A Breath of Fresh Air for COPD Relief

Transcript Generated by AI.

Dr. Mitchell Rothstein 0:00

Hi, I'm Mitchell Rothstein. I'm the medical director of the phase one unit at the Jacksonville Center for Clinical Research. Prior to that, I worked as a community physician for 30 years here in Jacksonville, practicing both pulmonary lung pulmonary disease and sleep medicine, and I'm board certified in both pulmonary disorders and sleep medicine. And what I wanted to talk about today was some new and exciting developments in the treatment of COPD. I want to kind of keep this talk concentrated on that and speak specifically to people who have COPD and people who live with people who have COPD. First, I think it's important that we define what COPD is. So chronic obstructive pulmonary disease is defined as a limitation in the amount and degree to which people can move air in and out of their lungs. And we make that definition based on a simple test called spirometry. So at the current time, about 7% of people in the United States have been told they have COPD. And in terms of how we make that definition, we use a spirometer which measures how quickly and how much airflow you get out of your lungs. So when people take a deep breath in and blow it out as quickly and as fast and as hard as they can, the air that comes out is recorded. And we know for normal functioning lungs, at least 70 to 80 percent of the total amount of air that comes out will come out in the first second. So this graph depicts time. So as you're exhaling, time is going out long, and as you're exhaling the volume is also being measured. So in the first second, in a normal lung, 80 percent, 70 to 80 percent of the total that comes out comes out in the first second. In people that have obstructive lung disease, that's reduced. So anything less than a ratio of 70 percent. For example, in this patient, air is coming out in the first second, about 50 percent of the total that comes out altogether comes out in the first second. So their FEV1% would be 50. So we diagnose COPD if your FEV1% is 70% or less. So how do we treat COPD? So resistance to airflow is determined by resistance in the airway. Airway diameter determines airway resistance. Airway diameter is then in turn controlled by our autonomic nervous system. So there are two branches to our autonomic nervous system our sympathetic part and then our parasympathetic part. The sympathetic nervous system and the parasympathetic nervous system both innervate muscles in the airway. When the sympathetic system is activated, those muscles are stimulated to relax and dilate. When the parasympathetic system is activated, those same muscles are activated to constrict. So they're in a balance one on the other. And so, for example, during exercise, our airways, our airways dilate, so our sympathetic system becomes dominant. During sleep, our airways constrict, so our parasympathetic system becomes dominant. Other things that can affect the sympathetic and parasympathetic dominance is inflammation or infections in the airways themselves. So medicines, bronchodilators, work on the airways in one of two fashions. Either they stimulate the sympathetic system, and those are called beta agonists. And there's two forms, short-acting, SABAs, short-acting beta agonists, and long-acting beta agonists, LABAS. The other part of the way we can use this autonomic nervous system is to inhibit the parasympathetic system. So if we hit inhibit constriction, we cause dilatation. And those medications are also divided in half into what are called SAMAs, short-acting muscarinic agents, or LAMA's, long-acting muscarinic agents. To help people that have chronic airflow obstruction, what was determined to be the best form of treatment was to initiate either a first-line long-acting beta agonist or a first-line long-acting muscarinic agent. If those were ineffective as a single agent, we added them together. So people got on what's called LABA-LAMA therapy. And then on top of that, we added inhaled corticosteroids or what was called triple therapy. So most patients with COPD today are automatically placed on triple therapy. So you're covering both bronchal by inhibiting bronchoconstriction, you're enhancing bronchodilatation, and you're inhibiting local inflammation. As it turns out, even though we have almost all of our patients on these this triple therapy, 50% of them are still experiencing exacerbations or having problems with quality of life. So there was something else in the mix that we weren't quite handling despite having patients on LABA, LAMA's, and inhaled corticosteroids. One of the other things we found, too, is that some patients were effectively treated with either a single agent LABA or a single agent LAMA and didn't need all that extra medicine, but they were put on it as well. So I tell all the patients that I know that have COPD is to number one, check with their doctor to make sure they have COPD, make sure that spirometry has been checked, and number two, to check how their quality of life is. Do they need all that medicine on top of either a single agent to control their symptoms? So this has kind of been the state of the art in pulmonary medicine until about four or five years ago, when we developed another class of medications called phosphodiesterase inhibitors. And there are