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Original Article

Assessment of Sleep and Quality of Life Among Chronic Obstructive


Airways Disease Patients
Mahima Malhotra, Ruchi Sachdeva1, Sandeep Sachdeva2

Department of Psychiatry, Objective: To assess sleep and quality of life among chronic obstructive airway

ABSTRACT
Govind Ballabh Pant disease patients. Materials and Methods: Patients with primary, mild-to-moderate,
Institute of Medical
Education and Research,
stable chronic obstructive airways disease [asthma and chronic obstructive pulmonary
New Delhi, 1Department disease (COPD)] on treatment visiting outpatient department of a government hospital
Respiratory Medicine, ESIC were interviewed using a predesigned, pretested, semi-structure schedule. The
Medical College, Faridabad, patients were then administered standardized Pittsburgh sleep quality index
Haryana, 2Department of (PSQI), St. George’s respiratory questionnaire (SGRQ), and Epworth sleepiness
Community Medicine, North scale (ESS) questionnaires. Patients with any other known chronic disease, chest
Delhi Municipal Corporation deformity, or long-term oxygen therapy were excluded. Using purposive sampling
Medical College and Hindu
frame, 120 chest patients (asthma and COPD) and in addition, 30 ambulatory patients
Rao Hospital, New Delhi,
India without having any underlying chronic respiratory diseases were also recruited for
comparison purpose. Results: Mean age was 50.2 years. Mean duration of sleep
during night was 5.40 h [±1.6; 95% confidence interval (CI) = 4.98–5.82] for patients
with COPD; 5.53 h (±1.6; 95% CI = 5.11–5.95) for patients with asthma, and 6.97 h
(±1.0; 95% CI = 6.57–7.36) for control patients (P < 0.001). It was noticed that 63.3%
of control patients had at least 6 h of night sleep in comparison to 23.3% of chest
patients (P < 0.01). Good PSQI score (up to 5 points) was found in 86.6% of control
patients while it was found only in 35.0% of chest patients (P < 0.01); mean PSQI
score among asthma was 8.08, 8.06 (COPD), and 3.46 among control patients,
respectively. All the control patients (100%) reported good score for quality of
life while chest patients reported good score for SGRQ (activity, impact, and
symptoms) as 64.1, 83.3, and 82.5%, respectively (P < 0.01). Based on ESS,
none of the patients complained of daytime sleepiness. To conclude, poor sleep
was noticed in our study sample.
KEYWORDS: Asthma, chest, chronic respiratory diseases, COPD, ESS, MMSE, PSQI,
Received: July 2017
Accepted: March 2018 quality of life, SGRQ, sleep quality, smoking, tobacco

INTRODUCTION have many systemic effects and complications related to

A sthma and chronic obstructive pulmonary disease cardiovascular, musculoskeletal, neurological system,
(COPD) are important public health respiratory with nutritional, and metabolic effects.[4,5]
problems over the world. The global prevalence of Sleep-related disturbances and insomnia have been shown
asthma and COPD in general population ranges from 1 to be higher in patients with COPDs than that in the general
to 18% and 3 to 11%, respectively.[1] India is currently population, ranging between 50 and 70% of patients
harboring a staggering 57,000,000 people suffering from
obstructive airway diseases with at least 35% of adult
Address for correspondence: Dr. Ruchi Sachdeva, Department
population consuming tobacco in some form.[2,3] Although Respiratory Medicine, ESIC Medical College, Faridabad,
chronic respiratory diseases affect primarily the Haryana, India.
respiratory tract/lungs but lately have been found to E-mail: drsachdeva@hotmail.com

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DOI: How to cite this article: Malhotra M, Sachdeva R, Sachdeva S.


10.4103/jacp.jacp_20_17 Assessment of Sleep and Quality of Life Among Chronic Obstructive
Airways Disease Patients. J Assoc Chest Physicians 2018;6:45-52.

