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01 THE EU PEAK FLOW METER

04 THE BUYERS’ GUIDE TO RESPIRATORY CARE PRODUCTS

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THE EU PEAK FLOW METER: HISTORICAL
PERSPECTIVE, WHY CHANGE AND WHAT’S
AVAILABLE
M.R. Miller
The measurement of peak
expiratory flow (PEF) was first
introduced about 50 years ago [1, 2]
as a simple and convenient measure
to aid the diagnosis and
management of patients with
airflow obstruction. Its clinical use
has waxed and waned in the
intervening years and now its role
in asthma management is better
Correspondence defined.
Dr Martin R Miller
University Hospital Birmingham
The purpose of this article is not to
NHS Trust
Selly Oak Hospital
argue the evidence concerning the
Birmingham use of PEF monitoring in the
B29 6JD management of asthma [3], but to
UK discuss how the measurement of
PEF has changed recently and
E-mail: martin.miller@uhb.nhs.uk which types of meter may best suit
certain applications. After covering
the background to where PEF
meters are today, the article will
give an understanding of the
characteristics of various types of
meter for recording PEF, followed
by a discussion concerning the
clinical settings where PEF
monitoring is used, so that the best
match of device to purpose can be
made.
Background
The first PEF meters [1, 2]
represented a tremendous step
THE BUYERS’ GUIDE TO RESPIRATORY CARE PRODUCTS
THE EU PEAK FLOW METER 01
forward in the ability to record
aspects of lung function in a
simple and repeatable way in
order to help manage common
lung disorders. The original
calibration of these devices was
undertaken to the best degree
available at the time. Subsequent
work found that when systems
were available that could generate
accurate and repeatable known
flows, the readings from these
meters were inaccurate in the mid-
range, with a significant over-
reading [4, 5]. While some believed
this error was relatively
unimportant for a device used to
look at changes in PEF within
individuals, in fact the
measurement of within-subject
PEF variability – a hallmark of
asthma – is importantly distorted
by this error such that clinical
decisions based on PEF monitoring
had in the past underestimated
asthma severity [6]. New
standards for accuracy were set [7]
and have now been refined in a
European Commission standard
[8] that means all PEF meters sold
in European Union countries now
meet accuracy requirements and
no longer need their results
correcting for the known error in
older instruments. Furthermore,
the new standard covers aspects
05
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01 THE EU PEAK FLOW METER
Figure 1. Some of the devices available. (Left to right and top to bottom: MicroLife, Personal Best, PiKo-1, Pocket Peak, Microplus, Pulmolife,
Micro, Mechanical Peak Flow Meters, Asma-1).
concerning frequency response
(vide infra) that previously had
been ignored.
PEF meter characteristics
For a PEF meter to function
correctly, it must be accurate within
the required flow range, it should
offer a suitably low resistance to
flow and it must be able to record
the types of flow input signals that
patients produce, i.e. the frequency
response characteristics must be
adequate for purpose. In addition,
the meter must be reliable and
appropriately robust for its
purpose. There are now many
types of meter available that are of
small size and practical to use
(fig. 1). These use a range of
transduction systems to convert the
6 THE BUYERS’ GUIDE TO RESPIRATORY CARE PRODUCTS
flow of gas through the device into
a signal that can be measured. As
the performance characteristics of
meters are dependent on the type
of transduction system, this aspect
will be discussed first, followed by
the performance requirements.
Transduction systems
For a PEF device to work, the rapid
flow of gas through the instrument
has to be converted into a signal
that can be measured. The methods
most commonly used in devices
available today are described
below.
Variable-orifice devices
Figure 2 shows the design principle
for these devices. At the start, a
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THE EU PEAK FLOW METER 01

PRODUCT LISTINGS

EU Standard
EN13826
• Designed specifically to
meet EN13826 scale standard
• Movable asthma management
colour zones that won’t wash off
• In-built internal check valve, avoiding
cross-infection concerns
• Available with either European or ATS scale

Micro Medical Ltd

PO Box 6, Rochester,
Kent ME1 2AZ, United Kingdom
Tel +44 (0) 1634 893500
Fax +44 (0) 1634 893600

MicroPeak Peak Flow Meter Micro DiaryCard Spirometer

The new standard in Peak Flow A new powerful and flexible replacement
measurement for paper diaries and mechanical PEF
meters

Designed specifically for European
standard (EN13826)
Measures and stores PEF,
FEV1 and FVC, Flow/Volume

