Empyema and Pneumothorax: Update Course 2014

Um, so next up is, uh, Dan Osley, who's going to talk to us about Empanhia. All right, you guys hear me? Yeah, we hear you perfect. Great. See if I can get Yeah, we'll get your, we'll get your talk up. We go back to the beginning. How's the weather there in Madison, Dan? Gorgeous today. It was 38 the other day, but now it's going to be 74 today, so beautiful. That's connecting Oh, I think, OK. So, Dan, if you, if you can hear us, we can see your slides. Can you see them? I can see my slides. OK, great. Sorry, I can't be there with you guys. No, it's OK. We're actually kind of glad. We had a really good party last night. We're kind of happy you weren't there. That's the only reason I'm sorry I'm not with you. I think everybody agrees that This would be the standard uh initial evaluation for MIEA um sorry I'm just typing my name in to join the um chat room um. Let's just start with the patient scenario here. You know, a 5-year-old female. Her parents report that she's not been feeling well for 7 days. She's febrile. She has a productive cough. She hasn't been eating well. This is her chest X-ray. Dan, go ahead and turn on your webcam. Sorry I logged off there, huh? Should be coming up. Yeah, we're getting it. OK. You see me? Yep. All right. You handsome devil. The chest X-ray shows the left sided, uh, pneumonia pleural fusion. Um, you get an ultrasound and it shows loculated pleural fusion. Let's go back here. What would, what would most people do at this point? All right, do we have a poll question for that, or do you want to just free, free discussion here? No, let's just go to here. Would you do, uh, this is a stage 2, emphyema. Would you do a plural debridement? Would anybody do fiberanalytic therapy? Would anybody just put a chest tube in by itself? Wait, go back, Dan, for a second. So, I see. So this is a patient now you've, OK, you just had an just an ultrasound, no CT, OK. Right. Yeah. Can we stop on that point? Who here would operate just symptoms and those findings? Yes, just a chest X-ray. Would anyone intervene with just a chest X-ray without getting further imaging in the panel here. So, so everyone here would either get an ultrasound or a CAT scan, uh, rapid fire ultrasound or CAT scan. Let's start with an ultrasound. Is there anyone that would get a CAT scan? I'm the only one. I think we're, I, I, well, that's a whole another discussion. We'll get into CAT scans later. I think that we're too afraid of them. I think, I think that the literature, the literature on this fear of radiation from a CAT scan is a little overrated, but, uh, so I would get a CAT scan because I like to see it better. I've been fooled by ultrasound. So fooled in what way? fooled in what way that they say there's a big effusion, we go in and there's not a big effusion. So when you say go in, what do you mean go in? I do vats. I don't do, I don't do, we'll get into this. I don't gotten into that. No, no, no, that's what he wants to know now. You do a vats at 7 days. I do a vats when there is a substantial, well, we'll get into this because I don't want to steal dance on her, but I do a vats even before the kids had a trial of antibiotics. Oh no, no, no, try antibiotics. They're they're symptomatic. They're getting an enlarging effusion, and it's it's substantial enough that I think they would benefit from the decortication, then I would, I would intervene and. I would do it. I would get it. So Dan, Dan, go ahead. Sorry, I didn't mean to tell him what he should be doing. I know what Dan says I should be doing, but I'll argue against that. Good. So we all agree it's a stage 2. It's delayed. She's a week out. So I think Arnie's point is, would you do antibiotics? Yeah, I think in the stage 1s we would all do antibiotics, but once you have A defined uh emyema, i.e., oculations with, you know, greater than 100,000 white cells, then you're down the pathway. Is, is really antibiotics the right choice and probably not, honestly, you need to do something to get, get the, uh, the fibrinous X8 out of the chest. So the question was, would you do, uh, the either plural to be an i.e vat or fibrino therapy or just a chest tube, which some people still would do a chest tube by themselves. So, yeah, so, so let's just go through the room. So Matt rapid fire, yeah, so I would try the fiber analytic and that yeah, I would try the fiber. I've been converted to fiber fibrinolytic Steve, as of 3 weeks ago, Dan convinced me to try. So I, I do fibroanalytic therapy. VATs, that's, I've done both, but I do vats mostly fibroanalytic therapy to start. Yeah, same down. We're still doing that. So I don't think so the acron, the acron analytic therapy. I mean, it's not going to complicate your subsequent procedure. Uh, it has a reason, you