CHICAGO-- The National Lung Health Education Program (NLHEP), working in conjunction with government agencies and medical and health professional associations, is putting some new steam in its theme, "Test your lungs; know your numbers." Those admonitions emphasize the need for early testing to detect chronic obstructive pulmonary disease (COPD) before clinical symptoms emerge. The program's other call to action, "Put 'm out; keep 'm out," is aimed at boosting patient, provider, and public awareness of the only known intervention that can stop, reverse, or slow the progression of COPD: smoking cessation.

In a panel discussion at CHEST 1999, the annual meeting of the American College of Chest Physicians held recently in Chicago, a distinguished panel of experts--chaired by Thomas Petty, MD, chairman of the NLHEP and professor of medicine at the University of Colorado in Denver and Rush Medical College of Chicago--detailed the program's goals of preventing lung disease and promoting lung health.

COPD develops over a period of about 30 years. Unfortunately, neither physical examination nor chest films can detect the early stages of the disease. However, spirometry can identify signs of the onset of lung abnormalities. Because pulmonologists rarely see COPD patients before marked symptoms appear, it is up to primary care physicians and other health care providers to initiate widespread use of spirometry.

Statistics attest to the need to target COPD in the primary care venue. COPD is the fourth leading cause of death in the United States and the only one of the top 10 leading causes with rapidly rising mortality and prevalence rates, Dr. Petty noted. Furthermore, COPD is associated with an increased risk of lung cancer, heart attack, and stroke. Yet about half of patients with COPD do not know they have it. Approximately 90% of all COPD cases result from smoking. Tobacco dependence and its associated morbidities account for roughly 10% of the nation's health care costs.

A SPIROMETER IN EVERY OFFICE

"Seventy percent of smokers see a physician once a year," Dr. Petty said, "and 70% of that 70% claim they want to stop--if they could, if anybody would help them." Talking to these patients about lung health and smoking cessation can be a crucial part of that help. But equally important is routine, ongoing spirometric evaluation for every patient older than age 45 who is a smoker or former smoker. Panelist Dennis Doherty, MD, director of pulmonary and critical care medicine at the University of Kentucky in Lexington and a member of the NLHEP's executive committee, referred to spirometric results as "a vital sign." The NLHEP also recommends spirometry testing for any patient with persistent cough, mucus, wheezing, or shortness of breath, as well as for anyone exposed to environmental smoke or workplace irritants.

Getting that message to primary care physicians, however, has been a challenge. The NLHEP lacks the government funding that fueled earlier efforts to include cholesterol and blood pressure testing in routine screenings, Dr. Petty reported. However, community initiatives and soon-to-be-published clinical articles should help bring "Test your lungs; know your numbers" into the forefront, he said.

The new generation of office spirometers gives a big boost to the initiative. "In the last decade or so, spirometry has become less costly and more accurate, safer, and easier to use," explained panelist Paul Enright, MD, an associate professor of medicine at the University of Arizona in Tucson. Dr. Enright, who is also a member of the NLHEP executive committee, noted that office spirometers cost less than $800, and the test takes less than 10 minutes to administer.

FEAR OF FALSE READINGS

Some physicians resist using spirometry--in part because they fear the problems associated with false readings. But Dr. Petty points out that falsely normal results are impossible and falsely low results are highly unlikely because results must be repeatable within 3%. Furthermore, the goal is to obtain multiple readings over time, not one measurement. As Dr. Petty noted, the idea is to detect patients with declining lung function by tracking forced expiratory volume in 1 second and forced vital capacity over months or years. By repeating these tests over several office visits, physicians can plot results over time and thereby determine if a patient is a "rapid decliner," Dr. Doherty explained.

Another worry that primary care physicians often mention is that diagnosing COPD in a patient who has yet to manifest symptoms could hurt more than help; a smoker with a single normal result might presume that he or she had been given a clean bill of health and decline repeat tests. Patient education is the key to avoiding this problem, Dr. Enright noted; physicians must make sure that patients understand the meaning of positive and negative test results. Each of the panelists also stressed that early detection is vital; detection of airflow obstruction is often a strong motivator for patients to quit smoking.

Further motivation may come from other findings. Dr. Enright noted that "susceptible smokers typically lose half a liter of forced expiratory volume per decade. If they stop smoking, they restore about 0.2 L. The rate of decline then becomes that associated with normal aging (ie, 0.3 L per decade)."

STOP! IN THE NAME OF LUNGS

Panelist Michael Fiore, MD, MPH, a professor of medicine at the University of Wisconsin in Madison, detailed a practical approach to smoking cessation. His advice: Shift the emphasis from success rates for various anti-smoking aids to a broader focus on the chronic disease of tobacco dependence.

About 25% of US adults currently smoke. In 1965, the smoking rate was about 44%. Although the smoking rate declined steadily from 1965 until 1990, it has held steady since then. Most smokers say that they want to quit, but they are equivocal, Dr. Fiore said. "They know it's harming them, and they recognize that smoking is a powerful risk factor, but they also know they're addicted to a powerful drug."

Noting that about eight in 10 smokers have tried to quit and failed, he advised primary care physicians and pulmonologists to stress the importance of repeated attempts. Yes, the patient may fail (again), Dr. Fiore noted; and yes, success is difficult--hence the chronicity of the tobacco-dependence disease. But the benefits of finally succeeding are so enormous that it is vital that patients keep trying. Thus, it is important that physicians "remind patients that new smoking cessation aids can make a difference," he said.

Simply telling patients to attend an American Lung Association program or a community smoking cessation class "is not an appropriate standard of care," Dr. Fiore declared. He then outlined the components of a more adequate response, which are summarized in the box above.

The ideal, Dr. Doherty concluded, is for the general public to want to know how their lungs function and to ask their doctors for spirometric tests so that they can "know their numbers." He urged clinicians to ask detailed questions about such symptoms as cough or dyspnea on exertion--symptoms that patients often fail to report either because they have unconsciously adjusted their activity level to compensate or assumed that the symptoms are "normal" side effects of smoking. "And remember that early treatment, which includes smoking cessation, for those with abnormal [test] results can decrease symptoms, exacerbations, and hospitalizations and may actually decelerate rapidly declining lung function," he emphasized. Ending the panel presentation on an optimistic note, Dr. Doherty said, "Many people see COPD as an irreversible disease, but I think we can reverse at least some of its components."

--Helen Lippman