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Hello, everyone and welcome to our primary care. Uh What else might it be? Um With Steve Holmes, we have a lot of teaching from Steve on the platform. I've put the link in the chat for you to grab some of his other teaching, incredible teaching. You will not be disappointed. So if you want to take a look at that another time, please do for tonight. Um We're gonna have a listen to Steve. If you can pop your questions in the chat, we'll get round to them right at the end. OK. So without any further ado I'm gonna hand you over. Thank you. Thank you very much. Indeed. Sue and great pleasure to be here again, talking about a subject that I feel very strongly and passionately about and that's about us in primary care and hospitals and elsewhere, producing a really good clinical job for our patients and improving their health. Um I'm Steve Holmes, I'm a general practitioner in the UK in Shepton, Mala in Somerset, the south of England. Um I do some work strategically with our health board um around trying to develop respiratory services and integrated care across boundaries and I do some other work um with NHS England at a national level linked to cardiovascular and respiratory disease and a variety of other respiratory areas probably important are the primary care Respiratory Society, the International Primary Care Respiratory Group. Uh Both of those have really good resources online. And I also do quite a lot of work with the British Thoracic Society which is the specialist organization in the, in the UK. And I sit on their um council at the moment been involved with a variety of guidelines including um some of the Asper guidelines in the past other bits of work, academic, some work with the pharmaceutical industry. None of this has been funded by the pharmaceutical company. So this is really a a full on clinical session and I do a a variety of work for other educational providers. So if you want to learn more about making a diagnosis of asthma, look elsewhere, we did the session on that a little bit earlier. But remember the diagnosis of asthma is very much like a jigsaw. It's putting cardinal symptoms together. It's fitting in with eosinophil counts, potentially fraction, exhaled nitric oxide. If you've got that peak flows showing reversibility in airway function or spirometry, putting all those together to get a clinical picture that says this is very likely to be asthma and often confirmed when we use treatment for asthma, which shows a good response. Remember, treat treatment for asthma is an inhaled corticosteroid, which should help to improve our patients function quite dramatically quick plug here for the International Primary Care Respiratory Group. They've got some desktop helpers that are suitable at a global level to help and do cover because I know quite a few parts of the UK and Europe don't have easy access to fractional exhaled nitric oxide. Uh that is true in many parts of the world equally. So access to spirometry varies as well. So some of the tests that we talk about aren't easily um accessible to all of us. And this is a pragmatic way of helping us to make the best from the situation we're in. So there's also a lot of other good free resources on the I PCR G website and really privileged to work with a bunch of colleagues from across the globe in trying to improve things at a global level and collaborate, collaborate globally. So this is a slide that was produced about 15 years ago talking about the differential diagnosis or potential additional diagnoses in people with asthma. And the first thing to remember is that somebody with asthma might have asthma and other problems. Oh, it might not be asthma, their symptoms might be caused by something else thinking that through and I'm not gonna go through all of the, the diagnoses put on there fully, the glottic dysfunction and hyperventilation. Um We're often now calling um not dysfunctional breathing but breathing pattern disorder, gastroesophageal reflux disease uh with the ee from the US is again, quite a common association with asthma and other conditions. And it talks about allergic rhinitis. Again, fairly typical that we'd expect I'm gonna cover some cases tonight just to highlight some of the other things that are worthwhile listening out for when we have a patient who says I've got asthma, I've been given an inhaler and this is what's going on. And I think the first one, the first case, every time I push myself, I get more breathless, I'm finding it better to avoid exercise. Um, but this is probably one of the first things just to contemplate through. Um, we know that globally, many of the world's best athletes suffer from asthma but have it well controlled, they can't afford to have poorly controlled asthma. They're not gaining any advantage by having asthma treatment, but they are gaining an advantage in having good lung function like the rest of us who don't have asthma. And it's very easy. If you think that you have symptoms when you get, when you're exercising and you're getting more breathless, it's very easy to try and avoid exercise and then you can get into a vicious cycle that can often involve eating more than perhaps you need to, um, getting more deconditioned. So, thinking through how we manage that sort of situation, um, deconditioning, what is that all about? We see that a lot in many of the people we observe in clinical practice we saw that a huge amount in older people during the pandemic who stayed at home and didn't take their dog for a walk, didn't go out and do their gardening, didn't walk down to a local shop to collect whatever food they needed. But people brought it to them and that act inactivity and just resting at home results in a loss of muscle strength. The same way that it, many of us have had an episode of um, a, a nasty chest infection, a flu like illness. We might when we get up again, start feeling quite weak and tired when we get going or if we do exercise regularly and we stop for two or three weeks, it takes a while to get that muscle strength back again. There are two bullet points that are very important on this deconditioning about hospital. The first is that 3 to 5 weeks of bed rest will result in about 50% of muscle strength lost and that will take months