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on, uh, welcome back, Teo. The final session off our collaborative hybrids Airway Webinar Workshop. I sincerely hope that you enjoyed the content that you've been receiving so far. We have now concluded the practical a technique or interacted part of the webinar on. I'm very excited to transition shortly into the International presentations. Three. International Expert Session If I just can't spend a minute on a little bit of housekeeping just before we make some introductions for the international workshop you will receive. If you registered for the event on email afterwards, that will give you a link to a A feedback that certificate. Sorry, a feedback question there that is being held through a third party collaborator. Medal. You'll need to register to do the feedback with your email. You'll get a CBD certificate issued immediately afterwards. It is useful portfolio and platform, but if you feel that you do not want to use that platform for words, you can cancel your account after you receive your certificate in. Additionally, on that email they'll be a link to a year or albut. We will host recording off this entire event so that if you had to miss things because of clinical commitments or otherwise. And you'd like to go back on review something that that wasn't entirely clear. There will be the city to do that for a period of 5 to 7 days after this event. Um, also, if you're we've had some feedback from a few centers around the country, if you are interested moving forwards as we take this inaugural event into its next interational in in the coming months, watch the space will promote when we already move this forward. If you're interested in hosting a satellite hands on workshop, very open to having that dialogue with you, please to get in touch with the contact details on the registration page. Now it brings me great pleasure to initially introduce my colleague, my friend Jay Dawson, to my left here. First and foremost. J has been a mentor to me on Still is on. I continued to benefit from his wisdom and his technical excellence on expertise. J has been not only a consultant to me when I was a senior registrar, um, but a colleague now, as a consultant for the last seven years on J is very well placed. Teo House, This international session he has presented internationally at numerous workshops and conferences. He is taking the king's difficult airway workshop internationally on collaborated with many of our colleagues that are present today on the expert session and we're very, very thankful to have him with us. So Okay, I'm just going to go through a few introductions and I'm gonna let you sort of talk to the audience about how this session is gonna run. So first of all, it brings me great pleasure to introduce a doctor, Ted one his a senior consultant, Any statist at Singapore. General Ted is very generously agreed. Teo partake and give his expert input during the session, despite the fact that he's waited very patiently after a long day at work. I know it's not long been home his seven hours ahead of GMT time in Singapore on. Yet that was no impediment to him partaking in this pen. He was born raised in, trained in Canada. His completed your anesthesia fellowships in London, Ontario, Canada. He spent over 20 years in Singapore gaining extensive experience in every management had neck surgery. Hey, heads the airway group in Singapore General Hospital. Hey has been instrumental evaluating and procuring various airway junks. He's presently platform director of the critical Care and anesthesia workshops at such a single general hospital in the Surgical Skill Center. It was full service mental in starting the first National Airway program on directed the inaugural Naps Course National Airway program, Singapore. In 2018, uh, doctor was published. There's articles and airway management has been given numerous talks and conducted workshops both locally and internationally. Imagine it difficult. Airway is Ted Kennedy. Here's and high to you from London. Thank you so much. Hi. I'm going to proceed to a few more introductions and I'm gonna have over to J for the rest for the rest of the session To Mexico's me. Equal pressure to introduce doctor racket guard all the way from Delhi. Doctor Guard is a senior consultant in critical care pain on a pallet of medicine. His editor of Engine Journal of Anesthesia Hey is completed. Fellowships in palette of medicine is an image just intense fist pain. Imperative Medicine Physician. The list goes on. Who's associate associate professor at the department of on Coke. And it's the Z ology intensive care pain medicine at the all Indians to to medical science. He has. He has hundreds, if not thousands of international publications. Is offered countless books chapters. It's delivered hundreds of guessed lectures on it's been a panel member of various discussions that National and International Conference is on his conducted. Many, many workshops in the field of Difficult Airway Management is a serving editor and extraoral board member and revere for various national international journals and has extensive research exposure in the difficult airway management. The situation continues to be serious in the Indian subcontinent on, despite the fact that he has been huge demand clinically on his non clinical time is significantly taken up here. Managed to the most recent coated surgeon deli with his usual skill and expertise on Has still found time to be with us this evening. So very nice to have you with this rash on. We'll be hearing from you shortly. Um, also, I'd like to introduce Doctor Bardia gonna tell from Columbia true longer bar here, and I go back quite a way. I think it was about 16 years ago when I was starting out. My anesthetic journey is another. Anything that South and hospital when we first came together and work together on. That was definitely a fun time. In an instructive time, I think, for both of us on Bar G was new to the United Kingdom at the time. We have reconnected in the most recent years when he was instrumental bringing and collaborating with Kings International Airway workshops on Bring Us Up to their annual anesthetic in intensive care Congress in Colombia a few years ago, where we delivered one of our workshops with his collaboration. He's a senior lecturer in anesthesia in the division of anesthesia. Critical care pain in department surgery at the University Off Colonia and Strong. His interest include purpose of care for compatibility, anesthesia, liver transplants easier. And he's been a driving force in developing that service in for longer. Other interest includes the eye surgery airway management with limited resources. Once again, the situation of your lung is serious, cases are increasing and he has been incredibly busy and still found. Time to prepare partake with this exciting session and finally, but certainly not least, Li like to introduce doctor car fixed in duration. Hey is a anything test from the Rasheed Hospital and Trauma Center in the Tube i Health authority. Carpet has been a collaborative the King's International Airway workshops for several years now we have strongly with by health authority. He's a friend and colleague Teo, the King's international unit on Until the pandemic began last year, we had been riding on site support aimed difficult airway fact. See development by on. He's been helping associate with that when we go there a couple of times a year in running their own local events on. But we have developed a reciprocal partnership where cardigans colleagues have come to kings and been faculty at our own work shots in London. It's a specialty interest in clued regional psoriasis, even difficult airway management. And he's a faculty member of the King's international difficult workshops on That's Enough. In May, we have a very esteemed panel I'm gonna handle with Jay. He's gonna tell you about how the following sessions gonna work on. We look forward to some interesting cases. That's very much thank you very much. Brown, that is. An exhaustive list of qualities are for this international present is on faculty today. I'm glad