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The use of self-reported race/ethnicity to interpret lung function measurements has historically assumed that the observed differences in lung function between racial and ethnic group were due to thoracic cavity size differences relative to standing height. Very few studies have considered the influence of environmental and social determinants on pulmonary function. Consequently, the use of race and ethnicity specific reference equations may further marginalize disadvantaged populations.To develop a race-neutral reference equation for spirometry interpretation.NHANES III data (n=6,984) were re-analyzed with sitting height and the Cormic index to investigate whether body proportions were better predictors of lung function than race and ethnicity. Further, the original Global Lung Function Initiative (GLI) data (n= 74,185) were re-analyzed with inverse-probability weights to create race-neutral GLI Global (2022) equations.The inclusion of sitting height slightly improved statistical precision of reference equations compared with using standing height alone, but did not explain observed differences in spirometry between the NHANES III race and ethnic groups. GLI-Global (2022) equations, which do not require the selection of race and ethnicity, had similar fit to the GLI-2012 'other' equations and wider limits of normal.The use of a single "Global" spirometry equation reflects the wide range of lung function observed within and between populations. Given the inherent limitations of any reference equation, the use of GLI Global equations to interpret spirometry requires careful consideration of an individual's symptoms and medical history when used to make clinical, employment, and insurance decisions.

Spirometrietests in de huisartsenpraktijk blijken vaak niet te voldoen aan de ATS/ERS-kwaliteitscriteria. Betekent dat ook dat de kwaliteit van spirometrie voor dagelijks klinisch gebruik niet voldoende is? We probeerden die vraag te beantwoorden door een vergelijking te maken tussen de diagnoses van huisartsen en die van longartsen. Ook vroegen we longartsen de klinische bruikbaarheid van de spirometrietests te evalueren, en we vroegen longfunctieanalisten om de tests op basis van de ATS/ERS-kwaliteitscriteria te beoordelen. De klinische bruikbaarheid van spirometrie in de huisartsenpraktijk blijkt goed te zijn, hoewel er weinig overeenkomst is tussen de diagnoses van longartsen en die van huisartsen.

Coronavirus disease 2019 (COVID-19) has negatively affected the delivery of respiratory diagnostic services across the world due to the potential risk of disease transmission during lung function testing. Community prevalence, reoccurrence of COVID-19 surges and the emergence of different variants of SARS-CoV-2 have impeded attempts to restore services. Finding consensus on how to deliver safe lung function services for both patients attending and for staff performing the tests are of paramount importance.This international statement presents the consensus opinion of 23 experts in the field of lung function and respiratory physiology balanced with evidence from the reviewed literature. It describes a robust roadmap for restoration and continuity of lung function testing services during the COVID-19 pandemic and beyond.Important strategies presented in this consensus statement relate to the patient journey when attending for lung function tests. We discuss appointment preparation, operational and environmental issues, testing room requirements including mitigation strategies for transmission risk, requirement for improved ventilation, maintaining physical distance and use of personal protection equipment. We also provide consensus opinion on precautions relating to specific tests, filters, management of special patient groups and alternative options to testing in hospitals.The pandemic has highlighted how vulnerable lung function services are and forces us to re-think how long-term mitigation strategies can protect our services during this and any possible future pandemic. This statement aspires to address the safety concerns that exist and provide strategies to make lung function tests and the testing environment safer when tests are required.

