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Quality of life in COPD patients

Article October 2012

DOI: 10.1016/j.ejcdt.2012.08.012

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Egyptian Journal of Chest Diseases and Tuberculosis (2012) 61, 281289

The Egyptian Society of Chest Diseases and Tuberculosis

Egyptian Journal of Chest Diseases and Tuberculosis

www.elsevier.com/locate/ejcdt
www.sciencedirect.com

ORIGINAL ARTICLE

Quality of life in COPD patients

Mohammed A. Zamzam a, Nourane Y. Azab a, Rabab A. El Wahsh a,*
,
Afaf Z. Ragab b, Enas M. Allam c

a
Chest Department, Faculty of Medicine, Menouya University, Shebin El-Kom, Egypt
b
Psychiatry Department, Faculty of Medicine, Menouya University, Shebin El-Kom, Egypt
c
Chest Hospital, Shebin El-Kom, Egypt

Received 17 July 2012; accepted 28 August 2012

Available online 10 February 2013

KEYWORDS Abstract Quality of life (QOL) can be severely impaired in patients with COPD. They usually
COPD; show an accelerated decline in lung function and progressive impairment of physical performance.
Quality of life; Aim: To study quality of life in patients with COPD and to examine its relationship with the
SGRQ-C severity of the disease.
Patients and methods: Quality of life was determined in 40 COPD patients using the St. Georges
Respiratory Questionnaire for COPD patients (SGRQ-C).
Results: Mild COPD patients differed signicantly from other grades of COPD in their total
SGRQ-C score, symptoms score, activity score and impact score (p 6 0.001). There was a
statistically signicant negative correlation between spirometric data (FEV1, FEV1/FVC, PEFR,
FEF2575%) and SGRQ-C score (total score, symptoms score, activity score and impact score).
There was a statistically signicant positive correlation between smoking index and both symptoms
score and impact score.
Conclusion: Quality of life is impaired in patients with COPD and it deteriorates considerably
with increasing severity of disease. Increasing severity of COPD is associated with a signicant
increase in SGRQ-C score. A higher smoking index affects the COPD subjects QOL especially with
patients symptoms and impact of disease. Psychological assessment and psychiatric consultation
are important for improving COPD symptoms, QOL and for early detection and treatment of
superimposed psychiatric symptoms that could worsen COPD condition and seriously affect QOL.
2012 The Egyptian Society of Chest Diseases and Tuberculosis. Production and hosting by Elsevier B.V.
All rights reserved.

* Corresponding author. Mobile: +20 1006896262.
E-mail address: rababwahsh@yahoo.com (R.A. El Wahsh).
Peer review under responsibility of The Egyptian Society of Chest
Diseases and Tuberculosis.
Production and hosting by Elsevier
Introduction
Chronic obstructive pulmonary disease (COPD) is a major and
increasing global health problem with enormous amount of
expenditure of direct/indirect health-care costs [1].
COPD impairs quality of life, by preventing people with the
condition from socializing and enjoying their hobbies. It also

