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Oh, good evening, My, It's pretty. Cuba. I, um running interest, healthcare. Welcome to our session on anyway and breathing, so we'll start with It's sad news. Unfortunately, Saudia, who was supposed to during the session, has come down quite bad. Migraine is unable to divert, so I've had to take over last minute in order to deliver. Sorry for those e who are expecting Saudia, hopefully get it back for another session later on. Hopefully I'll be being joined by Josh using one of our speaker's bit. Later, it was going to come along and help moderate the chapped for me. For the time being, it's on loans to do Bear with me. If you put things in the chat, I might take a couple of minutes just to notice them, but I'm trying to check it periodically. I'm Freddy Cooper. I'm third year medical student at G. Katie Med School, which is King's College London. That's me being a medic for football club. Quite nice place to be, uh, every week we said this making the most the session. Do take notes if you want to. It's a really good way of helping stealing things in your brain I'm really guilty of not to get actually lectures lately, and you definitely learn better when you're writing things down. Helps sort of hold information your head for longer. Do ask questions. Really pleased to ask questions. If I haven't got a moderator for the time being, I can't check them. But it is really useful for me to engage where we're at in this session on to tailor it. Better to you guys on. Finally, if you enjoy any bits, please let us know we're more than happy to find you're more resources. Talk about you. Talk about them with you for our email things that they're pleased to get in contact. If you want to learn more, walk out bits. Any questions? That's my email. Most people we should have it because we'll see you in major ounce the joining like, um, girls on Instagram and Facebook. I run them and I'm really poor of them. Sorry, that do give him a follow up Slowly getting better very slowly. Here is the next couple of months of sessions we have lined up so that this week off his airway and breathing, we're gonna come circulation in two weeks' time. That will be Josh with a case of session. I think it's also just again doing that one on, then disabilities exposure on. Then we're sorting out Tony's tweaking the dates slightly for the nutrition and nursing evening, but they are planned, so we should have some good stuff coming up. So after we do, we'll move on to airway and breathing. Could check the chatter from no one has asked anything before we start. Perfect. Please don't put stuff in the chap, uh, honestly, really, really good to help gauge where you guys were out. Also, slow down your questions. Makes it much more useful. Session for you guys away and breathing. Um, the plane was what suggested by Power Point. I thought it was a good little joke. It's a different sort of their their way out of line. Guess anyway, we'll start with brief overview of what the 80 exam is Anyone who follows on the instagram. Well, since I'm a little post about what you know, he was a couple weeks ago. Basically, this is what we're sort of basing the next sort of 34 sessions off for Atria is this particular exam Previously That's the eight B A B C exam or Dr ABC on Basic is your hierarchy of how you're going to assess someone when they're young? Well, we do it sometimes. For patients who are immediately on, Well, that's sort of one awards. These are important things to sort of effect. It gives you a hierarchy of what is most likely to call someone to die or court. Someone detriment. So we look at their airway. We look at their breathing, their circulation on disability and exposure. The doctor better start is danger response, that sort of things you need to do before we do this danger is make sure you're safe and patient is safe before you try and do this. No point. Getting munched by a tiger while they're trying to figure out some was breathing responses is working out their level of consciousness or their ability to respond and then in the dots as someone corrected me on, some added on our instagram within the dot there are things like catastrophic bleed, which is if they're just losing blood. Deal with that first. If there might be an injury to their neck, worry about that at this point and also get support. We're not really gonna worry about that because we're tailoring. That's not just to that sort of acute emergency. We're talking to patients in general. We're gonna worry about the 8. 80 on eighties. That's like a more extended version of a B. C. Basically, um, So I planned for today. So we're gonna start with Bit of the anatomy and physiology of the airway on when Airway Airways differ. We'll talk about that in a minute. We're going to the anatomy and basic physiology breathing. It's really complicated. Actually. When you go into a little detail about it, we'll do some of the basics that without breathing, we could talk about your conditions that might affect your airway and you're breathing on. Then we'll finish off with a bit of the emergency side of it and things we can do to resolve these in an emergency. That's the plan. We'll start with the airway so your airway starts singular. We'll kind of pleural singular. So you got your nasal cavity the bit behind your nose. You get your oral cavity, What's inside your mouth? That and these both joining the back of the pharynx sometimes divided into nasopharynx are referring, so the big connects the nose is connected to the mouth. Overall, he's become the pharynx. This then goes into the larynx. This is a bit, well, things like voice box of house. This is basically the top of the trachea, and then that goes down into the trachea. Career is the base of your height. Your windpipe, something called that eventually goes down to a point called the Carina, which is somewhere behind your stern. It varies a little bit person to person, but it's behind your sternum. You can be rest assured about that fact, Um, and this will divide into two main bronchi, the's. Then divide into bronchioles, which are very small. Smaller airways on these continue to divide up until you end up with tiny, tiny little our is that each provide one single alvie? Oh, that's the only, uh, the only the plural on these are basically little sacks full of thinking like tiny balloons. Your airway and Corporates, I said, the pharynx, the larynx. The trick here, these, well, singular, then your bronchi and bronchioles. These real plus from a cross section of your airway is predominantly made of smooth muscle is a big, smooth muscle layer on this one gives it. Its structure is then covered. This is on the inside, covered by, uh uh, what's called a mucosa. This is like a mucus membrane. It's sort of cells secrete mucous. Most of it also has what's called cilia, which are small hair like projections. And they watched push things upwards against gravity to get it up to the top of your airway. So if you were different level breathing, a bunch of dust, this would stick to the mucus on the lining produced by the mucosa. It would then get wafted into little balls but cilia and sort of walked it up and out so you can cough it's out and spit it out or swallow it. Actually, majority of mucus from your your lungs actually gets swallowed and digested and broken down by acid in your stomach and lessen the the end result of it. But also you can spit it out, get rid of it on, for example, he had a cold or some of those things inflamed this, and you're producing a lot of mucus. You could blow it by blowing your nose you cough it up, you probably don't know what it's like to be, but flemmy orbit mucusy when you've got disease. And that's what's going on normally, but much smaller in much smaller quantities. Coughing and sneezing is there to sort of help shift this up? Because obviously, if you get a lot of it is quite heavy and tiny little hairs are very muscular, not musculature. There's no muscle in the middle there, ovary powerful, but they struggled with heavy matter. So if you were to breathe in a peanut, for example, it's a long time before that is sufficiently broken down into sort of gunk for it to be watched it out, sneaking over them being stuck, um, peanuts about example specific consult rather than that. But you know, sometimes people inhale small amounts of food, and it does take a while to sort of slowly broken down by continues wafting and by the enzymes would find a mucus to make it a paste enough to be wafted up and out. That can make people quite six or talk about that later on. Actually, well, keeping this open. As I said, it's muscle. It's a it's a ring of muscle effectively, whole way down tube. The problem with that is the actually muscle is quite floppy when there's nothing for it to hold onto. Um, it's quite squishy, like if you find your arm while it's sort of not doing anything, you squeeze it. Actually, the muscle is quite soft. It's quite on. We don't want that with an airway, because that means your airway's gonna collapse or is easy to collapse any sort of small. That's the pressure, and it'll close is so to prevent this, we have a serious a cartilaginous rings. Cartilage is not quite bone. There's a couple of bones, and it's actually high old bone right at the top. But the rest of it's cartilage rings on these basic keep it opened. It means if you have a small amount of pressure applied to your throat, it keeps your airway open. You can keep breathing, but also because cartilage has a nature that it can collapse of a slightly were breaking. It means you can get, for example, punched in the neck on it won't break all these bones and cause your detriment. Damage will just sort of hurt, and they bounce back and they'll recover on guard. Allergic, um, heal. So if you do get some damage to your neck, this will recover. Some of the cartilage is there named mainly the thyroid cartilage, which some people would call the Adam's Apple? This is the very protruding of one you can feel it front on. Underneath that is your cry quick cartilage and the rest of the much. It's called the Tricky all cartilages, certainly car in preventing the, uh, what's the name. Think it's most most of the Ethmoid cartilages? Well, somewhere way tooth. Really worry about your thyroid cartilage and your crackers cartilage underneath it, Um, and they're used. This land marks for certain things, like surgery of the throat. We used them there, but yeah, Otherwise, these things hold your airway open so you can keep breathing. And any small amounts of pressure doesn't just collapse your your airway and wind you entirely walking a wrong predominantly. What goes wrong with your airway? It's things like a blockage, this community like choking. Or it could be that the epiglottis, which we talked about in a minute. It's basically a little flap that face it prevents when you swallow it closed over the airway to stop food going down into trachea. But then, when you're sort of breathing normally, it covers over your esophagus so that you're not inhaling loads of air into your stomach because that's not great. Um, so if that ends up closed over your airway, which we talk about it later and drowning, that is not great. I mean, you can't breathe the inflammation. So things that asthma or infection, allergies or even burns, that mucosa layer becomes inflamed and also that close in because it can't push out against muscle layer. So it comes into the middle. The Big Three, which we breathe, find it collapse. It can't. It's kind of rare, but you can get some traumas, which basically collapse the cartilage rings, and it comes in a closed on That's not great becomes impossible. There are two main medical emergencies I want to mention at this point. We're going to talk more about them later wrong, but I think these are the two most, um, critical airway emergencies, all dimensions epiglottitis. This is severe inflammation of the epiglottis, any means that gets really big and swollen and basically close over the trachea or can close over the trachea, making very, very difficult to breathe. Slash nylon impossible. A lot rare these days used to be fairly common before vaccines. Nowadays, we get vaccinated against quite a lot. The common pathogens cause it, um, so it's sort of disappears a lot. It went from being outside of stays, at least from when I've spoken to some sickness surgeons. It is one of the main nightmares. For like an anti surgeon, your nose and throat surgeon is something you don't want a clot itis because it is bad on the on the, um on it's anaphylaxis. This is severe life threatening allergic reaction in which makes the entire airway becomes very inflamed and close over, very different to breathe or impossible to breathe. So those the ones I just wanted to mention quickly Teo keep wear off. We'll talk about little bit more detail, but later on on a bit more about managing them later on. But I wanted to mention it at this point because they are very know, working, moving onto breathing. So that's sort of anatomy and physiology was going on. Your airway is fairly basic that, thankfully, the airway is quite basic in that sense in getting too low. It's like weird, like need things, talking about what actually goes on in the in the new Kirsten in the