| [Background]Chronic obstructive pulmonary disease (COPD) is a chronic inflammatory disorder characterized by persistent airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases. And the lesion site could affect multiple systemic organs resulting in systemic inflammatory response other than confined only to the lung. COPD is aslo a leading cause of high morbidity, disability rate and mortality worldwide and results in an economic and social burden that is predicted to rank fifth for costs of treatment in2020, and to rank third for mortality and seventh for disability rate in2030respectively. Disease-related malnutrition is a common complication of COPD.20-40%of patients with COPD are reported to suffer from body weight loss and cachexia and17%-83%hospitalized patients with COPD are malnourished according to foreign epidemiological data. Domestic scholars have found that the incidence of malnutrition is22.3%in outpatients with COPD and33.0%of them are at risk of malnutrition. Malnutrition could not only affects the progression and prognosis of COPD resulting in decreased quality of life in patients but also increases the risk of exacerbations and mortality leading to economic and social burden. Current treatment for COPD are focused on pharmacotherapy such as bronchodilators. However, the non-pharmacological interventions including pulmonary rehabilitation and nutritional support are relatively insufficient.Currently, the internationally accepted indicators to assess the nutritional status of COPD patients include weight, body mass index (BMI), mini nutritional assessment (MNA), subjectivity comprehensive nutritional assessment (SGA), arm muscle circumference (AMC), lean body mass (FFM), fat free mass index (FFMI) and so on. FFM and FFMI are deemed to be accurate to assess the nutritional status according to a number of studies and are obtained mainly through bioelectrical impedance (Bioelectric Impedance Analysis, BIA) measurements. FFM and FFMI are mainly used to assess metabolic disease (eg. obesity, diabetes) and chronic wasting diseases (eg. tumour, COPD) in the foreign courtries while domestic applications to COPD are still in its infancy. By analyzing the nutritional status of patients with COPD and to explore the relationship between nutrition and the severity of disease, we’ll believe it could lead to a better understanding of the role of malnutrition in development of COPD as well as the significance of early nutrition management.[objective]The present study aims to detect the incidence of malnutrition in stable COPD patients using Bioelectric Impedance Analysis combining with BMI and MNA methods to obtain FFMI. And we’d like to analyze the correlation between FFMI and respiratory muscle function as well as exercise capacity in different stage of COPD. Moreover, we’d like to analyze the risk factors may lead to malnutrition in COPD patients. It would have important clinical significance to provide an evidence for pulmonary rehabilitation and nutritional interventions in early clinical and practice management.[Methods]We did a retrospective investigation of288patients with COPD from the Department of Respiratory Medicine, Zhujiang Hospital, Southern Medical University, and recorded patients basic information (Age, gender, smoking history, exacerbations in previous1year and so on) and clinical data (course of disease, lung function, body mass index, complications, medication history and so on). Of the investigated patients,199who kept stable status of COPD were selected as objects of study between June2013and January2014. We recorded the follow-up related auxiliary examination (blood, liver and kidney function, fibrinogen, high-sensitivity C-reactive protein, imaging data and so on). After tested the height, using multi-frequency electrical impedance and8-point-contact method to measure body composition in patients by BIA at8:30-10:30am on the first day of the follow-up, and we recorded FFM, obtained the FFMI by using FFM divided the height square. Measured maximal inspiratory pressure (PImax) and maximal expiratory pressure (PEmax) for three times that every time interval less than30seconds to decide the maximal value, and the six minutes walk testing would be followed after10-minute break. The questionnaire was discussed by the respiratory specialist in the design process. Before the formal investigation, the investigators carried on the preliminary investigation, the collection of all information is completed by the same investigator. Statistical significance of differences in all study groups were estimated with one-way analysis of variance for multiple comparisons, between two groups were determined using Independent-sample t test, study parameters (independent variables) were determined using Spearman or Pearson correlation coefficient analysis. Univariate and Multivariate logistic regression analysis was used to calculate the odds ratios (OR) and95%confidence intervals (CI) by SPSS13.0software. And to explore the influence of the selected suspicious risk factors on malnutrition in patients with stable COPD.