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Hello, I'm Dave Chapman on On the Airway group product Manager It into surgical. It's a pleasure to join you today for the King's Webinar Um, workshop. I'd like to talk to you today about a I view videos. Ring a scope I've you is a one adult size single use video laryngoscope with a Macintosh blade. This makes it ideal for use in circumstances such as those during the current pandemic, where infection control is a particular concern. It's also those ideal for use on recess. Trolleys are difficult airway carts and satellite areas of the hospital, where a video laryngoscope may not generally be available. What follows is a short introduction to the device, which we hope you find informative. I would like to talk to you today about I've you video the ring a scope. My view is a one adult size single use video laryngoscope with a Macintosh blade. The advantage of having a single use device is, of course, from any infection control perspective. There are no reusable or re process about departs on my view, so as a result you use the device, turn it off and then it should be put into clinical ways for disposal. The advantage of having a Macintosh blade is that unlike devices which have a hyper angulated blade with, I have you, you can use the device for both direct laryngoscopy as well as video laryngoscopy. I'm now going to show you how to use the device so you turn it on to turn it on you simply to press on off. Switch with the back of the device on after a couple of seconds to get into surgical screen, and then it will be operational. So I'm now going to shave how to insert the device itself. The distal tip of the blade of the device should be inserted into the patient's mouth under direct vision on the blade, gently advanced down the tongue, and so the epiglottis has been identified. The tip of the blade should then be advanced into the vallecula with minimal force. Indirectly lift the epiglottis with the eye view until the glottis comes into view. This could be achieved using a direct or indirect you if deemed necessary by manual. Aaron, gossipy and or head elevation, can be used to improve the view. Once the glottis has been identified on appropriately sized track. Your June could be passed through the vocal cords to the required death on the I. Have you gently removed confirmation of correct placement of track. Your tube should be assessed by the use of waveform capnographer on other methods in accordance with applicable guidelines, I've You should then be switched off by depressing the on off button. As I've use single use of fully disposable. It provides the opportunity for video laryngoscopy wherever, whenever you intubate is ideal for use for the availability of the laryngoscope. Maybe more restricted or purchase, a portable device is prohibitive, such as in pre hospital, the emergency department, intensive care or maternity. So that's the idea. Thank you very much for watching Thank you. We hope the workshop goes well today, and we look forward to joining you in person at the next Kings Airway workshop. Thank you. I use up to flow for ERCP because for me it makes a clinically challenging procedure a lot more simple. At times, it can be extremely lengthy, depending upon the co morbidities of the patient and the difficulty in accessing the bile ducts. There is a requirement for stillness at times during placement of the wire and ballooning of the vial ducks and trying to capture stones. There's the requirement for taking an endoscope out, and possibly putting another one in in adequate access can't be gained. In addition, during instrumentation of the bile duct, we need absolute stillness of the patient, and it can be a period of time where stimulation of the patient by that procedure, Kenly to movement. And that's not what we want. So deepening the sedation. Possibly entering an apneic period could be something where often flow is a great use for complex procedures like Ercp. My practice is to use up to flow 100% of the time. I will say that it's especially important in certain classes of patients. However, patients in the gastro sweet today, as we all know, are becoming much more complicated. We're seeing a high level of obesity. We're seeing lots of patients come through with sleep apnea. We're seeing a lot of cardiovascular and respiratory cold morbidities where patients are not suitable for surgery, so we're having interventional procedures instead. These patients, who were not chosen for a general anesthetic because they weren't suitable, are much easier to cope with with optic flow. When I use off to flow for Ercp, I'm generally varying my flow rate, depending upon the type of sedation I'm providing. If the patient is relatively lightly sedated, breathing spontaneously, I'll happily run a flow rate of 40 liters per minute. However, there's times during the procedure insertion of devices changes in position of the patient that I might want to have the patient apnea for these time points. I'm actually looking to increase my flow stent the airway open. Make sure the patient doesn't become hypothesis because they're actually afternoon for those times. All increase the flow rate up to 60 or 70 leaders a minute. I generally run the patients on 100% the entire case. I don't vary the oxygen percentage for me. I think that the new oh to device available with