[90] Velasco-Torres Y, Ruiz V, Montaño M, Pérez-Padilla R, Falfán-Valencia R, Pérez-

[91] Vogelmeier CF, Criner GJ, Martinez FJ, Anzueto A, Barnes PJ, Bourbeau J, Celli BR, Chen R, Decramer M, Fabbri LM, Frith P, Halpin DM, Lopez Varela MV, Nishimura M, Roche N, Rodriguez-Roisin R, Sin DD, Singh D, Stockley R, Vestbo J, Wedzicha JA, Agusti A. Global Strategy for the

2017; 195: 557-582.

48: PA654.

2019; 9.

Ramos J, Pérez-Bautista O, Ramos C. Participation of the miR-22-HDAC4- DLCO Axis in Patients with COPD by Tobacco and Biomass. *Biomolecules*

Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2017 Report. GOLD Executive Summary. *American Journal of Respiratory and Critical Care Medicine*

[92] Deb A, Agarwal M, Reddy V, Kodgule R, Hemalatha V, Awasthi A, al. e. Effects of a fixed dose once-daily triple drug combination in smokers and non-smokers with COPD. . *The European Respiratory Journal* 2016;

[93] Chen J, Li C, Ristovski Z, Milic A, Gu Y, Islam MS, Wang S, Hao J,

[94] Naeher LP, Brauer M, Lipsett M, Zelikoff JT, Simpson CD, Koenig JQ, Smith KR. Woodsmoke health effects: a review. *Inhalation Toxicology* 2007;

[95] Zelikoff JT, Chen LC, Cohen MD, Schlesinger RB. The toxicology of inhaled woodsmoke. *Journal of Toxicology and Environmental Health Part B, Critical Reviews* 2002; 5: 269-282.

Zhang H, He C, Guo H, Fu H, Miljevic B, Morawska L, Thai P, Lam YF, Pereira G, Ding A, Huang X, Dumka UC. A review of biomass burning: Emissions and impacts on air quality, health and climate in China. *Science of The Total Environment* 2017; 579: 1000-1034.

**24**

19: 67-106.

## Work - Related Chronic Obstructive Pulmonary Disease

*Biruk Getahun and Abebe Ayalew Bekel*

#### **Abstract**

Chronic obstructive pulmonary disease (COPD) is a progressive lung disease characterized by airflow obstruction and increasing breathlessness. COPD is increasing worldwide, both in developed and developing countries. The most important risk factor of developing COPD is cigarette smoking; however, occupational exposures such as vapors, gases, dusts and fumes present an important risk factor for the development of the disease, by itself and through interaction with other risk factors. The dusts from coal, stone quarries, wood, cereals and agricultural work, animal stables, textiles, and paper production that can arise in occupational environments have been regulated by the International Labor Organization and considered possible as contributors to COPD. A better understanding of these causes paves the way for effective interventions to reduce the future incidence of this unpleasant condition. Breathlessness and occupational exposures to vapors, gases, dusts and fumes were identified as the main modifiable factors associated with unemployment and poor work productivity in COPD patients.

**Keywords:** occupational exposures, work place, air pollutions, airflow obstruction

#### **1. Introduction**

Chronic obstructive pulmonary disease (COPD) accounts worldwide for considerable and increasing morbidity and mortality [1].

COPD is a long-term respiratory disease which is not completely reversible and is characterized by airflow obstruction. For several months, the airflow obstruction does not alter markedly and is typically progressive. COPD is mainly caused by smoking [2]. Other factors, such as harmful dust and chemicals, can also contribute to the development of COPD, especially occupational exposure [3]. People with COPD often have exacerbations when symptoms are quickly and sustainably exacerbated beyond their normal regular variation. The prevalence of COPD has major regional differences and is closely correlated with levels of deprivation. The prevalence of COPD has not decreased in recent years, unlike many other prevalent chronic illnesses [2].

Early diagnosis and treatment will help to delay the deterioration in lung function and improve the amount of time people with COPD have to enjoy an active life. COPD is treatable but not curable. In spite of having only minimal or no effect on airflow obstruction, pharmacological and other therapies can help manage symptoms and disabilities caused by COPD and improve the quality of life of the individual [1].

### **2. Definition and description of COPD**

COPD is a progressive lung disease, characterized by airflow limitation [4]. Chronic respiratory disease is generally divided into obstructive and restrictive conditions (**Figure 1**). The Global Initiative on Obstructive Lung Disease (GOLD) has recommended that obstruction should be defined as the ratio of the forced expiratory volume in 1 s (FEV1) to forced vital capacity (FVC) of <70% (**Table 1**).

#### **Table 1.**

*Global initiative for chronic obstructive lung disease (GOLD) classification disease severity staging [4].*

**27**

*Work - Related Chronic Obstructive Pulmonary Disease DOI: http://dx.doi.org/10.5772/intechopen.96131*

restriction appear to be present [7, 8].

**3. Occupational exposure and COPD**

regulations may not be as advanced [13].

If any of the FVC, FEV1, PEF or FEV1/FVC are outside the normal range, the presence of ventilator abnormality can be inferred. A reduction of FEV1 would result in a low FEV1/FVC in comparison to the forced vital capacity and is characteristic of obstructive ventilator defects. The lower limit of normal for FEV1/FVC is around 70–75% but the exact limit is dependent on age. In restrictive ventilator defect the FEV1/FVC ratio remains normal or high (typically >70%) with a reduction in both FEV1 and FVC. A reduced FVC together with a low FEV1/FVC ratio is a feature of a mixed ventilator defect in which a combination of both obstruction and

Associations between chronic respiratory symptoms and workplace exposures have been suggested as early as the 15th century, although documentation of the connection between 'dusty trades' and chronic bronchitis has been more prominent from the 19th century. The inconsistent definitions of COPD and unreliable measure of exposures have led to a delay in the recognition of the causal link between occupational exposures and COPD. However, over recent years strong associations have been found between particular occupational groups and exposures to vapors,

gases, dusts and fumes (VGDF) and the development of COPD [4, 9].

Strong evidence implicates occupational exposures as one of the causes of COPD [4, 10, 11]. A significant part of the literature accumulated over the past two decades demonstrated the relationship between vapor, gases, dust, and fumes (VGDF) and the development of COPD. Based on a review by the American

Thoracic Society (ATS) [12], and a subsequent updated review it has been estimated that approximately 15% of COPD may be attributable to workplace exposures [4]. Workers are exposed to respiratory toxicants in various occupations such as mining, manufacturing, and even office buildings, which can cause disease along the respiratory tract at any point [13, 14]. Up to 15 percent of asthma and 10 percent of lung cancer can be due to occupational exposure. Workers are exposed to a distinct and more complex spectrum of respiratory exposures in developing countries than workers in developed countries, as laws may not be as functional and environmental

At any point along the respiratory tract, which spans the nasal cavity into the small air sacs (alveoli) in the lung tissue, disease may occur. Disease may involve the airways inside the lung itself, contributing to common diseases such as asthma and chronic obstructive pulmonary disease (COPD). There is a wide variety of exposures to airway disease, including animal and plant materials, various synthetic chemicals, metal and wood products, and irritants such as welding fumes and acid gases [13, 14]. Inflammation and scarring of lung parenchyma, the internal lung tissue, may also be caused by lung disease [13, 15]. Popular causes of such diseases include exposure to asbestos in the textile and shipping industries and exposure to

Industrialization has exposed workers to high levels of respiratory toxicants in developing countries, many of which have been successfully controlled in industrialized countries [13, 17, 18]. For example, a program to eradicate silicosis worldwide has been launched by the World Health Organization (WHO). Agricultural work-

A number of narrative and systematic reviews, indicate that a substantial proportion of cases of COPD are indeed attributable to exposures in the workplace. Occupationally-related causes of COPD have been identified from a wide-range of industry based studies including those in: coal mining; work with crystalline silica

silica in the sandblasting and concrete breaking industries [13, 16].

ers' respiratory health has also earned growing attention.

*Chronic Obstructive Pulmonary Disease - A Current Conspectus*

**Disease severity GOLD staging Spirometry criteria** Mild GOLD 1 FEV1/FVC < 0.70

Moderate GOLD 2 FEV1/FVC < 0.70

Severe GOLD 3 FEV1/FVC < 0.70

Very severe GOLD 4 FEV1/FVC < 0.70

*Global initiative for chronic obstructive lung disease (GOLD) classification disease severity staging [4].*

*Volume-time and flow-volume curves: A & B are volume – Time curves; C: Flow volume curve [5, 6].*

FEV1 > 80% predicted

FEV1 < 30% predicted

50% < FEV1 < 80% predicted

30% < FEV1 < 50% predicted

COPD is a progressive lung disease, characterized by airflow limitation [4]. Chronic respiratory disease is generally divided into obstructive and restrictive conditions (**Figure 1**). The Global Initiative on Obstructive Lung Disease (GOLD) has recommended that obstruction should be defined as the ratio of the forced expiratory volume in 1 s (FEV1) to forced vital capacity (FVC) of <70% (**Table 1**).

**2. Definition and description of COPD**

**26**

**Table 1.**

**Figure 1.**

If any of the FVC, FEV1, PEF or FEV1/FVC are outside the normal range, the presence of ventilator abnormality can be inferred. A reduction of FEV1 would result in a low FEV1/FVC in comparison to the forced vital capacity and is characteristic of obstructive ventilator defects. The lower limit of normal for FEV1/FVC is around 70–75% but the exact limit is dependent on age. In restrictive ventilator defect the FEV1/FVC ratio remains normal or high (typically >70%) with a reduction in both FEV1 and FVC. A reduced FVC together with a low FEV1/FVC ratio is a feature of a mixed ventilator defect in which a combination of both obstruction and restriction appear to be present [7, 8].

### **3. Occupational exposure and COPD**

Associations between chronic respiratory symptoms and workplace exposures have been suggested as early as the 15th century, although documentation of the connection between 'dusty trades' and chronic bronchitis has been more prominent from the 19th century. The inconsistent definitions of COPD and unreliable measure of exposures have led to a delay in the recognition of the causal link between occupational exposures and COPD. However, over recent years strong associations have been found between particular occupational groups and exposures to vapors, gases, dusts and fumes (VGDF) and the development of COPD [4, 9].

Strong evidence implicates occupational exposures as one of the causes of COPD [4, 10, 11]. A significant part of the literature accumulated over the past two decades demonstrated the relationship between vapor, gases, dust, and fumes (VGDF) and the development of COPD. Based on a review by the American Thoracic Society (ATS) [12], and a subsequent updated review it has been estimated that approximately 15% of COPD may be attributable to workplace exposures [4]. Workers are exposed to respiratory toxicants in various occupations such as mining, manufacturing, and even office buildings, which can cause disease along the respiratory tract at any point [13, 14]. Up to 15 percent of asthma and 10 percent of lung cancer can be due to occupational exposure. Workers are exposed to a distinct and more complex spectrum of respiratory exposures in developing countries than workers in developed countries, as laws may not be as functional and environmental regulations may not be as advanced [13].

At any point along the respiratory tract, which spans the nasal cavity into the small air sacs (alveoli) in the lung tissue, disease may occur. Disease may involve the airways inside the lung itself, contributing to common diseases such as asthma and chronic obstructive pulmonary disease (COPD). There is a wide variety of exposures to airway disease, including animal and plant materials, various synthetic chemicals, metal and wood products, and irritants such as welding fumes and acid gases [13, 14]. Inflammation and scarring of lung parenchyma, the internal lung tissue, may also be caused by lung disease [13, 15]. Popular causes of such diseases include exposure to asbestos in the textile and shipping industries and exposure to silica in the sandblasting and concrete breaking industries [13, 16].

Industrialization has exposed workers to high levels of respiratory toxicants in developing countries, many of which have been successfully controlled in industrialized countries [13, 17, 18]. For example, a program to eradicate silicosis worldwide has been launched by the World Health Organization (WHO). Agricultural workers' respiratory health has also earned growing attention.

A number of narrative and systematic reviews, indicate that a substantial proportion of cases of COPD are indeed attributable to exposures in the workplace. Occupationally-related causes of COPD have been identified from a wide-range of industry based studies including those in: coal mining; work with crystalline silica

in the construction industry, tunneling, brick manufacture, pottery and ceramic work, the silica sand industry and iron and steel foundry work; welding; cotton manufacture; and agriculture [16, 19]. Other occupations of concern are work in smelters, iron and steel processing, rubber and tyre manufacturing and exposure to wood dust, ceramic fibers and a range of chemicals such as cadmium, isocyanates, vanadium, polycyclic aromatic hydrocarbons, particularly in asphalt fumes, and those in spray painting, and in coke oven work [20, 21].

#### **3.1 Occupational dust exposure and COPD**

Productive dust refers to solid micro-particles produced by the activities of human production that can float for a long period of time in the production atmosphere. Industrial and agricultural development sectors, such as mining, machinery manufacturing, smelting, building materials, textiles, road construction, hydropower, and food industries, generate productive dust. It can be categorized as inorganic dust, organic dust, and mixed dust according to the composition of the dust. Mineral dust, metal dust, and artificial inorganic dust are inorganic dust; biological dust, plant dust, and animal dust are organic dust [22]. It is a significant hazardous occupational hazard that pollutes the workplace environment and affects workers' health, contributing to the creation of different occupational lung diseases. Studies stated that occupational dust exposure may be causally associated with the pathogenesis of COPD [23]. Different literature on coal miners' airflow obstruction concluded that there was an obvious link between exposure to coal dust and the creation of chronic obstruction of airflow. In-depth research on the role of occupational dust exposure in the occurrence and development of COPD is therefore of great importance in reducing its incidence and alleviating the burden of its disease [21, 24]. Based on prior observations and using new data from published literature, the association between occupational dust exposure and COPD risk was further evaluated [24].

