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

Trend of prevalence and characteristics of preserved ratio impaired spirometry (PRISm): Nationwide population-based survey between 2010 and 2019

PURPOSE

This study aimed to evaluate the prevalence, trends, and factors of preserved ratio with impaired spirometry (PRISm) by using a nationally representative sample.

PATIENTS AND METHODS

The datasets of the Korea National Health and Nutrition Examination Survey 2010-2019 were used: of total 32,949 participants aged ≥40 and no missing data on spirometry, 24,523 with normal, 4,623 with obstructive, and 3,803 with PRISm were identified. PRISm was defined as FEV1/FVC ≥70% and FEV1% of the predicted value (%pred) <80. PRISm-lower limit of normal (LLN) was defined when FEV1/FVC ≥LLN and FEV1

RESULTS

Estimated average prevalence of PRISm was 10.4% (PRISm-LLN 11.1%). Joinpoint regression analyses found a relatively stable trend of PRISm for both fixed ratio and LLN. The multivariable-adjusted logistic regression model showed female sex, BMI ≥25 kg/m2, metabolic syndrome, hypertriglyceridemia, abdominal obesity, low HDL-choleterol, hypertension, and diabetes were associated with the increased probability of PRISm.

CONCLUSION

Whenever a PRISm pattern is identified in a clinical context, it may be necessary to measure absolute lung volumes to investigate underlying physiological abnormalities and to identify factors that is modifiable.

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Key Words Collapse

MESH Headings

• Humans
• Spirometry
• Female
• Male
• Middle Aged
• Prevalence
• Republic of Korea/epidemiology
• Adult
• Aged
• Nutrition Surveys
• Forced Expiratory Volume
• Pulmonary Disease, Chronic Obstructive/epidemiology
• Pulmonary Disease, Chronic Obstructive/physiopathology
• Pulmonary Disease, Chronic Obstructive/diagnosis

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Grants

• Ministry of Health and Welfare
• Korean Health Industry Development Institute

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Affiliation(s)

Hyunji Choi Department of Laboratory Medicine, Kosin University Gospel Hospital, Kosin University College of Medicine, Busan, Republic of Korea
Chul-Ho Oak Division of Pulmonology, Department of Internal Medicine, Kosin University Gospel Hospital, Kosin University College of Medicine, Busan, Republic of Korea
Mann-Hong Jung Division of Pulmonology, Department of Internal Medicine, Kosin University Gospel Hospital, Kosin University College of Medicine, Busan, Republic of Korea
Tae-Won Jang Division of Pulmonology, Department of Internal Medicine, Kosin University Gospel Hospital, Kosin University College of Medicine, Busan, Republic of Korea
Sung-Jin Nam Division of Pulmonology, Department of Internal Medicine, Kosin University Gospel Hospital, Kosin University College of Medicine, Busan, Republic of Korea
Taemin Yoon Center for Future Medicine, Kosin University Gospel Hospital, Busan, Republic of Korea

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Risks of Dementia in a General Japanese Older Population With Preserved Ratio Impaired Spirometry: The Hisayama Study

BACKGROUND

Studies on the association between preserved ratio impaired spirometry (PRISm) and dementia are limited. Indeed, PRISm has often been overlooked or ignored as an index of lung function impairment. Therefore, we investigated the association of PRISm with the risk for the development of dementia in an older Japanese population.

METHODS

A total of 1,202 community-dwelling, older Japanese participants aged ≥65 years without dementia were followed up for a median of 5.0 years. Participants were categorized by spirometry as follows: normal spirometry (FEV1/FVC ≥0.70 and FEV1 ≥80% predicted), PRISm (≥0.70 and <80%), airflow limitation (AFL) Global Initiative for Chronic Obstructive Lung Disease (GOLD) 1 (<0.70 and ≥80%), and AFL GOLD 2 to 4 (<0.70 and <80%). Hazard ratios (HRs) and their 95% confidence intervals (CIs) were computed using a Cox proportional hazards model.

