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This PDF is a print-friendly reproduction of the content included in the Diagnosis Children section of the
Australian Asthma Handbook at asthmahandbook.org.au/diagnosis/children
Please note the content of this PDF reflects the Australian Asthma Handbook at publication of Version 1.2
(October 2016). For the most up-to-date content, please visit asthmahandbook.org.au
Please consider the environment if you are printing this PDF to save paper and ink, it has been designed
to be printed double-sided and in black and white.
CFC chlorofluorocarbon LAMA long-acting muscarinic antagonist
COPD chronic obstructive pulmonary disease LTRA leukotriene receptor antagonist
COX cyclo-oxygenase MBS Medical Benefits Scheme
ED emergency department NIPPV non-invasive positive pressure ventilation
EIB exercise-induced bronchoconstriction NSAIDs nonsteroidal anti-inflammatory drugs
FEV1 forced expiratory volume over one second OCS oral corticosteroids
FVC forced vital capacity OSA obstructive sleep apnoea
FSANZ Food Standards Australia and New Zealand PaCO carbon dioxide partial pressure on blood gas analysis
GORD gastro-oesophageal reflux disease PaO oxygen partial pressure on blood gas analysis
HFA formulated with hydrofluroalkane propellant PBS Pharmaceutical Benefits Scheme
ICS inhaled corticosteroid PEF peak expiratory flow
ICU intensive care unit pMDI pressurised metered-dose inhaler or 'puffer'
IgE Immunoglobulin E SABA short-acting beta2 -adrenergic receptor agonist
IV intravenous LAMA long-acting muscarinic antagonist
LABA long-acting beta2-adrenergic receptor agonist TGA Therapeutic Goods Administration
ABN 61 058 044 634 The Australian Asthma Handbook has been officially
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Suite 104, Level 1, 153-161 Park Street South
Melbourne, VIC 3205, Australia The Royal Australian College of General
Practitioners (RACGP)
Tel: 03 9929 4333
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Email: nac@nationalasthma.org.au Association (APNA)
Website: nationalasthma.org.au The Thoracic Society of Australia and New
Zealand (TSANZ)
National Asthma Council Australia. Australian Asthma National Asthma Council Australia would like to
Handbook, Version 1.2. National Asthma Council acknowledge the support of the sponsors of
Australia, Melbourne, 2016. Version 1.2 of the Australian Asthma Handbook:
The Australian Asthma Handbook has been compiled by the The information and treatment protocols contained in the
National Asthma Council Australia for use by general Australian Asthma Handbook are intended as a general guide only
practitioners, pharmacists, asthma educators, nurses and other and are not intended to avoid the necessity for the individual
health professionals and healthcare students. The information examination and assessment of appropriate courses of treatment
and treatment protocols contained in the Australian Asthma on a case-by-case basis. To the maximum extent permitted by law,
Handbook are based on current evidence and medical knowledge acknowledging that provisions of the Australia Consumer Law may
and practice as at the date of publication and to the best of our have application and cannot be excluded, the National Asthma
knowledge. Although reasonable care has been taken in the Council Australia, and its employees, directors, officers, agents and
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as to the accuracy, completeness, currency or reliability of its may arise from use of the Australian Asthma Handbook or from
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HOME > DIAGNOSIS > CHILDREN
It can be difficult to diagnose asthma with certainty in children aged 05 years, because:
episodic respiratory symptoms such as wheezing and cough are very common in children, particularly in children under 3
years
objective lung function testing by spirometry is usually not feasible in this age group
a high proportion of children who respond to bronchodilator treatment do not go on to have asthma in later childhood
(e.g. by primary school age).
A diagnosis of asthma should not be made if cough is the only or predominant respiratory symptom and there are no
signs of airflow limitation (e.g. wheeze or breathlessness).
In this section
Initial investigations
Investigating asthma-like symptoms in children
https://www.asthmahandbook.org.au/diagnosis/children/initial-investigations
Alternative diagnoses
Considering alternative diagnoses in children
https://www.asthmahandbook.org.au/diagnosis/children/alternative-diagnoses
Provisional diagnosis
Making a provisional diagnosis in children
https://www.asthmahandbook.org.au/diagnosis/children/provisional-diagnosis
1
Treatment trial
Conducting a treatment trial to confirm the diagnosis in children
https://www.asthmahandbook.org.au/diagnosis/children/treatment-trial
Further investigations
Considering further investigations in children
https://www.asthmahandbook.org.au/diagnosis/children/further-investigations
2
Figure: Steps in the diagnosis of asthma in children
* Consider options (treatment trial or further investigations) according to individual circumstances, including child's ability to do bronchial provocation test or
cardiopulmonary exercise test.
Asset ID: 17
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HOME > DIAGNOSIS > CHILDREN > INITIAL INVESTIGATIONS
Lung function
4
HOME > DIAGNOSIS > CHILDREN > INITIAL INVESTIGATIONS > HISTORY AND PHYSICAL EXAMINATION
Investigate respiratory symptoms in children with wheezing or asthma-like symptoms (e.g. episodic breathlessness).
Confirm that the breathing sounds described by parents as wheezing are actually wheeze:
1
Brandet al.2008
Global Initiative for Asthma (GINA), 20092
Weinberger and Abu-Hasan, 20073
Ask about:
current symptoms
pattern of symptoms, including frequency and timing of wheezing episodes (whether they occur only when child has
a viral cold, or are unrelated to colds, and whether child coughs or wheezes at other times, e.g. when playing or
laughing)
appearance of childs chest during episodes of noisy breathing to identify chest recession (e.g. ask whether chest
appears to be sucked inwards as child breathes in)
whether child is generally alert, active, socially responsive
home environment (e.g. exposure to smoke, pets)
allergies, including atopic dermatitis (eczema) and allergic rhinitis (hay fever)
family history of asthma and allergies.
5
inspection of upper airway for signs of allergic rhinitis (e.g. swollen turbinates, transverse nasal crease, mouth
breathing) or polyps
auscultation of chest
inspection of fingers for clubbing
skin inspection for atopic dermatitis (eczema), transverse nasal creases, allergic shiners (darkness and swelling
under eyes caused by sinus congestion).
Identify any signs and symptoms that suggest an alternative diagnosis and which require investigation.
Finding Notes
Onset of signs from birth or very early in life Suggests cystic fibrosis, chronic lung disease of
prematurity, primary ciliary dyskinesia,
bronchopulmonary dysplasia,congenital
abnormality
Family history of unusual chest disease Should be enquired about before attributing all the
signs and symptoms to asthma
Severe upper respiratory tract disease (e.g. severe Specialist assessment should be considered
rhinitis, enlarged tonsils and adenoids or nasal polyps)
Crepitations on chest auscultation that do not clear on Suggest a serious lower respiratory tract condition
coughing such as pneumonia, atelectasis, bronchiectasis
Systemic symptoms (e.g. fever, weight loss, failure to Suggest an alternative systemic disorder
thrive)
Feeding difficulties, including choking or vomiting Suggests aspiration specialist assessment should
be considered
Inspiratory upper airway noises (e.g. stridor, snoring) Acute stridor suggests tracheobronchitis (croup)
Chronic (>4 weeks) wet or productive cough Suggests cystic fibrosis, bronchiectasis, chronic
bronchitis, recurrent aspiration, immune
abnormality, ciliary dyskinesia
6
Finding Notes
Severe chest deformity Harrisons Sulcus and Pectus Carinatum can be due
to uncontrolled asthma, but severe deformity
suggests an alternative diagnosis
Asset ID: 59
More information
Definition of wheeze
Wheeze is defined as a continuous, high-pitched sound coming from the chest during expiration.1,2It is a non-specific sign
caused by turbulent air flow due to narrowing of intrathoracic airways and indicates expiratory airflow limitation,
irrespective of the underlying mechanism1 (e.g. bronchoconstriction or secretions in the airway lumen).
Various forms of noisy breathing, including wheezing, are common among babies and preschoolers.1 Noisy breathing is
particularly common among infants under 6 months old, but only a small proportion have wheeze.1
Parents and doctors sometimes use the word wheeze to mean different things,1, 3 including cough, gasp, a change in
breathing rate or style of breathing. If based on parental report alone, children may be labelled as having wheeze when
they do not have narrowed airways and expiratory flow limitation.1
There are no validated questionnaire-based instruments to identify wheeze in preschoolers,1 so wheezing is best
confirmed by listening with a stethoscope during an episode.
