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Hansen MRH, Schmid JM. Screening for impaired pulmonary function using peak expiratory flow: Performance of different interpretation strategies. Respir Med Res 2023; 83:101015. [PMID: 37087903 DOI: 10.1016/j.resmer.2023.101015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 03/29/2023] [Accepted: 03/30/2023] [Indexed: 04/09/2023]
Abstract
BACKGROUND Spirometry is the gold standard for diagnosis of impaired pulmonary function, but is often unavailable in resource-constrained settings. Some authors have suggested using peak expiratory flow (PEF) to screen for impaired pulmonary function when spirometry is unavailable, but with no consensus on how to define abnormally low PEF. Strategies have included cutoffs based on absolute value of PEF, PEF in percent predicted, PEF Z-score, PEF × height-2, and gender-specific cutoffs of absolute PEF. The objective of this paper is to determine the PEF interpretation strategy with the highest predictive ability for low pulmonary function, with spirometry as the gold standard. METHODS We analyzed data on individuals aged 40-79 years in the United States National Health and Nutrition Examination Survey 2007-2012. 6,144 individuals fulfilled inclusion criteria for the main analysis. For each PEF interpretation strategy, we calculated the area under the receiver operating curve (AUC) for the detection of low pulmonary function (defined by FEV1 Z-score < -1.645, < -2, < -2.5 or < -3). RESULTS The AUC was substantially and statistically significantly higher for PEF in percent predicted and PEF Z-score than for absolute value and PEF × height-2, including after stratification by gender. There was no difference in AUC between PEF in percent predicted and PEF Z-score. CONCLUSION If using PEF to screen adults aged 40 years or older for impaired pulmonary function defined by low FEV1 Z-score, basing cutoffs on PEF in percent predicted or PEF Z-score may result in improved predictive ability. As percent predicted is a mathematically simpler term than Z-score, it may be preferable to use cutoffs based on PEF in percent predicted.
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Affiliation(s)
- Martin Rune Hassan Hansen
- Department of Medicine, Randers Regional Hospital, Skovlyvej 15, DK-8930 Randers NØ, Denmark; Environment, Occupation and Health, Department of Public Health, Aarhus University, Bartholins Allé 2, DK-8000 Aarhus C, Denmark; Danish Big Data Centre for Environment and Health (BERTHA), Aarhus University, Frederiksborgvej 399, Postboks 358, DK-4000 Roskilde, Denmark; Department of Infectious Diseases, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, DK-8200 Aarhus N, Denmark.
| | - Johannes Martin Schmid
- Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, DK-8200 Aarhus N, Denmark
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Ferreira-Cardoso H, Jácome C, Silva S, Amorim A, Redondo MT, Fontoura-Matias J, Vicente-Ferreira M, Vieira-Marques P, Valente J, Almeida R, Fonseca JA, Azevedo I. Lung Auscultation Using the Smartphone-Feasibility Study in Real-World Clinical Practice. SENSORS (BASEL, SWITZERLAND) 2021; 21:4931. [PMID: 34300670 PMCID: PMC8309818 DOI: 10.3390/s21144931] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 07/03/2021] [Accepted: 07/16/2021] [Indexed: 11/17/2022]
Abstract
Conventional lung auscultation is essential in the management of respiratory diseases. However, detecting adventitious sounds outside medical facilities remains challenging. We assessed the feasibility of lung auscultation using the smartphone built-in microphone in real-world clinical practice. We recruited 134 patients (median[interquartile range] 16[11-22.25]y; 54% male; 31% cystic fibrosis, 29% other respiratory diseases, 28% asthma; 12% no respiratory diseases) at the Pediatrics and Pulmonology departments of a tertiary hospital. First, clinicians performed conventional auscultation with analog stethoscopes at 4 locations (trachea, right anterior chest, right and left lung bases), and documented any adventitious sounds. Then, smartphone auscultation was recorded twice in the same four locations. The recordings (n = 1060) were classified by two annotators. Seventy-three percent of recordings had quality (obtained in 92% of the participants), with the quality proportion being higher at the trachea (82%) and in the children's group (75%). Adventitious sounds were present in only 35% of the participants and 14% of the recordings, which may have contributed to the fair agreement between conventional and smartphone auscultation (85%; k = 0.35(95% CI 0.26-0.44)). Our results show that smartphone auscultation was feasible, but further investigation is required to improve its agreement with conventional auscultation.
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Affiliation(s)
| | - Cristina Jácome
- MEDCIDS-Department of Community Medicine, Health Information and Decision, Faculty of Medicine, University of Porto, 4200-450 Porto, Portugal
- CINTESIS-Center for Health Technology and Services Research, Faculty of Medicine, University of Porto, 4200-450 Porto, Portugal
| | - Sónia Silva
- Department of Pediatrics, Centro Hospitalar Universitário de São João, 4200-319 Porto, Portugal
| | - Adelina Amorim
- Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal
- Department of Pulmonology, Centro Hospitalar Universitário de São João, 4200-319 Porto, Portugal
| | - Margarida T Redondo
- Department of Pulmonology, Centro Hospitalar Universitário de São João, 4200-319 Porto, Portugal
| | - José Fontoura-Matias
- Department of Pediatrics, Centro Hospitalar Universitário de São João, 4200-319 Porto, Portugal
| | | | - Pedro Vieira-Marques
- CINTESIS-Center for Health Technology and Services Research, Faculty of Medicine, University of Porto, 4200-450 Porto, Portugal
| | - José Valente
- MEDIDA-Serviços em Medicina, Educação, Investigação, Desenvolvimento e Avaliação, LDA, 4200-386 Porto, Portugal
| | - Rute Almeida
- MEDCIDS-Department of Community Medicine, Health Information and Decision, Faculty of Medicine, University of Porto, 4200-450 Porto, Portugal
- CINTESIS-Center for Health Technology and Services Research, Faculty of Medicine, University of Porto, 4200-450 Porto, Portugal
| | - João Almeida Fonseca
- MEDCIDS-Department of Community Medicine, Health Information and Decision, Faculty of Medicine, University of Porto, 4200-450 Porto, Portugal
- CINTESIS-Center for Health Technology and Services Research, Faculty of Medicine, University of Porto, 4200-450 Porto, Portugal
- MEDIDA-Serviços em Medicina, Educação, Investigação, Desenvolvimento e Avaliação, LDA, 4200-386 Porto, Portugal
| | - Inês Azevedo
- Department of Pediatrics, Centro Hospitalar Universitário de São João, 4200-319 Porto, Portugal
- Department of Obstetrics, Gynecology and Pediatrics, Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal
- EpiUnit, Institute of Public Health, University of Porto, 4050-091 Porto, Portugal
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The diagnostic accuracy of lung auscultation in adult patients with acute pulmonary pathologies: a meta-analysis. Sci Rep 2020; 10:7347. [PMID: 32355210 PMCID: PMC7192898 DOI: 10.1038/s41598-020-64405-6] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 04/15/2020] [Indexed: 12/12/2022] Open
Abstract
The stethoscope is used as first line diagnostic tool in assessment of patients with pulmonary symptoms. However, there is much debate about the diagnostic accuracy of this instrument. This meta-analysis aims to evaluate the diagnostic accuracy of lung auscultation for the most common respiratory pathologies. Studies concerning adult patients with respiratory symptoms are included. Main outcomes are pooled estimates of sensitivity and specificity with 95% confidence intervals, likelihood ratios (LRs), area under the curve (AUC) of lung auscultation for different pulmonary pathologies and breath sounds. A meta-regression analysis is performed to reduce observed heterogeneity. For 34 studies the overall pooled sensitivity for lung auscultation is 37% and specificity 89%. LRs and AUC of auscultation for congestive heart failure, pneumonia and obstructive lung diseases are low, LR− and specificity are acceptable. Abnormal breath sounds are highly specific for (hemato)pneumothorax in patients with trauma. Results are limited by significant heterogeneity. Lung auscultation has a low sensitivity in different clinical settings and patient populations, thereby hampering its clinical utility. When better diagnostic modalities are available, they should replace lung auscultation. Only in resource limited settings, with a high prevalence of disease and in experienced hands, lung auscultation has still a role.
