Investigating Clinical Variation in COPD
and CHF
A QuIC update on the role of
spirometry in COPD-X
Jin-Gun Cho
Westmead Hospital
Introduction
Staff Specialist Respiratory and Sleep Medicine,
Westmead Hospital
Medical Coordinator Pulmonary Rehabilitation Program,
Western Sydney Local Health District
Clinical Lead in COPD, Leading Better Value Care
Program, Westmead Hospital
COPD Integrated Care Physician, Westmead Hospital
Westmead Hospital Snapshot
Tertiary referral hospital
580 admissions for acute
exacerbation of COPD from Oct
2016 to Sept 2017
Av LOS = 4.8 days
94% admitted via ED
Av. age = 72 years
71% of patients in A-DRG group
(more complex)
28 day readmission rate = 24%
Google Maps
Health Roundtable Data
Bureau of Health Information
http://www.bhi.nsw.gov.au/__data/assets/pdf_file/0020/356213/WSLHD_D224_R_Westmead.pdf
Main aim of talk
To demonstrate the value of inpatient spirometry in patients
admitted with acute exacerbations of COPD in accordance
with COPD-X guidelines
Overview
What is COPD?
What is COPD-X?
What is spirometry?
Role of spirometry in COPD (minus the X)
Role of spirometry in COPD-X (the X bit)
Summary
1. What is COPD?
Chronic obstructive pulmonary disease (COPD)
A preventable and treatable disease
Some significant extrapulmonary effects that may
contribute to the severity in individual patients
Pulmonary component characterised by airflow limitation
which is not fully reversible
Airflow limitation is usually progressive and associated with
an abnormal inflammatory response of the lung to noxious
particles or gases
Global Initiative for Chronic Obstructive Lung Disease 2017
►COPD is currently the fourth leading cause of death
in the world.1
►COPD is projected to be the 3rd leading cause of
death by 2020.2
►More than 3 million people died of COPD in 2012
accounting for 6% of all deaths globally.
►Globally, the COPD burden is projected to increase
in coming decades because of continued exposure
to COPD risk factors and aging of the population.
1. Lozano R, Naghavi M, Foreman K, et al. Global and regional mortality from 235
causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the
Global Burden of Disease Study 2010. Lancet 2012; 380(9859): 2095-128.
2. Mathers CD, Loncar D. Projections of global mortality and burden of disease from
2002 to 2030. PLoS Med 2006; 3(11): e442.
COPD in Australia - facts
COPD is common among people > 40 years and increases
with age1
– Cross-sectional community study in 6 Australian sites
– GOLD stage II or higher (FEV1/FVC<0.70 and
FEV1<80%) was 7.5% in ≥ 40 yrs and 29.2% in ≥ 75
years
– 7.5% of Australians ≥ 40 yrs have COPD with symptoms
that affect daily life. Half of these people will not know
they have it2
– COPD is 2nd leading cause of avoidable hospital
admissions
1. Toelle et al. Respiratory symptoms and illness in older Australians: the Burden of Obstructive Lung
Disease (BOLD) study. Med J Aust 2013; 198(3):144-148)
2. Lung Foundation Australia. https://lungfoundation.com.au/health-professionals/clinical-
resources/copd/copd-the-statistics/
2. What is COPD-X?
Guidelines for the diagnosis and management
of COPD
Joint project of TSANZ and Lung Foundation Australia
Guidelines aim to:
– Effect changes in clinical practice based on sound
evidence
– Shift emphasis from a predominant reliance on
pharmacological treatment of COPD to range of
interventions including patient education, self-
management of exacerbations and pulmonary
rehabilitation
https://copdx.org.au
2. What is COPD-X?
First COPD-X guidelines published in MJA in 2003
COPD-X produced by Lung Foundation Australia’s
COPD Guidelines Committee
Undertake quarterly updates of the guidelines for the
Australian and NZ context
Quarterly updates to COPD-X website (https://copdx.org.au)
Yang IA, Dabscheck E, George J, Jenkins S, McDonald CF, McDonald V, Smith B, Zwar
N. The COPD-X Plan: Australian and New Zealand Guidelines for the management of
Chronic Obstructive Pulmonary Disease 2017. Version 2.52, December 2017.