© 2018 The Journal of Association of Chest Physicians | Published by Wolters Kluwer - Medknow 45
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Malhotra, et al.: Sleep and quality of life in asthma and COPD patients

reporting difficulty in initiating or maintaining sleep, or 0 to 3, with a maximum total score of 21 and a minimum
having poor sleep quality.[6] Disturbed sleep has been score of 0. The sum of the component scores yields
found to be associated with more severe disease, a global PSQI score. A global score up to 5 indicates
frequent exacerbations, and increased mortality. Poor “good” overall sleep quality, whereas a score >5 indicates
sleep quality also affects the quality of life in COPD “poor” sleep quality with a diagnostic sensitivity
and patients with asthma.[7,8] There are limited studies and specificity of 89.6 and 86.5%, respectively. In
performed in Indian context exploring the sleep quality comparison with other tools to measure sleep, the PSQI
pattern among chronic respiratory disease patients. has undergone extensive psychometric evaluation. It
With this background a study was undertaken to has been shown to have high test–retest reliability and
determine sleep and quality of life among primary construct validity.
obstructive airway disease as well as control patients
St. George’s respiratory questionnaire
visiting a government hospital. It is designed to measure impact on overall health, daily
life, and perceived well-being in patients with obstructive
MATERIALS AND METHODS airways disease. It covers three domain-symptoms,
The interview schedule captured sociodemographic activity, and impact. It addresses the frequency of
details and consisted of mix of self rating response respiratory symptoms and patient’s current health
items elicited in local language by researcher followed state (i.e., how they are these days). The activity score
by treatment, advice, and counseling. Sociodemographic measures disturbances in daily physical activity. The
variables included age, gender, marital status, education, impacts score covers a range of disturbances of psycho-
tobacco consumption/smoking, duration of illness, social function.[10] Score ranges from 0 to 100 with
history of hospitalization of at least 24 h in past 1-year, zero indicating best and higher score indicating worse
sleep pattern, and duration. Some of the details, especially state.
duration of sleep, daytime sleepiness, etc. was re-checked
with the patient’s accompanying spouse, if available. Mini mental status examination
The patients were then assessed using standardized It has 22 items, which examines various cognitive
Pittsburgh sleep quality index (PSQI), St. George’s capacities (orientation to time and place, memory,
respiratory questionnaire (SGRQ), Epworth sleepiness attention, concentration, recognition of objects, language
scale (ESS), mini mental status examination (MMSE). function, comprehension and expressive speech, motor
Patients with any known chronic liver, kidney, heart, functioning, and praxis). The total score is 30
neurological disease, malignancy, chest deformity, or with higher score indicating worse condition. Hindi
long-term oxygen therapy were excluded. adaptation of the MMSE instrument was used in this
A study was performed in Hindu Rao Hospital, New study.[11]
Delhi a government teaching hospital among ambulatory, Epworth sleepiness scale
stable, adult patients in a comfortable, confidential, The ESS is intended to measure daytime sleepiness.[12]
and nonjudgemental manner. Using purposive sampling The patients were interviewed to rate their probability
frame, 120 diagnosed chest patients (asthma and COPD) of falling asleep on a scale of 0–3 with increasing
on treatment visiting outpatient department were probability for eight situations that most people engage
clinically evaluated and interviewed using predesigned, during their daily lives, though not necessarily every
pretested, semi-structure interview schedule during the day. The scores for the eight questions are added
period January to March 2014 after seeking informed together to obtain a single number. A number in the
written consent of patients and ethical consideration. 0–9 range is considered to be normal, while a number
In addition, 30 ambulatory patients without having in the 10–24 range indicates that expert medical advice
any underlying chronic respiratory disease reporting should be sought.
for common cold/muscular pain/generalized weakness,
etc., were also mobilized for comparison purpose. Statistical and data analyses
All categorical variables were expressed as frequencies
Brief on study instruments. and percentages, and continuous variables were expressed
Pittsburgh sleep quality index as mean and standard deviation. For the purpose of
Sleep quality was measured using the PSQI, a self-rated analysis, PSQI score of 0 and 1 (better score) was
subjective questionnaire comprising 19 questions that classified into good and score of 2 and 3 as worse.
generate seven “component” scores (sleep quality, sleep Same concept was applied to other scales as applicable.
latency, sleep duration, habitual sleep efficiency, sleep Among all the patients, it was found out that average
disturbances, use of sleeping medication, and daytime night sleep was 5.7 h; therefore, sleep duration in the night
dysfunction).[9] Each component score is marked from was dichotomised into less than and more 6 h duration to

