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Hi guys thanks for joining, I'm just gonna wait for a few more people to join before we start, that's okay, can you just let me know. If you can hear me on the chat great, thanks and you able to see my screen as well. Obviously, I will change to the power point in a minute. Great, Thank you just wait a couple more minutes and then we'll make a stop all right. We'll make a start now um okay, so so, I'm not sure how many of you have attended the other 80 s p sessions, but my name's paddy I'm an f two and I work at um Wigan Infirmary and this is the third a tSP session with chronic and we're going to focus on more e. N. T. Related airway problems um airway problems can can really cause people problems, and they tend to worry quite a lot. Um So hopefully, after this session, um we'll help you guys feel a little more comfortable at managing uh. Um If you're not able to hear me at any point let me know, um there will be a feedback form at the end, so you'll get a certificate. If you, if you feel if you feel that in for me and it's much appreciated uh and there will be polls throughout, so um I'm going to try and make it as interactive as possible okay, So the objectives of the session are essentially to develop a logical standardized approach to assessing and managing airway problems um to understand the main differentials for stride or slash airway obstruction in the acute setting, and to become more familiar with the first line investigations and management in common scenarios as an f one f two. I did forget to ask are you f one's of twos medical students, I just want to know who who I'm pitching it are, so I'm not pitching it too far up for you, you just put it in the chap, okay third year medical student. Thank you for joining. I'm assuming we've had we have a mix of people because we've had a mix of people in the past um but okay another year, three students great um and to become more comfortable with s. Bar and escalating patient's appropriately knowing who to escalate to and at what point to escalate. Um If you're worried about patient okay, so strider is a very common presenting complaint. When it comes to early problems, so um taking a really good history um is very important so we're gonna start off the session by doing what we usually do and looking into what's important in the history so um I would take when you take the socrates approach to pain. You can't have stridor associated with pain, so is there any pain anywhere um was the stridor of acute or gradual onset how long has it been there four and has it gotten worse um anything that does make it better or worse. Um So there's a large number of associated symptoms when it comes to stride, or, but the most important ones uh short of breath with it is there a cough. Um is a starter, which is different to stridor and we'll cover that soon um is there any tongue lip next swelling more sort of angioedema. Kind of symptoms is there a rash, is there a fever. Do they have difficulty swallowing, is a painful swallowing, is there any like hoarseness of voice, which is dysphonia are they drooling, saliva because of the obstruction. Um do they have any weight loss um more sort of red flag chronic symptoms, um and then the past medical history they've got any known sort of swallowing difficulties like strictures found your pouches, malignancies, other things like do they have recurrent consul. Itis, um that the past medical history is fairly extensive, but these are sort of common things you're encounter and they had any trauma to the airway or the neck. They swallowed something um chicken pieces are quite common or meat pieces tend to get stuck in the throat quite commonly um so that's something or is it like a deliberate foreign body ingestion, um and then the surgical history of the heart of previous tonsillectomy, any recent dental procedures. Um Allergies or see if they allergic to anything um do they have asthma, do their prime itis, um that they had previous anaphylaxis before to anything very important to know um And then in the social history, very commonly what you'd ask alcohol is making history, occupation any recent travel, catching any interesting infections and then family history um mainly in this case, it's malignancies, um So just doing a really quick recap of airway anatomy just um just so it's easier for them when you look at the cases and things, so obviously this is this is your air at the anatomy of your airway. You've got the, your nasal cavities right at the top um working like your nasal me, notices and then your nasal pharynx working your way down to your oropharynx and letting go pharynx and then um you've got your esophagus um more posterior to your larynx, um and you got your turkey and volunteer really um and then you've got various structures um extending from your larynx like the epiglottis, glottic. This you've got your verbal cords and then you've got your thyroid glands right at the front, um and then if you look from the top, this is is what it looks like, so you've got your vehicle cords um which sort of almost sort of the gateway to your your larynx and trickier to your airways through that opening and the left image is, was like when your vehicle cords are open and this is what it's like when they're closed. Um So, what's the difference between stridor and starter um People get confused between the two and they're very two very different things, and it's I think it's important to understand the difference between the two because they're indicating two different issues altogether, so, um the definition of stridor is noisy breathing due to partial airway obstruction at the level of