THE ROYAL FREE HAMPSTEAD

NHS TRUST

Peak Expiratory Flow Rate

Measurements Guidelines

APRIL 2009
Validation Grid

Policy title Peak Expiratory Flow Rate Measurements in clinical

practice
Author Tareq Ayoob (CNS Asthma/ COPD)
Target audience This policy is relevant for all staff caring for adult patients in
clinical areas of the Royal Free Hampstead NHS trust
Commissioning Clinical Practice Committee
body
Stake holders Clinical Practice Committee
consulted Clinical Directorates:
Anaesthetics and critical care
Clinical haematology, oncology and private practice
Hepatology, nephrology and transplantation
Medicine
Neurosciences
Women’s and children’s
RNTNE, ENT%, audiology and ophthalmology

Linked policies Respiratory Assessment

Nursing Guidelines for the administration of Nebulisers
Nursing Guidelines for the administration of Inhalers

Guideline Yes, Peak Expiratory Flow Rate Measurement 2004

replacement
Date of April 2009
submission
Review date April 2011

Key words Peak Expiratory Flow, Asthma, Chronic Obstructive

Pulmonary Disease
Abstract
The Peak Expiratory Flow Rate (PEFR) is the maximum rate at which air is
expelled from the lungs, measured in litres per minute. In those patients with
suspected obstructive airways disease, whether acute or chronic, measuring
of the PEFR provides an objective indication of the degree of obstruction,
primarily in the larger airways. The ‘obstruction’ may be due to
bronchoconstriction or inflammation. Readings are generally obtainable from
age 5 years and onwards.

Aim
To provide accurate reproducible measurements of the peak expiratory flow
rate (PEFR)

Staff Who May Undertake This Procedure

Within this Trust measuring PEFR is regarded as a clinical practice. A clinical
practice may be defined as an aspect of care, which may be undertaken by
registered nurses, and midwives who accept accountability for their actions
and feel competent to undertake the procedure. There is no formal
assessment for these practices but they may be aspects of care, which
require a period of supervised, guided practice. They should form part of
preceptorship or mentorship programmes.

Student nurses and midwives may undertake this practice under the
supervision of a registered nurse or midwife who feels competent in this
aspect of care and in the supervisory role.

Health care assistants may undertake this practice following competency

assessment (See appendix 1)

In line with guidelines laid down by the NMC code standards of conduct,
performance and ethics for nurses and midwives (2008), you must keep clear
and accurate records of the discussions you have and the assessments you
make. You must also complete records as soon as possible after an event
has occurred and you must keep your colleagues informed when you are
sharing the care of others by making a referral to another practitioner when it
is in the best interests of someone in your care.

Supportive Information

Predicted Values
An individual’s predicted PEFR is calculated based upon age, height and sex.
A graph is available on the back of the peak flow chart. It is important to
determine the predicted PEFR value as action plans are often based upon
this value. For example, the British Guideline on the Management of Asthma
(BTS, 2008), recommend that those admitted with an exacerbation of asthma
should not be discharged until their PEFR is greater than 75% of best or
predicted.
Indications
The most common groups of patients for whom this measurement is
performed, are those with asthma or chronic airways disease. Recording the
PEFR when the patient first presents provides a baseline for monitoring
progress and response to treatments. It will also be measured to monitor the
patient’s response to bronchodilator treatment and in some patients who are
not receiving bronchodilators in order to monitor variations throughout the 24
hour period, as this is an important characteristic of asthma.

Serial measurements of PEFR should be performed at home and at work if

there is a potential problem of a work related exposure causing respiratory
symptoms.

Measurements should be recorded four times a day as a single measurement

provides insufficient information as it is relevant only to the time of its
recording. Using a peak flow chart enables visual trends to be noted.

The first reading should be made when the patient first wakes, before any
bronchodilators are taken. The other readings should be spread evenly
throughout the day and timed around bronchodilators if they are being taken.

Bronchodilator response
The PEFR response to bronchodilators is recorded by means of pre and post
drug administration measurements. For example, if the patient is receiving
regular bronchodilators via nebulisers, readings should be taken before
starting and then no more than 20 minutes after the nebulisation has finished.
Two lines are then evident on the Peak Flow Chart.

Patient Technique
Reliable readings are only obtained if the patient is carefully educated in the
technique for using the peak flow meter.

It is important that the patient understands that the measurement is effort

dependent, i.e. the greater the effort, the more accurate the result.

For those patients who are unable to perform the test due to poor technique,
the following measures may be helpful:
1. like the procedure to the blowing out of a candle, i.e. a short, quick
blow
2. ask the patient to demonstrate such a blow (without using a meter)
3. proceed then to asking the patient to blow through a disposable
mouth piece
4. attach the mouthpiece to the meter and repeat.

For young children, specially designed ‘windmills’ have been designed which
may be attached to Mini-Wright meters. These windmills rotate when the
individual exhales under force.

