Comparison of clinical manifestation among Australian Indigenous and non-indigenous patients presenting with pleural effusion

Retrospective cross-sectional study on bronchiectasis in adult Aboriginal Australians: disease characteristics and comparison with ethnically diverse global bronchiectasis registry cohorts

BACKGROUND

Globally, adult Indigenous people, including Aboriginal Australians, have a high burden of chronic respiratory disorders, and bronchiectasis is no exception. However, literature detailing bronchiectasis disease characteristics among adult Indigenous people is sparse. This study assessed the clinical profile of bronchiectasis among adult Aboriginal Australians and compared against previously published international bronchiectasis registry reports.

METHODS

Aboriginal Australians aged >18 years with chest CT confirmed bronchiectasis between 2011 and 2020 in the Top End Northern Territory of Australia were included. Demographics, chest CT findings, pulmonary function results, sputum microbiology, coexistent medical comorbidities, and pharmacotherapy use were assessed and compared against five published international bronchiectasis registry reports (Australian (ABR), European (European Multicentre Bronchiectasis Audit and Research Collaboration (EMBARC)-Europe), Indian (EMBARC-India), Korean (KMBARC) and the USA (USBRR)).

RESULTS

A total of 459 patients were assessed. In comparison with international and non-Aboriginal Australian national cohorts, Aboriginal Australians were younger (median 56 years (IQR (48, 65)); however, sex distribution (55% female) and body mass index (23 kg/m2 (IQR 19.4-27)) were comparable . Smoking rates were higher at 85% compared with other registry cohorts (22-46%) as was the prevalence of comorbidities (97%): cardiovascular diseases (73%), diabetes mellitus (50%) and chronic obstructive pulmonary disease (83%) compared with other registry cohorts (4-32%; 6-14%; and 14-37%, respectively). Spirometry demonstrated forced expiratory volume in 1 s of 38% predicted in comparison with 61-77% in other cohorts. Sputum microbiology showed Haemophilus influenzae (57%) isolated at 3.4 to 6 times the rate of other registry cohorts and Pseudomonas aeruginosa in 31%. Chest CT demonstrated multilobar and lower lobes involvement in 73% and inhaled pharmacotherapy use was recorded in up to 62% and long-term antibiotics in 5%.

CONCLUSION

The overall bronchiectasis disease burden is higher in Aboriginal Australian adults in comparison with global ethnically diverse non-Indigenous populations. Further efforts are required to address this disparity secondary to bronchiectasis among Indigenous people.

Applicability and Validity of the "Bronchiectasis Severity Index" (BSI) and "FACED" Score in Adult Aboriginal Australians

Background

The prevalence of bronchiectasis is significantly higher among adult Aboriginal Australians (the Indigenous peoples of Australia) compared to non-Aboriginal Australians. Currently, there is no well-established tool to assess bronchiectasis severity specific to Indigenous peoples. Nor has the applicability and validity of the two well-established bronchiectasis severity assessment tools - The "Bronchiectasis Severity Index" (BSI) and "FACED" scale been vigorously tested in an Indigenous population. This retrospective study evaluated the validity of the BSI and FACED amongst an adult Aboriginal Australian cohort with bronchiectasis in the Top End Northern Territory (NT) of Australia.

Methods

Patients with CT confirmed bronchiectasis identified between 2011 and 2020, residing in the Top End of the NT were eligible to be enrolled. The primary endpoint of 4-year mortality was assessed via hospital records, and sensitivity and specificity of the BSI and FACED assessed against this using area under the curve (AUC) receiver operating characteristics analysis. For patients with missing data, a relative BSI / FACED score was used which divided the score recorded for that patient by the total potential score based on their available clinical data.

