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The American Thoracic Society committee on Proficiency Standards for Pulmonary Function Laboratories has recognized the need for a standardized reporting format for pulmonary function tests. Although prior documents have offered guidance on the reporting of test data, there is considerable variability in how these results are presented to end users, leading to potential confusion and miscommunication. A project task force, consisting of the committee as a whole, was approved to develop a new Technical Standard on reporting pulmonary function test results. Three working groups addressed the presentation format, the reference data supporting interpretation of results, and a system for grading quality of test efforts. Each group reviewed relevant literature and wrote drafts that were merged into the final document. This document presents a reporting format in test-specific units for spirometry, lung volumes, and diffusing capacity that can be assembled into a report appropriate for a laboratory's practice. Recommended reference sources are updated with data for spirometry and diffusing capacity published since prior documents. A grading system is presented to encourage uniformity in the important function of test quality assessment. The committee believes that wide adoption of these formats and their underlying principles by equipment manufacturers and pulmonary function laboratories can improve the interpretation, communication, and understanding of test results.

The heat-related risk of hospitalization for respiratory diseases among the elderly has not been quantified in the United States on a national scale. With climate change predictions of more frequent and more intense heat waves, it is of paramount importance to quantify the health risks related to heat, especially for the most vulnerable. To estimate the risk of hospitalization for respiratory diseases associated with outdoor heat in the U.S. elderly. An observational study of approximately 12.5 million Medicare beneficiaries in 213 United States counties, January 1, 1999 to December 31, 2008. We estimate a national average relative risk of hospitalization for each 10°F (5.6°C) increase in daily outdoor temperature using Bayesian hierarchical models. We obtained daily county-level rates of Medicare emergency respiratory hospitalizations (International Classification of Diseases, Ninth Revision, 464-466, 480-487, 490-492) in 213 U.S. counties from 1999 through 2008. Overall, each 10°F increase in daily temperature was associated with a 4.3% increase in same-day emergency hospitalizations for respiratory diseases (95% posterior interval, 3.8, 4.8%). Counties' relative risks were significantly higher in counties with cooler average summer temperatures. We found strong evidence of an association between outdoor heat and respiratory hospitalizations in the largest population of elderly studied to date. Given projections of increasing temperatures from climate change and the increasing global prevalence of chronic pulmonary disease, the relationship between heat and respiratory morbidity is a growing concern.

Asthma and iron deficiency are common conditions. Whether iron status affects the risk of asthma is unclear. To determine the relationship between iron status and asthma, lung function, and pulmonary inflammation. Relationships between measures of iron status (serum ferritin, serum soluble transferrin receptor (sTfR), and sTfR/log10ferritin (sTfR-F Index)) and asthma, lung function, and pulmonary inflammation were examined in women 20-49 years in the National Health and Nutrition Examination Survey. Logistic, linear, and quadratic regression models accounting for the survey design of NHANES were used to evaluate associations between iron status and asthma-related outcomes and were adjusted for race/ethnicity, age, smoking status, income, and BMI. Approximately 16% reported a lifetime history of asthma, 9% reported current asthma, and 5% reported a recent asthma episode/attack (n = 2906). Increased ferritin (iron stores) was associated with decreased odds of lifetime asthma, current asthma, and asthma attacks/episodes in the range of ferritin linearly correlated with iron stores (20-300ng/ml). The highest quintile of ferritin (>76 ng/ml) was also associated with a decreased odds of asthma. Ferritin levels were not associated with FEV1. Increased values of the sTfR-F Index and sTfR, indicating lower body iron and higher tissue iron need, respectively, were associated with decreased FEV1, but neither was associated with asthma. None of the iron indices were associated with FeNO. In US women, higher iron stores were inversely associated with asthma and lower body iron and higher tissue iron need were associated with lower lung function. Together, these findings suggest that iron status may play a role in asthma and lung function in US women.