High visibility EU scale
curves and symptom

ATS scale version also available responses

Wash-proof Colour-Zone asthma

All data electronically date
management system
and time stamped

Built-in check valve

Easily configured for clinical

Fully customisable for promotional
trial protocols
purposes

Easily cleaned
Simple to use for
patients at home

Secure audit path for

regulatory clinical trials

www.micromedical.co.uk www.micromedical.co.uk
Phone: +44 (0) 1634 893500 Phone:+44 (0) 1634 893500

THE BUYERS’ GUIDE TO RESPIRATORY CARE PRODUCTS 7

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01 THE EU PEAK FLOW METER
baffle occludes the orifice of the
mouthpiece. When the subject
blows through the meter, the baffle
moves forward, uncoiling a spring.
As the baffle progressively moves
up the meter it exposes more and
more of an exhaust orifice (shaded
Flow
grey in the figure). The area of the
orifice exposed is proportional to
the peak flow. Some devices have a
bending piece of metal (Pocket
Peak), rather than a baffle attached
Figure 2. Variable-orifice device such as the
to a coiled spring, that opens up the
mini-Wright meter.
area of the orifice (mini-Wright,
Micro Peak, Vitalograph mechanical
meter). The reading from these
devices is dependent on gas density
and so readings are affected by
Flow marked changes in atmospheric
pressure such as at high altitude.
The usual ambient weather
variations in barometric pressure
P1 > P2 and temperature are not important
in this respect.
Figure 3. The Venturi or fixed-orifice
principle.
Fixed-orifice or Venturi devices
Figure 3 shows the principles for
devices where the pressure drop
Flow across a fixed orifice is measured.
This drop is proportional to the
square of the flow. The flow is
turbulent and so the signal is
dependent on gas density (i.e.
altitude). These devices require
pressure transducers to be very
accurate in the low-pressure
range, as the signal is very small
at low flows, such as when
Figure 4. The stator/rotor device.
recording at the end of the
manoeuvre. The nonlinearity of
these devices can be corrected by
a) electronics holding an array of
calibration factors for the range of
flows.
Stator/rotor devices
P1 > P2
Figure 4 shows the principle of
b)
devices where the flow of gas is
turned into a vortex, usually by
passing it through a fixed set of
angled blades. This vortex then
rotates a finely balanced vane that
is very light with low inertia and
set with precision bearings. The
P1 > P2
movement of the vane can be
Figure 5. a) Fleisch and b) Lilly measured by its rorotation, which
pneumotachographs. causes the path of a visible light or
8 THE BUYERS’ GUIDE TO RESPIRATORY CARE PRODUCTS
infra-red beam to be interrupted.
These interruptions are counted
and the frequency of the counts is
related to flow. These devices have
a stable calibration and the output
is not altered by changes in gas
composition which makes them
suitable for recordings at altitude.
The engineering of the bearings is
critical to prevent the vane from
either stopping too early or
overrunning, either of which
would affect the registration of low
flows.
Pneumotachographs
Pneumotachographs were the first
truly accurate flow meters to be
used in respiratory practice. They
are essentially of two designs: the
Fleisch flow head (fig. 5a) and the
Lilly mesh screen (fig. 5b). The
pressure drop recorded is
dependent on the viscosity of the
gas passing through and not its
density, so the signal is not altered
by altitude but is sensitive to
temperature and condensation
building up in the flow head. The
Lilly has less thermal mass but is
intrinsically not quite as linear as
the Fleisch [9]. The latter has
considerable thermal mass and the
flow head can change in
temperature over a period of
testing, which will influence the
results. To avoid condensation and
keep the flow-sensing element at a
stable temperature, it is best
practice to place these devices in
the flow stream of a fan between
blows [10]. Heating of the flow
head can be undertaken to help
prevent condensation and
maintain thermal stability, but the
heating controller must be
extremely sophisticated to avoid
temperature changes [11], so using
flow heads unheated when
recording single expiratory
manoeuvres is more accurate.
These devices need accurate and
regular calibration and so are
essentially only suitable for a
laboratory, workplace or primary
care setting when used by
technical staff adequately trained
in their maintenance.
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THE EU PEAK FLOW METER 01

Table 1. A list of manufacturers, their devices with characteristics and estimated cost.

