Subtyping preserved ratio impaired spirometry (PRISm) by using quantitative HRCT imaging characteristics

Abstract

Background: Preserved Ratio Impaired Spirometry (PRISm) is defined as FEV1/FVC ≥ 70% and FEV1 < 80%pred by pulmonary function test (PFT). It has highly prevalence and is associated with increased respiratory symptoms, systemic inflammation, and mortality. However, there are few radiological studies related to PRISm. The purpose of this study was to investigate the quantitative high-resolution computed tomography (HRCT) characteristics of PRISm and to evaluate the correlation between quantitative HRCT parameters and pulmonary function parameters, with the goal of establishing a nomogram model for predicting PRISm based on quantitative HRCT.

Methods: A prospective and continuous study was performed in 488 respiratory outpatients from February 2020 to February 2021. All patients underwent both deep inspiratory and expiratory CT examinations, and received pulmonary function test (PFT) within 1 month. According to the exclusion criteria and Global Initiative for Chronic Obstructive Lung Disease (GOLD) classification standard, 94 cases of normal pulmonary function, 51 cases of PRISm and 48 cases of mild to moderate chronic obstructive lung disease (COPD) were included in the study. The lung parenchyma, parametric response mapping (PRM), airway and vessel parameters were measured by automatic segmentation software (Aview). One-way analysis of variance (ANOVA) was used to compare the differences in clinical features, pulmonary function parameters and quantitative CT parameters. Spearman rank correlation analysis was used to evaluate the correlation between CT quantitative index and pulmonary function parameters. The predictors were obtained by binary logistics regression analysis respectively in normal and PRISm as well as PRISm and mild to moderate COPD, and the nomogram model was established.

Results: There were significant differences in pulmonary function parameters among the three groups (P < 0.001). The differences in pulmonary parenchyma parameters such as emphysema index (EI), pixel indices-1 (PI-1) and PI-15 were mainly between mild to moderate COPD and the other two groups. The differences of airway parameters and pulmonary vascular parameters were mainly between normal and the other two groups, but were not found between PRISm and mild to moderate COPD. Especially there were significant differences in mean lung density (MLD) and the percent of normal in PRM (PRM^Normal) among the three groups. Most of the pulmonary quantitative CT parameters had mild to moderate correlation with pulmonary function parameters. The predictors of the nomogram model using binary logistics regression analysis to distinguish normal from PRISm were smoking, MLD, the percent of functional small airways disease (fSAD) in PRM (PRM^fSAD) and Lumen area. It had a good goodness of fit (χ² = 0.31, P < 0.001) with the area under curve (AUC) value of 0.786. The predictor of distinguishing PRISm from mild to moderate COPD were PRM^Emph (P < 0.001, AUC = 0.852).

Conclusions: PRISm was significantly different from subjects with normal pulmonary function in small airway and vessel lesions, which was more inclined to mild to moderate COPD, but there was no increase in pulmonary parenchymal attenuation. The nomogram based on quantitative HRCT parameters has good predictive value and provide more objective evidence for the early screening of PRISm.

Keywords: Chronic obstructive pulmonary disease; Computed tomography; Preserved ratio impaired spirometry; Pulmonary function test; Quantitative.

Fig. 1

Flow diagram. PFT pulmonary function test, GOLD Global Initiative for Chronic Obstructive Lung Disease

Fig. 2

A The imaging measurement parameters for MLD, PRM^fSAD and lumen area of sixth bronchus in three patients with normal lung function, PRISm and moderate COPD. The blue color in the first column represents the area with a CT value less than − 950 HU on inspiratory CT. In the PRM obtained from inspiration and expiration CT, red represents the emphysema area, yellow represents the functional small airway disease area, and green represents the normal lung tissue area. The last column is the 3D bronchial tree, and the four small images on the right represent sections of the sixth bronchus. The normal patient was a 56-year-old man (FEV1%pred = 121.0%, FEV1/FVC% = 94.27%). The MLD was − 851.7 HU; the emphysema, fSAD and normal percent of PRM was 1.5%, 11% and 87.5%; the lumen area of the sixth bronchus was 10.4 mm². The patient with PRISm was a 52-year-old man (FEV1%pred = 76.4%, FEV1/FVC% = 70.63%). The MLD was − 798.0 HU; The emphysema、fSAD and normal percent of PRM was 12%, 24% and 64%; The lumen area of was the sixth bronchus 5.4 mm². The patient with GOLD 2 was a 68-year-old man (FEV1% pred = 58%, FEV1/FVC% = 69.11%). The MLD was − 863.6 HU; The emphysema, fSAD and normal percent of PRM was 29%, 36% and 35%; the lumen area of the sixth bronchus was 5.8 mm². B The bar chart shows that there were significant differences in the parameters of MLD, PI-1 and PI-15 among the three groups of normal, PRISm and mild to moderate COPD, especially in MLD. C The bar chart shows that there were significant differences in PRM^Emph between PRISm and mild to moderate COPD, as well as PRM^fSAD between the normal and PRISm patients

Fig. 3

A nomogram of the model to predict PRISm from normal, LA lumen area; B calibration curve of the nomogram

Fig. 4

A ROC curve of the nomogram and parameters to predict PRISm from normal. The AUC value of the model was 0.786 (sensitivity 82.35%, specificity 65.96%). B ROC curve of PRM^Emph to predict mild to moderate COPD from PRISm. The cutoff criterion value was 4%. This indicated that when the proportion of emphysema in PRM was 4%, it was helpful to distinguish the Mild to Moderate COPD group from the PRISm Group. The sensitivity and specificity of this index were 89.58% and 68.63%, which had good significance