Interpretation of 2021 ERS/ATS interpretive strategies for routine lung function tests_Chinese Journal of Evidence-Based Medicine

Authors：

LI Yun ^1,2 , GAO Yi ^1,2 ,  ZHENG Jinping ^1,2

1. Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, P. R. China;
2. State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, National Center for Respiratory Medicine, Guangzhou 510120, P. R. China;

Corresponding author：

ZHENG Jinping, Email: jpzhenggy@163.com

Keywords：

Pulmonary function test; Interpretive strategy; Guideline; Interpretation

DOI：

10.7507/1672-2531.202206044

Video：

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In 2005, interpretative strategies for pulmonary function tests were issued jointly by the American Thoracic Society (ATS) and the European Respiratory Society (ERS), and they have since been updated in 2021. In this article, we introduced the updated key points, including reference equations and normal limits, natural changes in lung function over time, bronchodilator responsiveness testing, the classification of physiological impairments, and the severity of lung function impairment. We also put forward some suggestions from the viewpoint of our national conditions. We expected it to provide useful references for those concerned with the application of pulmonary function tests in China.

Citation： LI Yun, GAO Yi, ZHENG Jinping. Interpretation of 2021 ERS/ATS interpretive strategies for routine lung function tests. Chinese Journal of Evidence-Based Medicine, 2022, 22(12): 1375-1381. doi: 10.7507/1672-2531.202206044 Copy

