Clinical Investigations
Respiration 1999;66:242–250
Static Lung Volumes: Reference Values
from a Latin Population of Spanish
Descent
Pedro J. Cordero a Pilar Morales a Eduardo Benlloch a Luis Miravet c
Javier Cebrian b
a Servicio de Neumologı́a y b Unidad de Cuidados Intensivos, Hospital Universitario La Fe, Valencia;
c Servicio de Neumologı́a, Hospital de Vinaroz, Castellón, Spain
Key Words
Reference values W Static lung volumes W Caucasians W
Lung function
Abstract
Background and Objectives: The aim of this study was to
develop a set of prediction equations and 90% confi-
dence intervals for static lung volumes using the multi-
breath helium equilibration method from a sample of
asymptomatic Caucasian subjects of Spanish descent.
Moreover, these equations were compared with those of
previous studies. Methods: Measurements of static lung
volumes using techniques recommended by the Ameri-
can Thoracic Society and the European Community for
Steel and Coal were carried out on a selected sample of
591 healthy nonsmoking volunteers (305 men and 286
women) aged 18–88 years, living in the metropolitan
area of Valencia, on the east coast of Spain. Multiple
regression analysis using height, age and weight as
independent variables were used to provide predicted
values for both sexes. These reference values were com-
pared with other sets of prediction equations reported in
the literature using an independent sample of 69 sub-
jects (32 men and 37 women). Results: Simple linear
© 1999 S. Karger AG, Basel
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Received: June 5, 1998
Accepted after revision: October 1, 1998
regression equations using age, height and body weight
predicted all the subdivisions of lung volumes (vital
capacity, expiratory reserve volume (ERV), inspiratory
capacity, functional residual capacity (FRC), residual vol-
ume (RV), total lung capacity (TLC), FRC/TLC and RV/
TLC) as well as more complex equational models. The
distribution of residuals fulfilled the assumptions of mul-
tiple regression analysis (independence, homoscedastic-
ity and Gaussian distribution of residuals), except for
ERV, using simple linear models. The derived equations
did not differ significantly from most of the previously
reported equations and were usually superior in their
ability to predict the lung volumes. Conclusions: The use
of the present prediction equations is recommended in
the Latin population of Spanish descent and in popula-
tions with similar Caucasian characteristics.
Introduction
A review of reference values for static lung volumes
shows remarkable discrepancies in predicted values
among different authors [1, 2]. Such differences may be
ascribed to the selection of subjects, methodological and
Dr. Pedro J. Cordero
Lluis Vives 8, 3
E–46700 Gandia (Spain)
Tel. +34 96 2876282, Fax +34 96 1704106
E-Mail pcordero@separ.es
technical differences in the assessment and variability due Table 1. Age distribution of normal subjects subdivided by sex and
to the inclusion of different ethnic groups. anthropometric features
Ideally, reference values should be derived from per-
Age n Age Height Weight BMI
sons without present or previous conditions that affect years cm kg kg/m2
ventilatory function [1]. Most studies on lung function in
healthy men and women of European descent refer to a Men
rather small number of subjects recruited among men and 18–29 49 25B3 175B8 74B10 24B3
women without evidence of chest disease, who were 30–39 41 34B3 172B7 77B10 26B3
40–49 49 45B3 169B7 77B11 26B3
usually members of the staff and visitors as well as outpa- 50–59 61 55B3 165B5 74B10 27B3
tients attending the other departments of the hospital. 60–69 66 64B3 165B6 75B10 27B4
Current smokers and former smokers were not, as a rule, 670 39 75B4 161B7 71B9 27B3
excluded [3–5]. Moreover, since most of the studies were Total 305 50B17 168B8 75B10 26B3
performed at least 2 decades ago, they may not fulfil cur-
Women
rent quality criteria and may not fit present day popula- 18–29 38 23B3 162B5 57B7 22B2
tions due to cohort effects [2]. Thus, prediction equations 30–39 35 35B3 158B6 61B9 24B4
should be derived from a healthy and representative pop- 40–49 50 45B3 157B6 63B11 26B4
ulation tested by standardized technical methods and 50–59 52 55B3 156B6 66B8 26B3
subjected to appropriate statistical analysis [1, 2]. The 60–69 61 64B3 153B5 68B9 27B4
670 50 75B4 151B7 63B10 27B4
aim of this study was to develop a set of prediction equa-
tions and 90% confidence intervals (90% CI) for lung vol- Total 286 52B17 156B7 64B10 26B4
umes using the multibreath helium equilibration method
Data are expressed as means B SD. n = Number of subjects.
from a sample of asymptomatic subjects of Spanish de-
scent and to compare the derived equations with those
reported previously.