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Malhotra, et al.: Sleep and quality of life in asthma and COPD patients

explore association with other co-variables. There were no RESULTS


missing values. Descriptive statistics and association Background details
between variables were determined using chi-square Out of a total of 150 patients, there were 60 (40%)
test while the strength of association with co-variables patients with asthma; 60 (40%) patients with COPD;
was measured by contingency coefficient and considered and 30 (20%), control patient. Overall mean age
significant at P < 0.05. Data management was undertaken was 50.2 years [chest patients had mean age of 51.0
using the Statistical Package for the Social Sciences (±13.4) years while control patients were 47.2 (±12.7)
version 16.0 software (IBM, Chicago, USA). Some of years old (P > 0.05)]. Table 1 shows the background
the inherent limitations of this study include hospital information of patients.
based convenience sampling; sleep duration was
assessed on subject recall that is prone for bias; in Sleep duration
addition, patients could not undergo polysomnography Mean duration of sleep during night was 5.40 h [±1.6;
evaluation due to resource constraints. 95% confidence interval (CI): 4.98–5.82] for patients

Table 1: Background information of study patients (chest and control patients)


Variable Control Chest patients Total Chi square value CC P value
patients (asthma and COPD) subjects
N = 30 (%) n = 120 N = 150 (%)
Age (years) Up to 50 9 (30.0) 31 (25.8) 40 (26.6) 0.213 0.038 0.644
>50 21 (70.0) 89 (74.1) 110 (73.3)
Gender Female 7 (23.3) 45 (37.5) 52 (34.6) 2.127 0.118 0.145
Male 23 (76.6) 75 (62.5) 98 (65.3)
Marital status Un-married 0 6 (5.0) 6 (4.0) 1.562 0.102 0.211
Married 30 (100) 114 (95.0) 144 (96.0)
Education Up to primary 15 (50.0) 59 (49.1) 74 (49.3) 0.007 0.007 0.953
> Primary 15 (50.0) 61 (50.9) 76 (50.6)
Tobacco Yes 13 (43.3) 69 (57.5) 82 (54.6) 1.94 0.041 0.616
consumption No 17 (56.6) 51 (42.5) 68 (45.3)
Psych illness Yes 2 (6.6) 8 (6.7) 10 (6.6) 0 0 1.0
No 28 (93.3) 112 (93.3) 140 (93.3)
Sleep-night <6 h 11 (36.6) 92 (76.6) 103 (68.6) 17.84 0.32 <0.01
≥6 h 19 (63.3) 28 (23.3) 47 (31.3)
PSQI-global Good 26 (86.6) 42 (35.0) 68 (45.3) 25.85 0.383 <0.01
Worse 4 (13.3) 78 (65.0) 82 (54.6)
PSQI-duration Good 23 (76.6) 48 (40.0) 71 (47.3) 12.94 0.282 <0.01
Worse 7 (23.3) 72 (60.0) 79 (52.6)
PSQI-disturbance Good 30 (100) 76 (63.3) 106 (70.6) 15.56 0.307 <0.01
Worse 0 44 (36.6) 44 (29.3)
PSQI-latency Good 24 (80.0) 43 (35.8) 67 (44.6) 18.94 0.335 <0.01
Worse 6 (20.0) 77 (64.1) 83 (55.3)
PSQI-daytime Good 28 (93.3) 54 (45.1) 82 (54.6) 22.62 0.362 <0.01
dysfunction Worse 2 (6.9) 66 (55.0) 68 (45.3)
PSQI-habitual Good 28 (93.3) 73 (60.8) 101 (67.3) 11.52 0.267 <0.01
sleep efficiency Worse 2 (6.9) 47 (39.1) 49 (32.6)
PSQI-quality Good 30 (100) 117 (97.5) 147 (98.0) 1.02 0.082 0.598
Worse 0 3 (2.5) 3 (2.0)
PSQI-medication Good 30 (100) 115 (95.8) 145 (96.6) 1.26 0.092 0.261
Worse 0 5 (4.2) 5 (3.3)
SGRQ-activity Good 30 (100) 77 (64.1) 107 (71.3) 49.03 0.496 <0.01
Worse 0 43 (35.8) 43 (28.6)
SGRQ-impact Good 30 (100) 100 (83.3) 130 (86.6) 29.06 0.404 <0.01
Worse 0 20 (16.6) 20 (13.3)
SGRQ-symptom Good 30 (100) 99 (82.5) 129 (86.0) 20.42 0.346 <0.01
Worse 0 21 (17.5) 21 (14.0)
PSQI = Pittsburgh sleep quality index, SGRQ = St. George’s respiratory questionnaire, CC = contingency coefficient. Percentage given in
brackets.

