|Year : 2019 | Volume
| Issue : 1 | Page : 14-23
Assessment of comorbidities in patients with chronic obstructive pulmonary disease: a cross-section study
Ammar M Nashwat, Hamada Kawshty, Yasin Abd-ElKareem, Ibrahim M Shalan
Department of Chest Diseases, Faculty of Medicine, Al-Azhar University, Assiut, Egypt
|Date of Submission||24-Sep-2018|
|Date of Acceptance||25-Mar-2019|
|Date of Web Publication||12-Sep-2019|
Ibrahim M Shalan
Assiut Dirut, Assiut
Source of Support: None, Conflict of Interest: None
Background Chronic obstructive pulmonary disease (COPD) is common and usually coexists with other diseases. The aim of this study was to assess comorbidities in patients with COPD.
Patients and methods This is a cross-sectional controlled study of comorbidities in patients with COPD that was carried out on 200 patients with COPD and 180 non-COPD patients as control. They were admitted to or investigated in outpatient clinic of Chest Disease Department of Assiut Hospital, Al-Azhar University, during the period from November 2016 to May 2018. A patient with COPD was defined as a smoker with forced expiratory volume in first second/forced vital capacity less than 0.7, and comorbidities were defined based on objective laboratory findings and questionnaires.
Results This study included 380 patients, comprising 200 patients with COPD (75% males and 25% females, with mean age of 62±10.1 years) and 180 non-COPD patients (76.7% males and 23.3% females, with mean age of 61.1±5.6 years). The most common comorbidities reported in our COPD population versus non-COPD in decreasing order of frequency were hypertension (40 vs. 30%) followed by dyslipidemia (35 vs. 30%), asthma (30 vs. 13.8%), gastroesophageal reflux disease (30 vs. 16.1%), obesity (22.5 vs. 20%), bronchiectasis (21 vs. 6.1%), diabetes mellitus (19 vs. 12.2%), anemia (19 vs. 12.2%), ischemic heart disease (17 vs. 10%), and pneumonia (15.5 vs. 7.8%).
Conclusion COPD is more common in smoker old aged male individuals, and the most common comorbid conditions associated with COPD are hypertension, dyslipidemia, gastroesophageal reflux disease, diabetes mellitus, and ischemic heart disease.
Keywords: assessment, comorbidity, chronic obstructive pulmonary disease
|How to cite this article:|
Nashwat AM, Kawshty H, Abd-ElKareem Y, Shalan IM. Assessment of comorbidities in patients with chronic obstructive pulmonary disease: a cross-section study. Al-Azhar Assiut Med J 2019;17:14-23
|How to cite this URL:|
Nashwat AM, Kawshty H, Abd-ElKareem Y, Shalan IM. Assessment of comorbidities in patients with chronic obstructive pulmonary disease: a cross-section study. Al-Azhar Assiut Med J [serial online] 2019 [cited 2020 Jun 2];17:14-23. Available from: http://www.azmj.eg.net/text.asp?2019/17/1/14/266742
| Introduction|| |
Chronic obstructive pulmonary disease (COPD), ‘a common preventable and treatable disease, is 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.’ Comorbidities contribute to the severity in individual patients .
COPD is the chronic respiratory condition that represented the most significant health problem at international level . The effect of COPD is constantly increasing, and COPD will be the third leading cause of death in the world by 2030 .
COPD can affect function of other organs such as liver, kidney, heart, and brain; it is frequently associated with several disorders . One-third of the adult population has comorbidity, and its percentage increases with age .
COPD usually coexists with other diseases that are considered a main prognostic factor of the squally of COPD. Some of these diseases occur regardless of COPD; some share risk factors and others are related to a common cause(s). For example, inflammation caused by smoking can be a common risk factor for several diseases, such as ischemic heart disease, anemia, cancer, osteoporosis, depression, and diabetes .
The aim of study was to assess different comorbidities in patients with COPD.
| Patients and methods|| |
This cross-sectional study of comorbidities in patients with COPD was carried out on 200 patients of COPD and 180 non-COPD patients as a control; they were admitted to or investigated in outpatient clinic of Chest Disease Department of Assiut Hospital, Al-Azhar University, during the period from November 2016 to May 2018. The study was approved by the local ethical committee of Assiut Faculty of Medicine, Al-Azhar University, to evaluate and publish information. After explanation to the patients, a written or verbal consent was taken from all patients. Inclusion criteria were (a) patients diagnosed as having COPD after assessment of the presence of chronic cough, sputum production, dyspnea, or history of exposure to risk factors as smoking and fumes and (b) their mean age was more than or equal to 40 years. Exclusion criteria were patients presented with bronchial asthma or other lung diseases other than COPD.
