Iqbal 3622024 J Pri 114123

Journal of Pharmaceutical Research International
Volume 36, Issue 2, Page 55-75, 2024; Article no.JPRI.114123

ISSN: 2456-9119, NLM ID: 101716968
(Past name: British Journal of Pharmaceutical Research, Past ISSN: 2231-2919,
NLM ID: 101631759)
Confounders Effecting Quality of Life

of COPD Patients in European Union:
A Systematic Review
Sara Shahid a, Zuha Tariq a++, Obeda Asghar a++,
Arooj Majeed a++, Umair Amjad a++, Wasiq Ali a++,
Ahmad Sarfaraz a++, Muhammad Ahmed Saeed a++,
M.Sohaib Sultan Sabri a++, Mohammad Abdullah a++,
Azwa Zaheer a++, Muhammad Aamir a++, Talha Rehman a++
Asfa Iqbal a++ and Muhammad Zahid Iqbal a*
a Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Lahore University of
Biological & Applied Sciences, Lahore, Pakistan.
Authors’ contributions
This work was carried out in collaboration among all authors. All authors read and approved the final
manuscript.
Article Information
DOI: 10.9734/JPRI/2024/v36i27501
Open Peer Review History:

This journal follows the Advanced Open Peer Review policy. Identity of the Reviewers, Editor(s) and additional Reviewers,
peer review comments, different versions of the manuscript, comments of the editors, etc are available here:
https://www.sdiarticle5.com/review-history/114123
Received: 02/01/2024
Systematic Review Article Accepted: 07/03/2024
Published: 12/03/2024
ABSTRACT
Introduction: Chronic Obstructive Pulmonary Disease (COPD) is a respiratory disease
characterized by restriction in expiratory airflow. It is among one of the major causes of illness and
death globally. COPD causes severe negative effects on physical and mental health. It has a drastic
effect upon the health-related quality of life of patients. Numerous factors contribute towards
morbidity of COPD that include smoking, obesity, air pollutants and comorbid conditions
(cardiovascular diseases, diabetes mellitus, arterial hypertension, infections).
_____________________________________________________________________________________________________
++
Research Student;
*Corresponding author: E-mail: [email protected];
J. Pharm. Res. Int., vol. 36, no. 2, pp. 55-75, 2024

Shahid et al.; J. Pharm. Res. Int., vol. 36, no. 2, pp. 55-75, 2024; Article no.JPRI.114123
Aims and Objectives: The current systematic review was conducted with the aim to determine the
health-related quality of life of COPD patients as well as the confounders of quality of life.
Methodology: A systematic review was conducted of 22 studies. The electronic databases used to
search the articles were Pubmed, Scopus, Science Direct, ProQuest, Web of Science. Total 1880
studies were found, out of which only 22 studies met the inclusion criteria. All the studies included
are within 2017-2022. Patients met inclusion criteria have less than 70% FEV1/FVC ratio and
diagnosis of patients was according to the GOLD staging system. Majority study design were
observational, some were cross sectional, experimental and randomized clinical trials. Mean age of
patients observed was 40-85 years. To assess the quality of life of COPD patient specific
questionnaires has been used like SGRQ, CAT, CCQ, EQ-5D-5L.
Results: Included studies shows that the quality of life of COPD is compromised physically as well
as mentally. It is due to less physical activities, smoking habits, psychological issues, comorbidities
like diabetes mellitus, cardiovascular diseases, arterial hypertension.
Conclusion: All the studies concluded that COPD patients diagnosed on basis of GOLD criteria
and their quality of life is assessed via disease specific questionnaires that majorly includes SGRQ,
CAT, CCQ, EQ-5D-5L. And it shows that quality of life of COPD decreases overall. However, the
major confounders of reduced quality of life in COPD patients were: Smoking, raised BMI, high
cholesterol, Depression/ anxiety, traffic related air pollutants, malnutrition and co-morbid conditions
such as hypertension, asthma, anemia and diabetes mellitus.
Keywords: Quality of life; COPD patients in European union, assessment of HRQoL of COPD
patients; CAT; SGRQ; acute exacerbations in COPD patients.
ABBREVIATIONS restriction, skeletal muscle dysfunction and co-