Results

A total of 456 adult Aboriginal Australian patients >18 years of age were included (55.5% female, median age 49 years). According to the BSI score 43.4% of patients were assessed to have mild, 30.5% moderate and 26.1% severe bronchiectasis (median score 4 (IQR 2, 8)). According to the FACED 80.9% were assessed to have mild, 17.8% moderate and 1.3% severe (median score of 1 (IQR 0, 2)). Four-year mortality was 11.2% (median age of death 55.6 years). Sensitivity and specificity of the BSI combining moderate and severe were 86.3 and 47.2% respectively, and for severe alone 51% and 77%. Sensitivity and specificity of the FACED combining moderate and severe were 21.6% and 81.2%, respectively, and for severe alone 2% and 98.8%. The AUC for the continuous total BSI was 0.703, and the FACED 0.515. Utilising a relative score, based only on data available for patients with missing data (ie lung function or BMI) resulted in slightly improved AUCs for both the BSI (0.717) and FACED (0.571).

Conclusion

Both BSI and FACED bronchiectasis assessment tools may not be ideal in an Indigenous/Aboriginal people's context. However, it may be reasonable to utilise the relative BSI score in this population until Indigenous people's specific bronchiectasis severity assessment tools are developed.

Significance of lung nodules detected on chest CT among adult Aboriginal Australians - a retrospective descriptive study

INTRODUCTION

There are limited data on chest computed tomography (CT) findings in the assessment of lung nodules among adult Aboriginal Australians. In this retrospective study, we assessed lung nodules among a group of adult Aboriginal Australians in the Northern Territory of Australia.

METHODS

Patients who underwent at least two chest CT scans between 2012 and 2020 among those referred to undergo lung function testing (spirometry) were included. Chest CT scans were assessed for the number, location, size and morphological characteristics of lung nodules.

RESULTS

Of the 402 chest CTs assessed, 75 patients (18.7%) had lung nodules, and 57 patients were included in the final analysis with at least two CT scans available for assessment over a median follow-up of 87 weeks. Most patients (68%) were women, with a median age of 58 years and smoking history in 83%. The majority recorded only a single nodule 43 (74%). Six patients (10%) were diagnosed with malignancy, five with primary lung cancer and one with metastatic thyroid cancer. Of the 51 (90%) patients assessed to be benign, 64 nodules were identified, of which 25 (39%) resolved, 38 (59%) remained stable and one (1.8%) enlarged on follow-up. Nodules among patients with malignancy were typically initially larger and enlarged over time, had spiculated margins and were solid, showing no specific lobar predilection.

CONCLUSIONS

Most lung nodules in Aboriginal Australians are likely to be benign. However, a proportion could be malignant. Further prospective studies are required for prognostication and monitoring of lung nodules in this population.

Factors influencing survival and mortality among adult Aboriginal Australians with bronchiectasis-A 10-year retrospective study

Background

The prevalence of bronchiectasis among adult Aboriginal Australians is higher than that of non-Aboriginal Australians. However, despite evidence to suggest higher prevalence of bronchiectasis among Aboriginal people in Australia, there is sparce evidence in the literature assessing clinical parameters that may predict survival or mortality in this population.

Methods

Aboriginal Australians residing in the Top End Health Service region of the Northern Territory of Australia aged >18 years with chest computed tomography (CT) confirmed bronchiectasis between 2011 and 2020 were included. Demographics, body mass index (BMI), medical co-morbidities, lung function data, sputum microbiology, chest CT scan results, hospital admissions restricted to respiratory conditions and all-cause mortality were assessed.

Results

A total of 459 patients were included, of whom 146 were recorded deceased (median age at death 59 years). Among the deceased cohort, patients were older (median age 52 vs. 45 years, p = 0.023), had a higher prevalence of chronic obstructive pulmonary disease (91 vs. 79%, p = 0.126), lower lung function parameters (median percentage predicted forced expiratory volume in 1 s 29 vs. 40%, p = 0.149), a significantly greater proportion cultured non-Aspergillus fungi (65 vs. 46%, p = 0.007) and pseudomonas (46 vs. 28%, p = 0.007) on sputum microbiology and demonstrated bilateral involvement on radiology. In multivariate models advancing age, prior pseudomonas culture and Intensive care unit (ICU) visits were associated with increased odds of mortality. Higher BMI, better lung function on spirometry, prior positive sputum microbiology for Haemophilus and use of inhaled long-acting beta antagonist/muscarinic agents may have a favourable effect.

