Blog posts

Geographical variation in lung function

Lung function varies across countries and within regions

Measurements of lung function are used by medics to help decide whether someone has a respiratory disease or not. These measurements are usually compared against population reference values. However, sometimes it is difficult to say if a person with lung function below the expected values for their age, sex, and height really have a disease or are part of a disadvantaged group whose lungs did not grow as much as expected.

Using data from adults in the multinational Burden of Obstructive Lung Disease (BOLD) study, we estimated how far certain measures of lung function, that is the forced vital capacity (FVC) and the forced expiratory volume in one second (FEV1) to FVC ratio (FEV1/FVC), vary between and within world regions. We made this using data from people who have never smoked, do not have respiratory symptoms of disease and have not been diagnosed with a respiratory disease.

We found that the FVC in relation to age and height varies geographically, but that there is no geographical variation in the FEV1/FVC ratio.

The low values of FVC in some world regions should not be considered optimal as they may well be associated with increased mortality (more on this here).

This manuscript has been published in Pulmonology and is available in open access here: doi.org/10.1080/25310429.2024.2430491.

 

Workplace exposures in low- and middle-income countries: filling in the gaps

Workplace exposures

Adequate control of harmful work exposures should be a universal priority. However, its execution varies widely across the world. These exposures can significantly impact workers’ health leading to disease and mortality. Our recent review on occupational exposures in low- and middle-income countries (LMICs) explores the levels reported across different industries in different countries.

We searched available literature and identified the publications that reported measured exposure levels to occupational agents across multiple industries in LMICs.

What did we find?

Brief summary

We found a total of 58 publications reporting quantitative exposure levels between 1998 to 2022. The countries with greatest number of publications were China, followed by Iran and Tanzania. The most common industries were manufacturing, mining, and agriculture with factory workers and miners being the most common job titles.

Occupational exposures and their levels in this review

Why does this matter?

  • High exposure, limited regulation: Workers in LMICs face high exposure to harmful agents like dust, gases, metals, and pesticides. Compared to high-income countries, regulatory frameworks in LMICs may be underdeveloped, contributing to health risks.
  • Industries at risk: Manufacturing, mining, and agriculture dominate the studies reviewed, with factory workers and miners being the most common occupations. Emerging industries like e-waste recycling present emerging challenges, often in unregulated settings.
  • Sex disparities: Most studies focused on male workers, and therefore little data is available on female-dominated sectors, like informal cottage industries, which remain under-researched despite high exposure risks.
  • Important research needs: The review highlights uneven data availability across regions and industries. It emphasises the need for accurate report of exposure measurements that can contribute to tailored tools, such as job-exposure matrices, to better adapted to LMICs to assess and mitigate the risk of occupational exposures.

Take home message

Occupational exposures significantly contribute to global disease burdens, especially in LMICs where protective measures may be scarce. Addressing these gaps help to mitigate adverse health outcomes resulting from high exposure levels in working populations in developing countries.

The findings of this study were published in the peer-reviewed journal PLOS Global Public Health. The article can be freely accessed and read here: https://doi.org/10.1371/journal.pgph.0003888 

Unmasking the threat of small airways obstruction

Tiny Airways, Big Impact

The damage of the small airways of the lungs can result in inflammation, structural changes, and increased airway resistance. This is a common characteristic of chronic respiratory diseases such as asthma or chronic obstructive pulmonary disease (COPD). While the small airways of the lungs may not be the star of the show, they are a crucial part of the lung health story.

Spirometry: The Lung Detective

Small airways obstruction (SAO) can be detected using spirometry. Traditionally, the mean forced expiratory flow rate between 25% and 75% of the forced vital capacity (FEF25-75) is the preferred parameter. However, novel parameters such as the forced expiratory volume in 3 seconds as a ratio of the forced expiratory volume in 6 seconds (FEV3/FEV6), have proven effective at detecting SAO.

We know that chronic respiratory diseases are leading causes of mortality around the world. Can SAO, even without ticking all the boxes for a doctor diagnosis of respiratory disease, predict death?

The big UK Biobank Study: What did we find?

We analysed the data of over 250,000 participants from the UK, who had high quality spirometry, and found some novel results:

  • About 24% of participants had SAO. Among these, about 10% had isolated SAO, meaning their small airways were obstructed, but their larger airways were not.
  • People with SAO had increased risk of death from all causes, including respiratory diseases, cardiovascular diseases, and cancers. The risk was especially high for respiratory diseases, with more than double compared to those without SAO.
  • Even without respiratory disease (isolated SAO), the mortality risk was increased for cardiovascular diseases and cancers. Importantly, these findings were also true among people who have never smoked, indicating that SAO itself, regardless of smoking, is a critical factor.

