and think, actually, I know it's an effusion.

I don't know what type yet, but it's an effusion, so my next step is to drain it. I know that this cat actually has dry lungs on this scan. So what is that ruled out?

If he hasn't got an effusion on the ultrasound, if he's got dry lungs rather than wet lungs, what kind of things am I looking at? I know that this patient is actually showing signs of upper respiratory, so actually, I'm now less concerned about taking. My chest X-rays, I'm moving out of that comfort zone and I'm looking at what can I do to help with that.

And it might be that we're going for a sedation and cooling protocol. It might be that we want that patient to wake up more slowly from any sedations so that we've got a better chance. And that's why it's good to get even partially there.

So do not ever underestimate the value of getting a partial diagnosis in these guys, and then tailoring it and then going on to the next step. So in conclusion, compared to our learning outcomes that we're looking at, I've got a long one hedgehog in the corner there. Respiratory emergencies are inherently unstable.

I think we all agree on that one. The non-invasive approach is. Really can often yield greater benefits and it's quite surprising the amount of information you can get out of them.

There are gonna be value and limitations to every diagnostic choice, every stabilisation choice, every treatment choice that you go for with these guys. And so actually, if you're just keeping in mind. What your concern is and what you're aiming to get out of that intervention, you will find that you'll actually be able to tailor.

The best possible plan to that individual patient. Communicating rapidly but gently with your owners and recognising their often afternoon shock is really, really helpful, knowing that it is that unexpected. Scary aspect for them.

And having a perception of control yourself that actually, if you're feeling like you know what to do with these guys, you're feeling calm about how you can plan it, what your steps will be, what you're going to do if you don't immediately know what's going on, then actually, that's going to help to calm you and your team. Which is really reassuring. So making sure in advance that you have actually got that crash box, you've got the training you need, you've got the medications and the diagnostics available that you want so that you know how you're gonna address these guys.

And each of mine I'll do slightly differently. But it still works out really nicely for them in that. I'm trying to tailor it.

To their own individual presentation, so we don't often have protocols for step one we do this, step 2, we do this. We go entirely on the patients, and that gives us that flexibility to respond. So going forwards, I'd like you just to take a moment, again with your pen and paper, or tablet.

And just think about a respiratory case you've seen. Using the learning outcomes we've considered here, just take a moment and just assess your case. So was he unstable?

What noninvasive approaches did you use? And what more invasive approaches did you use? What are the benefits of these?

What were the limits of these? And with the power of hindsight. Were they the best choices that you would use for?

An identical case next week. Were there any aspects that you would alter? How did your communication go with Mr.

Johnson in that case? How did your communication go with your team in that case? Is there anything there that you might alter?

Or do you actually feel that one really well? And how in control did you feel with that case? And if there were any aspects that made you feel particularly worried, particularly out of your comfort zone.

What did you find? Looking back on it. That you would prefer to have in place next time.

And is there an aspect that you're proud of there? As well as the aspects you could try differently, which bits are you really quite chuffed that actually, you, you did good on that. And for the bits where you would try something differently, what would you need to achieve that?

Ready for the next one? Is it further training? Is your next webinar going to be performing thoracic ultrasound?

Is there different equipment you need? Was it actually a struggle to find the three-way tap? Do you not have a stock of nice chest strains that you can put into that by a thorax patients, so you used intermittent drainage instead?

Because, in conclusion, these cases do need rapid assessment. And, unfortunately, because they tend to happen quite quickly when they come into us, if you've got a preparation in advance, it makes it so much easier for when you then get landed with one. Whereas trying to think on your feet at the time can be really quite stressful.

Ideally a minimally invasive approach, but it needs to be tailored to the patient and it might be, like we were saying, oxygen is very minimally minimally invasive, but actually the rackocentesis in an effusion case will be more useful in terms of stabilisation after the initial oxygen than continued oxygen. If you can narrow down what's happening, even if it's just to which part of the airway, you can prioritise your diagnostic and treatment choices. And common presentations are common.

But you'll also get the odd ones too. So we'll all see an asthmatic cat, we'll all see a pyothorax cat, depending on which area of the country you're in. We usually see sort of lung worm, hemothorax, you know, you, you can see some really.

Really sensible ones that have read the textbook, but you can also see some really odd ones too. Like the trauma that he didn't realise had actually sustained any trauma, but he fell off the wardrobe and ruptured his tyre for around two weeks before. Which is one of my particular favourites.

And with those ones, if in doubt, if you're not quite sure what's going on, if you're not quite sure where to start from, if you start from the major body systems and ask yourself which bit of the respiratory systems affected, which bit of the cardiovascular system is affected. What impact is it having there? Could there be a neurological component?

Because another one of my favourite ones was the cat that bit through an electric wire, and actually it was a, a neurogenic pulmonary edoema that he presented with. So, it's looking at the major body systems, cause they're the ones that are going to. Be most affected and most dangerous for the pet's continued survival.

And it's using your first principles of building on what do you know, what can you find out? What have you got to get this patient back into sort of homeostatic balance. And then progress from there, and it's a little bit like the diagram at the bottom here, of sometimes you'll only be able to put the bottom layer on.

But that opens up the path to then put the top layer on after the initial stabilisation. Sometimes you'll really clearly be able to see exactly what's going on and sprint straight to the diagnosis, straight up the ladder. It's really easy, but that's not always the case with them, and it's OK if you need to take a few building blocks and a few stages to get your ultimate answers and your ultimate conclusion.

Thank you very much for listening to this session. I've had a lot of fun discussing it. I like these guys.

And I hope it's provided you some new thoughts and some helpful recaps in a short, sweet fashion. If you've got any queries or further options that you'd like to discuss them, do please feel free to get in touch. And I would highly recommend the thoracic ultrasound training for anybody who isn't completely comfortable with that at this stage in their respiratory workups.

Take care guys, and bye-bye.