|Year : 2021 | Volume
| Issue : 2 | Page : 71-75
Pattern of co-morbidities in patients of chronic obstructive pulmonary disease
Devendra Kumar Singh1, Sanjeev Anand2, Abhinit Kumar3, Santosh Kumar4, Anuj Kumar Pandey5, Ajay Kumar Verma5
1 Department of Respiratory Medicine, School of Medical Sciences & Research, Sharda Hospital, Greater Noida, India
2 Department of T.B. & Chest, F H Medical College, Agra, Uttar Pradesh, India
3 Department of Psychiatry, School of Medical Sciences and Research, Sharda Hospital, Greater Noida, Uttar Pradesh, India
4 Department of Tuberculosis & Chest Disease, Sarojini Naidu Medical College, Agra, Uttar Pradesh, India
5 Department of Respiratory Medicine, King George’s Medical University, Lucknow, Uttar Pradesh, India
|Date of Submission||24-Jul-2020|
|Date of Decision||08-Oct-2020|
|Date of Acceptance||30-Nov-2020|
|Date of Web Publication||4-Aug-2021|
Dr. Ajay Kumar Verma
Department of Respiratory Medicine, King George’s Medical University, Lucknow, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Background: Chronic obstructive pulmonary disease (COPD), a disease of the elderly population is continuously increasing across the globe. COPD can be associated with the comorbidities, which in turn affect the course or severity of the disease. Objectives: To study the pattern of comorbidities in stable patients of COPD, and their comparison with apparently healthy attendant of the age of ≥35 years. Materials and Methods: A total of 121 COPD patients and 130 healthy attendants of patients coming to the respiratory disease department were enrolled in the study. All participants were evaluated for detailed clinical history, physical examinations, laboratory investigations, Hamilton depression rating scale, polysomnography, echocardiography, and ophthalmological tests to get the different variables. Results: Comorbidities in the case group having COPD were found more prevalent. Prevalence of hypertension (cases [n = 32], control [n = 12], odds ratio = 3.53, P = 0.004), depression (cases [n = 38], control [n = 18], odds ratio = 2.85, P = 0.0013), bronchiectasis (cases [n = 14], control [n = 3], odds ratio = 5.54, P = 0.0046), tuberculosis (cases [n = 20], control [n = 9], odds ratio = 2.66, P = 0.0187), ischemic heart diseases (cases [n = 19], control [n = 9], odds ratio = 2.5, P = 0.043), and musculoskeletal disorder including arthritis, peri-arthritis, and osteoporosis (cases [n = 28], control [n = 13], odds ratio = 2.70, P = 0.0060) found statistically significant in COPD patients in comparison to healthy controls. Other comorbidities such as diabetes, cataract, dyslipidemia, and uterine prolapsed were more common in COPD patients but these differences were not statistically significant. Also, 85.98% of COPD patients had at least one comorbidity. Conclusion: Our data showed that comorbidities viz hypertension, depression, bronchiectasis, tuberculosis, ischemic heart diseases, and musculoskeletal disorders are prevalent in COPD patients compared to healthy individuals.
