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Haynes JM, Kaminsky DA, Ruppel GL. The Role of Pulmonary Function Testing in the Diagnosis and Management of COPD. Respir Care 2023; 68:889-913. [PMID: 37353330 PMCID: PMC10289615 DOI: 10.4187/respcare.10757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/25/2023]
Abstract
Pulmonary function testing (PFT) has a long and rich history in the definition, diagnosis, and management of COPD. For decades, spirometry has been regarded as the standard for diagnosing COPD; however, numerous studies have shown that COPD symptoms, pathology, and associated poor outcomes can occur, despite normal spirometry. Diffusing capacity and imaging studies have called into question the need for spirometry to put the "O" (obstruction) in COPD. The role of exercise testing and the ability of PFTs to phenotype COPD are reviewed. Although PFTs play an important role in diagnosis, treatment decisions are primarily determined by symptom intensity and exacerbation history. Although a seminal study positioned FEV1 as the primary predictor of survival, numerous studies have shown that tests other than spirometry are superior predictors of mortality. In years past, using spirometry to screen for COPD was promulgated; however, this only seems appropriate for individuals who are symptomatic and at risk for developing COPD.
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Affiliation(s)
- Jeffrey M Haynes
- Pulmonary Function Laboratory, Elliot Health System, Manchester, New Hampshire.
| | - David A Kaminsky
- Division of Pulmonary and Critical Care Medicine, University of Vermont College of Medicine, Burlington, Vermont
| | - Gregg L Ruppel
- Division of Pulmonary, Critical Care and Sleep Medicine, St. Louis University, St. Louis, Missouri
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2
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Soler-Cataluña JJ, Almagro P, Huerta A, González-Segura D, Cosío BG. Clinical Control Criteria to Determine Disease Control in Patients with Severe COPD: The CLAVE Study. Int J Chron Obstruct Pulmon Dis 2021; 16:137-146. [PMID: 33531800 PMCID: PMC7846874 DOI: 10.2147/copd.s285385] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 01/07/2021] [Indexed: 11/26/2022] Open
Abstract
Background Clinical control in chronic obstructive pulmonary disease (COPD) has not been completely characterized. A proposal of clinical control criteria (CCC) has been recently defined and validated as a tool for determining control, but there is scarce information on patients with severe COPD. Objective To evaluate clinical control in severe COPD using the CCC. Patients and Methods The study design was observational, multicenter, cross-sectional study involving 4801 patients with severe COPD in Spain. Clinical control was defined according to clinical impact (dyspnea grade, use of rescue treatment in last week, sputum color, and daily physical activity) and stability (exacerbations in last 3 months and patient’s perception about health status). Clinical control of COPD was alternatively evaluated with the COPD assessment test (CAT) and the presence of exacerbations in the last 3 months. Results According to CCC, 61.0% of patients had low clinical impact, and 41.4% showed clinical stability. Overall, 29.9% of patients had both low clinical impact and stability (controlled), whereas 70.1% showed high clinical impact and/or no clinical stability (non-controlled). COPD control was also assessed by using only the definition of CAT≤16 and no exacerbations in the last 3 months. Results obtained with this definition were similar to those obtained by CCC, and the concordance between both definitions was high (Kappa index = 0.698). Conclusion By using the CCC, approximately only one third of patients with severe COPD were considered as controlled. Physical activity, adherence to inhalers, age, post-bronchodilator FEV1, age-adjusted Charlson comorbidity index, and healthcare level were independent factors associated with COPD control.
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Affiliation(s)
| | - Pere Almagro
- Multimorbidity Patients Unit. Internal Medicine Department, H. Mutua Terrassa University Hospital, Terrassa, Barcelona, Spain
| | - Arturo Huerta
- Emergency Department - Medicine and Pulmonary Section, H. Clínic de Barcelona, Barcelona, Spain
| | | | - Borja G Cosío
- Department of Pneumology, H. Universitari Son Espases Hospital-IdISBa and CIBERES, Palma de Mallorca, Balearic Islands, Spain
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3
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Anane I, Guezguez F, Knaz H, Ben Saad H. How to Stage Airflow Limitation in Stable Chronic Obstructive Pulmonary Disease Male Patients? Am J Mens Health 2020; 14:1557988320922630. [PMID: 32475199 PMCID: PMC7263160 DOI: 10.1177/1557988320922630] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
No study has evaluated the utility of different classifications of chronic obstructive pulmonary disease (COPD) airflow limitation (AFL) in terms of the refined “ABCD” classification of the Global Initiative for Chronic Obstructive Lung Disease (GOLD) or in terms of the impacts on quality of life. This study aimed to compare some relevant health outcomes (i.e., GOLD classification and quality-of-life scores) between COPD patients having “light” and “severe” AFL according to five COPD AFL classifications. It was a cross-sectional prospective study including 55 stable COPD male patients. The COPD assessment test (CAT), the VQ11 quality-of-life questionnaire, a spirometry, and a bronchodilator test were performed. The patients were divided into GOLD “A/B” and “C/D.” The following five classifications of AFL severity, based on different post-bronchodilator forced expiratory volume in 1 s (FEV1) expressions, were applied: FEV1%pred: “light” (≥50), “severe” (<50); FEV1z-score: “light” (≥−3), “severe” (<−3); FEV1/height2: “light” (≥0.40), “severe” (<0.40); FEV1/height3: “light” (≥0.29), “severe” (<0.29); and FEV1Quotient: “light” (≥2.50), “severe” (<2.50). The percentages of the patients with “severe” AFL were significantly influenced by the applied classification of the AFL severity (89.1 [FEV1z-score], 63.6 [FEV1%pred], 41.8 [FEV1/height3], 40.0 [FEV1Quotient], and 25.4 [FEV1/height2]; Cochrane test = 91.49, df = 4). The CAT and VQ11 scores were significantly different between the patients having “light” and “severe” AFL. In GOLD “C/D” patients, only the FEV1Quotient was able to distinguish between the two AFL severities. To conclude, the five classifications of COPD AFL were not similar when compared with regard to some relevant health outcomes.
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Affiliation(s)
- Ichraf Anane
- Laboratory of Physiology and Functional Explorations, Farhat HACHED Hospital, Sousse, Tunisia.,Heart Failure (LR12SP09) Research Laboratory, Farhat HACHED Hospital, Sousse, Tunisia
| | - Fatma Guezguez
- Laboratory of Physiology and Functional Explorations, Farhat HACHED Hospital, Sousse, Tunisia.,Heart Failure (LR12SP09) Research Laboratory, Farhat HACHED Hospital, Sousse, Tunisia
| | - Hend Knaz
- Laboratory of Physiology and Functional Explorations, Farhat HACHED Hospital, Sousse, Tunisia
| | - Helmi Ben Saad
- Laboratory of Physiology and Functional Explorations, Farhat HACHED Hospital, Sousse, Tunisia.,Laboratory of Physiology, Faculty of Medicine of Sousse, University of Sousse, Tunisia
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4
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Vaz Fragoso CA, Magnussen H, Miller MR, Brusasco V. Spirometry-based Diagnostic Criteria That Are Not Age-Appropriate Lack Clinical Relevance. Am J Respir Crit Care Med 2019; 197:963-964. [PMID: 29096065 DOI: 10.1164/rccm.201709-1789le] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Carlos A Vaz Fragoso
- 1 Yale University School of Medicine New Haven, Connecticut.,2 Connecticut Healthcare System and Clinical Epidemiology Research Center West Haven, Connecticut
| | - Helgo Magnussen
- 3 North German Center for Lung Research Grosshansdorf, Germany
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5
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Opina MTD, Nicklas BJ, Lovato JF, Files DC, Kritchevsky SB, Moore WC. Association of Symptoms of Obstructive Lung Disease and All-Cause Mortality in Older Adult Smokers. J Am Geriatr Soc 2019; 67:2116-2122. [PMID: 31250432 DOI: 10.1111/jgs.16052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 05/17/2019] [Accepted: 05/28/2019] [Indexed: 01/10/2023]
Abstract
OBJECTIVES This study aims to investigate the impact of respiratory symptoms in current and former smokers with and without obstructive lung disease (OLD) on all-cause mortality. DESIGN Secondary analysis in a prospective cohort (the Health, Aging and Body Composition study). SETTING Memphis, Tennessee, and Pittsburgh, Pennsylvania. PARTICIPANTS Black and white men and women with a history of current and former smoking (N = 596; 63% male and 37% female) aged 70-79 years followed for 13 years. Participants were categorized into 4 mutually exclusive groups based on symptom profile and forced expiratory volume in the 1st second to forced vital capacity ratio. The groups were Less Dyspnea-No OLD (N = 196), More Dyspnea-No OLD (N = 104), Less Dyspnea-With OLD (N = 162), and More Dyspnea-With OLD (N = 134). MEASUREMENTS All-cause mortality. RESULTS Overall, 53% in Less Dyspnea-No OLD, 63% in More Dyspnea-No OLD, 67% in Less Dyspnea-With OLD, and 84% in More Dyspnea-With OLD died within the 13- year follow up period (log-rank χ2 = 44.4, P < .0001). The hazard ratio was highest for participants with OLD, both with (HR =1.91, 95% CI 1.44 - 2.54; P < .0001) and without dyspnea (HR = 1.52, 95% CI 1.15 - 2.02; p = .004). Participants without OLD but with dyspnea had a similar risk of death to subjects who had OLD but fewer symptoms. CONCLUSIONS OLD is associated with high risk of death with different risk profiles based on symptom group. Patients with symptoms of shortness of breath without OLD should be considered an at-risk group given their similar mortality to those with OLD with minimal symptoms. J Am Geriatr Soc 67:2116-2122, 2019.
