The diagnostic value of history and physical examination for COPD in suspected or known cases: a systematic review

Chronic Obstructive Pulmonary Disease and the Physical Examination

Performing a hypothesis-driven examination in patients with possible chronic obstructive pulmonary disease (COPD) is an important component of increasing the recognition and diagnosis of this avoidable and costly medical condition. Using known likelihood ratios for various physical examination maneuvers can be combined with known individual risk factors and symptoms to adjust a patient's post-test probability of having COPD and inform appropriate diagnostic work-up. Equally important is intentionality in history-taking and physical examination procedures for patients with known COPD to mitigate the decreased quality of life and mortality and to monitor response to treatment.

Difference in diaphragmatic motion during tidal breathing in a standing position between COPD patients and normal subjects: Time-resolved quantitative evaluation using dynamic chest radiography with flat panel detector system ("dynamic X-ray phrenicography")

OBJECTIVES

To quantitatively compare diaphragmatic motion during tidal breathing in a standing position between chronic obstructive pulmonary disease (COPD) patients and normal subjects using dynamic chest radiography.

MATERIALS AND METHODS

Thirty-nine COPD patients (35 males; age, 71.3±8.4years) and 47 normal subjects (non-smoker healthy volunteers) (20 males; age, 54.8±9.8years) underwent sequential chest radiographs during tidal breathing using dynamic chest radiography with a flat panel detector system. We evaluated the excursions and peak motion speeds of the diaphragms. The results were analyzed using an unpaired t-test and a multiple linear regression model.

RESULTS

The excursions of the diaphragms in COPD patients were significantly larger than those in normal subjects (right, 14.7±5.5mm vs. 10.2±3.7mm, respectively, P<0.001; left, 17.2±4.9mm vs. 14.9±4.2mm, respectively, P=0.022). Peak motion speeds in inspiratory phase were significantly faster in COPD patients compared to normal subjects (right, 16.3±5.0mm/s vs. 11.8±4.2mm/s, respectively, P<0.001; left, 18.9±4.9mm/s vs. 16.7±4.0mm/s, respectively, P=0.022). The multivariate analysis demonstrated that having COPD and higher body mass index were independently associated with increased excursions of the bilateral diaphragm (all P<0.05), after adjusting for other clinical variables.

CONCLUSIONS

Time-resolved quantitative evaluation of the diaphragm using dynamic chest radiography demonstrated that the diaphragmatic motion during tidal breathing in a standing position is larger and faster in COPD patients than in normal subjects.

Development of a simple binary response questionnaire to identify airflow obstruction in a smoking population in Argentina

The CODE questionnaire (COPD detection questionnaire), a simple, binary response scale (yes/no), screening questionnaire, was developed for the identification of patients with chronic obstructive pulmonary disease (COPD). We conducted a survey of 468 subjects with a smoking history in 10 public hospitals in Argentina. Patients with a previous diagnosis of COPD, asthma and other respiratory illness were excluded. Items that measured conceptual domains in terms of characteristics of symptoms, smoking history and demographics data were considered. 96 (20.5%) subjects had a diagnosis of COPD according to the 2010 Global Initiative for Chronic Obstructive Lung Disease strategy document. The variables selected for the final questionnaire were based on univariate and multivariate analyses and clinical criteria. Finally, we selected the presence or absence of six variables (age ≥50 years, smoking history ≥30 pack-years, male sex, chronic cough, chronic phlegm and dyspnoea). Of patients without any of these six variables (0 points), none had COPD. The ability of the CODE questionnaire to discriminate between subjects with and without COPD was good (the area under the receiver operating characteristic curve was 0.75). Higher scores were associated with a greater probability of COPD. The CODE questionnaire is a brief, accurate questionnaire that can identify smoking individuals likely to have COPD.

A nomogram was developed to enhance the use of multinomial logistic regression modeling in diagnostic research

OBJECTIVES

We developed a nomogram to facilitate the interpretation and presentation of results from multinomial logistic regression models.

