Chronic Obstructive Pulmonary Disease: Screening --Asymptomatic adults


General

Grade: D The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits. Discourage the use of this service.

Specific Recommendations

The USPSTF recommends against screening for chronic obstructive pulmonary disease (COPD) in asymptomatic adults.

Frequency of Service

No information available.

Risk Factor Information

No information available.


Clinical

Patient Population Under Consideration

This recommendation statement applies to asymptomatic adults who do not recognize or report respiratory symptoms. It does not apply to at-risk persons who present to clinicians with symptoms such as chronic cough, sputum production, dyspnea, or wheezing. It also does not apply to persons with a family history of α1-antitrypsin deficiency.

Risk Assessment

Exposure to cigarette smoke or toxic fumes increases the risk for COPD. Epidemiological studies have found that 15% to 50% of smokers develop COPD.3 More than 70% of all COPD cases occur in current or former smokers. Occupational exposure to toxins, dusts, or industrial chemicals contributes an estimated 15% of all COPD cases. Environmental pollution, including wood smoke and traffic pollutants, is also associated with increased risk for COPD. Nonmodifiable risk factors for COPD include history of asthma or childhood respiratory tract infections and α1-antitrypsin deficiency.

Screening Tests

Screening adults in primary care involves either risk assessment via a formal prescreening questionnaire and, if positive, follow-up with diagnostic spirometry testing or screening spirometry administered without a bronchodilator and, if positive, follow-up with diagnostic spirometry testing. Patients identified as high risk by a prescreening questionnaire or screening spirometry are referred for diagnostic spirometry testing. Diagnosis by spirometry requires persistent airway obstruction after administration of an inhaled bronchodilator, such as albuterol (ie, postbronchodilator spirometry). Chronic obstructive pulmonary disease is diagnosed when the patient has a postbronchodilator FEV1/FVC ratio of less than 0.70. Severity is defined by the percentage of predicted postbronchodilator FEV1; 80% or more is mild, 50% to 79% is moderate, 30% to 49% is severe, and less than 30% is very severe.

Other Approaches to Prevention

Prevention of exposure to cigarette smoke and other toxic fumes is the best way to prevent COPD.  Interventions to prevent the initiation of tobacco use are an effective way to prevent exposure to cigarette smoke. Current smokers should receive smoking cessation counseling and be offered behavioral and pharmacological therapies to stop smoking.

Useful Resources

The USPSTF recommends that clinicians ask all adults, including pregnant women, about tobacco use and provide tobacco cessation interventions for those who use tobacco products. The USPSTF also recommends that clinicians provide interventions, including education or brief counseling, to prevent initiation of tobacco use in school-aged children and adolescents. These recommendations and their supporting evidence are available on the USPSTF website (www.uspreventiveservicestaskforce.org).

Rationale

Importance

About 14% of US adults aged 40 to 79 years have COPD, and it is the third leading cause of death in the United States.1, 2Persons with severe COPD are often unable to participate in normal physical activity due to deterioration of lung function.

Detection

Chronic obstructive pulmonary disease is defined as airflow limitation that is not fully reversible. Chronic obstructive pulmonary disease is associated with an abnormal inflammatory response of the lung to harmful particles or gases. Diagnosis is based on postbronchodilator spirometry, which detects fixed airway obstruction; a forced expiratory volume in 1 second to forced vital capacity (FEV1/FVC) ratio of less than 0.70 is the current criterion for a positive COPD diagnosis. Persons with COPD often, but not always, have symptoms such as dyspnea (difficulty breathing or shortness of breath), chronic cough, and chronic sputum production. Patients often have a history of exposure to risk factors such as cigarette smoke or heating fuels or occupational exposure to dusts or chemicals. Although postbronchodilator spirometry is required to make a definitive diagnosis, prescreening questionnaires can elicit current symptoms and previous exposures to harmful particles or gases.

Benefits of Detection and Early Treatment

The USPSTF found inadequate evidence that screening for COPD in asymptomatic persons using questionnaires or spirometry improves health outcomes.

Harms of Detection and Early Treatment

The USPSTF found inadequate evidence on the harms of screening. However, given the lack of benefit of early detection and treatment, the opportunity cost associated with screening asymptomatic persons may be large. The amount of time and effort required to screen for COPD in asymptomatic persons (using screening spirometry with or without prescreening questionnaires) is not trivial.

USPSTF Assessment

The USPSTF determined that early detection of COPD, before the development of symptoms, does not alter the course of the disease or improve patient outcomes. The USPSTF concludes with moderate certainty that screening for COPD in asymptomatic persons has no net benefit.  Thus, screening is not recommended in persons who do not have symptoms suggestive of COPD.  The USPSTF recommends against screening for COPD in asymptomatic adults.


Others

In 2011, the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society issued joint guidelines recommending that spirometry be used to diagnose airflow obstruction in patients with respiratory symptoms.16 The joint panel recommended against screening for COPD with spirometry in asymptomatic patients, citing the lack of benefit. Similarly, in 2010, the UK National Institute for Health and Care Excellence recommended against screening for COPD in asymptomatic patients.17 Recent guidelines from the Global Initiative for Chronic Obstructive Lung Disease recommended case-finding in symptomatic patients but did not recommend screening in asymptomatic populations.18


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