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Sarkar M, Bhardwaz R, Madabhavi I, Modi M. Physical signs in patients with chronic obstructive pulmonary disease. Lung India 2019; 36:38-47. [PMID: 30604704 PMCID: PMC6330798 DOI: 10.4103/lungindia.lungindia_145_18] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
We reviewed the various physical signs of chronic obstructive pulmonary disease, their pathogenesis, and clinical importance. We searched PubMed, EMBASE, and the CINAHL from inception to March 2018. We used the following search terms: chronic obstructive pulmonary disease, physical examination, purse-lip breathing, breath sound intensity, forced expiratory time, abdominal paradox, Hoover's sign, barrel-shaped chest, accessory muscle use, etc. All types of studies were chosen. Globally, history taking and clinical examination of the patients is on the wane. One reason can be a significant development in the field of medical technology, resulting in overreliance on sophisticated diagnostic machines, investigative procedures, and medical tests as first-line modalities of patient's management. In resource-constrained countries, detailed history taking and physical examination should be emphasized as one of the important modalities in patient's diagnosis and management. Declining bedside skills and clinical aptitude among the physician is indeed a concern nowadays. Physical diagnosis of chronic obstructive pulmonary disease (COPD) is the quickest and reliable modalities that can lead to early diagnosis and management of COPD patients. Bedside elicitation of physical signs should always be the starting point for any diagnosis and therapeutic approach.
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Affiliation(s)
- Malay Sarkar
- Department of Pulmonary Medicine, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India
| | - Rajeev Bhardwaz
- Department of Cardiology, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India
| | - Irappa Madabhavi
- Department of Medical and Pediatric Oncology, GCRI, Ahmedabad, Gujarat, India
| | - Mitul Modi
- Department of Pathology, University of Pennsylvania, Philadelphia, PA, USA
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Aggarwal AN, Das S, Agarwal R, Singh N. Utility of forced expiratory time as a screening tool for identifying airway obstruction and systematic review of English literature. Lung India 2018; 35:476-482. [PMID: 30381556 PMCID: PMC6219144 DOI: 10.4103/lungindia.lungindia_3_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Setting: This study was conducted at a pulmonary function laboratory of a tertiary care hospital in North India. Objective: The objective was to study the diagnostic characteristics and clinically useful threshold of forced expiratory time (FET, measured by auscultation over trachea) as a screening tool for identifying airway obstruction and to substantiate the diagnostic utility of FET through a systematic review of English literature. Methods: FET was compared in seventy patients with airway obstruction (Group A) and seventy controls with normal spirometry (Group B). Within-subject reproducibility of FET, and its correlation with spirometric parameters, was assessed. Diagnostic accuracy of FET in detecting airway obstruction was evaluated at various time thresholds. A systematic review of English literature on FET was also carried out. Results: Median FET was significantly longer in Group A (7.04 s [interquartile range (IQR) 6.67–7.70 s] vs. 4.14 s [IQR 3.60–4.68 s], P < 0.001). At a threshold of 5 s, FET had high sensitivity (0.943) and reasonable specificity (0.814) in detecting airway obstruction. FET measurements were reproducible and correlated negatively with forced expiratory volume in first second (FEV1), FEV1/forced vital capacity, and peak expiratory flow. The systematic review yielded 13 publications. At a widely used threshold of 6 s to describe airway obstruction, pooled sensitivity and specificity from five datasets were 0.802 (95% confidence interval [CI] 0.668–0.890) and 0.837 (95% CI 0.570–0.952), respectively. Conclusion: FET of 5 s or more, rather than the commonly recommended threshold of 6 s, should be regarded as abnormal.
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Affiliation(s)
- Ashutosh Nath Aggarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sharmishtha Das
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Navneet Singh
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Allgar VL, Chen H, Richfield E, Currow D, Macleod U, Johnson MJ. Psychometric Properties of the Needs Assessment Tool-Progressive Disease Cancer in U.K. Primary Care. J Pain Symptom Manage 2018; 56:602-612. [PMID: 30009964 DOI: 10.1016/j.jpainsymman.2018.07.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 07/03/2018] [Accepted: 07/04/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND The assessment of patients' needs for care is a critical step in achieving patient-centered cancer care. Tools can be used to assess needs and inform care planning. The Needs Assessment Tool:Progressive Disease-Cancer (NAT:PD-C) is an Australian oncology clinic tool for assessment by clinicians of patients' and carers' palliative care needs. This has not been validated in the U.K. primary care setting. AIM The aim of this study was to test the psychometric properties and acceptability of a U.K. primary care adapted NAT:PD-C. DESIGN Reliability: NAT:PD-C-guided video-recorded consultations were viewed, rated, and rerated by clinicians. Weighted Fleiss' kappa and prevalence- and bias-adjusted kappa statistics were used. Construct: During a consultation, general medical practitioners (GPs) used NAT:PD-C, patient measures (Edmonton Symptom Assessment Scale; Research Utilisation Group Activities of Daily Living; Palliative care Outcome Score; Australian Karnofsky Performance Scale), and carer measures (Carer Strain Index; Carer Support Needs Assessment Tool). Kendall's Tau-b was used. SETTING/PARTICIPANTS GPs, nurses, patients, and carers were recruited from primary care practices. RESULTS Reliability: All patients' well-being items and four of five items in the carer/family ability to care section showed adequate interrater reliability. There was moderate test-retest reliability for five of six in the patients' well-being section and five of five in the carer/family ability to care section. Construct: There was at least fair agreement for five of six of patients' well-being items; high for daily living (Kendall's Tau-b = 0.57, P < 0.001). The NAT:PD-C has adequate carer construct validity (five of eight) with strong agreement for two of eight patients. Over three-quarters of GPs considered the NAT:PD-C to have high acceptability. CONCLUSION The NAT PD-C is reliable, valid, and acceptable in the UK primary care setting. Effectiveness in reducing patient and carer unmet needs and issues regarding implementation are yet to be evaluated.
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Affiliation(s)
| | - Hong Chen
- Hull York Medical School, Allam Medical Building, University of Hull, Hull, UK
| | - Ed Richfield
- Elderly Medicine, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - David Currow
- Faculty of Health, University of Technology Sydney, Broadway, New South Wales, Australia
| | - Una Macleod
- Hull York Medical School, Allam Medical Building, University of Hull, Hull, UK
| | - Miriam J Johnson
- Hull York Medical School, Allam Medical Building, University of Hull, Hull, UK
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Aviles-Solis JC, Vanbelle S, Halvorsen PA, Francis N, Cals JWL, Andreeva EA, Marques A, Piirilä P, Pasterkamp H, Melbye H. International perception of lung sounds: a comparison of classification across some European borders. BMJ Open Respir Res 2017; 4:e000250. [PMID: 29435344 PMCID: PMC5759712 DOI: 10.1136/bmjresp-2017-000250] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 11/20/2017] [Accepted: 11/22/2017] [Indexed: 12/28/2022] Open
Abstract
Introduction Lung auscultation is helpful in the diagnosis of lung and heart diseases; however, the diagnostic value of lung sounds may be questioned due to interobserver variation. This situation may also impair clinical research in this area to generate evidence-based knowledge about the role that chest auscultation has in a modern clinical setting. The recording and visual display of lung sounds is a method that is both repeatable and feasible to use in large samples, and the aim of this study was to evaluate interobserver agreement using this method. Methods With a microphone in a stethoscope tube, we collected digital recordings of lung sounds from six sites on the chest surface in 20 subjects aged 40 years or older with and without lung and heart diseases. A total of 120 recordings and their spectrograms were independently classified by 28 observers from seven different countries. We employed absolute agreement and kappa coefficients to explore interobserver agreement in classifying crackles and wheezes within and between subgroups of four observers. Results When evaluating agreement on crackles (inspiratory or expiratory) in each subgroup, observers agreed on between 65% and 87% of the cases. Conger's kappa ranged from 0.20 to 0.58 and four out of seven groups reached a kappa of ≥0.49. In the classification of wheezes, we observed a probability of agreement between 69% and 99.6% and kappa values from 0.09 to 0.97. Four out of seven groups reached a kappa ≥0.62. Conclusions The kappa values we observed in our study ranged widely but, when addressing its limitations, we find the method of recording and presenting lung sounds with spectrograms sufficient for both clinic and research. Standardisation of terminology across countries would improve international communication on lung auscultation findings.