STUDY DESIGN AND SETTING

We analyzed data from 376 frail elderly with complaints of dyspnea. Potential underlying disease categories were heart failure (HF), chronic obstructive pulmonary disease (COPD), the combination of both (HF and COPD), and any other outcome (other). A nomogram for multinomial model was developed to depict the relative importance of each predictor and to calculate the probability for each disease category for a given patient. Additionally, model performance of the multinomial regression model was assessed.

RESULTS

Prevalence of HF and COPD was 14% (n = 54), HF 24% (n = 90), COPD 20% (n = 75), and Other 42% (n = 157). The relative importance of the individual predictors varied across these disease categories or was even reversed. The pairwise C statistics ranged from 0.75 (between HF and Other) to 0.96 (between HF and COPD and Other). The nomogram can be used to rank the disease categories from most to least likely within each patient or to calculate the predicted probabilities.

CONCLUSIONS

Our new nomogram is a useful tool to present and understand the results of a multinomial regression model and could enhance the applicability of such models in daily practice.

The RESPECT study: RESearch on the PrEvalence and the diagnosis of COPD and its Tobacco-related etiology: a study protocol

BACKGROUND

Smoking remains a leading health risk factor among Europeans. Tobacco, together with other factors, will lead to an expansive epidemic of chronic diseases, including COPD, among the working population in Russia. The general aim of the RESearch on the PrEvalence and the diagnosis of COPD and its Tobacco-related etiology (RESPECT) study is to gain a better understanding of the prevalence, pathogenesis and symptoms of COPD.

METHODS/DESIGN

The RESPECT study is a prospective, population-based cohort study of subjects aged 35-70 years in two north-west regions of the Russian Federation (Saint Petersburg and Arkhangelsk). The study includes three components: a cross-sectional study (prevalence), a case-control study and a cohort study (diagnostic). An investigator who interviewed the patient completed three questionnaires. Spirometry, including a reversibility test, was offered to all participants. Individuals displaying forced expiratory volume in 1 s (FEV1)/forced vital capacity (FVC) < 0.7 and/or FEV1/FVC < the lower limit of normal before and/or after bronchodilation were included in a follow-up study and were examined by a pulmonologist using a standardized comprehensive examination protocol. A future case-control study of two matched groups of patients (heavy smokers with COPD versus heavy smokers without COPD) will provide information on which factors (biomarkers, including pneumoproteins, in serum and induced sputum) are related to tobacco-induced COPD.

DISCUSSION

In total, 3133 individuals (2122 from St. Petersburg and 1012 from Arkhangelsk) aged 35-70 years agreed to participate in this study and met the inclusion criteria. In total, 2974 participants met the quality criteria for spirometry, and 2388 reversibility tests were performed. A cohort of newly defined obstructive pulmonary disease patients (247 persons) was established for follow-up investigation. The RESPECT study will provide information regarding the prevalence of COPD in the north-west region of the Russian Federation. Moreover, the comprehensive RESPECT database will enable us to explore new research questions, provide novel insight into the risk factors and different phenotypes of COPD, and contribute to an improved understanding of the reasons why some heavy smokers develop the disease whereas others do not.

CLINICAL TRIAL REGISTRATION

NCT02307799 (the release date: 12/01/2014).

Flow-Volume Parameters in COPD Related to Extended Measurements of Lung Volume, Diffusion, and Resistance

Classification of COPD into different GOLD stages is based on forced expiratory volume in 1 s (FEV1) and forced vital capacity (FVC) but has shown to be of limited value. The aim of the study was to relate spirometry values to more advanced measures of lung function in COPD patients compared to healthy smokers. The lung function of 65 COPD patients and 34 healthy smokers was investigated using flow-volume spirometry, body plethysmography, single breath helium dilution with CO-diffusion, and impulse oscillometry. All lung function parameters, measured by body plethysmography, CO-diffusion, and impulse oscillometry, were increasingly affected through increasing GOLD stage but did not correlate with FEV1 within any GOLD stage. In contrast, they correlated fairly well with FVC%p, FEV1/FVC, and inspiratory capacity. Residual volume (RV) measured by body plethysmography increased through GOLD stages, while RV measured by helium dilution decreased. The difference between these RV provided valuable additional information and correlated with most other lung function parameters measured by body plethysmography and CO-diffusion. Airway resistance measured by body plethysmography and impulse oscillometry correlated within COPD stages. Different lung function parameters are of importance in COPD, and a thorough patient characterization is important to understand the disease.

