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Event: 1250

Key Event Title

A descriptive phrase which defines a discrete biological change that can be measured. More help

Decrease, Lung function

Short name
The KE short name should be a reasonable abbreviation of the KE title and is used in labelling this object throughout the AOP-Wiki. More help
Decreased lung function
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Biological Context

Structured terms, selected from a drop-down menu, are used to identify the level of biological organization for each KE. More help
Level of Biological Organization
Individual

Key Event Components

The KE, as defined by a set structured ontology terms consisting of a biological process, object, and action with each term originating from one of 14 biological ontologies (Ives, et al., 2017; https://aopwiki.org/info_pages/2/info_linked_pages/7#List). Biological process describes dynamics of the underlying biological system (e.g., receptor signalling).Biological process describes dynamics of the underlying biological system (e.g., receptor signaling).  The biological object is the subject of the perturbation (e.g., a specific biological receptor that is activated or inhibited). Action represents the direction of perturbation of this system (generally increased or decreased; e.g., ‘decreased’ in the case of a receptor that is inhibited to indicate a decrease in the signaling by that receptor).  Note that when editing Event Components, clicking an existing Event Component from the Suggestions menu will autopopulate these fields, along with their source ID and description.  To clear any fields before submitting the event component, use the 'Clear process,' 'Clear object,' or 'Clear action' buttons.  If a desired term does not exist, a new term request may be made via Term Requests.  Event components may not be edited; to edit an event component, remove the existing event component and create a new one using the terms that you wish to add.  Further information on Event Components and Biological Context may be viewed on the attached pdf. More help
Process Object Action
respiratory function trait decreased

Key Event Overview

AOPs Including This Key Event

All of the AOPs that are linked to this KE will automatically be listed in this subsection. This table can be particularly useful for derivation of AOP networks including the KE. Clicking on the name of the AOP will bring you to the individual page for that AOP. More help
AOP Name Role of event in AOP Point of Contact Author Status OECD Status
Decreased lung function AdverseOutcome Karsta Luettich (send email) Under development: Not open for comment. Do not cite Under Development
Lung surfactant function inhibition leading to decreased lung function AdverseOutcome Jorid Birkelund Sørli (send email) Open for comment. Do not cite Under Development
Oxidative stress Leading to Decreased Lung Function AdverseOutcome Karsta Luettich (send email) Open for comment. Do not cite
AHR activation decreasing lung function via AHR-ARNT tox path KeyEvent Dianke Yu (send email) Under development: Not open for comment. Do not cite
AHR activation decreasing lung function via P53 tox path AdverseOutcome Dianke Yu (send email) Under development: Not open for comment. Do not cite
Ox stress-mediated CFTR/ASL/CBF/MCC impairment AdverseOutcome Karsta Luettich (send email) Open for comment. Do not cite
ox stress-mediated FOXJ1/cilia/CBF/MCC impairment AdverseOutcome Karsta Luettich (send email) Open for comment. Do not cite

Taxonomic Applicability

Latin or common names of a species or broader taxonomic grouping (e.g., class, order, family) that help to define the biological applicability domain of the KE.In many cases, individual species identified in these structured fields will be those for which the strongest evidence used in constructing the AOP was available in relation to this KE. More help
Term Scientific Term Evidence Link
human Homo sapiens High NCBI

Life Stages

An indication of the the relevant life stage(s) for this KE. More help
Life stage Evidence
Adult High

Sex Applicability

An indication of the the relevant sex for this KE. More help
Term Evidence
Mixed High

Key Event Description

A description of the biological state being observed or measured, the biological compartment in which it is measured, and its general role in the biology should be provided. More help

Lung function is a clinical term referring to the physiological functioning of the lungs, most often in association with the tests used to assess it. Lung function loss can be caused by acute or chronic exposure to airborne toxicants or by an intrinsic disease of the respiratory system. 

