Page 1 of 42, AIRCCM Ancien Pros, Published on 1-Septamber 2015 a 10.1164eem.201507-14090C Title: Lung clearance index and structural lung disease on computed tomography in early cystic fibrosis Authors: Kathryn A Ramsey'~", Tim Rosenow'*", Lidija Turkovie', Billy Skoric’*, Georgia Banton’, Anne-Marie Adams“*, Shannon J Simpson', Conor Murray’, Sarath C Ranganathan**", Stephen M Stick'® Graham L Hall'$ on behalf of AREST CF" Affiliations: 1. Telethon Kids Institute, University of Western Australia, Roberts Road, Subiaco, Wester Australia 6008, Australia 2. Cystic Fibrosis Research and Treatment Centre, University of North Carolina at Chapel Hill, Mason Farm Road, Chapel Hill, North Carolina 27599, USA. 3. School of Paediatrics and Child Health, University of Wester Australia, Roberts Road, Subiaco, Western Australia 6008, Australia 4, Murdoch Children’s Res Victoria 3052 srch Institute, Flemington Road, Parkville, Australia, 5. Department of Respiratory Medicine, Royal Children’s Hospital, Flemington Road, Parkville, Vietoria 3052 Australia. 6. Department of Diagnostic Imaging, Princess Margaret Hospital for Children, Roberts Road, Subiaco, Western Australia 6008, Australia 7. Department of Paediatrics, University of Melbourne, Grattan Street, Parkville, Victoria 3010, Australia, 8. Department of Respiratory Medicine, Princess Margaret Hospital for Children, Roberts, Road, Subiaco, Western Australia 6008, Australia Copyright © 2015 by the American Thoracic SocietyAIRCCM Antils in Press. Published om I-September-2015 a 11 6teem 201807-14090C *Co-first authors. SCo-senior authors. Corresponding author: Professor Graham Hall Paediatric Respiratory Physiology, Telethon Kids Institute 100 Roberts Road, Subiaco, WA 6008 Australia Graham Hall@telethonkids.org.au +618 9489 7816 # The full membership of the Australian Respiratory Early Surveillance Team for Cystic Fibrosis (AREST CF) is available at http//www.arestef.org, Author contributions: KAR and TR performed the literature search, study design, data collection, data analysis, data interpretation, figures, and manuscript writing. SCR, SJS, SMS and GLH contributed to the study design, data analysis, data interpretation, and manuscript writing. CM, BS, GB and AA contributed to data collection, data analysis, data interpretation and manuscript writing. LT contributed to data analysis, data interpretation, figures and manuscript writing, Funding: Funding for the AREST CF program was obtained from the Cystic Foundation Therapeutics (SLY04A0, STICKO9A0), the National Health and Medical Research Council of Australia (NHMRC; APPS13730, APP1020555, and Centre of Research Excellence #1000896), and Lung Institute of Westem Australia (Ramsey 2012). G Hall (APP1025550) and K Ramsey (APP1088389) are NHMRC Fellows. Copyright © 2015 by the American Thoracic Society Page 2 of 42Page 3 of 42, AIRCCM Aces in ros, Published on 1-September 2015 a 10.1164eem.201507-14090C Running head: LCI and structural lung disease on CT in early CF Deseriptor number: 9.17 Manuscript word count: 3,428 Ata Glance Commentary Scientific Knowledge on the Subject: The lung clearance index has been suggested as a surrogate for chest computed tomography to detect structural lung abnormalities in individuals with cystic fibrosis, however the associations between lung clearance index and early structural lung disease are unclear. What This Study Adds to the Field: This study is the first to examine the associations between lung clearance index and structural lung disease detected on chest computed tomography across the entire paediatric age range Our data indicates that the lung clearance index is sensitive to the presence and extent of structural lung disease in preschool and school-aged children with CF, but is not sensitive to mild structural abnormalities in infancy. The lung clearance index may be a useful tool to monitor structural diseas progression, and an important outcome measure in clinical trials in young children with cystic fibrosis. However, our data indicate that lung clearance index should not be used as a surrogate to chest imaging to screen for bronchiectasis in children with cystic fibrosis. This article has an online data supplement, which is accessible from this issue's table of content online at www.atsjournals.org, [Copyright © 2015 by the American Thoracic SocietyAIRCCM Anil in Press. Published on I -September-2015 a 11 6teem 201807-14090C Abstract Rationale: The lung clearance index is a measure of ventilation distribution from the multiple breath washout technique. Lung clearance index has been suggested as a surrogate for chest computed tomography to detect structural Iung abnormalities in individuals with cystic fibrosis, however the associations between lung clearance index and early structural lung disease are unclear. Objective: We assessed the ability of lung clearance index to reflect structural lung disease on chest computed tomography across the entire paediatric age range. Methods: Lung clearance index was assessed in 42 infants (0-2y), 39 preschool (3-6y), and 38 school-aged (7-16y) children with cystic fibrosis prior to chest computed tomography, and 72 healthy controls. Scans were evaluated for CF-related structural lung disease using the PRAGMA quantitative outcome measure. Measurements _and Main Results: In infants with cystic fibrosis, lung clearance index is insensitive to structural disease (Kappa -0-03 (-0-05, 0-16)). In preschool children with cystic fibrosis, lng clearance index correlates with total disease extent. In school-aged children lung clearance index correlates with extent of total disease, bronchiectasis, and air trapping In preschool and school aged children, lung clearance index has a good positive (83-86%), but poor negative (50-55%), predictive value to detect the presence of bronchiectasis. Conclusions: These data suggest lung clearance index may be a useful surveillance tool to ‘monitor structural lung disease in preschool and school age children with cystic fibrosis. However, lung clearance index cannot repl chest imaging using computed tomography to screen for bronchiectasis in this population. Abstract word count: 247 Keywords: Multiple breath washout, infant, child, imaging, cystic fibrosis. 