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Affiliation(s)
- Juan Carlos Aviles-Solis
- General Practice Research Unit, Department of Community Medicine, UiT The Arctic University of Norway, Tromsø, Norway
| | - Sophie Vanbelle
- Department of Methodology and Statistics, University of Maastricht, Maastricht, The Netherlands
| | - Peder A Halvorsen
- General Practice Research Unit, Department of Community Medicine, UiT The Arctic University of Norway, Tromsø, Norway
| | - Nick Francis
- Department of Primary Care and Public Health, Cardiff University, Cardiff, UK
| | - Jochen W L Cals
- Department of Family Medicine, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| | - Elena A Andreeva
- Department of Family Medicine, Northern State Medical University (NSMU), Arkhangelsk, Russia
| | - Alda Marques
- Lab 3R-Respiratory Research and Rehabilitation Laboratory, School of Health Sciences (ESSUA) and Institute for Research in Biomedicine (iBiMED), University of Aveiro, Aveiro, Portugal
| | - Päivi Piirilä
- Unit of Clinical Physiology, HUS Medical Imaging Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Hans Pasterkamp
- Department of Pediatrics and Child Health, University of Manitoba College of Medicine, Winnipeg, Manitoba, Canada
| | - Hasse Melbye
- General Practice Research Unit, Department of Community Medicine, UiT The Arctic University of Norway, Tromsø, Norway
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Abstract
Preview In all cases of obstructive lung disease, smoking cessation, proper use of metered-dose inhalers, up-to-date immunizations, adequate nutrition, and general physical conditioning are important components of treatment. Dr Jacobs summarizes these components as well as stepwise pharmacologic approaches to controlling the inflammation of asthma, the bronchospasm of chronic bronchitis and emphysema, and the symptoms of secondary or coexisting conditions.
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Melbye H, Garcia-Marcos L, Brand P, Everard M, Priftis K, Pasterkamp H. Wheezes, crackles and rhonchi: simplifying description of lung sounds increases the agreement on their classification: a study of 12 physicians' classification of lung sounds from video recordings. BMJ Open Respir Res 2016; 3:e000136. [PMID: 27158515 PMCID: PMC4854017 DOI: 10.1136/bmjresp-2016-000136] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 04/08/2016] [Accepted: 04/10/2016] [Indexed: 12/04/2022] Open
Abstract
Background The European Respiratory Society (ERS) lung sounds repository contains 20 audiovisual recordings of children and adults. The present study aimed at determining the interobserver variation in the classification of sounds into detailed and broader categories of crackles and wheezes. Methods Recordings from 10 children and 10 adults were classified into 10 predefined sounds by 12 observers, 6 paediatricians and 6 doctors for adult patients. Multirater kappa (Fleiss' κ) was calculated for each of the 10 adventitious sounds and for combined categories of sounds. Results The majority of observers agreed on the presence of at least one adventitious sound in 17 cases. Poor to fair agreement (κ<0.40) was usually found for the detailed descriptions of the adventitious sounds, whereas moderate to good agreement was reached for the combined categories of crackles (κ=0.62) and wheezes (κ=0.59). The paediatricians did not reach better agreement on the child cases than the family physicians and specialists in adult medicine. Conclusions Descriptions of auscultation findings in broader terms were more reliably shared between observers compared to more detailed descriptions.
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Affiliation(s)
- Hasse Melbye
- Faculty of Health Sciences, General Practice Research Unit , UIT the Arctic University of Norway , Tromsø , Norway
| | - Luis Garcia-Marcos
- Pediatric Respiratory and Allergy Units, Arrixaca University Children's Hospital, University of Murcia, Murcia, Spain; IMIB-Arrixaca Biohealth Research Institute, Murcia, Spain
| | - Paul Brand
- Princess Amalia Children's Center, Isala Hospital, Zwolle, The Netherlands; Postgraduate School of Medicine, University Medical Centre and University of Groningen, Groningen, The Netherlands
| | - Mark Everard
- School of Paediatrics, University of Western Australia, Princess Margaret Hospital , Subiaco, Western Australia , Australia
| | - Kostas Priftis
- Children's Respiratory and Allergy Unit, Third Dept of Paediatrics , "Attikon" Hospital, University of Athens Medical School , Athens , Greece
| | - Hans Pasterkamp
- Section of Respirology, Dept of Pediatrics and Child Health , University of Manitoba , Winnipeg, Manitoba , Canada
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Bozarth AL, Covey A, Gohar A, Salzman G. Chronic obstructive pulmonary disease: clinical review and update on consensus guidelines. Hosp Pract (1995) 2014; 42:79-91. [PMID: 24566600 DOI: 10.3810/hp.2014.02.1095] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
In the last 2 decades, chronic obstructive pulmonary disease (COPD) has been increasingly recognized as a major public health problem. Since the introduction of the Global Initiative for Chronic Obstructive Lung Disease in 1998, growing interest in the pathogenesis and management of patients with COPD has led to notable improvements in patient care and quality of life. Despite greater awareness of this common preventable disease and major therapeutic advances during this period, the global impact of COPD remains strikingly large. We provide an evidence-based clinical review on COPD, with a focus on internists as the target audience.
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Affiliation(s)
- Andrew L Bozarth
- University of Missouri-Kansas City School of Medicine, Kansas City, MO.
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11
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Oshaug K, Halvorsen PA, Melbye H. Should chest examination be reinstated in the early diagnosis of chronic obstructive pulmonary disease? Int J Chron Obstruct Pulmon Dis 2013; 8:369-77. [PMID: 23983462 PMCID: PMC3751499 DOI: 10.2147/copd.s47992] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Although proven to be associated with bronchial obstruction, chest signs are not listed among cues that should prompt spirometry in the early diagnosis of chronic obstructive pulmonary disease (COPD) in established guidelines. AIMS We aimed to explore how chest findings add to respiratory symptoms and a history of smoking in the diagnosis of COPD. METHODS In a cross-sectional study, patients aged 40 years or older, previously diagnosed with either asthma or COPD in primary care, answered questionnaires and underwent physical chest examination and spirometry. RESULTS Among the 375 patients included, 39.7% had forced expiratory volume in 1 second/forced vital capacity <0.7. Hyperresonance to percussion was the strongest predictor of COPD, with a sensitivity of 20.8, a specificity of 97.8, and likelihood ratio of 9.5. In multivariate logistic regression, where pack-years, shortness of breath, and chest findings were among the explanatory variables, three physical chest findings were independent predictors of COPD. Hyperresonance to percussion yielded the highest odds ratio (OR = 6.7), followed by diminished breath sounds (OR = 5.0), and thirdly wheezes (OR = 2.3). These three chest signs also gave significant diagnostic information when added to shortness of breath and pack-years in receiver operating-characteristic curve analysis. CONCLUSION We found that chest signs may add to respiratory symptoms and a history of smoking in the diagnosis of COPD, and we conclude that chest signs should be reinstated as cues to early diagnosis of COPD in patients 40 years or older.
