Will Recommendations against Spirometry Make Chronic
Obstructive Pulmonary Disease Harder to Treat?
First published as a Letter to the Editor in Annals of Internal Medicine 149(7):512-13, October 7, 2008.
Comment / Response
TO THE EDITOR: We are concerned about the recent series of guideline
papers and recommendation statements published in Annals (1-3), which seem to advise primary care physicians not to perform
spirometry. This could be a big blow (no pun intended) to a nationwide
effort to diagnose and treat chronic obstructive pulmonary disease
(COPD) early (4,5). Chronic obstructive pulmonary disease is
the only disease among the top 5 fatal diseases in the United States
that is increasing in morbidity and mortality (6). What separates the
diseases that are decreasing (heart disease, stroke, cancer, and accidents)
from COPD are effective early detection and prevention strategies.
The recommendation in the U.S. Preventive Services Task
Force (USPSTF) clinical summary figure, in large bold letters, states:
"Do not screen for chronic obstructive pulmonary disease using spirometry"
(2). In the text below the figure, however, there are caveats:
this recommendation applies to healthy adults who do not recognize
or report symptoms to a clinician and does not apply to individuals
with a family history of α1-antitrypsin deficiency. Thus, the flip side
of the argument against screening is that unhealthy people (particularly
those with a diagnosed respiratory disease), people with respiratory
symptoms, and people with a family history of α1-antitrypsin
deficiency should have spirometry done. We would add to this list
people who are at increased risk for COPD (adults older than 40
years with current or former tobacco use or exposure to occupational
or environmental pollutants). This, of course, is not screening but
appropriate clinical care.
How are we doing in this regard as clinicians? Not very well.
National data from the United States and other countries demonstrate
that a high proportion of adults with documented impaired
lung function have not had any respiratory disease diagnosed (7-9).
Furthermore, among people with a clinical diagnosis of COPD, in
whom spirometry is mandatory, few patients has had testing done
(10,11). If spirometry use in a group with a clear-cut indication is so
low, one can imagine that use in patients with chronic respiratory
symptoms but no diagnosis is even lower.
Can information obtained from spirometry provide information
beyond detecting severe COPD (the end point used in the USPSTF
guideline's background paper [3])? Yes. Even small decrements in
lung function, which can be related to such processes as heart disease
and diabetes (12), are associated with an increase in all-cause mortality,
which has been known since the Framingham Study (13,14).
Furthermore, in the early stages of COPD, patients frequently have
no symptoms but avoid dyspnea by progressively restricting activity.
The resulting deconditioning is a major clinical problem that further
compromises performance. Failure to diagnose COPD at this stage
removes the opportunity to intervene early to interrupt a vicious
cycle that often leads to a severely restricted functional status that is
very difficult to treat when diagnosis is finally made. Finally, without
readily obtainable spirometry, the clinician will be tempted to diagnose
COPD by using clinical judgment, which is strikingly inaccurate.
Specifically, not only are most patients with COPD without
diagnosis, but a large proportion of individuals with the diagnosis do
not have COPD.
The USPSTF argued that spirometry does not influence smoking
cessation. Several new studies refute this conclusion (15-18).
The most recent, by Parkes and colleagues (17), in which all patients
(smokers age ≥35 years) had spirometry and equal exposure to cessation
resources but patients in the intervention group were told
their lung age, found that cessation rates more than doubled in the
intervention group (6.4% vs. 13.6%).
Performance of spirometry is both easy and inexpensive. Industry
has responded to the need for spirometry by providing
devices that cost $1000 to $2000, and reimbursement is established
at a very reasonable rate, averaging about $30 (Current
Procedural Terminology code 94040) or $57 with bronchodilator
evaluation (Current Procedural Terminology code 94060). Most
important, this test not only provides strong evidence for a diagnosis
of COPD but also can indicate the presence of other diseases,
such as restrictive lung disease.
So what's the bottom line? Should we continue the national
drive to find and treat COPD and related disorders early, or should
we abandon facts and reason and retreat to where we were a halfcentury
ago, when COPD was essentially ignored by the medical
profession? At a minimum, good clinical practice mandates that
adults with COPD or other chronic respiratory disease (asthma, sarcoidosis,
pulmonary fibrosis) should have spirometry. In addition,
patients with respiratory symptoms or a family history of α1-antitrypsin
deficiency should have spirometry. This is case finding and
appropriate treatment of our patients. Finally, we hope that the Task
Force will expeditiously reevaluate the evidence for spirometry as an
adjunct in encouraging smoking cessation.
