The report by Dr Scarfone and his colleagues1 concluded that "a greater emphasis must be placed on teaching methods to optimize drug delivery and to instruct patients about the importance of self-monitoring of disease severity." While these recommendations are unequivocally desirable and essential if the current endemic problem of emergency care and hospitalization for asthma are to be favorably influenced, the investigators' emphasis on the use of the peak flow meter is not well supported by controlled clinical trials. The weight of evidence indicates that symptom monitoring (and consequent need for intervention with an inhaled β2-agonist) has been demonstrated to be generally equal to2,3 or better than4,5 peak flow monitoring in providing early warning of an exacerbation requiring intervention. The authors lament in their conclusions that nonadherence to the guidelines of the National Heart, Lung, and Blood Institute persists a decade after the first set was introduced. Perhaps it is time to recognize the excessive complexity and specific limitations of those guidelines and examine the components of care in specialty-based programs that do seem to substantially influence outcome.6 Simply improving the process of care, such as routine peak flow meter use, without ensuring that therapeutic measures are effectively applied will not improve outcome. While the peak flow meter may be of value for selected patients who underperceive or overperceive symptoms, routine use does not seem to improve overall outcome when compared with careful symptom monitoring, close follow-up by a knowledgeable clinician, recognition by the patient or family of bronchodilator subresponsiveness (which does of course require appropriate use of an inhaled bronchodilator), appropriate maintenance medication when clinically indicated, and early intervention with a short course of an oral corticosteroid when necessary.
Weinberger M. Peak Flow Meter Use Is Not Where Emphasis Should Be Placed. Arch Pediatr Adolesc Med. 2002;156(9):945-946. doi: