ACMJ
Anatolian Current Medical Journal

Anatolian Current Medical Journal (ACMJ) is an unbiased, peer-reviewed, and open access international medical journal. The Journal publishes interesting clinical and experimental research conducted in all fields of medicine, interesting case reports, and clinical images, invited reviews, editorials, letters, comments, and related knowledge.

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Original Article
Association between reduced mid-expiratory flow and early airway impairment in smokers with preserved spirometry: a cross-sectional analysis
Abstract
Aims: To determine whether active smokers with preserved post-bronchodilator spirometry (FEV0/FVC ? lower limit of normal [LLN]) and normal thoracic computed tomography (CT) show lower FEF²5?75 values and a higher prevalence of isolated small airway dysfunction than never-smokers, and to assess PEF-FEV0 agreement for Global Initiative for Chronic Obstructive Lung Disease (GOLD) severity staging. Methods: We analysed spirometry data from 286 consecutive adults (?40 years) at a single pulmonary function laboratory. Two chest radiologists independently reviewed all thoracic CT scans (ICC=0.95). Logistic regression included FVC z-score as a prespecified covariate to account for the volume-dependence of FEF²5-75; model stability was confirmed by penalised regression and bootstrap validation. Results: Among 244 participants with preserved FEV0/FVC (136 smokers, 108 never-smokers), FEF²5?75 was lower in smokers (76.2±26.1% vs 93.5±21.9%; p

Keywords : FEF²5?75, small airway disease, pre-COPD, peak expiratory flow, spirometry