deformities, cardiorespiratory and abdominal symptoms in the

Material and Methods
Reference Population
Subjects were selected among a Latin Caucasian population of
healthy volunteers (18–88 years of age and nonsmokers), living at sea
level in the Valencia Metropolitan area, on the east coast of Spain.
Volunteers were recruited to reflect the socioeconomic diversity of
the population of Valencia by targeting advertisements to different
socioeconomic groups (residential homes for the elderly, large stores,
parishes and religious communities, small transportation enterprises,
feeding, building, insurance and agricultural workers as well as free-
lance professionals). We defined nonsmokers as those who had never
smoked, those who smoked less than 1 cigarette/day for less than 6
months and those who had not smoked cigarettes for more than 5
years before the onset of the study. The study protocol and rationale
were explained to all patients, both verbally and in writing. Informed
consent was obtained from all subjects in accordance with the
requirements of the local Committee on the Ethics of Human Experi-
mentation.
Each of the subjects filled out a self-administered modified ver-
sion of the questionnaire cited by the Epidemiology Standardization
Project [6], which formed the basis for assessing the respiratory
health status. Specific sociological inquiries included in the question-
naire helped to reduce the possibility of a socioeconomical bias in the
sample selection. Moreover, all subjects underwent physical exami-
nation, chest radiographic evaluation and an electrocardiogram
when the subject was over 45 years old. The following items were
considered exclusion criteria: the presence of thoracoabdominal wall
present or in the past which could lead to study limitations, neuro-
muscular disease and a known systemic disease, overweight above
20% [7], pregnancy, high risk occupational lung disease and concom-
itant treatments with sedative, heart or respiratory drugs.
Of the 621 subjects studied, 591 subjects, 305 males (51.6%) and
286 females (48.4%), were finally included. From these, 396 subjects
were natives and 195 (33%) were immigrants from other regions of
Spain, 498 subjects (83%) worked and 103 (17%) were retired; 490
subjects (83%) answered they had never smoked and 101 (17%) had
stopped smoking at least 5 years before and they had smoked less
than 1 cigarette/day during a maximum of 6 months. The remaining
30 (4.7%) were excluded: 12 subjects (1.9%) due to smoking history,
9 (1.4%) because of a poor cooperation when performing the spirom-
etry, 7 (1.1%) due to a suspected clinical history of asthma, and 2
(0.3%) due to a recent infection of upper airways. Subjects were
divided into six subgroups according to age: 18–29, 30–39, 40–49,
50–59, 60–69 and 670 years, comprising about 50 men and 50 wom-
en in each subgroup (table 1).
Static Lung Volume Determination
Data were gathered from July 1990 to October 1994. Spirometric
tests were performed on working days between 9 a.m. and 1 p.m. and
the distribution throughout the year was homogeneous. Standing
height was measured to the nearest millimeter without shoes, and
weight was measured (in kg) without shoes and with light indoor
clothing.
Spirometry was conducted using a 10-liter dry spirometer (Mijn-
hardt, Volugraph 2000), with a helium analyzer incorporated and
automatic reading of the different lung volumes that meets require-