RESULTS

During the follow-up period, 122 participants developed dementia. The age- and sex-adjusted incidences of dementia in the participants with normal spirometry, PRISm, AFL GOLD 1, and AFL GOLD 2 to 4 were 20.5, 37.0, 18.4, and 28.6 per 1,000 person-years, respectively. Participants with PRISm had a higher risk of dementia (HR 2.04; 95% CI, 1.19-3.49) than those with normal spirometry after adjusting for confounders. Moreover, both reduced FEV1% predicted values and FVC% predicted values were associated with the risk of dementia.

CONCLUSION

PRISm was associated with an increased risk of dementia in a general older Japanese population.

Preserved Ratio Impaired Spirometry (PRISm): A Global Epidemiological Overview, Radiographic Characteristics, Comorbid Associations, and Differentiation from Chronic Obstructive Pulmonary Disease

Preserved Ratio Impaired Spirometry (PRISm) manifests notable epidemiological disparities across the globe, with its prevalence and influential factors showcasing pronounced diversities among various geographical territories and demographics. The prevalence of PRISm fluctuates considerably among regions such as Latin America, the United States, and Asian nations, potentially correlating with a myriad of determinants, including socioeconomic status, environmental factors, and lifestyle modalities. Concurrently, the link between PRISm and health risks and other disorders, especially its distinction and interrelation with chronic obstructive pulmonary disease (COPD), has become a pivotal subject of scientific enquiry. Radiographic anomalies, such as perturbations in the pulmonary parenchyma and structural alterations, are posited as salient characteristics of PRISm. Furthermore, PRISm unveils intricate associations with multiple comorbidities, inclusive of hypertension and type 2 diabetes, thereby amplifying the intricacy in comprehending and managing this condition. In this review, we aim to holistically elucidate the epidemiological peculiarities of PRISm, its potential aetiological contributors, its nexus with COPD, and its association with radiographic aberrations and other comorbidities. An integrative understanding of these dimensions will provide pivotal insights for the formulation of more precise and personalised preventative and therapeutic strategies.

Proportions and risk factors of chronic obstructive pulmonary disease and preserved ratio impaired spirometry, and association with small airway disease, in the positive screening older population from China: a cross-sectional study

BACKGROUND

Early diagnosing Chronic Obstructive Pulmonary Disease (COPD) is relatively difficult. Therefore, the concepts of preserved ratio impaired spirometry (PRISm) and small airway disease (SAD) were proposed to achieve early diagnosis for COPD. Besides, the occurrence of COPD is positively related to age. However, the relationship among COPD, PRISm, and SAD still requires clarification. Thus, we estimated the proportions and risk factors of COPD and PRISm in the positive screening participants, and searched the methods of early diagnosing COPD via the SAD indicators.

METHODS

A total of 53,641 residents aged more than 60 years old from Shaoxing City, Zhejiang Province, China, completed a series of screening projects. And 2327 of positive screening participants ultimately finished bronchodilator tests. The data were statistically analyzed to figure out the proportions and risk factors of COPD and PRISm, and the efficacy of early diagnosing COPD by the SAD indicators.

RESULTS

Totally 2229 positive screening participants were included, the proportion of PRISm was 6.3% (141/2229), and of COPD was 78.2% (1743/2229). Statistical analyses showed that COPD patients were more likely to be smokers, males, and older. And COPD patients had higher questionnaire scores, meaning that they were more prone to have family history of respiratory diseases and more severe respiratory symptoms. Additionally, COPD patients had lower maximal mid-expiratory flow (MMEF) pred, forced expiratory flow (FEF) 75pred, and FEF50pred. And we found that male sex and presence of respiratory symptoms might lead to COPD and PRISm. Also, the methods of early diagnosing COPD through the SAD indicators might be acceptable.

CONCLUSION

There is a close association between COPD and decreased small airway function (SAF) among the participants included. Age, smoking, male sex, worse SAF, and respiratory symptoms might cause the progressing from normal people to PRISm, then to COPD patients. Besides, the SAD indicators such as MMEFpred, FEF75pred, and FEF50pred were included in lung function tests and bronchodilator tests. Intriguingly, it was found that early diagnosing COPD via the SAD indicators might be feasible. In the future, early diagnosis for COPD requires further research.

