Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Yeah. Okay. Yeah. Okay. Do we need to be visible? That's the other thing. Uh So the New York, as you do see a okay, right soup and you'll see the screen and sometimes it happens that the screen doesn't move on when I move on the slides. So if it happens, please could somebody uh mute and let me know that the slides are stuck on one. Okay. Should I kick off? But perhaps Emily, you could just uh confirm that I can go on. Yeah. So you're perfect start now. Okay. Very good. So thank you very much for giving me the chance to talk to you about COPD. And although the topic um I mentioned initially is going to be about management, diagnosis and management, I'm going to make it a little bit more interesting and a bit bit more overlap with other things that might sometimes mimic COPD presentation. And I think that that will help you understand uh COPD better and also understand how we distinguish between symptoms which present almost in a very similar way. So, um I'm a chest physician and I work mainly an acute medicine at present at Saint George's Hospital. In London. Um and you know, do ask questions as we go along. So, the first thing um I would like to mention is uh that's good. So I hope you can see the second slide. Now, uh this should be showing you uh what is basic knowledge about COPD. Now, I'm going to assume that uh you all have heard about chronic obstructive Pulmonary disease and you have a fair understanding of what it is and we will just touch on um main things and I'll give you some sign posting to resources that you can do as part of your own reading. Uh So COPD is, is generally a combination of two very distinct path of physiological processes. Um One is chronic bronchitis and the other is emphysema and chronic bronchitis is a process which causes inflammation within the linings of the airways that leads to increase in the amount of mucus production, uh thickening of the mucous membranes, uh lots of secretions within the areas. Um And you know, and then that leads to uh obstruction, narrowing of the airways with sputum. Uh and that initiates the process of coughing because the sensitivity of the airways with the nerve endings is such that anything within the airways makes you cough, that the cough process is to try and get the mucus out. And the mucus is that milieu of mucus within the airways is important for area protection and you would be aware of them in a global in a which is secreted within the uh wet airways and that leads to the process. So that's essentially what chronic bronchitis's and to be chronic, you have to have it for at least three months in a year, mostly during the autumn and winter months in the northern hemisphere. Um And during the similar colder months in the southern hemisphere, and that process has to happen for at least two consecutive years in order to qualify as chronic bronchitis. Anything that happens acutely or over a shorter period of time, uh usually about 2 to 3 weeks is an acute bronchitis. And sometimes you have conditions where patient's have an acute on chronic bronchitis. So they have uh an acute exacerbation on a background of chronic sputum production. So, bronchitis, the classical presenting features are going to be a cough and mucus production. Um so that, you know, the two in combination is required to diagnose bronchitis. And as I said, it has to be at least three months uh for two consecutive years to qualify as chronic bronchitis. Um and it is driven by inflammation. Then the emphysema is a slightly different process which leads to alveolar destruction or the alveolar structure is being destroyed. And along with the alveolar structure, the blood vessels or the capillaries which set with that also get damaged and that leads to increased pulmonary vascular resistance in the uh capillaries and also obstruction in the alveoli. So alveolar destruction, which leads to emphysema causes air trapping. Um and bronchitis causes obstruction in the airways. And a combination of these two things usually go hand in hand in most patient's. And therefore, we combine them together too formulate the diagnosis of chronic obstructive Pulmonary disease. So, essentially, to remember that emphysema causes uh increased vascular resistance and air trapping. And bronchitis causes mucus production, uh narrowing of the airways and obstruction with coffin makers. So essentially, there are three cardinal presentations of chronic obstructive pulmonary disease, uh cough, breathlessness and mucus production. So, those three are ultimately the uh you know, the the standard features which you have to have in any particular patient in order to consider the diagnosis of chronic obstructive permanent disease. So, um let's move on. Uh and as it's a progressive condition, um it starts much earlier. So most people when they come up to diagnosis are between 2 to 10 years from when they start having the symptoms. The first thing is airflow limitation, which is when the spyrometry values are still normal, but people experience on exercise, a difficulty in managing their breath, the work of breathing goes up and that leads to trapping of air which leads to hyperinflation. And as the spiral progresses, you get more breathless as you do things, um then your exercise tolerance goes down, you become less active, then it starts to lead to muscle dysfunction. You know that muscles, if you're not using them adequately, become deconditioned uh and that leads to uh also a state comes when the work of breathing is so much more effort. Uh that the whole process becomes cata bolic and you start to lose energy, you become tired and you start to lose weight. So most people with predominant emphysema tend to lose