Evaluation of the Severity of Chronic Obstructive Pulmonary Disease
|School||Southern Medical University,|
|Keywords||Chronic obstructive pulmonary disease Chronic obstructive pulmonarydisease assessment test Improved version of the British Medical Research Councildyspnea index score St.George’s Respiratory questionnaire Severity Comprehensive assessment|
BackgroundCOPD is a preventable and treatable disease with some significant extra pulmonary effects that may contribute to the severity in individual patients. Its pulmonary component is characterized by airflow limitation that is not fully reversible. The airflow limitation is usually progressive and associated with an abnormal inflammatory response of the lung to noxious particles or gases. COPD makes bad impacts on patients living by dyspena and decreased exercise capacity caused by abnormal lung function.FEV1%could not fully capture the impact on a patient’s health, although it is the standard for monitoring the progression of COPD.We need a total measure to assess a patient’s quality of life, so than the severity of COPD.Worldwide, FEV1%is taken as the standard to assess COPD severity, improvement of FEV1%is the key of treatment. However, there is only an imperfect relationship between the Spiro metric index and patient’s total healthiness. The improvement of disease dose not only depends on the Spiro metric improvement. Spiro metric test is currently not widespread, especially in remote rural areas, or even developed cities. The cost of frequent Spiro metric test is a burden of family with chronic disease. It is also difficult to perfoment to elders and some patients who could not cooperate. There are several methods worldwide used as measurement of COPD:(a) St. George’s Respiratory Questionnaire;(b) Assessment of Chronic Respiratory Disease Questionnaire;(c) CAT Scale;(d) dyspnea grade;(e)6-minute walk distance. However, are they right for most of basic medical institutions in our country? For example, clauses and sub clauses in SGRQ are too complex, requiring complicated statistics and consuming too much time, it is hard to finish by poorly educated patients.MMRC need patient’s certain exercise capacity. CAT is not good for making a diagnosis and giving treatment to COPD patients with complications, it is either helpless for evaluating complications and making decisions about diagnosis and treatment. Since each scale has its own merits and demerits, it is necessary to find out the relationships among them, so that we can investigate into a system that could be conveniently used in Chinese basic medical institution to evaluate COPD severity.Suggestion by GOLD update2011about complete assessment of COPD include:1.symptoms;2. the severity of airflow limitation evaluated by Spiro metric test;3. risk;4.complecations. The rate of decline in lung function, complications and severity of the disease determines the length of the course of COPD. Frequency of acute exacerbation is related to COPD severity. The more often acute attack happens, the higher the rate of hospitalization, the more obvious decline in lung function, the worse the prognosis of patients, and the shorter the survival time, the worse the quality of life. So the standard to evaluate the treating effect and stability of disease should include:Reduce hospitalization rates, reduce the frequency of acute exacerbation, prolong the survival time and improve quality of life. Many scales could be used clinically to assess disease, since each scale has its own merits and demerits, it is necessary to find out the relationships among them. This study aims to analyze the CAT, MMRC, SGRQ,6MWD, FEV1%in the evaluation of COPD severity, and establish the relationships among them, as well as find out the feasibility of CAT, MMRC, and SGRQ in clinical practice, affording more bases for the three ratings in further clinical applications.PurposeThrough the investigation of COPD patients’ lung function, CAT, MMRC, SGRQ score, and6MWD,each year the number of acute attacks, to observe the pair wise correlation of CAT, MMRC, SGRQ score; correlation between each of CAT score, MMRC score SGRQ score and FEV1%predicted value and6MWD. Explore the relationship of FEV1%and6minutes walking distance. Study three ratings ease of use in clinical applications. Explore the significance of the CAT score,MMRC score the SGRQ score with6minutes walking distance in the assessment of severity of COPD. Study the comprehensive assessment of objected patients, and the significance of it in the COPD severity.Subjects and methods1study object:Guizhou hospital of Shunde District, Foshan, Guangdong, Respiratory Medicine clinic, from January2011to