1.	Miller MR, Hankinson J, Brusasco V, et al. Standardisation of spirometry. Eur Respir J, 2005, 26(2): 319-338.
2.	Wanger J, Clausen JL, Coates A, et al. Standardisation of the measurement of lung volumes. Eur Respir J, 2005, 26(3): 511-522.
3.	Macintyre N, Crapo RO, Viegi G, et al. Standardisation of the single-breath determination of carbon monoxide uptake in the lung. Eur Respir J, 2005, 26(4): 720-735.
4.	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): 1600016.
5.	中华医学会呼吸病学分会肺功能专业组. 肺功能检查指南(第二部分)-肺量计检查. 中华结核和呼吸杂志, 2014, 37(7): 481-486.
6.	中华医学会呼吸病学分会肺功能专业组. 肺功能检查指南(第三部分)––组织胺和乙酰甲胆碱支气管激发试验. 中华结核和呼吸杂志, 2014, 37(8): 566-571.
7.	高怡, 韩江娜, 蒋雷服, 等. 肺功能检查指南(第四部分)-支气管舒张试验. 中华结核和呼吸杂志, 2014, 37(9): 655-658.
8.	中华医学会呼吸病学分会肺功能专业组. 肺功能检查指南–肺弥散功能检查. 中华结核和呼吸杂志, 2015, 38(3): 164-169.
9.	中华医学会呼吸病学分会肺功能专业组. 肺功能检查指南-肺容量检查. 中华结核和呼吸杂志, 2015, 38(4): 255-260.
10.	中华医学会呼吸病学分会肺功能专业组. 肺功能检查指南-呼气峰值流量及其变异率检查. 中华结核和呼吸杂志, 2017, 40(6): 426-430.
11.	中华医学会呼吸病学分会肺功能专业组. 肺功能检查指南-体积描记法肺容量和气道阻力检查. 中华结核和呼吸杂志, 2015, 38(5): 342-347.
12.	Pellegrino R, Viegi G, Brusasco V, et al. Interpretative strategies for lung function tests. Eur Respir J, 2005, 26(5): 948-968.
13.	Culver BH, Graham BL, Coates AL, et al. Recommendations for a standardized pulmonary function report. an official American Thoracic Society technical statement. Am J Respir Crit Care Med, 2017, 196(11): 1463-1472.
14.	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(1): 2101499.
15.	中国呼吸医师协会肺功能与临床呼吸生理工作委员会, 中华医学会呼吸病学分会呼吸治疗学组. 肺功能检查报告规范-肺量计检查,支气管舒张试验,支气管激发试验. 中华医学杂志, 2019, 99(22): 1681-1691.
16.	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(6): 1324-1343.
17.	Stanojevic S, Graham BL, Cooper BG, et al. Official ERS technical standards: global lung function initiative reference values for the carbon monoxide transfer factor for Caucasians. Eur Respir J, 2017, 50(3): 1700010.
18.	Hall GL, Filipow N, Ruppel G, et al. Official ERS technical standard: global lung function initiative reference values for static lung volumes in individuals of European ancestry. Eur Respir J, 2021, 57(3): 2000289.
19.	Jian W, Gao Y, Hao C, et al. Reference values for spirometry in Chinese aged 4-80 years. J Thorac Dis, 2017, 9(11): 4538-4549.
20.	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(1): 52-59.
21.	Oelsner EC, Balte PP, Bhatt SP, et al. Lung function decline in former smokers and low-intensity current smokers: a secondary data analysis of the NHLBI Pooled Cohorts Study. Lancet Respir Med, 2020, 8(1): 34-44.
22.	Redlich CA, Tarlo SM, Hankinson JL, et al. Official American Thoracic Society technical standards: spirometry in the occupational setting. Am J Respir Crit Care Med, 2014, 189(8): 983-993.
23.	Miller MR, Pedersen OF. New concepts for expressing forced expiratory volume in 1 s arising from survival analysis. Eur Respir J, 2010, 35(4): 873-882.
24.	Pedone C, Scarlata S, Scichilone N, et al. Alternative ways of expressing FEV1 and mortality in elderly people with and without COPD. Eur Respir J, 2013, 41(4): 800-805.
25.	Huang TH, Hsiue TR, Lin SH, et al. Comparison of different staging methods for COPD in predicting outcomes. Eur Respir J, 2018, 51(3): 1700577.
26.	Stanojevic S, Filipow N, Ratjen F. Paediatric reproducibility limits for the forced expiratory volume in 1 s. Thorax, 2020, 75(10): 891-896.
27.	Graham BL, Steenbruggen I, Miller MR, 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(8): e70-e88.
28.	Tan WC, Vollmer WM, Lamprecht B, et al. Worldwide patterns of bronchodilator responsiveness: results from the burden of obstructive lung disease study. Thorax, 2012, 67(8): 718-726.
