1. Symptoms The burden of COPD

2. 2 The central role of airflow limitation leading to symptoms in COPD Disability Disease progressionDeath Air trapping Expiratory flow limitation Hyperinflation DeconditioningInactivity Reduced exercise capacity Exacerbations COPD Shortness of breath Quality of life Exercise COPD = chronic obstructive pulmonary disease Adapted from Cooper CB. Respir Med 2009;103:325–34.

3. 3 COPD pathophysiology Hyperinflation  Expiratory airflow limitation and airway obstruction trap air progressively during expiration, leading to hyperinflation 1  Hyperinflation is thought to develop early in the disease, and is the main mechanism for exertional shortness of breath 1  Hyperinflation reduces IC, such that functional residual capacity increases, particularly during exercise (dynamic hyperinflation) 1 Results in worsening of shortness of breath and limitation of exercise capacity 1 Exercise intolerance is one of the main factors limiting participation in activities of daily living 2  Hyperinflation manifests as: an increase in TLC 3 an increase in RV (i.e. ‘gas trapping’) 3 an increase in RV/TLC 3 COPD = chronic obstructive pulmonary disease; IC = inspiratory capacity; RV, residual volume; TLC = total lung capacity. 1.GOLD 2014. Available from: http://www.goldcopd.org/ 2.Nici L et al. Am J Respir Crit Care Med 2006;173:1390–413 3.O’Donnell DE and Laveneziana P. Eur Respir Rev 2006;15:61–7

4. 4 Physiological consequences of dynamic hyperinflation  Increased lung elastance / dynamic elastance 1  Reduced inspiratory muscle force 1  Reduced ventilatory expansion 1  Negative cardiovascular effects 2 Impaired left ventricular filling, reduced stroke volume, lower cardiac output 2 1.Loring SH J Appl Physiol 2009;107:309–14. 2.Barr RG N Engl J Med 2010;362:217–27

5. 5 COPD pathophysiology Sputum production and chronic cough symptoms  Chronic airway irritation from noxious particles leads to: increased number of goblet cells 1 enlarged submucosal glands 1  This results in mucus hypersecretion and a chronic, productive cough 1 Feature of chronic bronchitis 1 Not necessarily associated with airflow limitation 1 These symptoms have been suggested as a risk factor for exacerbations of COPD 2  Cough often considered ‘normal’ by patients (‘smokers’ cough’) 1  Chronic cough is often under-recognised, despite its impact and significant burden 2,3 COPD = chronic obstructive pulmonary disease 1.GOLD 2014. Available from: http://www.goldcopd.org/. 2.Blanchette CM et al. Int J Chron Obstruct Pulmon Dis 2011;6:73–81. 3.Miravitlles M. Respir Med 2011; 05:1118–28.

6. 6 Multiple symptoms of COPD have a real impact on patient well-being IMPACT ON WELL-BEING 1–5 Activity/exercise limitation Anxiety and depression Apprehension about future events Lack of confidence about steps to take action Risk of increasing social isolation Loss of independence SYMPTOMS 1–4 Shortness of breath Cough Wheezing Chest tightness Sputum production Worse in morning Fatigue COPD = chronic obstructive pulmonary disease 1.GOLD 2014 (http://www.goldcopd.org/)http://www.goldcopd.org/ 2.O’Donnell DE. Eur Respir Rev 2006;15:37–41 3.Rennard. Eur Respir J 2002; 20:799–805 4.Barnett M. J Clin Nurs 2005;14:805–12 5.Cleland JA. Fam Pract 2007; 24:217–23

7. 7 Shortness of breath is the most bothersome symptom  Shortness of breath is gradual in onset, so patients often relate it to the ageing process or lack of fitness As lung function deteriorates, shortness of breath becomes more intrusive 1,2  Patients report that shortness of breath is the most bothersome symptom and is the reason most seek medical attention 1,2  Patients restrict activities to avoid shortness of breath 1,2 Patients with COPD spend only a third of the day walking or standing 3 Healthy age-matched healthy individuals spend over half of their time in these activities 3  This leads to gradual deterioration of HRQoL, 4 increased dependency and social isolation 1 COPD = chronic obstructive pulmonary disease; HRQoL = health-related quality of life 1.Barnett M. J Clin Nurs 2005;14:805–12. 2.GOLD 2014 (http://www.goldcopd.org/)http://www.goldcopd.org/ 3.Cooper CB. Respir Med 2009;103:325–34. 4.O'Donnell DE. Eur Respir Rev 2006;15:37–41

