Comparing performance of primary care clinicians in the interpretation of SPIROmetry with or without Artificial Intelligence Decision support software (SPIRO-AID): a protocol for a randomised controlled trial.

INTRODUCTION: Spirometry is a point-of-care lung function test that helps support the diagnosis and monitoring of chronic lung disease. The quality and interpretation accuracy of spirometry is variable in primary care. This study aims to evaluate whether artificial intelligence (AI) decision support software improves the performance of primary care clinicians in the interpretation of spirometry, against reference standard (expert interpretation). METHODS AND ANALYSIS: A parallel, two-group, statistician-blinded, randomised controlled trial of primary care clinicians in the UK, who refer for, or interpret, spirometry. People with specialist training in respiratory medicine to consultant level were excluded. A minimum target of 228 primary care clinician participants will be randomised with a 1:1 allocation to assess fifty de-identified, real-world patient spirometry sessions through an online platform either with (intervention group) or without (control group) AI decision support software report. Outcomes will cover primary care clinicians' spirometry interpretation performance including measures of technical quality assessment, spirometry pattern recognition and diagnostic prediction, compared with reference standard. Clinicians' self-rated confidence in spirometry interpretation will also be evaluated. The primary outcome is the proportion of the 50 spirometry sessions where the participant's preferred diagnosis matches the reference diagnosis. Unpaired t-tests and analysis of covariance will be used to estimate the difference in primary outcome between intervention and control groups. ETHICS AND DISSEMINATION: This study has been reviewed and given favourable opinion by Health Research Authority Wales (reference: 22/HRA/5023). Results will be submitted for publication in peer-reviewed journals, presented at relevant national and international conferences, disseminated through social media, patient and public routes and directly shared with stakeholders. TRIAL REGISTRATION NUMBER: NCT05933694.

Prognostic role of minute ventilation/carbon dioxide production slope for perioperative morbidity and long-term survival in resectable patients with nonsmall-cell lung cancer: a prospective study using propensity score overlap weighting.

BACKGROUND: The role of minute ventilation/carbon dioxide production ( / CO 2 ) slope, a ventilation efficiency marker, in predicting short-term and long-term health outcomes for patients with nonsmall-cell lung cancer (NSCLC) undergoing lung resection has not been well investigated. MATERIAL AND METHODS: This prospective cohort study consecutively enrolled NSCLC patients who underwent a presurgical cardiopulmonary exercise test from November 2014 to December 2019. The association of / CO 2 slope with relapse-free survival (RFS), overall survival (OS), and perioperative mortality was evaluated using the Cox proportional hazards and logistic models. Covariates were adjusted using propensity score overlap weighting. The optimal cut-off point of the E/ CO 2 slope was estimated using the receiver operating characteristics curve. Internal validation was completed through bootstrap resampling. RESULTS: A cohort of 895 patients [median age (interquartile range), 59 (13) years; 62.5% male] was followed for a median of 40 (range, 1-85) months. Throughout the study, there were 247 relapses or deaths and 156 perioperative complications. The incidence rates per 1000 person-years for relapses or deaths were 108.8 and 79.6 among patients with high and low E/ CO 2 slopes, respectively [weighted incidence rate difference per 1000 person-years, 29.21 (95% CI, 7.30-51.12)]. A E/ CO 2 slope of greater than or equal to 31 was associated with shorter RFS [hazard ratio for relapse or death, 1.38 (95% CI, 1.02-1.88), P =0.04] and poorer OS [hazard ratio for death, 1.69 (1.15-2.48), P =0.02] compared to a lower / CO 2 slope. A high E/ CO 2 slope increased the risk of perioperative morbidity compared with a low E/ CO 2 slope [odds ratio, 2.32 (1.54-3.49), P <0.001]. CONCLUSIONS: In patients with operable NSCLC, a high E/ CO 2 slope was significantly associated with elevated risks of poorer RFS, OS, and perioperative morbidity.

ERS International Congress 2021: highlights from the Allied Respiratory Professionals assembly.

