BIOMASS SMOKE BIOMASS SMOKE PREDISPOSES RURAL PREDISPOSES RURAL

WOMEN TO PULMONARY WOMEN TO PULMONARY HYPERTENSION SOONER HYPERTENSION SOONER

AND EARLIER THAN COPDAND EARLIER THAN COPD

Bülent ÖzbayBülent Özbay** Bünyamin Sertoğullarından Bünyamin Sertoğullarından** Selvi Aşker Selvi Aşker** Müntecep Aşker Müntecep Aşker**** Mustafa TuncerMustafa Tuncer******

**Yuzuncu Yıl UniversityYuzuncu Yıl University,, Medical Medical FFacultyaculty,, PulmonaryPulmonary MMedicineedicine,, VAN VAN

****Higher Education Hospital of Health Ministry, VANHigher Education Hospital of Health Ministry, VAN

*** *** Yuzuncu Yıl UniversityYuzuncu Yıl University,, Medical Medical FFacultyaculty,, Cardiology VAN Cardiology VAN

The use of biomass fuel for cooking and The use of biomass fuel for cooking and

heating is commonplace in developing heating is commonplace in developing

countries countries (1, 2(1, 2,3,3))

1- Uzun K, Ozbay B. 1- Uzun K, Ozbay B. Prevalence of Chronic Bronchitis – Asthma Prevalence of Chronic Bronchitis – Asthma symptoms in Biomass Fuel Exposed Females.symptoms in Biomass Fuel Exposed Females. Environmental health Environmental health and Preventive Medicine 2003; 8: 13 - 17and Preventive Medicine 2003; 8: 13 - 17

2- Ozbay B, Uzun K. Functional and radiological impairment in women 2- Ozbay B, Uzun K. Functional and radiological impairment in women highly exposed to indoor biomass fuels. Respirology 2001; 6: 255 - 8 highly exposed to indoor biomass fuels. Respirology 2001; 6: 255 - 8

3-Regalado J, Perez-Padilla R. The effect of biomass burning on 3-Regalado J, Perez-Padilla R. The effect of biomass burning on respiratory symptoms and lung function in rural Mexican women Am J respiratory symptoms and lung function in rural Mexican women Am J Respir Crit Care Med. 2006 Oct 15;174(8):901-5. Epub 2006 Jun 23. Respir Crit Care Med. 2006 Oct 15;174(8):901-5. Epub 2006 Jun 23.

Common respiratory irritants Common respiratory irritants included in biomass included in biomass combustioncombustion

CO, COCO, CO22, NO, NO22, SO, SO22,,

Ammonium, Ammonium, CCyanide, yanide,

AldeAldehydehyde, Keton, Ketonee, A, Accroleinrolein

Common Biomass Related DiseasesCommon Biomass Related Diseases ( 1, 2 ) ( 1, 2 )

Low birth weightLow birth weight

Growth retardationGrowth retardation

Recurrent upper and lower respiratory tract Recurrent upper and lower respiratory tract infections,infections,

Chronic Bronchitis,Chronic Bronchitis,

COPDCOPD

Reactive BronchitisReactive Bronchitis

Bronchiolitis ObliteransBronchiolitis Obliterans

1-Baris YI. Solunum Hastalıkları. Atlas Kitapçılık, 1998.1-Baris YI. Solunum Hastalıkları. Atlas Kitapçılık, 1998.

2-Bariş Yİ. Primitive biomass related health problem. Toraks Dergisi 2006 2-Bariş Yİ. Primitive biomass related health problem. Toraks Dergisi 2006 ( supp )( supp )

Biomass fuel has deleterious effects on Biomass fuel has deleterious effects on pulmonary function and structure leading pulmonary function and structure leading to obstructive and restrictive pathologiesto obstructive and restrictive pathologies (1,2,3,4,5,)(1,2,3,4,5,)

1-1-Demirtaş N, Seyfikli Z, Topçu S.Demirtaş N, Seyfikli Z, Topçu S. The relationships between traditional biomass combustion The relationships between traditional biomass combustion and development of COPD in women of Sivas area. Solunum Hastalıkları 1999; 10: 156 – 8.and development of COPD in women of Sivas area. Solunum Hastalıkları 1999; 10: 156 – 8.

