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Dr. Elizabeth Goudie-DeAngelis - The Ins and Outs of Anesthetizing Dogs and Cats in Respiratory Distress
394 Plays18 days ago
Don’t hold your breath - this episode has you covered! In this episode of the North American Veterinary Anesthesia Society Podcast, host Dr. Bonnie Gatson in joined by anesthesiologist and owner of Tristate Veterinary Anesthesia, Dr. Elizabeth Goudie-DeAngelis. Together, they tackle the ins and outs of anesthetizing dogs and cats in respiratory distress - covering stabilization, airway management, and recovery tips to help you breathe easier in a crisis. Tune in and inhale some practical pearls that will help you exhale with confidence the next time you're faced with a respiratory emergency.
For more details about references mentioned in this episode:
High risk of anesthetizing brachycephalic dogs
The success of implementing a standardized anesthesia protocol for brachycephalic patients
The pharmacokinetics and efficacy of rectally administered trazodone
The use of nebulized epinephrine to reduce the severity of brachycephalic airway syndrome
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Transcript
Welcome and Introduction
00:00:07
Speaker
Welcome back to the North American Veterinary Anesthesia Society podcast. I'm your host, Dr. Bonnie Gatson, the podcast where we strive to promote the safe administration of anesthesia and analgesia to all animals.
00:00:20
Speaker
Today, we're diving into an episode that was suggested a while back from one of our listeners, and it's one of the more nerve-wracking scenarios we face in veterinary anesthesia, caring for dogs and cats in respiratory distress.
00:00:36
Speaker
These patients are often unstable on presentation, panicking, oxygen hungry, and teetering on the edge of decompensation. These are patients that can turn critical in seconds, which means that decisions need to be made for these patients just as fast.
00:00:54
Speaker
Our hope is that after listening to this episode, you will have some knowledge in place so your team can be better prepared to face a crisis like this.
Expert Guest Introduction
00:01:03
Speaker
Before we get started, I'd like to thank our sponsor, DECRA, for their continued support of the NavVest podcast.
00:01:09
Speaker
DECRA is dedicated to providing innovative pharmaceuticals, equipment, and resources that help veterinary teams deliver the highest quality of care. And we're grateful for their partnership in advancing veterinary anesthesia and analgesia education.
00:01:24
Speaker
Back to the episode. To help us navigate this challenging topic, I'm joined by Dr. Elizabeth Gaudi DeAngelis, a board-certified veterinary anesthesiologist with extensive experience managing high-risk patients.
00:01:39
Speaker
Dr. Gaudi works as an on-site anesthesiologist at multiple specialty practices around the Northeast, and she brings a wealth of knowledge on how to approach these emergencies safely.
Background of Dr. Gaudi
00:01:50
Speaker
Together, we're going to talk about drug choices, airway management, and post-op recovery strategies that we've used for both animals that present with respiratory distress, as well as elective cases that have the possibility to go sideways quickly.
00:02:07
Speaker
In other words, consider this episode an ode to the French Bulldog. So take a deep breath. We're about to unpack the art and science of anesthetizing small animals with respiratory emergencies with insights from Dr. Gaudi DeAngelis.
00:02:28
Speaker
Welcome. Can you tell our listeners a little bit about yourself as well as your experience? So I'm Liz Gowdy and i
Challenges in Respiratory Distress
00:02:36
Speaker
am a veterinary anesthesiologist. I went to Ross University and then i did my clinical year in Missouri, went and did an internship at Blue Pearl Veterinary Partners in New York City After that, went and did my residency and got my master's at the University of Minnesota in comparative anesthesiology.
00:02:53
Speaker
And then came back, ran the anesthesia department for four hospitals in New York, right back at Blue Pearl, then kind of went out on my own and started my own business where I do a lot of consulting. Most of my experience is small animal. Obviously, I was trained in all different species, but at this point, I mostly do small animal anesthesia, some exotics.
00:03:14
Speaker
I do love horses, though. And then I consult with like pretty large multi-specialty hospitals as well as dermatology, dentistry.
00:03:25
Speaker
I'll help out GPs. So I kind of have a wide variation in what kind of experience I have day to day and week to week. I want to mention two things. Number one, Dr. Gowdy is recording at the beach. So if you hear any fun beach sounds, just realize that she's giving us a little bit of her time while she's on vacation. So I really appreciate that.
00:03:45
Speaker
We've actually gotten to know each other pretty well because we both have anesthesia consulting businesses. So we've kind of had a lot of back and forth as we were both kind of getting started, kind of leaned on each other a little bit while we were creating our businesses.
00:03:59
Speaker
The other reason that I have you on is because this episode is actually inspired by a listener who sent an email to us asking if we could focus an episode on respiratory emergencies.
00:04:13
Speaker
Meaning like if you are just going about your day-to-day practice and an animal walks in the door and they are cyanotic, they're Dipsnick, how do you handle that? How do you go through that situation? How do you navigate that?
00:04:26
Speaker
I guess my first question for you, just as an icebreaker, is can you start by telling me a little bit about maybe a scenario that you found yourself in recently where a patient you were caring for experienced respiratory distress?
00:04:43
Speaker
Yeah. So I work in the tri-state area, tri-state New York, so near New York City, and unfortunately, a lot of French bulldogs that are heavily overbred. So when Bonnie asked me to be on here and was talking about respiratory emergencies, there's obviously a lot of different respiratory emergencies that happen.
00:04:59
Speaker
You know, the cat that has a laryngeal mass. anaphylaxis in some patients will present that way. Obviously, heart failure, intrathoracic masses or fluid. But for me, and I think bread and butter day to day, the respiratory emergencies that I'm seeing are often brachycephalics.
00:05:20
Speaker
So either they're coming in and they are very anxious during their consults and they're coming in for BAS. So brachycephalic airway surgery and coming to see our surgeons and then coming in for another procedure later on.
00:05:32
Speaker
Or sometimes, especially when it's warm out, they're presenting in respiratory distress from being out on a walk. You know, everyone decided to take their brinkies out that's used to being in the AC. It's slightly overweight. And they're like, we need to get back in shape. And they decide to do it 90 degree weather for some reason. And that patient presents in respiratory distress and rapidly needs to be stabilize So I think that's a good example of what we're seeing.
00:05:58
Speaker
Specific cases, I mean, that's every week we're doing brachiosphalic airway syndrome surgery along with a spay and neuter. And so every single week it's a, okay, what size tubes do we need to have? How are we going to bring this patient in as sedate as possible?
00:06:13
Speaker
How quickly can we get it intubated? How can we get it extubated? What kind of things do we have to have in place? And what kind of sedation do we need in order to have this patient extubate successfully and be able to go home?
