Article
Rethinking Race in Pulmonary Function Testing: Moving Toward Equity in Lung Health
Ethan Wilson, M.Sc., B.Sc. • November 12, 2025

It’s been well-documented that racial and ethnic disparities exist across many areas of healthcare. In recent years, however, the focus has begun to shift—from simply recognizing these disparities to actively addressing them. Nowhere is this more critical than in the tools and practices we use to diagnose and manage disease.


One such tool is the pulmonary function test (PFT), a standard test used to assess how well the lungs work (1). For over a decade, major medical organizations—including the American Thoracic Society (ATS)—have recommended using race- and ethnicity-specific reference equations to interpret these tests. The idea was to “normalize” expected lung function based on the patient’s racial or ethnic background (2, 3).


But this approach has a major flaw: race is a social construct, not a biological one. By embedding race into the very algorithms we use for diagnosis, we risk reinforcing the very disparities we're trying to dismantle.


The Problem with Race-Specific Equations


Using race-specific equations in pulmonary testing can unintentionally normalize lower lung function values in certain populations—particularly Black individuals. This can lead to underdiagnosis or delayed treatment of pulmonary conditions like asthma or COPD.


In fact, it wasn’t until 2022 that the Global Lung Function Initiative (GLI) released race-neutral average reference equations (GLI-Global and GLI-Other), and it was only in 2023 that the ATS and the European Respiratory Society (ERS) formally recommended transitioning to these updated equations (2).


What the Research Shows


A study by Rosenfeld and colleagues explored what happens when we stop adjusting pulmonary test results for race. They found that using the GLI-Global equations led to a higher average ppFEV1 (percent predicted forced expiratory volume in one second) in White patients (+4.6%) and a lower ppFEV1 in Black patients (-7.7%) (2).


This is significant. The decline seen in Black patients with the race-neutral model suggests that prior race-specific equations may have underestimated the severity of lung disease in this population (2). What was once considered "normal" for Black patients may have, in fact, masked serious illness (2).


Similarly, a study by Burbank and colleagues found that applying race-neutral spirometry equations led to more children being classified with uncontrolled asthma (ppFEV1 < 80%)—regardless of whether their asthma control test (ACT) labelled them as controlled (ACT >19) or uncontrolled (ACT ≤19). Among children with controlled asthma (measured by ACT score >19), those who shifted from “controlled” (≥80%) to “uncontrolled” (<80%) lung function also had significantly lower FEV1/FVC ratios, indicating worse airway obstruction (3).


What This Means for Health Equity


These findings highlight a stark reality: race-specific equations, though well-intended, may perpetuate disparities by obscuring the true burden of disease in certain racial and ethnic groups (2, 3).


Shifting to race-neutral reference equations is not just a technical correction—it’s a step toward more equitable healthcare. It allows us to detect disease earlier, treat it more effectively, and ensure that our diagnostic tools do not unintentionally reflect or reinforce systemic biases.


The Road Ahead


As the medical community continues to reevaluate long-standing practices, it’s vital to center health equity in our decisions. The adoption of race-neutral equations in pulmonary function testing is a powerful example of how evidence-based updates can drive more just and inclusive care.


While this transition is still unfolding, it represents meaningful progress in aligning science with social responsibility—and in ensuring that all patients, regardless of race, receive the care they truly need.

 

  1. Lung Function Tests [Online]. American Lung Association: [date unknown]. https://www.lung.org/lung-health-diseases/lung-procedures-and-tests/lung-function-tests [7 Oct. 2025].
  2. Rosenfeld M, Cromwell EA, Schechter MS, Ren C, Flume PA, Szczesniak RD, Morgan WJ, Jain R. The impact of switching to race-neutral reference equations on FEV1 percent predicted among people with cystic fibrosis,. Journal of Cystic Fibrosis 23: 443–449, 2024. doi: 10.1016/j.jcf.2024.03.013.
  3. Burbank AJ, Atkinson CE, Espaillat AE, Schworer SA, Mills K, Rooney J, Loughlin CE, Phipatanakul W, Hernandez ML. Race-specific spirometry equations may overestimate asthma control in Black children and adolescents. Respiratory Research 24: 203, 2023. doi: 10.1186/s12931-023-02505-3.