1 Copyright © 2015 by the American Thoracic Society Page 4 of 42Page 5 of 42, AIRCCM Ancien Pros, Published on 1-Septamber 2015 a 10.1164eem.201507-14090C Introduction Structural lung abnormalities develop early in individuals with cystic fibrosis (CF) and progress rapidly into irreversible structural discase (1-3). To delay the onset and progression of Tung disease interventions should ideally commence early in life. However, effective and personalised interventions require accurate and simple means to monitor disease severity (4). As such there is a clear imperative for the development of minimally invasive and sensitive ‘markers of structural lung disease that can be applied routinely in the clinical setting, Chest computed tomography (CT) is the gold standard for assessing the presence and extent of CF-related structural lung dises ¢ (1, 3), and outcome measure appropriate for infants and young children with mild disease have recently been developed (5). However, despite ongoing improvements in technology resulting in lower doses (6, 7), the use of ionising radiation limits the frequency at whi CT can be performed. Altemative techniques, such as ung function measurements, may allow the sessment of lung disease at more frequent intervals, reduce the number of CT scans required for the monitoring of structural lung disease progression in early life, and serve as endpoints for clinical trials. Spirometry, particularly forced expiratory volume in 1 second (FEV;), is the most widely used method of monitoring CF lung disease... However FEV) is insensitive to detect the onset and progression of early CF lung disease (8), and difficult to obtain reliably in infants and young children (9, 10). Lung clearance index (LCI) is a marker of global ventilation distribution derived from the multiple breath washout technique (MBW). LCI is elevated in @ small proportion of infants (11, 12), and the majority of preschool (13, 14) and school aged (8, 15) children with CF, In 2 Copyright © 2015 by the American Thoracic SocietyAIRCCM Antils in Press. Published om I-September-2015 a 11 6teem 201807-14090C older children with CF, LCI has been shown to be more sensitive than FEV; to detect the presence of structural lung disease (8, 16, 17). However, there are only weak correlations between LCI and structural lung disease in infants with CF (18) and there are no data on the ability of LCI to indicate the presence or severity of structural ung disease in preschool children aged three to six years. This is arguably the most important age group due to the rapid progression of structural disease during this period (3). For LCI to be considered as routine clinical investigation or outcome measure for intervention trials, further evidence regarding the ability of LCT to accurately reflect structural lung damage in infants and children with CF of all ages is required. The aim of this study was to assess the associations between MBW outcomes and C1 clated structural lung disease across the entire paediatric age range. We hypothesized that the associations between MBW outcomes and structural lung disease would be age dependent, with stronger associations seen in older children with more established CF-related lung disease. Some of the results of these studies have been previously reported in the form of abstracts (19, 20). Methods Study population Infants and children with CF undergoing annual surveillance or clinically indicated chest CT scan at Princess Margaret Hospital in Perth and the Royal Children’s Hospital in Melbourne, Australia were eligible to take part in this study (detailed methods are provided in the online data supplement), Healthy children without CF over the age of two years were recruited from the local population in Perth to undertake lung function measurements. The ethics committee of cach institution approved the study, and parents gave written informed consent to each aspect of the study separately. 3 Copyright © 2015 by the American Thoracic Society Page 6 of 42Page 7 of 42, AIRCCM Ancien Pros, Published on 1-Septamber 2015 a 10.1164eem.201507-14090C Multiple Breath Washout The Exhalyzer D system was used for MBW data collection (Ecomedics AG, Duernten, Switzerland). Infant MBW (3 months to two years) was performed in the supine position using 4% sulphur-hexafluoride (SF) while asleep following chloral hydrate sedation (18, 21), In children over two years, MBW was performed using 100% oxygen to washout resident nitrogen gas from the lungs (22). Functional residual capacity (FRC), LCI, the first (MI/MO) and second (M2/M0) moment ratios were derived from visits with at least two acceptable measurements with no evidence of leak or imegular breathing pattem (23). The Jung clearance index was considered the primary outcome from MBW testing in this study. Chest Computed Tomography Chest CT was only obtained in patients with CF. CT seans in infants and preschool children were performed prior to bronchoalveolar lavage collection under intravenous general anaesthetic. Volumetric inspiratory scans were obtained at a positive airway opening pressure of 25 emH,0, and volumetric or limited slice expiratory scans obtained at an airway opening pressure of 0 cmH,0 (ie. relaxed end expiratory volume) (3, 24). In school-aged children, spirometry-assisted volumetric chest CT scans were obtained, whereby inspiratory scans ‘were obtained at total lung capacity and expiratory scans were collected at residual volume QS). To assess CT-determined structural lung disease, the quantitative PRAGMA-CF scoring method was used (5). Briefly, a grid overlaid on ten equidistant axial slices is annotated for the presence of bronchiectasis (outer edge bronchus-artery cross-sectional area ratio > 1), mucus plugging (high density airway occlusion or tree-in-bud appearance), bronchial wall thickening (assessed subjectively as airway walls that are thicker or have incr sed signal 4 Copyright © 2015 by the American Thoracic SocietyAIRCCM Anil in Press. Published on I -September-2015 a 11 6teem 201807-14090C density relative to normal airways) on inspiratory scans, and trapped air (geographic low density regions) on expiratory scans (5). The extents (represented as volume proportions of the lung) of total airways disease (% disease), bronchiectasis (% bronchiectasis) and trapped air (% air trapping) were calculated and considered the primary outcome from chest CT. Chest CT scans were also scored for the presence and extent of bronchiectasis, mucus plugging, bronchial wall thickening and air trapping using a simplified CF-CT scoring method as described previously (2, 3). Statistical analysis ‘The upper limit of normal for MBW indices were calculated from a prospective healthy control population of preschool and school aged children (n = 72) and published reference ‘equations for infants (LCI only as there are no reference data are available for moment ratios in infants) (26). The agreement between MBW indices and the presence of bronchiectasis and air trapping was .ssessed using the Kappa coefficient of agreement and receiver operating characteristic (ROC) curves. Sensitivity, specificity, positive and negative predictive values were calculated together with 95% exact binomial confidence intervals. Associations between MBW indices and the extent of structural lung disease were assessed using linear mixed effects models with random intercepts for repeated visits to account for clustering, The coefficients of the fixed effects of the linear mixed models, with 95% confidence intervals and p-values are presented. All analyses were performed using Stata 13.0 (Stata Corp. 2013, College Station, TX), Results Study population 5 Copyright © 2015 by the American Thoracic Society Page 8 of 42Page 9 of 