cells lining it and all this. But actually for a basic point of view, it's a tube made a muscle supported by cartilage with the mucosa layer to help you with small particle matter out breathing. We use our lungs to breathe. We need lungs to breathe when don't believe any of us of gills. If anyone does, please let me know they'll be really interesting. Generally, humans don't during breathing, we have gas exchange occurring between the air. We breathe I/O blood, and this is two ways. So we bring. We take oxygen from the air into the blood and we get calmed outside from the blood into the air. Get rid of it. Carbon is produced by the body Contact center. Pretty body to your carbon. Carbon is doing. We generate in cell metabolism. So basically, through being alive, we make carbon on it's a waste. So we put it on bite. It's, um, oxygen, because that makes it nice and sort of nerve. So we get it through to the lungs on, then release it. Carbon dioxide is slightly acidic, and that's it's sort of a fairly key thing to remember is that that comes into the next step. Quite big thing. Just remember that basic carbon dioxide produces slight acidity to the to the blood. Um, three main things have to happen for gas exchange really to happen. Your lungs have to have breathing air self so you can breathe in a row. That's not really the ball side like a poisonous gas helium. That was a thing for a while. People choking on helium or notice oxide sort of a drug abuse sometimes gives a little silver canisters. Basically, if you breathe too much of that, you got breathing. Blair, you're not gonna get any oxygen out of this, which is not good. Your lungs have to be able to have to have except a usable supply of blood. So that has to be blood that has he minute. It's things like anemia doesn't. It's not as great on. Actually, the blood has to have blood in it. So sometimes in big emergencies, this more comes into what Josh be talking about. A couple weeks time the circulation. But you want a lot of red blood in your blood. And if you haven't got enough red blood in your blood, you're not gonna get much oxygen out of your lungs. This'll a little diagram here, show it. Basically, the blood supply goes all around the capillary around. Yeah, the only trying to take out oxygen and put in carbon on. There's a couple of more complicated bits about how our lungs maximized this this efficiency I thought we were putting in this one time. Just remember, this is sort of what's going on. There's a little bit more complex city to it, but for the most basic one of you, this the last thing that has to happen for gas exchange is that the membrane between the air and the blood has to be pretty soon. There's this phrase of semi permeable membrane that's basically it has to be. It has to be allowing guess to transfer across it, but not so much fluid, because if it allows fluids to transfer across, you end up with a lung full of liquid, which you don't really want. We're talking about when that can happen later on But so you want to say purple membrane allowing gases to transport across That has to be very thin to allow this, Um, and that's what you need the gas exchange. And for the most part, problems affect your breathing effect. One of those three things. So have we not getting enough air in? That could be. You're suffocating. That could be anything wrong with the airway. You have problems with the blood that's more circulatory issues. Just be talking about them in couple weeks time. Or you have problems that thick in that lining or loose in that lining so things can pass the artist gases or things can't pass a little bit more about This is things in a minute. How do we actually breathe? So the basic is often muscles, so your your diaphragm base, your lungs flattens, pulled tight so that comes down, expands the space in your chest so more it comes in. I intercostal muscles relax, and that allows you to sort of the contract. Sorry to pull your pull your ribs together and pull your reps forward, so that makes a bigger space. This creates and negative pressure inside your chest, so air gets sucked in from outside into the chest on. Then when you breathe out to do the opposite So your your ribs relax your diaphragm relaxes the weight of it, then pushed it in on out goes there very straight forward. Um, it's basically about improved, increasing and decreasing the size that the available space in your chest simply Why do we breathe? So obviously, I said earlier that we have to breathe that we need lungs to breathe. We need to breathe to live straightforward. But actually, what is stimulating us to breathe? What determines how quickly we breathe is based on balancing oxygen carbon dioxide levels logically. You think if you go, I've got not enough oxygen? I'm going to have a breath that makes sense. Wouldn't you know? I need more air, but actually, we don't quite do it that way. We go more. I need less carbon dioxide. So we have two different sorts of chemo receptors peripheral and central. I'm not gonna go into little the complex details differentiating them peripheral, which is located down in the chest. These detective levels of carbon dioxide in the blood and stimulate you to take a breath. If carbon dioxide level's getting quite high. You have central ones which are in the brain in the medulla. On these Basically, look at how a cytic your blood is, and if your blood is quite acidic, it'll stimulate you to breathe more. He sort of work together. So that's the peripheral ones, obviously telling you I've got too much carbon. Let's have a breathe in your central instantly. I've got too much acid. Let's have a brief. So sometimes patients who are acidic will breathe a bit more. So, for example, when recovering from running or something, if you don't like to kassid, you'll breathe a bit more to just bring down your pH. Bring up your pH. Sorry, I think it bring down your acid. Does bring up your pH on, uh, like way too much carbon. You might breathe bit more to get rid of some on these together, stimulate us to take a breath. That's the most basic form of it. I put in here. This little note, the bottom that sometimes the system lost. This is the normal system. High levels of carbon low levels of pH. Too much acid, too much carbon. We take a breath to deal with it. Some patients that some people become what's called carbon retainers on this basically means that because of excessive high levels of carbon dioxide of carbon exposure over time, their body just gets too used to it, and they don't really react in the same way non carbon retaining patients do. So this means that actually they need much higher levels of carbon in their blood to actually stimulate them to breathe. And if you bring that down too much, so you put them on oxygen and that drops, they just stop. They just won't breathe anymore, because that what he goes yet great. We're doing really wonderfully don't need to do that, which isn't great. And we'll talk more about carbon retainers in a minute when we talk about things with COPD. Yeah, any questions there, and that's been a whistle stop run through. That was the sort of basic anatomy and basic physiology of the airway and breathing. We're going to talk a little bit about plying this to actually conditions. Now what questions? Please don't put in the chat. Uh, I'll check it again in a couple of minutes to see if not we'll move on to actual conditions of the airway, good stops and airway conditions. I mentioned it, so start with it. Anaphylaxis. So this is a result of a severe allergic reaction. It happens all around the body that multiple things react at the same time, but effectively, all of those new coastal membranes we have. So I mentioned we have them in the airway into the lungs. We also have, um, you know, around the eyes, we have them in the mouth. We have, um, in the gut. We have them in the reproductive systems way like a mucosa. Membranes are body's a big fan of thumb. They're they're sort of how our immune system deals with potentially external pathogens entering body. All of those react basically, So we end up with a lot of swelling. The one we're talking about today is the airway that's also normal. The most life threatening one c. It's not great. Your gut can swell up a swell. You end up with diarrhea and vomiting. You can end up with that of the reproductive system, which isn't great. You can end up with your skin, your hives itchiness, so you end up with not great things happening all over the body. Also stay with worrying about airway big ones. There'll be things that swelling of the tongue and the throat and swelling of the airway as a whole. Because also, this prevents a rent tree. And that's no good. Yeah, probably as swells the Lumen, which is the space in the middle of the airway. The bit through which we breathe becomes narrowed, and that's not good. It makes it harder to breathe in on. It can make people very tired trying to breathe against it, or just means they don't get enough oxygen and they collapse. So if they collapse that it can't get help. If they can't get help and they can't breathe, that adds up to a very bad end result. What do we do about it? So the main thing people can do about having this severe allergic reaction is avoid what triggers it, so avoid allergens. Result. If you're anaphylactic reaction to peanuts, avoid peanuts. There's also this little thing that some people we'll have a mild reaction once, and then a slightly more severe one the next time and slightly more than X, slightly more the next and I can keep building up. Some patients get Maurine Mawr severe in their reaction to certain allergens as they're exposed to um, so not great. Um, how people get allergic things is very good. Varied some elegance. Very simple solutions are That's a much longer session if we want to discuss about it, so avoid it for the time being. But simply put, avoiding whatever makes you have the reaction is the best management in the immediate, as someone's having this reaction as they're getting breathless and very unwell. Administering adrenaline eso that's it could be in a pre drawn in. And auto injectors are like an EpiPen or an a pen. It could be from a vial using a syringe, depending on what you have, where you are. We inject that that helps reduce the swelling and improve air entry. But that's a very sort of acute solution. If they still got that allergen in their system, they still got the peanut they swallowed, For example, that's not going to fix the problem. That's just gonna lengthen the amount time before the problem comes back. So you might give you an hour or so, probably not more. 20 minutes a lot of time in which they can't breathe. But in 20 minutes time they're just going to go straight back to how they were because that allergen it's still in their system. So calling for an ambulance if you're not in a hospital or if you're in the hospital calling for an adult basically putting out crash course getting hold of more senior personnel to come and sort out for you, that's your best solution. After that. The patients that managed on a combination of steroids, anti histamines and oxygen so steroids reduce information. The antihistamine it stops, the histamine reaction that causes the inflammation in this case most well, allergies. Pretty much, of course, by excessive histamine production. It's white antihistamine tablets were things that have a fever and then supplementary oxygen. You give them more oxygen so that every breath they're taking is getting the most use it can. So if your breathing in normal rumors that 21% oxygen if you're on 15 liters, high flow for a normally breathe a mask will explain what that stuff means later, they're actually breathing in some 18 90% oxygen off. They're going to get better from from each of breath, um, and basically monitor them until the allergen has left. So if they're eating peanut, you Martin for a few hours until the past, it was officially broken it down. It's not react. It's not like cat dander. Like be a lot quicker, basically waiting until they are safe and not going to go back into anaphylaxis after it's given drugs to end it. And then you walk after them until the danger has passed. Some people, um, we'll move on to the next one, choking and drowning. So this is again another airway. Conditional asleep. Choking is generate a blocking or obstruction of the airway due to something Nextel factor could be food or drink. Saliva could be a toy. Whatever they decided to try to swallow. Drowning is fairly similar, but it's just due to fluid. So it's, you know, people is that thing of like you could drown in a glass of water. Ow! It's choking or drowning, but basically liquid, causing it drown. Normally, quite a lot of liquid goes into tramp on basic. What's going on in this situation is either the obstructions got into your airway, and it's stopping air getting past it, or it could be in the esophagus. So in the food pipe, but as such a point that it's compressing the airway. It's before there before the cartilage rings. This is possible to collapse the the airway from from behind the other one. That could be is also the epiglottis, which I mentioned earlier that closes over the trickier when you swallow so you don't just breathe in all your food. Um, if it gets stuck around the point of