Feedback Can Improve Perception of Lung Function in Older Adults With Asthma

Peak expiratory flow feedback was associated with a clinically meaningful improvement in Asthma Control Questionnaire scores.

An asthma intervention program for older adults that provided patients with feedback regarding peak expiratory flow (PEF) was associated with an increased perception of PEF that was more beneficial to patients than supportive counseling. This was among study findings published in the American Journal of Respiratory and Critical Care Medicine.

Research indicates that older adults with asthma are more likely to under-perceive airflow obstruction, which may increase their risk of fatal and near-fatal asthma attacks. Investigators therefore conducted a pilot randomized controlled trial to determine the value of using feedback to correct misperception of airflow obstruction in older adults. The trial compared a specific intervention — a PEF feedback session combined with motivational interviewing — with a counseling session, which served as the control. The goal of the trial was to determine whether the intervention resulted in improvement in patients’ perception of airway obstruction, PEF values, self-reported asthma control, and/or medication adherence.

Study participants were at least 60 years of age, with a physician diagnosis of asthma, and had demonstrated an under-perception of their airflow obstruction at least 25% of the time in another longitudinal, observational study. Patients’ under-perception of airflow obstruction was determined pre-intervention based on 6 weeks of home data collection, in which patients twice daily recorded their predicted PEF in a programmable peak flow monitor (PFM) and then immediately measured their PEF using the PFM.

The participants were randomly assigned to receive PEF feedback with motivational counseling (ie, the intervention group) or to receive a supportive counseling session without PEF feedback (ie, the control group). The PEF feedback group included 28 participants (mean [SD] age, 67.0 [4.9] years; 75% female), and the control group included 25 participants (mean age, 65.7 [5.6] years; 92% female).

Both groups of patients attended a 45-minute in-person session with an interventionist that included asthma education. Intervention group participants received guidance to help them identify their misperception of their PEF and implement behavioral changes to improve their PEF perception as well as asthma control. Control group participants received empathy for their asthma struggles and praise for their asthma control efforts.

For the next 4 weeks, participants in both groups continued their use of the PFM, however the PRMs were reprogrammed in different ways for each group: the intervention group participants were able to compare their perceived and actual PEF values, while control group participants received encouraging messages via PFM but were not shown their actual PEF values.

A postintervention visit occurred 1 month later to download perception data and reprogram the PFM to blind all participants to actual PEF. Self-report measures were based on use of the Medication Adherence Response Scale, Asthma Control Questionnaire (ACQ-6), and treatment credibility and expectancy of improvement in asthma control.

These findings suggest that training and feedback can decrease under-perception of airflow obstruction and increase lung function in older adults with asthma.

The PEF feedback group had a large decrease in under-perception and medium increase in accurate perception. At pre-intervention, postintervention, and 1-month follow-up, the PEF feedback group had under-perception rates of 39.68%, 11.86%, and 11.79%, respectively, and accurate perception rates of 55.29%, 71.52%, and 72.23%, respectively.

The supportive counseling group had no change in accurate or under-perception. Notably, the effect of the intervention compared with the control session regarding under-perception (P =.053) and accurate perception (P =.065) was “just outside the range of significance in this small pilot study,” said study authors. The 2 groups had medium increases in over-perception after treatment.

The PEF feedback group had a large increase in PEF from pre-intervention to post-treatment and a medium-large increase at 1 month, which were statistically significant compared with the control group (P <.0001). The within-group effects were not significant for medication adherence in either group.

PEF feedback was associated with clinically meaningful improvement in ACQ scores at follow-up, although it was not statistically significant. Participants in both groups rated their intervention as highly credible with high expectations for improvement in asthma.

Both groups had high treatment fidelity coding (PEF feedback: 77%; control group: 84%; P = .25) and adherence to the protocol at home (number of PEF predictions-blows in PEF feedback: mean 48.8 [13.0]; control group: mean 50.6 [15.7]; P =.685).

“These findings suggest that training and feedback can decrease under-perception of airflow obstruction and increase lung function in older adults with asthma,” stated the researchers. “Improvement in asthma control was not statistically significant and further studies with larger samples are needed.”

Disclosure: One of the study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.


Feldman JM, Ankam J, Barry M, et al. A pilot RCT of an intervention to improve perception of lung function in older adults with asthma. Am J Respir Crit Care Med. Published online November 7, 2022. doi:10.1164/rccm.202206-1132LE