Chronic Obstructive Pulmonary Disease In India Research Articles

Rational inhalation therapy in COPD in India: Hope or hype!

Chronic obstructive pulmonary disease (COPD) is common chronic lung disease usually treated in all health care settings as per knowledge of disease, availability of medicines and affordability of patients in India. COPD is second leading cause of death in list of all cause of mortality. COPD is under evaluated and half-heartedly treated with irrational oral medicines in spite of rational inhalation therapy in primary to tertiary care settings. More than half of the cases died due to cardiovascular causes are having underlying COPD as precipitating factor. More disease awareness regarding use of spirometry in health care professionals for proper diagnosis of COPD with more emphasis on rational inhalation treatment is must to prevent morbidity of mortality of this treatable disease.

Prevalence of chronic obstructive pulmonary disease in India: A systematic review and meta-analysis.

Background and Objective:The prevalence of chronic obstructive pulmonary disease (COPD) is increasing worldwide. There is a lack of national-level estimates on the magnitude of COPD in India. Hence, we estimated the prevalence of COPD among adults in India.Methods:We searched PubMed, Embase, Cochrane Library, Google Scholar, and Scopus and included community-based cross-sectional studies reporting data on the prevalence of COPD among adults based on spirometry. A random-effects model was used to estimate the pooled prevalence of COPD.Results:In the eight identified studies, (pooled sample of 8,569 individuals), the estimated prevalence was 7.4% (95% confidence interval: 5.0%–9.8%), I2 = 95.4% (P < 0.001). The prevalence was higher among males, in the urban area, and the northern region.Conclusion:Adequate training and resources should be provided to diagnose COPD at primary health care level for early management. A nationwide population-based survey is indicated to provide reliable estimates of the burden to inform evidence-based community-based interventions.

Baseline Vitamin D as a Predictor of Mortality among Hospitalized Patients with Acute Exacerbations of Chronic Obstructive Pulmonary Disease in an Endemically Vitamin D-Deficient Area in North India

Background: Conflicting data suggest that Vitamin D reduces the risk of developing chronic obstructive pulmonary disease (COPD) and COPD exacerbations. Scant data are available regarding the Vitamin D status in patients with COPD in India where Vitamin D deficiency is rampant. Objectives: We set out to study the role of baseline Vitamin D on the outcome of acute exacerbation of COPD (AECOPD) in terms of exacerbations, hospitalizations, and mortality. Materials and Methods: In a prospective observational design, 147 consenting participants with AECOPD were recruited and serum Vitamin D assessed at admission. The patients were followed for 3 months for treatment outcomes in terms of mortality, readmissions and exacerbations. Standard statistical methods were used to compare the results among those with sufficient and insufficient Vitamin D status at baseline. Results: Out of 147 completely followed participants, 113 (76.9%) were deficient in Vitamin D (mean ± standard deviation = 11.79 ± 8.5 [normal 30–100 ng/ml]). Patients with low Vitamin D were found to have a significantly higher 90-day mortality than those with normal Vitamin D status (P = 0.42; hazard ratio 4.8, P = 0.032). No statistically significant differences were observed in rates of exacerbations or hospital admission. Conclusion: Patients of AECOPD having baseline Vitamin D deficiency at admission have a higher mortality than those with normal Vitamin D level. Thus, Vitamin D level can serve as a prognostic indicator of the outcome of AECOPD. Larger studies are suggested to further study the association and also determine any role of Vitamin D in the treatment of such cases.

The first state-level public health program for obstructive airway disease in India: An early field-level evaluation.