#### **3.2 Street sweepers and dust**

In the maintaining of health and hygiene in cities, street sweepers play an important role. This work exposes street sweepers to a number of risk factors that make them vulnerable to some occupational diseases, such as dust, bioaerosols, volatile organic matter and mechanical stress (**Figure 2**). The major morbid conditions observed in these workers include respiratory and eye diseases, accidents, burns, cuts and wounds, skin infections, animal bites, etc. [25, 26].

Dusts are solid particles that, depending on their origin, physical characteristics and environmental conditions, may be or become airborne, varying in size from below 1 μm to at least 100 μm [27].

Examples of the dust types contained in the working environment include:

**29**

**Figure 2.**

increasingly involved in the modern period.

*Street sweeper at work, not using any protective devices [25].*

**respiratory regions**

*Work - Related Chronic Obstructive Pulmonary Disease DOI: http://dx.doi.org/10.5772/intechopen.96131*

In the gaseous phase (gases and vapors) or as aerosols, airborne pollutants exist. In the form of airborne particles, sprays, mist, smoke and fumes, aerosols can exist. Both these types may be relevant in the occupational setting since they contribute to a wide range of occupational diseases. Airborne dust is of particular concern since it is well known that it is associated with typical widespread occupational pulmonary diseases such as pneumoconiosis, as well as systemic intoxications such as lead poisoning, especially at higher exposure levels. Other dust-related illnesses, such as cancer, asthma, allergic alveolitis and irritation, as well as a wide variety of non-respiratory diseases, which can occur at much lower levels of exposure, are also

**3.3 Penetration and deposition mechanism of dust particles in human**

Dust particles small enough to stay airborne may be inhaled through the nasal route (nose) or the oral route. Dust passes through the different regions of nasopharyngeal or extra-thoracic region, trachea-bronchial region and alveolar region. The probability of inhalation depends on particle aerodynamic diameter,

• Biohazards, such as viable particles, spores and molds

*Work - Related Chronic Obstructive Pulmonary Disease DOI: http://dx.doi.org/10.5772/intechopen.96131*

*Chronic Obstructive Pulmonary Disease - A Current Conspectus*

those in spray painting, and in coke oven work [20, 21].

**3.1 Occupational dust exposure and COPD**

further evaluated [24].

**3.2 Street sweepers and dust**

below 1 μm to at least 100 μm [27].

in the construction industry, tunneling, brick manufacture, pottery and ceramic work, the silica sand industry and iron and steel foundry work; welding; cotton manufacture; and agriculture [16, 19]. Other occupations of concern are work in smelters, iron and steel processing, rubber and tyre manufacturing and exposure to wood dust, ceramic fibers and a range of chemicals such as cadmium, isocyanates, vanadium, polycyclic aromatic hydrocarbons, particularly in asphalt fumes, and

Productive dust refers to solid micro-particles produced by the activities of human production that can float for a long period of time in the production atmosphere. Industrial and agricultural development sectors, such as mining, machinery manufacturing, smelting, building materials, textiles, road construction, hydropower, and food industries, generate productive dust. It can be categorized as inorganic dust, organic dust, and mixed dust according to the composition of the dust. Mineral dust, metal dust, and artificial inorganic dust are inorganic dust; biological dust, plant dust, and animal dust are organic dust [22]. It is a significant hazardous occupational hazard that pollutes the workplace environment and affects workers' health, contributing to the creation of different occupational lung diseases. Studies stated that occupational dust exposure may be causally associated with the pathogenesis of COPD [23]. Different literature on coal miners' airflow obstruction concluded that there was an obvious link between exposure to coal dust and the creation of chronic obstruction of airflow. In-depth research on the role of occupational dust exposure in the occurrence and development of COPD is therefore of great importance in reducing its incidence and alleviating the burden of its disease [21, 24]. Based on prior observations and using new data from published literature, the association between occupational dust exposure and COPD risk was

In the maintaining of health and hygiene in cities, street sweepers play an important role. This work exposes street sweepers to a number of risk factors that make them vulnerable to some occupational diseases, such as dust, bioaerosols, volatile organic matter and mechanical stress (**Figure 2**). The major morbid conditions observed in these workers include respiratory and eye diseases, accidents,

Dusts are solid particles that, depending on their origin, physical characteristics and environmental conditions, may be or become airborne, varying in size from

• Mineral dust, such as free crystalline silica (e.g. quartz), coal and cement dust;

Examples of the dust types contained in the working environment include:

• Metallic particles, such as dust of lead, cadmium, nickel, and beryllium;

• Dusts of organic and vegetables, such as flour, wood, cotton and tea dusts,

• Other chemical dusts, e.g., many bulk chemicals and pesticides:

• Biohazards, such as viable particles, spores and molds

burns, cuts and wounds, skin infections, animal bites, etc. [25, 26].

**28**

pollen;

**Figure 2.** *Street sweeper at work, not using any protective devices [25].*

In the gaseous phase (gases and vapors) or as aerosols, airborne pollutants exist. In the form of airborne particles, sprays, mist, smoke and fumes, aerosols can exist. Both these types may be relevant in the occupational setting since they contribute to a wide range of occupational diseases. Airborne dust is of particular concern since it is well known that it is associated with typical widespread occupational pulmonary diseases such as pneumoconiosis, as well as systemic intoxications such as lead poisoning, especially at higher exposure levels. Other dust-related illnesses, such as cancer, asthma, allergic alveolitis and irritation, as well as a wide variety of non-respiratory diseases, which can occur at much lower levels of exposure, are also increasingly involved in the modern period.

#### **3.3 Penetration and deposition mechanism of dust particles in human respiratory regions**

Dust particles small enough to stay airborne may be inhaled through the nasal route (nose) or the oral route. Dust passes through the different regions of nasopharyngeal or extra-thoracic region, trachea-bronchial region and alveolar region. The probability of inhalation depends on particle aerodynamic diameter, air movement around the body and breathing rate. The inhaled particles may then either be deposited or exhaled again, depending on a whole range of physiological and particle-related factors.

Tiny dust particles have the potential to penetrate the lungs and the body more easily posing a risk to the health of exposed individuals. Although coarse dust is collected in the airways that conduct (nasal passages and bronchi). The fine dust in the bronchioles will enter (smaller airways). Ultrafine dust is almost entirely capable of accessing the deepest regions of the lungs (the alveoli) where oxygen reaches the blood and waste gases are left to be exhaled.

#### **3.4 Effects of dust on the respiratory function**

Occupational exposures to dust, fumes, and gases are associated with increased prevalence of respiratory symptoms and impairment of lung function. Any part of the respiratory tract can be adversely affected by poor air quality from the nose to the alveoli [23, 28] mechanisms, the inherent toxicity of particles, pattern of deposition, removal from the respiratory tract and the properties of the air contaminants (WHO, 2005).

The respiratory problems caused by dust exposure include chest pain, occasional cough, occasional shortness of breath and wheezing. Dust inhalation over time contributes to proliferation and fibrotic changes in the lungs. Severity depends on many factors, including the chemical nature, physical condition of the material inhaled, size, dust particle concentration, length of exposure, and individual susceptibility to exposure. The extent of impact is influenced by the proximity to sensitive receptors, wind speed, velocity and nature of work topography. The reaction of the respiratory system to inhaled particles largely depends on where the particles settle. The most important lung reactions occur in the deepest regions of the lungs. Dust particles and dust containing macrophages collect in the lung tissues, causing injury to the lungs [28].

#### **3.5 Exposure to disinfectants with incidence of chronic obstructive pulmonary disease**

Exposure to cleaning products and disinfectants is prevalent at work and at home, and among women it is more common. In the health care sector, exposure levels are particularly high. There is a growing awareness of the respiratory health risks associated with exposure to cleaning products and disinfectants. Studying a wider variety of respiratory effects confirms the irritant properties of certain chemicals used in disinfectants. Studies have documented an increased risk of COPD among cleaning workers, an accelerated decrease in lung function and higher rates of death due to COPD.

#### *3.5.1 Cleaning agents*

A cleaning product is defined as any material used in general work environments to clean or disinfect surfaces. These items have become an essential part of everyday life, as they are used in almost all workplaces and homes on a daily basis. To facilitate dust and dirt removal, and for disinfection and surface maintenance, a wide range of cleaning agents have been developed [29]. In general, cleaning agents can be defined as natural or synthetic substances used to assist with the cleaning process.

However, cleaning is not without risks. Both volatile and non-volatile compounds contain cleaning agents. Excessive exposure to potentially harmful volatile contaminants results from the application of popular cleaning products [29].

**31**

*Work - Related Chronic Obstructive Pulmonary Disease DOI: http://dx.doi.org/10.5772/intechopen.96131*

disorders, including job-related asthma [29, 30].

entity known as reactive airway dysfunction syndrome [34].

are well-known causative agents of occupational asthma [29].

working involved work that worsening their COPD [40, 41].

asthma inducer for cleaning employees [31].

**4. COPD and its effect on work**

their personal, social and work life [36, 37].

occupational asthma [31, 32].

For staff, cleaning materials have emerged as a major respiratory threat. Most cleaning agents (e.g. chlorine and ammonia) have an irritating effect on mucous membranes and the skin and have a sensitizing ability (e.g. monoethanolamine and aldehydes). These products have also been implicated in numerous respiratory

which can irritate the skin, eyes, mouth, and lungs. A family of chemicals recognized for their disinfectant and detergent properties are ammonium quaternary compounds. They are found in cleaning products such as disinfectant sprays and toilet cleaners, and have been identified among cleaning workers as a known cause of

The most widely used disinfecting and cleaning agent is chlorine bleach or sodium hypochlorite. It is also used for various applications in everyday life, such as water and food disinfection and surface cleaning in public and private buildings [33]. Chlorine bleach, however, is unstable and is a highly reactive chemical. Chlorine bleach can emit chlorine or tri-chloramine, two gases that are significant irritants to the eyes and the respiratory tract, when mixed with other cleaning agents. Chlorine gas exposure can lead to coughing, shortness of breath, chest pain, nausea, and other symptoms [31, 33]. The acute inhalation of respiratory irritants such as hypochlorite and chlorine gas at toxic concentrations results in a clinical

Monoethanolamine (MEA) is a surfactant that is frequently found in detergents that improves its cleaning efficiency. MEA is used in cleaning items such as laundry detergents and floor cleaners and has been described as a suspected occupational

Aldehydes are commonly used to clean heat-sensitive devices, such as fiber optic endoscopes, in medical facilities. They may induce hypersensitivity reactions induced by mucous irritation, respiratory symptoms and immunoglobulin IgE, and

The burden of chronic obstructive pulmonary disease (COPD) and its effect on quality of life is well known. Of the main long-term health conditions, there is a growing interest in the impact of chronic obstructive pulmonary disease (COPD) on the ability to work [35, 36]. As COPD progresses patients are increasingly faced with a number of functional limitations, and as a result, can experience effects on

COPD is a debilitating disease affecting the daily lives of patients. Having COPD

In addition to causing work to stop, COPD contributes to increased absenteeism. People with COPD are almost half as likely to have a short-term disability and are

adversely affects patients' rates of employment and work productivity. Physical activity levels are low even in patients in the early stages of COPD [38]. Increasing severity of COPD is associated with decreasing physical activity [39]. In a more recent study of approximately 2,500 patients aged 45–67 years in Brazil, China, Germany, Turkey, the United States, and the United Kingdom, nearly 40% retired early due to COPD at an average age of 54 years, and several subsequent studies have shown that people with COPD are more likely not working because of COPD. In certain cases, failure to work can indicate the fact that occupational exposure worsens symptoms and, of course, exposure may also lead to the development of COPD (**Figure 3**). COPD employees indicated that problems causing them to stop

The glass cleaner and other hard-surface cleaner chemicals also contain ammonia,

*Chronic Obstructive Pulmonary Disease - A Current Conspectus*

reaches the blood and waste gases are left to be exhaled.

**3.4 Effects of dust on the respiratory function**

and particle-related factors.

contaminants (WHO, 2005).

tissues, causing injury to the lungs [28].

higher rates of death due to COPD.

*3.5.1 Cleaning agents*

**disease**

air movement around the body and breathing rate. The inhaled particles may then either be deposited or exhaled again, depending on a whole range of physiological

Tiny dust particles have the potential to penetrate the lungs and the body more easily posing a risk to the health of exposed individuals. Although coarse dust is collected in the airways that conduct (nasal passages and bronchi). The fine dust in the bronchioles will enter (smaller airways). Ultrafine dust is almost entirely capable of accessing the deepest regions of the lungs (the alveoli) where oxygen

Occupational exposures to dust, fumes, and gases are associated with increased prevalence of respiratory symptoms and impairment of lung function. Any part of the respiratory tract can be adversely affected by poor air quality from the nose to the alveoli [23, 28] mechanisms, the inherent toxicity of particles, pattern of deposition, removal from the respiratory tract and the properties of the air

The respiratory problems caused by dust exposure include chest pain, occasional

cough, occasional shortness of breath and wheezing. Dust inhalation over time contributes to proliferation and fibrotic changes in the lungs. Severity depends on many factors, including the chemical nature, physical condition of the material inhaled, size, dust particle concentration, length of exposure, and individual susceptibility to exposure. The extent of impact is influenced by the proximity to sensitive receptors, wind speed, velocity and nature of work topography. The reaction of the respiratory system to inhaled particles largely depends on where the particles settle. The most important lung reactions occur in the deepest regions of the lungs. Dust particles and dust containing macrophages collect in the lung

**3.5 Exposure to disinfectants with incidence of chronic obstructive pulmonary**

Exposure to cleaning products and disinfectants is prevalent at work and at home, and among women it is more common. In the health care sector, exposure levels are particularly high. There is a growing awareness of the respiratory health risks associated with exposure to cleaning products and disinfectants. Studying a wider variety of respiratory effects confirms the irritant properties of certain chemicals used in disinfectants. Studies have documented an increased risk of COPD among cleaning workers, an accelerated decrease in lung function and

A cleaning product is defined as any material used in general work environments to clean or disinfect surfaces. These items have become an essential part of everyday life, as they are used in almost all workplaces and homes on a daily basis. To facilitate dust and dirt removal, and for disinfection and surface maintenance, a wide range of cleaning agents have been developed [29]. In general, cleaning agents can be defined

as natural or synthetic substances used to assist with the cleaning process.