2-Ozbay B, Uzun K, Arslan H, Zehir I. Functional and radiological impairment in women highly 2-Ozbay B, Uzun K, Arslan H, Zehir I. Functional and radiological impairment in women highly exposed to indoor biomass fuels. Respirology. 2001 Sep;6(3):255-8.exposed to indoor biomass fuels. Respirology. 2001 Sep;6(3):255-8.

3-Weis S.T, DeMeo D.L, Postma D. S. COPD: Problems in diagnosis and measurement. Eur 3-Weis S.T, DeMeo D.L, Postma D. S. COPD: Problems in diagnosis and measurement. Eur Respir J 2003; 21: Supll. 41, 4s – 12s.Respir J 2003; 21: Supll. 41, 4s – 12s.4-Arslan M, Akkurt I, Egilmez H, Atalar M, Salk I.Biomass exposure and the high resolution 4-Arslan M, Akkurt I, Egilmez H, Atalar M, Salk I.Biomass exposure and the high resolution computed tomographic and spirometric findings.Eur J Radiol. 2004 Nov;52(2):192-9. computed tomographic and spirometric findings.Eur J Radiol. 2004 Nov;52(2):192-9.

5-Chronic pulmonary disease in rural women exposed to biomass fumes.Kiraz K, Kart L, Demir 5-Chronic pulmonary disease in rural women exposed to biomass fumes.Kiraz K, Kart L, Demir R, Oymak S, Gulmez I, Unalacak M, Ozesmi M.Clin Invest Med. 2003 Oct;26(5):243-8R, Oymak S, Gulmez I, Unalacak M, Ozesmi M.Clin Invest Med. 2003 Oct;26(5):243-8

Alteratıons ın respıratory tractus of anımal Alteratıons ın respıratory tractus of anımal models exposed to bıomass smoke have models exposed to bıomass smoke have been demonstrated (1, 2)been demonstrated (1, 2)

1-Bülent Özbay, Şükrü Acar, Zabit Yener, Mehmet Kanter 1-Bülent Özbay, Şükrü Acar, Zabit Yener, Mehmet Kanter Hıstopathologıcal alteratıons ın respıratory tractus of rats Hıstopathologıcal alteratıons ın respıratory tractus of rats exposed to bıomass smoke. Thorax Society 8th Annual Congress, exposed to bıomass smoke. Thorax Society 8th Annual Congress, MS 337,MS 337,

28 . 04. 2005, ANTALYA28 . 04. 2005, ANTALYA

2-Fidan F, Unlu M, Sezer M, Sahin O, Tokyol C, Esme H.2-Fidan F, Unlu M, Sezer M, Sahin O, Tokyol C, Esme H. Acute effects Acute effects of environmental tobacco smoke and dried dung smoke on lung of environmental tobacco smoke and dried dung smoke on lung histopathology in rabbitshistopathology in rabbits Pathology. 2006 Feb;38(1):53-7Pathology. 2006 Feb;38(1):53-7

The relationships between traditional The relationships between traditional biomass combustion and development of biomass combustion and development of COPD in women of Sivas area. COPD in women of Sivas area.

*Demirtaş N, Seyfikli Z, Topçu S. Solunum Hastalıkları 1999; 10: 156 *Demirtaş N, Seyfikli Z, Topçu S. Solunum Hastalıkları 1999; 10: 156 –8.–8.

Biomass fuel has deleterious effects on Biomass fuel has deleterious effects on pulmonary function and structure leading to pulmonary function and structure leading to obstructive and restrictive pathologiesobstructive and restrictive pathologies**

**Functional and radiological impairment in women highly exposed to Functional and radiological impairment in women highly exposed to indoor biomass fuels.indoor biomass fuels.Ozbay B, Uzun K, Arslan H, Zehir I.Ozbay B, Uzun K, Arslan H, Zehir I. Respirology. 2001 Sep;6(3):255-8.Respirology. 2001 Sep;6(3):255-8.

Biomass fuel exposure causes obstructive and Biomass fuel exposure causes obstructive and restrictive spirometric impairments. restrictive spirometric impairments.

