1. BLOOD PLEURODESIS IN A GREAT DANE WITH A PERSISTENT, SPONTANEOUS PNEUMOTHORAX Advisors: Dr. DiFazio, Dr. Flanders Maggie Winter 4/23/13

2. The Patient 7yr, FS, Great Dane 3 day history of tachypnea and dyspnea while at boarding facility rDVM took radiographs and found…

3. Pneumothorax

4. What is a pneumothorax? Accumulation of air in the pleural space

5. Pneumothorax- review Open vs. Closed vs. Both Traumatic HBC, high rise syndrome, bite wounds Excellent Prognosis Iatrogenic Thoracocentesis, ET cuff, PEEP barotrauma Good Prognosis Spontaneou s 1°- no lung dz 2°- lung dz

6. Etiology  Bullae/bleb rupture (bullous emphysema )  Parasites  Dirofilaria immitis (heart worm)  Paragonimus spp. cysts (lung fluke)  Migrating FB  Grass awns, porcupine quills  Severe pneumonia  Feline asthma  Neoplasia Prognosis: variable dependent upon etiology and treatment modality

7. Risk Factors  Siberian Huskies  Bullous emphysema  Medium/Large breeds  No age or sex predilection

8. Diagnosis  Decreased BV sounds  Diagnostic/therapeutic thoracocentesis  Thoracic radiographs  Often no evidence of etiology  Thoracic CT  Determine etiology  Surgical planning

9. Treatment  Stabilization- thoracocentesis/thoracostomy tubes + O 2 supplementation + antacid  Risk of regurgitation 2° to aerophagia  Exploratory median sternotomy  UNLESS there is non-surgical dz identified pre- operatively Parasites Diffuse pulmonary dz  Significantly lower recurrence & mortality in patients treated surgically

10. Let’s return to our patient- rDVM (9/10/13)  Radiographs  Bilateral pneumothorax  Diffuse interstitial pattern  Thoracocentesis  >1 liter of air from each hemithorax  Bilateral Mila chest tubes  Continuous suction  Referred to CUHA the next morning

11. CUHA Emergency Service (9/11/13):  PE:  Tachycardic (HR=180 bpm)  Tachypneic (RR=60 brpm)  Decreased BV sounds dorsally  Under conditioned (BCS 3/9) + muscle atrophy  Short strided gait  Severe medial buttress (L > R)  Claws scuffed down to P3 x 4  Severe pododermatitis

12. Initial diagnostics & treatments  QATs = normal  Venous blood gas = mild respiratory alkalosis  SpO 2 = 97% (on room air)  Stabilization: O 2 supplementation via intranasal cannulas, tapped chest via tubes, analgesia  Overnight: continuous suction, antibiotics, IV fluids, gastroprotectant  Transferred to the soft tissue surgery service the next day

13. Problem List  Spontaneous pneumothorax  DDX: ruptured bullae, neoplasia, infectious  Diffuse interstitial pattern  DDX: atelectasis, lung lobe torsion, pneumonia, neoplasia, immune mediated dz, hemorrhage  Severe generalized muscle wasting  DDX: paraneoplastic, malabsorption/maldigestion, nutritional, orthopedic disease  Abnormal gait (with scuffed claws)  DDX: OA, disc disease, wobbler’s, poor muscle tone  Pododermatitis  DDX: allergies, pain, peripheral neuropathy, behavioral

14. Surgery Service Plan:  Stifle radiographs  R/O: neoplasia  Results: Osteoarthritis  Thoracic CT  Etiology  ± Exploratory Thoracotomy

15. Bullae

16. Treatment Plan: Our patient:  Median sternotomy  Multiple partial lung lobectomies + Histopathology  5 days post-op supportive care in the ICU with persistent pneumothorax!  Owner wanted to bring patient home REMEMBER: Spontaneous pneumothorax is a surgical disease!

