869 peak expiratory flow rate measurements final (2)
THE ROYAL FREE HAMPSTEAD NHS TRUSTPeak Expiratory Flow RateMeasurements Guidelines APRIL 2009
Validation GridPolicy title Peak Expiratory Flow Rate Measurements in clinical practiceAuthor 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 trustCommissioning Clinical Practice CommitteebodyStake holders Clinical Practice Committeeconsulted 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 ophthalmologyLinked policies Respiratory Assessment Nursing Guidelines for the administration of Nebulisers Nursing Guidelines for the administration of InhalersGuideline Yes, Peak Expiratory Flow Rate Measurement 2004replacementDate of April 2009submissionReview date April 2011Key words Peak Expiratory Flow, Asthma, Chronic Obstructive Pulmonary Disease
AbstractThe Peak Expiratory Flow Rate (PEFR) is the maximum rate at which air isexpelled from the lungs, measured in litres per minute. In those patients withsuspected obstructive airways disease, whether acute or chronic, measuringof the PEFR provides an objective indication of the degree of obstruction,primarily in the larger airways. The ‘obstruction’ may be due tobronchoconstriction or inflammation. Readings are generally obtainable fromage 5 years and onwards.AimTo provide accurate reproducible measurements of the peak expiratory flowrate (PEFR)Staff Who May Undertake This ProcedureWithin this Trust measuring PEFR is regarded as a clinical practice. A clinicalpractice may be defined as an aspect of care, which may be undertaken byregistered nurses, and midwives who accept accountability for their actionsand feel competent to undertake the procedure. There is no formalassessment for these practices but they may be aspects of care, whichrequire a period of supervised, guided practice. They should form part ofpreceptorship or mentorship programmes.Student nurses and midwives may undertake this practice under thesupervision of a registered nurse or midwife who feels competent in thisaspect of care and in the supervisory role.Health care assistants may undertake this practice following competencyassessment (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 clearand accurate records of the discussions you have and the assessments youmake. You must also complete records as soon as possible after an eventhas occurred and you must keep your colleagues informed when you aresharing the care of others by making a referral to another practitioner when itis in the best interests of someone in your care.Supportive InformationPredicted ValuesAn 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 todetermine the predicted PEFR value as action plans are often based uponthis value. For example, the British Guideline on the Management of Asthma(BTS, 2008), recommend that those admitted with an exacerbation of asthmashould not be discharged until their PEFR is greater than 75% of best orpredicted.
IndicationsThe most common groups of patients for whom this measurement isperformed, are those with asthma or chronic airways disease. Recording thePEFR when the patient first presents provides a baseline for monitoringprogress and response to treatments. It will also be measured to monitor thepatient’s response to bronchodilator treatment and in some patients who arenot receiving bronchodilators in order to monitor variations throughout the 24hour period, as this is an important characteristic of asthma.Serial measurements of PEFR should be performed at home and at work ifthere is a potential problem of a work related exposure causing respiratorysymptoms.Measurements should be recorded four times a day as a single measurementprovides insufficient information as it is relevant only to the time of itsrecording. Using a peak flow chart enables visual trends to be noted.The first reading should be made when the patient first wakes, before anybronchodilators are taken. The other readings should be spread evenlythroughout the day and timed around bronchodilators if they are being taken.Bronchodilator responseThe PEFR response to bronchodilators is recorded by means of pre and postdrug administration measurements. For example, if the patient is receivingregular bronchodilators via nebulisers, readings should be taken beforestarting and then no more than 20 minutes after the nebulisation has finished.Two lines are then evident on the Peak Flow Chart.Patient TechniqueReliable readings are only obtained if the patient is carefully educated in thetechnique for using the peak flow meter.It is important that the patient understands that the measurement is effortdependent, 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 whichmay be attached to Mini-Wright meters. These windmills rotate when theindividual 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 thoroughlyThe reading should be recorded as 0 if the patient is unable to perform thetest DUE TO THE SEVERITY OF DISEASE – REPORT IMMEDIATELY IFTHIS IS THE CASE!Serial Peak Flow Monitoring at HomeFor those patients admitted with asthma, continuation of PEFRmonitoring is strongly recommended following discharge. This enablespatients to monitor their progress at a time when they are especiallyvulnerable. Early signs of deterioration can be detected and action taken toprevent 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 orbest 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 metersshould be ordered from Pharmacy if the patient does not have their ownmeter. Morning and evening readings only are sufficient for home monitoring.Current PEF meterThe adoption of the EN 13826 Standard is likely to cause the most issues withDoctors and Nurses responsible for the long-term care of patients withasthma.