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now it brings me great pleasure to introduce our next speaker. We're very lucky to have him. Doctor Nicholas Parry. He's a colleague and friend of mine. He is an extremely skilled educator on Do Airway operator. I have benefited as a senior training and as a consultant colleague from his wisdom and expertise. He's a brilliant teacher on always. University gets fantastic feedback during are practical hands on workshop, where he takes the lead for fibrotic intubation instruction. And so I went waste any time on my colleague Nick Perry to talk you through a practical approach to fiber optic information, much brand for that very kind and generous interrupt introduction. And I think we've prepared a video based very much on what I teach on our in person anyway workshops kings on. But I think this we might have just go straight on into the video where we talk about the I talk about the what I consider to be the fundamental points behind becoming more successful in with fibrotic innovation. So I think we'll just move straight on on, uh, go to the video, please. That's good. Before we talk about five properties, I'd like you to imagine for a little while and fast jet like a fighter jet like this, flying through a narrow and tortuous can can it twists and turns left right? Cliffside crowd me narrow areas. Rocky outcrops stick out from cliff size almost going to play. And I'm like It's like maybe about what sort of person is piloting this plane on the knowledge that they have. And it seems to me that really not make this is successful. Flight highlight. It will be very experienced. Pilot will have a very big knowledge of controls that playing be very fluid with those controls exactly how that plane relax to any control inputs, and they will also have very good knowledge of the former feet that they're flying through. Think to launch somebody fast jet through such a dangerous environment without prying a little suicide mission. So I can imagine that the pilot would probably have studied maps of the canyon. I imagine that they might have flown through the canyon, much reduce speed on that they would probably have pictures of the canyon, and I know exactly the way in which the route to be flowing alters is the progress through the through the landscape. May I think when we do fibrosis, cancer patient were presented very much similar sort of challenges. We need to know how our machine works. We need to have a certain fluency and confidence with controls our machine, which is fine. We also needs to know on the anatomy of the landscape we are moving through now course with fiber optic innovation. There's a a new little complication because if we get back to our craft, just like, imagine the nose cone of the airplane. There is a tiny little camera, and that's what that camera sees is projected onto a relatively small screen. That was something. Put black paint over the canopy, and so the only you of the surroundings that the pilot has is this somewhat distorted, an artificial You. The little camera with those to show you on the small screen in a copy of the pilot can look out window because they're all coming in and this really applies to us as well. When we do follow up information, we can actually look around in reality as what we're surrounded by at the anatomy that we are moving through. What would concede we use a representation of that's not from the dimensions screen. So how do we go about improving knowledge familiar with? Well, I think, to do the anatomy well. I've always helpful to try to construct inside my head and three d mole of the anatomy of the landscape that we are trying to navigate through that I do that using a sagittal section of the anatomy on a Correctol section on. But we'll try to flush up a couple of those background here and usually my amazing together. I think it's helpful to try and establish in your head any sort of person alive. Virtual reality and imagine yourself navigating through that reality on so you know exactly every point exactly where you are. Secondly, I good to just plain escape. Homestake Usually scale. I think it's going to just hold the end of the scope. Inside. You have just have a look at your fingers as you just move the control slightly rotate. It's likely it gives you an idea of the movements that happen when you're actually using it in real life. But there's no there's no real substitute for just spending time with a scope, using it just generally playing because you need to know what control what exactly Confident that you can't be thinking about it. It's a bit like you drive a car, you still change gear used without any conscience thought it becomes an unconscious thing. You need to achieve that same level of familiarity with it. And I think thirdly, we need to just get through how that three D landscape peers on the two dimensional screen, so that we are confident that we know what we're looking at. The screen where that fits with our in our brain, three dimensional virtual reality model we've constructed from. So let's study escape. They're all pretty much say What I like to do is check the alignment before I start some control. Moving the sit with the scope up and down. I think it's useful to make sure that that movement is actually happening in line with scale, So it's good to visualize down the length of escape to make sure this is offset. That's very useful to know, because if you want to stay in line, you need to know your family is going to be slightly off set when I pull with my phone The That's very easy to understand when I can't see this anymore. It's very easy to forget what happens on. So why do you think that really when I pull up my phone, I'm either going to be holding escape down that up there somewhere between those two orientation, Which means that when I pulled with my phone, I'm actually looking up it away from me. So pulling means up. In a way, I'm very rarely gonna have my scapula, and you're worried any other orientation other than something between vertically