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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 in the feedback form, 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. OK. So I think we'll make a start because um it's all, we're already a few minutes ahead. So, um thanks for joining everyone. Um We, I've done a few of these as to see the patient sessions before. Um And this session is actually one 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 don't really know how to manage, um especially out of hours. So hopefully this helps in some ways. Um My name's Tay, I'm one of the F twos at, uh Wigan Infirmary. And I had, um, an F one job as an, an ENT and I did general surgery as an F two, which also covers ent out of hours and, um, came across a fair few, um, ent slash airway issues in my time. So I thought I'd just come and share some important ones. So, like, um, all the other sessions I've done, which, um, to see the patient, I've sort of put together a structure on how to approach airway problems. So our objectives today will be to develop a logical standardized approach to assessing and managing airway problems, mainly ent related to understand the main differentials for stridors airway obstruction in the acute setting. And to become more familiar with important first line investigations and management, um, common and common scenarios is an F one slash F two and, um, become more comfortable with SB R and escalating patients appropriately, especially when it comes to managing the airway. So, um, I usually ask this, but can you, um, just let me know, um, what kind of level you are at? Because, um, if there's something that I'm saying that that doesn't make sense at all, at least I know how to sort of tailor my teaching a little bit more. So, are you medical students, junior doctors, if so what level you just put it in the chart and I'll have a look. No. OK. All right. I'll, 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 you'd gain a lot from it to sort of engage with them. Um So we'll, we'll make a start. Ok. Great Lim students and one, right. So approach to Stridor. 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 Stridor, if it's the onset is quite important, if it's quite acute or gradual, makes a big difference, um the duration and progression. So if it's lasted weeks or just hours, any exacerbating or relieving factors has um has Amy given them anything that's actually helped um, before you've seen them or are you the person in Amy and then associated symptoms? There's a whole host of them. So most important ones to be thinking about are shortness of breath, cough, Stridor, stir to tongue, lips, neck swelling, rashes, fevers, dysphasia, ano dysphonia, drooling, 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 pharyngeal 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 they ingest any foreign bodies. Um, and it seems to be that a lot of meats and bones, fish bones, 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 tonsillectomies, recent dental procedures 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 A to P uh and then always ask a social history, uh know what their comorbidities are. Any recent travel, family history, any malignancies? Mm. Ok. So that's the history. Then you've got the airway anatomy that I'm just going to whi through quickly. So, in terms of airway anatomy, obviously, we've, we start with uh the nasal cavities that lead into the nasopharynx. You've got your um opening of the eustachian tube, which is in the nasopharynx and then that leads into the oropharynx. Um You've got your, your tongue base of your tongue and then you've got your epiglottis more posteriorly, you've got your laryngopharynx um behind the epiglottis and then you've got your esophagus and then more anteriorly you've got your um trachea. 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 this sort of structure here and then you've got your vocal cords here and then you've got the base of your tongue here. Um And this is what it looks like when it, your vocal cords are closed. So when, when the intern examinations, which we'll, we'll touch on later, um, we get patients to say e to have a look at their vocal cords and you, you assess vocal cord movement by looking at the opening and closing of them. So we're just looking at the, the difference between Stridor and stir because they're two quite different things and people can get quite um mixed up with them. So I've just put in a slide that covers both. So, Stridor is essentially noisy breathing due to partial airway obstruction and St's 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 in the supraglottis, glottis level where is further up near the nasopharynx or oropharynx. Stridor occurs at both during the inspiratory and expiratory phase where a ST is just purely inspiratory. Stridor is much more of a higher pitched sound when you breathe rather than ST to which is more low pitched and the snoring 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 Stridor? It can be quite scary, but this is sort of a generalized approach. Um So in terms of differentials, I've classified them mainly into infective and noninfective and in different age groups, because you get sort of a class of uh categories of, of conditions more common in the groups. So, in the neonate, there's no real major causes of infective stridor, but the most common cause of noninfective stridor is Lary, laryngo malas, which is sort of the um the cartilage isn't fully sort of intact and struct structurally, not great. So it can, it can sort of cause obstruction to your airway. And then similarly, tracheomalacia and then subglottic stenosis. And then as you move on to Children, you've got in common infective causes such as croup and epiglottitis. Um However, the croup croup is caused by parainfluenza and sort of historically, epiglottitis was caused by um Hemophilus influenza B. But I believe that after vaccinating, that's become less common. Now. And then you've got quinsy deep neck space infections. So you've got parapharyngeal and retropharyngeal abscesses. Um submandibular um swellings, which is Ludwig's angina, which can commonly caused by dental procedures and bacterial tracheitis less common than the rest. And then noninfective are really, really big. One is foreign body inhalation, especially in your, your toddlers and anaphylaxis is 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 causes in the adult. Again, you've got supraglottitis, epiglottitis, bacterial tracheitis. Um I've seen more, more commonly epiglottitis and supraglottitis this winter. Um, and then you've got deep neck space infections as well. And then the noninfected, you've got a whole host of them there. Common, usually tumors, trauma, postextubation, you can have um, stridors as well. And then you've got a whole host of other, other less common problems and that could cause stridor. 