29.	Quanjer PH, Ruppel GL, Langhammer A, et al. Bronchodilator response in FVC is larger and more relevant than in FEV1 in severe airflow obstruction. Chest, 2017, 151(5): 1088-1098.
30.	Singh D, Agusti A, Anzueto A, et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive lung disease: the GOLD science committee report 2019. Eur Respir J, 2019, 53(5): 1900164.
31.	Qaseem A, Wilt TJ, Weinberger SE, et al. Diagnosis and management of stable chronic obstructive pulmonary disease: a clinical practice guideline update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society. Ann Intern Med, 2011, 155(3): 179-191.
32.	Pellegrino R, Brusasco V, Miller MR. Question everything. Eur Respir J, 2014, 43(4): 947-948.
33.	Ronish BE, Couper DJ, Barjaktarevic IZ, et al. Forced expiratory flow at 25%-75% links COPD physiology to emphysema and disease severity in the SPIROMICS cohort. Chronic Obstr Pulm Dis, 2022, 9(2): 111-121.
34.	Yee N, Markovic D, Buhr RG, et al. Significance of FEV3/FEV6 in recognition of early airway disease in smokers at risk of development of COPD: analysis of the SPIROMICS cohort. Chest, 2022, 161(4): 949-959.
35.	Zimmermann SC, Tonga KO, Thamrin C. Dismantling airway disease with the use of new pulmonary function indices. Eur Respir Rev, 2019, 28(151): 180122.
36.	Green M, Mead J, Turner JM. Variability of maximum expiratory flow-volume curves. J Appl Physiol, 1974, 37(1): 67-74.
37.	Forno E, Weiner DJ, Mullen J, et al. Obesity and airway dysanapsis in children with and without asthma. Am J Respir Crit Care Med, 2017, 195(3): 314-323.
38.	Thompson BR. Dysanapsis-once believed to be a physiological curiosity-is now clinically important. Am J Respir Crit Care Med, 2017, 195(3): 277-278.
39.	Smith BM, Kirby M, Hoffman EA, et al. Association of dysanapsis with chronic obstructive pulmonary disease among older adults. JAMA, 2020, 323(22): 2268-2280.
40.	Marott JL, Ingebrigtsen TS, Çolak Y, et al. Trajectory of preserved ratio impaired spirometry: natural history and long-term prognosis. Am J Respir Crit Care Med, 2021, 204(8): 910-920.
41.	Fortis S, Comellas A, Kim V, et al. Low FVC/TLC in preserved ratio impaired spirometry (PRISm) is associated with features of and progression to obstructive lung disease. Sci Rep, 2020, 10(1): 5169.
42.	Wan ES, Fortis S, Regan EA, et al. Longitudinal phenotypes and mortality in preserved ratio impaired spirometry in the COPDGene study. Am J Respir Crit Care Med, 2018, 198(11): 1397-1405.
43.	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(3): 253-260.
44.	Quanjer PH, Pretto JJ, Brazzale DJ, et al. Grading the severity of airways obstruction: new wine in new bottles. Eur Respir J, 2014, 43(2): 505-512.
45.	Miller MR, Cooper BG. Reduction in T LCO and survival in a clinical population. Eur Respir J, 2021, 58(5): 2002046.
46.	郑劲平, 梁晓林. “美国胸科学会推荐的标准化肺功能报告”之解读和商榷. 中国循证医学杂志, 2018, 18(3): 249-253.
47.	Topalovic M, Das N, Burgel PR, et al. Artificial intelligence outperforms pulmonologists in the interpretation of pulmonary function tests. Eur Respir J, 2019, 53(4): 1801660.
48.	Das N, Verstraete K, Stanojevic S, et al. Deep-learning algorithm helps to standardise ATS/ERS spirometric acceptability and usability criteria. Eur Respir J, 2020, 56(6): 2000603.
49.	Wang Y, Li Q, Chen W, et al. Deep learning-based analytic models based on flow-volume curves for identifying ventilatory patterns. Front Physiol, 2022, 13: 824000.
50.	Wang Y, Li Y, Chen W, et al. Deep learning for automatic upper airway obstruction detection by analysis of flow-volume curve. Respiration, 2022, 101(9): 841-850.
51.	Wang Y, Chen W, Li Y, et al. Clinical analysis of the "small plateau" sign on the flow-volume curve followed by deep learning automated recognition. BMC Pulm Med, 2021, 21(1): 359.

