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# Use of Spirometry for Case Finding, Diagnosis, and Management of Chronic                Obstructive Pulmonary Disease (COPD)

*Evidence Reports/Technology Assessments, No. 121*

Investigators: Timothy J Wilt, MD, MPH, Dennis Niewoehner, MD, Chun-Bae Kim, MD, Robert L Kane, MD, Amy Linabery, BS, James Tacklind, BS, Roderick MacDonald, MS, and Indulis Rutks, BS.

Agency for Healthcare Research and Quality (US)2005 Sep

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## Structured Abstract

#### Context:

Chronic Obstructive Pulmonary Disease (COPD) is a leading                cause of morbidity and mortality. COPD is diagnosed in symptomatic individuals                through spirometric testing demonstrating irreversible airflow obstruction.                Spirometry in primary care settings for case-finding, diagnosis, and management in                all adults with persistent respiratory symptoms or having a history of exposure to                pulmonary risk factors is controversial.

#### Objectives:

Conduct a systematic review to determine: 1) the prevalence                of COPD and airflow obstruction; 2) if spirometry improves smoking cessation; 3) if                effectiveness of COPD therapies varies based on baseline or change in spirometric                severity; and 4) whether spirometry provides independent prognostic value related to                pulmonary outcomes.

#### Data Sources:

Articles published in English from 1966 to May 2005 were                identified by searching MEDLINE® and the Cochrane Database. Children and individuals                with asthma or alpha-1 antitrypsin disease were excluded.

#### Study Selection:

Ten cohort studies were included for prevalence; seven                randomized clinical trials (RCTs) for smoking cessation; 53 RCTs and six                meta-analyses for therapies; and five cohort studies for prognosis.

#### Data Extraction:

Study and patient characteristics and outcomes were                abstracted. Main outcomes according to age, race, gender, and spirometric, smoking,                or symptom status by question were: 1) prevalence of airflow obstruction and                clinical diagnosis of COPD; 2) smoking abstinence rates; 3) exacerbation rates,                hospitalizations, mortality and respiratory health status; and 4) spirometry as an                independent predictor of future COPD stage and symptoms.

#### Data Synthesis:

Prevalence and severity of airflow obstruction,                respiratory symptoms, and clinical diagnosis of COPD vary according to definition,                country, and populations. Applying recent diagnostic criteria to a nationally                representative U.S. survey, 7.2 percent were categorized as “at risk,” 7.2 percent                had mild airflow obstruction, 5.4 percent had moderate obstruction, and 1.5 percent                had severe to very severe airflow obstruction. Airflow obstruction prevalence was                higher in current or past smokers and older individuals. Symptoms were associated                with severity of airflow obstruction, but one-third of individuals with normal                airflow reported respiratory symptoms and 21 percent with severe to very severe                airflow obstruction did not report respiratory symptoms. In this survey, more than                80 percent of adults reporting a clinical diagnosis of chronic bronchitis or                emphysema did not have current airflow obstruction or spirometry. Evidence regarding                the effect of spirometry on smoking cessation was limited and flawed. Data indicate                that spirometry is of limited use in predicting a patient's future likelihood of                quitting. Seven randomized studies assessed the effect of spirometry alone or with                other interventions on smoking cessation. The only study designed to evaluate the                independent effect of spirometry in conjunction with clinical counseling found a 1                percent greater quit rate at 12 months in the group assigned to receive spirometry                plus repeat smoking cessation counseling. Spirometry is useful in adults with                bothersome respiratory symptoms for determining at what threshold of airflow                obstruction initiation of therapy is likely to be beneficial. COPD treatment trials                evaluated inhaled medications, pulmonary rehabilitation, disease management,                supplemental oxygen, or surgery. Most were less than 1 year in duration and involved                subjects with severe to very-severe airflow obstruction and frequent COPD                exacerbations. Treatments reduced the percentage of subjects having one or more                exacerbations by an absolute reduction of 5–6 percent but did not reduce mortality                (except for oxygen in a small subset of individuals). The average magnitude of                improvement for respiratory and dyspnea functional status measures was less than                considered clinically significant though some subjects may notice considerable                improvement.

Five large studies of greater than 1 year duration found little to no improvement in                symptoms with inhaled medications among subjects with mild to moderate airflow                obstruction, many of whom had respiratory symptoms and were detected based on                spirometry. Analysis of one of these studies that included individuals who reported                no respiratory symptoms showed that ipratropium did not prevent development of                symptoms at 3 years of followup. Studies have not examined the value of spirometry                to monitor need for additional therapy or to identify candidates for treatment among                patients who do not report symptoms. However, it is unlikely to be effective because                effectiveness of inhaled interventions are comparable, spirometry is not a useful                guide for selecting among inhaled therapies, higher doses of inhaled interventions                or combination therapies were not more effective than lower doses or monotherapy,                clinical improvement was not associated with an individual's spirometric response to                therapy, treatments other than smoking cessation did not alter spirometric decline,                and interventions did not prevent symptom development in asymptomatic individuals.                We estimated that the costs of routine spirometry of all adult smokers, ex-smokers,                and non-smokers with any respiratory symptom would exceed $1 billion. Based on the                prevalence of respiratory symptoms, levels of airflow obstruction identified in the                U.S., and the effectiveness of drug therapy, we estimated that such a strategy                applied to a clinic population of 10,000 adults would identify 6,588 for spirometric                testing, detect 129 (1.3 percent) who would be candidates for COPD therapy, and                result in 8 who would benefit from reduction in exacerbations. On average,                respiratory status measures and survival would not be improved. Hospitalizations                were rarely reported but the absolute reduction was 4–7 percent. If subjects with                moderate airflow obstruction (FEV1 between 50–80 percent predicted) are                assumed to benefit, then 529 (5.3 percent) adults would be treatment candidates and                32 (0.3 percent) would benefit. These benefits would be retained at reduced costs                and testing if spirometry was targeted to adults reporting bothersome symptoms.                Spirometry provides independent prognostic value regarding morbidity and mortality.                Subjects with chronic sputum production and normal spirometry are not at increased                risk for developing airflow obstruction, and more than half of these subjects do not                have chronic sputum production after 10 years of followup.