[Result]Data in this study included147male cases and52female cases, of which the percentage was73.87%and26.13%respectively. Age (67.31±11.26year old); stature (163.47±8.45m); body weight (58.31±12.51kg); smoking status:smoking history133cases (66.83%) and non-smoking history66cases (33.17%), total smoking index (.625.57±216.15year cigarette); course of disease (8.47±1.56years); breathing difficulties assessment (mMRC)(2.02±1.90points); exercise tolerance (6MWD)(408.80±123.53m); lung function:FEV11.40±0.59L, FVC2.58±0.88L, FEV1%Pred59.56±20.75(%), FEV1/FVC54.31±12.60(%). Complications:hypertension65cases (67.71%), sinusitis6cases (6.25%), coronary heart disease12cases (12.50%), prostatic hyperplasia7cases (7.29%), pulmonary heart disease5cases (5.20%) and chronic gastritis15cases (15.63%); the number of acute exacerbation past a year:1.62±0.88(times); COPD symptom assessment test (CAT):19.41±6.85(points); St. George’s respiratory questionnaire score (SGRQ):30.87±14.14(points); Inhaled corticosteroids using:98cases (49.25%); BODE:2.89±2.40, respiratory muscle function PImax76.28±20.90(cmH20) and PEmax88.57±24.74(cmH20); mini nutritional assessment score (MNA):22.84±3.44(points); fat free mass index (FFMI):15.62±1.60(kg/m2), body mass index (BMI):22.07±4.01(kg/m2). COPD classification based version GOLD2006:the mild32cases (16.08%), the moderate83cases (41.71%), the severe61(30.65%) and the very severe23cases (11.56%); COPD classification based version GOLD2011:group A of41patients (20.60%), group B of30cases (15.08%),42cases in group C (21.11%) and86cases in group D (43.21%).2. Nutrition status survey results of COPD patients in stable phaseThree methods of BMI, MNA and FFMI were used respectively to evaluate nutrition status of COPD patients in stable phase(1). Comparison of BMI, MNA and FFMI in evaluating nutrition status of COPD patients in stable phase.Based on body mass index (BMI) Grade:Nutrition normal had160cases (80.40%) and39cases (19.60%) were lower than the normal; Based on mini nutritional assessment (MNA) Grade:malnutrition had14cases (7.04%),87cases (43.72%) had nutritional risk and98cases (49.24%) were well-nourished; according to fat free mass index (FFMI) level:normal nutrition has106cases (53.27%) and93cases (46.73%) were lower than the normal (Table4). Among three kinds of nutritional assessment methods, FFMI assess had the highest incidence of malnutrition, indicating it had a higher sensitivity and was more suitable for the early detection of malnutrition.(2). Comparison of FFMI normal patients and subnormal patients in stable phase of COPD.The study found that compared the FFMI normal group and the subnormal group in age, duration, pulmonary function, dyspnea scores, mini nutritional assessment score, body mass index, respiratory muscle function, exercise tolerance, BODE index, serum albumin, serum total protein and hormone use, the difference was significant and has statistically significant (P<0.05).(3). Nutritional status distribution of different grade COPD patients in stable phase with FFMI assessment. According to the version GOLD2006COPD classification standard, among199cases of COPD patients whose FFMI was lower than normal:the mild had9cases (4.52%), the moderate had31cases (15.58%), the severe had36cases (18.09%) and17cases (8.54%) were very severe. The incidence of severe malnutrition was highest. Based on the version GOLD2011COPD classification standard, among199cases of COPD patients whose FFMI was lower than normal:13patients (6.53%) in group A,12patients (6.03%) in group B,13cases in group C (6.53%) and55cases (27.64%) in D group. The incidence of malnutrition in group D was the highest.3. Comparison and correlation analysis of clinical symptoms, nutritional status, exercise tolerance and respiratory muscle function from different grade COPD patients in stable phase.