Increased postoperative complications after laparoscopic gastrectomy in patients with preserved ratio impaired spirometry

BACKGROUND

Preserved ratio impaired spirometry (PRISm), defined as decreased forced expiratory volume in the first second in the setting of normal ratio, is associated with an increased risk of respiratory disease and systemic comorbidities. Unlike severe obstructive pulmonary disease, little is known about the impact of PRISm on short-term outcomes in patients undergoing laparoscopic gastrectomy (LG) and its association with small airway dysfunction (SAD).

METHODS

This study enrolled 830 patients who underwent preoperative spirometry and LG between January 2021 and August 2023. Of these, 228 patients were excluded. Participants were categorized into 3 groups based on their baseline lung function, and postoperative outcomes were subsequently analyzed. Potential associations between postoperative outcomes and various clinical variables were examined using univariate and multivariate analyses.

RESULTS

PRISm was identified in 16.6% of the patients, whereas SAD was present in 20.4%. The incidence of postoperative pulmonary complications (PPCs) was notably higher in the SAD group (20.3% vs 9.8%, P = .002) and the PRISm group (28.0% vs 9.8%, P < .001) than the normal group. Among the 3 groups, pneumonia was the most frequently observed PPC. Multivariate analysis revealed that both SAD (odds ratio [OR], 2.34; 95% CI, 1.30-4.22; P = .005) and PRISm (OR, 3.26; 95% CI, 1.80-5.90; P < .001) independently constituted significant risk factors associated with the occurrence of PPCs. Univariate analysis showed that female was a possible risk factor for PPCs in PRISm group.

CONCLUSION

Our study showed that PRISm and SAD were associated with the increased PPCs in patients undergoing LG for gastric cancer.

Prevalence, characteristics and significant predictors for cardiovascular disease of patients with preserved ratio impaired spirometry: A 10-year prospective cohort study in China

BACKGROUND AND OBJECTIVE

Patients with preserved ratio impaired spirometry (PRIsm) have higher incidence rate of cardiovascular disease (CVD). However, few studies focused on PRIsm in China. We determined the prevalence and characteristics of patients with PRIsm in Chinese population. We also aimed to investigate the significant predictive factors of CVD in PRIsm patients.

METHODS

In total, 6994 subjects aged from 35 to 70 years old and free of CVD at baseline were categorized into normal (n = 3895), PRIsm (the ratio of forced expired volume in the first second (FEV1) to forced vital capacity (FVC) ≥0.7 and FEV1 <80 % predicted; n = 1997) and obstructive spirometry (FEV1:FVC<0.7; n = 1102). Cox proportional hazards multivariable regression was performed to investigate how baseline characteristics impact CVD incidence.

RESULTS

In participants with PRIsm, men had a 0.68-fold higher risk of CVD incidence than women (HR, 1.68; 95%CI, 1.09-2.59; p = 0.020). Our study showed that the rate of CVD incidence increased by 6.0 % with every year's increase in age (HR, 1.06; 95%CI, 1.04-1.09; p < 0.001). A 0.1 increase in FEV1/FVC was significantly associated with a 23.0 % decrease in CVD incidence (HR, 0.77; 95%CI, 0.61-0.97; p = 0.028). Family history of CVD greatly increased the risk of cardiovascular disease incidence (HR, 1.83; 95%CI, 1.18-2.83; p = 0.007). Higher BMI was also a significant risk factor of CVD incidence (HR, 1.06; 95%CI, 1.01-1.10; p = 0.013).

CONCLUSION

The prevalence of PRIsm in China was high. PRIsm subjects should be monitored carefully, especially for the older, male, those with higher BMI, lower FEV1/FVC and family history of CVD.

Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2023 Guidelines Reviewed

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) report is an essential resource for all clinicians who strive to provide optimal care to patients with chronic obstructive lung disease (COPD). The annual report of GOLD makes few revisions and updates besides including data from the preceding year. At an interval, GOLD comes up with a significant modification in its guidelines, which is generally a major overhaul of the pre-existing guidelines. According to the latest 2023 updates, published in November 2022, there have been significant advancements made in the field of COPD. These include the development of more precise definitions for COPD and its exacerbations, the introduction of a new set of parameters to measure exacerbation severity, and updating the COPD assessment tool. Additionally, revisions have been made to the initial and follow-up treatment guidelines. The report also simplifies the treatment algorithm and sheds light on new findings that suggest the use of pharmacological triple therapy can reduce mortality rates. Furthermore, the report includes discussions on inhaler device selection and adherence to COPD medications. These improvements demonstrate a continued effort to enhance COPD treatment and management. Although there are some areas that could benefit from more detailed guidance and explanation, such as the proper utilization of blood eosinophil counts for treatment decisions, and the establishment of treatment protocols post-hospitalization, the latest modifications to the GOLD recommendations will undoubtedly aid healthcare providers in addressing any gaps in patient care. We aim to highlight key changes in the GOLD 2023 report and present a viewpoint about their potential implications in a real-world clinical scenario.

Impact of the metabolic syndrome on cardiopulmonary morbidity and mortality in individuals with lung function impairment: a prospective cohort study of the Danish general population

Background

Whether the metabolic syndrome plays a role for the prognosis of individuals with lung function impairment (preserved ratio impaired spirometry (PRISm) or airflow limitation) is unclear. We hypothesised that the metabolic syndrome in individuals with lung function impairment is associated with increased cardiopulmonary morbidity and mortality.

Methods

The Copenhagen General Population Study was initiated in 2003 based on a random sample of white men and women aged 20-100 years drawn from the Danish general population. The risk of ischemic heart disease/heart failure, respiratory disease, and all-cause mortality was analysed with Cox models adjusted for age, sex, current smoking, and asthma during 15 years of follow-up.

Findings

Among 106,845 adults, 86,159 had normal lung function, 6126 had PRISm, and 14,560 had airflow limitation. We observed 10,448 hospital admissions for ischemic heart disease/heart failure, 21,140 for respiratory disease, and 11,125 deaths. Individuals with versus individuals without the metabolic syndrome generally had higher 5-year absolute risk of all outcomes, including within those with normal lung function, mild-moderate-severe PRISm, and very mild-mild-moderate-severe airflow limitation alike. Compared to individuals without the metabolic syndrome and with normal lung function, those with both the metabolic syndrome and severe PRISm had hazard ratios of 3.74 (95% CI: 2.53-5.55; p < 0.0001) for ischemic heart disease/heart failure, 5.02 (3.85-6.55; p < 0.0001) for respiratory disease, and 5.32 (3.76-7.54; p < 0.0001) for all-cause mortality. Corresponding hazard ratios in those with both the metabolic syndrome and severe airflow limitation were 2.89 (2.34-3.58; p < 0.0001) for ischemic heart disease/heart failure, 5.98 (5.28-6.78; p < 0.0001) for respiratory disease, and 4.16 (3.50-4.95; p < 0.0001) for all-cause mortality, respectively. The metabolic syndrome explained 13% and 27% of the influence of PRISm or airflow limitation on ischemic heart disease/heart failure and all-cause mortality.

Interpretation

The metabolic syndrome conferred increased risk of cardiopulmonary morbidity and mortality at all levels of lung function impairment.

Funding

Danish Lung Foundation, Danish Heart Foundation, Capital Region of Copenhagen, and Boehringer Ingelheim. JV is supported by the NIHR Manchester BRC.

adults

We examined 9556 individuals aged 18 to 79 years who had information on spirometry testing and heavy metals and used multivariable logistic or linear regression to evaluate associations between serum levels of cadmium, lead, and mercury and PRISm and lung function in U.S. adults, which were conducted first in all participants, and then separately in never/former smokers and current smokers. The overall prevalence of PRISm was 7.02%. High levels of serum cadmium were significantly associated with PRISm in all individuals, no matter in never/former smokers (quartile 4 vs 1, the OR = 2.517, 95% CI = 1.376-4.604, p-trend = 0.0077) and current smokers (quartile 4 vs 1, the OR = 2.201, 95% CI = 1.265-3.830, p-trend = 0.0020). Serum lead and mercury were not significantly correlated with PRISm, regardless of smoking status. Serum cadmium was strongly correlated with lower FEV1/FVC, regardless of smoking status. Besides, serum cadmium was also significantly related to lower FVC % predicted in never/former smokers and lower FEV1% predicted in current smokers. Serum lead was strongly correlated with lower FVC % predicted and FEV1/FVC in all individuals and never/former smokers. And serum mercury was significantly associated with decrements in FVC % predicted in all individuals and current smokers. These findings demonstrate that serum cadmium is associated with a higher risk of PRISm and lower lung function, with the most significant effect on FEV1/FVC in particular. Our results also indicate that exposure to lead and mercury negatively affects lung function in never/former smokers and current smokers, respectively.