Pulmonary Function Trajectories Over 6 Years and Their Determinants in Type 2 Diabetes: The Fremantle Diabetes Study Phase II

OBJECTIVE

To assess whether there are clusters of people with type 2 diabetes with distinct temporal profiles of lung function changes and characteristics.

RESEARCH DESIGN AND METHODS

Group-based trajectory modeling (GBTM) identified groups of participants with type 2 diabetes from the community-based observational Fremantle Diabetes Study Phase II (FDS2) who had at least two biennial measurements of forced expiratory volume in 1 s as a percentage of predicted (FEV1%pred) over 6 years. Independent associates of group membership were assessed using multinomial regression.

RESULTS

Of 1,482 potential FDS2 participants, 1,074 (72.5%; mean age, 65.2 years; 45.5% female; median diabetes duration, 8.0 years) were included in the modeling. The best fitting GBTM model identified four groups categorized by FEV1%pred trajectory: high (19.5%; baseline FEV1%pred, 106.5 ± 9.5%; slope 0%/year), medium (47.7%; FEV1%pred, 87.3 ± 8.7%; slope, -0.32%/year), low (25.0%; baseline FEV1%pred, 68.9 ± 9.8%; slope, -0.72%/year), and very low (7.9%; baseline FEV1%pred, 48.8 ± 9.6%; slope, -0.68%/year). Compared with the high group, the other groups were characterized by nonmodifiable and modifiable risk factors associated with lung function decline in the general population (including ethnicity, marital status, smoking, obesity, coronary heart disease, and chronic respiratory disease). The main, diabetes-specific, significant predictor of group membership was a higher HbA1c in the very low group. There was a graded increase in mortality from 6.7% in the high group to 22.4% in the very low group.

CONCLUSIONS

Measurement of lung function in type 2 diabetes could help optimize clinical management and improve prognosis, including addressing glycemic control in those with a very low FEV1%pred.

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.

The many faces of COPD in real life: a longitudinal analysis of the NOVELTY cohort

Background

The diagnosis of COPD requires the demonstration of non-fully reversible airflow limitation by spirometry in the appropriate clinical context. Yet, there are patients with symptoms and relevant exposures suggestive of COPD with either normal spirometry (pre-COPD) or preserved ratio but impaired spirometry (PRISm). Their prevalence, clinical characteristics and associated outcomes in a real-life setting are unclear.

Methods

To investigate them, we studied 3183 patients diagnosed with COPD by their attending physician included in the NOVELTY study (clinicaltrials.gov identifier NCT02760329), a global, 3-year, observational, real-life cohort that included patients recruited from both primary and specialist care clinics in 18 countries.

Results

We found that 1) approximately a quarter of patients diagnosed with (and treated for) COPD in real life did not fulfil the spirometric diagnostic criteria recommended by the Global Initiative for Chronic Obstructive Lung Disease (GOLD), and could be instead categorised as pre-COPD (13%) or PRISm (14%); 2) disease burden (symptoms and exacerbations) was highest in GOLD 3-4 patients (exacerbations per person-year (PPY) 0.82) and lower but similar in those in GOLD 1-2, pre-COPD and PRISm (exacerbations range 0.27-0.43 PPY); 3) lung function decline was highest in pre-COPD and GOLD 1-2, and much less pronounced in PRISm and GOLD 3-4; 4) PRISm and pre-COPD were not stable diagnostic categories and change substantially over time; and 5) all-cause mortality was highest in GOLD 3-4, lowest in pre-COPD, and intermediate and similar in GOLD 1-2 and PRISm.

Conclusions

Patients diagnosed COPD in a real-life clinical setting present great diversity in symptom burden, progression and survival, warranting medical attention.

Impact of preserved ratio impaired spirometry on coronary artery calcium score progression: a longitudinal cohort study

Background

Preserved ratio impaired spirometry (PRISm) is associated with increased cardiovascular disease (CVD) risk and mortality. However, a causal relationship between PRISm and CVD remains unclear. We investigated the progression of coronary artery calcium (CAC) scores based on the presence of PRISm and reduced forced vital capacity (FVC).

