Original Research
19 July 2022

Comparing Racial Differences in Emphysema Prevalence Among Adults With Normal Spirometry: A Secondary Data Analysis of the CARDIA Lung Study

Publication: Annals of Internal Medicine
Volume 175, Number 8
Visual Abstract. Racial Differences in Emphysema Prevalence in Adults With Normal Spirometry.
In this secondary data analysis of 2674 participants from the CARDIA (Coronary Artery Risk Development in Young Adults) study, 6.5% of patients with 80% to 99% of predicted race-specific FEV1 had radiographic evidence of emphysema. Black men and women had almost 4-fold and 2-fold greater prevalence of emphysema than White men and women, respectively. Findings suggest that reliance on spirometry alone may result in underrecognition of emphysema in Black men and women.

Abstract

Background:

Computed tomography (CT) imaging complements spirometry and may provide insight into racial disparities in respiratory health.

Objective:

To determine the difference in emphysema prevalence between Black and White adults with different measures of normal spirometry results.

Design:

Observational study using clinical data and spirometry from the CARDIA (Coronary Artery Risk Development in Young Adults) study obtained in 2015 to 2016 and CT scans done in 2010 to 2011.

Setting:

4 U.S. centers.

Participants:

Population-based sample of Black and White adults.

Measurements:

Self-identified race and visually identified emphysema on CT in participants with different measures of “normal” spirometry results, calculated using standard race-specific and race-neutral reference equations.

Results:

A total of 2674 participants (485 Black men, 762 Black women, 659 White men, and 768 White women) had both a CT scan and spirometry available for analysis. Among participants with a race-specific FEV1 between 80% and 99% of predicted, 6.5% had emphysema. In this group, emphysema prevalence was 3.9-fold (95% CI, 2.1- to 7.1-fold; 15.5% vs. 4.0%) higher among Black men than White men and 1.9-fold (CI, 1.0- to 3.8-fold; 6.6% vs. 3.4%) higher among Black women than White women. Among participants with a race-specific FEV1 between 100% and 120% of predicted, 4.0% had emphysema. In this category, Black men had a 6.4-fold (CI, 2.2- to 18.7-fold; 13.9% vs. 2.2%) higher prevalence of emphysema than White men, whereas Black and White women had a similar prevalence of emphysema (2.6% and 2.0%, respectively). The use of race-neutral equations to identify participants with an FEV1 percent predicted between 80% and 120% attenuated racial differences in emphysema prevalence among men and eliminated racial differences among women.

Limitation:

No CT scans were obtained during the most recent study visit (2015 to 2016) when spirometry was done.

Conclusion:

Emphysema is often present before spirometry findings become abnormal, particularly among Black men. Reliance on spirometry alone to differentiate lung health from lung disease may result in the underrecognition of impaired respiratory health and exacerbate racial disparities.

Primary Funding Source:

National Institutes of Health.

