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Spirometry for COPD Is Both Underutilized and Overutilized

2007; Elsevier BV; Volume: 132; Issue: 2 Linguagem: Inglês

10.1378/chest.07-0994

1931-3543

Paul Enright, Philip H. Quanjer,

Nursing Diagnosis and Documentation

An excellent study from the National Committee for Quality Assurance (NCQA) in this issue of CHEST (see page 403)1Han ML Kim MG Mardon R et al.Spirometry utilization for COPD: how do we measure up?.Chest. 2007; 132: 403-409Abstract Full Text Full Text PDF PubMed Scopus (162) Google Scholar confirms that when a diagnosis of COPD is made in both primary care and subspecialty settings in the United States, spirometry is performed for only one third of the cases. When spirometry was done—either before or after the initial diagnosis of COPD—it included postbronchodilator (post-BD) spirometry less than half of the time. These rates demonstrate that we as pulmonary specialists have a lot of work ahead of us to educate our colleagues (primary care providers as well as specialists) about the necessity to perform an objective test to confirm this common disease and stage its severity. As Doctor Tom Petty has said many, many times in the past 3 decades, “Nobody would ever think of treating hypertension without measuring BP.” One piece of good news from this study of > 5,000 patients with an new diagnosis of COPD was the lack of a gender gap: women were no less likely than men to undergo spirometry. The other possibly good news is that when spirometry was done, it was done in an outpatient office setting, as recommended in the year 2000 by the National Lung Health Education Program (NLHEP),2Ferguson GT Enright PL Buist AS et al.Office spirometry for lung health assessment in adults: a consensus statement from the National Lung Health Education Program.Chest. 2000; 117: 1146-1161Abstract Full Text Full Text PDF PubMed Scopus (399) Google Scholar approximately 60% of the time, and in the traditional setting of a hospital-based pulmonary function testing (PFT) laboratory approximately 40% of the time. We believe that primary care practitioners should be encouraged to perform spirometry wherever the quality has been demonstrated to be good (where > 85% of the tests done meet American Thoracic Society/European Respiratory Society quality goals),3Miller MR Hankinson J Brusasco V et al.Standardisation of spirometry.Eur Respir J. 2005; 26: 319-338Crossref PubMed Scopus (11506) Google Scholar and where post-BD spirometry is done whenever pre-BD results show airway obstruction. The NCQA study1Han ML Kim MG Mardon R et al.Spirometry utilization for COPD: how do we measure up?.Chest. 2007; 132: 403-409Abstract Full Text Full Text PDF PubMed Scopus (162) Google Scholar showed that only 15% of the 174 patients > 85 years old with a new diagnosis of COPD underwent spirometry. Given the very high rates of comorbidity in the oldest old, this is a major problem if these high-risk patients are then prescribed long-acting bronchodilators and/or medium to high daily doses of inhaled corticosteroids. Most clinical trials of COPD medications have excluded patients in this age range, so little is known about their effectiveness or side effect profiles. A prudent gerontologist would first confirm the disease and then objectively measure the therapeutic response for each individual patient using spirometry and the 6-min walk test. Should our response to the proven underutilization of spirometry for confirming a diagnosis of COPD be the widespread promotion of screening spirometry, as generously funded by pharmaceutical companies in some countries,4Buffels J Degryse J Heyrman J et al.Office spirometry significantly improves early detection of COPD in general practice: the DIDASCO Study.Chest. 2004; 125: 1394-1399Abstract Full Text Full Text PDF PubMed Scopus (216) Google Scholar5Lusuardi M DeBenedetto F Paggiaro P et al.A randomized controlled trial on office spirometry in asthma and COPD in standard general practice.Chest. 2006; 129: 844-852Abstract Full Text Full Text PDF PubMed Scopus (110) Google Scholar or the continued promotion of office spirometry for every adult smoker seen in a medical care setting, as recommended by the NLHEP2Ferguson GT Enright PL Buist AS et al.Office spirometry for lung health assessment in adults: a consensus statement from the National Lung Health Education Program.Chest. 2000; 117: 1146-1161Abstract Full Text Full Text PDF PubMed Scopus (399) Google Scholar (a somewhat more cautious approach)? We believe that both of these responses are overreactions to the problem, potentially causing more harm than good when applied inappropriately, as frequently done during the past 5 to 10 years.6Enright P Does screening for COPD by primary care physicians have the potential to cause more harm than good?.Chest. 2006; 129: 833-835Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar We recommend that spirometry to detect COPD be used only for current or former smokers seen in medical care settings who have a high pretest probability of COPD, as determined by a questionnaire that includes age, body mass index (obesity indicating a lower risk of COPD), pack-years of smoking, dyspnea on exertion, wheeze, and a history of allergies (indicating a lower risk of COPD).7Price DB Tinkelman DG Nordyke RJ for the COPD Questionnaire Study Group et al.Scoring system and clinical application of COPD diagnostic questionnaires.Chest. 2006; 129: 1531-1539Abstract Full Text Full Text PDF PubMed Scopus (126) Google Scholar Unless the FEV1 is < 50% of predicted from a good quality baseline spirometry test, the diagnosis of COPD should not be made without performing spirometry after an inhaled bronchodilator (post-BD), as recommended by the Global Initiative for Chronic Obstructive Lung Disease guidelines.8Pauwels RA Buist AS Calverley PM et al.Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: NHLBI/WHO global initiative for chronic obstructive lung disease (GOLD) workshop summary.Am J Respir Crit Care Med. 2001; 163: 1256-1276Crossref PubMed Scopus (4340) Google Scholar That's because more than one fourth of adult smokers with mild airway obstruction during baseline spirometry no longer have airway obstruction after bronchodilation.9Perez-Padilla R Hallal PC Vazquez-Garcia JC on behalf of the PLATINO group et al.Impact of bronchodilator use on the prevalence of COPD in population-based samples.COPD. 2007; 4: 113-120Crossref PubMed Scopus (75) Google Scholar So if a primary care provider does not have the time to perform post-BD spirometry, inhaled medication for COPD should not be prescribed until the patient is referred to a PFT laboratory and moderate-to-severe airway obstruction after bronchodilation is confirmed. There is no evidence that any inhaled medication for COPD is beneficial when airway obstruction is mild to moderate (FEV1 > 50% of predicted).10Wilt TJ Niewoehner D Kim C et al.Use of spirometry for case finding, diagnosis, and management of COPD. Agency for Healthcare Research and Quality, Rockville, MD2005Google Scholar COPD inhalers cost $1,000 to $3,000 per year per patient, have a risk for side effects, and are rarely discontinued by a physician until death. If the patient has asthma instead of COPD, as demonstrated by a large bronchodilator response, many additional and generally more effective therapeutic interventions are available.