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Underestimation of airflow obstruction among young adults using FEV₁/FVC <70% as a fixed cut-off: a longitudinal evaluation of clinical and functional outcomes

¹ Division of Respiratory Diseases, IRCCS "San Matteo" Hospital Foundation, University of Pavia, Pavia, Italy
² Unit of Epidemiology and Medical Statistics, Department of Medicine and Public Health, University of Verona, Verona, Italy
³ Centre for Research in Environmental Epidemiology (CREAL) at Institut Municipal d’Investigació Mèdica (IMIM), Barcelona, Spain
⁴ Department of Experimental Sciences and Health, Universitat Pompeu Fabra (UPF), Barcelona, Spain, and CIBER in Epidemiology and Public Health
⁵ Institució Catalana de Recerca i Estudis Avançats (ICREA), Barcelona, Spain
⁶ Department of Medical Sciences, Respiratory Medicine and Allergology, University of Uppsala, Uppsala, Sweden
⁷ Respiratory Epidemiology and Public Health Group, National Heart and Lung Institute, Imperial College, London, UK
⁸ Department of Thoracic Medicine, Haukeland University Hospital, Bergen, Norway
⁹ Department of Allergy, Respiratory Medicine and Sleep, Landspitali University Hospital, Reykjavik, Iceland
¹⁰ Institute of Epidemiology, GSF-National Research Centre for Environment and Health, Neuherberg, Germany
¹¹ Department of Epidemiology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands

Correspondence to:
Dr A G Corsico, Clinica Malattie Apparato Respiratorio, Fondazione IRCCS Policlinico San Matteo, via Taramelli 5, 27100 Pavia, Italy; angelo.corsico{at}unipv.it

Background: Early detection of airflow obstruction is particularly important among young adults because they are more likely to benefit from intervention. Using the forced expiratory volume in 1 s (FEV₁) to forced vital capacity (FVC) (FEV₁/FVC) <70% fixed ratio, airflow obstruction may be underdiagnosed. The lower limit of normal (LLN), which is statistically defined by the lower fifth percentile of a reference population, is physiologically appropriate but it still needs a clinical validation.

Methods: To evaluate the characteristics and longitudinal outcomes of subjects misidentified as normal by the fixed ratio with respect to the LLN, 6249 participants (aged 20–44 years) in the European Community Respiratory Health Survey were examined and divided into three groups (absence of airflow obstruction by the LLN and the fixed ratio; presence of airflow obstruction only by the LLN; presence of airflow obstruction by the two criteria) for 1991–1993. LLN equations were obtained from normal non-smoking participants. A set of clinical and functional outcomes was evaluated in 1999–2002.

Results: The misidentified subjects were 318 (5.1%); only 45.6% of the subjects with airflow obstruction by the LLN were also identified by the fixed cut-off. At baseline, FEV₁ (107%, 97%, 85%) progressively decreased and bronchial hyperresponsiveness (slope 7.84, 6.32, 5.57) progressively increased across the three groups. During follow-up, misidentified subjects had a significantly higher risk of developing chronic obstructive pulmonary disease and a significantly higher use of health resources (medicines, emergency department visits/hospital admissions) because of breathing problems than subjects without airflow obstruction (p<0.001).

Conclusions: Our findings show the importance of using statistically derived spirometric criteria to identify airflow obstruction.

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