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why don't you? So, um, I've made my presentation based on the latest British thoracic Society guidelines, and you will be able to find my references and resources and links at the end of the presentation. So I'm just gonna share my screen for now and start with the, um, animation. Are you able to see my screen position? The patient's sitting upright or lying supine with the ipsilateral arm abducted fully. You should insert a chest drain into the triangle of safety. This is bordered by the lateral edge of pectorals. Major. The lateral edge of latissimus dorsi did or I don't think your screen is sharing. No, no, I think I would have to make you the host for that to share. I'm just going to do that now. Yeah. What about now? It's still just on your video. Like, uh, yeah, that's okay. Position The patient's sitting upright or lying supine with the ipsilateral arm abducted fully, you should insert a chest drain into the triangle of safety. This is bordered by the lateral edge of pectoral major, the lateral edge of latissimus dorsi, the fifth intercostal space and the base of the axilla before inserting a chest drain. Check the patient's chest X ray, full blood count and coagulation except in an emergency. Correct any coagulopathy before inserting the chest. Drain chest drains for pleural fluid should be inserted under ultrasound. Guidance by an operator trained in thoracic ultrasound. Prepare the seldinger chest Train equipment on a sterile trolley. Wash your hands and wear a sterile disposable gown. Sterile gloves and I protection. Identify the correct position for drain insertion, which is the fifth intercostal space in the midaxillary line. The manubrium stern I is continuous with the second rib, and the intercostal spaces can be counted down from here. To find the fifth intercostal space, clean the chest wall with antiseptic solution in a circular motion and allow the skin to dry. Place a fenestrated sterile drapes over the patient. Infiltrate local anesthetic into the skin at the point for drain insertion and continue to infiltrate into the subcutaneous tissues above the sixth rib and deeper to anesthetize the parietal pleura. Aspiration of air or pleural fluid will confirm adequate infiltration of local anesthetic into the tissues and parietal pleura. After a few minutes inside the introducer, needle and syringe. At this point with the bevel of the introducer needle facing upwards. Advance to introduce the needle while aspirating until fluid or air is easily aspirated and seen in the syringe, then advanced to introduce the needle by another 1 to 2 millimeters to ensure the whole level of the needle is within the pleural cavity. Do not add the needle any further because you risk damaging soft tissue. If you insert it blindly, note the depth of which you could ask great fluid or air. If you're draining a pleural effusion, rotate the needle through 100 and 80 degrees, so the bevel of the needle is pointing down. If you're draining a pneumothorax, keep the needle with the bevel facing up. This will help direct the guidewire and subsequently the drain into the best position. Disconnect the syringe. Insert the guidewire through the introducer needle and pass the wire gently into the chest. The length of insertion of the guidewire depends on the build of the patient. Make sure that you do not let go of the guidewire at any time removed the remainder as a guidewire from the holding spoon removed to introduce the needle while holding the guidewires, secure the imposition make a small stab incision into the skin where the guidewire enters the chest to allow the dilator to pass through the skin. The horizontal incision should be parallel to the rib to reduce the risk of damaging the neurovascular bundles. Are you able to see my screen now? Can I start with the presentation? Yeah, we can see your screen. It's still on the video. Yeah. Is there anyone in the waiting room before you start? No. Okay. Shall we start, then? Chest training session. So I'm going to talk mainly about the self finger technique. So, uh, my name is Tecfidera. Those of you don't know me. Uh, I am currently working as a foundation yet to doctor at the Royal Sorry County Hospital in Gilford. Um, so I make this presentation according to be TS guidelines, which stands for British Thoracic Society. Uh, so basically, a chest train is a tube which is inserted into the intercrural space, which is the space, um, made with the parietal plethora. Visceral pleura. So that's the space between these two, Clara. And the goal is to drain, um, its contents. Meaning either air in the case of pneumothorax or fluid in the case of pleural effusion, and, uh, that can be either for diagnostic purposes or therapeutic purposes. Uh, there are two main, uh, techniques to insert the chest train. Uh, the first student, the most common is the sultan. Your technique, which is a guidewire technique, basically where we introduced the GUIDEWIRE. And then we dilate the area when you put the train, uh, as it was shown in the video. And then the second technique is the open technique, which is basically a blunt dissection and is usually, um, uh, requiring experienced. Let's say, um, doctors to do that. Uh, and it's usually under, um, in general anesthesia, although I've seen it under local anesthesia as well. So it depends, uh, on the doctor doing the procedure. So the main indications for chest training session is a pneumothorax. So that can be either tension