Knowledge of chronic obstructive pulmonary disease, presence of chronic respiratory symptoms and use of spirometry among the Spanish population: CONOCEPOC 2019 study

OBJECTIVE

The aim of this study was to analyze current data on the population's level of knowledge about COPD and to evaluate certain diagnostic interventions, such as the use of spirometry.

MATERIAL AND METHODS

An epidemiological, observational, cross-sectional study by telephone interview, with random dialing of landline telephone numbers, was conducted in November 2019, in a nationally representative sample of adults over 40 years of age.

RESULTS

From a total of 51,079 telephone calls, a total of 1920 individuals responded. Mean age was 61.9 years and 31.6% were men. Overall, 19.4% were current smokers and 13.4% reported respiratory disease (5% reported COPD). In total, 27.9% had spontaneous knowledge of COPD, which is a relative increase from the 17% observed in 2011. The most frequent information channel was the media (35.5%), with a significant presence of social networks and the Internet (25.7%). Almost one fifth (18.1%) had chronic respiratory symptoms. Of these, 59.3% had requested medical care, and 66.2% had undergone spirometry. Spirometry was performed less frequently in subjects treated in primary care compared to respiratory medicine departments (51.9% versus 79.1%; P < .001).

CONCLUSIONS

Knowledge of COPD is still scarce, and strategies are needed to increase awareness and the importance of assessing respiratory symptoms and increased use of spirometry.

Association between chronic obstructive pulmonary disease (COPD) and occupational exposures: A hospital based quantitative cross-sectional study among the Bangladeshi population

The association between chronic obstructive pulmonary disease (COPD) and occupational exposures are less studied in Bangladeshi context, despite the fact that occupational exposures are serious public health concerns in Bangladesh. Therefore, this study aimed to evaluate this association considering demographic, health and smoking characteristics of Bangladeshi population. This was a hospital-based quantitative study including 373 participants who were assessed for COPD through spirometry testing. Assessment of occupational exposures was based on both self-reporting by respondents and ALOHA based job exposure matrix (JEM). Here, among the self-reported exposed group (n = 189), 104 participants (55%) were found with COPD compared to 23 participants (12.5%) in unexposed group (n = 184) that differed significantly (p = 0.00). Similarly, among the JEM measured low (n = 103) and high exposed group (n = 236), 23.3% and 41.5% of the participants were found with COPD respectively; compared to unexposed group (14.7%; n = 34), that differed significantly also (p = 0.00). Likewise, participants with longer self-reported occupational exposures (>8 years) showed significantly (p = 0.00) higher proportions of COPD (79.5%) compared to 40.4% in shorter exposure group (1-8 years). Similarly, significant (p = 0.00) higher cases of COPD were observed among the longer cumulative exposure years (>9 years) group than the shorter cumulative exposure years (1-9 years) group in JEM. While combining smoking and occupational exposure, the chance of developing COPD among the current, former and non-smokers of exposed group were 7.4, 7.2 and 12.7 times higher respectively than unexposed group. Furthermore, logistic analysis revealed that after adjustments for confounding risk factors, the chance of developing COPD among the self-reported exposure group was 6.3 times higher (ORs: 6.3, p = 0.00) than unexposed group; and JEM exposure group has odds of 2.8 and 1.1 respectively (p<0.05) for high and low exposures. Further studies are needed to reinforce this association between COPD and occupational exposure in Bangladesh.

Significance of Best Spirometry in the First Year After Bilateral Lung Transplantation: Association With 3-Year Outcomes

BACKGROUND

Spirometry is the cornerstone of monitoring allograft function after lung transplantation (LT). We sought to determine the association of variables on best spirometry during the first year after bilateral LT with 3-year posttransplant survival.

METHODS

We reviewed charts of patients who survived at least 3 months after bilateral LT (n = 157; age ± SD: 54 ± 13 y, male:female = 91:66). Best spirometry was calculated as the average of 2 highest measurements at least 3 weeks apart during the first year. Airway obstruction was defined as forced expiratory volume in 1-second (FEV1)/forced vital capacity (FVC) ratio <0.7. Survival was compared based on the ventilatory defect and among groups based on the best FEV1 and FVC measurements (>80%, 60%-80%, and <60% predicted). Primary outcome was 3-year survival.

RESULTS

Overall, 3-year survival was 67% (n = 106). Obstructive defect was uncommon (7%) and did not have an association with 3-year survival (72% versus 67%, P = 0.7). Although one-half patients achieved an FVC>80% predicted (49%), 1 in 5 (19%) remained below 60% predicted. Irrespective of the type of ventilatory defect, survival worsened as the best FVC (% predicted) got lower (>80: 80.8%; 60-80: 63.3%; <60: 40%; P < 0.001). On multivariate logistic regression analysis, after adjusting for age, gender, transplant indication, and annual bronchoscopy findings, best FVC (% predicted) during the first year after LT was independently associated with 3-year survival.

CONCLUSIONS

A significant proportion of bilateral LT patients do not achieve FVC>80% predicted. Although the type of ventilatory defect on best spirometry does not predict survival, failure to achieve FVC>80% predicted during the first year was independently associated with 3-year mortality.

Possible risk factors for poor asthma control assessed in a cross-sectional population-based study from Telemark, Norway

This cross-sectional study of the general population of Telemark County, Norway, aimed to identify risk factors associated with poor asthma control as defined by the Asthma Control Test (ACT), and to determine the proportions of patients with poorly controlled asthma who had undergone spirometry, used asthma medication, or been examined by a pulmonary physician. In 2014–2015, the study recruited 326 subjects aged 16–50 years who had self-reported physician-diagnosed asthma and presence of respiratory symptoms during the previous 12 months. The clinical outcome measures were body mass index (BMI), forced vital capacity (FVC) and forced expiratory volume in one second (FEV₁), fractional exhaled nitric oxide (FeNO), immunoglobulin E (IgE) in serum and serum C-reactive protein (CRP). An ACT score ≤ 19 was defined as poorly controlled asthma. Overall, 113 subjects (35%) reported poor asthma control. The odds ratios (ORs) and 95% confidence intervals (CIs) for factors associated with poorly controlled asthma were: self-reported occupational exposure to vapor, gas, dust, or fumes during the previous 12 months (OR 2.0; 95% CI 1.1–3.6), body mass index ≥ 30 kg/m² (OR 2.2; 95% CI 1.2–4.1), female sex (OR 2.6; 95% CI 1.5–4.7), current smoking (OR 2.8; 95% CI 1.5–5.3), and past smoking (OR 2.3; 95% CI 1.3–4.0). Poor asthma control was also associated with reduced FEV₁ after bronchodilation (β –3.6; 95% CI –7.0 to –0.2). Moreover, 13% of the participants with poor asthma control reported no use of asthma medication, 51% had not been assessed by a pulmonary physician, and 20% had never undergone spirometry. Because these data are cross-sectional, further studies assessing possible risk factors in general and objectively measured occupational exposure in particular are needed. However, our results suggest that there is room for improvement with regards to use of spirometry and pulmonary physician referrals when a patient’s asthma is inadequately controlled.

Planned primary health care asthma contacts during 12-year follow-up after Finnish National Asthma Programme: focus on spirometry

Primary health care (PHC) providers are at the front line of asthma management. To evaluate how planned asthma follow-up occurred in PHC and whether lung function tests were used, 203 patients were followed for 12 years as part of a real-life asthma cohort Seinäjoki Adult Asthma Study (SAAS). A total of 152 patients had visits in PHC attending on average to four planned contacts during 12-year follow-up corresponding to one visit every third year. National guideline recommends annual visits. Patients with ≥4 contacts seemed to have more difficult asthma and better adherence to inhaled corticosteroid medication. Lung function tests were performed on average in 87.5% of annual planned follow-up contacts. Spirometry was performed in 70%, 71% and 97% of all contacts depending on whether it was a contact to GP, nurse or both. Overall, the frequency of follow-up contacts was insufficient but PHC adherence to lung function testing was excellent.

