During bronchoscopy, it may be difficult to visually estimate the severity of an airway obstruction, because of augmentation through the lenses of the bronchoscope. Structures appear much bigger than they really are. This holds especially true for situations in which a suboptimal view is obtained due to mucous or blood. In contrast, during direct laryngoscopy or videolaryngoscopy, it is easier to estimate if the tip of the tube can pass the obstruction because both targets, the glottis and the tip of the tube, appear in the same field of vision. During fibreoptic intubation however, it is not possible to visualize the outside of the tube during intubation, because the tube is railroaded over the insertion cord. Sometimes it may be easier to use a guiding catheter through the suction canal of the bronchoscope. This way it can be seen whether a small catheter can be passed through a small opening and also if the remaining space around the catheter will be sufficient to accommodate a larger tracheal tube [ 11, 12]. As some of the most striking of Howard’s pictures in the Gallery in the Gardens show, another of his obsessions is the majesty of pine trees and the skeletal beauty of trees shorn of their summer camouflage. Most of these images show groups of trees set on steep hillsides or in formal avenues. Drawn slowly and in meticulous detail, the images capture the natural geometry that every branch of every tree makes to the whole composition. Clearly, the number one priority of the entire care sector remains to deal with the crisis in front of it right now. However, as well as dealing with day-to-day operational issues, providers need to ensure they keep an eye on compliance and have robust audit trails covering the steps they have taken in terms of infection control with risk assessments against the relevant (and changing) guidance; and maintain appropriate documentation around deprivation of liberty authorisations. They would also be advised to obtain legal advice immediately if faced with emergency situations – such as families seeking to remove residents without the necessary authorisations in place, or enforcement action from their regulators.

Infection control – guidance from Public Health England on required infection controls has evolved frequently as the outbreak has progressed Three dimensional CT reconstruction of the larynx, yellow structures are air. Gray areas are bony structures. There is narrowing of the airway of 4 mm over a 4 cm long trajectory at the subglottic level. White arrow: reconstruction of air column in the feeding tube which is present in the oesophagus. https://www.hsj.co.uk/emergency-care/exclusive-the-three-vital-lessons-italian-hospitals-have-learned-in-fighting-covid-19/7027220.article?Discharges into care homes – although the guidance requires the Hospital Discharge Service to confirm the Covid-19 status of residents during the process of transfer to a care home, in practice this has not always happened During the intubation procedure, we could not pass the fibrosis with the insertion cord of the flexible scope nor tracheal tube, which is an unusual situation. This problem, however, caused acute laryngospasm and airway obstruction that mandated emergency coniotomy.

Increased costs – care providers have faced dramatically increased costs at this highly difficult time, particularly in relation to staffing, agency costs, and the additional costs of PPE. Joint guidance(1) from the Local Government Association, Association of Directors of Adult Social Services (ADASS) and the Care Providers Alliance indicated that providers would be reimbursed by commissioners for extra costs, but, again, this has been mixed to date. As a business that designs and delivers projects, from office buildings and homes to entire public realms and streetscapes, we understand that reflecting the needs of the communities we serve is key to long-term success – not just for our clients but for those that use and interact with these spaces. We provide a Director led approach for all clients, with commercial expertise to deliver the best results for each and every project. We pride ourselves in having an efficient and proactive approach and a network of partners capable of resourcing all design, technical and legal requirements. Three-dimensional CT reconstructions could have been performed before the procedure; however, this is not a standard procedure, and, in this patient, we only had the CT scan that was available from another hospital. It was not yet available in our computer system. There are not many medical centres in the world where this is routinely performed. Only, when a patient presents with an inspiratory stridor, which is a warning sign for severe upper airway narrowing, this is sometimes done when a recent CT scan is available. We offer a multi-disciplinary service across building, highways and infrastructure and transportation sectors.

Maverick Bell Statistics

NAPICU is also pleased to report the outcomes of a collaboration to systematically evaluate the performance of PPE used during physical intervention. A brief summary of this project is included in Appendix 2. The full manuscript and data are currently submitted for peer review and publication. In the interim, the learning from the evaluation has been used to inform developments in this Guidance which may be of assistance to Inpatient Services considering this difficult area. Along with their obligations to service users, providers must also discharge their responsibilities to staff under the Health & Safety At Work legislation. The issue of PPE is prominent again here, if members of staff feel that they have not been provided with all the equipment they needed to keep them safe. Inevitably, situations could arise where there is a tension between a provider’s obligations towards their service users and towards their staff. Videolaryngoscopy may be of help to give an indication of the severity of the airway problems if mouth opening is sufficient which is not the case in our patient was. A videolaryngoscopic-assisted fibreoptic intubation would probably have warned us for the impeding airway disaster [ 13]. https://www.rcpsych.ac.uk/about-us/responding-to-covid-19/responding-to-covid-19-guidance-for-clinicians