have a reasonable chance for response. I was the last one here to quit doing. I was doing chest tubes on these kids trying to break up the oculations, and my partners were putting two, taking them to surgery, putting in 25 millimeter ports, cleaning them out, and they went home in a day or two, so I've converted. So, so in the last two weeks I've done, uh, I think 2 patients with fibroanalytics, but I will tell you that my preferred approach is still that. But anyways, we'll get to that. Yeah, let's go forward. Let's, let's kind of just. Let's talk real briefly. I don't wanna spend a lot of time on or any on, on, uh, evidence, but I wanna know what kind of to show where this all came from, right? So here's a real quick review. Um, it's a little bit dated, but it's about 170 pages. We looked at chest tube with with fiber analytic, chest tube with fiber analytic and delayed thoracoscopy versus thoracotomy or just, just primary vats, OK? Try just to get to the point where why we do what we did. There were 60 patients in the M1 arm, 38 in M2, and 41 in M3, and what it showed was that the M3 arm, which was the primary VAT, did a lot better than the chest tube with the thoracotomy or vat. So not surprising why we got to the point that we were doing vats without fiber therapy going on to do VATs. The problem with this is you can look at what what was done during these years. So the M3 arm, the vats arm, was much more common in the later years. So there's, you're really comparing the apples over here to the oranges over here. It's just not, not really a good comparison, but truly vats was better than what we were doing. So this is a little better trial. 60 patients, they looked at urokinis with a small drain, saline with a small drain, urokinis with a large drain, and saline with a large drain. So no operations in these patients. Now you might make the argument that the patients weren't as sick as some of the patients we see, and that may be true, but let's just take this for what it is. These are patients that have emphyema and they weren't treated with an operation, OK. What did they show? It showed that the, the tube, small tube with urokinase did better than any of the others. So this is a large tube with uric kinase, um, kind of counterintuitive to everything that we thought would have ever been able to be done because we just can't see ourselves being able to get this out of the chest with fibrinolysis. Would everybody agree to that? Yeah, so real briefly, just, uh, two other, this is a study protocol that was done in basically two institutions, one in Great Ormond Street, one in Kansas City. Uh, this is the data from the London's trial, and I'm just going to draw your attention to these red numbers, OK? They used your kindness instead of TPA. They treated everybody the same though, as was done in the Kansas City trial. Uh, length of stay was no different, 6 and 6. The cost was 13. 11.3% versus 9, and there was a 16% failure rate. So somebody said that there was a failure rate, and the failure rate is real. It's 15 to 16%. This trial was being done when we were doing the trial in Kansas City, but we didn't know this trial was being done because it wasn't, wasn't registered with clinicalTrials.gov. So we're completely naive to this trial actually being done, and it's published in 2006. This is what we showed. Remember those red numbers length of stay 6.8 days, 6.8 days. Cost 11.6 versus 11.3 and 7.5 versus 9, and 15% failure rate. So the two trials show that fibrinolysis works in 85% of the patients. So I would argue, and this is where I think we should really have a conversation, is it worth putting 100% of the patients through a vat if only 15% of them need to be operated on? So, uh, since I'm the black sheep here who's still doing vats, um, the one thing, and I actually do vats because of your study. Um, I did switch a little bit for to TPA, but, and my question to you is, I don't know if you looked at this, and maybe I have to go re-review your study, um, is how fast they get better. I know the length of stay is the same, but the reason I do have that is that you basically showed they're the same except for cost, right? The clinically they were the same. So if I could take a patient who's tachypnic and very uncomfortable and febrile and in, in an hour, I can have them completely emptied, clean out their chest. I don't, I don't see, I see that as a better route, and I'm willing to, I'm actually very willing to be convinced. So tell me what the patients, the patients that are sick afterwards are sick because of their pneumonia, not because it's like the stuff in the chest. It's like, so you still have the pneumonia and that's why they're sick. So I mean we've all done plenty of vats where you have a patient who stays sick or even gets sicker