Correlation Between Body Mass Index And Peak Expiratory: Fill & Download for Free

Cystic fibrosis has historically been considered a pulmonary disease, but with the increasing life expectancy of these patients, gastrointestinal manifestations are becoming more important.Cystic fibrosis is the result of a defect in the cystic fibrosis transmembrane regulator (CFTR), which is responsible for the excretion of salt. The defect results in viscous secretions in multiple organ systems. For decades, cystic fibrosis was thought to only be a disease of childhood, given the low life expectancy associated with it. Largely because of improvements in nutrition, the average life expectancy of patients with cystic fibrosis is now well into adulthood.Defects in the CFTR result in multisystemic disease involving lung, liver, and gastrointestinal disease as well as pancreatic insufficiency. The majority of cystic fibrosis mutations cause lung disease, which is closely tied to growth and nutritional status. Having a body mass index (BMI) greater than or equal to 50% of a patient’s age has been shown to correlate with the predicted percentage of forced expiratory volume in 1 second (FEV1) greater than or equal to 90%, which is an important marker of lung function. For cystic fibrosis patients age 20 years or older, it is recommended that women maintain a BMI at or above 22 and that men maintain a BMI at or above 23.Nutritional failure in cystic fibrosis is multifactorial. Malabsorption of fat, protein, and fat-soluble vitamins is a result of insufficient production of pancreatic enzymes, which can be exacerbated by bile salt abnormalities in the presence of concurrent liver disease. Progressive pulmonary infection can lead to increased work of breathing, reduced appetite, and increased caloric needs from inflammatory catabolism. Other factors that affect nutrition include cystic fibrosis-related diabetes mellitus, altered motility of the gastrointestinal tract, and small bowel bacterial overgrowth.Pancreatic insufficiency results in malabsorption and maldigestion of nutrients and fat-soluble vitamins. In fact, cystic fibrosis derives its name from the cysts and fibrosis noted in the pancreas of patients with the disease. Pancreatic enzyme replacement therapy (PERT) and optimization of nutritional deficiencies can prevent growth failure and improve other outcomes in patients with cystic fibrosis, including quality of life, resistance to infection, and chronic lung disease, which can lead to longer life expectancy. The type of the genetic mutation causing cystic fibrosis determines whether a patient is pancreatic-sufficient or pancreatic-insufficient, although approximately 85% of patients are pancreatic-insufficient by age 1 to 2 years. Pancreatic sufficiency in the setting of cystic fibrosis is a risk factor for recurrent pancreatitis, and recurrent pancreatitis can often be a presentation for the diagnosis of cystic fibrosis.Gastrointestinal tract manifestations of cystic fibrosis are related to mucous inspissation and dysmotility and include meconium ileus (MI), constipation, distal intestinal obstruction syndrome (DIOS), gastroesophageal reflux disease (GERD), and small bowel bacterial overgrowth. DIOS is caused by inspissated intestinal contents that completely or partially block the small intestinal lumen, most commonly at the ileocecal junction.5 This is thought to be related to a cascade of intestinal inflammation in the setting of the defect in the CFTR.6Intussusception occurs in approximately 1% of patients with cystic fibrosis.5 The intussusception is usually caused by inspissated bowel contents that serve as a lead point for the intussusception.Hepatobiliary disease in cystic fibrosis occurs as a patchy biliary disease and is thought to have a prevalence of approximately 10% to 15% and peaks in pre-adolescence.7 Screening consists of annual liver transaminase measurement; if the levels are elevated, an abdominal ultrasound (US) is obtained and done annually thereafter if cystic fibrosis-related liver disease is suspected. US findings of the liver can show coarse echotexture, steatosis, and progressive portal hypertension. End-stage liver disease can result in liver transplant. The risk of gallstones is also higher in cystic fibrosis.The pancreas is responsible for secreting enzymes that aid in the absorption of nutrients, including fat-soluble vitamins (vitamins A, D, E, and K). In order to counteract this malabsorption, PERT is used. Lipase is the enzyme responsible for fat absorption. PERT is based on the dosage of lipase in the supplement and is dosed at 500 to 2500 units lipase per kilogram body weight per meal or less than 10,000 units lipase per kilogram body weight per day. Chronic administration of PERT in excess doses can result in fibrosing colopathy, which is characterized by ileocecal inflammation with lower gastrointestinal bleeding, abdominal pain, and obstructive abdominal symptoms. Thus, the Cystic Fibrosis Foundation issued a consensus statement regarding PERT