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The National Pectus multi-disciplinary team (MDT) meeting was commissioned by NHS England in April 2023 to review all cases of pectus excavatum (PE) being considered for surgical management. In cases of severe PE, the chest wall compresses the heart and lungs, which may result in cardiac or respiratory function compromise on exercise, measured during cardio-pulmonary exercise testing (CPET). This MDT has led to a further ongoing study on the impact of the timing of surgery on patient-reported improvement in quality of life, and improvement in CPET parameters (the RESTORE trial).All patients discussed in the MDT require prior CPET and pulmonary function testing (PFT) to assess for physiological limitation and investigate for other potential causes. The majority of PE patients have restrictive spirometry, however a subset of 28 patients potentially had an obstructive spirometry pattern (table 1), with a mean FEV1/FVC 0.72. This population was predominantly male (85.7%) with an average age of 22.3 years.Prior to surgical intervention, we propose these patients undergo further investigation to exclude undiagnosed obstructive airways disease, and in event of a diagnosis being made, receive a trial of treatment which may alleviate the need for an invasive surgical procedure.Abstract P255 Table 1Demographics (N=28)

BackgroundPreserved Ratio Impaired Spirometry (PRISm) is defined by reduced forced expiratory volume in one second (FEV1) with a preserved FEV1/FVC ratio. It is associated with increased morbidity and may represent an intermediate stage in the development of chronic respiratory disease. Small airway dysfunction (SAD) contributes to conditions such as COPD, asthma, and idiopathic pulmonary fibrosis.AimTo examine the association between PRISm and SAD in an Irish adult population.MethodsA cross-sectional study was conducted at the Respiratory Department, Connolly Hospital, Dublin. Spirometry results from patients were retrospectively reviewed. Data included demographics, clinical history, and post-bronchodilator spirometry. PRISm was defined as FEV1/FVC ≥ 0.70 with FEV1 < 80% predicted. SAD was diagnosed when at least two of MMEF, FEF5 0, and FEF7 5 were <65% predicted.ResultsOver five years, 962 (24.2%) met PRISm criteria. Of these, 51.4% were male (p = 0.044). PRISm patients were significantly older (p = 0.001). Although more common in Caucasians, this was not significant (p = 0.125). Most were overweight or obese (p = 0.689, not significant). Mean FEV1 was significantly reduced in PRISm (p < 0.001). MMEF7 5–2 5 was significantly lower (p = 0.040), with marginal reductions in FEF5 0 and FEF7 5 (p = 0.093, p = 0.058).ConclusionPRISm is a prevalent spirometric pattern in Irish adults and shows a significant association with SAD, supporting its recognition as a distinct early airway disease phenotype.

Background: Preserved ratio impaired spirometry (PRISm), which identifies a population at high risk for COPD, has drawn increasing attention. However, definitions for PRISm vary across studies, and researches comparing these definitions are limited. Objective: We aim to assess the agreement, the clinical features, and the prevalence of PRISm defined by restrictive spirometric pattern (RSP) method [that is forced vital capacity (FVC) method] versus forced expiratory volume in the first second (FEVj) method and by fixed values versus the lower limit of normal (LLN). Methods: All 1862 participants from the ECOPD study underwent questionnaire investigation, spirometry, biphasic CT, and impulse oscillometry. Participants were categorized into control and two targeted groups (RSP fixed and PRISm fixed excluding RSP fixed) based on FVC and FEV1 fixed definitions. Similar categorizations were conducted for RSP LLN versus PRISm LLN and PRISm fixed versus PRISm LLN. We assessed the agreement, the clinical features, and the prevalence of PRISm among these various definitions, repeating all analyses using Global Lung function Initiative (GLI) equation. Results: Significant overlap with merely moderate agreement (Kappa coefficient = 0.706, P value <0.001) existed between RSP fixed and PRISm fixed definitions. Participants identified as PRISm by both definitions exhibited lower lung function, higher airway reactance, and increased airway resistance compared to the control group. Similar findings were observed in RSP LLN versus PRISm LLN and PRISm fixed versus PRISm LLN. Our sensitivity analysis verified the consistency of these results. Furthermore, the prevalence of PRISm varied from 2.0% to 12.5% depending on the definitions and predicted equations, with the Chinese equation, LLN definition in Chinese equation and fixed definition in GLI equation yielding higher prevalence rates. Conclusion: Our findings highlight concerns about the comparability of studies and the interchangeability of various definitions and reference equations for PRISm. Keywords: PRISm, definitions, clinical features, prevalence, reference equations

