Spirometry for patients in hospital and one month after admission with an acute exacerbation of COPD

Article (PDF Available)inInternational Journal of COPD 6(1):527-32 · October 2011with22 Reads
DOI: 10.2147/COPD.S24133 · Source: PubMed
Abstract
To assess whether spirometry done in hospital during an admission for an acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is clinically useful for long-term management. Patients admitted to hospital with a clinical diagnosis of AECOPD had spirometry post-bronchodilator at discharge and approximately 4 weeks later. Spirometry was achieved in less than half of those considered to have AECOPD. Of 49 patients who had spirometry on both occasions, 41 met the GOLD criteria for COPD at discharge and 39 of these met the criteria at 1 month. For the 41, spirometry was not statistically different between discharge and 1 month but often crossed arbitrary boundaries for classification of severity based on FEV(1). The eight who did not meet GOLD criteria at discharge were either misclassified due to comorbidities that reduce FVC, or they did not have COPD as a cause of their hospital admission. Spirometry done in hospital at the time of AECOP is useful in patients with a high pre-test probability of moderate-to-severe COPD. Small changes in spirometry at 1 month could place them up or down one grade of severity. Spirometry at discharge may be useful to detect those who warrant further investigation.
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International Journal of COPD 2011:6 527–532
International Journal of COPD
Spirometry for patients in hospital and one
month after admission with an acute exacerbation
of COPD
Harry Rea
1
Timothy Kenealy
1
Jacqui Adair
1
Elizabeth Robinson
2
Nicolette Sheridan
3
1
Section of Integrated Care, South
Auckland Clinical School, University
of Auckland,
2
Biostatistics and
Epidemiology, School of Population
Health, University of Auckland,
3
Section of Integrated Care, South
Auckland Clinical School and School
of Nursing, University of Auckland,
Auckland, New Zealand
Correspondence: Timothy Kenealy
Section of Integrated Care,
South Auckland Clinical School,
University of Auckland, Middlemore
Hospital, Private Bag 93311, Otahuhu,
Auckland 1640, New Zealand
Tel +64 9 276 0044 ext 8415
Fax +64 9 276 0066
Email t.kenealy@auckland.ac.nz
Aim: To assess whether spirometry done in hospital during an admission for an acute exacer-
bation of chronic obstructive pulmonary disease (AECOPD) is clinically useful for long-term
management.
Methods: Patients admitted to hospital with a clinical diagnosis of AECOPD had spirometry
post-bronchodilator at discharge and approximately 4 weeks later.
Results: Spirometry was achieved in less than half of those considered to have AECOPD.
Of 49 patients who had spirometry on both occasions, 41 met the GOLD criteria for COPD at
discharge and 39 of these met the criteria at 1 month. For the 41, spirometry was not statistically
different between discharge and 1 month but often crossed arbitrary boundaries for classification
of severity based on FEV
1
. The eight who did not meet GOLD criteria at discharge were either
misclassified due to comorbidities that reduce FVC, or they did not have COPD as a cause of
their hospital admission.
Conclusion: Spirometry done in hospital at the time of AECOP is useful in patients with a
high pre-test probability of moderate-to-severe COPD. Small changes in spirometry at 1 month
could place them up or down one grade of severity. Spirometry at discharge may be useful to
detect those who warrant further investigation.
Keywords: classification of COPD, spirometry, acute exacerbation of COPD, primary care,
cohort study
Introduction
The diagnosis of chronic obstructive pulmonary disease (COPD) is based on clinical
features and spirometry.
1
Spirometry is required in the assessment of severity which
determines guideline treatment recommendations. It is also valuable to predict risk of
death
2
and readmission to hospital.
3
In patients admitted to our hospital with an acute
exacerbation of COPD (AECOPD), often spirometry appears to never have been done
prior to admission, and is seldom done during admission. Primary care clinicians and
patients need a confirmed diagnosis and severity classification to support manage-
ment decisions. There are often practical barriers to spirometry in the community,
4
whereas it may be readily accessible while patients are in hospital, with trained staff
available to administer and interpret the test. However, Global Initiative for Chronic
Obstructive Lung Disease (GOLD) guidelines state that spirometry should be done
“when the patient is clinically stable and free from respiratory tract infection”.
