Clearing the air about COPD
Battling a cough that you just can’t seem to shake off? Do you find yourself clearing your throat repeatedly? That you need to rest and catch your breath after taking two flights of stairs? These commonplace symptoms could be harmless. But there’s also a good chance that they are indicative of a serious underlying problem known as chronic obstructive pulmonary disease (COPD). An umbrella term used to describe progressive, inflammatory lung diseases, including chronic bronchitis and emphysema, COPD is an often overlooked but serious global health threat. Given that pollution is one of the leading causes of this ailment, India, which is home to 16 of the world’s 30 most polluted cities, according to a 2016 World Health Organization (WHO) report, faces a heightened risk.
Even as WHO predicts that COPD will become the third leading cause of death worldwide by 2030, it’s difficult to pinpoint how widespread the problem is in India. According to one of the few nationwide studies sponsored by the Indian Council of Medical Research (ICMR), in 2009, an estimated 14.84 million (3.49%) Indians suffer from chronic bronchitis.
Experts consider this a conservative estimate; globally, and in India, COPD is underdiagnosed as a lung function test, spirometry, is often not conducted during preliminary investigations. Lancelot Pinto, respirologist at the PD Hinduja Hospital in Mumbai, who specializes in treatment of COPD, says that of 326 patients who participated in an year-long Hinduja hospital study in 2015, 12% were diagnosed with COPD by a spirometry test. These patients had exhibited no symptoms of COPD, such as coughing up phlegm, breathlessness or wheezing, and reinforce the theory that asymptomatic patients may remain undiagnosed.
The figures may differ, but experts are in agreement that the ailment, which follows a slow, progressive course and manifests symptoms only after age 40, poses a serious health risk regardless of rural-urban status and socio-economic background. That’s because the leading causes of COPD are tobacco consumption (which includes cigarettes, khaini, vapes and electronic cigarettes), exposure to biomass fuel smoke and external pollutants such as smog. Second-hand smoke exposure is also a factor. “Whether you are a white-collar or poor person, COPD doesn’t spare anybody who is exposed to these risk factors,” says Digambar Behera, professor and head, department of pulmonary medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh. A genetic predisposition to this ailment, though rare, does exist; new research has shown that people who have had pulmonary tuberculosis at some point can develop a disease that mimics COPD.
Lifting the smoke screen
Smoking has long been considered the main cause of COPD, but experts believe pollution has emerged as the new threat. According to “The Lancet Countdown On Health And Climate Change” report published in October,, more than half a million Indians are estimated to have died prematurely in 2015 due to particulate matter (PM) 2.5 air pollution. The “State Of Global Air Report 2017”, conducted jointly by the US-based Health Effects Institute and the Institute of Health Metrics and Evaluation, found that India saw a 150% increase in annual deaths due to COPD caused by ozone exposure between 1990 and 2015.
While this may be true, doctors say that establishing a direct link between air pollution and development of COPD will not be easy. “COPD is a multi-factorial disease,” says Satyanarayana Mysore, interventional pulmonologist at Manipal Hospital, Bengaluru. “If a person has a genetic predisposition to developing COPD, even smoking or using a chullah for a short while can pose a big threat as compared to someone who is not predisposed, but is a long-time smoker. These factors, combined with exposure to a sustained polluted environment in, say, a city like Delhi, may hasten the onset of COPD. But we cannot say COPD has been caused by air pollution alone. We need more research for that,” says Dr Mysore. Dr Pinto concurs, stating that the only clear and absolute evidence we currently have is that pollution worsens COPD symptoms).
Experts believe it wouldn’t be a stretch to say that in the future, more Indians are likely to develop COPD due to exposure to external air pollution. Studies have already linked indoor air pollution—caused by fuel sources such as wood, charcoal and animal dung—to COPD deaths. Without research evidence, they are unwilling to equate air exposure with number of cigarettes, but admit it is as dangerous —and equivalent to—inhaling cigarette smoke. “Studies have shown people of South Asian descent start out with lower lung function than Caucasians. We already have poor lungs, and then we subject them to noxious ambient air. It’s not just possible, but highly probable, that we will see COPD cases go up because of air pollution,” says Dr Pinto.
A hidden problem
Symptoms of COPD, a “hidden” problem, tend to be ignored. “People dismiss it as a minor illness for a very long time,” says Rajesh Chawla, pulmonologist at Indraprastha Apollo Hospital, Delhi. The cough is rarely turbulent; usually, it’s intermittent for at least two years. “People who lead sedentary lives can lose 40% of their lung function and not bat an eyelid,” says Dr Pinto.
Breathlessness, another sign, is often attributed to ageing, not illness. Dr Chawla says patients usually prefer an immediate course of treatment over further testing, another reason why COPD remains underdiagnosed. Also, opting for chronic cough treatment when the underlying problem is COPD can be dangerous. “Many people think cough medicine is the solution. But in COPD you should never suppress the cough. If the sputum is retained, there’s a chance it can get infected and cause pneumonia,” says Dr Chawla, who has seen a 10% increase in COPD cases in the last two years.
The disease is irreversible—the damage to the lungs cannot be repaired. “As is the case with any chronic illness, quality of life does suffer. Repeated chest infections can leave a person miserable,” says Dr Behera, adding that COPD patients often battle depression. An early diagnosis can help check further damage to the lungs and enable a person to lead a normal life, with medication and certain lifestyle changes.
Life after diagnosis
Today, newer treatments and programmes like pulmonary rehabilitation are helping COPD patients breathe and function at the highest level possible. Unfortunately, there’s no real way to prevent COPD; all you can do is, say, quit smoking or limit your exposure to biomass fuel.
Ahead of World COPD Day on 15 November, medical experts believe a lot more needs to be done to create awareness about how to diagnose, treat and live with this ailment. As Dr Pinto points out, we don’t even have a Hindi name for COPD—it’s usually referred to as dama, which is asthma, a different condition. People living in highly polluted cities should consider getting regular spirometries —once every three years if you’re over age 40, annually if you’re over 60. “Nowadays, if people get chest pain, they instantly run to a hospital and get an ECG done because they are so sensitized to heart attacks and cardiac emergencies,” says Dr Pinto. “We need to ensure they are as mindful about respiratory problems like COPD as well,”