morbidities contribute to the functional decline
BMI : Body Mass Index, and obstruction in airways, that COPD patients
COPD : Chronic Obstructive Pulmonary experience on daily basis” [2]. The stated
Disease, prevalence of COPD varies according to the
CVD : Cardiovascular Diseases, geographic area; in Europe, it is about 4% [3].
CAT : COPD Assessment Test,
CRQ : Chronic Respiratory Questionnaire, “Patients with this chronic illness experience
CCQ : Clinical COPD Questionaries, severe negative effects on their physical and
FEV : Forced Expiratory Volume, mental health, as it negatively affects systems
FVC : Forced Vital Capacity, and organs other than the lungs. This can result
GOLD : Global Initiative for Chronic in pneumonia , pulmonary hypertension , and
Obstructive Lung Disease, cardiovascular disease (CVD)” [3].
HRQoL : Health Related Quality of Life,
SGRQ : St George's Respiratory “The World Health Organization estimates that
Questionnaire, 210 million people worldwide suffer from COPD,
WHOQOL : World Health Organization Quality and that the disease claimed 3 million lives in
of Life Questionnaire, 2005. A substantial decline in quality of life (QoL)
RCT : Randomized Controlled Trial. and high rates of morbidity and mortality are
linked to COPD, particularly but not only in the
1. INTRODUCTION later stages of the illness. According to the most
recent estimates provided by the Global Burden
“Chronic obstructive pulmonary disease (COPD) of Disease Study, COPD ranked third globally in
is a respiratory disease with obstruction in the 2010 for causes of death” [4]. “Between 1994
respiratory airflow. Numerous anatomical and 2010, 2,348,184 fatalities were ascribed to
abnormalities including fibrosis could be the COPD in the European Union. The prevalence of
reason of this obstruction in air flow. Airflow COPD in Europe has been reported to range
restriction can also be occasionally caused by between 4% and 10%. Forced expiratory volume
bronchi secretions, edema and air ways in one second (FEV1) is used to determine the
inflammation” [1]. severity of COPD. Nevertheless, there is little
correlation between FEV1 and the disease's
“One of the main causes of morbidity and clinical signs.For a more thorough evaluation of
mortality globally is chronic obstructive the severity of the disease, and standardized
pulmonary disease (COPD). Dyspnea, airflow measurement of patient-related outcomes (such
56
as health status) has been suggested. Patients disease is possible even though it cannot be
with COPD have been found to have high rates cured. Along with recommendations for patient
of diabetes, cardiovascular illness, and mental treatment, the guidelines that offer information to
disorders (such as depression and anxiety)” [4]. aid in the diagnosis of COPD also include risk-
reduction tactics, lifestyle modifications, and
“When it comes to inflammatory cells, mediators, medication recommendations. Supplemental
inflammatory effects, and therapy response, the oxygen can help patients with severe COPD who
inflammatory process in COPD differs greatly may also have hypoxemia and/or hypercapnia.
from that in asthma” [5]. “COPD is of late onset, This treatment can also increase the patients'
slowly progressive symptoms, poor response to ability to exercise. Participation in pulmonary
inhaled therapy, and typically associated with rehabilitation, which is advised for all patients
long-term smoking, asthma typically has an early with COPD, is a beneficial adjunct to medication
onset with intermittent symptoms, a good [15].
response to inhaled therapy, and is frequently
associated with other allergy diseases” [6,7]. “Previous studies related to quality of life in
COPD patients tells the following: Loanna,et al
Whereas COPD is caused by a Noxious Agent described that chronic obstructive pulmonary
(primarily cigarette smoking), asthma is caused disease (COPD) is a prevalent disease in the
by a Sensitive Agent. While airflow restriction in general population and a considerable burden for
asthma is fully reversible, it is not in COPD patients with the disease. This burden differs
cases. Asthma is characterized by variable between patient groups. Some patients can live
wheezing, while COPD is characterized by their lives almost untouched by the disease,
persistent symptoms. In asthma, bronchial while others are almost completely handicapped.
hyperreactivity (BHR) is expressive, whereas in One way to indicate the burden of the disease to
COPD, it is minimal. In cases of asthma, patients is assessment of health-related quality
bronchodilators and corticosteroids are of life (HRQoL) and health status. Quality of life
beneficial; in cases of COPD, they are essentially (QoL) in general refers to the patient’s ability to
ineffective [6]. enjoy normal life activities” [16]. “Margarethe
reported that health-related quality of life (HRQL)
It is acknowledged that one of the most prevalent of COPD patients typically declines: The overall
and significant symptom of COPD is fatigue. [8] severity of COPD is influenced by symptoms
One of COPD's hallmark symptoms, dyspnea, such as cough, dyspnea, and sputum production,
can be a powerful inducer of anxiety. In the as well as by acute exacerbations of the disease
multivariable analysis, COPD was linked to an and comorbidities that are common in COPD
increased risk of anxiety. Anxiety was linked to patients” [17]. Regis, et Al described that
worse health outcomes in COPD patients and patients with COPD have been found to have
make them avoid any physical activities [9,10]. high rates of diabetes, cardiovascular illness, and
Research has indicated that malnourishment or mental disorders (such as depression and
low body weight is prevalent amongst people anxiety). According to reports, these
with COPD; it affects roughly 10-15% of patients comorbidities greatly raised the probability of
with mild-to-moderate disease and 50% of treatment expenditures as well as death and
patients with chronic respiratory failure and hospitalizations for COPD patients. It has been
advanced stages of the disease [11,12]. Patients observed that several respiratory characteristics,
with COPD complained of a variety of symptoms such as the degree of airflow restriction,
and experienced a lower standard of living [13]. dyspnea, and recurrent exacerbations, are
independently linked to a lower quality of life
Reduced dyspnea, increased exercise tolerance, (HRQoL). There is limited information available
enhanced quality of life, and averting future risks regarding the effects of other comorbidities, such
are the objectives of care for COPD patients. as diabetes and cardiovascular disorders, on
Drugs with anti-inflammatory qualities and both HRQoL. However, recent research have further
short- and long- acting bronchodilators are revealed that COPD participants with anxiety
included in pharmacological approaches [14]. and/or depression had decreased HRQoL [18].
The bronchodilators may be used as needed or
as a long-term maintenance treatment, The questionnaires used to assess quality of life
depending on the severity of the illness. Inhaled in COPD patients are as following. The Chronic
corticosteroids are added to the treatment Respiratory Questionnaire (CRQ) [19], Severe
regimen when the disease reaches a severe Respiratory Insufficiency (SRI) instrument was
stage. Treating COPD at any stage of the studied in one study in oxygen dependent COPD
57
patients [20], COPD Assessment Test (CAT) 2.1.1 Inclusion criteria

