Prim Care Respir J. 2010 Jun 7. pii: pcrj-2009-07-0060-R2. doi: 10.4104/pcrj.2010.00034. Minas M, Hatzoglou C, Karetsi E, Papaioannou AI, Tanou K, Tsaroucha R, Gogou E, Gourgoulianis KI, Kostikas K. Respiratory Medicine Department, University of Thessaly Medical School, University Hospital of Larissa, Greece.

AIMS: To evaluate the prevalence and severity of COPD in a primary care population participating in a spirometry program. Differences between newly and previously diagnosed COPD patients were identified.

METHODS: A spirometry program was conducted in 15 primary care centres. Visitors aged over 30 years who were willing to perform spirometry were included in this program.

RESULTS: A total of 1,526 subjects provided acceptable spirometries. COPD prevalence in our population was 18.4%, of whom 69.0% were newly diagnosed. Most patients were classified as GOLD stages I and II (26.0% and 54.0%, respectively). COPD diagnosis was related to gender (men), age (older subjects), history of repeated respiratory infection in childhood, smoking (>10 pack-years) and presence of symptoms (cough, dyspnoea, wheezing). Variables related to newly diagnosed COPD were younger age and absence of chronic cough.

CONCLUSIONS: A primary care spirometry program may identify a large proportion of undiagnosed COPD patients especially in the early stages of the disease. Newly diagnosed COPD patients were of younger age and presented with less symptoms. These results support the need for spirometry programs in primary care for early COPD detection.

Why are people with "poor lung function" at increased atherothrombotic risk? A critical review with potential therapeutic indications.

Curr Vasc Pharmacol. 2010 Jul;8(4):573-86. Fimognari FL, Scarlata S, Antonelli-Incalzi R. Unit of Respiratory Diseases, Division of Internal Medicine, Leopoldo Parodi-Delfino Hospital, ASL Roma G, Colleferro (Rome), Italy.

Patients classified as having a "poor lung function" in large populations studies are at increased risk of atherothrombosis, but potential mechanisms are unclear. A large proportion of these people are affected by chronic obstructive pulmonary disease (COPD), a recognized risk factor for vascular events. Systemic inflammation is the main atherothrombotic abnormality in COPD, but hypoxia-related platelet activation, pro-coagulant status and oxidative stress may play a role. Systemic inflammation is presumably a leading mechanism of atherothrombosis also in people who have a "restrictive" spirometric dysfunction, rather than the classic obstructive pattern of COPD. Many persons with "poor lung function" are affected by diabetes and their cardiovascular risk is therefore linked to the diabetic status. Patients affected by diabetes tend to have a "restrictive" dysfunction, rather than COPD. Recent studies show that restriction at spirometry precedes the onset of diabetes, thereby representing a marker of mechanisms involved in the pre-diabetic, insulin-resistant state. This is also proved by the fact that most patients with metabolic syndrome, a pre-diabetic condition, have a restrictive ventilatory pattern at spirometry. A significant proportion of people with "poor lung function" have visceral obesity, a cardiovascular risk factor. By hampering lung expansion, visceral obesity causes a restrictive ventilatory pattern.

In conclusion, the term "poor lung function" includes various chronic illnesses with different mechanisms of atherothrombosis. Research is needed for better understanding why persons with lung dysfunctions have higher cardiovascular risk, and for identifying adequate preventive strategies.

Longitudinal change of prebronchodilator spirometric obstruction and health outcomes: results from the SAPALDIA cohort.

Thorax. 2010 Feb;65(2):150-6. Probst-Hensch NM, Curjuric I, Pierre-Olivier B, Ackermann-Liebrich U, Bettschart RW, Brändli O, Brutsche M, Burdet L, Gerbase MW, Knöpfli B, Künzli N, Pons MG, Schindler C, Tschopp JM, Rochat T, Russi EW. Institute of Social and Preventive Medicine, Chronic Disease Epidemiology, University of Zürich, Sumatrastr. 30, CH-8091 Zürich, Switzerland.

BACKGROUND: Understanding the prognostic meaning of early stages of chronic obstructive pulmonary disease (COPD) in the general population is relevant for discussions about underdiagnosis. To date, COPD prevalence and incidence have often been estimated using prebrochodilation spirometry instead of postbronchodilation spirometry. In the SAPALDIA (Swiss Study on Air Pollution and Lung Disease in Adults) cohort, time course, clinical relevance and determinants of severity stages of obstruction were investigated using prebronchodilator spirometry.

METHODS: Incident obstruction was defined as an FEV(1)/FVC (forced expiratory volume in 1 s/forced vital capacity) ratio >or=0.70 at baseline and <0.70 at follow-up, and non-persistence was defined inversely. Determinants were assessed in 5490 adults with spirometry and respiratory symptom data in 1991 and 2002 using Poisson regression controlling for self-declared asthma and wheezing. Change in obstruction severity (defined analogously to the GOLD (Global Initiative for Chronic Obstructive Lung Disease) classification) over 11 years was related to shortness of breath and health service utilisation for respiratory problems by logistic models.

RESULTS: The incidence rate of obstruction was 14.2 cases/1000 person years. 20.9% of obstructive cases (n = 113/540) were non-persistent. Age, smoking, chronic bronchitis and non-current asthma were determinants of incidence. After adjustment for asthma, only progressive stage I or persistent stage II obstruction was associated with shortness of breath (OR 1.71, 95% CI 0.83 to 3.54; OR 3.11, 95% CI 1.50 to 6.42, respectively) and health service utilisation for respiratory problems (OR 2.49, 95% CI 1.02 to 6.10; OR 4.17 95% CI 1.91 to 9.13, respectively) at follow-up.

CONCLUSIONS: The observed non-persistence of obstruction suggests that prebronchodilation spirometry, as used in epidemiological studies, might misclassify COPD. Future epidemiological studies should consider both prebronchodilation and postbronchodilation measurements and take specific clinical factors related to asthma and COPD into consideration for estimation of disease burden and prediction of health outcomes.

Exploring the need to update lung age equations.

Prim Care Respir J. 2010 May 12. pii: pcrj-2009-11-0096-R2. doi: 10.4104/pcrj.2010.00029. Newbury W, Newbury J, Briggs N, Crockett A. Discipline of General Practice, School of Population Health and Clinical Practice, University of Adelaide; Spencer Gulf Rural Health School, University of Adelaide and University of South Australia.

AIMS: A renewed interest in lung age is evidenced by recent smoking cessation publications. This research compares the original Morris lung age equations (1985) with contemporary Australian lung age equations.

METHODS: Both lung age equations were applied to the spirometry results of two sub-groups (never-smokers n=340, and current smokers n=50) from an independent dataset. Means of both lung age estimates were compared to the mean of the chronological age of each group by paired Student's t-test.

RESULTS: The Morris lung age estimates were paradoxically lower (younger) than chronological age in both groups. The new Australian equation produced lung age estimates that were equivalent to chronological age in the never-smoker group and significantly higher (older) than chronological age in the current smoker group.

CONCLUSIONS: These results strongly suggest that the Morris lung age equations are in need of review. The use of contemporary lung age equations may translate into greater success for smoking cessation programs. The new Australian equations seem to possess internal validity.

The ratio of FEV1 to FVC as a basis for establishing chronic obstructive pulmonary disease.

Am J Respir Crit Care Med. 2010 Mar 1;181(5):446-51. Vaz Fragoso CA, Concato J, McAvay G, Van Ness PH, Rochester CL, Yaggi HK, Gill TM. Yale Claude D. Pepper Older Americans Independence Center, New Haven, Connecticut, USA.

RATIONALE: The lambda-mu-sigma (LMS) method is a novel approach that defines the lower limit of normal (LLN) for the ratio of FEV1/FVC as the fifth percentile of the distribution of Z scores. The clinical validity of this threshold as a basis for establishing chronic obstructive pulmonary disease is unknown.

OBJECTIVE: To evaluate the association between the LMS method of determining the LLN for the FEV1/FVC, set at successively higher thresholds, and clinically meaningful outcomes.

METHODS: Using data from a nationally representative sample of 3,502 white Americans aged 40-80 years, we stratified the FEV1/FVC according to the LMS-LLN, with thresholds set at the 5th, 10th, 15th, 20th, and 25th percentiles (i.e., LMS-LLN5, LMS-LLN10, etc.). We then evaluated whether these thresholds were associated with an increased risk of death or prevalence of respiratory symptoms. Spirometry was not specifically completed after a bronchodilator.

MEASUREMENTS AND MAIN RESULTS: Relative to an FEV1/FVC greater than or equal to LMS-LLN25 (reference group), the risk of death and the odds of having respiratory symptoms were elevated only in participants who had an FEV1/FVC less than LMS-LLN(5), with an adjusted hazard ratio of 1.68 (95% confidence interval, 1.34-2.12) and an adjusted odds ratio of 2.46 (95% confidence interval, 2.01-3.02), respectively, representing 13.8% of the cohort. Results were similar for persons aged 40-64 years and those aged 65-80 years.

CONCLUSIONS: In white persons aged 40-80 years, an FEV1/FVC less than LMS-LLN5 identifies persons with an increased risk of death and prevalence of respiratory symptoms. These results support the use of the LMS-LLN5 threshold for establishing chronic obstructive pulmonary disease.

Diagnosis of COPD in hospitalised patients.

Arch Bronconeumol.. Pellicer Císcar C, Soler Cataluña JJ, Andreu Rodríguez AL, Bueso Fabra J; en representación del grupo EPOC de la Sociedad Valenciana de Neumología. Unidad de Neumología, Hospital Francesc de Borja, Gandía, Valencia, España.

OBJECTIVE: To examine the quality of COPD diagnosis in hospitalised patients.

MATERIAL AND METHODS: Retrospective multicentre cross-sectional audit review of the clinical histories of patients discharged with a diagnosis of COPD. The diagnosis of COPD was considered correct (DxC) in cases where the combination of a bronchial obstruction (FEV1/FVC<70%) and smoking (>10packets/year) could be documented. In the rest of the cases the diagnosis was considered deficient (DxD). A DxC in at least 60% of patients was required to be considered an acceptable quality health care diagnosis. Demographic data such as, smoking, spirometry, the specialist who discharged the patient (P: Pneumologist; MS: Medical Specialty; CS: Surgical Specialty), and health care level (hospital complexity; low (H1), intermediate (H2) and high (H3)).

RESULTS: A total of 840 cases were analysed (718 males, 122 females); mean age (SD) 73 (10), from 10 hospitals (3 H1, 4 H2, 3 H3). A DxD was obtained in 597 (71.1%), due to either lack of spirometry (538, 64%) or smoking criteria (319, 38%), (P<0.001). Only two of the ten hospitals complied with the criteria of an acceptable quality health care diagnosis. Significant differences (P<0.0001) were seen on comparing DxC and DxD by health care level (DxC: 56.2% in H1, 29.9% in H2, 20.9% in H3), and by specialist (DxC: 47.6% en P, 24.6% in SP, 17.4% in MS). A multivariate analysis associated DxC with the male sex, H1 and pneumology reports.

CONCLUSIONS: 1. The quality health care for the diagnosis of COPD is deficient. 2. The lack of spirometry is the most common cause of DxD.

Quality of Spirometry in Primary Care for Case Finding of Airway Obstruction in Smokers.

Respiration. 2009 Sep 26. [Epub ahead of print] Leuppi JD, Miedinger D, Chhajed PN, Buess C, Schafroth S, Bucher HC, Tamm M. Clinic for Pneumology, University Hospital, Basel, Switzerland.

Background: Diagnosis of chronic obstructive pulmonary disease (COPD) and its severity determination is based on spirometry. The quality of spirometry is crucial. Objectives: Our aim was to assess the quality of spirometry performed using a spirometer with automated feedback and quality control in a general practice setting in Switzerland and to determine the prevalence of airflow limitation in smokers aged >/=40 years.

Method: Current smokers >/=40 years of age were consecutively recruited for spirometry testing by general practitioners. General practitioners received spirometry training and were provided with an EasyOne spirometer. Spirometry tests were assigned a quality grade from A to D and F, based on the criteria of the National Lung Health Education Program. Only spirometry tests graded A-C (reproducible measurements) were included in the analysis of airflow limitation.

Results: A total of 29,817 spirometries were analyzed. Quality grades A-D and F were assigned to 33.9, 7.1, 19.4, 27.8 and 11.8% of spirometries, respectively. 95% required </=5 trials to achieve spirometries assigned grade A. The prevalence of mild, moderate, severe and very severe airway obstruction in individuals with spirometries graded A-C was 6, 15, 5 and 1%, respectively.

Conclusion: Spirometries in general practice are of acceptable quality with reproducible spirometry in 60% of measurements. Airway obstruction was found in 27% of current smokers aged >/=40 years. Office spirometry provides a simple and quick means of detecting airflow limitation, allowing earlier diagnosis and intervention in many patients with early COPD.

Respiratory patterns in spirometric tests of adolescents and adults with cystic fibrosis.

J Bras Pneumol. 2009 Sep;35(9):854-9. Ziegler B, Rovedder PM, Dalcin Pde T, Menna-Barreto SS. Serviço de Pneumologia, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brasil.

OBJECTIVE: To evaluate spirometric patterns of respiratory disorders and their relationship with functional severity and maximal expiratory flows at low lung volumes in patients with cystic fibrosis (CF).

METHODS: A retrospective cross-sectional study including adolescents and adults with CF. All of the patients were submitted to spirometry. Patients were classified as having preserved respiratory function, obstructive lung disease (OLD), OLD with reduced FVC, presumptive restrictive lung disease (RLD) or mixed obstructive and restrictive lung disease (MORLD). Maximal expiratory flows at low lung volumes were assessed using FEF(25-75%), FEF(75%) and FEF(75%)/FVC. We included 65 normal subjects, also submitted to spirometry, as a control group.

RESULTS: The study group included 65 patients: 8 (12.3%) with preserved lung function; 18 (27.7%) with OLD; 24 (36.9%) with OLD and reduced FVC; 5 (7.7%) with presumptive RLD; and 10 (15.4%) with MORLD. The FEV1 was significantly lower in the OLD with reduced FVC group and the MORLD group than in the other groups (p < 0.001). In the patients with preserved respiratory function, FEF(25-75%) and FEF(75%) were significantly reduced in 1 patient, as was FEF(75%)/FVC in 2 patients.

CONCLUSIONS: The respiratory pattern was impaired in 88% of the patients with CF. The most common pattern was OLD with reduced FVC. The degree of functional impairment was greater in the OLD with reduced FVC group and in the MORLD group than in the other groups. Maximal expiratory flows at low lung volumes were impaired in a low percentage of patients with preserved respiratory function.

Nocturnal hypoxia and sleep disturbances in cystic fibrosis.

Pediatr Pulmonol. 2009 Nov;44(11):1143-50. de Castro-Silva C, de Bruin VM, Cavalcante AG, Bittencourt LR, de Bruin PF. Universidade Federal do Ceará, CEP: 60430 040, Fortaleza, Ceará, Brazil.

Disrupted sleep and nocturnal hypoxia are common in cystic fibrosis (CF). However, the predictors of nocturnal hypoxia in CF are still controversial. In order to identify the risk factors for nocturnal desaturation and sleep disturbances, we carried out a clinical and polysomnographic investigation of CF patients. We studied 30 clinically stable CF cases with clinical lung disease (mean age = 12.8; mean FEV1 = 65.2), 10 CF cases without significant lung disease (mean age = 13.3; mean FEV1 = 99.8), and 20 controls (mean age = 15.5). Patients were evaluated by spirometry, 6-min walk test, the Shwachman-Kulczycki (S-K) score, and full overnight polysomnography. Cases with clinical lung disease had lower body mass index, forced vital capacity, and S-K scores. During sleep, five CF cases with clinical lung disease (15%) had SaO(2) <90% during more than 30% of total sleep time and 11 cases (36.6%) had a nadir SaO(2) below 85%. FEV1 values for CF cases with clinical lung disease were related to nadir SaO(2) (P < 0.03) and to mean SaO(2) (P = 0.02). A receiver operating characteristic (ROC) analysis determined FEV1 at 64% to be predictive of nocturnal desaturation as defined by minimum SaO(2) <85% (sensitivity = 92.3%; specificity = 77.3%) or SaO(2) <90% for 30% of sleep time (sensitivity = 81.8%; specificity = 85.2%). Frequency of impaired sleep was not different in CF cases with (N = 2) and without significant lung disease (N = 5, P = 0.53). Sleep architecture was not significantly different between the two groups. Sleep apnea was present in three CF cases with clinical lung disease and in one case without significant lung disease.

In summary, desaturation during sleep can be predicted by FEV1 <64% with good sensitivity and specificity. There are no significant differences in sleep architecture between clinically stable CF cases with and without significant lung disease.

Walk-in spirometry pilot project for discovering of early chronic obstructive pulmonary disease

Ugeskr Laeger. 2009 Oct 19;171(43):3083-8. Løkke A, Christensen LB, Fuglsang C. Medicinsk Afdeling, Regionshospitalet Silkeborg, DK-8600 Silkeborg, Denmark.

INTRODUCTION: In Denmark, 10% of the health budget is spent on treating chronic obstructive lung disease (COPD) and the economic burden from COPD looks more than likely to grow in the near future. With this in mind we initiated a pilot project with The Danish Lung association to discover early stages of COPD by using spirometry.

MATERIAL AND METHODS: A total of 344 persons from Aarhus and the surrounding area participated in a free anonymous walk-in spirometry project in the Health Centre, Aarhus. Among these, 291 persons were asked to fill in a questionnaire. A total of 135 smokers and/or persons with reduced lung function came to a second examination with yet another spirometry measurement and an advanced questionnaire. COPD staging was performed according to the GOLD and ERS/ATS criteria.

RESULTS: 61% of the participants were women aged 60 years or older. 43% had normal lung function at the first examination. Only every fourth of those with COPD were aware of the fact that they had a lung disease. 33% would have visited their GP to have their lungs examined. 11-16% gave up smoking between the two examinations.

CONCLUSION: This rather cost-effective walk-in design makes it possible to discover a substantial group of persons with previously unknown, mild and moderate COPD prior to examination and at the same time motivate people to give up smoking. Whether this is a long-term effect has yet to be determined.

Reference values for lung function testing in adults--results from the study of health in Pomerania" (SHIP)

Dtsch Med Wochenschr. 2009 Nov;134(46):2327-32. Koch B, Schäper C, Ittermann T, Völzke H, Felix SB, Ewert R, Gläser S. Klinik für Innere Medizin B - Bereiche Kardiologie, Pneumologie, Infektiologie und Internistische Intensivmedizin, Ernst-Moritz-Arndt Universität Greifswald.

BACKGROUND AND OBJECTIVE: The assessment of lung function with spirometry is a frequently performed diagnostic procedure and is considered an important tool in medical monitoring of pulmonary diseases. This study aimed at establishing current reference standards, derived from a representative population sample in West Pomerania of Germany and to compare them to existing data.

PATIENTS AND METHODS: Standardized spirometric function tests were performed - 1sec forced respiratory volume (FEV1) and forced vital capacity (FVC) - on 1,809 participants (885 men, 924 women) of a cross-sectional epidemiological survey, called Study of Health in Pomerania ( SHIP).

RESULTS: All persons with cardiac disorders, current smokers and those who were on specific medication which could influence lung functions were excluded, leaving a total of 904 healthy subjects (439 men, 465 women, aged 25-85 years. The results were analysed by quantile regression.

CONCLUSION: The study provides a representative, gender specific set of predictive equations for lung function parameters by spirometry. Comparison to existing prediction equations revealed a consistent underestimation in the current population. The results help to interpret the results of lung function tests: it is therefore recommended that the existing prediction equations be revised.

Pulmonary function correlates with arterial stiffness in asthmatic patients.

Respir Med. 2009 Nov 3. Weiler Z, Zeldin Y, Magen E, Zamir D, Kidon MI. Pulmonary Unit, Barzilai Medical Center, Ashkelon 78306, Israel Affiliated to the faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheba.

BACKGROUND: At the population level, asthma has been associated with chronic systemic inflammation as well as adverse cardiovascular outcomes.

OBJECTIVES: The aim of this study was to investigate peripheral vascular hemodynamic variables of arterial stiffness (AS) and their relationship to pulmonary function tests in asthmatic patients.

METHODS: Young asthmatic patients from the tertiary center for pulmonary diseases at the Barzilai Medical Center underwent pulmonary function evaluation and non-invasive radial artery hemodynamic profiling, pre- and post-exercise. Results were compared to age matched, non-asthmatic controls.

RESULTS: 23 young asthmatics and 41 controls, completed all evaluation points. Pulmonary flow parameters were significantly reduced in the asthma group at all points. There were no differences between groups in BMI, blood pressure, pulse rate or measurements of AS at baseline or after bronchodilation. The % predicted forced expiratory volume in the first second at baseline (FEV1%) in asthmatics was positively correlated with the small arteries elasticity index (SAEI) and negatively correlated with the systemic vascular resistance (SVR) in these patients. These correlations were not observed in non-asthmatic controls. In multifactorial regression FEV1 remained the major factor associated with measurements of AS in asthmatic patients, while gender was the only significant factor in non-asthmatic controls.

