Johansen, Maria Judi Wagner Oxbøl

Nielsen, Line Bjerrehave

Weinreich, Ulla Møller

English

Scoping review protocol:Review title: The effect of alcohol consumption on pulmonary function – A scoping reviewFirst reviewer: Line Bjerrehave Nielsen, MD, Ph.D.-student, Department of Respiratory Diseases, Aalborg University Hospital, Aalborg, DenmarkSecond reviewer: Maria Oxbøl Johansen, MD, Department of Respiratory Diseases, Aalborg University Hospital, Aalborg, DenmarkSupervisor: Signe Juul Riddersholm, MD, PhD, Department of Cardiology, Aalborg University Hospital, Aalborg, DenmarkSupervisor: Ulla Møller Weinreich, MD, PhD, Professor, Department of Respiratory Diseases, Aalborg University Hospital, Aalborg, Denmark Keywords: Respiratory Function Tests, Alcoholic Drinking, Alcohol BeveragesABSTRACT:Introduction: Alcohol has for centuries been a part of human culture. Health effects of alcohol have been extensively studied but the influence on pulmonary function remains debated. There are indications that small amounts of alcohol are beneficial compared with abstinence and that heavy consumption is harmful.Objectives: The objectives of this scoping review are to describe the effect of alcohol consumption on different pulmonary function parameters. This scoping review will provide an overview of the current state of research and identify any gaps in this field.Methods and analysis: The identified studies will be examined using the Joanna Briggs Institute (JBI) methodological framework for scoping reviews. A comprehensive search from Pubmed, Embase, Cochrane and CINAHL will be performed. The reference list of included studies will be screened for additional studies. Two reviewers will independently carry out the screening and data extraction processes in parallel. In cases of disagreement, a third reviewer will be consulted to reach a consensus. A data extraction form has been created based on the key themes derived from the research questions. The extracted data will be subject to qualitative analysis and will be presented visually in diagrams or tables, accompanied by a narrative summary, in line with Preferred Reporting Items for Systematic Reviews and Meta-Analysis: extension for Scoping Reviews reporting guidelinesEthics and dissemination: All data will be collected from published literature. Ethics approval is therefore not a requirement. We will present our findings at relevant conferences and submit them for publications in peer-reviewed journals.Strengths and limitations of this study:A systematic and comprehensive search of four electronic databases and grey literature sources will ensure that all available evidence is identified.The work procedure will follow the JBI Methodology for conducting scoping reviews A formal assessment of the quality of evidence will not be performed and this may lead to some studies of poor quality being included.Only studies written in English, Danish, Swedish and Norwegian will be includedNo limits regarding publication date or study designINTRODUCTION:Alcohol consumption has been an integral part of human culture and social gatherings for thousands of years, leaving a significant mark on societies across the globe. Approximately 2.3 billion people worldwide are current drinkers and every year around 3 million deaths can be attributed to the harmful use of alcohol1. The effects of alcohol on various organ systems in the human body have been extensively studied and we know that alcohol affects mortality and alcohol abuse contributes to over 200 internationally classified diseases and conditions including liver cirrhosis, pancreatitis and various cancers2. Though its impact on pulmonary function remains a subject of ongoing research and debate. Alcohol, primarily ethanol, is known for its diverse acute and chronic physiological effects. When alcohol is consumed it is rapidly absorbed into the bloodstream and subsequently distributed throughout the body including the respiratory system. The lungs play a pivotal role in the exchange of oxygen and carbon dioxide facilitating the respiratory process essential for sustaining life. Therefore, any substance that potentially affects pulmonary function, such as alcohol, holds particular significance in relation to public health. Research into the relationship between alcohol consumption and pulmonary function has yielded conflicting results, contributing to the complexity of this association. Chronic alcohol abuse has been associated with detrimental effects on lung health. These adverse effects include impaired mucociliary clearance, increased risk of acute respiratory disease, decreased cough reflex and increased susceptibility to pulmonary infections3–5. Certain studies have even suggested that moderate alcohol consumption could potentially result in enhanced pulmonary function and a reduced incidence of symptoms from COPD6,7. These findings have ignited significant interest and prompted inquiries into the precise nature and scope of the influence of alcohol on the respiratory system. Examining the association between alcohol consumption and pulmonary function presents challenges due to a significant number of smokers in most research, which can be a significant factor affecting the results. Furthermore, elements like the quantity, frequency, duration of alcohol consumption, preference for specific alcoholic beverages, and one’s overall health status can play a role in causing differences in the outcomes observed. Thus, comprehending the intricate link between alcohol and pulmonary function necessitates a thorough review of existing studies and the synthesis of existing information. OBJECTIVES:This scoping review aims