Emerging Treatment Modalities in COPD

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Emerging Treatment Modalities in COPD

10 Oct, 3:30 PM

welcome good evening everyone this is Dr vishali and I welcome you all on behalf of Netflix today's session is emerging treatment modalities in COPD for that we have with us Dr Rahul Sharma after doing his MD DNB medicine he's also done his DM pulmonology and critical care and also on Fellowship in sleep medicine he has over 12 years of experience in this field of pulmonology and is currently working as the additional director pulmonology at POTUS hospitals Noida so we welcome you uh thank you so much for sparing time for us to talk about these very interesting topic that is what are the new modalities in treating COPD so I would hand it over to you I'm sure our doctors are waiting to listen from you uh thank you very much and good evening everyone and thank you very much joining in so late uh for this topic so the topic is very very important in terms of that we have so the data scissors that we have approximately highest number of COPD patients in India we have crossed China also recently and the number of mortality is also very very high yeah in India so other than inhalers that probably is still a struggle by most of the doctors to give to their patients and providing them good treatment we need to see beyond these inhalers that what extra can be done to be patient right so this is my topic and I'll start sharing my slide slide Also regarding the same so So currently I am working in 45 Hospital Noida as an additional director and the talk of today is what are the emerging treatment modalities so we'll be discussing that the what are the emerging treatment modalities as far as the COPD is concerned worldwide and what is available in things right so when we talk about cop your definition has given by by goal guidelines which also defines the treatment and the modalities what treatment should be provided to the patient so it is a common preventable and treatable which is characterized by persistent respiratory symptoms and airflow limitation which which is most commonly seen in smoker patients but as the Global changes are there in terms of lot of construction pollution we are seeing so many patients who are not smoker but still having COPD and it is very very important to differentiate COPD from bronchial asthma why because uh bronchial asset COPD initially thought to be thought to have the same kind of inhaler but now it has been realized that the difference is totally the treatment is totally different for both the diseases so it is very very important that you correctly diagnose your patient as COPD before going or jumping into any advanced treatment so so this is the trial that has to be failed when you are talking about that my patient might or have confirmed you you need to look into the symptoms of the patient which has sharpness of breath cough and glucum which is more or less persistent we service asthma where these are intermittent symptoms to start with and then later on on it goes in and becomes more or less permanent if the treatment is not very good then the risk factor that you need to consider when you are diagnosing your patient as cubity it is not only the tobacco consumption you need to look into the host factor in terms of associated occupational Factor pollution which can be indoor or outdoors and then the conformation has to be done with the help of pulmonary function test or what we call as spirometry if the spirometry confirms obstruction when you decide that what kind of treatment your patient needs and the management goal of ubd is again very very simple as any patient come to us the first and the foremost goal is that you delete the patient from the symptom and is taking long-term maintenance goal is that you try to decrease the exacerbation so there should be no admission or no possible symptoms which might lead to mortality in these questions so by doing so what we are doing we are reducing the symptoms reducing the extra submission and improving overall quality of life of our patients and when we look into the therapeutic option or the drugs that are available for our patients there is a number of inhaled as well as oral medication which are available in different strength different combinations this basket you need to identify that what is the best treatment for so the most commonly used treatment and the oldest treatment is beta2 against in terms of short acting beta2 agonists or long active meter to admit then we can have anticholinergics here which is against short acting or long acting other than this we have now methyls and things inhaled corticosteroids lava plus corticosteroids lava plus Lama and triple dark combination so so these short acting therapies are mostly for the patients who has acute extra service or who we think coming to your emergencies and are being hospitalized most of the time what we are doing we are going towards long-term therapy in our patient in terms of Lama lava and again it is not only the drug the other important thing is the device that you are using so most of the time whatever therapy you are giving try and use a single device for operation it creates less confusion less errors and patient has to take these medications for a longer period of time compliance is also very very good in such patient where you are not mixing the device rather than giving a simple single device to your operation and there are add-on oral drugs are available unfortunately most of our patients still rely on oral magnification for the treatment of their airway disease which is totally wrong in terms of that it has more side effects and it these are weaker medication to control your disease so it is very very prudent to make your patient understand that the inhaled route of medication is the best route of medication for your patients then the treatment has again been redefined defined it is not only on the basis of your spirometry there are two parameter