Using Handheld Point-of-care Ultrasound to Assess Feline Respiratory Distress: A Case Example | Veterinary Videos & Podcasts

Excellent. Thank you very much, Charlotte. I apologise.

It's a very long introduction. You made me look, very good. next time we'll, we'll shorten out if we do a second one.

But thank you all for joining us this evening. It's lunchtime here, 1 o'clock in Calgary, Canada, where I'm coming to you virtually online. And as, Charlotte.

Mentioned, we're gonna talk about point of care ultrasound, the handheld applications in some of our patients with feline respiratory stress. This will go over, 60 minutes. I was planning on a 90 minute, lecture.

So if you guys have to go, please, and you have questions, just fire those to me in an email. My email will be at the end of the talk. It's also here as well, and I will say that a lot of the presentations, if you've listened to me in the past, will be done with Doctor Sir Shaloub.

Unfortunately, he couldn't access to the internet where he is because he's on vacation with the family. I didn't have internet access, so he won't be able to join us tonight, but you will see him come up from time to time. I would also like to refer you guys back to a previous lecture that Doctor Chris Garin did that really went through some of the core basics when it comes to lo space and lung sound.

He did this session for Butterfly, so you should be able to find that, and we'll put a link in the talk later if you want to go back and review that, cause it does complement today's talk quite nicely. The objectives for today, we're gonna introduce point of Groan. We're gonna go through the definitions evolution, history of how we got to where we're at, some binary questions that we really use.

Use point of care ultrasound to keep us focused. We're gonna talk about the general formats and clinical applications. So this is gonna be a really, a sort of an umbrella overview of how we can use point of care ultrasound in the clinical setting.

And then to tie it all together, we're gonna have a case that we present to you, feline respiratory stress, is it cardiac or respiratory in origin, and just sort of show, it's only really gonna scratch the surface of what we can do with Poi sound, but we'll see if we can use Poiar sound to help us figure out the. Problem in our case as we go through this session today. So we're gonna start with the definitions evolution of veterinary appointed care all sound.

And this really all started with the fast exam. Most people are very, very comfortable or familiar with the fast exam, but just to reiterate, what is it, it is a focused assessment with sonography for trauma. And if you think about the FAT exam, which is something again that a lot of us are using in our general or emergency practises, pretty much on a daily basis, where did that or where did that initially start?

It was developed to pathology in trauma patients in both human and veterinary. Started on the human side. We adapted that to the veterinary profession with the original FAST exam that was published on the Tufts.

This was, created in 1999, published in 2004. It was a very simple exam. It was an abdominal focused assessment exam, 4 points, patients positioned in later recumbency.

And if you look at the first two papers that Came out on fast on the veterinary side. It really did parallel the human side. What was the goal or objective?

What was it we were looking for in those veterinary patients? Really simple. We were looking for free fluid.

That was it. That was all. 4 points, abdomen, free fluid.

And then Doctor Luandro published a landmark study in 2008, following on from the, search for fluid in the abdomen with the thoracic fast exam. Again, this was what was being done. On the human side, we adapted it.

Dr. Leandro did in 2008, and he adapted the extended fast from the human lilature, turned it the thoracic fast, and applied it in our veterinary patients. What was the goal at that point in time when he first published it?

Again, this was really easy. Four point exam, patients were in right lateral, and it was for trauma, looking for once again, simple things like they did on the human side, not making it complicated. Pneumothorax, so air in the plural space, along with pleural effusion and pericardial effusion.

Those were the original goals when you look at both the human and the veterinary fast exam, and they were limited initially to trauma. However, we did say, well, just like in humans, can we use these formats outside of trauma? Can we make this something that's used in the emergency, more applicable for general practise on our patients presenting, whether they're cats or dogs?

So we did a study, and this is actually one that was done by one of our students, which really emphasises that this is a format and an exam that anybody can do with minimal experience because this study was published by one of our 4th year veterinary students. So, what is the application beyond tramadam? If we look at this actual study, it's interesting.

They looked again for what FAST was designed to look for free fluid in any cavity, plural space, pericardial space, and abdomen. We did not look for pneumothorax in this particular study because it was non-trauma and the incidence was gonna be low. But we did want to see what the incidence of free fluid in non-trauma patients is using that AAST and TFAST format to look for that fluid.

This is where it's interesting. If you look at stable patients based on your triage exam, patient comes in, absence of trauma, it's a cat or a dog. You look at the heart, brain, lungs, and you say to yourself, is this patient stable or unstable?

And if your patient's stable on heart brain lungs coming in through the emergency and you put a probe on it looking for fluid in the pericardial plural or abdominal spaces, you got a less than 10% chance of finding fluid, whether it's a cat or a dog. Now that's not negligible, it's not super high. But there's still a chance you're gonna find something, it's just that chance is low.

So it's still worth doing, but less than 10% chance if your patient's stable when it comes to the emergency. Here's where it gets really, really interesting. If we take those same patients that come in and now they're unstable, cats and dogs, based on heart, brain, lungs.

So maybe they're tachycardic, maybe they've got pale mucus membranes, prolonged refill time, respiratory distress. They're unstable based on that triage assessment. What are the odds if we put a probe on, doing a fast exam, we will find fluid in the plural space, pericardial space, or abdominal space.

This is where it gets really interesting. If they're unstable. Cat or dog, doesn't matter which, it's greater than 75% chance that we're going to find fluid in that patient.

To me, that's amazing. More than 75% chance this fluid somewhere that will direct potentially your next diagnostic or therapeutic intervention because you find that fluid in the unstable patient. And you have to consider that this was originally done just looking for fluid based on the fast exam.

We've moved from fast into point. So, we're going to come back to that in a second. But we've moved into Poy Carroll Sound.

There's probably 30 things that we now rapidly look for in 5 minutes to figure out what's going on in our patients. And if we repeat this study, I'm willing to bet if we start looking for bee lines, we're looking for halo signs in the gallbladder wall, we're looking for free air in the abdomen, in addition to the plural space, then I'm willing to bet that this is going to be greater than 90%. And the crew in Belgium is actually, in the process of repeating the study with more applications of Point.

So this is one that I do think is quite remarkable in the sense that serious conditions that result in unstable patients have a very high probability that we're gonna find something if we put a probe on that patient. So this to me is, unbelievably sensitive and incredibly useful when it comes to finding something in our patients becoming unstable. So we've really extended that physical exam and triage exam to include point of care I shot.

So if we go there and say, well, OK, let's actually wrap this up then we talked about fluid in the original studies in the early 2000s of veterinary medicine, following on from what was done in the human literature. And in the human literature, they've moved beyond the fast exam, they're doing point of Carro sound. So, let's look at then, where's the evidence or what is the support to suggest that we should be doing more than just free fluid in our veterinary patients.

So, as we know, Back in the beginning, the thoracic and abdominal fast exams, they were looking for free fluid in the abdomen, to space and pericardic space. And the way I think about this, thoracic fast and abdominal fast, 4 points and the F and fast, you could also think of it as being for fluid. In the abdominal pericardial space, and you can take the A in fast for air in the plural space for pneumothorax.

That's all we were looking for back in the early 2000s. And then we said, you know what, when we're looking into the abdomen, we can see beyond the diaphragm. We can actually diagnose plural and pericardial pathology, called a lung pathology that via the abdomen at that subziploid site.

So we included that then in our exam as well. So it's kind of a four-point exam still, but also included the thorax via the abdomen. And then based on the literature on the human side, they were saying, well, we can look at the lungs.

That was something that nobody thought you could ever look at. You can actually look at the lungs, even though the hair failed, and diagnose pathology based on what's the lung surface. So, we added then in our veterinary profession, multiple different regional lung scanning protocols.

Lots of them out there, and we'll go through some of those today. But we added the lung to that. And then we said, well, you know what, we're doing a lot when we do our abdominal pointing car I sound, our originalA exam.

We're looking at these different sites in the abdomen. Can we look for something beyond fluid at those 5 sites? So we expanded it from 4 sites to 5 sites and then started to actually do the research to say, yes, non-specialists can look for things other than fluid in the abdomen with a high degree of accuracy.

And what were some of those things we did? We started looking at the renal pelvis and the kidneys. We started looking at GI motility.

We started looking at anaphylaxis, the gallbladder halo signs. We started actually looking at pneumoperitoneum. Not a lot of things that a lot of people are comfortable looking for, but we can diagnose pneumoperitoneum in a rapid, short period of time in our patients presenting to the emergency critical care service.

We also looked at tracking urinary bladder volume over time. All evidence-based research. Done by non-specialists with that five-point abdominal ultrasound evaluation.

Then we said, you know what? What about the heart? Cardiologists have always done the evaluation of the heart.

It was been a limitation that some of us on the ER or general practise, patients in respiratory stress, hm I wonder if you give furosemide or not, does that require a specialist to answer that question? Not underlying heart pathology in its fine. Details, but can a non-specialist pick up a probe, put it on the chest of a patient, and tell me whether or not I should give furosemide based on assessment of that left atrialic ratio.