Keywords: chronic obstructive pulmonary disease, co-morbidity, prevalence, spirometryintroduction
|How to cite this article:|
Singh DK, Anand S, Kumar A, Kumar S, Pandey AK, Verma AK. Pattern of co-morbidities in patients of chronic obstructive pulmonary disease. J Assoc Chest Physicians 2021;9:71-5
|How to cite this URL:|
Singh DK, Anand S, Kumar A, Kumar S, Pandey AK, Verma AK. Pattern of co-morbidities in patients of chronic obstructive pulmonary disease. J Assoc Chest Physicians [serial online] 2021 [cited 2021 Dec 1];9:71-5. Available from: https://www.jacpjournal.org/text.asp?2021/9/2/71/323091
| Intoduction|| |
In the year 2011, a new chapter “COPD and comorbidities” was included in the Global Initiative for Chronic Obstructive Lung Disease (GOLD)-2011 report for better management of disease. Chronic obstructive pulmonary disease (COPD) is one of the leading causes of mortality and morbidity in the whole world. COPD may be associated with the comorbidities, which in turn affect the course or severity of disease; and finally, worsen its prognosis. Some of them appear independently, whereas others are incidentally related to COPD. Comorbidities need to be evaluated carefully as these have a major impact on the quality of life and survival of the patients. The frequent and major comorbidity associated with COPD is cardiovascular disease (e.g., ischemic heart disease, heart failure, arrhythmias, peripheral vascular disease, and hypertension). Other comorbidities are musculoskeletal disorders (osteoporosis); anxiety and depression; metabolic disorders and diabetes; malignancies; bronchiectasis; obstructive sleep apnea (OSA), ophthalmic; gastroesophageal reflux; and nutritional disorders.,,,,, The guidelines suggest that the treatment of comorbidities should be carried out in accordance with standards, regardless of whether COPD is present. Recent evidence had suggested that multimorbidity (at least two chronic diseases) is also linked to COPD patients. In the case of multimorbidity, attention should be directed to ensure the simplicity of treatment, as well as polypharmacy, should be minimized. The current therapies for comorbid diseases, such as statins and peroxisome proliferator-activated receptor agonists, may provide benefits in such patients. Hence, in the present study, we had evaluated the different types of comorbidities in stable patients of COPD and that in apparently healthy individuals.
| Materials and methods|| |
In this prospective, case-control study 160 COPD patients (case) and 158 non-COPD individuals (control) were approached. The study was conducted at the Tuberculosis and Respiratory Disease Department from May 2012 to October 2013. The complaints of breathlessness, chronic cough or sputum production, and/or history of exposure to risk factors, and about spirometry was asked from the participants. The diagnosis of COPD was based on the criteria laid down by the GOLD-2011 guidelines. Patients having FEV1/FVC < 70%, at any stage by spirometry, were included in the study. The patients had an acute exacerbation in the previous month and those who did not give consent were excluded from the study.
Out of 160 COPD cases, 15 (9.37%) unstable patients with a history of hospitalization during the previous month, 14 patients (8.75%) denied participating and 10 patients (6.25%) did not complete the study period and thus were excluded from the study. One hundred twenty-one cases were finally included in the study. On the other hand, out of 158 controls, 17 (10.76%) denied participating and 11 (6.96%) were lost during study period. One hundred thirty subjects were finally evaluated in the control group.
Study design and setting
All patients were analyzed systematically with the following protocol. A detailed history and physical examination were carried out. Investigations including complete blood cell count, routine chemistry, lipid profile, chest X-ray posteroanterior (PA) view, and computed tomography (CT) scan were done in both groups. X-ray knee, hip, elbow, and other body parts were also done in cases suspected of musculoskeletal disorders. Bone densitometry was performed where it was clinically indicated. Patients in the study group and controls were screened by the Epworth Sleepiness Scale score. Epworth sleepiness scale >10 and females having neck circumference >16 inches or >17 inches in males with or without a history of snoring were subjected to polysomnography. Echocardiography and electrocardiography were performed in all cases and controls, treadmill test and stress echocardiography were performed wherever it was clinically indicated to rule out cor-pulmonale, ischemic heart disease, rheumatic heart disease, and valvular heart diseases. All cases and controls were evaluated by Hamilton Rating scale-24 items for Depression and Vision tests with the help of Snellen chart, slit lamp examination, and tonometry to rule out or confirm the ocular ailments. All females of both groups were examined by gynecologist and sample for Pap smear was collected with the help of Ayer spatula.