the office low equipment has been useful. I can monitor patients risperidone or e rate or lack thereof if they're apnea, uh, without worrying that I have to have a constant year or hand near the patient, I use up the phlegm. Yeah, CP, because it can be a long procedure. It can be a complex procedure, and it's important that once we start, we can complete the intervention. I don't want to be interrupted during the procedure, if with patients desex writing. So we use it in that sitting on because it optimizes the deep sedation up. The flow fits into our daily routine because it's just so easy to set up and we just set it up every day at the start of the day and and use and use it in our practice. We try and encourage visiting doctors to use up to flow if we feel it's appropriate. Obviously, the decisions up to them, the other areas where I find up to flow very helpful procedurally are bronchoscopy and persistent pain procedures. Up to flow is the ideal solution for my airway in the ercp way you use up. The five proposed and said it care to improve patient safety in particular for those patients recognized by the treaty. And he said this to improve or reduce they incidences of hypo ventilation and subsequent hypoxia. We use it within the postoperative, the inner city care department and also want the woods. A recent order it off. Patients at this hospital showed that the majority of patients who have the high flow ordered include bariatric surgery and some orthopedic surgery. Those patients with sleep apnea and those with unrecognized the bad news. But perhaps ever stop being school greater than three and also those with obesity, with the being like, on average, around 35. Other indicators for its use in our department include perioperative events, particularly anesthetic. Whether it's induction, say, for example, a difficult airway, which may have difficulty with a mask and elation or on extra vacation. Such a high Boksic event, where the innocents feels that there may need a little extra support but not remain intubated in the POSTOP for the face. The advantages to the patient is that compared to dry oxygen in the form of nasal problems or ask the humidified oxygen that comes through high flow is very well tolerated, and I can see why patients preferred over the humidified oxygen with us personally, it means that we're happy to have a much higher percentage of patients for turned on the ward, rather need HD. You are see you how elective admission right is about 1% of other major centers. For that reason, we're happy for the patients to go back toward be monitored, and it gives the nursing staff and also made personally a lot of three shots. We set up the up the flow as a standard off 50 leaders per minute and 50% so that is our beginning. Baseline. Obviously, from that point of on, depending on the patient's requirements, we are able to titrate as required, whether it goes on to the wart or not. Sometimes patients may just need it in recovery and have it removed and go the world without it. I tend if you've already instigated the therapy, the costs being spent that the patients are going to get benefit over night, particularly if they had surgery. That is particularly painful, and that might need significant opioids. There's always a risk of the hypo ventilation associated with a P or use. It just adds that extra level of safety. We use it immediately in the postoperative anesthetic, a unit as ordered by the anesthetist. Usually they have it overnight and it's removed. The following day, we changed out and civic record to include a prescriptive order in the record, which included flow right between 30 and 50 ladies, a minute on oxygen between 21 50% with a standard temperature of 37 degrees. If the nursing staff will recognize someone who is hypoventilating or had ah hypoc sick event, they may discuss it with the anesthetist to instigate the high fly therapy and the nursing staff as they come to use the high flow becoming more attuned to its capabilities and those patients that do best on it. I'm a nursing point of view. The up the flow is extremely easy to sit up. It has become part of our basic post anesthetic care of practice and minuses, A very confident with it. It's very easy to use. We're getting good outcomes with the Suboxone flow in our post anesthetic care unit. We believe our length of stay has greatly improved with the use of up the flow on our patients, and we're able to transfer patients that are requiring on going up to flow to the wards with the appropriate monitoring for overnight. So for our patients receiving ever in the post anesthetic A, you know we have the capability to be able to deliver are higher if i 02 due to the fact that we have a higher flow meter, which can deliver up to 70 leaders. When we transfer a patient to the ward. That high flow meter is not present. It is actually the wall oxygen that issues which only has the capacity to go up to 15 leaders. Therefore, the F I 02 that they're able to deliver on the ward sits around 50%. If you feel like the patient would benefit from it, then use it. It's a fairly low cost form of therapy for the benefit. I feel that you get in reducing the possible hypoxic or hypercholesteremia that it does give you peace of mind. We find anecdotally that the patients do have less hypoxic and hotter than laterally events. So you convey more confident that