0
Correspondence |

FEV1/FVC Fixed Ratio Again! FREE TO VIEW

Leonardo M. Fabbri, MD, FCCP
Author and Funding Information

From the Department of Oncology, Haematology and Respiratory Diseases, Section of Respiratory Diseases, University of Modena and Reggio Emilia.

Correspondence to: Leonardo M. Fabbri, MD, FCCP, Department of Oncology, Haematology and Respiratory Diseases, Section of Respiratory Diseases, University of Modena and Reggio Emilia, via del Pozzo 71, Modena 41124, Italy; e-mail: leonardo.fabbri@unimore.it


Financial/nonfinancial disclosures: The author has reported to CHEST the following conflicts of interest: Dr Fabbri has served as a consultant to AstraZeneca, Boehringer-Ingelheim, Chiesi Farmaceutici, GlaxoSmithKline, Medestea, Merck Sharp & Dohme, Nycomed, and Sigma Tau; he has been paid lecture fees by AstraZeneca, Boehringer-Ingelheim, Chiesi Farmaceutici, GlaxoSmithKline, Merck Sharp & Dohme, Novartis, Nycomed, and Pfizer Inc; and he has received grant support from Almirall, AstraZeneca, Boehringer-Ingelheim, Menarini, Schering Plough, Chiesi Farmaceutici, Chiesi Foundation, GlaxoSmithKline, Merck Sharp & Dohme, Novartis, Nycomed, Pfizer Inc, Italian Ministry of Health, and Italian Ministry for University and Research.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


© 2011 American College of Chest Physicians


Chest. 2011;139(5):1252-1253. doi:10.1378/chest.10-3148
Text Size: A A A
Published online

To the Editor:

I read with great interest in a recent issue of CHEST (November 2010) the Point/Counterpoint Editorials1,2 on the FEV1/FVC fixed ratio of <0.7 to detect airflow obstruction and limitation. Although I was satisfied with the pro arguments of Drs Celli and Halbert,1 I found no real novel evidence on the con side compared with a similar debate I had on the same issue a few years ago.3-5 I still do not understand why Drs Enright and Brusasco2 criticized only the GOLD (Global Initiative for Obstructive Lung Disease) initiative6 for the choice of the fixed ratio, as the fixed ratio is recommended by all national and COPD guidelines, including the most recent National Institute for Health and Clinical Excellence 2010 COPD guidelines that extensively discuss the same issue and confirm its choice of the FEV1/FVC fixed ratio of <0.7.7

In addition to the many good reasons proposed by Drs Celli and Halbert, I believe that the main reason for recommending the fixed ratio at the time of developing the GOLD initiative8 was, and still is, that recommendations should be based on evidence, and the fixed ratio has been used as a diagnostic and an inclusion criterion in almost all randomized controlled trials (RCTs) conducted in patients with COPD. These RCTs provide the evidence to make and grade treatment recommendations for patients with COPD.6

Curiously, Drs Enright and Brusasco conducted and coauthored some of those RCTs using the fixed ratio. For example, the first large long-term RCT in COPD was the Lung Health Study,9,10 which indeed used the FEV1/FVC ratio and was coordinated and coauthored by Dr Enright. Similarly, the GOLD criteria and the fixed ratio were used as inclusion criteria of patients with COPD in two recent large RCTs coordinated and coauthored by Dr Brusasco.11-13 Finally, no reference to percent predicted FEV1/FVC was done, and only the absolute FEV1/FVC was analyzed in a recent prestigious scientific publication on COPD also coauthored by Dr Enright.14

Because the two authors have made a crusade over the past several years against the fixed ratio and the GOLD initiative15 (by the way, an interesting example of self-plagiarism16), I believe that it would be helpful for readers to understand their rationale for not quoting their own studies and papers using the GOLD definitions and criteria in which they did not even care to use, mention, or analyze the lower limit of normal that they propose to replace the fixed ratio. The lower limit of normal was indeed used as an inclusion criterion in one large RCT without raising any reactions17; if we had more of these studies, we could certainly rediscuss the case. However, I have to say, “Those who cannot remember the past are condemned to repeat it.”18

Celli BR, Halbert RJ. Point: should we abandon FEV1/FVC < 0.70 to detect airway obstruction? No. Chest. 2010;1385:1037-1040. [CrossRef] [PubMed]
 