Reported noisy breathing that responds to bronchodilator therapy is likely to be genuine wheeze and to be caused, at
least in part, by constriction of airway smooth muscle.1
7
Wheezing is the most common symptom associated with asthma in children aged 5 years and under.2Among people with
a diagnosis of asthma at any time in their life, approximately 80% will have shown signs of respiratory disease, such as
wheezing, in the first years of life.5
However, the presence of wheeze does not mean a child has asthma or will develop asthma:
wheezing in infants up to 12 months old is most commonly due to acute viral bronchiolitis or to small and/or floppy
airways
wheezing in children aged 15 years is usually associated with viral upper respiratory tract infections, which recur
frequently in this age group.1, 2Many children wheeze when they have viral respiratory infections, even if they do not
have asthma2
among preschoolers with recurrent wheezing, only approximately one in three will have asthma at age 6 years5
wheezing can also be due to many conditions other than asthma, including anatomical abnormalities of the airways,
cystic fibrosis, bronchomalacia.1
Some international guidelines1 avoid using the term asthma for preschool children, because there is not enough evidence
to know whether the pathophysiology of recurrent wheezing and asthma-like symptoms in preschool children is the same
as that of asthma in older children and in adults,1 and because many young children with wheezing will not go on to
develop asthma at school age.1 The more general term wheezing disorder is sometimes used in preference to asthma for
children aged 5 years and under.1
Table. Definitions of asthma patterns in children aged 05 years not taking regular preventer
Frequent intermittent asthma Flare-ups more than once every 6 weeks on average but no
symptoms between flare-ups
Daytime symptomsdaily
Night-time symptomsmore than once per week
8
Category Pattern and intensity of symptoms (when not taking regular
treatment)
Symptoms between flare-ups.A flare-up is defined as a period of worsening asthma symptoms, from mild (e.g.
symptoms that are just outside the normal range of variation for the child, documented when well) to severe (e.g.
events that require urgent action by parents and health professionals to prevent a serious outcome such as
hospitalisation or death from asthma).
Note:Use this table when the diagnosis of asthma can be made with reasonable confidence (e.g. a child with wheezing
accompanied by persistent cough or breathing difficulty, no signs or symptoms that suggest a potentially serious
alternative diagnosis, and the presence ofother factors that increase the probability of asthma such as family history
of allergies or asthma).
Asset ID: 14
Table. Definitions of asthma patterns in children aged 6 years and over not taking regular preventer
Frequent intermittent asthma Flare-ups more than once every 6 weeks on average but no
symptoms between flare-ups
Persistent asthma Mild FEV1 80% predicted and at least one of:
9
Category Pattern and intensity of symptoms (when not taking regular
treatment)
Daytime symptomscontinual
Night-time symptoms frequent
Flare-ups frequent
Symptoms frequently restrict activity or sleep
It may not be appropriate to make the diagnosis of asthma in children aged 6 or older who wheeze only during upper
respiratory tract infections. These children can be considered to have episodic (viral) wheeze.
Symptoms between flare-ups.A flare-up is defined as a period of worsening asthma symptoms, from mild (e.g.
symptoms that are just outside the normal range of variation for the child, documented when well) to severe (e.g.
events that require urgent action by parents and health professionals to prevent a serious outcome such as
hospitalisation or death from asthma).
Asset ID: 15
For children already taking regular preventer treatment, adjustments to the treatment regimen are based on finding
the lowest dose of medicines that will maintain good control of symptoms.
Transient wheeze Wheezing commences before the age of 3 years and disappear
by age 6 years
10
Classification Phenotypes Description
system/source identified
Tucson Childrens Persistent wheeze Wheezing continues until up to or after age 6 years
Respiratory Study
Late-onset wheeze Wheezing starts after age 3 years.
Avon Longitudinal Transient early Wheezing mainly occurs before 18 months, then mainly
Study of Parents wheeze disappears by age 3.5 years
and Children
Not associated with hypersensitivity to airborne allergens
Prolonged early Wheezing occurs mainly between age 6 months and 4.5 years,
wheeze then mainly disappears before childs 6th birthday
Persistent wheeze Wheezing mainly begins after 6 months and continues through
to primary school
Notes
Terms can only be identified after the child has stopped wheezing for several years and cannot be applied to a
preschool child.
Transient wheeze, persistent wheeze and late-onset wheeze can be episodic or multiple-trigger wheeze.#
Sources
Martinez FD, Wright AL, Taussig LM et al. Asthma and wheezing in the first six years of life. The Group Health
Medical Associates. N Engl J Med 1995; 332: 133-8. Available from:
http://www.nejm.org/doi/full/10.1056/NEJM199501193320301#t=article
Morgan WJ, Stern DA, Sherrill DL et al. Outcome of asthma and wheezing in the first 6 years of life: follow-up
through adolescence. Am J Respir Crit Care Med 2005; 172: 1253-8. Available from:
http://ajrccm.atsjournals.org/content/172/10/1253.long
Henderson J, Granell R, Heron J et al. Associations of wheezing phenotypes in the first 6 years of life with atopy, lung
function and airway responsiveness in mid-childhood. Thorax 2008; 63: 974-80. Available from:
http://thorax.bmj.com/content/63/11/974.long
11
# Brand PL, Baraldi E, Bisgaard H et al. Definition, assessment and treatment of wheezing disorders in preschool
children: an evidence-based approach [European Respiratory Society Task Force]. Eur Respir J 2008; 32: 1096-110.
Available from: http://erj.ersjournals.com/content/32/4/1096.full
Asset ID: 10
Early childhood wheezing phenotypes cannot be recognised or applied clinically, because they are recognised
retrospectively.1 In an individual child with episodic wheeze, it is not possible to accurately predict epidemiological
phenotype from clinical phenotype.1
Currently available tools for predicting whether a wheezing preschool child will have asthma at school age (e.g. the
Asthma Predictive Index5) have limited clinical value.7
Go to: National Asthma Council Australia'sAsthma and wheezing in the first years of life information paper
'Wheeze-detecting' devices
Some hand-held devices and smart phone applications are marketed for detecting and measuring wheeze by audio
recording and analysis.
There is not enough evidence to recommend these devices and apps for use in monitoring asthma symptoms or asthma
control in adults or children, or in distinguishing wheeze from other airway sounds in children.
Recurrent pneumonia
Clubbing of fingers
Source
Gibson PG, Chang AB, Glasgow NJ et al.,CICADA: Cough in Children and Adults: Diagnosis and Assessment. Australian
cough guidelines summary statement. Med J Aust, 2010; 192: 265-71. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/20201760
Asset ID: 13
Chronic cough (cough lasting more than 4 weeks)without other features of asthma is unlikely to be due to asthma.4
12
Cough is a frequent symptom in children with asthma, but may have a different mechanism from other symptoms of
asthma (e.g. wheeze, chest tightness or breathlessness). Children who have recurrent cough, but do not wheeze, are
unlikely to have asthma.10A very small minority of children with recurrent nocturnal cough, but no other asthma
symptoms, may be considered to have a diagnosis of atypical asthma.10 This diagnosis should be only made in
consultation with a paediatric respiratory physician.
In children with no abnormalities detected on physical examination, chest X-ray or spirometry, and no wheezing or
breathlessness, chronic coughis most likely:4
due to protracted bacterial bronchitis (resolves with 26 weeks treatment with antibiotics)4
post-viral (resolves with time)
due to exposure to tobacco smoke and other pollutants.4
Frequency of cough reported by parents correlates poorly with frequency measured using diary cards or by audio
recording monitors.11
0-5 years
Most cases of coughing in preschool children are not due to asthma:
Recurrent cough in preschool children, in the absence of other signs, is most likely due to recurrent viral bronchitis.
Cough due to viral infection is unresponsive to bronchodilators and preventerssuch as montelukast, cromones or
inhaled corticosteroids.
Children attending day care or preschool can have a succession of viral infections that merge into each other,11giving
the false appearance of chronic cough (cough lasting more than 4 weeks).
