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Re: The diagnostic value of history and physical examination for COPD
- Berna DL Broekhuizen, [Alfred PE Sachs] [ Arno W Hoes] [Theo JM Verheij] [Karel GM Moons] (19 June 2009)
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The diagnostic value of history and physical examination for COPD
- Robert Badgett (6 June 2009)
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Berna DL Broekhuizen, general practitioner Utrecht 3508 AB, [Alfred PE Sachs] [ Arno W Hoes] [Theo JM Verheij] [Karel GM Moons]
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Prof. Badgett regrets that studies on “diminished breath sounds” were excluded and not discussed. We extensively reviewed the studies by Holleman (1) and Badgett (2;3). They were excluded from our analysis, however, because of not meeting our inclusion criteria pertaining to the population studied, i.e. “the study population consisted - at least partially- of patients suspected of COPD (thus studies on screening of asymptomatic people or on subjects that were already known with COPD were excluded)”. We defined this criterium according to the STARD and QUADAS guidelines which advice diagnostic studies to select participants on their indication for testing, or on their suspicion of having the studied disease.(4;5) In our example, the diagnostic problem was which patients, suspected of having COPD by their physician, should undergo spirometry. The study by Badgett included outpatients recruited by notices, who were (former) smokers, or had COPD or asthma. The study of Holleman included patients referred for outpatient medical preoperative risk assessment. We documented the review of Holleman (6) in our introduction. The study of Melbye et al was excluded because of Norwegian language and the other studies for (again) the studied populations. We agree that we should have made our inclusion criteria more explicit. Diminished breath sounds was studied in only one of the included studies, which does not suggest that it has no diagnostic value for COPD. Considering the nature of COPD and the results of the mentioned studies, it probably has. Nevertheless, our goal was to summarize the evidence for the diagnostic value of history and physical examination in patients suspected of COPD, and not to overview history and physical examination findings, that are common in COPD. Recently, we finished a diagnostic study in primary care patients, suspected of having COPD, on the accuracy of history, physical examination and additional tests for COPD. The results of this study, in which diminished breath sounds was included as a potential predictor, will be published soon. Reference List (1) Holleman DR, Jr., Simel DL, Goldberg JS. Diagnosis of obstructive airways disease from the clinical examination. J Gen Intern Med 1993; 8(2):63-68. (2) Badgett RG, Tanaka DJ, Hunt DK, Jelley MJ, Feinberg LE, Steiner JF et al. Can moderate chronic obstructive pulmonary disease be diagnosed by historical and physical findings alone? Am J Med 1993; 94(2):188-196. (3) Badgett RG, Tanaka DJ, Hunt DK, Jelley MJ, Feinberg LE, Steiner JF et al. The clinical evaluation for diagnosing obstructive airways disease in high-risk patients. Chest 1994; 106(5):1427-1431. (4) Bossuyt PM, Reitsma JB, Bruns DE, Gatsonis CA, Glasziou PP, Irwig LM et al. The STARD statement for reporting studies of diagnostic accuracy: explanation and elaboration. Ann Intern Med 2003; 138(1):W1-12. (5) Whiting P, Rutjes AW, Reitsma JB, Bossuyt PM, Kleijnen J. The development of QUADAS: a tool for the quality assessment of studies of diagnostic accuracy included in systematic reviews. BMC Med Res Methodol 2003; 3:25. (6) Holleman DR, Jr., Simel DL. Does the clinical examination predict airflow limitation? JAMA 1995; 273(4):313-319. Conflict of Interest:None declared |
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Robert Badgett, Clinical Professor of Medicine UTHSCSA. San Antonio, TX
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I believe this review would benefit from more explicit methods and documentation of excluded studies. It is not clear why the authors excluded the studies by Holleman (PMID 8441077) and myself (PMID 8430714; PMID 7956395). In addition, it is not clear why the systematic review (PMID 7815660) carefully done by Holleman for the Rational Clinical Examination was not considered systematic by the authors. Excluding these studies might undersell the value of auscultating diminished breath sounds. Diminished breath sounds were the most sensitive finding in our study as well as in the study of Holleman. Breath sounds were not statistically significant in Holleman's study because they were not added to the protocol until the last third of the study. In addition, diminished breath sounds have been found helpful in other studies with (van Schayck et al, PMID 1792447) and without (Hepper et al, PMID 5351681; Schneider, PMID 14263096; Bohadana, PMID 684671; Melbye, PMID 9656782; Pardee, PMID 7357938) multivariable analysis. The highest sensitivity for diminished breath sounds was found in our study; we had each examiner attend a session before the study in which they auscultated patients with normal, moderately, and severe airway obstruction. While most doctors will not have this opportunity for training, individual doctors can calibrate their listening by comparing their patients with known, severe obstruction with patients known to be normal. Admittedly, the sensitivity of diminished breath sound is probably less than 50%, but this is better than the sensitivity of other physical examination findings for airway obstruction and should be noted in a summary of this topic. Conflict of Interest:None declared |
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