Manufacturer / Supplier Website Device Transduction PEF only Price € Logging

Clement Clarke www.clementclarke.com mini Wright variable orifice yes 15 no

International airzone variable orifice yes 15 no
Edinburgh Way mini Wright digital fixed orifice no 35 yes
Harlow one flow tester fixed orifice no 535 yes
Essex
CM20 2TT, UK

Micro Medical www.micromedical.co.uk MicroPeak variable orifice yes 10 no

PO BOX 6 PulmoLife stator/rotor no 165 no
Rochester Micro Spirometers stator/rotor no 335 yes
Kent. ME1 2AZ
United Kingdom
(part of VIASys
Healthcare Inc.)

nSpire Health www.nspirehealth.com Pocket Peak variable orifice yes 25 no

Louisville, Colorado, PiKo-1 fixed orifice no 25 yes
USA KoKo fixed orifice no 25 yes
(formerly Ferraris
Respiratory)

ndd Medizintechnik www.ndd.ch Easyone ultrasonic no 1875

Technoparkstrasse 1
CH-8005 Zürich,
Switzerland

Respironics peakflowfamily.respironics.com Assess variable orifice yes 15 no

1010 Murry Ridge Lane AsthmaCheck/Mentor variable orifice yes 15 no
Murrysville, Personal best variable orifice yes 15 no
PA 15668-8525, USA

Vitalograph www.vitalograph.co.uk mechanical PEF meters variable orifice yes 10 no

Maids Moreton, Asma-1 stator/rotor no 28 yes
Buckingham Vitalograph Micro pneumotacho- no 500 yes
MK18 1SW, UK graph

Table 2.. Clinical settings for recording PEF and instrument requirements

Setting Requirements to consider

Accident and emergency, outpatient dept, ward Low cost, robust, multi-patient use, fixed calibration
Home, workplace Low cost, robust, fixed calibration, data logging
Lung function laboratory, primary care Absolute accuracy, multi-patient use

sending beams in both directions, promise for many applications.

Flow
Figure 6. The ultrasonic flow meter.
Ultrasonic
Figure 6 shows the design for
devices where an ultrasonic beam
is passed diagonally across a flow
of gas and the transit of the beam
is affected by the gas flow
according to the Doppler effect. By
various corrections can be made to
render this an extremely accurate
and low-resistance device. The
calibration is stable and the output
is affected by properties that
determine the speed of sound,
such as gas density. The cross-
sectional area of the beam needs to
be adequately matched to the
diameter of the tube through
which the gas flow profile is
passing. For example, measuring
the Doppler effect on a very
narrow beam passing across the
flow in a much wider-bore tube
would not give a signal
representative of the whole of the
flow profile. These devices are
technically sophisticated and offer
Their calibration is stable, which
has advantages for non-laboratory
applications.
Accuracy
All PEF meters in the EU must meet
the CE standard PrEN13826 [8],
which means the accuracy of
readings from handheld PEF meters
will now agree with the standards
met by larger laboratory-based
equipment. In addition, the meters
have to meet a drop test
requirement to show they are
suitably robust for patient self-
administered use. PEF meters in use
in the USA do not have to meet

THE BUYERS’ GUIDE TO RESPIRATORY CARE PRODUCTS 9

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01 THE EU PEAK FLOW METER

PRODUCT LISTINGS

PiKo Monitors Mini-Wright Digital

nSpire Health introduces PiKo Lung Health Monitors, the
world’s smallest electronic PEF, FEV1, and FEV6 meters.
All PiKo monitors provide automatic test quality alerts,
electronic data storage of 96 patient tests, single button
review, and offer optional PiKoNET software for extended
tracking and trending. PiKo monitors are downloadable to
a personal computer. Revolutionary in their design, these
miniaturized devices exceed all published accuracy
standards, and remarkably, is priced at a similar cost to
mechanical peak flow meters. For more information call
+44 (0) 1992 526300 or visit www.nspirehealth.com.
THE NAME SPEAKS VOLUMES
It’s Intelligent. It’s Simple. It’s Accurate.
It’s Compact. It’s Easy to Clean. It’s a Mini-Wright.
Not only the name speaks volumes, so does the product.
Accurate PEF and FEV1 measurements for treating both
asthma and COPD patients at the touch of a button.
Easily customised, intelligent patient monitoring in the
palm of your hand. A water tight seal for simple
sterilisation required under industry standards. And a
name synonymous with accuracy, reliability and
performance.

Visit www.clement-clarke.com to find out more about the

digital peak flow meter that speaks volumes or for the
distributor nearest you.

