COPD is a leading cause of morbidity and mortality worldwide. Spirometry is the most common lung function test for diagnosing COPD with a post-bronchodilator FEV1/FVC < 0.70 confirming the presence of the disease. However, diagnosticians appear reluctant to use bronchodilators, which have been linked to the misdiagnosis of COPD. Therefore, we investigated whether the threshold for diagnosing COPD should be modified when diagnosing COPD based on pre-bronchodilator spirometry.
METHODS:
Data from 23,433 participants were merged from the National Health and Nutrition Examination Survey (NHANES) 2007–2012. Participants were excluded for having no post-bronchodilator spirometry, for being below the age of 40, and for having asthma or lung cancer. These exclusion criteria resulted in 680 participants being included in the present study. Participants with COPD were defined as those with a post-bronchodilator FEV1/FVC < 0.70. The threshold for diagnosing COPD based on pre-bronchodilator FEV1/FVC was varied while calculating accuracy, sensitivity, specificity, positive predictive value, and negative predictive value.
RESULTS:
Diagnosing COPD based on pre-bronchodilator FEV1/FVC < 0.70 contributes to the misdiagnosis of COPD through poor classification rates. By adjusting the threshold and diagnosing COPD based on a pre-bronchodilator FEV1/FVC < 0.66, the overall classification rates increase noticeably, resulting in a 15% increase in accuracy.
CONCLUSION:
We suggest a slight adjustment using pre-bronchodilator FEV1/FVC < 0.66 when diagnosing COPD based on pre-bronchodilator spirometry. This approach could prevent cases of misdiagnosed COPD, which can lead to potentially harmful treatment of people who do not have COPD and foregone treatment in patients with COPD.
Global Initiative for Chronic Obstructive Lung Disease. Pocket Guide to COPD Diagnosis, Management, and Prevention: A Guide for Health Care Professionals, 2017 edition. https://goldcopd.org/download/361/. Accessed August 3, 2018.
2.
BousquetJ, KhaltaevN. Global surveillance, prevention and control of chronic respiratory diseases: a comprehensive approach. Geneva, Switzerland: World Health Organization; 2007: 1–146.
3.
LozanoR, NaghaviM, ForemanK, LimS, ShibuyaK, AboyansV, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet, 2012; 380(9859):2095–2128.
4.
CelliBR, DecramerM, WedzichaJA, WilsonKC, AgustíA, CrinerGJ, et al. An official American Thoracic Society/European Respiratory Society statement: research questions in chronic obstructive pulmonary disease. Am J Respir Crit Care Med, 2015; 191(7):e4–e27.
5.
AggarwalAN, GuptaD, AgarwalR, JindalSK. Comparison of the lower confidence limit to the fixed-percentage method for assessing airway obstruction in routine clinical practice. Respir Care, 2011, 56(11):1778–1784.
6.
CerveriI, CorsicoAG, AccordiniS, NinianoR, AnsaldoE, AntóJM, et al. Underestimation of airflow obstruction among young adults using FEV1/FVC <70% as a fixed cut-off: a longitudinal evaluation of clinical and functional outcomes. Thorax, 2008; 63(12):1040–1045.
7.
SchermerTRJ, SmeeleIJM, ThoonenBP, LucasAEM, GrootensJG, van BoxemTJ, et al. Current clinical guideline definitions of airflow obstruction and COPD overdiagnosis in primary care. Eur Respir J, 2008; 32(4):945–952.
8.
PistelliR, FerraraL, MisuracaC, BustacchiniS. Practical management problems of stable chronic obstructive pulmonary disease in the elderly. Curr Opin Pulm Med, 2011; 17(Suppl 1):S43–S48.
9.
BrazzaleDJ, UpwardAL, PrettoJJ. Effects of changing reference values and definition of the normal range on interpretation of spirometry. Respirology, 2010; 15(7):1098–1103.
10.
HansenJE, SunXG, WassermanK. Spirometric criteria for airway obstruction: use percentage of FEV1/FVC ratio below the fifth percentile, not <70%. Chest, 2007; 131(2):349–355.
11.
HardieJA, BuistAS, VollmerWM, EllingsenI, BakkePS, MørkveO. Risk of over-diagnosis of COPD in asymptomatic elderly never-smokers. Eur Respir J, 2002; 20(5):1117–1122.
12.
HangaardS, HelleT, NielsenC, Hejles. Causes of misdiagnosis of chronic obstructive pulmonary disease: a systematic scoping review. Respir Med, 2017; 129:63–84.
13.
GüderG, BrennerS, AngermannCE, ErtlG, HeldM, SachsAP, et al. GOLD or lower limit of normal definition? A comparison with expert-based diagnosis of chronic obstructive pulmonary disease in a prospective cohort-study. Respir Res, 2012; 13(1):13.