1
The
guideline injunction is based on concern that spirometry at this time might lead to false
positive diagnosis or overestimation of severity. We wanted to explore the validity
of this concern.
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There are only limited data available on the reproduc-
ibility of spirometry when comparing tests completed
around the time of an AECOPD with tests done after reso-
lution of the acute episode.
4–7
White and colleagues found
that pre- and post-bronchodilator spirometry measurements
were ‘stable’ between day 5 and day 28 on patients after
initiating treatment for AECOPD.
4
However, patients in
this study were diagnosed and treated in primary care, and
mostly had mild-to-moderate COPD – post bronchodilator
Forced Expiratory Volume in 1 second (FEV
1
) was around
60% of predicted. Similarly, Herpel and colleagues found
relatively little change in spirometry in clinically stable
patients with a wider range of COPD severity, but reported
only pre-bronchodilator measurements.
5
However, most
patients in hospital with AECOPD are given frequent
salbutamol or another short-acting bronchodilator, making
valid pre-bronchodilator measurement difficult to achieve
and raising concerns that to do so might interfere with
therapy.
Donohue
6
reported that the minimally clinical impor-
tant difference (MCID) in FEV
1
is not definitively known,
although major trials have used figures ranging from 45 to
180 mL. Most studies use pre-bronchodilator tests, and a pre-
bronchodilator FEV
1
improvement of about 100 mL corre-
lates with other important clinical outcomes. The author also
noted that change in FEV
1
can be practically useful only if it
exceeds the bounds of measurement error, ie, mean change
score for the group +/- 2SD; any smaller change would be
indistinguishable from measurement error.
We therefore sought, in our patient population, to assess
whether post-bronchodilation spirometry done in hospital just
prior to discharge following a clinical diagnosis of AECOPD
produces measurements which are not clinically different to
measurements made 1 month later.
Methods
Participants
Patients were eligible if they were admitted to an adult
medical ward at a large teaching hospital in New Zealand
( Middlemore Hospital) with a diagnosis of AECOPD.
We note that there is no universally accepted definition of
AECOPD but accept the criteria of the Canadian Thoracic
Society which specifies a worsening of COPD symptoms
leading to increased use of medications.
7,8
Patients were
excluded if they were discharged after-hours or over week-
ends or public holidays, or if they had a condition making
technically adequate spirometry impossible, such as a stroke
or dementia. Patients were recruited from September 2008
to March 2009. The study was approved by the Northern X
Regional Ethics Committee, ref NTX/07/11/123.
Spirometry
Spirometry was performed on a Microlab spirometer
and Spida 5 software (both from Micro Medical Ltd,
Rochester, Kent, UK). These use NHANES III data for pre-
dicted values
9
with a 10% correction factor for Polynesian
people.
10
We used Caucasian values for European and
‘Polynesian’ values for Maori and Pacific Island patients.
The device was calibrated weekly. Testing was done by two
registered nurses who were trained and certified to local stan-
dards which align with American Thoracic Society/European
Respiratory Society standards.
11
All spirometry was done
post-bronchodilation. The protocol called for spirometry on
the day of discharge and at home 30 days after discharge.
If a patient cannot produce a satisfactory Force Vital
Capacity (FVC, defined as expiration for 6 seconds or plateau
on the volume-time curve), the FEV
1
/FVC ratio can be spu-
riously high due to an invalid FVC. This ratio may also be
raised due to comorbidities limiting FVC. In this case the
protocol called for the spirometry to be reviewed by a respi-
ratory physician (HR) looking for other features of COPD,
in particular for a mid-expiratory concavity.
Analyses were based on detecting a statistically sig-
nificant change in FEV
1
(see power calculations), a change
sufficient to alter severity grading according to the GOLD
criteria
1
or a change that exceeded 100 mL or 150 mL (rep-
resenting the MCID).