to say the the 1000 soap paper loved on to the meeting. In the moment, we'll be blessed by sharing these expertise around the world to discuss media's cases touched upon there clinical context within their resources, on within their limitations, on at the same time that they're more than way off doing babies, things we can discuss in detail with all our police internationally through this program, that's the name of the program. The case would be the same anywhere in the world. But the manage on the philosophy on little sources are different. A different part of the world. So, really, sometimes you have an open mind approach things in healthcare on patient safety. So once again, thank you. Or, if you, for taking part in this international session off kidneys collaborative webinar. So, um, to start from Ted. So I guess Did you have a case to share with us? We would love to hear from you on. Could you take us through a place? Okay. Thank you, Brand. And thank you J for that wonderful introduction. And, uh, thank you very much for inviting me to speak up so really great. Simple game. I know it takes a lot of work. Uh, since we have a limited time. I'm just going to go quickly through this case. Uh um, I getting through. Okay. Can you hear me? Can you hear me? Okay. Okay. So thank you for the introduction. Thanks for the introduction to you and Brand and J. And, uh, thanks so much for inviting me. So I know how much work you put into this. Um, I'm just gonna go since the last time we just go straight through the case presentation. It's actually a 33 year old female she presented in 2015. She, um she had she was coming for, Ah, suspension laryngoscopy and laser excision of multiple laryngeal problem stomach Tosis, which is from human papilloma virus. And she's been having this problem since age nine. Have multiple GH multiple suspension laryngoscopy, some laser and excision. She actually presented a three weeks post partum, and she was having breathing difficulties through, uh, her last term, but she delivered, okay? And then one week after she, um, postpartum, she presented the n e. The emergency department of Dyspnea. She actually settled down and then was discharged under ent to come back a week later to have her, uh, essential endoscopy and laser. She was seen by one of my team colleagues who's airway specialist. Uh, and, uh, he actually committed to having a week awake bond piece to secure area because their airway was grade four. Uh, laser went okay on, but she was discharged quite quickly. But two years later, she returned. She was 35 years old now, and she she came 13 weeks pregnant, and she's quite symptomatic. She needed two pillows sitting upright, almost sneak. She was, uh, at mild strider at rest again. She was coming in for laser surgery for either suspension laryngoscopy maybe with the inclusion of the robot. Ah, but this time she refused. Actually refused it refused awake a manipulation of our area, including a week tricky ostomy. Uh, as you can see on your nasal scope One week in ent. She has multiple, uh, papillomatous lesions, almost including the entire airway. Uh, so the glottic opening is actually quite obscured. So what was the plan from my colleagues? Um I steam colleague. Uh, his plan was to inhale the patient down the evil and tried directly laryngoscopy with the bond piece. Rigid scope Plan B was needle cannulation cricothyroidotomy combined with a monsoon jet ventilator plan to see you with to do it A a tracheostomy now in discussion with anti he discussed on table name is a needle scope before inducing. But together they found that it may be a bit too worrisome to stimulating. And she may go into letting us as, um so that was not done at this site this time. So everything was set up. All the equipment is set up. Everything was checked. Ent was scrubbed and ready to do it. A tracheostomy. Uh, the patient was well preoxygenated and inhaled with evil. Florida 6% when she got to unending title of CVA. Oh, 2.2, though she started, uh, obstructing. And she actually, they lost the 02 completely obstructed, uh, cpap that background, but her oxidation still maintain it 100%. So they inserted Robison, which has a little crackling fire daughter me 13 gauge was inserted. Check. She was paralyzed with rocuronium, and the monsoon was hooked up, but it failed despite having working, uh, 15 minutes before. So, Buckley, we have found by and they had ready what we call a rapid Oh, to set. No, it was hooked up the patients, and 1 m of option was delivered to the patient through the rapid. Oh, to set, uh, she decided, traded down to 63%. But with that insulation, the saturation quickly, you came back up to 100% within 20 seconds. Okay, The rapid Oh, to set, um, we don't have availability of, uh, manufactured one. Uh, so we make our own, and it's basically a knocks it in to being hooked up to an oxygen source. There's a T piece there for your thumb to include, and then another tubing that goes and your locks to the IV cannula. Uh, and all you need to do is crank the auction into 15 liters per minute. Uh, which is 250 cc's for second. And if you give a four second breath by including the of tea piece by your thumb, you'll deliver one leader of oxygen. Okay, so she was reaction ated. They tried a combined using ah McCoy, blade laryngoscopy and a bond, but they couldn't intubate because there was extensive proliferation of the lesion, which is completely covering the glottic opening. If you see in this picture oh, they used the rapid. Oh, two to insufflate, Uh, two second breath, uh, to prevent the saturations two from falling below 95%. So if the so, if they held in 95% they gave it to second breath and they were able to maintain oxygenation while he and he did a sleep. Tricky Austin, unfortunately, are unexpected. There was a goiter that prevented ent from cannulated for 40 minutes. And at the 30 minute mark, uh oh. Two was 130. The oxygenation was fine. Um, they After the airway was secured with the tracheostomy, they proceeded with the laser resection. Everything went on Remarkable. What the I see you was decannulated within 48 hours and sent home with less than a week. And six months later she was discharged. She delivered a healthy term baby. Sorry, I can't hear you today. Uh, can you give me now? Ted? Hello? Can you hear me? Hello? Ted, can you hear me? Sorry. I can't I can't hear Jay. Um Bhakti? Yep. Can you give me now? Yeah, okay. Yes, indeed. One of these cases where you plan ahead everything on then. Everything is standby, including you. The surgeon Stand by. Yeah, on. Do you take a a decision to go ahead on, um, then you know, Well, good. We got a always that is the the saturation we can deal with it because any moment you got any decided standby to do something to go to for a transtracheal access, but this'll kind of cases that can end up in any hospital on. But sometimes it can be extremely difficult to manage at the time. Because of the tumor e of shown on that screen, that is almost close the glories. Now, my interest is would you consider What do you think this is a good practice to have a nasal endoscope? E one routinely, for all the supraglottic relation patients, Yes. Uh, it's I think it's actually a vital important to do actually on table nasal scope to take a look at the area in these situations. Because even in this situation, even in ah week's time, something has changed. There was progressive growth that, uh, changed. The basically changed the airway in the situation from being being able to possibly intubate from the top, being impossible to intubate from the top. Uh, and, uh, and we. And unfortunately, my colleague Patrick Long was, uh, handcuff by having the patient refusing awake tracheostomy or awake manipulation of the airway in most of the procedures in this time it is it is tricky. As you said, that patient, they won't give a consent for a wake Truculent a patient or awake bronchoscope e or any off the form off the of a technique. Then you are You're handsome, Tired. I could agree. Nice endoscopies. I have feelings. Having seen the slides from you and listening to the story, it has to be a mandate for all office to try and to see