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Aaron SD, Montes de Oca M, Celli B, Bhatt SP, Bourbeau J, Criner GJ, DeMeo DL, Halpin DMG, Han MK, Hurst JR, Krishnan JK, Mannino D, van Boven JFM, Vogelmeier CF, Wedzicha JA, Yawn BP, Martinez FJ. Early Diagnosis and Treatment of Chronic Obstructive Pulmonary Disease: The Costs and Benefits of Case Finding. Am J Respir Crit Care Med 2024; 209:928-937. [PMID: 38358788 DOI: 10.1164/rccm.202311-2120pp] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 02/14/2024] [Indexed: 02/16/2024] Open
Affiliation(s)
- Shawn D Aaron
- The Ottawa Hospital Research Institute, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Maria Montes de Oca
- Universidad Central de Venezuela, Caracas, Venezuela
- Hospital Centro Médico de Caracas, Caracas, Venezuela
| | | | - Surya P Bhatt
- Pulmonary, Allergy and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jean Bourbeau
- Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Gerard J Criner
- Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Dawn L DeMeo
- Channing Division of Network Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - David M G Halpin
- University of Exeter Medical School, University of Exeter, Exeter, United Kingdom
| | - MeiLan K Han
- Division of Pulmonary & Critical Care, University of Michigan, Ann Arbor, Michigan
| | - John R Hurst
- UCL Respiratory, University College London, London, United Kingdom
| | - Jamuna K Krishnan
- Division of Pulmonary and Critical Care, Weill Cornell Medicine, New York, New York
| | - David Mannino
- College of Medicine, University of Kentucky, Lexington, Kentucky
| | - Job F M van Boven
- Department of Clinical Pharmacy & Pharmacology, University Medical Center Groningen, Groningen Research Institute for Asthma and COPD, University of Groningen, Groningen, The Netherlands
| | - Claus F Vogelmeier
- Philipps-Universität Marburg, German Center for Lung Research, Marburg, Germany
| | - Jadwiga A Wedzicha
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Barbara P Yawn
- Department of Family Medicine and Community Health, University of Minnesota, Minneapolis, Minnesota; and
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Gerstein E, Bierbrier J, Whitmore GA, Vandemheen KL, Bergeron C, Boulet LP, Cote A, Field SK, Penz E, McIvor RA, Lemière C, Gupta S, Hernandez P, Mayers I, Bhutani M, Lougheed MD, Licskai CJ, Azher T, Ezer N, Ainslie M, Alvarez GG, Mulpuru S, Aaron SD. Impact of Undiagnosed Chronic Obstructive Pulmonary Disease and Asthma on Symptoms, Quality of Life, Healthcare Use, and Work Productivity. Am J Respir Crit Care Med 2023; 208:1271-1282. [PMID: 37792953 DOI: 10.1164/rccm.202307-1264oc] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 10/04/2023] [Indexed: 10/06/2023] Open
Abstract
Rationale: A significant proportion of individuals with chronic obstructive pulmonary disease (COPD) and asthma remain undiagnosed. Objectives: The objective of this study was to evaluate symptoms, quality of life, healthcare use, and work productivity in subjects with undiagnosed COPD or asthma compared with those previously diagnosed, as well as healthy control subjects. Methods: This multicenter population-based case-finding study randomly recruited adults with respiratory symptoms who had no previous history of diagnosed lung disease from 17 Canadian centers using random digit dialing. Participants who exceeded symptom thresholds on the Asthma Screening Questionnaire or the COPD Diagnostic Questionnaire underwent pre- and post-bronchodilator spirometry to determine if they met diagnostic criteria for COPD or asthma. Two control groups, a healthy group without respiratory symptoms and a symptomatic group with previously diagnosed COPD or asthma, were similarly recruited. Measurements and Main Results: A total of 26,905 symptomatic individuals were interviewed, and 4,272 subjects were eligible. Of these, 2,857 completed pre- and post-bronchodilator spirometry, and 595 (21%) met diagnostic criteria for COPD or asthma. Individuals with undiagnosed COPD or asthma reported greater impact of symptoms on health status and daily activities, worse disease-specific and general quality of life, greater healthcare use, and poorer work productivity than healthy control subjects. Individuals with undiagnosed asthma had symptoms, quality of life, and healthcare use burden similar to those of individuals with previously diagnosed asthma, whereas subjects with undiagnosed COPD were less disabled than those with previously diagnosed COPD. Conclusions: Undiagnosed COPD or asthma imposes important, unmeasured burdens on the healthcare system and is associated with poor health status and negative effects on work productivity.
