Impaired function in the complex patient with COPD: a matter to be considered
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Da Silva, M.T.A. Pessoa Morano, A.G. De Matos Cavalcante, N.M. De Andrade, E. De Francesco Daher, E.D.B. Pereira" "autores" => array:6 [ 0 => array:2 [ "nombre" => "G.P.F." "apellidos" => "Da Silva" ] 1 => array:2 [ "nombre" => "M.T.A. Pessoa" "apellidos" => "Morano" ] 2 => array:2 [ "nombre" => "A.G. De Matos" "apellidos" => "Cavalcante" ] 3 => array:2 [ "nombre" => "N.M." "apellidos" => "De Andrade" ] 4 => array:2 [ "nombre" => "E. De Francesco" "apellidos" => "Daher" ] 5 => array:2 [ "nombre" => "E.D.B." "apellidos" => "Pereira" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S217351151500086X?idApp=UINPBA00004E" "url" => "/21735115/0000002100000005/v3_201605090007/S217351151500086X/v3_201605090007/en/main.assets" ] ] "en" => array:11 [ "idiomaDefecto" => true "titulo" => "Impaired function in the complex patient with COPD: a matter to be considered" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "227" "paginaFinal" => "229" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "R. Tonelli, E.M. Clini" "autores" => array:2 [ 0 => array:3 [ "Iniciales" => "R." "apellidos" => "Tonelli" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 1 => array:4 [ "Iniciales" => "E.M." "apellidos" => "Clini" "email" => array:1 [ 0 => "enrico.clini@unimore.it" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor1" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "DU of Medical and Surgical Sciences, University of Modena-Reggio Emilia, Italy" "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] 1 => array:3 [ "entidad" => "Ospedale Villa Pineta, Pavullo n7F (Modena), Italy" "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor1" "etiqueta" => "<span class="elsevierStyleSup">*</span>" "correspondencia" => "Corresponding author. University of Modena-Reggio Emilia, Ospedale Villa Pineta, Pavullo n/F (Modena), Italy. Tel.: +39 0536 42039; fax: +39 0536 42039. enrico.clini@unimore.it" ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig1" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "320v21n05-90436489fig1.jpg" "Alto" => 966 "Ancho" => 2296 "Tamanyo" => 126285 ] ] "descripcion" => array:1 [ "en" => "Relationship between number of the (considered) comorbidities and functional impairment as assessed by health status CAT score (from ref#11)." ] ] ] "textoCompleto" => "<p class="elsevierStylePara">The very frequent association between chronic obstructive pulmonary disease (COPD) and other chronic disorders sharing common risk factors,<a href="#bib1" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">1</span></a> has been widely recognized as a major burden on individuals and healthcare systems. If we exclude lung cancer, the most common co-existing conditions that can be objectively measured in COPD patients are cardiovascular diseases, type II diabetes, skeletal muscle dysfunction and osteoporosis, which are represented in different clusters.<a href="#bib2" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">2</span></a></p><p class="elsevierStylePara">In the last few years the term “comorbidities” has been replaced by “multimorbidities” to better reflect the nature of this link, with clear reference to a shared pattern of metabolic abnormalities, systemic inflammation and defined risk factors that identifies COPD as one component - not necessarily the most relevant - of the clinical phenotype of a chronic complex patient.<a href="#bib1" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">1</span></a></p><p class="elsevierStylePara">In a recent study, Miller et al. demonstrated that cardiovascular diseases and diabetes have the highest impact on several patient-related outcomes in COPD patients, even after adjusting for age, sex and smoking history.<a href="#bib3" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">3</span></a> As a matter of fact, the mutual interaction between COPD and cardiac dysfunction is based not only on similar risk factors and pathobiological features such as systemic inflammation, but also on pathophysiological mechanisms such as lung hyperdistension,<a href="#bib4" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">4</span></a> which may impair both ventilatory and cardiac function during effort, thus limiting exercise performance both at maximal or submaximal level. In particular, the dynamic hyperinflation on exertion found in COPD patients with different degrees of airflow obstruction, is associated with a reduction of cardiac output during exercise, limiting both venous return and left ventricle filling volume.