https://copdx.org.au
2. What is COPD-X?
C: Case finding and confirm diagnosis
O: Optimise function
P: Prevent deterioration
D: Develop a plan of care
X: Manage exacerbations
https://copdx.org.au
3. What is spirometry? (GOLD 2018)
Spirometry is the most reproducible and objective
measurement of airflow limitation
It is a noninvasive and readily available test
Good quality spirometric measurement is possible in any
healthcare setting and all healthcare workers who care for
COPD patients should have access to spirometry
Spirometry resources (free):
– https://www.nationalasthma.org.au/living-with-asthma/resources/health-
professionals/information-paper/spirometry-handbook
– http://goldcopd.org/gold-spirometry-guide/
– https://www.brit-thoracic.org.uk/document-library/delivery-of-respiratory-
care/spirometry/spirometry-in-practice-a-practical-guide-(2005)/
Definitions
A spirometer is a device used to measure timed expired
and inspired volumes
From these we can calculate how effectively and how
quickly the lungs can be emptied and filled
Key measurements include FEV1, VC and FEV1/VC (or
FVC) ratio
FEV1 = volume expired in the first second of maximal
expiration after a maximal inspiration
VC (vital capacity) = maximum volume of air which can be
exhaled
http://goldcopd.org/gold-teaching-slide-set/
Spirometry opportunities in COPD
Outpatient Inpatient AECOPD
(ED)
Inpatient AECOPD
(admission) Follow-up
C2.3
C3
C4.1
P9
D1.1
COPD-X C2.3 X2.1 X3.9
4. Role of Spirometry in COPD (minus the X)
Outpatient Inpatient AECOPD
(ED)
Inpatient AECOPD
(admission) Follow-up
C2.3
C3
C4.1
P9
D1.1
COPD-X C2.3 X2.1 X3.9
COPD-X Spirometry
C2.3: Spirometry
– COPD is confirmed by the presence of persistent
airflow limitation (post-bronchodilator
FEV1/FVC<0.7)
– Because COPD is defined by demonstration of airflow
limitation which is not fully reversible, spirometry is
essential for its diagnosis
https://pathways.nice.org.uk/pathways/chronic-obstructive-
pulmonary-disease
www.goldcopd.org
Point 1
Spirometry is required to make a diagnosis of COPD
(COPD-X, GOLD, NICE)
But can’t we diagnose COPD from physical examination?
(I’m an expert…surely I can?)
COPD-X Spirometry - Diagnosis
Why is spirometry important in the outpatient setting?
Can moderate COPD be diagnosed by historical and
physical findings alone? (Badgett et al. Am J Med Feb
1993)
92 outpatients with self-reported history of cigarette
smoking or COPD (15 had moderate COPD)
Pulmonary history questionnaire, peak flow and spirometry
Each subject independently examined for 12 physical signs
by 4 physicians (blinded)
Badgett et al 1993
C2.2: Physical examination
– Sensitivity of physical examination for detecting mild to
moderate COPD is poor (Badgett 1993)
– Wheezing is not an indicator of severity of disease and is
often absent in stable, severe COPD
– Presence and severity of airflow limitation is impossible
to determine by clinical signs (Badgett 1993)
– Objective measurements such as spirometry are
essential
GOLD 2018
Although an important part of patient care, a physical
examination is rarely diagnostic in COPD
Physical signs of airflow limitation are usually not present
until significant impairment of lung function has occurred
Detection of airflow limitation based on physical
examination has relatively low sensitivity and specificity
Physical signs may be present in COPD, but absence does
not exclude the diagnosis
Spirometry in outpatient setting
Spirometry is “gold standard” for diagnosing asthma and
COPD but is rarely used in general practice
Random sample of adults between 45 and 70 drawn from
electoral roll. Underwent respiratory questionnaire,
spirometry and lung function testing.
1224 completed spirometry. 39 (3.5%) had GOLD stage 2
or 3 COPD, 40 (3.6%) had both asthma and COPD
>40% of subjects with COPD did not have a diagnosis of
COPD from their doctors
Less than 50% of COPD patients had ever been prescribed
medications for their breathing
Matheson et al. How have we been managing chronic obstructive pulmonary disease in
Australia. Int Med J 2006;36(2):92-9
Spirometry in outpatient setting
COPD remains substantially underdiagnosed in Australian
GP practices
In 278 patients in 31 Melbourne GP practices, COPD was
correctly diagnosed in only 61%.
Most general practices only used spirometry in
diagnostically difficult cases leading to more accurate
diagnosis of asthma (69%), but substantial underdiagnosis
of COPD (14%) who had fixed airflow obstruction on
spirometry
Cost (potential financial loss and time loss) were key
concerns
Abramson et al. Accuracy of asthma and COPD diagnosis in Australian general
practice: a mixed methods study. Primary Care Respiratory Journal 2012;21:167-173
Can I determine COPD severity from
history and physical examination alone?
