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Sunday, 23 November 2014





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World Chronic Obstructive Pulmonary Disease Day:

Smoking: main cause for chronic lung diseases

World Chronic Obstructive Pulmonary Disease (COPD) Day was marked in November with the theme “It’s not too late,” to raise awareness worldwide of this widespread disease. Efforts to improve early diagnosis, develop new treatments and better predict patients’ prognoses are leading to renewed optimism in the fight against one of the world’s most prevalent respiratory diseases.COPD Day is organised by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) in collaboration with health care professionals and COPD patient groups aims at raising awareness about chronic obstructive pulmonary disease (COPD) and improve COPD care throughout the world.

In Sri Lanka, recent clinical studies of health officials have shown a steady rise in COPD over the past 20 years. Officials have warned the disease could escalate in the future, if the smoking which is the main cause for it, is not minimised.

Sri Lanka Pulmonary Association President and Consultant Physician, National Hospital for Respiratory Diseases, Welisara, Dr SAMAN KULARATNE gives us some insights into how and why the disease is caused and more importantly how it could be prevented. Excerpts…

Q. Nov.19 was World Chronic Obstructive Pulmonary Disease (COPD) Day. Could you tell us more about it?

A. COPD is a general term which includes the conditions, Chronic Bronchitis and Emphysema. Chronic means persistent. In chronic bronchitis you get persistent inflammation of the bronchi (breathing tubes). Emphysema is damage to the smaller airways and air sacs (alveoli) of the lungs. Pulmonary means ‘affecting the lungs'. Chronic bronchitis or emphysema can cause narrowing (obstruction) of the airways. These two conditions commonly occur together. The term Chronic Obstructive Pulmonary Disease (COPD) describes a lung disease with a persistent narrowing (obstruction) of the airways due to chronic bronchitis, emphysema, or both.

Q. What causes it? Environmental pollutants such as dust, diesel fumes, pollen, genetic disorders? Or smoking over a long period?

A. Smoking is the most common cause of COPD. Environmental pollutants may cause some cases of COPD. The combination effect of work place exposure to air pollutants (vapors, irritants, and fumes) and smoking increases the risk of developing COPD. Exposure to indoor air pollution, such as the use of biomass fuels for cooking is a significant cause of COPD in developing countries.

Biomass fuels used by women for cooking account for the high prevalence of COPD among non smoking women in these countries. A very rare genetic disorder known as alpha-1-antitrypsin deficiency, a protein deficiency, can be the cause of COPD in less than one percent of cases. Pollen is known to cause Asthma which has similar symptoms to COPD. But of all of these causes, smoking heads the list.

Fifteen percent of people who smoke one packet of cigarettes a day, and 25 percent of people who smoke 40 a day develop COPD if they continue to smoke. Some may develop COPD even with passive smoking.

Cigarette (tobacco) smoke and other air pollutants can irritate the walls of the airways (bronchi) and air sacs (alveoli), and with persistent exposure will lead to inflammation and permanent damage to lungs. As a result of this inflammation, walls of the airways thicken and more mucus (phlegm) is produced. Damage to walls of the air sacs causes emphysema and the lungs lose their normal elasticity. The smaller airways also become scarred and narrowed. These changes cause the symptoms of breathlessness, cough, and phlegm associated with COPD.

Q. Who is most at risk? Young, old, men or women?

A. COPD mainly affects people over the age of 40 and becomes more common with increasing age. It is more common in men than in women.

Q. Can children get it from passive smoking or environmental pollution?

A. COPD is not a well defined entity in children. But passive smoking, air pollution, and irritants may cause asthma and persistent cough in children.

Q. What parts of the human body are affected by the disease? All? Lungs? Upper respiratory tract?

A. In COPD, the changes are mainly in the lungs.

Q. Is it infectious?

A. No. However infections (viral, Bacterial) can exacerbate the symptoms of COPD.

Q. How long does it take for it to develop? Is it a sudden illness or does it occur over a period of time?

A. It is not a sudden onset illness. It occurs through exposure to tobacco smoke and other environmental pollutants over a period of time (months, years).

Q. When is it usually diagnosed?

A. COPD is usually diagnosed when they develop symptoms. Main symptoms of COPD include cough, breathlessness and wheeze, and production of sputum. Cough tends to come and go at first, and then gradually become persistent (chronic). It is productive with phlegm. Breathlessness and wheeze may occur only with exertion at first. These symptoms become gradually worse over the years if continue to smoke. Patients produce lot of sputum due to damaged airways.

Q. How is it detected and diagnosed? X-rays? Sputum test?

A. COPD is suspected because of the symptoms and the signs. The chest may show signs of over-inflation (hyperinflation) and the doctor may hear wheezes in the chest.

The most important test to diagnose COPD is called Spirometry. The test estimates lung volumes by measuring how much air you can blow into a machine.

This test will help the doctor to detect the airway obstruction as well as the severity of the disease.

Chest X-ray may show evidence of over inflation of the lungs.

