Fulfilling the promise of primary care spirometry.

I t is a truth universally acknowledged that the simplest and most reliable way of assessing the function of the lungs is to make a spirometric measurement. Well, perhaps not universally acknowledged, but there is an increasing acceptance that the diagnosis of many lung diseases should involve a measurement of the functional capacity of the respiratory system and although this does not always tell us the whole truth [1, 2], it represents a substantial improvement on diagnostic criteria based solely on history examination and plain chest radiography. This is particularly true for diseases associated with airflow obstruction, such as chronic obstructive pulmonary disease (COPD), and those involving restriction of the lungs or chest wall, such as idiopathic pulmonary fibrosis or kyphoscoliosis. For doctors in primary care, the former is much more likely to be seen than the latter, and COPD along with bronchial asthma constitute the most frequent chronic respiratory diseases in this setting. While the importance of making an accurate diagnosis is not in doubt for patients with diabetes or chronic renal failure, we have been slow to adopt a similarly rigorous approach to respiratory conditions, especially COPD. Thanks to the efforts of many organisations, especially the European Respiratory Society (ERS) and the American Thoracic Society (ATS) [3], and also the Global Initiative for Chronic Obstructive Lung Disease (GOLD) programme [4], there is now a much wider appreciation of the need for objective diagnosis in common conditions such as COPD. As recent data from the Burden of Obstructive Lung Disease initiative has shown [5], this is a frequent and underappreciated problem, not only in developed European countries but particularly in many developing countries. One of our major tasks for the next decade will be to produce clear and consistent guidance as to how the relatively simple manoeuvres of spirometry can be applied as part of routine general care rather than just in specialist institutions with sophisticated pulmonary function laboratories.