down or is that pulling with my means? I look up. I tend to think of vases being in front of the sky, and that's beside the script, which is what was it side to me? And I think this is the back of the scope, Mr. Besides, escape is facing when I say in front of escape, I mean literally in front of the actual cable. I don't mean in the in the distance ahead of something that is in front of escape. To me, it's on the opposite side of the scope today, something that is behind us go between me. And when I pulled my fellow. I'm looking up, away push with my phone. I'm looking down towards me. And what's important to remember also is that although our control inputs are here, move. The movement of the state that we're interested in is happening down here. So we need to try. Sure, that's what I put we put here is faithfully reproduced down here, and generally we're transmitting movements. That transmission is Maurie, if excited on more, actually through a mechanism that is tight rather than from mechanism. And it's just demonstrate that I always suggest that school is help quite tightly between my support on handle top on my support, my finger and much lower down here. This is especially important when we making rotational movements of the way. But if I tilts the tip off on four words like this, if I make a rotational movement to the right with my right hand, and I reproduce that with my left hand by rolling my phone on my fourth finger, the A put that I put that tall is faithfully reproduced the bottle, and that is because movement of the top is transmitted during the torch cable that is running between my two hands. If, however, I have a large redone loop between the controlling and the distal, I may get transmission of my control input, but I may get something else. So if I break, take it to the right of the toll because the moon isn't faithfully transmitted down. I'm actually getting a slight movement to the left. Where is my control? Important to the right if I move to the left eye now moved back to Senator, and I haven't really gone to the left. If anything, I may have gotten a little bit to the right. They're pretty in variation. Change according to what degree of slackness in the connecting cable between the controlling of escape on just so I always recommend. But it's very helpful in terms of controlling the to keep this going tight between your two hands and stomach, anywhere that you have with your right hand with a roll of your finger and thumb with your left hand to keep the control actually possible. So with that knowledge in fluency of the controls of escape with that sort of knowledge, that gives us allowing us to to maneuver without coming to think too much about it. We could, you know, move on to looking at how often dimensional reality appears on screen. Remember that if you get back from flying analogy, we fly through this can in the early view, now that we have is artificial You what? That nose camera is showing us. We can actually just turned a head to look around at the window. So we have a very distorted and narrow, and it's important for us to know how that reality is represented on our screen name. So if I imagine tissue playing running down my left side be like my hand is remember, Of course, the distance is involved in Viroptic Airway. Absolutely. Time I run my hand right against the side and I'm running out of left. So if I write it down so we just positive we can see the tissue in the left side of escape appears as a continuous plane coming in from the left side of the screen about free t simple, not going to allow us to take our Selves quite quite intuitive. Quite a logical, similarly a tissue right side off escape. He's going to appear that you should be coming in a curtain coming in from the right hand side screen. And that's what a logical selecting, more complicated when we get in front of the scope behind this key to our understanding and key to neighboring us to navigate successfully on or intake ourselves successfully in place in the landscape that we're going through. So if there is a tissue in front of you, so my hand, just touching out from all the stream have their tissue plate in front of escape appears like a cousin. So you see anything coming down from the top of the screen. You are looking at the tissue that is only opposite side of the scope you a tissue planes that is in front of the scale that is key to remember. Similarly, that is behind. He's getting to appear as it should be coming from. So if you see something coming up from the bottom of the screen, you know that you are looking at a tissue play that is lying behind. That is between scape and you and knowledge of these two ways in which the reality is represented on screen, or what will allow us to navigate successfully on Orencia's ourselves successfully in our three dimensional virtual reality model. We are navigating through in our heads as we perform this. So here we are going to demonstrate the way on orientation that we've got manic. It is horizontal standing. So this is the orientation. Have to sleep. Remember every stage during our usual ization going to do three calls principles that we've talked to you throughout this presentation of principles of knowledge that to me of control pills, interpretation of the picture that we're seeing so that we can establish a virtual reality. A few heads of what we're going to enter the left nostril on this you need against the falls was on fire way. Have a you can see that we have a structure coming into the left extremity issue planning to be left in the street that works, left lateral see in the distance down. But it looks like up his limitation from lateral wall counted coming in from the right street. Have a structured right left nostril will be accepted with this model deviated coming down from the street we have floor for which this early from past four tops see, is any issues coming up? That's because he asked. Topical structure like behind this is the roof of the name of the roof of the nasal, too far away to be seen