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Affiliation(s)
- Maria Theresa D Opina
- Section on Pulmonary, Critical Care, Allergy, and Immunologic Disease, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina.,Sticht Center on Healthy Aging and Alzheimer's Prevention, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Barbara J Nicklas
- Sticht Center on Healthy Aging and Alzheimer's Prevention, Wake Forest School of Medicine, Winston-Salem, North Carolina.,Section on Gerontology and Geriatric Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - James F Lovato
- Division of Public Health Sciences, Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Daniel C Files
- Section on Pulmonary, Critical Care, Allergy, and Immunologic Disease, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina.,Sticht Center on Healthy Aging and Alzheimer's Prevention, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Stephen B Kritchevsky
- Sticht Center on Healthy Aging and Alzheimer's Prevention, Wake Forest School of Medicine, Winston-Salem, North Carolina.,Section on Gerontology and Geriatric Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Wendy C Moore
- Section on Pulmonary, Critical Care, Allergy, and Immunologic Disease, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina.,Sticht Center on Healthy Aging and Alzheimer's Prevention, Wake Forest School of Medicine, Winston-Salem, North Carolina
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6
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Aggarwal AN, Agarwal R, Dhooria S, Prasad KT, Sehgal IS, Muthu V, Singh N, Behera D, Jindal SK, Singh V, Chawla R, Samaria JK, Gaur SN, Agrawal A, Chhabra SK, Chopra V, Christopher DJ, Dhar R, Ghoshal AG, Guleria R, Handa A, Jain NK, Janmeja AK, Kant S, Khilnani GC, Kumar R, Mehta R, Mishra N, Mohan A, Mohapatra PR, Patel D, Ram B, Sharma SK, Singla R, Suri JC, Swarnakar R, Talwar D, Narasimhan RL, Maji S, Bandopadhyay A, Basumatary N, Mukherjee A, Baldi M, Baikunje N, Kalpakam H, Upadhya P, Kodati R. Joint Indian Chest Society-National College of Chest Physicians (India) guidelines for spirometry. Lung India 2019; 36:S1-S35. [PMID: 31006703 PMCID: PMC6489506 DOI: 10.4103/lungindia.lungindia_300_18] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Although a simple and useful pulmonary function test, spirometry remains underutilized in India. The Indian Chest Society and National College of Chest Physicians (India) jointly supported an expert group to provide recommendations for spirometry in India. Based on a scientific grading of available published evidence, as well as other international recommendations, we propose a consensus statement for planning, performing and interpreting spirometry in a systematic manner across all levels of healthcare in India. We stress the use of standard equipment, and the need for quality control, to optimize testing. Important technical requirements for patient selection, and proper conduct of the vital capacity maneuver, are outlined. A brief algorithm to interpret and report spirometric data using minimal and most important variables is presented. The use of statistically valid lower limits of normality during interpretation is emphasized, and a listing of Indian reference equations is provided for this purpose. Other important issues such as peak expiratory flow, bronchodilator reversibility testing, and technician training are also discussed. We hope that this document will improve use of spirometry in a standardized fashion across diverse settings in India.
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Affiliation(s)
- Ashutosh Nath Aggarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sahajal Dhooria
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - K T Prasad
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Inderpaul S Sehgal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Valliappan Muthu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Navneet Singh
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - D Behera
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - S K Jindal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Virendra Singh
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rajesh Chawla
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - J K Samaria
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - S N Gaur
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Anurag Agrawal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - S K Chhabra
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vishal Chopra
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - D J Christopher
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Raja Dhar
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Aloke G Ghoshal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Randeep Guleria
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ajay Handa
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Nirmal K Jain
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashok K Janmeja
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Surya Kant
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - G C Khilnani
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Raj Kumar
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ravindra Mehta
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Narayan Mishra
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Anant Mohan
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - P R Mohapatra
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Dharmesh Patel
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Babu Ram
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - S K Sharma
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rupak Singla
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - J C Suri
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rajesh Swarnakar
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Deepak Talwar
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - R Lakshmi Narasimhan
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Saurabh Maji
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ankan Bandopadhyay
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Nita Basumatary
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Arindam Mukherjee
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Milind Baldi
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Nandkishore Baikunje
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Hariprasad Kalpakam
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Pratap Upadhya
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rakesh Kodati
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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7
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Pirozzi CS, Gu T, Quibrera PM, Carretta EE, Han MK, Murray S, Cooper CB, Tashkin DP, Kleerup EC, Barjaktarevic I, Hoffman EA, Martinez CH, Christenson SA, Hansel NN, Graham Barr R, Bleecker ER, Ortega VE, Martinez FJ, Kanner RE, Paine R. Heterogeneous burden of lung disease in smokers with borderline airflow obstruction. Respir Res 2018; 19:223. [PMID: 30454050 PMCID: PMC6245799 DOI: 10.1186/s12931-018-0911-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Accepted: 10/09/2018] [Indexed: 01/03/2023] Open
Abstract
Background The identification of smoking-related lung disease in current and former smokers with normal FEV1 is complex, leading to debate regarding using a ratio of forced expiratory volume in 1 s to forced vital capacity (FEV1/FVC) of less than 0.70 versus the predicted lower limit of normal (LLN) for diagnosis of airflow obstruction. We hypothesized that the discordant group of ever-smokers with FEV1/FVC between the LLN and 0.70 is heterogeneous, and aimed to characterize the burden of smoking-related lung disease in this group. Methods We compared spirometry, chest CT characteristics, and symptoms between 161 ever-smokers in the discordant group and 940 ever-smokers and 190 never-smokers with normal FEV1 and FEV1/FVC > 0.70 in the SPIROMICS cohort. We also estimated sensitivity and specificity for diagnosing objective radiographic evidence of chronic obstructive pulmonary disease (COPD) using different FEV1/FVC criteria thresholds. Results The discordant group had more CT defined emphysema and non-emphysematous gas trapping, lower post-bronchodilator FEV1 and FEF25–75, and higher respiratory medication use compared with the other two groups. Within the discordant group, 44% had radiographic CT evidence of either emphysema or non-emphysematous gas trapping; an FEV1/FVC threshold of 0.70 has greater sensitivity but lower specificity compared with LLN for identifying individuals with CT abnormality. Conclusions Ever-smokers with normal FEV1 and FEV1/FVC < 0.70 but > LLN are a heterogeneous group that includes significant numbers of individuals with and without radiographic evidence of smoking-related lung disease. These findings emphasize the limitations of diagnosing COPD based on spirometric criteria alone. Electronic supplementary material The online version of this article (10.1186/s12931-018-0911-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Cheryl S Pirozzi
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Utah, 26 N 1900 E, Salt Lake City, UT, 84132, USA.
| | - Tian Gu
- Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA
| | - Pedro M Quibrera
- Department of Biostatistics, Collaborative Studies Coordinating Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Elizabeth E Carretta
- Department of Biostatistics, Collaborative Studies Coordinating Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - MeiLan K Han
- Department of Internal Medicine, University of Michigan, Ann, MI, USA
| | - Susan Murray
- Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA
| | - Christopher B Cooper
- Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Donald P Tashkin
- Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Eric C Kleerup
- Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Igor Barjaktarevic
- Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Eric A Hoffman
- Department of Radiology, University of Iowa, Iowa City, IA, USA
| | - Carlos H Martinez
- Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA
| | | | - Nadia N Hansel
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - R Graham Barr
- Department of Medicine, Columbia University, New York, NY, USA
| | | | - Victor E Ortega
- Department of Medicine, Wake Forest University, Winston-Salem, NC, USA
| | | | - Richard E Kanner
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Utah, 26 N 1900 E, Salt Lake City, UT, 84132, USA
| | - Robert Paine
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Utah, 26 N 1900 E, Salt Lake City, UT, 84132, USA.,Department of Veterans Affairs Medical Center, Salt Lake City, UT, USA
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8
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Liu S, Zhou Y, Liu S, Zou W, Li X, Li C, Deng Z, Zheng J, Li B, Ran P. Clinical impact of the lower limit of normal of FEV 1/FVC on detecting chronic obstructive pulmonary disease: A follow-up study based on cross-sectional data. Respir Med 2018; 139:27-33. [PMID: 29857998 DOI: 10.1016/j.rmed.2018.04.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Revised: 04/13/2018] [Accepted: 04/17/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Criteria of obstruction that establish a diagnosis of COPD have been debated in recent years. We carried out a follow-up study to assess the impact of the new LLN reference equation for Chinese on detecting COPD compared with the traditional 0.7fixed criteria. METHODS We examined the prevalence and characteristics of airflow limitation for a non-child population using post-bronchodilator airflow with both age-dependent predicted lower limit of the normal value and fixed-ratio spirometric criterion. Questionnaires and spirometry were completed for all eligible subjects during the baseline examination. Participants with inconsistent diagnosis according to the two criteria, normal participants (controls) and COPD patients in stages I or II, were invited to take a cardiopulmonary exercise testing (CPET) examination and follow up for 2-4 years. RESULTS A total of 5448 (mean age 50.51 ± 13.2 yr) study subjects with acceptable spirometry and complete questionnaire data were included in our final analyses. COPD detection based on LLN was consistent with the GOLD 0.7 fixed-ratio in general, as 51 subjects (0.9%) were underdiagnosed, and 61 subjects (1.1%) were overdiagnosed when using LLN as the reference diagnostic criterion. The underdiagnosed subjects were younger, had more symptoms, more exposure to biofuels and worse FEV1 than the normal group; they also demonstrated a damaged cardiopulmonary reserve capacity and significant FEV1 decline. Except for being older, the overdiagnosed subjects differed little from the normal group. CONCLUSIONS Individual-dependent LLN appears to better reveal impacts on detecting airflow limitation. Participants underdiagnosed by GOLD criterion should be paid more attention. CLINICAL TRIAL REGISTRATION ChiCTR-ECS-13004110.