which has been added by gold in terms of defining the treatment of the patient and it gives them having added advantage in terms of that you don't have to repeat the pulmonary function test because it is not still not available in second Tire cities or many of the centers so once the diagnosis of copity is confirmed by spirometry you can read Define or restructure your treatment on the basis of symptoms and fixed classification occupation so there are two parameters that you need to see that patients who have number of extra submission and on the basis of this like this ABCD categorization can be done and on your x-axis you have mmrc or income score application the other score is cat score which is which is a bit lengthy score so most of the people still using mmrc score and mmrc score you don't have to you know ask all the questions a simple question that whether you walk slower than your buddies or your peers or you pause when you are walking at your own pace that defines whether your patient is coming into the category of this Mark mmn RC 0 to 1 or 2 or no again for exacerbation you need to ask your patient that in the last one year how many times your symptom worsens to an extent that you need an antibiotic steroid or inhalational or injectable drugs that defines the extra solution exacerbation is not only always hospitalization even an emergency reason or using oral particles right taking nebulization at home which which significantly change the patient day-to-day medication is defined as a translation so exercise doesn't mean always hospitalization but yes if your patient has a single exacerbation in a year then these patient comes into the higher category and these patient needs more intensified treatment so the treatment approach is again very very simplified and the major Focus has been given on bronchodilators rather than inhaled corticosteroid as far as COPD treatment is function so you can see the patient who has mild symptoms no exacerbation bronchodilator is the treatment of choice patient who has higher symptoms but no exacerbation again long-acting bronchodilator or lab is the treatment of choice applications patients who have extractivation llama scores over lava in terms of reducing the extra submission so it is the drug of choice but if your patient is not getting relieved you can always add on on Lake dual combination of bronchodilators rather than jumping onto inhale cortical stride and nowadays inhale corticosterite has been very very limited role where you see that your patient has frequent exacerbation not because of pneumonia patient has high eucinox will count in the blood then these are probably the candidates that you are going for a triple therapy in the equation so bronchodologic is the three key as far as the management of COPD is concerned dual bronchodilators in terms of lava lava acts in different part of the lungs the Llama acts on the peripheral part and lava acts on the central part so the there is an add-on coverage or added coverage when you add both the bronchodilated plumber and lava for the management of your patient not only bronchodilate it improves the respiratory muscle function reduces the hyperinflammation and increase the lyric the chances of infection also goes down so this is this is how it works that muscarinic receptors basically anticological receptors Works more on the proximal Airways while the beta T8 energy receptors Works more on the display levels and by this in direct and indirect it gives them bronchonylation effect and this is what we are looking into in 2022 we have two set of patients one who is dismissed and the treatment of choice is either lamalaba to start with it's not really a combination of llama lava and if it is not really rather than jumping onto llama ICS formulation trines which are inhaleration device or molecule this is again a very very important add-ons that gold had given we have seen that some patients do not respond to some molecule and they respond wonderfully to the other molecules now they nowadays willing to all human clean idiom is available in the applications and these are Odin and these patients wonderfully working for these patients for these molecules the other subset of patient is patients who are exacerbation form when the patient is exacerbation prone and you believe that ICS is not the correct choice either lava force over lamba sorry llamas course of our lab and then you decide whether your patient is optimally controlled in terms of symptom relief and exercise solution if not then you go for the Dual bronchodilator if your patient has high eucino field count frequent extra submission then you go for lava Lama ICS combination and then the the probably now the Love by Talk starts that what if this is not working where a patients are still having dysmoric saturation what do we do so so so when we talk about this exacerbation it has a huge impact in the quality of life operation outcome of exacer solution as far as patients who are going directly to ICU mortality Distributing of 20 to 24 percent in hospitalization Hospital mortality is very very high patients are repeatedly coming so that they are in the revolving door of emergency visits that it comes and goes even in outpatient the treatment failure is very very high so once these exacerbation is a problem for your patient patient has poor quality of life persistent inflammation because every transformation increases the risk or further you know further initiate the next exercise position this is what sports trials tells us that every extra solution is a seed for negative transformation copy division it increases inflammation where it starts to decline in the lung function increase likelihood of hospitalization and increase mortality in the equation so this is this is very very important and when we are not able to control our patient on this chart in edcd group we have to look Beyond so how do we look Beyond there are certain non-pharmacological management that you need to Define in your