through. And if you can do by yourself through any anti surgeon, can you do, in essence, a scope? You get a picture? Can we have a little bit? Make an assessment on. I'm sure you can do that under just topical Is Asian want you Correct? Yeah, it's a simple procedure, but there is something we can learn from that kind of an assessment tool and 17 cases off upper airway tumors and pathology. What? Do you get it? Yes, Yes, I don't. I think my colleague was agreeable to go through this process because access to her the front of that access was quite free. And he was quite comfortable that if something were to happen from above that he could quickly secure, sort of ah, oxygenate her through the needle. Cannulation In this situation, I couldn't quite agree. That's right again. Having had the Plan B in your mind make it life bit more easier, I could agree. Now I just want to raise a discussion that I'm sure the years would have the same kind of a kind of a night idea. In their mind, it's case like this. Would it be reasonable? Teo, do transtracheal oxygenation while we are manipulating the airway or inducing the patient. Um, I I think it's a it's a good idea to do it. Um, there are three main methods of oxygen through the cannula. Um, and, um, one is the classic hook up three pieces for three cc syringe, 70 TD connector and bag valves. Uh, use the bag mess lard old bag the bag through that. But that is the resistance. Inspiration to bag is tremendous, and the egress is quite slow, so that's not very good. As I said, the Manugel is Ah, horrible machine. Uh, it pressurize is too much. There's no feedback. Uh, you need, um it's high risk for barrel trauma, and you need to actually disconnect to get egress and expiration out. It's a highly dangerous instrument. Monsoon is better because it has pressure. Relief are pressure limiting factors. But again, it doesn't have any feedback on it. And but the expiration is not too bad. The but the rapid Oh, to set that I showed is cheap. Easy, fast the hookup. Get the oxygen in, uh, there's you oxygen it based on saturation and not buy time, not buy volume. So you have plenty of time for exploration through that tubing. So, uh, wrap. And since you have a tiny hole when you candique cannulate, everything is fine and d can it. There's only a tiny hole that used the repairs. Itself close is over, as opposed to a scalpel Bujji technique that has a size six p p into that cycle. Thyroid. So it takes time for that to heal, so it's not so innocuous agree. Now I just want to ask our other international panels, starting with Kartik. Do you think it's like this would you put them awake Transtracheal oxygenation under local anesthesia here before he induced. Is that a possibility? In you were practice? I'm feeling better today. Yeah, for this patient, I would like to because, you know, with the victim streaking Look last take it. It's just a nice present, the patient cough keeping here. So, you know, and it comes to the popular Spoke here in something. Thank you. Rocky, would you what should be on it? I think this is a good option. But I think off the for us. On with us, I think. Okay, Nations that interruption. Because once on one side, we are openly and separating the idea that will help us to prevent a puffing and back injury in the management but simultaneously Mission Also hoping for the surgical access in this on. But it's not a race with here because when it is even if you recognize the medication has some type of every concerns issues the letting your woman please a lot. So if there's something of it the the movement of the operation but not the main strategy Andrabi elected give the others on machine. Also animal, get a management. Yes, You are not under the point. Don't now to localize you sell the sound scan to look. Look at exactly where you're going. Identify the place on Put the cannula in oxygen it before he induced. Thank you very much for all this. Anything bad idea. Would you like to add anything for that conceptive? Maybe up here, we're We're trying to see cases like this to give it a thought for Other's gonna say for practice. That's That's the one of the one of things we can do for the listeners. So what do you What would you say to that? I got you? Um, geez, patient was a I remember, right? Patient was breathing, but reading with the little difficult. So I know she might have sent her down a little bit with type flow oxygen, and she might have. You better be in bigger from situation, too Front access, if you thank you. You already have appointment with now than high flow oxygen on top of it. That's even adding a better safety. But remember, this is on a background patient doesn't give incentive for a Vectra killing depression. Otherwise, he wouldn't do any of these things called agree, but that that we all agree with you the management off transit your oxygenation is a good option. But the instrument we use can be different from one place to the other. There are issues we transit that using manage. It has a a tid if you say if the BP sitting is not on the right More to start with as a problem to king or sort of things are possible. I critically on that issue. It's just very carefully performed technique. If you want to succeed so and also we don't use it on a regular basis. A swell so like of experience also cannot have to the complexity to it. So I guess you have a part to for this case, Ted. Yeah, going then? Okay. Sure. Um, can we put up a flight? Can you see this? Like now this case 10. Okay. Just the bee need to go back. Okay. Now the same patient comes back two years later. So in 2019 to seeming the ent clinic, she was asymptomatic, but on nasal scope, they saw extensive lesions and it may possibly go subglottic in terms of the extension again. She refused awake. Tracheostomy. So this is the picture even worse than before. Um, so the plan this time was again, uh, a week nasal scope on the table or sitting up the check If she's intubated from the top, Uh then a week later and your mask are awake Super glad device, maybe for ability for egress Or maybe even for low skill Fiberoptic meaning intubating through the air and Dilma fancy was again sleep needle Daniel a shin and jet ventilation and plan D was asleep tricky off for me. So she was given sedation with, ah, 1 mg of midazolam infusion of Remicade Sentinel. She was topical eyes is the Neris and the nasal scope again extensive, uh, lesions that they determined that it was not safe to pass any tt from the top. So she was topical eyes her or a fairing by gargling picnic A knee and spring with 10% picnicking And the size three Ambu was inserted while she was awake and seated quite nicely She had acceptable spontaneous dental a shin through the, uh Superbowl like device and entitled to tracing was good. Uh, people with started gentle uh, positive pressure was initiated and they lost the airway. Uh, this is just a schematic of low skill fiberoptic intubation. Um, again. So, uh, Robison was inserted immediately. 