Why should we care?

  1. Early Detection: Catching SAO early could be crucial in preventing more severe lung diseases later in life.
  2. Lifestyle Factors: Smoking is a big no-no for lung health, but even people who have never smoked can have SAO. This is likely to be caused by other factors.

While the UK Biobank cohort’s lack of representativeness and the relatively short follow-up period pose limitations, the study’s large sample size adds significant weight to the findings. Future research should aim to replicate these results in more diverse populations and explore the underlying mechanisms linking SAO to increased mortality.

Take home message.

Understanding and detecting SAO can give us a head start in managing chronic respiratory diseases such as COPD and asthma. Ultimately, this can aid to reduce respiratory morbidity worldwide. The findings of this study were published in the peer-reviewed journal CHEST. The article can be freely accessed and read here: https://doi.org/10.1016/j.chest.2024.04.016

Cough! Cough! Cough!

Chronic cough is a common respiratory symptom that affects the life of millions of people

Coughing on most days, without having a cold, for several months is one of the most common reasons why people book an appointment with their GP. Chronic cough is bothersome and has been linked to poorer health in people without obvious disease. However, the prevalence of – that is the proportion of people with – chronic cough and its associated risk factors are not well known in different regions of the world.

Using data from adults in the multinational Burden of Obstructive Lung Disease (BOLD) study, we estimated the prevalence of chronic cough in 41 locations from 34 countries around the globe and identified the factors that are more likely to determine the occurrence of chronic cough. We found a wide variation in the proportion of people with chronic cough across the different study locations – from 3% in Pune (India) to 24% in Lexington, KY (United States of America). Perhaps not surprisingly, tobacco smoking and working in a dusty job were the main risk factors for chronic cough. We identified other factors such as passive smoking, having had tuberculosis, being obese, having a low level of education and having hypertension.

Chronic cough population attributable risk for several factors across 41 sites of the BOLD study.

 

Despite our findings, in many locations, we still cannot explain all of the prevalence of this chronic cough.

This manuscript has been published in eClinicalMedicine and is available here: doi.org/10.1016/j.eclinm.2024.102423. This work was conducted as part of the PhD thesis of Hazim Abozid.

Spirometric assessment of the small airways, clinically useful after all?

Chronic obstructive pulmonary disease (COPD) is a common illness of the lungs, and one of the leading causes of death globally, particularly in the poorest countries in the world. Chronic airflow obstruction (CAO) is a key characteristic of a COPD diagnosis. It is identified using a lung function test called spirometry and reflects a reduction in the flow of air through the airways, which is present even after taking inhaled medication.

In early COPD, inflammatory changes occur in the small airways. These are airways less than 2mm in diameter. Their small size makes it easier for noxious particles and gases, such as tobacco smoke, to collide with their walls, meaning they are particularly susceptible to damage. This presents an opportunity for the early detection and treatment of COPD if lung function tests can be used to identify changes in the small airways before they progress to more severe disease.

Isolated small airways obstruction (SAO) reflects a reduction in the flow of air through the small airways, measured using spirometry. We have previously shown that isolated SAO is common globally, and what’s more, individuals with isolated SAO are more likely to have respiratory symptoms than those with otherwise normal lung function. We have now conducted a further study to investigate whether individuals with isolated SAO are more likely to progress to CAO over time and have a greater decline in lung function than the rest of the population. We used data from 3957 participants of the multinational Burden of Obstructive Lung Disease (BOLD) study. Participants were from 18 sites across the world.  At their baseline visit, participants performed spirometry before and after inhalation of a bronchodilator, which is a medication designed to open the airways, and completed a health questionnaire. They repeated the same measurements at a follow-up visit.

After an average of 8 years of follow-up, we found that individuals with isolated SAO were 2 to 3 times more likely to progress to CAO and had lower lung function at follow-up compared to those with normal lung function. This was true in both males and females, even in those who had never smoked. We also found that isolated SAO is better than basic information such as smoking history, age, sex, and body mass index (BMI) to predict future CAO. To confirm these findings, we replicated our research using data from the UK Biobank study and found similar results.

We have shown that using spirometry to assess small airways function can identify those who are at risk of developing COPD, who would be classed as having normal lung function using current criteria. This has implications for the early intervention and prevention of a disease that is associated with significant morbidity and mortality globally.

