Smooth reference equations for slow vital capacity and flow-volume curve indexes

We derived reference values for slow vital capacity (VC) and flow-volume curve indexes (FVC, FEV(1), and flows) from the 1,185 tracings provided by 1,039 "normal" subjects who participated in one or both cross-sectional surveys of the Po River Delta study in 1980-1982 and in 1988-1991. Definition of "normal" was based on negative answers to questions on respiratory symptoms/diseases or recent infections, current/past tobacco smoking, and work exposure to noxious agents. Reference equations were derived separately by sex as linear regressions of body mass index (BMI = weight/height(2)), BMI-squared, height, height-squared, and age. Age entered all the models by natural cubic splines using two break points, except for the ratios FEV(1)/VC and FEV(1)/FVC. Random effects models were applied to adjust for the potential intrasubject correlation. BMI, along with height and age, appeared to be an important predictor, which was significantly associated with VC, FEV(1), FVC, FEV(1)/FVC, and PEF in both sexes, and with FEV(1)/VC and FEF(25-75) in females. Natural cubic splines provided smooth reference equation curves (no "jumps" or "angled points") over the entire age span, differently from the conventional reference equations. Thus, we recommend the use of smooth continuous equations for predicting lung function indexes, along with the inclusion of BMI in the equations.