ERS technical standard: Global Lung Function Initiative reference values for exhaled nitric oxide fraction (F _ENO )

Elevated exhaled nitric oxide fraction at a flow rate of 50 mL·s^-1 (F _ENO ) is an important indicator of T-helper 2-driven airway inflammation and may aid clinicians in the diagnosis and monitoring of asthma. This study aimed to derive Global Lung Function Initiative reference equations and the upper limit of normal for F _ENO .

Available individual F _ENO data were collated and harmonised using consensus-derived variables and definitions. Data collected from individuals who met the harmonised definition of "healthy" were analysed using the generalised additive models of location, scale and shape (GAMLSS) technique.

Data were retrospectively collated from 34 782 individuals from 34 sites in 15 countries, of whom 8022 met the definition of healthy (19 sites, 11 countries). Overall, height, age and sex only explained 12% of the between-subject variability of F _ENO (R²=0.12). F _ENO device was neccessary as a predictor of F _ENO , such that the healthy range of values and the upper limit of normal varied depending on which device was used. The range of F _ENO values observed in healthy individuals was also very wide, and the heterogeneity was partially explained by the device used. When analysing a subset of data in which F _ENO was measured using the same device and a stricter definition of health (n=1027), between-site heterogeneity remained.

Available F _ENO data collected from different sites using different protocols and devices were too variable to develop a single all-age reference equation. Further standardisation of F _ENO devices and measurement are required before population reference values might be derived.