8. 8 Morning is when COPD symptoms are most severe All patients with COPD (N=803) Patients with severe COPD (n=289) MorningMiddayAfternoonEveningNightNo particular time of day Difficult to say 50 40 30 20 10 0 Patients (%) 37* 46 † 4 11 9 16 21 27 25 34 28 17 9 7 Time when COPD symptoms are worse than usual 1 60 100 Morning was defined as from the time respondents woke up until they were dressed, had breakfast and were ready to start the day; midday as the time around lunch; afternoon as the time before they had dinner; evening as from the time they had dinner until they went to bed; and night as from the time they went to bed until they woke up in the morning. Multiple answers were possible. *p<0.001 vs ‘midday’, ‘afternoon’, ‘evening’, ‘night’ and ‘difficult to say’ groups; p=0.006 vs ‘no particular time of day’ (all patients with COPD); † p<0.001 vs ‘midday’, ‘afternoon’, ‘evening’, ‘no particular time of day’ and ‘difficult to say’ groups; p=0.001 vs ‘night’. Data are weighted for age and severity. 2 COPD, chronic obstructive pulmonary disease. COPD = chronic obstructive pulmonary disease 1.Partridge MR et al. Curr Med Res Opin 2009;25:2043–8. 2.Partridge MR et al. Curr Med Res Opin 2012;28:1405 [Erratum]

9. 9 COPD symptoms are most troublesome for patients in the morning  Although COPD symptoms were present throughout the day, all symptoms were most problematic upon waking in the morning Pan-European study of 2441 COPD outpatients. Patients who had reported experiencing symptoms in the previous 7 days were asked during what times of the day the symptoms were most troublesome. Breathlessness (n=1769) 60 40 20 0 31.0 24.0 22.5 19.5 10.6 Cough (n=1433) 48.9 22.3 14.9 18.7 17.3 Chest tightness (n=690) 28.8 25.9 25.4 25.5 16.7 Phlegm (n=1551) 56.7 26.2 16.3 16.6 11.8 Wheezing (n=1018) 31.1 21.7 18.3 26.1 25.1 Patients (%) On waking Later in the morning In the afternoon In the evening At night 100 60 40 20 0 100 60 40 20 0 100 60 40 20 0 100 60 40 20 0 100 On waking Later in the morning In the afternoon In the evening At night On waking Later in the morning In the afternoon In the evening At night On waking Later in the morning In the afternoon In the evening At night On waking Later in the morning In the afternoon In the evening At night COPD = chronic obstructive pulmonary disease Adapted from Kessler R et al. Eur Respir J 2011;37:264–72

10. 10 Breathlessness affects simple morning routine activities  Breathlessness was most strongly correlated with extent of problems experienced with morning routine Impact on morning activities (scale 1–10)* 10 8 6 4 2 0 Walking up/Putting onMakingShowering/Drying body down stairssocks/shoesthe bedhaving a bath with a towel 9 7 5 3 1 All patients with COPD (N=803) Patients with severe COPD (n=289) *Rated on a scale from 1 to 10, where 1=it is not affected at all and 10=it is greatly affected. Data are weighted for age and COPD severity. COPD = chronic obstructive pulmonary disease Partridge MR et al. Curr Med Res Opin 2009;25:2043–8

11. 11 Patients report COPD symptoms in the morning may increase time needed for normal activities  Routine activities took 10–15 minutes longer, and more strenuous activities ~30 minutes longer, since symptoms became worse in the morning  Symptoms caused half of all patients to make changes to their previous morning routine  Physicians are unlikely to discuss with patients how their ability to perform tasks might be improved I wake up earlier in order to get going with my day I avoid stairs in the morning I wash at a different time of day Someone else makes breakfast for me I skip breakfast I sleep in a different room avoiding stairs to minimize physical activity in the morning Someone else now takes my children to school for me Online survey of 811 patients conducted in eight countries. Patients had physician-confirmed COPD diagnosis, were aged 30–70 years, and experienced at least one of the following COPD symptoms to a greater extent in the morning (compared with the rest of the day): shortness of breath, increased coughing/coughing up phlegm, increased tightness in the chest, and/or increased wheezing. COPD = chronic obstructive pulmonary disease O’Hagan P, Chavannes NH. Curr Med Res Opin 2013;30:301–14