42 AIRCCM Aces in ros, Published on 1-September 2015 a 10.1164eem.201507-14090C Matched MBW and chest CT data were available for 49 visits in 42 infants (3 months to two years), $2 visits in 39 preschool children (three to six years) and 48 visits in 38 school-aged children (seven to 16 ye with CF (Table 1), In addition, MBW data were available on a prospective healthy control population of 72 preschool and school aged children (three to 15 years) with no history of respiratory disease (Table E1 in the online data supplement). In the control population LCT, MI/MO and M2/MO were found to be independent of height or age (Figure 1), We found that 22% of infants, 58% of preschool and 58% of school-aged children with CF had an LCI above the upper limit of normal (Table 2) Agreement between MBW indices and the presence of bronchiectasis The agreement between LCI and the presence of bronchiectasis on chest CT is shown in Table 2. An abnormal LCI and detectable bronchiectasis was uncommon in infants with CF resulting in a low sensitivity and low positive predicted value. The majority of preschool and school aged children with CF had an LC! above the upper limit of normal (58%) and had bronchiectasis detected on CT (69%), resulting in a high concordance between the two measures (~70%). In these older age groups LCI had a sensitivity and specificity of ~70% to detect bronchiectasis. The positive predictive value for LCI was high indicating that in over 80% of visits when LCI is abnormally elevated bronchiectasis can be detected on chest CT. However, the negative predictive value of LCT was low (50-55%) indicating that in half of the visits where LCI is within the normal range bronchiectasis was still detected on CT. The results for the moment ratios were similar to that of LCI and are presented in Table E2 in the onfine data supplement, In addition, we performed an ROC analysis for LCT and the presence of bronchiectasis (Table E3 in the online data supplement). We determined the optimal LCT value (calculated to maximise sensitivity and specificity) to detect bronchiectasis, to be 7.8 lung turnovers for each age group. 6 (Copyright © 2015 by the American Thoracic SocietyAIRCCM Anil in Press. Published on I -September-2015 a 11 6teem 201807-14090C Agreement between MBW indices and the presence of air trapping ‘The agreement between LCI and the presence of air trapping on chest CT is shown in Table 3. The prevalence of air trapping increased with age from 58% in infants, 85% in preschool children, and 94% in school-age children. There was significant agreement between LCI and the presence of air trapping on CT in infants with CF. However the sensitivity of LCI to detect air trapping on CT was only 38%. There was no agreement between LCI and air ‘rapping presence in preschool and school-aged children with CF. In preschool children, LCI had a lower positive (73%) and negative (41%) predictive value to detect air trapping presence than in infants. In school-aged children, LCT had a high positive (93%), but almost negligible negative (5%) predictive value to detect air trapping. The results for the moment ratios were similar to that of LCT and are presented Table E4 in the online data supplement. Associations between MBW outcomes and extent of structural disease We examined the association between MBW outcomes and the extent of structural disease abnormalities on chest CT using PRAGMA-CF scores (Table 4; Figure 2). In infants with CF, LCI and MI/MO did not correlate with any structural disease extent scores. There was, however, a significant association between M2/MO and the extent of bronchiectasis and air trapping. In preschool children with CF, LCI positively correlated with total structural disease extent but not the extent of bronchiectasis or air trapping. Both M1/MO and M2/MO in preschool children correlated with total structural disease and bronchiectasis extent, but not air trapping. In school-aged children with CF, LCI and M2/MO positively correlated with total disease, bronchiectasis, and air trapping extent, MI/MO did not correlate with any disease extent scores in school-aged children, We found similar associations between MBW outcomes and structural disease extent scores using the simplified CF scoring method (Table E5 in the online data supplement), 7 Copyright © 2015 by the American Thoracic Society Page 10 of 42,Page 11 of 42, AIRCCM Ancien Pros, Published on 1-Septamber 2015 a 10.1164eem.201507-14090C Discussion The objective of this study was to determine the ability of MBW measures of ventilation distribution to act as a minimally invasive surrogate for structural lung disease in children with CF. We compared MBW outcomes against chest CT, the current gold standard method to detect structural lung disease in CF. We found that LCI is relatively insensitive to the presence and extent of carly structural abnormalities in infants with CF. In preschool and school-aged children, LCI had good agreement and correlation with the presence and extent of structural abnormalities on CT. However, the low negative predictive value of LCT for the presence of bronchiectasis and air trapping in infants and children with CF suggests that LCT should not be used as a surrogate for chest CT to indicate the presence of structural disease Despite the limitations of LCT to identify lung damage, LCI could be a useful tool for monitoring early lung disease in CF, and therefore longitudinal assessments of LCI in relation to other clinical outcomes including inflammation, infection and structural lung disease trajectory are needed. We found that LCI was relatively insensitive to the presence and extent of structural lung disease in infants with CF. This supports data from a previous study by our group, that examined associations between LCI, moment ratios and structural lung disease on limited slice chest CT scans scored using a CF-CT scoring method modified for use in children (18). This study found a weak correlation between LCI, moment ratios and the extent of ait trapping on CT (18). Our current study utilised volumetric chest CT scans, that have been shown to be more sensitive to detect early structural lung disease, and the PRAGMA-CF scoring method that quantifies early structural disease (5). We found that LCI was relatively insensitive to detect the presence of bronchiectasis and air trapping on chest CT, and did not correlate with any structural disease extent parameter in infants with CF. There was, 8 Copyright © 2015 by the American Thoracic SocietyAIRCCM Antils in Press. Published on I-September-2015 at 11 6teem 201807-14090C however, a correlation between M2/MO and bronchiectasis and air trapping extent, suggesting that moment ratio analysis may be more sensitive to the extent of early disease than LCL Structural lung disease in the first two years of life in infants with CF following newbom screening and treatment in a specialist centre is mild; only 20% of infants in our study had detectable bronchiectasis and the