00:06:26
Speaker
And so I think I can talk about a case like that from like start to finish, if you want. I think that's actually good way to even approach these guys when they come into the hospital, because it's very similar.
00:06:38
Speaker
Extubating them, it's very similar to them coming in in respiratory distress and then trying to get them out of the respiratory
Sedation and Medication Strategies
00:06:45
Speaker
distress. So let's say you have a five-year-old male intact BCS score of maybe a little over-conditioned, maybe like a seven out a nine French bulldog that comes in and he's getting surgery. He's coming in for a castration and he's getting his airway examined at intubation and the surgeon's probably going to be some traumatic surgery there.
00:07:08
Speaker
So you get the patient, when you have him coming in you kind of prepare ahead of time. These patients should be going first thing in the morning. They should have gastro protectants on board and they should have sedatives on board when they get in the hospital and everyone should try and keep them as calm as possible.
00:07:24
Speaker
I also like to have them go as early in the morning as possible so that quick care can be involved. We're not trying to scramble at the end of the day to get this patient excavated. And everyone in the hospital knows that they're present and that they're coming downstairs to ICU or next door to ICU, wherever your ICU is.
00:07:41
Speaker
So most of the time I'll have these guys come in on gabapentin and trazodone. My doses are usually 10 mg per kg of gabapentin, and then somewhere between 7 and 10 mg per kg of trazodone, depending on their personalities.
00:07:54
Speaker
There was a study, it's a little bit of an older study now, where they looked at GI i reflux acidity using some gastroprotectins, and they found that omeprazole, while it didn't decrease the regurgitation,
00:08:08
Speaker
It does cause the pH to be a little bit more normal. So hopefully you're not getting as much irritation and then subsequent esophagitis or chemical pneumonitis. It doesn't completely fix it, but it does help. So it's a cheap thing to do. And I had the owners give just plain omeprazole, one mig per kg SID for three days before the procedure, if possible.
00:08:28
Speaker
If they can't give it, you can always give pantoprazole as well in their premedication. So again, this patient comes in, i do a physical exam on them. Ideally, they should have chest radiographs. The reason is that some of them have silent pneumonia that you don't know about. And so it's kind of nice to have a baseline and to push the case off if you need to.
00:08:48
Speaker
That being said, sometimes getting chest radiographs on these guys prior to heavy sedation is not always possible in the respiratory distress. So it's got to be a balance. Remember that brachycephalic airway syndrome is composed of the malformations of their upper respiratory system. So the stenotic nares, hypoplastic trachea, averted saccules, they can have laryngeal collapse.
00:09:11
Speaker
very small airway. And then they also have a tendency to have GI signs as well. It's a study that I think really needs to be done is just CT-ing or fluoroing all of these brachycephalics, like even normal ones that are not having any clinical signs of GI signs, because I think a lot of them have hiatal hernias that we just don't even know about due to the negative pressure.
00:09:36
Speaker
Especially in a dog, say this five-year-old male intact that we're talking about, he's never been anesthetized before, so we don't know how he does under anesthesia. And he's been breathing against a closed cocktail straw for his whole life, which can cause his saccules to be averted because the negative pressure, can cause chronic bronchitis and bronchointerstitial arthritis.
00:09:55
Speaker
pattern within his lungs and possibly even some pulmonary hypertension as well. And then that negative pressure maybe is affecting his the hiatal hernia that may be there. getting might be getting sucked into the esophagus more. And he's probably having regular regurgitation, vomiting, GI signs that the owner might not even notice. So a lot of times these people think these dogs are normal.
00:10:14
Speaker
And I often hear owners say, he has no clinical signs. And I meet the dog and i'm like, well, obviously they do, but it's kind of like the the frog in the boiling water analogy where like they have gotten so used to this dog snoring and snorting and silently regurgitating they don't notice it So anyway, so then once the when this dog comes in, you've done your physical exam, i premedicate them.
00:10:39
Speaker
I like dexmedetomidine, acepromazine, and I usually use methadone because we're doing something painful for him. I prefer a methadone. I find that there's not nearly as much GI signs. And I am these dogs. I don't want them struggling for a catheter. i don't like it.
00:10:52
Speaker
So I will I am them. I obviously have good eyes on them. I have my intubation supplies ready to go. In case we have to rapidly put a catheter in, i have oxygen available in a mask if they need it.
00:11:02
Speaker
But usually they just calm themselves down. We get an IV catheter in. I usually try to put a back leg in. actually prefer to put medial saphenous catheters into these fatter brachycephalics. I find that the catheters slip in a little bit easier and there's a little less tissue over the medial saphenous.
00:11:19
Speaker
It also keeps me away from the upper airway situation while the surgeon's working. That being said, i still but put catheters in the forelimbs. From there, we'll rapidly induce and rapidly intubate.
00:11:30
Speaker
So usually what I use is just regular propofol. I often like to have lidocaine on board, two mgs per kg, just to decrease the cough reflex as well. The surgeon will come over, take a look, say, okay, I need to do...
00:11:44
Speaker
whole thing and do all of the airway. Or they'll sometimes say, hey, it's not that bad. The soft pit palate isn't that long. Let's see how this dog wakes up. We may need to go forward. The surgeon has already talked to the owners. They've warned them about mechanical ventilation, re-intubation, possibly needing to put a temporary or permanent tracheostomy into these dogs.
00:12:04
Speaker
This conversation has been had as well as talking about the higher risk of aspiration pneumonia. A recent study about perianesthetic risk did show conclusively that these guys are at a much higher anesthetic risk than our standard patients. And I don't remember the exact number, but it was significantly higher. We all knew this, but it was nice to have the confirmation. In addition, a recent study came out of Tufts where they were looking at a standardized brachycephalic protocol.
00:12:32
Speaker
So that's something that you should implement in your hospital. And we have all owners sign a brachycephalic risk form so that they have read and know that these patients are at much higher risk. So they know that if we have to rapidly put a tracheostomy into this dog, it's going to happen quickly. And they are probably not getting a phone call.
00:12:50
Speaker
Anyway, so the airway has been obsessed. Remember that these guys take very small tubes. So usually my techs have a wide variety of tubes set out. This patient would probably take a five and a half or six, like a very small ET tube, but we'll have everything from a four all the way up.
00:13:06
Speaker
Another piece of equipment I really like to have, if you guys are seeing a lot of respiratory distress patients, is a Cook airway exchanger. It is a life changer. It's not that expensive. It comes in a variety of sizes. It's a human product.
00:13:20
Speaker
And so what it has, and Mila has a similar one that I think it might be a little bit more affordable, but it's an airway exchanger in that it it looks kind of like a ah flexible stylet. And at the end of it, you can put an adapter that will actually hook up to your anesthesia machine and hook up to a normal anesthesia machine.