Although signs of cellular injury are typically exhibited first in the nose and larynx, alveolar-capillary barrier breakdown may ultimately arise and result in local edema (Miller and Chang, 2003). Clinically, bronchoconstriction and hypoxia are seen in the acute phase, with affected subjects exhibiting shortness of breath (dyspnea) and low blood oxygen saturation, and with reduced lung function indices of airflow, lung volume and gas exchange (Hert and Albert, 1994; and How it is Measured or Detected;). When alveolar damage is extensive, the reduced lung function can develop into acute respiratory distress syndrome (ARDS). This severe compromise of lung function is reflected by decreased gas exchange indices (PaO2/FIO2 ≤200 mmHg, due to hypoxemia and impaired excretion of carbon dioxide), increased pulmonary dead space and decreased respiratory compliance (Matthay et al., 2019). Acute inhalation exposures to chemical irritants such as ammonia, hydrogen chloride, nitrogen oxides and ozone typically cause local edema that manifests as dyspnea and hypoxia. In cases where a breakdown of the alveolar capillary function ensues, ARDS develops. ARDS has a particularly high risk of mortality, estimated to be 30-40% (Gorguner and Akgun, 2010; Matthay et al., 2018; Reilly et al., 2019).

Lung function decrease due to reduction in lung volume is seen in pulmonary fibrosis, which can be linked to chronic exposures to e.g. silica, asbestos, metals, agricultural and animal dusts (Meltzer and Noble, 2008; Cheresh et al., 2013; Cosgrove, 2015; Trethewey and Walters, 2018). Additionally. decreased lung function occurs in pleural disease, chest wall and neuromuscular disorders, because of obesity and following pneumectomy (Moore, 2012). Decreased lung function can also be a result of narrowing of the airways by inflammation and mucus plugging resulting in airflow limitation. Decreased lung function is a feature of obstructive pulmonary diseases (e.g. asthma, COPD) and linked to a multitude of causes, including chronic exposure to cigarette smoke, dust, metals, organic solvents, asbestos, pathogens or genetic factors.

How It Is Measured or Detected

A description of the type(s) of measurements that can be employed to evaluate the KE and the relative level of scientific confidence in those measurements.These can range from citation of specific validated test guidelines, citation of specific methods published in the peer reviewed literature, or outlines of a general protocol or approach (e.g., a protein may be measured by ELISA). Do not provide detailed protocols. More help

Pulmonary function tests are a group of tests that evaluate several parameters indicative of lung size, air flow and gas exchange. Decreased lung function can manifest in different ways, and individual circumstances, including potential exposure scenarios, determine which test is used. The section outlines the tests used to evaluate lung function in humans (https://www.nhlbi.nih.gov/health-topics/pulmonary-function-tests, accessed 22 March 2021) and in experimental animals.

Lung function tests used to evaluate human lung function

The most common (“gold standard”) lung function test in human subjects is spirometry. Spirometry results are primarily used for diagnostic purposes, e.g. to discriminate between obstructive and restrictive lung diseases, and for determining the degree of lung function impairment. Specific criteria for spirometry tests have been outlined in the American Thoracic Society (ATS) and the European Respiratory Society (ERS) Task Force guidelines (Graham et al., 2019). These guidelines consist of detailed recommendations for the preparation and conduct of the test, instruction of the person tested, as well as indications and contraindications, and are complemented by additional guidance documents on how to interpret and report the test results (Pellegrino et al., 2005; Culver et al., 2017).

Spirometry measures several different parameters during forceful exhalation, including:

  • Forced expiratory volume in 1 s (FEV1), the maximum volume of air that can forcibly be exhaled during the first second following maximal inhalation
  • Forced vital capacity (FVC), the maximum volume of air that can forcibly be exhaled following maximal inhalation
  • Vital capacity (VC), the maximum volume of air that can be exhaled when exhaling as fast as possible
  • FEV1/FVC ratio
  • Peak expiratory flow (PEF), the maximal flow that can be exhaled when exhaling at a steady rate
  • Forced expiratory flow, also known as mid-expiratory flow; the rates at 25%, 50% and 75% FVC are given
  • Inspiratory vital capacity (IVC), the maximum volume of air that can be inhaled after a full expiration

A reduced FEV1, with normal or reduced VC, normal or reduced FVC, and a reduced FEV1/FVC ratio are indices of airflow limitation, i.e., airway obstruction as seen in COPD (Moore, 2012). In contrast, airway restriction is demonstrated by a reduction in FVC, normal or increased FEV1/FVC ratio, a normal spirometry trace and potentially a high PEF (Moore, 2012).