The prevalence of the fibrotic bands, The prevalence of the fibrotic bands, peribronchperibronchiiovascular thickenings, nodular radio ovascular thickenings, nodular radio opacities, and curvilinear densities in the high opacities, and curvilinear densities in the high resolution computed tomographic examinations resolution computed tomographic examinations were 7, 5,7, and 16 times higher in the exposure were 7, 5,7, and 16 times higher in the exposure group than the control group, respectivelygroup than the control group, respectively**

*Arslan M, Akkurt I, Egilmez H, Atalar M, Salk I.Biomass exposure and the *Arslan M, Akkurt I, Egilmez H, Atalar M, Salk I.Biomass exposure and the high resolution computed tomographic and spirometric findings.Eur J Radiol. high resolution computed tomographic and spirometric findings.Eur J Radiol. 2004 Nov;52(2):192-9.2004 Nov;52(2):192-9.

Rural women exposed to biomass fumes are Rural women exposed to biomass fumes are more likely to suffer from CB and COPD than more likely to suffer from CB and COPD than urban women even though the prevalence of urban women even though the prevalence of smoking is higher among the latter groupsmoking is higher among the latter group**

*Kiraz K, Kart L, Demir R, Oymak S, Gulmez I, Unalacak M, Ozesmi M. Chronic *Kiraz K, Kart L, Demir R, Oymak S, Gulmez I, Unalacak M, Ozesmi M. Chronic pulmonary disease in rural women exposed to biomass fumes. Clin Invest Med. pulmonary disease in rural women exposed to biomass fumes. Clin Invest Med. 2003 Oct;26(5):243-8.2003 Oct;26(5):243-8.

Asthma related symptoms were reported Asthma related symptoms were reported

in 63.3 % of those who used biomass fuel, in 63.3 % of those who used biomass fuel,

and in 12.9 % of nonusersand in 12.9 % of nonusers**

*Uzun K, Özbay B, Ceylan E, Gencer M, Zehir İ. Prevalence of Chronic *Uzun K, Özbay B, Ceylan E, Gencer M, Zehir İ. Prevalence of Chronic

Bronchitis – Asthma symptoms in Biomass Fuel Exposed Females. Bronchitis – Asthma symptoms in Biomass Fuel Exposed Females.

Environ Health Prev Med 2003; 8: 13 – 17.Environ Health Prev Med 2003; 8: 13 – 17.

In the living conditions existing in the rural Hill In the living conditions existing in the rural Hill

Region of Nepal domestic smoke pollution is an Region of Nepal domestic smoke pollution is an

important contributing factor in the development important contributing factor in the development

of chronic bronchitis of chronic bronchitis * * The findings support a causal role of domestic The findings support a causal role of domestic wood smoke exposure in chronic bronchitis and wood smoke exposure in chronic bronchitis and chronic airflow obstruction *chronic airflow obstruction *** *Pandey MR. Domestic smoke pollution and chronic bronchitis in a rural *Pandey MR. Domestic smoke pollution and chronic bronchitis in a rural community of the hill region of Nepalcommunity of the hill region of Nepal.. Thorax 1984; 39: 337 – 9. Thorax 1984; 39: 337 – 9. ****Perez-Padilla R, Regalado J, Vedal S, Pare P, Chapela R, Sansores R, Perez-Padilla R, Regalado J, Vedal S, Pare P, Chapela R, Sansores R, Selman MSelman M. . Exposure to biomass smoke and chronic airway disease in Exposure to biomass smoke and chronic airway disease in Mexican women. A case-control studyMexican women. A case-control study Am J Respir Crit Care Med. 1996 Am J Respir Crit Care Med. 1996 Sep;154(3 Pt 1):701-6.Sep;154(3 Pt 1):701-6.

Biomass Lung*Biomass Lung*

*Primitive Biomass Combustion and Lung Disease. Barış Yİ, Hoskins JA, *Primitive Biomass Combustion and Lung Disease. Barış Yİ, Hoskins JA, Seyfikli Z, Demir A. Indoor and Built Environment 2002; 11: 351- 8.Seyfikli Z, Demir A. Indoor and Built Environment 2002; 11: 351- 8.

