Dr SUNDEEP SALVI MD, DNB, PhD(UK)CHEST RESEARCH FOUNDATION

Pune

WHY DO WE NEED A REFRESHER COURSE ON OBSTRUCTIVE AIRWAYS DISEASES?

www.crfindia.com

LUNGS: THE ORGAN OF RESPIRATION

420 Lts of oxygen delivered every day350 Lts of carbon dioxide removed every day

10,000 Lts air pass in and out every 24

hours

10,000 Lts blood pass every 24

hours

WHY DO WE NEED A REFRESHER COURSE ON

OBSTRUCTIVE AIRWAYS DISEASES?

• Is OAD a major health problem in India?

• A good history and a good clinical examination are enough to diagnose OAD. Or is it not?

• Are we not managing patients with OAD better in our practice?

0

10000000

20000000

30000000

40000000

50000000

60000000

70000000

Cancer IHD Stroke Diabetes Chronic respiratory disease

0.6 million

25 million

1 million

28 million

65 million

ESTIMATED MORBIDITY FOR NON COMMUNICABLE DISEASES IN INDIA

(Nongkynrih B et al, JAPI 2004 Feb; 52: 118-123)WHO, 2002 data

AsthmaCOPD

0

5

10

15

20

25

30

35

ESTIMATED NUMBER OF OBSTRUCTIVE AIRWAY DISEASE PATIENTS IN INDIA

Million

AsthmaCOPD28 million

17 million

35 million

22.2 million

25% 30%

2006 2016

( Murthy KJR, NCMH Background Papers – Burden of Diseases in India, 2005 )

PREVALENCE OF ASTHMA IN SCHOOL CHILDREN IN INDIA

(ISAAC STUDY)

(n = 15,621)

0

5

10

15

20

25

30

35

1979 1984 1989 1994 1999

Pune, Nagpur Bangalore

5 – 6%

Prevalence of asthma in Indian school children varies from 2% - 30%

TOBACCO SMOKING

5- times more harmful1 cigarette = 1 bidi

Not 15-20%, but close to 50% of smokers develop COPD

1 BILLION SMOKERS WORLD-WIDE

NON-SMOKING COPD

70% of Indian homes

50% of COPDs are non-smokers

3 BILLION PEOPLE WORLD-WIDE EXPOSED

0

1

2

3

4

5

6

7

8

Cancer IHD Stroke Diabetes Chronic Resp diseases

Injuries

2.92

1.201.02

0.21

5.77

7.49

ESTIMATED MORTALITY FOR NON COMMUNICABLE DISEASES IN INDIA

(Nongkynrih B et al, JAPI 2004 Feb; 52: 118-123)

WHO, 2002 data

Number in lacs

0.0

0.5

1.0

1.5

2.0

2.5

3.0Coronary

HeartDisease

Stroke Other CVD COPD All OtherCauses

0.5

1.0

1.5

2.0

2.5

3.0

1965 - 1998 1965 - 1998 1965 - 1998 1965 - 1998 1965 - 1998

–59% –64% –35% +163% –7%

% change in Age-Adjusted Death Rates, U.S.A., 1965-1998

OADs ARE A MAJOR AND GROWING HEALTH BURDEN

IN INDIA?

UNIQUE SET OF RISK FACTORS FOR OAD IN INDIA

HOW DO WE DIAGNOSE OBSTRUCTIVE AIRWAYS DISEASES IN

CLINICAL PRACTICE?

HOW RELIABLE IS THIS?

UNDERDIAGNOSIS OF OLD IN OUT-PATIENT CLINICS AND COMMUNITY SURVEYS

• American Study – NHANES III, >20,000 US adults underwent spirometry (1988-1994)Prevalence of OAD – 8.5%63.3% under-diagnosis(NHANES Study, Mannino et al, Arch Int Med 2000; 160: 1683-1689)

• Similar observations in UK, France, Spain and other European countries(Huchon, ERJ 2002; Pena, Am J Respir Crit Care Med 2001)

• More than 75% of patients with OAD have never had a spirometry done in their life

• Spirometry is poorly utilized in India

• Myths about of Spirometry in India –- Not really necessary for diagnosis of OAD- Expensive test for the patients- Difficult test to perform- Difficult test to interpret- Doesn’t make any difference in the management of OAD

USE OF SPIROMETRY IN INDIA

HOW GOOD ARE WE AT MANAGING ASTHMA AND COPD IN

CLINICAL PRACTICE?

• 420 cases of Obstructive Airways Disease• 43.8% Asthma; 56.2% COPD• Exacerbations - Daily: 52.6%

- Monthly: 31.2%- < 1 mthly: 16.2%

• History of hospital admissions: 52%• Usual treatment: - Antibiotics:

94.1%- Oral theophylline:

93.1%- Parenteral theophylline:

41.9%- Salbutamol Inhaler:

81.2%- Steroid Inhaler:

29.3%- Oral steroids:

23.6%

EXPERIENCE OF OADs BY A CHEST PHYSICIAN IN MUMBAI

(Kamat SR et al, Lung India, August 2006)

Tablet Salbutamol 2-4mg thrice dailyVersus

Inhaled Salbutamol 100-200mcg thrice daily

1000 excess tablets over a period of 6 months

0

10

20

30

40

50

60

UQMP QMP Specialist Institute

Use of pMDI by asthmatic subjects (Rohtak, India)

Prescribed inhaler Correct use

(n = 1400)

(Gupta PP et al, Ind J Chest Dis Allied Sci 2001; 43: 91-95 )

%

(Chest Research Foundation and B.J. Medical College Pune, 2006)

DO MEDICAL PERSONNEL KNOW HOW TO USE pMDI CORRECTLY?

1. Educate Patients2. Assess and Monitor Severity3. Avoid Exposure to Risk Factors4. Establish Medication Plans for Chronic Management: Adults and Children5. Establish Plans for Managing Exacerbations6. Provide Regular Follow-up Care

Six-Part Asthma ManagementProgram

0

2000

4000

6000

8000

10000

12000

14000

1995 2000 2005 2010 2015

Current If we follow guidelines

7641 crores

(Murthy KJR et al, NCMH Background Papers, 2005)

ECONOMIC BURDEN OF ASTHMA AND COPD IN INDIA

Am

o unt

in C

r or e

s

05000

100001500020000250003000035000400004500050000

25,209 crores

1996 2001 2006 2011 2016

SUMMARY• Obstructive Airways Diseases are a major health

burden in India.• The prevalence of OAD is only going to increase in

the future• A large number of OADs remain undiagnosed in

clinical practice because of want of use of Spirometry• Inhalation therapy is poorly used in India• Patients suffering with OAD in India remain poorly

managed• Doctors do not communicate effectively with patients

suffering with OADs• OADs contribute to a huge economic loss in India

REFRESHER COURSE ON OBSTRUCTIVE AIRWAYS DISEASE