was studied in eight studies in mainly pulmonary
rehabilitation patients and in one study in primary 22 studies met the inclusion criteria. Criteria is as
care patients, St. George Respiratory follows:
Questionnaire (SGRQ) was studied in 26 papers
in different settings (community, hospital, and 1- All the patients suffering from COPD
pulmonary rehabilitation), Shorter form SF-12 2- Population to be taken is from Europeon
(SF-12) was studied in one study in exacerbation Union
patients [21], HRQOL was assessed using the 3- Assessment of HRQoL of COPD patient is
EQ-5D-3L, which is a validated instrument, done in study
Clinical COPD Questionnaire (CCQ) was studied 4- Studies that used specific questionnaires
in eight studies. Utility measure EuroQol EQ5D for assessing QoL
was studied in five studies in hospital [22]. 5- Age of patients is above 55 years
6- Studies were published in English
2. METHODOLOGY language
7- The studies were published in peer
2.1 Study Design reviewed journals
8- Measurement of FEV1/FVC value is done
Study protocols were according to the PRISMA
in studies
flow diagram guidelines. This study is a literature
9- Patients classified according to GOLD
review of about 22 studies from the Europeon
staging system
Union. Study search is done by the electronic
databases along with the manual search on
2.1.2 Exclusion criteria
Google scholar. The research is restricted to the
English language. The study designs of the
Exclusion criteria were as follows:
studies involved were cross sectional, corhort,
observational, longitudinal, randomized,
1- Patients having asthma are excluded
nonrandomized controlled and controlled
2- Articles that were related to oxygen
perspective study.
therapy
In identification step, all the data collected is 3- Questionnaire that doesn’t measure QoL of
searched from different databases and registers COPD patients were excluded
like Pubmed, Scopus, Science Direct, ProQuest, 4- Study other than in English language was
Web of Science. Almost 1880 studies were excluded
searched from databases like 648 from Pubmed, 5- Studies other than from European Union
578 from Scopus, 340 from science direct, from were excluded
ProQuest we got 200 and from Web of Science
we found 114 studies. Out of 1880, after 2.1.3 Data extraction
screening 750 studies were removed because of
duplicate record. 25 studies were record The data which was extricated from research
renounced and were also removed from the studies included: study titles, authors, study year,
record. 1105 studies left in record. After further university country, study design, mean
screening 945 studies were again excluded from age/gender, inclusion criteria, study population,
the records. 160 studies sought for retrieval out questionnaire, result of QoL, factors that are
of which 43 studies did not have full text causing reduced QoL.
available and on this basis they were excluded
from record. Studies remain in assessment for 2.1.4 Data synthesis and analysis
eligibility are 117 at this point. They are further
filtered out. 40 studies got excluded because The effect of Chronic obstructive
they didn’t belong to Europeon Union. 25 studies pulmonary disease on the patients’ health has
screened out because they had no clear impact been investigated from all the studies. And how
on quality of life in COPD patients. Further on 20 COPD reduces the quality of life of COPD
articles were not published in journals and 10 patients and factors that are involved in reducing
studies didn’t explain any questionnaire for the HRQoL has been assessed. Decrease in
quality of life of COPD patients. At last stage only physical activities and exercise has been
22 studies were included that met the criterias for observed. Hypoxemia and dyspnea is also seen
review. in COPD patients.
58
3. RESULTS included retired individuals with an HRQOL of

41.7% and married patients with an HRQOL of
The topic of our study is “Systematic review of 58.3%. Furthermore, the study included
quality of life of COPD patients in European computer-illiterate people with more than two
Union”. The studies included in this review were hospitalizations and patients with respiratory
22 in number. All the studies showed the failure.
assessment of quality of life in COPD patient.
Shows all the factors and activities that reduces Study Population: Study population shows the
the quality of life. For the assessment of HRQoL, sample size of patients involved in studies and
there are some specific and standard surveys. All the patients in studies participated
questionnaires i.e. SGRQ, CAT, EQ-5D-3L etc. gave written informed consent. The evaluation of
Data extracted includes study year, author, study patients has been done over the years from 1-5
design, inclusion criteria, sample population, age, year in differnet studies. And majority of patients
gender, factors affecting QoL of patients. were taken from hospital settings.
Study Year: Total 22 studies were conducted Maximum sample size includes 11,577 patients
from 2017-2022. Out of which two studies were under study. One of the study based on real
from year 2017, three studies from 2018, three world analysis examined 3016 COPD patients
studies from 2019, eight studies from 2020, two over one year. Another study shows 543 patients
studies from 2021, and four studies from 2022 in sample size examined over 5 years and at the
were taken. end of period only 324 left.
Country: All the studies taken were from Mostly sample includes geriatrics. Minimum
countries included in Europeon Union. Out of 22 sample size included was of 94 patients and its
studies, five studies were collected from Spain, study period was 12 months, at the end of study
three studies from Denmark, four studies from 53 patients left.
Germany, one from Austria and one from Each Sample size further divided into two or
Netherlands. In a similar manner, one study was three groups of control group, cohort group,
picked from each of these following: Bulgaria, pysical therapy group, self management group
Marbug, Hungary, the Solvak Republic, Sweden, etc.
and Poland.
Questionnaire: Different questionnaire are used
Study Design: In these 22 studies, fourteen for the assessment of health related quality of life
studies belong to observational study design, in COPD patients. Out of 22 studies, 7 studies
eight studies from cross sectional study, one used St. George’s Respiratory questionnaire
study from cohort clinical trial, four studies from (SGRQ). In these 7 studies, 5 studies used
observational longitudinal study, one from SGRQ alone and one study used it along with
controlled prospective study, seven studies from other questionnaires including EQ-5D-5L and
experimental study design, six studies from Clinical COPD questionaries’ (CCQ). One
randomized clinical trial, one from non- study used SGRQ, EQ-5D-5L, CCQ and also
randomized clinical trial, and last from descriptive CAT (COPD assessment test) to assess quality
study (survey data) has been included. of life.
Mean Age/Gender: Both male and female Further on, 8 studies used the questionnaire
subjects were participated in our study. Mean CAT. Out of 8, 4 articles used CAT questionnaire
age of the subjects was between the range of 40- along with combination of different other
85. questionnaires for the assessment of quality of
life. These includes EORTC30, EQ-5D-5L, CCQ,
Ratio of males were comparatively greater than mMRC, 15D QoL.
females.
15D questionnaire is used in one study. Short
Inclusion Criteria: Patients with age >40 years form-12 and short form-36 health survey
who are diagnosed with GOLD criteria were questionnaire are being used in the study of
selected in our study. FEV1/FVC ratio less than Germany and Sovak Republic respectively.
70% of patients were included. Patients who
received a diagnosis based on ATS/ERS were Clinical COPD questionnaire has been used in 3
also included. Patients with a history of smoking of the studies in combination with different
10–20 packs per day were chosen. The study questionnaires.
59
In one study Chronic Respiratory Questionnaire Health Organization (WHOQOL-100)

