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Pulmonary Function Testing

General reviews

The following ATS/ERS statements are widely recognized as the standard by which clinicians and researchers perform and interpret pulmonary functions tests:

Miller MR, Crapo R, Hankinson J, et al. ATS/ERS Task Force. General considerations for lung function testing. Eur Respir J. 2005; 26:153-61.

PMID: 15994402

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Graham B, Steenbruggen I, Miller M, et al. Standardization of spirometry 2019 update. An official american thoracic society and european respiratory society technical statement. Am J Respir Crit Care Med. 2019; 200:e70-e88.

PMID: 31613151

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Wanger J, Clausen JL, Coates A, et al. ATS/ERS Task Force. Standardization of the measurement of lung volumes. Eur Respir J. 2005; 26:511-22.

PMID: 16135736

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Graham BL, Brusasco V, Burgos F,  et al. 2017 ERS/ATS standards for single-breath carbon monoxide uptake in the lung. Eur Respir J. 2017; 49(1).

PMID: 28049168

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Coates AL, Wanger J, Cockcroft DW, et al. ERS technical standard on bronchial challenge testing: general considerations and performance of methacholine challenge tests. Eur Respir J  2017; 49:1601526. New recommendations noteworthy for basing result on the delivered dose of methacholine during the course of the test rather than upon a methacholine concentration. Also includes practical information such as how far in advance various bronchodilators need to be discontinued.

PMID: 28461290

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Stanojevic S, Kaminsky DA, Miller MR, et al. ERS/ATS technical standard on interpretive strategies for routine lung function tests. Eur Respir J. 2022; 60:2101499. Provides a comprehensive review of reference equations, types of ventilatory defects, PFT and DLCO interpretation, severity classifications, and a new criterion for bronchodilator response.

PMID: 34949706

Race Adjustments in PFTs

Bhakta NR, Kaminsky DA, Bime C, et al. Addressing race in pulmonary function testing by aligning intent and evidence with practice and perception. Chest. 2022; 161:288-297. This review summarizes the basis for, and multiple limitations of, race-based interpretation of PFTs.  The article includes discussion of the negative,  consequences of race-based interpretation, potential concerns with abandoning race adjustments, and cautions against the over reliance on use of PFTs to make clinical decisions on an individual basis in general.

PMID: 34437887

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Baugh AD, Shiboski S, Hansel NN, et al. Reconsidering the utility of race-specific lung function prediction equations. Am J Respir Crit Care Med. 2022; 205:819-829. This study found that in individuals with, or at risk of, COPD, use of race-specific equations for predicted lung function may underestimate the severity of disease among African Americans.

PMID: 34913855


Miller MR, Quanjer PH, Swanney MP, et al. Interpreting lung function data using 80% predicted and fixed thresholds misclassifies more than 20% of patients. Chest 2011;139:52-9. In addition to a discussion of the diagnostic errors associated with use of the fixed FEV1/FVC ratio of 0.7, this article highlights the misclassification associated with fixed 80%-predicted thresholds for spirometry variables. The authors suggest the fifth-percentile should be used to determine the lower limit of normal for spirometric variables and ratios.

PMID: 20522571

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Iyer VN, Schroeder DR, Parker KO, et al. The nonspecific pulmonary function test: longitudinal follow-up and outcomes. Chest, 2011; 139:878-88. This study of nearly 1,300 patients sheds light on the commonly encountered combination of reduced FVC but normal FEV/FVC and TLC. Roughly 2/3 of patients maintained this pattern during a median of 3 years of follow-up while the remaining 1/3 evolved into restrictive and obstructive patterns in equal numbers. 

PMID: 20724741

Hyatt RE, Cowl CT, Bjoraker JA, et al. Conditions associated with an abnormal nonspecific pattern of pulmonary function tests. Chest, 2009; 135:419-24. Study found airway hyperresponsiveness and obesity were the most common causes of nonspecific PFT results in which the FVC is reduced but the FEV1/FVC and TLC are normal. Other studies found weakness and bronchiectasis associated with this pattern.

PMID: 18812444

Berry C, Wise RA. Interpretation of pulmonary function test: Issues and controversies. Clin Rev Allergy Immunol. 2009; 37:173-180. A review of many of the shortcomings from using formulaic interpretation and the application of “normal” values, including the complexity and controversies surrounding “race adjustment” of normative equations.

PMID: 19305954

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Pulse oximetry

Sjoding MW, Dickson RP, Iwashyna TJ, et al. Racial bias in pulse oximetry measurement. N Engl J Med. 2020; 383:2477-2478. This analysis of 2 cohorts found patients self-identified as Black were significantly more likely than self-identified white patients to have a PaO2 < 88% despite a concurrent SpO2 of 92 – 96% (11.7% vs 3.7% and 17% vs. 6.2%, respectively, in the 2 cohorts).

PMID 33326721

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Exercise Testing

Weisman IM, Zeballos RJ. Clinical exercise testing. Clin Chest Med 2001;22:679-701. The focus is on cardiopulmonary exercise testing, but this review also briefly summarizes the 6-minute walk, testing for exercise-induced bronchoconstriction, and cardiac stress testing. An excellent starting point for the novice.

PMID: 11787659

ATS/ACCP Statement on cardiopulmonary exercise testing. Am J Respir Crit Care Med 2003; 167:211-77. Somewhere between a textbook and a clinical review, this article provides more details on CPET than the above Weisman article.

PMID: 12524257

Holland AE, Spruit MA, Troosters T, et al. An official European Respiratory Society/American Thoracic Society technical standard field walking tests in chronic respiratory disease. Eur Respir J. 2014; 44:1428-46. This document standardizes procedures for performing the 6-minute walk test as well as incremental and endurance shuttle walks. The potential for differences in methodology to produce large changes in results is emphasized.

PMID: 25359355

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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 disese. Eur Respir J. 2014; 44:1447-78.  This review summarizes the literature that is the basis for the technical standard above by Holland et al.

PMID: 25359356

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