CONCLUSIONS: Significant correlations between measurements of AS and FEV1 in young asthmatics, suggest the presence of a common systemic, most likely inflammatory pathway involving both the cardiovascular and respiratory systems.

Screening for and early detection of chronic obstructive pulmonary disease.

Lancet. 2009 Aug 29;374(9691):721-32. Soriano JB, Zielinski J, Price D. CIMERA (International Center for Advanced Respiratory Medicine), Recinte Hospital Joan March, Bunyola, Spain.

Chronic obstructive pulmonary disease (COPD) is a substantially underdiagnosed disorder, with the diagnosis typically missed or delayed until the condition is advanced. Spirometry is the most frequently used pulmonary function test and enables health professionals to make an objective measurement of airflow obstruction and assess the degree to which it is reversible. As a diagnostic test for COPD, spirometry is a reliable, simple, non-invasive, safe, and non-expensive procedure. Early diagnosis of COPD should provide support for smoking cessation initiatives and lead to reduction of the societal burden of the disease, but definitive confirmation of both proves elusive. Despite substantial effort and investment, implementation of quality spirometry is deficient because of several hurdles and limitations, described in this Review.

All in all, spirometry is recognised as the essential test for diagnosis and monitoring of COPD.

Spirometry in primary care case-identification, diagnosis and management of COPD.

Prim Care Respir J. 2009 Aug 18. Price D, Crockett A, Arne M, Garbe B, Jones RC, Kaplan A, Langhammer A, Williams S, Yawn BP. Centre for Academic Primary Care, University of Aberdeen, Scotland, UK.

Chronic obstructive pulmonary disease (COPD) is an important cause of morbidity and mortality worldwide, yet it remains significantly under-diagnosed. Systematic and opportunistic case-identification efforts in primary care, using questionnaires, careful assessment to identify symptoms, and follow-up spirometry, might improve diagnosis rates and enable earlier detection and management of COPD. The aims of spirometry performed for case-identification purposes are to exclude those patients with symptoms but normal lung function and identify those who require more complete investigation for COPD, including 'diagnostic standard' spirometry. Among patients with a confirmed diagnosis of COPD, spirometry monitoring is useful in identifying those with rapid deterioration in lung function who require further assessment.

Spirometry in primary care can also support patient education and may encourage smoking cessation and treatment adherence.

Prevalence of airway obstruction in recreational SCUBA divers.

Wilderness Environ Med. 2009 Summer;20(2):125-8. Weaver LK, Churchill SK, Hegewald MJ, Jensen RL, Crapo RO. Pulmonary and Critical Care Division, Intermountain Medical Center, Murray, UT, USA.

OBJECTIVE: The prevalence of airflow obstruction in recreational self-contained underwater breathing apparatus (SCUBA) divers is unknown. Since airflow obstruction is a relative contraindication for diving, we conducted a study to determine its prevalence and magnitude in a cohort of recreational divers in Saba, Netherlands Antilles.

METHODS: Prior to diving, divers were asked to complete a diving/health questionnaire and then to perform spirometry administered by trained dive store personnel. Spirometry instrumentation provided immediate feedback regarding test quality.

RESULTS: Of 8365 eligible divers during the study period (November 1997-March 1999), 668 enrolled and completed questionnaires. Of those completing questionnaires, 46% reported a history of smoking, 13% were current smokers, 15% wheezed, 6% had asthma, 4% used bronchodilators, and 3% took oral steroids. Of 654 completing spirometry, 231 had acceptable spirometry quality and complete questionnaires. By forced expiratory volume in 1 second/forced vital capacity, 10% had mild, 1.7% had moderate, and 0.4% had severe airflow obstruction.

CONCLUSIONS: The prevalence of airflow obstruction was 6% to 15% by report and 12% by spirometry, approximating the combined prevalence of asthma and chronic obstructive pulmonary disease in the general population. Study limitations include possible self-selection and low enrollment rate. Prospective lung function testing can be conducted at remote sites using nonmedical personnel as "testers." This study could guide future investigations to determine if asthma is a risk factor for decompression illness.

Assessing lung function and respiratory health in schoolchildren as a means to improve local environmental conditions.

J Public Health Policy. 2009 Jul;30(2):144-57. Hutter HP, Borsoi L, Wallner P, Moshammer H, Kundi M. Institute of Environmental Health, Center for Public Health, Medical University of Vienna, Kinderspitalgasse 15, A-1095 Vienna, Austria.

In response to the World Health Organization Children's Environment and Health Action Plan for Europe (CEHAPE), a town near Vienna initiated a health survey of schoolchildren. To create recommendations for the community's decision makers, the health survey tried to identify the environmental factors influencing the respiratory health of children. The survey consisted of a questionnaire and spirometry. For 186 of 207 children of first and second grade, parents consented to include their children and answered a questionnaire. Spirometry was performed in 177 children. Results of lung function testing revealed that lung function was significantly reduced in children with visible mould infestation at home and living on a street with frequent lorry traffic. Larger family size and living in a rural area had positive effects on lung function. Our study provides an example for a feasible strategy to provide local decision makers with recommendations based on scientific evidence and actual observations and to help them implement measures in accordance with CEHAPE.

Diagnostic accuracy of spirometry in primary care.

BMC Pulm Med. 2009 Jul 10;9(1):31. Schneider A, Gindner L, Tilemann L, Schermer T, Dinant GJ, Meyer FJ, Szecsenyi J.

BACKGROUND: To evaluate the sensitivity, specificity and predictive values of spirometry for the diagnosis of chronic obstructive pulmonary disease (COPD) and asthma in patients suspected of suffering from an obstructive airway disease (OAD) in primary care.

METHODS: Cross sectional diagnostic study of 219 adult patients attending 10 general practices for the first time with complaints suspicious for OAD. All patients underwent spirometry and structured medical histories were documented. All patients received whole-body plethysmography (WBP) in a lung function laboratory. The reference standard was the Tiffeneau ratio (FEV1/VC) received by the spirometric maneuver during examination with WBP. In the event of inconclusive results, bronchial provocation was performed to determine bronchial hyper-responsiveness (BHR). Asthma was defined as a PC20 fall after inhaling methacholine concentration <= 16mg/ml.

RESULTS: 90 (41.1%) patients suffered from asthma, 50 (22.8%) suffered from COPD, 79 (36.1%) had no OAD. The sensitivity for diagnosing airway obstruction in COPD was 92% (95%CI 80-97); specificity was 84% (95%CI 77-89). The positive predictive value (PPV) was 63% (95%CI 51-73); negative predictive value (NPV) was 97% (95%CI 93-99). The sensitivity for diagnosing airway obstruction in asthma was 29% (95%CI 21-39); specificity was 90% (95%CI 81-95). PPV was 77% (95%CI 60-88); NPV was 53% (95%CI 45-61).

CONCLUSIONS: COPD can be estimated with high diagnostic accuracy using spirometry. It is also possible to rule in asthma with spirometry. However, asthma can not be ruled out only using spirometry. This diagnostic uncertainty leads to an overestimation of asthma presence. Patients with inconclusive spirometric results should be referred for nitric oxide (NO) - measurement and/or bronchial provocation if possible to guarantee accurate diagnosis.

The FEF25-75 and its decline as a predictor of methacholine responsiveness in children.

J Asthma. 2009 May;46(4):375-81 Drewek R, Garber E, Stanclik S, Simpson P, Nugent M, Gershan W. Department of Pediatric Pulmonology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.

BACKGROUND: Methacholine challenge (MCC) is an important diagnostic tool for asthma, especially in patients in whom routine pulmonary function testing (PFT) is normal or equivocal. The basis for a positive test per American Thoracic Society (ATS) guidelines is a methacholine concentration < or = 16 mg/mL that causes a 20% decrease in forced expiratory volume in 1 second (FEV(1)) (termed the PC20 for FEV(1)). There is little information in the medical literature that utilizes other flow rates during MCC, including small airway function parameters such as the forced expiratory flow rate 25-75% (FEF(25-75)). We question whether the FEF(25-75) may be a useful parameter to monitor during MCC and whether it may be predictive of a positive MCC.

HYPOTHESIS: The baseline FEF(25-75) and its decline during a MCC are useful in the interpretation of a MCC. METHODS: We retrospectively analyzed all MCC performed at this institution between December 1998 and December 2006. Parameters reviewed included age, gender, race, weight, height, baseline PFT data including FVC, FEV(1), FEF(25-75), and forced expiratory time, methacholine PC20 for FEV(1), the relative changes from baseline for FEV(1) and FEF(25-75) during the MCC, and clinical symptoms during the MCC.

RESULTS: A total of 532 MCC were completed during the 8-year study period in children 4 to 18 years of age. A total of 203 MCC (38%) were positive (defined by a PC20 < or = 16 mg/mL) and 329 studies were negative (62%). The baseline % predicted FEF(25-75) in positive MCC was 82.4 +/- 21.9 vs. 98.7 +/- 21.3 in the negative studies (p < 0.001). The FEF(25-75)/FVC ratio in positive MCC was 0.82 +/- 0.21 vs. 0.97 +/- 0.23 in negative studies (p < 0.001). In the positive MCC, the decrease in FEF(25-75) was much faster and of much greater degree than in the negative challenges. When a significant reduction in FEF(25-75) was defined as greater than 10% by the second concentration of methacholine (0.25 mg/mL), the sensitivity for a positive MCC was 63%, the specificity was 71%, the positive predictive value was 57%, and the negative predictive value was 76%. A comparison of the baseline FEF(25-75) to the PC20 for the positive MCCs revealed no statistical significance.

CONCLUSIONS: The FEF(25-75) and its decline during a MCC appear to be useful information and potentially predictive of a positive MCC. We suggest that the forced expiratory flow rate 25-75% (FEF(25-75)) be considered as an adjunct to the FEV(1) to define a positive study.

Should FEV1/FEV6 replace FEV1/FVC ratio to detect airway obstruction? A metaanalysis.

Chest. 2009 Apr;135(4):991-8 Jing JY, Huang TC, Cui W, Xu F, Shen HH. Respiratory Department, Second Affiliated Hospital, School of Medicine, Zhejiang University, Jiefang Road #88, Hangzhou, Zhejiang Province, People's Republic of China.

BACKGROUND: The conventional FEV(1)/FVC test is the "gold standard" to quantitate airway obstruction, but elderly subjects or patients with severe respiratory diseases quite frequently cannot make such an effort. Many studies have investigated the usefulness of FEV(1)/forced expired volume in 6 s (FEV(6)) measurements as an alternative for FEV(1)/FVC for diagnosis of airway obstruction. We conducted a meta-analysis to determine the FEV(1)/FEV(6) substitute for FEV(1)/FVC in the diagnosis of airway obstruction.

METHODS: After a systematic review of all-language studies, sensitivity, specificity, and other measures of accuracy of FEV(1)/FEV(6) in the diagnosis of airway obstruction were pooled using random-effects models. Summary receiver operating characteristic curves were used to summarize overall test performance.

RESULTS: Eleven studies met our inclusion criteria. The summary estimates for FEV(1)/FEV(6) in the diagnosis of airway obstruction in the studies included were as follows: sensitivity, 0.89 (95% confidence interval [CI], 0.83 to 0.93); specificity, 0.98 (95% CI, 0.95 to 0.99); positive likelihood ratio, 45.46 (95% CI, 18.26 to 113.21); negative likelihood ratio, 0.11 (95% CI, 0.08 to 0.17); diagnostic odds ratio, 396.02 (95% CI, 167.32 to 937.31); and diagnostic score, 5.98 (95% CI, 5.12 to 6.84).

CONCLUSIONS: FEV(1)/FEV(6) is a sensitive and specific test for the diagnosis of airway obstruction. FEV(1)/FEV(6) can be used as a valid alternative for FEV(1)/FVC in the diagnosis of airway obstruction.

Healthcare for obstructive lung disease in an industrial spirometry surveillance program

J Occup Environ Med. 2009 Mar;51(3):336-42. Gulati M, Slade MD, Fiellin MG, Cullen MR. Yale University School of Medicine, New Haven, Conn., USA.

OBJECTIVE: The efficacy of workplace spirometry surveillance programs is unclear. We examine whether aluminum industry workers with airflow obstruction (AO) received health care for obstructive lung disease.

METHODS: We performed a cross sectional analysis over 7 years of 6821 aluminum production workers. The primary outcome was the association between obstructive lung disease insurance claims and the presence of AO. We also examined whether the presence of claims was associated with increasing AO severity.

RESULTS: Although workers with AO more frequently had claims, 60% of workers with AO, most frequently those with mild and borderline obstruction, had no claim.

CONCLUSIONS: Workers with AO, particularly borderline and mild obstruction, frequently do not receive health care despite respiratory surveillance. Further investigation is needed to determine if workers with undiagnosed AO are symptomatic or have accelerated losses in lung function over time.

Portable spirometry during acute exacerbations of asthma in children

J Asthma. 2009 Mar;46(2):122-5. Langhan ML, Spiro DM. Department of Pediatrics, Section of Pediatric Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA.

BACKGROUND: Spirometry is the gold standard for assessment of asthma and is objective and non-invasive. This is a pilot study to evaluate whether portable spirometry can be successfully performed by children in the pediatric emergency department for acute exacerbations of asthma.

METHODS: We enrolled children more than 6 years of age presenting to an urban pediatric emergency department with a history of asthma during an acute exacerbation. On arrival and after each bronchodilator treatment, vital signs and a clinical score were recorded. Portable spirometry was then performed. Attempts were continued until acceptable and reproducible measurements were obtained or until the patient was unable to perform further attempts. Outcomes included success at spirometry and correlation of spirometry with clinical signs.

RESULTS: Thirty-four subjects were enrolled with a median age of 12 years. Ninety-one percent of subjects completed at least one attempt at spirometry. Seventy-three percent of all spirometry attempts were reproducible. Portable spirometry demonstrated increased severity of the exacerbation in comparison to clinical signs and peak expiratory flow. Percent of predicted forced expiratory volume in 1 second, ratio of forced expiratory volume in 1 second to forced vital capacity, and peak expiratory flow are all poorly correlated with degree of wheezing, clinical score, respiratory rate, and oxygen saturation (r < 0.5).

CONCLUSION: Portable spirometry can be successfully performed by children with acute exacerbations of asthma in the emergency department and demonstrated greater degrees of airway obstruction than did clinical signs. Spirometry provides objective, non-invasive measurements of the severity of airway obstruction in the emergency department for children with acute exacerbations of asthma.

A Method to Derive Lower Limit of Normal for the FEV1/Forced Expiratory Volume at 6 s of Exhalation Ratio From FEV1/FVC Data.

Chest. 2009 Feb;135(2):408-18 Capderou A, Berkani M, Becquemin MH, Zelter M. CCML, 133 Ave de la Résistance, 92350, Le Plessis Robinson, France.

BACKGROUND: The FEV(1)/forced expiratory volume at 6 s of exhalation (FEV(6)) ratio has been suggested as a surrogate for the FEV(1)/FVC ratio to detect airway obstruction. Current guidelines require that lower limit of normal (LLN) values be implemented to detect an abnormality. In most populations, LLN equations are available for the FEV(1)/FVC ratio but not for the FEV(1)/FEV(6) ratio. We propose a simplified statistical method to approximate reasonably the FEV(1)/FEV(6) LLN in a population for which FEV(1)/FVC LLN values are already available.

METHODS: Spirometric data were collected from 8,273 European patients aged 20 to 85 years. We computed by receiver operator characteristics analysis the best-fit cutoff FEV(1)/FEV(6) ratio distributions in function of age and sex for obstruction as diagnosed from FEV(1)/FVC LLN values obtained from the relevant reference equations for subjects aged 20 to 70 and 65 to 85 years. We compared the diagnosis of obstruction obtained from these surrogate equations against the reference diagnosis made by FEV(1)/FVC LLN.

RESULTS: Misdiagnoses from the surrogate equations (FEV(1)/FEV(6) = 75.58 - 0.11 x age for men, and 77.70 - 0.09 x age for women aged 20 to 70 years) were all within 2.3 +/- 2.0% of the reference LLN. Similar results were found in the group aged 65 to 85 years.

CONCLUSIONS: The study confirms the feasibility of computing a surrogate LLN equation for the FEV(1)/FEV(6) ratio in a population for which the accepted FEV(1)/FVC LLN already exists. Surrogate equations for FEV(1)/FEV(6) ratio may extend its use for screening and case finding when simplified spirometry is needed.

New reference equations for forced spirometry in elderly persons

Respir Med. 2009 Apr;103(4):621-8 Smolej Narancić N, Pavlović M, Zuskin E, Milicić J, Skarić-Jurić T, Barbalić M, Rudan P. Institute for Anthropological Research, Zagreb, Croatia.

This study identifies equations for predicting lung function values in a population of 'healthy', nonsmoking older adults, explores the applicability of prediction equations derived from younger adult populations to the elderly, and examines the justification of developing population-specific reference equations for older age.

FVC, FEV(1), and PEF were measured according to the ATS criteria in 651 ambulatory volunteers aged 65-86 years, representative for the Croatian Mediterranean population. After exclusion of eversmokers and subjects with respiratory symptoms and/or diseases, 261 asymptomatic subjects were included in the analyses. Sex-specific reference equations and lower limits of normal were derived by using a linear model with height and age as predictors. The equations for lung volumes were more reliable than those for PEF.

The new FVC and FEV(1) reference equations were found to be in agreement with those generated previously from primarily young and middle-aged adults. The latter perform reasonably well when extrapolated for ages beyond 65 years. Cross-validation of reference equations existing for the elderly showed that almost all European and U.S. equations systematically overpredicted lung function parameters in the Croatian sample. The overpredictions in means ranged between 14% and 34% for FVC and between 10% and 20% for FEV(1). Differences increased towards the extremes of distribution, which rendered these equations inappropriate for our elderly subjects. They identified FVC in 25-55% of the subjects as being below the lower limit of normal.

The observed discrepancies strongly support the establishment of age- and population-specific reference equations for lung function assessment in older age.

Health-related quality of life in young adults with asthma

Respir Med. 2009 May 27. Sundberg R, Palmqvist M, Tunsäter A, Torén K. Department of Respiratory Medicine and Allergology, Sahlgrenska University Hospital, S-413 45 Göteborg, Sweden.

BACKGROUND: The aim was to study health-related quality of life, five years after an intervention study among young adults with asthma.

METHOD: The design was a follow-up study of a cohort of young adults with asthma (n=64) and 248 general population controls. Both groups were investigated at follow-up with a respiratory questionnaire and one generic quality-of-life instrument, and the asthma cohort also completed one-asthma-specific questionnaire. The material was analyzed with multivariate models.

RESULTS: Female gender and low FEV (1) at baseline predicted both a decline during follow-up and a low quality of life at follow-up. The asthma cohort and controls scored similarly regarding generic quality of life. However, in the asthma cohort, females scored significantly lower in the physical dimension of the generic instrument, especially in the domain of general health.

CONCLUSIONS: There is an association between low FEV(1) and a decline in quality of life among young adults with asthma, i.e. low FEV(1) predicts a decline in quality of life during a five-year period. Young females with asthma seem to have lower quality of life compared with young males with asthma.

Validation of "lung age" measured by spirometry and handy electronic FEV1/FEV6 meter in pulmonary diseases.

Intern Med. 2009;48(7):513-21. Toda R, Hoshino T, Kawayama T, Imaoka H, Sakazaki Y, Tsuda T, Takada S, Kinoshita M, Iwanaga T, Aizawa H. Division of Respirology, Neurology and Rheumatology, Department of Medicine, Kurume University School of Medicine, Kurume.

OBJECTIVE: The concept of "lung age" is thought to be useful for understanding pulmonary function. In this study, we validated "lung age" to detect pulmonary function abnormalities in pulmonary diseases.

METHODS: We used both spirometry and an electronic FEV(1)/FEV(6) meter (FEV(6) meter) to perform pulmonary function tests. We evaluated the sensitivity and specificity of FEV(6) and FEV(1)/FEV(6), and calculated "lung age" in Japanese subjects including those with chronic obstructive pulmonary disease (COPD), bronchial asthma (BA), and interstitial lung diseases (ILD).

RESULTS: FEV(1) (spirometer) vs. FEV(1) (FEV(6) meter), FVC (spirometer) vs. FEV(6) (FEV(6) meter), and FEV(1)/FVC (spirometer) vs. FEV(1)/FEV(6) (FEV(6) meter) measurements were all significantly and closely correlated. For the difference of "lung age" and "actual age", the area under the receiver operating characteristic curve (ROC-AUC) for detecting obstructive impairment was 0.807 (spirometer) and 0.772 (FEV(6) meter), respectively. The corresponding ROC-AUC for detecting restrictive impairment was 0.891 and 0.836, respectively, and that for detecting both obstructive and restrictive impairment was 0.918 and 0.853, respectively. For detection of both obstructive and restrictive impairment, the difference of the "lung age" and "actual age" cut-off value, corresponding to the greatest sum of sensitivity and specificity, was 18.3 years (spirometer) and 19.8 years (FEV(6) meter), respectively. The sensitivity was 0.783 (spirometer) and 0.801 (FEV(6) meter), and the specificity was 0.895 (spirometer) and 0.790 (FEV(6) meter), respectively.

