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Yeah. Okay. Okay. Yeah. Okay. Okay. Okay. Thank you for joining us for the King's Airway workshop. It's great that you've been able to join us virtually today. Some, some people have joined virtually some people are some of our satellites centers, and it will become clear what we're doing later. But thank you so much for joining the King's Difficult Airway Workshop has been running for many years, but this is the first time that we've done something completely new. The the King's Airway works always focused on practical skills. So letting any STIs onda soc ated colleagues get hands on experience of the techniques needed to manage airways and difficult airways on on we realized in Covert, obviously. What? Do something different on D. What? Well, I'm It's a medical director. I'm a sign medical director at King's College Hospital. But I'm also a consultant in East It. So some of the last year of my time has been spent looking after patients with Kobe looking after patients who are having emergency surgery. You don't have covitz, but a lot of my time has been spent looking after the DeMarco of sight of King's college hospital and making sure that the site is safe for all the patients that come through, particularly those with Cove it. I also do a little bit of international work. I've had the opportunity to work in South America on Africa on also work in the Middle East with some colleagues there on what I can say is that safe airway care is universal on what Covitz tortoises that actually, wherever you are in the world, looking after patients with with their airways is really important. And the fact that we're all doing that to the same standard is really important. There's gonna be a lot of people to thank a day who have made today happen, and I won't go to now. But I would just like Tina Liver doctor Mirotic Crystals Place, who was our Advanced Airway Fellowship. Fellow Kings. She's on a tremendous amount of work in the background to make today happen, and she's somewhere above us looking after the sort of technical aspects on Also she's she'll be helping support the questions and comments that you have today, So if you've got anything that you want to ask you to comment or question, do you put it in the in the function that you've got on the bottom of your screen and we can coordinate, coordinate those questions and hopefully, feedback some of it live in some of it later is, well, what is COV taught me? Well, it's taught me that life has changed a lot, but the life has carried on being work, relationships and home life, and we've all had to adapt to that. And it's brought new opportunities and a lot of new challenges as well. After the first wave of covert at King's, we asked three questions of our staff, and it's three questions that still sit with me. And I'm gonna answer a couple of the things around this this course today about what I think important. But I really want you to think about these questions as well, and particularly to help us when you feedback on today so that we can work out what we should do differently next time. And the first question is, what do we do now? Since covert that we want to keep doing on? I think the virtual opportunity for meetings for COPD for education has really transforming the way the healthcare is delivered. I don't believe for some time if it all will ever go back to an entirely face to face experience of learning. What do we want to get back to is the second question is what we want to regain that we weren't able to do during Kobe will. Actually, that is that hand on experience, that ability to learn new techniques learn new skills in a Practicals face to face setting. And the third thing, the third question I've got is what we still want to change. Well, that's the question that I want you to answer. Let us know. We're trying to quite quite innovative thing today with this webinar hosting with with some hub workshops around where you'll see a day goes on, what people are doing around the country and around the world. But we want you to tell us what's going well and what has it on what we can do better next time. Please do give your feedback. On the other hand, over to Dr Brand Right there, sitting doctor written a singer is our General Theater lead at King's consultant in East Texas. He's a bariatric on airway specialist on He's been incredible person through the year. I won't go into the number of things that he's done in terms of both making the clinical aspects of kings function well but also support in the department on making it feel a friendly on keys that place to work. So doctor witnessing thanks very much, very kind. Thanks for taking time out of your schedule as site medical director Kings to support this NorCal Hybrid Webinar Workshop event. If I may start by just saying that our team would like to extend a warm welcome toe out of you have chosen to join us for the next 3 to 4 hours and what we hope will be an interesting on innovative and educationally valuable event Cave. It has become a globally recognized word. Its impact has been a big criticism and unrelenting and like the unrelenting nature of cave did. The healthcare response globally has also been unrelenting in it's dedication, professionalism and often self sacrifice. And the King's collaborative faculty would like to take a moment to acknowledge you All are international colleagues on in particular, that is from India in a port and flanker have not had the relative luxury of resource that we have had here and have faced challenges on a scale continue to do so that we can only be thankful that we have not seen here. Despite our tails loss, airway management has always been