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Affiliation(s)
- Katja Oshaug
- General Practice Research Unit, University of Tromsø, Tromsø, Norway
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Accuracy of symptoms, signs, and C-reactive protein for early chronic obstructive pulmonary disease. Br J Gen Pract 2012; 62:e632-8. [PMID: 22947584 DOI: 10.3399/bjgp12x654605] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Guidelines recommend detection of early chronic obstructive pulmonary disease (COPD), but evidence on the diagnostic work-up for COPD only concerns advanced and established COPD. AIM To quantify the accuracy of symptoms and signs for early COPD, and the added value of C-reactive protein (CRP), in primary care patients presenting with cough. DESIGN AND SETTING Cross-sectional diagnostic study of 73 primary care practices in the Netherlands. METHOD Four hundred primary care patients (182 males, mean age 63 years) older than 50 years, presenting with persistent cough (>14 days) without established COPD participated, of whom 382 completed the study. They underwent a systematic diagnostic work-up of symptoms, signs, conventional laboratory CRP level, and hospital lung functions tests, including body plethysmography, and an expert panel decided whether COPD was present (reference test). The independent value of all items was estimated by multivariable logistic regression analysis. RESULTS According to the expert panel, 118 patients had COPD (30%). Symptoms and signs with independent diagnostic value were age, sex, current smoking, smoking more than 20 pack-years, cardiovascular comorbidity, wheezing complaints, diminished breath sounds, and wheezing on auscultation. Combining these items resulted in an area under the receiver operating characteristic curve (ROC area) of 0.79 (95% confidence interval = 0.74 to 0.83) after internal validation. The proportion of subjects with elevated CRP was higher in those with early COPD, but CRP added no relevant diagnostic information above symptoms and signs. CONCLUSION In subjects presenting with persistent cough, the CRP level has no added value for detection of early COPD.
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Diagnostic accuracy of clinical symptoms in obstructive airway diseases varied within different health care sectors. J Clin Epidemiol 2012; 65:846-54. [PMID: 22640568 DOI: 10.1016/j.jclinepi.2011.12.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2011] [Revised: 12/19/2011] [Accepted: 12/23/2011] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To determine the diagnostic accuracy and diagnostic patterns of clinical symptoms in patients suspected to suffer from obstructive airway diseases (OADs) within different health care sectors. STUDY DESIGN AND SETTING Ten general practices (219 patients), one practice of pneumologists (259 patients) and one specialist hospital (300 patients). Sensitivities, specificities, positive (LR+), and negative (LR-) likelihood ratios of clinical symptoms were compared with lung function testing. RESULTS Thirty-one percent had chronic obstructive pulmonary disease (COPD), 21% had asthma. Sensitivities increased and specificities decreased from outpatient to hospital setting. The multivariate model of adjusted likelihood ratios for COPD showed LR+=4.86 (95% confidence interval [CI]=2.09-11.29) and LR-=0.07 (95% CI=0.01-0.43) of the combination "wheezing," "dyspnea when going upstairs," "smoking" in general practice. In hospital, the combination "dyspnea when going upstairs," "dyspnea during minimal exercise," and "smoking" showed LR+=3.34 (95% CI=2.08-5.31) and LR-=0.02 (95% CI=0.01-0.12). The combination "no coughing," "dyspnea attacks," and "no smoking" showed LR+=4.08 (95% CI=1.67-10.4) and LR-=0.24 (95% CI=0.12-0.58) for asthma in general practice. The combination "dyspnea attacks" and "no dyspnea when walking" showed LR+=6.48 (95% CI=1.01-40.94) and LR-=0.28 (95% CI=0.11-0.75) for asthma in hospital. CONCLUSION Clinical decision rules for OAD need to be derived from original studies in their respective settings or assessed on their transferability to other settings.
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Does a decision aid help physicians to detect chronic obstructive pulmonary disease? Br J Gen Pract 2012; 61:e674-9. [PMID: 22152850 DOI: 10.3399/bjgp11x601398] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Numerous decision aids have been developed recently, but the value they add above that of the initial clinical assessment is not well known. AIM To quantify whether a formal decision aid for chronic obstructive pulmonary disease (COPD) adds diagnostic information, above the physician's clinical assessment. DESIGN AND SETTING Subanalysis of a diagnostic study in Dutch primary care. METHOD Sixty-five primary care physicians included 357 patients who attended for persistent cough and were not known to have COPD. The physicians estimated the probability of COPD after short history taking and physical examination. After this, the presence or absence of COPD was determined using results of extensive diagnostic work-up. The extent to which an 8-item decision aid for COPD, which included only symptoms and signs, added diagnostic value above the physician's estimation was quantified by the increase of the area under the receiver operating characteristic curve (ROC area), and the improvement in diagnostic risk classification across two classes: 'low probability of COPD' (<20%) and 'possible COPD' (≥20%). RESULTS One hundred and four patients (29%) had COPD. Adding the decision aid to the clinical assessment increased the ROC area from 0.75 (95% confidence interval [CI] = 0.70 to 0.81) to 0.84 (95% CI = 0.80 to 0.89) (P<0.005), and improved the diagnostic risk classification of the patients, such that 35 fewer patients needed spirometry testing and eight fewer COPD cases were missed. CONCLUSION A short decision aid for COPD added diagnostic value to the physician's clinical assessment.
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Benbassat J, Baumal R. Narrative review: should teaching of the respiratory physical examination be restricted only to signs with proven reliability and validity? J Gen Intern Med 2010; 25:865-72. [PMID: 20349154 PMCID: PMC2896600 DOI: 10.1007/s11606-010-1327-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2009] [Revised: 12/02/2009] [Accepted: 03/04/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To review the reported reliability (reproducibility, inter-examiner agreement) and validity (sensitivity, specificity and likelihood ratios) of respiratory physical examination (PE) signs, and suggest an approach to teaching these signs to medical students. METHODS Review of the literature. We searched Paper Chase between 1966 and June 2009 to identify and evaluate published studies on the diagnostic accuracy of respiratory PE signs. RESULTS Most studies have reported low to fair reliability and sensitivity values. However, some studies have found high specificites for selected PE signs. None of the studies that we reviewed adhered to all of the STARD criteria for reporting diagnostic accuracy. CONCLUSIONS Possible flaws in study designs may have led to underestimates of the observed diagnostic accuracy of respiratory PE signs. The reported poor reliabilities may have been due to differences in the PE skills of the participating examiners, while the sensitivities may have been confounded by variations in the severity of the diseases of the participating patients. IMPLICATION FOR PRACTICE AND MEDICAL EDUCATION: Pending the results of properly controlled studies, the reported poor reliability and sensitivity of most respiratory PE signs do not necessarily detract from their clinical utility. Therefore, we believe that a meticulously performed respiratory PE, which aims to explore a diagnostic hypothesis, as opposed to a PE that aims to detect a disease in an asymptomatic person, remains a cornerstone of clinical practice. We propose teaching the respiratory PE signs according to their importance, beginning with signs of life-threatening conditions and those that have been reported to have a high specificity, and ending with signs that are "nice to know," but are no longer employed because of the availability of more easily performed tests.
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Affiliation(s)
- Jochanan Benbassat
- Myers-JDC-Brookdale Institute, Smokler Center for Health Policy Research, Jerusalem, Israel.
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Mattos WLLDD, Signori LGH, Borges FK, Bergamin JA, Machado V. Accuracy of clinical examination findings in the diagnosis of COPD. J Bras Pneumol 2009; 35:404-8. [PMID: 19547847 DOI: 10.1590/s1806-37132009000500003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2008] [Accepted: 11/19/2008] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE Simple diagnostic methods can facilitate the diagnosis of COPD, which is a major public health problem. The objective of this study was to investigate the accuracy of clinical variables in the diagnosis of COPD. METHODS Patients with COPD and control subjects were prospectively evaluated by two investigators regarding nine clinical variables. The likelihood ratio for the diagnosis of COPD was determined using a logistic regression model. RESULTS The study comprised 98 patients with COPD (mean age, 62.3+/- 12.3 years; mean FEV1, 48.3 +/- 21.6%) and 102 controls. The likelihood ratios (95% CIs) for the diagnosis of COPD were as follows: 4.75 (2.29-9.82; p < 0.0001) for accessory muscle recruitment; 5.05 (2.72-9.39; p < 0.0001) for pursed-lip breathing; 2.58 (1.45-4.57; p < 0.001) for barrel chest; 3.65 (2.01-6.62; p < 0.0001) for decreased chest expansion; 7.17 (3.75-13.73; p < 0.0001) for reduced breath sounds; 2.17 (1.01-4.67; p < 0.05) for a thoracic index > or = 0.9; 2.36 (1.22-4.58; p < 0.05) for laryngeal height < or = 5.5 cm; 3.44 (1.92-6.16; p < 0.0001) for forced expiratory time > or = 4 s; and 4.78 (2.13-10.70; p < 0.0001) for lower liver edge > or = 4 cm from lower costal edge. Inter-rater reliability for those same variables was, respectively, 0.57, 0.45, 0.62, 0.32, 0.53, 0.32, 0.59, 0.52 and 0.44 (p < 0.0001 for all). CONCLUSIONS Various clinical examination findings could be used as diagnostic tests for COPD.