July2012, patients with first diagnosis of chronic obstructive pulmonary disease (COPD), and FEV1%<80%; diagnosis of all patients comply with the conditions of the Chinese Society of Respiratory Diseases, chronic obstructive pulmonary disease study group of chronic obstructive pulmonary disease treatment guidelines (2007Revision) diagnosis of COPD.2. Inclusion criteria:clinically stable patients with first diagnosis of chronic obstructive pulmonary disease, in line with FEV1%<80%; regardless of patient age, duration of disease. The patient himself is fluent in Chinese, all included patients with COPD,after the explaining by investigators, must be able to understand the CAT, MMRC, SGRQ,6MWD, and can independently accomplish the CAT, SGRQ, MMRC questionnaire.3Exclusion criteria:coexistence of acute myocardial infarction, cerebral infarction, congestive heart failure, severe liver and kidney of chronic diseases and tumors; consciousness is not clear, mental disorders or a history, or diagnosis of anxiety and depression by department of neurology of our hospital; unstable angina or myocardial infarction in one month; heart rate over120beats/min, systolic blood pressure more than180mmHg, diastolic blood pressure more than100mmHg in resting condition; aortic stenosis, musculoskeletal disorders, limited exercise capacity, Alzheimer’s mental illness, with difficulties filling in the questionnaire, unable to speak.Methods:1. Pulmonary function tests:technician perform Pulmonary function tests after explaining the breath way. First, Detection of forced vital capacity (FVC), one second forced expiratory volume (FEV1) and one second forced expiratory volume occupying the percentage of vital capacity (FEV1/FVC), one second forced expiratory volume percentage of predicted value (FEV1%). Then bronchodilator tests, to determine patients’ lung function after inhaling bronchodilators, getting the gold standard for diagnosis of COPD.2dyspnea grading:The British Medical Research Council dyspnea scale (MMRC) is used to evaluate the patient’s dyspnea.3. Determination of quality of life scores (CAT):according to Chinese version of CAT Respiratory Questionnaire evaluation of the patient’s quality of life, and calculate the total score of each patient’s CAT. Finishing time and the need for help to complete the questionnaire are recorded.anual calculation method is used for total scores.4. Determination of George’s Respiratory Questionnaire (SGRQ) score:the Chinese version of which come up with by4scholars of School of Medicine of the British St. George’s University in1991. On the same day with pulmonary function tests, questionnaire is completed independently by the patient himself. Any hinting reminding is not allowed, observer check for missing by him. If patients cannot complete independently, explanation is allowed. Finishing time and the need for help to complete the questionnaire are recorded. The questions in completed questionnaire would be input into software by professional physicians, directly obtaining three-part score and total score.5.6minutes walking distance (6MWD) Determination:performed in the room, along a closed, long and straight flat corridor.30meters long, every3meters is marked. Course:when pressing the time-meter, patients simultaneously began walking from the starting point with their own usual pace according to their own situation, and turn back at the end of30meters. The end of the trial shouted "stop" and let the patient stops. The end of the trial:come to the patient’s side. If the patient looks tired to consider taking the chair.Quality control:Strict implementation of design for inclusion and exclusion criteria, and elected to comply with the conditions of patients with COPD. CAT score, SGRQ score, MMRC score,6-minute walk distance, pulmonary function. All enrolled patients with COPD, to explain to them by the same observer CAT Questionnaire, SGRQ, MMRC, independently finished by the patient. Lung function performed by trained examiners. Calculated CAT score by two observers were checked every CAT total score of patients with COPD, compared entered into the computer, and ensure consistent score statistics. Strictly check the patient’s the SGRQ questionnaire answers to calculate the fraction of the scores and the total score of the SGRQ three parts by the two observers were to verify every COPD patients SGRQ total score, and then entered into the computer, checked by two observers.Results1. CAT, SGRQ, MMRC have correlation with each other:The correlation coefficient of CAT and MMRC is0.794; CAT and SGRQ correlation coefficient to0.426; MMRC and SGRQ correlation coefficient of0.366(P<0.01).6MWD and CAT, MMRC, SGRQ was