Archived Published Comment - Will Recommendations against Spirometry Make Chronic Obstructive Pulmonary Disease Harder to Treat?
Other Supporting Document for Chronic Obstructive Pulmonary Disease (COPD): Screening
Originally published on: January 17, 2014
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Disclaimer:Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.
TO THE EDITOR: We are concerned about the recent series of guideline papers and recommendation statements published in Annals1-3, which seem to advise primary care physicians not to perform spirometry. This could be a big blow (no pun intended) to a nationwide effort to diagnose and treat chronic obstructive pulmonary disease (COPD) early 4, 5. Chronic obstructive pulmonary disease is the only disease among the top 5 fatal diseases in the United States that is increasing in morbidity and mortality6. What separates the diseases that are decreasing (heart disease, stroke, cancer, and accidents) from COPD are effective early detection and prevention strategies. The recommendation in the U.S. Preventive Services Task Force (USPSTF) clinical summary figure, in large bold letters, states: "Do not screen for chronic obstructive pulmonary disease using spirometry"2. In the text below the figure, however, there are caveats: this recommendation applies to healthy adults who do not recognize or report symptoms to a clinician and does not apply to individuals with a family history of α1-antitrypsin deficiency. Thus, the flip side of the argument against screening is that unhealthy people (particularly those with a diagnosed respiratory disease), people with respiratory symptoms, and people with a family history of α1-antitrypsin deficiency should have spirometry done. We would add to this list people who are at increased risk for COPD (adults older than 40 years with current or former tobacco use or exposure to occupational or environmental pollutants). This, of course, is not screening but appropriate clinical care.
How are we doing in this regard as clinicians? Not very well. National data from the United States and other countries demonstrate that a high proportion of adults with documented impaired lung function have not had any respiratory disease diagnosed7-9. Furthermore, among people with a clinical diagnosis of COPD, in whom spirometry is mandatory, few patients has had testing done10, 11. If spirometry use in a group with a clear-cut indication is so low, one can imagine that use in patients with chronic respiratory symptoms but no diagnosis is even lower.
Can information obtained from spirometry provide information beyond detecting severe COPD (the end point used in the USPSTF guideline's background paper )? Yes. Even small decrements in lung function, which can be related to such processes as heart disease and diabetes12, are associated with an increase in all-cause mortality, which has been known since the Framingham Study13, 14. Furthermore, in the early stages of COPD, patients frequently have no symptoms but avoid dyspnea by progressively restricting activity. The resulting deconditioning is a major clinical problem that further compromises performance. Failure to diagnose COPD at this stage removes the opportunity to intervene early to interrupt a vicious cycle that often leads to a severely restricted functional status that is very difficult to treat when diagnosis is finally made. Finally, without readily obtainable spirometry, the clinician will be tempted to diagnose COPD by using clinical judgment, which is strikingly inaccurate. Specifically, not only are most patients with COPD without diagnosis, but a large proportion of individuals with the diagnosis do not have COPD.
The USPSTF argued that spirometry does not influence smoking cessation. Several new studies refute this conclusion15-18. The most recent, by Parkes and colleagues17, in which all patients (smokers age ≥35 years) had spirometry and equal exposure to cessation resources but patients in the intervention group were told their lung age, found that cessation rates more than doubled in the intervention group (6.4% vs. 13.6%).
Performance of spirometry is both easy and inexpensive. Industry has responded to the need for spirometry by providing devices that cost $1000 to $2000, and reimbursement is established at a very reasonable rate, averaging about $30 (Current Procedural Terminology code 94040) or $57 with bronchodilator evaluation (Current Procedural Terminology code 94060). Most important, this test not only provides strong evidence for a diagnosis of COPD but also can indicate the presence of other diseases, such as restrictive lung disease.
So what's the bottom line? Should we continue the national drive to find and treat COPD and related disorders early, or should we abandon facts and reason and retreat to where we were a half-century ago, when COPD was essentially ignored by the medical profession? At a minimum, good clinical practice mandates that adults with COPD or other chronic respiratory disease (asthma, sarcoidosis, pulmonary fibrosis) should have spirometry. In addition, patients with respiratory symptoms or a family history of α1-antitrypsin deficiency should have spirometry. This is case finding and appropriate treatment of our patients. Finally, we hope that the Task Force will expeditiously reevaluate the evidence for spirometry as an adjunct in encouraging smoking cessation.
Thomas L. Petty, MD
University of Colorado
Denver, CO 80220
David M. Mannino, MD
University of Kentucky College of Public Health
Lexington, KY 40356
Qaseem A, Snow V, Shekelle P, Sherif K, Wilt TJ, Weinberger S, et al. Clinical Efficacy Assessment Subcommittee of the American College of Physicians. Diagnosis and management of stable chronic obstructive pulmonary disease: a clinical practice guideline from the American College of Physicians. Ann Intern Med 2007;147:633-8. [PMID: 17975186]
U.S. Preventive Services Task Force. Screening for chronic obstructive pulmonary disease using spirometry: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2008;148:529-34. [PMID: 18316747]
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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. [PMID: 16160134]
Mannino DM, Gagnon RC, Petty TL, Lydick E. Obstructive lung disease and low lung function in adults in the United States: data from the National Health and Nutrition Examination Survey, 1988-1994. Arch Intern Med 2000;160:1683-9. [PMID: 10847262]
Shahab L, Jarvis MJ, Britton J, West R. Prevalence, diagnosis and relation to tobacco dependence of chronic obstructive pulmonary disease in a nationally representative population sample. Thorax 2006;61:1043-7. [PMID: 17040932]
Menezes AM, Perez-Padilla R, Jardim JR, Muino A, Lopez MV, Valdivia G, et al. PLATINO Team. Chronic obstructive pulmonary disease in five Latin American cities (the PLATINO study): a prevalence study. Lancet 2005;366:1875-81. [PMID: 16310554]
Damarla M, Celli BR, Mullerova HX, Pinto-Plata VM. Discrepancy in the use of confirmatory tests in patients hospitalized with the diagnosis of chronic obstructive pulmonary disease or congestive heart failure. Respir Care 2006;51:1120-4. [PMID: 17005056]
Joo MJ, Lee TA, Weiss KB. Geographic variation of spirometry use in newly diagnosed COPD. Chest 2008;134:38-45. [PMID: 18347201]
Mannino DM, Holguin F, Pavlin BI, Ferdinands JM. Risk factors for prevalence of and mortality related to restriction on spirometry: findings from the First National Health and Nutrition Examination Survey and follow-up. Int J Tuberc Lung Dis 2005;9:613-21. [PMID: 15971387]
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Van Schayck CP, Loozen JM, Wagena E, Akkermans RP, Wesseling GJ. Detecting patients at a high risk of developing chronic obstructive pulmonary disease in general practice: cross sectional case finding study. BMJ 2002;324:1370. [PMID: 12052807]
Parkes G, Greenhalgh T, Griffin M, Dent R. Effect on smoking quit rate of telling patients their lung age: the Step2quit randomised controlled trial. BMJ 2008;336:598-600. [PMID: 18326503]
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Internet Citation: Published Comment - Will Recommendations against Spirometry Make Chronic Obstructive Pulmonary Disease Harder to Treat?: Chronic Obstructive Pulmonary Disease (COPD): Screening. U.S. Preventive Services Task Force. February 2014.