[Prevalence and quality of spirometry and the impact of spirometry training in Hunan, People's Republic of China]

Objective: To explore quality of spirometry in Hunan province and the impact of education on it. Methods: Cross-sectional study and a prospective randomized cohort study. (1) A total of 460 public hospitals in Hunan province were investigated. Research assistants collected 20 consecutive reports of pulmonary ventilation test reports (PVTRs) and basal information of those hospitals which owned spirometry. (2) To measure the effect of education, 28 randomly selected 2(nd) level hospitals which owned spirometry were randomized to intervention and control group (1∶1). The intervention group received a short-time training which included face-to-face lectures and a hand-by-hand operation training course, while the control group received usual care. PVTRs were investigated 3 months after the intervention. All PVTRs were classified to grade A, B, C, D and E according to the Chinese pulmonary ventilation test (PVT) guidelines. Results: The recovery rate was 100%. The spirometry-equipped ratio was 1.6% (2/129) at 1(st) level hospitals, 39.0% (105/269) at 2(nd) level hospitals, 100% (62/62) at 3(rd) level hospitals in Hunan province. There were 100% (2/2), 91.4% (96/105) and 93.5% (58/62) utilization rate at 1(st), 2(nd) and 3(rd) level hospitals. Common reasons for not owning a spirometer were equipment cost and insufficient insurance. Lack of knowledge about spirometry and inadequate benefits were the top two reasons for low utilization rate. There were 3 120 PVTRs from 156 hospitals which used spirometry, a total of 50.4% (1 574/3 120) PVTRs got grade A, a total of 14.8% (462/3 120) PVTRs were judged as unreliable (grade D, E). There were 560 PVTRs and 28 questionnaires, respectively, before and after intervention. The technicians' knowledge improved after education compared to before (9.8±0.6 vs 8.6±1.1) (P<0.05). And 75.0% (210/280) PVTRs got A grade in the intervention group, which was significantly higher than those in the control group (75.0% vs 37.9%, P<0.05). While none of PVTRs was unreliable, which was lower than that in the control group (0 vs 14.6%, P<0.05). Conclusions: The equipment ratio and the utilization rate of spirometry are still low and imbalanced among three levels hospitals in Hunan. The short-time training is helpful to improve quality of spirometry.

Correlation of spirometry and body plethysmography during exercise-induced bronchial obstruction

BACKGROUND

The exercise challenge is the gold standard for diagnosing exercise-induced bronchoconstriction (EIB). Airway obstructions appear up to 30 min after the challenge, with a maximum decrease in spirometry and a maximum increase in airway resistance. There is evidence that changes in body plethysmography parameters are more sensitive to the exercise challenge and precede those in spirometry.

PURPOSE

To compare changes in body plethysmography and spirometry parameters after exercise challenges and to verify the cut-off values of sReff in EIB.

PROCEDURES

In 82 subjects with suspected EIB, a total of 473 lung function tests were measured at baseline and at 5, 10, 15, and 30 min after exercise challenges at different stages of bronchial obstruction.

FINDINGS

The maximum changes in the body plethysmography parameter sReff significantly preceded the maximum changes in the spirometry parameter FEV₁ (sReff: 12.2 min ±8.8, FEV₁: 15.2 min ±9.3, p < 0.005). The parameters of sReff and FEV₁ had a strong negative correlation (r = -0.63, p < 0.0001) with a nonlinear, polynomial relationship. Furthermore, sReff and Reff had a strong linear correlation (r = 0.86, p < 0.001), and Reff and Rtot had a perfect linear correlation (r = 0.99, p < 0.001). Based on baseline values and on quantile regression, an increase of 0.25 kPa s in sReff was defined as significant. Using this cut-off value, FEV₁ and sReff almost equally detected EIB.

CONCLUSION

The changes in sReff were more sensitive and better indicated lung impairment than did the changes in FEV₁, which underestimated the degree of hyperinflation.

Clinical characteristics of patients newly diagnosed with COPD by the fixed ratio and lower limit of normal criteria: a cross-sectional analysis of the TargetCOPD trial

Background

Consensus on the definition of airflow obstruction to diagnose COPD remains unresolved.

Methods

We undertook systematic case finding for COPD in primary care using the fixed ratio (FR) criterion (forced expiratory volume in 1 s/forced vital capacity [FEV1/FVC] <0.7) for defining airflow obstruction and also using the lower limit of normal (LLN). We then compared the clinical characteristics of those identified by the 2 criteria.

Results

A total of 3,721 individuals reporting respiratory symptoms were invited for spirometry. A total of 2,607 attended (mean age 60.4 years, 52.8% male, 29.8% current smokers) and 32.6% had airflow obstruction by FR ("FR+") and 20.2% by LLN ("LLN+"). Compared with the LLN+/FR+ group, the LLN-/FR+ group (12.4%) was significantly older, had higher FEV1 and FEV1/FVC, lower COPD assessment test scores, and less cough, sputum, and wheeze, but was significantly more likely to report a diagnosis of heart disease (14.2% versus 6.9%, p<0.001). Compared with the LLN+/FR+ group, the LLN-/FR- group was younger, had a higher body mass index, fewer pack-years, a lower prevalence of respiratory symptoms except for dyspnea, and lower FVC and higher FEV1. The probability of known heart disease was significantly lower in the LLN+/FR+ group compared with those with preserved lung function (LLN-/FR-) (adjusted odds ratio 0.62, 95% CI: 0.43-0.90) but this was not seen in the LLN-/FR+ group (adjusted odds ratio 0.90, 95% CI: 0.63-1.29).

Conclusion

In symptomatic individuals, defining airflow obstruction by FR instead of LLN identifies a significant number of individuals who have less respiratory and more cardiac clinical characteristics.

Effects of exposure to ambient ultrafine particles on respiratory health and systemic inflammation in children

It is known that ultrafine particles (UFP, particles smaller than 0.1 μm) can penetrate deep into the lungs and potentially have adverse health effects. However, epidemiological data on the health effects of UFP is limited. Therefore, our objective was to test the hypothesis that exposure to UFPs is associated with respiratory health status and systemic inflammation among children aged 8 to 11 years. We conducted a cross-sectional study among 655 children (43.3% male) attending 25 primary (elementary) schools in the Brisbane Metropolitan Area, Australia. Ultrafine particle number concentration (PNC) was measured at each school and modelled at homes using Land Use Regression to derive exposure estimates. Health outcomes were respiratory symptoms and diagnoses, measured by parent-completed questionnaire, spirometric lung function, exhaled nitric oxide (FeNO), and serum C reactive protein (CRP). Exposure-response models, adjusted for potential personal and environmental confounders measured at the individual, home and school level, were fitted using Bayesian methods. PNC was not independently associated with respiratory symptoms, asthma diagnosis or spirometric lung function. However, PNC was positively associated with an increase in CRP (1.188-fold change per 1000 UFP cm^-3 day/day (95% credible interval 1.077 to 1.299)) and an increase in FeNO among atopic participants (1.054 fold change per 1000 UFP cm^-3 day/day (95% CrI 1.005 to 1.106)). UFPs do not affect respiratory health outcomes in children but do have systemic effects, detected here in the form of a positive association with a biomarker for systemic inflammation. This is consistent with the known propensity of UFPs to penetrate deep into the lung and circulatory system.

