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I have two doctors, part of the N I Foundation Doctors Anesthetics IC Society. So today we are doing our first talk in our preparation for a final series. So this talk is going to be on Airway Management and tracheostomies. So I think we'll just make a start. Um If anybody has any questions or anything, they want to clarify throughout the presentation, just feel free to put a message in the chat box. So, so the first thing about airway management and oxygen delivery devices um is it's important to understand what F IO two is because it's something we talk about quite a lot in relation to oxygen delivery. So F IO two is your fraction of inspired oxygen. So for example, room air contains approximately 21% of oxygen. So therefore the fractional inspired oxygen um of room air is 0.21. So whenever we have an unwell patient, we want to supplement them with additional oxygen and therefore increase their fractional inspired oxygen. So what is our fraction inspired oxygen dependent on it is dependent on how we supplement the oxygen, whether it's a variable or fixed device that we use to deliver the oxygen or how effective the airway device is at actually delivering the supplementary oxygen. So as I was saying, we can deliver oxygen with variable performance and fixed performance oxygen delivery devices. So variable performance oxygen devicess, so they vary in terms of the amount of fraction inspired oxygen delivered. So with these devices, patients will intra normal room air as well as the supplementary oxygen. So this is therefore going to dilute the mixture of air that they are um inhaling as such. So the fraction inspired oxygen will therefore depend on a few things. So it'll depend on the patient's respiratory demand. So this is their respiratory rate. How quickly they're actually inhaling the oxygen or the mixture of air that's being entrained, the inspiratory flow rate and the expiratory pauses. Examples of variable performance oxygen devices would be your nasal cannula, which a lot of you would be very familiar with seeing on the wards. Hud and face masks are also used on the wards quite a lot tracheostomy masks, which you may not have seen quite as much and non rebreather masks as well. So we'll talk about nasal cannula first or what we often call nasal specks. So their fractional inspired oxygen is 0.24 to 0.36 and their flow rate is between 2 to 4 L a minute. So they work by using the dead space of the nasopharynx um at the back of the nose as a reservoir for oxygen. And when the patient breathes in the room, air is entrained and mixes with this reservoir of oxygen. So you get a bit of dilution of the oxygens, as I said before, this is suitable for most patients, to be honest with you, um it's quite good because patients won't really feel claustrophobic with it. And you'll often see a lot of patients will use this for long term oxygen. The advantages are that patients aren't usually bothered by nasal nasal cannula and they will be able to eat, drink and speak freely without having to disconnect their oxygen. The main problems that you'll get with nasal cannula, nasal specks is that whenever you come in, sometimes the nasal specks will be not at all in the right place. They might be on the patient's face, they may not be delivering any form of oxygen. Um They can also get some drying of their nasal nasal passage and that can cause crusting and bleeding. Um And usually we can just give the patient a bit of nein just to ease that dryness. Ok. So the Hudson mask, so I've got an image of each of, of the airway devices there. Um So the fraction inspired oxygen of a Hud Hudson mask is between 0.35 and 0.6. And it is able to deliver a higher flow rate of oxygen of between four and 15 L a minute. It is a mask that's placed both over the nose and the mouth. The poor compliance comes with the fact that patients kind of pull it off to be able to eat, drink and speak. Um compared with the nasal cannula, the non rebreather we would use most often in the setting of a critically unwell patient, it has a higher fraction inspired oxygen again, of between 0.6 and 0.85 with a flow rate of 10 to 15 L per minute. So as I was saying, it's used in the setting of unwell patient and there's minimal entrainment of air and you'll usually see it cranked up to the full 15 L of oxygen before then it's weaned. So the reservoir bag, particularly if this comes up in your Aussies, you need to make sure that you fill the reservoir bag. Otherwise you're not bringing any oxygen. So what you do is you put your finger over the one way valve. So it's hard to kind of get in this picture. But the one way valve kind of sits in there if you can see my mouse. Um So whenever the patient expires, the one way valve then closes and prevents any of the expired carbon dioxide entering the reservoir bag and prevents then rebreathing. The disadvantages are the same as the Hudson mask. Whenever patients are unwell, they can become quite deteriorated and agitated and pull the mask off. So it's about making sure that the band around the face is fitted correctly and is tight enough. Um And then just trying to monitor the patient as much as possible to see that they're actually being compliant with the mask. So now we're going to move on to fixed performance oxygen delivery