that center of caring for critically unwell patients, and scrutiny and investment during the past 15 months regarding safe airway management for both conditions and patients has been in power. The buying for video laryngoscopy in particular, have seen a significant proportion of previously ambivalent practitioners and breaks newer techniques during this period. The challenge to deliver hands on technical airway training in larger groups allowing national and international delegate reach and fact faculty collaboration has been significant in this prohibitive environment of social distancing. This has been the driving force for the King's College Collaborative airway. Been on, we have described. This is a hybrid learning event. For whilst we're broadcasting this live Webinars only is into that are collaborative. Faculty are running hands on satellite practical workshops showcasing the same techniques simultaneously, too small socially distance greens. We will have crossover and live interaction as the afternoon goes on with work shot leads our satellite centers to gain some additional insights on these essential core topics advance of advanced every month. Now we're only able to bring this to you because of the sport of our industry. Partners on this event wouldn't happen without them. I three partners are VeriFone into surgical on Fisher on paper and the significant efforts of our collaborative colleagues in Birmingham, Lewisham in Portsmouth. And of course, we have our international session. At the end of the practical seminars, I would like to thank our experts and friends in Dubai, India, the portal anchor in Singapore. Whilst we would not be able to hold this event without support but partners, there's no financial gain for any of our Webinar Workshop. Faculty on this undertaking reflect our collective commitment to further safe, effective, advanced their weight management and also due to the very real avoiding technical training that coats the coated pandemic has left in. It's like I'm so a little bit more about this thing. Kings Workshop in the Airway Workshop, A Z Olive said my colleague Dust in the airway lead at King's College Hospital founded the first Kings Difficult Airway work around 16 years ago. We've delivered 33 work chills at King's over this time, and this is expanded to include collaboration with international colleagues on We Run Things International Airway Walk Shops across the Middle East and Southern Asia. This is a practical themed weapon on workshop. It very much focus is on technique and tips to increase your confidence in clinical success with advanced their way techniques on That's very much the focus have been lots of webinars about updates and expert opinion, but this is very much about hands on technical approach to using some key, um, a rescue manevitz. There's no real substitute for hands on experience with quit mint in workshops or in patients. Nearly a lucky few have secure place is on the Web shots today. We feel there is value in this interactive, tutorial based learning experience. Provide unnecessary grounding to take the next steps in your advanced their weight management journey. Like many conditions, none of it's an actually comfortable in front of the camera. But my colleagues and I have overcome the resistance of taking sent stage to share their expertise, experience in skill. We have populated the event itself may tutorial videos which stuff like that access to to sandal eyes, the content that they're delivering locally and we intend to progress and evolved. Delivery moving forwards What's the evidence that indicate that I could never claim to be the next Spielberg know normal school? Say Z. Nevertheless, I'm hopeful that you'll find the content to be value and if you're involved in some capacity, especially involved in some capacity there we management where we have any patient video. We want to take additional consents separately for their use instead occasional event and on day, if you have any questions from the webinar ordinance that you'd like to direct to either our in house life speakers or are satellite you know, experts please do in the function tool you find on the link. Okay, so I think that further ado, we're going to start our first practical session off this workshop. Webinar, which is video laryngoscopy on afraid you're stuck with me for another a little while when we get through this topic, so I have no disclosures to make. It's a very long gossipy historically Laryngoscopy involved a direct manipulation of the airway to look at the got a canal me on video endoscopy is is an indirect approach using an optical device to improve. Got it. Anatomy Visual ization without the need to rely on your classic three axes, the oral access the parent relaxes. This is a particularly unique value, and neck extension may be limited on mandibular. Advancement is restricted. The technique is device dependent on requires a degree of expertise. There are many devices out there. You can classify them in a whole host of ways. Channeled non channel devices. Portable. One portable device is, um, they're not a one stop solution for all Thala Geez and or difficult airway cases. You do require minimum degree of math opening an aura pharyngeal space to operate. This will depend on your manufacturer. The Blade Sign and profile. There's been a dramatic evolution in this regard on blades a thinner on. Actually, we can utilize these devices to good effect in people with relatively limited mouth opening. They were traditionally problems with these devices where you have multiple cases with trauma, secretions, blood fucking and that is still the case. Newer devices that anti fucking device devices built into theblaze