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Reference Equations for Pulmonary Function Tests

  • Bruce H. Culver
  • Sanja Stanojevic
Chapter
Part of the Respiratory Medicine book series (RM)

Abstract

Lung function parameters vary with age, sex, ethnicity, and body size, such that interpretation of pulmonary function test results requires comparison to an individualized predicted value that is calculated from reference equations derived from healthy individuals. Over the years, these reference data have evolved from small regional samples described by simple linear equations to very large collated, often international, samples described by more complex statistical methods. The interpretive comparison of a test result to the predicted value and the normal range has also evolved from oversimplified “rules of thumb” to the use of a properly individualized lower limit of normal, generally taken to be the 5th percentile of the healthy population. Rapid changes in lung function and variability in growth rates add a challenge to the interpretation of lung function during childhood and adolescence. Newer reference equations allowing continuous tracking of individuals throughout growth and aging are particularly helpful for pediatric laboratories. Due to the slow progression of many chronic lung diseases, the values associated with early disease will inevitably overlap with low normal values, requiring an understanding of the clinical uncertainty around values near the limits of normal, especially among older persons. Better data on the outcomes of individuals with low normal or borderline function in relation to identifiable risk factors would help the clinician in estimating the likelihood of progression to impactful disease.

Keywords

Reference equations Lower limit of normal Interpretation of lung function Spirometry Diffusing capacity Lung volumes 

Selected References

Guidelines and Statements

  1. American Thoracic Society. Snowbird workshop on standardization of spirometry. Am Rev Respir Dis. 1979;119:831–8.Google Scholar
  2. American Thoracic Society. Lung function testing: selection of reference values and interpretative strategies. Am Rev Respir Dis. 1991;144:1202–18.CrossRefGoogle Scholar
  3. American Thoracic Society. Standardization of Spirometry,1994 update. Am J Respir Crit Care Med. 1995;152:1107–36.CrossRefGoogle Scholar
  4. Stocks J, Quanjer PH. Reference values for residual volume, functional residual capacity and total lung capacity. ATS workshop on lung volume measurement. Official statement of the ERS. Eur Respir J. 1995;8:492–506.CrossRefGoogle Scholar
  5. Pellegrino R, Viegi G, Brusasco V, Crapo RO, Burgos F, Casaburi R, Coates AL, van der Grinten CP, Gustafsson PM, Hankinson JL, Jensen RL, Johnson DC, MacIntyre NR, McKay RT, Miller MR, Navajas D, Pedersen OF, Wanger JK. Interpretative strategies for lung function tests. Eur Respir J. 2005;26:948–68.CrossRefGoogle Scholar
  6. Graham BL, Brusasco V, Burgos F, Cooper BG, Jensen R, Kendrick AH, MacIntyre NR, Thompson BR, Wanger J. ERS/ATS standards for single-breath carbon monoxide uptake in the lung. Eur Respir J. 2017;49:1600016.  https://doi.org/10.1183/13993003.00016-2016.CrossRefGoogle Scholar
  7. Culver BH, Graham BL, Coates AL, JWanger J, Berry CE, Clarke PK, Hallstrand TS, Hankinson JL, Kaminsky DA, MacIntyre NR, McCormack MC, Rosenfeld R, Stanojevic S, Weiner DJ. Recommendations for a standardized pulmonary function report: an official ATSTechnical statement. Am J Respir Crit Care Med. 2017;196:1463–72.CrossRefGoogle Scholar
  8. Pauwels RA, Buist AS, Calverley PM, Jenkins CR, Hurd SS. On behalf of the GOLD scientific committee. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: NHLBI/WHO global initiative for chronic obstructive lung disease (GOLD) workshop summary. Am J Respir Crit Care Med. 2001;163:1256–76.CrossRefGoogle Scholar

Spirometry Reference Equation Sources

    GLI-2012

    1. Quanjer PH, Stanojevic S, Cole TJ, Baur X, Hall GL, Culver BH, Enright PL, Hankinson JL, Ip MSM, Zheng J, Stocks J. ERS global lung function initiative. Multi-ethnic reference values for spirometry for the 3-95 year age range: the global lung function 2012 equations. Eur Respir J. 2012;40:1324–43.CrossRefGoogle Scholar

NHANES III

  1. Hankinson JL, Odencrantz JR, Fedan KB. Spirometric reference values from a sample of the general US population. Am J Respir Crit Care Med. 1999;159:179–87.CrossRefGoogle Scholar
  2. Canada

    1. Coates AL, Wong SL, Tremblay C, Hankinson JL. Reference equations for spirometry in the Canadian population. Ann Am Thorac Soc. 2016;13:833–41.CrossRefGoogle Scholar

    Comparisons of GLI-2012 to Earlier Sources

    1. Brazzale DJ, Hall GL, Pretto JJ. Effects of adopting the new global lung function initiative 2012 reference equations on the interpretation of spirometry. Respiration. 2013;86:183–9.CrossRefGoogle Scholar
    2. Quanjer PH, Brazzale DJ, Boros PW, Pretto JJ. Implications of adopting the global lungs initiative 2012 all-age reference equations for spirometry. Eur Respir J. 2013;42:1046–54.CrossRefGoogle Scholar
    3. Quanjer PH, Weiner DJ. Interpretative consequences of adopting the global lungs 2012 reference equations for spirometry for children and adolescents. Pediatr Pulmonol. 2014;49:118–25.CrossRefGoogle Scholar
    4. Linares-Perdomo O, Hegewald M, Collingridge DS, Blagev D, Jensen RL, Hankinson J, Morris AH. Comparison of NHANES III and ERS/GLI-2012 for airway obstruction and severity. Eur Respir J. 2016;48:133–41.CrossRefGoogle Scholar
    5. Swanney MP, Miller M. Adopting universal lung function reference equations. Eur Respir J. 2013;42:901–3.CrossRefGoogle Scholar
    6. Miller MR. Choosing and using lung function prediction equations. Eur Respir J. 2016;48:1535–7.CrossRefGoogle Scholar