Methods

This retrospective cohort study included 11 420 participants aged ≥40 years with forced expiratory volume in 1 s (FEV1)/FVC ≥0.7 who underwent at least two health screening examinations with coronary computed tomography scan between 2003 and 2020, and were without a history of CVD or interstitial lung disease. Participants with PRISm, defined as FEV1/FVC ≥0.7 and FEV1 <80% predicted, were further divided by low FVC (FVC <80% predicted). We estimated the 5-year progression rates of CAC by comparing participants with and without PRISm at baseline using mixed linear models.

Results

Of the 11 420 participants, 8536 (75%), 811 (7%) and 2073 (18%) had normal spirometry, PRISm with normal FVC and PRISm with low FVC, respectively. During the mean (range) follow-up of 6.0 (0.5-17.2) years, the multivariable adjusted ratio of 5-year CAC progression rates comparing participants with PRISm to those with normal spirometry was 1.08 (95% CI 1.04-1.13). This rate was higher in participants with PRISm with low FVC (1.21 (95% CI 1.12-1.30)) than in those with normal FVC.

Conclusion

In this longitudinal cohort study of subjects without a history of CVD, PRISm was significantly associated with CAC progression, which was more evident in the group with PRISm and low FVC.

Preserved Ratio Impaired Spirometry and Risks of Macrovascular, Microvascular Complications and Mortality Among Individuals With Type 2 Diabetes

BACKGROUND

The prospective associations of preserved ratio impaired spirometry (PRISm) with new-onset macrovascular and microvascular complications and mortality among individuals with type 2 diabetes (T2D) and whether PRISm enhances the prediction ability of an established office-based risk score remain to be elucidated.

RESEARCH QUESTION

Can PRISm be used as a predictor of poor prognosis in individuals with T2D?

STUDY DESIGN AND METHODS

We included 20,047 study participants with T2D and complete data on spirometry at recruitment from the UK Biobank cohort. Multivariable Cox proportional hazards models were used to assess the associations of baseline PRISm (FEV1 to FVC ratio, ≥ 0.70; FEV1, < 80% predicted) with subsequent risks of incident stroke (any type), ischemic stroke, myocardial infarction, unstable angina, coronary heart disease, diabetic retinopathy, diabetic kidney disease, all-cause mortality, cardiovascular mortality, and respiratory mortality.

RESULTS

For this cohort analysis, 4,521 patients (22.55% of participants with T2D) showed comorbid PRISm at baseline. Over a median follow-up of 11.52 to 11.87 years, patients with T2D with PRISm at baseline showed higher risks than those with normal spirometry findings of various T2D complications developing and mortality; the adjusted hazard ratios for PRISm were 1.413 (95% CI, 1.187-1.681) for stroke (any type), 1.382 (95% CI, 1.129-1.690) for ischemic stroke, 1.253 (95% CI, 1.045-1.503) for myocardial infarction, 1.206 (95% CI, 1.086-1.339) for coronary heart disease, 1.311 (95% CI, 1.141-1.506) for diabetic retinopathy, 1.384 (95% CI, 1.190-1.610) for diabetic kidney disease, 1.337 (95% CI, 1.213-1.474) for all-cause mortality, 1.597 (95% CI, 1.296-1.967) for cardiovascular mortality, and 1.559 (95% CI, 1.189-2.044) for respiratory mortality, respectively. The addition of PRISm significantly improved the reclassification ability, based on the net reclassification index, of an office-based risk score by 15.53% (95% CI, 10.14%-19.63%) to 33.60% (95% CI, 20.90%-45.79%).

INTERPRETATION

Individuals with T2D with comorbid PRISm, accounting for a considerable proportion of the population with T2D, showed significantly increased risks of adverse macrovascular and microvascular complications and mortality.

Clinical Characteristics and Medical Utilization of Smokers with Preserved Ratio Impaired Spirometry

Purpose

To investigate the clinical characteristics and medical utilization of smokers with preserved ratio impaired spirometry (PRISm).

Patients and Methods

We used data from the Korean National Health and Nutrition Examination Survey between 2007 and 2012, linked to the Health Insurance Review and Assessment Service. Clinical characteristics and medical utilization, including inpatient admission, emergency department visit, prescribed medication, and medical cost, were retrospectively compared among three groups: normal spirometry, PRISm, and chronic obstructive pulmonary disease (COPD).