Phone: +44 (0) 1992 526300 Phone: +44 1279 414 969
www.nspirehealth.com www.clement-clarke.com

Telehealthcare SIBEL – DATOSPIR PEAK-10

The DATOSPIR PEAK-10 peak flow meter provides an

objective measurement of your Peak expiratory Flow (PEF)
A modern medicine technique and is valuable information of your lung functions. It includes a
colour zone asthma management. The correct use of this
with definitive solutions instrument will help you and your doctor to follow your
condition closely and will enable him/her to provide the most
beneficial treatment for you. It is important to keep a record of

Remote Patient Monitoring (RPM) your peak flow. Readings should be taken twice a day; first
thing in the morning and at bed time, or as directed by your

Effective monitoring of chronic disease physician. You should also measure and note your peak flow if
you suddenly become wheezy or breathless at any time of the

Effective therapy control day or night. The peak flow meter DATOSPIR PEAK-10 has
been designed and manufactured according to the Medical

Cost efficient Device Directive 93/42/CEE. This device meets new EN 13826
scale standard. This device has been verified and calibrated at

Remote diagnostic possibilities SIBEL, S.A., according to the verification and adjustment
procedure.

Selective emergency management

www.viasysclinical.com Phone: +34 93 436 00 07

Phone: +49 (0) 931 4972 900 www.sibelmed.com

10 THE BUYERS’ GUIDE TO RESPIRATORY CARE PRODUCTS

BG-01 Peak flow 6/8/07 20:24 Page 11
this standard but are tested against
a less demanding standard from the
American Thoracic Society [7]. The
readings from old devices based on
the original Wright meter scale
[1, 2] can be clinically misleading
[6], depending on where across
their range the reading is being
made [4, 5]. The CE standard has
addressed these accuracy issues and
also addressed the frequency
characteristics of these devices for
the first time. It had been noted by
paediatric clinicians that astute
children could generate falsely high
PEF readings by “tongueing” the
delivery of the blow – a bit like
spitting into the meter – which in
under-damped meters would give a
high flow. This new aspect of PEF
meter testing found that some
meters available in the USA were
severely under-damped [12], that is
they over-read with flow profiles
that have a rapid rise up to and fall
off from the peak. These meters do
not meet the new EC standard,
which is the only standard to test
this aspect of performance.
Calibration
Most hand held PEF meters do not
need day-to-day calibration. This is
ideal for unsupervised patient use
of the meter. The more
sophisticated flow measuring
devices common in lung function
laboratories do need frequent
calibration, since their transduction
systems for converting flow into a
measurement signal are usually not
so stable and are influenced by
ambient conditions. Although
devices are marketed as not
requiring calibration, it is possible
with misuse or accident that the
device no longer reads correctly.
Most manufacturers state that if a
device gives surprising readings
then a calibration check procedure
is required [13].
For handheld devices that are only
giving a flow output, such as
variable orifice meters, a
calibration check is beyond the
capability of all but the most
THE EU PEAK FLOW METER 01
sophisticated laboratories, since a
pump system is needed that can
deliver calibrated flows [14].
Human calibration can be used
where, for instance, lung function
laboratory staff who are free of
lung disease regularly check their
own PEF on a meter. This can soon
detect an unexpected trend in the
output of the device. If the device
records volume as well as flow,
then discharging a 3-L syringe
several times through the device
using a range of flows can give an
indication if there is a significant
error in the device.
Resistance to flow
PEF meters offer a complex
impedance to flow, which will be
referred to here as a resistance.
When compared with variable-
orifice meters, some devices, such as
pneumotachographs or ultrasonic
devices, offer very little resistance.
This can be easily appreciated when
blowing through one such device
and then through a variable-orifice
meter. Standards for PEF meters
state what is the acceptable limit for
resistance [8, 13]. Turbine devices
offer greater resistance at higher
flows, while for variable orifice
meters it is the reverse [15]. A high-
resistance meter has been found to
reduce the achieved PEF by an
average of 8% compared with PEF
measured with a low-resistance
device, but the PEF readings were
also less variable [16], which may be
an advantage in some settings.
Reliability
The variable-orifice meters such as
