Lung transplant has become one of the commonly employed methods in treating end-stage lung diseases (1). In 1963, Doctor Hardy conducted the first lung transplantation surgery worldwide. Since 1990s, lung transplant has been applied spreading the world. A total of 32 652 cases of lung transplant have been registered in OSHLT until 2009, and the 1-, 3-, and 5- year survival rates were 79%, 63%, 52%, and 29%, respectively (2). Professor Yuling Xin, from Beijing Turberculosis Institute, performed the first lung transplantation in China in 1979. By the end of 2005, over 10 hospitals had carried out lung transplant, totaling more than 50 cases across China, and the survival rate ranged from 50% to 60% (3). However, the patients needed to wait for 12 to 18 months for matched donors because of the uncertainty of donor source. What’s worse, 16% of the patients died during the period awaiting suitable donors (4). The quality of life of those patients awaiting lung transplantation decreased due to long waiting time, exaggerated dyspnea, and social role transformation. This study aims at investigating the quality of life of patients awaiting lung transplant and identifying the factors influencing quality of life, and providing scientific evidence for enhancing the quality of life in patients awaiting lung transplantation, reported as herein.

A total of 55 patients, who registered for awaiting lung transplant in certain hospital in Guangzhou from July 2009 to December 2010, were enrolled in this investigation, 46 males and 9 females, aged between 38 and 75 years old averagely (54.23±8.85) years old. Primary disease included 32 cases of chronic obstructive pulmonary disease (COPD), 10 cases of pulmonary fibrosis, 4 cases of pulmonary hypertension, and remaining 9 cases (2 cases of bronchiectasia, 3 cases of pulmonary liomyoma, and 2 cases of pneumoconiosis, and 2 cases of pulmonary fibrosis interstitial pneumonia). Dyspnea grading scale ≥ grade II. BMI ranged from 15.94 to 23.38, averagely (19.64±1.83). Family monthly per capita income: 19 cases < 2 000 yuan, 16 cases between 2 000 and 3 000 yuan, and 20 cases > 3 000 yuan. Source of medical cost coverage: 22 families paid at their own expenses, 12 families partially covered at public expenses, 3 cases totally covered at public expenses, and 18 cases paid by medical insurance. Highest education level: 10 cases of illiteracy, 13 cases of elementary school, 30 cases of junior and senior high schools, and 2 cases of college and university or above. Fifty two married cases, 2 unmarried cases, and 1 divorce case. Waiting time for lung transplantation: 0 to 8 months, averagely (3.24±1.13) months.

(i) Short Form 36 Health Survey Questionnaires (SF-36) (5) included 36 clauses, 8 domains of PF, RP, SF, VT, RE, MH, BP, and GH. Score scale ranged from 0 to 100, and a higher score represented a better quality of life. Ningxiu Li et al. (6) previously measured the norm scores by Chinese population in SF-36. (ii) Self-rating Depression Scale (SDS) (7) contained 20 clauses reflecting the subjective feelings of depression individuals. Each item was classified into 4 grades according to the frequency of related occurring symptoms. The limited values for standard score was 50, 50 to 59 representing mild depression, 60 to 69 representing moderate depression, 70 above indicating severe depression. (iii) Self-rating Anxiety Scale (SAS) (8) included 20 clauses reflecting the subjective feelings of anxious individuals. Each item was classified into 4 grades according to the frequency of related occurring symptoms. The limited values for standard score was 50, 50 to 59 representing mild anxiety, 60 to 69 representing moderate anxiety, 69 above indicating severe anxiety. (iv) Perceiving Social Support Scale (PSSS) (9) covered 12 self-evaluating clauses. The score scale for each item ranged from 1 to 7. The experts in China categorized 12 clauses into family support and outside family support by using factor analysis. The score scale of each factor ranged from 1 to 7, and a higher score represented a higher social support. (v) Common questionnaire included age, gender, marital status, education level, family monthly per capita income, source of medical cost, grading of dyspnea, BMI, and awaiting time, etc.

All questionnaires were distributed to the patients and their relatives registered in lung transplant center during time awaiting lung transplantation. Full-time nurses in lung transplant center and the writers of this study were responsible for explaining the purpose, method to patients and their relatives, and ensuring the informed consents were obtained from all participants. All the questionnaires were spread out to patients at a time. Assisted by further explanations, the patients finished the questionnaires independently. For those unable to complete self-evaluation, the investigators repeated the questions and available answer choices to them who made a choice by independently. Finally, the investigators helped the patients record their answers. All questionnaires were collected, immediately reviewed, and the missed questions were supplemented to make sure the effectiveness of the questionnaires. A total of 55 questionnaires were distributed and all were effective, with an effective collection rate of 100.0%.

