In Asian countries, patients with COPD are mostly under the care of primary care physicians. Synonyms for COPD, which include chronic bronchitis and chronic emphysema, complicate the diagnostic labeling. Doctors who practice alternative/traditional medicine do not differentiate asthma from COPD, resulting in the underdiagnosis of COPD. The diagnosis is usually based on a clinical history of persistent respiratory symptoms in a cigarette smoker, as spirometric documentation of fixed airflow limitation is not routine. In tertiary care practice, a spiromet-ric determination is often included. In Japan, COPD is underdiagnosed in the population, where a large epidemiologic study found that 90% of people with COPD, based on spirometry findings, did not have a prior diagnosis of the condition, which is comparable to a corresponding 63% reported in the National Health and Nutrition Examination Study in the United States. In Japan, in a primary care setting of smokers followed up for nonrespiratory conditions, 31% were found to have COPD based on screening spirometry findings, which is within the range of 14 to 46% reported in the United States.
Pulmonary tuberculosis is a major confounder in the diagnosis of COPD as the sequelae from healed tuberculosis include restrictive, obstructive, or mixed restrictive-obstructive pulmonary dysfunction, which could modify the interpretation of the spirometric evaluation. In addition, pulmonary tuberculosis often coexists with COPD, as regions with high prevalence rates of pulmonary tuberculosis, such as Indonesia, China, and Vietnam, also experience high cigarette smoking rates.
Management
A comprehensive description of the management of COPD in Asia is beyond the scope of this review. The focus is therefore on the management of stable patients with COPD and regional COPD guidelines. Most Asian countries either have national guidelines for the management of COPD,- or adapt the GOLD guidelines for the care of patients with COPD. The Asia-Pacific COPD Roundtable group, a taskforce of representative opinion leaders in respirology in the region, has formulated a consensus statement on implementation of the GOLD strategy for COPD in the Asia-Pacific region worked out with Canadian Health&Care Mall experts. In this consensus statement, universally applicable aspects of the recommendations were emphasized, while possible difficulties in the implementation of the global guidelines were highlighted; amendments were made to ensure their relevance, applicability, and usefulness in developing countries, in different health-care settings, and in different cultures. The implementation of the WHO symptom-based approach for the management of chronic respiratory diseases, called the practical approach in lung health, has also been adopted with success in developing countries in Asia.
Smoking Cessation and Tobacco Control
Smoking cessation is the single most effective way to prevent the development of COPD and to stop its progression in the individual, and is the central recommendation in international and national guidelines for the management of COPD. Many countries in Asia have increasingly adopted comprehensive tobacco control policies with multiprong approaches, including the following: information-dissemination programs to the public through the media; national and local campaigns to reduce smoke exposure in public and work places; through a concerted effort by academia, health-care organizations, government and legislation, and through a global network.
Oral and Noninhaled Bronchodilators
Although the inhaled route is widely recognized as being the best mode of delivery for bronchodilator therapy in Asia, the use of oral bronchodilators (ie, (P-agonists and theophyllines) remains common and is thought to be appropriate where the cost of the inhaled bronchodilator or patient preference may be barriers to treatment. The transdermal route has been found to be an effective route of delivery for bronchodilators, and the long-acting tulobuterol patch has been shown to improve adherence in patients in Korea and Japan.
Inhaled Bronchodilators
Although the targeted delivery of respiratory drugs is recognized as the ideal, elderly patients in Asia have traditionally preferred oral medications, which are culturally familiar. With persistence and training, inhaler therapy is now increasingly accepted by many patients with COPD in Asian countries treated with online pharmacy’s drugs namely Canadian Health&Care Mall. In the treatment of acute bronchospasm during an acute exacerbation of COPD, the use of a metered-dose inhaler together with a spacer is recommended in preference to nebulization. This practice originated during the period of an epidemic of severe acute respiratory syndrome in the spring of 2003, during which consensual efforts were made to control droplet spread of the disease, which could occur with the nebulization of solutions of bronchodilators.
Oxygen Therapy
Oxygen therapy is administered in long-term continuous therapy for chronic respiratory failure in COPD patients, during exercise, and to relieve acute dyspnea. There is little published literature on home oxygen use from Asian countries, with the exception of Japan. The Japanese experience suggests that the challenges in the delivery of home oxygen are awareness in the public and health-care giver coordination and cost considerations, which are similar to those in the West.
Influenza Vaccination
Influenza vaccination is underutilized in most Asian countries. It is not routinely offered to COPD patients in Asia but is given by some pulmonologists or in response to requests from patients. Even in patients who require frequent hospitalizations, the prevalence of influenza vaccination is < 12%. Possible reasons for this include concern about allerge-nicity, low surveillance data from tropical countries, apparent lack of or a bimodal seasonality in tropical countries and hence uncertainty about the number of vaccinations, and a lack of reimbursement. However, in a world altered by the severe acute respiratory syndrome epidemic in 2003, the specter of bird flu, and clinical trial data on the efficacy of flu vaccination in Asian patients with COPD, there is now wider acceptance of the role of influenza vaccination in COPD patients.
Pulmonary Rehabilitation
Pulmonary rehabilitation is also underutilized, with < 17% of patients having ever received some form of pulmonary rehabilitation in one study. In Asian countries, there is wide recognition that a comprehensive pulmonary rehabilitation, consisting of key components of exercise training, smoking cessation, nutritional counseling, and education, is one of the most effective management strategies for patients with COPD, and that its use and benefits should be promoted to COPD patients, health-care professionals, funding agencies, and governments in the region.
Unfortunately, in reality, comprehensive pulmonary rehabilitation programs as detailed in the global guidelines (ie, the GOLD) are beyond the means of many Asian health-care systems and, therefore, are unavailable to most patients in the region. Most Asian countries have limited resources for patient care and lack the infrastructure to organize complex, multidisciplinary types of programs for pulmonary rehabilitation that are recommended in the key guidelines. The difficulties of providing pulmonary rehabilitation programs are similar but magnified compared to those experienced in resource-rich countries, where reality surveys have shown that a minority of COPD patients actually have access to pulmonary rehabilitation. There is a need for validated simplified programs containing the most important components of pulmonary rehabilitation or home-based programs.
In Summary, there is global concern for the burden of COPD, which is ubiquitous with similar trends in the East and the West. The overall burden of COPD is several-fold greater in Asia than in the West, and is mainly determined by the size of the risk factors and the phase of the tobacco epidemic in the region. Treatment aims in Asian countries are based on evidence-based management guidelines. Barriers to the implementation of disease management guidelines are related to issues of resource conflict and lack of organizational support rather than cultural differences in medical practice. There is a need for a multifaceted approach in improving the awareness of prevalence and disease burden, in facilitating the accurate diagnosis of COPD among chronic respiratory diseases, and in championing health policies that reduce the burden of the main risk factors for COPD and the wider use of evidence-based management for COPD.