12. 12 Morning symptoms have a significant impact on clinical and patient-reported outcomes  Morning symptoms were associated with: -Significantly higher CAT scores -Higher exacerbation frequency -More frequent worsening of symptoms -Increased impact on normal daily activities Univariate analysis (1,489 patients) Without morning symptoms (897) With morning symptoms (592)p-value CAT score (mean)20.2124.22<0.001 a Exacerbations in last 12 months (mean)0.891.74<0.001 b Patient-reported worsening of symptoms (mean) 2.724.52<0.001 b Impact on normal daily activities (mean) c 3.293.96<0.001 b EQ-5D score (mean)0.750.69<0.001 b Data from 1489 patients in a European and USA sample in the Adelphi Respiratory Disease Specific Program (DSP). a Unpaired t-test; b Mann–Whitney; c measured on a 7-point Likert scale of no impact to constant impact. CAT, COPD assessment test; COPD, chronic obstructive pulmonary disease. COPD = chronic obstructive pulmonary disease; EQ-5D = EuroQolDSP Roche N, et al. COPD. 2013;10:679–86

13. 13 Patients ‘accommodate’ symptoms of COPD  67% of patients with COPD report that their condition has ‘a lot’ or ‘quite a lot’ of negative impact on their QoL 1 *  Patients choose to do less 2 …as a result they are able to do less 2  Patients often accept and learn to accommodate their symptoms 2  Important, therefore, to encourage exercise and explain its value and potential benefits *Quantitative internet interviews with patients with COPD (N=719) from Europe. COPD = chronic obstructive pulmonary disease; QoL = quality of life. 1.Partridge MR et al. Prim Care Respir J 2011;20:315–23. 2.Davies N. Nurs Times 2012;108(34–35):17,19–20.

14. 14 Improvement in morning activities is a major treatment expectation of most patients  Major treatment expectations of patients are greater symptomatic relief and mobility, faster symptomatic relief, and improvement in morning activities 1 *  Approximately 10% of patients require assistance with normal morning activities Of these patients, 67.5% felt worried they were a burden to other people as a result 2† *n=514; a multicentre study conducted in Turkey; † Pan-European study of 2441 COPD outpatients COPD = chronic obstructive pulmonary disease; EQ-5D = EuroQolDSP 1.Kuyucu T et al. Tuberk Toraks Dergisi 2011;59:328–39 2.Kessler R et al. Eur Respir J 2011;37:264–72

15. 15 Conclusions  Airflow limitation plays a central role in symptoms of COPD, leading to: 1,2 Hyperinflation and shortness of breath Inactivity Reduced exercise capacity Deconditioning  COPD may present with various symptoms including, shortness of breath, cough, wheezing, chest tightness and sputum production 2,3,4  Shortness of breath is the most bothersome symptom and the most frequent reason for seeking medical attention 2,3 Breathlessness restricts daily activities and impairs HRQoL 1,2,4  Symptoms of COPD are usually worst in the morning 5 Morning symptoms increase the time taken for normal activities, affect routines during the rest of the day and impair clinical and patient-reported outcomes 6,7  Patients expect treatment to provide rapid symptomatic relief and improvement in morning activities 8 COPD = chronic obstructive pulmonary disease; HRQoL = health-related quality of life 1. Cooper CB. Respir Med 2009;103:325–34; 2. GOLD 2014 (http://www.goldcopd.org/); 3. Barnett M. J Clin Nurs 2005;14:805–12;http://www.goldcopd.org/ 4. O’Donnell DE. Eur Respir Rev 2006;15:37–41; 5. Partridge M et al. Int J Clin Pract 2009;25:2043–8; 6. O’Hagan P, Chavannes NH. Curr Med Res Opin 2013;30:301–14; 7. Roche N, et al. COPD. 2013;10:679–86; 8. Kuyucu T et al. Tuberk Toraks Dergisi 2011;59:328–39