[THE PREVALENCE OF RESPIRATORY SYMPTOMS AMONG RESIDENTS OF THE RUSSIAN FAR NORTH]

To study the frequency of respiratory symptoms among the reindeer herders of the Yamal region in the Far North of Russia. We conducted a cross-sectional study of the occurrence of respiratory symptoms among 500 subjects of the tundra Nenets population (28.1% of the adult Nenets population in the district), of which 38.3% were men and 61.7% women (average age 40.1 years). All patients were matched for age and occupation. Medical examination was carried out by a pulmonologist with the use of the GARD questionnaire (WHO, 2004) and spirometry. Spirometry was performed with a SpiroUSB device (UK) according to a unified standard and the criteria of ATS/ERS 2005. The frequency of respiratory symptoms among the tundra population was estimated at 71.8%. Cough with expectoration and dyspnea were found in 22.8% of the respondents. 70.0% of the examined subjects worked in the cold, 33% were exposed to the open flame at home, and 34.4% smoked. Respiratory symptoms developed in 16.3% of those working in the cold and in 37% exposed to open fire. The combination of such complaints as cough and sputum production occurred in smokers twice as frequently as in non-smokers (54.1%) (p<0.01).The combination of such complaints as cough and sputum production was twice as likely note in his those who smoked (54.1% vs 20.2%) (p<0.01). The combination of these problems dyspnea was three times more common in the smokers (23,3%vs 7,3%) (p<0.001). At presence at patients of such a factor as work in the cold and the absence of other only 16.3% of them have respiratory symptoms. When using at home the open flame and the absence of other factors leading up 37.0% of the individuals with symptoms of chronic bronchitis. Cough, sputum and dyspnea are formed only among 26.3% of the smokers face when smoking is the only risk factor. If the surveyed residents of all three negative factors respiratory symptoms met at 62.1%. Disorders of respiratory function according to spirometry were not observed in none of the study participants. Respiratory symptoms developed in 62.1% of the subjects exposed to all three risk factors. External respiration indices remain normal in all he examine subjects. It is concluded that residents of the Far North frequently suffer respiratory symptoms without disorders in the external respiratory function. In most cases they associated with three factors (work in the cold, exposure to open fire at home, and smoking). Compensatory stimulation of lung functions may create additional difficulties for diagnostics of bronchial obstruction.

Assessment of Airway Bronchodilation by Spirometry Compared to Airway Obstruction in Young Children with Asthma

A reversibility test by an increase of greater than 12% in FEV1 can support a diagnosis of asthma and alter a patient's treatment plan but may not be applicable to the young ages. We retrospectively gathered spirometric data from 85/271 asthmatic children having mild obstruction (FEV1 > 80% predicted), age 2.6-6.9 years. Spirometry was performed before and 20 min after inhalation of 200 mcg Albuterol. We defined a deviation below -1.64 z scores from control as obstruction and an increased above 1.64 scores from control as a positive response to bronchodilators. Sensitivity of the index was considered significant if it captured >68% of the participants. The sensitivity of detecting airway obstruction in these children by FEV1 was 15.3% and 62.4% by FEF25-75. A positive response to Albuterol was an increase of 9.2% for FEV1 (12% for adults) and 18.5% for FEF25-75. The sensitivity for detecting a response to Albuterol in mild asthma was 64.7% by FEV1 and 91.8% by FEF25-75. Young children having normal spirometry can demonstrate airway reversibility. The response of spirometry parameters to bronchodilators may be more sensitive than obstruction detection and may help to support the diagnosis of asthma and adjust treatment plan.

Socioeconomic status is associated with reduced lung function in China: an analysis from a large cross-sectional study in Shanghai

BACKGROUND

An inverse association between socioeconomic status and pulmonary function has emerged in many studies. However, the mediating factors in this relationship are poorly understood, and might be expected to differ between countries. We sought to investigate the relationship between socioeconomic status and lung function in China, a rapidly industrializing nation with unique environmental challenges, and to identify potentially-modifiable environmental mediators.

METHODS

We used data from the Shanghai Putuo Study, a cross-sectional study performed in Shanghai, China. Participants completed a questionnaire and spirometry. The primary exposure was socioeconomic status, determined by education level. The primary outcomes were FEV1 and FVC percent predicted. Multiple linear regressions were used to test this association, and the percent explained by behavioral, environmental, occupational, and dietary variables was determined by adding these variables to a base model.

RESULTS

The study population consisted of a total of 22,878 study subjects that were 53.3 % female and had a mean age of 48. In the final multivariate analysis, the effect estimates for FEV1 and FVC percent predicted for low socioeconomic status (compared to high) were statistically significant at a p-value of <0.01. Smoking, biomass exposure, mode of transportation to work, a diet low in fruits or vegetables, and occupational category partially attenuated the relationship between SES and lung function. In a fully-adjusted age-stratified analysis, the socioeconomic disparity in lung function widened with increasing age.

CONCLUSIONS

We found cross-sectional evidence of socioeconomic disparities in pulmonary function in Shanghai. These differences increased with age and were partially explained by potentially modifiable exposures.

Current care services provided for patients with COPD in the Eastern province in Saudi Arabia: a descriptive study

BACKGROUND

COPD is a leading cause of morbidity and mortality worldwide. The prevalence rate of COPD in the general Saudi population is estimated to be 2.4% and 14.2% among smokers. Not much is known about current health care services for patients with COPD in Saudi Arabia. The objective of this study was to determine the current care services for patients with COPD provided by government hospitals in the Eastern province of Saudi Arabia.

METHODS

A cross-sectional study was conducted in the Eastern province of Saudi Arabia. Directors of the Department of Internal Medicine from all 22 general government hospitals that are under the responsibility of the Ministry of Health or the Ministry of Higher Education in this region were asked to participate. Data were collected using a questionnaire.

RESULTS

The study results indicated that there are limited hospital facilities for patients with COPD: no respiratory departments in any of the included hospitals, no spirometry in 77.3% of the hospitals, no intensive care units in 63.7% of the hospitals, and no pulmonary rehabilitation program in any of the hospitals. Among the included 22 hospitals, 24 respiratory physicians, 29 respiratory therapists, and three physiotherapists were involved in COPD care.

CONCLUSION

In conclusion, current care services provided by government hospitals in the Eastern province of Saudi Arabia for patients with COPD do not meet international recommendations for COPD management. Increased awareness, knowledge, and implementation of COPD guidelines by health care providers will most probably improve COPD management in Saudi Arabia. In addition, the government could improve dissemination of information about COPD management through national programs and by offering specific education regarding respiratory diseases.

Prevalence of Spirometrically-defined Restrictive Ventilatory Defect in Korea: The Fourth-2, 3, and Fifth Korean National Health and Nutrition Examination Survey, 2008-2012

The aim of the study was to evaluate the prevalence of restrictive ventilatory defect and to determine the risk factors in subjects with spirometrically-defined restrictive ventilatory defect. We used the population-based, fourth-2, 3 (2008, 2009) and fifth (2010-2012) Korea National Health and Nutrition Examination Survey (KNHANES) to analyze 15,073 subjects, aged ≥40 yr who underwent spirometry. Chest radiographs were also analyzed to identify restrictive lung disease. Spirometrically-defined restrictive ventilatory defect (FEV1/FVC≥70% and FVC<80% of mean predicted value) was detected in 11.3% (n= 1,709) of subjects aged ≥40 yr. The prevalence increased to 12.3% on using the lower limit of normal (LLN) criteria. Approximately 99.4% of subjects were classified as mild restrictive. Among these, 11.3% had inactive tuberculosis (TB) lesion, 2.2% cardiac disease, 2.0% previous operation scar or radiation injury and/or mediastinal disease, and 7.4% other pulmonary disease suggestive of restrictive lung diseases on chest radiograph. Evidence of previous TB history was independently associated with restrictive ventilatory defect (odds ratios [OR], 1.78; 95% confidence interval, 1.45-2.18) after adjustment for gender, age, smoking, area for residence and body mass index. The prevalence of restrictive ventilatory defect among the nationwide population in Korea was 11.3% with fixed ratio criterion and 12.3% with LLN criterion. Most cases were of the mild restrictive category and previous TB history is the independent risk factor for restrictive ventilatory defect.