6
Power calculations
To determine whether spirometry was ‘stable’ over 1 month,
we needed sufficient patients to allow us to detect the
smallest clinically important change.
We assumed mean FEV
1
at discharge as 1.5 L (SD 0.42);
and that within-patient variation is 0.106 L (SD 0.10) (based
on data from Herpel et al).
5
The small standard deviation of
the difference in repeated measures implies that the correlation
between the measurements within-patient is relatively large.
A series of power calculations were made. Using a correlation
of 0.75, power of 90%, and a significance of 1%, we would need
a sample size of 63 to detect a difference of 150 mL between
two measures, or 36 to detect a difference of 200 mL.
Statistical analysis
We used Stata software for statistical analysis (v 10.1;
StataCorp, College Station, TX). Means are compared by
paired t-test. Statistical significance is cited at P , 0.05.
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Rea et al
International Journal of COPD 2011:6
Results
Numbers at each stage of the recruitment process are given in
Figure 1. Consent to join the study was given by 54, however
four were excluded as unlikely to have COPD after review
of all patient records by a respiratory physician (HR) who
was blind to the study spirometry results. One had a history
of childhood asthma and was a lifelong non-smoker. One
had severe left sided heart failure, a 10 pack-year history of
smoking, and normal spirometry in 2006. One had a 20 pack-
year history of smoking, stopping in 1975, normal spirometry
in 2007, and a CT scan in 2009 that showed no evidence of
COPD. One had normal spirometry in October 2009. One
further patient declined the 1-month spirometry due to illness
at the time, leaving data on 49 patients at both discharge and
1 month. All 49 patients fitted the phenotype of COPD, with
slowly progressive shortness of breath and cough and sputum
production, onset in middle age, with a prolonged history of
cigarette smoking, and having excluded asthma as the primary
diagnosis. They all had a clinical diagnosis of COPD accepted
by a senior clinician and met the criteria for AECOPD. The
median number of admissions to hospital in the previous
2 years, including the index admission, and for reasons that
included COPD, was 3.5 with a range of 1 to 22.
Median time from admission to ‘discharge’ spirometry
was 4 days (inter-quartile range 2 to 7). Median length of stay
in hospital was 6 days (inter-quartile range 4 to 11). Counting
from ‘discharge’ spirometry, data from the ‘1-month’ check
was collected at a mean of 34.3 days (SD 6.3). Three patients
were readmitted to hospital within 2 weeks of discharge, so
we used their baseline spirometry collected at the end of the
first admission, but counted days after discharge from their
second discharge.
Forty-one patients met GOLD criteria for COPD at
discharge and 39 of these met the criteria at 1 month. The
two who no longer met GOLD criteria had FEV
1
/FVC of
0.56 and 0.67 at discharge and 0.70 and 0.71 at 1 month,
respectively (GOLD criteria specifies ,0.70). Their FEV
1
percentages predicted were 26 and 23 at discharge and 49
and 45 at 1 month, respectively. Their FEV
1
decreased from
discharge to 1 month by 60 mL and 130 mL, respectively.
One of the patients who did not meet GOLD criteria at dis-
charge did so at 1 month (FEV
1
/FVC 0.70 and 0.68, FEV
1
percent predicted 51 and 46, respectively).
For the 41 patients meeting GOLD criteria at discharge,
mean patient age was 67.8 (SD 10.9) years, there were
15 women, and the ethnic breakdown was 15 European,
15 Maori, and 11 Pacific Island. Table 1 shows their spirom-
etry and severity classification at discharge and at 1 month.
Spirometry change was not statistically significant. Apart
from the two patients who no longer met GOLD COPD
117 considered eligible
66 invited, all consented
54 included
49 completed spirometry at discharge and 1 month
41 met GOLD COPD criteria at discharge, 39 met the criteria at 1 month
51 charge nurse or family deemed unfit to
participate (mostly dementia, severe physical or
mental illness, infectious isolation)
12 withdrew (3 died, 4 no longer cognitively
capable, 1 family bereavement, 4 deteriorated
physical health)
4 withdrawn as unlikely to have COPD (see text)
1 declined spirometry at 1 month
Figure 1 Patient numbers in study.
