Professional Documents
Culture Documents
Lopes2019 PDF
Lopes2019 PDF
To cite this article: Agnaldo José Lopes (2019): Advances in spirometry testing for lung function
analysis, Expert Review of Respiratory Medicine, DOI: 10.1080/17476348.2019.1607301
DOI: 10.1080/17476348.2019.1607301
Advances in spirometry testing for lung function analysis
t
ip
a
Post-graduate Program in Medical Sciences, State University of Rio de Janeiro, Rio de
cr
Janeiro, Brazil.
2
Rehabilitation Sciences Master’s Program, Augusto Motta University Center, Rio de
us
Janeiro, Brazil. an
CONTACT: Agnaldo José Lopes. Rehabilitation Sciences Master’s Program, Augusto
M
Motta University Center, Praça das Nações, 34, Bonsucesso, 21041-010, Rio de Janeiro,
Introduction: Spirometry, the most common lung function test, is used to evaluate
t
ip
underutilization and the misinterpretation of its parameters are causes for concern.
cr
Areas covered: This review describes new spirometry-derived metrics, new reference
us
equations, recent recommendations for presentation of results, recent spirometry-based
that increase awareness of the importance of spirometry. New metrics derived from
ed
spirometry, together with traditional spirometric criteria, can identify individuals with
structural lung disease and respiratory morbidity. Some problems with the reference
pt
equations were solved by the Global Lung Function Initiative (GLI), which covers a
ce
wider age range and more ethnic groups and provides limits of normality using the z-
score. Despite these advantages, the GLI equations lack data from large populations
Ac
(especially those from Africa, South Asia, and Latin America) and greater
representation of older people. Another disadvantage attributed to the GLI is the lack of
predicted values for peak expiratory flow and other airflows, limiting the interpretation
Article Highlights
t
ip
management of airway disease during follow-up.
cr
expiratory flow-volume curves are associated with structural lung disease,
us
dyspnea, and respiratory quality of life in computed tomography and may be
• There has been much enthusiasm for adopting Global Lung Function Initiative
M
(GLI) equations because they are applicable to a wider age range and more
ed
during growth.
pt
• A graph showing the differences between test results and predicted values in
lung function.
Ac
parameters and presenting the lower limit of normal next to the measured value
• The international data repository of the GLI allows the development and
at risk, and therefore, it should be complemented with imaging tests and other
functional tests.
t
ip
• Spirometry performed in the workplace should be part of a comprehensive
cr
• Spirometric parameters appear to be more important than fractional exhaled
us
nitric oxide measurements for predicting the outcomes of asthma.
Organ volume measurements date from the second century, when Claudius Galenus
measured variations in bladder volume before and after the bladder was inflated by a
t
ip
Giovani Borelli (1608-1679), Humphry Davy (1778-1829), and Nestor Grehant (1838-
1910), whose sketches of their gasometers are still available. The first known
cr
spirometer was developed by the English physician John Hutchinson in 1846 [1].
us
Spirometry is the most commonly performed pulmonary function test (PFT) in
effects of pulmonary disease treatments [2]. Despite its clinical relevance, spirometry is
M
underused due to a lack of awareness of its importance, limited access to the test [3,4],
and inappropriate techniques [5,6] and interpretations [7,8]. Several medical societies
ed
have published guidelines for standardizing the test methodology and improving data
pt
interpretation [9–11].
decades, especially those related to portable devices. Furthermore, new indices and
ways of analyzing test results have been proposed, which may be useful for individuals
Ac
with borderline or mild lung disease based on traditional spirometric criteria [12,13]. A
more recent cause for concern is the presentation of results [14]. Numerous variables
can be tested, and large amounts of data can be obtained; however, not all results are
This narrative review addresses the technical aspects that should guide the
execution of spirometry and provides new insights. This review also describes
population-based studies that stress the importance of this method, proposals for using a
standard report model, and new reference equations for interpreting the results, with an
t
ip
emphasis on the multinational population study conducted by the Global Lung Function
cr
are also presented.
us
2. Spirometric parameters and their importance
an
Spirometry requires the understanding and collaboration of the patient, accurate
personnel. According to the ATS/ERS task force, the main spirometry parameters are
vital capacity (VC), forced vital capacity (FVC), forced expiratory volume in the first
ed
FEV1/FVC) [11]. In addition to airflow and volume, analysis of the shape of the
volume-time and volume-flow curves may provide important information (Figure 1).
