Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Hello, everyone. Thanks for joining. Um We'll start in a few minutes just when there's more people. That's okay. Are you able to see my screen? I know I haven't shared the Point powerpoint yet. So if you can just let me know in the chop, great. Thanks to you. We'll just wait a few more minutes until we have a bit more people. I've just put a feedback form in the chat um um for you guys to fill out before you leave the session. So if you could fill the feedback form after that would be great because it's really useful and I always change my presentations according to the feedback and, and do sessions that you hope to, to, to be put on. So thank you for the feedback you've given in the past. Um So let me just check how many people are on now. Okay. So I think we'll make a start because it's all were already a few minutes head. So, um thanks for joining everyone. Um We, I've done a few of these ask to see the patient sessions before. Um And this session is actually what I've done um just before the holidays, but there wasn't that many people. So I thought I'd repeat it because it's quite an important session in general. And I think it's something that a lot of people are quite scared of and, um, I don't really know how to manage, especially out of hours. So hopefully this helps in some ways. Um, my name's TV, and one of the F two S, uh, Wigan Infirmary and I had an F one job as in, in the ent and I did general surgery is an F two, which also covers ent out of hours and, um, came across a fair few E N T slash airway issues in my time. So I thought I'd just come and share some important ones. So like all the other sessions I've done which fast to see the patient, I've sort of put together a structure how to approach airway problems. So our objectives today will be to develop a logical, standardized approach to a second, managing airway problems, mainly EMT related to understand the main differentials for stride or slash airway obstruction in the acute setting. And to become more familiar with important first line investigations and management, common and common scenarios as the Metformin slash up to and become more comfortable with S bar and escalating patient's appropriately, especially when it comes to managing the airway. So, um, I, I usually ask this, but can you just let me know, um, what kind of level you are at because if there's something that I'm saying that it doesn't make sense at all. At least I know how to sort of tailor my teaching a little bit more. So you medical students, junior doctors. If so what level, you just put it in the chat and I'll have a look. Nope. Okay. All right. I'll make a start then. Um, this session is quite interactive. It's got lots of polls, um, to answer as we do the scenarios and things. So if you gain a lot from it to sort of engage with them, um, so we'll, we'll make a start. Okay. Great. Livia med students and after films, right? So approached, tried or obviously, first of all, you take a history for any patient you see, uh in the acute setting, if there's any pain related to the stride or if it's the onset is quite important. If it's quite acute or gradual, makes a big difference. Um, the dura duration and progressions of it's lasted weeks or just hours, any exacerbating or relieving factors has, has any given the money thing that's actually helped before you've seen them or are you the person in any and then associated symptoms? There's a whole host of them. So, most important ones to be thinking about the shortness of breath, cough, stride or starter tongue, lips, neck swelling, rashes, fevers, dysphasia, odynophagia, dysphonia, drilling saliva and more sort of insidious symptoms like weight loss. Um, the associated symptoms can generally give you an idea of what exactly the obstruction is or if it's an obstructive problem. So, in terms of past medical history, um, do they have any strictures? Do they have found your pouch? Do they have a new malignancy? It's important to know, um, if there's been any recent trauma in more so in younger kids, but if, if they're just turning foreign bodies, um, and it seems to be that a lot of meat and bones, fishbones, that kind of thing in elderly people, um is quite common foreign body in adults that we encounter. Um And then any surgical history, previous tonsillectomy is recent dental procedure is important to know um when it comes to taking a history. Um and then any allergies, do they have a history of anaphylaxis to anything, uh any history of H P? Uh And then I always ask the social history. Uh no, what their comorbidities are any recent travel, family history, any malignancies? Okay. So that's the history. Then you've got the airway anatomy that I'm just going to whiz through quickly. So in terms of airway anatomy, obviously, we've, we stopped with the nasal cavities that lead into the nasopharynx. You've got your opening of