This paper provides an overview of some of the most memorable sessions that were (co)organised by the Allied Respiratory Professionals Assembly during the 2021 European Respiratory Society International Congress, which was held online for the second consecutive year due to the COVID-19 pandemic. Early Career Members from Assembly 9 summarised the content of the sessions (three oral communication sessions, two symposia and one Expert View) with the support of the chairs from the four Assembly groups: Respiratory Function Technologists and Scientists (Group 9.01); Physiotherapists (Group 9.02); Nurses (Group 9.03); and Psychologists and Behavioural Scientists (Group 9.04). The sessions covered the following topics: impact of COVID-19 on lung function and healthcare services, and the importance of quality assurance and technology in lung function assessment; diagnosis and management of sarcopenia in patients with chronic respiratory disease; maintenance of the effects of pulmonary rehabilitation; solutions outside the hospital for the management of patients with COVID-19 in need of health care; the nursing perspective during the COVID-19 pandemic; and psychological and behavioural issues in respiratory care. This highlights article provides valuable insight into the latest scientific data and emerging areas affecting clinical practice of allied respiratory professionals.

Respiratory morbidity, healthcare utilisation and cost of care at school age related to home oxygen status.

UNLABELLED: The aim of the study was to determine whether respiratory morbidity, lung function, healthcare utilisation and cost of care at school age in prematurely born children who had bronchopulmonary dysplasia (BPD) were influenced by use of supplementary oxygen at home after neonatal intensive care unit discharge. Healthcare utilisation and cost of care in years 5 to 7 and respiratory morbidity (parent-completed respiratory questionnaire) and lung function measurements at least at age 8 years were assessed in 160 children. Their median gestational age was 27 (range 22-31) weeks and 65 of them had received supplementary oxygen when discharged home (home oxygen group). The home oxygen group had more outpatient attendances (p = 0.0168) and respiratory-related outpatient attendances (p = 0.0032) with greater related cost of care (p = 0.0186 and p = 0.0030, respectively), their cost of care for prescriptions (p = 0.0409) and total respiratory related cost of care (p = 0.0354) were significantly greater. There were, however, no significant differences in cough, wheeze or lung function results between the two groups. CONCLUSION: Prematurely born children who had BPD and supplementary oxygen at home after discharge had increased healthcare utilisation at school age. Whether such children require greater follow, in the absence of excess respiratory morbidity, merits investigation.

Early respiratory diagnosis: benefits of enhanced lung function assessment.

INTRODUCTION: The National Health Service for England Long Term Plan identifies respiratory disease as one of its priority workstreams. To assist with earlier and more accurate diagnosis of lung disease they recommend improvement in delivery of quality-assured spirometry. However, there is a likelihood that patients will present with abnormal gas exchange when spirometry results are normal and therefore there will be a proportion of patients whose time to diagnosis is still protracted. We wished to determine the incidence rate of this occurring within our Trust. METHODS: A retrospective review of all patients attending the lung function laboratory for their first pulmonary function assessment from June 2006 to December 2020 was undertaken. Forced expiratory volume in 1 s/forced vital capacity (FEV1/FVC) >-1.64 standardised residual (SR) was used to confirm no obstructive lung function abnormality and FVC >-1.64 SR to confirm no suggestion of a restrictive lung function abnormality. Lung gas transfer for carbon monoxide (TLCO) and transfer coefficient of the lung for carbon monoxide (KCO) <-1.64 SR confirmed the presence of a gas exchange abnormality. Spirometry and gas transfer reference values generated by the Global Lung Initiative were used to determine normality. RESULTS: Of 12 835 eligible first visits with normal FEV1/FVC and FVC, 4856 (37.8%) were identified as having an abnormally low TLCO and 3302 (25.7%) presenting with an abnormally low KCO. Of 3494 with FEV1/FVC SR <-1.64, 3316 also had a ratio of <0.70, meaning 178 (5%) of patients in this cohort would have been misclassified as having obstructive lung disease using the 0.70 cut-off recommended by the Global Initiative for Chronic Obstructive Lung Disease for diagnosing obstructive lung disease. DISCUSSION: In conclusion, to assist with ensuring more accurate and timely diagnosis of lung disease and enhance patients' diagnostic pathway, we recommend the performance of lung gas transfer measurements alongside spirometry in all healthcare settings. To assess and monitor gas transfer at the earliest opportunity we recommend this is implemented into new models being developed within community hubs. This will increase the identification of lung function abnormalities and provide patients with a definitive diagnosis earlier.

The risks of applying normative values in paediatric cardiopulmonary exercise testing: a case report.