13 gauge IV checked again, and the monsoon was, uh, connected. And this time it worked. Driving pressure was 1.5 bar. Uh, inspiratory time was 40% 100% auction. So on the pasta pressure, the politician was less than 20 centimeters of water and Tyler to with being through the paper chart device. So there was expiration past lesion up into the laryngeal mass. So at that point in time, the decision was to proceed with the tricky ostomy. So, um, once the tricky off new was in place, uh, cannula was renewed moved, and they lasered off the inferior portion. Then they, uh, lasered off the superior lesion that was just attached to the undersurface of the epiglottis. Then they lasered the lateral walls, and you can see the glottic opening a bit and the vocal cords distally. And then they changed to suspension laryngoscopy from the robot. And then they continued on with the excision so that they could see the glottic opening on the vocal cords. That's a lesson to learn. from you. That is a patient with a difficult that never go ahead. And from you they would come back to you. Probably because you you look up with very well. That may be the reason why. But either way, you can get it off them that we need. We have an obligation to recover them when they come back again and again. That's another example. No, I just Hypothetically, I just this it take this the next level. And I would really love to see you expert opinion on that situation. Say, for example, this patient engagement. She came second time you try to put the equally be honest constipation. You couldn't wait till eight. Um, you could in the debate only. So you try to be in the late with the house in and need, um, unfortunately, take for example, if you could invent let you succeed in this one, but it occurs to me That's great. You got time for that? It was something happened. You couldn't oxygenate through that needle. You know, if you go for a friend off neck access in that rush, would you go for a scalpel body technique, or would you go for my board Cannula technique. Calm me? Yes, in your part of the world. Oh. So, um, we initially try, uh, needle cannulation and rapido to, uh, usually, uh, up to probably one or two attempts. Uh, if that feels, uh, and actually, I don't usually recommend the rabbits cannula. We actually recommend the 14 gauge inside catheters because they're cheaper. And they, uh, they don't think a smudge as Robison cannulas and the cannula, the Robison's are can only be tried once because there's a curvature. So you cannot read. Put the needle back in or you poke a hole through the cannula. Despite that, we usually recommend are algorithm is 2 to 3 attempts with the new cannulation. If that fails, you go to scalpel Bujji technique, and we have three packages prepackaged, um, except on all our anesthetic carts for this. So, uh, needle crack a thoracotomy, followed by If that fails. Scalpel. Booty technique. Uh, that's for a pop alone that, you know, the way you practice in six. That's that's really really information. Thanks a lot, because they have a society. It's a different part of the world of different teams. But thank you for sharing with us that one. So just to summarize dead in this case, became with them Is the northern always some bringing something back in the cases like a supraglottic tumor where you don't get a consent for a break. Fiberoptic information Potentially transtracheal oxygenation under local anesthesia here could be a safer option as all of the international fighting degree on that one. That is something be explored from your case. Thank you very much. Sure. I just want to point that that is. Our algorithm comes from the Australian group who's gone through, like, 10,000. More than 10,000 cases live animal workshops and they've tried everything, all the equipment and all the techniques and things like that. And let's where this algorithm case from in terms of needle crackers coming because you can do need a car, Kasarda army. If that fails, you can go to a scalpel. Fuji Technol. But if you start with scalpel booty technique, you can not go to needle cannulation. And the other thing is, the most important thing is if you cannot help the anatomy, uh, scalpel. Boogie techniques don't usually are not as successful in my mind. And if you do a scalpel Boogie technique on deep untapable. Tracy is you'll fail because, uh, just because of the anatomy itself, Um, I think I have a slide. Ah, that. Oh, but because of the trachea is so deep. Yeah, and you're holding it between your two fingers and you put a scalpel into that trachea. Your booty will not follow the Tradjenta really about scalpel blade, and I'll go into the paratracheal fascia and you'll kill the patient. Whereas if you hold the trachea with your hand fingers, it's much easier to cannulate with the needle into the trachea. Slide the cannula in and hook up an auction it through the temporary to get oxygen in the patient. Thank you very much for that discussion at Ted. So I let me go back to, um, rockets now, like it's how you doing. Thank you. Thank you, Thank you. I know that you have a very interesting case to share with us. Could you go ahead, please? Absolutely perfect. So we'll go ahead with this is which is a little was nightmare for us, but successfully not off learning experience worse on at our parts for a country, we are getting such cases mark very frequently, but not very rare. Also. So we get such last two months which are ignored because of the students off people they can't quite fast, better on their own as you lose muscles in the neck, which I did and we had a passing moment basis now. So I guess I see this case is they're 65 year old gentlemen, they don't stick easy on us. Progressively been sweating over the back with years. But he was complaining that this swelling was going over years of any answer. So but last six months, it Insulin, please, And see the mask here. This's vision was initially you had many testing and sit down, so I So it appears to be a benign pattern. Mass index cents on examination. I just love it. Normally when I had the party history, a party waas a hyperplastic not a doctor, but some amount of sleep acidic in preparation for the cataract is on. That is what this patient for subject. Let's see now if you see the pulse, I love this tumor. This is just not a lot of mass. But you received the rescue therapy because of the Venus trainers have enough for any hospital of the vessels. It was draining the area from the Internet area between this part and they all work very, very enclosed on this mass was almost served on building the suppression Arabia. He was at the immediate and it was extending all the work for the last, you had a mass eso. He must plan for a little tired on districts issue. Because when we get such type of difficult pass, what every certainly are we looking for If you see that there are really say that yes, animal person of gives a lot off. Help us to add an immediate send these patients. But in such basements, it becomes here Emitted also So, um, conventional about Opie was appropriate. Remember the last 1 to 3 in that movements, but otherwise he was not a banding off any other areas like a spine, but one of the neck mass. His movement in the neck was similarly is especially perfection on even the neck. Because of this mass, it was not able to rest in property. He underwent a unity one reason for the open pass. It was left a little more much fixed the left from cause I was not opening up. Probably this means that the mass was desperate externally, but it was impeding some of the environment barking cough and Extavia also on the the paramedics examination was done by us, and I have to look for what other thing needs to be done. You see, the echocardiogram most normal. The patient was padded, but he still had a patient pause on elevation. Now there becomes the issue that J What investigations are you looking for? For this patient, we have already know off assessing clinical perimeters. You know, it's not always very useful, can look externally but actually happen internally. You do not know it always become a day limit. That what external? And we have a suspect from the body morality that we have, which requires, um, a raise. It is an immunity construction to render scoping ultrasonography insulin before on be, um, using them more. Now that it's more interesting Center humping incest. If it is this on. When we were there for this patient for CT scan, we found out deficient as And now this is the accident again. Before that, you're not able to show that it was some substance extraction part for this because the mask, while overhanging externally or restaurant but we couldn't be very sure about that. It's going to send. You also see CT off this patient for the compression off atrichia on the stripping was happening that this is an important point because of times will be missed. The structures on CT scan because if you see the sickest and reporting by the radiologist, they usually recommend in the mail about the area. That would be mass mass compressing on this area, but no much pills out there. We are in a habit to have a discussion for all those amazing that be on it. So I don't know exactly that regarding in. But what is the external tumor on what would be our plan and see and found that there was a percent also equally normal for