Background:Chronic obstructive pulmonary disease (COPD) is the second leading cause of mortality in India; however, there are no programs for COPD in India at primary care level. Kerala became the first state in India to implement a program at primary care for COPD, called the Step Wise Approach to Airway Syndrome program.Objective:The objective of the study was to evaluate and document the implementation status of a program for obstructive airway disease (OAD) in Trivandrum district of Kerala state in India and compare the treatment characteristics of patients with OAD seeking care from the centers implementing and not implementing this program for OADs.Methods:A cross-sectional study was done as early evaluation of a program for OAD implemented in Kerala state, India, from October 2018 to February 2019.Results:A reflection of the health-seeking behavior due to better facilities at the FHCs. There was no difference in the hospital visits or emergency department visits between the two groups. However, there was a statistically significant difference in the average number of visits per patient to health center for taking injectable drugs and visits for nebulization. Forty-nine (94%) of the COPD and 36 (100%) of the asthma patients underwent spirometry from implementing center itself. A higher proportion of patients receiving care from implementing centers (30.9%) never had to buy inhalers from outside.Conclusion:This is the first time that a public health programme for chronic respiratory disease management at primary care level was evaluated in India. The study has provided valuable insights on the need for strengthening the training for health care providers as well as patient education in bringing about a change in patient attitudes.

The burden of chronic respiratory diseases and their heterogeneity across the states of India: the Global Burden of Disease Study 1990-2016.

SummaryBackgroundIndia has 18% of the global population and an increasing burden of chronic respiratory diseases. However, a systematic understanding of the distribution of chronic respiratory diseases and their trends over time is not readily available for all of the states of India. Our aim was to report the trends in the burden of chronic respiratory diseases and the heterogeneity in their distribution in all states of India between 1990 and 2016.MethodsUsing all accessible data from multiple sources, we estimated the prevalence of major chronic respiratory diseases and the deaths and disability-adjusted life-years (DALYs) caused by them for every state of India from 1990 to 2016 as part of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2016. We assessed heterogeneity in the burden of chronic obstructive pulmonary disease (COPD) and asthma across the states of India. The states were categorised into four groups based on their epidemiological transition level (ETL). ETL was defined as the ratio of DALYs from communicable diseases to those from non-communicable diseases and injuries combined, with a low ratio denoting high ETL and vice versa. We also assessed the contribution of risk factors to DALYs due to COPD. We compared the burden of chronic respiratory diseases in India against the global average in GBD 2016. We calculated 95% uncertainty intervals (UIs) for the point estimates.FindingsThe contribution of chronic respiratory diseases to the total DALYs in India increased from 4·5% (95% UI 4·0–4·9) in 1990 to 6·4% (5·8–7·0) in 2016. Of the total global DALYs due to chronic respiratory diseases in 2016, 32·0% occurred in India. COPD and asthma were responsible for 75·6% and 20·0% of the chronic respiratory disease DALYs, respectively, in India in 2016. The number of cases of COPD in India increased from 28·1 million (27·0–29·2) in 1990 to 55·3 million (53·1–57·6) in 2016, an increase in prevalence from 3·3% (3·1–3·4) to 4·2% (4·0–4·4). The age-standardised COPD prevalence and DALY rates in 2016 were highest in the less developed low ETL state group. There were 37·9 million (35·7–40·2) cases of asthma in India in 2016, with similar prevalence in the four ETL state groups, but the highest DALY rate was in the low ETL state group. The highest DALY rates for both COPD and asthma in 2016 were in the low ETL states of Rajasthan and Uttar Pradesh. The DALYs per case of COPD and asthma were 1·7 and 2·4 times higher in India than the global average in 2016, respectively; most states had higher rates compared with other locations worldwide at similar levels of Socio-demographic Index. Of the DALYs due to COPD in India in 2016, 53·7% (43·1–65·0) were attributable to air pollution, 25·4% (19·5–31·7) to tobacco use, and 16·5% (14·1–19·2) to occupational risks, making these the leading risk factors for COPD.InterpretationIndia has a disproportionately high burden of chronic respiratory diseases. The increasing contribution of these diseases to the overall disease burden across India and the high rate of health loss from them, especially in the less developed low ETL states, highlights the need for focused policy interventions to address this significant cause of disease burden in India.FundingBill & Melinda Gates Foundation; and Indian Council of Medical Research, Department of Health Research, Ministry of Health and Family Welfare, Government of India.

