Diagnosis of COPD and clinical course in patients with unrecognized airflow limitation

Abstract

Chronic obstructive pulmonary disease (COPD) is frequently under-recognized and underdiagnosed. To determine the natural history of recognized and unrecognized COPD, we studied the rate of diagnosis, health care utilization, and mortality in patients with airflow limitation (AFL). Three hundred forty-seven outpatients at the Cincinnati Veterans Administration Medical Center performed spirometry and completed a respiratory questionnaire. Patients were followed for a minimum of 30 months and medical records were reviewed for COPD diagnosis, mortality, respiratory-related health care utilization, comorbidities, and respiratory medications. Three hundred twenty-five of 347 (94%) patients performed technically adequate spirometry and completed questionnaires. When AFL was defined by fixed ratio (FR, forced expiratory volume in 1 second [FEV1]/forced vital capacity [FVC] < 0.7), patients with AFL and a diagnosis of COPD had a higher annual mortality rate (7.1% ± 2% versus 2.4% ± 0.8%, P = 0.01), more hospitalizations per year (0.2 ± 0.06 versus 0.04 ± 0.01, P < 0.001 mean ± standard error of the mean), increased respiratory symptoms (12.0 ± 0.9 versus 7.2 ± 0.6, P < 0.0001), and higher Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage compared with undiagnosed patients. Ninety-two of 137 patients with AFL (67%) had unrecognized AFL; 16 (17%) of the 92 were subsequently diagnosed. When AFL was defined by the lower limit of normal (LLN, FEV1/FVC < LLN), 67 of 103 patients (65%) had unrecognized AFL; 12 (18%) of the 67 were subsequently diagnosed. Patients with AFL defined by FR who were subsequently diagnosed had more emergency department visits per year (0.33 ± 0.11 versus 0.11 ± 0.05, P = 0.009), increased respiratory symptoms (10.2 ± 1.6 versus 6.5 ± 0.7, P < 0.05), and higher GOLD stage, but similar mortality and hospitalizations compared with the persistently undiagnosed patients. The annual rate of documented COPD diagnosis was 7% for both FR and LLN definitions. Patients with AFL and a diagnosis of COPD have more severe disease, higher health care utilization, and mortality than undiagnosed patients. The annual rate of COPD diagnosis is 7% among individuals with unrecognized AFL. Worse AFL, increased respiratory symptoms, and ED visits are associated with a subsequent COPD diagnosis in individuals with unrecognized AFL.

Therapeutic paralysis in Veterans with COPD

“…ED physicians diagnosed COPD in approximately 6% of respondents, which corroborates our previous finding that ED visits often precede a new diagnosis, and that Veterans with undiagnosed COPD had more than twice as many ED visits for respiratory disorders compared with Veterans with previously diagnosed COPD. 44, 45 Thus, the PCP plays an essential role in not only the recognition and diagnosis of COPD but also the communication of the diagnosis of COPD to the patient and ED visits seem to precipitate the diagnosis of COPD.…”

ALAT-2014 Chronic Obstructive Pulmonary Disease (COPD) Clinical Practice Guidelines: Questions and Answers

“…[28][29][30][31][32] The main factors associated with underdiagnosis are: younger age, less severe airway obstruction, and few respiratory symptoms. [28][29][30][31][32] The main factors associated with underdiagnosis are: younger age, less severe airway obstruction, and few respiratory symptoms.…”

“…[28][29][30][31][32] The main factors associated with underdiagnosis are: younger age, less severe airway obstruction, and few respiratory symptoms. 30,[33][34][35] The absence or mildness of symptoms at this pre-clinical stage of the disease contributes to underdiagnosis. 30,[33][34][35] The absence or mildness of symptoms at this pre-clinical stage of the disease contributes to underdiagnosis.…”

Development of a simple screening tool for opportunistic COPD case finding in primary care in Latin America: The PUMA study

“…In Latin America, the PLATINO (the Latin American Project for Investigation of Obstructive Lung Disease) study showed a prevalence of 14.3%, and an under‐diagnosis of 89% . One‐third of patients detected using population‐based studies or case finding approaches in primary care settings are asymptomatic and more than half have mild symptoms …”