devices. So the difference is between these invariable performance is that these have a predictable and very accurate fractional inspired oxygen. So examples of these would be high airway flow oxygen enriched devices. Um So these are open systems where the intra of air is fixed, such as a venturia mask and anesthetic breathing circuits. So they do not rely on any intra of air such as an Ambu bag. So we're going to go into these in more detail. So the venturia mask, um generally, you don't see these an awful lot in medical wards. It would be more so in respiratory wards. But um what it does is it increases the flow of oxygen and it doesn't affect the increase in the flow of oxygen, doesn't affect your fractional inspired oxygen. Therefore, it's fixed and precise. You'll have a number of entrainment port sizes and that determines the fractional inspired oxygen. So the larger your port, the more room air that you're in training and therefore lowers your fraction inspired oxygen. So the the setting in which you'll see these being used will be in COPD patients um who might have a history of type two respiratory failure just to ensure that they're able to entrain more room air so that they don't get um system that their hypoxic drive. So there's usually the blue is 0.24 white is 0.28. We don't usually see orange but it is 0.31. The yellow is 0.35 red is 0.4 and the green is 0.6. Um So as I said for the larger the port, the more room air that you're going in treating. So each port shows the flow rate required for the relevant F IO two to be delivered. So as you can see below, um as it gets bigger, they have a higher flow rate required to reach that F IO two going up to 1215 L per minute to deliver an F IO two of 0.6 or 60%. So as I said, you'll often see these um being used on the wards for CO PD patients, nebulizers again, very commonly used on the wards. These will convert liquids into aerosols which then will be inhaled into the lower respiratory tract. Um They're most commonly used for inhaled bronchodilators, but they can also be used for medications such as adrenaline, um particularly in Children. Optimal flow rates for nebulizers are between 4 to 6 L per minute. And that is the flow rate required to a aerosolize the liquid appropriately, bag, valve mask or Ambu bag. So you'll very often see these um on your anesthetic placements or if you're someone who wants to do anesthetics. Um So these are often used to ventilate patients who either aren't breathing knee assisted ventilation or are critically unwell in hospital. The the port will be connected to supplementary oxygen on the wall, but you can use the Ambu bag as well. So the flow rate is between 12 and 15 L a minute and the F IO two is up to 0.8. So that depends on the quality of the seal, the bag size and the depth of ventilation. So what that means in terms of the quality of the seal, um whenever you're using an AMU bag, you tend to use a seal three approach. So just making a seal and using your other three fingers, and what you want to do is seal the mask over the patient's face and use those three fingers to pull their jaw up into the mask. And that's how you create an effective seal. Um But obviously, as you know, the user, it depends on user technique and um if the user becomes more tired and stuff, you may get a reduction in the quality of the seal and in terms of the depth of ventilation as well as just how much they're squeezing the bag. So I was saying there, so particularly at our stage, we would be using a two handed approach. It's the most safe way to do it. Um And then having someone else um bagging the patient if required. So what you can do with a bag bag, valve mask is you can look to see if the chest is rising to see if you're ventilating appropriately. And then if capnography is attached, which is very often will be in a theater setting to see that um CO2 is being delivered over zealous bagging can cause distention in the stomach, which can then increase the intraabdominal pressure and therefore increase the intrathoracic pressure and makes the patient more difficult to ventilate of. So what I my last point is patients will often have bag valve masks used before intubation. So usually they will be oxygenated for 2 to 3 minutes before ventilation before sorry, they're intubated and they'll be um ventilated using the bag valve mask. So humidified or high flow nasal cannula or oxygen. So this will deliver heated and humidified oxygen and on the wards, they're very often called vo or opti flow, which are the manufacturer names. So oxygen can be delivered at higher flow rates through large bore nasal cannula. So they look slightly different than standard nasal cannula. They are much broader in terms of the diameter and they can be, they can deliver oxygen at up to 60 L per minute. Um continuous high flow rates will then splint the patient's airways open and add positive peak expiratory pressure or peak and this will reduce the patient's airway resistance and reduces their work of breathing. Um These would very commonly be used on respiratory wards in the case of very critically unwell patients. Um and particularly more so in kind of 2020 you would see a lot of COVID patients on VO. So it delivers both warm and humidified oxygen and that improves the mucociliary clearance that reduces the patient's risk of atelectasis