Equity in Clinical Guidance on Application of Global Lung Function Initiative Guidelines for Pediatric Pulmonary Health Assessment

Respiratory health is the result of genetics and socioenvironmental factors that influence optimal lung development and function. Adverse socioenvironmental exposures are linked with pediatric respiratory diseases. Since pulmonary symptomatology is non-specific, objective assessment of respiratory health is based on pulmonary function testing. Historically, pulmonary function testing was adjusted for race. With increased recognition of race being social rather than a biological construct, the American Thoracic Society issued guidelines in 2023 recommending a 'race-neutral' approach to the interpretation of lung function, as put forth by the Global Lung Function Initiative (GLI)-Global equations. Using disease examples of asthma and pulmonary involvement in sickle cell disease, we describe effects of these guidelines on disease reclassification, including identification of worse airflow obstruction in Black children, that corresponded with disease burden. Despite the greater alignment of the race-neutral approach with disease burden, there is a possibility that reclassifying disease may widen the racial gaps. For these reasons, while we recommend clinicians to routinely incorporate spirometry for assessment of respiratory disease, we suggest that in the setting of an abnormal result, they not only address the underlying disease but also assess for, and address, adverse socioenvironmental factors that are known determinants of low lung function. This contextual analysis of pulmonary function is key in providing equitable respiratory health for all children. The recommendations also identify the need for additional research on its implications among healthy children and the role of biological variables such as genetic variation that associated with ancestry and is independently associated with lower lung function.