Indian

8 Dikshit
J Physiol
et Pharmacol
al 2005; 49 (1) : 8–18 Indian J Physiol Pharmacol 2005; 49(1)

REVIEW ARTICLE

LUNG FUNCTIONS WITH SPIROMETRY : AN INDIAN

PERSPECTIVE-I. PEAK EXPIRATORY FLOW RATES

M. B. DIKSHIT*, S. RAJE AND M. J. AGRAWAL

Department of Physiology,
MIMER Medical College,
Talegaon, Dabhade Dist., Pune – 410 507

( Received on June 15, 2004 )

Abstract : Peak expiratory flow rate is an effective measure of effort
dependent airflow. It is relatively a simple procedure, and may be carried
out in the field using portable instruments. The average PEFR of healthy
young Indian males and females is around 500 and 350 lpm respectively.
The PEFR reaches a peak at about 18-20 years, maintains this level up to
about 30 years in males, and about 40 years in females, and then declines
with age. Common regression equations for Indians enveloping major
studies from various parts of the country have been formulated. Indian
PEFR values compare favourably with other ethnic groups such as
Americans and Europeans.

K e y w o r d s : FVC PEFR regression equations standard values

Peak Expiratory Flow Rate (PEFR) peak for about 10 ms (1). It may be reliably
recorded using portable equipment, and thus
PEFR as a measurement of ventilatory can be used in field studies. Even in normal
function was introduced by Hadorn in 1942, subjects the values may be variable as the
and was accepted in 1949 as an index of parameter is entirely effort dependent
spirometry (1). By definition, it is “The resulting in a high intra subject variability.
largest expiratory flow rate achieved with Nevertheless it remains an effective tool for
a maximally forced effort from a position of assessing a limited aspect of ventilatory
maximal inspiration, expressed in liters/min function.
(BTPS) (2).
Measurement of PEFR : The Wright’s Peak
The PEFR is an effort dependent Flow Meter (Air Med, UK) has been used
parameter emerging from the large airways universally to measure PEFR. The dial
within about 100–120 ms of the start of the range is 0–1000 litres/min (lpm) though the
forced expiration (2, 3). It remains at its ATS recommends a range of 100 lpm to

*Corresponding Author : E-mail : [email protected]; Tel. : Off. (02114) 227938 Extn. 221; Res. (020) 25657307
Indian J Physiol Pharmacol 2005; 49(1) Lung Functions with Spirometry 9

< 850 lpm (2). It is an accurate, rugged, s h o u l d n o t e x c e e d 2 . 5 c m H 2O / l i t e r / s e c

and portable instrument. More recently, a (2).
number of Mini peak flow meters have been
introduced (range usually 60–800 lpm for For making the measurement, the
adults and 60–400 lpm for children). The subject/patient breathes out (blows out;
more popular ones available in India are blasts out) maximally into the peak flow
the Vitalograph mini (Vitalograph UK), meter after having taken a maximum
Assess (Healthscan USA), and Clement inspiration. The basic requirements and
Clerk Mini Wright (Clement Clerk UK). precautions for an acceptable effort are
Some pocket versions are also available similar to those required for making a forced
(LR Wright Pocket, Ferraris; LR Pocket expirogram measurement (7). As PEFR is
peak, Micro Medical). All contemporary achieved after 100–120 msec of initiating a
computerized pulmonary function test maximal expiratory effort (3), the expiratory
equipments record the PEFR as a part of effort need not continue up to residual
the flow volume curve. Most of these volume. At least 5 efforts must be made, of
incorporate the pneumotachograph as the which 3 should fall within 10% of one
basic transducer. Other measuring devices another, as against the FVC manouevre
include rolling seal dry spirometers, and the where a difference of 5% between two efforts
whole body plethysmograph with a Fleisch is the minimum acceptable (2). The best of
pneumotachograph. Unlike the volume the three efforts is recorded. For research
measuring devices, it is generally difficult measurements, the mean of three acceptable
to calibrate flow measuring ones. Fan values maybe taken. This flow rate may
airflow generators with rota-meters, which show a diurnal variation of about 7% in the
may or may not be very accurate, have been morning and 3% in the evening as estimated
helpful. Using a gravity influenced piston by measuring the variation in the amplitude
and cylinder type flow calibrator, various % of the mean (8), while pollution in the
types of PEFR measuring devices have been atmosphere can also contribute to this effect
evaluated (4). The error produced by the (9).
instruments varied from 0–26%. The Mini
version of the Wright’s peak flow meter was The PEFR can not be obtained from the
the least consistent. This instrument has forced expirogram that is recorded on a
however been used to measure PEFR for mechanical spirometer. The parameter
physiological studies, and found to be which can be calculated from this graph
suitable (5, 6). It is suggested that for that has some proximity to PEFR is the
research oriented measurements, the easy Vmax 200–1200 ml. , or its equivalent, the volume
to handle Mini peak flow meters may be 80 msec PEF, the flow rate determined from
avoided, and if used, are best tested against the volume-time curve using a 80 m sec
a standard, well used Wright’s peak flow segment. It has been suggested that PEFR
meter before being accepted. The frequency recorded using a peak flow meter (open
response of the measuring device should be circuit) may not be corrected to BTPS. But
within ± 5% up to 12 Hz, with an accuracy the ATS (2) recommends otherwise. In our
of ± 20 lpm. The resistance in the system laboratory, we make the BTPS correction.
10 Dikshit et al Indian J Physiol Pharmacol 2005; 49(1)

