The Top 5 Respiratory Conditions placing the biggest burden on Irish Health Care

Written by C. Hayes & Professor Eddie Moloney, Respiratory Consultant, Tallaght University Hospital

In 2003 the Irish Thoracic Society (ITS) published a report entitled ‘Ireland Needs Healthier Airways and Lungs – the Evidence’ which was the first report to highlight the scale and impact of respiratory disease in this country. More recently, in 2018, the ITS published ‘Respiratory Health of the Nation’, once again bringing focus to the burden of respiratory disease on the Irish Health Care system. However, much of this respiratory disease burden could be prevented, or potentially detected earlier, with improved public health awareness and lifestyle interventions.

Chronic Obstructive Pulmonary Disease (COPD):

Chronic obstructive pulmonary disease (COPD) is a common, preventable, treatable disease that is characterised by persistent respiratory symptoms of breathlessness and wheeze, and airflow obstruction that is not fully reversible. The natural timeline of the disease features symptomatic exacerbations and progressive decline in lung function with resultant significant impact on quality of life.1 It is estimated that up to 500,000 people in Ireland have COPD with only approximately half of these formally diagnosed.2 Spirometry is key to diagnosing non-reversible airflow obstruction in COPD. Smoking is the most important risk factor for developing COPD with approximately 40-50% of lifelong smokers developing the disease.3 Prevalence increases with age and is also higher in areas with high social deprivation.2 COPD is Ireland’s fourth leading cause of death after cardiovascular disease, stroke and lung cancer.4 While the vast majority of COPD cases are managed in the primary care setting, COPD further places a notable burden on tertiary care services.

Ireland had the highest hospitalisation rate for COPD among the 37 OECD member countries in 2020 and COPD accounts for 3.4% of all hospital bed days.

Of particular relevance to the Irish population, the American Thoracic Society and European Respiratory Society both recommend testing for Alpha-1 Antitrypsin Deficiency (AATD) in all patients with COPD, regardless of age or smoking history. After Cystic Fibrosis, AATD is the most common genetic condition in Ireland, with an estimated 250,000 people with mild or moderate deficiency and 3,000 with severe deficiency. Smoking cessation is of particular importance in this cohort as even those with mild deficiency are at significantly higher risk of developing COPD with cigarette exposure.5

Many effective treatments are available for COPD. However, prevention is key and all patients should be encouraged and offered assistance with smoking cessation.1 Inhaled bronchodilators comprising of long-acting muscarinic antagonist (LAMA) and/ or long-acting beta agonist (LABA) agents are typically the first line for pharmacological management.1 Patient education on the importance of inhaler technique and adherence is essential. The benefit of inhaled corticosteroids (ICS) in COPD is topical. The blood eosinophil count (BEC) has been shown to be predictive of response to ICS therapy in those COPD patients who need a step up in therapy from LAMA/ LABA therapy.6 Current guidelines suggest considering their use in those with a BEC of >300 per μL and to consider avoiding in those with BEC <100 per μL.1

Influenza and pneumococcal vaccination are recommended and can decrease the rate of acute exacerbations. Prophylactic macrolides, particularly azithromycin, can be considered for those non-smoker COPD patients with recurrent infective exacerbations despite maximal inhaled therapy.1

Non-pharmacological management and risk factor modification are also key components of treatment. Those with chronic hypoxaemia may warrant long-term oxygen therapy, especially in the presence of coexisting pulmonary hypertension. Pulmonary rehabilitation is a cornerstone of management and has been shown to be beneficial in improving both symptoms, exercise tolerance and decreased health care utilisation.7

More recently the use of surgical or bronchoscopic interventions should be considered in those with advanced disease. Lung volume reduction surgery and endobronchial valves can be an option in appropriately selected patients with advanced emphysema and evidence of significant air trapping/lung hyperinflation causing marked symptoms.8, 9 In carefully selected patients with severe and progressive COPD, referral for lung transplantation may be appropriate. COPD (AATD and non-AATD) is the most common indication for lung transplantation globally accounting for 40% of all lung transplants performed.10 Benefits have been shown in both survival and functional capacity. However, the decision to proceed with transplant and the timing of referral remains complex.10

