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MEFx%, FEFx%

Maximum expiratory flow when x% of the FVC has been exhaled (FEFx%) or x% of the FVC remain to be exhaled (MEFx%, now deprecated) is assessed in either of three ways:

  1. Reproducible flow-volume curves with the 3 largest reproducible FVCs are superimposed at the starting point (TLC). The largest flow values at 25%, 50% and 75% of the largest FVC are reported (envelope method) (ref. 1).
  2. Expiratory flow at 25%, 50% and 75% of the FVC is taken from three flow-volume curves that are reproducible with respect to shape and size. Report the largest value derived from the maneuver the FVC of which differs less than 5% from the largest FVC (ref. 2).
  3. Report the value taken from a curve with the largest sum of FEV1 and FVC (ref. 3 and 4).

The reproducibility of forced expiratory flows diminishes in the cited order of recommendations in adults and adolescents. In practice the third recommendation (ATS) is most frequently used, but it cannot be applied in young children.

If the maneuver is performed properly, forced expiratory flows between 25% and 75% of the FVC are effort independent because they are determined by a flow limiting segment developing in intrathoracic airways. Effort independence has led to the misconception that forced expiratory flows would provide more reliable and more ‘sensitive’ indices of airway obstruction than for example the FEV1. The opposite is the case:

Relationship between MEF50 (FEF50) and MMEF (FEF25-75%)On that account predicted values of FEFx% are of little value, but the shape of flow-volume curves provides very valuable information (see characteristic flow-volume curves). If FEV1 is within normal limits but forced expiratory flow below the ‘limit of normal’, disregard the latter observation (ref. 5).

MEF50%FVC correlates very highly (explained variance 98%) with the MMEF = FEF25-75%, so that one of these indices suffices in practice; the logarithmic transformation in the right part of the illustration was necessary to more or less stabilize the variance around the regression line. MEFx% is assessed at a specific percentage of the FVC and therefore an unsuitable index of airway obstruction or bronchodilatation if the FVC is abnormal (obstructive and restrictive ventilatory defects), as explained in the paragraph about the MMEF (FEF25-75%).

Measurements of FEF25-75% and FEF75 do not contribute any useful information that is not available from measurements of the FEV1, FVC and FEV1/FVC ratio and therefore have no clinical utility (ref. 6).

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Ref. 1 - ECCS and ERS
  In the revised version of the 1983 report (ref. 2) of the European Community for Coal and Steel (ECCS) published in 1993 predicted values of lung indices were unchanged. They are almost universally applied in Europe. The 1993 report was officially adopted by the European Respiratory Society (ERS).
The following chapter deals with spirometry, predicted values and bronchodilator responsiveness:
Quanjer PhH, Tammeling GJ, Cotes JE, Pedersen OF, Peslin R, Yernault JC. Lung volumes and forced ventilatory flows. Eur Respir J 1993; 6 suppl. 16: 5-40. Erratum Eur Respir J 1995; 8: 1629.
Ref. 2 - ECCS 1983
  Quanjer PhH (ed.) Standardized lung function testing. Bull Eur Physiopathol Respir 1983; 19 suppl. 5: 45-51.
Ref. 3 - Recommendation of ATS
  American Thoracic Society. Standardization of spirometry: 1994 update. Am J Respir Crit Care Med 1995; 152: 1107-1136.
Ref. 4 - ERS/ATS consensus
  Miller MR et al. Standardisation of spirometry. ATS/ERS task force: standardisation of lung function testing. Eur Respir J 2005; 26: 319-338.
Ref. 5 - Interpret the FEV1, not the FEFx%
  American Thoracic Society. Lung function testing: selection of reference values and interpretative strategies. Am Rev Respir Dis 1991; 144: 1202-1218.
  Quanjer PhH, Tammeling GJ, Cotes JE, Pedersen OF, Peslin R, Yernault JC. Lung volumes and forced ventilatory flows. Eur Respir J 1993; 6 suppl. 16: 5-40. (recommendations European Community for Coal and Steel, and European Respiratory Society). Erratum Eur Respir J 1995; 8: 1629.
  Quanjer PH, Stanojevic S, Cole TJ, Baur X, Hall GL, Culver B, Enright PL, Hankinson JL, Ip MSM, Zheng JP, Stocks J and the ERS Global Lung Function Initiative. Multi-ethnic reference values for spirometry for the 3-95 year age range: the Global Lung Function 2012 Equations. Eur Respir J 2012; 40: 1324–1343.
Ref. 6 - Measurements of FEF25-75% and FEF75 do not contribute clinically useful information
  Quanjer PH, Weiner DJ, Pretto JJ, Brazzale DJ, Boros PW. Measurement of FEF25-75% and FEF75% does not contribute to clinical decision making. Eur Respir J 2014; 43: 1051-1058.
  Pellegrino R, Brusasco V, Miller MR. Question everything. Eur Respir J 2014; 43: 947-948.
  Boutin B, Koskas M, Guillo H et al. Forced expiratory flows’ contribution to lung function interpretation in schoolchildren. Eur Respir J 2015; 45: 107-115.
  Lukic KZ, Coates AL. Does the FEF25-75 or the FEF75 have any value in assessing lung disease in children with cystic fibrosis or asthma? Pediatr Pulmonol 2015; 50: 863-868.
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