Skip to main content

Main menu

  • Home
  • Current issue
  • ERJ Early View
  • Past issues
  • Authors/reviewers
    • Instructions for authors
    • Submit a manuscript
    • Open access
    • COVID-19 submission information
    • Peer reviewer login
  • Alerts
  • Podcasts
  • Subscriptions
  • ERS Publications
    • European Respiratory Journal
    • ERJ Open Research
    • European Respiratory Review
    • Breathe
    • ERS Books
    • ERS publications home

User menu

  • Log in
  • Subscribe
  • Contact Us
  • My Cart
  • Log out

Search

  • Advanced search
  • ERS Publications
    • European Respiratory Journal
    • ERJ Open Research
    • European Respiratory Review
    • Breathe
    • ERS Books
    • ERS publications home

Login

European Respiratory Society

Advanced Search

  • Home
  • Current issue
  • ERJ Early View
  • Past issues
  • Authors/reviewers
    • Instructions for authors
    • Submit a manuscript
    • Open access
    • COVID-19 submission information
    • Peer reviewer login
  • Alerts
  • Podcasts
  • Subscriptions

Coming together: the ATS/ERS consensus on clinical pulmonary function testing

V. Brusasco, R. Crapo, G. Viegi
European Respiratory Journal 2005 26: 1-2; DOI: 10.1183/09031936.05.00034205
V. Brusasco
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
R. Crapo
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
G. Viegi
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Info & Metrics
  • PDF
Loading

Since 1979, guidelines for standardising pulmonary function tests have been published and updated by both the American Thoracic Society (ATS) 1–6 and the European Respiratory Society (ERS) 7–9. In addition, several joint ATS/ERS workshops on pulmonary function testing have been held and the resulting reports published 10, 11. In 1995, European scientists participated in the ATS updates of standards for spirometry and single-breath carbon monoxide diffusing capacity of the lung (DL,CO), but no joint statement has been published by the two societies. Although generally concordant, the spirometry and DL,CO guidelines published separately by the ATS and the ERS differed in some aspects that were of appreciable importance. Official guidelines for the measurement of lung volumes were made available by the ERS 7, 10, but not the ATS.

In recent years, global initiatives were undertaken for the diagnosis and treatment of pulmonary diseases, and the worldwide market for instruments to test lung function widened considerably. This increased the pressure for more uniform pulmonary function testing across the world, and prompted the ATS and the ERS to appoint a joint Task Force to provide new combined standards for clinical pulmonary function testing, with the hope that they will be accepted by other respiratory societies. A new Task Force on pulmonary function testing, implemented by the Forum of International Respiratory Societies (FIRS), has recently started its work based on the ATS/ERS documents.

Our Task Force consisted of 19 scientists with recognised expertise in pulmonary function testing. The group worked on a “one-draft” system, in which each of five sections was assigned to a small subgroup and eventually discussed by the whole committee. There was a general feeling that previous standards published by the two societies tended to be difficult to use because of their overwhelming details and the lack of a user-friendly indexing system. Therefore, one of the goals was a change in format, including a more comprehensive indexing system. We worked hard to make it easy for people to quickly find what they need.

From its beginning in 2001 (a “new millennium project”) to the final approval in 2005, the Task Force met many times and had some tough negotiations, both face to face and by e-mail or conference call. We count it as one of our successes that all participants stayed in the process until reasonable solutions were found. As agreed, the new standards are due to appear as a series in five consecutive issues of the European Respiratory Journal, starting from the current one, which discusses general considerations for lung function testing 12.

The spirometry section 13, mainly drafted by M.R. Miller and J. Hankinson, is a model of clean user-friendly prose, which walks the reader through all the important elements of the test, from instrument to procedure quality control. One of the major steps forward is the recommendation that a standardised computer output format should be available on all instruments. This does not require equipment manufacturers to store their data in a specific format, but it does require them to provide a means of delivering the data in a standard way. This means that users won't be tied to a specific manufacturer in order to maintain their database structure. It also means that it will be relatively easy to write software to move spirometric data into healthcare databases where they can be used to monitor and guide therapy for patients with lung diseases. Such data can also be used for clinical research, including research into the efficacy of using pulmonary function tests in managing patients. Furthermore, International Organization for Standardization metrology terminology (www.iso.org) has been adopted.