Different aspects of indoor air pollution such as chronic biomass Different aspects of indoor air pollution such as chronic biomass smoke or wood smoke may be relevant to the development of smoke or wood smoke may be relevant to the development of obstructive lung diseaseobstructive lung disease**

The evidence that indoor pollution biomass cooking and heating The evidence that indoor pollution biomass cooking and heating in poorly ventilated dwellings is an important risk factor for COPD in poorly ventilated dwellings is an important risk factor for COPD (especially among women isdevelopeng countres) continues to (especially among women isdevelopeng countres) continues to grow, with case-control studies and other robustly designed grow, with case-control studies and other robustly designed studies now available **studies now available **

**Weis S.T, DeMeo D.L, Postma D. S. COPD: Problems in diagnosis and Weis S.T, DeMeo D.L, Postma D. S. COPD: Problems in diagnosis and measurement. Eur Respir J 2003; 21: Supll. 41, 4s – 12s.measurement. Eur Respir J 2003; 21: Supll. 41, 4s – 12s.

**** GOLD 2006. Burden of COPD, Risk factors s 3 GOLD 2006. Burden of COPD, Risk factors s 3

RATIONALRATIONAL

Pulmonary hypertension are frequently encountered Pulmonary hypertension are frequently encountered among women patients who exposed to biomass among women patients who exposed to biomass smoke in our region. First one may consider it was smoke in our region. First one may consider it was related to hypoxemia due to COPD. However in some related to hypoxemia due to COPD. However in some cases we cannot detect any pathology by PE and cases we cannot detect any pathology by PE and PFT. Common characteristic of these cases is heavly PFT. Common characteristic of these cases is heavly exposure to biomass smoke exposure to biomass smoke **. .

*Bülent Özbay, Bünyamin Sertoğullarından. Biomass maruziyeti ve izole *Bülent Özbay, Bünyamin Sertoğullarından. Biomass maruziyeti ve izole pulmoner hipertansiyon. Toraks derneği 10. Yıllık Kongresi, PS 230, 28. 05. pulmoner hipertansiyon. Toraks derneği 10. Yıllık Kongresi, PS 230, 28. 05. 2007, ANTALYA2007, ANTALYA

RATIONALRATIONAL

Medial thickening and perivascular lenfoid cells Medial thickening and perivascular lenfoid cells infiltrations in pulmonary vessel have been infiltrations in pulmonary vessel have been previously demonstrated*.previously demonstrated*.

**Bülent Özbay, Şükrü Acar, Zabit Yener, Mehmet Kanter Bülent Özbay, Şükrü Acar, Zabit Yener, Mehmet Kanter Hıstopathologıcal alteratıons ın respıratory tractus of rats exposed Hıstopathologıcal alteratıons ın respıratory tractus of rats exposed to bıomass smoke. Thorax Society 8th Annual Congress, MS to bıomass smoke. Thorax Society 8th Annual Congress, MS 337,28 . 04. 2005, ANTALYA337,28 . 04. 2005, ANTALYA

Figure 1 :Figure 1 : Sclerosis; medial thickening Sclerosis; medial thickening and perivascular lenfoid cells and perivascular lenfoid cells infiltrations in pulmonary vesselinfiltrations in pulmonary vessel**

**Bülent Özbay, Şükrü Acar, Zabit Yener, Mehmet Kanter Thorax Bülent Özbay, Şükrü Acar, Zabit Yener, Mehmet Kanter Thorax Society 8th Annual Congress, MS 337, 28 . 04. 2005, ANTALYASociety 8th Annual Congress, MS 337, 28 . 04. 2005, ANTALYA

RATIONALRATIONAL

In the light of mentioned findings, we In the light of mentioned findings, we decided to investigate the prevalance of decided to investigate the prevalance of PHT among appearently healthy women PHT among appearently healthy women who exposed to biomass smoke which who exposed to biomass smoke which widely used by women living in our area.widely used by women living in our area.