In preschool-aged children, cough may be due to asthma when it occurs during episodes of wheezing and breathlessness
or when the child does not have a cold.
6 years and over
Chronic cough may be due to asthma if the cough is episodic and associated with other features of asthma such as
expiratory wheeze, exercise-related breathlessness, or airflow limitation objectively demonstrated by spirometry
(particularly if responsive to a bronchodilator).4
Cystic fibrosis
Habit-cough syndrome
13
Conditions characterised by cough
Tracheomalacia
Hyperventilation
Anxiety
Source
Weinberger M, Abu-Hasan M. Pseudo-asthma: when cough, wheezing, and dyspnea are not asthma. Pediatrics 2007;
120: 855-64. Available from: http://pediatrics.aappublications.org/content/120/4/855.full
Asset ID: 11
14
Asthma more likely Asthma less likely
Sources
British Thoracic Society (BTS), Scottish Intercollegiate Guidelines Network (SIGN).British Guideline on the management
of Asthma. A national clinical guideline. BTS/SIGN, Edinburgh, 2012. Availablefrom:https://www.brit-
thoracic.org.uk/guidelines-and-quality-standards/asthma-guideline
Respiratory Expert Group, Therapeutic Guidelines Limited. Therapeutic Guidelines: Respiratory, Version 4. Therapeutic
Guidelines Limited, Melbourne,2009.
Asset ID: 12
Both denial and overplay of symptoms has been observed among adolescents.14 Adolescents with new or re-emerging
asthma symptoms may deny their symptoms.14 US data suggest that risk factors for undiagnosed asthma among
adolescents include female sex, smoking (current smoking and exposure to others smoke), low socioeconomic status,
family problems, low physical activity and high body mass.15
Health professionals should discuss confidentiality and its limits with adolescents.16, 13 Adolescents are more willing to
communicate honestly with healthcare professionals who discuss confidentiality with them.17
Health professionals need to clearly explain which personal health information can be confidential and which must be
shared with parents, and keep parents informed.
Health care providers should advise adolescents that they can obtain their own Medicare card once they turn 15.16
Go to: Royal Australasian College of Physicians Working with young people online resource (see Privacy and
confidentiality in adolescent health care in Topic 2: Ethical and legal issues)
Go to: Australian Government Department of Human Services'Young people becoming independent webpage
15
Exercise-related symptoms in adolescents
In adolescents, exercise-related wheezing and breathlessness are poor predictors of exercise-induced
bronchoconstriction. Only a minority of adolescents referred for assessment of exercise-induced respiratory symptoms
show objective evidence of exercise-induced bronchoconstriction.13
For adolescents with exercise-related symptoms, common conditions that should be considered in the differential
diagnosis includepoor cardiopulmonary fitness, exercise-induced upper airway dysfunction and exercise-induced
hyperventilation.14,18
In addition to spirometry, other objective tests (e.g. cardiopulmonary fitness testing, bronchial provocation tests) may be
helpful to clarify the diagnosis and inform management.
References
1. Brand PL, Baraldi E, Bisgaard H, et al. Definition, assessment and treatment of wheezing disorders in preschool
children: an evidence-based approach. Eur Respir J. 2008; 32: 1096-1110. Available from:
http://erj.ersjournals.com/content/32/4/1096.full
2. Global Initiative for Asthma (GINA). Global strategy for the diagnosis and management of asthma in children 5 years and
younger. GINA, 2009. Available from: http://www.ginasthma.org/
3. Weinberger M, Abu-Hasan M. Pseudo-asthma: when cough, wheezing, and dyspnea are not asthma. Pediatrics. 2007;
120: 855-864. Available from: http://pediatrics.aappublications.org/content/120/4/855.full
4. Gibson PG, Chang AB, Glasgow NJ, et al. CICADA: cough in children and adults: diagnosis and assessment. Australian
cough guidelines summary statement. Med J Aust. 2010; 192: 265-271. Available from:
http://www.lungfoundation.com.au/professional-resources/guidelines/cough-guidelines
5. Castro-Rodriguez JA. The Asthma Predictive Index: a very useful tool for predicting asthma in young children. J
Allergy Clin Immunol. 2010; 126: 212-216. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20624655
6. Schultz A, Devadason SG, Savenije OE, et al. The transient value of classifying preschool wheeze into episodic viral
wheeze and multiple trigger wheeze. Acta Paediatr. 2010; 99: 56-60. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/19764920
7. Savenije OE, Kerkhof M, Koppelman GH, Postma DS. Predicting who will have asthma at school age among preschool
children. J Allergy Clin Immunol. 2012; 130: 325-331. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/22704537
8. Martinez FD, Wright AL, Taussig LM, et al. Asthma and wheezing in the first six years of life. N Engl J Med. 1995; 332:
133-138. Available from: http://www.nejm.org/doi/full/10.1056/NEJM199501193320301#t=article
9. Henderson J, Granell R, Heron J, et al. Associations of wheezing phenotypes in the first 6 years of life with atopy, lung
function and airway responsiveness in mid-childhood. Thorax. 2008; 63: 974-980. Available from:
http://thorax.bmj.com/content/63/11/974.long
10. van Asperen PP. Cough and asthma. Paediatr Resp Rev. 2006; 7: 26-30. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/16473813
11. Bush A. Diagnosis of asthma in children under five. Prim Care Respir J. 2007; 16: 7-15. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/17297521
12. Craven V, Everard ML. Protracted bacterial bronchitis: reinventing an old disease. Arch Dis Child. 2013; 98: 72-76.
Available from: http://www.ncbi.nlm.nih.gov/pubmed/23175647
13. British Thoracic Society (BTS), Scottish Intercollegiate Guidelines Network (SIGN). British Guideline on the
Management of Asthma. A national clinical guideline. BTS, SIGN, Edinburgh, 2012. Available from: https://www.brit-
thoracic.org.uk/guidelines-and-quality-standards/asthma-guideline/
14. Towns SJ, van Asperen PP. Diagnosis and management of asthma in adolescents. Clin Respir J. 2009; 3: 69-76.
Available from: http://www.ncbi.nlm.nih.gov/pubmed/20298380
15. Yeatts K, Davis KJ, Sotir M, et al. Who gets diagnosed with asthma? Frequent wheeze among adolescents with and
without a diagnosis of asthma. Pediatrics. 2003; 111: 1046-54. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/12728087
16. The Royal Australasian College of Physicians Joint Adolescent Health Committee. Confidential Health Care for
Adolescents and Young People (1224 years). The Royal Australasian College of Physicians, 2010. Available from:
http://www.racp.edu.au/
17. The Royal Australasian College of Physicians. Routine adolescent psychosocial health assessment. Position statement. The
Royal Australasian College of Physicians, Sydney, 2008. Available from:
http://www.racp.edu.au/fellows/resources/paediatric-resources
18. Tilles SA. Exercise-induced respiratory symptoms: an epidemic among adolescents. Ann Allergy Asthma Immunol.
2010; 104: 361-7; 368-70, 412. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20486325
16
HOME > DIAGNOSIS > CHILDREN > INITIAL INVESTIGATIONS > LUNG FUNCTION
In children able to perform spirometry, measure bronchodilator reversibility by performing spirometry before and after
giving inhaled rapid-onset beta2 agonistbronchodilator (e.g. 4 puffs of salbutamol 100 mcg/actuation)by metered-dose
inhaler and spacer.
Notes
If reliable equipment and appropriately trained staff are available, spirometry can be performed in primary care. If not, refer to an
appropriate provider such as an accredited respiratory function laboratory.
Most children aged 6 and older can perform spirometry reliably.
Airflow limitation is defined as reversible (i.e. bronchodilator response is clinically important) if FEV1 increases by 12%.
Operators who perform spirometry should receive comprehensive training to ensure good quality.
More information
Spirometry in children
Measuring lung function in young children is difficult and requires techniques that are not widely available.1 Generally,
spirometry cannot be performed to acceptable standards in children younger than 45 years.2
Some older children cannot perform spirometry either. However, children who are unable to perform spirometry
satisfactorily on their first visit are often able to perform the test correctly at the next visit.2
Spirometry is poor at discriminating between children with asthma and those with airway obstruction due to other
conditions.1
Normal spirometry in a child, especially when asymptomatic, does not exclude the diagnosis of asthma.1 FEV1 is often
normal in children with persistent asthma.1
Reduced FEV1 alone does not indicate that a child has asthma, because it may be seen with other lung diseases (or be due
to poor spirometric technique).