the U stationed tube which is in the nasal pharynx and then that leads into the oropharynx. Um You've got your, your tongue and base of your tongue and then you've got your epiglottis more posteriorly, you've got your laryngopharynx behind the epiglottis and then you've got your esophagus and then more anteriorly, you've got your um trickier. So in terms of the view from above, so if you were to look from the top to your vocal cords, this is, this is what they would look like. So you would see your epiglottis, which is this like the sort of structure here. And then you've got your vehicle cords here and then you've got the base of your tongue here. Um And this is what it looks like when your vocal cords are closed. So when, when in certain examinations, which will will touch on later, um we get patient's to say, eee to have a look at their vocal cords and you assess vocal cord movement by looking at the opening and closing of them. So we're just looking at the difference between stridor and stir to because they're two quite different things and people can get quite um mixed up with them. So I just put in a slide that covers both so stride or is essentially you're always breathing due to partial airway obstruction and start is noisy, breathing also due to partial airway obstruction, but they're both at different levels. So the stridor occurs at the level of the larynx or trachea level can also occur on the supraglottic scotus level, Crestor to is further up near the knees of pharynx or oropharynx strider occurs at birth during the inspiratory and Xperia Torrey phase where a starters just purely inspiratory stridor is much more of a higher pitched sound when you breathe rather than starting, which is more low pitched and a storing sound when you breathe. So you will be able to notice the difference and that, that is just basically the difference between the two. So how do you approach stride? All? It can be quite scary, but this is sort of a generalized approach. Um So in terms of differentials, I've classified the mainly into infective and non infective and in different age groups because you get sort of a classic categories of, of conditions more common in the group. So in the neonate, there's no real major causes of infective strider, but the most common cause of non infective stridor is lowering, lowering go Malaysia, which is sort of the, the cartilage is and fully sort of intact and the structure is structurally not great. So it can, it can sort of cause obstruction to your airway and then similarly, trachea, Malaysia and then subglottic stenosis. And then as you move on to Children, you've got common infective causes such as croup and epiglottitis. Um However, croup croup is caused by power influenza and sort of historically, epiglottitis was caused by him. A feel ius influenza B. But I believe that after vaccinating, that's become a little less common now. And then you've got Quinn's ease deep next space infections. So you've got para Frenzel and retropharyngeal abscess is um submandibular, the um swellings which is Ludwig's angina, which can commonly caused by dental procedures and bacterial tracheitis less common than the rest and then non infective. A really, really big one is foreign body inhalation, especially in your toddler's and anaphylaxis also a big one when they're trying different foods and you don't really know what, what allergies they have yet and then burns is another one as well, but less common. And then in terms of infective cause is in the adult. Again, you've got hepatitis, epiglottitis, bacterial tracheitis. Um I've seen more, more commonly epiglottitis and super keratitis this winter. Um And then you've got deep next space infections as well and then the non infective, you've got a whole host of them. There's common, usually tumor's trauma, post excavation, you can have um striders as well. And then you've got a whole host of other, other less common problems that could cause straddle. So how do you, how do you investigate it? So, to start with, it's always good to do bloods, especially to sort of differentiate infected versus non infective along with your history. Um You can do a glandular fever screen which is more sort of um to differentiate if you lie to something else. And then if you think that something is so severe that we'll need to go to surgery, then it's always good to do a group and saving cross match as well. And then in terms of imaging, um it really depends on the clinical situation. But, and what, what kind of obstruction you're expecting if it's infective, non infective, if you're suspecting an abscess versus just a foreign body ingestion. So it's always good to do a lateral neck, X ray. Uh chest X ray can be considered or two sound next ct necks. Again, it just really depends on the clinical scenario. So how long do you assess airway compromise? Like always if you've attended my previous sessions, it is largely been