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Affiliation(s)
- Sha Liu
- The State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Diseases, Guangzhou Institute of Respiratory Disease, The First Affiliated Hospital, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Yumin Zhou
- The State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Diseases, Guangzhou Institute of Respiratory Disease, The First Affiliated Hospital, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Shiliang Liu
- The Third Affiliated Hospital, Guangzhou Medical University, Guangzhou, Guangdong, China; Department of Epidemiology and Community Medicine Faculty of Medicine University of Ottawa, Ottawa, Ontario, Canada
| | - Weifeng Zou
- Guangzhou Chest Hospital, Guangzhou, Guangdong, China
| | - Xiaochen Li
- The State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Diseases, Guangzhou Institute of Respiratory Disease, The First Affiliated Hospital, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Chenglong Li
- The State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Diseases, Guangzhou Institute of Respiratory Disease, The First Affiliated Hospital, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Zhishan Deng
- The State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Diseases, Guangzhou Institute of Respiratory Disease, The First Affiliated Hospital, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Jinzhen Zheng
- The State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Diseases, Guangzhou Institute of Respiratory Disease, The First Affiliated Hospital, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Bing Li
- College of Life Science, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Pixin Ran
- The State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Diseases, Guangzhou Institute of Respiratory Disease, The First Affiliated Hospital, Guangzhou Medical University, Guangzhou, Guangdong, China.
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9
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Pedone C, Giua R, Scichilone N, Bellia V, Antonelli-Incalzi R. GOLD Staging System is Appropriate to Predict Mortality in Older People With Chronic Obstructive Pulmonary Disease. Arch Bronconeumol 2018; 54:S0300-2896(18)30037-1. [PMID: 29530351 DOI: 10.1016/j.arbres.2018.01.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 12/18/2017] [Accepted: 01/15/2018] [Indexed: 10/17/2022]
Abstract
INTRODUCTION In the new GOLD classification the reduction of FEV1, expressed as percentage of predicted value (FEV1PP), is considered an important prognostic factor. However, the use of FEV1PP may introduce bias, especially if based on equations derived from populations different from the one under study. We evaluated how well the GOLD classification stratifies the mortality risk when FEV1PP is based on an equation developed in the same population that gave rise to cases, externally developed equations, or as FEV1 divided by cubed height (FEV1/Ht3). METHODS We studied 882 participants aged ≥65 years. Bronchial obstruction was defined using a fixed cut-off of 0.7 for FEV1/FVC. Predicted values of FEV1 were derived from equations based on the same sample of the cases included in this study and from the European Respiratory Society equations. Severity of bronchial obstruction was also classified according to quartiles of FEV1/Ht3. RESULTS All the classification systems showed a non-statistically significant linear tendency with 5-years mortality risk. For the 15-years mortality, the linear trend across severity stages is more evident for GOLD classifications, with significant increments in the hazard ratio. Stratification by FEV1/Ht3 could better discriminate the functional status of participants. CONCLUSION The severity of bronchial obstruction according to GOLD classes may stratify mortality risk better than quartiles of FEV1/Ht3, whereas the second seems to be more suited to stratify the risk of clinical outcomes. Concerns about the use of externally developed reference values to calculate FEV1PP do not seem confirmed, at least for GOLD classification.
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Affiliation(s)
- Claudio Pedone
- Area di Geriatria, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Renato Giua
- Area di Geriatria, Università Campus Bio-Medico di Roma, Rome, Italy.
| | - Nicola Scichilone
- Dipartimento Biomedico di Medicina Interna e Specialistica (Di.Bi.MIS), Università di Palermo, Palermo, Italy
| | - Vincenzo Bellia
- Dipartimento Biomedico di Medicina Interna e Specialistica (Di.Bi.MIS), Università di Palermo, Palermo, Italy
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10
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Chronic Obstructive Pulmonary Disease: Defining the Indefinable. Ann Am Thorac Soc 2018; 15:390. [DOI: 10.1513/annalsats.201710-830le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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11
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Fortis S, Eberlein M, Georgopoulos D, Comellas AP. Predictive value of prebronchodilator and postbronchodilator spirometry for COPD features and outcomes. BMJ Open Respir Res 2017; 4:e000213. [PMID: 29435342 PMCID: PMC5759707 DOI: 10.1136/bmjresp-2017-000213] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 10/17/2017] [Accepted: 11/07/2017] [Indexed: 01/26/2023] Open
Abstract
Introduction We compared the predictive value of prebronchodilator and postbronchodilator spirometry for chronic obstructive pulmonary disease (COPD) features and outcomes. Methods We analysed COPDGene data of 10 192 subjects with smoking history. We created regressions models with the following dependent variables: clinical, functional and radiographic features, and the following independent variables: prebronchodilator airflow obstruction (PREO) and postbronchodilator airflow obstruction (POSTO), prebronchodilator and postbronchodilator FEV1% predicted. We compared the model performance using the Akaike information criterion (AIC). Results The COPD prevalence was higher using PREO. About 8.5% had PREO but no airflow obstruction in postbronchodilator spirometry (POSTN) (PREO-POSTN) and 3% of all subjects had no aiflow obstruction in prebronchodilator spirometry (PREN) but POSTO (PREN-POSTO). We found no difference in COPD features and outcomes between PREO-POSTN and PREN-POSTO subjects. Although, both prebronchodilator and postbronchodilator spirometries are both associated with chronic bronchitis, dyspnoea, exercise capacity and COPD radiographic findings, models that included postbronchodilator spirometric measures performed better than models with prebronchodilator measures to predict these COPD features. The predictive value of prebronchodilator and postbronchodilator spirometries for respiratory exacerbations, change in forced expiratory volume in 1 s, dyspnoea and exercise capacity during a 5-year period is relatively similar, but postbronchodilator spirometric measures are better predictors of mortality based on AIC. Conclusions Postbronchodilator spirometry may be a more accurate predictor of COPD features and outcomes.
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Affiliation(s)
- Spyridon Fortis
- Division of Pulmonary, Critical Care and Occupational Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA.,Medical School, University of Crete, Heraklion, Greece
| | - Michael Eberlein
- Division of Pulmonary, Critical Care and Occupational Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Dimitris Georgopoulos
- Medical School, University of Crete, Heraklion, Greece.,Departments of Pulmonary Medicine and Intensive Care Medicine, University Hospital of Heraklion, Heraklion, Greece
| | - Alejandro P Comellas
- Division of Pulmonary, Critical Care and Occupational Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
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12
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Parulekar AD, Martinez C, Tsai CL, Locantore N, Atik M, Yohannes AM, Kao CC, Al-Azzawi H, Mohsin A, Wise RA, Foreman MG, Demeo DL, Regan EA, Make BJ, Boriek AM, Wiener LE, Hanania NA. Examining the Effects of Age on Health Outcomes of Chronic Obstructive Pulmonary Disease: Results From the Genetic Epidemiology of Chronic Obstructive Pulmonary Disease Study and Evaluation of Chronic Obstructive Pulmonary Disease Longitudinally to Identify Predictive Surrogate Endpoints Cohorts. J Am Med Dir Assoc 2017; 18:1063-1068. [PMID: 29169736 PMCID: PMC5955393 DOI: 10.1016/j.jamda.2017.09.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 09/29/2017] [Indexed: 12/26/2022]
Abstract
RATIONALE The prevalence of chronic obstructive pulmonary disease (COPD) and its associated comorbidities increase with age. However, little is understood about differences in the disease in patients over 65 years of age compared with younger patients. OBJECTIVES To determine disease characteristics of COPD and its impact in older patients compared with younger patients. METHODS We examined baseline characteristics of patients with COPD (global obstructive lung disease stage II-IV) in 2 large cohorts: Genetic Epidemiology of COPD Study (COPDGene) and Evaluation of COPD Longitudinally to Identify Predictive Surrogate Endpoints (ECLIPSE). We compared demographics, indices of disease severity, prevalence of comorbidities, exacerbation frequency, and quality of life scores in patients ≥65 years of age vs patients <65 years of age. We also tested for associations of age with disease characteristics and health outcomes. RESULTS In the COPDGene cohort, older patients (n = 1663) had more severe disease as measured by forced expiratory volume in 1 second (1.22 vs 1.52 L, P < .001), use of long-term oxygen therapy (35% vs 22%, P < .001), 6-minute walk distance (355 vs 375 m, P < .001), and radiographic evidence of emphysema (14% vs 8%, P < .001) and air trapping (47% vs 36%, P < .001) and were more likely to have comorbidities compared with younger patients (n = 2027). Similarly, in the ECLIPSE cohort, older patients (n = 1030) had lower forced expiratory volume in 1 second (1.22 vs 1.34 L, P < .001), greater use of long-term oxygen therapy (7% vs 5%, P = .02), shorter 6- minute walk distance (360 vs 389 m, P < .001), and more radiographic evidence of emphysema (17% vs 14%, P = .009) than younger patients (n = 1131). In adjusted analyses of both cohorts, older age was associated with decreased frequency of exacerbations [odds ratio = 0.52, 95% confidence interval (CI) = 0.43-0.64 in COPDGene, odds ratio = 0.79, 95% CI = 0.64-0.99 in ECLIPSE] and a better quality of life (lower St. Georges respiratory questionnaire score) (β = -8.7, 95% CI = -10.0 to -7.4 in COPDGene, β = -4.4, 95% CI = -6.1 to -3.2 in ECLIPSE). CONCLUSIONS Despite greater severity of illness, older patients with COPD had better quality of life and reported fewer exacerbations than younger patients. Although this observation needs to be explored further, it may be related to the fact that older patients change their expectations and learn to adapt to their disease.
