BACKGROUND: The impact of the new 2021 European Respiratory Society (ERS)/American Thoracic Society (ATS) pulmonary function test interpretation guidelines on the interpretation of bronchodilator responsiveness (BDR) in subjects with airway obstruction is still required. Therefore, the objective of this study was to explore the agreement between the 2005 and 2021 ERS/ATS criteria regarding the interpretation of the BDR. Moreover, we explore the factors that influenced the discordance of positive bronchodilator responsiveness (BDR+) between these two criteria.
METHODS: The agreement regarding the interpretation of BDR + between the two criteria was assessed using kappa (κ). The percentage of agreement in the interpretation of BDR + between the two criteria was calculated. The factors that influenced the discordance of BDR + between these two criteria were also analyzed.
RESULTS: A total of 500 subjects with a mean age of 60.5 ± 15.6 years, 62.2% male were included. The study observed a good level of agreement in the interpretation of BDR + between the two criteria with kappa values = 0.782. The percentages of agreement on the interpretation of BDR + between the two criteria were high, with values = 90.6%. Male sex was the only factor that influenced the discordance of BDR + between these two criteria.
CONCLUSIONS: A good level of agreement was observed in the interpretation of BDR + between the 2005 and 2021 criteria. Therefore, the 2005 and 2021 ERS/ATS criteria for BDR can be used interchangeably. However, the discordance of BDR + between these two criteria could be affected by sex.

The objective of this review is to provide new advances in our understanding of the clinical importance of establishing peripheral airway impairment (PAI) by impulse oscillometry (IOS) and targeted therapy, which could result in better asthma outcomes. Data sources include PubMed and Google search, limited to English language and human disease, with key words IOS and asthma. Key findings include PAI being consistently associated with uncontrolled asthma across ethnicities, using IOS reference equations factoring Hispanic and White reference algorithms. It is noted that PAI is common even in patients considered well-controlled by asthma guidelines. In a large longitudinal analysis (Assessment of Small Airways Involved in Asthma or ATLANTIS study), a composite of R5-R20, AX, and X5 ordinal scores were independently predictive of asthma control and exacerbation in a multivariate analysis, but forced expiratory volume in 1 second was not significantly predictive of morbidities. However, combining forced expiratory volume in 1 second less than 80% with PAI resulted in greater odds of identifying uncontrolled asthma and exacerbations, than either alone. Applying an external validation method in children with asthma offers the clinician the IOS reference equations best fit for their own specific population. Several clinical phenotypes can also identify PAI with high probability, useful when IOS is not available. Poor asthma outcomes for obese patients with asthma are associated with dysanapsis and PAI, not obesity alone. Extrafine inhaled corticosteroids achieve better asthma control and improve peripheral airway function with fewer exacerbations at lower dosages than nonextrafine inhaled corticosteroid aerosols. In conclusion, these data support the benefit of adding IOS to spirometry in future asthma guidelines and suggest the potential benefit from targeted therapy.

Pectus excavatum is the most common congenital anterior chest wall deformity. Currently, a wide variety of diagnostic protocols and criteria for corrective surgery are being used. Their use is predominantly based on local preferences and experience. To date, no guideline is available, introducing heterogeneity of care as observed in current daily practice. The aim of this study was to evaluate consensus and controversies regarding the diagnostic protocol, indications for surgical correction, and postoperative evaluation of pectus excavatum.
The study consisted of 3 consecutive survey rounds evaluating agreement on different statements regarding pectus excavatum care. Consensus was achieved if at least 70% of participants provided a concurring opinion.
All 3 rounds were completed by 57 participants (18% response rate). Consensus was achieved on 18 of 62 statements (29%). Regarding the diagnostic protocol, participants agreed to routinely include conventional photography. In the presence of cardiac impairment, electrocardiography and echocardiography were indicated. Upon suspicion of pulmonary impairment, spirometry was recommended. In addition, consensus was reached on the indications for corrective surgery, including symptomatic pectus excavatum and progression. Participants moreover agreed that a plain chest radiograph must be acquired directly after surgery, whereas conventional photography and physical examination should both be part of routine postoperative follow-up.
Through a multiround survey, international consensus was formed on multiple topics to aid standardization of pectus excavatum care.