Conclusion

The results of this study may be of use to stratify high risk adult Aboriginal patients with bronchiectasis and to develop strategies to prevent future mortality.

Hospital admission rates and related outcomes among adult Aboriginal australians with bronchiectasis - a ten-year retrospective cohort study

BACKGROUND

This study assessed hospitalisation frequency and related clinical outcomes among adult Aboriginal Australians with bronchiectasis over a ten-year study period.

METHOD

This retrospective study included patients aged ≥ 18 years diagnosed with bronchiectasis between 2011 and 2020 in the Top End, Northern Territory of Australia. Hospital admissions restricted to respiratory conditions (International Classification of Diseases (ICD) code J) and relevant clinical parameters were assessed and compared between those with and without hospital admissions.

RESULTS

Of the 459 patients diagnosed to have bronchiectasis, 398 (87%) recorded at least one respiratory related (ICD-J code) hospitalisation during the 10-year window. In comparison to patients with a recorded hospitalisation against those without-hospitalised patients were older (median 57 vs 53 years), predominantly females (54 vs 46%), had lower body mass index (23 vs 26 kg/m2) and had greater concurrent presence of chronic obstructive pulmonary disease (COPD) (88 vs 47%), including demonstrating lower spirometry values (forced vital capacity (FVC) and forced expiratory volume in 1 s (FEV1) (median FVC 49 vs 63% & FEV1 36 vs 55% respectively)). The total hospitalisations accounted for 3,123 admissions (median 4 per patient (IQR 2, 10)), at a median rate of 1 /year (IQR 0.5, 2.2) with a median length of 3 days (IQR 1, 6). Bronchiectasis along with COPD with lower respiratory tract infection (ICD code-J44) was the most common primary diagnosis code, accounting for 56% of presentations and 46% of days in hospital, which was also higher for patients using inhaled corticosteroids (81 vs 52%, p = 0.007). A total of 114 (29%) patients were recorded to have had an ICU admission, with a higher rate, including longer hospital stay among those patients with bronchiectasis and respiratory failure related presentations (32/35, 91%). In multivariate regression model, concurrent presence of COPD or asthma alongside bronchiectasis was associated with shorter times between subsequent hospitalisations (-423 days, p = 0.007 & -119 days, p = 0.02 respectively).

CONCLUSION

Hospitalisation rates among adult Aboriginal Australians with bronchiectasis are high. Future interventions are required to explore avenues to reduce the overall morbidity associated with bronchiectasis among Aboriginal Australians.

Correlation of spirometry indices to chest radiology in the diagnosis of chronic airway disease among regional and rural Indigenous Australians

BACKGROUND

The majority of Indigenous Australians reside in non-urban locations, with reduced access to chest radiology such as computed tomography (CT). Spirometry and chest X-ray (CXR) may be used in the absence of CT; however, the correlation of spirometry indices to CT-defined chronic airway diseases (i.e. chronic obstructive pulmonary disease (COPD) and bronchiectasis) compared with CXR among Indigenous people is sparsely reported.

AIM

To evaluate spirometry indices against CXR and CT findings among adult Indigenous Australians.

METHODS

Indigenous patients who had undergone a spirometry test between 2012 and 2020 and had a CXR or chest CT scan assessed for the presence (+ )/absence (- ) of airway diseases were included in this study.

RESULTS

Of 643 patients (57% female, 31% remote/very remote), 364 (57%) had CT and CXR available. Patients who were 'CT- and CXR- ' for airway diseases (48%) recorded a mean FVC, FEV1 and FEV1 /FVC of 61%, 59% and 0.76 compared to 57%, 49% and 0.66 in the 'CT+ and CXR- ' group and 53%, 39% and 0.58 in the 'CT+ and CXR+ ' group. CXR showed sensitivity (44%) and specificity (88%), while spirometry showed 62% and 77% compared to CT. Spirometry demonstrated predominately restrictive impairment among 'CT- and CXR- ' and mixed/obstructive impairment among 'CT+ and CXR- ' and 'CT+ and CXR+ ' groups.