A significant increase in FEV1 (>12% from baseline) after administering a bronchodilator (e.g. 4 puffs of salbutamol 100
mcg/actuation)indicates thatairflow limitation is reversible and supports the diagnosis of asthma. In children with
asthma, it is also predictive of a good lung functionresponse to inhaled corticosteroids.1 However, an absent response to
bronchodilators does not exclude asthma.1
17
Bronchial provocation (challenge) tests in children
Clinical assessment is more sensitive for confirming the diagnosis of asthma than tests for airway hyperresponsiveness.
The main roles of bronchial provocation (challenge) tests of airway hyperresponsiveness (airway hyperreactivity) are to
confirm or exclude asthma as the cause of current symptoms, including exercise-associated respiratory symptoms such as
dyspnoea or noisy breathing.3,4
Challenge tests are performed in accredited lung function testing laboratories. These tests are usually difficult to perform
in children under 8 years of age because they involve repeated spirometry tests.
If challenge testing is needed, consider referring to a paediatric respiratory physician for investigation, or discussing with
a paediatric respiratory physician before selecting which test to order.
Do not test during a respiratory infection, or initiate inhaled corticosteroid treatment afew weeks before challenge
testing, because these could invalidate the result.
Bronchial provocation tests of airway hyperresponsiveness include:
References
1. British Thoracic Society (BTS), Scottish Intercollegiate Guidelines Network (SIGN). British Guideline on the
Management of Asthma. A national clinical guideline. BTS, SIGN, Edinburgh, 2012. Available from: https://www.brit-
thoracic.org.uk/guidelines-and-quality-standards/asthma-guideline/
2. Johns DP, Pierce R. Pocket guide to spirometry. 3rd edn. McGraw Hill, North Ryde, 2011.
3. Anderson SD. Bronchial challenge tests: usefulness, availability and challenges. Breathe. 2011; 8: 53-60. Available
from: http://www.ers-education.org
4. Cockcroft DW. Direct challenge tests: airway hyperresponsiveness in asthma: its measurement and clinical
significance. Chest. 2010; 138(2 Suppl): 18S-24S. Available from:
http://journal.publications.chestnet.org/article.aspx?articleid=1086632
5. Anderson SD, Pearlman DS, Rundell KW, et al. Reproducibility of the airway response to an exercise protocol
standardized for intensity, duration, and inspired air conditions, in subjects with symptoms suggestive of asthma.
Respir Res. 2010; Sept 1: 120. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2939602/
6. Barben J, Roberts M, Chew N, et al. Repeatability of bronchial responsiveness to mannitol dry powder in children with
asthma. Pediatr Pulmonol. 2003; 36: 490-4. Available from: http://www.ncbi.nlm.nih.gov/pubmed/14618640
7. Kersten ET, Driessen JM, van der Berg JD, Thio BJ. Mannitol and exercise challenge tests in asthmatic children.
Pediatr Pulmonol. 2009; 44: 655-661. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19499571
8. Liem JJ, Kozyrskyj AL, Cockroft DW, Becker AB. Diagnosing asthma in children: what is the role for methacholine
bronchoprovocation testing?. Pediatr Pulmonol. 2008; 43: 481-9. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/18383334
9. Carlsten C, Dimich-Ward H, Ferguson A, et al. Airway hyperresponsiveness to methacholine in 7-year-old children:
sensitivity and specificity for pediatric allergist-diagnosed asthma. Pediatr Pulmonol. 2011; 46: 175-178. Available
from: http://www.ncbi.nlm.nih.gov/pubmed/20963839
10. Child F. The measurement of airways resistance using the interrupter technique (Rint). Paediatr Respir Rev. 2005; 6:
273-7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16298310
18
11. Oostveen E, MacLeod D, Lorino H, et al. The forced oscillation technique in clinical practice: methodology,
recommendations and future developments. Eur Respir J Supplement. 2003; 22: 1026-41. Available from:
http://erj.ersjournals.com/content/22/6/1026.long
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HOME > DIAGNOSIS > CHILDREN > ALTERNATIVE DIAGNOSES
Sources
20
British Thoracic Society (BTS), Scottish Intercollegiate Guidelines Network (SIGN).British Guideline on the management
of Asthma. A national clinical guideline. BTS/SIGN, Edinburgh, 2012. Availablefrom:https://www.brit-
thoracic.org.uk/guidelines-and-quality-standards/asthma-guideline
Respiratory Expert Group, Therapeutic Guidelines Limited. Therapeutic Guidelines: Respiratory, Version 4. Therapeutic
Guidelines Limited, Melbourne,2009.
Asset ID: 12
Do not assume that cough is due to asthma in the absence of wheezing or breathlessness. Misdiagnosis of asthma in a
child with nonspecific coughcan result in overtreatment in children.
Gibson et al.20103
Gibsonet al.20103
bronchiolitis (babies)
tracheobronchitis (croup)
sleep-disordered breathing
inhaled foreign body
structural airway problems (e.g. tracheomalacia, bronchopulmonary dysplasia, malformation causing narrowing of
intrathoracic airways, vascular ring anomaly compressing bronchus)
infections (e.g. recurrent respiratory tract infections, chronic rhinosinusitis, protracted bacterial bronchitis)
chronic suppurative lung disease (e.g. consider cystic fibrosis, immune deficiency, primary ciliary dyskinesia or
chronic aspiration as underlying cause)
aspiration (e.g. due to gastro-oesophageal reflux, discoordinated swallowing, anatomical connection such as tracheo-
oesophageal fistula or laryngeal cleft, or neurodevelopmental abnormalities)
congenital heart disease
other upper airway disease (e.g. rhinosinusitis, postnasal drip, obstructive sleep apnoea, upper airway dysfunction)
tumours
pulmonary oedema.
21
Conditions characterised by cough
Cystic fibrosis
Habit-cough syndrome
Tracheomalacia
Hyperventilation
Anxiety
Source
Weinberger M, Abu-Hasan M. Pseudo-asthma: when cough, wheezing, and dyspnea are not asthma. Pediatrics 2007;
120: 855-64. Available from: http://pediatrics.aappublications.org/content/120/4/855.full
Asset ID: 11
More information
Definition of wheeze
Wheeze is defined as a continuous, high-pitched sound coming from the chest during expiration.4,5It is a non-specific sign
caused by turbulent air flow due to narrowing of intrathoracic airways and indicates expiratory airflow limitation,
irrespective of the underlying mechanism4 (e.g. bronchoconstriction or secretions in the airway lumen).
Parents and doctors sometimes use the word wheeze to mean different things,4, 6 including cough, gasp, a change in
breathing rate or style of breathing. If based on parental report alone, children may be labelled as having wheeze when
they do not have narrowed airways and expiratory flow limitation.4
There are no validated questionnaire-based instruments to identify wheeze in preschoolers,4 so wheezing is best
confirmed by listening with a stethoscope during an episode.
22
Reported noisy breathing that responds to bronchodilator therapy is likely to be genuine wheeze and to be caused, at
least in part, by constriction of airway smooth muscle.4
Wheezing is the most common symptom associated with asthma in children aged 5 years and under.5Among people with
a diagnosis of asthma at any time in their life, approximately 80% will have shown signs of respiratory disease, such as
wheezing, in the first years of life.7
However, the presence of wheeze does not mean a child has asthma or will develop asthma:
wheezing in infants up to 12 months old is most commonly due to acute viral bronchiolitis or to small and/or floppy
airways
wheezing in children aged 15 years is usually associated with viral upper respiratory tract infections, which recur
frequently in this age group.4, 5Many children wheeze when they have viral respiratory infections, even if they do not
have asthma5
among preschoolers with recurrent wheezing, only approximately one in three will have asthma at age 6 years7
wheezing can also be due to many conditions other than asthma, including anatomical abnormalities of the airways,
cystic fibrosis, bronchomalacia.4
Table. Definitions of asthma patterns in children aged 05 years not taking regular preventer
Frequent intermittent asthma Flare-ups more than once every 6 weeks on average but no
symptoms between flare-ups
Daytime symptomsdaily
Night-time symptomsmore than once per week
Symptoms sometimes restrict activity or sleep
23
Category Pattern and intensity of symptoms (when not taking regular
treatment)
Symptoms between flare-ups.A flare-up is defined as a period of worsening asthma symptoms, from mild (e.g.
symptoms that are just outside the normal range of variation for the child, documented when well) to severe (e.g.
events that require urgent action by parents and health professionals to prevent a serious outcome such as
hospitalisation or death from asthma).
