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Table of Contents
ORIGINAL ARTICLE
Year : 2019  |  Volume : 7  |  Issue : 4  |  Page : 117-119

A study of chronic obstructive lung disease among women


1 Past DNB General Medicine Resident, St. Martha's Hospital, Bengaluru, Karnataka, India
2 Consultant Physician, Retired HOD, Department of General Medicine, St. Martha's Hospital, Bengaluru, Karnataka, India

Date of Submission28-May-2019
Date of Acceptance27-Aug-2019
Date of Web Publication18-Oct-2019

Correspondence Address:
Dr. Indira Ramaiah
Department of Medicine, St. Martha's Hospital, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AJIM.AJIM_1_19

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  Abstract 

Background: Chronic obstructive pulmonary disease (COPD) is a preventable cause of globally occurring chronic illness. Although it is known to affect both men and women, there is a prevailing notion that it is essentially an illness of men. Hence, sufficient attention has not been given to COPD among women in our country. We undertook this study in this context. Aims and Objectives: We intended to study the clinical profile of COPD in women and the effect on biomass exposure on lung function. Materials and Methods: A total of 87 women with clinical and lung functional evidence of COPD were included. An enquiry was made to understand the risk factors for COPD. Biomass exposure index was calculated. Results: The severity of illness according to the Global Initiative for Chronic Obstructive Lung Disease staging revealed that 49.4% were in Grade 1 and 2 and 50.5% were in Grades 3 and 4. The duration of symptoms correlated with severity. Most patients were exposed to biomass smoke; the mean biomass index was 136.8 hour-years. The nature of exposure did not appear to influence the severity of illness. Conclusion: Multiple risk factors other than smoking also play a major role in development of COPD. Biomass exposure is a major risk factor in women and duration of exposure correlates with severity of the disease.

Keywords: Biomass fuel, chronic obstructive pulmonary disease, women


How to cite this article:
Karnam A, Ramaiah I. A study of chronic obstructive lung disease among women. APIK J Int Med 2019;7:117-9

How to cite this URL:
Karnam A, Ramaiah I. A study of chronic obstructive lung disease among women. APIK J Int Med [serial online] 2019 [cited 2019 Dec 6];7:117-9. Available from: http://www.ajim.in/text.asp?2019/7/4/117/269558




  Introduction Top


Chronic obstructive pulmonary disease (COPD) is a preventable and treatable illness, with a large global burden. It is ranked as the sixth most common cause of mortality in 1990 and is predicted to become the third most common cause in the near future.[1],[2] The influence of gender on COPD seems to have received limited attention. The prevailing notion that it is essentially an illness of men might have contributed to limited attention among women.[3] One-third of the world's population depends on burning biomass for cooking and heating. In India, 75% of households use this source of energy, leading to high levels of indoor air pollution with its health consequences.[4] About 50% of deaths from COPD in developing countries are attributable to biomass smoke, of which about 75% are of women.[5] The purpose of this endeavor, therefore, was to study the clinical and functional aspects of COPD among women. The center was St. Martha's Hospital, a DNB-accredited tertiary care hospital in Bengaluru.


  Subjects and Methods Top


This study was a prospective observational one. The duration of the study was 2 years, between April 2015 and March 2017. The inclusion criteria among women with chronic cough for periods over 2 months for 2 or more years include sputum production, dyspnea, and one or more risk factors in terms of exposure. Patients with spirometry parameters of forced expiratory volume (FEV) 1.0/forced vital capacity (FVC) <70%; FEV 1.0 <80% of predicted normal; and patients with less than 12% and 200ml decrease in FEV1 after administration of bronchodilator were included in the study. Criteria of exclusion were as follows:

  1. Patients with over 12% and 200 ml of FEV1 bronchoreversibility and history of asthma
  2. Patients with active tuberculosis
  3. Cardiovascular illness
  4. Unwilling participants, not giving informed consent.