the epiglottis, the epiglottis could just stay closed on Stop you being able to breathe so quite often, what actually happens certainly in early stages of drowning is that because those water entering your mouth and enter your body your body's shut over the epiglottis to stop you inhaling. It'll and you stop breathing because you're trying to not breathe in a lot of water. So actually, water entering your lungs doesn't tend to happen in the early stages of drowning. That test happened after someone's passed out. It's not been breathing long enough. They got exhausted. They got floppy on, then the epiglottis for relax and then water come into the lungs. So actually, water entering the lungs bit later on. Just a misconception to clarify that covered everything. They're actually choking normal. It's solid matter, drowning, sort of choking or liquid, but actually generally are much more liquid. Where you define is a drowning or choking, I think varies a lot, Um, and it's basically not enough air getting past the blockage, either because in the airway or it's next to the airway, preventing the airway from being open. How do we manage it? I've got these lovely photos here. Two of the bottom after a central ambulance website always got plugs into an ambulance because they brilliant things. The one above, I thought, was just a bit less accurate to reality in terms of the guys. Positioning the one below is sort of how you actually want people. Best solution for choking is get the obstruction out. So for choking, this could be doing backslaps, which we've got demonstrated, uh, with this lovely Chapin, the radar of slapping the strap on the back or down here, this lady slapping the person on the back on, then abdominal thrusts. That's what used to be called the Heimlich maneuver home licks, then going on to like copy, right? His own name and things. They can't call that anymore. That paying in money. Um, so don't call it that. Just call the abdominal thrust, which is what this Chapman here was performing on down here. And that's simply pushing in and up from the abdomen. Try and force. Exhale, push whatever it is out on the backslaps to try to loosen it and knock it out Well for drowning. The most useful thing to do is just remind the lungs to breathe. So by putting oxygen on or by administering rescue breaths, uh, to stimulate the epiglottis to go look a rope enough again so the person can return to normal breathing. Don't be award with drowning. Patients do tend to throw up after they've been given the oxygen again because their body is gone. Right now we can bring it again. Oh yeah, we're now full of water. Let's get rid of some of that. So you stand back. If someone's once they start breathing again because it can get that Messi remember, with drownings and everything with secondary drowning just worth mentioning if they've succumbed underwater, that passed out and the epiglottis is opened up against the water can into the lungs. Your lungs are meant to be full of water, so even if you get them back to breathing, that water can cause irritation because inflammation cause infection. And these things are great. So although that person might come back to breathing and have a good couple days, couple days down the line, that might be more problems coming, they might get more sick. Eso It's worth keeping that sort of follow up after someone's had a potential drowning or drowning incident. Um, yeah, just worth noting. Anyone has a lifeguard probably should know that a little tightness and they mentioned again, really, er, on this number, one of the big emergencies that I think noteworthy I mentioned the epiglottis is we've got this beautiful drawing. I think it's from Grey's Anatomy, which is a textbook, not just a show. Call me, Um, Textbook is one of the best anatomy textbooks has ever been. It's iconic, and they named a show after it because of how it colic the actual text book. It's remember, it's that way around. So, yeah, drawing from Grey's Anatomy, the epiglottis we could see up here is this fold, which would close over to prevent the prevent the entry of food or liquid or whatever into the into the airway, which is this sort of quite dark. But here label trachea. Uh, and basically, if this gets big and swollen and could just close over this area entirely and stop a rental happening, Uh, this is not great. We don't want that, Uh, Normally, it's caused by something like an infection. Most the time It's an infection. You can get some burns. Sometimes it might cause it, but but it's predominately. An effective thing becomes inflamed. It's a medical emergency because it can completely constrict the street here on stop you being able to get any air down into your lungs with each breath, which is not good, we solve it. As with anaphylaxis, the best prevention is the best. Management is prevention most people have vaccinated these days. Most of the pathogens that cause epiglottitis are in the vaccines. In end of our and the other one, it was called. Basically, the majority of things might cause your medical Titus. We vaccinate against the UK Different countries vaccinate against different things. I think most of Europe vaccinate against things that cause this, Uh, certainly all the ones I've looked up. Do you? I'm sure I think anywhere that I know off the dozen. But it is fairly standard routine things vaccine to prevent in vaccines. Um, that being said, I mean, there's a lot of things going on a moment with people not wanting to be vaccinated. Also in the markets modern sort of global world, where people move around a lot. You might miss vaccination to be in a way, you were born or dependable country. You're in a time of vaccination, sort of vaccinated age. So we are seeing a bit more of this sort of thing happening in hospital now because people to start vaccinating against it properly. Also cause even if you're vaccinated, some people get a different pathogen that will cause it. So it's not an exact science. Vaccination equals prevention. Yeah, um, after the next best prevention is the next best management is early intervention. So seeing this might be happening early on looking So it's throwing. You got a cough. What's going on on day? Getting in place to t find it it before it gets severe. This could be antibiotics, which fight the infection, can also be things like steroids, which helped reduce information saying Gives meant steroids early on on some, bring it under control before it gets severe enough to have to go for major intervention. The if it gets too severe and it reaches that unburden. See states that point where it's potentially blocking off the trachea altogether and stopping you from being able to breathe we need to do is make an airway. You need to preserve the airway that can be done through putting a tube down the airway so that obviously the swelling comes up to the tube and then it can't con construct whole area. Um, to this, the patient needs to be sedated. They don't tolerate very well if they're awake slash Don't tolerate a tool if they're weak all on there on your death. This one now you 100% to be asleep for really is creating a surgical airway. So cutting a hole in the cutting a hole through into the trachea, putting a tube in that. So now you got a different way of breathing you completely by passing this this swelling once in place, we can get things that steroids and antibiotics and wait for the body to fight off the infection and bring the epiglottis back under control. What's your controlling your breathing again? Probably. We can just pop those tubes out, close up whatever search glad we've made in Central and put you back into some normal breathing. These are pretty important is a pretty big. They're pretty scary, not things Patients really want to know things. Doctors or nurses or paramedics or anyone really wants to see. These are quite sick people, and they go. They get very sick very quickly. So management this really if you're outside of the hospital is No. Nine getting ambulance? If you're in hospital, it's whatever your protocol is to get hold of a crash team. Most hospitals it's to to to to get that team to come and sort this out because you really do need an ent doctor who can do with cutting you bet and or in any statistical, do the whole TB thing and the the past, the or surgical. That way, if needed, you need one or both of those those varieties of specialists, um, to come in some soup. That's what I want for you. Last one I think I've got on the way of airway is asthma. So people often think grass. Um, it's a condition of breathing, and it kind of is. But actually it's a problem of the airway more than anything else. Basically the new cosa, which we talked about earlier. The coastal membranes become inflamed, and this makes the area through which we breathe. Lumen, as lovingly demonstration on this diagram that looks like a shrimp becomes smaller prone. Sorry. What is the shrimp English problem anyway? Uh, the this last space here, this brown, the space is the area air has to travel them. So with someone who's having a bit of an asthma attack, it become narrow, narrower to the point that they just aren't getting out from it very easily. What this means that eight breath trying to fill your lungs with a recumbent hard That makes you very tired. So the patient becomes exhausted and gives up breathing eventually. But it also means that the air you're getting in is less effective. It takes a lot of effort to get fresh air down and get the air from your lungs back out. So actually starts not doing that very effectively, and that means you get less oxygen in your blood. And in turn, that also means that you get more tired because you just don't have enough. Oh, yeah. Lack of option makes you more tired. So you get really exhausted on patients, just sort of get very, very sick and eventually give up on it. And the possible A. Sadly, if if not managing quite severe attacks. Management's obviously reducing in preventing the information. So the certain medications that can do that that preventative and also when, when having the attack, there's other medications we can give it to steel With. This, um, main ones we would use are things like so beautiful, which is commonly found in a blue inhaler. Certainly in the UK it's coming down to the blue inhaler, a steroid Harris. Different stories he used couple more than others. Last comedy found in a brown inhaler. I think I petroleum bromide, which is commonly not in inhaler, but we use that in emergencies during an emergency would do the same thing. It's not beautiful via nebulizer. Want to I petroleum bromide for a nebulizer give supplemental oxygen so make sure each breath is as good as it can be, um, on. But we'll give steroids in order to help reduce the inflammation. And again you give it. You reduce the information and you look after the patient and tell the attack until they've taken over their own breathing again properly and start sweating up of a really good thing. I'll say this with most of the other conditions, is avoid theory. Journal Trigger. So Asthma Attacks Committee gets on the cold or dry air. Avoiding that's really useful. Cigarette smoke is quite common. Cause of vascular axis Well, certain pollutants, arguably allergens. So technically an asthma caused by an allergen. It's called rhinitis, but no one really pays attention that anymore. So you can have allergic asthma. It has got his own name, but it's fairly widely accepted these days to call it asthma. So allergens is they want to avoid a zest you possibly can on using your medications so you're so beautiful pumps your steroid pumps if you're diagnosed if you're administer. If you'll prescribe these using them properly, knowing how to use them using them effectively. Is this really important just to prevent the attacks the attacks could be really quite severe. Questions always worth asking Any asthma patient or any patient tells me they have asthma is have you ever been to I see you before. Have they ever been so severe in their attack? They let her out of intensive care, so that might not be then. It's only like intubating and ventilating or anything like this, but it could be They have to be monitored on the see you because that tells you basically have severe their tanks can get Some people have very mild asthma to be very severe asthma so mild patient will never probably end up. When I see you, a severe patient might end up on. I see you more than once or even, you know, fairly regularly because of how bad their asthma gets. So it's worth knowing sort of what you're expecting in terms of this patient on that asthma. Yeah, uh, I think it's about what we want to mention. We'll move on to breathing conditions. Now. I'm just quickly check that shot. Anyone has any questions? Please do Ask him if you have a test me hammer me. All these things will also do it. This point is share the feedback link. Guess anyone needs to disappear on the earliest side filter. It fell out, please. Different out because really useful for us to see what we did. Well, we did wrong how we can improve after you get the attendance difficult if you want it. Some people need them for, like, CPG things that let's just to prove that been doing more learning. Um, but yet please to get feedback. And please don't be nice that