you so in front of the nasal cavity, we don't see a tissue screen because we get involved between you could see Wait a minute. Changes stream off the septum coming from the right and three doesn't move back to the first year was instantly firing. Come to the end of the sector way Find we've got a tissue played that is coming down from the top of the screen on the tissue planes coming up from the bottom. Between that, we have to shoot in front behind. In contrast, when you were in front structure, they What happens is the shape of the nasal changes in the roof of the amazing aren't she's around before the first year with parents, the whole cavity funnels so that the front of the captain back of the close together into that area, you can see both. So first of all is posterior end off the floor, which this is a nasal Sinus, which is a form that structure post world is going to go away because the tissue planes is posterior pharynx for continuous flat. Seems they really? So what? Consideration way. Just follow that way. This satiating screen, the posterior aspect of the floor nasal cavity, is formed by the name on extremity about distal extremities is usually so. As we follow the nasal side of the soft palate down. You would expect to see you for coming down from the top of the screen, and we've also slightly receive that. Of course, we knew that was coming. Way to expect it because we will be exiting the medicine, pharynx or distance we can see. The tip of the glass is coming up from the bottom of the screen, looking after posting or firing on as we pass the tip of the epiglottis. Just weigh now have a different structure, which is coming down from the top of the Stream I instructor, which is lying in front of escape. And that's the basis of time there is on Back in the distance. They're elected foster with a play. If we can a Gang wars rooms towards yeah, in every realizations, structural changes massively appearance as you move closer to it passed it here. It's a distance it looks like they're going to move to being not structure in the distance with the structure is a line in front of will appear tissue planned coming down as you're following the posterior pharynx, which is behind the scale, which is a tissue up from the bottom of the watch. Um, the way the epiglottis is represented changes fast. They passed now you got a line in front of a scare there. Four years post weight course this orientation. Gravity pulling us down towards the softness. What I like to do is a my scale upwards towards the A tax. Of course, getting places are way very close to four to look down. Elevated flying. That's wall demonstration. That's clearly on, Man. It came in a warm orientation, demonstrating what one might see you for a C four. Things demonstrated that using those principle to be control interpretation, that's how we're going to improve off skills, become more successful. Okay, Um I hope you found that useful. Obviously, that is a demonstration that's, you know, manic in ondas I looted to in the video thie approach can change now. This was approach from behind. But you can obviously Thea alternative approaches to have an approach from in front of the patient on when you're in front of the patient, Theoneste Um e will be represented the other way around compares to when you're behind the patient, because what, when you're behind the patient is in front of the scope will now be behind the scope. And so we do have another short video, much shorter on which is unskilled me a demonstration off under wake fiberoptic intubation in a real patient patients suffering from acute epical Titus, which is from the front and therefore gives a demonstration off how the anatomy looks different. But the principals behind orientated yourself remain the same. So if we could just play that video, right, right, So you can hear the patient having difficulty breathing. There were in the right nostril from the front. Therefore, on the left side of the screen we've got we've rotated a bit left side of the screen. We've got the lateral wall of the right nostril on the right side of the screen. We have the septum. You can see the turbinates. They're moving back past the turbinate's into the nasopharynx. There's the posterior wall of the nasopharynx now coming down from the top of the screen on the tip of the uvula, has just disappeared from the bottom of the screen. There it is, because that is now behind the scope in this orientation, when we're approaching this way. Beautiful demonstration. They're off the posterior wall of the soft palate, touching the posterior wall of the nasopharynx with to tissue planes coming down one from the top of the screen, one from the bottom of the screen in the distance. There you can see the epiglottis, which is very swollen, typical of a case of acute hepatitis. I'm coming down from the top of the screen. You can see the poster of all of the or oh, pharynx becoming the toast. Your wall of the laryngopharyngeal follow that. Behind the scope is thie epiglottis, which will come into view coming up from the bottom of the screen. There is you got a little glimpse of it there. There's a very good demonstration of how different it is in a a really breathing patient compared to a manic it. This is obviously a patient with a significant degree off airway obstruction. Who's awake? So there's a lot of movement. It's a very dynamic process there the cords. There was demonstration there of how the view of the epiglottis changes, how it becomes in this orientation a tissue planes coming up from the bottom of the screen. What you're past the tip of it, something we talked about in the video on. We going to see the tip off the scope going past the cords, which happens quite quickly and has to happen quite quickly in a awake breathing patient to get into the trick here and there were We can see the trick earrings, so that's very short video on there's the patient breathing away through an unobstructed secured airway. Um, we can see in that video that the orientation was different, but the