mean percentage of the lung affected by bronchiectasis was prevalence of bronchiectasis in this study is higher than that previously reported by our group (3), which is likely due to the greater sensitivity to detect bronchiectasis in volumetric scans compared with the 3-slice technique used previously. While the extent of structural disease in infants with CF is low, we have previously shown that disease extent is associated with more rapid progression of lung disease over the subsequent two years in infants with CF, and thus is likely to be clinically relevant (5). The LCT may be more useful as a tool to reflect potentially reversible changes in the lungs associated with inflammation and infection in this age group (11, 27), but the results from our current study indicate that MBW indices are not sufficiently sensitive to be used as a surrogate for the detection and monitoring of early structural lung disease in infants with CF. ‘This study is the most comprehensive examination of the relationships between LCI and structural hung disease in infants and preschool children with CF, This developmental period is associated with increasing prevalence and extent of structural lung disease along with worsening ventilation inhomogeneity (increased LCI) (1, 13, 14). The prevalence of bronchiectasis in our population was 69% in preschool children, compared with only 20% in infants with CF. Given the rapid increase in the prevalence of bronchiectasis in the preschool years, this period arguably represents a window of opportunity for interventions aimed at preventing or slowing the development of irreversible structural disease. In the present study MBW outcomes, Lt and moment ratios had good agreement, sensitivity and specificity to 9 Copyright © 2015 by the American Thoracic Society Page 12 of 42,Page 13 of 42, AIRCCM Aces in ros, Published on 1-September 2015 a 10.1164eem.201507-14090C detect the presence of bronchiectasis on chest CT. We also found positive correlations between MBW outcomes and the extent of structural lung disease. These data suggest that MBW outcomes could be used as a surveillance tool for the monitoring of established structural disease in children with CF, However, we advise caution regarding the use of LCT as a screening tool or surrogate for chest CT to detect the presence of structural lung disease. While we found that the majority of children with an abnormal LCI had bronchiectasis detected on their CT (positive predictive value ~ 3%), we found that only half of the children with an LCI within the normal range did not have bronchiectasis detected on CT (negative predictive value = 50%). This means that a significant portion of children would be misdiagnosed as not having bronchiectasis if LCI was used as the sole sc ing/detection tool. We believe that the LCI would be ideally suited as a non-invasive monitoring tool for preschool children with CF that could be applied regularly in the clinical setting in conjunction with imaging techniques for the detection and monitoring of structural disease. These data support previous studies regarding the ability of LCI to reflect structural disease in school-aged children with CF. We found that LCI and moment ratios correlated with the presence and extent of structural lung disease in school-aged children with CF, as has been reported previously (8, 16, 17). We found that over 85% of children with an abnormal LCI had bronchiectasis detected on chest CT. However, the negative predictive value of LCT was again low (55%) indicating that in half of the visits where LCI was normal, bronchiectasis was still de! ied on CT. In a study of individuals with CF aged five to 19 years, LCI had a lower positive (71%) and higher negative predictive (69%) to detect the presence of bronchiectasis on CT compared with the present study (8). In individuals with CF aged six to 26 years with a normal FEV, (80% predicted), LCI had a positive predictive value of 88% and negative predictive value of 63% to detect an abnormal chest CT (16). Similarly, in a 10 (Copyright © 2015 by the American Thoracic SocietyAIRCCM Anil in Press. Published on I -September-2015 a 11 6teem 201807-14090C younger cohort of school-aged children (6 — 10 years) LCI had a positive predictive value of 88% and negative predictive value of 44% to reflect an abnormal chest CT (17). It is important to note that positive and negative predictive values are dependent on the prevalence of structural lung disease in the population and may not be generalizable to a population with a different prevalence. Together these data support the notion that an abnormal LCI is highly predictive of the presence of structural lung disease, however, an LCI within the normal range does not rule out structural lung disease detected on chest CT. Strengths of the present study include the use of a prospective healthy control cohort for the calculation of upper limits of normal for LCI and moment ratios in preschool and school-aged children, In infants with CF, the second moment ratio was more strongly correlated with the extent of structural lung disease than LCT, possibly because moment ratios can detect more peripheral ventilation inhomogeneity at the latter portion of the washout compared with LCL ‘As a result moment ratios may be most valuable to calculate in early life where the disease is dominated by small changes to the peripheral airways. We also utilised the novel PRAGMA- CF quantitative CT scoring method, aimed specifically at quantifying the extent of early structural abnormalities in early CF lung disease (5). While we did not see any appreciable difference in the structure-function extent relationships between PRAGMA and CF-CT scores, we believe that the PRAGMA.CF is the most appropriate method for assessing CT scans in young children with CF. Limitations of the current study include the differences in the MBW testing in infancy (sedated, supine, SFs gas) compared with children (awake, seated, 100% oxygen to washout resident nitrogen gas). Sedation during lung function may have caused atelectasis or air trapping. It is also possible that the use of an exogenous tracer gas (SF6) for MBW testing in infancy could underestimate ventilation inhomogeneity due to the ‘6 gas not penetrating occluded lung units. In addition there were difference in chest CT 1 Copyright © 2015 by the American Thoracic Society Page 14 of 42,Page 15 of 42, AIRCCM Ancien Pros, Published on 1-September 2015 a 10.1164eem.201507-14090C scanning techniques in infants and preschool (anaesthetised, expiratory scan at functional residual capacity) and school-age (awake, spirometry-assisted, expiratory scan at residual volume). Our study aimed to determine if LCI could be used as a surrogate for chest CT to detect structural disease, and thus was not designed to examine the effect of clinical variables, such as pulmonary infection status, inflammation, ot exacerbations on the associations between MBW and CT outcomes. All the children in our