0422-7638 2012 The Egyptian Society of Chest Diseases and Tuberculosis. Production and hosting by Elsevier B.V. All rights reserved.
http://dx.doi.org/10.1016/j.ejcdt.2012.08.012
282
makes many feel frustrated and angry about not being able to
do the things they want to [2].
The Global Initiative for Chronic Obstructive Lung Disease
(GOLD) guidelines have identied the goals of treatment for
patients with COPD, these include the patients goals of im-
proved exercise tolerance and emotional function (health-re-
lated quality of life) and also important clinical goals such as
prevention of disease progression and minimization of symp-
toms [3].
Anxiety and depression are frequently associated with
COPD and with acute and chronic respiratory diseases in gen-
eral. Whereas anxiety may appear earlier than depression, the
latter is related to the severity of COPD and to the degree of
impaired functioning. Both conditions signicantly affect
COPD prognosis. Unfortunately, psychiatric disorders are
not systematically evaluated and diagnosed in COPD patients,
and consequently they are not always treated adequately. This
negatively affects the evolution of the respiratory disease and
the patients quality of life; it also increases healthcare and so-
cial costs [4].
Quality of life (QOL) is an important domain for measuring
the impact of chronic disease. Both general and disease-specic
instruments have been used to measure QOL in patients with
COPD [5,6].
Among the disease specic questionnaires frequently used
to evaluate the QOL of pulmonary patients is St. Georges
Respiratory Questionnaire (SGRQ). A new version of the
SGRQ, the SGRQ-C specic only to COPD, is now available
[7].
Aim
The aim of this work was to study quality of life (QOL) in pa-
tients with COPD and to examine its relationship with the
severity of the disease.
Patients and methods
This work was carried out on 40 patients with COPD diag-
nosed and classied according to GOLD 2010 [8], referred to
chest hospital in Shebin El-Kom during the period, from Jan-
uary 2011 to December 2011.
Criteria of exclusion
1- Acute exacerbation of COPD or respiratory failure.
2- Other underlying chest diseases.
3- Underlying heart diseases.
Part 1
Question 1: I cough
Most days
Several days
With chest infections
Not at all
Question 2: I bring up phlegm (sputum)
M.A. Zamzam et al.
4- Other medical conditions that affect the QOL as diabe-
tes mellitus, hypertension, malignancy, etc.
After having an informed consent; each patient underwent:
1- Full history taking and clinical examination.
2- Chest X-ray (postero- anterior and lateral views).
3- Pulmonary function tests:
Morning spirometry was done and post bronchodilator spi-
rometry was performed after giving the patient a bronchodila-
tor, such as an inhaled beta-agonist e.g. salbutamol 200 lg) [3].
The following parameters were measured:
a- Forced expiratory volume in the rst second (FEV1) pre
and post bronchodilator.
b- Forced vital capacity (FVC).
c- FEV1/FVC ratio.
d- Peak expiratory ow rate (PEFR).
e- Forced expiratory ow at 25%- 75% of maximal lung
volume (FEF2575%).
Patients were classied according to GOLD staging system
(GOLD 2010) [8] into:
Stage I: Mild COPD (FEV1/FVC <70%; post bronchodi-
lator FEV1 P80% predicted)
Stage II: Moderate COPD (FEV1/FVC <70%, 50% 6post
bronchodilator FEV1 680% predicted)
Stage III: Severe COPD (FEV1/FVC <70%, 30% 6post
bronchodilator FEV1 650% predicted)
Stage IV: Very Severe COPD (FEV1/FVC <70%, post
bronchodilator FEV1 630% predicted or post bronchodi-
lator FEV1 650% predicted plus chronic respiratory
failure).
1- St. Georges Respiratory Questionnaire for COPD
patients (SGRQ-C) [9]:
A Administration:
Using simple Arabic version of SGRQ-C consisting of 14
questions, the questionnaire was completed in a quiet area, free
from distraction and the patient was sitting at a desk or table.
We explained to the patients why they were completing it, and
how important it is for clinicians and researchers to under-
stand how their illness affects them and their daily life. Patients
were asked to complete the questionnaire as honestly as they
can and stress was made that there are no right or wrong an-
swers, simply the answer is that they feel best applies to them
[10].
Weight
80.6
46.3
28.1
0.0
Quality of life in COPD patients 283

Most days 76.8

Several days 47.0
With chest infections 30.2
Not at all 0.0

Question 3: I have shortness of breath

Most days 87.2
Several days 50.3
Not at all 0.0

Question 4: I have attacks of wheezing

Most days 86.2
Several days 71.0
A few days 45.6
With chest infection 36.4
Not at all 0.0

Question 5: How many attacks of chest trouble have you had

3 or more 80.1
1 or 2 attacks 52.3
None 0.0

Question 6: How often do you have good days (with little chest trouble)?
None 93.3
A few 76.6
Most are good 38.5
Every day 0.0

Question 7: If you have a wheeze, is it worse in the morning?

