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Burden of COPD in Butwal, Nepal: an epidemiological study in Lumbini Zonal Hospital, Butwal, Nepal--AMSA-Nepal.

Contents

Abstract
Introduction
Definition
Pathophysiology
Treatment
Methods
Results
Policies
Conclusion


Introduction

Chronic Obstructive Pulmonary Disease (COPD) is defined by WHO as a lung disease characterized by chronic obstruction of lung airflow that interferes with normal breathing and is not fully reversible. COPD includes emphysema, an anatomically defined condition characterized by destruction and enlargement of the lung alveoli; chronic bronchitis, a clinically defined condition with chronic cough and phlegm; and small airways disease, a condition in which small bronchioles are narrowed. The main risk-factors for COPD are active and/or passive cigarette smoking, airway hyper responsiveness, respiratory infections, occupational exposures & ambient air pollution, and genetic factors like [[alpha].sub.1] antitrypsin deficiency. The patients with COPD present primarily with cough, sputum production and exertional dyspnoea.

Pathophysiology

COPD is characterized by chronic inflammation of the airways, lung tissue and pulmonary blood vessels as a result of exposure to inhaled irritants such as tobacco smoke.

The inhaled irritants cause inflammatory cells such as neutrophils, CD8+ T-lymphocytes, B cells and macrophages to accumulate. When activated, these cells initiate an inflammatory cascade that triggers the release of inflammatory mediators such as tumour necrosis factor alpha (TNF-[alpha]), interferon gamma (IFN-[gamma]), matrix-metalloproteinases (MMP-6, MMP-9), C-reactive protein (CRP), interleukins (IL-1, IL-6, IL-8) and fibrinogen. These inflammatory mediators sustain the inflammatory process and lead to tissue damage as well as a range of systemic effects. The chronic inflammation is present from the outset of the disease and leads to various structural changes in the lung which further perpetuate airflow limitation.

Structural changes

Airway remodeling in COPD is a direct result of the inflammatory response associated with COPD and leads to narrowing of the airways. Three main factors contribute to this: peribronchial fibrosis, build-up of scar tissue from damage to the airways and over-multiplication of the epithelial cells lining the airways.

Parenchymal destruction is associated with loss of lung tissue elasticity, which occurs as a result of destruction of the structures supporting and feeding the alveoli (emphysema). This means that the small airways collapse during exhalation, impeding airflow, trapping air in the lungs and reducing lung capacity.

Mucociliary dysfunction

Smoking and inflammation enlarge the mucous glands that line airway walls in the lungs, causing goblet cell metaplasia and leading to healthy cells being replaced by more mucus-secreting cells.5 Additionally, inflammation associated with COPD causes damage to the mucociliary transport which is responsible for clearing mucus from the airways. Both these factors contribute to excess mucus in the airways which eventually accumulates, blocking them and worsening airflow.

Treatment

A diagnosis of COPD is not the end of the world. For all stages of disease, effective therapy is available which can control symptoms, reduce your risk of complications and exacerbations, and improve your ability to lead an active life.

Smoking cessation

The most essential step in any treatment plan for COPD is to stop all smoking. It's the only way to keep COPD from getting worse--which can eventually reduce your ability to breathe. But quitting smoking isn't easy. And this task may seem particularly daunting if you've tried to quit and have been unsuccessful. Talk to your doctor about nicotine replacement products and medications that might help, as well as how to handle relapses. It's also a good idea to avoid secondhand smoke exposure whenever possible.

Medications

Doctors use several kinds of medications to treat the symptoms and complications of COPD. You may take some medications on a regular basis and others as needed:

Bronchodilators. These medications--which usually come in an inhaler--relax the muscles around your airways. This can help relieve coughing and shortness of breath and make breathing easier. Depending on the severity of your disease, you may need a short-acting bronchodilator before activities, a long-acting bronchodilator that you use every day, or both.

Inhaled steroids. Inhaled corticosteroid medications can reduce airway inflammation and help prevent exacerbations. Side effects may include bruising, oral infections and hoarseness. These medications are useful for people with frequent exacerbations of COPD.

Combination inhalers. Some medications combine bronchodilators and inhaled steroids.

Oral steroids. For people who have a moderate or severe acute exacerbation, oral steroids prevent further worsening of COPD. However, these medications c an have serious side effects, such as weight gain, diabetes, osteoporosis, cataracts and an increased risk of infection.

Phosphodiesterase-4 inhibitors. A new type of medication approved for people with severe COPD. This drug decreases airway inflammation and relaxes the airways. Common side effects include diarrhea and weight loss.