 

The manuscript published in BMJ Open Respiratory research is available here: http://dx.doi.org/10.1136/bmjresp-2023-002056

The Burden of Obstructive Lung Disease cohort

The BOLD study’s past and present

The Burden of Obstructive Lung Disease (BOLD) cohort is a large, multinational, prospective study of chronic respiraWorld map showing sites where the large multinational prospective BOLD study was conducted.tory disease. It started with the intention to measure the prevalence, risk factors, and impact of chronic obstructive pulmonary disease (COPD) in different populations around the world. COPD is a common and serious lung condition that causes breathing difficulties, coughing, wheezing, and reduced quality of life. It is estimated that COPD affects around 300 million people worldwide and is a leading cause of death globally.

The BOLD study has been a reference in the study of COPD because of its strengths:

• wide coverage of world regions and ethnic groups;

• large sample of representative population-based data;

• use of a standardised protocol, including the same questionnaires and same model of machine to test lung function, across study sites;

• centralised training and certification of interviewers and spirometry technicians. The quality of the data was monitored throughout the study, and re-training of staff was carried out if necessary;

• high quality of lung function measurements made before and after administration of a bronchodilator, with centralized quality control and assessment of all spirometry curves.

The BOLD cohort is still ongoing and will continue to provide important data and insights for the prevention, diagnosis, and management of COPD. More details about the past and present BOLD cohort can be found on the study’s website and in the profile published in the International Journal of Epidemiology (https://doi.org/10.1093/ije/dyad146).

Spirometric small airways obstruction (SAO) is associated with clinically important outcomes

People with obstructive lung diseases, such as asthma and COPD, commonly report respiratory symptoms, including shortness of breath, chronic cough, chronic phlegm, and wheezing.  Small airways disease is an important feature of both conditions, where the airways of the lungs that are less than 2mm in diameter become narrowed due to inflammation. Damage to the small airways is thought to precede the development of more severe lung disease. Therefore, the measurement of small airways function has implications for early detection and prevention of disease. Spirometric small airways obstruction (SAO) is a term used to describe obstruction of the small airways detected using a lung function test called spirometry. We conducted a study to investigate whether people with SAO are more likely to report respiratory symptoms, have a history of cardiometabolic disease, and a lower quality of life, even in the absence of established lung disease. We used data from 21,934 participants of the multinational Burden of Obstructive Lung Disease (BOLD) study. All participants performed spirometry before and after inhalation of salbutamol, which is a medication designed to open the airways. Participants completed a questionnaire which enabled us to collect information on their history of shortness of breath, chronic cough, chronic phlegm, and wheezing, as well as cardiovascular disease, hypertension, and diabetes. They also provided us information about their physical and mental quality of life.

We found that approximately 1 in 5 participants had SAO. Participants with SAO were 2-3 times more likely to report shortness of breath, chronic cough, chronic phlegm, and wheezing compared to those without SAO. In addition, we found that participants with SAO were approximately 30% more likely to have a history of cardiovascular disease but not diabetes or hypertension. We also found that physical and mental quality of life were lower in individuals with SAO. These results were also true in people who had never smoked.

We also investigated whether these findings were true among study participants with SAO but with ‘normal’ lung function and, in general, they were. The main difference was that these participants’ quality of life was unaffected

Although the spirometry parameters used to define SAO have long been considered of little use clinically, we have shown that spirometric SAO is not only common in general populations but is associated with outcomes of clinical interest. Further studies are needed to replicate our findings, as well as to investigate whether those with SAO are more likely to develop more serious lung disease in later life.

 

The manuscript published in Respiratory Research is available here: https://doi.org/10.1186/s12931-023-02450-1

The small airways, quiet no more

The small airways of our lungs are less than 2mm in diameter. Since the 1960s, these airways have been considered are a “quiet zone” where diseases progress unnoticed. That is until they cause symptoms and can be detected using specialist diagnostic equipment. Dysfunction or more appropriately obstruction of the small airways is a key feature of lung diseases such as asthma and chronic obstructive pulmonary disease (COPD). A lung function test called spirometry is the most widely used method of assessing the small airways. However, it is largely unknown how common small airways obstruction is in the general population and what its likely determinants are.

We conducted a study to estimate the prevalence and associated risk factors for small airways obstruction across several world regions. We used data from the multinational Burden of Obstructive Lung Disease (BOLD) study, which included 26,500 participants from 41 study sites, across 34 countries. All participants performed spirometry before and after inhalation of salbutamol, which is a medication designed to open the airways. Participants also had their height and weight taken and completed a questionnaire which enabled us to collect information on exposures such as tobacco smoking. Due to the lack of agreement as to which spirometry parameter is best for assessing small airways obstruction, we compared results for two different parameters, the mean forced expiratory flow rate between 25% and 75% of the forced vital capacity (FEF25-75) and the forced expiratory volume in 3 seconds as a ratio of the forced vital capacity (FEV3/FVC).

