1. Effect of primary-care spirometry on the diagnosis and management of COPD P.P. Walker, P. Mitchell, F. Diamantea, C.J. Warburton and L. Davies Eur Respir J 2006 ; 28: 945-952

2. Background In primary care, commonly misdiagnosed In primary care, commonly misdiagnosed as asthma when in fact they have COPD as asthma when in fact they have COPD ->also lead to incorrect management ->also lead to incorrect management In light of this, the widespread use of spirometry testing to improve the diagnosis of COPD In light of this, the widespread use of spirometry testing to improve the diagnosis of COPD has been promoted has been promoted The aim of this study The aim of this study investigate whether the use of spirometry in primary care to diagnosis COPD investigate whether the use of spirometry in primary care to diagnosis COPD resulted in improvements in management resulted in improvements in management

3. Materials and methods 11 primary care groups and 29 primary care physicians 11 primary care groups and 29 primary care physicians deliver services to 57,000 people deliver services to 57,000 people Recommendation of referral Recommendation of referral -> >40yrs and smoker(or ex-smoker) and respiratory symptoms -> >40yrs and smoker(or ex-smoker) and respiratory symptoms -> asked to omit the use of short-acting bronchodilators for 6hrs and long-acting bronchodilators for 12hrs before spirometry -> asked to omit the use of short-acting bronchodilators for 6hrs and long-acting bronchodilators for 12hrs before spirometry Respiratory technical officer with >25 yrs experience performed spirometry testing Noncomputerised wedge bellow spirometer, which produced a real-time, volume-time, was used Perfomed forced spirometry manoeuveres in accordance with European Respiratory Society guidelines

4. Materials and methods Bronchodilator reversibility testing Bronchodilator reversibility testing - pre-bronchodilator airflow obstruction(AFO) - pre-bronchodilator airflow obstruction(AFO) FEV1/FVC <0.7 and/or FEV1 <80% predicted FEV1/FVC <0.7 and/or FEV1 <80% predicted - 5mg salbutamol and 500μg ipratropium bromide, diluted in 2mL 0.9% saline though a Porta-neb sidestream nebulizer - 5mg salbutamol and 500μg ipratropium bromide, diluted in 2mL 0.9% saline though a Porta-neb sidestream nebulizer - Spirometry repeated after 45min - Spirometry repeated after 45min Oral corticosteroids reversibility testings Oral corticosteroids reversibility testings - 30mg prednisolone daily for 14 days - 30mg prednisolone daily for 14 days - Then, spirometry repeated - Then, spirometry repeated

5. Results – demographics

6. Results- reversilbilty testing

7. Results- impact of spirometry testing 1. Effect of spirometry upon diagnosis

8. Results- impact of spirometry testing 2. Demographics of the COPD pts

9. Results- impact of spirometry testing 3. Effect of spirometry testing on management

10. Conclusions Primary-care spirometry not only increases rates of COPD diagnosis, but it also leads to improvements in COPD treatment

11. Discussion Previous study Previous study - primary-care spirometry testing improves the accuracy of diagnosis in COPD - primary-care spirometry testing improves the accuracy of diagnosis in COPD Present study, for the first time Present study, for the first time - primary-care spirometry testing also results in improvement in management - primary-care spirometry testing also results in improvement in management After spirometry had been performed After spirometry had been performed - Most current smokers provided smoking cessation advice - Most current smokers provided smoking cessation advice - More patients prescribed anticholinergics, long-acting ß- agonists and inhaled corticosteroids - More patients prescribed anticholinergics, long-acting ß- agonists and inhaled corticosteroids Potential sequelae based on evidence from this sudy Potential sequelae based on evidence from this sudy improved lung function, better exercise capacity and improved health-related quality of life improved lung function, better exercise capacity and improved health-related quality of life

12. Primary-care spirometry Primary-care spirometry often performed by primary-care staff had little training often performed by primary-care staff had little training -> potential quality-control issues -> potential quality-control issues in present study in present study involves an experienced physiologist which meet accepted standards for testings and then interpreted for the referrer involves an experienced physiologist which meet accepted standards for testings and then interpreted for the referrer Present authors Present authors this model is an alternative that produce more accurate results and hence subsequent diagnosis this model is an alternative that produce more accurate results and hence subsequent diagnosis Although significant improvements in managements Although significant improvements in managements there is still significant undertreatment of anticholinergics and long acting ß-agonists there is still significant undertreatment of anticholinergics and long acting ß-agonists - impossible to establish exactly how symptomatic patient is - impossible to establish exactly how symptomatic patient is mild AFO and few symptoms would not be considered for pharmacological or exercise therapy mild AFO and few symptoms would not be considered for pharmacological or exercise therapy

13. Despite general undertreatment,over-prescription of inhaled corticosteroids Despite general undertreatment,over-prescription of inhaled corticosteroids inhaled corticosteroids prescribed for persistent breathlessness despite maximum bronchodilator therapy inhaled corticosteroids prescribed for persistent breathlessness despite maximum bronchodilator therapy even after spirometry testing, even after spirometry testing, inhaled corticosteroids were added to 25 pts, although 5 pts of only a clear indication inhaled corticosteroids were added to 25 pts, although 5 pts of only a clear indication -> need for improvement in primary-care education -> need for improvement in primary-care education