Note:Use this table when the diagnosis of asthma can be made with reasonable confidence (e.g. a child with wheezing
accompanied by persistent cough or breathing difficulty, no signs or symptoms that suggest a potentially serious
alternative diagnosis, and the presence ofother factors that increase the probability of asthma such as family history
of allergies or asthma).
Asset ID: 14
Table. Definitions of asthma patterns in children aged 6 years and over not taking regular preventer
Frequent intermittent asthma Flare-ups more than once every 6 weeks on average but no
symptoms between flare-ups
Persistent asthma Mild FEV1 80% predicted and at least one of:
24
Category Pattern and intensity of symptoms (when not taking regular
treatment)
It may not be appropriate to make the diagnosis of asthma in children aged 6 or older who wheeze only during upper
respiratory tract infections. These children can be considered to have episodic (viral) wheeze.
Symptoms between flare-ups.A flare-up is defined as a period of worsening asthma symptoms, from mild (e.g.
symptoms that are just outside the normal range of variation for the child, documented when well) to severe (e.g.
events that require urgent action by parents and health professionals to prevent a serious outcome such as
hospitalisation or death from asthma).
Asset ID: 15
For children already taking regular preventer treatment, adjustments to the treatment regimen are based on finding
the lowest dose of medicines that will maintain good control of symptoms.
Tucson Childrens Transient wheeze Wheezing commences before the age of 3 years and disappear
Respiratory Study by age 6 years
Persistent wheeze Wheezing continues until up to or after age 6 years
25
Classification Phenotypes Description
system/source identified
Avon Longitudinal Transient early Wheezing mainly occurs before 18 months, then mainly
Study of Parents wheeze disappears by age 3.5 years
and Children
Not associated with hypersensitivity to airborne allergens
Prolonged early Wheezing occurs mainly between age 6 months and 4.5 years,
wheeze then mainly disappears before childs 6th birthday
Persistent wheeze Wheezing mainly begins after 6 months and continues through
to primary school
Notes
Terms can only be identified after the child has stopped wheezing for several years and cannot be applied to a
preschool child.
Transient wheeze, persistent wheeze and late-onset wheeze can be episodic or multiple-trigger wheeze.#
Sources
Martinez FD, Wright AL, Taussig LM et al. Asthma and wheezing in the first six years of life. The Group Health
Medical Associates. N Engl J Med 1995; 332: 133-8. Available from:
http://www.nejm.org/doi/full/10.1056/NEJM199501193320301#t=article
Morgan WJ, Stern DA, Sherrill DL et al. Outcome of asthma and wheezing in the first 6 years of life: follow-up
through adolescence. Am J Respir Crit Care Med 2005; 172: 1253-8. Available from:
http://ajrccm.atsjournals.org/content/172/10/1253.long
Henderson J, Granell R, Heron J et al. Associations of wheezing phenotypes in the first 6 years of life with atopy, lung
function and airway responsiveness in mid-childhood. Thorax 2008; 63: 974-80. Available from:
http://thorax.bmj.com/content/63/11/974.long
# Brand PL, Baraldi E, Bisgaard H et al. Definition, assessment and treatment of wheezing disorders in preschool
children: an evidence-based approach [European Respiratory Society Task Force]. Eur Respir J 2008; 32: 1096-110.
Available from: http://erj.ersjournals.com/content/32/4/1096.full
Asset ID: 10
26
Early childhood wheezing phenotypes cannot be recognised or applied clinically, because they are recognised
retrospectively.4 In an individual child with episodic wheeze, it is not possible to accurately predict epidemiological
phenotype from clinical phenotype.4
Currently available tools for predicting whether a wheezing preschool child will have asthma at school age (e.g. the
Asthma Predictive Index7) have limited clinical value.9
Go to: National Asthma Council Australia'sAsthma and wheezing in the first years of life information paper
Recurrent pneumonia
Clubbing of fingers
Source
Gibson PG, Chang AB, Glasgow NJ et al.,CICADA: Cough in Children and Adults: Diagnosis and Assessment. Australian
cough guidelines summary statement. Med J Aust, 2010; 192: 265-71. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/20201760
Asset ID: 13
Chronic cough (cough lasting more than 4 weeks)without other features of asthma is unlikely to be due to asthma.3
Cough is a frequent symptom in children with asthma, but may have a different mechanism from other symptoms of
asthma (e.g. wheeze, chest tightness or breathlessness). Children who have recurrent cough, but do not wheeze, are
unlikely to have asthma.12A very small minority of children with recurrent nocturnal cough, but no other asthma
symptoms, may be considered to have a diagnosis of atypical asthma.12 This diagnosis should be only made in
consultation with a paediatric respiratory physician.
In children with no abnormalities detected on physical examination, chest X-ray or spirometry, and no wheezing or
breathlessness, chronic coughis most likely:3
due to protracted bacterial bronchitis (resolves with 26 weeks treatment with antibiotics)3
post-viral (resolves with time)
due to exposure to tobacco smoke and other pollutants.3
Frequency of cough reported by parents correlates poorly with frequency measured using diary cards or by audio
recording monitors.13
0-5 years
27
Most cases of coughing in preschool children are not due to asthma:
Recurrent cough in preschool children, in the absence of other signs, is most likely due to recurrent viral bronchitis.
Cough due to viral infection is unresponsive to bronchodilators and preventerssuch as montelukast, cromones or
inhaled corticosteroids.
13
Children attending day care or preschool can have a succession of viral infections that merge into each other, giving
the false appearance of chronic cough (cough lasting more than 4 weeks).
In preschool-aged children, cough may be due to asthma when it occurs during episodes of wheezing and breathlessness
or when the child does not have a cold.
6 years and over
Chronic cough may be due to asthma if the cough is episodic and associated with other features of asthma such as
expiratory wheeze, exercise-related breathlessness, or airflow limitation objectively demonstrated by spirometry
(particularly if responsive to a bronchodilator).3
Cystic fibrosis
Habit-cough syndrome
Tracheomalacia
Hyperventilation
Anxiety
Source
Weinberger M, Abu-Hasan M. Pseudo-asthma: when cough, wheezing, and dyspnea are not asthma. Pediatrics 2007;
120: 855-64. Available from: http://pediatrics.aappublications.org/content/120/4/855.full
28
Asset ID: 11
Sources
British Thoracic Society (BTS), Scottish Intercollegiate Guidelines Network (SIGN).British Guideline on the management
of Asthma. A national clinical guideline. BTS/SIGN, Edinburgh, 2012. Availablefrom:https://www.brit-
thoracic.org.uk/guidelines-and-quality-standards/asthma-guideline
Respiratory Expert Group, Therapeutic Guidelines Limited. Therapeutic Guidelines: Respiratory, Version 4. Therapeutic
Guidelines Limited, Melbourne,2009.
Asset ID: 12
29
Asthma is commonly misdiagnosed in young people presenting with exercise-related symptoms or cough.15 Conditions
associated with dyspnoea include hyperventilation, anxiety, and poor cardiopulmonary fitness.6
Both denial and overplay of symptoms has been observed among adolescents.15 Adolescents with new or re-emerging
asthma symptoms may deny their symptoms.15 US data suggest that risk factors for undiagnosed asthma among
adolescents include female sex, smoking (current smoking and exposure to others smoke), low socioeconomic status,
family problems, low physical activity and high body mass.16
References
1. British Thoracic Society (BTS), Scottish Intercollegiate Guidelines Network (SIGN). British Guideline on the
Management of Asthma. A national clinical guideline. BTS, SIGN, Edinburgh, 2012. Available from: https://www.brit-
thoracic.org.uk/guidelines-and-quality-standards/asthma-guideline/
2. Respiratory Expert Group, Therapeutic Guidelines Limited. Therapeutic Guidelines: Respiratory, Version 4. Therapeutic
Guidelines Limited, West Melbourne, 2009.
