World COPD Day: Know your lung function

Every year on 3rd Wednesday of November World COPD day is celebrated. It is the world’s 3rd leading cause of death. Smoking tobacco is one of the main causes of COPD as believed traditionally. This assumption has been challenged by recent research that demonstrated that many other risk factors beyond smoking can also lead to fixed airflow limitation (i.e. “COPD”) in adulthood, including prematurity, asthma, allergies, nutrition, pollution, infections, and others has roots much earlier.

The resultant concept of “early” COPD has been under evaluation. Exposure to airborne pollutants from household fuel burning, occupation and ambient sources, as risk factors need to be considered in non-smokers. Chronic obstructive pulmonary disease (COPD) should be considered in patients who present with respiratory symptoms such as dyspnoea, cough, sputum production for extended periods.

This year’s theme being “know your lung function” which highlights the importance of spirometry in diagnosis and management of COPD. This is a hand held device which was invented by John Hutchinson in 1846 “with a view of establishing a precise and easy method of detecting disease”. While spirometry is considered the gold standard for diagnosis of COPD. It shows the percentage of air which can be expired forcefully in the first one second and the effect of bronchodilator on similar parameters. However, several studies from various countries show a substantial underuse of spirometry in the initial assessment of patients Both over- and underdiagnoses of COPD may thus occur, leading to suboptimal COPD care.

Under diagnosis and incorrect diagnosis are the major hurdles in getting the true prevalence of these conditions, which further makes it complicated by debates over using spirometry thresholds and predictive value of respiratory symptoms. Further, those diagnosed or diagnosed lately are not managed and treated appropriately due to low awareness and knowledge among the general practitioners. GPs the first point of contact for patients at the initial stage of the disease, and therefore it is essential that they make an early and accurate diagnosis of COPD. Other challenges faced are, Non-availability of spirometry, especially at rural, semi-urban, remote, tribal level; High cost of PFT services in private health sector making it unaffordable for rural & urban poor.

In India the average cost of spirometry is around 300–500 Indian rupees. Which is approximately more than a day’s salary for over half of the Indian population, and hence an expensive test. In India, >70% of patients pay through their pockets for medical services, and health insurance companies do not reimburse for lung function tests. Poor accessibility due to Long distances, need for multiple visits, daily wages lost, expenditure of travel, lodging, etc. moreover District hospitals have large number of patients and inadequate manpower and infrastructure to cope leading to long waiting time due. Also accurate spirometry results are dependent on daily calibration, maintenance, operator training and competence and patient performance. It is advisable to gather data from local population from calculation of predictive values which are used to interpret data. Appropriate steps need be taken to increase the use of spirometry among GPs, such as education about spirometry and making spirometers available at an affordable cost.

This gap in primary care has led to the advent of innovative digital “Make in India” solutions. These include a handheld digital spirometer, with use of AI (Artificial Intelligence) software and setting up spirometry verification by a qualified doctor remotely. One such example is SAVE™ (Spirometry Assisted Virtually Early™) program in Dindori subdivision of Nashik district, Maharashtra state where they used such techniques for early diagnosis and stratification.

Having spoken about diagnosis one more less spoken about intervention in COPD is Physical Rehabilitation(PR). Which includes, education about smoking cessation, counselling, strength and endurance training exercises, mental & health support groups. In the early stages of the disease, patients usually avoid strenuous physical activity to avoid feeling breathless. This itself warrants a need to improve exercise capacity and physical activity in COPD patients in order to improve outcomes. Patient-tailored therapies should be initiated that include exercise training, education, self-management intervention aiming at behaviour change.

The point of importance is that the initial training load should match the particular requirements and health status of the patient but still exceed demands encountered in activities of daily living. Training should exceed the loads required for activities of daily living and should increase or decrease according to the progress of the patient.

These benefits are even applicable to patients late in the disease. It is also found that lower extremity endurance exercises such as cycling and treadmill show high grade evidence in improving dyspnoea in patients with COPD, making it a highly recommended component of PR. The ideal duration of such programs is 6–8 weeks. Maintenance therapy of up to 2 years is essential to sustain improved clinical outcomes. Once again to concur that COPD management requires a holistic approach beyond treatment with medicines and support groups facilitating the same are the need of the hour.

Dr Udaya Sureshkumar, Consultant Pulmonologist, Dr. B.R Ambedkar Circle, Mangaluru