Shobha Shukla, CNS ColumnistBoth asthma and chronic obstructive pulmonary disease (COPD) are chronic diseases involving airflow obstruction and are consequences of gene environment interaction. COPD includes progressive respiratory diseases like emphysema and chronic bronchitis and is characterized by decreased airflow over time and increased inflammation. While airway obstruction in asthma is reversible, airflow limitation in COPD is usually not reversible, although one third of COPD patients do respond to bronchodilators agents and show good reversibility.
Long standing asthma that has become unresponsive to treatment can lead to chronic irreversible airflow obstruction with reduced lung function resulting in COPD.
The delicate nuances between these two seemingly similar diseases were brought out through interesting panel discussions at the recently concluded 20th NESCON (20th National Conference on Environmental Sciences and Pulmonary Diseases), organized by the Academy of Respiratory Medicine in Mumbai under the auspices of Environmental Medical Association.
COPD and asthma have several overlapping symptoms, and at times even doctors find it difficult to differentiate between the two. Both may cause shortness of breath and cough. A daily morning cough that produces phlegm is characteristic of chronic bronchitis, a type of COPD. Wheezing and chest tightness is more common with asthma. Thus a history of wheezing strongly suggests asthma, whereas sputum producing chronic cough is more indicative of COPD. Also, patients with asthma are more likely to have allergies such as allergic rhinitis or atopic dermatitis.
Dr Raj Kumar, Professor and Head, Department of Respiratory Allergy and Applied Immunology and National Centre of Respiratory Allergy, Asthma and Immunology (NCRAAI), at Vallabhbhai Patel Chest Institute (VPCI), advocated the use of allergen specific immunotherapy for treating allergic bronchial asthma. Specific immunotherapy has long term preventive effects on seasonal and perennial asthma and can benefit selected asthma patients by reducing symptoms, reducing requirement of medication, improving quality of life and has long term benefits. According to a Cochrane meta-analysis immunotherapy can reduce asthma symptoms, need for medications, and risk of severe asthma attacks after future exposure to the allergen. “We need to identify the clinically relevant antigens and then treat the patient with them. The mechanism is to produce blocking antibodies IgG to reduce production of IgE antibodies which are responsible for type 1 hypersensitive reaction. After initiation of immunotherapy there is an initial rise in IgE levels and then gradual but consistent fall. However, this therapy carries the risk of anaphylactic reactions and should be prescribed only by physicians who are adequately trained for treating allergies.”
A breathing test called spirometry is carried out to assess the severity of airways obstruction. The spirometer takes two measurements: the volume of air breathed out in one second (called the forced expiratory volume in one second or FEV1) and the total amount of air breathed out (called the forced vital capacity or FVC).
FEV1 value is more than 80% or more of the predicted value indicates mild asthma, and COPD is diagnosed if post-bronchodilator FEV1/ FVC value is less than 0.7. FEV1 more than 50% indicates severe COPD.
COPD is not limited to lungs but extra pulmonary effects on muscles and metabolism are also severe. Although non- smoker COPD is also possible, COPD is almost always associated with a long history of smoking and/or exposure to biomass fuel smoke in poorly ventilated kitchens; while asthma occurs in non-smokers as well as smokers although smoking can worsen asthma. Approximately 10% of patients of COPD may have features of asthma also.
Dr Suhas Bardapurkar, senior consultant respiratory physician in Aurangabad, Maharashtra, lamented that most of his COPD patients are not able to even pronounce that word correctly let alone understand the implications of the disease. Calling COPD ‘beedi ki peeda' (the pain of smoking), he said that although it is more serious than asthma, it is often misunderstood as asthma. COPD is preventable, while asthma is not. Yet COPD is an under diagnosed, under treated and a neglected respiratory disease and its burden is substantially under estimated since non-respiratory diseases account for more than 50% of underlying causes of death in COPD.
In the opinion of Dr. Bardapurkar, “Spirometry is the best test for diagnosing and monitoring treatment outcomes of COPD. Without spirometry we cannot diagnose COPD, yet it is not very popular with doctors due to their lack of understanding and knowledge about it. Of course, the technician performing the test should be well trained so that he/she can demonstrate to the patient how to breathe in and hold air and exhale to check for COPD.”
Dr JK Samaria, Professor in Department of TB and Respiratory Diseases, Institute of Medical Sciences of Banares Hindu University (BHU), informed that, “Pulmonary manifestation of COPD is one more form of expression of a systematic inflammatory state with multiple organ involvement including cardiovascular system. COPD patients have higher prevalence of ischemic heart disease and pulmonary hypertension. COPD is a powerful independent risk factor for cardio vascular mortality and over 50% COPD patients die of cardio vascular diseases and not in a respiratory ICU.”
“Treatment with beta blockers reduces the risk of exacerbations and improves survival in patients of COPD with or without CVD, possibly as a result of dual cardiopulmonary protection. But the fact is that less than 10% of COPD patients receive beta blockers. There is need for chest specialists to extend their expertise to broader diagnostic and treatment approaches that are traditionally the domain of cardiology/internal medicine to help patients of COPD with comorbidities,” he said.
The take home message is that smoking cessation and reduction of exposure to biomass fuel smoke have beneficial effects not only on COPD and asthma but also on comorbidities like coronary artery diseases. Moreover the benefits of pneumococcal and influenza vaccines in COPD patients should not be undermined.
30 June 2014
(The author is the Managing Editor of Citizen News Service - CNS. She is a J2J Fellow of National Press Foundation (NPF) USA and received her editing training in Singapore. She has earlier worked with State Planning Institute, UP and taught physics at India's prestigious Loreto Convent. She also co-authored and edited publications on gender justice, childhood TB, childhood pneumonia, Hepatitis C Virus and HIV, and MDR-TB. Email: shobha@citizen-news.org, website: www.citizen-news.org)
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