and improves their ventilation perfusion and oxygenation. So the use is so it can be used in acute hypoxic respiratory failure, which it very commonly is on the wards, hyper cabinet, respiratory failure, acute heart failure, bronchoscopy, rescue, preventative therapy, and post extubation, respiratory failure. Um this would kind of be the highest ward level of oxygenation. So if a patient, if it really depends on the ward, um but patients may have to require to go to the ICU to get IR O or if they do have it on the ward, then that'll be their maximum um respiratory support provided on the ward. So this is an M CQ. So you can, you can see the answer here. So I'm just going to talk through it. So you are working as an F one on a medical ward and you get called to see Mrs Smith who is a 77 year old female who was admitted with an infective exacerbation of CO PD, she has a history of type two respiratory failure. The nurses tell you that her oxygen levels have dropped to 78%. And what is the most suitable form of oxygen delivery device to initially use. So, what we're going to do is talk through all the answers and then we can talk through why the incorrect answers are incorrect. So the first answer is nasal specs. So this would be wrong um because the patient's oxygen saturation levels are 78%. And as we know, um nasal specks only provide an F IO two of 0.24 to 0.36 and they can only deliver oxygen of 4 to 6 L per minute effectively. Um So that wouldn't be suffice for someone in this acute hypoxic respiratory failure, a venturing mask, a lot of people would probably be tempted to go for it because this patient has a history of type two respiratory failure and CO PD. However, in this case, you want to make sure the patient is adequately oxygenated. So, um you know, you'll require a 15 L nonrebreather mask. And then following that, you can do an ABG and um switch to a ventura or switch to another oxygen delivery device if they are becoming hypercapnic. So, if the, if the patient's oxygen levels weren't 78% if they were maybe, you know, 88% and then you could consider venturing masks. But just because they're acutely hypoxic, you would need something, something um higher level than a vur so a nebulizer again, not in this instance, this patient probably is going to require a nebulizer at some stage, but not while their oxygen levels are 78%. Um that will be used for their bronchodilators further down the management once they're more stable. So a 15 L nonrebreather mask is the answer to this. Um And as I've said, and the answer is they do have a history of type two respiratory failure. However, they will die much quicker from hypoxia than hypercapnia. So therefore, it's the most suitable oxygen delivery device. And if the patient oxygen saturations improved, you can do an ABG and then it can be ascertained and switched to vur or N if required. And then the last answer is vo um So again, that could be something you could consider if the patient's oxygen wasn't improving on the 15 L nonrebreather. Ok. So we're going to move on to airway maneuvers and devices. Um And this is something that you deal with a lot as an F one and F two doctor. Um So whenever you come to see a patient, you may be able to pick up if they have an airway obstruction. So if they have a partial airway obstruction, you may hear noisy breathing or snoring kind of breathing or a stridor with complete obstructed airways, you will hear nothing. Um And this very quickly can lead to cardiac arrest and death is inevitable if the obstruction isn't relieved. So the main things that you want to do and approach a patient who's unresponsive is you want to look, listen and feel. So it means putting your, putting your ear right down to their nose and mouth and see if you can hear any movement of air and see if you can see they're chas rising and feeling any air as well. So what causes airway obstruction? There are many, many causes. Um CNS depression is probably the most common one that you see on the ward. So patients drop their G CS for whatever reason, a foreign body, peripheral um nervous system and neuromuscular disorders such as sleep apnea, laryngospasms or gain barry infections such as epiglottitis and croup can very often cause partial airway obstructions because the child's airway is much more narrower than in adults. So a small amount of inflammation can cause obstruction, laryngeal edema such as anaphylaxis trauma, neoplasm such as pharyngeal or laryngeal and hemorrhages or hematomas. Yeah. So in a patient who's unconscious, anesthetized or sedated, the most common cause of airway obstruction is loss of airway, muscle tone. And the most common sites of this obstruction are your soft palate as number one, your tongue or your egos. And the most important initial management that you can do is um an airway maneuver. So your head tilt, chin lift and jaw thrust. And I really can't emphasize how valuable they are um to be able to do effectively. So these are just some diagrams of showing how you do it head tilt, chin lift. So head tilt chin lift is very kind of self explanatory and your jaw thrust, you want to um get your little finger behind the ankle of their jaw and thrust their jaw up into your hands and you should look, listen and feel for any signs of air moving. So once you have done your airway maneuvers, you can