Selecting reference values for pulmonary function tests
- Meredith C McCormack, MD, MHS
Meredith C McCormack, MD, MHS
- Assistant Professor of Medicine
- Medical Director, Pulmonary Function Laboratory Pulmonary and Critical Care Medicine Johns Hopkins University
Correct interpretation of pulmonary function tests (PFTs) requires the use of appropriate reference values to which the patient's results are compared [1-4].
Unlike many physiologic parameters, for which normal values do not vary with the characteristics of the particular patient, predicted values of pulmonary function depend upon age, height, sex, and race/ethnicity. Therefore, interpretation of PFTs performed for the first time must take these and other factors into consideration. In practice, spirometers and pulmonary function test equipment have software that uses reference equations for calculation of "predicted values," as determined by published studies of large numbers of healthy individuals [3,4].
The American Thoracic Society (ATS) statement on the standardization of spirometry, as well as other ATS guidelines, can be accessed through the ATS web site at www.thoracic.org/statements.
The effects of age, height, sex, and race/ethnicity on the development of normal prediction parameters for interpretation of PFTs are reviewed here. The technique and interpretation of PFTs are discussed separately. (See "Office spirometry" and "Overview of pulmonary function testing in adults" and "Overview of pulmonary function testing in children" and "Diffusing capacity for carbon monoxide".)
EFFECT OF AGE, GROWTH, AND SEX
PFT results are dependent upon age, growth, and sex.
- Miller MR, Hankinson J, Brusasco V, et al. Standardisation of spirometry. Eur Respir J 2005; 26:319.
- Hankinson JL, Odencrantz JR, Fedan KB. Spirometric reference values from a sample of the general U.S. population. Am J Respir Crit Care Med 1999; 159:179.
- Pellegrino R, Viegi G, Brusasco V, et al. Interpretative strategies for lung function tests. Eur Respir J 2005; 26:948.
- Quanjer PH, Stanojevic S, Cole TJ, et al. Multi-ethnic reference values for spirometry for the 3-95-yr age range: the global lung function 2012 equations. Eur Respir J 2012; 40:1324.
- Wang X, Dockery DW, Wypij D, et al. Pulmonary function between 6 and 18 years of age. Pediatr Pulmonol 1993; 15:75.
- Stanojevic S, Wade A, Stocks J, et al. Reference ranges for spirometry across all ages: a new approach. Am J Respir Crit Care Med 2008; 177:253.
- Robbins DR, Enright PL, Sherrill DL. Lung function development in young adults: is there a plateau phase? Eur Respir J 1995; 8:768.
- Kerstjens HA, Rijcken B, Schouten JP, Postma DS. Decline of FEV1 by age and smoking status: facts, figures, and fallacies. Thorax 1997; 52:820.
- Kohansal R, Martinez-Camblor P, Agustí A, et al. The natural history of chronic airflow obstruction revisited: an analysis of the Framingham offspring cohort. Am J Respir Crit Care Med 2009; 180:3.
- Scanlon PD, Shriver MD. "Race correction" in pulmonary-function testing. N Engl J Med 2010; 363:385.
- Gaultier C, Crapo R. Effects of nutrition, growth hormone disturbances, training, altitude and sleep on lung volumes. Eur Respir J 1997; 10:2913.
- Kumar R, Seibold MA, Aldrich MC, et al. Genetic ancestry in lung-function predictions. N Engl J Med 2010; 363:321.
- Korotzer B, Ong S, Hansen JE. Ethnic differences in pulmonary function in healthy nonsmoking Asian-Americans and European-Americans. Am J Respir Crit Care Med 2000; 161:1101.
- Babb TG, Wyrick BL, DeLorey DS, et al. Fat distribution and end-expiratory lung volume in lean and obese men and women. Chest 2008; 134:704.
- Sood A. Altered resting and exercise respiratory physiology in obesity. Clin Chest Med 2009; 30:445.
- Parameswaran K, Todd DC, Soth M. Altered respiratory physiology in obesity. Can Respir J 2006; 13:203.
- Sutherland TJ, Goulding A, Grant AM, et al. The effect of adiposity measured by dual-energy X-ray absorptiometry on lung function. Eur Respir J 2008; 32:85.
- Salome CM, King GG, Berend N. Physiology of obesity and effects on lung function. J Appl Physiol (1985) 2010; 108:206.
- Jones RL, Nzekwu MM. The effects of body mass index on lung volumes. Chest 2006; 130:827.
- Garcia-Rio F, Dorgham A, Pino JM, et al. Lung volume reference values for women and men 65 to 85 years of age. Am J Respir Crit Care Med 2009; 180:1083.
- Stocks J, Quanjer PH. Reference values for residual volume, functional residual capacity and total lung capacity. ATS Workshop on Lung Volume Measurements. Official Statement of The European Respiratory Society. Eur Respir J 1995; 8:492.
