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.
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.
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.
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).
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.
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.
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.
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.
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.
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.
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.
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.
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).
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.
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.
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.
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.