A detailed history was taken with validated questionnaire, used by Mahesh et al.[6] This included duration of cough and dyspnea, past treatment, and family history of asthma or COPD. Dyspnea is quantified as per the modified Medical Research Council grading. Documentation of the following risk factors was performed: tobacco smoking, passive smoking, past lung tuberculosis, and exposure to indoor air pollution. Particular attention was paid to exposure to biomass smoke exposure and its quantification. Biomass fuel exposure in hours/day multiplied by the years of such exposure (hour/years) was computed based on history. A comprehensive physical examination was performed to assess the findings of COPD and its severity. Spirometry was done with an electronic spirometer and the following parameters were documented: FVC, FEV 1.0, FEV 1.0/FVC, peak expiratory flow rate, and forced expiratory flow 25%–75%. To assess bronchoreversibility, these parameters were repeated after inhaled salbutamol delivered with a valve-triggered spacer device. Arterial blood gases were analyzed on room air at rest. Chest skiagrams were done in all the patients. In patients with clinical diagnosis of cor pulmonale, echocardiography was performed. The results of the study were subjected to conventional statistical analyses.

Statistical methods

Data were entered into Microsoft Excel (Windows 7; Version 2007) and analyses were done using the Statistical Package for the Social Sciences for Windows software (version 22.0; SPSS Inc., Chicago, IL, USA). Descriptive statistics such as mean and standard deviation for continuous variables, frequencies, and percentages were calculated for categorical variables. Comparison between groups were analyzed using Chi-square test of independence and Fisher's test (when appropriate) for categorical variables and analysis of variance was used to compare quantitative variables having more than two groups. Pearson's correlation coefficient was calculated between two quantitative variables. Level of significance was set at 0.05.


  Results Top


During the period in review, 4160 women were admitted in our wards, of which 87 had COPD (2.09%). This compares with 150 men with COPD (ratio of M:F = 1.72:1) [Table 1].
Table 1: Clinical presentation

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The association between severity of dyspnea and Global Initiative for Chronic Obstructive Lung Disease (GOLD) staging was analyzed. [Table 2] depicts these data.
Table 2: Association between grade of dyspnea and GOLD staging

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Analysis of the grading of dyspnea at presentation and correlation with FEV 1.0 revealed a significant (P < 0.001) relationship. Similarly, the relation between the duration of symptoms and GOLD staging showed that, greater the duration, higher the grade (P < 0.001). We noted that the burden of biomass index, i.e., number of hours of exposure multiplied by the number of years is important. Unsurprisingly, we noted a correlation between the GOLD stage and the mean biomass exposure index. [Table 3] shows these data.
Table 3: Association between GOLD stage and Mean Biomass index

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Among the participants with a history of biomass exposure, we tried to subdivide the nature of the fuel used in terms of wood, crop residue, cow dung, kerosene stove, and gas stove. We made an attempt to see if the type of exposure was related to FEV 1.0. However, there was no such correlation (P = 0.0816).

Analysis of the biomass exposure index and the FEV 1.0 showed that there was inverse correlation between these two (P < 0.001). [Table 4] shows these data.
Table 4: Biomass exposure index and decline in FEV1

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  Discussion Top


In this prospective observational study, we attempted to assess the prevalence of COPD among women and also to note the risk factors which might be causative. We noted a prevalence in hospitalized women of 2.09% and a male:female ratio of 1.72. This is similar to previous studies in India.[7] The mean age in the present study was 64.1 ± 10.4. This is slightly higher that of Jain et al. (58.34 ± 9.99 years).[2] In our study, 14.9% had a history of longstanding asthma. They also had history of biomass fuel exposure later in life. We did not have old records showing bronchoreversibility in these women. We noted a positive correlation with duration of asthma and the development of COPD. In our context, the exposure to biomass has been a confounding variable. It is interesting to note that Mahesh et al. noted that a minimum of 60 biomass index hours is needed for the onset of COPD.[8]

Other workers too have studied this aspect with correlation of biomass index and its importance in causation and worsening of COPD.[9],[10],[11],[12]

A proportion of our patients had evidence of cor pulmonale secondary to COPD. It has been our clinical impression that women are suboptimally treated even when substantially symptomatic. This might explain the severe functional impairment of the GOLD Stages 3 and 4 in our as well as in other similar studies. Tobacco smoking is uncommon in Indian women; yet, it is perhaps the passive exposure to tobacco smoke which might add to the burden of indoor pollution these women. This indeed may be contributing to the complex of asthma/COPD overlap syndrome, which is progressively less amenable to management. This needs supportive evidence and further research on the points mentioned above.


