Transcript Confirming the Diagnosis COPD by Spirometry: A Clinical Review

Cary Peterson, DO FP PGYIII
Supervising Physician: Keith Felstead, DO
June 11, 2009
Chronic Obstructive Pulmonary Disease (COPD) is a
preventable and treatable disease. The disease is
characterized by airfow limitation that is not fully
reversible. The airflow limitation is usually
progressive in nature (7).
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COPD was the 4th leading cause of death in 2002 and represents a
significant economic burden, with an estimated $18 billion in
direct and $14.1 billion in indirect costs annually (1).
According to the Global Initiative for Chronic Obstructive Lung
Disease (GOLD), “A diagnosis of COPD should be considered in
any patient who has dyspnea, chronic cough or sputum
production, and/or history of exposure to risk factors for the
disease”.
The diagnosis should by confirmed by:
“SPIROMETRY”
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Underuse may lead to an inaccurate COPD diagnosis
Diagnosis of COPD
SYMPTOMS
cough
sputum
shortness of breath
EXPOSURE TO RISK
FACTORS
tobacco
occupation
indoor/outdoor pollution
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SPIROMETRY
Changes in Lung Parenchyma in COPD
Alveolar wall destruction
Loss of elasticity
Destruction of pulmonary
capillary bed
↑ Inflammatory cells
macrophages, CD8+ lymphocytes
Source: Peter J. Barnes, MD
- Measure airflow obstruction to help make a definitive diagnosis of
COPD
- Confirm presence of airway obstruction
- Assess severity of airflow obstruction in COPD
- Detect airflow obstruction in smokers who may have few or no
symptoms
- Monitor disease progression in COPD
- Assess response to therapy (FEV1) in COPD
- Perform pre-operative assessment
- Bellows spirometers:
Measure volume; mainly in lung function units
- Electronic desk top spirometers:
Measure flow and volume with real time display
- Small hand-held spirometers:
Inexpensive and quick to use but have no print out
- FEV1 - Forced expiratory volume in one second:
The volume of air expired in the first second of the forced
expiration
- FVC - Forced vital capacity:
The total volume of air that can be forcibly exhaled in one breath
- FEV1/FVC ratio:
The fraction of air exhaled in the first second relative to the total
volume exhaled
- Confirmed by post–bronchodilator FEV1/FVC < 0.7
- Post-bronchodilator FEV1/FVC measured 15 minutes after 400µg
salbutamol or equivalent
- Helps to differentiate COPD from asthma
-
Must be interpreted with clinical history
Neither asthma nor COPD are diagnosed on
spirometry alone
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“Spirometry Use in Clinical Practice Following Diagnosis of COPD” (4)
 Published in Chest 2006
 Todd A. Lee, Brian Bartel and Kevin B. Weiss
 Methods:
 Cohort of pts > 40 years of age associated with Veterans Affairs
Hospital
 Diagnosed with COPD
 Spirometry was identified over a 12 month period
 Of 197,878 Pts only 33.7 % underwent spirometry
 The use of spirometry for newly diagnosed COPD pts decreased
with age and was 3.3 times higher for those visiting a
pulmonologist
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Conclusion:
• Spirometry is inconsistently used in the diagnosis of COPD
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“Spirometry Utilization for COPD”(5)
 Published in Chest 2007
 Meilan K. Han
 Methods:
 Subject data was collected on patients > 40 years of age from 5 different
health plans recruited by “The National Committee for Quality Assurance”
 New Diagnosis of COPD
 Was spirometry done during the interval 720 days prior to diagnosis and
ending 180 days after the dx.
 Of the 5,039 pts studied, approximately 32% of the new diagnosis of COPD
had undergone spirometry in the specified time frame.
 Spirometry frequency was lowest in older patients, with the lowest
frequency in those > 75 yoa.
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Conclusion:
 Study showed that spirometry is infrequently used in clinical practice for
diagnosis of COPD and suggests opportunities for practice improvement.
Other
Reasons for
Spirometry
Performance Measures:
As of May 2009, Catholic IPA
of Western NY collected data
on 1,662 Medicare members
with COPD and of those pts,
889 (53%) had spirometry (6).
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In 2007, the American College of Physicians strongly recommended that
pts with respiratory symptoms, particularly dyspnea, spirometry should
by used to diagnose airflow obstruction (2).