add in some airway adjuncts. So these are things that you can add to essentially maintain a patient's airway until a more secure airway is established. And then you can deliver oxygen on top of these adjuncts. So the ones that you'll see are your op airways or your Cadel, your nasopharyngeal airways, your superglottic airway devices and et tubes, particular anesthetics. Ok. So, Aussies, so airways very often come up on acies, they can come up in isolation or they can commonly come up as part of an ABCD E scenario. Um So in our final year o we had a patient who was drowsy following an overdose and then became obstructed. And what you have to do is weigh up with the information you have about the patient and the clinic scenario as to which airway device would be appropriate. There are times that there is more than one right answer. So that's just important to keep in mind. Um Mainly you want to establish is the patient drowsy or are they unconscious? And are they suitable to have a Gaelle airway? And, and make sure just in these stations that you are comfortable inserting your airways to make sure if you're not, that you get a room in CS and just go through all the airways and make sure you're really confident inserting them because it can take a matter of seconds. And, um, if you're confident doing it really shows. So airway, only ay stations are also quite common. They haven't come up in a few years, but I think there was one year, I think that they came up in fourth year and fifth year. Um And it was something that whenever I was practicing, practicing for my ay, I found quite intimidating, but it actually is a very simple station. So what you basically do is pick up the airway, each airway in turn. So you might go in and there may be four or five different airways in front of you and the station may just be to explain the use of each airway and when it's appropriate to use it and how you would use it. So you pick up each airway state, the name of the airway and where it exerts its action. So whether it's a nasopharyngeal, an oropharyngeal or super glottic airway device, how you measure it. So how are you going to measure it whenever you want to insert it into a patient? So for example, with the gel, you measure it hard to hard um and make sure you're talking through this and you're not just assuming the examiner knows what you're talking about for the LMA, you will look at the airway that you've been given state the size um and the weight denoted it on the airway. And is that appropriate for the patient there in front of you explain how you're going to insert it and demonstrate where possible. And if there is inflation of the cuff required, for example, in a first generation LMA, then make sure that you'd mention that you would test that the cuff is um is working and that there's no air leak prior to inserting it and then state at what stage that you would inflate the cuff. And if you have time, then you can talk about circumstances in which it can and cannot be used. And the main point that I would want to point out here is um if you are in anesthetics, get one of each airways, they are disposable. They're usually happy for you to take one and practice your ay with them. Um You will get a lot of your information simply by looking at the airway. So I've got an example here. So for example, you can pick this airway up and say that this is an eye gel. It is a second generation laryngeal mask airway. So it acts as a super glottic airway and exerts its effect by sitting in the superglottic space. So you can see just by looking at it, this is a size four airway, it is disposable. Um and it is latex free and it is suitable for a patient weighing between 50 90 kg. You can see that there's also a bite guard present and there's a line that indicates the depth of insertion of the airway. The good thing about an eye gel that you can point out is that there is a gastric port. So it starts kind of down here and brings the whole way up and it can be used. Um You can use to suction, the gastric contents in case of an aspiration of the patient. And then you can say in what circumstances these are used. So they are often used interoperatively in an emergency and cardiac arrest situations and eye gels are very commonly used in difficult airway scenarios. So it sounds quite intimidating that you get quite a lot of information from just looking at the airway. So now oral gel or gel airways. So when can you use it? So this has to be in an unconscious patient. If the patient isn't unconscious, then you can stimulate a powerful gag reflex and then they can um vomit and then aspirate and then that just leaves you in another, another lot of ball there because you would have to log roll the patient and suction them with the anchor suction. How do you size it? So you want to measure heart to heart and make sure you explain what that means. So you want to explain that you're going to measure it from the angle, angle of the mandible to the incisors. So generally use orange for females, green for males and red for very large adults. And how do you insert it? So I've put a diagram in, you will insert it what it looks like upside down. And then once you hit the back of the throat, you're going to rotate it, then 180 degrees so that it sits in the airway flush like so mm so Nasar Jail airways, when can you