The consequences of the use of spirometry in the treatment of COPD are also debated in the scientific literature.
There are intervention studies that prospectively evaluate the impact of the introduction of spirometry in the management of patients with COPD in primary care. These have demonstrated an improvement in the management of these patients, better approach of the differential diagnosis, increased frequency of anti-smoking or quitting advice and modification in the treatment especially in the use of corticosteroid therapy. Comorbidity is defined as the group of alterations and disorders that can be associated with COPD for one reason or another and which, to a greater or lesser degree, have an impact on the disease, patient prognosis, and mortality.
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Senior COPD patients tend to have more complications due to the greater risk of concomitant diseases, such as cardiovascular diseases, lung cancer, diabetes, chronic renal disease, depression, and osteoporosis, all of which contribute to the high mortality associated with COPD. But it is precisely the comorbidities and age that have repeatedly been exclusion criteria in most research, and this has made it difficult to estimate the prognostic capacity of comorbidities in COPD.
In recent years, however, several studies have paid more attention to this older age group and some conclude that COPD patients have an average of 9 comorbidities as well as a very limited understanding of their disease. Higher risk for lung cancer and cardiovascular diseases has also been reported in the initial phases of the disease.
Here again, the question is raised as to whether they are merely related with the smoking risk factor, or if likewise it is the disease itself that favors other entities.. Briefly, we will review some of the most frequent comorbidities.. This well-known association was the subject of an excellent publication in this journal, 61 which reviewed data such as the risk for developing heart failure HF in COPD patients 4.
Some studies of hospitalized COPD patients show that HF is the most frequently found comorbidity in patients who do not survive. The difficulty for the differential diagnosis between both entities, especially in acute situations, is a clinical reality that should not be obviated.. A strong association has been demonstrated between COPD and coronary disease. Regarding the treatment of both entities, the most recent developments are related with the safe use of cardioselective beta blockers when they are necessary for HF, as long as they are well tolerated and are used with gradual increments.
Beyond the causal relationship with tobacco, several studies have demonstrated that COPD is an independent risk factor for lung cancer and that this cancer is between 2 and 5 times more frequent in smokers with COPD than in smokers without COPD; an inverse relationship has been observed between the degree of obstruction and the risk for developing cancer. The prevalence of anxiety disorders and depression is higher among patients with COPD than in the general population, and these conditions seem to increase the mortality of the pulmonary disease. The associated variables may be dyspnea and comorbidity..
The prevalence of osteoporosis can be very variable, but in several studies it is shown to be higher in COPD than in healthy people or in those with other respiratory diseases.
This association can be related with age, smoking, malnutrition, limited physical activity, the use of corticosteroids or vitamin D deficiency. Nevertheless, it seems that, even when isolated from these factors, the prevalence is higher in COPD, which has raised suspicions and led to the study of its relationship with the systemic inflammatory component of COPD.
One of the characteristics of COPD is the existence of exacerbations. These are periods of clinical instability that occasionally require hospitalization.
They are currently considered key elements in the natural history of COPD, and recent studies emphasize the strong impact of exacerbations on the state of health of patients, their extrapulmonary repercussions and influence on the progression and prognosis of the disease. This definition presents some limitations due to the difference in the perception of the symptoms and the possible confusion with recurring diseases pneumonia, IC, pneumothorax, etc.
Some authors have suggested incorporating the inflammatory concept in the definition 73 due to the fact that during exacerbation there is an amplification of the inflammatory response that is both local 74 as well as systemic. The repercussions of the exacerbations on the individual depends on different aspects, among which are the baseline state and particularly the severity and duration of the exacerbations. COPD patients are estimated to have an average of between 1 and 4 annual exacerbations.
Thus, and due to the evidence that the severity and the prognosis are not only related with FEV1, as commented in this review, in recent years there have been many studies about the different COPD phenotypes groups of patients who share a specific characteristic or combinations of characteristics with different clinical outcomes. There is also a well-known high rate of re-hospitalizations, which reflects the complexity of advanced pathologies, comorbidity, fragility and also the relationship between the different levels of health-care, all of which lead to more than one-third of the patients being re-hospitalized within one year of a hospitalization, with a mean discharge of 5 months.
The concept of quality of life can be defined as the difference between what one wants to do and what one can do 90 or, in other words, the state of health perceived by the patient. It is the result of the interaction of many physiological and psychological factors and its alteration is mainly a consequence of the symptoms, emotional disorders and physical limitations as well as the social role caused by the disease.