CONCLUSION: "Lung age" can provide an easy interpretation of the results, and can detect pulmonary function abnormalities in pulmonary diseases.

Using the lower limit of normal for the FEV1/FVC ratio reduces the misclassification of airway obstruction

Thorax. 2008 Dec;63(12):1046-51. Swanney MP, Ruppel G, Enright PL, Pedersen OF, Crapo RO, Miller MR, Jensen RL, Falaschetti E, Schouten JP, Hankinson JL, Stocks J, Quanjer PH. Respiratory Physiology Laboratory, Christchurch Hospital, Private Bag 4710, Christchurch 8140, New Zealand.

AIM: The prevalence of airway obstruction varies widely with the definition used.

OBJECTIVES: To study differences in the prevalence of airway obstruction when applying four international guidelines to three population samples using four regression equations.

METHODS: We collected predicted values for forced expiratory volume in 1 s/forced vital capacity (FEV(1)/FVC) and its lower limit of normal (LLN) from the literature. FEV(1)/FVC from 40 646 adults (including 13 136 asymptomatic never smokers) aged 17-90+years were available from American, English and Dutch population based surveys. The prevalence of airway obstruction was determined by the LLN for FEV(1)/FVC, and by using the Global Initiative for Chronic Obstructive Lung Disease (GOLD), American Thoracic Society/European Respiratory Society (ATS/ERS) or British Thoracic Society (BTS) guidelines, initially in the healthy subgroup and then in the entire population.

RESULTS: The LLN for FEV(1)/FVC varied between prediction equations (57 available for men and 55 for women), and demonstrated marked negative age dependency. Median age at which the LLN fell below 0.70 in healthy subjects was 42 and 48 years in men and women, respectively. When applying the reference equations (Health Survey for England 1995-1996, National Health and Nutrition Examination Survey (NHANES) III, European Community for Coal and Steel (ECCS)/ERS and a Dutch population study) to the selected population samples, the prevalence of airway obstruction in healthy never smokers aged over 60 years varied for each guideline: 17-45% of men and 7-26% of women for GOLD; 0-18% of men and 0-16% of women for ATS/ERS; and 0-9% of men and 0-11% of women for BTS. GOLD guidelines caused false positive rates of up to 60% when applied to entire populations.

CONCLUSIONS: Airway obstruction should be defined by FEV(1)/FVC and FEV(1) being below the LLN using appropriate reference equations.

Prevalence of chronic obstructive pulmonary diseases in general clinics in terms of FEV1/FVC.

Int J Clin Pract. 2009 Feb;63(2):269-74. Fukahori S, Matsuse H, Takamura N, Hirose H, Tsuchida T, Kawano T, Fukushima C, Mizuta Y, Kohno S. Second Department of Internal Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan.

BACKGROUND: The prevalence of chronic obstructive pulmonary disease (COPD) continues to increase all over the world. Nonetheless, COPD is often misdiagnosed in general clinics because of insufficient use of spirometry.

OBJECTIVES: To estimate the prevalence of COPD in general clinics in Japan, we performed spirometry to screen patients who consulted general clinics.

METHODS: Patients 40 years of age and older who consulted clinics in Nagasaki Prefecture, Japan, for non-respiratory diseases and who met certain inclusion criteria had their airflow limitation measured by spirometry. We defined COPD as forced expiratory volume in the first second (FEV(1)) over forced vital capacity (FVC) (FEV(1)/FVC) of < 70% in patients without active pulmonary disease, including physician-diagnosed asthma.

RESULTS: Of the 1424 patients included in the study, 193 (13.6%) showed airflow limitation. Airflow limitation was significantly related to older age, male gender and cumulative pack-years. FEV(1)/FVC in patients with hypertension and chronic hepatitis were significantly lower than in patients without these diseases when adjusted for age, gender and pack-years.

CONCLUSIONS: We showed that there are potentially a number of cases with COPD that are undiagnosed by general physicians in Japan. Measuring airflow limitation by spirometry in smokers with coexisting diseases, such as hypertension and chronic hepatitis, may be very beneficial because COPD is thought to be a systemic disease. The distribution of spirometers to general clinics is definitely needed to detect undiagnosed COPD.

A Method to Derive Lower Limit of Normal for the FEV1/Forced Expiratory Volume at 6 s of Exhalation Ratio From FEV1/FVC Data.

Chest. 2009 Feb;135(2):408-18. Capderou A, Berkani M, Becquemin MH, Zelter M. CCML, 133 Ave de la Résistance, 92350, Le Plessis Robinson, France.

FEV1/FVC and FEV1 for the assessment of chronic airflow obstruction in prevalence studies: do prediction equations need revision?

Respir Med. 2008 Nov;102(11):1568-74. Roche N, Dalmay F, Perez T, Kuntz C, Vergnenègre A, Neukirch F, Giordanella JP, Huchon G. Université Paris René Descartes, Service de Pneumologie et Réanimation, Hôpital Hôtel-Dieu, Paris, France.

Little is known on the long-term validity of reference equations used in the calculation of FEV(1) and FEV(1)/FVC predicted values. This survey assessed the prevalence of chronic airflow obstruction in a population-based sample and how it is influenced by: (i) the definition of airflow obstruction; and (ii) equations used to calculate predicted values.

Subjects aged 45 or more were recruited in health prevention centers, performed spirometry and fulfilled a standardized ECRHS-derived questionnaire. Previously diagnosed cases and risk factors were identified. Prevalence of airflow obstruction was calculated using: (i) ATS-GOLD definition (FEV(1)/FVC<0.70); and (ii) ERS definition (FEV(1)/FVC<lower limit of normal) with European Community for Coal and Steel (ECCS) reference equations and with predicted values derived from the presumably normal fraction of the studied population. A total of 5008 subjects (4764 adequate datasets) were studied.

Prevalence of airflow obstruction was 8.71% with ATS-GOLD definition and 6.40% with ERS definition and ECCS predicted values. The ERS definition with predicted values derived from the studied population provided a 7.96% prevalence. Severity distribution of airflow obstruction was also influenced by the equation used to calculate predicted values of FEV(1).

Prevalence and severity of chronic airflow obstruction are influenced not only by the definition used but also by equations used to calculate predicted FEV(1)/FVC and FEV(1) values. These equations likely need to be periodically revised.

Diagnostic assessments of spirometry and medical history data by respiratory specialists supporting primary care: are they reliable?

Prim Care Respir J. 2009 Jan 12 Lucas AE, Smeenk FJ, van den Borne BE, Smeele IJ, van Schayck CP. Research Institute Caphri, Department of General Practice, Maastricht University, Maastricht, The Netherlands.

AIM: To determine the intra- and inter-observer reliability of respiratory specialists' diagnostic assessments of spirometry and written medical history data obtained from primary care.

METHOD: Five respiratory specialists assessed spirometry data and the history of 156 patients randomly selected from referrals to an asthma/COPD-service. The inter-observer reliability was evaluated. After six months, all specialists repeated the assessments and the intraobserver reliability was evaluated.

RESULTS: The diagnostic assessments for all patients had reasonable intra- and inter-observer reliability, resulting in a Cohen's kappa (kappa) of 0.67 and 0.66 respectively. The intra-observer reliability for assessing the need for additional diagnostic examinations had an average kappa 0.56 for new patients and an average kappa 0.39 for follow-up examinations. The assessments of clinical stability in follow-up patients - on which therapeutic advice was based - were inconsistent.

CONCLUSION: GPs who are reluctant to perform or interpret spirometry themselves may be supported diagnostically by respiratory specialists in an asthma/COPD-service. The reliability of this advice varies. More appropriate criteria for assessing clinical stability in patients with asthma and COPD are necessary to improve the reliability of the therapeutic advice.

Forced inspiratory flow volume curve in healthy young children.

Pediatr Pulmonol. 2009 Jan 13;44(2):105-111 Vilozni D, Efrati O, Barak A, Yahav Y, Augarten A, Bentur L. The Pediatric Pulmonary Unit, The Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center Tel-HaShomer, Affiliated with the Sackler Medical School, Tel Aviv University, Tel Aviv, Israel.

INTRODUCTION: Spirometry testing should include both expiratory and inspiratory measurements. Inspiratory forced maneuvers can demonstrate extrathoracic airway abnormalities, of which various symptoms may suggest asthma. However, the inspiratory portion of the forced flow/volume maneuver in young healthy children has not yet been described.

OBJECTIVES: To document and analyze the forced inspiratory flow volume curve indices in healthy young children.

SETTINGS AND PARTICIPANTS: Healthy preschool children (age 2.5-6.5 years) from community kindergartens around Israel.

METHODS: The teaching method included multi-target, interactive spirometry games and accessory games for inspiration (e.g., inspiratory whistle).

RESULTS: One hundred and fourteen out of a total of 157 children performed duplicate full adequate inspiratory maneuvers. Repeatability between two maneuvers was 5.6%, 4.0%, 5.1%, 7.3% for inspiratory capacity (IC), forced inspiratory vital capacity (FIVC), peak inspiratory flow (PIF), and mid inspiratory flow (FIF50). Inspiratory flow indices were significantly lower than the expiratory flow indices. The time to reach PIF was significantly longer (mean +/- SD; 229 +/- 21 msec) than the time to reach peak expiratory flow (92 +/- 8 msec; P < 0.0001). The shape of the inspiratory curve was parabolic and did not vary with age. The formed predicted equations were in agreement with the extrapolated values for older healthy children.

CONCLUSIONS: The majority of healthy young children can perform reliable maximum inspiratory flow volume curves. Our results provide a framework of reference equations for maximum inspiratory flow volume curve in the young children.

Quality of life measured by the St George's Respiratory Questionnaire and spirometry

Eur Respir J. 2009 Jan 22. Weatherall M, Marsh S, Shirtcliffe P, Williams M, Travers J, Beasley R. Wellington, New Zealand.

We aimed to determine if the criteria for the diagnosis of COPD and its classification by severity as recommended by the Global Initiative for Obstructive Lung Disease are supported by measurements of respiratory health-related quality of life.

A community-based sample of adults aged 25 to 75 years had pre- and post-bronchodilator spirometry and completed the St George's Respiratory Questionnaire (SGRQ). Loess scatter plot smoothers of SGRQ versus post-bronchodilator FEV1/FVC ratio and post-bronchodilator FEV1 as percent predicted together with receiver operating characteristic (ROC) curve analysis were used to determine the relationship between spirometric variables and clinically important differences in the SGRQ score.

The scatter plot smoother and ROC curve analyses supported the value of 0.7 for post-bronchodilator FEV1/FVC, which was about four units higher than the nadir of the SGRQ. To represent a distance of eight units on SGRQ, the cut-points for post-bronchodilator FEV1 that delimit COPD severity stages were 80%, 60% and 40% predicted.

To diagnose COPD the use of a post-bronchodilator FEV1/FVC of 0.7 is supported by health-related quality of life measurements. There may be advantages in using FEV1 cut-points of 80%, 60% and 40% predicted for the classification of mild, moderate and severe COPD, similar to the approach recommended for asthma.

Office Spirometry In Detection And Diagnosis Of Obstructive Airmay Disease In Primary Care

Dr. Johan Buffels, Doctoral Thesis in Medical Sciences – Leuven 2009 Katholieke Universiteit Leuven, Group Biomedical Sciences, Faculty of Medicine, Department of Public Health, Academic Centre of General Practice Chapter 1

The accuracy of office spirometry performed by trained primary care physicians using the Spirobank handheld spirometer

Research questions

1. What is the accuracy of spirometry performed with the MIR Spirobank? How do the measurements obtained with this spirometer rate to those from pneumotachograph (Jaeger MasterScope) in a pulmonary function laboratory

2. How accurately can trained primary-care physicians perform spirometrie by means of a portable electronic spirometer and how do the measurements obtained by four different primary-care physicians using their own devices relate to each other

Conclusion

The Spirobank spirometer performed very well compared with the Jaeger MasterScope in a laboratory environment, and trained primary-care physicians managed to generate accurate measurements with this equipment. The study also showed that in practice other sources of errors such as timing of the test will be much more important than the small measurement errors by the devise itself. Within a research design, patients are rarely or never examined at the same moment of the day. Thus, the Spirobank device seems to be appropriate for research purposes if the standardized protocol is used correctly and the acceptability criteria are respected.

Reference values for peak flow and FEV1 variation in healthy schoolchildren using home spirometry.

Eur Respir J. 2008 Nov;32(5):1262-8. Brouwer AF, Roorda RJ, Duiverman EJ, Brand PL. Princess Amalia Children's Clinic, Isala Clinics, Zwolle, The Netherlands.

Current reference values for diurnal peak flow variation in healthy children (median 8.2%; 95th percentile 31%) are so high that considerable overlap exists with those of asthmatic children. These values have been obtained using written peak flow diaries, which are unreliable. The aim of the present study was to obtain reliable reference values for the variation in peak flow and forced expiratory volume in one second (FEV(1)) in healthy schoolchildren using home spirometry with electronic data storage. Healthy schoolchildren (n = 204; 100 males) aged 6-16 yrs measured their peak flow and FEV(1) twice daily for 2 weeks using an electronic home spirometer. The variation in peak flow and FEV(1) were calculated as a diurnal amplitude as a percentage of the day's mean. The mean peak flow variation was 6.2% (95th percentile 12.3%) and the mean FEV(1) variation was 5.7% (95th percentile 11.8%). Using home spirometry with electronic data storage, healthy schoolchildren show considerably less peak flow and forced expiratory volume in one second variation than previously reported on the basis of written peak flow diaries. Being the 95th percentiles of the distributions in healthy children, a peak flow variation of 12.3% and an forced expiratory volume in one second variation of 11.8% are suggested as cut-off values for disease when using home spirometry.

Help smokers quit: Tell them their "lung age"

J Fam Pract. 2008 Sep;57(9):584-586 Deane K, Stevermer JJ, Hickner J. Department of Family and Community Medicine, University of Missouri, Columbia, MO USA.

Perform spirometry on patients who smoke-even if they're asymptomatic-and show them their lung age-that is, the average age of a nonsmoker with a forced expiratory volume at 1 second (FEV1) equal to theirs. Doing so can help patients kick the habit.

Diagnostic certainty, co-morbidity and medication in a primary care population with presumed airway obstruction: the DIDASCO2 study.

Prim Care Respir J. 2008 Aug 13 Buffels J, Degryse J, Liistro G. Research Associate and General Practitioner, Department of General Practice, K.U.Leuven, Leuven, Belgium.

STUDY OBJECTIVES: To document the rate of diagnostic certainty, co-morbidity and use of medication in patients with presumed obstructive airway disease (OAD) in a primary care setting.

METHODS: Twenty-six general practitioners (GPs) were asked to select the last 50 contacts with patients older than 40 years of age who were taking bronchodilators and/or inhaled corticosteroids or who had known OAD. After reviewing their medical data on file, the GPs gave their diagnostic opinion and rated their certainty about the diagnosis using a Likert-type scale.

RESULTS: Analysis of 1126 files revealed that in at least 523 patients (46.4%), a diagnostic work-up was judged necessary. The GPs judged that 6% of the patients had no OAD. Less than 33% of the study population underwent spirometry during the two years preceding the survey. The number of co-morbid conditions was on average 2.2 for patients with asthma and 3.2 for patients with COPD. Patients with presumed COPD took significantly more drugs (mean, 5.1; 95% CI, 4.8-5.3) than did patients with other diagnostic labels (mean, 4.6 95%; CI, 4.4-4.8).

CONCLUSIONS: We confirmed the underuse of spirometry as a diagnostic tool in presumed airway obstruction in primary care. Nearly half of the patients older than 40 years who were taking bronchodilators and/or inhaled corticosteroids needed a diagnostic work-up. This population had a high prevalence of co-morbidity and polypharmacy.

Primary care spirometry

Eur Respir J. 2008 Jan;31(1):197-203 Derom E, van Weel C, Liistro G, Buffels J, Schermer T, Lammers E, Wouters E, Decramer M. Dept of Respiratory Diseases, Ghent University Hospital, De Pintelaan 185, B-9000 Ghent, Belgium.

Primary care spirometry is a uniquely valuable tool in the evaluation of patients with respiratory symptoms, allowing the general practitioner to diagnose or exclude chronic obstructive pulmonary disease (COPD), sometimes to confirm asthma, to determine the efficacy of asthma treatment and to correctly stage patients with COPD. The use of spirometry for case finding in asymptomatic COPD patients might become an option, once early intervention studies have shown it to be beneficial in these patients. The diagnosis of airway obstruction requires accurate and reproducible spirometric measurements, which should comply with the American Thoracic Society (ATS)/European Respiratory Society (ERS) guidelines. Low acceptability of spirometric manoeuvres has been reported in primary care practices. This may hamper the validity of the results and affect clinical decision making. Training and refresher courses may produce and maintain good-quality testing, promote the use of spirometric results in clinical practice and enhance the quality of interpretation. Softening the stringent ATS/ERS criteria could enhance the acceptability rates of spirometry when used in a general practice. However, the implications of potential simplifications on the quality of the data and clinical decision making remain to be investigated. Hand-held office spirometers have been developed in recent years, with a global quality and user-friendliness that makes them acceptable for use in general practices. The precision of the forced vital capacity measurements could be improved in some of the available models.

Geographic variation of spirometry use in newly diagnosed COPD

Chest. 2008 Jul;134(1):38-45 Joo MJ, Lee TA, Weiss KB. Center for Management of Complex Chronic Care, Hines VA Hospital, Hines, IL, USA.

BACKGROUND: Studies indicate that not all physicians in clinical practice use spirometry routinely in the diagnosis of COPD. Understanding the patterns of spirometry use across geographic regions in patients with newly diagnosed COPD may help to identify the factors associated with the use of spirometry and to improve the quality of COPD care. The objective of this study was to characterize the regional variation in spirometry use for patients with newly diagnosed COPD using the Healthcare Effectiveness Data and Information Set (HEDIS) 2006 spirometry performance measure.

METHODS: We identified patients within the Veteran Health Administration who were >42 years of age who had received a new diagnosis of COPD between July 2003 and June 2004. The date of the COPD diagnosis was the index date. Spirometry use from 760 days prior to the index date to 180 days after the index date was identified. The Veterans Integrated Service Networks (VISNs) was used as the geographic unit for comparison.

RESULTS: Of the 93,724 patients included in the study, 36.7% underwent spirometry during the study period. Using the largest VISN as the referent, there was more than a threefold difference in the adjusted odds ratios (AORs) for spirometry use between the regions with the lowest use (AOR, 0.52; 95% confidence interval [CI], 0.48 to 0.57) and the highest use (AOR, 1.61; 95% CI, 1.46 to 1.78).

CONCLUSIONS: Overall, the use of spirometry in patients with newly diagnosed COPD was low using the new HEDIS spirometry measure with a significant regional variation comprising a more than threefold difference between the regions with the lowest and highest rates of spirometry use.

Spirometry Quality-Control Strategies in a Multinational Study of the Prevalence of Chronic Obstructive Pulmonary Disease.

Respir Care. 2008 Aug;53(8):1019-1026. Pérez-Padilla R, Vázquez-García JC, Márquez MN, Menezes AM; on behalf of the PLATINO Group. Instituto Nacional de Enfermedades Respiratorias, Tlalpan 4502, Distrito Federal, Ciudad de México, México 14080.

We report the characteristics of a centralized spirometry quality-control program developed for a population-based survey of the prevalence of chronic obstructive pulmonary disease in 5 cities: São Paulo, Brazil; México City, México; Montevideo, Uruguay; Santiago, Chile; and Caracas, Venezuela (the Latin American Project for the Investigation of Obstructive Lung Diseases [PLATINO]).

METHODS: We developed and used a 3-level quality-control system. Level 1: The spirometer used in the survey (EasyOne), gives quality-control messages to the user/clinician. All the spirometry technicians were trained by the same team, with the aim of meeting what became the 2005 spirometry quality criteria of the American Thoracic Society/European Respiratory Society (ATS/ERS). Level 2: In each of the 5 cities a local supervisor identified poor-quality spirometries that needed to be repeated. Level 3: Once a week during the survey, all spirometry results were sent via e-mail to the study's quality-control center in México City for review and feedback.

RESULTS: In the overall totals at the end of the study, 94% of the 5,315 subjects had spirometries that met the 1994 ATS quality criteria, and 89% met the 2005 ATS/ERS criteria. In their overall totals at the end of the study, 90% of the 64 spirometry technicians were successful in getting 86% of their subjects to meet the 1994 ATS criteria, and got 75% of their subjects to meet the 2005 ATS/ERS criteria. In the first 10 subjects they tested, 90% of the 64 spirometry technicians were successful in getting 70% of their subjects to meet the 1994 ATS criteria, and got 60% of their subjects to meet the 2005 ATS/ERS criteria.

CONCLUSIONS: Standardization of equipment, training, and supervision of spirometry is essential in a multinational spirometry survey. Centralized quality control can be done via e-mail with good reliability and low cost.

