© 2008 American Thoracic Society
Time to Wake Up!From the Authors:We thank Professor Paul Enright for his interesting, albeit incorrect interpretation of the thoughts in our editorial on COPD (1). We find the discussion of stage 0 and criteria for detecting airflow limitation (i.e., post-bronchodilator FEV1/FVC < 0.7 vs. the lower limit of normal) of little clinical relevance. We challenge the utility of spirometry for diagnosing and assessing severity in COPD. Experienced pulmonary specialists (2) and general practitioners (3) find that up to 40% of smokers/ex-smokers with chronic respiratory symptoms and clinical findings compatible with COPD do not fit the spirometric definition of COPD. Therefore, we suggest revising the criteria for diagnosis and assessment of severity of COPD to include clinical findings such as symptoms, imaging, and comorbidities. As for other chronic diseases almost invariably associated with COPD, a broader term, chronic systemic inflammatory syndrome (CSIS), has been suggested to reflect the complexity of illness in patients with any chronic disease induced by smoking (4). In this perspective, spirometry might become a biomarker of pulmonary, cardiovascular, and/or metabolic diseases (4). Regarding the title of Professor Enright's letter, we suspect that he found the lullaby of the Beatles' song ("Golden Slumbers") effective and long-lasting. Reversibility of airflow limitation is no longer recommended for differential diagnosis between COPD and asthma (5). The post-bronchodilator FEV1/FVC ratio does not need endorsement by the American Thoracic Society (ATS), as it is recommended by the ATS/European Respiratory Society (ERS) guidelines, along with the same pharmacologic treatment algorithm recommended by the GOLD guidelines (6). Thus, no risk of overtreatment of elderly smokers/ex-smokers (COPD should not be diagnosed in nonsmokers) is induced by guideline writers corrupted by industry to promote sales of drugs. In fact, the GOLD (5), ATS/ERS (6), and Canadian guidelines (7) recommend pharmacologic treatment only to prevent or attenuate symptoms and exacerbations and to improve quality of life—not to reverse airflow limitation or prevent excessive decline of lung function! We suggest that Professor Enright expand his approach to patients with chronic diseases and to regard spirometry as just one, and possibly not the most important, of the several clinical parameters we have to consider in COPD. All truth passes through three stages. First, it is ridiculed. Second, it is violently opposed. Third, it is accepted as being self-evident. Arthur Schopenhauer, 1788–1860
University of Modena and Reggio Emilia
University of Ferrara FOOTNOTES
Conflict of Interest Statement: L.M.F. reports having served as a consultant to Altana Pharma, AstraZeneca, Boehringer Ingelheim, Chiesi Farmaceutici, GlaxoSmithKline (GSK), Merck, Sharp & Dohme, Novartis, Roche, and Pfizer; he reports having been paid lecture fees by Altana Pharma, AstraZeneca, Boehinger Ingelheim, Chiesi Farmaceutici, GSK, Merck, Sharp & Dohme, Novartis, Roche, and Pfizer, and having received grant support from Altana Pharma, AstraZeneca, Boehringer Ingelheim, Menarini, Miat, Schering Plough, Chiesi Farmaceutici, GSK, Merck, Sharp & Dohme, UCB Pharma, and Pfizer. P.B. has no financial relationship with a commercial entity that has an interest in the subject of this manuscript. C.M. serves as a consultant to Pfizer, and received $3,000 in 2007 and REFERENCES
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2,500 for speaking at a conference sponsored by Almirall.