CONCLUSION

Indigenous Australians tend to demonstrate restrictive impairment in the absence of radiological evidence of airway disease. However, in the presence of airway disease, combinations of mixed and obstructive impairments were common. Obstructive impairment shows greater sensitivity for identifying COPD than that shown by CXR; however, CXR shows greater specificity. Hence, spirometry in conjunction with chest radiology should be utilised to aid in the assessment of airway diseases in this population.

Significance and prognostication of mediastinal lymph node enlargement on chest computed tomography among adult Indigenous Australians

INTRODUCTION

There is a lack of data on chest computed tomography (CT) findings on mediastinal lymph node enlargement (MLE), including normal size threshold of less than 10 or 15 mm for MLE among Indigenous Australians. In this study, we assessed the significance and the applicability of the current guidelines for the threshold for abnormal MLE among adult Indigenous Australians.

METHODS

Patients who underwent chest CT between 2012 and 2020 among those referred to undergo lung function test (spirometry) were assessed for the presence of MLE which were classified as Group A (no measurable nodes), Group B (<10 mm), Group C (≥10 to 14.99 mm) and Group D (≥15 mm).

RESULTS

Of the total 67 patients identified to have MLE, 49 patients had at least two CT scans available for assessment over a median follow-up period of 101.3 weeks (IQR: 62.4, 235.6) and were included in the analysis. Evidence of chronic lung disease was common, with a significant proportion demonstrating either COPD or bronchiectasis and a high proportion with smoking history (93%). During the first CT scan, 34/49 (69%) had >10 mm nodes, of which 12/34 (35%) reduced in size, 22/34 (65%) remained stable, and 3/34 (9%) had malignancy on follow-up.

CONCLUSION

Despite most patients demonstrating the presence of significant MLE with varying size and in most >10 mm, the majority remain stable or benign in nature and only a minor proportion showed evidence of lung malignancy. Further prospective studies are needed in the characterisation of MLE among Indigenous patients.

The Impact of Lung Function Parameters on Sleep Among Aboriginal Australians - A Polysomnography and Spirometry Relationship Study

Background

Sleep disorders such as obstructive sleep apnoea (OSA) are known to overlap significantly with airway diseases in various populations. This study assessed the relationship between lung function parameters against polysomnography (PSG) and continuous positive airway pressure (CPAP) adherence data amongst an Aboriginal Australian population.

Methods

Patients who undertook both a diagnostic PSG and spirometry were included. Restrictive, obstructive, and mixed impairments were assessed via global lung function initiative (GLI-2012, ATS/ERS) criteria/guidelines. PSG and CPAP data were evaluated between patients with or without spirometry impairments.

Results

Of the total 771 patients, 248 had PSG and spirometry data available (52% female, 44% remote residents, 78% obese). The majority (89%) had OSA (51% severe), 95 (38%) were observed to have a restrictive impairment, and 31 (13%) had an obstructive or mixed impairment on spirometry. Compared to patients with no spirometric impairment, those with restrictive or obstructive/mixed impairments demonstrated significantly lower sleep efficiency (median 84% vs 79% and 78%), higher apnoea-hypopnea index (AHI) during rapid eye movement (REM) sleep (median 32 vs 52 and 55 events/hour), reduced REM oxygen saturation (SpO₂) (median 94.0% vs 92.0% and 92.5%) and reduced adherence to CPAP therapy (median 39% vs 22% and 17%). Differences in sleep efficiency, REM AHI, and NREM SpO₂ held for patients with obstructive/mixed impairments in multivariate modelling.

Conclusion

Aboriginal Australian patients with OSA have a higher concurrent lung function' impairment. Spirometric impairment appears to negatively influence sleep efficiency, nocturnal SpO₂ and CPAP adherence. This may have substantial implications for OSA management among Aboriginal Australians.

The Prevalence of Bronchodilator Responsiveness "Asthma" Among Adult Indigenous Australians Referred for Lung Function Testing in the Top End Northern Territory of Australia

Background

Among Indigenous Australians, studies examining the clinical significance of airway bronchodilator responsiveness (BDR) are limited. In this retrospective study, we examined the nature of underlying lung disease in adult Indigenous patients with BDR referred for lung function testing (LFT) in the Top End Health Service region of the Northern Territory of Australia.

