BreatheTV Episode 28
COVID-19 Patients on Non-Invasive Respiratory Support – Considerations & Transmission Protection | A Webinar
Allan Young: Good morning everyone. Everyone welcome to our webinar, COVID-19 Patients on Non-Invasive Respiratory Support, Considerations and Transmission Prevention. For all the healthcare professionals on the call, appreciate you taking the time out of your schedule to attend this morning. I would like to introduce you to our main speaker, Ron Fantl. Ron is a senior international medical educator Vapotherm. He’s been with our organization for over four years. Liaison between our global organization, consultants, research fellows and clinicians right in both education and medical science support. Ron is an ICU practitioner, respiratory therapist and he has over 20 years of clinical practice experience. His last role before joining Vapotherm, was managing the… Department of Europe’s largest thoracic hospital, University of Heidelberg. He has experience also in ventilation, including mechanical… AITS, DCMO treatment, and he is ideally placed to present current information regarding treating COVID-19 patients on an IV support. There will be an opportunity for questions when the webinar’s completed. You could ask your question in the chat window provided. I’d like to pass over to Ron to start the presentation. Over to you Ron.
Ron Fantl: Thank you very much, Allan. Good morning everybody. Allan? Yeah. Just a second. All right. Again, good morning everybody. It’s a pleasure having you with us. It’s a pretty international meeting. I will start my presentation immediately and please feel free to post your questions in the text message section on the bottom right side of your screen. We will answer all the questions within the time after the presentation, and the questions that we don’t manage to address we will follow up with these questions absolutely latest by the end of today. So the reason why we’re meeting today actually is that we are facing a worldwide pandemic. I want to have a quick look together with you into the current situation. I want to introduce you into two currently publicized different phenotypes of COVID-19 respiratory distress. We want to talk a little bit about different anonymized support modalities, and absolutely cover the risk and mitigation of aerial generating procedures.
We are in the middle of a really worldwide operating crisis. It’s a worldwide pandemic that’s spreaded starting from China all around the world. And the big issue of COVID-19 disease is basically that a lot of countries experienced and still do experience an exponential growth, means that extremely quick growth based on the extremely highly contagious disease. The Ro number which describes how many people can be infected by one positive person, ranges right now between two and a half and three, which means that one COVID positive infected patient will infect 2.4 up to 3.1 non-infected patients. And that’s the reason why this disease grows that quickly. Just to compare with the normal flu where there are not a number is only one.
Also, the mortality, we don’t know the mortality rates yet, we will know in maybe in half a year from now when we can retrospectivity evaluate all the numbers all around the globe. But the estimation of the mortality for COVID-19 disease is 1%, and that doesn’t seem very much especially giving mortality rates that we get reported from Quebec, or Italy or Spain right now. Even this 1% is pretty much or pretty high if you compared to the normal flu, the normal flu has a mortality rate of 0.1%, which is 10 times less than the estimated mortality rate in COVID-19. The big problem with mortalities right now and actually with all percentages and numbers right now is the extreme different policies of testing in the different countries, the different qualities of healthcare systems but also the different capacities of these healthcare systems.
So the highest mortalities over a couple of days were seen in Italy, whereas the healthcare system in Italy is extremely powerful with a lot of really high experienced intensivists in the country and actually a good equipped ICU system. The problem is that they simply didn’t have enough ICU beds, they didn’t have enough staff and they didn’t have enough technology. And first of all, if you don’t test a lot of people then the amount of patients that have a severe disease and are likely to die is higher. And second of all, if there’s simply not enough clinicians, there’s not enough nurses and doctors to treat those patients, mortality rates increased tremendously as well. So that’s really the big task to try to flatten the curve and try to keep numbers low so that healthcare systems can deal with the amount of patients that come up.
Just to make clear a little bit the terminology. The Coronavirus is a family of viruses, the Coronavirus II that we are right now dealing with is one of them. COVID is the abbreviation for Coronavirus Disease 19 because it was firstly described by the end 2019 in China, and SARS COV-2 is the abbreviation for severe acute respiratory syndrome caused by Coronavirus 2. COVID19 disease presentation can range completely from asymptomatic all the way up through normal flu symptoms to a severe pneumonia, multiorgan failure and even death. The mean incubation period is between five and six days with a huge range between one and 14 days. First cases are described with an incubation rate even above 14 days. We know that approximately 80% of the cases have a moderate disease with lung pneumonia symptoms, or low pneumonia symptoms, and all the normal flu symptoms, approximately 14% of the patient’s experience respiratory distress and more severe symptoms like tachypnea and dyspnea, and only around 6% have really a critical disease including respiratory failure, multiorgan failure and the need for mechanical ventilation.