down to any, anything acute comes down to the A TUI um, one second, just looking at my polls. Okay. Um All right. So when you look at your A TUI, obviously, we're looking purely on airway at the moment. So what do you do you inspect first? See if there's any signs of cyanosis, it can indicate indicate a significant airway compromise. The person just looks cyanosed. Um The position of the patient, are they really struggling to breathe? They tripoding? Do they have any obvious angioedema at the sort of side of the bed could indicate anaphylaxis? Are they drooling? Can they not swallow that own spit because of the obstruction? Can you hear a stride or also is, is something that you can observe from the side of the bed if there's any obvious asymmetrical neck swelling, if there's any sort of floor of the mouth slash tongue swelling or elevation. Um And then you palpate there's any pain or palpations. Can you feel any palpable next swellings uh and then movement. Do they have any restricted neck movements? Um Sometimes restricted neck movements can indicate a deep neck space infection. They have any Trismus Trismus, meaning that they're able to open their drawers without pain. Um And this can be indicative of mainly a Quincy. So this is the first question in the pole. Sorry, I think I've just given you answer though. But um can everyone just answer this question? What instrument is used to visualize the vocal cords by the ent team when suspecting airway obstruction, I'll give you another minute, few seconds. Okay. So, um yes, if any is absolutely the right answer. Uh laryngoscope can also be used but not commonly used by the ent team. It's more used sort of by the um anesthetics team. Fo knee is a really good way of assessing for our obstruction more superior early in the airway just above the vocal chords, individualize the vocal cords. It doesn't really look at anything else. Um So a laryngoscope, they used to intubate and things like that. Um Whereas the epiphany goes through the nose just, just like an N G tube generally just looks above the level of the vocal cord, see if there's any obvious obvious swellings or obstruction. So, yeah. So in terms of breathing, obviously, you look at the respiratory rate, oxygen saturations, respiratory effort, they're using any accessory muscles. Um In Children more obviously, trickle tugs of casal initial recessions on auscultation. You may hear a wheeze, um maybe a sign of obstruction due to more distal obstruction to the large. Uh So if someone has anaphylaxis or asthma or things like that, then you may hear an audible lease. Um and there could be a newsom reduced air entry as well. So in terms of circulation, you've got to assess your posts. Obviously, if someone's tachycardic, um they may also have an increased respiratory effort and hypoxia and anxiety. And if they've already had some nebulized adrenaline because of this ride, or then this may just further exacerbate tachycardia. So you may just want to do an E C G to make sure there's nothing, nothing else you're missing. So in terms of BP may become hypertensive because you've got systemic phase of vilification, especially in things like anaphylaxis or other infective causes um like sepsis and then you've got disability and exposure. So, in terms of disability, what is a conscious level like is very important, it could be reduced secondary to hypoxi or hypercapnia, it gives you a good indication of how well this patient is at this point in time and how quickly they could be deteriorating. So you can use the APU and GCS scale to measure that. And then in terms of exposure, um look at any evidence of anaphylactic anaphylaxis such as urticaria, rashes or angioedema, any potential allergens, what their temperature is, are they pyrexia? Well, so obviously, in, in this presentation, we're focusing more on the airway because the airway itself is quite a large topic to color in this session. So I'm not going to go through the A full A two E and every scenario we do, I'm going to mainly cover the cases because the rest of B C D and E are quite similar. So, um, initial management of airway obstruction is quite common for everything to be honest. So, immediate interventions, if you think someone's got acute airway obstruction is a head tilt chin lift. Um inspect the airway for any obvious obstruction. If you see something that's visible more anteriorly than a finger sweep or suction, any foreign bodies, but don't push anything back in. Um because then you can cause more distal obstruction, which is not good. So the draw thrace can help if you're suspecting any spinal trauma, um just to open up the airway and then in unconscious patient's, you can use an referential airway. But if they're not, if they're conscious than a nasopharyngeal airway is probably a better option. If you're struggling, just call anesthetics because that's why they're there. And at this point, if you're