American Thoracic Society Recommendations Research Articles

Measurement Variability in Single-Breath Diffusing Capacity of the Lung

The single-breath diffusing capacity of the lung (DLCO) is a commonly performed pulmonary function test. The current American Thoracic Society (ATS) recommendations for reproducibility of DLCO measurements suggest that two measurements for the DLCO agree within 10% or 3 mL/min/mm Hg of the average value. The European Respiratory Society (ERS) recommends that two measurements should agree within 10%. The objectives of the present study were to examine whether the current reproducibility criteria were met in a general pulmonary function laboratory and to determine whether alternative criteria might be appropriate. Cross-sectional study. University-based pulmonary function laboratory. Patients referred for spirometry, helium lung volumes, and DLCO measurement. None. In a sample of 6,193 patients referred for clinical testing, 98.3% had two DLCO values that fulfilled the current ATS criteria for reproducibility. The coefficient of variation (CV) and the percentage difference between two repeat measurements were inversely associated with the baseline DLCO and the FEV(1). As the baseline DLCO (percentage of predicted) or FEV(1) (percentage of predicted) decreased, there was an increase in the CV and the percentage difference. In contrast, the absolute difference between repeat measurements was relatively stable irrespective of the baseline DLCO or FEV(1) values. Other patient factors, such as gender and race, were not associated with measurement variability. Using an absolute difference of 2 to 2.5 mL/min/mm Hg between two DLCO measurements as alternative criteria for reproducibility, 91.5% and 95.8% of the patient sample fulfilled these criteria, respectively. Reproducibility of the DLCO measurement is generally much better than current standards allow. Future standards should consider an absolute difference rather than a percentage difference criterion for DLCO reproducibility.

The effect of low-dose inhaled fluticasone propionate on exhaled nitric oxide in asthmatic patients and comparison with oral zafirlukast

Exhaled nitric oxide (ENO) is a noninvasive marker of ongoing inflammation in asthmatic patients. Comparison between inhaled and oral anti-inflammatory medications in reduction of ENO in asthmatic patients has not been performed. We measured changes in ENO, spirometry, need for rescue medication, quality of life (QOL), and diary scores (DS) after inhaled and oral anti-inflammatory therapy in adults with moderate asthma. A randomized, double-blind, placebo-controlled, crossover design with 4-week washout periods was used. A plateau level of ENO, measured in parts per billion (ppb), was obtained by chemiluminescence with a Sievers 280NOA as per American Thoracic Society recommendations. Eighteen asthmatic adults (15 Hispanic, with a percentage predicted forced expiratory volume in 1 second (FEV1%) of 50% to 85%) on bronchodilators (beta2) only were studied. Subjects used fluticasone propionate (FP) metered-does inhaler (44 microg), two puffs twice daily, and matching placebo (PB) for 4 weeks. Eight of the asthmatic patients (7 Hispanic, FEV1% 50% to 85%) on bronchodilators only then received blinded zafirlukast (ZK) 20 mg and matching PB twice daily for 4 weeks. Low-dose inhaled FP resulted in significant improvements in ENO, spirometry, QOL, DS, and beta2 use. A significant difference in mean ENO was found (P < 0.01) before and after FP from 34+/-7 ppb to 13+/-3 ppb. A significant improvement was found (P < 0.05) with FEV1% from 75+/-3 to 85+/-3 with FP treatment. The other measured parameters, percentage predicted of peak expiratory flow rate, beta2 need, DS, and QOL measurements, were improved with low-dose FP treatment. No significant reduction was found in ENO with oral ZK for 4 weeks. After oral ZK washout and the second extension arm of placebo, ENO significantly increased back to 47+/-14 ppb (P < 0.05), but spirometry measures did not worsen. Significant improvements were found with DS and beta2 use with oral ZK therapy. These results reveal ENO is reduced with only low-dose inhaled FP in asthmatic patients not on anti-inflammatory medication. In the smaller extension study, ENO was reduced with FP and not with oral ZK treatment, and ENO levels increased back to near prestudy levels after ZK washout and the second extension arm of placebo. As a marker of inflammation, ENO levels reveal an improvement with anti-inflammatory medication and worsening when it is discontinued.

