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a Department of
Medicine, Queen Elizabeth Hospital, Birmingham B15 2TH, UK, b Department of Radiology
Correspondence to: Professor R A Stockley email: r.a.stockley{at}bham.ac.uk
Received 22 November 1999; Returned to authors 9 February 2000; Revised version received 27 March 2000; Accepted for publication 10 April 2000
BACKGROUND
Chronic
obstructive pulmonary disease (COPD) is common although often poorly
characterised, particularly in primary care. However, application of
guidelines to the management of such patients needs a clear
understanding of the phenotype. In particular, the British guidelines
for the management of COPD recommend that the diagnosis is based on
appropriate symptoms and evidence of airflow obstruction as determined
by a forced expiratory volume in one second (FEV1) of
<80% of the predicted value and an FEV1/VC ratio of
<70%.
METHODSA study
was undertaken of 110 patients aged 40-80 years who had presented to
their general practitioner with an acute exacerbation of COPD. The
episode was treated at home and, when patients had recovered to the
stable state (two months later), they were characterised by full lung
function tests and a high resolution computed tomographic (HRCT) scan
of the chest.
RESULTSThere was a
wide range of impairment of FEV1 which was in the normal
range (
80%) in 30%, mildly impaired (60-79%) in 18%, moderately
impaired (40-59%) in 33%, and severely impaired (<40%) in 19% of
patients. A reduced FEV1/VC ratio was present in all patients with an FEV1 of <80% predicted but also in 41%
of those with an FEV1 of 80% predicted. Only 5% of
patients had a substantial bronchodilator response suggesting a
diagnosis of asthma. Emphysema was present in 51% of patients and
confined to the upper lobes in most (73% of these patients). HRCT
evidence of bronchiectasis was noted in 29% of patients and was
predominantly tubular; most (81%) were current or ex-smokers. A
solitary pulmonary nodule was seen on 9% of scans and unsuspected lung
malignancy was diagnosed in two patients.
CONCLUSIONSThis study
confirms that COPD in primary care is a heterogeneous condition. Some
patients do not fulfil the proposed diagnostic criteria with
FEV1 of 80% predicted but they may nevertheless have
airflow obstruction. Bronchiectasis is common in this group of
patients, as is unsuspected malignancy. These findings should be
considered when developing recommendations for the investigation and
management of COPD in the community.
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