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Early Detection of COPD in a High-Risk Population Using Spirometric Screening^*

Jan Zieliñski, MD, PhD, FCCP; Micha Bednarek, MD, and the Know the Age of Your Lung Study Group

^* From the Department of Respiratory Medicine, Institute of Tuberculosis and Lung Diseases, Warsaw, Poland. A complete list of investigators of the Know the Age of Your Lung Study Group is located in the ^Appendix.

Correspondence to: Jan Zieliñski, MD, PhD, FCCP, Department of Respiratory Medicine, Institute of Tuberculosis and Lung Diseases, Plocka 26, 01–138 Warsaw, Poland; e-mail: j.zielinski{at}igichp.edu.pl

	Abstract

TOP Abstract Introduction Materials and Methods Results Discussion Appendix 1 References

 
Study objectives: To evaluate the efficacy of mass spirometry use for the detection of airflow obstruction in a high-risk population.

Design: Free spirometry was offered to smokers who were > 39 years of age with a smoking history of > 10 pack-years. Action was preceded by the dissemination of information on the causes and symptoms of COPD in the local mass media.

Setting: Pulmonary outpatient clinics in 12 large cities of Poland.

Participants: Eleven thousand twenty-seven subjects with the following characteristics were screened: mean (± SD) age, 51.8 ± 12.5 years; men, 57%; current or ex-smokers, 80%; and mean smoking history, 26.1 ± 16.8 pack-years.

Interventions: Smoking history, simple spirometry (FVC and FEV₁), and an antismoking advice.

Results: Spirometric signs of airway obstruction were found in 24.3% of the subjects who were screened. Of those subjects, mild obstruction was found in 9.5%, moderate obstruction was found in 9.6%, and severe obstruction was found in 5.2%. In smokers aged 40 years who had a smoking history of > 10 pack-years, airway obstruction was found in 30.6%. Airway obstruction was present in 8.3% of smokers < 40 years of age who had a smoking history of < 10 pack-years. Of the 2,200 subjects who had never smoked in their lives, airway obstruction was found in 14.4%.

Conclusions: Mass spirometry in high-risk groups is an effective and easy method for the early detection of COPD.

Key Words: COPD • high-risk group • mass spirometry.

	Introduction

TOP Abstract Introduction Materials and Methods Results Discussion Appendix 1 References

 
COPD is the most frequent chronic lung disease in developed countries. Epidemiologic surveys in the United Kingdom,¹ France,² and Poland³ have demonstrated that approximately 10% of the adult population presents with chronic cough and sputum production accompanied with spirometric signs of airflow obstruction. The high prevalence and inexorable progression of the disease result in a high mortality rate. In the United States, COPD, from which > 100,000 persons die each year, is the fourth leading cause of death.⁴

Contrary to the declining trends in mortality rates observed during the last 2 decades for cardiovascular diseases, the mortality rate for COPD is still rising. The mortality rate from chronic lung diseases (COPD being the prevailing cause) rose by 46.6% between 1979 and 1993.⁵ COPD is an important cause of sick leaves,⁶ hospital admissions,⁷ and doctor office visits.⁸ In the United States, the estimated direct and indirect costs related to COPD amounted, in 1993, to $23.9 billion.

COPD usually is diagnosed late in its natural course. The National Health and Nutrition Examination Survey, which was conducted in the United States from 1988 to 1994, demonstrated that 63.3% of subjects with documented low lung function had no prior or current diagnosis of obstructive lung disease.⁹ For many years, the early symptoms (ie, chronic cough and sputum production) are usually neglected. Most often, a patient is inclined to seek medical advice when he or she becomes dyspneic. By that time, more than half of the patient’s ventilatory reserves are irreparably lost. Because of the increase in prevalence and mortality of COPD, and its high medical costs, it is important to identify patients and to treat them before they reach the symptomatic and costly stages of the disease.

The aim of the study was to investigate the effects of spirometric screening in the detection of airflow obstruction, the principal sign of COPD, on a high-risk population.

	Materials and Methods

TOP Abstract Introduction Materials and Methods Results Discussion Appendix 1 References

 
Pulmonary physicians, members of the Know the Age of Your Lung Study Group, performed their investigations in pulmonary outpatient clinics in 12 Polish cities. They prepared written materials for local TV, radio, or newspapers. Materials included information on the causes and symptoms of COPD. In some places, it was thought that the term COPD was unfamiliar, and it was replaced by the better known term emphysema. Information that not all smokers are susceptible to COPD and that spirometry is a simple noninvasive method to detect COPD at an early stage of the disease was also included. Smokers > 39 years of age with a history of > 10 pack-years of smoking were invited for a free spirometry test. However, all people who presented themselves for spirometry, whether younger or nonsmokers, also were accepted.