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommends at least annual spirometry for patients with chronic obstructive pulmonary disease (COPD). Since spirometry acquisition is variable in clinical practice, identifying characteristics associated with annual spirometry may inform strategies to improve care for patients with COPD.
We included veterans hospitalized for COPD at Veterans Health Administration (VHA) facilities from 10/2012 to 09/2015. Our primary outcome was spirometry within 1 year of COPD hospitalization. Patient demographics, health factors, and comorbidities as well as practice and geographic variables were identified using Corporate Data Warehouse; provider characteristics were obtained from the Survey of Healthcare Experiences of Patients. We used logistic regression with a random intercept to account for potential clustering within facilities.
Spirometry was completed 1 year before or after hospitalization for 20,683/38,148 (54.2%) veterans across 114 facilities. Patients with spirometry were younger, (mean=67.2 years (standard deviation (SD)=9.3) vs. 69.4 (10.3)), more likely non-white (21.3% vs. 19.7%), and more likely to have comorbidities (p<0.0001 for asthma, depression, and post-traumatic stress disorder). Pulmonary clinic visit was most strongly associated with spirometry (odds ratio (OR)=3.14 [95% confidence interval 2.99-3.30]). There was no association for facility complexity. In a secondary analysis including provider-level data (3862 patients), results were largely unchanged. There was no association between primary care provider age, gender, or type (physician vs. advanced practice registered nurse vs. physician assistant) and spirometry.
In a cohort of high-risk COPD patients, just over half completed spirometry within 1 year of hospitalization. Pulmonary clinic visit was most strongly associated with 1-year spirometry, though provider variables were not. Spirometry completion for high-risk COPD patients remains suboptimal and strategies to improve post-hospitalization care for patients not seen in pulmonary clinic should be developed to ensure guideline concordant care.

BACKGROUND: Recent attempts to refine the definition bronchopulmonary dysplasia (BPD) have based its predictive capacity on respiratory outcome in the first 2 years of life, eliminating the pre-existing requirement of 28 days of oxygen therapy prior to 36 weeks postmenstrual age (PMA). The objective of this study was to assess the utility of the 2001 consensus definition in predicting impaired lung function at preschool age.
METHODS: This cohort study included children aged 4-6 years old who were born at gestational age (GA) <32 weeks or bodyweight <1500 g. Univariate and multivariate analyses were performed to assess differences in antenatal and neonatal variables between BPD and non-BPD children. All participants underwent incentive spirometry. Lung function parameters were contrasted with the Global Lung Function Initiative (GLI-2012) reference equations and, together with antenatal and neonatal variables, compared among the different subgroups (no BPD, mild BPD, and moderate-to-severe BPD). A multivariate model was generated to identify independent risk factors for impaired lung function.
RESULTS: GA, hemodynamically significant patent ductus arteriosus, and late sepsis were independent risk factors for the development of BPD. A total of 119 children underwent incentive spirometry. All lung function parameters were significantly altered relative to reference values. Greater impairment of lung function was observed in the mild BPD vs. the no BPD group (forced expiratory volume in the first 0.75 seconds [FEV0.75]: -1.18 ± 0.80 vs. -0.55 ± 1.13; p = 0.010), but no difference in forced vital capacity (FVC) was observed (-0.32 ± 0.90 vs. -0.18 ± 1; p = 0.534). The moderate-to-severe BPD group exhibited the most severe FEV0.75 reduction (FEV0.75: -2.63 ± 1.18 vs. -0.72 ± 1.08; p = 0.000) and was the only condition with FVC impairment (FVC: -1.82 ± 1.12 vs. -0.22 ± 0.87; p = 0.000). The multivariate analysis identified a diagnosis of moderate-to-severe BPD as an independent risk factor for lung function impairment.
CONCLUSIONS: The 2001 consensus definition of BPD has adequate predictive capacity for lung function measured by spirometry at 4-6 years of age. Moderate-to-severe BPD was the best predictor of respiratory impairment. Children with mild BPD showed greater alteration of FEV0.75 than those without BPD.

