Summary of how the guidelines recommend spirometry could be used in the diagnosis and management of asthma in children

Guideline [ref.]Year of publicationRegionRecommendations for using spirometry
To diagnose asthma (for children aged >5 years)To monitor asthma
BTS/SIGN [11]2019UKIf probability of asthma is high, no testing may be required
Spirometry is the recommended initial investigation
If FEV1/FVC <LLN and BDR ≥12%, asthma is suspected
If PEF monitoring over 2–4 weeks ≥20% variability, asthma is suspected
Spirometry or PEF monitoring at least annually
Aim is to obtain a normal lung function expressed by FEV1 and/or PEF >80% predicted or best; anything less becomes significant
ERS task force for diagnosis of asthma [12]2021EUSpirometry is the recommended initial investigation
If FEV1/FVC or FEV1 <LLN or <80% predicted, BDR should be done; if BDR ≥12% and/or ≥200 mL, asthma is confirmed
If spirometry normal, FENO should be done; if FENO is raised, PEF variability should be done; if PEF variability ≥12%, asthma is confirmed
Not applicable
ERS task force for monitoring asthma [13]2015EUNot applicableSpirometry with BDR at least annually or more frequently in children with reduced lung function and poor asthma control
No recommendations for value interpretation
PEF not recommended
GINA [1]2019, updated in 2022GlobalSpirometry is the recommended initial investigation
If abnormal, i.e. FEV1/FVC <LLN, and if FEV1 changes by >12% after 1) BDR or 2) trial of asthma preventer, or if 3) PEF variability >13%, then variable expiratory airflow (asthma) is confirmed
FEV1 recorded at the beginning of treatment, after 3–6 months of controller medication and then “periodically”
Repeated spirometry every 1–2 years
Advice to plot FEV1 and FEV1/FVC to assess trends
ICON paediatric asthma [9]2012GlobalLung function tests are supportive of diagnosis
Spirometry with BDR is preferred to PEF measurements
The following features would be suggestive of asthma: FEV1 <80% predicted with positive BDR expressed by FEV1 ≥12%, ≥200 mL or ≥10% predicted
Spirometry and PEF measurements (recommended for severe patients or with little perception of severity)
No mention of how often these should be done
NAEPP [8]2007, updated in 2020USSpirometry is recommended as the initial investigation
Asthma diagnosis requires FEV1 and FEV1/FVC <80% predicted, also with positive BDR
Spirometry every 1–6 months
PEF monitoring can also be included for patients with moderate or severe persistent asthma
NICE [10]2017, updated in 2021UKSpirometry is recommended as the initial investigation
When FEV1/FVC <70% predicted or <LLN, BDR should be done; a positive BDR confirms an asthma diagnosis
If spirometry is normal, FENO should be done; if FENO raised and PEF variability >20%, asthma is confirmed
Either spirometry or PEF at each annual medical review
No indications for value interpretation

BTS/SIGN: British Thoracic Society/Scottish Intercollegiate Guidelines Network; ERS: European Respiratory Society; GINA: Global Initiative for Asthma; ICON: International consensus on; NAEPP: National Asthma Education and Prevention Program; NICE: National Institute for Health and Care Excellence; EU: European Union; FEV1: forced expiratory volume in 1 s; FVC: forced vital capacity; LLN: lower limit of normal; BDR: bronchodilator response; PEF: peak expiratory flow; FENO: exhaled nitric oxide fraction.