Normal values : Most PEFR measurements equipment, to generate flow volume loops,
reported in Indian literature have been a relatively low mean PEFR of only 474 lpm
carried out using Wright’s peak flow meter. has been reported in 20 yr old male athletes
The technique of obtaining a successful (13). It is difficult to explain this observation
attempt by the subject at giving the test is made by using a state of the art recording
less exacting than that required for device when a value of around 550 lpm in
recording the forced expirogram/flow volume healthy young non-athlete males were
curve, and most workers quoted would have reported from the same region (10). The
been reasonably successful in getting the latter used Wright’s Peak Flow meter for
best out of their subjects while recording making their measurements.
PEFR. This makes comparisons of different
results more possible. Singh and Peri (10) Data from Indian studies (ref nos 1, 10
have tabulated PEFRs obtained from a to 31) which have looked at PEFR in males
number of Indian studies. From this it is and females has been plotted in Fig. 1. All
seen that young Indian males have a PEFR subjects concerned were healthy, mostly
of about 450-550 lpm, while in young non-smokers. From the figure, it is seen that
females it is a little lower (320–470 lpm). A the males achieve a peak at about 20–25
larger sample surveyed later (1) also brings years of age, maintain this level up to about
out similar results. In one of our own 30 years, and thereafter their PEFR starts
studies (11) we have reported that healthy to decline. Females appear to achieve
young medical students (mean age 18.3 yr) maximum flow a little before 20 years, and
had a PEFR of 587 lpm, the slightly older appear to maintain that level for almost 2
ones at 24.4 yr were at 541 lpm, and 38 decades. The expected decline with age
year olds recorded 548 lpm. The 10 Army begins at about 40–45 years. The relatively
athletes (mean age 25.5 yr) had a PEFR prolonged maintenance of peak values in
which was also 587 lpm. More recently, females seems to coincide with their
while studying effects of bronchodilator reproductive life. Prevalence of female sex
aerosols in left handers and right handers, hormones may be responsible for this
we found that the mean pre-treatment phenomenon. That female sex hormones
PEFRs of 13 healthy male medical students affect airway behaviour is known (32).
(mean age 22 yr; height 171.6 cm) recorded Others also report that males reach their
from acceptable flow-volume curves on highest PEFR by about 25 years, while the
a Schillers Computerised Pulmotest females achieve it a earlier at about 20 years
equipment was 9.2 lps (550 lpm) (12). of age. (33). The beginning of decline of lung
Mechanical instruments which generate function parameters has been reported to
some degree of resistance to airflow may be begin at about 30 years of age in both males
expected to record slightly lower values of and females (26), around 25 years in males,
the flow rate as compared with computerized and 21 years in females (33) while others
equipment. A review of values obtained concluded that it begins at about 40 years
using both types of equipments does (34, 35), and becomes obvious only after 50
not substantiate this assumption. On the years of age. The latter two studies have
other hand, using Morgan computerized not reported PEFR measurements, but take
Indian J Physiol Pharmacol 2005; 49(1) Lung Functions with Spirometry 11

