Accuracy of symptoms, signs, and C-reactive protein for early chronic obstructive pulmonary disease

Weighing the evidence for pharmacological treatment interventions in mild COPD; a narrative perspective

There is increasing focus on understanding the nature of chronic obstructive pulmonary disease (COPD) during the earlier stages. Mild COPD (Global Initiative for Chronic Obstructive Lung Disease [GOLD] stage 1 or the now-withdrawn GOLD stage 0) represents an early stage of COPD that may progress to more severe disease. This review summarises the disease burden of patients with mild COPD and discusses the evidence for treatment intervention in this subgroup.

Overall, patients with mild COPD suffer a substantial disease burden that includes persistent or potentially debilitating symptoms, increased risk of exacerbations, increased healthcare utilisation, reduced exercise tolerance and physical activity, and a higher rate of lung function decline versus controls. However, the evidence for treatment efficacy in these patients is limited due to their frequent exclusion from clinical trials. Careful assessment of disease burden and the rate of disease progression in individual patients, rather than a reliance on spirometry data, may identify patients who could benefit from earlier treatment intervention.

Drop in lung function during asthma and COPD exacerbations - can it be assessed without spirometry?

BACKGROUND

When assessing patients with exacerbation of asthma or COPD, it may be useful to know the drop in forced expiratory volume in 1 second (FEV₁) compared with stable state, in particular when considering treatment with oral corticosteroids. The objective of the study was to identify indicators of drop in FEV₁ during exacerbations.

METHODS

In this prospective multicenter study from primary care, patients diagnosed with asthma or COPD were examined at stable state and during exacerbations the following year. Symptoms, chest findings, and pulse oximetry were recorded, and spirometry was performed. A fixed drop in FEV₁ (10% and ≥200 mL) and percentage change in FEV₁ were outcomes when possible indicators were evaluated.

RESULTS

Three hundred and eighty patients attended baseline examination, and 88 with a subsequent exacerbation were included in the analysis. Thirty (34%) had a significant drop in FEV₁ (10% and 200 mL). Increased wheezing was the only symptom associated with this drop with a likelihood ratio of 6.4 (95% confidence interval, 1.9-21.7). Crackles and any new auscultation finding were also associated with a significant drop in FEV₁, as was a ≥2% drop in oxygen saturation (SpO₂) to ≤92% in the subgroup diagnosed with COPD. Very bothersome wheezing and severe decrease in SpO₂ were also very strong predictors of change in FEV₁ in linear regression adjusted for age, gender, and baseline FEV₁% predicted.

CONCLUSION

Increased wheezing, as experienced by the patient, and a decreased SpO₂ value strongly indicated a drop in lung function during asthma and COPD exacerbations and should probably be taken into account when treatment with oral corticosteroids is considered.

A nomogram was developed to enhance the use of multinomial logistic regression modeling in diagnostic research

OBJECTIVES

We developed a nomogram to facilitate the interpretation and presentation of results from multinomial logistic regression models.

STUDY DESIGN AND SETTING

We analyzed data from 376 frail elderly with complaints of dyspnea. Potential underlying disease categories were heart failure (HF), chronic obstructive pulmonary disease (COPD), the combination of both (HF and COPD), and any other outcome (other). A nomogram for multinomial model was developed to depict the relative importance of each predictor and to calculate the probability for each disease category for a given patient. Additionally, model performance of the multinomial regression model was assessed.

RESULTS

Prevalence of HF and COPD was 14% (n = 54), HF 24% (n = 90), COPD 20% (n = 75), and Other 42% (n = 157). The relative importance of the individual predictors varied across these disease categories or was even reversed. The pairwise C statistics ranged from 0.75 (between HF and Other) to 0.96 (between HF and COPD and Other). The nomogram can be used to rank the disease categories from most to least likely within each patient or to calculate the predicted probabilities.

CONCLUSIONS

Our new nomogram is a useful tool to present and understand the results of a multinomial regression model and could enhance the applicability of such models in daily practice.

Laryngeal measurements and diagnostic tools for diagnosis of chronic obstructive pulmonary disease

PURPOSE

The purpose of this study was to evaluate sensitivity, specificity, and positive and negative likelihood ratios of laryngeal height, lung function, and diagnostic questionnaires for screening and diagnosis of chronic obstructive pulmonary disease (COPD).

METHODS

We undertook a cross-sectional study of 233 people aged between 40 and 75 years. Measured variables were age, sex, weight, height, body mass index, tobacco use, maximum laryngeal height, and spirometry, and we administered a COPD questionnaire and the Lung Function Questionnaire.

RESULTS

For laryngeal height, we found a positive likelihood ratio of 5.21, and for the Lung Function Questionnaire, we found a negative likelihood ratio of 0.10. Combining a maximum laryngeal height of ≤4 cm with Lung Function Questionnaire findings of ≤18 yielded a positive likelihood ratio of 29.06, and a negative likelihood ratio of 0.26.

CONCLUSIONS

The intrinsic validity of the lung function questionnaire makes it useful for screening. Combining Lung Function Questionnaire results and laryngeal height can help confirm or dismiss COPD.

Should chest examination be reinstated in the early diagnosis of chronic obstructive pulmonary disease?

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.

Guidelines for diagnosis and management of chronic obstructive pulmonary disease: Joint ICS/NCCP (I) recommendations

Chronic obstructive pulmonary disease (COPD) is a major public health problem in India. Although several International guidelines for diagnosis and management of COPD are available, yet there are lot of gaps in recognition and management of COPD in India due to vast differences in availability and affordability of healthcare facilities across the country. The Indian Chest Society (ICS) and the National College of Chest Physicians (NCCP) of India have joined hands to come out with these evidence-based guidelines to help the physicians at all levels of healthcare to diagnose and manage COPD in a scientific manner. Besides the International literature, the Indian studies were specifically analyzed to arrive at simple and practical recommendations. The evidence is presented under these five headings: (a) definitions, epidemiology, and disease burden; (b) disease assessment and diagnosis; (c) pharmacologic management of stable COPD; (d) management of acute exacerbations; and (e) nonpharmacologic and preventive measures. The modified grade system was used for classifying the quality of evidence as 1, 2, 3, or usual practice point (UPP). The strength of recommendation was graded as A or B depending upon the level of evidence.