And if you look again at the evidence and the research that's out there, multiple studies have shown non-specialists, and we'll come back to this, non-specialists can put a pro on the chest, assess the heart, get the windows, and make a decision. On whether or not that left atrium's enlarged or not, which is going to be hugely impactful when it comes to treating our patients with furosemide, for example, coming in with respiratory stress. So you can see that we've come a long way from the original goals of trauma patients looking for fluid in the abdomen or in the low space to a lot of different things we can assess across multiple cavities and organs when it comes to point of sound.

So then, because of this, we said, well, you know what, this is getting confusing. When I come in to the ICU in the morning and transfers come to me from the ER doctors on overnight, and they say fast negative. I'm like, OK, what was involved in that fast exam?

So we sent out a survey across Canada to see what people were doing. And it's nice to see that the general practitioners and emergency doctors are doing fast exams across Canada. The problem is if you actually look at what they're doing and include in their past exams, everybody includes something different.

Some are including volume estimates. Via the cola, some weren't. Some were looking at the gallbladder wall, some weren't.

Some were looking at the heart, some weren't. Some were looking at the plural space for pneumothorax. Some didn't feel comfortable doing that.

So everybody had a different skill set or level of comfort that they included in their past exams. And that got very confusing when they were transferred to the critical care service and they ER doctors just write fast positive or fast negative. I don't know what they're actually looking for or assessing, and everybody's got a different skill set.

So it became difficult. And that's where we really started to switch over from the fast terminology to point of sound, which is what they're currently using in the human profession. So this is why I really like and I've switched from fast to point of Carl sound because it's more inclusive.

It's not restricted in terms of what you Looking for. And this is the definition that I really like. This is out of the New England Journal of Medicine in 2021.

You can see that here by Dr. Gomez. This is a really nice review article if you have access to it, just to read where they're at on the human side, which is essentially where we're headed on the veterinary side.

So what is Point of Carroo? The acquisition, interpretation, and immediate, immediate clinical integration of sonographic imaging. Performed patient side or cage side by the attending clinician.

So that's you guys with the probe in your hand, regardless of your skill set, with the goal of answering a focused question or often series of questions rather than assessing all structures of all organs by a specialist. So instead of saying, hm I don't really know what's going on in the abdomen of this patient, I'll send it to a radiologist to scan every possible open differential diagnosis by scanning through all planes of all organs. Over the course of 2 hours, we can now say, whoa, whoa, wait a second.

I think this problem exists in this patient based on how it presented. I'm gonna put a probe on to see if I can rule in or rule out that specific problem based on my skill set. So this is where we go not only with free fluid from the original.

Studies, but we also look at condona cava size, gastric motility, gallbladder wall edoema, etc. And we'll go through each of those questions that we have studied, answered, and can apply in under 5 minutes at the cage side in a point of care fashion. And this is why I like point of care.

I'll sound and why we move towards it in the veterinary profession. So, what are the general applications then? What are the things that we've studied in general when it comes to point of care I sound?

Well, let's look at these. We've done abdominal point of care of sound. We're gonna go through that in our feline case.

We'll tie together some of these different things when it comes to what we can do with our Patients. So we've got abdominal ponyar sound, we've got plural space and lung ultrasound, and we got cardiac ultrasound, cardiovascular ponycar sound. These are the big ones that we've studied, and these are the big ones that we tend to teach in most of the labs of the universities when it comes to point Carl sound.

Now, I will say there are lots of new techniques being developed as research expands. We've come a long way from just fluid as research expands and as research continues to expand, we continue to add more and more to it. So, if you look at then, where we're going now.

Now, right now, if I ask the audience, if I was live, I would say how many of you guys are doing optic nerve sheet diameter. Every time I ask that, almost nobody puts their hand up. Optic nerve sheet diameter is something you're using in the human emergency critical care settings to assess.

For intracranial pressure increases and cerebral edoema. So they're looking at the optic optic, so they're looking at the optic nerve sheath diameter to say, oh look at that, this patient's diameter is big, it's getting bigger. This patient's got increased in cranial pressures and cerebral edoema.

We give a masalt, look at that, that optic nerve sheath diameter is getting smaller and returning to normal. Are we doing that yet in veterinary medicine? No.

Reference values are out there. There are studies that have looked at it in cats and dogs as well as horses actually, and there is a correlation. We're starting to see the evidence to say, yes, we can get a feel for intracranial pressures and cerebral edoema and response to therapy with the optic nerve she diameter.

So this is something that I'm sure in 5 years' time will become a part of the. Training and the lectures. Same thing with anaesthesia, they're doing a lot of ultrasound-guided nerve blocks.

So we do do that as well in our veterinary patients, and that is something I think that we'll start to see more and more outside of anaesthesia in the general stream when it comes to Poo sound. But we're gonna focus because this is the area that has the current support abdominal floor space lung, and cardiac point caro sound. All right.

So let's come back and break these down then and look at the questions we can ask and answer at each of the sites then, because this is actually not that complicated. If you look at 5 sites in the abdomen, based on the originalA study, what are the questions we can ask and answer at this point in time? With point of care of sound, all within 5 minutes in a rapid fashion.

So we can look at like the original studies did, all 5 of those locations in the abdomen for free abdominal fluid. Free abdominal fluid will fall to gravity dependent sites, so we need to change where we look in the abdomen based on patient positioning and the pathology we're looking for. This isn't rocket science.

All you got to do is ask yourself, what am I looking for? Looking for fluid. I want to rule it out in this patient that presents for shock, clots, and I'm worried about hemo abdomen.

You put a probe on the abdomen, think about he's lateral, I got to go to that gravity dependent spot if I wanna rule out smaller quantities of fluid that might accumulate over time. So we look at all sites and it changes where the most likely site is to find that fluid based on patient positioning. We also look for free abdominal air.

Which will also change based on patient positioning. Fluid falls, air rises. So we check the most non-gravity dependent site in our patients based on patient positioning to look for or rule out pneumo peritoneum in the abdomen.

Now, in addition to those things that could shift based on patient positioning, we have things we look for specifically at each of the five sites because they're not going to shift. At that urinary bladder site, then we will also look for and assess the urinary bladder for volume estimation over time. That is the calculation of a sphere.

In our female patients that are intact, beautiful spot as well at that urinary bladder site to assess the uterus for pyometra, as well as at the umbilical site for the uterine horns to see if they're also fluid filled. At the two para lumbar sites, what else can we look for there? We've looked for and documented.

Ilias and assessment of GI motility at the duodenum off that right para lumbar site. Great spot to look for if you're worried about, has my patient got ileus? Should I put him on a pro kinetic?

Nice spot to assess that duodenum off the right paralumbar site, just call them and a bit more, towards midline. You can pick up that duodenum and assess it for motility. Same thing, both those sites.

We got the kidneys there. We look at the renal pelvis for dilation at that site as well. And then the big site that we get the most information from, that is the sub-ziploid site.

Lots of information we get there cause lots of different structures we can assess there. What else have we looked at in our general and emergency practise, settings? Gallbladder wall edoema.

Yes or no. Gastric ileus or fluid distention, yes or no. OK to give a fluid bolus by assessing the callna cava.

Pericardial fusion via the subziploid site beyond the diaphragm. Beautiful spot to pick that up. Pericardial effusion, yes or no.

During active CPR when we're doing chest compressions, patients are lateral. Subziploid, we can often see the heart and then assess it for cardiac activity when we switch our compressors during active CPR. Something that's done on the human side that I'm sure we'll start to see more and more.

On the side, pleural fusion, one of the originals, still something we're gonna look for in that thorax, via that subziploid site, and also a nice view of the caudal lung surface that we can't assess transthorastically at that subziploid site. So those are the general questions that we're gonna answer as in addition to the umbilical site where we can look for and find the spleen. Now, this is one where Often, if we see a hemo abdomen, we look for a splenic mass, or sometimes we just see a splenic mass.

I'm gonna say this is an area that we don't yet, despite all the research and the other sites, have the research to say that non-specialist general practitioners can accurately assess or determine whether there's a splenic mass or not. So we need a bit more research on that, but it is a site and we can see the spleen very easily umbilical site. Now, remember, when we're doing this, it's really important that this is integrated.

This is patient-centered and targeted. We need to incorporate our history, clinical findings, and all of those diagnostics when we assess our patients. So, remember, history and clinical findings help you narrow differential diagnosis and help you determine where you're going to put the probe, OK?

All right, excellent. So that's kind of the general of the abdomen. Let's move into the thorax.

All right, so Thoracic, plural space and lungoff sound. This one's super easy. If you're looking at the abdomen and you saw there was probably 15 questions in the abdomen that we can assess, ask and answer.

What about the plural space? This is super simple, plural space and lung of sound. How do we find the correct sites and what are we looking for?

There's only 4 pathologies we look for in the the plural space and lungs. So this is why I really like low space and lungs. It's got to be my favourite thing to assess because it only looks for 4 pathologies.

In the plural space, what are those pathologies? The big ones we look for pneumothorax and pleural effusion. So this is plural space pathology, pneumothorax pleural fusion.