All patients were subjected to full medical history (age, sex, smoking history, and BMI, and dyspnea as per the modified Medical Research Council), clinical examination, chest radiography, chest computed tomography (CT) scans for suspected cases of pulmonary comorbidity, abdominal ultrasound, ECG, echocardiography if needed, and broadband ultrasound attenuation to measure bone mineral density.
Laboratory investigations include C-reactive protein, complete blood count (white blood cells, hemoglobin, hematocrit, and platelets), liver function tests (alanine aminotransferase, aspartate aminotransferase, albumin, total bilirubin, and international normalized ratio), renal function tests (serum creatinine and urea), blood sugar, and lipogram (total cholesterol, triglyceride, high-density lipoprotein and low-density lipoprotein).
Pulmonary function tests
Pulmonary function tests (PFT) were performed with a spirometer (Medical Equipment Europe, Hammelburg, Germany); the primary purpose of them was to identify the severity of pulmonary impairment. Prebronchodilation and postbronchodilation spirometry measurements were performed in all study participants. Forced expiratory volume in first second (FEV1), forced vital capacity (FVC), and FEV1/FVC ratio were recorded. ‘Postbronchodilator values (i.e. 30 min after the administration of 400 µg salbutamol with a spacer) were used for the evaluation of COPD severity, according to GOLD guidelines (stage I: mild COPD, FEV1 >80.0% predicted; stage II: moderate COPD, 50.0%≤FEV1<80.0% predicted; stage III: severe COPD, 30.0%≤FEV1<50.0%; stage IV: very severe COPD, FEV1<30.0%, or FEV1<50.0% predicted with respiratory failure) .
Comorbidities in patients were defined based on the answers to self-reported questionnaires asking ‘Have you been diagnosed with the disease by a doctor?’ (yes/no), or ‘Do you take medicine or treatment for the disease?’
Definition of chronic obstructive pulmonary disease
COPD was defined as a former or current exposure to noxious particles or gases (mostly smoking) with proven spirometric airflow limitation (ratio of FEV1/FVC <70%). Smoking history was supplemented to the COPD definition to reduce the possibility of including asthmatic cases .
Definition of other conditions
Hypertension was defined as mean systolic blood pressure more than or equal 140 mmHg or mean diastolic blood pressure less than or equal 90 mmHg on examination and/or current intake of antihypertensive drugs . Other comorbidities, including ischemic heart diseases (IHD), heart failure (HF), pulmonary hypertension (PHT), arrhythmia, and cardiac valve diseases, were defined based on clinical symptoms and signs, ECG and echocardiography, or receiving treatment for the disease. Diabetes mellitus was defined by fasting glucose more than 126 mg/dl or HbA1c more than 6.5% or current use of oral hypoglycemic agents or insulin for glycemic control . Obesity was defined by a BMI more than or equal 30 kg/m2 .
Other comorbidities, including pneumonia, lung abscess, bronchiectasis, plural effusion, tuberculosis, pneumothorax, lung cancer, pulmonary fibrosis, and pulmonary embolism (PE), were defined based on clinical symptoms and signs, chest radiography, high-resolution CT (HRCT) chest, CT pulmonary angiography, CT chest with contrast, lesion biopsy with histopathological examination, sputum analysis of acid-fast bacillus, or receiving treatment for the disease.
Obstructive sleep apnea (OSA) is suspected in population with typical nocturnal clinical signs (snoring, poor sleep, nocturnal awakening, witnessed apneas, etc.) and daytime signs (morning headaches, excessive daytime sleepiness, and daytime fatigue), as well as impaired gas exchange or inadequately explained PHT by lung function and results of blood gas test. The diagnosis is confirmed by using a type 3 portable monitoring device, with polysomnography, which rarely is necessary .
Anemia was defined by hemoglobin less than 13 mg/dl in males and less than 12 mg/dl in females or receiving treatment for the disease. Polycythemia was defined by hemoglobin more than 16.5 and 16 g/dl in men and women, respectively, or hematocrit more than 49 and 48% in men and women, respectively, or red cell mass more than 25% above mean normal predicted value. Thrombocytopenia was defined by platelet count less than 150 000/mm2 or receiving treatment for the disease. Thrombocytosis was defined by platelet count more than 600 000/mm3 .