PurposePurpose

AiAimm was to investigate the frequencies and was to investigate the frequencies and relations of pulmonary hypertension (PH) relations of pulmonary hypertension (PH) and COPD among women exposed to and COPD among women exposed to biomass smokebiomass smoke

MethodMethod

We randomly selected 137 women living in We randomly selected 137 women living in traditional houses near Van and having cooking traditional houses near Van and having cooking or heating with biomass fuel, and 71 women or heating with biomass fuel, and 71 women living in apartments in the city having central living in apartments in the city having central heating and cooking with fuels other than heating and cooking with fuels other than biomass ones biomass ones

MethodMethod

Inclusion criteria for biomass exposure Inclusion criteria for biomass exposure groupgroup

•Exposure to biomass fuel at least 10 yearExposure to biomass fuel at least 10 year•Having no cardiac or pulmonary disease Having no cardiac or pulmonary disease

Inclusion criteria for control groupInclusion criteria for control group ; ;•No active exposure to biomass smokeNo active exposure to biomass smoke•Having no cardiac or pulmonary diseaseHaving no cardiac or pulmonary disease

MethodMethod

•Symptom of COPDSymptom of COPD; Cough, sputum, ; Cough, sputum, dyspnea dyspnea •Findings of PEFindings of PE; Decreased chest sounds, ; Decreased chest sounds, prolonged expirium, ronchus, crackles prolonged expirium, ronchus, crackles peripheral edema, cyanosisperipheral edema, cyanosis•SpirometerSpirometer; COPD= FEV1/FVC; COPD= FEV1/FVC%70 %70 •EchocardiographyEchocardiography; PHT= (PAB)≥ 30 ; PHT= (PAB)≥ 30 mmHgmmHg

MethodMethodThe individual exposure index was calculated as the The individual exposure index was calculated as the average number of hours spent daily for biomass average number of hours spent daily for biomass multiplied by the number of years of biomas.multiplied by the number of years of biomas.

GroupGroup Exposure indexExposure index11 No exposureNo exposure

2a2a 10 hour/year10 hour/year

2b2b 20 hour/year20 hour/year

2c2c 30 hour/year30 hour/year

2d2d >>30 hour/year30 hour/year

Statistical analysisStatistical analysis

Unpaired Student’s Unpaired Student’s tt-test was used to compare -test was used to compare differences between means of continuos variablesdifferences between means of continuos variables

Chi-square test was used to compare the Chi-square test was used to compare the differences between proportions of the differences between proportions of the control and research groups’ variables. The control and research groups’ variables. The chi-square test yielded different risk levels. chi-square test yielded different risk levels. In this case, the risk level was determined In this case, the risk level was determined using Fisher exact chi-square test. Odds using Fisher exact chi-square test. Odds ratios (OR) are reported as OR (95% ratios (OR) are reported as OR (95% confidence ınterval).confidence ınterval).

ResultsResults

208208 p peopleeople were followed up were followed up24 subjects were excluded from the 24 subjects were excluded from the

study due to; study due to; 10 not examined by Echocardiography10 not examined by Echocardiography2 patients pregnant2 patients pregnant1 patient with asthma1 patient with asthma5 patients with COPD5 patients with COPD2 patients being current smoker2 patients being current smoker8 patients with cardiac diseases 8 patients with cardiac diseases Finally, study included 184 peopleFinally, study included 184 people

GrupGrup 11 2a2a 2b2b 2c2c 2d2dnn 7171 8484 1616 99 44Mean Mean ageage±±SDSD

45±1045±10** 43±1043±10** 50±850±8 57±1157±11 62±562±5

**P P >>0.050.05

Age characteristics of subjects for Age characteristics of subjects for groupsgroups

Spirometric results of the control and biomass Spirometric results of the control and biomass exposure groupexposure group