However, cleaning is not without risks. Both volatile and non-volatile compounds contain cleaning agents. Excessive exposure to potentially harmful volatile contaminants results from the application of popular cleaning products [29].

**30**

For staff, cleaning materials have emerged as a major respiratory threat. Most cleaning agents (e.g. chlorine and ammonia) have an irritating effect on mucous membranes and the skin and have a sensitizing ability (e.g. monoethanolamine and aldehydes). These products have also been implicated in numerous respiratory disorders, including job-related asthma [29, 30].

The glass cleaner and other hard-surface cleaner chemicals also contain ammonia, which can irritate the skin, eyes, mouth, and lungs. A family of chemicals recognized for their disinfectant and detergent properties are ammonium quaternary compounds. They are found in cleaning products such as disinfectant sprays and toilet cleaners, and have been identified among cleaning workers as a known cause of occupational asthma [31, 32].

The most widely used disinfecting and cleaning agent is chlorine bleach or sodium hypochlorite. It is also used for various applications in everyday life, such as water and food disinfection and surface cleaning in public and private buildings [33]. Chlorine bleach, however, is unstable and is a highly reactive chemical. Chlorine bleach can emit chlorine or tri-chloramine, two gases that are significant irritants to the eyes and the respiratory tract, when mixed with other cleaning agents. Chlorine gas exposure can lead to coughing, shortness of breath, chest pain, nausea, and other symptoms [31, 33]. The acute inhalation of respiratory irritants such as hypochlorite and chlorine gas at toxic concentrations results in a clinical entity known as reactive airway dysfunction syndrome [34].

Monoethanolamine (MEA) is a surfactant that is frequently found in detergents that improves its cleaning efficiency. MEA is used in cleaning items such as laundry detergents and floor cleaners and has been described as a suspected occupational asthma inducer for cleaning employees [31].

Aldehydes are commonly used to clean heat-sensitive devices, such as fiber optic endoscopes, in medical facilities. They may induce hypersensitivity reactions induced by mucous irritation, respiratory symptoms and immunoglobulin IgE, and are well-known causative agents of occupational asthma [29].

#### **4. COPD and its effect on work**

The burden of chronic obstructive pulmonary disease (COPD) and its effect on quality of life is well known. Of the main long-term health conditions, there is a growing interest in the impact of chronic obstructive pulmonary disease (COPD) on the ability to work [35, 36]. As COPD progresses patients are increasingly faced with a number of functional limitations, and as a result, can experience effects on their personal, social and work life [36, 37].

COPD is a debilitating disease affecting the daily lives of patients. Having COPD adversely affects patients' rates of employment and work productivity. Physical activity levels are low even in patients in the early stages of COPD [38]. Increasing severity of COPD is associated with decreasing physical activity [39]. In a more recent study of approximately 2,500 patients aged 45–67 years in Brazil, China, Germany, Turkey, the United States, and the United Kingdom, nearly 40% retired early due to COPD at an average age of 54 years, and several subsequent studies have shown that people with COPD are more likely not working because of COPD. In certain cases, failure to work can indicate the fact that occupational exposure worsens symptoms and, of course, exposure may also lead to the development of COPD (**Figure 3**). COPD employees indicated that problems causing them to stop working involved work that worsening their COPD [40, 41].

In addition to causing work to stop, COPD contributes to increased absenteeism. People with COPD are almost half as likely to have a short-term disability and are

	-

	-

**33**

**Author details**

**Conflict of interest**

Biruk Getahun1

\* and Abebe Ayalew Bekel<sup>2</sup>

experience effects on their personal, social and work life.

The authors declare that they have no competing interest.

Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia

Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia

\*Address all correspondence to<EMAIL_ADDRESS>
provided the original work is properly cited.

1 Department of Medical Physiology, School of Medicine, College of Medicine and

2 Department of Human Anatomy, School of Medicine, College of Medicine and

© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

*Work - Related Chronic Obstructive Pulmonary Disease DOI: http://dx.doi.org/10.5772/intechopen.96131*

disabling.

**5. Conclusion**

an issue in low and middle income countries. In addition, most patients are not paid in those countries and typically continue to function until the illness is serious and

Chronic obstructive pulmonary disease (COPD) is a slowly progressive, potentially highly disabling, respiratory condition with many potential causes. COPD is a major cause of chronic morbidity and mortality throughout the world. Many people suffer from this disease for years and die prematurely from it or its complications. The most important risk factor of developing COPD is cigarette smoking; however, occupational exposure, exposure to air pollutions, and respiratory infections can also be attributed to developing COPD. Workers in various occupations such as mining, construction, and even office buildings are exposed to respiratory toxicants, which can cause disease at any point along the respiratory tract. The dusts from coal, stone quarries, wood, cereals and agricultural work, animal stables, textiles, and paper production that can arise in occupational environments have been regulated by the International Labor Organization and considered possible as contributors to COPD. A better understanding of these causes paves the way for effective interventions to reduce the future incidence of this unpleasant condition. There is a growing interest in the impact of chronic obstructive pulmonary disease on the ability to work. As COPD progresses patients are increasingly faced with a number of functional limitations, and as a result, can

#### **Figure 3.**

*Chronic obstructive pulmonary disease (COPD) and work [40].*

more than four times more likely to have a long-term disability, but this can also be affected by comorbidity. The efficacy of patients who stay at work can also be limited by symptoms (**Figure 3**). In the United States and other nations, a number of major cross-sectional studies showed that people with COPD were substantially more likely to report presentism, and findings from studies using self-report data suggest that about 13–18 percent are restricted in what they can do [40].

Working generally has a positive effect on health and functioning [40]. There is increasing evidence that being in work is good for physical and mental health and wellbeing. Being in work provides a feeling of self-worth but also has economic advantages for both the individual and society. Evidence suggests that being out of work may be harmful for individuals [4].

Becoming unemployed, together with lower self-esteem and trust, is associated with significantly higher levels of depression and anxiety; however, it can lead to improved physical health in the short term, particularly when symptoms have been aggravated by working conditions. In countries that do not have welfare programs to help the unemployed or in which healthcare must be paid for, the impact of COPD-related loss of jobs on individuals is likely to be highest [42]. In 2010, 384 million people are projected to have COPD worldwide, with the largest burden falling in Latin America, Sub-Saharan Africa, India, China, and Southeast Asia. Compared to average earnings, the cost of medicine is very high in many of these countries, and its availability across government health services is low. These costs intensify the financial insecurity of households in low- and middle-income countries without an income and may push patients to fund treatment by household borrowing and selling functional properties [40].

Occupational chronic respiratory diseases pose a public health concern with economic consequences in all countries. In the world's poorest countries, innovations which are outdated or banned in developed countries are still largely used. Occupational diseases are usually less apparent and are not sufficiently regarded as an issue in low and middle income countries. In addition, most patients are not paid in those countries and typically continue to function until the illness is serious and disabling.

### **5. Conclusion**

*Chronic Obstructive Pulmonary Disease - A Current Conspectus*

more than four times more likely to have a long-term disability, but this can also be affected by comorbidity. The efficacy of patients who stay at work can also be limited by symptoms (**Figure 3**). In the United States and other nations, a number of major cross-sectional studies showed that people with COPD were substantially more likely to report presentism, and findings from studies using self-report data

Working generally has a positive effect on health and functioning [40]. There is increasing evidence that being in work is good for physical and mental health and wellbeing. Being in work provides a feeling of self-worth but also has economic advantages for both the individual and society. Evidence suggests that being out of

Becoming unemployed, together with lower self-esteem and trust, is associated with significantly higher levels of depression and anxiety; however, it can lead to improved physical health in the short term, particularly when symptoms have been aggravated by working conditions. In countries that do not have welfare programs to help the unemployed or in which healthcare must be paid for, the impact of COPD-related loss of jobs on individuals is likely to be highest [42]. In 2010, 384 million people are projected to have COPD worldwide, with the largest burden falling in Latin America, Sub-Saharan Africa, India, China, and Southeast Asia. Compared to average earnings, the cost of medicine is very high in many of these countries, and its availability across government health services is low. These costs intensify the financial insecurity of households in low- and middle-income countries without an income and may push patients to fund treatment by household

Occupational chronic respiratory diseases pose a public health concern with economic consequences in all countries. In the world's poorest countries, innovations which are outdated or banned in developed countries are still largely used. Occupational diseases are usually less apparent and are not sufficiently regarded as

suggest that about 13–18 percent are restricted in what they can do [40].

work may be harmful for individuals [4].

*Chronic obstructive pulmonary disease (COPD) and work [40].*

borrowing and selling functional properties [40].

**32**

**Figure 3.**

Chronic obstructive pulmonary disease (COPD) is a slowly progressive, potentially highly disabling, respiratory condition with many potential causes. COPD is a major cause of chronic morbidity and mortality throughout the world. Many people suffer from this disease for years and die prematurely from it or its complications. The most important risk factor of developing COPD is cigarette smoking; however, occupational exposure, exposure to air pollutions, and respiratory infections can also be attributed to developing COPD. Workers in various occupations such as mining, construction, and even office buildings are exposed to respiratory toxicants, which can cause disease at any point along the respiratory tract. The dusts from coal, stone quarries, wood, cereals and agricultural work, animal stables, textiles, and paper production that can arise in occupational environments have been regulated by the International Labor Organization and considered possible as contributors to COPD. A better understanding of these causes paves the way for effective interventions to reduce the future incidence of this unpleasant condition. There is a growing interest in the impact of chronic obstructive pulmonary disease on the ability to work. As COPD progresses patients are increasingly faced with a number of functional limitations, and as a result, can experience effects on their personal, social and work life.

#### **Conflict of interest**

The authors declare that they have no competing interest.

### **Author details**

Biruk Getahun1 \* and Abebe Ayalew Bekel<sup>2</sup>

1 Department of Medical Physiology, School of Medicine, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia

2 Department of Human Anatomy, School of Medicine, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia

\*Address all correspondence to<EMAIL_ADDRESS>
© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

### **References**

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[2] Cho Y, Lee J, Choi M, Choi W, Myong JP, Kim HR, Koo JW. Workrelated COPD after years of occupational exposure. Annals of occupational and environmental medicine. 2015; 27(1).

[3] Naidoo R. Work-related chronic obstructive pulmonary disease. Continuing Medical Education. 2009; 27(11).

[4] Kalirai KK. The effects of Chronic Obstructive Pulmonary Disease on work related outcomes (Doctoral dissertation, University of Birmingham); 2016.

[5] Levy ML, Quanjer PH, Rachel B, Cooper BG, Holmes S, Small IR. Diagnostic Spirometry in Primary Care: Proposed standards for general practice compliant with American Thoracic Society and European Respiratory Society recommendations. Primary Care Respiratory Journal. 2009; 18(3):130-47.

[6] West JB. Respiratory physiology: the essentials. Lippincott Williams & Wilkins; 2012.

[7] Eisner MD, Anthonisen N, Coultas D, Kuenzli N, Perez-Padilla R, Postma D, Romieu I, Silverman EK, Balmes JR. An official American Thoracic Society public policy statement: Novel risk factors and the global burden of chronic obstructive pulmonary disease. American journal of respiratory and critical care medicine. 2010; 182(5):693-718.

[8] Williamson JP, Twaddell SH, Lee YG, Salamonsen M, Hew M, Fielding D,

Nguyen P, Steinfort D, Hopkins P, Smith N, Grainge C. Thoracic ultrasound recognition of competence: a position paper of the Thoracic Society of Australia and New Zealand. Respirology. 2017; 22(2):405-8.

[9] Torén K, Vikgren J, Olin AC, Rosengren A, Bergström G, Brandberg J. Occupational exposure to vapor, gas, dust, or fumes and chronic airflow limitation, COPD, and emphysema: the Swedish CArdioPulmonary BioImage Study (SCAPIS pilot). International journal of chronic obstructive pulmonary disease. 2017; 12:3407.

[10] Sadhra S, Kurmi OP, Sadhra SS, Lam KB, Ayres JG. Occupational COPD and job exposure matrices: a systematic review and meta-analysis. International journal of chronic obstructive pulmonary disease. 2017; 12:725.

[11] Mazitova NN, Saveliev AA, Berheeva ZM, Amirov NK. COPD and occupation: a retrospective cohort study of industrial workers. Archives of Industrial Hygiene and Toxicology. 2012; 63(3):345-56.

[12] Balmes J, Becklake M, Blanc P, Henneberger P. American Thoracic Society Statement: Occupational contribution to the burden of airway disease. American journal of respiratory and critical care medicine. 2003; 167(5):787.

[13] Lemière C, Vandenplas O. Occupational Allergy. InMiddleton's Allergy Essentials 2017; (pp. 361-375). Elsevier.