3. Gibson PG, Chang AB, Glasgow NJ, et al. CICADA: cough in children and adults: diagnosis and assessment. Australian
cough guidelines summary statement. Med J Aust. 2010; 192: 265-271. Available from:
http://www.lungfoundation.com.au/professional-resources/guidelines/cough-guidelines
4. Brand PL, Baraldi E, Bisgaard H, et al. Definition, assessment and treatment of wheezing disorders in preschool
children: an evidence-based approach. Eur Respir J. 2008; 32: 1096-1110. Available from:
http://erj.ersjournals.com/content/32/4/1096.full
5. Global Initiative for Asthma (GINA). Global strategy for the diagnosis and management of asthma in children 5 years and
younger. GINA, 2009. Available from: http://www.ginasthma.org/
6. Weinberger M, Abu-Hasan M. Pseudo-asthma: when cough, wheezing, and dyspnea are not asthma. Pediatrics. 2007;
120: 855-864. Available from: http://pediatrics.aappublications.org/content/120/4/855.full
7. Castro-Rodriguez JA. The Asthma Predictive Index: a very useful tool for predicting asthma in young children. J
Allergy Clin Immunol. 2010; 126: 212-216. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20624655
8. Schultz A, Devadason SG, Savenije OE, et al. The transient value of classifying preschool wheeze into episodic viral
wheeze and multiple trigger wheeze. Acta Paediatr. 2010; 99: 56-60. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/19764920
9. Savenije OE, Kerkhof M, Koppelman GH, Postma DS. Predicting who will have asthma at school age among preschool
children. J Allergy Clin Immunol. 2012; 130: 325-331. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/22704537
10. Martinez FD, Wright AL, Taussig LM, et al. Asthma and wheezing in the first six years of life. N Engl J Med. 1995; 332:
133-138. Available from: http://www.nejm.org/doi/full/10.1056/NEJM199501193320301#t=article
11. Henderson J, Granell R, Heron J, et al. Associations of wheezing phenotypes in the first 6 years of life with atopy, lung
function and airway responsiveness in mid-childhood. Thorax. 2008; 63: 974-980. Available from:
http://thorax.bmj.com/content/63/11/974.long
12. van Asperen PP. Cough and asthma. Paediatr Resp Rev. 2006; 7: 26-30. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/16473813
13. Bush A. Diagnosis of asthma in children under five. Prim Care Respir J. 2007; 16: 7-15. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/17297521
14. Craven V, Everard ML. Protracted bacterial bronchitis: reinventing an old disease. Arch Dis Child. 2013; 98: 72-76.
Available from: http://www.ncbi.nlm.nih.gov/pubmed/23175647
15. Towns SJ, van Asperen PP. Diagnosis and management of asthma in adolescents. Clin Respir J. 2009; 3: 69-76.
Available from: http://www.ncbi.nlm.nih.gov/pubmed/20298380
30
16. Yeatts K, Davis KJ, Sotir M, et al. Who gets diagnosed with asthma? Frequent wheeze among adolescents with and
without a diagnosis of asthma. Pediatrics. 2003; 111: 1046-54. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/12728087
17. Tilles SA. Exercise-induced respiratory symptoms: an epidemic among adolescents. Ann Allergy Asthma Immunol.
2010; 104: 361-7; 368-70, 412. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20486325
31
HOME > DIAGNOSIS > CHILDREN > PROVISIONAL DIAGNOSIS
A provisional diagnosis of asthma can be made if the child has (all of):
Notes
If reliable equipment and appropriately trained staff are available, spirometry can be performed in primary care. If not, refer to an
appropriate provider such as an accredited respiratory function laboratory.
Most children aged 6and older can perform spirometry reliably.
Airflow limitation is defined as reversible (i.e. bronchodilator response is clinically important) if FEV1 increases by 12%.
If spirometry does not demonstrate a clinically important response to bronchodilator, the test can be repeated when the child has
symptoms.
32
Asthma more likely Asthma less likely
Sources
British Thoracic Society (BTS), Scottish Intercollegiate Guidelines Network (SIGN).British Guideline on the management
of Asthma. A national clinical guideline. BTS/SIGN, Edinburgh, 2012. Availablefrom:https://www.brit-
thoracic.org.uk/guidelines-and-quality-standards/asthma-guideline
Respiratory Expert Group, Therapeutic Guidelines Limited. Therapeutic Guidelines: Respiratory, Version 4. Therapeutic
Guidelines Limited, Melbourne,2009.
Asset ID: 12
Cystic fibrosis
Habit-cough syndrome
Tracheomalacia
Hyperventilation
Anxiety
Source
Weinberger M, Abu-Hasan M. Pseudo-asthma: when cough, wheezing, and dyspnea are not asthma. Pediatrics 2007;
120: 855-64. Available from: http://pediatrics.aappublications.org/content/120/4/855.full
Asset ID: 11
33
Finding Notes
Onset of signs from birth or very early in life Suggests cystic fibrosis, chronic lung disease of
prematurity, primary ciliary dyskinesia,
bronchopulmonary dysplasia,congenital
abnormality
Family history of unusual chest disease Should be enquired about before attributing all the
signs and symptoms to asthma
Severe upper respiratory tract disease (e.g. severe Specialist assessment should be considered
rhinitis, enlarged tonsils and adenoids or nasal polyps)
Crepitations on chest auscultation that do not clear on Suggest a serious lower respiratory tract condition
coughing such as pneumonia, atelectasis, bronchiectasis
Systemic symptoms (e.g. fever, weight loss, failure to Suggest an alternative systemic disorder
thrive)
Feeding difficulties, including choking or vomiting Suggests aspiration specialist assessment should
be considered
Inspiratory upper airway noises (e.g. stridor, snoring) Acute stridor suggests tracheobronchitis (croup)
Chronic (>4 weeks) wet or productive cough Suggests cystic fibrosis, bronchiectasis, chronic
bronchitis, recurrent aspiration, immune
abnormality, ciliary dyskinesia
Severe chest deformity Harrisons Sulcus and Pectus Carinatum can be due
to uncontrolled asthma, but severe deformity
suggests an alternative diagnosis
34
Asset ID: 59
Make an initial assessment of the pattern of asthma (infrequent intermittent, frequent intermittent, or persistent).
Table. Definitions of asthma patterns in children aged 05 years not taking regular preventer
Frequent intermittent asthma Flare-ups more than once every 6 weeks on average but no
symptoms between flare-ups
Daytime symptoms more than once per week but not
every day
Night-time symptoms more than twice per month but not
every week
Daytime symptomsdaily
Night-time symptomsmore than once per week
Symptoms sometimes restrict activity or sleep
Symptoms between flare-ups.A flare-up is defined as a period of worsening asthma symptoms, from mild (e.g.
symptoms that are just outside the normal range of variation for the child, documented when well) to severe (e.g.
events that require urgent action by parents and health professionals to prevent a serious outcome such as
hospitalisation or death from asthma).
Note:Use this table when the diagnosis of asthma can be made with reasonable confidence (e.g. a child with wheezing
accompanied by persistent cough or breathing difficulty, no signs or symptoms that suggest a potentially serious
35
alternative diagnosis, and the presence ofother factors that increase the probability of asthma such as family history
of allergies or asthma).
Asset ID: 14
Table. Definitions of asthma patterns in children aged 6 years and over not taking regular preventer
Frequent intermittent asthma Flare-ups more than once every 6 weeks on average but no
symptoms between flare-ups
Persistent asthma Mild FEV1 80% predicted and at least one of:
Daytime symptomscontinual
Night-time symptoms frequent
Flare-ups frequent
Symptoms frequently restrict activity or sleep
It may not be appropriate to make the diagnosis of asthma in children aged 6 or older who wheeze only during upper
respiratory tract infections. These children can be considered to have episodic (viral) wheeze.
Symptoms between flare-ups.A flare-up is defined as a period of worsening asthma symptoms, from mild (e.g.
symptoms that are just outside the normal range of variation for the child, documented when well) to severe (e.g.
events that require urgent action by parents and health professionals to prevent a serious outcome such as
hospitalisation or death from asthma).