Lung capacity or lung volumes can be measured using one of three basic techniques: 1) plethysmography, 2) nitrogen washout, or 3) helium dilution. Plethysmography consists of a series of sequential measurements in a body plethysmograph, starting with the measurement of functional residual capacity (FRC), the volume of gas present in the lung at end-expiration during tidal breathing. Once the FRC is known, expiratory reserve volume (ERV; the volume of gas that can be maximally exhaled from the end-expiratory level during tidal breathing, i.e., the FRC), vital capacity (VC; the volume change at the mouth between the positions of full inspiration and complete expiration), and inspiratory capacity (IC; the maximum volume of air that can be inhaled from FRC) are determined, and total lung capacity (TLC; the volume of gas in the lungs after maximal inspiration, or the sum of all volume compartments) and residual volume (RV; the volume of gas remaining in the lung after maximal exhalation) are calculated (Weinstock and McCannon, 2017).

The other two techniques used to measure lung volumes—helium dilution and nitrogen washout—are based on the principle of conservation of mass: [initial gas concentration] x [initial volume of the system] = [final gas concentration] x [final volume of the system]. The nitrogen washout method is based on the fact that nitrogen is present in the air, at a relatively constant amount. The subject is given 100% oxygen to breathe, and the expired gas, which contains nitrogen in the lung at the beginning of the test, is collected. When no more nitrogen is noted in the expirate, the volume of air expired and the entire amount of nitrogen in that volume are measured, and the initial volume of the system (FRC) can be calculated. In the helium dilution method, a known volume and concentration of helium is inhaled by the subject. Helium, an inert gas that is not absorbed significantly from the lungs, is diluted in proportion to the lung volume to which it is added. The final concentration of helium is then measured and FRC calculated (Weinstock and McCannon, 2017).

Measurements of lung volumes in humans are technically more challenging than spirometry. However, they complement spirometry (which cannot determine lung volumes) and may be a preferred means of lung function assessment when subject compliance cannot be reasonably expected (e.g. in pediatric subjects) or where forced expiratory maneuvers are not possible (e.g. in patients with advanced pulmonary fibrosis). There are recommended standards for lung volume measurements and their interpretation in clinical practice, issued by the ATS/ERS Task Force (Wanger et al., 2005; Criée et al., 2011).

Finally, indices of gas exchange across the alveolar-capillary barrier are tested by diffusion capacity of carbon monoxide (DLCO) studies (also referred to as transfer capacity of carbon monoxide, TLCO). The principle of the test is the increased affinity of hemoglobin to preferentially bind carbon monoxide over oxygen (Weinstock and McCannon, 2017). Complementary to spirometry and lung volume measurements, DLCO provides information about the lung surface area available for gas diffusion. Therefore, it is sensitive to any structural changes affecting the alveoli, such as those accompanying emphysema, pulmonary fibrosis, pulmonary edema, and ARDS. Recommendations for the standardization of the test and its evaluation have been outlined by the ATS/ERS Task Force (Graham et al., 2017). An isolated reduction in DLCO with normal spirometry and in absence of anemia suggests an injury to the alveolar-capillary barrier, as for example seen in the presence of pulmonary emboli or in patients with pulmonary hypertension (Weinstock and McCannon, 2017; Lettieri et al., 2006; Seeger et al., 2013). Reduced DLCO together with airflow obstruction (i.e., reduced FEV1) indicates lung parenchymal damage and is commonly observed in smokers and in COPD patients (Matheson et al., 2007; Harvey et al., 2016), whereas reduced DLCO with airflow restriction is seen in patients with interstitial lung diseases (Dias et al., 2014; Kandhare et al., 2016).

Lung function tests used to evaluate experimental animal lung function

Because spirometry requires active participation and compliance of the subject, it is not commonly used in animal studies. However, specialized equipment such as the flexiVent system (SCIREQ®) are available for measuring FEV, FVC and PEF in anesthetized and tracheotomized small laboratory animals. Other techniques such as plethysmography or forced oscillation are increasingly preferred for lung function assessment in small laboratory animals (McGovern et al., 2013; Bates, 2017).

In small laboratory animals, plethysmography can be used to determine respiratory physiology parameters (minute volume, respiratory rate, time of pause and time of break), lung volume and airway resistance of conscious animals. Both whole body and head-out plethysmography can be applied, although there is a preference for the latter in the context of inhalation toxicity studies, because of its higher accuracy and reliability (OECD, 2018a; Hoymann, 2012).