No 0.0
Yes 62.0

Part 2
Question 8: How would you describe your chest condition?
The most important problem I have 82.9
Causes me a few problems 34.6
Causes no problem 0.0

Question 9: Questions about what activities usually make you feel breathless
Getting washed or dressed 82.8
Walking around the home 80.2
Walking outside on the level 81.4
Walking up a ight of stairs 76.1
Walking up hills 75.1

Question 10: More questions about your cough and breathlessness

My cough hurts 81.1
My cough makes me tired 79.1
I get breathless when I talk 84.5
I get breathless when I bend over 76.8
My cough or breathing disturbs my sleep 87.9
I get exhausted easily 0

Question 11: Questions about other eects your chest trouble may have on you
My cough or breathing is embarrassing in public 74.1
My chest trouble is a nuisance to my family, friends or neighbors 79.1
I get afraid or panic when I cannot get my breath 87.7
I feel that I am not in control of my chest problem 90.1
I have become frail or invalid because of my chest 89.9
Exercise is not safe for me 75.7
Everything seems too much of an eort 84.5

Question 12: Questions about how activities may be aected by your breathing
I take a long time to get washed or dressed 74.2
I cannot take a bath or shower, or I take a long time 81.0
I walk more slowly than other people, or I stop for rests 71.7
284 M.A. Zamzam et al.

Jobs such as housework take a long time, or I have to stop for rests 70.6
If I walk up one ight of stairs, I have to go slowly or stop 71.6
If I hurry or walk fast, I have to stop or slow down 72.3
My breathing makes it dicult to do things such as walk up hills, 74.5
carry things up stairs, light gardening such as weeding, dance, play bowls or play golf
My breathing makes it dicult to do things such as carry heavy loads, 71.4
dig the garden or shovel snow, jog or walk at 5 miles per hour, play tennis or swim
Question 13: We would like to know how your chest trouble usually aects your daily life
I cannot play sports or games 64.8
I cannot go out for entertainment or recreation 79.8
I cannot go out of the house to do the shopping 81.0
I cannot do housework 79.1
I cannot move far from my bed or chair 94.0
Question 14: Tick the statement which you think best describes how your chest aects you
It does not stop me doing anything I would like to do 0.0
It stops me doing one or two things I would like to do 42.0
It stops me doing most of the things I would like to do 84.2
It stops me doing everything I would like to do 96.7

B Item weights:
Each questionnaire response has a unique weight [11]. The
lowest possible weight is zero and the highest is 100.
C Scoring algorithm:
A total and three component scores are calculated: symp-
toms, activity, impacts. Each component of the questionnaire
is scored separately:
a- Sum the weights for all items with a positive response
1- Symptoms component:
This consists of all the questions in part 1. The weights for
questions 17 are summed. A single response is required to
each item.
1- Activity component:
This is calculated from the summed weights for the positive
responses to items in questions 9 and 12 in part 2 of the
questionnaire.
Score = 100 summed weights from all positive items in
that component/sum of maximum possible weights for all
items in that component.
The total score is calculated in a similar way:
Score = 100 summed weights from all positive items in
the questionnaire/sum of maximum possible weights for all
items in the questionnaire.
Sum of maximum possible weights for each component and total
Symptoms 566.2
Activity 982.9
Impacts 1652.8
Total (sum of maximum for all three components)
3201.9
(Note: these are the maximum possible weights that could
be obtained for the worst possible state of the patient).
Statistical analysis:
Data were collected, tabulated, statistically analyzed by
computer using SPSS version 16, two types of statistics were
done:

1- Impacts component:
This is calculated from questions 8, 10, 11, 13, 14 in part 2
of the questionnaire. The weights for all positive responses to
items in questions 10, 11, 13 are summed together with the re-
sponses to the single item that should have been checked
(ticked) in questions 8 and 14. In the case of multiple responses
to either of these items, the average weight for the item should
be calculated.
a- Calculate the score
The score for each component is calculated separately by
dividing the summed weights by the maximum possible
weight for that component and expressing the result as a
percentage:
1- Descriptive statistics:
Quantitative data are expressed to measure the central ten-
dency of data and diversion around the mean, mean (x) and
standard deviation (SD).
Qualitative data expressed in number and percentage.
1- Analytic statistics:
Krauskal Wallis test was used for comparison of more than
two groups of non normally distributed variables, LSD
post hoc test was used to detect the intergroup differences.
Pearson correlation (r) was used to detect association
between quantitative variables.
P value >0.05 was considered statistically non signicant.
P value 60.05 was considered statistically signicant.
P value 60.001 was considered statistically highly
signicant.
Quality of life in COPD patients 285

Results

Table 1 Characteristics of the studied patients.