Until we have more comprehensive data from all regions in the world, we must be careful not to apply GLI equations indiscriminatelyhttps://bit.ly/3g1r9Q5

The American Thoracic Society and European Respiratory Society commissioned a task force to update the technical standards for spirometry testing with the aim of increasing the accuracy, precision and quality of spirometry measurements and improving the patient experience. To inform the task force with patient experiences, the European Lung Foundation, in collaboration with the task force, conducted an online survey in 10 languages between August and September 2018. There were 1760 respondents from 52 countries. The majority were adults (97.1%); the most common reasons for spirometry referral were diagnosis (35.0%) and management of an ongoing condition (60.1%). 53.2% reported regularly using inhalers. Respondents were very experienced with spirometry: 89.9% completed more than one test; 48% completed 10 or more tests. However, most reported not knowing what forced expiratory volume in 1 s (FEV1) means (59.4%) and only 39.6% knew their most recent FEV1; the exception was respondents with cystic fibrosis who reported much greater knowledge. Respondents rated as moderately or seriously problematic: being told to keep blowing when they felt nothing is coming out (31.4%), coughing (30.4%), tiredness (26.3%) and concern about shortness of breath (20.1%). Overall, respondents found spirometry to be acceptable; however, an important minority (17%) found it difficult. Patients want clear information before, during and after the test, including information on stopping medications. Operators have an important role in increasing the ease of patients and changes to the testing environment can increase patient comfort. Patients want access to their results and want to understand how they relate to their individual health., “Why do I need spirometry and what do my results mean?”: a survey of patient experiences highlights the need for clear information before, during and after spirometry testing, and underlines the important role of operators https://bit.ly/35L1Huk

American and European societies' (ATS/ERS) criteria for spirometry are often not met in primary care. Yet, it is unknown if quality is sufficient for daily clinical use. We evaluated quality of spirometry in primary care based on clinical usefulness, meeting ATS/ERS criteria and agreement on diagnosis between general practitioners (GPs) and pulmonologists. GPs included ten consecutive spirometry tests and detailed history questionnaires of patients who underwent spirometry as part of usual care. GPs and two pulmonologists assessed the spirometry tests and questionnaires on clinical usefulness and formulated a diagnosis. In total, 149 participants covering 15 GPs were included. Low agreements were found on diagnosis between GPs and pulmonologists 1 (κ = 0.39) and 2 (κ = 0.44). GPs and pulmonologists rated >88% of the tests as clinically useful, although 13% met ATS/ERS criteria. This real-life study demonstrated that clinical usefulness of routine primary care spirometry tests was high, although agreement on diagnosis was low. ispartof: NPJ PRIMARY CARE RESPIRATORY MEDICINE vol:30 issue:1 ispartof: location:England status: published

Global Lung Function Initiative reference equations help to standardise interpretation of pulmonary function tests; however, there is a need to balance precision and generalisability with the uncertainty of interpretationhttps://bit.ly/3iheRFv

The Global Lung Function Initiative (GLI) Network has become the largest resource for reference values for routine lung function testing ever assembled. This article addresses how the GLI Network came about, why it is important, and its current challenges and future directions. It is an extension of an article published in Breathe in 2013 [1], and summarises recent developments and the future of the GLI Network. Key points The Global Lung Function Initiative (GLI) Network was established as a result of international collaboration, and altruism between researchers, clinicians and industry partners. The ongoing success of the GLI relies on network members continuing to work together to further improve how lung function is reported and interpreted across all age groups around the world. The GLI Network has produced standardised lung function reference values for spirometry and gas transfer tests. GLI reference equations should be adopted immediately for spirometry and gas transfer by clinicians and physiologists worldwide. The recently established GLI data repository will allow ongoing development and evaluation of reference values, and will offer opportunities for novel research. Educational aims To highlight the advances made by the GLI Network during the past 5 years. To highlight the importance of using GLI reference values for routine lung function testing (e.g. spirometry and gas transfer tests). To discuss the challenges that remain for developing and improving reference values for lung function tests., Learn about the GLI Network, the largest resource reference for routine lung function testing http://ow.ly/ZZor30epWgi

