Neonate With Pectus Excavatum

[bklyn]

So as you can probably tell last night was stressful. What has been happening is that first thing in the morning and then late at night, he has these pretty big episodes. They consist of labored breathing with screaming thrown in. Then most of the day he is content, eating normally, breathing completely normally, playing. Last night I tried to do the massages, but he clearly was in more pain. I left him alone a bit, then he happily ate and went to sleep. This morning, waking up with some sleep under my belt I realized that I was stupidly applying pressure more to the bottom of the ribs versus the sides like I should have. I have a video to show what I'm doing now. Do I have to post to youtube? In it you can see he begins with labored breathing. I massage him with three fingers on each side of his ribs, and then he seems to pull himself out of it. I'm going to continue to do this as much as possible today. I've been trying to squeeze only the natural duration of his exhale, but I can push longer if you think that's necessary.

Also, I was doing research online, and read that clinical signs and physical severity of the formation often don't go hand in hand. So as my vet said his chest is not that severely flattened (and looking from the x-rays it definitely didn't seem to be), but he's still experiencing serious clinical signs. My hope is that because it's not that flat, and his spine is nowhere near his ribs, that the massages can still make a big impact, but we'll see.

 

[catwoman707]

You should be able to post video clip here.
If you are unable then just link your clip to youtube.
I'm anxious to see.

 

[bklyn]

Followed up with vet and he does have a slight enlarged, slightly misplaced heart. Is it likely once the pressure is off that this will resolve? Or is it just getting more hopeless? I've read that PE often causes this.

Also, change of plans. Currently creating a vest, will update with video once he's in it to show how he reacts.

I have been thinking about this a lot:

When he inhales: No inversion
When he exhales: Slight inversion

Vest: Resistance against inhale
Massage: Pressure on exhale

I think I have to do the vest, which will only constrict him when his ribs are in the right position. I can't realistically create meaningful resistance during inhale with my hand, and pressure by squeezing during inhale feels almost violent, like I'm forcing his breath back out versus just resisting against it.

The massaging on exhale seems wrong when I really think it through, because I'm encouraging his ribs when they're in the wrong position. That said, it has seemed to both calm him at times, and upset him more at other times. So I'm at a loss. Definitely massaging is partially a problem because he is just so sensitive to my touch. It wakes him, causes him to move, and breaks his sleep if I even graze him.

For the vest, how much tension should I put when I tie it across the bottom? I know it's probably hard to describe over the Internet, but do I want it to allow him to take a full deep breath, or just short of it? Also, am I fastening it so that its designed to resist when he's breathing normally, or when he's deep breathing? Because those would be two totally different tightnesses. I would imagine its almost better to have it resist when he's breathing deep, because it's likely the ends of the ribs will be at their flattest then.

 

[catwoman707]

I'm actually glad to hear this, I am not a vet and have no right to advise the vest when you are telling me his chest plate inverts.
However, I think at this point that, 1, you have a clearer understanding of what's happening, 2, that it's coming down to the wire here, and because of this, if he were here with me I would be going for the vest, it certainly can't hurt and can only help.
But, and it's a big but, he needs to be watched with your full attention for the first period once it's adjusted, as you will be needing to adjust the fit often. It's easier with him to squeeze too tight by just a very small amt causing him lack of filling his lungs, which he needs of course.

Ideally adjust it so that there is a small amt of pressure on side ribs only on inhale and exhale, but there's a fine line between enough to help and enough to hurt, by hurt I mean limit his breathing which we don't want at all and why it's crucial to watch how he does in the period after it's on and adjusted.

Did you see his chest x-rays?
I wish I felt confident that his center rib area will not invert when using the vest.
While the vest is on you should not see breathing issues or struggling at all, the struggling action from him would mean he feels suffocated because there is not enough room in his chest to expand them.
If this happens, take it off immediately of course, and the only thing left would be to start manually squeezing his ribs together in hopes it's enough to encourage ribs to grow correctly.
Not massaging anymore.

 

[catwoman707]

 

[bklyn]

I will definitely watch him like a hawk. I did see his x-rays, I'm waiting on a copy of them now, so I can post them once I have them if you'd be able to make anything of them. To me, it didn't look that bad, but that's because the cases I read about online all showed pretty severe cases, so my comparison may be off. There was definitely plenty of space between his spine and ribs, and the inversion at the end did seem slight. But again, I don't have much to compare to.