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By Ethan Wilson, B.Sc., M.Sc. • November 1, 2025
As a parent, watching your child struggle to breathe is one of the most frightening experiences imaginable. Asthma, a common but serious condition, affects thousands of Canadian children and millions of children around the world —and understanding it is the first step toward managing it with confidence. What Is Asthma? Asthma is a chronic lung condition that causes inflammation and narrowing of the airways, making it harder to breathe. Children with asthma may experience: Coughing Wheezing Chest tightness Shortness of breath These symptoms can be triggered by allergens, viruses, exercise, or even cold air. While asthma has no cure, it can be managed effectively with the right tools and knowledge. How Is Asthma Diagnosed? Even if your child seems to breathe normally most of the time, asthma can still affect their lung function. A spirometry test to measure how well the lungs are working is most commonly used. This test is part of a group called Pulmonary Function Tests (PFTs). Key Measurements in Spirometry: Forced Vital Capacity (FVC): The total amount of air your child can exhale after taking a deep breath. It helps ensure the test is consistent and reliable. Forced Expiratory Volume (FEV): Measures how much air is exhaled in the first 0.5, 0.75 or one second. Healthcare providers use it to assess if there are limitations in air flow which can be associated with outcomes and severity of obstruction. If this number is below 80% of what’s expected for your child’s age, it may indicate airway obstruction. Peak Expiratory Flow (PEF): Shows how fast and forcefully your child can blow air out. It’s a good indicator of effort and lung strength. Forced Expiratory Flow (FEF): Focuses on the middle part of the breath and is more sensitive to show issues in the smaller airways. It is also referred to as Maximum Mid-Expiratory Flow (MMEF). FEV/FVC Ratio: This ratio compares how much air is forcefully exhaled in the first 0.5 (FEV 0.5 ), 0.75 (FEV 0.75 ) or one (FEV 1 ) second compared to the total exhaled. In children, this value is typically larger due to the larger relative size of their large airways compared to their total lung volume. According to the Global Initiative for Obstructive Lung Diseases (GOLD), a ratio lower than 0.70 may be a signal of more serious lung issues and your clinician may want to monitor more closely. Why This Matters for Your Child Asthma is the most common chronic condition in children, and early detection and management are key. Understanding these measurements helps you and your child’s healthcare provider track progress and adjust treatment plans. Making Lung Health Fun with Sparky™ Managing asthma doesn’t have to be scary or boring. That’s why Lung Games International Inc. created Sparky™, a cuddly digital companion that turns breathing exercises into a game. Using a handheld spirometer as a controller, kids help Sparky™ complete fun challenges—while learning proper breathing techniques and tracking their lung health. It’s a playful way to build healthy habits and give parents peace of mind. Want to learn more about Sparky™ or how to support your child’s lung health? Stay tuned for more tips, tools, and stories from families just like yours. References Asthma - What Is Asthma? NHLBI, NIH [Online]. 2024. https://www.nhlbi.nih.gov/health/asthma [7 Oct. 2025]. Asthma - Symptoms and causes [Online]. Mayo Clinic: [date unknown]. https://www.mayoclinic.org/diseases-conditions/asthma/symptoms-causes/syc-20369653 [7 Oct. 2025]. What Is Asthma? [Online]. Cleveland Clinic: [date unknown]. https://my.clevelandclinic.org/health/diseases/6424-asthma [7 Oct. 2025]. Lung Function Tests [Online]. American Lung Association: [date unknown]. https://www.lung.org/lung-health-diseases/lung-procedures-and-tests/lung-function-tests [7 Oct. 2025]. Spirometry [Online]. American Lung Association: [date unknown]. https://www.lung.org/lung-health-diseases/lung-procedures-and-tests/spirometry [7 Oct. 2025]. Pulmonary Function Test: Purpose, Procedure & Results [Online]. Cleveland Clinic: [date unknown]. https://my.clevelandclinic.org/health/diagnostics/17966-pulmonary-function-testing [7 Oct. 2025]. Graham BL , Steenbruggen I , Miller MR , Barjaktarevic IZ , Cooper BG , Hall GL , Hallstrand TS , Kaminsky DA , McCarthy K , McCormack MC , Oropez CE , Rosenfeld M , Stanojevic S , Swanney MP , Thompson BR . Standardization of Spirometry 2019 Update. An Official American Thoracic Society and European Respiratory Society Technical Statement. Am J Respir Crit Care Med 200: e70–e88, 2019. doi: 10.1164/rccm.201908-1590ST. Nève V , Edmé J , Devos P , Deschildre A , Thumerelle C , Santos C , Methlin C , Matran M , Matran R . Spirometry in 3–5‐year‐old children with asthma. Pediatric Pulmonology 41: 735–743, 2006. doi: 10.1002/ppul.20389. Lazova S , Priftis S , Petrova G , Naseva E , Velikova T . MMEF25-75 may predict significant BDR and future risk of exacerbations in asthmatic children with normal baseline FEV1. Int J Physiol Pathophysiol Pharmacol 14: 33–47, 2022. Kwon DS , Choi YJ , Kim TH , Byun MK , Cho JH , Kim HJ , Park HJ . FEF25-75% Values in Patients with Normal Lung Function Can Predict the Development of Chronic Obstructive Pulmonary Disease. Int J Chron Obstruct Pulmon Dis 15: 2913–2921, 2020. doi: 10.2147/COPD.S261732. Jo YS , Kim SK , Park SJ , Um S-J , Park Y-B , Jung KS , Kim DK , Yoo KH . Longitudinal change of FEV1 and inspiratory capacity: clinical implication and relevance to exacerbation risk in patients with COPD. Int J Chron Obstruct Pulmon Dis 14: 361–369, 2019. doi: 10.2147/COPD.S189384. Peak expiratory flow HealthLink BC [Online]. [date unknown]. https://www.healthlinkbc.ca/healthwise/peak-expiratory-flow [2 Oct. 2025]. Aurora P , Stocks J , Oliver C , Saunders C , Castle R , Chaziparasidis G , Bush A . Quality Control for Spirometry in Preschool Children with and without Lung Disease. Am J Respir Crit Care Med 169: 1152–1159, 2004. doi: 10.1164/rccm.200310-1453OC. Torén K , Schiöler L , Lindberg A , Andersson A , Behndig AF , Bergström G , Blomberg A , Caidahl K , Engvall JE , Eriksson MJ , Hamrefors V , Janson C , Kylhammar D , Lindberg E , Lindén A , Malinovschi A , Lennart Persson H , Sandelin M , Eriksson Ström J , Tanash H , Vikgren J , Johan Östgren C , Wollmer P , Sköld CM . The ratio FEV1/FVC and its association to respiratory symptoms—A Swedish general population study. Clin Physiol Funct Imaging 41: 181–191, 2021. doi: 10.1111/cpf.12684.

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