to help mitigate against that somewhat on this discussion going around currently. With that, we've evolved to the situation certainly an environment similar to the United Kingdom and whether we should be using these devices is first line of rescue device is, and that will depend on your local set up an expertise. And there are many debates about that which we may go into during our live interaction in a while. Video gossipy on direct laryngoscopy have compared, compared in a whole host of studies that have been systematic reviews. Meta Analysis e's, which have been quite well published, publicized on it's now established that video endoscopy certainly associate it with reduced laryngeal area trauma. An expert hands when people are using them in the appropriate way. Reduced number of failed intubations reduced difficult view of the anatomy on increased first past success increases overall success of intubation on greater first attempt success on I think that last point is key will come back to that. So we've all heard anyone involved in a row A management of this heard about making your first part success. Your best attempt on dad is a matter of well here the matter what airway technique you are discussing, um, utilizing so that further deem I have a video tutorial following next, which will take you through basic approach to the clinical utility of using a standalone video video escaped system. But I'm just going to say that for you now. I'll see you shortly. So now I'm gonna talk to you through a approach to increasing your chemical success in patients with the Glad State School system, which is a standard system with its self contained stack. The principles that we're going to describe in the next few minutes when using this device would be translatable toe other similar manufacturers that was seen back the courses, as my colleagues will describe in subsequent presentations after me, have advantage of the picture in picture system. I'm going to take us on the big, gossipy and off the gland stage. There are some basic principles when it comes to the discussion. What you do need to be familiar with is your device. I need to know the range of blades, and there are some choices available on these choices of people's, so they're really a range of blades with a number of different manufacturers. The glass A system comes with a range or pediatric plates such as yes, one in the ST Now that's escaped this discussion weight with fixing a pediatric, but that is something that we do in other weight, right? It also has a range off familiar back. 34 Quint video. Gossipy blades. I also regulated lights. Yes, three Choice is one of the most important decisions you make when increasing of success rate. There is a tendency with anything tests who are perhaps a familiar with gossipy Teo defaults to using a Mac appointment. I would suggest that that's fine for training. It's fine in terms of the mill off blamed design and in the waste in Surf it. However, for truly challenging airway or anterior or disorder, whilst these will be successful in 80 or 90% of patients with relatively normal that's me and some with a Macintosh grade three grade four, you quibbling, it will not resolved. There's truly challenging airways for that. I would recommend King with Grace recommend using. Now we have studied the Estring That's for low pro blades before in manic in studies and in patients on what we found. Well, mainly, is that for over 90% of patients, yes, three late probably is a quick one stop solution as initial approach and someone that hasn't happened got to be passed on. I will just demonstrate a difference between this for both hyper angulated blades. As you can see, if I a line them up side by side, I think it will become self evident. That's the hype. Regulation angle is actually very, very simple. Yes, three is in front in the fall. What I would say it is the clear month difference is the length of the hyperinflation on the S four blades on Also, it is a slight. There are circumstances were in export. Crow is gonna be appropriate. Where there's the previous documentation, that s three labor. It's been insufficient to give you an adequate you on adequate airspace. To need your cheek into the glass is in here. But as we said, we would always recommend starting with the next three as a default choice with this Is that in our experience that collectively enough anyway, he, with several 1000 video of introductions last way, talked a little bit about the importance of Blake choice in terms of the general principles setting with this device with any device, I think we did it. I almost being blank choice we covered. Blame. Positioning is the next most important choice in terms of improving your separate minimizing trauma on then tube advancements. Cannulation of the trachea is the Bible based on that phase dependent device of using whether it's a channel. More devices we discussed leave them all separately on also incorporates the use off, which could be a stylus. Manufacturers supply. Start that, or a booty or calling will cover potentially a flexible bronchoscope. Teo provide advance their way support. So let's cover blade and search. It's a different technique to using a standard metal doctoring escape. Were conventional talked to insert on sweet time off to the left side. This is a midline approach on. The other key thing is to avoid screen fixation. Now you're ergonomics with any anesthetic practical technique really important for the benefit of this video positions the core widescreen system to my left in practice that would be in my line of vision. I have slight, slight the patient. There's a temptation with nice optics to get screened, fixated, indeed it, and