you're allowed to be harsh way like harsh feedback because it means we know what we've done wrong. Not just what we've done well on gets a really good way for us to, like, develop and improve what we do. Make everything better for you guys who attend. So please, you don't You don't have to be nice. We don't mind, um, and we do read it. Honestly, we really do. You read it, but we spent time going through it and figuring out what we need to do to get better in the future. Like, for example, this session. I know there's not much interaction, but I did have to write it very last minute. So haven't been able to put much into the interactive side of it. Hopefully, it's still good. Do you let me know? Uh, so I'm moving to breathing conditions. Just don't check. There's no one's personal questions. Ah, here we go. There has been one question, and Josh is here, so he's answered it. Ah, Joshi beauty Because I wouldn't have remembered exactly made other day. Oh, yeah, Flex is 500 micrograms. Absolution of one in 1000, isn't it, Josh? Yeah, one of 1000. So I am one in 10,004 on across? Yes. So, yeah, there's a quantity for you on, obviously, like auto injectors already have it drawn up whatever you have. And this is why you shouldn't really use someone else daughter injector, because you might have a slight different amount in it. The child's one will be slightly less than I don't want. Um, so if you have an auto injector, whatever form is EpiPen on a pen inject pen. Although it's going to inject the car always called, other brands are available. Please do Harry it with you. Don't feel like I've got it, but it's a home because when something goes wrong homes. No use. Having it on you is is the only thing of use there. Um, yeah, but I think you just, um I'll carry on with it. And that's a thing. You want to mention this point, Josh with any of the airway stuff. Glad that you carry on with the breathing bit differently to correct me if I'm ever wrong, so we'll start with COPD. COPD. Anyone during a healthcare course becomes very vanilla. This is something you just need to know about because it's so common and it is quite a big thing. Uh, you'll find this in every area of medicine. Really, it's the COPD is the condition associate. It's most commonly like 99.9, something percent associated with smoking. Patients have smoked. Normally, the more you've smoked the worship COPD gets off at various bit. Some people will smoke very little. It will get very unlucky and have quite bad COPD. Some people might smoke a ton constantly and never develop it. That sort of better luck of the draw really lack of genetics and circumstance. Um, not every single patient it's associated with smoking, but that's majority. It is some. It's things like exposure toxins. Some of it could be exposed to certain workplace things. So some farmers get this from inhaling dust. Some builders could get it from inhaling dust of there and use the correct of respiratory masks. But the thoughts majority of the time. It's a smoking if the disease associate with smoking. Um, and basically it causes chronic, which means basically very long term inflammation of some of the smaller airways has demonstrated in this little bit up here, you can see there was one out here. You could see this airway is much think this lining is much thicker than over here on also by the D elastistic a shin, which I think is a bad isn't a real word. I think it's a word of the alveoli. So they become bigger Sagheer, less elastic on do also some of them still break down a bit. So, um, that was sort of fewer, bigger, less efficient. Our yearly on this basically means you get really poor air entry's. They can't. You can't breathe in a swell or bring down to where you can't expel very well on. It also means to get really cold gas exchange because you've got less. It's area on the air that's in your lungs isn't That's a high quality air we like from a normal, better breathing. Um, that is no great in that sense, Simply not very nice for your lungs. And it makes the breathing know fantastic. Here's a nice little charter decide to borrow to demonstrate how this conveyer you have mild, which you probably wouldn't notice very much. Your airways, not your air flow isn't as good as a support without any sort of COPD. But actually you might only notice it when you're exercising. So you have your your air flow is not as good as the next person, but not enough, you know, to sit like a little time this then obviously progressively gets worse, won't read through all of them. But they say you get mawr and more problems with your breathing to the point that eventually you get to very poor air flow on somewhere between sort of severe and very severe. You probably gonna need constant supplemental oxygen so that every breath you take is that little bit better that little bit more extra nated So you're getting a bit a bit Mawr. I wanted a bit more for your money, but basically each breath is a little bit more oxygen in it. Um, definitely in severe and variously also get these things called exacerbations that could be an infection. Or it could just be a short term worsening of the condition, making it very difficult to breathe in. These patients often end up in hospital management, so management COPD. You'll see a lot of patients with COPD. If you go into any healthcare career, they'll be all throughout all sorts of healthcare because basically people with other conditions smoke, so you might wanna gastric guest reward make a promise that gut. But they've also smokes. They also got COPD. So these appear these patients of here everywhere, just a normal life. They're all over the place. Most useful thing for patients with COPD is to quit. Smoking. Reduction is good. Quitting is better. This is if they are a smoker, basically removing whatever it is that's causing them to develop COPD. This doesn't mean they're going to get better, so stopping smoking doesn't magically fiction once they're going to stay really poor. But it's going to stop from getting worse or least slow them down. Getting worse. Saying that as I put here just because he stopped smoking doesn't mean your lungs aren't going to continue to deteriorate because actually, depending on how much damage you've done that can then put stress on the rest of the lungs healthy lung tissue and in time, this will just continue to toe worse. And so just because you stopped smoking doesn't mean you're not going to get worse over time. It just means that it'll be much slower. A less likely, um, with patients like that supplemental oxygen to maximize the quality of the air there, breathing in so more oxygen, what you're breathing in on Day four maximize the gas exchange you can do. This gets tailored to the patient, so people who have more severe COPD will have think. Basically, it's called venturi masks or nasal cannula. We'll talk a bit more about these delivery mechanisms in a minute. Basically, Taylor, how much oxygen their breathing in because, as I said, some patients become carbon retainers in this quite common with in COPD, which means actually, by breathing in too much oxygen and out too much carbon, they said, Stop breathing which we don't really want. Um, we go see his asthma medications. Similar medications how you use an asthma tell. Reduce the inflammation in a similar way to how we would asthma. Some things that some you tomorrow with the Eye Petroleum's section on the last is to manage manage infections because this poor quality lung isn't very good expelling pathogens. Second, breathe in common. One of the moment I think over you're more likely to get sick with it because you're not getting out of your lungs. Stay in your lungs on that poor quality lung tissue. Get infections really easily and could be really badly affected by that by those infections. Um, manage infections or exacerbations oxygen if needed. Um, and to the right amount that is needed on some of the aspirin medications. Um, that's almost going to sail COPD, but I know I said quite a lot in there. So if anyone's got questions, uh, also did That's when I just answered it in the chat. I'll read it out. Can you get COPD by being around smokers constantly, or do you have to be a smoker to get it? And it's just very correctly, said that if you want to throw out loud your shoe off your me too. I really don't give you the chance if you want it. Yeah, I was just had a quick look on a sudden it will just make your correct. Yeah. Um, this journal from the BMJ will be basically says increasing process smoke exposure was independently associated with increased risk of COPD with aunts ratio of 1.5, um, 1.18 more than 20 hours of exposure. That basically says that if you have more than 20 hours of exposure to secondhand smoke a week, your risk of COPD increases by 20. Yeah, a lot. So, yeah, above the risk of for being a direct smoking is greater, but yeah, So second hand smoking can be a cause for COPD. It's one of these things. That quite common problem is that patients who were smokers for a long time give up, But then they're partner or that the house make whatever who was also a smoker doesn't give up, so you know you can quit. But if they don't, you're still inhaling smoke. And it also makes it much harder to quit because you see them smoking constantly. So actually, you kind of want it makes it less likely for you to quit. But actually, you giving it up and then not doesn't necessarily give you the benefit you're after, but yeah, most conditions that you get from smoking. You can also get from second hand smoking because actually, the only thing you're missing from second hand smoking rubble first hand is the nicotine which cause certain conditions do nerve system. It's all certain things to do with babies and things that it's like if you're pregnant. But second, smoking generally still pretty bad. So avoid it. Likewise, sort of digging around any major air pollutant. So, you know, if you work in, like an indoor car arena or some of that, I'm trying to think of one way you're gonna be heavily exposed to a lot of pollution. Um, not great for you. So breathe Morphine air. That's my luck. Health. A women's bit of the day. Yeah, good questions, guys. Pleased to ask more test. Josh. He's very he's He needs very high level of questioning, testing properly. So Testim thoroughly, um, live on two new Meridia. So So what? I want to talk about because this is again of reasonable patients. End up in hospital is in your mouth. You're particularly the elderly patients say pneumonia is a severe lung condition in which we want to begin to have fluid filling up those sexy All the only, um, I guess it makes us unable to perform gas exchange in that area. Exhausted. They're full of gunk. They're full of fluid there, full of puss, whatever it is, Um, you just can't breathe because there's no air in the area. So it's not good to see you lose a chunk of your lung. Lose a chunk of the functionality of your lung. Um, severity of it depends. So if you have part of the load versus an entire lobe versus multiple lobes versus both sides or just one side. Basically, however much is new monitor pneumonic. That's the right word, isn't it? Basically, how much of your lung is has pneumonia? That's both lungs having pneumonia offset. The less has it, the better it is for you. The more that has it, the worse it is, um, predominantly, it's caused by pathogens, so bacteria or viruses or fungi, but sometimes it could be cause both called aspiration and aspiration. Pneumonia is quite a big thing, particularly in patients who have your disabilities or elderly patients. Basically problems with the musculature of the coordination, the musculature when you swallow, because this makes it more likely for you to basically inhale whatever is a swallowing food or drink probably other things other than food or drink well. But mostly it's food or drink basic. That matter, then goes down into lung. It becomes very good breeding ground for bacteria infection, but it also, as I said earlier, it's solid. It takes a long time for the mucus mucosal layer of your lung to very slowly break down that sort of solid, thick matter into a gunk. You can then cough up or bring up for insemination. So takes a long time for things that shouldn't be in your lungs. Getting in your lungs to get out your lungs. That that makes sense. That's not good for you. And it can cause inflammation. They can cause infection. It can just really not to a nice thing for your lungs. Pneumonia depends on the severity. Ah, very mild pneumonia in a very healthy person. You might be able to leave thumb. The ultimate end result is that you need to allow the body to re absorb the fluids or cough them out, especially clear the lungs out on that takes time. So in a healthy person they might be able to do it on their own. In a less healthy person, they might need support of antibiotics in a very severe. You know, you definitely need antibiotics to help support this base to help your body fight off whatever infection it is. You give supplemental oxygen if they need it to maximize that. The quality of the air there breathing for the rest of the lung tissue that is still working. Um, and then this thing called prone, in which we used to use quite bit your encoded I'm going to quickly show slide on it in a second. Um, it