Variability of COPD Symptoms During the Day and Impact on Patients' Morning Routine – Survey Results

Study Methodology and Population

The study included a total of 803 patients (56% men) diagnosed with COPD. Of these, 298 had severe COPD, which is defined by meeting all of the following criteria:

• Regular pharmacotherapy
• ≥ 3rd degree of breathlessness on the MRC scale (Medical Research Council)
• ≥ 1 exacerbation in the last 12 months

The inclusion criteria were as follows:

• Age ≥ 40 years
• Diagnosis of COPD, chronic bronchitis, emphysema or disease with chronic airway obstruction
• Current smoker/former smoker
• No diagnosis of bronchial asthma before the age of 40

Patients from Europe or the USA participated in an online interview with a physician between May and June 2008 and subsequently completed a questionnaire regarding the nature and severity of COPD symptoms and their impact on daily life.

Results

Among the patients, 49% were current smokers. The most commonly used medications were inhaled corticosteroids (ICS), long-acting (β₂-agonists (LABA), short-acting (β₂-agonists (SABA), anticholinergics, or ICS/LABA combinations.

Patients most frequently reported worsening COPD symptoms (in 37% of cases) in the morning after waking up. In the group of patients with severe COPD, up to 46% mentioned worsening symptoms at this time of day. The next most common time of worsening was at night.

Morning symptoms most commonly included expectoration, persistent or recurrent cough, breathlessness, and fatigue. Among patients with severe COPD, breathlessness, expectoration, and cough were reported by 78%, 63%, and 60% of patients, respectively. Approximately 50% of these patients experienced symptoms (almost) every day immediately upon waking. Expectoration was more common among current smokers than former smokers (70% vs. 46%, p < 0.001; in severe stages 68% vs. 60%, non-significant). Similarly, cough was more common among current smokers (62% vs. 36%, p < 0.001; in severe stages 77% vs. 52%, p < 0.001).

Patients experiencing fatigue reported more frequent symptom worsening at night (29% vs. 17% of patients not experiencing fatigue, p = 0.003; in patients with severe COPD 36% vs. 24%, non-significant). A similar trend was observed in patients with chronic back pain (59% vs. 42%, p < 0.001; in patients with severe COPD 54% vs. 44%, non-significant).

37% of COPD patients and 73% in severe stages indicated that symptoms (especially breathlessness) interfered with their morning routine. 74% and 96% of patients reported that their morning routine took longer than before, with 48% and 84% having to adapt, most commonly by slowing down and taking breaks. 21% and 40% even needed assistance during their morning routine, most commonly with making the bed (52%) and washing dishes (46%).

From morning activities, patients most frequently had difficulties with walking up and down stairs, putting on shoes, dressing, and showering or bathing.

Only 35% of patients reported taking their first dose of medication in the morning immediately upon waking, while 49% took it later in the day.

22–44% of patients were not asked by their treating physician about morning COPD symptoms, and in 9–22% they were not asked about problems performing their morning routine.

Conclusion and Discussion

For the majority of COPD patients (especially in severe stages), symptoms (especially breathlessness) are worst in the morning, often disrupting their morning routine.

According to the study results, most patients take their medications later in the day, not in the morning when symptoms are most pronounced. It is therefore advisable to consider the use of fast-acting medications immediately upon waking. It is crucial to ask specifically about morning difficulties.

Nighttime worsening of symptoms in patients with chronic back pain may be due to insomnia, making them more aware of the symptoms.

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Source: Partridge M. R., Karlsson N., Small I. R. Patient insight into the impact of chronic obstructive pulmonary disease in the morning: an internet survey. Curr Med Res Opin 2009; 25 (9): 2043–2048, doi: 10.1185/03007990903103006.