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33G.. Spirometry reversibility (v12)
COPD is diagnosed if:
• the patient has an FeV1 of less than 80 per cent of predicted normal
• and has an FeV1/FVC ratio of less than 70 per cent
• and the patient has symptoms consistent with COPD.
Spirometry should be performed after the administration of an adequate dose of an inhaled bronchodilator (e.g. 400mcg salbutamol).
Prior to performing post-bronchodilator spirometry, patients do not need to stop any therapy, such as long acting bronchodilators or inhaled steroids.
All of these elements are required to make the diagnosis of COPD. Routine reversibility testing is not recommended in NICE, and the GOLD guidelines require post bronchodilator spirometry for diagnosis and grading. Failure to use post bronchodilator readings overestimated the prevalence of COPD by 25% (Johannessesn et al. Thorax 2005; 60(10): 842-847). This change will reduce workload in primary care and removes the conflict with evidence based guidelines.
Where doubt occurs as to whether the diagnosis is asthma or COPD, reversibility testing may add additional information to post bronchodilator readings alone and peak flow charts are useful. It is acknowledged that COPD and asthma can co-exist and that many patients with asthma who smoke will eventually develop irreversible airways obstruction. However, where asthma is present, these patients should be managed as asthma patients as well as COPD patients. This will be evidenced by a greater than 400mls response to a reversibility test and a post bronchodilator FeV1 of <80% of predicted normal as well as an appropriate medical history.
Patients with reversible airways obstruction should be included on the asthma register. Patients with coexisting asthma and COPD should be included on the register for both conditions.
Further information: Global Strategy for the Diagnosis, Management and Prevention
of COPD 2006
www.goldcopd.org
NICE Clinical Guideline 2004
www.nice.org.uk/guidance/index.jsp?action=download&o=29303
www.thorax.bmj.com/content/vol59/suppl_1/
For the purposes of the QOF, post bronchodilator spirometry undertaken between three months before and twelve months after a diagnosis of COPD being made would be considered as meeting the requirements of this indicator.
Practices should report the percentage of patients diagnosed after 1st April 2008 who are on their COPD register, who have a record that the diagnosis has been confirmed by post bronchodilator spirometry.
In verifying that this information has been correctly recorded, a number of approaches could be taken by a PCO:
i. Inspection of the output from a computer search that has been used to provide
information on this indicator.
ii. Inspection of a sample of records of patients with COPD to look at the proportion
with a record of post bronchodilator spirometry.
iii. Inspection of a sample of records of patients for whom a record of post
bronchodilator spirometry is claimed, to see if there is evidence of this in
the medical records.
Prepared By Jean Keenan