Investigating Clinical Variation in COPD

and CHF

A QuIC update on the role of

spirometry in COPD-X

Jin-Gun Cho

Westmead Hospital

jin-gun.cho@health.nsw.gov.au

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