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 ValuesInfection controlMeters must be restricted to single patient use only (see single use medicaldevices policy), to prevent any risks of cross infection. All patients includingthose in isolation or with a suspected infection must have their own meter. Inareas where meters are shared, disposable mouthpieces should be used andparticular attention paid to cleaning the meter after use. The plastic metersshould be washed in hot water with detergent, rinsed or wiped with Clinelluniversal sanitizing wipes and dried thoroughly at least once a week. Patientsshould be cautioned not to inhale through the meter prior to performing thetest.When patients are known to be infectious, special high density filtermouthpieces 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 todischarge. If there are problems regarding the care of meters please contact amember of the infection control team.Procedure Action RationaleExplain 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 sameor 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 theand 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 blowand 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 onbe noted on the peak flow chart. technique and effort.AuditCompliance with the guideline will be monitored. This will achieved withregular checks by the Thoracic team members, respiratory physiotherapists,respiratory technicians and senior nurses. An official audit will be performedon an annual basis, led by the CNS for Asthma and COPD and reported tothe 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 1/2Health Care Assistant AssessorName Name & TitleSignature SignatureWard/Department Ward/DepartmentDate DateResult of AssessmentCompetent Not CompetentIf the Health Care Assistant does not master the competence please indicatethe 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 SIGNATUREThe Health Care Assistant: Asse Asse Asses Self Self Self ssor ssor sor1. Gives a clear and relevant explanation of the procedure to the patient and obtains the patient’s verbal consent and co-operation2. Ensure that peak flow readings are taken immediately before the patient takes their nebuliser / inhaler as instructed by the registered nurse3. 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 nurse4. Washes hands5. 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 policy6. Ensures that patients in isolation or those who are suspected of having an infection have their own Peak Flow Meter7. Makes sure that the patient has their peak flow reading measured using only one type of Peak Flow Meter8. Uses a clean mouth piece for each individual patient9. 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 test11. Checks that the Peak Flow Meter indicator is at the bottom of the scale prior to the test -012. 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 escaping14. Then asks the patient to blow out as hard and as fast as possible, to push the pointer up the scale15. Notes the reading on the scale16. When the patient is ready, asks them to repeat the test twice more17. Accurately records the highest of the three readings on the peak flow chart18. Reports the peak flow reading result to the nurse in charge of the patient19. Is aware that the that the patients first peak flow reading of the day should be when the patient wakes up20. Is able to state the patients predicted range of peak flow recordings21. Is able to state normal peak flow recordingsdepending on age/ sex/ height etc.ATTITUDERecognises own level of competence and canexplain the implications of professionalaccountability when undertaking this procedureMaintains the patient’s privacy, dignity andsafety throughout the procedureRecognises the individual needs of the patientand deals with them in a sensitive and efficientmanner
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 ChecklistName of policy/service Peak Expiratory Flow Rate MeasurementsIs this a new or existing policy/service Update of existing guidelinePurpose of the policy/service To promote safe and effective practiceStakeholders in policy/service development See validation GridPerson responsible for policy/service impact Tareq AyoobassessmentProposed date for implementation of April 2009policy/serviceDo you think the policy/service will impact upon any group within the population based upon:Race/ethnicity No Lower socio-economic groups NoGender No Involvement in the criminal justice system NoReligion/belief No Homelessness NoDisability (including long term No Looked after children Noconditions and mental health) Population groups more at risk of developingAge No certain conditions (based on community health No profile data)Sexual orientation or gender identity No Any other groups NoWhat 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 lifeWill the policy/service have any impact on the social environment? For example: Social status Employment (paid or unpaid) Social/family support Stress IncomeWill 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 controlWill 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 sheet1. Positive impacts (Note groups affected) 2. Negative impacts (note groups affected)The policy promotes principles of Appropriate communication will begood care and safety for all groups employed for all groups to ensure consent and understanding isIt provides equality of opportunity gained. It is important that theand access for all groups. 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 requiredThe procedure will be the same for all patient groups to maintain patientsafety.4. RecommendationsLanguage and communication requirements are routinely recorded inthe nursing documentation, to enable access of appropriate interpretingservices employed by the trustFor young children, specially designed ‘windmills’ have been designedwhich 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 identified6. 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 safetyDate for completion of screening checklist review /completion of full impact assessment :April 2009Managers name and signature: Date:Tareq Ayoob April 2009Approved by Operational manager for Equality Date:and Diversity(name and signature) April 2009Jennifer Kenward