Correspondence

Pulmonary-Function Testing

N Engl J Med 1994; 331:1313-1314November 10, 1994

Article

To the Editor:

In Crapo's review of pulmonary-function testing (July 7 issue),1 I was surprised by the statement, “Some subgroups (e.g., cigarette smokers and people exposed to known agents of lung injury, such as asbestos or diisocyanates) are at higher risk of lung disease; screening and monitoring are appropriate for them.” The references cited do not appear to support screening and do not offer or refer to data that would justify spirometric screening of all smokers.2,3

The standard references for the evaluation and recommendation of screening procedures for the general population or subpopulations are the position papers on screening issued by the Canadian Task Force on the Periodic Health Examination, the U.S. Preventive Services Task Force, and the American College of Physicians. None recommend the use of spirometry for screening any population or subpopulation. In addition, a recent review of screening procedures by Sox did not mention spirometry as a possible screening procedure for smokers.4

There are at least two questions that have to be answered before spirometry can be considered a routine screening test for smokers. First, will the demonstration of an accelerated decline in lung function in the 10 to 15 percent of smokers destined to have airflow obstruction result in a higher rate of smoking cessation than that associated with the strong recommendation to quit smoking that every physician should make to every smoker? Second, will the “normal” rate of decline in lung function in the remaining 85 to 90 percent of smokers provide a measure of reassurance and detract from the physician's ability to influence smokers to quit? Since these questions have yet to be answered by appropriate studies, it is premature to recommend screening of smokers with spirometry.

Winston Warr, M.D., M.P.H.
South Austin Health District, Austin, TX 78704

4 References

1. 1

   Crapo RO. Pulmonary-function testing. N Engl J Med 1994;331:25-30
   Full Text | Web of Science | Medline

2. 2

   American Thoracic Society, Task Group on Screening for Adult Respiratory Disease. Screening for adult respiratory disease. Am Rev Respir Dis 1983;128:768-774
   Web of Science | Medline

3. 3

   Hankinson JL. Pulmonary function testing in the screening of workers: guidelines for instrumentation, performance, and interpretation. J Occup Med 1986;28:1081-1092
   CrossRef | Medline

4. 4

   Sox HC Jr. Preventive health services in adults. N Engl J Med 1994;330:1589-1595
   Full Text | Web of Science | Medline

Author/Editor Response

Dr. Crapo replies:

To the Editor: I appreciate Dr. Warr's comments and basically agree with them. It was not my intent to imply that all smokers should be screened with spirometry. If, however, Dr. Warr's references to the position papers on screening by the Canadian Task Force and the American College of Physicians are taken to mean that there are no indications for using spirometry to screen any group of smokers, I disagree. My position on screening coincides with that of the American Thoracic Society,1 which states, in part, “Apparently healthy, high risk patients should be considered for spirometric testing as part of their regular examination.” As examples, they include heavy smokers and people with occupational exposure to the inhalation of hazardous substances.

Robert O. Crapo, M.D.
LDS Hospital, Salt Lake City, UT 84143

1 References

1. 1

   American Thoracic Society, Task Group on Screening for Adult Respiratory Disease. Screening for adult respiratory disease. Am Rev Respir Dis 1983;128:768-774
   Web of Science | Medline