There are 2 types of quality-of-life questionnaires: generic and specific. The generic ones have been designed to compare patient populations, and have demonstrated to be useful as discriminative tools among them, being insensitive to the changes in the state of health. These are used to evaluate oxygen therapy, 95 pulmonary rehabilitation, 96,97 re-hospitalizations 98 and the exacerbations of COPD patients.
There is a self-administered version of the questionnaire. A change of 0. The patient needs 10—15 min to complete the survey. Because the answers are weighted, the calculation of the score is a rather complex procedure, and a computer program is needed. The score for each of the dimensions and the total score range between 0 and In this questionnaire, the highest scores indicate a poorer quality of life.
In this case, a change of 4 units in the score is considered a clinically significant difference.. As for the follow-up of the patients, it is important to underline that the practice should be based on a control of the symptoms, basically dyspnea, which has been shown to have a clear relationship with patient quality of life. COPD patients require specific know-how about the concepts about their disease, as well as skills in order to follow their regular treatment and to take immediate steps in situations of deterioration.
An understanding of the disease and its treatment is essential, as with it the patients can modify their behavior, improve their degree of satisfaction and consequently improve their quality of life, while reducing the cost of care. In order to reach the best possible results, it is also necessary to improve the health-care skills and abilities of patient caretakers. It guides necessary changes in health conduct and provides patients with emotional support to control their disease and to live a functional life. Several studies have been published and Effing et al.
There is also an observed positive tendency in quality of life. However, due to the heterogeneity of the interventions, study populations, follow-up period and result measures, the data are still not sufficient to formulate clear recommendations for the shape and the content of the education programs in self-care for COPD patients.
Recently, there have been important changes in COPD management that have modified the focus of the disease towards personalized, predictive, preventive care with the participation of the patient in the health process and preventive actions. The evaluation of the program is done with surveys that analyze habits, lifestyles, self-care, dyspnea scale, doctors and nursing visits, exacerbations and hospitalization.
The preliminary results include an observed tendency towards a reduction in hospitalizations, a reduction in primary care visits and the maintained improvement in the level of comprehension, with the acquisition of more resources given the disease and treatment. The fight against smoking is the cornerstone of COPD patient health care.
Smoking cessation is the most effective individual intervention for reducing the risk of developing the disease and for delaying its progression. At the same time, a review about tobacco and publicity shows how the incidence and impact of tobacco advertising are high and use culturally and socially adapted messages. Another key point of health education is teaching the correct inhalation technique for the administration of medication, as there is much evidence that an optimal benefit is not being obtained from inhaled therapies, mainly due to the incorrect use of inhalers.
Health-care professionals must teach patients the inhalation technique: explain the technique for using the device, use practical demonstrations and use devices without medication in order to ensure correct handling, make periodical evaluations of the errors, explain maintenance, secondary effects, and how to avoid them. It is a complex process that is influenced by inter-related factors and are: the patient level of education, personality, beliefs , the drug adverse effects, cost, active ingredient , the disease chronic diseases have higher levels of incompliance , and the health-care professional time, difficulties in communication, etc.
Strategies for improvement include simplifying the prescription regime, behavioral techniques reminders or calendars , education or social support home assistance and support from the health-care professional communication techniques, behavioral techniques, behavioral strategies. One study in primary care with patients demonstrated that, when an individualized system of medication dosage was used, patient therapeutic compliance improved.
Takemura et al.
They concluded that the repeated instruction of the inhalation techniques can contribute to adherence to therapeutic regimes, which at the same time is related with a better state of health in COPD. As for COPD patients, the perceptive component knowing the opinion of affected persons, their preoccupations and preferences , therapeutic adherence and compliance have recently gained protagonism.
Therefore, tools have been designed to obtain this information, whether through quality-of-life questionnaires or rather with so-called POR patient outcome reports. These are suggested by the COPD strategy of the National Health System 52 as they obtain information on a dimension of the disease from the patient without the need for functional testing.
Other dimensions are also being studied, such as the repercussions in physical activity, emotional state and the social or family impact.. Given the complexity of chronic diseases, and of COPD in particular, many initiatives have been developed to improve understanding, circuits and strategic planning. Presented below are some of these experiences, although not as an exhaustive review, but instead with the intention of presenting illustrative examples..
These are directives for clinicians and their aim is to unify criteria and compile the most recent evidence. In recent years, there has been a proliferation of COPD guidelines and the most recent revisions or updates all include aspects related with the systemic effects of the disease and comorbidity.
In this sense, and in the context of the management of COPD patients as chronic patients, we highlight from among these:. In January , this conference approved the previously mentioned consensus document 2 and promoted the state of integral plans for patients with chronic diseases in the autonomous communities provinces , based on comprehensiveness, continuity of care and intersectoral collaboration.