significantly negatively correlated.6MWD and FEV1%was positively correlated:6MWD and CAT correlation coefficient of-0.607;6MWD and MMRC correlation coefficient-0.455;6MWD and SGRQ correlation coefficient of-0.500;6MWD FEV1%correlation coefficient of0.901(P<0.01).FEV1%and CAT, MMRC, SGRQ significant negative correlation:FEV1%and CAT correlation coefficient of-0.437; FEV1%and MMRC correlation coefficient of-0.588; FEV1%and SGRQ correlation coefficient of-0.582(P<0.01).BMI and MMRC negative correlation, BMI and6MWD, FEV1%was significantly positively related:BMI and MMRC the correlation coefficient-0.303; BMI and6MWD the correlation coefficient0.387; BMI and FEV1%coefficient of0.408(P<0.01).2. Gender and annual exacerbation group:BMI, FEV1%, CAT score, MMRC grading, SGRQ score,6MWD was no significant difference. GOLD groups:three groups the average age difference was not statistically significant; GOLD classification of lung function, FEV1%of the moderate group:64.0±7.1; the severe group FEV1%to40.9±4.8; very severe group FEV1%23.3±3.1; BMI, SGRQ scores, the6MWD and CAT were not statistically significant. Smoking grouping: two groups of patients with BMI, FEV1%, MMRC, SGRQ, CAT,6MWD, year-on-year increase the number of differences not statistically significant. To whether hypertension, diabetes, coronary heart disease groups:two groups of patients with BMI, FEV1%, MMRC, SGRQ, CAT,6MWD was not statistically significant, but the annual increase the number of complications patients compared with patients without co morbidity group Multi. In6MWD sub-groups:patients with mild group BMI, severe and very severe patients with smaller BMI; FEV1%, MMRC score, CAT score, SGRQ score and6MWD. MMRC groups:age composition was not statistically significant; MMRC lower the score, the higher of the patients with FEV1%, the longer the6MWD, the lower the CAT score, the lower the SGRQ score. CAT score groups:CAT score and FEV1%, MMRC score SGRQ score. CAT score and6MWD.3. Enrolled patients completed three questionnaires need help and need help patients influencing factors:the percentage to complete the SGRQ need help is86.7%; percentage of completed CAT need help is53.3%; completed MMRC need help20%. The three groups of patients, age, gender, FEV1%,6MWD was no significant difference. Patients completed the SGRQ and MMRC need help, with the degree of patient education correlation (P<0.01), and complete the CAT need help patients, no significant correlation with the degree of patient education. As a result, the difficulty will increase in the SGRQ and MMRC patients, patients with low levels of education, independently completed questionnaires. Moreover, MMRC need to help the lowest percentage, CAT higher, while SGRQ highest. Therefore, in a certain extent, SGRQ is more complex than CAT and MMRC.Conclusion 1, CAT, MMRC, SGRQ score have significant correlation with each other; CAT,SGRQ,MMRC have significantly associated with FEV1%,6MWD;6MWD and FEV1%was significantly positively correlated; BMI and MMRC have a significant negative correlation; BMI and6MWD, FEV1%was significantly positively correlated.2,6MWD is related with FEV1%, MMRC, BMI, severe, extremely heavy of COPD patients the sports endurance significantly decreased. SGRQ, CAT, MMRC than those in patients with severe and extremely heavy degree of high score in patients with moderate,6MWT can be used for COPD the patient’s daily condition monitoring.6MWD, CAT, SGRQ, MMRC as lung function grading an effective complement to, but not a separate classification for COPD.3、patients completed the SGRQ,CAT,MMRC need help, with the degree of patient education correlation. The difficulty will increase in the SGRQ, CAT, MMRC patients, patients with low levels of education, independently completed questionnaires. Moreover, MMRC need to help the lowest percentage, CAT higher, SGRQ highest. Therefore, in a certain extent, SGRQ than CAT and MMRC complex. CAT, MMRC in terms of ease of use, significantly better than the SGRQ.Using MMRC grading method is simple and practical, significantly associated with lung function classification for the evaluation of the condition of patients with COPD, more comprehensive clinical evaluation and recommended for the primary hospital or pulmonary function test equipment.4、2011GOLD comprehensive evaluation of patients with COPD, the contents of the comprehensive evaluation of the patients can be evaluated in patients with COPD disease severity, predict COPD patients prognosis, evaluation of the quality of life of patients with COPD to evaluate the efficacy of pulmonary rehabilitation, to evaluate the therapeutic effect of COPD, guidance COPD patients with treatment programs.