could be used, and it basically helps move that that statement. Fluid around public. Nice to prevent stagnation, forming blood clots. Best areas of lung been completely useless for a prolonged period. It's very severe. Patients could require intensive care. They're going to, and I see you for monitoring or even ventilation if needed. Since what Pronin is so effectively it's rotating the patient over time. So from on their belly to one side to the back, or in this case, sitting up to the other side back to the belly. And you still do this routinely to just move that fluid around the lung, get the lung gift areas of lung, bit of break, the chance to do some work. And also it helps with the preventing, like sort of fluids becoming more solid, thicker, which we don't necessarily what we want to quite thin so we can get them up. Um, and yet basically protein is used to deal with pneumonias on very bad chest infections that have just some comments, um, burning, um, related. We saw a lot more of this during covered because it became quite effective way to manage quite sick Koven patients. Yeah, so, no, I think it's the last one I wanted to mention. Actually, for for lung problems is heart failure, which seems about we need to go, which will go up into the lungs and talk about the heart that'll explain. So, basically, your heart heart failure is when your cardiac output, especially how much blood your heart is pushing out in a minute is reduced. This means that the blood there's a backflow basically so think of it like a traffic jam. It's not much traffic is moving out. Traffic builds up behind on This increases the pressure in the blood vessels in your lungs your pulmonary blood vessels and basically leads to leakage from the so fluid exits into the lungs. Causing was called pulmonary Dema In England, we using Oh, on the Dema in other parts of the world they don't. So this diagram, which I borrowed, has a new a demon that actually, when I write it, you'll see it down here a Dema Um I don't really know why there's that dropping of a vowel, so I might be able to explain that for you, but I just don't know why it's not back. Um, anyway, so Palm Redeemer is basically fluid building up in the lungs as demonstrated over here on basically a small amount. This is not great, but we could deal with it. A lot of this is pretty bad, and we basically end up with fluid and in each of the alveoli, which in turn makes a wrecks change less effective because there's not as much space for air to fill. It also causes problems because it makes it very labored for your breathing. Anything mortification to breathe I/O makes you tired. Makes him quite well. Um yeah. And again similar how we were talking about with with other breathing problems. Uh, positive aspect we're talking about, I think, is that your breathing becomes harder, so you use more energy to breathe. We also don't get as much oxygen, so you can't make a much energy as well. So these two together, making more tired on give you problems that way? Um, yeah. Management heart fit. So you can see it, actually. Pulmonary edema. It could be secondary to heart failure. The heart's no pushing that blood ran very effectively. Yeah. Traffic jam of blood that leads to fluid leaking into your lungs also lead to, like fluid. Build a place like your ankles. People get quite puffy ankles sometimes for heart failure. This is similar, but in your lungs. Um and so how do we manage this? How do we deal with these patients having this fluid buildup in their lungs? Um, simply It's it's well, we sort out The heart is a good start, but I'm not gonna talk about the heart because that comes out of circulation, which is just a section for a couple of weeks time. So I'm going north that come back then. If you want to learn more about heart, um, patient portal, redeem it because of the heart failure off. So we can try and help fix the heart failure and get the heart working bit better since for it moves, the other thing is just to remove reduce the amount of fluid we have in the body. So depending on how severe it is, we can fluid limit patients. They have a certain amount they're allowed to drink during the day just to try and reduce the amount fluid they have. Um, but we can also try and get more fluid out so we can use in diabetics, which basically increase the amount of water we let out during urine. So you, we we mawr, um, and also reducing how if we take in, that's the base. Most basic elements of it is getting more liquid out the body, and we'll we'll basically draw more back out of the loans from it. Um, that's ignoring the heart beats which office is quite large part of it. But we'll we'll ignore that. Exits complicates day session of it too much? Um, yeah, that's pretty want to say heart? Well, we've got some emergencies. Are there any questions that the moments before um, we wanted this lost chapter is it would be, um, give him, see if anyone's got any queries. That part. I'm not seeing anything. Okay, we've gone to the emergency, so we'll start with what you do. So during an emergency, if patient is very unwell, we start to assess that. Figure out what's going to kill them. Quickest. So we'll do the eight we assessment. First we look at is the airway, because that's the thing that's most like to get in to kill you, other than as I mentioned the very start things like a lot of blood leading body very, very quickly, Um, is another thing that killed people have fostered but the most about having your airway open having no air entry pretty bad. What we're looking for is, is it open? So patent on Are they keeping it open? So if you look at me right now, I'm using the muscle of my neck to keep my air with my head up. Get my hair it open. If I'm sort of a bit wobbly off of it slumped, I might drop my head. And that concludes the airway at the top. If I'm lying flat on my back things that my tongue might roll to the back of my throat back of my mouth and let me from breathing. These are great other things, like fluid. Saliva re like much saliva, basically, or vomit could build up the back of my throat from lying on my back, and I've nominated or five drooled on this compress went the risk of calls the trachea to the because the epiglottis forget the right word to close over and stop me from breathing very much. Or I could even inhale that. And that's not very good for me, either, Um, because they're not keeping. They're open. We do. Three simple maneuvers are a combination off the three simple maneuvers to open the airway and keep it open. We can also, if he's using called adjuncts these things to support us and keeping this airway open to make it more secure on. Finally, if everything else goes wrong, we can do surgical airways, which is cutting a whole in the neck in order to bypass into the trachea. If this obstruction, for example, or we're really not managing to keep the airway open. So you got a hole in on Make a basic Make a new Entry fee Moves was mentioning. Some people would argue that head tilt and chin lift are synonymous. They sort of go together at the head. Children left, but I was taught as they are different because you can sort of do them separately. Just you don't tend to tend to do them together on the last one is called the jaw Thrust. So in this top diagram, we see the head tilt on the chin lift happening together. So they're lifting the chin, and they are pushing head back. I personally have never seen it work very well. When people just push on the forehead, it doesn't tend to do very well. Actually, normally placed the hand on sort of the the crown of the head here so you could sort of lift it and shift it at the same time because, particularly, you're on a non smooth surface like carpet. If you're just trying to push that head back, it just doesn't go very well. So lift it slightly and open it properly. That's why actually vice City from From the Real World and that's basically secures the tongue gets pulled forward with the lower jaw pulled away from the from the airway itself, giving you a much better open airway, and it might constrict in the mouth. Still the tongue. But actually it still gives you the nasal airway. Open t three on. Then the other one is the jaw thrust, and this does a fairly similar thing. It lifts the lower draw out the way for taking the tongue with it to prevent it from sitting at the back of the throat is we can see here. Um, base, basically is he push basis. Push the jaw. It's really uncomfortable to do it awake person, so the patient normally has to be fairly basically not have very much muscle tones and on the subway unconscious. To do this on, because basically just push it forward and normally is quite a good way to do is either hold another bony prominence, basically, so the cheek bones or in this case, for some reason, they're holding the forehead. I don't think it really tends to work very effectively, but normally cheekbones and you push with the as I would hear my thumbs normally do with your fingers and just push that jaw forward just to keep the tongue out of the way. Um, on. Normally, it's Nestle's Airways completely. If they're completely floppy, they're not maintain their airway. You do some combination of these told it open. But these could be quite difficult because the very floppy you gotta hold it and they're quite difficult to hold in place and be because actually holding a jewel for us for a long time, cause quote pain in your hands and you get tired and then you let go and they're not breathing, and it's not great. So that's why we have adjuncts. So here is a big old sheet in adjunct. I've borrowed these images or not, but I found this on Google images. The one that comes all of these things was cursing a of think the Royal Society Majesty's missed easier. I think it was my been the Australian, and it's easier society. Anyway. These are various tubes, and then I put one more and down here because the only other one you ever really might come across those pretty extinct these days because you know it's effective alternatives. So up here we have a cold or a fur Angela Airways or Opie's. That's what I was. Just call them. There's another name for them as well, which I think is good, L or Goodell's, which I think is one of the brands of them. Correct me if I'm wrong. Any point here, Josh. But these basic common variety sizes and these pop in the mouth on these basically hold the tongue after the way. So bypasses the tongue to ensure they can continue to breathe through their mouth even when they're not holding urine airway we also can use these is what's called a bite block. So if the patient still has some muscle tone but isn't maintaining their airway, they might bite down on a different attempt and airway May management and these prevent that from happening so nicely Hard plastic. They come in a variety Sinuses, these tiny ones down here for babies and Children right up to exercise. Here is red things called size seven. Think there's seven of them? 123451234567 years of seven. And that will that's for a larger adult. Slash. Probably most adults, most adults. Sometimes you get taught it that that men tend to tolerate a red and women something smaller. Honestly, you get a lot of variety insides of in, genders said. I wouldn't really think about it that way. It's it's you figure out what next patient I could teach you had a size these, But realistically, without having them physically in front of you and doing with your physical like in person, session is kind of pointless. Um, the basic. Just be aware. They go in the mouth and they keep the airway open. They support you to keep your airways open side of the mouth. Comparatively, we don't have these ones in the bottom, right? These called nasal pharyngeal airways and these are the same, but they go in the nose simply, um, and help you to support the nasal airway open. You can use these two together because the ones that the mouth ones in the nose. Do you? Realistically, if you can get the good airway maintained with a normal fragile airway, you don't have to use a nasal one as well. Um, but actually, the nasal ones tend to be tolerated a little bit better. So if your patient isn't fully unresponsive, there's sort of a little bit awake, but they're not fully awake. Actually, they tend to tolerate one of these in the nose. Better they will one of these in their mouth simply, Um and again, this coming variety of sizes. The next step up is these That was down here, which I was talking, is an eye gel. I think they're called a super political airway is the other word for them. I was, I was told, by gel I think I just might be a brand that is fairly universal. I think it was yet Super Gluteal Airways and these again go in the mouth similar to the O. P. Would for these go bit further. So these come right the tongue down to just above the epiglottis on the beauty of these. They've got a gel in them that will react to the body's warmth. and we'll basically swell up. Eso basically makes it much morgue effective seal so you can get much better air entry and sort of bypasses the tongue as well. So so you've got a much more open airway that way on. There's a pretty effective you can use these vast majority of patients who are on responsive on deep, very good airway open on. They could be attached right into