Good evening everybody and welcome to Thursday night members webinar. My name is Bruce Stevenson and I have the privilege of chairing tonight's webinar. Apologies for being a couple of minutes late.

We've had a couple of technical issues and but hopefully they're all behind us now and we can get on to what promises to be an absolutely amazing webinar. I don't think we have any new members in tonight, so you all know how it works with popping your questions into the Q&A box and we'll hold them over to the end and then our presenter has kindly agreed to answer those questions. So without further ado, let me introduce our speaker tonight who is more than qualified to talk to us.

Doctor Elka Rudlf is a 1991 graduate of Purdue University. Of veterinary medicine. She completed her residency training at the Animal Emergency centre and achieved board certification in the American College of Veterinary Medicine and Critical Care in 1995.

She has supervised and mentored 28 ACVECC diplomats and is currently a clinical supervisor at the Lake Shore Veterinary Specialist in Glendale, Wisconsin. She's certified in veterinary medical acupuncture. And she has served as the IVECCS programme director from 1998 to 2009 and then again from 2013 until current time.

She's the 2008 recipient of the IRA ZAO Award for Distinguished Service in the fields of Veterinary Emergency and critical care and is an internationally recognised educator in the field of veterinary emergency and critical care. Elka routinely incorporates her medical acupuncture skills into her everyday practise to enhance the well-being and pain management of critical ill, critically ill and injured patients. Her special interests include fluid therapy, emergency surgery and anaesthesia, and trauma management, topics on which she has been published in peer-reviewed journals and books, various book chapters.

Elka with that mouthful, welcome and it's over to you. Thank you so much, Bruce and, and Simon in the background. Yeah, that was a lot of, of me that probably took up a little bit of time for our lecture, so I apologise for that.

I, put up my email address and I spelled it wrong. There's only two F's in my last name instead of 3. But I wanted to share that with you if any of you ever have questions about cases or where you want to come visit us, here in Wisconsin, you're welcome to email me and it's e Rudlof at LakeshorevetSpecialists.com.

And as Bruce mentioned, one of my quote unquote jobs, is to, assist the veterinary emergency and Critical Care Society in programming for their, yearly CE meeting, and the Critical Care Society is an organisation that's open to anybody. There's no special qualifications that you need to have to join us. If you have any interest in emergency and critical care, I welcome you to check us out.

So, we, of course, are going to be talking about thoracostomy tubes and thocostomy tubes mean that we've got patients that have pleural space disease and how do we recognise plural space disease to even know that a patient may need to have a a need for a thoracostomy tube. And on clinical evaluation, what we're going to do is initially visualise the patient and look for reduced lung expansion. And so if we can, can, imagine having resistance outside of our lungs, between the lungs and the chest wall, if we try to breathe against that, we will Not be able to fully expand our lungs and so there's going to be a greater inspiratory effort.

And as we do that, or a patient does that, if they really work with their intercostals, the diaphragmatic muscles are going to actually move in. And what you'll see clinically is what we call asynchronous breathing. So instead of the chest and the abdomen coming out together during inhalation, The chest will come out and the abdomen will get sucked in.

So we'll look at this little bit graphon on the lower left here and as he's breathing, you can see that as the chest comes out during inhalation, the abdomen gets sucked in. That's very classic asynchronous type of breathing pattern where the greatest effort is on inhalation. And this little guy got hit by a car.

He had a pneumothorax. Cats can be a little bit more tricky to evaluate, but they will have a similar pattern where they're working to, to inhale against that plural space pressure and their abdomen gets sucked in. And when you sculpt the lungs, you will have a decrease in the lung sounds, compared to when you have normal lung expansion and you can hear air movement.

The asynchronous breathing pattern can also occur with lower airway disease where there's an expiratory push. So you really wanna pay attention to see where the greatest effort is. So with plural space disease, it will be on inhalation versus with lower airway disease, it will be with exhalation.

So we have our first poll question here and if we are presented with a patient that has this typical asynchronous breathing pattern that identifies a plural space disease, what is going to be the first step in trying to help that patient? OK, I'm afraid our technical issues are continuing. So sorry folks, you are not going to be able to vote on the polling questions tonight.

As I said to you, we were a bit late because of the polls. So, LK if you wouldn't mind, I apologise to you profusely, but if you wouldn't mind just talking through the answers, please, we're not going to be able to get voting in. Not at all.

I don't mind at all. And I think everybody else will be a little relieved that they don't have to lay a stake to their claim and what they want to do. But when we have a patient with respiratory distress, it can be a very stressful situation for us as clinicians ourselves.

And, and many times we rely on wanting to prove that a has a certain problem before we intervene and if that patient is having a lot of respiratory difficulty, it can be a heightened situation where you know you need to do something quickly for that pet, but you're not quite sure how to identify it. So do we take an X-ray to evaluate and prove that that patient has pleural disease? Do we anaesthetize and intubate because they have respiratory distress?

