COPD: clinical features may help diagnose COPD

Clinical bottom line (level 1b)

  1. 40% of patients attending a pre-operative assessment clinic had obstructive airways disease.
  2. COPD was more likely with
    • wheezing on examination (LR+12)
    • a history of chronic bronchitis (LR+3.8)
    • clinical impression of moderate-severe disease (LR+4.2)
    • a history of wheezing (LR+3.1)
  3. COPD was less likely with no history of smoking (LR-0.23) .
  4. No clinical features diagnosed or excluded COPD safely - further investigations were required.
Holleman et al: Journal of General Internal Medicine 1993; 8: 63-68
Expires November 2002

The study

Setting: pre-operative evaluation clinic, Veterans's Affairs hospital, USA

164 patients (aged mean 66 years, 100% male) outpatients being considered for elective surgery

Excluded if
  • examiner knew prior pulmonary results or patient unable to undergo reference standard spirometry
Independent blinded reference standard, applied in all patients from a consecutive appropriate spectrum.
Reference standard:
  • spirometry: COPD if FEV1 and FEV1/FVC low (below 5th percentile predicted for age and height)
Diagnostic test: history and physical examination
  • The logistic regression model was validated in 84 additional patients (100% male; mean age 65).

The evidence

pre-test probability of COPD: 44%, (95% CI: 36% to 52%)

diagnostic test COPD no COPD LR+
(95% CI)		 post-test probability LR-
(95% CI)		 post-test probability
smoking (ever) 68 70 1.2
(1.1 to 1.4) 		48% 0.23
(0.08 to 0.64) 		15%
dyspnoea (any) 59 62 1.2
(1.02 to 1.5) 		48% 0.55
(0.31 to 0.98) 		30%
cough 37 27 1.8
(1.2 to 2.6) 		58% 0.69
(0.52 to 0.90) 		35%
wheezing 37 15 3.1
(1.9 to 5.2) 		71% 0.58
(0.45 to 0.75) 		31%
chronic bronchitis 30 10 3.8
(2.0 to 7.2) 		75% 0.66
(0.53 to 0.81) 		34%
wheezing on examination 10 1 12
(1.7 to 98) 		90% 0.87
(0.79 to 0.96) 		41%
total 72 92


diagnostic test COPD no COPD LR
(95% CI)		 post-test probability
exertional dyspnoea grade III or IV 2.0
(1.1 to 3.6) 		61%
exertional dyspnoea grade II 1.2
(0.82 to 1.9) 		48%
exertional dyspnoea grade I 0.56
(0.37 to 0.84) 		30%
total 72 92


diagnostic test COPD no COPD LR
(95% CI)		 post-test probability
clinical impression: moderate-severe 4.2
(2.2 to 8.0) 		77%
clinical impression: mild 0.82
(0.55 to 1.2) 		39%
clinical impression: no disease 0.42
(0.25 to 0.70) 		25%
total 72 92

smoking history: ? =0.95
other clinical features: ? =0.09
  • Number of years smoking, patient-reported wheezing, wheezing on auscultation, forced expiratory time and peak expiratory flow rate were all found to be independent predictors of COPD.

Comments

  1. A nomogram was provided using smoking history, wheezing on exam or PEFR to predict probability of airflow obstruction.

Citation

  1. Holleman DR, Simel DL, Goldberg JS: Diagnosis of obstructive airways disease from the clinical examination. Journal of General Internal Medicine 1993; 8: 63-68
Search Terms: ?
Contributor: Chris Ball and Clare Wotton, November 1999
Reviewer: Sylvie Antonini-Revaz

Clinical Question.
Patient pre-operative
Intervention or Exposure history and examination
Outcome COPD