54 Proceedings S.Z.M.C. Vol: 35(3): pp. 54-57, 2021. PSZMC-809-35-3-2021 Frequency and Pattern of Bronchiectasis in Patients with Chronic Obstructive Pulmonary Disease Presenting in a Tertiary Care Hospital 1Asifa Karamat, 2Huma Batool, 3Sohail Anwar, 4Shazia Akram, 5Atif Masood, 5Wajid Ali Rafai 1Department of Pulmonology, Gulab Devi Hospital, Lahore 2Department of Pulmonology, Lahore General Hospital, Lahore 3Department of Pulmonology, University of Lahore Teaching Hospital, Lahore 4Department of Pulmonology, Pakistan Atomic Energy Commission, Chashma 5Department of Medicine, University of Lahore Teaching Hospital, Lahore ABSTRACT Introduction: Chronic Obstructive Pulmonary Disease (COPD) is a high burden respiratory issue all over the world. It has high morbidity and mortality in the United States. Bronchiectasis is associated with chronic obstructive pulmonary disease (COPD) and is under diagnosed as diagnostic tools like HRCT though easily available but an expensive test in developing countries like Pakistan. We aim to establish the frequency and patterns of bronchiectasis in patients of COPD. Aims and Objectives: To establish the frequency and pattern of bronchiectasis in COPD in our population so that we can improve patient care and quality of life of these patients. Place and duration of study: We did a cross sectional survey in Department of Pulmonology, Gulab Devi Hospital, Lahore. Study was completed from 1st September 2017 to 28th February 2018. Material & Methods: After taking an informed consent 150 already diagnosed COPD patients were included. Bronchiectasis was seen on high resolution CT scan (HRCT). Data was collected on a structured proforma and analyzed on SPSS version 20. Results: Bronchiectasis was observed in 76 (50.6%) patients of COPD while 74 patients had no bronchiectasis. Out of 76, cylindrical bronchiectasis was seen in 82%. Lower lobe and bilateral involvement was more common. Means of age, gender, exacerbations of COPD, and history of pulmonary tuberculosis were not related to bronchiectasis while pack years of smoking, duration of illness and Modified Medical Research Council (MMRC) Dyspnea Scale were significantly related to bronchiectasis. Conclusion: This is observed that bronchiectasisis quite common (50.6%) in patients of COPD in our population. Key words: Bronchiectasis, Chronic obstructive pulmonary disease INTRODUCTION Chronic Obstructive Pulmonary Disease (COPD) is a high burden health issue globally. It is the 4th major cause of morbidity and mortality in the United States, and according to recent data, it is projected to cause heavy burden of disease globally.1,2,3 Despite the diagnostic and therapeutic advancements the prevalence of respiratory diseases is increasing.1 The prevalence of COPD is around 14%, 7%, and 3% in smokers, former smokers and non-smokers respectively.2 Recent studies have projected that worldwide heavy budget will be spent on respiratory disease by 2030. In contrast, the per year will be the cost of smoking cessation program for controlling tobacco-related diseases is significantly low.4,7,8,9,10 Patients with COPD and bronchiectasis have more severe disease with poor outcome and higher frequency of exacerbations and complications.5 High resolution Computed Tomography (HRCT) is a good diagnostic tool for determining the extent and severity of bronchiectasis.6,11,12 In a quite a few studies bronchiectasis was found in more than 50% of COPD patients. Cylindrical bronchiectasis was present in majority and cystic bronchiectasis in almost 20% of cases. Commonly lower lobes were involved. Mostly COPD patients have bilateral involvement with no specific segmental predominance.7 Various patients factors influence the frequency of bronchiectasis among COPD patients, like mean smoking pack year, active smoking, duration of disease, number of exacerbations leading to hospital admission, MMRC score (Modified Medical 55 Frequency and Pattern of Bronchiectasis in Patients with Chronic Obstructive Pulmonary Disease Research Council Dyspnea Scale), past history of tuberculosis