this patient. Not this patient was posted for on the remember us out to go, but that go for a week situation are you Are you using off your list of blocking it? So I think this wasabi dilemma because initially, when we tried to talk being a difficult every being a difficult that personal by a dissipation probably would be okay for a week. Information. Somehow the patient refused for a week on the managed, ideally discipline we have fixed up in more discipline, expiration at times and patient. Absolutely. Choose that. Do anything. He's not going to get gently intermitted of it. So he insisted that it has to be under here on that. One big dilemma with us for managing is that a big mass eyes, a big issue and strictly about Christmas spirit, you know that a longstanding weather probably would have a documentation on those times that it was a really a nice situation and just thinking, What about it on, uh, 20. Keep this was a planet we were thinking off. What other options to be Have a plan B. You can go ahead and do a check there endoscopy and see what actually is the location after this? Whether we can survive prostate. So, you know the plan? We were thinking of state. So any comments from your side off? I was just thinking that, but the plan and strategy would be okay for this type of patients. So, uh, so what? I'm going check Letting was probably a big dip tight for check during osteopenia. Really? This is for awake and that looks like on at this point of time, we started giving the patient in relation induction hoping that the junky are not prolapsed because of this last mask You had an assistant. If you had it up on, probably it waas happy. We were able to maintain this point in this revelation without every are special at this point of buying, we tried that it was okay, but you were not able to look for anything. The tracking opening, the bloating up being was not visible. It was such a mass. They just need some portion off the molecular on five off, but not able to look nice. But the doctor says, um, probably it was for anything in the cities and so that it's just not getting, but it was shipped it literally and opened it posteriorly. And that's why you're not able to locate the location off. Ignore it is to put a bet you options were we could go ahead with the most asleep fiber optic preparation for this patient. But again, now that we've tried asleep have information for this patient even having a lot of issues because they're not localize properly on. But we realize that the notice what? Just not chipped in literally and posteriorly. But before that, the mass it waas literally compressed. Also on that is what a dynamic teacher happens here. Assessment of Astelin investments for again for us that when we get a stick city limits, probably it will not give it the same one. The patient it induced anesthesia before they changed it. And change in that is reckless and you're seeing and lot of patients who are coming for every management for every certainly that. Is that a big agenda? It's absolutely a big issue plan was so proud of. Device is a rescue medicine and we thought using the same because finally, suddenly wants to be done. Not in the device is it has to be directly incubated on probably on a limb. A common rescue breather for us. Obviously the surgically and it is absolutely got option. Are you gonna be my last movie? We don't keep understand Bite size and noncardiac here going back, especially on now that we were able to succeed. You think I made on because you detected interventions using clue. I limit on five. Broken the wonders off using devices. Waas. Why? I mean, why not at this particular device is the reason being I mentioned? Check your blood. This was, you know, period. Ship on compressed. So we want a proper circulation off it and probably the I am a guided us looking. It's come over the noticed by rotating it on. It helps us to know it appropriately, and it must guided by fiberoptic from Pacific information. Probably this type off combination off lose. Probably help us to secure the instructions on that is how labor matter. What do you do? Thank you very much for sharing that wonderful case. I just can't take my eyes elf from that slide with that type of tumor. That's muscle. Everybody would be hesitant to anesthetized case like this building, guys. Mm. That a couple of things. I just wanted us because I know you do a lot of media center to mirrors, and it is kind of mitral kill mass lesions, including cancers. So I just want to use your expertise to light the people on listening to this talk it you said in your presentation that it's a CT an MRI. Come back and say two centimeter, Track your opening or 2.5 centimeter. Typical appearance in the situation. You've got a number. So when we have a number like this, we know for sure that is the number at a particular face off the scanning. How would you take that number To make a useful information for you to guide that this struck here, Metro Kia is okay for me to pass the tube. If I get into the trachea up, a trickier I can't push it down. How can you assess or guarantee as such a small measure on the CT scan through a dynamic investigation? From your point of view, I think this is how wonderful question. And I understand we have many cases where we have found that the dynamic in aging got animal numbers were not matching really time management to do with the patients. So finally, I think that might be just mentioned that you have not to treat CT scan. We have not complete numbers about Pradaxa. Finally, that patient on the stepping down and the pictures they just give the future. This is going to happen. So if the staffing, um, it gives me that that you could that we don't need this much, probably this will help me out that Yeah, I would plan something because if there is a plaque in infiltration, if I pound up for these and is just compressing on the street here. But the trick, Wallace, normal the factories and with you here on the mask is clear. This means the infiltration is not happening. So this assured me that in case if even I am talking about this easier to year, maybe Interventionally intravenous if the checkup, the lapses further, I have some reading to lift it up, as happens, invited. But if you see the malignant leaders on, it's the same number is mentioned for. The malignant is, um there is not much at one days off lifting the mass because it's a hard cast on it will remain the same. So in that sense, I will say that the American legions are better far for last understanding as competitive, benign reasons where the disgrace, absolutely, really time when we do our management. So this is a learning experience that it becomes important for us to understand How much is the duration off Mass? What in the city? Extent of the mask, Just not the everything but the mask. Also, we need proceed ourselves in the in the picture and in the radiology. But that is a clear fact late between the lesion on the trachea on also be a little unfortunately, the patient finding if you see this patient facial able to sleep so fine, just keeping up through pillows under the head. So if somebody can leave sleep, so find this means probably even the dynamic compression was not happening. So this means that clinical picture, maybe at times we can even exaggerating at times. But the patient I just asked him to. Nice to find and take a big breathing and fast breathing. You want to try to three. And if there is a borderline trickier constriction, the clinical put the first and the treatment starts happening. So it should be giving a pill that the idea of problematic thank thanks very much that's in the system. That's a lot to add, just just apartment just from. But seeing on one is on the CT findings to go along with the clinical features on the high kiss the way, as exactly said the positioning Asleep have pillows or the world these things out up, I would imagine in a center with the facilities you could offer a diagnostic bronchoscopies on to see the dynamic city on the construction. Now, at any point say you mentioned about the carcinoma on the tumor is malignant. Would you consider at any point distending if it