Symptom variability in patients with severe COPD: a pan-European cross-sectional study

R. Kessler, M.R. Partridge, M. Miravitlles, M. Cazzola, C. Vogelmeier, D. Leynaud, J. Ostinelli
European Respiratory Journal 2011 37: 264-272; DOI: 10.1183/09031936.00051110

Figures

  • Figure 1–
    Figure 1–

    Patient recruitment flow chart. #: part A of the questionnaire (symptoms) not completed; : part A of the questionnaire (symptoms) completed.

  • Figure 2–
    Figure 2–

    Patients were asked if they had experienced any symptoms (breathlessness (n = 1,769), phlegm (n = 1,552), cough (n = 1,433), wheezing (n = 1,018) or chest tightness (n = 690)) in the 7 days prior to the telephone interview. Multiple answers were possible. □: a little; ░: moderately; ▒: very; ▪: extremely.

  • Figure 3–
    Figure 3–

    Patients who reported respiratory symptoms during the week prior to the telephone interview were asked if they experienced daily (black shading) and weekly (grey shading) variations in the severity of the symptom (breathlessness: n = 1,769; phlegm: n = 1,552; cough: n = 1,433; wheezing: n = 1,018; or chest tightness: n = 690). Data shown are percentages of patients who answered “Yes, it varied a little” (hatched bars) or “Yes, it varied a lot” (solid bars).

  • Figure 4–
    Figure 4–

    Patients who had reported experiencing symptoms in the previous 7 days were asked during what times of the day the symptoms were most troublesome. a) Breathlessness, n = 1,769; b) phlegm, n = 1,551; c) cough, n = 1,433; d) wheezing, n = 1,018; and e) chest tightness, n = 690.

  • Figure 5–
    Figure 5–

    Patients were asked how, if at all, they modified the use of their COPD medications when experiencing symptom variability during the day (n = 2,333) or over the course of several days (n = 2,333).

Tables

  • Table 1– Patient characteristics
    Available data#
    Sex2440 (99.96)
     Male1916 (78.5)
     Female524 (21.5)
    Age yrs2427 (99.43)67.3±9.4
    Body mass index kg·m−22394 (98.07)26.0±5.0
    Smoking status2337 (95.74)
     Current smoker565 (24.2)
     Ex-smoker1772 (75.8)
    Time since COPD diagnosis yrs2365 (96.89)8.9±7.6
    MRC dyspnoea score2429 (99.51)
     1172 (7.1)
     2791 (32.6)
     3803 (33.1)
     4561 (23.1)
     5102 (4.2)
    FEV1 % pred
     Pre-bronchodilator2279 (93.36)38.8±9.8
     Post-bronchodilator1510 (61.86)42.2±11.2
    FVC % pred
     Pre-bronchodilator2195 (89.92)66.2±17.5
     Post-bronchodilator1458 (59.73)69.8±18.2
    FEV1/FVC %
     Pre-bronchodilator2077 (85.09)47.1±10.4
     Post-bronchodilator1398 (57.27)48.3±11.4
    Reversibility+1310 (53.67)
     %9.07±14.9
     Yes199 (15.2)
    Type of current COPD maintenance treatment2431 (99.59)
     Only inhaled SABD§50 (2.1)
     Only one inhaled LABDƒ272 (11.2)
     Only a combination of LABD##94 (3.9)
     Only inhaled glucocorticosteroids¶¶39 (1.6)
     LABD plus inhaled glucocorticosteroids++1634 (67.2)

