 So I was just to talk about the use of point-of-cuter sound outside the opera, you know, that's my field as a non-anesthesiologist. And I will try to show you how I use in my practice and a little bit of literature on this. This is my disclosure is that the main disclosure I have is as you can see here I'm so passionate that my daughter has been practicing ultrasound when she was essentially one year old. Time is a problem because in 20 minutes there's no much opportunity. Happy to answer a question at the end. And I saw that does that has been posted in literature. This is a great way of providing more material for the audience. I know that you all know about when we talk about Pocos, especially in a group of very expert anesthesiologists that do transasophageal and you are considered the expert in the field. What do you think about Paul to kill ultrasound. This is the definition that I like the most is where every time you think about the political ultrasound is that he's a clinician that perform an interpreter and ultrasound based on a problem. So it's clinician perform is very limited in scope and go directed. He's done at the bedside and I will show you cases. The interpretation is real time not hours after the fact that the findings are recognizable and definite is mostly a yes no often characterization. And of course it's part of my momentarium is that I still use a lot my status scope. I still use a lot my hands when I assess in the patient and of course the training it's something that we can talk at the very end. So to explain and show you how this concept can work is that I'm just going to present you one case is that it was a patient that I saw a few years ago. In 1962. She has history schizophrenia and the series order. It was admitted to the psychiatric ward hospital day seven was part of the rapid response team and we were called because of the critical consciousness to be honest is that they told us we think she's when I arrived on the floor. She was cleaning shop take a cardiac with a 30 pulse so we could not get a saturation. No idea access present the skin skin was modest she was still obeying but honestly quite drowsy. I was clearly facing under freshened in shock in a almost on a style environment as a psychiatric war with no much resources and no have the access. So the first thing I did is that looking at the VC and Andre presentation was clearly showing how you can actually use this contrast elastic contrast of a jail in my case was transatlantic. And in all surprises that was expecting us collapse in a VC the vast majority of the situation that we see on the floor when we are called is usually sepsis. Hypovolemia. This was a very surprising VC to be honest. And for the audience that will be more expert you can immediately see that was something that you immediately call my attention at this level all the right. But of course is that because as a congestive I VC pattern I immediately and quickly turn to this cost of view. And this is what I saw is that an RV that is dilated and something floating or it looked like floating in the right atrium and an under fill of the quickly moving to the parasternal the shape of the septum there was a presentation this morning talking about RV dysfunction the estimated indexes was clearly showing me pressure of a load of the right ventricle and in RV in flow view, you can clearly see here that it was a trombos or at least a ecogenic mobile mass, coming from the infinite cable what I showed you at the very beginning, because it's not just ultrasound echo cardiography, but this critical ultrasound from my perspective is that I quickly moved to the groin, and I found the confirmation my hypothesis that there was a trombos in the common femoral vein. I use ultrasound to put a central line in this patient on the floor, we quickly transfer the patient to the issue she got TPA at arrival in the ICU because I called the team to prepare for TPA. And the patient managed to be not intubated and leave the ICU in two days with shock resolution in less than 24 hours. We later did a CT chest that they confirm our findings and the radiology called us very what about the findings and we thought that we know already and the patient already got treatment for this. Really, if you think is that I was the clinician, and I did it. My question was, what is the shock here is obstructive is hyperbolemic. I did it at that side, not even a ICU but the only psychiatry word I interpret the findings in real time and they were pretty simple and definite. And of course that they was part of my physical examination as I started with the vitals and observing the patient. And what is the literature on this is that this is a systematic review method analysis the city published on the use of point of ultrasound for diagnosis shock etiology. And look at the likelihood ratio is that if you add point of ultrasound to your clinical momentum, your likely positive like ratio negative like ratio they are significant and you will dramatically improve your diagnostic accuracy for any form of shock. But it's not just the diagnostic accuracy because again is that life is not so simple is that this patient was very straightforward from a certain way and the diagnosis was unique. But we do know that a patient are complex and often these multifactorial. So in this study, published in critical medicine 2015 they use a very interesting index is a sort of the explorer, the concept of reduction