is a critical artery happening before the anesthetized? Absolutely a lot off standing. But for you open it like boom two months. Because if they're not incident in the cheek, Yeah, we don't give you a standing for these patients because they are able to be a A Get them operated. We keep them integrated for 24 hours for you. I think you have being up the issue of accumulation this patient, because expression can happen extrication the bottom of feet. Long standing, vital masses hemorrhage. It happened. So we keep the pill for a couple of us, usually a day on, then look for the response. So we're not doing standing off. The and the zombie of our patients were able to extubate pretty for forget us, even with these large muscles, because fibrosis will happen around the trachea, the collapse, it really was. But yes, even in positively, we would ask the other surgical police that how much is this softening off Hilary's on How much is the number off? Three killings, which have been softened by the mass. So if it is one or two, we are happy it will take the conclusion of limiting. But if there are four or five things which are suffering extensively, Saltman, that it becomes a shin. And we are partial that these patients may be quiet last me at end of surgical, but yes, in a curative in and we're not putting the question, but in case if it's for value, depends on Last Mass is yes, we are going for putting up expenses. Will standing for these patients are the times that panic person. We put up a silicon stand for his thank you very much against that is humid inside into the dynamic airway is conceptive. You will talk about all the time, but we don't put that in the practice until something goes wrong. So a million 70 more or redose telling tumor or a front of neck, and it's a swelling, but you think they're extending for the down and symptomatic If we could land something from your case to say dynamic Laden's that dynamic airway assessment, either by symptomatically looking at how the patients hours, if you need you may have to go for a bronchoscope e under topical is a shin just just to see whether the inflammation or how compressibility is Thank you very much for sharing the time with us. So I have to move to a bad idea at the for this case now by get any Hear me, you j All right. Okay. Should be up moving, Going to write. I'm going to read out your slides. Uh, so can you give me now? But I can't make you Okay, so we have a 45 year old fit A patient who had an idea Cervical decompression Down on the day three POSTOP, the patient developed an acute shortness of breath. Basically, this patient was coming out from the toilet suddenly basis felt short of breath and control on suddenly decided aerated. So the three post indeed a cervical decompression in the world. The patient was managed with this 100% sorry. 10 liters of oxygen on the face mask on saturation was still going down to 70% and lower when examination the neck was from the Solan on the hard on palpations. So, uh, to the question is rising now is if you are to give us you are especially is to be on this case. What are your initial thoughts regarding this patient's condition? So these patients had a recent interest receptor me. Um, and this, uh, acute problem is progress very rapidly. So, um, he's his hypoxia is evolving rapidly, and this patient is in the war. So that's not the idea of environment to manage it. Um, so a few few problems that I need to consider mean concerns would be this rapidly progressing. Hypoxia, Gary, obstruction. Um, would I be able to handle this case in the water, or do I need to move this patient? Is it safe to move this picture? And you know, if I'm off this patient, how easy is it going to be to secure the progression? So it's probably given the history. It's probably a woman, uh, possible it may be an abscess. But given these it is, I think it's like a B vitamin, which needs to be decompressed. Big things that I would consider. Okay, so to you, this is a rapidly deteriorating patient on it. Something need to be done on, but, um, so become palpate water pump. It is a hard on insulin. As you mentioned, I agree with you that most likely thing in there because a day three POSTOP um so patient is, um if this patient is mine, is there were management. What do I say? Would you give in terms of a restaurant? Itty. But we can see in your view, So whatever strategy I think this patient needs to be oxygen and it. So using high floor human fat oxygen might buy us some time. So maybe you get special into an operating theater or intrinsic area things. I don't control it. Um, my, uh, shot that you would be try, uh, let in jail abroad. But maybe using a week during a scopic technique just to have a look, see if there's a possibility of have in the store he started and the RV. But I would also be ready for front of me access you for now, Uh, in case that feels I would also get my surgical colleagues in because, uh, legends it like us to me. My your life. Saving this situation, cortical. You highlighted the points. Absolutely. That's right. Gravity that this is something I can't go by myself. I need some help. Expert help is anybody can auction it with more better by high floor, if I can. Yes. It's a good option to consider another letting us copy if you can. Most of Thomas, you know, not really. The outside is swollen inside is swollen as well. In this case is like a city postal bleed. So yes, court rightly said so. All those things. So what happened? Let's have a look. So what side? Because oxidation Moscow to happen early or decide in division attempted. It was a consultant sled ever care, but unfortunately, they couldn't see anything in the structures. Everything was swollen up on, but they created a bit. So patient was still desaturated badly. So, um, that friend of neck waas tried And luckily, a size six endotracheal tube or excited on the patient Waas oxidated. So at this day, specialist able Now. Now, this is where we need a bit of discussion on a bit of, ah, guys from you. If you were managing this patient, what would be the decision to do the case in the world war in theater? You mean following the know if this was this this happened in the board? Yes. What? Do you do that in the water, or would you advise those people who have done it Say, Is that the right place to do it or what would be you? Are you on it? Oh, I think given that this patient is deteriorating rapidly, I don't think we would have time to shift this patient to award. So it's not ideal, but it's probably probably needs front of me access in the world. Um, whatever facilities available. Yeah. Okay. Now, if you take this as an example for us to layer to be old and from listen, let's let me lessons from incidences. If we pick up this mid earlier if there was a bit of time in our hand, what would your wise with your wife, Teo? Other recent? Yes. Definitely. Because, uh, you have skilled assistance. You have your equipment that the surgeons ready? Scrambling, ready to go in. It's a more controlled situation. So, uh, operating did it would be idea. Thank you. That's be done in the world because of the situation. But we could have picked up more, Alia. It just it could have been highlighted. You basically got a lot of time in the world. I would say if that Wasner the case basically have been done The attar on a bit more safer. Where exactly? She said thank you for that input. Uh, Now, um, there is one thing I would really like you to just add on to it sometimes the surgeons they trite. So we called for surgeons for help. We put the front of the neck access with the size 60 years. I'm sure this morning in the discussion this has been discussed as well. So I just want the group to go through that again. If once you is established with the size 60 you a different ethnic access. The reaction is most of paper. They positively thinking why this next one is next. Next know, in real tapes, what is next to you, Jake? Um said wants to be secure area. The acute problem started. Have. Really Good morning. I'm on the hands. So, um, with the surgeons, uh, open the wound ErecAid the clots that you want, Um, a they're even might set. And we might be