We found that approximately one in five study participants have small airways obstruction. Prevalence estimates for individual sites varied from 5% to 33%. We identified several preventable risk factors for small airways obstruction including tobacco smoking, including passive smoking, low education level, low body mass index, working a dusty job for over ten years, family history of COPD and past tuberculosis infection. Results were similar for both FEF25-75 and FEV3/FVC parameters.

Small airways obstruction is relatively common in general populations around the world, with prevalence estimates greater than those of both asthma and COPD. Risk factors for small airways obstruction are like those of COPD, however, further studies are needed to corroborate our findings. It is especially important for future research to investigate whether those with SAO are more likely to develop established lung disease in later life, which could have significant implications for public health policy making.

The findings of this study were published in the open access, peer-reviewed journal The Lancet Global Health. The article can be read here: https://doi.org/10.1016/S2214-109X(22)00456-9

 

 

 

Lung disease and exposures in occupational settings

Respiratory symptoms are common among dust- and fume-exposed workers

It has been suggested that about 15 in 100 cases of chronic lung disease are caused by workplace exposures. These exposures can be anything from noxious gases, dust, which are very small dry airborne particles of biological or mineral origin, and fumes, such as those generated from welding. Most of the evidence that supports this estimate comes from wealthy countries in Europe and North America. Data on the association of lung disease with occupational exposures in other regions of the world are limited.

To improve the understanding of the relationship between occupational exposures and lung disease across the world, we used data from almost 29,000 adults, aged 40 and above, who participated in the Burden of Obstructive Lung Disease (BOLD) study. In this study, we asked participants about their job. We asked whether they worked in any of 11 settings considered to increase their exposure to dust or fumes. We also asked them whether they had a frequent cough, recurring mucous production, shortness of breath or wheezing. In addition, each of them had their lung function measured through spirometry.

We found that respiratory symptoms, that is frequent cough, recurring mucous production, shortness of breath and wheezing, were more common among people who worked in settings considered to have higher exposure to dusts and fumes. These findings were consistent across the several world regions. Interestingly and contrary to previous reports, we saw no evidence of a link between occupational exposures and worse lung function. At any rate, actions to avoid or reduce occupational exposures are still advised.

To learn more about this study check out the open-access peer-reviewed article in the European Respiratory Journal (https://doi.org/10.1183/13993003.00469-2022). This work was conducted as part of the PhD thesis of Jate Ratanachina.

Using spirometry to measure small airways obstruction, time for a rethink?

The airways in our lungs are like the branches of a tree. At their widest they resemble the sturdy tree trunk and at their most narrow, the fragile twigs. Due to their size, these twig-like structures are called the small airways and they are easily damaged by noxious particles or gases we inhale, for example cigarette smoke. When they are damaged, our small airways become inflamed, which stops air moving freely and leads to something called small airways obstruction. In conditions like asthma and chronic obstructive pulmonary disease (COPD), small airways obstruction is common. However, evidence also suggests that this condition can occur on its own and may be a sign of future and more serious lung disease. A test called spirometry is often used to investigate whether the small airways are obstructed or not, however, there is no agreement on how best to do this.

We conducted a systematic review of the scientific literature to identify and summarise studies that measured small airways obstruction in the general population using spirometry. We extracted information from suitable studies on the choice of spirometry parameter used to measure small airways obstruction, criteria used to diagnose this condition, the proportion of people affected by it, and any factors that could be increase the odds of having this type of obstruction.

We found that only 25 studies have measured small airways obstruction in general populations around the world. Across these studies, 16 different spirometry parameters were used to measure it, along with 8 different diagnostic criteria. The proportion of people with small airways obstruction ranged from 7.5% to 45.9% and varied depending on the choice of spirometry parameter and world region. Just two studies identified potential risk factors for this type of obstruction, with cigarette smoking, passive smoking, increasing age, being women, low education level, and exposure to high levels of air pollution being the most promising.

Small airways obstruction is a common but understudied condition in general populations around the world. Risk factors for this condition appear to be similar to more established lung diseases, such as COPD. However, there is no consensus on the best spirometry parameter or diagnostic criteria to use when measuring this type of obstruction. For this reason, more research is required to identify the best measure of small airways obstruction and to assess whether having it increases the risk of future lung disease.

The findings of this study were published in the peer-reviewed journal Respiratory Research. The article can be read here: https://doi.org/10.1186/s12931-022-01990-2