Electronic feedback messages for home spirometry lung transplant recipients.

Heart Lung. 2008 Jul-Aug;37(4):299-307. Pangarakis SJ, Harrington K, Lindquist R, Peden-McAlpine C, Finkelstein S. School of Nursing, University of Minnesota, Minneapolis, Minnesota 55455, USA.

BACKGROUND: Lung transplant recipients use a telemedicine device known as the electronic home spirometer to gauge the function of their lungs when they are away from the hospital or clinic setting. Health care providers review transmitted spirometry tests and user's symptom responses to detect early signs of infection and or rejection. Current home spirometry users have questions, concerns, and preferences about spirometry that may influence their daily adherence. A spirometer with two-way electronic messaging has the capability to deliver feedback messages to potentially address these questions and concerns.

OBJECTIVES: The purpose of this study was to identify the type of messaging content users prefer to receive and recognize as positively influencing their spirometry use.

METHODS: The study design followed a qualitative approach investigating the experiences, perceptions, preferences, and realities of home spirometry. Three focus group sessions were used to generate opinions and interests about automatic messaging content.

RESULTS: The focus group approach revealed the nature of six categories and five subcategories for feedback messaging content. These include education (general, lifestyle, and infection), goals, timing, technique, monitoring, and reminders (time sensitive, positive). Messages were created according to length, feasibility, past experience, and neutrality for electronic implementation.

CONCLUSION: The narrative content served as the primary source of electronic feedback messages. Actual quotes were used when applicable. It is believed that pertinent automated electronic feedback messages will enhance home spirometry connection, raise confidence in spirometry use, and influence daily adherence to the spirometry protocol. The content also serves as a foundation for establishing a plan of care individualized to each home spirometry user.

Lower limb activity and its determinants in COPD.

Thorax. 2008 Aug;63(8):683-9. Walker PP, Burnett A, Flavahan PW, Calverley PM. Division of Infection and Immunity, School of Clinical Science, University of Liverpool, Liverpool, UK.

BACKGROUND: Patients with chronic obstructive pulmonary disease (COPD) walk less than healthy older people and their self-reported activity predicts exacerbation risk. The relationship between lower limb activity and total daily activity is not known, nor are there any data which relate objectively assessed daily activity to laboratory assessments made before and after rehabilitation.

METHODS: Lower limb activity was measured by leg actigraphy over 3 days in 45 patients with moderate to severe COPD and 18 controls of similar age. Thirty-three patients with COPD entered an 8-week rehabilitation programme in which the change in leg activity was measured and related to other outcomes.

RESULTS: In patients with COPD the mean level of activity measured by whole body and leg activity monitors was closely related (r = 0.92; p<0.001), but leg activity was consistently reduced compared with controls of similar age (p = 0.001). Mean leg activity, mean intensity of leg activity and the time that patients spent mobile at home were all related to forced expiratory volume in 1 s (FEV(1)) (r = 0.57, p = 0.001; r = 0.5, p = 0.003; and r = 0.51, p = 0.002, respectively), but intensity of activity and time spent mobile were not related. Subjects completing pulmonary rehabilitation showed significant improvements in mean activity (p = 0.001) and spent more time moving (p = 0.014). These changes were unrelated to improvement in muscle strength or walking distance but correlated with baseline FEV(1) (r = 0.8, p<0.001).

CONCLUSIONS: Total daily activity in patients with COPD is closely related to leg activity which is reduced compared with controls of similar age. Individuals differ in the time spent mobile during the day, but subjective and objectively assessed activity improves after rehabilitation and is predicted by FEV(1). The change in activity is unrelated to improvements in corridor walking and health status.

Spirometric values in Gypsy (Roma) children.

Respir Med. 2008 Jul 5. Kaditis AG, Gourgoulianis K, Tsoutsou P, Papaioannou AI, Fotiadou A, Messini C, Samaras K, Piperi M, Gissaki D, Zintzaras E, Molyvdas AP. Department of Pediatrics, Larissa University Hospital, University of Thessaly School of Medicine, P.O. Box 1425, Larissa 41110, Greece.

Values of spirometry indices vary among subjects of similar age, gender and somatometrics but of different ethnic origins. Low socioeconomic status in childhood is inversely related to lung growth. The aim of this investigation was to assess spirometry values in Gypsy children and compare them to reported values for Caucasians. Gypsy students attending primary schools in Central Greece were recruited. Spirometry indices were measured using a portable spirometer. Regression analysis was applied to construct prediction equations for forced vital capacity (FVC) and other spirometric indices (FEV(1), FEF(50), FEF(25), FEF(25-75)) based on standing height. Predicted spirometric values were compared to values for Caucasians from published studies. In 152 children (ages 5-14 years; 57 girls) lung function increased linearly with height: spirometry index=intercept+[slopexheight], (r(2)=0.68 for FVC and FEV(1) in girls; r(2)=0.78 for FVC and r(2)=0.74 for FEV(1) in boys). Excluding boys-but not girls-in puberty increased fit for FVC (r(2)=0.83) and FEV(1) (r(2)=0.79).

Mean predicted values were 5-10% lower than values for Caucasians. In Gypsy children, FVC and expiratory flow function increase linearly with standing height and predicted values are lower than those for Caucasians of similar height.

Reference values for peak flow and FEV1 variation in healthy schoolchildren, using home spirometry.

Eur Respir J. 2008 Apr 16. Brouwer AF, Roorda RJ, Duiverman EJ, Brand PL. Isala klinieken, Zwolle, the Netherlands; and University of Groningen/University Medical Center, Beatrix Children's Hospital, Dept of paediatric Pulmonology, Groningen, the Netherlands.

Current reference values for diurnal peak flow variation in healthy children (median 8.2%; 95(th) centile 31%) are so high that considerable overlap exists with asthmatic children. These values have been obtained with written peak flow diaries, which are unreliable.

To obtain reliable reference values of peak flow variation and forced expiratory volume in the 1(st) second (FEV1) variation in healthy schoolchildren using home spirometry with electronic data storage. Two-hundred-and-four healthy schoolchildren (100 boys), 6-16 years of age, measured peak flow and FEV1 twice daily for two weeks using an electronic home spirometer. Variation of peak flow and FEV1 were calculated as diurnal amplitude as a percentage of the day's mean.Mean peak flow variation was 6.2% (95%CI 5.8 to 6.7%; 95(th) centile 12.3%) and mean FEV1 variation was 5.7% (95%CI 5.4 to 6.1%; 95(th) centile 11.8%).

Using home spirometry with electronic data storage, healthy schoolchildren show considerably less peak flow and FEV1 variation than previously reported with written peak flow diaries. Being the 95(th) centiles of the distributions in healthy children, we suggest using 12.3% for peak flow variation and 11.8% for FEV1 variation as cut-off values for disease when using home spirometry.

Predictive value of lung function below the normal range and respiratory symptoms for progression of chronic obstructive pulmonary disease.

Thorax. 2008 Mar;63(3):201-7. Albers M, Schermer T, Heijdra Y, Molema J, Akkermans R, van Weel C. Radboud University Nijmegen Medical Centre, Department of Primary Care [117-HAG], PO Box 9101, 6500 HB Nijmegen, The Netherlands.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is an insidiously starting disease. Early detection has high priority because of the possibility of early implementation of smoking cessation interventions. An evidence based model for case finding of COPD is not yet available.

OBJECTIVE: To describe the early development of COPD, and to assess the predictive value of early signs (respiratory symptoms, lung function below the normal range, reversibility).

DESIGN AND METHODS: In a prospective study, based in general practice, formerly undiagnosed subjects (n = 464) were assessed at baseline and at 5 years for respiratory symptoms and pulmonary function. Odds ratios for early signs were calculated (adjusted for age, gender, pack-years at baseline and smoking behaviour during follow-up), and defined as possible indicators of disease progression.

RESULTS: Over a 5 year period, the percentage of subjects with obstruction increased from 7.5% (n = 35) at baseline to 24.8% (n = 115) at 5 years. The presence of mild early signs and lung function below the normal range at baseline were related to an increased risk of developing mild to moderate COPD (GOLD I: OR 1.87 (95% CI 1.22 to 2.87); GOLD II: OR 2.08 (95% CI 1.29 to 3.37) to 2.54 (95% CI 1.25 to 5.19)) at 5 years.

CONCLUSION: Lung function below the normal range and early respiratory signs predict the development and progression of COPD.

Impact of allergic rhinitis on asthma: effects on spirometric parameters

Allergy. 2008 Mar;63(3):255-60. Ciprandi G, Cirillo I, Pistorio A. Department of Internal Medicine, Azienda Ospedaliera Universitaria San Martino, Genoa, Italy.

BACKGROUND: Close association exists between allergic rhinitis and asthma. Moreover, allergic rhinitis is a strong risk factor for the onset of asthma in adults. This study was aimed at evaluating a large group of patients with moderate-to-severe and persistent allergic rhinitis alone for investigating the presence of spirometric abnormalities and possible risk factors related to it.

METHODS: A total of 392 patients with persistent allergic rhinitis were prospectively and consecutively evaluated. Clinical examination, skin prick test and spirometry were performed in all patients.

RESULTS: There were 24 (6.1%) patients with forced vital capacity (FVC < 80%) of predicted, 50 (12.8%) with forced expiratory volume in the first second (FEV(1) < 80%) of predicted and 341 (87.0%) with forced expiratory flow at 25% and 75% of the pulmonary volume (FEF(25-75)) < 80% of predicted. The logistic regression analysis evidenced that rhinitis duration (OR(Adj): 1.9/year) and sensitization to house dust mites (OR(Adj): 8.2) were significantly associated with impaired values of 2 or 3 spirometric parameters.

CONCLUSION: This study highlights the close link between upper and lower airways and the role of some risk factors, such as duration and mites sensitization, as early prognostic markers of bronchial involvement in patients with moderate-to-severe and persistent allergic rhinitis alone.

Tobacco smoke exposure and tracking of lung function into adult life.

Paediatr Respir Rev. 2008 Mar;9(1):39-44. Landau LI. University of Western Australia, Crawley, WA, Australia.

Maternal smoking during pregnancy leads to abnormal lung function in infancy that tracks through to later childhood and continues into adult life. This is associated with transient wheezing illnesses through early childhood. Both social and physiological factors are likely to predispose those exposed to passive smoke to become active smokers.

Adult smokers demonstrate an increased decline of lung function with age. The effects of passive smoke exposure vary with genetic factors, gender, race and exposure to other pollutants. Exposure to environmental tobacco smoke and subsequent active smoking both aggravate symptoms and have a negative effect on lung function in those with asthma.

Effect on smoking quit rate of telling patients their lung age: the Step2quit randomised controlled trial

Gary Parkes, general practitioner, Trisha Greenhalgh, professor, Mark Griffin, lecturer in medical statistics, Richard Dent, consultant chest physician department of chest medicine The Limes Surgery, Hoddesdon, Hertfordshire EN11 8EP, Department of Primary Care and Population Sciences, University College London, London N19 5LW, Queen Elizabeth II Hospital, Welwyn Garden City, Hertfordshire AL7 4HQ

Objective: To evaluate the impact of telling patients their estimated spirometric lung age as an incentive to quit smoking.

Design: Randomised controlled trial.

Setting: Five general practices in Hertfordshire, England.

Participants: 561 current smokers aged over 35.

Intervention: All participants were offered spirometric assessment of lung function. Participants in intervention group received their results in terms of "lung age" (the age of the average healthy individual who would perform similar to them on spirometry). Those in the control group received a raw figure for forced expiratory volume at one second (FEV1). Both groups were advised to quit and offered referral to local NHS smoking cessation services.

Main outcome measures: The primary outcome measure was verified cessation of smoking by salivary cotinine testing 12 months after recruitment. Secondary outcomes were reported changes in daily consumption of cigarettes and identification of new diagnoses of chronic obstructive lung disease.

Results: Follow-up was 89%. Independently verified quit rates at 12 months in the intervention and control groups, respectively, were 13.6% and 6.4% (difference 7.2%, P=0.005, 95% confidence interval 2.2% to 12.1%; number needed to treat 14). People with worse spirometric lung age were no more likely to have quit than those with normal lung age in either group. Cost per successful quitter was estimated at £280 ({euro}366, $556). A new diagnosis of obstructive lung disease was made in 17% in the intervention group and 14% in the control group; a total of 16% (89/561) of participants.

Conclusion: Telling smokers their lung age significantly improves the likelihood of them quitting smoking, but the mechanism by which this intervention achieves it's effect is unclear.

A pilot study of inspiratory capacity and resting dyspnea correlations in exacerbations of COPD and asthma.

Int J Chron Obstruct Pulmon Dis. 2007;2(4):651-6. Pretto JJ, McMahon MA, Rochford PD, Berlowitz DJ, Jones SM, Brazzale DJ, McDonald CF. Department of Respiratory and Sleep Medicine, Institute for Breathing and Sleep,Austin Health, Heidelberg, Victoria, Australia.

Measurement of inspiratory capacity (IC) as a marker of dynamic lung hyperinflation has been shown to correlate with dyspnea and exercise performance in stable COPD, and is therefore of potential utility in the management of this condition.

We have examined whether similar relationships exist during acute exacerbations of COPD and asthma in order to determine whether there is a role for IC monitoring in acute management of these conditions. Eight patients with COPD and ten with asthma requiring hospital admission for acute exacerbations were studied with spirometry (including IC) at admission and at discharge and had concurrent self-perceived resting dyspnea ratings recorded.

Over the admission there were significant improvements in resting dyspnea for the COPD group only, and improvements in spirometric indices in the asthma group only. No significant correlations were found between changes in dyspnea and changes in IC, in terms of acute responses to bronchodilator and in response to treatment over the hospital admission.

These data suggest that dynamic hyperinflation during acute exacerbations of COPD and asthma is not as sensitive an indicator of resting dyspnea as in stable disease. A role for IC monitoring in the management of acute exacerbations of these diseases has not been identified.

Forced expiratory volume in one second: not just a lung function test but a marker of premature death from all causes.

Eur Respir J. 2007 Oct;30(4):616-22. Young RP, Hopkins R, Eaton TE. Department of Medicine, Auckland Hospital, Private Bag 92019, Auckland, New Zealand.

The clinical utility of spirometric screening of asymptomatic smokers for early signs of air flow limitation has recently come under review. The current authors propose that reduced forced expiratory volume in one second (FEV(1)) is more than a measure of airflow limitation, but a marker of premature death with broad utility in assessing baseline risk of chronic obstructive pulmonary disease (COPD), lung cancer, coronary artery disease and stroke, collectively accounting for 70-80% of premature death in smokers.

Reduced FEV(1) identifies undiagnosed COPD, has comparable utility to that of serum cholesterol in assessing cardiovascular risk and defines those smokers at greatest risk of lung cancer. As such, reduced FEV(1) should be considered a marker that identifies smokers at greatest need of medical intervention. Smoking cessation has been shown to attenuate FEV(1) decline and, if achieved before the age of 45-50 yrs, may not only preserve FEV(1) within normal values but substantially reduce cardiorespiratory complications of smoking. Recent findings suggest inhaled drugs (bronchodilators and corticosteroids), and possibly statins, may be effective in reducing morbidity and mortality in patients with chronic obstructive pulmonary disease.

The current authors propose that spirometry has broad utility in identifying smokers who are at greatest risk of cardiorespiratory complications and greatest benefit from targeted preventive strategies, such as smoking cessation, prioritised screening and effective pharmacotherapy.

Primary care spirometry.

Eur Respir J. 2008 Jan;31(1):197-203. Derom E, van Weel C, Liistro G, Buffels J, Schermer T, Lammers E, Wouters E, Decramer M. Dept of Respiratory Diseases, Ghent University Hospital, De Pintelaan 185, B-9000 Ghent, Belgium.

Primary care spirometry is a uniquely valuable tool in the evaluation of patients with respiratory symptoms, allowing the general practitioner to diagnose or exclude chronic obstructive pulmonary disease (COPD), sometimes to confirm asthma, to determine the efficacy of asthma treatment and to correctly stage patients with COPD.

The use of spirometry for case finding in asymptomatic COPD patients might become an option, once early intervention studies have shown it to be beneficial in these patients.
The diagnosis of airway obstruction requires accurate and reproducible spirometric measurements, which should comply with the American Thoracic Society (ATS)/European Respiratory Society (ERS) guidelines.

Low acceptability of spirometric manoeuvres has been reported in primary care practices. This may hamper the validity of the results and affect clinical decision making. Training and refresher courses may produce and maintain good-quality testing, promote the use of spirometric results in clinical practice and enhance the quality of interpretation. Softening the stringent ATS/ERS criteria could enhance the acceptability rates of spirometry when used in a general practice. However, the implications of potential simplifications on the quality of the data and clinical decision making remain to be investigated.

Hand-held office spirometers have been developed in recent years, with a global quality and user-friendliness that makes them acceptable for use in general practices. The precision of the forced vital capacity measurements could be improved in some of the available models.

Validation of FEV6 in the elderly: correlates of performance and repeatability.

Thorax. 2008 Jan;63(1):60-6. Bellia V, Sorino C, Catalano F, Augugliaro G, Scichilone N, Pistelli R, Pedone C, Antonelli-Incalzi R. Universitè di Palermo, DIMPEFINU, via Trabucco 180, 90146 Palermo, Italy.

BACKGROUND: Forced expiratory volume in 6 s (FEV6) has been proposed as a more easily measurable parameter than forced vital capacity (FVC) to diagnose airway disease using spirometry. A study was undertaken to estimate FEV6 repeatability, to identify correlates of a good quality FEV6 measurement and of volumetric differences between FEV6 and FVC in elderly patients.

METHODS: 1531 subjects aged 65-100 years enrolled in the SA.R.A project (a cross-sectional multicentre non-interventional study) were examined. FEV6 was measured on volume-time curves that achieved satisfactory start-of-test and end-of-test criteria. Correlates of FEV6 achievement were assessed by logistic regression.

RESULTS: Valid FEV6 and FVC measurements were obtained in 82.9% and 56.9%, respectively, of spirometric tests with an acceptable start-of-test criterion. Female sex, older age, lower educational level, depression, cognitive impairment and lung restriction independently affected the achievement of FEV6 measurement. Good repeatability (difference between the best two values <150 ml) was found in 91.9% of tests for FEV6 and in 86% for FVC; the corresponding figures in patients with airway obstruction were 94% and 78.4%. Both FEV6 and FVC repeatability were affected by male sex and lower education. Male sex, airway obstruction and smoking habit were independently associated with greater volumetric differences between FEV6 and FVC.

CONCLUSIONS: In elderly patients, FEV6 measurements are more easily achievable and more reproducible than FVC although 1/6 patients in this population were unable to achieve them.

Use of spirometry and patterns of prescribing in COPD in primary care.

Respir Med. 2007 Aug;101(8):1753-60.
Miravitlles M, de la Roza C, Naberan K, Lamban M, Gobartt E, Martin A.
Department of Pneumology, Institut Clínic del Tòrax (IDIBAPS), Servicio de Neumología, Hospital Clínic, Villarroel 170 08036, Barcelona, Spain.

OBJECTIVE: To investigate the use and interpretation of spirometry in primary care (PC) in the diagnosis of chronic obstructive pulmonary disease (COPD) and to identify the treatment schedules administered.

METHODS: An observational study was performed in a randomized sample of 251 PC physicians including 2130 patients with COPD. Data on the performance of spirometry and the results and the treatment administered were collected as were sociodemographic and clinical data. RESULTS: Spirometric results were obtained in 1243 (58.4%). Most (1118/1243; 89.9%) corres

onded to FEV1 (%) values with a mean of 57% (SD=21.5%). It is of note that only 31.8% of spirometric results provided post-bonchodilator results, and 42.9% and 43.1% of the spirometries presented not plausible FVC or FEV1 values, respectively. Treatment varied greatly, with more than 3 drugs being prescribed in 30.6% of the cases. Long-acting beta-2 agonists and inhaled corticosteroids were prescribed in more than 50% of the patients. Tiotropium was administered in 32.4%. According to the GOLD guidelines, 22.8% of the patients in GOLD II, 50% in III and 66.7% in IV were receiving incorrect treatment.

CONCLUSIONS: Only 58.4% of the cases included had undergone spirometry. Important deficiencies were observed in the interpretation of the results of spirometry. These difficulties may influence the low implementation of treatment guidelines in COPD in PC.

The Interaction of Genes and Smoking on Forced Expiratory Volume: A Classic Twin Study.

Chest. 2007 Nov 7
Zhai G, Valdes AM, Cherkas L, Clement G, Strachan D, Spector TD.
Twin Research & Genetic Epidemiology Unit, King's College London School of Medicine, UK.

Background
Genetic influences on lung function measured by the forced expiratory volume in one second (FEV(1)) have been reported from twin and family studies. The aim of this study was to estimate heritability of the ratio of measured (mFEV(1)) to expected (eFEV(1)) FEV(1) in a Caucasian population and to examine the interaction between genetic factors and smoking on this ratio.

