1. CLASS 1 Regent: Prof. Dr. Altamiro Pereira Professor: Dr. Tiago Jacinto INTRODUCTION TO MEDICINE 2009/2010 SPIROMETRY REFERENCE VALUES: - A SYSTEMATIC REVIEW OF STUDIES IN THE LAST DECADE -

2. i.How many and how good are the studies published in the last decade? Are they different in terms of methodological quality? ii. Are they different in terms of methodological quality? Research Questions

3. Reference values provide a point of reference to help to interpret and determine a patient’s condition: a test result is normal if it falls within the range predicted for the age, sex and height of the patient, based on large population studies 4 Reference values are important statistical parameters to obtain medical relevant information It is crucial to have adequate reference values when performing a test, in order to avoid misdiagnosis; 4 Hughes, 2007 Introduction

4. Spirometry is an exam that allows to assess a patient’s pulmonary function using a spirometer: Two reference values are commonly used: the FVC (total amount of exhaled air) and FEV1 (exhaled air during the first second) 6,7 The spirometer measures the volume and flow of the forced exhaled air during a period of time 2 2 Enright, n.d. 6 Kuster, 2008 8 Miller, 2007

5. Different People have Different Values Pre-calculated values Having inappropriate reference values leads to Bad diagnostic 1,3,5,6 1 Baur, 1999 3 Garcia-Rio, 2004 5 Ip, 2006 6 Kuster, 2008

6. i. Summarize data published in the last decade; iv. Propose the most suitable values for Portugal or suggest the conduction of a study ii. Analyze and rate the obtained information using the STROBE checklist 9 ; 9 STROBE statement Aims iii. Collect new reference values and equations

7. Methods

8. Key words: Spirometry, Reference Values, FEV1, FVC Study design: Systematic review ; Data Sources (online databases): 7 Liberati, 2009 Procedure: 1. Search for articles 2. Select and layout articles that meet the criteria 3. Rate using the STROBE checklist 4. Conclusion General Methods

9. Criteria Inclusion CriteriaExclusion Criteria Includes the MeSH terms “Spirometry” and “Reference Values” or their synonyms in the title; (Published from 1998 to 2008) o Articles whose full text can not be achieved for free; o Study subjects with occupational exposure to inhalable materials; o Articles about studies with missing data (reference equations, FEV1 or FVC values); o Study subjects with history of pulmonary disease, smoking or current disease; o Articles in languages other than Portuguese or English; o Studies conducted in animals; o Articles that don’t refer the equipment used; o Participants under 18 years old; o Not cross-sectional;

10. ONLINE DATABASE QUERY USED: ARTICLES FOUND (N) ("1998"[Publication Date] : "2008"[Publication Date]) AND ("Spirometry"[tiab] AND ("Reference values"[mh] OR "Reference equations")) 218 814 (TITLE-ABS-KEY(spirometry) AND TITLE-ABS-KEY(“reference values” OR “reference equations” OR “normal values” OR “normative values”)) AND (LIMIT-TO(PUBYEAR, 2008) OR LIMIT-TO(PUBYEAR, 2007) OR LIMIT- TO(PUBYEAR, 2006) OR LIMIT-TO(PUBYEAR, 2005) OR LIMIT-TO(PUBYEAR, 2004) OR LIMIT-TO(PUBYEAR, 2003) OR LIMIT-TO(PUBYEAR, 2002) OR LIMIT-TO(PUBYEAR, 2001) OR LIMIT-TO(PUBYEAR, 2000) OR LIMIT- TO(PUBYEAR, 1999) OR LIMIT-TO(PUBYEAR, 1998)) 276 QUERY APPLICATION ON MARCH 5TH, 2010

11. Research Method Schematic representation of our work plan

12. 1. Search for articles 2. Select and layout articles that meet the criteria Procedure

13. Author; YearTitleCountrynAgeHeightGenderSpirometer M.H. Boskabadya et al.; 2002 Lung Function Values in Healthy Non-Smoking Urban Adults in IranIran572 (246 f 326 m)18–65 154–195 M; 143–174 FBoth Model ST90, Fukuda Sangyo Gutierrez, Carlos et al.; 2004 Reference values of pulmonary function tests for Canadian caucasiansCanada627 (327 f, 300 m)20-80Both Morgan Model USA System; Med Science wedge spirometer model 570, PK Morgan Rolling seal spirometer, Stead wells spirometer A. Langhammer et al.; 2001 Forced spirometry reference values for Norwegian adults: the Bronchial Obstruction in Nord-Trøndelag studyNorway908 (546 f 362 m)20-80Both MasterScope spirometer, version 4.15, Erich Jaeger GmbH, Wuerzburg, Germany Eva Hnizdo et al.; 2000 Lung function prediction equations derived from healthy South African gold minersSouth Africa1852420-70170 (average)Male Hans Rudolph pneumotachograph M. Susan Marion et al.; 2001 Spirometry Reference Values for American Indian Adults: Results From the Strong Heart StudyUSA262445-74159.7 F; 173,5 MBoth Mijnhart S&M Instruments Falaschetti, E. et al; 2004 Prediction equations for normal and low lung function from the Health Survey for EnglandEngland6053 (2497 m 556 f)16-75162±6.4 f 176±6.8 mBoth Vitalograph Escort Spirometer Marsh, S. et al; 2006 Complete reference ranges for pulmonary function tests from a single New Zealand populationNew Zealand21218-70147–190 cmBoth Jaegar Master Screen Body Variable Extraction Data collected (SPSS software):