this is where you're going to cause your first chance of trauma on. I really cannot stress enough importance or directly inspecting your or, if I drink, taking your midline approach Minimal trauma, avoiding contact with with the teeth on inserting a blade around the back of the time. Now with hyper angulated blades with a mannequin, it is difficult to appreciate. It may be challenging to come in completely initially from the front, especially in obstetrics patients, very active places where the chest may physically impinge on your tube in session on alteration to that technique in those patients is to come in society off midline from an animal, getting around the back of the time and then come back rabbits a midline like that. But I haven't even looked at a screen at this point. Now that I'm in the midline, I'm around the back of the tongue. I'm going to see where I am in terms of my order for Julie. I just bring that back as I'm inserting that you can appreciate. I'm getting around. We've got tons of period, but I'm just going to record this hit on. We have the evil er at coming into view, inferior or at six o'clock position, I'm going around the back of the tongue on Blake Positionally is key is what it's played. Insertion talked about Choice Blade insertion blade positioning. Now this is incredibly important. Historic. Here's a tendency with new uses to advance the blade very proximal to got to get this great video on it. Translated that a call saying Cascal description. You put a grade on you. Difficulty with that is the proximity means that by the time you insert your cheek, I'm gonna do this as a soldier, it comes in too late to view on often posteriorly, and what would happen is people describe. I get a great deal, but I can't get a tube to get around one C that seriously, it's like to slip into the esophagus, or it's like to hit you in tonight's So what? We describe what might be the endoscopy petitions describes this intermediate So you insert yes, like broke on to see this. Just see that we've got the molecular tip of the epiglottis, and that is the ideal place. Physician, You blade, you don't need Teo point degree of pressure upwards and not being mindful of the upper side. So this is a robbery, but that is your optimum position on an adequate view. So that is not quite a great one of you. You may get a great one of you by doing that. I don't necessary described to the fact that you must intentionally aimed for a great TV. It may be that you get a great TV, but Blake positioning is so typical blade into that behind you, The Lantus on the airway. Minimal trauma within the mouth teeth. So it's covered. Great choice. Insertion positioning. Now, with this system, we would strongly recommend utility first house of the supply manufacturers. You can see that you've got this straight shape or what he states dialect that has been preformed on inserted with a bit of lubrication which is important into a standing order your cheek. It is important to ensure that the cough is fully deflected some cheap come partially inflated. That obstructive you come in. So that is the usual tip. You must know Use the stylet on a cartoon. If you cut your tube in advance, your silent to slip through. I will be difficult to minute plate negotiates and it and it will become much less so. That is another tip intensive. Using the stylet in combination with you in terms of your pro church, we generally once again would recommend having a midline approach and again really important. Doubly important with the silent, which would use it appropriately. Well, because, see, did you have blood and trauma to the airway? Optical devices become much less useful on your chances. Excess start deteriorating on. You're gonna get into that vicious cycle. Human factors when you make a poor choices, especially if you identify this is being difficult. So focused on a nontraumatic conception is being being know screen excited but inserting. Um, now again, we recommend coming in from the front and getting around the back of the time. I'm gonna give you that again. Players. It's like this is way would I would get the tube and side of public back in time before I even started looking at We're coming again. Bariatric step to patients or patient position suboptimally. You may need to adapt that techniques Likely you can see that concerning with you by holding it very high up, and we would come in slightly from the side, get it around the back of the tongue and bring it back to the 12 o'clock position. I'm stabilizing that with one hand here. So I've got my left hand and my thumb and middle and index thing is supporting that together. And as I bring that around now, now causing and waiting, there are three planes in motion with your style of cheese complex. You can advance forwards and backwards doing that. You can tip anteriorly and posteriorly, and you can rotate left and right, similar to how we would describe fiber optics. Cape Dynamics with my colleague. But parent will be so, as we've discovered, just to recap, we've had blade choice we had played. Insertion is midline. We've had blamed positioning in the optimum position were introduced this tube in silent complex. Yes, you'll get away without using Sign a good report of the time. But if you're truly having airways, you will fail. We want to minimize the number of times you minute later, narrowing inseparably. First success has become a mantra. Your first attempt to your best. We were very much describe that so we would recommend silent introduced, as we said, direct vision, minimal trauma. There are several case reports across a number of things, including our rain. Well, there have been damaged from there to inside a complex