With the in-depth research on chronic obstructive pulmonary disease (COPD) in recent years, many key aspects of its pathogenesis have been gradually revealed, and new drugs and treatments have been developed accordingly. A large number of international multicenter clinical studies have proved that COPD is a preventable and treatable disease, and proper treatment can improve patients’ symptoms, improve their quality of life, and even slow down the disease process. In order to better prevent and treat COPD, the Global Initiative on Chronic Obstructive Lung Disease (GOLD) was launched to guide physicians to diagnose, treat and prevent COPD in a standardized and rational way.
First, the number of COPD patients is huge, and the incidence and death rate of COPD is high
At present, China has a population of 1.3 billion, accounting for 1/5 of the world’s population, and the proportion of the population aged over 40 years old has exceeded 40%, about 500 million people. It is speculated that by 2030, half of our population will be older than 40 years old. Since the incidence of COPD will increase exponentially after the age of 40, the number of people suffering from COPD in China will also increase year by year, and the number of patients will be extremely large.
The results of a recent large cross-sectional survey of COPD in China (BOLD study) showed that the overall incidence of COPD in people older than 40 years of age was 8.2%. Although the incidence of COPD varies between regions of the country, ranging from 5% to 13%, the incidence in most regions is still higher than the 6.7% estimated by the World Health Organization (WTO) and higher than the 4-10% incidence in Western countries. According to the WHO, COPD will be the third leading cause of death in the world after ischemic heart disease and cerebrovascular disease by 2030, up from the 6th in 1990. Data from China’s Ministry of Health show that among the top 10 causes of death in China, respiratory diseases (mainly COPD) account for 13.89% in urban areas, ranking 4th; and 22.04% in rural areas, ranking 3rd. The annual number of COPD deaths in China is 1.28 million, which is equivalent to 2.5 deaths from COPD every minute.
The large patient base, the changing age structure of the population, and the high mortality rate of the disease itself pose great challenges to the standardization of COPD prevention and treatment nationwide.
Second, the health economic burden of COPD is high
In China, the cost of COPD treatment and its proportion to the patient’s household income are extremely high, imposing a huge economic burden on both the patient’s family and society. According to a survey in 2006, urban COPD patients in China spent US$1,732.24 per capita on direct medical care and US$231.6 on indirect care and transportation, accounting for 40% of the average household income in China. The cost of maintenance medication during the stabilization period is US$443-738 per capita per year, which is already a huge financial burden for most families or individuals in China, especially those in rural areas. According to the survey, less than 40% of COPD patients with chronic hypoxia use oxygen therapy because of the high cost ($517/year). Globally, the overall disease burden of COPD will double in the next 25 years if calculated by disability-adjusted life years (DALYs). By 2030, COPD will rise from its current ranking of 13th in the global burden of disease to 7th. And the disease burden of COPD in China far exceeds that of developed countries, having become the 2nd chronic disease causing loss of DALYs in China as early as 2001.
Third, there are many risk factors for COPD
Smoking is the most important risk factor for COPD, and the incidence of COPD is closely related to the total amount of smoking. China is the world’s largest producer and consumer of tobacco, with about 30% of the world’s tobacco produced and consumed in China in 2002. It is estimated that China has 350 million smokers, the largest smoking population in the world, and 66.9% of men and 4.2% of women smoke, accounting for 1/3 of the total number of smokers worldwide. in addition, the exposure rate of secondhand smoke in Chinese households is increasing year by year, and the passive smoking rate among non-smoking women has reached as high as 82.5%. Even more serious is the increasing number of young smokers. If both smokers and passive smokers are counted, the tobacco exposure rate for people over 15 years old in China is 72%. Quitting smoking is a key component in reducing the occurrence of COPD, but surveys in China show that 74% of smokers are unwilling to quit, 20% have tried to quit at least once, but half of them relapse after quitting, which is mainly due to the current lack of public awareness of the harmful effects of active and passive smoking in China.