Prediction Equations for Static Lung Respiration 1999;66:242–250 243

Volumes
ments of the European Community for Steel and Coal (ECSC) and Table 2. Mean values and standard deviations of age, height, weight,
the American Thoracic Society (ATS) [1, 8]. All measurements were BMI and lung function variables for women and men
performed on seated subjects, sitting upright, and fitted with a nose
clip. The accessory devices used (chair with a straight rigid back, nose Women Men p value
clips and mouthpieces) were the same in all the subjects studied. The
technical personnel consisted of only two technicians, each with Age, years 52B17 50B17 ! 0.001
more than 10 years of full-time experience in performing spirometry, Height, cm 156B7 168B8 ! 0.001
and two physicians who were involved in the project. Weight, kg 64B10 75B10 ! 0.001
The tests were carried out in the following order: (1) forced spi- BMI, kg/m2 26.4B4.2 26.6B3.3 NS
rometry, (2) determination of static lung volumes by the multibreath FVC, liters 2.97B0.76 4.20B1.01 ! 0.001
helium equilibration method and (3) determination of the inspirato- FEV1, liters 2.43B0.70 3.38B0.88 ! 0.001
ry vital capacity after the helium rebreathing test. Both the calibra- FEV1/FVC 0.81B0.06 0.80B0.11 ! 0.05
tion of the devices and the performance of the maneuvers were per- FEF25–75%, liters 2.62B0.99 3.42B1.25 ! 0.001
formed following strictly the requirements recommended by the VC, liters 3.07B0.75 4.36B0.98 ! 0.001
ECSC and the ATS [1, 8]. All volumes and flows were corrected for ERV, liters 0.81B0.43 1.22B0.55 ! 0.001
body temperature and pressure saturated conditions [9]. IC, liters 2.25B0.51 3.14B0.71 ! 0.001
The static lung volumes were measured following the closed cir- FRC, liters 2.36B0.52 3.18B0.76 ! 0.001
cuit helium dilution technique [1]. The first step was to flush the RV, liters 1.54B0.39 1.96B0.56 ! 0.001
spirometer with ambient air, to place the bell in its lowest position TLC, liters 4.61B0.80 6.32B1.08 ! 0.001
and close the circuit. Oxygen was added until a concentration of 25– RV/TLC 0.34B0.09 0.31B0.08 ! 0.001
30% was reached and the volume added recorded, then the helium FRC/TLC 0.51B0.07 0.50B0.08 NS
meter was adjusted to zero when a stable reading was obtained. The
system was fit by adding about 2 liters of air and enough amount of Mean B SD. NS = Nonsignificant (Mann-Whitney U test).
helium so as to reach an initial concentration of 10%. The patient
breathed room air through the mouthpiece while he had the nose clip
placed. The test started once a stable expiratory level at rest was
reached, i.e. the functional residual capacity (FRC) position, and
after a preliminary period so that the patient became accustomed to the different parameters was calculated [(SD of the differences/mean
the apparatus and attained a stable breathing pattern. At the end of a value)*100].
normal expiration, the valve of the mouthpiece was opened to con-
nect the patient to the spirometer. The patient breathed again consec- Development of the Prediction Equations
utively in the closed circuit in which the gas mixture circulated. The The following prediction equations corresponding to vital capaci-
CO2 was absorbed by the soda lime contained in a canister while O2 ty (VC), inspiratory capacity (IC), expiratory reserve volume (ERV),
was added through a valve and the flow meter was automatically functional residual capacity (FRC), residual volume (RV) and total
adjusted to the rate of the O2 consumption of the patient (in adults lung capacity (TLC) in liters and to the ratios FRC/TLC and RV/
about 250–300 ml/min). As the helium (contained at the beginning in TLC were obtained. The equations were calculated separately for
the device) mixed with the air in the lung, its concentration dimin- men and women. Age (years), height (cm), weight (kg) and body mass
ished, as could be seen in the gas analyzer. The stabilization of index (BMI; kg/m2 ) were taken as predictors or independent vari-
helium concentration was indicated by a change rate in the concen- ables. Regression equations were also calculated using the following
tration below 0.02% during an interval of 30 s indicating the point at transformations of both the independent and dependent variables:
which balance was achieved in the whole system [1]. In healthy sub- (1) logarithmic (y* = ln y); (2) square root (y* = ! y); (3) quadratic
jects, the end point of the test is reached in less than 7 min. In this (y* = y2 ); and (4) interacting variables: (y*= y1*y2).
study, the test never took more than 10 min. Measurements were
repeated for each subject with a 15-min interval until two FRC deter- Comparison among Prediction Equations for Lung Volumes
minations did not differ more than 200 ml. In order to compare with other prediction equations, an indepen-
Appropriate corrections suggested in the literature were made [1, dent sample of 69 subjects (32 men and 37 women) was studied
10], especially in those patients who did not connect to the spirome- between October 1994 and October 1995. All patients fulfilled the
ter exactly at the mean resting end-expiratory level. inclusion criteria mentioned above. The procedure and the techni-
The devices were periodically calibrated according to the follow- cians who made the determinations corresponded to those of the pre-
ing criteria: (1) daily calibration of the spirometer with an accuracy vious phase, but lung volumes were determined with a sealed-water
metallic syringe (Sibelmed) of 3 liters. The contents of the syringe spirometer (Collins DS II/PLUS) that meets ECSC and ATS require-
were ejected at three different speeds. The maximum differences tol- ments [1, 8]. In this group of patients, the values observed were com-
erated were: B3% or B50 ml [1]; (2) weekly calibration with a pared with those obtained after applying different sets of prediction
dynamic signal provided by an explosive decompressor with a capac- equations reported in the literature [3–5, 11–13] including those of
ity of 4 liters (Sibelmed 122), and (3) monthly calibration of the ana- the present study. TLC, RV, FRC and VC were analyzed.
lyzer at two levels and checking of its linearity every 3 months. In
order to assess the intrasubject variability, lung volumes were mea- Statistical Analysis
sured on 20 subjects, chosen at random, twice in the same day (at All continuous data were tested for Gaussian distribution using
9 a.m. and at 1 p.m.) and 1 month later (at 9 a.m.). From the data the Kolmogorov-Smirnov test. The different variables were com-
obtained, the coefficient of variation for multiple measurements of pared regarding sex by Mann-Whitney U test. Intrasubject variabili-