Methods

Presence or absence of BDR as per usual (FVC or FEV₁ change pre to post ≥12% and ≥0.2L) and updated (2021 ">10% predicted) ATS/ERS criteria among Indigenous and non-Indigenous Australians was determined. The radiological findings in the Indigenous study participants with and without BDR were next assessed for the presence of underlying chronic airway/lung disease.

Results

We found that 123/742 (17%) Indigenous and 578/4579 (13%) non-Indigenous patients had a significant BDR. Indigenous patients with BDR were younger (mean difference 7 years), with a greater proportion of females (52 vs 32%), underweight (15 vs 4%) and current smokers (52 vs 25%). Indigenous patients with BDR displayed lower LFT values, and a higher proportion exhibited FVC BDR compared to non-Indigenous (34 vs 20%). Almost half (46%) of Indigenous patients with BDR had evidence of COPD and/or bronchiectasis on radiology. Adjusting for the presence of radiologic or spirometric evidence of COPD, the presence of BDR was similar between Indigenous and non-Indigenous patients (5-8 vs 7-11%), irrespective of which BDR criteria was used.

Conclusion

BDR was higher overall among Indigenous in comparison to non-Indigenous patients; however, a significant proportion of Indigenous patients demonstrating BDR had evidence of underlying COPD/bronchiectasis. This study highlights that although presence of BDR among Indigenous people may indicate asthma, it may also be observed among patients with COPD/bronchiectasis or could represent asthma/COPD/bronchiectasis overlap. Hence, a combination of clinical history, LFT and radiology should be considered for precise diagnosis of lung disease in this population.

COPD disease knowledge, self-awareness and reasons for hospital presentations among a predominately Indigenous Australian cohort: a study to explore preventable hospitalisation

Background

The prevalence of chronic obstructive pulmonary disease (COPD) is higher among Indigenous Australians than that of non-Indigenous Australians. However, no studies have investigated COPD disease awareness and knowledge among Indigenous Australians. In this study, we assessed the COPD disease awareness among Indigenous and non-Indigenous patients in the Top End Health Service region of the Northern Territory of Australia.

Methods

Of a total convenience sample of 100 adults, 86 patients consented to participate in this study over a 15-month period. A structured interview was conducted to identify participant’s level of knowledge about COPD, medications, self-management, healthcare interaction and utilisations.

Results

Most (69%) participants were Indigenous and men (52%). Indigenous patients were significantly younger (mean 56 vs 68 years p<0.001), with a higher proportion of remote residence and current smoking. COPD knowledge across the cohort was low, with 68% of Indigenous and 19% of non-Indigenous participants reporting they ‘know nothing/had never heard of COPD’. Most patients self-reported use of puffers/inhalers and were able to identify medication used; however, adherence to therapy was observed in only 18%. Shortness of breath was the most common symptom for hospital presentation (83%) and 69% of Indigenous patients reported seeking medical attention during an exacerbation. Self-management and COPD action plans were poorly implemented. A significant proportion (49%) reported ≥2 hospital admissions in the preceding 12 months. During exacerbation, although the majority of Indigenous patients were transferred to a tertiary centre from remote communities, patient’s preference was to be managed in their respective local communities.

Conclusions

Awareness and understanding of COPD are low in this cohort on several domains. Tailored and culturally appropriate initiatives for both patients and health professionals alike are required to improve COPD disease management among Indigenous population. This will not only improve quality of life but also reduce recurrent hospitalisation, healthcare cost and utilisation.

Differences in the Spirometry Parameters Between Indigenous and Non-Indigenous Patients with COPD: A Matched Control Study

Background

Comparison of spirometry parameters between Indigenous and non-Indigenous patients with underlying chronic obstructive pulmonary disease (COPD) has been sparsely reported in the past. In this study, differences in the lung function parameters (LFPs), in particular spirometry values for forced vital capacity (FVC), forced expiratory volume in one second (FEV₁) and FEV₁/FVC ratio between Indigenous and non-Indigenous patients with COPD were assessed.