Do we give furosemide and oxygen, or do we perform a thoracentesis. So of those four options, each of you should write down what you would do first. And now I'm going to tell you what I think you could do that would basically give you both a diagnostic proof that the patient has pleural space disease and actually help the patient, and that would be D to perform a thoracentesis.

Properly performing a thoracentesis on a patient can be safely done without any imaging and gives you your diagnosis that they do have pleural space disease and the opportunity to try to rapidly remove the air or fluid that's in there. So, visualising and breathing, the breathing pattern as we talked about looking for an asynchronous breathing effort. A sculpting the lung sounds and typically when there is something padding airflow in, in, in the, from the lungs, either in the form of air or fluid around the lungs, then there's going to be dampening of the transmission of that noise and lack of lung sounds.

There'll be a rare occasion that if you hear bowel sounds in the thoracic cavity, then you should think that this patient may actually have a diaphragmatic hernia and in which case you want to be cautious about doing a thoracentesis for that particular patient. If you do have a concern for a diaphragmatic hernia, you may palpate a very empty abdomen, and that might give you a clue. Would I do a thoracentesis on that patient?

I might not in that particular situation unless I thought the stomach was extremely distended and causing a constriction, a breathing that was life threatening. And then as we talked about, if we do feel that there may be air or fluid in the pleural space, then during that pleocentesis first, giving the patient relief and then taking a radiograph because ultimately, if you have a patient with respiratory distress that you position for a radiograph, you could make them worse because you are making them trying to try to put them in a position that is not comfortable. It deprived of oxygen.

If you have the luck to have an ultrasound unit and in your hospital, then certainly this might be a quicker way to evaluate the plural space and if you do have an ultrasound machine or not, you may have started to become Familiar with the TFAS or the focused assessment of sonography of trauma, and you can put the probe on the chest and evaluate for fluid as well as air. So as you can see on the picture on the right, we've got a complex fluid in the plural space. That's going to be restricting, lung movement.

And you can also evaluate for a lack of glide sign that will give you an indication that the patient actually has a pneumothorax. And that can be, take a little bit more practise to identify because the air interface of plural space disease and pneumothorax can look similar to just normal expanding lung. But with normal expanding lung, there's movement.

at the edge of the lung field that you can detect whereas with a pneumothorax, you won't be able to detect that lung movement and that's called the lack of a glide sign. Patients can also have unilateral or bilateral presentation. If their mediastinum is intact, there may be only one side that is containing the air or fluid compared to when the mediastinum is not intact when it can spread.

So, in terms of trying to stabilise them, we have three different options. One is the thoracentesis, as we talked about, and initially, you likely are going to be doing that prior to any thoraccostomy tube placement. And then in terms of putting a tube in the chest that's going to remain there, we have two options with a pleural catheter insertion or a thoraccostomy tube placement.

The difference between the two is the pleural catheter insertion is a smaller tube. It is easily placed, and, can be used for smaller volume, fluid or air accumulation. I will also use it in patients, for example, that may have had a chronic accumulation of fluid and it's a big patient and many of us who have tried to do thoracentesis on a bull mastiff that has a large volume of fluid know that it can take a half hour to 45 minutes with 3 to 4 people restraining the pet.

In trying to evacuate that plural space with just thoracentesis and pleural catheter insertion can be very easily done and takes only a few people then to, to empty the space. The thoraccostomy tube placement, the indications for that is if we have large volume, continuous drainage, and you are looking for more complete drainage. And if you find that you are putting a patient under general anaesthesia for maybe a a surgical Or they need positive pressure ventilation, then that particular patient may benefit from having a thoraccostomy tube placed as well.

Cardiovascularly unstable patients were part of their instability is because they have large volume, air or fluid, in their plural space, they're going to benefit more from thoracostomy tube placement as well. In management of the thoraccostomy too with drainage, we'll talk about a little bit later in the, in the the, the talk, but that can be fairly labour intensive. So for those practises where you're trying to look just for a bridge to get a patient through a particular procedure or to another facility, then the plural catheter insertion might work the best.

So briefly reviewing thoracentesis, in the dog, I'll give you a few tricks here. We've got the chest wall prepped and we're taking a 1.5 inch needle, and in this particular dog who's got a tension pneumothorax, we're using an 18 gauge needle.

And we're inserting it in between the ribs, anywhere from the 7th to the 9th intercostal space, putting a little bit of sterile saline in the hub, and we will know that we are in the plural space when that column of fluid moves either into or out of the chest cavity. So as you see that the column of fluid got blown out. So we know we're in the plural space and now we can add our extension set that is now attached to a syringe and start aspirating.