My vet did say today, which I had mentioned yesterday as well, that the actual deformity could be very severe, and the cat could show no symptoms, or very mild, and the cat could show severe symptoms. My hope stems from the fact that even though he's really symptomatic, the formation isn't that awful, and hopefully it can be fixed quickly, and relieve his stress quickly. Be we're all learning here, so I really don't know. I will definitely show you the x-ray once I have them.

My dad and I have been workshopping the vest out of paper first to see how it would fit him, and he's putting it together out of the actual materials now, so I'll get it on him soon. He definitely is at a very hyper aware stage, and won't like me fussing with him with the vest. But I will be patient and do my best. Causing him stress makes me feel sick, but I know he needs this.

 

[catwoman707]

All of his stress is due to things that cause him to become short breathed, which anyone would resist.
I picture someone putting a balloon over my nose/mouth that only allows 1/2 of the capacity of my lungs, so I go to breathe and get cut off halfway, repeatedly, I would be fighting to get that thing away from my face like crazy! lol

Headed to the dentist now but will be right back.

 

[bklyn]

Sounds like the next couple hours will be rough for both of us Speak soon

 

[catwoman707]

I'm back, the worst part was the waiting so not too bad, def not my favorite place to be though!
How's things going?

 

[bklyn]

Okay so, vest round one was a nonstarter. Bear with me on this one while I try to think out loud. My guy has the opportunity to shape his ribs and possibly lose the inversion during exhale, when he doesn't have the inversion at all. In order for me to do that, I need a support material (the q-tip, popsicle material in a typical vest), that is both firm but also can slightly hug the curve of his rib, to try to guide it downward. I'm going to upload a diagram of what I'm thinking/trying to say. The blue is the material, the pink is direction of the pressure, the green is the direction I expect movement in. Option 1 represents pretty much any version where the stick is only pushing in one direction, no matter where it's placed I think the ends of the ribs go straight. I'm trying to create downward, diagonal pressure to try to encourage the ends outward, because I think the opportunities there.

That said, I'm pretty tired and having trouble really articulating it. But what I do know is I'm able to place and push with my hands with confidence exactly where and how I think the pressure should be on exhale, to create a rounding and down effect on his ribs, so I'm trying to mimic that with some sort of material. I have some ideas and I think tomorrow morning I'll be able to go get what I need and try again to get it right. Using my hands really isn't an option because like I've said before it's hard for me to force movement on him during exhale without forcing the breath out of his body, versus just restricting it with the vest.

Now, for whatever reason, he had a great day. These are the different versions of his breathing:

1. Completely regular
2. Slightly heavy, but no sign of pain or awareness of heavy breathing.
3. Moderately labored, and restlessness and crying
4. Very labored, and screaming in pain. Seems almost like a panic attack, where he realizes something is wrong and it escalates partially out of discomfort and partially out of fear.

A typical day for him (for the past 4 days) is mostly 1, with short stints (1 minute or less) of 2 sprinkled throughout the day, one or two short stints of 3, and a morning and night 2-3 minute episode of 4 (the real stressor). Prior to Friday, I only saw 1 and 2.

Today was mostly 1, with some 2, and no 3 or 4. Even when I kept trying the vest on him, he stayed calm at 1. He didn't skip any meals today either, which prior he would have some lighter meals.

I'm not going to make too much of it, because I don't see what could've really changed, except maybe some delayed relief from the constipation, or maybe all of his side sleeping as of late is starting to do the job naturally. I'm skeptical of either of those doing too much though. Regardless, in the morning I am going for the vest again. I think at the very least I want him wearing it when he's on his feet and there's no competing pressure.

Didn't get the x-ray but will follow up on that tomorrow, I know there was an issue sending it because of file size so I may have to pick it up on a cd.

 

[bklyn]

Forgot to add the diagram

 

[catwoman707]

Get some rest. Tmrw we will work through the design. It's clear in reading you are tired and having focused on him and helping him for days now, it's consuming your mind.
Get rest, and btw yes the side sleeping may have helped just a bit and your squeezing and massages too.
We just need to get a vest on him tmrw and watch how fast it works.
You only need pressure at the sides of his ribs where it is out the furthest.
Then I'm thinking fastening it in front with a rubberband if possible but making the closure away from his chest.
Let's hit it tmrw and I'll explain better.