pneumothorax after trauma or, um, in the case of spontaneous pneumothorax, or it can be traumatic hemo pneumothorax. So, in the case of a traumatic hemo pneumothorax, we will usually, uh, put the white board, uh, train, which I'm gonna talk in my next slide. The difference between a narrow board and a white board, Uh, tube and their indications. Another indication for HS training session is in the case of malignant pleural effusions plus minus pleurodesis. Um, in the case of M p m. A and complicated parapneumonic pleural effusions Or, uh, it can also be inserted after an operation, Let's say after a thoracotomy or esophagectomy or a cardiac surgery to prevent, um, m p m A or pleural effusions. Uh, we can still insert a chest train in any ventilated patients. So, uh, ventilated patient is not a contraindications for a chest train. Um, so contraindications will be if, let's say, um, the I N A is more than 1.5, and then we have to think about reversing that, um, according to trust guidelines. So we can just call the hematology and ask about their opinion. Uh, or we can just give vitamin K to reverse that. And if the platelet count is less than 50 then it's questionable whether or not the patient needs to have the chest train. As a matter of urgency. Um, according to studies, there has been no major bleeding in patients who have had from aside opinion, but again, it depends on your hospital policy basically and guidelines. Um, so, of course, in case of an emergency, then, uh, if the patient will benefit from a chest training session, then we we don't have to think about i n r and platelet count. Uh, of course. Um, uh, chest training session shouldn't be done out of hours. Uh, so we we first have to think about whether or not a chest train really needs to be inserted out of ours and whether or not it is safe to insert it and whether or not there are sufficient people around in case something happens to the patient in terms of complications after the chest training session. So it all depends. Um, whether or not it's urgent to insert the chest rain. Um, usually we do, um between certain ages train under ultrasound guidance, especially for pleural effusions. In the case of pneumothorax, it is not mandatory to do an ultrasound scan. Um, you just stick basically the tube in the triangle of safety, which was also shown on the video, and I'm going to mention in my next slides the borders. Um, and of course, we need to think about differential diagnosis of pneumothorax Um because let's say if a patient has a diaphragmatic hernia or a large colon, then that's a country indication for inserting chest train. Um, because a diaphragmatic hiatus can mimic pneumothorax the same as with Ebola. So we need to make sure we know it is a pneumothorax, and it's not something else. So the difference between white and not, uh, chest strains. So the other one is 10 to 14 French, um, up to 24 French. So we can still, um, insert up to 24 hour French, uh, drain if needed for a pneumothorax. M. P m, uh, plural effusions. But in the case of massive hemithorax or even traumatic pneumothorax AFL a chest and just wounds, usually a white poor train is needed. Let's say more than 24 French. And the reason for that is because if we do insert another one, then there is a high risk of blockage, and then we have to reinsert the train, which is going to cause a possible damage to the patient pain and, um, uh, increase the risk of complications. Uh, so it's important to know whether a narrow or a white uh, board train is needed. And in which case, So this is a very nice algorithm according to be ts guidelines, which basically says, uh, do we really need to insert the chest train out of ours either for, uh, pneumothorax or for pleural effusions? Do we really need to do that? If that's a matter of emergency, let's say intention pneumothorax, then yes, Uh, we have to insert it. But if that's not urgent and that can be done, um, under usual, let's say normal working hours. Then we should wait. We should order food, Blood count. Calculation screen. Make sure the I N. R is less than 1.5. Make sure the platelets are about 50 times 10 to the power of nine. And make sure there is, um, enough stuff and people around to help in case something happens. Um, so if the patient does not have significant respiratory compromise, then we can wait. Uh, and let's say the patient is, um, not needed to have that as a matter of, uh, urgency. Um, of course, the person who is doing the chest train, uh, must have sufficient training and X experienced, uh, because there is a risk of misplacing the chest train. Uh, and that can cause complications as well. Uh, we should always succeed your help and basically, no our limits And make sure we've done the procedure before because it's not. It's not easy so it can get tricky. I will talk about the equipment at some point in my next slide as well, but basically, we need to have 1% of, uh, lidocaine, which is a local anesthetic. We need to make sure we have the sterile drapes needles. So the needle is usually the green one we use, uh, addressing the closed system drain and the chest should kids. So it basically it It usually comes up as a as a kid, but sometimes you just have to collect every single equipment on its own. We need to make sure there is a written consent in place, and we've explained the procedure to the patient as well as the reason for inserting the train as well as the complications. Now, if the patient does not have the capacity to make decisions, then