to recover really good at solid evidence about that over time. So person who comes out of hospital who is more breathless and not able to keep going, whatever the cause for their admission, often that links in with deconditioning, their muscles are tired, it hurts when they do things, they're not as strong as they used to be. Sadly, there is really good evidence that promoting physical activity, especially in hospital and afterwards can improve that. But most systems aren't particularly good at getting that activity going strongly. And that means that the people that we see after a nasty infection or certainly after any period of hospital hospitalization have often got into a cycle of becoming weaker and, and less able to exercise and therefore when they do exert, they feel more breathless. So what sort of things should I think about? I'll go back in a second. What sort of things should I think about with deconditioning? Well, the first thing is graduated exercise helps simple tip, very safe to exercise. V every condition is better if you take more activity, including cardiac problems and stroke and other areas. The second thing is that if we are training a fit young, healthy person to do a marathon, we don't say run as far as you can, then when you've recovered, have another go and see how you get on. You should be able to get there in the end. We say start off 100 m walk for 100 run for 100 nice and gently. And we gradually build it up to perhaps over 67 weeks, being able to run five K and then over another eight weeks, getting up to um, 10-K and building it up from there. So it's a slow process, important, slow process, think about even relatively fit people to begin with trying to get to doing running and that sort of thing. Exactly the same with our patients who either have had an illness or for reasons of their own fear. But I don't want to get breathless because my asthma, if they have slowed down, it can often take several months to get that muscle strength back. So this is a quite a slow process. And then most people talk about an increase of about 10% a week. Be that distance walked, number of steps, you take a length of time, you're doing exercise for keeping it straight forward, trying to encourage the patient not to go on really long, extreme bits of exercise and then take time to recover, but to steadily build up that endurance on a regular basis. How do we distinguish between it? That's the person who comes in unusually breathless. And when we examine them, we're not hearing that prolonged expiratory wheeze, we're not hearing the, um, any of the features that we'd expect with asthma. They say when I get breathless, but there's none of that objective airways narrowing that we'd expect with asthma and equally so with other respiratory conditions like CO PD, we're not picking up those same signals, their peak flow remains good and it's always good. It's back to their normal for, for what we expect. Uh Again, that's because this isn't a condition of the airways closing down. This is a condition of the muscles around it and everything else not working as well. What's also important to remember on that is people who have CO PD will often be able to walk much, much more if they get fitter, but it needs a bit of time and determination to do that and encouragement from us as healthcare professionals. So one thing always to watch through is the deconditioning. The other one that links into that certainly with asthma and more commonly in women. Really good article in um the Asthma and lung UK, British website talking about asthma and women showing that obesity is quite strongly linked with more severe outcomes in women with asthma. And that we probably need to be thinking much more carefully about the hormonal impacts of obesity and the effect that has on people's breathing. If we think about it as a very basic level, if somebody is 30 kg overweight, if you think about taking around a 30 kg weight with you every day, walking up and down stairs, you will get more breathless. That's not because of your lungs playing up. That's because of the additional weight, the body is having to transport around to keep you going. So a couple of things to be thinking through there. Let's think about case two. my asthma just isn't getting better. They put me on higher and higher doses of inhaled steroids and my running is no better either. This was a real case. I saw they've been seeing somebody in a hospital setting and were on really quite high doses of inhaled corticosteroids aged about 12 was doing very well in their regional running competitions, but then started to fail a bit, wasn't doing as well, had been diagnosed with asthma and was just putting on escalating doses without get, getting things back. What was really interesting from the discussion with this is mum and dad saying she, she, it's obvious that she's really poorly because her wheezing is so bad. We can hear it at the other side of the athletic track. Now, I want you all to think about acute asthma and what you've seen in a, in hospitals and in practice where somebody's got a proper acute asthma episode and that's where they breathe in fine. Their breath out is prolonged expiration, but you wouldn't hear it across 100 m across an athletics field. You wouldn't hear it 1015 yards away. It's a prolonged expiratory quiet, wheeze in the chest that we're hearing. That's one of the signals just to watch out for what this person was talking about was a noise that could be heard at 50 m and that is virtually always a upper respiratory laryngeal noise. Oh, that's me doing it voluntarily. We can do that involuntarily where you get muscle spasm coming in off and on exertion. Let me talk to you a little bit about that. So this is our case. Number two is something called exercise, inducible laryngeal obstruction. It used to be called um glottic dysfunction, but it's, it's a common cause of people who are exercising, getting breathless. Now, you see a lovely picture there of uh a lady this was produced by the European Respiratory Journal. Um The lady has an indirect laryngoscope going up her nose and looking down onto the larynx and behind her, you can see a video camera footage of the larynx area. She's also standing on a treadmill and she's gonna be asked to run whilst