Physicians in primary practice are likely to underestimate
their patients’ COPD severity or inadequately characterise
their patients’ lung disease
Spirometry changed physicians’ clinical impressions and
treatment for ~ 1/3 of these patients
Spirometry is valuable in primary care
Mapel et al. A clinical study of COPD severity assessment by primary care physicians
and their patients compared with spirometry? Am J Med 2015
COPD-X Spirometry
C2.3: Spirometry
– COPD is confirmed by the presence of persistent
airflow limitation (post-bronchodilator
FEV1/FVC<0.7)
– Because COPD is defined by demonstration of airflow
limitation which is not fully reversible, spirometry is
essential for its diagnosis
– May be performed in the community or prior to discharge
from hospital (Rea 2011)
– Evidence of underdiagnosis (Toelle 2013) and
misdiagnosis of COPD in the community (Zwar 2011)
Underdiagnosis of COPD in community
Toelle 2013
Misdiagnosis of COPD in community
44 Sydney GP practices
445 patients identified as having clinical diagnosis of COPD
recruited between 2006-2008
257 (58%) had spirometry consistent with COPD+/-asthma
188 (42%) did not have COPD
Zwar et al. Predictors of accuracy of diagnosis of chronic obstructive
pulmonary disease in general practice. Med J Aust 2011;195:168-171
Zwar et al. 2011
Point 2
You cannot rely on physical signs to diagnose COPD
Spirometry underperformed in the community
Underdiagnosis and misdiagnosis of COPD in general
practice
COPD-X: Spirometry allows assessment
of severity of COPD
C3. Assessing the severity of COPD
Diagnosis of COPD should be accompanied by regular
assessment of severity
Spirometry is the most reproducible, standardised and objective way
of measuring airflow limitation, and FEV1 is the variable most closely
associated with prognosis (Peto 1983).
https://pathways.nice.org.uk/pathways/chronic-obstructive-pulmonary-disease
Spirometry opportunities in COPD:
hospital admissions
Outpatient Inpatient AECOPD
(ED)
Inpatient AECOPD
(admission) Follow-up
C2.3
C3
C4.1
P9
D1.1
COPD-X C2.3 X2.1 X3.9
https://pathways.nice.org.uk/pathways/chronic-obstructive-pulmonary-disease
No mention of spirometry
GOLD 2018
No mention of spirometry during admission
for AECOPD
Recommends measurement of spirometry
12-16 weeks follow-up
When features related to rehospitalisation
and mortality have been studied, defects in
perceived optimal management have been
identified including spirometric assessment
and ABG analysis.
GOLD guidelines previously mentioned that
spirometry should be performed when the
patient is “stable and free from respiratory
infection”
Establishing correct diagnosis of AECOPD
in the hospital setting
As shown there are problems with diagnosis of COPD in
the community
But surely, we as experienced hospital clinicians can
diagnose exacerbations of COPD based on history,
examination and investigations (CXR, ABG etc)
Therefore who need spirometry? (Spirometer always
“broken” in ED)
Jennings et al.
Chest 2015; 147(5):1227-1234
Inclusion critera: diagnosis of COPD with acute
exacerbation, age > 40 years, and current or ex-smoker
with at least 20 pack year history
Diagnosis of AECOPD made by primary treating team
AECOPD diagnosis confirmed by research team prior to
assessing eligibility for inclusion from previous recorded
spirometry up to 1 year ago, previously validated
questionnaire for COPD diagnosis.
Presence of airflow obstruction then confirmed by
spirometry prior to discharge
304 of 1225 subjects excluded from study as admitting
diagnosis determined not to be AECOPD
Misdiagnosis in frequent exacerbators
Two pulmonologists reviewed 333 patients with physician-
diagnosed COPD and/or asthma.
Patients had two or more emergency room visits or
admissions over the preceding 12 months, with prospective
evaluation over the next 10 months.
Previous post-bronchodilator spirometry in only 24%
A third of the patients had neither asthma nor COPD
A quarter may not even have any form of airflow
limitation. The study highlighted the importance of
spirometry in making the correct diagnosis, which had been
performed in less than a third of the patients studied
Jain et al. Misdiagnosis Among Frequent Exacerbators of
Clinically Diagnosed Asthma and COPD in Absence of
Confirmation of Airflow Obstruction. Lung 2015;193(4):505-512
Point 3
High degree of misdiagnosis of AECOPD in patients who
may be admitted with AECOPD, even in recurrent
admitters
Spirometry can help to diagnose COPD in an acute setting
COPD-X: X2.1 statement
Assessment of severity of the exacerbation includes a
medical history, examination, spirometry and, in severe
cases (FEV1<40% predicted), blood gas measurements,
chest x-rays and electrocardiography.
Spirometry: Unless confused or comatose, even the
sickest of patients can perform an FEV1 manoeuvre. An
FEV1 less than 1.0 L (or < 40% predicted) is usually
indicative of a severe exacerbation in patients with
moderate COPD. For patients with stable levels below
these values (i.e. severe COPD), the most important signs
of a severe exacerbation will be worsening hypoxaemia,
acute respiratory acidosis (carbon dioxide retention) or
both.