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Spirometry over 1 month after acute exacerbation of COPD
International Journal of COPD 2011:6
Table 1 Patients with COPD according to GOLD spirometry
criteria at hospital discharge
Discharge 1 month P value
FEV
1
1.04 (0.51) 1.08 (0.48) 0.26
FVC 2.09 (0.89) 2.18 (0.81) 0.12
FEV
1
/FVC 0.50 (0.11) 0.50 (0.12) 1.00
FEV
1
% predicted 38.7 (14.4) 40.6 (14.3) 0.18
Classication (FEV
1
% predicted)
Moderate (50 to ,80)
10
Mild 0
Moderate 8
Severe 2
Severe (30 to ,50)
18
Moderate 4
Severe 11
Very severe 2
Very severe (,30)
13
Severe 6
Very severe 6
Notes: Spirometry measures and GOLD severity classication at discharge and
at 1 month. Results are mean (SD) or counts. N = 41. One ‘severe’ and one ‘very
severe’ patient at discharge no longer met GOLD criteria at 1 month (see text).
2000
15001000
Mean of FEV
1
at discharge and 1 month (mL)
Change FEV
1
at discharge and 1 month (mL)
500
−1000
−500
0
500
Figure 2 Difference between FEV
1
at 1 month and FEV
1
at discharge from hospital for each patient. Central line is observed average agreement. Upper and lower lines are
95% limits of agreement.
Note: N = 41.
criteria, no patient moved more than one severity grade
up or down. Following discharge, five patients decreased
FEV
1
by more than 200 mL, five patients decreased by more
than 150 mL, and seven decreased by more than 100 mL;
15 increased by more than 100 mL, 11 increased by more than
150 mL, and nine increased by more than 200 mL. Individual
changes for each of the 41 patients meeting GOLD criteria
at discharge are shown in Figure 2. This figure shows that
smaller or larger changes in FEV
1
seem to occur regardless
of mean value (which is an approximation of baseline or
underlying value for each patient).
For the eight patients who failed to meet GOLD spirom-
etry criteria for COPD at discharge, mean age was 65.1
(SD 8.7), five were women, and the ethnic breakdown was
one European, five Maori, and two Pacific Islanders. At
1 month they all had a FEV
1
/FVC ratio of 0.7 or greater.
Discussion
Between discharge and follow up at 1 month, post-
bronchodilator spirometry did not significantly change
and no patient moved more than one GOLD COPD sever-
ity grade up or down. Absolute changes were typically
short of the MICD. These results were the same whether
we considered all the patients who were clinically diag-
nosed as having AECOPD, those who met GOLD criteria
for COPD at discharge, or those who met the criteria at
1 month. We interpret these results to mean that spirometry
done 4 days after admission is clinically stable over the
following month.
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Rea et al
International Journal of COPD 2011:6
Of 41 patients who met GOLD COPD criteria at discharge,
only two did not meet the criteria at 1 month. In this group
of patients it seems that false positive diagnosis from doing
spirometry close to an acute exacerbation is not a clinical
problem.
Although many patients crossed guideline classification
boundaries of severity, with implications for guideline-based
management decisions, we note that these boundaries are
arbitrary points on a continuum. The GOLD guidelines state
that they provide a “simple classification” “for educational
reasons” using cut points “that have not been clinically
validated”.
1
Changes that shift patients across such boundar-
ies may reflect noise of measurement more than real airways
change, which supports the need for clinical judgment when
applying guidelines to individual patients.
Study strengths include testing patients from our own
population, which has a unique ethnic mix. Limitations
include a relatively small study size. Prior power calculations
indicated that our 41 participants gave sufficient power to
detect a change in FEV
1
of 200 mL. The assumed standard
deviation of samples proved correct. The assumed correlation
0.75 between FEV
1
at baseline and 1 month proved well short
of the correlation 0.88 in our real sample (indicating greater
‘stability’ or ‘lack of change’ than we had anticipated).