the larynx or trachea, whereas start is noisy breathing do the partial obstruction created at the back of the nasal pharynx or firing, so it's not quite as far down as as what you would get with stride all and the level of stride or is the super glottis. Clot is the blood is tricky as all of those areas, whereas starter is just the nasal pharynx and all referring so higher up and you get stride or in both the inspiratory and Xperia torrey phase of breathing, whereas status just an inspiratory noise because it's just at the back of the throat, essentially or the nose and striders more of a high pitch sound or a start of tends to be a more low pitched sound so how do you sort of approach it. Um At this point, I usually I usually do different systems, but this is all the airway, so I've sort of categorized into infected and non infective symptoms um or non infective conditions. Even um so in me and eight you don't have any sort of predominating um major infective causes, but you've got more non infective causes for laryngo malaysia, which is sort of the weakening of the larynx and the muscles surrounding the larynx um which sort of progressively strengthens as you become a child and an adult, so that's more common subglottic stenosis is more common in the in eights um In children, you've got infective causes such as group, which is very commonly caused by power influenza. You got epiglottitis, which used to be um more commonly caused by haemophilus influenza B, but since they've been vaccinating, it's it's less um it's less common, but it's still quite common in children. In particular, you've got peritonsillar abscess is deep. Next space infections such as para, fragile and retropharyngeal abscess is um you've got submandibular abscesses, which is also called Ludwig's angina um and bacterial tracheitis and then the non infective cause of uh stridor and children includes foreign body inhalations, very very, very common one, especially in sort of the 2 to 3 year old range. You get a lot of children just putting ramen, things that they don't know in their mouths um anaphylaxis as they start eating new things and not know what they're allergic to quite yet uh and then burns also, um and then in the adult, you've got infected and non infective causes, the infective, got super glue, otitis, epiglottitis, bacterial tracheitis, deep backspace infections, and then you've got a much longer list been on infective causes and adults, so tumor's are a big one and very big red flag um trauma. If someone's been intubated, then post ex excavation it's not uncommon to develop dried or um any blood for penetrating trauma, burn injuries um anaphylaxis, um angioedema, gord, psychogenic, and then you've got vocal cord issues as well, which is less common, but also can give you some form of stride or that comes and goes and then how do you investigate it well. It really really depends on the situation you're in and the age group and whether you're suspecting an infective or non infective cause, but as a standard, I think you'd you'd approach it with your bedside bloods and imaging. So in terms of bedside, obviously, you do your normal observations and then bloods I can think of all of these that I've listed um. Obviously, if you're suspecting more of an infective cause, then you do glandular fever screen and sort f. B, c, crps and sloots, but if you think they're good, it's something that would need urgent surgery then you do group and saves and cross match is if it's not noneffective, then you may want to leave out the glandular fever screen. It's all it all really depends on the clinical context and then imaging kind of ranges from a lateral neck x ray, chest x ray. If you're suspecting other breathing problems, an ultrasound neck um especially in children, when you don't really want to expose and expose them to radiation just up front, so a lot of the time you do an ultrasound and then if you're suspicious of something, then you'll do a ct neck but sometimes in adults. If it's more urgent, then we'll just get a ct neck mhm, so how do you actually assess their way compromise, so I usually do this a little bit differently. Um um I go through each section briefly, but I think airways a really important one, so I'm going to go through in a bit more detail uh. So obviously you do everything from with the 80 approach, and when you're looking at airway in particular, there's three things that you want to do is inspect, palpate and try and move the neck so when you inspect someone with the potential airway compromise, then you may see signs of cyanosis, which indicates significant airway compromise at that point, they could be tripoding. I'm not sure if your sin copd, patient's before, but they some some of the really severe copd, can adapt the tribe proposition, which basically shows there in a lot of respiratory distress, so you can see the same an airway compromise as well, so is there any undue dema, um that you can visibly see um because that could indicate anaphylaxis how they drooling saliva. Um If they're not able to swallow their into live, and then there's a good indication that that there is something um impact in the airway. Can you see any visible next swelling. Um If you inspect the floor of the mouth or the tongue, if there's any swelling or elevation um at the floor of the mouth, then that's highly suggestive of ludwig's angina, which is the submandibular infection, especially um mainly mainly after dental procedures that's a big risk factor for it um. And then obviously you palpate there's any pain or palpitation, are there any sort of cervical lymphadenopathy, any palpable sort of masses you can feel in the neck that you you're