Diffusing Capacity Reference Equations

  1. Stanojevic S, Graham BL, Cooper BG, Thompson B, Carter K, Francis R, Hall GL. Official ERS technical standards: global lung function initiative reference values for the carbon monoxide transfer factor for Caucasians. Eur Respir J. 2017; in pressGoogle Scholar

Lung Volume Reference Equations

  1. Goldman HI, Becklake MR. Respiratory function tests: normal values at median altitudes and the prediction of normal results. Am Rev Tuberc. 1959;79:457467.Google Scholar
  2. Crapo RO, Morris AH, Clayton PD, Nixon CR. Lung volumes in healthy nonsmoking adults. Bull Eur Physiopathol Respir. 1982;18(3):419–25.PubMedGoogle Scholar
  3. Quanjer PH, Tammeling GJ, Cotes JE, Pedersen OF, Peslin R, Yemault JC. Standardization of lung function tests: lung volumes and ventilatory flows. Report working party. European Community for steel and coal and European Respiratory Society. Eur Respir J. 1993;6(Suppl.16):5–40.CrossRefGoogle Scholar
  4. Roca J, Burgos F, Barbera J, Sunyer J, Rodriguez-Roisin R, Castellsague J, et al. Prediction equations for plethysmographic lung volumes. Respir Med. 1998;92(3):454–60.CrossRefGoogle Scholar
  5. Gutierrez C, Ghezzo RH, Abboud RT, Cosio MG, Dill JR, Martin RR, McCarthy DS, Morse JLC, Zamel N. Reference values of pulmonary function tests for Canadian Caucasians. Can Respir J. 2004;11:414–24.CrossRefGoogle Scholar
  6. Marsh S, Aldington S, Williams M, Weatherall M, Shirtcliffe P, McNaughton A, et al. Complete reference ranges for pulmonary function tests from a single New Zealand population. N Z Med J. 2006;119(1244):U2281.PubMedGoogle Scholar
  7. Koopman M, et al. Reference values for paediatric pulmonary function testing: the Utrecht dataset. Respir Med. 2011;105(1):15–23.CrossRefGoogle Scholar

Limits of Normal and Interpretation

  1. Fletcher C, Peto R. The natural history of chronic airflow obstruction. Br Med J. 1977;1(6077):1645–8.CrossRefGoogle Scholar
  2. Cosio M, Ghezzo H, Hogg JC, Corbin R, Loveland M, Dosman J, et al. The relation between structural changes in small airways and pulmonary function tests. N Engl J Med. 1978;298:1277–81.CrossRefGoogle Scholar
  3. Clausen JL. Prediction of normal values. In: Clausen JL, editor. Pulmonaryfunction testing: guidelines and controversies. New York: Academic Press; 1980.Google Scholar
  4. Hardie JA, Buist AS, Vollmer WM, Ellingsen I, Bakke PS, Morkve O. Risk of over-diagnosis of COPD in asymptomatic elderly never-smokers. Eur Respir J. 2002;20:1117–22.CrossRefGoogle Scholar
  5. Levy ML, Quanjer PH, Booker R, Cooper BG, Holmes S, Small IR. Diagnostic spirometry in primary care: proposed standards for general practice compliant with ATS and ERS recommendations. Prim Care Respir J. 2009;18:130–47.CrossRefGoogle Scholar
  6. Vaz Fragoso CA, Concato J, McAvay G, Van Ness PH, Rochester CL, Yaggi HK, Gill TM. The ratio of FEV1 to FVC as a basis for establishing chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2010; 181:446–451.CrossRefGoogle Scholar
  7. Turkeshi E, Vaes B, Andreva E, Mather C, et al. Airflow limitation by the global lungs initiative equations in a cohort of very old adults. Eur Respir J. 2015;46(1):123–32.CrossRefGoogle Scholar
  8. Vaz Fragoso CA, McAvay G, Van Ness PH, Casaburi R, Jensen RL, MacIntyre N, Gill TM, Yaggi HK, Concato J. Phenotype of normal spirometry in an aging population. Am J Respir Crit Care Med. 2015;192:817–25.CrossRefGoogle Scholar
  9. Jones RL, Nzekwu MMU. The effects of body mass index on lung volumes. Chest. 2006;130:827–33.CrossRefGoogle Scholar
  10. Bates JHT, Poynter ME, Frodella CM, Peters U, Dixon AE, Suratt BT. Pathophysiology to phenotype in the asthma of obesity. Ann Am Thorac Soc. 2017;14(Suppl 5):S395–8.CrossRefGoogle Scholar
  11. Wouters EFM. Obesity and metabolic abnormalities in chronic ObstructivePulmonary disease. Ann Am Thorac Soc. 2017;14(Suppl 5):S389–94.CrossRefGoogle Scholar
  12. Harik-Khan RI, Fleg JL, Muller DC, Wise RA. 2001. The effect of anthropometric and socioeconomic factors on the racial difference in lung function. Am J Respir Crit Care Med. 2001;164:1647–54.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Pulmonary, Critical Care and Sleep MedicineUniversity of Washington School of MedicineSeattleUSA
  2. 2.Translational Medicine, The Hospital for Sick ChildrenTorontoCanada

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