In addition to smoking, the use of biofuels is also an important risk factor for COPD. Studies have reported that solid fuels such as wood, crop straw and coal are used in more than 70% of Chinese households and even more than 90% in rural areas. An epidemiological survey of people aged >40 years in urban and rural areas of Guangdong found that rural non-smoking women were at higher risk of COPD than urban non-smoking women. In addition, due to the cooking habits of Chinese families, pollution from kitchen fumes is a factor that cannot be ignored.
In addition, outdoor air pollution is also a risk factor for COPD. Atmospheric particulate matter ≤2.5 μm in diameter can be inhaled into the lungs, which is called PM2.5 and comes mainly from the combustion of fossil fuels, such as motor vehicle exhaust, coal combustion, and natural gas. It can produce oxygen radicals in the body, deplete endogenous antioxidants, affect mitochondrial function, cause oxidative damage to lipids and DNA, and increase oxidation products at the molecular level, causing harm to the organism. PM2.5 less than 10μg/m3 is a safe value, while in North, East and Central China all are higher than 50μg/m3. According to this standard, the proportion of Chinese cities meeting air quality standards is only 20%. In the winter of 2011, the PM2.5 concentration in Beijing was as high as 522μg/m3.
The high number of smoking population, the household use of solid biofuels, and the increasing severity of air pollution have all become huge environmental obstacles to the prevention and treatment of COPD in China.
Fourth, the early diagnosis and intervention of COPD are insufficient
Early diagnosis of COPD can force patients to quit smoking early and start effective treatment as early as possible to slow down the development of COPD. The process of COPD However, the lack of knowledge about COPD risk factors and early manifestations of the disease has led to a lag in diagnosis and intervention. The BOLD study in China found that only 35.1% of all patients diagnosed with COPD had been previously diagnosed with COPD, suggesting that COPD is severely underdiagnosed. In a survey conducted in rural areas in northern China among people over 40 years of age, 148 cases of COPD were diagnosed among 1624 subjects, but none of the 148 COPD patients had been previously diagnosed with COPD. another study in southern China found that only 15.9% of COPD patients were moderate COPD at the time of diagnosis, and most of the patients In addition to the lack of awareness of COPD among primary care providers, another important reason may be that most Chinese patients, especially those in rural areas, have a high level of symptom tolerance and a lack of medical resources, and these patients usually only seek care when their symptoms are already severe or even acutely exacerbated. The majority of Chinese patients, especially in rural areas, have a high level of symptom tolerance and a lack of medical resources.
The diagnosis of COPD requires not only the appropriate clinical presentation and exposure to risk factors, but also a more important indicator, lung function. Pulmonary function tests are necessary to diagnose COPD and can clarify the diagnosis of COPD and reflect the severity of COPD. However, less than 1/3 of COPD diagnoses in China are made with the help of spirometry, and in some rural areas COPD diagnoses are never made with spirometry. A survey found that among 185 patients previously diagnosed with COPD, only 67 cases were confirmed as COPD by pulmonary function measurements, while 47 cases had normal pulmonary function. Accordingly, we can easily see that the lack of use of spirometers is also one of the important reasons for the misdiagnosis and underdiagnosis of COPD in China at present. It is not difficult to apply simple spirometers in clinical practice, but currently they are not available even in large hospitals in major cities in China, and even less in rural hospitals as a routine medical equipment. The reasons for this phenomenon are many, including the lack of awareness of the diagnostic value of lung function instruments, insufficient national economic investment, and lack of technical personnel and equipment, which is even more serious in primary care institutions.
Fifth, the treatment of COPD is not standardized
Due to the low awareness of COPD diagnosis and treatment among a considerable number of physicians in China, their treatment plans and recommendations often contradict the standardized prevention and treatment of GOLD guidelines. According to the survey, only 20% of primary care physicians are fully aware of the pharmacological treatment of COPD. According to the GOLD guidelines, β2 agonists, anticholinergics and bronchodilators such as theophylline should be the basic drugs for COPD treatment, and inhaled glucocorticoids are only recommended for COPD patients with moderate to severe obstruction or with frequent acute exacerbations. In a survey involving about 700 patients with stable COPD in China, the most used drugs were found to be expectorants, followed by β2 agonists and anticholinergic drugs. Among the patients who used bronchodilators, more than half of them used short- or medium-acting drugs. Also, the guidelines recommend that for stable COPD treatment should be selected according to the severity of the disease, and if there is no significant adverse drug reaction or deterioration, long-term regular therapy should still be maintained at the same level, and usually no step-down therapy is indicated. However, in clinical practice, we often find that it is very common for both physicians and patients to arbitrarily downgrade the level of treatment and prematurely discontinue medication.