weight. Some people with bronchitis would also tend to retain fluid uh and have a, what used to be described in the old days as blue blotter versus a pink puffer uh situation. The weight loss and the inability to get out leads to isolations socially, people become depressed, people lose motivation. Um uh and the depression leads to lack of nutrition. You start getting protein and energy deficient breathlessness gets worse because deconditioned muscles are unable to keep up with the hard work that is required to move air I/O of an obstructed um airway and that leads to then hypoxia. So not enough oxygen getting in hypoxia, as you will understand, it's quite a late presentation in COPD and then it leads to right heart failure, pulmonary hypertension and eventually to to death. So that's the sort of uh process that occurs here. Uh Let's move one step down. Okay. Now, hopefully the slides are moving. Um we will talk about as conditions called overlap syndromes in this and this will help you understand, as I said. So if you think about what are the cardinal features, cough, breathlessness and sputum. Now, all these symptoms are also present in certain other conditions which are not COPD but can present in the same way. So it's useful to understand where we begin. Most patients with COPD developed their condition in between 40 to 60 age group. Um you know, 40 is very early. Uh and certain 1% of patient's have an alpha one and trips in deficiency, which is a genetic condition that leads to early onset of uh emphysema. In addition to many other conditions, um most people would be around 50 to 60 years by the time they would have a diagnosis or have symptoms of COPD. Um You would expect to have at least um 10 back years of smoking or sometimes it may not be smoking, it maybe exposure to air pollution in various other formats. Sometimes you will have people within, you know, who have open fires within houses, either for heating or for cooking with in closed spaces. And that also biomass uh lead air pollution also leads to a similar process of damage within the areas. But majority of patient's would have been smokers at some stage with at least a minimum 10 pack years of smoking before they get to the stage of diagnosis. As I said, you know, 1% of patient's have alpha one antitrypsin deficiency. So the majority, the vast majority have normal alpha one antitrypsin levels. Sometimes you may have a history of uh pneumonia as a child which could have left people with scarred lungs. Uh Sometimes there is an overlap with hay fever and usually admission's to hospital start happening in the 4th, 5th and 6th decades of life. Uh Communist symptoms would be we's um and uh phlegm production and normally you'll find that COPD patient's tend not to have. We's in between uh there exacerbation stages uh in order to get a diagnosis and this, you will find if you look at the guidelines, the FEV one, the first exploratory volume in one second, by the first vital capacity will have to be less than 70% for a diagnosis. Um And the FEV and the F you in a visual issue will be less than 70% and the FEV one will be less than 70 to 80%. Uh So, and then if you look at the Gold Guide, uh you will find that there are four stages. Um and, and the stages are based on the FEV 1% predicted. Um And in order to distinguish between asthma and COPD, we use a reversibility of 20% for asthma and anything less than that is would be COPD. So COPD by definition is not completely reversible and that's one way of distinguishing asthma. So what about patient's who have symptoms of asthma and COPD together? So people who grew up with symptoms of hay fever and eczema who had asthma as a child who then become smokers, who then continue to develop features. Uh a chronic obstructive airways disease, which does not reverse completely. Uh you know, how would you diagnose them? And for this, we consider uh it works on uh we, we considered a condition called asthma COPD Overlap Syndrome. And some of you may have heard of this. Um and it's relatively recent um uh diagnosis and this is because there are patient's about 25% maybe 30% of patient's who have um features, both of asthma and COPD. And studies have demonstrated that there um progression through uh their natural history is very different from either asthma or COPD. And therefore, it's important to understand um the existence of an overlap condition, both to distinguish how you would treat different phases of the disease. And also to know when to be when when to differentiate between asthma COPD and the overlap syndrome. So I hope you have heard of this. And again, if you look at the um international guidelines, you will see the features. So let's go through some of these features that would be useful to recognize. So these are usually patient's with the background of asthma, as I mentioned. Uh in order to get to this condition, you need to be at least 40 years old. So that you have a chronic picture which has developed, there's usually a requirement that they have to have at at least 5 to 10 years of smoking um in, in the background or significant exposure to air pollution they have to have a persistent and non reversible airflow limitation. So they're five you and a vision issue has to be less than 70%. And they also have to have breathlessness and cough, which is very common. Then, you know that COPD patient's have characteristic exacerbations and asthma patient also have characteristics exacerbations. But there are, there are very different in their path of physiology. Asthma being an eosinophil driven exacerbation which occurs very quickly. We as being a very common presentation. Whereas in COPD, it's neutrophil driven and sputum or purulent sputum is the commonest