operation so smoking suggestion is one of the very very important thing yet then physical activity vaccination for flu pneumococcal and nowadays they say that the patient has also been vaccinated for covid and pdap it is again very very important if your patient is coming into the B C or D category it is not only physical activity you need to go for structural pulmonary rehabilitation program for your patients which includes exercise training physical activity education self-management and you know nutritional support and Optimum therapy for your patients so these are non-pharmacological therapy that must go hand in hand with your pharmacological therapy for the management of your patient even after that if the patient has persistent exacerbation so what are the options the two options that have been advocated by uh gold is draft lumilar and azithromycin and there is a robust data regarding this so where do we add roughly relax patient who has ate even less than 50 percent predicted and chronic bronchitis phenotype so patient who has more sputum production they are probably the best candidate for uh drug formulas rather than patient who has emphysematers phenotype and they are not being producing much of the symptoms so this is very very important that we should realize that rare of formulas should be added it is not for everyone who are exacerbating and not getting response the other important thing is natural light so the evidence for Metro Light or azithromycin is specially seen in patients who are not current smokers and these are the patient in which there is some resistance organ which is causing recurrent enough information in these patients so the the data is again very very robust when you utilize low-fliminalize in your patient with chances of you know exacerbation decrease by 13 percent and overall benefit is also being seen in this Forest it's got glass so the effect of flimulus versus placebo in the incidence of COPD extra patient definitely favors use of profliminal in selected patients it should not be given to the patient who has low weight a patient who had persistent tendency of diarrhea then you need to look into these factors when you are applying proflim velocity operation azithromycin again has a very very important role Asians who are frequent exacerbations and who has quit smoking so this is again a capillary graph where you can see that the patients who are using azithromycin uh 250 milligrams per day the exacerbation rate significantly goes down as compared to patients who are not uh using azithromagnetism the only concern that we have here is the adverse effect in terms of ear toxicity cardiac arrhythmias so these things needs to be considered in mind whenever you are providing azithromycin to your patient as a maintenance therapy the other important aspects of management of COPD is looking into the comography most of these COPD patients are not that you know obese so they have this systemic inflammation going on which causes weight loss muscle loss in the ocean still these patients have sleep disorder breathing which needs to be considered in the equation because most of the time this is a progressive disease and patients usually have this respiratory failure started in the night the patient has sleep hypoxemia when patient has sleep hypoxemia patients have frequent Awakening in terms of respiratory effort related arousals or radar later on they start developing sleep hyperventilation and Osa can also be seen up 30 percent of these patients who have underlying COPD and are not well controlled so it is very very important to see in patients who you are not able to control with your pharmacotherapy physiotherapists look into the Sleep disorders so what predicts sleep disorder building in Cuba do we screen all our patients with sleep apnea which is not possible because it is a combustion test and it is costly also so what are the pointers that decide that yes my patient can have sleep apnea so patients who have hypoxemia or hypercarbia increase pulmonary artery pressure features of car pulmonary although it is a very very late features so once the core permanent of this everyone knows that the patient has lip disorder bleeding patients who start developing peripheral edema whole day frequent exacerbation and central obesity so it is not only that the Hefty coffee patients that we see in Europe America are patients who has simple central obesity Central tummies these are all the candidates for sleep apnea evaluation in patients who have COPD and this Red Dot I think is probably the most important part when you ask your patient so most of the time what happens that we see that our patient has persistent respiration terms and most of our patients undergo this cardiac clearance in terms of that there should not be any Associated card entities but the most important striking things if a patient has any kind of embiotic hypertension in the Eco probably these are the patients who must undergo sleep evaluation and should be screened for absolutely sleep apnea otherwise the parameters that has been given on your right are the indicators with three passenger evaluation is be quiet this study shows that it is an independent risk factor for cardiovascular event and increase the risk of exacerbation and up to 50 percent of the patients who have frequent extra solution can have underlying sleep apnea which is very very you know commonly missed scenario as we see that the patient has fatigue sleepiness and we all try to correlate it with the progressive disease of the patient but then mind you that patients who have exacerbation and sleep apnea the title of this revolving door of ICU and hospitalized admission cut down significantly when you can pick these things in your patient other than this there are n number of Commodities that meets your attention so COPD is not the disease of lung it is the systemic disease so you need to optimize hyperglycemia it is closely hypertension dyslipidemia osteoporosis and sleep disorder