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In Replay: Influence of Spirometry on Patient Management in Diagnostic Studies Unknown
etry in addition to a questionnaire administered in the primary care setting, changed the management plans in 21% of patients. Spirometry results may change the diagnosis and/or management of the disease by the demonstration or exclusion of airflow obstruction, which can be assessed through before-and-after testing. However, such designs may easily overlook the confirmative role of spirometry results. Particularly when the signs and symptoms are conflicting, spirometry improves the diagnostic accuracy in subjects in whom COPD is part of the physician’s differential diagnosis and is therefore a useful diagnostic tool. This may play a role in much more than 21% of cases. We promote the performance of further research to explore these epidemiologic and additional values of spirometry in a primary care setting. Patrick J.P. Poels, MD Tim C. olde Hartman, MD Tjard R. Schermer, PhD Mieke Albers, MSc Chris van Weel, MD, PhD Radboud University Nijmegen Medical Centre Nijmegen, the Netherlands Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal. org/misc/reprints.shtml). Correspondence to: Patrick J.P. Poels, MD, Department of Family Practice (117), Radboud University Nijmegen Medical Centre, PO Box 9101, 6500 HB Nijmegen, the Netherlands; e-mail: [email protected]
References 1 Dales RE, Vandemheen KL, Clinch J, et al. Spirometry in the primary care setting: influence on clinical diagnosis and management of airflow obstruction. Chest 2005; 128:2443– 2447 2 Smith-Sivertsen, Rortveit G. Should general practitioners screen smokers for COPD? Scand J Prim health Care 2004; 22:196 –201 3 Schermer TR, Jacobs JE, Chavannes NH, et al. Validity of spirometric testing in a general practice population of patients with chronic obstructive pulmonary disease (COPD). Thorax 2003; 58:861– 866 4 Boushey H, Enright P, Samet J. Spirometry for chronic obstructive pulmonary disease case finding in primary care? Am J Respir Crit Care Med 2005; 172:1481–1482 5 Chavannes N, Schermer T, Akkermans R, et al. Impact of spirometry on GPs’ diagnostic differentiation and decisionmaking. Respir Med 2004; 98:1124 –1130 6 Yawn B, Wollan P, Pace W, et al. Can we do office spirometry and do the results impact the care of asthma and COPD [abstract]? Paper presented at: NAPCRG Annual Meeting; October 15–18, 2005; Quebec City, QC, Canada To the Editor: We screened ⬎ 1,000 primary care patients for airflow obstruction and assessed the clinical impact of screening.1 This resulted in physicians making a new diagnosis of unsuspected airflow obstruction in 9% of patients, and having a prior diagnosis of airflow obstruction removed in 11%. Physicians reported that based on spirometry results, they would change management in 15%. Poels et al2 state that “the results confirm that spirometry should not be used to screen smokers for COPD because it is not yet known if [early] diagnosis will help patients stop smoking.” We would agree with this if diagnosing COPD is of no benefit to the patient, if determining that a patient received a misdiagnosis of COPD is of no value, and if a physician’s decision to change management is of no consequence. Knowing a patient has airflow limitation allows the physician to consider vaccination, exercise 1734
prescription, and medication that improve quality of life.3 Discovering that a patient does not have airflow obstruction allows the physician to consider other causes of the symptoms that initially prompted the diagnosis, such as cardiac disease. Concerning future research, we agree with Poels et al2 on the importance of assessing spirometry as a diagnostic tool for primary care patients presenting with respiratory complaints. It would be helpful to develop techniques to improve the quality of the test and its interpretation in primary care. Finally, now that we know spirometry can detect new cases and physicians are willing to consider management changes, we need to assess the impact of these actions on the quality of life of the patients, the important end result. Robert E. Dales, MD Katherine L. Vandemheen, BSc Jennifer Clinch, MSc Shawn D. Aaron, MD University of Ottawa Ottawa, ON, Canada Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal. org/misc/reprints.shtml). Correspondence to: Robert E. Dales, MD, University of Ottawa, 501 Smyth Rd, Box 211, Ottawa, ON, Canada K1H 8L6; e-mail: [email protected]
References 1 Dales RE, Vandemheen KL, Clinch J, et al. Spirometry in the primary care setting: influence on clinical diagnosis and management of airflow obstruction. Chest 2005; 128:2443– 2447 2 Poels PJP, Hartman TC, Schermer TR, et al. Influence of spirometry on patient management in diagnostic studies unknown [letter]. Chest 2006; 129: 3 Lacasse Y, Brosseau L, Milne S, et al. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews 2002; 3:CD003793