(CRQ) is used. Two studies holds EQ-5D-3L and questionnaire for the assessment of quality of life
SRI questionnaire respectively. of COPD patients.
One article from Ukarian and Poland, did not use Total 3 studies used EuroQoL Five-Dimensional
particular HRQoL questionnaire for COPD Five-Level Questionnaire (EQ-5D-5L) with
patients. They used Ukrainian version of World combination with other questionnaires.
Fig. 1. Prisma flow diagram for systematic review
*Consider, if feasible to do so, reporting the number of records identified from each database or register searched
(rather than the total number across all databases/registers)
**If automation tools were used, indicate how many records were excluded by a human and how many were
excluded by automation tools
From: Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020
statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. doi: 10.1136/bmj.n71
For more information, visit: http://www.prisma-statement.org/
60
Table 1. Quality assessment of included studies using AXIS tool
AXIX tool items
(Szentes et al., 2020)
Study 10
Study 11
Study 12
Study 13
Study 14
Study 15
Study 16
Study 17
Study 18
Study 19
Study 20
Study 21
Study 22
Study 1
Study 2
Study 3
Study 4
Study 5
Study 6
Study 7
Study 8
Study 9
[23]
[24]
[25]
[26]
[27]
[28]
[29]
[30]
[31]
[32]
[33]
[34]
[35]
[36]
[37]
[38]
[39]
[40]
[41]
[42]
[43]
Were the aims/objectives of the Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
study clear?
Was the study design appropriate Yes No Yes Yes Yes Yes No Yes No No Yes Yes Yes Yes No No Yes Yes Yes Yes Yes Yes
for the stated aim(s)?
Was the sample size justified? Yes Yes Yes Yes Yes Yes No Yes No Yes Yes Yes Yes Yes No No Yes Yes Yes Yes Yes Yes
Was the target/reference population No Yes Yes No No Yes Yes Yes Yes No Yes No Yes No Yes Yes No No Yes Yes Yes Yes
clearly defined?
Was the sample frame taken from Yes Yes Yes Yes Yes Yes Yes Yes No No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
an appropriate population base so
that it closely represented the
target/reference population under
investigation?
Was the selection process likely to Yes Yes Yes Yes Yes Yes Yes Yes Yes yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
select subjects/participants that
were representative of the
target/reference population under
investigation?
Were measures undertaken to No No No No No Yes Yes Yes No No Yes No Yes No Yes No No No Yes Yes Yes Yes
address and categorise non-
responders?
Were the risk factor and outcome Yes No No Yes No Yes No Yes No No Yes Yes Yes Yes No Yes Yes No Yes Yes Yes Yes
variables measured appropriate to
the aims of the study?
Were the risk factor and outcome Yes Yes No Yes Yes Yes No Yes No No Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes
variables measured correctly using
instruments/measurements that
had been trialled, piloted or
published previously?
Is it clear what was used to Yes No Yes Yes Yes Yes Yes Yes yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
determined statistical significance
and/or precision estimates? (e.g. p-
values, confidence intervals)
Were the methods (including Yes No No Yes Yes Yes No Yes No Yes Yes Yes Yes Yes Yes Yes yes Yes Yes Yes Yes Yes
statistical methods) sufficiently
described to enable them to be
repeated?
61
AXIX tool items
(Szentes et al., 2020)
Study 10
Study 11
Study 12
Study 13
Study 14
Study 15
Study 16
Study 17
Study 18
Study 19
Study 20
Study 21
Study 22
Study 1
Study 2
Study 3
Study 4
Study 5
Study 6
Study 7
Study 8
Study 9
[23]
[24]
[25]
[26]
[27]
[28]
[29]
[30]
[31]
[32]
[33]
[34]
[35]
[36]
[37]
[38]
[39]
[40]
[41]
[42]
[43]
Were the basic data adequately Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
described?
Does the response rate raise No No No No No Yes No Yes No No Yes No Yes No No No No No Yes Yes Yes Yes
concerns about non-response bias?
If appropriate, was information No No No No No Yes Yes Yes No No Yes No Yes No No No No No Yes Yes Yes Yes
about non-responders described?
Were the results internally Yes No No Yes Yes Yes No Yes No No Yes Yes Yes Yes Yes No Yes Yes yes Yes Yes Yes
consistent?
Were the results presented for all Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
the analyses described in the
methods?
Were the authors' discussions and Yes yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
conclusions justified by the results?
Were the limitations of the study Yes No No Yes Yes Yes Yes Yes Yes Yes Yes yes Yes Yes Yes Yes Yes Yes No Yes No Yes
discussed?
Were there any funding sources or No No No No No No No No No Yes No No No No No yes No No Yes No No Yes
conflicts of interest that may affect
the authors’ interpretation of the
results?
Was ethical approval or consent of Yes Yes No Yes Yes Yes Yes Yes Yes No Yes Yes Yes No Yes No Yes No Yes No Yes Yes
participants attained?
62
Table-2. Study characteristcs of the included 22 studies
Sr. Study Study University / Study design Mean age / Gender Inclusion Criteria Study Questionnaire QoL QoL-
No. year Country population used Confounders
1. Quality of Life and 2020 Kepler University Cross-sectional 62.8% men; mean age Inclusion: age ≥40 850 patients; St. George’s Half of the patients Diabetes
Limitations in Daily Hospital, study design 66.2 ± 0.3 (SE) years years, a physician’s mean Respiratory (50.3%) reported mellitus, Arterial
Life of Stable COPD Department of diagnosis of COPD FEV1%pred. Questionnaire not being able to hypertension,
Outpatients [23] Pulmonology, according to GOLD 51.5 ± 0.6 for COPD do any sports and Cardiac disease,
Austria recommendations. (SE)) were patients 78.7% stated that Smoking status
analys ed. their respiratory
symptoms did not
allow them doing
anything they
would like to do.
2. Two-year mortality 2022 Department of observational *Mean age, years 65.1 included patients 152 CAT and mMRC the presence of Low HDL,
following a severe Occupational (± 9.9) years * Male / had FEV1/FVC ratio consecutive questiinarre severe Smoking
COPD exacerbation Diseases, Female= 108 (71.1%) / < 0.70 following COPD patients exacerbation,
in Bulgarian patients Department of 44 (28.9%) administration of a hospitalized for reduced quality of
[24] Pulmonary bronchodilator. COPD life, low BMI—
Diseases, Central exacerbation increased
Clinical who gave mortality
Laboratory, written in-
Medical University formed
Sofia Bulgaria consent
3. Effect of tele– health 2018 Institute of Clinical Randomized 68-70 years old females *Post-bronchodilator 281 (51.2%) 15D Qol A small degree of
care on quality of life Medicine, clinical trial forced expiratory patients gave questionnaire, improvement in symptoms and
in patients with severe University of volume in 1 second written CAT the QoL physical
COPD Copenhagen, [FEV1]/forced vital informed functioning
[25] Copenhagen, capacity ,0.7. consent to
Denmark *Post-bronchodilator study
FEV1,60% of participation
predicted value.
4. Factors associated 2017 University of cross-sectional 65 years old (SD Patients were 206 COPD Short-Form 12 HRQol, is reduced Depression,
with generic health- Regensburg, study, =8.85) 2/3 are male sex recruited from patients (SF-12) Health by psychiatric anxiety
related quality of life Regensburg, prospective primary care and (60.7% male; Survey activities
(HRQOL) in patients Germany patient cohort specialist practices mean age: Questionnaire
with (COPD) study as well as from in- 65.3 years)
[26] and outpatients from
hospital settings
5. Measuring quality of 2019 Ludwig- cross-sectional 65± 5years Analyzed patient- 1,350 EuroQoL Five- Reduced QoL is --
life in COPD patients: Maximilian’s- study level information participants Dimensional seen in patients
comparing disease- University Munich, from DMP Five- Level
specific supplements Germany documentation and Questionnaire
to the EQ-5D-5L health insurance (EQ-5D-5L),
(Szentes et al., 2020) claims data. No CAT, CCQ,
more iclusion criteria SGRQ
is mentioned in
study
6. The relationship 2020 Institute of Health Survey data Age 65 ±5years, Patients who 11,577 patients -- severe COPD Obesity
between BMI and Economics and (real-world Female: 4,751 (41.0%), participated in the might improve
health-related quality Health Care evidence) Male: 6,826 (59.0%) COPD disease following weight
63