dosing, as noted above.Nutritional ManagementAccording to the Cystic Fibrosis Foundation, higher energy intake is needed for improved weight gain. In order to achieve an energy intake of110% to 200% of the energy intake of the healthy population, the Cystic Fibrosis Foundation recommends a high-calorie, unlimited-fat meal.8,9For cystic fibrosis patients age 1 to 12 years, intensive behavioral and nutritional counseling is recommended to promote weight gain.10-13 For children with growth deficits and adults who are having difficulty maintaining weight gain, oral or enteral nutritional supplements are recommended.In addition, fat-soluble vitamin supplements are routinely administered.4 The fat-soluble vitamins A, D, E, and K are supplemented in all children with cystic fibrosis. Supplements are started at diagnosis, including in asymptomatic infants and those without pancreatic insufficiency. Standard supplements tend to overestimate vitamin A and underestimate vitamins D and K. This can be problematic, for example in cystic fibrosis patients who also have cystic fibrosis—related liver disease, as vitamin A toxicity can affect the liver. Furthermore, the risk of vitamin A toxicity may change, as the amount and type of vitamin A in cystic fibrosis-specific formulations can differ.Vitamin A deficiency is rare except at the time of diagnosis. Vitamin A is necessary for vision, gene expression, growth, and immune function. The available forms of vitamin A include preformed vitamin A (retinol, retinoic acid) and provitamin A (alpha-carotene, beta carotene). Vitamin A levels are monitored via serum retinol and retinol-binding protein. Vitamin A toxicity is possible in cystic fibrosis patients and is marked by bone mineral loss and liver abnormalities.Vitamin D deficiency is common in cystic fibrosis. Vitamin D helps the body use calcium obtained from a person’s diet, and deficiency can lead to poor bone mineralization.14 Vitamin D3 (cholecalciferol) is contained in most supplements and is the form produced in the skin by sunlight. The Cystic Fibrosis Foundation recommends vitamin D3 vs vitamin D2 (ergocalciferol) because a small study showed that it achieved better target 25-hydroxyvi- tamin D. Levels are checked annually at the end of winter. Bone disease in cystic fibrosis patients results from decreased mineral density, which worsens with age, severity of lung disease, and malnutrition. There is also an increase in fracture rates and kyphosis in young adults with cystic fibrosis. In addition to vitamin D deficiency, chronic corticosteroid use and reduced weight-bearing activity can contribute to bone disease.Vitamin E is an antioxidant, and its deficiency could contribute to inflammation and lung disease in cystic fibrosis patients. Vitamin E deficiency leads to delayed stretch reflexes, cerebellar ataxia, and peripheral neuropathy. Some studies have shown a correlation between vitamin E status, polyunsaturated fatty acid (PUFA) status, and inflammation in cystic fibrosis. Eight different forms of vitamin E exist, with the most common being alpha tocopheryl acetate. The recommended intake for cystic fibrosis patients is 20 times the generally recommended intake. Serum vitamin E levels are influenced by serum lipid levels.Vitamin K deficiency is associated with coagulation abnormalities and bone disease. Vitamin K is found in green vegetables, and vitamin K status is monitored by a serum prothrombin time. As intestinal bacteria are a source of vitamin K, supplementation should be provided during courses of antibiotics, a common occurrence in cystic fibrosis patients.Essential fatty acids are long-chain PUFAs and include omega-3 and omega-6 fatty acids. Deficiency may contribute to an inflammatory state, including scaly dermatitis, alopecia, and growth failure, and tends to be more common in infants.4 Routine supplementation is not recommended at this time. However, a systematic review showed that supplementation with omega-3 fatty acids improved several markers of lung disease. The most common fatty acid abnormalities in patients with cystic fibrosis are lin- oleic acid and docosahexaenoic acid (DHA) deficiencies.15 A study looking at DHA supplementation in cystic fibrosis patients has shown improvement in inflammatory markers but inconsistent improvement in FEV1.16Cystic fibrosis patients are prone to hyponatremic dehydration under conditions of heat stress secondary to sodium losses through sweat. Sodium chloride supplementation can be used, especially in warm months or climates and in infants.The Cystic Fibrosis Foundation recommends a trial of zinc supplementation for children younger than age 2 years who are not growing well. Dermatitis can be a symptom of zinc deficiency.17 Iron deficiency has been noted in several studies of cystic fibrosis patients and is monitored yearly by serum hemoglobin and hematocrit levels.Oral supplements are used in cystic fibrosis but are often less effective because they may displace ordinary food.18,19 Studies have shown that calorie-protein