into the soft tissue of the orthotics that would be through the reef, a soft and hard palate. It certainly could be three tonsil pillars. Talk to us optician. We have accident facial set, surgical support. One site we have had occasions where inexperience user has become screen fixated has caused some inadvertent, which is required surgical repair on that was very much for outcome. Say, I'm stabilizing this with one hand once I put it where once it gets. So where do we want to get? We want to approach the glove office using those three pains of motions, and I'm going to stop there just a level of records. And I'm holding that together in one hand independently. And that's what a nice way of dealing with this. You actually have an assistant, and yet you need to describe to assist in advance how you're planning to utilize this equipment so they're familiar with what you're gonna be if you were to just advance with the style it in place at this point because of the anterior ambulation of that J shaped, you will potentially scrape the anterior part of the Kia and cause damage. And again, you must know how to use this device in a traumatic way. I am now going to see with my son lift the style it up a few centimeters, which is taken the metal traumatic part back on. I'm gonna show you a technique which allows you, Teo, not require an assistant and advance your tube off the stylet. So by then turning your hand on the top surface of the style of using your thumb, you can sequentially push your cheek down. You can see we've got the point where our second line got the vocal courts. You can. Then we've got this curvature you to bring your style it up. You're gonna extubate true, but you have to. If you're using a consistent at this point, you need Teo. Explain that way are bringing are silent, too complex forwards and it come out if again you have a tissue back. Typical approach your angle slightly up to one side but that's easily adjustable. And then you would confirm to places with coughing election in the usual way and hope that tutorial covered the essentials To give you a framework of how to use video laryngoscopy safe. Yes, it's one particular device that GlideScope it is translatable. As I said, Teo, a number of different devices and within the scope of this webinar, it is difficult to cover the full remits off different devices that we would normally cover with our hands on workshops. And certainly, if you were interested, please engage with this one of those. Another event. There are some additional considerations with video or endoscopy. There is the educational impact being able to demonstrate the anatomy to multiple theater learners at the same time, with no crowding out over a clinician appearing, uh, over there, shoulder is clearly an advantage on a step forward from conventional direct laryngoscopy. Um, it's also really reassuring to know definitively what the training you're seeing. It automatically reduces anxiety if you're the clinical supervisor or the senior operator in the room, it allows learning Teo occur without a premature interruption to their technique on it confers confidence at an early stage for new users, and the letters really recognition off difficulty for a assistant is also really important attempted patient outcomes because it means you can interview intervene more quickly because you can directly see that they're running into trouble on you can perhaps lead to better patient outcomes and not get them into the territory where they're already becoming, um, deteriorating in terms of their weight management. Um, another educational benefit of the visualization you get with video endoscopy is allows a anesthetic assistant Teo Assess on view the impact of their criteria. Pressure, For example. We will know that that's an essential tool at certain stages of airway management in certain scenarios, and it could be done badly and it could be done well when it's done badly. There could be a significant hindrance to safe management, and that is a very useful learning tool with video. Other secondary benefits include minimizing trauma, increasing first part success with traditionally blind or Fangio procedures That could be, for example, inserting a nasogastric tube or or a gastric tube, which wanted ventilated patient. Certainly in the intensive care setting, you can be quite challenging and has caused significant soft tissue and found your trauma in the process. Um, having a visual record of intubation increasing the this is gonna become something that features more strongly again for difficult airway management. Airway alerts on be able to capture that in real time and have still shots of airway and at me as it occurred. We'll have a medical legal bearing, certainly in the future, I have no doubts. It also allows you to communicate for subsequent airway management, planning and strategy. In this awkward cases, like it just move onto the next light. That's great. Some some other additional considerations passing, other or pharyngeal instrument such a transesophageal echo. Pray Upper GI I endoscopy equipment that is facilitated. If it's been challenging so again you don't cause trouble. It has been reports of video and just being used for foreign body removal, it remote side anesthesia. It's very reassuring in intensive care. The adaptation of video laryngoscopy techniques and this high risk group of people with poor reserve has been phenomenal, especially during the last 15 minutes. Months of the pandemic on giving that continuous got a view during medieval such a CT endotracheal tube exchange eyes profoundly reassuring. It's also been described in intubation scenarios in unconventional positions that in case reports or feuding