Methods and subjects
The sample consisted of unselected monozygotic (MZ) and dizygotic (DZ) twin pairs from the TwinsUK registry. FEV(1) was measured with a spirometer and the ratio of mFEV(1) to eFEV(1) was calculated.

Results
A total of 475 MZ and 1054 DZ twin pairs with a mean age of 47 (range 18 - 84) participated. The ratio of mFEV(1) to eFEV(1) was 0.057 lower in smokers than non-smokers (p<0.0001). The difference in the correlation for the mFEV(1) to eFEV(1) ratio between MZ and DZ twin pairs was 0.32 in non-smokers and 0.19 in current smokers, suggesting a significant genetic influence on lung function that was modified in current smokers. Using structural equation modelling, the heritability estimate for the mFEV(1) to eFEV(1) ratio was found to be 66% (95% CI 59 - 72%) in non-smokers but significantly reduced to 32% (95% CI 12 - 53%) in current smokers. However, there was no clear difference in the heritability of the mFEV(1) to eFEV(1) ratio between non-smokers and ex-smokers.

Conclusion
Genes are the major influence on the variability of the ratio of mFEV(1) to eFEV(1) in non-smokers. However, this strong genetic influence is strongly modified by an interaction with cigarettes.

Efficacy of the FEV1/FEV6 ratio compared to the FEV1/FVC ratio for the diagnosis of airway obstruction in subjects aged 40 years or over.

Braz J Med Biol Res. 2007 Dec;40(12):1615-21.
Rosa FW, Perez-Padilla R, Camelier A, Nascimento OA, Menezes AM, Jardim JR.
Disciplina de Pneumologia e Centro de Reabilitação Pulmonar, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brasil.

The present cross-sectional, population-based study was designed to evaluate the performance of the FEV1/FEV6 ratio for the detection of airway-obstructed subjects compared to the FEV1/FVC <0.70 fixed ratio test, as well as the lower limit of normality (LLN) for 1000 subjects (3)40 years of age in the metropolitan area of São Paulo, SP, Brazil.

After the exclusion of 37 (3.7%) spirometries, a total of 963 pre-bronchodilator (BD) and 918 post-BD curves were constructed. The majority of the post-BD curves (93.1%) were of very good quality and achieved grade A (762 curves) or B (93 curves). The FEV1/FEV6 and FEV1/FVC ratios were highly correlated (r(2) = 0.92, P < 0.000). Two receiver operator characteristic curves were constructed in order to express the imbalance between the sensitivity and specificity of the FEV1/FEV6 ratio compared to two FEV1/FVC cut-off points for airway obstruction: equal to 70 (area under the curve = 0.98, P < 0.0001) and the LLN (area under the curve = 0.97, P < 0.0001), in the post-BD curves. According to an FEV1/FVC <0.70, the cut-off point for the FEV1/FEV6 ratio with the highest sum for sensitivity and specificity was 0.75.

The FEV1/FEV6 ratio can be considered to be a good alternative to the FEV1/FVC ratio for the diagnosis of airway obstruction, both using a fixed cut-off point or below the LLN as reference. The FEV1/FEV6 ratio has the additional advantage of being an easier maneuver for the subjects and for the lung function technicians, providing a higher reproducibility than traditional spirometry maneuvers.

Spirometry in 5-year-olds-validation of current guidelines and the relation with asthma.

Pediatr Pulmonol. 2007 Dec;42(12):1144-51.
Turner SW, Craig LC, Harbour PJ, Forbes SH, McNeill G, Seaton A, Devereux G, Helms PJ.
Department of Child Health, University of Aberdeen, Aberdeen, UK.

Introduction. Spirometry is more frequently measured in younger children. Our primary aim was to validate 2005 ATS-ERS Task Force standards for spirometry in adults and older children among a population of 5-year-old children. Our secondary aim was to relate spirometry to asthma symptoms

METHODS: Children were participants in a longitudinal cohort study where asthma symptoms and spirometry were assessed.

RESULTS: Of the 827 children assessed, spirometry was obtained in 638 (85 with wheeze). A back-extrapolated volume/FVC ratio of <5% was achieved in 99% of children, the best two FVC were /=3 sec, whereas 80% had an FET of >/=1 sec. All criteria (including FET >/=1 s and FVC

CONCLUSIONS: The standards for spirometry are mostly achieved in this age group but are not necessarily valid and require revision. Reliable spirometry is feasible in 5-year-old children where reduced measurements are associated with asthma symptoms and in whom FEF(50) appears to be the most discriminatory variable.

Diagnostic labeling of COPD in five Latin American cities.

Chest. 2007 Jan;131(1):60-7
Tálamo C, de Oca MM, Halbert R, Perez-Padilla R, Jardim JR, Muiño A, Lopez MV, Valdivia G, Pertuzé J, Moreno D, Menezes AM; PLATINO team.
Universidad Central de Venezuela, Facultad de Medicina, Hospital Universitario de Caracas, Cátedra de Neumonologia Piso 8, Caracas 1040, Venezuela.

BACKGROUND: COPD is a major worldwide problem with a rising prevalence. Despite its importance, there is a lack of information regarding underdiagnosis and misdiagnosis of COPD in different countries. As part of the Proyecto Latinoamericano de Investigación en Obstrucción Pulmonar study, we examined the relationship between prior diagnostic label and airway obstruction in the metropolitan areas of five Latin American cities (São Paulo, Santiago, Mexico City, Montevideo, and Caracas).

METHODS: A two-stage sampling strategy was used in each of the five areas to obtain probability samples of adults aged >or= 40 years. Participants completed a questionnaire that included questions on prior diagnoses, and prebronchodilator and postbronchodilator spirometry. A study diagnosis of COPD was based on airway obstruction, defined as a postbronchodilator FEV(1)/FVC < 0.70.

RESULTS: Valid spirometry and prior diagnosis information was obtained for 5,303 participants; 758 subjects had a study diagnosis of COPD, of which 672 cases (88.7%) had not been previously diagnosed. The prevalence of undiagnosed COPD was 12.7%, ranging from 6.9% in Mexico City to 18.2% in Montevideo. Among 237 subjects with a prior COPD diagnosis, only 86 subjects (36.3%) had postbronchodilator FEV(1)/FVC < 0.7, while 151 subjects (63.7%) had normal spirometric values. In the same group of 237 subjects, only 34% reported ever undergoing spirometry prior to our study.

CONCLUSIONS: Inaccurate diagnostic labeling of COPD represents an important health problem in Latin America. One possible explanation is the low rate of spirometry for COPD diagnosis.

Risk indexes for exacerbations and hospitalizations due to COPD

Chest. 2007 Jan;131(1):20-8. Niewoehner DE, Lokhnygina Y, Rice K, Kuschner WG, Sharafkhaneh A, Sarosi GA, Krumpe P, Pieper K, Kesten S. Department of Medicine at Veterans Affairs Medical Centers in Minneapolis, MN 55417, USA.

METHODS: Spirometry, demographics, and medical history were obtained at baseline in 1,829 patients with moderate-to-very severe COPD who entered a trial of inhaled tiotropium. Information about exacerbations and hospitalizations due to exacerbation was collected during the 6-month follow-up period. Analyses of first outcomes were modeled using univariable and multivariable Cox proportional hazards regressions.

RESULTS: During follow-up, 551 patients had at least one exacerbation and 151 patients had at least one hospitalization due to exacerbation. In the multivariable model for exacerbation, older age, percentage of predicted FEV(1), duration of COPD, a productive cough, antibiotic or systemic corticosteroid use for COPD in the prior year, hospitalization for COPD in the prior year, and theophylline use at baseline predicted a higher risk. In the multivariable model for hospitalization, older age, percentage of predicted FEV(1), unscheduled clinic/emergency department visits for COPD in the prior year, any cardiovascular comorbidity, and prednisone use at baseline were associated with greater risk. Both the exacerbation and the hospitalization models provided moderately good discrimination, the validated concordance indexes being 0.66 and 0.73, respectively. Methods for calculating risk in individual patients are provided.

CONCLUSIONS: Spirometry along with a few questions directed to the patient are strongly predictive of exacerbations and related hospitalizations over the ensuing 6 months.

Impact of allergic rhinitis on asthma: effects on spirometric parameters.

Allergy. 2007 Oct 18
Ciprandi G, Cirillo I, Pistorio A.
Department of Internal Medicine, Azienda Ospedaliera Universitaria San Martino, Genoa, Italy.

Background: Close association exists between allergic rhinitis and asthma. Moreover, allergic rhinitis is a strong risk factor for the onset of asthma in adults. This study was aimed at evaluating a large group of patients with moderate-to-severe and persistent allergic rhinitis alone for investigating the presence of spirometric abnormalities and possible risk factors related to it.

Methods: A total of 392 patients with persistent allergic rhinitis were prospectively and consecutively evaluated. Clinical examination, skin prick test and spirometry were performed in all patients.

Results: There were 24 (6.1%) patients with forced vital capacity (FVC < 80%) of predicted, 50 (12.8%) with forced expiratory volume in the first second (FEV(1) < 80%) of predicted and 341 (87.0%) with forced expiratory flow at 25% and 75% of the pulmonary volume (FEF(25-75)) < 80% of predicted. The logistic regression analysis evidenced that rhinitis duration (OR(Adj): 1.9/year) and sensitization to house dust mites (OR(Adj): 8.2) were significantly associated with impaired values of 2 or 3 spirometric parameters.

Conclusion: This study highlights the close link between upper and lower airways and the role of some risk factors, such as duration and mites sensitization, as early prognostic markers of bronchial involvement in patients with moderate-to-severe and persistent allergic rhinitis alone.

The Role of FVC and FEV6 in the Prediction of a Reduced TLC.

Eur Respir J. 2007 Oct 10
Vandevoorde J, Verbanck S, Schuermans D, Broekaert L, Devroey D, Kartounian J, Vincken W.
University of Brussels (VUB), Laarbeeklaan 103, B-1090 Brussels, Belgium.

The present study aims to derive guidelines that identify patients for whom spirometry can reliably predict a reduced total lung capacity (TLC).

A total of 12, 693 lung function tests were analysed on Caucasian subjects, aged 18-70 yrs. Restriction was defined as a reduced TLC. Lower limits of normal (LLN) for TLC were obtained from ERS recommended reference equations. For FVC and FEV6 reference equations from NHANES III were used. The performance of FVC and FEV6 to predict the presence of restriction was studied (a) using two-by-two tables, and (b) by logistic regression analysis. Both analyses were performed in obstructive (defined as FEV1/FVC or FEV1/FEV6

The two-by-two tables showed generally low PPV and high NPV for FVC or FEV6 100%pred (men) or >85%pred (women).

In obstructive patients, spirometry cannot reliably diagnose a concomitant restrictive defect, but it can rule out restriction for patients with FVC or FEV6 >85%pred (men) or >70%pred (women).

Six-Second Spirometry for Detection of Airway Obstruction: A Population-based Study in Austria.

Am J Respir Crit Care Med. 2007 Sep 1;176(5):460-4.
Lamprecht B, Schirnhofer L, Tiefenbacher F, Kaiser B, Buist SA, Studnicka M, Enright P.
Muellner Hauptstrasse 48, Department of Pulmonary Medicine, 5020 Salzburg, Austria.

Rationale: The presence of airway obstruction is currently defined by Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines on the basis of the post-bronchodilator (BD) FEV(1)/FVC. It has been proposed that the traditional FVC can be replaced with the shorter and less demanding FEV(6) for detecting airway obstruction.

Objectives: A comparison of FEV(1)/FVC and FEV(1)/FEV(6) for the detection of airway obstruction in population-based post-bronchodilator spirometry data.

Methods: A population-based sample of 1,349 adults participated in the Burden of Obstructive Lung Disease study in Austria. Specially trained and certified technicians conducted pre-BD and post-BD spirometry according to American Thoracic Society guidelines and administered standardized questionnaires. A total of 93% of the post-BD test sessions were acceptable, and were included in this analysis. The Third National Health and Nutrition Examination Survey reference equations were used to calculate predicted values and lower limits of normal (LLN) for FEV(1), FEV(6), FVC, FEV(1)/FVC, and FEV(1)/FEV(6).

Measurements and Main Results: The post-BD FEV(1)/FVC was below the LLN in 199 (15.8%) subjects. The sensitivity of the FEV(1)/FEV(6) for airway obstruction depended greatly on the threshold of percent predicted FEV(1) also used in the definition. The overall sensitivity of FEV(1)/FEV(6) for a diagnosis of airway obstruction, as defined by FEV(1)/FVC (including participants with an FEV(1) above the LLN), was 72.9%, with 98.8% specificity. The sensitivity increased to 98.0% when a low FEV(1) was also required to diagnose post-BD airway obstruction. The discordant cases had long forced expiratory times, often showed a flow-volume curve pattern consistent with two-compartment emptying, and were more often never-smokers.

Conclusions: Six-second spirometry maneuvers (which measure FEV(6)) are as sensitive and specific for post-BD airway obstruction as traditional (prolonged exhalation time) FVC maneuvers only when the definition of airway obstruction includes a low FEV(1).

Capital Souffle: results of a 2005 public awareness campaign about breath measurements in France

Presse Med. 2007 Jun;36(6 Pt 1):824-31
Collectif Capital Souffle.

AIM: A national public awareness campaign (Capital Souffle, or Breath Matters) about prevention and detection of chronic obstructive respiratory diseases was carried out in seven large French cities. The principal objective was to collect demographic and respiratory-related characteristics and increase population awareness of breath measurements for detecting chronic obstructive respiratory diseases, particularly asthma and chronic obstructive pulmonary disease (COPD). The secondary objective was to assess the immediate impact of lung function measurements on the subjects who participated in the campaign.

METHODS: This multicenter cross-sectional survey was conducted in October and November 2005 in 7 large French cities. Subjects completed 2 questionnaires, one collecting demographic and medical, especially respiratory-related, data and the second assessing subjects' response to the campaign. Data collection was completed by measurement of their FEV1/FEV6 ratio with an electronic pocket spirometer.

RESULTS: Data from 8294 questionnaires could be analyzed: 14.4% of subjects reported having asthma and 4.1% COPD. Approximately 10% reported they were followed by a physician for a chronic respiratory disease. Half were current (28.5%) or former (21.9%) smokers, who began smoking at a median age of 17 years (10-50). The FEV1/FEV6 ratio was normal (>80%) in 79.4% of subjects, required further monitoring in 15.5% (70-80%) and abnormal (<70%) in 5.1%. In all 1416 subjects (17.1%) had a FEV1/FEV6 ratio that was either abnormal or required follow-up and were not followed by a physician for respiratory disease. This campaign produced a high level of public awareness: 85.8% of subjects reported they wanted to know more about respiratory health, 64% said they would discuss it with their physician and 62.7% that the campaign would encourage them to take their medication.

PERSPECTIVES: This survey demonstrates the feasibility of a national public awareness campaign about chronic respiratory diseases in France, based on a simple lung function measurement. The immediate impact of the campaign was high. Additional studies are necessary to determine the number of chronic respiratory disease diagnosed and managed by physicians.

Pulse oximetry coupled with spirometry in the emergency department helps differentiate an asthma exacerbation from possible vocal cord dysfunction.

Pediatr Pulmonol. 2007 Jul;42(7):605-9
Nolan PK, Chrysler M, Phillips G, Goodman D, Rusakow LS.
Texas Tech University HSC, Amarillo, Texas.

PURPOSE: Spirometry performed by adolescents with refractory wheeze or stridor and respiratory distress, with normal room air oxygen saturation, may differentiate subjects not having an acute asthma exacerbation (AE-) from those who are (AE+). A subpopulation may also be identified that has flow volume loop (FVL) patterns consistent with vocal cord dysfunction (VCD).

METHODS: Spirometry was performed by adolescents who presented to a pediatric emergency department (ED) with respiratory distress attributed to an acute AE who, after therapy, were still symptomatic and had room air oxygen saturation >/=97%. Spirometry findings were classified as: (a) consistent with an acute AE, (b) variable extrathoracic airway obstruction pattern consistent with VCD, (c) a combination of the two, or (d) normal airflow.

RESULTS: Of 2,073 adolescent visits for asthma seen in the ED in 2005, 20 encounters among 17 adolescents were examined during the period of 0700-2200 on weekdays when an investigator was available, of which, 15 encounters were classified as AE-. In the AE- group, nine had FVL evidence of variable extrathoracic airway obstruction consistent with VCD, and six had normal spirometry. Three of the five encounters that were AE+ had FVL evidence consistent with VCD.

CONCLUSIONS: Spirometry, performed on therapy-resistant wheezing or stridorous adolescent patients in respiratory distress with oxygen saturation >/=97%, may help differentiate patients who are not having an acute AE from those who are. In those subjects not having an acute AE, respiratory distress may prove to be due to VCD.

Spirometry can be done in family physicians' offices and alters clinical decisions in management of asthma and COPD.

Chest. 2007 Jun 5
Yawn BP, Enright PL, Lemanske RF, Israel E, Pace W, Wollan P, Boushey H.
Department of Research, Olmsted Medical Center, Rochester, MN.

Background: Spirometry testing is recommended for diagnosis and management of obstructive lung disease. While many patients with asthma and COPD are cared for in primary care practices, limited data is available on the use and results associated with spirometry testing in primary care.

Object: To assess the technical adequacy, accuracy of interpretation and impact of office spirometry testing.

Design: A before and after quasi-experimental design. Setting 382 patients from 12 family medicine practices across the U.S. Participants Patients with asthma and COPD and the staff within the 12 practices.

Measurements: Technical adequacy of spirometry results, concordance between family physician's and pulmonary expert's interpretations of the spirometry test results and changes in asthma and COPD management following spirometry testing.

Results: Of the 368 tests completed over the six months, 71% were technically adequate for interpretation. Family physician and pulmonary expert interpretations were concordant in 76% of completed spirometry tests. Spirometry testing was followed by changes in management in 48% of subjects with completed tests including 107 medication changes (over 85% concordant with guideline recommendations) and 102 non-pharmacological changes. Concordance between family physician and expert interpretations of spirometry test results were higher in those patients with asthma compared to those with COPD. Discussion and

CONCLUSIONS: U.S. family physicians can perform and interpret spirometry testing for asthma and COPD patients at rates comparable to those published in the literature for international primary care studies and the results of the spirometry tests modify care.

Lung function testing in the elderly-Can we still use FEV(1)/FVC<70% as a criterion of COPD?

Respir Med. 2007 Jun;101(6):1097-105
Medbo A, Melbye H.
Institute of Community Medicine, University of Tromso, 9038 Tromso, Norway.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) can be diagnosed when the FEV(1)/FVC ratio is below 70%, according to global initiative for chronic obstructive lung disease (GOLD). COPD is known as a disease which is frequently under-diagnosed. However, there is a risk of over diagnosis when this diagnostic threshold is applied among the elderly.

AIMS: To contribute to the discussion about the criteria for diagnosing COPD, by describing lung function and pulmonary symptoms in a population aged 60 years or more, and in particular the changes in the mean and 5% percentile of the FEV(1)/FVC ratio by increasing age.

METHODS: A cross sectional population-based study was performed in the city of Tromso, Norway, in 2001-2002. Spirometry was performed in 4102 people 60 years and older (54.6% women), who also filled in a questionnaire.

RESULTS: Decreased FEV(1)% predicted and FEV(1)/FVC ratio were associated with smoking, increasing age, and reported pulmonary and cardiovascular diseases. Dyspnoea and coughing were also strongly associated with smoking and reported pulmonary and cardiovascular diseases, but coughing did not become more frequent by increasing age. In never smokers aged 60-69 years the frequency of FEV(1)/FVC ratio<70% was approximately 7% compared to 16-18% in those 70 years or more (p<0.001). FEV(1)/FVC ratio<70% among never smokers aged 60-69 years was just as frequent as FEV(1)/FVC ratio <65% in never smokers older than 70 years.

CONCLUSION: Adjustments of the GOLD criteria for diagnosing COPD are needed, and FEV(1)/FVC ratios down to 65% should be regarded as normal when aged 70 years and older.

Telemetric monitoring of pulmonary function after allogeneic hematopoietic stem cell transplantation.

Transplantation. 2007 Mar 15;83(5):554-60. Guihot A, Becquemin MH, Couderc LJ, Randrianarivelo O, Rivaud E, Philippe B, Sutton L, Neveu H, Tanguy ML, Vernant JP, Dhedin N. Service de Pneumologie, Hopital Foch, Suresnes, France.

BACKGROUND: Late-onset noninfectious pulmonary complications (LONIPC) are both frequent and severe after allogeneic hematopoietic stem cell transplantation (HSCT). The high mortality rate (40-80%) may be related to delayed diagnosis. We assessed the use of telemetric home surveillance of pulmonary function for early diagnosis of LONIPC in transplant recipients.

METHODS: This prospective study monitored pulmonary function in 37 allogeneic HSCT recipients. About 3 months after HSCT, they received a portable spirometer that measured forced vital capacity, forced expiratory volume per second, and midexpiratory flow 25-75 (MEF25-75). Data were transmitted twice weekly by telephone. Conventional plethysmography confirmed any significant deterioration (>20%).