able to visualize or they're just small lymph nodes and non painful or painful hey, and and obviously you want to try and move the neck restricted that movement some more sort of concerning, so if someone can move the neck um Then that that's definitely more concerning because it means it's invading more spaces. Is the only trismus, so trismus is when they can't open the jaw very wide because because it causes pain. Um This happens a lot in quincy ease um or deep next base infections um yeah, so another one in inspection is uh torticollis um in children, so when when inflammation or abscesses invade the sternocleidomastoid muscle then um sometimes it can cause just deflection of the neck called torticollis and it's like in response to pain, So I think that brings us to our first question on the polls. If you can kindly respond to it, so one minute let me just bring that up, so what instrument is used to visualize the vocal cords by the ent team. When suspecting airway obstruction. Okay. I've got three responses, anyone else want to give it a go okay um So the answer as much as laryngoscope is like very tempting and because it's got the word larynx center uh it would it would probably be the obvious answer, however, the answer is um an f. Any, which is a flexible nasal windows group. So actually it's um yeah it's basically a very small scoop that the anti team put through the nose um it kind of hovers to just visualize above the vocal cords to see if there's any obstruction, um whereas a laryngoscope is usually more commonly used by anesthetics um in order to intubate patient's so if you, if you ever have any n. T. Placement, then I'd highly recommend shadowing the ent team uh When they go and scope patient's because quite interesting and you can like see the airway and stuff. So the next part is breathing. So obviously, when you're assessing breathing and someone with airway obstruction, it's very important to look at the respiratory rate because it's a good indication of how hard they're working um the oxygen saturations, the respiratory effort they're using their accessory muscles. Um. If there's a trivial tug, especially in sort of children, these things trickle turks have costal intercostal recessions is a very giving sign that um there's a very high Xperia torrey effort and then your auscultate is there a wheeze that may be reduced air entry, um and then circulation all the, all, all of the a. T. E. Is sort of with respect to airway problems. I'm going to focus more on that and what you may see in. They do an assessment with airway issues, so in circulation, the pulse is important are they tachycardic due to the increased respiratory effort, hypoxia, anxiety have they already had some mobilized adrenaline that can further excessive a, the tachycardia. Um The BP is very important is there any hypertension. It could suggest assess systemic visa debilitation um can happen due to sepsis, anaphylaxis, and then disability and exposure um so in disability, how conscious are they that they got a reduced consciousness secondary to the hypoxia or hypercapnia while they're scoring on the g. C. S. Or after food scale and an experience. Obviously, it's just a topical examining top to toe examination. So are there any signs of anaphylaxis. Is there a rash, so you strip them off completely look at look at them. Head to toe. Do you find any rashes, is there any swelling anywhere, um identify any potential allergens around them or on them like any like pollin, has anything what's the temperature there pyrexia, well suspecting the more infective cause. So in terms of the initial management of the airway obstruction, um it really depends what you're suspecting and how unwell the patient is so based off the a. T. E, um but immediate things you can do um If you can see that someone struggling to breathe and you think that you can help them are interventions such like a head tilt chin lift um inspect the airway for any obvious instruction. If you think it's within reach, then you can attempt to finger sweep If you see anything obvious, but you don't for whatever reason use your finger and try to get something out and actually push things any further down because that would just make it worse, and then you can also attempt to suction if you've got a suction nearby. Um When you're suspecting spinal involvement indicate in insignificant trauma, then ahead, tulchin lived is less um appropriate and you do a jaw thrust um and then in unconscious patient's you consider putting an or referential airway in um I'm not sure if any of you have seen these um but if if you have any practical sessions and it's it's definitely useful just knowing what they look like and how to put them in because they're very easy to put in and a nasopharyngeal airway um obviously goes through your nose and it's more and more used in a patient's who are still conscious and that would tolerate it. Um conscious patient's wouldn't tolerate in or a frontal airway, so trick you'll intubation is something that would happen if everything else fails and you think that if there's an impending respiratory arrest going to happen because then they're not breathing for themselves um and you put out a crash call hopefully, as soon as you identified as someone who's got an airway problem or any anyone who well you're going to put it put out a crash call and on that crash call, there will be um uh anesthetics team or ICU team someone qualified and managing airways, but these are just things you can do in the meantime because if someone's gone into respiratory arrest and you don't manage to find a definitive airway, then they're most likely going to try and intubate them, um but you