244 Respiration 1999;66:242–250 Cordero/Morales/Benlloch/Miravet/

Cebrian
Table 3. Global analysis of intrasubject
variability and coefficients of variation 1st day (9 a.m.) 1st day (1 p.m.) 30th day (9 a.m.) p value CV, %

VC, liters 3.31B0.59 3.28B0.61 3.32B0.59 NS 2.3

IC, liters 2.46B0.39 2.35B0.44 2.40B0.42 NS 8.5
ERV, liters 0.85B0.38 0.91B0.33 0.92B0.35 NS 21.0
FRC, liters 2.31B0.39 2.33B0.46 2.37B0.51 NS 14.2
RV, liters 1.38B0.35 1.41B0.34 1.45B0.40 NS 17.3
TLC, liters 4.70B0.55 4.67B0.58 4.78B0.52 NS 5.1
FRC/TLC 0.48B0.07 0.49B0.07 0.49B0.08 NS 15.3
RV/TLC 0.29B0.07 0.30B0.07 0.30B0.08 NS 11.2

Mean B SD. NS = Nonsignificant (Friedman’s test); CV = coefficient of variation.

ty was studied by applying Friedman’s test for repeated measures. Table 4. Linear simple correlation coefficients
Spearman’s test was applied to establish correlations between depen-
dent and independent variables. This analysis was repeated by Age Height Weight BMI
applying the different transformations to the variables. Prediction
equations were obtained following the multiple linear regression tech- Men
nique by the stepwise procedure. In all cases, the goodness of fit was VC –0.692** 0.795** 0.327** –0.233**
studied by: (1) multiple correlation coefficient (R), (2) standard error of IC –0.547** 0.631** 0.514** 0.088
estimate (SEE) and (3) residual behavior (independence, Gaussian dis- ERV –0.511** 0.588** –0.064 –0.500**
tribution and homoscedasticity). For all pulmonary volumes and FRC –0.081 0.515** –0.050 –0.431**
ratios, 90% CI were calculated as the product between the SEE of each RV 0.407** 0.118 –0.004 –0.090
equation times 1.64. Prediction equations of TLC, RV, FRC and VC TLC –0.416** 0.775** 0.302** –0.244**
reported by some authors [3–5, 11–13] as well as those of the present FRC/TLC 0.345** –0.086 –0.411** –0.382**
study were compared using the Wilcoxon’s matched-pairs signed-rank RV/TLC 0.714** –0.390** –0.211** 0.060
test. A 5% significance level was used in all statistical tests.
Women
VC –0.750** 0.715** –0.047 –0.424**
IC –0505** 0.560** 0.284** –0.030
Results ERV –0.704** 0.579** –0.413** –0.697**
FRC –0.287** 0.549** –0.191* –0.476**
Characteristics of the Reference Sample RV 0.405** 0.093 0.211** 0.144
Table 2 shows the results obtained from a comparative TLC –0.505** 0.715** 0.056 –0.330**
FRC/TLC 0.211** –0.056 –0.399** –0.352**
analysis of the variables regarding sex. Statistically signifi-
RV/TLC 0.767** –0.430** 0.150 0.368**
cant differences were found in all the variables except in
BMI and in the FRC/TLC ratio. Therefore, prediction * p ! 0.01; ** p ! 0.001 (Spearman’s test).
equations were derived separately for both sexes.
In men, variables such as age, height, ERV and the
FRC/TLC and RV/TLC ratios did not show a Gaussian
distribution. All these variables, except age, became
Gaussian following logarithmic transformation. In wom- Simple Linear Correlation Analysis between
en, age, weight, RV/TLC did not show a Gaussian distri- Dependent and Independent Variables
bution. After applying the logarithmic transformation The results are shown in table 4. In some cases the cor-
and square root all the variables, except age, became relation coefficients improved, although very slightly, af-
Gaussian. ter simple transformations.

