ATS Recommends Race-Neutral Equations for Pulmonary Function Test Outcomes

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The new recommendations buck against the organization's prior guidance, noting the variability of reported race and ethnicity that applies to clinical assessment.

The American Thoracic Society (ATS) released a statement recently advocating against their previously recommended use of race- and ethnicity-based factor equations to interpret pulmonary function test (PFT) outcomes.1

The statement—endorsed additionally by the European Respiratory Society (ERS)—includes recommendations such as the adoption of race-neutral average reference equations and the continued research into not only the impact of race and ethnicity in pulmonary function outcomes, but potentially more distinct modifiable risk factors associated with poor PFT.

Because the classification of people by racial and ethnic groups can differ based on geography and temporal factors, such classifications’ roles in biological meaning and interpretation of outcomes in PFT testing may be inconsistent, if not counterintuitive. The new recommendation, penned by ATS Committees on Pulmonary Function Testing and on Health Equity and Diversity co-chairs Nirav R. Bhakta, MD, PhD, and Christian Bime, MD, stated that the “superficial appearance of race should not be used to infer biological characteristics” in PFT.

“Continued use of race in PFT interpretation risks perpetuating false ideas that race distinguishes people on the basis of innate and immutable features,” the committee wrote. “Beyond the categories’ lack of biological meaning, there is significant heterogeneity within these categories and lack of consistency of the definitions across time and geography.”

They recommended the Global Lung Initiative (GLI) average equation, which represents race as a composite but not mandatory item in its equation, as a reference race-neutral PFT equation.

“The aforementioned recommendations are paired with a call for urgent engagement of people living with chronic pulmonary diseases, other professional societies, and agencies external to medicine for continued research and education,” the committee wrote. “Further research in more diverse populations across the world is needed regarding the social and environmental determinants of lung health and how to measure these factors in a way that could be translated to public policies and the application of pulmonary function testing in the clinic.”

In a statement accompanying the recommendation, Bhakta, an associate professor at the University of California, San Francisco School of Medicine, stressed recent scientific evidence pointing the benefit of race-neutral approaches to not only interpreting PFT, but in assessing the impact of environmental factors such as tobacco smoke exposure in pulmonary patients.2

“Significant heterogeneity within these categories and lack of consistency of the definitions across time and geography further undermine attempts to use race and ethnicity to achieve precision in describing individuals,” Bhakta said. “Normalization of perceived differences through the use of race/ethnicity-specific equations in PFT interpretation potentially contributes to medical harms caused by the lack of attention to modifiable risk factors for lower pulmonary function including those related to structural racism.”

In an editorial addressing the new recommendation, Kevin C. Wilson, MD, of the department of medicine at Boston University School of Medicine, noted the potentially unpopular evolution of clinical guidance since the ATS and ERS first recommended race-specific interpretation of PFT tests in 2005.3

“ATS’s leadership is aware that the recommendation may be controversial and may initiate passionate debate. However, it sees the statement as an important first step to ignite discussion and accelerate research regarding not only race in pulmonary function testing but also race in other areas of pulmonary, critical care, and sleep medicine,” Wilson wrote. “ATS’s leadership expects the recommendation to evolve as new evidence is created. Future changes will be viewed as further advances rather than an admonition of prior guidance.”

The committee concluded there remains an “urgent need” to collaborate with relevant thought leaders in thoracic surgery, occupational medicine, lung transplantation and other stakeholders to continue assessment of a race-neutral PFT test equation recommendation on the entirety of pulmonary health.1 Research that reflects the country’s diverse population, the heterogeneity and variability of respiratory disease, and the utility of PFTs other than spirometry remain priorities for the ATS committee.

“Race and ethnicity data are often characterized by absence of information, inconsistent methods of ascertainment, and internal disagreement within a single patient’s records,” they wrote. “There is a mismatch between self-identified race and phenotypic appearance. We need to increase the diversity of the participants in studies that include pulmonary function.”


  1. Bhakta NR, Bime C, Kaminsky DA, et al. Race and Ethnicity in Pulmonary Function Test Interpretation: An Official American Thoracic Society Statement [published online ahead of print, 2023 Mar 27]. Am J Respir Crit Care Med. 2023;10.1164/rccm.202302-0310ST. doi:10.1164/rccm.202302-0310ST
  2. ATS publishes official statement on race, ethnicity and pulmonary function test interpretation. News release. EurekAlert!. Published March 30, 2023. Accessed April 1, 2023.
  3. Wilson KC. Role of Race in the Interpretation of Pulmonary Function Tests: ATS' Efforts to Mitigate Bias in Its Clinical Guidance [published online ahead of print, 2023 Mar 28]. Am J Respir Crit Care Med. 2023;10.1164/rccm.202303-0351ED. doi:10.1164/rccm.202303-0351ED