Comparison of Spirometric Thresholds in Diagnosing Smoking-related Airflow Obstruction

Overview

Journal Thorax

Date 2013 Mar 26

PMID 23525095

Citations 36

Authors

Surya P Bhatt

Jessica C Sieren

Mark T Dransfield

George R Washko

John D Newell Jr

Douglas S Stinson

Gideon K D Zamba

Eric A Hoffman

Affiliations

Soon will be listed here.

Abstract

Background: Diagnosis of chronic obstructive pulmonary disease is based on detection of airflow obstruction on spirometry. There is no consensus regarding using a fixed threshold to define airflow obstruction versus using the lower limit of normal (LLN) adjusted for age. We compared the accuracy and discrimination of the Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommended fixed ratio of forced expiratory volume in the first second/forced vital capacity<0.70 with LLN in diagnosing smoking-related airflow obstruction using CT-defined emphysema and gas trapping as the disease gold standard.

Methods: Data from a large multicentre study (COPDGene), which included current and former smokers (age range 45-80 years) with and without airflow obstruction, were analysed. Concordance between spirometric thresholds was measured. The accuracy of the thresholds in diagnosing emphysema and gas trapping was assessed using quantitative CT as gold standard.

Results: 7743 subjects were included. There was very good agreement between the two spirometric cutoffs (κ=0.85; 95% CI 0.83 to 0.86, p<0.001). 7.3% were discordant. Subjects with airflow obstruction by fixed ratio only had a greater degree of emphysema (4.1% versus 1.2%, p<0.001) and gas trapping (19.8% vs 7.5%, p<0.001) than those positive by LLN only, and also smoking controls without airflow obstruction (4.1% vs 1.9% and 19.8% vs 10.9%, respectively, p<0.001). On follow-up, the fixed ratio only group had more exacerbations than smoking controls.

Conclusions: Compared with the fixed ratio, the use of LLN fails to identify a number of patients with significant pulmonary pathology and respiratory morbidity.

Citing Articles

Risk of All-Cause Mortality in Mild Chronic Obstructive Pulmonary Disease: Evidence From the NHANES III and 2007-2012.

Zou W, Ou J, Wu F, Xiao S, Deng Z, Li H Int J Chron Obstruct Pulmon Dis. 2025; 20:217-229.

PMID: 39901929 PMC: 11789505. DOI: 10.2147/COPD.S497634.

Unadjusted Lower Limit of Normal for Airflow Obstruction.

Bhatt S, Bodduluri S, Nakhmani A, Oelsner E Am J Respir Crit Care Med. 2024; 209(8):1028-1030.

PMID: 38301239 PMC: 11531222. DOI: 10.1164/rccm.202312-2301LE.

GOLD 2024: a brief overview of key changes.

Agusti A, Vogelmeier C J Bras Pneumol. 2023; 49(6):e20230369.

PMID: 38126685 PMC: 10760434. DOI: 10.36416/1806-3756/e20230369.

Reply to Neder, to Ogata , and to Graham.

Bhatt S, Nakhmani A, Fortis S, Strand M, Silverman E, Sciurba F Am J Respir Crit Care Med. 2023; 209(3):343-345.

PMID: 38033318 PMC: 10840780. DOI: 10.1164/rccm.202311-2016LE.

Distinctive features of the oropharyngeal microbiome in Inuit of Nunavik and correlations of mild to moderate bronchial obstruction with dysbiosis.

Flahaut M, Leprohon P, Pham N, Gingras H, Bourbeau J, Papadopoulou B Sci Rep. 2023; 13(1):16622.

PMID: 37789055 PMC: 10547696. DOI: 10.1038/s41598-023-43821-4.

References

. Diagnosis and classification of diabetes mellitus. Diabetes Care. 2011; 35 Suppl 1:S64-71. PMC: 3632174. DOI: 10.2337/dc12-s064. View

Decramer M, Rennard S, Troosters T, Mapel D, Giardino N, Mannino D . COPD as a lung disease with systemic consequences--clinical impact, mechanisms, and potential for early intervention. COPD. 2008; 5(4):235-56. DOI: 10.1080/15412550802237531. View

Garcia-Rio F, Soriano J, Miravitlles M, Munoz L, Duran-Tauleria E, Sanchez G . Overdiagnosing subjects with COPD using the 0.7 fixed ratio: correlation with a poor health-related quality of life. Chest. 2010; 139(5):1072-1080. DOI: 10.1378/chest.10-1721. View

Song G, Barbosa Jr E, Tustison N, Gefter W, Kreider M, Gee J . A comparative study of HRCT image metrics and PFT values for characterization of ILD and COPD. Acad Radiol. 2012; 19(7):857-64. DOI: 10.1016/j.acra.2012.03.007. View