that 1st 24 hours after. No question. So let me take those one by one. So absolutely they're both going to still have pneumonia, and he showed that the outcomes are the same. He didn't talk about how fast they get better. The length, but the length of stay is the same, right? So they'll get out of the hospital at the same time. If you have a patient, if you presumably you send them when they get better. Wait a second, wait a second. I'm saying Todd, they make 55% are like Akron. They do immediate vets, right? So exactly. So but I'm not again, let me start by saying the reason I love this form is I'm looking to be convinced. OK, I'm looking to be convinced, but when I have a kid, because they may ultimately come together and leave the same time, that may be over 6 days, because I see TPA in my brain is a small catheter that it's gonna, it's going to drain over time, but it's not going to drain as fast as if I do a bachelor suck it out. Hang on one second. Remember this, this study, all these numbers include intention to treat, right? So all these numbers here include all of the children, the 15% that failed and needed more therapy and had to go on to vat. So your, your, your argument doesn't hold up because all the kids that get better immediately with bats are way shorter than this. Yes, so, so that, so his TPA group includes patients that ultimately ended up with that, right? They had to stay there because it's intention to treat. So how can you argue with the numbers? I mean, it's, I mean, it's, it becomes, it's in my experience, but I mean the numbers would tell you that it's that it is more cost effective overall to do it this way. If, if you pulled out the non-failures, failures, this number would be 4. What would you use 4 days later? What intermediate data point would you use in those 6 days? I'd want to look at say fever and tachypnia. So if fever and tachypnia was Gone in 24 hours versus 36 hours versus 3 days versus 3 days or 4 and why would that be important if they're leaving the hospital at the same time and it's less expensive because some of these kids are on the verge of getting intubated, which we just had last week, and I totally agree, Mark. It's funny because I was actually arguing the other direction before, but I can argue both ways, so. That in this arm right here of the kid, I'm sorry, in this arm right here, the kids that went to me at vats, there were 2 kids that ended up on the oscillator and 1 child that went on to develop renal failure requiring hemodialysis. That never happened in this arm. And as far as I know in the London trial there were several patients that were more ill in this arm than this arm too, but I don't remember the exact details, so don't hold me for that. OK? Don't forget, when you're taking in the vats, you're, they're intubated. You know, so are you keeping them intubated for another 24 hours, whatever? I mean, you're still fair enough, fair enough, yeah, Todd, there's one bit of data that's missing in all these studies, and that is at what point in the child's illness did they get to see the surgeon in terms of deciding whether or not they're going to do vets, whether they're going to do fibrolytic therapy. This child is 7 days at home. I mean, as you know, in a hospital, you don't necessarily get called the minute that child has a problem by the medical people or the pulmonologist. So if you get called on a kid that's 3 weeks along the way with pneumonia and a bad effusion, that's a very different scenario than one that was at home for 7 days with fever and, uh, you know, not feeling well. OK, so, so that. That's a good point. That is so that data really is not comparable in terms of making that kind of decision. So let me, let me, um, Mark, can you put a poll up for those of you, since 50% do VATs, for those of you who do VATs, would you now switch after this discussion to TPA? I'm just curious, by the way, when I do a VAT and they reaccumulate. Then I put TPA. So in the chest tube instead of redoing the in full disclosure, I, I want, so on the poll results, if you look at the poll results, it's 48% immediate vats. Now 48% chest, so it's changed, it's switched, and then there's still a sliver of, uh, of chest tube followed by vats if, uh, if it fails. If the chest tube alone fails, and it may be related, it may be related to. Maybe not avail nonavailability of the fiber analytic therapy. I don't know. All right, so next time we do this, I'll tell you about my results with TPA. Yeah, but that's gonna be anecdotal. That's with TPA. Oh, now it's OK. No, no, no, it's still, it's, you can't go by your one. What percentage of the faculty does, uh, their chest tube under general anesthesia versus local anesthesia at the bedside? So that's a great question. So we, we actually used to, that