Spirometry was performed in some places on working days, and in others on Saturdays. Three models of spirometers (Pneumo 2000; ABC Med; Kraków, Poland; and Lungtest 500 or Lungtest 1000; MES; Kraków, Poland) were used in the majority of centers, except in Warsaw where another was used (Alpha or model 2120 spirometer; Vitalograph; Maidenhead, UK). Spirometric measurements were taken by an experienced technician using American Thoracic Society recommendations.¹⁰ FVC and FEV₁ were measured. The reference values were those of the European Community of Coal and Steel that have been approved by the European Respiratory Society.¹¹ The FEV₁/FVC ratio was calculated. The obstructive pattern of ventilatory impairment was classified according to the European Respiratory Society Guidelines¹² when FEV₁/FVC ratio was < 85% of the predicted normal value. The severity of the airway obstruction was categorized as mild (FEV₁, 70% of normal), moderate (FEV₁, 50 to 69% of normal), and severe (FEV₁, < 50% of normal). A restrictive pattern of ventilatory impairment was recognized when FVC was < 80% of normal and the FEV₁/FVC was > 100% of normal. A mixed-pattern group (FVC, < 80% of normal; FEV₁, 70% of normal; FEV₁/FVC ratio, 85 to 99% of normal) was distinguished that described spirometry studies showing both restrictive and obstructive ventilatory impairment.

While waiting to undergo spirometry testing, subjects filled out a short questionnaire concerning their smoking habits. The results of spirometry (the absolute values and the percent predicted) were written into a small booklet entitled the Lung Health Identity Card distributed to each subject. The booklet included basic recommendations related to the results of spirometry. One part of the booklet was devoted to smoking habits, including a suggestion to enter the patient’s actual smoking status every 3 months. Also, in the spirometric part of the booklet, there was a place for multiple future entries.

Subjects with normal spirometry levels were informed of the results of their testing and, in addition to the Lung Health Identity Card, were presented with an antismoking booklet containing information about the harmful effects of smoking and advice on how to stop smoking. Physicians participating in the study consulted with subjects presenting with abnormal spirometry, explained the relationship between the results of spirometry and smoking, strongly advised smoking cessation, and suggested a visit to a family physician by writing an appropriate referral letter for the subject.

The demographics of the investigated subjects, the results of the smoking questionnaires, and the spirometric measurements in each cooperating center were entered into a database and were sent to the Institute of Tuberculosis and Lung Diseases in Warsaw where they were centrally analyzed using software (Statistica; SAS Institute; Cary, NC).

	Results

TOP Abstract Introduction Materials and Methods Results Discussion Appendix 1 References

 
A total number of 11,027 evaluable spirograms and questionnaires were reviewed. Subjects consisted of 57.3% men and 42.7% women, with a mean (± SD) age of 51.8 ± 12.5 years. Eighty percent of subjects were current smokers or ex-smokers with a smoking history of 26.1 ± 16.8 pack-years. Two thousand two hundred subjects declared themselves as lifelong nonsmokers. Exposure to passive smoking was not investigated. One thousand five hundred eighty-four subjects (14.4%) were < 40 years of age. The youngest subject was 13 years old, and the oldest subject was 89 years old. The age group distribution is shown in Figure 1 . The demographic and smoking habit data of different age groups are shown in Table 1 .

View larger version (34K): [in this window] [in a new window] [Download PPT slide]   Figure 1.. Age distribution of the studied subjects.

	Discussion

TOP Abstract Introduction Materials and Methods Results Discussion Appendix 1 References

Approximately 15 to 20% of smokers develop COPD.¹⁴ As smoking is a behavior that can be changed, a key issue in avoiding the development of severe forms of COPD would be to identify susceptible smokers at an early stage of the disease and to persuade them to stop smoking. The early diagnosis of COPD at a preclinical phase of the disease may be attempted by spirometric screening of smokers.

The present study showed that voluntary spirometry screening of a high-risk population of smokers gave a very high yield of subjects presenting with spirometric signs of airway obstruction. Interestingly, the percentage of subjects with airway limitation was very close to that in the results of screening performed in the United States and Canada for the Lung Health Study (LHS).¹⁵ Spirometric screening was performed in > 73,000 smokers aged 35 to 60 years who were recruited in 10 centers. The percentage of subjects with airway obstruction varied from 21.8 to 35.7% (mean, 25%). Additionally, 5% had severe airway obstruction (FEV₁, < 50% of predicted). This makes a total of 30% of subjects with airway obstruction, which is 6% higher than in our study (24.3%). The LHS demonstrated that COPD could be detected in its early stages in smokers. The difference between the studies may be explained by the fact that in the LHS only active smokers were screened while ex-smokers and lifelong nonsmokers also were included in our study in Poland. After the exclusion of lifelong nonsmokers from the Polish group, the difference was reduced to 3%.