The comorbidities were labeled as hypertension (blood pressure ≥ 140/90 mm Hg, or on medication.), osteoporosis (T-score ≤ −2.5 in postmenopausal women and men aged ≥50 years.), osteoarthritis (≥50 years old and Kellgren–Lawrence grade of knee or hip joint ≥2), diabetes mellitus (fasting blood glucose ≥126 mg/dL, postprandial blood glucose ≥200 mg/dL, or on diabetes medication), dyslipidemia (serum cholesterol levels ≥240 mg/dL, triglyceride level ≥200 mg/dL, low HDL cholesterol <40 mg/dL, and LDL cholesterol ≥130 mg/dL), obesity (defined by body mass index ≥ 30.0 kg/m2), depression (Hamilton depression rating scale-24 items, score ≥ 5), and obstructive sleep apnea (Apnea-Hypopnea index ≥ 5 per hour).
The comparisons of various parameters in cases and controls were performed by Fisher test. Odds ratios were also calculated to measure the association of different outcomes. Statistical Package for the Social Sciences Version 15.0 (SPSS, Version 15.0. Chicago, SPSS Inc.) was used for statistical tests. P<0.05 was considered as statistically significant and P < 0.01 was considered as highly significant.
| Results|| |
Demographic profile of the participants
Out of the 121 patients in COPD group (cases), 12.40% were older than 45 years of age; 58.68% were in age group of 46 to 60 years, and 28.92% were >60 years old. In non-COPD (control) participants, 26.92% participants were <45 years of age, 50% in age group of 46 to 60 years and rest 23.08% were in age group of more than 60 years. Mean age of cases was 54.45 ± 9.04 (mean ± SD) and control was 52.50 ± 10.20 (mean ± SD). There was statistically no significant (P = 0.1112) difference in the age distribution between both the groups. Out of 121 cases, there were 101 males (83.47%) and 20 females (16.53) and among 130 controls, there were 100 males (76.92%) and 30 females (23.08%). Also, there was no statistically significant (P = 0.2092) difference in the sex distribution between both the groups. The details about age and gender of participants are depicted in [Table 1] and [Table 2].
|Table 2 Distribution of COPD (cases) and non-COPD (controls) according to gender|
Click here to view
Clinical characteristics of the studied population
The body mass index in COPD group was 19.53 ± 3.04 (mean ± SD), whereas in non-COPD group was 21.36 ± 3.77 (mean ± SD) and a statistically significant (P < 0.0014) difference was found [Table 3]. When male subjects of both groups were compared on applying two-tailed by conventional criteria, P value was 0.0014, which is very statistically significant, and when the female subjects of both groups were compared, P value was 0.0050, which is found to be statistically significant. In the COPD group (n = 121), 55 patients were underweight (45.45%), 56 (46.28%) were in the normal range, and 10 patients were overweight (8.26%), whereas in the control group (n = 130), only 40 subjects were underweight (30.77%), 60 were in the normal range (46.15%), and 30 were overweight (23.08%) [Table 4].
The smoking index in the COPD group was 627.02 ± 446.9, and 366.15 ± 370.10 in the non-COPD group. The P value was <0.0001 and the difference was statistically significant [Table 5].
Spirometry was performed to suspected patients and COPD staging (I–IV) was done according to GOLD guideline-2011. In COPD group, 12.45% of patients were in stage I, 54.55% patients were in Stage II, 24.8% patients in Stage III, and 8.26% patients in Stage IV, whereas in control group, whoever found to have obstruction were registered in the study group. Since the control group consisted of healthy attendants, therefore statistic was not applied [Table 6].