Roberts S, Farber M, Knox K, Phillips G, Bhatt N, Mastronarde J . FEV1/FVC ratio of 70% misclassifies patients with obstruction at the extremes of age. Chest. 2006; 130(1):200-6. DOI: 10.1378/chest.130.1.200. View

Silverman E, Weiss S, Drazen J, Chapman H, Carey V, Campbell E . Gender-related differences in severe, early-onset chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2000; 162(6):2152-8. DOI: 10.1164/ajrccm.162.6.2003112. View

Hansen J, Sun X, Wasserman K . Spirometric criteria for airway obstruction: Use percentage of FEV1/FVC ratio below the fifth percentile, not < 70%. Chest. 2007; 131(2):349-55. DOI: 10.1378/chest.06-1349. View

Pauwels R, Buist A, Calverley P, Jenkins C, Hurd S . Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. NHLBI/WHO Global Initiative for Chronic Obstructive Lung Disease (GOLD) Workshop summary. Am J Respir Crit Care Med. 2001; 163(5):1256-76. DOI: 10.1164/ajrccm.163.5.2101039. View

Izquierdo Alonso J, de Lucas Ramos P, Rodriguez Glez-Moro J . The use of the lower limit of normal as a criterion for COPD excludes patients with increased morbidity and high consumption of health-care resources. Arch Bronconeumol. 2012; 48(7):223-8. DOI: 10.1016/j.arbres.2012.02.007. View

10.

Vaz Fragoso C, Concato J, McAvay G, Van Ness P, Rochester C, Yaggi H . Chronic obstructive pulmonary disease in older persons: A comparison of two spirometric definitions. Respir Med. 2010; 104(8):1189-96. PMC: 2890041. DOI: 10.1016/j.rmed.2009.10.030. View

11.

Vaz Fragoso C, Concato J, McAvay G, Van Ness P, Rochester C, Yaggi H . Defining chronic obstructive pulmonary disease in older persons. Respir Med. 2009; 103(10):1468-76. PMC: 2739264. DOI: 10.1016/j.rmed.2009.04.019. View

12.

Stanojevic S, Wade A, Stocks J, Hankinson J, Coates A, Pan H . Reference ranges for spirometry across all ages: a new approach. Am J Respir Crit Care Med. 2007; 177(3):253-60. PMC: 2643211. DOI: 10.1164/rccm.200708-1248OC. View

13.

Kim D, Jacobson F, Washko G, Casaburi R, Make B, Crapo J . Clinical and radiographic correlates of hypoxemia and oxygen therapy in the COPDGene study. Respir Med. 2011; 105(8):1211-21. PMC: 3116986. DOI: 10.1016/j.rmed.2011.02.015. View

14.

Mannino D, Buist A, Vollmer W . Chronic obstructive pulmonary disease in the older adult: what defines abnormal lung function?. Thorax. 2006; 62(3):237-41. PMC: 2117148. DOI: 10.1136/thx.2006.068379. View

15.

Mannino D, Diaz-Guzman E . Interpreting lung function data using 80% predicted and fixed thresholds identifies patients at increased risk of mortality. Chest. 2011; 141(1):73-80. DOI: 10.1378/chest.11-0797. View

16.

Roche N, Dalmay F, Perez T, Kuntz C, Vergnenegre A, Neukirch F . Impact of chronic airflow obstruction in a working population. Eur Respir J. 2008; 31(6):1227-33. DOI: 10.1183/09031936.00089607. View

17.

Swanney M, Ruppel G, Enright P, Pedersen O, Crapo R, Miller M . Using the lower limit of normal for the FEV1/FVC ratio reduces the misclassification of airway obstruction. Thorax. 2008; 63(12):1046-51. DOI: 10.1136/thx.2008.098483. View

18.

Coxson H, Rogers R, Whittall K, Dyachkova Y, Pare P, Sciurba F . A quantification of the lung surface area in emphysema using computed tomography. Am J Respir Crit Care Med. 1999; 159(3):851-6. DOI: 10.1164/ajrccm.159.3.9805067. View

19.

Mahler D, Wells C . Evaluation of clinical methods for rating dyspnea. Chest. 1988; 93(3):580-6. DOI: 10.1378/chest.93.3.580. View

20.

Madani A, Zanen J, De Maertelaer V, Gevenois P . Pulmonary emphysema: objective quantification at multi-detector row CT--comparison with macroscopic and microscopic morphometry. Radiology. 2006; 238(3):1036-43. DOI: 10.1148/radiol.2382042196. View