breathing in operation so this is a multi-mobility multi-system involvement which needs multi-disciplinary approach in patients who are not getting well controlled in your patients right after that if your patient is not well controlled then probably we we initially we have this lung volume reduction surgery which has maximum mobility and mortality that's why probably it has not gained that much of uh popularity or it is not a routine practice to you know subject your COPD patient for lung volume reduction surgery but nowadays bronchoscopic minimally invasive therapies are available which is as good as or better than lung reduction surgery in terms of benefit and in terms of decreased side effect or Adverse Events which are associated with uh surgical therapy so how these intervention improve the symptoms of COPD so this is a basic slide where patients who has you know Advanced COPD they have this static hyperinflated lungs so you can see in this pictorial diagram that the upper lobe has hyperinflation the lower lobe the lower lobe has been compressed with the help with due to this increased disease activity in these patients right so this is very very important to understand that if I can decrease the size of this disease level I can give space to my normal lungs to breathe and the diaphragm also comes to a position that the lungs can breathe better and patients feel symptomatically this is the basic physiological idea to decrease the size of lungs which is most affected in COPD by surgery or by bronchoscopic lung volume reduction surgery to give symptomatic benefit and space of the normal lung to breathe right so so we have so this not only improve your lung function it improve your Exercise capacity improve quality of life and improve overall survival so there was a problem with this next trial which was basically evaluating the you know role of surgical lung volume reduction but it has lot of learning also so the complications what great was the Prime problem in the patients who underwent this surgery there was reintubation arrhythmias pneumonia readmissions patients were you know prolongedly on ventilators and in eyes you need trichostomy so so this was the problem problem that's why surgery was not favored at most of the center for COPD and right now but the learning was that that you are able to identify the characteristic of hemphasis who might have benefited from lung volume reduction surgery it is not for oh for every patient of COPD who are at high risk the most favorable subgroup are patients who has upper lobe disease and low Baseline exercise solvent so should and there are contraindication also that the patient who has sp1 less than 20 DLC less than 20 percent and homogeneous overall implies you know probably so they are not the best candidate for the surgery so when it comes to so bronchoscopic land volume reduction surgery this attempt was taken as energy because it was less invasive or probably non-indigent it reduces the risk as well as cost and it potentially reversible and may or may uh may be more suitable for the patient who might not be good candidates approach right so the indications that our patient has emphysema predominant COPD symptomatic despite optimal management low fev1 between 15 to 50 percent six men's walkways are between 100 meter to 5500 meters evidence of hyperinflation which needs to be tackled or seen with the help of total lung capacity which is more than 100 and residual volume more than 175 percent heterogeneous as well as homogeneous emphysema the contraindication are unstable COPD with recent extra solution very very low Fe even or six minute walk test hypoxia presence of triggered paracetal emphysemas large Boolean adjacent row and coexisting for pathologies like fibrosis and malignancy so this is a very important slide if you consider your patient for Advanced Therapy you must know that what are the indication and what are the contraindication what are the options in terms of bronchoscopies what we can do in our operation so there are walls available there are plugs coils bio lvr or you know glue therapies to obstruct these lungs there are Airway bypass and thermal ablation so so this this is probably the most uh you know ancient uh timed therapy which is available and unfortunately it is still not available in India there are two types of walls therefore wall and intra-bronchial wall they have different design but does almost the same function so how does it work so basically you put this wall into the most effective part of your lung it open now and creates a one-way ventilation by which it you know collapse the lung which is affected let's say upper Loop and the other lung get the space so that it can expand and physiologically does most of the work so that is how it works that because these are a one-way wall the problem here is that it is not you are not able to clear this secretions of the patient often patients get infection and pneumonia by doing so you can the the same concept apply here but the drainage and the you know clearance is much better with with intra bronchial wall as compared to differ wall again a balloon is inflated to see whether the collateral ventilation is there or not and then through bronchoscope it can disclose these multiple walls in the Airways which provides one-way ventilation and good secretion clearance for the lung and it again collapses the lung so this you can see in the video also that the secretion clearance is much better as compared to zipper walls and by doing so again it causes the same on the same principle it decreases the affected lungs volume so in a way it is also a lung volume reduction without surgery or by bronchoscopy we are doing lung volume production therapy all right so benefit of walls are again selecting more frequent in patients who has heterogeneous emphysema who developed anatomical uh atelectasis lower bronchial occlusion and do not guarantee electricity in all patients greater response to the treatment I've seen in patients who