can start initiating breaths via via the back valve mask so how do you manage stride. Or so again, it really really depends on the initial presentation and what you're suspecting, however, there is sort of a generic thing that any does um which does help um just until e ent, usually comes and scopes them to figure out if there's any sort of obstruction above the vocal cords or what exactly is causing the obstruction, so immediate measures obviously call for help is very important make the patient sit upright, give them high flow oxygen um monitor their observations throughout this whole process. Because if there's an immediate drop in saturations or increase in respiratory rate, they become really tachycardic and hypertensive, then obviously that patient is then unstable. Um have a crush trolley near you because it has all the airway devices um and if someone was to go into respiratory or cardiac arrest, then you need that there um secure access, So IV cannula is very important to give drugs at this point and take bloods giving drugs um So I don't fully understand why this is given, but a lot of papers have suggested, but it's very beneficial and using adrenaline this dreidel um and it's commonly used in a and e a lot of the time so nebulized adrenaline um one in 1000 so you can use between 1 to 5 mg um driven by oxygen and you can reassess and, and sort of prescribe more according to the response to achieve and if there's any um sort of improvement in the observations, high dose steroids um so we usually tend to give this in sort of infective causes because it reduces inflammation quite quickly, um But if you don't know what the cause is, then it's worth just giving a start dose of iv dexamethasone. In some trust, they give a combination of helium and oxygen and I've been told that it can it sort of brings down the respiratory rate, but I have not, I've not seen it personally used in the hospitals yet. And then procedures you can do obviously under trick you'll intubation if that's not possible and there is that much swelling or the airway is completely closed off and you can't even um intubate the airway, then the only thing that's possible in that case is front of neck airway, which basically means you open it open up the airway, and you have to you have to um use a back valve via that to um to give the patient breaths and allow them to breathe, so the open scalpel boogie, cricothyroidotomy or a needle cricothyroidotomy. Um So I do have some cases, which I think is the best way to kind of learn um more and make it a little bit more interactive and exciting, So there's just four cases, I think and then I've got some bits on tracheostomy and laryngectomy is and things like that because I don't think people are very familiar with those so if people can just open the poles up and I'll do this first case, so, so you've got an 18 year old male with a one week history of sore throat, not able to eat and drink for two days. Associated symptoms um include pyrexia and lethargy. And then on examination, got bilateral edematous executive tonsils, bilateral, large sample inthe nodes, and you've got a fever pain score of five. I say the first question is actually very straightforward if you could answer. Please okay. Interestingly, people of sub center so Central used to be the gold standard, however, for the last few years, it's either pain and basically it's just how how likely is this to be a bacterial versus viral tonsillitis and hence um it gives you sort of good direction on whether to prescribe antibiotics or not, all give delayed antibiotics um for trans litis um but having said that what is the most likely diagnosis for this case given the history and the examination, you could answer the poll. Again, I've put another one up right okay, so the answer to this question is actually glandered a fever um just because it's it's it's it's difficult to know, but given the one week history, 18 year old male, it's quite an appropriate age for glandular fever in general, and I think the real giveaway is bilateral large cervical lymph nodes in glandular fever. You get really really large lymph nodes, you can entrance litis as well, but given the history and the age and the lymph nodes in particular, is suggestive of glandular fever, but you're right it could it could be tonsilitis. It's less likely to be a para fragile abscess just because it's just sore throat, just pyrexia and lethargy. There's no other sort of associated symptoms. You'd expect someone with a para, fanjul abscess to be much more sort of unwell um There may be sort of restriction in that movement. I haven't really put a detailed examination town, but we'll come onto talking about that soon, so how do you manage quantum a fever, so it's very similar to tonsilitis, but you absolutely should not give them oxacillin because it can cause a type of three sensitivity reaction um in the form of a rush, If you do give them amoxicillin, two people with glandular fever. So in terms of IV antibiotics, you just you can if the fever, if the fever pain score is high, then you can treat it like trans litis um and give finn oxymetholone penicillin. Um If they have really large tonsils, they're really struggling to swallow than in hospital and they're not eating and drinking. We give some iV decks an episode just to bring down the swelling, we give really really good analgesia. The one reason I find that people stay in hospital because of tonsilitis is because they have not been given enough analgesia oh so they can swallow and eat and drink and that's the only reason they're there, so I tend to give paracetamol. If that doesn't work, then you give some cocoa dumb, all that doesn't