Peptic ulcer and gastroesophageal reflux disease (GERD) were defined based on clinical symptoms and signs and upper gastrointestinal endoscopy or receiving treatment for the disease . Other comorbidities, including nonalcoholic fatty liver disease, liver cirrhosis, liver hemangioma, cholecystitis, benign prostatic hyperplasia (BPH), nephrolithiasis, hydronephrosis, and some other malignancies, were defined based on clinical symptoms and signs, abdomino-pelvic ultrasonography, abdomino-pelvic CT with contrast, lesion biopsy with histopathological examination, tri-phasic CT abdomen, noncontrast abdomino-pelvic CT scan, or receiving treatment for the disease.
Anxiety and depression were defined by current use of anxiety or depression medications or HADS score more than 10 points . Osteoporosis was defined by current use of osteoporosis medications or a lumbar spine, total hip, or femur neck T-score less than 2.5 on dual-energy radiograph absorptiometry .
The collected data were tabulated and statistically analyzed using the SPSS 17.0 (Chicago, IL, USA) software package. Data were expressed as the mean, range, SD, frequency, and percentage. For the statistical assessment, independent t test and χ2 tests were applied, and P value less than 0.05 was considered significant.
| Results|| |
This study included 380 patients, comprising 200 patients with COPD and 180 non-COPD patients. In patients with COPD, 75% were males and 25% were females, with mean age of 62±10.1 years, whereas in non-COPD patients, 76.7% were males and 23.3% were females, with mean age of 61.1±5.6 years. The smoking status among patients with COPD was 34.5% were current smokers, 41% exsmokers, 22.5% biomass exposure, and 2% nonsmokers, whereas in non-COPD patients, 31.1% were current smokers, 28.9% exsmokers, 18.3% biomass exposure, and 21.7% nonsmokers. According to smoking index, among patients with COPD, 62% were heavy smokers, 11.5% moderate smokers, and 2% mild smokers, whereas in non-COPD patients, 37.78% were heavy smokers, 17.2% moderate smokers, and 5% mild smokers. There are highly significant differences between COPD and non-COPD patients ([Table 1]).
|Table 1 Sociodemographic characteristics among patients with chronic obstructive pulmonary disease (total N=200) and non-chronic obstructive pulmonary disease patients (total N=180)|
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According to BMI, among patients with COPD, 20.5% were normal, 48.5% overweight, 8.5% underweight, 20% obese, and 2.5% morbid obese, whereas in non-COPD patients, 27.2% were normal, 56.67% overweight, 1.67% underweight, 10.56% obese, and 3.88% morbid obese. According to modified Medical Research Council scale, among patients with COPD, 19% were grade 1, 27% were grade 2, 37.5% were grade 3, 10.5% were grade 4, and 6% were grade 5. Overall, 51.5% of the patients developed two or more exacerbations in the last year ([Table 1]).
Cough, expctoration, and dyspnea were present in all patients, chest wheezes in 62.5%, orthopnea and/or paroxysmal nocturnal dyspnea in 19%, hemoptysis in 10.5%, fever in 14%, palpitation in 11%, and chest pain in 14.5% ([Figure 1]). Overall, 89% of studied patients presented with regular pulse, 8.5% extrasystole, and 2.5% atrial fibrillation. Moreover, 40% of the studied patients were hypertensive, 29.5% showed increased jugular venous pressure, 29.5% had lower limb edema, 21.5% had hepatomegaly, 21% of studied patients had central cyanosis, 19% had pallor, 14% had fever, whereas jaundice and clubbing were less presented ([Figure 2]).
