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Diagnosis of asthma: following initial assessment

After an initial assessment, if a patient has a high probability of asthma:

Record patient as likely to have asthma & commence a monitored course of treatment
The initial choice of treatment will be based on an assessment of the degree of asthma
severity. Typically this will be six weeks of inhaled steroids through a device the patient can
use. A reasonable starting dose of inhaled corticosteroids will usually be low dose for adults
(see Table 9 in guideline). In more acute clinical circumstances a course of oral steroids may
be appropriate
Assess patients progress with a validated symptom questionnaire and lung function tests,
either FEV1 measurements at clinic or home serial peak flows
If good symptomatic and objective response to treatment, confirm diagnosis
If poor response, check inhaler technique and adherence and revisit diagnosis
If low probability of asthma, consider alternative diagnosis and /or refer for further tests

Alternative diagnoses in adults

Potential alternative diagnoses presenting in similar way to asthma can include (not exhaustive
Without airflow obstruction

Predominant cough without lung function abnormalities consider chronic cough syndromes
including pertussis
Associated with dizziness, light headedness & peripheral tingling, consider dysfunctional
Recurrent severe asthma attacks without lung function abnormality consider vocal cord
Predominantly nasal symptoms without lung function abnormalities consider rhinitis
Postural and food related symptoms consider gastro-oesophageal reflux
Crackles on auscultation consider pulmonary fibrosis
Orthopnoea, paroxysmal nocturnal dyspnoea, peripheral oedema pre-existing heart disease
consider cardiac failure

With airflow obstruction

Significant smoking history (i.e. >30 pack years, age of onset >35 years consider COPD
Chronic persistent cough in the absence of wheeze or breathlessness consider
bronchiectasis, inhaled foreign body, obliterative bronchiolitis , large airways stenosis
New onset in smoker, systemic symptoms, weight loss, haemoptysis consider lung cancer
or sarcoisdosis

Intermediate possibility of asthma

If there is an intermediate possibility of asthma in either adults or children, i.e. they have some
but not all the typical features of asthma then further clinical assessment and investigation is
required before treatment is commenced (unless the condition is acute).
Particular care is needed in conditions that may overlap with asthma e.g. COPD, obesity and
anxiety or panic attacks.
Investigations include spirometry, and possibly investigation of atopic status or FeNO
Spirometry, with bronchodilator reversibility as appropriate, is the preferred initial test for
investigating intermediate probability of asthma in adults, and in children old enough to undertake
a reliable test. Spirometry enables differentiation of obstructive and non-obstructive lung function.
It is useful for confirming the diagnosis of asthma but not enough to rule it out.

Diagnostic indications for referral in adults

Referral for tests not available in primary care
Diagnosis unclear
Suspected occupational asthma
Poor response to asthma treatment
Severe/ life-threatening asthma attack

Red Flags & indicators of other diseases

Prominent systemic features (myalgia, fever, weight loss)

Unexpected clinical findings e.g. crackles, clubbing, cyanosis cardiac disease monophonic
wheeze or stridor
Persistent non variable breathlessness
Chronic sputum production
Unexplained restrictive spirometry
Chest x-ray shadowing
Marked eosinophilia

Case history: Adrian Andrews

Mr Andrews comes to see you with his wife and small son Adrian who is 3-years-old. They have
noticed that he has been coughing a lot and appears to get breathless when he runs around.
They wonder whether this could be asthma as well.
What alternative diagnoses should you consider in a child?
When should you consider referral?

Indications for referral in children

Referral for tests not available in primary care

Diagnosis unclear
Poor response to monitored initiation of asthma treatment
Severe/life-threatening asthma attack

Red Flags & indicators of other diagnoses

Failure to thrive
Unexplained clinical findings e.g. focal signs, abnormal cry, dysphagia, inspiratory stridor
Symptoms present from birth or perinatal lung problem
Excessive vomiting or posseting
Severe URTI
Wet or persistent cough
Family history of unusual chest disease
Nasal polyps

Uncertain diagnosis in children

Asthma is the most common cause of airways obstruction identified through spirometry in
If child too young to undertake spirometry and there is not enough evidence to make a
diagnosis of asthma then the approach depends on the severity & frequency of symptoms
Watchful waiting: many children have an intermittent wheeze with viral infection and
watchful waiting after discussion with parents is reasonable
Monitored initiation of treatment e.g. inhaled steroids. A reasonable starting dose of
inhaled corticosteroids will usually be very low dose for children (see Table 10 in
guideline). Monitor treatment for 6-8 weeks and if there is improvement regard as having
asthma & consider withdrawal of treatment later
If no improvement consider alternative diagnoses and referral for specialist assessment

Non-pharmacological treatments in adults

Obese and overweight adults with asthma should be offered dietary and exercise advice
Smoking cessation is of course important
Air ionisers are not recommended for the treatment of asthma
Breathing exercise programmes can be offered to people with asthma in addition to
pharmacological treatments
There is no evidence at present for dietary supplementation with probiotics, anti-oxidants and
electrolytes in the treatment or prevention of asthma

Case history: Peter and Adrian Andrews

After assessing both Mr Andrews and Adrian you decide that they both have asthma.
How will you manage them?
How will you monitor their progress?

Non pharmacological management in children

Primary Prevention
Measures to reduce in utero or early life exposure to single aeroallergens e.g. house dust
mite or pets are not recommended for primary prevention
There is no evidence for maternal food allergen prevention in pregnancy or lactation
Breast feeding should be encouraged as it has a protective effect in relation to early asthma
Weight reduction for overweight or obese children is advised
Parental smoking is associated with increased wheezing in infancy and increased risk of
persistent asthma
Children should be immunised as normal as there is no evidence of an adverse effect on the
incidence of asthma
For children at risk of developing asthma, complex, multifaceted interventions targeting
multiple allergens may be considered in families able to meet the costs, demands and
inconvenience of such a demanding programme

Secondary Prevention

Physical and chemical methods of reducing house dust mite in the home are ineffective
Parents who smoke should be offered help to stop
There may be a place for family therapy as an adjunct pharmacotherapy

Monitoring asthma

Use a directive questionnaire e.g. RCP 3 questions:

Have you had difficulty sleeping because of your asthma symptoms (including
cough)? Have you had your usual asthma symptoms during the day (cough, wheeze,
chest tightness or breathlessness)? Has your asthma interfered with your usual activities
(e.g. housework, work/school etc)?
No to all three questions indicates good control. Yes to 2 or 3 questions indicates poor
control.Yes to 1 question indicates that more detailed questioning is needed to assess
level of asthma control (using another validated questionnaire or by asking about
frequency of daytime symptoms, reliever requirement, limitation of activities and
symptoms at night or on waking during the previous month).

Or other questionnaires can include Asthma Control Questionnaire or Test to assess

symptomatic asthma control

Lung function as assessed by spirometry or peak flow

Asthma attacks, oral CS use and time off work
Inhaler technique
Bronchodilator reliance
Possession of and use of self-management plan


Use closed questions

Consider symptom scores e.g. childrens asthma control test, asthma control
Asthma attacks, oral corticosteroid use and time off school due to asthma
Inhaler technique
Medication adherence
Possession of self-management plan
Exposure to tobacco smoke
Growth (height and weight) should be monitored at least annually
HCP should be aware that the best predictor of future asthma attacks is current control