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 infective versus noninfective along with your history. Um You can do a glandular fever screen which is more sort of um to differentiate if you like 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 um do a group and seven and cross match as well. And then in terms of imaging, um it really depends on the clinical situation but um what kind of obstruction you're expecting if it's infective, noninfective, if you're suspecting an abscess versus just a foreign body ingestion. So it's always good to do a lateral neck x-ray. Um, chest x-ray can be considered ultrasound, neck ct. Next. Again, it just really depends on the clinical scenario. So how do you assess the airway compromise? Like always. Um If you've attended my previous sessions, it is largely been down to any anything acute comes down to the A two E um one second just looking at my pulse? Ok. Um All right. So when you look at your A two E, 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 in, indicate a significant airway compromise. The person just looks cyanosed um position of the patient. Are they really struggling to breathe that they tried prodding? Do they have any obvious angioedema at the, at the sort of side of the bed could indicate anaphylaxis. Are they drooling? Can they not so swallow that own spit because of the obstruction. Can you hear a stridor also is, is, is something that you can observe from the 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 is any pain on palpation? Can you feel any palpable neck swellings and then movement? Do they have any restricted neck movements? Um Sometimes restricted neck movements can indicate a deep neck space infection. Do they have any Trismus um Trismus, meaning that they're able to open their drawers without pain? Um And this can be indicative of mainly a Quinsy. So this is the first question in the poll. Sorry, I think I've just given you an answer there. 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. Ok. So, um yes, FNE 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 uh um anesthetics team. The FNE is a really good way of um, assessing for airway obstruction more superiorly in the airway just above the vocal cords, individualize the vocal cords. It doesn't really look at anything else. Um So a laryngoscope they use to intubate and things like that. Um Whereas the FNE goes through the nose, just, just like an NG tube generally just looks above the level of the vocal cords, see if there's any obvious obvious swellings or obstruction. Say, yeah. So in terms of breathing, um obviously, you look at the respiratory rate, oxygen saturations, respiratory effort, they're using any accessory muscles um in Children more obviously, tracheal tugs of cost or recessions on auscultation, you may hear a wheeze um may be a sign of obstruction due to more distal obstruction to the large bronchi. So if someone has anaphylaxis or asthma, things like that, then you may hear an audible wheeze. Um and there could be some reduced air entry as well. So in terms of circulation, you've got um to assess your pulse. Obviously, if someone's tachycardic, um they may also have an increased respiratory effort and hypoxia and anxiety you and if they've already had some nebulized adrenaline because of the stridor, then this may just further exi exacerbate tachycardia. So you may just want to do an ECG to make sure there's nothing, nothing else you're missing. So in terms of BP, you may become hypertensive because you've got systemic vasodilation, 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 con level like is very important, it could be reduced secondary to hypoxia 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 AU and G CS scale to measure that. And then in terms of exposure, um look at any evidence of anaphylactic anaphylaxis such as urticarial rashes or angioedema, any potential allergens, what their temperature is, are they pyrexia? So obviously, in, in this presentation, we're focusing more on the airway um because the airway itself is quite a large topic to cover in this session. So I'm not going to go through the A full A to e in every scenario we do. I'm going to mainly cover the cases um because the rest of B CD 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 an 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 a draw thrush can help if you're suspecting any spinal trauma, um just to open up the airway and then in unconscious patients, you can use an oropharyngeal airway. But if they're not, ca if they're conscious, then 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 start to ventilate via back valve mask. If you think kind of 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. So in terms of, of the Stridor, you've got immediate measures. So obviously, call for help, crash call anesthetics will come. Um A lot of the time the ent team will also come if it's Stridor specifically because a lot of the ent causes, a lot of them are ent causes of stridor. I think the patients sit upright, give them high flow oxygen, put them on intensive monitoring So put the SAS probe on monitor the respirator heart rate DP, get the crash trolley ready because if there's stridor, then that means it's impending airway obstruction and respiratory arrest, um secure access in case someone's hypertensive, likely needing bloods, um aggressive fluid resuscitation, get the drugs ready. Um The fi stri specifically, you can give nebulizer adrenaline and the strength is one in 1000 and you can give between 1 to 5 mg. Um And this can be oxygen and you can just reassess and sort of give them more if it's not resolved or not improving, you can give them high dose steroids. Um We give a lot of steroids and ent 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 trusts, they give helios. We I've never seen it used, but it is on the um protocol in some trusts for Stridor and then procedures obviously endotracheal intubation. If everything fails, if, if there's an airway obstruction and there's no time for tracheal 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 g Cricothyroid cricothyroidotomy in the meantime, so this is where it gets a little bit more interactive. Um So please do answer the poles. 