Title of Guideline (must include the word Guideline (not protocol, policy, procedure etc) Contact Name and Job Title (author) Directorate & Speciality Guideline for Peak flow recording Caroline Youle, Paediatric Respiratory Nurse Specialist Family Health Date of submission March 2014 Date on which guideline must be reviewed (this should be one to five years) Explicit definition of patient group to which it applies (e.g. inclusion and exclusion criteria, diagnosis) Abstract Key Words March 2019 Inclusion criteria: Patients over 6 years, with a diagnosis of asthma This guideline describes how to perform peak flow recordings with children over six years of age. Peak flow Statement of the evidence base of the guideline has the guideline been peer reviewed by colleagues? Evidence base: (1-6) 1 NICE Guidance, Royal College Guideline, SIGN (please state which source). 2a 2b 3a 3b meta analysis of randomised controlled trials at least one randomised controlled trial at least one well-designed controlled study without randomisation at least one other type of well-designed quasiexperimental study 4 well designed non-experimental descriptive studies (ie comparative / correlation and case studies) 5 expert committee reports or opinions and / or clinical experiences of respected authorities 6 recommended best practise based on the clinical experience of the guideline developer Consultation Process Target audience Janice Mighten (Children's Respiratory/Community Nurse Specialist) and Debra Forster (Children's Respiratory/Allergy & Community Nurse Specialist) reviewed the guideline Paediatric Hospital Nurses This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date. 1
NOTTINGHAM CHILDREN S HOSPITAL Nursing Guideline Guideline for Peak Flow Recording Standard statement Asthma is an inflammatory disease of the airways. The severity and re-occurrence of the symptoms of wheezing and breathlessness vary for each individual person (World Health Organisation 2010). The prevalence in asthma in children in the United Kingdom is 1.1 million (Asthma UK 2013). The Peak flow meter is used to measure the variability and reversibility of asthma (Bostock 2010). It can be useful in monitoring the response to asthma therapy and to detect deterioration (Bailey and Gerald 2013). The doctor may request peak flows and the frequency of the recordings depend on the severity of illness and the co-operation of the child. In the community peak flow recordings can be used as part of an asthma action plan (AAP). Recording serial peak flow rates assist with diagnosis and monitoring treatment. At home it may also be suggested to record two to four times a day for two weeks to obtain a base line when they are well (Bailey and Gerald 2013). Spirometry is now a more reliable test for the diagnosis of asthma as peak expiratory flow has no recognised reference values and does not detect abnormalities with air flow such as obstruction. A Peak flow is the maximum flow achievable from a forced expiration starting at a full inspiration (Education for Health 2006). A Peak flow meter is generally used over 6 years of age as under this age recordings may not be reproducible (Booker 2007). Equipment required for peak flow recording Mini Wright Peak Flow Meter. Younger children peak flow meter 30-400 litres per minute Teenagers/ young adults peak flow meter 60-800 litres per minute Disposable mouth piece, single patient use only. Peak flow chart. (European Union scale) 2
Guideline for peak flow recording Action 1. Establish predicted peak flow by obtaining the child s height and referring to Appendix (A). This will give the child s expected peak flow rate. The child s best peak flow reading should also be noted. 2. Demonstrate and explain the procedure and the purpose of the test to the child, parent / carer. Use the correct peak flow monitor and mouth piece. If the child blows more than 400, the larger Mini Wright should be used. 3. Check the peak flow meter cursor is registered at zero. 4. Ask child to stand up or sit up straight. The position should be consistent. Rationale Obtaining the child s predicted or best peak flow, can be used as a benchmark or standard against which action levels can be calculated. Their best peak flow reading may be higher or lower than their predicted. Explanation and visual display gives better understanding, therefore better results are obtained. To give an accurate result. Different peak flow meters give different readings By setting equipment properly accurate results can be obtained By increasing lung expansion, better results will be obtained. The same position will assist in the consistency of the readings (BTS/SIGN 2012). The readings should all be about the same, if they are not, the person may not be blowing correctly. 