was my argument for doing vats. I mean, I was on the vat side of this for a long time, especially after Dan's first, uh, article. But, and, and because I said, well, we're taking all these kids to the OR anyhow for a chest tube, you might as well just put a scope in and clean it up. We've been now doing percutaneous Selinger type chest tubes at the bedside under local, and you know, you can give them a little bit of sedation. It takes 2 minutes or well tolerated. No, it's a serious question. You and your fellows, because I think there's a difference when you have fellows or residents in the hospital who can go do that for you as opposed to a majority who may be in private practice where that then becomes your issue to try and organize and coordinate that very well, very well taken because it's my, but it isn't an emergency, Steve. You can, you can. Do it 6 hours later when you have no, no, I, I understand. I just think, I think I'm not saying it's right or wrong. I'm just saying I think that it certainly was an issue for daily that daily work flows and logistics of life do do play, do play into this. But you know, I think we've been using, we have been using somewhat smaller tubes, but these tubes drain very well. And so just to show the impact these, uh, these, these broadcasts have, so 80, almost 80% of the people that did that are now going to try switching to TPA. Good discussion. Dan, this is obviously a very boring topic, so keep going. Let's go on to, I have a couple of real quick other scenarios here real quick. So how about this patient, 3 year old female, she's been sick for 5 days. She's been febrile, productive cough, also has not been eating. Uh, I don't know why that showed up, sorry. I'm going backwards, there we go. So next step in this case, let, let me just kind of go through this at the same time because we want to talk about the pneumothorax stuff too. Um, so you get a chest X-ray. It shows an effusion, maybe left lower lobe pneumonia. You get a lateral decubi film. It shows no layering, OK. What would people do at this point? Anybody do a CT or go to ultrasound ultrasound ultrasound. OK, you do an ultrasound, let's say, and it doesn't show any layering or any oculations, OK? That's CTs too. OK, so you get the CT, yeah, yeah. What do you guys think about that? Is that necrotic lung? Looks like a lung. That's what it looks like to me. Yeah, so I think, I think the point I put this in here is because ultrasound can sometimes, I think Todd said that early on, they can sometimes fool you, so you need to trust your ultrasound techs because in this case this is all intraparenchymal disease, right? You don't, you don't want to do anything but treat this like Arnie said with antibiotics. It doesn't need an operation or anything, so you need to be comfortable that what the data you're getting from the diagnostic studies you're using is accurate. Hm Thoughts about that? Well, the patient might need surgery, but it'll be a week or two later when that lung falls apart and you get an infusion and a fistula. OK, let's talk a little bit about, uh, pneumothorasis here. So spontaneous pneumothorasis specifically, uh, we're gonna avoid the traumatic stuff. So let's have a patient scenario here. I don't know if you guys can see this real well. It's a 15 year old male. He presents to the ER. He has minimal chest pains. He felt some crackles in his chest. He has no significant short of breath. Next step. Can you, can you see the X-ray or can't you? We can see it. What, what do you see? We don't see the pneumothorax. We're too far away for us. There you go. So there's an arrow there. You can see that little tiny kind of 5 10% pneumothorax in the apex. So I'd observe, I'd observe that. Would you, would everybody put him on oxygen? I do. Does anyone believe it does anything? No, I don't think it does at all. Absolutely. Yes, but I don't know how. So we all agree with that diffusion, put him on oxygen and not do anything else. Sorry. So those are the choices. What about simple aspirations? Anybody thought of that? Not for that. No reason to do that. Yeah, you'll cause more, cause more trouble. Get a bigger pneumo if you do that 30% pneumothorax, which one of these would you guys do? Chest, yeah, and again we do, we do a percutaneously saltinger technique, a little chest tube for air. So has anybody, anybody considered this last algorithm simple aspiration? No, so the only purpose of the, well, the two purposes, I guess, Dan, is that you're proposing that number 1, by having the lung opposed to the chest wall, it may seal faster, or number 2, to get rid of the symptoms. Would that be, well, no, I think when you put in a chest tube in a lot of these, you never see an air leak, right? But then there's no reason to aspirate. My point is there's