have greater heterogeneity of emphasis without their lungs and complete fissure on the city evaluation so if application has a incomplete tissue then there is a collateral ventilation so the lung will not deflate even if you put in a wall there this is again a shortcoming of these balls because that time this evaluation was not done in all the patients that whether the fissure is complete or not but later on it has been you know it has been realized that looking into the fissure is again very very important when we are blocking any part of the lung to that there should not be not many uh collateral ventilation so how to check for this or how to look for Collective ventilation so there is a charity system which is available which can be you can do it with the help of your city that the patient has clear complete fissure here but this facial doubtful whether it is complete or not so sometimes it is very very difficult to Define on the basis of your CT whether you have a complete fissure or not so there is a static system what it does it basically inflate a balloon and block around and try to see that how much air is coming out because no air is going in if over a period of time the size is decreasing or the air flow is decreasing that suggests that there is no collateral ventilation and these are the patients who are the candidate for bronchoscopic lung production approach so this is a unilateral occlusion with intra-bronchial wall in the patient with heterogeneous and plasma significant number of patients were not the right candidates when when the static system was applied before uh endobronchial valve or the placement it has been released 50 percent of these patients are not the right candidate for wall due to Collective conditions what can be done for these patients so the New Concept can that you put in a methanol wire and collapsed at now so how do you collect that link this is a collapsible spring which can be uh you know deployed with the help of a capital and when when you retract the garden this is a real-time uh see you can see that this this clip just coils and it retracts the lung and it decreases the size of the lungs the only problem here is sometimes it cause pneumothorax but it is again to the tune of 15 percent but there is no need of checking for a collateral ventilation because you are not relying on the flow of air to block but rather than you can structurally collapse in the lab so that is the benefit of these coils over uh ball this is probably the the most important and most talked about technique and now it is available in India also bronchoscopic thermal people are admination very very simple technique what they are doing they are looking into your lungs the CT goes to U.S they decide that which part of the lung needs to be they have no obliterated then they produce a vapor induced inflammatory reaction with subsequent fiber so there is no sudden collapse of the lungs like we are doing with the help of our spring towards the wires there are no walls which you are relying on uh collateral ventilation so it basically works on simple thermal Vapor technique you inflate a balloon and a calculated amount of steam is infused into the affected part of lung which causes inflammation and subsequent fibrosy so the effects are not immediate it takes at least 8 to 12 weeks for this lung volume reduction and by that time patient has some symptoms in terms of inflammation increase exercise food and production or sometimes pneumonia but this is probably the most promising technique so far with minimal Invasion to our patients so so all these therapies so no therapy still now have any a little bit outside of it and that is true for all these therapies there are chances of exacerbation ball movement pneumothorax hemostasis but the death is very very very very rare right so this is again very very important that all these patients should be selected very very carefully to decide that who is who gets the maximum benefit out of it so by doing so what we are doing we are physiologically decreasing the affected part of the lung and providing good lung to breathe better putting our diaphragm in a condition that it can also support the lung in terms of breathing so does it also decrease exacerbation so exacerbation decrement is not that significant that has been seen in different trial and meta-analysis but yes overall quality of life the perception of brightness is the lung function improves better so what do we consider when these therapies are not working these are the patients for long term one and lung transplant has also uh you know available in India nowadays so you again need to understand this slide very well that you are the patient in COPD we all know that ild patients we start thinking about lung patient but still in the world the most common cause of lung transplant is COPD not ild the patient who has Progressive disease not a candidate for endoscopic or surgical lung volume surgery patient who has board index of five to six pco2 more than 50 or tier 2 less than 6C and actually even less than 25 percent predicted these are the patients who should be referred for lung transplant when you refer these lung transplant patients for lung transplant there is a criteria for listing so one of these criteria are board index more than seven fe1 15 to 20 percent three or more severe Transportation per year and once you get accessible acute hypoxic related layer of patient who has moderator this slide is again very very important as far as the lung transplant is function so there are some new therapies which are in the research and not available [Music] it has been seen that the patient who has COPD the paracetic activity is very very high indication and acetylcholine regulates Airways bone muscle tone and secretion so somehow if we can control this then we can you know block this smooth muscle exacerbations or constriction and mucous regression so pharmacologically we are blocking it with the help of masculinic receptor but if you can do