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Peak flow meter with a questionnaire and mini-spirometer to

help detect asthma and COPD in real-life clinical practice: a
cross-sectional study
Yogesh T. Thorat1, Sundeep S. Salvi1 and Rahul R. Kodgule 1

Peak flow meter with questionnaire and mini-spirometer are considered as alternative tools to spirometry for screening of asthma
and chronic obstructive pulmonary disease. However, the accuracy of these tools together, in clinical settings for disease diagnosis,
has not been studied. Two hundred consecutive patients with respiratory complaints answered a short symptom questionnaire and
performed peak expiratory flow measurements, standard spirometry with Koko spirometer and mini-spirometry (COPD-6).
Spirometry was repeated after bronchodilation. Physician made a final diagnosis of asthma, chronic obstructive pulmonary disease
and others. One eighty nine patients (78 females) with age 51 ± 17 years with asthma (115), chronic obstructive pulmonary disease
(33) and others (41) completed the study. “Breathlessness > 6months” and “cough > 6months” were important symptoms to detect
obstructive airways disease. “Asymptomatic period > 2 weeks” had the best sensitivity (Sn) and specificity (Sp) to differentiate
asthma and chronic obstructive pulmonary disease. A peak expiratory flow of < 80% predicted was the best cut-off to detect airflow
limitation (Sn 90%, Sp 50%). Respiratory symptoms with PEF < 80% predicted, had Sn 84 and Sp 93% to detect OAD. COPD-6 device
under-estimated FEV1 by 13 mL (95% CI: −212, 185). At a cut-off of 0.75, the FEV1/FEV6 had the best accuracy (Sn 80%, Sp 86%) to
detect airflow limitation. Peak flow meter with few symptom questions can be effectively used in clinical practice for objective
detection of asthma and chronic obstructive pulmonary disease, in the absence of good quality spirometry. Mini-spirometers are
useful in detection of obstructive airways diseases but FEV1 measured is inaccurate.
npj Primary Care Respiratory Medicine (2017)27:32 ; doi:10.1038/s41533-017-0036-8

INTRODUCTION and COPD and hence, there is a need for a single questionnaire for
Asthma and chronic obstructive pulmonary disease (COPD) detection of both asthma and COPD.
present to a clinician in various forms and usually with non- The peak flow meter is a simple, easy to use tool that measures
specific symptoms and signs, leading to significant under- peak expiratory flow (PEF) and detects airflow limitation.
diagnosis and mis-diagnosis. Around 70% of asthmatics in the Compared to spirometry, peak flow measurements are less-time
population aged more than 40 years remain undiagnosed and consuming, are not dependent on trained manpower, easy
around 30% of patients diagnosed to have asthma do not have for patients to perform and are less costly. Although, not as
asthma.1–3 In India, >95% of patients with COPD remain reliable as spirometry, a peak flow meter is a recommended
undiagnosed and around 50% of patients diagnosed to have alternative for diagnosis of asthma.10 There has been a recent
COPD, may not necessarily have COPD.4 The most commonly used interest in the role of peak flow meter for screening of COPD.
objective tool to diagnose asthma and COPD is spirometry. Jackson et al. conducted an analysis of the data from the third
However, spirometry is poorly used in India for several reasons national health and nutrition survey (NHANES III) and defined a
including lack of time, cost, lack of availability, and lack of PEFR of <80% predicted as abnormal.11 Using this definition
knowledge.5 they found a sensitivity of 91% and specificity of 82% to detect
There have been several attempts to develop simpler diagnostic COPD. From the analysis of the data of the Latin American
tools with reasonable sensitivity and specificity that can help Project for the Investigation of Obstructive Lung Diseases
detect asthma and COPD in the community and in primary care (PLATINO) study and the Burden of Obstructive Lung Disease
practice.6–9 The sensitivity and specificity reported using these (BOLD) study, Perez–Padilla et al. suggested that a pre-
tools ranged between 50 and 96% depending on the criteria used
bronchodilator PEF of less than 70% of predicted can rule
for the diagnosis. The questionnaires for asthma have been tested
out stages III and IV of COPD.12 The reliability of PEF to detect
for assessing prevalence of asthma in the community. The COPD
airflow limitation13 and COPD14, 15 in a community setting has
diagnostic questionnaire has been tested for diagnosing COPD in
previously been studied. However, the accuracy of peak flow
primary care practice. However, these questionnaires are relatively
large and scoring system is complex. Also, in real-life practice, meter to detect both asthma and COPD, in a clinical setting, has
primary care practitioners are required to diagnose both asthma not been studied.