00:13:37
Speaker
And so what it allows you to do is put that stylet in. It's very small. And you can hook it up and get some oxygen going into the patient at the same time. And then you can use it as a stylet to get your tubes in. So if you're having trouble getting a tube in, sometimes I find the cookie airway exchanger will go in and then you can thread the tube over it. So we always have that kind of ready to go in case we get into a pickle.
00:14:00
Speaker
In addition, it's nice to have because if you get a tube in to a patient that maybe was a little bit difficult to intubate and it's a small tube and you know you have to anesthetize them so you don't want the waste gas floating around, you can put the airway exchanger in there and this is what it's made for. Pull the tube that you already had in and put a larger tube on and so that way you're not losing your airway in between if you have to re-intubate your patient.
00:14:25
Speaker
And we use it often under the drapes if a patient's tube is not holding air in the cuff or something like that. Anyway, So rapidly induce the patient, get the patient induced. Ideally, you should have positive end expiratory pressure on these patients to increase their to decrease their atelectasis and increase their ability to ventilate appropriately, decrease their VQ mismatch, of which they have a lot.
00:14:48
Speaker
And then I maintain them on inhaled anesthetics. I usually do not find that I need to do much in the way of CRIs for these guys, for brachiosphalic airway syndrome or for castration, you know,
00:14:59
Speaker
whether or not you do a testicular block to help you along. If anything, I'll do like a lidocaine CRI or another lidocaine bolus. At the end, traditionally, we will put more trazodone rectally.
Managing Unplanned Emergencies
00:15:12
Speaker
So there was a JVEC paper that looked at seven megs per kg of trazodone made into a slurry inserted into the rectum. It kicks in 30 minutes. The pharmacokinetics are actually faster than oral trazodone.
00:15:24
Speaker
If the dog is really calm, we won't do this, but for the most part, this really smooths out our recoveries. I use five mgs per kg because I find that the seven is more than I need. And then we have a bottle of acepromazine, bottle of propofol, new ET tubes, a laryngoscope ready to go, and dexmedetomidine.
00:15:41
Speaker
Most of the time, these patients will try and wake up and will need to be kind of sedated back down. I give them all the time that they need. i always make sure to test these patients off of oxygen with their ET tube in and while they're sedated before I will recover them.
00:15:57
Speaker
So for example, they will be on the table. I'll have given them their rectal trazodone. I'll have my acepromazine, which is a 0.005 microkig dose ready to go and a half microkig of dexmedetomidine ready to go.
00:16:10
Speaker
And i will put a, I call it a brachy block. It's just a roll of tape that I've covered in vet wrap and I wedge it into their mouth so that their mouth stays open. And if they've had their soft palate trimmed, we usually use a mannitol soaked gauze in the back of their mouth. So the surgeon will do her soft palate surgery, will shove the mannitol soaked gauze in there and then take it out right at the end of the procedure.
00:16:34
Speaker
And then i pull the tongue over to the side, leave the pulse ox on and take them off of oxygen. The purpose being that if they have significant atelectasis, significant lower airway disease that we didn't realize, they'll desaturate with the ET tube in If they can maintain, that means that their lower airway is hopefully in an okay spot. And so if we have issues, then it's mostly just upper airway.
00:16:56
Speaker
Because I've had that happen as well, where a patient has gotten extubated, then we figure out after the fact that they aspirated at some point or something something happened. These guys usually have macroglossia, so their tongues are usually quite large.
00:17:09
Speaker
I have had it where I've put, and this is a bit of voodoo, I've put epi, a drop of epi, underneath their tongues, and I find that it does decrease the size of their tongues, and that's for patients that I really just cannot get the tongue out of the way. That's usually, i don't do that unless a patient has had to be re-intubated a couple of times.
00:17:27
Speaker
Again, it's not uncommon if the patient wakes up and starts flailing that we pull the tube, And if the patient starts to go into respiratory distress, we'll rapidly give them sedation, and then I'll even propofol them down and re-intubate them.
00:17:41
Speaker
What I always like to tell people, especially when they're first starting, and I think this applies even to ah like a respiratory emergency, is if a brachycephalic is not making a ton of noise, they're not breathing. They're not passing air.
00:17:52
Speaker
So don't look at their chest. Don't say, oh, like they're being very quiet. Maybe the surgery was super successful, or and maybe they're finally fine. If they're not making... airway noise, if they're not stertorous, they are not passing air.
00:18:05
Speaker
So open their mouths, pull their tongue out of the way, and you'll hear that flapping of all that tissue back there. And it's a mistake that I think a lot of people make until they turn p cyanotic. And then they're like, oh, they're not breathing. So if a lot of times I can give them the ACE, give them the Dexmed, open their mouths and with some flow by, and they will recover.
00:18:23
Speaker
If not, the next step is to give them couple of mints per kg of propofol. Don't go crazy. Stay calm. And just re-intubate and try again. Give more sedatives and try and keep them calm.
00:18:36
Speaker
Very rarely do I not have oxygen cage ready for these guys. And I just throw them into an oxygen cage with sedation and just let them hang out because they usually get hot. They really don't want to deal with people touching them and the anxiety of it. So if you can get a pulse ox on them, especially in one of the reflectance probes, so a flat probe, and just shave a spot and tape it onto their foot, that works great and that doesn't seem to bother them.
00:18:59
Speaker
So kind of going back to the beginning, you me the example of a brachiosphalic dog, which, you know, I live in Florida. We see a ton of these. And the other thing that we see as far as respiratory emergency, not just do they come in for airway surgery, but they also come in because they get heat exhaustion. yeah We also see this with other forms of upper respiratory emergencies, which are going to be things like laryngeal paralysis or tracheal collapse.
00:19:26
Speaker
You know, these are things we see all the time.
Distinguishing Respiratory Issues
00:19:28
Speaker
Okay. Yeah. So, i think kind of what I want to do really quickly is just kind of separate the difference between if you have a respiratory emergency like presenting to you, what do you do to try to tell the difference between if this animal is having an upper respiratory issue or a low respiratory issue? I think sometimes that can be really confusing.
00:19:47
Speaker
And I guess if I had an opinion on it, I usually just breed profile. a Yorkie or a French Bulldog are presenting to me, I'm going to assume that we're dealing mostly with an upper respiratory issue.
00:20:01
Speaker
But sometimes it's not as like clear cut. And so I'm just wondering if you have an animal you're presenting with like respiratory issues, do you treat upper and lower respiratory emergencies differently? Are you kind of just doing the same thing differently? What's your approach to figuring out the difference between those two types of patients?