Asset ID: 15
36
How this recommendation was developed
s
Consensus
Based on clinical experience and expert opinion (informed by evidence, where available).
More information
Spirometry in children
1
Measuring lung function in young children is difficult and requires techniques that are not widely available. Generally,
2
spirometry cannot be performed to acceptable standards in children younger than 45 years.
Some older children cannot perform spirometry either. However, children who are unable to perform spirometry
satisfactorily on their first visit are often able to perform the test correctly at the next visit.2
Spirometry is poor at discriminating between children with asthma and those with airway obstruction due to other
conditions.1
Normal spirometry in a child, especially when asymptomatic, does not exclude the diagnosis of asthma.1 FEV1 is often
normal in children with persistent asthma.1
Reduced FEV1 alone does not indicate that a child has asthma, because it may be seen with other lung diseases (or be due
to poor spirometric technique).
A significant increase in FEV1 (>12% from baseline) after administering a bronchodilator (e.g. 4 puffs of salbutamol 100
mcg/actuation)indicates thatairflow limitation is reversible and supports the diagnosis of asthma. In children with
asthma, it is also predictive of a good lung functionresponse to inhaled corticosteroids.1 However, an absent response to
bronchodilators does not exclude asthma.1
37
Impulse oscillometry, tests of specific airways resistance, and measurements of residual volume are being investigated for
use in asthma diagnosis and management,10, 11but their availability is mainly restricted to specialist and research centres.1
References
1. British Thoracic Society (BTS), Scottish Intercollegiate Guidelines Network (SIGN). British Guideline on the
Management of Asthma. A national clinical guideline. BTS, SIGN, Edinburgh, 2012. Available from: https://www.brit-
thoracic.org.uk/guidelines-and-quality-standards/asthma-guideline/
2. Johns DP, Pierce R. Pocket guide to spirometry. 3rd edn. McGraw Hill, North Ryde, 2011.
3. Anderson SD. Bronchial challenge tests: usefulness, availability and challenges. Breathe. 2011; 8: 53-60. Available
from: http://www.ers-education.org
4. Cockcroft DW. Direct challenge tests: airway hyperresponsiveness in asthma: its measurement and clinical
significance. Chest. 2010; 138(2 Suppl): 18S-24S. Available from:
http://journal.publications.chestnet.org/article.aspx?articleid=1086632
5. Anderson SD, Pearlman DS, Rundell KW, et al. Reproducibility of the airway response to an exercise protocol
standardized for intensity, duration, and inspired air conditions, in subjects with symptoms suggestive of asthma.
Respir Res. 2010; Sept 1: 120. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2939602/
6. Barben J, Roberts M, Chew N, et al. Repeatability of bronchial responsiveness to mannitol dry powder in children with
asthma. Pediatr Pulmonol. 2003; 36: 490-4. Available from: http://www.ncbi.nlm.nih.gov/pubmed/14618640
7. Kersten ET, Driessen JM, van der Berg JD, Thio BJ. Mannitol and exercise challenge tests in asthmatic children.
Pediatr Pulmonol. 2009; 44: 655-661. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19499571
8. Liem JJ, Kozyrskyj AL, Cockroft DW, Becker AB. Diagnosing asthma in children: what is the role for methacholine
bronchoprovocation testing?. Pediatr Pulmonol. 2008; 43: 481-9. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/18383334
9. Carlsten C, Dimich-Ward H, Ferguson A, et al. Airway hyperresponsiveness to methacholine in 7-year-old children:
sensitivity and specificity for pediatric allergist-diagnosed asthma. Pediatr Pulmonol. 2011; 46: 175-178. Available
from: http://www.ncbi.nlm.nih.gov/pubmed/20963839
10. Child F. The measurement of airways resistance using the interrupter technique (Rint). Paediatr Respir Rev. 2005; 6:
273-7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16298310
11. Oostveen E, MacLeod D, Lorino H, et al. The forced oscillation technique in clinical practice: methodology,
recommendations and future developments. Eur Respir J Supplement. 2003; 22: 1026-41. Available from:
http://erj.ersjournals.com/content/22/6/1026.long
38
HOME > DIAGNOSIS > CHILDREN > TREATMENT TRIAL
05 years
Conducting a treatment trial to confirm the diagnosis in children 05 years
https://www.asthmahandbook.org.au/diagnosis/children/treatment-trial/0-5-years
39
HOME > DIAGNOSIS > CHILDREN > TREATMENT TRIAL > 05 YEARS
For children over 12 months old with wheezing episodes that are associated with increased work of breathing (i.e.
intercostal retraction), consider a trial of treatment with an inhaled short-acting beta2 agonist given as needed over a
48-hour period:
Show parents how to give salbutamol via a mask (infants) or spacer (pre-school children).
Tell parents to give 24 puffs (200400 mcg) when child wheezes, and repeat if wheezing does not stop or recurs.
Ask parents to watch closely for whether childs breathing becomes normal (i.e. child stops showing signs of
increased work of breathing) and report effects.
For children aged 612 months or less, consider a trial of treatment with as-need short-acting beta2 agonist, as for
children over 12 months. Monitor closely and assess response, because asthma is less likely to be the cause of wheezing
in this age group.
For children under 6 months old, consider discussing with a paediatric respiratory physician or paediatrician before
conducting a treatment trial with an inhaled short-acting beta2 agonist.
Brand et al.20081
If increased work of breathing resolves in response to inhaled bronchodilator (either during a treatment trial at home or
observed in the clinic or hospital), this supports a provisional diagnosis of asthma.
Brand et al.20081
40
For children aged 12 months and over with a provisional diagnosis of asthma, consider a trial of preventertreatment if
(either of):
wheezing episodes are accompanied by increased work of breathing and are severe enough to interrupt eating, play,
physical activity or sleep
the child has been hospitalised due to acute wheezing and difficulty breathing.
or
Viral-induced wheeze
or
Viral-induced wheeze
or
Viral-induced wheeze
or
Multiple-trigger wheeze
Moderatesevere persistent
asthma
41
Age Pattern of symptoms Management options and notes *
* In addition to use of rapid-onset inhaled beta2 agonist when child experiences difficulty breathing
Starting dose sodium cromoglycate 10 mg (two inhalations of 5 mg/actuation inhaler) three times daily. If good
response, reduce to 10 mg twice daily when stable.Cromone inhaler device mouthpieces require daily washing to
avoid blocking.
Asset ID: 20
If wheezing accompanied by increased work of breathing is markedly reduced during a treatment trial with a preventer,
then recurs when treatment is stopped, this supports a provisional diagnosis of asthma in a preschool child.
wheezing in the first few years of life does not mean the child will have asthma or allergies by primary school age
it is not possible to be certain that the child has asthma until he or she is old enough for objective lung function
testing (spirometry) to assess whether lung function is excessively variable(i.e. demonstrate variable airflow
limitation).
Brandet al.20081
Martinez et al.19953
Morgan et al.20054
Henderson et al.20085
Castro-Rodriguez, 20106
42
More information
Definition of wheeze
Wheeze is defined as a continuous, high-pitched sound coming from the chest during expiration.1,2It is a non-specific sign
caused by turbulent air flow due to narrowing of intrathoracic airways and indicates expiratory airflow limitation,
irrespective of the underlying mechanism1 (e.g. bronchoconstriction or secretions in the airway lumen).
Parents and doctors sometimes use the word wheeze to mean different things,1, 7 including cough, gasp, a change in
breathing rate or style of breathing. If based on parental report alone, children may be labelled as having wheeze when
they do not have narrowed airways and expiratory flow limitation.1
There are no validated questionnaire-based instruments to identify wheeze in preschoolers,1 so wheezing is best
confirmed by listening with a stethoscope during an episode.
