Episode #53 Advocating for Race-neutral Approach to Pulmonary Function Testing with Drs. Meredith McCormack & Loretta Que

Dr. Albert Rizzo:
Welcome back to Lungcast, the monthly respiratory health podcast series from the American Lung Association and medical news site HCP Live.com. I'm your host, Dr. Albert Rizzo, Chief Medical Officer of the American Lung Association.

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Today, we are discussing race-based normal values in medicine, particularly in pulmonary function testing. Race-based normal values refer to the practice of using a person's self-reported race to adjust a standard or “normal” range for certain medical tests. By doing this, it implies that different racial groups may have inherently different physiological values for specific health metrics, like blood pressure or kidney function.

This practice has been shown to lead to potential misdiagnosis and disparities in healthcare delivery. For this reason, it is increasingly criticized due to the complex and often inaccurate nature of using race as a biological marker, and the potential for racial bias in medical decision-making. Many experts argue that using race as a sole factor to adjust normal ranges is problematic because race is a social construct, not a biological category, and often fails to account for other factors like socioeconomic status, which can significantly impact health outcomes.

While race-based interpretation of pulmonary function tests is still somewhat prevalent, there is a growing movement to phase it out. Major medical organizations, like the American Thoracic Society, now advocate for the use of race-neutral reference equations, significantly reducing reliance on race in PFT interpretation. This shift is largely due to concerns about racial bias and the recognition that using race as a sole factor in lung function assessment is neither accurate nor equitable.

To give an expert perspective on this topic, we have two guests today:

Dr. Albert Rizzo:
Dr. Meredith McCormack is Professor of Medicine in the Division of Pulmonary and Critical Care at the Johns Hopkins School of Medicine and Environmental Health Services at the Johns Hopkins Bloomberg School of Public Health. Dr. McCormack has clinical expertise in asthma and COPD, as well as pulmonary physiology and pulmonary function testing. She serves as Medical Director of the Johns Hopkins University Pulmonary Function Lab and is the immediate past chair of the American Thoracic Society Committee for Proficiency Standards in Pulmonary Function Testing.

Dr. Albert Rizzo:
We also have with us today Dr. Loretta Quay, Professor of Medicine at Duke University. She serves as Chief of the Division of Pulmonary, Allergy, and Critical Care Medicine and is the current Principal Investigator of the American Lung Association Clinical Research Center Program at Duke. Dr. Quay has clinical expertise in asthma and COPD and is a clinical translational researcher studying mechanisms underlying airway remodeling and airway inflammation in asthma. She also serves on the American Thoracic Society Committee for Proficiency Standards in Pulmonary Function Testing and is an ad hoc member of the National Heart, Lung, and Blood Institute.

Dr. Meredith McCormack & Dr. Loretta Quay:
Thank you for inviting us.

Dr. Albert Rizzo:
Now, welcome back. In 1840, John Hutchinson, a surgeon, recognized that the volume of air that can be exhaled from fully inflated lungs is a powerful indicator of longevity. As a result, he invented the spirometer to measure what he called “vital capacity” or the capacity to live.

Much later, the concept of the timed vital capacity, which became known as the FEV1, was added. Together, these two numbers—vital capacity and FEV1—are useful in identifying patients at risk of many diseases, including COPD, lung cancer, heart attack, stroke, and all-cause mortality.

As more data was collected, it was noted that vital capacity increased with height, declined with age in adulthood, differed between sexes, and varied by occupation, for example, sedentary versus active jobs. Another early and consistent observation was that vital capacity varied between social classes. Subsequently, descriptions ascribed to social class were overtaken by studies focused on population differences based on the social and political construct of race. Average vital capacity for the same sex, height, and age was reported to be lower in non-white compared with white groups, although some investigators argued for environmental sources for these differences, such as early-life nutrition, respiratory illness, air pollution, exercise, or altitude.

The mechanisms and quantification of these effects were not systematically pursued. Rather, a narrative of innate racial differences took hold.