A clinical case in a paediatric subject highlights the urgent requirement for cardiopulmonary exercise testing age-related reference values to be harmonised, to ensure appropriate clinical interpretation and patient management https://bit.ly/36WgOSO.

Lung function in prematurely born infants after viral lower respiratory tract infections.

BACKGROUND: Chronic respiratory morbidity has been reported in prematurely born infants after respiratory syncytial virus (RSV) and human metapneumovirus (hMPV) lower respiratory tract infections (LRTIs). The aim of this study was to determine the impact of viral LRTI on lung function at follow-up of prematurely born infants. METHODS: Fifty-nine infants born before 32 weeks of gestational age were prospectively followed after neonatal unit discharge. Nasopharyngeal aspirates were obtained when the infants developed LRTIs in hospital or the community. RSV was identified by immunofluorescence and/or culture. In addition, RSV and other viral infections were identified by real time reverse transcription polymerase chain reaction. At a corrected age of 1 year, measurements of lung volume [functional residual capacity (FRC)pleth] and airway resistance (R(aw)) were made by plethysmography, and lung volume was also assessed by helium gas dilution (FRC(He)). Before the measurements, parents completed diary cards for 1 month documenting on a daily basis whether their infant wheezed, coughed, or required bronchodilator therapy. RESULTS: Twenty-five infants had at least 1 proven RSV LRTI (RSV-positive group). The RSV-positive group compared with the rest of the cohort had similar lung volumes, but significantly higher R(aw) (P = 0.002), more days of wheeze (P < 0.001), and bronchodilator requirement (P = 0.027). Regression analysis also identified that hMPV LRTI was associated with elevated airways resistance at follow-up. CONCLUSION: RSV and hMPV LRTIs in prematurely born infants are associated with abnormal lung function at follow-up.

Airway hyperresponsiveness and acute chest syndrome in children with sickle cell anemia.

To determine the occurrence and magnitude of airway hyperresponsiveness (AHR) in children with sickle cell anemia (SCA) who had or had not had acute chest syndrome (ACS) episodes. A subsidiary aim was to determine whether cold air and exercise challenge testing gave similar results in children with SCA. AHR would be greater in SCA children who had had an ACS episode compared to those who had not. Prospective observational study. Forty-two SCA children (median age of 11.5 [range 6.1-16.8] years); 12 children had been previously hospitalized for an ACS episode. AHR was assessed by the change in forced expiratory volume in 1 sec (FEV1) to a cold air challenge and in a subset of the children to an exercise challenge. A positive result to either challenge was deemed to have occurred if the FEV1 fell by at least 10% from the pre-challenge baseline. The magnitude of change in FEV1 following the cold air challenge was similar in children who had or had not had an ACS episode. Six children had a positive response to the cold air challenge (AHR); none had had an ACS hospitalization. Similar proportions of children responded to the cold air and exercise challenge and the magnitude of response to the two tests was similar. Some children, however, responded only to a cold air challenge and others only to an exercise challenge. SCA children who had had an ACS hospitalization episode compared to those who had not were not more likely to respond to a cold air challenge. Importantly, if AHR is to be correctly diagnosed, some SCA children will require to undergo both cold air and exercise challenge testing.

Temporal relationship of asthma to acute chest syndrome in sickle cell disease.

Acute chest syndrome (ACS) is an important cause of mortality and morbidity in children with sickle cell disease (SCD). An association between asthma and ACS has been reported. Our aims were to determine whether asthma was more common in SCD children than controls and the relationship of the timing of the SCD children's first ACS episode to a diagnosis of asthma. One hundred and sixty-five SCD children median age 8.2 (range 0.3-17.3) years and 151 similar ethnic origin and aged controls were prospectively recruited into the study and a detailed history was taken from all of the children to determine if they were taking anti-asthma medication. The medical records of the SCD children were examined to assess whether they had an ACS episode, the age this episode occurred and when any diagnosis of asthma had been made. A similar proportion of the SCD children and controls were taking anti-asthma medication (7% and 9%). Thirty-three SCD children had at least one ACS episode. More of the children who had an ACS compared to those who had not were taking anti-asthma medication (P = 0.02). The ACS children had been diagnosed as asthmatic at a median of 3.5 (range 0.5-7) years prior to their first ACS episode. In conclusion, these results suggest asthma exacerbations may predispose to ACS episodes.