Parameter
Age in years Range 4770
Mean SD 59.9 4.7
Sex No. (%) Male 39 (97.5%)
Female 1 (2.5%)
Smoking habits Yes 38 (95%)
No. (%) No 2 (5%)
Smoking index Mild <10 1 (2.6%)
(pack.year) No. Moderate 1020 2 (5.3%)
(%) Heavy >20 35 (92.1%)
Spirometric Post 46.5 22.5
parameters bronchodilator
(x SD) FEV1 % of
predicted
FEV1/FVC 57.95 10.1
FVC % of 68.25 25.1
predicted
PEFR % of 28.65 16.1
predicted

Table 2 Comparison between grades of COPD severity regarding age and smoking index.
Parameter COPD Kruskal P
Wallis test value
Mild (I) Moderate (II) Severe (III) Very severe (IV)
(n = 6) (n = 11) (n = 13) (n = 10)
Age in years (x SD) 62 4 61.73 4.5 57.9 5.1 59.1 4.1 5.65 >0.05
Smoking index in pack.years (n = 38) (x SD) 26.5 9.05 36.4 10.4 51.4 14.6 54.7 28.3 12.7 60.001**
(n = 6) (n = 11) (n = 12) (n = 9)
**
Highly statistically signicant.

Table 3 Comparison between grades of COPD severity regarding SGRQ-C score.

SGRQ-C score Grades of severity of COPD patients Kruskal P LSD
Wallis test value (Post
Mild (I) (n = 6) Moderate (II) (n = 11) Severe (III) (n = 13) Very severe (IV) (n = 10)
Hoc
test)
**
Total score (x SD) 14.22 5.6 42 4.9 44.25 10.01 44.83 10.5 15.56 I&II
60.001 I&III
I&IV
**
Symptom score (x SD) 23.03 6.6 60.65 9.5 67.55 14.6 65.38 16.8 15.9 I&II
60.001 I&III
I&IV
**
Activity score (x SD) 15.67 15.4 65.97 9.4 67.98 16.32 71.81 21.01 15.51 I&II
60.001 I&III
I&IV
**
Impact score (x SD) 8.68 1.47 20.65 3.30 20.90 3.1 21.57 3.09 15.8 I&II
60.001 I&III
I&IV
**
Highly statistically signicant.
286 M.A. Zamzam et al.

Table 4 Correlation coefcient (r) between smoking index and SGRQ-C score (total, symptoms, activity, and impact) in COPD
patients (n = 38).
SGRQ-C Smoking index (N = 38)
r P value
Total score 0.27 >0.05
Symptoms score 0.39 60.05*
Activity score 0.25 >0.05
Impact score 0.43 60.05*
*
statistically signicant.

Table 5 Correlation coefcient (r) between SGRQ-C score and spirometric parameters (n = 40).
Spirometric parameter Total SGRQ-C score Symptoms SGRQ-C score Activity SGRQ-C score Impact SGRQ-C score
r P value R P value R P value R P value
FEV1 0.65 60.001** 0.64 60.001** 0.67 60.001** 0.67 60.001**
FEV1/FVC 0.53 60.001** 0.58 60.001** 0.51 60.001** 0.39 60.05*
FVC 0.02 >0.05 0.01 >0.05 0.052 >0.05 0.07 >0.05
PEFR 0.37 60.05* 0.35 60.05* 0.42 60.05* 0.40 60.05*
FEF2575% 0.33 60.05* 0.32 60.05* 0.37 60.05* 0.43 60.05*
*
statistically signicant.
**
Highly statistically signicant.