There can be other things in the floor space, but for the most part, we are going to focus on looking for pneumothorax, air, and fluid in that floor space. And the lungs then, again, not a lot you can look for. There's two big things if you put a probe on the surface of the lung and you can see the surface of the lung, two big things you're looking for increased bee lines as opposed to a normal lung surface, often referred to as wet lung, and consolidation, which is simply worse.

Condition in the lungs, progressing from bee lines to consolidation. So those are, this is why I love the pore space and lung sound. If you think about what's in the thorax, it's the lungs and the polar space plus the heart that we look at, look at separately.

So really, there's only 4 pathologies that we really concentrate on in the thorax. Occasionally you can see masses or you can see dramatic hernias, but these are the 4 big ones that we look for. And then we've got cardiac point of care of sound.

Now this is another one that again we don't want to overstep our bounds. We got to stay within the comfort zone. What is it we're looking for on the point of care emergency setting under 5 minutes when we're looking for our point of care assessment of the heart.

This one is again super simple. Start with pericardial fusion. Start with what we did originally in the human and the veterinary applications when it comes to point of care some fast exams, pericardial effusion.

The next step we're gonna do, once we've got our level comfort with pericardial fusion, we're gonna go after that left atrial aortic ratio and heart failure and volume overload. So we start with heart failure and that LAAO. Again, lots of evidence to say that we can run that.

And then we do volume estimation. So what is it we do with our volume estimation? So this is again by looking at the heart and also looking at the vena cava.

So those are the questions we'll start with when it comes to point of ultrasound of the heart and vascular system. So that covers the abdomen, the floor space in the lungs, and the heart and the questions that we can ask and answer in our veterinary patients when they present to us in the general practise or emergency medicine. All right.

So, let's now turn our attention to the clinical setting and how we can apply this in the clinical setting. So, Applying point of care I sound again, varies depending on the patient that comes in and the clinical setting that's encountered. So, I always tell people to think of this similar to a physical exam.

When you do your physical exam, you don't do exactly the same physical exam on every single patient. If the patient is unstable, you do a triage exam. If your patient has a lameness, you do an orthopaedic exam as opposed to a general physical exam.

So, I compare point of care ultrasound when we're applying it in the clinical setting, similar to a physical exam and similar to the fact that the clinical exam varies depending on the patient presents on whether or not you're gonna do a full ophthalmic exam or whether you're gonna do a full, physical versus a triage and abbreviated exam, same situation with point of care. So, how does that, relate to our patients then? Again, then, I always tell people this is patient-centered and targeted.

You have to think about the patient. You got to consider the history and your clinical exam findings to tell you where you should start and what you should do. So regardless if it's abdominal, plural, or cardiovascular, regardless of the four big things we talked about, we need to focus on our patients.

Then we combine the clinical other diagnostics history of that patient to come up with what we think the most likely underlying problem is for that patient's presenting complaint and initial physical exam for triage findings. That's our pretest probability or Bayer's theorem. What is the likelihood of this problem existing based on my assessment at this point in time?

And that will dictate how and what we do with Poni Carl. So, for example, you assess your patient and your patient's unstable. Heart, brain, lungs, unstable.

Where do we start with our point of care ultrasound then? Well, we're not gonna assess everything we possibly can in that patient with ultrasound, just like we wouldn't with the physical exam, assess everything if our patient's unstable. We do a triage exam.

So just like the triage exam, we're doing a triage point of care ultrasound application to try and prevent our Patient from decompensating minimal windows to find the underlying problem. Perfect example of that. Patient comes in, there's a dog.

He's collapsed in the park. He's been out there running, comes in, he's tachycardic, he's got pale mucous membranes, propillary full time. You're feeling the pulses, you what?

No, you don't feel the pulse. Wait, oh, there it is. Nope.

Wait, no, yes, it's coming, it's going. It's waxing and waning with the respiration. That pulse is hard to feel at times when the patient is breathing in and becomes more palpable when it breathes out.

Based on that information, it's a golden. It's 6 years old, it collapsed. And let's throw in some muffled heart sounds, and you've got waxing and waning pulses for respirations.

What do you guys think? I'll actually let somebody type something in the chat box. What do you guys think is the most likely cause based on that presentation?

Goldman, 6 years old, muffled heart sounds, waxing and waning pulses, pericardial effusion, thank you very much, Natalie. That is brilliant. I suspect pericardial fusion.

So if my patients got and I suspect pericardio fusion based on that history and initial triage. Do I start by putting the probe on the kidneys? No.

And do I want to assess everything possible in that patient. It's trying to die. No, what am I gonna do?

That patient, I suspect pericardio fusion, I assess the heart. If he's got pericardio fusion, he's unstable, and he's got tampa ab. I tap that pericardial space, just like you see we're doing in this image here.

You got to stabilise the patient before you do additional diagnostics. Your patients really unstable. So it's just like that triage exam, find the problem, stabilise the patient, then come back and do additional diagnostics.

And that brings us to our next step. If we find something on that initial triage or during our more stable point of care o evaluation, we can do an intervention. This is where treatment comes in.

This guy came in in respiratory stress. We gave him an anxiolytic. You can actually see when we, flip over the other side here that this patient.

Is on oxygen. So you can see we got him on oxygen. And here we are.

We're walking and needling without some guidance in that to space. And right up here, look, there's the needle comes in, nice, safe way to stay away from the lungs or other vital structures to treat that patient. So we can definitely use point of care ultrasound then again for treatment.

What about when we see a problem and it doesn't necessarily allow us to do an immediate intervention that's also. So it's not fluid or pneumothorax that we see. We're going to do an intervention.

Well, this is one where this is a patient that came in. If you're not familiar with the space and lung ultrasound, this is the lung surface that we're looking at in this upper image here. Do you see how bright white it is, right below where my arrow is.

This is all bright white. This is a rib shadow you see here. This is all bright white lung.

This is actual fluid in the lung or, pulmonary edoema, extravascular water. The patient came in with congestive heart failure, and we had this in start. We started furosemide.

And about 45 minutes later, you can see now, I've got a stripe, we almost call a zebra stripe pattern, black and white, less white than the top. This means there's less fluid in the lungs in response to my therapy. And at about the 2 hour, 3-hour mark, you can see, we've got marked improvement in this patient, we're down to, 1 beeline.

So we can track this. Severity of changes in response to therapy with that point of sound. So this is our serial evaluation, works really, really well to say, ah, is this fluid getting worse?

Is this pneumothorax getting better or getting worse? Is this edoema in the lungs getting better or worse? Or even with things that change more slowly, for example, pulmonary contusions or aspiration pneumonia, there's evidence out there to show that we can track that serially over time with sound.

How often we do it does vary depending on the disease. And the therapy that we're doing. And if it's not responding, then we probably got the wrong diagnosis or our therapy is not working.

We need to add to it or change what we're doing. So that's our serial evaluation. And the last one that's in there, we've got our systemic point of care ultrasound.

And this is one where the patients are more stable. These are the ones that get transferred to the ICU that aren't dying, that aren't in need of triage and immediate intervention. These are the patients, I'll pick them up in the morning.

I read through the record, I do a full physical exam. Assess that patient thoroughly and do a baseline point care ultrasound, which involves a systemic evaluation of that patient. If I'm really worried about something that's outside my skill set, that's where I bring the specialist in to take a look with me.

But the systemic point of care sound, this is pre or post-surgery, prior to discharge, make sure nothing's changed, or like I said, when I pick it up. This is Doc Schlu who unfortunately couldn't be here today, but he's doing an evaluation. He picked this patient up.

He just checked the heart. Now he's checking the kidneys. He's going to do a Baseline abdominal point of care of sound evaluation, scan through, make sure everything's OK.

And now he's on the, floor space and lungs. He's checking the lungs to make sure everything looks nice in the thorax before he puts it on therapy and to monitor that patient, more thoroughly over time. There you go.

You can see that we have multiple different applications. And if you're thinking this in terms of with the past exam, we talked about, trauma, triage and tracking. Well, if we go to point of care ultrasound and the more extensive things.

We're doing. Again, we've got trauma, we've got triage, we've got tracking, but we've also got that treatment or intervention and that total systemic evaluation. So just think about, if you'd like to use the Ts, just think about the different Ts that you could potentially apply when it comes to point of ultrasound.

Regardless, it's a past exam or it's a point of care ultrasound evaluation, there are 5 Ts that we can essentially apply to those patients to make us think, where are the indications. All right. That was our introduction.

That took us about half an hour to get through the introduction there. We're now going to move into a case example. So we're gonna look at a cat and see where we can go with pointing ultrasound in this patient.

So we're gonna go through this and see, a few quizzes. I may ask you guys a few questions. You did an awesome job, answering in the chat box.

I didn't prepare any specific webinar, polls, but we are going to, ask you a few questions in the chat box. So, team, This is Bains present for difficulty breathing, not eating three days indoor outdoor cat. 9 year old male neutered domestic short hair.

So you can see here, and yeah, there's a bit of an effort there. So this isn't one that I'd say is agile, but definitely got difficulty breathing, owner noticed that, not eating indoor outdoor cat. All right, let's active for 3 weeks.

