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Multi-ethnic reference values for spirometry for the 3–95-yr age range: the global lung function 2012 equations

Philip H. Quanjer, Sanja Stanojevic, Tim J. Cole, Xaver Baur, Graham L. Hall, Bruce H. Culver, Paul L. Enright, John L. Hankinson, Mary S.M. Ip, Jinping Zheng, Janet Stocks, the ERS Global Lung Function Initiative
European Respiratory Journal 2012 40: 1324-1343; DOI: 10.1183/09031936.00080312
Philip H. Quanjer
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  • For correspondence: pquanjer@xs4all.nl
Sanja Stanojevic
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Tim J. Cole
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Xaver Baur
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Graham L. Hall
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Bruce H. Culver
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Paul L. Enright
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John L. Hankinson
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Mary S.M. Ip
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Jinping Zheng
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Janet Stocks
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  • Figure 1–
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    Figure 1–

    Age distribution in the final sample (n=74,187) of a) Caucasians, b) African–Americans, c) North East Asians and d) South East Asians. The large number of 8-yr-olds did not lead to any bias in predicted values [14].

  • Figure 2–
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    Figure 2–

    Predicted values for a, b) forced expiratory volume in 1 s (FEV1), c, d) forced vital capacity (FVC) and e, f) FEV1/FVC by sex and ethnic group. a, c, e) Males and b, d, f) females. Graphs were generated using mean height for age in Caucasians to illustrate proportional differences between ethnic groups of the same height and age; in practice, differences in height for age further affect predicted values. The rise and fall in FEV1/FVC around adolescence is due to differential changes in FEV1 and FVC [15].

  • Figure 3–
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    Figure 3–

    Coefficient of variation (CoV) for forced expiratory volume in 1 s (FEV1) in healthy Caucasian males in four large recent studies, and in the collated Global Lungs Initiative (GLI) material. Graphs were generated using mean height for age in Caucasians to illustrate proportional differences between ethnic groups of the same height and age; in practice, ethnic differences in height for age further affect predicted values. Findings for National Health and Nutritional Examination Survey (NHANES) IV [29] and NHANES III were practically identical. SAPALDIA: Swiss Cohort Study on Air Pollution and Lung Heart Diseases in Adults; HSE: Health Survey for England.

  • Figure 4–
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    Figure 4–

    a) Age-related cross-sectional annual change in forced expiratory volume in 1 s (FEV1) is larger in tall subjects rather than short subjects. This shown for Caucasian males of height 160 cm, 175 cm and 190 cm. b) Standardising FEV1 for height by taking the ratio FEV1/heightk, where k is ∼2, largely removes differences in age-related changes between adult males and females. These findings have no bearing on within-subject longitudinal decline.

  • Figure 5–
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    Figure 5–

    Between-subject coefficients of variation (CoV) of a, b) forced expiratory volume in 1 s (FEV1), c, d) forced vital capacity (FVC) and e, f) FEV1/FVC in Caucasians, African–Americans, and North and South East Asians by age. a, c, e) Males, and b, d, f) females.

  • Figure 6–
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    Figure 6–

    The lower limit of normal (LLN), based on the 5th centile (-1.64 z-scores), values for forced expiratory volume in 1 s (FEV1) and forced vital capacity (FVC) in a) Caucasian females and b) males. As can be seen, the use of 80% of predicted as the LLN gives rise to age-related bias. Graphs were generated using mean height for age in Caucasians.

  • Figure 7–
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    Figure 7–

    Percentage of healthy male and female nonsmokers (n=74,187) in whom a) forced expiratory volume in 1 s (FEV1) is <80% predicted or b) FEV1/forced vital capacity (FVC) is <0.70. If it is assumed that FEV1/FVC is <0.70 (instead of below the 5th centile lower limit of normal) implies pathological airflow limitation, cases are missed in those <50 yrs of age, whereas over diagnosis occurs above that age. Thus, at 80 yrs of age, 20–25% of the reference population would have low values compatible with pathological airflow limitation instead of the expected 5%; this represents 75–80% false-positive test results (b).

  • Figure 8–
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    Figure 8–

    a) Illustration of how z-scores relate to percentiles. b) Pictogram showing test results as z-scores (arrows) for a male from North China, aged 34 yrs, height 166 cm. White area in the bars delineates observations that are above the mean -1.64 z-score (lower limit of normal (LLN) 5%) and light grey delineates mean -1.96 z-score (LLN 2.5%). Reproduced from [133] with permission from the publisher.

Tables

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  • Table 1– Summary of datasets included in the initial analysis#
    GroupCountriesMalesFemales
    NAge range yrsNAge range yrs
    African–American115296–8520296.1–87
    India and Pakistan228374–8630033–79
    Latin America523376.7–89.425787.4–89.7
    Mexican–American116226.2–8622826.5–87
    Iran133985–8527395–80
    Oman16386–656186–65
    North East Asia2217615.3–91452615.5–90
    South East Asia441873.3–8863713.1–92
    North Africa25416–786026–90
    Caucasian14242292.5–95288442.5–95
    Other1996.2–934745.8–91
    Total33436932.5–95540662.5–95
    • #: total sample included 97,759 subjects.

