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Diagnosis and Management of Stable Chronic Obstructive Pulmonary Disease A Clinical Practice Guideline Update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society Annals of Internal Medicine. Norman H. Edelman. Download Wall Hack Cabal Ph 2012. Stony Brook University School of medicine, Stony Brook, New York, 1. August 3, 2. 01. 1. Characterizing COPD Solely on Basis of Single Spirometric Measurement The authors of the new revision of the COPD clinical guidelines should be congratulated for the integrity of their efforts. The American Warmblood Registry AWR is an organization founded to support and promote the breeding and enjoyment of American Warmblood Sporthorses. A special fundraising event sponsored by the Santa Cruz Beach Boardwalk to benefit the American Cancer Society Relay for Life. Includes Camping Under the Stars on. 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American Cancer Society Ride Program' title='American Cancer Society Ride Program' />Although each of the sponsoring institutions receives substantial support from the pharmaceutical industry the recommendations are notably parsimonious concerning the use of highly promoted medications, especially combination inhalers. On the other hand they may have been a bit too reductionist in choosing to characterize COPD solely on the basis of a single spirometric measurement. It has long been clear that COPD is a spectrum of entities with diverse phenotypes. A recent study shows, for example, that frequent exacerbations may exist as a separate phenotype over a wide range of severity by spirometric criteria 1. Might not this, by itself, be an indication for prescribing treatment shown to reduce exacerbations Definitive evidence for this approach may not have been present in the literature reviewed but surely the possibility should be recognized in guiding physicians. Norman H Edelman MD Stony Brook University School of medicine Stony Brook, New York, 1. Reference 1 Hurst, JR et. Susceptibility to Exacerbation in Chronic Obstructive Pulmonary Disease. New England Journal of Medicine 2. Conflict of Interest None declared. August 7, 2. 01. 1. FEV1FVC ratio below the 5th percentile. Given the fact that FEV1FVC ratio decreases naturally with age as a result of the fact that age related decline is greater for FEV1 than for FVC1, it has been proposed that an FEV1FVC ratio which falls below the 5th percentileie below lower limit of normal should be the preferred parameter for defining airflow obstruction so as to mitigate the risk of overdiagnosis of airflow obstructionincluding chronic obstructive airways disease2 inherent in the use of the fixed 0. Global Initiative for Chronic Obstructive Lung Disease3. In a population based sample of 3,8. FEV1FVC lt 5th percentileso called lt LLN, vs FEV1FVC lt 0. Subjects were allocated to the ratio only group if their FEV1FVC was lt 0. LLN1. 75 subjects, and into mild,and moderate to severe COPDchronic obstructive pulmonary diseasegroups if they had FEV1FVC lt 0. LLN2. 11 subjects. The rest3,4. 16 subjects were classified an non COPD. In the ratio only subgroup the proportion of never smokers was 2. COPD and moderate to severe COPD, respectively. Ratio only subjects comprised 4. If one accepts the proposition that, some, if not all of the patients in that subgroup had age related decline in lung function as opposed to COPD, then, at the very least, the proportion of never smokers in the ratio only category might have been completely misclassified as having COPD. Accordingly, guidelines such as the ones recently published in the Annals4 ought to acknowledge the existence of an alternative classification of COPD, and the potential for misclassification, especially of never smokers, with sole reliance on the ratio only parameter. References 1Garcia Rio F., Pino JM., Dorgham A., Alonso A., Villamor J Spirometric reference equations for caucasian european women and men aged 6. Eur Respir J 2. 00. Garcia Ro F., Soriano JB., Miravitlles M et al Overdiagnosing subjects with COPD using the 0. Correlation with a poor health related quality of life CHEST 2. Rabe KF., Hurd S., Anzueto A et al Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease Gols executive summary Am J Respir Crit Care Med 2. Qaseem A., Wilt TJ., Weinberg SE et al Diagnosis and management of stable chronic obstructive pulmonary disease A clinical practice guideline update from the Americam Cpllege of Physicians, American College of Chest Physicians, American Thoracic Society, and European respiratory Society Ann Intern Med 2. Conflict of Interest None declared. Robert P. Young. Schools of Biological Science and Health Sciences, University of Auckland, New Zealand. August 8, 2. 01. 1. Halo 3 Pc Trial. Clinical Practice Guidelines on the diagnosis and management of COPD. We read with disappointment the first recommendation of these recently published guidelines which state Spirometry should not be used to screen for airflow obstruction in individuals without respiratory symptoms 1. In our opinion, this would be like recommending fasting blood sugar not be measured in obese patients until angina develops. Even if performing spirometry does not in itself modify the underlying risk smoking cessation or warrant immediate treatment use of bronchodilators, airflow limitation is a marker of premature death from all causes, in particular heart attack and lung cancer 2,3. We believe this recommendation reflects an unduly nihilistic attitude to the wider use of spirometry, primarily due to its poor implementation to date rather than poor clinical utility. By not screening high risk individuals, such as chronic asymptomatic smokers, we are loosing the opportunity for a teachable moment, which demonstrates to smokers their inherent susceptibility and irreversible end organ damage. That smokers do not quit smoking in greater numbers in response to poor spirometry is possibly because we do not sufficiently emphasise the substantial increased risk of heart attack and lung cancer conferred by reduced FEV1 2,3. Moreover, if we wait for symptoms before spirometry is offered, many smokers will have irreversibly lost as much as 5. Evidence shows the greatest potential to optimize lung health preservation of lung function and reduced lung cancer risk comes from quitting smoking before significant airflow limitation is established. Another lost opportunity would be in identifying smokers most at risk of lung cancer 3 at a time when CT based screening for lung cancer appears to show a significant survival benefit 4. For lung cancer screening to be widely and cost effectively adopted, it will be necessary to identify current and former smokers at greatest risk, over and above that conferred by age and smoking exposure 3. If we abandon spirometric screening of asymptomatic smokers we will lose this opportunity, as we and others have shown reduced FEV1 confers a 6 fold greater risk of lung cancer compared to smokers with normal lung function 5. We believe the use of spirometry as a diagnostic test is far outweighed by its utility in establishing end organ lung damage, increased all cause mortality and targeted risk mitigating interventions. In our view, to abandon the use of spirometry in asymptomatic smokers will certainly promote if not worsen the continued under diagnosis and under resourcing of COPD. References 1. Qaseem A, Wilt TJ, Weinberger SE, Hanania NA, Criner G, van der Molen M, et al. Diagnosis and management of stable chronic obstructive pulmonary disease A clinical practice guideline update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society. Ann Int Med 2. 01.