principals were the same on, obviously in on Awake patient. The three idea that you need to topical eyes the airway and Anesthetized Airway is critical on. But that brings us on to our live link, where we're going to join my colleague King's College Hospital doctor Holly Jones, who is an expert in fiber optic intubation, particularly in a neuro anesthetic context on. But we'll be able to talk to her a little bit about topical izing airway because she is on expert in that. Holly, can you hear me? You excellent. Yeah, I can hear you to. Fantastic. How's things going at King's? Have a great time. Okay, Excellent. So obviously, I demonstrated the concepts of anatomy control the scope in interpretation of the view. As we saw from the second video in an awake patient. The fourth sort of critical aspect is, and on anesthesia of the airway, local anesthesia of the airway and awake patient. I wonder if you could give us the benefit of your expertise and knowledge on that, and you just give us a few pointers about that and the importance of it? Sure. So, um, as essentially two main ways to anything ties the airways for this procedure on the first would be the topical is a shin approach. On the second will be a drug on then obviously, you can combine on, makes a match and choose whichever technique is suitable for that patient. What you can do, however, is just had one technique. It's all because these patients were becoming with all sorts of different pathologies, different surgeries. And so you will need to know both methods to be able to. Anything ties the patients that come through a tickly, a hospital like this. Before you even go near that nose, however, you will always on basal constrictor. The nostrils kings were used. This leg pick a day being on the medication, and it comes in a little prefilled bottle so you can't get too much, and they only has about four or five squirts in it. And you need two scripts, both sides of the nose, even if you are definitely going down. The right side is a little area as such a good bilateral blood, so always, always they're constricting those. Otherwise, you will give the patient a nose bleed and then you'll be in trouble with blood on the scale. So and topical is a shin approach, so this will be the utilization of liquid came so it could be delivered her a myriad of different ways. I know, Nick, you, like Teo, like to give the patient a lignocaine they nebulizer on. That's obviously a really nice thing to do. You need a bit of time to be able to do that, but you set them quietly with a nebulizer, and it's a beautiful should. Anything ties thumb all the way down just to the cords and sometimes even beyond what we often do at King's on on our fiber opticals is the use of this, which is a new Cozaar at immunization device. On all it is, it's a bit of plastic with a bit of wire on it, so you can angle whichever way you want, and it just gives a very nice fine spray on diffuse coat. Respond your spray with patients. Inspiration. Patient. Hey, little bit like they're having a nebulizer, but you're actually spraying it. It normally starts if you're doing a nasal the front of the nose with 1% lidocaine and then move a bit further back, and then you would increase your strength of the brain maybe 3% and then you might move to 4% back of the mouth on Ben. When you get to the courts, you're going to need to use some spray directly onto the cords, which we used to deliver using an epidural capital that could be placed down the suction port off the fibrotic scopes. But the scopes that we have now these disposable scopes, you will just spray. You'll just put your syringe and you can just spray directly down them. You could. Your captain doesn't fit terribly well down. So for that you'd be using your 4% lignocaine. And you need a couple of sprays of that to unequal ties course and then maybe one spray below the courts. So you complacent tube without income, a second way of doing it using drugs. I think the most common way that it's used now by maybe particularly and by my colleagues is a combination off remifentanil delivered as a TCI onda. I used dexmedetomidine. So maybe fentanyl is obviously about state, or of toning all of those reflexes that patients have. You'll need to give it a quite a good going dose. You should still be able to have the patient breathing at that dose, but they might look a bit last, er, me on. They often you might need to remind you breathe, cause that's the thing that really isn't it increased dose. They lose that drive to pre, so you'll have to keep an eye on everything, but you remind them to breathe. Um, and that's about the right level you to be able to actually pass through the course the dexmedetomidine and often sedate that patient enough that they're very, very calm, and they really don't mind what you're doing to them. At the last patient we did with this combination of drugs on the register all was doing. The fibrotic was a little bit nervous, and the patient kept on safe know, worried. Everything's I take the time on that. Honestly, this poor patients are so common, have a that the dexmedetomidine. So it's it's tough breathing so it doesn't do what propofol used to do with People were using propofol. That's quite a dangerous combination of following many friends. Now you could quite easily use anyway, so you could use it as a lamb. You could use clonidine. You could use, um, many other drugs, but you need to have a significant depths of anesthesia to be able to pass a tube if you're using just the drug and not the topical is a shin. And the reason I use that technique, of course, is in your, uh, a lot of the times we are doing a fiber optic because we've got a factor. C spine. We don't want this patient coughing, and if you're using the sprays, you go to get me out of the way. That that technique works is by using the cough to move the local and set it up and down the airway. Every five got a fracture. Neck patient is coughing away. The surgeon will come in and say, What are you doing? The whole idea of this is Stop the