Gas diffusion tests are not frequently performed in animals, because reproducible samplings of alveolar gas are difficult and technically challenging (Reinhard et al., 2002; Fallica et al., 2011). Modifications to the procedure employed in humans have, however, open possibilities to obtain a human-equivalent DLCO measure or the diffusion factor for carbon monoxide (DFCO)—a variable closely related to DLCO, which can inform on potential structural changes in the lungs that have an effect on gas exchange indices (Takezawa et al., 1980; Dalbey et al., 1987; Fallica et al., 2011; Limjunyawong et al., 2015).

Domain of Applicability

A description of the scientific basis for the indicated domains of applicability and the WoE calls (if provided).  More help

Pulmonary function tests reflect the physiological working of the lungs. Therefore, the AO is applicable to a variety of species, including (but not limited to) rodents, rabbits, pigs, cats, dogs, horses and humans, independent of life stage and gender.

Regulatory Significance of the Adverse Outcome

An AO is a specialised KE that represents the end (an adverse outcome of regulatory significance) of an AOP. More help

Established regulatory guideline studies for inhalation toxicity focus on evident clinical signs of systemic toxicity, including death, or organ-specific toxicity following acute and (sub)chronic exposure respectively. In toxicological and safety pharmacological studies with airborne test items targeting the airways or the lungs as a whole, lung function is a relevant endpoint for the characterization of potential adverse events (OECD, 2018a; Hoymann, 2012). Hence, the AO “decreased lung function” is relevant for regulatory decision-making in the context of (sub)chronic exposure (OECD, 2018b; OECD, 2018c).

Regulatory relevance of the AO “decreased lung function” is evident when looking at the increased risk of diseases in humans following inhalation exposure, and because of its links to other comorbidities and mortality.

To aid diagnosis and monitoring of fibrosis, current recommendations include both the recording of potential environmental and occupational exposures as well as an assessment of lung function (Baumgartner et al., 2000). The latter typically confirms decreased lung function as demonstrated by a loss of lung volume. As the disease progresses, dyspnea and lung function worsen, and the prognosis is directly linked to the decline in FVC (Meltzer and Noble, 2008).

Chronic exposure to cigarette smoke and other combustion-derived particles results in the development of COPD. COPD is diagnosed on the basis of spirometry results as laid out in the ATS/ERS Task Force documents on the standardization of lung function tests and their interpretation (Pellegrino et al., 2005; Culver et al., 2017, Graham et al., 2019). Rapid rates of decline in the lung function parameter FEV1 are linked to higher risk of exacerbations, increased hospitalization and early death (Wise et al., 2006; Celli, 2010). Reduced FEV1 also poses a risk for serious cardiovascular events and mortality associated with cardiovascular disease (Sin et al., 2005; Lee et al., 2015).

References

List of the literature that was cited for this KE description. More help

Ackermann-Liebrich, U., Leuenberger, P., Schwartz, J., Schindler, C., Monn, C., Bolognini, G., et al. (1997). Lung function and long term exposure to air pollutants in Switzerland. Study on Air Pollution and Lung Diseases in Adults (SAPALDIA) Team. Am. J. Resp. Crit. Care Med. 155, 122-129. 

Adam, M., Schikowski, T., Carsin, A.E., Cai, Y., Jacquemin, B., Sanchez, M., et al. (2015). Adult lung function and long-term air pollution exposure. ESCAPE: a multicentre cohort study and meta-analysis. Eur. Resp. J. 45, 38-50.

Andersen, M.H.G., Frederiksen, M., Saber, A.T., Wils, R.S., Fonseca, A.S., Koponen, I.K., et al. (2019). Health effects of exposure to diesel exhaust in diesel-powered trains. Part. Fibre Toxicol. 16, 21.

Ashley, F., Kannel, W.B., Sorlie, P.D., and Masson, R. (1975). Pulmonary function: relation to aging, cigarette habit, and mortality: the Framingham Study. Ann. Int. Med. 82, 739-745.

Bates, J.H.T. (2017). CO

Bergstra, A.D., Brunekreef, B., and Burdorf, A. (2018). The effect of industry-related air pollution on lung function and respiratory symptoms in school children. Environm. Health 17, 30. 

Baumgartner, K.B., Samet, J.M., Coultas, D.B., Stidley, C.A., Hunt, W.C., Colby, T.V., and J.A. Waldron (2000). Occupational and environmental risk factors for idiopathic pulmonary fibrosis: a multicenter case-control study. Collaborating Centers. Am. J. Epidemiol. 152, 307-315.