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Malhotra, et al.: Sleep and quality of life in asthma and COPD patients

with COPD; 5.53 h (±1.6; 95% CI: 5.11–5.95) score was 8.08 (asthma), 8.06 (COPD), and 3.46
for patients with asthma; and 6.97 h (±1.0; 95% CI: (control) patients, respectively, with higher score
6.57–7.36) for control patients (P < 0.001). Association indicating worse condition. On considering duration of
between demographic variables, sleep quality, and illness among chest patients into <2 and ≥2 years, mean
sleep duration is shown in Table 1. Significantly PSQI score was 6.5 and 8.19 for asthma while it was 8.2
higher proportion of control patients had positive and 8.0 for patients with COPD. With regard to
feature in comparison to chest patients, that is, presence or absence of psychiatric co-morbidity
63.3% of control patients had more than 6 h of among chest patients, average PSQI score was 9.5
night sleep in comparison to 23.3% of chest patients (present) and 7.98 (normal) among asthma while it
(P < 0.01). was 12.5 (present) and 7.75 (normal) patients with
COPD. On considering tobacco consumption, overall
Sleep quality mean PSQI score was 7.20 for tobacco consumer
Good PSQI score (up to 5) was found in 86.6% and 7.08 for nonconsumer. Component wise PSQI
of control patients while it was found only in score (good/worse) is shown in Figures 1 and 2,
35.0% of chest patients (P < 0.01). Mean PSQI respectively.

Proportion of asthma patients with good and worse PSQI score

100% 2 4
90%
20 22
80%
28
70% 34
41 39
60%
50% 58 56
40%
40 38
30%
32
20% 26
19 21
10%
0%
PSQI dur PSQI dist PSQI late PSQI dady PSQI effic PSQI qual PSQI med PSQI
global

Good score Worse score

Figure 1: Proportion of asthma patients (n = 60) with good and worse PSQI score

Proportion of COPD patients with good and worse PSQI score

100% 1 2
90%
80% 24 25
70% 38 36 38 39
60%
50% 59 58
40%
30% 36 35
20% 22 24 22 21
10%
0%
PSQI dur PSQI dist PSQI late PSQI dady PSQI effic PSQI qual PSQI med PSQI
global

Good score Worse score

Figure 2: Proportion of COPD patients (n = 60) with good and worse PSQI score

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Malhotra, et al.: Sleep and quality of life in asthma and COPD patients