The currently estimated and calculated Ro number we are looking into is 2.2 which is lower than the three point something that we are experiencing or we experienced in many countries. We had phases, especially in Germany I know the numbers pretty well. We had weeks in Germany where the Ro number was above seven. So one, COVID positive patient infected seven healthy patients, or healthy people. So the estimated Ro number is going to end up 2.2 and please always remember compared to the normal flu the normal who has a Ro number of one. And this is one of the biggest risks of this special disease. Many, many clinicians, many healthcare systems and many publications report observing completely different phenotypes of SARS COV-2 intensive care patients and which Luca Gattinoni and his team took the time and publicized a really very well done paper, not even two weeks ago where they described two different phenotypes of severe COVID-19 cases, and they call themed L type and H type.
And these L types patients, they appear with a very low lung elastance, which means with very high compliance. They have low ventilation profusion ratio and a very low lung weights, or the lung is very well aerated. They have little edema and this phenotype cures in approximately 70 to 80% as per his description. In opponing to that we have the H type patients that look more like a severe ARDSM patient. They have a very high elastance which means they have a very, very low lung compliance. They have a severe right to left shunt and a very high lung weight due to severe edema. Those patients thankfully cure only in 20 to 30%. Both of these type patients appear with a really low oxygen saturation. Also, the L type patients can be seen in the hospital with oxygen saturations far below 80%.
If you look at to the CT scan, that’s a CT scan of a sample type L patient. You’ll see the lung is very well aerated, you don’t have a lot of edema, you don’t see very much brown glass infiltration or besties here, but they still suffer a loss of hypoxic pulmonary vasoconstriction. They have a near to normal pulmonary arterial pressure. And if you remember the CT scan you saw a couple of seconds ago it’s easy to understand that they have a very, very low recruitability as the lung is very well aerated already. Still these patients are severely hypoxemic, but they are able to compensate it. So it’s very typical that these patients increase the normal minute ventilation up to a tidal volume of 15 to 20 milliliters per kilogram of body weight, which is three to four times the normal tidal volume.
And they don’t experience any, or only little dyspnea because their compliance is so good. They have a really near normal compliance, so they are able to increase the tidal volume to compensate their hypoxemia, and this obviously results in a decreased PIC02 due to the hyperventilation. On the other hand, we see the type H patients with a very low lung compliance and the high lung weight. If you see this sample CT scan it’s easy to understand why the lung weight is so high, they have severe edema. They develop early brown glass opacities and they have severely right left shant. Obviously the total gas volume is extremely reduced, these patients show basically all symptoms and cover all criteria of severe ARDS as per the Berlin definition.
So they are severely hypoximic, they show bilateral infiltration, they have a very low lung compliance. They have usually a very good recruitability due to the bad ventilation. If they show up in your emergency department or on your ICU, they are usually severely destroyed. They are not able to increase them in ventilation to cover their dyschesia due to the very low lung compliance. So they really seem very dyschesic and also usually show up with beginning signs and symptoms of multiorgan dysfunction, and usually the first symptom that she can experience with those patients is on acute confusion. And also these patients due to the fact that they are not able to increase them in the ventilation, usually have a pretty high PACO2.
Obviously these five patients are so different that the treatment methods and the treatment strategies should be different in those patients, and Gattinoni and colleagues basically recommend that these type H patients that really poll like normal severe ARDS they really should be treated like CVRDS they need to be early intubated, mechanically ventilated, deeply sedated at least at the beginning to really be sure to be able to deliver a protective ventilation with only limited risk of ventilator induced lung injury, which is always the biggest risk in ARDS patients and also in type H COVID-19 patients.
On the other hand side, the type L patients with a very good compliance and actually also very low subjective symptoms, these patients are not severely dyspneic, they are usually pretty cold, one publication out of the US described those patients as [inaudible 00:13:41] hypoxemic or even happy hypoxemic patients. I don’t feel that happy is a good description for those patients, but there really don’t seem to be very dyspneic and Gattinoni and colleagues and I fully agree with them as this is really inline with what we would do with other patients as well, recommend noninvasive respiratory support for those patients such as high flow CPAP or noninvasive positive pressure ventilation.