ce
The maximal expiratory flow-volume (MEFV) curve shows that the flow is maximal at
the beginning of expiration and decreases as the lung volume approaches the residual
Ac
volume (RV). Flow volumes at the beginning of expiration correspond to the effort-
dependent portion of the curve because they can increase with greater patient effort. The
maximum flow volumes after expiration of the first 30% of the FVC occur with modest
expiratory effort and represent the effort-independent portion of the curve [10,11].
forced expiratory flow in the middle half of the FVC (FEF25-75%), are largely effort-
independent but rely heavily on lung volume and airway size [15]. Thus, the normal
range for these flow volumes is much larger than those for effort-dependent measures
such as FEV1 and peak expiratory flow (PEF). This disadvantage of intermediate and
end flow volumes is partially offset by their significant changes in disease states,
t
ip
causing them to be abnormal in isolation in the early stages of an obstructive defect and
cr
The forced expiratory volume in the third second/FVC (FEV3/FVC) ratio is
us
recommended by some authors as a routine spirometric measure to diagnose airflow
limitation (AFL) [13,16]. Bhattarai et al. [17] showed that more than 10% of subjects
an
with a normal FEV1/FVC ratio presented an abnormal FEV3/FVC ratio, and this
parameter was more accurate than FEF25-75% for diagnosing SAD. Piorunek et al. [13]
M
compared the utility of FEV3/FVC and the difference in airway resistance at 5 Hz and
ed
pulmonary disease (COPD). R5-R20 was highly sensitive for detecting mild lung
pt
disease, and FEV3/FVC was highly specific for excluding a SAD diagnosis. Although
spirometry and IOS are complementary for diagnosing SAD [18], the importance of
ce
FEV3/FVC has not yet been discussed in the guidelines of the American Thoracic
alternative for FVC [19]. Because of the 6-second expiratory maneuver, FEV6
spirometry in the clinic is easier, faster, and safer than FVC measurement [20].
Furthermore, FEV1/FEV6 use simplifies testing procedures and reduces data variability,
improving diagnostic accuracy [16,19], although the cut-off points to define obstructive
ratio <0.70 as a fixed cut-off point for detecting COPD. FEV6 is useful in some clinical
settings but has been associated with misdiagnoses in older adults. Therefore, in the
elderly, there may be excessive diagnoses of AFL using FEV1/FEV6, indicating that
t
ip
In children unable to perform forced maneuvers for 1 second, the forced
expiratory volume in 0.5 seconds (FEV0.5) or the forced expiratory volume in 0.75
cr
seconds (FEV0.75) can be used as alternatives to FEV1 [10]. More recently, the
us
FEV0.75/FVC ratio was useful to evaluate wheezing management in preschool children
subsequent onset of asthma and allergy during the first 7 years of life and found that
M
reduced FEV0.5 was significantly associated with elevated C-reactive protein and other
ed
According to the ATS/ERS task force, the FEV1/VC ratio is the main parameter
Ac
used to define obstructive defects [11]. Both FEV1 and VC are decreased in restrictive
defects, leading to a normal FEV1/VC ratio. Because FEF25-75% and other instantaneous
airflow measurements are not accurate for diagnosing AFL in cases in which the
FEV1/VC ratios are borderline [15,24], clinical and radiological correlations are helpful
interpretation [25].
A fixed value of 80% to predict the lower limit of normal (LLN) has been used
parameters in adults and the elderly [26]. Using a fixed value of 0.70 of the FEV1/FVC
ratio as the lower limit may result in overdiagnosis of COPD in asymptomatic older
t
ip
adults who have never smoked [27]. Thus, clinical decisions based on fixed values
should be evaluated with caution considering the age group [9]. FEV1/FVC values are
cr
independent of ethnicity, and therefore the LLN is a useful indication of AFL, even
us
when ethnicity is uncertain [14]. The difference between FVC and slow VC (VC–FVC)
is associated with AFL in patients with obstructive defects [11]. Although this
an
measurement is simple and easily obtained, Martinez et al. [28] demonstrated that it was
inspiratory capacity during the 6-minute walk test in patients with COPD. This result
ed
suggests that lung volumes evaluated using PFTs at rest provide insufficient information
confirmed through CT [29]. For earlier AFL diagnosis, the isolated decrease in FEF25-
may help diagnosis mild airway obstruction in symptomatic smokers, despite its
Ac
75%
high variability [11,16]. Bhatt et al. [12] used advanced computational tools combined
AFL metrics based on MEVT (Parameter D) and MEFV (Transition Point and
Transition Distance) curves (Figure 2). All assessed metrics had significant associations
with emphysema, SAD, dyspnea, and quality of life (QoL). Parameter D identified 9.5%
cause mortality. To differentiate healthy older adults from those with mild COPD,
Dominelli et al. [30] calculated the slope ratio at 20-80% of the MEFV curve to
quantify its concavity. More recently, Wang et al. [31] used the “angle of collapse” of
the MEFV curve ≤137° to diagnose patients with asthma-COPD overlap (ACO) with
t
ip
respectively.
