International consensus on lung function testing during COVID-19 pandemic and beyond

COVID-19 has negatively affected the delivery of respiratory diagnostic services across the world due to the potential risk of disease transmission during lung function testing. Community prevalence, reoccurrence of COVID-19 surges, and the emergence of different variants of the SARS-CoV-2 virus have impeded attempts to restore services. Finding consensus on how to deliver safe lung function services for both patients attending and for staff performing the tests are of paramount importance.This international statement presents the consensus opinion of 23 experts in the field of lung function and respiratory physiology balanced with evidence from the reviewed literature. It describes a robust roadmap for restoration and continuity of lung function testing services during the COVID-19 pandemic and beyond.Important strategies presented in this consensus statement relate to the patient journey when attending for lung function tests. We discuss appointment preparation, operational and environmental issues, testing room requirements including mitigation strategies for transmission risk, requirement for improved ventilation, maintaining physical distance, and use of personal protection equipment. We also provide consensus opinion on precautions relating to specific tests, filters, management of special patient groups, and alternative options to testing in hospitals.The pandemic has highlighted how vulnerable lung function services are and forces us to re-think how long term mitigation strategies can protect our services during this and any possible future pandemic. This statement aspires to address the safety concerns that exist and provide strategies to make lung function tests and the testing environment safer when tests are required.

Lung Function Tests in Children with and without Sickle Cell Anaemia at South Western Nigerian Tertiary Hospitals

Sickle cell anaemia (SCA) is a common cause of morbidity and mortality in Nigerian children. Sickle cell haemoglobin disorder and carrier state have incidence at birth in Nigeria of about 2% and 25% respectively. The Chronic anaemia and recurrent vaso-occlusion in this disease condition can lead to impairment of function of body organs or systems. The knowledge on how SCA affects the lung and pulmonary tissue function in Nigerian children is inadequate. Aims: To compare lung function tests results of apparently healthy sickle cell anaemia patients recruited from tertiary hospitals in South West Nigeria with those of apparently healthy controls. Method: A comparative cross sectional study of children attending the Sickle Cell anaemia clinics of Wesley Guild Hospital, Obafemi Awolowo University Teaching Hospital Complex and Ladoke Akintola University of Technology Teaching Hospital was done. Ethical approval was obtained from the Ethical review boards of the different hospitals where the studies were conducted. Randomly selected consenting matched apparently well children and children with Sickle cell anaemia had their weights, height and Packed cell volume on the days of their clinics. In addition the Forced Expiratory Volume at one second, Forced Vital capacity and Peak expiratory flow rates were measured and recorded. The data obtained was analyzed using SPSS 12 version. Results: The total of 74 HBSS patients studied comprised of 35(43.7%) boys and 39 (52.7%) girls, giving a male to female ratio of 1: 1.1, while the 73 apparently healthy controls were made up of 39(53.4%) boys and 34(46.6%) girls, giving a male to female ratio of 1.2 : 1.0. The mean weight and BMI of the children with SCA were 24.9 ± 8.0kg and 14.4 ± 1.8m2 compared with 29.4 ± 2.9kg and 15.4 ± 1.8m2 in the apparently healthy controls. Higher values of weight and BMI in healthy controls than in the SCA subjects and statistically significant p< 0.05. The mean values of the FEV1 , FVC, PEFR and FEV percent were 1.54 ±0.51, 1.76 ± 0.45, 271.37 ± 72.20 and 87.5 ± 4.43 respectively in children with SCA as against 1.83 ± 0.61, 2.03 ± 0.65, 296.44±75.0 and 90.2 ± 5.76 respectively in the healthy controls. Higher lung function tests are statistically significant (p < 0.05). Conclusion: Children with Sickle Cell anaemia have significantly lower anthropometric measurement and lung function test values (FEV1, FVC, & PEFR) than controls. The lower lung function test values in the sickle cell anaemia patients may be as a result of the lower anthropometric measurements. Further studies need to be conducted find out why the lung function tests are lower in children with sickle cell anaemia preferably after eliminating cofounders such as anthropometry. Key words: Lung Function Tests, Sickle Cell Anaemia, Children.