currently two that are available. One is Roflumilast, the other is Ensifentrine. Both of them inhibit phosphodiesterase. What phospodiesterase does is it inhibits the breakdown of cyclic AMP, which is the inner molecule that causes pulmonary bronchodilatation. So it makes that bronchodilatation last even longer. Ensifentrine is now available by a nebulized medication, so you don't have to take it in pill form. The other thing that has become prominent is that when people are using inhaled medications, are they using it correctly? And I found that in my clinical practice, more than 50% of my patients, despite being coached over and over again on how to use their inhalers, still aren't using them well. And since inhaled medicines are really local medicines, they have to get down to your lungs in order to be effective. You can't just swallow them. If you can't coordinate, in certain cases, the actuation of the device, the inhalation of the product, and proper laminar flow during inhalation to get it down into your lungs, you're not going to get the benefit of the medicine. So it's important that you review your inhaler technique with your physician, hopefully your pulmonologist. And if you're incapable of inhaling the medicine correctly, you get a device that you can use effectively. For example, the most common device is a meter dose inhaler, the kind that you have to squeeze and actuate. Well, you have to squeeze and actuate it at the same time you synchronize your inhalation, and your inhalation has to be deep enough to get the medicine down into your chest. So if you're incapable of doing that, despite having the best technique, we can also provide people with calls a spacer to go on the end of their inhaler so that they don't have to synchronize the actuation and the inhalation, but they still have to be able to inhale the product into their lungs to get the full effect of the medicine. So there are meter dose inhalers, there's dry powder inhalers where you first load the device and then you just have to suck the medicine in, but you have to be able to maintain a sufficient airflow to get the medicine past your upper airway into your lungs to get the benefit. There's now something called the soft mist inhaler, and then there's nebulizers. And all these medicines can be effectively delivered through a nebulizer for a lot of patients if they're deemed not capable of being able to inhale, actuate, and synchronize with the other methods. So you need to review your inhaler technique with your physician. And then the thing that's been most exciting in the field that's really been discovered in the last five years has been that when we try to look at patients with COPD, we found that there were certain patients that were, we'd call them frequent flyers, where they'd have recurrent exacerbations. So when we're treating patients with COPD, what we're trying to do is minimize symptoms, improve quality of life, and reduce exacerbations. And the reason exacerbations are so important is that we know if you're hospitalized with an exacerbation for COPD, your mortality rate for all causes in one year after that hospitalization is 20%. We know that the average survival of patients that are admitted to the hospital with an exacerbation is three and a half years, and those are strikingly bad numbers. So we're trying to prevent those exacerbations from happening. What we've learned after looking at patients that are on these LAMA and LABA combinations with inhaled corticosteroids is that there were a percentage of patients, about 30 or 40 percent, who were exhibiting what we call type 2 inflammation. Type 2 inflammation is the kind of inflammation we see in chronic inflammatory conditions like eczema, like psoriasis, people that have eosinophilic esophagitis. And this is characterized in most cases by having a blood eosinophil count of about 300. So in those subsets of patients with COPD that are having ongoing symptoms not controlled by their inhaled medications, we are recommending currently, and there are two studies out that prove this, that using monoclonal antibodies against some of these inflammatory components that are called either alarmins or interleukins or cytokines are effective in reducing recurrent exacerbations. So there's two products so far that have been approved for this. They're reducing exacerbation rates or timed exacerbation, the next exacerbation significantly. So that's another avenue that needs to be evaluated by your treating physician. So if you have COPD, I recommend the following. Number one, make sure you have COPD. Your spirometry should be checked at least yearly. Of course, you should get all the proper vaccines, you shouldn't smoke anymore, you should go to pulmonary rehab. Number two, you need to review your inhaler technique to make sure that the medicine you're using is effectively getting to your lungs appropriately so that you're benefiting from those medications. Number three, if your quality of life is still impaired, if you're not able to do the kinds of things you want to do, or you're having exacerbations, you need to be evaluated in terms of a peripheral blood eosinophil count. And if it's elevated, you need to consider this new type of biologic therapy for COPD that's shown to be effective. Thank you.

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