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Draft Recommendation Statement

Chronic Obstructive Pulmonary Disease: Screening

November 02, 2021

Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.

This topic is being updated. Please use the link(s) below to see the latest documents available.

Recommendation Summary

Population Recommendation Grade
Asymptomatic adults The USPSTF recommends against screening for chronic obstructive pulmonary disease in asymptomatic adults. D

Additional Information

Tools
Related Resources
  • Screening for Chronic Obstructive Pulmonary Disease (Consumer Guide): Draft Recommendation | Link to File

Full Recommendation:

Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.

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Chronic obstructive pulmonary disease (COPD) is an irreversible reduction of airflow in the lungs. Progression to severe disease can prevent participation in normal activities because of deterioration of lung function.1 In 2019, approximately 6% of U.S. adults reported being diagnosed with COPD.2 Chronic lower respiratory disease, composed mainly of COPD, is the fourth leading cause of death in the United States.3 COPD-related deaths are higher in men than in women but trending downwards.4 Prevalence of COPD is highest among Native American/Alaska Native populations, likely because of disproportionate socioeconomic challenges and health risk behaviors such as smoking.5,6 Mortality rates are highest in White adults, followed by Native American/Alaska Native adults.7 Black adults have more hospitalizations and worse COPD-related quality of life compared with White adults, despite having lower prevalence of COPD than White adults.8

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Reaffirmation

In 2016, the U.S. Preventive Services Task Force (USPSTF) reviewed the evidence for screening for COPD and issued a D recommendation.9 The USPSTF decided to use a reaffirmation deliberation process to update this recommendation. The USPSTF uses the reaffirmation process for well-established, evidence-based standards of practice in current primary care practice for which only a very high level of evidence would justify a change in the grade of the recommendation.10 In its deliberation of the evidence, the USPSTF considers whether the new evidence is of sufficient strength and quality to change its previous conclusions about the evidence.

Using a reaffirmation process, the USPSTF concludes with moderate certainty that screening for COPD in asymptomatic adults has no net benefit.

See the Table for more information on the USPSTF recommendation rationale and assessment.

For more details on the methods the USPSTF uses to determine the net benefit, see the USPSTF Procedure Manual.10

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Patient Population Under Consideration

This recommendation applies to asymptomatic adults who do not recognize or report respiratory symptoms. It does not apply to persons who present to clinicians with symptoms such as chronic cough, sputum production, difficulty breathing, or wheezing. The evidence review did not include persons with α1-antitrypsin deficiency, an inherited disorder that increases risk for COPD.

Definitions

A diagnosis of COPD is confirmed by demonstration of persistent airway obstruction with a postbronchodilator spirometry forced expiratory volume in one second/forced vital capacity (FEV1/FVC) ratio of less than 0.70.11,12 Severity of disease can be classified by the degree of obstruction, symptoms, or both. Airflow obstruction is classified by the postbronchodilator FEV1% predicted; 80% or more is mild, 50% to 79% is moderate, 30% to 49% is severe, and less than 30% is very severe. Symptoms are categorized using scoring from standardized tools assessing symptom burden (e.g. shortness of breath, cough, and phlegm production) and history of exacerbations.11,12

Assessment of Risk

Although the USPSTF does not recommend screening for COPD in asymptomatic adults, there are factors that may increase a person’s risk for COPD. Cigarette smoking is the leading cause of COPD in the United States.1 About 15% of current smokers and 8% of former smokers report being diagnosed with COPD compared with 3% of adults who have never smoked.6 Exposure to other lung irritants such as secondhand smoke, traffic pollutants, and wood smoke also contribute to COPD. Toxic fumes, dust, and chemicals from workplace exposures are estimated to contribute to 15% of COPD cases. Nonmodifiable risk factors for COPD include history of asthma or childhood respiratory tract infections and α1-antitrypsin deficiency.11

Screening Tests

Although the USPSTF does not recommend routine screening for COPD in the general population using any method, screening questionnaires and spirometry without a bronchodilator have sometimes been used to identify persons at increased risk for COPD. If positive, such screening tests would require followup diagnostic testing.