Asthma:

Asthma is a chronic, eosinophilic inflammatory condition of the airways characterised by the presence of episodic and reversible airflow obstruction. Common symptoms include cough, wheeze, dyspnoea and chest tightness, often with diurnal variation. It is estimated that approximately 450,000 people in Ireland currently have a diagnosis of asthma comprising 1 in 10 children.11

While globally the mortality and number of hospital admissions from asthma has declined significantly over the past 30 years, Ireland continues to have one of the highest prevalences of asthma in Europe today.3 While the vast majority of asthma cases are mild, 5-10% of patients will have severe asthma which is defined by the Global Initiative for Asthma (GINA) as ‘asthma that is uncontrolled despite high dose ICS-LABA, or that requires high dose ICS-LABA to remain controlled’.12 Although a minority of cases, these severe asthma patients comprise a large proportion of the Irish healthcare and resource burden associated with asthma.

There are approximately 8,000 asthma related admissions to Irish hospitals every year and the total cost of asthma care to the state is approximately ¤472 million per annum.11

Asthma management has evolved significantly over the last 20 years particularly with the emergence of biological agents. GINA guidelines recommend a stepwise approach to asthma management with continual re-assessment of asthma control and treatment side effects and subsequent escalation or de-escalation of treatment as appropriate. Education on the adequacy of inhaler technique and adherence is a key component of management.

Prior studies have shown at least 50% of patients do not take controller medications as prescribed and up to 80% cannot use their inhaler correctly.12 Smoking cessation and trigger avoidance also play a key role in management. The preferred initial treatment for patients with mild asthma is now as needed low dose ICS-formoterol. Escalation of treatment typically includes regular ICS-LABA therapy and then intensification of ICS dose. Additional options then include adding a LAMA or a leukotriene receptor antagonist.

Biologic agents against several cytokines involved in the asthma inflammatory pathway have shown great success in recent years. These include targeted therapies against IL- 5/IL-5R, IL-4R and more recently thymic stromal lymphopoietin. These agents have shown to be highly effective in reducing exacerbation rates, improving symptom control and decreasing the need for maintenance corticosteroid in appropriate patients,; predominantly those who exhibit signs of type 2/eosinophilic airway inflammation.12

Lung Cancer:

Lung cancer is the leading cause of cancer-related deaths in Ireland in both males and females. There were 3271 new lung cancer cases diagnosed in Ireland in 2020, with the majority of cases being advanced, and non-operable, at diagnosis.134 Approximately 85-90% are related to smoking. The incidence of lung cancer is higher in lower socioeconomic groups. This is likely due to higher rates of smoking but may also reflect greater occupational exposure to harmful dust, fibres and fumes.2 Advice and encouragement of smoking cessation at every healthcare contact is essential to try and decrease the significant public health burden associated with lung cancer. All smokers should be offered either nicotine replacement therapy or other smoking cessation medication, and counselling, which has been shown to increase the chances of successfully quitting.14

There have been many recent advances in lung cancer treatment which have improved outcomes and offered hope for further breakthroughs in the future. The management of metastatic non-small cell lung cancer (NSCLC) has been revolutionised by the development of targeted therapies based on the presence of certain driver mutations. Many of these mutations exist with several available therapeutic options.15

Immune checkpoint inhibitors have drastically changed the management of many lung malignancies. These may be used alone or in combination with chemotherapy and have significantly improved survival in appropriate patients.16

Pneumonia:

Acute lower respiratory tract infections (LRTI) are a significant cause of morbidity and mortality in both children and adults. Pneumonia is the 5th most common cause of death in Ireland.2 In 2016 pneumonia and LRTI accounted for 4.5% of all inpatient hospitalisations and 6.3% of all inpatient bed days.2 However, a significant majority of patients are treated in the community with hospitalisations representing only a small proportion of the overall burden placed on the healthcare service. Over 90% of deaths from pneumonia are in those aged 70 years and over.2