in a patient that you haven't left intubated or haven't sent or high dependency in it. But it's going to award that you are going to be reassured that they're going to say Stay safer. Yeah, okay. GlideScope core. The most comprehensive and flexible airway visualization system for video laryngoscopy bronchoscopy and multimodal airway procedures. Light scope core isn't all in one system, offering immediate access to the tools you need to visualize the airway and tracheobronchial tree, designed around a high definition touch screen monitor and comprehensive work station. GlideScope core delivers elevated visibility and improved workflow with both the 10 inch and 15 inch GlideScope poor monitors. Now you can see more and do more with dual connection ports. Lied Scope Core is the first airway visualization system to offer live multi motile imaging picture in picture on GlideScope Quart 10 and dueled view on GlideScope Core 15. You can now view the airway via a GlideScope video laryngoscope and be flex single use bronchoscope simultaneously helping to navigate routine and difficult airways record. Take photos and annotate through one device. Display playback and export captured videos, images and patient notes from the monitors Gallery. Completely redesigned, based on user feedback, Comprehensive work station features an adjustable arm for optable. Monitor placement over your patient, putting the monitor and S P 02 and pulse rate reading in your direct line of sight. Cable organizer and convenient prep tray. Ensure easy access to the airway tools you need right when you need them. GlideScope core work station adapts to your space and offers the flexibility you need to fully focus on your patient. GlideScope poor is compatible with GlideScope extensive portfolio of angulated and Max style video laryngoscope blades and be flex single use bronchoscopes. Light scope core is always ready with everything in reach. No more having to use multiple systems or vendors for video, laryngoscopy and bronchoscopy or when utilizing the multi motile airway approach. Now your airway visualization system does morbid I supporting bronchoscopy assisted procedures in O R I C u N e d from the brand, you know, and trust, like scope core gives you the power to see more and do more. Welcome back after those videos up. Next we got a really interesting session. And what of the great things have happened with the evolution of video laryngoscopy and bronchoscopy is that we can now use a hybrid technique using both of those simple, tentatively in the same patient to really improve patient care. Presenting this session is Dr J. To San Doctor. The sand is the difficult airway lead at King's College Hospital. He's someone that trained me as a training in East test is now a colleague on a friend. We've worked together quite extensively on improving our equipment at King's and so my role with the standardization group and procurement team. We now have a really excellent facilities and systems across the whole of kings, both of Denmark, in the last outside. So wherever you go, we've got the same equipment available and doctor decides going to talk you through, particularly his clinical and practical experience of using Ah, heart protective. Does that sound? Thank you dot long for the kind in direction. So, um, I would like to take you through a concept which is a hybrid in division technique. So far, Doctor reckoned, see him on down. He had gone through a video endoscope be how elegant that system off calories. At the same time, a doctor patty cake Patty already very well explained to you about the basic principles on the dance technique off a product innovation technique. Both seems to you like an absolute a technique for every kid. To some extent, that's true. But there are situations where we get stuck daily Intervention technique has got its limits. So my job here today is to take the positive points. Take the good qualities off these two techniques together. Can we do a better, safer record can perform this combination technique using the best qualities off the video. Lyrica, Scooby, I'm flexible. Bronchoscopy enable us to intubate in a difficult situation. Probably we may have to practice that literally. But when the time comes, there's something for you to think about and then save I'm airway a problem. So just take it through one of my cases. I would like to present you with this case, which I had to do with my other two other concern little corn eggs. Because which is a difficult case. This is a 60 year old female. She came for a tongue reduction surgery. The problem she was facing Waas She suffer from medical polysaccharide asses for a long time, many, many years. For that reason, her tongue became patrol it and large on hard, and she was not able to take the time backwards. And she could lie flat or eat. Had necrosis so stiff on dmard. Opening is almost what you see on the picture is not existed at one of these. What do you see? That most of these fall off the 10, which is hard and it doesn't go back. So for this operation. We decided we will go from there, make fiber optic in division my topic like nicely, exactly us you had in the previous presentations or been very well. We tried to debate Nathalie and Orderly. We tried with the fiber optic flexible interventions system. Unfortunately, the green past behind the tongue because of the hard