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Hello and welcome to this um Scottish Intensive Care Society evening education Update. Um Thank you for joining us. Um This evening, we are er delighted to be joined by Professor Brendan mcgrath um from with and in Manchester who is going to talk about all things Tracheostomy. Um I know that many of you on the um call already are SI CS members, but for those of you who aren't, this is a shameless plug. Um The Scottish Intensive Care Society is an organization which uh is set up to try and promote uh excellence in the care of critically ill adults in Scotland. And it really tries to achieve that through three ways and that is through education audit and then having large events like our um our annual meeting. Um uh there's a number of different membership categories available for different healthcare professionals. Um And there's a number of benefits from joining the society including Comprehensive Transfer Insurance for those of you that do transfers and reduced attendance fees at our meetings and then access to um education resource and also education and travel bursaries. For those of you who are wanting to um develop yourself professionally So, moving on to our speaker this evening. Um I'm delighted to welcome Professor mcgrath. He is a consultant in intensive care medicine and anesthesia at with and in Manchester. His many of you will be familiar with his work. But his research interests really in patient safety and airway management led to the initiation of the UK National Tracheostomy Safety Project in which there was a widespread collaboration in developing education result to guide the MDT in response to airway emergencies. And then realizing that the real work was actually in prevention of airway emergencies. He helped to develop the global Tracheostomy collaborative in 2012 which draws um expertise from all over the world. He has an NHS England role and is the European lead of the global trachys collaborative, supporting UK and European sites to improve care for patients and families. So, thank you so much, Professor mcgrath for joining us this evening. I'm going to hand over to you and you will notice there's a chat function on the right hand side of your screen. And should you wish to ask questions, please text them on the chat throughout the talk and we'll feel questions to Professor M at the end. That's great. Thanks very much. Thank you for the invitation. It's very nice to be here from the comfort of my front room. Let me just start sharing my screen. So as Julie says, my name is Brendan. I work in a moderately large hospital in the south of Manchester. We used to think we were quite big, but by some intensive care standards were ad DH with a special interest. I've been working in Tracheostomy care probably for about as long as I can remember. And it started off with personal experiences of, of trying to sort out situations that I was sort of grabbed by the arm and dragged towards and realized I didn't actually know what to do because no one had ever told me and I'd never actually thought about it. And so a lot of the work that I've done has been um basically trying to round people up to help, put all these resources together into one place, very multidisciplinary, very cross specialty because that's what Tracheostomy patients need. This title. First Class Care for second class Airway was something that I pitched to the Association of AYS last month. If any of you actually saw that talk. Um It is a different talk. I just kept the title because I quite liked it. So I'm going to try and explain what I mean by first class care and why I think patients with tracheostomies get a little bit of a raw deal, but I'll show you some of the stuff that we've done, some of the stuff that other people have done. And hopefully we can, er, conclude by agreeing that we can all do something to improve tracheostomy care. Er, I reckon I'll talk for about 40 45 minutes. And I'm very happy to take questions on, on anything at the end. I might not know the answer but I will have a go. Um, I've got a few QR codes for you at the end, so I don't mind if you're on your phones. So I've got a few jobs around Tracheostomy carers as Julie explained, but none of them give me any money. And which is my wife's disappointment, which does mean I've got nothing to declare that's relevant to this. Talk. What I'm going to talk about is, is what I think first class care looks like. Talk about some of the problems that we've got in trying to deliver first class care. Talk about a project that we've done called improving Tracheostomy Care, which involved a couple of sites up in Scotland and then talk about the focus for the next 10 years for me and some of my team which are around laryngeal rehabilitation. Everything I talk about you can find on the internet. So if you Google Tracheostomy and type in the letters U and K, if you're outside the UK, you'll find the National Tracheostomy Safety Project. Um This is where all our stuff is. It's mostly youtube videos with supportive resources which get hammered a lot, about 35,000 hits per month from all over the world. People find them really useful. The longest video is about 2.5 minutes. So if you need a quick refresher or you're trying to teach someone in theater or an ICU or in the corridor. Um That's where I think these videos get the most use. And this is our attempt to scoop everything together into a one stop shop around Tracheostomy care. Most of it is, is recycled. We haven't invented this stuff. We've just put it all together into one place. So you're gonna meet people with tracheostomies and I'm aware there's a very diverse group of people on this uh webinar. Er, if you work in theaters, you will put patients tracheostomies to sleep, either for the tracheostomy or with their tracheostomy. If you work in intensive care unit, you will meet a surprising amount of patients with tracheostomies and they spend a long time with their tracheostomy in which I'll show you in a second. You may be involved in actually putting tracheostomies in and if you meet people out on the wards or in the outpatients, um a good proportion, then we will have tracheostomies and depending on where you work, that proportion might be quite high. And if you look after little people, little people get tracheostomies too and they come with their own unique set of not necessarily problems, things to think about. So, first class care, why is tracheostomy often considered second class? Well, it's a second airway which is pretty obvious the native airway usually needs absolutely no care. Um So if you think about what happens in hospital. You know, we don't worry too much about native airway management. If you go on a cardiac life support, course, we tell people how to look after the native airway, including non airway experts and the tracheostomy because its complexity actually needs a lot more attention, I think than the native upper airway. So it is a second class airway tracheostomy is often viewed quite negatively. And if you think about the patient populations who get a tracheostomy, if you don't work in head and neck units or you don't work in intensive care units, the perception is that these are complex long stay patients, maybe they're all blokes in their fifties who smoke or drink. Um There's a lot of misconceptions around quality of life and prognosis and a lot of misconceptions around the complications that patients with tracheostomies have. And a lot of that is fear and to some degree, a bit of ignorance about why we put tracheostomies in the fact that the vast majority of them are temporary and as patients get better, they don't need them anymore. But tracheostomies are often seen as either an emergency procedure or something that's just inconvenient for a short period of time. And this is a fairly common conversation that I hear. I used to be an aist. I don't do that anymore. But this was the sort of fairly common theater corridor chat that taking an ICU patient to theater and doing a track takes all morning, let's face it. And so they do get a bit of a raw deal. I think around our hospitals, the other big perception is that tracheostomies are intensive care problem. And I think to some extent that's true. And certainly when we started doing this work, the perception was that it was all about ent and head and neck back, fact surgical patients, you know, that they were the patient with the tracheostomies. But in fact, in intensive care, we do the vast majority of tracheostomies. Now, around 80% of all tracheostomies in the sort of Western world are performed by intensivist on intensive care patients. So it is to some extent an I see problem, but those patients leave IC they go elsewhere. There's still a significant throughput of tracheostomies through head and neck surgical units through pediatric units. And so it's not just an ICU problem and because of the range of healthcare professionals that patients with tracheostomies interact with. Um there are a lot of opportunity I think to interact with patients with tracheostomies. This always say amuses me, but it always sort of piques my interest where you look at the amount of training that people have to have