supplements are not superior to monitoring and dietary advice from a health professional and nutritionist.18,19 Enteral nutrition is generally started via gastrostomy tube for patients with growth failure. Although there are no randomized, controlled trials to support this, enteral nutrition is thought to improve and maintain lung function in patients with cystic fibrosis. For toddlers, a combination of daytime feeds, daytime meals, and nighttime continuous feeds is used.Pancreatitis is treated with supportive care. It is important to ensure that constipation does not worsen with the use of narcotics to treat pancreatitis-related abdominal pain.In terms of the treatment of gastrointestinal manifestations, it is important to treat GERD symptoms, especially in patients with progressive lung disease and those who have undergone lung transplant. Importantly, the use of acid suppression enhances the use of PERT, as pancreatic enzymes require a bicarbonate-rich environment under normal physiologic conditions, which does not exist with cystic fibrosis, where pancreatic bicarbonate secretion is impaired.20Patients with cystic fibrosis are thought to be at an increased risk for GERD-related anatomic changes that occur to the lungs over time, perhaps also exacerbated by intestinal dysmotility. A retrospective study in 2013 showed that Nissen fundoplication helped improve lung function and nutritional status in cystic fibrosis patients, especially in those with milder pulmonary disease.21 Although fundoplication is not routinely recommended, it is important to address and control GERD symptoms with proper acid blockade in cystic fibrosis patients.MI is a condition diagnosed in the newborn period and characterized by inspissated meconium in the intestine of newborns with cystic fibrosis. Approximately 10% of patients with cystic fibrosis present as neonates with MI. This condition is treated by a radiocontrast enema or surgical intervention. MI is thought to be a precursor to DIOS later in life.22 DIOS is defined as acute complete or incomplete obstruction of the ileocecum by inspissated intestinal contents (Table 2). DIOS must be distinguished from constipation and is characterized by gradual onset of fecal impaction of the colon, starting at the sigmoid and extending proximally. DIOS can occur at any age, but it is more common in those with pancreatic insufficiency.5 It is important to note that DIOS can mimic appendicitis. Finally, treatment of constipation is important, as it can be a cause of abdominal discomfort and rectal prolapse, and it can result in decreased appetite.As patients with cystic fibrosis are living longer, it has become clear that cystic fibrosis carries a higher prevalence of intestinal cancers diagnosed at a younger age than that in the general population.23,24 However, the reasons for this are unclear at this time.Ursodeoxycholic acid is used to treat cystic fibrosis—related liver disease and can result in normalization of liver transaminases, but it is not known if this treatment affects histologic changes in the liver associated with cystic fibrosis. Liver biopsies are not routinely obtained in cystic fibrosis-related liver disease unless another diagnosis is being considered that would change management. Furthermore, cystic fibrosis-related liver disease is patchy and can be missed on routine liver biopsy.

Distribution of 10-Year Historical Ozone Concentration by Study SiteThe boxes indicate the interquartile range (IQR); the lower hinge (bottom of box), the 25th percentile value; the center line, the median concentration; and the upper hinge (top of box), the 75th percentile value. The upper whisker represents the maximum observation that falls within the upper limit (75th percentile + 1.5 × IQR); the lower whisker, the minimum observation that falls within the lower limit (25th percentile − 1.5 × IQR). The circles represent outlier values.AA indicates Ann Arbor, Michigan; Bal, Baltimore, Maryland; LA, Los Angeles, California; NYC, New York City, New York; ppb, parts per billion; SF, San Francisco, California; SLC, Salt Lake City, Utah; WS, Winston-Salem, North Carolina.Adjusted Associations of 10-Year Historical Ozone Concentration With Selected Outcomes of InterestFEV1 indicates forced expiratory volume in the first second of expiration; ppb, parts per billion; SGRQ, St. George Respiratory Questionnaire. Shaded areas represent 95% CIs.Effect Estimate of Ozone on Outcomes by Time Spent Outdoors and Smoking StatusCAT indicates COPD (chronic obstructive pulmonary disease) Assessment Test; mMRC, modified Medical Research Council Dyspnea Scale; ppb, parts per billion; SGRQ, St. George Respiratory Questionnaire. Error bars represent 95% CIs. P for interaction <.05 for analyses.Baseline Participant CharacteristicsAssociation Between 10-Year Ozone Concentration and Health Outcomes in Current and Former SmokersShining New Light on Long-term Ozone HarmsInvited CommentaryDecember 9, 2019See More AboutTobacco and e-Cigarettes Chronic Obstructive Pulmonary