Assessment of heart rate variability in participants with chronic obstructive pulmonary disease

Background: Chronic obstructive pulmonary disease (COPD) is one of the main causes of morbidity and mortality worldwide. COPD kills half a million people in India every year, more than those who die due to tuberculosis, malaria, or Acquired immune deficiency syndrome, and 30 million people suffer with COPD in India.[1] The hypoxemia due to COPD might be associated with autonomic dysfunction which could be evaluated with heart rate variability (HRV). Aims and Objective: To determine the HRV in patients with COPD and to compare with normal individuals. Materials and Methods: This cross-sectional study was carried out in 30 COPD patients attending the Department of Pulmonology, SRM Medical College Hospital and Research Centre and 30 age and sex-matched healthy individuals as a control group. A detailed history from the participants, such as weight and height, was obtained, and HRV parameters such as mean RR, mean HR, successive normal sinus RR intervals >50 ms (NN50), the percentage of successive normal sinus RR intervals >50 ms (pNN50), root mean square of successive heartbeat interval differences (rMSSDs), high frequency (HF), low frequency (LF), and LF/HF were estimated using physio-pac instrument. Results: HRV parameters such as rMSSD, NN50, PNN50, LF, HF, and LF/HF ratio show significant differences between the COPD and control (P < 0.05), which indicates sympathovagal imbalance. Conclusion: HRV analysis shows that COPD participants have an autonomic imbalance suggestive of an increased sympathetic tone or decreased parasympathetic tone. Sympathetic overactivity may lead to cardiovascular disease development in patients with COPD.

Effectiveness of clinical pharmacist intervention on health-related quality of life in chronic obstructive pulmonary disorder patients - a randomized controlled study.

Chronic obstructive pulmonary disease (COPD), a preventable and treatable disease, has been described as '10% medication and 90% education'. Extreme physician scarcity limits the implementation of quality healthcare delivery in India. We conducted this study to evaluate the effectiveness of clinical pharmacist intervention on health-related quality of life (HRQoL) in patients with COPD in an Indian tertiary care hospital. An open-labelled randomized controlled study was conducted over a 3-year period, at Kasturba Medical College Hospital, Manipal, India, after obtaining institutional ethics clearance (IEC 88/2012). The study was registered with the Indian clinical trial registry (CTRI/2014/08/004848). Patients were randomly assigned to two groups (intervention group [IG] and control group [CG]) by envelope method. St. George's Respiratory Questionnaire (SGRQ) was used to assess the HRQoL. The pharmacist intervention laid emphasis on (i) importance of medication compliance, (ii) need for smoking cessation, (iii) simple exercise, (iv) proper use of inhaler devices and (v) need for timely follow-up by pulmonary medicine department. SGRQ assessment was repeated at 6, 12, 18 and 24 months. Of 328 patients with COPD screened during the study period (March 2012 to June 2013), 260 (79%) were recruited. Of these, 202 (78%) patients completed follow-up (98 in CG and 104 in IG). Both groups were matched for baseline, sociodemographics and clinical characteristics. SGRQ scores and its subscales (symptoms, activity and impact) improved significantly after the pharmacist intervention in IG at follow-up (P < 0·001). Our randomized controlled study shows that pharmacist intervention improved the HRQoL of patients with COPD in India. The generalizability of our results requires exploration even within other settings in India. Nonetheless, our results provide support for a greater involvement of pharmacists in the care of patients with COPD.

A disintegrin and metalloprotease 33 polymorphism association with COPD in long-term tobacco smokers of the ethnic Kashmiri population of India

Background:Chronic obstructive pulmonary disease (COPD) is characterized by an interaction of various environmental influences especially cigarette smoking and genetic determinants. The prevalence of this disease is ever increasing and characterization of the genetic determinants of the disease has been undertaken globally. The ‘A disintegrin and metalloprotease 33’ (ADAM 33) gene is one candidate gene that has been studied.Objective:Our objective was to investigate whether single nucleotide polymorphisms in ADAM33 gene are associated with COPD in long-term tobacco smokers in the ethnic Kashmiri population of northern India.Materials and Methods:This was a randomized case-control study, which included 78 stable COPD (GOLD stage11-IV) patients, who were compared with 77 age- and sex-matched long-term tobacco smokers (>20 pack years) without any evidence of COPD. Polymorphic analysis for three single nucleotide polymorphisms (SNPs), (T1, T2, and Q1) of the ADAM33 gene was done by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) followed by sequencing. The data were analyzed by descriptive statistics and comparative evaluation was done by parametric/non-parametric tests.Results:The analysis of the T1, T2, and Q1 SNPs, revealed that the frequencies of the T2GG, T1GG, and the Q1AG genotypes were significantly higher in patients with COPD in comparison with the controls (P < 0.001). Similarly, the T1G and T2G allele frequency was higher in the patients than in the controls (p = 0.177 and 0.43, respectively).Conclusion:Three SNPs of the ADAM33 gene were significantly associated with COPD in the Kashmiri population of India. This study establishes the possible role of ADAM33 SNPS in the causation of COPD. Further studies across different geographical areas in the country will unravel the contribution of this gene in the causation of COPD in India.

