Correspondence (reply): In Reply

Hausen’s comments have strengthened our intention to use lung function testing in primary care more often for the early diagnosis of chronic obstructive pulmonary disease (COPD). His comment, that symptoms are often not articulated spontaneously and active prompting is required, is of particular importance. Frequent acute respiratory infections are among the clinical symptoms of COPD and should (especially in smokers) provide grounds for a spirometric examination. In smokers aged 40–75 and in former smokers without previously known bronchial or pulmonary disorders, spirometry at 4–5 weeks after an acute infection shows measurements that indicate COPD in about a quarter of cases. More than half of such patients have at least moderately severe airway obstruction (1). According to what is currently known on the subject, however, screening examinations in asymptomatic smokers do not provide valid prognostic information or evaluated preventive treatment options. In our opinion, overdiagnosis is not in the patients’ interests. Enough arguments exist in support of the health benefits of abstaining from nicotine. Furthermore, we do not support routine bronchospasmolytic testing in patients with normal results on spirometry. An increase in FEV₁ after inhalation of a bronchodilator is physiologic (the mean is 139 mL in healthy non-smokers), since the basal tone of the smooth bronchial muscles is lowered (2). Indications of sex-associated differences in symptoms and in the course of COPD require further research. Currently, the differences have been confirmed to a rather unsatisfactory degree, and a sex-specific diagnostic approach cannot be deduced (3). We do not follow the comment about a lack of a billing option and refer our correspondents to No 03330 in the uniform assessment standard and 605/605a of the medical fee schedule.

Spallek rightly points out the opportunities inherent in the low-threshold access of occupational medicine to smokers. We wish to add the following: this is also relevant for the hospital setting because the prevalence of smokers is particularly high. Our occupational physician at the Neukölln Hospital participates in this preventive mission in an exemplary fashion, not only by providing individual advice to colleagues who smoke, but also through her collaboration in our working group on the topic of “smoke free hospital”.

Sybrecht reminds us of the importance of pulmonary overinflation for the understanding of dyspnea in COPD. Spirometry is subject to the disadvantage of capturing only mobilizable lung volumes. Low spirometric volumes in COPD are often misinterpreted as restrictive ventilation disorders in clinical practice. It is the intention of our Figure 4 to clarify this fact and to visualize the larger residual volume as the “iceberg beneath the waterline.” The total capacity of the column marked as “severe emphysema” is therefore also marked notably larger.