the original mini-Wright meter have
working parts that have been found
to work correctly for up to 15 years
of continuous patient use without
loss of accuracy [17]. However, if a
PEF meter is mistreated then it can
fail to work properly even when
new. Thus instruction to the user
about how to use and care for the
meter is a key part of the clinician’s
role in suggesting the patient uses
THE BUYERS’ GUIDE TO RESPIRATORY CARE PRODUCTS 11
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01 THE EU PEAK FLOW METER
a PEF meter to help manage their
asthma. This is equally true for
healthcare professionals in accident
and emergency depts or in primary
care who use PEF meters. Cleaning
of PEF devices can cause more
harm than benefit and so the
manufacturer’s instructions must be
followed. Disassembling a device
can lead to damage to important
key components, such as the spring
in the mini-Wright meter and other
variable-orifice meters, which then
render all subsequent readings
invalid. Many devices are affected
by excess heat and so leaving a
device close to a heater may distort
its component parts, rendering it
useless.
Environmental conditions
Most PEF meters are used at home,
at work or in a hospital setting. The
ambient conditions in these settings
do not usually present a problem. If
accurate PEF recordings are needed
at altitude, then turbine devices or
pneumotachographs would be the
best choice, as their readings are not
affected by the changes in gas
density at altitude [14].
Clinical settings
Accident and emergency depts and
outpatient depts
In this setting, the instrument needs
to be readily available and suitable
for multi-patient use. Devices
through which the patient cannot
inhale can be used for different
patients without the necessity for
ensuring cleaning of the insides of
the instrument itself. One-way
mouthpieces can also be used to
facilitate the use of one instrument
for difference patients. Ideally this
environment also requires rugged,
robust and calibration-free
instruments.
In-patient wards
Ward patients with asthma will be
recording their PEF for several days
12 THE BUYERS’ GUIDE TO RESPIRATORY CARE PRODUCTS
while they recover and can
individually use a single instrument
for this time. A number of patients
will take this instrument home on
discharge to facilitate the
monitoring of their condition. The
environment is otherwise as
demanding as the accident and
emergency dept. Cleaning of such
meters should be undertaken,
especially for high-risk patients
such as those with cystic fibrosis
and tuberculosis. Suggestions have
been made about how this can be
done for simple mechanical variable
orifice meters [18]. The
manufacturer’s instructions must be
followed to ensure the PEF readings
remain accurate after cleaning.
Home, school, work
These settings require the PEF
meter to be used by the patient
without supervision. Thus the
instrument has to be reliable, robust
and calibration free. Most devices
for patient use fulfil these
requirements. However, the results
from unsupervised recordings can
be less than accurately registered
for a number of reasons [19, 20].
Electronic data logging meters may
then be necessary to obtain faithful
results. Another consideration is
that if the readings are to be taken
in open social environments, the
instruments should not be awkward
to use. For children the device may
need to “look cool” to be acceptable
and so increase the likelihood it will
be used appropriately.
Primary care
Increasingly, it is hoped that
satisfactory lung function
measurements will be made in the
primary care setting rather than in a
hospital laboratory. There are
tensions between the technical
requirements for using instruments
for diagnosis, which require that
their calibration and results are
accurate, and the simplicity of
cheaper calibration-free instruments.
In primary care other lung function
indices, such as forced expiratory
volume in one second (FEV1) may
BG-01 Peak flow 6/8/07 20:24 Page 13
also be required from the
instrument in order to facilitate
making a diagnosis in chronic
obstructive pulmonary disease or
asthma. When measurements are
made at a single interaction that
then lead to a diagnosis being made,
there is a necessity for the
measurements to be undertaken
with the highest technical standards
being achieved [13].
Laboratory
In a pulmonary function laboratory,
PEF is often recorded incidentally at
the same time as other spirometric
measures. Evidence suggests that it
is essential that the device must be
recording flow as the primary
measure in order to get an accurate
representation of PEF.
Differentiation of volume
REFERENCES
1. Higgins ITT. Respiratory symptoms,