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Affiliation(s)
- Amit D Parulekar
- Section of Pulmonary, Critical Care, and Sleep, Baylor College of Medicine, Houston, TX
| | | | - Chu-Lin Tsai
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | | | - Mustafa Atik
- Section of Pulmonary, Critical Care, and Sleep, Baylor College of Medicine, Houston, TX
| | - Abebaw M Yohannes
- Department of Physical Therapy, Azusa Pacific University, Azusa, CA.
| | - Christina C Kao
- Section of Pulmonary, Critical Care, and Sleep, Baylor College of Medicine, Houston, TX
| | - Hassan Al-Azzawi
- Section of Pulmonary, Critical Care, and Sleep, Baylor College of Medicine, Houston, TX
| | - Ali Mohsin
- Section of Pulmonary, Critical Care, and Sleep, Baylor College of Medicine, Houston, TX
| | | | - Marilyn G Foreman
- Pulmonary and Critical Care Medicine Division, Morehouse School of Medicine, Atlanta, GA
| | - Dawn L Demeo
- Channing Division of Network Medicine and Pulmonary and Critical Care Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | | | - Barry J Make
- Department of Medicine, National Jewish Health, Denver, CO
| | - Aladin M Boriek
- Section of Pulmonary, Critical Care, and Sleep, Baylor College of Medicine, Houston, TX
| | - Laura E Wiener
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Nicola A Hanania
- Section of Pulmonary, Critical Care, and Sleep, Baylor College of Medicine, Houston, TX
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13
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Kainu A, Timonen K, Lindqvist A, Piirilä P. GOLD criteria overestimate airflow limitation in one-third of cases in the general Finnish population. ERJ Open Res 2016; 2:00084-2015. [PMID: 28053971 PMCID: PMC5152847 DOI: 10.1183/23120541.00084-2015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2015] [Accepted: 07/15/2016] [Indexed: 01/09/2023] Open
Abstract
The Global Initiative for Chronic Obstructive Lung Disease (GOLD) diagnostic criteria for chronic obstructive pulmonary disease (COPD) use a fixed threshold of forced expiratory volume in 1 s (FEV1)/forced vital capacity (FVC) ratio (<0.70) in post-bronchodilation spirometry to indicate disease, which has been shown to underestimate and overestimate disease prevalence in younger and older adults, respectively, whilst criteria based on reference values have better accuracy. Differences in reference values have limited their use in international studies. However, the new Global Lung Function Initiative reference values (GLI2012) showed FEV1/FVC to be the least dependent on ethnicity. The aim of this study was to assess the prevalence of airflow limitation with GLI2012 and the degree of underdetection or overestimation related to the use of GOLD in the general population. A Finnish population sample of 1323 subjects (45% male) with post-bronchodilation spirometry was studied. 80 subjects (6.0%) and 55 subjects (4.2%) were identified with airflow limitation with GOLD and GLI2012 criteria, respectively. The proportion of overestimation with GOLD increased with age from 25% of cases in 50-year-olds to 54% in 70-year-olds. Using z-score-based grading resulted in more dispersion in severity grading. In conclusion, the GOLD criteria cause a marked overestimation already from 50-year-olds and should be replaced with the GLI2012 criteria to improve diagnostic accuracy.
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Affiliation(s)
- Annette Kainu
- Heart and Lung Center, Peijas Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Kirsi Timonen
- Dept of Clinical Physiology, Central Hospital of Central Finland, Jyväskylä, Finland
- Dept of Clinical Physiology and Nuclear Medicine, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
| | - Ari Lindqvist
- Research Unit of Pulmonary Diseases, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Päivi Piirilä
- Dept of Clinical Physiology and Nuclear Medicine, HUS Medical Imaging Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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14
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Vaz Fragoso CA, McAvay G, Van Ness PH, Casaburi R, Jensen RL, MacIntyre N, Yaggi HK, Gill TM, Concato J. Phenotype of Spirometric Impairment in an Aging Population. Am J Respir Crit Care Med 2016; 193:727-35. [PMID: 26540012 DOI: 10.1164/rccm.201508-1603oc] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE The Global Lung Initiative (GLI) provides age-appropriate criteria for establishing spirometric impairment, including mild, moderate, and severe chronic obstructive pulmonary disease (COPD) and restrictive pattern, but its association with respiratory-related phenotypes has not been evaluated. OBJECTIVES To evaluate respiratory-related phenotypes in GLI-defined spirometric impairment. METHODS In COPDGene (N = 10,131 patients; age range, 45-81 yr; average smoking history, 44.3 pack-years), we evaluated spirometry, dyspnea (modified Medical Research Council grade, ≥2), poor respiratory health-related quality of life (St. George's Respiratory Questionnaire total score, ≥25), poor exercise performance (6-minute-walk distance, <391 m), bronchodilator reversibility (FEV1 change, >12% and ≥200 ml), and computed tomography-diagnosed emphysema and gas trapping (>5% and >15% of lung, respectively). MEASUREMENTS AND MAIN RESULTS GLI established normal spirometry in 5,100 patients (50.3%), mild COPD in 669 (6.6%), moderate COPD in 865 (8.5%), severe COPD in 2,522 (24.9%), and restrictive pattern in 975 (9.6%). Relative to normal spirometry, graded associations with respiratory-related phenotypes were found for mild, moderate, and severe COPD, with respective adjusted odds ratios (95% confidence intervals) as follows: dyspnea-1.31 (1.10-1.56), 2.20 (1.81-2.68), and 10.73 (8.04-14.33); poor respiratory health-related quality of life-1.49 (1.28-1.75), 2.69 (2.08-3.47), and 14.61 (10.09-21.17); poor exercise performance-1.11 (0.94-1.31), 1.58 (1.33-1.88), and 4.58 (3.42-6.12); bronchodilator reversibility-2.76 (2.24-3.40), 5.18 (4.29-6.27), and 6.21 (5.06-7.62); emphysema-4.86 (3.16-7.47), 6.41 (4.09-10.05), and 17.79 (10.79-29.32); and gas trapping-3.92 (3.12-4.93), 5.20 (3.82-7.07), and 16.28 (9.71-27.30). Restrictive pattern was also associated with multiple respiratory-related phenotypes at a level similar to moderate COPD, but it was otherwise not associated with emphysema (0.89 [0.60-1.32]) or gas trapping (1.15 [0.92-1.42]). CONCLUSIONS GLI-defined spirometric impairment establishes clinically meaningful respiratory disease, as validated by graded associations with respiratory-related phenotypes.
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Affiliation(s)
- Carlos A Vaz Fragoso
- 1 Veterans Affairs Clinical Epidemiology Research Center, West Haven, Connecticut.,2 Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Gail McAvay
- 2 Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Peter H Van Ness
- 2 Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Richard Casaburi
- 3 Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, Los Angeles, California
| | - Robert L Jensen
- 4 LDS Hospital and University of Utah, Salt Lake City, Utah; and
| | - Neil MacIntyre
- 5 Division of Pulmonary and Critical Care Medicine, Duke University School of Medicine, Durham, North Carolina
| | - H Klar Yaggi
- 1 Veterans Affairs Clinical Epidemiology Research Center, West Haven, Connecticut.,2 Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Thomas M Gill
- 2 Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - John Concato
- 1 Veterans Affairs Clinical Epidemiology Research Center, West Haven, Connecticut.,2 Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
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15
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Vaz Fragoso CA, McAvay G, Van Ness PH, Casaburi R, Jensen RL, MacIntyre N, Gill TM, Yaggi HK, Concato J. Phenotype of normal spirometry in an aging population. Am J Respir Crit Care Med 2016; 192:817-25. [PMID: 26114439 DOI: 10.1164/rccm.201503-0463oc] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
RATIONALE In aging populations, the commonly used Global Initiative for Chronic Obstructive Lung Disease (GOLD) may misclassify normal spirometry as respiratory impairment (airflow obstruction and restrictive pattern), including the presumption of respiratory disease (chronic obstructive pulmonary disease [COPD]). OBJECTIVES To evaluate the phenotype of normal spirometry as defined by a new approach from the Global Lung Initiative (GLI), overall and across GOLD spirometric categories. METHODS Using data from COPDGene (n = 10,131; ages 45-81; smoking history, ≥10 pack-years), we evaluated spirometry and multiple phenotypes, including dyspnea severity (Modified Medical Research Council grade 0-4), health-related quality of life (St. George's Respiratory Questionnaire total score), 6-minute-walk distance, bronchodilator reversibility (FEV1 % change), computed tomography-measured percentage of lung with emphysema (% emphysema) and gas trapping (% gas trapping), and small airway dimensions (square root of the wall area for a standardized airway with an internal perimeter of 10 mm). MEASUREMENTS AND MAIN RESULTS Among 5,100 participants with GLI-defined normal spirometry, GOLD identified respiratory impairment in 1,146 (22.5%), including a restrictive pattern in 464 (9.1%), mild COPD in 380 (7.5%), moderate COPD in 302 (5.9%), and severe COPD in none. Overall, the phenotype of GLI-defined normal spirometry included normal adjusted mean values for dyspnea grade (0.8), St. George's Respiratory Questionnaire (15.9), 6-minute-walk distance (1,424 ft [434 m]), bronchodilator reversibility (2.7%), % emphysema (0.9%), % gas trapping (10.7%), and square root of the wall area for a standardized airway with an internal perimeter of 10 mm (3.65 mm); corresponding 95% confidence intervals were similarly normal. These phenotypes remained normal for GLI-defined normal spirometry across GOLD spirometric categories. CONCLUSIONS GLI-defined normal spirometry, even when classified as respiratory impairment by GOLD, included adjusted mean values in the normal range for multiple phenotypes. These results suggest that among adults with GLI-defined normal spirometry, GOLD may misclassify normal phenotypes as having respiratory impairment.