[Table 2] showed that nine (4.5%) cases were in stage I COPD, 87 (43.5%) cases stage II COPD, 68 (34%) cases stage III, and 36 (18%) cases stage IV. It also showed that 29 (14.5%) cases were grade A COPD, 68 (34%) cases grade B COPD, nine (4.5%) cases grade C COPD, and 94 (47%) cases grade D COPD.
|Table 2 Stages and grades of patients with chronic obstructive pulmonary disease (total N=200)|
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[Table 3] showed that there are significant differences in laboratory findings of the studied COPD and non-COPD patients in white blood cells, hemoglobin, hematocrit, platelets, serum creatinine, urea, alanine aminotransferase, aspartate aminotransferase, albumin, total bilirubin, international normalized ratio, total cholesterol, triglyceride, high-density lipoprotein, and low-density lipoprotein. In contrast, there is no significant relation in random blood sugar between patients and controls.
|Table 3 Laboratory findings of the studied patients with chronic obstructive pulmonary disease (total N=200) and non-chronic obstructive pulmonary disease patients (total N=180)|
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[Table 4] showed PFT of the studied patients with COPD, including FEV1 (50.18±19.39%), FVC (81.98±21.2%), and FEV1/FVC ratio (49.22±12.9%), and also showed PFT of the studied non-COPD patients, including FEV1 (92.23±12.05%), FVC (91.59±11.04%), and FEV1/FVC ratio (84.43±8.05%). It also showed arterial blood gases of the studied patients with COPD, including pH (7.4±0.51), PCO2 (45.8±10.4), PO2 (57.21±21.2), and H2CO3 (31.56±8.5), and also showed arterial blood gases of the studied non-COPD patients, including pH (7.39±0.32), PCO2 (38.32±8.4), PO2 (79.43±16.83), and H2CO3 (23.65±7.21).
|Table 4 Pulmonary function tests and arterial blood gases of the studied patients with chronic obstructive pulmonary disease (total N=200) and non-chronic obstructive pulmonary disease patients (total N=180)|
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[Table 5] showed the pattern of comorbidities in patients with COPD and non-COPD patients. The comorbidities reported in our COPD population versus non-COPD in decreasing order of frequency were hypertension (40 vs. 30%) followed by dyslipidemia (35 vs. 30%), asthma (30 vs. 13.8%), GERD (30 vs. 16.1%), obesity (22.5 vs. 20%), bronchiectasis (21 vs. 6.1%), diabetes mellitus (19 vs. 12.2%), anemia (19 vs. 12.2%), IHD (17 vs. 10%), pneumonia (15.5 vs. 7.8), BPH (15 vs. 12.2%), nonalcoholic fatty liver disease (14 vs. 9.4%), HF (11 vs. 3.3%), arrhythmia (11 vs. 5%), plural effusion (10.5 vs. 3.8%), hernia (10 vs. 4.4%), PHT (9 vs. 3.8%), osteoporosis (9 vs. 6.1%), OSA (8.5 vs. 6.7%), chronic calculous cholecystitis (8.5 vs. 7.2%), depression (8 vs. 5%), cerebrovascular disease (8 vs. 5%), pulmonary fibrosis (7.5 vs. 2.2%), myocardial infarction (7 vs. 6.1%), chronic renal failure (6 vs. 2.2%), lung cancer (6 vs. 1.1%), polycythemia (5.5 vs. 2.2%), cardiac valve disease (5 vs. 4.4%), peptic ulcer (5 vs. 2.7%), tuberculosis (4 vs. 2.2%), anxiety (4 vs. 2.2%), liver cirrhosis (3.5 vs. 3.8%), nephrolithiasis (3.5 vs. 2.7%), thrombocytopenia (3 vs. 2.7%), others cancers (3 vs. 2.2%), pneumothorax (2.5 vs. 0.5%), PE (2 vs. 0.5%), liver hemangioma (2 vs. 2.2%), hepatitis C virus (2 vs. 2.2%), urinary tract infection (2 vs. 2.7%), hypothyroidism (1.5 vs. 0.5%), thrombocytosis (1.5 vs. 2.2%), hydronephrosis (1.5 vs. 2.2%), and lung abscess in two (1 vs. 0.5%) cases.
|Table 5 Relation between chronic obstructive pulmonary disease and non-chronic obstructive pulmonary disease regarding comorbidities (total N=380)|
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Moreover, it showed that there are significant differences in comorbidities of the studied COPD and non-COPD patients in hypertension, IHD, HF, arrhythmia, PHT, dyslipidemia, obesity, diabetes mellitus, bronchiectasis, pneumonia, plural effusion, pulmonary fibrosis, asthma, GERD, chronic calculous cholecystitis, anemia, polycythemia, chronic renal failure, osteoporosis, and hernia. There are no significant differences in comorbidities of the studied COPD and non-COPD patients in myocardial infarction, cardiac valve disease, hypothyroidism, OSA, tuberculosis, pneumothorax, PE, lung abscess, nonalcoholic fatty liver disease, peptic ulcer, liver cirrhosis, liver hemangioma, hepatitis C virus, thrombocytopenia, thrombocytosis, BPH, nephrolithiasis, urinary tract infection, hydronephrosis, lung cancer, others cancers, depression, cerebrovascular disease, and anxiety.