tongue base we just protruding protruding into the financial war. So there is no way to push that to scope through without making bleeding. So we try a combination technique at this stage. What made it waas. We put the GlideScope first. I have a look again. We could see the tip off the epic lotus around the heart base of the time, but you couldn't get with the still at or any other way to get there. So what, you did wasp reuse a fibrotic system which I helped at this situation. It's a flexible on a visible booty, so we use a really, like a scope in order to get behind the time that slowly do compress the tongue to create a bit of fatty Jill space on use the intubation bye. Using fiber optic system behind the if this space behind the blade off the blood scope. So that's one example of my own case where I managed a good teaching on training situation on my colleagues later on found that it's useful and they have done many cases afterwards. We have come a close with this situation where you can't see the landing's very anti lightings, but the media like a scope. But sometimes we may not be able to get there because what you see when we did your scope is a three dimensional view cut or paste into a two dimensional frame. So we don't know the depth when you see it. You know this is there is a lot of these. I can see it, but when you reach up to it because of the depth inability to appreciate it, you may find it's difficult to get the tube or the way down. Even with this. Still, it sometimes can be struggling so we could work around the situation using a hybrid in depression technique. Okay, what is actually hybrid technique I don't want anybody to confuse on hybrid innovation technique is just a combination off to intimating instruments where you use the best qualities off these two together. Ideally, one should be treated instrument, for example, like scope on one should be a flexibility baiting system, which is a fiber optic in dimension system. So you can see why we are talking about hybrid in depression. Taking it at this stage, which we never thought about it, you know, by the introduction off hyperinflated blanks in video endoscope e. Relying a Skopje's become very easy. I'm possibly 99% of the lines we can we can see. Or it'd make medical visible even very until Alliance Week and visualized through the last scope because with the current blade. But at the same time, these current Blakes created a little problem because of the curvature, that compression of the tongue become less efficient, which be managed that using Macintosh lighting a scope. So here that creation off the hyper later system behind the time on less compressible time made they ready to get up to the linings better, difficult or to go around the cover, become difficult. That's where all these additional procedures like fiber optic system on various other, even still, at the use of. Still, it is justifiable because of the blanks. So what's happened in our practice is we have a very visible lightings, but sometimes it's struggle to get around the corner to intubate. So how can we bridge the service to Aladdin's off a difficult airway on a really convert, curved or angulated part to reach up to their How can you, Bridget, that bridging is done by a hybrid intubation system. Begin is an instrument you like if you like. You got a glad Scott off or we could see Mac truck deep. It's, um, very work you can you see any form off the lining, a scope which enable you to visualize very going on all sitting Web am recorded for the product system to pass through a swell on intense, off flexible systems. Weekend is stored system Olympus about it on the flex or, um, boost up anything in your area, which is available. It doesn't matter which instrument to use, but the property off the system it has for that distinct character. One is rigid, which is you can use it to create a space. Second is, um, as flexible as possible to go through that part that so intense off clinical roars you can use as That's according to your imagination. You can use anywhere you like, but in your normal practice, when you come across with an anti delighting so where you can't get there at, don't think you should panic. You should oxygenate the patient at the point, using a lot of mascara. Very what? A face mask. Mental a shin. What we're finding that way on months. Yolks in a the patient you get. Think about how you can perform the the information you can use in the same kind of concept in the fixed neck as you have seen on my first slide. And also you can use in front of neck where patients come into some bigger cooler. You don't have to take the colon out. We can just, But you do get this used to. This is a a hybrid system we can intimate without neck mobility. You have a lot of fun fascial facial fractures on blood and secretions in their way off after trauma. But if you can try to intimidate well and good, but if you con again, the rigid system will give you the space for sexually clearing the degrees and situation and get up to very want to and also upper airway humans is again a good opportunity for you to have a look on that without disrupting the two months. You can go around the corner by using the five dropping system so we can do fiberoptics intervention by different techniques. Again, under general seizure is one option. If you get stuck at subway, what I can find a head, a