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Supplemental Material

Supplement. Supplementary Tables

References

1.
Qaseem A, Wilt TJ, Weinberger SE, et al; American College of Physicians. Diagnosis and management of stable chronic obstructive pulmonary disease: a clinical practice guideline update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society. Ann Intern Med. 2011;155:179-91. [PMID: 21810710] doi: 10.7326/0003-4819-155-3-201108020-00008
2.
Stanojevic S, Kaminsky DA, Miller M, et al. ERS/ATS technical standard on interpretive strategies for routine lung function tests. Eur Respir J. 2021. [PMID: 34949706] doi: 10.1183/13993003.01499-2021
3.
Woodruff PG, Barr RG, Bleecker E, et al; SPIROMICS Research Group. Clinical significance of symptoms in smokers with preserved pulmonary function. N Engl J Med. 2016;374:1811-21. [PMID: 27168432] doi: 10.1056/NEJMoa1505971
4.
Rodriguez-Roisin R, Han MK, Vestbo J, et al. Chronic respiratory symptoms with normal spirometry. A reliable clinical entity. Am J Respir Crit Care Med. 2017;195:17-22. [PMID: 27598473] doi: 10.1164/rccm.201607-1376PP
5.
Labaki WW, Han MK. Improving detection of early chronic obstructive pulmonary disease. Ann Am Thorac Soc. 2018;15:S243-S248. [PMID: 30759006] doi: 10.1513/AnnalsATS.201808-529MG
6.
Liu GY, Kalhan R. Impaired respiratory health and life course transitions from health to chronic lung disease. Chest. 2021;160:879-889. [PMID: 33865834] doi: 10.1016/j.chest.2021.04.009
7.
Washko GR, Colangelo LA, Estépar RSJ, et al. Adult life-course trajectories of lung function and the development of emphysema: the CARDIA lung study. Am J Med. 2020;133:222-230.e11. [PMID: 31369720] doi: 10.1016/j.amjmed.2019.06.049
8.
Han MK, Tayob N, Murray S, et al; COPDGene and SPIROMICS Investigators. Association between emphysema and chronic obstructive pulmonary disease outcomes in the COPDGene and SPIROMICS cohorts: a post hoc analysis of two clinical trials [Letter]. Am J Respir Crit Care Med. 2018;198:265-267. [PMID: 29485901] doi: 10.1164/rccm.201801-0051LE
9.
Lowe KE, Regan EA, Anzueto A, et al. COPDGene 2019: redefining the diagnosis of chronic obstructive pulmonary disease. Chronic Obstr Pulm Dis. 2019;6:384-399. [PMID: 31710793] doi: 10.15326/jcopdf.6.5.2019.0149
10.
Oelsner EC, Hoffman EA, Folsom AR, et al. Association between emphysema-like lung on cardiac computed tomography and mortality in persons without airflow obstruction: a cohort study. Ann Intern Med. 2014;161:863-73. [PMID: 25506855] doi: 10.7326/M13-2570
11.
Eisner MD, Blanc PD, Omachi TA, et al. Socioeconomic status, race and COPD health outcomes. J Epidemiol Community Health. 2011;65:26-34. [PMID: 19854747] doi: 10.1136/jech.2009.089722
12.
Ejike CO, Woo H, Galiatsatos P, et al. Contribution of individual and neighborhood factors to racial disparities in respiratory outcomes. Am J Respir Crit Care Med. 2021;203:987-997. [PMID: 33007162] doi: 10.1164/rccm.202002-0253OC
13.
Mamary AJ, Stewart JI, Kinney GL, et al; COPDGene Investigators. Race and gender disparities are evident in COPD underdiagnoses across all severities of measured airflow obstruction. Chronic Obstr Pulm Dis. 2018;5:177-184. [PMID: 30584581] doi: 10.15326/jcopdf.5.3.2017.0145
14.
Gaffney AW, McCormick D, Woolhandler S, et al. Prognostic implications of differences in forced vital capacity in black and white US adults: findings from NHANES III with long-term mortality follow-up. EClinicalMedicine. 2021;39:101073. [PMID: 34458707] doi: 10.1016/j.eclinm.2021.101073
15.
McCormack MC, Balasubramanian A, Matsui EC, et al. Race, lung function, and long-term mortality in the National Health and Nutrition Examination Survey III [Letter]. Am J Respir Crit Care Med. 2022;205:723-724. [PMID: 34597248] doi: 10.1164/rccm.202104-0822LE
16.
Baugh AD, Shiboski S, Hansel NN, et al. Reconsidering the utility of race-specific lung function prediction equations. Am J Respir Crit Care Med. 2022;205:819-829. [PMID: 34913855] doi: 10.1164/rccm.202105-1246OC
17.
Culver BH, Graham BL, Coates AL, et al; ATS Committee on Proficiency Standards for Pulmonary Function Laboratories. Recommendations for a standardized pulmonary function report. an official American Thoracic Society technical statement. Am J Respir Crit Care Med. 2017;196:1463-1472. [PMID: 29192835] doi: 10.1164/rccm.201710-1981ST
18.