no reason to aspirate if they're. unless it's the symptoms you're trying, either the symptoms you're trying to get rid of, or that you think if there's a tiny hole, it may seal because otherwise, why not just leave it alone if you're going to aspirate it, I don't know if you're going to use a needle or not where you might stick the lung, but I mean you'll use a needle to get into the chest, but aspirate the air through the needle, or would you use like a Fermin or a blit catheter to. To aspirate if you're gonna do that, why not leave it in overnight because a certain percentage of those patients will fail and you'll save people two procedures. If you have an apical pneumothorax that was small like you originally had and you put a needle in, you'll have a bigger pneumothorax, yeah, absolutely. So, uh, you know, and if you got a little one, just leave them alone. What do you do, Dan? So I, I have historically used the chest tube, but I bring this up because let's talk a little bit about some stuff here. Um, there's, you know, a 50% chance of, of, uh, failure with chest tube alone, right? And you have all these issues that go along with it. And if you go to primary vats, which I thought about doing for a long time, is that justified when it commits everyone to surgery when I just presented to you that 85% of people can avoid an operation with Eyhima. So that's why the question becomes, in my mind, is simple aspiration or reasonable management. If you could aspirate, watch them for 6 hours and send them home and not have them in the hospital. Now maybe that works. Maybe it doesn't. Here's some conflicting guidelines that give you some data for it. 2001 Adelphi consensus said there was no role for simple aspiration. British thoracic surgery 2010 simple aspiration should be first line therapy. These are adult studies, but as we know, most of these patients are teenagers approaching adulthood anyway. Then there's a Cochrane review in 2007 with only one randomized controlled trial looking at manual aspiration versus chest tube, OK. What that showed was that I've brought this up here just because the range included 16-year-olds, which is kind of where we are at with spontaneous pneumothorases. And it showed an immediate success rate of aspiration of 59%, which is what we can get with chest tube. Um, there were 11 failures. 9 of them got chest tubes, and only 2 of them went on to VAT, and they avoided hospitalization in 50% of the patients with no difference in overall hospital stay or recurrence rate or timed recurrence. So it raises the question of, of, is this something that should be done in children? It's not very well studied in children. Uh, because there isn't a lot of patients, a lot of patients that occur in that under 16 years old, so I think that there is a need for a quality study to look at this possibility in children that are minimally symptomatic. I'm not saying you take a child who's got excruciating chest pain and, and, um, uh, you know, shortness of breath and on oxygen. That's not, that's not where I'm saying we should go. But we don't, we don't see this in children. We see it in teenagers and adults. If you've done, if you've been in, uh, adult thoracic surgery, every one of these patients has blebs on the top of the lung, and so you can't just say we're going to treat it with a chest tube and get away with it because it's gonna come back again because of the blebs. So you're committed to tell you to set me up like this, Ernie, because I really, really appreciate it. What's that? You, you set him up for his next question. Did I, did I actually tell you to set me up like that? The purpose of where I want to go with this. So the next patient scenario, a 15 year old male presents to the ER. He has significant chest pain, feels crackles in his chest, and he has significant shortness of breath, and you can see this big pneumothorax here on the right side. Next step, I think all of us would agree that we would treat that with a chest tube to begin with. Do we, is that what people would say? Yeah, the other thing you want to look carefully at that chest X-ray, that's a classic chest X-ray of these kids that have it. They're very authentic. Uh, they, they got a sort of a very thin, chest capacity, and every one of those ends up with blebs in the, uh, in the upper part of the lung. So would anyone here do a primary vats? OK. So we get a chest CT and exactly what what Arnie's talking about. You can see these blebs up here. At this point, would people just treat this with a single chest tube, or they would go, would they go after that with the vets? That's, vets. Well, wait, hold on. So why did we get the CT? To see the blebs. Why? So you can prove does everyone get a CT? You want, you want to prove that they have blebs. I know they have