Lethargic anorexic. We do our physical exam. There is a bit of nasal flaring.

Our patient is dismic. Depending on whether or not you're manipulating this cat, he gets very, very arthonic and pulls his elbows out. He is, again, as we said, less active for 3 weeks.

Crackles are sculpted on both sides of the thorax bilaterally, so we definitely have some crackles there, and it is a bit difficult to hear the heart. So, looking at this then, I'm thinking, OK, what are we dealing with? This is a cat with respiratory stress.

He's got dyspnea, some crackles, and a little bit hard to hear the heart. So, the questions are, is this polar space disease? Is this cardiac disease?

Is this pachimal disease, or is this a combination thereof based on how he presents? I would argue the crackles could certainly suggest a pulmonary pachimal disease, the decreased heart sound. Are difficult.

That's a little bit concerning. Maybe there's a chance he's got some pleural effusion or some pleural space disease. Asthma is always a tough one to diagnose in our feline patients, and that differentiation between cardiac and asthma can be very, very challenging.

So we're gonna go through that and see. And it is important to differentiate these causes because we do treat our cardiac respiratory stress differently than we would a pleural effusion or a yothorax differently than we would an asthma, for example. So what's our assessment at this point then?

How is our patient doing? So, first question I'll ask them, we're in respiratory distress, not stable. And therefore, if we put a probe on, it's probably a pretty good chance we're going to find something in Bains given that we are in respiratory stress.

It's going to be greater than 75% based on that research that we talked about earlier. So what are the general causes in cats? Is this likely an upper airway disease?

Based on our physical exam, I didn't hear any stur or, I didn't hear any stride or, I didn't hear anything suggested upper airway problem. So that seems less likely on the initial physical examination. So now the question is, plural, pulmonary or cardiac, where are we gonna go next?

Well, in these patients that are unstable, again, do no harm. Pool sounds very non-invasive, but at the same time, withholding emergency stabilisation procedures can be detrimental if we're trying to get that point of Carol sound done. So we want to do it concurrent with stabilisation.

So what do we do in our patients with respiratory stress, for example, in Bains? Well, we're gonna go with oxygen, and that could be an oxy. Cage, it could be a face mask, it could be full by oxygen, but we are going to do something to provide some oxygen because our patients in respirator stress, and we're gonna give an anxiolytic to decrease work of breathing.

This is an example here on the right. This cat was maybe a little bit overdosed. You can see he got very, very, very sedate.

But on the bright side, if you actually look at this video again, you can see how much easier this patient's breathing just because of the decreased work of breathing and the anxiety that was provided. So you can see that we did do that here. I'll play that one more time.

And see, we got some nasal flaring here initially when we're coming in. This patient was difficult to manage to work with, put in oxygen. You see there's a fair bit of effort to the respiratory movement there.

You see that effort to breathe. So we did, and there's no catheter in when this patient first came in. We gave the burophroil.

We got the catheter in. We got the cat more comfortable, kept it in the oxygen. You can see it's in the cage as well as with the oxygen flow by here for when we have to manipulate the cat, but look how much more comfort.

Our patient is breathing with that auction and leaving it alone for 10 minutes to allow those anxiolytics to kick in. So that's where we start. Don't kill the patient.

Pony car sounds very non-invasive, but we still want to be cautious with that. Now, differential diagnosis based on history and physical exam findings, we're going to go through and say, OK, is it cardiac or pulmonary? Now, before we put the probe on, there are some Feelings on which direction that patient's gonna go, and there are things that we definitely want to look at that might help point us in one direction or another.

Cardiac versus pulmonary. This is a nice, algorithm. I, I know that the, 3rd edition has just come out, for Silverstein and Hopper.

I have not actually had a chance to read that to see if there's a new updated algorithm. So this is based on the 2nd edition of Silverstein and Hopper. But the nice thing here is, is it doesn't matter which edition it is.

There are certain things that will lead us. In one direction or another when it comes to cardiac versus non-cardiac causes of respiratory stress in our feline patients. So for example, find suggested cardiac failure, sudden onset of clinical signs.

Most of our cats would come in, for example, with asthma, have a more insidious onset, not all, but most. And if our owners are astute, they'll have a history of a cough or maybe some intermittent respiratory distress or waxing and waiting signs at times. That's, again, what we tend to see with the asthma or pulmonary diseases compared to most of our congestive heart failure cats, they do tend to come in more acute with sudden onset of clinical signs.

Our cardiac, one of the other things that we often use to help us differentiate that, hypothermia. So we're going to check the temperature of our patients. We often say that cats with cardiac disease are more likely to be hypothermic compared to some of our respiratory distress patients that have pulmonary parranchimal disease, or feline patients, they have hyperthermia.

Murmur gallop rhythm, had to play the odds. Is it cardiac or is it non-cardiac disease causing respiratory stress? Well, if you got a murmur and gallop, we're gonna lean more towards cardiac.

Cardiac explication in our non, cardiac respiratory distressed cats tends to be fairly normal. These are things that will help us direct us. Again, same thing.

What about the history of recent medications? If we've had recent anaesthesia or corticoids and our patients. She develops respiratory stress within a day or two after that, then the first thing that I think in those guys then is that, OK, could I be pushing this patient into congestive heart failure because he had subclinical cardiac disease and it's that anaesthesia, glucocorticoids that's destabilising the heart.

And the same thing, man. This is, a cat that I saw a while ago. His name's Bob, this is his first name, his last name's blah blah.

So his name's Bob blah, blah. It's a really nice cat. I really love this cat.

He came in with a non-traumatic front limb paresis paralysis. You can see it here on that front right limb. So if I get a patient that comes in, he's in respiratory stress, and he's got, Uhparesis or paralysis, then I'm thinking, oh, could that be thrombolys and secondary to, congestive heart failure, hypertrophic cardiomyopathy was a specific problem that we had in blah blah blah.

So, these are some of the things that will help us differentiate those two situations. How accurate though, we do this, and we teach our students this, and I do this in clinics all the time. Give me a feel for which way I should lean with my feline patient in respiratory stress.

This is a nice study that was done by Ward at all. This is in the Journal of Veterinary Internal Medicine. Did a nice job on this, case here.

This is the study. We'll come back to this. I'll show you the actual paper.

This is when they looked at ProMBB and, They also looked at ultrasound for diagnosis. So they're differentiating respiratory stress with congestive heart failure versus non-cardiac disease. And you can see here that they've got CATs, 51 in total, 33 with congestive heart failure, 18 that were non-congestive causes of respiratory stress, so not heart failure, non-cardiac.

And we said temperature should be lower in our patients with congestive heart failure than non-cardiac disease causing respiratory stress in our feline patients. Temperatures almost exactly the same. So we talked about lower temperature in our feline patients suggesting congestive heart failure, but you can see this study, there was no difference in temperature between the two.

Small groups, but still no difference, which was interesting. Murmur present. So this one, again, is fairly specific cause most of the time you heard a murmur, it was a result of congestive heart failure that that patient presented with respiratory stress.

However, you can see there's some Non-cardiac causes of breast retress, 2 out of 18 of those patients had a murmur. So, it is leaning us towards congestive heart failure, but look at the percentage of patients that were in heart failure that did not have a murmur, 60%. So again, it's not very sensitive.

And then a gallop rhythm, this one was very specific. If you had a gallop rhythm and a cat coming in with respiratory stress, it was gonna be because of congestive heart failure. But only 40% of them have a Gallop rhythm.

So again, it's specific, helps you differentiate it if you hear the gallop, but 60% did not have a gallop, despite being in congestive heart failure, so it's not sensitive, OK? So you can see we still use those things to help get a feel for what the patient might have, but you can see there are some limitations with regards to sensitivity and specificity when it comes to differentiating congestive heart failure versus non-cardiac causes of respiratory stress in our feline patients. So what about point of Carol sound?

What's the advantage or is there even an advantage to us doing or putting a probe on the patient? Why is this potentially beneficial? Well, the reality is it can be performed on distant patients in a rapid, very, quick manner to assess that plural space and lungs.

It can be done in less than 5 minutes. Based on the human literature, if you look at pointing Carro Sound compared to radiographs for a lot of, not all, but a lot of diseases is actually more sensitive than radiographs. It requires minimal experience.

We've joined that on the veterinary side as well. We're starting to see the evidence that in some conditions, it is more sensitive than radiographs in our feline and canine patients to diagnose plural and pulmonary space disease. Again, a lot of research and room to play there to see further evidence to see how good it really is, but we're starting to see that now.

It's repeatable, as we said, we can do this seriously and it's non-invasive. It is actually no more stressful to the patient or invasive than listening. At this point in time, we all listen.

We all lean in with our stethoscope, and we listen by putting a stethoscope on that cat or that dog in respirator stress. Now, you can just take the probe. You don't even have to get into that animal's personal space by leaning in with the stethoscope.

You can just reach in or reach over like you see in this image here and scan that patient with no more stress than you would to listen to that patient. So not only can you hear, you can also look now to see what might be going on in the lungs of the space. One thing I will say though, bring the machine to the patient.