Intrasubject Variability Prediction Equations for Lung Volumes

The parameters analyzed showed no significant differ- Tables 5 and 6 show the equations obtained for men
ences (table 3). The lowest variation coefficient was found and women as well as the 90% CI of the equations
in VC (2.3%) while the highest was in ERV (21.0%), being obtained for each variable and 95% CI of their coeffi-
14% in FRC. cients. The equations obtained both in men and women

Prediction Equations for Static Lung Respiration 1999;66:242–250 245

Volumes
Table 5. Prediction equations for lung volumes in men

Equations R SEE 90% CI

VC 0.073* H –0.021* A –6.866 0.85 0.51 0.83

(+0.065 to +0.082) (–0.026 to –0.017) (–8.467 to –5.264)
IC 0.023* H +0.025* W –0.016* A –1.89 0.74 0.47 0.77
(+0.014 to +0.033) (+0.019 to +0.031) (–0.019 to –0.011) (–3.407 to –0.373)
ERV 0.046* H –0.021* W –0.006* A –4.661 0.71 0.38 0.62
(+0.038 to +0.054) (–0.026 to –0.016) (–0.009 to –0.003) (–5.905 to –3.416)
FRC 0.089* H –0.033* W +0.018* A –10.185 0.68 0.55 0.90
(+0.078 to +0.099) (–0.039 to –0.026) (+0.013 to +0.022) (–11.954 to –8.416)
RV 0.043* H –0.012* W +0.024* A –5.654 0.60 0.44 0.72
(+0.035 to +0.052) (–0.018 to –0.006) (+0.020 to +0.028) (–7.071 to –4.236)
TLC 0.106* H –11.396 0.77 0.68 1.11
(+0.096 to +0.115) (–13.032 to –9.759)
FRC/TLC 0.005* H –0.005* W +0.003* A –0.134 0.62 0.06 0.08
(+0.038 to +0.006) (–0.005 to –0.004) (+0.002 to +0.003) (–0.338 to –0.071)
RV/TLC 0.001* H –0.002* W +0.004* A +0.028 0.73 0.05 0.09
(+0.000 to +0.002) (–0.002 to –0.000) (+0.003 to 0.004) (–0.155 to +0.211)

H = Height (in cm); W = weight (in kg); A = age (in years); VC, IC, ERV, FRC, RV and TLC in liters; R = multiple regression coefficient.
90% CI = 90% CI calculated as the product between the SEE of each equation times 1.64. 95% CI of the equation coefficients are given in
parentheses.

Table 6. Prediction equations for lung volumes in women

Equations R SEE 90% CI

VC 0.049* H –0.023* A –3.409 0.84 0.40 0.78

(+0.041 to +0.057) (–0.026 to –0.019) (–4.750 to –2.066)
IC 0.020* H +0.018* W –0.013* A –1.280 0.69 0.36 0.70
(+0.011 to +0.027) (+0.013 to +0.023) (–0.016 to –0.010) (–2.519 to –0.040)
ERV 0.029* H –0.018* W –0.009* A –2.114 0.83 0.24 0.47
(+0.024 to +0.034) (–0.021 to –0.014) (–0.011 to –0.007) (–2.928 to –1.300)
FRC 0.052* H –0.018* W +0.004* A –4.858 0.63 0.40 0.78
(+0.043 to +0.061) (–0.024 to –0.013) (+0.001 to +0.008) (–6.224 to –3.491)
RV 0.023* H +0.014* A –2.790 0.53 0.33 0.65
(+0.016 to +0.029) (+0.011 to +0.016) (–3.886 to –1.693)
TLC 0.072* H –0.009* A –6.125 0.73 0.54 1.06
(+0.061 to +0.082) (–0.013 to –0.004) (–7.930 to –4.319)
FRC/TLC 0.003* H –0.004* W –0.002* A +0.183 0.73 0.05 0.09
(+0.001 to +0.004) (–0.005 to –0.003) (+0.001 to +0.003) (–0.011 to +0.376)
RV/TLC +0.004* A +0.142 0.76 0.05 0.09
(+0.003 to 0.004) (+0.129 to +0.162)

