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Pulmonary Function Testing

General reviews

The following ATS/ERS statements are widely recognized as the standard by which clinicians and researchers perform and interpret pulmonary functions tests:

Miller MR, Crapo R, Hankinson J, et al. ATS/ERS Task Force. General considerations for lung function testing. Eur Respir J. 2005; 26:153-61 Eur Respir J. 2005; 26:153-61.

PMID: 15994402

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Graham B, Steenbruggen I, Miller M, 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:e70-e88.

PMID: 31613151

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Wanger J, Clausen JL, Coates A, et al. ATS/ERS Task Force. Standardisation of the measurement of lung volumes. Eur Respir J. 2005; 26:511-22.

PMID: 16135736

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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).

PMID: 28049168

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Coates AL, Wanger J, Cockcroft DW, et al. ERS technical standard on bronchial challenge testing: general considerations and performance of methacholine challenge tests. Eur Respir J  2017; 49:1601526. New recommendations noteworthy for basing result on the delivered dose of methacholine during the course of the test rather than upon a methacholine concentration. Also includes practical information such as how far in advance various bronchodilators need to be discontinued.

PMID: 28461290

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Pellegrino R, Viegi G, Brusasco V, et al. Interpretative strategies for lung function tests. Eur Respir J 2005: 26:948-68. An excellent comprehensive review of reference equations, types of ventilatory defects, PFT and DLCO interpretation, severity classifications, bronchodilator response thresholds, central and upper airway processes, and interpretation of changes in pulmonary function. This includes a recommendation to use the lower limit of normal when interpreting pulmonary function tests, an issue which is discussed in more detail in the article below.

PMID: 16264058

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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;139:52-9. In addition to a discussion of the diagnostic errors associated with use of the fixed FEV1/FVC ratio of 0.7, this article highlights the misclassification associated with fixed 80%-predicted thresholds for spirometry variables. The authors suggest the fifth-percentile should be used to determine the lower limit of normal for spirometric variables and ratios.

PMID: 20522571

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Iyer VN, Schroeder DR, Parker KO, et al. The nonspecific pulmonary function test: longitudinal follow-up and outcomes. Chest, 2011; 139:878-88. This study of nearly 1,300 patients sheds light on the commonly encountered combination of reduced FVC but normal FEV/FVC and TLC. Roughly 2/3 of patients maintained this pattern during a median of 3 years of follow-up while the remaining 1/3 evolved into restrictive and obstructive patterns in equal numbers. 

PMID: 20724741

Hyatt RE, Cowl CT, Bjoraker JA, et al. Conditions associated with an abnormal nonspecific pattern of pulmonary function tests. Chest, 2009; 135:419-24. Study found airway hyperresponsiveness and obesity were the most common causes of nonspecific PFT results in which the FVC is reduced but the FEV1/FVC and TLC are normal. Other studies found weakness and bronchiectasis associated with this pattern.

PMID: 18812444

Exercise Testing

Weisman IM, Zeballos RJ. Clinical exercise testing. Clin Chest Med 2001;22:679-701. The focus is on cardiopulmonary exercise testing, but this review also briefly summarizes the 6-minute walk, testing for exercise-induced bronchoconstriction, and cardiac stress testing. An excellent starting point for the novice.

PMID: 11787659

ATS/ACCP Statement on cardiopulmonary exercise testing. Am J Respir Crit Care Med 2003; 167:211-77. Somewhere between a textbook and a clinical review, this article provides more details on CPET than the above Weisman article.

PMID: 12524257

Holland AE, Spruit MA, Troosters T, et al. An official European Respiratory Society/American Thoracic Society technical standard field walking tests in chronic respiratory disease. Eur Respir J. 2014; 44:1428-46. This document standardizes procedures for performing the 6-minute walk test as well as incremental and endurance shuttle walks. The potential for differences in methodology to produce large changes in results is emphasized.

PMID: 25359355

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Singh SJ, Puhan MA, Andrianopoulos V, et al. An official systematic review of the European Respiratory Society/American Thoracic Society: measurement properties of field walking tests in chronic respiratory disese. Eur Respir J. 2014; 44:1447-78.  This review summarizes the literature that is the basis for the technical standard above by Holland et al.

PMID: 25359356

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