before they can be deemed fit to manage an upper airway on an ICU. So there's the initial assessment of competence which has to be observed and assessed after three months, typically of of sort of anesthetic apprenticeship. And then on your first night on call on the IC where you are now qualified to manage airways, you may have had zero, tracheostomy training. And if you look around the unit, there's probably about 20% of the patients on a typical ICU will have a tracheostomy. Um, so I think that's something that we need to take ownership of locally in intensive care units. And if you've got a lot of patients with tracheostomies, particularly if they're on ventilators, then I think they need at least as much training as the um the more conventional airway management. And I know in our inductions we just used to have that. Here's the difficult airway trolley. Um You know, it's a bit different in ICU, you just need to get a move on. We now spend quite a few hours talking about how we're going to manage airways. And we include tracheostomies very much in that. Somewhere between 10 to 15% of anyone who gets ventilated in what I called a Western ICU. So North America Europe, some parts of Asia. And then down in Australia, New Zealand, about 10 to 15% will end up with a tracheostomy depending on where you are. So if you work in a neuroscientist center or a big trauma center, you'll get more truck. If you work in a small hospital, perhaps less on average, it's about 12%. So that's 12% of anyone that gets ventilated will get a truck. And somewhere between 10 and 20% of major head and neck surgical patients. So if you're a major head and neck center, you know, one in 10, 1 in five patients will end up with a trucky if you have an a and then patients present with a bra obstruction. And again, maybe 5 to 10% of patients get a trache. So we are going to get asked to look after patients with tracheostomies if you look at that for the UK, um there's about 200,000 intensive care patients admitted per year. I think the last I saw was about 220. That means about 20,000 intensive care. Um Tracheostomies, most of which are um percutaneous. So about 14, 15,000, it's about 1200 kids a year in the UK, get a tracheostomy and about 5000 surgical trachea per year, not all of whom come through an ICU but it, it, it, it depends on, on how your um services are set up locally. Er 80% of tracheostomies are to facilitate long term ventilation in, in adults and kids. And about 20% are for um some sort of airway problem. Ok. If you look at the figure particularly on the right. Um If you need a tracheostomy, you're in hospital for about 50 days and of those 50 days, you will spend 28 of those days with the tracheostomy tube in place. 23 of those days will be on an intensive care unit. So it's an expensive business requiring a tracheostomy. And you're in ICU for quite a long time. And these are data from the United Kingdom if you look at bed days. So this is our own hospital which now comprises of four big I CS um in our trust. So if you look at bed days, so 12% of patients, but 46% of ICU bed days are spent with patients with tracheostomies. And that takes me back to that slide about the training that we subject our trainees and staff to, to manage upper airways and intubation. Um Nearly 50% of the time the airway is actually a tracheostomy on the ICU. So that's worth I think bearing in mind and I suspect if you did something similar on your own unit, um It gives you an answer that's actually quite helpful if you're trying to argue for better tracheostomy care. So this is a very simple thing to do, which I would encourage you to do if you're trying to leave us some funds or some time. Ok. What about some challenges with tracheostomy care? Well, Trach have been around for a very long time. So the ancient Egyptians were doing tracheostomies. There's a story that Alexander the great performed the tracheostomy with the tip of his sword on some poor soldier who had some sort of horrendous facial trauma, probably died of sepsis or bled to death within a few hours. I'd imagine but, you know, they've been around for a long time and the technique was refined throughout the middle ages and then uh in the sort of 1617 100s um that leaves us taking through to sort of modern times with complex patients and not just patients with upper airway problems and complex patients. These are patients who can't breathe so well, can't cough so well, who've got heart failure, they're typically the patients that we can't get off ventilators and complex care needs complex teams. So lots of different people who are involved in providing care for these complex patients and that in itself leads to its own problems. People get confused about tracheostomies and if tracheostomies are new to you, this is probably the most important slide, I'm going to flash up tonight. So the difference between a tracheostomy and a laryngectomy. So I apologize for labeling this for those of you that know, but a tracheostomy is an additional airway. It's often temporary and you still should have an upper airway, particularly on the ICU where we do the tracheostomy for weaning and usually not for airway management. That contrast with the laryngectomy where the larynx is chopped out and thrown in the bin and the trachea is then stitched to the front of the neck. So there is no communication with the nose and mouth and that's really important. What's a person with laryngectomy going to tell you about their airway probably very little because they haven't got a voice box anymore. There are ways to get around that, but I get to read national incidents and this happens on a depressingly frequent basis that somebody with a laryngectomy goes into hospital, usually having some sort of cardiac event cos they typically have been smokers. That's why they've lost the larynx and they go to a coronary care unit, get a bit agitated, the staff sedate them because they don't know what they're trying to tell them and they're trying to tell them that the oxygen doesn't go on my face, it goes on my neck and then they get sedated and then they come to harm. This happens depressingly frequently. And so I think as sort of custodians of the airway, that's something just to bear in mind. And when we're putting our sort of tracheostomy, lungectomy services in order, I think we have to start up their own house. So I think, you know, looking at your own intensive care unit and thinking what can you do to sort out care. But also thinking about your role outside of the ICU and making sure that your hospitals are set up to safely. Look after people who've had a laryngectomy, which is often a curative procedure. People go back to work, they live happily ever after and we don't want them coming to hospital and having worse care than they would have when they're out and about at home. This is a lady who's got a tracheostomy and it's come out. So, if you met this lady, do you know what to do? I suspect a lot of you on the call do know what to do. But the challenge is, do your staff know what to do? And if you're not there and it's two o'clock in the morning, can you guarantee that somebody will be there to spot that problem and somebody will be there to sort it out? We used to call it the 2 a.m. test. Um But when we tried to apply that to the wards, the answers were a bit a bit worrying. Um But the systems that we need to get in our hospitals are that wherever you look after patients with tracheostomies or laryngectomies, you need to be assured that they're gonna have good care at two in the morning. We've looked at problems and I won't la this slide, but there's lots of data. You can find all this on the website about problems with tracheostomy care and it was probably crystallized best by the NC pod report which some of you may have contributed to. It was over 10 years ago now, but it's probably the biggest, most detailed case series 2.5 1000 cases with a few detailed reviews. They found measurable harm in about a quarter of all. I see patients with the Tracheostomy, more harm on the wards, which was depressing. If you look at the themes, they're predictable education staffing, provision of equipment, infrastructure, a lack of patient focus. A lot of these problems are preventable which while it's very depressing that they're preventable, it does mean that we can do something about them. So they're all amenable to prospective quality improvement strategies. And so that is what became the focus of our work over the last sort of 10 years is to try and stop this harm happening in the first place. So what the N TSP did was sort of take all these bits of the jigsaw and try and scoop them together. You might be familiar with the emergency algorithms. We're looking at updating these because these are 2012, 2012. It says on the slide that's when they were published. Um They aren't perfect but they will solve. We think about 95% of the problems people have with tracheostomies, which are a lot better off than we were before we published these algorithms. They address the common problems so that the commonest things that happen to our patients with tracheostomies and lead down to more and more invasive options for, for sorting the airway out. The