COPD COPD Problems in DiagnosisProblems in Diagnosis

Lütfi Çöplü M.D.Lütfi Çöplü M.D.

Hacettepe University School of Hacettepe University School of MedicineMedicine

Chest DepartmentChest Department

Diagnosis of COPDDiagnosis of COPD

• Medical HistoryMedical History Cough, sputum production, dyspnea Cough, sputum production, dyspnea

Risk factors /Smoking historyRisk factors /Smoking history

• Physical examinationPhysical examination

• Assesment of airway obstructionAssesment of airway obstruction

Physical ExaminationPhysical Examination• İncreased expiriumİncreased expirium• Wheezing in forced expiriumWheezing in forced expirium• Barrel chestBarrel chest• Chest wall expansion Chest wall expansion • Sonority Sonority • Respiratory soundsi Respiratory soundsi • RonchiRonchi• Heart Sounds Heart Sounds • Pursed lips breathing Pursed lips breathing • Intercostal retractionIntercostal retraction• Juguler venous distentionJuguler venous distention• Liver enlargementLiver enlargement• CyanosisCyanosis• Pheripheral edemaPheripheral edema

Erkendönemd

e

Terminaldönemde

Hastalıkgeliştiğinde

SYMPTOMS

coughcough

sputum sputum

dyspneadyspnea

RISK FACTORS

smokingsmoking

occupationoccupation

air pollutionair pollution

SPIROMETRYSPIROMETRY

Diagnosis of COPDDiagnosis of COPD

Diagnostic TestsDiagnostic Tests• Pulmonary Pulmonary

function testsfunction tests– SpirometrySpirometry– ReversibilityReversibility– Lung volumesLung volumes– Diffusion testDiffusion test– PEFPEF

• CXR (or thorax CXR (or thorax CT)CT)

• CBC and biochemistryCBC and biochemistry• ABG analysisABG analysis

• Sputum analysisSputum analysis

• ECGECG -1 antitr-1 antitryypsinpsin

• Quality of life, Dyspnea Quality of life, Dyspnea scoresscores

• Respiratory muscle Respiratory muscle functionfunction

• Exercise capacityExercise capacity

• Tests for pulmonary Tests for pulmonary arterial hypertensionarterial hypertension

• Sleep studiesSleep studies

SpirometrySpirometryFlow-Time CurveFlow-Time Curve

FEVFEV11 FVCFVC FEVFEV11/FVC/FVC

NormalNormal 4.1504.150 5.2005.200 %80%80

COPDCOPD 2.3502.350 3.9003.900 %60%60

COPD

FEVFEV11

FEVFEV11

FVCFVC

NormalNormal

SaniyeSaniye11 22 33 44 55 66

00

11

22

33

44

55

Litre

Litre

Flow-Volume LoopFlow-Volume Loop

GOLD GOLD EExecutive Summary, NIH, 2003xecutive Summary, NIH, 2003

TLCTLCTLCTLC FRCFRCFRCFRC RVRVRVRV

Eksp

irasy

on

Eksp

irasy

on

Eksp

irasy

on

Eksp

irasy

on

İnsp

irasy

on

İnsp

irasy

on

İnsp

irasy

on

İnsp

irasy

on

Reversibility TestReversibility Test

• Increase in FEV1 > %12 and >200 Increase in FEV1 > %12 and >200 ml ml

• 400 400 µµg salbutamol or terbutaline should g salbutamol or terbutaline should be givenbe given

• Asses the response in 15 minutesAsses the response in 15 minutes

GOLD NHLBI/WHO Workshop Report. 2004GOLD NHLBI/WHO Workshop Report. 2004ATS 1995ATS 1995BTS BTS NICE Guideline – Chronic obstructive pulmonary diseaseNICE Guideline – Chronic obstructive pulmonary disease.. 20042004

Peak Expiratory Flow (PEF)Peak Expiratory Flow (PEF)

• There is poor relationship between There is poor relationship between PEF and FEV1 in COPD patientsPEF and FEV1 in COPD patients

• It is impossible to predict FEV1 from It is impossible to predict FEV1 from the PEFthe PEF

Bourbeau J Comprehensive Management of COPD 2002

Lung VolumesLung VolumesH

acim

VT

KOAH

TLC

IC

Normal

RV

IC

TLC

FRC/EELV

ERV

IRV

FRC/EELV

*FRC=TGV

Spirometry and other PFTsSpirometry and other PFTs

SpirometrySpirometryPre-/postbronchodilatorPre-/postbronchodilator

Essential for airflow Essential for airflow obstruction and possible obstruction and possible reversibilityreversibility

Lung VolumesLung Volumes may be necessary in may be necessary in moderate and severe moderate and severe casescases

Diffusion capacityDiffusion capacity

DLCODLCOemphysema and emphysema and disproportional dyspneadisproportional dyspnea