considering to call anesthetics, and you're really worried about an airway, you should really be putting out a crash call. Um and to start to ventilate via back well, mask, if you think and respiratory arrest is impending what has happened. Um And if you're unable to manage the airway, then anesthetics will have to come and intubate the patient. Okay. So in terms of mind of the stride or you've got immediate measures. So obviously call for help, crash call anaesthetics will come a lot of the time the ent team will also come if it's stride or specifically because a lot of the ent causes, a lot of them are ent causes of strider. Think the patient sit up, right? Give them high flow oxygen, put them on intensive monitoring. So put the starts probe on monitor the respirator heart rate. DP, get the crash trolley ready because if there's dreidel, then that means there's impending airway obstruction and respiratory arrest, um secure access in case someone's hypertensive, likely needing blood's aggressive fluid resuscitation, get the drugs ready, um destroyed or specifically, you can give nebulized adrenaline and the strength is one in 1000 and you can give between 1 to 5 mg. Um and this can be oxygen and, and you can just reassess and sort of give them more if it's not resolved or not improving, give them high dose steroids. Um We give a lot of steroids and E N T generally just to bring down any swelling. Um and it can help while you're sort of making decisions to maybe take a patient to theater. Um in some trust, they give Heliox. We I've never seen it used, but it is on the protocol in some trustful stride all and then procedures obviously under trick you'll intubation if everything fails if, if there's an impact airway obstruction and there's no time for tricky a intubation, then this won't be done by any junior member of staff, but a front of neck airway is probably the last resort. So an open scalp apology, Cricothyroid, cricothyroidotomy in the meantime. So this is where it gets a little bit more interactive. Um So please do answer the polls. Um And here we go. So case one, you can see the image already. It's an 18 year old male with one week history of sore throat not able to eat and drink for two days, associated symptoms of pyrexia and lethargy on examination. It's got bilateral edematous exudative tonsils, bilaterally large, large cervical lymph nodes. Um So he's got a fever pain score five. And the first question is this is a bit obvious, but there could be another option. What is the gold standard scoring system and tonsillitis to assess the need for antibiotics? Okay. So we've got two responses percent or two responsible fever pain. None for Glasgow. Very good. Um So yeah, central. It used to be the gold standard one. I was in early medical school but now is fever pain. Um But that's just, I don't think it really matters because both are just as good as the other is just fever pain is more up to date. So um this, this um gentlemen has a fever pain score of five. Um and um what is the most likely diagnosis based on what I've just given you. So it's a tricky question. There's no right answer to this one. Oh So if you can just answer this poll and there's another question, what test would provide a definitive diagnosis? So if you can answer both speak, let me just pull the other question again. Okay. That one's disappeared. Never mind. Okay. So we've got, what is the gold standard scoring system in tonsilitis? And then what is the most likely diagnosis? We've got tonsilitis, three votes and Quincy one vote. So the answer is there's no real answer here because it could be anything. Tonsilitis is probably the most likely. But given his age and the large cervical lymph nodes, it could equally be glandular fever. And the only really, the only way you could really differentiate is by doing EBV serology to determine the difference because he's got high fever, pain score. You would start treating him with antibiotics. Um Don't give him amoxicillin because if this person for some reason has glandular fever, then there if you give amoxicillin or call moxie cloud, then they're more likely to develop a rash. So we don't give amoxicillin. So you will just give penicillin V. Um You will do an E B B serology to make sure it's um not glandular fever, but given his age and the large cervical lymph nodes, it could very easily the glandular fever. And if you're suspecting glandular fever, then you need to safety net, the patient that they shouldn't, they should avoid contact sports for six weeks because there are increased risk of splenic rupture. Um, so that's just something you need to do to safety net. But otherwise it's managed conservatively, symptoms should settle sometimes. Um, um, if they're struggling to eat and drink a dose of IV dexamethasone could really help. You can give IV fluids if they're really dehydrated and struggling to keep down fluids give really, really, really