Results

A total of 7115 smokers were included (4743 normal spirometry, 689 PRISm, and 1683 COPD subjects). The mean age was the highest in the COPD group, followed by the PRISm and normal groups, and the proportion of women was the highest in the PRISm group. The tobacco exposure, socioeconomic status (SES), and schooling level of the PRISm group were at levels between those of the normal and COPD groups. However, the PRISm group had the highest proportion of current smokers, highest body mass index (BMI), and lowest mean FEV1 and FVC % predicted. During the study period, the medical utilization of 92 smokers (13.4%) in the PRISm group and 436 smokers (25.9%) in the COPD group was related to respiratory diseases. Emergency department visit or hospitalization and overall medical cost of the PRISm group were comparable to those of the COPD group, except for outpatient clinic visit. Old age, women, low BMI, low SES, low schooling level, high amount of tobacco exposure, wheezing, and decreased FEV1 and FVC % predicted were factors associated with medical utilization in PRISm.

Conclusion

Medical utilization was comparable between the PRISm and COPD groups. Smokers with PRISm who were older, women, or heavy smokers with low BMI, low SES and schooling level, wheezing, or low FEV1 and FVC might need close observation and early treatment.

Should we be screening for COPD? - looking through the lens of lung cancer screening

INTRODUCTION

In May 2022, the US Preventive Services Task Force published their recommendation against screening for chronic obstructive pulmonary disease (COPD) in asymptomatic adults. However, we argue the routine use of spirometry in both asymptomatic and symptomatic high-risk smokers has utility.

AREAS COVERED

We provide published and unpublished observations from a secondary analyses of the American College of Radiology Imaging Network (ACRIN), arm of the National Lung Screening Trial, including 18,463 high-risk current or former smokers who underwent pre-bronchodilator spirometry at baseline. According to history alone, 20% reported a prior diagnosis of 'COPD,' although only 11% (about one half), actually had airflow limitation (Diagnosed COPD) and 9% had Global Initiative for Obstructive Pulmonary Disease GOLD 0 Pre-COPD. Of the remaining 80% of 'asymptomatic' screening participants, 23% had airflow limitation (Screen-detected COPD) and 13% had preserved ratio impaired spirometry (PRISm). This means 45% of this high-risk cohort were reclassified by spirometry, and together with comorbid disease, identified subgroups where lung cancer screening efficacy could be optimized by between 2-6 fold.

EXPERT OPINION

Our preliminary findings suggest lung cancer screening outcomes vary according to 'new' COPD-related spirometric-defined subgroups and that screening spirometry, together with comorbid disease, identifies those for whom lung cancer screening is mostly beneficial or potentially harmful.

Restrictive spirometry pattern among construction trade workers

BACKGROUND

Spirometry-based studies of occupational lung disease have mostly focused on obstructive or mixed obstructive/restrictive outcomes. We wanted to determine if restrictive spirometry pattern (RSP) is associated with occupation and increased mortality.

METHODS

Study participants included 18,145 workers with demographic and smoking data and repeatable spirometry. The mortality analysis cohort included 15,445 workers with known vital status and cause of death through December 31, 2016. Stratified analyses explored RSP prevalence by demographic and clinical variables and trade. Log-binomial regression models explored RSP risk factors while controlling for important confounders such as smoking, obesity, and comorbidities. Cox regression models explored mortality risk by spirometry category.

RESULTS

Prevalence of RSP was very high (28.6%). Mortality hazard ratios for RSP were 1.50 for all causes, 1.86 for cardiovascular diseases, 2.31 for respiratory diseases, and 1.66 for lung cancer. All construction trades except painters, machinists, and roofers had significantly elevated risk for RSP compared to our internal reference group. RSP was significantly associated with both parenchymal and pleural changes seen by chest X-ray.

CONCLUSIONS

Construction trade workers are at significantly increased risk for RSP independent of obesity. Individuals with RSP are at increased risk for all-cause mortality as well as mortality attributable to respiratory diseases, cardiovascular diseases, and lung cancer. RSP deserves greater attention in occupational medicine and epidemiology.

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.