Methods

In this retrospective study, Indigenous and non-Indigenous patients with a diagnosis of COPD between 2012-2020 according to spirometry criteria (ie; post-bronchodilator (BD) FEV₁/FVC < 0.7) were included. A further analysis was undertaken to compare the differences in the spirometry parameters, including lower limit of normal (LLN) values matching for age, sex, height and smoking status between these two diverse ethnic populations.

Results

A total of 240/742 (32%) Indigenous and 873/4579 (19%) non-Indigenous patients were identified to fit the criteria for COPD. Indigenous patients were significantly younger (mean difference 9.9 years), with a greater proportion of females (50% vs 33%), underweight (20% vs 8%) and current smokers (47% vs 32%). Prior to matching, Indigenous patients' post-BD percent predicted values for FVC, FEV₁, and FEV₁/FVC ratio were 17, 17%, and -2 points lower (Hedges G measure of effect size large (0.91), large (0.87), and small (0.25), respectively). Among the matched cohort (111 Indigenous and non-Indigenous), Indigenous patients LFPs remained significantly lower, with a mean difference of 16%, 16%, and -4, respectively (Hedges G large (0.94), large (0.92) and small (0.41), respectively). The differences persisted despite no significant differences in LLN values for these parameters.

Conclusion

Indigenous Australian patients with COPD display a significantly different demographic and clinical profile than non-Indigenous patients. LFPs were significantly lower, which may or may not equate to greater severity of disease in the absence of normative predictive lung function reference values specific to this population.

Sex differences in pulmonary function parameters among Indigenous Australians with and without chronic airway disease

BACKGROUND

Studies assessing normative values and sex differences in pulmonary function test parameters (PFTPs) among Indigenous populations are sparse.

METHODS

PFTPs were compared between male and female Indigenous Australian adults with and without chest radiologically proven chronic airway diseases (CADs).

RESULTS

485 adults (56% were female) with no significant difference in age, body mass index or smoking status between sexes were included. Females displayed a higher prevalence of radiology without CADs compared to males (66 vs. 52%, respectively). Among patients without CADs, after adjustment for age, stature and smoking, males displayed significantly higher absolute values of Forced Vital Capacity (FVC) (mean difference, 0.41L (0.21,0.62), p<0.001) and Forced Expiratory Volume in one second (FEV1) (mean difference 0.27L (0.07,0.47), p<0.001), with no significant difference in FEV1/FVC ratio (mean difference -0.02 (-0.06, 0.02), p = 0.174). Male and female patients with radiologically proven CADs demonstrated lower FEV1/FVC values. However, compared to females, males showed significantly greater reductions in pre- [-0.53 (-0.74, -0.32) vs. -0.29 (-0.42, -0.16), p = 0.045] and post- [-0.51 (-0.72, -0.3) vs. -0.27 (-0.39, -0.14), p = 0.049] bronchodilator FEV1.

CONCLUSIONS

There are significant sex differences in the PFTPs among Indigenous Australians. Recognising these differences may be of value in the accurate diagnosis, management, monitoring and prognostication of CADs in this population.

Comparison and outcomes of emergency department presentations with respiratory disorders among Australian indigenous and non-indigenous patients

Background

There is sparse evidence in the literature assessing emergency department presentation with respiratory disorders among Indigenous patients. The objective of this study was to evaluate the clinical characteristics and outcomes for Indigenous Australians in comparison to non-Indigenous patients presenting to Emergency Department (ED) with respiratory disorders.

Methods

In this study, two non-contiguous one-month study periods during wet (January) and dry (August) season were reported on, and differences in demographics, respiratory diagnosis, hospital admission, length of hospital stay, re-presentation to hospital after discharge and mortality between Australian Indigenous and non-Indigenous patients was assessed.