able to, uh, to bed from about. So that may be why did a customer Amy the special likely to need prolonged intubation medication? Because this problem probably get started or people 42 72 hours. But in case the patient guess the the process and the anatomy is rusty distorting education transplant in June, intubation is not possible. Then we might have to consider just, um uh, but, uh, following a discussion that surgeon critics, That's great. This is that. That's that's a crucial lesson. Be learned from you. Baggy. So a patient in a corner debate convent late scenario, we establish a friend of, like, access with size six tube on digoxin it to the patient at the time. Possibly exactly what you suggested. Which is the time for us to think yes, to stop on the thing on the C what we got now. We managed the oxen. It the patient patient is safe. So what's next? Depends on the clinical condition. Whether this patient need any further management in terms of airway or that's this patient needed to customers or not, or this, especially that one day or two off and elation through the existing tube. War can be come from the upper airway or early or nicely, but we can into bit or not. So this is This is a is a concert we need to develop because it's a kind of a rare event. Be carry on with it occurs to me or whatever it is probably sometimes maybe unnecessary. So thank you for sharing your thoughts on this case that we learned something from you. Thanks very much. Thank you so much. Thank you. Let me warn Teo car take good. Can you hear me? Yeah. I can hear a lot of years. Okay. Can we have the next slight? Right? I think I'm going to need at that case for you from this light. So we have a 24 year old female cyclist. She have fell over from a clave off. Meat is high. Uh, this was happened in August 2020. Initial injury and grow that pan facial fracture, bilateral elbow fracture. Multiple rib fracture at that time on, um, the fracture maxilla on mandible was corrected at that time. As you can see on the X ray on them, she was concerned, ideally managed a rib fracture. She was the shot from I see you on she went home, but later on, six months later, she presented with almost serum out opening because she developed the CVS Christmas she called open. That's exactly what she the best you can do in the picture. There is almost zero about opening. Um, so she's using, um, straw to lick to for liquid diet. And she lost a lot of weight. So they plant boss to dio chronic to me, which is loosening the coroner up coronoid process, which is connected to temporal muscle on. Then release the jaw toe open the job. To some extent, that wasa procedure. Um, So, um, to me, that is something we need to plan on everybody. So what would be your thoughts at this stage if that's a patient coming to you can take looking into the patient history on my It's a classical cases off for anticipated difficult airway, because from the beginning, we know that this is a difficult rate. So my first and foremost concern based. So how do I secured this area on my second country? Will be. It's a shared a day between So journalist, it's all this. So I have to take care about the complication in order with these things on. My third concern is how do I extra weight This patient, which is equally important US information on needs to be well planned on the forties or more. Obviously, the postoperative health is here taking into everything into consideration my choice for securing it. Being this patient would be in of eight nasal fibrotic information you elegantly point out, or the four cardinal points. That's wonderful. I completely agree with you. This also has exactly a suit set. I don't think anybody would disagree with you. That is an anticipated a big Five dropped intubation in this case. So I just want your practice. How do you topical eyes for make intubation in this patient? Okay, First thing is we need to get the patient confidence because any patients coming for breaking probation there quite stressful. So I will explain her clearly what we expect, like a little How do I topical eyes the airway on what All the things she can expect, for example, have better things to 10 for local anesthetic Asian or she might even expense or difficulty in swallowing after the air is really honest place. After explaining her, I will use that on a piece I log to die the secretion. I would prefer a glycopyrrolate 0.2 mg intermuscular 40 minutes prior to start consideration early. I will use a nasal cannula in her, but recent dot state guidelines recommend use. Often Hypokinesis can but returned experience. We are still okay with the nasal cannula on my charts off local anesthetic in her will be like in after calculating a maximum of those, which is her own down 9 mg per kilo. But back Piccoli, this does is rarely leader, so I first start by a blazing with 4% lidocaine Finals are on asking the patient basically inhale so that there is a liquid spread of local anesthetic. Asian. Then that's both the know. Still, with the help of vasoconstrictors, I will use or today that said, Xylometazoline on, then also used 10% lignocaine spray to understand her both nostrils this would be around there to three puffs in his nostrils on depending on how patients cooperate. Taken as the patient of gargle again, You you might say that this patient doesn't have any more opening, but still she is drinking liquids with the help of straw, so we cannot patient toe goggle. But if she's able to do so otherwise in this patient, I will strongly use the translator lidocaine injection because sometimes with nebulizations, there might be an improper and sit tight and stay on top of it. So I use a formula for 2% lidocaine can, strictly the patient coughing, getting low. I know the uniforms spread out for local instead occasion and then check a dramatically with the help of suction catheter on Benji when they're doing a fibro scope. But depending on the need, I might use a safer technique that is the spray as you go to the walking channel off for school on with. All this time, I'm keeping mind the maximum pox. It goes up like a cane so that I don't exceed the toxic dose. I can see that you are Monday morning access off and leg. Topical agent, you're using you can feel I can get into you. Thank you for sharing that way off the nose, the trachea, the gargle amount on. Uh, yeah, that's a That's a wonderful technique. I'm pretty sure you said that most of time we suddenly be the patient, open the mouth, but they're bringing something through the straw. You're absolutely right. They could use that that way. Two topical eyes amount about at the time. If you like. That's going to court. Agree. Now, my next question would be Would you give in the situation for the special in your practice? Well, off for this pictures will be know the pathology on. We know that it is no, gradually over a period of time in this patient. Yeah, I really use sedation in this patient because, as we said that recticare intervention is quite stressful on the sedation will release the patient, exacting, reduce the patient discomfort and increase the position tolerance Even little increased the patient's satisfaction. So, like you. Yeah, well, this patient, But would he use Yeah for this patient? I would like to use the next minute, or Mirena is the soul sedative a gyn. After supplementing oxygen I would start with the loading. Those off 0.81 microgram specula or 10 minutes on. The key thing is constant communication with the patient on. Then maintain that 0.5 micrograms per kilo per minute. Again, there are no recommended ducks here. How they can use these. Don't unusual for friends on patient condition we can use like, um, a friend of mine as well. Um, mentally are proper for But the key here is to avoid bullets dozing when not overseas. Always remember, we should never use sedation as a substitute for the medical. Every topical is is, um, the sedation is just to make the patient come on cooperating. That's I'm glad you mentioned that. Point. Highlighted that sedation is not an alternative for local anesthetic. That necessarily important. I repeatedly here from many. Thank you for that handwriting