Should chest examination be reinstated in the early diagnosis of chronic obstructive pulmonary disease?

Figures & data

Table 1 Questions on shortness of breath, cough, and phlegm in the clinical COPD questionnaire (CCQ)

On average, during the past week, how often did you feel:

1. Short of breath at rest?

2. Short of breath during physical activities?

In general, during the past week, how much of the time:

5. Did you cough?

6. Did you produce phlegm?

One score (0–6) for each question

0 = Never

1 = Hardly ever

2 = A few times

3 = Several times

4 = Many times

5 = A great many times

6 = Almost all the time

Abbreviation: COPD, chronic obstructive pulmonary disease.

Table 2 Sex, age, diagnosis, smoking history, lung function (by GOLD stages), respiratory symptoms, and chest signs in 375 patients aged ≥40 years diagnosed with asthma or COPD in primary care

	n	%
Sex
Men	143	38.1
Women	232	61.9
Age
<65 years	224	59.7
≥65 years	151	40.3
Diagnosis by General Practitioner (GP)
Only COPD	74	19.7
Only asthma	210	56.0
Both COPD and asthma	91	24.3
Smoking history
Never smoked	96	25.6
Smoking now	106	28.3
Previously smoked	173	46.1
Pack-yearsa
Never smoked	96	27.0
<10	45	12.7
10–20	75	21.1
≥20–40	102	28.7
≥40	37	10.4
Lung function
Normal spirometry/restriction	226	60.3
GOLD I	18	4.8
GOLD II	87	23.2
GOLD III or GOLD IV	44	11.7
Respiratory symptoms during the past week (from CCQ)
Short of breath at rest, several times or moreb	41	11.0
Short of breath doing physical activities, several times or morec	191	51.5
Short of breath doing physical activities, many times or mored	127	33.9
Short of breath doing physical activities, a great many times or moree	69	18.6
Cough, several times or moref	149	40.3
Phlegm, several times or moreg	134	35.7
Chest signs
Wheezes/rhonchi
Unilateral and/or bilateral	63	16.8
Bilateral	53	14.1
Crackles
Unilateral and/or bilateral	37	9.9
Bilateral	26	6.9
Diminished breath sounds
Unilateral and/or bilateral	65	17.3
Bilateral	54	14.4
Prolonged expiration	58	15.5
Hyperresonance to percussion
Unilateral and/or bilateral	36	9.6
Bilateral	33	8.8
Any of the five chest signs	145	38.7

Notes:

a n = 355, missing = 20

b missing = 3

c missing = 4

d missing = 4

e missing = 4

f missing = 5

g missing = 6

Abbreviations: GOLD, Global Initiative for Chronic Obstructive Lung Disease; COPD, chronic obstructive pulmonary disease; CCQ, clinical COPD questionnaire.

Figure 1 Frequency of heavy smoking, shortness of breath, and chest findings by level of lung function in 375 patients aged ≥40 years diagnosed with asthma or chronic obstructive pulmonary disease (COPD) in primary care. The patients were in a stable phase of illness.

Table 3 Values of smoking habit, respiratory symptoms, and chest signs in predicting COPD (postbronchodilator FEV₁/FVC < 0.7) in 375 patients diagnosed with asthma or COPD

	Sensitivity	Specificity	LR	CI	PPV (%)
Smoking
>0 pack-years	0.87	0.34	1.3	1.2–1.5	46.6
≥20 pack-years	0.61	0.76	2.5	1.9–3.3	62.6
≥40 pack-years	0.19	0.95	4.1	2.0–8.2	73.0
Respiratory symptoms during the previous week
Short of breath at rest, several times or more	0.13	0.90	1.3	0.8–2.4	46.3
Short of breath doing physical activities, several times or more	0.63	0.57	1.4	1.2–1.8	48.7
Short of breath doing physical activities, many times or more	0.42	0.71	1.4	1.1–1.9	48.0
Short of breath doing physical activities, a great many times or more	0.27	0.87	2.0	1.3–3.0	56.5
Cough, several times or more	0.40	0.60	1.0	0.8–1.3	39.6
Phlegm, several times or more	0.36	0.63	1.0	0.7–1.3	38.8
Chest signs
Wheezes/rhonchi	0.26	0.89	2.3	1.5–3.7	60.3
Crackles	0.09	0.90	0.9	0.5–1.8	37.8
Diminished breath sounds	0.34	0.93	5.1	3.0–8.7	76.9
Prolonged expiration	0.29	0.93	4.3	2.5–7.5	74.1
Hyperresonance to percussion	0.21	0.98	9.5	3.7–23.7	86.1
Any of the five chest signs	0.58	0.74	2.3	1.8–3.0	60.0

Note: The overall prevalence of COPD was 39.7%.

Abbreviations: COPD, chronic obstructive pulmonary disease; FEV₁, forced expiratory volume in 1 second; FVC, forced vital capacity; LR, likelihood ratio; CI, confidence interval; PPV, positive predictive value.