bedhead signs pair up with those algorithms. And that will tell you what the tracheostomy is. Why it's there, what the upper airwaves like. And if it took three and a cysts 40 minutes to secure the upper airway, I'd like to know what kit they used and what was successful and what didn't work. So that's a good place to recall all that information um In the digital age. These are a little bit more challenging. Um So we've got like metal ones of these that we can write on that still got at the end of the bed. Because if I turn up to emergency, these are bits of information that you need to know immediately. So we find these really helpful and I know lots of people around the world who found them pretty helpful. If you haven't got an upper airway, we need to know. So a different management algorithm, the principles are the same, but clearly the upper airway bits are missed out different bedhead side. And the management of Children with tracheostomies is slightly different. So it's an early emphasis on emergency tube change because kids don't tend to have inner cannulas in their tubes just because they're smaller. So your first step, usually if you can't pass a suction catheter is to change the tube. But the principles of the rest of this algorithm are the same. Importantly, we got a lot of different groups to endorse these guidelines. And you can see from the diversity of the groups popping up on the slide there that we were able to get a lot of wide support. That was basically by going to these groups and saying, look, we're going to try and sort this out and they were like, great, we don't have to do it. Um But it was really helpful to get all this endorsement. And you know, we continued to engage with all these different groups. There's a lot of e-learning. So ele for healthcare have supported us in producing some e learning modules with the Royal College of AIS. They're free to access, anyone around the world can access them. You get a certificate at the end if you need it for any CPD and lots of hospitals just use this as a way of demonstrating trachys CPD. We put it all together into a book which you can either buy or you can just go to the website and download it a great big PDF. And what we realized about 10 years ago was that video is actually the way to communicate this stuff. So this was something that someone taught me when I was a trainer. You know, how you can ventilate someone through a stoma and trying to read that in a book is quite a challenge. Watching it on your iphone is a lot easier. And so a little videos like this can really help explain to trainees and other colleagues how you go about managing somebody's airway when they've got all in it because it's amazing how easy it is to throw someone off when you turn up and they've got a hole in their neck. So again, on the website, all these videos are broken down at sections with supporting resources and you're very welcome to use them. So does it work. So this is one of the early pieces of work that we did looking at the impact of our educational tools. And when we looked at the impact in four hospitals in the northwest of England on patient safety incidents and you'll be able to read that. So I'll just put the, the summary up there. These are the incident rates per month in these hospitals where some harm occurred and you can see it dropped from about two and a quarter to 1.5. So a relative risk reduction of about 0.65. So what we did before training and after training was drop in our resources, we've got a half day training course which again, you can assemble from all the material you got on the website and, er, staff found this really useful and they were able to er, show that they could reduce um incidents and that was by being better prepared by recognizing incidents early and then doing something about it. This led onto a couple of projects funded by the Health Foundation and we call this improving tracheostomy care. And I'll just run through some of the, the things that we did and some of the headlines from this, there's the paper there. If you want to have a look, it's also on the website where you can find it. Uh We went to 20 very different sites up and down the country including Scotland and Wales we didn't get as far as Northern Ireland, unfortunately, but we're very grateful to our Scottish sites for contributing to this project. Um There were 18 different interventions focused on effectiveness, safety. And then I can't see what the other one is. I can't remember three themes. We engaged a lot of staff. So about 1500 staff, what we wanted to do was do things that staff were willing to do. Um We also wanted to learn how staff made changes because it's all very well. Me saying, oh, here's 18 interventions. We need to you to go and sort it out. But we wanted to create like a rescue book of, of how to do stuff. And then we evaluated the impact over about a 24 month period with about 2.5 1000 patients. And we looked at the quality of care, the safety of care and then the economic impact, the important things that we'd learned from the global Tracheostomy collaborative was that you need to put the patients at the very center of what you're doing. And one of the first pieces of work that we did was to try and just crystallize some of the work that others were doing basically involving patients and saying, OK, what do you want us to do? Because we had this idea that we could try and address safety. But when patients turn up to the hospital, they expect that we know what we're doing. They expect if they had a tracheostomy, we should be able to look after it. What patients told us was they wanted to focus on eating, drinking, talking, active rehab, getting out of bed. Not people not being petrified because they were on a ventilator with a tracheostomy. They wanted us to stick cameras up their noses because they wanted to know, um, were they able to have tea and toast like this f they wanted us to take their cuffs down and take a bit of a risk with their ventilation and they wanted the track is out ASAP er, because they knew that that would help get them back on that road to recovery. So our initial focus, as I said was on reducing harm from emergencies, but we very quickly realized that actually basic care done well, prevents those emergencies from happening in the first place. And that was the focus of the educational sort of work that we did. And then the more we got patients involved, the more it turned into quality improvement or better safer care everywhere. And if any of you know anything about quality improvement, you'll know that if you improve the quality of your care, you naturally improve the, the quality, the efficiency and the safety of care. This is the incident count over the pretty much 30 months that we collected data for. And you can see at the end of the project, we were still having patients having incidents. We were still having incidents that were severe. There's a death there in month 27. And I think that reflects that this is a high stakes group. They're sick people, about 20% of people that we tracheostomise on the ICU do not survive because of their illness. Um, but we were having incidents related to the airway. Um, but the incidents, as you can see from the trend line were less severe and they were less frequent. So we were able to influence the nature, the severity and the frequency of patient safety incidents by training staff. And we trained nearly just over 4000 staff in the course of that project with a cascade training model. So overall that was about a 55% reduction in the severity of, of incidents. But noting that incidents were still occurring, this lady was readmitted to one of our hospital wards um after the staff had had training and she said it was like being admitted to a different hospital because she was surrounded by staff who weren't afraid of a tracheostomy. They were proactive in looking after it. They were proactive in making sure that she could eat, drink and talk rather than people not want to touch it because they thought if they touched it something bad would happen. And she noticed this and told us that that was some of the feedback from her. We measured anxiety in all those patients and we have the 50% reduction in anxiety and depression, which patients attributed to better care. These are the process metrics. So they're all down by about 20%. So that is er, time on a ventilator, time in attentive care, time in the hospital, er all down by about 1/5. And that translates through into a significant cost savings. So about three and a bit 1000 lbs per day on an ICU and about 350 lbs per day. And there's been various pieces of work looking at um, the economic impact of improving tracheostomy care. Again, you can find those on the website, but I've not labored those for you tonight. So, the thing I'm interested in currently is laryngeal rehabilitation. So I'll probably spend uh 1015 minutes or so talking about laryngeal rehab. So you can get a lot of complications when you've had a tube down your throat and you've been attached to a ventilator. And Sarah Wallace is a colleague of mine. She's a consultant, speech and language therapy, the therapist. I'm a professor now of speech and language therapists