Theophylline. This very inexpensive medication helps improve breathing and prevents exacerbations. Side effects may include nausea, fast heartbeat and tremor.

Antibiotics. Respiratory infections, such as acute bronchitis, pneumonia and influenza, can aggravate COPD symptoms. Antibiotics help fight acute exacerbations. The antibiotic azithromycin prevents exacerbations, but it isn't clear whether this is due to its antibiotic effect or its anti-inflammatory properties.

Lung therapies

Doctors often use these additional therapies for people with moderate or severe COPD:

Oxygen therapy. If there isn't enough oxygen in your blood, you may need supplemental oxygen. There are several devices to deliver oxygen to your lungs, including lightweight, portable units that you can take with you to run errands and get around town. Some people with COPD use oxygen only during activities or while sleeping. Others use oxygen all the time. Oxygen therapy can improve quality of life and is the only COPD therapy proven to extend life. Talk to your doctor about your needs and options.

Pulmonary rehabilitation program. These programs typically combine education, exercise training, nutrition advice and counseling. You'll work with a variety of specialists, who can tailor your rehabilitation program to meet your needs. Pulmonary rehabilitation may shorten hospitalizations, increase your ability to participate in everyday activities and improve your quality of life. Talk to your doctor about referral to a program.

Managing exacerbations

Even with ongoing treatment, you may experience times when symptoms become worse for days or weeks. This is called an acute exacerbation, and it may lead to lung failure if you don't receive prompt treatment. Exacerbations may be caused by a respiratory infection, air pollution, or other triggers of inflammation. Whatever the cause, it's important to seek prompt medical help if you notice a sustained increase in coughing, a change in your mucus or if you have a harder time breathing.

When exacerbations occur, you may need additional medications (such as antibiotics or steroids), supplemental oxygen or treatment in the hospital. Once symptoms improve, you'll want to take measures to prevent future exacerbations, such as taking inhaled steroids or long-acting bronchodilators, getting your annual flu vaccine and avoiding air pollution whenever possible.

Surgery

Surgery is an option for some people with some forms of severe emphysema who aren't helped sufficiently by medications alone:

Lung volume reduction surgery. In this surgery, your surgeon removes small wedges of damaged lung tissue. This creates extra space in your chest cavity so that the remaining lung tissue and the diaphragm work more efficiently. In some people, this surgery can improve quality of life and prolong survival.

Lung transplant. Lung transplantation may be an option for certain people who meet specific criteria. Transplantation can improve your ability to breathe and to be active, but it's a major operation that has significant risks, such as organ rejection and the need for lifelong immune-sup pressing medications.

Methods

Data collection was performed in Lumbini Zonal Hospital, Butwal, Nepal. In-depth interviews were performed with key stakeholders, policy makers, medical professionals, COPD patients and their family members to explore the current scenario of the disease, the policies being implement ed by government and other organization and the role of medical students in addressing the disease.

All interviews were performed in Nepali and English by Medical Students and intern Doctors from Nepal. Tapes of the interviews were also taken by the interviewer. In the first stage of the interview, interviewees determined themes rather than being guided by the interviewer. In the second stage, interviewees were prompted on any of the themes that had not already been covered. Themes were identified based on the lack of accurate data, shortage of good quality medicines, illiteracy, social stigma, political instability, lack of specialized health care facilities and lack of skilled human resources. Where necessary, interviewees were interviewed on more than one occasion, to build trust and rapport, and to probe specific issues. Interviews took on average about 45 minutes. No-one identified as a potential interviewee refused to be interviewed, although several interviewees asked that the interview take place in a discrete location to avoid being seen by anyone known to the interviewee.

Informed consent was obtained from all interviewees.

Study duration: 4 weeks

Study design: Retrospective, Descriptive

Study population: COPD cases treated at LZH from 15th April 2010 to 14th April 2013.

Study method: Quantitative

Literature review

Data collection: secondary data review from hospital discharge register

Data analysis and interpretation

Results

1) Time Distribution

A. Yearly Trend

The yearly trend of COPD cases in LZH is fairly static over the past 3 fiscal year

2) Person Distribution

A. Age Wise Distribution of COPD Cases

The figure shows that the incidence of COPD in <40 years age group is uncommon as they constitute only 2% of the total patients with COPD. On the other hand, 84% of the total patients are above 60 years of age which shows that COPD is more common in elderly age groups.

B. Sex Wise Distribution of COPD Patients

The pie diagram below shows that the majority of the COPD patients (56%) are female. It may be due to the fact that there are many female smokers in our country and most of the rural females work in the kitchen with "smoking chulhos (wood and cowdung burning stoves) without proper ventilation.