presentation for these features. Now, patient's with accosts usually have both. So during exacerbations, they have wheeze, they have high eosinophil counts and at other times, they have high neutrophil counts and they have lots of uh lots of uh sputum that is existing there. And also it's important to realize that the decline of fev one which determines mortality and survival in patient's is much more rapid uh with patient's with a cost than you would have with individual conditions. Now, if you haven't come across these two organizations and the international guidelines, I would recommend that you look at the Gold Guide for COPD and the Gina Guide for asthma and they are usually updated every 5 to 10 years and they will give you the best international consensus on how to diagnose and how to treat and that would be a very, very good resource uh that you would need to go down too. So what is the prevalence of these types of patient's? We are calling because amongst COPD and asthma and you would find that it could be anything from 10 12% up to half of patient's would have overlap syndrome features. Uh They usually have more severe disease, uh tend to have a greater number of hospitalizations and um you know, and have disease which is much more persistent. So the recovery phase is much, much longer. Now, if you think about a comparison, uh most patient's with COPD tend to have between one and 1.4 exacerbations per year. So anyone who's having more than two exacerbations um would be in a much more severe category of COPD. But overall, you expect one exacerbation or, or in two years, uh maybe two exacerbations or three exacerbations. That's the usual pattern for COPD in people with symptomatic asthma exacerbations are between two and three per year, usually during spring, autumn or winter months and they are much more short lived. So, asthma exacerbations are about five days. COPD. Exacerbations usually last 10 to 14 days and sometimes much longer. So, patient's who have the overlap syndrome tend to have a much more number of exacerbations per year around three uh and tend to have a much longer period of recovery. Then you would with either asthma or COPD and their between exacerbations. They are overall, the condition is much more progressive quicker than it happens. So it is important therefore, that we recognize um you know, the increased burden of disease in the US. Um you know, um again, we understand that a cost patient's are younger by about four or five years. So average age for diagnosis is about 64 but it could be anything from 50 to 70 COPD. Patient diagnosis is towards the latter part of 60. These age groups are much more younger in certain parts of the world. Um Asthma patient's tend to be um uh more younger about by 10 years. At least from, from this particular group, the ECOS patient's have higher body mass index. So they tend to be retaining fluid, they require much more steroids in their use and they also have a much more deprived, socially educational background. Um you know, overall, which is probably a reflection of the impact of the disease on their conditions and almost 90% have at least one additional co morbidity could be hypertension renal disease or diabetes and have a much higher need for hospitalization than um either COPD or asthma on their own. Moving on. In terms of uh diagnosis, we know that, you know, the patient's who have a higher emphysema index. So they have more damage, usually affect the upper zones, have more smoking history um and tend to have a slightly lower BM I. Uh in terms of gender issues, there's not much difference between men and women. You know that in COPD is slightly more prevalent in men. And that's because smoking is more prevalent in men in, in at least certain parts of the world. Um, asthma is, has got a slight predominance for women. Again, uh, you know, again, it varies with, in different parts of the world. Um And in terms of the amount of exposure to smoke or air pollution, there's not much difference between this particular group. But certainly if you look at exacerbations, uh patient's who have more predominant asthma have more exacerbations as I explain, compared to ones which have an overlap syndrome. Um Now, if you look at the, uh the slide sort of gives you a distinction between the two types of conditions. Uh you'll see on the left, we have COPD, which is predominantly um mucus uh and peribronchial inflammation, mucus hyper secretion and then the alveolar um destruction which you see in emphysema. And if you look at the graph showing the progression of disease, you'll see that the fev one person predicted, which is usually at its highest at the age of around 25 tends to have a natural decline over, you know, each 5 to 10 years that you can see patient's who have COPD. Generally, you will see the green um line. You'll see that at each exacerbation, the Phoebe one drops and then picks up when they recover drops again and, and continues to, to get down to around 50% when patient's are at 50% which is moderate COPD, uh, they become much more symptomatic and after that progression tends to be much quicker. Um, and, and towards the seventh or eighth decade of life, patient's are below 20% FPV. 1% predicted when they are practically not able to do activities of daily living and become very much dependent asthma. Again, chronic asthma has a similar picture, but, uh again, when there is an overlap, um you tend to find that the recovery tends to go down. Chronic asthma. Patient's also have a reduced recovery from phase, but then they usually end up uh in a slightly higher. Uh FPV one state, something around 33 35% over time. Uh Now thinking along healthcare utilization, which is one of the biggest uh impacts