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1. Global Initiative for Chronic Obstructive Lung Disease. Global strategy for prevention, diagnosis and management of COPD: 2025 Report. Bethesda: GOLD; 2025.
2. Regan EA, Lynch DA, Curran-Everett D, et al. Clinical and radiologic disease in smokers with normal spirometry. JAMA Intern Med. 2015;175(9):1539-1549. doi:10.1001/jamainternmed.2015.2735
3. Han MK, Agusti A, Celli BR, et al. From GOLD 0 to Pre-COPD. Am J Respir Crit Care Med. 2021;203(4):414-423. doi:10.1164/rccm.202008-3328PP
4. Agustí A, Celli BR, Criner GJ, et al. Global Initiative for Chronic Obstructive Lung Disease 2023 Report: GOLD Executive Summary. Am J Respir Crit Care Med. 2023;207(7):819-837. doi:10.1164/rccm.202301-0106PP
5. Wan ES, Balte P, Schwartz JE, et al. Association between preserved ratio impaired spirometry and clinical outcomes in US adults. JAMA. 2021; 326(22):2287-2298. doi:10.1001/jama.2021.20939
6. Knox-Brown B, Potts J, Santofimio VQ, et al. Isolated small airways obstruction predicts future chronic airflow obstruction: a multinational longitudinal study. BMJ Open Respir Res. 2023;10(1):e002056. doi:10. 1136/bmjresp-2023-002056
7. Fan J, Fang L, Cong S, et al. Potential pre-COPD indicators in association with COPD development and COPD prediction models in Chinese: a prospective cohort study. Lancet Reg Health West Pac. 2023;44:100984. doi:10.1016/j.lanwpc.2023.100984
8. Tanabe N, Vasilescu DM, Kirby M, et al. Analysis of airway pathology in COPD using a combination of computed tomography, micro-computed tomography and histology. Eur Respir J. 2018;51(2):1701245. doi:10.1183/ 13993003.01245-2017
9. Verleden SE, Hendriks JMH, Snoeckx A, et al. Small airway disease in pre-chronic obstructive pulmonary disease with emphysema: a cross-sectional study. Am J Respir Crit Care Med. 2024;209(6):683-692. doi:10. 1164/rccm.202301-0132OC
10. Bhatt SP, Soler X, Wang X, et al. Association between functional small airway disease and FEV1 decline in chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2016;194(2):178-184. doi:10.1164/rccm.201511-2219OC
11. Ronish BE, Couper DJ, Barjaktarevic IZ, et al. Forced expiratory flow at 25%-75% links COPD physiology to emphysema and disease severity in the SPIROMICS cohort. Chronic Obstr Pulm Dis. 2022;9(2):111-121. doi: 10.15326/jcopdf.2021.0241
12. Tan DJ, Lodge CJ, Walters EH, et al. Can we use lung function thresholds and respiratory symptoms to identify pre-Chronic Obstructive Pulmonary Disease? A prospective, population-based cohort study. Am J Respir Crit Care Med. 2024;209(12):1431-1440. doi:10.1164/rccm.202212-2330OC
13. Pothirat C, Chaiwong W, Phetsuk N, et al. Peak expiratory flow rate as a surrogate for forced expiratory volume in 1 second in COPD severity classification in Thailand. Int J Chron Obstruct Pulmon Dis. 2015;10:1213-1218. doi:10.2147/COPD.S85166
14. Hansen MRH, Schmid JM. Screening for impaired pulmonary function using peak expiratory flow: performance of different interpretation strategies. Respir Med Res. 2023;83:101015. doi:10.1016/j.resmer.2023.101015
15. Graham BL, Steenbruggen I, Miller MR, et al. Standardization of spirometry 2019 update. An official American Thoracic Society and European Respiratory Society technical statement. Am J Respir Crit Care Med. 2019;200(8):e70-e88. doi:10.1164/rccm.201908-1590ST
16. Quanjer PH, Stanojevic S, Cole TJ, et al. Multi-ethnic reference values for spirometry for the 3-95-yr age range: the global lung function 2012 equations. Eur Respir J. 2012;40(6):1324-1343. doi:10.1183/09031936.00080312
17. Hankinson JL, Odencrantz JR, Fedan KB. Spirometric reference values from a sample of the general U.S. population. Am J Respir Crit Care Med. 1999;159(1):179-187. doi:10.1164/ajrccm.159.1.9712108
18. Menezes AM, Perez-Padilla R, Jardim JR, et al. Chronic obstructive pulmonary disease in five Latin American cities (the PLATINO study): a prevalence study. Lancet. 2005;366(9500):1875-1881. doi:10.1016/S0140-6736(05)67632-5
19. Quanjer PH, Weiner DJ, Pretto JJ, Brazzale DJ, Boros PW. Measurement of FEF25-75% and FEF75% does not contribute to clinical decision making. Eur Respir J. 2014;43(4):1051-1058. doi:10.1183/09031936.00128113
20. Bazzan E, Semenzato U, Turato G, et al. Symptomatic smokers without COPD have physiological changes heralding the development of COPD. ERJ Open Res. 2022;8(2):00202-2022. doi:10.1183/23120541.00202-2022
21. Agustí A, Hughes R, Rapsomaki E, et al. The many faces of COPD in real life: a longitudinal analysis of the NOVELTY cohort. ERJ Open Res. 2024;10(1):00895-2023. doi:10.1183/23120541.00895-2023
22. Venkatesan P. GOLD COPD report: 2026 update. Lancet Respir Med. doi:10.1016/S2213-2600(25)00432-1
23. Çolak Y, Nordestgaard BG, Lange P, Afzal S. Sex differences in COPD in relation to smoking exposure: a population-based cohort study. Thorax. 2025;80(8):512-519. doi:10.1136/thorax-2024-222682
24. Sørheim IC, Johannessen A, Gulsvik A, Bakke PS, Silverman EK, DeMeo DL. Gender differences in COPD: are women more susceptible to smoking effects than men? Thorax. 2010;65(6):480-485. doi:10.1136/thx.2009.122002
25. Bhatt SP, Bodduluri S, Nakhmani A, et al. Sex Differences in Airways at Chest CT: Results from the COPDGene Cohort. Radiology. 2022;305(3): 699-708. doi:10.1148/radiol.212985
26. Galbán CJ, Han MK, Boes JL, et al. Computed tomography-based biomarker provides unique signature for diagnosis of COPD phenotypes and disease progression. Nat Med. 2012;18(11):1711-1715. doi:10.1038/nm.2971
27. Dharmage SC, Faner R, Agustí A. Treatable traits in pre-COPD: time to extend the treatable traits paradigm beyond established disease.Respirology. 2024;29(7):551-562. doi:10.1111/resp.14760
Article available in :
Volume 8, Issue 3, 2026
Page : 560-568
https://doi.org/10.38053/acmj.1924635
Article Information
Received : 06 Nis 2026
Accepted : 18 May 2026
Published : 22 May 2026
Corresponding Author :

Abdurrahman Koç: Department of Pulmonology, Meram State Hospital, Konya, Turkiye

[email protected]
Citation : Koç A, Ataş AE, Eryeşil H. Association between reduced mid-expiratory flow and early airway impairment in smokers with preserved spirometry: a cross-sectional analysis. Anatolian Curr Med J. 2026;8(3):560-568. doi:10.38053/acmj.1924635

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