blebs. No, not 100%. I've not had a patient that has not had them. You want to get a CT because you want to see the other side. Yeah, I don't want to see the other side. Oh, I do want to see the out of sight out of mind. I don't want to know about it because I'm going to fix you look at the other hernia side too. We'll talk about that later. I, I, I want to see what I'm dealing with on the other side because I'm either going to Tell the family they have an incidence of something developing on the other side, or I'm gonna schedule the kid and do something elective on the other side. OK, so what are you gonna do? So they come in, this kid's got, I'm just saying you got a CT, OK, you got getting a CT on these kids. Fine. So, but you're getting it because you're going to change your management. So now you have your CT and you see blebs on both. You see your pneumo on the one side and blebs on the other side, right? You're going to do bilateral vats at the time, you'll do one side at a time. I'll do one side and then I'll, and then, and then I'm gonna do the other side. So you bring him back without it, without him getting a pneumothorax on the other side. Absolutely. Well, if you look at the adult thoracic literature, that's not usually the paradigm. You, you fix the side with the blebs that's symptomatic. You verify that the other side has blebs, and then if they get one pneumothorax, that's the indication to go ahead because they don't always get a pneumothorax. I see. So now that's finally an argument that I could maybe go to my partner Dr. McCallum's technique, which is this is what we argue about because I don't get scans. But that makes sense. So I won't necessarily treat that side, but if they come in, I don't need to waste time with the chest tube. I go straight to that. So I would argue the first time out, if you're just gonna put it on the first time out, put a chest tube in, doesn't matter even if you see a little bleb or not, or does it? Well, you know, you do a primary vats if you see a bleb on a first timer. I think in this day and age we do. Before the era of, of, uh, vats and, uh, thoracoscopy, it was a thoracotomy you had to do. So the rule of thumb was I was a thoracic resident was you waited for a second pneumothorax and then you went in and did a little anterior thoracotomy, took out the blebs, and roughed up the pleura. Today I think that paradigm is a little more aggressive by doing it the first time, but I don't think anybody. Can I don't think it makes a lot of sense to say you're going to prophylactically do the other side. I think, I think that's, I think in some kids you do. I think you have the discussion with the family and the child. I mean, I did a girl a few summers ago who spent 2 months hiking in the backcountry. That was her plan. She was like, that's a, that's a little bit different. But, but I think you still, you, you can have that discussion with the family. You have to, you know, talk to them about it. I have to. I don't, I don't think it's wrong to have that discussion, but I think it's reasonable to one minute left. One minute left, Dan. So do you have any, uh, I think this is a big controversy and I don't think this is near as controversial as I would. I think that has a role that we should be thinking about picking picking a pneumothorax size, you know, we're estimating 25% in simple aspiration. This, I don't think is near as controversial in terms of what we do with this. I would agree with. With Arnie in that unless there was extenuating circumstances such as Steve's kid going hiking or somebody's traveling to sub-Saharan Africa, I would probably not do anything on the left side in this. So rapid fire, what do you, what do you do like for the contralateral, no, no, asymptomatic, no, no, no, for the vats. How do you do the vats for a pneumothorax? What, yeah, so yeah, I do, I do an apical wedge with, you know, thoracoscopic apical wedge and then rough up the, the pleura, and then depending on if this kid's been out and had a couple of chest tubes, then I would probably also consider top pleurodesis. OK, Lou, we just rough it up, rough it up. Say no talc yet. Yeah, no, yeah, no, no tal, right. Remove the blebs and rough up the plural with a scratch pad. Yeah, I remove the blebs and I do twel. Would anybody do doxycycline? I did before. No, I mean, the talc lap thoracoscopically just snows so beautifully everywhere. So what do you do? But I do talc, but I want to try tis seal. To seal goes away. Yeah, yeah, well, they, they, they, they say that if you rough up the edges and then you apply to seal, it, it might, they're not advocating that, but I, it's just more expensive than, yeah, Jay. I usually just rough the edges, mechanical, mechanical, mechanical, but I also mechanically do the visceral pleura