of life in COPD Management, management reduction
[27] Germany program (DMP) in
the respective year
were included in this
evaluation
7. Optimizing COPD 2020 Copenhagen Experimental Age: 65±5 Females Patients with an 114 patients CAT and In this population Lung cancer,
treatment in patients University (randomized patients FEV1/FVC ratio EORTC30 of severely ill head and neck
with lung or head and Denmark control trial) <0.70, no significant questionnaire cancer patients, cancer
neck cancer does not RCT beta-2- reversibility we did not find
improve quality of life and no actual or that this
– a randomized, pilot, previous doctor- intervention,
clinical trial [28] diagnosed asthma focusing on
were eligible inhaled COPD
medication, for the
management of
COPD had any
convincing
positive impact on
the patients’
perceived quality
of life compared
with usual care
8. Impact of Lung 2021 1-Helmholtz Observational, 59.8% were male, -- 3016 COPD EQ-5D-5L, (St. FEV1 decrease Smoking
Function and Zentrum München, longitudinal mean age was 68.9 patients George’s was associated Obesity
Exacerbations on Neuherberg, study years, Respiratory with a significant
Health-Related Germany Questionnaire but not minimal
Quality of Life in 2-IBE, Ludwig- (SGRQ), Clinical important
COPD Patients Within Maximilians COPD difference (MID)
One Year: Real-World University Munich, Questionnaire deterioration in
Analysis Based on Germany (CCQ)) disease-specific
Claims Data [29] 3-Philipps- HRQoL (mean
University change [95% CI]:
Marburg, Germany CAT +0.74 [0.15
to 1.33])
9. Implementation of an 2020 Son Espases Controlled Age: 75±5years COPD patients 141 patients CAT Decreases ER Age,
integrated care model University Hospital prospective Male/Female = for diagnosed and hospital Pseudomonas
for frequent- – IDISBA study standard care group according to gold admission and aeruginosa are
exacerbator COPD Spain 102 (77.3)/30 (22.7) criteria with history improves health factors that
Patients And for ICM group 101 of >2 AECOPD status, but not causes severity
[30] (71.6)/40 (28.4) Required mortality of disease.
hospitalization and
fulfilled inclusion
criteria with no
exclusion criteria for
ICM
10. Role of physical 2022 Pompeu Fabra Cross sectional Mean age of 69years Patients Sample size CAT, CCQ Reduced QoL in Traffic related air
environment in health- University study 85% of males. approaching any of was 407 patients pollutants,
related quality of life Barcelona, (Randomized 33 primary care geriatrics residential
in patients with COPD Spain controlled trial) centers and five patients distances to blue
[31] tertiary hospitals of green spaces
64
five seaside and
diagnosed with
COPD according to
ATS/ERS were
recruited
11. Patient education 2018 University Jaume I, Controlled and Age: Mean±(SD) = 73.0 Patients diagnose Sample size SGRQ Mean hrql score Smoking,
during hospital Castellon de la randomized (9.4) Males: 94 (81.0) with COD based on was 446 upon admission malnutrition
admission due to Plana, Spain experimental Females: 22 (19.0) a history of smoking was 48.3+-20.0
exacerbation of study of 20 packs per year Decreased in the
COPD along with barely IG on average by
[32] reversible air flow 6.83 points. CG
obstruction barely shows
changes in scores
with avg reduction
of 0.26 points
Average drop of
15.76 in absolute
change and an
average drop of
23.99% in relative
change
12. Effects of omega-3 2022 Semmelweis CROSS Age: Omega3 Inclusion criteria 400 patients CAT We observed Higher BMI
supplementation on University, Faculty SECTIONAL consumer: 57.5-72.5 were: age ≥40 years better quality of reduces the
quality of life, of Medicine, Omega3 non- and diagnosis of life {CAT: 25 [21– quality of life.
nutritional status, Budapest, consumer: 61-73 COPD [post- 30.5] vs. 26 [20–
inflammatory Hungary Man: Omega bronchodilation of 31]; P=0.519} ,
parameters, lipid consumer=10 (52.63%) forced expiratory lower number of
profile, exercise Omega3 non- volume in one exacerbations in
tolerance and inhaled consumer=180 second/forced vital the previous half
medications in COPD (47.24%) capacity year [0 (0–1) vs. 1
[33] Woman: Omega (FEV1/FVC) <70%]. (0–2); P=0.023],
consumer= 9 (47.37%) higher 6MWT
Omega3 non- values in the
consuemr= 201 (52.76) group with omega-
3 supplementation
13. Effects of the “Living 2017 University of prospectively Age years: LWWCOPD Inclusion criteria for 467 patients; Chronic LWWCOPD Lack of patient
well with COPD “ Zurich, planned, non- group= 69.3±10.3 both the mediX and 71 in the Respiratory intervention counselling and
intervention in primary Switzerland, randomised Control group= ICE COLD ERIC LWWCOPD Questionnaire improved HRQoL self-management
care [34] University of controlled study 67.1±10.0 cohorts were as self- domain to a clinically
Amsterdam, The Male: LWWCOPD= 28 follows: age ⩾40 management relevant extent
Netherlands (39.4%) years; a smoking group and 396 and reduced
Control= 225 (56.8%) habit (current or in the ICE COPD
past) ⩾10 pack- COLD ERIC exacerbations
years; a confirmed routine care
diagnosis of COPD; control group
and a ratio
(FEV1/FVC) ⩽0.70,
with less than 12%
and less than 200
mL increases in
65
FEV1, post
dilatation, according
to the GOLD &
GOLD II–IV
classifications . All
participants be able
to attend training
sessions for 6
weeks.
14. The Effect of 2018 Department of Observational Age (years) Comparing 2 groups 128 QoL significant insufficient use of
Pulmonary Physical Medicine, comparison COPD 65.7±11.9 of patients (patients consecutive questionnaire improvement rehabilitation
Rehabilitation in Balneology and with COPD and patients (90 SF-36 after the options
Mountain Medical patients with CB) diagnosed with intervention in all lack of research
Environment on Rehabilitation, before initiation of COPD and 38 the monitored focused on
Exercise Capacity Medical Faculty of the treatment with diagnosed with subscales and mountain climate
and Quality of Life in P. J. Šafárik baseline CB) summative scores therapy
Patients with Chronic University and L. measurements, and in both CB
Obstructive Pasteur University again after the patients and
Pulmonary Disease Hospital in Košice, intervention of 3 COPD patients
(COPD) and Chronic Košice, Slovak weeks of pulmonary (p<0.001) for all.
Bronchitis [35] Republic rehabilitation in a
mountain
environment.
15. Cross-sectional study 2020. Department of Cross-sectional Mean age of the The majority of the 933 EQ-5D-3L The present study Unemployment
evaluating the Health Services study participants was 62.1 participants were respondents showed that and ageing were
association between Research, (14.4) years. married (70.3 %) participated patients with a associated with
integrated care and Maastricht 54.7% of the sample and almost half (49 better organi- lower HRQOL,
health-related quality University, were female %) were retired. Of sational care and people who
of life (HRQOL) in Maastricht, The the participants, 449 coordination were married
Dutch primary care Netherlands were categorised in experience were reported less
[36] the high HRQOL more likely to have anxiety and
group (58.3 %) and a higher HRQOL. depression
the remaining 321
were in the low
HRQOL group
(41.7%).
16. Results on health- 2019 Department of Randomized Age (years): Patients of both a total of 66 The EQ-5D is a At 3 months, cardiovascular
related quality of life Physiotherapy, clinical trial Control sexes were patients were self- HRQoL shows disease,
and University of group=71.35±9.88 included as long as randomized in administered, reductions in all orthopedic
functionality of a Granada, Physical they were older than the three health-related subscores in diseases
patient-centered Granada, Spain therapy=71.20±11.53 40 years of age, groups and quality-of-life Control Group and
selfmanagement Self-management were performed the questionnaire Physical Therapy
program in group=72.63±7.37 diagnosed with intervention groups, while Self-
hospitalized COPD: a severe COPD with pre- and Management
randomized control according to the post- group shows
trial [37] criteria of the GOLD assessment. minimal
3 or maintenance
4), were hospitalized of the values
due to acute
exacerbation of
66
COPD and
agreed to
participate.