Duchenne muscular dystrophy (DMD) is a devastating, progressive neuromuscular disease that results in cardiopulmonary failure and death. In 2018, the DMD Care Considerations guidelines were updated to improve the multidisciplinary approach to care and promote early respiratory management. We sought to evaluate the impact of a multidisciplinary clinic on access to pulmonary care and adherence to respiratory care guidelines.
Utilizing retrospective data, we assessed for pulmonary care between 2016-2019 and congruence with guidelines from March 2018-February 2019. Using a standardized visit protocol, subjects were monitored for adherence to pulmonary function testing (PFT) and polysomnography (PSG) recommendations.
Of the 84 subjects with DMD, only 51.2% had prior pulmonary involvement, and approximately one-third were seen in the year prior to clinic onset. Only 23% of subjects with a pulmonary referral completed this visit. After clinic initiation, the average age of a subject\'s first pulmonary contact decreased from 11.8 y to 7.9 y (P < .001), and 45% of the 77 unique clinic subjects had no previous pulmonary encounter. Adherence to PFT guidelines increased in both ambulatory (8.7% to 86.1%) and non-ambulatory subjects (25.9% to 90.1%). Approximately 79% of subjects seen in clinic either completed or had an order for PSG in the last 12 months.
Development of a multispecialty clinic expanded access to pulmonary care and evaluation in subjects with DMD. Continued care in this clinic will allow a better understanding of barriers to access and the opportunity to monitor long-term pulmonary health.

Respiratory complications are common in the patient with muscular dystrophy. The periodic clinical and instrumental respiratory evaluation is extremely important. Despite the presence in the literature of updated guidelines, patient associations often report lack of knowledge of these pathologies, particularly in peripheral hospitals. The purpose of this work, inspired by the Italian Muscular Dystrophy Association (UILDM) is to improve management of respiratory problems necessary for the management of these patients complex. To this end, the main items that the specialist can meet in the follow-up of these pathologies have been analyzed and discussed, among which the respiratory basal evaluation, the criteria of adaptation to non-invasive ventilation, management of bronchial secretions, situations of respiratory emergency, indications for tracheostomy and the subject of advance directives of treatment (DAT).

Diagnosing asthma in children represents an important clinical challenge. There is no single gold-standard test to confirm the diagnosis. Consequently, over- and under-diagnosis of asthma is frequent in children.
A task force supported by the European Respiratory Society has developed these evidence-based clinical practice guidelines for the diagnosis of asthma in children aged 5-16 years using nine Population, Intervention, Comparator and Outcome (PICO) questions. The task force conducted systematic literature searches for all PICO questions and screened the outputs from these, including relevant full-text articles. All task force members approved the final decision for inclusion of research papers. The task force assessed the quality of the evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach.
The task force then developed a diagnostic algorithm based on the critical appraisal of the PICO questions, preferences expressed by lay members and test availability. Proposed cut-offs were determined based on the best available evidence. The task force formulated recommendations using the GRADE Evidence to Decision framework.
Based on the critical appraisal of the evidence and the Evidence to Decision framework, the task force recommends spirometry, bronchodilator reversibility testing and exhaled nitric oxide fraction as first-line diagnostic tests in children under investigation for asthma. The task force recommends against diagnosing asthma in children based on clinical history alone or following a single abnormal objective test. Finally, this guideline also proposes a set of research priorities to improve asthma diagnosis in children in the future.