cr
[11,32]. However, a decreased VC value with preserved FEV1/VC in a clinical and
us
radiological context suggestive of a restrictive defect should be valued, especially
accompanied by TLC reduction, the opposite is not true, and there is a good correlation
ed
between normal VC and absence of reduced TLC. Therefore, complementation with the
recommendation is to use %FEV1 as the basis for this classification [11], although this
ce
approach uses an arbitrary number of severity categories. Thus, the use of the %
predicted in this way entails a pronounced age-related bias. Quanjer et al. [34] evaluated
Ac
an alternative to grade obstructive defects and thereby overcome biases related to age,
height, and gender. Using a simple classification system, these authors proposed the
LLN for FEV1/(F)VC and z-scores for FEV1 of -2, -2.5, -3 and -4 to delineate severity
levels of AFL.
different reports, and some clinical laboratories customize their reports. These
approaches may lead to confusion and make it difficult to compare results from
different laboratories. The ATS recently recognized the need for a standardized
t
ip
reporting format for PFTs [14]. The committee emphasizes that simplifying the data
cr
spirometry, which may lead to a strong incentive for its use.
us
The ATS recently recommended that only relevant variables be included in the
report because including a large number of variables increased the probability of one
an
variable falling below an arbitrary LLN, consequently increasing the chances of a false-
positive result. To avoid excessive data, the predicted values should be omitted because
M
they do not help interpret the abnormality; instead, the LLN value should be prioritized.
ed
Regardless of the reference source or the chosen LLN, examiners should be aware of
Normal data from several predicted equations may change considerably, and the
use of the predicted percentage leads to an age bias because the variability in spirometry
ce
tests varies widely during the lifetime. However, age bias can be avoided by using a z-
score specific for sex, age, and height [36]. In this respect, the ATS stresses the
Ac
from the mean or, for regression equations, the number of standardized residuals from
the predicted value (Figure 3). Linear graphs show the z-scores for the normal range,
helping to evaluate the significance of abnormal values because these scores indicate
disease severity relative to the predicted value [32]. In contrast to the predicted
consequently, is useful for defining the lower and upper limits of normality. Moreover,
The simplified report model proposed by the ATS (Figure 4) does not emphasize
that all obtained curves should be available to improve analysis by clinicians. Height,
weight, sex, and ethnicity should also be included in the report; when evaluating test
t
ip
results, age should be recorded in years with an accuracy of at least one decimal place
during periods of rapid growth (preferably as the date of measurement minus the date of
cr
birth). For any height and sex, a difference of 1 year in age may change the predicted
us
value by up to 8.5% in individuals <20 years [37]. The absolute values and predicted
percentages of FVC and FEV1 should be reported. For FEV1/FVC, reporting only the
an
absolute value as a decimal fraction (leaving the column for the predicted percentage
blank) has been recommended by the ATS to avoid confusion in interpretation (Figure
M
4) [32,35]. In patients with suspected AFL, the vital capacity (VC) and FEV1/VC values
ed
The differences between reference equations stem from factors including health of the
ce
individuals selected, sample size, equipment used, quality control, and statistical
method used to calculate the equations [14,38,39]. These differences may significantly
Ac
impact data interpretation, and the results for the same individual may be abnormal
using one equation but normal using another [40]. Anthropometric characteristics are
(Figure 5). One of the oldest problems with reference equations is the lack of a single
move from one set of equations used in an age group to another set used in another age
group. Many pediatric equations include only height and omit age because of rapid
barrier to the creation of an equation for all age groups was the limited availability of
t
ip
statistical methodologies, although the recent availability of more flexible
cr
age range [39].
us
The solution to many of these problems was obtained by the GLI Network,
which shared more than 74,000 medical records from 26 countries from various ethnic
an
groups, including Caucasians, African Americans, and Asians [14,39]. Because many
populations were not represented in these groups, a composite equation was derived
M
from the means of the available data to facilitate data interpretation in these populations.
ed
In the GLI, prediction equations were developed using the Lambda-Mu-Sigma (LMS)
method [41]. Through the LMS, the complex effects of explanatory variables on the
pt
dependent variable are modeled using splines, which vary the dependent variable
Currently, there is a general tendency to adopt the GLI equations [38] due to the
elaboration of data from multiethnic groups, the wide age range contemplated by the
Ac
equations (3-95 years of age), the uniformity in comparing data from the international
literature, and the availability of limits of normality obtained using a z-score [42]. The
threshold of the FEV1/FVC ratio to determine AFL is based on 1.64 SDs instead of 5%
of the LLN, and the severity of FEV1 is established using SD and z-scores [34,43]. In
addition, the GLI equations were derived from cross-sectional data that were later
and therefore improve the epidemiological analysis of respiratory risk factors [36].