17. Anemia Severely 2022 Witten/Herdecke cohort study Age [years]= 65.6 ± Patients were only A total of 128 SRI Overall, 32.8% of Anemia plays a
Reduces Health- University, Faculty 8.1 included if their patients were the patients were highly important
Related Quality of Life of Health/School of Female/male [%] chronic respiratory enrolled for anemic, while role in reducing
in COPD Patients Medicine, 46.1/53.9 failure was primarily data analysis. 4.7% had HRQL in patients
Receiving Long-Term Germany attributable to Overall, 32.8% polycythemia. with chronic
Home Non-Invasive COPD. of the patients respiratory failure
Ventilation [38] Regularly scheduled were anemic,
follow-up visits as while 4.7% had
well as those with polycythemia
acute problems
18. The Health Diary 2022 Linköping, cross-sectional patients aged ≥65 Elderly computer- 94patients St. Georges the disease- Cardio vascular
Telemonitoring and Linköping study. years. illiterate subjects were enrolled Respiratory speciﬁc HRQoL diseases,
Hospital- Based University, with ≥2 of which 53 Questionnaire was worsened at Smoking
Home Care Improve sweden. hospitalizations the subjects (SGRQ) the 12 month
Quality of Life Among previous year were completed the evaluation. At end-
Elderly Multimorbid included 12-month stage diseases
COPD and Chronic study period subjects with
Heart Failure Subjects COPD and CHF
[39] typically
experience
impaired
functioning and
impaired Qol.
19. Chronic rhinosinusitis 2020 Copenhagen cross sectional Age, mean (SD)= 70.2 -- 222 patients CAT CRS decreases asthma,
in COPD: A prevalent University study (8.9) HRQoL bronchiectasis,
but unrecognized Hospital, Denmark cystic fibrosis
comorbidity impacting and primary
health related quality ciliary dyskinesia
of life [40]
20. Can simvastatin 2020 Medical University randomized Patients aged till 85 GOLD grade 2–4 208 patients St George’s simvastatin at a --
reduce COPD Vienna, Austria double-blind years/ Males were enrolled Respiratory dose of 40 mg
exacerbations? A controlled study according to lung Questionnaire daily significantly
randomized double- function criteria: (SGRQ) prolonged time to
blind controlled study ratio of forced first COPD
[41] expiratory volume in exacerbation and
1 s (FEV1) to forced reduced
vital capacity (FVC) exacerbation rate.
<70% and FEV1
<80% predicted
after bronchodilator
use. They were
current or former
smokers with ⩾20
pack-years lifetime
cigarette
consumption.
67
21. The quality of life in 2019 Nicolaus randomized Adult population. 124 patients. Ukrainian improvement of --
COPD patients in the Copernicus control trial average age was 59.19 64 (51.61%) version of the the overall quality
process of physical University, Toruń, (RCT) ± 0.74 years males and 60 World Health of life
rehabilitation [42] POLAND (48.39%) Organization increased
females Quality of Life indicators in
Questionnaire problematic
(WHOQOL-100) facets.
decreased
discomfort,
decreased drug
addiction,
increased mobility,
vital activity
22. Predictive factors over 2020 Respiratory prospective 67years ±5 Patients were in- Geriatrics, 543 Saint George’s PA was related to Reduced
time of health- related Department, observational Males 308 cluded in study if patients at Respiratory a 13 to 35% better physical activity
quality of life in COPD Hospital Galdakao- longitudinal Females 16 they diagnosed with start. Questionnaire activity and and hospitaliza-
patients [43] Usansolo, study COPD for at least Over 5year (SGRQ), impacts scores of tions for
Galdakao, Bizkaia, 6months and had 324 left. HRQoL, exacerbation.
Spain been stable for depending on the
6weeks. Other level of PA,
inclusion criteria hospitalizations
were (FEV1) post- were related to 5
bronchodilator to 45% poorer
<80% of the HRQoL scores.
predicted value and Pulmonary
a FEV1/forced vital function was
capacity ratio<70% associated with all
HRQoL
components, with
an approximately
5% improvement
in HRQoL
68
Results of quality of life: Out of 22 studies, Lack of counselling and self-management has
nine studies showed the reduced quality of life also been the reason for decreased QoL in one
due to various factors. study.
Remaining studies showed the improvement in One study collected from Sovak Republic says
quality of life due to hospital admissions, insufficient use of rehabilitations options and lack
increased physical activities, and use of drugs for of research focused on mountain climate therapy
exacerbation reduction, better organisational are the factors.
care, LWWCOPD intervention, supplementation
and weight reduction. Two studies didn’t mention factors that causes
the reduction of QoL. And one study described
Factors that causes reduction of quality of that hospitalization for exacerbations and
life: Out of 22 studies, four studies discussed physical activities can influence the health
comorbidities as a factor of reduced quality of life related quality of life.
along with COPD. Major diseases reported are
Diabetes Mellitus, Cardiovascular diseases, 4. DISCUSSION
Arterial hypertension, asthma, cystic fibrosis,
orthopaedic diseases. The state of health in individuals with COPD is
impacted by numerous variables. However,
Smoking has been a prime factor of reducing the because there are numerous questionnaires in
quality of life in COPD patients. Three studies use and some factors affect multiple sections or
majorly highlighted smoking and tobacco as a domains of the existing questionnaires, it is
factor. Malnutrition and low HDL has also been challenging to assess the degree of influence of
discussed with this. each factor on health status. Several studies
have also been conducted on evaluation of
Two studies explains psychiatric issues like quality of life among COPD patients. This review
depression and anxiety as a factor that reduces evaluates the quality of life among COPD
quality of life in COPD patients. Also reported patients in European union countries and the
that people who are married are reported with effects of variable factors and different
other factors majorly instead of depression and interventions on the quality of life.
anxiety in reduced QoL.
This review presents that smoking is a prime
One study from Denmark explained cancer of factor of reducing the quality of life in COPD
lung, neck and head as a factor of reduced patients .Three studies majorly highlighted that
quality of life in COPD patients. smoking and tobacco as a cofactor .Similar
results were shown by study conducted in chest
One of the study has discussed obesity as a disease research institute Kyoto ,Japan on 132
factor that plays a part in reducing quality of life. patients using Nottingham Health Profile as a
general HRQL measure that reported air flow
Anemia has also been discussed as the reason limitation, diffusing capacity ,life time cigarette
in one study picked from Germany along with consumption were significant predicators of
chronic respiratory failure in reducing the QoL of HRQL in stable COPD patients.[44] In contrast a
COPD patients. review article having databases from 2006 to
2007 from different countries of world by
Three studies described high degree of N.S.Godtfredson suggested that smoking
symptoms i.e. sever exacerbation, decreased cessation recommendation is not proportionate
physical activities, unemployment, ageing as a to degree of morbidity cause by smoking. .
main factors in reducing or decreasing the quality “Smoking cessation in mild-to-moderate disease
of life. can prevent progression of disease severity;
however, it is not known what characterizes
According to one study from Hungary, says high smokers with different stages of COPD who
body mass index (BMI), less walk also leads to choose to stop smoking compared with those
the same condition. Two studies from Spain who continue”. (Godtfredsen, Lam et al. 2008)
described age, gender, traffic related air
pollutants (NO2, PM2), residential distances to This systemic review provides insight into the
blue green spaces and pseudomonas association of comorbidities and reduced quality
aeroginosa for the severity of COPD and of life in COPD patients .out of 22 studies four
reduction of quality of life. studies discussed comorbidities like Diabetes
69
mellitus, cardiovascular disease, arterial related to dyspnea. Similarly , a prospective