14.
DeromE, van WeelC, LiistroG, BuffelsJ, SchermerT, LammersE, et al. Primary care spirometry. Eur Respir J, 2008; 31(1):197–203.
15.
ArneM, LisspersK, StällbergB, BomanG, HedenströmH, JansonC, EmtnerM. How often is diagnosis of COPD confirmed with spirometry?. Respir Med, 2010; 104(4):550–556.
16.
MiravitllesM, de la RozaC, NaberanK, LambanM, GobarttE, MartinA. Use of spirometry and patterns of prescribing in COPD in primary care. Respir Med, 2007; 101(8):1753–1760.
17.
National Center for Health Statistics. National Health and Nutrition Examination Survey. Atlanta, Georgia: Centers for Disease Control and Prevention. https://www.cdc.gov/nchs/nhanes/. Accessed May 28, 2018.
RaherisonC, GirodetPO. Epidemiology of COPD. Eur Respir Rev, 2009; 18(114):213–221.
20.
KnudsonRJ, SlatinRC, LebowitzMD, BurrowsB. The maximal expiratory flow-volume curve normal standards, variability, and effects of age. Am Rev Respir Dis, 1976; 113(5):587–600.
21.
ManninoDM, Diaz-GuzmanE, BuistS. Pre- and post-bronchodilator lung function as predictors of mortality in the Lung Health Study. Respir Res, 2011; 12:136.
22.
Mohamed HoeseinFAA, ZanenP, SachsAPE, VerheijTJM, LammersJWJ, BroekhuizenBDL. Spirometric thresholds for diagnosing COPD: 0.70 or LLN, pre- or post-dilator values?. COPD, 2012; 9(4):338–343.
23.
JohannessenA, OmenaasER, BakkePS, GulsvikA. Implications of reversibility testing on prevalence and risk factors for chronic obstructive pulmonary disease: a community study. Thorax, 2005; 60(10):842–847.
24.
WaheedZ, IrfanM, HaqueAS, SiddiquiNH, AwanS, SyedB, KhanJA. Assessing two spirometric criteria of pre-bronchodilator and post-bronchodilator FEV1/FVC ratio in detecting air flow obstruction. J Pak Med Assoc, 2011; 61(12):1172–1175.
25.
Probst-HenschNM, CurjuricI, Pierre-OlivierB, Ackermann-LiebrichU, BettschartRW, BrändliO, et al. Longitudinal change of prebronchodilator spirometric obstruction and health outcomes: results from the SAPALDIA cohort. Thorax, 2010; 65(2):150–156.
26.
ChenCZ, OuCY, WangWL, LeeCH, LinCC, ChangHY, HsiueTR. Using post-bronchodilator FEV1 is better than pre-bronchodilator FEV1 in evaluation of COPD severity. COPD, 2012; 9(3):276–280.
27.
FortisS, EberleinM, GeorgopoulosD, ComellasAP. Predictive value of prebronchodilator and postbronchodilator spirometry for COPD features and outcomes. BMJ Open Respir Res, 2017; 4(1):e000213.
28.
HwangYI, KimCH, KangHR, ShinT, ParkSM, JangSH, et al. Comparison of the prevalence of chronic obstructive pulmonary disease diagnosed by lower limit of normal and fixed ratio criteria. J Korean Med Sci, 2009; 24(4):621–626.
29.
LamprechtB, SchirnhoferL, KaiserB, BuistSA, ManninoDM, StudnickaM. Subjects with discordant airways obstruction: lost between spirometric definitions of COPD. Pulm Med, 2011; 2011:780215.
30.
MillerMR, QuanjerPH, SwanneyMP, RuppelG, EnrightPL. Interpreting lung function data using 80% predicted and fixed thresholds misclassifies more than 20% of patients. Chest, 2011; 139(1):52–59.
31.
VollmerWM, GíslasonT, BurneyP, EnrightPL, GulsvikA, KocabasA, BuistAS. Comparison of spirometry criteria for the diagnosis of COPD: results from the BOLD study. Eur Respir J, 2009; 34(3):588–597.
32.
SchermerTRJ, QuanjerPH. COPD screening in primary care: who is sick?. Prim Care Respir J, 2007; 16(1):49–53.
33.
Mohamed HoeseinFAA, ZanenP, LammersJWJ. Lower limit of normal or FEV1/FVC < 0.70 in diagnosing COPD: an evidence-based review. Respir Med, 2011; 105(6):907–915.
HardinM, ChoM, McDonaldML, BeatyT, RamsdellJ, BhattS, et al. The clinical and genetic features of COPD-asthma overlap syndrome. Eur Respir J, 2014; 44(2):341–350.