they keep an eye on what's going on and they can monitor oxygen levels as well. So this isn't the sort of thing I'm doing in general practice in a indeed in the UK, most hospitals aren't doing testing for this at the moment increasing. They're starting to get uh involved in doing that to really make clear diagnosis where it's difficult. But asking a patient top tip and this comes from James Hull, who's one of the key authors on exercise induced symptoms is a, if the patient can take a video clip of the effect they have when they're feeling breathless on exertion, that can often help quite a bit. And a lot of certainly my population have access to video phones nowadays and cameras that will do a quick clip and they can bring back in to show you and often you'll hear that quite marked inspiratory noise. So let's talk about induced laryngeal obstruction a little bit, maybe a, a subject that you're very familiar with. But let's, let's just really think it through number one, the prevalence is as common in young adolescents and young adults as it as is asthma. It's about 5 to 7% of the population get it. I guess most of you don't have that prevalence in your own practice population. But it's out there, it may be just as common in older people when I speak to a bigger audience. Quite a few people say, you know, I get this as well. It may be pretty common still as we get older, we just haven't done the prevalent studies there. Number two, it can coexist with asthma but it can be on its own. And number three, it can occur with gastroesophageal reflux and it's that inappropriate closing down of the larynx um when you're exerting and it takes a little bit of time and then it settles down treatment. No acute treatment works. If you try things, they'll get better in a few minutes anyway, when they stop exercising and get hold of inhaler or whatever it is, it's the resting a bit that allows the muscle spasm to settle down in the larynx and it all goes back to normal can be triggered by exercise, can also be triggered by volatile substances. So that's things like perfumes or smoke environments, inhaled volatile substances and it can be made worse with stress. The treatment I've put down as the formal list, which is described, but I think probably what I would be taking from that is um speech therapy physiotherapy with physios or speech therapists who have an interest in this are usually the best by far at helping people to get better. I haven't seen certainly in primary care, a great number of patients benefiting from any medication at all if they've got gastroesophageal reflux. Yeah. Good idea. Um, and sometimes you can find some information online about breathing exercises people can do. But again, it's not asthma, the person that we're talking about, uh, were prompted uh to get some speech therapy. It was a little bit tricky. I work in a fairly rural area. Um, but having had that the patient then was able to drop down her asthma treatment, dose back to a very normal level. And she went back to competing very well at a regional level in the run that she was involved in, it affects people who run, but also people just normally exercising. So it's not just about elite problems there. Um, next case to keep things moving along a little bit, symptoms seem to come on all these sorts of times. It makes me feel really awful. I can't get the air in. I really, it isn't going anymore. And hopefully you will pick up that sort of comment quite often. Think about asthma with asthma. You hear people say I can get the air in but it's that prolonged expiration, difficult to get the air out. Yeah. Made it slightly exaggerated noise wise. But people who say I can't get the air in. That isn't a typical symptom of asthma. Makes me think about other things and makes us think about other things. And there's a whole group of conditions called breathing Pattern disorder that are worthwhile. Um, just thinking through a little bit more again, can coexist with asthma but might be separate, can get air in, not getting enough into my chest. It's feeling a bit tight round here. I have to keep sighing quite a bit yawning. Um There are other symptoms of breathing pattern disorder or dysfunctional breathing. The commonest one is hyperventilation. And with that, you can sometimes get that dizziness or feeling lightheaded. You can get blurred vision, fast, heart rate, tingling, fingers, tingling around the lips, that sort of sensation we know picks up with people who are, who are hyperventilating. All of those are symptoms of a breathing pattern disorder. No breathing pattern disorders used to be called dysfunctional breathing. I don't think breathing pattern disorder is the greatest word and uh phrase in the world, but it's certainly better than dysfunctional breathing. Cos most of my patients if uh if they say, you know, if I say to them, your child is dysfunctional, that means they're dysfunctional parents that doesn't feel good. And it has all sorts of very negative connotations ways to explain breathing pattern changes are a, it is quite common. It's more common in women than men. It is a bit like driving a car where we slowly fall into bad habits in a live audience. I'd ask you to put your hands up if you think you would pass your driving test tomorrow if you were to take it. And two or three people say, yeah, I would. But most of us say, mm, not sure. And that's because we realize as time goes on we slip into little habits that probably aren't what we would have done if we were doing the test for the first time. And that isn't something we're doing deliberately. It's something that just gets into the way in which we do things. Now, I want you to imagine. I'm either playing a physical contact sport and getting bruised around the ribs or being in a road accident and getting a cracked rib that hurts. And if I take a big breath in, it'll hurt more. So, what I'm gonna probably do is I'm going to a, have some painkillers but be avoiding situations where I'm gonna have to take really big breaths in like exerting myself. So I'll get unfit because it's gonna take a couple of months before my fracture heals up. Similarly, I'm gonna do shallow breathing a lot of the time cos the big breasts are the ones that hurt and I don't want it to hurt. Cos II don't like pain. That's