use it? So NP airways can be used in most circumstances. So in your os, if you're not sure and it's not a trauma patient, you, you probably will have one of the right answers in saying an NP airway. So it can be given to a conscious or semiconscious patient and it is generally quite well tolerated. So what it does is it aims to bypass an upper airway obstruction. So in the nose, the nasopharynx or the base of the tongue in those areas of um obstruction. So how do you size it? MP Airway, you're going to size it by measuring soft to soft. So that's the tip of the nose to the trach of the ear and they size by length and diameter. So generally a large adult will have a size eight, a medium adult will have a size seven and small adults are size six. How do you insert it? So you want to use a small amount of lubricant and make sure that you don't block the lumen with the lubricant and then just gentle pressure backwards and downwards when not to use it. If the patient is having active nosebleeds, known or suspected nasal fractures, known or suspected basal fractures, just generally avoid it in trauma patients. Lauren g mask airways. Um So you don't tend to see these used as often anymore. It would be more so the eye gels, but it doesn't mean that it can come up and it's always important to be aware of them. So Lary, a mask airways um have a little small mask which sits in the patient's hypopharynx and covers the superglottic structures. Therefore, it's a super glottic airway and when can you use it again? It can be used intraoperatively used frequently in emergency and cardiac arrest situations um and used in the case of difficult airways. So in a crash trolley, you find an eye gel um to be used. So how do you measure it again? It's based on weight as we'd seen in the previous picture and it'll say on the airway, what weight it's suitable for. So what you just have to do is take a an approximate guess you could look at to see if any of the nursing staff are aware of the, the weight of the patient or you know, if they're getting IV medications, there should be a record of their weight somewhere. Um But in an emergency situation, you may just have to estimate how do you insert it. So you're going to insert this into the mouth and move it along with the soft palate and then direct pressure downwards and backwards. So you will find the words that eye gels are used much more commonly than the classic LMA S and you'll find them in the crash trolleys. The eye gel has a gastric port as well, which can be used to suction gastric contents directly, which makes it um preferred to the LMA, the classic LMA, which does not have a gastric port. So this is just images of an eye gel versus an LMA. Um So you can see here, they do differ quite a lot and it's important just to make sure that you're aware of which one is which and how they're different. So, um we'll look at the eye gel first as you can see as we've gone through for you. You've got the size, the weight and the eye gel, the line which indicates the point of insertion. Um And then it's got this internal bite guard as well and it's got this gastro port and then this is the airway going down here and this is where you're going to connect the oxygen to the eye gel. Then you've got the LMA. So this is the mask here and whenever it's inserted, it will not be inflated. So you'll need to um inflate the cuff here. Um And again, you've got this area of the tubing which you're going to connect the oxygen to, there is no gastric port there either. And as I said previously, you just need to make sure there's no air leak. So again, in an emergency situation, you don't want to be messing about too much. Um But you'll always want to check that there's no air leak before you insert it relative contraindications to LMA. So I say relative because you know, there's no absolute contraindications doing it. And it is a matter of clinical judgment and is it appropriate to insert the XY into the patient? So, considerations that you need to have in mind is you shouldn't give it to nonfasted patients, severe gastroesophageal reflux disease, morbidly, obese patients, pregnant patients or abnormal anatomy of the oropharynx. But again, they are relative. So it's they're not absolute et tubes. So will be seen very, very often in anesthetics. And they are the most reliable airway and considered the only type of secure airway and to be able to insert an et tube, you need to be advanced airway trained. So whether that's an anesthetics, ed, et cetera, the et tube, it sits in the trachea above the crena and once the cuff is inflated, it is presumed that the lungs are then protected against any aspiration risk. Whenever it's inserted, it needs a laryngoscope for insertion. So, um you've got either the mcgrath or the Macintosh. So this is your Macintosh blade here and the mcgrath, which you'll see more and more often it's got a camera. So it's got direct visualization of the cords whenever it's being inserted. There's also another a number of other accessories which can be used for um insertion of an ET tube, which you've probably seen on in theaters. Um So you've got your bougie, which is your elastic bougie and it can be manipulated um in terms of shape to go down to help insert him with the tube and then it's removed. Um You've also got the stylet which has a similar