[14] GBD 2016 Occupational Chronic Respiratory Risk Factors Collaborators. Global and regional burden of chronic respiratory disease in 2016 arising from non-infectious airborne occupational exposures: a systematic analysis for the Global Burden of Disease Study

**35**

457-469.

*Work - Related Chronic Obstructive Pulmonary Disease DOI: http://dx.doi.org/10.5772/intechopen.96131*

> Occupational chronic obstructive pulmonary disease: a standard of care. Occupational Medicine. 2015;

[23] Peng C, Yan Y, Li Z, Jiang Y, Cai Y. Chronic obstructive pulmonary disease caused by inhalation of dust: A metaanalysis. Medicine. 2020; 99(34).

[24] Oxman AD, Muir DC,

Respiratory Disease. 2012.

33(4):224.

dust. 2005.

Shannon HS, Stock SR, Hnizdo E, Lange HJ. Occupational dust exposure and chronic obstructive pulmonary disease: a systematic overview of the evidence. American Review of

[25] Sabde YD, Zodpey SP. A study of morbidity pattern in street sweepers: a cross-sectional study. Indian Journal of Community Medicine: Official Publication of Indian Association of Preventive & Social Medicine. 2008;

[26] Dalju I, Dessie A, Bogale L,

Mekonnen TH. Occupational risk factors associated with respiratory symptoms among tannery workers in Mojo town, Southeast Ethiopia, 2018: a comparative cross-sectional study. Multidisciplinary Respiratory Medicine. 2019; 14(1):27.

[27] World Health Organization. The world health report, (2002); pp.81-92.

(WHO). Hazard prevention and control in the work environment: airborne

[29] Quirce, S. & Barranco, P. (2010). Cleaning agents and asthma. J Investig Allergol Clin Immunol, 20, 542-50.

[30] Dumas O, Varraso R, Boggs KM, Quinot C, Zock JP, Henneberger PK, Speizer FE, Le Moual N, Camargo CA. Association of occupational exposure to disinfectants with incidence of chronic obstructive pulmonary disease among US female nurses. JAMA network open.

2019; 2(10):e1913563.

[28] World Health Organization

65(4):270-82.

2016. Occupational and environmental

Raynal A, Rooijackers J, Santonen T, Sastre J. Current and new challenges in occupational lung diseases. European Respiratory Review. 2017; 26(146).

[16] Hnizdo E, Vallyathan V. Chronic obstructive pulmonary disease due to occupational exposure to silica dust: a review of epidemiological and pathological evidence. Occupational and environmental medicine. 2003;

[17] Torén K, Järvholm B. Effect of occupational exposure to vapors, gases, dusts, and fumes on COPD mortality risk among Swedish construction workers: a longitudinal cohort study.

[18] Maio S, Baldacci S, Carrozzi L, Pistelli F, Viegi G. The global burden of chronic respiratory diseases. Breathe.

[19] Rushton L. Chronic obstructive pulmonary disease and occupational exposure to silica. Reviews on environmental health. 2007;

[20] Dodd KE, Mazurek JM. Prevalence of COPD among workers with workrelated asthma. Journal of Asthma.

Mannino DM. Epidemiology of chronic

Chest. 2014; 145(5):992-7.

2006; 3(1):20-9.

22(4):255-72.

2020; 57(11):1179-87.

[21] Rosenberg SR, Kalhan R,

obstructive pulmonary disease: prevalence, morbidity, mortality, and risk factors. InSeminars in respiratory and critical care medicine 2015; 36(4):

[22] Fishwick D, Sen D, Barber C, Bradshaw L, Robinson E, Sumner J, COPD Standard Collaboration Group.

60(4):237-43.

medicine. 2020; 77(3):142-50.

[15] De Matteis S, Heederik D, Burdorf A, Colosio C, Cullinan P, Henneberger PK, Olsson A,

*Work - Related Chronic Obstructive Pulmonary Disease DOI: http://dx.doi.org/10.5772/intechopen.96131*

2016. Occupational and environmental medicine. 2020; 77(3):142-50.

[15] De Matteis S, Heederik D, Burdorf A, Colosio C, Cullinan P, Henneberger PK, Olsson A, Raynal A, Rooijackers J, Santonen T, Sastre J. Current and new challenges in occupational lung diseases. European Respiratory Review. 2017; 26(146).

[16] Hnizdo E, Vallyathan V. Chronic obstructive pulmonary disease due to occupational exposure to silica dust: a review of epidemiological and pathological evidence. Occupational and environmental medicine. 2003; 60(4):237-43.

[17] Torén K, Järvholm B. Effect of occupational exposure to vapors, gases, dusts, and fumes on COPD mortality risk among Swedish construction workers: a longitudinal cohort study. Chest. 2014; 145(5):992-7.

[18] Maio S, Baldacci S, Carrozzi L, Pistelli F, Viegi G. The global burden of chronic respiratory diseases. Breathe. 2006; 3(1):20-9.

[19] Rushton L. Chronic obstructive pulmonary disease and occupational exposure to silica. Reviews on environmental health. 2007; 22(4):255-72.

[20] Dodd KE, Mazurek JM. Prevalence of COPD among workers with workrelated asthma. Journal of Asthma. 2020; 57(11):1179-87.

[21] Rosenberg SR, Kalhan R, Mannino DM. Epidemiology of chronic obstructive pulmonary disease: prevalence, morbidity, mortality, and risk factors. InSeminars in respiratory and critical care medicine 2015; 36(4): 457-469.

[22] Fishwick D, Sen D, Barber C, Bradshaw L, Robinson E, Sumner J, COPD Standard Collaboration Group. Occupational chronic obstructive pulmonary disease: a standard of care. Occupational Medicine. 2015; 65(4):270-82.

[23] Peng C, Yan Y, Li Z, Jiang Y, Cai Y. Chronic obstructive pulmonary disease caused by inhalation of dust: A metaanalysis. Medicine. 2020; 99(34).

[24] Oxman AD, Muir DC, Shannon HS, Stock SR, Hnizdo E, Lange HJ. Occupational dust exposure and chronic obstructive pulmonary disease: a systematic overview of the evidence. American Review of Respiratory Disease. 2012.

[25] Sabde YD, Zodpey SP. A study of morbidity pattern in street sweepers: a cross-sectional study. Indian Journal of Community Medicine: Official Publication of Indian Association of Preventive & Social Medicine. 2008; 33(4):224.

[26] Dalju I, Dessie A, Bogale L, Mekonnen TH. Occupational risk factors associated with respiratory symptoms among tannery workers in Mojo town, Southeast Ethiopia, 2018: a comparative cross-sectional study. Multidisciplinary Respiratory Medicine. 2019; 14(1):27.

[27] World Health Organization. The world health report, (2002); pp.81-92.

[28] World Health Organization (WHO). Hazard prevention and control in the work environment: airborne dust. 2005.

[29] Quirce, S. & Barranco, P. (2010). Cleaning agents and asthma. J Investig Allergol Clin Immunol, 20, 542-50.

[30] Dumas O, Varraso R, Boggs KM, Quinot C, Zock JP, Henneberger PK, Speizer FE, Le Moual N, Camargo CA. Association of occupational exposure to disinfectants with incidence of chronic obstructive pulmonary disease among US female nurses. JAMA network open. 2019; 2(10):e1913563.

**34**

*Chronic Obstructive Pulmonary Disease - A Current Conspectus*

Nguyen P, Steinfort D, Hopkins P, Smith N, Grainge C. Thoracic ultrasound recognition of competence: a position

paper of the Thoracic Society of Australia and New Zealand. Respirology. 2017; 22(2):405-8.

[9] Torén K, Vikgren J, Olin AC,

Rosengren A, Bergström G, Brandberg J. Occupational exposure to vapor, gas, dust, or fumes and chronic airflow limitation, COPD, and emphysema: the Swedish CArdioPulmonary BioImage Study (SCAPIS pilot). International journal of chronic obstructive pulmonary disease. 2017; 12:3407.

[10] Sadhra S, Kurmi OP, Sadhra SS, Lam KB, Ayres JG. Occupational COPD and job exposure matrices: a systematic review and meta-analysis. International

journal of chronic obstructive pulmonary disease. 2017; 12:725.

[11] Mazitova NN, Saveliev AA, Berheeva ZM, Amirov NK. COPD and occupation: a retrospective cohort study of industrial workers. Archives of Industrial Hygiene and Toxicology.

[12] Balmes J, Becklake M, Blanc P, Henneberger P. American Thoracic Society Statement: Occupational contribution to the burden of airway disease. American journal of respiratory

and critical care medicine. 2003;

[13] Lemière C, Vandenplas O. Occupational Allergy. InMiddleton's Allergy Essentials 2017; (pp. 361-375).

[14] GBD 2016 Occupational Chronic Respiratory Risk Factors Collaborators. Global and regional burden of chronic respiratory disease in 2016 arising from non-infectious airborne occupational exposures: a systematic analysis for the Global Burden of Disease Study

2012; 63(3):345-56.

167(5):787.

Elsevier.

[1] Trupin L, Earnest G, San Pedro M, Balmes JR, Eisner MD, Yelin E, Katz PP, Blanc PD. The occupational burden of chronic obstructive pulmonary disease. European Respiratory Journal. 2003;

[2] Cho Y, Lee J, Choi M, Choi W, Myong JP, Kim HR, Koo JW. Workrelated COPD after years of occupational exposure. Annals of occupational and environmental

[3] Naidoo R. Work-related chronic obstructive pulmonary disease. Continuing Medical Education.

[4] Kalirai KK. The effects of Chronic Obstructive Pulmonary Disease on work related outcomes (Doctoral dissertation, University of Birmingham); 2016.

[6] West JB. Respiratory physiology: the essentials. Lippincott Williams &

[7] Eisner MD, Anthonisen N, Coultas D, Kuenzli N, Perez-Padilla R, Postma D, Romieu I, Silverman EK, Balmes JR. An official American Thoracic Society public policy statement: Novel risk factors and the global burden of

chronic obstructive pulmonary disease.

[8] Williamson JP, Twaddell SH, Lee YG, Salamonsen M, Hew M, Fielding D,

American journal of respiratory and critical care medicine. 2010;

[5] Levy ML, Quanjer PH, Rachel B, Cooper BG, Holmes S, Small IR. Diagnostic Spirometry in Primary Care: Proposed standards for general practice compliant with American Thoracic Society and European Respiratory Society recommendations. Primary Care Respiratory Journal. 2009; 18(3):130-47.

medicine. 2015; 27(1).

22(3):462-9.

**References**

2009; 27(11).

Wilkins; 2012.

182(5):693-718.

[31] Gorman A. Household hazards: Potential hazards of home cleaning products. Women's Voices for the Earth; 2007.

[32] Driscoll T, Steenland K, Nelson DI, Leigh J, Prüss-Üstün A, Campbell-Lendrum DH, Corvalán CF, Woodward A, World Health Organization. Occupational airborne particulates: Assessing the environmental burden of disease at national and local levels. World Health Organization; 2004.

[33] Nickmilder M, Carbonnelle S, Bernard A. House cleaning with chlorine bleach and the risks of allergic and respiratory diseases in children. Pediatric allergy and immunology. 2007; 18(1):27-35.

[34] DEMİRALAY R. Effects of the use of hypochlorite as a cleaning substance on pulmonary functions. Turkish Journal of Medical Sciences. 2001; 31(1):51-7.

[35] Rai KK, Adab P, Ayres JG, Jordan RE. Systematic review: chronic obstructive pulmonary disease and work-related outcomes. Occupational Medicine. 2018; 68(2):99-108.

[36] de Sousa Sena R, Ahmed S, Tan WC, Li PZ, Labonté L, Aaron SD, Benedetti A, Chapman KR, Walker B, Fitzgerald JM, Hernandez P. Work productivity loss in mild to moderate COPD: lessons learned from the CanCOLD study. European Respiratory Journal. 2017; 50(3).

[37] Fishwick D, Barber CM, Darby AC. Review series: Occupational and environmental lung disease: Chronic obstructive pulmonary disease and the workplace. Chronic Respiratory Disease. 2010; 7(2):113-22.

[38] Onoue A, Omori H, Katoh T, Kubota K, Nonami Y, Ogata Y, Inoue H. Relationship of airflow limitation severity with work

productivity reduction and sick leave in a Japanese working population. International journal of chronic obstructive pulmonary disease. 2016; 11:567.

[39] Bepko J, Mansalis K. Common occupational disorders: asthma, COPD, dermatitis, and musculoskeletal disorders. American family physician. 2016; 93(12):1000-6.

[40] Halpin D. Chronic Obstructive Pulmonary Disease and Work: Is It Time to Stop? Am J Respir Crit Care Med. 2019; 200(10): 1195-1207.

[41] Fan Y, Xu W, Wang Y, Wang Y, Yu S, Ye Q. Association of occupational dust exposure with combined chronic obstructive pulmonary disease and pneumoconiosis: a cross-sectional study in China. BMJ open. 2020; 10(9):e038874.

[42] Sin DD, Stafinski T, Ng YC, Bell NR, Jacobs P. The impact of chronic obstructive pulmonary disease on work loss in the United States. American journal of respiratory and critical care medicine. 2002; 165(5):704-7.

