Express Healthcare along with S.P.A.G. organised a Knowledge Exchange with Dr Prashant N Chhajed, Chief Pulmonologist: Lung Care and Sleep Centre, Fortis Hospitals, Vashi and Mulund and consultant, Lilavati & Nanavati Hospitals and Dr Lancelot Pinto, Consultant Respirologist, Department of Respiratory Medicine, PD Hinduja National Hospital and Medical Research Centre, on the occasion of World COPD Day, in order to spread awareness on the right diagnosis and management of the disease. Excerpts from the programme
Throw some light on the prevalence of COPD in India. What are the determinants for the rise of COPD ? What are the treatment protocols currently available in our country?
One of the dominant causes of COPD is smoking. Long-term smoking is definitely linked to COPD. There is another concept known as non-smoking COPD.
The elements for non-smoking COPD are:
- Indoor pollution: Indoor pollution particularly in countries like India and other developing countries is basically due to chula fume exposures.
- Exposure to biomass fuel, which is widely used across the country
- Environmental pollution also contributes to COPD particularly in areas where there are high urbanisation or high pollution levels. People living in those areas have a high risk of developing COPD.
What are the current treatment protocols available for Indian COPD patients today?
Dr Chhajed: I think the treatment protocols are uniform. The therapy for COPD is at multiple levels. There is a multi-disciplinary approach to the management of COPD. It includes giving inhalers, particularly inhaled bronchodilators. We also recommend use of oral tablets, oral Theophyllines, pulmonary rehabilitation, vaccinations, taking care of osteoporosis and patients who are at advanced COPD might need oxygen therapy at home and non-invasive ventilation.
The therapy for COPD should be uniform everywhere.
Give us an overview of what is happening abroad and how it’s different in India (with reference to the treatment protocols) and the rest of the world?
Diagnosis will involve the use of a spirometer which is the GOLD standard for the diagnosis of COPD and it is what is used all over the world. A recent study in India among general practitioners states that less than 25 per cent prescribe spirometry to their patients. Which means if we are not diagnosing them then treatment is still far off.
When it comes to the treatment, it is pretty uniform all over the world. What you need is good dual bronchodilators which are used everywhere in the world but there is a big phobia in India to prescribe inhalers. Inhalers are associated with all sorts of myths in India. Patients constantly ask if they will get addicted to inhalers. They don’t ask a diabetologist if they will get addicted to their diabetes medication but for some reason, the concept of ‘you need inhalers’ is equivalent to ‘you will get dependent on inhalers’. As a result, most physicians end up prescribing tablets instead of inhalers. And that is not recommended globally. This is where we lack and there is huge reluctance to prescribe. When it comes to things like follow up, vaccinations or pulmonary rehabilitation for example which are shown to alter the quality of life to a great extent, hardly anyone practices pulmonary rehabilitation. and there are a various reasons associated with it. It involves intense follow up, a system where a patient has a referral point and can visit again and again. We don’t have the kind of infrastructure to deal with the situation.
What is the ideal treatment protocol that Indians should follow, especially what physicians should prescribe to their patients?
Dr Chhajed: There should be an uniform protocol as also pointed out by Dr Pinto. A lot of effort should be put in preventing COPD. As Dr Pinto mentioned,it is more difficult to smoke in public places. But it needs to implemented in a much stronger way.
Exposure to bio-mass fuels need to be tackled in a big way because a large chunk of patients who are non-smoking COPD end up inhaling polluted air. Hence, prevention at that level is very important. Once preventive aspects are taken into account, you need to diagnose them properly. Early diagnosis is important as progression of the disease can be delayed and you can actually give them a better quality of life. Exacerbations can be reduced. Every time a patient has an exacerbation, he/she loses lung function. So, I think the treatment protocol has to be same.
The Indian guidelines have been slightly tweaked so that Indian practitioners can implement them properly. But mind you, the mean principles of therapy remain the same. A few recommendations may go up and down based on the availability of medication, cost of medication etc, but overall, I think the approach is same. Being part of various committees in India also, we would not like to have something tangent to what the world is doing.
What are the Indian protocols followed?
Dr Chhajed: Prevention protocols remain the same. As for the treatment protocols, we provide inhaled bronchodilators. Inhaled bronchodilators are important for patients with COPD. And now recently, there has been a lot of evidence emerging that the focus should be mainly on inhaled bronchodilators or rather inhaled dual bronchodilation which actually improves the symptoms of the patient and gives them a better quality of life. This is the first approach.
As Dr. Pinto also mentioned, many patients are being prescribed oral tablets first. Oral tablets should be prescribed much later, as they are more of an add on therapy rather than the main stay therapy. Of course inhaled corticosteroids, which are the main stay of asthma treatment are again add ons, which can be used on selected number of patients. Hence, according to me, these protocols should be followed by our physicians. A general physician should ask for a spirometry on the same lines as asking for for an X-ray or for a complete blood count. Once the practise is inculcated,the next step would be to enquire about the lung function followed by what is going to be the therapy.