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. He's got bilateral edematous exudative tonsils, bilaterally la um large cervical lymph nodes. Um So he's got a fever pain score of five. And the first question is, this is a bit obvious, but that could be another option. What is the gold standard scoring system in tonsillitis to assess the need for antibiotics? Ok. So we've got um two responses for center, two responses for fever pain. No, for Glasgow. Very good. Um So yeah, center, it used to be the gold standard when I was in early medical school, but now it is fever pain. Um but that's just, I don't think it really matters because both are just as good as the other. It's just fever pain is more up to date. So um this, this um gentleman has a fever pain score of five. 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 If you can just answer this pole and there's another question, what test would provide a definitive diagnosis. So if you can answer both, let me just pull the other question again. OK. That one's disappeared. Nevermind. OK. So we've got, what is the gold standard scoring system in tonsillitis? And then what is the most likely diagnosis? We've got tonsillitis, three votes and Quinsy one vote. So the answer is there's no real anx here because it could be anything. Tonsillitis is probably the most likely. But given his age and the large cervical lymph nodes, it could equally be glandular fever. And the only re the only way you could really differentiate is by doing EBV serology to determine the difference because he's got a um high fever pain score. You would start treating him with antibiotics. Um Don't give him uh amoxicillin because if this person for some reason has glandular fever, then the if you give amoxicillin or colic cla, then they're more likely to develop a rash. So we don't give amoxicillin. So you, we'll just give penicillin V. Um You will do an ebb serology to make sure it's um not glandular fever, but given his age and the large cervical lymph nodes, it could very easily be 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 um they're at 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, a dose of IV dexamethasone can really help. Um You can give IV fluids if they're really dehydrated and struggling to keep down fluids and give really, really, really good analgesia in um in tonsilitis and glandular fever. Most patients I see um who are requiring sort of hospital admission is because they just can't deal with the pain and hence they admitted just for analgesia and IV fluids. So I think give the paracetamol, give the codeine, give, um, give Diam 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 give another dose of dexamethasone. People tend to feel quite good after it, but that's only in the hospital setting. Ok. So case two. So you've got a two year old female. So quite a young, young patient at this time, five day history of a sore throat and today unable to eat and drink. The 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 a ST and she's got torticollis. So torticollis is when they flex the neck to one side. So the first question on the pole is what is the most likely diagnosis? So I'll just stop polling that and if you could answer, that would be great. Ok. So we've got two responses to Quinsy and one the deep neck space 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 DS. 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. Ok. So we've got two for a CT neck and none needed at present. Just treat with antibiotics and monitor and then we've got one for ultrasound 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 Quinsy, it could be a deep next case infection. However, the telling signs in this history is obviously she is now unable to eat and drink, so it still could be tonsillitis. There's a dysphonia, she's pyrexia irritable. She has got signs of more upper airway obstruction. So she's got a stir to and 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. It essentially means that the sternocleidomastoid muscle is irritated and hence, that's what 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. And so it could actually, it could be any of those. But the most important thing you'd want to rule out is a deep neck space infection. So a parapharyngeal or a retropharyngeal abscess. And in terms of the first line investigation, you wouldn't be wrong to just treat with antibiotics and monitor. You'd e you'd hope that that would have already been started given the, the symptoms. However, if you're, if you're looking to rule out a collection and, and this torticollis, then 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 unwell 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 the retropharyngeal abscess here, which is sort of pushing against the airway and how would you manage this? So obviously, you'd, you'd start, start on either 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 abscesses. So, if you can just and to the pole, I think this is the case that has the most polls, right? So we got one for sepsis, one for mediastinitis. That's it so far. All right, cool. We'll just move on. Um so in this case, mediastinitis 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 space is continuous with your alla fascia that leads into your mediastinum. And so if, if this infection extends it, it can, it can cause mediastinitis 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 ac t thorax at this point to rule that out. Ok. 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 NAIN cream for epistaxis. 