5) Patient Distribution According to Associated Conditions

As can be seen from the pie diagram below, the majority of the COPD patients (56%) came with some form of co-morbid conditions. The pie diagram below shows that HTN, cor pulmonale, and pneumonia consist of the majority among all the conditions associated with COPD.

1. Interaction with policy makers and key stakeholders:

Nepal's general health policies give a low priority to Non Communicable Diseases (NCD). However, a national NCD policy and strategy has been drafted and awaits government review and adoption. The Framework Convention on Tobacco Control (FCTC) was adopted. On this theme, a Smoking Prohibition and Control Act had been drafted in 2001, but has not yet been approved.

Tobacco control efforts point in right direction but have not yet yielded major results. The Ministry of Finance has set a tax on tobacco products. There is also a partial ban on tobacco advertising (applicable to electronic media only). Smoking has been banned in major public places. Anti-tobacco programs are implemented by a tobacco control cell within the Ministry of Health and Population (MoHP) and the National Health Education Information and Communication Center (NHEICC). The Ministry of Education also includes in the school curriculum elements on the ill-effects of tobacco consumption. Finally, the Nepal Health Research Council recently conducted a training program in alcohol and tobacco control.

Several other NCD-related programs are ongoing or under preparation. An NCD awareness program is under preparation for implementation in three districts. Implementation of the World Health Organization (WHO)'s Global Strategy on Diet, Physical Activity and health has also been started.

2. Interaction with medical professionals:

The chronic obstructive pulmonary disease (COPD) is one of the most common diagnoses at District Hospitals of Butwal--we've found little in the way of helpful guidelines designed for resource-limited settings. With the example of COPD, there are guidelines from the Global Initiative for Chronic Obstructive Lung Disease (the GOLD guidelines). However, they state that COPD should be diagnosed by spirometry, and only provide a tiny footnote for settings that do not have spirometry, providing the vague advice that clinicians should then "use all available tools."

We do not have a spirometer at our hospitals, nor is there one available anywhere in the district or any surrounding district. I've not seen one in any district hospital in Nepal. I would like to see us obtain a spirometer, but the present reality is that the vast majority of COPD patients in Nepal are diagnosed and cared for without spirometry, and we can provide them good care. Good clinical protocols are a necessary component.

Three decades ago Dr Mirgendra Raj Pandey with the help of young doctors and health workers showed that indoor pollution in the homes due to open hearths was a major cause of ill health in Nepal. Changes were made in constructing better chimneys and smokeless "chulos". People were able to breathe better as a result. How ever the problem of open fireplaces in homes persists and continues to wreak havoc. Nearly 2 million people die prematurely in the developing world due to indoor pollution.

Sadly, even today one of the most important problems we see in the hospitals in Nepal especially in the winter time is chronic obstructive lung disease (COPD). Visit any medical ward in Nepal and almost every other bed has a COPD patient. Once the patient has the full blown disease, it is game over because doctors cannot do much at that stage. Prevention is better than cure applies very clearly to COPD.

The most intriguing finding from Dr Pandey's early work in the villages in Jumla, rural Kathmandu, and the Terai was that women had significant amount of COPD which lead to early heart failure and death. This catastrophe happened notwithstanding the fact that women smoked far fewer cigarettes/bidis/tamakhu than men. In these women there was an obvious co relation of the excessively high prevalence of COPD and hours spent cooking with firewood and cow patties in soot filled kitchens. Relatively young woman in their forties suffer from this disease if they cook in the smoky atmosphere year in and year out. Amazingly these women some of whom smoke only 3 or 4 cigarettes a day have lungs that resemble four pack a day smoker of a veteran's hospital in the US. This is the additive effect of using firewood and "guitha" for cooking.

This exposure to the deadly smoke in the home continues in Nepal. Cigarette smoking and atmospheric pollution have not helped. But women in Nepal as in many parts of the developing world continue to cook in open hearths. Besides COPD, a whole host of other problems are caused by smoky homes and open fireplaces: eye problems, heart problems, lung cancer, pneumonia, and burn injuries especially in children while playing.

Many villagers are averse to change because they feel the smoke filled homes provides warmth in the winter and termite prevention from eating away the roof of the house. So, dealing with these possible misperception and fears will be as important as installing a new stove or chimney. Otherwise projects of this kind are bound to fail regardless of their good intentions.

3. Interaction with COPD patients and their family members

This 79 year old female has suffered with what she describes as a bad chest for over ten years frequently experiencing dyspnoea and chest infections. She recalls suffering many exacerbations and put this down to experiencing asthma attacks. The patient admitted she had smoked 10 cigarettes a day for 64 years--a 32 pack year history. She was experiencing recurrent exacerbations of shortness of breath, inability to walk without fatigue and sputum production.