This also helps in detecting associated other illnesses such as infections and lung cancers. Sputum testing helps to detect infections. Pulse oximeter is another important device which detects oxygen levels in the blood. Low levels of oxygen are a frequent finding in COPD patients especially during exacerbation.

Q. What are the diagnostic tests you do here in Sri Lanka?

A. Spirometry, Testing to detect oxygen levels in the blood, Chest X-ray, and tests to detect alpha-1-antitrypsin levels.

Q. Can COPD be mistaken for another ailment? E.g. Some people dismiss it as smokers cough and so delay seeking treatment. What is the difference?

A. As smoker’s cough develops the patients will develop progressive symptoms if they continue to smoke. Lot of other lung problems and heart problems can have similar symptoms. Differentiation between asthma and COPD could be difficult in some patients. Some may have both these conditions.

Lung cancers, chronic infections such as tuberculosis, lung diseases due to exposure to dusts are some of the conditions which may have similar symptoms.

Q. I understand that in the US a COPD is used to describe two conditions - Emphysema and Chronic Bronchitis, as most people with COPD have both these conditions.Your comments?

A. Chronic bronchitis is a condition of increased swelling and mucus (phlegm, sputum) in the breathing tubes (airways) which leads to airway obstruction and breathlessness. The diagnosis of chronic bronchitis is made based on symptoms of cough that produces phlegm on most days, for three months, for two or more years, after other causes for the cough have been excluded.

Emphysema is a condition that involves damage to the walls of the air sacs As a result of that, alveoli (air sacs) lose their stretchiness and trap air. This air trapping within the lungs causes hyperinflation of the lungs. Airway obstruction occurs in emphysema because the alveoli that normally support the air ways open are damaged.

Q. Is it treatable? Is there a cure for it?

A. It is treatable, but there is no cure at present.

Q. Is it true that symptoms often worsen with time and can limit your ability to do routine activities like walking, cooking or taking care of yourself?

bYes. The symptoms of COPD worsen with time. If you continue to smoke, the progression will be very rapid.

Finally you may end up with breathlessness even when resting.. Regular exercises, breathing exercises are important in the management of COPD. Programs to rehabilitate these patients with COPD are available in some countries. These programs are called pulmonary rehabilitation programs.

Q. How is it prevented?

A. Stopping smoking is the single most important thing. This prevents the disease from worsening. Even if you have fairly advanced COPD, smoking cessation will improve your symptoms and slow down further progression.

There are inhalers to improve the symptoms of COPD. These are called broncho-dilators and these will dilate the breathing tubes. Some may need steroid inhalers.

The patients with COPD repeatedly get exacerbations due to infections (viral, bacterial) and also due to exposure to pollutants. Some may need admission to hospital. These patients need antibiotics, steroids and oxygen therapy in addition to other general measures and monitoring. Severe cases may need assisted breathing with the help of artificial breathing apparatuses.

Surgery is an option in a very small number of cases. Removing a non – functioning air filled sacs (called bullae) may improve symptoms in some patients.

Q. Can it lead to cancer or some other serious health issues?

A. It will not lead to cancer but smoking is the primary cause of both, the lung cancers and COPD.

Therefore one should suspect the possibility of lung cancer if there are new symptoms such as presence of blood in sputum, weight loss, and worsening of cough in a patient with COPD. Reduced level of oxygen in the blood and changes in the lung can cause increased pressure in the blood vessels in the lungs.

This increased pressure can put a strain on the heart muscle, leading to heart failure. In addition to these changes, patients with COPD may have other problems such as muscle wasting, depression and problems due to smoking (heart disease, cancers, and stroke).

Q. Can it result in lifelong disabilities?

A. Yes. COPD results in lifelong and permanent disabilities. Patients with advanced disease need lifelong home oxygen treatment in addition to their daily medications. Some may even need artificial breathing apparatuses to assist their breathing at home (NIV - Non Invasive Ventilation).

Q. Can the condition be reversed if a person adopts healthy life styles e.g. quits smoking?

A. This condition cannot be reversed but smoking cessation will definitely improve the symptoms and life expectancy of these patients.

Q. How can you prevent it?

A. Quitting smoking is the single most important thing. One has to make the home smoke free and should take measures to protect against chemicals, dusts, and fumes at home and at work place. Using respiratory protective equipment at work place is also important. There should be adequate ventilation if one is using biomass fuel for cooking. Vaccines such as pneumococcal vaccine and influenza vaccines may prevent infective exacerbations (flare-ups) of COPD.

Q. Roughly how many patients do you see at the Welisara Chest Hospital for this disease per day/month?

A. Every day, there are several patients (4-5) with COPD admitted with exacerbations to National Hospital for Respiratory Diseases (NHRD), Welisara. The sitation is similar in most other hospitals.

Q. Are these facilities available in all leading state hospitals? If not, what is most urgently required to help such patients?

A. Some tests such as spirometry are not available in some of the hospitals. Development of specialised Respiratory units with smoking cessation clinics, pulmonary rehabilitation programs in major hospitals is a priority need.