For further details, see table 5.

by introducing the variables transformed did not signifi-
cantly improve the goodness of fit regarding the equations
obtained with the nontransformed variables.
All the variables studied fulfilled the application con-
ditions of the model of multiple regression except in ERV
which did not fulfil the assumption of Gaussian distribu-
tion of the residuals not even when they were repeated
with the transformed variables. The exclusion of the out-
liers did not significantly modify the prediction equations
so they were finally included.

246 Respiration 1999;66:242–250 Cordero/Morales/Benlloch/Miravet/

Cebrian
 Fig. 1. Examples of comparisons of reference values for RV from the present study and some previous studies [3–5,
11–13]. Calculations were made for a 40-year-old person. Weights for the data of Grimby and Soderholm [5] and the
present study are average weights from actuarial tables for each height [14].

Table 7. Comparison of the values found

in VC, FRC, RV and TLC in an References VC, liters FRC, liters RV, liters TLC, liters
independent sample of subjects with No.
those estimated by the different equations
Men (n = 32; age = 48B17 years; height = 168B7 cm; weight = 75B 14 kg)
P. study –0.157B0.645 –0.017B0.558 –0.017B0482 –0.177B0.826
3 0.191B0.611 –0.134B0.480 –0.130B0.417 –0.167B0.795
11 0.359B0.610** –0.039B0.475 0.002B0.402 0.293B0.763*
5 –0.040B0.638 0.171B0.586 0.177B0.496* 0.117B0.886
12 –0.127B0.631 0.074B0.474 0.118B0.408 –0.004B0.817
13 0.194B0.626 0.715B0.460*** 0.407B0.399*** 0.371B0.795*
Women (n = 37; age = 51B13 year; height = 155B6 cm; weight = 67B12 kg)
P. study 0.001B0.405 –0.055B0.307 –0.052B0.222 –0.057B0.443
3 0.408B0.398*** –0.307B0.371*** –0.153B0.218*** 0.077B0.488
11 0.272B0.424*** –0.129B0.329* –0.051B0.264 0.169B0.448*
5 0.268B0.418*** 0.630B0.306*** 0.378B0.259*** 0.656B0.432**
12 0.137B0.410* –0.344B0.396*** –0.191B0.230*** –0.089B0.498
4 –0.056B0.391 –0.190B0.356** –0.150B0.230*** 0.039B0.437

Mean differences B SD were obtained by substracting the values estimated by different

equations from the values observed; P. study = present study. * p ! 0.05; ** p ! 0.01; *** p !
0.001 (Wilcoxon’s matched-pairs signed-rank test).

Comparison with Other Prediction Equations (table 7)
The mean (standard deviation) of the differences be-
tween observed and predicted values showed remarkable
discrepancies among the different authors considered in
the analysis (fig. 1). Our prediction equations best esti-
mated all the variables, no significant differences oc-
curred between the values observed and those estimated.
Then, the prediction equations that showed a better good-
ness of fit were those of the ECSC [3] and those derived by
Crapo et al. [12]; nevertheless, both of them showed sig-
nificant differences regarding the values observed in the
variables VC, FRC and RV for women. The prediction
equations reported by Grimby and Soderholm [5] showed
results more distant from the values observed, being sta-