Renin-Angiotensin System Blockade and COPD To the Editor: In a recent article in CHEST (December 2005),1 Matsuyama et al found that nutritional support with a diet that is rich an omega-3 polyunsaturated fatty acids had antiinflammatory effects and improved exercise tolerance in patients with COPD. However, they did not mention whether the studied population was receiving treatment with angiotensin-converting enzyme (ACE) inhibitors or angiotensin II type 1 receptor blockers. Increasing evidence2–5 has suggested that renin-angiotensin system blockade exerts an antiinflammatory action in many systems. Furthermore, in COPD patients, lower ACE activity has been shown to be associated with improved pulmonary hemodynamic variables and improved tissue oxygenation during exercise.6 Therefore, therapy with ACE inhibitors or angiotensin II type 1 receptor blockers, which should be recommended in most patients with COPD, might have been a confounder in the study by Matsuyama and colleagues.1 Luca Mascitelli, MD Comando Brigata Alpina “Julia” Udine, Italy Francesca Pezzetta, MD Ospedale di San Vito al Tagliamento San Vito al Tagliamento, Italy Correspondence
References 1 Dales RE, Vandemheen KL, Clinch J, et al. Spirometry in the primary care setting: influence on clinical diagnosis and management of airflow obstruction. Chest 2005; 128:2443– 2447 2 Smith-Sivertsen, Rortveit G. Should general practitioners screen smokers for COPD? Scand J Prim health Care 2004; 22:196 –201 3 Schermer TR, Jacobs JE, Chavannes NH, et al. Validity of spirometric testing in a general practice population of patients with chronic obstructive pulmonary disease (COPD). Thorax 2003; 58:861– 866 4 Boushey H, Enright P, Samet J. Spirometry for chronic obstructive pulmonary disease case finding in primary care? Am J Respir Crit Care Med 2005; 172:1481–1482 5 Chavannes N, Schermer T, Akkermans R, et al. Impact of spirometry on GPs’ diagnostic differentiation and decisionmaking. Respir Med 2004; 98:1124 –1130 6 Yawn B, Wollan P, Pace W, et al. Can we do office spirometry and do the results impact the care of asthma and COPD [abstract]? Paper presented at: NAPCRG Annual Meeting; October 15–18, 2005; Quebec City, QC, Canada To the Editor: We screened ⬎ 1,000 primary care patients for airflow obstruction and assessed the clinical impact of screening.1 This resulted in physicians making a new diagnosis of unsuspected airflow obstruction in 9% of patients, and having a prior diagnosis of airflow obstruction removed in 11%. Physicians reported that based on spirometry results, they would change management in 15%. Poels et al2 state that “the results confirm that spirometry should not be used to screen smokers for COPD because it is not yet known if [early] diagnosis will help patients stop smoking.” We would agree with this if diagnosing COPD is of no benefit to the patient, if determining that a patient received a misdiagnosis of COPD is of no value, and if a physician’s decision to change management is of no consequence. Knowing a patient has airflow limitation allows the physician to consider vaccination, exercise 1734
prescription, and medication that improve quality of life.3 Discovering that a patient does not have airflow obstruction allows the physician to consider other causes of the symptoms that initially prompted the diagnosis, such as cardiac disease. Concerning future research, we agree with Poels et al2 on the importance of assessing spirometry as a diagnostic tool for primary care patients presenting with respiratory complaints. It would be helpful to develop techniques to improve the quality of the test and its interpretation in primary care. Finally, now that we know spirometry can detect new cases and physicians are willing to consider management changes, we need to assess the impact of these actions on the quality of life of the patients, the important end result. Robert E. Dales, MD Katherine L. Vandemheen, BSc Jennifer Clinch, MSc Shawn D. Aaron, MD University of Ottawa Ottawa, ON, Canada Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal. org/misc/reprints.shtml). Correspondence to: Robert E. Dales, MD, University of Ottawa, 501 Smyth Rd, Box 211, Ottawa, ON, Canada K1H 8L6; e-mail: [email protected]
References 1 Dales RE, Vandemheen KL, Clinch J, et al. Spirometry in the primary care setting: influence on clinical diagnosis and management of airflow obstruction. Chest 2005; 128:2443– 2447 2 Poels PJP, Hartman TC, Schermer TR, et al. Influence of spirometry on patient management in diagnostic studies unknown [letter]. Chest 2006; 129: 3 Lacasse Y, Brosseau L, Milne S, et al. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews 2002; 3:CD003793
Renin-Angiotensin System Blockade and COPD To the Editor: In a recent article in CHEST (December 2005),1 Matsuyama et al found that nutritional support with a diet that is rich an omega-3 polyunsaturated fatty acids had antiinflammatory effects and improved exercise tolerance in patients with COPD. However, they did not mention whether the studied population was receiving treatment with angiotensin-converting enzyme (ACE) inhibitors or angiotensin II type 1 receptor blockers. Increasing evidence2–5 has suggested that renin-angiotensin system blockade exerts an antiinflammatory action in many systems. Furthermore, in COPD patients, lower ACE activity has been shown to be associated with improved pulmonary hemodynamic variables and improved tissue oxygenation during exercise.6 Therefore, therapy with ACE inhibitors or angiotensin II type 1 receptor blockers, which should be recommended in most patients with COPD, might have been a confounder in the study by Matsuyama and colleagues.1 Luca Mascitelli, MD Comando Brigata Alpina “Julia” Udine, Italy Francesca Pezzetta, MD Ospedale di San Vito al Tagliamento San Vito al Tagliamento, Italy Correspondence