Airway obstruction and bronchodilator responsiveness in adults with acute cough

PURPOSE

We sought to determine the prevalence of airway obstruction and bronchodilator responsiveness in adults consulting for acute cough in primary care.

METHODS

Family physicians recruited 3,105 adult patients with acute cough (28 days or shorter) attending primary care practices in 12 European countries. After exclusion of patients with preexisting physician-diagnosed asthma or chronic obstructive pulmonary disease (COPD), we undertook complete case analysis of spirometry results (n = 1,947) 28 to 35 days after inclusion. Bronchodilator responsiveness was diagnosed if there were recurrent complaints of wheezing, cough, or dyspnea and an increase of the forced expiratory volume in 1 second (FEV(1)) of 12% or more after bronchodilation. Airway obstruction was diagnosed according to 2 thresholds for the (postbronchodilator) ratio of FEV(1) to forced vital capacity (FEV(1):FVC): less than 0.7 and less than the lower limit of normal.

RESULTS

There were 240 participants who showed bronchodilator responsiveness (12%), 193 (10%) had a FEV(1)/FVC ratio of less than 0.7, and 126 (6%) had a ratio of less than the lower limit of normal. Spearman's correlation between the 2 definitions of obstruction was 0.71 (P <.001), with discordance most pronounced among those younger than 30 years and in older participants.

CONCLUSIONS

Both bronchodilator responsiveness and persistent airway obstruction are common in adults without established asthma or COPD who consult for acute cough in primary care, which suggests a high risk of undiagnosed asthma and COPD. Different accepted methods to define airway obstruction detected different numbers of patients, especially at the extremes of age. As both conditions benefit from appropriate and timely interventions, clinicians should be aware and responsive to potential underdiagnosis.

Pragmatic research and outcomes in asthma and COPD

Asthma and chronic obstructive pulmonary disease (COPD) are common diseases which cause patients and society considerable difficulties. These are costly diseases which cause substantial morbidity and death. Health care policy makers have made improving outcomes in asthma and COPD a priority. Application of guideline recommended approaches to asthma and COPD care in the real-life setting has been emphasized but outcomes have not improved. Failure to improve outcomes may not be because of inconsistent applications of guideline recommendations, but rather because there are difficulties implementing the Expert Panel Report III (EPR 3) method for categorizing asthma severity and the Global Initiative for Obstructive Lung Disease (GOLD) method for diagnosing COPD. As these serve as the foundation for treatment recommendations for these diseases, alternative approaches should be considered for categorizing asthma severity and identifying COPD patients. Claims-based algorithms provide an intriguing option for identifying persistent asthma patients and symptomatic COPD patients in administrative databases. These methods could be used as the basis for pragmatic research, both retrospective and prospective, on assessing outcomes of guideline recommended treatment approaches in asthma and COPD. Important questions urgently need to be answered about how guideline recommended approaches regarding use of long-acting inhaled β-agonist/inhaled corticosteroid (LABA/ICS) in asthma and long-acting inhaled anti-muscarinic agent (LAMA) and LABA/ICS in COPD affect outcomes in real-life situations.

[The adequacy of the diagnostic in chronic obstructive pulmonary disease]

OBJECTIVES

To assess the adequacy to the clinical guides (GOLD/SEPAR) for the diagnosis of the patients classified as COPD.