in diagnostic uncertainty. Think about our clinical reason right is that we often have a patient that he is a shocky and we start thinking about all this would be this this and this. And the reality is ultrasound may not be able to give us the smoking gun, the single diagnosis, but definitely we'll be able to rule out other causes will be able to reduce our diagnostic uncertainty and showing this in the study where for all the diagnosis of shock, there was a 27% reduction in diagnostic uncertainty. So when you think about the point occur ultrasound is this is fast, because you have it at the bedside and the previous peak and even discuss about the user on crazy emergency like difficult airway management is quite accurate. And when he's not perfect, he still help us by mitigating the diagnostic uncertainty. I show you already briefly by doing basketball to sound this is not just echocardiography. I really use the ultrasound as my status copper, even more is that I use it for brain chest diaphragm airway heart abdomen and basketball applications for the wonder interesting. Great consensus and expert recommendation. Manuscript that we publish last year in collaboration with the ESICM. Just to show you two very quick cases about how this is all body ultrasound is Christian Azora talk about in the pregnant patients. This was a gentleman. He was generally admitted to our world with post severe traumatic brain injury. And the team on the floor called us because the patient was to keep me. And they even called the nephrologist because it was having increased creatinine and they were thinking about some form of kidney injury. The patient arrived to the world, the patient was again in shock to keep naked clearly without 30 pulse hypotensive and the IVC was collapsing. As I look at the admin. I noticed that there was free fluid in the admin is that Andre show you how you can assess free fluid from a trastophogea is that in transport is even easier. And it was not just free fluid there was, as you can see here, some ecogenicity inside the free fluid, something very strange. So, at that point, I asked myself why a patient with traumatic brain injury now is showing a free fluid in the admin associated with sepsis. I quickly ask the nurse at the bedside that if any procedure had been done in the past 48 hours and the patient to now that he had a very challenging in social gastro stomach tube. And at that point, I, I immediately suspected the amal position in my end of the g tube with essentially feeding into the patronium the patient went straight to the operating room after being debated and resuscitated. And there was misplacement of the tube with several essentially liters of feeds in this particular cavity. And here's another gentleman. It was a multi system trauma that unfortunately develops to be respiratory failure with the PF pressure less than a hundred. There was some concern about his brain. He had of course sinus and multivariate as a part of the multi system trauma, and the neurosurgeon they wanted to repeat a CT imaging decide if it was indicated or not to insert. And then they came and monitor for ICP measurement. The problem was it was very unstable. And we were insured it would have been safe for him to be moved to the or to the city, sorry. So what I did I did to brain ultrasound of a technique transclerial Doppler on the side and here opt in a sheet diameter assessment. And just for the one that are not familiar here I'm at the level of the middle silver arteries. And this is a very concerning flow. This is a patient that has a very reduced the story flow. If I see this, this is a levator will call positive index that is being associated to be delegating the kind of attention. At that time, he was very easy at the point for me to discuss with the surgeon and decision was to insert an ICP monitor. Unfortunately, the patient progress over the course of the next few days in terms of his intracranial hypertension and this is again the mca at the level of here is in terms of artery here and recently mca. Just to tell you is that that usually there is a sister that started flowing means that there is a continuous flow at the level of this vessel and you can see here there is a possibility you only see stroke volume essentially flow during sisterly and on parts where Doppler the flow change dramatically compared to the one I showed you before. This is now an auxiliary flow when you have flow reverse under the Astrid and suggestive an extremely elevated ICP and unfortunately the patient progress to bring that. Again, without moving the patient to see T we were able to immediately identify life threatening condition and have a proper discussion within our social team. This is a very interesting study that was published this year, the impressive to study where they look at the transcanial Doppler use as a screening test to exclude intracranial hypertension and then you can see here there is an excellent negative predictive value. And the idea is that if I do transcanial Doppler in a patient where I'm suspecting or I'm afraid of intracranial hypertension and I don't see any. There is a formula in this study that is used to estimate the ICP and if the ICP is not elevated according to the transcanial Doppler unlikely the patient will actually have intracranial hypertension. So again, it's a very useful tool when there is some uncertainty, and you want to increase your likelihood of doing the right