Nicole Ramsey, MD, PhD, assistant professor of pediatrics in the division of pediatric allergy and immunology at the Icahn School of Medicine at Mount Sinai.

Nicole Ramsey, MD, PhD

 Race-Neutral Spirometry Gains Support as Standard Practice, With Nicole Ramsey, MD, PhD

Updated guidance on lung function testing has prompted growing discussion around 

2026 American Academy of Allergy, Asthma & Immunology (AAAAI) 

annual meeting in Philadelphia, Nicole Ramsey, MD, PhD, assistant professor of pediatric allergy and immunology at the Icahn School of Medicine at Mount Sinai, discussed the rationale for race-neutral equations for spirometry and their potential clinical impact.

, Ramsey described a study in which surgeons evaluated a hypothetical patient and recommended lobectomy based on spirometry values calculated using either race-neutral or race-specific equations.

“It showed that surgeons would be less likely to do surgery on patients…if they're using the race-neutral and more likely to do it if they're using the race-specific. It's actually a counterargument using race-neutral equations,” Ramsey said. “However, it's possible that those people [who] would be less likely to do surgery on have worse outcomes. We don't know, but it's just because they have poor lung function that they’re less they're less excited to do surgery on someone because the numbers suggest that they might not have a good outcome.”

Spirometry is a fundamental tool used to evaluate lung function and diagnose conditions such as asthma and chronic obstructive pulmonary disease. Historically, interpretation of spirometry results relied on race-specific reference equations, which adjusted predicted lung function values based on a patient’s racial category. Earlier models, including the 1999 reference equations, required clinicians to modify raw spirometry values differently for patients identified as Black, White, or Mexican American.

Ramsey explained that these adjustments were originally based on the assumption that biological differences between racial groups influenced lung capacity. However, emerging evidence suggests that environmental exposures and social determinants of health, rather than race itself, better explain differences observed in lung function across populations.

She noted that historical environmental inequities likely contributed to early observations that shaped race-based equations. For example, greater exposure to industrial pollution and occupational hazards among Black populations during earlier decades may have influenced lung function measurements used in historical datasets.

Professional societies have begun responding to this evolving evidence base. The American Thoracic Society now recommends using race-neutral spirometry equations, including updated reference values introduced through the Global Lung Function Initiative’s 2022 model. These equations incorporate data from diverse populations without applying race-specific correction factors.

Despite these recommendations, adoption has not yet been universal. Ramsey noted that practical barriers, such as outdated spirometry equipment and software, may slow implementation. Many older spirometers cannot easily integrate newer reference equations, meaning clinics may need to upgrade hardware or software to transition fully.

Beyond clinical care, changes in spirometry interpretation could have broader societal implications. Ramsey highlighted that algorithms used in areas such as life insurance underwriting may interpret lung function differently depending on whether race-based adjustments are applied.

Ramsey emphasized that race-neutral spirometry represents a step toward more accurate and equitable lung health assessment, though continued research will be needed to refine predictive tools.

“We need better risk calculators to take people's whole [clinical context] into account, not just their race, not just their height, but other things that they might be exposed to that might be contributing to their lung health,” Ramsey said. “We need additional studies, and we need different predictors, potentially using AI or other advanced statistical tools, to help us interpret our spirometry results.”

ALK-Abello, Inc., and Genentech USA, Inc.

Ramsey, N. Using Race-Neutral Spirometry Equations Improves Diagnostic Accuracy. Session presented at the 2026 American Academy of Allergy, Asthma, & Immunology in Philadelphia on March 2, 2026.

Videos

At AAAAI 2026, Ramsey discussed the shift toward race-neutral spirometry equations, their clinical implications, and barriers to widespread adoption.

Race-Neutral Spirometry Gains Support as Standard Practice, With Nicole Ramsey, MD, PhD

Race-Neutral Spirometry May Improve Diagnostic Accuracy, With Nicole Ramsey, MD, PhD

Using race-neutral reference equations to interpret 

 may improve diagnostic accuracy and reduce disparities in respiratory care, according to Nicole Ramsey, MD, PhD, assistant professor of pediatrics in the division of pediatric allergy and immunology at the Icahn School of Medicine at Mount Sinai.

On March 2, 2026, at the American Academy of Allergy, Asthma, & Immunology (AAAAI) annual meeting in Philadelphia, Ramsey presented the session, “Using Race-Neutral Spirometry Equations Improves Diagnostic Accuracy.” She discussed the clinical implications of shifting away from race-adjusted spirometry equations, which is an approach historically used in pulmonary function testing. She emphasized that clinicians should consider adopting race-neutral reference equations, such as those derived from the Global Lung Function Initiative (GLI), to interpret spirometry results more consistently across patient populations.

“The main takeaway message from my session is that physicians should be using race-neutral reference equations to interpret their spirometry,” Ramsey told 

 “Whether that has to do with using the mixed equation from the GLI 2012 reference equations or just using the GLI ’22 or July global equations, they will improve diagnostic accuracy if they use those equations.”

Spirometry remains a foundational tool for diagnosing and monitoring obstructive and restrictive lung diseases, including conditions such as asthma and chronic obstructive pulmonary disease (COPD). Traditional interpretation of spirometry results has relied on race-specific correction factors, which adjust predicted lung function values based on racial categories. However, Ramsey noted that this approach is increasingly questioned because race is a social construct rather than a biological determinant of lung function.

Race-neutral equations aim to address this limitation by applying the same reference standards to all individuals. According to Ramsey, removing race-based adjustments can improve diagnostic accuracy by preventing misclassification of lung disease severity.

In particular, the shift may have meaningful implications for patients who identify as Black. Ramsey explained that race-adjusted spirometry equations can sometimes produce falsely normal interpretations, potentially delaying diagnosis or masking clinically meaningful impairment. Spirometry results influence a wide range of clinical and administrative decisions, including treatment selection, disability assessments, and referral for advanced interventions such as lung transplantation.

Ramsey highlighted how race-adjusted equations can lead to differences in treatment classification. For example, two children, 1 Black and 1 White, with identical symptoms and pulmonary function measurements could be categorized differently when race-specific equations are used. In some cases, the White child might be classified as having moderate impairment, while the Black child might be categorized as having only mild impairment.

“What that could potentially mean is that the White child would get better or more comprehensive treatment,” Ramsey explained. “The Black child might not receive treatment as quickly, which could lead to more long-standing detrimental effects from asthma.”

Reanalysis of existing datasets also suggests that race-neutral spirometry could alter eligibility for disability benefits. Ramsey noted that analyses indicate Black and Asian veterans with COPD may have been undercompensated when disability assessments relied on race-adjusted lung function thresholds. In some cases, monthly disability payments could differ by as much as $3000 when race-neutral equations are applied.

Modeling studies suggest the interpretation change could influence transplant referral timelines. Analyses of population datasets have estimated that Black patients could qualify for lung transplant listing sooner when race-neutral spirometry equations are used, potentially shortening wait times by several weeks in some scenarios.

Ramsey acknowledged that the transition to race-neutral spirometry may produce unintended consequences. For example, certain professions that rely on spirometry thresholds, such as firefighting or military service, could see eligibility criteria shift for some individuals if race-neutral reference standards are adopted without broader policy adjustments.

“Race-neutral reference equations are not perfect,” Ramsey said. “But because race-adjusted equations falsely consider race a biological concept, they’re the best thing that we have…they improve diagnosis… and [help patients] get to care faster.”

Using race-neutral spirometry equations such as GLI 2012 and GLI 2022 may improve diagnostic accuracy and reduce disparities in lung disease assessment.

Nicole Ramsey, MD, PhD

Articles