Critical in all patients, but especially in these type L patients, although they sometimes look pretty stable is really a very close monitoring because there is a pretty higher risk that a type L patient can transition to a type H patient, and a type H patient must really be identified early and intubated and mechanically ventilated early to prevent any risk of ventilator induced lung injury or patient’s self-inflected lung injury, which may occur if the noninvasive respiratory support is not optimal, and usually as soon as the compliance severely decreases noninvasive respiratory support is something that does not work with a non-sedated patient. So extremely important to monitor, especially the work of breathing. It would be optimal to monitor the infrathoracic pressure by esophageal pressures and pressure catheter. And Gattinoni and colleagues and that’s inline with all ARDS recommendations actually suggest to think about intubation pretty near to a negative inspiratory pressure of a -15 centimeters of water because this is basically where the risk really starts to get critical.
If you don’t have esophageal pressure measurements you can use surrogate parameters such as… pressure swings or you can simply monitor clinically the patients as soon as they get more dyspneic, as soon as the… gets more, as soon as that PACO2 which is there usually hypocapnic, as soon as the PACO2 starts to rise to normal or even hypercapnia, that’s usually the time where I’ve usually witnessed the patients tend to transition from L type to H type and you should take a quick and early and consent decision to proceed to intubation. What kind of weapons do we have to noninvasively respiratory support patients, especially in type L COVID-19 disease and that’s basically the three ones that we know always it’s high flow nasal oxygen therapy, it’s continuous positive airway pressure or noninvasive positive pressure ventilation.
And let’s have a quick look into the mechanisms of action of each of those. And the upsides and downsides and noninvasive positive pressure ventilation obviously is a good tool to control the FIO2, by using peep we can increase the FRC, the functional residual capacity and increase some gas exchange. When you manage to set the devices well and to synchronize well with a patient, you also decrease work of breathing and obviously by applying the driving pressure you also increase the tidal ventilation with moderate positive pressure ventilation.
The critical thing is it’s a pressure based therapy and type L or type H we are always talking about hypoxemic respiratory failure. We are always talking about type one respiratory failures and we know from many, many, many studies, not COVID-19 related that NiPPV is not the best go to tool to respiratory support, respiratory distressed or respiratory failure on patients type one. As we always see a risk from ventilator induced lung injury because it’s simply impossible to really protectively ventilate those patients, and these patients really need lung protective ventilation as soon as you are using a driving pressure. You need a sealed masks, that’s more of a practical problems. It needs to be pretty well sealed depending on the device you’re using. You really need to avoid leakages to avoid ventilator disynchrony, and you need pretty differentiated settings, you need to be really aware what you’re doing first of all to mitigate the risk of VILI, and secondly also to increase the patient compliance, and that’s not always easy.
With the CPAP, we also can control the FIO2, and we do increase the FRC, that’s the main mechanism of action by applying the PEEP, we are not using the driving pressure. So simply I’m controlling the FIH while increasing the FRC, that’s the mechanisms of action of CPAP, which is good mechanisms of action in the view of COVID-19 type one respiratory failure, especially in the L type patients, but also here you need to a sealed mask, you absolutely need to avoid leakage, first of all to make sure that the pressure column that you want to build up really reaches the airway. And secondly also to control aerosol dispersion, but we will discuss this a little bit later.
It’s important to manage the expiratory gas stream. Usually these are systems that are open to atmosphere. You don’t have an expiratory limb of the breathing circuits, so usually these are open to atmosphere bias, some kind of off a valve and you need to be sure that you control this expiratory gas stream as this is a high risk of carrying infectious aerosols. So it’s a good idea to use your viral filter there if applicable. It’s easier to gain patient compliance with CPAP in comparison to NiPPV, no doubt. But still these patients need a sealed face mask which is not always complimenting the comfort of patients. And I see as one of the greatest risks of CPAP, which all over is a good therapy for COVID-19 physiology or pathophysiology, but the big risk in CPAP is the inability to heat and humidify the breathing gases.
That’s not so much an issue in NiPPV where you can use heat and moisture exchanger, but in CPAP depending on the devices you’re using for CPAP it’s a huge problem, you can’t use HME filters as you don’t have a point where you need an expiration and pass over humidifiers are not recommended in an open system due to the risk of aerosol dispersion. And humidification is really critical to every intensive care patient, but especially to the COVID-19 patients. All guidelines actually call for a fluid restrictive therapy, and we all know from descriptions of many, many publications and also found its way in different guidelines is that COVID-19 patients really are challenged in term of secretion clearance. Many cases show up with a really tough and high viscous gel like bronchial secretion, and they need to get rid of it.