00:20:20
Speaker
I mean, I have to say that usually this is more of an emergency critical care. They're usually the ones getting presented with this, and then I'll come in try and help with intubation sometimes or things like that. I think the trickiest animals actually, like you said, breed profiling, you know, you get a lab.
00:20:35
Speaker
You know with that is. Yeah, you're breed profiling. Yeah. You're to have to have something around that because otherwise like that noise is going to be like confusing to people. But anyway, cats.
00:20:46
Speaker
I find that cat airway stuff is really confusing. So whether they're presenting... with like heart failure or like pleural effusion or like a pneumothorax, or do they have a laryngeal problem? I think cats are really tricky.
00:21:02
Speaker
I think the biggest thing with any species, any breeds, any anyone that's presenting with respiratory compromise is just to get them a little bit calmer and a little worse. I think that the biggest thing is that these patients are making things worse because they're wound up and they're anxious.
00:21:21
Speaker
So I always just tell people, like get your intubation stuff ready. And people, I find that owners and newer vets, and even sometimes yeah ER vets, are like very paranoid about having to put a tube in.
00:21:32
Speaker
And to me, we're just biased, obviously. like i feel my most comfortable with a tube in a patient. But like it's not that big a deal to put a tube and then take it right back out. I've had plenty of patients where I put a tube in, it gives me a minute to think.
00:21:45
Speaker
I know that I have control their airway, even if they have lower airway stuff, right? Because you can freeze for them. Yeah. And they're not panicked. They're anesthetized. Exactly. and you can deliver 100% oxygen.
00:21:57
Speaker
Exactly. So I think that obviously if you can do a physical exam on these patients, that's going to be the biggest thing, right? So if they're wound up and they're anxious and they're freaking out, you can't do a good physical exam. So I think so sedating them is a good plan.
00:22:10
Speaker
Yeah. Ideally, if you're going to have surgery, you don't give them butorphanol, but butorphanol is a really nice choice. It's got less like GI signs. It's a little bit more sedative, I find, than sometimes the full muse. Sometimes the full muse, they'll excite a little bit with.
00:22:26
Speaker
So I'll do somewhere between 0.1 and 0.3 mg per kg of butorphanol IV. If you can't get a catheter, you can always go IM and give them a minute. And I'm really like a titch of acepromazine IV for any respiratory.
00:22:39
Speaker
Dexmed is fine. I don't have a problem with dexmedetomidine, especially if you're going IM. It's nice and fast. So I think that that's fine to do three mics per kg of dexmed. But acepromazine, like a lot of times these patients are hot. and They can't pant properly for a dog. They can't breathe off some of that heat.
00:22:55
Speaker
And so this will vasodilate them and kind of calm them as well as... cool them off. And yes, it's longer acting. Sometimes people get really wigged out about that. And i'm like, look, if they're coming in for a respiratory compromise, this isn't going to be fast.
00:23:08
Speaker
We're not going to suddenly calm them down and they're going to go home. Like there's something else going on. If they need to be a little sedated for a while, I think that's okay. So I'll do a 0.005 or 0.01 mg per kg of acepromazine IV with the butorphanol.
00:23:20
Speaker
And another thing that I think people should remember is that TORB is reversible. People seem to think that naloxone doesn't reverse it because TORB can be used as a partial reversal itself. But naloxone is for all opioid receptors. And so don't feel bad about giving butorphanol and then being like, oh, I have to send this animal home or something like that.
00:23:38
Speaker
You can give naloxone to reverse that. And TORB is pretty short acting. So Torb, Ace, and then obviously if you can get catheter in, you might need to twilight anesthesia. Sometimes these patients just need half a mg per kidg one mg per kg of propofol, and it doesn't knock them out enough that you can intubate them, but it allows you to put a mask on them. It allows you to position them. It allows you to do a physical exam. It allows all of those things.
00:24:02
Speaker
So for me, then you can do a fast scan of their thorax, see whether or not you have beelines, gives you an idea there. You can move on to chest radiographs if you need to. You can listen to the patient.
00:24:14
Speaker
You can check their CRT. You can get a blood gas, all of these things that kind of give you an idea of whether or not this patient is lower airway or upper airway. And once they've sedated a little bit, you may be able to open their mouth and look in there and see, is there an object? Yeah. So obstructing, those are usually like the most exciting, right? Like they, it's not a traditional breed that should be, and it's usually a young, stupid puppy or a young, stupid dog.
00:24:40
Speaker
And the dog presents and the owner's, it's never had any kind of respiratory anything. Turns out like it ate something and aspirated something down its trachea. And those are really rewarding because sometimes you can just sedate them with some propofol and pull that out. And the dog- they feel better immediately. It's awesome. Yeah.
00:24:56
Speaker
those are Yeah. So what I'm hearing is that i think like for your airway surgeries that are coming in, that are scheduled, I think like you can come up with a plan, which I think you totally, you know, described already. yeah But if you have an animal coming in that is not planned, it's true emergency. I'm hearing the best things to do are to give oxygen and date and don't be afraid to intubate. If you really are struggling to figure out what to do,
00:25:25
Speaker
Give IM sedation, maybe even rectal sedation yeah and intranasal sedation. There's a lot of other routes that you can do. You know, midazolam is another drug you can give IM or sorry, intranasally. There's a lot of drugs out there you can give intranasally. I think dexmedetomidine also. You can give transmucosally.
00:25:42
Speaker
Like there are other routes besides just like giving something be sedate them.
Pre-Anesthesia Medication Use
00:25:48
Speaker
Don't be afraid to even use induction agents at low doses like alfaxilin or propofol if you have a catheter.
00:25:54
Speaker
And don't be afraid to just put a tube in. If you don't know, I think that's totally reasonable to do that. That is my opinion. And I think you agree with that. Yeah. Or even put them into an oxygen cage too yeah right but to have someone turning on an oxygen cage and just put them in there and give yourself a minute to decide what you're doing next.
00:26:14
Speaker
Yeah, another thing also that sometimes for me too, and I don't think about this, but some of these animals, you know, you don't know if it's respiratory or cardiac, which you've kind of talked about with cats. but This is true of dogs too.
00:26:27
Speaker
And if they're just like showing up in your clinic, you have no history of what's going on. I never find it wrong to just give them like a little furosemide sub-Q. Yeah. And I agree with that because worst case scenario, I mean, yes, if they've got some kidney, like I can understand people's concern about that, right? Oh, do they have some underlying kidney stuff? We haven't gotten any blood work yet. Are we going to give this and then mess with their electrolytes and alter their kidney status?