The GLI lacks data from large populations, especially those from Africa, South
Asia, and Latin America. Although spirometry reference equations have been developed
for the Asian population, the analysis of the effects of migration on lung function in this
t
ip
population both within the geographical region and to Western countries is necessary to
cr
[45,46]. Another disadvantage attributed to the GLI is the lack of predicted values for
us
PEF and other airflows, limiting the interpretation of the MEFV curve [38]. Notably,
the collection of GLI data is continuous via an active repository; therefore, new
an
reference equations can be derived [38].
Another widely discussed issue is reference equations for older adults. Aging is
M
affect baseline values [32,47,48]. By including age-related changes in lung function, the
pt
Limitations regarding the use of GLI equations in older adults include the need for
ce
greater representation of individuals aged >75 years and survival bias in the older
elderly [37,50]. Moreover, more data in the geriatric population are needed to develop
Ac
age-appropriate updated criteria for test performance [50]. For these reasons, caution is
required when interpreting pulmonary function data in the geriatric population using
In recent years, several studies evaluated the fit and applicability of GLI
equations in different populations, and the results are discordant [32,36,51–53]. Linares-
United States and found that differences in minimum and maximum height were higher
in older subjects. Brazzale et al. [54] reported that the effects of changing to GLI
equations on interpretation are minimal when changing from National Health and
Nutrition Examination Survey (NHANES III) equations and most significant when
changing from European Community of Steel and Coal (ECSC) equations. Using the
t
ip
GLI equations instead of the NHANES III equations, Embling et al. [55] observed a
change in diagnosis of lung disease in 5.9% of the individuals. Belo et al. [32]
cr
compared baseline values from the NHANES III and GLI. The lowest %FVC and
us
%FEV1 values were obtained using GLI equations, and the prevalence of AFL was
higher using ECSC equations, whereas GLI equations indicated restrictive defects. GLI
an
equations tend to recognize AFL less frequently than do NHANES III equations [43];
using the z-score, as recommended by GLI, changed the diagnosis category in 10.7% of
M
the cases, and discordance was higher in individuals aged >65 years. Chaiwong et al.
ed
[56] evaluated the differences and agreements regarding spirometry results using the
GLI, NHANES III, Knudson, and Siriraj reference equations in the Thai population.
pt
based studies [68–70], and paradigm in the diagnosis of ACO [71] have been
extensively discussed.
and elderly adults, respectively, whereas LLN-based criteria are more accurate [7,8,57–
59]. Comparing FEV1/FVC fixed-rate and LLN-based criterion, Pothirat et al. [7]
obstructive airway diseases and chronic respiratory symptoms, mostly associated with
t
ip
rhinitis. A recent study indicated that 6.0% and 4.2% of individuals were diagnosed
with AFL using the GOLD and GLI criteria, respectively, and the rate of overestimation
cr
using GOLD criteria increased with age, ranging from 25% of cases at 50 years to 54%
us
at 70 years [60].
[62], only one-third of subjects with COPD were aware of the disease. This result
M
highlights the known problem of underdiagnosis, which is higher for males, younger
ed
individuals, never and current smokers, those with a lower education, and those with no
previous spirometry [63]. In contrast, Lenoir et al. [62] observed that more than 50% of
pt
the individuals diagnosed with COPD had normal spirometric parameters, indicating the
occurrence of COPD misdiagnoses or the possibility that diagnosis was based solely on
ce
diagnosed with COPD in the hospital setting might be misdiagnosed using spirometry.