we need to make sure we inform the family and we do a lack of capacity consent for so again, it has to be a competent operator of supervisor, and the purpose is to relieve patients symptoms. And it can be done as either diagnostic or therapeutic procedure. Basically, um so back to the anti platelets and anti coagulation, which I think is really important. Um so usually dogs should be stopped 24 to 48 hours prior to the procedure. And the reason for that, of course, is to minimize the risk of bleeding. Clopidogrel and prasugrel should be suspended for at least five days, according to be TS guidelines, but some hospitals say seven days so again, it depends on your hospital policy. Ticagrelor should be stopped seven days prior to the procedure and aspirin there is, so there is no need to hold the aspirin. The patient can still have the procedure, uh, while taking the aspirin. So now, if the patient has iron, are more than 1.5 abnormal calculation in the sense of platelets and requires an invasive pleural procedure, then the best thing to do is contact the, uh, hematologist or the local dermatology department basically for an advice. So the consent form. So it's basically our responsibility as doctors to, um, make sure the patient knows why we are doing the procedure, the risks and the benefits of having not having the procedure. And, um, I think the important thing to say here is that the doctor who is going to carry out the chest training session should consent the patient. So let's say I'm the f Y two in the world, but the respiratory registrar is going to accept the chest rain. I shouldn't be consenting the patient because I have not done the procedure before. And it's not safe for me, not for the patient to for me to consent the patient. Basically, it has to be the person who is going to carry out the procedure, uh, and and their responsibility to consent the patient. And it has to be, um, clear enough for the patient to understand. So basically avoiding medical journal antibiotics. So what do you think about giving antibiotics in patients who will have a chest training session? Just put what you think in the chat group? Do you think antibiotics should be given to patients having a chest training session? So, according to the guidelines, BTS guidelines, there is no indication to give antibiotics, and that's because the, uh, chances of having an infection because of the chest pain is very low and also because they have not been, uh, beneficial. And given the high risks of hospital acquired infections such as Clostridium difficile. Basically, there is no need to prescribe antibiotics just for the chest training session. However, some patients might have been on antibiotics prior to the chest training session. Let's say, because you are suspended, you're suspecting an empyema because a patient is having a pleural effusion and then patients infection markets are very high. Then you are suspecting M p M A. You start a patient on antibiotics for Let's say, I'm waiting a pleural tap, then that's a different story. But if you are putting a chest strain, uh, for a pneumothorax or for diagnostic purposes and the infection markets are unremarkable, then you do not need to start the patient on antibiotics even prophylactically. You shouldn't be doing that unless absolutely needed. So positioning of the patient is very important. And basically there are different ways to, um, position the patient. Uh, it can be, um, in the lateral decubitus position, which is, um, picture. See, uh, picture be is basically asking the patient to be seated. Um, and a is just, uh, laying on the bed. And basically, the purpose is to make sure there is a 45 degree angle and sufficient exposure of the axilla to make sure you are able to see the safe triangle, which is the place you're gonna insert the chest train, the triangle of safety. I think it was mentioned in the video as well. And that is bounded, uh, immediately by the lateral edge of the pectoral. Major muscle laterally is bounded by the lateral edge of the Latissimus dorsal and then superior Lee is basically the base of the axilla and inferior Lee is the fifth intercostal space, which is usually along the patients in April approximately. So now how do you know where the fifth intercostal space is? So we know that the manubrium of the sternum is approximately at the second intercostal space, so we should count downwards from there, and the fifth intercostal space should be approximately at the level of the nipple. But just double check. Um, just make sure you can palpate the manubrium of this tournament. That's going to be the second intercostal space so the layers of, uh, the skin and basically as you go through with the needle. So initially we have the skin, and then under the skin, it's going to be the superficial fascia with the subcutaneous fat. And then it's going to be the external intercostal muscle, then the internal intercostal muscle, then the transversus psoriasis muscle and then the Clara. So we have different complications, depending, um, to the position of the brain related to the insertion and related to infection. Um, the most common complication after a chest training session, apart from pain is blockage. So there have been, uh, high complication rates. Um, after a chest training session, that was because the, um, drain was blocked. And basically, to prevent that from happening, we should, uh, flash the train regularly and make sure it is bubbling or swinging. Um, other complications, uh, include