Factors Affecting Quality of Life in Patients with Chronic Respiratory Diseases

  

    
Variables 
    
Adherent    (n, %) 
    
Non-adherent    (n, %) 
    
p-value 
  
  

    
n=200 
    
138 (69.00) 
    
62 (31.00) 
    

  
  

    
Age (in years) 
    
59 (62-73) 
    
66 (60-71) 
    
0.367 
  
  

    
Sex 
    

    

    

  
  

    
Man 
    
62 (44.92) 
    
34 (54.84) 
    
0.194 
  
  

    
Woman 
    
76 (55.08) 
    
28 (45.16) 
    

  
  

    
School    education 
    

    

    

  
  

    
Primary school 
    
43 (31.16) 
    
32 (51.61) 
    
0.009 
  
  

    
Secondary /High school 
    
70 (50.72) 
    
23 (37.09) 
    
0.089 
  
  

    
College/University 
    
25 (18.12) 
    
7 (11.30) 
    
0.291 
  
  

    
Smoking    status 
    

    

    

  
  

    
Active smoker 
    
59 (43.38) 
    
28 (43.75) 
    
0.961 
  
  

    
Non-smoker 
    
8 (5.88) 
    
2 (3.12) 
    
0.403 
  
  

    
Former smoker 
    
69 (50.74) 
    
34 (53.13) 
    
0.752 
  
  

    
Smoking (years) 
    
35 (25-45) 
    
40 (30-50) 
    
0.025 
  
  

    
Alcohol    consumer 
    

    

    

  
  

    
Yes 
    
19 (13.76) 
    
16 (25.81) 
    
0.045 
  
  

    
No 
    
119 (86.23) 
    
46 (74.19) 
    

  
  

    
Comorbidity 
    

    

    

  
  

    
None 
    
14 (10.14) 
    
3 (4.84) 
    
0.213 
  
  

    
=1 
    
124 (89.86) 
    
59 (95.16) 
    

  
  

    
GOLD stage 
    

    

    

  
  

    
A, B 
    
57 (41.31) 
    
20 (32.26) 
    
0.223 
  
  

    
C, D 
    
81 (58.69) 
    
42 (67.74) 
    

  
  

    
FEV1 (ref%) 
    
47 (34.2-58.7) 
    
45 (33.5-53.5) 
    
0.262 
  
  

    
6MWD (m) 
    
310 (158-345) 
    
250 (150-358) 
    
0.878 
  
  

    
CAT (points) 
    
22 (10-30) 
    
26 (21-31) 
    
<0.001 
  
  

    
COPD exacerbation =2 
    
23 (16.67) 
    
22 (35.48) 
    
0.041 
  
  

    
Data are presented as median (IQR) or as    frequency and percentage; COPD: Chronic Obstructive Pulmonary Disease; GOLD: Global    Initiative for Chronic Obstructive Lung Disease; FEV1: Forced Expiratory    Volume in First Second; CAT: COPD Assessment Test; 6MWD: 6-Minute Walk    Distance; p <0.05 means the two indicators were significantly correlated. 
  

Table 4: Comparison of cooperative and non-cooperative patients (n=200).

Discussion

Our study focused on the quality of life of patients with chronic respiratory diseases and related factors. The question is particularly relevant because this group of diseases is becoming more prevalent. In many cases, due to the progressiveness of the disease, improving quality of life should be a priority. Literature shows that among people with chronic respiratory disease, those diagnosed with COPD have a particularly poor quality of life [19,20] and therefore we should aim to maintain a better quality of life and increase life expectancy by encouraging patients to make lifestyle changes and engage with their doctor on a sustained basis. Our results show that patients’ educational level, socioeconomic status, smoking and alcohol consumption habits, cooperation with physicians - based on good doctor-patient communication, physical activity, nutritional status, respiratory function, influenza and pneumococcal vaccination status, vitamin D and omega-3 supplementation, and the presence of comorbidities are significant factors influencing quality of life.

It is natural and well established that patients’ quality of life deteriorates with age, but our results show that COPD patients experience their respiratory symptoms as a relatively age-independent burden. Our results showed that there was no significant difference in quality of life scores between men and women, i.e. neither age nor gender was a determining factor. Similar results were reported by Rosinczuk J et al. in their study, where quality of life was not related to patient gender nor age but higher education improved quality of life scores; the presence of comorbidities, longer duration of illness, worsening respiratory function and the need for oxygen therapy were identified as determinants [21].