Enright P, Brusasco V. Counterpoint: should we abandon FEV1/FVC < 0.70 to detect airway obstruction? Yes. Chest. 2010;1385:1040-1042. [CrossRef] [PubMed]
 
Fabbri LM, Boschetto P, Mapp CE. Global Initiative for Chronic Obstructive Lung Disease Global Initiative for Chronic Obstructive Lung Disease Global Initiative for Asthma Management and Prevention Global Initiative for Asthma Management and Prevention COPD guidelines: the important thing is not to stop questioning. Am J Respir Crit Care Med. 2007;1766:527-528. [CrossRef] [PubMed]
 
Enright PL. Are GOLDen slumbers drug induced? Am J Respir Crit Care Med. 2008;1776-1291
 
Fabbri LM, Boschetto P, Mapp CE. Time to wake up! Am J Respir Crit Care Med. 2008;177:1291-1292. [PubMed]
 
Rabe KF, Hurd S, Anzueto A, et al; Global Initiative for Chronic Obstructive Lung Disease Global Initiative for Chronic Obstructive Lung Disease Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit Care Med. 2007;1766:532-555. [CrossRef] [PubMed]
 
National Institute for Health and Clinical ExcellenceNational Institute for Health and Clinical Excellence Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care. National Clinical Guideline Centre (2010). NICE Web site.http://guidance.nice.org.uk/CG101/Guidance/pdf/English. Accessed June 28, 2010.
 
The Global Initiative for Chronic Obstructive Lung Disease (GOLD)The Global Initiative for Chronic Obstructive Lung Disease (GOLD) GOLD Web site.www.goldcopd.org. Accessed January 2011.
 
Anthonisen NR, Connett JE, Kiley JP, et al. Effects of smoking intervention and the use of an inhaled anticholinergic bronchodilator on the rate of decline of FEV1. The Lung Health Study. JAMA. 1994;27219:1497-1505. [CrossRef] [PubMed]
 
Wise RA, Kanner RE, Lindgren P, et al; Lung Health Study Research Group Lung Health Study Research Group The effect of smoking intervention and an inhaled bronchodilator on airways reactivity in COPD: the Lung Health Study. Chest. 2003;1242:449-458. [CrossRef] [PubMed]
 
Brusasco V, Hodder R, Miravitlles M, Korducki L, Towse L, Kesten S. Health outcomes following treatment for six months with once daily tiotropium compared with twice daily salmeterol in patients with COPD. Thorax. 2003;585:399-404. [CrossRef] [PubMed]
 
Brusasco V, Hodder R, Miravitlles M, Korducki L, Towse L, Kesten S. Health outcomes following treatment for 6 months with once daily tiotropium compared with twice daily salmeterol in patients with COPD. Thorax. 2006;611:91. [CrossRef] [PubMed]
 
Calverley PM, Kuna P, Monsó E, et al. Beclomethasone/formoterol in the management of COPD: a randomised controlled trial. Respir Med. 2010;10412:1858-1868. [CrossRef] [PubMed]
 
Barr RG, Bluemke DA, Ahmed FS, et al. Percent emphysema, airflow obstruction, and impaired left ventricular filling. N Engl J Med. 2010;3623:217-227. [CrossRef] [PubMed]
 
Quanjer PH, Enright PL, Miller MR, et al; Pulmonaria Group Pulmonaria Group Open letter: the need to change the method for defining mild airway obstruction. Prim Care Respir J. 2010;193:288-291. [CrossRef] [PubMed]
 
Self-plagiarism: unintentional, harmless, or fraud? Lancet. 2009;3749691:664
 
Decramer M, Rutten-van Mölken M, Dekhuijzen PNR, et al. Effects of N-acetylcysteine on outcomes in chronic obstructive pulmonary disease (Bronchitis Randomized on NAC Cost-Utility Study, BRONCUS): a randomised placebo-controlled trial. Lancet. 2005;3659470:1552-1560. [CrossRef] [PubMed]
 
Santayana G. Life of Reason: I. Reason in Common Sense. 1906; London, England Archibald Constable
 

