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Role of Spirometry in the Diagnosis of COPD
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The autonomic nervous system may be disturbed in chronic respiratory failure. We tested the hypothesis that there is increased sympathetic activity in patients with chronic hypoxemia. Furthermore, we examined the effect of short-term oxygen on muscle sympathetic nerve activity (MSNA) in these patients. We performed microneurography of the peroneal nerve in 11 patients with hypoxemia due to chronic obstructive pulmonary disease (COPD, n = 6) or lung fibrosis (n = 5) and in 11 healthy subjects matched for age and sex. MSNA was measured during normal breathing in all subjects. In eight patients and in seven control subjects, MSNA was also measured during nasal oxygen (4 L/min). MSNA was higher in the patients with chronic respiratory failure compared with the healthy subjects during normal breathing (61 +/- 5 versus 34 +/- 2 bursts/min, mean +/- SEM; p = 0.0002, paired t test). During oxygen administration, MSNA decreased from 63 +/- 6 to 56 +/- 6 bursts/min in the patients (p = 0.0004, ANOVA); there was no change in sympathetic activity in the control subjects. For the first time, there is direct evidence of marked sympathetic activation in patients with chronic respiratory failure. This is partly explained by arterial chemoreflex activation and may play an important role in the pathogenesis of the disease.
An attempt has been made to estimate the gross burden of chronic obstructive pulmonary disease (COPD) and its smoking association by reviewing the population studies available from India. Of the 14 studies which were reviewed, there were 11 conducted in general populations. The median values of different prevalence rates (i.e. 5 percent in male and 2.7 percent in female population) were accepted as the most appropriate figures to calculate the overall estimates. The overall M:F ratio was 1.6:1, i.e. 61.6 percent males. The estimated total number of adult patients aged 30 years and above in 1996 were 8.15 million males and 4.21 million females. The smoker:non-smoker ratio in males was assessed at 82.3 percent with an estimated burden of 6.7 millions. When the prevalence rates of COPD and its smoking associations were assessed in three different time periods (before 1970; between 1971-1990; after 1990), the median rates of 1971-1990, when the maximum number of studies were conducted, were nearly the same as the overall rates. However, the total burden as well as the smoking associated COPD, increased with time due to an increase in the eligible base population. In conclusion, these figures can be used to estimate the burden of COPD and its smoking association in India for different statistical analyses.
Chronic obstructive pulmonary disease (COPD) remains a major public health problem. It is the fourth leading cause of chronic morbidity and mortality in the United States, and is projected to rank fifth in 2020 in burden of disease worldwide, according to a study published by the World Bank/World Health Organization. Yet, COPD remains relatively unknown or ignored by the public as well as public health and government officials. In 1998, in an effort to bring more attention to COPD, its management, and its prevention, a committed group of scientists encouraged the U.S. National Heart, Lung, and Blood Institute and the World Health Organization to form the Global Initiative for Chronic Obstructive Lung Disease (GOLD). Among the important objectives of GOLD are to increase awareness of COPD and to help the millions of people who suffer from this disease and die prematurely of it or its complications. The first step in the GOLD program was to prepare a consensus report, Global Strategy for the Diagnosis, Management, and Prevention of COPD, published in 2001. The present, newly revised document follows the same format as the original consensus report, but has been updated to reflect the many publications on COPD that have appeared. GOLD national leaders, a network of international experts, have initiated investigations of the causes and prevalence of COPD in their countries, and developed innovative approaches for the dissemination and implementation of COPD management guidelines. We appreciate the enormous amount of work the GOLD national leaders have done on behalf of their patients with COPD. Despite the achievements in the 5 years since the GOLD report was originally published, considerable additional work is ahead of us if we are to control this major public health problem. The GOLD initiative will continue to bring COPD to the attention of governments, public health officials, health care workers, and the general public, but a concerted effort by all involved in health care will be necessary.
Short term variability in FEV1 and responsiveness to inhaled bronchodilator were measured in 150 patients with obstructive ventilatory defects. The range of initial FEV1 was 0.5-4.71 and the natural variability over a 20 minute period when expressed in absolute terms was similar over the entire range, and differed insignificantly from that found in normal subjects. The increase in FEV1 and vital capacity (VC) required to exclude natural variability with 95% confidence in these patients was 160 ml and 330 ml respectively. Natural variability when expressed in percentage terms was negatively correlated with the level of FEV1 recorded. The analysis of changes in FEV1 and VC after administration of bronchodilator used absolute and percentage criteria for response. The number of responders differed considerably according to the criterion used. In those defined by the absolute criterion as responders there was no evidence that size of response was related to level of FEV1. Percentage criteria have traditionally been used to identify responses to bronchodilator that may be clinically useful, while absolute criteria, although statistically valid, have not been favoured. Reappraisal of the criteria used and their limitations and implications is required.
We recruited 985 patients with COPD but without hypoxemia or other serious disease, treated them in a standard fashion, and followed them closely for nearly 3 yr. At the time of recruitment the patients were carefully characterized as to symptom severity, lung function, exercise tolerance, and quality of life, and studies of lung function were repeated during follow-up. Overall mortality was 23% in 3 yr of follow-up. Patient age and the initial value of the FEV1 were the most accurate predictors of death; when FEV1 before bronchodilator was used, the response to bronchodilators was directly related to survival, but this relationship became nonsignificant when postbronchodilator FEV1 was used as a primary predictor. After adjustment for age and FEV1, mortality was related positively to TLC, resting heart rate, and perceived physical disability, and related negatively to exercise tolerance. These relationships, though significant, were relatively weak. When standardized for age and FEV1, mortality in the present series was less than that of a previous series (4), and the same as that of hypoxemic patients with COPD who received continuous home O2 therapy. Changes in FEV1 with time averaged -44 ml/yr, but the standard deviation was large. Patients with low initial values of FEV1 showed relatively little further decline, probably indicating a survivor effect. In patients with well-preserved initial FEV1, rate of decline correlated negatively with bronchodilator response, symptomatic wheezing, and psychological disturbances.