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Affiliation(s)
- Carlos A Vaz Fragoso
- 1 Veterans Affairs Clinical Epidemiology Research Center, West Haven, Connecticut.,2 Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Gail McAvay
- 2 Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Peter H Van Ness
- 2 Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Richard Casaburi
- 3 Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, Los Angeles, California
| | - Robert L Jensen
- 4 LDS Hospital and University of Utah, Salt Lake City, Utah; and
| | - Neil MacIntyre
- 5 Division of Pulmonary and Critical Care Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Thomas M Gill
- 2 Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - H Klar Yaggi
- 1 Veterans Affairs Clinical Epidemiology Research Center, West Haven, Connecticut.,2 Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - John Concato
- 1 Veterans Affairs Clinical Epidemiology Research Center, West Haven, Connecticut.,2 Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
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16
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Matsuzaki A, Hashimoto N, Okachi S, Taniguchi T, Kawaguchi K, Fukui T, Wakai K, Yokoi K, Hasegawa Y. Clinical impact of the lower limit of normal of FEV1/FVC on survival in lung cancer patients undergoing thoracic surgery. Respir Investig 2015; 54:184-92. [PMID: 27108014 DOI: 10.1016/j.resinv.2015.11.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Revised: 09/16/2015] [Accepted: 11/17/2015] [Indexed: 12/01/2022]
Abstract
BACKGROUND Previously, it has been shown that using a fixed ratio of FEV1/FVC of 0.7 to classify airway obstruction could not predict survival outcomes in lung cancer patients undergoing thoracic surgery. We demonstrated that use of the lower limit of normal (LLN) of FEV1/FVC may allow better risk stratification for postoperative outcomes in patients with chronic obstructive pulmonary disease (COPD) patients. Nevertheless, it remained unclear whether survival outcomes in this population could be predicted by LLN-defined airway obstruction. OBJECTIVE To evaluate the clinical relevance of LLN-defined airway obstruction to survival outcomes. METHODS The clinical relevance of LLN-defined airway obstruction was analyzed and compared in 699 subjects, using Kaplan-Meier curves and the log-rank test. A Cox regression model was used to explore prognostic risk factors. RESULTS One hundred-and-seventy-eight subjects were assigned to the below-LLN group, in which airflow obstruction determined by the FEV1/FVC ratio was below the LLN. Five hundred-and-twenty-one subjects were assigned to the above-LLN group. The below-LLN group had a worse overall survival (OS) and disease-free survival (DFS) than the above-LLN group. The diffusing capacity of the lung for carbon monoxide and the ratio of the inspiratory capacity divided to the total lung capacity were independent risk factors for OS and DFS. CONCLUSIONS A standardized assessment of LLN-defined airway obstruction may allow risk stratification for survival likelihood in lung cancer patients who undergo thoracic surgery.
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Affiliation(s)
- Asuka Matsuzaki
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Naozumi Hashimoto
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Shotaro Okachi
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Tetsuo Taniguchi
- Department of Thoracic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Koji Kawaguchi
- Department of Thoracic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Takayuki Fukui
- Department of Thoracic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Kenji Wakai
- Department of Preventive Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Kohei Yokoi
- Department of Thoracic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Yoshinori Hasegawa
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan.
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Abstract
Current epidemiologic practice evaluates COPD based on self-reported symptoms of chronic bronchitis, self-reported physician-diagnosed COPD, spirometry confirmed airflow obstruction, or emphysema diagnosed by volumetric computed chest tomography (CT). Because the highest risk population for having COPD includes a predominance of middle-aged or older persons, aging related changes must also be considered, including: 1) increased multimorbidity, polypharmacy, and severe deconditioning, as these identify mechanisms that underlie respiratory symptoms and can impart a complex differential diagnosis; 2) increased airflow limitation, as this impacts the interpretation of spirometry confirmed airflow obstruction; and 3) "senile" emphysema, as this impacts the specificity of CT-diagnosed emphysema. Accordingly, in an era of rapidly aging populations worldwide, the use of epidemiologic criteria that do not rigorously consider aging related changes will result in increased misidentification of COPD and may, in turn, misinform public health policy and patient care.
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Affiliation(s)
- Carlos A. Vaz Fragoso
- Veterans Affairs Clinical Epidemiology Research Center, West Haven, CT. USA
- Yale School of Medicine, Department of Internal Medicine, New Haven, CT. USA
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18
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Zaigham S, Wollmer P, Engström G. Lung function, forced expiratory volume in 1 s decline and COPD hospitalisations over 44 years of follow-up. Eur Respir J 2015; 47:742-50. [PMID: 26647443 DOI: 10.1183/13993003.01575-2015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Accepted: 11/05/2015] [Indexed: 11/05/2022]
Abstract
The use of baseline lung function in the prediction of chronic obstructive pulmonary disease (COPD) hospitalisations, all-cause mortality and lung function decline was assessed in the population-based "Men Born in 1914" cohort.Spirometry was assessed at age 55 years in 689 subjects, of whom 392 had spirometry reassessed at age 68 years. The cohort was divided into three groups using fixed ratio (FR) and lower limit of normal (LLN) criterion: forced expiratory volume in 1 s (FEV1)/vital capacity (VC) ≥70%, FEV1/VC <70% but ≥LLN (FR(+)LLN(-)), and FEV1/VC <70% and <LLN (FR(+)LLN(+)).Over 44 years of follow-up, 88 men were hospitalised due to COPD and 686 died. Hazard ratios (95% CI) for incident COPD hospitalisation were 4.15 (2.24-7.69) for FR(+)LLN(-) and 7.88 (4.82-12.87) for FR(+)LLN(+) (reference FEV1/VC ≥70%). Hazard ratios for death were 1.30 (0.98-1.72) for FR(+)LLN(-) and 1.58 (1.25-2.00) for FR(+)LLN(+). The adjusted FEV1 decline between 55 and 68 years of age was higher for FR(+)LLN(-) and FR(+)LLN(+) relative to the reference. Of those with FR(+)LLN(-) at 55 years, 53% had progressed to the FR(+)LLN(+) group at 68 years.Airflow obstruction at age 55 years is a powerful risk factor for future COPD hospitalisations. The FR(+)LLN(-) group should be carefully evaluated in clinical practice in relation to future risks and potential benefit from early intervention. This is reinforced by the increased FEV1 decline in this group.
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Affiliation(s)
- Suneela Zaigham
- Dept of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Per Wollmer
- Dept of Translational Medicine, Lund University, Malmö, Sweden
| | - Gunnar Engström
- Dept of Clinical Sciences Malmö, Lund University, Malmö, Sweden
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19
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Quanjer PH, Ruppel G, Brusasco V, Pérez-Padilla R, Fragoso CAV, Culver BH, Swanney MP, Miller MR, Thompson B, Morgan M, Hughes M, Graham BL, Pellegrino R, Enright P, Buist AS, Burney P. COPD (confusion over proper diagnosis) in the zone of maximum uncertainty. Eur Respir J 2015; 46:1523-4. [DOI: 10.1183/13993003.01295-2015] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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20
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Wollmer P, Frantz S, Engström G, Dencker M, Löfdahl CG, Nihlén U. Fixed ratio or lower limit of normal for the FEV1/VC ratio: relation to symptoms and extended lung function tests. Clin Physiol Funct Imaging 2015; 37:263-269. [DOI: 10.1111/cpf.12294] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Accepted: 06/29/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Per Wollmer
- Department of Translational Medicine; Clinical Physiology and Nuclear Medicine; Lund University; Malmö Sweden
| | - Sophia Frantz
- Department of Translational Medicine; Clinical Physiology and Nuclear Medicine; Lund University; Malmö Sweden
| | - Gunnar Engström
- Department of Clinical Sciences; Cardio-vascular Epidemiology; Lund University; Malmö Sweden
| | - Magnus Dencker
- Department of Translational Medicine; Clinical Physiology and Nuclear Medicine; Lund University; Malmö Sweden
| | - Claes-Göran Löfdahl
- Department of Clinical Sciences; Respiratory Medicine and Allergology; Lund University; Lund Sweden
| | - Ulf Nihlén
- Department of Clinical Sciences; Respiratory Medicine and Allergology; Lund University; Lund Sweden
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Nonato NL, Nascimento OA, Padilla RP, de Oca MM, Tálamo C, Valdivia G, Lisboa C, López MV, Celli B, Menezes AMB, Jardim JR. Occurrence of respiratory symptoms in persons with restrictive ventilatory impairment compared with persons with chronic obstructive pulmonary disease: The PLATINO study. Chron Respir Dis 2015; 12:264-73. [PMID: 26041119 DOI: 10.1177/1479972315588004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Patients with chronic obstructive pulmonary disease (COPD) usually complain of symptoms such as cough, sputum, wheezing, and dyspnea. Little is known about clinical symptoms in individuals with restrictive ventilatory impairment. The aim of this study was to compare the prevalence and type of respiratory symptoms in patients with COPD to those reported by individuals with restrictive ventilatory impairment in the Proyecto Latinoamericano de Investigacion en Obstruccion Pulmonar study. Between 2002 and 2004, individuals ≥40 years of age from five cities in Latin America performed pre and post-bronchodilator spirometry and had their respiratory symptoms recorded in a standardized questionnaire. Among the 5315 individuals evaluated, 260 (5.1%) had a restrictive spirometric diagnosis (forced vital capacity (FVC) < lower limit of normal (LLN) with forced expiratory volume in the first second to forced vital capacity ratio (FEV1/FVC) ≥ LLN; American Thoracic Society (ATS)/European Respiratory Society (ERS) 2005) and 610 (11.9%) were diagnosed with an obstructive pattern (FEV1/FVC < LLN; ATS/ERS 2005). Patients with mild restriction wheezed more ((30.8%) vs. (17.8%); p < 0.028). No difference was seen in dyspnea, cough, and sputum between the two groups after adjusting for severity stage. The health status scores for the short form 12 questionnaire were similar in restricted and obstructed patients for both physical (48.4 ± 9.4 vs. 48.3 ± 9.8) and mental (50.8 ± 10.6 vs. 50.0 ± 11.5) domains. Overall, respiratory symptoms are not frequently reported by patients with restricted and obstructed patterns as defined by spirometry. Wheezing was more frequent in patients with restricted pattern compared with those with obstructive ventilatory defect. However, the prevalence of cough, sputum production, and dyspnea are not different between the two groups when adjusted by the same severity stage.