Results

There were a total of 528 respiratory ED presentations, 258 (49%) during wet and 270 (51%) in dry season, from 477 patients (52% female and 40% Indigenous). The majority of ED presentations (84%) were self-initiated, with a difference between Indigenous (80%) and non-Indigenous (88%) presentations. Indigenous presentations recorded a greater proportion of transfers from another healthcare facility compared to non-Indigenous presentations (11% vs. 1%). Less than half of presentations (42%) resulted in admission to the ward with no difference by Indigenous status. Lower respiratory tract infections were the most common cause of presentation (41%), followed by airway exacerbation (31%) which was more commonly seen among Indigenous (34%) than non-Indigenous (28%) presentations. Almost 20% of Indigenous patients reported multiple presentations to ED compared to 1% of non-Indigenous patients, though mortality on follow up did not differ (22% for both).

Conclusions

The results of this study may be an avenue to explore possibilities of implementing programs that may be helpful to reduce preventable ED presentation and recurrent hospitalisations among Indigenous population.

Implications of using the GLI-2012, GOLD and Australian COPD-X recommendations in assessing the severity of airflow limitation on spirometry among an Indigenous population with COPD: an Indigenous Australians perspective study

BACKGROUND

Assessment of airflow limitation (AFL) is crucial in the clinical evaluation of patients with chronic obstructive pulmonary disease (COPD). However, in the absence of normative reference values among adult Australian Indigenous population, the implications of utilising the Global Lung Function Initiative (GLI-2012), Global Initiative for Chronic Obstructive Lung Disease (GOLD) and the Australian concise COPD-X recommended severity classifications is not known. Moreover, spirometry values (forced vital capacity (FVC) and forced expiratory volume in 1 s (FEV1)) are observed to be 20%-30% lower in an apparently healthy Indigenous population in comparison to Caucasian counterparts.

METHODS

Adult Indigenous patients diagnosed to have COPD on spirometry (postbronchodilator (BD) FEV1/FVC <0.7 ((GOLD, (COPD-X)) and ≤lower limit of normal (others/mixed reference equations) for GLI-2012) were assessed for AFL severity classifications on Post-BD FEV1 values (mild, moderate, severe, very severe) as per the recommended classifications.

RESULTS

From a total of 742 unique patient records of Indigenous Australians, 253 were identified to have COPD via GOLD/COPD-X criteria (n=238) or GLI-2012 criteria (n=238) with significant agreeance between criteria (96%, κ=0.901). Of these, the majority were classified as having moderate or severe/very-severe AFL with significant variability across classification criteria (COPD-X (40%-43%), GOLD (33%-65%), GLI-2012 (18%-75%)). The FVC and FEV1 values also varied significantly between classification criterion (COPD-X/GOLD/GLI-2012) within the same AFL category, with COPD-X 'moderate' AFL almost matching 'severe' AFL categorisation by GOLD or GLI-2012.

CONCLUSIONS

Health professionals caring for Indigenous patients with COPD should be aware of the clinical implications and consequences of utilising various recommended AFL classifications in the absence of validated spirometry reference norms among adult Indigenous patients.

Validity of the New "Top End Sleepiness Scale" (TESS) against the STOP-Bang Tool in Predicting Obstructive Sleep Apnoea among Indigenous Australian Adults

BACKGROUND

The validity of the newly developed sleepiness assessment tool the "Top End Sleepiness Scale" (TESS) against other established obstructive sleep apnea (OSA) screening tools has not been evaluated.

AIMS

To compare the utility and validity of the culturally safe and clinically relevant subjective daytime sleepiness assessment tool the "TESS" for use among Indigenous Australians against STOP-Bang screening tool in predicting OSA in a regional and remote Indigenous Australian cohort.

METHODS

The TESS questionnaire consisting of pictorial representations of six items representing daily activities that would induce daytime sleepiness specific for Indigenous Australians was assessed for its correlation in predicting moderate to severe OSA according to apnea hypopnea index (AHI, ≥15) against STOP-Bang screening tool.

RESULTS

Eighty Indigenous Australian patients (51% male, mean age 45.1 ± 11.5 years were included in this study with the majority (n=70, 88%) having OSA of which 65 (93%) had an AHI ≥15. AUC statistics for overall scores showed no significant difference between TESS or STOP-Bang in the prediction of OSA (p=0.16). A moderate risk score of TESS (≥3) was superior to the STOP-Bang (score 3-4) in sensitivity (84% vs. 33%) and specificity (39% vs. 30%). The sensitivity for a high risk score for the STOP-Bang (≥5) was superior to the TESS (≥8) (60% vs. 33%), though specificity was comparable (83% vs. 91% respectively).