in Woodshore where I work. And this is a pretty old study, but it's a lot of patients in Japan. I think about 30,000 patients, they looked for um, airway problems and they compared it with the duration of intubation. So these are people just having long anesthetics. So you can see that if you have your um, tube across your cord for longer, then you run into more problems with your airway and that sort of is extrapolated even further when we're talking about ICU patients. And as we've already said, we're looking to tracking probably about 12% of anyone who gets ventilated. Um, I won't worry too much about when, why and how we do the tracheostomy. That's a sort of to in itself. Um, and I think the decannulation endpoints are, are, are pretty clear. So, you know, we can have a separate discussion about when to put them in and when to take them out. But the bit that I want to focus on is this weaning bit in the middle because problems with the larynx can really impact on that, that weaning bit. The prevalence of injury depends on how you detect it. So if you send someone a questionnaire two weeks after they've had day case surgery, you'll find a very low incidence of problems. If you scope everyone in recovery, you'll find a much higher incidence of problems. Um How you follow them up is obviously very relevant, whether you do a history, examine them or you even the type of endoscopy you use. And I'll show you some different types in a second in terms of what happens. The sort of early problems that we get tend to be, excuse me around sort of edema erythema, sometimes a bit of dysphonia, sometimes a bit of dysphagia, very rarely more significant problems like vocal cord injury. The sort of later problems tend to be vocal cord, palsy, sometimes atrophy of the larynx edema that won't go away. People who are hoarse for, for long periods of time or, or they can't swallow and then some of the issues that we actually find with the, the retina is a structural structural problem uh with the larynx. So, the reason why people, er, can't swallow or they can't speak so well is because when we jam the tube down, er, in a hurry with a bougie and then turn them prone. We've actually the larynx, the very late problems tend to be around sort of glottic stenoses or laryngeal or tracheomalacia. And if you throw a tracheostomy into the mix, then we've obviously got stoma problems as well. With infection wound breakdown, granulation can be a real pain, um desensitization and then long term sort of poor cough. Where do you get the problems? Well, they're fairly predictable. So, uh edema ulcers sort of high up around the cords, um dislocation at the background, the retinoids. And if we turn that slide into a sort of longitudinal slide, uh you can see where these problems commonly occur, you will see pressure damage in nearly everyone. So when you take the tube out, if you're doing a tracheostomy, you know, if you look at the upper airway, you, you will see uh plenty of problems and the nerve palsies are surprisingly frequent. They don't all need intervention. But if you've got a vocal cord paralysis, then that really affects your, your aspiration risk. And these are some figures that we report in this paper. But the actual true incidence of laryngeal injury depending on how you look is probably somewhere between 60 80%. Some of it's mild, so hoarseness, dysphonia, but the dysphagia is actually pretty high that 50% of patients will have trouble swallowing and that's swallowing secretions or swallowing, um, uh food. The biggest problem I think we see is when we've got a cuff in the airway, um the upper airway doesn't get any airflow and that complete lack of stimulation totally down regulates the larynx. And I'll show you some, some images and some diagrams that explain that I do think it's a problem. So if you've got an occult laryngeal injury that you don't know about, you get worse breathing, you have worse vocal symptoms and these symptoms will persist for up to 10 weeks after you take that tube out. This sort of manifests itself as failed extubation. You know, you pull the tube out you, oh, they're not breathing very well. Actually, it's an airway problem. It might delay their weaning. It mean that they don't manage the secretions very well. If you throw into that mixed, delayed oral feeding, you know, you got all sorts of risk around malnutrition, particularly if you discharge those patients off in ICU. We know if you've got dysphagia, you have prolonged hospital stays and, and excess mortality. And that sort of laryngeal recovery is, is definitely delayed with significant psychological impacts um for, for patients. And I was just talking to about, I see follow up before we start this webinar and a lot of patients will come back to follow up clinics still not able to eat and drink properly, which has a big psychosocial impact. So we definitely know that it prevents and delays recovery. It can cause all sorts of positive misdiagnosis. People get reintubated, they might get a tracheostomy unnecessarily. Er, it might delay decannulation and, and increase your length of stay and the way we manage this, I think it's all about prevention and then early investigation. So if you think about intubation trauma, you know, we've gotta be careful. So, video or endoscopes. So use experienced staff for intensive care intubations, thinking about how long the tube is across the vocal cords for. So, maybe if you know the pace, we need to track you anyway, why not get on and do it rather than leave a tube sitting there pranking the CHD. We see a lot of oops, sorry, we see a lot of reflux. Um and we, we tend to treat reflux really aggressively. We assume people have got it and treat it. Um Thrush can be a bit of an issue if the patient's agitated and thrashing around the bed, that's obviously no good if you've got a tube in your airway and getting the speech and language therapy team involved early. If you've got limited access to speeches, then think about some shared protocols that you can have um which may involve airway endoscopy and then sharing the images or protocols for starting oral intake. And what we found certainly over the last 10 years is you just need to have a look. So we scope nearly everyone who's got a tracheostomy. Um This is Sarah just demonstrating to one of our patients that how easy it is for us to do this nas endoscopy, they do lots of slightly different things that what we would do, just assessing the airway that the speeches will give people a challenge or give them a drink and watch what happens. This bloke looks like he's had yogurt. So you can see the image of the larynx, hopefully across the internet that when he tries to drink, we can tell him at the bedside that look, you can see the yogurt has, has gone down into your airway. That's why we're not giving you pie and chips there. He is having a drink with the camera up his nose and we can watch to see what happens to that drink. So this is done at the bedside, you know, giving them a challenge and it would be surprised how many patients actually pass these following assessments. And so you can be there, you know, with a tracheostomy tube in on a ventilator, eating and drinking quite happily, you can do video fluoroscopy. This requires transfer to X ray which is a bit of a pain. But you can see here very clearly that there is uh um dye going down into this patient's trache. So this is an unsafe swallow, very similar sort of sensitivity specificity to uh to the fees, the endoscopy and this I hope comes across on the video, this is something called video stroboscopy, which is like a sort of very fast flickery light way of looking at the vocal cords and you can pick up some res subtle changes in the vocal cord shape and vocal cord movement. There are some more invasive things you can do with LE MG and sort of having a look at the larynx under G A. But there are some things we can do about it and this is what I want to talk about for the next few minutes. So promoting that laryngeal physiological function and getting things back to normal, um can definitely reduce the time to oral intake, reduce the time to talk and and and really sort of motivate the patients to to sort of get moving a lot of the time. So what we mean by that is early cuff deflation trials to see uh see what happen using speaking vowels very early while they're on a ventilator and above cuff vocalization if you can't get the cuff down. So I want to spend a few moments just thinking about butting some myths and this was the most relevant Scottish myth that I could find. And if you've seen a lot, nice answer, then I do apologize. So I'm going to hang this on a recent patient of ours. This is a guy called Mark who was a roofer from Manchester. Quite a, quite a character on our cardiac intensive care unit. You can see he looks absolutely enamored to be on a ventilator with a tracheostomy. But he's very happy for me to take these pictures and for me to share this story. And this is Sarah and I are trying to work out what to do about his larynx and you can see what Mark thinks about our plans. So if in doubt, get your camera out. And so Sarah is doing NAS endoscopy on this guy for those of you who's got very good