Ac
Factors that contribute to inaccurate COPD diagnosis include lower smoking load, high
body mass index, and comorbidities [64]. Heffler et al. [3] observed that only 69.5%
and 13.3% of patients with doctor-diagnosed asthma and COPD, respectively, had
whether the different definitions of AFL (FEV1 <0.7 vs. FEV1 <LLN) affect the
rate or LLN definitions and assessed by NHANES III equations presented similar risk
A recent study [68] evaluated the role of spirometry and fractional exhaled nitric
oxide (FENO) measures in predicting poor outcomes in 1,122 children with asthma and
indicated that repeated measures of %FEV1 better predicted worse asthma control and
t
ip
asthma exacerbation than did repeated FENO measurements. In a large cohort of
children with asthma, risk factors for exacerbation varied according to the seasons,
cr
although lung function impairment was associated with higher likelihood of
us
exacerbations in all seasons [69]. Patients with asthma exhibited a significant
association between decreased FEV1/FVC ratio and acute exposure to particles ≤10 μm
an
in spring or sulfur dioxide in autumn or winter [70].
evaluated 11,923 participants and determined the prevalence and risk factors for ACO
ed
in six low- and middle-income countries (LMICs) [71]. The authors used spirometry as
a basis for diagnosis and indicated that ACO might be as prevalent and more severe in
pt
exposure and sociodemographic variables [10]. In a study [72] using NHANES data
Ac
obstruction and COPD was 12.4% and 3.47%, respectively; moreover, the prevalence of
(~2050 m) and lowland (~750 m) and showed that the prevalence of COPD and air
Lowe et al. [74] used spirometry to follow up 4,826 smokers and observed that low
income was an independent predictor of decreased FEV1 and increased rate of airway
diseases. Agustí et al. [75] observed that early life events can affect health in later life.
In a transgenerational cohort analysis, low lung function in early adulthood may identify
t
ip
Spirometry can assess the impact of lung function impairment on nonrespiratory
cr
lung function [76]. Lutsey et al. [77] evaluated the link between lung function
us
impairment and risk of dementia in a community-based cohort followed for 27 years.
Restrictive defects and, to a lesser extent, obstructive defects were associated with
an
increased risk of dementia, including Alzheimer's disease-related dementia and
[78] and found that the risk of abnormal lung function was comparatively higher in
been recent progress in office spirometers (OSs). The main advantages of OSs are lower
Ac
cost and smaller size, although low precision in FVC measurements, difficulty of
calibration, inability to show MEVT and MEFV curves, and limited number of
predicted equations available to the user may limit their applicability [9,10].
furthermore, 87% of the subjects had concordant spirometry data for AFL. In 155
individuals with suspected COPD, the ROC curve for the FEV1 calculated by OSs
reached an area under the curve of 0.86 (95% CI: 0.78–0.92), whereas the Youden’s
index with a cut-off point of 0.70 for FEV1/FEV6 reached an area under the curve of
0.97 [80]. Tupper et al. [81] evaluated a cohort of patients with stage 3 and 4 COPD for
t
ip
6 months and indicated that home telemonitoring with OSs improved overall QoL. Watz
et al. [82] also used OSs to monitor patients with severe COPD in the home setting and
cr
observed that FEV1 began to decrease 2 weeks before the onset of exacerbation
us
symptoms and did not return to presymptomatic levels 8 weeks after the event.
several diseases in the home setting. PS advantages include ease of use, portability, and
M
low cost. However, compared to standard spirometers, PSs are not sensitive enough to
ed
used for abnormal test results [9,10]. Schermer et al. [83] used the prebronchodilation
patients with respiratory symptoms who consulted general practitioners (GPs), most
Ac
reduce costs and improve accessibility, convenience, and portability [84]. Joo et al. [85]
compared real-time SGA and classic LS parameters and found that SGA data were
Therefore, SGA may be a useful tool in clinical practice for pulmonary function
some studies have shown that smartphone spirometry can effectively measure lung
function using only microphone audio data from a standard smartphone. Electronic
systems have been designed that allow the microphone to work as a flow sensor and
t
ip
record the exhaled air [86].
cr
7. Expert Opinion
us
Although spirometry is the most relevant test for assessing pulmonary function and
screening overall respiratory health, its limited use and the high rate of misdiagnosis in
an
patients with suspected chronic lung diseases who are seen by primary care physicians
are concerning. Strategies to overcome this limitation include raising awareness about
M
PFTs in the primary care network, increasing access to spirometry, and implementing
measures that may assist GPs in interpreting spirometric patterns. These approaches
ed
FEV1/VC) ratio is within the normal range, the FEV3/FVC ratio may be incorporated
ce
into clinical practice because of its high specificity to exclude an SAD diagnosis. In
contrast, the FEV1/FEV6 ratio is a good alternative to the FEV1/FVC ratio for COPD
Ac
screening. In addition, some data points in MEVT and MEFV curves may be useful for
obtaining AFL indices and identifying individuals with obstructive defects who are
reduces the potential bias when using predicted values. A simple linear graph containing
t
ip
understanding the spirometry results. In addition, the wide adoption of a standardized
report format for spirometry by PFT equipment manufacturers and laboratories may
cr
improve interpretation, communication, and understanding of test results.
us
Despite the importance of FEV1/FVC, caution is required when using this ratio
in older adults and individuals with mild airway obstruction. This problem can be
an
partially solved by adopting GLI criteria to improve the precision of the diagnosis of
COPD; notably, the GOLD criteria overestimate COPD starting at the age of 50 years.
