Skip to main content

Main menu

  • Home
  • Current issue
  • ERJ Early View
  • Past issues
  • For authors
    • Instructions for authors
    • Submit a manuscript
    • Author FAQs
  • 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

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
  • For authors
    • Instructions for authors
    • Submit a manuscript
    • Author FAQs
  • Alerts
  • Podcasts
  • Subscriptions

Inclusion of children with airway disease for the development of spirometry reference data

Anke Hüls, Ursula Krämer, Antje Schuster, Monika Gappa, Matthias Wisbauer, Christine Müller-Brandes, Tamara Schikowski, Barbara Hoffmann, Andrea von Berg, Dietrich Berdel
European Respiratory Journal 2016 47: 1290-1292; DOI: 10.1183/13993003.01465-2015
Anke Hüls
IUF-Leibniz Research Institute for Environmental Medicine, Düsseldorf, Germany
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • For correspondence: Anke.Huels@IUF-Duesseldorf.de
Ursula Krämer
IUF-Leibniz Research Institute for Environmental Medicine, Düsseldorf, Germany
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Antje Schuster
Heinrich-Heine University, University Children's Hospital, Düsseldorf, Germany
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Monika Gappa
Marien Hospital Wesel, Children's Hospital and Research Institute, Wesel, Germany
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Matthias Wisbauer
Heinrich-Heine University, University Children's Hospital, Düsseldorf, Germany
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Christine Müller-Brandes
Dept of Anaesthesiology and Intensive Care Medicine, Medical School of Hanover, Hanover, Germany
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Tamara Schikowski
IUF-Leibniz Research Institute for Environmental Medicine, Düsseldorf, GermanySwiss Tropical and Public Health Institute, Basel, University of Basel, Basel, Switzerland
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Barbara Hoffmann
IUF-Leibniz Research Institute for Environmental Medicine, Düsseldorf, GermanyMedical Faculty, Deanery of Medicine, Heinrich-Heine University of Düsseldorf, Düsseldorf, Germany
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Andrea von Berg
Marien Hospital Wesel, Children's Hospital and Research Institute, Wesel, Germany
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Dietrich Berdel
Marien Hospital Wesel, Children's Hospital and Research Institute, Wesel, Germany
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Figures & Data
  • Info & Metrics
  • PDF
Loading

Abstract

Children/adolescents with asthma or current respiratory tract infection should not be included in a reference population for spirometry http://ow.ly/VBVe8

To the Editor:

When establishing normative data for the development of spirometric reference equations, generally measurements have to fulfil internationally accepted criteria [1, 2] and should be derived from data taken from healthy subjects. In their recent publication Lum et al. [3] discussed how “healthy” children should be when selecting reference samples for spirometry. They investigated this in the context of a study designed to explore ethnic differences in the lung function of school children aged 5–11 years from London. They recommended including children with current respiratory tract infection, a history of prior asthma or minor pre-existing risk factors, such as prematurity and low birth weight in normative analysis.

In contrast, we have come to a different conclusion, and we advocate that recommendations for patient samples should be less inclusive in the development of reference data. Our group analysed data from our LUNOKID study (LUng function NOrmal values for KIDs in Germany), where we measured lung function (N=5104; aged 4–18 years) between 2007 and 2009 in three German communities under field conditions [2, 4, 5]. Spirometric reference values were developed with the same regression model used by the Global Lung Initiative (GLI) [6]. For the reference data set, the following subgroups (not overlapping) were excluded. 1) Subjects with asthma diagnosis ever (n=417); a) with no current asthma medication (n=195) and b) with current asthma medication (n=222). 2) Upper respiratory tract infection (RTI) on the day of the investigation (n=734) (without asthma). 3) lower RTI within 6 weeks prior to testing (n=180) (without asthma and without upper RTI). 4) Children who have ever been diagnosed with wheezy bronchitis (“obstructive”, “asthmatic” or “spastic bronchitis”) (n=629) (without asthma and either an upper or lower RTI).

From the total group, 3205 children fulfilled American Thoracic Society (ATS)/European Respiratory Society (ERS) quality criteria. Compared to healthy children, the proportion of visually acceptable manoeuvres was lower in children with upper RTIs on the day of investigation (72% and 62%, respectively; p<0.01), whereas it was higher in asthmatics (80%; p<0.01). No further statistically significant differences related to the fulfilment of quality criteria were observed.