thing for the patient. From this few initial example you can see how point okay ultrasound can be used essentially in two big categories is that one is that you know the ultrasound may help you but it's not prompt available. So, when there is an emerging eugenie for clinical evaluation and your cardiovascular anesthesiologist that is excellent. or your cardiologist colleague are not available. One of the biggest findings from Pocos facet of physical examination essentially is that I'm expanded my physical exam. A low for water more rapid triage. I thrombolyzed the patient in less than 20 minutes from my initial call. And of course is that the clinical management was very very directed and for focus. The only way of using this is that when it's not practical right is that I cannot ask the cardiology team with a collab to come every day multiple times a day to do an ultrasound in my issue patient. And so when I need frequency examination to follow up on some findings or really as a physical examination and chance. To give you again a little bit more example is that how you can use these in the situation is that he was a patient that the nephrology team call me. I have known a institution disease on dialysis and meet the night and I prior to an emergency department for respiratory failure. And the nephrology was concerned because the pressure was a little bit softer, and they asked me to meet the patient today see you for facilitating a sled, because they told me I don't think she can tolerate. So I went to see the patient she was bet space on a surgical world because there were no beds in the nephrology world and to my surprise. Look at this ABC this ABC is very different from what you would expect in a patient that has fluid overload and she skip dialysis session and everyone thinking that she is overloaded from a fluid perspective. So, I initially say okay this is nice make sense so of course I look at the heart. And if you look at the heart is that there we doesn't look particularly dilated. And you start to appreciate that there's something strange on the mitral valve the battle but doesn't look normal and again at that time actually the there was nothing in the admission note talking about vulgulopathy. I moved to the apical for chamber view and again this mitral valve is clearly no normal and when you look at the Doppler, there was even flow assertion and Pisa at velocity to 61. So give it a per second and so clearly suggesting a severe model to severe mitral stenosis. And you can see also here in the process on the long axis view of this mitral valve into now that the patient had a known mitral stenosis it was in a model to severe spectrum and she recently transfer to another dialysis center and that was not known to our nephrology team. As I was performing the Paracena long axis view, I noticed something on the background that's why I keep this 20 centimeter deep Paracena long you can see here is that again not just hard one or so long is that there is something in the left over a space that is ecogenic. So there was a consolidation there so I moved my attention to the lung. Let's keep this. I move my attention to the lungs and that this is on the right side the right side was absolutely normal is that Christian show you patient with be lines and I think you saw so this morning and one of the first presentations is that this patient the right lung was completely normal again completely the initial diagnosis of fluid overload. But when I moved to the right side here I'm at the apex okay this is the apex of the lung. And here is the basic and appreciate here is the diaphragm and this is the screen. This patient had a complete collapse and consolidation of the left lung. At the point I knew that the patient was a very different diagnosis on what she was sold to me. I transfer today see you I order for a Texas Ray and this is the new chest x-ray, less than 10 hours after the initial one. And it turned out that the patient had MSSA bacteria with a left lower non pneumonia and mucous blood that had in left main step. And this again in less than 20 minutes by performing ultrasound. What do we know about the effect the efficacy of using a point of care ultrasound for patient with respiratory symptoms is that this is a study from Kristen Lawson in from the Denmark. And the medicine when emergency medicine patient presenting to the emergency department with respiratory failure were randomized to a point of care ultrasound multi organ ultrasound approach versus standard care whatever standard care. And what they clearly found is that the point of care ultrasound was associated with the better diagnosis, faster diagnosis. Most of the patients should be so far they were patient that was involved as a part of the rapid response team so not necessarily in the ICU. And this is a study from friends where they implemented a point of care ultrasound sort of a protocol in their rapid response team. When they look at the boat respiratory failure and shock. And what they found is that in the patient that they have a point of care ultrasound assistant assessment. There was much higher. Correct immediate other diagnosis correct diagnosis. And again, this was a small study so I don't think we can make any inference or mortality but they show some more type of difference but honestly it was a small group. Small numbers so we can really make this such an inference for this. What about this second part right is that