Background Metformin is associated with improved respiratory outcomes in asthma; however, metformin in COPD and asthma-COPD overlap (ACO) remains unexplored. Objective To determine the association between metformin use and respiratory outcomes in COPD and ACO. Study design and methods Participants with COPD (FEV1/FVC < 0.70) in the Genetic Epidemiology of COPD study (COPDGene®) were categorized as ACO (n = 510), defined as concurrent physician-diagnosed asthma before age 40 years, or COPD alone (n = 3459). We estimated the association of baseline metformin use with (1) rate of total and severe respiratory exacerbations during follow-up, (2) cross-sectional St. George’s Respiratory Questionnaire (SGRQ) score, six-minute walk distance (6MWD), and post-bronchodilator FEV1 percent predicted (FEV1pp), and (3) 5-year change in SGRQ, 6MWD, and FEV1pp. We also examined change in SGRQ, 6MWD and FEV1pp among participants who initiated metformin during follow-up (n = 108) compared to persistent metformin non-users (n = 2080). Analyses were adjusted for sociodemographic factors, medications, and comorbidities. Results Among participants with ACO, metformin use was associated with lower rate of total (adjusted incidence rate ratio [aIRR] 0.3; 95% confidence interval [95%CI] 0.11, 0.77) and severe exacerbations (aIRR 0.29; 95%CI 0.10, 0.89). Among participants with COPD alone, there was no association between metformin use with total (aIRR 0.98; 95%CI 0.62, 1.5) or severe exacerbations (aIRR 1.3; 95% CI 0.68, 2.4) (p-interaction < 0.05). Metformin use was associated with lower baseline SGRQ score (adjusted mean difference [aMD] − 2.7; 95%CI − 5.3, − 0.2) overall. Metformin initiation was associated with improved SGRQ score (aMD –10.0; 95% CI − 18.7, − 1.2) among participants with ACO but not COPD alone (p-interaction < 0.05). There was no association between metformin use and 6MWD or FEV1pp in any comparison. Conclusions Metformin use was associated with fewer respiratory exacerbations and improved quality of life among individuals with ACO but not COPD alone. Results suggest a potential role for metformin in ACO which requires further prospective study. Trial Registry: NCT00608764

Background Anemia is a prevalent comorbidity in COPD associated with increased morbidity. However, the significance of longitudinal anemia status and variation in anemia status trends over time in COPD are not known. Furthermore, individuals with COPD and smoking history often have multiple comorbidities, in particular cardiovascular disease. The objective of this study was to evaluate the association between longitudinal anemia status and COPD outcomes, accounting for comorbid cardiovascular disease. Methods Serial hemoglobin measures and clinical outcomes were obtained in former smokers with moderate to severe COPD from two clinical studies over a 6-to-9-month period. In the first analysis, the association between repeated measures of time-varying anemia status and outcomes was assessed by generalized estimating equations adjusted for covariates including cardiovascular disease. In the second analysis, each participant’s anemia risk profile during the study period was characterized as high versus low anemia risk-growth rate. Mean differences in the progression of COPD outcomes over time between the two groups were assessed using a generalized linear mixed model. Effect modification by baseline coronary artery calcium (CAC) burden was explored. Results There were 159 individuals with mean age of 66.5 years (± 8.3) and mean FEV 1 % predicted of 51.4% (± 17.0), of which 41% were ever-anemic during the study period. Repeated measures of anemia status were associated with higher St. George’s Respiratory Questionnaire (SGRQ) scores (β 2.5, 95% CI: 0.1,4.8, p  = 0.04), lower 6-minute walk distance (6MWD) (β -38.6, 95% CI: -67.7,-7.4, p  = 0.02), and higher rate of moderate-to-severe exacerbations over the prospective follow-up period (IRR 1.8, 95% CI: 1.1,2.8, p  = 0.02). There was effect modification by CAC burden such that with higher burden the mean difference in COPD outcome by anemia status was greater for a subset of symptom scores. Participants with profiles of increasing anemia risk had higher estimated rates of decline in the FEV 1 % predicted and 6MWD and increase in SGRQ scores compared to those with stable or decreasing anemia risk. Conclusions Longitudinal anemia status trends may be predictive of COPD disease trajectory. Anemia status by repeated measures analysis is associated with COPD morbidity with potentially stronger associations in the setting of high CAC burden.