not something I'm doing consciously. But if you think about that two months in when I'm suddenly find, oh, that's all right again. Now, I can, I can get going as I start to exert because I've got so used to that pattern of breathing slowly, small amount of the time to avoid the pain, it's become almost insetting. And I've, I've learned to breathe differently so that when I try to push myself, it all goes wrong. So quick reasons for breathing pattern disorder, panic, anxiety, making us do that sort of thing. Some of the uh people with depression and stress, the same sort of area pain certainly around the chest can do it. Um Asthma co PD again, the condi the lung conditions or cardiac conditions because we don't want to get pain if it's a pneumonia or we don't want to feel breathless. We tend to adapt instinctively the way we breathe and that can sometimes let us down when things are a bit better. So this is not a dysfunctional deliberate thing. This is a pattern that people develop to and to accommodate to where they are worthwhile thinking in that sort of situation. And there's a good website here. The Association of Chartered Physios and Respiratory Care have quite a lot of information on this. Most of us know about hyperventilation syndrome and the use of a brown bag to help people too breathing more slowly. A few of us will have seen um box breathing techniques to take slow breaths while you breathe in a bit, breathe out, breathe in a bit, breathe out. So it just slows down someone's respiratory rate and trains them to breathe slightly differently. Several other things, people who breathe primarily with their upper chest rather than gentle use of the diaphragm and the abdomen need a bit of helping to, to reestablish a better breathing pattern and people are pushing hard with their tummy to breathe out again, we can improve things. Um With physiotherapy, there are some online resources available if you don't have easy access to respiratory physios. Uh The I PCR G have a good article on breathing pattern disorders uh linked around CO PD, but it's equally relevant in asthma as well. So another area to think through depending on what the history uh is telling us about. Ok, next case is on the, what else might it be? And this is really a clinical experience thing. And most of these are outside the guidelines, cos guidelines concentrate on the disease. They don't concentrate on what else it might be. They assume we've got the disease, right? And one of the commonest things I've seen over time is a patient with asthma who says, like they know I've got asthma, they've given me steroids and nebulizers. It's not working. This isn't the same, it's just not what I'm expecting. And there's probably two ways that people describe that one is they, they will sometimes say I've, I've, I just feel dreadful. Absolutely horrible. I'm hot and cold and shivery and shaky. This isn't like my normal asthma. Or they say I'm not wheezy and I'm not free. It's just, I've suddenly become breathless. Should make us think about a couple of things. And again, it's that pattern. Listen to what our patients tell us and then examine carefully. The first thing to remember about exacerbations of asthma is they're probably not as common in people who are on treatment as we think. And these are real world figures from the US and the UK published about 67 years ago. Now showing that the average exacerbation during long term follow up is about once every 10 years for a person with asthma and to turn up at an emergency department because most of the exacerbations are managed in primary care probably 56 times more than they ever go to an emergency department or have an admission, the average patient will have an exacerbation about every 50 years that requires them to go to an emergency department or be hospitalized. Wow, 10 years for an exacerbation, 50 for going to an emergency department. Just think that through a patient who's had two or three exacerbations that's really poor asthma control. Think about that, carefully examine, evaluate work out whether they're on on the right treatment, whether they're using their inhalers, whether they need support from a more specialist input of one of the new biologics. But assuming the patient is right, a couple of other things are worthwhile just highlighting usually patients have a good idea what the pattern is when they have their exacerbations and that exacerbation, it doesn't usually start over a couple of minutes. It's usually, oh, I've been feeling a little bit less active over 56 days before. I don't want to do the washing up or drying. Don't quite have the energy to take the dog for a walk. Don't want to do my normal exercise. And then within one or two days it escalates upwards And that escalation of symptoms was really well shown by, um, tats field quite a number of years ago and was the basis behind quite a lot of the treatments we use to try, try to, um, prevent exacerbations. One of the main main ones being maintenance and reliever therapy, which is especially good at reducing exacerbations. The g, the nice little graph you can see there is increase in, uh, use of rescue medication during the day and night, increase in symptoms, day and night and a reduction in peak flow in the morning and the evenings and all following that sort of pattern of brewing up a little bit before and then escalating up to the peak and then settling down over 5 to 7 days. So the person who is unwell and feverish, really watch out for proper pneumonia, um, they are often, um, the sort of person who if you're listening carefully will have a consolidation there. Um, they can be, they can get really quite quickly, poorly, they sometimes need admission, but it's worth examining carefully because the patient who says it's not like my normal asthma. I'm not wheezing like my own normal asthma could be something else doing it. The acute wheeze that I've seen quite a few times. Not, sorry, not wheeze, not feverish, sudden onto, I suddenly became breathless within seconds. Remember that graph we showed getting worse over a few days just like that. Think pneumothorax that is really quite rapid. But again, it often gets construed. And people are saying, well, we've got to treat your asthma. It must be your asthma because you've