M
In asthma, changes in %FEV1 can be used to assess disease risk, and this parameter is
ed
more accurate than changes in FENO. Strategies to control the target sources of air
pollution are necessary for this group of patients because this control directly affects the
pt
spirometry results.
health services, and lack of awareness about the risks of smoking), and high altitude
Ac
may exacerbate chronic lung disease. Furthermore, low FEV1 and FVC values in middle
advancing age. Therefore, effective public health policies may decrease the prevalence
spirometry and health care outcomes in individuals with chronic lung disease. Although
there are still several barriers to the widespread use of OSs, these devices, when
t
ip
carefully evaluated using LSs for diagnosing these clinical conditions.
cr
artificial intelligence, spirometry advances point to two perspectives:
us
• The inclusion of new metrics derived from spirometric tracings using
In the coming years, the increased use of GLI equations may help overcome
pt
many problems involving reference values. Nonetheless, two open issues for future
research remain:
ce
geographical conditions, and social conditions with an increased risk of lung disease. In
addition to the effects of ethnicity and current smoking, income disparity appears to be
an important factor for the progression of chronic lung disease. Research should focus
on defining the spirometric criteria of the ACO more accurately and the possibility of
including biomass fuel smoke exposure in the diagnostic criteria of this condition.
t
ip
Funding
cr
This research was supported by the National Council for Scientific and Technological
us
Development (#304625/2016-7), Coordination for the Improvement of Higher
Education Personnel (Finance Code 001), and Foundation Carlos Chagas Filho
an
Research Support of the State of Rio de Janeiro (#E-26/202.679/2018).
M
Declaration of interest
The author has no relevant affiliations or financial involvement with any organization or
ed
entity with a financial interest in or financial conflict with the subject matter or
pt
pending, or royalties.
Ac
Reviewers Disclosure
to disclose.
Papers of special note have been highlighted as either of interest (•) or of considerable
t
ip
patients: what are the gaps? Int J Chron Obstruct Pulmon Dis, 11, 1553–1567
(2016).
cr
3. Heffler E, Crimi C, Mancuso S, et al. Misdiagnosis of asthma and COPD and
us
underuse of spirometry in primary care unselected patients. Respir Med, 142,
48–52 (2018).
an
4. Sokol KC, Sharma G, Lin YL, Goldblum RM Choosing wisely: adherence by
primary care practice: the importance of quality assurance and the impact of
ce
401 (2013).
t
ip
11. Pellegrino R, Viegi G, Brusasco V, et al. Interpretative strategies for lung
cr
12. Bhatt SP, Bhakta NR, Wilson CG, et al. New spirometry indices for detecting
us
mild airflow obstruction. Sci Rep, 8(1), 17484 (2018).
•• The results showed that data points in expiratory spirometry curves could
an
be used to obtain airway obstruction indices and identify individuals with
• This study evaluated the utility of forced expiratory volume in the third
chronic obstructive pulmonary disease and compared this index with those
14. Culver BH, Graham BL, Coates AL, et al. Recommendations for a Standardized
15. Lukic KZ, Coates AL Does the FEF25-75 or the FEF75 have any value in
1090 (2016).
17. Bhattarai B, Ghosh M, Sinha A, et al. Can the FEV3/FVC ratio be reliably used
t
ip
Conference. San Diego, CA, USA, 16-21 May 2014.
18. Su ZQ, Guan WJ, Li SY, et al. Significances of spirometry and impulse
cr
oscillometry for detecting small airway disorders assessed with endobronchial
us
optical coherence tomography in COPD. Int J Chron Obstruct Pulmon Dis, 13,
3031–3044 (2018).
an
19. Ng SC, Abu Samah F, Helmy K, Sia KK Comparison between FEV1/FEV6 and
20. Chung KS, Jung JY, Park MS, et al. Cut-off value of FEV1/FEV6 as a surrogate
21. Wang S, Gong W, Tian Y, Zhou J FEV1/FEV6 in primary care is a reliable and
ce
easy method for the diagnosis of COPD. Respir Care, 61(3), 349–353 (2016).