Treatment or Interventions

Currently, there is no cure for COPD. Prevention of exposure to cigarette smoke and other toxic fumes is the best way to prevent COPD. Interventions to prevent the initiation of tobacco use are an effective way to prevent exposure to cigarette smoke. Current smokers (regardless of whether COPD is diagnosed or not) should receive smoking cessation counseling and be offered behavioral and pharmacological therapies to stop smoking.12

Pharmacologic (e.g., bronchodilators and anti-inflammatory therapies) and nonpharmacologic therapies (e.g., interventions addressing self-management of disease, diet, exercise, and immunizations) are available for disease management in persons with mild to moderate or minimally symptomatic COPD. Decisions to start or advance treatment are primarily based on symptoms and exacerbations, rather than measured obstruction.12

Additional Tools and Resources

The Centers for Disease Control and Prevention, the National Institutes of Health, and other federal agencies provide a comprehensive systems-based COPD National Action Plan to reduce the burden of COPD at https://www.nhlbi.nih.gov/health-topics/all-publications-and-resources/copd-national-action-plan.

The National Institutes of Health’s “Learn More Breathe Better” program provides information about the prevention, diagnosis, and treatment of COPD at https://www.nhlbi.nih.gov/health-topics/education-and-awareness/copd-learn-more-breathe-better.

The U.S. Surgeon General provides tools to prevent tobacco use and promote smoking cessation at https://www.hhs.gov/surgeongeneral/reports-and-publications/tobacco/index.html.

Other Related USPSTF Recommendations

The USPSTF recommends that clinicians ask all adults, including pregnant persons, about tobacco use, advise them to stop using tobacco, and provide interventions for cessation for those who use tobacco.13 The USPSTF also recommends that clinicians provide interventions, including education or brief counseling, to prevent initiation of tobacco use among school-aged children and adolescents.14

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Scope of Review

To reaffirm its recommendation, the USPSTF commissioned a reaffirmation evidence update. The aim of evidence updates that support the reaffirmation process is to identify if there is new and substantial evidence since the previous review that is sufficient enough to change the prior recommendation.10 The reaffirmation update focuses on targeted key questions for benefits and harms of screening for COPD in asymptomatic adults and treatment in screen-detected or screen-relevant adults. A new treatment modality evaluated in this review was nonpharmacologic interventions.

Accuracy of Screening Tests and Risk Assessment

Based on foundational evidence, externally validated questionnaires that assess risk factors, symptoms, or both and are applicable to U.S. primary care settings had high sensitivity but poorer specificity for detecting COPD (sensitivity ranged from 67% to 90%; specificity ranged from 25% to 73%). Evidence evaluating the accuracy of pulmonary function tests alone to detect COPD was limited.15

Benefits of Early Detection and Treatment

The USPSTF found no new studies that directly assess the effects of screening for COPD in asymptomatic adults on morbidity, mortality, or health-related quality of life.11

The USPSTF reviewed three trials with newly published analyses (n=20,058) that evaluated pharmacologic treatment in persons with mild to moderate COPD (based on airway obstruction) and varying levels of symptoms.11 No treatment trials were conducted in asymptomatic populations. Studies included treating persons with COPD with long-acting beta-agonists (LABAs), long-acting muscarinic antagonists (LAMAs), inhaled corticosteroids (ICS), or combination therapy. One large randomized, controlled trial (SUMMIT; n=16,590) in persons with or at risk for cardiovascular disease demonstrated in adults with fairly symptomatic moderate COPD (e.g., mean FEV1 ~60% predicted) that LABAs, ICS, or LABAs/ICS reduced the annual rate of exacerbations and hospitalizations for exacerbations compared with placebo at a median of 1.8 years followup, although exacerbation rates were low at baseline (<1 exacerbation/year). The percent reduction in the annual rate of moderate to severe exacerbations was higher for LABAs/ICS (29% [95% CI, 22% to 35%]) than for LABAs (10% [95% CI, 2% to 18%) or ICS (12% [95% CI, 4% to 19%) alone.11

