67 year old Mr.Ram Neupane was a teacher by profession. He retired 7 years back and has been living under government pension. He struggles with an everyday shortness of breath and cough. He has been having the same for last 10 years duration but he has been told by his friends that this was “age related”. Finally when the shortness of breath was too much to bear, he came to the hospital. It became clear that he had been a heavy smoker in the past, smoking 20 cigarettes per day for last 25 years and had left smoking 2 years back. He did not realize the link between his shortness of breath and smoking.
63 year old Mrs.Kopila Thapa has been a housewife in a small village near Dhankuta. She has been cooking with firewood her entire life but does not smoke and drink. She has been having shortness of breath for last 5 years duration and finally consulted after it interfered with her daily routine. She presumed that her shortness of breath was also “age related” and that she was unlikely to have a lung disease as she had never smoked.
These two characters are representative of many in Nepal out there today who have been silently bearing the increasing morbidity of lung related disease. Such is the apathy to the lung problems that first, they are not recognized at all, and secondly, even if recognized are hardly taken seriously.
What both these people in fact have is a disease called Chronic Obstructive Pulmonary Disease. As the name suggests Chronic means it won’t go away, Obstructive means partly blocked, Pulmonary means in the lungs and Disease means sickness.
WHO data shows that More than 3 million people died of COPD in 2012, which is equal to 6% of all deaths globally that year.More than 90% of COPD deaths occur in low- and middle-income countries.
It is not simply an age related decline, it is much more. It is not a “smoker’s cough” it is way much more. Chronic obstructive pulmonary disease (COPD) kills on average one person every 10 seconds. COPD is projected to have the fifth leading burden of disease worldwide by the year 2020. It is one of the leading causes of disability worldwide and is the only disease for which the prevalence and mortality rates continue to rise.
Although it has been difficult to estimate the costs associated with COPD, they include direct costs relating to outpatient and inpatient care expenses, the indirect costs resulting from the loss of productivity caused by premature disability and death, and the additional cost of disability. In the U.S., hospitalization accounts for the bulk of all COPD-related health costs. In 2007, direct health costs of COPD were $23.6 billion, and the overall cost burden was estimated at more than $42 billion. By hospital estimates in BPKIHS, 30% of medical admissions in patient aged more than 60 years is COPD related.
The tragedy of this apathy lies in the fact that COPD is preventable if not treatable and even quality of life of the likes of Mr.Ram Neupane and Mrs.Kopila Thapa can be improved with the current medications.
Tobacco smoking and Household air pollution
COPD is primarily a disease of the tobacco smokers where the cumulative damage because of smoke slowly goes on to damage the lungs. Around 90% of patients with COPD are smokers. Interestingly, its not only active smokers who get COPD but even passive smokers (those who do not smoke but are exposed to environmental tobacco smoke) and those who used to smoke in the past and have quit now. Even passive smokers are 3-4 times more likely to develop COPD than those not exposed to environmental tobacco smoke.
However a sizable populace of COPD in Nepal comprises of exposure to household air pollution. Whereas the link to Smoking is always explored, more often than not, Mrs.Kopila’s shortness of breath would have been attributed to “age”. It is very important in this context to realize the harmful effects of smoke and indoor air pollution as a result of cooking and heating their homes using open fires and simple stoves burning biomass (wood, animal dung and crop waste) and coal. The exposure to this biomass has been linked to myriad of diseases ranging from childhood pneumonia due to soot extending to heart attacks, COPD and lung cancer. Over one third of premature deaths from chronic obstructive pulmonary disease (COPD) in adults in low- and middle-income countries are due to exposure to household air pollution. Women exposed to high levels of indoor smoke are 2.3 times as likely to suffer from COPD than women who use cleaner fuels. Among men (who already have a heightened risk of COPD due to their higher rates of smoking), exposure to indoor smoke nearly doubles (i.e. 1.9) that risk.
Do I have COPD?
COPD is not infective, meaning that you do not get COPD from someone else. It’s a disease of one’s own making in most cases. It is also a disease of adulthood with most cases occurring after the age of 40 years on a suitable background of smoking or biomass fuel exposure. COPD should be considered in a person over the age of 40 who have a risk factor (generally smoking) and who present with one or more of the following symptoms shortness of breath, chronic cough, regular sputum production, frequent winter ‘bronchitis’ and noisy breathing. If a person has three of the symptoms listed before then a visit to a doctor is warranted. The diagnosis of COPD is based on a test called Spirometry where a person has to actively breathe into a hand held turbine, the result of which is available then and there.