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Affiliation(s)
- Nívia L Nonato
- Pulmonary Rehabilitation Center of Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Oliver A Nascimento
- Pulmonary Rehabilitation Center of Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
| | | | | | - Carlos Tálamo
- Universidad Central de Venezuela, Caracas, Venezuela
| | - Gonzalo Valdivia
- Pontificia Universidad Católica de Chile, Santiago de Chile, Chile
| | - Carmen Lisboa
- Pontificia Universidad Católica de Chile, Santiago de Chile, Chile
| | | | | | | | - José R Jardim
- Pulmonary Rehabilitation Center of Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
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Vaz Fragoso CA, Pretto JJ, Quanjer PH. Comment on: Wollmer P, Engström G. Fixed ratio or lower limit of normal (LLN) as cut-off value for FEV1/VC: An outcome study. Respiratory Medicine (2013) 107, 1460-1462.: Fixed ratio or lower limit of normal (LLN) as cut-off value for FEV1/VC. Respir Med 2015; 109:928. [PMID: 25979574 DOI: 10.1016/j.rmed.2013.09.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2013] [Revised: 09/20/2013] [Accepted: 09/21/2013] [Indexed: 12/18/2022]
Affiliation(s)
- Carlos A Vaz Fragoso
- Yale University School of Medicine, Department of Internal Medicine, New Haven, CT, USA; Veterans Affairs Clinical Epidemiology Research Center, West Haven, CT, USA.
| | - Jeffrey J Pretto
- Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, New South Wales, Australia; School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
| | - Philip H Quanjer
- Department of Pulmonary Diseases, Erasmus Medical Centre, Erasmus University, Rotterdam, The Netherlands; Department of Paediatrics, Erasmus Medical Centre, Erasmus University, Rotterdam, The Netherlands
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Wollmer P, Engström G. Fixed ratio or lower limit of normal as cut-off value for FEV1/VC: An outcome study. Respir Med 2013; 107:1460-2. [DOI: 10.1016/j.rmed.2013.06.016] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2013] [Accepted: 06/18/2013] [Indexed: 11/28/2022]
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Gupta D, Agarwal R, Aggarwal AN, Maturu VN, Dhooria S, Prasad KT, Sehgal IS, Yenge LB, Jindal A, Singh N, Ghoshal AG, Khilnani GC, Samaria JK, Gaur SN, Behera D. Guidelines for diagnosis and management of chronic obstructive pulmonary disease: Joint ICS/NCCP (I) recommendations. Lung India 2013; 30:228-67. [PMID: 24049265 PMCID: PMC3775210 DOI: 10.4103/0970-2113.116248] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is a major public health problem in India. Although several International guidelines for diagnosis and management of COPD are available, yet there are lot of gaps in recognition and management of COPD in India due to vast differences in availability and affordability of healthcare facilities across the country. The Indian Chest Society (ICS) and the National College of Chest Physicians (NCCP) of India have joined hands to come out with these evidence-based guidelines to help the physicians at all levels of healthcare to diagnose and manage COPD in a scientific manner. Besides the International literature, the Indian studies were specifically analyzed to arrive at simple and practical recommendations. The evidence is presented under these five headings: (a) definitions, epidemiology, and disease burden; (b) disease assessment and diagnosis; (c) pharmacologic management of stable COPD; (d) management of acute exacerbations; and (e) nonpharmacologic and preventive measures. The modified grade system was used for classifying the quality of evidence as 1, 2, 3, or usual practice point (UPP). The strength of recommendation was graded as A or B depending upon the level of evidence.
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Affiliation(s)
- Dheeraj Gupta
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashutosh Nath Aggarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - V. N. Maturu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sahajal Dhooria
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - K. T. Prasad
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Inderpaul S. Sehgal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Lakshmikant B. Yenge
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Aditya Jindal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Navneet Singh
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - A. G. Ghoshal
- Department of Pulmonary Medicine, Indian Chest Society, India
| | - G. C. Khilnani
- Department of Pulmonary Medicine, National College of Chest Physicians, India
| | - J. K. Samaria
- Department of Pulmonary Medicine, Indian Chest Society, India
| | - S. N. Gaur
- Department of Pulmonary Medicine, National College of Chest Physicians, India
| | - D. Behera
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Gáldiz JB, Martinez Llorens J. New spirometric reference values. Arch Bronconeumol 2013; 49:413-4. [PMID: 23684313 DOI: 10.1016/j.arbres.2013.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Revised: 03/15/2013] [Accepted: 03/18/2013] [Indexed: 11/30/2022]
Affiliation(s)
- Juan B Gáldiz
- Laboratorio de Exploración Funcional, Servicio de Neumología Ciberes, Hospital Universitario Cruces, UPV/EHU, Barakaldo, Bizkaia, España.
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Bhatt SP, Sieren JC, Dransfield MT, Washko GR, Newell JD, Stinson DS, Zamba GKD, Hoffman EA. Comparison of spirometric thresholds in diagnosing smoking-related airflow obstruction. Thorax 2013; 69:409-14. [PMID: 23525095 DOI: 10.1136/thoraxjnl-2012-202810] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Diagnosis of chronic obstructive pulmonary disease is based on detection of airflow obstruction on spirometry. There is no consensus regarding using a fixed threshold to define airflow obstruction versus using the lower limit of normal (LLN) adjusted for age. We compared the accuracy and discrimination of the Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommended fixed ratio of forced expiratory volume in the first second/forced vital capacity<0.70 with LLN in diagnosing smoking-related airflow obstruction using CT-defined emphysema and gas trapping as the disease gold standard. METHODS Data from a large multicentre study (COPDGene), which included current and former smokers (age range 45-80 years) with and without airflow obstruction, were analysed. Concordance between spirometric thresholds was measured. The accuracy of the thresholds in diagnosing emphysema and gas trapping was assessed using quantitative CT as gold standard. RESULTS 7743 subjects were included. There was very good agreement between the two spirometric cutoffs (κ=0.85; 95% CI 0.83 to 0.86, p<0.001). 7.3% were discordant. Subjects with airflow obstruction by fixed ratio only had a greater degree of emphysema (4.1% versus 1.2%, p<0.001) and gas trapping (19.8% vs 7.5%, p<0.001) than those positive by LLN only, and also smoking controls without airflow obstruction (4.1% vs 1.9% and 19.8% vs 10.9%, respectively, p<0.001). On follow-up, the fixed ratio only group had more exacerbations than smoking controls. CONCLUSIONS Compared with the fixed ratio, the use of LLN fails to identify a number of patients with significant pulmonary pathology and respiratory morbidity.
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Affiliation(s)
- Surya P Bhatt
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Alabama at Birmingham, , Birmingham, Alabama, USA
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Vaz Fragoso CA, Gill TM, McAvay G, Quanjer PH, Van Ness PH, Concato J. Respiratory impairment in older persons: when less means more. Am J Med 2013; 126:49-57. [PMID: 23177541 PMCID: PMC3529831 DOI: 10.1016/j.amjmed.2012.07.016] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2012] [Revised: 07/11/2012] [Accepted: 07/11/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Among older persons, within the clinical context of respiratory symptoms and mobility, evidence suggests that improvements are warranted regarding the current approach for identifying respiratory impairment (ie, a reduction in pulmonary function). METHODS Among 3583 white participants aged 65 to 80 years (Cardiovascular Health Study), we calculated the prevalence of respiratory impairment using the current spirometric standard from the Global Initiative for Obstructive Lung Disease (GOLD) and an alternative spirometric approach termed "lambda-mu-sigma" (LMS). Results for GOLD- and LMS-defined respiratory impairment were evaluated for their (cross-sectional) association with respiratory symptoms and gait speed, and for the 5-year cumulative incidence probability of mobility disability. RESULTS The prevalence of respiratory impairment was 49.7% (1780/3583) when using the GOLD and 23.2% (831/3583) when using LMS. Differences in prevalence were most evident among participants who had no respiratory symptoms, with respiratory impairment classified more often by the GOLD (38.1% [326/855]) than LMS (12.3% [105/855]), as well as among participants who had normal gait speed, with respiratory impairment classified more often by the GOLD (46.4% [1003/2164]) than LMS (19.3% [417/2164]). Conversely, the 5-year cumulative incidence probability of mobility disability for respiratory impairment was higher for LMS than GOLD (0.313 and 0.249 for never-smokers, and 0.352 and 0.289 for ever-smokers, respectively), but was similar for normal spirometry by LMS or GOLD (0.193 and 0.185 for never-smokers, and 0.219 and 0.216 for ever-smokers, respectively). CONCLUSIONS Among older persons, the LMS approach (vs the GOLD approach) classifies respiratory impairment less frequently in those who are asymptomatic and is more strongly associated with mobility disability.