RESULTS: Thirteen episodes of spirometric deterioration were detected by telemetry in 11 patients during a median 17-month (4-41) follow-up period after transplantation. In these cases, examinations including spirometry, high-resolution thoracic computed tomography and bronchoalveolar lavage diagnosed LONIPC in eight episodes in seven patients (cumulative incidence 23.4%, SE 0.08, at month 24 after transplant): bronchiolitis obliterans (BO, n=3), interstitial pneumonia (IP, n=4), or both BO and IP (n=1). Five episodes improved and three were stabilized with increased immunosuppressive therapy. At the last follow-up, of the seven patients with LONIPC, one successfully stopped immunosuppressive therapy, two were receiving low-dose mycophenolate mofetil, and four were receiving low-dose corticosteroid therapy. There were no cases of respiratory failure and no patient died from LONIPC.

CONCLUSION: Telemetric home monitoring of pulmonary function is a useful procedure for early diagnosis of LONIPC before clinical pulmonary symptoms and may improve outcome after allogeneic HSCT.

COPD screening efforts in primary care: what is the yield?

Prim Care Respir J. 2007 Feb;16(1):41-8. Tinkelman DG, Price D, Nordyke RJ, Halbert RJ. UCLA School of Public Health, Los Angeles, CA, USA.

INTRODUCTION: Underdiagnosis of COPD appears to be common, although the degree of underdiagnosis is rarely measured. To document the extent of underdiagnosis in a high risk group of ambulatory patients, we performed spirometry in smokers aged 40 years and over drawn from general practices in two countries.

METHODS: Subjects were recruited from primary care practices in Aberdeen, Scotland, and Denver, Colorado, via random mailing. Current and former smokers aged 40 or older with no prior diagnosis of chronic obstructive respiratory disease (and no respiratory medications within the past year) were enrolled. Participants underwent pre- and post-bronchodilator spirometry. A study diagnosis of COPD was defined as post-bronchodilator FEV1/FVC < 0.70.

RESULTS Spirometric examination was complete in 818 patients, of whom 155 (18.9%) had a study diagnosis of COPD. Using the Global Initiative for Chronic Obstructive Lung Disease (GOLD) severity criteria, the COPD was mild in 57.4%, moderate in 36.8%, and severe in 5.8%. No patients had very severe disease according to GOLD criteria.

DISCUSSION: Screening of smokers over 40 in general practice may yield 10 - 20% undiagnosed COPD cases, with a substantial proportion of these having moderate to severe disease. Earlier diagnosis through targeted case-finding will allow early, aggressive smoking cessation efforts and may lead to a reduction in the burden of COPD symptoms and a reduced impact of the disease on health-related quality of life in these patients.

Reference values of Forced Expiratory Volumes and pulmonary flows in 3-6 year children: a cross-sectional study.

Respir Res. 2007 Feb 22;8(1):14
Piccioni P, Borraccino A, Forneris MP, Migliore E, Carena C, Bignamini E, Fassio S, Cordola G, Arossa W, Bugiani M.

BACKGROUND: The aims of this study were to verify the feasibility of respiratory function tests and to assess their validity in the diagnosis of respiratory disorders in young children.

METHODS: We performed spirometry and collected information on health and parents lifestyle on a sample of 960 children aged 3-6.

RESULTS: The cooperation rate was 95.3%. Among the valid tests 3 or more acceptable curves were present in 93% of cases. The variability was 5% within subjects in 90.8% of cases in all the parameters. We propose regression equations for FVC (Forced Vital Capacity), FEV1, FEV0.5, FEV0.75(Forced Expiratory Volume in one second, in half a second and in 3/4 of a second)and for Maximum Expiratory Flows at different lung volume levels (MEF75, 50, 25). All parameters are consistent with the main reference values reported in literature. The discriminating ability of respiratory parameters versus symptoms always show a high specificity (>95%) and a low sensitivity (<20%) with the highest OR (10.55; IC95% 4.42-25.19) for MEF75. The ability of FEV0.75 to predict FEV1 was higher than that of FEV0.50: FEV0.75 predicts FEV1 with a determination coefficient of 0.95.

CONCLUSIONS: Our study confirms the feasibility of spirometry in young children, however some of the current standards are not well suited to this age group. Moreover, in this restricted age group the various reference values have similar behaviour.

Spirometric pulmonary function in 3- to 5-year-old children.

Pediatr Pulmonol. 2007 Mar;42(3):263-71.
Pesant C, Santschi M, Praud JP, Geoffroy M, Niyonsenga T, Vlachos-Mayer H.
Department of Pediatrics, Division of Respiratory Medicine, University of Sherbrooke, Quebec, Canada.

Forced expiratory maneuvers are routinely used in children, 6 years of age and older for the diagnosis and follow-up of respiratory diseases. Our objective was to establish normative data for an extensive number of parameters measured during forced spirometry in healthy 3- to 5-year-old children. Children aged between 3 and 5 years were tested in 11 daycare centers. Usual parameters, including FEV(1), FVC, PEF, FEF(25-75), FEF(25), FEF(50), FEF(75), and Aex were measured and analyzed in relation to sex, age, height, and weight. In addition, the same analysis was performed for FEV(0.5) and FEV(0.75). One hundred sixty-four children were recruited for testing including 87 girls and 77 boys. Thirty-five were 3 years old, 63 were 4 years old, and 66 were 5 years old. Overall, 143 children (87%) accepted to perform the test and 128 children (78%) were able to perform at least two technically acceptable expiratory maneuvers. Analyses using different regression models showed that height was the best predictor for every parameter.

In conclusion, the present study confirms that most healthy 3-5 years old children can perform valid forced expiratory maneuvers. In agreement with other studies, we found that height is the most important single predictor of various parameters measured on forced spirometry. The present study is the first to establish normative values for FEV(0.75), as well as to demonstrate that Aex can be easily performed in the majority of children aged 3-5 years. These are likely important parameters of lung function in this age range.

Risk indexes for exacerbations and hospitalizations due to COPD.

Chest. 2007 Jan;131(1):20-8
Niewoehner DE, Lokhnygina Y, Rice K, Kuschner WG, Sharafkhaneh A, Sarosi GA, Krumpe P, Pieper K, Kesten S.
Department of Medicine at Veterans Affairs Medical Centers in Minneapolis, MN 55417, USA.

OBJECTIVE: The ability to predict exacerbations in patients with COPD might permit more rational use of preventive interventions. Our objective was to develop risk indexes for exacerbations and hospitalizations due to exacerbations that might be applied to the individual patient.

METHODS: Spirometry, demographics, and medical history were obtained at baseline in 1,829 patients with moderate-to-very severe COPD who entered a trial of inhaled tiotropium. Information about exacerbations and hospitalizations due to exacerbation was collected during the 6-month follow-up period. Analyses of first outcomes were modeled using univariable and multivariable Cox proportional hazards regressions.

RESULTS: During follow-up, 551 patients had at least one exacerbation and 151 patients had at least one hospitalization due to exacerbation. In the multivariable model for exacerbation, older age, percentage of predicted FEV(1), duration of COPD, a productive cough, antibiotic or systemic corticosteroid use for COPD in the prior year, hospitalization for COPD in the prior year, and theophylline use at baseline predicted a higher risk. In the multivariable model for hospitalization, older age, percentage of predicted FEV(1), unscheduled clinic/emergency department visits for COPD in the prior year, any cardiovascular comorbidity, and prednisone use at baseline were associated with greater risk. Both the exacerbation and the hospitalization models provided moderately good discrimination, the validated concordance indexes being 0.66 and 0.73, respectively. Methods for calculating risk in individual patients are provided.

CONCLUSIONS: Spirometry along with a few questions directed to the patient are strongly predictive of exacerbations and related hospitalizations over the ensuing 6 months.

Use of office spirometers in Flemish general practice: results of a telephone survey.

Monaldi Arch Chest Dis. 2006 Sep;65(3):128-32 Boffin N, Van der Stighelen V, Paulus D, Van Royen P. Scientific Society of Flemish GPs (WVVH), Antwerp, Belgium.

BACKGROUND: While office spirometry is seen as potentially useful and feasible in general practice, little is known about its use in Flemish general practice. Our aim was to describe the use of spirometers by Flemish GPs, characteristics of their spirometry practice, training needs and preferences, and attitudes towards office spirometry.

METHODS: A telephone survey was set up in a random sample of Flemish GPs. Interviews were carried out by a GP researcher using a structured piloted questionnaire.

RESULTS: 197 out of 243 eligible GPs (81%) were interviewed. Most GPs (66%) had never used an office spirometer, 17.3% were using one and 16.7% stopped using one. Time constraints (54%) and insufficient knowledge and skills (27%) were the main reasons for not using an office spirometer (any longer). GPs particularly used their spirometer to diagnose COPD and asthma, and less frequently in follow-up. GPs (67.9%), especially current users (91.2%), considered spirometry as a GP task. Spirometry training should be provided (86%) and spirometry by GPs should be reimbursed (79.5%). More information on spirometry would be very useful (62.3%), with a marked preference for training in small groups (86.8%).

CONCLUSION: Although office spirometry is not widespread in Flemish general practice, GPs show an undoubted interest in it. They need educational and financial support to overcome prevailing barriers in establishing office spirometry on a routine basis.

Results of the second "Day of Spirometry"

Belgian Society of Pulmonology

The Belgian Society of Pulmonology has presented the results of the second "Day of Spirometry".

Participants had answered positively to one or more of the following questions:
- Do you cough regularly?
- Do you cough up sputum regularly?
- Are you experiencing more dyspnoea then other people of your age?
- Are you older then 40 years of age?
- Are you a smoker or former smoker?

Of 1313 participants, 22% had spirometric signs of obstructive lung disease, without having any history of asthma or COPD or exposure to toxic gases and fumes. Smokers showed a significant decrease in FEF25-75 values.

39% of the participants that had a history of smoking more then 20 cigarettes per day for at least 20 years showed obstructive lung disease with FEV1/FVC ratio <70%.

Distinguishing obstructive from non-obstructive people was only possible with a spirometer and not with a peak flow meter. It is concluded that peak flow measurement is not an adequate diagnostic tool.

Association between level of physical activity and lung function among Norwegian men and women: the HUNT study.

Int J Tuberc Lung Dis. 2006 Dec;10(12):1399-405. Nystad W, Samuelsen SO, Nafstad P, Langhammer A. Division of Epidemiology, Norwegian Institute of Public Health, Nydalen, N-0403 Oslo, Norway

OBJECTIVE: To estimate the association between level of physical activity in 1984-1986 and 1995-1997 and lung function in 1995-1997 among Norwegian men and women aged 28-80 years.

DESIGN: In 1984-1986 and 1995-1997, all residents of Nord-Trondelag County, Norway, aged > or =20 years were invited to participate in the Nord-Trondelag Health Studies. These analyses included a sample that took part in both studies and underwent spirometry (n = 8047). We used linear regression models adjusting for potential confounders stratified by sex and age groups (28-49 years, 50-69 years and > or =70 years) to estimate the association between forced expiratory volume in 1 second (FEV1) and physical activity.

RESULTS: Men and women who were physically active in 1985 and 1995 had the highest lung function in both sexes and in all age groups. The reduction in FEV1 ranged from 20 ml to 170 ml, similar to 1-7% of predicted values dependent on physical activity level. Lung function was also associated with body mass index (BMI), height, smoking and subjective health.

CONCLUSIONS: The findings show that a high level of physical activity corresponds to about 3-5 years of normal decline in FEV1 (30 ml/year), and may therefore overcome the disadvantages of a decline in FEV1 from increasing age.

Mild to moderate asthma affects lung growth in children and adolescents

J Allergy Clin Immunol. 2006 Nov;118(5):1040-7. Strunk RC, Weiss ST, Yates KP, Tonascia J, Zeiger RS, Szefler SJ; for the CAMP Research Group. Division of Allergy and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, St Louis, MO 63110, USA.

BACKGROUND: The effect of childhood asthma on lung growth is unclear.

OBJECTIVE: To show the effect of mild to moderate childhood asthma on lung growth.

METHODS: A total of 1041 children with mild to moderate asthma from the Childhood Asthma Management Program (CAMP) were compared with 5415 children without asthma from the Harvard Six Cities Study (H6CS). Sex-age-specific comparisons of lung growth in CAMP with the H6CS were made by using repeated-measures multiple linear regression models. Sex-age-specific percentages of children with asthma with abnormal (<5th percentile of H6CS) pulmonary function values were calculated.

RESULTS: In both boys and girls, the ratio of FEV(1) to forced vital capacity (FVC) was significantly lower for children with than without asthma (P < .001), with corresponding increases for children with asthma in FVC (P < .001). FEV(1) was lower for boys with asthma than for boys without asthma (P < .001), but not for girls (P = .14). Percentages of CAMP children with abnormal FEV(1)/FVC ratios increased with age for both sexes (P < .001). The patterns of lung growth for children with asthma compared with children without asthma did not differ among children treated for 4.3 years with budesonide or nedocromil and placebo during the CAMP trial.

CONCLUSION: Mild to moderate asthma results in a pattern of airway obstruction that increases in magnitude from age 5 to 18 years.

CLINICAL IMPLICATIONS: Periodic spirometry is needed to monitor children with asthma for signs of increasing airway obstruction with appropriate intervention following national guidelines.

Smokers with airway obstruction are more likely to quit smoking.

Thorax. 2006 Oct;61(10):869-73. Bednarek M, Gorecka D, Wielgomas J, Czajkowska-Malinowska M, Regula J, Mieszko-Filipczyk G, Jasionowicz M, Bijata-Bronisz R, Lempicka-Jastrzebska M, Czajkowski M, Przybylski G, Zielinski J. National Research Institute of Tuberculosis and Lung Diseases, 2nd Department of Respiratory Medicine, 26 Plocka Street, 01-138 Warsaw, Poland.

BACKGROUND: Chronic obstructive pulmonary disease (COPD), usually caused by tobacco smoking, is one of the leading causes of morbidity and mortality. Smoking cessation at an early stage of the disease usually stops further progression. A study was undertaken to determine if diagnosis of airway obstruction was associated with subsequent success in smoking cessation, as advised by a physician.

METHODS: 4494 current smokers (57.4% men) with a history of at least 10 pack-years of smoking were recruited from 100 000 subjects screened by spirometric testing for signs of airway obstruction. At the time of screening all received simple smoking cessation advice. 1177 (26.2%) subjects had airway obstruction and were told that they had COPD and that smoking cessation would halt rapid progression of their lung disease. No pharmacological treatment was proposed. After 1 year all subjects were invited for a follow up visit. Smoking status was assessed by history and validated by exhaled carbon monoxide level.

RESULTS: Nearly 70% attended a follow up visit (n = 3077): 61% were men, mean (SD) age was 52 (10) years, mean (SD) tobacco exposure 30 (17) pack-years, and 33.3% had airway obstruction during the baseline examination. The validated smoking cessation rate in those with airway obstruction was 16.3% compared with 12.0% in those with normal spirometric parameters (p = 0.0003). After correction for age, sex, nicotine dependence, number of cigarettes smoked daily, and lung function, success in smoking cessation was predicted by lower lung function, lower nicotine dependence, and lower tobacco exposure.

CONCLUSIONS: Simple smoking cessation advice combined with spirometric testing resulted in good 1 year cessation rates, especially in subjects with airway obstruction.

Effect of primary-care spirometry on the diagnosis and management of COPD

Eur Respir J. 2006 Nov;28(5):945-52 Walker PP, Mitchell P, Diamantea F, Warburton CJ, Davies L. Clinical Science Centre, University Hospital Aintree, Lower Lane, Liverpool, L9 7AL, UK.

Primary-care spirometry has been promoted as a method of facilitating accurate diagnosis of chronic obstructive pulmonary disease (COPD). The present study examined whether improving rates of diagnosis lead to improvements in pharmacological and nonpharmacological management.

From 1999 to 2003, the current authors provided an open-access spirometry and reversibility service to a local primary-care area, to which 1,508 subjects were referred. A total of 797 (53%) had pre-bronchodilator airflow obstruction (AFO). Of the subjects who underwent reversibility testing, 19.3% were no longer obstructed post-bronchodilator. The results and records of a subgroup of 235 subjects with post-bronchodilator AFO were examined. Of the 235 subjects, 130 received a new diagnosis, most commonly COPD. The patients with COPD were significantly undertreated before spirometry and testing led to a significant increase in the use of anticholinergics (37 versus 18%), long-acting beta-agonists (25 versus 8%) and inhaled steroids (71 versus 52%). More than three quarters of smokers received smoking cessation advice but very few were referred for pulmonary rehabilitation.

In conclusion, primary-care spirometry not only increases rates of chronic obstructive pulmonary disease diagnosis, but it also leads to improvements in chronic obstructive pulmonary disease treatment. The use of bronchodilator reversibility testing in this setting may be important to avoid misdiagnosis

Technical and functional assessment of 10 office spirometers: A multicenter comparative study.

Chest. 2006 Sep;130(3):657-65. Liistro G, Vanwelde C, Vincken W, Vandevoorde J, Verleden G, Buffels J; COPD Advisory Board. Pneumology Unit, Cliniques Universitaires Saint-Luc, Avenue Hippocrate 10, 1200 Bruxelles, Belgium.

STUDY OBJECTIVES: To investigate the technical properties and user friendliness of 10 office spirometers devoted for use in general practice, and to compare the results with standard diagnostic spirometers.

DESIGN: Multicenter study.

SETTING: Ten spirometer models were tested independently in three pulmonary function laboratories and by three general practitioners (GPs).

MEASUREMENTS: The laboratories studied the technical quality of the office spirometers in terms of precision and agreement with standard spirometers, whereas the three GPs assessed their user friendliness. The spirometers tested were as follows: Spirobank; Simplicity; OneFlow; Datospir 70; Datospir 120; SpiroPro; EasyOne; MicroLoop; SpiroStar; and Pneumotrac. FVC and FEV1 were measured in 399 subjects. User friendliness was assessed by the three GPs using a questionnaire.

RESULTS: The precision of FEV1 of the office and standard spirometers was comparable, but three office spirometers had > 200 mL limits of precision for FVC. Some devices presented a proportional difference on the FEV1 with standard spirometers, underestimating the small values. The limits of agreements between standard and some office spirometers for FEV1/FVC ratio was > 10%. The overall user friendliness was estimated as good.

CONCLUSIONS: The global quality and user friendliness of several office spirometers make them acceptable for the detection of COPD, although differences between the laboratory and some of the office spirometers values suggest that the misclassification rates may be increased when using some models of office spirometers.

Pulmonary function and sleep-related breathing disorders in severely obese children

Clin Nutr. 2006 Oct;25(5):803-9. Dubern B, Tounian P, Medjadhi N, Maingot L, Girardet JP, Boule M. Armand-Trousseau Teaching Hospital, Department of Pediatric Gastroenterology and Nutrition, Avenue du Dr Arnold Netter, Paris, France.

BACKGROUND & AIMS: To evaluate the frequency of pulmonary function and sleep-breathing disorders in severely obese children and to search for their association with obesity phenotypes.

METHODS: Sleep studies and spirometry were performed for 54 severely obese children.

RESULTS: Upper airway resistances (RAWs) were increased with RAW>200% and forced 25s expiratory volume<80% in 83% and 60% of individuals, respectively. A decrease in functional residual capacity (FRC)<80% was found in 43%. Fifty-two percent of the children had a desaturation index>10 during sleep, and 41% of children presented at least one of three severity criteria (snoring index>300 per hour, respiratory events index (REI)>10 and arousal index>10). Univariate analyses showed a positive correlation between snoring index and BMI Z-score and neck/height ratio (P=0.01 and 0.04, respectively) as between REI and the same parameters (P=0.01 and 0.03, respectively). In a multivariate model with BMI Z-score, NHR still correlated with the snoring index (P=0.02) and REI (P=0.01).

CONCLUSIONS: In our cohort, obese children showed frequent pulmonary function and sleep-breathing disorders. The later were associated with impaired upper airway respiratory conductance.

The FEV(1)/FEV(6) ratio is a good substitute for the FEV(1)/FVC ratio in the elderly

Prim Care Respir J. 2006 Sep 13 Melbye H, Medbo A, Crockett A. Institute of Community Medicine, University of Tromso, 9037 Tromso, Norway.

AIMS: To determine the agreement between the FEV(1)/FEV(6) ratio and the FEV(1)/FVC ratio in an elderly population.

METHOD: The study sample consisted of 3874 participants in a cross-sectional population survey in Tromso, Norway, aged 60 years or more, in whom acceptable spirometry had been obtained. Mean differences between the FEV(1)/FEV(6) ratio (%) and the FEV(1)/FVC ratio (%) were calculated according to age, sex, smoking habit, and the degree of airflow limitation. ROC-curve analysis and Kappa-statistics were used to estimate the utility of the FEV(1)/FEV(6) ratio in predicting an FEV(1)/FVC ratio<70%.

