Chronic Obstructive Pulmonary Disease
Chronic Obstructive Pulmonary Disease Diagnostic Algorithm in Primary Care – A Review
Dionisios Spyratos, Diamantis Chloros and Lazaros Sichletidis Pulmonary Department, Aristotle University of Thessaloniki
Abstract
Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality and the only one with increasing prevalence, despite worldwide efforts against smoking. Ten years after publication of the Global Strategy for the Diagnosis, Management, and Prevention of COPD by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) in 2001 the disease remains underdiagnosed in about half of cases. The main reasons are patients’ own underestimation of the symptoms and lack of knowledge in the general practitioners (GPs) who confront the patients first. In this article we provide GPs with a practical algorithm for COPD diagnosis. Patients with a smoking history of ≥20 pack-years and relevant symptoms should fill in a screening questionnaire and undergo spirometry with a hand-held device. If these screening tools are both negative then an alternative diagnosis should be considered. If either is positive then the patient should undergo official spirometry. We believe that this approach will increase the possibility of early and accurate diagnosis of COPD in the primary care setting even though prospective studies are needed to confirm the usefulness of this algorithm.
Keywords Chronic obstructive pulmonary disease, questionnaires, spirometry, case identification, primary care, diagnosis
Disclosure: The authors have no conflicts of interest to declare. Received: 10 August 2011 Accepted: 23 August 2011 Citation: European Respiratory Disease, 2011;7(2):127–30 Correspondence: Lazaros Sichletidis, Pulmonary Department, Aristotle University of Thessaloniki, G Papanikolaou Hospital, Exohi, 57010 Thessaloniki, Greece. E:
sichlet@med.auth.gr
Chronic Obstructive Pulmonary Disease Prevalence and Impact of Disease Burden for the Health System
COPD is a leading cause of disability and death, with a prevalence of clinically significant COPD (Global Initiative for Chronic Obstructive Lung Disease [GOLD] Stage II or higher) of about 10.1 %, according to the results of the Burden of lung disease (BOLD) study, a recent international population-based prevalence investigation conducted on 9,425 subjects at 12 sites in the same number of countries worldwide.2
It was estimated that one in every
four men and one in every six women without COPD at the age of 55 years will eventually develop COPD at some time during their future life.3
Prevalence rates of COPD are expected to increase in the next decades, notably among women and in developing-country populations.4
By 2030, COPD is expected to become the third leading cause of death in middle-income countries.5
Trends in
age-standardised death rates for the six leading causes of death in the US from 1970 to 2002 indicate that, while mortality from several of these chronic conditions declined over the period, COPD mortality increased.6
In the EU the total direct cost of respiratory diseases is estimated to be about 6 % of the total healthcare budget, with COPD © TOUCH BRIEFINGS 2011
Chronic obstructive pulmonary disease (COPD) is a preventable and treatable disease characterised by airflow limitation that is not fully reversible. The airflow limitation is usually progressive and associated with an abnormal inflammatory response of the lung to noxious particles or gases.1
accounting for over 50 % (€38.6 billion) of this cost.7 this cost is attributed to hospitalisations for exacerbations.8
Adverse Effects on Patients’ Health
COPD exacerbations influence mortality, pulmonary function, physical activity and quality of life of patients.10–12
Patients with COPD face a significantly increased risk of premature death.9
Physical activity in
COPD patients is lower than that observed in healthy subjects of similar age13
and is reduced even in stable GOLD Stage II patients.14 Smoking cessation is the only effective way to change the natural history of the disease and to oppose the deleterious effects of smoking on lung function.15
Underdiagnosis of Chronic Obstructive Pulmonary Disease in the Primary Care Setting The phenomenon of COPD underdiagnosis has been uniformly observed worldwide. In a large epidemiological, multicentre, population-based study conducted in Spain, a total of 4,035 men and women (40–69 years), who were randomly selected from a target population of 236,412 subjects, had answered a relevant questionnaire and underwent spirometry. The prevalence of COPD was 9.1 %: 15 % in smokers, 12.8 % in ex-smokers and 4.1 % in non-smokers. There was no previous diagnosis of COPD in 78.2 % of cases. Multivariate analysis showed that individuals had a higher probability of having received a previous diagnosis of COPD if they lived in urban areas, were of male gender, were >60 years old, had higher educational levels, had >15 pack-year smoking history or had symptoms of
127
The majority of
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