00:26:50
Speaker
Two mix per kg of furosemide is not going to make or break the situation. And I totally agree with that. And if it is heart, it'll fix the problem. If it's not heart... They're just people. It's not going to do much. You just won you won't do it again.
00:27:05
Speaker
Okay. So one of the things I really liked that you talked about specifically with brachycephalics was about gastroprotectants and having those on board beforehand. And I think with the protocol, you know, a lot of people ask me about this in general when I'm consulting.
00:27:20
Speaker
So this is just like my general recommendation. Very similar to you. Yeah. I should have said I don't use a CRI, but I use medical overmind as a CRI. Yeah. So just to go back with the that, so my recommendation, i actually follow that Tufts paper that you're talking about where it talks about a standardized brachycephalic protocol.
00:27:41
Speaker
If I have a dog that has a known history of regurgitation, That dog is going on three to five days before anesthesia of Omeprazole and Thysipride before they even come into the hospital. Omeprazole takes about three to five days hit peak effect. But just like you said, like if a patient hasn't been on Omeprazole for a few days, i will still use Pantoprazole my antacid of choice usually.
00:28:07
Speaker
That's just because there there has been some evidence to suggest that even a single dose can lower some acidity. It's just that you're not going to hit your like – peak effect essentially. And then I also incorporate metoclopramide. I don't necessarily do a CRI during surgery. I'll do one post-op.
00:28:23
Speaker
The reason for that, for me anyway, is that there's not a lot of evidence to suggest that Reglin as a CRI is going to reduce gastroesophageal reflux during anesthesia unless you give very high doses, which I do. Yeah.
00:28:38
Speaker
I've seen animals go on those very high dosages and I don't like the way they recover. I think they recover little like neurologic and I don't want that for my brachycephalics. Like I want them to be quiet. yeah So I will put them on a post-op CRI of Reglin, but I will do a bolus beforehand. I usually do a half a McBurkig AV beforehand or sub-Q, like depending on, you know, how bad they
Fasting and Rapid Sequence Induction
00:28:58
Speaker
are.
00:28:58
Speaker
Either one to me is like fine. And then yeah, just an anti-medic of some sort. So Serenia, either orally, if the owner can get it in them beforehand or IV, there's some evidence to suggest IV performs better as an anti-medic than oral, but the oral is so much cheaper.
00:29:15
Speaker
Yeah, I usually do two mix per keg. honestly think all animals should be coming in into the hospital before they get in the car on Serenia. As somebody who gets car sick, like I find they always come in and they're drooly and weird and stressed out. And I maintain that some of that is just car ride as well. So I like i try and push for Serenia for everybody. I'm like, Serenia for everyone. Yeah. If you are able to do like a consult on these patients, like a surgery consult beforehand, it's so nice to send these patients home with just like a little packet, or like a pre-anesthetic packet of just like gabapentin, trazodone, and serenia. you tell the owner like, you know, you gave your gabapentin, trazodone the night before and then you give it the morning of with your serenia and they come in with that, you know, two hours before they come in.
00:30:01
Speaker
And i think that is really like a big game changer. I have one practice I work at that's really adopted that. And you can put IV catheters in these animals, whether they're brain sphellic or not, you know, on that combination 95% of patients.
00:30:18
Speaker
Yep. Same here. Plus they don't struggle. Like I find also like I like to IM my patients just because I actually think it's a time saver for me to come in, like, especially at the dental practice I work at, they all come in on like GABA plus or minus TRAS or TRAS plus or minus GABA and Srenia.
00:30:33
Speaker
but So I just pop them and then finish doing other tasks. So you're just IMing them as they're walking in the door. Yeah, exactly. But I find that I can IM most of those patients on my own. like Even cats, I let go into the cage, IM them, pet pet them at the same time, and I don't even need someone to restrain them. like Most of the time, they're so chill about it.
00:30:54
Speaker
And I just like IMs just because I'm all about ease of catheter placement. like I do not like to poke more than once or shave more spots because corners get really weird. I do use metaclopramide. So based on that really old landmark Deb Wilson study, gra granted it wasn't breakycephalics, I wish that we had that same study. like This is residents out there. I wish we did like exactly that same study in breakies and or that exact same study in normal dogs, but looking at Cisipride and looking at Erythro.
00:31:26
Speaker
I would like love to see if those are better at reducing regurg because I think most criticalists... mean erythromycin? Sorry. Yes. Sorry. not Okay. Yeah. Erythromycin. So, which I feel like a lot of cri criticalists really like Cispride and erythromycin as, you know, prokinetics.
00:31:43
Speaker
So... Yeah, I've been using a lot more CISO probably recently. That's not something that I did a lot in my like earlier years. yeah And recently I had a case where there was a dog that had a history of megaesophagus.
00:31:55
Speaker
And you know we didn't talk about fasting protocols per se and fasting brachycephalics or things like that. But there's some evidence that's coming out that suggests that potentially shorter fasting times are associated with less gastroesophageal reflux under anesthesia.
00:32:11
Speaker
so Luckily, this was a very good owner, and I don't think we could have done this with just like about anybody, but are the dog had a history megasophagus and needed like a dental, some dental, or excuse me, needed oral surgery.
00:32:25
Speaker
And so we decided to try with the shorter fasting times, and that dog was like refluxing like crazy in the room. So, you know, we talked to the owner. We said, how about we reschedule this? Because I don't think this is a really good scenario for your dog.
00:32:41
Speaker
Yeah. And then we decided to add Sysipride for five days with a long fasting period. Instead, we did, I think, eight to 12 hours. So we did 12 hours, no food, and then six hours, no water. Yeah. then that actually did the trick with the Sysipride.
00:32:58
Speaker
Interesting. I'm not saying that is going to work for everybody, but since that particular case, I've been adding a lot more Cisopride or recommending Cisopride for these animals with a history of reflux, plus the longer fasting times.
00:33:12
Speaker
Even though we don't really have a lot of data to suggest for animals with history of rears, if that's actually better or not, like we just don't know. Again, another study. Another study needs to be done, but that's been like my general recommendation has been, know,
00:33:26
Speaker
pulling water for at least six hours, pulling food for eight to 12 hours for these guys. And for the most part, I think that's what most of the clinicians I work with recommend. And I'm like mixed about it and I'm not sure. So there's a bunch of human studies in humans.
00:33:40
Speaker
If, If you read the ASA journal, they're big on reflux and regurgitation and stuff like that because people have it terribly. If people are like overweight and they have a history of GERD, they will fast them for much longer than like regular people.
