Prejudgement towards the quality of spirometry in primary care does not help our case

To the Editors:

We very much appreciate the contribution by Zielinski et al. 1 on the topic of early detection of chronic obstructive pulmonary disease (COPD) by high-risk population screening in the April issue of the European Respiratory Journal. The authors mention that “insufficient quality of spirometries performed in the primary care setting was also reported recently by Schermer et al.” We were quite surprised to notice that in referring to our paper on the validity of spirometry in general practice 2, Zielinski et al. 1 fail to appreciate the observation that the 61 primary-care practices involved in our study actually achieved comparable, or even slightly higher, forced expiratory volume in one second and forced vital capacity values and produced an identical proportion of reproducible tests as the four hospital-based pulmonary function laboratories involved. In contrast to our findings, the study reported recently by Enright et al. 3 clearly demonstrates that the performance rate of technicians in a pulmonary function laboratory can indeed be very high. However, significant variation in spirometry test results between laboratories has previously been reported by Dowson et al. 4. This should be kept in mind when judging the quality of spirometry in primary-care settings.

In addition, we have previously shown that trained primary-care physicians are able to recognise obstructive flow patterns correctly in >90% of cases 5. Sufficient quality of basic spirometry tests and recognition of subjects with undiagnosed COPD can thus be performed in the primary-care setting, provided that personnel is adequately trained and regular feedback on performance is available. When touching upon the important issue of raising COPD awareness, one ought to consider mobilising the vast potential of primary healthcare professionals, who deliver essential care to the majority of patients with chronic respiratory disease worldwide.

The suboptimal accuracy of primary-care spirometry may come at the cost of an inevitable but small number of false-positive cases. Still, when one pursues to reach the large pool of as yet undiagnosed subjects with chronic obstructive pulmonary disease in the population, the involvement of primary care professionals is indispensable.