At the end of 2019, in Wuhan, the Hubei Province\'s capital city in China, the first cases of COVID-19 disease caused by the novel coronavirus, SARS-CoV-2, were described. The rapid spread of the infection through the world resulted in the World Health Organization announcing the COVID-19 a global pandemic in March 2020. The main routes of transmission of the novel coronavirus SARS-CoV-2, according to current evidence, are via droplets inhalation, direct contact with contaminated surfaces, and transmission via the mucous membranes of the mouth, nose, and eyes, and probably through airborne particles from the respiratory tract, generated during coughing and sneezing of infected individuals. During the pulmonary function testing (PFTs), which require strenuous breathing maneuvers and generate high-intensity airflow, aerosols, and micro-aerosols are formed from respiratory secretions and may contain viral and bacterial particles. Therefore, such forced respiratory maneuvers pose a significant risk of spreading the infection to patients and laboratory staff. According to current knowledge, the source of infection may also be an asymptomatic and a pre-symptomatic individual. Coronavirus SARS-CoV-2 has been increasingly prevalent in the community, and this increases a potential risk to all patients tested lung function and staff working there. As the patients\' and staff\'s safety is of unprecedented importance, the additional precautions when performing pulmonary function tests are necessary and unquestionable. In consequence, the greater availability of consumables and personal protective equipment is indispensable. The reorganization of daily practice will prolong test time, reduce the number of tests performed, and slow down patients\' flow. The guidance provides practical advice to health care professionals on performing pulmonary function tests during the COVID-19 pandemic. It has been developed basing on currently available information and recommendations from relevant health care institutions. As the COVID-19 pandemic is a rapidly evolving situation and the new scientific data has been becoming are available, the guidance will be updated over time.

The diffusing capacity for carbon monoxide (DLCO) is, after spirometry the standard and noninvasive pulmonary function test of greater clinical use. However, there are substantial errors in the interpretation of the physiological significance of the DLCO, its derived measures and, therefore the clinical significance of its alterations. In addition to the use of different nomenclatures, other sources of confusion have contributed to some negative view of the test. The technical aspects of the DLCO test have the advantage of being well standardized. But unlike what happens with other pulmonary function tests where we have reference values which allow us to determine their \"normality or abnormality\", it is difficult to apply this route of analysis in the case of DLCO. The central fact in the analysis of DLCO, transference factor for CO (KCO), and alveolar volume (VA) is that for a correct interpretation it is necessary to think about the mechanism by which the pathology induces change. A KCO of 100% can be considered normal in some circumstances or pathological in others and, for the moment, the automated study report cannot discriminate. This article will address the principles of the DLCO test; present different models of analysis submit concrete examples and provide guidelines for their correct interpretation. It is considered essential to carry out an integrated analysis of the DLCO test in relation to other functional tests and clinical data.
La capacidad de difusión de monóxido de carbono (DLCO) es, después de la espirometría, la prueba de función pulmonar rutinaria y no invasiva de mayor utilidad clínica. No obstante, hay sustanciales errores de interpretación del significado fisiológico de la DLCO, de sus medidas derivadas y por consiguiente del significado clínico de sus alteraciones. Además de la utilización de diferentes nomenclaturas, otras fuentes de confusión han contribuido a cierta visión negativa de la prueba. Los aspectos técnicos de la prueba de DLCO tienen la ventaja de estar estandarizados. Pero a diferencia de lo que ocurre con otras pruebas de función pulmonar donde disponemos de valores de referencia que permiten determinar la \"normalidad o anormalidad\" de las mismas, es difícil aplicar esta vía de análisis en el caso de la DLCO. El hecho central en el análisis de la DLCO, el factor de transferencia para el CO (KCO), y el volumen alveolar (VA) es que para una correcta interpretación es necesario tener en cuenta el mecanismo por el cual la patología induce el cambio. Un KCO del 100% puede ser considerado normal en unas circunstancias o patológico bajo otras y, por el momento, el informe automatizado del estudio no puede discriminar. Este artículo describirá los principios de la prueba de DLCO, presentará diferentes modelos de análisis, expondrá ejemplos concretos y ofrecerá pautas para su correcta interpretación. Se considera indispensable efectuar un análisis integrado de la prueba de DLCO en relación con otras pruebas funcionales y con los datos clínicos.