The section on measurement of single-breath carbon monoxide uptake in the lung (i.e. DL,CO) 14, mainly drafted by N. MacIntyre, R. Crapo, G. Viegi, D.C. Johnson and C.P.M. van der Grinten, stirred up some controversy first in the drafting of the document and again in the comments received from reviewers. The areas of concern were primarily related to adjustments of DL,CO for lung volume (i.e. the use of DL,CO/alveolar volume (VA)) and how to interpret unadjusted and adjusted values if the decision was to adjust for lung volume. All agreed that the DL,CO relationship to VA is complex, and that the simple DL,CO/VA value does not necessarily “correct” for a reduced DL,CO in the setting of a comparably reduced VA. There was also a significant discussion over how to deal with adjustments for haemoglobin and carboxyhaemoglobin concentrations. Upon recognition that adjustments for haemoglobin are under-utilised, we decided to adjust for these, but the adjustments need to be made to the predicted rather than the measured values. After the document was finalised, several committee members were informally polled to find out how they personally use DL,CO/VA. The responses mirrored the review process. There was wide variation, ranging from “do not use it at all” and “do not print it on the report” to saying something about it on every interpretation. This variation amongst committee members suggests that more research on the clinical utility of DL,CO/VA is required, to be possibly included in a future version. The decision to use the term DL,CO rather than the carbon monoxide transfer factor (TL,CO) was not controversial until the document went for outside review. Everyone on the Task Force understood that TL,CO is more correct from a terminology and scientific standpoint, but perhaps it was the long history of DL,CO and its common usage that gave it the edge. Exercise and positional changes in DL,CO were not addressed, although it was recognised that they may provide an assessment of capillary recruitment and might, therefore, be useful clinically, and this may be another addition for a future version.

The lung volume section 15, mainly drafted by J. Wanger, J.L. Clausen, A. Coates and O.F. Pedersen, largely reflects a document that was produced after an international workshop held in 1990, funded by the National Heart Lung and Blood Institute (NHLBI). That document was very large and never published in full print, but those interested in all the details can find it posted on the ATS website 16. In the new document, the relevant technical aspects and the limitations of the methods currently available for lung volume measurements are summarised in a user-friendly way. The position of lung volume measurements in the diagnosis of respiratory disorders and their cost-to-benefit ratio were probably the most controversial aspects of the Task Force.

The section on interpretative strategies 17, mainly drafted by R. Pellegrino, G. Viegi, P. Enright, V. Brusasco and R. Crapo, generated rather strong controversy, but only in a couple of areas. It emphasises the importance of selecting appropriate reference values and lower limits of the normal range, and provides a good listing of available reference studies with suggestions for dealing with ethnicity. Nevertheless, the committee realised that no single set of reference values can be recommended and more work will be necessary in this area. A detailed interpretative algorithm is presented, outlying the position of each test for a state-of-the-art diagnostic procedure in large hospital-based laboratories. Its use is not intended as mandatory and simpler assessments of pulmonary function are acceptable in different settings, keeping in mind the limitations that are inherent to simplicity. The assessment of reversibility of bronchoconstriction is covered in more detail than in previous documents, with reminders that a number of chronic obstructive pulmonary disease patients are more likely to respond with improvements of lung volumes than forced expiratory volume in one second.

As for any recommended standard, this one is not perfect, but reflects the current knowledge in the field. Therefore, it should be used as a guide for good clinical practice until changes are made based on new scientific evidence. A future goal would be the creation of standard pulmonary function reports, which present the relevant data in a format that enables an “easy interpretation and digestion of the information” 18.

Acknowledgments

On behalf of the whole group, we wish to thank E. Wouters (Maastricht, Netherlands) for the initial input to the project and B. Culver (Seattle, WA, USA) for the useful suggestions for revision. We are also indebted to P. Silvi (Pisa, Italy) and J. Embry (Salt Lake City, UT, USA) for editorial assistance.