into account FEV1 which is an effort age range becomes complicated. Various
dependent volume. statistical models have been developed to
relate PEFR to age, height and weight of
Age and height together are often used the subjects. These models have been linear,
to determine PEFR in regression equations. multiplicative, polynomial and proportional
Effect of one on PEFR is influenced by the (36). However, only the linear model
presence of the other. If a total population adequately explains variations in PEFR. We
is considered, PEFR is distributed normally have used the pooled data to construct
with age and exponentially with height. linear regression equations using age and
Hence it is difficult to combine both these height as the regressors for 3 age groups:
parameters in the regression equation for < 20 yr, 20–60 yr, and > 60 yr. (Table I)
prediction of PEFR for a wide range of age Using these, we estimated PEFRs at the
extending from childhood to late adulthood. designated age groups, and compared these
Secondly, height in adults plateaus after a values with those obtained for the same
certain age. Thus one single equation to age groups from various published data.
predict PEFR with both age and height as (Table II). The PEFR values for estimated
parameters encompassing extremes of the and actual data were quite similar, and the

TABLE I : Regression equations for males and females of various age groups. Linear model: PEFR = Constant
(a) + ht cm*b + age*c. P denotes statistical significance at <0.05: *sig.; **highly sig.; NS not significant.

Age (yrs) Females SE Males SE P for (F) P for (M)

<20 Constant a –347.20 88.98 –801.42 147.75 ** **

Height b 3.99 1.06 9.59 1.78 ** **
Age c 5.49 5.09 –19.94 8.87 NS *
20–60 Constant –1072.47 508.48 –16.15.70 615.45 * **
Height 9.52 3.25 12.79 3.57 ** **
Age yr –0.43 0.43 –0.32 0.80 NS NS
>60 Constant 2275.60 2166.96 –9253.03 0.00 NS **
Height –9.77 12.15 51.32 0.00 NS **
Age –8.19 5.47 18.9 0.00 NS **

TABLE II : Mean±SD of observed PEFR values taken from studies in refs 10–31 are tabulated
with PEFR values estimated by using regression equations given in Table I.

Males Females
Age group
Observed Estimated Observed Estimated

<20 308.1±135.0 298.4±135.6 273.5±98.8 251.9±101.7

21–30 544.1±37.5 535.7±43.0 371.3±38.7 395.2±4.9
31–40 525.5±37.5 528.9±25.1 334.7±51.2 372.7±16.6
41–50 485.3±52.8 571.5±23.2 338.1±58.7 396.2±50.9
51–60 442.5±33.3 455.3±19.9 336.2±51.6 356.4±26.9
>60 379.2±67.9 377.0±71.8 265.8±33.5 265.8±27.4
12 Dikshit et al Indian J Physiol Pharmacol 2005; 49(1)