Drives me nuts when I come into the, ER and I see the students or maybe an intern. They've got the probe on a patient. I'm like, oh, what, what's, what's going on here?

And they're like, Oh, we've got a patient that came in and it had, history of hit my car, and we started to do the scan and they brought it to the imaging suite to do it though. So, The big thing here is, as you can see in this image in the background, you can see that this patient over here, he's got the oxygen on, it's got an anolytic on board. We brought the machine from the ICU into the ER.

We're scanning this patient cage side, not moving it from the area. He's getting his resuscitation to see what the underlying problem is. This guy has pleural fusion, we're gonna tap him here.

But the key is, don't. Take that patient off to radiology land or elsewhere when it's unstable. Continue your stabilisation.

Keep that patient alive, bring the machine to the patient, so then you can complement your initial evaluation while you're stabilising that patient. And again, you can do this like you said, you saw it in the cat, you saw it in the dog here. You can scan these patients while they're being stabilised.

So, Assessment then, which are the big three-line and respiratory stress causes of point of care, so, sorry, assessment, which are the three big pathologies that we can diagnose? What are the three big things we see in our cats and respiratory stress and can point of care sound really help us with that. So you see up here we got 3 differentials, pleural effusion, or plural space disease, pulmonary disease, So primary parunchimal disease, whether that's cell infiltration, neoplasia, or fluid in the lungs, and we've got cardiac, left atriotic enlargement causing cardio pulmonary edoema.

Can we diagnose these things with point of ultrasound? So it's a really good question. Is there evidence out there?

And yes, there is. There's probably 3 papers. This is one here by the crew.

I chose this one because it's out of the UK, which is where we're hosting the, the webinar from this evening. So this is the diagnostic actually of lung sound for detection of pleural fluid, pneumothorax, and lung pathology, dogs and cats. This study is really nice.

It found that you do get a fairly good correlation between pleural effusion and, But the diagnosis of pleural fusion using point of sound and CT. So this can definitely diagnose prankomal and pleural space disease. So we have a lot of evidence out there, lots of studies out there showing that point Carol sound in our canine and our feline patients is really nice.

For diagnosis of cardiogenic pulmonary edoema. We see that with the Bazozi study down here on the bottom left, and you can see this one here by Ward at all. This is the one, if you're curious about those physical exam findings and how they correlate between cats with cardiac causes of breast distress and non-cardiac.

This is the paper here that that table came from earlier. Really nice paper that also shows, yes, point also is good at diagnosing congestive heart failure, cardiogenic pulmonary. Edoema.

So a couple of papers out there on that. And then what about, finding left atrial changes? What about cardiac disease?

So we can definitely see pleural effusion without sound. We definitely see pulmonary diseases and, changes in the aeration of the lung. What about cardiac diseases?

Can non-specialists pick up a probe and put it on a patient? Really nice study, you haven't read this one by Luffer out of the crew at Tufts. This was just recently published in JBIM as well.

You can see that in 2019 and non. General practitioners with a minimal online training course, and a little bit of hands-on practise can accurately diagnose left a enlargin even in patients before they get into respiratory stress. So this is a nice pre-clinical, precongestive heart failure state that general practitioners can diagnose.

So lots of evidence then to say, yes, we can put a probe on as non-specialists and identify plural, pulmonary and cardiac diseases and help differentiate those. And again, how stable that patient need to be, we can reach into the cage and scan that patient in the cage without causing distress or risk of curation. So, now, a few questions though.

We talked about 2, we're gonna come back to Baggins in a couple of minutes. Do all cats presenting with dyspnea, so here's a cat comes in with respiratory distress. Do all cats with respiratory distress have detectable abnormal abnormalities on floor space and mone?

That's an interesting question. Does every patient that comes in with respiratory stress have findings that we can see on pointing girls. So, greater than 75%, I agree, but it also, it depends a bit on how and what the underlying problem is.

So there are gonna be cases that come in where that pathology in the lung that might be causing risk of stress does not reach the lung surface, or there can be cases where we actually see increased aeration in the lung with feline asthma, which isn't going to be sected with point of carrotone. So, there are situations where patients can come in with respiratory stress and we will not see. That with ultrasound.

So just be aware, ultrasound is very, very useful, but there are going to be cases where it's negative and a negative ultrasound finding does not rule out disease. This patient's in distress. He's got disease, ultrasound may not pick it up if it's gonna cause, for example, asthma, air trapping, and increased aeration in the lung, as opposed to decreased aeration in the lung.

We tend to see our pathologies in the lung with ultrasound when there's decreased air at the periphery of the lung. All right. So, asthma is a great example.

Not all of our feline asthma patients, you can see that on the right, we'll have, lung ultrasound findings when we put a probe on the patient. And over here on the left, this yenymal, disease, this is a, a mass in the lung itself causing some respiratory, difficulty. It does not reach the lung surface, so we will not see it.

So there are diseases that can cause respiratory. In our patients that we're not gonna pick up. So just keep that in mind.

Now, what's flip this around, we talked about patients that are unstable in general, when we put a probe on to see if we can find pathology. But what are the chances a dissonant cat with left-sided congestive heart failure will have abnormal plus findings. So if that cat has left-sided congestive heart failure, to the point that it presents in respiratory distress, what are the odds that we're gonna find something on point Carls?

And this is extremely sensitive to picking it up. If that cat comes in and respirator stress and therefore it's secondary to congestive heart failure, it's gonna have decreased aerated lungs because of that congestive heart failure and or it's gonna have low effusion. So again, I don't have the numbers on this from studies, but speaking clinically from empirical experience.

The probability of finding something if that patient's in respiratory stress because of congestive heart failure, that means he's got fluid in the lungs causing respiratory stress and or fluid in the floor space causing respiratory stress. The chances of picking that up are extremely high, and I'm willing to bet it's greater than 95%, although again, I haven't seen the specific studies for that. And again, Dr.

Go. And covered this. This is a link to one of the previous butterfly talks.

If you haven't seen this, it does complement what we're talking about today quite nicely. It goes into more specific details just on pace and alone, and this is the webinar link here by Dr. Gin.

So you can cut and paste that and see what Dr. Gomain also presented on to complement what we're talking about today. So, after all that, all that discussion, hopefully at this point, you're convinced that you're not already using Point of Car sound, that there's going to be an application to put this probe on Bains to see if we can figure out what's going on.

So, where do we start then? Let's go through this again and go back through our algorithm tying everything together, because again, it's an integrative approach. Initial evaluation on that patient triage.

Patients are unrest or stress. All right. Let's stabilise that patient.

Give him anxiety, get him on oxygen, make them more stable. Perfect. Let's look at that history of clinical exam findings.

We talked about some of the things that might lean us more towards cardiac versus respiratory. Excellent. I've now got an idea in my head.

I'm thinking, hm, I think this patient's got problem XYZ based on my assessment at this point in time. And I asked myself then, what do I think the The problem is, and our radiographs indicating. And more importantly, is my patient stable enough to allow me to take it off the RADA, restrain it in a position to get a radiograph and get a diagnosis.

So radiographs unbelievably helpful. All of us are trained in radiographs or some form of imaging might have computer tomography in there as well. So if we've got a patient that's stable, we can look at all audit stuff, decide what we think is the most likely cause, and decide if we want to go get.

Those, advanced imaging. But if our patient's unstable. All right, he's not gonna go to radiology.

We're not gonna send him off to the, cardiology suite. We're not gonna get him away and do a CT. This patient is unstable.

And we I say, do we need emergency interventions at this point to keep that patient alive? Do we have to say this is a patient that I don't think I can do anything with? I need him on oxygen.

I need him on anxie, I need to hit him with a bronchodilator. I need to him with steroids, or I need to hit him with a diuretic based on the initial presentation. There are situations like this, but fortunately, like I said, ultrasound is very low stress.

It's like listening to a patient with a stethoscope. So the odds are that patient's not going to drop dead in the next few minutes, and we don't need to do something before we put the probe on. So, if he's sufficiently stable, Then for us to at least, a cult and put a probe on, we're gonna go ahead and do that.

And then we're gonna say, OK, which of the big diseases are we dealing with? Is it alveolar interstitial disease? Is it pleural effusion?

Is it feline asthma? Is it cardiogenic pulmonary edoema? Those are the four big ones that we're gonna worry about in our feline patients.

And therefore, what are we gonna look for on point of care ultrasound to help us try and figure this out? Well, if he's got alveolar tiss disease, decreased area of lung at the periphery of the lung surface, we'll see increased beelines and consolidation. If he's got pleural effusion, we're gonna see black anechoic separation between the two pleural, between the parietal and the visceral pleura.

We can pick that up with ultrasound. If he's got feline asthma. And it's not complicated, then often we're not gonna see anything at all, either at the heart or in the lungs when we put a probe on it.

And if he's got congestive heart failure, then we're probably gonna see increased beelines as well as on the large left atrioic ratio. So there's how we're really gonna take this once we've gone through the initial evaluation of this patient, decide, OK, I'm ready, I'm putting the probe on. These are the things I'm gonna look for.

