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The addition of peak expiratory flow monitoring to symptom-based self management did not enhance outcome in children with asthma
  1. Thomas M Ball, MD, MPH
  1. University of Arizona
 Tucson, Arizona, USA

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 Q In children with asthma, does the addition of routine peak expiratory flow (PEF) monitoring to symptom-based self management improve outcome over symptom-based self management alone?

    Clinical impact ratings GP/FP/Primary care ★★★★★★☆ Paediatrics ★★★★★★☆ Respirology ★★★★★☆☆


    Embedded ImageDesign:

    randomised controlled trial.

    Embedded ImageAllocation:


    Embedded ImageBlinding:


    Embedded ImageFollow up period:

    12 weeks.

    Embedded ImageSetting:

    children were recruited from primary care practices and a children’s hospital in Leicester, UK.

    Embedded ImagePatients:

    90 children aged 7–14 years (median age 11 y) who had moderate asthma, were taking regular inhaled corticosteroids, had had stable treatment for 1 month, were competent at spirometry, and had no other respiratory problem.

    Embedded ImageIntervention:

    PEF monitoring plus symptom-based management (n = 44) or symptom-based management alone (n = 46) were given after a 4 week run in period. Children and the main caregiver were given training on self management.

    Embedded ImageOutcomes:

    mean daily symptom score, proportion of symptom free days, spirometric lung function, changes in PEF, overall quality of life (Paediatric Asthma Quality of Life Questionnaire), and reported use of health services.

    Embedded ImagePatient follow up:



    No differences were seen between the 2 groups in proportion of symptom free days (table), mean daily symptom score, spirometric lung function, changes in PEF, overall quality of life, or reported use of health services.

    Peak expiratory flow monitoring plus symptom-based self management (intervention) v symptom-based self management alone (control) in children with asthma*


    In children with asthma, the addition of routine peak expiratory flow monitoring to symptom-based self management did not enhance outcome over symptom-based self management alone.


    Patient education on self management of their asthma is a cornerstone of proper medical care.1 As part of this process, an individualised action plan should be developed in collaboration with the child and parents. The study by Wensley and Silverman tested whether an action plan with self management decisions based upon PEF monitoring was more effective than one based upon symptoms for the care of children with asthma.

    This methodologically strong study showing no benefit to PEF monitoring differed from a previous study,2 which showed advantages of PEF monitoring in 2 potentially important ways. This study tested PEF use among 7–14 year olds with stable asthma, whereas the previous study included adolescents and adults who were seen after a visit to the emergency department for an asthma exacerbation. It is quite certain that successful use of PEF monitoring is age dependent, with children generally unable to do it successfully before 7 years of age. In addition, a patient’s or family’s receptiveness to learn and use PEF monitoring might vary by their perceived risk of the disease, which presumably would be greater among patients recently seen for an exacerbation than those with stable disease.

    It now seems clear that PEF monitoring is not advantageous for most adults and children with asthma.3 Patient education for children must remain developmentally appropriate for the growing child and move from being parent centred to being directed to the patient. During this continuing and collaborative process, it should become apparent whether the patient is being self managed successfully with a symptom-based action plan or might benefit from a trial of PEF monitoring. The addition of PEF monitoring to the self management plan remains a relatively simple and economical alternative for children who are able to perform PEF in the office, yet struggle to perceive onset of asthma exacerbations by symptoms alone.


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    • * See glossary.

    • Information provided by author.

    • For correspondence: Dr M Silverman, Leicester Royal Infirmay, Leicester, UK.

    • Sources of funding: United Kingdom Asthma Campaign and Glaxo SmithKline.