Call to revisit COPD guidelines


By Amanda Sheppeard

2 Jun 2016

A leading Australian thoracic specialist and researcher has called for a revision of current COPD criteria to include cough and sputum as red flags for the disease.

Professor Christine Jenkins, head of Respiratory Trials at The George institute for Global Health, Senior Staff Specialist in Thoracic Medicine at Concord Hospital, Sydney, and Clinical Professor and Head of Respiratory Discipline at the University of Sydney, says not all patients with early-stage disease will meet the spirometry criteria for a diagnosis of COPD.

She said smokers and ex-smokers were particularly likely to be symptomatic – with cough and sputum – but not meet the spirometry criteria for COPD.

“I think the symptoms are telling us something really really important,” she told the limbic.

“Even if they (patients) don’t meet the spirometry criteria they might still have COPD – they just don’t yet meet all the symptom criteria. It looks as if these people are on a trajectory – and it does tell you that they have symptoms and you can intervene.”

Professor Jenkins was commenting on an observational study published in the New England Journal of Medicine which supports this.

“Currently, the diagnosis of chronic obstructive pulmonary disease (COPD) requires a ratio of forced expiratory volume in 1 second (FEV1) to forced vital capacity (FVC) of less than 0.70 as assessed by spirometry after bronchodilator use,” the authors wrote.

“However, many smokers who do not meet this definition have respiratory symptoms.”

The researchers found respiratory symptoms were present in 50% of current or former smokers with preserved pulmonary function. Among symptomatic current or former smokers, 42% used bronchodilators and 23% used inhaled glucocorticoids.

“Although they do not meet the current criteria for COPD, symptomatic current or former smokers with preserved pulmonary function have exacerbations, activity limitation, and evidence of airway disease,” the authors concluded. “They currently use a range of respiratory medications without any evidence base.”

But Professor Jenkins believes early intervention in symptomatic patients had strong advantages, and presented an opportunity to improve patient outcomes, through the introduction of treatment regimes that include exercise, symptom management (with or without medication) and smoking cessation.

“There are many cases where early intervention could have made a difference,” she said “There are many missed opportunities, partly because we are focussing mainly on breathlessness (as the criteria for COPD diagnosis).”

She conceded that while breathlessness was a key symptom in diagnosing COPD, it did lead to a very late diagnosis for many patients.

“Once they get to breathlessness they are already avoiding exercise,” she said.

Professor Jenkins believes the COPD diagnosis criteria needs an overhaul to allow for earlier diagnosis and intervention.

“I personally do thing this warrants a revisiting of the guidelines,” she said. “This study tells us that smokers’ cough is not inconsequential. Cough and sputum, and recurrent lower respiratory tract infections are important symptoms. You don’t know if they will all go on to develop COPD but we need to consider this.”


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