Management of patients with obstructive lung disease in South India: a retrospective study of spirometry and bronchodilator use in an urban health centre

Niger David, Sajitha M. F. Rahman, Ruby Angeline Pricilla, Sunil Abraham, Kirubah V. David


Background: Based on the burden of obstructive lung diseases program (BOLD), the global prevalence of chronic obstructive pulmonary disease (COPD) was 11.7% in which 90% of the deaths occur in low- and middle-income countries. India and China are estimated to account for 66% of total global COPD mortality. The Indian Chest Society (ICS) recommends spirometry to document irreversible airflow limitation in patients suspected of having COPD. However, the reported usage of spirometry among primary care physicians in India is only 10-20% as primary health care centers in India are not equipped with spirometry or inhaler devices.

Methods: A retrospective study was done on patients treated for respiratory symptoms with bronchodilators at an urban health centre to document the practice pattern of primary care physicians with regards to use of spirometry in patients on bronchodilators.

Results: Of the 1196 patients on bronchodilators, spirometry was documented in 15.5%. Patients on inhalers, using more than one therapy and males less than 55 years were more likely to undergo spirometry. About 52.4% of patients who underwent spirometry were found to have post bronchodilator forced expiratory volume at first second (FEV1)/ forced vital capacity (FVC) less than 0.7 of which 43% had severe disease and 44% had poor post-broncho-dilator reversibility.

Conclusions: Besides diagnostic spirometry, management guidelines for COPD should be complemented by health education to change patients’ perception of respiratory symptoms, increase awareness of COPD in those with risk factors and change their health seeking behaviour along with continuous professional development activities for primary care physicians.


Spirometry, Primary care, Secondary care, Urban health centre

Full Text:



Chronic Obstructive Pulmonary Disease Fact Sheet. 2017 Available at: centre/factsheets/fs315/en/ Accessed on 19 February 2019.

Adeloye D, Chua S, Lee C, Basquill C, Papana A, Theodoratou E, et al. Global and Regional Estimates of COPD Prevalence: Systematic Review and Meta-analysis. J Glob Health. 2015;5(2):020415.

Lopez AD, Shibuya K, Rao C, Mathers CD, Hansell AL, Held LS, et al. Chronic obstructive pulmonary disease: current burden and future projections. Eur Respir J. 2006;27:397-412.

Kalkana T, Moitra S, Jindal SK. Increasing burden of COPD in rural India: an example why India warrants primary healthcare reforms. ERJ. Open Res. 2016;2(2):00032.

Bhome AB. COPD in India: Iceberg or Volcano? J Thorac Dis. 2012;4(3):298-309.

Gupta D, Agarwal R, Aggarwal AN, Maturu VN, Dhooria S, Prasad KT, et al. Guidelines for diagnosis and management of chronic obstructive pulmonary disease: joint recommendations of Indian Chest Society and National College of Chest Physicians (India). Indian J Chest Dis Allied Sci. 2014;56:5-54.

Salvi S, Apte K, Madas S, Barne M, Chhowala S, Sathi T, et al. Symptoms and medical conditions in 204 912 patients visiting primary health-care practitioners in India: a 1-day point prevalence study (the POSEIDON study). Lancet Glob Health. 2015;3(12):e776-84.

Kaur I, Aggarwal B, Gogtay J. Understanding perception of chronic obstructive pulmonary disease among general practitioners, physicians and pulmonologists in India: Results from a face-to-face survey. Perspect Clin Res. 2016;7(2):100–5.

The Commonwealth Fund. International Profiles of Health Care Systems 2015. Available at: ntl_profiles_2015_v7.pdf. Accessed on 9 February 2019.

Levy ML, Quanjer PH, Booker R, Cooper BG, Holmes S, Small I. Diagnostic spirometry in primary care: Proposed standards for general practice compliant with American Thoracic Society and European Respiratory Society recommendations. Prim Care Respir J. 2009;18(3):130-47.

Vanjare N, Chhowala S, Madas S, Kodgule R, Gogtay J, Salvi S. Use of spirometry among chest physicians and primary care physicians in India. NPJ Prim Care Respir Med. 2016;26:16036.

Kotwani A. Access to essential medicines and standard treatment for chronic diseases. Indian. J. Pharm. 2010;42(3):127-8.

Global Strategy for The Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease 2018 Report. Available at: https://goldcopd. org/wp-content/uploads/2017/11/GOLD-2018-v6.0-FINAL-revised-20-Nov_WMS.pdf Accessed on 8 March 2019.

Koefoed MM. Spirometry utilisation among Danish adults initiating medication targeting obstructive lung disease. Dan Med J. 2015;62(2):B5004.

Nielsen LO, Olsen S, Jarbol DE, Pederson ML. Spirometry in Greenland: a cross-sectional study on patients treated with medication targeting obstructive pulmonary disease. Int J Circumpolar Health. 2016;75:33258.

Albers M, Schermer T, Molema J, Kloek C, Akkermans R, Heijdra Y, et al. Do family physicians’ records fit guideline diagnosed COPD? Fam Pract. 2009;26(2):81-7.

Arne M, Lisspers K, Stallberg B, Boman G, Hedenstrom H, Janson C, et al. How often is diagnosis of COPD confirmed with spirometry? Respir Med. 2010;104(4):550-6.

Mc Geachie MJ, Yates KP, Zhou X, Guo F, Sternberg AL, Van Natta ML, et al. Patterns of Growth and Decline in Lung Function in Persistent Childhood Asthma. N Engl J Med. 2016;374(19):1842-52.

Guirguis-Blake JM, Senger CA, Webber EW, Mularski RA, Whitlock EP. Evidence Report for the USPSTF. Screening for Chronic Obstructive Pulmonary Disease. JAMA. 2016;315(13):1378-93.

Kotwani A. Availability, price and affordability of asthma medicines in five Indian states. Int J Tuberc Lung Dis. 2009;13(5):574-9.

Das A, Uppe A, Sinha K, Jayalakshmi TK, Nair G, Nagpal A. The adequacy of inhaler technique in patients with chronic obstructive pulmonary disease and asthma attending a tertiary care hospital in Navi Mumbai. Indian J Allergy Asthma Immunol. 2016;30:95-8.

Dong YH, Hsu CL, Li YY, Chang CH, Lai MS. Bronchodilators use in patients with COPD. Int J Chron Obstruct Pulmon Dis. 2015;10:1769–79.