COMMENTARY
Application of artificial intelligence in respiratory medicine: Has
the time arrived?
Key words: lung cancer, statistics, X-rays.
Artificial intelligence (AI) has seen increasing use across
all sectors, as enabled by increasing volumes of data,
greater computing power and novel algorithm architec-
tures. In health care, there has been an exponential
increase in research involving AI, as reflected by a surge
in publications and academic funding. AI could play a
role in automating lung cancer screening1 and is being
trialled by the UK’s National Health Service for triaging
chest X-rays for radiologist review.2 Potential applications
within respiratory medicine are legion, particularly in the
analysis of data for diagnosis, but there are associated
challenges with its implementation. Additionally, its role
will be as an adjunct, rather than a replacement, for the
experience and human touch that skilled physicians
provide.
Machine learning (ML) encompasses a group of AI
methods by which computers can identify patterns and
relationships between data (such as radiological images
or blood tests) and outcomes of interest. Traditional sta-
tistical methods characterize such patterns with mathe-
matical equations. In ML, the computer analyses large
volumes of data to learn complex, non-linear relation-
ships that enable greater accuracy and cannot easily be
expressed as an equation. ML also enables the analysis of
types of data that were previously not amenable to com-
putational analysis, such as imaging and auditory data.
The diagnosis of respiratory conditions relies on cen-
tral tenets of medicine: the history, the examination,
bedside tests and imaging. Skilled respiratory physi-
cians can detect subtle changes in breath sounds on
auscultation, interpret variations in pulmonary function
test (PFT) scores and analyse images from X-rays, com-
puted tomography (CT) scans and bronchoscopy. AI
may play a role in supporting physicians in these areas.
ML analysis of breath sounds obtained from elec-
tronic stethoscopes is objective, not prone to inter-
clinician variability and is not restricted to the human
auditory frequency range. Genetic algorithms and neu-
ral networks have shown good specificity and sensitiv-
ity for detecting wheezes and crackles.3 However, we
should avoid to become overly reliant on such analysis,
or we risk becoming de-skilled.
ML may enhance the analysis of PFT scores. Com-
plex, multidimensional patterns of PFT variation may
identify disease subtypes, personalizing diagnosis and
treatment. Standardization of interpretation could also
be improved. One AI model identified the correct diag-
nostic category more often than pulmonologists,4
although the true clinicians’ performance was under-
estimated as they received limited clinical information.
© 2019 Asian Pacific Society of Respirology
Using ML in bronchoscopy, to analyse images and
diagnose potential cancers, has been explored. One
study achieved 86% diagnostic accuracy.5 However,
treatment decisions are better informed by the defini-
tive histology results, which are typically reported
within days. Real-time highlighting of potentially mis-
sed lesions could be a more useful approach, and anal-
ogous efforts have shown promise in colonoscopy.
Convolutional neural networks (CNNs) are specialized
ML methods, excelling at imaging analysis, which may
support assessment of respiratory disease on chest X-ray
or CT scan. The former is the most commonly per-
formed radiological investigation. Thorough interpreta-
tion of such volume is time-consuming, which can lead
to fatigue-based diagnostic error and requires a suffi-
cient number of radiologists. Early ML studies focused
on identifying specific lesions while more recently CNNs
have been trained to detect multiple pathologies.6 While
reasonable accuracies have been obtained, such algo-
rithms will not enable full automation unless they are
trained to recognize all possible pathologies, or else
rarer conditions may be missed. When such algorithms
are implemented clinically, it is important to communi-
cate to users the specificity of their focus.
Such algorithms could still play a useful role in prior-
itizing scans for review, screening for potentially mis-
sed pathologies and enabling objective measurements
of radiographical features. One study demonstrated
that an AI algorithm for prioritizing chest X-rays
reduced the average time for scans with a critical find-
ing to be reviewed by a radiologist from 11.2 to
2.7 days.7 AI may enable an objective, standardized
measurement of signs, such as consolidation, where
there is significant variability in reporting but develop-
ing standardized guidelines is challenging.
ML may support the use of CT scans for diagnosis
and screening. Nodules are prevalent but only a small
percentage is cancerous. One algorithm analysed
parenchymal features to identify cancerous nodules
with an area under the curve (AUC) of 0.965.8 A novel
‘end-to-end’ deep learning model, which learns the
features of lesions and compares them to earlier scans,
identified cancer with an AUC of 0.944.1
There is potential for ML to enhance methods for
treating respiratory disease, but the research field is
less substantiated. One application is to support lung
movement tracking for the accurate delivery of radio-
therapy to lung cancers. The system latency of existing
techniques limits their accuracy while real-time
retraining of neural networks has been shown to
improve precision of delivery.9
There are important considerations to ensure the
safe and effective implementation of AI into health
Respirology (2019) 24, 1136–1137
doi: 10.1111/resp.13676

Commentary
care. Data collection and usage must follow informed
consent. Although AI is complex, we should proactively
communicate to patients exactly about how their data
are being used. Data security and privacy are key fea-
tures. Cases like the Theranos scandal damage public
trust and waste investment potential, which could jeop-
ardize the development of potentially life-saving tech-
nology. Development of AI algorithms requires large
volumes of well-structured data. Clinician input is key,
given their unique insight, so such collaboration should
be encouraged. We must guard against over-reliance
on algorithms and de-skilling of our workforce. There
are challenges of apportioning responsibility to algo-
rithms, meaning it may ultimately lie with the clinician.