1. Miller MR, Hankinson J, Brusasco V, et al. Standardisation of spirometry. Eur Respir J, 2005, 26(2): 319-338.
2. Wanger J, Clausen JL, Coates A, et al. Standardisation of the measurement of lung volumes. Eur Respir J, 2005, 26(3): 511-522.
3. Macintyre N, Crapo RO, Viegi G, et al. Standardisation of the single-breath determination of carbon monoxide uptake in the lung. Eur Respir J, 2005, 26(4): 720-735.
4. 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): 1600016.
5. 中华医学会呼吸病学分会肺功能专业组. 肺功能检查指南(第二部分)-肺量计检查. 中华结核和呼吸杂志, 2014, 37(7): 481-486.
6. 中华医学会呼吸病学分会肺功能专业组. 肺功能检查指南(第三部分)––组织胺和乙酰甲胆碱支气管激发试验. 中华结核和呼吸杂志, 2014, 37(8): 566-571.
7. 高怡, 韩江娜, 蒋雷服, 等. 肺功能检查指南(第四部分)-支气管舒张试验. 中华结核和呼吸杂志, 2014, 37(9): 655-658.
8. 中华医学会呼吸病学分会肺功能专业组. 肺功能检查指南–肺弥散功能检查. 中华结核和呼吸杂志, 2015, 38(3): 164-169.
9. 中华医学会呼吸病学分会肺功能专业组. 肺功能检查指南-肺容量检查. 中华结核和呼吸杂志, 2015, 38(4): 255-260.
10. 中华医学会呼吸病学分会肺功能专业组. 肺功能检查指南-呼气峰值流量及其变异率检查. 中华结核和呼吸杂志, 2017, 40(6): 426-430.
11. 中华医学会呼吸病学分会肺功能专业组. 肺功能检查指南-体积描记法肺容量和气道阻力检查. 中华结核和呼吸杂志, 2015, 38(5): 342-347.
12. Pellegrino R, Viegi G, Brusasco V, et al. Interpretative strategies for lung function tests. Eur Respir J, 2005, 26(5): 948-968.
13. Culver BH, Graham BL, Coates AL, et al. Recommendations for a standardized pulmonary function report. an official American Thoracic Society technical statement. Am J Respir Crit Care Med, 2017, 196(11): 1463-1472.
14. 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(1): 2101499.
15. 中国呼吸医师协会肺功能与临床呼吸生理工作委员会, 中华医学会呼吸病学分会呼吸治疗学组. 肺功能检查报告规范-肺量计检查,支气管舒张试验,支气管激发试验. 中华医学杂志, 2019, 99(22): 1681-1691.
16. 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(6): 1324-1343.
17. Stanojevic S, Graham BL, Cooper BG, et al. Official ERS technical standards: global lung function initiative reference values for the carbon monoxide transfer factor for Caucasians. Eur Respir J, 2017, 50(3): 1700010.
18. Hall GL, Filipow N, Ruppel G, et al. Official ERS technical standard: global lung function initiative reference values for static lung volumes in individuals of European ancestry. Eur Respir J, 2021, 57(3): 2000289.
19. Jian W, Gao Y, Hao C, et al. Reference values for spirometry in Chinese aged 4-80 years. J Thorac Dis, 2017, 9(11): 4538-4549.
20. 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(1): 52-59.
21. Oelsner EC, Balte PP, Bhatt SP, et al. Lung function decline in former smokers and low-intensity current smokers: a secondary data analysis of the NHLBI Pooled Cohorts Study. Lancet Respir Med, 2020, 8(1): 34-44.
22. Redlich CA, Tarlo SM, Hankinson JL, et al. Official American Thoracic Society technical standards: spirometry in the occupational setting. Am J Respir Crit Care Med, 2014, 189(8): 983-993.
23. Miller MR, Pedersen OF. New concepts for expressing forced expiratory volume in 1 s arising from survival analysis. Eur Respir J, 2010, 35(4): 873-882.
24. Pedone C, Scarlata S, Scichilone N, et al. Alternative ways of expressing FEV1 and mortality in elderly people with and without COPD. Eur Respir J, 2013, 41(4): 800-805.
25. Huang TH, Hsiue TR, Lin SH, et al. Comparison of different staging methods for COPD in predicting outcomes. Eur Respir J, 2018, 51(3): 1700577.
26. Stanojevic S, Filipow N, Ratjen F. Paediatric reproducibility limits for the forced expiratory volume in 1 s. Thorax, 2020, 75(10): 891-896.
27. Graham BL, Steenbruggen I, Miller MR, 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(8): e70-e88.
28. Tan WC, Vollmer WM, Lamprecht B, et al. Worldwide patterns of bronchodilator responsiveness: results from the burden of obstructive lung disease study. Thorax, 2012, 67(8): 718-726.
29. Quanjer PH, Ruppel GL, Langhammer A, et al. Bronchodilator response in FVC is larger and more relevant than in FEV1 in severe airflow obstruction. Chest, 2017, 151(5): 1088-1098.