work, then you escalate up to codeine. You give the dexamethasone, you give some diff lamb spray, which really numbs the throat once they're eating and drinking and that's a good sign to send someone home um But once you once you've prescribed everything and they've had everything. People usually do start eating and drinking quite quickly and obviously if they're dehydrated, then you give some iV fluids as well, but the most important thing is analgesia and encourage them to eat and drink themselves um So the second case we've got is a two year old female for the five day history of a sore throat and today unable to eat and drink, so associated symptoms got dysphonia, pyrexia, generally unwell and irritable. On examination, the signs of enlarged tonsils and large cervical influence, starter and torticollis, and obviously the child's quite generally and well and quite irritable, are not able to eat and drink, so there are two questions here the case to let me just start this poll, so what is the most likely diagnosis for this for this child okay, so we've got six responses and the majority think quincy, so the answer to this question is actually a deep next space infection. Obviously, it's very difficult to exactly know based off just me describing the examination, but deep next space infections are basically para frenzel or retro frenzel abscesses. It can occur as a complication of a sore throat just like quincy is, which are perry tonsil er abscesses, but quincy, Czar less common, and that I age group and deep next base infections are more common and very young children. In terms of epidemiology, um and the giveaway really is the just being really generally unwell and irritable, the starter, and the torticollis. The torticollis is is a big indication for um extension of a deep next face infection so invading into the sort of sternocleidomastoid and, and that neck flexion in response to pain, so in my opinion if there's anything to take away, her child was torticollis shouldn't be ignored because it can. It definitely represents something more and in terms of what would be the first line investigation for this child, if you can fill in the pool for me, okay. Yeah, that's great guys, um I would definitely see an older sound neck, it's a two year old, you don't want to really expose them to radiation and necessarily you could you this some would argue that you could potentially just treat it with antibiotics and no imaging required at this point, but you're suspecting a really unwell child that's not able to eat and drink, children can really go off quite quickly and become very unwell quite quickly, So you want to do something about it and see if see if there's a collection there. Sometimes if an ultrasound neck is um not not adequate and you're not able to, it's not very conclusive, then you can always consider a ct back after that. However, if there is a collection then um and then you can always do a ct neck after or you can at least sort of assess whether surgical intervention is needed or not. But I think in children, especially up systems are very good, so in this image I'm not sure how many ct scans you've done you've seen before, but the black bit is basically air in the airway and here you have a retropharyngeal absence just compressing that airway. Um You're not expected to know this by the way it's all sort of very specifically anti stuff, but things that can cause airway compromise, so how would you manage it, IV antibiotics, iV fluids, algesia um I think in wigan, we sometimes do ben, pen and metro, um but IV fluids is important. IV analgesia. IV analgesia. IV antibiotics um depends on the size of the collection, um It may need surgical drainage, which will be done by the n. T. T. And does anyone know what complications. You should be aware of impatience with um deep next space infections, specifically retro financial abscesses. I'm just gonna stop pulling this one um yeah, yeah okay, this is this is a bit of a tricky one. It's not very common knowledge but well done it is it is media stein artist, so essentially the retropharyngeal space is continuous with a fascial plane that extends deep into your mediastinum, so when you have an abscess, which extends it can cause mediastinal notice and it can cause significant surgical and eczema that you can feel in the patient's neck um and just but of course it can also cause sepsis, um But mediastinum untis is uh is a really really important complication to be a while. That these questions because they can they can die very quickly from that okay. So case three we've got 56 year old female with a sudden onset swelling of tongue and neck, struggling to breathe following application of nous ept um cream, which is given for Qwest axis. Um She's got a past medical history of a hematology. On examination, it's got a rush over her trunk significant swelling and tongue swelling. She's hypertensive and tuckey kartik, and her oxygen starts at 72%. What is the diagnosis just started a poll. This one should be quite straightforward, yeah almost immediate yep, It's anaphylaxis and what is the first step in the management of anaphylaxis. Uh Yeah, yeah okay a little bit the split here, but it is 0.5 mg of one in 1000 adrenaline is the correct answer, So it's very different to the dose you give in cardiac arrests um so just something to, to remember for finals and things like that okay, So this is just the pathway for from the recess guidelines that I've picked up um which I think is the best the best resource you can use for anaphylaxis or um cardiac arrest or anything in the acute setting. So um obviously you look at going to look for airway and breathing you ssat like we