Dr Pinto, you talked about the myths that patients have about inhalers. How much do doctors have these myths and how do we break it?
Dr Pinto: Education is the answer to all problems. Whether doctors genuinely believe in these myths themselves or whether they are catering to their clientele, it’s a difficult question to answer. Very often, you do not, not want the patient to come back to you simply because you prescribed a medicine which is not in line with their social believes or what they believed to be right. The thing about inhalers is that when you take it is very visible to people around you and that’s the big stigma attached to it, that people in the family think you have a disease. But it’s a strongly held believe. And physicians also to a large extent, are reluctant to prescribe these inhalers. One of the ways we can dispel such myths is through educating people that the dose which you get in an inhaler is a minute fraction of the dose that you would take as a tablet because it directly gets deposited into the lungs versus going into the circulation, going to the blood stream, then reaching your lungs. Explaining that to patients often helps. I usually put numbers down to it saying that if I had to give you something orally it would be in milligrams, what I am giving you now is in micrograms. So people usually understand it if it is explained properly. Therefore, I think educating physicians as well as patients will make a huge difference. Another reality is that inhalers are more expensive than tablets and there is also a cost dynamic to the whole situation. So it’s not just the myth. Bringing down the price of inhalers would also help.
Dr Chhajed: Having said that , acceptance of inhalers in on the rise. Particularly in the urban areas where we practice, we see it is not as difficult to initiate someone on a inhaler therapy than it was some years ago. Thanks to educating patients and multiple campaigns, CME’s, media etc which have actually promoted this.
Do you see a lack of understanding in treatment protocols among physicians?
Dr Chhajed: I think it is universal. What is happening is that within few years, you are having newer guidelines. But I think an important step has been taken as far as the medical council requirements are there, which is called as the CME points. It is forcing people to attend CME’s, which allows us to dissipate knowledge to the physicians or the practitioners at large.
Do you see a lack of diagnosis happening where patients are concerned?
Dr Pinto: That’s a huge problem for sure. There is a lack of spirometers in the country. Studies that have looked at the diagnostics skills of physicians have found that if a physician solely relies on the diagnostic skills for diagnosing COPD, about half of all the patients will be missed. OS spirometry should be performed on patients suspected of having Obstructive Airway disease. And that is solely lacking in our country and the lack of trained technicians to conduct spirometry. That is the unfortunate part. Unlike an ECG, where you can pretty much train anybody to just get it done, spirometry is a patient-effort dependent process. So the same patient going for spirometry with three different technicians all of whom are variably trained will have different results with all those technicians. Good quality spirometry makes a huge difference and is the first step towards diagnosing COPD.
People usually associate Asthma with COPD. I want you to throw some light on whether asthma literally means COPD or there is a difference between the two diseases.
Dr Chhajed: There is a difference between asthma and COPD. In India, asthma has different names in local languages, ‘Dama’ etc. Unfortunately, COPD does not. So most often, asthma and COPD get clubbed as dama and the approach for treating both have been the same. However, it is important to highlight the difference between them. Asthma can happen in young patients; COPD typically happens in people who are elderly who have a history of smoking or those who have exposure to some air pollutants. In asthma, patients can have symptoms and once they are treated they completely become normal. However, if you look at COPD, it is a progressive disease. So the symptoms stay for a long time and patients require regular therapy. In case of asthma patients, they require regular therapy especially in cases of progressive asthma. Another thing about asthma and COPD to differentiate is asthma is a reversible disease, but COPD is not. So if someone is getting an airway narrowing, if you give inhalers to the patient if you give treatment the airway becomes normal. COPD patients will get symptomatic benefit but the airways do not open up completely therefore, it is not a reversible disease. Another important reason that we must differentiate between the two is the change in the therapy approach. We have emerging evidence to say that it is important to differentiate between the two.
What role should physicians play in creating awareness about asthma and COPD and the difference between the two?
Dr Pinto: Asthma is predominantly an allergic diseases. In patients who have nasal allergies, skin allergies and have shortness of breath it is most likely asthma than COPD. In terms of awareness, putting a label to a disease makes a huge difference. One of the things we commonly notice is physicians are normally little reluctant to tell a patient with asthma that he has asthma so we have a lot of terms floating around like bronchitis, like allergic lung disease, like allergic bronchitis etc. Just telling a patient he has asthma is very empowering because you have given him or her a diagnosis, you have given him/her a prognosis on a disease which can be worked on. It’s a disease if you take regular treatment you can live an absolutely normal life. And the same holds true for individuals with COPD. Putting a label on their diseases makes them sensitise towards how important stopping smoking is, makes them sensitize towards new treatments available, and one can work on those new treatments and I think giving a patient a rock solid diagnosis and not being a little blurry in terms of diagnosis is important. And as physicians of course all of us play a role in disseminating information as part of CME’s, as part of like world COPD day where you go out and educate people about the diseases such as COPD whether it is in the media or newspapers, through whatever channels you have access to that is very important as well.