Disease Pulmonary Medicine Environmental HealthOthers Also LikedElevated circulating MMP-9 is linked to increased COPD exacerbation risk in SPIROMICS and COPDGeneJ. Michael Wells et al., JCI Insight, 2018Chronic Obstructive Pulmonary Disease in Older Adults: Part I: Case StudyNicole J Brandt et al., Journal of Gerontological NursingHeme scavenging reduces pulmonary endoplasmic reticulum stress, fibrosis, and emphysemaSaurabh Aggarwal et al., JCI Insight, 2018Ref: online December 9, 2019Association of Long-term Ambient Ozone Exposure With Respiratory Morbidity in Smokers Author Affiliations Article Information Question What is the association of long-term ambient ozone exposure with health outcomes among individuals with a heavy smoking history and with or without airways obstruction?Findings In this cross-sectional study of 1874 current and former smokers with or without chronic obstructive pulmonary disease, higher concentration of 10-year historical ambient ozone exposure was associated with greater computed tomography scan–measured emphysema and gas trapping, worse patient-reported outcomes and functional status, and increased respiratory exacerbations.Meaning This study found that long-term ambient ozone exposure was associated with worse respiratory outcomes and increased emphysema and gas trapping, independent of smoking and workplace exposures, in smokers with or at risk for chronic obstructive pulmonary disease.AbstractImportance Few studies have investigated the association of long-term ambient ozone exposures with respiratory morbidity among individuals with a heavy smoking history.Objective To investigate the association of historical ozone exposure with risk of chronic obstructive pulmonary disease (COPD), computed tomography (CT) scan measures of respiratory disease, patient-reported outcomes, disease severity, and exacerbations in smokers with or at risk for COPD.Design, Setting, and Participants This multicenter cross-sectional study, conducted from November 1, 2010, to July 31, 2018, obtained data from the Air Pollution Study, an ancillary study of SPIROMICS (Subpopulations and Intermediate Outcome Measures in COPD Study). Data analyzed were from participants enrolled at 7 (New York City, New York; Baltimore, Maryland; Los Angeles, California; Ann Arbor, Michigan; San Francisco, California; Salt Lake City, Utah; and Winston-Salem, North Carolina) of the 12 SPIROMICS clinical sites. Included participants had historical ozone exposure data (n = 1874), were either current or former smokers (≥20 pack-years), were with or without COPD, and were aged 40 to 80 years at baseline. Healthy persons with a smoking history of 1 or more pack-years were excluded from the present analysis.Exposures The 10-year mean historical ambient ozone concentration at participants’ residences estimated by cohort-specific spatiotemporal modeling.Main Outcomes and Measures Spirometry-confirmed COPD, chronic bronchitis diagnosis, CT scan measures (emphysema, air trapping, and airway wall thickness), 6-minute walk test, modified Medical Research Council (mMRC) Dyspnea Scale, COPD Assessment Test (CAT), St. George’s Respiratory Questionnaire (SGRQ), postbronchodilator forced expiratory volume in the first second of expiration (FEV1) % predicted, and self-report of exacerbations in the 12 months before SPIROMICS enrollment, adjusted for demographics, smoking, and job exposure.Results A total of 1874 SPIROMICS participants were analyzed (mean [SD] age, 64.5 [8.8] years; 1479 [78.9%] white; and 1013 [54.1%] male). In adjusted analysis, a 5-ppb (parts per billion) increase in ozone concentration was associated with a greater percentage of emphysema (β = 0.94; 95% CI, 0.25-1.64; P = .007) and percentage of air trapping (β = 1.60; 95% CI, 0.16-3.04; P = .03); worse scores for the mMRC Dyspnea Scale (β = 0.10; 95% CI, 0.03-0.17; P = .008), CAT (β = 0.65; 95% CI, 0.05-1.26; P = .04), and SGRQ (β = 1.47; 95% CI, 0.01-2.93; P = .048); lower FEV1% predicted value (β = −2.50; 95% CI, −4.42 to −0.59; P = .01); and higher odds of any exacerbation (odds ratio [OR], 1.37; 95% CI, 1.12-1.66; P = .002) and severe exacerbation (OR, 1.37; 95% CI, 1.07-1.76; P = .01). No association was found between historical ozone exposure and chronic bronchitis, COPD, airway wall thickness, or 6-minute walk test result.Conclusions and Relevance This study found that long-term historical ozone exposure was associated with reduced lung function, greater emphysema and air trapping on CT scan, worse patient-reported outcomes, and increased respiratory exacerbations for individuals with a history of heavy smoking. The association between ozone exposure and adverse respiratory outcomes suggests the need for continued reevaluation of ambient pollution standards that are designed to protect the most vulnerable members of the US population.IntroductionTropospheric, or ground-level, ozone is generated mainly in and downwind of large urban areas by chemical reactions between multiple pollutants in the presence of sunlight.1 Exposure