- Quanjer PH, Tammeling GJ, Cotes JE, et al. Lung volumes and forced ventilatory flows. Eur Respir J 1993; 6 Suppl 16:5.
- Dykstra BJ, Scanlon PD, Kester MM, et al. Lung volumes in 4,774 patients with obstructive lung disease. Chest 1999; 115:68.
- Knudson RJ, Kaltenborn WT, Knudson DE, Burrows B. The single-breath carbon monoxide diffusing capacity. Reference equations derived from a healthy nonsmoking population and effects of hematocrit. Am Rev Respir Dis 1987; 135:805.
- Miller A, Thornton JC, Warshaw R, et al. Single breath diffusing capacity in a representative sample of the population of Michigan, a large industrial state. Predicted values, lower limits of normal, and frequencies of abnormality by smoking history. Am Rev Respir Dis 1983; 127:270.
- Crapo RO, Morris AH. Standardized single breath normal values for carbon monoxide diffusing capacity. Am Rev Respir Dis 1981; 123:185.
- Paoletti P, Viegi G, Pistelli G, et al. Reference equations for the single-breath diffusing capacity. A cross-sectional analysis and effect of body size and age. Am Rev Respir Dis 1985; 132:806.
- Roca J, Rodriguez-Roisin R, Cobo E, et al. Single-breath carbon monoxide diffusing capacity prediction equations from a Mediterranean population. Am Rev Respir Dis 1990; 141:1026.
- Cotes JE, Hall AM. The transfer factor for the lung: normal values in adults. In: Introduction to the definition of normal values for respiratory function in man, Arcangeli P, Cotes JE, Cournand A. (Eds), Panminerva Medica, Torino 1970. p.327.
- Thompson BR, Johns DP, Bailey M, et al. Prediction equations for single breath diffusing capacity (Tlco) in a middle aged caucasian population. Thorax 2008; 63:889.
- Enright PL, Kronmal RA, Manolio TA, et al. Respiratory muscle strength in the elderly. Correlates and reference values. Cardiovascular Health Study Research Group. Am J Respir Crit Care Med 1994; 149:430.
- Enright PL, Sherrill DL. Reference equations for the six-minute walk in healthy adults. Am J Respir Crit Care Med 1998; 158:1384.
- ATS Committee on Proficiency Standards for Clinical Pulmonary Function Laboratories. ATS statement: guidelines for the six-minute walk test. Am J Respir Crit Care Med 2002; 166:111.
- Singh SJ, Puhan MA, Andrianopoulos V, et al. An official systematic review of the European Respiratory Society/American Thoracic Society: measurement properties of field walking tests in chronic respiratory disease. Eur Respir J 2014; 44:1447.
- Cerveri I, Corsico AG, Accordini S, et al. Underestimation of airflow obstruction among young adults using FEV1/FVC <70% as a fixed cut-off: a longitudinal evaluation of clinical and functional outcomes. Thorax 2008; 63:1040.
- Henderson AJ. The effects of tobacco smoke exposure on respiratory health in school-aged children. Paediatr Respir Rev 2008; 9:21.
- Sack CS, Kaufman JD. Air Pollution Levels and Children's Lung Health. How Low Do We Need to Go? Am J Respir Crit Care Med 2016; 193:819.
- Chen Z, Salam MT, Eckel SP, et al. Chronic effects of air pollution on respiratory health in Southern California children: findings from the Southern California Children's Health Study. J Thorac Dis 2015; 7:46.
- Li S, Williams G, Jalaludin B, Baker P. Panel studies of air pollution on children's lung function and respiratory symptoms: a literature review. J Asthma 2012; 49:895.
- Rice MB, Rifas-Shiman SL, Litonjua AA, et al. Lifetime Exposure to Ambient Pollution and Lung Function in Children. Am J Respir Crit Care Med 2016; 193:881.
- Gauderman WJ, Avol E, Gilliland F, et al. The effect of air pollution on lung development from 10 to 18 years of age. N Engl J Med 2004; 351:1057.
- Fuertes E, Bracher J, Flexeder C, et al. Long-term air pollution exposure and lung function in 15 year-old adolescents living in an urban and rural area in Germany: The GINIplus and LISAplus cohorts. Int J Hyg Environ Health 2015; 218:656.
- EFFECT OF AGE, GROWTH, AND SEX
- EFFECT OF HEIGHT, RACE, AND WEIGHT
- PULMONARY FUNCTION REFERENCE EQUATIONS
- Other pulmonary function tests
- UPPER AND LOWER LIMITS OF NORMALITY
- ENVIRONMENTAL INFLUENCES
- SUMMARY AND RECOMMENDATIONS