Using all acceptable tests, mean z-scores were then calculated for the subgroups (table 1). As suggested by Hall et al. [7] and Thompson et al. [8] a difference in z-score of 0.5 was considered relevant. The mean LUNOKID based z-scores for the healthy reference children are zero by definition [4]. Children with a history of physician diagnosed asthma had relevantly lower mean z-scores for forced expiratory volume in 1 s (FEV1)/forced volume capacity (FVC) irrespective of current treatment (−0.52 and −0.66). Furthermore, the standard deviation for this group was higher than the expectation (=1), and it was higher than in the other groups. No relevant mean differences were found for the other subgroups or for the total study population when all subgroups were included. These findings are in accordance with the observations of Lum et al. [3]. However, the percentage of values below the lower limit of normal (LLN) for FEV1/FVC is larger than the expected 5% in the total group, if these additional subgroups are included.

View this table:
  • View inline
  • View popup
TABLE 1

Distribution of LUNOKID-based z-scores in groups defined by airway disease

Many children with an upper RTI on the day of testing were excluded from our reference population because they had not been able to produce technically acceptable manoeuvres. This finding is in accordance with the findings of Lum et al. [3] who also showed that children who were symptomatic on the day of investigation had a higher failure rate in performing technically acceptable manoeuvres. Acceptable tests, however, were indeed not different from our healthy reference population.

We agree that in order to establish the reference data the reference population should be as large as possible. Lum et al. [3] propose to include children with current upper respiratory symptoms and/or a history of asthma. Our data confirm that spirometry data from children with upper RTIs and no asthma diagnosis may not be different from healthy children's data in cases where the ATS/ERS quality criteria (including careful visual control) are fulfilled. Statistically, there is also no reason to exclude children without an asthma diagnosis but a history of lower RTIs within 6 weeks of testing, or a history of wheezy bronchitis from the reference population. However, clinical assessment may differ between investigators, thereby potentially influencing the results. The correct diagnosis of an RTI as upper or lower, with or without obstruction, may be difficult for field staff to ascertain; therefore, strict criteria to define a healthy population should be adhered to. While success rates in children with a history of asthma may be higher, the differences in results (especially FEV1/FVC) are clinically relevant.

Although the mean reference data would only slightly change when including asthmatics because of the low prevalence of asthma, for clinical reasons, we would like to challenge the recommendation generated by Lum et al. [3] to include children/adolescents with a present or past history of asthma or current respiratory tract infection in a reference population for spirometry. Inclusion will result in higher standard deviations and lower LLNs, which may finally negatively affect diagnostic accuracy.

Acknowledgements

The authors would like to thank the children and their families for taking part in this study. The authors would also like to thank the following people for their technical assistance: Christina Beckmann, Julia Bienen, Cornelia Bisdorf, Irene Groß, Christina Müller, and Sandra Werth (Children's Hospital and Research Unit, Marien Hospital, Wesel, Germany); Heike Beermann and Marion Kliemt (Paediatric Pulmonology, Allergology and Neonatology, Hannover Medical School, Germany); Sabina Illi (University Childreńs Hospital, LMU, Munich, Germany); Özgü Altin, Gisela Bartkowiak, Ursula Pfeiffer and Michaela Strempel (University Hospital, Heinrich-Heine University, Düsseldorf, Germany).

Footnotes

  • Support statement: Funding for has been provided by GlaxoSmithKline GmbH & Co. KG, Munich, Germany; Aerocrine AB, Solna, Sweden; MSD Sharp & Dohme GmbH, Haar, Germany; AstraZeneca GmbH, Wedel, Germany; Novartis Pharma GmbH, Nuernberg, Germany; Astellas Pharma GmbH, Munich, Germany; Deutsche Atemwegsliga; Ndd Medizintechnik AG, Zürich, Switzerland. Funding information for this article has been deposited with FundRef.

  • Conflict of interest: None declared.