video and gossipy to intubate in the forward facing lateral and prone position on finally video, Laryngoscopy is not just in a sleep technique. It is now established as perfectly safe and reasonable. A week away. Trickier intubation procedure. So Wait Rykiel information we always used to Trish in the associate. If I brought the information, I'm not going touch too much on that. That's the next session, but it's now on established technique. They're difficult. Airway Society guidelines, as you can see, have been published by colleagues from it from death on. We have done this several times to get outcomes on, certainly over the last year, with concerns if operators, safety and patient to operate a distance thing established guidelines. Dogma has been video laryngoscopy potentially is first line for covert 19 era. And again, that's something that is continued to be baited, and it depends on operator expertise in many other factors. So on that note that brings in the end off the tutorial on video laryngoscopy on. But I have a couple of short videos just to show you to really re emphasize blade positioning and how that makes a difference. So this is a quick video automatic in that shows you're very proximal to the glottis. You will struggle to get your tube or two tubes Dialect complex. Teo, go where you want it to go. Often it'll get posterior. Hit the retinoids on by manipulating your blade position into the molecular foster, as we described in the tutorial that gives you the parent or a fragile airspace on time to redirect your tubes. I like complex to get your cheap to where you want to go for successful intubation. Finally, this is a bariatric patient. One of my lessons, 200 kg consented to be filmed on the top. You can see the ring escape of you and you can see optimal blade position. You can see on the bottom of go pro my head, which is showing that I don't get screened excited when I'm putting the blade in on when I'm inserting stylet on that would avoid before George. That's just re emphasizing this key points off successful, meaning the atraumatic laryngoscopy. So that's why I've got to say on now we're going to transition to our first live interactive session over the afternoon. We're going to go Teo Lucian in Greenwich, any chest trust where they are running live. Currently, the practical elements of this hand's on difficult airway workshop on we should have. Doctor Andrew McKechnie. He is a colleague of mine. I've known for 30 years, both professionally and perhaps unprofessionally. I know him to be a highly competent in skilled Anethe test on video Laryngoscopy Cyst. He is vice chair of the Society of Bariatric Anesthesia. Escape of Clinical practice. Well, it's bariatric. Anesthesia would include head and neck and ent surgery on. We have very privileged to have his input this afternoon. Hi, Andy. I'm just gonna pops. Um, if you said I could actually hear you. Yeah. Hi there, brown hating. And you will have. Yeah. Yeah, we can hear you. Well, thanks very much. House has the workshop going ocean. Yeah, well, good. As you can see behind us. A practical father Work is going well. We actually intrude with your your video that I think we shared on the webinar as well. First. And then we've gone into some practical demonstration of those techniques that you were you outlined earlier. Great. We've had a question come for you in the webinar. And it was talking about changing practices during the pandemic of the last 15 months. Andi, how new operators or previously skeptical or ambivalent operators are now. I'm bracing video and gossipy as perhaps first line or certainly is a rescue technique. What challenges or barriers do you think there are two white training in video and gossipy? Currently? Yeah, I think. I think obviously things have changed little bit. Certainly hope it has pushed a lot of people into into the L news. I think in the past we've got a bit hung up to some extent on the idea of most airways being able to be done with it laryngoscope on a strong right arm, that sort of argument, which I think creative bit of a barrier towards VL use. But I think in addition to that, there was off the moves towards using the L's purely when we knew it was going to be a difficult airway. So we predicted airway many of us that that were quite early adopter. This all really disagree with that from the start. But I think there is much more removed now. You're sort of universal use of the L's. Actually, you know, it's not that they have seen many benefits of it. I think the fact that there was far more widespread use amongst the amongst trainees initially annals you, then more senior consultants as well in these airways, in which we needed to get control fairly quickly as Sattler were dropping below 30 2010 and below. I think a lot more people were using the l's have now host of. It's starting to realize that you know, universal use for all Airways, not just predictively difficult ones is probably gonna be the thing going forward. No, I'm like with anything that you said just maybe on from that we've also had a question coming from the Webinar, I think, from a CT one on day. I think their question wars. And it's a question that's a cage traditionally by some sort of more resistant practitioners that as a new CT one, obviously it's important to learn direct laryngoscopy on what do you How would you approach that question with people saying that this approach would be skill, our trainees reading D skill and incoming generation off anything it's Yeah, I think I think we do hit that argument quite a bit, actually. But again it kind of goes back to the The Y. Rely on a standard Macintosh played on the strong, you know, on a strong left arm when we