1
Chest Research Foundation, Marigold Premises, Kalyani Nagar, Pune 411014, India
Correspondence: Rahul R. Kodgule (rahulkodgule@gmail.com)

Received: 15 December 2016 Revised: 23 March 2017 Accepted: 4 April 2017

Published in partnership with Primary Care Respiratory Society UK

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YT Thorat et al.
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Fig. 1 Patient disposition

Another simpler alternative to spirometry could be the use of categorized as “others” included allergic rhinitis (78%), gastro-
handheld mini-spirometers that measure forced expiratory esophageal reflux (22%), cardiac failure (7%), interstitial lung
volume in one second (FEV1) and forced expiratory volume in disease (5%), and anemia (2%).
six seconds (FEV6). Airflow limitation, using mini spirometers, is Table 2 shows the accuracy of each symptom independently for
diagnosed based on the ratio of FEV1 to FEV6. However, the quality detecting OAD and for detecting asthma and COPD. After
assurance checks for the measurements made by peak flow meter stepwise backward logistic regression, “age at cough onset”
and mini-spirometer are less stringent than those for a standard (p = 0.025), “history of wheeze” (p = 0.003), and “cough with
spirometer and hence, it is important to study their performance expectoration” (p = 0.031) remained in the final model as
compared to standard spirometry. FEV1/FEV6 measured by significant predictors of diagnosis of OAD. As decided a priori,
standard spirometer has been shown to be a reliable alternative we retained “breathlessness >6 months” and “cough >6 months”
to FEV1/FVC for detecting airflow limitation.16–23 The reliability of in the model. After addition of these symptoms, only “wheeze”
mini-spirometer has been evaluated in at least 3 studies.24–26 FEV1 (p < 0.01) remained a significant predictor in addition. “Breath-
measured is used to assess bronchodilator reversibility and classify lessness >6 months” was the most sensitive (sensitivity = 95%) and
severity of the disease. Hence, it is important to study the accuracy “history of wheeze” was the most specific (specificity = 93%)
of a mini-spirometer to measure FEV1 in real-life practice. symptoms for the physician diagnosed OAD.
Previous work on accuracy of peak flow meter and mini- For differentiating between asthma and COPD only “presence of
spirometer was carried out separately for asthma and COPD and asymptomatic (no breathlessness, cough, and wheeze) period for
was population based. In real-life practice, a diagnostic tool should >2 weeks” (p < 0.01) remained a significant predictor of asthma
be able to detect both asthma and COPD. Hence, we aimed to diagnosis with a sensitivity of 92% and specificity of 88%.
study, in real-life practice the sensitivity and specificity of: (i) peak
flow meter with and without a questionnaire to detect airflow Peak flow meter with symptoms
limitation detected by conventional spirometry and physician The best cut-off of PEF for detection of spirometry defined airflow
diagnosis of OAD, (ii) peak flow meter with and without a limitation (pre-BD FEV1/FVC < 0.70) was at ≤80% predicted (Fig. 2),
questionnaire to predict clinical diagnosis of asthma and COPD with the AUC 0.82, sensitivity 90%, and specificity 50%.
and (iii) mini spirometer to detect airflow limitation detected by Similarly, the best cut-off of PEF, for clinical diagnosis of an
conventional spirometry. obstructive airways disease (OAD) was at 80% predicted with AUC
0.85, sensitivity 89%, and specificity 68%. Patients who were
detected to have OAD were categorized as asthma if they had “an
RESULTS asymptomatic period >2 weeks in last 1 year” and others were
Two hundred subjects provided consent for study participation categorized as COPD. Table 3 shows the accuracy of peak flow
out of which 189 completed all the study procedures and were meter with chronic respiratory symptoms (breathlessness and/or
analyzed (Fig. 1). The characteristics of patient population are cough >6 months and PEF < 80% predicted) for detection of
summarized in Table 1. clinical diagnosis of OAD, asthma, and COPD. Addition of other
Final physician diagnosis was asthma in 115 subjects, COPD in symptoms did not improve the accuracy over just these two
33 subjects and “others” in 41 subjects. The diagnosis of patients symptoms.