Lung gas transfer in children with sickle cell anaemia.

The impact of sickle cell anaemia (SCA) on respiratory function of children must be determined if their management is to be optimised. Pulmonary diffusing capacity (DL(CO)), corrected for haemoglobin (DL(COc)), therefore was assessed in 24 children with SCA and 24 ethnic matched controls, mean age 11 (range 7-16) years. To determine if any differences found correlated with other measures of lung function, spirometry was undertaken and lung volumes assessed. The SCA children compared to the controls had lower weight (p=0.01), body mass index (p=0.002), DL(CO) (p<0.0001), K(CO) (p=0.003), V(CSB) (p=0.01), FEV(1) (p<0.0001) and FVC (p<0.0001), but greater K(COc) (p=0.001). K(COc) results correlated significantly with PEF (r=-0.58, p=0.02), but not TLC(pleth) (p=0.36), FEV(1) (0.39) or FVC (p=0.36). In conclusion, when corrected for haemoglobin levels, the SCA children compared to controls of similar age had elevated gas transfer per unit lung volume results. Our results suggest this abnormality is independent of other lung function abnormalities.

Problems in the measurement of functional residual capacity.

Accurate assessment of lung volume in infancy is important to determine the impact of disease and the efficacy of therapies. A new generation of infant plethysmographs with lower apparatus deadspace has been produced, but gives lower volume results than those from older traditional plethysmographs. We hypothesized that the new plethysmographs might have greater sensitivity to the adiabatic effect and hence they, rather than the traditional plethysmographs, produced erroneous results. Our aim was to assess the influence of the adiabatic effect on the results of a contemporary plethysmograph, an older traditional plethysmograph and a helium gas dilution system using a lung model. Altering the amount of copper wool within the lung model allowed the influence of the adiabatic effect on the plethysmographic results to be assessed. The measured compared to the actual volumes were significantly lower for the contemporary plethysmograph compared to the traditional plethysmograph (p < 0.001) and to the helium gas dilution system (p < 0.001). Under optimal testing conditions the contemporary plethysmograph under-recorded by 11-13%, whereas the other two systems gave similar results to the actual volumes. As the effect of the adiabatic effect was increased, the discrepancy between the results of the contemporary and the traditional plethysmographs increased. We conclude, the contemporary plethysmograph is more sensitive to adiabatic effects and hence under-records.

Lung volumes in healthy Afro-Caribbean children aged 4-17 years.

Lung volumes in healthy children differ according to their ethnic origin. We wished to determine if any differences in the lung volumes of Afro-Caribbean (AC) children from those predicted by Caucasian reference values disappeared if the results were related to sitting height or to 90% or 77% of lung volumes predicted for height from Caucasian reference values based on standing height. We took, as our working hypothesis, that it is inappropriate to use Caucasian reference values to interpret data from Afro-Caribbean children, and that ethnic-specific reference values are required. This was a prospective, observational study. Subjects included 80 AC children with a median age of 9 (range, 4.3-17.8) years. Standing and sitting height were measured. Lung volumes were measured by body plethysmography (total lung capacity, TLC(pleth); functional residual capacity, FRC(pleth); and vital capacity, VC(pleth)), helium gas dilution (functional residual capacity, (FRC(He)), spirometry (forced expiratory volume in 1 sec, FEV(1)), and forced vital capacity (FVC). The lung volumes of AC children correlated significantly with standing height, but differed significantly from values predicted from Caucasian reference values based on standing height (P < 0.05). Significant differences remained for TLC(pleth), FRC(pleth), FRC(He), RV(pleth), VC(pleth), FEV(1), and FVC when the results were related to sitting height or 90% or 77% of values predicted from Caucasian reference values based on height (P < 0.05). Lung volumes in Afro-Caribbean children should be compared to ethnic-specific reference values.

Cold air and exercise challenge -- influence of minute ventilation.