like we went through before call. The recess team plateau practical, remove any triggers. If there's any infusions running, if it's drug related. If you think it's drug related uh lie, the patient flat with your legs elevated, you can make them um sit up if it makes it any easier to breathe and if it's a pregnant patient then lie, lie them on the side. So you give that I am adrenaline because you've suspected anaphylaxis, So it's very important you give it as soon as possible. Um The most common site um they use is the antral lateral aspect of the mid third of the thigh because it's quite chunky, you establish an airway. If there's impending airway obstruction, so an n. P. A, if they're conscious and or a fragile airway. If they're unconscious, give high flow oxygen to keep their sets up apply the monitoring. If there's no response to that, I am adrenaline repeat after five minutes, give give IV fluid bonus to keep the BP appropriately maintained. If there's no improvement in the breathing of the circulation problems despite the two doses. If I am adrenaline then make sure the research team is there because then you have to follow another algorithm for the refractory anaphylaxis. I've not mentioned that here, however, it involves giving an adrenaline infusion under the specific things you need to do at different times, but I haven't mentioned that here, so so in different age groups, it's very different so in an adult and child over 12 years, you're gonna give 500 micrograms or 5000.5 mg of I am a journal in one in 1000 so it's the same concentration just different doses for different age groups, which is given here and then you always give iv fluid challenges to keep the BP up appropriately okay, so this is the last case, so you've got 36 year old male with rapidly worsening dysphasia, norden of asia, associated symptoms, I dysphonia, drooling, pyrexia, kerasal symptoms, pyrexia. Wall On examinations, tachycardic, hypoxic pyrexia well. He's got arithmetic and slightly enlarged tonsils, but not too bad. The EMT team is called to perform an epiphany, so it's the, the scope I was talking about earlier and they've done a lateral neck x ray yes. Sir this is this is what you see based on, based on these images, what is the diagnosis give it a good guess if you can remember the airway anatomy picture, yeah it might give you a good gas okay, well done guys, yeah it's absolutely epiglottitis. I can see why someone thought it's tonsilitis, just because if you were looking straight at the oropharynx, then you could mistake it as your uvula, but this is this is a bioscope, so you sort of hovering above the vocal cords, which you cannot see because the epiglottis is just that big can see all of this is just so inflamed. It's kind of obstructing the airway itself um and then on a lateral neck. Actually you've got this here, so usually it's just a little bit of a slither whereas it looks like a thumb and they call that sign like some like a thumbprint in epiglottitis. This um so yeah that's epiglottitis which we've done and so the management of epic lot itis is broad spectrum and iv antibiotics, high high dose iv steroids, and you sort of taper it off in a few days um As the patient gets better, you give prn adrenaline numbers, if they've got started or um keep them know by mouth because they're likely not to be able to eat anything anyway uh because of the significant swelling, um sometimes we give humidified oxygen as well uh give IV fluids because obviously if they're going to be not my mouth and you repeat the chinese group to monitor and respond accordingly, so as the patient's swimming comes down and the epiglottis becomes more it's normal size, then you can sort of introduce them on liquids in a soft diet, and then once they're happy with sort of that, then you can you can introduce like more of a normal diet and I'll be ready to go home by then OK so just to sort of finish off the session, I like to cover a little bit on tracheostomy ease and laryngectomy knees, and the difference between the two because I did ent as an F one and the two used to kind of convince the concept of the two used to confuse me a little bit and I can appreciate that when you're a third year medical student or even a 50 a medical student, or sometimes even enough, one you've probably not seen seen them. Um It's very difficult to appreciate the difference, so for that reason, you've got your normal neck here um So you've got airflow this way through your nerves and through your mouth um all the way down into your trachea, you got your larynx and epiglottis. This is your tricky and this is your esophagus more posture really in someone with a tracheostomy, it's pretty much the same, however, there's this inlet into the trachea, so tracheostomy patient's have to airways. They've got there original airway here and they've got on our way here as well. Okay. However, in a laryngectomy patient, the entire larynx is removed and basically the airways opened up as a sturmer more anteriorly which you can see here, so laryngectomy patient's only have one airway because all of this is basically dead space. I'm not sure if that makes sense, but if you have any questions, please please let me know in the chat, so that's essentially the difference and I don't want to complicate it by going too far into detail, so one other thing I will mention is that sometimes a laryngectomy patient can have a tube but a lot of the time they don't need it and it it will just be a stoma opening, so that can be a good indication that it's a laryngectomy patient, however, tracheostomy patient's will always have a tube um and there's something called an inner tube that goes inside, which