Prediction Equations for Static Lung Respiration 1999;66:242–250 247

Volumes
tistically significant in VC, FRC, RV and TLC for women
and in RV for men and tending to their underestimation
(117B886 ml for TLC in men, and 656 B 432 ml for TLC
in women).
Discussion
This study reports a set of prediction equations and
90% CIs for static lung volumes using the multibreath
helium equilibration method from a sample of asymp-
tomatic Caucasian subjects of Spanish descent. The sub-
jects represent a wide range of heights and ages and were
drawn from various occupational and social classes.
The following basic criteria required to obtain the ref-
erence values of the static lung volumes were fulfilled in
our study: (1) a sufficient number of subjects for each sex;
(2) a defined reference population: healthy nonsmoking
individuals living in an urban area at sea level; (3) stan-
dardization of measurements and quality control proce-
dures; (4) accurate statistical analysis, and (5) internal
consistency of the reference equations proposed.
In order to be able to extend the results obtained, the
sample must represent the population studied. The ideal
design of a reference sample demands a randomization of
the components selected prior to the application of the
inclusion and exclusion criteria. Nevertheless, due to its
complexity, most of the studies reported in the literature
do not fulfil such randomization criteria. On the other
hand, Van Ganse et al. [15], in a revision of the medical
criteria for selecting ‘normal’ subjects, reported that the
differences among different models of prediction equa-
tions which are currently used in respiratory physiology,
mainly depend on the different biological characteristics
of the individuals and/or the technical factors used, but
not on the selection criteria of the volunteers. The patients
included in our study were not randomly selected. To try
to avoid this inconvenience, we considered the following
aspects: (1) to diversify the sources of the volunteers
included in the study, therefore diminishing the sample
bias, and (2) to accurately define the individual as well as
the inclusion and exclusion criteria. Individuals were ini-
tially subdivided regarding their sex in all the assessments
based on the literature [3–5, 11–13] and later because of
the significantly higher values in our series in men regard-
ing women.
According to Stocks and Quanjer [2], published refer-
ence values are unsatisfactory by today’s standards. Dis-
crepancies among sets of prediction equations for static
lung volumes in Caucasians for either men or women
248 Respiration 1999;66:242–250
reflect differences: (1) in the selection of the reference sub-
jects , and (2) in the techniques applied and/or in the qual-
ity control of the measurements [2].
Differences in the Selection of the Reference Subjects
The selection criteria used by many authors were very
different. Therefore, while Crapo et al. [12] only included
nonsmoking volunteers, others included health care per-
sonnel, not excluding smokers. According to Clausen [16],
the achievement of independent prediction equations for
nonsmokers, former smokers and smokers has resulted in
statistically significant differences among them, so that
ATS recommends obtaining different reference values in
nonsmokers [8].
Other differences are related to the ethnic group since
lung volumes are lower in members of the black race and
in Asiatic subjects than in the white population. The dif-
ferences found among races are mainly due to the TLC
which has shown to be up to 15–20% higher in Caucasians
than in the Chinese or Indian population [17, 18]. FRC
and RV showed no significant differences among differ-
ent races. The differences in the distribution of the body
fat, the thorax dimensions and different pressures pro-
duced by the respiratory muscles may partially account
for the differences observed [19].
Physical activity during childhood, especially those
which develop the shoulder girdle, e.g. rowing, swimming
and diving, contribute to the development of larger lung
volumes [1, 20]. There are doubts whether reference val-
ues must be adjusted in athletes. In our study, profession-
al athletes were not included although some sportsmen
and sportswomen were included.
Subjects who live at high altitude have larger lung vol-
umes than those who live at sea level. Malik and Singh
[21] proved that the VC was 15–18% larger in adolescents
who lived in 13,500 m compared with the population
with similar characteristics who lived at a lower altitude
(1,500–2,000 m). Although in most studies lung volumes
were determined at sea level, Goldman and Becklake [11]
carried out their determinations at altitudes of 1,750 m,
while Crapo et al. [12] performed them at 1,520 m, this
fact could account for larger volumes.
Finally, the socioeconomic status could also affect the
lung function since a low social level is usually related to
other factors, e.g. unfavorable environmental conditions.
Living in urban areas results in increased environmental
and occupational exposure to harmful substances, higher
contamination levels, higher rate of respiratory disorders,
more difficulties in having medical care and malnutrition
[19].
Cordero/Morales/Benlloch/Miravet/
Cebrian
 Differences in the Techniques Applied and/or in the
Quality Control of the Measurements