00:33:57
Speaker
But there was an interesting study that looked at pregnant women who were getting epidurals. And they actually found that women who got epidurals, and continued to eat throughout their labor were less likely to regurgitate and aspirate versus the women who didn't have, had an epidural with fasting or didn't have an epidural and were fasted as well. So it's really interesting. And I think it's something that even in human medicine, they're like, they're waffling about, but they haven't even made a consensus there either because it depends on the age of the person and all that kind of stuff. So I don't think we know exactly. And I'm not sure that it's not like something where it's like,
00:34:35
Speaker
every individual is a little bit different, right?
Airway Management Techniques
00:34:37
Speaker
Because we know that some animals get bilious, like, gurg, vomiting, whatever, when they don't eat. so yeah So it's hard to say. like Sometimes I'll have owners that are like, if this animal doesn't eat, they will gurg and regurgitate and they will vomit or something like that. And for those patients, I'm like, okay, give them a small meatball four hours before.
00:34:56
Speaker
That's fine. yeah It does have to be highly digestible. And that's the other thing that gets tricky, right? If you have, a like you said, a really good owner that you can trust them be like, okay, when I say a meatball, I mean a meatball, like a small meatball of what highly digestible food versus somebody giving them their kibble that doesn't leave the cell for 8-12 hours.
00:35:13
Speaker
True. The next thing I want to kind of talk a little bit more about is about induction. And you mentioned doing like rapid sequence induction. What drugs are you usually using in order to accomplish like a rapid sequence induction? For rapid, it's always propofol or alfaxalone, right? Atomidate is lovely for certain kinds of patients, but it's not a smooth rapid.
00:35:34
Speaker
induction. And sometimes those patients will actually get like muscle contraction, which can actually worsen regurgitation. I've seen that happen. And then ketamine, benzo, that's always slow. It always is funny to me when people use five minutes per keg of ketamine with a benzodiazepine to induce, they're always like, this is taking so long. I'm like, just give it a minute because we're so used to propofol and alfaxalone at this point. Yeah.
00:35:56
Speaker
I like Ketofol, so two mix per kg of ketamine, two mix per kg of Propofol. But again, Propofol or Alphax is kind of always there for rapid induction. but Very rarely do I not have a co-induction agent. Very rarely am I doing six mix per kg of Propofol or four mix per kg of Alphax and inducing them off of just that.
00:36:13
Speaker
I'm usually doing some lidocaine. they've got respiratory stuff, if they've got cough for dogs, I'm always using lidocaine. In humans, they've shown that suppresses the cough reflex. And I find it does a nice job.
00:36:24
Speaker
I'll use ketamine, especially for patients. Sometimes I'll do that with brachycephalics that are really bradycardic to decrease the amount of vagal. I like doing cataphyl for cats with airway stuff because I find that cats have a tendency to vagal down pretty quickly if it's a difficult intubation. And so the ketamine...
00:36:42
Speaker
increases your sympathetic outflow from your central nervous system. And so it's almost like giving an anticholinergic. So you almost give yourself like a little bit of wiggle room if they do want a bagel. So if their heart rate is 220 and they bagel down to 160, it's not as scary as going from 160 down 75. Correct. Yeah. Okay.
00:36:56
Speaker
x yeah like okay Yeah, absolutely. You mentioned having the cook exchanger and I'm personally i've never worked with one of those things, but I've used like a quote unquote ghetto type of cook exchanger. yeah and I've actually will take like red rubber tubes yeah and I will make a long, I'll take two of them and I'll stick them together with some like tape. And then on the end of the red rubber, meaning like the machine end, I guess we'll call it, I will put a endotracheal tube adapter Yeah.
00:37:26
Speaker
yeah of that red rubber and then that you can hook up to the anesthesia machine yeah it's definitely not as like nice as the cook exchanger but it will help if you're having you know a surgeon i have some surgeons that i work with that to do the averted sacues actually during induction Because I just find it it's like a lot faster. And if I know that it's going to take a while to do the airway, a lot of times I'd like to at least have that red rubber tube that I can place down into the trachea so that I am providing some amount of oxygen for some kind of like prolonged induction.
00:38:03
Speaker
And again, I can't emphasize enough that you need to have like lots of different size endotracheal tubes because you never know what you're going to be able to fit in there. Yeah. It's always an adventure. Sometimes you get six in and you're like, yay! I know. I had a French bulldog the other day. I got a six and a half in and I was like, wow. I know. And you're like, you ain't going to anesthetize one.
00:38:21
Speaker
yeah I also will say, as an aside, I don't know if there was a study on this or not, but i know some people will use like a lateral thoracic radiograph to try to get an idea of what the diameter of the trachea is. And I would say i personally don't find that to be very helpful.
00:38:35
Speaker
And that is just because endotracheal tubes, when they talk about like the size, it's usually talking about the internal diameter, not the full diameter of the tube. but And you never know how thickened their airways are. You know what I mean? So even if you look on a radiograph, you're like oh, it looks like the diameter is six and a half centimeters or millimeters or whatever. No, totally. And the other thing I would say about that is like... My opinion. Yeah. The other thing i would say about that is I actually... They do... Can have hypoplastic and small tracheas, but like sometimes they actually have like relatively normal size tracheas. It's the...
00:39:07
Speaker
upper airway part that you can't get past. Yeah. Like and I think there was a study. I think it might've been the year that I presented at IBEX as a resident. Cause I think that the resident who presented this one, i think she won the abstract award and cause she was looking at lateral radiographs and to try and predict ET2 size. And I think the conclusion was like,
00:39:29
Speaker
This was useless. So yeah, I don't know if it ever became like a full paper or if it just was presented as an abstract, but it was interesting. Like they made me think of it because they didn't have enough data or something like that. But yeah.
00:39:40
Speaker
I think there was a paper also, i just want to put this out there, that if you are doing an airway assessment, meaning you are trying to look at whether or not the retinoids are abducting properly,
00:39:54
Speaker
There was a study comparing propofol and alfaxalone. And my memory, propofol performed better as far as being able to assess for laryngeal abduction. So if that is part of your airway exam, for example, if you're trying to diagnose laryngeal paralysis with it with an airway exam, I would stick with propofol for the most part because I think it performed better.
00:40:16
Speaker
Just putting that out there. Yeah. Ideally, you'd use Thio, but we don't have that. So, you know. Yeah. That's gone. Gone. So for the last little bit of our talk, I want to focus a little bit on extubation because i think it's easy when an animal presents either in a respiratory emergency setting or if they're getting airway surgery or something like that. I think that part is pretty straightforward. I think it does get a little scary when animals present they're purple and you don't really know, should I intubate them? Should I not? you know I think we both have a consensus that if you don't know, it's okay to intubate them.