30. Singh D, Agusti A, Anzueto A, et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive lung disease: the GOLD science committee report 2019. Eur Respir J, 2019, 53(5): 1900164.
31. Qaseem A, Wilt TJ, Weinberger SE, et al. Diagnosis and management of stable chronic obstructive pulmonary disease: a clinical practice guideline update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society. Ann Intern Med, 2011, 155(3): 179-191.
32. Pellegrino R, Brusasco V, Miller MR. Question everything. Eur Respir J, 2014, 43(4): 947-948.
33. Ronish BE, Couper DJ, Barjaktarevic IZ, et al. Forced expiratory flow at 25%-75% links COPD physiology to emphysema and disease severity in the SPIROMICS cohort. Chronic Obstr Pulm Dis, 2022, 9(2): 111-121.
34. Yee N, Markovic D, Buhr RG, et al. Significance of FEV3/FEV6 in recognition of early airway disease in smokers at risk of development of COPD: analysis of the SPIROMICS cohort. Chest, 2022, 161(4): 949-959.
35. Zimmermann SC, Tonga KO, Thamrin C. Dismantling airway disease with the use of new pulmonary function indices. Eur Respir Rev, 2019, 28(151): 180122.
36. Green M, Mead J, Turner JM. Variability of maximum expiratory flow-volume curves. J Appl Physiol, 1974, 37(1): 67-74.
37. Forno E, Weiner DJ, Mullen J, et al. Obesity and airway dysanapsis in children with and without asthma. Am J Respir Crit Care Med, 2017, 195(3): 314-323.
38. Thompson BR. Dysanapsis-once believed to be a physiological curiosity-is now clinically important. Am J Respir Crit Care Med, 2017, 195(3): 277-278.
39. Smith BM, Kirby M, Hoffman EA, et al. Association of dysanapsis with chronic obstructive pulmonary disease among older adults. JAMA, 2020, 323(22): 2268-2280.
40. Marott JL, Ingebrigtsen TS, Çolak Y, et al. Trajectory of preserved ratio impaired spirometry: natural history and long-term prognosis. Am J Respir Crit Care Med, 2021, 204(8): 910-920.
41. Fortis S, Comellas A, Kim V, et al. Low FVC/TLC in preserved ratio impaired spirometry (PRISm) is associated with features of and progression to obstructive lung disease. Sci Rep, 2020, 10(1): 5169.
42. Wan ES, Fortis S, Regan EA, et al. Longitudinal phenotypes and mortality in preserved ratio impaired spirometry in the COPDGene study. Am J Respir Crit Care Med, 2018, 198(11): 1397-1405.
43. 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(3): 253-260.
44. Quanjer PH, Pretto JJ, Brazzale DJ, et al. Grading the severity of airways obstruction: new wine in new bottles. Eur Respir J, 2014, 43(2): 505-512.
45. Miller MR, Cooper BG. Reduction in T LCO and survival in a clinical population. Eur Respir J, 2021, 58(5): 2002046.
46. 郑劲平, 梁晓林. “美国胸科学会推荐的标准化肺功能报告”之解读和商榷. 中国循证医学杂志, 2018, 18(3): 249-253.
47. Topalovic M, Das N, Burgel PR, et al. Artificial intelligence outperforms pulmonologists in the interpretation of pulmonary function tests. Eur Respir J, 2019, 53(4): 1801660.
48. Das N, Verstraete K, Stanojevic S, et al. Deep-learning algorithm helps to standardise ATS/ERS spirometric acceptability and usability criteria. Eur Respir J, 2020, 56(6): 2000603.
49. Wang Y, Li Q, Chen W, et al. Deep learning-based analytic models based on flow-volume curves for identifying ventilatory patterns. Front Physiol, 2022, 13: 824000.
50. Wang Y, Li Y, Chen W, et al. Deep learning for automatic upper airway obstruction detection by analysis of flow-volume curve. Respiration, 2022, 101(9): 841-850.
51. Wang Y, Chen W, Li Y, et al. Clinical analysis of the "small plateau" sign on the flow-volume curve followed by deep learning automated recognition. BMC Pulm Med, 2021, 21(1): 359.

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