Spirometry utilisation among Danish adults initiating medication targeting obstructive lung disease

This PhD thesis was written during my employment at the Research Unit of General Practice in Odense, University of Southern Denmark. It comprises an overview and three papers, all published or submitted for publication in international peer-reviewed scientific journals.  

BACKGROUND

Non-infectious dyspnoea, chronic cough and wheezing are common symptoms in the population. Patients often present with these symptoms in general practice and have a high probability of having obstructive lung diseases. However, there is an indication that the majority of these patients are treated empirically with pharmacotherapy targeting obstructive lung disease and only few have additional tests conducted, although the predictive value of respiratory symptoms for diagnosing obstructive lung disease has proven to be low. Spirometry is recommended as the gold standard for confirming obstructive lung disease, and testing can also rule out airway obstruction in patients with respiratory symptoms caused by other illnesses, such as heart failure or lung cancer. Initiating medication for obstructive lung disease without spirometry entails the risk of these patients experiencing unnecessary delay in the diagnostic process and being exposed to unnecessary economic costs and medication risks. The literature has indicated that many users of medication targeting obstructive lung medication have not had spirometry performed and do not actually have obstructive lung disease. This potential quality gap needs to be assessed. Also, in order to target interventions enhancing earlier spirometry utilisation among patients initiating medication targeting obstructive lung disease, improved knowledge on patient and practice factors associated with spirometry testing is needed.  

AIMS

Among first time users of obstructive lung medication we aimed: - To assess to what extent spirometry was performed within the first year of medication use (Study I) - To assess if patient characteristics like socioeconomic and demographic status were associated with spirometry testing (Studies I &II) - To assess if general practice characteristics were associated with spirometry testing (Study III)  

METHODS

Register-based observational studies on first time users of medication targeting obstructive lung disease among adults over 18 years of age in 2008. The patient cohort was identified in the Danish National Prescription Register where all redeemed prescriptions for medication targeting obstructive lung disease are registered. All spirometry tests provided to the patient cohort in the time period 2007-2010 were extracted from the Danish National Health Service Register and the Danish National Patient Register and we assessed if patients had a spirometry registered in an 18- month time period counting from 6 months before to 12 months after their first redemption of medication. We linked socioeconomic and demographic patient variables and variables on practice characteristics from National registers to assess their association with patients having spirometry performed.  

RESULTS

A total of 40,969 adults initiated medication targeting obstructive lung medication in 2008 in Denmark. The mean age of the cohort was 55.6 years (SD18.7) and approximately half of the mediations users had spirometry test performed. Initiating several types of medication targeting obstructive lung disease within the first year and redeeming medication repeatedly increased the odds of having spirometry performed. Women and patients in the oldest age categories had reduced odds of having spirometry performed. Being unemployed reduced the odds for spirometry testing among adults less than 65 years of age. Also, among the elderly (>65 years) living alone reduced the odds for spirometry testing; however this was only statistically significant among men. Some practice characteristics also influenced the odds for spirometry testing. Patients in partnership practices had higher odds for spirometry testing. Among singlehanded practices higher odds for spirometry testing was seen if practice had training practice status. We saw decreasing odds for spirometry testing with increasing age among doctors.  

CONCLUSION AND PERSPECTIVES

This study has shown a lack of spirometry testing among patients initiating medication targeting obstructive lung disease. This underuse of spirometry testing indicates a quality gap and increased focus of spirometry utilization is needed when patients initiate medication targeting obstructive lung disease. The variation reported in spirometry testing across patient and practice characteristics was most predominant with regard to increasing age among patients and doctors, the remaining variables only account for small variations. However identification of these variations can help guide general practitioners to identify patients at increased risk of not having spirometry performed and help target future interventions for primary care.

Mass and fat infiltration of intercostal muscles measured by CT histogram analysis and their correlations with COPD severity

RATIONALE AND OBJECTIVES

Chronic obstructive pulmonary disease (COPD) is characterized by progressive respiratory function impairment and respiratory muscle dysfunction. We hypothesized that the mass and fat infiltration of respiratory muscles correlates with COPD severity and emphysema extent.

MATERIALS AND METHODS

Ninety-eight male patients with COPD underwent chest computed tomography (CT) and spirometry. The mass and fat infiltrations of intercostal and latissimus muscles were quantified as the cross-sectional area (CSA) and attenuation of these muscles using CT histogram analysis. Intercostal index and latissimus index were defined as intercostal CSAs and latissimus CSAs divided by body mass index. The emphysema extent was measured as the ratio of the emphysematous lung volume to the total lung volume using a density-mask technique. Pearson correlation analyses were performed to evaluate the relationships between these parameters. Multiple regression analysis was performed using forced expiratory volume in 1 second (FEV1) as the dependent parameter and the clinical and CT data as the independent parameters.

RESULTS

FEV1 was significantly correlated with intercostal index (r = 0.57), latissimus index (r = 0.34), intercostal attenuation (r = 0.62), and latissimus attenuation (r = 0.38). Emphysema extent was significantly correlated with intercostal index (r = -0.36) and intercostal attenuation (r = -0.50). Multiple regression analysis showed that FEV1 was predicted by intercostal attenuation (B = 0.40), intercostal CSA (B = 0.23), emphysema extent (B = -0.23), and age (B = -0.21, R(2) = 0.64, P < .001).

CONCLUSIONS

A decrease in intercostal mass and an increase in intercostal fat are associated with worsening of COPD severity.

Support from the clinic

At around seven cases per 100,000 people, prevalence of fibrotic or interstitial lung disease (ILD) is relatively high. 'This represents a 35 per cent increase in the eight years to 2008, roughly 5,000 new cases each year,' reported Anne-Marie Russell, a National Institute of Health Research fellow at the Royal Brompton and Harefield NHS Foundation Trust.

Telepulmonology and telespirometry

Taking and interpreting spirometry tests has proven difficult in primary care practice. This may lead to mis- or underdiagnosis of pulmonary diseases, among others chronic obstructive pulmonary disease. Telespirometry and telepulmonology consultation (TPC) may play a role in monitoring and improving the quality of the spirometry tests, supporting GPs in interpreting spirometry test results and reducing the number of physical referrals to the pulmonologist. In telespirometry up to 10% of spirometry results uploaded by GPs were randomly sent to a pulmonologist. Both the GP or practice nurse and the pulmonologist interpreted the spirometry results and gave their diagnostic findings. Additionally the pulmonologist assessed the quality of the test. In TPC a GP could digitally consult a pulmonologist for advice or referral of patients. On sending and closing the TPC consult the GP was presented a number of questions. Based on these questions the percentage of prevented physical referrals and the educational effect experienced by the GPs were determined. Almost a third of the 227 telespirometry tests was of Moderate or Bad quality. The Kappa of the interobserver agreement on diagnostic findings between GP and pulmonologist was 0.38. Between April 2009 and January 2014, GPS sent 4.488 TPCs to pulmonologists. Sixty-nine percent of the TPCs were sent to gain advice, the others were sent in order to prevent a physical referral. Overall telepulmonology reduced the number of physical referrals by 22%. In 90% of the TPCs the GPs indicated they had learned from the consult.

