Breathing clean air in non-polluted environments free of tobacco smoke and vehicular emissions starting early in life from pregnancy to childhood to adulthood can ensure lung health and prevent those vulnerable from the risk of Chronic Pulmonary disease which is now on the rise resulting in serious health complications.
The Sunday Observer spoke to Pulmonary Disease Consultant, District General Hospital and District Chest Hospital Trincolmalee, and Assistant Editor, Sri Lanka College of Pulmonologists, Dr. Upul Pathirana for his views as to what has caused this disturbing new recent health trend, and new interventions recently introduced to prevent vulnerable patients and those already affected from serious health complications.
Excerpts
Q: World COPD (Chronic Obstructive Pulmonary Disease) Day) was observed recently. The theme selected for this year 2023 was “Breathing is life – Act Earlier.” What is the significance of this theme in relation to lung health in general?
Dr. Upul Pathirana
A. Keeping our lungs healthy is an essential part of our future health. Today, with the rising number of respiratory diseases leading to serious health outcomes, most chest physicians have thus come to the conclusion that we should act sooner than later in order to ensure we have healthy lungs for life. Hence the theme which highlights the importance of early lung health, early diagnosis and early interventions is both relevant and timely. And, while tobacco smoking was widely accepted in the past as the strongest risk factor for COPD., in keeping with the modern changes in our lifestyles, chest physicians are also calling for a new focus on other risk factors besides tobacco smoking, which play a vital role in developing COPD. These causative factors start early in life, from pregnancy through childhood and adulthood, while the identification of precursor conditions leading to COPD opens the door for researchers to study early diagnostic techniques and prompt treatment.
Q: Is COPD a common disease in Sri Lanka? If so, how common is it?
A. In 2017, a group of researchers offered lung function tests aiming to identify COPD in more than 1,000 individuals from both rural and urban areas. The prevalence of COPD was 10.5 percent in the study, and it was comparable to that of South Asian and global data on COPD.
Q: As this is a disease, which many readers don’t know much about, tell us what is Chronic Obstructive Pulmonary Disease? How does it affect our lungs and breathing?
A. The two human lungs have a branching network of tubes called airways, which end up in air sacs called alveoli. The breathing air should reach the alveoli through the airways so that oxygen can be transported to the blood at the level of the alveoli. There are structural damages to the airways in patients with COPD, and they are clogged with secretions, which results in obstruction to the passage of air. The alveoli are damaged, affecting the diffusion of oxygen from the air to the blood. These combinations make patients feel short of breath and tired.
Q: What are the most important risk factors that drive this disease?
A. Nature as well as nurture plays an interactive game to cause COPD. The genetic factors interplay with environmental risk factors to initiate the pathological process inside the lungs. Tobacco smoking has been identified as a strong risk factor for COPD since long ago. The other known risk factors are biomass, air pollution exposure, infections, developmental abnormalities of the lungs, and many unknown causes.
Q: Tobacco smoking has been cited as one of the biggest, if not the biggest, culprits. Why?
A. Because the risk of COPD among smokers is rising by the day. This is why most COPD preventive programs across the world have made smoking cessation a top strategy. Unfortunately despite such prevention strategies., COPD continues to remain a major health care burden . The solution is to focus on non-smoking-related COPD in addition to smoking-related diseases to achieve the goal of a COPD-free world.
Q: What are the symptoms of COPD that a vulnerable person should look out for?
A. The patient may not feel any symptoms until the lung is damaged to a certain extent. As the severity of the illness gets worse, you may experience breathlessness, mainly when you are engaged in physical activities like walking. Your breathing might be noisy (“wheezing”), similar to that of bronchial asthma. Chronic coughing with phlegm may trouble you further. The clinical course could further complicate infective exacerbations, and COPD patients are at risk of developing lung cancer and heart diseases.
Q: Are they visible no sooner that you are affected by COPD? Or are there stages in the progression of the disease?
A. In technical terms, new terminologies have been introduced to pick them up early. Early COPD, mild COPD, pre-COPD, and young COPD are some examples. The progressive stages of the established disease are assessed by lung function values.
Q: Age and gender-wise, who is most vulnerable to developing COPD?
A. The prevalence and mortality of COPD were higher among males in past studies. However, recent evidence shows that males and females are equally affected by COPD. One explanation for this change in epidemiology is due to increased tobacco smoking in females. Some studies suggest that the effect of tobacco smoking on lung health is more detrimental to females compared to males who smoke a similar quantity of cigarettes.
Q: Occupation-wise, who is most likely to develop it?
A. Those who are exposed to indoor and or outdoor air pollution are at risk. We cannot neglect the group of people who engage in occupations exposing them to passive smoking.
Q: How is COPD diagnosed? What are the tests one has to undergo if one suspects he or she has COPD?