Optimum humidification leads to increased secretion clearance which is really critical. It improves the mucociliary function and the mucociliary transport speed. It is able to prevent atelectasis and reduce nasal epithelium superinfection. And also due to the more homogeneous ventilation of the lung, it reduces the inspiratory effort and all over reduces the work of breathing. So perfect humidification or optimal humidification, this is really a critical part arc to critical stone in the bundle of COVID-19 therapy. The last one, noninvasive respiratory support technology is high flow nasal oxygen or high flow nasal cannula. And the mechanisms of action here are alike CPAP, you can control the FIO2, you can increase the FRC by a mild distending pressure, but it also reduces pretty effectively the work of breathing by an extratorily flushing the extrathoracic dead space.
So we basically wash out CO2 of the patient, decrease the dead space, and a decrease in dead space first of all reduces the work of breathing by increasing the alveolar ventilation and secondly also improves oxygenation as the alveola FIO2, dead space decreases because less O2 depleted gas is reventilated out of the dead space. So that’s the mechanisms of action of high flow nasal oxygen. You are using loosely fitting nasal cannular problems, it has a good patient tolerance because it’s not a sealed mask, patients can eat, drink and complain, which is usually the most important part and it’s really minimal settings that you need to gain an effective therapy. And last but not least, and I think that’s really one of the critical points. You are able to deliver an optimal humidification as these are systems that can provide completely heated humidified breathing gas without a great risk or with a possibility to mitigate the risk of aerosol dispersion.
Right. Let’s have a look into the aerosol generating procedures. We know that COVID-19 is spread by droplets transmission. We are not sure whether it’s possible to also airborne spread this disease, but there’s no reports available right now that report of a witnessed airborne spread. We know that there is feaceal aerosol spread possible, but this doesn’t appear to be the driver of spreading the disease. Especially at the beginning of the crisis, many, many countries, many healthcare systems were very, very worried about spreading aerosols and bringing their healthcare professionals in risk, and therefore recommended to not use high nasal oxygen or any other noninvasive respiratory support due to the aim to mitigate infection spread. And there’s only two countries left in the world that still recommend most to use high nasal oxygen. One of them is the UK NHS that still recommend to not use high nasal oxygen due to the risk of infection spread.
And that’s pretty amazing, and also concerning as the CDC as well as the WHO are recommending since more than four weeks now that we need to be aware of aerosol generating procedures, but they are absolutely appropriate to use for COVID-19 patients. Simply precautions must be taken, clinicians must be aware of what they are doing to be able to take the correct precautions to avoid the risk of an infection spread amongst the team. Basically all national and international organizations as of today recommend the use of high flow and mentioned the use of noninvasive positive pressure ventilation or CPAP within their guidelines. It’s like local organizations like the Chinese Thoracic Society with German society for Intensive Care Medicine, the Italian Thoracic Society but also international centers like WHO and the Center for Disease Control, recommend use of noninvasive respiratory support.
And I think especially for intensive care, the Society of Critical Care Medicine, the SCCM is a really good go to source and they publicized a really very well done guideline that they summarized in an infographic, and I really liked this infographic very much because I think it’s very practical to use on a day by day basis. They basically recommended a COVID-19 patient with hypoxemia to always first evaluate whether this patient has a direct indication for endotracheal intubation, and indications for endotracheal intubation are the normal indications that we all know from every patient, plus you always need to look whether this patient seems to be an H type patient with a low lung compliance and a high lung weight. If these patients seem to be H type, they seem to struggle, they’re severely dyspneic, they start to get confused, then the indication to intubate those patients should be taken pretty straightforward and pretty early.
There’s no need to intubate them directly. The guidelines suggest to use supplemental oxygen with a target of 92 to 96. If this works fine, if this doesn’t work they suggest to escalate the noninvasive respiratory support to high flow nasal canula or high flow oxygen therapy. And if this works, great, if this doesn’t work they suggest to intubate those patients, because if high flow nasal canula doesn’t work, this is another good clinical sign for the severity of disease and the transition from L to H type. Please pay close attention to the always repeated ask for a close monitoring. It’s important the less invasive you treat your patients, the more close you need to monitor the work of breathing to really do not miss the point where you need to escalate the respiratory support to mechanical ventilation.