don't need to. You know, the the the advent of the L's and the advancement of the technology now make make the l pretty much my go to every time. If I'm allowed to use it every time on from a training point of view, I think I think you alluded to in your in your webinar video. Actually the V l. The glass capable of using today on the others available. Actually, a fantastic training taught, you know, most now has the Macintosh blades again like you. I don't particularly use the Macintosh played I. I generally go to the hyper and elated. However, from a training point of view. Use of a Macintosh blades is great, so often I will use it in two ways, really. In terms of training, I will allow the trainee or encourage the training. That tube is normal and I will turn this screen away from them, so they almost using it entirely as to direct laryngoscopy technique. At the same time, I can keep an eye that they're not causing trauma, that there's no additional issues by watching the screen and also If there's other trainings with us, we can actually go through the airway and after me that we can all see on the screen together as it's performed. Obviously once the training is much better on. But, uh, you know, more used to using it, then fair enough they can start using the screen. I'm not strict about it, obviously, But you know, I think I think having the screen doesn't necessarily mean you have the automatic. He used the spring for training, sure, but I think it's I think it's a great tool on, you know, video laryngoscopy isn't going anywhere. We're not going to go back to the days off relying entirely on a A Macintosh blades on or you know, the other versions off them. If we ran into trouble video lowering steps here, technology is great, and with appropriate training, I think they go to to like, perfect again. I don't know what you'd say. It is a natural evolution with technological advancements, much like ultrasound has been for regional anesthesia on after me identification line placement. I think arguments habilitating in certain aspects, but as you say, and if you at least the better patient outcomes. Minimal trauma. First pass success, which is a mantra amongst all airway operators, cannot be a good thing. And finally, and the we've talked a little bit generally about it in terms of your own clinical years, we've talked a little bit around it. I know that you So they do a lot of bariatrics like myself, and you do see Ent anesthesia can just talk a little bit about how you used to get gossipy. Yeah, I think certainly, in terms of my parents practice, then video angle squeeze is my first line approach, but a lot of parents patients on. It's not simply the V L that allows that to happen. And there's other things around airway management in the Back in Barents Patient, which we don't have time to discuss fully now. But I think the V E l in combination with appropriate reaction agent, which may be inform of high flow nasal or mask with CPAP on, you know, appropriate patient positioning on then V. L is my kind of go to embarrass. So those three together, I think, uh, I think certainly make a massive improvement in a way. Management of what can be quite tricky patients. Obviously, there's there's lots of talk previously that by different, although these patients are difficult, intubate. That's simply not the case. However I use of the El because I don't want to have a 200 kg patient rapidly deteriorating rapidly. Desaturating whilst I'm trying to use a Macintosh played that I can't quite see anything. What's my ODP gets the B already so v l. Every time in combination, as I said, with appropriate reaction, a shin on appropriate patient positioning. Yeah, I would. Again. I think you made to great points there and the so I think certainly from a training perspective and for new adopters, a video and gossipy, I think we need to be clear. With our junior colleagues coming through the use of the laryngoscopy, I think they'll be a temptation to think that you can be relaxed and slack with every element of very management, whether it's patient positioning, whether it's preoxygenated in and I think you can get lulled into four cents security and having advanced optics, advanced equipment that make your life easier is no excuse for poor patient preparation. That's a recipe for disaster completely would echo what you said that on. Also, as you say with Bariatrics, I think perceived as you get into that situation where you know where you are having difficulty Yes, you know, they're not significantly more difficult to interpret it in the general population. What they are more difficult to do is to face, mask, ventilate with that soft tissue hypertrophy they get. And so you ordered into that potential human factor. If you get it, Is that a unavoidable problem or an avoid a problem where you could get into their can't intubate, difficult to ventilate scenario. So why wouldn't you have something that gives you think any any laryngoscopy becomes 10 times more difficult when you can hear those SATs dropping below about 90? I agree. I agree totally on the thank you to the Lupron Greenwich team that you're leading that have gone through a lot of effort in the background where you've got a lot of attention to prepare to run this simple tasty with this on. Well, but for to your feedback for this inaugural hybrid event, thanks for giving us some clinical expertise on do a lot with the rest of the workshop that you're running and we'll catch up with you. See that so much. Thanks, but okay, so that brings us to the end of the first practical session for the live hybrid Webinar Workshop Are collaborative event on, but that was very helpful to have and these insights there.