The pattern of comorbidities with participants
Prevalence and frequency of comorbidities in the studied population is depicted in [Table 7] and [Table 8]. The common comorbidities associated with COPD included hypertension, 32 cases and 12 controls had hypertension (odds ratio = 3.53, P = 0.0004); and 19 cases and 9 controls had ischemic heart disease (odds ratio = 2.5, P = 0.0043); both were statistically significant. Bronchiectasis (cases [n = 14], control [n = 3], odds ratio = 5.54, P = 0.0046), depression (cases [n = 38], control [n = 18], odds ratio = 2.85, P = 0.0013), musculoskeletal disorder including arthritis, peri-arthritis, and osteoporosis (cases [n = 28], control [n = 13], odds ratio = 2.70, P = 0.0060), and tuberculosis (cases [n = 20], control [n = 9], odds ratio = 2.66, P = 0.0187) were significantly more common in COPD patients compared to controls. Diabetes (cases [n = 11], control [n = 6], odds ratio = 2.04, P = 0.2099), cataract (cases [n = 62], control [n = 52], odds ratio = 1.58, P = 0.775), glaucoma (cases [n = 2], control [n = 0], P = 0.2314), dyslipidemia (cases [n = 14], control [n = 8], odds ratio = 1.99, P = 0.1796), obstructive sleep apnea (cases [n = 11], control [n = 5], odds ratio = 2.5, P = 0.1207), and gynecological disorder including uterine prolapsed, cervical dysplasia, and cervical cancer (cases [n = 3], control [n = 2], odds ratio = 1.62, P = 0.3772) were more prevalent in cases than controls but the difference was not statistically significant. The bronchogenic carcinoma was diagnosed in three cases of COPD and none in non-COPD controls (P = 0.1106), which was statistically not significant. 85.95% of COPD patients (n = 104) had at least one comorbidity. Overall 66.94% (n = 81) had two or more morbidities, whereas 38.84.8% (n = 47) had three or more morbidities. Only 14.04% patients (n = 17) had no comorbidity.
|Table 7 Comparison of prevalence of co-morbidities in COPD and non-COPD group|
Click here to view
| Discussion|| |
In the present study, 85.98.0% of COPD patients had at least one comorbidity compared with 48.9% in controls. In a study of Crisafulli E et al., reported 51% of COPD patients have at least one comorbidity. Further, they stated that important comorbidity was metabolic diseases viz hypertension, diabetes, and/or dyslipidemia that was found in 61% population and 24% of patients had heart diseases. Our data suggest that hypertension, bronchiectasis, depression, and arthritis were significantly more common in COPD patients compared to non-COPD. A previous study has shown that COPD is a complex disorder that involves more than airflow obstruction such as cardiovascular diseases (CVD), lung cancer, osteoporosis, and muscle wasting. The study also noted that these diseases are more common in COPD patients compared to controls.
Holguin et al. had demonstrated that comorbidities were frequently reported in patients who are hospitalized or diagnosed with primary or secondary COPD: 17% of hypertension, 25% of heart disease, 11% of diabetes, and 12% of pneumonia; all higher than the control group. Also, in our study diabetes, cataract and glaucoma were though more prevalent in cases than controls but the difference was not statistically significant. Another study had reported that among COPD patients, hypertension accounted for 28%, diabetes accounted for 14%, and ischemic heart disease accounted for 10%. These findings were in agreement with our study. In our study, 9.0% of the COPD group have diabetes, whereas in independent studies by Caterina Anecchino et al. and Chatila et al., diabetes was noted in 12.4% and 11% cases, respectively. V. K. Vijayan et al. had studied cachexia in COPD and controls, and concluded that body mass index was significantly lower in cases compared to controls, likewise our data. The authors also stated that comorbidities associated with COPD were osteoporosis and osteopenia, cachexia, and skeletal muscle weakness. This was in agreement with our study that reported higher prevalence of arthritis, peri-arthritis, and osteoporosis in our cases.The limitations of our study is the lower sample size with a single-center study. A large randomized control trial is essential to confirm the results. Here, we have studied age group and gender, detailed socio-economic profile was not evaluated. Although these points limit the generalization of this study through a single site, our data emphasize the need to evaluate COPD patients worldwide to understand its function and comorbidities, and to determine the suitable treatment.
| Conclusion|| |
Patients with COPD have significantly associated comorbidities. Comorbid conditions such as hypertension, ischemic heart disease, bronchiectasis, depression, and arthritis were significantly more common in COPD patients than non-COPD controls. However, comorbidities such as diabetes, cataract, glaucoma, dyslipidemia, uterine prolapsed, and obstructive sleep apnea were also more in the COPD group, but statistically nonsignificant from the control group. In this context, awareness of health workers is required for managing a case of COPD. Further research is needed on the efficacy of prevention and treatment measures for comorbidities.