npj Primary Care Respiratory Medicine (2017) 32 Published in partnership with Primary Care Respiratory Society UK
 Accuracy of peak flow meter with questionnaire
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Table 1. Patient characteristics

Total Asthma COPD Others

N 189 115 33 41

Females, n(%) 78 (41.3%) 63 (54.8%) 0 (0%) 15 (36.6%)

Age (years), mean ± SD 51 ± 17 47 ± 16 66 ± 8 50 ± 17
Smoking status
Non-smoker, n(%) 140 (74.1%) 105 (91.1%) 0 (0%) 35 (85.4%)
Current smoker, n(%) 14 (7.4%) 3 (2.6%) 10 (30.3%) 1 (2.4%)
Ex-smoker, n(%) 35 (18.5%) 7 (6.1%) 23 (69.7%) 5 (12.2%)
Pre-BD FEV1, % predicted ± SD 63.1 ± 22.9 62.0 ± 15.6 36.7 ± 12.8 87.3 ± 21.5
Pre-BD FVC, % predicted ± SD 83.6 ± 23.6 81.5 ± 18.1 70.0 ± 15.7 100.2 ± 32.2
Pre-BD FEV1/FVC, % ± SD 62.9 ± 18.8 63.2 ± 18.5 43.1 ± 12.0 77.6 ± 05.8

Table 2. Accuracy of each symptom (A) for detecting OAD and (B) for detecting asthma in patients who have OAD

Symptom Sensitivity, % Specificity, % Positive predictive value, % Negative predictive value, %

A Accuracy for detecting OAD

Breathlessness (mMRC grade ≥ 1) 97.30 75.61 93.51 88.57
Breathlessness > 6 months 94.59 78.05 93.96 80.00
Cough 93.24 78.05 93.88 76.19
Cough > 6 months 89.86 82.93 95.00 69.39
Cough with expectoration 42.57 85.37 91.30 29.17
Wheeze 83.11 92.68 97.62 60.32
B Accuracy for detecting asthma in patients who have OAD
Wheeze 89.57 39.39 83.74 52.00
Intermittent asymptomatic period 92.17 87.88 96.36 76.32
Smoker 85.22 75.76 92.45 59.52
Pack years < 10 years 90.43 75.76 92.86 69.44
Family history of atopy 53.91 78.79 89.86 32.91
Current age < 40 years 28.70 90.91 91.67 26.79
Age of onset of breathlessness < 40 years 66.09 87.88 95.00 42.65
Age of onset of cough < 40 years 68.70 87.88 95.18 44.62