to provide a comprehensive overview of the present state of research concerning the impact of alcohol on pulmonary function of individuals aged 18 and above. We intend to determine if there is an association between alcohol consumption and alterations in pulmonary function parameters. Our objective is to examine the potential protective effect of moderate alcohol intake and the detrimental effects of higher alcohol consumption. Additionally, we seek to investigate whether the existing body of literature can substantiate the concept of a U-shaped relationship. METHODOLOGY: The proposed scoping review will be conducted in accordance with the JBI methodology for scoping reviews8 and will be reported according to the guidance provided in the Preferred Reported Items for Systematic Reviews and Meta-analyses (PRISMA) extension for Scoping Reviews (PRISMA-ScR)9. The steps outlined in the JBI reviewers’ manual comprises the following five steps: (1) identifying the research question; (2) identifying relevant studies; (3) selection of eligible studies; (4) charting the data; (5) collating, summarizing, and reporting the results. Identifying research question:We constructed the following research question:” What is the effect of alcohol on the pulmonary function?”The research sub-questions include:1: How is alcohol consumption described in the literature?2: How is pulmonary function measured and what are the definitions of altered pulmonary function?3: How does different amounts of alcohol affect the different pulmonary function parameters such as FEV1, FVC, FEV1/FVC, TLC, RV and DLCO?Identifying relevant studies:Relevant papers will be identified from extensive literature search conducted using the Pubmed,Embase, CINAHL, and Cochrane library. The literature search is conducted under supervision of aresearch librarian from Aalborg University (AAU) with great experience in securing systematicresearch of high quality. Literature searches is conducted using Medical Subject Heading (MeSH)terms, relevant search word terms and free word search and finally chain search. Searches will bedivided in to two separate categories “Alcohol” and “Respiratory function”, using relevantsynonyms (e.g. drinking, pulmonary function). The search categories will be searched individuallyand combined. A preliminary version of the Pubmed search can be found in supplemental Appendix1 (conducted on 1st March 2023).  There will be no limitations concerning publication year or studydesign. We will search literature in English, Danish, Norwegian and Swedish only.Study selection:The study selection will follow a two-step screening process, consisting of a title and abstractscreening, followed by a full-text review. In both steps, two independent reviews Line BjerrehaveNielsen and Maria Oxbøl (LBN and MO) will screen the articles against the eligibility criteria. Anydisagreements will be discussed, and if no consensus can be reached a third reviewer Ulla MøllerWeinreich (UMW) will be consulted. We will consider eligible studies based on the inclusion- andexclusion criteria in Table 1. The articles will be transferred to the software program Covidencewhere there will be checked for duplicates. Hereafter they will be screened for relevance from titleand abstract. Next, the selected articles will be screened by reading the full text. If full text cannotbe obtained, the study is excluded from the review. Grey literature was searched using Google(including Google Scholar).Backward citation chaining was also undertaken which involved hand-searching the reference listsof the included studies to identify relevant research. This process follows the PRISMA guidelineswhich is depicted in figure 110. Two review authors (LBN and MO) will verify the final list ofincluded studies. Studies excluded at full-text stage will be described in the ‘Characteristics ofexcluded studies’ Table 2, where reasons for exclusion will be noted. Charting the data:During the formal data extraction stage, one reviewer (LBN) will retrieve the data in accordance with the objectives of this scoping review, and another reviewer (MO) will subsequently validate the extracted data. The reviewers will employ a structured recording template they have been developed, and the information will be logged using Microsoft Excel. The extracted data include details on the author; country; year of publication; study design; number of patients; study setting; participants characteristics; definition of alcohol intake; definition of one unit; measurements of pulmonary function; information regarding smoking; results. Any discrepancies between reviewers will be resolved through discussion and a third review author (UMW) will act as a mediator when consensus cannot be reached. Collating, summarizing, and reporting the results:The extracted data will be presented in graphical or tabular formats to provide a clear characterization and summary. In alignment with the objective of this study, we will provide an overview of the number of participants, study design and results. The tabulated and/or graphical results will be accompanied by a narrative summary, which will describe how the results meet the objectives and aims of this scoping review. We will report findings in line with the PRISMA statements9,10. DISCUSSION:The outlined scoping review will provide a comprehensive perspective on the impact of alcohol on various aspects of pulmonary function, while also shedding light on gaps in our knowledge. The strengths of this planned scoping review includes the predefined protocol, the systematic search, and compliant with PRISMA statements9. However, there are some limitations to consider. We will