MATERIAL AND METHODS

We selected all COPD cases in the registry of chronic patients of 28 general practitioners from 9 Health Centres in the province of Ourense (Spain). A total of 382 cases were included. Diagnostic accuracy was determined according to the results of spirometry. We identify factors associated with correct diagnosis by logistic regression which included age, gender, residence (rural/urban), smoking, severity, level of follow up and time since diagnosis.

RESULTS

Of the total number included, 297 were male (77.7%) and 172 patients (45.0%) came from rural areas. The average age was 77.0 (SD=±11.0) years, with a mean age at diagnosis of 64.9 (±12.0) years and the time from diagnosis was 11.5 (±8.0) years. Less than half (49.1%) patients had been smokers, and 13.1% still smoked. Twenty-six cases (6.8%) were diagnosed in Primary Care. The FEV(1)/FVC ratio was recorded in 174 (45.5%) patients, with less than 0.7 in 138 cases (36.1%), which were considered as correctly diagnosed. In these patients the FEV(1) had been recorded in 125 cases (90.6%). A correct diagnosis was associated with severe or very severe disease (OR 5.2; 95% CI; 1.5-17.4), urban areas (OR 6.1; 95% CI, 1.7-21.2), and younger than 60 years (OR 3.7; 95% CI, 1.3-11.2).

CONCLUSION

The number of spirometry results recorded in the Primary Care medical records of patients diagnosed with COPD was found to be low, and with little adaptation to the accepted diagnostic criteria in the guidelines that are used routinely.

Guidelines for the management of adult lower respiratory tract infections--summary

This document is an update of Guidelines published in 2005 and now includes scientific publications through to May 2010. It provides evidence-based recommendations for the most common management questions occurring in routine clinical practice in the management of adult patients with LRTI. Topics include management outside hospital, management inside hospital (including community-acquired pneumonia (CAP), acute exacerbations of COPD (AECOPD), acute exacerbations of bronchiectasis) and prevention. The target audience for the Guideline is thus all those whose routine practice includes the management of adult LRTI.

Guidelines for the management of adult lower respiratory tract infections--full version

This document is an update of Guidelines published in 2005 and now includes scientific publications through to May 2010. It provides evidence-based recommendations for the most common management questions occurring in routine clinical practice in the management of adult patients with LRTI. Topics include management outside hospital, management inside hospital (including community-acquired pneumonia (CAP), acute exacerbations of COPD (AECOPD), acute exacerbations of bronchiectasis) and prevention. Background sections and graded evidence tables are also included. The target audience for the Guideline is thus all those whose routine practice includes the management of adult LRTI.

Improving the differential diagnosis of chronic obstructive pulmonary disease in primary care

Chronic obstructive pulmonary disease (COPD) and asthma represent a substantial portion of primary care practice. In adults, differentiating asthma from COPD can be difficult but is important because of the marked differences in treatment, disease progression, and outcomes between the 2 conditions. Currently, clinical COPD is often misdiagnosed or undiagnosed until late in the disease. Earlier diagnosis could markedly reduce morbidity and improve quality of life. Establishing a diagnosis of COPD requires spirometry testing, interpreted in the context of the patient's symptoms, smoking status, age, and comorbidities. Additional tests and tools may be helpful in the differential diagnosis, including questionnaires specifically developed to discriminate between COPD and asthma and, in special cases, imaging studies. Follow-up and monitoring of asthma and COPD are always necessary and provide additional benefit in patients in whom only continued care and reassessment can confirm the final diagnosis, such as younger individuals with fixed airway obstruction, smokers with asthma, and patients with both disorders. Key areas for improvement include enhanced case identification, improved quality and interpretation of findings on spirometry, and increased use of tools such as differential diagnosis questionnaires and algorithms to guide the diagnostic and monitoring process. To achieve optimal outcomes, the primary care team should make every effort to establish a firm diagnosis. For this review, we conducted a PubMed search with no time limits using the Medical Subject Headings chronic obstructive pulmonary disease or COPD and asthma, in association with the following search terms: diagnosis, differential diagnosis, mixed or comorbid disease, diagnostic techniques, spirometry, questionnaires, and primary care.