Consistent with this was the mean change of 40 mL in our
patients which was lower than the lowest MCID reported in
the literature (45 mL) and well short of the more commonly
used figures of 100 or 150 mL.
6
For three patients, we used
discharge spirometry from one admission, but repeat test-
ing was carried out 1 month after second admission shortly
after the first. We would expect clinically that spirometry at
the end of the first admission was either similar to, or worse
than, spirometry at the end of the second admission – if the
latter, then measurements for these patients would overes-
timate the change from discharge to 1 month. We note that
less than half of those admitted with COPD were deemed fit
for spirometry which may have introduced some selection
bias into our study. We do not know whether those who did
participate were more or less ‘stable’ in their spirometry than
those who did not participate.
It is possible that our patients’ spirometry might have
continued to improve past 1 month. However, Parker et al
followed 20 patients for 60 days after an AECOPD and,
while their patients took a mean of 41 days to symptomatic
recovery, their FEV
1
was back to baseline within about
14 days.
7
This implies that FEV
1
is measuring a process that
is associated with, rather than central to, the pathophysiol-
ogy of COPD. Indeed, Fabbri and Rabe suggest that COPD
should no longer be considered a disease only of the lungs,
but a chronic systemic inflammatory syndrome.
12
A similar
point was made by Celli et al who noted that the BODE index
recognizes systemic manifestations not reflected in FEV
1
.
2
Eight patients had been admitted to hospital with a clinical
diagnosis of AECOPD, but failed to meet GOLD spirometry
criteria at discharge, in each case due to FEV
1
/FVC being
0.70 or greater. Percent predicted FEF
25–75
(age adjusted) in
these patients ranged from 12% to 73% and in each case the
flow loop had a concave shape. Clinically it was considered
that their FEV
1
/FVC may have been ‘artificially’ elevated
due to a low FVC that was consistent in each case with
known comorbidities, particularly obesity or congestive
heart failure.
Our 41 patients with COPD at discharge had a mean
of three comorbidities, including some with comorbidities
that may decrease FVC (especially heart failure and obe-
sity) and therefore raise the FEV
1
/FVC ratio or may reduce
airway caliber (especially obesity) and therefore decrease
FEV
1
/FVC ratio. Others have commented on the high rate of
false negative spirometry in patients who undoubtedly clini-
cally have COPD.
13
There has also been criticism of the use
of 0.7 as the cut point for FEV
1
/FVC ratio rather than using
the lower limit of normal of an age predicted ratio;
14,15
the
problem of reduced lung volume with age was specifically
noted in the GOLD guidelines.
1
Our patients who did not
meet COPD spirometry criteria at either time may have had
mixed lung disease but should not be thereby denied COPD
management. Such patients need more formal physiological
assessment including lung volumes and diffusion capacity
for carbon monoxide.
Guidelines state that spirometry should be performed
when the patient is stable and free from respiratory
infection”.
1
Apart from the fact that these patients are
probably never free of respiratory infection, this restriction
appears unnecessary, and in our own area this may be a bar-
rier to enrolment in the community chronic care management
program. Our patients living in South Auckland often expe-
rience difficulties in accessing community services (due to
cost, language barriers, travel, or taking time off work), and
may therefore miss the opportunity for spirometry. Others
have noted that it can be difficult to achieve spirometry in
community general practice.
4
The study suggests that, in patients with a high pre-test
probability of COPD, spirometry at the time of discharge
from hospital during an AECOPD can be used to confirm
the diagnosis and to make an initial judgment about severity.
However, for about one-fifth of our patients, the diagnosis of
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Spirometry over 1 month after acute exacerbation of COPD
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COPD was cast in doubt by the spirometry results at 1 month,
suggesting that they would warrant further investigation to
confirm COPD or an alternative or additional diagnosis for
their clinical symptoms. It would be helpful to have uni-
versally agreed criteria for grading severity others have
noted that some criteria may correlate better than others
with outcomes.
16
Acknowledgments
We would like to thank Boehringer Ingelheim (NZ) Ltd for
funding this study. No one associated with the company
took any part in design, conduct, analysis, interpretation, or
reporting of this study.