Good performance metrics do not guarantee a positive
clinical impact, and this must be validated through
prospective trials in clinical settings. Clinical workflows
must also be considered. Algorithms must generalize to
different populations and work with variable levels of
data quality. One challenge is limited interpretability,
particularly of deep learning algorithms.
AI has many potential applications in respiratory
medicine, particularly with assisting diagnosis from
examination, bedside tests and imaging. While there
are studies supporting the effectiveness of such analy-
sis, it remains to be validated in clinical settings and
the nature of integration into clinical workflows is yet
to be seen. If implemented successfully, AI can over-
come inefficiencies and better equip physicians with
enhanced diagnostic tools, freeing them to utilize their
unique skills and empathy in the provision of high-
quality care.
Christopher A. Lovejoy, MA (Cantab), MB BChir,1,2
Edward Phillips, MA (Cantab), MBBS3 and
Mahiben Maruthappu, MA (Cantab), BM BCh2
1
Emergency Department, St George’s Hospital, St
George’s University Hospitals NHS Foundation Trust,
London, UK; 2Cera Care, London, UK; 3Department of
Medicine, Northwick Park Hospital, London Northwest
University Healthcare NHS Trust, London, UK
Respirology (2019) 24, 1136–1137
14401843, 2019, 12, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/resp.13676 by Test, Wiley Online Library on [25/02/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
1137
Disclosure statement: C.A.L. is an employee of Cera Care.
M.M. is an investor and employee of Cera Care. Cera Care is a
domiciliary care provider conducting research into how AI can
be used to improve the care delivered to elderly people living at
home. No funding was received for this work.
REFERENCES
1 Ardila D, Kiraly AP, Bharadwaj S, Choi B, Reicher JJ, Peng L, Tse D,
Etemadi M, Ye W, Corrado G et al. End-to-end lung cancer screen-
ing with three-dimensional deep learning on low-dose chest com-
puted tomography. Nat. Med. 2019; 25: 954–61.
2 The Engineer. Chest X-ray triage gets AI boost. 2019. [Accessed
19 July 2019.] Available from URL: https://www.theengineer.co.uk/
chest-x-ray-triage/
3 Gurung A, Scrafford CG, Tielsch JM, Levine OS, Checkley W. Com-
puterized lung sound analysis as diagnostic aid for the detection of
abnormal lung sounds: a systematic review and meta-analysis. Res-
pir. Med. 2011; 105: 1396–403.
4 Topalovic M, Das N, Burgel P-R, Daenen M, Derom E,
Haenebalcke C, Janssen R, Kerstjens HAM, Liistro G, Louis R et al.
Artificial intelligence outperforms pulmonologists in the interpreta-
tion of pulmonary function tests. Eur. Respir. J. 2019; 53: 1801660.
5 Feng P-H, Lin Y-T, Lo C-M. A machine learning texture model for
classifying lung cancer subtypes using preliminary bronchoscopic
findings. Med. Phys. 2018; 45: 5509–14.
6 Rajpurkar P, Irvin J, Ball RL, Zhu K, Yang B, Mehta H, Duan T,
Ding D, Bagul A, Langlotz CP et al. Deep learning for chest radio-
graph diagnosis: a retrospective comparison of the CheXNeXt algo-
rithm to practicing radiologists. PLoS Med. 2018; 15: e1002686.
7 Annarumma M, Withey SJ, Bakewell RJ, Pesce E, Goh V,
Montana G. Automated triaging of adult chest radiographs with
deep artificial neural networks. Radiology 2019; 291: 272.
8 Uthoff J, Stephens MJ, Newell JD, Hoffman EA, Larson J, Koehn N,
De Stefano FA, Lusk CM, Wenzlaff AS, Watza D et al. Machine
learning approach for distinguishing malignant and benign lung
nodules utilizing standardized perinodular parenchymal features
from CT. Med. Phys. 2019; 46: 3207–16.
9 Bukovsky I, Homma N, Ichiji K, Cejnek M, Slama M, Benes PM,
Bila J. A fast neural network approach to predict lung tumor motion
during respiration for radiation therapy applications. Biomed. Res.
Int. 2015; 2015: 489679.
© 2019 Asian Pacific Society of Respirology