Spirometry can be done in family physicians' offices and alters clinical decisions in management of asthma and COPD
ABSTRACT Spirometry is recommended for diagnosis and management of obstructive lung disease. While many patients with asthma and COPD are cared for by primary care practices, limited data are available on the use and results associated with spirometry in primary care.
To assess the technical adequacy, accuracy of interpretation, and impact of office spirometry.
A before-and-after quasiexperimental design.
Three hundred eighty-two patients from 12 family medicine practices across the United States.
Patients with asthma and COPD, and staff from the 12 practices.
Technical adequacy of spirometry results, concordance between family physician and pulmonary expert interpretations of spirometry test results, and changes in asthma and COPD management following spirometry testing.
Of the 368 tests completed over the 6 months, 71% were technically adequate for interpretation. Family physician and pulmonary expert interpretations were concordant in 76% of completed tests. Spirometry was followed by changes in management in 48% of subjects with completed tests, including 107 medication changes (>85% concordant with guideline recommendations) and 102 nonpharmacologic changes. Concordance between family physician and expert interpretations of spirometry results was higher in those patients with asthma compared to those with COPD.
US family physicians can perform and interpret spirometry for asthma and COPD patients at rates comparable to those published in the literature for international primary care studies, and the spirometry results modify care.
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ABSTRACT: The standard respiratory function test for case detection of chronic obstructive pulmonary disease (COPD) is spirometry. The criterion for diagnosis defined in guidelines is based on the FEV1/FVC ratio forced expiratory ratio (FER) and its severity is based on forced expiratory volume in one second (FEV1) from measurements obtained during maximal forced expiratory manoeuvres. Spirometry is a safe and practical procedure, and when conducted by a trained operator using a spirometer that provides quality feedback, the majority of patients can be coached to provide acceptable and repeatable results. This allows potentially wide application of testing to improve recognition and diagnosis of COPD, such as for case finding in primary care. However, COPD remains substantially under diagnosed in primary care and a major reason for this is underuse of spirometry. The presence of symptoms is not a reliable indicator of disease and diagnosis is often delayed until more severe airflow obstruction is present. Early diagnosis is worthwhile, as it allows risk factors for COPD such as smoking to be addressed promptly and treatment optimised. Paradoxically, investigation of the patho-physiology in COPD has shown that extensive small airway disease exists before it is detectable with conventional spirometric indices, and methods to detect airway disease earlier using the flow-volume curve are discussed.
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ABSTRACT: Chronic obstructive pulmonary disease (COPD) is a preventable and treatable disease, but it often remains undetected in its mild and moderate forms. Patients frequently remain undiagnosed and untreated until the disease has become severe and debilitating, greatly impacting their quality of life. Primary care physicians (PCPs) are most often the first point of contact, and therefore they are in the best position to identify patients at risk of COPD in the early stages. Consequently, they play a critical role in the management of the disease, particularly smoking cessation. One of the earliest symptoms is activity-related dyspnea and subsequent exercise intolerance, often compensated for by reduction in physical activity. This review addresses the approaches used to identify COPD in the primary care setting, including simple tools such as handheld spirometers and questionnaires. A recent study demonstrated that, compared with usual care, use of the COPD Population Screener questionnaire alone and in combination with the copd-6 handheld spirometer significantly improved the odds of referral of patients with suspected COPD for pulmonary function testing or to a pulmonologist. Identification of patients suspected of having the disease and differentiation of COPD from asthma are important in order that treatment can be initiated in the mild stages to slow or prevent disease progression and reduce the risk of exacerbations. The review also discusses the evidence to date on pharmacologic treatment using short-acting and long-acting anticholinergics and β2-agonists, and nonpharmacologic interventions, such as smoking cessation, pulmonary rehabilitation, and influenza and pneumococcal vaccination in patients with mild and moderate COPD.Postgraduate Medicine 07/2014; 126(4):141-154. DOI:10.3810/pgm.2014.07.2792 · 1.54 Impact Factor
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ABSTRACT: Abstract Objective To investigate the reliability and utility of spirometry generated by community pharmacists participating in two large asthma intervention trials of 892 people. Methods The Pharmacy Asthma Care Program (PACP) and the Pharmacy Asthma Management Service (PAMS) involved up to 4 visits to the pharmacy over 6 months for counseling and goal setting. Pharmacists performed spirometry according to ATS/ERS guidelines to inform management. The proportion of A-E, F quality tests, as per EasyOne™ QC grades, were recorded. Lung function results between visits and for participants referred/not referred to their general practitioner on the basis of spirometry were compared. Results Complete data from 2593 spirometry sessions were recorded, 68.5% of spirometry sessions achieved 3 acceptable tests with between-test repeatability of 150 mL or less (A or B quality), 96% of spirometry sessions included at least one test that met ATS/ERS acceptability criteria. 39.1% of participants had FEV1/FVC values below the lower limit of normal (LNN), indicating a respiratory obstruction. As a result of the service, there was a significant increase in FEV1 and FEV1/FVC and asthma control. Lung function values were significantly poorer for participants referred to their general practitioner, compared to those not referred, on the basis of spirometry. Conclusions Community pharmacists are able to reliably achieve spirometry results meeting ATS/ERS guidelines in people with asthma. Significant improvements in airway obstruction were demonstrated with the pharmacy services. Pharmacists interpreted lung function results to identify airway obstruction for referral, making this a useful technique for review of people with asthma in the community.Journal of Asthma 01/2015; DOI:10.3109/02770903.2015.1004684 · 1.83 Impact Factor