#### Conclusions:

Spirometry, in addition to clinical examination, improves                COPD diagnostic accuracy compared to clinical examination alone and it is a useful                diagnostic tool in individuals with symptoms suggestive of possible COPD. The                primary benefit of spirometry is to identify individuals who might benefit from                pharmacologic treatment in order to improve exacerbations. These include adults with                symptomatic, severe to very severe airflow obstruction. Spirometry for case finding                among all adults with persistent respiratory symptoms or those with a history of                exposure to pulmonary risk factors as well as for monitoring individuals or                adjusting treatment is unlikely to be beneficial unless future studies establish                that spirometry improves smoking cessation rates, treatments other than smoking                cessation benefit individuals with airflow obstruction who do not report respiratory                symptoms, or that relative effectiveness between therapies varies according to an                individual's baseline or followup spirometry. Widespread spirometric testing is                likely to label a large number of individuals (many who do not report respiratory                symptoms) with disease and result in considerable testing and treatment costs and                health-care resource utilization.

## Contents

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                        - Preface
                        - Acknowledgments
                        - Summary
                        - 1. Introduction                           - Overview
                          - Background
                        - 2. Methods                           - Topic Assessment and Refinement and Literature Review
                          - Analytic Framework
                          - Literature Search and Data Abstraction
                        - 3. Results                           - Question 1 What is the prevalence of chronic obstructive pulmonary disease					(COPD) and airflow obstructions in various adult populations as defined by: 1)					spirometry and 2) clinical examination?
                          - Question 2 Can use of spirometry lead to increased smoking cessation rates?
                          - Question 3 Does the effectiveness of specific therapies to improve clinically					relevant outcomes in COPD vary based on baseline or followup spirometry, short					term spirometric response due to initial therapy, or spirometric progression					over time?
                          - Question 4 Is prediction of prognosis based on spirometry, with or without					clinical indicators, more accurate than prediction based on clinical indicators					alone?
                        - 4. Discussion                           - Summary
                          - Conclusion
                          - Limitations
                          - Future Research Needs
                        - Summary Tables
                        - List of Acronyms/Abbreviations
                        - Appendixes                           - Appendix A Technical Expert Panel Members
                          - Appendix B Exact Search Strings
                          - Appendix C: Abstraction Forms
                          - Appendix D Evidence Tables and Figures
                        - References and Included Studies
                        - Listing of Excluded Studies

                          - Expand All
                          - Collapse All

Prepared for: Agency for Healthcare Research and Quality, U.S. Department                of Health and Human Services.1                 Contract No. 290-02-0009.                Prepared by: Minnesota Evidence-based                    Practice Center, Minneapolis, Minnesota.

#### Suggested citation:

Wilt TJ, Niewoehner D, Kim C-B, Kane RL, Linabery A,                    Tacklind J, MacDonald R, Rutks I. Use of Spirometry for Case Finding, Diagnosis,                    and Management of Chronic Obstructive Pulmonary Disease (COPD). Evidence                    Report/Technology Assessment No. 121 (Prepared by the Minnesota Evidence-based                    Practice Center under Contract No. 290-02-0009.) AHRQ Publication No. 05-E017-2.                    Rockville, MD. Agency for Healthcare Research and Quality. September                2005.

This report is based on research conducted by the Minnesota Evidence-based Practice                Center (EPC), Minneapolis, Minnesota under contract to the Agency for Healthcare                Research and Quality (AHRQ), Rockville, MD (Contract No. 290-02-0009). The findings                and conclusions in this document are those of the authors, who are responsible for                its contents; the findings and conclusions do not necessarily represent the views of                AHRQ. Therefore, no statement in this report should be construed as an official                position of AHRQ or of the U.S. Department of Health and Human Services.

The information in this report is intended to help health care decisionmakers,                patients and clinicians, health system leaders, and policymakers make well-informed                decisions and thereby improve the quality of health care services. This report is                not intended to be a substitute for the application of clinical judgment. Anyone who                makes decisions concerning the provision of clinical care should consider this                report as they would any medical reference and in conjunction with all other                pertinent information, i.e., in the context of available resources and circumstances                presented by individual patients.

This report may be used, in whole or in part, as the basis for development of                clinical practice guidelines and other quality enhancement tools, or a basis for                reimbursement and coverage policies. Neither AHRQ's nor the U.S. Department of                Health and Human Services' endorsement of such derivative products may be stated or                implied.

                        - 1
                        - 
540 Gaither Road, Rockville, MD 20850. www​.ahrq.gov

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Bookshelf ID: NBK37773

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                    - Cite this Page Wilt TJ, Niewoehner D, Kim CB, et al. Use of Spirometry for Case Finding, Diagnosis, and Management of Chronic Obstructive Pulmonary Disease (COPD). Rockville (MD): Agency for Healthcare Research and Quality (US); 2005 Sep. (Evidence Reports/Technology Assessments, No. 121.)

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