Dr Mobin Ur Rehman, Associate Professor, Department of Pediatrics, Bolan

Medical College Quetta. mobin38@gmail.com

Profile of COPD patients in UAE

A cohort of BREATHE Study

Introduction; Chronic obstructive pulmonary disease (COPD) is a common

inflammatory disease of the airways characterized by airflow obstruction that is not
fully reversible. Smoking most often causes it, but other factors including exposure to
biological agents can play a significant role in its development(1). Tobacco
consumption, either in smokeless form or as smoking, is reported to be responsible for
major non-communicable diseases, namely, cardiovascular diseases, chronic
obstructive pulmonary diseases and cancers(2). Chronic obstructive pulmonary
disease (COPD) is one of the leading causes of mortality. Although more prevalent in
men, it is anticipated that, due to the convergence in smoking rates, the prevalence
rate in women will surpass that of men(3). The number of senile patients with chronic
obstructive pulmonary disease (COPD) has recently increased due to an increase in
life expectancy, the habit of smoking and the inhalation of toxic particles(4). Patients
with COPD are at risk for other comorbid diseases, like heart failure, coronary heart
disease, and depression(5). The poor recognition and related under diagnosis of
COPD contributes to an underestimation of mortality in subjects with COPD(6).
Apart from known COPD risk factors (age, smoking, lower educational level), a
history of tuberculosis may be associated with COPD even in high-income
countries(7). Patients with COPD show higher nicotine dependence and seem to have
greater difficulty in quitting smoking. Nevertheless, smoking cessation should be a
priority in these patients, as it constitutes the only measure able to halt progression of
the disease(8). Despite a large proportion of individuals at risk for COPD or having
COPD and a high prevalence of breathlessness, awareness of respiratory symptoms
and knowledge of COPD were limited(9). The World Health Organization has
estimated that by 2030, chronic obstructive pulmonary disease will be the third
leading cause of death worldwide. Most knowledge of chronic obstructive pulmonary
disease is based on studies performed in Europe or North America and little is known
about the prevalence, patient characteristics and change in lung function over time in
patients in developing countries(10). The current paper is part of a larger study and
concerns the prevalence of COPD in UAE.
Patients and methods: The BREATHE study was a cross-sectional,
observational,
population-based survey of COPD. It was conducted in six locations (four countries
and two regions. The present paper concerns the UAE data only, which was part of
Middle Eastern region. The number of individuals in target sample for UAE was
3500. The study was carried out by telephone, allowing the systematic screening of a
national sample in order to identify a national probability sample of individuals likely
to have COPD. Telephone numbers (landline and mobile phones) were randomly
generated using an assisted random-digit dialing procedure. Numbers were generated
by blocs. Subjects were contacted by dialing each telephone number on the list
consecutively. After 15 attempts of dialing the outcomes were categorized as

interview, formal refusal or not a valid number (out of service, professional number
or fax or not reachable). Work telephone numbers were considered to be non-eligible.
For eligible landline or mobile telephone numbers, the interviewer characterized the
subjects in terms of age, gender and region. Inclusion and exclusion criteria. During
the screening phase, male or female subjects aged 40 years, who agreed to participate
in the study, were enrolled. Subjects not domiciled in UAE or those of foreign origin
resident in UAE for less than six months at the time of the interview or having
comorbid mental illness were excluded. Eligible subjects were provided with
standardized information about the study, not mentioning COPD in order to avoid
potential bias, and were invited to respond to the screening questionnaire. Subjects
recruited: This is shown in Table no 1. In order to ensure representativeness of the
population of each country as a whole, cross-stratification was performed to ensure
representativeness by age and gender, and margin stratification to ensure
representativeness by region. Subjects fulfilling the screening criteria were invited to
complete a more detailed questionnaire on the disease (detailed COPD patient
questionnaire). At the end of this exercise four categories of subject populations were
defined. The first category concerns eligible subjects fulfilling the smoking criterion
as well as either the symptom criterion or the diagnosis criterion. This population was
identified as the COPD population. The second category, identified as the Possible
COPD population, corresponds to subjects fulfilling either the smoking criterion or
the symptoms criterion or the diagnosis criterion. The third category, corresponding to
subjects not fulfilling any of these criteria, was identified as the Non-COPD
population. The fourth category, identified as the Potential COPD population,
corresponds to those fulfilling at least one of these criteria and thus includes all the
COPD population as well as subjects in the Possible COPD population fulfilling
only a single criterion. Subjects included in the COPD population were considered
as positively screened and invited to undergo a more detailed telephone questionnaire
on the disease. All subjects in the COPD population were invited to complete a cost
of disease questionnaire. This questionnaire aimed to assess the cost of COPD and its
impact on quality of life and health as well as two questionnaires assessing the
severity of COPD. A randomly selected subgroup of subjects in the Potential COPD
group in each country was invited to undergo spirometry. A second ancillary study
investigated health status using the COPD Assessment Test (CAT). Data are presented
as proportions and means with standard deviations (SD), or medians with interquartile
ranges (IQR). 95% confidence intervals (95% CI) were calculated for binomial data.
Associations between categorical variables were estimated using the c2 test and the
Mantel Haenszel test for trends, as appropriate. Two-sided tests were used in all cases
and a probability threshold of 0.05 was considered significant. Bonferroni correction
was applied for multiple testing procedures, when appropriate. All statistical analyses
were performed using SPSS Version 17. Prevalence rates were estimated separately
for each country by dividing the total number of positively screened subjects by the
total number of screened subjects. Prevalence rates were adjusted for age and gender.
Results: A total of 3516 subjects were screened and the expected individuals were
3500. Women comprised 48% of subjects while men were 52% in the screened group.
The age wise distribution was 57.3% in 40-49 years, 31.2% in the 50-59 years and
only 11.5% in the >60 years group. The adjusted proportion of interviewees who
reported current or past smoking was 23.5% (n = 812); [95% CI: 21.1- 25.0%]). Out
of 812 smokers, only cigarette smoking was found in 688 individuals 19.9% [18.6
21.3%], 90 [1.5 2.5%] smoked water pipes alone while 55 smoked both cigarettes and