It was rather surprising that this difference was so small considering the large difference in the smoking habits between populations. The LHS group (mean age, 48 years) had a history of 40 pack-years of smoking, while the Polish cohort (mean age, 52 years) had a smoking history of 26.1 pack-years. Despite a lower cumulative exposure to tobacco smoke, one fifth of subjects with airflow obstruction in Poland had FEV₁ levels < 50% of predicted. This finding may be explained in part by the quality of cigarettes in Poland. Until recent years, 70% of the market was covered by cheap, filterless, high-tar cigarettes. Another factor that could play a role was the high level of environmental air pollution.

The surprisingly high frequency of airflow obstruction in lifelong nonsmokers requires comment. As the invitation for a free spirometry was addressed to smokers, claiming "nonsmoking status" was most probably genuine. Some of the nonsmoking subjects declared long-term high-level exposure to passive smoking. Among the subjects screened, there were couples composed of a heavy smoking husband and a nonsmoking wife. Signs of airflow obstruction usually were found in both.

Another factor that could have played a role in the development of airflow obstruction in lifelong nonsmokers was passive exposure to tobacco smoke and a history of lower respiratory tract infections in early childhood. Almost 25% of studied subjects were born between 1940 and 1949, during the second World War or soon thereafter. Poland was occupied for 5 years of the war. The population suffered from very bad housing conditions, famine, cold, and mass deportations.

Lower respiratory tract infections in early childhood, before the age of 3 years, was found to be responsible for the low lung function in adults.^{16 17} In one study investigating lung function in young British subjects born in 1946, it was found that bad social conditions and passive smoking in early childhood resulted in lowered spirometric values.¹⁸ Recently, Lopuhaä et al¹⁹ studied people born around the time of the Dutch famine from 1944 to 1945. They observed an increase in the prevalence of obstructive airways disease in subjects whose mothers were exposed to famine in mid-pregnancy and early pregnancy.

In the controlled clinical trials conducted thus far, attempts to slow down the FEV₁ decline in COPD patients with ipratropium bromide²⁰ or inhaled steroids^{21 22} have been unsuccessful. The only confirmed effective method is smoking cessation. The LHS²⁰ clearly demonstrated that smoking cessation at an early stage of COPD resulted in an improvement of FEV₁ during the first year after smoking cessation followed by a plateau and a very slow decline. At the end of the fifth year of follow-up, FEV₁ in sustained nonsmokers (22% of those who stopped smoking at entry) was only 73 mL lower than at entry. Thus, the rate of decline of FEV₁ after successful smoking cessation was 15 mL/year, which is similar to that seen in healthy nonsmoking populations. Also, Xu et al,²³ in a longitudinal study of > 8,000 COPD patients, found that those who stopped smoking ceased to lose pulmonary function at an accelerated rate. Historically, Fletcher and Peto²⁴ were the first to report beneficial effects of smoking cessation on the rate of FEV₁ decline in patients with COPD.

As we enter the new millennium, it seems that the only available method to prevent the development of severe forms of COPD is early diagnosis of the disease followed by persistent, concerted actions to persuade newly diagnosed patients to stop smoking. Simple, short antismoking advice reinforced by nicotine replacement therapy yields a 20 to 30% long-term success rate.²⁵ The preliminary results of combination therapy with the antidepressant drug bupropion and nicotine replacement therapy are even more promising.²⁶

The diagnosis of COPD at an early stage and awareness of the health consequences of COPD should be strong motivations for smoking cessation. It can be assumed that one third of subjects with airflow obstruction detected by mass spirometry would stop smoking. This would be a great advance in the control of COPD and would prevent alarming predictions for the future.

The efforts toward the early diagnosis of COPD and toward the prevention of severe forms of the disease may take different forms. In the United States, the National Lung Health Education Program, a project jointly sponsored by several professional societies crossing various medical disciplines and specialties, was created.²⁷ The program is designed to increase the awareness of lung health in patients, health-care practitioners, and health-care organizations. Recently, the group published a consensus statement²⁸ recommending the widespread use of office spirometry by primary-care providers for patients 45 years old who smoke cigarettes.

In Poland, the National Program of Early Diagnosis and Prevention of COPD will begin in 2001. The program will start by raising the awareness of the public health authorities, the medical community, and the general public that COPD is a public health issue. Spirometry screening of smokers aged 40 years of age will be performed in pulmonary outpatient clinics nationwide. Subjects with airflow limitation will be strongly advised to stop smoking and will be followed up at antismoking clinics. Subjects identified with the low lung function will undergo diagnosis and will be treated appropriately.

	Appendix 1

TOP Abstract Introduction Materials and Methods Results Discussion Appendix 1 References

	Acknowledgements

 
The authors thank Thomas L. Petty, MD, Master FCCP, of Denver, CO, for his inspiration and interest in the study.

	Footnotes

 
Abbreviation: LHS = Lung Health Study

None of the authors have any financial involvement with Boehringer Ingelheim, which supported the study.

Received for publication April 4, 2000. Accepted for publication November 3, 2000.

	References

TOP Abstract Introduction Materials and Methods Results Discussion Appendix 1 References

 

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