Chronic Obstructive Pulmonary Disease is an under-diagnosed and under-treated disorder. Although it is a relief to see some policy attention on the condition with its inclusion in the National Health Policy 2017, there needs to be a sharp focus on accurate diagnosis and use of superior evidence-based treatment for disease management. This need is highlighted by the global trend of most non-communicable disease burdens gradually plateauing, while COPD incidence is witnessing a rapid rise. Currently, COPD is the third largest killer affecting an estimated 210 million people. Almost 90 per cent of COPD deaths occur in low and middle-income countries. In India, it is the second largest killer Responsible for 22 million deaths, COPD destroys quality of life.

The National Commission on Macroeconomics and Health (NCMH) has identified India as one of the countries most affected by COPD. According to NCMH, in 2011, COPD contributed ₹35,000 crore to the economic burden of India and was estimated to reach ₹48,000 crore by 2016-17.COPD has direct healthcare costs, accounting for nearly two-thirds of total revenue, related to the detection, treatment, prevention, and rehabilitation of the disease. There is a direct relationship between the severity of COPD and the overall cost of care at the patient level. Hospital stay accounts for roughly 45-50 per cent of the total direct cost generated by COPD patients across all three stages.

The indirect cost emanates from morbidity and mortality, such as days off from work, poor exercise tolerance and disturbed sleep patterns. Half of all COPD patients say that the disease hinders their ability to work. However, the alarming fact is that 25-50 per cent of people with clinically significant COPD are ignorant about the disease; there is rampant misdiagnosis too. There are significant gaps in the clinical approach to the management of COPD and other airway diseases. Lack of awareness leads to underestimating disease prevalence resulting in disease progression and poor disease management.

Most primary healthcare units are ill-equipped and hence primary care physicians are unable to diagnose the disease in the early stages. They are also not comfortable with the use of inhalational drugs and prefer using much less efficacious oral medications, which also have greater side effects. Often due to symptomatic similarities between asthma and COPD, (wheezing, shortness of breath and chest tightness, pain or pressure), patients are put on asthma treatment protocol. Since patients respond to the treatment, physicians don’t feel the need to diagnose and distinguish between asthma and COPD. However, according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD), the disease classification comprising moderate, severe and very severe disease, need different treatment strategies.

All previous research studies on COPD looked at improvement of lung function as the primary criterion. However, in time it has become clear that the main killer in COPD is exacerbation. The recently published study in the New England Journal of Medicine called ‘FLAME’, the last of 11 studies in the IGNITE Phase III clinical trial programme for the treatment of COPD, compared the efficacy of two drug combinations in the treatment of COPD. Bronchodilators have proven to be the best treatment. The FLAME results are likely to impact the management and treatment of COPD and bring about an important change in the quality of care. GOLD recently announced a revised guideline in which pharmacologic treatment algorithms have been tailored to patient’s needs. Bronchodilator treatment is now thought to be the most important facet of management of COPD across all ‘GOLD Grades’ with inhaled steroids being used in a select few.

This is clearly good news. To sum it up, today, there is greater need to adopt a multi-pronged framework approach involving the reduction of risk factors, improving availability of health personnel and other infrastructure such as drugs and devices and effective surveillance systems.

The writer is a consultant pulmonologist at Fortis Hospital, Kolkata and one of the investigators of the FLAME study