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Affiliation(s)
- Carlos A Vaz Fragoso
- Veterans Affairs Clinical Epidemiology Research Center, West Haven, CT 06250-8025, USA.
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Vaz Fragoso CA, Concato J, McAvay G, Van Ness PH, Gill TM. Respiratory impairment and COPD hospitalisation in older persons: a competing risk analysis. Eur Respir J 2012; 40:37-44. [PMID: 22267770 PMCID: PMC3773173 DOI: 10.1183/09031936.00128711] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The aim of the present study was to evaluate, among older persons, the association between respiratory impairment and hospitalisation for chronic obstructive pulmonary disease (COPD), based on spirometric Z-scores, i.e. the LMS (lambda, mu, sigma) method, and a competing risk approach. Using data on 3,563 white participants aged 65-80 yrs (from the Cardiovascular Health Study) we evaluated the association of LMS-defined respiratory impairment with the incident of COPD hospitalisation and the competing outcome of death without COPD hospitalisation, over a 5-yr period. Respiratory impairment included airflow limitation (mild, moderate or severe) and restrictive pattern. Over a 5-yr period, 276 (7.7%) participants had a COPD hospitalisation incident, whereas 296 (8.3%) died without COPD hospitalisation. The risk of COPD hospitalisation was elevated more than two-fold in LMS-defined mild and moderate airflow limitation and restrictive pattern (adjusted HR (95% CI): 2.25 (1.25-4.05), 2.54 (1.53- 4.22) and 2.65 (1.82-3.86), respectively), and more than eight-fold in LMS-defined severe airflow limitation (adjusted HR (95% CI) 8.33 (6.24-11.12)). Conversely, only LMS-defined restrictive-pattern was associated with the competing outcome of death without COPD hospitalisation (adjusted HR (95% CI) 1.68 (1.22-2.32)). In older white persons, LMS-defined respiratory impairment is strongly associated with an increased risk of COPD hospitalisation. These results support the LMS method as a basis for defining respiratory impairment in older persons.
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Affiliation(s)
- Carlos A Vaz Fragoso
- Clinical Epidemiology Research Center, VA Connecticut Healthcare System, 950 Campbell Ave, Mailcode 151B, West Haven, CT, USA.
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Drummond MB, Hansel NN, Connett JE, Scanlon PD, Tashkin DP, Wise RA. Spirometric predictors of lung function decline and mortality in early chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2012; 185:1301-6. [PMID: 22561963 DOI: 10.1164/rccm.201202-0223oc] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
RATIONALE The course of lung function decline for smokers with early airflow obstruction remains undefined. It is also unclear which early spirometric characteristics identify individuals at risk for rapid decline and increased mortality. OBJECTIVES To determine the association between spirometric measures and 5-year decline in FEV(1) and 12-year mortality. METHODS We analyzed longitudinal data from the Lung Health Study, a clinical trial of intensive smoking cessation intervention with or without bronchodilator therapy in 5,887 smokers with mild to moderate airflow obstruction. Participants were stratified into bins of baseline FEV(1) to FVC ratio, using bins of 5%, and separately into bins of Z-score (difference between actual and predicted FEV(1)/FVC, normalized to SD of predicted FEV(1)/FVC). Associations between spirometric measures and FEV(1) decline and mortality were determined after adjusting for baseline characteristics and time-varying smoking status. MEASUREMENTS AND MAIN RESULTS The cohort was approximately two-thirds male, predominantly of white race (96%), and with mean age of 49 ± 7 years. In general, individuals with lower lung function by any metric had more rapid adjusted FEV(1) decline. A threshold for differential decline was present at FEV(1)/FVC less than 0.65 (P < 0.001) and Z-score less than -2 (2.3 percentile) (P < 0.001). At year 12, 575 (7.2%) of the cohort had died. Lower thresholds of each spirometric metric were associated with increasing adjusted hazard of death. CONCLUSIONS Smokers at risk or with mild to moderate chronic obstructive pulmonary disease have accelerated lung function decline. Individuals with lower baseline FEV(1)/FVC have more rapid decline and worse mortality.
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Affiliation(s)
- M Bradley Drummond
- Division of Pulmonary/Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD 21224, USA.
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Izquierdo Alonso JL, De Lucas Ramos P, Rodríguez Glez-Moro JM. The use of the lower limit of normal as a criterion for COPD excludes patients with increased morbidity and high consumption of health-care resources. Arch Bronconeumol 2012; 48:223-8. [PMID: 22480962 DOI: 10.1016/j.arbres.2012.02.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2011] [Revised: 02/05/2012] [Accepted: 02/13/2012] [Indexed: 11/18/2022]
Abstract
The objective of this study is to analyze the clinical characteristics of two COPD patient populations: one diagnosed using the lower limit of normal (LLN) and another diagnosed by the GOLD criteria. We also compared the population excluded by the LLN criterion with a non-COPD control population. The COPD patients determined with the LLN criterion presented significantly lower levels of FEV1/FVC at 0.55 (0.8) vs. 0.66 (0.2), P=.000; FEV1 44.9% (14) vs. 53.8% (13), P=.000, and FVC 64.7% (17) vs. 70.4% p 0.04. The two COPD groups presented more frequent ER visits in the last year (57% and 52% of the patients, respectively, compared with 11.9% of the control group), without any statistically significant differences between the two. This same pattern was observed in the number of ER visits in the last year: 1.98 (1.6), 1.84 (1.5) and 1.18 (0.7), respectively. When we analyzed the prevalence of the comorbidities that are most frequently associated COPD, there was a clear increase in the percentage of patients who presented associated disorders compared with the control group. Nevertheless, these differences were not very relevant between the two COPD groups. The differences also were not relevant between both COPD groups in the pharmacological prescription profile. In conclusion, the use of the LLN as a criterion for establishing the diagnosis of COPD, compared with the GOLD criteria, excludes a population with important clinical manifestations and with a high consumption of health-care resources. Before its implementation, the relevance of applying this criterion in clinical practice should be analyzed.
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Vaz Fragoso CA, Gill TM. Respiratory impairment and the aging lung: a novel paradigm for assessing pulmonary function. J Gerontol A Biol Sci Med Sci 2012; 67:264-75. [PMID: 22138206 PMCID: PMC3297762 DOI: 10.1093/gerona/glr198] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2011] [Accepted: 10/02/2011] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Older persons have an increased risk of developing respiratory impairment because the aging lung is likely to have experienced exposures to environmental toxins as well as reductions in physiological capacity. METHODS Systematic review of risk factors and measures of pulmonary function that are most often considered when defining respiratory impairment in aging populations. RESULTS Across the adult life span, there are frequent exposures to environmental toxins, including tobacco smoke, respiratory infections, air pollution, and occupational dusts. Concurrently, there are reductions in physiological capacity that may adversely affect ventilatory control, respiratory muscle strength, respiratory mechanics, and gas exchange. Recent work has provided a strong rationale for defining respiratory impairment as an age-adjusted reduction in spirometric measures of pulmonary function that are independently associated with adverse health outcomes. Specifically, establishing respiratory impairment based on spirometric Z-scores has been shown to be strongly associated with respiratory symptoms, frailty, and mortality. Alternatively, respiratory impairment may be defined by the peak expiratory flow, as measured by a peak flow meter. The peak expiratory flow, when expressed as a Z-score, has been shown to be strongly associated with disability and mortality. However, because it has a reduced diagnostic accuracy, peak expiratory flow should only define respiratory impairment when spirometry is not readily available or an older person cannot adequately perform spirometry. CONCLUSIONS Aging is associated with an increased risk of developing respiratory impairment, which is best defined by spirometric Z-scores. Alternatively, in selected cases, respiratory impairment may be defined by peak expiratory flow, also expressed as a Z-score.
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Affiliation(s)
- Carlos A Vaz Fragoso
- Department of Internal Medicine, Veterans Affairs Clinical Epidemiology Research Center, West Haven, Connecticut 06516, USA.