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Affiliation(s)
- Emily Gerstein
- The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Jared Bierbrier
- The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | | | | | - Celine Bergeron
- Department of Medicine, The University of British Columbia, Vancouver, British Columbia
| | | | - Andreanne Cote
- Centre de recherche, Hôpital Laval, Université Laval, Quebec, Quebec, Canada
| | - Stephen K Field
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Erika Penz
- Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - R Andrew McIvor
- Firestone Institute for Respiratory Health, McMaster University, Hamilton, Ontario, Canada
| | - Catherine Lemière
- Department of Medicine, University of Montreal, Montreal, Quebec, Canada
| | - Samir Gupta
- Department of Medicine and Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Paul Hernandez
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Irvin Mayers
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Mohit Bhutani
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - M Diane Lougheed
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | | | - Tanweer Azher
- Department of Medicine, Memorial University, St. John's, Newfoundland, Canada; and
| | - Nicole Ezer
- Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Martha Ainslie
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Gonzalo G Alvarez
- The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Sunita Mulpuru
- The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Shawn D Aaron
- The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
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Shin S, Whitmore GA, Boulet LP, Boulay MÈ, Côté A, Bergeron C, Lemière C, Lougheed MD, Vandemheen KL, Alvarez GG, Mulpuru S, Aaron SD. Anticipating undiagnosed asthma in symptomatic adults with normal pre- and post-bronchodilator spirometry: a decision tool for bronchial challenge testing. BMC Pulm Med 2023; 23:496. [PMID: 38071285 PMCID: PMC10709915 DOI: 10.1186/s12890-023-02806-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Accepted: 12/05/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Some patients with asthma demonstrate normal spirometry and remain undiagnosed without further testing. OBJECTIVE To determine clinical predictors of asthma in symptomatic adults with normal spirometry, and to generate a tool to help clinicians decide who should undergo bronchial challenge testing (BCT). METHODS Using random-digit dialling and population-based case-finding, we recruited adults from the community with respiratory symptoms and no previous history of diagnosed lung disease. Participants with normal pre- and post-bronchodilator spirometry subsequently underwent BCT. Asthma was diagnosed in those with symptoms and a methacholine provocative concentration (PC20) of < 8 mg/ml. Sputum and blood eosinophils, and exhaled nitric oxide were measured. Univariate analyses identified potentially predictive variables, which were then used to construct a multivariable logistic regression model to predict asthma. Model sensitivity, specificity, and area under the receiver operating curve (AUC) were calculated. RESULTS Of 132 symptomatic individuals with normal spirometry, 34 (26%) had asthma. Of those ultimately diagnosed with asthma, 33 (97%) answered 'yes' to a question asking whether they experienced cough, chest tightness or wheezing provoked by exercise or cold air. Other univariate predictors of asthma included female sex, pre-bronchodilator FEV1 percentage predicted, and percent positive change in FEV1 post bronchodilator. A multivariable model containing these predictive variables yielded an AUC of 0.82 (95% CI: 0.72-0.91), a sensitivity of 82%, and a specificity of 66%. The model was used to construct a nomogram to advise clinicians which patients should be prioritized for BCT. CONCLUSIONS Four readily available patient characteristics demonstrated a high sensitivity and AUC for predicting undiagnosed asthma in symptomatic adults with normal pre- and post-bronchodilator spirometry. These characteristics can potentially help clinicians to decide which individuals with normal spirometry should be investigated with bronchial challenge testing. However, further prospective validation of our decision tool is required.