option, providing equipment as well. It's never really useful. This is a slightly more fashioned thing that happened before the idea was invented. You still see it occasionally, but not very often there. And this works and exactly the same way of knowing it's actually called because it's so common. Um, Josh view, remember, Please do let me know this one was called, Um yeah, so the overall name is supraglottic of the of the courts, and that one is a marine deal mask. Airway them and then I guess, just kind of brand. With the gel basis of this one, you'll insert similar to how you would one of these. It goes into the back just about the vocal chords, but then the difference is you. Then inflate, inflate this part of the problem with that is it doesn't really mold the individual airway so you can over inflated and it's not great or you can under inflate. It doesn't quite fit. It's a bit less a bit less efficient than one of these molds to the specific what I was going on. And then finally, if all that doesn't work, there's this lovely lady up here, which is the ET tube for the industry keel tube. And this is what you call intubation. So the patient has this past beyond the epiglottis, down the focal courts, and then it is inflated below them. T sit perfect position, basically, so that is only going into into the trachea is going all the way normally from the mouth interest in here, we use that to ventilate the lungs on. It's a pretty good way of maintaining an airway. I think the only thing that's slightly more effective than that would probably be a surgical airway, though some people would argue this is probably just a good surgical that way. But it's like problems about whether or not you can get it. There could go big inflammation also epiglottitis, where you just can't get past the epiglottis because you've come a little bit late. You're probably not gonna get that passed it so that you might have to do Surgical Airway. And actually, you realistically, you probably use a similar style. Chew off. You made a hole to put it in there. There are more specific versions available, surgical airways, but in a pinch, one of these would work just a Well, um, if they have not mentioned about any of those Airways, Josh? I think so. No. Okay. Like I said, it's more effective normally to teach these face to face, uh, both the people attending a tree or all over the place. Not just in one country, but all over Europe, over the world. So I can't really just say, Oh, all of you come around and older show you what these are face to face. But if you ever do get chance to see these, have a look at them what they look like, See, we think of them. Ask someone how they use one of these just to demonstrate the actual way. You don't certain insights that slight differently. Um, but yeah, whatever you find, where you are just Just be familiar with the equipment you have available. Berman. Basically all of them go in the mouth, except this one in the bottom right, Which goes in the nose Onda in sort of a tapering up for that. So no pee or an NP is quite effective in a in a pinch. But actually, it's not quite as effective as one of these super little ones or the intubation. Yeah. Ah, so that's all I really want to say about airway moving on to the next. But the breathing. So once we've insured, we have a nice open airway. This could just be the patient sat in front of you talking so they've got their airway open themselves. Or it could be We've had to put in all sorts of tubes to make sure their breathing make sure they could breathe. Um, we now assess whether the patient is breathing, and so there are two observations we can measure. So with the airway, you can't really measure an observation to make sure it's working. There are two week commonly used is the third one. Actually, I just thought of which capnographer. Anyway, I'll mention that a second but the respiratory rate. So how fast the patient's breathing? We normally and for between 12 and 20 and adults office. He gets bit higher with Children because they like smaller lungs. The briefs like more to make up for it on doxidan saturations, which is greater than 94% for everyone. So a respirator is just basic how many times they take a breath. Saturations is shining a little red light through someone's normal for a finger and it for a year or two, and it's basically measuring. How great is there? Blood is the blood gets more red when it has oxygen in it, and darker, deeper red when it's not. This is measuring, basically how nice and shiny rate their blood is. So how much extra visit in patients with COPD? This could be a bit lower because, like I said, their lungs or bit pants but there adjusted for it. Tell me, um, I get going to sneeze and not, but, uh, they, uh, patient's, uh, pretty well, chronically. Just just consistently have lower saturations on yourself to figure out what's normal for that individual. Sometimes we say 88 to 92. Sometimes it might be even lower than that since, um, patients with quite advanced COPD quite comfortable sort of 88 2%. Um, And if someone of relatively healthy individual like myself for you guys, home probably was to come and see you and you take that saturations and then saturating it 82%. You go. Oh, no, that's pretty bad. Wax the oxygen on and bring it back up. Um, but actually, they're a COPD patient on their age to normally. And you want the auction on bring it up to, like, 88 90 something. They're just gonna forget to breathe. And it's not a good situation. Oh, so, yeah, be aware of COPD patients, but in a Yeah, So it's a judge your patient by how they present what they looked like. Not just these numbers. These numbers that support the other one that I haven't been here she's to cap in aquaphor, which basically measuring how much carbon their breathing out. And that's another way of measuring sort of how effectively their lungs are doing their job. Um, way. Then also, look, listen and feel for the patient's breathing. We look at their chest. So is expanding properly isn't doing it on equally or both sides expanding on Diz inflating all the way out? Or is it all just slightly rising and up? Doing much is one side doing a lot of work in the other one. Not a lot is. Once I'm not moving a tool is one bit moving on its own. Uh, just have a look. See what's going on there, Have a listen to it some. Are they making strange noises? Could be here. They actually breathing if we get stethoscope. When we listened to the chest, are bits of the chest wheezing? Are they bubbling? Is that like a gurgling sound? Is there a lack of sound? All together is a sort of a Velcro we sound or even a Velcro. We feel like we really want to feeling which think of surgical emphysema. We don't like surgical emphysema. It's a bad thing. I won't re talk about it much detail, but a base of this air bubbles in the tissue rather than in the lung. Um, and we feel the chest, so we feel is expanding it on both sides. We could do the auscultated, which is you put a finger in between two ropes on the intercostal and you tap and you listen to this or noise it makes and you're listening to places that are very residents that has increased sound or dullness. A decreased sound on that could tell you something wrong in that particular part of the chest is somehow we assess, um, was breathing about going till the particular findings getting It's very long, and that's also something might you might want to talk about. You know, increased dullness generally means that more material that could be fluid, solid, increased residents tends. To me, that's more air there. But I could actually mean that they've had, like, a collapsed to the lung, and they've got a he knew before access area there. But it's not in the lung. It gets a bit long, complicated, really, in sort of another session about managing emergency session itself, matching emergencies in the reading. But for now, just remember to look, listen, and feel what's going on with their chest to work out. If they're breathing is normal, or if it's a problem with it and then figure out how much they are, she's breathing. Um, any comments on that. But Josh have to get something catastrophic or anything. And the topping is custody because auscultated Yeah, I wrote this one was tired. I'm sorry. Yeah, The cussing is tapping. Auscultated is listening with the stethoscope. What stupid is what I wrote this. I put listening with a stethoscope, and I couldn't remember what it was called, which is just Yeah. Anyway, oscal tasting, listening for cussing, tapping. Thank you. Just that's gonna be an idiot that for a minute. Yeah, I think the last thing I want to talk about all together, actually here. You still check? Since the last, um, yes is going to oxygen. So with someone who's sick, we can give him oxygen. Uh, basically, uh, so if they're not breathing at all, so they're not take any breaths. We can do it for them. Basically forced air into their lungs and breathe for them externally. Similarly, if they're not breathing enough, so they're breathing very shallowly or they're just not breathing very often. So, you know, five or six breaths a minute rather than 12. We want, um Well, he's got a bag valve mass, which will show in a minute, and basically, we can push it into their lungs forth. Um, brilliant. So we can breathe for them. Or that's well as them to help him do it the better. Um, if they our breathing great. But they are breathing. So they're taking No, they Sorry I forgot where I was gonna go without, basically, if they're not breathing for themselves for a while, it gets kind of crampy if you're doing this. So we put them on a ventilator. On this Basically is a machine that will do it for us, actually. What ventilated looks like in a second as well. If you want to do anything, we can also apply oxygen to thumb. So, supplemental oxygen basically more oxygen than you get in the normal air for a couple of different devices which determined how much they're actually breathing in on this improves their oxygen in the blood. Because that I talked about earlier, it's actually improved the quality of their their breathing in. I want to demonstrate. So this up here is the ventilator. This is quite a swanky one. Sometimes they look a bit old and clunky. Depends what you are mentally. Just come in a lot of different shapes and sizes. Bit to point out, here is this is bag. So if you want to take over manually giving the patient breasts, you can use this bag or you could switch over and the machine will do it for you. And you do all sorts of different settings is how much air, how quickly you wanted to do it or pressure You wanna put behind the air, mixing the air up a bit where you're getting them. Lots of oxygen or room air or different anesthetic gases. For example, Acres on mix and match what you're after to go into the patient. And that's the job. And the PSA test. Basically, um, on down here is a bad valve mask. It's like more primitive version of this lovely big machine in a space of the manual quibbling. So you've got the mask. Understandably, that goes in the patient's face. A valve, which means that when I was in the bag is what you push through. And then when they when you release the bag and air's exits, a zit would do best of the breathing out it goes out, it doesn't go back into the bag, so you're putting what's in the bag into the patient that was coming from the patient leaves into the room rather than back into the bag. Um, on what we put in the bag varies so either you can have it on Aricept room air. So you just have to open. It's filling up from the normal room air, or we can give them oxygen in here. So you catch this bit of tubing and miss my Now, Scott, there is this big shooting at the bottom. You can attach onto an oxygen cylinder and give them pure oxygen. It's not entirely pure, because actually will always be a little bit of room here in this bag, and they'll always be a little bit of their normal thing. Air they're bringing out will remain in the mask and a little bit remaining that lung. So you never quite get to 100% oxygen. Breathe in. You can get fairly close particular this gadget and even closer with a ventilator over here because you can calculate, actually what they've still got on counteracted bit more. Yeah, Other than that, here are some other bits you can use to give oxygen, so actually the last book about so you can stop worry about listening to me in a minute. These various different forms of what we can use to give patients oxygen when their breathing for themselves, nasal cannula. And for any common, these are basically little things that go up to your nose. How much air you get for a You know, we put between one and sort of three liters through these, you can go a bit higher, but actually the manufacturers, certainly for the NHS, the manufacturers only recommend up to three liters. What is for the ones I've always read on basic. This basically glass a bit of extra oxygen near your nose. So when you breathe through your nose, you're inhaling. That's like a higher level of oxygen. Um, so normal room air what? 19 to 21% oxygen from a nasal cannula and go up to sort of 25 30% oxygen. So you're not getting tons. You're getting it a little bit more. You have a simple face mask again. Most of what you're breathing in with the room air. But this