Abstract
Chronic obstructive pulmonary disease (COPD) is a very common lung disease most often related to a history of smoking. It becomes more prevalent with increasing age but remains under-diagnosed and under-treated in the elderly population. The Global Initiative for Obstructive Lung Disease (GOLD) programme has been instrumental in providing standard diagnostic criteria as well as recommendations for prevention and management of COPD. GOLD recommendations define COPD as a post-bronchodilator forced expiratory volume in 1 second (FEV1)/forced vital capacity (FVC) of <70%, with the severity based on the value of FEV1. This recommendation is different from that of many previous reports that have recommended diagnosing obstruction using the statistically derived lower limit of normal (LLN), which varies for each person according to age, height, ethnicity and gender. While the use of a 70% ratio may be simpler, it may result in under-diagnosis of airflow obstruction in younger people and over-diagnosis in the elderly. This is particularly important as the elderly may be most sensitive to many of the adverse effects of medications used in the treatment of COPD, including corticosteroids and anticholinergic bronchodilators.
Most of the studies comparing the LLN and a fixed ratio of 70% have not been performed with post-bronchodilator testing as recommended by GOLD. Generation of post-bronchodilator reference sets and studies comparing the LLN with the post-bronchodilator FEV1/FVC ratio of <70% will help resolve this issue. One recent study examined patients admitted to hospitals who had an FEV1/FVC ratio of <70% but above the LLN, and found they were at increased risk of death and COPD complications. This would support the use of GOLD criteria. Further studies examining this population are needed.
In addition to the uncertainties about what diagnostic criteria should be utilized for diagnosis of airflow obstruction, different organizations make different recommendations on screening spirometry. A conservative recommendation is to perform spirometry in symptomatic individuals. It is important to remember that while COPD is under-diagnosed in the elderly, this group is also at a higher risk of being falsely classified as having airflow obstruction using the 70% ratio recommended by GOLD. This can result in unnecessary use of medications and increased risk of adverse effects to which the elderly are more prone.
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References
Piquette C, Rennard S, Snider G. Chronic bronchitis and emphysema. In: Murray J, Nadel J, editors. Textbook of respiratory medicine. Philadelphia (PA): W.B. Saunders Co., 2000: 1187–245
Pauwels RA, Buist AS, Calverley PM, et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: NHLBI/WHO Global Initiative for Chronic Obstructive Lung Disease (GOLD) Workshop summary. Am J Respir Crit Care Med 2001 Apr; 163(5): 1256–76
Global strategy for the diagnosis, management and prevention of COPD. Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2007 [online]. Available from URL: http://www.goldcopd.org [Accessed 2008 Mar]
Celli BR, MacNee W, Committee Members. Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper. Eur Respir J 2004 Jun; 23(6): 932–46
Halbert RJ, Isonaka S, George D, et al. Interpreting COPD prevalence estimates: what is the true burden of disease? Chest 2003 May; 123(5): 1684–92
Nacul LC, Soljak M, Meade T. Model for estimating the population prevalence of chronic obstructive pulmonary disease: cross sectional data from the Health Survey for England. Popul Health Metr 2007; 5: 8
Mannino DM, Homa DM, Akinbami LJ, et al. Chronic obstructive pulmonary disease surveillance: United States, 1971–2000. MMWR Surveill Summ 2002 Aug 2; 51(6): 1–16
Holguin F, Folch E, Redd SC, et al. Comorbidity and mortality in COPD-related hospitalizations in the United States, 1979 to 2001. Chest 2005 Oct; 128(4): 2005–11