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Nascimento OA, Camelier A, Rosa FW, Menezes AMB, Pérez-Padilla R, Jardim JR. Chronic obstructive pulmonary disease is underdiagnosed and undertreated in São Paulo (Brazil): results of the PLATINO study. ACTA ACUST UNITED AC 2008; 40:887-95. [PMID: 17653440 DOI: 10.1590/s0100-879x2006005000133] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2006] [Accepted: 03/28/2007] [Indexed: 05/16/2023]
Abstract
Chronic obstructive pulmonary disease (COPD) is a common disease in adults over 40 years of age and has a great social and economic impact. It remains little recognized and undertreated even in developed countries. However, there are no data about its diagnosis and treatment in Brazil. The objectives of the present study were to evaluate the proportion of COPD patients who had never been diagnosed and to determine if the COPD patients who had been identified were receiving appropriate treatment. The Latin American Project for the Investigation of Obstructive Lung Disease (PLATINO) was a randomized epidemiological study of adults over 40 years living in five metropolitan areas, including São Paulo. The studied sample was randomly selected from the population after a division of the metropolitan area of São Paulo in clusters according to social characteristics. All subjects answered a standardized questionnaire on respiratory symptoms, history of smoking, previous diagnosis of lung disease, and treatments. All subjects performed spirometry. The criterion for the diagnosis of COPD was defined by a post-bronchodilator FEV1/FVC ratio lower than 0.7. A total of 918 subjects were evaluated and 144 (15.8%) met the diagnostic criterion for COPD. However, 126 individuals (87.5%) had never been diagnosed. This undiagnosed group of COPD patients had a lower proportion of subjects with respiratory symptoms than the previously diagnosed patients (88.9 vs 54.8%) and showed better lung function with greater FEV1 (86.8 +/- 20.8 vs 68.5 +/- 23.6% predicted) and FVC (106.6 +/- 22.4 vs 92.0 +/- 24.1% predicted). Among the COPD patients, only 57.3% were advised to stop smoking and 30.6% received the influenza vaccine. In addition, 82.3% did not receive any pharmacological treatment. In conclusion, COPD is underdiagnosed and a large number of COPD patients are not treated appropriately.
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Affiliation(s)
- O A Nascimento
- Disciplina de Pneumologia e Centro de Reabilitação Pulmonar, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brasil
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Kalantri S, Joshi R, Lokhande T, Singh A, Morgan M, Colford JM, Pai M. Accuracy and reliability of physical signs in the diagnosis of pleural effusion. Respir Med 2007; 101:431-8. [PMID: 16965906 DOI: 10.1016/j.rmed.2006.07.014] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2006] [Revised: 06/20/2006] [Accepted: 07/24/2006] [Indexed: 11/29/2022]
Abstract
Although pleural effusion is a common disorder among patients presenting with respiratory symptoms, there is limited evidence on the accuracy and reliability of symptoms and signs for the diagnosis of pleural effusion. In our study, conducted at a rural hospital in India, two physicians, blind to history and chest radiograph findings, and to each other's results, independently evaluated 278 patients (196 men), aged 12 and older, admitted with respiratory symptoms. We did a blind and independent comparison of physical signs (asymmetric chest expansion, vocal fremitus, percussion note, breath sounds, crackles, vocal resonance and auscultatory percussion) with the reference standard (chest radiograph). We measured diagnostic accuracy by computing sensitivity, specificity, and likelihood ratios (LRs), and inter-observer reliability by using kappa (kappa) statistic. We performed multivariate analysis to identify the clinical signs that independently predict pleural effusion. The prevalence of pleural effusion was 21% (57/278). The LRs of positive signs ranged from 1.48 to 8.14 and their 95% confidence intervals (CIs) excluded 1. Except for pleural rub, the LRs for negative signs ranged between 0.13 and 0.71. The interobserver agreement was excellent for chest expansion, vocal fremitus, percussion and breath sounds (kappa 0.84-0.89) and good for vocal resonance, crackles and auscultatory percussion (kappa 0.68-0.78). The independent predictors of pleural effusion were asymmetric chest expansion (odds ratio [OR] 5.22, 95% CI 2.06-13.23), and dull percussion note (OR 12.80, 95% CI 4.23-38.70). For the final multivariate model, the area under receiver operating characteristic curve (ROC curve) was 0.88. In conclusion, our data suggest that physical signs may be helpful to rule out but not rule in pleural effusion.
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Affiliation(s)
- Shriprakash Kalantri
- Department of Medicine, Mahatma Gandhi Institute of Medical Sciences, Sevagram 442101, India
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Schneider A, Dinant GJ, Maag I, Gantner L, Meyer JF, Szecsenyi J. The added value of C-reactive protein to clinical signs and symptoms in patients with obstructive airway disease: results of a diagnostic study in primary care. BMC FAMILY PRACTICE 2006; 7:28. [PMID: 16670014 PMCID: PMC1479349 DOI: 10.1186/1471-2296-7-28] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/12/2005] [Accepted: 05/02/2006] [Indexed: 11/10/2022]
Abstract
Background To evaluate the diagnostic accuracy of clinical signs and symptoms, C-reactive protein (CRP) and spirometric parameters and determine their interrelation in patients suspected to have an obstructive airway disease (OAD) in primary care. Methods In a cross sectional diagnostic study, 60 adult patients coming to the general practitioner (GP) for the first-time with complaints suspicious for obstructive airway disease (OAD) underwent spirometry. Peak expiratory flow (PEF)-variability within two weeks was determined in patients with inconspicuous spirometry. Structured medical histories were documented and CRP was measured. The reference standard was the Tiffeneau ratio (FEV1/VC) in spirometry and the PEF-variability. OAD was diagnosed when FEV1/VC ≤ 70% or PEF-variability > 20%. Results 37 (62%) patients had OAD. The best cut-off value for CRP was found at 2 mg/l with a diagnostic odds ratio (OR) of 4.4 (95% CI 1.4–13.8). Self-reported wheezing was significantly related with OAD (OR 3.4; CI 1.1–10.3), whereas coughing was inversely related (OR 0.2; CI 0.1–0.7). The diagnostic OR of CRP increased when combined with dyspnea (OR 8.5; 95% CI 1.7–42.3) or smoking history (OR 8.4; 95% CI 1.5–48.9). CRP (p = 0.004), FEV1 (p = 0.001) and FIV1 (p = 0.023) were related with the severity of dyspnea. CRP increased with the number of cigarettes, expressed in pack years (p = 0.001). Conclusion The diagnostic accuracy of clinical signs and symptoms was low. The diagnostic accuracy of CRP improved in combination with dyspnea and smoking history. Due to their coherence with the severity of dyspnea and number of cigarettes respectively, CRP and spirometry might allow risk stratification of patients with OAD in primary care. Further studies need to be done to confirm these findings.
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Affiliation(s)
- Antonius Schneider
- University Medical Hospital Heidelberg, Dept. of General Practice and Health Services Research; Heidelberg, Germany
| | - Geert-Jan Dinant
- University Maastricht, Care and Public Health Research Institute, Dept. of General Practice, Maastricht, the Netherlands
| | - Inko Maag
- University Medical Hospital Heidelberg, Dept. of General Practice and Health Services Research; Heidelberg, Germany
| | - Lutz Gantner
- University Medical Hospital Heidelberg, Dept. of General Practice and Health Services Research; Heidelberg, Germany
| | - Joachim Franz Meyer
- University Medical Hospital Heidelberg, Dept. of Cardiology, Angiology and Pneumology, Heidelberg, Germany
| | - Joachim Szecsenyi
- University Medical Hospital Heidelberg, Dept. of General Practice and Health Services Research; Heidelberg, Germany
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Joshua AM, Celermajer DS, Stockler MR. Beauty is in the eye of the examiner: reaching agreement about physical signs and their value. Intern Med J 2005; 35:178-87. [PMID: 15737139 DOI: 10.1111/j.1445-5994.2004.00795.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Despite advances in other areas, evidence-based medicine is yet to make substantial inroads on the standard medical physical examination. We have reviewed the evidence about the accuracy and reliability of the physical examination and common clinical signs. The physical examination includes many signs of marginal accuracy and reproducibility. These may not be appreciated by clinicians and could adversely affect decisions about treatment and investigations or the teaching and examination of students and doctors-in-training. We provide a selected summary of the reliability and accuracy as well as important messages of key findings in the physical examination.
