Chronic Obstructive Pulmonary Disease
A practical approach is using only GOLD stages ≥II for establishing COPD diagnosis among the elderly.56
≥50 years the positive predictive value of pre-bronchodilator airflow obstruction was 84.2 % compared with the post-bronchodilator definition.55
Another option for primary care physicians with no direct approach to official spirometry is to use simple hand-held expiratory flow meters
that measure FEV1/FVC6 ratio, as FVC6 could be used as a good alternative to FVC.57
In a study among 204 undiagnosed current and
former smokers >50 years old, the pre-bronchodilator FEV1/FEV6 cut-off point of 0.75 showed a positive predictive value of 52 % and
negative predictive value of 91 % for COPD case-finding.58 In another
study among 1,078 subjects >40 years old who visited a GP (current smokers 48.4 %), the combination of positive International Primary Care Airways Guidelines (IPAG) questionnaire (>17 points) plus
post-bronchodilation FEV1/FVC6 <0.7 showed a positive predictive value of 71 % and negative predictive value of 97 % for COPD case-finding.59
A simplified diagnostic algorithm of COPD in the primary care setting is proposed in Figure 2 taking into account that we are far
1. Global Initiative for Chronic Obstructive Lung Disease (GOLD), Global strategy for the diagnosis, management and prevention of COPD, 2010. Available at:
www.goldcopd.com (accessed 29 July 2011).
2. Buist AS, McBurnie MA, Vollmer WM, et al., International variation in the prevalence of COPD (the BOLD Study): a population-based prevalence study, Lancet, 2007;370:741–50.
3. van Durme YMTA, Verhamme KMC, Stijnen T, et al., Prevalence, incidence and lifetime risk for the development of COPD in the elderly: The Rotterdam Study, Chest, 2009;135:368–77.
4. Mannino DM, Buist AS, Global burden of COPD: Risk factors, prevalence, and future trends, Lancet, 2007;370:765–73.
5. Mathers CD, Loncar D, Projections of global mortality and burden of disease from 2002 to 2030, PLoS Med, 2006;3:e442.
6. Jemal A, Ward E, Hao Y, Thun M, Trends in the leading causes of death in the United States, 1970-2002, JAMA, 2005;294:1255–9.
7. Loddenkemper R, Gibson G, Sibille Y (eds), European Lung White Book, Huddersfield: European Respiratory Society Journals, 2003.
8. Sullivan SD, Ramsey SD, Lee TA, The economic burden of COPD, Chest, 2000;117:S5–S9.
9. Shavelle RM, Paculdo DR, Kush SJ, et al., Life expectancy and years of life lost in chronic obstructive pulmonary disease: Findings from the NHANES III Follow-up Study, Int J Chron Obstruct Pulmon Dis, 2009;4:137–48.
10. Genen H, Hacievliyagil SS, Kosar F, et al., Factors affecting survival of hospitalized patients with COPD, Eur Respir J, 2005;26:234–41.
11. Spencer S, Calverley PM, Burge PS, Jones PW, Impact of preventing exacerbations on deterioration of health status in COPD, Eur Respir J, 2004;23:689–702.
12. Donaldson GC, Seemungal TA, Bhowmik A, Wedzicha JA, Relationship between exacerbation frequency and lung function decline in chronic obstructive pulmonary disease, Thorax, 2002;57:847–52.
13. Rodriguez-Roisin R, Roca J, Agustí AJ, et al., Physical Activity and Clinical and Functional Status in COPD, Chest, 2009;136;62–70.
14. Troosters T, Sciurba F, Battaglia S, et al., Physical inactivity in patients with COPD, a controlled multi-center pilot-study, Respir Med, 2010;104:1005–11.
15. Kohansal R, Martinez-Camblor P, Agustí A, et al., The natural history of chronic airflow obstruction revisited. An analysis of the Framingham Offspring Cohort, Am J Respir Crit Care Med, 2009;180:3–10.
16. Sobradillo Pena V, Miravitlles M, Gabriel R, et al., Geographic Variations in Prevalence and Underdiagnosis of COPD. Results of the IBERPOC Multicentre Epidemiological Study, Chest, 2000;118:981–9.
17. Mannino DM, Homa DM, Akinbami LJ, et al., Chronic Obstructive Pulmonary Disease surveiillance-United States, 1971-2000, MMWR Surveill Summ, 2002;51:1–16.