good analgesia and in tonsillitis and glandular fever, most patient's I see who are requiring sort of hospital admission is because they just can't deal with the pain and hence they admitted just final jeezy and IV fluids. So I think give the paracetamol, give the codeine, give um give the flamme spray everything that will help the patient's pain and allow them to eat and drink, um will allow them to go home. And then if you want, you can also given up the dose of dexamethasone. People tend to feel quite good after it, but that's only in the hospital setting. Okay. So case too. So you've got a two year old female. So quite a young, young patient this time, five day history of a sore throat and today unable to eat and drink, she's got associated symptoms of dysphonia, pyrexia, generally unwell and irritable on examination. She's got signs of enlarged tonsils, enlarged lymph nodes, she's got a bit of stir to and she's got torticollis. So torticollis is when they flex the neck to one side, sir. The first question on the pole is what is the most likely diagnosis? So I'll just start polling that and if you could. Um, so that would be great. Okay. So we've got two responses, the Quincy and want the deep next face infection. Um And I just want to know what you think the first line investigation as well would be and then we'll move on to dances. So what would be the most appropriate investigation for this child at this point in time? And they're all pretty reasonable, to be honest. However, there's a couple of things that would just ring alarm bells, okay. So we've got to for CT neck and then needed at present, just treat with antibiotics and monitor and then we've got one fold sound neck. So in terms of differentials, there are, there are quite a lot that obviously there could be, it could be tonsilitis, it could be Quincy, it could be a deep next place infection. However, telling signs in this history is obviously she is now unable to eat and drink, so it still could be tonsilitis. There's a dysphonia, she's pyrexia with irritable. She has got signs of more upper airway obstruction, so she's got a starter. Um She's got torticollis. So torticollis, if I've learned anything in the last year is a really, really sort of red flag sign in Children. Uh It essentially means that the sternocleidomastoid muscle is irritated and hence, that's making them flex the neck to one side, which means there's some structure that's swollen or making, making the neck flex to one side. Irritating the sternocleidomastoid muscle. So it could actually could be any of those. But the most important thing you'd want to rule out is a deep neck space infection. So a para fragile or retropharyngeal abscess and in terms of the first line investigation, you wouldn't be wrong to just treat with antibiotics and monitor, you'd, you'd hope that that would have already been started given the symptoms. However, if you're, if you're looking to rule out a collection, um and, and this torticollis and you would really need some imaging to determine whether you want to surgically intervene or not and determine the size of the, the size of the collection. So usually if the patient's stable and you have access to ultrasound imaging, then you're not wrong to go for an ultrasound. But if the patient's more and well and you're concerned and Children can deteriorate quite quickly. Um I would just go for a CT neck. So this is this is the ct neck finding and you can just see provide tro pharyngeal abscess here, which is sort of pushing against the airway and how would you manage this? So obviously, you'd start start online of the antibiotics immediately, give IV fluids to keep the patient hydrated, give analgesia and this is likely to need surgical drainage if not improving with antibiotics and the patient is more unstable. Does anyone know what complication you should be aware of in retropharyngeal abscess is. So, if you can just um to the pole. So I think this is the case that has the most polls. Great. So we got one for sepsis. One for media sinusitis. That's it so far. All right, cool. We'll just move on. So in this case, mediastinal itis is one of the most important complications you should be aware of. Obviously, sepsis is also um potentially something that can, can happen as a result of an infection. However, your retropharyngeal spaces continuous with your Allah fascia that leads into your mediastinum. And so if, if this infection extends, it can, it can cause mediastinum itis, which is extremely, extremely serious and can cause imminent death to the patient. So you may have a patient with surgical emphysema. And so they need a ct thorax at this point to rule that out. Okay. That's great. So, case three, you've got a 56 year old male, sudden onset of swelling of tongue and neck, struggling to breathe following an application of knee Septin cream for epis taxus. She's got past medical history of a peanut allergy