Arterial blood Arterial blood gasesgases

Respiratory failure, acute Respiratory failure, acute exacerbationsexacerbationsBourbeau J Comprehensive Management of COPD 2002

RadiologyRadiology

• CXR is insensitive CXR is insensitive detecting airflow detecting airflow obstructionobstruction

• CXR of patient with CXR of patient with mild COPD is likely mild COPD is likely to be normalto be normal

Bourbeau J Comprehensive Management of COPD 2002

SYMPTOMS

coughcough

sputum sputum

dyspneadyspnea

RISK FACTORS

smokingsmoking

occupationoccupation

air pollutionair pollution

SPIROMETRYSPIROMETRY

Diagnosis of COPDDiagnosis of COPD

Staging COPD for Disease Staging COPD for Disease SeveritySeverity

SeveritySeverity FEV1/FVCFEV1/FVC Post-Post-bronchodilatorbronchodilator

FEV1 %FEV1 % PredictedPredicted

Mild COPDMild COPD < 0,7< 0,7 > 80> 80

Moderate COPDModerate COPD < 0,7< 0,7 80-5080-50

Severe COPDSevere COPD < 0,7< 0,7 50-3050-30

Very severe Very severe COPDCOPD

< 0,7< 0,7 < 30 < 30

SpirometrySpirometry

• How does the patient perform maneuvers?

• Are they delivered with maximal effort and with a “blast” at the start?

• Are the maneuvers delivered without hesitation?

• Does leakage occur at the mouth piece?

• Does the maneuvers end prematurely?

Enright PL et al Eur Respir Mon 2005

SpirometrySpirometryFVC minimum FVC minimum durationduration

6 second or plateau in 6 second or plateau in volume-time curvevolume-time curve

FVC end of test FVC end of test criteriacriteria

Subject can not Subject can not continue further continue further exhalationexhalation

Maximum number of Maximum number of maneuversmaneuvers

8 8

FVC and FEV1 FVC and FEV1 reproducibilityreproducibility

The largest and The largest and second FVC and/or second FVC and/or FEV1 must not differ FEV1 must not differ by more than 150 mltby more than 150 mlt

Quanjer P, www.spirxpert.com

Six Second ManoeuvresSix Second Manoeuvres

• FEV6 is more reproducible than the FEV6 is more reproducible than the traditional FVCtraditional FVC

• The use of six second manoeuvres The use of six second manoeuvres reduces technologist and patient reduces technologist and patient fatiguefatigue

• Also eliminates the risk of syncopeAlso eliminates the risk of syncope

• However reference equations for FEV6 However reference equations for FEV6 are not widely avaliableare not widely avaliable

Enright PL et al Eur Respir Mon 2005

• PFT results of 5114 patients were PFT results of 5114 patients were retrospectively anaysedretrospectively anaysed

• When FEV1/FVC is taken gold When FEV1/FVC is taken gold standardstandard

• Negative predictive value 92,4 %Negative predictive value 92,4 %

• Sensitivity 86,09 %Sensitivity 86,09 %

• FEV1/FEV6 may underestimate the FEV1/FEV6 may underestimate the airway obstructionairway obstruction

Problems in Spirometry Problems in Spirometry PracticePractice

Spirometry in primary care ?Spirometry in primary care ?

• A prospective, randomized, comparative trial was planned involving 57 Italian pulmonology centers and 570 GPs who had to enroll consecutive subjects aged 18 to 65 years with symptoms of asthma or COPD without a previous diagnosis.

• Patients were randomized 1:1 into two groups with an interactive voice responding system: conventional evaluation alone vs conventional evaluation and spirometry.

• Office spirometry was performed by GPs who were trained by reference specialists using a portable electronic spirometer

• Of 333 patients enrolled, 136 nonrandom violators completed the protocol.

• Per-protocol analysis showed a concordant diagnosis between GPs and specialists in 78.6% of cases in the conventional evaluation-plus-spirometry group vs 69.2% in the conventional evaluation group (p = 0.35).

• In the intention-to-treat analysis, the respective percentages of concordant

diagnosis were 57.9 and 56.7 (p = 0.87).

Frequent protocol vialation and inadequate sample size did not allow us to prove a significant advantage of office spirometry in improving the diagnosis of asthma and COPD

• A prospective survey of the population aged 35 to 70 years (n=3408) visiting the GP during a 12-week period, using a questionnaire on symptoms of obstructive lung disease (OLD).

• Spirometry was performed in all participants with positive answers and in a 10% random sample from the group without complaints.

• The positive predictive power of the questionnaire was low (sensitivity, 58%; specificity, 78%; likelihood ratio, 2.6).

• Despite a negative predictive value of 95% for the questionnaire used, 42% of the newly diagnosed cases of OLD would not have been detected without spirometry.

