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State of the art review
Time to get serious about the detection and monitoring of early lung disease in cystic fibrosis
  1. Katie J Bayfield1,
  2. Tonia A Douglas2,3,
  3. Tim Rosenow4,5,6,
  4. Jane C Davies7,8,
  5. Stuart J Elborn9,
  6. Marcus Mall10,11,12,
  7. Anthony Paproki13,
  8. Felix Ratjen14,15,
  9. Peter D Sly16,
  10. Alan R Smyth17,
  11. Stephen Stick4,5,18,
  12. Claire E Wainwright2,3,
  13. Paul D Robinson1,19,20
  1. 1 Department of Respiratory Medicine, Children's Hospital at Westmead, Westmead, New South Wales, Australia
  2. 2 Department of Respiratory and Sleep Medicine, Queensland Children's Hospital, South Brisbane, Queensland, Australia
  3. 3 Child Health Research Centre, The University of Queensland, Brisbane, Queensland, Australia
  4. 4 Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia
  5. 5 Centre for Child Health Research, The University of Western Australia, Perth, Western Australia, Australia
  6. 6 Centre for Microscopy, Characterisation and Analysis, The University of Western Australia, Perth, Western Australia, Australia
  7. 7 National Heart and Lung Institute, Imperial College London, London, UK
  8. 8 Department of Paediatric Respiratory Medicine, Royal Brompton and Harefield NHS Foundation Trust, London, UK
  9. 9 Centre for Infection and Immunity, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
  10. 10 Department of Pediatric Pulmonology, Immunology, and Critical Care Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
  11. 11 Berlin Institute of Health, Berlin, Germany
  12. 12 Department of Translational Pulmonology, German Center for Lung Research, Berlin, Germany
  13. 13 The Australian e-Health Research Centre, CSIRO, Brisbane, Queensland, Australia
  14. 14 Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
  15. 15 University of Toronto, Toronto, Ontario, Canada
  16. 16 Children’s Health and Environment Program, Child Health Research Centre, The University of Queenland, Herston, Queensland, Australia
  17. 17 Division of Child Health, Obstetrics & Gynaecology. School of Medicine, University of Nottingham, Nottingham, Nottinghamshire, UK
  18. 18 Department of Respiratory Medicine, Princess Margaret Hospital for Children, Perth, Western Australia, Australia
  19. 19 Airway Physiology and Imaging Group, Woolcock Institute of Medical Research, Glebe, New South Wales, Australia
  20. 20 The Discipline of Paediatrics and Child Health, The University of Sydney, Sydney, New South Wales, Australia
  1. Correspondence to Dr Paul D Robinson, The Department of Respiratory Medicine, Children's Hospital at Westmead, Westmead, NSW 2145, Australia; paul.robinson1{at}health.nsw.gov.au

Abstract

Structural and functional defects within the lungs of children with cystic fibrosis (CF) are detectable soon after birth and progress throughout preschool years often without overt clinical signs or symptoms. By school age, most children have structural changes such as bronchiectasis or gas trapping/hypoperfusion and lung function abnormalities that persist into later life. Despite improved survival, gains in forced expiratory volume in one second (FEV1) achieved across successive birth cohorts during childhood have plateaued, and rates of FEV1 decline in adolescence and adulthood have not slowed. This suggests that interventions aimed at preventing lung disease should be targeted to mild disease and commence in early life. Spirometry-based classifications of ‘normal’ (FEV1≥90% predicted) and ‘mild lung disease’ (FEV1 70%–89% predicted) are inappropriate, given the failure of spirometry to detect significant structural or functional abnormalities shown by more sensitive imaging and lung function techniques. The state and readiness of two imaging (CT and MRI) and two functional (multiple breath washout and oscillometry) tools for the detection and monitoring of early lung disease in children and adults with CF are discussed in this article.

Prospective research programmes and technological advances in these techniques mean that well-designed interventional trials in early lung disease, particularly in young children and infants, are possible. Age appropriate, randomised controlled trials are critical to determine the safety, efficacy and best use of new therapies in young children. Regulatory bodies continue to approve medications in young children based on safety data alone and extrapolation of efficacy results from older age groups. Harnessing the complementary information from structural and functional tools, with measures of inflammation and infection, will significantly advance our understanding of early CF lung disease pathophysiology and responses to therapy. Defining clinical utility for these novel techniques will require effective collaboration across multiple disciplines to address important remaining research questions. Future impact on existing management burden for patients with CF and their family must be considered, assessed and minimised.

To address the possible role of these techniques in early lung disease, a meeting of international leaders and experts in the field was convened in August 2019 at the Australiasian Cystic Fibrosis Conference. The meeting entitiled ‘Shaping imaging and functional testing for early disease detection of lung disease in Cystic Fibrosis’, was attended by representatives across the range of disciplines involved in modern CF care. This document summarises the proceedings, key priorities and important research questions highlighted.

  • cystic fibrosis
  • imaging/CT MRI etc
  • paediatric lung disaese
  • respiratory measurement
  • lung physiology

https://doi.org/10.1136/thoraxjnl-2020-216085

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    Footnotes

    • KJB and TAD are joint first authors.

    • Twitter @ktjbay, @DrPLungResearch

    • KJB and TAD contributed equally.

    • Correction notice This article has been corrected since it was published Online First. Minor changes have been made to the author names.