it by Dena version it is again a very good idea so parasympatic deal of nerve disruption with interactable bronchial asthma has been reported to improve vital capacity and decrease food abduction that has been tried with this through bronchoscope there is a balloon which has this current which is very very sub-optimal and it only affects your submucosa where the maximum parasympratic activity is there so just create a kind of block in circumferential fashion so that this parasynthetic denotation occurs and patients should have less smooth muscle tone leading to less bronchoculation as well as lessons mucus production so so this can be done in different sitting to both the lungs by doing so we can decrease the sputum production as well as acute exacerbation or acute bronchoconstriction in the equation still it is an investigation therapy and the data is looking very very prompt so this is the long term safety 50 50 of the lung Innovation technique that has been evaluated and it has been found that it is very very safe in terms of freedom from bursting of COPD was seen in hundred percent so this therapy has this this role that patients the basic problem with any other therapy that it might create a submission which is not there with this Dena version so that is the add-on point there is this liquid nitrogen metered crisis so what it has it basically has a radial spray catheter which spray liquid nitrogen which is at the temperature of minus 196 degree Celsius in a circumferential pattern so what it does it freezes the the subnipus of the airway and causes rapid uh non-inflammatory response leading to the epithelial damage and when the new epithelial cells appears they have less uh you know they have less goblet cells and less secretion and less muscles and little more fibrosis so this regrowth of healthy cells with pure goblet cells and low scarring leads to less production and less exacerbation this therapy has already been granted as a c Mark approval in Europe but still under evaluation safety feasibility and proof of foreign there are short bursts of electric energy which is applied to entire accessible air drain because in two separate treatments this is more and less like bronchial thermoplasty for COPD patients and when this damage the epithelial cells regrowth this leads to reduction in low blood cells so there is less mucous reduction and less bronchitis exacerbation in this patient again in the research but again very very promising therapy and this is the late breaking acid which was uh presented in ERS in 2018 which shows that safety and feasibility of bronchial rioplasty in chronic bronchitis patients is very very good but there are for the studies which are required for further uh you know application of this therapy in clinical practice so it has already received the FDA breakthrough device designation for minimal invasive Xerox system for chronic bronchitis but still under resource so so this this is the charge which suggests the therapy for patients whom you believe that your pharmacological and non-pharmacological therapy is not working these are comes into the category of advanced upd management which includes lung surgery and bronchoscopic lung volume reduction if you feel that patient is not a candidate for these probably operation is best suited for lung transplant thank you very much for your patient listening if you have any question I'll be very very happy to thank you all for your patience uh we would take up the questions from the app now so all our audience members if you could just type up your questions in the comment section you would get it answered from Sir so uh we have a few questions already in there so you talked about the walls so Dr Rajesh succeed I would like to ask what is the cost of those two valves so the only problem is that these walls are still not available in India and outside India every wall was somewhere around two thousand dollars per dollar you need to put at least three to four or five walls in each fitting two operations so this is uh so this is as per U.S terms but whenever these therapies come to India the cost significantly goes down still they are trying to you know take up this therapy in India which is still not available for our tubidation okay that's great uh Dr Mohammad has the next question uh how about the oxygen therapy in COPD absolutely I think so I have not touched upon this part because this is not right Advanced healthy it is a very well established therapy in pubd patient who has hypoxia with the po2 less than 55 or your saturation less than 88 a patient who has signs and symptoms of core pulmonary or LT or OT is the only therapy that has shown mortality benefit but you should not or you should not over give overdose of oxygen therapy to your patient because sometimes it is counter productive okay thank you so much uh next question is sir what's the exact meaning of homozygous and heterozygous emphysema can you please elaborate a bit so I think this is very very important so homogeneous means that the M5 symmetic changes in your city or your lungs is present everywhere so like patient has paracetime price if it is present everywhere then it is called homogeneous but there is a subset of patient who has heterogeneous emphysema means that some part of the lobe is affected some part of the lung is affected most commonly if it is upper low back most of the time and fights you must start from upper Loop so if the patient has predominantly upper lobe and plasma the other part of the lungs are preserved then bronchoscopic lung volume reduction surgeries are done in such patients because you need to just decrease the size of affected particulum so if it is homogeneous probably you are not able to decide that which part of the land the large part of the lens you want to treat so that is the difference between homogeneous and heterogeneous most of these therapies are still available for homogeneous emphysema not for heterogeneous answered your question the next question is what