Clinical Manifestations of Subjects With the Non-Specific Pulmonary Function Test Pattern

Introduction

Non-specific pattern (NSP) is a subgroup of preserved ratio impaired spirometry (PRISm) that requires a normal total lung capacity measurement. NSP has been historically classified as being an obstructive lung disease pattern. There has been heightened interest and investigation into PRISm recently as it has been associated with an increased likelihood of developing chronic obstructive pulmonary disease (COPD). Given the inherent challenges of understanding the clinical significance of the NSP, the aim of this study was to further explore the clinical characteristics of patients with this pulmonary function test pattern.

Material and methods

We identified 111 and 79 subjects using pre-bronchodilator (pre-BD) and post-bronchodilator (post-BD) values, respectively, that met criteria for NSP. The outpatient medical records were retrospectively reviewed for associated diagnoses that were then clustered into 'obstructive' or 'non-obstructive' groups based on the treating physician's primary pulmonary clinical diagnosis.

Results

Within this NSP cohort, cough, wheezing and sputum production were documented more frequently in those with an obstructive lung disease diagnosis. Whether identified using pre-BD or post-BD spirometric values, those with NSP and a positive BD response were more likely to carry an obstructive lung disease diagnosis.

Conclusion

Approximately one third of patients with NSP in this study were not given an obstructive lung disease diagnosis by their clinician, which supports the classification of NSP as not an exclusively obstructive lung disease pattern. However, the presence of supporting clinical symptoms, such as cough with sputum production and wheeze, and/or a positive BD response on PFT, support a diagnosis of obstruction in patients with NSP.

The relationship between preserved ratio impaired spirometry and mortality in the myocardial infarction survivors: a population-based cohort study

INTRODUCTION

Preserved ratio impaired spirometry (PRISm) is a subtype of pulmonary function abnormality which is characterized by a proportional reduction in non-obstructive expiratory lung volume. Currently, no studies have shown a relationship between PRISm and mortality in myocardial infarction (MI) survivors.

METHODS

We used cohort data from U.S. adults who attended the National Health and Nutrition Examination Survey (NHANES) from 2007 to 2012. According to the ratio of forced expiratory volume in the first second (FEV1) to forced vital capacity (FVC), we divided lung function into normal spirometry (FEV1/ FVC) ≥ 70%, FEV1 ≥ 80%), PRISm (FEV1/FVC ≥ 70%, FEV1 < 80%) and obstructive spirometry (FEV1/FVC < 70%). Cox regression was used to estimate the correlation between lung functions and mortality among MI patients. Kaplan-Meier survival curves compared the prognosis of MI with three different lung functions. We further verify the stability of the results by sensitivity analysis.

RESULTS

411 subjects were included in our research. The mean follow-up time for the study was 105 months. Compared with normal spirometry, PRISm was significantly correlated with a greater relative risk for all-cause mortality (adjust HR 3.41, 95% confidence interval [95%CI]: 1.76-6.60, P < 0.001) and cardiovascular mortality (adjust HR 13.9, 95%CI: 2.60-74.6, P = 0.002). PRISm remains more correlated with all-cause mortality (adjust HR 2.73, 95%CI: 1.28-5.83, P = 0.009) relative to obstructive spirometry. The results are basically stable after sensitivity analysis. Kaplan-Meier survival curves showed that patients with PRISm tended to have the lowest survival during the follow-up period.

CONCLUSION

PRISm is an independent risk factor for all-cause and cardiovascular mortality in MI survivors. The presence of PRISm was associated with a significantly higher risk of all-cause mortality compared with obstructive spirometry.

Longitudinal mortality of preserved ratio impaired spirometry in a middle-aged Asian cohort

BACKGROUND

Although preserved ratio impaired spirometry (PRISm) has been determined to have poor prognosis, it is a heterogeneous state, and studies regarding its prognosis in Asians are limited. This study investigated the long-term all-cause and cardiovascular mortality of patients with PRISm compared with those of patients with chronic obstructive pulmonary disease (COPD) and normal individuals in the Korean middle-aged general population.