difficult case which haven't sure you are. Video. Later on where you go to a predicted patient, where we can topical eyes on perform happen in Division one route or by nasal. This one of the situations where you come across with you. I'm sure your office come across with a nasal intubation. You try to intubate, but unfortunately, let's go past through. But you could go up to and see the Carina, but you can pass the cheaper because to get stuck at their ignore it. As we all know, if you push harder, it is going to damage that it nodes. They have what their voice dysfunction later on. If you rotate very hard enough against that, nobody can produce blading and trauma, so we normally try to pull back or paid on. See whether you can get that level down. If in case if you can't do that, don't push too hard because you can damage the Latins. There. You can use fact hybrid division system for that one. I have a couple of videos for you to see. So I will take you through this one from the previous sessions on the scene. The quantity on how or so we have to see if I But if you make this call can use to retain information What? These are difficult, difficult situation is what these are really having said that you have or so hey, well, come on, host situations. One of these sufficient to company doing division by perform. You can see in that situation at the same time. You know the quality off immigration where that plaque super school can use a flexible would be where that guy So whatever trying to demonstrate in the next few seconds is to combine these two on immigration system face the you can see the when I smoke at the same time insisting use. You're going to see the video screen like see the individual see off the so I'm going to get my license and help me out so that you have I'm trying to, you know, get you off the last I got what? I didn't get a blockage. Second problem. So I would have to be just for test. Let's it is pre form, he said. I still itch. As you can see, it's similar, but still a limited amount off flexibility. So, lubricating snow, you do. I mean, approach just right behind, that's all. I can go a moment. So place to order these two together Now go to the store. So I need a system. We made me to get this Help me to get the division company So I will see you in a second. See, Just get the you off the lines from a distance. Got national. So this is a flexibility off the bronchoscope coming by, which is still not being to get that angry or limited space where we're limited. So beauty of the flexible system, he's that nicely looking. Yeah, I just want to stay on these that see, they probably gets so obviously I tried the mating with the first time, but I was not able to navigate the tube because of the ENT about the same time, very limited space behind the black because of the exception of neck emitted Or some of these So So if you come in just for the days, Thank you. So I have the stop here. Notice that just thank you very much. So at this stage, I'm going to use the scope in the mouth so I can see all mostly. But so I get it by you on the Spiriva, which is please, So I can see the course of that get you between get official eyes on the previous year. So it's enormous, right? Guys had departed, carry your fingers do institute so she can see the cheapest coming along the flexible. So by the second one, I have more stuff to use. Just the flexibility off the Promise Corp in order to navigate the tube. And I could really anti lives are really limited space that so usually I might have that too. So we have just done the application of division take only division Now. What happened show you you might have seen, um, a situation where we find information. I have to go back there once too many for human after day intestine. Too many occasions, so much demonstrate to you how you can have that situation by depression Technique Hiprex concept. Summer on the salt with the C Are you watching past? Just get a special to the No, she that stage feeding assistance. So I tried to prepare the cheeks. I'm going to see that to see that problem. He's so showing you your superior. Let's stop it. You could see I got a stack can see the cheated. It's right on the records. So that's what it further So what I'm going to do now that back on. Um so now I'm going to apply that patient taking it If I can see that location, right? Distal ends. I see that down. So once I get that stage, I just to see if you can see that. So that's a condition. The Depression. Thank you. That's two last one. I can place come back again. So what you have seen now we have to techniques or intervention on necessary depression, which we have seen us. We have a monster in a mannequin. I would like to show you a case where in really patient. We applied the hybrid in division technique in order to establish intubations successfully. This a patient who had failed information when she came for elective procedure, we tried the standard lighting a scope, really leading a scope on, then fiberoptic. Still, we failed to intubate. Vision came back again on a semi elective procedure. So we topical eyes to patient on managed do on our bake already hybrid intubation Just a small clip. Have a look so you can see it's a moving target because patient is awake on topical ized. So once we get up to the epiglottis, you need to get the tube underneath. So at this stage, it would use