that point this extremely elegantly. You've done that. Thank you. Consider getting any situation whether you want to use sedation tone in a fibrotic intermission. Yeah. Be honest with you. Today we can do a rectal probe, take intubation you on without any sedation. So there are situations like a big clot like this. I could a big trauma or even the the base patient. You know, over sedation can lead to a critical of those consequences. So it is better to avoid dust addition in the's kind of patients. So you advice would be choose the sedated insulation. Appropriately. In each case, we're likely calls. It's all depending on the patient condition and all right, how much helping and you have. Thank thank you. Come back. I will take you through the journey of this patient after the operation, which was done on a fiber optic information we got about opening up to 1.5 centimeters after the resection off. The paranoia the process on, um, we could go for expression started because the lack of time I'm moving to the next one. She came back at five days later. She's still in the hospital, but sort of like surgeon's found her both elbow. We're flexed and fixed. So before she go home, they wanted to correct it. So five days later, she is back in theater for the correction of the elbow. So they're going to do arthroscopy on. They open afterwards. The after the arthroscopy on open the elbow joint on, they resect all the fibrotic tissue. That's a plan. Now, would you consider a regional block for this patient? Who would you have? A definitive of a strategy at this stage? A sudden is putting in trouble, but I can't help the our facility, the surgery. Um, so here this is a topic for debate. It's a very tricky one on, uh, I think we can argue in both the ways. But in my personal view, I will definitely go for another general anesthesia with anaerobic fiber optic intubation. I will not any take any chance with regionalist is that the reasons are she is so still a difficulty, really hardly any more opening And the elbow surgery might take time, say, for example, 2 to 3 hours on any break in Texas block or so quickly get better. There might be some sparing on. Also, we should consider about the tonic it being on a little. Imagine this patient in the middle of the surgery. If you want to give any sedation or if you want to get this, it will be a nightmare. So personally, I don't want to take any chance. I will proceed with the having fiber optic information again. Thanks very much. I'll take your advice on that one. I think that's a wise decision. Your choice test. I think that's what What exactly. You know, But I may be wrong. The experts might have different opinion, but you I don't want to take a chance for an elbow surgery with the regional anesthesia. We be about for the best interest of the patient on so that this is you made a hospital basis. We appreciate that. This is again. As you said, it's a discussion topic, but bottom when you do, it has to be justified in them sufficiency. Thank you. Got the time. Wonderful. So may I think all of you at Ted. Brackish account, take on baguette. Thank you very much for joining us to make the the international debate on the case presentation session to really, really use for from all of you, we go. Interesting points raised from each case is be one very, very important point that the three years and other cells to share each other. So thanks a lot, sharing all of these things with us. Hopefully we can do this more often on, uh, we may collaborate. I get the future if you're a billing to join us. So for behalf of gains thank or if you, for spending time I noted it is a midnight for you. Thank you very much on drug Asian. All off you. Thanks a lot. Thank you very much. Thank you. Thanks a lot. Thank you. I will handle two brand Now for the some few words regarding the closing off the session. Thanks very much. I have to say I found that basically stimulating session. Um, we have run. What is the inaugural hybrid workshop for? Rest is the king's have got away Faculty on, I think sort of nationally is possibly first where we've delivered life practical, difficult airway workshops with live webinar material with ALS that practical hands on tutoring It means nothing without have to practice it in real life difficulty cases and actually showcasing these interesting cases that are colleagues from abroad have faced and that we faced here hearing their perspective in their opinion, I think is a very nice combination off the messages and the techniques that we've been talking about. And actually there's a lot of value added on the perspective and tight and the types of problems that we all face our university, and I think that much is complete. And I'd like to echo thanks to our expert international panel for the significant efforts and for staying up late on a Friday. I'm sure they would have liked to have had a a drink. Right now. They can't hear me because I'm not on the on the soon call. I'm bringing the session too close. Now I have my phone because there's a few things that we just need to say just to remind you, you will get your COPD certificates after you complete your feedback on there is a You're a link on the home page on the event private station page. If you follow the instructions there, there will be a post event email detail ing that if it's not clear, I would also just like to say a few words to thanks to a few people. I know that we've run over slightly, so I'm not going to label this particularly. You got Friday evenings to get to on. It's the Euro 2000 twenties. They're carrying 2021. I'm sure a number of you'll be keen to get that in your preparation. This wouldn't have been possible without support by industry supporters VeriFone into surgical and fish and pickles who have hosted this help hold of it. Yes, on All of us have done this out of our desire to deliver on educational event when there's been a relative drought. Be able to deliver this sort of teaching over the pandemic. But a special mention. Teo Island Sherry are key account manager from London for parathormone and pull Willis very much driving force in partnership with this for this event. Dan Connie from Fisher and pick out on Also Pizzey Me on David Chapman from Into Surgical have been long time partners with the Kings Airway Group. We really couldn't have held this event without your partnerships. I think much of all the reps that supported the satellite units that which brings me to the faculty. This is nothing without our expert faculty, but the international colleagues as well as our satellite expert to have really provided fantastic value at it. That material with interactive sessions after each detail, really on the life percent is it wasn't their comfort zone to be in front of you in these cameras today on, but she brings me on nicely. I mentioned earlier that I'm no Martin Scorsese. However, we've in anyway come across as looking a professional and slick, a large part that is down to our distal hosts. Box Bear Digital, who are helping it's produced this event, so I just like to briefly mention the team. Estrogen. It's way. Thank you so much for your efforts and maybe making it look a little bit better than we deserved. The feedback on the interactive sessions has been fantastic that looked through so far. Once again. If anyone would like to partner with us in delivering interactive hybrid workshops in the future and becoming a satellite unit, please do get in touch. I don't like extend thanks to the satellite faculty leads for burning in Bluish in Kings on Port Smith. So Dan Able, Holly Jones, Cage a Bala Rajneesh, Chirac, Helen, Brian James Dean's more ports were Thank you for all your efforts and delivering what I've found a lot of feedback that we're hearing that was found to be a really effective day. Thank you for joining us. I'm sorry. We've run over slightly from the King's collaborative group would like to wish you a very happy Friday on to joy the rest of your weekend. Thanks for listening. There will be recording for those of you have to dial out periods or one every ciento session once again details. Well, thanks very much attention. And of me that.