not assess the risk of bias in individual studies. Furthermore, we expect some heterogeneity amongst the included studies regarding population, setting and intervention.Ethics and dissemination:Ethical approval is not required for this study. In terms of dissemination activities, an article reporting the results of the scoping review will be submitted for publication to a scientific journal and presented at relevant conferences. We anticipate the results of the scoping review will provide a comprehensive overview of the effect of alcohol on pulmonary function.Patient and public involvement: Patients or the public were not involved in the research design and no plans exist for patients or public involvement in the execution, reporting or dissemination of this study.Acknowledgements: We want to thank Conni Skrubbeltrang, Master of Library and Information Science and Chief Librarian at Aalborg University Hospital for her contribution to the searches performed in the selected databases.Author contributions: LBN conceptualized the idea for the scoping review, led the protocol and methodology design and authored the initial draft of the manuscript. LBN, MO, SJR, UMW contributed to the methodology design, designed the search strategy, and critically revised the manuscript. LBN, MO and UMW designed the data extraction form. All authors provided valuable inputs to the research questions and subject matter. Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. Competing interests None declared. Patient consent for publication: Not applicable. Provenance and peer review: Not commissioned; externally peer reviewedData availability statement: The scoping review is still being conducted and no data are available for now.Table 1: Inclusion- and exclusion criteria:Inclusion criteria:	Exclusion criteria:Age 18+	Animal studies, in vitro studies, or autopsy studies.Information regarding alcohol intake either as quantity, frequency, duration, blood-test, or AUDIT-score	Editorials, review articles, case reports or	conferences abstract	Spirometry performed	Languages other than English, Danish, Swedish or NorwegianInformation regarding smoking	Table 2: Characteristics of excluded studies:LanguageWrong settingWrong outcomesWrong comparatorWrong interventionPediatric populationMissing data on spirometryNot available in full textMissing data on alcohol intakeEditorials, review articles, case reports or conferences abstractAnimal studies, in vitro studies, or autopsy studies.Figure 1: Flow diagram of study selection process, as depicted by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelinesAppendix 1: Search string Pubmed:Search number	Search details	Results3	("Respiratory Function Tests"[MeSH Terms] OR "spirometr*"[Text Word] OR "forced expiratory flow rate*"[Text Word] OR "respiratory function*"[All Fields] OR "respiratory test*"[All Fields] OR "respiratory measure*"[All Fields] OR "pulmonary function*"[Text Word] OR "pulmonary test*"[Text Word] OR "pulmonary measure*"[Text Word] OR "lung function*"[Text Word] OR "lung test*"[Text Word] OR "lung measure*"[Text Word]) AND ("Alcohol Drinking"[MeSH Terms] OR "Alcoholism"[MeSH Terms] OR "Alcoholic Beverages"[MeSH Terms] OR "liqueur*"[Text Word] OR "alcohol*"[Text Word] OR "wine*"[Text Word] OR "beer*"[Text Word])	1,6832	"Alcohol Drinking"[MeSH Terms] OR "Alcoholism"[MeSH Terms] OR "Alcoholic Beverages"[MeSH Terms] OR "liqueur*"[Text Word] OR "alcohol*"[Text Word] OR "wine*"[Text Word] OR "beer*"[Text Word]	485,7731	"Respiratory Function Tests"[MeSH Terms] OR "spirometr*"[Text Word] OR "forced expiratory flow rate*"[Text Word] OR "respiratory function*"[All Fields] OR "respiratory test*"[All Fields] OR "respiratory measure*"[All Fields] OR "pulmonary function*"[Text Word] OR "pulmonary test*"[Text Word] OR "pulmonary measure*"[Text Word] OR "lung function*"[Text Word] OR "lung test*"[Text Word] OR "lung measure*"[Text Word]	294,009References:1.	Hammer, J. H., Parent, M. C., Spiker, D. A. & World Health Organization. Global status report on alcohol and health 2018. Global status report on alcohol vol. 65 (2018).2.	Rehm, J. et al. Alcohol Consumption and Burden of Disease - an Overview. Addiction 105, 817–843 (2010).3.	Brown, L. A. S. et al. Acute and chronic alcohol abuse modulate immunity. Alcohol. Clin. Exp. Res. 30, 1624–1631 (2006).4.	Liang, Y., Yeligar, S. M. & Brown, L. A. S. Chronic-alcohol-abuse-induced oxidative stress in the development of acute respiratory distress syndrome. Sci. World J. 2012, (2012).5.	Todd A. Wyatt, Martha J. Gentry-Nielsen, Jacqueline A. Pavlik,  and J. H. S. Desensitization of PKA-Stimulated Ciliary Beat Frequency in an Ethanol-Fed Rat Model of Cigarette Smoke Exposure Todd. Alcohol Clin Exp Res 998–1004 (2004).6.	Makino, K. et al. Unbiased, comprehensive analysis of Japanese health checkup data reveals a  protective effect of light to moderate alcohol consumption on lung function. Sci. Rep. 11, 15954 (2021).7.	Tabak, C. et al. Alcohol Consumption in Relation to 20-Year COPD Mortality and Pulmonary Function in Middle-Aged Men from Three European Countries. (2001).8.	Chapter 11: Scoping reviews. in JBI Manual for Evidence Synthesis (JBI, 2020). doi:10.46658/JBIMES-20-12.9.	Tricco, A. C. et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. Ann. Intern. Med. 169, 467–473 (2018).10.	Page, M. J. et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ n71 (2021) doi:10.1136/bmj.n71.

The effect of alcohol consumption on pulmonary function – A scoping review

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The effect of alcohol consumption on pulmonary function – A scoping review

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