Spirometry use among older adults with chronic obstructive pulmonary disease: 1999-2008

RATIONALE

Clinical practice guidelines recommend spirometry to diagnose chronic obstructive pulmonary disease (COPD) and facilitate management. National trends in spirometry use in older adults with newly diagnosed COPD are not known.

OBJECTIVES

To examine the rate and beneficiary characteristics associated with spirometry use in subjects with newly diagnosed COPD between 1999 and 2008.

METHODS

We examined newly diagnosed beneficiaries with COPD using a 5% Medicare population from 1999 to 2008. A new COPD diagnosis required two outpatient visits or one hospitalization with primary International Classification of Diseases, 9th edition code 491.xx, 492.xx, or 496 occurring at least 30 days apart with none in the prior 12 months. The primary measurement was spirometry performed within 365 days (±) of the first claim with a COPD diagnosis.

MEASUREMENTS AND MAIN RESULTS

Between 1999 and 2008, 64,985 subjects were newly diagnosed with COPD. Of these, 35,739 (55%) had spirometry performed within 1 year before or after the initial diagnosis of COPD. Spirometry use increased from 51.3% in 1999 to 58.3% in 2008 (P < 0.001). Subjects with younger age, men, whites, those with higher socioeconomic status, and those with a greater number of comorbidities were more likely to have spirometry. In a multivariable analysis, compared with 1999, subjects diagnosed in 2008 had 10% higher odds (odds ratio, 1.10; 95% confidence interval, 1.06-1.13) of having spirometry performed.

CONCLUSIONS

Despite an increase in the use of spirometry over time in newly diagnosed older adults with COPD, spirometry use remains low. Clinical practice guidelines and educational efforts should focus on increasing the use of spirometry to diagnose and manage COPD.

COPD: an underdiagnosed disease at hospital environment

BACKGROUND AND AIM

Chronic obstructive pulmonary disease (COPD) is a serious disease with morbidity and mortality due to delayed diagnosis until significant symptoms arise. We aimed to assess the utility of spirometry and COPD Assessment Test (CAT) in detecting undiagnosed COPD patients in a localized area.

MATERIAL AND METHODS

People who came to the hospital for patient visit or examination with a smoking history of > 10 pack-years (> 40 years old), and with no known chest disease were invited to study. The participants completed a questionnaire and performed spirometry. Spirometry was performed according to ATS/ERS Task Force on spirometry. COPD was defined as according to the Global Initiative for Chronic Obstructive Lung Disease guidelines.

RESULTS

There were 800 subjects screened, and 648, capable of performing spirometry, were included to the study. The mean age was 48.3 ± 9.0 and 38 % of the study population was male. Post-bronchodilator FEV1/FVC ratio was lower than 0.70 in 17 % of the subjects. Median (25-75 percentiles) total CAT scores and among the questions of CAT; cough, phlegm, chest tightness and breathlessness scores for COPD and non-COPD subjects were; 15(9-22) vs 12(6-18) (p  = .004), 2(1-3) vs 1(0-2) (p  < .001), 2(0-3) vs 1(0-3) (p  = .004), 3(1-4) vs 2(0-3) (p  > .001), 4(3-5) vs 3(2-4) (p  = .001), respectively. Symptom prevalence was as follows: exertional dyspnea 91 %, dyspnea 80.9 %, cough 56.3 % and phlegm 58.3 % in COPD.

CONCLUSION

Our study showed that spirometric screening together with the CAT questionnaire may improve the awareness of disease and may determine undiagnosed patients.

[Predictive equations of lung function for adults in north China urban areas]

OBJECTIVE

To establish predictive equations of lung function for adults in urban areas in north China.

METHODS

A survey was conducted in 600 male and 600 female healthy adults in the urban areas in north China. Five flow-volume test parameters were measured including forced vital capacity (FVC) and forced expiratory volume in one second (FEV1). Stepwise multiple regression was carried out to establish the predicative equations for the parameters for male and female adults separately. The predicted values from these equations and those from other commonly used equations (such as ECCS equation and Knudson equation) were compared with the actual measurements in pulmonary function tests.

RESULTS

Four flow-volume test parameters, namely FVC, FEV1, 25% forced expiratory flow (FEF25%), and FEF75%, showed obvious differences between the male and female adults, while FEV1/FVC was not correlated with gender. Multiple regression analysis showed that FVC, FEV1, FEF25% and FEF75% were positively correlated with height and negatively with age, and FEV1/FVC was negatively correlated with both height and age. The parameters were not affected by body weight. The predicted values from our equations were closer to the actual measurements than those calculated from other equations.

CONCLUSION

The equations we established are more appropriate than the generally used equations for predicting lung functions in adults in north China urban areas.

Estimating the U.S. prevalence of chronic obstructive pulmonary disease using pre- and post-bronchodilator spirometry: the National Health and Nutrition Examination Survey (NHANES) 2007-2010

BACKGROUND

During 2007-2010, the National Health and Nutrition Examination Survey (NHANES) conducted a spirometry component which obtained pre-bronchodilator pulmonary lung function data on a nationally representative sample of US adults aged 6-79 years and post-bronchodilator pulmonary lung function data for the subset of adults with airflow limitation. The goals of this study were to 1) compute prevalence estimates of chronic obstructive pulmonary disease (COPD) using pre-bronchodilator and post-bronchodilator spirometry measurements and fixed ratio and lower limit of normal (LLN) diagnostic criteria and 2) examine the potential impact of nonresponse on the estimates.

METHODS

This analysis was limited to those aged 40-79 years who were eligible for NHANES pre-bronchodilator spirometry (n=7,104). Examinees with likely airflow limitation were further eligible for post-bronchodilator testing (n=1,110). Persons were classified as having COPD based on FEV1/FVC < 70% (fixed ratio) or FEV1/FVC < lower limit of normal (LLN) based on person's age, sex, height, and race/ethnicity. Those without spirometry but self-reporting both daytime supplemental oxygen therapy plus emphysema and/or current chronic bronchitis were also classified as having COPD. The final analytic samples for pre-bronchodilator and post-bronchodilator analyses were 77.1% (n=5,477) and 50.8% (n=564) of those eligible, respectively. To account for non-response, NHANES examination weights were adjusted to the eligible pre-bronchodilator and post-bronchodilator subpopulations.

RESULTS

In 2007-2010, using the fixed ratio criterion and pre-bronchodilator test results, COPD prevalence was 20.9% (SE 1.1) among US adults aged 40-79 years. Applying the same criterion to post-bronchodilator test results, prevalence was 14.0% (SE 1.0). Using the LLN criterion and pre-bronchodilator test results, the COPD prevalence was 15.4% (SE 0.8), while applying the same criterion to post-bronchodilator test results, prevalence was 10.2% (SE 0.8).

CONCLUSIONS

The overall COPD prevalence among US adults aged 40-79 years varied from 10.2% to 20.9% based on whether pre- or post-bronchodilator values were used and which diagnostic criterion (fixed ratio or LLN) was applied. The overall prevalence decreased by approximately 33% when airflow limitation was based on post-bronchodilator as compared to pre-bronchodilator spirometry, regardless of which diagnostic criterion was used.