Reference values and prediction equations for FVC and FEV(1) in the Greek elderly.

Spirometry prediction equations obtained from middle-age adults, when extrapolated for the elderly, may lead to inaccurate interpretations. The purpose of this study was to determine prediction equations for forced vital capacity (FVC) and forced expiratory volume (FEV(1)) in the Greek elderly population. Spirometry prediction equations for normal FVC and FEV(1) have been derived from tests on 71 healthy persons (38 men, 33 women) aged older than 60 years (range, 65-85 years), nonsmokers, white race, urban population using techniques and equipment that meet American Thoracic Society recommendations. Regression analysis using age, height, and weight as independent variables was used to provide prediction equations and values for both sexes. The FVC age coefficient in this healthy group was about 47.19 mL/y for elderly men and 34.27 mL/y for elderly women, and the FEV(1) age coefficient was about 52.8 mL/y for elderly men and 46.4 mL/y for elderly women. Values from this study predicted equations were compared with those from some of the most commonly used sources of spirometry predicted equations. The FVC and FEV(1) predicted values were found to be of less mean square error than that of other compared studies. Higher correlation is between FVC and FEV(1) predicted values by the present model and FVC and FEV(1) observed values in both sexes. The higher correlation between FVC and FEV(1) predicted and observed from this study allows the use of our model for predicting in a rather reliable way the FVC and FEV(1) for elderly Greek individuals.

Pneumonia in Immunocompromised and Immunocompetent Patients Requiring Mechanical Ventilation

The role of bronchoscopic sampling including bronchoalveolar lavage (BAL) was assessed in patients with clinical symptoms consistent with pneumonia requiring mechanical ventilation. A total of 173 lavages were performed, with 144 patients on prior antibiotic regimens and 53 patients having human immunodeficiency virus (HIV) infection. The overall diagnostic yield was 34% (59 positive samples) with bacterial infection identified in 28 cases, Pneumocystis carinii in 24 cases, cytomegalovirus in 10 cases, fungal infection in 5 cases, and Mycobacterium tuberculosis in 2 cases. Seven patients had more than one pathogen identified. The diagnostic yield was higher in HIV-infected patients than other groups (chi-square = 17.21, P < .001). Prior antibiotics appeared to have no effect on the diagnostic yield. There was no difference in the type or sensitivity patterns of bacteria isolated from immunocompromised (19) versus immunocompetent (9) patients. We compared the bacterial sensitivities versus the American Thoracic Society recommendations for severe nosocomial pneumonia and found that up to one third of bacteria would have been resistant to the proposed treatments. The most common organisms causing failure were Staphylococcus aureus and Le-gionella (making up 7 of the bacterial isolates). The use of BAL allowed for an accurate diagnosis of pneumonia in more than one third of patients with ventilator-associated pneumonia despite widespread use of antibiotics.

Selection of Reproducible Forced Expirograms: Percentage or Fixed-Volume Criterion

The aim of this study was to evaluate whether the intrasession reproducibility of forced vital capacity (FVC) and forced expiratory volume in 1 s (FEV₁) depends on height and lung volume. FVC tracings of 740 subjects (350 males) from a general population sample living in North Italy were analyzed. Subjects filled out a standardized questionnaire and performed three acceptable FVC maneuvers following the American Thoracic Society recommendations. The differences between the largest and the second largest FVC and FEV₁ were computed as absolute (ΔFVC, ΔFEV₁) and as percentage values (ΔFVC%, ΔFEV₁%). The higher the tertiles of the largest FVC and FEV₁ were, the higher were ΔFVC and ΔFEV₁. Regarding FVC, borderline differences in both sexes for ΔFVC and in males significant differences for ΔFVC% were found among the tertiles. Regarding FEV₁, in both sexes ΔFEV₁ significantly differed among the tertiles. ΔFVC and ΔFEV₁ correlated with height and lung volume in both sexes, except for ΔFVC versus the largest FVC in females. When ΔFVC and ΔFEV₁ were analyzed with respect to respiratory symptoms/diseases and smoking habit, no significant differences were observed in both sexes, except for ΔFEV₁ between ever- and never-smoking males. It may be concluded that the intrasession within-subject variability of FVC and FEV₁ is proportional to lung volume and height, regardless of the sex, presence of symptoms and smoking habit. Thus, our results confirm the usefulness of a reproducibility criterion based on a percentage rather than on a fixed volume.

