Case Study

A 50-year-old woman presents for a routine check-up and medication refills. She has smoked a pack of cigarettes daily for more than 30 years but does not report chest pain or breathing problems. She asks whether she should be checked for emphysema, which her father developed in his 50s. There is no family history of alpha₁-antitrypsin deficiency.

Case Study Questions

• 1. Based on recommendations from the U.S. Preventive Services Task Force (USPSTF) on screening for chronic obstructive pulmonary disease (COPD) using spirometry, which one of the following is the most appropriate next step for this patient?

  A. She should be screened because of her smoking status.

  B. She should be screened after a history and physical examination.

  C. She should not be screened because screening provides few or no benefits.

  D. She should be screened because of her family history of COPD.

  E. She should be screened because of her age.

• 2. Which one of the following statements about screening for COPD is correct?

  A. The USPSTF recommendation applies to healthy adults who do not recognize or report respiratory symptoms.

  B. Spirometry testing is not indicated in asymptomatic patients with a family history of alpha₁-antitrypsin deficiency.

  C. Physical examination is reliable for diagnosing COPD.

  D. Screening with spirometry could prevent many COPD-associated deaths.

  E. More than 90 percent of persons with objective airflow obstruction identified by screening spirometry have severe or very severe COPD.

• 3. Which of the following preventive services is/are recommended for this patient?

  A. Spirometry screening.

  B. Smoking cessation counseling.

  C. Influenza immunization.

  D. Pneumococcal immunization.

Answers

1. The correct answer is C. The USPSTF recommends against screening for COPD using spirometry, regardless of a patient's age, smoking status, or family history of COPD. This recommendation does not apply to persons with a family history of alpha₁-antitrypsin deficiency.

The potential benefit of spirometry-based screening for COPD is the prevention of one or more exacerbations by treating patients with previously undetected airflow obstruction. Even in groups with the greatest prevalence of airflow obstruction, hundreds of patients would need to be screened with spirometry to defer one exacerbation. Under the best-case assumptions about response to therapy, an estimated 455 adults between 60 and 69 years of age would need to be screened to defer one exacerbation. This small benefit would likely be outweighed by the inconvenience of spirometry, the possibility of false-positive screening results, and the adverse effects of subsequent unnecessary therapy.

Good evidence indicates that history and physical examination are not accurate predictors of airflow limitation in asymptomatic patients.

2. The correct answer is A. The USPSTF recommendation applies to healthy adults who do not recognize or report respiratory symptoms to a physician. It does not apply to persons with a family history of alpha₁ antitrypsin deficiency.

Spirometry is indicated as a diagnostic test for COPD, asthma, and other pulmonary diseases in persons with chronic cough, increased sputum production, wheezing, or dyspnea.

Good evidence indicates that history and physical examination are not accurate predictors of airflow limitation. Fair evidence indicates that fewer than 10 percent of patients identified by screening spirometry have severe or very severe COPD, using current diagnostic criteria.

It is unknown whether persons who do not recognize or report symptoms but who meet spirometric criteria for a diagnosis of severe to very severe COPD would benefit from pharmacologic treatment to the same degree as symptomatic persons, or at all.

3. The correct answers are B and C. The USPSTF recommends that physicians identify adults who use tobacco, and provide interventions to help them quit. Because four out of five cases of COPD are caused by tobacco use, an early intervention strategy of providing evidence-based therapies proven to increase smoking cessation rates and smoking abstinence is likely to be significantly more effective than an early detection strategy of performing spirometry on patients who do not recognize or report respiratory symptoms.

Fair evidence indicates that spirometry can lead to substantial overdiagnosis of COPD in persons older than 70 years who have never smoked, and that it produces fewer false-positive results in other healthy adults. Pharmacologic therapies are associated with adverse effects, including oropharyngeal candidiasis, easy bruising, dry mouth, urinary retention, and sinus tachycardia. Therefore, the USPSTF concludes that there is at least moderate certainty that screening for COPD using spirometry has no net benefit.

All patients 50 years and older should be offered influenza immunization annually. A one-time pneumococcal immunization is recommended for patients 65 years and older.