And if you feel that this is the point, you shouldn’t delayed intubation because last thing you want to happen in these patients is to get into the situation where you need to emergency incubate those patients. If we look a little bit deeper into these guidelines, I want to show you some of the recommendations and suggestions. In a closer look, the guideline has more than 50 different recommendations. I just mentioned a couple of them. So they suggest to maintain oxygen saturation between 92 and 96%. They suggest to use high flow nasal oxygen when the patient remains hypoxemic despite low-flow oxygen therapy, they recommend to use a high flow over an NiPPV and trial an NiPPV only if the patient is hypoxemic no urgent indication for intubation and no high flow nasal cannula available in your department, so they’re absolutely recommend high flow over NiPPV and I can’t repeat it enough, and they absolutely recommended close monitoring especially under noninvasive respiratory support to really not miss the time where you should escalate the… of care.
And we could carry on citing other guidelines, basically most of the guidelines match, this is the Australian and New Zealand Intensive Care Society and that also recommends high flow nasal oxygen as recommended therapy and recommends NiPPV not to be routinely used in COVID-19 patients. The question of transmission of aerosols and the risk of healthcare professionals being infected doesn’t appear the first time in history. In 2012 after the SARS-1 crisis, and Tran and colleagues publicized a meta analyzes looking into different studies that investigated different aerosol generating procedures, they calculated odds ratios, so risk ratios as well as simply identified, which is actually the greatest step of this publication. They identified different aerosol generating procedures.
And just to mention some of them, I think they identified 30 to 50 different aerosol generating procedures. Just to mention some of them, like tracheal intubation, obviously manipulating around a BiPAP mask is a aerosol generating procedure, but also manipulating a normal oxygen mask suction before intubation. Bag mask ventilation is a aerosol generating procedure. And high flow obviously as well, if you look into the odds ratios, you see the tracking intubation has the highest risk of those aerosol generating procedures in high flow, the lowest risk. Lowest risk doesn’t mean no risk and no risk it’s still risk, so there’s still good reasons to really trying to avoid this risk. After crisis began many, many healthcare societies gave the order to basically incubate those patients directly. This was removed out of all recommendations and guidelines as of the last two weeks or something.
There’s many reasons why it’s not a great idea to incubate these patients as first line. First of all, we just learned from trend intubation is an aerosol generation procedure as well. And that’s pretty self explanatory. Extubation is even the most severe aerosol generating procedure as it’s always accompanied by severe coughing, and we don’t have clinical data on that one, but if you intubate patients always when they need more than six liters of oxygen, you will end up with a lot of intubations and extubations because these patients will not stay mechanical ventilated for two weeks, you will usually extubate them pretty quickly again because they stabilize. But when you extubate them and don’t support them respiratorily after the extubation they will get reintubation again. So you will end up with loads of intubations and extubations when you don’t use any noninvasive respiratory support.
Also, despite of any COVID risk for healthcare professionals, we know the risks of mechanical ventilation and intubation for patients. Not to mention that the risks of intubation. Mechanical ventilation itself is more than 50% of all ARDS are simply caused by mechanical ventilation, not by underline disease. So actually we know this is something we need to try to avoid. We shouldn’t push it too hard, patients that need intubation, mechanical ventilation should get intubation, mechanical ventilation and should not be delayed. But if there’s a chance to avoid this, this is absolutely beneficial for the patient. And in the crisis also the number of available ventilators as well as the number of staff and the quality or the qualification, sorry, of staff, it’s absolutely a good reason to not intubate everybody, a mechanically ventilated patient absolutely needs more staff attention as well as a more staff expertise than a patient on high flow nasal oxygen.
So we saw that the risks of aerosol transmission is pretty low in high flow, but low is not knows. So there’s good reasons to try to even reduce it further. The Chinese Thoracic Society publicized a recommendation a couple of weeks ago where they recommended to place a surgical face mask over the patient’s nose and mouth and over the high flow nasal cannula to reduce aerosol’s dispersion. And that’s actually a great idea. And… science and innovation team, build a team of physiologists and researchers and delivered a study a couple of weeks ago, I think publicized two or three weeks ago where they looked into high flow, low flow oxygen and nano tidal ventilation, and they measured the aerosol dispersion with and without using a surgical face mask. And the results were really very interesting, it was so interesting that actually the Journal Chest decided only within a week to publicize it and that’s where you also can find the publication.