Background: Spirometry is the most common pulmonary function test. It is widely used in the assessment of lung function to provide objective information used in the diagnosis of lung diseases and monitoring lung health. In 2005, the American Thoracic Society and the European Respiratory Society jointly adopted technical standards for conducting spirometry. Improvements in instrumentation and computational capabilities, together with new research studies and enhanced quality assurance approaches, have led to the need to update the 2005 technical standards for spirometry to take full advantage of current technical capabilities. Methods: This spirometry technical standards document was developed by an international joint task force, appointed by the American Thoracic Society and the European Respiratory Society, with expertise in conducting and analyzing pulmonary function tests, laboratory quality assurance, and developing international standards. A comprehensive review of published evidence was performed. A patient survey was developed to capture patients’ experiences. Results: Revisions to the 2005 technical standards for spirometry were made, including the addition of factors that were not previously considered. Evidence to support the revisions was cited when applicable. The experience and expertise of task force members were used to develop recommended best practices. Conclusions: Standards and consensus recommendations are presented for manufacturers, clinicians, operators, and researchers with the aims of increasing the accuracy, precision, and quality of spirometric measurements and improving the patient experience. A comprehensive guide to aid in the implementation of these standards was developed as an online supplement.

BackgroundMeasurement of lung volumes across the life course is critical to the diagnosis and management of lung disease. The aim of the study was to use the Global Lung Function Initiative methodology to develop all-age multi-ethnic reference equations for lung volume indices determined using body plethysmography and gas dilution techniques.MethodsStatic lung volume data from body plethysmography and gas dilution techniques from individual, healthy participants were collated. Reference equations were derived using the LMS (lambda-mu-sigma) method and the generalised additive models of location shape and scale programme in R. The impact of measurement technique, equipment type and being overweight or obese on the derived lung volume reference ranges was assessed.ResultsData from 17 centres were submitted and reference equations were derived from 7190 observations from participants of European ancestry between the ages of 5 and 80 years. Data from non-European ancestry populations were insufficient to develop multi-ethnic equations. Measurements of functional residual capacity (FRC) collected using plethysmography and dilution techniques showed physiologically insignificant differences and were combined. Sex-specific reference equations including height and age were developed for total lung capacity (TLC), FRC, residual volume (RV), inspiratory capacity, vital capacity, expiratory reserve volume and RV/TLC. The derived equations were similar to previously published equations for FRC and TLC, with closer agreement during childhood and adolescence than in adulthood.ConclusionsGlobal Lung Function Initiative reference equations for lung volumes provide a generalisable standard for reporting and interpretation of lung volumes measurements in individuals of European ancestry.

DL,CO measurements are often used to evaluate and monitor lung diseases as well as cardiovascular diseases. Whether the combination of DL,CO and DL,NO will improve the management of cardiovascular diseases needs to be investigated. It is hoped that the standardization of the DL,NO measurement will facilitate research. Scientific evidence that DL,NO can provide more accurate information than DL,CO alone, can take away the barriers that prevents DL,NO to become a routine test in pulmonology.

Introduction: In the diagnosis of lung diseases, FEV1/FVC and FEV1 are important parameters. An FEV1/FVC below the normal range implies airway obstruction. FEV1 with a Z-score of -1.64 or less could also indicate pathology. This would also apply to an accelerated rate of decline of FEV1. Workers who are exposed to smoke, dust or gases are often periodically examined by means of spirometry. This makes it possible to determine the rate of decline of FEV1. Method: 23 male workers (31-63 years of age) employed in a paint factory, have participated in a periodic screening programme, every other year over 8 to 34 years (mean 19 years). Among other tests, spirometry was performed. FEV1/FVC and FEV1 Z-score of the last spirometry were compared to the rate of decline of FEV1 in ml/year for each subject. The rate of decline was calculated from the data of the preceding years (“Spirola” NIOSH, 2014) with an average period of 9 years and 9 measurements. Results: Regression analysis showed no relationship between the rate of decline of FEV1 and FEV1/FVC (r= 0,01, p = 0,94), A significant but weak correlation with FEV1 Z-score was found (r= 0,44, p = 0,036). Conclusion: Pathology could be missed in many individuals if de rate of decline of FEV1 is not taken into account (see figure). Therefore the determination of the rate of decline of FEV1 has added value.