And that particular dog, the poor thing, he, you can see that he's been poked multiple times. He has some other little bruises, ventral to this. So we do know with the amount of air that we're getting out and the fact that we've had to tap him multiple times, he is a candidate for a pleural catheter, thoraccostomy tube, and because we're worried about attention, pneumothorax, the thoraccostomy tube will be the best choice because we will need continuous suction.

To be able to evacuate and keep the air, the plural space collapsed. In the cat, the hanging drop technique that I just described doesn't really work because of course, cats are, are different than dogs. And we will still choose a similar spot on the chest cavity between, in this case, around the 8th intercostal space, we're just pushing the soft tissue down with my thumb and then I'm inserting a 1.5 inch needle, again, this is a 22 gauge needle.

And just going into the chest cavity and occasional, and I'll ask the aspirator to occasionally aspirate. If we don't get anything, I'll go a little bit further in. And then when we get air or fluid out, that's where we start to drain and hold the needle tip in place.

You can also tip the bevel of the needle down a little bit more parallel to the ribs so that as the lungs expand, we limit any trauma to them. So, now, moving on to the pleural catheter. We've made a diagnosis of pleural space disease with our thoracentesis, air or fluid, and we want a way to keep the fluid, we want a means to remove the fluid.

And we think it's a smaller volume accumulation or it's in a smaller patient, then we might choose to do a plural catheter. And this may be a temporary procedure where we're trying to evacuate. And either remove the pleural catheter or evacuate and transport the patient, then these can be very easily placed and handy to use.

The pleural catheters originally Mila had made these feline chest tubes and they purpose made these as feline chest tubes. And they worked so well and eas were so easy to place that we started using them in, in dogs and so they just changed to just a chest tube. The one thing about a plural catheter, you have to understand is you cannot use this with continuous suction.

And so if you feel you need continuous suction, then you need a, a purpose-made thoracostomy tube. These you can only intermittently drain using a syringe because the size of the attachment is too small for the tubes on the continuous suction apparatuses to fit. So these pleural catheters are are put in using the Seldinger technique and I'll give you a little demonstration on the samoid, who has a spontaneous pneumothorax.

He actually was being just walking on his With his pet owner and started to have difficulty breathing and came in. He had an asynchronous pattern and an initial thoracentesis. He had a lot of air that was removed and we were preparing him for a CT scan.

So, in this case, we do a surgical preparation and all the materials we need are in the package for the myelo tube placement and again through the 7th to 9th intercostal space. We're just going straight through the middle, directing a regular peripheral catheter in a cranial direction. I pulled the styli out just briefly to keep that in place.

And now there's this J wire that's curled up in this plastic tubing and there's a little hook on the end. I'm sure, sorry I didn't show you, but the, the, the tip of the, the wire is in a J shape so that as it hits any lung on the inside, it's not poking it. And there are hash marks.

So there's two black hash marks right here telling me this tube is about 10 centimetres in. And then I'm going to Feed the catheter over the wire and make sure that the wire is coming out before we start to insert this into the plural space. The tip of this catheter is blue telling us there's a it's, it, it'll help dilate that space as we advance it and you can see that there are centimetre hash marks depending on how far you want to put it in.

Now, in this particular dog, he's pretty large, so we can put the whole tube in. But if you're working with a cat and you can only maybe use half the tube, there are additional butterfly attachments that you can put on so that you can secure that catheter to the skin. And then this particular dog, he was given butterphenol as a sedative, 0.4 milligrammes per kilogramme, and then a little bit of a local anaesthetic.

And as you can see, he required minimal restraint for placement of this catheter. The same goes for cats. I've not had to anaesthetize cats or dogs to place this catheter.

Therefore, I suggest, all of you look. Into how to use this catheter in your practise for those complicated situations where you do, maybe you don't have a thoracostomy tube, or a way to do it, and this is a way to drain the plural space while you're getting a patient to another facility or in like in this case, we knew we were going to do a CT scan on them and we wanted to make sure we could have access to his plural space, to, to make sure the lungs could get as maximally insufflated or because he was going under general anaesthesia, we have a way to drain his chest cavity without having to do a thoracentesis with him in a, in a position for anaesthesia. And in this case, we would attach There's a different, there's a number of different attachments that you can get, but in his particular case, we probably would just use a one-way valve to aspirate or you could potentially put in a stop or yeah, stopcock, three-way stopcock.

So, going over again, the reasons to put a thoraccostomy tube would be large volume rapid expansion, in which case thoracentesis having, would have to be done multiple times. The pleural catheter may not allow you to do continuous suction on the pleural space if they are cardiovascularly unstable. If you anticipate a prolonged anaesthetic procedure or they're having positive pressure ventilation with pleural space disease, then a thoracostomy tube with continuous suction will be indicated.