to ambient concentrations of tropospheric ozone is regulated by the US Environmental Protection Agency Clean Air Act, and data from controlled human exposure studies and observational cohort studies support a causal relationship between ozone exposure and adverse health effects in humans.1 Short-term ozone exposure (which varies from hours to weeks) is associated with adverse respiratory outcomes, including acute changes in lung function,1-3 and increases in asthma symptoms2 and respiratory-related emergency department (ED) visits.4 Less is known about the respiratory sequelae of long-term ozone exposure (which varies from months to years). Although previous studies suggest that long-term ozone exposure is associated with increased respiratory-related mortality,5-9 few studies have focused on the implications of ozone exposure for those with a heavy smoking burden who may be at high risk for developing chronic lung disease.10,11 Furthermore, little is known about the association of ozone exposure with respiratory morbidity in individuals with chronic obstructive pulmonary disease (COPD), despite the knowledge that exposure to particles and gases can cause COPD.12 A recent scientific assessment by the Environmental Protection Agency acknowledges the scarcity of epidemiologic studies into the association between long-term ozone exposure and COPD-related health outcomes.1The goal of this cross-sectional study was to investigate the association between 10-year historical ozone exposure and the respiratory health of current and former smokers with or without airways obstruction. These individuals were enrolled in the Subpopulations and Intermediate Outcome Measures In COPD Study (SPIROMICS), an ongoing multicenter prospective cohort study that aims to identify new COPD subgroups and intermediate markers of disease progression.13 We hypothesized that exposure to higher concentrations of 10-year historical ozone, estimated with fine-scale spatiotemporal modeling, was associated with increased risk of respiratory disease, worse respiratory-related morbidity, and higher exacerbationMethodsRisk Study PopulationThe current cross-sectional study, conducted from November 1, 2010, to July 31, 2018, is an analysis of data collected at the SPIROMICS enrollment visit as part of the SPIROMICS Air Pollution Study (SPIROMICS AIR), an ancillary study that included 2382 participants enrolled at 7 (New York City, New York; Baltimore, Maryland; Los Angeles, California; Ann Arbor, Michigan; San Francisco, California; Salt Lake City, Utah; and Winston-Salem, North Carolina) of the 12 SPIROMICS clinical sites.14 A total of 1874 SPIROMICS AIR participants (648 smokers without airways obstruction and 1226 smokers with COPD) had available 10-year historical ozone exposure data. SPIROMICS was approved by the institutional review board at each of the 12 clinical centers throughout the United States. All study participants provided written informed consent. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.Participants in SPIROMICS were 40 to 80 years of age at baseline and were current or former smokers (≥20 pack-years) with or without evidence of obstructive lung disease.13 Healthy persons with a smoking history of 1 or more pack-years were not included in the present analysis. Spirometry was performed before and after the administration of a bronchodilator.15 Current and former smokers were categorized as having either no spirometric evidence of airflow obstruction or having COPD (postbronchodilator forced expiratory volume in the first second of expiration/forced vital capacity [FEV1/FVC] < 70%).Ambient Ozone Exposure AssessmentResidential address at baseline and over the previous 10 years was obtained and geocoded with a geographic information system (ArcGIS 10.3; ESRI). Two-week mean outdoor concentrations of ozone outside each participant’s home were predicted using spatiotemporal modeling methods.14,16,17 Models incorporated cohort-focused monitoring conducted by SPIROMICS AIR; pollutant concentrations previously measured by the MESA (Multi-Ethnic Study of Atherosclerosis and Air Pollution) Air Study in Baltimore, New York City, Los Angeles, and Winston-Salem; monitoring by the New York City Community Air Study; and regulatory agencies in all SPIROMICS AIR communities.18,19 The 2-week mean concentration predictions were calculated to obtain a long-term historical ozone concentration for the 10 years prior to the baseline visit that was specific to the residential history reported. Ozone estimates were unavailable for 239 individuals with at least 1 address outside the geographic areas covered by the prediction models and for 269 individuals whose addresses could not be geocoded accurately.Participant CharacterizationTrained staff at the clinical sites collected demographic and clinical data. Smoking history was defined as lifetime cumulative pack-years and as a binary indication (yes or no) of smoking within the past month. Occupational exposure to vapors, gas, dust, or fumes (VGDF) at the