Quality of life good PSQI score (good quality) slept for >6 h. This
All the control patients (100%) reported good score for is adequately reflected by moderately incremental
quality of life (SGRQ-activity, impact and symptoms) values of contingency coefficient, a factor of strength
while only 64.1, 83.3, and 82.5% of chest patients of association.
reported good score for SGRQ, respectively (P < 0.01).
Based on MMSE, all the chest and control patients had
Mean values of quality of life (SGRQ score) is shown in
normal cognitive capacities. Similarly on ESS, none of the
Table 2.
patient complained of daytime sleepiness.
Duration of night-sleep, PSQI and SGRQ score was
significantly associated (P < 0.01) with type of patients
(chest vs. control). Further association was explored for
DISCUSSION
sleep duration (less than and >6 h) with sleep quality. A descriptive study was undertaken to assess subjective
Details are shown in Tables 3 and 4. Quality and sleep pattern among ambulatory, mild-to-moderate, stable,
quantity (duration) of sleep is an inter-linked primary cases of obstructive airway disease (asthma and
concept. Higher proportion of patients with poor COPD) on treatment presenting as follow up visits
PSQI score (poor quality) slept for <6 h while the at outpatient department of a mid level government
inverse, that is, higher proportion of patients with hospital of Delhi, India. Our study showed significant
differences reflecting poor quality of sleep and quality
of life among chronic obstructive airway disease (asthma
Table 2: Quality of life score among all study patients and COPD) patients in comparison to controls. Among
Quality of life (SGRQ) Asthma COPD Control chest patients, it was noticed that only 23.3% had at least
Mean value (range: 0–100)* 6 h of night sleep while 65% had poor PSQI global score
SGRQ-activity 63.69 67.26 10.49 (>5 points); 35.8, 16.6, and 17.5% had poor SGRQ score
SGRQ-impact 50.16 54.27 5.93 related to activity, impact and symptoms, respectively. All
SGRQ-symptoms 45.53 54.25 8.77 the patients were nonobese, had normal cognitive capacity
Total score 53.13 58.16 9.27 with none reporting daytime sleepiness. Globally it is
*Value near 0 indicates best while 100 indicates worst quality of life known that poor sleep quality is observed more
score. frequently among patients with COPD; however, in our

Table 3: Association of sleep quality with sleep duration (<6 h) among patients
Sleep quality parameter Sleep duration (<6 h)
Score Control Asthma COPD Total Chi-square CC P value
N = 11 N = 45 N = 47 N = 103
PSQI-global Good 7 (63.6) 12 (26.6) 10 (21.2) 29 (28.1) 7.99 0.268 0.018
Worse 4 (36.3) 33 (73.3) 37 (78.7) 74 (71.8)
PSQI-duration Good 4 (36.3) 11 (24.4) 9 (19.1) 24 (23.3) 1.53 0.121 0.464
Worse 7 (63.6) 34 (75.5) 38 (80.8) 79 (76.6)
PSQI-disturbance Good 11 (100) 29 (64.4) 26 (55.3) 66 (64.0) 7.73 0.264 0.021
Worse 0 16 (35.5) 21 (44.6) 37 (35.9)
PSQI-latency Good 7 (63.6) 12 (26.6) 16 (34.0) 35 (33.9) 5.38 0.223 0.068
Worse 4 (36.3) 33 (73.3) 31 (65.9) 68 (66.0)
PSQI-daytime dysfunction Good 11 (100) 22 (48.8) 15 (31.9) 48 (46.6) 16.77 0.374 0
Worse 0 23 (51.1) 32 (68.0) 55 (53.3)
PSQI-habitual sleep efficiency Good 9 (81.8) 25 (55.5) 23 (48.9) 57 (55.3) 3.901 0.191 0.142
Worse 2 (18.1) 20 (44.4) 24 (51.0) 46 (44.6)
PSQI-quality Good 11 (100) 43 (95.5) 46 (97.8) 100 (97.0) 0.80 0.08 0.668
Worse 0 2 (4.4) 1 (2.1) 3 (2.9)
PSQI-medication Good 11 (100) 41 (91.1) 46 (97.8) 98 (95.1) 5.27 0.222 0.072
Worse 0 4 (8.8) 1 (2.1) 5 (4.9)
SGRQ-activity Good 11 (100) 28 (62.2) 29 (61.7) 68 (66.0) 6.34 0.241 0.042
Worse 0 17 (37.7) 18 (38.2) 35 (33.9)
SGRQ-impact Good 11 (100) 35 (77.7) 39 (82.9) 85 (82.5) 3.27 0.176 0.195
Worse 0 10 (22.2) 8 (17.0) 18 (17.4)
SGRQ-symptoms Good 11 (100) 39 (86.6) 40 (85.1) 90 (87.3) 2.72 0.16 0.256
Worse 0 6 (13.3) 7 (14.8) 13 (12.6)
PSQI = Pittsburgh sleep quality index, SGRQ = St. George’s respiratory questionnaire, CC = contingency coefficient. Percentage given in brackets.