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Mannino DM, Diaz-Guzman E. Interpreting Lung Function Data Using 80% Predicted and Fixed Thresholds Identifies Patients at Increased Risk of Mortality. Chest 2012; 141:73-80. [DOI: 10.1378/chest.11-0797] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
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Fragoso CAV, Concato J, McAvay G, Yaggi HK, Van Ness PH, Gill TM. Staging the severity of chronic obstructive pulmonary disease in older persons based on spirometric Z-scores. J Am Geriatr Soc 2011; 59:1847-54. [PMID: 22091498 PMCID: PMC3227010 DOI: 10.1111/j.1532-5415.2011.03596.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Among older persons, the use of spirometric Z-scores as calculated by the Lambda-Mu-Sigma (LMS) method has a strong scientific rationale for establishing a diagnosis of chronic obstructive pulmonary disease (COPD), but its clinical validity in staging COPD severity is not yet known. The current study has therefore evaluated the association between LMS-staged COPD and health outcomes, in two separate cohorts of older persons. DESIGN Longitudinal cohort study. SETTING The Cardiovascular Health Study (CHS, N = 3,248) and the Third National Health and Nutrition Examination Survey (NHANES-III, N = 1,354). PARTICIPANTS Community-living white participants aged 65 to 80. MEASUREMENTS Using spirometric data, COPD was staged as mild, moderate, or severe based on LMS-derived Z-scores. Clinical validity was then evaluated according to all-cause mortality, respiratory symptoms (chronic bronchitis, dyspnea, or wheezing), and moderate to severe dyspnea (available in CHS only). RESULTS In CHS, the LMS staging of COPD as mild, moderate, and severe was associated with mortality (adjusted HR (aHR) = 1.50, 95% confidence interval (CI) = 1.15-1.94; aHR = 1.31, 95% CI = 1.03-1.67; and aHR = 2.00, 95% CI = 1.70-2.36, respectively) and with respiratory symptoms (adjusted OR (aOR) = 1.69, 95% CI = 1.12-2.56; aOR = 1.87, 95% CI = 1.28-2.73; and aOR = 3.99, 95% CI = 2.91-5.48, respectively). Also in CHS, moderate and severe, but not mild, LMS-staged COPD was associated with moderate to severe dyspnea (aOR = 2.16, 95% CI = 1.24-3.75; aOR = 3.98, 95% CI = 2.77-5.74; and aOR = 0.84, 95% CI = 0.35-2.01, respectively). Similar associations were found for mortality and respiratory symptoms in NHANES-III, except mild severity was not associated with mortality (aHR = 0.93, 95% CI = 0.62-1.40). CONCLUSION In white older persons, the spirometric staging of COPD severity based on LMS-derived Z-scores was associated with several clinically relevant health outcomes. These results support the use of the LMS method for staging the severity of COPD in older populations.
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Affiliation(s)
- Carlos A Vaz Fragoso
- Veterans Affairs Clinical Epidemiology Research Center, West Haven, Connecticut 06516, USA.
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Vaz Fragoso CA, Gill TM, McAvay G, Yaggi HK, Van Ness PH, Concato J. Respiratory impairment and mortality in older persons: a novel spirometric approach. J Investig Med 2011. [PMID: 22011620 PMCID: PMC3198012 DOI: 10.231/jim.0b013e31822bb213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND The Lambda-Mu-Sigma (LMS) method calculates the lower limit of normal for spirometric measures of pulmonary function as the fifth percentile of the distribution of z scores, suitably accounting for age-related changes in pulmonary function. Extending prior work, and to assess whether the LMS method is clinically valid when evaluating respiratory impairment in the elderly, our current objective was to evaluate the association of LMS-defined respiratory impairment (airflow limitation and restrictive pattern) with all-cause mortality and respiratory symptoms (chronic bronchitis, dyspnea, or wheezing) in older persons. METHODS Spirometric data and outcome data on white participants aged 65 to 80 years were obtained from the Third National Health and Nutrition Examination Survey (NHANES-III, n = 1497) and the Cardiovascular Health Study (CHS, n = 3583). Multivariable analyses determined the corresponding associations, adjusting for important covariates. RESULTS In the NHANES-III and CHS populations, respectively, LMS-defined airflow limitation had adjusted hazard ratios (95% confidence interval) of 1.64 (1.28-2.11) and 1.69 (1.48-1.92) for mortality; adjusted odds ratios for respiratory symptoms were 2.71 (1.92-3.83) and 2.63 (2.11-3.27). The LMS-defined restrictive pattern was also significantly associated with mortality (adjusted hazard ratios of 1.98 [1.54-2.53] and 1.68 [1.44-1.95]), as well as with respiratory symptoms (adjusted odds ratios of 1.55 [1.03-2.34] and 1.37 [1.07-1.75]) in NHANES-III and CHS, respectively. CONCLUSIONS The LMS-defined airflow limitation and restrictive pattern confers a significantly increased risk of death and likelihood of having respiratory symptoms. These results support the use of LMS-derived spirometric z scores as a basis for evaluating respiratory impairment in older persons.
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Affiliation(s)
- Carlos A. Vaz Fragoso
- Veterans Affairs (VA) Clinical Epidemiology Research Center, West Haven, CT,Yale University School of Medicine, Department of Internal Medicine, New Haven, CT
| | - Thomas M. Gill
- Yale University School of Medicine, Department of Internal Medicine, New Haven, CT
| | - Gail McAvay
- Yale University School of Medicine, Department of Internal Medicine, New Haven, CT
| | - H. Klar Yaggi
- Veterans Affairs (VA) Clinical Epidemiology Research Center, West Haven, CT,Yale University School of Medicine, Department of Internal Medicine, New Haven, CT
| | - Peter H. Van Ness
- Yale University School of Medicine, Department of Internal Medicine, New Haven, CT
| | - John Concato
- Veterans Affairs (VA) Clinical Epidemiology Research Center, West Haven, CT,Yale University School of Medicine, Department of Internal Medicine, New Haven, CT
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Vaz Fragoso CA, Gill TM, McAvay G, Van Ness PH, Yaggi HK, Concato J. Use of lambda-mu-sigma-derived Z score for evaluating respiratory impairment in middle-aged persons. Respir Care 2011; 56:1771-7. [PMID: 21605489 DOI: 10.4187/respcare.01192] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND The lambda-mu-sigma (LMS) method calculates the lower limit of normal for spirometric values as the 5th percentile of the distribution of Z scores. Conceptually, LMS-derived Z scores account for normal age-related changes in pulmonary function, including variability and skewness in reference data. Evidence is limited, however, on whether the LMS method is valid for evaluating respiratory impairment in middle-aged persons. OBJECTIVE To evaluate the association of LMS-defined respiratory impairment (airflow limitation and restrictive pattern) with mortality and respiratory symptoms. METHODS We analyzed spirometric data from white participants ages 45-64 years in the Third National Health and Nutrition Examination Survey (NHANES III, n = 1,569) and the Atherosclerosis Risk in Communities study (ARIC, n = 8,163). RESULTS LMS-defined airflow limitation was significantly associated with mortality (adjusted hazard ratios: NHANES III 1.90, 95% CI 1.32-2.72, ARIC 1.28, 95% CI 1.06-1.57), and respiratory symptoms (adjusted odds ratios: NHANES III 2.48, 95% CI 1.75-3.51, ARIC 2.27, 95% CI 1.98-2.62). LMS-defined restrictive-pattern was also significantly associated with mortality (adjusted hazard ratios: NHANES III 1.98, 95% CI 1.08-3.65, ARIC 1.38, 95% CI 1.03-1.85), and respiratory symptoms (adjusted odds ratios: NHANES III 2.34, 95% CI 1.44-3.80, ARIC 1.89, 95% CI 1.46-2.45). CONCLUSIONS In white middle-age persons, LMS-defined airflow limitation and restrictive-pattern were significantly associated with mortality and respiratory symptoms. Consequently, an approach that reports spirometric values based on LMS-derived Z scores might provide an age-appropriate and clinically valid strategy for evaluating respiratory impairment.
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Affiliation(s)
- Carlos A Vaz Fragoso
- Clinical Epidemiology Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA.
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Mohamed Hoesein FAA, Zanen P, Lammers JWJ. Lower limit of normal or FEV1/FVC < 0.70 in diagnosing COPD: an evidence-based review. Respir Med 2011; 105:907-15. [PMID: 21295958 DOI: 10.1016/j.rmed.2011.01.008] [Citation(s) in RCA: 107] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2010] [Revised: 12/21/2010] [Accepted: 01/11/2011] [Indexed: 11/15/2022]
Abstract
AIM To review the currently available literature comparing the FEV1/FVC <LLN with a fixed value of FEV1/FVC < 0.70 in diagnosing airflow obstruction in subjects aged >40 years. METHODS A structured MEDLINE, EMBASE and Cochrane search of English-language literature was conducted. Studies comparing prevalence rates according to the LLN and a fixed value were included. Attention was paid to the choice of the reference test or gold standard used. RESULTS Eighteen studies met the inclusion criteria. Sixteen studies compared the rates of subjects diagnosed with airflow obstruction by either definition of airflow obstruction without using a non-independent reference standard (level 4 studies). Using a fixed value of FEV1/FVC, an overall higher number of subjects were diagnosed with airflow obstruction that increased with age. Two studies included a follow-up phase comparing risks of either hospitalization or occurrence of respiratory symptoms and mortality (level 2b studies). Adjusted risks of hospitalization (HR 2.6) or mortality (HR 1.3) were significantly larger in subjects with an FEV1/FVC below 0.70 but above the LLN (in-between group) compared to subjects with normal lung function. CONCLUSION The prevalence of spirometry-based COPD is greater when using the fixed value of FEV1/FVC in comparison to using the LLN. Based on one longitudinal study the in-between group appears to have a higher risk of hospitalization and mortality; therefore it seems that using the LLN of FEV1/FVC underestimates COPD. In absence of a gold standard of COPD longitudinal research will be necessary to determine which criterion is better and more clinically relevant.
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Affiliation(s)
- Firdaus A A Mohamed Hoesein
- Department of Respiratory Medicine, Division Heart & Lungs, University Medical Center Utrecht, Heidelberglaan 100, HP. F.02.333, P.O. Box 85500, 3508 GA Utrecht, The Netherlands
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Current world literature. Curr Opin Pulm Med 2011; 17:126-30. [PMID: 21285709 DOI: 10.1097/mcp.0b013e3283440e26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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