**37**

**Chapter 4**

**Abstract**

disease management

**1. Introduction**

COPD-Related Factors Affect the

Over the past decades, health-related quality of life (HRQL) has become a major topic of research in the context of chronic conditions, including chronic obstructive pulmonary disease (COPD). HRQL assessment became a part of the mandatory criteria for judging the effectiveness of a therapeutic care plan. COPD still imposes an enormous burden on patients and health care systems. Daily symptoms, poor pulmonary function, and medication use can affect the social and physical life components of patients. Indeed, HRQL predictors in COPD patients were controversial in the literature. To this end, we conducted a review of the literature to describe COPD-related factors that influence the HRQL of patients. This study included research articles published in English from 2010 to 2020. This review of sparse and well-designed literature gave a current state-of-the-art that could be useful for clinicians, and in establishing advanced COPD management plans.

**Keywords:** COPD, quality of life, dyspnea, exacerbation, comorbidity,

which was equal to 6% of all deaths globally [4].

chronic condition management [7].

Chronic obstructive pulmonary disease (COPD) is a lung disease that is characterized by a persistent blockage of the flow of inhaled gases. It tends to be an under-diagnosed condition, which engages the life prognosis [1]. In fact, COPD is a growing global health problem that caused 4.07% of total disability adjusted life years in adults aged 50 to 69 years [2]. It is currently the fourth leading cause of death worldwide [3]. More than 3 million people worldwide died of COPD in 2012,

Although this condition is not curable, pharmacological and non-pharmacological treatments can slow the progression of the disease [1]. Symptoms, such as dyspnea, cough, and sputum, can lead to exercise intolerance and restriction in daily life activities of patients with COPD [5, 6]. Consequently, they progressively impair the health related quality of life (HRQL) [6]. According to Roche and Similowski, impaired HRQL is a major issue in chronic disease management. Its measurement is currently part of the mandatory criteria for judging the effectiveness of a treatment or a plan of

Indeed, HRQL was defined by the World Health Organization since 1984 as the individual's perception of his place in life, in the context of the culture and value system in which he or she lives, in relation to his objectives, expectations, standards and concerns. It is a very broad concept, influenced in a complex way by the physical health of the person, his or her psychological state, his or her level

Quality of Life of Patients

*Maha Dardouri and Manel Mallouli*

#### **Chapter 4**

*Chronic Obstructive Pulmonary Disease - A Current Conspectus*

productivity reduction and sick leave in a Japanese working population. International journal of chronic obstructive pulmonary disease.

[39] Bepko J, Mansalis K. Common occupational disorders: asthma, COPD, dermatitis, and musculoskeletal disorders. American family physician.

[40] Halpin D. Chronic Obstructive Pulmonary Disease and Work: Is It Time to Stop? Am J Respir Crit Care Med.

[41] Fan Y, Xu W, Wang Y, Wang Y, Yu S, Ye Q. Association of occupational dust exposure with combined chronic obstructive pulmonary disease and pneumoconiosis: a cross-sectional study in China. BMJ open. 2020;

[42] Sin DD, Stafinski T, Ng YC,

medicine. 2002; 165(5):704-7.

Bell NR, Jacobs P. The impact of chronic obstructive pulmonary disease on work loss in the United States. American journal of respiratory and critical care

2016; 11:567.

2016; 93(12):1000-6.

2019; 200(10): 1195-1207.

10(9):e038874.

[31] Gorman A. Household hazards: Potential hazards of home cleaning products. Women's Voices for the

[32] Driscoll T, Steenland K, Nelson DI, Leigh J, Prüss-Üstün A, Campbell-Lendrum DH, Corvalán CF,

Woodward A, World Health Organization. Occupational

Organization; 2004.

18(1):27-35.

31(1):51-7.

airborne particulates: Assessing the environmental burden of disease at national and local levels. World Health

[33] Nickmilder M, Carbonnelle S, Bernard A. House cleaning with chlorine bleach and the risks of allergic and respiratory diseases in children. Pediatric allergy and immunology. 2007;

[34] DEMİRALAY R. Effects of the use of hypochlorite as a cleaning substance on pulmonary functions. Turkish Journal of Medical Sciences. 2001;

Jordan RE. Systematic review: chronic obstructive pulmonary disease and work-related outcomes. Occupational

CanCOLD study. European Respiratory

[37] Fishwick D, Barber CM, Darby AC. Review series: Occupational and environmental lung disease: Chronic obstructive pulmonary disease and the workplace. Chronic Respiratory Disease.

[38] Onoue A, Omori H, Katoh T, Kubota K, Nonami Y, Ogata Y, Inoue H. Relationship of airflow limitation severity with work

[35] Rai KK, Adab P, Ayres JG,

Medicine. 2018; 68(2):99-108.

[36] de Sousa Sena R, Ahmed S, Tan WC, Li PZ, Labonté L, Aaron SD, Benedetti A, Chapman KR, Walker B, Fitzgerald JM, Hernandez P. Work productivity loss in mild to moderate COPD: lessons learned from the

Journal. 2017; 50(3).

2010; 7(2):113-22.

Earth; 2007.

**36**

## COPD-Related Factors Affect the Quality of Life of Patients

*Maha Dardouri and Manel Mallouli*

#### **Abstract**

Over the past decades, health-related quality of life (HRQL) has become a major topic of research in the context of chronic conditions, including chronic obstructive pulmonary disease (COPD). HRQL assessment became a part of the mandatory criteria for judging the effectiveness of a therapeutic care plan. COPD still imposes an enormous burden on patients and health care systems. Daily symptoms, poor pulmonary function, and medication use can affect the social and physical life components of patients. Indeed, HRQL predictors in COPD patients were controversial in the literature. To this end, we conducted a review of the literature to describe COPD-related factors that influence the HRQL of patients. This study included research articles published in English from 2010 to 2020. This review of sparse and well-designed literature gave a current state-of-the-art that could be useful for clinicians, and in establishing advanced COPD management plans.

**Keywords:** COPD, quality of life, dyspnea, exacerbation, comorbidity, disease management

#### **1. Introduction**

Chronic obstructive pulmonary disease (COPD) is a lung disease that is characterized by a persistent blockage of the flow of inhaled gases. It tends to be an under-diagnosed condition, which engages the life prognosis [1]. In fact, COPD is a growing global health problem that caused 4.07% of total disability adjusted life years in adults aged 50 to 69 years [2]. It is currently the fourth leading cause of death worldwide [3]. More than 3 million people worldwide died of COPD in 2012, which was equal to 6% of all deaths globally [4].

Although this condition is not curable, pharmacological and non-pharmacological treatments can slow the progression of the disease [1]. Symptoms, such as dyspnea, cough, and sputum, can lead to exercise intolerance and restriction in daily life activities of patients with COPD [5, 6]. Consequently, they progressively impair the health related quality of life (HRQL) [6]. According to Roche and Similowski, impaired HRQL is a major issue in chronic disease management. Its measurement is currently part of the mandatory criteria for judging the effectiveness of a treatment or a plan of chronic condition management [7].

Indeed, HRQL was defined by the World Health Organization since 1984 as the individual's perception of his place in life, in the context of the culture and value system in which he or she lives, in relation to his objectives, expectations, standards and concerns. It is a very broad concept, influenced in a complex way by the physical health of the person, his or her psychological state, his or her level of independence, his or her social relations, as well as his or her relationship to the essential elements of his or her environment [8]. This perception may vary with age, health status, maturity, and over time [9, 10]. Thus, it is important to periodically assess the HRQL of patients.

In fact, HRQL assessment is an important indicator in healthcare since it provides an overview of the impact of the disease on the patient's life. It is substantial for optimizing patient comfort and improving care [7]. In research, HRQL assessment is interesting to justify various forms of treatment. It helps in improving therapies and providing significant data to judge the Cost/Effectiveness ratio of healthcare therapies [11].

One of the main objectives of COPD treatment was to improve the general health condition of patients. As a result, HRQL has become a major topic of research in COPD patients [12, 13]. Several studies assessed the factors determining the HRQL in patients with COPD using various methods and instruments. Indeed, predictors of HRQL were controversial in the literature. Furthermore, it is crucial to identify clinical factors related to COPD that affect the HRQL of patients. This could be useful and time-saving for health care providers in developing advanced and evidence-based COPD management programs.

In this chapter, we aimed to describe the findings of studies that analyzed clinical factors determining the HRQL of COPD patients published in the past decade.

#### **2. Methods**

#### **2.1 Study design**

This was a literature review of analytical studies that assessed the clinical factors determining the HRQL in patients with COPD.

#### **2.2 Sources of information and data search**

The data search was carried out using three electronic databases, namely, MEDLINE, ScienceDirect, and Mendeley. Data collection was conducted from December 2020 to January 2021. Studies identified in the references of the selected articles, and that met the inclusion criteria were included in this review.

The terms used for the search were 'quality of life', 'Pulmonary Disease, Chronic Obstructive', 'epidemiologic factors', 'risk factors', 'influencing factors', 'outcomes and process assessment' in different combinations.

#### **2.3 Inclusion criteria**

Studies were primarily assessed basing on their titles and abstracts. After exclusion of duplicates, studies were included in this review according to the following inclusion criteria: English language articles published in scientific journals, the study included generic or specific instruments or both of them to collect information on predictors of HRQL among COPD patients, the study included only COPD patients, the work included quantitative information on clinical predictors of HRQL and articles published from 2010 to 2020.

#### **2.4 Data extraction**

For each study included in this literature review, the following variables were recorded: author and country, study design, study period, sample size, tools

**39**

*COPD-Related Factors Affect the Quality of Life of Patients*

to IV) and with co-morbidities were included in the studies.

assessed by the "Medical Research Council (MRC) dyspnea scale".

for HRQL assessment, and findings of the study regarding clinical factors

Basing on the titles and abstracts, forty-two articles seemed to meet the objectives of this review. Twenty-six articles were excluded for one of the following reasons: articles not written in English language, articles published before 2010 (n = 24), samples were not exclusively COPD patients, articles aimed to assess HRQL without identifying predictive factors. Consequently, the final sample was

**Table 1** shows the characteristics of the included studies. The studies were conducted in different regions in the world, namely European countries, South Korea, China, Egypt, Tunisia, and United States. Most of the studies used a multicenter, cross-sectional analytical design, with studies' periods ranged from 3 months to 6 years. Five studies used a multicenter, prospective analytical design, with 6-month to 5-year period [14–18]. The minimal sample size used in the studies was n = 42, and the maximum one was 5619. The mean age of studied populations ranged from 59 ± 10.1 to 72.2 ± 8.11. Patients with all COPD severity stages (GOLD I

Various tools of HRQL assessment were used in the literature (**Table 1**). The St George's Respiratory Questionnaire (SGRQ ), which is a COPD-specific tool, was largely used (10 studies). Two studies used the COPD Assessment Test [19, 20]. Regarding generic instruments, the Medical Outcome Study 36-Item Short-Form Health Survey (SF-36) and the EuroQol-5 Dimension (EQ-5D) were used in 6 studies. Also the Medical Outcome Study 12-Item Short-Form Health Survey (SF-12) was used in one study as a second tool. The severity of dyspnea was mainly

All of the studies reported a significant HRQL impairment in patients with COPD. The prospective studies recorded the changes of HRQL status over time at

Twelve papers identified more than one clinical factor affecting the HRQL in COPD subjects, and five articles identified only one factor [18, 19, 21–23]. COPD symptoms [14–16, 18, 21, 23–26], COPD severity [5, 6, 12, 24, 27], and co-morbidities [5, 12, 16, 20, 24, 26, 27] were commonly identified as predictors of HRQL in

The current review reported sixteen studies with two different designs: cross sectional and prospective. The cross sectional study design is limited in its ability to draw valid conclusions as to the association between COPD-related factors and HRQL. Also, cross-sectional studies can present a memorization bias. Nevertheless, the sample size used in most of the documented studies was large enough to assess HRQL with adequate precision. In regards with prospective studies (n = 5), they eliminate the memorization bias as there is no need for information recall. Follow-up can provide more information concerning the changes that patients experience and their possible impact on HRQL. For instance, Monteagudo and colleagues observed a clinically important changes in HRQL in nearly two thirds of the study population (36.7% improving and 29.2% worsening HRQL). However, the loss to follow-up is

common in prospective studies, which is an important limitation [28].

*DOI: http://dx.doi.org/10.5772/intechopen.96825*

influencing HRQL.

reduced to sixteen studies.

6 months to 5 years' follow-up.

COPD subjects.

**4. Discussion**

**3. Results**

for HRQL assessment, and findings of the study regarding clinical factors influencing HRQL.

#### **3. Results**

*Chronic Obstructive Pulmonary Disease - A Current Conspectus*

and evidence-based COPD management programs.

determining the HRQL in patients with COPD.

**2.2 Sources of information and data search**

and process assessment' in different combinations.

and articles published from 2010 to 2020.

cally assess the HRQL of patients.

healthcare therapies [11].

**2. Methods**

**2.1 Study design**

**2.3 Inclusion criteria**

**2.4 Data extraction**

of independence, his or her social relations, as well as his or her relationship to the essential elements of his or her environment [8]. This perception may vary with age, health status, maturity, and over time [9, 10]. Thus, it is important to periodi-

In fact, HRQL assessment is an important indicator in healthcare since it provides an overview of the impact of the disease on the patient's life. It is substantial for optimizing patient comfort and improving care [7]. In research, HRQL assessment is interesting to justify various forms of treatment. It helps in improving therapies and providing significant data to judge the Cost/Effectiveness ratio of

One of the main objectives of COPD treatment was to improve the general health condition of patients. As a result, HRQL has become a major topic of

research in COPD patients [12, 13]. Several studies assessed the factors determining the HRQL in patients with COPD using various methods and instruments. Indeed, predictors of HRQL were controversial in the literature. Furthermore, it is crucial to identify clinical factors related to COPD that affect the HRQL of patients. This could be useful and time-saving for health care providers in developing advanced

In this chapter, we aimed to describe the findings of studies that analyzed clinical factors determining the HRQL of COPD patients published in the past decade.

