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

Updated guidance on lung function testing has prompted growing discussion around race-neutral spirometry. At the 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.

In an interview with HCPLive, 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.”

Reported disclosures for Ramsey include ALK-Abello, Inc., and Genentech USA, Inc.

References

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.