Since you are into management of COPD and empowering patients, what should be done to empower patients to better understand COPD and to manage their disease on their own?
Dr. Pinto: Education is the most important thing in terms of empowerment of patient. Starting with the diagnosis, giving them a diagnosis and letting them know what they have, giving them all the treatment options that are available. In terms of education, prevention again is the most important key, so educating people on the ill effects of indoor and outdoor air pollution that itself could lead to a mass movement where you pressurise your local government and try and make a difference in terms of air pollution. Switching over to healthier fuel for example is extremely important and I think that kind of empowerment is needed. We are seeing a lot of public campaigns now-a-days to change things, and that’s where the change usually begins. In terms of treatment of course, educating your patient every step along the way, letting him why he is on the treatment that he is, what to anticipate in a few years, things like vaccinations which are preventive measures. We do something like a written action plan which is when the patient symptoms worsen, what to do even before they reach a physician. How to they step up their drugs. All that is very empowering because then it becomes a work that is collaborative. Rather than doctor dictating things to their patients and labelling them as smoking related lung disease, which is itself a lot of guilt, it’s telling the patient this is what you did wrong, now you have to suffer. Rather than that empowering them and having a collaborative frame work in which you work makes a huge difference. And we also run a pulmonary rehabilitative programme. The whole foundation of the rehabilitative programme is empowering a patient to come exercise to improve their lifestyle and quality of life through measures they do on a daily basis. So, I think all of this is important.
There is a rising population of people with CVD’s and COPD, so how can physicians educate their patients and firstly diagnose this dual condition and how to manage it?
Dr Pinto: Some are them are what we call shared co-morbidities. The fact that an elderly person is already prone to developing heart disease whether he has COPD or not. Then also there is a clear link that has been established between COPD and CVD’s. The no 1 cause of death for COPD patients is cardiovascular disease. One fifth of the patients with COPD will have underlying chronic heart failure. A clinical examination of course makes a difference. When a physician is seeing a patient and you suspect COPD, you need to look at signs of heart failure as well. Doing a screening always help simple things like an ECG to begin with. What also helps is if a person has shortness of breath, which seems to be out of proportion to the degree of impairment seen on a spirometry or once you optimised the treatment for the COPD and if the patient still feels short of breath, then you definitely need to think in terms of other possibilities for that shortness of breath such as heart disease. You need to look out for signs of co-morbidities and those include heart disease, high blood pressure, metabolic disease such diabetes, OSA and of course diseases such as osteoporosis and even depression. So, patients with COPD are about 2.5 times likely to be depressed than patients without COPD. And therefore it becomes important to screen COPD patients for these diseases because it is not enough just to treat COPD and ignore all these other conditions along with it.
Dr Chhajed: You basically have to proactively look for other co-morbidities that might exist with COPD.
Share some insights on the research activities happening on COPD in India? And where do we stand when compared to other countries?
Dr Chhajed: We stand very low as far as research activities are concerned. There is a potential to do more, as far as research activities are concerned. Because we have local factors that influence COPD, which is the patient’s locality, understanding of the disease, factors leading to COPD for these patient’s, what therapies are feasible, for example first line molecule and is it easily available to the common man. There is a big need that we should initiate and increase the research in this field. An important step has been taken in India.
For example, the non-smoking COPD, the dominant research in this area has actually come from India. So it’s not completely bad. There is some research activity happening in India as well. We are contributing to the literature in the science and medicine of COPD. But it is also important to understand the local factors so that we can identify our special cases. We can identify our patients who are at a higher risk, diagnose them early and put them onto the therapies earlier. For example in the West you will see that most of the teaching institutions or university hospitals will have a COPD cohort for example. A COPD cohort is a group of COPD patients who come to a clinic and they are monitored over a period of time. And that gives a tremendous insight into how local patterns are, local behaviour, how are the patients responding. The co-morbidities which the patient will face, is it similar in the West or different. You will have an answer to these questions only if you study your local COPD population. I think there needs to be a concentrated effort at all levels, private research institutes, medical institutions, industry support, government support. Support is required at all levels just because COPD is becoming the third leading cause of death and is becoming a huge cause of morbidity worldwide. The current expenditure cost of COPD burden is at Rs 35000 crores and in the next few years is expected to reach Rs 48000 crores. I think a little bit of investment in research will go a big way in tackling this problem.