when frequency as ammunition and follow up with some findings so the physical summation agenda. We are finally awfully coming out of this long COVID era. And this is one of the patients that we saw during I think way two or three. We were again call on the floor was on the medicine world patient with the initial disease, COVID positive. The team consulted us because they thought it was progressing on COVID pneumonia. So they called us if we need to need to bring it down because the patient is with a common pneumonia. I started with my ultrasound assessment. And this is what I found on the right side. So, quite dense consolidation some pro-refusion and if you notice this is first of all this is not a typical characteristics of a COVID pneumonia. COVID pneumonia has very different characteristics online ultrasound usually if you the consolidation are not large and massive. And on top of that also, there was a few pay attention here that are multiple sort of nodural lesion. This is a typical characteristics of a necrotizing pneumonia. These are all multiple lung abscesses and the patient turned out to have been a staff or pneumonia. On superimposed on his COVID infection for sure, but this was not a simple COVID pneumonia. As a part of the assessment we look at the heart and as you can see here out the heart was hyper dynamic with a very small RV is the patient at a very, very poor parasitic of you so I turn out doing a soup costal short axis view. It's now day three, and the patient is now having worsening shock so again, being able to repeat my ultrasound and also to take advantage of the fact that I knew already how the patient look like on ultrasound prior. He's now on significant shock is that is on norepinephrine vasopressin and epinephrine. So something has changed. I have a question for ultrasound. So I start with my problem is a cardiac ultrasound here because it's in shock. And if I don't have the answer on the cardiac ultrasound what I do is that I look at other areas. And you can see here that we see is very different from septic patient. And when I look at the soup costal view and Parastinal view is that the RV dramatically change. This is not anymore on an RV that is small and under fill. COVID pneumonia, as you know, is associated with the increase got on Moses, I immediately move. I immediately moved to the groin and I found a clot again in 10 minutes. We had a different diagnosis. Of course something that he was in our differential but at that time moving a patient with COVID pneumonia was very difficult and CT as you may remember is that the world in fashion prevention control quite different at that time. And we started treatment right away. It's now day nine, same patient. And again, as I told you, as a part of my physical examination, if I can, I always bring with me ultrasound, not every patient, but especially patient particularly challenges. It's a little bit small here, I apologize for this, but if you can see here with this was on May 7. Okay, May 7. On the right side that is sliding and trust me, if it is smaller, there was some sliding here. But when I look at the new image on May 10, I could not see sliding paths of vertical artifact. At that point I had suspicion of a complication there is new motor access. And as I moved down and laterally, I found what we call the long point. This is a very interesting one point because it's not just air and air, but he's hydro long point on this side, the air in the porous space and here also a fluid in the porous space. And of course, at that point, our order not just say we don't do it in the anymore just excited in the ICU, and clearly we identify the new motomics. This is a patient that we, we omitted the last year in terms of what you can do with ultrasound in terms of decision making the ICU is that you can see is a dense consolidated lung is a patient unfortunately was a near drowning in Lake Ontario. Very toxic and difficult to manage what I tried to do I tried to do a quick recruitment maneuver with ultrasound visualization and you can see is that by increasing my people and doing a 30 by 30, but a very simple sustained inflation. I noticed immediately that the lung was from being density consolidated was moving to a be pattern with multiple be like clearly telling me that this patient was recruitable and I felt more comfortable even in the context of a shock to increase dramatically. In this study from 2022 and this is a study from a group from the Netherlands, will they look at the look at the across different departments and show me new ICU but there are also medicine and emergency department in their study. I showed us how performing lung ultrasound in these populations in these settings can dramatically change your diagnosis and also lead to a therapeutic impact change 40% more than 40% of the patient. The lung ultrasound in your ICU will lead to the most change think about the patient just described to you and also management change increasing people decreasing people doing a bronchoscopy or, for example, doing a recruitment maneuver or putting a chest you don't forget that it's focus is only one piece of the puzzle. Be very careful because what can lead is that you can actually cause harm if you use ultrasound as the only way of assessing your patient. This was a guy that was admitted a few years ago when I was still working at Toronto Western presented the magic department with abdominal pain a little bit of elevator