METHODS

Participants were recruited between 2001 and 2002 from a community-based prospective cohort in South Korea. Mortality data were collected over a 16.5-year mean follow-up period. The all-cause and cardiovascular mortality risks of PRISm were compared between patients with COPD and healthy controls.

RESULTS

The PRISm group had a mean age of 53.4 years and mean body mass index of 24.9 kg/m²; furthermore, 55.2% of the PRISm patients had never smoked, and the prevalence of comorbidities was not higher than that in the other groups. Compared with normal individuals, PRISm patients did not show increased all-cause mortality, whereas COPD patients showed increased all-cause mortality (PRISm: adjusted hazard ratio [aHR], 1.19; 95% confidence interval [CI], 0.85-1.65; COPD: aHR, 1.34, 95% CI, 1.07-1.69). Furthermore, the PRISm patients did not show increased cardiovascular mortality compared with normal individuals (PRISm: aHR, 1.65; 95% CI, 0.92-2.95; COPD: aHR, 1.83; 95% CI, 1.09-3.07).

CONCLUSION

In our population-based cohort, all-cause and cardiovascular mortality risk did not increase in individuals with PRISm compared with normal individuals. Further studies are needed to distinguish a lower-risk subgroup of PRISm with certain characteristics, such as middle-aged, light-smoking Asians without additional cardiovascular risk.

Association between preserved ratio impaired spirometry and sleep apnea in a Chinese community

OBJECTIVE

This study investigated the association between obstructive sleep apnea (OSA) and preserved ratio impaired spirometry (PRISm) in a community population.

METHODS

Baseline data from a prospective cohort study, the Predictive Value of Combining Inflammatory Biomarkers and Rapid Decline of FEV1 for COPD (PIFCOPD), were used for cross-sectional analysis. Participants aged 40-75 years were recruited from the community and their demographic information and medical history were collected. The STOP-Bang questionnaire (SBQ) was used to assess the risk of OSA. Pulmonary function tests were performed using a portable spirometer (COPD-6) and forced expiratory volume in 1 s (FEV1) and 6 s (FEV6) were measured. Routine blood, biochemical, high-sensitivity C-reactive protein (hs-CRP), and interleukin-6 tests were also performed. The pH of the exhaled breath condensate was determined.

RESULTS

A total of 1183 participants were enrolled, of which 221 with PRISm and 962 with normal lung function. The neck circumference, waist-to-hip ratio, hs-CRP concentration, proportion of males, cigarette exposure, number of current smoker, high risk of OSA, and prevalence of nasal and ocular allergy symptoms were significantly higher in the PRISm group than in the non-PRISm group (p < .05). Logistic regression showed that the risk of OSA (odds ratio, 1.883; 95% confidence interval, 1.245-2.848), waist-to-hip ratio, current smoking, and prevalence of nasal allergy symptoms were independently associated with PRISm after correcting for age and sex.

CONCLUSION

These findings showed that OSA prevalence is independently associated with PRISm prevalence. Further studies should confirm the relationship between systemic inflammation in OSA, localized inflammation of the airways, and impaired lung function.

Clinical relevance of multiple confirmed preserved ratio impaired spirometry cases in adults

BACKGROUND

Preserved ratio impaired spirometry (PRISm) is a common spirometry finding, but its heterogeneous manifestations and frequent transitions to airflow limitation (AFL), chronic obstructive pulmonary disease, or normal spirometry hinder establishing an appropriate management strategy. This study examined whether transition to AFL and baseline comorbidities are more frequent in subjects with definite PRISm (PRISm confirmed on both current and past two spirometry tests) versus incident PRISm (PRISm confirmed only on a current test with past normal spirometry records) than in normal spirometry.

METHODS

Archived medical check-up data of subjects aged ≥40 years (n = 10828) with two past spirometry records, in a Japanese hospital, were cross-sectionally analyzed. Among them, data from those with follow-up spirometry after three years (n = 6467) were used to evaluate transition to AFL. PRISm was defined as forced volume in 1 s (FEV₁)/forced vital capacity ≥0.7 and % predicted FEV₁ < 80%.