18. Rennard S, Decramer M, Calverley PMA, et al., Impact of COPD in North America and Europe in 2000: subjects perspective of Confronting COPD International Survey, Eur Respir J, 2002;20:799–805.
19. Derom E, van Weel C, Liistro G, et al., Primary care spirometry, Eur Respir J, 2008;31:197–203.
from establishing a spirometer in every GP site and spirometry has not been proven to be cost-effective as a screening tool for every asymptomatic smoker. Based on the high negative predictive
value of both COPD screening questionnaires and FEV1/FVC6 measurements45,46,58,59
we believe that a negative combination could be
used to exclude COPD diagnosis. On the other hand, their positive predictive value is >50 % in most studies so we proposed that if either of them is positive then official spirometry is recommended. We propose using pre- or post-bronchodilator FEV1/FVC6.58,59
It is important for a GP who is involved in COPD management to understand that COPD diagnosis is the result of a holistic decision- making strategy that takes into account medical history, risk factors, physical examination, spirometry, radiographic examinations and long- term response to inhaled bronchodilators and/or corticosteroids. A normal spirometry a few weeks/months after treatment confirms the diagnosis of bronchial asthma; meanwhile, some patients demonstrate characteristics of both diseases and spirometry alone, even with a reversibility test, is not enough to establish a clear diagnosis. n
20. Poels PJ, Shermer TR, van Weel C, Underuse of spirometry in the diagnosis of COPD, Monaldi Arch Chest Dis, 2005;63:234–5.
21. Caramori G, Bettoncelli G, Tosatto R, et al., Underuse of spirometry by general practitioners for the diagnosis of COPD in Italy, Monaldi Arch Chest Dis, 2005;63:6–12.
22. Miravitlles M, de la Roza C, Naberan K, et al., Use of spirometry and patterns of prescribing in COPD in primary care, Respir Med, 2007;101:1753–60.
23. Han MK, Kim MG, Mardon R, et al., Spirometry utilization for COPD. How do we measure up?, Chest, 2007;132:403–9.
24. Lusuardi M, de Benedetto F, Paggiaro P, et al., A Randomized Controlled Trial on Office Spirometry in Asthma and COPD in Standard General Practice, Chest, 2006;129:844–52.
25. Enright P, Does screening for COPD by primary care physicians have the potential to cause more harm than good?, Chest, 2006;129:833–5.
26. Sichletidis L, Chloros D, Spyratos D, et al., The validity of the diagnosis of chronic obstructive pulmonary disease in general practice, Prim Care Respir J, 2007;16:82–8.
27. Enright PL, Respiratory therapists should offer spirometry expertise to local primary care providers (editorial), Respir Care, 2010;55:780–1.
28. Swallow EB, Reyes D, Hopkinson NS, et al., Quadriceps strength predicts mortality in patients with moderate to severe chronic obstructive pulmonary disease, Thorax, 2007;62:115–20.
29. Eisner MD, Blanc PD, Yelin EH, et al., Influence of anxiety on health outcomes in COPD, Thorax, 2010;65:229–34.
30. Bridevaux PO, Gerbase MW, Probst-Hensch NM, et al., Long- term decline in lung function, utilisation of care and quality of life in modified GOLD stage 1 COPD, Thorax, 2008;63:768–74.
31. Lin K, Watkins B, Johnson T, et al., Screening for chronic obstructive pulmonary disease using spirometry: summary of the evidence for the U.S. Preventive Services Task Force, Ann Intern Med, 2008;148:535–43.
32. Anthonisen N, Skeans M, Wise R, et al., The effects of smoking cessation intervention on 14.5 year mortality: a randomized clinical trial, Ann Intern Med, 2005;142:233–9.
33. Wilt TJ, Niewoehner D, Kim CB, et al., Use of spirometry for case finding, diagnosis and management of chronic obstructive pulmonary disease (COPD). Evidence Report/Technology Assessment No. 121. AHRQ Publication No. 05-E017-2, Rockville, MD: Agency for Healthcare Research and Quality, 2005;1–169.
34. Bednarek M, Gorecka D, Wielgomas J, et al., Smokers with airway obstruction are more likely to quit smoking, Thorax, 2006;61:869–73.
35. Anthonisen NR, Connett JE, Murray RP, Smoking and lung function of Lung Health Study participants after 11 years, Am J Respir Crit Care Med, 2002;166:675–9.
