The interest of the Indian pulmonologists on PH (pulmonary hypertension) has been created and rejuvenated after the availability of anti PH drugs. They are now getting concerned about the presence of class III PH in their day to day practice.

Unfortunately, the country does not have any database on the prevalence of PH or PAH (pulmonary arterial hypertension). Limited and recent publications suggest that the class III PH is an entity of concern and the only available etiological distribution of PH is credited by Institute of Pulmocare & Research. ⁽¹⁾

There are several issues that actually hinder understanding the dimension of PH in the country. Firstly, all the guidelines preach the PH diagnosis to be based on RHC (right heart catheterization) ^{(2, 3)}. Although radiological signs exist with cent percent specifically^(4,5,6,7), they are not given much importance. Doppler echocardiography is not precise enough, ⁽⁸⁾ though a value of pulmonary arterial pressure ≥50 mm of Hg been measured by echocardiography cannot be ignored. Finally, the treatment of class III PH in different conditions is also not clearly delineated by the international guidelines.

Naturally, the lacunae offer freedom for individual physicians to diagnose and treat PH but it demands good justification for treatment without RHC. It is agreeable ethically to treat a patient with respiratory symptoms (when implied to PH) despite optimum treatment of the underlying disease. The authors in the article 'Sildenafil in treating Pulmonary Hypertension: the initial experience in a tertiary out-patient department practice' have chosen to impress us with the bold decision of offering anti PH therapy to such population of class III PH in our country. Agreeably again, RHC may not be essential for monitoring patients on anti PH therapy. The follow up of the patients however, could be made more objective with inclusion of 6 minute walk test.

In a scenario of no database and an unlikely prospect of quick inclusion of RHC in diagnostic practice for PH, the article ignites questions to initiate a debate for consideration of a non-invasive diagnosis of PH as an indication for treatment especially in patients with advanced WHO functional status and refractoriness of symptoms despite the best possible the treatment of an the underlying pulmonary pathologies.

Beyond that, supporting the decision with measurement of quality of life change is welcome though CAT (COPD assessment test) is not validated for PH and not been use for many conditions beyond COPD (chronic obstructive pulmonary disease), ⁽⁹⁾ and ILD (interstitial lung disease). ⁽¹⁰⁾ Despite appreciating logistic problem as admitted by the authors, other objective parameters could have been better to support the outcome. The article reflects a desperate effort to overcome the existing deficiencies at the ground realities to match the 'evidence based' standards of the guidelines in the best possible scientific and humane way. The pivotal question that lingers for response from the scientific community is "can we deprive suffering patients with the excuse of lack of quality evidence?"

REFERENCE

1. Saha D, Bhattacherjee P D, Das S K, Dey R, Ghosh M, Dutta I, Sarma M, Ghosh A, Bhattacharyya P S. Group III Pulmonary Hypertension: relative frequency of different etiologies in a referral pulmonary OPD. Pulmo Face, Vol. XIII No. 1, Sep.-2013 (non indexed journal ISSN no. 2347 – 4823).

2. Galie N, Hoeper M M, Humbert M, Torbicki A, Vachiery J L, et al. Guidelines for the diagnosis and treatment of pulmonary hypertension: the Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS), endorsed by the International Society of Heart and Lung Transplantation (ISHLT). Eur Heart J 2009; 30: 2493–2537.

3. Mc Laughlin V V, Park M H, Rosenson R S, Rubin L J, Tapson V F, Vagre J. ACCP/AHA: 2009 Expert Consensus Document on Pulmonary Hypertension. Jr A. Col Cardiol 2009; 35:14, 1573- 1619.

4. Kanemoto N, Furuya H, Etoh T, Sasamoto H, and Matsuyama S. Chest roentgenograms in primary pulmonary hypertension. Chest, 1979: 76, 45 – 49

5. Bush A, Gray H, Denison D M. Diagnosis of pulmonary hypertension from radiographic estimates of pulmonary arterial size. Thorax 1988; 43:127-131.

6. Tan RT, Kuzo R, Goodman LR, Siegel R, Hassler GB, Presberg KW. Utility of CT scan evaluation for predicting pulmonary hypertension in patients with parenchymal lung disease. Medical College of Wisconsin Lung Transplant Group. Chest 1998; 113(5): 1250–1256.

7. Ng CS, Wells AU, Padley SP. A CT sign of chronic pulmonary arterial hypertension: the ratio of main pulmonary artery to aortic diameter. J Thorac Imaging 1999; 14(4):270–278.

8. Bhattacharyya PS. Can we treat class III Pulmonary Hypertension without Right Heart Catheterization? (Manuscript ID: "pvri_2_13". Send it to PVRI Journal as an editorial).

9. Jones PW, Harding G, Berry P et al. Development and first validation of the COPD Assessment Test. Eur Respir J 2009;34:648-654.

10. Tachikawa R, Otsuka K, Takeshita J, Tanaka K, Matsumoto T, Monden K. Evaluation of the chronic obstructive pulmonary disease assessment test for measurement of health-related quality of life in patients with interstitial lung disease. Respirology. 2012 Apr; 17(3):506-12. doi: 10.1111/j.1440-1843.2012.02131.x.

Dr. Dhiman Ganguly,
Institute of Pulmocare and Research
CB-16, Sector-1, Salt Lake,
Kolkata, West Bengal, India
E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.

Improvement of the quality of health care is a dynamic and ever demanding area. As the issue involves both the care givers and the recipients, it is imperative that the system should evolve a mechanism of getting these two poles in a common platform of understanding and acting with the provision of effective communication between the two ends. This is a highly challenging job especially in a country with enormous and extremes of geo-socio-economic diversities.

To achieve a tenable and visible positive change mere recognizing the problem is not enough; a physician needs to get into the issue in depth both at the macro and micro structure of the problem at his or her social arena in order to act positively. Getting to the grass root with sincerity and simplicity will help in a spontaneous development of the skill of addressing the problem with one's limited or unlimited capabilities. If a systematic approach is added to it, the harvest can be multiplied.

Our institute, with its extremely limited physical resources, has experienced this fact in its recent benevolent ventures of rural COPD education and training program at Birbhum. This program got a big encouragement initially by the Chest Foundation Award from the American College of Chest Physicians in 2009. Initially, we did not have any desire for a proper scientific study with objective data analysis at the backend. With the help of a locally acting organization, we had been able to motivate and gather patients from different villages with the suspected disease, identify COPD in the camps through spirometry, examine them clinically, educate and train them on the basic issues related to treatment and rehabilitation for the disease.

With time again, this lead us to a tremendously rewarding and honest self-appreciation that resulted in adding a systematic approach and introduction of the use of visual analogue scale to the recording format. The addition had yielded a rewarding insight again. The analysis of the small data demonstrates significant improvement in symptomatology and the appreciation of the overall improvement in the well being by the patients themselves. (see our article in page no. 5-9 ).

We had also enjoyed a wonderful interaction with our rural folks. All this were possible by proper training and mobilization of the right manpower from locally and from our institute. Further introduction more objective parameters were subsequently done and we wish to show the impact in future. To our mind, dissipating the disease related education, introducing the best possible treatment and rehabilitation at a particular ground reality demands motivation and synergistic efforts in a systematic fashion with appropriate and the best use of the local human resources. At the end, what we have realized that things can be done with honest and organized efforts and the demand for such interventions is tremendous at our rural areas.

Dr. Parthasarathi Bhattacharyya
Institute of Pulomocare and Research
CB- 16, Salt Lake Sector – 1
Kolkata - 700064
Email: This email address is being protected from spambots. You need JavaScript enabled to view it.