re expansion pulmonary edema. Uh, causing pneumothorax is, uh, ironically, a complication of the chest training session and puncturing a solid organ, which is basically, uh, inserting the chest train out of the triangle of safety. And that could be the spleen. If it is, of course, the left side that if it is the right sided chest train. There is a risk of damage in the liver. Uh, and there have been, uh, complications with puncturing the intercoastal artery, and that caused major bleeding. So then you should think if you need to take the patient to theaters for a thoracotomy. So points to consider is, um, depending on the indication of the chest rain insertion and whether it was a hemothorax and pneumothorax or a pleural effusion. So again, in case of hemothorax, if there is more than 1.5 liter of blood loss, or if the patient is losing blood more than 200 mL per hour over two hours to four hours, then you need to think, Have I done something wrong? Is there any active bleeding going on? And do I need to take the patient to theaters for a thoracotomy? In the case of, uh, pneumothorax, if there is a massive erlich and the patient becomes unwell, hemodynamically unwell. Uh, then we should suspect a major Broncos injury and again thinking about taking patients theater. In the case of pleural effusion, um, draining a pleural effusion ideally should be controlled to prevent any potential complications from that. And, um, there have been a lot of studies whether or not we should clamp a chest rain. And the answer to this is no. We should never clamp a chest train because there is a high risk of pneumothorax. Unless the patient, uh, was having the chest train because of a pleural effusion. And if there is, um, 1.5 liter out put in the very first hour of the insertion, then we should clamp the train and wait for approximately 30 minutes before we start training again. Basically, Uh, And of course, once we clamp the train, we should observe the patient for any signs of deterioration if they develop chest pain, if they develop any calf, and then we should remove the clamp. But for a pneumothorax, we should never clamp a chest rain. And in case of pleural effusion, it has to be a 1.5 liter outcome in the very first hour for us to think about clamping the train. And that's from the BTS guidelines. Um, and it's just for me to emphasize that the most common complication of chest training session is draining blockage, which, uh was the most common complication and mullah position was the second most common. Of course, pain is so If you get an M. C. Q. Question asking about the most common complication and pain is among the answers, then obviously, pain is the most common complication, although we do give local anesthetics and painkillers to patients after that. And that's basically a list of the equipment uh, we need, although it usually comes up as a readymade kit. Um, we usually, uh, suture the train to, uh, stabilize it with a silk suture. Usually size. Oh oh, one. And we usually use a 21 to 25 g needle, Which is the Green needle initially in the first place. Priority inserting the guidewire. Basically, uh, so after the procedure, we need to obtain a chest X ray. We need to make sure we have documented clearly in the patient notes. Uh, we need to make sure we've documented the consent that the patient was consented basically prior to the procedure and the risks and the benefits have been explained to the patient. We need to make sure we give some painkillers and we need to observe the patient and, um observing meaning, uh, ops wise. So, uh, SATs and respiratory rate and temperature, but important. The most important thing is to make sure we, um uh there is some swinging or bubbling in the chest tube. We need to make sure there is no high output coming out from the brain. Uh, and we need to observe the side of the wound, uh, to make sure there is no bleeding. There are no signs of infection. There is no, uh, chemotic changes basically in the skin, suggesting that there has been some, uh, injury. And this is some terminology about swinging and some physiology, which, basically, when the patient inspired the intra thoracic pressure falls. And when the patient expires, the intra thoracic pressure increases. So you can ask the patient to, um, cough. So it's basically any valsalva maneuver. Um, I think just to make sure the there is bumbling, uh, in the underwater tube. Basically, uh, and that would suggest that the drain is, um, functioning. So I've mentioned about blockage as a complication. Um, So if, uh, the chest train stops swinging with inspiration, then this suggests that the tube might be blocked. Uh, so we should think about flashing the train or, uh, we can just remove it and reinsert it. But ideally, we should obtain a chest X ray to, um see if there was any long re expansion. And if the patient has improved or deteriorated according to the chest X ray, Uh, and usually we usually we do remove the chest. Train is after 24 to 48 hours, but that depends on the indication. So why we've put the the chest pain in the first place? We can keep it for more than 48 hours. In the case of pneumothorax, uh, but usually for a pleural effusion, we tend to, uh, remove it after 24 to 48 hours unless we are worried about, um, the pleural effusion not being sufficiently trained. And we can obtain another chest X ray or it depends if we are quivering about something else. And again, we should never clamp the chest train, especially with the pneumothorax. Unless, um, it