Abstract
COPD symptoms show a diurnal variability. However, morning and night variability has generally not been taken into consideration in disease management plans. The aims of this study were to cross-sectionally assess morning and night symptom prevalence and correlation with health status and disease severity in COPD, and to determine to what extent they could predict longitudinal outcomes, exacerbations and health status. A further aim is to explore whether the CCQ is able to depict this morning/night symptomatology. We included 2,269 primary care COPD patients (58% male, 49% current smokers, with a mean age of 65±11 years) from a Dutch Asthma/COPD service. Spirometry, patient history, the Clinical COPD Questionnaire(CCQ) and the Asthma Control Questionnaire(ACQ) were assessed; we used the latter to evaluate morning (question 2) and night symptoms (question 1). A total of 1159 (51.9%) patients reported morning symptoms (ACQ question 2>0) and 879 (39.4%) had night complaints (ACQ question 1>0). Patients with morning/night symptoms were mostly smokers and had on average poorer lung function, higher CCQ scores and used more rescue inhalers (P<0.0001). Patients using long-acting muscarinic antagonists (LAMAs) had less night symptoms, showing a possible favourable effect. Only a small proportion of stable or slightly unstable patients (CCQ total scores <2) had severe morning symptoms (ACQ 2⩾4: n=19, 1.1%) or severe night symptoms (ACQ 1⩾4: n=11, 0.7%). Night symptoms seemed to predict future exacerbations; however, baseline exacerbations were the strongest predictors (n=346, OR:4.13, CI: 2.45−6.95, P<0.000). Morning symptoms increased the odds of poor health status at follow-up (n=346, OR:12.22, CI:4.76−31.39, P<0.000). Morning and night symptoms in COPD patients are common, and they are associated with poor health status and predicted future exacerbations. Our study showed that patients with morning/night symptoms have higher scores in CCQ, and therefore we do not really miss patients with high morning/night symptomatology when we only measure CCQ. Severe morning symptoms predicted worsening of COPD health status.
Highlights
Chronic obstructive pulmonary disease is a progressive disease characterised by persistent airflow limitation associated with substantial morbidity and mortality.[1]
Our study showed that morning and night symptoms were common in real-life primary care chronic obstructive pulmonary disease (COPD) patients
Morning and night symptoms are common in COPD patients
Summary
Chronic obstructive pulmonary disease is a progressive disease characterised by persistent airflow limitation associated with substantial morbidity and mortality.[1]. Recognising the importance of the severity of symptoms, patients are categorised in the A,C (few symptoms) or B,D (more symptoms) categories.[1] a measure of risk is included in the algorithm Both low lung function (forced expiratory volume in 1 s (FEV1) below 50% of predicted) or previous exacerbations (more than 2 in the last year or a hospital admission) result in classification in high risk (C,D).[1] The classification in A–D will lead to management suggestions in the GOLD guideline. The decision tree for management is based on this classification With this categorisation, GOLD recommendations attempt a more personalised approach to disease management.[1] Symptom assessment is included in the three questionnaires used by GOLD (CAT, mMRC and CCQ) and in most patient-reported outcome questionnaires. GOLD guidelines do not mention morning and night-time symptoms as targets for therapeutic interventions, and they do not offer a specific guidance on appropriate management strategies or pharmacological interventions for patients with COPD who report diurnal variability in their symptoms.[1,6] it appears that patients do not report symptom variability and do not modify treatment when symptoms worsen,[6,7] and physicians are unlikely to discuss diurnal variability with patients.[6,8]
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