36. Silverman EK, Palmer LJ, Mosley JD, et al., Genome-wide linkage analysis of quantitative spirometric phenotypes in severe early-onset chronic obstructive pulmonary disease, Am J Hum Genet, 2002;70:1229–39.
37. Ohar JA, Sadeghnejad A, Meyers DA, et al., Do symptoms predict COPD in smokers?, Chest, 2010;137:1345–53.
38. Celli BR, Halbert RJ, Nordyke RJ, Schau B, Airway obstruction in never smokers: results from the Third National Health and Nutrition Examination Survey, Am J Med, 2005;118:1364–72.
39. Lamprecht B, McBurnie MA, Vollmer WM, et al., COPD in
never smokers. Results from the population-based Burden of Obstructive Lung Disease study, Chest, 2011;139:752–63.
40. Zhou Y, Wang C, Yao W, et al., COPD in Chinese nonsmokers, Eur Respir J, 2009;33:509–18.
41. Balmes J, Becklake M, Blanc P, et al., American Thoracic Society Statement: Occupational contribution to the burden of airways disease, Am J Respir Crit Care Med, 2003;167:787–97.
42. Miravitlles M, Llor C, de Castellar R, et al., Validation of the COPD severity score for use in primary care: the NEREA study, Eur Respir J, 2009;33:519–27.
43. Jones PW, Brusselle G, Dal Negro RW, et al., Properties of the COPD assessment test in a cross-sectional European study, Eur Respir J, 2011;38:29–35.
44. Domingo-Salvany A, Lamarca R, Ferrer M, et al., Health- related quality of life and mortality in male patients with chronic obstructive pulmonary disease, Am J Respir Crit Care Med, 2002;166:680–5.
45. Price DB, Tinkelman DG, Halbert RJ, et al., Symptom-based questionnaire for identifying COPD in smokers, Respiration, 2006;73:285–95.
46. Martinez FJ, Raczek AE, Seifer FD, et al., Development and initial validation of a self-scored COPD population screener questionnaire (COPD-PS), COPD, 2008;5:85–95.
47. Pellegrino R, Viegi G, Brusasco V, et al., Interpretative strategies for lung function tests, Eur Respir J, 2005;26:948–68.
48. Miller MR, Hankinson J, Brusasco V, et al., Standardisation of spirometry, Eur Respir J, 2005;26:319–38.
49. American Association for Respiratory Care, Apply for the office spirometry certificate (OSC). Available at:
www.aarc.org/osc (accessed 23 September 2011)
50. Cooper BG, Steenbruggen I, Mitchell S, et al., HERMES Spirometry: the European Spirometry Driving Licence, Breathe, 2011;7:259–64.
51. Leuppi JD, Miedinger D, Chhajed PN, et al., Quality of spirometry in primary care for case finding of airway obstruction in smokers, Respiration, 2010;79:469–74.
52. Borg BM, Hartley MF, Fisher MT, Thompson BR, Spirometry training does not guarantee valid results, Respir Care, 2010;55:689–94.
53. Vollmer WM, Gíslason T, Burney P, et al., Comparison of spirometry criteria for the diagnosis of COPD: results from the BOLD study, Eur Respir J, 2009;34:588–97.
54. Hardie JA, Buist AS, Vollmer WM, et al., Risk of over-diagnosis of COPD in asymptomatic elderly never-smokers, Eur Respir J, 2002;20:1117–22.
55. Schermer TRJ, Smeele IJM, Thoonen BPA, et al., Current clinical guideline definitions of airflow obstruction and COPD overdiagnosis in primary care, Eur Respir J, 2008;32:945–52.
56. Calverley P, Fulfilling the promise of primary care spirometry (editorial), Eur Respir J, 2008;31:8–10.
57. Vandevoorde J, Verbanck S, Schuermans D, et al., FEV1/FEV6 and FEV6 as an alternative for FEV1/FVC and FVC in the spirometric detection of airway obstruction and restriction, Chest, 2005;127:1560–4.
58. Frith P, Crockett A, Beilby J, et al., Simplified COPD screening: validation of the PiKo-6® 2011;20:190–8.
in primary care, Prim Care Respir J,
59. Sichletidis L, Spyratos D, Papaioannou M, et al., A combination of the IPAG questionnaire and PiKo-6®
flow
meter is a valuable screening tool for COPD in the primary care setting, Prim Care Respir J, 2011;20:184–9.
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