17. What happens if surgery fails or isn’t an option? Pleural port Blood pleurodesis Sclerosing agents

18. Pleural Port  Not recommended as first line of treatment  Case report:  2 patients with persistent pneumothrax despite thoracotomy  tapped on outpatient basis until resolution (≤ 2 weeks)  then went 17 & 23 months before euthanasia

19. How it works… 22g Huber needle Placed SQ in the 7 th or 8 th ICS

20. Our Patient’s Pleural Port

21. Autologous Blood Pleurodesis  Infusing a patient’s own blood into their pleural space to treat pneumothorax or thoracic effusion  MOA: unknown  Elicits inflammatory rxn  pleural adhesions  obliterates space for air to accumulate  Sealing sites of air leakage with clots  Signs resolve rapidly- immediately to <24hrs  Autologous blood dose: none established  Rat study- 2-3 mL/kg  Case reports- up to 5mL/kg  Our patient- 4.2mL/kg (250mL)

22. Autologous Blood Pleurodesis  Minimal reported side effects in dogs  Humans- fever  Variable efficacy  Human studies show efficacy in 57%-100% Tx  Rabbit study showed ineffective Tx using 1mL/kg autologous blood Conclusion: Safe, simple, inexpensive Tx for persistent pneumothorax when surgery is not an option or fails

23. Sclerosing Agents Second line of treatment Lack of prospective randomized studies 1.Talc powder 2.Silver nitrate 3.Tetracycline 4.Doxycycline

24. Sclerosing Agents  Talc  Slurry vs. Poudrage – similar efficacy  ARDS reported rarely  ~87% success rate (humans) Widely used  Ineffective in rabbit study, effective in dog & pig studies Species-dependent dosage?  Silver nitrate  Rabbits- more intense pleural reaction than talc in 1 st 6hrs Hemothorax, atelectasis post treatment

25. Sclerosing Agents  Tetracycline  Historically used  Not available  Doxycycline  Proven to form adhesions/fibrosis  Associated with longer hospital stay and discomfort Conclusion:  No single “best” sclerosing agent  Talc has high reported success  Need randomized prospective studies to determine efficacy and dosages

26. Our Patient  250mL autologous blood pleurodesis  Blood from jugular  infused through chest tube  Alternated down side a few times  distribute blood  Pulled thoracostomy tube and discharged from CUHA several hours later

27. rDVM Update 1 month later  No respiratory issues for 1 month  Presented to rDVM for:  Progressive weight loss, anorexia, lethargy  Recurrent urinary tract infection refractory to antibiotics  T = 103°F  Mature neutrophillia  Rads: scant pleural effusion

28. Cost  Exploratory thoracotomy + lung lobectomy = $1,856  Stifle rads + thoracic CT w/contrast = $552  Pleural port placement = $806  Huber needles (5) = $31  Blood pleurodesis = $115  Hospitalization + diagnostics + stabilization + care + meds = $3,983.36 Total = $7,343.36

29. References  Cahalane, Kosanovich A, Flanders J. Use of Pleural Access Ports for Treatment of Recurrent Pneumothorax in Two Dogs. J Am Vet Med Assoc 2012; 241.4:467-471.  Jerram R, Fossum T, Berridge B, Steinheimer D, Slater M. The Efficacy of Mechanical Abrasion and Talc Slurry as Methods of Pleurodesis in Normal Dogs. Vet Surg 1999; 28.5:322-332.  Merbl Y, Kelmer E, Shipov A, et al. Resolution of persistent pneumothorax by use of blood pleurodesis in a dog after surgical correction of a diaphragmatic hernia. J Am Vet Med Assoc 2010; 237:299–303.  Mitchem R, Herndon B, Fiorella R, et al. Pleurodesis by Autologous Blood, Doxycycline, and Talc in a Rabbit Model. Ann Thorac Surg 1999; 67:917-921.  Oliveira, Frederico H, Cataneo D, Ruiz R, Cataneo A. Persistent Pleuropulmonary Air Leak Treated with Autologous Blood: Results from a University Hospital and Review of Literature. Respiration (2010); 79.4:302-306.  Ozpolat B, Gazyagci S, Gozubuyuk A, et al. Autologous Blood Pleurodesis in Rats to Elucidate the Amounts of Blood Required for Reliable and Reproducible Results. J Surg Res 2010; 161:228-232.  Puerto D, Brockman D, Lindquist C, et al. Surgical and non-surgical management of and selected risk factors for spontaneous pneumothorax in dogs: 64 cases (1986-1999). J Am Vet Med Assoc 2002; 220:1670–1674.  Smith S, Byers C. Spontaneous Pneumothorax Compendium 2009; 11.3:5-11.  Tschopp J, Rami-Porta R, Noppen M, Astoul P. Management of Spontaneous Pneumothorax: State of the Art. Eur Respir J 2006; 28.3:637-650.

30. Questions?