Quality of Life Changes Over Time in Patients With Chronic Obstructive Pulmonary Disease

Gary L. Jones


Curr Opin Pulm Med. 2016;22(2):125-129. 

In This Article

Course of Chronic Obstructive Pulmonary Disease Over Time

One pleasant finding of recent studies is that, contrary to classic teaching, COPD may not be a relentlessly progressive disease in all patients. In the ECLIPSE study (Evaluation of COPD Longitudinally to Identify Predictive Surrogate Endpoints),[16] in more than half of the patients with COPD, the decline in FEV1 over 3 years was not greater than that seen in people without lung disease. Unfortunately, HRQoL was not assessed. More recently Lange, et al.[17] combined data from three independent cohorts (the Framingham Offspring Cohort, the Copenhagen City Heart Study, and the Lovelace Smokers Cohort) and evaluated the decline in FEV1 over 22 years of observation. Only half of the patients with COPD followed the classic course of starting with normal lung function and then experiencing a rapid decline in FEV1 over time. The other half failed to achieve full lung function in early adulthood but through the normal aging-related decline in FEV1 eventually developed airflow obstruction and COPD. Unfortunately, HRQoL measures were not reported in this study, either. Nevertheless, it is clear that not all patients with COPD have accelerated loss of lung function, implying many may experience slower disease progression and a potentially more benign course.

Other investigators have observed similar findings, but also contributed information on HRQoL. The Hokkaido COPD Cohort Study investigators[18] categorized patients into three groups using annual change in FEV1 over 5 years: Rapid Decliners (-63 ± 2 SE ml/yr), Slow Decliners (-31 ± 1 SE ml/year), and Sustainers (-2 ± 1 SE ml/year). In this study, 25% of the patients were Sustainers, with minimal decline in FEV1 over 5 years, and another 50% were labeled as Slow Decliners. For patients in the Sustainer group, HRQoL as measured by all components of the SGRQ actually improved over the course of the study. For the Slow Decliners, the SGRQ activity scores worsened but the SGRQ symptom scores improved, with overall stability in the total SGRQ score, that is, stable HRQoL. Not surprisingly, in the Rapid Decliners, all components of the SGRQ score deteriorated. Thus, in this Japanese cohort, over 5 years of observation 75% of the COPD patients did quite well from pulmonary function and HRQoL perspectives. Similarly, Casanova et al.[19] followed 1198 patients with COPD in Florida and Spain from 1997 until 2009. Utilizing the BODE (Body-mass index, airflow Obstruction, Dyspnea, Exercise) index [BMI, FEV1 percentage predicted, mMRC score, 6-min walk distance (6MWD)], these investigators found that over 12 years of observation 73% of the patients did not have a significant annual decrease in FEV1 or a decline in HRQoL as measured by BODE index. So, although a substantial portion of patients who develop COPD will follow the classic course of progressive deterioration, perhaps 50–75% may have a much more benign course, losing lung function at roughly the rate seen with aging and little deterioration in HRQoL.

Additional hope comes from a number of studies that suggest active interventions may improve patient outcomes, such as prevention of acute exacerbations of COPD (AECOPD). In the United States, this complication of COPD is estimated to result in more than 50 000 hospitalizations with 110 000 deaths/year, and is known to become more frequent as the stage of COPD increases.[20] Experiencing more than two exacerbations per year is associated with increased dyspnea, decreased HRQoL, diminished exercise capacity, a more rapid decline in FEV1, and an increased likelihood of becoming housebound.[20] Although one study found that it may take up to 12 weeks following an AECOPD for full recovery of health status (as measured by SGRQ),[21] Anzueto[20] notes that 6 months after hospitalization for AECOPD, 54% of patients required assistance with at least one activity of daily living and 49% reported poor HRQoL. Fortunately, several therapies have been reported to favorably influence the frequency of exacerbations. In patients who experience frequent AECOPD, inhaled corticosteroids (ICS) have been demonstrated to reduce exacerbations, slow the decline in HRQoL and FEV1, decrease hospitalizations and decrease the risk of death.[22–24] Unfortunately, these beneficial effects do not appear to be sustained if the ICS are stopped. Kunz et al.[25] found that if ICS are discontinued after 30 months of use, FEV1, HRQoL, and airway hyperresponsiveness all deteriorate over 5 years of observation. Alternatively, inhaled anticholinergic agents may be utilized with the same goals in mind. In a meta-analysis of 22 trials with more than 22 000 patients, the long-acting anticholinergic tiotropium was demonstrated to decrease dyspnea, significantly improve HRQoL, decrease AECOPD, decrease hospitalizations because of AECOPD, reduce hyperinflation, and improve overnight arterial oxygen saturations,[26] with the number needed to treat to benefit being 16, that is, one needs to treat 16 patients to prevent one exacerbation. Finally, Jiang et al. reported in a study performed in a Shanghai suburb that adherence to the GOLD treatment guidelines[10] had a positive impact on 6MWD, dyspnea as measured by mMRC scores and HRQoL when compared to usual care.[27]