Also if you want to follow up with any of the publications I mentioned, please send me an email. I’m more than happy to send you the publications via email. So that’s one of the really impressive pictures. On the left hand side you see a patient on 40 liters of high velocity nasal insufflation, so high flow nasal oxygen therapy without a surgery face mask, and you see basically the big aerosol that is generated. And on the right hand side you see the exact same model with the exact same therapy, but with a surgical face mask placed over the nose and the mouth and the results, I’m not going to walk you through all the results, not even through all the results on this paper, but if you look into the percentage of aerosol droplets that is caught in the surgical face masks, then it’s basically the same when you’re using 40 liters of high-flow compared to no therapies, or nano tidal ventilation with a surgical face mask and high flow, 40 meters per minute with a surgical face mask basically have the same risk of aerosol dispersion around. The patients surrounding.
My takeaways for you today are, I think the continuum of care of the COVID-19 patient is slightly different from a normal patient in respiratory distress type one, we suggest to start with oxygen therapy up to six liters per minute and early decide to escalate the noninvasive respiratory support. Most guidelines recommend to use high flow nasal respiratory support as it’s able to really control the FIO2. It’s able to increase the FRC and it decreases the work of breathing without the need of using a tight fitting mask, and mostly important without applying a driving pressure that always brings the risk of a ventilator in just lung injury, but they always also suggest to really closely monitor those patients to not miss the point where they really need protective and mechanical ventilation. I really think this is a great summary of the current available recommendations and clinical data.
I can highly recommend to print this and use this on your ICU wards and despite the recommendations and COVID-19 please keep in mind the high flow nasal oxygen is proven to reduce in any type one respiratory distress patient. To reduce the need of intubation we have plenty of clinical data for this. And it’s even better in some cases, especially in the severely hypoxemic patients with a PF ratio below 200, it seems to be better to prevent intubation than noninvasive positive pressure ventilation. It addresses a lot of symptoms that come with COVID-19 life thicken secretion, cough, dyspnea, hypoxemia. Cough is a very important thing. We know that heating and humidifying breathing gas reduces coughing. And we also know that coughing is one of the major symptoms in COVID-19 patients. And we also know coughing as one of the major risks for aerosol generating situation where healthcare professionals are in risk to be infected because cough has a higher speed than only 40 liters per minute.
And also if the patients need to be mechanically ventilated, high flow is proven to reduce the rates of reintubation when used directly after extubation. And all of that happens unlike mask based therapies without increasing the driving pressure, I think that’s one of the really critical points. High flow does not increase the driving pressure and therefore high flow does not carry the risk of ventilator induced lung injury. It doesn’t cause any or only little interface in tolerance as well as skin breakdown. It requires no complicated settings and we all know to set a really well done NiPPV needs a lot of skills, a lot of patients, and a lot of time too, a lot of resources to really promote as well. And also in terms of aerosol, please keep in mind the aerosol generation with high flow can be really mitigated by using a surgical face mask.
There’s no way using a surgical face mask over a CPAP or an NiPPV mask. And also it’s really uncontrollable to know where the leakages are, these masks always have a little leakage somewhere, and it’s simply very, very hard to control that. So last but not least, please remember intubations, absolutely the therapy number one for the type H patients with severe dyspnea and signs of multiorgan dysfunction or failure, but there’s no need to intubate everybody that needs more than six liters of oxygen. We have other arms in our tool belt that can be used to stabilize those patients. Please remember using a surgical face mask, the risk of aerosol dispersion with high flow is low, but it’s even lower with using a surgical face mask. And with this I want to thank you for your attendance and hand over to Allan to moderate the questions.
Allan Young: Many thanks Ron. We have no questions on the chat but I don’t know if there’s anyone wants to speak up on the call, just admit yourself and ask a question. There are no questions.
Ron Fantl: Any questions? If you want to place your questions, you can use English, you can use German, you can use Czech, I saw we have some Czech people on the call and I would translate them but that’s all I can English, German, Czech. And if somebody wants to ask an Austrian question we will be able to translate this as well. All right. Either we killed them with PowerPoint or we answered all questions.
Allan Young: The presentation will also… You see we’re recording the presentation so it will be available for a download so you can share with your colleagues and your colleagues within your business. So you either contact Ron, there is his email address there. I’ll be in touch with a follow up and if you want the… I’ll be very happy to share it with it. That concludes the presentation for this morning. Thank you very much for attending and thank you Ron for the presentation.
Ron Fantl: Have a great day everybody. Thank you for joining.