Financial support and sponsorship
Conflicts of interest
The authors reported no conflicts of interest.
| References|| |
Gruffydd-Jones K. GOLD guidelines 2011: what are the implications for primary care? Prim Care Respir J 2012;21:437-41.
Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease(2020 Report). Global Initiative for Chronic Obstructive Lung Disease, Inc. http://www.goldcopd.com
. Accessed July 23, 2020.
Anecchino C, Rossi E, Fanizza C, De Rosa M, Tognoni G, Romero M. Prevalence of chronic obstructive pulmonary disease and pattern of comorbidities in a general population. Int J Chron Obstruct Pulmon Dis 2007;2:567-74.
Fabbri LM, Luppi F, Beghé B, Rabe KF. Complex chronic comorbidities of COPD. Eur Respir J 2008;31:204-12.
Curkendall SM, DeLuise C, Jones JK, Lanes S, Stang MR, Goehring E Jr, She D. Cardiovascular disease in patients with chronic obstructive pulmonary disease, Saskatchewan Canada cardiovascular disease in COPD patients. Ann Epidemiol 2006;16:63-70.
Campo G, Pavasini R, Malagù M, Mascetti S, Biscaglia S, Ceconi C, Papi A, Contoli M. Chronic obstructive pulmonary disease and ischemic heart disease comorbidity: overview of mechanisms and clinical management. Cardiovasc Drugs Ther 2015;29:147-57.
van den Bemt L, Schermer T, Bor H, Smink R, van Weel-Baumgarten E, Lucassen P, Van Weel C. The risk for depression comorbidity in patients with COPD. Chest 2009;135:108-14.
Kinnunen T, Saynajakangas O, Tuuponen T, Keistinen T. Impact of comorbidities on the duration of COPD patients’ hospital episodes. Respir Med 2003;97:143-6.
Vestbo J, Hurd SS, Rodriguez‐Roisin R. The 2011 revision of the global strategy for the diagnosis, management and prevention of COPD (GOLD)-why and what? Clin Respir J 2012;6:208-14.
Crisafulli E, Costi S, Luppi F, Cirelli G, Cilione C, Coletti O, Fabbri LM, Clini EM Role of comorbidities in a cohort of patients with COPD undergoing pulmonary rehabilitation. Thorax 2008;63:487-92.
Barnes PJ, Celli BR. Systemic manifestations and comorbidities of COPD. Eur Respir J 2009;33:1165-85.
Holguin F, Folch E, Redd SC, Mannino DM. Comorbidity and mortality in COPD-related hospitalizations in the United States, 1979 to 2001. Chest 2005;128:2005-11.
Antonelli Incalzi R, Fuso L, De Rosa M, Forastiere F, Rapiti E, Nardecchia B, Pistelli R. Co-morbidity contributes to predict mortality of patients with chronic obstructive pulmonary disease. Eur Respir J 1997;10:2794-2800.
Chatila WM, Thomashow BM, Minai OA, Criner GJ, Make BJ: Comorbidities in chronic obstructive pulmonary disease. Proc Am Thorac Soc 2008;5:549-55.
Sin DD, Anthonisen NR, Soriano JB, Agusti AG. Mortality in COPD: role of comorbidities. Eur Respir J 2006;28:1245-57.
Vijayan V.K. Chronic obstructive pulmonary disease. Indian J Med Res 2013;137:251-69.
] [Full text]
Tinetti ME, Bogardus ST, Agostini JV. Potential pitfalls of disease-specific guidelines for patients with multiple conditions. N Engl J Med 2004;351:2870-4.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]