  • Table 2– Subjects in the groups for which prediction equations were derived#
    GroupMalesFemalesTotal
    NAge range yrsNAge range yrs
    Caucasian258272.5–95315682.5–9557395
    African–American15206–8520256.1–873545
    North East Asian141416–91357816–884992
    South East Asian30953.3–8651603.2–928255
    Total318564233174187
    • #: the countries of origin are listed in table E1 in the online supplementary data.

  • Table 3– Percentage difference in mean pulmonary function by sex and ethnic group compared to Caucasians
    GroupFemalesMales
    FEV1FVCFEV1/FVCFEF25–75%FEV1FVCFEV1/FVCFEF25–75%
    African–American-13.8-14.40.6-11.7-14.7-15.50.8-12.9
    North East Asian-0.7-2.11.1-7.7-2.7-3.60.9-3.2
    South East Asian-13.0-15.72.9-4.3-9.7-12.32.8-0.9
    • FEV1: forced expiratory volume in 1 s; FVC: forced vital capacity; FEF25–75%: forced expiratory flow at 25–75% of FVC.

  • Table 4– Comparison of predicted values in adult Caucasian males according to different authors
    Author [ref.]a) 17.9 yrs, 160 cmAuthor [ref.]b) 18.0 yrs, 160 cm
    FEV1FVCFEV1/FVCFEV1FVCFEV1/FVC
    Polgar [7]3.093.42NAECSC/ERS [8]3.674.230.83
    Rosenthal [82]2.703.690.84Hankinson [17]¶3.584.120.84
    Zapletal [83]2.933.530.85Stanojevic [13]#3.464.090.85
    Stanojevic [13]#3.454.080.85GLI 20123.614.130.88
    Wang [6]3.493.930.87
    GLI 20123.614.120.88
    Author [ref.]c) 17.9 yrs, 180 cmAuthor [ref.]d) 18.0 yrs, 180 cm
    FEV1FVCFEV1/FVCFEV1FVCFEV1/FVC
    Polgar [7]4.304.69NAECSC/ERS [8]4.535.380.83
    Rosenthal [82]4.275.170.82Hankinson [17]¶4.535.390.84
    Zapletal [83]4.114.990.85Stanojevic [13]#4.565.450.85
    Stanojevic [13]#4.555.440.85GLI 20124.695.490.86
    Wang [6]4.465.200.86
    GLI 20124.685.470.86
    Author [ref.]e) 25 yrs, 175 cmAuthor [ref.]f) 55 yrs, 175 cm
    FEV1FVCFEV1/FVCFEV1FVCFEV1/FVC
    Crapo [84]4.455.320.84Crapo [84]3.714.670.79
    ECSC/ERS [8]4.315.090.83ECSC/ERS [8]3.444.310.77
    Hankinson [17]¶4.445.360.83Hankinson [17]¶3.634.740.77
    HSE [49]4.435.290.85HSE [49]3.604.630.79
    Knudson [85]4.395.240.84Knudson [85]3.524.350.81
    Stanojevic [13]#4.425.360.83Stanojevic [13]#3.634.750.77
    GLI 20124.465.320.85GLI 20123.654.660.79
    • FEV1: forced expiratory volume in 1 s; FVC: forced vital capacity; GLI: Global Lungs Initiative; ECSC: European Community for Steel and Coal; ERS: European Respiratory Society; HSE: Health Survey for England 1995–1996; NA: not available. #: all age; ¶: National Health and Nutritional Examination Survey (NHANES) III. The transition from one set of equations to another on the 18th birthday (a versus b or c versus d) is not smooth using older equations. The discontinuity, and the disparity between predicted values is much worse in those who are short for their age (a versus b), than in those of average height (c versus d). In adult males there is fair agreement between predicted values, although those derived from the ECSC/ERS are systematically lower than others for subjects ≥25 yrs of age (e versus f).

Additional Files

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  • Supplementary material

    Please note: supplementary material is not edited by the Editorial Office, and is uploaded as it has been supplied by the author.

    Files in this Data Supplement:

    • Supplementary material updated April 2013
    • Supplementary material correction details
    • Look-up tables
    • wersja polska -

      Polish translation

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Multi-ethnic reference values for spirometry for the 3–95-yr age range: the global lung function 2012 equations
Philip H. Quanjer, Sanja Stanojevic, Tim J. Cole, Xaver Baur, Graham L. Hall, Bruce H. Culver, Paul L. Enright, John L. Hankinson, Mary S.M. Ip, Jinping Zheng, Janet Stocks, the ERS Global Lung Function Initiative
European Respiratory Journal Dec 2012, 40 (6) 1324-1343; DOI: 10.1183/09031936.00080312

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Multi-ethnic reference values for spirometry for the 3–95-yr age range: the global lung function 2012 equations
Philip H. Quanjer, Sanja Stanojevic, Tim J. Cole, Xaver Baur, Graham L. Hall, Bruce H. Culver, Paul L. Enright, John L. Hankinson, Mary S.M. Ip, Jinping Zheng, Janet Stocks, the ERS Global Lung Function Initiative
European Respiratory Journal Dec 2012, 40 (6) 1324-1343; DOI: 10.1183/09031936.00080312
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