Spirometric reference values from a sample of the general U.S. population.

Spirometric reference values for Caucasians, African-Americans, and Mexican-Americans 8 to 80 yr of age were developed from 7,429 asymptomatic, lifelong nonsmoking participants in the third National Health and Nutrition Examination Survey (NHANES III). Spirometry examinations followed the 1987 American Thoracic Society recommendations, and the quality of the data was continuously monitored and maintained. Caucasian subjects had higher mean FVC and FEV1 values than did Mexican-American and African-American subjects across the entire age range. However, Caucasian and Mexican-American subjects had similar FVC and FEV1 values with respect to height, and African-American subjects had lower values. These differences may be partially due to differences in body build: observed Mexican-Americans were shorter than Caucasian subjects of the same age, and African-Americans on average have a smaller trunk:leg ratio than do Caucasians. Reference values and lower limits of normal were derived using a piecewise polynomial model with age and height as predictors. These reference values encompass a wide age range for three race/ethnic groups and should prove useful for diagnostic and research purposes.

Spirometry Reference Values for Healthy Elderly Blacks

Pulmonary function was assessed by spirometry in 497 black and 2,980 white ambulatory elderly male and female participants of the Cardiovascular Health Study. The quality assurance program prompted technicians to exceed American Thoracic Society recommendations for spirometry. A "healthy" subgroup of 235 black and 1,227 white participants age 65 years and older was identified by excluding current and former smoker, and those with self-reported asthma or emphysema, congestive heart failure, and poor-quality results of spirometry tests, since those factors were associated with a lower FEV1. Reference equations and normal ranges for elderly blacks for measurements of FEV1, FVC, and the FEV1/FVC ratio were then determined from the healthy group. These elderly blacks had an FVC about 6% lower than elderly whites, even after correcting for standing height, sitting height (trunk length), and age. The popular use of spirometry reference values from studies of middle-aged white subjects by applying a 12% race correction factor for black patients appears to overestimate predicted values.

Lung disease due to alpha 1-antitrypsin deficiency.

The association between alpha 1-antitrypsin deficiency and heritable emphysema was discovered in 1963. Subsequent epidemiologic evidence suggested that a serum alpha 1-antitrypsin level of 11 mumol/L (about 80 mg/dL by the still-used "commercial standard"), which is about 35% of the normal level, represents a "threshold" value, below which the risk of developing emphysema is increased and above which the emphysema risk is not increased. Recently, the ability to isolate and purify the alpha 1-antitrypsin protein from human blood has made "specific" augmentation therapy possible. Intravenous infusion of alpha 1-antitrypsin raises serum and alveolar levels above the putative thresholds, but clinical efficacy (i.e., decreased rate of decline in lung function and/or improved survival) remains presumptive. Based on available evidence, the American Thoracic Society recommends augmentation therapy for individuals with both a documented severe deficiency of alpha 1-antitrypsin and fixed airflow obstruction.

Reference values for pulmonary function tests of Japanese-American men aged 71 to 90 years.