RESULTS: The mean difference between FEV(1)/FEV(6)% and FEV(1)/FVC% was 2.7% in both men and women. The difference between the two measures increased somewhat with increasing age, and was more pronounced with smoking and decreasing FEV(1)/FVC ratio. The value for the FEV(1)/FEV(6) ratio which best predicted an FEV(1)/FVC ratio of 70%, was 73%, and a very good agreement was found between these two cut-off values (kappa=0.86).

CONCLUSION: The FEV(1)/FEV(6) ratio appears to be a good substitute for the FEV(1)/FVC ratio in an elderly population.

Office-based spirometry for early detection of obstructive lung disease.

J Am Acad Nurse Pract. 2006 Sep;18(9):414-21 Wallace LD,Troy KE. Division of Cardiology, The Heart and Vascular Institute of Florida, Morton Plant Hospital, Clearwater, Florida.

Purpose: To review the research-based evidence supporting smoking cessation as the only proven method to reduce chronic obstructive pulmonary disease (COPD) progression and to show that early detection of disease with office-based spirometry can lead to therapeutic intervention before physiologic symptoms arise.

Data sources: Extensive review of national and international scientific literature supplemented with drawings and algorithms.

Conclusions: Early detection of COPD with spirometry, along with smoking cessation, and aggressive intervention can alter the insidious course of this highly preventable disease. It is imperative that nurse practitioners utilize this simple and inexpensive procedure to identify COPD in its earliest stages, so treatment can reduce individual and community disease burden, reduce morbidity and mortality, and help reduce healthcare costs.

Implications for practice: Determination of early airflow obstruction supports smoking cessation education, provides objective data for patient motivation, thereby doubling patient compliance and reducing further disease burden.

The impact of spirometry on pediatric asthma diagnosis and treatment

J Asthma. 2006 Sep;43(7):489-93. Holt EW, Tan J, Hosgood HD. Yale University School of Epidemiology and Public Health, New Haven, Connecticut, USA.

Research has shown that spirometry is underutilized in the clinical setting. This study profiles the use of spirometry in an asthma management program at an inner-city community health clinic. Eligible subjects included 56 children who presented with an acute asthma exacerbation. Physicians recorded patient diagnosis before and after viewing spirometry. Bivariate and multivariate analysis was used to determine associations between symptoms and forced expiratory volume in 1 second (FEV1). Physicians changed 30.4% of patients' treatment plans after viewing spirometry results. Wheezing was significantly associated with FEV1 in bivariate analysis; however, multivariate modeling failed to identify significant relationships. The use of spirometry influenced patient diagnosis and treatment.

The impact of repeated spirometry and smoking cessation advice on smokers with mild COPD.

Scand J Prim Health Care. 2006 Sep;24(3):133-9.
Stratelis G, Molstad S, Jakobsson P, Zetterstrom O.
Primary Health Care Centre Brinken, Motala and Department of Health and Society, Faculty of Health Sciences, University of Linkoping, Linkoping.

Background. Smoking cessation is the most important therapeutic intervention in patients with chronic obstructive pulmonary diseases (COPD) and the health benefits are immediate and substantial. Major efforts have been made to develop methods with high smoking cessation rates.

Objectives. To study whether a combination of spirometry and brief smoking cessation advice to smokers with COPD, annually for three years, increased their smoking cessation rate in comparison with groups of smokers with normal lung function.

Method. Prospective, randomized study in primary care. Smoking cessation rates were compared between smokers with COPD followed-up yearly over a period of three years and smokers with normal lung function followed-up yearly for three years or followed-up only once after three years.

Results. The point-prevalence abstinence rate and prolonged abstinence rate at 6 and 12 months increased yearly and in smokers with COPD at year 3 was 29%, 28%, and 25%, respectively. The abstinence rates were significantly higher in smokers with COPD than in smokers with normal lung function. Smoking cessation rates among smokers with normal lung function did not increase with increasing number of follow-ups.

Conclusion. Smokers diagnosed with COPD stopped smoking significantly more often than those with normal lung function.

The challenge of diagnosing atopic diseases: outcomes in Cuban children depend on definition and methodology.

Allergy. 2006 Sep;61(9):1125-31. Wordemann M, Polman K, Diaz RJ, Menocal Heredia LT, Madurga AM, Sague KA, Gryseels B, Gorbea MB. Department of Parasitology, Prince Leopold Institute of Tropical Medicine, Antwerp, Belgium.

Prevalences of childhood asthma and other atopic diseases are increasing worldwide, and so is the number of diagnostic methods and definitions used. We determined the occurrence of atopic diseases in Cuban children with a range of diagnostic approaches commonly used or proposed in epidemiological studies, and compared the different outcome measures. A total of 398 Cuban schoolchildren between 5 and 13 years of age were diagnosed by International Study of Asthma and Allergies in Childhood (ISAAC) questionnaire, clinical examination, pre- and post-exercise spirometry, and skin prick testing. All results were considered separately, as well as jointly by using scores and definitions as described in the literature. Using questionnaire-based approaches, 21-39% of the children were positive for asthma, 9-19% for atopic dermatitis, and 15-46% for rhinoconjunctivitis. With spirometry, 7% of the children had asthma. Definitions based on a combination of questionnaire and spirometry results yielded asthma rates of 5%. Of all children, 6% wheezed on clinical examination, and only one child showed clinical signs of atopic dermatitis. Eleven percent of the children had a positive skin prick test. In total, 254 children (64%) had an atopic disease as based on the ISAAC questionnaire, and 263 (66%) based on all approaches used. Diagnostic outcomes on atopic diseases vary considerably depending on definition and methodology. Our results clearly demonstrate the need for consensus on diagnosing asthma and other atopic diseases in epidemiological studies. Based on the most commonly used ISAAC questionnaire, our data suggest prevalences of atopic diseases in Cuban children that rival those found in some other Latin American countries and developed nations with the highest prevalences in the world.

Bronchial hyperresponsiveness and the development of asthma and COPD in asymptomatic individuals: SAPALDIA Cohort Study

Thorax 2006;61:671-677 M H Brutsche1, S H Downs2, C Schindler2, M W Gerbase3, J Schwartz4, M Frey5, E W Russi6, U Ackermann-Liebrich3, P Leuenberger7 for the SAPALDIA Team

Background: Bronchial hyperresponsiveness (BHR) is a common feature of asthma. However, BHR is also present in asymptomatic individuals and its clinical and prognostic significance is unclear. We hypothesised that BHR might play a role in the development of chronic obstructive pulmonary disease (COPD) as well as asthma.

Methods: In 1991 respiratory symptoms and BHR to methacholine were evaluated in 7126 of the 9651 participants in the SAPALDIA cohort study. Eleven years later 5825 of these participants were re-evaluated, of whom 4852 performed spirometric tests. COPD was defined as an FEV1/FVC ratio of <0.70.

Results: In 1991 17% of participants had BHR, of whom 51% were asymptomatic. Eleven years later the prevalence of asthma, wheeze, and shortness of breath in formerly asymptomatic subjects with or without BHR was, respectively, 5.7% v 2.0%, 8.3% v 3.4%, and 19.1% v 11.9% (all p<0.001). Similar differences were observed for chronic cough (5.9% v 2.3%; p = 0.002) and COPD (37.9% v 14.3%; p<0.001). BHR conferred an adjusted odds ratio (OR) of 2.9 (95% CI 1.8 to 4.5) for wheezing at follow up among asymptomatic participants. The adjusted OR for COPD was 4.5 (95% CI 3.3 to 6.0). Silent BHR was associated with a significantly accelerated decline in FEV1 by 12 (5–18), 11 (5–16), and 4 (2–8) ml/year in current smokers, former smokers and never smokers, respectively, at SAPALDIA 2.

Conclusions: BHR is a risk factor for an accelerated decline in FEV1 and the development of asthma and COPD, irrespective of atopic status. Current smokers with BHR have a particularly high loss of FEV1.

The fraction of ischaemic heart disease and stroke attributable to smoking in the WHO Western Pacific and South-East Asian regions

Tobacco Control 2006;15:181-188;
A L C Martiniuk, C M Y Lee, T H Lam, R Huxley, I Suh, K Jamrozik, D F Gu, M Woodward for the Asia Pacific Cohort Studies Collaboration

Background: Tobacco will soon be the biggest cause of death worldwide, with the greatest burden being borne by low and middle-income countries where 8/10 smokers now live.

Objective: This study aimed to quantify the direct burden of smoking for cardiovascular diseases (CVD) by calculating the population attributable fractions (PAF) for fatal ischaemic heart disease (IHD) and stroke (haemorrhagic and ischaemic) for all 38 countries in the World Health Organization Western Pacific and South East Asian regions.

Design and subjects: Sex-specific prevalence of smoking was obtained from existing data. Estimates of the hazard ratio (HR) for IHD and stroke with smoking as an independent risk factor were obtained from the ~600 000 adult subjects in the Asia Pacific Cohort Studies Collaboration (APCSC). HR estimates and prevalence were then used to calculate sex-specific PAF for IHD and stroke by country.

Results: The prevalence of smoking in the 33 countries, for which relevant data could be obtained, ranged from 28–82% in males and from 1–65% in females. The fraction of IHD attributable to smoking ranged from 13–33% in males and from <1–28% in females. The percentage of haemorrhagic stroke attributable to smoking ranged from 4–12% in males and from <1–9% in females. Corresponding figures for ischaemic stroke were 11–27% in males and <1–22% in females.

Conclusions: Up to 30% of some cardiovascular fatalities can be attributed to smoking. This is likely an underestimate of the current burden of smoking on CVD, given that the smoking epidemic has developed further since many of the studies were conducted.

Obstructive and restrictive spirometric patterns: fixed cut-offs for FEV1/FEV6 and FEV6.

Eur Respir J. 2006 Feb;27(2):378-83. Vandevoorde J, Verbanck S, Schuermans D, Kartounian J, Vincken W. Dept of General Practice, Academic Hospital, University of Brussels, Brussels, Belgium.

The purpose of this study was to determine fixed cut-off points for forced expiratory volume in one second (FEV(1))/FEV(6) and FEV(6) as an alternative for FEV(1)/forced vital capacity (FVC) and FVC in the detection of obstructive and restrictive spirometric patterns, respectively.

For the study, a total of 11,676 spirometric examinations, which took place on Caucasian subjects aged between 20-80 yrs, were analysed. Receiver-operator characteristic curves were used to determine the FEV(1)/FEV(6) ratio and FEV(6) value that corresponded to the optimal combination of sensitivity and specificity, compared with the commonly used fixed cut-off term for FEV(1)/FVC and FVC.

The data from the current study indicate that FEV(1)/ FEV(6) <73% and FEV(6) <82% predicted can be used as a valid alternative for the FEV(1)/FVC <70% and FVC <80% pred cut-off points for the detection of obstruction and restriction, respectively. The statistical analysis demonstrated very good, overall, agreement between the two categorisation schemes. For the spirometric diagnosis of airway obstruction (prevalence of 45.9%), FEV(1)/FEV(6) sensitivity and specificity were 94.4 and 93.3%, respectively; the positive and negative predictive values were 92.2 and 95.2%, respectively. For the spirometric detection of a restrictive pattern (prevalence of 14.9%), FEV(6) sensitivity and specificity were 95.9 and 98.6%, respectively; the positive and negative predictive values were 92.2 and 99.3%, respectively.

This study demonstrates that forced expiratory volume in one second/forced expiratory volume in six seconds <73% and forced expiratory volume in six seconds <82% predicted, can be used as valid alternatives to forced expiratory volume in one second/forced vital capacity <70% and forced vital capacity <80% predicted, as fixed cut-off terms for the detection of an obstructive or restrictive spirometric pattern in adults.

Effects of environmental tobacco smoke on respiratory symptoms and pulmonary function.

Inhal Toxicol. 2006 Jul;18(8):569-73. Alipour S, Deschamps F, Lesage FX. Department of Occupational Health, Faculty of Medicine, Reims Cedex, France.

The aim of this study was to examine the effects of environmental tobacco smoke (ETS) on pulmonary function and respiratory symptoms. During periodic medical examination, 392 French nonsmokers responded to an interviewer-administered questionnaire. Then spirometry was performed to assess pulmonary function. All of the subjects were carefully examined by two occupational physicians.

ETS exposure at the workplace was more common than this exposure at home (20% vs. 5%). ETS exposure was significantly associated with forced vital capacity (FVC; -3.16%; 95% CI: -5.67 to -0.64) and forced expiratory volume in 1s (FEV1; -2.90%; 95% CI: -5.59 to -0.23). Abnormal FVC results were significantly increased in exposed subgroup [odds ratio = 2.71 (95% CI: 1.09 to 6.75)]. We did not find any significant dose-response relationship between ETS exposure and lung function results. The effects of ETS exposure on respiratory symptoms and diseases (asthma, wheezing, chronic bronchitis, and dyspnea) were not significant.

Thus, this study showed that there was a significant inverse association between exposure to ETS and pulmonary function. Even pulmonary function results inferior to the lower limit of normal may be possible. A stricter legislation against ETS is proposed.

Smoking cessation-but not smoking reduction-improves the annual decline in FEV(1) in occupationally exposed workers.

Bohadana AB, Nilsson F, Westin A, Martinet N, Martinet Y
Respir Med. 2005 Dec 12
INSERM ERI 11, Faculte de Medecine, B.P. 184-9, Av de la Foret de Haye, 54505 Vandoeuvre-les-Nancy Cedex, France; Service de Pneumologie, CHU de Nancy, INSERM EMI 0014, Vandoeuvre-les-Nancy, France.

INTRODUCTION: Individuals exposed both to cigarette smoke and respiratory pollutants at work incur a greater risk of development of airway hyperresponsiveness (AHR) and accelerated decline in forced expiratory volume in 1s (FEV(1)) than that incurred by subjects undergoing each exposure separately. We examined whether smoking cessation or smoking reduction improves AHR and thereby slows down the decline in FEV(1) in occupationally exposed workers.

METHODS: We examined 165 workers (137 males and 28 females) participating in a smoking cessation programme. Nicotine tablets were used for smoking cessation or smoking reduction. Respiratory symptoms were assessed by questionnaire, FEV(1) by spirometry and AHR by methacholine challenge test. At 1 year, subjects were classified into quitters, reducers, or continuing smokers.

RESULTS: Sixty-seven subjects completed the study (32 quitters; 17 reducers; 18 continuing smokers). Respiratory symptoms improved markedly in quitters (P<0.001 for all comparisons) and less so in reducers (P values between 0.163 and 0.027). At 1 year, FEV(1) had slightly but significantly improved in quitters (P=0.006 vs. smokers; P=0.038 vs. reducers) and markedly deteriorated in reducers and continuing smokers. Concurrent, 1-year change in AHR did not differ significantly among the groups.

CONCLUSION: In occupationally exposed workers, stopping smoking markedly improved respiratory symptoms and, in males, slowed the annual decline in FEV(1). Smoking reduction resulted in smaller improvements in symptoms but deterioration in FEV(1). These findings were independent of AHR. While smoking cessation should remain the ultimate goal in workplace cessation programmes more studies are necessary to better ascertain the benefits of smoking reduction.

Spirometry in the primary care setting: influence on clinical diagnosis and management of airflow obstruction.

Chest. 2005 Oct;128(4):2443-7. Dales RE, Vandemheen KL, Clinch J, Aaron SD. Department of Medicine, University of Ottawa, Ottawa, ON, Canada.

STUDY OBJECTIVE: To determine if screening spirometry in the primary care setting influences the physician's diagnosis and management of obstructive lung disease.

DESIGN: Diagnosis and management assessed before and after the intervention of screening spirometry.

PARTICIPANTS: A total of 1,034 patients who had ever smoked and were at least 35 years of age presenting to primary care practices for any reason.

SETTING: Rural primary care practices.

MEASUREMENTS AND RESULTS: Physicians were asked prior to and following presentation of spirometry test results if they thought airflow obstruction was present and if they planned to change management based on the results. A new diagnosis of unsuspected airflow obstruction was made by the physician in 93 patients (9%), and a prior diagnosis of airflow obstruction was removed after spirometry in 115 patients (11%). After viewing the spirometry results, physicians reported that they would change patient management in 154 patients (15%). Most planned management changes occurred when airflow obstruction was newly diagnosed (57 of 93 patients, 61%) and when the diagnosis of airflow obstruction remained unchanged (80 of 195 patients, 41%). A 6-month chart review documented the addition of respiratory medications in 8% of patients.

CONCLUSION: Screening spirometry influences physicians' diagnosis of airflow obstruction and management plans especially in patients with moderate-to-severe obstruction.

Spirometry in the primary care setting: influence on clinical diagnosis and management of airflow obstruction

Chest. 2005 Oct;128(4):2443-7 Dales RE, Vandemheen KL, Clinch J, Aaron SD. Division of Respirology, The Ottawa Hospital (General Campus), 501 Smyth Rd, Box 211, Ottawa, ON K1H 8L6, Canada.

STUDY OBJECTIVE: To determine if screening spirometry in the primary care setting influences the physician's diagnosis and management of obstructive lung disease.

DESIGN: Diagnosis and management assessed before and after the intervention of screening spirometry.

PARTICIPANTS: A total of 1,034 patients who had ever smoked and were at least 35 years of age presenting to primary care practices for any reason.

SETTING: Rural primary care practices.

CONCLUSION: Screening spirometry influences physicians' diagnosis of airflow obstruction and management plans especially in patients with moderate-to-severe obstruction.

Prevalence of chronic obstructive pulmonary disease in Japanese people on medical check-up.

Tohoku J Exp Med. 2005 Sep;207(1):41-50. Takemura H, Hida W, Sasaki T, Sugawara T, Sen T. SS30 Clinic Health Screening Center, Sendai, Japan.

In Japan, spirometry has not been included as an item in medical check-ups for all persons. The purpose of this study was to show evidence to recommend spirometry routinely on medical check-up for the early detection of chronic obstructive pulmonary disease (COPD). There were 12,760 enrolled persons who underwent medical check-up. COPD was defined as a ratio of forced expiratory volume in one second to slow vital capacity of 70% or less. We investigated the prevalence and its characteristics of COPD in people on medical check-up. The prevalence of COPD was 3.6% in all subjects, 4.5% in males, and 1.8% in females. In the comparison between males and females, the prevalence of COPD in males of most age groups was higher than that of females, and this difference was greater with aging. Males in their 50s and over 60 years old and females over 60 years old showed remarkably high prevalences. Occupations associated with a high smoking rate such as transportation-related occupations showed a higher prevalence of COPD. These results suggest that spirometry for all persons in medical check-ups can identify many COPD patients not aware of this disease. Spirometry should be carried out routinely on medical check-up.

Clinical application of portable spirometry in asthma

Zhongguo Yi Xue Ke Xue Yuan Xue Bao. 2005 Jun;27(3):337-43. Yin XW, Han JN, Zhu YJ, Xu WB, Van de Woestijne KP, Van den Bergh O. Department of Pneumology, PUMC Hospital, CAMS and PUMC, Beijing 100730, China.

OBJECTIVE: To investigate the clinical applications of portable spirometry in asthma. METHODS: Twenty patients with asthma were recruited from Peking Union Medical College Hospital. Flow-volume loop, simultaneous asthma symptoms, and mood were monitored three times a day for consecutive 14 days.

RESULTS: In patients with a normal daytime spirometry, marked decline of forced expiratory volume in one second (FEV1) and peak expiratory flow (PEF) were observed at night and/or in the early morning. A within subject correlation analysis between FEV1, PEF, and asthma symptoms showed that the correlation between symptoms and airway obstruction was found only in seven out of twenty patients (35%). Four patients (20%) reported many symptoms with nearly normal portable spirometry. Accordingly, their symptoms were not correlated with FEV1 and PEF. This group of patients was defined as over-perceivers. On the contrary, another two patients (10%) did not report any symptoms while obvious airways obstruction was recorded by a portable spirometry. These patients were defined as under-perceivers.

CONCLUSIONS: Dynamic monitoring of flow-volume loop with a portable spirometry is more accurate than routine lung function test in assessment of asthma severity. In addition, combined with simultaneous monitoring of symptoms, it would be of particularly helpful in identifying two specific types of asthma patients, e.g. over-perceivers and under-perceivers.

FEV1/FEV6 and FEV6 as an alternative for FEV1/FVC and FVC in the spirometric detection of airway obstruction and restriction.

Chest. 2005 May;127(5):1560-4. Vandevoorde J, Verbanck S, Schuermans D, Kartounian J, Vincken W. Department of General Practice, Dutch-Speaking University of Brussels (Vrije Universiteit Brussel), Brussels, Belgium.

STUDY OBJECTIVES: To evaluate the use of the FEV(1)/forced expiratory volume at 6 s of exhalation (FEV(6)) ratio and FEV(6) as an alternative for FEV(1)/FVC and FVC in the detection of airway obstruction and lung restriction, respectively.

SETTING: Pulmonary function laboratory of the Academic Hospital of the Free University of Brussels.

PARTICIPANTS: A total of 11,676 spirometric examinations were analyzed on subjects with the following characteristics: white race; 20 to 80 years of age; 7,010 men and 4,666 women; and able to exhale for at least 6 s.