A. Spirometry will help establish the diagnosis. During this test, you will be advised to take a deep breath and then blow out as fast as you can into a tube. The tube is attached to a computerised system so that it can measure how much air you can blow out of your lungs and how fast you can blow. If the result is abnormal, the test is repeated 15-20 minutes after an inhaled or nebulised medication. The second test helps to decide whether the abnormal results are reversible with medication and make an alternative diagnosis like bronchial asthma. Radiological testing like a chest X-ray or computed tomography (CT) will provide supportive evidence to arrive at a diagnosis.
Q: Are these tests available in most of our state hospitals, including those in remote areas?
A. The testing facility is available in almost all the respiratory medicine units and clinics in Sri Lanka. And also, spirometry-testing facilities are further extended to non-respiratory units in many state hospitals. There is enough coverage for spirometry in Sri Lanka, even though it is not available in small hospitals.
Q: Are they free for patients visiting these hospitals?
A. The state hospitals do not charge patients for any testing; similarly, spirometry is free.
Q: Who makes the final diagnosis? A chest specialist, or any general practitioner?
A. Any doctor, irrespective of whether a specialist or a non-specialist, can make the diagnosis, provided that he or she is updated on the latest definitions. Complex and difficult patients could be referred to a specialised centre for a comprehensive assessment. We, as respiratory medicine specialists, welcome any suspected COPD patients from other doctors.
Q: Do these tests need a hospital setting? If the patient is too ill with some other disease, can they be done at home?
A. The machines for the testing are placed in hospital laboratories, clinics, and wards. We have to have trained technicians to perform the procedure. However, there are small portable machines that can be carried to the doorstep. The state hospitals do not have the capacity to offer home testing at present, and there are private technicians who offer this service.
Q: What is the usual procedure followed when treating a patient with COPD?
A. Your physician will stage the disease based on your clinical characteristics and spirometry results. The main forms of medicinal treatment are inhalers, which help to open and dilate the closed or narrowed airways. Thereby, the inhalers enhance your exercise capacity. Additionally, the doctor might prescribe pills and capsules as required, especially in flares of symptoms. As the disease progresses, your lung fails to oxygenate the blood, necessitating home oxygen therapy.
On rare occasions, surgeons can help COPD patients with surgical interventions as decided by a multidisciplinary team led by a respiratory physician. Finally, replacing your diseased lung with a donor lung (lung transplantation) is going to be the last option.
Q: Can COPD be mistaken for some other disease and result in the wrong diagnosis? E.g., since asthma and bronchitis are also respiratory diseases that cause wheezing,
A. This is correct. There are COPD mimics of common diseases like asthma or some other rare illnesses. Wheezing is a non-specific symptom and a sign; there are other medical problems associated with this sign.
Q: COPD was said to be the 3rd leading cause of death worldwide, causing 3.23 million deaths in 2019. Where does Sri Lanka rank in this global data?
A. Ischemic heart disease and stroke cause the highest number of deaths globally and in low- to middle-income countries, including Sri Lanka. COPD is in 3rd place in world statistics, and it is 4th in low- and middle-income countries.
Q: Pulmonary rehabilitation for COPD is included in the Package of Interventions for Rehabilitation, currently under development as part of this WHO initiative. Can you elaborate on this?
A. COPD patients are chronically breathless, limiting their mobility and physical activities, which subsequently causes muscle wasting. Therefore, you feel tired and weak despite well-controlled COPD with your medications.
Targeted exercise sessions in a specialised institution supervised by a respiratory physician and physiotherapists enable patients to engage in activities at home to regain lost muscle power. This type of training program is coupled with nutritional assessment, appropriate advice, and psychological support.
The whole program is called pulmonary rehabilitation, which is happening in respiratory units, including in Sri Lanka. We receive fascinating feedback from patients who have joined our pulmonary rehabilitation programs.
Q: What are the gaps you see in the delivery of quality care for COPD patients in our health system at present? How would you like to close them? Any suggestions?
A. Patients should realise that COPD is a chronic disease and that it is not curable, although it is treatable. They should attend the clinics and pulmonary rehabilitation (PR) programs regularly as instructed by the treating physician.
However, there are practical issues with transportation to visit the centralised pulmonary rehabilitation centers. The solution would be PR centers at the community level.
Q: Since smoking is the main cause, if a smoker wants to quit smoking what is the role of the community in helping him?
A. People who are currently smoking can seek help from health care workers for smoking cessation. There are community organisations that should look at this issue deeply and address it appropriately.
Q: As most young people are now leading risky lives under the new normal, what is your advice to them on the adverse impacts of smoking and why early lung health is important?
A. Smoking leads to many adverse health consequences, like heart attacks, strokes, cancers, COPD and many other diseases. Therefore, refraining from active and passive smoking not only protects your lungs but also other vital organs.