If the reading indicator still does not move:

 check the fingers are not covering the indicator area
  check the meter is not dirty - wipe the indicator area, or wash the
meter thoroughly

The reading should be recorded as 0 if the patient is unable to perform the

test DUE TO THE SEVERITY OF DISEASE – REPORT IMMEDIATELY IF
THIS IS THE CASE!

Serial Peak Flow Monitoring at Home

For those patients admitted with asthma, continuation of PEFR
monitoring is strongly recommended following discharge. This enables
patients to monitor their progress at a time when they are especially
vulnerable. Early signs of deterioration can be detected and action taken to
prevent a significant exacerbation.

Serial monitoring also enables the effectiveness of treatment to be monitored,

with the aim of ensuring the patient remains within 80% of their predicted or
best readings.

Peak Flow Diaries are available from the CNS Asthma/ COPD (blp 71-1273)
for this purpose, and include instructions for the patient. Peak flow meters
should be ordered from Pharmacy if the patient does not have their own
meter. Morning and evening readings only are sufficient for home monitoring.

Current PEF meter

The adoption of the EN 13826 Standard is likely to cause the most issues with
Doctors and Nurses responsible for the long-term care of patients with
asthma.

Three key areas need consideration:

1) The new patient, using a peak flow meter for the first time
2) The existing patient, who has already used a peak flow meter
3) The health professional, using PEF readings and Normal Values

Infection control
Meters must be restricted to single patient use only (see single use medical
devices policy), to prevent any risks of cross infection. All patients including
those in isolation or with a suspected infection must have their own meter. In
areas where meters are shared, disposable mouthpieces should be used and
particular attention paid to cleaning the meter after use. The plastic meters
should be washed in hot water with detergent, rinsed or wiped with Clinell
universal sanitizing wipes and dried thoroughly at least once a week. Patients
should be cautioned not to inhale through the meter prior to performing the
test.

When patients are known to be infectious, special high density filter

mouthpieces should be used if the equipment is not for single patient use, i.e.
in the Pulmonary Function Laboratory.
Patients must be advised on the appropriate care of their meter prior to
discharge. If there are problems regarding the care of meters please contact a
member of the infection control team.

Procedure
Action Rationale
Explain the procedure to the patient. To ensure compliance.
Use the same meter for the series of To ensure accuracy.
readings.
Position the patient to be sitting upright To allow full lung expansion. The same
or preferably standing. position should be used each time.
Ensure indicator is at bottom of scale, i.e. To ensure accuracy.
0.
Ask the patient to take a deep breath in, Air must not escape around the
and then to place their lips tightly around mouthpiece.
the mouthpiece.
Ask the patient to blow out as quickly The test is dependent on effort - the blow
and hard as possible, to push the pointer must be forced.
up the scale.
Note the reading on the scale.
When patient is ready, repeat the test To ensure reliability of the reading.
twice more.
The highest of the three readings should Readings may vary depending on
be noted on the peak flow chart. technique and effort.

Audit
Compliance with the guideline will be monitored. This will achieved with
regular checks by the Thoracic team members, respiratory physiotherapists,
respiratory technicians and senior nurses. An official audit will be performed
on an annual basis, led by the CNS for Asthma and COPD and reported to the
clinical practice group.
Appendix 1

The Royal Free Hampstead NHS Trust

Health Care Assistant Course Certificate of Competence
Taking and Recording Peak Expiratory Flow Measurements
KSF Dimensions Core 1,2,3,5 And 6, Hwb5, Hwb6 Level 1/2
Health Care Assistant Assessor
Name Name & Title

Signature Signature

Ward/Department Ward/Department

Date Date

Result of Assessment

Competent Not Competent

If the Health Care Assistant does not master the competence please indicate
the reason.
Comments:
 The Royal Free Hampstead NHS Trust
Health Care Assistant Course Essential Competence
Taking and Recording a Peak Expiratory Flow Measurement

Has Has Practiced Can perform

Observed / competency competency
been with applied with indirect
orientated to knowledge supervision in
and skills a safe and
ASSESSMENT competent
manner

SIGNATURE SIGNATURE
SIGNATURE
The Health Care Assistant: Asse Asse Asses
Self Self Self
ssor ssor sor
1. Gives a clear and relevant explanation of
the procedure to the patient and obtains the
patient’s verbal consent and co-operation
2. Ensure that peak flow readings are taken
immediately before the patient takes their
nebuliser / inhaler as instructed by the
registered nurse
3. Ensures that the patients peak flow reading
is recorded no more than 20 minutes after
they have taken their nebuliser / inhaler, as
instructed by the registered nurse
4. Washes hands

5. Ensures that the Peak Flow Meter is clean.

If the meter is not clean ensures that it is
cleaned as per the peak flow clinical
practice guidelines policy
6. Ensures that patients in isolation or those
who are suspected of having an infection
have their own Peak Flow Meter
7. Makes sure that the patient has their peak
flow reading measured using only one type
of Peak Flow Meter
8. Uses a clean mouth piece for each
individual patient
9. Ensures that the patient is sitting upright or
preferably standing to allow for full lung
expansion. (The same position should be
used for every reading)
10. Informs the patient not to inhale through the
meter prior to the test