The sudden worsening of the respiratory symptoms in a patient of COPD is Lung Attack. Lung attacks may not be as well-known as heart attacks but they are no less dangerous. About 5 to 20 per cent of people who have a lung attack die within a year after being hospitalized for it. This is similar to the proportion of patients dying after being hospitalized for a heart attack. An attack is often triggered by a chest infection, common cold or other infections of the respiratory tract, though it can also happen for no apparent reason. Unfortunately, an attack is often mistaken for being an acute infection, rather than a flare-up of a progressive lung condition. Once a person has a lung attack, his risk of having another increases by 2.5 times. The alarming fact about lung attacks is that they are not merely symptoms being exhibited. Each time they occur, they cause the patient’s lung function to deteriorate, often irreversibly, increasing his risk of hospitalization and death. Delaying the treatment of COPD and lung attacks has contributed to rising numbers of hospital admissions and early deaths in the United States and Europe.
Individual approach to management
Stop smoking. It is the most important thing one can do to help their lungs. It is never too late to stop smoking. By quitting, the speed at which the lung function is deteriorating can significantly slow down and improve quality of life. For those exposed to biomass fuel, the use of alternative sources of fuel is necessary. If not possible, at least proper ventilation of the fumes is a must.
The symptoms of the disease can also be controlled by medicine which comes in many forms such as inhalers, pills and syrup. However, the mainstay is inhalers and there is much confusion and misunderstanding about its use among general people. It is necessary that the techniques of using these inhalers be taught to the patients by trained physicians and nurses. Vaccination has also been recommended where patients with COPD are given vaccines (just like childhood vaccines) in the expectation that these will prevent “lung attacks”. An emerging concept in the management is exercise often called “pulmonary rehabilitation”. The essence of these exercises is to selectively strengthen muscles which are used in respiration and the results have been very encouraging with improvement in quality of life. Even yoga exercises focusing on breathing techniques have been found to be helpful.
Once the disease is not controlled by these measures, it becomes very troublesome with patients requiring 24 hour oxygen support.
Perhaps the most important challenge is lack of awareness of the disease as a whole, leading to lag time in years before hospital consultation as in the case of Kopila and Ram. This lag time leads to delay in intervention and thus lost “lung years”. Even in cases that are diagnosed, almost 90% do not have a spirometry. This can be due to lack of availability, something the government should be looking into, or lack of awareness that spirometry is a must to categorize treatment and tell patient prognosis. There is also much variation in standard of treatment even in established tertiary care centers and a dire need to standardize the treatment as per recommendations.
At the government level, different initiatives have to be taken to discourage tobacco smoking in all forms with strict regulations. Display of health warnings on cigarette packets is a welcome initiative, however, more strict actions need to be taken such as increase in taxes on cigarettes and laws to strictly enforce ban on smoking on public spaces to decrease environmental tobacco smoke exposure. Incentives have to be in place to convert the general people from using biomass to other fuel sources. Similarly since it is a chronic disease with huge financial burdens on the family, financial support is cash and kind is needed for these patients similar to government funded program for chronic kidney disease, heart disease and cancers. By rough estimates, monthly therapy in the end stages cost Rs.2000 for the medicines and if oxygen is added, it costs around Rs.1000 for a cylinder of oxygen which lasts 2 days for a patient. This kind of cost is impossible to bear for general countryman and thus a strong lobby should be made to advocate for the right to “lung health”.
COPD cannot be swept under the carpet. It’s already an epidemic and earlier we brace for the social and financial challenges that will come with this the better. This article is to stimulate everyone in the health care system—administrators, physicians, and patients—to become more aware of the huge human and economic burden of COPD and to act now.
About the author:
Dr. Deebya Raj Mishra
DM trainee – Pulmonology, Critical Care and Sleep Medicine
Assistant Professor – Internal Medicine
B P Koirala Institute of Health Sciences (www.bpkihs.edu)
Cell no. 00977-9851134760