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Voluntary Lung Function Screening to Reveal New COPD Cases in Southern Italy

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Voluntary Lung Function Screening to Reveal New COPD Cases in Southern Italy Journal name: International Journal of COPD Article Designation: Original Research Year: 2017 Volume: 12 International Journal of COPD Dovepress Running head verso: Capozzolo et al Running head recto: Screening for new COPD cases in southern Italy open access to scientific and medical research DOI: http://dx.doi.org/10.2147/COPD.S136357 Open Access Full Text Article ORIGINAL RESEARCH Voluntary lung function screening to reveal new COPD cases in southern Italy Alberto Capozzolo Background: Underdiagnosis of COPD is a relevant issue, and most frequently involves Giorgio Castellana patients at early stages of the disease. Physicians do not routinely recommend smokers to Silvano Dragonieri undergo spirometry, unless they are symptomatic. Pierluigi Carratù Aims: To investigate the effectiveness of voluntary lung function screening in bringing Vito Liotino to light patients with previously unknown COPD and to evaluate the relationships among Maria Rosaria Vulpi symptoms, smoking status, and airway obstruction. A voluntary screening study for COPD was conducted during two editions of the Lorenzo Marra Methods: annual Fiera del Levante (2014 and 2015), an international trade fair in Bari. Subjects were Emanuela Resta eligible for the study if they fulfilled the following inclusion criteria: age 35 years, smoker/ Pierluigi Intiglietta ex-smoker 5 pack-years (PYs), or at least one chronic respiratory symptom (cough, sputum Onofrio Resta production, shortness of breath, and wheezing). A free post-β2-agonist spirometry test was For personal use only. Department of Cardiac, Thoracic, performed by trained physicians for each participant using portable spirometers. Post-β2-agonist and Vascular Science, Institute of forced expiratory volume in 1 second (FEV ):forced vital capacity ratio 0.7 was chosen to Respiratory Disease, School of 1 Medicine, University of Bari, Bari, Italy establish the diagnosis of COPD. Sensitivity, specificity, and negative and positive predictive values (NPVs and PPVs) of symptoms for the presence of obstruction were calculated. Results: A total of 1,920 individuals were eligible for the study; 188 subjects (9.8%) met COPD criteria. There was a 10.4% prevalence of COPD in subjects with one or more symptoms who had never smoked or smoked 5 PYs. Among COPD patients, prevalence of symptoms increased in the presence of FEV1 80%. COPD smokers were more symptomatic than smokers without COPD. Sensitivity and specificity in all subjects with one or more symptoms were 87% and 32%, respectively, whereas in smoker subgroups, sensitivity and specificity were 71% and 41% (5 PYs) and 74% and 35% (10 PYs), respectively. In all subjects, the presence of at least one symptom was associated with a low PPV for COPD of 11%, but a very high NPV (96%). These data did not change if the analysis was limited to smokers. Conclusion: Voluntary public lung function screening programs in Italy are effective, and may detect a large number of undiagnosed subjects with COPD in early stages. In our population, COPD symptoms had low specificity and PPV, even considering smokers only. International Journal of Chronic Obstructive Pulmonary Disease downloaded from https://www.dovepress.com/ by 54.70.40.11 on 21-Dec-2018 Keywords: COPD underdiagnosis, COPD early stages, screening, spirometry Introduction COPD is characterized by airflow obstruction, and it is an important cause of mortality Correspondence: Giorgio Castellana 1 Department of Cardiac, Thoracic, and and disability worldwide. COPD should be suspected in subjects aged over 40 years Vascular Science, Institute of Respiratory with any of the following signs: 1) persistent and progressive dyspnea, typically Disease, School of Medicine, University worsened by physical exercise; 2) chronic cough, which may be intermittent and may of Bari, 11 Piazzale Giulio Cesare, Bari 70124, Italy be unproductive, recurrent wheeze; 3) chronic sputum production with any pattern; Tel +39 080 559 2907 4) recurrent lower respiratory tract infections; 5) a history of risk factors, such as host Fax +39 080 559 2978 Email [email protected] factors (eg, genetic factors, congenital/developmental abnormalities), tobacco smoke, submit your manuscript | www.dovepress.com International Journal of COPD 2017:12 2035–2042 2035 Dovepress © 2017 Capozzolo et al. This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License (http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you http://dx.doi.org/10.2147/COPD.S136357 hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms (https://www.dovepress.com/terms.php). Powered by TCPDF (www.tcpdf.org) 1 / 1 Capozzolo et al Dovepress smoke from home cooking and heating fuels, occupational Materials and methods dust, vapors, fumes, gases, and other chemicals; and 6) family A voluntary screening study for COPD was carried out during history of COPD and/or childhood factors (ie, low birth two editions (September 2014 and 2015) of the yearly Fiera weight, childhood respiratory infections).2 del Levante, an international trade fair in Bari that gathers Cigarette smoking is one of the leading causes of respi- visitors from many regions of southern Italy (mainly Puglia, ratory diseases in Italy. In 2015, the Italian National Insti- Basilicata, Campania, and Calabria) over 8 days. In 2015, tute of Health found 25.1% smoking prevalence in Italian Puglia had a resident population of 4 million, Basilicata males and 16.9% in females, for a total of 20.8%.3 Tobacco 575,000, Campania 5.9 million, and Calabria 2 million. The smoke is the main risk factor for developing COPD, though percentage of smokers in the south and islands is 26.2% for some evidence suggests that other risk factors, such as men and 17.2 for women.3 With regard to environmental indoor air pollution, occupational exposure, and passive pollution, Italy has the highest concentrations of pollut- smoking, are relevant,4–6 especially in developing countries. ants in Europe, with registration of the highest levels in the Therefore, an estimated 25%–45% of patients with COPD northern regions.21 have never smoked.7 Nevertheless, that group, considered In order to offer lung function testing to a large number of at low risk, is usually excluded from screening studies of visitors, a program entitled “Breath Days” was planned by the COPD. The gold standard for COPD diagnosis is post- principal investigators. Permission was obtained to place a test- bronchodilator (post-BD) spirometry performed in those ing station in a central location of the fair, and the program was patients suspected of having COPD, allowing the detec- advertised in local newspapers. The study was approved by the tion of early-stage lung disease.2,8 The ongoing strategy institutional review board of Bari University General Hospital aims to identify undiagnosed COPD.2 Underdiagnosis and by the board of directors of the fair (Fiera del Levante). most frequently involves patients at early stages of COPD. All participants provided written informed consent. Interestingly, about 95% of those in stage 1 (mild airflow Subjects were eligible for the study if they fulfilled the limitation) and 80% of those in stage 2 (moderate airflow following inclusion criteria: age 35 years, smoker/ex- For personal use only. limitation) remain undiagnosed.9 The main reason is that smoker 5 pack-years (PYs), or at least one chronic respiratory physicians do not routinely recommend smokers to perform symptom (cough, sputum production, shortness of breath, spirometry10,11 unless they are symptomatic, particularly and wheezing). Noninclusion criteria were previous diag- with dyspnea. Moreover, mild and even moderate COPD nosis of obstructive lung disease and/or treatment with can occur without complaints or symptoms, also hampering long-acting BDs. Individuals unable to perform spirometry early diagnosis.12 The period of most rapid decline in lung were excluded. Complete demographic data were collected function may occur much earlier than previously thought, for each subject included. Initially, all subjects underwent and it is during this period that aggressive testing strategies, a brief health survey consisting of questions about previous smoking-cessation efforts, and the initiation of treatments diagnoses of chronic respiratory disease Afterward, Charlson may be beneficial.13,14 One method for early detection is a Comorbidity Index score was calculated according to the voluntary public screening program. An example of volun- specifications described by Charlson et al,22 and subse- tary screening is a respiratory therapist setting up a booth at quently a questionnaire on four respiratory symptoms items a fair and offering spirometry to anyone who walks by and (yes/no) – presence of cough, sputum production, shortness is interested.15,16 In Italy, few screening programs, usually of breath, and wheezing – was completed. Data on past and International Journal of Chronic Obstructive Pulmonary Disease downloaded from https://www.dovepress.com/ by 54.70.40.11 on 21-Dec-2018 based on regional cohorts, have been performed to assess present smoking habits were also collected. Participants
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