The Federal Democratic Republic of Nepal is a beautiful and stunning country which is part of the Himalayan mountain ranges. Nepal has a population of 30 million spread over 147,516 km2. The capital of Nepal is Kathmandu. Nepal is home to people from more than 100 ethnic groups, most of whom share the official Nepali language. As a small, landlocked country, Nepal's topography, climate, religion and population are diverse. Nepal has eight of the world's 10 tallest mountains and contains more than 240 peaks over 6096 m above sea level.1 Nepal is a low-middle income country; its per capita income was US$729 in 2016.2

In Nepal, health care is delivered by a hybrid system of public and private sectors with predominantly modern health care and some traditional Ayurveda health care and other alternative medicines. The public healthcare system is composed of hospitals, primary healthcare centres and outreach healthcare providers (the latter provides basic level of health care by paramedical staff targeting the rural population).3

Nepal used to have a high prevalence of communicable diseases (CDs); currently, the country has higher age-standardized death rates and disability-adjusted life years from non-CDs (NCDs) than CDs. NCDs account for 80% of outpatient visits and are the leading cause of death, with two thirds of deaths due to NCDs and an additional 9% due to injuries.4 The remaining 25% of deaths are due to communicable, maternal, neonatal and nutritional diseases.5 As a percentage of total deaths, the leading five causes in 2017 were ischaemic heart disease (16.4%), chronic obstructive pulmonary disease (COPD; 9.8%), diarrhoeal diseases (5.6%), lower respiratory infections (5.1%) and intracerebral haemorrhage (3.8%).5

The rising incidence of NCDs is partly due to changing age structure and lifestyles, such as increasing sedentary behaviour, tobacco use, modified eating habits and harmful use of alcohol.5 The increase in life expectancy as well as the burden of NCDs signals a demographic shift to an ageing population, which could have significant effects on resource distribution in the Nepalese health system.

Bronchiectasis and COPD are the most common chronic respiratory diseases diagnosed in developing countries. Despite differing aetiology, pathophysiology and prognosis, bronchiectasis clearly overlaps with features of COPD in a subset of patients. Bronchiectasis–COPD overlap syndrome (BCOS) is a discrete, chronic clinical entity meeting the structural and diagnostic criteria of bronchiectasis, that is, the presence of ‘bronchiectatic’ airway wall changes and physiological criteria for the diagnosis of COPD.6 There are no data on the prevalence of BCOS among patients presenting with respiratory symptoms complex (i.e., cardinal chronic symptoms of the respiratory system occurring together) in Nepal.

Within this context, we conducted a hospital-based cross-sectional study at the Department of Pulmonary, Critical Care and Sleep Medicine of the B. P. Koirala Institute of Health Sciences (BPKIHS), a tertiary care university teaching hospital in Dharan, Nepal (Figure 1). The aim was to study the occurrence of BCOS among 236 patients presenting with complex respiratory symptoms in a year. Ethical clearance to conduct the study was obtained from the Institutional Ethical Review Board (IRC/1529/01). We took a three-step approach to the diagnosis of BCOS: We compiled and compared the symptoms and findings that favoured a diagnosis of bronchiectasis or COPD; then Considered the level of certainty around the diagnosis of bronchiectasis or COPD, after ascertaining whether there are features of both, suggesting BCOS and We also explored the clinical trajectory along with disease severity and exacerbation risk.

Pulmonary ward of B. P. Koirala Institute of Health Sciences (A); chest x-ray of typical bronchiectasis–chronic obstructive pulmonary disease overlap syndrome patient (B) with spirometry being done of the same patient (C)

Most of the patients with complex respiratory symptoms seen at our study centre were referred from healthcare facilities in the same region (72.5%) and the majority (70%) required admission. This first observational cross-sectional study found that 22% of adult patients presenting with complex respiratory symptoms had BCOS. There was a male predominance (58%) with a mean age of 67.8 years (range 51–93 years); the majority were current smokers with high smoking index and pack-year history.

Chronic productive cough with profuse purulent sputum followed by dyspnoea were the most important symptoms in patients presenting with BCOS, and these symptoms (cough and sputum) were more prevalent in current versus ex-smokers. The presence of bilateral basal coarse crackles, together with wheezes and dyspnoea or gas exchange abnormalities indicated BCOS. These patients had an obstructive pattern of pulmonary functions, along with cystic type of bilateral bronchiectasis with a moderate amount of bronchial wall thickening.

Patients with BCOS had a mean FACED score of 3.94± 1.62, which implied that the contribution of the bronchiectasis component was severe. The FACED score (FEV1, Age, Chronic colonization, Extension of lobe, Dyspnea) is easy to obtain, calculate and interpret; it can have point-of-care utility in providing a quick assessment of the initial severity, in a multidimensional and heterogeneous disease like BCOS. Thus, we postulate that using the FACED score for care of patients with BCOS may be advantageous.

Based on our experience, we conclude that substantial numbers of patients presenting with complex respiratory symptoms in Nepal have BCOS. Our experience challenges the earlier simplistic diagnostic dichotomy between bronchiectasis and COPD, and suggests that tobacco smoking, toxic exposure to indoor air pollution and past pulmonary tuberculosis may cause bronchiectasis-dominant, COPD-dominant, or BCOS pathology, with differing implications for treatment, complications and prognosis.

The COVID 19 pandemic has not spared our country. The first case was an asymptomatic student from Wuhan, China, who had returned to Nepal and was managed in isolation. Subsequently, more cases were imported through international travel. Lockdown was imposed from 24 March 2020 and lasted for 6 months. During the initial phase of the pandemic, getting personal protective equipment was difficult which was overcome by using locally available materials. Nepal initially did not have RT-PCR (reverse transcription-polymerase chain reaction) testing laboratories which have since been developed throughout the country (totalling 102 public and private laboratories). We are now at the end of the second wave with daily reports of less than 5% of positive tests. As of 13 November 2021, Nepal had 0.9 million total cases with a recovery rate of 98% and a case fatality rate of 1.5% (total deaths 11,471). Around 25% of our total population has been fully vaccinated.7

The COVID-19 pandemic is likely to continue to pose a threat to patients with BCOS and other chronic respiratory conditions. The pandemic should act as a catalyst for governments to implement policies and programmes for early diagnosis and effective treatment for patients with BCOS. We hope that our observations will promote new and more comprehensive future research in this field in Nepal.

The authors have obtained signed consent from the patient to publish the photograph.