Bronchodilator therapy in COPD is deemed successful if it improves ventilatory mechanics to a degree where effective symptom alleviation and increased exercise capacity are achieved. A greater understanding of the pathophysiologic mechanisms of dyspnea and exercise intolerance in COPD has prompted a reevaluation of the manner in which we currently assess therapeutic efficacy. The traditional reliance on an improved postbronchodilator FEV(1) as indicative of a positive clinical response has recognized limitations. To the extent that pharmacologic volume reduction is a desirable therapeutic goal with favorable implications for dyspnea relief and increased exercise tolerance, the potential value of bronchodilator-induced changes in lung volume measurements is currently being studied. It is unlikely, however, given the multifactorial nature of dyspnea and exercise limitation in COPD, that resting spirometric measurements of maximal flows and volumes alone will be sufficiently sensitive to adequately predict a positive clinical response to bronchodilator therapy. Thus, additional direct measurements of exercise dynamic hyperinflation and exercise endurance together with reliable subjective measurements of dyspnea and quality of life are recommended in the setting of a suitable placebo-controlled design.
Chronic obstructive pulmonary disease has been associated with a high frequency of arrhythmias. Few studies have analysed the role of reduced lung function in predicting atrial fibrillation (AF). The aim of the present study was to investigate the relationship between forced expiratory volume in one second (FEV1) and risk of first episode of AF in a prospective study. Data from 13,430 males and females without previous myocardial infarction, who participated in the Copenhagen City Heart Study, were analysed. New AF was assessed at re-examination after 5 yrs and by hospital admission for AF during a period of 13 yrs. Multivariate analyses were used with adjustment for cardiopulmonary risk factors. There were 62 new cases of AF at 5-yr follow-up (0.58%) and 290 cases (2.20%) diagnosed at hospitalisations. Risk of new AF at re-examination was 1.8-times higher for FEV1 between 60-80% of predicted compared with FEV1 > or = 80% after adjustment for sex, age, smoking, blood pressure, diabetes and body mass index. The risk of AF hospitalisation was 1.3-times higher for FEV1 between 60-80% and 1.8-times higher for FEV1 < 60% compared with FEV1 > or = 80%, when additional adjustment was made for education, treatment with diuretics and chest pain at activity. The authors conclude that reduced lung function is an independent predictor for incident atrial fibrillation.
Burden of Obstructive Lung Disease (BOLD) Initiative sites worldwide.
To measure the prevalence of chronic obstructive pulmonary disease (COPD) and its risk factors, investigate variation in prevalence across countries and develop standardized methods that can be used in industrialized and developing countries.
Non-institutionalized adults aged > or =40 years were recruited using population-based sampling plans. Each site targeted a minimum of 600 participants (300 women, 300 men), who filled out questionnaires and performed spirometry before and after administration of 200 mug salbutamol using standardized methods. Random effects meta-analysis models were used to estimate pooled prevalence estimates and risk factor effects and to test for heterogeneity across sites and sex.
Data published from 12 sites (n = 8775) showed that the estimated population prevalence of COPD (Global Initiative for Chronic Obstructive Lung Disease [GOLD] Stage II and higher) was 10.1 +/- SE = 4.8% overall (11.8 +/- 7.9% for men and 8.5 +/- 5.8% for women). Prevalence increased with age and pack-years of smoking, but other less understood risk factors, such as biomass heating and cooking exposures, occupational exposures and tuberculosis, also contribute to the location-specific variations in disease prevalence that BOLD is finding.
BOLD has estimated the social and economic burden of COPD in 12 countries to date. BOLD and the Proyecto Latinoamericano de Investigación en Obstrucción Pulmonar (the PLATINO study) are developing a growing database of COPD prevalence. Cigarette smoking and age are the most important COPD risk factors, but other risk factors should also be explored.
Peak oxygen uptake (V'(O(2))) remains the gold standard measurement of exercise capacity and has been associated with survival. A modified BODE (body mass index, airflow obstruction, dyspnoea, exercise capacity) index replacing the 6-min walk distance (6MWD) with V'(O(2)) as % predicted (mBODE%) has been developed and found to have excellent correlation with the conventional BODE index. The objectives of the present study were to compare the ability of the conventional BODE and the mBODE% to predict mortality in 444 patients with chronic obstructive pulmonary disease (COPD) followed for a mean+/-SD period of 71+/-34 months. Anthropometrics, spirometry, lung volumes, comorbidity, cardiopulmonary cyclo-ergometry test and 6MWD were determined at entry. The mean BODE indices for the cohort were: BODE 4.1+/-2 and mBODE% 5.5+/-2. Both indices were significantly correlated with mortality. Logistic regression analysis with COPD survival as the dependent variable identified the BODE index, Charlson's and exercise capacity (in W) as variables associated with this outcome. In conclusion, the conventional BODE index, which uses the 6-min walk distance, predicts mortality in chronic obstructive pulmonary disease as well as the modified index using peak oxygen uptake. The results support the use of the simpler index, which includes the 6-min walk distance in the comprehensive evaluation of patients with chronic obstructive pulmonary disease.
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