<a href="#bib5" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">5</span></a> On the other hand, it has been shown that airflow limitation could negatively impact exercise capacity and physical performance in patients with chronic heart failure.<a href="#bib6" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">6</span></a> Systemic hypertension has been related to the increased inflammatory subset observed in COPD;<a href="#bib7" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">7</span></a> the correlation between hypertension, higher degree of dyspnea and reduced physical activity has also been reported.<a href="#bib8" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">8</span></a> This seems even more important if we consider the effect of hypertension on coronary artery disease progression and left ventricular dysfunction, with worsening in exercise tolerance.<a href="#bib9" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">9</span></a> Furthermore, Watz et al. showed that the presence of the metabolic syndrome –where systemic hypertension and diabetes coexist- among COPD patients is definitely associated with impaired level of physical activity.<a href="#bib10" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">10</span></a></p><p class="elsevierStylePara">In this issue of the journal, Da Silva and co-workers conducted a cross-sectional study to investigate to what extent the presence of co-existing hypertension, coronary heart disease and diabetes may affect functional capacity in a cohort of 79 patients with COPD.<a href="#bib11" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">11</span></a> These comorbidities have been chosen from others according to their higher prevalence in the population of COPD<a href="#bib12" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">12</span></a> and relevant effect on major outcomes. Patients were classified as having “<span class="elsevierStyleItalic">none</span>”, “<span class="elsevierStyleItalic">one</span>”, and “<span class="elsevierStyleItalic">two or three</span>” of these comorbidities, and the individual's functional capacity has been measured objectively by means of spirometry and six-minute walked distance (6MWT). As well as the perceived health status, 6MWT decreased progressively from “<span class="elsevierStyleItalic">none</span>” to “<span class="elsevierStyleItalic">two or three</span>” categories (see <a href="#f0005" class="elsevierStyleCrossRefs">Fig. 1</a>). Interestingly, the number of comorbidities of interest was independently associated with the submaximal exercise performance after adjusting for main confounders (age, severity of COPD, and score of health status).</p><a name="f0005" class="elsevierStyleCrossRefs"></a><p class="elsevierStylePara"><img src="320v21n05-90436489fig1.jpg" alt="Relationship between number of the (considered) comorbidities and functional impairment as assessed by health status CAT score (from ref#11)."></img></p><p class="elsevierStylePara">Fig. 1. Relationship between number of the (considered) comorbidities and functional impairment as assessed by health status CAT score (from ref#11).</p><p class="elsevierStylePara">These findings need to be discussed in more depth, ideally aspects such as weakness and strength should be addressed and clarified for the readers.</p><p class="elsevierStylePara">In line with previous literature,<a href="#bib3" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">3</span></a> authors confirm the lack of association between the degree of airflow obstruction and the number of concomitant disorders. However, this study only provides the evidence about 3 comorbidities, although they are the most important, which relate to the individual's function. Impaired 6MWT and 6MWT-derived variables (speed, work, exercise-induced oxygen saturation) have an additional predictive value of mortality in patients with COPD,<a href="#bib13" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">13</span></a> however this performance could be influenced by other coexisting diseases (i.e. musculoskeletal disorders) and factors that have not been taken into account by the authors. In addition, no information was given about the severity of each of these 3 comorbidities, nor about ongoing therapies for managing them.</p><p class="elsevierStylePara">We recognize that hypertension, coronary heart disease and diabetes are frequent forms of multimorbidity influencing the individual's function as single diseases or clustering together.<a href="#bib3" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">3</span></a><span class="elsevierStyleSup">, </span><a href="#bib8" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">8</span></a><span class="elsevierStyleSup">, </span><a href="#bib14" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">14</span></a> Indeed, authors have confirmed that these chronic diseases have a negative impact on the exercise capacity, here recorded as both the reduction in meters walked and the increased scores of the items assessing function in the COPD Assessment Test (CAT). Therefore, accurate assessment and count of comorbidities in the characterization of patients with COPD contribute to predicting their outcomes and risk of mortality.