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Earlier diagnosis possible ‘in many cases of COPD’

Most patients with COPD present with lower respiratory symptoms in primary or secondary care within the five years before they are diagnosed, claim UK researchers.

Their study showed 85% of patients presented to either primary or secondary care with lower respiratory symptoms at least once in the five years leading up to their actual diagnosis.

The study authors say the results show that opportunities to pick the disease up earlier are frequently being missed.

The study - published in The Lancet Respiratory Medicine - identified 38,859 patients diagnosed with COPD between 1990 and 2009, using data from general practice databases, and analysed their records for potential missed opportunities for diagnosis, such as consultations for lower respiratory symptoms and chest X-rays, as well as respiratory-related outpatient or unplanned hospital admissions.

Among smaller numbers of patients with sufficient data, the results suggested over half could potentially have been diagnosed between six and 10 years before actual diagnosis, while over two-fifths of patients could even have been diagnosed 11-16 years sooner.

Co-author Dr Rupert Jones, clinical research fellow at the Peninsular School of Medicine and Dentistry and a GP in Plymouth, told Pulse the main problem was patients who had repeated consultations for lower respiratory complaints without COPD being explored.

Dr Jones said: ‘There were certainly many, many cases where people had been followed up and diagnosed accurately. But there were some where there had been repeated consultations for symptoms and treatment with antibiotics, and some had chest X-rays on more than one occasion without having spirometry done.

He added: ‘What we’re really highlighting is, in those patients who come with [lower] respiratory symptoms or infections, bear in mind COPD, particularly if they’ve got risk factors. And if you’re going to do a chest X-ray then you ought to be thinking about whether they need to have spirometry at the same time.’

Dr Jones said the findings could be used to inform a case-finding strategy for COPD.

He said: ‘We don’t recommend doing spirometry on people who don’t have symptoms – COPD is a disease of symptoms. But it would be worth case-finding, so people with symptoms and risk factors should be considered for the diagnosis.

‘Spirometry is a good way of doing it, but some people use screening questionnaires, others use screening spirometry - quick hand held devices, which can rule out COPD, but if abnormal need to be followed up with quality-assured diagnostic spirometry.’

Lancet Respir Med 2014; available online 13 February


Readers' comments (5)

  • Vinci Ho

    I think the real problem was we put too much emphasis on using spirometry and forgot how important a good history as well as past medical history is vital. The old definition of persistently productive cough longer than 3 months , especially in smokers , still apply .
    Yes , then it triggers a test of spirometry . In fact , more than one spirometry if the first one displayed obstructive pattern . Spirometry is a way to support the diagnosis of COPD from clinical features( history and examination) and the test is not diagnostic.
    Truth is ten minutes consultation is never enough to even take a good history and undergo physical examination......

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  • I quite agree with Dr Ho.

    Isn't the real question this - will an earlier diagnosis in relatively asymptomatic patient make any difference? Will it stop them from smoking? Will tiotropium stop/slow progression? Will chest infection be managed differentlly? Will it change mortality/QoL?

    My personal experience is no. Many asymptomatic (and symptomatic) COPD patients continues to smoke despite numerous advice by different professionals.

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  • But in the same breath inspite of a good history without a positive spirometry you cannot diagnosis COPD and suffice QOF

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  • Vince Ho has a very valid argument. What I would like to add from my own experience is the risk of labelling smokers with breathing problems as having COPD when we may be overlooking the possibility of asthma or a co-morbidity. I insist that all patients referred to my clinic have a minimum 30 min. consultation, and even that is barely enough. I always revisit the history; it's time consuming but well worth it.

    Paul Radnan
    Respiratory Specialist Pharmacist

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  • I have to respectfully disagree with the attitude of 'anonymous' above. The percentage of smokers that do or do not cease smoking when diagnosed should have no bearing whatsoever on whether or not a patient is considered for such testing. Where it is reasonable to suspect the possibility of COPD then it should be tested for. The patient has the right to know that they have the condition and to make that personal choice, hopefully with the supportive attitude of their GP. After all, you would not turn a blind eye to heart disease or type2 diabetes simply because many patients do not adhere to suggested lifestyle changes.

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