In their article on the diagnosis of chronic obstructive pulmonary disease (COPD) in primary care, Conway and colleagues state that the diagnosis can be confirmed by a low FEV1/FVC (forced expiratory volume in one second/forced vital capacity) ratio,1 with a ratio

The most commonly used pulmonary function test is spirometry. This test measures how much air you can breathe in and out and how quickly you can move air out of your lungs. Spirometry is a powerful tool for the diagnosis and monitoring of asthma and COPD and its use is recommended by international guidelines for asthma and COPD [1–3]. The updated NICE guidelines of 2010 state that all health professionals managing patients with COPD should have access to spirometry and must be trained and competent in its use and interpretation. The increased availability of spirometers has led to improved access in primary care. Spirometry appears to be a simple test; however, it depends upon the quality of equipment and patient cooperation and, foremost, requires highly trained and competent staff to perform and evaluate the test correctly. Many European countries have shown a growing interest to regulate the quality of spirometry education. The American Thoracic Society/European Respiratory Society (ERS) Task Force on Standardisation of Lung Function Testing [4] recommends a standard training similar to the National Institute for Occupational Safety and Health-approved spirometry programme in the USA, which includes the fundamentals of spirometry standards and hands-on training. Competency is demonstrated by passing a written and practical examination in the presence of an experienced instructor. To assess the current situation of spirometry training in Europe, an online survey was carried out in 2008 by the ERS. This survey showed that, due to a lack of well-structured training opportunities, 94% of the respondents identified a need for standardised training courses. The results of this survey launched the European Spirometry Driving Licence (ESDL) HERMES (Harmonised Education of Respiratory Medicine in European Specialties) project. The aim …

[Graphic][1] A great sense of loss and sadness marked the recent death of Philip Quanjer, who passed away peacefully at his home in Nijverdal, the Netherlands on July 26, 2017 after a long and courageous battle against cancer, during which he defied all odds in order to complete the tasks he had set himself. Philip was a highly respected member of the global respiratory community, who devoted his life to understanding and describing lung health, remaining highly active in his field up to a few weeks before his death. Indeed, after “retiring” in 1997, he went on to publish a further 90 papers, an astonishing 55 of which being published during the last five years of his life. His efforts since the 1980s to improve the standard of lung function testing and develop more reliable reference values with which to interpret the results of such tests have won him international acclaim and immense respect and admiration from the global respiratory community. Such developments were essential in order to improve early detection of respiratory disease, irrespective of age, sex or ethnic background, and to clarify what factors impact negatively on lung development. Philip was born on September 12, 1936 in Pontianak (Netherlands East Indies, now Indonesia) and spent his formative years in a Japanese concentration camp (where he learnt to swim in crocodile infested rivers!) until liberation in 1945. His first two years of formal education, which did not commence until he was nine years of age, were spent in Thailand and Indonesia before his family returned to the Netherlands in 1948. Philip met the love of his life and future wife, Else Meijerink, while they were both high school students. They married in 1960, while he was still a student at Groningen University medical school (1955–1963), had four children (two sons … [1]: /embed/inline-graphic-1.gif

Diffusing capacity of the lung for nitric oxide (DLNO), otherwise known as the transfer factor, was first measured in 1983. This document standardises the technique and application of single-breathDLNO. This panel agrees that 1) pulmonary function systems should allow for mixing and measurement of both nitric oxide (NO) and carbon monoxide (CO) gases directly from an inspiratory reservoir just before use, with expired concentrations measured from an alveolar “collection” or continuously sampledviarapid gas analysers; 2) breath-hold time should be 10 s with chemiluminescence NO analysers, or 4–6 s to accommodate the smaller detection range of the NO electrochemical cell; 3) inspired NO and oxygen concentrations should be 40–60 ppm and close to 21%, respectively; 4) the alveolar oxygen tension (PAO2) should be measured by sampling the expired gas; 5) a finite specific conductance in the blood for NO (θNO) should be assumed as 4.5 mL·min-1·mmHg-1·mL-1of blood; 6) the equation for 1/θCO should be (0.0062·PAO2+1.16)·(ideal haemoglobin/measured haemoglobin) based on breath-holdingPAO2and adjusted to an average haemoglobin concentration (male 14.6 g·dL−1, female 13.4 g·dL−1); 7) a membrane diffusing capacity ratio (DMNO/DMCO) should be 1.97, based on tissue diffusivity.