22. Nève V, Hulo S, Edmé JL, et al. Utility of measuring FEV0.75/FVC ratio in
Ac
(2016).
23. Chawes BL Low-grade disease activity in early life precedes childhood asthma
FEF25-75% and FEF75% does not contribute to clinical decision making. Eur
t
ip
assessment of airway disease. Eur J Radiol, 85(11), 2144–2151 (2016).
26. American Thoracic Society. Lung Function testing: selection of reference values
cr
and interpretative strategies. Am Rev Respir Dis, 144(5), 1202–1218 (1991).
us
27. Hardie JA, Buist AS, Vollmer WM, Ellingsen I, Bakke PS, Morkve O Risk of
28. Martinez L, Rodrigues D, Donária L, et al. Difference between slow and forced
M
vital capacity and its relationship with dynamic hyperinflation in patients with
ed
29. Woodruff PG, Barr RG, Bleecker E, et al. Clinical significance of symptoms in
pt
(2016).
ce
30. Dominelli PB, Foster GE, Guenette JA, et al. Quantifying the shape of the
COPD overlap syndrome. Int J Chron Obstruct Pulmon Dis, 11, 3015–3022
(2016).
t
ip
118–122 (2017).
34. Quanjer PH, Pretto JJ, Brazzale DJ, Boros PW Grading the severity of airways
cr
obstruction: new wine in new bottles. Eur Respir J, 43(2), 505–512 (2014).
us
35. Culver B. Defining airflow limitation and chronic obstructive pulmonary
36. Ketfi A, Gharnaout M, Bougrida M, Ben Saad H The multi-ethnic global lung
37. 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.
ce
38. Cooper BG, Stocks J, Hall GL, et al. The Global Lung Function Initiative (GLI)
Ac
•• This study stressed the importance of expected values and the data
based on korean and non-korean reference equations. Ann Occup Environ Med,
25(1), 42 (2013).
40. Talaminos Barroso A, Márquez Martín E, Roa Romero LM, Ortega Ruiz F.
t
ip
41. Dejsomritrutai W, Chuaychoo B Impact of GLI-2012 spirometric references and
cr
Med Assoc Thai, 99(3):276–281 (2016).
us
42. Miller MR. Choosing and using lung function prediction equations. Eur Respir
J, 48(6):1535–1537 (2016).
an
43. Huprikar NA, Holley AB, Skabelund AJ, et al. A comparison of GLI12 with
Global Lung Initiative with those provided by the Third National Health
pt
44. Hüls A, Krämer U, Stolz S, et al. Applicability of the Global Lung Initiative
2012 reference values for spirometry for longitudinal data of elderly women.
Ac
45. Arigliani M, Canciani MC, Mottini G, et al. Evaluation of the Global Lung
47. Marcus BS, McAvay G, Gill TM, Vaz Fragoso CA Respiratory symptoms,
t
ip
48. Miner B, Tinetti ME, Van Ness PH, et al. Dyspnea in community-dwelling older
cr
2042–2050 (2016).
us
49. Vaz Fragoso CA, McAvay G, Van Ness PH, et al. Phenotype of normal
50. Miller MR, Thinggaard M, Christensen K, et al. Best lung function equations for
M
the very elderly selected by survival analysis. Eur Respir J, 43(5): 1338–1346
ed
(2014).
Dauchet LEJ. Global lung function initiative reference equations better describe
52. Kainu A, Tomonen K, Toika J, et al. Reference values of spirometry for Finnish
Ac
55. Embling LA, Zagami D, Sriram KB, Gordon RJ, Sivakumaran PEffect of
changing from the National Health and Nutritional Examination Survey III
spirometry reference range to that of the Global Lung Initiative 2012 at Gold
t
ip
Coast Hospital and Health Service. J Thorac Dis, 8(12), 3739–3743 (2016).
cr
reference equations for spirometry interpretation in Thai people. J Thorac Dis,
us
11(1), 113–122 (2019).
58. Turkeshi E, Vaes B, Andreeva E, et al. Airflow limitation by the Global Lungs
ed
Initiative equations in a cohort of very old adults. Eur Respir J, 46(1), 123-132
(2015).
pt
59. van Dijk W, Tan W, Li P, et al. Clinical relevance of fixed ratio vs lower limit of
limitation in one-third of cases in the general Finnish population. ERJ Open Res,
among adults aged 40-79: the National Health and Nutrition Examination
(2018).