    • Contributors All authors made substantial contributions to the conception or design of the work, or the acquisition, analysis or interpretation of data. Drafting the work was principally performed by KJB, TAD, TR, SS, CEW and PDR. All authors revised it critically for important intellectual content. Final approval of the version published was provided by all authors. All authors agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

    • Funding The Shaping Imaging and Functional Testing for early detection of lung damage in cystic fibrosis (SHIFT) meeting was held as a satellite meeting to the 2019 Australasian Cystic Fibrosis Conference and was sponsored by Vertex Pharmaceuticals Ltd. The rules of engagement were that Vertex did not have any input into the content or how the meeting was run, but they did support the venue, communication for the meeting, and where required, transportation costs and honoraria. Details regarding renumerations received across the author group are found in the authors’ declaration forms attached to the manuscript submission. PDR, CEW and SS were members of the steering committee that organised the meeting.

    • Competing interests TR reports personal fees from Vertex Pharmaceuticals during the conduct of the study; in addition, TR has a patent PCT/AU2016/000079 issued. JCD reports others from Algipharma AS, Bayer AG, Boehringer Ingelheim Pharma GmbH & Co. KG, Galapagos NV, ImevaX GmbH, Nivalis Therapeutics, Inc., ProQR Therapeutics III B.V., Proteostasis Therapeutics, Inc., Raptor Pharmaceuticals, Inc, Vertex Pharmaceuticals (Europe) Limited, Enterprise, Novartis, Pulmocide and Flatley; grants from CF Trust; and others from Teva, outside the submitted work. JSE reports grants from Ionis and the European Commission; personal fees and others from Vertex, during the conduct of the study. MM reports grants from the German Federal Ministry of Education and Research and Einstein Foundation Berlin, during the conduct of the study; personal fees and others from Boehringer Ingelheim and Vertex Pharmaceuticals; personal fees from Arrowhead Pharmaceuticals, Santhera, Galapagos, Sterna Biologicals, Enterprise Therapeutics and Antabio, outside the submitted work. FR reports non-financial support from Vertex during the conduct of the study and acts as a consultant to Vertex Pharmaceuticals, who was the sponsor of this meeting. ARS reports grants from Vertex and personal fees from Novartis, Teva and Vertex, outside the submitted work; and patent issued: 'Alkyl quinolones as biomarkers of Pseudomonas aeruginosa infection and uses thereof'. SS reports a patent licensed to Thirona, and a patent licensed to Resonance Health Ltd and Institutional reimbursement from Vertex Pharmaceuticals (Australia) Pty Ltd. for Steering Committee Member duties organising SHIFT at the Australasian Cystic Fibrosis Conference 2019, Perth. CEW reports institutional reimbursement from Vertex Pharmaceuticals (Australia) P/L for Steering Committee Member duties organising SHIFT at the Australasian Cystic Fibrosis Conference 2019, Perth; income on a per patient basis derived from Pharmaceutical Studies - Vertex Pharmaceuticals Inc., and Boehringer-Ingelheim; research grant from Novo Nordisk Pharmaceuticals P/L- CF-IDEA Study; other reimbursements from Vertex Pharmaceuticals P/L honorarium to attend CF International Advisory Board Meeting in February 2014, Vertex Pharmaceuticals P/L honorarium to attend CF Medical Advisory Board Meeting in Adelaide in April 2014, Novartis Pharmaceuticals P/L honorarium to present symposium at National Pediatric Congress in Lebanon in May 2014, European CF Conference in Gothenburg June 2014 Vertex Pharmaceuticals P/L return travel and honorarium for lecture and discussions, North American CF Conference Georgia October 2014 DKBmed, LLC honorarium to present symposium, Vertex Pharmaceuticals P/L honorarium to present as speaker in an educational meeting series in Brisbane and Sydney in April 2015, Vertex Pharmaceuticals P/L honorarium to attend the Vertex Steering Committee Meetings re VX15-770-123 Study in 2014, Vertex Pharmaceuticals P/L honorarium for Vertex Medical Advisory Board- Innovative endpoints in CF in August 2015, The University of Miami honorarium for meeting attendance in 2015, Thorax honorarium for associate editor duties Q3/Q4 2015, BMJ honorarium for work as reviewer, Vertex Pharmaceuticals 2015 Chicago return flight and accommodation as investigator in Lumacaftor study, Vertex Pharmaceuticals 2015–2017 honorarium as speaker at Vertex sponsored educational meeting series in Australia, Vertex Pharmaceuticals 2016 Phoenix return flight and accommodation as investigator in Next Gen study, Vertex Pharmaceuticals December 2016 honoraria as speaker at Vertex sponsored educational meeting in Liverpool, UK DKBmed eCF Review Issue honoraria in January 2017, Vertex Pharmaceuticals–March 2017 honoraria as speaker at TSANZ meeting Vertex Pharmaceuticals Inc. 2014–2018, honorarium for acting as consultant on the Vertex Orkambi 6-11 HTA Advisory Board, the Global Pediatric Advisory Committee, the Global Medical Advisory Board, and the VIA Grants Committee; Gilead Sciences Ltd. honorarium for meeting attendance on CF imaging; Honorarium for In Vivo Academy Limited for webcast meeting attendance at ECFC–2018; Vertex Pharmaceuticals P/L honorarium to present as speaker in an educational meeting at ECFC in Belgrade–2018; Vertex Pharmaceuticals Inc. honorarium to attend Next Gen Early Lifecycle Management Plan–London–2018; Vertex Pharmaceuticals P/L to act as consultant and to render such services in the form of documents, advice, meetings and conferences during the period October 2018; present Vertex Pharmaceuticals P/L to attend the EU Real World Evidence Steering Committee in Amsterdam–2019 Current Board Positions–International Advisory Board Vertex Pharmaceuticals P/L Deputy Editor Thorax /Associate Editor Respirology. PDR reports institutional reimbursement from Vertex Pharmaceuticals (Australia) Pty. Ltd for Steering Committee Member duties organising SHIFT at the Australasian Cystic Fibrosis Conference 2019, Perth.

    • Provenance and peer review Not commissioned; externally peer reviewed.