and degree of airway obstruction.7 We aim to establish the frequency and patterns of bronchiectasis in COPD patients of our population. By doing so, we can improve the patient care and management of these patients thus improving their quality of life and exacerbation rates. MATERIAL AND METHODS It was a cross-sectional study conducted in Gulab Devi Hospital, Lahore. Patients were labeled as having COPD on the basis of both of the following two criteria based on values of pulmonary function test (PFT’s) Post bronchodilator FEV1 less than or equal to 80% with reversibility less than 15% or less than 200ml. Post bronchodilator FEV1/ FVC, (forced expiratory volume in one second/forced vital capacity) less than 0.7. Bronchiectasis was diagnosed on the HRCT reported by consultant radiologist. The study was conducted in Department of Pulmonology, Gulab Devi Hospital, Lahore from 1st September 2017 to 28th February 2018.COPD patients with age ≥ 40 & ≤ 80 years were included in this. People with 15 pack year smoking history were considered as chronic smoker.8 Patient who were already diagnosed case of bronchiectasis were excluded from the study. Sampling Technique was non-probability consecutive purposive sampling. After taking informed consent from patient, data was collected. Pulmonary function tests (PFT’s) was done to measure FEV1 and FVC in each patient (As per inclusion criterion). Demographic characteristics included in this study were height, age, BMI, sex, current or ex-smoking history, history of Huqqa smoking, pack year of smoking, number of COPD exacerbations in previous one year and past history of anti-tuberculous treatment, and exposure to biomass fuel. MMRC dyspnea scale was used to assess functional status. HRCT was performed as per protocol was reported by same consultant radiologist. Presence of bronchiectasis as well as patterns of bronchiectasis was documented based on radiologist’s report. Selection bias was addressed by using appropriate sample size and by using non-probability consecutive sampling. Measurement bias was addressed by using uniform measurement scale/units for each patient. Data was collected on a structured proforma (attached). Statistical analysis: Standard deviation and mean was taken of different variables i.e. BMI, age, no. of COPD exacerbations, smoking pack years, FVC, MMRC score, and No. of COPD exacerbations). Frequency and percentages were taken for variables i.e. history of TB, gender, hukka smoker and biomass fuel exposure, current/Ex-smoker, and presence and pattern of bronchiectasis. SPSS 20 version was used for analysis of this study. Chi square and Fisher Exact Tests were applied. RESULTS Total 150 patients of mean age of 56.2± 5.9 years were included in the study. Characteristics of studied population are shown in table 1. According to findings there were 71% and 29% males and females respectively. Fifteen percent patients were previously treated for pulmonary tuberculosis. Half of the sampled population was exposed to cigarette and Huqqa. More than half of the patients (67%) have stopped smoking for past 1 year. In last one year average number of exacerbations is 3.2. 50% of our study population had bronchiectasis. 14 patients (18%) had cystic bronchiectasis while majority (82%) had cylindrical bronchiectasis on HRCT. Most of the patients having bronchiectasis in current study population have multiple lobe involvement (n = 65, 85%). Lower lobe was the common site involved. Majority (n=48, 64%) had bilateral involvement. (Table-2) On comparison of groups with and without bronchiectasis there was non-significant difference of patients of bronchiectasis between ages more than and less than 60 years. Similarly gender is also found not related with bronchiectasis in studied sample, p=0.14. Mean number of exacerbations is same for both groups of patients, p= 0.24 there was non-significant difference of patients of bronchiectasis between exacerbations more than and less than 3 per year (p= 0.1). But in bronchiectasis group, smoking years (p=0.03); time elapse since in years (p=<0.001); and MMRC score (p=<0.001) were significantly higher. It is seen that patients who had previously received antituberculous treatment were equally distributed in bronchiectasis and non-bronchiectasis groups (p=0.2). Similarly both ex-smokers and active were equally prone to develop bronchiectasis (p=0.58) as shown in Table-3 56 Frequency and Pattern of Bronchiectasis in Patients with Chronic Obstructive Pulmonary Disease Mean Age 56.2 ±SD Gender (%) Male Female 106/150(71) 43/150(29) Smoking status Cigarette smoker (%) Huqqa smoker (%) Cigarette + Huqqa Smoker (%) Biomass fuel exposure (%) Active smoker (%) Ex-smoker (%) 33/150(22) 13/150(9) 69/150(46) 34/150(23) 45/150(33) 100/150(67) History of pulmonary tuberculosis (%) 22/150(15) Mean COPD exacerbation in last one year 3.2 ±1.7 Mean duration of smoking(years) 41.3 ±18.9 Mean MMRC score 2.8 ± 0.74 Mean time elapsed since diagnosis (year) 7.09 ± 3 Table-1: Basic demographics of study population (n=150) Bronchiectasis Present (%) Absent (%) 76/150 (50.6%) 74/150 (49.3) Type of bronchiectasis Cystic (%) Cylindrical (%) 14/76 (18) 62/76 (82) Extent of bronchiectasis One lobe More than one lobe Upper lobe Lower lobe Right lung Left lung Bilateral 11/76(15) 65/76(85) 11/76(15) 65/76(85) 10/76(12) 18/76(24) 48/76(64) Table-2: Frequency and characteristics of Bronchiectasis (n=150) Parameter Bronchiectasis present Bronchiectasis absent P value Age <60years >60years 48 28 50 24 0.7 Gender Male Female 50 26 57 17 0.14 Time elapsed since diagnosis <5 years <5 years 1 75 50 24 < 0.001 Smoking status Current smoker Ex-smoker Mean duration of smoking 23 53 45 26 48 38 0.2 0.03 Mean mMRC 3 2.6 0.001 History of pulmonary tuberculosis 15 8 0.2 No. of exacerbation last year <3 >3 46 30 55 19 0.1 Table-3: Comparison of patient characteristics with and without bronchiectasis DISCUSSION In our study population COPD was unequally distributed in males and females (71% in males & 29% in females) likely because smoking is more prevalent in males while in another study by Aryals et all concluded COPD to becoming more prevalent in females causing increase mortality.15 Majority in our study though had quit smoking but were still having bronchiectasis (67%), showing contribution of smoking on permanent lung damage. Biomass fuel exposure was common in females due to use of high carbon fuel in rural areas. More than half of the study population was having bronchiectasis which was comparable to observation of Martínez-García MÁ et al.7 Although another study showed only 30% prevalence of bronchiectasis in COPD patients.13 The pattern and distribution of bronchiectasis found in our study was cylindrical affecting bilateral lower lobes which was consistent with Martínez-García MÁ et al observation.7 Bronchiectasis was significantly related to time elapsed since diagnosis, smoking pack years and MMRC score of severity of COPD. While age, gender, history of pulmonary tuberculosis and recurrent exacerbations were not significantly related to bronchiectasis in patients with chronic obstructive pulmonary disease. 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Influence of sex on chronic obstructive pulmonary disease risk and treatment outcomes. Int J Chron Obstruct Pulmon Dis. 2014; 9:1145-54. The Authors: Dr. Asifa Karamat Assistant Professor, Department of Pulmonology, Gulab Devi Hospital, Lahore. Dr. Huma Batool Assistant Professor, Department of Pulmonology, Lahore General Hospital, Lahore. Dr. Sohail Anwar Assistant Professor, Department of Pulmonology, University of Lahore Teaching Hospital, Lahore. Dr. Shazia Akram Assistant Professor, Department of Pulmonology, Pakistan Atomic Energy Commission, Chashma. Dr. Atif Masood Associate Professor, Department of Medicine, University of Lahore Teaching Hospital, Lahore. Dr. Wajid Ali Rafai Senior Registrar, Department of Medicine, University of Lahore Teaching Hospital, Lahore. Corresponding Author: Dr. Sohail Anwar Assistant Professor, Department of Pulmonology, University of Lahore Teaching Hospital, Lahore. E-mail: sohail.anwar@ucm.uol.edu.pk