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The recent paper in Thorax by Bhatt et al1 asserted that using the lower limit of normal (LLN) for FEV1/FVC to define airflow obstruction in the diagnosis of COPD fails to identify a number of patients with significant pulmonary pathology that are identified by using a fixed ratio for FEV1/FVC. However, they have not adequately proven that significant pulmonary pathology was being detected by using the fixed ratio. The authors first suggest that the LLN standard for defining airflow limitation from FEV1/FVC has not been clinically validated for lack of a gold standard. They then use CT-detected emphysema as a gold standard reference to judge …
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