“ If we are to achieve results never before accomplished, we must expect to employ methods never before attempted ” Sir Francis Bacon 1561–1626. British aviators Alcock and Brown made the first transatlantic flight in 1919 – In 2013, the total number of flights in Europe was 9.5 million. In July 1969, Apollo 11 Commander Neil Armstrong landed on the moon – today you can book your flight to space online with Virgin Galactic. Throughout the 1990s, medical education was transformed as a direct consequence of more complex patient needs and the reorganisation of healthcare delivery. Medical education refers to the educational process required to prepare the medical professional for entry into practice as well as provision of educational activities for lifelong learning. This educational process is aimed at physicians, nurses, technicians, physiotherapists, scientists and other related professions who deliver care to the patient and public. Today’s medical professional is bound by demanding healthcare systems [1–3], internationalisation of localised diseases [4], shorter more intense training periods and dependence on medical technology [5]. Global funds, trade and networks are all examples of initiatives that demonstrate our entry into an international, mobile era. In 1993, the European Council (EU) council directive 93/16 stipulated that those EU nationals holding an EU primary or specialist medical qualification were to be allowed to practice within any EU country [6]. We are aware that many European countries are heavily reliant on foreign-trained medical staff to support their medical systems [7]. Patient tourism has also warranted attention [8], as more and more patients opt to cross international borders in search of treatment. The European Respiratory Society (ERS) International Congress welcomes respiratory health professionals from all over the world. As a provider of continuous …

Screening and case-finding strategies in chronic obstructive pulmonary disease (COPD) remain controversial, with strong opinions all over, and with any statement raising both interest and criticism. Yet, the success of an earlier diagnosis would undoubtedly produce substantial public health benefits. Expert consensus states that there are 210 million people in the world suffering from COPD [1], although these world estimates could be soon modified [2, 3]. Whatever the number, the vast majority of individuals with COPD (70–90%) are as yet undiagnosed [4], and therefore not receiving any medical care whatsoever. Even more importantly, many continue to smoke and/or are exposed to other risk factors. Therefore, any effective strategy to reduce COPD underdiagnosis is urgently needed. In this issue of the European Respiratory Journal , Jithoo et al . [5] report on a collateral work from the landmark Burden of Lung Disease (BOLD) study, this time with a particular focus on the cost-effectiveness of different population case-finding strategies for COPD. They conclude that screening by using a simple pre-bronchodilator (BD) peak expiratory flow (PEF) measurement has the potential to serve as a cost-effective way to identify individuals most likely to benefit from confirmatory spirometry. Following the guidance of an earlier report [6], these authors expand on the PEF option with a sophisticated analysis, by …

1. Terragni PP, Rosboch G, Tealdi A, Corno E, Menaldo E, Davini O, Gandini G, Herrmann P, Mascia L, Quintel M, Slutsky AS, Gattinoni L, Ranieri VM. Tidal hyperinflation during low tidal volume ventilation in acute respiratory distress syndrome. Am J Respir Crit Care Med 2007;175:160–166. 2. HagerDN,Krishnan JA,HaydenDL, BrowerRG. Tidal volume reduction in patients with acute lung injury when plateau pressures are not high. Am J Respir Crit Care Med 2005;172:1241–1245. 3. Rouby JJ, Brochard L. Tidal recruitment and overinflation in acute respiratory distress syndrome: yin and yang. Am J Respir Crit Care Med 2007; 175:104–106.