Use of spirometry in the diagnosis of COPD: a qualitative study in primary care

Guidelines that recommend spirometry to confirm airflow obstruction among patients with suspected COPD are not routinely followed. We conducted a qualitative study to identify attitudes and barriers of primary care physicians to performing spirometry for patients with possible COPD. We conducted four focus groups, each with three primary care physicians (PCPs) who practice in an urban, academic medical center. In general, PCPs believed that spirometry was not necessary to confirm the diagnosis of COPD. Compared to other co-morbid conditions, in a patient with a diagnosis of COPD without self-reported symptoms, COPD was not a priority during a clinic visit. This was in part due to the belief that there was lack of evidence that medication used in COPD lead to improved outcomes and that there was no point of care measure for COPD compared to other co-morbid conditions such as diabetes mellitus or hypertension. Health system barriers specific to spirometry use was not identified. In conclusion, in our sample of PCPs, there was skepticism that spirometry is warranted to diagnose and manage COPD. Availability of spirometry was not a perceived barrier. Our results explain, in part, why previous interventions to improve access to spirometry and diagnosis of COPD in primary care settings have been difficult to conduct and/or have had marginal success. Our findings strongly suggest that a first step toward increasing the use of spirometry among primary care physicians is to have them believe in its utility in the diagnosis of COPD.

[Early diagnosis of COPD is important and possible]

Chronic obstructive pulmonary disease (COPD) is substantially underdiagnosed and under treated. The present review paper discusses the possibilities of early diagnosis by means of spirometry in the setting of Danish general practice. It is concluded that case finding of undiagnosed COPD is feasible by applying opportunistic spirometry in patients with relevant exposures and relevant respiratory symptoms. The potential barriers of this approach and possible solutions are discussed.

Spirometry reference equations for central European populations from school age to old age

Background

Spirometry reference values are important for the interpretation of spirometry results. Reference values should be updated regularly, derived from a population as similar to the population for which they are to be used and span across all ages. Such spirometry reference equations are currently lacking for central European populations.

Objective

To develop spirometry reference equations for central European populations between 8 and 90 years of age.

Materials

We used data collected between January 1993 and December 2010 from a central European population. The data was modelled using “Generalized Additive Models for Location, Scale and Shape” (GAMLSS).

Results

The spirometry reference equations were derived from 118'891 individuals consisting of 60'624 (51%) females and 58'267 (49%) males. Altogether, there were 18'211 (15.3%) children under the age of 18 years.

Conclusion

We developed spirometry reference equations for a central European population between 8 and 90 years of age that can be implemented in a wide range of clinical settings.

Spirometric standard of healthy Bangladeshi adults aged 18-40 years

Pulmonary function test of various types are utilized clinically and epidemiologically to measures the functional status of the lung and to asses the diseases. Spirometric standard for healthy Bangladeshi adults aged 18-40 years is conducted in National Institute of Diseases of Chest and Hospital (NIDCH). This is cross sectional study is establish normal value of lung functions for Bangladeshi adult. Total of 995 (628 males & 367 females) healthy adults were selected to obtain lung function values; from a healthy adult those who attended in the hospital as a patients attended and healthy stuff of NIDCH. A computerized spirometer was used to measure lung volume and flows in a standard way. The best of the three reading was taken as the correct value. Anthropometric parameters including age, weight and height were recorded appropriately and body mass index was calculated. The statistical package for the social science (SPSS-10.01) was used for the statistical analysis of the data. The pulmonary function data was separated by sex and classified on the basis of height weight age and body surface area. The mean and standard deviation was calculated for every such variable. The lung function variable shows a linear positive correlation with height, weight and age. Force vital capacity (FVC) and forced expiratory volume in 1st second (FEV1) increase in height. Males show higher values for lung function variables than female. Stepwise regression analysis was done using age, height and weight, BMI as independent variable strong correlation was found between lung function values and independent variables. Height shows the highest correlation. The regression equation for lung function variables was determined for males and females considering height as independent variable. Lung function values of Bangladeshi adult were significantly lower than Nigerian, British and American result but nearly similar to Indian result. Nomogram was constructed in relation to height for males and females.

Asthma symptom utility index: reliability, validity, responsiveness, and the minimal important difference in adult asthmatic patients

BACKGROUND

The evaluation of asthma symptoms is a core outcome measure in asthma clinical research. The Asthma Symptom Utility Index (ASUI) was developed to assess the frequency and severity of asthma symptoms. The psychometric properties of the ASUI are not well characterized, and a minimal important difference (MID) is not established.

OBJECTIVES

We assessed the reliability, validity, and responsiveness to change of the ASUI in a population of adult asthmatic patients. We also sought to determine the MID for the ASUI.

METHODS

Adult asthmatic patients (n = 1648) from 2 previously completed multicenter randomized trials were included. Demographic information, spirometric results, ASUI scores, and other asthma questionnaire scores were obtained at baseline and during follow-up visits. Participants also kept a daily asthma diary.

RESULTS

The internal consistency reliability of the ASUI was 0.74 (Cronbach α). Test-retest reliability was 0.76 (intraclass correlation). Construct validity was demonstrated by significant correlations between ASUI scores and Asthma Control Questionnaire scores (Spearman correlation r = -0.79; 95% CI, -0.85 to -0.75; P < .001) and Mini Asthma Quality of Life Questionnaire scores (r = 0.59; 95% CI, 0.51-0.61; P < .001). Responsiveness to change was demonstrated, with significant differences between mean changes in ASUI scores across groups of participants differing by 10% in percent predicted FEV(1) (P < .001) and by 0.5 points in Asthma Control Questionnaire scores (P < .001). Anchor-based and statistical methods support an MID for the ASUI of 0.09 points.

CONCLUSIONS

The ASUI is reliable, valid, and responsive to changes in asthma control over time. The MID of the ASUI (range of scores, 0-1) is 0.09.

Novel regression equations predicting lung age from varied spirometric parameters

Although lung age calculated backward from regression formulas constructed for FEV(1) estimation is widely used, it possesses a couple of faults. We developed novel equations predicting lung age from varied spirometric parameters (spirometry-derived lung age (SDL-age)). Applying multiple regression analysis, equations predicting SDL-age were invented using data from 8015 never-smokers with normal spirometry (group I). Validation was made based on data from 6398 never-smokers with normal spirometry (group II). Equations were further applied for 446 subjects with airflow limitation. FEV(1), FEV(1)/FVC, FEF(50), and PEF were selected as explanatory variables for reference value of SDL-age. Normal limits of difference between SDL-age and chronological-age were ± 13.4 years in the male and ± 15.0 years in the female. Established equations predicted SDL-age of group II. SDL-age was older than chronological-age only in subjects with severe airflow limitation. Novel regression equations allowing prediction of reference value of SDL-age and normal limits of difference between SDL-age and chronological-age were elaborated in both genders.

Spirometry in primary care: an analysis of spirometery test quality in a regional primary care asthma program

BACKGROUND

Primary care office spirometry can improve access to testing and concordance between clinical practice and asthma guidelines. Compliance with test quality standards is essential to implementation.

OBJECTIVE

To evaluate the quality of spirometry performed onsite in a regional primary care asthma program (RAP) by health care professionals with limited training.

METHODS

Asthma educators were trained to perform spirometry during two 2 h workshops and supervised during up to six patient encounters. Quality was analyzed using American Thoracic Society (ATS) 1994 and ATS⁄European Respiratory Society (ERS) 2003 (ATS⁄ERS) standards. These results were compared with two regional reference sites: a primary care group practice (Family Medical Centre [FMC], Windsor, Ontario) and a teaching hospital pulmonary function laboratory (London Health Sciences Centre [LHSC], London, Ontario).

RESULTS

A total of 12,815 flow-volume loops (FVL) were evaluated: RAP - 1606 FVL in 472 patient sessions; reference sites - FMC 4013 FVL in 573 sessions; and LHSC - 7196 in 1151 sessions. RAP: There were three acceptable FVL in 392 of 472 (83%) sessions, two reproducible FVL according to ATS criteria in 428 of 469 (91%) sessions, and 395 of 469 (84%) according to ATS⁄ERS criteria. All quality criteria - minimum of three acceptable and two reproducible FVL according to ATS criteria in 361 of 472 (77%) sessions and according to ATS⁄ERS criteria in 337 of 472 (71%) sessions. RAP met ATS criteria more often than the FMC (388 of 573 [68%]); however, less often than LHSC (1050 of 1151 [91%]; P<0.001).