And the tubes that we're going to use pretty much for most patients, if we're using a true thoraccostomy, purpose-made thocostomy tube and not a pleural catheter, it needs to be a large bore, which means greater than or equal to 14 French. The plural catheters that I just talked about, they come in a 12 and 14 French size. And before I move on, I just, with the example I gave of the giant mastiff with plural space fluid accumulation.

And that type of patient, I would put a plural catheter in, as we just talked about on both sides, secure it and then put a little dressing over it, put that patient in one of our runs with a technician, and the technician could sit with the dog and evacuate the fluid from that dog without any additional restraint and the rest of the, the assistance and you can move on to the next patient. So. So that's an example, another example of how you can use that pleural catheter.

Now, back to the thoracostomy tubes. There's two basic techniques that people talk about. One is blunt dissection and that's what I'm going to focus on today.

And then there's the harpoon technique which uses a trocar where you put the chest tube in with a pretty vigorous a pump. I don't know how to explain it actually, because I don't use this technique, but there's a, a, a very aggressive push to, to push the tube that has a harpooned, a guide in it into the chest cavity to bluntly. Force it through the tissue soft tissues into the chest cavity.

And I worry that this particular technique, you could, you could puncture a lung or the heart and so I really don't advocate it and we're just going to talk about the blunt dissection technique today. So thoraccostomy tubes come in many shapes and sizes. They were actually first described for use in the 5th century BC by Hippocrates who used them to treat emyema.

So they've been around for a while. Continuous suction was added to, to the, the process much, much later on and in the, in just in the last 100 years. Most of the tubes, are made, these are purpose-made for longer, and, care, and treatment.

People who have used red rubber tubes. They have used Foley catheters, in a way to try to, be less expensive, but ultimately, those types of tubes can kink more readily than the purpose-made tubes. They can be more irritating as well.

And they don't necessarily have a trocar with them that, that helps you guide them in. The red rubber tubes tend to cause more tissue irritation as well. So we have silicone and polyvinyl chloride options for purpose-made thocostomy tubes as you see here.

So the one on the bottom is a typical size we'd use for a cat, so that would be about 14 French and then we, they go up in size. And these, these tubes, you'll see a single hole on a side hole and then on the distal end that will be put in the chest and they also have a, most of them have a radioopaque line so that when you take an X-ray, you can see where the tube is at easily and then the sentinel hole will usually be over that raopaque line. The tube size that you want to pick is generally 1/2 to 1/3 of the width of the intercostal space.

So you don't want it so big that it pushes the ribs apart, but you don't want it so small that you actually are not. Able to the continuous suction drain wants to, to, to aspirate. And on these, you can see they've got centimetre marks as well to give you an idea of how far in you are and you want to pay attention to where the tip of your catheter is going to go prior to putting it in, so you have a bit of an idea of where this will come out of the skin.

These also have as you can see here, trocars that keep the tubes stiff as you're placing them. But be mindful that most of these trocars come out the tip of the tube and if they're sharp, you have to be very, very careful on how you handle them once they get into the chest cavity. So here we have some examples of silicone tubes.

Again, you can see the centimetre mark, the sentinel hole, and then here you have a little bit of a tissue spreader on the end of it and a very sharp trocard tip. So this is one that one if somebody wants to push the tube in, you might be able to do that, but again, you may end up in the lung or the heart. Other tubes may come with a blunted ended trocar tip which is safer, of course.

My, this type of silicone tube here, it's got multiple side holes, and you can also see there's two black marks that, give you an indication that at least this should be where the skin and it gives you a little space. This is where the entry to the pleural cavity would be, so that you have a little indication of how far in you're, you're at. One of the problems for, with this particular tube here is it's nice, it's got a clamp, but if you notice, it has an attachment that's a three-way stopcock.

And so this will be very difficult to attach to a continuous suction unit. And so if you're doing intermittent suctioning, that's fine with a syringe, but if you're doing continuous, this tube would not be appropriate for that. The Previous ones that we looked at are more appropriate for continuous suction because the tubing here is flared and the attachment and the connector to the continuous suction tubing will fit in this inside this, whereas it will not fit on a, on a three-way stopcock, a female adapter here.

There are also some polyurethane options as well. Again, pay attention to what the end of the, the the, the distal end, the proximal end of the tube is because again, if you're using continuous suction, this type of tube won't fit on the connector. There are also a variety of different connectors that can be put on and adapters.

Keep in mind that if you're using a large bore purpose-made thoracostomy tube, these ends will not fit in there. Yes, you can put an adapter on there and then screw on some of these attachments. However, realise that if you have a big tube in having a smaller diameter.

Attachment tube to it is going to negate what you're trying to do in trying to aspirate large volumes quickly. These adapters, and tube adapters can be a benefit because some of them will have a one-way valve on it so that if you attach them to a tubing like this, you can aspirate and without disconnecting, you can push out your fluid or air at the other end because there's a one-way valve attachment here. So we'll go with another poll question.