This was a literature review of analytical studies that assessed the clinical factors

The terms used for the search were 'quality of life', 'Pulmonary Disease, Chronic Obstructive', 'epidemiologic factors', 'risk factors', 'influencing factors', 'outcomes

Studies were primarily assessed basing on their titles and abstracts. After exclusion of duplicates, studies were included in this review according to the following inclusion criteria: English language articles published in scientific journals, the study included generic or specific instruments or both of them to collect information on predictors of HRQL among COPD patients, the study included only COPD patients, the work included quantitative information on clinical predictors of HRQL

For each study included in this literature review, the following variables were

recorded: author and country, study design, study period, sample size, tools

The data search was carried out using three electronic databases, namely, MEDLINE, ScienceDirect, and Mendeley. Data collection was conducted from December 2020 to January 2021. Studies identified in the references of the selected

articles, and that met the inclusion criteria were included in this review.

**38**

Basing on the titles and abstracts, forty-two articles seemed to meet the objectives of this review. Twenty-six articles were excluded for one of the following reasons: articles not written in English language, articles published before 2010 (n = 24), samples were not exclusively COPD patients, articles aimed to assess HRQL without identifying predictive factors. Consequently, the final sample was reduced to sixteen studies.

**Table 1** shows the characteristics of the included studies. The studies were conducted in different regions in the world, namely European countries, South Korea, China, Egypt, Tunisia, and United States. Most of the studies used a multicenter, cross-sectional analytical design, with studies' periods ranged from 3 months to 6 years. Five studies used a multicenter, prospective analytical design, with 6-month to 5-year period [14–18]. The minimal sample size used in the studies was n = 42, and the maximum one was 5619. The mean age of studied populations ranged from 59 ± 10.1 to 72.2 ± 8.11. Patients with all COPD severity stages (GOLD I to IV) and with co-morbidities were included in the studies.

Various tools of HRQL assessment were used in the literature (**Table 1**). The St George's Respiratory Questionnaire (SGRQ ), which is a COPD-specific tool, was largely used (10 studies). Two studies used the COPD Assessment Test [19, 20].

Regarding generic instruments, the Medical Outcome Study 36-Item Short-Form Health Survey (SF-36) and the EuroQol-5 Dimension (EQ-5D) were used in 6 studies. Also the Medical Outcome Study 12-Item Short-Form Health Survey (SF-12) was used in one study as a second tool. The severity of dyspnea was mainly assessed by the "Medical Research Council (MRC) dyspnea scale".

All of the studies reported a significant HRQL impairment in patients with COPD. The prospective studies recorded the changes of HRQL status over time at 6 months to 5 years' follow-up.

Twelve papers identified more than one clinical factor affecting the HRQL in COPD subjects, and five articles identified only one factor [18, 19, 21–23]. COPD symptoms [14–16, 18, 21, 23–26], COPD severity [5, 6, 12, 24, 27], and co-morbidities [5, 12, 16, 20, 24, 26, 27] were commonly identified as predictors of HRQL in COPD subjects.

#### **4. Discussion**

The current review reported sixteen studies with two different designs: cross sectional and prospective. The cross sectional study design is limited in its ability to draw valid conclusions as to the association between COPD-related factors and HRQL. Also, cross-sectional studies can present a memorization bias. Nevertheless, the sample size used in most of the documented studies was large enough to assess HRQL with adequate precision. In regards with prospective studies (n = 5), they eliminate the memorization bias as there is no need for information recall. Follow-up can provide more information concerning the changes that patients experience and their possible impact on HRQL. For instance, Monteagudo and colleagues observed a clinically important changes in HRQL in nearly two thirds of the study population (36.7% improving and 29.2% worsening HRQL). However, the loss to follow-up is common in prospective studies, which is an important limitation [28].

**41**

**Author(s), year, country of the study**

Martinez et

5619

—

Cross-sectional study

St George's Respiratory

Dyspnea severity.

Questionnaire.

al. (2016),

United States

Kwon &

2,734

6-year

Cross-sectional

EuroQol-5 dimension

surveys

data

Kim (2016),

South Korea

Lee et al.

1,264

4 years

Multi center,

St George's Respiratory

Questionnaire.

prospective study

(2017),

South Korea

Mallouli et

335

3 months

Cross-sectional study

Medical Outcome Study 36-Item

Short-Form Health Survey

(MOS SF-36)

5 level EuroQol-5 dimension

(EQ-5D 5 L)

al. (2017),

Tunisia

Brien et

735

2 years

Cross-sectional study

al. (2018),

United

Kingdom

Amini et al.

175

11 months

Cross-sectional study

Chronic Obstructive Pulmonary

Inhaler technique

Inhaled medication, smoking habit, FEV1, 6MWT distance, body mass index,

residual volume, diffusing capacity of the lung for carbon monoxide, physical

activity, and hospitalization.

COPD symptoms

Disease Assessment Test

St George's Respiratory

Questionnaire.

(2020), Iran

Esteban et

543

5 years

Prospective cohort

study

al. (2020),

Spain

Park (2020),

42

6 months

Longitudinal study

Medical Outcome Study 36-Item

Short-Form Health Survey

(MOS SF-36)

South Korea

**Table 1.**

*Characteristics of the Studies analyzing clinical outcomes influencing the HRQL of patients with COPD.*

**n**

**Study**

**Study design HRQL Instrument(s)**

**Clinical factors predicting HRQL of patients with COPD**

**period**

*COPD-Related Factors Affect the Quality of Life of Patients*

*DOI: http://dx.doi.org/10.5772/intechopen.96825*

Severity of COPD, co-morbidities (Depression, osteoporosis, diabetes,

cardiovascular disease)

Symptoms (dyspnea and cough), number of co-morbidities.

COPD severity (Moderate to very severe), 2 or more co-morbidities, MRC dyspnea

grade 4 and 5.

Dyspnea, depression, anxiety, 12-month exacerbations.

**Table 1.**

*Characteristics of the Studies analyzing clinical outcomes influencing the HRQL of patients with COPD.*

*COPD-Related Factors Affect the Quality of Life of Patients DOI: http://dx.doi.org/10.5772/intechopen.96825*

*Chronic Obstructive Pulmonary Disease - A Current Conspectus*

**40**

**Author(s),**

**n**

**Study**

**Study design HRQL Instrument(s)**

**Clinical factors predicting HRQL of patients with COPD**

**period**

**year,**

**country of**

**the study**

Jones et

1817

5 months

Cross-sectional

St George's Respiratory

Severity of COPD, exacerbation, presence of three or more co-morbidities.

Severity of COPD, Smoking index, forced expiratory volume in 1 second (FEV1),

FEV1/FVC ratio (FVC: Forced vital capacity), Peak expiratory flow rate (PEFR),

Forced expiratory flow at 25%- 75% of maximal lung volume (FEF25–75%).

Factors associated with HRQL worsening: Symptoms (dyspnea, expectoration),

hospital admissions

Severity of COPD, body mass index, FEV1, dyspnea, depression, anxiety, smoking

index.

MRC dyspnea grade, number of exacerbations

Co-morbid conditions: chronic bronchitis, depression, osteoporosis, and musculoskeletal symptoms

Symptoms: cough, dyspnea

Current cough in the previous 7 days.

Questionnaire, Short Form 12.

epidemiological, nonrandomized study.

al. (2011),

Europe

Zamzam et

40

1 year

Cross-sectional study

St George's Respiratory

Questionnaire.

al. (2012),

Egypt

Monteagudo

791

1 year

Multi center,

St George's Respiratory

Questionnaire.

prospective study

et al. (2013),

Spain

Negi et el

126

6 months

Cross-sectional study

St George's Respiratory

Questionnaire.

St George's Respiratory

Questionnaire.

(2014), India

Liang et

491

1 year

Prospective cohort

study

al. (2014),

China

Sundh et

373

11 months

Multicenter, crosssectional study

EuroQol-5 dimension, COPD Assessment Test.

al. (2015),

Sweden

Kendrovà et

80

7 months

Cross-sectional study

St George's Respiratory

Questionnaire, Short Form-36

al. (2015),

Slovakia

Deslee et

178

—

Cross-sectional

St George's Respiratory

Questionnaire.

multicenter study

al. (2016),

France

**41**

Regarding to the populations' characteristics, most of the studies addressed middle-age adults and/or older adults. Besides, most of the patients were between moderate and very severe COPD severity stages. They presented different comorbidities, such as diabetes, osteoporosis, depression, anxiety, and cardiovascular diseases.

HRQL is a multidimensional, subjective, and dynamic concept, which make it difficult to assess. Nevertheless, there are reliable and valid HRQL measurement tools in the literature. Indeed, Mercier and Schraub distinguished two methods to assess HRQL [29]. The first one is via psychological interview that allows a comprehensive evaluation of HRQL and has therapeutic value. The second method is via psychometric tools that consist of scales or questionnaires. It performs a restrictive evaluation of HRQL and allows standardized measurement. This method is generally easy to use. For that, we included the studies that used this type of HRQL evaluation in this review.

In the literature, the specific questionnaire mostly used to assess the HRQL was the St George's Respiratory Questionnaire. The generic questionnaires SF-36 and the EQ-5D were also widely used in the literature. These instruments reported that COPD altered the HRQL of patients even in a mild stage [5, 6, 14, 15, 21, 23–25].

HRQL is the result of the interaction of multiple physical, psychological and social components. Consequently, several factors can affect it, especially in COPD subjects.

This review demonstrated that multiple COPD-related factors had a significant negative influence on the HRQL of patients with COPD.

#### **4.1 COPD-related factors**

COPD-related factors include pulmonary function, physical activity, chronic cough, chronic wheeze, dyspnea, exacerbations, and hospitalizations. The first concept related to a chronic disease is the severity stage. Therefore, the impact of COPD severity on HRQL was often analyzed. Five studies demonstrated that HRQL was deteriorated across severity stages of COPD [5, 6, 12, 24, 27]. Indeed, the more the disease worsens the more the HRQL deteriorates. Thus, it is important to note that HRQL should be considered as a substantial health status indicator in this population.

Symptoms, including chronic cough/sputum, wheeze, and dyspnea, were commonly identified as predictors of HRQL (9 studies). Eight of nine studies showed that an advanced dyspnea grade was associated with a worsening of HRQL scores [14–16, 21, 23–26]. Frequent cough [21, 22] and expectoration [14] also deteriorated the HRQL scores.

The negative impact of exacerbations was reported in the literature. Authors declared that the degree of HRQL impairment depended on the frequency of exacerbations [5, 14, 15]. Indeed, Liang and colleagues revealed that COPD patients who had 3 exacerbations or more in the past 1 year had significantly an impaired HRQL [15].

One the main objectives of COPD treatment was to improve the patient's health status. Indeed, Monteagudo and colleagues revealed that patients taking multiple medications and ending respiratory rehabilitation had improved HRQL at 1-year follow-up [14]. Recently, Esteban and colleagues showed that using 2 out of longacting beta agonists, long-acting muscarinic antagonists, and inhaled corticosteroid, or 3 of them was significantly associated with HRQL scores [17]. Amini and colleagues demonstrated that appropriate inhaler technique was associated with better HRQL in patients with COPD [19]. This data suggested that optimizing inhaler technique should be considered in COPD management programs.

Pulmonary function was significantly associated with HRQL [6, 17, 24]. It was shown that residual volume, diffusing capacity of the lung for carbon

**43**

*COPD-Related Factors Affect the Quality of Life of Patients*

monoxide, and low forced expiratory volume in 1 second (FEV1) predicted

HRQL in comparison with other COPD- related factors and co-morbidities [12, 14–16, 24, 26]. Several research studies demonstrated that dyspnea was the best predictor of HRQL in COPD patients, especially MRC dyspnea grade 4 and 5 [15, 16, 26]. Indeed, Monteagudo and colleagues revealed that the onset of new

symptoms negatively influenced HRQL more than their persistence [14].

Patients with COPD often have at least one associated co-morbidity. Co-morbidities were significantly associated with HRQL impairment. Studies showed that the degree of impairment depended on the number of co-morbidities [5, 12, 16]. Indeed, COPD patients who had 2 to 3 or more co-morbidities had significantly lower HRQL score. Anxiety, depression and other chronic diseases, such as diabetes, hypertension, osteoporosis, and cardiovascular disease, were associated with HRQL impairment [20, 24, 26, 27]. In fact, several studies showed that depression was commonly associated with HRQL worsening [20, 24, 26, 27]. Brien and colleagues reported that depression was associated with higher HRQL [26]. Besides, Kwon and Kim showed that osteoporosis and depression had the highest impact on HRQL in comparison with cardiovascular disease, diabetes, cancer and hypertension [27]. However, Sundh and colleagues revealed that chronic bronchitis phenotype in COPD patients indicated a higher risk of low HRQL in comparison

with musculoskeletal symptoms, osteoporosis and depression [20].

new co-morbidities and to optimize the disease control.

The authors declare that this work was not funded.

The authors declare no conflict of interest.

Coping strategies can enhance the HRQL of COPD patients, but this might fail in case of co-morbid conditions [30]. Therefore, COPD management interventions should address co-morbid conditions along with COPD-related factors. Patienttailored care could be an appropriate strategy for optimal management of the

To conclude, COPD is a burdensome disease that progressively deteriorates the HRQL of patients. This literature review reported that disease severity, frequent symptoms and exacerbations, poor lung function, inappropriate medication use and co-morbidities were significantly associated with HRQL impairment. Dyspnea had the highest impact on HRQL in comparison with other COPD-related factors. Besides, depression was commonly associated with a higher impairment of HRQL. These factors should no longer be a matter of controversy. Disease management interventions should be delivered as early as possible in order to prevent the onset of

In brief, dyspnea had significantly and independently the highest impact on

*DOI: http://dx.doi.org/10.5772/intechopen.96825*

HRQL of COPD patients.