    • © ERS Journals Ltd

    References

    1. ↵
      American Thoracic Society. Snowbird workshop on standardization of spirometry. Am Rev Respir Dis 1979;119:831–838.
      OpenUrlPubMedWeb of Science
    2. American Thoracic Society. Standardization of Spirometry. 1987 update. Am Rev Respir Dis 1987;136:1285–1298.
      OpenUrlCrossRefPubMedWeb of Science
    3. American Thoracic Society. Single breath carbon monoxide diffusing capacity (transfer factor). Recommendations for a standard technique. Am Rev Respir Dis 1987;136:1299–1307.
      OpenUrlCrossRefPubMedWeb of Science
    4. American Thoracic Society. Lung function testing: selection of reference values and interpretative strategies. Am Rev Respir Dis 1991;144:1202–1218.
      OpenUrlCrossRefPubMedWeb of Science
    5. American Thoracic Society. Standardization of spirometry: 1994 update. Am J Respir Crit Care Med 1995;152:1107–1136.
      OpenUrlCrossRefPubMedWeb of Science
    6. ↵
      American Thoracic Society. Single breath carbon monoxide diffusing capacity (transfer factor). Recommendations for a standard technique – 1995 update. Am J Respir Crit Care Med 1995;152:2185–2198.
      OpenUrlCrossRefPubMedWeb of Science
    7. ↵
      Quanjer PH, ed. Standardized lung function testing. Report Working Party Standardization of Lung Function Tests, European Community for Coal and Steel. Bull Eur Physiopathol Respir 1983;19: Suppl. 5 1–95.
    8. Quanjer PH, Tammeling GJ, Cotes JE, Pedersen OF, Peslin R, Yernault JC. Lung volumes and forced ventilatory flows. Report Working Party Standardization of Lung Function Tests, European Community for Steel and Coal. Official Statement of the European Respiratory Society. Eur Respir J 1993;6: Suppl. 16 5–40.
      OpenUrlFREE Full Text
    9. ↵
      Cotes JE, Chinn DJ, Quanjer PH, Roca J, Yernault JC. Standardization of the measurement of transfer factor (diffusing capacity). Report Working Party Standardization of Lung Function Tests, European Community for Steel and Coal. Official Statement of the European Respiratory Society. Eur Respir J 1993;6: Suppl. 16 41–52.
    10. ↵
      Stocks J, Quanjer PH. Reference values for residual volume, functional residual capacity and total lung capacity. ATS Workshop on Lung Volume Measurements. Official Statement of The European Respiratory Society. Eur Respir J 1995;8:492–506.
      OpenUrlCrossRefPubMedWeb of Science
    11. ↵
      Clausen JL, Coates AL, Quanjer PH. Measurement of lung volumes in humans: review and recommendations from an ATS/ERS workshop. Eur Respir J 1997;10:1205–1206.
      OpenUrlFREE Full Text
    12. ↵
      Miller MR, Crapo R, Hankinson J, et al. General considerations for lung function testing. Eur Respir J 2005;26:153–161.
      OpenUrlFREE Full Text
    13. ↵
      Miller MR, Hankinson J, Brusasco V, et al. Standardisation of spirometry. Eur Respir J 2005;(In press):
    14. ↵
      MacIntrye N, Crapo R, Hankinson J, et al. Standardisation of the single-breath determination of carbon monoxide uptake in the lung. Eur Respir J 2005;(In press):
    15. ↵
      Wanger J, Clausen JL, Coates A, et al. Standardisation of the measurement of lung volumes. Eur Respir J 2005;(In press):
    16. ↵
      NHLBI workshop consensus document on lung volumes. www.thoracic.org/adobe/lungvolume.pdf. Accessed: May 19 2005
    17. ↵
      Pellegrino R, Viegi G, Enright P, et al. Interpretative strategies for lung function tests. Eur Respir J 2005;(In press):
    18. ↵
      Grasbeck R. The evolution of the reference value concept. Clin Chem Lab Med 2004;42:692–697.
      OpenUrlCrossRefPubMedWeb of Science
    PreviousNext
    Back to top
    View this article with LENS
    Vol 26 Issue 1 Table of Contents
    • Table of Contents
    • Index by author
    Email

    Thank you for your interest in spreading the word on European Respiratory Society .

    NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

    Enter multiple addresses on separate lines or separate them with commas.
    Coming together: the ATS/ERS consensus on clinical pulmonary function testing
    (Your Name) has sent you a message from European Respiratory Society
    (Your Name) thought you would like to see the European Respiratory Society web site.
    CAPTCHA
    This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
    Print
    Citation Tools
    Coming together: the ATS/ERS consensus on clinical pulmonary function testing
    V. Brusasco, R. Crapo, G. Viegi
    European Respiratory Journal Jul 2005, 26 (1) 1-2; DOI: 10.1183/09031936.05.00034205

    Citation Manager Formats

    • BibTeX
    • Bookends
    • EasyBib
    • EndNote (tagged)
    • EndNote 8 (xml)
    • Medlars
    • Mendeley
    • Papers
    • RefWorks Tagged
    • Ref Manager
    • RIS
    • Zotero

    Share
    Coming together: the ATS/ERS consensus on clinical pulmonary function testing
    V. Brusasco, R. Crapo, G. Viegi
    European Respiratory Journal Jul 2005, 26 (1) 1-2; DOI: 10.1183/09031936.05.00034205
    del.icio.us logo Digg logo Reddit logo Technorati logo Twitter logo CiteULike logo Connotea logo Facebook logo Google logo Mendeley logo
    Full Text (PDF)

    Jump To

    • Article
      • Acknowledgments
      • References
    • Info & Metrics
    • PDF
    • Tweet Widget
    • Facebook Like
    • Google Plus One

    More in this TOC Section

    • SARS-CoV-2-induced senescence as a potential therapeutic target
    • Are intravenous corticosteroid pulses superior to low dose corticosteroids in patients with severe Covid-19?
    • Commemorating World Tuberculosis Day 2022
    Show more Editorial

    Related Articles

    Navigate

    • Home
    • Current issue
    • Archive

    About the ERJ

    • Journal information
    • Editorial board
    • Reviewers
    • Press
    • Permissions and reprints
    • Advertising

    The European Respiratory Society

    • Society home
    • myERS
    • Privacy policy
    • Accessibility

    ERS publications

    • European Respiratory Journal
    • ERJ Open Research
    • European Respiratory Review
    • Breathe
    • ERS books online
    • ERS Bookshop

    Help

    • Feedback

    For authors

    • Instructions for authors
    • Publication ethics and malpractice
    • Submit a manuscript

    For readers

    • Alerts
    • Subjects
    • Podcasts
    • RSS

    Subscriptions

    • Accessing the ERS publications

    Contact us

    European Respiratory Society
    442 Glossop Road
    Sheffield S10 2PX
    United Kingdom
    Tel: +44 114 2672860
    Email: journals@ersnet.org

    ISSN

    Print ISSN:  0903-1936
    Online ISSN: 1399-3003

    Copyright © 2022 by the European Respiratory Society