Exercises testing and cold air challenges are frequently used to assess airway hyperresponsiveness (AHR), but different goals are set for the two tests. We, therefore, wished to determine whether cold air and exercise challenge testing yielded similar responses and if any differences were due to differences in the maximum minute ventilation achieved. Twenty asthmatic subjects each performed a cold air (CACh) and an exercise (EXCh) challenge. Baseline forced expiratory volume in one second (FEV(1)) was recorded immediately pre-challenge and then serially for at least 10 minutes post-challenge. The maximum minute ventilation achieved was recorded. In the subjects who had at least a decrease in FEV(1) of 15% in response to the first CACh, a second CACh was performed, but at the maximum minute ventilation achieved during EXCh. Eleven subjects after CACh and four after EXCh had a greater than 15% decrease in FEV(1) (p = 0.05). The median decrease in FEV(1) was greater following the CACh (16.7%[25th to 75th percentile 10.4 to 19.9]) than the EXCh (6.9%[25th to 75th percentile 4.3 to 14.6]); (p = 0.0004). The median maximum minute ventilation achieved was greater with the CACh (89[66-141] L/min) than with the EXCh (61(40 to 102)L/min); (p < 0.0001). Only one of seven subjects who had previously responded to the CACh had a 15% decrease in FEV(1) when the CACh was repeated at the same maximum minute ventilation achieved during EXCh (p = 0.007). In conclusion, cold air and exercise challenges do not produce the same response. Our results highlight than an explanation is the differences in the maximum-minimum ventilation achieved.

Impact of acute chest syndrome on lung function of children with sickle cell disease.

OBJECTIVE: To test the hypothesis that children with sickle cell disease (SCD) who experienced an acute chest syndrome (ACS) hospitalization episode would have worse lung function than children with SCD without ACS episodes. STUDY DESIGN: Forced expiratory volume in 1 second (FEV(1)); forced vital capacity (FVC); FEV(1)/FVC ratio; peak expiratory flow (PEF); forced expiratory flow at 25% (FEF(25)), 50% (FEF(50)), and 75% (FEF(75)) of FVC; airway resistance (Raw); and lung volumes were compared in 20 children with ACS and 20 aged-matched children without ACS (median age, 11 years; range, 6 to 16 years). Fourteen age-matched pairs were assessed before and after bronchodilator use. RESULTS: The mean Raw (P = .03), TLC (P = .01), and RV (P = .003) were significantly higher in the group with ACS than in the group without ACS. There were no significant differences in the changes in lung function test results in response to bronchodilator administration between the 2 groups, but the children with ACS had a lower FEF(25) (P = .04) and FEF(75) (P = .03) pre-bronchodilator use and a lower mean FEV(1)/FVC ratio (P = .03) and FEF(75) (P = .03) post-bronchodilator use. CONCLUSIONS: Children with SCD who experienced an ACS hospitalization episode had significant differences in lung function compared with those who did not experience ACS episodes. Our results are compatible with the hypothesis that ACS episodes predispose children to increased airway obstruction.

Exhaled carbon monoxide levels in children with sickle cell disease.

UNLABELLED: It is important to measure the rate of haemolysis in patients with sickle cell disease (SCD) to identify aplastic crises and indirectly assess the rate of vaso-occlusion and sequestration. The aim of this study was to assess whether end-tidal carbon monoxide (ETCOc) levels in children with sickle cell disease (SCD) could be measured reproducibly, reflected haemolysis and whether they were elevated compared to those of similarly aged, ethnic matched children without SCD (controls). ETCOc levels were measured non-invasively in 87 SCD children (age range 2.3-17.6 years) and 26 age and ethnic origin matched healthy controls using an electro-chemical sensor. The within- and between- occasion reproducibilities were assessed in ten and 15 SCD children respectively. ETCOc levels of 15 SCD children undergoing regular transfusions were related to carboxyhaemoglobin, haemoglobin and bilirubin levels. The within and between occasions' mean intrasubject coefficients of reproducibility were 5% and 18% respectively. Positive correlations were found between the ETCOc and carboxyhaemoglobin ( P =0.007) and bilirubin ( P =0.02) levels, and a significant negative correlation between the ETCOc and haemoglobin ( P =0.0002) levels. The mean and SD ETCOc levels of the SCD children (4.9 ppm; SD 1.7 ppm) were significantly higher than that of the controls (mean 1.3 ppm; SD 0.4 ppm) (difference between means 3.60; 95% C.I. 2.93-4.28; P <0.0001). CONCLUSION: These results suggest that measurement of end-tidal carbon monoxide levels is a reliable and useful method to monitor haemolysis in children with sickle cell disease.