Based on the available evidence, the task force is recommending against screening for COPD in asymptomatic adults. This is a “D” recommendation, and applies only to asymptomatic adults who do not recognize or report respiratory symptoms. It does not apply to people who present with symptoms such as chronic cough, difficulty breathing, sputum production or wheezing.
The task force also noted that its evidence review did not include patient populations at very high risk for COPD, such as workers with known occupational exposures or people with alpha-1 antitrypsin deficiency, a hereditary genetic disorder that may cause lung damage and thereby increase the risk for COPD.
“COPD is a serious condition that affects the health of many adults in the United States, but research continues to show it is not beneficial to screen people without symptoms for COPD,” said Katrina Donahue, M.D., M.P.H., a professor and vice chair of research in the Department of Family Medicine at the University of North Carolina School of Medicine at Chapel Hill and a member of the task force, in a USPSTF bulletin. “The USPSTF does not recommend screening for COPD in people who do not have signs or symptoms of the disease because it does not improve their overall health.”
“This recommendation will help guide family physicians on how to address requests from patients that may have risk factors for COPD but no lower respiratory symptoms,” added Corey Lyon, D.O., chair of the subcommittee on clinical recommendations and policies with the Academy’s Commission on Health of the Public and Science.
COPD is one of the leading causes of death in the United States. Tobacco smoke is considered the main risk factor, as up to 75% of people who have COPD are current or former smokers. Exposure to lung irritants such as air pollution, chemical fumes and dust, as well as some genetic conditions, also increase the risk of COPD. While there is no cure for the condition, treatment options such as lifestyle changes, medicines including bronchodilators, oxygen therapy and pulmonary rehabilitation can help with symptoms and slow disease progress.
The final recommendation reaffirms the task force’s 2016 recommendation statement on the topic, which also recommended against screening for COPD in asymptomatic adults. The AAFP supported the 2016 statement.
To update the recommendation, the task force chose a reaffirmation deliberation process, which it uses for well-established, evidence-based standards of practice in current primary care practice for which only a very high level of evidence would justify changing the grade of the recommendation.
Under this process, the USPSTF commissioned a reaffirmation evidence update to identify whether there was any new and substantial evidence of sufficient strength and quality to justify changing the prior recommendation. The reaffirmation update focused on targeted key questions for benefits and harms of screening for COPD in asymptomatic adults and treatment in screen-detected or screen-relevant adults. In addition, nonpharmacologic interventions were evaluated in the update.
For the update, investigators searched the Medline and Cinahl databases and the Cochrane Central Register of Controlled Trials for literature published between Jan. 1, 2015, and Jan. 22, 2021. Because the previous review did not include nonpharmacologic interventions, the investigators supplemented their search by examining reference lists of relevant recent reviews to identify studies published before 2015.
Altogether, a total of 24 studies cited in 48 articles were included in the update.
The task force found no new studies that directly assessed the effectiveness of screening for COPD in asymptomatic adults on morbidity, mortality or health-related quality of life.
While the task force found no trials of pharmacologic treatment of COPD in screen-detected patients, they did identify 16 trials and subgroup analyses that evaluated the treatment of mild-to-moderate or minimally symptomatic COPD in screen-relevant patients.
Three of these trials evaluated the use of bronchodilators and/or inhaled corticosteroids. Results from these trials and their subgroup analyses indicated that bronchodilators such as long-acting beta agonists or long-acting muscarinic antagonists (with or without inhaled corticosteroids) could reduce COPD exacerbations compared with placebo. In addition, results suggested that long-acting muscarinic antagonists could improve health-related quality of life in adults with fairly symptomatic moderate COPD and reduce exacerbations in minimally symptomatic moderate COPD at 48 months followup.
The remaining 13 trials evaluated a variety of nonpharmacologic interventions used in the management of mild-to-moderate COPD or COPD in people who are minimally symptomatic, including education and training on COPD care, supervised exercise, pulmonary rehabilitation and lifestyle modifications. Overall, no consistent benefit was seen across a range of outcomes (including COPD exacerbations, difficulty breathing, exercise or physical performance measures, mental health, quality of life and smoking cessation) at 26 to 104 weeks.