RationalePrevious evidence shows a 37.8% increase in diagnostic yield when gas transfer is used supplementary to a ‘normal’ spirometry based on conventional spirometry interpretation criteria.1 However, in individuals with a higher pre-test probability of lung restriction, smaller deviations from the predicted forced vital capacity (FVC) may be considered pathological.Research question: How much value does gas transfer add, in addition to spirometry, when a Z score of -1.645 (ARTP) and -1 (Bayesian) are applied to classify the FVC?MethodsRetrospective analysis of 560 patients confirmed to have ILD in the Birmingham Regional ILD multidisciplinary team (MDT) meeting was performed between 2015 and 2025. Evaluation of the frequencies and proportions of patients considered to have ‘normal’ lung function was performed using different cut-off thresholds. Lung function patters were split into normal, loss of volume and capillary structure (LVACS), extrapulmonary restriction (ER), and pulmonary vascular abnormality (PVA), based on ERS interpretive guidelines.2 ResultsSpirometry was diagnostic in itself in 242 (43.2%) and 354 (63.2%) cases when Z scores of -1.645 and -1 were applied, respectively. The addition of gas transfer identified 268 (47%) and 161 (28.7%) additional abnormalities, supplementary to spirometry, when Z scores of -1.645 and -1 were applied. The sensitivity of FVC to predict a low VA increased from 61.2% to 85.9% when a FVC Z score of -1 is used instead of -1.645. See figure 1 for Sanke diagram of breathing test outcomes.ConclusionUse of a Bayesian approach to classifying FVC increases the diagnostic yield in patients with a high pre-test probability of ILD. LVACS (VA reduced, KCO normal or reduced) was the most common lung function pattern seen in the local ILD population. An FVC Z score of -1 is highly sensitive to a reduced VA in these individuals with high pre-test probability for ILD.Abstract P11 Figure 1[Image Omitted. See PDF.]References Sylvester, et al. Early respiratory diagnosis: benefits of enhanced lung function assessment. BMJ Open Respiratory Research 2021. Stanojevic. ERS/ATS technical standard on interpretive strategies for routine lung function tests. ERJ. 2022.

IntroductionThe Global Lung Function Initiative (GLI) 2022 reference values are a race neutral approach to spirometry interpretation. We aimed to determine the impact of switching from GLI 2012 to GLI 2022 on spirometry results in patients seen at Great Ormond Street Hospital for Children (GOSH).MethodsA retrospective analysis of spirometry performed between 2020 and 2023. Results were interpreted and compared using both GLI 2012 and GLI 2022 to ARTP standards (LLN <-1.64z-score). Mean results between methods, and normal/abnormal classification were compared for white children and black children.ResultsSpirometry results were analysed in 3,254 patients aged (mean [SD]) 11.5[3.8] years. 54.5% were male. Patients/carers self-reported race using the GLI 2012 groups and at time of test as White (2,219, 68.2%), Black (512, 15.7%) and Other (523, 16.1%).When using GLI 2012, there were 1,183 (36.4%) results < LLN, compared to GLI 2022 with 1,117 (34.3%).Black children had lower spirometry z-scores with GLI 2022 than with GLI 2012 (FEV1: -1.54 vs -0.83, difference -0.71, p<0.01; FVC: -1.39 vs -0.65, difference -0.75, p<0.01).61 (11.9%) Black subjects whose results were classified as normal by GLI 2012 were reclassified as restrictive by GLI 2022. There was no change in the number of tests classified as obstructive.White children had higher spirometry z-scores with GLI 2022 than with GLI 2012 (FEV1: -0.68 vs -1.1, difference 0.40, p>0.01; FVC: -0.47 vs -0.90, difference 0.437, p<0.01. 118 (5.3%) White subjects whose results were classified as restrictive by GLI 2012 were reclassified as normal by GLI 2022. There was virtually no change in the number of tests classified as obstructive.ConclusionInterpretation of spirometry changes when switching from GLI 2012 to GLI 2022.

IntroductionSpirometry is routinely used to assess patients with suspected or confirmed airway disease. However, it has been criticised for its potential insensitivity in detecting early or mild airways disease and some patients struggle to meet the required technical standards. The use of the Forced Oscillation Technique (FOT) has been proposed to address these concerns but remains relatively unused in clinical practice. This service level evaluation aimed to assess the potential benefits of incorporating FOT into routine spirometry testing within a respiratory physiology outpatient service.MethodsPatients referred for spirometry ± reversibility testing at Hampshire Hospitals NHS Foundation Trust were also assessed using FOT (ResMon Pro Full V3). Abnormal spirometry (FEV1/VCmax z-score <-1.64), abnormal FOT parameters (total resistance; Rrs at 5 Hz > upper limit of normal and/or reactance; Xrs at 5 < lower limit of normal) and a positive bronchodilator response (BD; >200 mL AND 12% for FEV1; −32% for Rrs 5 Hz and/or +44% for Xrs 5) were defined accordingly.ResultsAnonymised data for 119 patients who attended clinic between April 2023 and June 2024 were analysed and grouped as follows; normal spirometry and normal FOT (n=56), abnormal spirometry and abnormal FOT (n=23), normal spirometry but abnormal FOT (n=10), and abnormal spirometry but normal FOT (n=30). Reversibility testing was performed in 19 patients. Of these, six had a positive BD response on spirometry but only one also demonstrated a positive BD response on FOT. One patient demonstrated a positive BD response on FOT but a negative response on spirometry.ConclusionsUnexpectedly, 57% of patients with airflow obstruction on spirometry had normal FOT results (total Rrs and Xrs at 5 Hz) and only 17% of patients with a positive BD response on spirometry demonstrated a positive response on FOT. These preliminary findings suggest that if performed as an alternative to spirometry, FOT may fail to identify abnormalities in patients with potential airflow obstruction. Further analysis will be carried out to classify the severity of airflow obstruction, assess additional FOT parameters including within-breath abnormalities, and attempt to understand the discrepancies seen in this evaluation between the two tests.