RESULTS

Overall PRISm prevalence was 6.5%. In multivariable models adjusted for age, sex, smoking status, and body mass index, definite PRISm (n = 290), but not incident PRISm (n = 183), was associated with elevated hemoglobin A1c and C-reactive protein levels, and higher rates of asthma, hypertension, hyperlipidemia, and diabetes than was consistent normal spirometry (n = 9694). The transition to AFL after three years was more frequent in definite PRISm, but not incident PRISm, than in normal spirometry (adjusted hazard ratio [95% confidence interval] = 6.21 [3.42-10.71] and 1.45 [0.23-4.73], respectively).

CONCLUSIONS

Multiple confirmed PRISm on past and baseline spirometry is closely associated with metabolic syndrome factors, asthma history, and future AFL development.

Preserved ratio impaired spirometry is associated with small airway dysfunction and reduced total lung capacity

BACKGROUND

Preserved ratio impaired spirometry (PRISm) refers to decreased forced expiratory volume in 1 s (FEV₁) in the setting of preserved ratio. Little is known about the role of PRISm and its complex relation with small airway dysfunction (SAD) and lung volume. Therefore, we aimed to investigate the associations between PRISm and SAD and lung volume.

METHODS

We conducted a cross-sectional community-dwelling study in China. Demographic data, standard respiratory epidemiology questionnaire, spirometry, impulse oscillometry (IOS) and computed tomography (CT) data were collected. PRISm was defined as post-bronchodilator FEV₁/FVC ≥ 0.70 and FEV₁ < 80% predicted. Spirometry-defined SAD was defined as at least two of three of the post-bronchodilator maximal mid-expiratory flow (MMEF), forced expiratory flow 50% (FEF50), and forced expiratory flow 75% (FEF75) less than 65% of predicted. IOS-defined SAD and CT-defined gas trapping were defined by the fact that the cutoff value of peripheral airway resistance R5-R20 > 0.07 kPa/L/s and LAA_- 856>20%, respectively. Analysis of covariance and logistic regression were used to determine associations between PRISm and SAD and lung volume. We then repeated the analysis with a lower limit of normal definition of spirometry criteria and FVC definition of PRISm. Moreover, we also performed subgroup analyses in ever smoker, never smoker, subjects without airway reversibility or self-reported diagnosed asthma, and subjects with CT-measured total lung capacity ≥70% of predicted.

RESULTS

The final analysis included 1439 subjects. PRISm had higher odds and more severity in spirometry-defined SAD (pre-bronchodilator: odds ratio [OR]: 5.99, 95% confidence interval [95%CI]: 3.87-9.27, P < 0.001; post-bronchodilator: OR: 14.05, 95%CI: 8.88-22.24, P < 0.001), IOS-defined SAD (OR: 2.89, 95%CI: 1.82-4.58, P < 0.001), and CT-air trapping (OR: 2.01, 95%CI: 1.08-3.72, P = 0.027) compared with healthy control after adjustment for confounding factors. CT-measured total lung capacity in PRISm was lower than that in healthy controls (4.15 ± 0.98 vs. 4.78 ± 1.05 L, P < 0.05), after adjustment. These results were robust in repeating analyses and subgroup analyses.

CONCLUSION

Our finding revealed that PRISm was associated with SAD and reduced total lung capacity. Future studies to identify the underlying mechanisms and longitudinal progression of PRISm are warranted.

Subtyping preserved ratio impaired spirometry (PRISm) by using quantitative HRCT imaging characteristics

BACKGROUND

Preserved Ratio Impaired Spirometry (PRISm) is defined as FEV1/FVC ≥ 70% and FEV1 < 80%pred by pulmonary function test (PFT). It has highly prevalence and is associated with increased respiratory symptoms, systemic inflammation, and mortality. However, there are few radiological studies related to PRISm. The purpose of this study was to investigate the quantitative high-resolution computed tomography (HRCT) characteristics of PRISm and to evaluate the correlation between quantitative HRCT parameters and pulmonary function parameters, with the goal of establishing a nomogram model for predicting PRISm based on quantitative HRCT.

