Affiliations: Hospital General Universitario, Elche, Spain,
University Medical Center Groningen, Groningen, the Netherlands,
Veterans Affairs Medical Center, Minneapolis, MN
Correspondence to: Eduardo Garcia-Pachon, MD, Section of Pneumology, Hospital General Universitario, E-03203 Elche, Spain; e-mail: email@example.com
The article by Niewoehner and coworkers (January 2007)1 is a much-needed contribution to the better understanding of COPD. Using prospective data, the authors propose risk indexes that are able to predict COPD exacerbations and related hospitalizations. These indexes include spirometry variables and a few clinical variables (age of the patients, unscheduled visits, cardiovascular comorbidity, and some prescribed medications) but do not include data from physical examination. However, in our experience, determining the presence of the Hoover sign (the paradoxical movement of the lateral rib margin during inspiration) may be useful for detecting those COPD patients with a higher risk of exacerbation including hospitalization.
The Hoover sign is a frequent finding in the clinical examination of COPD. In a series2 of 157 stable COPD patients, the sign was present in 36% of patients with moderate COPD, 43% of patients with severe COPD, and 76% of patients with very severe COPD. In our studies,2–3 the presence of the Hoover sign was independently associated with a higher dyspnea level and a higher number of exacerbations including hospitalizations. The Hoover sign is easy to detect, and there is good agreement between observers with different clinical experience.4In addition, it may be useful for differentiating the cardiac from the respiratory origin of acute dyspnea.5 In view of our experience, we propose including this physical sign in the evaluation of possible risk indexes for exacerbations in COPD patients.
The authors have no conflicts of interest to disclose.
Dr. Niewoehner has received grants, honoraria, or advisory fees from Boehringer-Ingelheim, Pfizer, AstraZeneca, GlaxoSmith-Kline, Adams Respiratory Therapeutics, and Sanofi Pasteur within the past 3 years.
The recent article by Niewoehner and colleagues (January 2007)1 describes the development of risk indexes for the prediction of exacerbations and hospitalization due to exacerbations in COPD. Of the different parameters they use, the authors suggest that quality of life might be the most important factor not included. The authors conclude that this is not problematic since there are no validated measures for the use in clinical practice, due to the significant administration time.
We disagree with this argument. Firstly, the authors contribute to the widespread misclassification of questionnaires by interchangeably using the terms health status, health-related quality of life (HRQoL), and quality of life, which each represent a different concept. The St. George’s Respiratory Questionnaire and the Short-Form-36V are classified by the developers as health status questionnaires.2–3 The Seattle Obstructive Lung Disease Questionairre is described as a HRQoL questionnaire.4 Both health status and HRQoL show predictive value in exacerbations.
Secondly, there are several validated health status instruments for COPD available, of which some are indeed lengthy and impractical for use in routine practice. However, the current Global Initiative for Chronic Obstructive Lung Disease guidelines5recommend several instruments for the use in the clinical context: the well known Medical Research Council dyspnea scale, the Clinical COPD Questionnaire (a health status instrument), and the International Primary Care Airways Group diagnostic questionnaire. Many clinicians already use these questionnaires in daily clinical practice. In a cohort of 168 patients 6 weeks after hospitalization due to an exacerbation of COPD, we showed that Clinical COPD Questionnaire scores were higher in patients with a subsequent hospital admission within the first year, compared to those patients who were not readmitted.6
Health status assessment could be an important and very valuable addition to more traditional measures of disease severity in daily clinical practice, not only to evaluate changes, but also to predict exacerbations. Well-validated practical measures are currently available for this purpose.
Drs. Garcia-Pachon and Padilla-Navas have suggested in their letter that the presence of Hoover sign might independently predict a risk for exacerbations in COPD patients. As we did not evaluate Hoover sign in our trial,1we can make no judgment as to its value. Most physical signs appear to be of rather limited value in detecting airflow obstruction, and many are not very reproducible.2–3 Nonetheless, Hoover sign might be worth a closer look.
To clarify a comment in the letter from Drs. Kock and van der Molen, we did not state that validated instruments for assessing quality of life (or health status) in clinical practice are unavailable. We did state that the time required for administering these questionnaires might pose a substantial barrier to their use in everyday practice, as the best-validated instruments require a minimum of 5 to 10 min to administer. That might be an unacceptably long time for a busy practitioner. Shorter questionnaires would be more acceptable, but possibly less informative. Drs. Kock and van der Molen propose the use of the Clinical COPD Questionnaire, which contains 10 items and can be self-administered in only 2 min, and they cite one of their studies as supporting evidence.4 In their study of 168 patients, higher (ie, worse) total scores on the Clinical COPD Questionnaire indeed did predict a higher rehospitalization rate over 1 year, but that difference was not statistically significant in a univariable analysis (p = 0.29).
We do encourage further studies to determine whether assessments of quality of life/health status add independent value to the terms already incorporated into our models. If intended for clinical use to predict exacerbations, instruments must be very brief, easy to administer, and fully validated.
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