National Heart Lung, and Blood Institute. 2007 NHLBI morbidity and mortality chart book. Bethesda (MA): National Institutes of Health, 2007
Waterer GW, Wan JY, Kritchevsky SB, et al. Airflow limitation is underrecognized in well-functioning older people. J Am Geriatr Soc 2001 Aug; 49(8): 1032–8
Coultas DB, Mapel D, Gagnon R, et al. The health impact of undiagnosed airflow obstruction in a national sample of United States adults. Am J Respir Crit Care Med 2001 Aug 1; 164(3): 372–7
Ferguson GT, Enright PL, Buist AS, et al. Office spirometry for lung health assessment in adults: a consensus statement from the National Lung Health Education Program. Respir Care 2000 May; 45(5): 513–30
Sobol BJ. Assessment of ventilatory abnormality in the asymptomatic subject: an exercise in futility. Thorax 1966 Sep; 21(5): 445–9
Sobol BJ, Sobol PG. Per cent of predicted as the limit of normal in pulmonary function testing: a statistically valid approach. Thorax 1979 Feb; 34(1): 1–3
Miller MR, Pincock AC. Predicted values: how should we use them? Thorax 1988 Apr; 43(4): 265–7
Hankinson JL, Odencrantz JR, Fedan KB. Spirometric reference values from a sample of the general U.S. population. Am J Respir Crit Care Med 1999 Jan 1; 159(1): 179–87
Hnizdo E, Glindmeyer HW, Petsonk EL, et al. Case definitions for chronic obstructive pulmonary disease. COPD 2006 Jun; 3(2): 95–100
American Thoracic Society. Evaluation of impairment/disability secondary to respiratory disorders. Am Rev Respir Dis 1986 Jun; 133(6): 1205–9
American Thoracic Society. Lung function testing: selection of reference values and interpretative strategies. Am Rev Respir Dis 1991 Nov; 144(5): 1202–18
Pellegrino R, Viegi G, Brusasco V, et al. Interpretative strategies for lung function tests. Eur Respir J 2005 Nov; 26(5): 948–68
Janssens JP. Aging of the respiratory system: impact on pulmonary function tests and adaptation to exertion. Clin Chest Med 2005 Sep; 26(3): 469–84, vi–vii
Janssens JP, Pache JC, Nicod LP. Physiological changes in respiratory function associated with ageing. Eur Respir J 1999 Jan 1; 13(1): 197–205
Zeleznik J. Normative aging of the respiratory system. Clin Geriatr Med 2003 Feb; 19(1): 1–18
Turner JM, Mead J, Wohl ME. Elasticity of human lungs in relation to age. J Appl Physiol 1968 Dec; 25(6): 664–71
Verbeken EK, Cauberghs M, Mertens I, et al. The senile lung: comparison with normal and emphysematous lungs: 1. Structural aspects. Chest 1992 Mar; 101(3): 793–9
Gillooly M, Lamb D. Airspace size in lungs of lifelong nonsmokers: effect of age and sex. Thorax 1993 Jan; 48(1): 39–43
Edge JR, Millard FJ, Reid L, et al. The radiographic appearances of the chest in persons of advanced age. Br J Radiol 1964 Oct; 37: 769–74
Estenne M, Yernault JC, De Troyer A. Rib cage and diaphragmabdomen compliance in humans: effects of age and posture. J Appl Physiol 1985 Dec; 59(6): 1842–8
Enright PL, Kronmal RA, Higgins MW, et al. Prevalence and correlates of respiratory symptoms and disease in the elderly. Cardiovascular Health Study. Chest 1994 Sep; 106(3): 827–34
Enright PL, Kronmal RA, Manolio TA, et al. Respiratory muscle strength in the elderly: correlates and reference values. Cardiovascular Health Study Research Group. Am J Respir Crit Care Med 1994 Feb; 149 (2 Pt 1): 430–8
Polkey MI, Harris ML, Hughes PD, et al. The contractile properties of the elderly human diaphragm. Am J Respir Crit Care Med 1997 May; 155(5): 1560–4
Tolep K, Higgins N, Muza S, et al. Comparison of diaphragm strength between healthy adult elderly and young men. Am J Respir Crit Care Med 1995 Aug; 152(2): 677–82
Enright PL, Adams AB, Boyle PJR, et al. Spirometry and maximal respiratory pressure references from healthy Minnesota 65- to 85-year-old women and men. Chest 1995 Sep; 108(3): 663–9
de Bisschop C, Marty ML, Tessier JF, et al. Expiratory flow limitation and obstruction in the elderly. Eur Respir J 2005 Oct 1; 26(4): 594–601