eyesight or a very big screen, you might be able to see that Mark has got a great big hole in his septum. So I asked him, could we video this assessment? He's very happy with the video it. And er, Sarah asked him why he had a big hole in his septum and he very kindly incriminated himself, er, several times explaining how he'd managed to get a hole in his septum. So, er I don't show this video, I'll just show you this still, this is what happened on the inside. So you can see the na gastric tube down the back of his throat. Er, so anterior is at the bottom of the screen. That's his laryngeal vestibule. So the, the bowl full of soup, um, you can see that his larynx is completely insensate. So he's got a load of sort of spit and secretion sitting on top of his larynx. He's not noticed it, he's not coughing it, he's not swallowing it. He's just sitting there. So I guess my question is, what would you do? How many of you fancy taking Mark's cuff down at that point? And if I told you that, you know, half the patients on your ICU with tracheostomies would have a fees that looked exactly like that. Would you want to take their cuff down? All these are the sort of things that go through my head when I'm thinking about the cuff. So, historically, if you take someone's cuff down, people think, oh, they're going to aspirate, but on the, on the plus side they'll get some around your airflow. But what about if you take the cuff down? They won't be able to ventilate very well, but they'll be able to talk, which is good. But if you take the cuff down, they're going to Deruiter, are they? Yeah, but on the plus side, we might be able to use one way valves which, which we know can help with recruitment. And if we leave the cuff up, then of course, we protect the airway, don't we? But that means there's no laryngeal airflow. But with the cough up, we get better ventilation, but the downside is they get no voice and then the cough up, the cough's not quite so good. But why would you take the cuff down? Because that's what we always do. And these are the sort of things that we commonly encounter when we're talking about what to do with the cuff. So the common perceptions are that if the cuff is down, ventilation is ineffective and there's a high aspiration risk. So that's the sort of thing that people perceive that you see the snot dropping straight into the lungs. If the CB, it prevents aspiration, you much better ventilation. But you and I all know that if you pour a load of spit or snot or whatever down the back of someone's throat, that little plastic cuff is not going to prevent aspiration. So this idea that an inflated cuff prevents aspiration is just not true. So, what do we do? Wasn't sure. Um Well, we have a structured weaning plan which I'm sure many of you do, but I'll just explain what we do and it hopefully might trigger a few questions for later on. So we need to prepare the patient physiologically. So have we fixed the underlying problem? Have we got their lungs as good as we can? Have we got their heart as good as we can because a lot of times when we drop the pressure, they go into heart failure because they've had about 10 L of fluid that they don't need. Um, if they can't wean, have they got some sort of neuromuscular problem that we didn't know about and obviously treating any infection. So the patient's got to be physiologically ready to wean. Are they physically ready? So, they've got to be strong. They've got to be in a good place and, you know, if they can't sort of sit up in bed, if they can't think about, you know, mobilizing the patient with the, with the physiotherapist, it might not be the right time to think about weaning. And then psychologically, they've got to be in the right space to wean it. And a lot of that preparation is, is establishing a sleep wake cycle where we get the patient to work during the day, rest at night, coordinating their rehab with the MDT. You know, there's not much point, the physio is getting them out of bed and tiring them out. And then we come along and say, right, we're going to try weaning you now by dropping your ventilation pressures, um transitioning to a spontaneous breathing mode and trying to stick with that and then being consistent. And I think that's what I've learned over the years that actually it doesn't really matter what the plan is quite so much as long as you're consistent unless I feel extremely strongly that the plan from the day before is not the right one for the patient. We tend to stick with it because consistency is good for the nursing staff. It's good for the patient. It's good for everyone involved, everyone's on the same page and the different strategies. Do we drop the cuff first? Do we drop the pressure first or do we sprint them or do we do it gradually? And I'll just explain some of the things that, that, that we do. This is a good review. So there is some evidence in this area. Um This is in BN J Open Respiratory and I'd commend that to you. But it does talk about protocolise weaning, it talks about cuff management. So early cuff deflation promotes talking and swallowing, which in itself is really striking for the patient. But as I say, we have got some data that it actually reduces time to decannulation. This review noted sites that paid attention to track tubes and downsized. They felt that that led to earlier speaking, valve trials, earlier oral intake and shorter stays, getting people communicating is actually really important and getting the cuffs down. If you're worried about high cuff pressure, get the cuff down or switch to an uncuffed tracheostomy tube, it's not as crazy as you might think. And so Mythbuster number one, so deflating the cuff means you can't ventilate properly. So if you've got a cuff up and you're on a ventilator, all the gas is in the breathing circuit. So between the lungs and the ventilator, if you've got, uh, a cuff up and you're not on a ventilator, you're breathing spontaneously, you've got no upper airway flow. So the driving pressure is only what the lungs or the ventilator can generate. Uh, you haven't got a very good cough and you need the larynx to be closed to have that explosive pressure build up, er, which gives you an effective cough. So you can't do that with the cuff inflated. So the patients, their control over their ventilation and coughing is essentially just triggering the ventilator. Er, and if there isn't a ventilator, then their coughing and er respiratory effort is actually quite reduced. People have studied what happens when you take the cuff down in terms of pressure. And er this nice little study just measured CPAP and CPAP is not affected by reducing and taking the, the, the cuff down, but it depends on what ventilator you're using. So if you've got what people refer to as an ICU ventilator, they do not like leaks because they can't generate the flows to compensate for the leak. So you need to switch to a non invasive ventilator. And the ventilators we use can generate flows of up to a couple 100 L per minute. And so if you take the cuff down, the ventilator, just jacks up its flow to compensate. So the measured inspiratory pressure doesn't fall and measured peep or CPAP doesn't fall. And the usual ventilatory parameters that we judge with CO2 respiratory rate. Um, they don't change where we take the cuff down. So taking the cuff down does not affect your ventilation. What about aspiration? Well, this is the sort of common diagram that we're going to see where you've got all that stuff falling down into the airway because there's no cough. What's actually happening is that there is a flow of gas coming up the airway CPAP if the patient's breathing spontaneously or peep, if you're being pedantic and on a ventilator, but there's a, a physical effect from blowing gas up the airway and that takes the secretions and blows it up. And if the patient's got some laryngeal sensitivity, then they'll swallow it or you can clear that with, with suction, but it's not just the physical effect. If you remember this big pool of soup that was down the back of Mark's throat. What happens at a second is the video fast forwards and we start to introduce some airflow down the back of Mark's neck. Co this is the fast forward bit while we did the rest of our assessment. And what you'll see in the lounge vestibule now is bubbles. So those bubbles are us. I can't remember if he dropped the cuff or did a CV. But we've introduced some airflow coming up, Mark's airway and you'll see what happens. The screen goes white because he swallows and the screen will go white again, cos he swallows again and that's because the airflow has triggered his swallowing. He's realized that there's a load of stuff at the back of his throat. And within two swallows, you can see his larynx and if you notice he's got a vocal cord palsy, I don't know how well this video is coming through over the internet, but we didn't know that because his larynx was hidden by all that soup. Um So that question of, should we take Mark's cuff down? The answer was in this case. Well, yeah, because that will clear the airway and you can see his larynx is moving. So we've effectively switched his larynx on by restoring airflow, restoring laryngeal function. If you