longest-held job was ascertained by interview.20-22 Educational attainment was defined as high school or less or more than high school, and personal income was categorized by yearly income of less than $15 000, $15 000 to $34 999, $35 000 to $49 999, $50 000 to $74 999, or more than $75 000. Neighborhood median household income was obtained using 2010 federal census data at the tract level.23 Participants reported the usual number of hours spent outside per day per season; mean seasonal values were calculated to obtain a yearly estimate.Respiratory OutcomesRespiratory-specific quality of life was ascertained using the St. George’s Respiratory Questionnaire (SGRQ),24 and health status was identified with the COPD Assessment Test (CAT).25 Dyspnea was assessed with the modified Medical Research Council (mMRC) Dyspnea Scale,26 and functional exercise capacity was evaluated with the 6-minute walk test (6MWT).27 Chronic bronchitis was defined by a positive response to either the classic or alternative SGRQ definition.28 Exacerbations were based on report of antibiotic and/or steroid use, unscheduled physician visits, ED visits and hospitalizations for COPD, and frequency of these instances over the past year. Severe exacerbations were defined as events requiring an ED visit or hospitalization.Participants underwent whole-lung multidetector helical computed tomography (CT) scans.29 Percentage of emphysema was defined as percent of total voxels in the field less than −950 HU (Hounsfield units) at total lung capacity, and percentage of air trapping was defined as percent of total voxels in the field less than −856 HU at residual volume. Pi10 (the square root of the wall area of a theoretical airway with a lumen perimeter of 10 mm) was used as a measure of airway wall thickness.30Statistical AnalysisFrom May 1, 2018, to September 1, 2019, we performed multivariable regression analyses to examine the association between 10-year historical ozone exposure concentration and outcomes assessed at the enrollment visit. A minimally adjusted model accounted for age, race/ethnicity (white vs non-white), sex, and study site, and a moderately adjusted model added personal and neighborhood income. Fully adjusted models accounted for body mass index, current smoking status, smoking pack-years, VGDF exposure, and educational status in addition to the covariates included in the moderately adjusted model.For continuous outcomes, including CT metrics and disease severity outcomes (ie, respiratory symptoms, lung function, and functional status), we used least-squares regression modeling to estimate the change in the predicted level of outcomes for a 5-ppb (parts per billion) increase in 10-year historical ozone concentration. For dichotomous outcomes, including COPD diagnosis, chronic bronchitis diagnosis, and exacerbations (event of reporting any exacerbation in the past 12 months), we used logistic regression models to estimate the odds ratio (OR) of the event for a 5-ppb increase in 10-year historical ozone concentration. We conducted standard regression analyses, including checking linearity assumption using a fractional polynomial model approach as well as evaluating residual distribution for normality and heteroscedasticity as appropriate (eFigure 1 in the Supplement). In addition, we used the fractional polynomial approach to explore the functional shape of the exposure-response associations.31Sensitivity analyses included the addition of 10-year historical concentration of particulates with a diameter of 2.5 μm (PM2.5) or less to the fully adjusted model, 1- and 5-year mean ambient ozone concentration as the main exposure variable, and modeled ozone concentration limited to the warm season (April-September) as the exposure. In separate analyses, to explore effect modification given a priori hypotheses, we ran fully adjusted 2-way interaction models, examining the interaction between COPD status, smoking pack-years, current smoking status, sex, and time spent outdoors with ozone exposure. For the COPD effect modification analysis, COPD was not included as an outcome.All analyses were performed with StataMP software, version 15.1 (StataCorp LLC). The threshold of statistical significance for the main associations and interaction terms was a 2-sided P < .05.ResultsThis cross-sectional study analyzed 1874 participants, with a mean (SD) age of 64.5 (8.8) years and among whom 1479 (78.9%) were white and 1013 (54.1%) were male. More than a third of participants (n = 688 [36.7%]) reported current smoking, and the mean (SD) pack-years reported were 49.8 (28.9). Mean (SD) postbronchodilator FEV1 was 74.7% (25.8%) predicted, and 1226 participants (65.4%) had a COPD diagnosis. Almost half of participants (904 [48.6%]) reported VGDF exposure. Over the course of the year, the median (interquartile range [IQR]) time spent outdoors was 3.3 (2.0-5.5) hours per dayDiscussionThis cross-sectional study of a multicenter cohort of heavy smokers with or at risk for COPD demonstrated an adverse association of