Niewoehner DE, Kleinerman J. Morphologic basis of pulmonary resistance in the human lung and effects of aging. J Appl Physiol 1974 Apr; 36(4): 412–8
Crapo RO, Morris AH, Gardner RM. Reference spirometric values using techniques and equipment that meet ATS recommendations. Am Rev Respir Dis 1981 Jun; 123(6): 659–64
Knudson RJ, Lebowitz MD, Holberg CJ, et al. Changes in the normal maximal expiratory flow-volume curve with growth and aging. Am Rev Respir Dis 1983 Jun; 127(6): 725–34
van Pelt W, Borsboom GJ, Rijcken B, et al. Discrepancies between longitudinal and cross-sectional change in ventilatory function in 12 years of follow-up. Am J Respir Crit Care Med 1994 May; 149(5): 1218–26
Cohn JE, Donoso HD. Mechanical properties of lung in normal men over 60 years old. J Clin Invest 1963 Sep; 42: 1406–10
Sprung J, Gajic O, Warner DO. Review article: age related alterations in respiratory function — anesthetic considerations. [Article de synthese: Les modifications de fonction respiratoire liees a l’age — considerations anesthesiques]. Can J Anaesth 2006 Dec; 53(12): 1244–57
Zaugg M, Lucchinetti E. Respiratory function in the elderly. Anesthesiol Clin North America 2000 Mar; 18(1): 47–58, vi
Fowler RW, Pluck RA, Hetzel MR. Maximal expiratory flow-volume curves in Londoners aged 60 years and over. Thorax 1987 Mar; 42(3): 173–82
Babb TG, Rodarte JR. Mechanism of reduced maximal expiratory flow with aging. J Appl Physiol 2000 Aug; 89(2): 505–11
DeLorey DS, Babb TG. Progressive mechanical ventilatory constraints with aging. Am J Respir Crit Care Med 1999 Jul; 160(1): 169–77
Bellia V, Cibella F, Cuttitta G, et al. Effect of age upon airway obstruction and reversibility in adult patients with asthma. Chest 1998 Nov; 114(5): 1336–42
Connolly MJ, Crowley JJ, Charan NB, et al. Impaired bronchodilator response to albuterol in healthy elderly men and women. Chest 1995 Aug; 108(2): 401–6
Kradjan WA, Driesner NK, Abuan TH, et al. Effect of age on bronchodilator response. Chest 1992 Jun; 101(6): 1545–51
Barros MJ, Rees PJ. Bronchodilator responses to salbutamol followed by ipratropium bromide in partially reversible airflow obstruction. Resp Med 1990 Sep; 84(5): 371–5
van Schayck C, Folgering H, Harbers H, et al. Effects of allergy and age on responses to salbutamol and ipratropium bromide in moderate asthma and chronic bronchitis. Thorax 1991; 46(5): 355–9
Schmidt CD, Dickman ML, Gardner RM, et al. Spirometric standards for healthy elderly men and women: 532 subjects, ages 55 through 94 years. Am Rev Respir Dis 1973 Oct; 108(4): 933–9
Milne JS, Williamson J. Respiratory function tests in older people. Clin Sci 1972 Mar; 42(3): 371–81
Enright PL, Kronmal RA, Higgins M, et al. Spirometry reference values for women and men 65 to 85 years of age: Cardiovascular Health Study. Am Rev Respir Dis 1993 Jan; 147(1): 125–33
Medbo A, Melbye H. Lung function testing in the elderly: can we still use FEV1/FVC<70% as a criterion of COPD? Respir Med 2007 Jun; 101(6): 1097–105
Garcia-Rio F, Pino JM, Dorgham A, et al. Spirometric reference equations for European females and males aged 65–85 yrs. Eur Respir J 2004 Sep; 24(3): 397–405
Falaschetti E, Laiho J, Primatesta P, et al. Prediction equations for normal and low lung function from the Health Survey for England. Eur Respir J 2004 Mar; 23(3): 456–63
Margolis ML, Montoya FJ, Palma Jr WR. Pulmonary function tests: comparison of 95th percentile-based and conventional criteria of normality. South Med J 1997 Dec; 90(12): 1187–91
Hardie JA, Buist AS, Vollmer WM, et al. Risk of over-diagnosis of COPD in asymptomatic elderly never-smokers. Eur Respir J 2002 Nov; 20(5): 1117–22
Roberts SD, Farber MO, Knox KS, et al. FEV1/FVC ratio of 70% misclassifies patients with obstruction at the extremes of age. Chest 2006 Jul 1; 130(1): 200–6
Lau AC-W, Ip MS-M, Lai C-W, et al. Variability of the prevalence of undiagnosed airflow obstruction in smokers using different diagnostic criteria. Chest 2008 Jan 1; 133(1): 42–8