METHODS: Published reference equations were used to determine lower limits of normal (LLN) for FEV(6), FVC, FEV(1)/FEV(6), and FEV(1)/FVC. We considered a subject to have obstruction if FEV(1)/FVC was below its LLN. A restrictive spirometric pattern was defined as FVC below its LLN, in the absence of obstruction. From these data, sensitivity and specificity of FEV(1)/FEV(6) and FEV(6) were calculated.

RESULTS: For the spirometric diagnosis of airway obstruction, FEV(1)/FEV(6) sensitivity was 94.0% and specificity was 93.1%; the positive predictive value (PPV) and negative predictive value (NPV) were 89.8% and 96.0%, respectively. The prevalence of obstruction in the entire study population was 39.5%. For the spirometric detection of a restrictive pattern, FEV(6) sensitivity was 83.2% and specificity was 99.6%; the PPVs and NPVs were 97.4% and 96.9%, respectively. The prevalence of a restrictive pattern was 15.7%. Similar results were obtained for male and female subjects. When diagnostic interpretation differed between the two indexes, measured values were close to the LLN.

CONCLUSIONS: The FEV(1)/FEV(6) ratio can be used as a valid alternative for FEV(1)/FVC in the diagnosis of airway obstruction, especially for screening purposes in high-risk populations for COPD in primary care. In addition, FEV(6) is an acceptable surrogate for FVC in the detection of a spirometric restrictive pattern. Using FEV(6) instead of FVC has the advantage that the end of a spirometric examination is more explicitly defined and is easier to achieve.

Attaining a correct diagnosis of COPD in general practice.

Respir Med. 2005 Apr;99(4):493-500. Epub 2004 Nov 11 Bolton CE, Ionescu AA, Edwards PH, Faulkner TA, Edwards SM, Shale DJ. Section of Respiratory Medicine and Communicable Diseases, University of Wales College of Medicine, Academic Centre, Llandough Hospital, Penlan Road, Llandough CF64 2XX, Vale of Glamorgan, South Wales, UK.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is common. Diagnosis should include objective evidence of airways obstruction and spirometry is recommended in guidelines and the general medical services contract in the UK. We assessed the impact of spirometry in general practice.

METHOD: We determined by questionnaire the availability, staff training, use and the interpretation results of spirometry in 72% of general practices in Wales. We reviewed the diagnosis of COPD previously made in two general practices without spirometry.

RESULTS: Most practices had a spirometer (82.4%) and used it (85.6%). Confidence in use and interpretation of results varied widely: 58.1% were confident in use and 33.8% confident in interpretation. Spirometry was performed more often if confident in use and interpretation (both P<0.001) and was related to greater training periods (P<0.001). Spirometric confirmation of COPD varied widely (0-100%, median 37%). Of the 125 patients previously diagnosed with COPD 61 had spirometric confirmation, while 25 had reversible obstruction (range 210-800 mls), 34 had normal and 5 had restrictive spirometry.

CONCLUSION: Despite incentives to perform spirometry in general practice, lack of adequate training in use and interpretation suggests use is confounded and the diagnosis of COPD is likely to be made on imprecise clinical grounds.

Smoking cessation, lung function, and weight gain: a follow-up study.

Lancet. 2005 May;365(9471):1629-35; discussion 1600-1. Chinn S, Jarvis D, Melotti R, Luczynska C, Ackermann-Liebrich U, Anto JM, Cerveri I, de Marco R, Gislason T, Heinrich J, Janson C, Kunzli N, Leynaert B, Neukirch F, Schouten J, Sunyer J, Svanes C, Vermeire P, Wjst M, Burney P. Department of Public Health Sciences, King's College London, 5th Floor Capital House, 42 Weston Street, London SE1 3QD, UK.

BACKGROUND: Only one population-based study in one country has reported effects of smoking cessation and weight change on lung function, and none has reported the net effect. We estimated the net benefit of smoking cessation, and the independent effects of smoking and weight change on change in ventilatory lung function in the international European Community Respiratory Health Survey.

METHODS: 6654 participants in 27 centres had lung function measured in 1991-93, when aged 20-44 years, and in 1998-2002. Smoking information was obtained from detailed questionnaires. Changes in lung function were analysed by change in smoking and weight, adjusted for age and height, in men and women separately and together with interaction terms.

FINDINGS: Compared with those who had never smoked, decline in FEV1 was lower in male sustained quitters (mean difference 5.4 mL per year, 95% CI 1.7 to 9.1) and those who quit between surveys (2.5 mL, -1.9 to 7.0), and greater in smokers (-4.8 mL, -7.9 to -1.6). In women, estimates were 1.3 mL per year (-1.5 to 4.1), 2.8 mL (-0.8 to 6.3) and -5.1 mL (-7.5 to -2.8), respectively. These sex differences were not significant. FEV1 changed by -11.5 mL (-13.3 to -9.6) per kg weight gained in men, and by -3.7 mL per kg (-5.0 to -2.5) in women, which diminished the benefit of quitting by 38% in men, and by 17% in women.

INTERPRETATION: Smoking cessation is beneficial for lung function, but maximum benefit needs control of weight gain, especially in men.

Relevance of a portable spirometer for detection of small airways obstruction.

Pediatr Pulmonol. 2005 Feb;39(2):178-84. Ezzahir N, Leske V, Peiffer C, Trang H. Service de Physiologie, Hopital Robert Debre, Paris, France.

While portable spirometers are increasingly used, little attention has been paid to test their validity for measurement of flows in small airways. The aim of this study was to compare the Spirotel portable spirometer to a laboratory spirometer (Jeager PFT), with regard to accuracy in measuring forced expiratory flows, and more specifically those influenced by small airways (FEF(25-75)).

Fifty-nine children (mean age, 12 years; range, 7-17), were studied at baseline and after a bronchodilator inhalation. Spirometers were tested separately in a randomly designed order. A total of 117 sessions of flow-volume curves was performed with each spirometer. We obtained at least two acceptable and reproducible curves in 88% and 76% of the sessions, with the laboratory and the portable spirometers, respectively. Unacceptable curves were easily detected by visual inspection of flow-time and flow-volume waveforms.

Agreement was excellent between spirometers for the measurement of all expiratory flows, both at baseline and postbronchodilator. More specifically, agreement between spirometers was as high for measurements of FEF(25-75) (intraclass correlation coefficients 0.97) as for proximal flows. High correlations were found between baseline expiratory flows measured by each spirometer (and expressed as percent of predicted values), both in large and small airways (P < 0.001). The portable spirometer was highly sensitive for detecting small airways obstruction, as compared to the laboratory spirometer. Finally, the magnitudes of bronchodilator-related flow changes were also highly correlated, both in large and small airways (P < 0.001 and P = 0.004, respectively).

We conclude that the Spirotel portable spirometer is reliable for measurement of forced expiratory flows, in large and small airways, provided that all curve waveforms can be stored and available for visual inspection.

beta-Blockers and Inspiratory Pulmonary Function in Chronic Heart Failure.

J Card Fail. 2005 Mar;11(2):112-6. Witte KK, Clark AL.

Background: Chronic heart failure (CHF) patients complain of breathlessness and fatigue. Respiratory muscle function is impaired in CHF patients and may contribute to their symptoms. beta-blockers cause fatigue but have become part of the standard management of CHF. We explored the relation between respiratory muscle power in CHF and the effects of long-term beta-blockade.

Methods and Results: A total of 52 CHF patients and 25 control subjects underwent echocardiography, peak exercise testing with metabolic gas exchange analysis, and measurement of forced vital capacity (FVC), forced expiratory volume in 1 second (FEV 1 ), peak inspiratory flow (PIF), and forced inspiratory volume in 1 second (FIV 1 ). Of the patients, 35 started beta-blocker therapy and were tested again at 1 year. Patients had lower peak oxygen consumption (pV o 2 ) (19.3 [4.5] versus 37.3 [8.4] mL/kg/min, P < .0001), exercise time (414 [134] versus 817 [193] seconds, P < .0001), and anaerobic threshold (13.8 [3.8] versus 27.2 [8.2] mL/kg/min, P < .0001). Patients also had a steeper relationship between ventilation (V e ) and carbon dioxide (CO 2 ) (V e /V co 2 ) (40.0 [6.8] versus 26.4 [2.0], P < .0001); lower FEV 1 , FVC, and FIV 1 (89 [15] versus 111 [24]% expected, P < .0001, 80 [20] versus 94 [21]% expected, P < .001 and 2.5 [1.6] versus 3.0 (0.9) L, P < .02); and there was a correlation between pVo 2 and FIV 1 ( r = 0.24, P < .05) for the patients. The slope relating symptoms of breathlessness (Borg score) to ventilation (Borg/V e slope) also correlated with FIV 1 ( r = 0.36, P < .02). beta-blocker therapy improved echocardiographic variables, but not pV o 2 . There was no change in PIF or FIV 1. There was a significant reduction in FEV 1 after beta-blocker treatment ( P < .01).

Conclusion: Inspiratory flows are impaired in patients with chronic heart failure and correlate with the degree of functional impairment. This may be due to a combination of respiratory muscle weakness and reduced lung compliance. The reduction in inspiratory capacity is not influenced by long-term beta-blockade.

Benefits of and barriers to the widespread use of spirometry.

Curr Opin Pulm Med. 2005 Mar;11(2):115-20. Petty TL. University of Colorado Health Sciences Center, Denver, Colorado, USA.

PURPOSE OF REVIEW: To review the basis for spirometry, its benefits in diagnosing and managing both acute and chronic pulmonary disorders with emphasis on chronic obstructive pulmonary disease, and to critically examine the barriers to its widespread use.

RECENT FINDINGS: A number of recent articles have established the scientific basis for spirometry in the early identification of chronic obstructive pulmonary disease and in improving smoking cessation in patients with chronic obstructive pulmonary disease. Economic and other considerations are reported.

SUMMARY: Spirometry is an important office diagnostic device that should be used by all primary care and most specialist physicians. Spirometry is to dyspnea as the electrocardiogram is to chest pain.

Are symptom reports useful for differentiating between acute rejection and pulmonary infection after lung transplantation?

Heart Lung. 2004 Nov-Dec;33(6):372-80.De Vito Dabbs A, Hoffman LA, Iacono AT, Zullo TG, McCurry KR, Dauber JH. Department of Acute and Tertiary Care, School of Nursing, University of Pittsburgh, 336 Victoria Bldg., Pittsburgh, PA 15261, USA.

BACKGROUND: Prompt treatment of acute rejection and pulmonary infection reduces morbidity and mortality in lung transplant recipients. Symptoms, spirometry, and bronchoscopy are used to detect these complications. Of these, symptom reporting is the least invasive, yet has received little critical examination.

OBJECTIVE: To examine the potential for using reports of symptoms, such as cough and shortness of breath, to recognize clinically significant acute rejection and pulmonary infection after lung transplantation.

METHODS: Symptoms reported during routine follow-up visits were compared between lung transplant recipients (LTR) with clinically significant acute rejection (grade >or= A2) and those without (grade A0 or A1) and between LTR with rejection (grade >or= A2) and those with pulmonary infection.

RESULTS: LTR with rejection (grade >or= A2) reported more symptoms (P<0.01) than did those without (grade A0, A1); however, the magnitude of difference was minimal. LTR with clinically significant acute rejection (grade >or= A2) reported symptoms at a rate comparable with those having pulmonary infection.

CONCLUSIONS: Although symptoms may alert LTR to changes in their condition, no symptoms (respiratory, general, or activities of daily living [ADL]) differentiate between grades of rejection or pulmonary infection.

Impact of spirometry on GPs' diagnostic differentiation and decision-making.

Respir Med. 2004 Nov;98(11):1124-30 Chavannes N, Schermer T, Akkermans R, Jacobs JE, van de Graaf G, Bollen R, van Schayck O, Bottema B. Centre for Quality of Care Research, University Medical Centre St Radboud, Nijmegen, The Netherlands.

BACKGROUND: Spirometry is increasingly implemented in general practice, while the ability of general practitioners (GPs) to interpret flow volume curves (F-V curves) has been questioned. Furthermore, the role of spirometry in the GPs decision-making process has barely been studied. AIM: To compare the achievements of trained GPs in spirometric diagnosis with an expert consensus panel (1) and to assess the influence of spirometry on the GPs decision-making (2). METHOD: Twelve cases including a wide range of F-V curves were interpreted by 39 GPs as well as the expert panel. Diagnostic test characteristics were calculated using multi-level analysis and summarised by diagnostic odds ratios (DOR). Differences in decision-making indicators were expressed as odds ratios and 95% confidence intervals. RESULTS: Normal F-V curves (DOR 65.0) and obstructive F-V curves (DOR 48.9) were reasonably well diagnosed, while rare and mixed pathological patterns achieved considerably lower scores (DOR 3.8). Intermediate scores were obtained in the recognition of incorrect test manoeuvres (DOR 24.4). Spirometry influenced the GPs decision-making in reducing the number of alternative diagnoses (OR 0.266 [0.200, 0.353]), but also increased referral rates (7.26 [4.71, 11.2]) and the use of diagnostic prednisolone courses (4.55 [3.12, 6.64]) substantially. CONCLUSION: Trained GPs were able to differentiate between normal and obstructive disease patterns, while F-V curves suggestive of rare and mixed pathology were often missed. Spirometry seems to influence the decision-making process of the GP; whether this represents an initial or a more sustained effect remains to be evaluated in studies of daily primary care practice.

Parental Smoking and Airway Reactivity in Healthy Infants.

Am J Respir Crit Care Med. 2004 Oct 22 Tepper RS, Williams-Nkomo T, Martinez T, Kisling J, Coates C, Daggy J. Department of Pediatrics, Indiana University Medical Center, Indianapolis, IN, USA.

Parental tobacco smoking is associated with lower airway function and an increased incidence of wheezy respiratory illnesses in infants. We evaluated in 76 healthy infants whether exposure to parental tobacco smoking was associated with airway hyper-reactivity, which could contribute to lower airway function and the increased wheezy illnesses. Airway function was measured using the raised volume rapid thoracic compression technique and airway reactivity was assessed by methacholine challenge (0.015 - 10 mg/ml), which was stopped for >30% decrease in FEF75 or the final dose with < 30% decrease. Parental tobacco smoking was associated with lower baseline airway function (FEF50: 600 vs. 676 ml/s, p < 0.04 and FEF25-75: 531 vs. 597 ml/s, p < 0.05). Infants exposed to tobacco smoking were about half as likely to develop >30% decline in FEF75 at any given MCh dose (hazard ratio = 0.4, p = 0.001). In addition, a history of asthma in an extended family member increased the likelihood that an infant would develop >/=30% decline in FEF75 (hazard ratio=1.7, p=0.04). We conclude that exposure to parental smoking is associated with lower airway function, but not increased airway reactivity; however, family history of asthma is associated with heightened airway reactivity.

Pulmonary outcome in adolescents of extreme preterm birth: a regional cohort study.

Acta Paediatr. 2004 Oct;93(10):1294-300. Halvorsen T, Skadberg BT, Eide GE, Roksund OD, Carlsen KH, Bakke P. Department of Paediatrics, Haukeland University Hospital, and Institute for Clinical and Molecular Medicine, University of Bergen, Norway.

AIMS: The pulmonary outcome of extreme prematurity remains to be established in adults. We determined respiratory health and lung function status in a population-based, complete cohort of young preterms approaching adulthood. METHODS: Forty-six preterms with gestational age < or = 28 wk or birthweight < or = 1000 g, born between 1982 and 1985, were compared to the temporally nearest term-born subject of equal gender. Spirometry, plethysmography, reversibility test to salbutamol and methacholine bronchial provocation test were performed. Neonatal data were obtained from hospital records and current symptoms from validated questionnaires. RESULTS: When entering the study at a mean age of 17.7 (SD: 1.2) y, a doctor's diagnosis of asthma and use of asthma inhalers were significantly more prevalent among preterms than controls (one asthmatic control compared to nine preterms, all but one using asthma inhalers). Peak expiratory flow (PEF) and forced expiratory volume in 1 s (FEV1) were decreased and the discrepancies relative to controls increased parallel to increased severity of neonatal lung disease. Parameters of increased neonatal oxygen exposure significantly predicted FEV1. Adjusted for height, gender and age, FEV1 was reduced by a mean of 580 ml/s in subjects with a history of bronchopulmonary dysplasia. Fifty-six percent of preterms had a positive methacholine provocation test compared to 26% of controls. CONCLUSION: A substantially decreased FEV1, increased bronchial hyperresponsiveness and a number of established risk factors for steeper age-related decline in lung function were observed in preterms. A potential for early onset chronic obstructive pulmonary disease is present in subsets of this group.

Relations between respiratory symptoms and spirometric values in young adults: the European community respiratory health study.

Respir Med. 2004 Oct;98(10):1025-33. Sunyer J, Basagana X, Roca J, Urrutia I, Jaen A, Anto JM, Burney P; ECRHS study. Institut Municipal Investigacio Medica, Doctor Aiguader 80, Unitat de Recerca Respiratoria i Ambiental, 08003 Barcelona, Catalonia, Spain.

We aim to assess whether respiratory symptoms are associated with lung function in young adults, and whether any such relation is similar in those with asthma, in men and women, and in different countries. Study participants (aged 20-44 years) were randomly selected from the general population in 35 centres in 15 countries as part of the European Community Respiratory Health Study. In all, 12,541 subjects (47%) completed a respiratory symptoms questionnaire and spirometry, metacholine challenge and immunoglobulin E tests. Indicators of diagnosed asthma showed the largest association with airways obstruction (FEV1--maximal 1-s forced expiratory volume/forced vital capacity--FVC < 70%), followed by symptoms of wheezing or shortness of breath, in both genders. Among the 96% of subjects whose FEV1/FVC ratios were greater or equal to 70%, wheezing or shortness of breath was associated with lower FEV1 levels (-211 ml in men and -169 ml in women (P < 0.01)), independent of diagnosed asthma, smoking, atopy or bronchial responsiveness. This association was not explained by a lower FVC. Symptoms of chronic bronchial mucus hypersecretion (chronic phlegm) were unrelated to both airways obstruction and FEV1 levels. Findings were homogeneous across all centres. These results suggest that lung diseases that cause wheezing are generally associated with impaired lung function.

Office spirometry significantly improves early detection of COPD in general practice: the DIDASCO Study.

Chest. 2004 Apr;125(4):1394-9. Buffels J, Degryse J, Heyrman J, Decramer M; DIDASCO Study. Department of General Practice, Katholieke Universiteit, Leuven, Belgium.

STUDY OBJECTIVES: To determine if spirometry is essential for the early detection of COPD in general practice, compared to the screening value of a short questionnaire. METHODS: A prospective survey of the population aged 35 to 70 years visiting their general practitioner (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. Twenty GPs were provided with a hand-held spirometer, and received training in performance and interpretation of lung function tests. All 35- to 70-year-old patients (n = 3,408) were screened for current use of bronchodilators. The subgroup receiving bronchodilators (n = 250, 7%) was assumed to have OLD, and was excluded. Airflow obstruction was defined according to the European Respiratory Society standards. RESULTS: The positive predictive power of the questionnaire was low (sensitivity, 58%; specificity, 78%; likelihood ratio, 2.6). One hundred twenty-six cases of formerly unknown OLD were detected in the group of patients with complaints, vs an extrapolated number of 90 in the group without complaints. 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. CONCLUSIONS: 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.

Association between the forced midexpiratory flow/forced vital capacity ratio and bronchial hyperresponsiveness.

Arch Bronconeumol. 2004 Sep;40(9):397-402. Urrutia I, Capelastegui A, Quintana JM, Muniozguren N, Payo F, Martinez Moratalla J, Maldonado JA, Basagana X, Anto JM, Sunyer J. Servicio de Neumologia. Hospital de Galdakao. Galdakao. Vizcaya. Espana.

Objective: A long-standing hypothesis is that a low ratio of airway caliber to lung size is associated with bronchial hyperresponsiveness (BHR). The aim of our study was to measure the association between airway caliber relative to lung size (expressed as the ratio between forced expiratory flow, midexpiratory phase, divided by forced vital capacity [FEF25%-75%/FVC]) and BHR measured by a methacholine challenge test, adjusting for age, height, sex, smoking history, geographic area, respiratory symptoms, and baseline forced expiratory volume in 1 second (FEV1). Material and methods: We carried out a multicenter cross-sectional study of the general Spanish population in 2647 subjects from the European Community Respiratory Health Survey (ECRHS I). The ECRHS questionnaire was administered, total and specific immunoglobulin E were measured, and skin tests, spirometry, and a methacholine challenge test were performed.Results: We show the relationship of the various clinical and sociodemographic variables with the 2 parameters indicative of a positive methacholine test. The lower the FEF25%-75%/FVC ratio was, the greater the risk of HRB, after adjustment for variables (odds ratio [OR]=0.09; 95% confidence interval [CI], 0.04-0.018 for the concentration provoking a 20% decrease in FEV1, and OR=0.06; 95% CI, 0.03-0.12 for the dose provoking a 20% decrease in FEV1). Conclusions: There is a significant association between the FEF25%-75%/FVC ratio and BHR after adjustment for age, atopy, smoking, geographic area, respiratory symptoms, and initial FEV1.

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