The Need to Embrace Race-Neutral Spirometry Equations, With Nicole Ramsey, MD, PhD

For decades, interpretation of spirometry results had relied on race- and ethnicity-specific reference equations, a practice intended to account for observed differences in lung function across populations which has increasingly drawn scrutiny for its potential to perpetuate inequities in diagnosis and care.^1,2

In response to growing concerns about the clinical and ethical implications of race-based adjustments, the American Thoracic Society (ATS) issued new recommendations in 2023 adopting a global average reference equation, known as the race-composite GLI Global, to derive spirometry reference values for all patients regardless of racial or ethnic background. The updated guidance represents a shift away from the historical use of race and ethnicity as variables in spirometry interpretation and toward a race-neutral approach for use in clinical practice and pulmonary function laboratories.

“The recent scientific evidence shows superiority of a race-neutral approach to PFT interpretation for assessing overall and pulmonary prognosis, and for assessing the impact of exposure to tobacco smoke,” said panel co-chair Nirav R. Bhakta, MD, PhD, associate professor, critical care specialist and pulmonologist, University of California, San Francisco School of Medicine.

This evolution in clinical thought is supported by 5 recent research studies demonstrating race-neutral equations are superior for assessing pulmonary prognosis and predicting clinical outcomes across diverse populations.

For the primary care physician, these changes underscore "race" is a social construct rather than a fixed biological characteristic. While adopting race-neutral standards is a critical step toward health equity, the ATS emphasizes the necessity of ongoing research into modifiable risk factors to achieve greater precision in respiratory care.

“We need better, maybe risk calculators to take people's whole picture into account, not just their race, not just their height, but other things that they might be exposed to that might be contributing to their lung health,” said Nicole Ramsey, MD, PhD, an assistant professor of pediatrics at the Icahn School of Medicine at Mount Sinai Hospital.³

For decades, the ATS and European Respiratory Society recommended race-specific interpretations, where reference values were derived from populations of the same race. The categorization of pulmonary function by race has been a staple of clinical practice, rooted in 19th-century beliefs that race reflects innate, immutable physical differences. These historical perspectives significantly predated modern investigations into the complex environmental and social determinants of lung health.^1,2

Under these previous standards, race-specific equations often required the results of Black patients to be significantly lower—in some cases by 15% than those of White patients of the same age, height, and sex to be labeled "abnormal". Clinical experts now argue "normalizing" these differences through race-specific adjustments ignores the profound impact of modifiable risk factors and structural racism. This approach has historically led to tangible medical harms for people of color, including delayed diagnoses and reduced access to essential therapies.

For more on the subject, Patient Care Online sat down with Ramsey at the 2026 American Academy of Allergy, Asthma & Immunology Annual Meeting to discuss her presentation titled “Using Race-Neutral Spirometry Equations Improves Diagnostic Accuracy”.

Ramsey has no relevant disclosures to report.

References:

1. Wilson KC. Role of Race in the Interpretation of Pulmonary Function Tests: The American Thoracic Society’s Efforts to Mitigate Bias in Its Clinical Guidance. American Journal of Respiratory and Critical Care Medicine. 2023;207(8):961-962. doi: https://doi.org/10.1164/rccm.202303-0351ed
2. American Thoracic Society | ATS Publishes Official Statement on Race,…. American Thoracic Society. Accessed March 4, 2026. https://site.thoracic.org/about-us/news/ats-publishes-official-statement-on-race-ethnicity-and-pulmonary-function-test-interpretation
3. Ramsey N. Using Race-Neutral Spirometry Equations Improves Diagnostic Accuracy. Presented at: 2026 American Academy of Allergy, Asthma & Immunology Annual Meeting; February 27-March 2, 2026; Philadelphia, Pennsylvania.