Pulmonary function was assessed by spirometry in 3,076 elderly Japanese-American men of the Honolulu Heart Program (HHP) cohort. The assessment was done with a stringent quality assurance program that adhered to American Thoracic Society (ATS) recommendations for spirometry. Less than 6% of the participants were unable to perform three acceptable spirometry maneuvers. A "healthy" subgroup of 528 men between the ages of 71 and 90 yr was identified by excluding almost all smokers and subjects with lung disease and other factors negatively influencing FEV1. Reference equations and normal ranges for FEV1, FVC, and the FEV1/FVC ratio were derived from the healthy group. Use of prediction equations from the Cardiovascular Health Study (CHS) of elderly European-American men consistently overpredicted FVC by 0.3 to 0.4 L and FEV1 by 0.15 L. Men in the HHP were on average 11 cm shorter than those in the CHS. Use of a prediction equation derived from the HHP cohort when the men in the cohort were on average 22.6 yr younger consistently overpredicted FEV1 by 0.2 to 0.3 L. These results underscore the importance of using prediction equations appropriate to the ethnicity, age, and height characteristics of the subjects being studied.

Spirometry and Maximal Respiratory Pressure References From Healthy Minnesota 65- to 85-Year-Old Women and Men

To obtain spirometry and maximal respiratory pressure (MRP) reference values for elderly persons. Survey. General community. Four hundred seventy-one healthy ambulatory white women and men age 65+ years. A stringent spirometry quality assurance program exceeded American Thoracic Society recommendations. A "healthy" subgroup of 176 women and 112 men between the ages of 65- and 85 years were identified by excluding those with conditions that negatively influenced FEV1 in a multiple regression analysis. Reference equations and normal ranges for FEV1, FVC, FEF25-75%, peak flow, and maximal inspiratory and expiratory pressures (MRPs) were determined from the healthy group with good quality maneuvers. Less than 10% of the subjects were unable to perform three acceptable spirometry maneuvers and ten MRP maneuvers. When the age and height corrected FEV1s from this group were compared with other spirometry reference studies, mean values from the women were nearly identical to those from Morris, while these men had substantially lower FEV1 values (by 0.3- to 0.5L) than elderly men in Crapo's study. Mean peak flow was over 20% higher when compared with previous studies, suggesting greater initial expiratory effort by our subjects. The maximal inspiratory pressure (MIP) values were about 20% higher than those reported by the Cardiovascular Health Study, perhaps because five MIP maneuvers were always performed. Spirometry and MRP reference values used for elderly patients should come from population studies using similar techniques and with large numbers of subjects over age 65 years.

Urinary iron excretion in patients with chronic obstructive airways disease (COAD).

~any patients with chronic obstructive airways disease (CGAD) do not develop polycythemia even though they have similar degree of hypoxia as normal high altitude dwellers and patients with cyanotic heart disease. I In an attempt to explain the lack of erythropoietic response to hypoxia in CGAD we evaluated the iron status in a group of CGAD patients. We chose serum ferritin measurement and the desferrioxamine test to evaluate iron status since liver biopsy was not justifiable. Twenty patients suffering from CGAD (18 men and 2 women, aged 72 ± 10 years) and 10 age matched healthy subjects (8 men and 2 women aged 73 ± 7 y) were studied. Diagnosis of CGAD was based on detailed history and spirometric parameters, according to the American Thoracic Society recommendations. All patients had abnormal spirometry (FEY I IFYC 6'13 kPa, a value established from results obtained in the control group). All studies were done when patients were in hospital and at a time when they were clinically free of acute infection. In none of the patients was there evidence of any other disease. At the time of study none of the patients was receiving any medication which might alter iron metabolism. All patients gave informed consent. None of the control subjects showed haematological problems or alterations of iron metabolism. All of them had normal respiratory function, as defined by clinical and spirometric methods. All samples were collected at 0900 h in order to avoid fluctuations due to circadian rhythm.

Sources of variation in FEV1.