  Conclusion Top


What measures can be taken to mitigate the burden of this illness? In our opinion, it is necessary that the primary care physicians should be more aggressive in diagnosing airflow limitation early in the course. Objective measures of lung function with a basic tool of spirometer and peak flow meter will empower clinicians in the early diagnosis of airflow limitation. In the later stages of the illness, adequate and optimal therapy, designed to halt the progressive decline of lung function, is of paramount importance. Substitution for biomass fuel does not seem to be an option in view of the economic constraints.

Limitations of the study

  1. During calculation of biomass exposure, recall bias regarding duration of exposure might have crept in
  2. Although the quantification of biomass exposure follows previous studies, finer details about the presence or absence of adequate ventilation has not been assessed, for reasons of feasibility
  3. In view of long duration of biomass fuel exposure and rapid societal transition, users might have migrated from one type of biomass fuel to another. This could be the reason for nonassociation between type of fuel used and declining lung function in our study.


Acknowledgment

We are grateful to the residents and nursing staff who cooperated in the conduct of this study. We are very grateful to all the patients who participated.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Jindal SK. Emergence of chronic obstructive pulmonary disease as an epidemic in India. Indian J Med Res 2006;124:619-30.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Jain NK, Thakkar MS, Jain N, Rohan KA, Sharma M. Chronic obstructive pulmonary disease: Does gender really matter? Lung India 2011;28:258-62.  Back to cited text no. 2
  [Full text]  
3.
Fullerton DG, Bruce N, Gordon SB. Indoor air pollution from biomass fuel smoke is a major health concern in the developing world. Trans R Soc Trop Med Hyg 2008;102:843-51.  Back to cited text no. 3
    
4.
Murthy KJ, Sastry JG. Economic burden of chronic obstructive pulmonary disease. Burden of disease in India. New Delhi: National Commission on Macroeconomics and Health; 2005. p. 264-74.  Back to cited text no. 4
    
5.
Salvi SS, Barnes PJ. Chronic obstructive pulmonary disease in non-smokers. Lancet 2009;374:733-43.  Back to cited text no. 5
    
6.
Mahesh PA, Jayaraj BS, Prahlad ST, Chaya SK, Prabhakar AK, Agarwal AN, et al. Validation of a structured questionnaire for COPD and prevalence of COPD in rural area of Mysore: A pilot study. Lung India 2009;26:63-9.  Back to cited text no. 6
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7.
Silva GE, Sherrill DL, Guerra S, Barbee RA. Asthma as a risk factor for COPD in a longitudinal study. Chest 2004;126:59-65.  Back to cited text no. 7
    
8.
Mahesh PA, Jayaraj BS, Prabhakar AK, Chaya SK, Vijaysimha R. Identification of a threshold for biomass exposure index for chronic bronchitis in rural women of Mysore district, Karnataka, India. Indian J Med Res 2013;137:87-94.  Back to cited text no. 8
[PUBMED]  [Full text]  
9.
Arora P, Gupta R, Chopra R, Gupta A, Mishra N, Sood S. Effect of chronic exposure to biomass fuel smoke on pulmonary function test parameters. Int J 2014;2:1488.  Back to cited text no. 9
    
10.
Bihari V, Iqbal SM, Srivastava LP, Kesavachandran C, Siddique MJ. Lung function impairment in women exposed to biomass fuels during cooking compared to cleaner fuels in Uttar Pradesh, India. J Environ Biol 2013;34:971-4.  Back to cited text no. 10
    
11.
Hu G, Zhou Y, Tian J, Yao W, Li J, Li B, et al. Risk of COPD from exposure to biomass smoke: A metaanalysis. Chest 2010;138:20-31.  Back to cited text no. 11
    
12.
Pérez-Padilla R, Regalado J, Vedal S, Paré P, Chapela R, Sansores R, et al. Exposure to biomass smoke and chronic airway disease in Mexican women. A case-control study. Am J Respir Crit Care Med 1996;154:701-6.  Back to cited text no. 12
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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Abstract
Introduction
Subjects and Methods
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