can't get the cuff down, then you can do something called A CV above cuff voicing above above cuff localization. And that's where you take the standard sub suction tubes that we stick in all of our patients and you reverse their mode of action and we blow gas er backwards. So it comes out above the cuff and out through the patient's airway. And we use this as a bridge if we can't get the cuff down for whatever reason. And that's usually because when we take the cuff down, the patient's respiratory function goes off. So for patients who've got brittle lungs that we can't get the cuff down, we use the A CV as a bridge. There are videos on the website where we're going through how to do A CV there's a very simple way of doing it with, um, with green oxygen tubing which you hopefully see on the screen. Um, if you go on the website and watch, er, you can hear this lady get a voice and she's on a ventilator with a cuff, inflated, completely mute. Er, but when you connect up the A CV gas flow, you'll hear her counting and you'll see how pleased she is that she's got a voice. So I'll skip the rest this video. What I would say is that I don't want you to just rush back to your ICU and stick this on someone. You need to know what you're doing with A CV. And there are risks with A CV. And so you need to be at the bedside looking what is happening. There's a few papers about it again, read about it on the website. The other things that are really interesting is this idea of switching the larynx back on. Well, there's a few things that we're borrowing from stroke research. So, pharyngeal electrical stimulation is essentially trying to kick start the larynx because if it's been disused for all that time, what the electrical stimulation does is it basically switches your brain back on. And there's some really neat studies where they've looked at FMRI in people who've had strokes and the swallowing sensor reactivates and swallowing function comes back and that's a bit like this sort of rehab. You know, no one would argue that this bloke lying in a bed with the proactive rehab we've got going on trying to stop his leg muscles wasting away. I think what we're doing with the laryngeal rehab is exactly the same. So, while he's sitting there in his ICU bed, we might as well get some airflow going. We might as well do some electrical stimulation if, if they need it in order to make sure that that voice box is in a good state when we want to take the cuff down, when we want to think about decannulate it, because the point of the physical rehab is so when we get this guy out of bed, his legs are strong and it's the same for the larynx. So when we take the cuff down and when we take the tube out, the larynx is already a couple of weeks, sort of better than it would have been had we just left it um until they've got off a ventilator. So just to draw this to a close. In summary, it's definitely a team game problems are, I think, predictable and they're definitely preventable. Anyone can lead tracheostomy quality improvement. And I think especially intensivist, especially people involved in airway management. So a nieces, anyone who is involved in looking after airways is very well placed to do this, but it's very much a team game, I'll just close by just telling you a few things that we're up to next. So we're working on techniques and devices to help us put trach in a bit more safely, better training. But I'm also really interested in what you want us to do with the N TSP. This is one of the things that we're doing at the moment, something called guided insertion for tracheostomy. This is where we are looking at this problem of trying to get the needle in the patient's neck but trying to get it in exactly the right place. So this is some technology that we've currently got in development where you can basically guide the needle into exactly the right spot. And we think this will make er PDT safer. We think it will make it a little bit more accessible. It's certainly a lot more accurate and that's work that's ongoing at the moment. The other thing that's really sort of caught my interest recently is is virtual reality training and tracheostomy training is a big pain in the backside, particularly if you've got 100s or sometimes thousands of people to try and train with the high turnover that we have. But this is the sort of thing that you can do in VR you can have people who are in completely different locations, managing tracheostomy emergencies and learning those human factor, skills, learning those interactions and basically learning everything you need to know about tracheostomies without having to go to expensive SIM suites or without even having to come to work. We've written about this again. You can read about this on the website, but we showed that VR tracking courses were able, you could generate the same knowledge and the same experience and the same performance in emergency management as you could in the VR world as you could face to face. And something that's a very hot topic. And important to me at the moment is thinking about the carbon footprint of education. And whilst we have to have a capital outlay on some headsets, it actually saves a lot of carbon by doing this training remotely. A few of the things you can get involved in. There's the track team game, which you can have a go on the website, but I'm really interested in what you guys want us to do. And so this survey is a QR code. So if you point your camera at that, this will tell you a little bit about, um, some of the work we're doing and I'm really interested in what you think we should be tackling. And if you've got any suggestions or resources you want to share, please get in touch. Again, there's contact details on the website and I'd be very grateful if some of you would take the time just to tell us via this form a little bit about your training needs. I close by thanking all the people who have helped us along the way with funding, er, and support and close with Tammy, who was that, er, lady you saw who was absolutely delighted to get her voice back er through a lot of the work that um other specialties were doing and that I seem to get the credit for. So, thank you for listening. I will flash up that QR code one more time if anybody wants to have a look and I will stop sharing my screen if I can work out how to do it. Very happy to answer any questions which I think are going to be posted in the website. Let me just try and stop sharing this. Perfect. Thank you so much Brendan for that. Absolutely fascinating. 45 minutes. Um, if you have any questions, please, er, type them in the chat box, um, and we'll try and field them, er, towards our speaker. I have a question to start with, if you don't mind, you've obviously over a space of a number of years been really successful in influencing change in practice in the place where you work. Uh, I mean many of the people of the call, but were you familiar with that? The NHS is a, a place that it can sometimes be very stuck in its ideas of the way that people do things. So I guess what, why do you think you were successful? What, what, what do you think helped in sort of driving change and moving things forward? So I think we were quite forensic about identifying the problem. So we, we had data. Um And so I think you can look at this at two levels. We've tried to influence things at a national and international level and you need big data for that, but actually having local data. So if you were trying to change, practice in your hospital in Edinburgh, and you said, oh, we've got this great data from Manchester, then the people that you're trying to twist their arm to do something they have to go well, that's not really relevant to us. So having your own data is really powerful if you can collect data around a patient experience as well, so that, you know, this isn't stuff that I've done. It's stuff I've learned from other people. So collecting data around eating, drinking, talking and then taking a patient to meet those people who you need on your side and letting them tell their story. So if they've had a bad experience or if they were sat for 10 days, not able to talk and because there's no speech and language therapist paid to work on your unit, for example, then that's a really powerful thing and then having exemplar sites that you can point to so that the global tracking collaborator is really good at that by essentially giving you business cases by sharing what other people have done and saying, look that they're doing this. Why aren't we doing this? So it's a combination of sticking carrot, I guess. So, showing people some of the shortfalls in care, being able to highlight what good care looks like and then trying to work out what you need to do in your place to get to that point and a lot of the changes that we made that it wasn't about introducing new services or doing new things. You know, if you think about track care, what would happen on, I'll pick on our ICU. I hope no one's listening. But if you went back 15 years, we'd have someone with a trie we'd go around and award round and we'd do our bit, then an ent surgeon would come around and say something else and they'd say we need to get speeches along and