How important is it for the medical fraternity to work with the government to streamline air control policies and implement them?
Dr Pinto: It is extremely important for the medical fraternity to liaison with the government and some of it comes from research. There is a paper that highlights incidence of obstructive airway disease and the distance to the highway, the closer you are to the highway the more likely you are to have an obstructive airway disease.
Our primary role would be to present data / evidence to the government and lobbying from both the community at large and from physicians in terms of sensitising the government. It is tricky because there are religious sentiments attached to these festivals like Diwali and bursting crackers. So, it is definitely not going to be an open and shut legislative thing, but engaging everybody and sensitising people on how important this and how it can go a long way in changing policy. People now realise about the ill effects of smoking. For example, if in a restaurant a person next to you is smoking, you would point it out and make him stop smoking. But this is not enough to tackle the air quality outside. I think that kind of momentum has to come from the public as well.
At present, if we can’t stop people from bursting crackers, are there any other strategies that can be implemented to control some amount of pollution?
Dr Pinto: Publish air quality indices. People with COPD can be advised not to venture outside when the air quality is extremely poor because it is linked with exacerbations. Having that kind of transparency on an on-going basis will help. There are websites where you can check out the air quality index. But doing that on a mass scale, for example having it at a traffic signal, telling people what the air quality is like on a daily basis would help. At the end of the day, disseminating information that you need air purifiers in the house would take the burden away from the government to ensure that we get clean air and would just shift the burden onto individuals to look after air quality for themselves.
Dr Chhajed: We need to think about the industrial pollution, the vehicular pollution as well and strategies need to be looked on those lines as well. As mentioned earlier, it helps to have healthier fuels or greener fuels and I think emphasis has to be made on this aspect as well. In Mumbai, we face this huge problem about the dumping areas which catches fire etc and leads to a tremendous health hazard.
Are we genetically more susceptible to COPD?
Dr Pinto: There was a study done when the lung function of different countries (pure study) were looked upon. Indians have around 33 per cent lower function than the reference which is Caucasians. We have one of the lowest lung functions in the world even lower than sub-Saharan Africa. We don’t know what the cause is, so if we begin at a lower lung function and then we smoke or are exposed to biomass fuels, then yes, we are definitely more susceptible to developing COPD.
Dr Chhajed: Cardiologists say that coronaries are much smaller than the Caucasians, hence you are a higher risk of coronary disease then your counterparts around the world.
We have been talking about a lack of data so how can we make COPD management more evidence based? Other than research is there any other strategy we can implement?
Dr Pinto: All of us can contribute in our own way in terms of developing this evidence. For example is Biomass-related COPD identical to smoking associated COPD, a question as simple as that, yet there are various studies related to that. And the few studies suggest yes they are different. Biomass fuel associated COPD is more likely to be associated to chronic bronchitis where you can produce a lot of sputum and would probably respond to inhaled corticosteroids. And that is not the same for smoking-related COPD. That is in creating and collection of evidence. The other part is in the dissemination of the evidence.
Dr Chhajed: How many institutions are providing research, how many teaching institutions are giving out quality publications? Is research encouraged in the curriculum? Can a doctor, who has finished his MBBS or MD, get into research for a few years? Does he have any person to support him? These are some of the important questions that need to be answered. In the western world, where we have both spent time, we could do research because there was a support which encourages research. As a clinician also there are systems that allow you to do research. Funding is available and yes research is in fact important and that needs to be inculcated more and more into our systems.
Is there a need for the government to create a fund in India for research?
Dr Chhajed: There are government funds, there are research institutes, we do have government centres of excellence and medical institutions that are doing research. What I am saying is that it needs to be done on a much larger scale. And it needs to be a priority which shows that we are looking at a long term goal and not a short term goal.
One message to the industry focusing on the right kind of diagnosis of COPD patients.
Dr Pinto: In terms of the healthcare, what is required is low cost diagnosis and technician independent. In terms of treatment good options are available. Dual bronchodilators have revolutionised or completely changed the life of COPD patients and improved their quality of life. We need to disseminate this information and also need to let them know that COPD is not the doomed disease that it was once portrayed to be. Currently, a lot of these medicines are out of the reach of the common man, so hopefully the volumes increase and we start prescribing properly they might become more accessible to more people. The bottom line is that it is not as bad as a disease it was ten years back. We have a lot of different therapeutic options and one should read about them and be updated.
Dr Chhajed: Spirometry should be really prescribed as part of diagnosis. I think newer medications are available, more research has become available to us which helps differentiate between asthma and COPD because treatment approach is different and lastly to add on if someone is diagnosed with COPD it is not the end of the world. There are several strategies available that can help you live a good quality life and have a less morbid life.
(The session was moderated by Raelene Kambli)