So, Let's come back then to one other thing that we should talk about briefly, and that is making this comfortable for people to assess their patients. So this is the value of asking binary questions. And this one I think is really, really important is that we train our students.

This is how we get most people that have never put a probe on a patient that are uncomfortable, that machine sitting in the corner, it's gathering dust and people are like, I, I'm not comfortable. I don't. Put probe on, I don't feel I have the confidence to do it.

Start with the basics. Start with a binary question approach. This makes life much, much easier.

So, for example, this patient comes in, that's stressful. This he got here, you look at, he's in respiratory distress. You're thinking, oh man, I'm, I'm worried.

If surge was here, he'd start running away. He wouldn't even deal with this patient. This patients can be stressful, especially if you don't know what the underlying causes.

No history, it's uncertain. Patients not doing too well. This is one where if you think, oh man, I don't know what it is, it could be many, many, many different things.

It's overwhelming. You're either confused like surgeons up here or you're crying like one of our colleagues at the UCBM also might be in this situation. Now, if we turn that around and say, no, not all, what are all the possibilities of re stress, we turn that around and say, in this cat is this.

Does it have increased beelines? Yes or no. I guarantee you every single person listening to this or every single general practitioner out there can put a probe on the thorax of a patient and say, yes, he's got increased bee lines or no, he does not.

This is something that's incredibly easy to do, takes very little skill, can be done in 30 seconds to 60 seconds. So, rather than what are all the causes, I don't know, I'm scared. I don't want to put a probe on.

Does this. Patient have increased bee lines, yes or no. Answer that question.

Simple question to ask and answer. Make sure you answer the question thoroughly. Check all sites that you need to to make sure he does or does not have increased beelines.

If yes, you see on the right, look how confused Sir was to start with. He doesn't know what to do. You put a probe on, you see these increased vertical white light.

Look how happy he is. This is simple. He's got increased beeline to this patient.

Absolutely does. So that is a very, very simple thing to do, increase beelines. Over here on the left, he's also happy because he's got a normal lung surface.

No increased beelines. No beelines at all. This normal lung surface at this probe location.

So we have to set multiple sites on the chest, and we have to do this in a certain way, but it's really easy to answer that question. If you do it thoroughly, does my patient have increased beelines? Yes or no.

And if he has increased beelines, well, then we can go one step further and you can see how happy surge is this patient on the right, he came in, it had increased beelines. He was worried that this patient might have congestive heart failure. He assessed the LAL.

It's got an enlarged left atrium. He's got a patient with congestive heart failure. He's super happy.

This side, he was like, Oh, did this patient have congestive heart failure? He saw an OB line. It's a normal LAAL.

He's not giving that patient grossmite. This patient does not have congestive heart failure. He's looking for other causes of respiratory stress, and a cat, this one was one where he was actually thinking asthma.

So again, you can see how this can be helpful when it comes to assessing our patients. And if you look at the human literature, we don't have this quite the same degree on our veter side, but human studies show the likelihood of false negatives and false positives are markedly decreased when asking binary questions, OK? So that's, avoid fishing expeditions.

Don't just put the probe on and say, I don't know, it's been sitting in the corner for a while, the ultrasound machine. I'm gonna get out and just randomly look to see if I see anything abnormal. Have a question in your head before you put the probe on.

It makes life much, much easier, and you can answer things with confidence. You can also build your skill sets one. Time.

Go back to the original research. What did we look for? Fluid in the abdomen.

What are we looking for now? More than 30 things. How do we get from 1 to 30?

One question at a time, building that skill set and doing their evidence to show we can do it. Make sure you do answer each question thoroughly though. Don't just put a probe on one spot in the chest and say, yeah, no, I didn't have bee lines.

I'm done. This patient doesn't have any lung pathology. Make sure you assess the patient thoroughly, whether it's abdominal, cardiac, or plural space in.

It's not a lot of skill set to do it, but it does work well. All right. So, what focus question to start with on Baggins then?

Let's come back to Baggins and think about this for a second. Here is that algorithm we showed you earlier, to try and put pieces of the puzzle together. We know that, Baggins did have a low temperature, 37.1.

Maybe we're leaning a bit towards, the cardiac side of things, but certainly still could be pulmonary based on that, table we showed you. It's not that specific or sensitive. So we're back to bagging.

What else on this physical exam? Where do we want to start? What question we want to try and answer first when we're listening to it?

We have crackles that sculpted in our patient. Crackles to me suggests that there's some inflammatory or fluid in the airways, and if there's fluid in the airways, not inflammatory necessarily, but if there's fluid in the airways, hopefully that will reach the lung surface. So this is congestive heart failure, which I'm thinking with that low temperature, I should see bee lines if I put a patient or a probe on this patient or I see pleural effusion.

But I can start with those bee lines. And therefore, we come back to Chris's, talk, which is David put the link for in the, in the chat box there. So go ahead and click that, if you want more detail on Popa and Long, you can watch that, webinar by Doctor Gan.

But the three rules then. The easiest thing to do is just know your borders. If you can find your borders, everything between your borders is long.

Now I'm looking for crackles, I'm looking along surface. I wanna make sure I'm scanning lung, not the, lumbar muscles, the front limb, or the abdomen. So know your borders for sure.

Think about patient positioning in the case of parentchial disease, it's not so much patient dependent, but if I was looking for pneumothorax or fluid, pleural effusion, I gotta think about how that fluid falls. Based on gravity or how air rises against gravity to find those pathologies and that will change on patient positioning. So again, that does depend on the pathology you're looking for.

But we're looking for predominantly that increased crackles. We're looking for those bee lines. We want surface to surface.

We're going between the borders and we're looking at the lung itself to say, yes, this is normal or. Nope, I've got too many bee lines. So, let's talk very briefly then about, and again, this will compliment from Chris's talk.

Let's talk very briefly about normal plus findings. And this is the A's and B's. The A's and B's of, we'll see when we put the probe on the chest.

Most of the time, when we put a probe on a healthy animal, we're only gonna see the pl line, which you see up here, this white line right here outlined in yellow. The first bright white line below the skin and below the ribs that you can see over here to the right, this is a rib to the right here, and that joins the rib shadows. So that's our plural line there.

And we get a reflection of that plural line through air. That's a lines. So all these horizontal white lines reflected through air-filled structures, OK?

So that's what we're seeing here, these horizontal white lines, perfectly normal a lines. The lines are what we want to look for. So, even if you don't know what a lines are, you don't really need to know them to identify the lines.

Just know that bee lines are vertical white lines, OK? And you can see them over here to the right, it's white and vertical. A lines are horizontal, be lines the one.

We worry about our vertical, vertical white lines. They move and they'll normally see them in our healthy patients in 11 to 50% of our animals depending on how much of the lung surface you scan. So occasionally, most of the sites will be normal, but occasionally we'll see a beeline.

And if Dr. Shalhoub is here today lecturing, he swears these look like lighting. Helps you to remember what a beeline looks like.

You can think about lights coming in as vertical laser-like projections from that plural line. More specifically, and this is a nice example here, we see that with the the butterfly here, you can see the rip shadow just here in the rib. There's our plural line.

You should be able to see that vertical white line that's dancing. Bee lines don't sit still. They originate at the lung surface.

As we said, occasion is normal. They are vertical white, so don't look for anything else, just look for vertical and white. They're at the lung surface, and because they're at the lung surface, and always, always originate at the lung surface, when the lung surface moves with breathing, the beeline always moves.

It dances. You can't keep it still. So, if you're seeing something that's not moving, when that patient's breathing.

Breathing with some effort, then it's not a beeline. Beelines will always move with the pleura, OK, as the patient breathes. You can see here this is set to 5 centimetres of depth, and that beeline, that vertical white line extends the entire depth of that image.

So that is one of the other things. It extends to the far field. And if you had a lines, like I said, it doesn't matter if you see them or don't see them, it will obliterate them if a lines were visible.

All right. So, What are the normal findings then when we do a lung ultrasound? Well, first thing you gotta ask yourself and the answer is, am I assessing the lung surface or not?

I can't see the lung without sound. So am I actually looking at lung to say it's normal or abnormal? How do you know you're looking at lung?

You need to look for lung sliding. So that's one of the things, and again, Doctor Garman will have covered this in his talks. You should go back and take a look at that as well.

But here's a ripped shadow. I chase that up. There's the rib.

First white line below the rib that joins the rip shadows is the floor line. So that's my floral line right here. And you gotta ask yourself, do you see, ignore all the movement up here above the floor line, ignore everything below the floor line.

You're gonna want to look at it. It's just natural. It's like one of those forbidden things.

Don't look at it. You're gonna want to look at it. Don't look at it though.

Don't look above or below the floor line. That's the floor line. Focus on the poral line.

Is there to and fro shimmering along that poral line? Yes or no. So I'll ask you guys, right where I've got the dot there, that's my floor line.

Do you see a shimmer? It's like looking at a tap when you turn it on, it's white water. Do you see that to and fro shimmer team where my laser pointer is?

Can you see a shimmer along that plural line? Yes or no? Yes, excellent.