Dr. Albert Rizzo:
As a starting point for today’s discussion, I would like our experts to tell us about the GLI, or the Global Lung Function Initiative, and its role in moving toward race-neutral equations.

Dr. Meredith McCormack:
The Global Lung Function Initiative is an international collaboration of physicians, physiologists, researchers, and industry partners. They formed a network around 2008 to improve how lung function is reported and interpreted across all age groups globally. This network has become the largest resource of reference values for routine lung function testing.

The GLI function data includes populations from different countries around the world, and lung function from healthy populations has been used to create reference equations that describe how a person’s lung function compares to what is expected for someone of similar age and height.

In 2022, the GLI introduced race-neutral equations—equations that do not require selection of race. In 2023, two significant publications were released in the journal Chest. One, in August 2023, discussed the effect of race and ethnicity on pulmonary function testing interpretation, and earlier that same year, the official ATS statement on race, ethnicity, and pulmonary function testing interpretation was released.

Dr. Loretta Quay:
Those publications reflect years of dialogue and scientific review. The movement to reconsider race in medical algorithms began years earlier, in part sparked by medical students and early-career trainees noticing race in several clinical algorithms across specialties. This led the ATS and other professional organizations to examine the historic precedent, assess whether race was necessary in lung function interpretation, and review the scientific evidence rigorously. The conclusion was to no longer include race in interpreting lung function.

Dr. Meredith McCormack:
Manufacturers of spirometry software are also updating their systems. Measurements of lung function, such as liters of air exhaled during a forced breath, do not change. What changes is how we interpret those values. Race previously influenced the assessment of what is considered normal or expected. Now, software algorithms are adapting to show results using race-neutral reference equations.

Dr. Loretta Quay:
Educational efforts are ongoing. Respiratory societies, including the ATS, American College of Chest Physicians, American Lung Association, and European Lung Foundation, have prepared educational materials for both patients and physicians. At Duke, we developed handouts and videos explaining the impact of diversity and the use of race-neutral equations on pulmonary function testing, including how to interpret Z-scores.

Dr. Meredith McCormack:
For most patients with normal or severe lung disease, nothing changes. But for patients near thresholds, results may shift from normal to mild disease or vice versa. Borderline values now highlight areas where we may need more monitoring or intervention.

Dr. Loretta Quay:
These changes can have real-world implications, including insurance, disability benefits, and job eligibility. The categorization of lung function may shift between normal, mild, moderate, or severe, affecting eligibility for certain benefits or positions, such as firefighting or jobs requiring respiratory protective equipment.

Dr. Albert Rizzo:
Since both of you have been involved, what’s the status of using GLI predictive values at your institutions?

Dr. Loretta Quay:
At Duke, we started using the GLI predictive reference equations for spirometry in 2024, then adapted them for carbon monoxide gas transfer, and are now implementing them for static lung volumes. It required software upgrades and equipment, which can be expensive and a barrier for some institutions.

Dr. Meredith McCormack:
At Johns Hopkins, we followed a similar process—updating reports, software, and communication with providers—so that lung function over time could be interpreted accurately using the new reference values.

Dr. Loretta Quay:
Next steps include broader dissemination to patients, providers, disability organizations, insurance companies, and other stakeholders, with materials available in multiple languages.

Dr. Meredith McCormack:
Manufacturers have also been involved, helping laboratories implement GLI race-neutral approaches.

Dr. Albert Rizzo:
Any closing comments?

Dr. Meredith McCormack:
This process reflects ongoing efforts to question and improve our practices to better care for patients. Engaged dialogue with patients, providers, and the medical community is key.

Dr. Albert Rizzo:
Thank you both for your time and contributions. For our listeners, be sure to subscribe to Lungcast, rate our show, and visit Lung.org and HCP Live.com for more respiratory news and resources. Until next time, I’m Dr. Albert Rizzo, reminding you: if you can’t breathe, nothing else matters.