METHODS

A prospective and continuous study was performed in 488 respiratory outpatients from February 2020 to February 2021. All patients underwent both deep inspiratory and expiratory CT examinations, and received pulmonary function test (PFT) within 1 month. According to the exclusion criteria and Global Initiative for Chronic Obstructive Lung Disease (GOLD) classification standard, 94 cases of normal pulmonary function, 51 cases of PRISm and 48 cases of mild to moderate chronic obstructive lung disease (COPD) were included in the study. The lung parenchyma, parametric response mapping (PRM), airway and vessel parameters were measured by automatic segmentation software (Aview). One-way analysis of variance (ANOVA) was used to compare the differences in clinical features, pulmonary function parameters and quantitative CT parameters. Spearman rank correlation analysis was used to evaluate the correlation between CT quantitative index and pulmonary function parameters. The predictors were obtained by binary logistics regression analysis respectively in normal and PRISm as well as PRISm and mild to moderate COPD, and the nomogram model was established.

RESULTS

There were significant differences in pulmonary function parameters among the three groups (P < 0.001). The differences in pulmonary parenchyma parameters such as emphysema index (EI), pixel indices-1 (PI-1) and PI-15 were mainly between mild to moderate COPD and the other two groups. The differences of airway parameters and pulmonary vascular parameters were mainly between normal and the other two groups, but were not found between PRISm and mild to moderate COPD. Especially there were significant differences in mean lung density (MLD) and the percent of normal in PRM (PRM^Normal) among the three groups. Most of the pulmonary quantitative CT parameters had mild to moderate correlation with pulmonary function parameters. The predictors of the nomogram model using binary logistics regression analysis to distinguish normal from PRISm were smoking, MLD, the percent of functional small airways disease (fSAD) in PRM (PRM^fSAD) and Lumen area. It had a good goodness of fit (χ² = 0.31, P < 0.001) with the area under curve (AUC) value of 0.786. The predictor of distinguishing PRISm from mild to moderate COPD were PRM^Emph (P < 0.001, AUC = 0.852).

CONCLUSIONS

PRISm was significantly different from subjects with normal pulmonary function in small airway and vessel lesions, which was more inclined to mild to moderate COPD, but there was no increase in pulmonary parenchymal attenuation. The nomogram based on quantitative HRCT parameters has good predictive value and provide more objective evidence for the early screening of PRISm.

Association between Comorbidities and Preserved Ratio Impaired Spirometry: Using the Korean National Health and Nutrition Examination Survey IV-VI

BACKGROUND

Preserved ratio impaired spirometry (PRISm) patients have more frequent respiratory symptoms and an increased risk of mortality. However, studies on comorbidities in these patients are lacking.

OBJECTIVES

We investigated the association between PRISm and comorbidities using the Korea National Health and Nutrition Examination Survey (KNHANES).

METHOD

This cross-sectional study included participants aged ≥50 years from the KNHANES (2007-2015). Participants who did not undergo spirometry or performed inadequately were excluded. We classified participants into 3 groups according to spirometry: PRISm (forced expiratory volume in one second [FEV1] /forced vital capacity [FVC] ≥ 0.7 and FEV1 <80%), chronic obstructive pulmonary disease (COPD) (FEV1/ FVC <0.7), and normal. Multivariate logistic regression analyses were used to evaluate the risk of comorbidities in the PRISm group compared to that in the normal group.

RESULT

The study included 17,515 participants: 12,777 (73.0%), 1,563 (8.9%), and 3,175 (18.1%) in normal, PRISm, and COPD groups, respectively. After adjustment for known risk factors of each disease, hypertension (adjusted odds ratio [95% confidence interval]; 1.31 [1.14-1.50]), diabetes (1.51 [1.29-1.78]), hypercholesterolemia (1.20 [1.04-1.37]), obesity (1.31 [1.15-1.48]), ischemic heart disease (1.58 [1.13-2.22]), chronic renal disease (2.31 [1.09-4.88]), and thyroid disease (1.41 [1.09-1.83]) risks were significantly higher in the PRISm group than in the normal group. The average number of comorbidities was 2.45 in the PRISm group, which was higher than that in the normal (2.1) and COPD (2.03) groups (p < 0.05).

CONCLUSION

The number of comorbidities was significantly higher in the PRISm group than in others. Hypertension, diabetes, obesity, ischemic heart disease, chronic renal disease, and thyroid disease were associated with PRISm after adjustment for risk factors.