Increasing awareness of the prevalence and significance of Preserved Ratio Impaired Spirometry (PRISm), alternatively known as restrictive or Global Initiative for Chronic Obstructive Lung Disease (GOLD)-unclassified spirometry, has expanded the body of knowledge on cross-sectional risk factors. However, longitudinal studies of PRISm remain limited. To examine longitudinal patterns of change in lung function, radiographic characteristics, and mortality of current and former smokers with PRISm. Current and former smokers, aged 45 to 80 years, were enrolled in COPDGene (phase 1, 2008-2011) and returned for a 5-year follow-up (phase 2, 2012-2016). Subjects completed questionnaires, spirometry, chest computed tomography scans, and 6-minute-walk tests at both study visits. Baseline characteristics, longitudinal change in lung function, and mortality were assessed by post-bronchodilator lung function categories: PRISm (FEV /FVC < 0.7 and FEV  < 80%), GOLD0 (FEV /FVC > 0.7 and FEV  > 80%), and GOLD1-4 (FEV /FVC < 0.7). Although the prevalence of PRISm was consistent (12.4-12.5%) at phases 1 and 2, subjects with PRISm exhibited substantial rates of transition to and from other lung function categories. Among subjects with PRISm at phase 1, 22.2% transitioned to GOLD0 and 25.1% progressed to GOLD1-4 at phase 2. Subjects with PRISm at both phase 1 and phase 2 had reduced rates of FEV decline (-27.3 ± 42.1 vs. -33.0 ± 41.7 ml/yr) and comparable proportions of normal computed tomography scans (51% vs. 52.7%) relative to subjects with stable GOLD0 spirometry. In contrast, incident PRISm exhibited accelerated rates of lung function decline. Subjects with PRISm at phase 1 had higher mortality rates relative to GOLD0 and lower rates relative to the GOLD1-4 group. PRISm is highly prevalent, is associated with increased mortality, and represents a transitional state for significant subgroups of subjects. Additional studies to characterize longitudinal progression in PRISm are warranted.

BackgroundThe new UK (NICE/BTS/SIGN) asthma diagnostic guidelines for children include the use of House Dust Mite skin prick test (SPT) or Total IgE along with eosinophil count (eos), where exhaled nitric oxide (FeNO), spirometry/reversibility (BDR) or peak flow (PEFv) testing is either unavailable, negative or the child is unable to complete the test. A positive mite SPT (>3 mm wheal diameter) or elevated Total IgE (>120 KU/L) and eosinophil count (>0.5x109cells/L) with symptoms suggestive of asthma are sufficient to make the diagnosis in children aged 5–16 yrs. Within an observational asthma diagnostic cohort study we investigated the sensitivity and specificity of these tests in children with suspected asthma.MethodChildren aged 5–16 yrs, referred from primary care with suspected asthma underwent clinical history, examination, FeNO, spirometry, BDR, PEFv, bronchial challenge, SPT to common inhaled allergens, Total IgE, blood eosinophils, and completed 8 weeks inhaled corticosteroid treatment. A panel of at least 3 asthma specialists using all available data confirmed or rejected the diagnosis of asthma.Results95 children underwent testing and had a definitive diagnostic outcome (51.6% male; mean (SD) age 10.0 (2.8) years; 73 Asthma, 22 Not Asthma). Positive house dust mite SPT had the lowest sensitivity and specificity of all the tests. Elevated Eos had the highest specificity which was not improved by the addition of Total IgE. However, the standard lung function tests had higher specificity than the newly proposed tests, but not all children could complete these tests. Sensitivity of all the tests was poor. See table 1.Abstract S47 Table 1 Sensitivity (%) Specificity (%) PPV (%) NPV (%) Eosinophil count (n=95) 46.6 81.8 89.5 31.6 Total IgE (n=95) 75.3 68.2 88.7 45.5 Mite SPT (n=94) 61.1 59.0 83.0 31.7 Total IgE and Eos (n=95) 45.2 81.8 89.2 31.0 FeNO (n=80) 45.8 95.0 96.4 38.5 BDR (n=87) 32.3 100 100 33.3 PEFv (n=71) 30.3 100 100 27.8 ConclusionIn children who are unable to complete standard lung function tests for asthma, an eosinophil count above 0.5x109 cells/L may be an alternative test to consider. In our cohort, the addition of Total IgE did not improve diagnostic accuracy. If children are diagnosed only on the basis of mite SPT, the poor specificity needs to be noted (2 in 5 cases will be wrong) and their response to treatment should be carefully reviewed.