Background-Portable peak flow meters are used in clinical practice for measurement of peak expiratory flow (PEF) at many different altitudes throughout the world. Some PEF meters are affected by gas density. This study was undertaken to establish which type of meter is best for use above sea level and to determine changes in spirometric measurements at altitude. Methods-The variable orifice mini-Wright peak flow meter was compared with the fixed orifice Micro Medical Microplus turbine microspirometer at sea level and at Everest Base Camp (5300 m). Fifty one members of the 1994 British Mount Everest Medical Expedition were studied (age range, 19-55). Results-Mean forced vital capacity (FVC) fell by 5% and PEF rose by 25*5%. However , PEF recorded with the mini-Wright peak flow meter underestimated PEF by 31%, giving readings 6-6% below sea level values. FVC was lowest in the mornings and did not improve significantly with ac-climatisation. Lower PEF values were observed on morning readings and were associated with higher acute mountain sickness scores, although the latter may reflect decreased effort in those with acute mountain sickness. There was no change in forced expiratory volume in one second (FEVy) at altitude when measured with the turbine microspirometer. Conclusions-The cause of the fall in FVC at 5300 m is unknown but may be attributed to changes in lung blood volume, interstitial lung oedema, or early airways closure. Variable orifice peak flow meters grossly underestimate PEF at altitude and fixed orifice devices are therefore preferable where accurate PEF measurements are required above sea level. Portable peak flow meters are widely used in clinical practice for measurement of peak ex-piratory flow (PEF) at many different altitudes throughout the world. At altitude the decrease in air density mechanically causes variable orifice meters, such as the mini-Wright, to underestimate flow."l An under-reading of 26% at a simulated altitude of 5455m has been demonstrated in hypobaric chamber experiments .3 However, fixed orifice spirometers such as the Micro Medical Microplus turbine spirometer have recently been evaluated in a hypobaric chamber and are unaffected by barometric pressure.4 In the same way that decreased air density causes variable orifice meters to under-read, by decreasing resistance to respiratory gas flow5 it causes true PEF to rise at altitude.36 Forced vital capacity (FVC) falls with ascent to al-titude"9 and a decrease of 3% at 5500 m simulated altitude has been recorded.6 We compared the mini-Wright peak flow meter with the a hand held turbine spirometer to assess the performance of the two meters in a field study at altitude. FVC, PEF, and forced expiratory volume in one second (FEV1) were documented using a turbine spirometer, and PEF using the mini-Wright peak flow meter, in a large study of members of the 1994 British Mount Everest Medical Expedition. Methods After obtaining informed consent, spirometric data were collected from 51 members of the 1994 British Mount Everest Medic...