lefties, and a new onset at affibulation. Apocos was done in the magic department. And there was a reporter in the chart say normal just on fraction, no original motion or martyrs and the patient will refer to general surgery for pancreatitis. This is day three, and our rapid response team is called because of worsening respiratory status was in Takicardia. This is is paracetamol long axis view is Takicardic in the concept of a fair but you can see here maybe a little bit reduced ejection fashion monoterval. This is Paracetamol short axis again very good. This is the apical for chamber view. Again, something that an ESO cost of you something that very consistent with the initial purpose that was done in the magic department so what's the problem is that what's happening here is that at the time that the fellow was a wonderful anesthesiology actually that was working with us and is now in London Ontario is with Fredo Quentus and with Fredo put his status cop on the chest of the patient. And he heard a significant murmur. So, what will further that is that he continues examination and he found a flail valve. The patient has a rapture cord and it was a quick identified transfer to the general went for surgical repair and he did extremely well. And this patient is elevated lefty examiners was actually cardiac congestion, leading to liver congestion. So, it's a great tool, but we need to be very careful, because as just one piece of the analysis puzzle, of course, is that focus funding may corroborate the support of a pre test hypothesis, but can also dramatically mislead us. If you're not aware of our limitation. They can also be completing consequential and not supported, but not changing the hypothesis plan. It's okay. Well, I will continue with other tests. And in extreme in very not very rare but in some circumstances that completely changed the protest hypothesis and lead to something completely unexpected think about the lady where I was really not thinking about pulmonary ambulance to be honest. I was mostly thinking about 70 shock or bipolar. So in terms of take home messages is that you can use point of culture son when you don't have access, rapidly to the expert sonographer, or where really is that this is not practical because you can only have your cardiac sonographer or your cardiac cancer is coming every day multiple times a day to do your physical exam for you. Parkers may narrow differential diagnosis. And if, even if it's something that is not really changing my hypothesis definitely to give me more confidence. Now for repeat monitoring can lead the remembering I see you more than 40% of those only to the management changes. And of course the system for procedure. What we don't have yet is create data on patient outcomes. And so, I think is that we need to be very careful with the perspective and that's to be some of the work that we all should consider for the future is to really show that there is a benefit for this patient. There is a statement for endocrine Patrick that is an intensive is a trauma surgeon from Alberta that the years ago wrote the greatest benefit of the patient will be realized when these diagnostic technology is incorporated into tough for patient assessment your physical exam your history your pre test and incorporate your possible information consider the patient physiology. This is the hour I think when I approach point okay ultrasound, I asked myself with the patient as if the probe as a question for the probe if I can answer something with the sound if that son is not. I just go straight for MRI CT or whatever. And then I focus on the acquisition. I need to get good views, and only when I have good views, I proceed with interpretation, and then I put all the pieces of my puzzle together. And I'm happy to take questions. And I hope that you found the top useful. Thank you very much. Thank you, Alberto. As always, amazing topic. Really practical. I, I've watched it like your presentation so many times and I, you always bring something new to me. Thank you so much. Before, before we start the focus case and Q&A sessions. We have a few like questions. The first question goes to the Dr. Dono, Dr. Bola can and also to you, Alberto. The question is any pearls on distinguishing atelectasis from pinion from pneumonia and ultrasound. And also, Dr. Dono, Dr. Bola. How difficult it is to do this diagnosis using T. I missed the question was going to open the camera. Okay, no, no problem. I'm going to repeat. So the, the Odyssey is asking any pearls on distinguishing atelectasis from, from pneumonia or ultrasound. And also for you two guys that talk about tea. Is it possible to make this diagnosis using tea instead of tea tea only. So, I think I took a yes at the similar question this morning, regarding how to differentiate pneumonia from atelectasis. One of the way that people have taught is that when you have atelectasis, you have epoxy visual constriction. Okay. When you have pneumonia, you're going to have a shunt. That's why the patient will will be so that will have epoxy. So, so in the case in some cases where I clearly had a pneumonia, when you put color Doppler on the long tissue, you're going to see flow everywhere, everywhere. On the other hand, when you have atelectasis, you don't see as much flow probably because there's a visual constriction of this. So that's, that could be one way. One of my colleague was looking at seeing if he could use Doppler velocities