Disclosure
The authors report no conflicts of interest in this work.
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    • "Our finding demonstrates that adequate quality spirometry can be obtained early in the hospital course in most patients with asthma or COPD exacerbations. This finding expands previous work by Rea and colleagues [13], who showed that patients hospitalized with COPD exacerbations were able to perform spirometry on the day of discharge. None of the participant characteristics we examined were different between those who were able to produce adequate vs. not adequate quality spirometry, except for a trend between the number of days between hospital admission and spirometry testing. "
    [Show abstract] [Hide abstract] ABSTRACT: Background Objective measurement of airflow obstruction by spirometry is an essential part of the diagnosis of asthma or COPD. During exacerbations, the feasibility and utility of spirometry to confirm the diagnosis of asthma or chronic obstructive pulmonary disease (COPD) are unclear. Addressing these gaps in knowledge may help define the need for confirmatory testing in clinical care and quality improvement efforts. This study was designed to determine the feasibility of spirometry and to determine its utility to confirm the diagnosis in patients hospitalized with a physician diagnosis of asthma or COPD exacerbation. Methods Multi-center study of four academic healthcare institutions. Spirometry was performed in 113 adults admitted to general medicine wards with a physician diagnosis of asthma or COPD exacerbation. Two board-certified pulmonologists evaluated the spirometry tracings to determine the proportion of patients able to produce adequate quality spirometry data. Findings were interpreted to evaluate the utility of spirometry to confirm the presence of obstructive lung disease, according to the 2005 European Respiratory Society/American Thoracic Society recommendations. Results There was an almost perfect agreement for acceptability (κ = 0.92) and reproducibility (κ =0.93) of spirometry tracings. Three-quarters (73%) of the tests were interpreted by both pulmonologists as being of adequate quality. Of these adequate quality tests, 22% did not present objective evidence of obstructive lung disease. Obese patients (BMI ≥30 kg/m2) were more likely to produce spirometry tracings with no evidence of obstructive lung disease, compared to non-obese patients (33% vs. 8%, p = 0.007). Conclusions Adequate quality spirometry can be obtained in most hospitalized adults with a physician diagnosis of asthma or COPD exacerbation. Confirmatory spirometry could be a useful tool to help reduce overdiagnosis of obstructive lung disease, especially among obese patients.
    Full-text · Article · Dec 2012
  • [Show abstract] [Hide abstract] ABSTRACT: Background: Chronic obstructive pulmonary disease (COPD) is a disease that is characterized by a persistent blockage of airflow from the lungs. It is an under-diagnosed, life-threatening disease which is not fully reversible. COPD is not only global health problem, the disease is also serious economic problem. Objective: The aim of this study was to evaluate the effects of implementation of new guidelines Global Initiative for Chronic Obstructive Lung Disease (GOLD) for diagnosis and treatment of chronic obstructive pulmonary disease (COPD). Design: Consecutive, observational, retrospective, mono-centric study. Methods: Into the study were included all patients admitted with COPD exacerbations to Department of Pneumology and Phtiseology, Jessenius Faculty of Medicine in Martin and University Hospital, separately in year 2008 and year 2013, who have satisfied the inclusion criteria. Those years were chosen specifically from the reason of biennial application of diagnosis and treatment, according to recommended guidelines GOLD 2006 and GOLD 2011, in practice. The study was focused on the basic anthropometric parameters, data of medical history, complications of underlying disease, comorbidities, laboratory parameters, treatment strategy of patients after release from hospital and mortality within one year were evaluated. Results: Patients in group 2013, when were applied guidelines GOLD 2011 had a higher average oxygen saturation and higher pO Conclusions: The implementation and application of guidelines GOLD 2011 in practice is a challenging and complex process, which is in region of University hospital Martin gradually and successfully implemented. The achievement the objectives of the GOLD 2011 not only contributes to the efficiency of prevention and timely diagnosis, but mainly on setting of adequate treatment, improves survival and quality of life of patients with COPD.
    Full-text · Article · Sep 2015