SEE for the estimated values were relatively the degree of cardio-respiratory conditioning
low. This demonstrated that even though following athletic training was not well
data from different studies across the established at the time of recording. Even
country was used to generate these then, the values reported are lower than
equations, there were almost no outliers. the average value of 550–590 for males of
We are convinced therefore that these that age group (10, 11, 29).
equations can be used to predict PEFRs in
any part of India with reasonable accuracy. High altitude natives (HANs) like the
Other recognized studies from the West also Ladhakis, are adapted to that environment
use the linear model for their regression over generations. Apte and Rao, (unpublished
equations (37, 38). observations) (39) while recording MEFV
curves in such subjects, noted that HANs
PEFR of special groups : Peak flow rate is and healthy lowlander soldiers acclimatized
higher in fitter, healthier populations such to HA (3400 m) had PEFRs in the range of
as Armed Forces personnel, and athletes. 569 lpm and 616 lpm respectively (NS). As
Goyle et al (15) found a value of over 500 such these values were not particularly
lpm in all their subjects between 19 and 42 high, considering those reported in some of
years. Similarly, elite military athletes the studies quoted above. Also the authors
(national/international level; 27.3 yr; 174.2 have not given values measured in their
cm) had a mean value of 620 lpm as against subjects when at sea level with which to
healthy non-athlete soldiers of similar age compare the HA data. However, their
and height (593 lpm, (NS) (29). Military contention that the PEFRs were high at HA
athletes in our study had lower PEFRs at because of lowered airway resistance as a
587 lpm at a mean age of 25.5 yr (11). All result of the thinner atmospheric air is
these measurements were made using the interesting, and could be further elucidated.
standard Wright’s peak flow meter. It is These authors argue that because of the
surprising therefore that PEFRs measured special environmental factors at HA, a
in national level athletes (22) were 570 lpm separate regression equation should be
for North Indian male athletes (24 yr), 538 developed for HANs for use there. At this
for South Indian males (22.5 yr), and 403 point of time this seems premature. The
lpm for international level women athletes lowlanders and HANs have similar PEFRs.
(22.5 yr). All the athletes concerned were If a regression equation is developed for this
runners who are expected to develop high parameter, it should be for all subjects
degree of cardio-respiratory conditioning. It who have acclimatized/adapted to HA. Also
is possible that the Wright peak flow meter the height of the laboratory where the
used had offered more than the expected measurements will be made, must be pre-
resistance which went unnoticed. In another selected viz 3400 m in this case. The other
study using flow volume loops recorded on possibility would be to establish the
computerized equipment (PK Morgan), the % increase in PEFRs of subjects at HA
peak flow rates of college level athletes were as compared with subjects at low altitude,
relatively low for 19 year olds (473 lpm (13). and develop statistics accordingly for
The reason for this is not clear. Perhaps comparison. In the same unpublished data,
Indian J Physiol Pharmacol 2005; 49(1) Lung Functions with Spirometry 13

the authors (39) point out that the effort diaphragm during pregnancy in these
independent airflows of the HANs are women. There is no apparent reason as to
significantly greater than acclimatized why certain ethnic groups of women are
low landers, and that this is a part of genetically predisposed towards a better
the adaptive phenomena that the HANs maintenance of their ventilatory attributes
have undergone. There is a strong case here during pregnancy which is a universal
for generating a large amount of data on phenomenon. The issue of PEFRs during
flow volume curves of HANs be they pregnancy therefore needs to be investigated
Ladhakis or Sherpas, and then develop in its various aspects.
regression equations for peak air flows, as
also airflows from the lower part of the Information on this aspect
PEFR in children :
MEFV curve. of spirometry in India is relatively wanting.
Children, as also adults on many occasions,
PEFR during PEFR decreases
pregnancy : find the forced expiratory spirogram/flow
significantly in pregnant women (40). The volume loop difficult to perform. But even 4
decline begins in the first trimester, and year olds have been known to make
reaches its lowest value towards the end of successful PEFR efforts with the peak flow
the 3rd trimester. The rate of decline is 4.8 meter (16). Using some of the available
lpm/month of gestation in the first regression equations, PEFRs were calculated
trimester, and about 8.5 lpm in the later for boys and girls having heights of 110 cm,
period. Lack of proper nutrition during 140 cm and 160 cm (adolescence) (Table III).
pregnancy, anemia of pregnancy (Hb% <6-8
gm), and a reduction in overall muscle PEFRs of girls was found to be higher
strength, are some of the reasons cited. Vital than that of boys in early childhood while
capacity increases slightly with pregnancy, during adolescence the trend reversed (14).
mainly as result of reduction in expiratory But this is not in evidence in the other
reserve volume (41, 42). This factor in tact Indian studies for children having a height
should help in an increase in PEFR rather of 110 and 140 cm (5, 16), nor was there a
than its decrease. The post partum recovery gender difference found amongst Indian
of PEFR takes about 8–10 weeks (40). It children domiciled in the UK (24). The
would also be worthwhile comparing PEFRs gender difference (girls having greater
of well nourished, non-anemic women from expiratory flow rates) is evident when
a high socio-economic status with those from dealing with effort independent flows (32)
a low socio-economic status. Puranik et al rather than the effort dependent ones. Two
(40) do not mention the socio-economic studies on PEFR in children were reported
status of their subjects. from Delhi in 1997 (5, 46). It is interesting
to note that the PEFRs reported in one (46)
Western women did not show a reduced were lower than those reported in the other
PEFR during pregnancy (32, 42). It has been (5). Both studies, conducted by experienced
suggested that a more effective force workers, were carried out in carefully
development in the respiratory muscles selected, healthy children belonging to
occurs because of realignment of the similar socio-economic status and age
14 Dikshit et al Indian J Physiol Pharmacol 2005; 49(1)

