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Correspondence |

Shifting the Goalpost To Stay Younger Response: Normal Spirometry but Short of Breath! FREE TO VIEW

Surya Prakash Bhatt, MD
Author and Funding Information

Affiliations: St. Luke’s Hospital, Bethlehem, PA,  Harbor UCLA Medical Center, Torrance, CA

Correspondence to: Surya Prakash Bhatt, MD, Internal Medicine, 801 Ostrum St, St Luke’s Hospital, Bethlehem, PA 18015; e-mail: suryabhatt@gmail.com



Chest. 2007;131(6):1990. doi:10.1378/chest.07-0423
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At a time when COPD as a cause of death is increasing, and efforts are being made to increase the awareness and diagnosis of COPD, the recent article in CHEST by Hansen et al (February 2007)1seems to be a needless obscuration of a simplified approach.23 Lung function declines with age. With baby boomers aging and more apparently healthy nonsmokers expected in each older age group, a cutoff at less than the fifth percentile is bound to include lower values of FEV1/FVC ratio percent predicted, leading to a false reduction of airflow obstruction prevalence at a time when a greater collective effort should be directed at tackling this killer disease.

The study1 states that about half of nonsmoking young adults with an FEV1/FVC ratio percent predicted below the fifth percentile were misidentified as normal by using fixed ratios. What constitutes normal is difficult to define. It is important not to fall into the trap of overestimation and the formation of new disease categories just because someone falls beyond the fifth percentile when what matters is clinical correlation. While prehypertension and prediabetes might be legitimate risk categories, there would be no limit to the creation of new disease categories without regard to clinical profile.

By calculating fifth percentiles for each decade, the authors1 disregarded the effects of the aging process. It is a known fact that respiratory capacity declines with aging. It would be interesting to compare how those in the eighth decade of life fared against those in the third decade in terms of symptoms and arguably better indexes of respiratory capacity like the 6-min walk test and the BODE index.4 Using postbronchodilator values partially overcomes what the authors of this study feared: an overestimation of obstructive lung disease in the elderly. Medicine is not just about numbers, and this study underlines the importance of clinical correlation for all tests. Parallels can be drawn to the glomerular filtration rate in patients with kidney disease. Irrespective of whether the condition is due to disease or age, a decline in glomerular filtration rate identifies the same risk. Let us not pretend that we are getting any younger by pushing the goal post farther away. It is time that we gave this debate an age-appropriate burial.

The author has reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

The authors have no conflicts of interest to disclose.

Hansen, JE, Sun, XG, Wasserman, K (2007) Spirometric criteria for airway obstruction: use percentage of FEV1/FVC ratio below the fifth percentile, not < 70%.Chest131,349-355. [PubMed] [CrossRef]
 
Pauwels, RA, Buist, AS, Calverley, PM, et al Global strategies for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: NHLBI/WHO Global Initiative for Chronic Obstructive Lung Disease (GOLD) Workshop summary.Am J Respir Crit Care Med2001;163,1256-1276. [PubMed]
 
Pelligrino, R, Viegi, G, Brusasco, V, et al ATS/ERS task force: standardization of lung function testing: interpretative strategies for lung function tests.Eur Respir J2005;26,948-968. [PubMed]
 
Celli, BR, Cote, CG, Marin, JM, et al The Body Mass Index, Airflow Obstruction, Dyspnea, Exercise Performance (BODE) index in chronic obstructive pulmonary disease.N Engl J Med2004;350,1005-1012. [PubMed]
 
To the Editor:

The authors thank Dr. Bhatt for his comments. We agree that obstructive airways diseases are a serious health concern and that clinical correlation with any test is always useful. We disagree with his statement that “by calculating fifth percentiles for each decade, the authors disregard the effects of the aging process.” Just the opposite; we assert that the objective standards for airway obstruction should not be a fixed ratio (ie, 70%), but the age of the individual should be taken into account.1Thus, an FEV1/FVC of 70% would be abnormally low in a young adult who wants to play football. This relatively low FEV1/FVC should be of much greater concern to the individual clinician (and the medical profession) than an FEV1/FVC of 70% in an octogenarian taking a morning walk. We believe our findings constructively reinforce the more recent conclusions of other expert clinicians and epidemiologists.3

References
Hansen, JE, Sun, XG, Wasserman, K Spirometric criteria for airway obstruction: use percentage of FEV1/FVC ratio below the fifth percentile, not < 70%.Chest2007;131,349-355. [PubMed] [CrossRef]
 
Townsend, MC Conflicting definitions of airway obstruction: drawing the line between normal and abnormal.Chest2007;131,325-326
 
Pelligrino, R, Viegi, G, Brusasco, V, et al ATS/ERS task force: standardization of lung function testing: interpretative strategies for lung function tests.Eur Respir J2005;26,948-968. [PubMed]
 

Figures

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References

Hansen, JE, Sun, XG, Wasserman, K (2007) Spirometric criteria for airway obstruction: use percentage of FEV1/FVC ratio below the fifth percentile, not < 70%.Chest131,349-355. [PubMed] [CrossRef]
 
Pauwels, RA, Buist, AS, Calverley, PM, et al Global strategies for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: NHLBI/WHO Global Initiative for Chronic Obstructive Lung Disease (GOLD) Workshop summary.Am J Respir Crit Care Med2001;163,1256-1276. [PubMed]
 
Pelligrino, R, Viegi, G, Brusasco, V, et al ATS/ERS task force: standardization of lung function testing: interpretative strategies for lung function tests.Eur Respir J2005;26,948-968. [PubMed]
 
Celli, BR, Cote, CG, Marin, JM, et al The Body Mass Index, Airflow Obstruction, Dyspnea, Exercise Performance (BODE) index in chronic obstructive pulmonary disease.N Engl J Med2004;350,1005-1012. [PubMed]
 
Hansen, JE, Sun, XG, Wasserman, K Spirometric criteria for airway obstruction: use percentage of FEV1/FVC ratio below the fifth percentile, not < 70%.Chest2007;131,349-355. [PubMed] [CrossRef]
 
Townsend, MC Conflicting definitions of airway obstruction: drawing the line between normal and abnormal.Chest2007;131,325-326
 
Pelligrino, R, Viegi, G, Brusasco, V, et al ATS/ERS task force: standardization of lung function testing: interpretative strategies for lung function tests.Eur Respir J2005;26,948-968. [PubMed]
 
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