However, the evidence did not support periodic spirometry after the
initiation of therapy to monitor ongoing disease or to modify therapy (2).
But according to the GOLD, spirometry can be used to monitor disease
progression, but to be reliable the intervals between measurements must
be at least 12 months (6).
The US Preventive Services Task Force (USPSTF) recommends against
screening adults for chronic obstructive pulmonary disease using
spirometry (Grade D)(8).
The purpose of this review is to determine whether or
not spirometry is adequately used to confirm the
diagnosis of COPD in a small outpatient primary care
setting.
Chart Review (EMR From May 2007 – March 2009)
Involved 1 Primary Care Outpatient Clinic
Participants:
Ages 43-89 yoa
55 patients were included
Males-26 (47%)
Females-29 (53%)
Inclusion Criteria:
1. All patients had to have Electronic Medical Records (EMR)
EMR defined as having PMHX tab completed
2. All patients had to have an EMR diagnosis of COPD – 496
Spirometry or pulmonary function testing (includes spirometric indices) @ anytime as
documented in the EMR Chart was included as long as the inclusion criteria was
met.
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Primary end points:
 14 patients (25%) had spirometry documented
 17 patients (31%) had pulmonary function testing
documented
 Total of 31 (56%) of the 55 patients had either PFT’s
or spirometry documented in EMR with a
corresponding diagnosis of COPD
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Secondary Endpoints:
 45 of 55 patients (82%) were on COPD medications
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30 patients (55%) in this study had a diagnosis of Smoking use
(305.1)
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It should be noted that there was a much smaller studied
population than with the 2 larger studies.
Also, in this study, the inclusion population only included those
who were completely EMR.
There are large numbers who are still in paper charts that were
not accounted for which could have also affected the results.
Incomplete EMR conversion and a lack of spirometry/PFT entry
also could have affected the study.
The time line in our study was broader, with a 2 year window for
spirometry to confirm the COPD diagnosis.
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As shown in the references articles, spirometry use in outpatient primary care
offices has been less than adequate to either establish or support the diagnosis of
COPD.
In this review, the clinic did have a higher percentage of documented spirometry
or pulmonary function testing then the 2 reference studies as well as the CIPA
study group.
Men and women were tested equally.
There is also abundant information that smoking is a major contributor to COPD
and was once again confirmed in this study as noted in the secondary endpoints.
It does appear that COPD and it’s diagnosis, however it is made was documented
to be treated aggressively in our studied outpatient setting with almost 82% of
subjects on some form of COPD treatment.
Smoking must continually be addressed in whatever medical setting one is
involved.
There must be added emphasis in assuring that COPD is confirmed in our primary
care community through the use of spirometry and/or PFT’s.
Physicians in the future can be assured that they are employing gold standard care
to their patients when they use spirometry in their offices.
1.
2.
3.
4.
Chronic obstructive pulmonary disease: national clinical guideline on
management of chronic obstructive pulmonary disease in adults in
primary and secondary care. National Collaborating Centre for Chronic
Conditions. Thorax 2003, 59 (suppl 1); 1-232.
Diagnosis and Management of Stable Chronic Obstructive Pulmonary
Disease: A Clinical Practice Guideline from the American College of
Physicians. Annals of Internal Medicine 2007; 633-638.
Global Initiative for Chronic Obstructive Lung Disease. Global strategy
for the diagnosis, management, and prevention of chronic obstructive
pulmonary disease (updated 2008).
Lee TA, Bartle B, Weiss KB. Spirometry use in clinical practice following
diagnosis of COPD. Chest 2006; 129 (6): 1509-15.
5.
6.
7.
8.
Han MK, Kim MG, Mardon R, et al. Spirometry utilization for COPD:
How do we measure up? Chest 2007; 132: 403-09.
Medicare Data on Spirometry and COPD from Catholic Independent
Practice Association, Dr. Mike Edbauer (Medical Director), May 27, 2009.
Pocket Guide to COPD Diagnosis, Management, and Prevention; A
Guide for Health Care Professionals. Global Initiative for Chronic
Obstructive Lung Disease (Updated 2008).
Screening for Chronic Obstructive Pulmonary Disease Using Spirometry:
U.S. Preventative Services Task Force Recommendation Statement.
Annals of Internal Medicine 2008; 148: 529-534.