Elka, just to let you know that we've got the polls working again hopefully so we can actually run this one as a poll this time. Excellent. Right, folks, so I'm launching the poll.

The question is, general anaesthesia is required for thoraccostomy tube placement. True or false? Simply click on the answer, you know how it works and we'll give you 30 or 40 seconds to get those answers in and then we'll reveal them up.

Just a big thanks to Simon in the background for getting these working. Well done, Simon, thank you. Right, folks, let's get those votes coming in another 15 seconds and then I'm going to close the poll.

Just click on the answer. Remember it is anonymous so it really doesn't reflect anything. If you're wrong, it's just take your best guess on what has, has been said by ECA so far.

Right, we've got a couple of stragglers that don't seem to be taking a vote. So let's end that poll and reveal the answers to you. There you go.

OK, you should be able to see those. Yes, thank you. All right, so most of you said false and and I agree with, with you.

I think it can be easier and probably a more controlled environment, if you do do general anaesthesia, but it's, it's not required. In some cases where you have a patient with a tension pneumothorax that really is, it might be about to, to, die before your eyes, you may just want to get that tube in with a sedative and a local block right away and Getting a patent exit for that air will be better than having that tension pneumothorax build up. If you do do general anaesthesia, you want to have all of your equipment ready and your person ready to, whoever is putting the thocostomy tube and ready to go because, again, you are going to have restricted air movement and the anaesthetist needs To be well aware that they cannot give the same volumes of inspired air when they are giving assisted ventilation to the patient that has pleural space disease.

So good. I'm glad that we all are mostly in agreement. So anxiolysis and sedation, very typical things that we'll use are butterphenol and we can also use alfaxolone.

The alexolone, although it's a general anaesthetic, you may use it just to the effect that you want to get to, to restrain the pet enough. It's, receiving oxygen flow by and you can put the local anaesthetic in. If you do use general anaesthesia, again, as we talked about, you will want to have a dedicated anaesthetist who understands that that patient is going to need assisted ventilation and how to do that.

Appropriate monitoring with EKG pulse oximetry, and if they are intubated, or a tracheally then entitle CO2 and surgical preparation. And if you are going to put the patient under general anaesthesia, make sure you do your surgical clip, and initial cleaning before you anaesthetize them to minimise the time that they are going to be unable to ventilate for themselves. So, I'm going to show you the catheter or thoracostomy tube placement in a cat and then in a dog.

These are clients owned pets who died and the clients. They are aware that we were doing these procedures on their pets. They agreed to that.

Thankfully, they were very kind and know that we are doing this to help other pets that, that may be in need, so please know that that is what was happening. So, we're not going to do a surgical prep on this cause so that you can see what we're doing. And in this particular cat, we're going to make an incision in the skin just big enough of the diameter of the chest tube.

You don't want too much opening around the chest tube because then you may have air that can leak out or communication. So around the 10th, 11th rib space, I'm going to make my skin incision and then I'm going to go 2 to 3 intercostal spaces cranial to that, so there's a bit of a tunnelling effect. And then if you notice I had put my thumb at the tip of that tube as I punctured it through.

To make sure that I only went a certain depth into the plural space. I then pulled back the trocar and moving the tube in a cranial ventral direction, I leave the trocar in but just with that tip within the tube rather than extending out of it to minimise trauma, but it keeps it stiff and then I can remove the tip, the trocar. Some of those trocars also have retractable tips so that if you put any pressure on them, they get pushed into the, the trocar.

So there's lots of options out there. In terms of securing it, there's a lot of different ways that people will describe. And what I'm going to do in this particular cat is to actually try to go around the rib with a large gauge catheter, non-absorbable suture.

And while you're doing this procedure, make sure to communicate with the anaesthetist if they are anaesthetized to not ventilate the PET as you just initially put the chest tube in and as you initially get your needle in around the, the rib there. So, make a bit of a loose suture in the, in the skin around the rib, and then I'm going to go around a couple of times with the end of my suture and collapse down the suture. Some people prefer to do a finger trap.

I think it takes a bit of skill, which I don't have to make sure those are secure. So I just collapse all of those . Circular sutures down together so I can bring them together and just indent the tube a little bit to know that it's secure.

And then I'll come across without cutting the suture and do the same thing on the other side. I'm having a little bit of difficulty here trying to get that needle to come around. So I'm going to just bend that needle a little bit to reduce the curve so that'll come around and up and out.

I've asked if this cat were anaesthetized, I'd ask the anaesthetist to stop ventilating while I do this and then pull that needle and suture through. Tell the anaesthetist if it's anaesthetized to start ventilating again. So, The biggest thing, if you happen to make the skin incision a little wider than you wished, then just put a little suture to close that skin incision a little bit.

I personally am not a fan of doing the cir circumferential sutures around the tube because I feel like the skin can lose the blood supply if we do that. So here's one of those myola adapters. That, Allows you to do intermittent suction.