**4.2 Co-morbidities**

disease and its associated factors.

**5. Conclusions**

**Acknowledgements**

**Conflict of interest**

monoxide, and low forced expiratory volume in 1 second (FEV1) predicted HRQL of COPD patients.

In brief, dyspnea had significantly and independently the highest impact on HRQL in comparison with other COPD- related factors and co-morbidities [12, 14–16, 24, 26]. Several research studies demonstrated that dyspnea was the best predictor of HRQL in COPD patients, especially MRC dyspnea grade 4 and 5 [15, 16, 26]. Indeed, Monteagudo and colleagues revealed that the onset of new symptoms negatively influenced HRQL more than their persistence [14].

#### **4.2 Co-morbidities**

*Chronic Obstructive Pulmonary Disease - A Current Conspectus*

negative influence on the HRQL of patients with COPD.

evaluation in this review.

**4.1 COPD-related factors**

subjects.

population.

the HRQL scores.

Regarding to the populations' characteristics, most of the studies addressed middle-age adults and/or older adults. Besides, most of the patients were between moderate and very severe COPD severity stages. They presented different comorbidities, such as diabetes, osteoporosis, depression, anxiety, and cardiovascular diseases. HRQL is a multidimensional, subjective, and dynamic concept, which make it difficult to assess. Nevertheless, there are reliable and valid HRQL measurement tools in the literature. Indeed, Mercier and Schraub distinguished two methods to assess HRQL [29]. The first one is via psychological interview that allows a comprehensive evaluation of HRQL and has therapeutic value. The second method is via psychometric tools that consist of scales or questionnaires. It performs a restrictive evaluation of HRQL and allows standardized measurement. This method is generally easy to use. For that, we included the studies that used this type of HRQL

In the literature, the specific questionnaire mostly used to assess the HRQL was the St George's Respiratory Questionnaire. The generic questionnaires SF-36 and the EQ-5D were also widely used in the literature. These instruments reported that COPD altered the HRQL of patients even in a mild stage [5, 6, 14, 15, 21, 23–25]. HRQL is the result of the interaction of multiple physical, psychological and social components. Consequently, several factors can affect it, especially in COPD

This review demonstrated that multiple COPD-related factors had a significant

COPD-related factors include pulmonary function, physical activity, chronic cough, chronic wheeze, dyspnea, exacerbations, and hospitalizations. The first concept related to a chronic disease is the severity stage. Therefore, the impact of COPD severity on HRQL was often analyzed. Five studies demonstrated that HRQL was deteriorated across severity stages of COPD [5, 6, 12, 24, 27]. Indeed, the more the disease worsens the more the HRQL deteriorates. Thus, it is important to note that HRQL should be considered as a substantial health status indicator in this

Symptoms, including chronic cough/sputum, wheeze, and dyspnea, were commonly identified as predictors of HRQL (9 studies). Eight of nine studies showed that an advanced dyspnea grade was associated with a worsening of HRQL scores [14–16, 21, 23–26]. Frequent cough [21, 22] and expectoration [14] also deteriorated

The negative impact of exacerbations was reported in the literature. Authors declared that the degree of HRQL impairment depended on the frequency of exacerbations [5, 14, 15]. Indeed, Liang and colleagues revealed that COPD patients who had 3 exacerbations or more in the past 1 year had significantly an impaired HRQL [15]. One the main objectives of COPD treatment was to improve the patient's health status. Indeed, Monteagudo and colleagues revealed that patients taking multiple medications and ending respiratory rehabilitation had improved HRQL at 1-year follow-up [14]. Recently, Esteban and colleagues showed that using 2 out of longacting beta agonists, long-acting muscarinic antagonists, and inhaled corticosteroid, or 3 of them was significantly associated with HRQL scores [17]. Amini and colleagues demonstrated that appropriate inhaler technique was associated with better HRQL in patients with COPD [19]. This data suggested that optimizing inhaler technique should be considered in COPD management programs.

Pulmonary function was significantly associated with HRQL [6, 17, 24]. It was shown that residual volume, diffusing capacity of the lung for carbon

**42**

Patients with COPD often have at least one associated co-morbidity. Co-morbidities were significantly associated with HRQL impairment. Studies showed that the degree of impairment depended on the number of co-morbidities [5, 12, 16]. Indeed, COPD patients who had 2 to 3 or more co-morbidities had significantly lower HRQL score. Anxiety, depression and other chronic diseases, such as diabetes, hypertension, osteoporosis, and cardiovascular disease, were associated with HRQL impairment [20, 24, 26, 27]. In fact, several studies showed that depression was commonly associated with HRQL worsening [20, 24, 26, 27]. Brien and colleagues reported that depression was associated with higher HRQL [26]. Besides, Kwon and Kim showed that osteoporosis and depression had the highest impact on HRQL in comparison with cardiovascular disease, diabetes, cancer and hypertension [27]. However, Sundh and colleagues revealed that chronic bronchitis phenotype in COPD patients indicated a higher risk of low HRQL in comparison with musculoskeletal symptoms, osteoporosis and depression [20].

Coping strategies can enhance the HRQL of COPD patients, but this might fail in case of co-morbid conditions [30]. Therefore, COPD management interventions should address co-morbid conditions along with COPD-related factors. Patienttailored care could be an appropriate strategy for optimal management of the disease and its associated factors.

#### **5. Conclusions**

To conclude, COPD is a burdensome disease that progressively deteriorates the HRQL of patients. This literature review reported that disease severity, frequent symptoms and exacerbations, poor lung function, inappropriate medication use and co-morbidities were significantly associated with HRQL impairment. Dyspnea had the highest impact on HRQL in comparison with other COPD-related factors. Besides, depression was commonly associated with a higher impairment of HRQL. These factors should no longer be a matter of controversy. Disease management interventions should be delivered as early as possible in order to prevent the onset of new co-morbidities and to optimize the disease control.

#### **Acknowledgements**

The authors declare that this work was not funded.

#### **Conflict of interest**

The authors declare no conflict of interest.

#### **Author details**

Maha Dardouri1,2\* and Manel Mallouli3

1 Higher School of Health Sciences and Techniques, University of Sousse, Sousse, Tunisia

2 Research Laboratory LR12ES03 "Quality of Care and Management of Maternal HEALTH Services", Faculty of Medicine of Sousse, University of Sousse**,** Sousse, Tunisia

3 Research Laboratory LR12ES03 "Quality of Care and Management of Maternal Health Services", Department of Community and Family Medicine, Faculty of Medicine, University of Sousse, Sousse, Tunisia

\*Address all correspondence to<EMAIL_ADDRESS>
© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

**45**

*COPD-Related Factors Affect the Quality of Life of Patients*

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*COPD-Related Factors Affect the Quality of Life of Patients DOI: http://dx.doi.org/10.5772/intechopen.96825*

#### **References**

*Chronic Obstructive Pulmonary Disease - A Current Conspectus*

**44**

**Author details**

Tunisia

Tunisia

Maha Dardouri1,2\* and Manel Mallouli3

Medicine, University of Sousse, Sousse, Tunisia

provided the original work is properly cited.

1 Higher School of Health Sciences and Techniques, University of Sousse, Sousse,

2 Research Laboratory LR12ES03 "Quality of Care and Management of Maternal HEALTH Services", Faculty of Medicine of Sousse, University of Sousse**,** Sousse,

3 Research Laboratory LR12ES03 "Quality of Care and Management of Maternal Health Services", Department of Community and Family Medicine, Faculty of

© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

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[7] Roche N, Similowski T. *Qualité de vie et BPCO*. John Libbey Eurotext, https://livre.fnac.com/a1916725/ ROCHE-N-SIMILOWSKI-T-Qualitede-vie-et-BPCO (2007, accessed 16 February 2021).

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[10] Formarier M. La qualité de vie pour des personnes ayant un problème de santé. Rech Soins Infirm 2007; 88: 3.

[11] Goodinson SM, Singleton J. Quality of life: a critical review of current concepts, measures and their clinical implications. Int J Nurs Stud 1989; 26: 327-341.

[12] Mallouli M, Dardouri M, Ajmi T, et al. Factors Determining the Quality of Life of Patients With COPD. Clin Pulm Med 2017; 24: 227-231.

[13] Vaske I, Kenn K, Keil DC, et al. Illness perceptions and coping with disease in chronic obstructive pulmonary disease: Effects on healthrelated quality of life. J Health Psychol 2017; 22: 1570-1581.

[14] Monteagudo M, Rodríguez-Blanco T, Llagostera M, et al. Factors associated with changes in quality of life of COPD patients: A prospective study in primary care. *Respir Med*; 107. Epub ahead of print 2013. DOI: 10.1016/j. rmed.2013.05.009.

[15] Liang L, Lin Y, Yang T, et al. Determinants of health-related quality of life worsening in patients with chronic obstructive pulmonary disease at one year. Chin Med J (Engl) 2014; 127: 4-10.

[16] Lee H, Jhun BW, Cho J, et al. Different impacts of respiratory symptoms and comorbidities on COPD-specific health-related quality of life by COPD severity. *Int J COPD*; 12. Epub ahead of print 2017. DOI: 10.2147/ COPD.S145910.

[17] Esteban C, Arostegui I, Aramburu A, et al. Predictive factors over time of health-related quality of life in COPD patients. *Respir Res*; 21. Epub ahead of print 5 June 2020. DOI: 10.1186/s12931-020-01395-z.

[18] Park SK. Changes in symptoms and health-related quality of life in patients with exacerbated chronic obstructive pulmonary disease. *Appl Nurs Res*; 54. Epub ahead of print 1 August 2020. DOI: 10.1016/j.apnr.2020.151278.

[19] Amini S, Ghasemi A, Solduzian M, et al. Is Inhaler Technique Associated with Quality of Life in Patients with Chronic Obstructive Pulmonary Disease? *Curr Ther Res*; 93. Epub ahead of print 2020. DOI: 10.1016/j. curtheres.2020.100608.

[20] Sundh J, Johansson G, Larsson K, et al. Comorbidity and health-related quality of life in patients with severe chronic obstructive pulmonary disease attending swedish secondary care units. Int J COPD 2015; 10: 173-183.

[21] Kendrová L, Mikuľáková W, Nechvátal P, et al. QUALITY OF LIFE IN PATIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE IN SLOVAKIA. Hrvat Rev za Rehabil istraživanja 2015; 51: 57-63.

[22] Deslee G, Burgel PR, Escamilla R, et al. Impact of current cough on health-related quality of life in patients with COPD. Int J COPD 2016; 11: 2091-2097.

[23] Martinez CH, Diaz AA, Parulekar AD, et al. Age-related differences in health-related quality of life in COPD: An analysis of the COPDGene and SPIROMICS Cohorts. Chest 2016; 149: 927-935.

[24] Negi H, Sarkar M, Raval A, et al. Health-related quality of life in patients with chronic obstructive pulmonary disease in North India. J Postgrad Med 2014; 60: 7-11.

[25] Deslee G, Burgel PR, Escamilla R, et al. Impact of current cough on health-related quality of life in patients with COPD. *Int J COPD*; 11. Epub ahead of print 2016. DOI: 10.2147/COPD. S106883.

[26] Brien SB, Stuart B, Dickens AP, et al. Independent determinants of diseaserelated quality of life in COPD – Scope for nonpharmacologic interventions? *Int J COPD*; 13. Epub ahead of print 2018. DOI: 10.2147/COPD.S152955.

[27] Kwon HY, Kim E. Factors contributing to quality of life in COPD patients in South Korea. *Int J COPD*; 11. Epub ahead of print 2016. DOI: 10.2147/ COPD.S90566.

[28] Hammoudeh S, Gadelhaq W, Janahi I. Prospective Cohort Studies in Medical Research. IntechOpen, pp. 11-28.

[29] Mercier M, Schraub S. *Qualité de vie : quels outils de mesure ? Comment mesurer la qualité de vie ?* DaTeBe, Courbevoie (FRA), http://documents. irevues.inist.fr/handle/2042/9760 (2005, accessed 18 February 2021).

[30] Van Manen JG, Bindels PJE, Dekker FW, et al. The influence of COPD on health-related quality of life independent of the influence of comorbidity. J Clin Epidemiol 2003; 56: 1177-1184.

**47**

**Chapter 5**

**Abstract**

of life in patient with COPD.

