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Long-Term Outcomes in Mild/Moderate Chronic Obstructive Pulmonary Disease in the European Community Respiratory Health Survey

¹ Unit of Epidemiology and Medical Statistics, Department of Medicine and Public Health, University of Verona, Verona, Italy; ² Centre for Research in Environmental Epidemiology (CREAL); ³ Municipal Institute of Medical Research (IMIM); ⁴ CIBER in Epidemiology and Public Health (CIBERESP); ⁵ Department of Experimental and Health Sciences, Universitat Pompeu Fabra, Barcelona, Spain; ⁶ Department of Respiratory Medicine and Sleep, Landspitali University Hospital and Faculty of Medicine, University of Iceland, Reykjavik, Iceland; ⁷ Institute of Epidemiology, Helmholtz Zentrum München, German Research Center for Environmental Health, Neuherberg, Germany; ⁸ Department of Medical Sciences, Respiratory Medicine and Allergology, Uppsala University, Uppsala, Sweden; ⁹ Respiratory Epidemiology and Public Health Group, National Heart and Lung Institute, Imperial College, London, United Kingdom; ¹⁰ Catalan Institution for Research and Advanced Studies (ICREA), Barcelona, Spain; ¹¹ Unit 700 Epidemiology, National Institute of Health and Medical Research (INSERM), Paris, France; ¹² Bergen Respiratory Research Group, Institute of Medicine, University of Bergen, Bergen, Norway; ¹³ Institute for Inhalation Biology, Helmholtz Zentrum München, German Research Center for Environmental Health, Neuherberg, Germany; and ¹⁴ Institute of Genetic Medicine, EURAC Research, Bolzano, Italy

Correspondence and requests for reprints should be addressed to Prof. Roberto de Marco, Ph.D., Sezione di Epidemiologia & Statistica Medica, Dipartimento di Medicina e Sanità Pubblica, Università degli Studi di Verona c/o Istituti Biologici II, Strada Le Grazie 8, 37134 Verona, Italy. E-mail: roberto.demarco{at}univr.it

Rationale: Little is known about the long-term outcomes of individuals with mild/moderate chronic obstructive pulmonary disease (COPD) according to spirometric criteria.

Objectives: To test whether nonsmokers and asymptomatic subjects with a spirometric diagnosis of COPD have a steeper decrease in lung function and higher hospitalization rates than subjects without airway obstruction.

Methods: A total of 5,205 subjects without asthma (20–44 years of age) from the general population, with FEV₁ 50% predicted at baseline, were followed for 9 years in the frame of an international cohort study. Percent decrease in FEV₁ (FEV₁%) and the annual hospitalization rate for respiratory causes during the follow-up were assessed for each subject.

Measurements and Main Results: At baseline, 324 (6.2%) subjects had the prebronchodilator FEV₁/FVC ratio less than the lower limit of normal (LLN-COPD), and 105 (2.0%) subjects had the same ratio less than 0.70 (modified GOLD-COPD). At follow-up, smokers with LLN-COPD (n = 205) had a greater mean FEV₁% (1.7%; 95% confidence interval [CI], 0.8–2.7) and a higher hospitalization rate (rate ratio [RR], 2.52; 95% CI, 1.65–3.86) than normal subjects. Similarly, symptomatic subjects with LLN-COPD (n = 104) had FEV₁% (2.0%; 95% CI, 0.8–3.3) and the hospitalization rate (RR, 4.18; 95% CI, 2.43–7.21) higher than the reference group. By contrast, nonsmokers and asymptomatic subjects with LLN-COPD had outcomes that were similar or even better than normal subjects. Among subjects with LLN-COPD, the association of symptoms with FEV₁% varied according to smoking habits (P = 0.007); it was particularly strong in symptomatic smokers and disappeared in symptomatic nonsmokers. Similar results were found with the modified GOLD classification.

Conclusions: In relatively young populations, COPD is associated with poor long-term outcomes in smokers and in symptomatic subjects only.

Key Words: COPD • cohort studies • spirometry • hospitalization • smoking

AT A GLANCE COMMENTARY Scientific Knowledge on the Subject Little is known about the long-term outcomes of subjects diagnosed as mild/moderate chronic obstructive pulmonary disease according to spirometric criteria. What This Study Adds to the Field Young adults without asthma with the same spirometric diagnosis of mild/moderate chronic obstructive pulmonary disease show a different decrease in lung function and different hospitalization rates during the following 9 years, according to smoking habits and respiratory symptoms.