5. Hold the peak flow meter horizontally (level), keeping fingers away from the cursor, ask the child to take a deep breath in, and close the lips around the mouthpiece to make a tight seal. Give a short sharp blow into mouth piece with minimal delay. 6. Repeat the procedure three times, allowing adequate rest in between each blow. Record the best reading on a peak flow chart, with a dot for pre- bronchodilator inhalation. 7. Administer inhaled/nebulised medication as prescribed. Ask the child to perform the peak flow readings approximately 15-20 minutes after their inhaled medication. Record the best reading on the peak flow chart using a cross for post inhalation 8. If the child is experiencing respiratory distress i.e. cough, wheeze or shortness of breath, record one reading. If unable to do any, record on the chart. Short sharp blow gives maximum forced expiratory volume. To ensure reproducibility the highest two readings should be within 20-40L/min of each other (Education for Health 2006). To note effectiveness of inhaled/nebulised reliever medication Bronchoconstriction may occur in patients with unstable asthma, and if peak flow readings are falling do not repeat (Booker 2007) 3
9. Observe for errors in the procedure: Leaks around the mouth piece:- Obstructing the mouthpiece with the tongue Blowing the cheeks out Not forming a tight seal around the tube Not resting enough between the blows To ensure the procedure is performed correctly Not putting the effort into the blows Poor co-ordination Not taking a deep breath in before exhaling Coughing or spitting into meter (Education for Health 2006) Reversibility Test Peak flow should be recorded, prior to inhalation of prescribed medication. These results should be recorded on a peak flow chart, with a dot for pre-inhalation and a cross for post inhalation, (see appendix A). After the administration of the inhaled medication wait approximately 20 minutes and repeat the peak flow. Serial Peak Flow Record peak flows 2-4 times daily for two weeks, usually in the morning and evening Large differences between morning and evening readings may indicate asthma is worsening.. Results Life threatening asthma: PEF < 33% best or predicted Acute Severe asthma: PEF 33-50% best or predicted Moderate asthma exacerbation: PEF > & = 50 % best or predicted Discharge PEFR >75% of best or predicted Positive reversibility: an increase of >60 litres per minute and 20% change Serial Peak Flow Rate for diagnosing asthma: diurnal variation >20% and 60 litres per minute on three or more days a week during a two week period The variability is calculated as the difference between the highest and lowest PEF expressed as a percentage of either the mean or highest PEF. (BTS/SIGN 2012) 4
References Asthma UK www.asthma.org.uk (Accessed December 2013) Bailey, W. and Gerald, B. (2013). Peak expiratory flow rate monitoring in asthma. Available from: www.uptodate.com/contents/peak-expiratory-flow-rate-monitoring-in-asthma? (Accessed December 2013) Booker, R. (2007). Peak expiratory flow measurement. Nursing Standard. 21 (39) 42-43 Bostock, B. (2010). Revisiting diagnosis and assessment of asthma. Practice Nursing. 21 (6) 285-288 British Thoracic Society/Scottish Intercollegiate Guidelines Network (2012) British Guideline on the Management of Asthma. A national clinical guideline. Available from: http://www.britthoracic.org.uk/portals/0/guidelines/asthmaguidelines/sign101%20jan%202012.p df (Accessed December 2013) Education for Health (2006). Spirometry for Practice. Salvo Warwickshire World Health Organization (2010). Asthma definition. Available from: www.who.int/respiratory/asthma/definition/en (Accessed December 2013) Author: Caroline Youle Date: March 2014 Update due: March 2019 Ratified by: Nottingham Children s Hospital Clinical Educators Group (KW, RK, LH, AK, LB, MF, VS, JS) Signed off by: Angela Horsley, Kerry Webb and Rachel Keay 5
Nottingham Children s Hospital Peak Flow Meter Reading Chart Name. Ward NHS / K No Height cms 1. Expected PEFR 2. Best PEFR 3. 75% Expected Draw three horizontal lines for 1, 2, and 3. Mark with a dot for pre-inhalation of bronchodilators and a cross for post inhalation. Date Boys and girls Time HT PEFR HT PEFR HT PEFR 100 123 130 260 160 396 101 128 131 264 161 401 102 132 132 269 162 405 103 137 133 273 163 410 104 141 134 278 164 415 500 105 146 135 282 165 419 106 150 136 287 166 424 107 155 137 292 167 428 108 160 138 296 168 433 109 164 139 301 169 437 400 110 169 140 305 170 442 111 173 141 310 171 446 112 178 142 314 172 451 113 182 143 319 173 456 114 187 144 323 174 460 300 115 191 145 328 175 465 116 196 146 333 176 469 117 201 147 337 177 474 118 205 148 342 178 478 119 210 149 346 179 483 200 120 214 150 351 180 487 121 219 151 355 181 492 122 223 152 360 182 497 123 228 153 364 183 501 124 232 154 369 184 506 100 125 237 155 374 185 510 126 242 156 378 186 515 127 246 157 383 187 519 6
128 251 158 387 188 524 129 255 159 392 199 528 7