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Affiliation(s)
- A M Joshua
- Department of Medical Oncology, Sydney Cancer Centre, Sydney, New South Wales, Australia.
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21
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Vrijhoef HJM, Diederiks JPM, Wesseling GJ, van Schayck CP, Spreeuwenberg C. Undiagnosed patients and patients at risk for COPD in primary health care: early detection with the support of non-physicians. J Clin Nurs 2003; 12:366-73. [PMID: 12709111 DOI: 10.1046/j.1365-2702.2003.00736.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Given the increasingly heavy workload in the primary health care sector, the option of allocating activities involving the management of chronic diseases to non-physicians has recently come under scrutiny. The purpose of this study was to assess the feasibility of the support provided by non-physicians to general practitioners (GPs) in the early detection of chronic obstructive pulmonary disease (COPD). A convenience sample consisting of 231 patients [40-70 years; >10 pack years (number of packs of cigarettes smoked per day multiplied by the number of years the individual has smoked)] from eight general practices in the Maastricht region in the southern Netherlands, who consulted their GP for reasons unrelated to respiratory diseases, were assessed for their respiratory function. Prior to the first assessment, patients were interviewed about their medical history and symptoms. By taking the results of the lung function measurement as the starting point, the predictive value of medical history and symptoms in the identification of patients at risk for airflow obstruction or of COPD was assessed and compared with findings in the literature. Seventeen patients (7.4%) were diagnosed with COPD, 11 patients (4.8%) with asthma. In addition to age and moderate smoking history, breathlessness and a history of heavy smoking were identified as risk factors for airflow limitation and COPD. Early detection of COPD in primary health care by non-physicians is feasible and should be considered for middle aged, moderate and heavy smokers experiencing breathlessness.
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Straus SE, McAlister FA, Sackett DL, Deeks JJ. Accuracy of history, wheezing, and forced expiratory time in the diagnosis of chronic obstructive pulmonary disease. J Gen Intern Med 2002; 17:684-8. [PMID: 12220364 PMCID: PMC1495102 DOI: 10.1046/j.1525-1497.2002.20102.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To determine the accuracy of the history and selected elements of the physical examination in the diagnosis of chronic obstructive pulmonary disease (COPD). DESIGN Independent blind comparison of the standard clinical examination (evaluating the accuracy of history, wheezing, and forced expiratory time [FET]) with spirometry. The gold standard for diagnosis of COPD was a forced expiratory volume at 1 second (FEV1) below the fifth percentile (adjusted for patient height and age). SETTING Seven sites in 6 countries, including investigators from primary care and secondary care settings. PARTICIPANTS One hundred sixty-one consecutive patients with varying severity of disease (known COPD, suspected COPD, or no COPD) participated in the study. MAIN RESULTS One hundred sixty-one patients (mean age 65 years, 39% female, 41% with known COPD, 27% with suspected COPD, and 32% normal) were recruited. Mean (+/-SD) FEV1 and forced vital capacity were 1,720 (+/-830) mL and 2,520 (+/-970) mL. The likelihood ratios (LR) for the tested elements of the clinical examination (and their P values on chi2 testing) were: self-reported history of COPD, 5.6 (P <.001); FET greater than 9 seconds, 6.7 (P < 0.01); smoked longer than 40 pack years, 3.3 (P =.001); wheezing, 4.0 (P <.001); male gender, 1.6 (P <.001); and age over 65 years, 1.6 (P =.025). The accuracy of these elements was not appreciably different when reference standards other than FEV1 below the 5th percentile were applied. Only 3 elements of the clinical examination were significantly associated with the diagnosis of COPD on multivariate analysis: self-reported history of COPD (adjusted LR 4.4), wheezing (adjusted LR 2.9), and FET greater than 9 seconds (adjusted LR 4.6). Area under the receiver operating characteristic curve for the model incorporating these 3 factors was 0.86. CONCLUSIONS Less emphasis should be placed on the presence of isolated symptoms or signs in the diagnosis of COPD. While numerous elements of the clinical examination are associated with the diagnosis of COPD, only 3 are significant on multivariate analysis. Patients having all 3 of these findings have an LR of 33 (ruling in COPD); those with none have an LR of 0.18 (ruling out COPD).
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Affiliation(s)
- Sharon E Straus
- The Division of General Internal Medicine, University Health Network-Mount Sinai Hospital, University of Toronto, Toronto, Canada.
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Garcia-Pachon E. Paradoxical movement of the lateral rib margin (Hoover sign) for detecting obstructive airway disease. Chest 2002; 122:651-5. [PMID: 12171846 DOI: 10.1378/chest.122.2.651] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVE To evaluate the diagnostic accuracy of Hoover sign for detecting obstructive airway disease (OAD), compared with wheezes, rhonchi, reduced breath sounds, and clinical impression, and to analyze the observer agreement on these signs. DESIGN Prospective, blind comparison, with a reference standard (spirometry) among a consecutive series of patients. SETTING Outpatient pulmonary clinic. PATIENTS One hundred seventy-two patients (117 men [68%] and 55 women [32%]), who were > 40 years of age, had not been known previously by the participating physicians, and met at least one of the following criteria: smokers of > 20 pack-years; patients who had received a diagnosis of or had self-reported COPD (or chronic bronchitis or emphysema); patients who had received inhaler bronchodilator treatment for > 6 months; or patients with any degree of dyspnea. MEASUREMENTS Patients were examined by a first-year resident in family medicine and by a pulmonologist. Spirometry was performed by a blinded trained technician. OAD was defined as an FEV1/FVC ratio of < 0.70. RESULTS OAD was present in 64 patients (37%). Observer agreement (kappa statistic) was 0.74 for Hoover sign and was lower for the rest of the signs. Hoover sign had a sensitivity of 58% and a specificity of 86% for detecting OAD, and it had a positive likelihood ratio of 4.16, which was higher than that of the other signs. CONCLUSIONS Hoover sign, a frequently forgotten sign, is easy to recognize and is useful for detecting OAD.
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Affiliation(s)
- Eduardo Garcia-Pachon
- Section of Pneumology, Department of Internal Medicine, Hospital Vega Baja, Orihuela-Alicante, Spain.
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Abstract
Asthma continues to be a challenging disease to treat in both the inpatient and outpatient settings. The growing database on therapeutic interventions at the time of transition from the acute to chronic phase of this disease is encouraging. Glucocorticoids and inhaled beta-agonists clearly reduce readmission and relapse. Other medications and educational interventions also appear effective. Still, no true discharge guidelines have been established. Multiple statements by consensus panels have recommended using FEV1 or PEFR as indicators of readiness for discharge, but this has not been prospectively validated from either the emergency department or inpatient setting. In contrast, some studies argue that pulmonary functions do not accurately predict relapse and readmission, so the usefulness of these discharge recommendations is debatable. Large studies, especially in the adult asthmatic population, are needed to validate these recommendation.