would be the role of prophylactic antibiotic therapy so I talked about this prophylactic and azithromycin therapy in patients who have chronic bronchitis or frequent exacerbation the only concern is that that it has long term antibiotic has two problems one if you are giving azithromycin to your patient then it tells you that he might get resistance to this one and second is the side effect profile in terms of create toxicity and QT prolongation so if you feel that your patient is a candidate for the kind of therapy your patient needs strict monitoring along with this therapy but it has good results in selective okay and what would be the dose of Azithromycin so yes so there are two School of 13 days one state that you give 250 milligrams of Azithromycin every day now this is you can give this 500 milligrams of Azithromycin twice weekly both of them work equally well but it is again the patient for the doctor strike what I personally believe that giving 250 milligram every day is a better uh patient shows better compliance otherwise it keeps on forgetting that which day patient has to take care of and this day it is not so the the as far as if you start therapy my personal preference is 250 milligrams per day but people use 500 milligrams twice a week also okay that's great I hope Dr Iqbal that answered your question um is uh does vaccination play any role again a question okay absolutely so to role of a role and importance of vaccination we have seen in postcode era that vaccines has a huge impact in the overall quality of life as well as decreasing the mortality because it indirectly decreases the chances of infection in you chances of hospitalization chances of IC visit and translucent mortality so although there is no great uh direct impact that you see in the research but definitely if your patient has frequent extra solution in which you can cut down even 70 percent of their exacerbation it makes a huge impact in the overall quality of life a Health Resources and health burden and the mortality organization all right great next question is by Dr Baba Irfan can doxycycline be given instead of Azithromycin so that trial has been seen But the results are still not being a bad promising in terms of toxicity although in terms of atypical coverage both doxycycline and azithromycin works very well but as far as this COPD extra submission prophylactic therapy concerned the doctor cycling has not been considered okay uh wait I think those were the questions so I would give the audience a few more minutes to type out the question uh so next question is what would be the role of NSAIDs and steroids initially it was shown that patient who has high respiratory rate and chips can decrease this aspective but as far as the therapies or the evidence concerned there is no role of attitudes for the management of the OBD process order Dr Iqbal again says that there's much confusion in the schedule of pneumococcal vaccine so yes vaccine initially why there is a conclusion I will tell you that initially CDC comes up with a sequential vaccination that you need to give prevnar first and then give pneumovac vaccines but later on they have realized that since the mask coverage has been done in pediatric population with pedia with this uh vaccine there is an uh you know hard immunity which has already been covered so now what they recommend that you can give single pneumovac 23 vaccination to your patients if your patient is less than uh 65 year of a and has this COPD or any comorbidity it has to be given at an interval of five years if your patient is more than 65 year of age it has to be given only one the other vaccine is influenza vaccine that has to be given every year because every year new chain comes from the vacuum okay right uh next question is can you explain the dode index the board index is a index in which people try to understand that how much your patient can perform so there are questions in this five questions are there on the basis of this you decide that what are the overall you know capacity of your occupation in terms of breathlessness perception of breathlessness all these things has to be considered together and these are very very freely available on the net so when we are doing these six minute walk test we always ask for the board index to to see the perception of your operation regarding breathlessness and the parameters that is getting changed so board index is a very very important research index whenever you are looking for any kind of breathlessness or respiratory disease the free and the treatment output okay all right I have that answered your question uh other than this we have many positive like Dr joginder Sharma says excellent guidance Dr ravindra saxena says wonderful session and uh bhavi Kumar John thanks for answering his question and many more such that the session was very good then they've understood excellent guidance excellent presentations so yes I think those were the questions for today so I would like to thank you on behalf of Netflix thank you so much for joining us uh you've been here uh like this is your third or fourth session and we are really really happy and honored to have you that you are taking out time from your schedule for us and our doctors so thank you so much and for our audience uh thank you for joining in thank you so much thank you very much everyone


Chronic obstructive pulmonary disease (COPD) has been better managed with current therapies, but novel therapeutic strategies are still urgently needed, especially to slow the illness's progression and mortality.  There is no denying that the use of non-pharmacological measures, such as pulmonary rehabilitation and noninvasive ventilation, and the introduction of more potent medicines have significantly improved the management of COPD. Watch Dr. Rahul Sharma, Additional Director, Pulmonology, Fortis Hospital, Noida, as he discusses the most recent developments in the treatment of COPD.


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