Figures

Tables

References

Celli BR, Halbert RJ. Point: should we abandon FEV1/FVC < 0.70 to detect airway obstruction? No. Chest. 2010;1385:1037-1040. [CrossRef] [PubMed]
 
Enright P, Brusasco V. Counterpoint: should we abandon FEV1/FVC < 0.70 to detect airway obstruction? Yes. Chest. 2010;1385:1040-1042. [CrossRef] [PubMed]
 
Fabbri LM, Boschetto P, Mapp CE. Global Initiative for Chronic Obstructive Lung Disease Global Initiative for Chronic Obstructive Lung Disease Global Initiative for Asthma Management and Prevention Global Initiative for Asthma Management and Prevention COPD guidelines: the important thing is not to stop questioning. Am J Respir Crit Care Med. 2007;1766:527-528. [CrossRef] [PubMed]
 
Enright PL. Are GOLDen slumbers drug induced? Am J Respir Crit Care Med. 2008;1776-1291
 
Fabbri LM, Boschetto P, Mapp CE. Time to wake up! Am J Respir Crit Care Med. 2008;177:1291-1292. [PubMed]
 
Rabe KF, Hurd S, Anzueto A, et al; Global Initiative for Chronic Obstructive Lung Disease Global Initiative for Chronic Obstructive Lung Disease Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit Care Med. 2007;1766:532-555. [CrossRef] [PubMed]
 
National Institute for Health and Clinical ExcellenceNational Institute for Health and Clinical Excellence Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care. National Clinical Guideline Centre (2010). NICE Web site.http://guidance.nice.org.uk/CG101/Guidance/pdf/English. Accessed June 28, 2010.
 
The Global Initiative for Chronic Obstructive Lung Disease (GOLD)The Global Initiative for Chronic Obstructive Lung Disease (GOLD) GOLD Web site.www.goldcopd.org. Accessed January 2011.
 
Anthonisen NR, Connett JE, Kiley JP, et al. Effects of smoking intervention and the use of an inhaled anticholinergic bronchodilator on the rate of decline of FEV1. The Lung Health Study. JAMA. 1994;27219:1497-1505. [CrossRef] [PubMed]
 
Wise RA, Kanner RE, Lindgren P, et al; Lung Health Study Research Group Lung Health Study Research Group The effect of smoking intervention and an inhaled bronchodilator on airways reactivity in COPD: the Lung Health Study. Chest. 2003;1242:449-458. [CrossRef] [PubMed]
 
Brusasco V, Hodder R, Miravitlles M, Korducki L, Towse L, Kesten S. Health outcomes following treatment for six months with once daily tiotropium compared with twice daily salmeterol in patients with COPD. Thorax. 2003;585:399-404. [CrossRef] [PubMed]
 
Brusasco V, Hodder R, Miravitlles M, Korducki L, Towse L, Kesten S. Health outcomes following treatment for 6 months with once daily tiotropium compared with twice daily salmeterol in patients with COPD. Thorax. 2006;611:91. [CrossRef] [PubMed]
 
Calverley PM, Kuna P, Monsó E, et al. Beclomethasone/formoterol in the management of COPD: a randomised controlled trial. Respir Med. 2010;10412:1858-1868. [CrossRef] [PubMed]
 
Barr RG, Bluemke DA, Ahmed FS, et al. Percent emphysema, airflow obstruction, and impaired left ventricular filling. N Engl J Med. 2010;3623:217-227. [CrossRef] [PubMed]
 
Quanjer PH, Enright PL, Miller MR, et al; Pulmonaria Group Pulmonaria Group Open letter: the need to change the method for defining mild airway obstruction. Prim Care Respir J. 2010;193:288-291. [CrossRef] [PubMed]
 
Self-plagiarism: unintentional, harmless, or fraud? Lancet. 2009;3749691:664
 
Decramer M, Rutten-van Mölken M, Dekhuijzen PNR, et al. Effects of N-acetylcysteine on outcomes in chronic obstructive pulmonary disease (Bronchitis Randomized on NAC Cost-Utility Study, BRONCUS): a randomised placebo-controlled trial. Lancet. 2005;3659470:1552-1560. [CrossRef] [PubMed]
 
Santayana G. Life of Reason: I. Reason in Common Sense. 1906; London, England Archibald Constable
 
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543