Hankinson JL, Odencrantz JR, Fedan KB. Spirometric reference values from a sample of the general U.S. population. Am J Respir Crit Care Med. 1999;159:179-87. [PMID: 9872837]
19.
Quanjer PH, Stanojevic S, Cole TJ, et al; ERS Global Lung Function Initiative. Multi-ethnic reference values for spirometry for the 3-95-yr age range: the global lung function 2012 equations. Eur Respir J. 2012;40:1324-43. [PMID: 22743675] doi: 10.1183/09031936.00080312
20.
Friedman GD, Cutter GR, Donahue RP, et al. CARDIA: study design, recruitment, and some characteristics of the examined subjects. J Clin Epidemiol. 1988;41:1105-16. [PMID: 3204420]
21.
Webb WR. Thin-section CT of the secondary pulmonary lobule: anatomy and the image—the 2004 Fleischner lecture. Radiology. 2006;239:322-38. [PMID: 16543587]
22.
Standardization of spirometry—1987 update. Statement of the American Thoracic Society. Am Rev Respir Dis. 1987;136:1285-98. [PMID: 3674589]
23.
Han MK, Agusti A, Celli BR, et al. From GOLD 0 to pre-COPD. Am J Respir Crit Care Med. 2021;203:414-423. [PMID: 33211970] doi: 10.1164/rccm.202008-3328PP
24.
Martinez FJ, Han MK, Allinson JP, et al. At the root: defining and halting progression of early chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2018;197:1540-1551. [PMID: 29406779] doi: 10.1164/rccm.201710-2028PP
25.
Regan EA, Lynch DA, Curran-Everett D, et al; Genetic Epidemiology of COPD (COPDGene) Investigators. Clinical and radiologic disease in smokers with normal spirometry. JAMA Intern Med. 2015;175:1539-49. [PMID: 26098755] doi: 10.1001/jamainternmed.2015.2735
26.
McAllister DA, Ahmed FS, Austin JH, et al. Emphysema predicts hospitalisation and incident airflow obstruction among older smokers: a prospective cohort study. PLoS One. 2014;9:e93221. [PMID: 24699215] doi: 10.1371/journal.pone.0093221
27.
Oelsner EC, Smith BM, Hoffman EA, et al. Associations between emphysema-like lung on CT and incident airflow limitation: a general population-based cohort study [Letter]. Thorax. 2018;73:486-488. [PMID: 29074811] doi: 10.1136/thoraxjnl-2017-210842
28.
Centers for Disease Control and Prevention (CDC). Chronic obstructive pulmonary disease among adults—United States, 2011. MMWR Morb Mortal Wkly Rep. 2012;61:938-43. [PMID: 23169314]
29.
Wan ES, Fortis S, Regan EA, et al; COPDGene Investigators. Longitudinal phenotypes and mortality in preserved ratio impaired spirometry in the COPDGene study. Am J Respir Crit Care Med. 2018;198:1397-1405. [PMID: 29874098] doi: 10.1164/rccm.201804-0663OC
30.
Wijnant SRA, De Roos E, Kavousi M, et al. Trajectory and mortality of preserved ratio impaired spirometry: the Rotterdam Study. Eur Respir J. 2020;55. [PMID: 31601717] doi: 10.1183/13993003.01217-2019
31.
Tessum CW, Paolella DA, Chambliss SE, et al. PM2.5 polluters disproportionately and systemically affect people of color in the United States. Sci Adv. 2021;7. [PMID: 33910895] doi: 10.1126/sciadv.abf4491
32.
Woo H, Brigham EP, Allbright K, et al. Racial segregation and respiratory outcomes among urban black residents with and at risk of chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2021;204:536-545. [PMID: 33971109] doi: 10.1164/rccm.202009-3721OC
33.
Thatipelli S, Kershaw KN, Colangelo LA, et al. Neighborhood socioeconomic deprivation in young adulthood and future respiratory health: the CARDIA lung study. Am J Med. 2022;135:211-218.e1. [PMID: 34509450] doi: 10.1016/j.amjmed.2021.07.048
34.
Keet CA, McCormack MC, Pollack CE, et al. Neighborhood poverty, urban residence, race/ethnicity, and asthma: rethinking the inner-city asthma epidemic. J Allergy Clin Immunol. 2015;135:655-62. [PMID: 25617226] doi: 10.1016/j.jaci.2014.11.022
35.
Tai A, Tran H, Roberts M, et al. The association between childhood asthma and adult chronic obstructive pulmonary disease. Thorax. 2014;69:805-10. [PMID: 24646659] doi: 10.1136/thoraxjnl-2013-204815
36.
Iwane MK, Chaves SS, Szilagyi PG, et al. Disparities between black and white children in hospitalizations associated with acute respiratory illness and laboratory-confirmed influenza and respiratory syncytial virus in 3 US counties—2002-2009. Am J Epidemiol. 2013;177:656-65. [PMID: 23436899] doi: 10.1093/aje/kws299
37.
Shaheen SO, Barker DJ, Holgate ST. Do lower respiratory tract infections in early childhood cause chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 1995;151:1649-51; discussion 1651-2. [PMID: 7735628]

