Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.
Respir Res. 2012 Feb 6;13(1):13. doi: 10.1186/1465-9921-13-13.
The Global initiative for chronic Obstructive Lung Disease (GOLD) defines COPD as a fixed post-bronchodilator ratio of forced expiratory volume in 1 second and forced vital capacity (FEV1/FVC) below 0.7. Age-dependent cut-off values below the lower fifth percentile (LLN) of this ratio derived from the general population have been proposed as an alternative. We wanted to assess the diagnostic accuracy and prognostic capability of the GOLD and LLN definition when compared to an expert-based diagnosis.
In a prospective cohort study, 405 patients aged ≥ 65 years with a general practitioner's diagnosis of COPD were recruited and followed up for 4.5 (median; quartiles 3.9; 5.1) years. Prevalence rates of COPD according to GOLD and three LLN definitions and diagnostic performance measurements were calculated. The reference standard was the diagnosis of COPD of an expert panel that used all available diagnostic information, including spirometry and bodyplethysmography.
Compared to the expert panel diagnosis, 'GOLD-COPD' misclassified 69 (28%) patients, and the three LLNs misclassified 114 (46%), 96 (39%), and 98 (40%) patients, respectively. The GOLD classification led to more false positives, the LLNs to more false negative diagnoses. The main predictors beyond the FEV1/FVC ratio for an expert diagnosis of COPD were the FEV1 % predicted, and the residual volume/total lung capacity ratio (RV/TLC). Adding FEV1 and RV/TLC to GOLD or LLN improved the diagnostic accuracy, resulting in a significant reduction of up to 50% of the number of misdiagnoses. The expert diagnosis of COPD better predicts exacerbations, hospitalizations and mortality than GOLD or LLN.
GOLD criteria over-diagnose COPD, while LLN definitions under-diagnose COPD in elderly patients as compared to an expert panel diagnosis. Incorporating FEV1 and RV/TLC into the GOLD-COPD or LLN-based definition brings both definitions closer to expert panel diagnosis of COPD, and to daily clinical practice.
慢性阻塞性肺疾病全球倡议（GOLD）将 COPD 定义为支气管扩张剂后 1 秒用力呼气量与用力肺活量（FEV1/FVC）之比固定低于 0.7。已提出将此比值从一般人群中得出的下五分之一位数（LLN）以下的年龄依赖性截断值作为替代方法。我们希望评估 GOLD 和 LLN 定义与基于专家的诊断相比的诊断准确性和预后能力。
在一项前瞻性队列研究中，招募了 405 名年龄≥65 岁的全科医生诊断为 COPD 的患者，并进行了 4.5 年（中位数；四分位数 3.9；5.1）的随访。根据 GOLD 和三种 LLN 定义计算 COPD 的患病率以及诊断性能测量。参考标准是使用所有可用诊断信息（包括肺活量测定法和体描法）的专家小组对 COPD 的诊断。
与专家小组诊断相比，“GOLD-COPD”错误分类了 69 例（28％）患者，三种 LLN 分别错误分类了 114 例（46％），96 例（39％）和 98 例（40％）患者。GOLD 分类导致更多的假阳性，LLN 导致更多的假阴性诊断。除 FEV1/FVC 比值外，专家诊断 COPD 的主要预测指标为 FEV1%预计值和残气量/总肺容量比（RV/TLC）。将 FEV1 和 RV/TLC 添加到 GOLD 或 LLN 中可提高诊断准确性，从而使误诊数量减少多达 50％。专家对 COPD 的诊断比 GOLD 或 LLN 更好地预测恶化，住院和死亡。
与专家小组诊断相比，GOLD 标准会过度诊断 COPD，而 LLN 定义则会低估老年患者的 COPD。将 FEV1 和 RV/TLC 纳入 GOLD-COPD 或基于 LLN 的定义可使这两种定义更接近专家小组对 COPD 的诊断，并更接近日常临床实践。
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