Post-hoc subgroup analysis of minimally symptomatic patients with moderate COPD (n=357) in the UPLIFT trial suggests that LAMAs reduced the proportion of persons with exacerbations compared with placebo at 48 months (48% vs. 54%, respectively; rate ratio, 0.64 [95% CI, 0.47 to 0.89]). A post-hoc subgroup analysis in the PINNACLE trial (n=729) comparing LAMAs, LABAs, and LAMAs/LABAs vs. placebo in minimally symptomatic adults was underpowered in sample size and followup time. No studies showed that treatment reduced cardiovascular morbidity or mortality or all-cause mortality.11 Overall, consistent with the previous review, the evidence showed that pharmacotherapy may reduce exacerbations in adults with fairly symptomatic moderate COPD, which may not be generalizable to an asymptomatic population. Also, the magnitude of these treatment benefits is limited by portions of the data coming from small post-hoc subgroup analysis and persons having low rates of exacerbations at baseline.

The USPSTF reviewed 13 new trials (n=3,658) evaluating nonpharmacologic interventions used in the management of mild to moderate COPD or minimally symptomatic persons; seven trials of self-management interventions (e.g., education on COPD, medications, healthy lifestyle, tobacco cessation, and an exacerbation management/action plan), one trial of exercise-only counseling, three trials of intensive supervised exercise or pulmonary rehabilitation, and two trials of clinician education/training on COPD care. Overall, there was no consistent benefit observed across a range of outcomes (e.g., exacerbations, quality of life, difficulty breathing, exercise or physical performance measures, mental health, and smoking cessation) at 26 to 104 weeks.11

Harms of Screening and Treatment

The USPSTF reviewed new data from six of the included treatment trials and two observational studies (n=243,517) that reported on pharmacologic or nonpharmacologic treatment harms in adults with mild to moderate or minimally symptomatic COPD. None of the included treatment trials that reported adverse effects (n=17,676) found significant harms; however, studies were limited by the small number of included participants and limited length of followup. In addition, two observational studies addressed the harms of medications. One study of cardiovascular risk associated with treatment with LABAs or LAMAs found an increased risk of a serious cardiovascular event following the initiation of LABAs or LAMAs (n=183,858; adjusted odds ratio, 1.50 [95% CI, 1.35 to 1.67] and 1.52 [95% CI, 1.28 to 1.80], respectively); cardiovascular risk association with LABAs or LAMAs was absent, or even reduced, with prevalent use of inhaled therapy. A second study found that ICS may increase the risk of developing diabetes (n=9,923 for diabetes onset in a subset of persons classified in GOLD [Global Initiative for Chronic Obstructive Lung Disease] category A/B; hazards ratio, 1.32 [95% CI, 1.06 to 1.64]). These two observational studies represent a subset of a much larger body of evidence on serious harms of bronchodilators and ICS in the treatment of COPD such as heart failure and pneumonia, as described in meta-analyses not included in this review.11 In addition to potential treatment harms, there are opportunity costs to screening that may include time spent on counseling and providing services and patient referrals for diagnostic testing.

Overall, generally consistent with the previous review, serious harms from treatment trials were not consistently reported. However, large observational studies in screen-relevant populations suggest possible harms for LAMA or LABA initiation or use of ICS.

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Studies are needed that provide more information on the following.

  • The effectiveness of screening asymptomatic adults for COPD to reduce morbidity or mortality or improve health-related quality of life, with long-term followup.
  • The effectiveness of early treatment for asymptomatic, minimally symptomatic, or screen-detected populations to slow disease progression and improve health outcomes, with long-term followup.
  • The harms of screening in and treatment of persons with asymptomatic or minimally symptomatic COPD.
  • The drivers of health disparities in COPD among different racial and ethnic groups and effective prevention strategies that may improve health inequities.
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In 2011, the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society issued joint guidelines recommending that spirometry be used to diagnose airflow obstruction in patients with respiratory symptoms. The joint panel recommended against screening for COPD with spirometry in asymptomatic patients.16