Thank you very much. So this is positive for lung sliding. What does that tell me?

That tells me even though I can't see the lung, that the lung is against that floor line and therefore I have permission to look for beelines. All right, so that's step one, make sure you can see the lung surface via lung sliding. What do you look for?

Like we said, this is simple. You're looking for white vertical. Lines.

What's the normal if you scan a hemi thorax? If you scan a hemithorax, the vast majority of sites you scan are going to be lung sliding and no vertical white lines like you see on the left. That's normal.

Most sites are like that. Almost, if you scan up lung, you'll probably find in at least 50% of your cats and dogs, at least one beeline. You can, although it's less common, when you're scanning the hemothorax, you might find a site that's Two bee lines.

And although it's very rare, very, very rare, it is reported that at single sites on cats and dogs, you will see 3 beelines. So this is very rare. This is less common.

You're probably going to see this if you stand up lung surface on both sides of the chest. Otherwise, you're gonna see this in the far left. That's what we normally see.

That would be a normal lung surface at that probe location, OK? And you need to also tie it together though. So not only do you look at each probe location on the thorax, you add up all the sites you scan.

You, you draw a map of the lung surface. So, here we go, we're scanning, we're gonna scan in an S-shaped, dorsal, middle, and ventral third of the lungs. It doesn't really matter what protocol you do.

Lungs, you scan a lot of lung surface in the dorsal, middle, and ventral thirds. And if you got lung sliding and only 8 lines, all these windows are normal. And adding up all these windows on this side of the chest, this hemihorax is normal.

Awesome. We scan this one here, team, and we see that all sites have no bee lines except for one site that's got 3. Is that normal or abnormal at that lung surface where that probe is located?

So, is this finding of 3 beelines normal or abnormal? This is what I'm going to say you got to put it into clinical context. Yes, you could find 3 bee lines in a healthy animal, but it's rare.

And because it's rare, you should ask yourself, is this acceptable for this patient? Yes or no. So, We need to tie it together.

So, for example, a patient comes in, I get transferred to me on the ICU. I scan that patient in the morning. All the sites are negative.

I've got nice lung sliding and no bee lines. That patient gets put on a good clip of fluids, so it's getting, replacement fluids for dehydration, ongoing losses, and it's had some bolus overnight because it came in unstable. He's got a lot of fluids and he's still a lot of fluids.

I scan that patient an hour later and I see 3 bee lines at a site that I didn't see it before. That to me is a problem. That patient's probably going in the volume overload because it's done human literature.

The development of beelines where they weren't previously seen is highly suggestive of fluid overload, OK. So, exactly, Greg, thank you. Overhydrated.

100% agree. So in this case, I see 3 be lines that weren't there before. Patients on fluids.

That's a problem. That's not normal in that patient. But that was a kitten that came in, he's 100% happy, jumping around.

He's all, active and playing, no problems breathing. Owners reported no issues, and I see 3 lines. That's probably normal in that patient.

Put it into clinical context team. All right, so I got another one for you here. At each window, each individual site.

Would I be able to see this in a patient? Can I see one bee line in a healthy patient up here on the top right? Well, for that window, yes, 50% of patients will have one bee line.

No bee lines, that's normal, that's normal, that's normal. Two bee lines at one site? Sure, I can see that in a healthy animal.

It's less common, but I could see it. No, that one looks normal that window, and two, again, that would be normal that window. So each individual window here.

Is actually normal. But adding this up, how many windows should I see with one or more bee lines in it? Well, anytime I've got more than 2 windows that are positive, regardless of the number of beelines, I worry.

So again, put it into clinical context, this is a patient that I might do more work up on because I don't traditionally see, regardless of the number of beelines, more than 2 sites that have bee lines on a hemihorox, OK? So something to think about. This patient here, I'm scanning it.

Everything looks normal. I get to one site with 4 bee lines, 4 bee lines and one site's too many. I'm worried.

I gotta work this patient out because those 4 bee lines are abnormal at that window. So again, think about it in terms of how many bee lines do we see in the window, how many sites are positive on a heathhorax. Add it all up in terms of how many bee lines and whether you're trying to determine if that patient is normal or abnormal.

All right, so let's come to abnormal then. So here I've got excessive bee lines, more than 3 in a single window, or more than 2 positive windows on a hemihorax. So the patient in the bottom left, this patient's breathing.

I see vertical white lines, 1234, probably 4 to 5 in that window to the left. The one in the middle. Yeah, he's got more bee lines than the one on the left.

This is vertical white lines. This is a problem. This patient's got decreased aerated lung at the lung periphery.

I should be figuring out why that is. This is not normal. You can look at a transassky, like both these cases here that you see in the video, as well as the stimulator.

We can come in, like we said at that subs. And assess the caudal lung surface. You can see that beyond the diaphragm here.

This will be where the lung interfaces with the diaphragm in the liver. You can see all these vertical white lines radiating off the diaphragm. These are increased numbers of beelines at the subziploid location as well.

So this patient here, this is a problem, we got to work them up. And all those stories says they look like light sabres. These are rays of sunshine from the heavens.

I was about, hiking it's actually like this. I was hiking with a buddy of mine like he's like, wow, that sunset. I'm like, sunset, look at those beelines.

Bulls are freaking awesome beelines. Now you will see these everywhere you go. And as I like to tell Serge, they look more like beelines because the more beelines you have, the closer you are to heaven.

Rays of sunshine from the heavens, that's what they look like, not light sabres, but whatever works to make you think of vertical white lines to identify them, that will work for you as well. All right. Now, like we said, you look at each site, you look at the entire hemithorax.

We've got about 10 slides left, just for those of you that are wondering, I did warn you, we would go overtime a little bit. We've got about, we got about 10 slides left, so we got about 15 minutes and, we'll be wrapped up. It is recorded.

If you don't have time to stick around, you can watch the recording, and again, if there's no time for questions, you can send me an email. But this does tell us there's decreased aerated lungs. So we've got institial alveolar disease just like on an X-ray.

If you see an X-ray, you've got a set of differentials. When you see this X-ray in the middle, that tells you, ah, I've got a problem with my lungs. There's decreased aeration there.

I've got institial alveolar disease. This is what it looks like you take an X-ray. This is what it looks like you put an ultrasound on at that same location where there's an abnormality on an X-ray.

I always tell people, you're looking for the same disease. Just two different modalities to find that same disease. One where you have to take a patient out and get the axial X-ray.

One where you bring the machine to the patient, put it on the patient. You're looking at the same different things or you're looking at the same things, there's two different modalities to do it, OK? So, therefore, just like an X-ray, you got to think of the history and physical.

Patient comes in, this is a cat, Dic. You pop a probe on, you see a tonne of beelines craniovent after the cat's been vomiting, your number one thought in that situation. Aspiration.

Patient comes in, it's a cat or a dog hit by car, respiratory stresslow bee lines, particularly on one side versus the other. Your thought when it comes in hit by car and it's got beelines. This is lung decreased aeration in the lung.

This is gonna be pulmonary contusions until proven otherwise. So let's come back to Bains again, man, and take a look at Bains. So we did take.

Bains, we, put the butterfly on and we assessed multiple lung regions. So up here in this caudal dorsal site, oh, I've got some vertical white lines right there. This is the abdomen to the right here.

This is the curtain sign. So, this is right where we're transitioning from lung to abdomen. And in this region of lung here, I've got probably 3, maybe 4 vertical white lines.

I scan more cranial here. I come over to this side. I can see the rib shadows here, the black.

I see a little bit of a line in and out, but I can see lots of vertical white lines. So I see lots of B lines here to the right. Scanning the rest of these sites, if you look at these in the different locations we got them, all 5 sites that we scan in Bains has vertical white lines varying in severity from individual and identifiable to almost coalescing and forming white sheets.

So we can see that as we drive around on the chest. We've got increased beelines in all 5 sites. All right, so we've got increased beelines, decreased irritated lung.

So based on our point of your ultrasound, that's all we found in Bains. We did not see pleural effusion. It's unlikely feline asthma because feline asthma does not cause diffuse bilateral beelines.

I'm worried that this patient's got primary ranal disease of some sort or congestive heart failure. One of the two because it's diffuse bilateral, decrease aerated lung. So congestive heart failure would certainly do that.

That's high on my list. So, do we hit them with furosemide right now then? Well, again, we still haven't ruled out other causes of diffuse bilateral beelines.

Maybe this patients got arts. Maybe this patient has got some other systemic diffuse disease that's causing bilateral increased beelines. So before we get them, we throw some.

We are going to ask the next question. He's got beelines, he's got crackles. He's a cat, rest their stress, low temperature.

I'm thinking this patient with diffuse bilateral beelines has probably got congestive heart failure. I want to look at the heart. So, what are the chances then that that heart will be enlarged if a patient presents with dyspnea, causing or secondary to congestive heart failure.

So if it Patient comes in and he's just because of congestive heart failure. Is it a small change in the heart I'm looking for, or is it an obvious change that makes my life easier as a novice sonographer to find that left atrial enlargement? Well, if you look at all the the research that's out there, whether it's cat or dog, this is a nice one here.