hypertension, asthma, cystic fibrosis and study conducted in department of chest diseases
orthopedic disease as factor of reduced quality of in Istanbul Turkey by Banu et al on 65 COPD
life. Similar results were shown in a systematic patients also suggested that malnutrition is linked
review by Manuel B.Huber, who concluded to a marked decrease in the strength and
results from 25 studies of different parts of world endurance of the respiratory muscles, an
,in which it was clearly shown that certain increase in airflow restriction, and an
comorbidities like CVD and diabetes worsen the exacerbation of respiratory muscle dysfunction
quality of life in COPD patients.[27] “In contrast a already present caused by hyperinflation. [48]. In
cross sectional study conducted in 2002 in contrast a prospective randomized controlled trial
Netherland institute for health services research study conducted by Efthimiou et al in UK to
among 161 COPD patients and 395 asthma investigate the effect of 3 months of oral
patients recruited from general practice reported supplementation in 14 poorly nourished
that cardiac disease is associated with HRQoL in outpatients with COPD reported that following
asthma but not in COPD. The presence of three months of nutritional supplements, there
hypertension is not associated with poor disease were no differences in the pulmonary functions of
specific HRQoL in COPD patients” [45]. moderate-to-severe COPD patients who were
undernourished compared to those who were
“The data from the studies also showed that the well-nourished [49].
psychiatric issues like depression and anxiety
are also the major factors that reduce the quality The data from the study also showed that the
of life in COPD patients. Similar results were cancer of head, neck and lung also contribute to
shown in a cross section analysis of data from reduce the quality of life. This finding is similar to
the French COPD cohort initiatives BPCO ,data the retrospective study conducted in South Korea
recorded in stable state and included spirometry by Young soo-yi which reported that high
,dyspnea, mood disorders and comorbidities . prevalence of COPD was found in patients with
The data suggested that in presence of dyspnea non-small cell lung cancer with diminished
and exacerbations ,depression is the most quality of life [13].
important contributor to HRQoL impairment
measured by SGRQ in COPD patients”. [18 “In The data from the studies also suggest
contrast a systematic review by Amy Baranaik in association between obesity and reduced health
2009 data collected from electronic journals and related quality of life in COPD patients. Similar
databases suggested that efficacy of results were shown by the cohort study
psychological interventions to improve anxiety, conducted on 364 patients in Washington by
depression and quality of life in COPD patients is Laura et al in which obese patients reported
relatively sparse”.[18] increased severity of dyspnea and overall poor
health related quality of life [50]. In contrast a
Anemia has also been discussed as the reason cohort study conducted in France by Pierre on
in one study picked from Germany along with 633 patients reported that in presence of
chronic respiratory failure in reducing the QoL of dyspnea ,depression was the most important
COPD patients .similar evidence shown in a factor in reducing quality of life while
retrospective study conducted by Marcello in Italy obesity has little effect in reducing quality of life
in which previous record of 105 patients [18].
analyzed .the study suggested that prevalence of
anemia is 12.3% in COPD patients .anemia This review also depicted an important factor
associated with reduction of exercise capacity, traffic related air pollutant in reducing the quality
an increase of dyspnea and deterioration of of life in COPD patients .Similarly a cross
quality of life. [46] In contrast a study conducted sectional study conducted in Hong kong by
by Casanova et al in hospital Universitario Fong et al also described a strong association
Quiron Madrid on 130 COPD patients suggested between the quality of air and the reduced quality
that anemia prevalence was only 6.2% in of life in COPD patients [51].
patients ,it was less prevalent [47].
In same way a cross sectional study on 407
The data from the studies in this review also stable COPD patients conducted in Spain by
depicted an association between nutritional Moitra et al also showed that high residential
status and the quality of life in COPD patients. exposure to traffic related air pollutants are
Malnutrition increases dyspnea and exercise associated with poorer quality of life in COPD
intolerance in COPD patients. BMI is closely patients [31].
70
The study included in this review suggested that COMPETING INTERESTS