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Table 4: Association of sleep quality with sleep duration (>6 h) among patients
Sleep quality parameter Sleep duration (≥6 h)
Score Control Asthma COPD Total Chi-square CC P value
N = 19 N = 15 N = 13 N = 47
PSQI-global Good 19 (100) 9 (60.0) 11 (84.6) 39 (82.9) 9.53 0.411 0.009
Worse 0 6 (40.0) 2 (15.3) 8 (17.0)
PSQI-duration Good 19 (100) 15 (100) 13 (100) 47 (100) –
Worse 0 0 0 0
PSQI-disturbance Good 19 (100) 11 (73.3) 10 (76.9) 40 (85.1) 5.652 0.328 0.059
Worse 0 4 (26.6) 3 (23.0) 7 (14.8)
PSQI-latency Good 17 (89.4) 7 (46.6) 8 (61.5) 32 (68.0) 7.423 0.369 0.024
Worse 2 (10.5) 8 (53.3) 5 (38.4) 15 (31.9)
PSQI-daytime dysfunction Good 17 (89.4) 10 (66.6) 7 (53.8) 33 (70.2) 5.251 0.317 0.072
Worse 2 (10.5) 5 (33.3 6 (46.1) 13 (27.6)
PSQI-habitual sleep efficiency Good 19 (100) 13 (86.6) 12 (92.3) 44 (93.6) 2.545 0.227 0.28
Worse 0 2 (13.3) 1 (7.6) 3 (6.3)
PSQI-quality Good 19 (100) 15 (100) 13 (100) 47 (100) –
Worse 0 0 0 0
PSQI-medication Good 19 (100) 15 (100) 12 (92.3) 46 (97.8) 2.595 0.231 0.273
Worse 0 0 1 (7.6) 1 (2.1)
SGRQ-activity Good 19 (100) 10 (66.6) 10 (76.9) 39 (82.9) 7.061 0.361 0.029
Worse 0 5 (33.3) 3 (23.0) 8 (17.0)
SGRQ-impact Good 19 (100) 15 (100) 11 (84.6) 45 (95.7) 5.463 0.323 0.065
Worse 0 0 2 (15.3) 2 (4.2)
SGRQ-symptoms Good 19 (100) 12 (80.0) 11 (84.6) 42 (89.3) 3.953 0.279 0.139
Worse 0 3 (20.0) 2 (15.3) 5 (10.6)
PSQI = Pittsburgh sleep quality index, SGRQ = St. George’s respiratory questionnaire, CC = contingency coefficient. Percentage given in brackets.