then the speeches would come on the next day, didn't know exactly what Ent wanted. So they put a question in the notes and then the Ent would come back next Tuesday and it was all just uncoordinated. So, but actually thinking about who is, who needs to be involved and bringing them all together. It was a bit of an effort to round everyone up. But everyone realized quite quickly, we could save a lot of time by seeing these people together. And so instead of having to refer to Ent or Max Fax or the speeches or see what the physios thought about, you know, drying agents just making decisions altogether, it actually made things a lot more efficient. And then with some of the bigger Q I projects that we've done, we've tried to tackle it from a patient safety point of view, showing the process metrics that you can get people out of ICU faster, which comes with a pound sign. And then, um, looking at some of those quality of care things. So trying to, I guess something for the patients, something for the staff and something for the organization. So I think track care hasn't historically been done very well. And so it's fertile ground for some quality improvement. Um So I think by thinking about all the different elements and the sort of Q I methodology of easy wins, do something easy, do something visible that gets everyone saying, oh right. OK. Time to eating has come down by two weeks. That's really powerful, patient focused stuff. And if you've got any barriers or any people, you need to particularly engage, then there's plenty of resource out there of how others have done that that you can lean on. Perfect. Thank you. There's a few questions coming through. So the first one is here, uh how many whole time equivalent speech and language therapists you have in your unit? And do, do you, do you manage? And for how many beds is the question? I think people are curious. So our speeches cover two ICU S. So one ICU has got 19 beds and the others got about 46. I think the card ICU. Um We have three speech and language therapists. One of whom is Sarah, who does three days a week and we've got two others who I'm pretty sure are full time. So that would be about 2.5, full time equivalents that work on the ICU. They do other stuff as well. So they don't just do ICU but we're lucky, but they, they could always do more. I'm particularly lucky, I think with the people I work with that, they, we're pushing at an open door. So, you know, as I said before, looking at the different people that need to be evolving, there's lots of pockets of people who've been trying to improve care for years. And I think what we did with the N TSP is basically create a vehicle for people to hang their hats on and say, hang on, we can do this. And so the getting the speeches on to ICU was, was really quite pivotal. And then, you know, our tracking ward rounds are usually with the speech and language therapists, the physiotherapists, er, the medical staff and then we'd pull in surgeons as and when we need them. Uh, there's a question here from Les Wilson about, do you think the larger external diameters of subglottic drainage tubes have had an effect on vocal cord injury or laryngeal injury? We had wondered that locally when we were seeing some patients, not sure what you think. So, I don't think they're that big. Um, they are bigger but I don't think it's a huge problem. I think when you put the track tubes in, you know, I guess the actual laryngeal injury that occurs usually occurs around the translaryngeal intubation. Um, so I think that the size of the track tube, the only real problems you get from the size of the track tube is how much space there is around the tube to vocalize. Um, so I don't think it's a problem. We use a particular brand of track tubes and we have done for a long time. We don't have any problems with airflow. We tend to stick the same track that we put in. When we do the track, we tend to wean on the same track. We don't bother downsizing. So most patients get one trie at our place and we use typically 8 to 9 subglottic suction tubes and we don't see a problem. I will caveat that by saying I, I'm not aware of any data that can support my um answer, but I II don't think it's directly relevant. And I think do, does it specifically impact Lara Gilling? I would say almost certainly not. And then Liz is also asking about in follow up patients with severe dysphagia. Um Would you advocate medial injection, laryngoplasty? Wow, maybe, I mean, we, if I'm honest, I think our role on the intensive care unit is to identify them. Um And then we usually hand them on to our ent colleagues. So often time is is what they need. Um, I think probably the only intervention we do typically on the ICU is that Angio electrical stimulation? So, if we think it's a neurological problem or, you know, it's off to something fairly complex, um, or sometimes stimulate them while they're still in the ICU. Um, most of the time for that sort of, um, more interventional sort of, er, treatment that's happening a little bit down the line often when they left the ICU. So I don't know enough about that technique to say yes, everyone should have it. Um But yeah, I II hand that on to um like a surgical airway expert which is not me. Um Lots of a chat about um uh uh Pedes kind of finding it very interesting and peds. Um There's a question here, I think if I'm correctly interpreting this question is, can we not just leave patients with the cuff down all the time when they're in a weaning phase? Um That's what we tend to do. So we tend to wean them quickly. So, uh we, we, we put the cuff up to start with um as soon as they're awake and trying to communicate as long as their secretion burden is OK, like they're all secretion burden and we treat that aggressively with a ladder approach. You know, we stick some atropine drops on the tongue, first of all, and glycopyrrolate or hyoscine and we're quite aggressive in managing secretions. So we can get the cuff down early, but we'd often take the cuff down anyway and just see what happens usually within a day or two of putting the track in. So as soon as they're awake, we'll get the cuff down and we'll try and establish cuff down in 24 hours. So our approach is let's get the cuff down. So you leave the ventilator parameters as they are. So typically they're a nice e ventilator with a tube in the mouth. We, we'll do the per tracking next day, we'll be switching them to a like a non invasive ventilator with a view to get the cuff down and we'll start off with five minutes and then an hour later, try for 10 minutes. If they're ok, we'll prolong that quite quickly. So usually by day three, post tracking, we're looking to get the cuff down for 24 hours and once it's down for 24 hours, it stays down. And then we start our ventilatory strategy, which is then usually sprints just because we're impatient. But yeah, it's cuffed down first and the cuff stays down. We don't bother swapping for an uncuffed tube. We just leave the cuff tube in with the cuff down because we don't seem to have any major issues with it. And then Alicia is asking a question here about, is there benefit from EC V if your patient isn't vocalizing? Do, do you get the benefit of, of the airflow? Anyway, from it. Yeah. So, um, the current study we're doing, we're looking in a lot of detail at 60 patients who have had a CV. So they all get a scope at the start, then they all get a CV for up to a week and then we scope them again. We also do um, electrical stimulation. So, as a sort of surrogate for how sensitive your larynx is, I mean, you can see when you're looking with the camera. If there's a load of snot, sitting there and they're not coughing it, then you know that their larynx isn't very sensitive. And so we've, um, we've actually got the precursor to that Pics kit and po up the nose down to pharynx and we basically crank up the mains until the patients can feel it and we keep going until they've had enough of it and the sort of occurrences if you put the caffin between your fingers and you turn the current up, you can feel it. It's sort of two or three millimeters millimeters milliamps and it's a bit like, you know, touching a car battery, you know, it's quite unpleasant. So two or three mill mill, you can feel it if you put the catheter down patients noses and you turn it up and they've got an insensate larynx. We're getting values in the fifties and sixties. So really markedly impaired larynx, you turn on a CV and immediately that laryngeal sensitivity plummets and we see that as you saw in that video that they were patients start to swallow, they start to cough just with a bit of airflow. So even if they're not vocalizing, restoring airflow is, is really important. Uh I guess the one caveat I would have is is that if they're not vocalizing, you've just got to be really sure that the air is actually coming out of their upper airway. So we don't do a CV, unless we've scoped the patient because I'm a bit paranoid, um, that we're going to cause a problem and it's a device trial. So I don't want to mess up the device trial. Um I mean, I think if they had a normal airway maybe put them off to sleep and if their airway looks ok when you do the tracheostomy, you can pretty