Broekema, M., ten Hacken, N.H., Volbeda, F., Lodewijk, M.E., Hylkema, M.N., Postma, D.S., et al. (2009). Airway epithelial changes in smokers but not in ex-smokers with asthma. Am. J. Resp. Crit. Care Med. 180, 1170-1178.

Celli, B. R. (2010). Predictors of mortality in COPD. Respir. Med. 104, 773-779.

Cheresh, P., Kim, S.J., Tulasiram, S., and D.W. Kamp (2013). Oxidative stress and pulmonary fibrosis. Biochim. Biophys. Acta, 1832, 1028–1040.

Cosgrove, M.P. (2015). Pulmonary fibrosis and exposure to steel welding fume. Occup. Med. 65, 706-712.

Criée, C.P., Sorichter, S., Smith, H.J., Kardos, P., Merget, R., Heise, D., Berdel, D., Köhler, D., Magnussen, H., Marek, W. and H. Mitfessel (2011). Body plethysmography–its principles and clinical use. Respir. Med. 105, 959-971.

Dalbey, W., Henry, M., Holmberg, R., Moneyhun, J., Schmoyer, R. and S. Lock (1987). Role of exposure parameters in toxicity of aerosolized diesel fuel in the rat. J. Appl. Toxicol. 7, 265-275.

Dias, O.M., Baldi, B.G., Costa, A.N., C.R. Carvalho (2014). Combined pulmonary fibrosis and emphysema: an increasingly recognized condition. J. Bras. Pneumol. 40, 304-312. 

Fallica, J., Das, S., Horton, M., and W. Mitzner (2011). Application of carbon monoxide diffusing capacity in the mouse lung. J. Appl. Physiol. 110, 1455–1459.

Forbes, L.J., Kapetanakis, V., Rudnicka, A.R., Cook, D.G., Bush, T., Stedman, J.R., et al. (2009). Chronic exposure to outdoor air pollution and lung function in adults. Thorax 64, 657-663.

Gold, D.R., Wang, X., Wypij, D., Speizer, F.E., Ware, J.H., and Dockery, D.W. (1996). Effects of cigarette smoking on lung function in adolescent boys and girls. N. Engl. J. Med. 335, 931-937. 

Gorguner, M., and M. Akgun (2010). Acute inhalation injury. Euras. J. Med. 42, 28–35.

Graham, B.L., Brusasco, V., Burgos, F., Cooper, B.G., Jensen, R., Kendrick, A., MacIntyre, N.R., Thompson, B.R. and J. Wanger (2017). 2017 ERS/ATS standards for single-breath carbon monoxide uptake in the lung. Eur. Respir. J. 49, 1600016.

Graham, B.L., Steenbruggen, I., Miller, M.R., Barjaktarevic, I.Z., Cooper, B.G., Hall, G.L., Hallstrand, T.S., Kaminsky, D.A., McCarthy, K., McCormack, M.C. and C.E. Oropez (2019). 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.

Harvey, B.G., Strulovici-Barel, Y., Kaner, R.J., Sanders, A., Vincent, T.L., Mezey, J.G. and R.G. Crystal (2016). Progression to COPD in smokers with normal spirometry/low DLCO using different methods to determine normal levels. Eur. Respir. J. 47, 1888-1889.

Hert, R. and R.K. Albert (1994). Sequelae of the adult respiratory distress syndrome. Thorax 49, 8-13.

Hoymann, H.G. (2012). Lung function measurements in rodents in safety pharmacology studies. Front. Pharmacol. 3, 156.

Johnson, J. D., and W. M. Theurer (2014). A stepwise approach to the interpretation of pulmonary function tests. Am. Fam. Phys. 89, 359-366.

Kandhare, A.D., Mukherjee, A., Ghosh, P. and S.L. Bodhankar (2016). Efficacy of antioxidant in idiopathic pulmonary fibrosis: A systematic review and meta-analysis. EXCLI J. 15, 636.

Kim, C.S., Alexis, N.E., Rappold, A.G., Kehrl, H., Hazucha, M.J., Lay, J.C., et al. (2011). Lung function and inflammatory responses in healthy young adults exposed to 0.06 ppm ozone for 6.6 hours. Am. J. Respir. Crit. Care Med. 183, 1215-1221.