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Information & Authors

Information

Published In

cover image Annals of Internal Medicine
Annals of Internal Medicine
Volume 175Number 8August 2022
Pages: 1118 - 1125

History

Published online: 19 July 2022
Published in issue: August 2022

Keywords

Authors

Affiliations

Division of Pulmonary and Critical Care Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois (G.Y.L., D.M., P.H.S.S.)
Division of Cardiology, Department of Medicine, and Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois (S.S.K.)
Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois (L.A.C.)
Division of Pulmonary and Critical Care Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois (G.Y.L., D.M., P.H.S.S.)
George R. Washko, MD
Applied Chest Imaging Laboratory and Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, Massachusetts (G.R.W.)
Division of Pulmonary and Critical Care Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois (G.Y.L., D.M., P.H.S.S.)
David R. Jacobs Jr., PhD https://orcid.org/0000-0002-7232-0543
Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota (D.R.J.)
Lung Health Center, University of Alabama at Birmingham, Birmingham, Alabama (M.T.D.)
Mercedes R. Carnethon, PhD https://orcid.org/0000-0001-7035-0848
Division of Pulmonary and Critical Care Medicine, Department of Medicine, and Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois (M.R.C., R.K.).
Division of Pulmonary and Critical Care Medicine, Department of Medicine, and Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois (M.R.C., R.K.).
Note: Drs. Liu and Kalhan had full access to all of the data in the study and take responsibility for the integrity of the data and accuracy of the data analysis. This manuscript has been reviewed by CARDIA for scientific content.
Financial Support: Dr. Liu is supported by grant F32-HL162318 from the National Institutes of Health. Dr. Kalhan is supported in part by grant R01 HL122477 from the National Heart, Lung, and Blood Institute (CARDIA lung study) and the Respiratory Health Association Solovy Award for Advancement in COPD. CARDIA is conducted and supported by the National Heart, Lung, and Blood Institute in collaboration with the University of Alabama at Birmingham (HHSN268201800005I and HHSN268201800007I), Northwestern University (HHSN268201800003I), University of Minnesota (HHSN268201800006I), and Kaiser Foundation Research Institute (HHSN268201800004I).
Reproducible Research Statement: Study protocol: Available at www.cardia.dopm.uab.edu. Statistical code and data set: Available from Dr. Liu (e-mail, [email protected]).
Corresponding Author: Gabrielle Y. Liu, MD, 240 East Huron Street, McGaw 2-410, Chicago, IL 60611; e-mail, [email protected].
Author Contributions: Conception and design: R. Kalhan, G.Y. Liu, P.H.S. Sporn, G.R. Washko.
Analysis and interpretation of the data: L.A. Colangelo, M.T. Dransfield, D.R. Jacobs, R. Kalhan, S.S. Khan, G.Y. Liu, P.H.S. Sporn, G.R. Washko.
Drafting of the article: D.R. Jacobs, R. Kalhan, G.Y. Liu, G.R. Washko.
Critical revision for important intellectual content: M.R. Carnethon, L.A. Colangelo, M.T. Dransfield, D.R. Jacobs, R. Kalhan, S.S. Khan, G.Y. Liu, D. Meza, P.H.S. Sporn, G.R. Washko.
Final approval of the article: M.R. Carnethon, L.A. Colangelo, M.T. Dransfield, D.R. Jacobs, R. Kalhan, S.S. Khan, G.Y. Liu, D. Meza, P.H.S. Sporn, G.R. Washko.
Statistical expertise: M.R. Carnethon, L.A. Colangelo.
Obtaining of funding: M.R. Carnethon, R. Kalhan, G.Y. Liu.
Administrative, technical, or logistic support: R. Kalhan, G.R. Washko.
Collection and assembly of data: M.R. Carnethon, R. Kalhan, G.Y. Liu, G.R. Washko.
This article was published at Annals.org on 19 July 2022.

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Gabrielle Y. Liu, Sadiya S. Khan, Laura A. Colangelo, et al. Comparing Racial Differences in Emphysema Prevalence Among Adults With Normal Spirometry: A Secondary Data Analysis of the CARDIA Lung Study. Ann Intern Med.2022;175:1118-1125. [Epub 19 July 2022]. doi:10.7326/M22-0205

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