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Level IV – Chronic Obstructive Pulmonary Disease Using Spirometry

Level IV Services: Preventive services that are not supported by evidence and should not be recommended.

The USPSTF recommendations are fully endorsed by the ICSI Preventive Services work group.
Grade of Recommendation and Level of Certainty as Evaluated by USPSTF
  1. “Against screening adults for chronic obstructive pulmonary disease (COPD) using spirometry.”
(USPSTF Last Revised 2008 – Update in Progress)
Grade of Recommendation:
  1. D

Level of Certainty:

  1. Moderate
“Benefits:
No controlled studies have compared clinical outcomes between screened and non-screened populations. Randomized, controlled trials of pharmacologic therapies have generally enrolled patients with clinically detected COPD; this population is unlikely to be similar to a population with spirometric screening-detected COPD. Patients identified through screening do not recognize or report symptoms, and, on the basis of prevalence studies, most would be expected to have mild or moderate COPD. A systematic review and meta-analysis of randomized, controlled trials of treatment found small improvements in exacerbations, health status measures and mortality only in symptomatic patients with severe COPD.
The hypothesis that early detection of COPD with spirometry, alone or as part of a multi-component intervention, leads to improved smoking cessation rates has been tested in several randomized, controlled trials. Two randomized, controlled trials that evaluated the independent effect of spirometry found no statistically significant difference in cessation rates between smokers who were provided spirometry results and control participants.
Harms:
Opportunity costs (time and effort required by both patients and the health care system), anxiety associated with false-positive results, and adverse effects from appropriately or inappropriately prescribed medications are all potential harms of screening for COPD using spirometry. Several good- or fair-quality meta-analyses have concluded that inhaled COPD therapies are commonly associated with minor adverse effects. Evidence of their association with major adverse effects (myocardial infarction, hip fracture, pneumonia) is inconsistent.
Benefits-Harms Assessment:
In patients similar to those in the randomized, controlled trials, inhaled COPD therapies can result in an absolute reduction in exacerbations. Using estimates obtained from population-based studies, one can determine the number of patients needed to screen with spirometry to defer the first exacerbation in various age groups. Assuming that patients who do not recognize or report symptoms benefit to the same degree as patients in the randomized, controlled trials, and that benefits of therapy are similar across all age groups, the number needed to screen ranges from 400 (in patients ages 70 to 74 years) to 2,500 (in patients ages 40 to 49 years). Limiting screening spirometry to smokers older than age 40 years, as advocated by some groups, produces a number needed to screen of 833 to defer the first exacerbation.
Weighing this benefit against potential harms, there is at least moderate certainty that screening for COPD using spirometry has no net benefit.”
Relevant Resources:
http://www.uspreventiveservicestaskforce.org/uspstf/uspscopd.htm