The American Thoracic Society (ATS) recommendations to establish reproducibility of the forced expiratory volume in one second (FEV1) are that the value come from "at least 3 acceptable forced expiratory curves" where "the largest forced vital capacity maneuver (FVC) and the second largest FVC should not vary by more than 5%." It has been suggested that there is a "negative effort dependence" of the FEV1 and, alternatively, that the magnitude of the FVC influences the FEV1. We examined the relationship between FEV1 and a direct measurement of effort, or work, defined as the area under the alveolar pressure-volume curve in 1 s. Thirteen normal individuals and 17 patients with cystic fibrosis or asthma were instructed to make a series of maximal efforts, as in routine testing. Comparing the maneuver that resulted in the greatest work to that with the lowest work, all with FVCs within 5% of one another, there was no correlation between change in work and change in FEV1 (delta FEV1). There was a significant relationship between delta FEV1 and changes in FVC (r = 0.49, p < 0.01). The delta FEV1 did not correlate with the degree of hyperinflation (the FRC) or degree of airflow limitation (the initial FEV1). The magnitude of changes in FEV1 was small and almost always within acceptable limits for reproducibility. Because a larger FVC is due either to an increased inspiration, which could affect the FEV1, or to an increased expiratory reserve volume, which occurs only after the first second, these results emphasize the importance of a maximal inspiration at the start of the test.

Standardisation of gas mixtures for estimating carbon monoxide transfer factor.

The American Thoracic Society recommends that the inspired concentration used for the estimation of carbon monoxide transfer factor (TLCO) mixture should be 0.25-0.35% carbon monoxide, 10-14% helium, 17-21% oxygen, balance nitrogen. Inspired oxygen influences alveolar oxygen and hence carbon monoxide uptake, such that transfer factor increases by 0.35% per mm Hg decrease in alveolar oxygen. To aid in the standardisation of TLCO either a known inspired oxygen concentration should be used, or TLCO should be corrected to a standard inspired oxygen concentration. The range of gas mixtures used in practice and the implications for cost and accuracy have been investigated. A questionnaire was sent to 185 respiratory units in the UK requesting information on (1) the method used to estimate TLCO, (2) the manufacturer of the equipment, (3) the mixture used, (4) whether "medical quality" gas was ordered, and (5) the level of satisfaction with supplier service. Replies were received from 106 units. Most used the single breath breath holding method for which 17 different test mixtures were ordered. One unit also used the single breath exhalation method. Inspired oxygen ranged from 17.94% to 25%, giving a wide variation in alveolar oxygen and hence TLCO. Forty seven units ordered a specific inspired oxygen, the rest ordering "air" as balance. The cost per litre of gas varied greatly, with the mixture 14% helium, 0.28% carbon monoxide, balance air (17.9% oxygen) and 10% helium, 0.28% carbon monoxide, balance air (18.8% oxygen) being cheapest to produce. Ordering a specific inspired oxygen concentration increased the cost. Large cylinders of gas were cheaper for the same mixture. The mixture for the exhalation method was the most expensive. Sixty seven units ordered "medical quality" gas and six assumed this was supplied. Twenty nine (27%) were dissatisfied with their supplier due to (1) poor service, (2) long delivery times, (3) costs, or (4) wrongly labelled cylinders. It is recommended that two mixtures be available: (a) 14% helium, 0.28% carbon monoxide, balance air for a helium analyser reading up to 15%, and (b) 10% helium, 0.28% carbon monoxide, balance air for lower reading helium analysers. The mixture should be produced under a medical product licence. The advantage of the single exhalation method for routine clinical use needs to be investigated in view of the higher cost of the mixture.

Prediction Equations for Single-Breath Carbon Monoxide Diffusing Capacity from a Chinese Population