purpose, it holds its shape a bit better. Um And then you've also can use um mcgill's Forceps as well. The main complications associated with insertion of an endotracheal tube are esophageal intubation. So, if someone's inserting an ET tube, it's really important to make sure that there are signs that the patient is being ventilated. So, as we said earlier, make sure that the chest is rising and you want to definitely make sure that there's capnography on this because if a patient has been intubated into their esophagus, there will be no ent CO2. Um So whenever it's inserted, you'll always see the anesthetist looking at the trace of the ent CO2, endobronchial intubation is essentially whenever it's um put into one bronchus and is only in intubating or ventilating one lung and then impaction is when it can kind of be and cause trauma into the carina. So I was going to go through actually this diagram. So you can see the et tube goes down into the mouth, goes past the vocal cords. So that's where we use the blade and the visualization. Um it'll go down past the vocal cords and then sit in the trachea. So this is another question we'll just talk through. So um this is a case where you're the F one on an orthopedic ward, you get called to a patient who has suddenly become unresponsive. They are drowsy with the G CS, which is fluctuating between 11 and 13 and their oxygen saturations are 86%. What is the most appropriate airway adjunct using the situation? So the main, the main points of this question that you want to pick out, they're drowsy and their G CS is fluctuating between 11 and 13. So they're not unconscious, they are drowsy. So therefore, they're not going to tolerate a Cadel. Um And again, what we want to emphasize is in your initial management. So, you know, if this patient does progress to an arrest, then your, your airway management is going to change. But um, so the answer is going to be a nasopharyngeal airway. So we'll just go through this as a Cadel, as we said, it's not appropriate because the patient's drowsy, not unconscious, you could stimulate their gag reflex and then cause them to vomit and aspirate an eye gel isn't needed at this stage because they're drowsy, their saturations are 86%. Um But if things aren't improving, then you could insert an eye gel if they become more unwell. A NASA fire in jail is definitely appropriate in this situation. So if the patient is unresponsive or drowsy, for whatever reason, we don't really know what's caused them to drop their G CS, but they've probably caused a narrow obstruction, most likely of their soft palate. So if you put it in a nasal jail area where you're going to bypass that obstruction, um And the patient is drowsy, so they will tolerate it most likely first generation LMA again, not really needed at this stage. Um And youtube again, definitely not needed at this stage as well. Ok. Um So this is another question. You're one of the f ones covering the medical wards on the weekend, your cardiac arrest bleed goes off and you attend a cardiac arrest. The person leading the arrest asks you to manage the airway, what airway should you try and insert in this situation when appropriate? So again, in the main points of this question, the patient's in cardiac arrest. So you want, you don't want to be putting an NP or a gel in, you want to put something in that's a bit more secure. Um And then what airway should do insert in this situation when it's appropriate to do. So, so you're not just going to shove an airway in you want to make sure that there is an element of um preoxygenation before you do. So. So the patient will be the Ambu bag and we'll be getting bag valved. Um So again, a Cadel is not appropriate in this situation, it's not secure. An eye gel is going to be what you're going to reach for first. So, and then when the patient um there'll be someone on the chest doing the chest compressions and there'll be someone bagging the patient. Um And then whenever it's appropriate to do so, whenever the compressions are stopped, then you can switch to an eye gel quite quickly. A nasopharyngeal. Again, it's not secure enough for this for this unwell patient, first generation LMA A would have been considered maybe five years ago, but an I gel would be reached for before an LMA and then an ET tube is what the anesthetists are going to come then and insert afterwards. So you as an F one, you're not inserting an ET two because you are not airway trained, but that's ultimately what they will be having. So we're just, I'm not going to go into too much detail in tracheostomies because there's not a whole lot that you need to know about them. Um But it's more so just to be aware of them on the wards. So there are many reasons patients might have a trache. So to bypass an airway obstruction, removal of or suction of airway secretions to ventilate patients with a neuromuscular disorder or to wean patients off ventilatory support often in icu circumstances. Um And it's important to note that tracheostomies and laryngectomies are quite diff different with a tracheostomy. You've got a surgical opening made to access the trachea and laryngeal anatomy is completely intact and their airway, their upper airways are completely intact and it's, whereas with the laryngectomy, the trachea is brought to the skin as a stoma, but there's no