on examination. She's got a rash over her trunk, significant neck swelling and tongue swelling. She's hypertensive and tachycardic. She's got an oxygen sense of 72%. So, what is the diagnosis? I'm just going to start polling again. This should be Fanny, straightforward. Great. I think we've all got the anaphylaxis and it's absolutely anaphylaxis. And then what is the first step of management of this condition? Yeah. Yeah. Be a little bit confusing to know all the numbers. But yeah, a little bit low. It can be a little bit confusing. So in a lady at 56 years old, the answer is I am adrenaline 0.5 mg one in 1000. Okay. So in terms of anaphylaxis, this is what the recess guideline states you need to do. Obviously do an A T E. Look at the onset of the airway or breathing problem for any skin changes, any itchy itchiness or rashes call for help our crash call, remove any immediate triggers of any allergens present by the patient flat with or without legs elevated sometimes, but sometimes the sitting position can make that breathing easier. And if they're pregnant lie on the left side, okay. So these are the doses of I am adrenaline you can generally give. Um so in an adult and child over 12, it's 500 micrograms, one in 1000. And this dose changes for Children of varying age groups. So just something to bear in mind. Um if there's a, you know, give IV fluid challenges because they're likely to drop their BP quite quickly. Um And you can always repeat that I am adrenaline and assess the response to the treatment. Um I haven't included the refractory pathway for anaphylaxis on here, but it is part of the recess guidelines. So you can always check that if you're unsure. So you need to give the two doses of I um adrenaline first before you start that. Okay. So you've, the next one is case four, you've got a 36 year old nail with rapidly worsening dis pasion, odynophagia, got associated symptoms of dysphonia, drooling, pyrexia, coryza symptoms. Um, on examination, he's tacky cardiac hypoxic, um, pyrexia. Well, um arithmetic, sin slightly and large tonsils. The ent team is called to perform an epiphany and he's had a lateral neck X ray done. So, the first question is, what is the diagnosis based on these investigations? So, if you can just answer this poll, what is the diagnosis based on these investigations present? So the first picture on the left is an epiphany and the one on your right is a lateral neck X ray. So what is it? That's uh you know, so, so if you can sort of take yourself back to the image of looking from the top at your vocal cords, you might be able to recall a structure that I pointed at. Okay. So we got two votes of the glossitis and one for epiglottitis. And the answer is epiglottitis. So this this big swollen structure here is your epiglottitis is epiglottitis. It's extremely slow, done. Okay. And then one more question on this, right. Image. What is this arrow? What is the sign called on the lateral neck X ray? Okay. So we got to for steeple sign so far one for thumb printing. Okay. So this sign, yes, correct is thumb printing. Um It is a sign specifically seen in epiglottitis and on a lateral neck X ray staple sign is typically found um in on an anterior view of your neck X ray and it is it is still narrowing of the airway seen. But this is specifically thumb printing seen on a lateral neck X ray which which goes with the diagnosis of epiglottitis. This and lead piping is actually an abdominal lecturer finding which is just something where do I put in there. So again, we've look towards the diagnosis is epic lock itis. And how do you manage a pig lock itis. So you give broad spectrum IV antibiotics, regular high dose IV steroids to bring down the information and then you tape in 1 to 1 to two days and then you give prn adrenaline nebulizers to help with any strider associated with that. You keep the patient know by mouth because they're unlikely to be able to eat and drink. So you give them good amounts of IV fluids, you give them humidified oxygen. Um Usually they say it's just makes it makes it more comfortable if the patient is requiring oxygen, give IV fluids and then repeat the eff any to monitor and respond accordingly to see if the information is actually coming down or not. And if the patient's inflammation has come down, more than 50% usually they can just be discharged home. Okay. So those are the four cases. Um But usually I find that there's a lot of patient. Um a lot of people, you have anxiety when it comes to sort of looking at laryngectomy tubes, tracheostomy tubes, and sometimes it can just be difficult to differentiate um the anatomy and what one is over the other. So I've just gotta slide on other things to know. So in terms of, in terms of your normal neck, you've got your larynx, which is here and this, this, this blue line is basically representing a air flow. So through your mouth and through your nose all the way down through