study, including the three adolescent patients who underwent clinically indicated chest CT scans, were clinically stable at the time of CT and MBW testing. Current studies that have examined relations between LCI and structural lung disease have been cross-sectional in nature, and thus we are not yet able to determine whether LCI can track the development and progression of structural lung disease over time. Treatment and monitoring of lung disease should commence early in life in individuals with CF in order to prevent the onset and/or slow the progression of lung disease. The LCI is a promising lung function outcome that can be measured across the entire paediatric age range. The results from this study suggest that the LCI is sensitive to detect the presence and extent of structural lung disease detected by chest CT in preschool and school-aged children with but is not sensitive to detect mild structural abnormalities in infancy. While LCI may be a ‘useful surveillance tool in CF and potentially a feasible clinical trial outcome, our data indicate that LCI should not be used as a surrogate to chest imaging for the detection of bronchiectasis in children with CF Acknowledgements; The authors thank Caroline Gallagher, Jasmine Grdosie and the respiratory fellows at both centers who assisted with lung function and chest CT data R (Copyright © 2015 by the American Thrace SocietyAIRCCM Anicles in Press, Published on II-Septere-201S as 10.1 16sem 201507-14090C " Page 16 of 42, collection. The authors also thank the participants and their families who contribute to the AREST CF program. 2B Copyright © 2015 by the American Thoracic SocietyPage 17 of 42, AIRCCM Aces in ros, Published on 1-September 2015 a 10.1164eem.201507-14090C References 1, Mott LS, Park J, Murray CP, Gangell CL, de Klerk NH, Robinson PJ, Robertson CF, Ranganathan SC, Sly PD, Stick SM, Arest CF. 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Ellemunter H, Fuchs SI, Unsinn KM, Freund MC, Waltner-Romen M, Steinkamp G, Gappa M. Sensitivity of Lung Clearance Index and chest computed tomography in carly CF lung disease. Respir Med 2010; 104: 1834-1842, 17, Owens CM, Aurora P, Stanojevie S, Bush A, Wade A, Oliver C, Calder A, Price J, Carr SB, Shankar A, Stocks J, London Cystic Fibrosis C. Lung Clearance Index and HRCT are complementary markers of lung abnormalities in young children with CF. Thorax 2011; 66: 481-488 18, Hall GL, Logie KM, Parsons F, Schulzke SM, Nolan G, Murray C, Ranganathan S, Robinson P, Sly PD, Stick SM, Berry L, Garratt L, Massie J, Mott L, Poreddy S, Simpson S. Air trapping on chest CT is associated with worse ventilation distribution in infants with cystic fibrosis diagnosed following newbom screening. PLoS One 2011; 6: €23932. 19. Ramsey K, Rosenow TT, Skoric B, Adams A, Callagher C, Banton G, Murray C, Ranganathan S, Stick S, Hall G. Agreement between the lung clearance index and bronchiectasis detected via chest computed tomography in infants and children with cystic fibrosis (CF). Fur Respir J Suppl 2014; 44: 1974 20, Ramsey KA, Rosenow T, Skoric B, Adams AM, Gallagher C, Banton GL, Murray C, Ranganathan §, Stick SM, Hall GL. The ability of the lung clearance index to detect, bronchiectasis on chest computed tomography in infants and children with cystic fibrosis. Pediatr Pulmonol Suppl 2014; 49: 359, 16 Copyright © 2015 by the American Thoracic SocietyAIRCCM Anil in Press. Published on I -September-2015 a 11 6teem 201807-14090C 21. Schibler A, Hall GL, Businger F, Reinmann B, Wildhaber JH, Cemele M, Frey U. Measurement of lung volume and ventilation distribution with an ultrasonic flow meter in healthy infants, Eur Respir J 2002; 20: 912-918. 22, Singer F, Houltz B, Latzin P, Robinson P, Gustafsson P. A realistic validation study of a new nitrogen multiple-breath washout system, PLoS One 2012; 7: e36083, 23. Robinson PD, Latzin P, Verbanck S, Hall GL, Horsley A, Gappa M, Thamrin C, Arets HG, Aurora P, Fuchs SI, King GG, Lum S, Macleod K, Paiva M, Pillow JJ, Ranganathan S, Ratjen F, Singer F, Sonnappa S, Stocks J, Subbarao P, Thompson BR, Gustafsson PM. Consensus statement for inert gas washout measurement using ‘multiple and single- breath tests. Eur Respir J 2013; 41: 507-522. 24, Thomas KE, Wang B. Age-specific effective doses for pediatric MSCT examinations at a large children’s hospital using DLP conversion coefficients: a simple estimation method. Pediatric radiology 2008; 38: 645-656. 25, Robinson TE, Leung AN, Moss RB, Blankenberg FG, al-Dabbagh H, Northway WH. Standardized high-resolution CT of the lung using a spirometer-triggered electron beam CT scanner. Am J Roentgenol 1999; 172: 1636-1638. 26. Lum S, Stocks J, Stanojevie S, Wade A, Robinson P, Gustafsson P, Brown M, Aurora P, Subbarao P, Hoo AF, Sonnappa S. Age and height dependence of lung clearance index and functional residual capacity. Eur Respir J 2013; 41: 1371-1377 27. Simpson SI, Ranganathan S, Park J, Turkovie L, Robins-Browne R, Skoric B, Ramsey KA, Rosenow T, Banton GL, Berry L, Stick SM, Hall GL. Progressive ventilation inhomogeneity in infants with cystic fibrosis after pulmonary infection. Eur Respir J 2015; In Press. ” Copyright © 2015 by the American Thoracic Society Page 20 of 42,AIRCCM Attics in Pres, Published on 1-September2015 a 10.1164. 201507-14090C Page 21 of 42, " 28. de Onis M, Onyango A, Borghi E, Siyam A, Nishida C, Sickmann J. Development of a WHO growth reference for school-aged children and adolescents. Bull World Health Organ 2007; 85: 661-668. 29. WHO Multicentre Growth Reference Study Group. WHO Child Growth Standards based on lengtlvheight, weight and age. Acta Paediatrica Suppl 2006; 450: 76-85. 18 Copyright © 2015 by the American Thoracic SocietyAIRCCM Anil in Press. Published on I -September-2015 a 11 6teem 201807-14090C Figure legends Figure 1: Lung clearance index plotted against age for healthy control children (circles) and children with cystic fibrosis (triangles). LCI = lung clearance index. Horizontal lines indicate the upper (7.7) and lower (5.7) limits of normal for LCI, Figure 2: Scatter plots of LCI plotted against % disease, % bronchiectasis, and % air ‘rapping scores in infants (A — red markers), preschool (B — green markers) and school-aged (C—blue markers) children with CF. LCI = lung clearance index. 