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Affiliation(s)
- Sheojung Shin
- The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada
| | | | - Louis-Philippe Boulet
- Institut universitaire de cardiologie et de pneumologie de Québec-Université Laval, Québec, QC, Canada
| | - Marie-Ève Boulay
- Institut universitaire de cardiologie et de pneumologie de Québec-Université Laval, Québec, QC, Canada
| | - Andréanne Côté
- Institut universitaire de cardiologie et de pneumologie de Québec-Université Laval, Québec, QC, Canada
| | - Céline Bergeron
- The Lung Center, Vancouver General Hospital, Vancouver, BC, Canada
| | | | | | | | - Gonzalo G Alvarez
- The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada
| | - Sunita Mulpuru
- The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada
| | - Shawn D Aaron
- The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada.
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Neder JA, Berton DC, O'Donnell DE. The role of the pulmonary function laboratory to assist in disease management: Asthma. J Bras Pneumol 2023; 49:e20230236. [PMID: 37729249 PMCID: PMC10578945 DOI: 10.36416/1806-3756/e20230236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2023] Open
Affiliation(s)
- José Alberto Neder
- . Pulmonary Function Laboratory and Respiratory Investigation Unit, Division of Respirology, Kingston Health Science Center & Queen's University, Kingston (ON) Canada
| | - Danilo Cortozi Berton
- . Unidade de Fisiologia Pulmonar, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre (RS) Brasil
| | - Denis E O'Donnell
- . Pulmonary Function Laboratory and Respiratory Investigation Unit, Division of Respirology, Kingston Health Science Center & Queen's University, Kingston (ON) Canada
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Boulet LP, Boulay MÈ, Côté A, FitzGerald JM, Bergeron C, Lemière C, Lougheed MD, Vandemheen KL, Aaron SD. Airway inflammation and hyperresponsiveness in subjects with respiratory symptoms and normal spirometry. Eur Respir J 2023; 61:13993003.01194-2022. [PMID: 36396140 DOI: 10.1183/13993003.01194-2022] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 11/01/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Subjects without a previous history of asthma, presenting with unexplained respiratory symptoms and normal spirometry, may exhibit airway hyperresponsiveness (AHR) in association with underlying eosinophilic (type 2 (T2)) inflammation, consistent with undiagnosed asthma. However, the prevalence of undiagnosed asthma in these subjects is unknown. METHODS In this observational study, inhaled corticosteroid-naïve adults without previously diagnosed lung disease reporting current respiratory symptoms and showing normal pre- and post-bronchodilator spirometry underwent fractional exhaled nitric oxide (F ENO) measurement, methacholine challenge testing and induced sputum analysis. AHR was defined as a provocative concentration of methacholine causing a 20% fall in forced expiratory volume in 1 s (PC20) <16 mg·mL-1 and T2 inflammation was defined as sputum eosinophils >2% and/or F ENO >25 ppb. RESULTS Out of 132 subjects (mean±sd age 57.6±14.2 years, 52% female), 47 (36% (95% CI 28-44%)) showed AHR: 20/132 (15% (95% CI 9-21%)) with PC20 <4 mg·mL-1 and 27/132 (21% (95% CI 14-28%)) with PC20 4-15.9 mg·mL-1. Of 130 participants for whom sputum eosinophils, F ENO or both results were obtained, 45 (35% (95% CI 27-43%)) had T2 inflammation. 14 participants (11% (95% CI 6-16%)) had sputum eosinophils >2% and PC20 ≥16 mg·mL-1, suggesting eosinophilic bronchitis. The prevalence of T2 inflammation was significantly higher in subjects with PC20 <4 mg·mL-1 (12/20 (60%)) than in those with PC20 4-15.9 mg·mL-1 (8/27 (30%)) or ≥16 mg·mL-1 (25/85 (29%)) (p=0.01). CONCLUSIONS Asthma, underlying T2 airway inflammation and eosinophilic bronchitis may remain undiagnosed in a high proportion of symptomatic subjects in the community who have normal pre- and post-bronchodilator spirometry.
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Affiliation(s)
- Louis-Philippe Boulet
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, QC, Canada
| | - Marie-Ève Boulay
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, QC, Canada
| | - Andréanne Côté
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, QC, Canada
| | | | - Céline Bergeron
- The Lung Center, Vancouver General Hospital, Vancouver, BC, Canada
| | | | - M Diane Lougheed
- Department of Medicine, Queen's University, Kingston, ON, Canada
| | | | - Shawn D Aaron
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
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