Due to the chronic progressive nature of COPD (severe physical disability, respiratory insufficiency, significant reduction in exercise capacity), it is paramount important to draw attention to lifestyle changes, i.e. avoiding smoking and alcohol, depending on exercise capacity, regular exercise in the open air, and supplementation of essential vitamins (e.g. vitamin D), as in our study vitamin D intake was also found to be suboptimal. Research supports the hypothesis [22,23], that vitamin D supplementation is effective, safe, necessary and cost-effective in the management of COPD, with optimal serum levels of vitamin D reducing systemic inflammation and the frequency of exacerbations, yet it is consumed at very low rates by patients, only 27% of patients in our present study. Of note, low serum 25-hydroxyvitamin D (25 (OH) D) levels, which reproduce vitamin D status, occur in 60-75% of patients with severe COPD [24]. Studies have described that vitamin D supplementation significantly improved patients’ 6-minute walking distance (6MWD), a very important parameter, as physical activity and exercise capacity are important predictors of survival in COPD patients [25]. Rezk and colleagues described a significant improvement (p <0.003) in the mMRC (Modified Medical Research Council) Dyspnea Scale, a significant decrease (p <0.001) in the number of exacerbations (p <0.001) and a significant decrease (p <0.001) in the level of C-Reactive Protein (CRP), one year after starting vitamin D supplementation [26]. In our own previous research, when we asked patients about the main functions of vitamin D in human body, only half of the patients (49%) answered correctly that it regulates calcium and phosphorus metabolism, maintains bone health and supports the immune system. Some people incorrectly associated it with healthy bowel function (13%), keeping eyesight sharp (10%), keeping hair and nails healthy (9%), healthy cell function (8%) and some could not tell at all what vitamin D does (11%). Asking about the time that they usually spend each day outdoor in sunny weather, only one third (35%) of patients answered spending 20 minutes or more, and two thirds (65%) spent less than 15 minutes a day outdoor [23]. In conclusion, vitamin D in addition to regulating many important physiological functions is essential for the proper functioning of the immune system and improves the quality of life of patients, yet very few patients take it regularly, so patients need to be informed about the need for vitamin D supplementation.

Researchers are increasingly recognizing that COPD patients require a holistic approach from healthcare professionals, who need to take into account not only basic medical parameters, but also other indicators that affect overall well-being, i.e. identifying factors that have the potential to positively influence their quality of life and incorporating them into a comprehensive treatment programme [27- 29]. One of these very important prognostic and modifiable factors is malnutrition, which is common in COPD (upto 45%) and often associated with a poor prognosis [30], poorer quality of life, increased exacerbations, longer hospital stays and higher healthcare costs [31]. Timely screening and initiation of nutritional therapy can lead to significant improvements in respiratory function, exercise tolerance and quality of life, as well as reduce morbidity and mortality in COPD patients [32], and low BMI has been shown to be an independent risk factor for mortality in COPD patients [33]. Previous studies have shown that the majority of COPD patients (more than 80%) do not meet their body’s energy and protein needs, Vitamin D and omega-3 requirements through their diet [8,34]. In our previous research asking about the food they like to eat, most people said pasta (pizza, pastries and other confectionery), followed by meat, vegetables, fruit, oilseeds and fish. However, it should be noted that more than half of the respondents (53%) do not eat fish (sardines, salmon, tuna, cod). One third of the patients surveyed (29%) do not consume dairy products, one reason for that is lactose intolerance (5%). This means that foods, which are rich in vitamin D and omega-3 (fish, dairy products, oilseeds) are presented in very low proportions in the diets of COPD patients [23]. Nutrition counselling should include the following key messages: patients should choose from a variety of foods each day, focusing on protein-rich foods such as meat, seafood, eggs, milk, oilseeds, choose energy- and protein-rich foods that are locally available, and also include smaller meals in addition to the three main meals [35].

Research has described that polyunsaturated fatty acid intake may be associated with quality of life in patients with COPD [36,37]. The PUFA (polyunsaturated fatty acids) intake recommended by the American Dietetic Association is daily >0.5g EPA (eicosapentaenoic acid) and DHA (docosahexaenoic acid) [38], compared to which the daily intake is extremely low, with an average EPA + DHA intake for COPD patients (mean ± SD: 0.11 ± 0.21g) [14,39]. Our study found that patients’ omega-3 intake is inadequate, with only 5% of patients taking 0.5g/day regularly. It is also clear and certain that new anti-inflammatory strategies need to be developed, as no single agent, including corticosteroids, can slow down the chronically progressive inflammatory process in COPD [40]. A diet, rich in vitamin D and omega-3 fatty acids has anti-inflammatory effects, improves patients’ exercise tolerance and is a safe and practical method when supplemented of treating COPD without side effects [41,42]. A case-control study demonstrated that those who received omega-3 supplementation (0.5-1.0 g/day) had fewer infectious complications and higher 6-Minute Walk Distance (6MWD) [43]. Among the beneficial effects of omega-3 fatty acids, the best known are their inhibitory effects on inflammation and tumour growth, inhibiting the production of prostaglandins and leukotrienes derived from arachidonic acid, and inhibiting proliferation in cancer cell lines [44,45]. Dietary supplementation with polyunsaturated fatty acids reduces the incidence of cardiovascular disease, and its anti-atherosclerotic effect is based on reducing lipoprotein lipase production, lowering serum triglyceride, LDL cholesterol, increasing HDL cholesterol and improving cell membrane phospholipid composition [46]. Polyunsaturated fatty acids also have a positive cardiac haemodynamic effect, increasing cardiac oxygenation, improving cardiac diastolic and respiratory function, and reducing exercise-induced bronchoconstriction [47]. Despite the numerous positive effects of polyunsaturated fatty acid intake, the omega-3 intake of patients is still insufficient.