CONCLUSIONS

Health care providers with limited training and experience operating within a simple quality program achieved ATS⁄ERS quality spirometry in the majority of sessions in a primary care setting. The quality performance approached pulmonary function laboratory standards.

The general public's knowledge of chronic obstructive pulmonary disease and its determinants: current situation and recent changes

BACKGROUND

The objective of this study was to determine the level of knowledge about chronic obstructive pulmonary disease (COPD) and its determinants in the general population of Spain, and to compare it with a similar survey conducted in 2002.

METHODS

We conducted a cross-sectional, observational, epidemiological study in September 2011 by means of a telephone interview with a representative sample of individuals aged 40-80 years living in all 17 regions of Spain.

RESULTS

A total of 6,528 responses were obtained (response rate of 13.1%), 53% of respondents were females with a mean age of 59.8 years. Regarding tobacco use, 19.4% were current smokers while 27.9% reported being former smokers. Only 17.0% spontaneously recognized the term «COPD». Valencia was the region with the highest degree of ignorance regarding COPD (91%), while Aragon had the lowest (73.7%). Nevertheless, COPD is considered a severe disease, following angina pectoris in severity. Upon comparing these results with the previous survey from 2002, we observed significant improvements in the knowledge and understanding of COPD (8.6% vs. 17.0%), with a marked variability between the regions (P<.05). Currently, only 4.7% of the Spanish population knows that there is a National Strategy for COPD, although 86.0% have a favorable or very favorable opinion about the new Anti-tobacco Law.

CONCLUSION

The lack of knowledge about COPD and its determinants in the general population remains high compared to 2002; thus, more and better educational and awareness programs are necessary.

Subclinical atherosclerosis, airflow obstruction and emphysema: the MESA Lung Study

Airflow obstruction is an independent risk factor for cardiovascular events in the general population. The affected vascular bed and contribution of emphysema to cardiovascular risk are unclear. We examined whether an obstructive pattern of spirometry and quantitatively defined emphysema were associated with subclinical atherosclerosis in the carotid, peripheral and coronary circulations. The Multi-Ethnic Study of Atherosclerosis recruited participants aged 45-84 yrs without clinical cardiovascular disease. Spirometry, carotid intima-media thickness (IMT), ankle-brachial index (ABI) and coronary artery calcium (CAC) were measured using standard protocols. Percentage of emphysema-like lung was measured in the lung windows of cardiac computed tomography scans among 3,642 participants. Multiple linear regression was used to adjust for cardiac risk factors, including C-reactive protein. Decrements in forced expiratory volume in 1 s (FEV(1)) and FEV(1)/forced vital capacity ratio were associated with greater internal carotid IMT, particularly among smokers (p=0.03 and p<0.001, respectively) whereas percentage emphysema was associated with reduced ABI regardless of smoking history (p=0.004). CAC was associated with neither lung function (prevalence ratio for the presence of CAC in severe airflow obstruction 0.99, 95% CI 0.91-1.07) nor percentage emphysema. An obstructive pattern of spirometry and emphysema were associated distinctly and independently with subclinical atherosclerosis in the carotid arteries and peripheral circulation, respectively, and were not independently related to CAC.

Chronic obstructive pulmonary disease and associated health-care resource use - North Carolina, 2007 and 2009

Chronic obstructive pulmonary disease (COPD), including emphysema and chronic bronchitis, is a progressive condition in which airflow becomes limited, making it difficult to breathe. Chronic lower respiratory diseases, primarily COPD, are the third leading cause of death in the United States, and 5.1% of U.S. adults report a diagnosis of emphysema or chronic bronchitis. Smoking is the primary cause of COPD, and at least 75% of COPD deaths are attributable to smoking in the United States. Information on state-specific prevalence of COPD is sparse, as are data on the use of COPD-related health-care resources. To understand how COPD affects adults in North Carolina and what resources are used by persons with COPD, 2007 and 2009 data from the North Carolina COPD module of the Behavioral Risk Factor Surveillance System (BRFSS) were analyzed. Among 26,227 respondents, 5.7% reported ever having been told by a health professional that they had COPD. Most adults with COPD reported ever having had a diagnostic breathing test (76.4% in 2007 and 82.4% in 2009). Among adults with COPD, 43.0% reported having gone to a physician and 14.9% visited an emergency department (ED) or were admitted to a hospital (2007) for COPD-related symptoms in the previous 12 months. Only 48.1% of persons reported daily use of medications for their COPD (2007). These results indicate that many adults with COPD might not have had adequate diagnostic spirometry, and many who might benefit from daily medications, such as long-acting bronchodilators and inhaled corticosteroids, are not taking them. Continued and expanded surveillance is needed to evaluate the effectiveness of prevention and intervention programs and support efforts to educate the public and physicians about COPD symptoms, diagnosis, and treatment.

Inpatient management of sickle cell pain: a 'snapshot' of current practice

The Sickle Cell Disease Clinical Research Network (SCDCRN) designed the PROACTIVE Feasibility Study (ClinicalTrials.gov NCT00951808) to determine whether elevated serum levels of secretory phospholipase A2 (sPLA2) during hospitalization for pain would permit preemptive therapy of sickle cell acute chest syndrome (ACS) by blood transfusion. While PROACTIVE was not designed to assess pain management and was terminated early due to inadequate patient accrual, collection of clinical data allowed a "snapshot" of current care by expert providers. Nearly half the patients admitted for pain were taking hydroxyurea; hydroxyurea did not affect length of stay. Providers commonly administered parenteral opioid analgesia, usually morphine or hydromorphone, to adults and children, generally by patient-controlled analgesia (PCA). Adult providers were more likely to prescribe hydromorphone and did so at substantially higher morphine equivalent doses than were given to adults receiving morphine; the latter received doses similar to children who received either medication. All subjects treated with PCA received higher daily doses of opioids than those treated by time-contingent dosing. Physicians often restricted intravenous fluids to less than a maintenance rate and underutilized incentive spirometry, which reduces ACS in patients hospitalized for pain.

[Effects of biomass combustion and occupational exposures on lung function in random population sample of Malopolska inhabitants]

INTRODUCTION

Risk factors other than tobacco smoking contribute to about 20% of chronic obstructive pulmonary disease cases. Exposure to these risk factors and their influence on lung function has not been adequately studied in the population of Malopolska.

MATERIAL AND METHODS

In random population sample of adults at least forty years old, residents of 2 districts of Malopolska, data on exposure to known and probable respiratory risk factors were collected using questionnaire. All subjects without contraindications performed pre- and post-bronchodilatator spirometry.

RESULTS

We analyzed data from 618 subjects; 94,8% subjects lived for longer than 6 months in a dwelling where stove using coal or wood has been used for cooking and/or heating. At the time of study as many as 32.5% subjects were still using coal or wood for cooking or heating. Coal or wood were used as fuel on average for more than 30 years; 67% of subjects have ever worked in professions carrying a risk of exposure to potential respiratory risk factors. We have identified an independent relationship of farming with lower FEV1/FVC values as well as increased chronic obstructive pulmonary disease risk.

CONCLUSIONS

Significant proportion of Malopolska inhabitants has been exposed to risks associated with cooking or heating with coal or wood. In the studied population farming was related to increased risk of chronic obstructive respiratory disease.