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Affiliation(s)
- B A Markoff
- Division of Pulmonary and Critical Care, University of California, Davis, 4150 V Street, Suite 3400, Sacramento, CA 95817, USA
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Fernández Vargas AM, Bujalance Zafra MJ, Leiva Fernández F, Martos Crespo F, García Ruiz A, Pradós Torres D. [Correlation between subjective and objective health measurements in patients with chronic obstructive pulmonary disease (COPD)]. Aten Primaria 2001; 28:579-87. [PMID: 11747770 PMCID: PMC7679522 DOI: 10.1016/s0212-6567(01)70457-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
AIMS Analyze the relation between objective health assessment (OHA) -Forced spirometry- and subjective health assessment (SHA) -quality of life- in patients with chronic obstructive pulmonary disease (COPD). Analyze the correlation between two different questionnaires to assess quality of life. DESIGN Cross-sectional study. PARTICIPANTS 278 patients with COPD (confidence level 95%) from two urban health centers. MAIN MEASUREMENTS Personal interview. VARIABLES quality of life (Nottingham Health Profile; St George Respiratory Questionnaire); sociodemographic profile; diagnose of COPD; comorbidity; recent spirometry. STATISTICAL ANALYSES Descriptive statistics; test ji-squared, Kruskal-Wallis and the correlation coefficient. RESULTS Age: 66,9 years; sex: 88% male. Quality of life scales (mean and confidence intervals): Nottingham Health Profile subscales (total score 100 points): energy 40 (35.6-44.4), pain 35.9 (32.3-39.5), emotional reactions 32.5 (29.4-38.6), sleep 41.9 (37.8-45.9), social isolation 15.3 (12.7-17.9), mobility 36.7 (33.9-39.5) and global score 33.4 (30.8-36). St George Respiratory Questionnaire subscales (total scores 100 points): impact 38.01 (35.08-40.18), activity 53.8 (50.2-57.4), symptoms 37.7 (35.2-40.3) and global score 40.0 (38.6-43.2). The correlation coefficients between the two questionnaires ranged between 0.12 (for the sleep and symptoms dimensions: p = 0.03) and 0.66 (for the mobility and activity dimensions; p < 0.0001). There is a positive lineal relation between the two questionnaires and the spirometric stages of COPD (measured by the maximum respiratory volume in the first second). CONCLUSIONS We found a good correlation between the two quality of life questionnaires, but St George was more specific for respiratory illness. There is a mild-light correlation between objective and subjective health assessment in patients with COPD.
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Affiliation(s)
- A M Fernández Vargas
- Especialista en Medicina Familiar y Comunitaria. Unidad Docente de MFyC Málaga, Spain.
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Abstract
Chronic obstructive pulmonary disease is a syndrome including illnesses such as asthma, chronic bronchitis, and emphysema. Although these diseases share a common obstructive component, their optimal treatment and prognosis differ. This article examines the salient features of the history, physical exam, pulmonary function tests, and radiological evaluation which may allow the clinician to differentiate the various diseases that make up COPD; thus allowing the clinician to better target the multiple therapeutic modalities available.
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Affiliation(s)
- K R Flaherty
- Department of Medicine, University of Michigan Health System, Ann Arbor, USA
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Colice GL, Burgt JV, Song J, Stampone P, Thompson PJ. Categorizing asthma severity. Am J Respir Crit Care Med 1999; 160:1962-7. [PMID: 10588614 DOI: 10.1164/ajrccm.160.6.9902112] [Citation(s) in RCA: 76] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The National Asthma Education and Prevention Program (NAEPP) Expert Panel II recommended a stepped care pharmacotherapy approach to asthma treatment based on an objective assessment of asthma severity using daytime symptoms, nocturnal symptoms, and physiologic lung function. The worst grade of the individual variables determines overall asthma severity. With this approach, patterns of asthma severity categorization might vary among individual variables; one variable might have a predominant effect on overall categorization. During the run-in, pretreatment phase of five controlled clinical trials, data from 744 inhaled steroid nonusers and 685 inhaled steroid users on asthma control were collected and asthma severity categorized. In inhaled steroid nonusers nocturnal symptoms classified the majority of patients as severe, persistent, but wheeze classified 27.3% of patients as mild, intermittent and 25.7% as mild, persistent. If the worst grade from the four asthma symptoms was used for severity grading, most patients were categorized as severe, persistent. beta-Agonist use and FEV(1) classified most as moderate, persistent. There was poor correlation between variables in severity categorization. Severity grading for European patients was similar to that for U.S. patients. Applying the Expert Panel II recommended method for asthma severity categorization to a large data set illustrates that a single variable, nocturnal symptoms, determined to a large extent overall categorization. Development of a validated method for asthma severity categorization is essential for using a stepped care approach to asthma pharmacotherapy.
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Affiliation(s)
- G L Colice
- Department of Clinical Research, 3M Pharmaceuticals, St. Paul, Minnesota 55144-1000, USA
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McAlister FA, Straus SE, Sackett DL. Why we need large, simple studies of the clinical examination: the problem and a proposed solution. CARE-COAD1 group. Clinical Assessment of the Reliability of the Examination-Chronic Obstructive Airways Disease Group. Lancet 1999; 354:1721-4. [PMID: 10568588 DOI: 10.1016/s0140-6736(99)01174-5] [Citation(s) in RCA: 72] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Kleerekoper M. Detecting osteoporosis. Beyond the history and physical examination. Postgrad Med 1998; 103:45-7, 51-2, 62-3 passim. [PMID: 9553587 DOI: 10.3810/pgm.1998.04.448] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
A number of developments are contributing to clinicians' understanding of osteoporosis as a clinical continuum characterized by low bone mass and increased risk of fractures rather than as a disease characterized by fragility fractures. With improved capability for accurate measurement of bone mass, the prevalence of this disease has increased to include at least 25 million Americans. The responsibility of primary care physicians to detect and treat osteoporosis has increased accordingly. Parents should be counseled regarding their children's diet and lifestyle to optimize peak adult bone mass and ensure adequate dietary calcium intake. Adults should be counseled to minimize behaviors that result in accelerated bone loss (e.g., smoking, alcohol use, anorexia, bulimia). Physicians need to be aware of the serious potential complications of osteoporosis and offer counseling to menopausal women about the disease and the benefits and risks of hormone replacement and estrogen replacement therapy. Physicians should be familiar with technologies available in their community for measuring bone mass and recognize the need to consider prescribing pharmacologic and nonpharmacologic therapies for patients with low bone mass or osteoporosis. Physicians also can educate caregivers about prevention of falls and fractures in elderly patients who are unsteady on their feet. Improved technologies for bone mass measurement and fracture risk assessment, as well as expanded options for treatment and prevention of osteoporosis, are likely to become available within the next 5 to 10 years, thereby increasing the wisdom of early detection and treatment of osteoporosis.
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Affiliation(s)
- M Kleerekoper
- Division of Endocrinology, Wayne State University School of Medicine, Detroit, USA.
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Abstract
This article reviews the differential diagnosis of obstructive lung disease, including lesions that may mimic chronic obstructive pulmonary disease, as well as the tools on which the clinician relies for making a proper diagnosis. The clinician's view of the radiologist's role is briefly discussed, but the details of specific radiologic techniques are discussed elsewhere in this issue.
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Affiliation(s)
- M S Stulbarg
- Department of Medicine, University of California-San Francisco, USA
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Abstract
BACKGROUND Many experts recommend spirometry to screen for chronic obstructive pulmonary disease (COPD) in asymptomatic patients; however, evidence for this recommendation has not been systematically reviewed. METHODS We examined whether screening spirometry meets standard criteria for effective screening. We performed structured searches of MEDLINE, followed by a selective search of the CITATION index, to locate randomized trials of interventions for asymptomatic patients with COPD. In regard to smoking cessation, we included all controlled trials of smoking cessation programs that used spirometry. We also included all studies that assessed the ability of spirometry to predict successful smoking cessation by comparing baseline lung function in smokers who subsequently quit versus those who did not. RESULTS With the exception of smoking cessation, all interventions for COPD have only been proven effective in symptomatic patients. Two studies found that multifaceted smoking cessation programs that included spirometry were efficacious. There was no effect in a third study that isolated the role of spirometry. Smokers with abnormal spirometric results are less likely than other smokers to quit over the ensuing year. CONCLUSIONS There is no evidence that spirometry, as an isolated intervention, aids smoking cessation.
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Affiliation(s)
- R G Badgett
- Department of Internal Medicine, University of Texas Health Science Center at San Antonio 78284, USA.