<a href="#bib12" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">12</span></a></p><p class="elsevierStylePara">Another problem with the present data might be that the presence of hypertension, coronary heart disease and diabetes was self-reported and/or derived by the assumed medications, there was no objective assessment. Recently, it has been shown that self-reporting may result in underestimation of chronic diseases and multimorbidity.<a href="#bib15" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">15</span></a></p><p class="elsevierStylePara">Walking performance, however, does not exclusively represent the functional capacity of patients with COPD. We can only speculate on whether there is direct correlation between 6MWT and the individual's physical activity (PA), since a good degree of exercise tolerance is pivotal to performing complex kinds of activities in daily living. In COPD subjects, lower levels of PA are associated with higher degree of severity<a href="#bib16" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">16</span></a> and a worse prognosis.<a href="#bib17" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">17</span></a> A decline to low PA over time is associated with an increased mortality risk in those with COPD but also those without.<a href="#bib18" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">18</span></a> This suggests that it is important to assess and encourage PA in the earliest stages of COPD in order to maintain it at the highest possible level, as this is associated with better prognosis. However, PA cannot be derived by the submaximal exercise test in the COPD population, nor did authors measure PA in their study sample. A deeper discussion on the existing links between exercise performance and PA should be taken in consideration in order to understand the extent to which other chronic co-existing diseases might limit function in patients with COPD.</p><p class="elsevierStylePara">The cumulative effect of multimorbidity in limiting physical performance should be carefully considered when a COPD patient is assessed and managed, paying particular attention to rehabilitation. To date, pulmonary rehabilitation, including exercise training, has proved to be one of the most effective therapies for COPD patients.<a href="#bib19" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">19</span></a><span class="elsevierStyleSup">, </span><a href="#bib20" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">20</span></a> Furthermore, recent studies have shown that even changes in the level of activity following rehabilitation have direct proportional effects on major outcomes in these patients.<a href="#bib18" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">18</span></a> At present, some retrospective studies have shown worse outcomes (in terms of exercise tolerance, and perceived well-being) in COPD patients with associated heart and metabolic diseases undergoing pulmonary rehabilitation, while others reported the opposite effect.<a href="#bib21" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">21</span></a> The reason behind this difference might be the higher degree of impairment in these patients who are generally more dyspnoeic<a href="#bib3" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">3</span></a> and less physically active.<a href="#bib22" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">22</span></a> However, evidence from available literature is incomplete and there is a need for adjunctive data to understand the effective role of coexisting diseases on rehabilitation outcomes in the population of COPD. For a given different pattern of response to exercise in the complex patients, a tailored intervention could be thus supposed as most important. Although the link between co-existing diseases and reduced performance during pulmonary rehabilitation has been clearly shown, the present study by Da Silva<a href="#bib11" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">11</span></a> did not consider this aspect.</p><p class="elsevierStylePara">In conclusion, taking all the limitations of the present study into account, results corroborate actual debate around the impact of COPD-associated multimorbidity on physical performance and the consequences when a physical therapy is applied to patients. The topic seems to be of critical importance in order to ensure the most effective and personalized treatment for COPD patients referred for a rehabilitation course.