SPSS 13.0 software was employed for statistical analysis. The quality of life in patients awaiting lung transplantation and its relevant influence factors were analyzed by using t-test and multiple linear regressions (stepwise method).

The comparison on quality of life scores between the subjects awaiting lung transplant and norms were shown in Table 1. As shown in Table 1, significant differences were noted between awaiting patients and normal controls in terms of scores of quality of life (all p<0.05).

In this study, 14 cases (25.5%) suffered from mild anxiety and 6 cases of moderate anxiety. Twenty cases (36.4％) had mild depression, 8 cases (14.5％) of moderate depression, and 2 cases (3.6%) of severe depression. The comparison on anxiety and depression indices scores between awaiting patients and normal controls were shown in Table 2. The scores of anxiety and depression indices obtained by awaiting patients were significantly lower compared with norms (p<0.01).

The social support scores obtained by awaiting patients were shown in Table 3. As table 3 shown, significant differences were noted among family support, outside family support and social total support in patients awaiting lung transplant (P<0.05).

Total score of SF-36 was deemed as dependent variable, and the total score of age, gender, marital status, family monthly per capita income, source of medical cost, dyspnea, having complication or not, BMI, SAS, SDS, PSSS was regarded as independent variable. A simple linear regression analysis was performed to screen independent variables, as shown in Table 4. All the independent variables influenced upon the quality of life in patients awaiting lung transplantation, with significant differences (all p<0.05).

Total score of SF-36 was deemed as dependent variable. Single factors were screened as meaningful independent variables. The total score of family monthly per capita income, source of medical cost, dyspnea, BMI, SAS, SDS, PSSS was integrated into regression formula for multiple-factor analysis, as shown in Table 5. More severe dyspnea and depression represented poorer quality of life in patients.

This study revealed that the quality of life in those patients awaiting lung transplant was relatively poor. The scores of 8 domains in SF-36 by those participants were significantly lower compared with norms (all P<0.05), indicating an undesirable quality of life in patients waiting for lung transplant. The score of RP was 23.18±37.53, which was the lowest mark among all scores, followed by PF score of 35.96±26.45. The obtained results are consistent with those by foreign investigations (10-14). RP serves to measure the functional constraints caused by health problems, including whether presenting constraints and reduction during work and activity, decreases in time and types of activity, or increases in difficulty in completing work and daily activities. RP score was the lowest, suggesting that RP was subject to the most evident constraints because the patients awaiting transplant surgery had end-stage disease, and their lung function deteriorated and dyspnea symptoms were exaggerated as waiting time prolonged. Most patients had to stay in bed or take some minor limb movements to avoid dyspnea by reducing the oxygen consumption. Thus, the work and activity were significantly limited, time and type of activity was reduced, and the difficulty in finishing work and activity was elevated accordingly for patients. PF measures whether health condition negatively affects normal physiological activities including movement, moving stuff, step climbing, working, wearing clothes, and bathing, etc. A relatively low PF score indicated that the physiological activities were extremely constrained for patients, probably caused by dyspnea-induced decline in activity tolerance and self-care ability, thus limiting the patients’ PF.

The results in this investigation indicated that the regression coefficient of dyspnea was -90.015 (p<0.05), hinting that more severe dyspnea caused poorer quality of life, which was consistent with previous findings (18). The reason may be more serious dyspnea reduced the self-care ability, shortened time and diversity of activities, increased the difficulty in finishing work and activity, decreased social interactions, caused mental disorders of various degree, thus causing significant influence upon patients physiologically, socially, and psychologically and leading to poor quality of life. Meantime, multiple-factor analysis noted that the regression coefficient of depression was -5.052 (p<0.05). Both domestic and abroad studies revealed that the depression symptoms presented by transplant patients decreased the quality of life, increased the incidence and death rate of diseases (18-22). These may be explained by the fact that the depression patients tended to seldom take active measures, present poor compliance, leading to deteriorated quality of life (23,24).

This survey indicated that the scores in various domains of quality of life by patients awaiting lung transplant were lower compared with norms. The overall quality of life in awaiting patients was not optimistic. Dyspnea and depression mainly contributed to decline in quality of life, suggesting that special attention and prevention should be provided regarding these two aspects to enhance the quality of life in patients awaiting pulmonary transplantation.