Institutional belief · Pulmonary medicine and clinical standards
Race-based pulmonary-function reference values
Race or ethnicity was treated as a patient characteristic that should determine which reference equations or adjustment factors were used to define expected normal pulmonary-function values.
1 episode
Current understanding
Current understanding
Race and ethnicity are social classifications rather than fixed biological variables suitable for blanket physiological correction. Current ATS guidance, endorsed by the ERS, recommends race-neutral average reference equations for pulmonary-function-test interpretation while calling for continued study of the effects of the transition.
Institutional episode
United States and Europe
ATS/ERS standards did not merely note population differences; they operationalized race and ethnicity in the reference values used to interpret pulmonary-function tests. The 2005 standard explicitly preferred race/ethnic-specific equations and allowed numerical adjustment factors when such equations were unavailable. In 2023 the ATS, with ERS endorsement, reversed that approach and recommended race-neutral average equations, citing evidence that race-specific interpretation did not provide the assumed clinical advantage and could contribute to inequitable decisions.
Institutions
- American Thoracic Society (ATS)
- European Respiratory Society (ERS)
Documented consequences
- Race-dependent thresholds for classifying pulmonary-function results as normal or abnormal
- Potential delayed recognition or lower assessed severity of respiratory impairment for people assigned to groups with lower predicted reference values
- Race-dependent effects on decisions involving treatment, disability, employment, insurance and transplant prioritization
- Need to revise laboratory reporting systems and clinical interpretation after the 2023 recommendation
Institutional machinery
The joint ATS/ERS 2005 interpretive standard instructed patients to identify their race or ethnic group and recommended race/ethnic-specific reference equations whenever possible, with adjustment factors as a fallback. Such reference values affected whether measured lung function was classified as normal or abnormal. Race-specific interpretation remained part of professional guidance into the early 2020s. In 2023 an official ATS statement, endorsed by the ERS, recommended replacing race- and ethnicity-specific equations with race-neutral average reference equations and urged a wider reassessment of how PFT thresholds are used in clinical, employment and insurance decisions.
Sources and what they establish
- Interpretative strategies for lung function testsEuropean Respiratory Journal / ATS–ERS Task Force
- ERS/ATS technical standard on interpretive strategies for routine lung function testsEuropean Respiratory Journal / ERS–ATS Task Force
2022 joint technical standard documenting the 2005 ATS/ERS framework and the continuing professional-standard context immediately before the 2023 race-neutral recommendation.
- Race and Ethnicity in Pulmonary Function Test Interpretation — An Official American Thoracic Society StatementAmerican Thoracic Society / American Journal of Respiratory and Critical Care Medicine
- ATS Publishes Official Statement on Race, Ethnicity and Pulmonary Function Test InterpretationAmerican Thoracic Society
ATS summary of the 2023 correction, including the rationale for abandoning race-specific equations and the potential effects of race-based interpretation on diagnosis, treatment and other consequential decisions.
Last reviewed: 26/08/2026