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Race-neutral spirometry reference equations change the interpretation of tests in South East Asian and Black
Josie Chrenek1, Akshdeep Sandhu2, Jasneet Dhillon3
1Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.
Insights
New race-neutral spirometry equations significantly alter pediatric lung function assessments. The Global Lung Function Initiative (GLI) Global equations reduce obstruction in South East Asians but increase impairment severity in Black children, necessitating careful clinical implementation.
Area of Science:
- Pediatric Pulmonology
- Respiratory Medicine
- Clinical Diagnostics
Background:
- The 2012 Global Lung Function Initiative (GLI) spirometry equations utilize race, potentially leading to disparities in respiratory condition diagnosis and management.
- The impact of newly introduced race-neutral GLI Global equations on pediatric populations remains understudied.
Purpose of the Study:
- To compare the identification of pediatric lung function impairments and their severity using race-specific versus race-neutral GLI equations.
- To assess the clinical implications of transitioning to race-neutral spirometry reference values in children.
Main Methods:
- Retrospective analysis of spirometry data from pediatric patients (5-18 years) at British Columbia Children's Hospital.
- Interpretation of data using both race-specific 2012 GLI and race-neutral GLI Global equations.
- Assessment of impairment severity via forced expiratory volume in 1 second (FEV1) z-scores and classification of tests (normal, obstructive, restrictive, mixed).
Main Results:
- Race-neutral equations decreased FEV1 z-scores in Black children (mean -0.77), increasing impairment severity in 22.7%, while Caucasian children showed increased FEV1 z-scores (mean +0.36) with decreased severity in 13.5%.
- Suspected restriction increased in Black children (20.5% to 43.2%) and decreased in Caucasian children (14.4% to 9.0%).
- South East Asian children experienced a significant reduction in obstructive impairments (17.1% to 7.8%) with race-neutral equations.
Conclusions:
- Race-neutral GLI equations significantly reduce obstruction in South East Asian children but increase lung function impairment severity and restriction in Black children.
- Clinical implementation of race-neutral GLI equations requires careful consideration of diagnostic and management implications for pediatric patients.
Rationale:
The 2012 Global Lung Function Initiative (GLI) spirometry reference equations rely on race to predict pulmonary function, which may disproportionately affect diagnosis and management of respiratory conditions in certain groups. However, the impacts of newly endorsed race-neutral GLI Global equations have been understudied in pediatric populations.
Objectives:
To evaluate differences in percentage and severity of pediatric lung function impairments identified using the race-specific 2012 GLI equations compared to the race-neutral GLI Global equations.
Methods:
Retrospective spirometry data for British Columbia Children's Hospital patients aged 5-18 years from August 2022 to June 2024 was interpreted using the race-specific and race-neutral GLI equations. Impairment severity was assessed with forced expiratory volume in 1 second (FEV1) z-scores. FEV1, forced vital capacity (FVC), and FEV1/FVC lower limits of normal were used to classify tests as normal, obstructive, suspected restrictive, or suspected mixed.
Results:
Spirometry results from 1759 Caucasian, 44 Black, 31 North East Asian, 421 South East Asian, and 691 Other/Mixed individuals were analyzed. Compared to the race-specific, the race-neutral equations identified a mean decrease in FEV1 z-score of 0.77 (95% CI, 0.67-0.86) in the Black population, corresponding to increased impairment severity in 22.7% (95% CI, 11.5%-37.8%) of this group. In contrast, the Caucasian population showed a mean increase in FEV1 z-score of 0.36 (95% CI, 0.35-0.37), with decreased severity observed in 13.5% (95% CI, 11.9%-15.2%). Percentage of suspected restriction increased in Black individuals from 20.5% (95% CI, 9.8%-35.3%) to 43.2% (95% CI, 28.3%-59.0%) and decreased in Caucasian from 14.4% (95% CI, 12.8%-16.2%) to 9.0% (95% CI, 7.7%-10.5%). The South East Asian group experienced the largest increase in mean FEV1/FVC z-score using the race neutral equations, rising by 0.45 (95% CI, 0.44-0.46), which corresponded to a reduction in obstructive impairments from 17.1% (95% CI, 13.6%-21.0%) to 7.8% (95% CI, 5.5%-10.8%).
Conclusions:
The race-neutral GLI equations produced the greatest decrease in obstruction in the South East Asian population, while the largest increases in severity and suspected restriction were found in the Black population. The diagnostic and management implications of these changes will require consideration as the race-neutral equations are implemented clinically for pediatric patients.
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