COPD management in a few guidelines [8, 9].

covid-era

**1. Introduction**

Exercise Training and Pulmonary

Systemic inflammation and deconditioning syndrome lead to loss of structural and function of body muscle, particularly in extremity muscle. Longer period of inactivity due to dyspnea worsen the destruction of muscle. Regular and gradually increase exercise training as part of pulmonary rehabilitation (PR) can improve the function of essential muscles in doing daily life so stable Chronic Obstructive Pulmonary Disease (COPD) patient can maintenance their daily activities with minimal limitations. Pulmonary rehabilitation consists of exercise training, nutritional support, smoking cessation, and self-management of COPD. The prescription of exercise training is mandatory. Assessment of clinical condition to adjust the type of training, duration, frequency, and intensity of training must be completed before beginning the training session. Regular and gradually increased training gives significant impact in improving lung function, dyspnea scale, and quality of life in patient with stable COPD. However, in this covid era, the restriction of hospital attending PR was significantly affect PR program. As immunocompromised population, COPD patient have higher risk for COVID19 infection and develops more severe complications compare with normal population. So, the modified supervised and unsupervised training was needed to revise the classic type of PR. Tele-rehabilitation with teleconference, phone calls, and interactive web based PR can be the good alternative in decreasing hospital admission and improving quality

**Keywords:** Pulmonary rehabilitation, exercise training, COPD, tele-rehabilitation,

Dyspnea is the main symptom of Chronic Obstructive Pulmonary Disease (COPD) that correlates with the limitation of daily activity [1, 2], anxiety and other psychological impacts [3, 4], low quality of life [5], and reduced survival rate [6]. Dyspnea can manifest across the degree of pulmonary obstruction. Either patients with moderate or severe obstruction can experience dyspnea in their daily activities [7]. All these facts cause dyspnea and exercise tolerance becoming the main focus in

Besides the pharmacological approach, pulmonary rehabilitation (PR) is considered an important part of comprehensive COPD treatment, particularly in group B-D [10]. Almost all types of pulmonary rehabilitation have a positive impact on the dyspnea scale of patients with COPD. Six-week of pulmonary rehabilitation was given to the end-stage of COPD outpatients and provide a significant improvement

*Amira Permatasari Tarigan and Fannie Rizki Ananda*

Rehabilitation in COPD

#### **Chapter 5**

*Chronic Obstructive Pulmonary Disease - A Current Conspectus*

[25] Deslee G, Burgel PR, Escamilla R, et al. Impact of current cough on health-related quality of life in patients with COPD. *Int J COPD*; 11. Epub ahead of print 2016. DOI: 10.2147/COPD.

[26] Brien SB, Stuart B, Dickens AP, et al. Independent determinants of diseaserelated quality of life in COPD – Scope for nonpharmacologic interventions? *Int J COPD*; 13. Epub ahead of print 2018.

DOI: 10.2147/COPD.S152955.

[27] Kwon HY, Kim E. Factors

[28] Hammoudeh S, Gadelhaq W, Janahi I. Prospective Cohort Studies in Medical Research. IntechOpen,

[29] Mercier M, Schraub S. *Qualité de vie : quels outils de mesure ? Comment mesurer la qualité de vie ?* DaTeBe, Courbevoie (FRA), http://documents. irevues.inist.fr/handle/2042/9760 (2005, accessed 18 February 2021).

[30] Van Manen JG, Bindels PJE, Dekker FW, et al. The influence of COPD on health-related quality of life independent of the influence of comorbidity. J Clin Epidemiol 2003; 56:

COPD.S90566.

pp. 11-28.

1177-1184.

contributing to quality of life in COPD patients in South Korea. *Int J COPD*; 11. Epub ahead of print 2016. DOI: 10.2147/

S106883.

over time of health-related quality of life in COPD patients. *Respir Res*; 21. Epub ahead of print 5 June 2020. DOI:

[18] Park SK. Changes in symptoms and health-related quality of life in patients with exacerbated chronic obstructive pulmonary disease. *Appl Nurs Res*; 54. Epub ahead of print 1 August 2020. DOI: 10.1016/j.apnr.2020.151278.

[19] Amini S, Ghasemi A, Solduzian M, et al. Is Inhaler Technique Associated with Quality of Life in Patients with Chronic Obstructive Pulmonary Disease? *Curr Ther Res*; 93. Epub ahead of print 2020. DOI: 10.1016/j.

[20] Sundh J, Johansson G, Larsson K, et al. Comorbidity and health-related quality of life in patients with severe chronic obstructive pulmonary disease attending swedish secondary care units.

10.1186/s12931-020-01395-z.

curtheres.2020.100608.

Int J COPD 2015; 10: 173-183.

[21] Kendrová L, Mikuľáková W, Nechvátal P, et al. QUALITY OF LIFE IN PATIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE IN SLOVAKIA. Hrvat Rev za Rehabil istraživanja 2015; 51: 57-63.

[22] Deslee G, Burgel PR, Escamilla R, et al. Impact of current cough on health-related quality of life in patients with COPD. Int J COPD 2016; 11:

[23] Martinez CH, Diaz AA, Parulekar AD, et al. Age-related differences in health-related quality of life in COPD: An analysis of the COPDGene and SPIROMICS Cohorts.

Chest 2016; 149: 927-935.

[24] Negi H, Sarkar M, Raval A, et al. Health-related quality of life in patients with chronic obstructive pulmonary disease in North India. J Postgrad Med

**46**

2014; 60: 7-11.

2091-2097.

## Exercise Training and Pulmonary Rehabilitation in COPD

*Amira Permatasari Tarigan and Fannie Rizki Ananda*

#### **Abstract**

Systemic inflammation and deconditioning syndrome lead to loss of structural and function of body muscle, particularly in extremity muscle. Longer period of inactivity due to dyspnea worsen the destruction of muscle. Regular and gradually increase exercise training as part of pulmonary rehabilitation (PR) can improve the function of essential muscles in doing daily life so stable Chronic Obstructive Pulmonary Disease (COPD) patient can maintenance their daily activities with minimal limitations. Pulmonary rehabilitation consists of exercise training, nutritional support, smoking cessation, and self-management of COPD. The prescription of exercise training is mandatory. Assessment of clinical condition to adjust the type of training, duration, frequency, and intensity of training must be completed before beginning the training session. Regular and gradually increased training gives significant impact in improving lung function, dyspnea scale, and quality of life in patient with stable COPD. However, in this covid era, the restriction of hospital attending PR was significantly affect PR program. As immunocompromised population, COPD patient have higher risk for COVID19 infection and develops more severe complications compare with normal population. So, the modified supervised and unsupervised training was needed to revise the classic type of PR. Tele-rehabilitation with teleconference, phone calls, and interactive web based PR can be the good alternative in decreasing hospital admission and improving quality of life in patient with COPD.

**Keywords:** Pulmonary rehabilitation, exercise training, COPD, tele-rehabilitation, covid-era

#### **1. Introduction**

Dyspnea is the main symptom of Chronic Obstructive Pulmonary Disease (COPD) that correlates with the limitation of daily activity [1, 2], anxiety and other psychological impacts [3, 4], low quality of life [5], and reduced survival rate [6]. Dyspnea can manifest across the degree of pulmonary obstruction. Either patients with moderate or severe obstruction can experience dyspnea in their daily activities [7]. All these facts cause dyspnea and exercise tolerance becoming the main focus in COPD management in a few guidelines [8, 9].

Besides the pharmacological approach, pulmonary rehabilitation (PR) is considered an important part of comprehensive COPD treatment, particularly in group B-D [10]. Almost all types of pulmonary rehabilitation have a positive impact on the dyspnea scale of patients with COPD. Six-week of pulmonary rehabilitation was given to the end-stage of COPD outpatients and provide a significant improvement

of dyspnea scale using a visual analog scale [11]. A meta-analysis study also suggests including upper extremity exercise in pulmonary rehabilitation because it can relieve dyspnea in COPD, although few studies showed the insignificant difference of Borg scale after the training [12]. A study that compares endurance training, combined endurance and strength training, and pharmacological alone showed the improvement of dyspnea in endurance and combined training, but not in a pharmacological alone group. It stated that strength training gives an additional impact on muscle force, but not different from endurance training alone in health status [13]. This is in line with the previous author's study that showed 4 weeks of upper extremity exercise without strength training had demonstrated the improvement of dyspnea scale using the mMRC scale [14].

On the other side, an intervention study with 6 weeks of cardiopulmonary exercise showed an insignificant improvement of dyspnea scale measured with 0–10 Category Ratio (CR) in COPD patients [15]. But as general, a review article that compiles few meta-analyses, randomized controlled study, reviews, and the clinical trial showed that pulmonary rehabilitation gives positive impacts in COPD patients according to functional outcomes, dyspnea scale, and quality of life [16]. Different results might be caused by different dyspnea scales used in the various study. But according to GOLD, the Borg scale and mMRC scale were recommended to measure the dyspnea scale in COPD patients (*Global Initiative for Chronic Obstructive Lung Disease*, 2019).

Breathing training as part of PR can improve regional ventilation and gas exchange and respiratory muscle function that later improves the exercise tolerance and quality of life of patients [17]. Breathing training includes diaphragm breathing, pursed-lip breathing, relaxation technique, and body position [18]. In a study, diaphragm breathing alone and the combination of diaphragm breathing and pursed-lip breathing can reduce the asynchrony of inspiration-expiration ratio and increase lung volume [19]. A study also stated the combination of upper limb training and pursed-lip breathing can decrease dyspnea, improve exercise capacity, and quality of life in patients with stable COPD [14]. Diaphragm breathing (DB) itself improves breathing patterns by coordinating the rib cage muscles and abdominal wall, reduce the activity of the accessory muscle, and lead to improving exercise tolerance [20].

#### **2. Deconditioning syndrome**

Decondition syndrome refers to the change in the structure and function of body muscle due to inactivity. This syndrome usually occurred in chronic cardiovascular and lung disease, including Chronic Obstructive Pulmonary Disease (COPD) [21, 22]. This change involved muscle, cardiac, lung, and vascular-related to the history of the disease [23]. This syndrome consisted of three steps:

**49**

*Exercise Training and Pulmonary Rehabilitation in COPD*

it will take to return to your previous level of functioning [21].

ventilation needed for running daily activities [24–26].

Decondition syndrome is a vicious cycle that occurred progressively. The longer the period of inactivity, the more severe the deconditioning will be, and the longer

Generally, three basic mechanisms contribute to deconditioning syndrome in chronic pulmonary disease. There is an imbalance between oxygen distributed along with the systemic and respiratory muscles and the amount of oxygen served, muscle dysfunctions include a structural and functional change in extremity and respiratory muscle, and imbalance between ventilation capacity and the amount of

The disturbance of exercise capacity may result in systemic manifestation rather than pulmonary disease. Systemic inflammation, hypoxia, and deconditioning syndrome are caused by muscle atrophy and loss of muscle functions [26]. Muscle atrophy occurs when there is an imbalance of protein synthesis due to lower testosterone levels [21, 22] and protein degradation. Increased levels of ubiquitin and TNF-α was seen in several studies [26, 27]. Further, malnutrition, chronic hypoxia, oxidative stress will increase systemic inflammation and muscle

Pulmonary rehabilitation is a substantial part of comprehensive treatment in COPD in every stage. According to GOLD 2021, pulmonary rehabilitation is recommended in stage B-D of stable COPD. Pulmonary rehabilitation includes exercise training, smoking cessation, nutrition, and education for self-management intervention [28]. Pulmonary rehabilitation should be offered to patients with COPD to improve dyspnoea and health status by a clinically important amount. Besides, pulmonary rehabilitation also alleviates psychological disturbance results in the

Exercise training is the main part of pulmonary rehabilitation. According to GOLD 2020, regular exercise training can improve shortness of breath, exercise tolerance, and quality of life status [29]. Exercise training includes endurance/aerobic training, strength training, and inspiratory muscle training. According to GOLD 2021, the combination of these training gives better

In COPD patients, the high level of katabolic cytokines contributed to malnutrition [30]. A high level of IL-6, IL-8, TNF-α showed in COPD patients and their levels have a role as predictors of worse outcomes in COPD [26, 30–32]. Also, high broadcasting of leptin in COPD patient play roles in decreased appetite consequently in decreased muscle mass and functions [33, 34]. Twentyfive to forty percent of COPD patients experienced malnutrition and 25% of them has moderate to severe malnutrition with low fatty fat mass [35].

The nutritional intervention showed a significant increase in muscle mass and function leads to exercise tolerance improvement. Antioxidant properties in vegetables and fruit may increase the antioxidant resulted in decreasing systemic inflammation [36]. Besides, high fat with low carbohydrate food also showed the improvement of pulmonary function in stable COPD

*DOI: http://dx.doi.org/10.5772/intechopen.97704*

disturbance [26].

**3. Pulmonary rehabilitation**

1.Exercise training

2.Nutritional support

long-term effect of chronic pulmonary disease.

outcomes compared with the method alone [28].

*Exercise Training and Pulmonary Rehabilitation in COPD DOI: http://dx.doi.org/10.5772/intechopen.97704*

*Chronic Obstructive Pulmonary Disease - A Current Conspectus*

dyspnea scale using the mMRC scale [14].

*Obstructive Lung Disease*, 2019).

exercise tolerance [20].

**2. Deconditioning syndrome**

biking, and swimming.

ing, shopping, and lifting some goods.

just laying on the hospital bed.

of dyspnea scale using a visual analog scale [11]. A meta-analysis study also suggests including upper extremity exercise in pulmonary rehabilitation because it can relieve dyspnea in COPD, although few studies showed the insignificant difference of Borg scale after the training [12]. A study that compares endurance training, combined endurance and strength training, and pharmacological alone showed the improvement of dyspnea in endurance and combined training, but not in a pharmacological alone group. It stated that strength training gives an additional impact on muscle force, but not different from endurance training alone in health status [13]. This is in line with the previous author's study that showed 4 weeks of upper extremity exercise without strength training had demonstrated the improvement of

On the other side, an intervention study with 6 weeks of cardiopulmonary exercise showed an insignificant improvement of dyspnea scale measured with 0–10 Category Ratio (CR) in COPD patients [15]. But as general, a review article that compiles few meta-analyses, randomized controlled study, reviews, and the clinical trial showed that pulmonary rehabilitation gives positive impacts in COPD patients according to functional outcomes, dyspnea scale, and quality of life [16]. Different results might be caused by different dyspnea scales used in the various study. But according to GOLD, the Borg scale and mMRC scale were recommended to measure the dyspnea scale in COPD patients (*Global Initiative for Chronic*