Thorax 2007; 62:200-210
COPD-X Spirometry
C2.3: Spirometry
– COPD is confirmed by the presence of persistent
airflow limitation (post-bronchodilator
FEV1/FVC<0.7)
– Because COPD is defined by demonstration of airflow
limitation which is not fully reversible, spirometry is
essential for its diagnosis
– May be performed in the community or prior to discharge
from hospital
Spirometry for patients in hospital and one
month after admission with AECOPD
NZ study: patients admitted to Middlemore Hospital with
diagnosis of AECOPD
Spirometry on discharge day and at home 30 days after
discharge from September 2008 to March 2009
54 included in study: 4 withdrawn as unlikely to have COPD. 1
declined spirometry at 1 month
41/49 subjects met GOLD COPD criteria at discharge and was
not statistically different at 1 month
Spirometry in hospital at time of AECOPD is useful in patients
with high pre-test probability of mod to severe COPD in
confirming diagnosis and making initial judgement about
severity
Rea et al. Spirometry for patients in hospital and one month after admission with an acute
exacerbation of COPD. Int J COPD 2011;6:527-532
Wu et al. Do patients hospitalized with COPD have airflow obstruction? Chest 2017;151(6):1263-1271
Clinical measurement of airflow with spirometry is a simple
and inexpensive test
It is underused and could be made readily available on
hospital wards and in outpatient clinics
False diagnosis of COPD may yield inappropriate long-term
pharmacologic therapy, with adverse clinical outcomes
Wu et al. Do patients hospitalized with COPD have airflow obstruction? Chest 2017;151(6):1263-1271
Point 4
Inpatient spirometry for AECOPD can improve the
accuracy of a COPD diagnosis
Spirometry opportunities in COPD
Outpatient Inpatient AECOPD
(ED)
Inpatient AECOPD
(admission) Follow-up
C2.3
C3
C4.1
P9
D1.1
COPD-X C2.3 X2.1 X3.9
COPD-X Spirometry
X3.9 Clinical review and follow-up
My views
Spirometry during admission for “AECOPD” (especially in
first hospital presenters) can:
– Establish a diagnosis of COPD
– Determine severity of airflow obstruction in acute setting
– Avoid misdiagnosis (eg. potential heart failure as cause
of increased SOB) and admission under inappropriate
team
– Serve as an incentive for patients to stop smoking
– Monitor recovery during admission and reassure patient
of safety for discharge
How we use spirometry in AECOPD at
Westmead Hospital
Agency for Clinical Innovation audit for AECOPD at
Westmead Hospital (Aug to Sept 2017)
40 patients admitted with primary diagnosis COPD (30 under
respiratory medicine, 10 other teams)
6/40 had a new diagnosis of COPD (5 had spirometry during
admission)
Previous spirometry results available for 12/40 patients (10/12
under respiratory)
Spirometry during admission in 27 patients (24/27 under
respiratory i.e. 80% of respiratory admitted COPD patients
had spirometry)
Case study
66 yo Australian born woman
Current smoker
Worsening dyspnoea > 1 year: diagnosed with COPD by a
GP with no spirometry
History of progressively worsening shortness of breath,
lethargy and 20kg weight loss over 12 months.
Seen multiple GPs and given oral antibiotics
Commenced on indacaterol (Onbrez – LABA) and
salbutamol prn
First presentation to ED 22/10/2015 with 3 weeks of cough,
sputum and exertional dyspnoea (100m on flat). No chest
pain, fevers.
Was still working as bus driver up to 1 day prior
No other medical problems
Exam: T 36.5C, SpO2 99% RA, P 100 bpm, BP 127/74
mmHg, RR 22 bpm, weight 38.3kg, height 166cm
Hyperinflation
Features of
extensive
bullous change
in R mid to
upper zone
WCC 8.9 x 109/L
Hb 140 g/L
CRP < 3
UEC and LFT normal
HS trop < 17ng/L
Sputum – normal respiratory flora
ABG (RA): pH 7.43, pCO2 37 mmHg, pO2 88 mmHg
Commenced on prednisone 50mg for 5 days
Indacaterol changed to indacaterol/glycopyrronium (Ultibro
– LAMA/LABA)
Commenced on Augmentin Duo for 5 days
Planned for outpatient endoscopy
Referred to pulmonary rehabilitation after reviewed by
Integrated Care team
Inhaler technique checked
Spirometry on admission:
– FEV1 0.93 L (39%)
– FVC 2.34 L (74%)
Spirometry on discharge:
– FEV1 1.1 L (46%)
– FVC 2.3 L (73%)
Summary
COPD is common in population and incidence increases with
age
COPD is underdiagnosed in community as spirometry not
often performed
Physical examination has poor sensitivity in diagnosing COPD
Many patients with hospitalisation for COPD may not have
COPD without spirometry
Hospital admissions are opportunities to perform spirometry to
confirm diagnosis and assess severity
Opportunity to change doctors behaviour in ED and wards to
improve care and outcomes of patients