MR lung perfusion measurements in adolescents after congenital diaphragmatic hernia: correlation with spirometric lung function tests

Objectives To evaluate whether lung perfusion continues to be reduced in 10-year-old children after congenital diaphragmatic hernia (CDH) and whether lung perfusion values correlate with spirometric lung function measurements. Methods Fifty-four patients after CDH repair received dynamic contrast-enhanced (DCE) magnetic resonance imaging (MRI)-based lung perfusion measurements at the age of 10 years (10.2 ± 1.0 years). Additionally, a control group of 10 children has been examined according to the same protocol. Lung spirometry was additionally available in 43 patients of the CDH group. A comparison of ipsilateral and contralateral parameters was performed. Results Pulmonary blood flow (PBF) was reduced on the ipsilateral side in CDH patients (60.4 ± 23.8 vs. 93.3 ± 16.09 mL/100 mL/min; p < 0.0001). In comparison to the control group, especially the ratio of ipsilateral to contralateral, PBF was reduced in CDH patients (0.669 ± 0.152 vs. 0.975 ± 0.091; p < 0.0001). There is a positive correlation between ipsilateral pulmonary blood flow, and spirometric forced 1-s volume (r = 0.45; p = 0.0024). Conclusions Pulmonary blood flow impairment persists during childhood and correlates with spirometric measurements. Without the need for ionizing radiation, MRI measurements seem promising as follow-up parameters after CDH. Key Points • Ten-year-old children after congenital diaphragmatic hernia continue to show reduced perfusion of ipsilateral lung. • Lung perfusion values correlate with lung function tests after congenital diaphragmatic hernia.

Short-term effects of exposure to PM2.5, PM10, NO2, CO, SO2, O3 on lung function test indices among students of Tehran city, Iran

Introduction: The adverse health effects of air pollution have been observed in many epidemiological studies. The aim of this research was to study the effects of air pollution on pulmonary functions in schoolchildren in Tehran city. Materials and methods: Total number of 167 schoolchildren were selected to participate in this study. Data were analyzed using analysis of variance (ANOVA) and generalized estimating equation (GEE) to determine the relationship of air pollution and lung function tests. Results: The result of this study showed that there are statistically significant differences in value of air pollution between areas. The results present that concentration of O3, PM10, NO2 has a negative association with lung function tests but concentration of CO, PM2.5, and SO2 had no association with decreased lung function tests. Time variable of air pollution was not statistically significant effect on lung function test. Conclusion: In this study, we conclude that air pollution in Tehran city can be decreased lung function test indexes that may be affected by short-time exposure to air pollutant.

Comparison of clinical characteristics between mild chronic bronchitis and severe chronic bronchitis in patients with chronic obstructive pulmonary disease

Background Chronic bronchitis (CB) is associated with poor outcomes in patients with chronic obstructive pulmonary disease. The aim of this study was to identify the characteristics that distinguish chronic bronchitis (CB) from non-CB. In addition, the features of mild CB vs. severe CB were compared and a cut-off level was defined according to CAT1 and CAT2 scores. Methods This study was based on the Korea COPD Subgroup Study (KOCOSS) database, constructed in a multicenter COPD cohort study that recruited patients from 54 centers. CB was defined as CAT1 and CAT2 scores ≥3; severe CB was defined as CAT1 and CAT2 scores ≥4, while mild CB was defined as either a CAT1 or a CAT2 score < 4. Baseline characteristics, 1-year exacerbation rate, and 3-year FEV1 decline were compared in non-CB vs. CB patients and in patients with mild CB vs. severe CB. Results Among the 2,162 patients enrolled in this study, 497 (23%) had CB. These patients were more likely than non-CB patients to be current smokers; they also had higher symptom and depression/anxiety scores. Lung function tests showed lower FEV1, FEV1/FVC, and DLco values in CB patients. Among CB patients, 67.6% had mild disease. Symptom and depression/anxiety scores were worse in patients with severe CB than in patients with mild CB. There were no significant differences in the lung function tests of the two groups. Analysis of 1-year exacerbation rates in CB patients and non-CB patients revealed that patients with CB more frequently had moderate-to-severe exacerbations (OR = 1.46, p < 0.01). More severe exacerbation was also present in patients with severe CB than in patients with mild CB (OR = 2.52, p = 0.01). The difference in annual FEV1 decline rate did not significantly differ either between CB patients and non-CB patients or between patients with severe CB and patients with mild CB. Conclusions CB patients had worse symptoms and lung function than non-CB patients; CB patients also had more frequent moderate-to-severe exacerbation. Patients with severe CB had higher symptom scores and more frequent severe exacerbation than did patients with mild CB.