anatomical connection between the oropharyngeal cavity. So the upper arteries are not intact. They are obligate neck breathers and it's permanent and they're usually in the case of um a malignancy. So why I'm kind of emphasizing that is if a patient has a tracheostomy in an acute situation where the tracheostomy isn't functioning, you can ventilate their upper airways um with oxygen. Whereas in a laryngectomy, you cannot because their upper airways are not patent. So this is just a diagram showing the difference between normal neck where a tracheostomy and then a laryngectomy. So you can see that there's air passing between all the upper airway, all the upper airways. Whereas laryngectomy, the point of oxygen delivery is just at the laryngectomy site. These are the main things you need to be aware of. If you have a patient on the ward that has a trie these should be very, very clearly displayed above their bed. So if they've got a tracheostomy, it should say when it was performed um and the tube size, if it's present and you want to know, is it percutaneous or has it got a flap? You don't really need to get into much detail. Um If it's percutaneous, it's usually been inserted by the IC or anesthetic staff where they have just made an incision, inserted into trachea with a flap. It's usually done by the ent stuff in um in theater laryngectomies again. Um You just, they want to know when it's performed, you want to know again that they have the appropriate algorithm in place as well. And it's good that they've outlined that if there's an emergency who you should call. So if the ent team are responsible for this tracking, they might want you to call them, but in all cases, anesthetics will want to be contacted. So what do you do if you get called to a patient who has a track problem, you want to keep calm. Um And then you'll want to get a colleague to believe anesthetics urgently. So this is one of the things that anesthetics will run and we will be with you in minutes, seconds or minutes if there's a problem with the tracheostomy, because these patients can deteriorate very quickly. And then you'll want to get the emergency management guidelines out as soon as you possibly can. So, examples of tracking complications, um dislodgement of the trachea, obviously, obstruction, bleeding, surgical emphysema or pneumothorax. So I'm just going to go through these quite briefly. So what you want to do, it's similar with a trie and a laryngectomy. But if there's a problem with the trie, then you want to get this sheet out, you want to bleed anesthetics urgently get as much help as you possibly can. You want to look, listen and feel over the side of the trie and see is there any air passing through it? Um and you can put an oxygen mask on the stoma and there are um track oxygenation masks that are just a bit more narrow. And in this case, because of the tracheostomy, you can then put oxygen on the side of their upper hours as well. So you can put a 15 L nonrebreather or any oxygen mask on as well. So you want to figure out is the patient is still breathing. If they're not breathing, then you want to start CPR. There's no point in filling about with the track. You, you have to start CPR while anesthetics are getting there. And, and as I was saying, if they are breathing, you can apply high flow oxygen to both the face and the tracking with them. What you want to do is just work through uh organized fashion of seeing how you can fix this problem. So what you want to do is remove any of the adjuncts such as a speaking tube, um and then remove the inner tube of the trachea as well and see if you can pass the suction catheter. If you can't pass the suction catheter, then you can try to deflate the cuff. Um, and then if you, if there's still no air through it, then you can just remove the trachea as well, if needs to be, hopefully, anesthetics will be with you before it gets to that. But it means that it can, it can keep you relatively calm because it means that in an emergency situation while health is on the way, you have a number of steps that you can do in the meantime, ok? And it's much the same with the laryngectomy. It's the same protocol. The main thing with this is that there's no point in giving them oxygen um through their, through their nose and mouth because there's no air passing through their upper airways. Um And again, help will be on the way very quickly. So just make sure that if you are working on a ward or, you know, there's a tracking patient or a patient with laryngectomy to make sure that all these things are in place and to make sure that there's emergency protocols there as well. So that is everything for me. Um If anybody has any questions, feel free to put them in the chat box, um in terms of the feedback form. So once this presentation is over, you'll be emailed with the link that will allow you to fill out feedback. And then once the feedback has been filled out. It will generate a certificate for you. So I will stay on for a few minutes. If anyone has any questions, just give me a shout. Thank you all very much. Thank you. I'll give you a few more minutes for questions and then I'll just end the presentation. Yes. Ok, guys, I think I'm just gonna end that there and thank you all very much for attending and filling out the feedback. Ok? Hope you all have a good evening.