Q. Despite the efforts of the Ministry of Health government to put an end to smoking, the habit is still widely prevalent and on the rise especially among adolescents. Do you see this as a setback to reducing COPD in Sri Lanka in the near future?

A. Yes, not only COPD, there will be a rise in other smoking related problems too such as lung cancer, heart problems, strokes and other vascular diseases.

Q What has the Health Ministry put in place in terms of 1) prevention 2) treatment?

A. The Ministry of health is now establishing Respiratory units in most of the major hospitals and appointing specialists to far away districts.

Q.Your message to the public?

A. Those who develop persistent cough, breathlessness wheeze should seek medical advice. Quitting smoking and avoiding air pollutants and regular exercises and adopting healthy lifestyles will help to improve disabilities arising from COPD.

Does green tea boost health as claimed?

Among many beverages that we consumed for generations, tea is given a major importance in our day to day lives. Tea from Camellia sinensis plant has been consumed for centuries as a part of the habitual diet of many Asian regions in three major forms: fermented black tea, semi-fermented oolong tea, and non-fermented green tea.

Disregarding the familiar black tea, green tea has been subjected to many discussions regarding its impressive health beneficial claims.

The chemical compound in green tea that is known as ‘polyphenolic flavonoids’, is mainly responsible for its health boosting effects including anti-obesogenic effect, control of fat build up in the body and liver, reduction of body fat and cholesterol levels, reduction of blood pressure and blood sugar levels in the body, anti-carcinogenesis, anti-oxidation and anti-inflammatory properties. Moreover, certain scientists claim that this compound improves memory power and cognition with the aid of many research evidence. Others suggest that polyphenolic flavanoids exert protective effect against psychological diseases as well.

These claims regarding green tea have made its consumption more and more popular over a very short course of time. The attention of the public has turned vastly towards it because, most believe that ‘Health is Wealth’ and ‘A healthy mind lives in a healthy body’.

Does it really fight obesity?

Obesity has become one of the fastest-rising burdens in today’s world. The adverse effects of obesity can be seen in physical and mental health as well as in social lives of many people.

This has made them seek out different alternatives with medicinal properties rather than avoiding meals that they enjoy or being put under the surgical knife. More, people find it difficult to allocate enough time to engage in physical activities with their urbanised, busy lifestyle.

Hence, research results on green tea’s health effects have grabbed more than their fair share of attention and consumption of this form of tea is being encouraged by funding organizations and governments all over the world.


Some studies have successfully proven the anti-obesogenic effect and the favourable effect on body lipid profile of green tea, suggesting it as a shield for obesity and related complications.

It has been found that green tea extract influences the thermogenesis of body fat, leading to fat regulation.

Flavanoids, especially ‘catechins’ interfere with fat absorption in the intestines as well.

These evidence make us believe that long term consumption of green tea can have an effect on body fat reduction. However, the effectiveness of green tea as a source of body fat regulation is on constant debate.

The protective effect is found with high doses of green tea extract and is not noteworthy according to the much proven research evidence of physical activity and calorie restriction on body fat mass regulation.

Is it heart-friendly?

Green tea ‘catechins’ are powerful antioxidants that exert protection against inflammation and oxidative stress in body. Hence, long term consumption of green tea has been found to inhibit the formation of oxidised lipids in blood vessels, which is a risk factor for developing atherosclerosis and strokes.

Moreover, management of oxidative stress and regulation of blood pressure in patients with obesity-related hypertension is also expected.

High blood cholesterol, atherosclerosis, obesity and its related hypertension are some of the major risk factors for heart diseases and heart attacks alike. So, even if it lacks evidence as a cure for heart diseases, green tea can be considered a heart-friendly beverage.

Battle against diabetes

Green tea has been found to be favorable on blood sugar regulation in diabetic patients.

It reduces resistance to the hormone known as ‘Insulin’ within the body via effective transport of blood sugar into cells. Furthermore, it reduces absorption of sugar from diet, by controlling the enzymes at intestines. Hence it controls diabetes.

Yet, the above evidence on blood sugar regulation are still under discussion. Anyhow, green tea is advised to be consumed without sugar which will inevitably makes it a better option than any other kind of sugary drink or fizzy beverage.

Does green tea fight cancer?

The current knowledge on the link between green tea and cancer is controversial. As evident by different studies, green tea is efficient in shielding against some forms of cancer including prostate and lung cancer. The cancerous tumor growth is hindered via reduction of tumor cell inflammation. But, some evidences reveal that green tea is of no use against breast cancer.

On the whole, green tea can be recognised as one of the most nutritive beverages. Although the available evidences reveal a protective role by green tea on obesity and other complications, they are contradictory and insufficient to draw a conclusion.

However, it would be better to consider green tea as a preventive source for several lifestyle diseases rather than a source of cure.

The efficacy of effects is enhanced with increasing doses and the health beneficial claims of green tea should neither be underestimated nor overlooked.

As a herbal beverage, green tea boosts one’s physical, mental and social well-being with its additional benefits and is a better option than any other beverage that has only water and sweetening agents with added chemicals.


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