This would not fit on a continuous suction. So, the one thing I didn't do on this cat is to put a second stay suture, just a little caddle to that, a few centimetres, just into the skin to secure it, just to have a backup so that it can't get accidentally pulled out. And then we're going to do a sterile dressing and a little bit of hipfi to secure it to the skin.

So this, this patient will need an E collar on to prevent it from inadvertently pulling the thoracostomy tube out. So, here's another technique that I'm going to show you in a dog and again, in real life, the patient would be sterilely prepared and have a drape. But I have an assistant here, instead of trying to enter the skin and then tunnel forward a few rib spaces, I'm actually going to have somebody pull the skin of the lateral thorax forward and then go straight in.

And so I'll count back and anywhere between the 7th and 8th intercostal space. I'll put that tube in, usually in the mid thorax, midway between the spinous, the spine and the sternum. And again, make an incision that's going to be about the width of the tube so that we can have the tube snug in there and not have the potential for leakage around the tube and In this case, I'll take a curved car malt, and I'm securing the tip of that car malt with my hand so that I don't let it go too far in and I'm going to puncture through the plural space and it can take a bit of force to do that, which a lot of, makes a lot of people a little bit nervous.

Some people are really good at using this method with the car malt to actually help guide the tube between and I never have success with that. So, I'm going to get rid of the car malt and I might use the, pull the tip back just a little bit to keep the tube stiff and then go back and the hole I made feed it through fairly easily, guided in a cranial ventral direction. I And then feed the tube and or sorry, take the, the trocar out.

Again, ensuring that all the holes are within the pleural cavity. Otherwise, if they're under the skin or outside of the skin, then we'll get, air, air from the outside and it won't be effective. So Here you can see that once we release the skin, it causes a natural tunnel.

And we're going to secure, as we did similar to what we saw on the cat. It's a little harder to get around the rib in a big dog like this. So you might, some people like to go through the periosteum.

To try to secure it to the rib. Again, the idea of when you secure this, you want the tube not to be able to move in and out of the skin and then potentially have the holes come in and out of the pleural cavity. It also can contaminate the pleural cavity if that tube has the opportunity to slide in and out.

So I'm gonna skip forward here to the end and you'll see that in addition to the securing sutures up at the exit site, I'm going to do a second one just to the skin using the collapsible the collapsing the sutures down over each other. And then again, we're going to put a sterile dressing with the hipfix over this, and this type of tube definitely can withstand continuous suction for this particular patient. Whenever we put a plural catheter or thoracostomy tube in, we do want to get confirming radiographs and make sure that we're satisfied with where the tubes are placed.

Occasionally, you will see the tube curl around on itself or go up in the dorsal space, and if that happens, if that tube is functional, go ahead and leave it. If the tube is kinked and not functional, then you may have to remove it or partially pull it out and try to, to, do it again. Let's see here.

All right, so post placement radiograph, we're going to ensure that all drain holes are within the thoracic cavity, cover the drain exit site with a sterile dressing, and then, depending on the amount and of, and the volumes of fluid or air accumulation, decide if we're going to aspirate intermittently or continuous. So let's talk a little bit in the last few minutes here about chest drainage and how We can allow that to, if we're not actively suctioning them, there might be other ways that we can allow air or fluid to come out. So one is with expiratory positive pressure, and I'll show you the Heimlich valve in just a minute.

Another is with gravity where we only have we have the patient working to expel things out of the plural space into the, into the chest tube. And then there's intermittent or continuous active section. So Heimlich valves are one-way flutter valves that are attached to the thoraccostomy tube.

You can, and then actually this is the same material they use as the Penrose drain in here. And that valve allows plural air, air and non-viscous fluids to be expelled during exhalation. And the patient needs to be spontaneously breathing and, and people, they are told to cough or, or make a valsalva manoeuvre where they then open up the lungs and then push the pleural air or fluid into this tubing and out the Heimlich valve.

They are inexpensive and simple, but they're, they are prone to malfunction and work well only for low vime air leaks and very mild pleural effusions. They are easily occluded by secretions and that potentially can be life-threatening. Additionally, patients that are weighing less than 15 kilogrammes may not be able to generate enough pressure to break that seal to open up that drain, and expel the air or fluid.

So, we, really, I guess you can have these on hand if you're using a thoraccostomy tube. Again, it's going to need a purpose-made thoraccostomy tube because of the attachments and the adapters that are on these Heimlich valves. But if, for example, you were looking to transport a patient with the tension pneumothorax, to another facility, this might be a way that you can do that fairly safely.