been diagnosed with it. That's the only thing it can be, uh, not true. Final thing just to think through in terms of recovery from normal pneumonia. Certainly those admitted, but also for many that are managed in primary care, a proper pneumonia, look at the time spans, it takes to get better. So, within about a month. And this is true in COVID influenza and bacterial infections. After about a month, the muscle aches and chest pain and spit will have reduced a lot but not gone. So, muscle aches gonna take several weeks and the chest pain and the sputum to settle by six weeks, their cough and breathlessness should be a lot better. And by about three months, they'll be back to normal except for feeling tired by six months, they're usually back to normal if they've been on intensive care. Often those figures, you double it often takes a year to get better, but for a normal pneumonia, not requiring intensive care, most symptoms should have settled by about three months, but showing improvement at 4 to 6 weeks and back to normal quite a long period afterwards. That's a normal recovery well published in the evidence. Um, if you want to have a look at the, er, nice guidance online, I know that's tricky outside the UK. That's got it all neatly summarized. The British Thoracic Society have also produced guidance which is available globally showing that management of community acquired pneumonia takes this sort of duration to improve. They don't get better in a week, 10 days. And one of the th one of the sort of bug bearers about life is people who are told I here's your antibiotics, you should be better in a week and back at work proper pneumonia. Please don't tell them that. Think about what we know from all the evidence about how long it takes to get better. So next one is, let's think about that blue inhaler. Not sure what I should be doing. The inhalers don't work except for the blue one which only works for a little while and needing to use that more and more things are, things are escalating upwards again, not uncommon. And probably one of the reasons why that isn't uncommon is the effect of a regular inhaled short acting beagon on its own. So salbutamol Ventolin used probably two or three times a week for 4 to 6 weeks. This is as this was a review of 19 trials. And what we they found in virtually one of those trials was that the majority of patients developed airway responsiveness or hyper responsiveness if using a short acting be agist three or four times a week, twice a day. So twice a day, 3 to 4 times a week for 44 to 6 weeks upwards happens quite quickly. Airways hyper responsiveness. What is airways hyperresponsiveness? Well, this is one of the trials showing what happened. Um If you look at the top line, that is the change in F EV one when we do nothing, the second highest line where it says Allergen placebo is where we expose someone to an allergen and give them a placebo inhaler. So the peak flow drops and then it comes back up again and then gradually stabilizes down the bottom. One is someone who has been using salbutamol for a while. They use their, they're exposed to the Allergen, they're given their albuterol or salbutamol and there's an improvement like there is with placebo, but it's not to the same extent as the, even the placebo. That's because the airways have become hyper responsive to use of salbutamol. What does that mean? So that's all the science 19 trials. You can't really repeat those. What does that mean in the real world? That means that people are using a blue inhaler fairly regularly. Most will develop bronchial hyperresponsiveness, not everyone but most. Well, that hyper responsiveness will mean they will get more wheezy when they get stressed when they're exposed to a virus, volatile substances. So again, smoke fumes, perfumes or when they exert themselves and they will need to keep using that salbutamol more and more because the respon hyper responsiveness escalates upwards. And what will they be thinking during that time? Probably what they'll be thinking is, oh, my, my asthma must be worse. Cos I need to use my blue inhaler more and more and more and more explaining to people about that. There's a variety of ways of doing it, but certainly talking about, we know that even normal people given the salbutamol inhaler will develop this people with asthma will do just the same if you manage to stop your Saba for a few days and just let things settle. Um, it will settle down. My experience is a couple of weeks. The paper from the 19 articles clinically was suggesting a few days. Um, but certainly with most of the people I see who've reduced dramatically over a period of a month to two months come back and say, well, why didn't no one? Tell me I feel better than I've done for a long time. So, really worthwhile thinking is this just the medication they're using, that's producing things and making things worse. Let's go through a little bit more. Now, um, in case I've been to the hospital twice. I had my reviews. I've seen the practice nurse. You've asked me to come in. Now, as you say, I'm using too much blue inhaler. Um, that's quite, that's quite a common sort of thing to think through. Um, this was a real case and again, just worthwhile thinking through as we talk through differentials. Uh, the person who has eight inhalers in the last five months, um, they had assistant that said you couldn't get some more if you need it. But a computer alert came up on my assistant said too many blue inhalers. And I put a little note on saying must see doctor or nurse before the next prescription. Now, that would be fairly routine, generalist practice if we're involved in prescribing for the patients. I know it's harder if they're not there. Um I'm making this up in terms of the names. So this is fictitious. Um, and I've manipulated things so you won't know who it, it was that was coming in with this. But the person who received that little note saying must see doctor said, um, well, a actually I'm and in the UK, um Mrs Sugar is trying to replicate uh Alan Sugar who's a very famous businessman who made a lot of money. Uh This person is chief exec who makes a lot of money for our company. Er, phoned up to say in the last six months, I've been admitted once I've been to the hospital twice for my reviews. I