Again, we came back to this one by Ward, the pro BMP that we talked about earlier, that has the, the table on it as well. You can see here, These patients, when they come in and they're in respiratory stress because of heart failure, it's heart failure that's causing the beeline to pleural fusion, that LAAO is not subtle. It's huge.

It's more than 2 to 1 on average. Same thing with dogs. If they're coming in with respirator stress and beeline secondary conges.

Heart failure and they haven't already been on furosemide, that left atriums on average going to be double the width of the aorta. As opposed to our non-cardiogenics where it is back to pretty much normal 1.2 to 1.

So this is really nice. It's not subtle change. This is an easy one to pick up.

2 to 1 or bigger on that left atrial ratio. All right. And that's what we're looking for.

And the nice thing here is as well, do you need to be a cardiologist, you need to freeze that image and measure it? Well, if you look at this paper again by Ward, given it is a cardiologist making a subjective call, but they were 97% accurate on a subjective estimation, is that left atrium enlarged or not. And they were making that call when it was slightly above normal, and like a 1.6 to 1, not a 2 to 1.

So I'm willing to bet when it gets to 2 to 1 or bigger, almost anybody can be trained to look for that. Unfortunately for us, Most of the times they come in and rest rest secondary congestive heart failure, that left atrium is gonna be in that 2 to 1 ratio. So, let's take a look at this then.

Here is our, a case. This is our aorta here that you see with the Mercedes. It's got the triangle in here.

You see the valves here for the aorta. So you see the aorta, it's a bit coldly shaped, and this is our left atrium here, it's the opposite direction to what a cardiologist scan, so it's mirrored, and this is our pulmonary vein. When I make our measurements, I Subjectively, I draw the line across the left atrium here.

I do not include the far wall of the pulmonary vein, because it makes it a much, much bigger area. I draw the left atrium across like this, and then I look at the aorta relative to that left atrium. And then I ask, is this left atrium more than double the width of the aorta?

Subjectively, I can make that call. This one looks 1 to 1, 1.2 to 1.

This is perfectly normal, as opposed to enlarged. So I'm gonna give you guys a quiz then, see if, those of you are still here. And get this one right, OK.

So we're looking for that greater than 2:1 ratio. So, here we go, two cats, both named Bains for the sake of simplicity, present with dysmia, and they have long of sound that shows this to the bottom left. So first question for you guys that are still with me, and paying attention.

Do I have increased beelines? Yes or no. Binary question at this site, do I have increased bee lines?

Yes or no. All right, everybody's weighing in very quickly and exactly simple question, yes is the correct answer. This this patient has increased felines.

Now my next question is, is this due to heart failure? Yes or no? Well, I want to look at that left atrium.

So I'm going after the left atrium. I'm gonna show you two cases with the LAA. Oh, you guys tell me which baggins, #1 or #2, you would treat with furosemide or not.

So, you check the left atrium based on that image to the left where you've got those increased beelines. Would you give furosemide to number 1 or number 2 based on that LAO? All right, everybody went in and they were saying, most people are saying they would give the furosemide to patient number 2, and I would 100% agree.

So this patient's got increased bee lines, that's step one. I have decreased aerated lung. I don't know why that lung is decreased in aeration.

It might be cells, it could be haemorrhage, it could be neoplasia, it could be cardiogenic pulmon edoema, it could be non-cardiogenic pulmonary edoema. It's got something that's decreased the aeration of the lung. I want to know if it's the heart.

I look at that left atriatic ratio. I look at number one up here. This left atrium, looking at that width is about 1.2, maybe 11.

To 1 with the aorta. It's definitely not large. This is the patient I'm not giving turoseite to.

I come down here and look at this number 2. There's my aorta. There's my left atrium.

I can definitely fit more than 2 aortas across that left atrium and with that's a patient that screams, this patient's got congestive heart failure. It's getting rosemide. This guy up here, I got to go look for something else.

What's that distribution on the chest? Is this just The cranial ventral regions that I'm seeing these bee lines, maybe it's an aspiration ammonia, in which case I would not expect that left atrium to be enlarged. Maybe this patient's got infiltrated disease, and that's causing the decreased ration and increased beelines, which again would normally be associated with an unremarkable left atrium.

So I gotta go looking for a different cause in number 1. #2 though, I'm giving him furosemide for sure. Well done team.

All right, so we're almost done. We got a few slides left. We're just about finished team.

And We've already answered the question. Sorry, I should have come up one slide earlier. Back to Baggins.

What did we actually see on Bains? Well, here you go. We got the butterfly.

We popped the probe on the, thorax. You can see we're over the heart, and this is how we were doing it in the cat. You can see the butterfly here, and we're checking the heart.

Here you go. This is Bains over here to the right. There's my aorta right here outlined by the, oops, there it is right there, outlined by the, laser.

We're shifting, back and forth between the aorta and the mitral valum and there's my left atrium. Oh, wait till we shipped up. That's micro there it is.

There's my lap atrium. So we add be lines that use some bilateral baggings. There it is, our left atrial ratio.

How many of you guys would give furosemide to baggins? Yes or no? Excellent.

So the majority of you are saying yes. So again then be lines large atrium, I'll be enough evidence for me to say yes, we're gonna go ahead and give hero some mind. Perfect.

Well done team. And then again, you can do a 4 chamber view. It's a tougher view to get, but this is also the 4th chamber.

You can see that our walls are very thickened, the left ventricle movement is very small. This is the left atrium right here on 4 chamber and Wow, that's a massive, huge left atrium compared to the right atrium here. You can see it's probably 4 times the size of the right atrium.

This is a patient that, screams, congestive heart failure, and in this case with the thickened walls, small lumen, probably going to be hypertrophic cardiomyopathy. Excellent. And there's the actual measurement.

You actually did stop and take a measurement. You can see it is much larger, 0.89 to 1.95 was the, estimation on this, and you can see that it is definitely greater than 2 to 1.

All right, now you feel comfortable giving that furosemide. So our case outcome, Bagins was successfully treated for congestive heart failure. We did start the pitool for angiolytic.

We did give the furosemide based on the left atrial size. We did give supplemental oxygen, and because I'm not a cardiologist and I don't want to deal with the long-term management of Bagans, hypertrophic cardiomyopathy, I sent them to the cardiology service that we're continued to follow up with them and do the recommendations for medication. So, in summary team.

Where are we at and where are we going? Well, as we've said, this is a problem-based clinical approach to answer specific clinical questions that are often binary in response, yes or no answers. It's patients that targeted, never do an ultrasound exam without considering.

The history and clinical exam findings. We talked about that earlier. There are essentially 5 Ts to point out on.

It's the Ts that, help you remember things, trauma, triage, treatment, tracking in total, different indications depending on how that patient presents and, what the clinical scenario is. Although it can be done in under 5 minutes and we can accurately assess feline patients for respiratory stress. And then I had to summarise this then when it comes to feline respiratory stress, cardiac plural, pulmonary, here is my summary slide.

If you've got black fluid down in that space separating the two pleura, so on the right here you can see we've got the black anechoic between the parietal and the visceral pleura. This is positive, this is pleural fusion. This case here, increased felines, that just.

I got decreased aerated lung. It might be heart failure, but it could be anything else that decreased the aeration of the lung. If I want to know it's heart failure or not, I gotta get that LAAO and you can see that that's enlarged in this case here.

If I don't see pleural effusion, I don't see bee lines, I don't see an enlarged left atrium. My history fits with potentially a cough. I'm going with asthma until proven otherwise as a diagnosis of exclusion.

And once he's stable, I will start therapy for that. And once he's stable, I'll get a radiograph to confirm. And on that note, team, I would like to thank you for, attending.

Again, we went over a little bit, I knew that was gonna happen, so hopefully, I didn't keep you guys up too late there, your side of the, the pond. It's only 2:30 here. If you have any questions, please put those in the chat box.

I'll try to answer any of those that I can now. Otherwise, also my email was, at the start of the lecture. Please feel free to send me an email.

I would like to say thank you to, the Eve Evec Group. We do have the Veus meeting on May 31st in Porto. So, if you're and you want to catch a full day of lectures on point of Carro Sound in veterinary medicine.

Portal, May 31st is the Veus meeting in conjunction with the EEC meeting. And I would also like to thank, Hugo Swanstein. He's based out of Copenhagen at the moment.

He provided some of the images you saw today. And on that note, I would like to take any questions. Thank you, Sen.

Wow, I just wanna say, I absolutely loved this webinar. So clear, informative. I don't know about you all, but I feel so much more confident using a pro after today.

With in regards to questions, we are just going to unfortunately collate them, today, just because of running over, and we will, get all these over to you and, and get them, passed on, in the next few days for everyone. But I just wanna say thank you again, for today's webinar, and thank you again to the Butterfly Network for sponsoring today's session. So we just unfortunately do have to wrap it up now, but, I just want to say thank you to everyone.

We hope you all enjoyed this evening's webinar and thank you for joining us. Thank you very much. Hopefully we'll see you in person at some time.

Yes. Take care, everyone.

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