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Sharon E. Straus, MD; Finlay A. McAlister, MD; David L. Sackett, MD; Jonathan J. Deeks, MSc; for the CARE-COAD1 Group

JAMA. 2000;283:1853-1857.

Context  The accuracy of the clinical examination in detecting obstructive airway disease (OAD) is largely unknown because of a paucity of methodologically rigorous studies.

Objective  To determine the accuracy of patient history, wheezing, laryngeal height, and laryngeal descent in the diagnosis of OAD.

Design  Comparison study conducted from November 3, 1998, to December 4, 1998, evaluating 4 clinical examination elements for diagnosis of OAD vs the gold standard of forced expiratory volume in 1 second (FEV₁) and FEV₁–forced vital capacity (FVC) ratio less than the fifth percentile (adjusted for patient height, age, and sex).

Setting  Twenty-five sites, including primary care and referral practices, in 14 countries.

Participants  A total of 309 consecutive patients were recruited (mean age, 56 years; 43% female), 76 (25%) with known chronic OAD, 114 (37%) with suspected chronic OAD, and 119 (39%) with neither known nor suspected OAD.

Main Outcome Measures  Sensitivity, specificity, and likelihood ratios (LRs) for each of the 4 elements of the clinical examination compared with the gold standard.

Results  Mean FEV₁ and FVC values were 2.1 L/s and 2.9 L; 52% had an FEV₁ and FEV₁-FVC ratio less than the fifth percentile. The LR for wheezing was 2.7 (95% confidence interval [CI], 1.7-4.2) and was not statistically significant in the multivariate model. The LR for laryngeal descent ranged from 0.9 (95% CI, 0.5-1.4) to 1.2 (95% CI, 0.4-3.4), depending on the cut point chosen, and did not enter the multivariate model. Only 4 of the history or physical examination elements we tested were significantly associated with the diagnosis of OAD on multivariate analysis: smoking for more than 40 pack-years (LR, 8.3), self-reported history of chronic OAD (LR, 7.3), maximum laryngeal height of at least 4 cm (LR, 2.8), and age at least 45 years (LR, 1.3). Patients having all 4 findings had an LR of 220 (ruling in OAD); those with none had an LR of 0.13 (ruling out OAD). The area under the receiver operating characteristic curve for the model incorporating these 4 factors was 0.86.

Conclusions  Further research is needed to validate our model, but in the meantime, our data suggest that less emphasis should be placed on the presence of individual symptoms or signs (such as wheezing or laryngeal descent) in the diagnosis of OAD.

Author Affiliations: The Centre for Evidence-Based Medicine, Nuffield Department of Medicine, Oxford, England (Drs Straus, McAlister, and Sackett); The Division of General Internal Medicine, Mt Sinai Hospital, University Health Network, Toronto, Ontario (Dr Straus); The Division of General Internal Medicine, University of Alberta, Edmonton (Dr McAlister); and The Imperial Cancer Research Fund/National Health Service Centre for Statistics in Medicine, Institute of Health Sciences, Oxford, England (Mr Deeks).

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