| Discussion|| |
The prevalence of COPD comorbidities varies significantly between studies depending on the definitions, population, and methods used. It is noted that mean age and source of the population vary between the studies. Moreover, the comorbidity definition was not uniform across studies. In most cases, the conditions are self-reported and rarely graded. Moreover, inaccurate estimation of these studies may be owing to variation in inclusion and exclusion criteria .
Our study included 200 patients with COPD (150 males and 50 females) and 180 non-COPD patients (138 male and 42 females) who were admitted to or investigated in outpatient clinic of Chest Department of Al-Azhar University, Assiut Branch Hospital, during the period from November 2016 to April 2018 and diagnosed as having COPD based on clinical history, examination, radiological investigations, and PFTs.
Regarding cardiovascular comorbidities, our results are in agreement with those from studies showing that cardiovascular problems are among the most common comorbid conditions in COPD . There was significant variation in estimation of cardiovascular disease prevalence in a recent systematic review. Coronary heart disease ranged from 4.7 to 60%, congestive HF ranged from 7.1 to 31.3%, and unspecified cardiovascular disease ranged from 29 to 70% . Hypertension is one of the most prevalent comorbid diagnoses in patients with COPD reported in 40–60% , which increases with disease severity; this finding is in agreement with our study (40 vs. 30%).
IHD in patients with COPD ranges between 16.1 and 53%  and includes various abnormalities (coronary artery disease, angina, and myocardial infarction). Our percentages (17 vs. 10%) were similar to those noted in previous studies.
In ECLIPSE study, ‘heart trouble’ as opposed to MI was reported in 9% of 2164 patients with COPD compared with 3% of 337 smoking controls . These findings were inconsistent with our study (7 vs. 6.1%) as a result of small number of cases and controls.
In patients with COPD, hyperlipidemia ranges between 36 and 52%  which is near to our study (35 vs. 30%). In this study, the prevalence of obesity in patients with COPD versus controls was 22.5 versus 20%. Similar to our study, Vozoris and O’Donnell  found that obesity represented 25% of COPD population compared with 17% of non-COPD. Contrary to our study, Rodríguez et al.  documented that obesity has been estimated between 29 and 43% in COPD population.
In our study, diabetes in COPD and non-COPD patients are 19 and 12.2%, respectively. This result agreed with the studies of Divo et al.  and Agusti et al.  who documented that diabetes ranges between 10 and 25% in patients with COPD.
Regarding bronchiectasis, our study showed that it is 21% in patients with COPD and 6.1% in non-COPD. This result is inconsistent with Martínez-García et al.  who found that 57% of patients with moderate-to-severe COPD experience coexistent bronchiectasis. This large difference as our diagnosis depends on doing HRCT chest in only suspected patients, but the previous study performed HRCT chest for all patients.
In our study, pneumonia rates in COPD and non-COPD patients are 15 and 7.8%, respectively. COPD is more frequently associated with pneumonia compared with other chronic diseases. Overall, 19% of 707 patients presenting with community-acquired pneumonia had COPD. Moreover, in 10% of the cases, pneumonia led to the new diagnosis of COPD. As expected, presence of COPD in patients with pneumonia leads to longer hospital stays, increased intensive care admissions, and mortality .
Obstructive sleep apnea syndrome (OSAS) is no more common in COPD than in the general population . In present study, OSAS in patients with COPD versus controls was 8.5 versus 6.7. This result disagreed with Qian et al.  who found that after stratification for BMI and age, prevalence of OSAS was approximately 14% among patients with COPD 40 years and older. This difference is owing to lower number of cases in our study and limited numbers of sleep study centers in Assiut governorate. However, the fact that OSAS is a common clinical entity in the general population gives a significant number of cases of coexistence with COPD.
In present study, the prevalence of pulmonary fibrosis in patients with COPD versus controls was 7.5 vs. 2.2%. This result coincided with Divo et al.  who reported that the prevalence of concurrent COPD and pulmonary fibrosis was 6.1%.