The WHO (World Health Organization) renewed recommendations include detailed guideline for the management of COPD patients, which are also reflected in everyday therapy [48]. To facilitate this, programmes are needed to motivate patients to help improve their own condition. A triad of smoking cessation programmes, prevention and effective treatment management is needed to manage the disease in a cost-effective way. Evidence shows that informed patients are more likely to adhere to treatment [49]. Our results demonstrate a significant association between adherence and disease-specific quality of life (CAT), in line with previous work by Corden et al. [50]. Discontinuation of medication can increase the frequency of exacerbations, the number of hospitalizations and mortality rates, and non-adherence to therapies can result in poorer health and increased healthcare costs [51]. In the present study, the proportion of cooperative patients was relatively high (69.0%), while another similar study from Hungary found that the proportion of COPD patients with optimal adherence was around 60% [52]. There is a wide variation in patient adherence among COPD patients in summary studies (20%-60%), even higher in clinical studies (up to 70- 90%) [53]. In our present study, the high rate is due to and explained by the fact that we interviewed patients in the hospital pulmonology ward undergoing rehabilitation, who were cooperative in their attendance at treatments, rehabilitation programmes, education and motivated to change their lifestyle.

Last but not least an important element of our research is the uptake of influenza and pneumococcal vaccinations, which are recommended for all COPD patients by the WHO, with influenza vaccination every year and pneumococcal vaccination every five years [4,54]. In our present study, the influenza vaccination rate among patients was 21.0% and the pneumococcal vaccination rate was 12.5%. The WHO influenza and pneumococcal vaccination targets for patients with COPD are shown in Table 5, and studies worldwide have shown [55-59] that vaccination coverage rates for both vaccines are much lower than the target, despite evidence of a reduced risk of developing deep respiratory tract infections and thus mortality in COPD [59]. When researching the reasons for refusal of vaccinations, Vandebos and his research team suggest that the main reasons for refusal of flu vaccination are negative attitudes towards vaccination and the lack of recommendation from a GP or other doctor, it is very important that doctors and health professionals recommend these vaccinations to patients [60]. In their study, Ciblak et al. identified the following as the main reasons for vaccine nonadherence: patients do not believe in the efficacy of vaccines, they do not believe that they are at risk, and patients are worried and fearful about the undesirable consequences of vaccination [61]. In our own previous research, we found that less than a third (28.4%) of COPD patients were adequately informed by their doctors about the need for recommended vaccinations for their chronic disease. In addition to that only a third (36%) of the patients found that the flu vaccine is useful and important, while only a quarter (26%) thought that it was beneficial to receive the pneumococcal vaccine. A third of patients (31.2%) believe that the influenza virus causes only mild illness, and more than half of patients (54%) have never heard of the Pneumococcus bacteria and the vaccine against it [59]. Related to the non-vaccination of recommended vaccines it is also important to mention the effects of extremely damaging anti-vaccine campaigns. On the internet and social media, false and misleading information is claimed on the composition, side effects and long-term health complications of vaccines, causing great harm [62]. The members of these campaigns most often live in developed countries and mislead people, sharing false information among themselves, which is causing serious damage in the current epidemiological situation. These observations show that patients are not well informed about vaccines and draw attention to the preventive role of doctors and health workers in communicating the effectiveness of vaccines, which is of paramount importance in the current epidemic situation.

  

    

    
Vaccination    coverage 
  
  

    

    
Influenza    vaccination coverage (%) 
    
Pneumococcal    vaccination coverage (%) 
    
WHO    recommendation (%) 
  
  

    
Hungary 
    
23.6 
    
10.8 
    
75 
  
  

    
USA 
    
70 
    
49.9 
    
90 
  
  

    
UK 
    
36.1 
    
16.8 
    
75 
  
  

    
Spain 
    
49.4 
    
32.5 
    
75 
  
  

    
Germany 
    
46.5 
    
14.6 
    
75 
  
  

    
France 
    
73 
    
53 
    
75 
  
  

    
Italy 
    
30.5 
    
13.3 
    
75 
  
  

    
Turkey 
    
36.5 
    
14.1 
    
75 
  
  

    
WHO: World Health Organization; USA: United    States of America; UK: United Kingdom; Source: 51-55. 
  

Table 5: Influenza and pneumococcal vaccination coverage and WHO
recommendation for COPD patients.