Most available prediction equations for the single breath carbon monoxide diffusing capacity, or DLCO, are based on white populations and do not account for racial differences. We performed this test on 436 Chinese adults. The method of measurement essentially followed the American Thoracic Society recommendations. Data on 306 subjects who had two technically acceptable test results provided prediction equations and upper and lower 95% confidence limits for healthy nonsmokers. Simple linear equations using age, height, and body weight as independent variables were generated and compared with nonlinear models. The use of nonlinear models did not add to the predictability of standard linear regressions. The distribution of residuals (predicted-measured values) was Gaussian with simple linear regressions. A comparison of predicted values for DLCO, calculated from different equations in an independent group of healthy subjects, revealed that the present set of equations had the smallest residual mean and standard deviation rankings compared with other equations for white subjects. These are the first DLCO equations proposed for Chinese men and women aged 20 to 70 yr. The predicted values from this study for DLCO and alveolar volume (VA), were significantly lower than those of most equations for white subjects, but were not for DLCO/VA. Although a portion of the differences may be explained by the additive effects of technical factors, the discrepancies can also be attributed to the smaller body size in this ethnic group, and consequently to the smaller lung volumes. Equations derived from whites, with inclusion of smokers, provided predicted values comparable to, or even lower than, those from this study.(ABSTRACT TRUNCATED AT 250 WORDS)

Spirometry Reference Values for Women and Men 65 to 85 Years of Age: Cardiovascular Health Study

Pulmonary function was assessed by spirometry in 5,201 ambulatory elderly participants of the Cardiovascular Health Study, sampled from four communities. A stringent quality assurance program exceeded American Thoracic Society (ATS) recommendations for spirometry. Less than 6% of the participants were unable to perform three acceptable spirometry maneuvers. A "healthy" subgroup of 777 women and men 65 to 85 yr of age was identified by excluding smokers and those with lung disease and other factors determined to independently, significantly, and negatively influence the FEV1. Results from black participants were examined separately. Reference equations and normal ranges for FEV1, FVC, and the FEV1/FVC ratio were determined from the healthy group. The results demonstrate differences in predicted values as great as 20% (0.5 to 1 L) for elderly patients when compared with the spirometry reference equations that are most commonly used in the United States.

Impairment after adult respiratory distress syndrome. An evaluation based on American Thoracic Society recommendations.

To test the hypothesis that impairment after the adult respiratory distress syndrome (ARDS) is uncommon, we evaluated 41 ARDS survivors using ATS standards for determination of impairment. A total of 101 trials of pulmonary function tests were obtained between 1 and 388 wk after the onset of ARDS. It was possible to evaluate impairment at 1 yr or more after ARDS in 27 subjects. Eighteen of the 27 were impaired. The percentage of ARDS survivors who were impaired on the basis of FVC, FEV1, FEV1/FVC, and DLCOsb was 50.0, 61.1, 33.3, and 82.4%, respectively. Impairment was mild in 13 (72.2%), moderate in four (22.2%), and severe in one (5.6%). Smoking status had no predictive value in determining impairment. Physiologic indices of ARDS severity (maximal pulmonary artery pressure, lowest static thoracic compliance, and maximal level of PEEP) were found to be significantly different when those impaired 1 yr or more after ARDS were compared with those not impaired. Symptoms were found to have no association with impairment. We conclude that, using ATS criteria, impairment 1 yr or more after ARDS onset is common. Patient characteristics and symptoms after ARDS have no association with impairment 1 yr or more after ARDS onset, whereas physiologic indices of severity during ARDS do.

Effect of effort on measurement of forced expiratory volume in one second.

The American Thoracic Society recommends that the largest FEV1 be reported from a set of forced expiratory vital capacity maneuvers performed with maximal expiratory effort. However, increased expiratory effort can decrease the FEV1. When we evaluated the peak expiratory flow rate (PEFR) in 5 normal subjects, measured from flow-volume curves, as a noninvasive index of expiratory effort, it was positively correlated with indices of effort obtained by using an esophageal balloon. We then measured the difference (dFEV1)between the largest FEV1 and FEV1 from the maneuver with the highest PEFR during 10 test sessions in 10 normal subjects. Thus, dFEV1 was always greater than or equal to 0. The mean dFEV1 was 110 ml for all sessions but decreased to 80 ml when maneuvers with poorly reproducible PEFR or forced expiratory vital capacity values were discarded. We also reviewed 9.471 spirometry sessions from outpatients and found dFEV1 to be greater than 50 ml in 26% of this population and greater than 151 ml in 7%. We concluded that during standard spirometry, FEV1 is inversely dependent on effort. Maximal effort decreases FEV1 because of the effect of thoracic gas compression on lung volume. We recommend that values from spirometry maneuvers that demonstrate submaximal effort, indicated by a decreased PEFR, be discarded. The flow-volume curve display of superimposed efforts facilitates the recognition of submaximal efforts.

