CRF celebrates 10th Foundation Day

Eminent scientists call for boosting Indian research

Chest Research Foundation celebrated its 10th Foundation Day
on November 13, 2011. On this occasion a seminar on Clinical
Research and Education was organized. Eminent personalities who
were present on the occasion included Dr. Nilima Kshirsagar,
National Chair (Clinical Pharmacology), Indian Council for Medical
Research (ICMR), Dr. Mrudula Phadke, Ex-Vice Chancellor of
Maharashtra University of Health Sciences, Dr. Bhushan Patwardhan,
Vice Chancellor of Symbiosis International University and Dr.
Sharad Joshi, Professor and Dean, Corporate Relations, Vishwakarma
Institute of Management.
India needs more dedicated researchers conducting relevant research and clinical studies, if the country were to gain the coveted
status of being the clinical research hub of the world I am looking forward to CRF being a centre of excellence for research in
India soon.
- Dr. Nilima Kshirsagar
The CRF laboratories have developed well. Research activities are of international standard. The organization is superb.
- Dr. Mrudula Phadke
Centres of research like CRF are precious for our country; they are the face of modern Indian research.
- Dr. Bhushan Patwardhan
It is a challenge to build an institution of the stature of CRF in a short period of 9 years.

What is your
diagnosis?

- Dr. Sharad Joshi

High prevalence of OAD in patients with IHD and hypertension

Patients with ischemic heart disease
(IHD) or hypertension (HT) are four times
more likely to have associated obstructive
airways disease (OAD), according to a
CRF study. This strongly suggests that
all patients of IHD and HT should be
routinely tested for OAD.
CRF recruited 122 patients with
diagnosed IHD or HT (mean age 53
years) and 135 healthy subjects (mean age
49 years) for this study. After obtaining
demographic and clinical data, spirometry
was performed according to ATS/ERS
guidelines. A FEV1/FVC ratio less than
70 percent was used to make a diagnosis
of OAD.

Turn to page 3
for the diagnosis...

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Patients with ischemic heart disease

or hypertension have 4-fold increased
odds of having associated obstructive
airways disease.
The study found that prevalence of OAD
in patients with IHD was 20 percent, while it
was 8 percent patients with hypertension. The
healthy population showed a prevalence of
3 percent.
If these findings hold true for the estimated
423 million people above the age of 35 years in
India, then more than 22 million people with
IHD are likely to have concomitant OAD.

1.

IHD and HT is strongly associated

with the presence of OAD.

2.

All patients of IHD and HT must be

screened for associated OAD using
spirometry.

Peak ow meter
Valuable diagnostic and monitoring tool in asthma, COPD
Peak flow meter is a simple, handy, easyto-use and inexpensive device of immense
clinical value in asthma practice. Although
spirometry is of primary importance in
the management of asthma and COPD, a
peak flow meter could be more useful in
certain situations like diagnosis of asthma in
absence of spirometry, monitoring response
to treatment, diagnosis of occupational
asthma and in-house monitoring of asthma
(especially in patients who are poor perceivers
of their symptoms). It may also be useful to
assess severity of an acute exacerbation.

The markings in the previous scale were

equidistant. It is not so in the new EU scale.
The EU scale reads PEFR correctly because
the scale has been modified to accommodate
the dynamics of a compressed spring.
A spring expands the most when in its
compressed form than when it is extended.
It is important to use a peak flow meter with
the new EU scale. Currently, such a meter
costs less than Rs. 400 in India.
Diagnosing Asthma Using Peak flow meter
1) More than 20% average variability in
morning and evening values of peak
flows monitored over at least 14 days
suggests presence of asthma.

How to monitor asthma

Once treatment starts, patient should be
asked to maintain a record of PEFR values.
The doctor must study this record during
every visit by the patient. An increasing
trend in PEFR suggests improvement in
lung function, while a decline indicates a
worsening situation.
The highest recorded PEFR value of
an individual is called as his/her personal
best. A PEFR value that is less than 80
percent patients of the personal best
recorded within the previous one year
suggests poor asthma control. It may be
necessary to step up current treatment.

2) More than 20% improvement in PEF

value 15-30 min after inhalation of
400mcg salbutamol usually suggests
a diagnosis of asthma. For example, an
increase in PEFR value from 300 L/min to
more than 360 L/min after bronchodilation with salbutamol suggests a
bronchodilator reversibility of more
than 20 percent.

Assessing asthma severity using

Peak Flow Meter
(To decide treatment modality)

Not long ago, a new peak flow meter was

introduced with the European Union (EU)
scale. The change was needed because meters
with the old scale tended to under-read peak
expiratory flow rate (PEFR) in the higher
range and over-read it in the middle range.