went into the teaching hospital as well for 10 days and been seen in their clinic and the nurse has seen me. So I don't really know why I'm being asked to have to come in again, but I'm still getting these flare ups and I'm still needing a lot of my inhaler. Anyway, I'll come in on Friday afternoon if I can get back from my meeting in Paris on time. All a bit strange rarely. So what happened, um, did get back came in said asthma since child o on treatment, um, two admissions in the last six months. Nothing for the 30 years before that never been in before. Usually very well controlled occasional in little bits of wheeze. So you usually used a blue inhaler. So the emergency reliever, perhaps one inhaler every uh 12 to 18 months, usually no problems at all, doing her exercise and keeping a out and about and quite a driven person, very business orientated, but also keeping herself well saying, um Right. Ok. This is what's been happening, told me about the reviews said no obvious trigger, no idea why it's worse. Now. Um Is there anyone else I should see because it's not going well at the moment, the importance of inhaler technique. So I asked her to demonstrate how she used the inhaler and she showed me her blue inhaler with a spacer and absolutely perfect technique at which point having gone through all that you've heard so far. I was thinking, oh my goodness. Now what I can't think of anything else. So I thought I would write in the note. It's always a good way like typing the notes, but writing the notes is always a good way to think of. What else do I need to ask what else might be going on? But I had to put down inhaler technique. Great. Uh She commented, you know, it just really knew what she was doing with that. When I looked up, I was a bit shocked she'd put her dry powder device also into the spacer and was trying to demonstrate how she viewed the preventer. You think about that? I've been sitting down typing as I looked up, this was happening and I sud suddenly realized what had happened. If I'm being very honest, I think that was luck. It wasn't skill or anything else. And I suspect the same thing had probably been overlooked when in, in the other clinic she'd been to. Um I assumed if you can use the complexity of a pressure meter dose inhaler with a dry with a spacer, you'll do. Well, I didn't think she could put a dry powder into that. Um So I looked a little bit my goodness, what's happened? And she looked the same saying, you, you said something there. What it it wasn't me being clever. This was just trying to do a good review. And actually I was thinking by that stage and it taught me check every bit of the inhaler technique, not just the one you think is difficult. Um, good news. II learned a lot from that. I think she did, um, even better news. She used the dry powder device. Well, after that and hasn't had an admission. This was a couple of years ago. Hasn't had an admission for three years, isn't using any emergency reliever anymore. Um, much better. And I got a lovely little present at Christmas as well. So I'm not complaining about that, but it does show how difficult it can be sometimes to get that um, that sort of story, right? Key learning point from this is the basics of a good review in primary or specialist care are very sensible, even if the person you're talking about is making huge profits for their company and are very rich and, and driven and clever and they've seen other people just do the basics cos sometimes you see things that perhaps haven't been seen by others or perhaps have been overlooked. Another quick tip when we're thinking about people. Is it asthma or is it something else about people who smoke? And this is quite high, well highlighted in the, in the British Thrust Society, Scottish Intercollegiate guideline networks on asthma. And it's also in the Gena guidance, people who smoke or have passive exposure to cigarette smoke, we know causes problems for acute asthma epi episode and long term control with an I CS, it appears that people who smoke, require a higher dose of inhaled corticosteroids to get the same impact if they're smokers or recent ex smokers. So don't be surprised if your smoker with asthma is coming in saying I'm using my proper brown inhaler or you know, my inhaler called steroid, possibly a long acting BTRI this with it. But it's not working. That can be because of the inflammatory process produced by cigarette smoke, reducing the efficacy of the drugs in reducing that eosinophilic inflammation. So, again, quite complex, some of these aren't a new diagnosis. We've talked about induced pal obstruction, deconditioning, um pneumothorax, pneumonia. But some of these are very basic part of that clinical review. And remember, most people will get most of their best treatment at levels of inhaled corticosteroids of between 408 100 mcg daily. Most of the dose response curve evidence as produced by um Matt Mazzoli and colleagues really doesn't show a great benefit above that. So let's go back to a couple of other things just to think through. And this is probably for more people that who are exercising more strongly. Um Quite a lot of people will get wheezy but only at the end of excising and not during they no will often say, well, my blue inhaler gets me better in 15 to 30 minutes, but it's not like my usual asthma if they have asthma or, um, but if, if I don't have my inhaler or I don't have an inhaler, it gets better anyway. And that's one of the key tips here is, it occurs after exercise. And the second thing along with that is it will often happen where they say, um, whether or not I use any treatment it gets better. And this is something called exercise in induced b bronchoconstriction. It occurs in people, um, after exercise. So you uh but you have to be fairly close to your peak exercise. So you exercise very hard and then relax that relaxation creates a neurological stimulation that produces a transient wheeze in susceptible individuals with asthma or without, which normally lasts between about 10 and 10 minutes up to an hour at the most I've heard of. But most it's, it's 56 minutes usually occurs a few minutes after stopping. So some people who get this and have to have a, have a break halfway through the, their, their sport like football, soccer will, will