the fiber optic system to visualize exactly where the TV is going to go. There we go. The scope is coming. Fibrotic system slowly coming up on used to be like a scope us a mechanism to push the tangle little forward at the same time, pre it more fire. It'll space behind. It can see the plate there. It's a bit too far, but we could pull that out a little bit. Yes, you can see that. Is the molecular gently going to lift that for the fibrotic to go through it again. Yep, to slowly that we had in the right place A So you can see so on established the individual so you can see through the other screen. The cheap is coming. Even if that hit at the notes you can stay. Manipulate it by looking at the glass scope as a half of the screen. So it is a good guide in time. So very it's going to get it stuck in there or not. You can see that black line is gently. There's passing through slowly but surely on the procedure to stand in the scalp is coming back on. Accomplished the mission. So I would take you from now. After this demonstration, we have Ah, lovely from Q and Elizabeth Hospital, Baby, Um, we have got a bottle up for short term in on day. Dragon is such ever so both of them are leading the workshop handsome but shop at Birmingham. So we will go alive to interact with their session there from Birmingham ballot. Can you give me? Yeah, you did. No. Hi, Bella. Can you hear me? Yeah. You can. You Can you hear us? Can hear me? Well, uh, can you hear us? We can hear you being a threat. Permit the one you're Let's see. Yeah. Hi, Bella. Can you get me? Yesterday? Just began. Let me try one second. Let me see. Yes. Yeah. Yes, indeed. How is it going, guys? It's been good. It's been good. Excellent. Thank you very much for coming life on. But hopefully you have a good session there. Yes, he does a good job here. Yeah, so it may have done they presentation and you guys done the hands on back shop as well. So it's time for you to reflect on what we what? You have left their on their something from your practice to share our experience on other people can take it some take home message from us. So So I just want to ask you something which I know I done the presentation here, and I've done a couple of cases, but not sure whether you have done this in your one shot. You've been teaching this for a long time. Can you tell us in your practice this hybrid innovation hospital in a role at all? Yes. I've used a few times the group up really useful in patients who have had a therapy for cancer now, so they're not completely distorted. So what I found useful is lines right there so pushed out one side on Gilenya. So it's impossible to just use this time technique to intubate this patients when I found I've been very, very useful in this group. Group uses know these patients are very ignorant, intubated this time that suggested techniques on the fiber because really useful. So yes, groups, I can feel good. Do you try to stick me so you feel not a door if you're there to advice others who are listening from us now from your experience, what kind of patients? Generally, you would say there is a role for hybrid ablation in our practice. So the main main group, I think that would be more useful in patients off, and they got like, very hard and neck tissue, and then nothing is very distorted. Some of these patients are very deviated distortment legs, so it's almost impossible to get that you just your still in the movies. You need something like a public system and use your flexibility of fiber optic together to do that, one more so than that is pushed. What's on then? If it's giving you the same, it's almost impossible to get it, you know? Geez, so you will need a fibrotic system to get that. So it's useful in that I quite agree with you from my own experience. What I what I found was exactly same When the neck is so rigid, Yeah, exception. A toll on we try. Teo put the blade in the relatively under try to elevate the lotus. But actually met we are doing is you make it bleed on. Then you lose vision. So I agree with you We could potentially add, um, the fiber A little constipated cases. We could do safely information without any trauma. That's one of the things Yeah, we can share among ourselves to you as well. And something day off course you can. So do you think Is that any situations that you can use this? Are there any limitation that you can stick me ask? You know I am expert, you know, that's normal technique. Eyes 100% use of really in old conditions. There are some limitations, but when we define hybrid ablation it's always within the bracket there is. There is a limit where we can extend our imagination on your science up to it. One other thing is we need to have a recent mouth opening. I believe you know you try. I always tell my Chinese, and very far I talk unless there is a two finger breath. Mouth opening quite a lot off in depression is difficult, so you have to have a minimum of that so bit up anything without recent amount opening, even the media Lighting a scrappy can be tricky because if you make a small bleeding, then you have no choice. You have to go for emergency procedures. So to afford that number one is the limitation. Is lack of mouth open. So really driving defined a role in the patient's room? It is going to benefit you call. The plan is to every case. I quite agree. That's that's one day. The other thing is, if