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Holleman DR, Simel DL. Quantitative assessments from the clinical examination. How should clinicians integrate the numerous results? J Gen Intern Med 1997; 12:165-71. [PMID: 9100141 PMCID: PMC1497082 DOI: 10.1007/s11606-006-5024-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To describe strategies for using multiple clinical examination items to estimate disease probabilities; and to evaluate the diagnostic accuracy of each strategy. DESIGN Prospective observational study. SETTING Medical preoperative evaluation clinic at a university-affiliated Veterans Affairs Medical Center. PATIENTS Previously reported consecutive series of patients referred for outpatient medical preoperative risk assessment. MEASUREMENTS AND MAIN RESULTS Pulmonary clinical examination and spirometry were the measurements. A strategy of using likelihood ratios (LRs) from seven clinical examination items was least accurate (p < .0001). Three alternative strategies were equivalent in diagnostic accuracy (p > or = .2): (1) using the single best clinical examination item and its LR, (2) using the LRs from three clinical examination items chosen by logistic regression, and (3) using the adjusted LRs chosen in strategy 2. When compared with using LRs from all seven items, the strategies of using three LRs chosen by logistic regression or using adjusted likelihood ratios better discriminated patients with airflow limitation from those without (receiver operating characteristic [ROC] areas 0.79 vs 0.69; p = .02). Using the single best clinical finding did not statistically degrade the clinical examination's discriminating ability (ROC areas 0.79 vs 0.75; p = .20). CONCLUSIONS Describing the rational clinical examination requires evaluating conditional independence of examination components. Conditional independence assumptions were violated when seven clinical examination items were used to estimate posterior probability of airflow limitation. Focusing on clinical examination items identified through logistic models overcame violations of independence; further statistical adjustment did not improve diagnostic accuracy. Clinicians can use the single most predictive clinical examination finding to avoid inaccuracy from violating the independence assumption.
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Affiliation(s)
- D R Holleman
- Medical Service, Lexington Veterans Affairs Medical Center, KY 40511, USA
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Mohr DN, Lavender RC. Preoperative pulmonary evaluation. Identifying patients at increased risk for complications. Postgrad Med 1996; 100:241-4, 247-8, 251-2 passim. [PMID: 8917336 DOI: 10.3810/pgm.1996.11.120] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
During surgical procedures, multiple physiologic changes affect the pulmonary system and its defense mechanisms. The presence of basic risk factors (eg, smoking, chronic obstructive pulmonary disease, severe obesity) can affect whether these physiologic changes result in pulmonary complications or even death. Therefore, the presence of risk factors should be ascertained in all patients before abdominal or thoracic surgery. The degree of risk can be further determined preoperatively by additional evaluation, such as pulmonary function testing, newer assessment of cardiorespiratory status, history taking, and physical examination. The presence of risk factors and the type of operation to be performed should guide decisions about whether to perform a procedure or to use prophylactic measures before and after surgery. New operative techniques may allow some procedures that were prohibited in the past to be performed in high-risk patients.
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Affiliation(s)
- D N Mohr
- Mayo Medical School, Rochester, Minnesota.
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Abstract
OBJECTIVE The purpose of this article is to review the medical history and physical examination of the asthmatic patient. DATA SOURCES English references identified from relevant articles and book chapters, experts, and MEDLINE search, using "asthma," "physical diagnosis," and "medical history." STUDY SELECTION Clinical studies of the medical history or physical examination in subjects with respiratory disease were selected for review. RESULTS Symptoms such as wheezing, chest tightness and difficulty in taking a deep breath suggest asthma, while symptoms such as gasping, smothering or air hunger suggest alternative diagnoses. Symptoms of asthma correlate poorly with airway obstruction in one-third to one-half of asthmatic patients. Respiratory signs such as wheezing, breath sound intensity, forced expiratory time, accessory muscle use, respiratory rate and pulsus paradoxus correlate roughly with airway obstruction. However, clinicians disagree on the presence or absence of respiratory signs 55% to 89% of the time. Furthermore, physicians correctly predict pulmonary function based on history and physical examination only about half the time, and correctly diagnose asthma based on the clinical examination 63% to 74% of the time. CONCLUSIONS The medical history and physical examination are moderately effective in diagnosing asthma and estimating its severity. Objective measures of lung function are necessary for the accurate diagnosis of asthma.
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Affiliation(s)
- J T Li
- Division of Allergic Diseases and Internal Medicine, Mayo Clinic and Foundation, Rochester, Minnesota, USA
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Abstract
OBJECTIVE To study the predictive value of clinical chest findings for bronchial airflow limitation in patients with respiratory tract infection. DESIGN Associations were analysed between FEV1 (forced expiratory volume in one second) in % of predicted and physical chest findings. SETTING The Municipal Emergency Clinic in Tromsø, Norway. PARTICIPANTS 398 adult patients with respiratory tract infection and 40 general practitioners. OUTCOME MEASURES Mean FEV1% predicted and frequency of FEV1 < 80% predicted according to chest findings. Regression coefficients of the findings with FEV % predicted as outcome variable. RESULTS Mean FEV1% predicted was 87 (range 25-129). Pathological chest findings were recorded in 127 patients (32%) and in 22 of the 24 patients (92%) with FEV1% predicted less than 60. The 78 patients with wheezes had a mean FEV1% predicted of 74 (range 29-120), significantly lower than those without wheezes (p < 0.0001), and 63% had FEV1% predicted less than 80. Prolonged expiration or strenuous respiration was recorded in 49 patients. The 29 patients with wheezes in this subgroup had a significantly lower mean FEV1% predicted, 65, than the 20 patients without wheezes (p < 0.005). By multiple regression wheezes and strenuous respiration were the most significant predictors of FEV1% predicted, together with patients' statement of very annoying dyspnoea. CONCLUSION When predicting the degree of bronchial obstruction in a patient with respiratory infection, the doctor may take into account wheezes heard by auscultation, an impression of strenuous respiration, and the patient's statement about severe dyspnoea.
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Affiliation(s)
- H Melbye
- Institute of Community Medicine, University of Tromsø, Norway
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Schapira RM, Reinke LF. The outpatient diagnosis and management of chronic obstructive pulmonary disease: pharmacotherapy, administration of supplemental oxygen, and smoking cessation techniques. J Gen Intern Med 1995; 10:40-55. [PMID: 7699485 DOI: 10.1007/bf02599577] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- R M Schapira
- Zablocki VA Medical Center, Section of Pulmonary & Critical Care Medicine, Milwaukee, WI 53295-1000, USA
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Badgett RG, Tanaka DJ, Hunt DK, Jelley MJ, Feinberg LE, Steiner JF, Petty TL. The clinical evaluation for diagnosing obstructive airways disease in high-risk patients. Chest 1994; 106:1427-31. [PMID: 7956395 DOI: 10.1378/chest.106.5.1427] [Citation(s) in RCA: 28] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVE We measured the ability of the medical history, physical examination, and peak flowmeter in diagnosing any degree of obstructive airways disease (OAD). DESIGN Prospective comparison of historical and physical findings with independently measured spirometry. SETTING University outpatient clinic. PATIENTS Ninety-two adult consecutive outpatient volunteers with a self-reported history of smoking, asthma, chronic bronchitis, or emphysema. MEASUREMENTS All subjects completed a pulmonary history questionnaire and received peak flow (PF) and spirometric testing. The subjects were independently examined for 12 pulmonary physical signs by four internists blinded to all other results. Multivariable analysis was used to create a diagnostic model to predict OAD as diagnosed by spirometry (FEV1 < 80 percent of predicted not secondary to restrictive disease, or FEV1/FVC less than 0.7). RESULTS The best model diagnosed OAD when any of three variables were present--a history of smoking more than 30 pack-years, diminished breath sounds, or peak flow less than 350 L/min. This model had a sensitivity of 98 percent and specificity of 46 percent. In addition, the model detected all subjects with probable restrictive lung disease. Thirty-one percent of subjects had none of these variables and were at very low (3 percent) risk of OAD. Fifty percent of subjects with one or more abnormal variables had OAD. CONCLUSIONS The history, physical examination, and peak flowmeter can be used to screen high-risk patients for OAD. Using this diagnostic model, 31 percent of subjects could be classified at very low risk of OAD while half of those referred for spirometry would have abnormal results.
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Affiliation(s)
- R G Badgett
- Department of Internal Medicine, University of Texas Health Science Center at San Antonio 78284-7879
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