PEFR
>80%

Variability
20-30%

Severity
Mild persistent

60-80%

>30%

<60%

>30%

Moderate
persistent
Severe persistent

Dr. Rahul Kodgule,

CRF

Normal Graph

Use in COPD
Although peak flow meter has no role
in diagnosis and management of COPD, a
pre-bronchodilator PEFR of more than 70
percent of predicted value, rules out severe
and very-severe COPD.
It should be borne in mind that a peak
flow meter, although a very useful device,
is not a substitute for spirometry, which is
more important in assessing COPD.

Chest Research Foundation has derived Predicted Value of Peak Expiratory Flow (PEF) for Indian adults using
EU scale Peak Flow Meter. To get the Indian Predicted PEFR values contact respimirror@crndia.com

CRF Crowned
Best Clinical Research Site in India
Chest Research Foundation (CRF)
received the Best Clinical Research Site in
India Award from the Indian Society for
Clinical Research (ISCR) for the year 2011.
The award was received by Dr. Sundeep
Salvi and Dr. Sneha Limaye at a national
event on October 21 in New Delhi in the
presence of a distinguished gathering
of industry leaders, academicians and
government representatives.
CRF was acclaimed for its valuable
contribution to clinical research in India
by generating high quality research data
using good ethical research practices. The
panel of judges comprised leading clinical
research and healthcare professionals from
industry, academia and the government.
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NAPCON Achievers

Dr. Komalkirti Apte

1st and 2nd Prize

Dr. Rahul Kodgule

3rd Prize

Members of CRF team bagged 3 prizes at NAPCON

which was held in New Delhi from November 27 to
30, 2011.
Dr. Komalkirti Aptes oral presentation on What are the
most common symptoms for which a patient visits a doctor
in India? A one-day-point prevalence study in 2,04,912
patients across India won the first prize.
Her poster presentation on a lung function study
conducted on employees of Andhra Pradesh State Road
Transport Corporation (APSRTC) fetched her second prize.
Dr. Rahul Kodgule bagged the third prize for his oral
presentation on Cellular and mediator inflammatory
profiles are similar in sputum of biomass fuel-associated
and tobacco-smoking associated COPD patients.

Article
Review

Mortality associated with tiotropium mist inhaler : how valid?

Tiotropium, an anti-muscarinic agent,

active for 24 hours, is the drug of choice
in the management of COPD. A popular,
systematic review and meta-analysis of
five randomized controlled trials, recently
published by Dr. Sonal Singh and others,
has triggered a debate regarding the safety
of tiotropium mist inhaler.
The authors found that the long-term
(one year) use of tiotropium mist inhaler
was associated with increased risk of allcause mortality (relative risk = 1.52, 95% CI:
1.06-2.16) compared to placebo. Although
this finding is a cause of concern, one should
not jump to conclusions.
In this meta-analysis, the results were
heavily influenced by a single trial (67
percent contribution). Previously, inhaled
corticosteroids (ICS) have been shown to
improve mortality. In this meta-analysis,
the contribution of ICS was not analyzed.
Higher use of ICS by patients on placebo,
might have led to reduced mortality in
this group.
Previously, higher mortality has been
found in patients having smoking history

- Kodgule R., Madas S.

of more than 55 pack years. In this metaanalysis, the contribution of smoking was
not studied.
Further, in these trials, the withdrawal
rate was higher in the placebo group.
Patients who withdrew might have shifted
to intensive treatment, which could have
affected mortality.
Besides, the bio-availability of tiotropium
in blood is much higher after inhalation from
a mist inhaler than it is after inhalation from
a powdered inhaler. Hence, higher mortality
found in the meta-analysis for mist inhalers
may not apply to powdered inhalers.
On account of these methodological
issues, the results of this meta-analysis
cannot be considered conclusive, unless
these results are supported by a properly
designed prospective clinical trial.
It must be noted that all the previous
meta-analyses, including the large-scale
UPLIFT trial of about 6000 patients, did not
find increased risk of mortality or cardiovascular events associated with the use of
tiotropium, even when it was administered
as a mist inhaler. In fact, most of these trials

(including the UPLIFT study) reported a

significant reduction in mortality with the
use of tiotropium.
In conclusion, based on the evidence that
is currently available, the use of powdered
tiotropium inhaler for the management
of COPD appears to be adequately safe.
However, due to lack of reliable data, it is
prudent to use tiotropium mist inhalers
cautiously.
Singh S. ET. AL. British Medical Journal
2001 ; Volume 342 : Page d3215

Important Respiratory
Days in 2012
World No Smoking Day : March 14
World Asthma Day