insufficient use of rehabilitation facilities has
great impact in reducing the quality of life in Authors have declared that no competing
COPD patients. Similarly a systematic review in interests exist.
Germany by Micheal et al interpreted that non
pharmacological interventions like pulmonary REFERENCES
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Journal of Pharmaceutical Research International

Volume 36, Issue 2, Page 55-75, 2024; Article no.JPRI.114123

Confounders Effecting Quality of Life

Open Peer Review History:

J. Pharm. Res. Int., vol. 36, no. 2, pp. 55-75, 2024

ABBREVIATIONS restriction, skeletal muscle dysfunction and co-

patients [20], COPD Assessment Test (CAT) 2.1.1 Inclusion criteria

3. RESULTS included retired individuals with an HRQOL of

In one study Chronic Respiratory Questionnaire Health Organization (WHOQOL-100)

Fig. 1. Prisma flow diagram for systematic review

Table 1. Quality assessment of included studies using AXIS tool

AXIX tool items

(Szentes et al., 2020)

AXIX tool items

(Szentes et al., 2020)

Table-2. Study characteristcs of the included 22 studies

mellitus, cardiovascular disease, arterial related to dyspnea. Similarly , a prospective

The study included in this review suggested that COMPETING INTERESTS

Chronic Obstructive Pulmonary Disease. Watz H, Leidl R, Vogelmeier C. Assessing

24. Mekov E, Petkov R, Tsakova A, Genova Implementation of an integrated care

symptoms, health-related quality of life, Available:https://doi.org/10.1080/14737167

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