62. Lenoir A, Fitting JW, Marques-Vidal PM, Vollenweider P, Nicod LP GLI 2012
t
ip
equations define few spirometric anomalies in the general population: the
cr
63. Lamprecht B, Soriano JB, Studnicka M, et al. Determinants of underdiagnosis of
us
COPD in national and international surveys. Chest, 148(4), 971–985 (2015).
(2017).
M
65. Celli BR, Decramer M, Wedzicha JA, et al. An Official American Thoracic
ed
(2015).
cause-specific mortality and the GOLD stages 1-4: a 30-year follow-up among
67. Torén K, Andersson M, Olin AC, Blanc PD, Järvholm B Airflow limitation
classified with the fixed ratio or the lower limit of normal and cause-specific
69. Teach SJ, Gergen PJ, Szefler SJ, et al. Seasonal risk factors for asthma
1473 (2015).
t
ip
70. Yu S, Park S, Park CS, Kim S. Association between the Ratio of FEV1 to FVC
cr
asthmatics using data clustered by patient in the Soonchunhyang asthma cohort
us
database. Int J Environ Res Public Health, 15(11), pii: E2349 (2018).
71. Morgan BW, Grigsby MR, Siddharthan T, et al. Epidemiology and risk factors
an
of asthma-chronic obstructive pulmonary disease overlap in low- and middle-
73. Brakema EA, Tabyshova A, Kasteleyn MJ, et al. High COPD prevalence at high
ce
altitude: does household air pollution play a role? Eur Respir J, 53(2), pii:
1801193 (2019).
Ac
74. Lowe KE, Make BJ, Crapo JD, et al. Association of low income with pulmonary
77. Lutsey PL, Chen N, Mirabelli MC, et al. Impaired lung function, lung disease
t
ip
and risk of incident dementia. Am J Respir Crit Care Med, (2019). [Epub ahead
of print]
cr
78. Fernandes FLA, Carvalho-Pinto RM, Stelmach R, et al. Spirometry in patients
us
screened for coronary artery disease: is it useful? J Bras Pneumol, 44(4), 299–
306 (2018).
an
79. Bambra G, Jalota L, Kapoor C, Mills PK, Vempilly JJ, Jain VV Office
• The results showed that in patients with previously diagnosed asthma and
80. Hidalgo Sierra V, Hernández Mezquita MÁ, Palomo Cobos L, et al. Usefulness
ce
of the Piko-6 portable device for early COPD detection in primary care. Arch
81. Tupper OD, Gregersen TL, Ringbaek T, et al. Effect of tele-health care on
quality of life in patients with severe COPD: a randomized clinical trial. Int J
exacerbations of COPD: a post hoc analysis of the WISDOM trial. Respir Res.
t
ip
84. Silsupadol P, Teja K, Lugade V Reliability and validity of a smartphone-based
cr
Body, bag, belt, hand, and pocket. Gait Posture, 58, 516–522 (2017).
us
85. Joo S, Lee K, Song CA Comparative study of smartphone game with spirometry
for pulmonary function assessment in stroke patients. Biomed Res Int, 2439312
an
(2018).
smartphone based spirometry using machine learning. Conf Proc IEEE Eng Med
ed
time curve (B). Note the peak expiratory flow (PEF) and the relationships of forced
us
expiratory volume in the first second (FEV1), forced expiratory volume in the third
second (FEV3), and forced expiratory volume in the sixth second (FEV6) with forced
an
vital capacity (FVC).
M
ed
pt
ce
Ac
curve. The calculation of the transition point is shown in A. The calculation of the
us
breakpoint and the change in the volume from the maximum to the breakpoint
(transition distance) is shown in B. The parameter D (not shown) describes the rate of
an
increase in volume. Adapted from [12] with permission.
M
ed
pt
ce
Ac
are within normality according to age, height, sex, and ethnicity. The arrows indicate
the points where the measures were obtained. FEV1 = forced expiratory volume in the
ed
first second; FVC = forced vital capacity; LLN = lower limit of normal; ULN = upper
pt
limit of normal. Adapted [Testing your lungs: spirometry. Breathe, 14(3), 257–260
Society. Only the tabulation of the data and curves of an individual who underwent the
M
test without bronchodilation is shown. FEV1 = forced expiratory volume in the first
ed
second; FVC = forced vital capacity; FET = forced expiratory time; GLI = Global Lung
Function Initiative; LLN = lower limit of normal. The slow vital capacity maneuver is
pt
not shown.
ce
Ac