14. Author; YearTitleCountrynAgeHeightGenderSpirometer Roca, J. et al.; 1998 References values for forced spirometry England 12900 (1500 m, 1500 f) 20-44164 - 177Both Sensor Medics 2130; Jaeger Pneumolab Vitalograph; Morgan Spirograph DS12; Sensor Medics Pne 12050; Spirotech S500; Hewlett Packard; Morgan Spirograph DS12 Muhammad Asif Memon et al.; 2007 Spirometric reference values in healthy, non-smoking, urban Pakistani population Pakistan50415-65Both Micromedical, Microloop and Microrint (airway resistant) in Conjunction with spida 5 PC software Cruz-Merida, A. J. et al; 2004 Prediction equations for spirometric parameters in Mexican adult population Not available Won Young, Kim et al; 1998 Prediction equations of pulmonary function parameters derived from the forced expiratory spirogram for healthy adults over 50 years old in rural area Not available Virani, S. N. et al; 2001 Pulmonary function studies in healthy non-smoking adults in Sri Aurobindo Ashram, Pondicherry Not available McDonnell, W. F et al; 1998 Spirometric reference equations for older adults Not available Baig, M. I. A. Et al; 2007 Pulmonary function tests: Normal values in non-smoking students and staff at the Aga Khan University, Karachi PakistanNot available Dejsomritrutai, W. et al; 2000 Reference spirometric values for healthy lifetime nonsmokers in Thailand ThailandNot available Mathur, N. et al; 1998 Lung function norms in healthy working women Not available

16. * Find at least one study that can be applied to Portugal; * Gather a set of adequate spirometry reference values for our country; * Expose the necessity for these kind of studies Expected Results

17. 1. Baur, X., S. Isringhausen-Bley, et al. (1999). "Comparison of lung-function reference values." International Archives of Occupational and Environmental Health 72(2): 69-83. 2. Enright P. Testing your lungs: spirometry [Internet]. European Lung Foundation. Available from: http://www.european-lung-foundation.orghttp://www.european-lung-foundation.org 3. Garcia-Rio, F., J. M. Pino, et al. (2004). "Spirometric reference equations for European females and males aged 65-85 yrs." Eur Respir J 24(3): 397-405. 4. Hughes, J.M.B.,Interpreting pulmonary function tests [Internet] ERS Education –Your best online source of CME in respiratory medicine [2007] European Respitatory Society. Available from: http://www.ers- education.org/media/2009/pdf/103639.pdf http://www.ers- education.org/media/2009/pdf/103639.pdf 5. Ip, M. S.-m., F. W.-s. Ko, et al. (2006). "Updated Spirometric Reference Values for Adult Chinese in Hong Kong and Implications on Clinical Utilization" Chest 129(2): 384-392. 6. Kuster, S. P., D. Kuster, et al. (2008). "Reference equations for lung function screening of healthy never- smoking adults aged 18-80 years." Eur Respir J 31(4): 860-868. 7. Liberati, A., D. G. Altman, et al. (2009). "The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration." Journal of Clinical Epidemiology 62(10): e1-e34. 8. Miller, Martin R. Interactive Course on Spirometry Training [Internet] ERS Education –Your best online source of CME in respiratory medicine [2007] European Respitatory Society. Available from: http://www.ers-education.org/pages/default.aspx?id=326 http://www.ers-education.org/pages/default.aspx?id=326 9. Unknown. STROBE Statement - checklist of items that should be included in reports of observational study [Internet] Strobe Statement: Strengthening the reporting of observational studies in epidemiology. [2009] ISPM - University of Bern. Available from: http://www.strobe-statement.orghttp://www.strobe-statement.org Information Sources

18. LEITE, Ana; PEIXOTO, Cláudia; MOURA, Diana; MARTINS, Diana; FERNANDES, Luís; ALMEIDA, Maria; BRITO, Nuno; ALMEIDA, Pedro; DIOGO, Pedro; MONTEIRO, Sara; PIMENTA, Sofia Class 1; turma1intromed@gmail.com 2009/2010