TABLE III : Comparison of PEFRs in children at three different heights as estimated by regression
equations of various studies. The numbers in parenthesis are the reference nos. as they
appear in the references list. For calculations for ref 5, ages considered are 8, 12 and 16 years.

PEFR lpm
Reference paper
For ht 110 cm For ht 140 cm For ht 160 cm
Girls Boys Girls Boys Girls Boys

1. Pande et al 1997 (5) 139 148 257 285 347 395

2. Parmar et al 1977 (14) 186 147 311 299 395 401
3. Singh & Peri 1978 (16) 116 130 266 280 366 380
4. Sitaram et al 2003 (21) NA 176 NA 324 NA 424
5. Patrick & Patel 1986 (24) NA 169 NA 296 NA 405
6. Sharma et al 1997 (45) NA NA 210 213 305 315
7. Mukhtar M et al 1989 (46) NA NA NA NA 396 416
8. Kasyap et al 1992 (47) 134 152 266 304 355 405
(High altitude natives)
9. Chowgule et al 1995 (49) 131 174 253 340 340 370

groups. There was however a difference in those reported in other studies (Table III)
the instruments used for making the Therefore, ethnic differences do not appear
measurements. Mini Wright’s peak flow to influence PEFR of children to any great
meter was used in one (5) while the PK extent as generally believed. Permanent
Morgan computerized system was used in residence at high altitude does not affect
the other (46). Pande et al (5) have PEFRs of children. (48).
commented that different instruments used
for measuring PEFR may account for the Factors affecting PEFR
variation in values reported in different
studies. A number of factors influence PEFR in
normal subjects. Age and height are the
It has been opined that Indian children obvious ones. PEFR is best correlated to
have lower PEFRs as compared with height in children, even though other physical
American white children (5). These authors factors such as age and body surface area
attribute lower Indian PEFRs to relatively also correlate well (25; and Fig. 1). It has
poor intra uterine growth. On the other been suggested that ventilatory functions
hand, a study in Nottingham UK found no of normal subjects can be predicted better
difference in the flow rates of Indian, by using sitting height. This reduced racial
Caucasian, and Black children (24), but the differences in ventilatory functions, PEFR
FVC and FEV 1 s of European children were included, between Mexican-American, white,
found to be higher by as much as 13%. and black children and adolescents (43).
Parmar et al (14) reported that Indian However, a study in which PEFR was
children whose heights and weights were determined using both standing height and
comparable to American children, had sitting height revealed that the latter does
PEFRs that were comparable. Similarly, not refine the prediction of the parameter
Arab adolescents (47) had PEFRs similar to (36).
Indian J Physiol Pharmacol 2005; 49(1) Lung Functions with Spirometry 15

Factors which have an adverse influence

on PEFR are i. low socio-economic status,
ii. overcrowding of residence, and iii.
smoking (33). The second factor is often a
reflection of low socio-economic status.
PEFR is also influenced by various
environmental factors during childhood,
level of physical activity (33), and possibly
by relatively poor intra-uterine growth (5).
Other authors have also linked lower PEFRs
to socio-economic status and under-
nourishment (10). Many workers advocate
that this fact should be taken into account
while interpreting PEFRs of such people. It
is however stressed that standards for
spirometry be based on the data acquired
in well nourished, healthy subjects, and
should not include data from under-
nourished subjects. If such subjects are
found to record a low PEFR, then it should
be reported as below normal, and the cause
for the low value may be debated upon
separately.