FEV1FEV1 FVCFVC FEV1/FVCFEV1/FVC

ControlControl2,6 2,6 ±±0,5 0,5

%99 %99 ±± 18 183,1 3,1 ± ± 0,60,6

% 101 % 101 ±± 19 198282 % %

Biomass Biomass exposureexposure

2,1 2,1 ±±0,7 0,7

% 87 % 87 ±± 34 342,4 2,4 ± ± 0,80,8

% 85 % 85 ±± 34 348484 % %

pp <<0.050.05 <<0.050.05 >>0.050.05

FEVFEV11

GroupGroup

11 2a2a 2b2b 2c2c 2d2d2,6 2,6 ±± 0.5 0.5** 2.3 2.3 ±±

0,70,7**2 2 ±± 0,8 0,8 1.7 1.7 ±±

0,70,71.6 1.6 ±± 0,80,8

FVCFVC

GroupsGroups

11 2a2a 2b2b 2c2c 2d2d3.1 3.1 ±± 0.6 0.6 **

2.6 2.6 ±± 0,70,7**

2.2 2.2 ±± 0,90,9

1.9 1.9 ±± 0,70,7

1.8 1.8 ±± 0,80,8

The prevalence of COPD (FEV1/FVCThe prevalence of COPD (FEV1/FVC<<70) 70) in in the control and biomass exposure groupthe control and biomass exposure group

Biomass Biomass exposureexposure

TotalTotal

NoNo YesYes

FEV1/FVCFEV1/FVC<<7070 2 (%3)2 (%3)** 5 (%4)5 (%4)** 77FEV1/FVCFEV1/FVC>>7070 6969 108108 6666ToplamToplam 7171 113113 184184 * P * P >> 0.05 0.05

Results of symptoms and findings of Results of symptoms and findings of control and biomass exposure groupcontrol and biomass exposure group

BıomasBıomass s exposurexposuree

Cough Cough SputumSputum DispneDispne Family Family historyhistory

Positive Positive respiratory respiratory findingfinding

NoNo n=16 n=16 %22%22

n=10 n=10 %14%14

n=27 n=27 %38%38

n=9 %12n=9 %12 n=3 %4n=3 %4

YesYes n=52 n=52 %46%46

n=43 n=43 %38%38

n=84 n=84 %74%74

n=51 n=51 %45%45

n=15 %13n=15 %13

pp <<0.050.05 <<0.050.05 <<0.050.05 <<0.050.05 <<0.050.05

Biomass ExposureBiomass Exposure TotalTotalNoNo YesYes

PAPABB

NoNo 6262 5656 117117

YesYesMean PABMean PAB±±SDSD

9 (%12)9 (%12)**31.431.4±±5mmHg5mmHg

57(%48)57(%48)**34.534.5±±5mmHg5mmHg

6666

TotaTotall

7171 113113 184184

Frequencies of pulmonary hypertension of Frequencies of pulmonary hypertension of control and biomass grupcontrol and biomass grup

pp<<0.0010.001

Control Biomass exposureControl Biomass exposure

n:71 n:113n:71 n:113

% % P OR (%95 % % P OR (%95 CI)CI)

9 48 9 48 <<0.001 0.001 6.06.0 (2.7- (2.7-12.9)12.9)

Crude odds ratio of pulmonary hypertension Crude odds ratio of pulmonary hypertension for biomass smoke exposed group across the for biomass smoke exposed group across the control group.control group.

GroupsGroups11 2a2a 2b2b 2c2c 2d2d totaltotal

PABPAB

NoNo 6262 4343 88 44 00 116116YesYes n=9*n=9*

12 %12 %n=41n=41

48 %48 %n=8n=8

50 %50 %n=5n=5

55 %55 %n=4n=4

100 100 %%

6868

TotalTotal 7171 8484 1616 99 44 184184

Frequencies of pulmonary hypertension of Frequencies of pulmonary hypertension of control and subgrups of biomass exposurecontrol and subgrups of biomass exposure

*(p*(p<<0.001)0.001)..

Mean PAB levels of grupsMean PAB levels of grups

groupgroup 11 2a2a 2b2b 2c2c 2d2d

PABPAB 31.431.4±±55

33.833.8±±44

35.735.7±±77

36.436.4±±55

38.238.2±±33

pp>>0.050.05

ControlControl Exposure Exposure grupsgrups

OR OR %95 CI%95 CI

Group 1Group 1

2a2a 5.4 5.4 2.4-12.2.4-12.