just jog around and keep themselves going before they play the second half. So this doesn't come on a key points on this. And again, some references there on the, on the papers affects about one in 5 to 1 in 20 are so common does affect most people with asthma, but it can affect people without asthma. So their only symptoms are after exercise. Fine, think about um just exercise induced bronchial constriction. They'll get better on their own. Normally lasts, um, about 10 to 10 minutes. But up to an hour usually develops within a quarter of an hour of finishing, but often within 5 to 10 minutes. And it's usually after high intensity exercise that brings it on. So a lot of people, if they're just doing a gentle jog or something won't get, that doesn't respond to other asthma treatment. Nice little graph here. And there's quite a neat um, clinical statement available online free um from the British Thoracic Society on uh assessing people with respiratory problems. If they're more athletic, talking about the difference between exercise induced laryngeal obstruction, peak exercise, then they get the symptoms but they might not have finished the exercise. That's your graf one exercise induced broncho, broncho constriction exercise finishes. Then the wheeze comes on and breathing pattern disorder coming on at a variety of times whether or not you're exciting at peak uh velocity that and that's got a few more references and a few other tips and if you're, if you're more interested. So we've actually covered quite a bit. We've talked about deconditioning exercise, induced laryngeal obstruction, breathing pattern disorders. Thinking differently in the acute episode of the patients giving us warnings, pneumonia or pneumothorax. Thinking about saber induced airways, hyperresponsiveness inhaler technique and exercise induced bronchoconstriction. Final thing just to think through is a patient who has exercise induced asthma needs asthma treatment. They've probably got if it's asthma treat the asthma, don't just use the short acting B12 list. That's not a good solution to pure exercise induced asthma. The vast majority of those actually need their inhaled corticosteroids as well. I think probably the sensible thing is to say again, worthwhile, making sure we get the diagnosis right. Check out more information on making good asthma diagnosis. But do think about those common associations in the real world when you're seeing patients coming in for review because the history will tell you an awful lot about it. Sometimes the test will help us, hopefully that's covered enough on that and I can hand back and see if there's any questions. Uh huh. We're getting some. Now I was gonna say please do pop your questions in the chat and we'll get through them, Steven. If you just wanna click on that, that's the one circle. So we do have 11 came in whilst you were talking earlier from Rosette. How can, oh dear, you're gonna have to explain that on Amy. Go on. Can you see it? Uh I can't at the moment. Is it up here? Hold on, hold on. I can, how can Amitriptyline help in inducible laryngeal obstruction? Um There's been a lot of things that have been tried. And so the, the important thing about inducible laryngeal obstruction is the vast majority of people that I see with that when we identify what the cause is, it makes it a lot easier. And I tend to go for either a speech and language therapist or a physio, both of whom have to have an interest. So we know that a musculoskeletal physio isn't gonna be any use. It has to be a respiratory interested physio, amitriptyline, bo Botox injections, all sorts of things have been tried. The amitriptyline, presumably people are thinking is working because it's drying secretion just helping somebody to relax a little bit more in that sort of area. But to be honest, I think most of us are not using that on a regular basis. Um So I put that in for completeness, but at a clinical level, I don't prescribe for inducible laryngeal obstruction, any medications. It's an explanation of what's going on and then exercises that physios or speech and language therapists do that help people to control their breathing a little bit more a bit like you hear, if you listen to quite a lot of music, you can hear a lot of pop singers breathe in on a microphone quite commonly as part of the part of their way of making sound. That's a learned behavior. The classical, uh certainly um traditional Western classical musicians and singers don't use that technique of breathing in. But again, it's something we can learn and train and, and get away with. Right. Got another question on the thing. Um Where am I up to a lot of patients have a non resolving cough after a viral upper respiratory tract infection went to diagnose it as a post viral bronchial hyperactivity syndrome and postviral symptom, how to manage it in primary care. Ok. So I think the first thing is that get to know what the normal resolution time is of a cough. So a viral upper respiratory cough tract infection, you'd normally expect two or three weeks worth of cough before it settles a bronchitis. A tightness across here, usually viral. Again, it takes longer if they have an antibiotic by about 7 to 10 days than if they don't have an antibiotic. Probably because it changes around the bacteria of flora. So, bronchitis in general takes longer if you give them a if or they've been given an antibiotic than if they don't. And that will take usually about 6 to 8 weeks to settle. I think what I'm often seeing is patients two weeks and expect themselves to be back to normal. It's trying to get that understanding of how long it will usually take for most people. And that's where the literature is really quite handy rather than the expectation of either what they were told in their emergency department or what they hope will happen when they come to see the magical clinician patients who have symptoms going on for a long time where they have evidence of um a um bronchial hyperreactivity that will mean their peak flow will be changing and be quite dramatic changes there. That may be an indication to use in how corticosteroids. But I think a lot of those are used as a placebo. And again, the vast majority, there are also some who get hypo um hyper reactive cough. It's more of a hyper