Discussion to higher prevalence of smoking in this gender, and also males

The importance of measurement of quality of life (QOL) in
COPD subjects is indicated because of two important facts.
The rst is that no single measurement of lung function can
satisfactorily summarize the various disturbances that may
cause breathlessness in patients with COPD. For example,
there is increasing evidence that increased functional residual
capacity may cause breathlessness and exercise limitation,
independently of disturbances in FEV1. The second is that
the correlation between measures of airways obstruction and
exercise impairment is frequently poor [12].
So, the aim of this work was to study QOL in patients with
COPD and to examine its relationship with the severity of the
disease.
This work was carried out on 40 patients with COPD diag-
nosed and classied according to GOLD 2010.
Six patients had grade I (mild) COPD, 11 patients had
grade II (moderate) COPD, 13 patients had grade III (severe)
COPD and 10 patients had grade IV (very severe) COPD.
In this study, the mean age of the patients was 59.9
4.7 years, there was a non statistically signicant difference be-
tween different grades of COPD severity regarding their age
(P > 0.05) Tables 1 and 2.
When evaluating age as a risk factor for COPD, an impor-
tant issue is also the spirometric criteria of COPD. A xed
ratio for the denition of airway obstruction (FEV1/FVC
<0.7) will overestimate COPD in elderly and underestimate
COPD among young adults [13].
Fletcher and Peto [14] reported that COPD is characterized
by an accelerated rate of decline of FEV1 with age. According
to this, one might expect patients with severe COPD to be old-
er [15].
In the present work, 97.5% of patients were males. COPD
is a male dominant disease, the high prevalence in males is due
are more exposed to smoking than females [16]. Also, more
frequent occupational exposures of signicance are present in
men [17].
In the present study there was a highly statistically signi-
cant difference between different grades of COPD severity as
regarding their smoking index (p 6 0.001) Table 2.
Many epidemiological studies have found that cigarette
smoking is by far the most important risk factor for COPD.
It is also known that total pack.years of smoking are predictive
of COPD mortality [18,19].
According to Lindstrom et al. [20] there is a relation be-
tween the increased risk of lung toxicity of chronic smoking
with the time and amount of smoking. Also, Lindberg et al.
[21] found a high cumulative incidence of COPD after 10 years
of smoking. This emphasizes the importance of early smoking
cessation in the reduction of incidence of COPD.
In this study there was a statistically signicant positive correla-
tion between smoking index and both symptoms score and impact
score. While the correlations between both total score and activity
score and smoking index were non signicant Table 4.
Prigatano et al. [22] reported that smoking was found to af-
fect QOL regardless the presence of COPD. There was a report
that showed worse QOL scores in younger and current smoker
patient with high FEV1 values than ex-smoker patients with
COPD. However, they found that COPD severity was inu-
enced by smoking status but current smoking affected the
quality of life by causing COPD exacerbations although it
did not directly cause QOL deterioration.
George and Constantine [23] have shown that Smoking ces-
sation was related to improved QOL scores, and a reduction in
COPD related symptoms, indicating the necessity for active
interventions by health professionals to help COPD patients
quit smoking as a primary tool for the adequate management
of COPD and the patients QOL.
Quality of life in COPD patients
On the other hand, another study stated that current smok-
ing and a higher number of pack.years have a weak negative
inuence on health status [24]. Some studies reported no corre-
lation [25,26].
In the present work, mild COPD patients differed signi-
cantly from other grades of COPD in their total SGRQ-C
score, symptoms score, activity score and impact score
(p 6 0.001) Table 3.
COPD is associated with signicant reductions in QOL,
even among patients with mild airway obstruction. A poor
QOL has been shown to be associated with high levels of dysp-
nea, physical impairment, depression, and anxiety, and a poor
prognosis in terms of readmission to hospital and death [27].
Also, it was mentioned that the patients with the greatest
impairment in their quality of life are those that present with
cough and exertional dyspnea, have a longer duration of the
disease and take more drugs [28].
The relationship of the SGRQ-C score with the symptoms
(symptoms score) has been extensively documented in the case