study COPD and patients with asthma had similar poor Ahmed et al. in Aligarh, Uttar Pradesh.[22] The mean
results. Quality of sleep can be improved by ensuring SGRQ score in this community based study was 49.54
compliance to treatment, management of co-morbidities (symptom score), 41.47 (activity score), 33.58 (impact
including gastro esophageal reflux, oxygen therapy, score) and 38.89 (total score). In our hospital based
providing training for inhaler technique, counseling, life study, the mean score (poor condition) was found to be
style changes, behavior change communication, avoidance slightly higher [Table 2].
of trigger factors and rehabilitation.[13-18] It is noted that according to Global Adult Tobacco
On review of literature, Nunes et al.[7] reported that Survey, prevalence of tobacco consumption among
70% of patients with COPD had poor sleep quality; and adults in India has decreased by 6.0% point from 35%
the quality of sleep was the major determinant of quality (2009–10) to 28.6% (2016–17).[23] Based on these,
of life in those patients. In another recent study more than there were 274.9 million tobacco users with 163.7
half of the patients with COPD experienced poor sleep million users of only smokeless tobacco, 68.9 million
quality. The most common sleep complaints included only smokers and 42.3 million users of both smoking
getting up for the bathroom, waking up at night or in and smokeless tobacco in the country with mean age at
the early morning, and coughing or snoring loudly.[19] In a initiation being 18.9 years. The survey also reported that
study by Scharf et al.[20] sleep quality was also associated 38.7% [rural (44.4%) to urban (27.9%)] of adults were
with quality of life and sleep disturbance predicted poor exposed to second-hand-smoke at home. According to
survival in patients with COPD.[21] The factors resulting Census 2011, two third of households in country are
in sleep disturbance are not well understood. There using firewood/crop residue, cow dung cake/coal, etc.,
are multi-factorial causation and/or determinants of a in their kitchen. The tobacco epidemic, environmental
particular health state yet conservatively it can be pollution, other risk exposure, and poor health practices
commented that quality of sleep was disproportionately worldwide and particularly in developing country along
more affected than quality of life among our sampled with extensive use of bio fuel is now presenting itself
asthma and patients with COPD. With regard to quality with its adverse and diverse consequences in community
of life, similar but slightly better status has been reported and at health facilities. This observation is further
among COPD in a community based study conducted by substantiated, as COPD accounted for second most

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Malhotra, et al.: Sleep and quality of life in asthma and COPD patients

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quality and low duration of sleep[30] as observed in challenge toward effective management. MAMC J Med Sci
our study too. 2015;1:80-4.
14. Budhiraja R, Siddiqi TA, Quan SF. Sleep disorders in chronic
In conclusion, this study can be considered to be unique, obstructive pulmonary disease: Etiology, impact, and management.
because the influence of chronic respiratory ailments on J Clin Sleep Med 2015;11:259-70.
sleep quality and quality of life was assessed simultaneously 15. Collop N. Sleep and sleep disorders in chronic obstructive
using diverse globally acknowledged measurement scale pulmonary disease. Respiration 2010;80:78-86.
upon clinical confirmation using standard definitions. The 16. Salles C, Terse-Ramos R, Souza-Machado A, Cruz AA. Obstructive
findings are suggestive of significantly impaired sleep sleep apnea and asthma. J Bras Pneumol 2013; 39:604-12.
quality among chronic obstructive airway disease 17. Jen R, Li Y, Owens RL, Malhotra A. Sleep in chronic obstructive
patient’s in-comparison to control patients. pulmonary disease: Evidence gaps and challenges. Can Respir J
2016;2016:7947198.
Financial support and sponsorship 18. Sachdeva S, Kar HK, Sachdeva R, Bharti XX, Tyagi AK.
Nil. Information, education and communication (IEC): A revisit to
facilitate change. JIACM 2015;16:106-9.
Conflicts of interest 19. Chang C-H., Chuang L-P., Lin S-W. Factors responsible for poor
There are no conflicts of interest. sleep quality in patients with chronic obstructive pulmonary
disease. BMC Pulm Med 2016;16:118.
20. Scharf SM, Maimon N, Simon-Tuval T, Bernhard-Scharf BJ,
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52 The Journal of Association of Chest Physicians ¦ Volume 6 ¦ Issue 2 ¦ July-December 2018