11. Checks that the Peak Flow Meter indicator

is at the bottom of the scale prior to the test
-0
12. Checks that the patients fingers are not
covering the indicator area prior to the test
13. Asks the patient to take a deep breath in
and to then place their lips tightly around
the mouth piece to stop any air escaping
14. Then asks the patient to blow out as hard
and as fast as possible, to push the pointer
up the scale
15. Notes the reading on the scale
16. When the patient is ready, asks them to
repeat the test twice more
17. Accurately records the highest of the three
readings on the peak flow chart
18. Reports the peak flow reading result to the
nurse in charge of the patient
19. Is aware that the that the patients first peak
flow reading of the day should be when the
patient wakes up
20. Is able to state the patients predicted range
of peak flow recordings
21. Is able to state normal peak flow recordings
depending on age/ sex/ height etc.
ATTITUDE
Recognises own level of competence and can
explain the implications of professional
accountability when undertaking this procedure
Maintains the patient’s privacy, dignity and
safety throughout the procedure
Recognises the individual needs of the patient
and deals with them in a sensitive and efficient
manner
References:

 BTS/SIGN 2008. British Guideline on the Management of Asthma.

Thorax. May , Vol 63.

 Drug and Therapeutics bulletin (1997) Peak Flow Meters and

Spirometry in General Practice. Drugs and Therapeutics Bulletin. 35,
(7).

 http://freenet/infectioncontroldocs/SINGLE%20USE%20MEDICAL
%20DEVICES.doc

 Ignareio-Garcia J.M (1995) Asthma: Self management education

program by home monitoring of peak expiratory flow rate. American
Journal of Critical Care Medicine. 151, 353-359.

 Levy M, Hilton S, Barnes G (1996) Monitoring and Control in. Asthma

at your fingertips. Class Publishing: London.

 Medical Devices Alert (2004) MDA/2004/025 http://www.mhra.gov.uk

 Peak Flow Charts http://www.peakflow.com

Equality and Health inequalities Impact Assessment Screening Checklist
Name of policy/service Peak Expiratory Flow Rate Measurements
Is this a new or existing policy/service Update of existing guideline
Purpose of the policy/service To promote safe and effective practice
Stakeholders in policy/service development See validation Grid
Person responsible for policy/service impact Tareq Ayoob
assessment
Proposed date for implementation of April 2009
policy/service
Do you think the policy/service will impact upon any group within the population based upon:

Race/ethnicity No Lower socio-economic groups No

Gender No Involvement in the criminal justice system No

Religion/belief No Homelessness No
Disability (including long term
No Looked after children No
conditions and mental health)
Population groups more at risk of developing
Age No certain conditions (based on community health No
profile data)
Sexual orientation or gender identity No Any other groups No

What impact will the policy/service have on lifestyles? For example:

 Diet and nutrition
 Exercise and physical activity
 Substance use; tobacco, alcohol, drugs
 Risk taking behaviour
 Education and learning or skills
 Functional ability
 Quality of life
Will the policy/service have any impact on the social environment? For example:
 Social status
 Employment (paid or unpaid)
 Social/family support
 Stress
 Income

Will the policy/service have any impact upon:

 Discrimination?
 Equality of opportunity?
 Relations between groups?
 Improving uptake of services by under represented groups?
Will the policy/service have any impact on the physical environment? For example:
 Living conditions
 Working conditions
 Pollution or climate change
 Accidental injuries or public safety
 Infection control
Will the policy/service impact on access to and experience of services? For example:
 Healthcare
 Transport
 Social services
 Housing services
 Education
 Equality impact assessment screening checklist summary sheet
1. Positive impacts (Note groups affected) 2. Negative impacts (note groups affected)

The policy promotes principles of Appropriate communication will be

good care and safety for all groups
It provides equality of opportunity
and access for all groups.
employed for all groups to ensure
consent and understanding is
gained. It is important that the
patient understands the procedure
as the result is effort dependant

The trust has a robust interpreting

service, enabling patients to
access information in different
languages/formats.

3. Additional information/evidence required

The procedure will be the same for all patient groups to maintain patient
safety.
4. Recommendations

Language and communication requirements are routinely recorded in

the nursing documentation, to enable access of appropriate interpreting
services employed by the trust

For young children, specially designed ‘windmills’ have been designed

which may be attached to Mini-Wright meters.
5. As a result of completing the impact checklist, have any negative impacts been identified, and if so
is a full impact assessment recommended?

Nil identified

6. If impact assessment has not been recommended please state the reasons why.

The procedure will be the same for all patient groups to maintain patient safety

Date for completion of screening checklist review /completion of full impact assessment :
April 2009

Managers name and signature: Date:

Tareq Ayoob April 2009

Approved by Operational manager for Equality Date:
and Diversity(name and signature) April 2009
Jennifer Kenward