Ninety three percent of patients who did not have OAD were also
found to be negative using peak flow meter (i.e., PEF ≥ 80%
predicted) with symptoms and 98% of patients detected to have
OAD using peak flow meter (PFM) with symptoms actually had an
OAD. Similarly, 93% of patients who did not have asthma were also
found to be negative using PFM + symptoms and 95% of patients
detected to have asthma using PFM + symptoms actually had
asthma. 95% of patients who did not have COPD were also found to
be negative using PFM + symptoms and 76% of patients detected
to have COPD using PFM + symptoms actually had COPD.
Out of 94 patients detected to have asthma using peak flow
meter with symptoms, 1 patient (1%) was healthy and 4 (4%) had
COPD. Similarly, out of 34 patients detected to have COPD using
these tools, 2 patients (6%) were healthy and 6 patients (18%) had
asthma.
Since, wheeze had the highest specificity of 93% to detect OAD
and breathlessness had highest sensitivity of 95%, we built a 2-
step model. In first step, all the patients with wheeze were
categorized as OAD. In the second step, all those without wheeze,
were categorized as OAD if they had either breathlessness or
cough >6 months and also had PEF < 80% predicted. Rest of the
patients were categorizes as “No OAD”. This model had 97%
sensitivity and 82% specificity to detect OAD (Table 3). Fig. 2 ROC of PEF for detection of OAD

Published in partnership with Primary Care Respiratory Society UK npj Primary Care Respiratory Medicine (2017) 32
 Accuracy of peak flow meter with questionnaire
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Table 3. Accuracy of peak flow meter with and without symptoms for detection of OAD and detection of asthma and COPD

Sensitivity, % Specificity, % Positive Predictive Value, % Negative Predictive Value, %

Peak flow meter (PEF < 80% predicted) for detection of 89 68 91 62

OAD
Peak flow meter and symptoms for detection of OAD 84 93 98 62
(breathlessness and/or cough > 6 months)
Peak flow meter and symptoms for detection of asthma 77 93 95 73
(breathlessness and/or cough > 6 months + presence of
asymptomatic period)
Peak flow meter and symptoms for detection of COPD 79 95 76 95
(breathlessness and/or cough > 6 months + absence of
asymptomatic period)
2-step model 97 82 95 90

Fig. 4 ROC of FEV1/ FEV6 measured by COPD6 device for detection

of OAD

In 150 patients (79%), the interpretation of airflow limitation

was same by both COPD-6 device and Koko spirometer. 28 (15%)
patients had airflow limitation detected by Koko which was not
detected by COPD-6 device. Airflow limitation was detected by
COPD-6 and not by Koko in 9 patients (5%).

DISCUSSION
To the best of our knowledge, this is the first study that has
assessed the accuracy of a peak flow meter together with a
Fig. 3 Bland–Altman plot of differences in (a) FEV1 and (b) FEV6
questionnaire and mini-spirometer, to help detect airflow limita-
measured by COPD6 device and Koko spirometer tion and help diagnose asthma and COPD in real-life practice.
Peak flow meter with a cut-off value of PEF < 80% predicted had
good sensitivity but low specificity to detect airflow limitation.
COPD-6 However, a combination of peak flow meter and a symptom
On an average, compared to the standard spirometer, the COPD-6 questionnaire increased the sensitivity to 84% and specificity to
93%. This high degree of sensitivity and specificity is encouraging
device under-estimated FEV1 by 13 mL (95% CI: −212, 185) and
and suggests that a peak flow meter with a questionnaire can be
FEV6 by 112 mL (95% CI: −339, 115) (Fig. 3). The difference in the
used to detect cases of OAD in clinical practice. Although the use
FEV1 and FEV6 measured by the two devices was more than 200 of spirometry will provide the best results, its availability in
mL in 14 (7.4%) and 43 (22.7%) subjects respectively. developing countries is poor and quality of testing done is
Figure 4 demonstrates the receiver operating curve (ROC) of questionable. Peak flow meter and questionaire being inexpen-
FEV1/FEV6 ratio for detection of OAD. At a cut-off of 0.75, the FEV1/ sive, handy, easy to use and less-time consuming are likely to
FEV6 had the best accuracy with the area under the curve 87%, receive larger acceptance than spirometry and may have
sensitivity 80%, and specificity 86%. The sensitivity and specificity significant effect in improving diagnosis of OADs.
at cut-off of 0.70 were 65 and 55%, respectively, and at a cut-off of Use of a peak flow meter and a questionnaire had lower overall
0.80 were 88 and 69%, respectively. sensitivity but good overall specificity for a specific diagnosis of