or signals, you know, to differentiate the two, but that's that's about that's about it. As Alex was mentioning, what's very useful. When you have an area that you wonder, is it a immatoma or blood clot, or is it a tissue long tissue. And if you see flow, you know it's not an immatoma. You know it's a tissue, it's long tissue. But if you don't see any Doppler signal that could indicate that you're having a blood clot over there so that could be some some of the ways that you could use Alberto you're doing a lot of long ultrasound would you like to comment. Yeah, if I can share my screen for a second I'm going to show you is that it is a study published from a group from the Netherlands and I was the reviewer that's why I know this study quite well. And what they did is what they did is that they use a sequential approach. So it's not just one finding my integration of three separate findings. They look at the presence of absence of dynamic program. They look as as you were mentioning Andre is the presence of absence of flow. And then that's what I like in also in the study is that they integrated the clinic presentation of the patient so they calculated this score right this CPS is a score that we use my routine in when we try to identify the diagnose happen but in the ICU. And what they show is that by using this integration, they were able to significantly increase the ability to differentiate pneumonia from a telekinesis. And it makes sense if you think and I think is that again is that the what I like is that the fact that we need to think more about it's not just one single finding often, but he's not. So our pre test probability and the use of our status code to be honest or hands our blood works. It's not a holy grail is a great tool in our momentarium. And I like what Alex presented this morning and said, when you have an unstable well, I would say I would say like you. You have a trans thoracic but in the or if you have already a T probe in, you should take full advantage if you decide to put the T probe to get as much information as you can. And as you mentioned, when you have a pneumonia, you can have RV dysfunction and you can have live intraculomal cordial depression. It can be in a patient with cirrhosis you'll see a sideways. So I think the same way that you use the trans thoracic probe to do your physical examination. I would say, and especially when you you're not under pressure you have times, which has happened in the IC, I think, take full advantage of the T probe get all the information that you can get. I had one case I didn't have time to show it, but was in the middle of the night were called because this patient was in shock lactate was increased. This patient already had LV dysfunction, but there was no reason why she would got worse. So finally look at the heart nothing look at the long nothing look at the abdomen, and then I look at the liver, and there was air in the portal way. So basically this patient was having this enteric ischemia, and there was air in the portal vessel. And the reason, and this this marker this is misenteric ischemia was creating a cardio intestinal syndrome, it was releasing cytokines which was making the heart worse. I think the right and the left heart worse. But the reason, you know, if you just look at the outside world the heart doesn't look bad but it was already bad that it was worse because there was misenteric ischemia. And then we only we got an autopsy and we confirm the findings, something we've published. So, so there's, there's always a reason. There's always an explanation sometime. I used to say when I call it idiopathic because I'm too idiot to find it. So that's my definition. But if you look for you'll find it. And, and T is not just a T broke to look at the heart. You can look everywhere, but always start if you cannot get the information with transfer I think I would always start with transfer I think but if you cannot get because the IC has no acoustic windows, then I go with TV. Thank you so much, Dr. Donald. Thanks so much, Alberto. Dr. We have a question for you in patients that have cardiac arrest the risk is like is higher to have a esophageal perforation. Do you think that's this like the risk go up even higher with T in place. Yeah, this is a very interesting question. And it's a frequent concern about the use of TV during cardiac arrest so my answer would be yes but as for safety issues we don't have any specific literature available regarding the risk of injury during CPR with a T probe in place. And to my knowledge no adverse events specific to T use during cardiac arrest have been reported so far. So we can only in fear from ambulatory settings. But there's a very interesting study published recently in 2020 I think in the Journal of American College of cardiology. And they looked at T safety during structural project heart procedures, mainly my microclips and LLA closures closer device. And in their study they had a very high rate of esophageal and gastric lesion. And about 86% of patients and 40% for 40% sorry of these lesions were classified as complex, meaning that they were intramural hematoma or mucosal lacerations. And interestingly independent factors, independent risk factors for those complex lesions were identified as being a longer procedural time under T manipulation, and also poor image quality. So we could in fear that during resuscitation with a T probe in place, we could have a longer