00:40:50
Speaker
But I think the decision to extubate is like way more tricky. and so I think you mentioned some really good strategies, which is to sedate them like while they're still anesthetized before you extubate them, whether that be with trazodone, as you mentioned rectally, which I personally am not done. So i'm kind of excited to try that. awesome Or acepromazine, which is actually what I usually do. I usually give them like a low dose of acepromazine before I wake them up.
00:41:18
Speaker
yeah Or dexmentomidine if they were like a French bulldog that was a complete psychopath before they came to see me. You know, I'll use dexmentomidine as kind of like my sedative for preference. Just, I mean, I'm sure we all have seen those French bulldogs have like the zoomies when they walk in the hospital, you know. Which is kind of cute. right So, you know, sedating them ahead of time, trying to maximize airway opening, either with a dental dam or something like that.
00:41:44
Speaker
You talked about mannitol and placing that on the airway. There's a few other things, just things that I have seen. I don't know if anyone's done a really good study on any this stuff, but here's a few other like little things.
00:41:55
Speaker
Number one is I've seen people use ice. So they'll take like a glove and stick ice into the middle finger of the glove and then shove the glove into the back of the throat and then just pull it, you know, after a few minutes. I've seen that.
00:42:13
Speaker
I've seen also animals that have failed extubation one or two times. I've seen nebulized epinephrine as well as nebulized hypertonic saline. Yep.
00:42:25
Speaker
I don't remember the doses of those off the top of my head, but we can probably do it. don't either, but usually our critical is to say if they failed extubation, we usually do it. Yeah. The last thing was going to ask you about is about steroids because i think I've seen lots of different people do lots of different things. yeah So I'm curious what your recommendation is for these upper airway animals.
00:42:47
Speaker
When do you give steroids? Do you give steroids to everybody? your process? Yeah. So yes and no. The surgeons I predominantly work with to get the steroids before we cut, right? Because we all understand if we have an anti-inflammatory on board, then it does a better job of preventing than trying to catch up.
00:43:05
Speaker
That being said, sometimes they're on an NSAID. And so we're trying to avoid giving them a steroid. I will still give them a 0.1 mg per kg of DEX-SP if they're on a steroid. If their airway is inflamed and I can't get them extubated, I'm giving them a steroid. I don't care.
Use of Steroids in Airway Management
00:43:20
Speaker
So it depends on the patient. So say ah we did like a BAL on a brachycephalic or any respiratory patient and they fail extubation and the internist said, hey, you know, it was pretty inflamed in the upper airway section of this dog.
00:43:36
Speaker
And I'll be like, okay, well, we're going to give a steroid, but we'll do it at the end. Like maybe once the patient has recovered, we'll see if it fails. If the patient fails and I put a tube back in, then we just give a steroid.
00:43:47
Speaker
I also think that intubating, extubating, if they fail is enough trauma for me to give a dex-SP dose because it it does cause irritation to even put a tube back in. And a lot of times these patients will need to have a smaller tube the next time. So it's just evidence that there's inflammation going on back there. So yeah, I do use steroids.
00:44:06
Speaker
I'm like you, I use acepromazine preferably, again, because of the heat, also because dexmedetomidine causes ileus and these dogs already have GI stuff. And so I'm trying to avoid more GI stuff.
00:44:18
Speaker
I do find that critical care likes dexmedetomidine and they'll put these guys on dexmedetomidine CRIs. Fine. They're usually on medical provide as well. So hopefully it's all just canceling everything out.
00:44:29
Speaker
Like you said, i have had patients get extra pyramidal on metaclopramide. When I was a resident, we would give it in, I was giving it in the cage before I induced. And I saw a MIG per keg over 15 minutes, I would put on a syringe pump to try and save time.
00:44:43
Speaker
And I had a couple of animals get really wacky. So now I don't give it unless they're fully induced. And then i have them on a MIG per keg per hour CRI as well. Okay. Yeah, I don't do a mig-breaking per hour during the surgery just because I find – it's just been my experience. Like I find – depending on how long the surgery is, if you're doing something really short, I think like under two hours, I haven't had an issue. But if – once I start going over two hours and they've been on that, I find that they get like kind of weird. i should actually – say that like I give a mig per keg as loading dose and then I do a mig per keg per hour but I usually don't go over like really an hour so yeah I usually do it for an hour just to give them the push and then they go on two minutes per keg per day post-op yeah I typically will just do the bolus ahead a time and i I only do a half a mig per keg personally okay
00:45:30
Speaker
yeah And then post-op, I'll give them one and a half mg per kg per day yeah just because i already did the half. So just to max it at the two mg per kg per day, which is the typical dose.
00:45:41
Speaker
That's what I've done so far. Knock on wood. Seems to be okay. But I think the reason that we each do something different is because there's nothing that we know that works great. Yeah.
00:45:52
Speaker
you know i think just do find something that works for you and do it, I guess. As far as the steroids are concerned, you know my advice is I usually will make sure that anytime I'm anesthetizing anything with any kind of upper airway issues, whether it be tracheal collapse, laryngeal paralysis, anything like that, even if these animals are having surgery,
00:46:16
Speaker
And we know there's a source of inflammatory pain. I usually will not give an NSAID to these patients unless like they fail extubation. So I guess what I mean by that is I hold my NSAID on these patients.
00:46:30
Speaker
And if they're not specifically getting airway surgery, if they're just getting – if it's a French bulldog or something like that, not necessarily getting airway surgery but getting like – A mass removal or yeah whatever, anything else.
00:46:41
Speaker
My goal usually is that if they're having a surgery procedure or if they're having like a dental procedure, I want to make sure that they have NSAIDs because you're usually creating a source of inflammation. So the goal is to give them an NSAID.
00:46:52
Speaker
But I want to make sure that they are excavated safely before i give them that NSAID. And so i will usually hold it, wait to extubate them, wait at least 30 minutes and make sure that they are breathing well.
00:47:07
Speaker
And then I will give an end at that point. For anything getting an airway surgery or if they present with airway compromise at any point in time, and we know it's an upper respiratory problem, I'm usually pretty heavy handed about giving them steroids. And I usually do it either before surgery, but usually I wait till after surgery, but before extubation. So I'll give it like when they're closing, I'll give it like either, depending on how bad they were, anywhere between 0.1 or 0.2, usually 0.2, mixed per keg of DEX SP, just right off the bat.
00:47:38
Speaker
yeah And then if we did create a source of inflammatory pain... and we know that they you know they needed those steroids, I'll send them home on prednisone just as a way of providing source analgesia, actually, because we do know that, at least in an anti-inflammatory dose, it is anti-inflammatory, and that does provide a source of analgesia as well. So don't be afraid to sub-PRED for NSAID if you have to.