of the disease on any healthcare system, you find that hospital visits are much higher in an a course or asthma COPD overlap syndrome compared to asthma or two COPD. And, and the figures are the ones that I mentioned earlier. And again, when the risk of exacerbations is much higher in these patient's compared to um you know, somebody with pure asthma or po COPD. Again, if you look at visits to hospital or visits to um you know, doctors for any causes, you'll find that patient's um tend to have a much higher prevalence. Uh if you look at the overlap syndrome compared to um either asthma on their own or COPD and this could be due to express emissions or due to any causes. So it has, does have an impact on, on other conditions. So in summary, we have patient's who have a much more rate of exacerbation, they have a much higher decline in lung function. Uh they lead to a higher mortality. They have a much more disproportionate use of healthcare resource. So they cost the healthcare system much higher and they, they experience a poorer quality of life. Again, how do you get to measure? It's it's a fino typical condition. So you would have to look at the clinical history and the uh presentations which would give you the diagnosis. Uh There are currently uh you know, experiments on to find a particular biomarker. Um and neutrophil gelatinous associated life Kellen is one of those which tends to be enhanced in neutrophilic inflammation. But again, at present, there is no consensus on what would be the uh the perfect biomarker for this particular condition, but we will know in the future, but overall mortality is much higher. Survival is much lower. Uh They're usually between 9 to 13 years, less survival than patient's with other conditions. So when you come across patient's with this sort of condition, think about the fact that is that pure asthma, is it pure COPD or could do they present features which are overlapping? I can't see the chat functions. But if there are any particular questions on that section, I could pause now or we could do it at the end. I'll wait and see if anybody wants to ask anything. Ok. Silence is golden. Um Shall I move on? Yeah, I'd move on. If anyone has any questions, I can just put them in the chat and you can come back to you later. Okay. No worries. Okay. Now, thinking quickly along the same COPD um conditions, remember we talked about the three cardinal features, cough breathlessness and sputum being the three features that always patient's with COPD will present with. Now, what if you have patient's who have uh cough breathlessness, but the sputum production is excessive. Now, what do you mean by excessive production at least half a cup full of sputum um on most days of the week. Now, this is in between exacerbations and if you have patient's who are excessive sputum producers and they produce sputum at all times every day, um You need to consider whether this is just COPD um or could there be an overlap with bronchiectases and the way to distinguish this is what we will discuss in the next few slides because again, it is important to recognize this condition which might just present a COPD and therefore, the treatment is going to be slightly different. Now, bronchiectases as you know, is a condition which you know, is most manifest um in patient's with cystic fibrosis, uh where excessively you have uh excessive mucus production, destruction of the bronchus. Uh and then, which becomes much dilated. Uh and you get lots of mucous retention. Uh and you know, it's an obstructive airways disease where the predominant feature is destruction of the bronchioles along with mucus mucus retention. Um Now COPD, as you imagine is also an overlap situation where we have thickened bronchial mucosa, excessive mucus production with high possibility of uh mucous causing airway obstruction, um and exacerbation. So, there's a significant overlap between the two conditions. Now, when we look at patient's in terms of diagnosis. Now, in order to diagnose COPD, as we said, that the cardinal features, if we just revise it, here is going to be the typical symptoms, which I said the 33 cardinal symptoms happening three months per year for two years, two consecutive years. And that sort of essential for the clinical diagnosis. COPD along with that spyrometry, which shows the fev one person predicted below below 70% and the review and a vision issue below 70. So that those are the features of diagnosis of COPD. Now, we tend to do X rays on patient's with COPD when they have an exacerbation. Usually COPD, patient's have hyperinflation in the airways uh in their chest x rays, but nothing more if you were to do high resolution CT scans, which you'll remember are one millimeter uh slices through the lungs. Um They will show evidence of emphysema, they may also show evidence of bronchial thickening or peribronchial cuffing or peribronchial thickening. Now, patient's with bronchiectases in addition, have bronchus, which is enlarged, so it's dilated, enlarged and on high resolution CT, you'll be able to see that they have uh you know, mucus retention. Now, that is very typical feature. So if you find patient's who have excessive mucus production on a regular basis, even when they're not having exacerbations, then you consider bronchiectases and the cardinal diagnosis of bronchiectases will depend on two things. One high resolution CT, which will show the bronchial dietician and the mucous retention for early stage is it doesn't appear on chest x rays until a very late stage. And the second is the amount of sputum and the fact that sputum may be colonized with bacteria are very important features for diagnosis. Now, if you have patient's with your PT, who have also got