Sputum Bacteriology and Antibiotic Sensitivity Pattern of Patients Having Acute Exacerbation of COPD in India – A Preliminary Study

Background: Chronic Obstructive Pulmonary Disease (COPD) is a common disease and equally affecting rural population. Majority of COPD exacerbations are infective and facilities of bacterial culture are not available at peripheral health institutions. Acute exacerbations can contribute to irreversible progression of disease. Objective: To find out the bacteria predominantly causing the AECOPD in our region, its relation with severity of the diseases and antibiotic most effective against these organisms. Material and Methods: Previously diagnosed patients presented with acute exacerbation were investigated for sputum characteristics, culture and drug sensitivity. Results: Culture was positive in 41 (82%) patients. Streptococcus pneumoniae (32%) was the most common pathogen isolated followed by Streptococcus pyogens (16%) and Pseudomonas (12%). Piperacillin+tazobactum was the most effective antibiotic against all organisms. Quinolones were less effective. Discussion: Sputum culture was positive in 82% of patients with AECOPD which was higher as compare to other studies. On the contrary positive growth in 97% of samples has also been found. This difference may be because of the fact that culture positivity depends on nature of sputum, time of collection sputum and previous antibiotic use. Conclusion: Streptococcus pneumoniae is still the most common pathogen in patients with AECOPD of this area. Piperacillin+tazobactum should be the first choice empirical antibiotic. Quinolones should be used cautiously in area where prevalence of tuberculosis is high. However more studies with larger population required which also includes bronchoscopic sampling along with sputum.

Prevalence of depression and its risk factors among patients with chronic obstructive pulmonary disease in a tertiary level hospital in West Bengal, India

In recent years, chronic obstructive pulmonary disease (COPD) has increased several folds in the developing coun-tries and the disease is accompanied with several co-morbidities among which depression is a major one. Still now there is a lack of data regarding the prevalence and risk factors of depression among the patients with COPD in In-dia. The aim of the study is to assess the prevalence of depression and associated risk factors in patients with COPD in Kolkata, India. In this cross-sectional study, 214 COPD patients were selected by purposive sampling at OPD of Pulmonary Medicine, RG Kar Medical College, Kolkata, India. The patients were diagnosed and grouped into dif-ferent stages of COPD by clinical examination and spirometry. A questionnaire was administered among the respon-dents to collect the data regarding their socio-demographic conditions followed by Patient Health Questionnaire 9 (PHQ-9) to measure the level of depression. The mean age of the respondents was 59.37±11.37 years and 99% were male. The proportion of depression among patients with COPD was 86%. Among the respondents, 36.9% had mod-erately severe depression, 32.2% had moderate depression and 6.1% had severe depression. The risk factors of de-pression among COPD patients were urban residence (OR=4.79, p=0.02), income group of 5000-9999 Rupees per month (OR=18, p=0.38), teetotalers (OR=8.36, p=0.02), Stage 2 COPD (OR= 83, p=0.001) and onset of COPD ?70 years of age (OR=20, p=0.02). The study showed that more than 8 out of 10 COPD patients and it can be considered very high proportion. The study highlight the importance of routine screening for depression of all COPD patients in all healthcare settings and implementation of effective strategies for proper prevention and management of depres-sion in those patients. DOI: http://dx.doi.org/10.3329/seajph.v2i2.15942 South East Asia J Public Health | Jul-Dec 2012 | Vol 2 Issue 2 | 34-40

Guidelines for diagnosis and management of chronic obstructive pulmonary disease: Joint ICS/NCCP (I) recommendations.