Thomas L. Petty, MD
University of Colorado
Denver, CO 80220
David M. Mannino, MD
University of Kentucky College of Public Health
Lexington, KY 40356
References
1. Qaseem A, Snow V, Shekelle P, Sherif K, Wilt TJ, Weinberger S, et al. Clinical
Efficacy Assessment Subcommittee of the American College of Physicians. Diagnosis
and management of stable chronic obstructive pulmonary disease: a clinical practice
guideline from the American College of Physicians. Ann Intern Med 2007;147:633-8.
[PMID: 17975186]
2. U.S. Preventive Services Task Force. Screening for chronic obstructive pulmonary
disease using spirometry: U.S. Preventive Services Task Force recommendation statement.
Ann Intern Med 2008;148:529-34. [PMID: 18316747]
3. Lin K, Watkins B, Johnson T, Rodriguez JA, Barton MB. U.S. Preventive Services
Task Force. Screening for chronic obstructive pulmonary disease using spirometry:
summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med
2008;148:535-43. [PMID: 18316746]
4. Petty TL, Weinmann GG. Building a national strategy for the prevention and
management of and research in chronic obstructive pulmonary disease. National Heart,
Lung, and Blood Institute Workshop Summary. Bethesda, Maryland, August 29-31,
1995. JAMA 1997;277:246-53. [PMID: 9005275]
5. Ferguson GT, Enright PL, Buist AS, Higgins MW. Office spirometry for lung
health assessment in adults: a consensus statement from the National Lung Health
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6. Jemal A, Ward E, Hao Y, Thun M. Trends in the leading causes of death in the
United States, 1970-2002. JAMA 2005;294:1255-9. [PMID: 16160134]
7. Mannino DM, Gagnon RC, Petty TL, Lydick E. Obstructive lung disease and low
lung function in adults in the United States: data from the National Health and
Nutrition Examination Survey, 1988-1994. Arch Intern Med 2000;160:1683-9.
[PMID: 10847262]
8. Shahab L, Jarvis MJ, Britton J, West R. Prevalence, diagnosis and relation to tobacco
dependence of chronic obstructive pulmonary disease in a nationally representative
population sample. Thorax 2006;61:1043-7. [PMID: 17040932]
9. Menezes AM, Perez-Padilla R, Jardim JR, Muino A, Lopez MV, Valdivia G, et al.
PLATINO Team. Chronic obstructive pulmonary disease in five Latin American cities
(the PLATINO study): a prevalence study. Lancet 2005;366:1875-81. [PMID:
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10. Damarla M, Celli BR, Mullerova HX, Pinto-Plata VM. Discrepancy in the use of
confirmatory tests in patients hospitalized with the diagnosis of chronic obstructive
pulmonary disease or congestive heart failure. Respir Care 2006;51:1120-4. [PMID:
17005056]
11. Joo MJ, Lee TA, Weiss KB. Geographic variation of spirometry use in newly
diagnosed COPD. Chest 2008;134:38-45. [PMID: 18347201]
12. Mannino DM, Holguin F, Pavlin BI, Ferdinands JM. Risk factors for prevalence of
and mortality related to restriction on spirometry: findings from the First National
Health and Nutrition Examination Survey and follow-up. Int J Tuberc Lung Dis
2005;9:613-21. [PMID: 15971387]
13. Friedman GD, Klatsky AL, Siegelaub AB. Lung function and risk of myocardial
infarction and sudden cardiac death. N Engl J Med 1976;294:1071-5. [PMID:
1256523]
14. Kannel WB. Vital epidemiologic clues in heart failure. J Clin Epidemiol 2000;53:229-35. [PMID: 10760631]
15. Bednarek M, Gorecka D, Wielgomas J, Czajkowska-Malinowska M, Regula J,
Mieszko-Filipczyk G, et al. Smokers with airway obstruction are more likely to quit
smoking. Thorax 2006;61:869-73. [PMID: 16809415]
16. Van Schayck CP, Loozen JM, Wagena E, Akkermans RP, Wesseling GJ. Detecting
patients at a high risk of developing chronic obstructive pulmonary disease in general
practice: cross sectional case finding study. BMJ 2002;324:1370. [PMID: 12052807]
17. Parkes G, Greenhalgh T, Griffin M, Dent R. Effect on smoking quit rate of telling
patients their lung age: the Step2quit randomised controlled trial. BMJ 2008;336:598-600. [PMID: 18326503]
18. Stratelis G, Mölstad S, Jakobsson P, Zetterström O. The impact of repeated
spirometry and smoking cessation advice on smokers with mild COPD. Scand J Prim
Health Care 2006;24:133-9. [PMID: 16923621]
Top of Page
IN RESPONSE: We appreciate the letter from Drs. Petty and Mannino
regarding the USPSTF's recent recommendation against screening
for COPD by using spirometry (1). Their comments provide
us the opportunity to emphasize some important issues that the
USPSTF considered in making this recommendation.
