Health-Related Quality of Life Varies in Different Respiratory Disorders

A Multi-case Control Population Based Study

Veronica Cappa; Alessandro Marcon; Gianfranco Di Gennaro; Liliya Chamitava; Lucia Cazzoletti; Cristina Bombieri; Morena Nicolis; Luigi Perbellini; Silvia Sembeni; Roberto de Marco; Francesco Spelta; Marcello Ferrari; Maria Elisabetta Zanolin


BMC Pulm Med. 2019;19(32) 

In This Article


In our study, respiratory disorders seemed to exert an influence on HRQL. Of importance, chronic diseases conditioned not only the physical, but also the mental health of affected subjects. This result is in line with other studies,[1,29] where scores of individuals with chronic conditions were lower (worse) than those of individuals not reporting any of the conditions studied.

Subjects suffering from COPD had the worse physical and mental health scores. This result seems to be of particular interest since it derives from a general population study. In their review, Joshi et al.,[21] highlighted that COPD causes disabling physical conditions and psychological distress similar to those of cancer. Many patients with the most severe form of COPD suffer from depression, anxiety and panic, as a result of their physical impairment and social isolation.[34,35] Recent studies have found that symptom burden of cancer and of severe COPD are similar.[21,36,37]

In this study, subjects suffering from CA had a lower PCS and MCS than controls. In a European study of 864 asthmatic subjects conducted by Siroux et al.,[38] asthma-severity was a predictor of PCS score of SF-36 quality of life questionnaire, but not of the MCS one. Ford et al.,[39] in a US study conducted on 163,773 adults, found that people with CA have a worse HRQL than past asthmatics (ever asthmatics without "current" symptoms) and than subjects who have never suffered from it. Legorreta et al.[40] reported that, among 5580 patients with asthma aged 14 to 65 years, the mean scores for eight subscales of functional status were lower than those reported by the general population. Furthermore, the authors found significant decreases in functional status with increasing severity of asthma.

According to our hierarchical classification of respiratory diseases, a substantial percentage of subjects with CA and PA also suffered from AR and NAR. We found that rhinitis in subjects without asthma had no significant impact on HRQL in our study. In fact, controls had similar scores. This finding is not in line with other studies[7,15] and ARIA guidelines.[14] This was probably due to the fact that asthma was also present in patients with allergic and non-allergic rhinitis in these studies.

The particularity of our survey was to study subjects with NAR and AR without past or current asthma and consequently, it was possible to assess the rhinitis effect on HRQL, without the interference of any respiratory comorbidity. Even if the physical and mental scores of the subjects suffering from rhinitis were lower than controls (except PCS for NAR cases), this difference was not statistically significant and it can be hypothesized that it is asthma that impairs HRQL, and not rhinitis alone.

Subjects suffering from CB had a lower physical and mental health than subjects without any respiratory disorder. It is of interest that the decrease in PCS and MCS is one of the highest among the considered respiratory diseases (Figure 2). This is a significant finding since there are few studies[22] evaluating quality of life in subjects with cough and phlegm but without bronchial obstruction and no one compared quality of life scores among different respiratory diseases. Clinically, the presence of respiratory symptoms among subjects with preserved lung function may offer opportunity for interventions potentially improving quality of life. Our findings could also suggest that the exclusion of GOLD stage 0 from the 2006 update might be re-considered. The association found by Marcon et al.[26] of a reduced 6 min walking distance in subjects suffering from CB gives a potential and partial explanation of our findings.

In a Serbian study,[11] the authors demonstrated that subjects suffering from CB and/or emphysema perceived their health status as bad/very bad, with respect to controls. In another population-based survey conducted in Finland,[12] the people with CB lived a worse daily life compared with the general population, and they had poor physical health.

It is not well established whether the differences in quality of life within subjects with respiratory diseases and controls are stable over time. In a study on the stability of normative data for the SF-36 in a sample of the general middle-aged Canadian population, mean SF-36 scores were found to change only slightly over three years.[41] It is possible that the variation could be greater in subjects with respiratory diseases, but to our knowledge, no longitudinal studies comparing directly healthy people and subjects with respiratory diseases have been done.

This study was performed on a sample from the general population of a single Italian centre, so the number of subjects with a particular disease was sometimes small: this fact could have somehow compromised the generalizability of the study.

To our knowledge, this is the first population-based study that investigates to what extent the most common chronic respiratory disorders affect HRQL. Unlike previous studies, we were able to consider several diseases at the same time by using a multicase-control design and a hierarchical classification of disease status. Furthermore, it is of note that this is the first study using SF-36 questionnaire in assessing simultaneously HRQL in a set of different respiratory diseases. We found that subjects who suffered from COPD, CA or CB had the poorest HRQL. On the whole, these findings emphasise that, even at the mild level of severity that is common in the general population, COPD and asthma have a significant impact on HRQL. Moreover, our data indicate that also CB, with lower impact on DALYs in comparison to COPD or CA[4] is not a trivial condition. It derives that clinicians should also carefully consider CB in relation to HRQL of these patients.

Moreover, our results highlights that not only physical but also psychological dimension of subjects with chronic respiratory diseases should be considered in clinical practice.