In order to obtain static lung volumes, we strictly fol-
lowed the ECSC and the ATS recommendations [1, 8, 22].
Since the existence of circadian [23] and seasonal [24]
variations has been demonstrated in the determination of
lung volumes, all the studies were performed in the morn-
ing and homogeneously all over the year.
Regarding the position in which the test is performed,
it has been proven that when the position is gradually
changed from standing to sitting, semirecumbent and
supine decubitus, there is progressive FRC and ERV
decrease and IC increase [25, 26]. TLC, VC and to less
extent RV diminish, though slightly. Most authors made
these determinations with the subject in a sitting position,
However, Boren et al. [13] studied their subjects in a se-
mirecumbent position which could account for the lower
volumes obtained.
Regarding the different methods used to measure stat-
ic lung volumes, all of them showed a high correlation in
healthy subjects [27]. Thus, comparison of TLC determi-
nation methods by means of Pearson’s correlation coeffi-
cient ranged from 0.87 to 0.96 between body plethysmog-
raphy and radiological methods [28–30], and from 0.93 to
0.94 between the radiological method and the closed cir-
cuit helium dilution technique [27, 31]; it was 0.929
between body plethysmography and closed circuit helium
dilution technique [32], and 0.99 between the latter and
the single-breath helium dilution method [33]. The single-
breath methods may slightly underestimate the lung vol-
umes in healthy subjects. In subjects with chronic obstruc-
tive pulmonary disease, the underestimation of the true
lung volume may become very large due to uneven distri-
bution of inhaled gas [34]. Therefore, the European Re-
spiratory Society does not recommend it for routine use
[1]. From the equations reported, we must emphasize that
in the equations obtained by Goldman and Becklake [11]
the closed circuit using hydrogen as a test gas was used, in
those of Crapo et al. [12], the single-breath helium dilu-
tion method, and in those of Boren et al. [13], the closed
circuit helium dilution technique and the open circuit
nitrogen dilution method. Therefore, we assume that pos-
sible differences may be partially due to the gas measure-
ment method chosen by other authors. These differences
are even more marked when the volumes obtained by gas
dilution methods are compared with other methods, e.g.
body plethysmography [34], in which FRC determination
may elicit values which are even 10% higher, or radiologi-
cal methods, although they are not usually employed for
this purpose.
Prediction Equations for Static Lung
Volumes
In order to control the quality of the determinations,
protocols were designed to enable us to prove the accuracy
and precision of the measurements. To ensure the accura-
cy of the measurements, the devices were periodically cal-
ibrated. To assess the precision, the intrasubject variabili-
ty was assessed in a group of subjects in whom repeated
determinations were performed on different days. The
coefficients of variation obtained for the different vari-
ables showed no significant differences regarding those
reported in literature [4, 12].
In the statistical analysis, simple linear models of pre-
diction equations for their goodness of fit and their sim-
plicity were used. The mathematical adjustment of our
equations represented by the multiple correlation coeffi-
cient and the standard error of estimate is very similar to
other models reported in the literature. Furthermore,
unlike previously reported series [3–5, 12, 13], our refer-
ence sample is larger and uniform in the different age
groups.
The equations obtained in the present study were com-
pared with those from other studies [3–5, 11–13] evaluat-
ing a sample of 69 subjects, independent of the initial
sample. Comparison was performed only with lung vol-
ume equations selected by the ATS in 1991 [35]. Only the
equations of Crapo et al. [12] strictly fulfilled all the rec-
ommendations of the ATS [8], since the remaining studies
included smokers. The differences occurring in the crite-
ria used in the sample selection, smoking habit, height
above sea level and the type of technique used account for
the differences found among different authors. The equa-
tions which showed worse fit were those of Grimby and
Soderholm [5], mainly in women. The equations pro-
posed by Boren et al. [13] for men, although they were
calculated from a large sample (n = 422), showed a trend
to underestimate the lung volumes. This fact may be
explained by the inclusion of ‘patients’ in the reference
population as well as testing in a semirecumbent position.
Overall, our equations showed the best fit, and there were
no significant differences in any of the variables analyzed
between the estimated and observed values.
In conclusion, the present study provides original pre-
diction equations for lung volumes using the multiple
breath helium dilution technique in 591 nonsmoking
Caucasian adults (from 18 to 88 years) living in Valencia
at the east coast of Spain, at sea level, and with no evi-
dence of disease. The prediction equations presented are
recommended as most suitable for the Latin population of
Spanish descent and for populations with similar Cauca-
sian characteristics.
Respiration 1999;66:242–250 249
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