UAB MEDICINE PULMONARY SERVICES
FEATURE STORIES
FALL 2019
To read this and previous issues online, please visit uabmedicine.org/pulmupdate
NEW RESEARCH HOPES TO IDENTIFY INDIVIDUALS AT RISK OF CLINICALLY SIGNIFICANT COPD
In an article published in the Journal of the American Medical
Association, Surya Bhatt, MD, associate professor in the UAB
Division of Pulmonary, Allergy, and Critical Care Medicine and
medical director of the UAB Pulmonary Function and Exercise
Physiology Lab, says there is much confusion and debate
in the medical community on what are the best spirometry
criteria to use for diagnosing chronic obstructive pulmonary
disease (COPD).
Currently, major respiratory society guidelines recommend
diagnosing airflow obstruction when the ratio of the forced
expiratory volume in one second (FEV1) to the forced vital
capacity (FVC) is less than a fixed threshold of 0.70. This
means that during a forced exhalation following a maximal
inhalation, normal individuals should be able to blow out at
least 70% of their lung size or vital capacity in the first second.
However, there is no rigorous, population-based evidence to
support the threshold of 0.70, which was set by expert opinion
as the optimal FEV1/FVC threshold for defining clinically
significant airflow obstruction, according to the published
research.
“A diagnosis of COPD needs confirmation by demonstrating
obstruction to airflow using spirometry,” Dr. Bhatt says. “The
currently used criteria are based on expert opinion, and until
these results were published, there was not enough evidence
to support their use.”
The multisite team, led by researchers from UAB and the
University of Columbia, analyzed data from a large, multi-
ethnic sample of 24,207 adults in the United States. They
found that the currently used threshold of 0.70 provided
discrimination of COPD-related hospitalization and mortality
that was not significantly different from – or was more accurate
than – other fixed thresholds.
The 0.70 threshold also was more accurate than other
thresholds that define normal lung function and are derived
from reference populations. These results support the
continued use of FEV1/FVC <0.70 to identify individuals at risk
of clinically significant COPD.
Cigarette smoking is the primary cause of COPD in the United
States, but air pollutants at home and work also can cause it.
COPD makes breathing difficult for the estimated 14 million
Americans who have this disease. Millions more suffer from
COPD but have not been diagnosed. Although there is no
cure, it can be treated.
“The ongoing disagreement between experts on the best
spirometry criteria to diagnose airflow obstruction has resulted
in a lack of clarity for clinicians,” Dr. Bhatt said. “Using a simple,
standard threshold has the potential to improve the diagnosis
and treatment of this common disease.”
CURRENT AND FORMER SMOKERS HAVE SIGNIFICANT UNMET MENTAL HEALTH CARE NEEDS
Physician scientists from the UAB Division of Pulmonary,
Allergy, and Critical Care Medicine – in partnership with
researchers across the country – found that smokers with
and without chronic obstructive pulmonary disease (COPD)
have significant unmet mental health care needs, particularly
anxiety and depressive symptoms. The findings were
published in the Journal of Psychosomatic Research.
“In the group of more than 5,000 smokers – with and without
COPD – from the multisite, longitudinal genetic epidemiology
of COPD (COPDGene) study, one in four had clinically elevated
anxiety/depressive symptoms,” says study lead author and
UAB assistant professor Anand S. Iyer, MD. “Of those with
elevated symptoms, two-thirds were not receiving any type of
medication to treat these symptoms, such as an anti-anxiety or
antidepressant medication.”
“While depressive symptoms were most frequent in those
with the most severe cases of COPD,” Dr. Iyer adds, “anxiety
symptoms were similar in frequency between smokers with
and without COPD, so the problem seems to start a lot earlier
in the disease.”
According to Dr. Iyer, untreated emotional symptoms leave
a major gap in COPD care that warrants early palliative care
or primary palliative care. He says emotional symptoms have
been shown to impact many COPD-related outcomes.
“We have previously found that depression predicts hospital
readmissions in COPD, and others have found associations
with exacerbations and poor adherence to medications,”
Dr. Iyer says. “Clinically, we treat many COPD patients and
smokers who have borderline COPD and also have clinically
important emotional symptoms that would warrant treatment.”
Dr. Iyer adds that pulmonary and primary care clinicians do
not assess these symptoms often enough, which leaves
many patients potentially untreated for elevated emotional
symptoms – a major gap in comprehensive COPD care. It is not
clear who is in charge of managing those symptoms.
“Since the elevated emotional symptoms we discovered
were also present in smokers who had milder COPD, earlier
assessment and triage in the primary care setting is needed,
potentially even early palliative care,” he says.
“There are similar receptors in the brain functioning in
smokers addicted to cigarettes and who have anxiety and
depression,” Dr. Iyer says. “In fact, most of the smoking
cessation medications frequently used to help patients quit are
antidepressants, too.”