    • Data are presented as n (%) or mean±sd. COPD: chronic obstructive pulmonary disease; MRC: Medical Research Council; FEV1: forced expiratory volume in 1 s; % pred: % predicted; FVC: forced vital capacity; SABD: short-acting bronchodilator; LABD: long-acting bronchodilator. #: n (%) of the total population of 2,441; : MRC dyspnoea grade 1, “I only get breathless with strenuous exercise”; grade 2, “I get short of breath when hurrying on the level or up a slight hill”; grade 3, “I walk slower than people of the same age on the level because of breathlessness or have to stop for breath when walking at my own pace on the level”; grade 4, “I stop for breath after walking 100 m or after a few minutes on the level”; grade 5, “ I am too breathless to leave the house”; +: reversibility was calculated for patients with available pre- and post-bronchodilator FEV1 data, and “yes” is defined as a post-bronchodilator increase in FEV1 of ≥200 mL and ≥12%; §: patients receiving only an inhaled short-acting β2-agonist (SABA) or an inhaled short-acting anticholinergic, or a fixed or free combination of inhaled SABA plus anticholinergic; ƒ: patients receiving only one LABD (inhaled long-acting β2-agonist (LABA), or oral LABA, or long-acting muscarinic antagonist (LAMA)) ± SABD ± methylxanthines; ##: patients receiving a combination of LABD (LABA or LAMA) ± SABD ± methylxanthines; ¶¶: patients receiving only inhaled glucocorticosteroids ± SABD; ++: patients receiving inhaled glucocorticosteroids plus LABA (inhaled or oral) and/or LAMA ± SABD ± methylxanthines.

  • Table 2– Patient comorbidities and current concomitant medication
    Comorbidity
     Hypertension1044 (42.8)
     Ischaemic heart disease349 (14.3)
     Diabetes332 (13.6)
     Osteoporosis266 (10.9)
     Left heart failure228 (9.3)
     Depression (current)209 (8.6)
     Metabolic syndrome208 (8.5)
     Sleep apnoea189 (7.7)
     Any other condition that significantly affects mobility#177 (7.3)
     Cancer (other than lung cancer)150 (6.1)
     Alcoholism120 (4.9)
    Concomitant medication
     Diuretics620 (25.4)
     Angiotensin-converting enzyme inhibitors521 (21.3)
     Statins465 (19.0)
     Angiotensin receptor blockers308 (12.6)
     Antidiabetics249 (10.2)
     Beta-blockers+242 (9.9)
     Antidepressants179 (7.3)
     Anxiolytics150 (6.1)
     Hypnotics93 (3.8)

    • Data are presented as n (%) of the total population of 2,441. #: e.g. previous stroke or amputation; : past or current; +: systemic and eye drops.

  • Table 3– Determination of factors that may influence breathlessness variation during the day and week#
    FactorWeekDay
    OR (95% CI)p-valueOR (95% CI)p-value
    Age calculated for 10-yr changes0.852 (0.752–0.965)0.01180.852 (0.754–0.963)0.0106
    Severity of breathlessness: answer “moderately” versus “a little”1.228 (0.933–1.615)ns1.469 (1.104–1.954)0.0083
    Severity of breathlessness: answer “very” versus “a little”1.791 (1.286–2.492)0.00062.848 (2.057–3.943)<0.0001
    Severity of breathlessness: answer “extremely” versus “a little”1.787 (1.016–3.144)0.04402.565 (1.518–4.333)0.0004
    Exacerbations during the previous 12 months: >2 versus 01.432 (1.058–1.937)0.0200NA
    Left heart failure: yes versus no0.532 (0.347–0.816)0.0038NA
    Maintenance treatment with only one LABD (LABA or LAMA): no versus yesNA2.062 (1.358–3.132)0.0007
    Physician activity: GP versus specialist1.569 (1.225–2.009)0.00041.390 (1.082–1.785)0.0099

    • ns: not significant; NA: not significant in the univariate analysis and therefore not included in the multivariate analysis; LABD: long-acting bronchodilator; LABA: long-acting β2-agonist; LAMA: long-acting muscarinic antagonist; GP: general practitioner. #: each factor listed was considered significant in the univariate analysis (p = 0.20) and thus eligible for inclusion in the logistic regression model. Factors were then selected using a backward, stepwise procedure with a significance level of p = 0.05 for entering or removing variables. Patients who reported breathlessness during the past 7 days (n = 1,769) and who answered the specific question regarding weekly (n = 1,733) or daily variability (n = 1,668) were included in the univariate analysis. : “yes” indicates patients taking only one LABD ± short-acting bronchodilator ± methylxanthines; “no” indicates other maintenance treatment (see table 1).

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Symptom variability in patients with severe COPD: a pan-European cross-sectional study
R. Kessler, M.R. Partridge, M. Miravitlles, M. Cazzola, C. Vogelmeier, D. Leynaud, J. Ostinelli
European Respiratory Journal Feb 2011, 37 (2) 264-272; DOI: 10.1183/09031936.00051110
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