Causes, diagnosis and treatment of occupational asthma

Occupational asthma is usually characterized by airway hyperresponsiveness, airway obstruction, and airway inflammation that usually result from exposure to specific irritants in the workplace and is not usually associated with any evidence of exacerbation outside the workplace. Occupational asthma can be associated with complicated long-term outcomes because affected patients are not usually aware of the hazards of the condition. Therefore, applying adequate diagnostic and management approaches is essential to enhance the outcomes among high-risk workers. In the present literature review, we have discussed the causes, diagnosis, and management of occupational asthma based on the evidence obtained from the current studies in the literature. Our findings indicated the presence of various environmental triggers that can lead to the development of asthma in the workplace, including HMW and LMW compounds. The diagnosis of asthma is based on obtaining a thorough personal and clinical history from the affected patient. However, such approaches have been reported to have low specificity rates, and therefore, the diagnosis should be established by other measures as lung function tests. The management of asthma is hugely dependent on the clinical phenotypes of occupational asthma. Nevertheless, applying adequate interventions can significantly enhance the outcomes in the affected patients, in addition to the other measures that have been adequately discussed in the manuscript.

Clinical value of bronchodilator response for diagnosing asthma in steroid-naïve adults

Spirometry and testing for bronchodilator response have been recommended to detect asthma, and a bronchodilator response (BDR) of ≥12% and ≥200 mL has been suggested to confirm asthma. However, the clinical value of bronchodilation tests in newly diagnosed steroid-naïve adult patients with asthma remains unknown. We evaluated the sensitivity of BDR in FEV1 as a diagnostic test for asthma in a real-life cohort of participants in the Seinäjoki Adult Asthma Study (SAAS). In the diagnostic phase, 369 spirometry tests with bronchodilation were performed for 219 steroid-naïve patients. The fulfilment of each test threshold was assessed. According to the algorithm of the National Institute for Health and Care Excellence, we divided the patients into obstructive (FEV11/FVC<0.70) and non-obstructive (FEV1/FVC≥0.70) groups. Of the overall cohort, 35.6% fulfilled ΔFEV1≥12% and ≥200mL for the initial FEV1, 18.3% fulfilled ΔFEV1≥15% and ≥400 mL for the initial FEV1 and 36.1% fulfilled ΔFEV1≥9% of predicted FEV1 at least once. One-third (31%) of these steroid-naïve patients was obstructive (pre-bronchodilator FEV1/FVC<0.7). Of the obstructive patients, 55.9%, 26.5% and 48.5%, respectively, met the same thresholds. In multivariate logistic regression analysis, different thresholds recognized different kinds of asthma patients. In steroid-naïve adult patients, the current BDR threshold (ΔFEV1≥12% and ≥200 mL) has low diagnostic sensitivity (36%) for asthma. In obstructive patients, sensitivity is somewhat higher (56%) but far from optimal. If the first spirometry test with bronchodilation is not diagnostic but asthma is suspected, spirometry should be repeated, and other lung function tests should be used to confirm the diagnosis.

EP.TH.1025The necessity of pre-operative investigations for elective surgical patients

Introduction Patients admitted for elective surgeries tend to get quite a few investigations at pre assessment. Are these strictly necessary? Are there significant cost implications? National Institute for health and Care Excellence first issued guidance on routine preoperative tests for elective surgery in 2003. Aims To carry out an audit of pre-operative investigations of elective surgical patients at pre-admission. To determine level of unnecessary tests. Results Regarding correlation between ASA grades and over testing, grade 4 is the highest and grade 2 is the lowest in meeting standard guideline per ASA grade. Only 20% intermediate surgical cases meet the guideline whereas 30% of minor and 85% of major cases meet guideline per surgery grade respectively. Majority of unnecessary tests are carried out in minor and intermediate cases. Very few cases of missing tests. Only four tests that should have been taken as per the guideline weren’t done in the whole cohort. For all cases,57.4% of FBC,38.2% of U&Es, 48.5% ECG and 5.9% lung function tests carried out unnecessarily. Conclusion Generally we are over-testing patients at pre-assessment. This seems to be an issue with minor and intermediate cases, with majors generally doing better in fulfilling the guidelines. This may not be deliberate but coincidence as major surgeries call for more tests. Over-testing is more of an issue in lower (1-2) ASA grades in minor and intermediate surgeries. Under-testing is very rare. Using NICE’s estimated costs for each test, approximately £965.78 was spent in 1.5 months for tests which were not needed.