features of bronchiectases, who on HRCT have thickened bronchioles or even dilated bronchioles, then you need to consider the overlap syndrome. Now, the structural findings on airways that we see on HR CT are not always correlated with the amount of symptoms. The symptoms also depend on people's condition, their muscle condition, their ability to clear makers and other things. So there's no straight predictability from that. But if you do see this, um you would be able to distinguish whether bronchiectases exists impatience. And I think this is a very important diagnosis or an overlap to consider because they, it will have a significant impact on how you treat patient's. Now, uh for example, if you look at someone who has, um um let's uh I've already explained this. Let's move to this one. Yeah. So these are patient's who are usually um have a smoking history, uh have a high risk of exacerbation. When you find on the sputum cultures, you will see that unlike patient's with bronchiectases who have him opulus as the commonest bacterial organism, you will find that these patient's tend to have pseudomonas as a common organism and sometimes staphylococcus, uh which is quite uncommon in this and and occasionally they will have east or Candida in their, in their milieu. So which is very typical of bronchiectasis, but you will see it in Sputum. So, sending sputum for culture is quite important in patient's who are with an overlap syndrome. Their airways obstruction tends to be much worse because they're not able to move there mucus adequately. Um And overall treatment, if you treat them with um uh an antibiotics such as Doxycycline for a week, it will not touch them at all. Uh You would need to treat patient's for a much longer period of time and guided by the sputum cultures. So, when we think about, you know, COPD S COPD patient's who tend to have more than one exacerbation per year. Um And you think about how you would approach their treatment, uh remember that before they become symptomatic, they have a condition where they will feel that their exercise capacity is reduced that they do not have any exacerbations, excess emissions become a feature of COPD. Usually when the FEV one is closer to 50% prior to that, they tend to manage with exercise intolerance as the main feature and a cough, but do not need regular hospital visits or do not need to be on, you know, do not present to treatment. So that's a sort of early phase of COPD When you get to the stage, when somebody is admitted to hospital or requires appropriate treatment for exacerbation, then you've reached the sort of moderate COPD stage, which is around 50% F ive you and percent predictive. The treatment at this stage usually involves a long acting beta agonist or a combination of the long acting antimuscarinic drug such as tiotropium. Um These are patient's who are prior to this, they would only need a short acting bronchodilators such as salbutamol or sometimes ipratropium. But when you get to this stage, when they start having their first exacerbations, then you are in need of either a llama, which is a long acting antimuscarinic such as JIA Tropea, um or a combination of a long acting beta agonist and a llama together. Then you get two periods where people have less than one exacerbation a year. These are patient's who are, you know, at a reasonable um uh state who continue to function. Um You can continue to treat them with just laba lama combination and corticosteroids are not necessary except for exacerbation. If they have more than one exacerbation per year, you need to think about whether they need um uh additional drugs. Now, in these situations, if you have a history of asthma, if you have high, using a fills in the blood, you need to think about asthma overlap. You need to think about a regular inhaled cortical steroid such as budesonide or Beckler metha zone to be added to them. If they have, you know, additional features of chronic bronchitis, which is predominantly mucus production. You need to think about chest physiotherapy to think about getting rid of the mucus with equal itics such as carbo Sistine and for more advanced cases, you would consider an anti phosphodiesterase is uh medications such as roflumilast. And if you have people who have two or three exacerbations per year and have additional um pseudomonas colonization, then you would consider a azithromycin or a uh inhaled or nebulized colonizing as that. So that's a, a basic way of dividing how you would approach the treatment options for these patient's as you go forward. So when you get to the stage of uh less than 50% FPV one and someone who's having more than one or two exacerbations per year, you're reaching a stage where you would need to have a combination of three drugs. So, inhale corticosteroids, um uh long acting man to mascara Nicks and uh protagonist drugs. And currently um there is, there are enough numbers of, uh, medication, um, triple therapy medication that is available and it would be ideal for patient's, um, to give that the great advantage of the current triple therapy meds is that they are once a day or sometimes twice a day therapy, which means that patient's don't have to remember them, remember to take them all the time. Um, you know, and compliance generally is better, you know, that compliance with medication, um such as in COPD or asthma when we describe them, um to what patients' actually take them. When you measure it, you find that about 50% of the times patient's are following instructions as you expect to actually expect them to. So, um if you can improve their compliance by giving them a drug, which they can take once a day and does the job, all the three things of opening up the airways, reducing