Perceived Stress Tied to Worsened Respiratory Outcomes, Decreased QoL in Adults with COPD

Obiageli Lynda Offor, MD MPH

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Higher levels of perceived stress were significantly associated with worse respiratory health status and elevated biomarkers of platelet activation and oxidative stress in former smokers with chronic obstructive pulmonary disease (COPD), according to a new study.1

“There is increased evidence that psychosocial factors, including perceived stress, are associated with worsened respiratory symptoms for people with COPD. Platelet activation, which may contribute to inflammation, and oxidative stress, which may lead to cell and tissue damage, are also impacted by increased perceived stress,” Obiageli Offor, MD, MPH, a Pulmonary and Critical Care Fellow at Johns Hopkins Medicine in Baltimore, and lead author of the trial said in a press release.2

The observational study included 99 participants from low-income, urban neighborhoods who completed baseline, 3-month, and 6-month assessments. Perceived stress was measured using the 10-item Perceived Stress Scale (PSS), categorized as low (0–13), moderate (14–26), or high (27–40). The mean age was 66.4 years; 56% were women, and 57% were Black. The average baseline PSS score was 12.9, with 52.5% of the cohort categorized as low stress, 45.5% moderate, and 2.0% high.1

The findings were published online in the Journal of the COPD Foundation.

A 4-point increase in PSS was associated with higher scores on the COPD Assessment Test (CAT) (β=0.91; 95% CI, 0.40–1.43), St. George’s Respiratory Questionnaire (SGRQ) (β=2.17; 95% CI, 1.21–3.13), Clinical COPD Questionnaire (CCQ) (β=0.11; 95% CI, 0.05–0.17), and Ease of Cough and Sputum Clearance (ECSC) (β=0.36; 95% CI, 0.11–0.61), but not the modified Medical Research Council (mMRC) scale (β=0.03; 95% CI, –0.05 to 0.10).1

Compared with low PSS, moderate stress was associated with worse CAT (mean difference=7.86; 95% CI, 5.10–10.63), SGRQ (12.04; 95% CI, 5.60–18.47), CCQ (0.70; 95% CI, 0.38–1.02), and ECSC (3.20; 95% CI, 1.41–4.99) scores. High stress was also significantly associated with poorer outcomes: CAT (2.39; 95% CI, 0.80–3.97), SGRQ (3.38; 95% CI, 0.02–6.78), CCQ (0.29; 95% CI, 0.07–0.52), ECSC (1.46; 95% CI, 0.63–2.28). High PSS was associated with greater odds of experiencing at least one moderate/severe exacerbation (OR=4.15; 95% CI, 1.28–13.47), but not any exacerbation overall.1

Stratified analyses showed that a 4-point increase in PSS was associated with increased respiratory morbidity primarily among participants with severe COPD (FEV₁ <50% predicted). For this subgroup, the increases were as follows: CAT (β=1.50; 95% CI, 0.74–2.25), mMRC (0.11; 95% CI, 0.01–0.22), SGRQ (3.95; 95% CI, 2.39–5.52), CCQ (0.22; 95% CI, 0.13–0.32), and ECSC (0.64; 95% CI, 0.38–0.90).1

Biomarker analysis revealed stress-associated changes that varied by disease severity. Among participants with mild-to-moderate COPD (FEV₁ >50%), high PSS was associated with increased urine 11-dehydro-thromboxane B₂ (11dTxB₂) levels (β=52.9%; 95% CI, 22.1–91.6) and 8-isoprostane (β=59.4%; 95% CI, 20.6–110.8%). Moderate stress was also associated with increased 11dTxB₂ (β=20.1%; 95% CI, 3.1–40.0%). In severe COPD, high PSS was associated with lower TBARS (thiobarbituric acid reactive substances) levels (β=–53.9%; 95% CI, –64.8 to –39.7).1

No associations were found between perceived stress and inflammatory biomarkers, including tumor necrosis factor-α, interleukin (IL)-6, IL-8, and interferon-γ. Sensitivity analyses that controlled for anxiety, depression, food insecurity, and neighborhood deprivation produced similar results, indicating the robustness of the findings.1

Offor and colleagues acknowledged limitations, including a small sample size, underrepresentation of individuals with persistently high stress, and lack of lung compartment biomarker data. Nonetheless, the study identifies perceived stress as an independent factor in COPD morbidity and highlights biological mechanisms potentially mediating this association.1

“While our study examined a small group of patients, our results demonstrate the need for further research on how perceived stress impacts respiratory health and the importance of addressing psychosocial factors to help improve people’s quality of life,” Offor concluded in the press release.2

References:

1. Offor O, Eakin MN, Woo H, et al. Perceived stress is associated with health outcomes, platelet activation, and oxidative stress in COPD. Chronic Obstr Pulm Dis. 2025;12:98-108. doi:10.15326/jcopdf.2024.0561
2. Feeling stressed may lead to worsened respiratory symptoms, decreased quality of life. News release. COPD Foundation. April 29, 2025. Accessed April 30, 2025. https://www.eurekalert.org/news-releases/1081508