Table 4 Diagnostic values of smoking habit, respiratory symptoms, and chest signs in predicting severe COPD (postbronchodilator FEV₁/FVC < 0.7 and FEV₁% predicted <50) in 375 patients diagnosed with asthma or COPD

	Sensitivity	Specificity	LR	CI	PPV (%)
Smoking
>0 pack-years	0.96	0.28	1.3	1.2–1.5	15.1
≥20 pack-years	0.72	0.65	2.1	1.6–2.7	22.3
≥40 pack-years	0.30	0.92	3.9	2.2–7.1	35.1
Respiratory symptoms during the previous week
Short of breath at rest, several times or more	0.23	0.91	2.4	1.3–4.6	24.4
Short of breath doing physical activities, several times or more	0.89	0.54	1.9	1.6–2.2	20.4
Short of breath doing physical activities, many times or more	0.64	0.70	2.1	1.6–2.8	22.0
Short of breath doing physical activities, a great many times or more	0.41	0.84	2.6	1.7–4.1	21.6
Cough, several times or more	0.52	0.61	1.6	0.9–2.9	15.4
Phlegm, several times or more	0.46	0.65	1.3	0.9–1.9	14.9
Chest findings
Wheezes/rhonchi	0.36	0.86	2.7	1.6–4.1	25.4
Crackles	0.09	0.90	0.9	0.3–2.5	10.8
Diminished breath sounds	0.57	0.88	4.7	3.2–6.9	38.5
Prolonged expiration	0.43	0.88	3.7	2.3–5.7	32.8
Hyperresonance to percussion	0.39	0.94	6.7	3.8–12.0	47.2
Any of the five chest signs	0.82	0.67	2.5	2.0–3.1	24.8

Note: The overall prevalence of severe COPD was 11.7%.

Abbreviations: COPD, chronic obstructive pulmonary disease; FEV₁, forced expiratory volume in 1 second; FVC, forced vital capacity; LR, likelihood ratio; CI, confidence interval (for LR); PPV, positive predictive value.

Table 5 Independent predictive values of smoking, respiratory symptoms, and chest signs for COPD (FEV₁/FVC < 0.7) and severe COPD (FEV₁/FVC < 0.7 and FEV₁% predicted <50), as evaluated by multivariate logistic regression in 351 patients diagnosed with asthma or COPD

	COPD		Severe COPD
	Odds ratio	CI	Odds ratio	CI
Male sex	1.8	1.1–3.2	NS
Age	2.7	1.6–4.7	2.4	1.1–5.1
Pack years
≥20–40	4.9	2.7–8.8	NS
≥40	3.3	1.3–8.3	NS
Short of breath doing physical activities the previous week
Several times	NS		1.7	1.1–2.5
Many times	NS		1.5	1.1–2.0
A great many times	NS		8.4	2.7–25.8
Chest signs
Wheezes/rhonchi	2.3	1.1–4.8	NS
Diminished breath sounds	5.0	2.2–11.3	4.4	2.0–9.8
Hyperresonance to percussion	6.7	2.0–22.0	5.3	2.0–13.7

Abbreviations: COPD, chronic obstructive pulmonary disease; FEV₁, forced expiratory volume in 1 second; FVC, forced vital capacity; CI, confidence interval; NS, not significant.

Figure 2 Receiver operating-characteristic curves showing predictive value of three different scores in predicting COPD (FEV₁/FVC < 0.7) and severe COPD (FEV₁/FVC < 0.7 and FEV₁% predicted <50): dyspnea score (short of breath doing physical activities in the clinical COPD questionnaire), summing up of dyspnea score and pack-years (0–10, 1; 10–20, 2; 20–40, 3; ≥40, 4), and summing up of dyspnea score, pack-years, and chest-finding score (addition of wheezes, 1; diminished breath sound, 2; hyperresonance to percussion, 3).

Abbreviations: COPD, chronic obstructive pulmonary disease; FEV₁, forced expiratory volume in 1 second; FVC, forced vital capacity; CI, confidence interval; AUC, area under the curve.

Table 6 Sensitivity analysis comparing lung function, the prevalence of any chest sign, and the sensitivity, specificity, and likelihood ratio of any chest sign for COPD in practices where patients were examined before spirometry and after spirometry

	n	Any chest sign, n (%)		COPD (FEV1/FVC < 0.7), n (%)		Sensitivity	Specificity	Likelihood ratio (95% CI)
Patients examined before spirometry (4 GP offices)
Evaluated against prebronchodilator spirometry	211	72	34.1a	98	46.4b	53.1	82.3	3.0 (1.9–4.7)
Evaluated against postbronchodilator spirometry	211	72	34.1	94	44.5c	56.7	83.8	3.5 (2.2–5.4)
Patients examined after spirometry (3 GP offices)	164	73	44.5	55	33.5	61.8	64.2	1.7 (1.2–2.4)

Notes:

a The difference between the subgroups examined before and after spirometry was statistically significant, P = 0.04

b the difference between the subgroups examined before and after spirometry was statistically significant, P = 0.01

c the difference between the subgroups examined before and after spirometry was statistically significant, P = 0.03.

Abbreviations: COPD, chronic obstructive pulmonary disease; FEV₁, forced expiratory volume in 1 second; FVC, forced vital capacity; CI, confidence interval; GP, General Practitioner.