npj Primary Care Respiratory Medicine (2017) 32 Published in partnership with Primary Care Respiratory Society UK
 Accuracy of peak flow meter with questionnaire
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asthma and COPD. Jithoo et al. conducted an analysis of data of Our study had some strengths and weaknesses. For the first
9000 participants from the BOLD study.27 The authors reported a time we studied the accuracy of peak flow meter with
sensitivity of 83–84% of PEF to detect COPD, which is comparable questionnaire and mini-spirometer for detection of asthma and
to a sensitivity of 89% found in our study to detect OAD. In a COPD, in one single study. Also, for the first time we studied the
prospective cross-sectional survey among 525 participants, accuracy in a clinical setting. The diagnosis of asthma and COPD in
Mahboub et al. reported a sensitivity of 73% and specificity of our study was based on physician opinion along with evidence of
80% to detect COPD.15 However, previous studies were aimed at obstruction on spirometry. In few cases additional testing in the
screening for COPD and were population based. Our study was form of chest X-ray, body plethysmography, bronchial challenge
clinical practice based and was aimed at assessing accuracy of testing, and DLCO was performed to confirm the diagnosis or rule-
simple diagnostic tools to detect asthma and COPD in patients out alternative diagnoses.
visiting clinical facility with respiratory symptoms. However, our study was single center based with a smaller
In our study we used a short symptom questionnaire for sample of 200 patients. Large multi-centric studies are required to
assessing symptoms and for differentiating between asthma and replicate our findings. Secondly, our center caters mainly to the
COPD. Presence of breathlessness or cough for more than patients with asthma and COPD. Hence, a large of patients in this
6 months along with reduced PEF (<80% predicted) had a study had OAD. Although, this could have led to sampling bias,
reasonably good accuracy to detect patients with OAD. “Presence having such a facility, allowed to screen adequate number of
of asymptomatic period of more than 2 weeks” was the strongest patients with asthma and COPD. Our findings need to be studied
symptom to differentiate between asthma and COPD. Using these in centers receiving large number of patients with cardiovascular
questions and PEF measurements, sensitivities, and specificities for disease and other chronic lung diseases.
reaching a diagnosis of asthma and COPD in patients with We found that only question (“intermittent asymptomatic
respiratory symptoms were around 75 and 95%, respectively. This periods >2 weeks”) was sufficient to differentiate between asthma
suggests that these tools can be used effectively, in clinical and COPD, although smoking history and onset of symptoms after
practice to aid diagnosis of asthma and COPD, in absence of the age of 40 years were other important symptoms. Larger
spirometry. Questionnaires have earlier been developed sepa- studies are required to validate this finding. Besides, we
rately for detection of asthma or COPD. However, these developed tools based on the data from this study and tested
questionnaires are bigger and more complex and aimed at their accuracies in the same data. This is likely to provide good
detecting these diseases and their risk factors in community internal validity but poor external validity. Hence, these tools need
settings.6–9 We identified minimal symptoms (wheeze, breath- to be tested in independent larger studies.
lessness/cough, and intermittent relief periods) that were suffi- Also, many patients with COPD do not have any symptom and
cient to provide enough accuracy for disease detection. Being are hence, likely to be missed using these tools. However, in real-
short and simple, these questions would be easy to use in busy life clinical practice, where reporting patient has some level of
clinical practice or by trained healthcare workers. However, being symptoms, these tools are likely to be most effective.
not so elaborate, the information from these tools can play only a
valuable supportive role to physician diagnosis.
We also developed a 2-step model for detection of OADs with CONCLUSION
impressive accuracy measures. However, this model needs to be Peak flow meter with few symptom questions can be effectively