the mucus and preventing exacerbations which inhale corticosteroids do. Then it's a huge advantage for that. So most patient's now with advanced COPD, um tend to be on triple therapy. There's one other condition I just want to touch on before we get to the end is the overlap with either sleep apnea or nocturnal hyperventilation. And that is a condition again, if we're not looking for it, uh is something that we would miss until very late. So, what are the telltale sort of signs of somebody who presents with this condition? Um First is that they would have a higher BM, I usually, they would have features of fluid retention. So it would be um presenting with a dependent edema. Sometimes they will have periods of nocturnal choking. They may have an overlap of snoring. They may be very tired when they wake up in the morning and they may be having features of CO2 retention which are, which is a headache or having a fuzzy feeling within the head, uh and feeling very and falling asleep at various times. So when you find features, any of these features in patient's with COPD, you need to think about the possibility that they may have nocturnal hypo ventilation or perhaps obstructive sleep apnea. And unless you specifically ask them about these particular conditions, uh it is very easy to miss and it takes so much longer time to diagnose. Now, if you look at the current graphs, you will see that patient's um you know, this compares the survival percentage of patient's with COPD where they have an overlap with obstructive sleep apnea, but without treatment and with treatment, and you'll see that there's a significant variability within the survival for that. So patient's who have COPD and an overlap, they will say, again, tend to have a much worse prognosis than patient's just with COPD. And similarly, if you look at exacerbations of COPD, patient's who have an undiagnosed or untreated sleep apnea or hyperventilation, tend to have a much higher number of uh um access ablations, then you will find. So essentially, um you know, when you look at COPD patient's, um just to recap the three things that you're looking for. Firstly, are cough breathlessness and sputum production. Then depending on which of these features are much more prominent than others, you need to consider whether it is purely COPD, which has two types of phenotypes. One being the emphysema phenotype who are thin, have catarrhalis state, then to have uh tend to retain their oxygen levels. So they're pink. Uh and they have a huge effort of breathing, which is um you know, so they usually have a purse lip breathing or you have features of bronchitis which is cough and mucus production and more frequent exacerbations in a combination. That's your COPD. But then you need to look carefully at that their past medical history. If there's any history of asthma, if they have at least three admission's to hospital or exacerbations and during exacerbations, if you find that they are very wheezy, um but don't produce a lot of phlegm, they are more likely to have an asthma overlap. Um If they have a lot of phlegm and even when they haven't recovered from exacerbation, they still have a lot of mucus that they're producing every day, then they may have an overlap with Bronch cactuses or if they have features of right heart failure, pulmonary hypertension, uh dependent edema, snoring or sleepiness, then you need to consider whether they have over uh nocturnal hyperventilation or sleep apnea feature. These are the sort of three categories of patient's that you need to have particularly extra attention to and therefore, when you're treating them, remember that for asthma treatment is more steroids, um and frequent exacerbation treatment, but less need for antibiotics. For COPD patient's, you need a combination. You need um a combination of a long acting beta agonist and long acting muscarinic. And if they have more than two exacerbations a year, an additional inhaler corticosteroid and that, that would be your, your key management steps. And if you have patient's who have phlegm all year round and on a high resolution CT scan show evidence of thickened airways or dilated airways and then they are people with bronchiectases. So you need to focus on the speed. Um Look at what bacteria is growing and consider whether giving them additional help with uh mucus clearance and antibiotics, either nebulized or on on a regular basis would be justified. And anyone who presents with features of heart failure, right, heart failure or type two respiratory failure where carbon dioxide retention happens or they're excessively sleepy. Look for a diagnosis of obstructive sleep apnea or do an overnight sleep study, do an early morning after your blood gas and consider whether giving them treatment with either CPAP or noninvasive ventilation would be necessary. So those are your sort of three or four you know, categories of uh of COPD uh an overlap that you need to be aware of because that's what commonly you will meet uh during your, you know, when you are suspicions. And again, I would recommend that you go back and look at the Gold Guide uh for COPD management updates and the GINA guide for the asthma management updates. Uh And that will give you a very good state of the art situation of where we stand at present. And if you, you know, you need to look into spyrometry and other management's the British Thoracic Society um guidance is also extremely useful. So I'll stop here and see if we have any specific questions that you may wish to answer. Okay, thank you. I may just stop share ing and then we can, you can see. Thank you so much. I'm just going to end the lecture recording and if anyone has any questions, we have another 10 minutes or so.