Background Chronic respiratory disease is a significant contributor to morbidity among persons living with HIV (PLWH). In the general population, indoor air pollution is associated with respiratory morbidity. There is limited data on the respiratory health effects of indoor air pollution among PLWH, and the potential role of air pollution exposure in driving respiratory comorbidities in HIV. Methods Participant data from the Study of HIV in the Etiology of Lung Disease (SHIELD), a cohort of participants with or at risk for HIV in Baltimore, MD, was utilized. The association between reported household exposures and chronic respiratory symptoms was analyzed from baseline questionnaire data. A complementary pilot study directly measured weeklong average household fine particulate matter (PM 2.5 ) and nitrogen dioxide (NO 2 ) concentrations in participant homes. Logistic regression models described associations between household pollutants and patient-reported measures of respiratory morbidity for participants with and without HIV after accounting for confounders including smoking and spirometry measures. Results A total of 1997 ( n  = 1109 PLWH) SHIELD participants were included. Most participants were black (83%, n  = 1665) and male (65%, n  = 1298) with low socioeconomic status. There was a high prevalence of current tobacco use (78%, n  = 1553). Most PLWH (69%, n  = 767) had HIV RNA < 400 copies/mL. 21% ( n  = 412) of participants had spirometry-confirmed airflow obstruction. Self-reported household environmental exposures were associated with chronic respiratory symptoms, and PLWH appeared more susceptible to certain sources of pollution. HIV notably modified the effect of reported household secondhand smoke and NO 2 producing appliances on respiratory symptoms including chronic wheeze. The SHIELD Home pilot ( N  = 36) revealed household PM 2.5 concentrations above WHO recommend limits, with elevated household PM 2.5 associated with cough, sputum production, and worse respiratory quality of life as measured by the COPD Assessment Test. Conclusions Household pollutant exposure was common in an urban cohort enriched for PLWH. Early evidence suggests that HIV may increase susceptibility to certain pollutants. The SHIELD Home pilot provides early evidence of the potential impact of household PM 2.5 on respiratory disease in HIV. Studies are needed to enhance our understanding of the contribution of indoor air pollution to lung disease among PLWH.

Background Omega-3 fatty acids, including alpha-linolenic acid (ALA), eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA) and derivatives, play a key role in the resolution of inflammation. Higher intake has been linked to decreased morbidity in several diseases, though effects on respiratory diseases like COPD are understudied. Methods The National Health and Nutrition Examination Survey (NHANES), with a focus on dietary assessment, provides a unique opportunity to explore relationships between omega-3 intake and morbidity in respiratory diseases marked by inflammation in the United States (US) population. We investigated relationships between ALA or EPA + DHA intake and respiratory symptoms among US adults with COPD, as well as variation in relationships based on personal characteristics or exposures. Results Of 878 participants, mean age was 60.6 years, 48% were current smokers, and 68% completed high school. Omega-3 intake was, 1.71 ± 0.89 g (ALA), and 0.11 ± 0.21 g (EPA + DHA). Logistic regression models, adjusting for age, gender, race, body mass index, FEV 1 , education, smoking status, pack-years, total caloric intake, and omega-6 (linoleic acid, LA) intake demonstrated no primary associations between omega-3 intake and respiratory symptoms. Interaction terms were used to determine potential modification of relationships by personal characteristics (race, gender, education) or exposures (LA intake, smoking status), demonstrating that at lower levels of LA intake, increasing ALA intake was associated with reduced odds of chronic cough (p int  = 0.015) and wheeze (p int  = 0.037). EPA + DHA, but not ALA, was associated with reduced symptoms only among current smokers who did not complete high school. Conclusions Individual factors should be taken into consideration when studying the association of fatty acid intake on respiratory diseases, as differential responses may reveal susceptible subgroups.