: May 1

World No Tobacco Day : May 31

World Spirometry Day : June 27
World COPD Day

: November 14

PURVIEW on TB on January 7
The second PURVIEW (Practical Updates
for Respiratory Post-graduates via the Web)
was conducted by Dr. Ashutosh Agarwal,
Dr. Ravindra Mehta and Dr. Sundeep Salvi
at CRF on November 12. An estimated 500
post-graduate students and doctors logged
in to the session.
The next PURVIEW will be on
tuberculosis on 7th Jan 2012 between
5.00 pm to 7.00 pm. Dr. Sujeet Rajan,
Dr. Udwadia Zarir, Dr. Sanjay Pujari and

Dr. Tushar Sahasrabuddhe will be addressing

participants on diagnosing TB in 2012,
challenges and opportunities in managing
MDR and XDR TB, managing HIV and TB
in 2012 and management of side effects of
anti-tubercular drugs resp.
Those interested in participating in the
webcast may write to purview@crfindia.
com. To attend the live webcast log in to
www.crfindia.com.

What is your diagnosis?

Flow volume loop:
PEFR decreased
FVC decreased
Deep concavity
Indicates severe airflow
obstruction

Volume time graph:

FEV1 reduced
Plateau not achieved
FVC reduced
Good bronchodilator reversibility
Indicates severe airflow obstruction
with good reversibility

Visual impression of the graphs:

Severe airways obstruction with good bronchodilator reversibility. (69 ml/400)
Suggestive of bronchial asthma.

Following is the Interpretation

Spirometry graph courtesy : Dr. Nandgopal, G.K.N.M. Hospital, Coimbatore.

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Chest Research Foundation

Liberation through research and education

CRF moots mission to free India from asthma suffering

CRF has proposed an ambitious National
Asthma Control Mission (NACM)to ensure
that at least 90 percent of the estimated 40
million Indians with asthma have the disease
under control, so that they are able to enjoy a
good quality of life without the fear of acute
attacks. It also seeks to eliminate deaths on
account of asthma.
NACM was launched at the National
Round Table Conference on Issues Related
to Adherence to Asthma Therapy held at
CRF earlier this year.
The mission is being driven by working
groups of doctors in various parts of the
country. CRF provides training inputs and
functions as a co-ordinating agency for the
mission. The final objective is to influence
the government to announce a National
Asthma Control Programme for the benefit
of patients in rural as well as urban India.
These are some of the challenges NACM
seeks to address.

Asthma now presents in new phenotypes making a correct and early diagnosis
all the more difficult. Not all patients of asthma get breathless. It can also present as long
standing cough, chest tightness or cough
just after exercise, repeated coughs and colds
in children.
Thanks to social stigma, a diagnosis of
asthma is not as readily accepted as a diagnosis of diabetes or high blood pressure.
Though inhalers are the mainstay of
asthma therapy, only about 16 percent of
patients are prescribed an inhaler by GPs.
Acceptance of inhaled corticosteroids (ICS)
is poor. These are the mainstay asthma

management. Out of those prescribed inhalers, very few know how to use it correctly.
According to key opinion leaders
present during the round table conference,
lack of adherence to the prescribed therapy
is a major problem in India. Adherence rates
are high in the initial 3 months but fall to as
low as 50 percent by 6 months. This could
be because people keep experimenting with
various therapies in their search for a permanent cure, even when their asthma is under control.
Lack of adherence, failure to take the
right medicines at the right doses at the
right times and for the right duration,
and incorrect techique of using the
inhaler devices are the important factors
for lack of control over asthma, even in
cases diagnosed correctly and put on
correct therapy.

www.crearning.org

Opinion

Training Programmes : Keep pace with the advancements in the respiratory eld.
Training programmes at CRF translate knowledge gained from research into practical application in the form of improved
respiratory management practices. Courses are on offer for doctors, nurses, technicians, paramedical staff and post-graduates.

Before attending ROAD programme my knowledge about Obstructive Airways Disease & Spirometry was poor.
I used to prescribe only oral medications. After attending the ROAD workshop I started treating my OAD
patients with Inhalation therapy. I have purchased spirometer I am performing 3-4 spirometries per day. I am now
confident to even treat severe COPD patients. ROAD proved to be million dollar programme for me. CRF is
doing a fabulous job by organizing these workshops.
- Dr. Zahir Abbas Shah, Medical Officer, Aurangabad

- To read the previous issues of Respimirror/or to watch the previous Webcast visit www.crndia.com -

CHEST RESEARCH FOUNDATION

Marigold Premises, Survey No 15, Vadgaonsheri,
Kalyaninagar, Pune 411014, Maharashtra, INDIA.
Phone: +91 20 27035361/66208053/54
Fax: : +91 20 27035371. Website: www.crfindia.com
NOTE : FOR PRIVATE CIRCULATION ONLY.

For your feedback / queries write to respimirror@crndia.com

Do you want to conduct a programme in your city? Please write to
Mrs. Monika Chopda at monikachopda@crndia.com
Published by : Chest Research Foundation, Pune
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