you're only your own, it is difficult because you saw on my video I had to get my assistant to hold the really, like a scope. I don't think it's you need to buy an extremely skilled person to do that. If you give that instruction to the your helper, be old now that we don't understand. I switched out without assistant like an IUD, so that's more than enough. But if you're practising in your hospital, I think we have to give an opportunity for to train the our assistance to do these kind of techniques. So when the time comes, they are best friends. So outside skill assistant is important, but which is available on we can train them on like more opening. That's only two things I can think off where it has scored a limitation dignity. It's like, Yeah, I agree. J. Can I ask you a couple of questions as such? Sure. So this was, I think we were discussing this and one off one of the clinics basically raise this one, but it can be used as a normal technique when you're having patients with bones, which got it quite a swollen here, a very a passing the cheap one. But then this can be used. Maybe not be anything for putting a double Lumen, too, because then you can see whether the coffee really where they just sticking on the bar to God, and this has got any role in extra vacation at all. Good is a good one. Good brother is, that's, um Let's cover the whole spectrum. Number one. The birds patients that come to you very often on repeatedly for many, many cities for various procedures and once it get consist one she established alone him contracture there got a freak snack. There's an ideal situation to use it in on acute patients coming with burns or any kind of burns injury. And in any patient coming to you, you can use it as long as your topical is nicely. If you can save it, oxygen it nicely. Nowadays, everybody's using up. The flow is a quote a lot. We can keep them oxygenated or the time we could plenty of time. Don't brush it. Don't put them sleep or stop them breathing. You can Topical is nicely and then slowly initialize the lightings. The mop, the mentioned you mentioned about the edema. They did this precious needed. If there's a demand, that means, uh, pressure is going to be. They did see care for the next few days to intellect, So even if you damage that area Yes, you can try for a ventilation. The intubation in this hybrid technique on a bones acute Been patient. But you have to make sure that you got somebody there to do for a friend of neck axis. Because if you get stuck at the swollen Glottic area, you can only have one girl. If you go more than twice that swells up more and then you have no room. So that is, must be a backup plan. But still what? Trying intervention Because you can afford it occurs to me in that place as well. Did I answer all the questions you or any more left and extradition exhibition exhibitions of a Tricky because extubation depends on the situation. What we don't if you look at my first slide one I did to us, we go for state of extermination. Procedure depends on the dust. I'll get them wherever the patient comes in. If it is unsafe to extubate, we don't even it's safe to intubate with lighting them, but we will be able to reintubate them in the critical situation by putting guide wearing. They're a lot off guide. Were systems available? I I used to Cook State expression case. We just a nice and flexible guidewire, which you can read through nicely existing 82 other. Then you can slowly withdrawn it under, then that that has to stay there. Now. If you want to topical eyes and see at that stage, you can do it. But I'm not sure that's going to make anything different, because once you topical, I said, You can lose a dust age doing exhibition. They lose the protective mechanism off the ever Do you need that? Probably not, but you can see these really Number one. You can see there is a leak around. The other thing is, you can see you, but if you put a guide wearing that is sight in the right place. So the answer to question is there always limited? But I would imagine yeah, before the extra bad. If you can answer sedation, if you can have a look, you get an idea about how the supraglottic swelling is on. You can make a decision on that point, but I would imagine there's a limited role. Thank you. Welcome about how we stay free back from the candidates, anything they can see that he said. there's something they get stuck so may have something. They're funny. Disease is a man. They think it's interesting and useful. Is there anything else? Do you think anything is? Be useful. My my choice to them is if they haven't got anything to suggest you don't use this Us A remote on diet technique. This is exactly what you're using every single time. When the thing is, you're combining these two together, you're not making it in complicated. But unless you try, you never see the benefit of it. And once you see the benefit of it, you will like it on. Then it will become a safest way to do it in the bed. On the ballot is an example for that, and he I'm sure he's a master of this out. Well, thank you very much for coming alive and participating in this collaborative process. I hope you'll enjoy the day. Continue after these sessions, we got other few more sessions to go so injured the rest of the day on the um we will, like, elaborate and work through that in the future too. Thank you too much. You know,