In addition to the above-mentioned problems, common irregularities in treatment by our physicians include: emphasis on the treatment of acute exacerbations of COPD and neglect of the management of stable COPD; emphasis on symptom reduction and short-term efficacy, lack of long-term treatment and control of future risks; arbitrary application of hormones and antibiotics in the stable phase and arbitrary shortening of the course of treatment; insufficient use of oxygen therapy and non-invasive intermittent positive pressure assisted ventilation; and risk factors such as smoking cessation The use of oxygen therapy and non-invasive intermittent positive pressure assisted ventilation is insufficient; risk factors such as smoking cessation are not taken seriously.
Sixth, poor self-management of COPD patients in China
In China, especially in rural areas, COPD patients pay relatively less attention to and manage their COPD condition due to the influence of education or family economic factors. The survey found that less than 30% of the people who frequently visit hospitals know the term “COPD”, and the awareness rate is even lower in rural areas. At the same time, COPD patients in China are not aware of the risk factors of COPD, the importance of lung function measurements, the significance of inhaled medication and home oxygen therapy. A survey showed that 23% of COPD patients who smoke are not aware of the health risks of smoking. At the same time, Chinese COPD patients have very poor medication compliance, often reducing the dose or frequency of medication without a doctor, and stopping medication when they feel relief or when they think they do not need it.
Inadequate development of new drugs for COPD
The lack of new drug development for COPD is not only a problem for COPD prevention and treatment in China, but also a global problem. Because the pathogenesis of COPD is still not fully understood, there has been a lack of breakthrough in the drug treatment of COPD. Although new targets and drugs such as novel bronchodilators, protease antagonists, phosphodiesterase 4 (PDE4) inhibitors, antioxidants, and non-antibiotic macrolides have emerged, it seems that the reversible degree of airway obstruction caused by COPD airway inflammation is very low, which makes it difficult to evaluate the efficacy of new drugs in clinical practice, and the development of new drugs is still a long way off. There is also the more realistic issue of drug costs in China, as even the stable inhaled hybrid formulations, which are now widely used worldwide, are already too expensive for some Chinese COPD patients to afford. The development of safe, effective, inexpensive and convenient drugs for COPD patients in China is a great challenge for Chinese pharmaceutical workers and R&D institutions.
Insufficient awareness of COPD and difficulty in promoting comprehensive management
COPD is not yet included in the top ten chronic diseases of medical insurance. The society pays more and more attention to coronary heart disease, tumor and cerebrovascular disease, but there is insufficient awareness of the hazards of COPD, and the awareness rate is very low. The media carries out less scientific propaganda on COPD and does not do enough to popularize the knowledge, which leads to many false drug advertisements to flourish and seriously disrupt the formal medical order. At the same time, China’s smoking cessation and control initiatives are still in their infancy, lagging far behind those of developed countries. Integrated management of COPD, achieving a set of integrated management from advice and guidance to quit smoking, improving air pollution and work environment, to advocating physical exercise and emphasizing individualized treatment and rehabilitation is the key to improving the effectiveness of COPD prevention and treatment in China, but its promotion is extremely difficult due to the constraints of various practical factors in China.
Due to the above-mentioned challenges, it is difficult to achieve breakthrough results in COPD prevention and treatment in China in the short term. Nevertheless, we need to take immediate action to make the whole society – whether it is the decision makers of the health protection system, clinical workers, COPD patients, their families, or even healthy ordinary people – aware of COPD, pay attention to COPD, and participate in the prevention and treatment of COPD, so as to meet the challenges of the disease together and create a better future for COPD patients in China. To create a better tomorrow for COPD patients in China!