of dyspnea, but it is more interesting to check its relationship
to cough and expectoration. Patients with high scores pre-
sented cough with a greater frequency and a tendency to a
greater frequency of expectoration, the effect of cough and
expectoration on the quality of life has been observed in young
patients with mild bronchial disease [29].
According to Doll and Miravitlles [30], Seemungal [31] and
Miravitlles [32] the effect of exacerbations on the quality of life
of patients with COPD has been demonstrated as patients with
a poor quality of life had more exacerbations.
Moreover, other studies have found respiratory symptoms
to be more closely related to QOL than impairment in
FEV1. This could indicate that QOL is impacted more by
symptoms than the actual airway narrowing that FEV1 mea-
sures [3335].
Javier et al. [36] have shown that COPD had a considerable
impact on daily activities in patients. Aspects of daily life are
most affected, either due to the severity of the disease or the
existence of social, economic, or occupational factors that
could interfere with the management of the disease or compli-
cate its progression.
Disease severity in COPD affects exercise tolerance such as
walking distance. A study in pulmonary rehabilitation has
shown that assessment of exercise tolerance correlates well with
disease severity. Also, it corresponds well with QOL scores. [37]
With respect to the different domains of the SGRQ-C, Bat-
lle and Esther [38] found that patients showed higher scores in
the impact domain than in the symptoms or activity domains;
the impact domain was also strongly associated with anxiety
(alone or with depression). The origin of the impact domain,
covering psychological disturbances resulting from respiratory
disease, partly explains these ndings. An analysis excluding
psychological items from SGRQ-C resulted in still clinically
relevant and statistically signicant associations between anx-
iety, depression, or both, and the Impact domain, suggesting
that psychological status plays an important role also in the so-
cial function of COPD patients.
Hill et al. [39] and Maurer et al. [40] had highlighted the
negative impact of psychological comorbidity on QOL in
COPD patients. Specically, previous studies of large samples
of COPD patients have found an association between psycho-
logical impairment (i.e., anxiety and/or depressive symptoms)
287
and worse respiratory-specic QOL, independent of COPD
severity [41,42].
Hajiro et al. [43] found that patients with mild-to-severe
COPD, reported that anxiety was associated with impairment
of QOL only in the subset of patients with FEV1 below 60% of
the predicted value.
Recently, it was found that when anxiety and depression
appear together, their inuence on QOL is greater in patients
with severe-to-very severe COPD than in those with mild-to-
moderate COPD [44].
In the present work, there was a statistically signicant neg-
ative correlation between FEV1, FEV1/FVC, PEFR, FEF2575%
and SGRQ-C score (total score, symptoms score, activity score
and impact score). But, the correlation with FVC was non
signicant Table 5.
Wlijkstra et al. [45] observed a correlation between the pul-
monary function parameters and the SGRQ-C, through its
components. The SGRQ-C activity domain was found to cor-
relate with all pulmonary function parameters. Finally, in the
multiple regression analysis, only FEV1 correlated signicantly
with the SGRQ-C.
However other investigations indicated a relatively weak
relationship between pulmonary function and QOL in patients
with COPD [46,47].
Although spirometry is traditionally seen as the most
important determinator of the diagnosis and severity of
COPD, the relation between health status and all spirometric
values mainly FEV1 is weak. This indicates that assessment
of COPD severity in clinical practice could benet from the
additional measurement of health status [48].
Conclusion
Quality of life is impaired in patients with COPD and it deteri-
orates considerably with increasing severity of disease. Increas-
ing severity of COPD is associated with a signicant increase in
SGRQ-C score. A higher smoking index affects the COPD sub-
jects QOL especially with patients symptoms and impact score
(which describe patients psychological state). Evaluation of
COPD patients should not be based only on pulmonary func-
tion tests, but also on measurement of QOL. Psychological
assessment and psychiatric consultation are important for
improving COPD symptoms, QOL and for early detection
and treatment of superimposed psychiatric symptoms that
could worsen COPD condition and seriously affect QOL.
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