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. Research Questions  How good are the studies published in the last decade?  Is there any study that can be applied to Portugal? If so, which one is the best?

3. Introduction  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

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. Spirometric reference values vary with individual characteristics. They should be tailored to each individual; At the time of diagnosis, there aren’t previous personal values. The spirometric data is compared to those calculated from population studies (reference values); Healthcare professionals may be using inappropriate reference values for their target-populations, resulting in compromised diagnosis. 1,3,5,6 1 Baur, 1999 3 Garcia-Rio, 2004 5 Ip, 2006 6 Kuster, 2008

6. Aims  Summarize the wide range of data that has been published in the last decade;  Propose, from all studies, the most suitable for Portugal or suggest the conduction of a study in our country.  Analyze and rate the obtained information using the STROBE checklist 9 ; 9 STROBE statement

7. Methods

8. Methods  Key words: “A systematic review attempts to collate all empirical evidence that fits pre-specified eligibility criteria to answer a specific research question.” 7 Spirometry Reference Values FEV1; FVC  Study design: Systematic review;  Data Sources (online databases): 7 Liberati, 2009

9. Query: ("1998"[Publication Date] : "2008"[Publication Date]) AND ("Spirometry"[tiab] AND ("Reference values"[mh] OR "Reference equations")) PUBMED

10. Query: ISI WEB OF KNOWLEDGE

11. (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)) Query: SCOPUS

12. Criteria Inclusion Criteria Exclusion Criteria o Articles whose full text can not be achieved for free; o Values referring to diseased individuals; o Articles about studies with insufficient or inconclusive data; o Study subjects with history of pulmonary disease Articles written in Portuguese or English; Articles referring to studies performed in humans; Articles which refer the equipment used; Articles published from 1998 to 2008. Study subjects over 18 years old Cross-sectional studies only

13. Research Method

14. 7 Liberati, 2009

15. 1. Search for studies 2. Select and layout the studies that meet the criteria 3. Rate using the STROBE checklist 4. Conclusion Procedure

16. Expected results  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

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=326http://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

19. 9 STROBE statement

20. AuthorPublicationDateTitle Number of participants Number of tested people Equipment Used equations CountryAgeGendersProfileScore Ruth Macdonald Nature2007 ´How often is diagnosis of COPD confirmed with spirometry? 13010……England23FeminineCaucasian 5 George Stevens JAMA2001 “ Reference values for lung function tests” 520265……USA47MasculineCaucasian 3 Frederico Andreoni Nature2004 “ Interpreting pulmonaruy function tests” 300170……Brasil38MasculineCaucasian 17