historical ozone exposure with COPD and emphysema risk as well as with several markers of respiratory morbidity, including patient-reported outcomes and exacerbations. We found that exposure to a higher concentration of 10-year historical ozone was associated with lower lung function, as well as with more emphysema and air trapping on CT scan, even after accounting for smoking history. These findings support the role of ambient ozone exposure in COPD morbidity, the fourth leading cause of death in the United States and which is often attributed to tobacco exposure in developed countries.32 Ten-year cumulative ozone exposure was also associated with greater symptom burden, worse quality of life and functional status, and more frequent exacerbations among SPIROMICS participants with or without COPD. These results take into account additional occupational and environmental exposures, smoking history, and individual and neighborhood socioeconomic factors. Thus, they highlight the association of long-term ozone exposure with individual-level health outcomes in smokers with or without COPD.These results are in line with findings of a general population study of 5780 individuals that demonstrated a long-term association between higher ozone concentration and increased emphysema9 and a study of 300 individuals with α1-antitrypsin deficiency that showed an association between higher concentration of 1-year ozone exposure and emphysema severity.33 The magnitude of the association between long-term ozone exposure and percentage of emphysema was similar to that seen with several other inhalational exposures, such as occupational exposures in the longest held job.34 In addition, we found that those with higher concentration of historical ozone exposure had significantly lower FEV1% predicted value, supporting previous studies that demonstrated an association between ozone exposure and decreased lung function in respiratory diseases, including both asthma2,35 and COPD.9 Furthermore, although the data in the present study support the existing literature describing the association between long-term ozone exposure and respiratory outcomes in asthma,36 this study fills a substantial knowledge gap by demonstrating that exposure to higher concentrations of long-term ambient ozone may also be a factor in increased respiratory symptoms and burden in adults at risk for chronic lung disease owing to smoking and among those with COPD, which is a leading driver of hospitalizations in the United States.37The effect sizes found in this analysis translate to meaningful health outcomes that have important implications for assessing the burden of disease in COPD. Specifically, ozone was associated with worse quality of life (as measured by SGRQ) and health status (as measured by CAT) such that living in areas with a 15-ppb higher concentration of historical 10-year ozone was associated with decrements of 4.0 points in SGRQ and 2.0 points in CAT that met the minimal clinically important difference. In addition, long-term ozone exposure was associated with worse dyspnea (according to the mMRC Dyspnea Scale), which, along with CAT score and exacerbation frequency, is a particularly important measure of disease severity and is currently used in the COPD Global Initiative for Chronic Obstructive Lung Disease guidelines to assess symptoms and risk of exacerbations.38 This assessment, along with the degree of airflow limitation based on FEV1% predicted value, provides a composite of disease severity and guides medical management. A 5-ppb increase in 10-year mean ozone concentration was associated with an increase in the odds of total and severe exacerbations (OR, 1.37 for both) in the 12 months before the baseline visit. According to data from the Centers for Disease Control and Prevention,39 approximately 7 million COPD-related ED visits occurred in 2015. A 5-ppb reduction in 10-year historical ozone concentration could potentially decrease ED visits by 27% to 5.1 million, resulting in an impressive reduction in the existing burden of health care resources spent on COPD.Indoor concentrations of ozone are substantially lower than outdoor levels thus, it is not surprising that the association of ozone exposure with COPD-related health status (CAT score) and quality of life (SGRQ score) tended to be greater in individuals who spent more time outdoors. Future research is warranted to address whether public health messaging concerning poor air quality may influence activity patterns and health outcomes in populations with COPD. Such health alerts on high-outdoor-pollution days should take into consideration the known adverse health implications of poor indoor air quality for COPD outcomes independent of outdoor air quality.The present study highlighted that ozone exposure had adverse implications for COPD risk and respiratory morbidity despite heavy smoking exposure (at least 20 pack-years) among all study participants. No effect modification of ozone by cumulative smoking history was found, such that the adverse