Implementation of Race-Neutral Spirometry Reference Equations Change the Interpretation of Tests in South East Asian and Black Pediatric Populations

Abstract RATIONALE: The 2012 Global Lung Function Initiative (GLI) spirometry reference equations rely on race to predict pulmonary function. Updated 2023 American Thoracic Society/European Respiratory Society guidelines now recommend race-neutral GLI Global equations to mitigate issues with the lack of a standardized race definition, the clinical implications of disproportionate spirometry standards between racial groups, and the overrepresentation of Caucasian populations in the equation derivation. While Black adults show improved interpretations with the race-specific equations compared to race-neutral, the inverse is found in Caucasian populations. However, these impacts remain understudied in children and non-Black populations of color. Here, we evaluate the differences in percentage and severity of pediatric lung function impairments identified using the race-specific compared to race-neutral GLI equations. METHODS: Retrospective spirometry data and self-identified race for BC Children's Hospital patients aged 5-18 years from August 2022 to June 2024 were interpreted using the race-specific and race-neutral GLI equations. Impairment severity was assessed with forced expiratory volume in one 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 increased impairment severity in 22.7% (95% CI, 11.5%-37.8%) of Black and 3.3% (95% CI, 1.8%-5.5%) of South East Asian individuals. Decreased severity was found in 13.5% (95% CI, 11.9%-15.2%) of Caucasian and 16.1% (95% CI, 5.5%-33.7%) of North East Asian individuals, with fewer changes in the Other/Mixed group. 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 individuals from 14.4% (95% CI, 12.8%-16.2%) to 9.0% (95% CI, 7.7%-10.5%) using the race-neutral equations. Among the South East Asian group, percentage of obstructive impairments decreased from 17.1% (95% CI, 13.6%-21.0%) to 7.8% (95% CI, 5.5%-10.8%), corresponding to a decreased proportion meeting asthma diagnostic criteria from 6.9% (95% CI, 4.2%-10.6%) to 3.6% (95% CI, 1.8%-6.6%). CONCLUSION: Compared to the race-specific, the race-neutral GLI equations produced the largest increase in severity and suspected restriction in the Black population, while the greatest decrease in obstruction was found in the South East Asian population. The diagnostic and management implications of these changes to spirometry interpretation will require consideration as the race-neutral equations are implemented clinically for pediatric patients.

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