your airway. So that's airflow in patient's, you have a tracheostomy. The only difference is that there's an additional airway pathway through the tracheostomy site, which is here and usually patient's will may or may not have a tube. Well, they usually will have a tube here. Whereas in patient's with a laryngectomy, the larynx is completely removed, so that red bit isn't here and those are patient's with one airway. So all of this is essentially dead space because the larynx has been removed. Um They have one airway which is here and sometimes it would just be open with no tube and they'll just be a open stoma site. So normally a laryngectomy patient won't have a tube and a tracheostomy patient will have a tube there. Okay. Um So some cool stuff. How do you know what this device is? It's just a quick picture test. I just put it on a pole. Just interested to know if you know what it is. Okay. So we've got two responses for tracheostomy tube, one for laryngectomy tube. Okay. So I don't really suspect anyone to have seen this before, but it is actually a tracheoesophageal puncture. And it's just a fancy word for a speech valve, which is commonly used in patients who have had laryngectomy is in the past and they don't have a functioning larynx. So can't, so can't speak as normal. So what this valve does is essentially close, closes off, closes off the space and it generates esophageal speech. So when someone breathes out, they make sound through their esophagus, which is generated as speech. You can also get devices, more electronic and vibration devices that patient's hold up against their neck to also reproduce sound without their larynx present. So it's just a prosthetic device that is very cool. So I thought I would share it. So yeah, that was, that was the question. And then sometimes you can do um encounter more scary things like airway assistance in patient's with tracheostomy, ease and laryngectomy knees. So the principles are essentially the same. So first you assess if the patient is breathing or not. If they are um then apply high flow oxygen. In Tracheostomy patient's, you apply high flow oxygen to both the face and the tracheostomy because they've got to airways on laryngeal, on laryngectomy, stoma patient's, um you just apply it to the stoma. But if you're unsure for whatever reason, then I would just apply it to both because there's no harm in doing that. Um Sometimes in tracheostomy patient's, the tube can become occluded with lots of secretions. So there's something called an inner tube in the tracheostomy within the tracheostomy tube. So if you just pull that out, sometimes it can cause immediate relief. Um and you just need to suction inside um and make sure it's patent and suction, any secretions and continue your air to a uh A T E assessment and assesses the patient's stable or improving. You can do the same and within laryngectomy sturmer and just perform any suctioning of secretions. Um And then if the patient isn't improving, then you can remove the tube from the tracheostomy. And if there is a to present in the laryngectomy stoma, then you can remove that too. Um Obviously, if there's no signs of life, you go down the CPR route. If they are breathing, then you continue your a tree assessment. Um Sometimes in patient's with tracheostomy is that aren't improving, then you'll attempt oral intubation. Obviously, by this point, you'll have a lot of help. Um And you can do the same for the laryngectomee stoners as well. So, um, that's just a brief overview of if your call for help um, to patient's with tracheostomy. Zor laryngectomy knees. Um, don't let it scare you. Just think about the anatomy. Ask the nurses if they have laryngectomy. Zor tracheostomy is, but if and out just put oxygen over both and just think about it systematically and I think the most important thing is just call for help, ask someone more senior. And the ent registrar should always be around to help with this kind of thing. It's something they're called for quite a lot across the hospital because they take it really seriously because these are most unwell patient's um E N T usually has so don't hesitate to ask for any help. And that brings me to the end of my presentation. If anyone has any questions, please just drop it in the chat Aurand, mute your microphones and I will answer them and I'm just gonna put the feedback form on again. So please um fill out the feedback for me if you have any questions. Um Let me know and you will get a certificate if you fill out the feedback form. So please do we do have I have an email address. So if if anyone has any questions at all, just drop me an email um or if you need any advice about anything. That's great. Thank you so much in your feedback. If you have any sessions, you want me to do in the future. Let me know my next session is asked to see the patient with reduced G C S. Yeah. All right. Thanks a lot for joining everyone.