will put a bit more oxygen around your face as you breathe in this comes about your mouth and your nose. It could be a bit claustrophobic, but again, this one's got a little bit high and normally up to sort of. I don't really want maximum. I put through This is probably I wouldn't put more than about 8 10 liters, but I'm not really read the masks, so I don't unlike this one. I don't know what the manufacturer actually recommends, but let's say probably between eight and 10 would be the maximum here. Josh Rubin If you've read these most's which one we're talking about. A simple face. Yeah, probably 8 to 10, maybe 66 to 8, maybe again basis just increasing the quality of their their breathing in. The difference between this and the nasal cannula particular is this. One covers the mouth as well, so actually they breathe through their mouth and nasal cannula kind of pointless. It doesn't do much for them where the simple facemask will. We'll put more oxygen for that, really worth remembering that is. Actually a lot of people put people on nasal oxygen and wonder why they haven't improved their breathing through their mouth, not the nose face. 10 time not recent, much off don't really know too much about it. Oximeter again Not so common, no recent it high flow nasal cannula is similar to a regular nasal cannula by the difference is that it's manufactured to have higher levels of oxygen of flow through it. Really Would you use it, you know, often are not seen them. Really, um, the only one. The ones that commonly used again Venturi masks here, very common in carbon retaining patients like the COPD patients on. Basically, it's similar to the simple facemask, except it's got this big plastic. Or let the changes it, and you can basically find that there's several different colors, and each one is slightly different. What it does, like how much allows. And this basically mixes the oxygen from the piping with air from the room on there Really quite clever. They have different size slits in them to determine how much air that's how much oxygen the patient will breathe in. And this will give you quite accurate variation on how much oxygen the patient will breathe through. So it could be anything I think from 18% up to. I think you can get up to sort of 45% on eventually mask, depending on which attachment you put in. But it gives you basically more controlled measure of Austin for those patients who a lot of oxygen will just stop the breathing. Um, and it gives me shouldn't give some supplemental oxygen to solve COPD without worrying about them. You know, stopping breathing season quite good, actually. Again, they're not entirely common because it's a smaller subset or smaller subset. You need it, but they're they're really good when you do need them. Theophylline that's quite common is a non rebreather, sometimes called a trough. The mask on this basis, or is a mask with a reservoir bag so the bag fills of oxygen, and then they take a breath and droxicin from the bag into the mask into their lungs and the bag refills on. This basically means that you're getting even oxygen and less room air, and it's normally breathe because got two little valves on it. So when you breathe out, that air leaves on, then they shut when you breathe back in and you draw back the option from the bag. So basically it's a good way of of This is a lot closer to 100% oxygen. Your breathing in again, you never get to 100%. I think these it's normal, or 75 to 80% oxygen. That's a lot more than the 21% in the room. See breathing in a lot higher quality quantity of oxygen. And these patients who basically need a lot more oxygen to talk about, um, sees people having real problems breathing. Or they could be having problems. Haven't got very good circulation, that blood or, for example, a trauma if it bled a bit. This helps sort of counteract the effects of not having very good blood supply. Um, that one has bypass bypass could be used to improve pressure behind the air on everything pushes air it. It pushes more air every time you breathe in, so you're breathing a normal amount of times just not very deeply again. It's used. Sometimes it's not know incredibly common. Um, there is useful when you do need it. Um, it has a once to worry about. Well, remember would be these four over here. So these are your nasal cannula. Give you a little bit extra oxygen if your breathing for your nose and none if you're not simple facemask give you a bit more oxygen. But it also works for you, great for your mouth and your A mask if you've got. If you try to limit, it will be very specific about how much oxygen patients breathing and the nonrebreather is. Let's get on the whole lot on yet that the ones I really try to take away, and I think that's is so a couple minutes. So everyone's got any questions. Please do us. There's one. That's a you question that's like, um, we have slight recording. Yes, so the recording will be available on this link. The same link used to join will be available as soon as I end this session, or maybe 20 minutes to load something. But I'll also download it and put it on metal. So where you have the feedback link that will be available for that same page If you want slides, he male meat, because the problem is the slides with pictures tend to be quite a large file, so I cannot blow them directly onto mental. But the recording will be on metal. That's probably your best bet after you can pause me on on the recording, you can, like, pause me whenever you want and shut me up. Need me? If you want to. Just look at the slides. Yeah, Thea other is when would use a cynical face mask instead of laundry breather. Okay, love you Masks So simple Face mask versus normally breathe. Something I didn't mention is that you can have too much oxygen, and actually, it's becoming a big part of research in the moment. It's becoming far more known currently is the fact that actually oxygen can be bad for you. So this singled free radicals and I won't go into it's It's complicated, but basically, if you have too much oxygen so above 9900% saturation of oxygen, Austria can become problematic. So if you're having, for example, a heart attack, um, our cardiac function of shorts to be more to do with circulation wrong or go back and watch my cardiac session. I did a while ago the the amount of damage you're getting from it. If you have too much oxygen in the blood, it's worse in the damage. So actually, unless you need lots and lots of oxygen you don't want. Just fill your patient up with it in the sunlight. Like if you're thirsty, you want a bit of water to top up, talk you up, but you don't need all the water you can find, just sort of pushed into you. That's that's sort of variance there. So if you need to give them a bit more oxygen just to bring their saturations up a little bit, so maybe they're breathe. Maybe on room air, that sort of like 88 89% oxygen. You might give them a nasal cannula, and it might bring them up to, like 94 fairly good. If they're sort of 85 86 maybe you might then decide a simple face mask to bring them up into the normal range is. Or as I said, actually, if they breathe through their mouth quite a lot, sometimes we put them on a nasal cannula. It's not doing anything. A simple face masks gonna be pretty good. Just capture at the fact that not breathing for the nose, but then it's when we're talking, you know they've got blood loss. They're quite sick or they're they're really struggling to breathe, and you're really trying to maximize that that quality of their, like, really maximize it because you need to do that's when you work out the non rebreather. Um, it used to be a while back that we'd we talked about using a non rebreathe that all the time, like every trauma patient, was meant to be, given a non degree of the masking and a huge amount of oxygen. 15 liter flow, which is like the maximum you can get from from Russian cylinder. Um, don't you worry about too much about that for the moment, that yes, you're talking lots and lots of oxygen through this. And actually, as time goes on and research catches up to the real world, we're sort of realizing that that's know what every patient needs and in some cases making people sicker example. I gave up super market infarction. Sometimes it can make the damage done to the heart. Worst on the researchers are catching up in the air at the moment, so we don't entirely know what's going on, but but we're getting to the moment now. That's the question, so simply it's do they need a bit of oxygen, a middling amount of oxygen or a lot of oxygen. And should it was aimed to try and just work off of their saturations on just how they look? Try and get the saturation summer between that 94 99 mark. Because if you're giving them oxygen, they are 100. You have no idea what they might be acts. They go well beyond the 100% saturation. The machines won't tell you what there at that makes sense. Um, with another over complicated. Not that simply little bit middle bit. A lot of it on. Tailor it to what your patient actually needs. Next one is a ham to choose different type of cute. You know, I'm going to guess that's going back to the airways one rather than the tubing for the oxygen. These ones over here, Um, basically, partly it's how unresponsive they are, and then how sick now. So if they are completely out like you've given them drugs to make thumb comatose effectively go for one of these normally, because once this is in, it's fairly secure. You could put them on the machines to breathe for them. If you need to All this stuff. Um, and it's very definitive. You know what's going on. And then if it gets knocked, the machine starts screaming and it tells you that it's not in place, and you can you can correct it, these ones slightly less effective. Same with one of here. Slight, less effective again. They're pretty good. And you could put them in for a very sick patient, Very responsive patient. But you do have some honest, um of it more directly. And if they're if you're gonna be taking over control their breathing altogether with ventilator, you want the T tube if you're gonna do it a little bit manually, like in the most situation working and I gel in is brilliant, and you could do some manual ventilation. So it's a cardiac arrest, Um, or first of a a short of surgical procedure, for example, with that unresponsive. But you're not taking over control of their breathing. These are pretty good. Um, but then it's It's then down that, you know, were you taking another control of their breathing, their breathing for themselves. I just need a bit of support to keep the airway patent. You can move on to the O. P Airways. There are so much easier to fit, like you can just throw one of them down. Normally, they're really, really used to get in. But then, actually, they're not fully unresponsive. So they're sort of a bit floppy, their their grunting, this little responsive. You give them a pinch rather than they're not awake and talking to you. But they're not fully out on NPR Way is quite good way of just giving you a little extra support. Imagine every day that that fully answer. Is it that effective? It is sort of looking at your patient of figuring out how severe are they? How much controlled or actually need to take over with these? On this off. All the way is the tube on a little bit is the MPI and there's a tailoring in between. Yeah, the next one is How would you decide to Lincoln? Size of thing traffic. I do know I do someone know the answer, but it gets more complicated. Well, yeah, so they're measured based on internal damage. So, like a size seven is seven millimeters in diameter in there. Also, they can either come like cuff tore uncuffed. That's what they have. Like the bloating thing you can inflate bottom on. So most generally feel like a That's a loon cuff bit here, and you inflate it by this up here, which has a little tube running down it into here. So generally for mail, you go for an 8 15 acre seven. Obviously, if you have a larger female or a smaller mail, you can adjust appropriately. You should go one size smaller. If it's a cuffed, seem like go for like a certain a half in eight, that kind of thing in a average size. I don't in kids used the equation aged amount of my four on for uncuff chips and then you take off a half size cuffed. So that's why you got like a four year old cast for the bottle before is one plus four. It's five. Um, Zetia is a 501 unconscious or 4.5 left Secrecy. Why? I didn't know this entirely. I knew that the how the gauging worked on. Generally I go on the idea of when I've been in hospital, put in the patient, whatever the ODP gives me which is a fairly medical student approach. After maids, I used the kids that someone told me to put in, but yeah, it gets more complicated generally if it fits it. Since I don't if that's the most scientific way of doing it, but yeah, Thank you. When? When could consider surgical away. Basically, we need an airway. We need it now or we can't get one down there. Mouth is pretty much it. So Burns epical tightest. Some of the severe, like upper airway drama. And you go, Well, I'm not getting a tube down this and we need something now and then you'd go for the surgical? Yeah, One is. That's the emergency surgical. At least there are sort of if they have things