can be done. But it can be done, Let's say by a consultant, respiratory consultant or thoracic surgeon who knows, uh, what he's doing. Basically, uh, and then we have some MCQ. I'm not quite sure if you guys have any questions. So the first question is question too. Well, where is question one? Uh, so in which of the following situations with a narrow bore chest rain the most appropriate and not a bore. So that's basically less than 24 French. So you can just basically put in the chat group. So for her mom pneumothorax, that would be a white bottle one, because there is a risk of blockage, Uh, for a flail chest, the patient will definitely need a white coat train. And if a patient has a pneumothorax with a persistent large air leak, then he will be a candidate for a white bottle one. So the correct answer will be be a patient with metastatic breast cancer with pleural effusions. Um, so second question is chest trains are inserted into the triangle of safety to reduce the risk of damage to the neurovascular handle. Um, and breast tissue, of course. So what are the boundaries of the triangle? A lateral edge of the pectoral major lateral edge of latissimus dorsi fourth intercostal space and the base of the maxilla be is going to be lateral edge of the pectoralis minor and the same as above. Then see is gonna be fifth intercostal space and pectoral major with the latissimus dorsi in the base of the Xeloda. And then D is going to be pectorals minor with fifth intercostal space and the base of the Exelon and the Latissimus Dorsi. And the correct answer is going to be seen because it's always the fifth intercostal space. And it's the pectoral major, which lies superficial to minor. Where should you make the skin incision? To insert the chest, train a above and parallel to the rib. Be below in parallel to the beep, see above and perpendicular to the rib and d below and perpendicular to the rib. So just put in the chat group. This is actually an interesting one, so the correct answer will be a And the reason for that is we want to insert the chest train just above the rip and parallel to that to avoid damage to the neurovascular bundles. So we have from superior to inferior in the intercostal space, we have the intercoastal vein on top, then the intercoastal artery and then the intercoastal nerve. Uh, so we don't want to puncture the vessels. So we should be going just parallel to the rib and above to that. Uh, of course, if we do that perpendicularly, we will have definitely damaged the resource. Um, so you are inserting a chest pain using the cells in your technique. You aspirated chloral fluid through the introducer needle, and you've rotated the pebble of the needle 180 degrees and removed the syringe. So what's the next step? So a will be inserted dilator over the introducer needle to a depth of one centimeter more than the recorded depth of fluid area aspiration. Be insert the guidewire into the cavity through the introducer needle. See, make a small incision with a scalpel around the introducer needle and d remove the introducer needle. So basically, you're going through with a needle, you're aspirating some fluids, and then you remove this range. So what's the next step? And that's going to be we're going to accept the guidewire, and we shouldn't make any incisions while the needle is in. So the incision is made after we make sure we are in with the guidewire. And then the last question is, uh, you are asked to review a patient with an intercostal drain, which was inserted to drain a pneumothorax. The train was inserted three days ago, and the under water seal is still bubbling. So what is the most likely cause? So that's basically 72 hours after the chest training session, and the underwater cell is still bubbling. So a blockage of the tube be clamped, has been removed from the train. Seem all position of the tube and D persistent early into the pleural cavity, and the correct answer will be in D. And that's because if there was a blockage of the tube, there wouldn't have been any bumbling or swinging of the underwater sell at all. Uh, if the clump has been removed from the train, then you wouldn't have bubbling, and you shouldn't even clamp, then train in a patient with a pneumothorax. So that's the contrary indication, anyway, uh, mala position of the tube. I think if if the tube was more positioned, it is more likely to have bleeding or, uh, deterioration of the patient's clinical status, and then it wouldn't have been bubbling, but it would have been likely blocked. Uh, and that's all. Basically, I do have my references in the Power Point presentation, which I'm happy to send. So you can basically send us an email if you are interested in getting this presentation, and I'm happy to send it to you guys, and that's all from my side. I'm not quite sure if you have any questions. I'm happy to. Um, so thank you for joining us. Uh, the next Webinar series will be next Tuesday, half past seven. Uh, and it's going to be, um uh, on we polls versus P, ppd. And it will be the main speaker will be a surgical registrar. So I think that will be an interesting topic to cover because most people don't know the difference between the polls and people PND, Uh, so I will send you the links. Uh, make sure you do complete the feedback form to get your certificates. If for some reason, you cannot get your certificates and you are struggling getting the feedback form, uh, just send us an email and I will send you the link of that. So thanks for attending