tested objectively in larger independent studies. used in real-life clinical practice for objective detection of asthma
In our study, we found that the mini-spirometer significantly and COPD, in absence of good quality spirometry. Mini-
underestimates FEV1 and FEV6 measured by full-standard spiro- spirometers are useful in detection of OADs but FEV1 measured
metry. Gochicoa–Rangel et al. reported a relatively higher (40 mL) is inaccurate. These tools are required to be tested in larger multi-
mean difference in FEV1 measurement and lower (7 mL) mean centric studies.
difference in the measurement of FEV6 with much wider
confidence intervals.28 We found relatively narrow confidence
METHODS
intervals probably because of larger sample size (82 vs. 189)
In this cross-sectional study we enrolled 200 consecutive adult patients
compared to Gochicoa–Rangel’s study. Since, FEV1 measured is
attending the clinical facility of Chest Research Foundation, Pune, with
often used to classify severity of the disease and to assess respiratory complains that required spirometry for diagnosis. Patients with
bronchodilator reversibility, its accurate measurement is impor- history of pulmonary tuberculosis, and those with contra-indications for
tant. Although, the mean difference in FEV1 measured by the two spirometry, and also pregnant and nursing mothers were excluded from
devices was small, in a significant proportion of patients (7.4%) the the study. Selected patients were administered a questionnaire developed
difference was more than 200 mL. by the Chest Research Foundation. The questionnaire consisted of seven
Also, the sensitivity (80%) and specificity (86%) to detect a questions aimed at suspecting OAD and differentiating between asthma
clinical diagnosis of OAD were lower in our study compared to and COPD. The questions were history of breathlessness with modified
those previously reported. These differences could be because in Medical Research Council grade ≥1, cough and wheeze, duration of
symptoms, age at the onset of symptoms, whether patient felt complete
most of the previous studies FEV6 was derived from the same
relief from breathlessness, cough, and wheeze for more than 2 weeks
maneuver and using a standard spirometer.18, 22, 23, 29–31 anytime in last 1 year, age, and smoking history.
Comparatively the sensitivities and specificities of FEV1/ FEV6 After questionnaire administration, PEF was measured using a hollow
were lower when a mini-spirometer was used.25, 26 Since, these cylinder, EU scale peak flow meter (Cipla Breathometer®). Peak flow
mini-spirometer devices do not show flow-volume and volume- measurements consisted of at least three acceptable blows after complete
time graphs for quality assurance, it is possible that, as a result inhalation, with the highest two PEF readings repeatable within 40 L/min.
FEV1 and FEV6 are often inaccurately measured leading to lower The highest PEF was captured as the PEF for the patient. Published
accuracy in detection of OADs. reference equations were use to obtain PEF% predicted.32
Eleven patients in our study could not perform standard After PEF measurement spirometry was performed using both, the mini-
spirometer (Vitalograph® COPD-6 device) and conventional pneumotach
spirometry, but all of them answered the questionnaire and spirometer (Koko® Sx) in a randomized sequence. Mini-spirometry was
performed peak flow meter test. Two out of these eleven patients performed according to the instructions in the manufacturer’s manual for
were able to perform mini-spirometry but not standard spirome- COPD-6. Each subject provided at least three acceptable blows with
try. All the 189 patients performed all the study procedures. This repeatability of 150 mL between highest two FEV1 and FEV6. The device
suggests wider usability of these tools than standard spirometry. was checked for calibration at the beginning and at the end of the study.

Published in partnership with Primary Care Respiratory Society UK npj Primary Care Respiratory Medicine (2017) 32
 Accuracy of peak flow meter with questionnaire
YT Thorat et al.
6
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COMPETING INTERESTS 25. van den Bemt, L., Wouters, B. C. W., Grootens, J., Denis, J., Poels, P. J. & Schermer,
The authors declare no competing financial interests. T. R. Diagnostic accuracy of pre-bronchodilator FEV1/FEV6 from microspirometry

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