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 gonna start polling again. This should be fairly 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, it be a little bit confusing to know all the numbers. But um yeah, a little bit little, it can be a little bit confusing. So in a lady 56 years old, the answer is I am adrenaline, 0.5 mg one in 1000. Ok. So in terms of anaphylaxis, this is what the reus guideline states you need to do. Obviously do an A to e look at the onset of the airway or breathing problem or any skin changes, any itchy itchiness or rashes call for help, put out a crash call, remove any immediate triggers of any allergens present lie, the patient flat with or without legs elevated sometimes, but sometimes the sitting position can make their breathing easier. And if they're pregnant lie on the left side. Ok. So these are the doses of iron 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, so, you know, give IV fluid challenges cause they're likely to drop their BP quite quickly. Um And you can always repeat the 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 research guidelines. So you can always check that if you're unsure. So you need to give the two doses of I adrenaline first before you start that. Ok. So you've the next one is case four, you've got a 36 year old nail with rapidly worsening dysphagia and odynophagia. It's got associated symptoms of dysphonia, drooling, pyrexia, carris symptoms. Um on examination, he's tachycardic hypoxic, um Pyrex, um, erythematous in slightly enlarged tonsils. The ent team is called to perform an FNE 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 pole, what is the diagnosis based on these investigations present? So, the first picture on the left is in the knee and the one on your right is a lateral neck x-ray. So what is it? Yes, no. 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. OK. So we got two bits for the glottis and one for epiglottitis. And the answer is epiglottitis. So this this big swollen structure here is your epiglottitis. Is epiglottitis? It's extremely swollen. OK. And then one more question on this right image. What is this arrow? What is the sign called on the lateral neck x-ray? OK. So we got two for steeple sign. So far. One for thumb printing. OK. So this sign, yes, correct is thumb printing. Um It is a sign specifically seen in epiglottitis and on an electron neck x-ray, stable sign is typically found um in on an anterior view of um your neck x-ray and it is it is still a narrowing of the airway scene, but this is specifically thumb printing scene on a lateral neck x-ray, which um which goes with the diagnosis of epiglottitis. And lead piping is actually an abdominal x-ray finding, which is just something we I put in there. So again, we've looked at what is the diagnosis is epiglottitis and how do you manage epiglottitis? So you give broad-spectrum IIV, antibiotics, regular high dose IV steroids to bring down the inflammation And then you tape it in 1 to 1 to 2 days. And then you give pur n adrenaline nebulizers to help with any stride or associated with that. You keep the patient no 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 FN to monitor and respond accordingly to see if the inflammation 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. Ok. So those are the four cases. Um But usually I find that there's a lot of patient, um a lot of people who 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 got a 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 air, air flow. So through your mouth and through your nose all the way down through your airway. So that's airflow in patients who have a tracheostomy. The only difference is that there's an additional airway pathway through the trache tra tracheostomy site, which is here and usually patients will may or may not have a tube. Well, they, they usually will have a tube here. Whereas in patients with a laryngectomy, the larynx is completely removed so that red bit isn't here and those are patients with one airway. So all of this is essentially dead space because the larynx has been removed and they have one airway which is here and sometimes it will 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 the tracheostomy patient will have a tube there. Ok. Um So some cool stuff. How do you know what this device is? It's just a quick picture test. I've just put it on a pole, just interest to know if you know what it is. Ok. So we've got two responses for tracheostomy tube. One for laryngectomy tube. Ok. 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 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 patients hold up against their neck to also reproduce sound without the larynx present. So it's just a prosthetic device that um is very cool. So I thought I would share it. So yeah, that was, that was the question. And then sometimes you can also um encounter more scary things like airway assistance in patients with tracheostomy and laryngectomy. 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 patients, you apply high flow oxygen to both the face and the tracheostomy because they've got two airways on Lary, on Laryngectomy stoma patients. 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 patients, 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, air to a uh a to e assessment and assess if the patient is stable or improving. You can do the same and within laryngectomy stoma and just perform any suctioning for 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 tube 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 eight reassessment. Um sometimes in patients with tracheostomy that aren't improving, then you'll attempt oral intubation. But obviously, by this point, you'll have a lot of help. Um And you can do the same for the laryngectomy stoma as well. So, um that's just a brief overview of if you call for help um to patients with tracheostomy or laryngectomy. Um Don't let it scare you just think about the anatomy, ask the nurses if they have laryngectomy or tracheostomy. But if in doubt, 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 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 cause these are most unwell patients. Um ent 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 or unmute 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. Um In your feedback. If you have any sessions you want me to do in the future, let me know. Um My next session is ask to see the patient with reduced G CS. So, yeah. All right. Thanks a lot for joining everyone.