Kuperman, A.S., and Riker, J.B. (1973). The variable effect of smoking on pulmonary function. Chest 63, 655-660. 

Lee, H. M., Liu, M. A., Barrett-Connor, E., and N. D. Wong (2014). Association of Lung Function with Coronary Heart Disease and Cardiovascular Disease Outcomes in Elderly: The Rancho Bernardo Study. Respir. Med. 108, 1779–1785.

Lettieri, C.J., Nathan, S.D., Barnett, S.D., Ahmad, S. and A.F. Shorr (2006). Prevalence and outcomes of pulmonary arterial hypertension in advanced idiopathic pulmonary fibrosis. Chest 129, 746-752.

Limjunyawong, N., Fallica, J., Ramakrishnan, A., Datta, K., Gabrielson, M., Horton, M., and W. Mitzner (2015). Phenotyping mouse pulmonary function in vivo with the lung diffusing capacity. JoVE 95, e52216.

Matheson, M.C., Raven, J., Johns, D.P., Abramson, M.J. and E.H. Walters (2007). Associations between reduced diffusing capacity and airflow obstruction in community-based subjects. Respir. Med. 101, 1730-1737.

Matthay, M.A., Zemans, R.L., Zimmerman, G.A., Arabi, Y.M., Beitler, J.R., Mercat, A., Herridge, M., Randolph, A.G. and C.S. Calfee (2019). Acute respiratory distress syndrome. Nature Reviews Disease Primers 5, 1-22.

McGovern, T.K., Robichaud, A., Fereydoonzad, L., Schuessler, T.F., and J.G. Martin (2013) Evaluation of respiratory system mechanics in mice using the forced oscillation technique. JoVE 75, e50172.

Meltzer, E.B., and P.W. Noble (2008). Idiopathic pulmonary fibrosis. Orphanet J. Rare Dis. 3, 8.

Miller, K. and A. Chang (2003). Acute inhalation injury. Emerg. Med. Clin. N. Am. 21, 533-557.

Miller, M.R., Crapo, R., Hankinson, J., Brusasco, V., Burgos, F., Casaburi, R., Coates, A., Enright, P., van der Grinten, C.M., and P. Gustafsson (2005a). General considerations for lung function testing. Eur. Respir. J. 26, 153-161.

Miller, M.R., Hankinson, J., Brusasco, V., Burgos, F., Casaburi, R., Coates, A., Crapo, R., Enright, P., van der Grinten, C., and P. Gustafsson (2005b). Standardisation of spirometry. Eur. Respir. J. 26, 319-338.

Moore, V.C. (2012). Spirometry: step by step. Breathe 8, 232-240.

OECD (2018a). OECD Guidance Document on Inhalation Toxicity Studies, GD 39.

OECD (2018b), Test No. 412: Subacute Inhalation Toxicity: 28-Day Study, OECD Guidelines for the Testing of Chemicals, Section 4, OECD Publishing, Paris, https://doi.org/10.1787/9789264070783-en.

OECD (2018), Test No. 413: Subchronic Inhalation Toxicity: 90-day Study, OECD Guidelines for the Testing of Chemicals, Section 4, OECD Publishing, Paris, https://doi.org/10.1787/9789264070806-en.

Park, Y., Ahn, C., and T.H. Kim (2021) Occupational and environmental risk factors of idiopathic pulmonary fibrosis: a systematic review and meta-analyses. Sci. Rep. 11, 4318.

Prada-Dacasa, P., Urpi, A., Sánchez-Benito, L., Bianchi, P., A. Quintana (2020). Measuring Breathing Patterns in Mice Using Whole-body Plethysmography. Bio. Protoc. 10, e3741.

Pelkonen, M., Notkola, I.-L., Nissinen, A., Tukiainen, H., and Koskela, H. (2006). Thirty-year cumulative incidence of chronic bronchitis and COPD in relation to 30-year pulmonary function and 40-year mortality: a follow-up in middle-aged rural men. Chest 130, 1129-1137.

Pellegrino, R., Viegi, G., Brusasco, V., Crapo, R., Burgos, F., Casaburi, R., Coates, A., van der Grinten, C., Gustafsson, P., and J. Hankinson (2005). Interpretative strategies for lung function tests. Eur. Respir. J. 26, 948-968.