water pipes. A total of 114 women smoked cigarettes, of whom 67(59.1%) smoked
>10 pack years. The age adjusted smoking exposure in women of UAE was 16.7+16.8 pack years while in men it was 28.2+-24.6 pack years. In men of UAE 622
smoked cigarettes, out of which 498(78.5%) smoked >10 pack years. As far as the use
of water pipes is concerned 33 women smoked with 22(66.7) smoking for more then
five years. Among men 90 patients smoked water pipes of which 63(70%) smoked for
more then five years. A total of 7.2% patients reported COPD related symptoms, out
of which 1.1% had productive cough, 5.2% had breathlessness while 0.98% had both
breathlessness and cough. Among women 7.1% patients had COPD related
symptoms, 0.9% patients had productive cough, 7% patients had breathlessness alone
while 1.1 had both breathlessness and productive cough. In men 6.1% patients had
COPD related symptoms, out of which 2% patients had productive cough, 3.6%
patients had breathlessness while 0.5% patients had both breathlessness and
productive cough. 21(0.6%) patients fulfilled the GOLD criteria while 66(1.9%)
fulfilled the official definition of COPD in UAE. 8 (50.0%) patients were obese, 6
(37.5%) patients were overweight (BMI 25-<30) while 2 (12.5%) patients were of
normal weight. 14 (51.9%) patients had comorbid conditions, 2 (7.4%) patients were
in poor health, 12 (44.4%) patients were in fair health, 8 (29.6%) patients were in
good health while 5 (18.5%) patients were in excellent health. The age of persistent
cough with phlegm was 39.6 7.6;the age at first dyspnea was 40.110.9 while the
known COPD diagnosis was present on 8(29.6%) patients. 15(55.55%) patients had
lung function performed at least once in the past while 12(44%) patients had done
lung function test in last year. Only 1 (3.8%) patient used oxygen, 1 (16.7%) patients
used antibacterials, 4 (66.7%) patients used bronchodilators without corticosteroids, 3
(50.0%) patients used long acting bronchodilators, 3 (50.0%) patients used long
acting bronchodilators. 16 (59.3%) [40.7-77.8%] patients consulted physicians, the
mean number of consultations being 4.64.9. Of these 5 (31.3%) patients visited
general practioners, 7 (43.8%) patients visited pulmonologists and 4 (25.0%) patients
visited other doctors. 11 (40.7%) [22.2 59.3%] patients stayed overnight in hospital or
longer, the mean number of hospitalization days was 2.41.6, the mean number of
nights spent at hospital was 3.85.0, and emergency room visits were 3.85.0 while
[6.5 37.9%] while mean number of emergency room visits was 4.55.1. 12 (44.4%)
patients said they are trying to stop smoking, 12 (85.7%) patients had discussed
cession with a doctor and 8 (47.1%) patients admitted to still smoking in the
household. 37% patients in UAE experienced exacerbations. The severity of asthma
was mild in 24%, moderate in moderate in 71% and severe in 5% of patients. As far
as the CAT population is concerned, 57.5% patients were 40-49 years, 29.9% patients
were between 50-59 years and 12.6%) patients were >60 years. The male population
in CAT was 44.1% patients while female were 55.9% patients. All patients in UAE
were married. 2 (40.0%) patients did not attend high school, 2 (40.0%) patients
attended high school and 1 (20.0%) patient attended college. 4 (80.0%) patients were
employed and 1 (20.0%) patient was homemaker. In the CAT population 2 (40.0%)
patients were obese, 2 (40.0%) patients were overweight and 1 (20.0%) patient had
normal weight. 3 (60.0%) had fair health, 1 (20.0%) had good health while 1 (20.0%)
was in excellent health. Comorbidities were present in 2 (40.0%) patients.