 

[bklyn]

Deliriously tired and consumed by trying to help him just about sums it up! He had a restless night, is calm now. Back to work on the vest. I'm going to try to get something on him asap and then modify throughout the day as needed. I do believe that what you see is what you get with his condition, and if he seems to be in discomfort with it, or soothed by it, then it's reflective of what's going on internally. I don't know if his condition is solvable with the vest, but I feel confident he won't make it to the age of surgery like this.

I wanted to add this as general advice to those with moms and kittens:

There was a time when mom was partially dried up, where he was still gaining weight. He spent his entire day nursing, often times not gaining any weight after a feeding, sometimes gaining a lot of weight after a feeding. My fear was that he was just exhausting himself and ruining his appetite, which is why we decided to separate him despite total weight gain over the course of the day. I now really wonder if all of the intense suckling throughout his time with mom is what caused the inversion. Just a thought for those decided whether or not to separate. I had no idea until now this issue even existed.

 

[bklyn]

Vest is on. Its made out of a big piece of velcro across his back, a rigid piece of velcro on the part of his ribs that are out the furthest, and a soft piece of velcro across his stomach and attaching to the rigid piece, that can be adjusted.

I am being cautious on making it too tight to see how he does with it for a little first. First impression is it isn't worsening his breathing or causing him to panic, he was playing in it at some point. Then he started breathing a bit heavy and meowing, like he typically has been. It didn't escalate, he calmed down again, and is now breathing normally. It also gives me easy access to the point where he needs pressure, so I can massage him there a bit too, which I think I should as long as he's calm. He can't walk well in it and he doesn't like that, but I think that's okay, and it also allows me to massage him easier since he's less mobile. Let me know your thoughts, modifications advice etc. I really like the velcro because I will be able to take it on and off easy, and adjust tightness as necessary.

 

[catwoman707]

This will work fine, however his sides need something in there at the widest point of his ribs that is stiff, so the roundness is gone. That is your primary goal, put pressure on only widest part of the ribs so his growth will be corrected.

Be sure the velcro is soft enough against his skin, like a piece of fabric that is soft.
Well he just looks so darn cute in this! lol

 

[bklyn]

The widest point are reinforced with a tougher piece of velcro, that almost is like a piece of plastic, although a bit softer.

I'm unsure what to make of his reaction to the vest so far. The first time, I left it on him for about 15 minutes. He was right beside me breathing normally. I looked at his face and noticed suddenly one of his eyes was watery and shut. I took off the vest immediately, and he was in good spirits. The second time I put it on again, his other eye was watery and shut!
He was a bit limp, I was so freaked out I thought I was losing him. I really definitely did not put in on that tight, but clearly he's sensitive to his condition to begin with.

So then, of course, I took the vest off. And now I swear he seems better than before. He played a good amount without having any heavy breathing. What's the likelihood though that his bones could've really shifted that fast? So my gut at this point tells me to try the vest or massages again with extreme caution, but still to try. If only because I think it's his only shot anyways. He's totally normal right now, ate well, and is breathing well.

I have a picture of his x-ray. They said it was less clear than normal because of his tiny size. I'm not an expert, but when I look up x-ray pictures of PE online, they look much worse. So I'm not sure, I can't make much of it. Can you?

 

[catwoman707]

From what I can see from the side view I don't see any inversion, but impossible to know from the pic entirely.
Actually, depending on how long the vest was on, it can change things a tiny amt but he is so sensitive that it may very well have helped a bit, but didn't wear it long enough for it to encourage growth changes. They're soft ribs at his little age for sure, if he could wear it for most of a day for a few days it would make a difference for sure.
I still want the sides reinforced more, almost with the curve going the opposite way so that the vest doesn't need to feel tight all the way around, just something pushing on his sides

 

[bklyn]

The vest is going back on now. When I sent my last message, I just received the x-rays but had to rush out to go pick up this guys mom from her spay. Now that I'm back and see all three of them, I realize one view (or maybe its just one side) definitely seems to have the inversion a good amount worse. I'll post it here. Do you think a popsicle stick would be good for the reinforcement? I did pick some up this morning.

 

[catwoman707]

Yes but cut down, to 1/2 or less. Be sure to pad the underside or it will not feel good to him.
You get what I meant by really only the sticks on sides will need to be touching him?
I'm sure you know but only have the vest on him when you are with him in case he shows any signs of distress in breathing and can be readjusted.

 

[bklyn]

Yes I think so. Technically the whole vest is touching him, only pulling/putting pressure on the sides of the ribs (via the popsicle sticks) where the ribs jut out most.