Raghu, G., Remy-Jardin, M., Myers, J.L., Richeldi, L., Ryerson, C.J., Lederer, D.J., Behr, J., Cottin, V., Danoff, S.K., Morell, F., and K.R. Flaherty (2018). Diagnosis of idiopathic pulmonary fibrosis. An official ATS/ERS/JRS/ALAT clinical practice guideline. Am. J. Respir. Crit. Care Med. 198, e44-e68.

Reilly, J.P., Zhao, Z., Shashaty, M.G., Koyama, T., Christie, J.D., Lanken, P.N., Wang, C., Balmes, J.R., Matthay, M.A., Calfee, C.S. and L.B. Ware (2019). Low to moderate air pollutant exposure and acute respiratory distress syndrome after severe trauma. Am. J. Respir. Crit. Care Med. 199, 62-70.

Reinhard. C., Eder, G., Fuchs, H., Ziesenis, A., Heyder, J. and H. Schulz H (2002). Inbred strain variation in lung function. Mamm. Genome 13, 429-437.

RP: Measurement of lung function in small animals. J. Appl. Physiol. 123, 1039-1046.

Schikowski, T., Sugiri, D., Ranft, U., Gehring, U., Heinrich, J., Wichmann, H.E., et al. (2005). Long-term air pollution exposure and living close to busy roads are associated with COPD in women. Respir. Res. 6, 152. 

Seeger, W., Adir, Y., Barberà, J.A., Champion, H., Coghlan, J.G., Cottin, V., De Marco, T., Galiè, N., Ghio, S., Gibbs, S. and F.J. Martinez (2013). Pulmonary hypertension in chronic lung diseases. J. Am. Coll. Cardiol. 62 Suppl. 25, D109-D116.

Sin, D. D., Wu, L., and S. P. Man (2005). The relationship between reduced lung function and cardiovascular mortality: a population-based study and a systematic review of the literature. Chest 127, 1952-1959.

Takezawa, J., Miller, F.J. and J.J. O'Neil (1980). Single-breath diffusing capacity and lung volumes in small laboratory mammals. J. Appl. Physiol. 48, 1052-1059.

Tantisuwat, A., and Thaveeratitham, P. (2014). Effects of smoking on chest expansion, lung function, and respiratory muscle strength of youths. J. Phys. Ther. Sci. 26, 167-170. 

Trethewey, S. P., and G. I. Walters (2018). The Role of Occupational and Environmental Exposures in the Pathogenesis of Idiopathic Pulmonary Fibrosis: A Narrative Literature Review. Medicina (Kaunas, Lithuania) 54, 108.

Tsui, H.-C., Chen, C.-H., Wu, Y.-H., Chiang, H.-C., Chen, B.-Y., and Guo, Y.L. (2018). Lifetime exposure to particulate air pollutants is negatively associated with lung function in non-asthmatic children. Environ. Poll. 236, 953-961. 

Vestbo, J., Anderson, W., Coxson, H.O., Crim, C., Dawber, F., Edwards, L., Hagan, G., Knobil, K., Lomas, D.A., MacNee, W. and E.K. Silverman (2008). Evaluation of COPD longitudinally to identify predictive surrogate end-points (ECLIPSE). Eur. Respir. J. 31, 869-73.

Wanger, J., Clausen, J.L., Coates, A., Pedersen, O.F., Brusasco, V., Burgos, F., Casaburi, R., Crapo, R., Enright, P., Van Der Grinten, C.P.M. and P. Gustafsson (2005). Standardisation of the measurement of lung volumes. Eur. Respir. J. 26, 511-522.

Weinstock, T, and J. McCannon (2017). Pulmonary Medicine. Pulmonary Function Testing. https://www.pulmonologyadvisor.com/home/decision-support-in-medicine/pulmonary-medicine/pulmonary-function-testing/ (accessed 22 March 2021). Decision Support in Medicine, LLC.

Wise, R. A. (2006). The value of forced expiratory volume in 1 second decline in the assessment of chronic obstructive pulmonary disease progression. Am. J. Med. 119, 4-11.

Zhang, L.P., Zhang, X., Duan, H.W., Meng, T., Niu, Y., Huang, C.F., et al. (2017). Long-term exposure to diesel engine exhaust induced lung function decline in a cross sectional study. Ind.l Health 55, 13-26.