CONCLUSIONS

The TESS screening tool could be a useful standalone or could be adopted alongside STOP-Bang OSA screening tools in the clinical assessment of sleep disorders among Indigenous Australians. This article is protected by copyright. All rights reserved.

The Effects of Inhaled Airway Directed Pharmacotherapy on Decline in Lung Function Parameters Among Indigenous Australian Adults With and Without Underlying Airway Disease

BACKGROUND

The trajectory of lung function decline among Indigenous patients with or without underlying chronic airway disease (COPD and concomitant bronchiectasis) and with use of inhaled pharmacotherapy, including inhaled corticosteroids (ICS), has not been reported in the past.

METHODS

Adult Indigenous Australian patients identified to have undergone at least two or more lung function tests (LFTs) between 2012 and 2020 were assessed for changes in the lung function parameters (LFPs) between the first and last recorded LFTs.

RESULTS

Of the total 1350 patients identified to have undergone LFTs, 965 were assessed to fulfil session quality, 115 (n=58 females) were eligible to be included with two or more LFTs. Among the 115 patients, 49% showed radiological evidence of airway diseases, and 77% were on airway directed inhaled pharmacotherapy. Median time between LFTs was 1.5 years (IQR 0.86,5.85), with no significant differences in LFPs noted between first and last LFT. Overall rate of change (mL/year) showed considerable variation for FVC (median -37.55 mL/year [IQR -159.88,92.67]) and FEV1 (-18.74 mL/year [-102.49,71.44]) with minimal change in FEV1/FVC (0.00 ratio/year [-0.03,0.01]). When stratified by inhaled pharmacotherapy group, however, patients using ICS showed significantly greater rate of FEV1 decline (-48.64 mL/year [-110.18,62.5]) compared to those using pharmacotherapy with no ICS (15.46 mL/year [-73.5,74.62]) and those using no pharmacotherapy (-5.76 mL/year [-63.19,67.34]) (p=0.022). Additionally, a greater proportion of these patients reached the threshold for excessive FEV1 decline (64%) compared to those using pharmacotherapy without ICS (44%) and those using no pharmacotherapy (52%).

CONCLUSION

Decline in LFPs occurs commonly among adult Indigenous population, especially, excessive so among those using inhaled pharmacotherapy containing ICS.

Chest computed tomography findings among adult Indigenous Australians in the Northern Territory of Australia

INTRODUCTION

There is sparse evidence in the literature in relation to the chest computed tomography (CT) findings among adult Indigenous Australians with chronic respiratory conditions.

METHODS

In this retrospective study, patients who underwent chest CT between 2012 and 2020 among those referred to undergo lung function tests (spirometry) were assessed for the prevalence of abnormal chest CT radiological findings.

RESULTS

Of the 402 patients (59% female) included in this study, 331 (82%) had an abnormality identified on chest CT. Most abnormalities occurred alongside one (25%) or multiple (46%) other CT abnormalities. Airway disease ((AD) (including, emphysema, airway wall thickening and small airway disease) (35%), atelectasis: segmental or lobar collapse (27%), inflammatory opacities (24%) and bronchiectasis (23%) were the most common findings. AD and bronchiectasis were also the most common concurrent abnormalities in 40-50%. Other CT abnormalities noted in isolation or in combination with other CT findings were lung nodules (19%), lymph node enlargement (17%), consolidation or mass (17%), followed by lung cysts, ground-glass opacity, lung parenchymal architectural distortion, cavitating lung lesions and chronic pleural effusion were observed in ≤10%. Predictive models for odds of abnormality and outcomes showed age, smoking and underweight were associated with AD, and male sex and very remote residence were associated with bronchiectasis.

CONCLUSION

This study has illustrated that Indigenous Australian adults have a high prevalence of multiple chest CT abnormalities that may impose unprecedented diagnostic and therapeutic challenges in this population. Further studies are warranted to determine the long-term implications and prognostic significance of the CT findings as demonstrated in this study.