Celli BR, Halbert RJ, Isonaka S, et al. Population impact of different definitions of airway obstruction. Eur Respir J 2003 Aug; 22(2): 268–73
Hansen JE, Sun XG, Wasserman K. Spirometric criteria for airway obstruction: use percentage of FEV1/FVC ratio below the fifth percentile, not <70%. Chest 2007 Feb; 131(2): 349–55
Johannessen A, Omenaas ER, Bakke PS, et al. Implications of reversibility testing on prevalence and risk factors for chronic obstructive pulmonary disease: a community study. Thorax 2005 Oct; 60(10): 842–7
Johannessen A, Lehmann S, Omenaas ER, et al. Post-bronchodilator spirometry reference values in adults and implications for disease management. Am J Respir Crit Care Med 2006 Jun 15; 173(12): 1316–25
Shirtcliffe P, Weatherall M, Marsh S, et al. COPD prevalence in a random population survey: a matter of definition. Eur Respir J 2007 Aug; 30(2): 232–9
Perez-Padilla R, Torre Bouscoulet L, Vazquez-Garcia JC, et al. Spirometry reference values after inhalation of 200 microg of salbutamol. Arch Bronconeumol 2007 Oct; 43(10): 530–4
Perez-Padilla R, Hallal PC, Vazquez-Garcia JC, et al. Impact of bronchodilator use on the prevalence of COPD in population-based samples. COPD 2007 Jun; 4(2): 113–20
Kim SJ, Suk MH, Choi HM, et al. The local prevalence of COPD by post-bronchodilator GOLD criteria in Korea. Int J Tuberc Lung Dis 2006 Dec; 10(12): 1393–8
Mannino DM, Sonia Buist A, Vollmer WM. Chronic obstructive pulmonary disease in the older adult: what defines abnormal lung function? Thorax 2007 Mar; 62(3): 237–41
Anthonisen NR, Connett JE, Kiley JP, et al. Effects of smoking intervention and the use of an inhaled anticholinergic bronchodilator on the rate of decline of FEV1: the Lung Health Study. JAMA 1994 Nov 16; 272(19): 1497–505
Scanlon PD, Connett JE, Waller LA, et al. Smoking cessation and lung function in mild-to-moderate chronic obstructive pulmonary disease: the Lung Health Study. Am J Respir Crit Care Med 2000 Feb; 161 (2 Pt 1): 381–90
Petty TL, Weinmann GG. Building a national strategy for the prevention and management of and research in chronic obstructive pulmonary disease: National Heart, Lung, and Blood Institute Workshop summary. Bethesda, Maryland, August 29–31, 1995. JAMA 1997 Jan 15; 277(3): 246–53
Ferguson GT, Enright PL, Buist AS, et al. Office spirometry for lung health assessment in adults: a consensus statement from the National Lung Health Education Program. Chest 2000 Apr; 117(4): 1146–61
Parkes G, Greenhalgh T, Griffin M, et al. Effect on smoking quit rate of telling patients their lung age: the Step2quit randomised controlled trial. BMJ 2008; 336: 598–600
Rabe KF, Hurd S, Anzueto A, et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit Care Med 2007 Sep 15; 176(6): 532–55
Qaseem A, Snow V, Shekelle P, et al. Diagnosis and management of stable chronic obstructive pulmonary disease: a clinical practice guideline from the American College of Physicians. Ann Intern Med 2007 Nov; 147(9): 633–8
Wilt TJ, Niewoehner D, Kane RL, et al. Spirometry as a motivational tool to improve smoking cessation rates: a systematic review of the literature. Nicotine Tob Res 2007 Jan; 9(1): 21–32
Lin K, Watkins B, Johnson T, et al. Screening for chronic obstructive pulmonary disease using spirometry: summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2008 Apr 1; 148(7): 535–43
Kunisaki KM, Rice KL, Niewoehner DE. Management of acute exacerbations of chronic obstructive pulmonary disease in the elderly: an appraisal of published evidence. Drugs Aging 2007; 24(4): 303–24
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Bhatt, N.Y., Wood, K.L. What Defines Abnormal Lung Function in Older Adults with Chronic Obstructive Pulmonary Disease?. Drugs Aging 25, 717–728 (2008). https://doi.org/10.2165/00002512-200825090-00001
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DOI: https://doi.org/10.2165/00002512-200825090-00001