Discussion:
In our study the majority of the population was male, this is in contrast to
international studies that have determined that the prevalence of COPD among
females has risen sharply over the last 20 years(11, 12). This is probably due to
cultural and social factors where smoking is seen as a predominantly male habit.
Moreover, women with COPD may present differently, may have a different pattern
of comorbidities, and may have a better survival after acute exacerbations(13). In our
study almost 60% of the patients were in the 40-49 age group. Again other workers
have documented only 10.89% in Russia(14) and 3.5% in japan(15). Our second age
group was also larger then found by Russian workers(14) and Sweden(16). More
studies are needed to explain this but dietary and genetic factors may be implicated.
Our smoking rate (23.5%) was less then reported by other workers in Europe (17, 18).
This may be due to increased health awareness experienced in this part of the world.
Under reporting and risk factors other than smoking may contribute to this
difference(19). Our age adjusted smoking exposure was also less then found in
Poland(20). This also reflects the decline of smoking in this part of the world. Our
study found the lesser prevalence of productive cough in women and this has been
reported in the literature(21, 22). Other studies have documented increased
breathlessness in women than found in our study(23). Indeed breathlessness has been
described as the most common symptom(24). Similarly our patients fulfilling the
GOLD criteria were less as compared to Korean population (0.6%vs 3.7%)(25).
Weight gain affects respiratory outcomes differently between obese and normalweight smokers. Whereas FEV1 and health status decrease with weight gain among
obese smokers, they improve among normal-weight smokers(26). Low BMI was not
only a systemic consequence of COPD but also an important risk factor for the
development of COPD, which raises the possibility that early intervention in subjects
with low BMI may reduce the incidence of COPD(27). Patients with COPD being
overweight or obese had a protective effect against mortality(28). In our study almost
half of the patients were obese. COPD is a strong predictor of reduced survival
independently of coexisting cardiovascular and metabolic disorders(29).
Comorbidities such as pulmonary artery disease and malnutrition are directly caused
by COPD, whereas others, such as systemic venous thromboembolism, anxiety,
depression, osteoporosis, obesity, metabolic syndrome, diabetes, sleep disturbance
and anemia, have no evident physiopathological relationship with COPD. The
common ground between most of these extra pulmonary manifestations is chronic
systemic inflammation(30). In COPD patients, mortality risk is influenced by age,
severity of respiratory disease, and comorbidities(31). In this study half of the patients
were obese. We found that the age of persistent cough with phlegm was less then
reported in the literature (39.6 years vs. 48.5 years)(+/- 6.8)(32). Dyspnea is
associated with mortality in a severity-dependent manner and dyspnea remission
normalizes mortality risk. Having or developing dyspnea is a risk factor for
mortality(33). We found that age at first dyspnea was more then reported by other
workers(34). Also we had a larger percentage of patients with diagnosed COPD then
reported in England(35). Unfortunately less proportion of patients under went
diagnostic breathing tests when compared internationally(36). The use of medications
of all classes was less when compared to international data(37). This may be
explained by the rational use of medication in this country. Airway inflammation and
hyperinflation independently contribute to impaired health status in COPD. This may

provide a rationale for anti-inflammatory therapy in this disease(38). The proportion

of our patients paying visit to pulmonologist was found higher then cited in the
literature(39). This represents the ability of general practioners to refer these patients
to pulmonologists rather than internists. We found the mean duration of
hospitalization to be significantly less then reported elsewhere(40). This may be due
to more specialized care and therapy given here. Our emergency room visits were also
less compared to western studies(41). More than 50% of the smokers with COPD are
amenable to smoking cessation support(42). In our study nearly half of them were
trying to quit which is almost double then found in other studies(43). The Chronic
Obstructive Pulmonary Disease (COPD) Assessment Test (CAT) is an eight-item
questionnaire designed to assess and quantify the impact of COPD symptoms on
health status(44). One of the aims of the COPD Assessment Test (CAT) is to aid
communication between the physician and patient about the burden of chronic
obstructive pulmonary disease (COPD) on the patient's life. The CAT is a diseasespecific instrument that aids physician assessment of COPD. It does not appear to
improve detection of non-COPD symptoms and co-morbidities(45). In patients with
COPD and severe airflow obstruction, the CAT score reflects a moderate to severe
impact of illness(46). The CAT is a potentially useful instrument to assess the efficacy
of treatments following COPD exacerbations(47). Our CAT scores were on from 3 to
7 while other studies have found these to be between 5 to 39(48).

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Figure 1: Gender Distribution of Study

population

40-49 yrs
50-59 yrs
>60 yrs

Figure 2:Age distribution of the study population

90
80
70
60
50
40
30
20
10
0
50-59 yrs

>60 yrs

Figure 3: Symptoms distribution in the study population.

Series 1= Male: Series 2=Female

Table 1: CAT profile of UAE patients

Mean CAT score
Smoker women
Non-Smoker
women
Smoker men
Non-Smoker men

Gender versus CAT Smoking

versus
p value
CAT p value

N=12
(7.176.74)
N = 129
(6.576.49)
N=46 (6.526.24)
N=68 (3.824.41)
0.0253

0.2535