Emergency Coordination and Calmness
00:48:05
Speaker
It's it's probably, and we don't actually, don't know if it's if we know if it has as much effective analgesia as NSAIDs, because i don't know if it's been studied in the same way, I'll be honest.
00:48:13
Speaker
I don't know. But still do it. I do that a lot for because they already came in. I get a lot of breaks with my derm groups. That's a really good point.
00:48:24
Speaker
Yeah. And it's what's interesting is I didn't – and I didn't know this until recently. The way that they close down their airways, they close down their ear canals too. So you got to move fast and you got to work really quickly. Yeah. so sometimes I'll read dex-SP them intra-op or intra-procedure dermatologist will be like, i they're closing up.
00:48:43
Speaker
And so I'll give them a dex-SP dose during that. So those dogs all have come in on steroids or those cats sometimes have come in on steroids because they're getting ear stuff done. And then we'll send those guys home on steroids for analgesia because you've poked around in their ear. You maybe did a maringotomy. It's uncomfortable.
00:48:59
Speaker
Yeah, absolutely. Yeah, but there's a lot of breakies there too. And those ones are not getting airways procedures. so but Right. Right. Okay. So I want to wrap this up by saying one thing.
00:49:12
Speaker
The first thing is that I wish that we had more things like this where anesthesiologists get together and kind of chat about what they do. Because I think I've learned a lot from you about how you approach it. Hopefully, maybe you learned something from me. I don't know. surprise Yeah. I'm going to start using Sysipride. Yeah.
00:49:27
Speaker
But it's really fun to talk to other people and see what they're doing because i think that we still, despite how many French Bulldogs and all these airway cases are presenting our day-to-day practice, you know everyone's doing something a little bit different. And that probably just goes to show that like we don't have a good consensus on what works. like We don't have enough data out there despite how many French Bulldogs there are. Yeah.
00:49:51
Speaker
The second thing I wanted to ask you is that if you had to really boil this down to, you know, a few bullet points, take home messages of, you know, how vets can handle these types of cases when you're in the middle of a crisis or a respiratory crisis, you know, what are some of those suggestions that you have? Yeah, I think staying calm.
00:50:12
Speaker
I think. even when it's an emergency, trying to be like, almost have a checklist in your head and be like systematic, be like, okay, what's the problem here? I need to sedate. I need to have oxygen and I need to have intubation supplies. Like those are the three things that you need.
00:50:28
Speaker
So just calm down, take a break. And then almost like how you run CPR, give people jobs. Say you go grab the intubation supplies. You go get the drugs. These the drug doses I need. You go get the oxygen cage turned on. And so that you're like...
00:50:43
Speaker
Someone stand with this patient with flow by oxygen. I need to quickly call the owner. I think running it similarly to how you run CPR and kind of thinking about it as one point person being in charge and not everyone just like running around trying to fix the problem. So I think that's the biggest thing. And i think that...
00:50:59
Speaker
It's also easy to say, right? Like I would say that all anesthesiologists, even though we might seem calm, there's probably some internal anxiety when we have a patient that we've had to re-intubate or that's turning purple. Like we too also get and anxious about these kinds of things and like whether or not we're going to be able to get something re-intubated.
00:51:15
Speaker
But I think just trying to be systematic about it is probably the best way. Like you're going to either have to put the tube in the dog or they're going to calm down you're going to be able to oxygenate them with a mask.
00:51:26
Speaker
It's going to be one of those two things and it is what it is. So intubate earlier than you would think you need to and calm everyone in the room, I think. Yeah. I think just remember that you being there is making the situation better. Yes.
00:51:42
Speaker
And it would have been if you weren't there. Yes.
Conclusion and Listener Engagement
00:51:45
Speaker
And I guess my other thing, too, is if you ever experience, you know, respiratory emergency in your hospital and you go through the motions, I think something that's really important to do is always after the situation is over, meet with your team and talk about, OK, if this ever happens again, you know, what are we going to do differently? What are we going to do the same?
00:52:06
Speaker
I think that M&M rounds are even like cage-sided M&M rounds or like debriefs are like highly underutilized. And I think that they can be unblamy and it's best to do them right away and not to let your emotions get too in there and be like, hey, you did a good job here. You did a good job here. But how could we have done better as a collective and realize that like the teamwork is what...
00:52:31
Speaker
saves animals at the end of the day, which is what all of our goals are, right? Nobody does anything maliciously. So if a case doesn't go well, or things like kind of go sideways, or things get stressed out, I think remembering that, hey, nobody that was in that room was trying to have something negative happen, but we can all figure out how we can do better the next time. So maybe if you're somewhere like Florida, and you get a lot of airway cases because for some reason people in miami think that a break is found because a good good life choice like maybe running like a fake airway like yeah people are letting their french bulldogs run around on the beach in like mid-august bad choice psa for everybody don't do that
00:53:19
Speaker
um Also, our listeners, if they have any questions for Dr. Gowdy, please email us at education mynavast.org and we can get those questions to her and hopefully answer your burning questions about respiratory emergencies.
00:53:34
Speaker
We hope you learned something from our discussion. Hope you learned some tips and tricks on how to handle these cases if they ever present to you at your hospital. Yep. Thanks, guys.
00:53:49
Speaker
That's all for today's episode of the North American Veterinary Anesthesia Society podcast. A huge thank you to Dr. Liz Gaudi DeAngelis for sharing her expertise and practical advice on managing small animal patients in respiratory distress.
00:54:03
Speaker
These cases are some of the most stressful we face, and I hope her insights have given you the tools to approach these patients with greater confidence. We'd also like to thank our sponsor, DECRA, for supporting this podcast and for their commitment to advancing veterinary anesthesia and analgesia through innovative products and supporting veterinary continuing education.
00:54:24
Speaker
If you've been enjoying our podcast, we'd love your support. Please consider liking, subscribing, writing a review, or sharing the podcast with friends and colleagues. Every bit of listener support helps us to reach more veterinary professionals like you.
00:54:38
Speaker
For questions about this episode or the podcast in general, or to suggest topics for future episodes, feel free to reach out to us at education at mynavass.org. We'd love to hear from you.
00:54:50
Speaker
I also want to thank the editor of this podcast, Chris Webster of Chris Webster Productions, and to Saul Jimenez for providing technical support for this podcast. And of course, thank you to our listeners for tuning in.
00:55:03
Speaker
We hope today's conversation helps you feel more prepared the next time you're faced with a respiratory emergency in practice. I'm Dr. Bonnie Gatson, and this has been the Navass podcast.
00:55:15
Speaker
Veterinary anesthesia is a lifelong journey of learning and growth, and we hope you'll join us next month as we continue exploring it together.