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Video transcript

and talking about treating emphysema I think the most important thing the first thing to talk about is to stop smoking and if all the therapies this is the only one that will stop the disease from getting any worse since smoking and cause emphysema it's like the first way to get out of the hole is to stop digging it any further right so stop smoking that's the first one now in terms of drug therapies they can't reverse what's already been done but it can help with the symptoms and I think it's important to divide it between chronic therapies and acute so chronic is what a patient would take every day to maintain their status but acute is when once in a while emphysema can have exacerbations you get a whole lot sicker really quickly and we use a different combination of drugs to get them through that acute disease an important first class of drugs in the chronic maintenance maintenance therapy I think are the bronchodilators so Branko which refers to the airways and dilator just refers to the fact that these drugs get your Airways to open up like a tube that becomes bigger in diameter so if this is our airway tree like this branching branching off if I take a cut right here so that we can look across this tube it will look something like this so you have the outside and you have the lumen which just means the inside where the air goes through and in here in the walls of the airway it's actually full of smooth muscle so smooth muscle are not skeletal muscles we can't control it with our mind but a whole combination of things in the body like the nervous system and other conditions affect how tightly wound this muscle is so smooth muscle and the way that I've drawn it here is actually pretty tightly wound so look at how small this lumen is becoming as the muscle tightens the muscles contract this way to squeeze down on that lumen now the bronchodilators can open up that airway now the lumen will dry it is this big because the muscles around it have relaxed a little bit it's not so tightly wound anymore you see how much room this gives us in the middle that will allow a lot more air through then this little lumen back here the bronchodilator is actually an umbrella term it includes several masses of drugs but all of them share the effect of opening of that airway now the first class of bronchodilators I want to mention are the beta-2 agonists so they stimulate the beta 2 receptors now beta 2 receptors are part of the sympathetic nervous system this is the fight-or-flight response and as part of it it wants to open up your lungs a little bit so stimulating the beta 2 receptors will do just that now one drug you might have heard of in this class would be albuterol and actually the drugs in this class I'll end with something rol it's a easy way to recognize them just from the names that can make no sense in English now the second class of drugs would be the anticholinergic s-- which are so anti so there are antagonists which means it turns off the receptor this involves different receptors on the airwaves but the effect is the same in these drugs their names often end in opium and as something to do with the drug opium it's just a coincidence like that okay so brach or later is open up the airway but one of the reasons that they are constricted in the first place is because there's too much inflammation in the next class I want to talk about are the leuco trying inhibitors and again what are these words they mean nothing in English now leukotriene is something important player in the Cascade that leads to inflammation so for example in the Cascade if we have a leading to be leading to C leading to D and so on eventually at least your leukotrienes which here I'll just write LT for the co trying so this is the goal of the information cascade we want to get here to cause inflammation which includes restricting the airway and other things so obviously by inhibiting leukotrienes we toned down and Liam implant inflammation so it gets rid of some of the mucus and the constriction in our lungs that were fighting the first place now especially in emphysema toning down the inflammation is a big deal because inflammation is how we get so much neutrophils in our last days so turning down the inflammation by eating some of the local training helps the disease from getting worse as quickly now a lot of emphysema patients can take these chronic medications every day but unfortunately sometimes they can still develop an exacerbation or a flare where the compensation system that have in place is not working all of a sudden and to get much sicker really quickly so our goal here is short-term get them back to their baseline and one of the first things we give them our antibiotics antibiotics now sometimes when they come to the hospital they already have an infection but if they don't we still give them antibiotics for prophylaxis which which means that disease hasn't happened yet we're giving it to prevent it prevention just in case because when they're having an exacerbation the ability to deal with the infection goes down it's a general rule in the body any time you have blockage or things not moving the way they should there can be infection behind it because our body is constantly clearing things out of our system so in the massima for example if you have these dilated Airways these walls and the air is trapped back here an exacerbation that gets even worse so imagine all these collapsed Airways now all the things moving out are not moving are not working gradient Azima to begin with and now they're even worse so we have a dramatic increase in the possibility of having infections so they're coming there's bacteria in the lungs all the time and the lungs try to clear them but now we're spinning out of control in this flare and the usual system to clear these bacteria is not working well so we give them antibiotics just because I have a pneumonia or some other infection on top of everything right now that would be horrible so we want to do everything we can to prevent that so antibiotics the next thing in terms of inflammation we got to give them a huge dose of something got to pull out the big guns here so we want to give them some steroids steroids are the universal tampering down the inflammation big guns so if we have our cast aid again a leading to B to C to D eventually to leukotrienes steroids work much earlier in the Cascade let's say it works in step C we usually give them a pretty big dose and the Cascade stops right here now that's good for preventing inflammation but since this is a cascade and it's connected so D is also not working all the other things that branch off of C and D the other arms of the immune system which inflammation is part of our also not working so with all these things out of commission yes our inflammation goes down that's our goal at the same time it also takes down the immune system so their immune compromised during their steroids treatment so immune system down this makes the antibiotics even more necessary but also this is what we try to not give people steroids for a long long time this is like an emergency save of our cars running down to hell we need to stop it first then we can think about how to get back on track so that's steroids and another thing so this person can't breathe they're having trouble getting air in and out come to the hospital you might seem kind of logical to put them on oxygen right in the hospital we put oxygen on people at the job if I had any time to have breathing problems but I'm going to put a question right here by oxygen because this is actually kind of tricky in emphysema patients to explain that let's talk about the respiratory drive respiratory drive is a combination of mechanisms in the body that make you breathe you notice that you don't have to think about breathing all day long that's because between your brain and the nervous system your lungs there's a system in place to make you breathe now usually let's say you're supposed to have this much oxygen this is o2 and you're only supposed to have this much carbon dioxide so when you breathe however dioxide is going out it's going out and oxygen is what you want to take in now usually the body is very sensitive to these levels exactly where each one is and usually the brain is programmed in such a way that if our co2 goes up this is what stimulates us to breathe so our respiratory center is more centred on extra having extra co2 but now emphysema obstructive disease right so we always have too much co2 and since that's chronic the body is smart it learns after a while that this patient is just going to have a little more co2 than usual look at this new dotted line that's that's our new normal we also have a little bit less of oxygen because their lungs are so inflated it's hard to take in more air so this is our new Oh too these are new co2 now since our co2 is always above that line leaving us to breathe the body's like okay I get it I'm going to change my signal so in emphysema patients the lack of oxygen here at this level is actually what drives them to breathe so the respiratory drive has shifted from co2 driven 2:02 driven they need to constantly be reminded that they lack oxygen to breathe okay so in our patient with an o2 heavy respiratory drive if you give them oxygen what happens that oxygen goes up and we'll lose our respiratory drive so ironically giving them oxygen can decrease the drive to breathe and that's the last thing you want in somebody who's having an emergency with breathing also the body chemistry and pH it's all used to having a little more co2 than usual so suddenly giving them oxygen can actually knock this system off balance so has to be given with caution if somebody's given oxygen their breathing has to be monitored making sure that they're still breathing and really if they really lose that respiratory drive there are machines with masks that can take over that drive and make sure that people breathe so this is a quick overview of some of the drugs that we use to treat emphysema whether it be everyday or acutely but most of all they have to stop smoking if they if smokings will cause the emphysema stop now before it gets worse and if they got in fátima through another way then definitely stop smoking to reduce the number of flares they have and to lessen the burden on the lungs and to stop digging further in this hole