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Diagnosis of COPD
  1. Emanuela Falaschetti1,
  2. Maureen P Swanney2,
  3. Robert O Crapo3,
  4. John L Hankinson4,
  5. Robert L Jensen5,
  6. Ole F Pedersen6,
  7. Philip H Quanjer7,
  8. Gregg L Ruppel8,
  9. Jan P Schouten9
  1. 1Royal Free and University College Medical School, London, UK
  2. 2Respiratory Function Laboratory, Christchurch Hospital, New Zealand
  3. 3Pulmonary Division, LDS Hospital, Salt Lake City, USA
  4. 4Valdosta, Georgia, USA
  5. 5Pulmonary Division, LDS Hospital, Salt Lake City, USA
  6. 6Institute of Public Health, Aarhus University, Denmark
  7. 7Leiden University, Leiden, The Netherlands
  8. 8Division of Pulmonary, Critical Care and Occupational Medicine, St Louis University Hospital, USA
  9. 9Department of Epidemiology and Bioinformatics, University Medical Center Groningen, The Netherlands
  1. Correspondence to:
    Dr Philip H Quanjer
    Erasmus University, Rotterdam, The Netherlands; pquanjer{at}

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Shahab et al recently reported significant under-diagnosis of chronic obstructive pulmonary disease (COPD) in England.1 Adults over 35 years were regarded as having airway obstruction (COPD) if the forced expiratory volume in 1 s/forced vital capacity (FEV1/FVC) ratio was <0.70. This conforms with the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines2 adopted by various organisations, albeit that no data were obtained after bronchodilation. Even the GOLD group acknowledges that there is no evidence that this cut-off point signifies clinically validated airway obstruction and that “the use of this fixed ratio may result in over-diagnosis of COPD in the elderly, especially of mild disease. Using the lower limit of normal (LLN) values for FEV1/FVC that are based on the normal distribution and classify the bottom 5% of the healthy population as abnormal is one way to minimize the potential misclassification.”2 This statement does justice to science and to authors of predicted values for spirometric indices who carefully defined the LLN for various indices, none …

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