19 Copyright © 2015 by the American Thoracic Society Page 22 of 42,Page 23 of 42, AIRCCM Ancien ros, Published on 1-September 2015 a 10.1164eem.201507-14090C Tables Characteristics Infants Preschool School-age Number of children 42 39 38 ‘Number of visits 49 32 48 Age (y) 0-94 (0-57) 5-42 (1-05) 9-77 (2-48) Sex [male: female] 16:26 16:23 2:17 Height z-score (95% CI) 0-03 (0-20, 0-28) 0-08 (-0-20, 0:34) -0:20 (-0-44, 0-04) Weight z-score (95% Cl) -0-12 (-0:33, 0-53) FEVI L (95% Cl) FEVI z-score (95% Cl) FYCL (95% Cl) FVC z-score (95% Cl) PheSO8del/PheSO8del 58% (25/42) PheSO8del/other 36% (16/42) Severe genotype 88% (38/42) ‘Multiple Breath Washout Functional residual 0-19 (0-13, 051) 62% (25/39) 30% (12/39) 91% (35139) 0-26 (-0-04, 0°55) 1,80 (1.65, 1.95) -0.13 (0.51, 0.26) 2.19 (2.03, 2.34) 0.23 (0.12, 0.57) 54% (21/38) 35% (14/38) 88% (34/38) capacity 0.19 (0.08) 0.91 (0.19) 1.51 (0.77) Lung clearance index 781 (0-80) 8:17 (1-22) 8:35 (1-78) First moment ratio 2:30 (0-28) 1-78 (0:24) 1-95 (0-91) Second moment ratio 11-02 (4.16) 8-80 (2-05) 7-19 (3-41) PRAGMA-CF scores Bronchiectasis present 20% (10/49) 69% (36152) 69% (33/48) Air trapping present 58% (29/49) 85% (44/52) 94% (45/48) Bronchiectasis extent (%) 0-18 (0-34) 1-88 (3-38) 2-05 (3-21) Air trapping extent (%) 1-35 (2-73) 6°37 (12-02) 20°8 (21-34) se extent (%) 1-35 (1-05) 4-26 (4-29) 4-86 (5-13) 20AIRCCM Anicles in Press, Published on II-Septere-201S as 10.1 16sem 201507-14090C " Page 24 of 42, ‘Table 1: Demographics of study population Data is presented as mean (standard deviation) ‘or % (proportion) unless otherwise stated. 95% Cl = 95% confidence interval. Height, weight cores were calculated using WHO growth standards (28, 29) a Copyright © 2015 by the American Thoracic SocietyAIRCCM Antics in Pres, Published on 1-September2015 a 10.1164. 201507-14090C Page 25 of 42, " Infant Preschool School-age Derived from LCI ULN 17 1 Lum et al, 2013, Abnormal LCI (%) 22% (11/49) 58% (30/52) 58% (28/48) Bronchiectasis present Concordance (%) Kappa coefficient Sensitivity Positive predictive value Negative predictive 20% (10/49) 65% (32/49) 0-03 (-0-05, 0°16) 20% (2:5, 56) 71% (61, 89) 18% (2.3, 52) 79% (63, 90) 69% (36/52) 69% (36/52) 0-35 (0-10, 0-60) # 69% (52, 84) 69% (41, 89) 83% (65, 94) 50% (28, 72) 69% (33/48) 73% (35/48) 0-42 (0-20, 0-64) # 73% (55, 87) 73% (45, 92) 86% (67, 96) 55% (32, 77) Table 2: Agreement between LCI and the presence of bronchiectasis on chest CT using PRAGMA-CF scores. Brackets contain n values or 95% confidence interval. LCI = lung clearance index; ULN = upper limit of normal. Upper limit of normal for LCI in infants was derived from the equation in Lum ef al, 2013, The upper limit of normal for LCI in preschool and school-age children was derived from our prospective healthy population (Table El in the online data supplement). * p < 0-05; # p < 0-01; @ p< 0-001, 2 15 bythe American Thoraie SocietyAIRCCM Antils ia Press. Published on II -September-2015 a 11 6teem 201807-14090C Page 26 of 42 Infant Preschool School-age Derived from LCI ULN 1 1 Lum et al. 2013 Abnormal LCI (%) 22% (11/49) 58% (30/52) 58% (28/48) Air trapping 58% (29/49) 85% (44/52) 94% (45/48) present Concordance (%) 65% (32/49) 60% (31/52) 56% (27/48) Kappa coefficient Sensitivity Specificity Positive predictive value Negative predictive value 0-30 (0-06, 0°54) ® 38% (19, 59) 92% (74, 99) 82% (48, 98) 61% (43, 76) 0-15 (0-13, 0-43) 63% (45, 79) 53% (28, 77) 73% (54, 88) 41% (21, 64) 0-02 (-0-16, 0°14) 58% (42, 72) 33% (0°84, 91) 93% (77, 99) 5% (0-13, 25) Table 3: Agreement between LCI and the presence of PRAGMA-CI ir trapping on chest CT using scores. Brackets contain n values or 95% confidence interval. LCI = lung clearance index; ULN = upper limit of normal. Upper limit of normal for LCI in infants was derived from the equation in Lum ef al, 2013. The upper limit of normal for LCI in preschool and school-age children was derived from a prospective healthy population (Table E1 in the online data supplement). p <0-05; # p <0-01; ® p<0-001 23 Copyright © 2015 by the American Thoracic SocietyPage 27 of 42, [AIROCM Aces in Pros, Published on 11-Sepember 2015 a 10.116Hrecr.201507-14090C Le MMO M2/MO Infants % Disease 0-03 (-0-14, 0-20) 0-00 (-0-01, 0-01) 0-02 (0-04, 0-16) % Bronchiectasis 0-33 (-0-82, 0-16) 0-01 0-02, 0-04) 0:31 (0-18, 0-45) ® % Air trapping 0-04 (-0-04, 0-12) 0-00(-0-00, 0:01) 0-05 (003, 0-08) & Preschool % Disease 0-10 (0-02, 0-19) * 0-02 (0-00, 0:04) * 0-17 (0-03, 0-31) * % Bronchicctasis 0-11 (0-00, 0-22) 0-02 (0-00, 0-05) * 0-20 (0-01, 0-39) * % Air trapping 0-02 (-0-01, 0-05) 0-00 (0-00, 0-01) 0-02 (-0-03, 0-07) School-age % Disease 0-18 (0-10, 0-27) 003 (-002, 0-08) 0-36 (0-19, 0:53) % Bronchiectasis 0-29 (0-14, 0-43) ® 0-04 (-0-05, 0-13) 0-55 (0-28, 0°83) @ % Air trapping 0-06 (0-04, 0-07) 0°01 (-0-01, 0-02) 0-10 (0-06, 0-14) @ Table 4: Association between MBW outcomes and the extent of structural disease on CT using PRAGMA.CF scores. Bracket % confiden contain 9: ¢ interval. LCI = lung rance index; MI/M0 = first moment ratio; M2/MO = second moment ratio. Coefficients indicate the increase in MBW outcomes for each unit increase in CT outcomes. * p < 0-05; # p< 0-01; p<0-001 24 Copyright © 2015 by the American Thoracic SocietyAIRCCM Antcles in Press, Published on I 1-Sepemben-201S a 10.1 164cem,201507-14090C " Page 28 of 42 Figures Figure 1: Lung clearance index plotted against age for healthy control children (circles) and. children with eystic fibrosis (triangles). LCI = lung clearance index. Horizontal lines indicate the upper (7.7) and lower (5.7) limits of normal for LCI. Health 144 Cystic fibrosis 4 A 124 a ‘ « aa i“ a = 104 A gM) a 8 ef an aha Pate 4 81 fA, , 4ptt ee 4 Oo zz is 16 Age (years) o © 25 Copyright © 2018 by the American Thoracic SocietyS08 seus watiowy a9 Kg S102 9 HBO ad wie + : ek. : 7 so mms — 4 . . Go eee) eo . 5 2 5 la ak aanewe =m 5 la a @) fooyasard “(stoxeur par — y) siueyuT Ut sazoas Surdden aye 9% pur ‘siseIoaTyaHION % ‘oseasIp So6or -u0sior UENO ‘xopuy aoureswa[9 Hun] = [3] “AO YUM UOAp|LYD (SiaxZeUL anyq — D) poFe-looyps pur (SioyseUL UDALT — % suede panoyd [97 Jo sioyd zones +z 94nd 240 67 oBedAIRCCM Articles in Press Published on 11-September-2015 as 10.1164ireem 201 ™ Page 30 of 42 Online Data Supplement Title: Lung clearance index and structural lung disease on computed tomography in early cystic fibrosis Authors: Kathryn A Ramsey'”", Tim Rosenow'”, Lidija Turkovic', Billy Skoric’’, Georgia Banton', Anne-Marie Adams", Shannon J Simpson’, Conor Murray®, Sarath C Ranganathan*®”, Stephen M Stick'** Graham L Hall'’ on behalf of AREST CF" *Co-first authors. SCo-senior authors. # The full membership of the Australian Respiratory Early Surveillance Team for Cystic Fibrosis (AREST CF) is available at hitp://www.arestef org, Copyright © 2015 by the American Thoracic SocietyPage 31 of 42 Table of Contents Methods: Study population... Multiple Breath Washout, Chest CT Scans. .. PRAGMA-CF Scoring Method. CF-CT Scoring Method... Statistical analysis ‘Supplemental Tables Supplemental Table 1... Supplemental Table 2. Supplemental Table 3... Supplemental Table 4... Supplemental Table 5 Copyright © 2015 by the American Thrace Society |AIRCCM Articles in Press Published on 11-September-2015 as 10.1164/rcem,201507-14090CAIRCCM Articles in Press Published on 11-September-2015 as 10.1164ireem 201 Page 32 of 42 Methods Study population Infants and children with CF who attended an annual review or clinically indicated chest CT sean at Princess Margaret Hospital (PMH) in Perth or the Royal Children’s Hospital (RCH) in Melbourne, Australia were eligible to take part in this study. The infants and preschool children in this