much guarantee that the air will come out. Ok. So when we do the tr when we finished, we spend quite a bit of time checking that the subglottic port is orientated in the right place that we're happy with the position of the tube. So we tend to leave the oral tube in because it's just dead easy then to look above the cuff, flush everything and check that the tube is ok. So we sort of make a note at the time of tracking what the sub sub port is doing. So we can be pretty confident if we were to blow some gas up it, it's going to come out of the airway. So, yeah, that's my only caveat. If the patient's trying to localize and there's no noise, then stop doing a fever. You need to investigate that. Um, but currently I think it's 93 or 95% of our patients are getting a voice with a CV. So previous work it was about 75 but it's really high. It's often a whisper, but you can pick up an accent. One of my favorite stories is a lady that, um, we didn't know was Scottish. She was sitting in a bed in Manchester and, and we stuck on the, the A CV. And we could pick her accent straight away. And it was fascinating watching how the nurses change interaction with her cos she went from being, you know, the one in bed eight with Guillain Barre to Sheila who'd moved down from Edinburgh to help her daughter look after their grandkids and you could see that interaction as well. Do you know she's, and when she's come from Edinburgh, you could see all this banter starting because she had a voice and she's the same lady. She was before she had a voice. But even though it was a whisper, it was a Scottish whisper and it was really powerful to see the effect of giving someone their voice back. So I've rambled a bit there, the answer is yes, perfect. So even if they're about and then, oh, Sophie's asking if you have cough down all the time. Do you always have a passing in your circuit or do you, does that go in and out? It depends. So some patients find that hard work. Um But we'll do the same. So to phase things, we get the cuff down might leave that a day. If they look, OK, then we'll think about our strategy. So that might be trials of passing your, if you put it in the patient struggles, then we take it out and try again. And I think the important thing is this is a dynamic thing. So just because they struggled on one day with a one way valve doesn't mean you can't use one ever again. And so we'll, we'll think, OK, we'll try that the next day. But generally with the passing mua valva, you get better upper airway flow, obviously. Um it also does lots of really subtle things that I had to have pointed out to me. So things like if you have been on a morphine infusion or an opiate infusion for a couple of weeks and then you're in an ICU and you need to go to the loo, we all go and, and you can't do that if you've got an open tracheostomy and if you've got a passy valve on, you can. So going to the loo is a lot easier with a one way valve on um when you try and get up, you know, if I'm trying to get up. Now you take a breath, you brace yourself when you get up and you can't do that if you've not got some sort of closing mechanism in your circuit. So once our patients are cuffed down, we'll nearly always try a one way valve. If they tolerate it, it's nearly always in. So by day, one way valve in because it just promotes that upper airway flow and does all these subtle things that we don't like to think about. But actually, from a patient perspective, they go, oh my God, that was a lot easier. So, mobilization and going to the loo are the secret um ingredients for my. That is absolutely fascinating. I wouldn't even have thought about that. Yep. So physios and he told me that nothing to do with me. Um Kirsten has got a really interesting question. I know she works with us locally and I feel this question too, which is uh established tracheostomies and laryngectomies out with an ICU environment just so much anxiety uh quite rightly so about those patients. Um And should we be aiming to have a specialist practitioner role or someone who lass um with patients who have um I guess either tracheostomies or laryngectomies in a ward based environment. Ideally, yes. So the hospital I work in, I presume there's no one from Manchester on your court, but there might be, I suppose. So we go around in circles and it's really frustrating that we get people in with these grants to project manage and while they're in there they're sorting out our own house. And then when these projects end, the organization goes, oh, great. We've solved track your care and then everyone forgets and then all the problems resurface. So we're currently at the top of that cycle again, you know, trying to work out who to a point and are gonna sort care out. So, it, it, it's frustrating even when you've got sort of me and my team here jumping up and down trying to sort stuff out. So it, it's a difficult problem to solve, but having someone with ownership is really helpful. Um The NC pod report highlighted that there's lots of different wards often in hospitals that can take tracking patients or laryngectomy patients. And so trying to round them up into sort of cohorted areas can really help with training, can help with equipment delivery of infrastructure support. You've got less staff to train, it causes problems because we've only got one ward really that looks after Tracheostomy patients that we're comfortable sending patients to the default is they hang around on the ICU, which usually gets people calling me names behind my back, but it's safer to do that. So I would say find someone or engage someone with responsibility if no one else is prepared to do it. I think we have a role in tens, we should get out there and we should lead and that's what we've done at our place if. Right. Ok, we'll sort it out. Um, and we sort of trying to embarrass groups into pulling the socks up a little bit. Nobody's dead keen on looking after the post intensive care tracking patients because they're hard work. But, you know, you might find someone who thinks it's a real challenge to trying to rehab these really complex patients. But having someone with name responsibility for care and training and support and looking at incidents outside of the unit is really quite powerful because then you can look at incidents, a lot of shared learning and if you've got a sort of team on the ICU task with track, you care again, you've got that overlap and that safety net. So, thinking about how your organization is set up, thinking about what you think will work, thinking about what your problems are, I think are the sort of ways that you can tackle that problem. Perfect. And then I'm gonna take this as the last question. Um, uh, uh, do you have, are you using pharyngeal electrical stimulation outside of trial settings as well? Yeah. So you can go and buy it now. Um, they're expensive. They're about, I don't know if I'm supposed to say this. They're about 1000 quid a pop for the catheter, but that's what, eight hours in ICU. So, actually it's nothing. Um, we've published something in Js quite recently about Real World. Use of these things and we've not done a study about P ES at all. A lot of the data is in stroke but there are groups in Europe who've been doing it for tracking patients. Some of the data, I found a bit too good to be true. They said they were treating patients and decannulated them the next day. Um which might have been the case. I think we probably use it too late. We are using it earlier and earlier because we're finding problems early and our speeches will say early on, we need, we need to get this person on a pe pathway. We don't have too much trouble now because we've seen people transform. You know, we've seen that sort of patients lying there with a huge aspiration risk thinking God, we're never going to get decannulated. They're going to have to get lined up for a nursing home and then after five days of treatment, we're pulling the tube out and that when your boss sees that you're like, oh, ok. This isn't such a bad thing to spend your money on. Um So again, sorry, it's a long answer. It is expensive but it's not that expensive considering how much a day in intensive care is. Business cases are available. The company is pretty switched on. They've got nice reps who are clinical. I don't work for them. I don't get paid for them. But if you're interested, I would certainly make contact with them. They've loaned us plenty of kits. I shouldn't probably say that either, but if you're interested, there's some good data and they're a good company to get involved with. Amazing. Thank you so much, er, everybody for all of your questions. Um I am just going to draw this to a close by um by thanking um Brendan for joining us this evening. Um And that was a really fantastic talk. Um You, I popped the feedback link in the chat. If you go to that, that will um if you fill in the feedback that will automatically generate your attendance CPD certificate as well. And the Scottish intensive care society updates will be back in a month's time with a, an update on the Scottish organ donation landscape. So please join us for that if you're able to and thank you again for joining this evening. Uh Goodnight eight.