The prevalence of asthma − COPD overlap in the elderly has been reported at rates as high as 50% . However, our study showed lower probability (30 vs. 13.8%), as our cases have risk to exposure to noxious materials.
Venous thromboembolism (VTE) is found in 3–29% of COPD cases during exacerbation . In a study of 211 consecutive patients with severe exacerbation of COPD, Tillie-Leblond et al.  reported that PE was present in 25% of patients. On the contrary, Rutschmann et al.  recently reported a low incidence of PE in 123 consecutive patients with acute exacerbation of COPD: clinical suspicion of PE is present in 6.2% of patients and only 1.3% of those with low suspicion. Our study showed lower probability of PE (2 vs. 5 %), as our diagnosis depends on doing HRCT chest to only suspected patients but the previous study performed HRCT chest for all patients.In studies reliant on self-reporting of diagnosis or symptoms, 7.7–30% of patients with COPD had GERD . However, Casanova et al.  used 24-h pH monitoring to assess acid GERD prevalence and demonstrated that acid GERD was present in 62% of patients with severe COPD (FEV1 range, 20–49%) versus 19% of controls. These finding are in agreement with our study (30 vs. 16%).
Prevalence of peptic ulcer disease ranged between 5.2 and 32% in patients with COPD ,. These are similar to our result (5 vs. 2.8%). Other gastrointestinal diseases that have been reported as prevalent in patients with COPD include liver cirrhosis (2%) . This finding was near to our study (3.5 vs. 3.8%).
Anemia in patients with COPD ranged between 7 and 43.9% ,, but estimates vary widely depending on severity of disease, age, and sex. Our percentages were similar to those noted in these studies (19 vs. 12.2%).
Polycythemia as a result of chronic hypoxemia in patients with COPD is less prevalent at ∼6% than in the past owing to the advent of long-term oxygen therapy . This result was consistent with our study (5.5 vs. 2.2%).
Prevalence of chronic kidney disease in patients with COPD ranged between 1.5 and 43% ,. These percentages were similar to our study (6 vs. 2.2%). In contrast, Gjerde et al.  revealed that 25% of patients with COPD over 64 years of age may have chronic renal failure even with normal serum creatinine values.
Prevalence of lung cancer in patients with COPD ranged between 3.8 and 8.0% based on the population and the severity of COPD but is estimated to be between 3.8 and 8.0% . Our percentages are near to those noted in these studies (6 vs. 1.1%).
In the present study, stroke in COPD versus non-COPD patients was 8 vs. 5%. Similar to our study, Feary et al.  reported that 9.9% of patients with COPD had stroke compared with 3.2% in the rest of the population.
In patients with COPD, the prevalence of anxiety ranges from 6 to 74% . However, the prevalence of anxiety in recent meta-analysis studies with diagnostic clinical interview ranged between 10 and 55% (median, 17%) in inpatients and 13–46% in outpatients . Depression prevalence in patients with COPD ranges from 8 to 80% . In our study, we found that the prevalence of anxiety and depression is 6 versus 2.2% and 8 versus 5%, which was compatible with previous studies. Anxiety and depression are more prevalent in COPD than in the general population .
In COPD, osteoporosis varies greatly between 8.4 and 69% . Our percentages were comparable with previous studies (9 vs. 6.1%). Graat-Verboom et al.  demonstrated that osteoporosis was significantly higher in patients with COPD than healthy controls (32.5 vs. 11.4%) in their systematic review.
Limited number of patients included was one of the limitations of our study, so generalization of our result to the whole COPD population cannot be done. Another limitation of our study was methodology used in reporting the presence of comorbidity, which is not completely objective, because it was not dependent on repeating or seeking confirmatory tests for each disease, which was expensive.
In our opinion, more studies are needed to understand the effect of COPD in various comorbidities and to understand the effect of treating this pulmonary disease on comorbidities.
| Conclusion|| |
Worldwide, COPD is a major burden of morbidity and is considered as a systemic disease. Attention should be focused on the role of comorbidities as part of the natural history of the disease process. Cigarette smoking is the main risk factor for COPD and other major diseases, such as cancer and cardiovascular disease, which are also more common with increasing age. There was a high frequency of comorbidities among patients with COPD. The most common comorbid conditions associated with COPD are hypertension, dyslipidemia, GERD, diabetes mellitus, and IHD.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]