Now, continuous drainage can get a little bit more tricky and pretty much any patient that has a pleural catheter in or a thoraccostomy tube, they do need continuous monitoring. So, the here we've got now the opportunity to talk about how to set up continuous drainage. So, initially, the, the very basic underwater water seal is a is a contraption where we've got the patient hooked up to a tube here that sits underwater, 2 centimetres of water, and this allows air and fluid as the patient spontaneously breathes to come out into this bottle and then as the volume gets displaced, there's then this exhaust valve, so to speak, that allows it to come out.

So this is a passive drainage system. And a one bottled water seal. The patient has to be higher than the drainage device and that can be somewhat difficult with large veterinary patients, but this is a very simple way to allow continuous drainage on a, on a patient if you don't have the more sophisticated chamber, three chamber type apparatus.

So, We can add to this a collection bottle so that When fluid is expelled out of the plural space that it can accumulate in the collection bottle. If the fluid accumulates here, we have to Occasionally then drain it out and maintain a 2 centimetre water seal. If the water accumulates, it gets harder for the patient to breathe, because there's more pressure against which it needs to breathe.

The other thing that can happen with this particular system is this water can evaporate if there's fluid not coming in, the water can evaporate and the, and the column gets smaller. To this, then, if we want to do continuous section, we will add a 3rd chamber. At which we will adjust the amount of pressure That will then go to the section.

We'll use a suction control column where we put anywhere from 1512 to 20 centimetres of, of water, and that is filled to that height with fluid and that depth of water in the suction bottle determines the amount of negative pressure that can be transmitted to the chest. So you can turn your suction on. Very high, but ultimately, this column of fluid is going to generate the pressure that will be transmitted to the chest.

So it doesn't, you don't have to worry about what your settings are for your suction unit. So this 3 bottle system has been converted now to a single unit that has the same parts in it, but instead of having 3 bottles, now we have a single unit that does the same thing. So we've got our collection unit here on the right that's coming from the patient and it's collecting the fluid and there's usually markers on here that tells you how much fluid is accumulating over time.

And then the next chamber is a water seal chamber, so there's 2 centimetres of water that's kept in here. But it's not affected by any more the fluid that's coming from, that might be coming from the patient. The, then the third chamber here, which is our suction control, is filled up to 20 centimetres of water and then to the suction apparatus, so that there can be continuous suction applied to help evacuate the plural space safe.

So again, whatever amount of pressure we adjust on the suction unit is, is not going to be actually what's applied to the patient. It will, it will be dependent on what the amount of water column of water that we have in the suction control chamber. So briefly, patient, tube coming from the patient, the tubing coming from the patient enters the collection chamber, the fluid collection chamber.

You can see here the millilitre marks. And then any air that's coming from the patient travels across the top and into our water seal chamber and it's going to bubble through this air leak monitor. And it's all going to be controlled by the amount of water that we put in the suction-controlled chamber that's attached to an external suction unit.

And the air leak monitor is pretty nice because it has these marks 1234, and 5 that allow you to somehow quantify the amount of air leakage from the patient. So you may start out with a patient with a tension pneumothorax where the bubbles are coming out to the 4 mark. And then over a period of 24, 48 hours as they go as the seal is formed in the lungs, the amount of air leak gets less and you may see only occasional bubbling or bubbling coming out to this one mark.

So this gives you a way to quantify how the patient is doing. There's a wet suction and a dry suction, and so far we've talked just about the wet suction, and that's where we'll see these two units on the right, where we're adding the column of water to the degree and the amount of pressure we want transmitted to the chest cavity. And newer technology has allowed these chambers to become dry, meaning you do no longer need to put in a column of water, to control negative pressure.

There's actually a little dial that's internally regulated and you can adjust that to the centimetres of water pressure that you want transmitted. And that makes it a little bit easier to use because if the, you don't have to add water, so it doesn't take time if you've got a a stat situation. And it also, if, if, if the, if the container tips over, you, you have less reason to have to, to to potentially add water and if it leaks out or, or, or not.

So, that's, if you're, if you, ideally you would ask for dry suction, collection unit. Although if you get a wet suction, it's less expensive to have, you know how to use them now. In terms of nursing care, dressing changes as needed.

It's important not to have dependent loops. As you can see on this particular pet who's on a ventilator, he's got some pleural effusion and it'll accumulate along the bottom of this tubing. And you can intermittently lift this tubing up so that it'll drain into the container, but if at all possible, we try to have as, as direct of a shot of that tubing going from the, the patient and to the collection chamber.

But if you need to, you can bleed the fluid. Most of the time they'll need oxygen support. We want to record their outputs and provide adequate analgesia.

Periodically, we may want to manually section them to make sure apparatus is working, but most of the time, if you're, if you, for example, have a pneumothorax and you see those bubbles going through and the patient is, is not having difficulty res respiring, inhaling, then you know your system is working. And so here you can see it, that's our suction unit generating negative pressure cause this is a wet system. Complications can include inappropriate placement of the tube into the abdomen.