responsive cough. Something seems to sensitize the mechanisms neurologically that a lot of people are looking at at the moment, um pragmatically with those is a question of exclude anything more sinister check that it's all nice and steady and say, fine, keep going. Some people might try an inhaled corticosteroid reasonable if the patient's happy with that, some people use an intranasal steroid if it's primarily upper respiratory tract. Um and, and again, the same is true, both in primary and secondary care. It's exclude other reasons with it. Um Right, if patients says somebody's helping with excise and induced bronchial constriction, when do they take it before or in the middle of exercise. Um I think if people are saying it's helping with the exercise induced bronchoconstriction, ie after exercise, they may as well take it after exercise. They've finished, they've done what they need to, they've won their race or they've run as much as they want. Now they're getting the, the wheezing at the end of it. But again, listening to what patients say, the vast majority of them say, well, it doesn't seem to make any difference. I get better on my own exercise induced bronchoconstriction is not a, a Sinop hilic inflammation, it's not muscle spasm there it's a different mechanism behind it. So it doesn't usually respond as well. Um, if they say, well, if I take it before it won't come, uh, again, complex to know these are all really difficult, messy type issues. If the patient isn't doing a gentle job, they'll never get to the phase where they're gonna get this wheezing. It's got to be when you're working pretty much 85 90% of your maximal, um, ability to exercise. Um, how do you pass across the information safely about airway hyperresponsiveness with saber use? I think a few things with that. I think it's a question of chatting to the patient as to when they use it, if they're using their saber to prevent problems in the first place, that is still gonna have the same problem. It's a bit like I talked about in the trial of let's all go and take a blue inhaler for a month or so. And most of us will come back with twitchy airways where you, it's the drug doing it. So if they're saying I'm using it before exercise and now I need to use more and more. That's probably, um, the drug initiating it. If they're saying I have, I exercise and I get very wheezy and I'm also wheezy when I go to bed at night and I cough a lot. They need an increase in their inhaler called a steroid. If they say I've, I've sat with groups of people who have interests in asthma. And it's extremely rare to hear of anybody who has genuine just asthma induced uh sorry, exercise induced asthma that just requires salbutamol and ok, and less. And there's two cases here that you may have in your practice, but perhaps not many, there are two groups of people that require a, a short acting beach agonist for excise induced symptoms. Group. One is people who are doing endurance sports for Winter Olympics usually at minus 10 to 15 °C. So not common. And with those, if you can, that will help because it's a different information. It's because of air going in causing muscle spasm a bit. They do need a SABA to help and the I CS doesn't help a great deal. The other group is very similar and that is elite armed forces working in the Antarctic or Antarctic for about two or three months a year at minus 10 to minus 20 °C doing endurance, hard work and physical effort. They've got the same process going on the others. I have asthma or they've got hyper responsive from their salbutamol or something else, but it's not usually your exercise induced asthma. So, really think carefully about that group um date on uh one asthma exacerbation per 10 years that just in adults. And if so there's similar data in Children. The, the, yeah, you're right on that. The figure that we had was primarily um for asthma and and the reason that's interesting is in, in adults, the exacerbation isn't particularly that great. And going to A&E is even less likely we'd expect that this is the average, so many patients will never have an exacerbation requiring steroids. They've just got milder symptoms and some of our patients that we probably remember vividly are those that have seven or eight and come in. They're the ones that we need to think about. Are they using their inhaler properly? Think about uh the person with their inhaler technique. I spoke about earlier. Um Are they um somebody who needs more specialist input? There are certain things and I showed that test with a laryngoscope going up and down onto throat. There are a variety of other things you can do in a specialized clinic at a tertiary level where you can really start to dig down if it's not quite typical asthma. Think about our specialist colleagues for that sort of thing in Children. I haven't seen uh long term studies uh that, that do the same, the same amount. Um Right breathing pattern disorder symptoms overlap with cardiac related symptoms. Um Yep, breathing pattern disorder symptoms are very similar to cardiac asthma. CO PD, all sorts of stress, anxiety, depression, they're often overlying what's going on. And the trick there is to listen to what the patient's saying. Certainly make sure you've optimized their medical conditions but be alive to the fact that often if you're a bit worried about having a heart attack. So you don't take big breaths in and out, that trains your breathing in a different way to the way in which it's designed to breathe and that can make you more likely to get symptoms. So that again may be where we want to be bringing in, um, a physiotherapist to help with their breathing. I think that's us. I don't think we have any other questions in the chat. So, thank you very, very much. Um, I did pop in the chat, your next event that you have with us. Um, that's on there. So if people want to, um, sign up for that event, it's on the 11th of December. Um, if everyone, if you could, you'll get your feedback form in about a minute, uh, in your inboxes, please fill that out. Let us know what your thoughts are on today's event. Um, and we will pass that on to Steve. Ok. And that's us. We will say goodnight to everyone and we will see you hopefully on the 11th. Thank you very much. Indeed. Thank you very much, everyone.