Gender Reference Use in Spirometry for Transgender Patients

ERS/ATS Global Lung Function Initiative normal values and classifying severity based on z-scores instead of per cent predicted

Among the most discussed issues in the field of pulmonary function testing are reference equations and standardised methods of interpreting pulmonary function test (PFT) results. The Global Lung Function Initiative (GLI) task force gathered information from multiple countries with diverse ethnicities to create a multi-ethnic reference formula suitable for a broad age range. Their first output was the GLI-2012 spirometry reference equations. Together with the GLI-2012 reference equations, the GLI document recommended the use of z-scores to standardise the interpretation of PFT results. Z-scores were introduced as an alternative to per cent predicted and fixed thresholds in interpreting PFTs. After more than a decade, there is still debate on which method of interpretation is better.

The Current State of Health Inequities in COPD

An understanding of the health inequities that surround the treatment and prevention of COPD is required to address the barriers that hinder improvement of care for underserved populations. This scoping review was conducted to identify the existing evidence of social factors that affect the health, health-care access, and health-care quality of patients with COPD within the United States, and to identify gaps in knowledge to help direct future research. We followed the guidelines from the Joanna Briggs Institute and Preferred Reporting Items for Systematic reviews and Meta Analyses Extension for Scoping Reviews. In July 2022, a literature search by using Ovid (Embase) and MEDLINE (PubMed) databases was conducted to identify articles on COPD, published between 2016 and 2021, written in English, and that investigated at least one health inequity as defined by the National Institutes of Health. All studies were screened for inclusion criteria and were extracted in a masked, duplicate manner. Each health inequity was investigated, extracted, and summarized. Thirty articles were screened in full text, and 19 were found to meet inclusion criteria. Common social factors investigated in the COPD literature included race/ethnicity, income, and education. Since the implementation of the National Institutes of Health's sex and gender minority category in 2016, only one study within our sample examined LGBTQ+ (lesbian, gay, bisexual, transgender, queer [or sometimes questioning], and others) patients with COPD. The least commonly investigated social factors that affect patients with COPD were rural/under-resourced (geography), sex and gender, and LGBTQ+ affiliation. In addition, occupational status was not investigated by any included studies in our sample. Our scoping review underlines the lack of research with regard to inequities that affect patients with COPD. We propose researching hormone replacement therapy's impact on lung function in transgender and nonbinary patients with COPD. Implementation science studies are suggested to enhance intervention for COPD medication adherence among racial/ethnic minority groups, given the intersectionalities of social factors that disproportionately affect this population. We, also recommend developing telemedicine pulmonary rehabilitation technology for rurally located patients with COPD.

Addressing sex and gender to improve asthma management

Sex (whether one is 'male' or 'female', based on biological characteristics) and gender (defined by socially constructed roles and behaviors) influence asthma diagnosis and management. For example, women generally report more severe asthma symptoms than men; men and women are exposed to different asthma-causing triggers; men tend to be more physically active than women. Furthermore, implicit, often unintended gender bias by healthcare professionals (HCPs) is widespread, and may result in delayed asthma diagnosis, which can be greater in women than men. The sex and gender of the HCP can also impact asthma management. Pregnancy, menstruation, and menopause can all affect asthma in several ways and may be associated with poor asthma control. This review provides guidance for considering sex- and gender-associated impacts on asthma diagnosis and management and offers possible approaches to support HCPs in providing personalized asthma care for all patients, regardless of their sex or gender.

ERS/ATS technical standard on interpretive strategies for routine lung function tests

BACKGROUND

Appropriate interpretation of pulmonary function tests (PFTs) involves the classification of observed values as within/outside the normal range based on a reference population of healthy individuals, integrating knowledge of physiological determinants of test results into functional classifications and integrating patterns with other clinical data to estimate prognosis. In 2005, the American Thoracic Society (ATS) and European Respiratory Society (ERS) jointly adopted technical standards for the interpretation of PFTs. We aimed to update the 2005 recommendations and incorporate evidence from recent literature to establish new standards for PFT interpretation.

METHODS

This technical standards document was developed by an international joint Task Force, appointed by the ERS/ATS with multidisciplinary expertise in conducting and interpreting PFTs and developing international standards. A comprehensive literature review was conducted and published evidence was reviewed.

RESULTS

Recommendations for the choice of reference equations and limits of normal of the healthy population to identify individuals with unusually low or high results are discussed. Interpretation strategies for bronchodilator responsiveness testing, limits of natural changes over time and severity are also updated. Interpretation of measurements made by spirometry, lung volumes and gas transfer are described as they relate to underlying pathophysiology with updated classification protocols of common impairments.

CONCLUSIONS

Interpretation of PFTs must be complemented with clinical expertise and consideration of the inherent biological variability of the test and the uncertainty of the test result to ensure appropriate interpretation of an individual's lung function measurements.