My initial thoughts were that she did not seem to be able to breathe well at all. This was quite alarming to me however she told me that this was usual for her. I felt somewhat reassured but I noticed that it was difficult to make conversation with her properly because of the degree of dyspnoea. She was diagnosed with COPD in 2000 A.D. and put on an inhaled corticosteroid and bronchodilator along with oral steroids. Her exacerbations were attributed to chest infections and she was given antibiotics to combat them. However, as the exacerbations kept coming back, the cause could be something more than respiratory infection. A cardiac cause was suspected, and more precisely--congestive cardiac failure. She showed symptoms of right sided or biventricular failure as she has peripheral oedema and symptoms of left sided heart failure such as, shortness of breath together with a reduction in mobility and fatigue. She was diagnosed with cardiac failure. She was prescribed a diuretic--Frusemide, it is possible that pulmonary oedema could have been triggering the attacks. She has received stents for ischaemic heart disease. The patient describes symptoms of paroxysmal nocturnal dyspnoea--unable to sleep lying down and needing the aid of pillows to prop her up. She reports sleeping with three pillows but is still unable to sleep well.

Conclusion

COPD is one of the leading causes of hospital admission in Lumbini Zonal Hospital (LZH). The number of admissions due to COPD is relatively stable, around 500 cases per year. The majority of patients are elderly females (60-69 age group), which is most likely due to the use of traditional wood and even cow patties burning stoves for cooking purposes for most of their lives. Most patients stay in the hospital for 2-4 days because most of them come due to acute exacerbation of COPD. 19% of patients admitted to the medical ward of LZH are admitted for COPD. Though that is a significant proportion, the actual prevalence of COPD is probably far higher as COPD is an "iceberg disease". So, preventive measures for COPD like smokeless cooking stoves, smoking control, and health awareness programs should be implemented in order to reduce the incidence and prevalence of COPD in the district.

Role of medical students:

Community education, involvement and organization around COPD issues.

Activities to foster community ownership and awareness of control programmes.

Coordination with all health-care providers (both public and private) for health awareness programmes.

Coordination with national and international partners for research based study.

LIMITATIONS OF THE STUDY

Association of COPD with smoking could not be found.

COPD being an "iceberg" disease, only the small proportion of cases seek hospital care. Hence only the "tip of the iceberg" were included in the study.

The patients coming for follow up were recorded more than once in the hospital register and hence counted more than once in our study.

The findings could not be compared to the district data as a whole due to inadequate record keeping about COPD in the peripheral health centres.

Reference:

Census 2001, Central Bureau of Statistics (CBS).

National Planning Commission Secretariat (NPCS).

Annual Report, Department of Health Services (DoHS), FY 2010/11, 2011/12, 2012/13.

Annual Report, FY 2010/11, 2011/12, 2012/13, DPHO, Butwal.

Medical Inpatient Record of LZH.

Morbidity and Mortality Records of LZH FYs 2010/11, 2011/12, 2012/13.

Handouts and power-point presentations from orientation classes.

Davidson's Principles and Practice of Medicine, 20th Edition.

Merk's Manual Professional Edition, 2009.

Annual Report, Western Regional Health Directorate FY 2010/11, 2011/12, 2012/13.

Preventive and Social Medicine, K. Park, 19th Edition.

Annual report 2010/11, 2011/12, 2012/13, Lumbini Zonal Hospital.

Authors: Khakurel Paras (1), B.C. Deewas (1), Singhal Aditya (1), Ranjan Nikhil (1)

(1) Final Year MBBS, Institute of Medicine, Kathmandu, Nepal

Percentage of patients per age group

         Percentage

<40      2
40-49    3
50-59    11
60-69    30
70-79    38
80+      16

Note: Table made from bar graph.

Associated Conditions

                % of patients

HTN             10.6%
Pneumonia       8.2%
Cor pulmonale   8.0%
UTI             5.8%
DM              4.9%
APD             4.7%
IHD             4.9%
CCF             4.1%
Other ...       3.8%
PTB             2.7%

Note: Table made from bar graph.
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Article Details
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Title Annotation:SCIENTIFIC PAPER COMPETITION--NEPAL
Author:Paras, Khakurel; Deewas, B.C.; Aditya, Singhal; Nikhil, Ranjan
Publication:Journal of Asian Medical Student Association
Article Type:Report
Geographic Code:9NEPA
Date:Mar 1, 2014
Words:3256
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