procedural time and also a harder time with image acquisition so with this study I think we could say that the risk may be higher during cardiac arrest when we have a T probe in place yes, but I don't have any specific data for as a visual perforation per se. Okay, now thank you there is another question here that I just received. How do you guys practically put put in the tea. Do they pause the CPR and how long does it take to to start this examination with the CPR in place. It's a very good question. It depends on if you have a protocol or not. If you do T rescue later during the rest station you put the program, the patient is already intubated the data show that it takes about 12 minutes before you have the first image acquisition and you have a great feeling Thank you. And, and when, when you have a more of a protocol, usually you can put the probe during the intubation so you don't necessarily need to stop the CPR, but some pay some physician just asked just for a little pause when they put the tube in so we could use the same post to put the probe just after. So yeah, that would be my answer. And if I can add, because we're getting more and more emergency physician that we train for T insertion. And in fact, that's what I do in my practice and that's what I teach is that when you take camera lowering ghost code, and you do your intubation the T probe is already ready. The machine is already open. And then you put the tube you put the T probe at the same time on the direct vision. There's been a recent study from India, and which they compare the old arrangoscopic insertion of the probe versus blind, and they clearly demonstrate reduce So at least you're going to eliminate the or reduce significantly the pharyngeal complication. So, so the idea is to be your have your T probe ready. And the tube ready, and you do both at the same time. So then it takes just a few seconds. And I always recommend also that when you insert the probe. You should always well when you do it under direct vision, you see that you're in suffocates but if you have any doubt. You recommend to keep your image open. So then you know exactly that you'll see the Arctic arch and you'll see that the anatomic the normal anatomic structure as you insert. As you insert the probe that's something we teach when we do workshops with team because sometimes just upon the insertion you'll see the Arctic dissection you'll see the pathology. So, you don't want to miss that information. Thank you so much. Thank you so much. Thank you so much. We have a few more questions. And doctors also since everything that you said is pretty much based on artifacts on ultrasound. Do you have any like, do you change how do you do you optimize the settings for those like, do you have any tips like how to make this image better since you're just looking at artifacts. Do you like change harmonics you turn off harmonics do change anything to make those image better. So when you look into into the identification of the crackle type of membrane. Most of the time the image is very clear because you don't have so many space in the neck. Of course you're looking to interface where you want to see bright so increasingly a little bit the brightness will be something that will be helpful. We normally use the linear probe, the simple linear probe for that so that's very straightforward. The imaging acquisition is not the biggest problem, even if you have like patients with high BMI is not as challenging normally a little bit more challenging with but like with a moderate level of experience in the technique you're going to be able to to identify with no problem. But there is a question in the Q&A about indications and I think that my, my, my thought about this is that is very, very unlikely that they're going to be able to use these in the emergency setting that's how it was like at the beginning, I believe more in pre-marking the membrane. And people have said okay crackle type of me will be like a very rare procedure but of course, if you're looking to the net for from UK, that the major complication is postponing like major complications that have been from from array management and leads to brain damage or death is because people keep postponing doing the crackle type of me so if you have it pre-market is going to help to make the decision so a lot of things that will direct you to into the right way. One thing that we do currently at Sinai we're using this technique to improve our, this is not in the literature actually but we are using the crackle type of membrane identification to improve our awake intubation techniques so we, we start to do like our trans tracheal blocks guided by ultrasound on real time. But like we mark the membrane and we can even like measure the depth and then this was going to give us like a more feasible block and more a higher success rate for that and our, our the quality of block that we get and the freezing that we get is very, very satisfactory for, for of course, the providers and the patient. Okay, no perfect thank you so much Fabrizio. Dr. Arzola, I noticed I would like to add something to what Fabrizio was mentioning about pre-marking the membrane and sometimes something new when you do it in the in the war. But I remember we have had a few cases in the past, for example, the typical case, preclincial, difficult airway, full stomach in the OR for a C-section. In those cases, we usually wouldn't do a way for abrupt intubation