Peak Flow Feedback Intervention Improves Underperception of Airflow Limitation in Pediatric Asthma: A Randomized Clinical Trial

<b>Rationale:</b> Underperception of asthma symptoms is associated with poor asthma outcomes. <b>Objectives:</b> We assessed the effects of a behavioral intervention for improving perception of airflow limitation and asthma outcomes. <b>Methods:</b> A two-arm randomized controlled trial compared peak expiratory flow (PEF) feedback versus supportive counseling. Latino and Black adolescents with asthma ages 10-17 years old and caregivers were recruited from hospitals in the Bronx, New York. PEF feedback sessions reviewed accuracy of PEF guesses and medication adherence data and targeted behavior change using motivational interviewing and problem-solving skills training. The supportive counseling group received emotional support related to asthma. Both groups received three sessions across 6 weeks. All participants were blinded to PEF while guessing PEF before intervention and at 1, 6, and 12-month follow-up. Children in the PEF feedback group saw actual PEF after guesses were locked in during the 6-week intervention. Participants and assessors were blinded to group assignment. The primary outcome was underperception of airflow limitation (divergence between actual PEF and guesses) on home spirometers. Secondary outcomes included daily PEF and forced expiratory volume in 1 second (FEV₁), inhaled corticosteroid adherence measured by electronic monitors, Asthma Control Test, and emergency health care use for asthma. <b>Results:</b> The sample comprised 354 children (mean = 13.2 ± 2.2 yr; 62% Latino, 38% Black) and caregivers. The PEF feedback group (<i>N</i> = 153 analyzed) demonstrated greater improvements at 1-month follow-up on underperception of airflow limitation (difference-in-differences, -12.64; 95% confidence interval [CI], -17.54 to -7.74), percent personal best PEF (9.89; 95% CI, 7.13 to 12.65), percent predicted FEV₁ (4.93; 95% CI, 0.95 to 8.90), and inhaled corticosteroid adherence (16.02; 95% CI, 7.15 to 24.89) compared with the supportive counseling group (<i>N</i> = 152 analyzed). At 12-month follow-up, the PEF feedback group maintained improvements on underperception of airflow limitation (-13.87; 95% CI, -19.03 to -8.71), maintained higher percentage personal best PEF (14.23; 95% CI, 11.37 to 17.08) and percent predicted FEV₁ (5.62; 95% CI, 1.56 to 9.67), and had smaller declines in inhaled corticosteroid adherence (17.51; 95% CI, 7.12 to 27.89) versus before intervention than the supportive counseling group. No between-group differences existed for asthma control or health care use. <b>Conclusions:</b> The efficacy and sustainability of PEF feedback was established in improving children's perception of airflow limitation, pulmonary function, and medication adherence. Clinical trial registered with www.clinicaltrials.gov (NCT02702687).