2b2b 5.7 5.7 1.7-18.71.7-18.7

2c2c 7.1 7.1 1.6-31.11.6-31.1

2d2d 17.2 17.2

Odd ratios of pulmonary hypertension Odd ratios of pulmonary hypertension according to exposure index according to exposure index

Although less than the effects of cigarette Although less than the effects of cigarette smoke, dried dung smoke had severe smoke, dried dung smoke had severe histopathological effects on rabbits' lungs. histopathological effects on rabbits' lungs. **

*Fidan F, Unlu M, Sezer M, Sahin O, Tokyol C, Esme HFidan F, Unlu M, Sezer M, Sahin O, Tokyol C, Esme H. Acute effects of Acute effects of environmental tobacco smoke and dried dung smoke on lung environmental tobacco smoke and dried dung smoke on lung histopathology in rabbits. Pathology. 2006 Feb;38(1):53-7histopathology in rabbits. Pathology. 2006 Feb;38(1):53-7

Women cooking with biomass fuels have Women cooking with biomass fuels have increased respiratory symptoms and a slight increased respiratory symptoms and a slight average reduction in lung function compared average reduction in lung function compared with those cooking with gas.with those cooking with gas.**

*Regalado J, Perez-Padilla R. The effect of biomass burning on respiratory symptoms and lung function in rural Mexican women. Am J Respir Crit Care Med. 2006 Oct 15;174(8):901-5. Epub 2006 Jun 23

Women exposed domestically to biomass Women exposed domestically to biomass develop chronic obstructive pulmonary develop chronic obstructive pulmonary disease with clinical characteristics, quality of disease with clinical characteristics, quality of life, and increased mortality similar in degree life, and increased mortality similar in degree to that of tobacco smokers.to that of tobacco smokers.**

** Ramirez-Venegas A, Sansores RH. Survival of patients with Ramirez-Venegas A, Sansores RH. Survival of patients with chronic obstructive pulmonary disease due to biomass smoke chronic obstructive pulmonary disease due to biomass smoke and tobacco. Am J Respir Crit Care Med. 2006 Feb and tobacco. Am J Respir Crit Care Med. 2006 Feb 15;173(4):393-7. Epub 2005 Dec 115;173(4):393-7. Epub 2005 Dec 1

PAH in wood-smoke inhalation-associated lung disease (WSIALD) appears to be more severe than in other forms of interstitial lung disease and tobacco-related COPD

Sandoval J, Sales J. at all. Pulmonary arterial hypertension and cor Sandoval J, Sales J. at all. Pulmonary arterial hypertension and cor pulmonale associated with chronic domestic woodsmoke inhalation. CHEST pulmonale associated with chronic domestic woodsmoke inhalation. CHEST Volume 103, Issue 1, 1993, Pages 12-20Volume 103, Issue 1, 1993, Pages 12-20    

Cor pulmonale is prevalent in Delhi, India.

EighteenEighteen necropsied cases of chronic cor pulmonale necropsied cases of chronic cor pulmonale All patient were women All patient were women Age of 20 to 50 Age of 20 to 50 All patient All patient fromfrom rural areas of rural areas of DDelhi elhi andand all cases all cases inin poor socio-econumic poor socio-econumic status status Six subjects having cSix subjects having cow-dung smoke exposure ow-dung smoke exposure FFive ive subjectssubjects having having wood smok exposure wood smok exposure Four subjects Four subjects commented upon in the othercommented upon in the otherNon of patient gave a history of smoking Non of patient gave a history of smoking Necropsy finding showed increased right ventricüler thicknessNecropsy finding showed increased right ventricüler thicknesseses 17 of 18. 17 of 18. PPulmonary ulmonary specimenspecimen sho showwed some emphysema in all cases and ed some emphysema in all cases and bronchiectasis in 61 per centbronchiectasis in 61 per cent

**Padmavati S, Joshi B. Incidence and etiology of chronic cor pulmonale in Delhi. A Padmavati S, Joshi B. Incidence and etiology of chronic cor pulmonale in Delhi. A necropsy study. Br J Dis Chest 1976 ;70:251-9necropsy study. Br J Dis Chest 1976 ;70:251-9

ConclusionConclusion

Biomass exposure poses a greater risk for PH than Biomass exposure poses a greater risk for PH than COPD in women. A 10 year exposure to biomass COPD in women. A 10 year exposure to biomass smoke is enough to develope PH before the smoke is enough to develope PH before the diagnosis of COPD establisheddiagnosis of COPD established

THANKSTHANKS