like throat cancer, you can start thinking like will will be more routine about this More methodical about this. We might put a surgical alien because in a couple of weeks time, this cancer might get big enough to close off the airway. Or we need to take a bit the airway out because there's tumors on it, this sort of thing. And you might go for surgical airway in a more routine sent before emergency. One of you, it's we need airway. We need it now. We're not getting it down the throat. You can also have them in writing you a lot less emergency. So if you got a patient who was on and et tube, but you want to sort of take the investigation a little bit and start to start weaning them off it, but they still need a ventilator. Support you comes haven't et tube down someone throat and be awake because they will not tolerate like they will pull. They will fight. It's not doable. However. You can have a tracheostomy on be on a ventilator and be awake on most patients whatsoever. So often they use it's off. Wean patients down from, um, E T chips. There is sometimes patients don't. If you're leaving et tube in a very long time, it can cause problems, so sometimes you might just want to go. We're not weaning them off it, but we don't want to keep this trip. Word is, for the time being, um, I could see some questions now. Does using an O, P or NP prevent vomiting into the airway? Know, simply put. So you have to be very aware of it. Similarly, the cuffed things like the eye gel on the masked one over here they don't either, because they sit above the epiglottis so you can still vomit up and inhale it as well. But normally they very nicely have a little a little hole through them down to here where you could insert a suction. Well, here, this one is a drain tube. They don't all come with that. This one doesn't seem, but most that will have a small tube of it like this that you could then insert suction down. So construction vomit or secretions out if needed. Whereas thie et tube does go down just into the airway and you cut it, so then they can't. Basically, vomit won't pass the cuff down into the airway. But you still would have to suction vomiting if they if they were to vomit. Does that make sense? Um, how would you choose sides or fragile airway without being face to face is quite hard to probably explain. But you go on a protocol of what's called hard to heart, which is basically the tip of the teeth, the incisors to the angle of the mandible, which is the sort of the prominence of the jaw bone on. Basically, that distance is the length of the tube of the opiate go for for NPR way go soft, soft Which of the tip of the nose to the tip of the ear lobe? Uh, and again it's that length. Um, probably not being face to face and can't read like, show you what you show you on our way and go Here you go, uh, curved and uncurved to being cuffed and uncuffed with the and that's basically like wherever it's got that cuff that will seal over the airway all together so that nothing else could get you know, nothing else. Come out that gives you the bill to some. Yeah, it's a bit more control of what's in their airways. They can't like vomit and then inhale it. Ulcer creations This or this because you get more control, goes down their airway and what comes out their airway. Um, how do you know how much oxygen you need to deliver to a patient? That wasn't a thing called Titration? I think probably most people have done chemistry and do you see Well, no, this will know. Basically have filtration. Sort of. What? Titration is basically working out how much you put in to get how much you get out. Um, so if he is a saturation probe and it tells you oxygen between give you percentage of oxygen, you won't like to be between 94 about 99. Maybe come down a bit in 97. I wouldn't want to go quite a side. There's no night just because Bit funny about overdosing patients. But you're nice 40 97 kind of thing. And I put him on oxygen. If they're really low, I'll start with, like, a nonrebreather go for the Big Mosque. If they're a little bit lower. Might start with the NPR way than than the nasal cannula. And what what way up? Um, basically put it on, which is when you go for, put the option on to whatever level it is. And if I put them on too much oxygen and I'm getting 100 I might then just turn down. The flow on the mountain is under on the supply from the wall. Um, generally your supplies between one and 15 liters, zero and 15 liters. Um, just accommodate. If it's 100% on the SATs probe and I'm on 15 liters, turn it down to 10. See what happens is now 90%. Turn up a little bit to the 12 and find that middle ground. If I've put them on a high, normal breathing mask and I'm a 10 liters, which is the least you could put through a non degree of the mosque and they're still saturating too high, swap down to a simple facemask. See what happens if I'm on a super face mask and I'm on the maximum amount for which we couldn't agree. It's like six or eight liters. A horrible, the manufacturer says probably eight, because then it's a jump between eight and 10 from the normal anyway, and then not saturating high enough. I can't get them above 94% saturations on the maximum flow through that mask. Swap it up. So it's a gang was sort of figuring out with your patient what's going on? Um, yeah, on the a bit, then it is part of the experience. You look at the patient, they look really sick. He might go straight for the big for the normally read the mask. They look fine. You might go from face mask. Yeah. Uh huh. Yeah. What is that? It's just give him love working down. If they're not very sick, give them a little bit and work your way up. Yeah, uh, when it started ET tube, Does they need sedation? If so, what is the recommend? I'll Blimey. Now we get to a full anesthesia talk. Let's go. The last one. There's another question. We're finished with these two, but I'll go into that would last. How do you relate a patient with permanent Truckee ostomy. Simply put, they basically you cover the drug cost me Really? If it's one of the ones that's in place without any, Uh, no one you've made there and then it's when they've had beforehand, either. If they've got a patient airway above it and the tracheostomy is for certain reason, you can cover the tracheostomy and then use the normal mouth and nose. If that's not the case, then you ignore the mouth and nose because they're not breathing for anyway. And you should have very little air entry past that on you. Just use the tracheostomy as though you though it was a a mouth effectively, so you can cover it with tube. Obviously, you can't necessarily use the same troops you do see you have to go straight First off the ET tube style thing or a specialist to be used for truck your tracheostomy because they're just a bit shorter. Pop that in or you can just cover it with the bag of mask. Actually, if you hold it well enough, the big mouthpiece probably would cover the neck. There are smaller size things, like a pediatric mask, that you might get over it to be able to just get better seal and you breathe through it as you were the mouth. Um, yeah, it gets more complicated if there's problems with his gun. Keeps inflamed if it's like collapsed, because sometimes that can collapse. But we won't go into that because long complication. To be honest, I'm not 100% sure on what I do with, um, it's sort of as you find it. You look at it to see what's going on at that moment time and you manage it to the best of the ability you have with equipment available at the time and call for help nine or nine ambulance or in a hospital call for an East test or a CT or any anti doctor to come in on day. Sort it out for you. That's the best thing, really, That one, Um, and then inciting et tube to the knee Sedation, yes or no? So if they're fully floppy, unresponsive like they're in a cardiac arrest there, unconscious whatever know, Because what's it gonna do? You know that already out for the count if they've got a bit of muscle tone or they aren't fully unconscious. Yes, you do need sedation on it. It works on a cocktail effectively. So it's it's You need drugs that make them unconscious so you could do things like propofol, uh, ketamine in If you get a really dirty with that, you can use things like fentanyl on morphine, even because if you use a lot of them, they'll they'll put them out. But normally it's fairly standard drugs, but things like propofol or kept him in or in Children you need things like volatile gases, things like it's a full reign if you want to really old fashioned, really dirty with you things like for a form or ether Ether? Um, that realistic. It depends on the patient. Depends what you are. Depends on what you like to use. If you're on any PSA test, you probably you come up with your normal sort of you over a period time workout cocktail you like to go for in that particular patient type Children you tend to use. The gas is a bit more than you with the IV drugs, but you work out your comfortable cocktail. Propofol is a brilliant truck. Normally, that's fairly standard. One is propofol Kettunen sometimes, yeah, on Then afterwards, if they still got muscle tone, you need to use, uh, something to paralyze. And they see a paralytic which fairly common, it stings like rock uranium Suxenda phony. Um, which both karar ease Caries so far since last May, A grass from South Asia. That's what they used in. Like blow doubts South America. Story used in blow doubts. When if you ever watch a film like Indiana Jones and they you blow dust to put people to sleep, kill people, that's what it is. It's It's a must severe muscle relaxing that basically paralyzes the diaphragm. They they stop using their lungs. They stopped using the tone in the neck, and that makes it much easier to get chewed them. That's a really long answer for the question. Simple answer. Sedate them if they need sedating. If they don't sedating, you don't have to. We're going to use whatever drugs are comfortable with. But that is very Doctory very advanced. Nurses and certain paramedics, little paramedics could even intubate. So there's only certain groups of people. Yeah, basically, use whatever you are allowed to use Whatever you are comfortable using, um, what, you're allowed to remember that one importantly, don't do it if you know, allowed. Don't know if you're not comfortable doing it because things go very wrong. Um, when I was in a romantic, difficult and how blind there are quite a few questions on here, the three that are now currently asked, These will be my last ones and I'll finish it there because we're gonna be going on forever. So I'll ask these last three questions and then we'll call it a day. Thank you. Everyone who's attended. I know some people are dropping out now because they were getting Yeah, until the end. Thank you for those who have shown up and coming along tonight and see you guys in two weeks for just a session on circulation. Since this one's excited. I am. And I gel element and I gel. When are contra indications off? Or a pharynx Airway or pharynx? Airway? You mean or a fur angel's said the opiate one basically wouldn't use it. If you have a basis girl fracture or they're not going to tolerate it like they're awake. Well, then just know they're gonna start gagging on it. Um, that's that one element of this eye gel is a professional judgment, really, Some extent, but basically they're they're pretty responsive, pretty floppy. But you're not gonna get a full ET pretty poor answer, but also the same time. I'm very conscious of time here, basically progression judgment more than anything else. When to consider a remodel. It's difficult house tackle. It basically are you able to maintain our they maintaining their airway themselves, know, probably good to go somewhere Weight management, Whether it's your just holding the airway and just letting the brief themselves is one thing. If they need adjuncts, use and There's a There's a world all these ones available just to judge which one you're after. Which one do you do? First station or paralytic? Oh, sedation. You do not want to be away from paralyzed. That sounds scary. Is anything on? Diovan is also this this problem of there have been patients who are paralyzed but not fully sedated. And they're like, remember bits of surgery. You don't want that game that sedate them, make the properly asleep, then normally you you oxygenate them is what you do is call pre oxygenation. So you get lots of action in them through bagging and just holding the airway open, and then you go for the paralysis and then you interviewed them. Um, yeah, do not start doing it that way around because that's just not gonna be fun for the poor patient. If you get it wrong. Um, I hope that answers all the questions. We got quite a few towards the end. There, actually quite interesting. Wants to thank you for nice. Tough questions hopefully are sufficient in answering them between myself or Josh Finishers. Thank you. Thank you for attending tonight. Thank you. Just becoming Let's help. Moderate Sorry, I'm not Saudia That said she was unwell. So we should be able to attend, not able to do the session. Hopefully it's an all right session. Something that I had to put a little bit last minute. Thank you for attending on. See you in two weeks. Good night.