•The use of a spirometer is mandatory if early stages of OLD are to be detected in general practice.

•Screening for airflow obstruction almost doubles the number of known patients with OLD.

Targets Population for Spirometry Targets Population for Spirometry ScreeningScreening

• All smokers 35 years of age and overAll smokers 35 years of age and over• Current or past smokers with a 20 pack-year Current or past smokers with a 20 pack-year

history of smokinghistory of smoking• Patients with recurrent or chronic respiratory Patients with recurrent or chronic respiratory

symptomssymptoms• Patients with occupational exposure to irritantsPatients with occupational exposure to irritants• Family history of obstructive pulmonary Family history of obstructive pulmonary

diseasedisease• History of hyperresponsiveness to provocative History of hyperresponsiveness to provocative

agentsagents• Patient with childhood risk factors that may be Patient with childhood risk factors that may be

associated COPDassociated COPDBourbeau J Comprehensive Management of COPD 2002

Problems in Spirometry Problems in Spirometry PracticePractice

Can all patients with COPD Can all patients with COPD be diagnosed correctly?be diagnosed correctly?

• ATS/ERS Task Force characterizes obstruction as a FEV1/FVC% below the statistically defined fifth percentile of normal.

• However, many recent publications continue to use GOLD criterion that defines obstruction as a FEV1/FVC% < 70%.

• Data from NHANES-III should identify and quantify differences, help resolve this conflict, and reduce inappropriate medical and public health decisions resulting from misidentification.

Airway ObstructionAirway Obstruction

•FEV1/FVC < 70 %FEV1/FVC < 70 %

oror

•FEV1/FVC % below the FEV1/FVC % below the statistically defined 5statistically defined 5thth percentile of normal (LLN)percentile of normal (LLN)

MethodsMethods

Individual values of FEV1/FVC % and Individual values of FEV1/FVC % and LLN compared by decades in 5906 LLN compared by decades in 5906 healthy never-smoking adults and healthy never-smoking adults and 3497 current smokers3497 current smokers

% abnormals misidentified as normals

% o

f M

isid

enti

fied

Su

bje

cts

40

20

C-SN-S

C-SN-S% of normals misidentified as normals

0

-40

-60

-20

3 4 5 6 7 8

RESULTSRESULTS Nearly one half of young adults with Nearly one half of young adults with FEV1/FVC % below fifth percentile of FEV1/FVC % below fifth percentile of normal were misidentified as normalnormal were misidentified as normal Approximately one fifth of older adults Approximately one fifth of older adults with observed FEV1/FVC % above the fifth with observed FEV1/FVC % above the fifth percentile had FEV1/FVC %ratios < 70 % percentile had FEV1/FVC %ratios < 70 % (normals misidentified as abnormal)(normals misidentified as abnormal)

CONCLUSIONCONCLUSION

• The main crux of diagnosis of COPD by The main crux of diagnosis of COPD by GOLD criteria are flawedGOLD criteria are flawed

• This will lead to more older subjects This will lead to more older subjects being diagnosed with COPD than is being diagnosed with COPD than is justifiedjustified

• As well as lead to false negative As well as lead to false negative findings in younger subjectsfindings in younger subjects

• Scientific community in Respiartory Scientific community in Respiartory Medicine move to correct this anomalyMedicine move to correct this anomaly

Quanjer P, www.spirxpert.com

• As part of the Copenhagen City Heart As part of the Copenhagen City Heart Study, 8045 men and women aged Study, 8045 men and women aged 30–60 years withnormal lung function 30–60 years withnormal lung function at baseline were followed for 25 years.at baseline were followed for 25 years.

• Lung function measurements were Lung function measurements were collected and mortality from COPD collected and mortality from COPD during the 25 year observation period during the 25 year observation period was analysed.was analysed.

• The percentage of men with normal lung The percentage of men with normal lung function ranged from 96% of never smokers function ranged from 96% of never smokers to 59% of continuous smokers; for women the to 59% of continuous smokers; for women the proportions were 91% and 69%, respectively.proportions were 91% and 69%, respectively.

• The 25 year incidence of moderate and The 25 year incidence of moderate and severe COPD was 20.7% and 3.6%, severe COPD was 20.7% and 3.6%, respectively, with no apparent difference respectively, with no apparent difference between men and women. between men and women.

•The absolute risk of developing COPD among continuous smokers is at least 25%, which is larger than was previously estimated.

Follow-Up AssessmentFollow-Up Assessment

• COPD patients are followed up no COPD patients are followed up no systemic mannersystemic manner

• Frequency of visits and the need for Frequency of visits and the need for investigations vary between physiciansinvestigations vary between physicians

• Age under 40 years, smoking history of Age under 40 years, smoking history of less than 10 pack years and disabled less than 10 pack years and disabled patients should be refered to patients should be refered to respirologistrespirologist