AMERICAN THORACIC SOCIETY DOCUMENTS

1 AMERICAN THORACIC SOCIETYDOCUMENTSR ecommendations for a Standardized Pulmonary Function ReportAn Official AMERICAN THORACIC SOCIETY Technical StatementBruce H. Culver, Brian L. Graham, Allan L. Coates, Jack Wanger, Cristine E. Berry, Patricia K. Clarke, Teal S. Hallstrand,John L. Hankinson, David A. Kaminsky, Neil R. MacIntyre, Meredith C. McCormack, Margaret Rosenfeld,Sanja Stanojevic, and Daniel J. Weiner; on behalf of the ATS Committee on Proficiency Standards for PulmonaryFunction LaboratoriesTHISOFFICIALTECHNICALSTATEME NT OF THEAMERICANTHORACICSOCIETY WAS APPROVEDOCTOBER2017 Background:The AMERICAN THORACIC SOCIETY committee onProficiency Standards for Pulmonary Function Laboratories hasrecognized the need for a standardized reporting format forpulmonary function tests.

2 Although prior DOCUMENTS have offeredguidance on the reporting of test data, there is considerablevariability in how these results are presented to end users, leading topotential confusion and :A project task force, consisting of the committee as awhole, was approved to develop a new Technical Standard onreporting pulmonary function test results. Three working groupsaddressed the presentation format, the reference data supportinginterpretation of results, and a system for grading quality of testefforts. Each group reviewed relevant literature and wrote draftsthat were merged into thefinal :This document presents a reporting format in test-specificunits for spirometry, lung volumes, and diffusing capacity thatcan be assembled into a report appropriate for a laboratory spractice.

3 Recommended reference sources are updated with datafor spirometry and diffusing capacity published since priordocuments. A grading system is presented to encourageuniformity in the important function of test quality :The committee believes that wide adoption of theseformats and their underlying principles by equipment manufacturersand pulmonary function laboratories can improve the interpretation,communication, and understanding of test :pulmonary function testing; reporting spirometry;reference equations; pulmonary function quality gradingContentsOverviewConclusionsIntrod uctionMethodsReport Format for Spirometry andOther Lung Function TestsGeneral ConsiderationsSpirometryTests of Lung VolumeDiffusing Capacity (TransferFactor)Comments and InterpretationSelecting and Reporting ReferenceValuesGeneral ConsiderationsCurrent Spirometry ReferenceValuesUsing Reference Data inInterpretation of ResultsReference SourceRecommendationsGrading the Quality of PulmonaryFunction TestsSpirometryLung VolumesDiffusing Capacity (TransferFactor)

4 The Quality ReviewerConclusionsSupported by a project grant from the AMERICAN THORACIC and requests for reprints should beaddressed to Bruce H. Culver, , Division of Pulmonary, Critical Care and Sleep Medicine, Universityof Washington School of Medicine, Campus Box 356522,Seattle, WA 98195-6522. E-mail: article has an online supplement, which is accessible from this issue s table of contents at J Respir Crit Care Med Vol 196, Iss 11, pp 1463 1472, Dec 1, 2017 Copyright 2017 by the AMERICAN THORACIC SocietyDOI: address: THORACIC SOCIETY Documents1463 OverviewThe AMERICAN THORACIC SOCIETY Committeeon Proficiency Standards for PulmonaryFunction Laboratories (ATS PFT Committee)has been concerned about the wide variabilityin pulmonary function test (PFT) reportsamong laboratories and has discussed the needfor a more standardized format, to includeinformation to assist accurate interpretationand to enhance the communication of resultsto end users.

5 ATS support was granted todevelop a technical standard to address thisneed and also to update reference sources andto propose a standardized quality uniform format for the presentation ofPFT results in reports to users and inthe medical record can reduce potentialmiscommunication ormisunderstanding. Only information with validatedclinical application should be included. The normal limit(s) of each testparameter should be displayed. Consistent with other laboratoryvalues, the measured value should beshown before reference values, ranges,or normal limits. Report and/or display of thedisplacement of the result from apredicted value in standard deviationunits (z-score) can help inunderstanding spirometry, many parameters can becalculated but most do not add clinicalutility and should not be routinelyreported.

6 Only FVC, FEV1, and FEV1/FVC needbe routinely reported. Measurement of slow VC andcalculation of FEV1/VC are a usefuladjunct in patients with suspectedairflow obstruction. Reporting FEV1/FVC (or FEV1/VC) asa decimal fraction, and not reporting itas a percentage of the predicted valuefor this ratio, will help to volumes The nitrogen washout plot formultibreath tests and the tracings forplethysmograph tests can be showngraphically to aid quality diffusing capacity the report isconsistent with the 2017 EuropeanRespiratory SOCIETY (ERS)/ATS TechnicalStandard for this test. Barometric pressure should bemeasured and reported and themeasured value corrected to thestandard pressure of 760 mm collated reference equations forspirometry and diffusing capacity havebeen developed since prior ATSdocuments and warrant wideimplementation.

7 The Global Lung Function Initiative(GLI)-2012 multiethnic spirometryreference values are recommended foruse in North America and elsewhere forthe ethnic groups represented. Theirsmooth continuity throughout growthis advantageous for laboratories testingchildren or adolescents. The National Health and NutritionExamination Survey (NHANES) IIIreference values (recommended forNorth America in 2005 ATS/ERSdocuments) remain appropriate wheremaintaining continuity is important. Regardless of the reference source orlower limit of normal (LLN) chosen, interpreters should be aware ofuncertainty when interpreting valuesnear any dichotomous boundary.

8 For lung volumes and diffusing capacity,no prior ATS recommendation has beenmade because of the wide divergence ofavailable reference values. A largecompilation of international data hasbeen completed for the diffusing capacityof the lung for carbon monoxide (DLCO)and is underway for lung volumes. Theresulting reference equations should bewidely adopted when function tests that fail tomeet optimal standards may still provideuseful information. A grading systemfor test quality can allow for this use,while providing an indication of theuncertainty imposed, and is most helpfulif widely standardized.

9 For spirometry, FVC and FEV1aregraded separately on an A F scaleeither manually or by software. Thereis evidence that grades A C areclinically useful, whereas grades D andE may have limited value, and grade Fshould not be used. The same scale,with different criteria values, is usedfor children. For diffusing capacity a similar gradingscale is presented on the basis of 2017 ERS/ATS range of reporting formats currentlyin use is wide; commercial PFT systemsoffer differing reports, and some clinicallaboratories customize their own. Differentlyarranged reports can lead to confusion orerrors and make comparisons of data fromdifferent laboratories unnecessarily equipment manufacturers haveexpressed a desire for, and a willingness toimplement, a standardized form once it hasbeen established.

10 Newer reference data forspirometry and diffusing capacity havebecome available since the publication ofprior guidelines , and a standardized systemfor grading the quality of lung function testswould be several years the ATS PFT Committee hasbeen discussing and sharing ideas forimprovement in the reporting of PFT project task force, consisting of thecommittee as a whole, was approved todevelop this new technical standard. Thecommittee included adult and pediatricpulmonologists and physiologists andrespiratory therapists with extensive PFTexperience. Three working groups addressedthe presentation format, the reference datasupporting interpretation of results, and asystem for grading quality of test efforts.