The Most Common NCD in Nepal

COPD is a common preventable and treatable disease characterized by persistent respiratory symptoms and airflow limitation due to airway and/or alveolar abnormalities, usually caused by significant exposure to noxious particles or gases. It is the fourth most common cause of mortality globally, with significant effect on socio-economic status, and having significant threat to public health. It is the most common non-communicable disease in Nepal, and alarmingly, the second most common cause of mortality in Nepal and India, which is perhaps because of increased biomass fuel usage and pollution exposure. A significant amount of health budget is utilized only for COPD, and in developing countries, the direct cost may be less important than indirect cost. COPD forces at least two individuals to leave the workplace, which further affects the health of the entire family, especially of economically deprived ones.

Risk factors for developing COPD
• Smoking
• Biomass fuels (brick making, fish smoking, tobacco curing, and leather working)
• Outdoor and indoor air pollution
• Poverty
• Poor lung development during childhood
• Recurrent respiratory tract infections

Symptoms
• Difficulty in breathing
• Cough
• Sputum production
• Muscle wasting

Diagnosis
COPD is diagnosed in patients having above risk factors like cigarette smoking, biomass fuel usage, etc. who have gradually progressive difficulty in breathing, along with cough, in whom pulmonary function test (Spirometry) shows obstruction, i.e. post bronchodilator FEV1/FVC Ratio <0.70. Ironically, most of the centers here do not have Spirometry, despite it being economical and simple to use, thus relying only on clinical diagnosis that either under-diagnose or over-diagnose COPD many a time.

Prevention
• Smoking cessation/ avoidance or minimization of biomass fuel utilization
• Vaccination: influenza (annual) and pneumococcal vaccination
• Education
• Pulmonary rehabilitation/exercise
• Adherence to treatment

Treatment
COPD is usually treated with bronchodilator medications like Tiotropium, Glycopyrenium, Formoterol, and Salmeterol, and corticosteroids like budesonide, fluticasone, etc. in various combinations, based on severity of disease. These medications are usually given in inhaler form, which is directly delivered to the lungs, leading to maximum effect and minimal systemic side effects. Most common ways of delivering these drugs are via metered dose inhaler with spacer, dry powder inhaler, breath actuated devices, and nebulization. All these delivery devices are equally good, with no superiority of one device over another. However, selection of device should be individualized and discussed with the patient. Various factors like old age, arthritis, poor inspiratory effort, and cognitive level will help guide one to the best device for an individual.
In addition to the above-mentioned medical therapy, many patients may require long-term oxygen therapy and non invasive ventilator (BiPAP) support at home, based on disease severity. Various surgical options are available outside our nation for advanced stage diseases. However, proper adherence and ineffective use of these devices leads to worsening of conditions. Hence, proper technique should be taught and checked on follow-up visit. Importantly, patient should be given advice regarding nutrition intake. They should be encouraged to eat calorie/energy-dense food in small amounts and multiple times a day.

Co-morbidities
Patients with COPD come with various common co-morbidities, which should be addressed and treated accordingly.
• Depression/anxiety/cognitive impairment
• Cardiovascular diseases like heart failure, ischemic heart disease, and arrhythmia hypertension, etc.
• Osteoporosis
• Lung cancer
• Metabolic syndrome and diabetes
• Gastro esophageal reflux diseases
• Obstructive sleep apnea

 

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