So, learn your, you learn your placement techniques and as much as you can on cadavers first, so that you're comfortable doing it on live patients. . Tube slippage.

So mark the end of your tubes, know where they're coming out of the the skin, and of course, infection. So aseptic technique and wearing gloves when dealing with this patient at all times. So in terms of removal, traditional recommendations are if it's fluid that you're trying to drain is when the drainage is less than 2 millilitres per kilogramme per day.

But in reality, the tube itself, no matter what it's made of, can cause some irritation and fluid production. And so you may have to use clinical experience to know when to remove it. .

We want minimal air drainage. There still may be some, but ultimately, we do a step-down process. So if we have a thocostomy tube in place with continuous drainage and we're ready to test the patient off of it, we will disconnect the continuous drainage and then put on a three-way stopcock system that we can Manually aspirate initially every hour or two and see how much residual is building up and then extend that time period between aspirations.

And once we have minimal, not necessarily negative, but we have minimal air accumulation after 12 hours, we might remove it. So, we'll go, we'll finish off with our last questions. Right, folks, poll is launched.

The question is, what is a hallmark sign of plural space disease? Simply click on the relevant answer, the one that you feel is most appropriate for what we have heard in this excellent presentation. Oh, we're getting fast, fast voting coming in because so that's always a good sign.

Oh, I think everybody wants to go and have a drink. The disadvantage you have is we can drink and listen to you. I'm on my way to work.

That's what I meant. You, you're you still got a day's work to do. We're at the end of our day, so it's all good.

Right, folks, another 10 seconds quickly. Right, let's end that poll and share those results. Excellent.

Yes, asynchronous breathing pattern. And remember that when they're trying to inhale against pressure in the plural space, that effort will come through on inhalation. Great.

We can move on to the next poll. This will take a little bit of reading, I apologise, but Wanna make sure everybody's on board. Right, so it's a question of which of the following statements are true.

So we'll give you a little bit longer on this one because there are multiple answers or multiple possibilities that need to be read through. Yeah, we got some speedy readers coming through quickly on the answers. Speedy readers and smart people.

Absolutely a lecture. So it's a good combination, a lovely team. Alright, we'll give you another 15 seconds on this one because it is a little bit more complicated, folks.

Alright, 5 more seconds. Few stragglers still coming in. Right, let's end that poll there and share those results with you.

Yeah, so the majority of you identified that ultrasound of the thorax can identify presence of pleural error. That's absolutely true. A radiograph is actually, yes, it can and will diagnose plural space disease.

However, our auscultation and a diagnostic thoraccocentesis might do that before we have to position the patient for a radiograph. Thoracentesis, can absolutely be performed prior to imaging. If you suspect that they have plural air or fluid based on an asynchronous breathing pattern, and you've got decreased lung sounds transmitted on auscultation.

Excellent. And we'll go to the last question here. Right, folks, there it is up on your screen when choosing a thoracostomy tube, the size should be.

Any one of the answers. Oh, we got some fast people coming through already on this one. Excellent.

It looks like everybody was paying really good attention, Elka, so that's good. Are they all know it already. No, I think it was a, a really, really good lecture.

We got a few variations coming through now. That's fine. Right, 5 more seconds, folks, and then we're going to end this poll.

Right, let's show those results quickly for you. Yes. So, we want a tube, if we're doing a true purpose-made thoracostomy tube placement for continuous drainage, we need that tube to be of a diameter that it can effectively and rapidly remove the amount of Accumulation as well as the sustained with continuous suction.

And so we if if we make it smaller than the, the width of the four thoracic vertebral body that actually may be a little too big, . And if it's greater than the width of the trachea, it's not likely going to fit in the intercostal space. And we certainly want a large enough tube.

So, knowing that that tube has to go in the intercostal space, we know we've got at least half of the width of that intercostal space. Some people will also say, well, what's the, what's the Worst leak I could have in the chest cavity and that might be that if there was a main stem bronchus that was lacerated, and so some people might use the size of the main stem bronchus as a general guide to the size of tube that they want. But you do have to think about what its purpose is.

So, thank you so much for listening and again, anybody's welcome to contact me if you've got additional questions or if you think I made an error. I'm certainly want to know that and you can send me an email. As I showed on the first, the first slide, except again I, I spelled my name wrong.

I'm sorry. I can't even spell my name right. That's OK.

OK, we popped your email address into the chat box. I did it right at the beginning. So, people have had time to write it down and everything else and .

OK, that was absolutely amazing. I know I've learned a lot and refreshed a lot of, of stuff that we've learned before that just comes back to the fore. So thank you for the time to share this knowledge with us.

Thank you for having me. Have a great evening, everybody. Folks, that's it from us for another member's webinar and we will catch you next time to Simon in the background who made all the technical things go away that we were able to have polls.

Thank you very much and good night to everybody.