outcomes of ozone were consistent across pack-years of exposure, suggesting that the association of ozone exposure may be independent of smoking intensity. Current smokers were more susceptible to the implications of ozone exposure only for the outcome of mMRC Dyspnea Scale; for most outcomes, ozone exposure was associated with increased morbidity regardless of smoking status. In addition, the adverse implications of ozone for respiratory outcomes were persistent despite adjustments for multiple confounders, including job exposures, which have been linked with poor outcomes in the SPIROMICS population.Furthermore, these results remained largely consistent with consideration of historical exposure to pollutant that has been implicated in both the development and worsening of COPD.The modest collinearity found between ozone and PM2.5 increases the uncertainty in the estimates of ozone outcomes. However, the general consistency in the patterns of associations between both models suggests an independent association between ozone and respiratory outcomes that is robust to the inclusion of additional pollutants. These results are among the first to highlight the distinct association of ozone with important disease outcomes in COPD.Epidemiologic and controlled chamber studies showed adverse health outcomes after exposure to relatively low concentrations of ozone, and the present study provides additional evidence of adverse outcomes associated with ozone throughout the observed concentration range, suggesting the absence of a safe threshold of exposure concentration. The 2015 US National Ambient Air Quality Standards (NAAQS) limited the maximum 8-hour mean concentration to 70 ppb, and no current long-term ozone standard exists. Although the mean time used in the current study did not allow for direct comparison with the NAAQS limit, 8-hour peaks are correlated with long-term mean concentrations,and more than a third of the US population lives in areas that exceed the current short-term ozone exposure limit. Since 2000, ozone concentrations have decreased the least as compared with other criteria air pollutants under NAAQS (ie, 16% decrease from 2000 to 2018, compared with a 39% decrease in PM2.5 concentration over the same period). The relative flattening of ozone reduction demonstrates that the US population has been exposed to relatively fixed concentrations of ozone over the past several decades. Results of this study support recent epidemiologic evidence that associated these long-term exposures, in addition to adverse short-term exposures, with health outcomes.We believe that further consideration of adopting the long-term ozone standard of the NAAQS is a public health necessity.Limitations and StrengthsThis study has some limitations. We were unable to establish outdoor behavior patterns over time, and participant report of outdoor activity at the baseline visit may differ from reports in previous years. In addition, generalizability beyond the study sites with available spatiotemporal ozone data may be limited. The potential nonlinear association between ozone and percentage of emphysema, FEV1% predicted, and 6MWT results is intriguing, and the underlying structure of these associations deserves further investigation. In addition, SPIROMICS comprises volunteer participants and thus is not a population-based study, which may introduce self-selection bias.This study also has several strengths. Previous studies often relied on pollution data gathered from local and national regulatory agencies, which limited the studies’ ability to capture participants’ actual exposure near their home, as local meteorological conditions, emissions, and geographic features can influence ozone levels, resulting in a large amount of spatial variability in ozone concentration.1 The pollution prediction models we used included additional fine-scale spatial information not available from existing public data sets. In addition, the extensive clinical phenotyping of SPIROMICS participants allowed us to examine the association of ozone exposure with several respiratory-specific outcomes in a vulnerable population of current and former heavy smokers.ConclusionsThis cross-sectional study found that long-term exposure to ozone was associated with worse outcomes in smokers with or at risk for COPD. Specifically, long-term ozone exposure was associated with lower lung function and a greater percentage of emphysema and air trapping on CT scan. Furthermore, the significant clinical association of ozone exposure with several measures of respiratory morbidity, including worse patient-reported outcomes, functional status, and higher exacerbation risk, provides additional evidence that long-term ozone exposure has a substantial association with a range of respiratory outcomes. We believe these findings support continued reexamination of ambient pollution standards that are designed to protect the health of the most vulnerable members of the US population.American Lung Association. The State of the Air. 2019.