[Spirometry: a comparison of prediction equations proposed by Lubinński for the Polish population with those proposed by the ECSC/ERS and by Falaschetti et al]

INTRODUCTION

Ethnic-specific equations are commonly acknowledged, however, either generally-European ECSC/ERS prediction equations or equations worked out by Falaschetti et al. for the English population are recommended to be used in Poland. The aim of the study is to compare those equations with equations elaborated by Lubinski and Golczewski for the Polish population.

MATERIAL AND METHODS

ECSC/ERS equations and Falaschetti's ones as well as Polish equations (elaborated on the basis of data for healthy, non-smoking Poles aged 18-85--1120 males, 1625 females--who performed spirometry manoeuvre according to ATS/ERS criteria) were analysed from the point of methodological correctness.

RESULTS

Main ECSC/ERS imperfections: a) the onset age of lung function variable (LF) decline with age is assumed a priori as the same for all LF and equal to 25 yrs; b) simple linear equations describing LF dependences on age higher than 25 yrs can reflect nonlinearity of these dependences inaccurately; c) lower limits of normal are determined as equations for means minus 1.645*SD (SD- standard deviation of differences between observed and predicted values of LF); d) the equations are old, i.e. they have been prepared for previous generations and old procedures of examinations. Main Falaschetti imperfections: a) unnecessarily complex nonlinearity of equations, b) wrong age distributions of general population samples (too low numbers of older subjects). Lubinski's equations have not those imperfections. In particular, age distribution is uniform, and separately for each individual LF: a) the onset age is determined mathematically together with the other equation coefficients; b) statistical significance of nonlinearity of dependence on age is examined. Moreover, Lubinski's predictions for advanced age are equal to results obtained by authors examining in detail the elderly group.

CONCLUSIONS

All the above suggest that Lubinski's equations should be used in Poland instead of ECSC/ERS or Falaschetti equations.

Asthma severity, child security, and child internalizing: using story stem techniques to assess the meaning children give to family and disease-specific events

Children with persistent asthma are at increased risk for mental health problems. Although mechanisms of effect are not yet known, it may be that children are less trusting of the family as a source of support and security when they have more severe asthma. This study tested whether asthma severity is related to children's perceptions of insecurity in the family, and whether insecurity is in turn associated with child adjustment. Children (N = 168; mean age = 8 years) completed story stems pertaining to routine family events (e.g., mealtimes) and ambiguous but potentially threatening asthma events such as tightness in the chest. Responses were evaluated for the extent to which appraisals portrayed the family as responding in cohesive, security-provoking ways. Asthma severity was assessed by both objective lung function testing and primary caregiver report. Caregivers reported child symptomatology. Beyond medication adherence, caregiver education, and child age and gender, greater asthma severity predicted more internalizing and externalizing symptoms. Greater asthma severity, assessed using spirometry (but not parent report), was related to less secure child narratives of the family, which in turn related to more child internalizing symptoms. Results suggest that asthma can take a considerable toll on children's feelings of security and mental health. Furthermore, given the difficulty in assessing young children's perceptions, this study helps demonstrate the potential of story stem techniques in assessing children's appraisals of illness threat and management in the family.

Determinants of spirometry use and accuracy of COPD diagnosis in primary care

BACKGROUND

It is unclear if primary care physicians are following guidelines or using other patient characteristics and factors to determine when to perform spirometry in patients at risk for COPD. It is also unclear to what degree a diagnosis of COPD is accurately reflected by spirometry results.

OBJECTIVES

To examine characteristics associated with use of spirometry in primary care for patients with increased risk for COPD and to determine the accuracy of COPD diagnosis in patients with spirometry.

DESIGN

Retrospective cohort study.

SUBJECTS

A cohort that met the following criteria was identified: ≥35 years of age; ≥ 2 primary care visits in internal medicine clinic in 2007; at least one respiratory or smoking cessation medication, or diagnosis of COPD or shortness of breath or dyspnea in 2007.

MAIN MEASURES

Medical records of all primary care physician visits prior to the time of inclusion in 2007 were reviewed. Data on patient demographics, co-morbidities, respiratory medication use, presence of symptoms, history of tobacco use, and pulmonary function tests were extracted.

KEY RESULTS

A total 1052 patients were identified. Dyspnea on exertion (Adjusted odds ratio (AOR) 1.52 [95% CI 1.06-2.18]) and chronic cough (AOR 1.71 [1.07-2.72]) were the only chronic symptoms associated with use of spirometry. Current (AOR 1.54 [0.99-2.40]) or past smoking (AOR 1.09 [0.72-1.65]) status were not associated with use of spirometry. Of the 159 patients with a diagnosis of COPD, 93 (58.5%) met GOLD criteria and 81(50.9%) met lower limit of normal (LLN) criteria for COPD.

CONCLUSION

Clinicians use spirometry more often among patients with symptoms suggestive of COPD but not more often among patients with current or past tobacco use. For patients who had a spirometry and a diagnosis of COPD, primary care physicians were accurate in their diagnosis only half of the time.

Staging the severity of chronic obstructive pulmonary disease in older persons based on spirometric Z-scores

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.

The standard range of peak expiratory flow rates of Korean children

BACKGROUND

The importance in asthma management of monitoring of peak expiratory flow rate (PEFR) has been emphasized.

OBJECTIVE

For effective asthma management in Korean children, we established reference ranges for the PEFR in children 4-18 years of age.

METHODS

The Mini Wright Peak Flow Meter (MWPFM) and spirometry were used in this study. All tests were conducted using a standardized method recommended by the American Thoracic Society.

RESULTS

From a total sample of 2389 children, 826 (34.5%) were excluded based on our exclusion criteria. For both sexes, the PEFR increased with height, age, weight, sitting height and body surface area (BSA). Height and BSA were found to be better predictors of PEFR than the other parameters. The correlation coefficient between FEV1 and PEFR using the MWPFM was 0.886 (p < .001). The reference values of PEFR for height in our study were higher for both sexes than for those previously reported in Korea (p < .005). When we compared our results with those from other countries, the values for boys of the same height were lower than those for European children, but higher than those for African and Turkish children (p < .001).

CONCLUSIONS

We have established reference values for PEFR obtained by MWPFM in Korean children in Seoul, and have provided the percentile curves for PEFR as a function of height asthma to assist clinical practices in treating children with asthma in Korea.

Utilisation of spirometry among hospitalised patients with clinical findings of COPD in a tertiary hospital in Nigeria

AIMS AND OBJECTIVE

The aim of this study was to determine the rate of spirometry utilisation among hospitalised patients with clinical findings of chronic obstructive pulmonary disease (COPD) in a tertiary hospital in Nigeria.

PATIENTS AND METHODS

A case record review of hospitalised patients with clinical findings of COPD from January 2002 to June 2009 from the record of the cardiopulmonary unit of the University of Ilorin Teaching Hospital Ilorin, Nigeria was carried out. Age and sex, hospital stay, admitting physician, and outcome of admission were obtained.

RESULTS

A total of 228 patients were hospitalised with clinical findings of COPD, 185 (81. 1%) were males and 43(18.9 %) were females. The rate of utilisation of spirometry in hospitalised patients (228) with clinical findings of COPD was 8.3%. More than half of those that had spirometry were aged ≥ 65 years. Majority (16; 84.2%) of those that underwent spirometry were under the care of the pulmonologist (p<O. 001). Age, sex, total days of hospitalisation of patients were not significantly associated with utilisation of spirometry.

CONCLUSIONS

The utilisation of spirometry among hospitalised patients with clinical findings of COPD in this study was very low when compared to the developed countries. Our study has highlighted the experience of a low income country and the need to increase the awareness of the role of spirometry in the evaluation of COPD among doctors.