next movement. So that's why I said at the beginning, you can have one technique that urine experts have need to be able to use different in different patients. Those insights holly on. But we have had a question come through online from a trainee who asks if they had any tips and tricks for performing fiberoptic guide intubation in a niece that ties patient. Because this person finds it more difficult to perform this task in an Easter type patient. Compared to the wake patient on Hollywood. You have any comments on that? Yes, I know creation. Sometimes weight often stand at the back of the patients when they are performing fiberoptics in an in the thighs patient, so your patient would be like white flat, and you will need to be standing on a stool with your arms completely straight so that you don't have any of these redundant loops in your fiber optic, and that's very, very tiring for you as a person on the patient. Being completely flat often has lots of secretions that all pulling inside. They're at the back of their mouth on often all of the musculature is falling backwards. And so all you concede mucus Ben membrane stuck down together. So I would say a niece that goats go to the front of the patient that the patient up a little bit on, then your find that they got a much better structure know secretions on. But you won't need to be standing in the store because you could just stand with your arms outstretched. So you're more comfortable. You're not rushing because you can't physically keep your hands. I are on the airway itself is easier. You will possibly need to get someone still to do your jaw thrust in the unit that I stations rows in the awake patient. As you saw from that video, I'm not sure if you heard there was a point in which they asked the patient to their tongue out on the whole airway opened up that you use that with underneath the ties patient. So use these two techniques. Go from the front. Have somebody help you with the jaw first, and you might be more successful. Yes, I completely agree with that. I think that what happens in a least type patient is obviously you get a a reduction in muscle tone on, but there's the patient doesn't automatically keep their own airway open. It compares to awake patient. So it's important, I think, to remember that the very basics of intubation about head positioning, about having an extended head on a flexed neck about making sure the the head is on a correctly sized and correct height pillow on, but also about getting your assistant to do a fairly sort of generous jaw thrust to move the base of the tongue on the soft palate away from the posterior wall of the pharynx. In order, Teo generate some space for you to get, which quite often that space will collapse down to nothing in in in in eastern type patient. So I don't forget the basics, even though you're using a Vance piece of kit. It's the basics. And the principles of positioning remain just a simple forten. We've I think we've got time for one last question on this is for you, Holly. What route and dose range of dexmeter that's expensive. Do you tend to use please? So I would always give it intravenously on the doses as city on any packaged dex medicine up to one mike kg hours an infusion on over 10 minutes as a bolus. So I would give very small, incremental doses. This is a serious point. One might kg and I would often give two or three boluses of that. Over the course of five minutes, us maxing out the infusion off Dex meds. So on somebody my size, that's about 15 mills, our on somebody on your size. Next 20 mils per hour. You do need to use Okay. Fantastic. Thank you very much. So thank you very much. Holly, I think we'll end our live link there. And I hope you enjoy the rest of the day and thank you very much for your contributions on. I think the coming to the end of the fiber optic section of this I think the key messages are for all fiber optics. Remember airway control and interpretation A C I A CIA to fiber optics for a B C is to resuscitation. Remember that on. Do If you have a wake patient. There is 1/4 plank to this. And this is regarding the anesthesia of the airway, which we went through with Holly on. That is just a simple didn't becomes just a simple as the other three principles from the weight patient will have four principles. You have principles, anatomy, control, interpretation on anesthesia of the airway. And I think those are the key. Take home messages from from our presentation today. Thank you very much for that. I hope you found that useful on It's now time. Teo, hand you back, Teo are continuity person on leader. Oh, you're back on back Some history. It's very brief introduction to the industry videos that we've got coming up. I suppose there's a couple things to say. First of all, whilst is brilliant, this form is free to you. It's actually not free to do is actually incredibly expensive to do, and we're incredibly grateful for the companies who have teamed up with us to support us and make sure that we can provide this. This really incredible content for you to teach you in your own home or in one of the workshop. It's really except they've supported us to do that. The other thing to say is not one of the jobs I have. A My hospital is working with our procurement team. Teo. Make sure that we've got the right Get in the hospital to develop, to deliver safe and effective patient care. You know, this this kind of weapon off for you is what you might call continues professional development and how you stay up today. And it's great to learn about new techniques on equipment you you may not have seen or use before. That's all well and good. But if you don't have that equipment in your hospital and available to you in a crisis or or in a routine setting, then it's no good to you. And so actually that the industry's on the company's supporting us today have produced a nice videos around the equipment that they use many which you have already seen today in the practical session, so please stay tuned for these important videos from them.