Chronic obstructive pulmonary disease (COPD) is a major public health problem in India. Although several International guidelines for diagnosis and management of COPD are available, yet there are lot of gaps in recognition and management of COPD in India due to vast differences in availability and affordability of healthcare facilities across the country. The Indian Chest Society (ICS) and the National College of Chest Physicians (NCCP) of India have joined hands to come out with these evidence-based guidelines to help the physicians at all levels of healthcare to diagnose and manage COPD in a scientific manner. Besides the International literature, the Indian studies were specifically analyzed to arrive at simple and practical recommendations. The evidence is presented under these five headings: (a) definitions, epidemiology, and disease burden; (b) disease assessment and diagnosis; (c) pharmacologic management of stable COPD; (d) management of acute exacerbations; and (e) nonpharmacologic and preventive measures. The modified grade system was used for classifying the quality of evidence as 1, 2, 3, or usual practice point (UPP). The strength of recommendation was graded as A or B depending upon the level of evidence.

Management of chronic obstructive pulmonary disease in India: a systematic review

ObjectivesChronic diseases are fast becoming the largest health burden in India. Despite this, their management in India has not been well studied. We aimed to systematically review the nature and efficacy of current management strategies for chronic obstructive pulmonary disease (COPD) in India.MethodsWe used database searches (MEDLINE, EMBASE, IndMED, CENTRAL and CINAHL), journal hand-searches, scanning of reference lists and contact with experts to identify studies for systematic review. We did not review management strategies aimed at chronic diseases more generally, nor management of acute exacerbations. Due to the heterogeneity of reviewed studies, meta-analysis was not appropriate. Thus, narrative methods were used.SettingIndiaParticipantsAll adult populations resident in IndiaMain outcome measures1. Trialled interventions and outcomes 2. Extent and efficacy of current management strategies 3. Above outcomes by subgroupResultsWe found information regarding current management – particularly regarding the implementation of national guidelines and primary prevention – to be minimal. This led to difficulty in interpreting studies of management strategies, which were varied and generally of positive effect. Data regarding current management outcomes were very few.ConclusionsThe current understanding of management strategies for COPD in India is limited due to a lack of published data. Determination of the extent of current use of management guidelines, availability and use of treatment, and current primary prevention strategies would be useful. This would also provide evidence on which to interpret existing and future studies of management outcomes and novel interventions.

Prevalence of COPD in India: a systematic review

The increasing burden of chronic diseases is a particular risk to countries with developing health systems. Chronic obstructive pulmonary disease (COPD) is contributing to the burden of chronic diseases. Understanding the current prevalence of COPD in India is important for the production of sustainable management strategies. To provide a systematic review of studies assessing the prevalence of COPD in India. Database searches, journal hand searches, and scanning of reference lists were used to identify studies. Studies of general adult populations resident in India were included. Data extraction and quality assessment were carried out using pre-tested proformas. Owing to the heterogeneity of reviewed studies, meta-analysis was not appropriate. Thus, narrative methods were used. We did not identify any studies from which we could draw a rigorous estimate of the prevalence of COPD by standard definition. Reliable standard estimates of chronic bronchitis were only available for rural populations. We identified four studies that gave estimated prevalences between 6.5% and 7.7%, and others suggestive that prevalences in some environmentally atypical regions may lie outside this range. Sex and smoking status were relatively important predictors of COPD prevalence. Residential environs, age, and domestic smoke exposure are also important, but investigation of their effect was limited by study heterogeneity. Although limited by the number and heterogeneity of studies and their unsuitability for meta-analysis, we found the most rigorous existing estimates of the general prevalence of chronic bronchitis in rural areas to lie between 6.5% and 7.7%. These figures are unlikely to apply to all Indian subpopulations, so the general prevalence of chronic bronchitis in India remains unknown. Accurate estimates of the prevalence of chronic bronchitis/COPD from across the country are required to supplement existing data if optimal management strategies are to be devised.