bronchitis and ventilatory capacity in a
random sample of agricultural
population. BMJ 1957; 2: 1198–1203.
2. Wright BM, McKerrow CB. Maximum
forced expiratory flow rate as a measure
of ventilatory capacity with a description
of a new portable instrument measuring
it. BMJ 1959; 2: 1041–1047.
3. The BTS/SIGN British Guideline on the
management of asthma. Thorax 2003;
58: Supplement 1. Updated Nov 2005
from:
www.enterpriseportal2.co.uk/filestore/bts
/asthmaupdatenov05.pdf. Date last
accessed: June 14, 2007.
4. Miller MR, Dickinson SA, Hitchings DJ.
The accuracy of portable peak flow
meters. Thorax 1992; 47: 904–909.
5. Gardner RM, Crapo RO, Jackson BR,
Jensen RL. Evaluation of accuracy and
reproducibility of peak flow meters at
1400 m. Chest 1992; 101: 948–952.
6. Miles JF, Tunnicliffe W, Cayton RM,
Ayres JG, Miller MR. Potential effects of
correction of inaccuracies of the mini-
Wright peak expiratory flow meter on the
use of an asthma self-management
plan. Thorax 1995; 51: 403–406.
7. American Thoracic Society.
Standardization of spirometry. 1994
update. Am J Respir Crit Care Med
1995; 152: 1107–1136.
measurements with respect to time
to obtain flow accentuates any noise
on the signal and complex
smoothing algorithms have been
recommended [7, 21] to obtain an
estimate of PEF from volume
measuring equipment. This practice
is not recommended since the
frequency response characteristics
to record PEF [12] are beyond that
which volume measuring
equipment can readily achieve.
Table 1 includes a nonexhaustive
list of manufacturers and their
devices with some essential
characteristics that can help
determine the best choice for the
patient or setting. Table 2 outlines
the various clinical settings for
recording PEF and the likely
characteristics for choice of
device.
8. European Standard prEN13826. Peak
Flow Meters. London, British Standards
Institute, 2000.
9. Fry DL, Hyatt RE, McCall B, Mallos AJ.
Evaluation of three types of respiratory
flowmeters. J Appl Physiol 1957; 10:
210–214.
10. Miller MR, Sigsgaard T. Prevention of
thermal and condensation errors in
pneumotachographic recordings of the
maximal forced expiratory manoeuvre.
Eur Respir J 1994; 7: 198–201.
11. Miller MR, Pincock AC. Linearity and
temperature control of the Fleisch
pneumotachograph. J Appl Physiol
1986; 60: 710–715.
12. Miller MR, Atkins PR, Pedersen OF.
Inadequate peak expiratory flow meter
characteristics detected by a
computerised explosive decompression
device. Thorax 2003; 58: 411–416.
13. Miller MR, Hankinson J, Brusasco V, et
al. Standardisation of spirometry. Eur
Respir J 2005; 26: 319–338.
14. Miller MR, Jones B, Xu Y, Pedersen
OF, Quanjer PH. Peak expiratory flow
profiles delivered by pump systems:
limitations due to wave action. Am J
Respir Crit Care Med 2000; 161:
1887–1896.
15. Pedersen OF, Miller MR, Sigsgaard T,
Tidley M, Harding RM. Portable peak
flow meters: physical characteristics,
THE BUYERS’ GUIDE TO RESPIRATORY CARE PRODUCTS
THE EU PEAK FLOW METER 01
Conclusion
PEF meters are useful in a wide
variety of settings. From its origins
in small, cheap, handheld PEF
meters the recording of PEF has
moved on to now include equally
small and useable devices which are
more sophisticated, with additional
features such as recording FEV1 and
data logging for subsequent
download into a computer. It is
remarkable and a credit to
engineering that for extremely low
cost there are very accurate and
reliable devices available. With the
information contained in this
article, it should be possible to
choose the best device for the
required clinical application. ■
influence of temperature, altitude, and
humidity. Eur Respir J 1994; 7:
991–997.
16. Pedersen OF, Rasmussen TR, Omland
Ø, Sigsgaard T, Quanjer PH, Miller MR.
Eur Respir J 1996; 9: 828–833.
17. Miles JF, Bright P, Ayres JG, Cayton
RM, Miller MR. The performance of
Mini Wright peak flow meters after
prolonged use. Respir Med 1995; 89:
603–605.
18. Bell J. Peak flow meter manufacturer’s
comment – single patient use? Prim
Care Respir J 2002; 11: 91–92.
19. Verschelden P, Cartier A, L’Archevêque
J, Trudeau C, Malo JL. Compliance
with and accuracy of daily self-
assessment of peak expiratory flows
(PEF) in asthmatic subjects over a
three month period. Eur Respir J 1996;
9: 880–885.
20. Malo JL, Trudeau C, Ghezzo H,
L’Archevêque J, Cartier A. Do subjects
investigated for occupational asthma
through serial peak expiratory flow
measurements falsify their results?
J Allergy Clin Immunol 1995; 96:
601–607.
21. American Thoracic Society.
Standardization of spirometry: 1987
update. Am Rev Respir Dis 1987; 136:
1286–1296.
13
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