can be removed, but there will be some form of tube all the time. So if there's no tube then then most likely to be a large actively patient. If there's a tube, then they're likely to be a tracheostomy patient okay, so some other cool stuff. Um If someone's had a laryngectomy, then you may see one of these devices, does anyone know what this is is one of my polls. I will be very impressed if you do mhm, okay um so we've got a good mix of answers and most of you are correct. It is a tep, so it's a tracheoesophageal puncture prosthesis. It's essentially a speech valve, so let's go through why it's the prosthesis because essentially this is the laryngectomy patient because you can see the stoma that's opened up, and there's a device that's going more posteriorly and what the structure is more posterior to the trickier is the esophagus, so it's going straight into the esophagus, essentially so it's a trickier esophageal puncture um more commonly called a speed valve, which essentially when is occluded, helps patient's speak through their esophagus, so it's it generates esophageal speech um as the patient's don't have um there larynx anymore to generate that sound um So it's all very cool so um I'm very very briefly touched on what to do in airway um problems in a tracheostomy or laryngectomy patient, they're both very similar now that you know the difference between the two, um but I'm going to go through them very briefly how that this isn't something you really need to know, but I thought I'd cover anyway because we're covering airways and I thought we'd cover different types of airways, so you essentially it's an 80 approach, exactly the same, call, the reasons team see if there are any signs of life. If the patient's breathing then you put them on high flow oxygen. If it's a tracheostomy patient then obviously there's two airways so put it over the tracheostomy under over the face of the patient, remove if there's an inner tube, an inner tube is basically something that comes I/O um just a part of the tracheostomy tube. Sometimes a lot of secretions can sit in the inner tube and block off the airway completely, so sometimes just removing the inner tube from the tracheostomy can really help and that's all you need to do you can suction inside to see if there's any more secretions, um you can look listen, and feel it the mouth and tracheostomy. Um you can use waveform cap pornography, which is something you just attached to see if there's uh what the e. CO2 is. Um If the tracheostomy is patent, then just suction, consider a partial obstruction you ventilate the tracheostomy um If the pay is if the patient's stable or improving, then you continue a TV assessment. If they're not improving, then remove the tracheostomy tube. Obviously, this is going to be done by someone more senior um is more most likely someone from the anesthetics team or ent, team and essentially you keep carrying out your a. To reassessment. You do all the airway maneuvers as you would you can cover the sturmer and you can use a bag valve mask and to once you've covered the sturmer, so you can at least use one of the patient's airways um and use the other airway of drunks and then you can always attempt oral intubation um but obviously that's going to be done by the anesthetics might see your team. It's very very similar in laryngectomy stoma, but obviously the patient has one airway, so everything you do is via the laryngectomy stoma and you can't use you can't you can't use the patient's face cause. It's all that space okay and that's pretty much that does anyone have any questions. If you do, then you can mute yourself or you can put it in the chart. If you don't have any questions, then I'd be very grateful. If you could provide feedback via the feedback form. You will get a certificate for attending as well, um. But if you I don't have any questions but have some questions later, then, please just drop me an email um with a very happy talent or any questions you have, and I can try the presentation with you. If if that's something you think would be useful, yeah, please please do fill out the feedback forms. It's it's very helpful for me to know and organizing recessions and if there's anything you want teaching on that, you think you'd benefit from then put that in the feedback form as well okay, so someone's asked what the indications for laryngectomy instead of a tracheostomy, so it really depends usually laryngectomy, Czar done in people with tumor's um to try and sort of, gives them to try and remove the tumor with more space around it, um so they can have a different chemo radiotherapy uh Okay ostomies are generally done in more emergency situation, say someone's got has an airway obstruction. Um Then a tracheostomy is a very quick urgent procedure that will be done um say someone's got tumor tumor compressing and it needs to be done urgently, then they do a tracheostomy as opposed to allow inject a me, but it really depends on it really depends on the situation, so if someone has got more infective causes and they're at risk of airway obstruction, there's nothing else they can do sometimes instead of doing the front of neck airway. They'll take them to theater as an emergency and do a tracheostomy as just a sort of temporary solution, does that. Answer your question because the laryngectomy is a very permanent solution. Because you're removing the legs great, does anyone have any other questions that's great guys um Thank you very much for attending again, Just please fill the feedback forms. Um It's very useful to me, but other than that, thank you for joining and I should be back within of a TSP session soon hopefully in the new year.