  • Received September 3, 2015.
  • Accepted November 22, 2015.
  • Copyright ©ERS 2016

References

  1. ↵
    1. Miller MR,
    2. Hankinson J,
    3. Brusasco V, et al.
    Standardisation of spirometry. Eur Respir J 2005; 26: 319–338.
    OpenUrlAbstract/FREE Full Text
  2. ↵
    1. Müller-Brandes C,
    2. Krämer U,
    3. Gappa M, et al.
    LUNOKID: Can numerical American Thoracic Society/European Respiratory Society quality criteria replace visual inspection of spirometry? Eur Respir J 2014; 43: 1347–1356.
    OpenUrlAbstract/FREE Full Text
  3. ↵
    1. Lum S,
    2. Bountziouka V,
    3. Sonnappa S, et al.
    How “healthy” should children be when selecting reference samples for spirometry? Eur Respir J 2015; 45: 1576–1581.
    OpenUrlAbstract/FREE Full Text
  4. ↵
    1. Hüls A,
    2. Krämer U,
    3. Gappa M, et al. Neue Spirometrische Referenzwerte für Kinder und Jugendliche in Deutschland unter berücksichtigung der Größe und nichtlinearer Alterseffekte: tie LUNOKID-Studie
    [New spirometric reference values for children and adolescents in Germany considering height and non-linear age effects: the LUNOKID-Study]. Pneumologie 2014; 68: 393.
    OpenUrlCrossRefPubMed
  5. ↵
    1. Berdel D,
    2. Beckmann C,
    3. von Berg A, et al.
    Erhebung von Lungenfunktionsnormalwerten (spirometrie) bei Kindern und Jugendlichen in Deutschland: die LUNOKID-Studie [Survey of lung function normal values (spirometry) in children and adolescents in Germany: the LUNOKID study]. Atemw -Lungenkrkh 2010; 395–404.
  6. ↵
    1. Quanjer PH,
    2. Stanojevic S,
    3. 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: 1324–1343.
    OpenUrlAbstract/FREE Full Text
  7. ↵
    1. Hall GL,
    2. Thompson BR,
    3. Stanojevic S, et al.
    The Global Lung Initiative 2012 reference values reflect contemporary Australasian spirometry. Respirology 2012; 17: 1150–1151.
    OpenUrlCrossRefPubMedWeb of Science
  8. ↵
    1. Thompson BR,
    2. Stanojevic S,
    3. Abramson MJ, et al.
    The all-age spirometry reference ranges reflect contemporary Australasian spirometry. Respirology 2011; 16: 912–917.
    OpenUrlCrossRefPubMedWeb of Science
View Abstract
PreviousNext
Back to top
View this article with LENS
Vol 47 Issue 4 Table of Contents
European Respiratory Journal: 47 (4)
  • Table of Contents
  • Table of Contents (PDF)
  • About the Cover
  • 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.
Inclusion of children with airway disease for the development of spirometry reference data
(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.
Print
Alerts
Sign In to Email Alerts with your Email Address
Citation Tools
Inclusion of children with airway disease for the development of spirometry reference data
Anke Hüls, Ursula Krämer, Antje Schuster, Monika Gappa, Matthias Wisbauer, Christine Müller-Brandes, Tamara Schikowski, Barbara Hoffmann, Andrea von Berg, Dietrich Berdel
European Respiratory Journal Apr 2016, 47 (4) 1290-1292; DOI: 10.1183/13993003.01465-2015

Citation Manager Formats

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

Share
Inclusion of children with airway disease for the development of spirometry reference data
Anke Hüls, Ursula Krämer, Antje Schuster, Monika Gappa, Matthias Wisbauer, Christine Müller-Brandes, Tamara Schikowski, Barbara Hoffmann, Andrea von Berg, Dietrich Berdel
European Respiratory Journal Apr 2016, 47 (4) 1290-1292; DOI: 10.1183/13993003.01465-2015
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
    • Abstract
    • Acknowledgements
    • Footnotes
    • References
  • Figures & Data
  • Info & Metrics
  • PDF

Subjects

  • Paediatric pulmonology
  • Lung structure and function
  • Tweet Widget
  • Facebook Like
  • Google Plus One

More in this TOC Section

Agora

  • Concomitant medications and clinical outcomes in IPF
  • Acute hypoxaemic respiratory failure in immunocompromised patients
  • Acute hypoxaemic respiratory failure in immunocompromised patients
Show more Agora

Correspondence

  • Acute hypoxaemic respiratory failure in immunocompromised patients
  • Acute hypoxaemic respiratory failure in immunocompromised patients
  • Testing bronchodilator responsiveness
Show more Correspondence

Related Articles

Navigate

  • Home
  • Current issue
  • Archive

About the ERJ

  • Journal information
  • Editorial board
  • Reviewers
  • CME
  • 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
  • Submit a manuscript
  • ERS author centre

For readers

  • Alerts
  • Subjects
  • Collections
  • 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 © 2019 by the European Respiratory Society