Lack of new antibiotics and expanding resistance to established agents are increasingly important threats to health and pneumonia survival, with approximately 10% of Streptococcus pneumoniae isolates now resistant to commonly used penicillin and/or macrolide antibiotics.17 Risk factors for pneumonia include older age, smoking, pre-existing lung disease, immunosuppression or neurological dysfunction which can increase risk of aspiration. Preventive measures including smoking cessation and vaccination are key to try and reduce disease impact on healthcare services. This includes promotion of the yearly influenza vaccine for the general public and pneumococcal polysaccharide (PPV23) vaccine for those over 65 or for those under 65 at higher risk of pneumococcal disease, including patients with Diabetes or chronic lung, heart, liver, or kidney disease.18

Pneumococcal polysaccharide (PPV23) vaccination has been shown to be an effective preventive measure, significantly decreasing the risk of both invasive and non-invasive pneumococcal pneumonia.19 Seasonal influenza vaccination is an important public health measure which can help decrease the significant burden placed on the health service every winter. Efficacy varies depending on a number of factors including age, baseline health, immune function and the degree of match between vaccine antigens and circulating virus strains.20 However, even for those with breakthrough influenza infection, vaccination is associated with reduced mortality and disease severity. In addition, in patients with underlying cardiovascular disease, influenza vaccination is associated with a significant reduction in cardiovascular mortality and major adverse cardiovascular events.21 Pneumonia due to Covid-19 infection is beyond the scope of this article and has been excluded.

Obstructive Sleep Apnoea:

Sleep disordered breathing encompasses a broad spectrum of sleep-related breathing disorders. The most common form of sleep disordered breathing is obstructive sleep apnoea (OSA). OSA is a disorder that is characterized by progressive snoring, obstructive apneas due to repetitive collapsibility of the upper airway during sleep, usually noticed by a bed partner, arousals and awakenings during sleep, and waking unrefreshed . Patients may experience symptoms including daytime sleepiness, depressed mood, irritability, cognitive dysfunction, and work and road traffic related accidents.22

Obesity is the most common predisposing factor and risk correlates with BMI and neck circumference.23 OSA prevalence is increasing mainly due to rising rates of obesity worldwide. It is estimated that one billion people on the planet have OSA.24 The excessive daytime somnolence can lead to significant decline in quality of life and cognitive performance as well as an increase in road traffic and occupational accidents.25 Moreover, the major health burden of patients with OSA relates to the cardiovascular system.

Epidemiological studies have demonstrated an independent relationship between OSA and the development of hypertension, atrial fibrillation and other cardiac arrhythmias, coronary artery disease, congestive cardiac failure and stroke.26 Access to diagnostics has improved in recent years with the availability of home sleep apnoea testing or home polysomnography. In appropriate patients with a high pretest probability of moderate to severe, uncomplicated OSA, this is a viable alternative to overnight hospital polysomnography and carries potential benefits including patient convenience and reduced time to diagnosis and commencement of treatment.27 Early recognition of OSA is important as effective treatments are available.

Weight loss and exercise should be recommended to all patients with OSA who are overweight or obese. This can further lead to reductions in blood pressure, metabolic parameters and markers of disease severity.268 Continuous positive airway pressure (CPAP) is the mainstay of treatment for OSA. There is extensive evidence showing its benefits in improving symptoms and quality of life as well as reducing cardiovascular mortality and morbidity.289 Monitoring and encouragement of adherence is important as this can improve the potential benefits of CPAP therapy. In patients with mild to moderate OSA who decline CPAP or fail to respond to it, oral appliances such as mandibular advancement devices are an alternative therapy that have been shown to improve signs and symptoms of OSA.29

References available on request

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