</p><p class="elsevierStylePara">Corresponding author. University of Modena-Reggio Emilia, Ospedale Villa Pineta, Pavullo n/F (Modena), Italy. Tel.: +39 0536 42039; fax: +39 0536 42039. enrico.clini@unimore.it</p>" "pdfFichero" => "320v21n05a90436489pdf001.pdf" "tienePdf" => true "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig1" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "320v21n05-90436489fig1.jpg" "Alto" => 966 "Ancho" => 2296 "Tamanyo" => 126285 ] ] "descripcion" => array:1 [ "en" => "Relationship between number of the (considered) comorbidities and functional impairment as assessed by health status CAT score (from ref#11)." ] ] 1 => array:6 [ "identificador" => "fig2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "descripcion" => array:1 [ "en" => "Relationship between number of the (considered) comorbidities and functional impairment as assessed by health status CAT score (from ref#11)." ] ] ] "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:22 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Risk Factors and Comorbidities in the Preclinical Stages of Chronic Obstructive Pulmonary Disease. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 10 | 5 | 15 |
| 2024 October | 38 | 29 | 67 |
| 2024 September | 56 | 38 | 94 |
| 2024 August | 63 | 42 | 105 |
| 2024 July | 47 | 39 | 86 |
| 2024 June | 45 | 20 | 65 |
| 2024 May | 39 | 35 | 74 |
| 2024 April | 45 | 21 | 66 |
| 2024 March | 32 | 22 | 54 |
| 2024 February | 55 | 30 | 85 |
| 2024 January | 60 | 32 | 92 |
| 2023 December | 32 | 31 | 63 |
| 2023 November | 29 | 34 | 63 |
| 2023 October | 30 | 40 | 70 |
| 2023 September | 27 | 35 | 62 |
| 2023 August | 25 | 18 | 43 |
| 2023 July | 39 | 32 | 71 |
| 2023 June | 30 | 21 | 51 |
| 2023 May | 52 | 20 | 72 |
| 2023 April | 42 | 20 | 62 |
| 2023 March | 98 | 21 | 119 |
| 2023 February | 47 | 25 | 72 |
| 2023 January | 35 | 17 | 52 |
| 2022 December | 58 | 16 | 74 |
| 2022 November | 95 | 38 | 133 |
| 2022 October | 41 | 30 | 71 |
| 2022 September | 27 | 26 | 53 |
| 2022 August | 53 | 43 | 96 |
| 2022 July | 49 | 41 | 90 |
| 2022 June | 71 | 35 | 106 |
| 2022 May | 51 | 38 | 89 |
| 2022 April | 27 | 34 | 61 |
| 2022 March | 32 | 49 | 81 |
| 2022 February | 35 | 40 | 75 |
| 2022 January | 28 | 42 | 70 |
| 2021 December | 30 | 34 | 64 |
| 2021 November | 28 | 32 | 60 |
| 2021 October | 33 | 50 | 83 |
| 2021 September | 31 | 32 | 63 |
| 2021 August | 24 | 23 | 47 |
| 2021 July | 24 | 20 | 44 |
| 2021 June | 20 | 19 | 39 |
| 2021 May | 36 | 31 | 67 |
| 2021 April | 58 | 71 | 129 |
| 2021 March | 58 | 23 | 81 |
| 2021 February | 33 | 14 | 47 |
| 2021 January | 34 | 18 | 52 |
| 2020 December | 30 | 14 | 44 |
| 2020 November | 35 | 20 | 55 |
| 2020 October | 36 | 16 | 52 |
| 2020 September | 56 | 16 | 72 |
| 2020 August | 47 | 22 | 69 |
| 2020 July | 76 | 16 | 92 |
| 2020 June | 60 | 18 | 78 |
| 2020 May | 66 | 15 | 81 |
| 2020 April | 50 | 17 | 67 |
| 2020 March | 52 | 12 | 64 |
| 2020 February | 54 | 25 | 79 |
| 2020 January | 60 | 17 | 77 |
| 2019 December | 63 | 16 | 79 |
| 2019 November | 62 | 19 | 81 |
| 2019 October | 59 | 19 | 78 |
| 2019 September | 37 | 12 | 49 |
| 2019 August | 158 | 18 | 176 |
| 2019 July | 236 | 12 | 248 |
| 2019 June | 208 | 10 | 218 |
| 2019 May | 186 | 18 | 204 |
| 2019 April | 199 | 19 | 218 |
| 2019 March | 232 | 17 | 249 |
| 2019 February | 205 | 11 | 216 |
| 2019 January | 235 | 19 | 254 |
| 2018 December | 136 | 6 | 142 |
| 2018 November | 59 | 3 | 62 |
| 2018 October | 82 | 7 | 89 |
| 2018 September | 36 | 8 | 44 |
| 2018 August | 41 | 24 | 65 |
| 2018 July | 36 | 16 | 52 |
| 2018 June | 43 | 12 | 55 |
| 2018 May | 58 | 17 | 75 |
| 2018 April | 87 | 18 | 105 |
| 2018 March | 105 | 24 | 129 |
| 2018 February | 37 | 12 | 49 |
| 2018 January | 84 | 10 | 94 |
| 2017 December | 125 | 20 | 145 |
| 2017 November | 42 | 19 | 61 |
| 2017 October | 19 | 13 | 32 |
| 2017 September | 29 | 18 | 47 |
| 2017 August | 38 | 20 | 58 |
| 2017 July | 26 | 8 | 34 |
| 2017 June | 29 | 11 | 40 |
| 2017 May | 37 | 16 | 53 |
| 2017 April | 30 | 2 | 32 |
| 2017 March | 28 | 6 | 34 |
| 2017 February | 17 | 5 | 22 |
| 2017 January | 12 | 7 | 19 |
| 2016 December | 15 | 6 | 21 |
| 2016 November | 12 | 7 | 19 |
| 2016 October | 7 | 2 | 9 |
| 2016 September | 7 | 2 | 9 |
| 2016 August | 15 | 9 | 24 |
| 2016 July | 14 | 13 | 27 |
| 2016 June | 0 | 11 | 11 |
| 2016 May | 1 | 6 | 7 |
| 2016 April | 16 | 1 | 17 |
| 2016 March | 31 | 26 | 57 |
| 2016 February | 35 | 20 | 55 |
| 2016 January | 30 | 21 | 51 |
| 2015 December | 73 | 49 | 122 |
| 2015 November | 85 | 62 | 147 |
| 2015 October | 114 | 73 | 187 |
| 2015 September | 151 | 130 | 281 |
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