The task force also reviewed data on treatment-associated harms from six treatment trials and two observational studies. While serious harms from treatment trials were not consistently reported, results from the observational studies in screen-relevant populations suggested a possible increased risk of serious cardiovascular event following the initiation of long-acting beta agonists or long-acting muscarinic antagonists, and a possible increased risk of diabetes associated with long-term use of inhaled corticosteroids.
In the USPSTF bulletin, the task force advised patients to share any concerns they have about their breathing with a health care professional. The task force also stated that clinicians should also be alert to patients with respiratory symptoms and use their clinical judgment to provide appropriate care.
“While screening for COPD in people without symptoms is not recommended, health care professionals can still help prevent their patients from getting COPD,” said Carol Mangione, M.D., M.S.P.H., chair of the task force. “Most cases of COPD are caused by smoking, so it’s essential health care professionals support their patients, including young people, in not starting to smoke and helping those who do smoke quit.”
The USPSTF also noted a number of research gaps and called for additional studies to determine the effectiveness of screening asymptomatic adults for COPD to reduce morbidity or mortality or improve health-related quality of life; the effectiveness of early treatments in slowing disease progression and improving health outcomes; the harms of screening in and treatment of people with asymptomatic or minimally symptomatic COPD; and factors that contribute to health disparities in COPD among different racial and ethnic groups, along with effective prevention strategies to improve health inequities.
To accompany the final recommendation statement, the task force provided links to two toolkits:
and three new resources for clinicians and patients:
The AAFP also has a collection of recommendations and guidelines on COPD tailored for family physicians on the COPD: Clinical Guidance and Practice Resources webpage.
A draft version of the recommendation statement was posted on the USPSTF website from Nov. 2, 2021, to Dec. 6, 2021. Following publication, the task force updated background information with the most current COPD-related mortality data and disease diagnostic criteria in the Importance and Practice Consideration sections, and clarified in the Practice Considerations section that the recommendation does not apply to workers with known occupational exposures.
In response to questions about whether smoking history should be a consideration for screening, the task force stated that although smoking is the primary risk factor for COPD, the evidence reviewed (which included current and former smokers) did not show an overall benefit for screening for COPD in asymptomatic adults.
Several comments also questioned whether screening for COPD could increase smoking cessation. In response, the task force stated that studies have not consistently shown that receipt of spirometry results or information about “lung age” increases smoking cessation.
Finally, the task force received numerous comments asking for clarification on the benefits and harms of COPD treatment. The USPSTF described the benefits and harms of pharmacologic and nonpharmacologic COPD treatments in the Supporting Evidence section. It also acknowledged the existence of a larger body of evidence not included in the evidence review that discusses harms of medications used to treat COPD and cited a number of meta-analyses for further reference.
Lyon, who is also an associate professor in the Department of Family Medicine at the University of Colorado School of Medicine in Denver, explained that if patients ask about COPD, family physicians can use the task force’s recommendation as a springboard to talk with their patients about different ways of preventing the condition or reducing symptoms.
“If patients bring up the risk of COPD, and if screening is indicated during their visit, this is a prime opportunity to discuss behavior modifications to prevent developing COPD, which mainly includes tobacco use cessation,” said Lyon.
Asked about the nonpharmacologic interventions cited in the review, Lyon again pointed to lifestyle changes and stopping tobacco use as ways to not just lower COPD risk, but to improve patient health in general.
“Discussing lifestyle modification and tobacco use cessation will support patients in achieving greater health overall, not just decreasing the risk of being diagnosed with COPD or reducing COPD complications,” Lyon said. “The evidence is lacking on if nonpharmacologic interventions help in the management of mild-to-moderate symptomatic COPD, which is another example of working with patients to minimize their risk of developing COPD, and healthy lifestyle changes and avoiding starting, or stopping, smoking may assist in decreasing that risk.”
The AAFP’s Commission on Health of the Public and Science will review the task force’s final recommendation statement, final evidence summary and evidence review, and will then determine the Academy’s stance on the recommendation.