study were all diagnosed with CF following newborn screening and were enrolled in the Australian Respiratory Early Surveillance Team for Cystic Fibrosis (AREST CF) early surveillance program. This program starts at diagnosis (~3 months) and involves annual age-appropriate (infant or preschool) lung function testing 2-4 days prior to a chest CT and bronchoalveolar lavage (BAL) until the age of six. School-aged children attending chest CT scans as part of their annual review or when clinically indicated were recruited to perform lung function testing on the day of their scan. None of the children in our study were undergoing a pulmonary exacerbation during the time of MBW testing or chest CT. Healthy children without CF over the age of two years were recruited from the local population in Perth, Children were excluded from the healthy group if they had a history of asthma, bronchiolitis, bronchitis, three or more occurrences of lower respiratory illnesses per year of life, were bom less than 36 weeks gestation, or had a coexisting heart, lung or neuromuscular disorder. The ethics committee of each institution approved the study and parents gave written informed consent to each aspect of the study separately. Multiple Breath Washout Infant lung function testing was performed in the supine position, following sedation with oral chloral hydrate (60-100mg/kg) between the ages of 3 months and 2 years. Multiple breath washout testing was performed with 4% sulphur-hexafluoride (SF,) as a tracer gas, using the Exhalyzer D ultrasonic flow meter and Spiroware 2 software (Ecomedics AG, Copyright © 2015 by he American Thoracic SocietyAstle in Press. Published on 11-September2015 as 10.1164eem 201507-14090¢ Page 33 of 42 * Duernten, Switzerland) as previously described (1). Data were corrected using a temperature model and analysed using the end-inspiratory molar mass step response with Whreath 3.28 software (ndd Medical Technologies AG, Zurich, Switzerland) (2). Multiple breath washout in children over 2 years was performed using 100% oxygen to washout resident nitrogen (N2) from the lungs using the Exhalyzer D hardware and Spiroware 3.1 software (Ecomedics AG, Duernten, Switzerland) as described previously (3). Functional residual capacity (FRC), Lung clearance index (LCD, the first moment ratio (M1/M0) and second moment ratio (M2/M0) were derived. Visits with at least two acceptable measurements with no evidence of leak or irregular breathing pattern were included in this analysis according to the consensus statement (4), Chest CT Seans Chest CT scans in infants and preschool children were performed prior to BAL collection, under intravenous general anaesthetic. Volumetric inspiratory chest CT scans were obtained at a positive airway opening pressure of 25 em H20 (100 kVp; 10 mAs; pitch 3; estimated radiation dose = 0.1 — 0.2 mSv) (5). Volumetric or limited slice expiratory chest CT scans were obtained at an airway opening pressure of 0 cm HO (ie. at functional residual capacity). In school-aged children, spirometry-assisted volumetric inspiratory and expiratory chest CT was performed (6). An experienced respiratory scientist trained the children to perform the breathing manoeuvres for the CT scan using a portable spirometer. For the inspiratory scan children were instructed to take a full inspiration to total lung capacity from residual volume and breath-hold for 5 seconds, For the expiratory chest CT scan children were instructed to exhale to residual capacity from total lung capacity and breath-hold for 5 seconds, Inspiratory and expiratory chest CT scans were initiated once 90% of the target vital Copyright © 2015 by the American Thrace SocietyAIRCCM Articles in Press Published on 11-September-2015 as 10.1164ireem 201 Page 34 of 42 capacity (best repeatable vital capacity value from the training) was reached, Details of the CT scanning protocols are described in a previous publication from our group (7). PRAGMA-CF Scoring Method ‘The quantitative PRAGMA-CF scoring method was used to quantify early structural lung, disease on chest CT scans. The method was performed by annotating a grid, which had been overlaid on ten equidistant axial slices, for the presence of bronchiectasis, mucus plugging or bronchial wall thickening (inspiratory scans) and trapped air (expiratory scans) (7). The volume proportion of the lung with airways disease (% disease) was determined by dividing the number of cells annotated with bronchiectasis, mucus plugging or bronchial wall thickening by the total number of annotated cells. The volume proportion of the lung with bronchiectasis (% bronchiectasis) was determined by dividing the number of cells annotated with bronchiectasis by the total number of annotated cells, and the volume proportion of the lung with trapped air (% air trapping), determined by dividing the number of trapped air cells by the total number of annotated cells. CF-CT Scoring Method Chest CT scans were scored by a single dual-fellowship-trained pediatric and thoracic radiologist (CM) with over 10 years of experience in CF-CT scoring, who was blinded to clinical status other than the diagnosis of CF (8, 9). In brief, each lung was divided into 6 lobes (with the lingula considered as a separate lobe) and scored for the presence of bronchiectasis (outer edge bronchus-artery cross-sectional area ratio > 1), mucus plugging (high density airway occlusion or tree-in-bud appearance), bronchial wall thickening (assessed subjectively as airway walls that are thicker or have increased signal intensity relative to normal airways) on the inspiratory scan, and trapped air (geographic low density Copyright © 2015 by the American Thoracic SocietyPage 35 of 42 |AIRCCM Articles in Press Published on 11-September-2015 as 10.1164/rcem,201507-14090C regions) on the expiratory scan. For each component of structural lung disease, a score of 0 indicated no presence, | indicated an extent of <= 50% of the airways or lung field, and 2 indicated an extent of > 50% of the airways or lung field. The lobe scores for each component were summed to produce a score out of 12. The total score was defined as the sum of all scores other than trapped air, out of 36. 4 Copyright © 2015 by the American Thrace SocietyAJRCCM Articles in Press. Published on 11-September-2015 as 10.1164iroem201507-14090C * Page 36 of 42 Supplemental Tables Healthy controls Characteristics ‘Sample size (n) n Age range (y) 3-0- 146 ‘Age —mean (SD) 7-8 (2'8) ight range (cm) 92:5 ~ 166-4 Height — mean (SD) 128-5 (17-7) CI -mean (SD) 6-71 (0-51) LCI - ULN (mean + 1:96*SD) 771 M1/M0 - mean (SD) 1-50 (0-10) M1/MO - ULN (mean + 1-96*SD) 1-70 M2/MO — mean (SD) 4-47 (0°54) M2/MO — ULN (mean + 1-96*SD) 5:53 Supplemental Table El: MBW outcomes and upper limit of normal from healthy control population, LCI = lung clearance index; ULN = upper limit of normal. 