to those pregnant patients, we mark. Of course, the first time we did it, people say, well, what are you going to do? Are you going to do? No, no, no, it's just pre-prevented just to know before you get to the point where you're no way rather than surgical airway. So we mark and then Fabrizio, we do the transmembrane installation of Lidocaine in a very nice, safe manner. So when you're doing your wave fiber optic, it's very elegant, you get into the care and that is not really rejected much by the patient. So it's elegant, you save because you can mark and it's something we advocate. And probably we go to the extreme, but we believe that every time you do an awake fiber optic intubation is the final step because you may be in a situation of not intubating, not bagmasking. So in that case, we always tried at least to scan and have an idea. But of course, have the kid for critical fiber membrane at puncture, which we have already customized kid ready next to us in case. So put yourself in the worst scenario in order to be prepared for that situation rather than actually attempted to do it. That makes total sense. Yeah. Thank you so much. And I am actually I was about to ask you a question as actually this question you already answered on the Q&A on the messages but for those who didn't have a chance to look at in patients with preeclampsia. I want to ask what's the mechanism of the pulmonary gema and related to the focus on on this type of patients. Do you see any sort of like a systolic or just follow this function on patients with pulmonary gema having preeclampsia? I want to be very honest and straight because there's a lot of research. And we know a lot of information. We know that in preeclampsia the pulmonary gema can be multifactorial. But when you read certain research, they still say it's still controversial decrease in oncotic pressure decrease in increase in permeability and also systolic or diastolic dysfunction. And all of those things is something you can check even an increased BMP can be a predictor for cardiac problems, cardiac complications in preeclampsic patients. So there's a lot of things you put together and what we do usually we try to do a screening like Alberto always is teaching us just to have an screening of the patient to have part of your physical examinations. So every time I have a preeclampsia patient that is severe, the blood pressure is not well controlled, urine output is not good, so they need to give fluid. We go there, we put the probe, a standard simple language of sound, we say, yeah, we're okay, we can give and then we come back later and we check again language of sound is still okay. In that way we can qualitatively listen from the practical point of view qualitatively know how things are going. Sometimes patients already come with some interstitial syndrome. And we know that it's a pre is a state before eventually pulmonary edema. But that is the situation sometimes we have systolic dysfunction, sometimes we have diastolic dysfunction that can be direct cause of the pulmonary edema. But again, at the bedside, if you're doing just pattern recognition, of course, you need to start doing pulse wave Doppler tissue Doppler to know the diastolic function, and it's something probably is beyond the bedside, the basic basic bedside. Okay. Okay, thank you so much. We have time for like just one other question. Um, Alberto. What are the features that you're looking brain pokers to exclude increased ICP. So the idea here is for Traskinia Doppler is that I can post in the chat that the impressive to there are cities of formulas that they've been published in the literature. The study they were mentioning my in my presentation essentially uses what they do is that you always look at two key features is that the flow velocity. It's very important to the diastolic velocity. The overall idea is this one is that in the brain is a continuous flow. Okay, so if the Astoli flow if you think about it is that our brain is a low resistant circulation. I'm expecting to have a quite high elevated diastolic flow. If I start developing intravenous hypertension. My resistance at the level of the capillary will go up and therefore the resistance of flow will lead to progressive reduction on the desktop flow. So, very simple thing is that just visually is that I show you is that if you're a systolic and that's all the flow velocity is very, very broad. That's a bad sign. The formula that been published. They all try to to regression formulas is to estimate either the CPP or estimate the right to the ICP. They are not the greatest to be honest and I think that that's why the imprecise to try to show truly show that that they're okay to rule out. Okay, and that's how I use it. I do it. If I see a great flow and with the formula there's nothing telling me that the CP is elevated. It's not unlikely that the patient has elevated ICP. But if I see an elevated ICP with the transgeneral Doppler, then I have to ask myself, is it real? Do I really think that this patient has CT features or pathophysiology and I've discussed with the children. But again, he's great at ruling out with a ruling in. But it will ultimately is all about the features of this desktop flow coming down. And then there are there are other more complex as you can do but that is a very simple one. Okay, no, thank you so much. I appreciate. This concludes the Q&A session from our afternoon session. Thank you so much, guys.