Identifying a disease earlier in its natural course does not automatically
improve health outcomes. Clinicians should screen patients
only if effective interventions are more beneficial during the asymptomatic
disease stage than at clinical diagnosis and if the harms of
screening or treatment do not outweigh the benefits. The USPSTF's
review of the evidence (2) found that for more than 90% of individuals
without respiratory symptoms who would have airflow obstruction
on spirometry, the sole effective therapy was tobacco cessation
interventions, which the USPSTF already recommends for all adult
smokers (3). Even accounting for the few individuals who might gain
symptomatic relief from medications, several hundred patients would
need to be screened with spirometry to defer a single COPD exacerbation.
The USPSTF judged that the harms of such screening—false-positive test results leading to adverse effects from treatment
(for example, tachycardia or urinary retention), coupled with the
substantial time and effort required by patients and the health care
system—were at least equal to this small potential benefit.
Although Drs. Petty and Mannino argue that providing smokers
with spirometry results may motivate them to quit smoking, no
studies they cite were designed to appropriately test this hypothesis.
For example, because all of the participants in the randomized trial
by Parkes and colleagues (4) had spirometry, the only definite conclusion
that can be drawn is that communicating spirometry results
to smokers in understandable terms (lung age) was more effective
than providing the underlying clinical data.
The USPSTF does not discourage clinicians from using spirometry
to diagnose unexplained respiratory symptoms or to monitor
patients with an established pulmonary diagnosis. We are puzzled by
the assertion that recommending against inappropriate overuse of
spirometry (screening) will lead to underuse of the test in appropriate
(diagnostic or monitoring) clinical situations.
Although the American College of Physicians' COPD practice
guideline (5) came to the same conclusion about screening as did the
USPSTF, the USPSTF includes a broad representation of primary
care clinicians and generalists and has an independent guideline development
process. The difference in the composition of and processes
used by these 2 groups support the idea that evidence-based
guidelines are highly reliable.
Ned Calonge, MD, MPH
Diana B. Petitti, MD, MPH
Kenneth Lin, MD
Agency for Healthcare Research and Quality
Rockville, MD 20852
References
1. U.S. Preventive Services Task Force. Screening for chronic obstructive pulmonary
disease using spirometry: U.S. Preventive Services Task Force recommendation statement.
Ann Intern Med 2008;148:529-34. [PMID: 18316747]
2. Lin K, Watkins B, Johnson T, Rodriguez JA, Barton MB. U.S. Preventive Services
Task Force. Screening for chronic obstructive pulmonary disease using spirometry:
summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med
2008;148:535-43. [PMID: 18316746]
3. U.S. Preventive Services Task Force. Counseling to prevent tobacco use and tobacco-caused disease. Rockville, MD: Agency for Healthcare Research and Quality, 2003.
Accessed at http://www.ahrq.gov/clinic/uspstf/uspstbac.htm on 18 July 2008.
4. Parkes G, Greenhalgh T, Griffin M, Dent R. Effect on smoking quit rate of telling
patients their lung age: the Step2quit randomised controlled trial. BMJ 2008;336:598-600. [PMID: 18326503]
5. Qaseem A, Snow V, Shekelle P, Sherif K, Wilt TJ, Weinberger S, et al. Clinical
Efficacy Assessment Subcommittee of the American College of Physicians. Diagnosis
and management of stable chronic obstructive pulmonary disease: a clinical practice
guideline from the American College of Physicians. Ann Intern Med 2007;147:633-8.
[PMID: 17975186]
Top of Page
Current as of November 2008
Internet Citation:
Will Recommendations against Spirometry Make Chronic
Obstructive Pulmonary Disease Harder to Treat? Published Comment and Response: Letter to the Editor and Response. First published in Annals of Internal Medicine 149(7):512-13. Agency for Healthcare Research and Quality, Rockville,
MD. http://www.ahrq.gov/clinic/tfcomments/tfcopdcom.htm
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