ObjectivesPulmonary function testing (PFT) data, such as forced expiratory volume (FEV1) has become increasingly siloed from the electronic health record (EHR). We hypothesised that FEV1 %pred is independently associated with mortality risk, even after adjusting for the Care Assessment Needs (CAN) score, a validated method developed by the Veterans Health Administration (VA) to predict mortality. Additionally, we hypothesised that the integration of PFT data into the EHR has declined in recent years.MethodsWe conducted a retrospective cohort study using national VA data on PFTs from 2013 to 2018. Using logistic regression adjusted for CAN scores, we assessed the associations between FEV1 percent predicted (%pred) and all-cause mortality at 1 year and 5 years.ResultsWhile the number of PFTs performed has generally increased since 2000, the integration of PFT data into the EHR has declined since 2006. The CAN-adjusted odds of 1-year mortality were 2.94 (95% CI: 2.66 to 3.24) for those with FEV1 %pred <35%, compared with those with FEV1 %pred ≥70%, while 5-year mortality odds were 3.83 (95% CI: 3.58 to 4.09).DiscussionOur study shows that FEV1 %pred is statistically significantly associated with increased risk of mortality, above and beyond the CAN score. However, the declining integration of PFT data into the VA EHR highlights a concerning trend of isolating critical test results from clinical care.ConclusionAmong people with FEV1 recorded in the EHR, FEV1 %pred is statistically significantly associated with increased risk of both 1-year and 5-year mortality, above and beyond the CAN score.

Synonyms were used to look for articles that address the AP region (i.e., \"Asia,\" \"Pacific,\" and \"Asia Pacific\"), air pollution (i.e., \"air,\" \"air pollution,\" \"atmosphere,\" \"environment,\" \"outdoor,\" \"outdoor air pollution,\" \"particulate matter,\" and \"PM2.5\"), and potential respiratory consequences of air pollution (i.e., \"respiratory,\" \"asthma,\" \"COPD,\" \"hospitalizations,\" \"influenza,\" \"lower respiratory tract infection,\" \"lung cancer,\" \"lung function,\" \"obstructive lung disease,\" \"spirometry,\" \"tuberculosis,\" and \"wheeze\"). According to the 2016 Global Burden of Disease report, air pollution is responsible for an estimated 6.1 million deaths annually and 163 million disabilityadjusted life-years (DALYs) globally (12, 29). According to the most recent Global Burden of Disease estimates, the highest burden of COPD-related DALYs in the world occur in India, Nepal, Bangladesh, Bhutan, and Papua New Guinea (.2,000 age-adjusted DALYs per 100,000 people), whereas China, Myanmar, Laos, Vietnam, and the Philippines also experience extremely high COPD disability in the global context (32). In Hong Kong and China, for example, air quality improvement is being achieved through a multimodality approach that includes a comprehensive motor vehicle emission control program, reducing marine vessel emissions with fuel regulations, instituting emissions caps for power plants, and government subsidies and other financial support for the transition from coal to cleaner fuels and renewable energy.

Impaired single breath carbon monoxide diffusing capacity (DLCO) is associated with emphysema. Small airways disease (SAD) may be a precursor lesion to emphysema, but the relationship between SAD and DLCO is undescribed. We hypothesized that in mild COPD, functional SAD (fSAD) defined by computed tomography (CT) and Parametric Response Mapping methodology would correlate with impaired DLCO. Using data from ever-smokers in the COPDGene cohort, we established that fSAD correlated significantly with lower DLCO among both non-obstructed and GOLD 1–2 subjects. The relationship between DLCO with CT-defined emphysema was present in all GOLD stages, but most prominent in severe disease. Trial registration NCT00608764 . Registry: COPDGene. Registered 06 February 2008, retrospectively registered.