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1. Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Population Health. Basics About COPD. Reviewed 2021. Accessed October 5, 2021. https://www.cdc.gov/copd/basics-about.html
2. Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Population Health. Chronic Disease Indicators. Reviewed 2021. Accessed October 5, 2021. https://nccd.cdc.gov/cdi
3. Centers for Disease Control and Prevention, National Center for Health Statistics. Deaths and Mortality. Reviewed 2021. Accessed October 5, 2021. https://www.cdc.gov/nchs/fastats/deaths.htm
4. Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Population Health. Chronic Obstructive Pulmonary Disease (COPD) Data and Statistics. Reviewed 2021. Accessed October 5, 2021. https://www.cdc.gov/copd/data.html
5. Laffey KG, Nelson AD, Laffey MJ, Nguyen Q, Sheets LR, Schrum AG. Chronic respiratory disease disparity between American Indian/Alaska Native and white populations, 2011–2018. BMC Public Health. 2021;21(1):1466.
6. Wheaton AG, Liu Y, Croft JB, et al. Chronic obstructive pulmonary disease and smoking status–United States, 2017. MMWR Morb Mortal Wkly Rep. 2019;68(24):533-538.
7. National Center for Health Statistics. Health, United States, 2019. Hyattsville, MD: Centers for Disease Control and Prevention; 2021.
8. Kuhn BT, Wick KD, Schivo M. An update in health disparities in COPD in the USA. Curr Pulmonol Rep. 2021;10:14-21.
9. US Preventive Services Task Force (USPSTF); Siu AL, Bibbins-Domingo K, et al. Screening for chronic obstructive pulmonary disease: US Preventive Services Task Force recommendation statement. JAMA. 2016;315(13):1372-1377.
10. U.S. Preventive Services Task Force. Procedure Manual. Updated 2017. Accessed October 5, 2021. www.uspreventiveservicestaskforce.org/uspstf/procedure-manual.
11. Lin, JS, Webber EM, Thomas RG. Screening for Chronic Obstructive Pulmonary Disease: A Targeted Evidence Update for the U.S. Preventive Services Task Force. Evidence Synthesis No. 215. Rockville, MD: Agency for Healthcare Research and Quality; 2021. AHRQ Publication No. 21-05287-EF-1.
12. Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease. Published 2020. Accessed October 5, 2020. https://goldcopd.org/wp-content/uploads/2019/12/GOLD-2020-FINAL-ver1.2-03Dec19_WMV.pdf
13. US Preventive Services Task Force; Krist AH, Davidson KW, et al. Interventions for tobacco smoking cessation in adults, including pregnant persons: US Preventive Services Task Force recommendation statement. JAMA. 2021;325(3):265-279.
14. US Preventive Services Task Force; Owens DK, Davidson KW, et al. Primary care interventions for prevention and cessation of tobacco use in children and adolescents: US Preventive Services Task Force recommendation statement. JAMA. 2020;323(16):1590-1598.
15. Guirguis-Blake JM, Senger CA, Webber EM, Mularski RA, Whitlock EP. Screening for chronic obstructive pulmonary disease: evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2016;315(13):1378-1393.
16. Qaseem A, Wilt TJ, Weinberger SE, et al. Diagnosis and management of stable chronic obstructive pulmonary disease: a clinical practice guideline update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society. Ann Intern Med. 2011;155(3):179-91.

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Rationale Assessment
Detection Externally validated questionnaires have good sensitivity but fair specificity for detecting COPD in primary care populations. There is more limited evidence on the accuracy of pulmonary function tests that are applicable to U.S. primary care populations.
Benefits of Early Detection and Intervention and Treatment
  • The USPSTF found inadequate direct evidence that screening for COPD in asymptomatic adults reduces morbidity or mortality or improves health-related quality of life.
  • The USPSTF found inadequate evidence that treatment of asymptomatic COPD reduces morbidity or mortality or improves health-related quality of life.
  • Limitations of the evidence on pharmacologic and nonpharmacologic interventions suggest that treatment benefits in adults with symptomatic moderate COPD is marginal. Therefore, the USPSTF bounds the benefits in asymptomatic adults as no greater than small.
Harms of Early Detection and Intervention and Treatment
  • The USPSTF found inadequate direct evidence of the harms of screening for and treatment of asymptomatic COPD.
  • Given the opportunity costs associated with screening asymptomatic persons may be large, the USPSTF bounds the magnitude of harms of screening to be at least small.
USPSTF Assessment
  • Using a reaffirmation deliberation process, the USPSTF concludes with moderate certainty that screening for COPD in asymptomatic adults has no net benefit.

Abbreviations: COPD=chronic obstructive pulmonary disease; USPSTF=U.S. Preventive Services Task Force.

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