PEFR has been well correlated to

maximum expiratory pressure which is a
representation of respiratory muscle
Fig. 1 : D i s t r i b u t i o n o f P E F R ( 1 / m i n u t e ) i n I n d i a n
strength (44, 45). Exercise training increases
males and females plotted against age (yr). the PEFR because of an increase in
Data obtained from references 10–31.
respiratory muscle strength.

Apart from the differences between men Smokers are known to have a lower
and women attributed to greater muscular PEFR over all age ranges in both the sexes,
strength of men, and their airways but the difference between smokers and non-
diameter, which may be larger in men by smokers becomes significant only in the fifth
as much as 17%, the female sex hormones decade of life. Ferns et al (37) have
are likely to influence airway behaviour developed two regression equations-one for
(32). During pregnancy, the airways may healthy non-smokers which includes ex-
also be affected by the fetal sex hormones. smokers, and another one for persons
The mother’s airways are less reactive if without respiratory disease which includes
the fetus is a male( 32). both smokers and non smokers. From their
16 Dikshit et al Indian J Physiol Pharmacol 2005; 49(1)

TABLE IV : (A) PEFR values are calculated for males ht 162 cm, females ht 154 cm. for various
age groups, The regression equations used for making the calculations are given at
the bottom of the table, using regression equations for Indians, Europeans and Americans
(B) in order to elucidate ethnicity as a factor. The numbers in parentheses represent
the reference numbers of studies quoted.

A
Indian American European
Age
Males Females Males Females Males Females

25 448 383 504 374 541 397

35 445 379 480 357 515 379
45 442 374 455 340 490 361
55 439 370 430 323 464 343
65 289 240 406 306 438 325

B
Ethnicity Regression Equations

1 Indian (Present report) Table I above

2 American (37) M 4.73* ht (cm) – 2.46* Age (yr) – 200.32
F 2.96* ht – 1.71* Age – 39.19
3 European (38) M 6.14* ht (m) – 0.043* Age (yr) + 0.15
F 5.50* ht (m) – 0.030* Age – 1.11

data it is obvious that moderately heavy to ethnicity as has been thought hitherto.
heavy smokers have lower PEFRs after the
age of 40 yr. Female smokers are at a Clinico-physiological PEFR
applications :
disadvantage from the 3rd decade of life measurement may be carried out in the out
(33). patient department, as also at the bed side
of the patient. Patients of asthma can be
It has been generally believed that as taught to use the peak flow meter to
an ethnic group, Indians have lower PEFRs measure their own PEFR in order to monitor
as compared with Europeans and American clinical status, as also their response to
whites. PEFR values for males and females bronchodilator treatment. Usually, the
of various ethnicities at a given age and patient is asked to record PEFR four times
height are given in Table IV. It is seen that during the day and maintain a record for
Indian PEFRs are at par with those the treating physician to peruse. Large
recorded in other ethnic groups. Malaysian population surveys may be easily conducted
aboriginal adult males (mean age 26 yr, ht using the peak flow meter. Directions for
163 cm) had a PEFR of 475 lpm (50). performing the PEFR manouevre is more
Comparative value for Indian males of the easily understood by the subject/patient
same age and height as calculated from our concerned as compared with the directions
composite regression equation is 488 lpm. for performing the forced expiratory one.
Elderly Chinese have PEFRs similar to Also, the effort is less tiring as it is not
those recorded in the Indian elderly required to be continued to residual volume.
population (51). These data suggest PEFR does not detect small airways
that PEFR is not greatly affected by obstruction. Nevertheless, it is a very useful
Indian J Physiol Pharmacol 2005; 49(1) Lung Functions with Spirometry 17

diagnostic and prognostic variable obtained side, or in the field using a peak flow meter.
during spirometry. The parameter is effort dependent, and the
forced expiration is not required to be
Conclusions : extended to residual volume when it is to
be measured using the portable instrument.
PEFR forms a part of routine spirometry. A set of regression equations for use for the
It may be done independently at the bed Indian population has been derived.

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