(1) Comparison of Clinical symptoms, nutritional status, exercise tolerance and respiratory muscle function from different grade COPD patients in stable phase. According to the version GOLD2006COPD classification standard, it was found that compared CAT, mMRC, SGRQ, FFMI,6MWD, BODE, PEmax and PImax mean in each grade of COPD, it had significant differences and statistical significance (P <0.05). The maximum of MNA, FFMI,6MWD, PEmax and PImax were in mild grade, and the maximum of CAT, mMRC, SGRQ and BODE index were in very severe grade. According to the version GOLD2011COPD classification standard, the difference of CAT, mMRC, SGRQ, MNA, FFMI,6MWD, BODE, PEmax and PImax mean in each grade of COPD were significant and had statistical significance (P <0.05). But BMI between groups was not statistically significant (P>0.05). The maximum of MNA, BMI, FFMI,6MWD, PEmax and PImax were in group A, and the maximum of CAT, mMRC, SGRQ and BODE index were in the group D.(2) Correlation analysis of clinical symptoms, nutritional status, exercise tolerance and respiratory muscle function from different grade COPD patients in stable phase. According to the version GOLD2006COPD classification standard, it was found that CAT, mMRC, SGRQ, BODE and COPD level were positively correlated and the result were statistical significance (P<0.05). Meanwhile, MNA, BMI, FFMI,6MWD, PEmax and PImax with COPD grade were negatively correlated with statistical significance (P<0.05). Among them, FFMI, PEmax and PImax level had a stronger correlation with the COPD grade in the version GOLD2006standard, but the rest had a stronger correlation with the COPD grade in the version GOLD2011standard.(3) FFMI of COPD patients in stable phase was significantly negatively correlated with CAT, mMRC and BODE, at the same time it had a significant positive correlation with MNA, BMI,6MWD, PEmax and PImax. Them all had statistically significant (P<0.05).4. Risk factors analysis for malnutrition of COPD patients in stable phase(1) Malnutrition univariate logistic regression analysis of COPD patients in stable phase assessed by FFMI indicators. The study found that malnutrition risk of COPD patients in stable phase whose were aged60years or older was3.007times (OR value) than that of those under age60; the risk of whose dyspnea score was two points or more than2points is3.412times than that of the person with points lower than2; the risk of whose SGRQ points value was25or more was2.506times than that of the person whose points was less than25; malnutrition risk of the patients associated with chronic gastritis was3.060times than that of those who did not merge, and malnutrition risk of those with combined pulmonary heart disease was5.592times than that of those without; the risk of hormone users2.542times than that of non-hormone users; malnutrition possibility of6MWD was17.333times than that of those with a distance greater than350meters; malnutrition possibility of severe and very severe COPD patients was4.155and9.476times respectively than that of the mild patients; the possibility of patients with BODE index grade IV was1.121times than that of patients with BODE index grade I. Based on the above results, we filter out the age, mMRC, SGRQ, chronic gastritis, pulmonary heart disease, hormone use,6MWD, COPD level and BODE index as suspect risk factors of malnutrition for COPD patients in stable phase.(2) Malnutrition Multivariate Binary Logistic Regression Analysis of COPD patients in stable phase assessed by FFMI indicators. Statistically significant variables selected by univariate analysis were included in the multivariate regression model and analyzed by stepwise Logistic regression with maximum likelihood estimation. Age, mMRC, severe and very severe COPD, PEmax and PImax were risk factors for malnutrition of COPD patients in stable phase (P<0.05). And Model had been tested and proved to have a statistical significance (X2=45.023, P=0.000).[Conclusion]The study found that the incidence of malnutrition was high in patients with stable COPD, FFMI was a sensitive assessment method; there were significantly correlation between respiratory muscle strength, exercise endurance and FFMI; implementation of nutrition interventions in moderate grade or group B, could ease the disease progression. Showed age, mMRC, severe grade of COPD, very severe grade of COPD, PEmax, PImax were the risk factors of malnutrition with stable COPD. Therefore, paying more attention to the presence of these risk factors, early nutrition intervention and pulmonary rehabilitation exercises may help slow the progression of COPD. |
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