5 Copyright © 2015 by the American Thoracic SocietyAIRCCM Articles in Press. Published on 11-September-2015 as 10.1164/reem.201507-14090C Page 37 of 42 MI/MO (ULN = 1.70) M2/MO0 (ULN = 5.53) Preschool School Age Preschool School Age Kappa 0-40 0-41 0:39 0:39 coefficient (0-15, 0-65) # (0°19, 0-63) # — (0-10,0-60)# — (0°14, 0-64) # 69% 61% 78% 10% (52, 84) (48, 82) (61, 90) (51, 84) 15% 80% 73% Specificity (48, 93) (52, 96) (45, 92) Positive 86% 88% 82% 85% predictive value (68, 96) (69, 98) (66, 93) (66, 96) Negative 52% 52% 56% 52% predictive value G1, 73) 1,73) G1, 79) (30, 74) Supplemental Table E2: Agreement between moment ratios and the presence of bronchiectasis on chest CT using PRAGMA-CF scores. Brackets contain 95% confidence interval. M1/MO = first moment ratio; M2/MO = second moment ratio; ULN = upper limit of normal. The upper limit of normal for moment ratios in preschool and school age children was derived from a prospective healthy population (upper limit of normal for infants are not available). * p< 0-05; # p < 0-01; ® p< 0-001 6 Copyright © 2015 by the American Thrace SocietyAJRCCM Articles in Press. Published on 11-September-2015 as 10.1164iroem201507-14090C " Page 38 of 42 AUC LCI cut-off Sensitivity Specificity Infant 0.54 7.81 50% 69% Preschool 0.75 7.79 69% 81% School age 0.81 7.87 70% 87% Supplemental Table E3: Agreement between LCI and the presence of bronchiectasis on chest CT using ROC analysis. AUC = area under curve. The optimal LCI cut-off was the value with the highest sensitivity and specificity to detect bronchiectasis. Copyright © 2015 by the American Thoracic SocietyPage 39 of 42 AIRCCM Articles in Press. Published on 11-September-2015 as 10.1164lreem 20107-14090 MI1/M0 (ULN = 1.70) M2/M0 (ULN 53) Preschool School Age Preschool School Age Kappa 0.20 0.05 0.01 -0.03 coefficient (0.00, 0.40) (0.00, 0.10) (0.05, 0.07) (0.17, 0.23) 63% 53% 66% 56% Sensitivity (45, 79) (38, 68) (48, 81) (40, 70) 59% 61% 33% 33% Specificity (33, 82) (9,99) (13, 59) (0.84, 91) Positive 76% 96% 68% 93% predictive value (57, 90) (80, 100) (50, 83) (76, 99) Negative 44% % 33% 5% predictive value (23, 66) (2, 28) (13, 59) (0.12, 24) Supplemental Table E4: Agreement between moment ratios and the presence of air trapping on chest CT using PRAGMA-CF scores. Brackets contain 95% confidence interval. M1/MO = first moment ratio; M2/MO = second moment ratio; ULN = upper limit of normal, The upper limit of normal for moment ratios in preschool and school age children was derived from a prospective healthy population (upper limit of normal for infants are not available). * p < 0-05; # p < 0-01; ® p <0-001.Supplemental Table E4: Agreement between LCI and the presence of bronchiectasis on chest CT using ROC analysis. AUC = area under curve. The optimal LCI cut-off was the value with the highest sensitivity and specificity to detect bronchiectasis. 8 Copyright © 2015 by the American Thrace SocietyAIRCCM Articles in Press Published on 11-September-2015 as 10.1164ircem 2015 Page 40 of 42 Ler MM MziMo Infants Total CT score 0-04 (-0-02, 0:09) -0-01 (-0-03, 0-01) 0-12 (-0:34, 0-10) Bronchiectasis score 0-10 (0-00, 0-19) * 0-04 (0-01, 0-04) # 035 0-11, 0:58) # Air trapping score 0-00 (-0-04, 0-04) 0-00 (-0-02, 0:01) 0-00 -0-11, 0-11) Bronchial wall 0:03, 0°03) A 0.01 (1 ee 0-00 (-0-03, 003) 0-01 (0-01, 0-01) 0-01 (-0-9, 0-06) Mucus PHHINe ——.30 -5.00,0560) 0-08 (002,017) 0740-03, 150) Preschool Total CT score 0-08 (0-03, 0:13) # 0-02 (0-01,0-03)@ ——0-14(0-07,022) @ Bronchiectasis score 0:22 (0:13, 0:31) ® 0-04 (0-00, 0:08) * 0-42 (0-24, 0:56) ® ‘Air trapping score 0-26 (0-13, 0:38) ® 0:04 (-0-02, 0:09) 0-39 (0-18, 0.64) # thekaniae were 0-21 (0-10, 0:32) ® 0-05 (0-00, 0:09) * 0-33 (0-10, 0-55) # Mucus plugging 0-32 (0-17, 0-47) ® 0-05 (-0-01, 0-12) 0-66 (0-37, 0-95) ® School Age Total CT score 0-11 0-07, 0:16) 0-01 60-01, 0:05) 0.21 0:12, 0:31) @ Bronchiectasis score 0-12 (004, 0-21) # 0-03 (0-08, 0-04) # 0-21 0-07, 0:35) # Air trapping score 0-11 0-01, 0:22)* 0-02 (-0-01, 0-04) 0-17 (0.01, 0:33) Bronchial wall 0-10 (0-00, 0-19) * 0-02 (0-00, 0-04) * 0-17 (0-02, 0-30) * thickening score , , 0° Mucus plugging 0-28 (-0-06, 0-62) 0-04 (-0-03, 0-11) 0-40 (-0-18, 0:98) score Supplemental Table ES: Association between MBW outcomes and the extent of structural disease on CT using CF-CT scores. Brackets contain 95% confidence interval, LCT = lung clearance index; M1/M0 = first moment ratio; M2/MO second moment ratio. * p <0-05; #p <0-01; & p <0-001 Copyright © 2015 by the A sn Thoracic Society|AIRCCM Articles in Press Published on 11-September-2015 as 10.1164/rcem,201507-14090C Page 41 of 42 * References 1. Schibler A, Hall GL, Businger F, Reinmann B, Wildhaber JH, Cemele M, Frey U. Measurement of lung volume and ventilation distribution with an ultrasonic flow meter in healthy infants. Eur Respir J 2002; 20: 912-918. 2. Anagnostopoulou P, Yammine $, Schmidt A, Korten I, Kieninger E, Mack I, Trachsel D, Hafen G, Moeller A, Casaulta C, Latzin P. False normal Lung Clearance Index in infants with cystic fibrosis due to software algorithms. Pediatr Pulmonol 2015; In Press, DOL: 10.1002/ppul.23256. 3. Singer F, Houltz B, Latzin P, Robinson P, Gustafsson P. A realistic validation study of a new nitrogen multiple-breath washout system. PLoS One 2012; 7: €36083 4, Robinson PD, Latzin P, Verbanck S, Hall GL, Horsley A, Gappa M, Thamrin C, Arets HG, Aurora P, Fuchs SI, King GG, Lum S, Macleod K, Paiva M, Pillow JJ, Ranganathan S, Ratjen F, Singer F, Sonnappa S, Stocks J, Subbarao P, Thompson BR, Gustafsson PM. Consensus statement for inert gas washout measurement using multiple- and single- breath tests. Eur Respir J 2013; 41: 507-522, 5. Thomas KE, Wang B. Age-specific effective doses for pediatric MSCT examinations at a large children's hospital using DLP conversion coefficients: a simple estimation method. Pediatric radiology 200: 8: 645-656. 6. Robinson TE, Leung AN, Moss RB, Blankenberg FG, al-Dabbagh H, Northway WH. Standardized high-resolution CT of the lung using a spirometer-triggered electron beam CT scanner. Am J Roentgenol 1999; 172: 1636-1638. 7. Rosenow T, Oudraad MC, Murray CP, Turkovie L, Kuo W, de Bruijne M, Ranganathan SC, Tiddens HA, Stick SM, Arest CF. PRAGMA-CF: a Quantitative Structural Lung Disease CT Outcome in Young Children with Cystic Fibrosis, Am J Respir Crit Care Med 2015; 191: 1158-1165 10 Copyright © 2015 by the American Thrace SocietyAIRCCM Articles in Press. Published on 11-September-2015 as 10.1164iroem201507-14090C ™ Page 42 of 42 8. Sly PD, Brennan S, Gangell C, de Klerk N, Murray C, Mott L, Stick SM, Robinson PJ, Robertson CF, Ranganathan SC. Lung disease at diagnosis in infants with cystic fibrosis detected by newbom screening. Am J Respir Crit Care Med 2009; 180: 146- 152. 9, Stick SM, Brennan S, Murray C, Douglas T, von Ungem-Stemnberg BS, Garratt LW, Gangell CL, De Klerk N, Linnane B, Ranganathan S, Robinson P, Robertson C, Sly PD. Bronchiectasis in infants and preschool children diagnosed with cystic fibrosis after newborn screening. J Pediatr 2009; 155: 623-628 e621. co Copyright © 2015 by the American Thoracic Society