Evaluation of the turbine pocket spirometer.

A compact electronic spirometer, the turbine pocket spirometer, which measures the FEV1, forced vital capacity (FVC), and peak expiratory flow (PEF) in a single expiration, was compared with the Vitalograph and the Wright peak flow meter in 99 subjects (FEV1 range 0.40-5.50 litres; FVC 0.58-6.48 l; PEF 40-650 l min-1). The mean differences between the machines were small--0.05 l for FEV1, 0.05 l for FVC, and 11.6 l min-1 for PEF, with the limits of agreement at +/- 0.25 l, +/- 0.48 l, and +/- 52.2 l min-1 respectively. The wide limits of agreement for the PEF comparison were probably because of the difference in the technique of blowing: a fast, long blow was used for the pocket spirometer and a short, sharp one for the Wright peak flow meter. The FEV1 and FVC showed a proportional bias of around 4-5% in favour of the Vitalograph. The repeatability coefficient for the pocket spirometer FEV1 was 0.18 l, for FVC 0.22 l, and for PEF 31 l min-1. These compared well with the repeatability coefficients of the Vitalograph and the Wright peak flow meter, which gave values of 0.18 l, 0.28 l, and 27 l min-1 respectively. At flow rates of over 600 l min-1 the resistance of the pocket spirometer marginally exceeded the American Thoracic Society recommendations. The machine is easy to operate and portable, and less expensive than the Vitalograph and Wright peak flow meter combined. It can be recommended for general use.

Japanese-American pulmonary reference values: Influence of environment on anthropology and physiology

Anthropometric measurements and pulmonary function (volumes, flows, and flow-volume curves) were evaluated in a community study of 59 male and 59 female, nonsmoking, healthy Japanese-American volunteers uniformly distributed in decades from 20 to 80 years. A control group of 36 Caucasians was similarly constituted. One technologist performed all tests. Techniques and equipment matched American Thoracic Society recommendations. A cohort effect was demonstrated for anthropometric measurements in the Japanese-Americans. They were smaller and lighter than the Caucasians but taller and heavier than the Japanese of Japan. The differences from whites diminished with youth. Although the group mean volumes and flows differed little from white reference series of Crapo et al. (1981, 1982), there was a difference in the older subjects. Flow-volume curves were increased in all Japanese-Americans. Prediction equations for pulmonary function have been prepared using standing height, age, and sex. More precise formulae would need to include skinfolds, lean body weight, and span. Our Caucasians did not differ anthropometrically or in their pulmonary function from those of the mainland. In conclusion, Japanese-American anthropometry and pulmonary function in Hawaii shows a gradation from that of Japanese to Caucasians, the extent depending on the age. This is secondary to an environmental influence on anthropometry and physiology. As a consequence race-specific reference values for volumes, flows, and flow-volume curves are necessary in evaluating pulmonary function of individual Japanese-Americans.

Evolution of Short-Course Antimicrobial Treatment of Tuberculosis in Children, 1951-1984

Although the first unrecognized indication that short-course antimicrobial treatment of tuberculosis might be effective came in reports of tuberculous meningitis and miliary tuberculosis in children so treated by Lorber (1951 to 1956), the 1977 American Lung Association-American Thoracic Society recommendation for antimicrobial therapy of tuberculosis in adults still specified an 18-month course. The first prospective study on the short-course antimicrobial treatment of children in the United States was published in December 1983. The long delay before recognition of the practicability of short-course antimicrobial treatment of tuberculosis has probably been occasioned by ignorance of drug actions and the mechanisms involved.