as well as the, the parietal pleura. Oh, that's different. You're gonna get a lot of air leaks. Well, I, I don't go to town on it, but, but clearly there's an, there's an abrasive process that I think improves. I, I've gone back on some kids that have had that have been recurrent pneumos that have had the pleural roughed up, and it looks like no one was ever there. See, I quit doing. I'm the one who quit doing it. It's as if no one's ever. If I see blebs and I get the blebs and staple them, I don't do pleurodesis. Has anybody has anybody operated on somebody who had talc put into his chest and had to go back in for a thoracotomy? OK. Would you describe that as funny or not funny? Can I ask, this is the that argument, this is the argument I don't get about that. Are we doing it or not? So I get that no pleurodesis. I get. Pleurodesis, but what's this half pleurodesis? Like? I want it to sort of stick, so I'm not going to do something where it's going to really stick. I don't want the top third of the chest, not the entire chest it probably doesn't work. That's the OK, so you only do pleurodesis on the apex, 4th and costal space up, OK. The way you do a pleurodesis with a scratch pad is you see little blood, you know, blood vessels becoming prominent on the. Pleura, when you've got to that point, then it'll stick, but to put Tin in this day and age is, I think, absolutely wrong. This might be my second management change today. Yeah, but you know what, what are you doing really, because we're, we're saying that these are congenital blebs in these kids and we've resected them. So you're looking at the top of the lung and you're saying there's no more pathology. Are you sure? But you, but the question is, is that you don't see the blebs, and if you've resected the pathology, why are you doing something? Your lungs collapsed. Are you sure you resected so I've done what you did before when I saw there's a whole school of thought that agrees with that. Just take out the blebs. My question is, can you be sure you removed all your blebs? That's the only question. Well, I deflate the lung and then have watches that comes reinflates, have anesthesia do that a couple of times, picked up blebs, particularly on the edges of the lower lobe in that way. I, that's actually what I do. You seal the blood. I seal them. I don't you put a stapler because then you get away with a 3 or 5 millimeter incision, although now they're 5 millimeter staplers, so you can do it, but you can seal it and get the same 3 millimeter sealer and then just boom, you're done. I remember I put chest tubes in. Yeah, yes, OK, so we got, we're on break now, right? We got a break. Yeah, although, although we did a study to show that you don't need to, so we did a combined study showing that there was known for, I think, how many patients did we have? 350 patients without a chest tube, and there wasn't a single I mean those were just so that you put chest tubes in or no this was in a. This is in a staple cohort. These weren't necessarily pneumothorax patients. These were, these were not patients. They were not spontaneous. Yeah, those were lung biopsies. They weren't pneumothorax. We're talking to a worldwide audience and in your institution and your institution, you're going to catch. Teenager that's dipnik at 2 in the morning, but that's not everywhere. Good point. So if you are, I mean, all of us go different places. So if you're not gonna, if, if the nursing care is the kid's mom who's asleep and tired from everything that's going on, you can't reliably say, OK, fine, my nurse is gonna catch it. So you have to be a little bit careful. I mean, the nursing care is phenomenal. Would you do them at the same time? Do one side, slide them over, and then do the other side. I don't think so. I mean, for the contralateral side, yeah, no, OK. So, but, but my only argument about the, the talc is it's like you were saying, why do a half, it's like if you're there to do if you ever need to go back in that kid's chest when he's an adult, it is it is if you've never gone into a towel chest, it is, it's awful. In fact, you can't get back in. You got to go retro plural to get back in. So I had the conversation with our adult thoracic guys and uh and. They, they said, they said it's OK. It's not. I spent, I spent a year. No, it's hard. No, I know, I know it's hard, and I tell you, it's, it's miserable. They said it's not easy, but it's doable. Well, hopefully, these kids won't need chest. Dan, uh, thank you for stimulating a very boring discussion. Um, uh, that was fantastic. Yeah, no, I was gonna, I wanna, I wanna thank, uh, Arnie, Dan, Steve, uh, great session. Thank you. Thanks. Thanks guys. Great session. We'll be coming back in about 5 or 10 minutes. Stefan, let's put 10 minutes on the clock.