Reported noisy breathing that responds to bronchodilator therapy is likely to be genuine wheeze and to be caused, at
least in part, by constriction of airway smooth muscle.1
Some international guidelines1 avoid using the term asthma for preschool children, because there is not enough evidence
to know whether the pathophysiology of recurrent wheezing and asthma-like symptoms in preschool children is the same
as that of asthma in older children and in adults,1 and because many young children with wheezing will not go on to
develop asthma at school age.1 The more general term wheezing disorder is sometimes used in preference to asthma for
children aged 5 years and under.1
Table. Definitions of asthma patterns in children aged 05 years not taking regular preventer
Frequent intermittent asthma Flare-ups more than once every 6 weeks on average but no
symptoms between flare-ups
Daytime symptoms more than once per week but not
every day
Night-time symptoms more than twice per month but not
every week
43
Category Pattern and intensity of symptoms (when not taking regular
treatment)
Daytime symptomsdaily
Night-time symptomsmore than once per week
Symptoms sometimes restrict activity or sleep
Symptoms between flare-ups.A flare-up is defined as a period of worsening asthma symptoms, from mild (e.g.
symptoms that are just outside the normal range of variation for the child, documented when well) to severe (e.g.
events that require urgent action by parents and health professionals to prevent a serious outcome such as
hospitalisation or death from asthma).
Note:Use this table when the diagnosis of asthma can be made with reasonable confidence (e.g. a child with wheezing
accompanied by persistent cough or breathing difficulty, no signs or symptoms that suggest a potentially serious
alternative diagnosis, and the presence ofother factors that increase the probability of asthma such as family history
of allergies or asthma).
Asset ID: 14
Table. Definitions of asthma patterns in children aged 6 years and over not taking regular preventer
Frequent intermittent asthma Flare-ups more than once every 6 weeks on average but no
symptoms between flare-ups
Persistent asthma Mild FEV1 80% predicted and at least one of:
44
Category Pattern and intensity of symptoms (when not taking regular
treatment)
Daytime symptomscontinual
Night-time symptoms frequent
Flare-ups frequent
Symptoms frequently restrict activity or sleep
It may not be appropriate to make the diagnosis of asthma in children aged 6 or older who wheeze only during upper
respiratory tract infections. These children can be considered to have episodic (viral) wheeze.
Symptoms between flare-ups.A flare-up is defined as a period of worsening asthma symptoms, from mild (e.g.
symptoms that are just outside the normal range of variation for the child, documented when well) to severe (e.g.
events that require urgent action by parents and health professionals to prevent a serious outcome such as
hospitalisation or death from asthma).
Asset ID: 15
For children already taking regular preventer treatment, adjustments to the treatment regimen are based on finding
the lowest dose of medicines that will maintain good control of symptoms.
45
Classification Phenotypes Description
system/source identified
Tucson Childrens Transient wheeze Wheezing commences before the age of 3 years and disappear
Respiratory Study by age 6 years
Persistent wheeze Wheezing continues until up to or after age 6 years
Avon Longitudinal Transient early Wheezing mainly occurs before 18 months, then mainly
Study of Parents wheeze disappears by age 3.5 years
and Children Not associated with hypersensitivity to airborne allergens
Prolonged early Wheezing occurs mainly between age 6 months and 4.5 years,
wheeze then mainly disappears before childs 6th birthday
Persistent wheeze Wheezing mainly begins after 6 months and continues through
to primary school
Notes
Terms can only be identified after the child has stopped wheezing for several years and cannot be applied to a
preschool child.
Transient wheeze, persistent wheeze and late-onset wheeze can be episodic or multiple-trigger wheeze.#
Sources
Martinez FD, Wright AL, Taussig LM et al. Asthma and wheezing in the first six years of life. The Group Health
Medical Associates. N Engl J Med 1995; 332: 133-8. Available from:
http://www.nejm.org/doi/full/10.1056/NEJM199501193320301#t=article
Morgan WJ, Stern DA, Sherrill DL et al. Outcome of asthma and wheezing in the first 6 years of life: follow-up
through adolescence. Am J Respir Crit Care Med 2005; 172: 1253-8. Available from:
http://ajrccm.atsjournals.org/content/172/10/1253.long
46
Henderson J, Granell R, Heron J et al. Associations of wheezing phenotypes in the first 6 years of life with atopy, lung
function and airway responsiveness in mid-childhood. Thorax 2008; 63: 974-80. Available from:
http://thorax.bmj.com/content/63/11/974.long
# Brand PL, Baraldi E, Bisgaard H et al. Definition, assessment and treatment of wheezing disorders in preschool
children: an evidence-based approach [European Respiratory Society Task Force]. Eur Respir J 2008; 32: 1096-110.
Available from: http://erj.ersjournals.com/content/32/4/1096.full
Asset ID: 10
Early childhood wheezing phenotypes cannot be recognised or applied clinically, because they are recognised
retrospectively.1 In an individual child with episodic wheeze, it is not possible to accurately predict epidemiological
phenotype from clinical phenotype.1
Currently available tools for predicting whether a wheezing preschool child will have asthma at school age (e.g. the
Asthma Predictive Index6) have limited clinical value.9
Go to: National Asthma Council Australia'sAsthma and wheezing in the first years of life information paper
Wheezing is the most common symptom associated with asthma in children aged 5 years and under.2Among people with
a diagnosis of asthma at any time in their life, approximately 80% will have shown signs of respiratory disease, such as
wheezing, in the first years of life.6
However, the presence of wheeze does not mean a child has asthma or will develop asthma:
wheezing in infants up to 12 months old is most commonly due to acute viral bronchiolitis or to small and/or floppy
airways
wheezing in children aged 15 years is usually associated with viral upper respiratory tract infections, which recur
frequently in this age group.1, 2Many children wheeze when they have viral respiratory infections, even if they do not
have asthma2
among preschoolers with recurrent wheezing, only approximately one in three will have asthma at age 6 years6
wheezing can also be due to many conditions other than asthma, including anatomical abnormalities of the airways,
cystic fibrosis, bronchomalacia.1
Highrates of incorrect inhaler use among children with asthma and adults with asthma or COPD have been reported,12,
13, 14, 15, 16
evenamong regular users.17Regardless of the type of inhaler device prescribed, patients are unlikely to use
inhalers correctly unless they receive clear instruction, including a physical demonstration,and have their inhaler
technique checked regularly.18
Poor inhaler technique has been associated with worse outcomes in asthma and COPD. It can lead to poor asthma
symptom control and overuse of relievers and preventers.12, 19, 17, 20, 21In patients with asthma or COPD, incorrect
technique is associated with a 50% increased risk of hospitalisation, increased emergency department visits and increased
use of oral corticosteroids due to flare-ups.17
Correcting patients' inhaler technique has been shown to improve asthma control, asthma-related quality of life and lung
22, 23
function.
Common errors and problems with inhaler technique
Common errors with manually actuated pressurised metered dose inhalersinclude:18
47
actuating the inhaler too late while inhaling
actuating more than once while inhaling
inhaling too rapidly (this can be especially difficult for chilren to overcome)
multiple actuations without shaking between doses.
not keeping the device in the correct position while loading the dose (horizontal for Accuhaler and vertical for
Turbuhaler)
failing to exhale fully before inhaling
failing to inhale completely
inhaling too slowly and weakly
exhaling into the device mouthpiece before or after inhaling
failing to close the inhaler after use
using past the expiry date or when empty.
difficulty manipulating device due to problems with dexterity (e.g. osteoarthritis, stroke, muscle weakness)
inability to seal the lips firmly around the mouthpiece of an inhaler or spacer
inability to generate adequate inspiratory flow for the inhaler type
failure to use a spacer when appropriate
use of incorrect size mask
inappropriate use of a mask with a spacer in older children.
Go to: National Asthma Council Australia'sUsing your inhalerwebpagefor information, patient resources and videos
on inhaler technique
Go to: National Asthma Council Australia's information paper for health professionals onInhaler technique for people
with asthma or COPD
Go to: NPSMedicineWise information onInhaler devices for respiratory medicines
References
1. Brand PL, Baraldi E, Bisgaard H, et al. Definition, assessment and treatment of wheezing disorders in preschool
children: an evidence-based approach. Eur Respir J. 2008; 32: 1096-1110. Available from:
http://erj.ersjournals.com/content/32/4/1096.full
2. Global Initiative for Asthma (GINA). Global strategy for the diagnosis and management of asthma in children 5 years and
younger. GINA, 2009. Available from: http://www.ginasthma.org/
3. Martinez FD, Wright AL, Taussig LM, et al. Asthma and wheezing in the first six years of life. N Engl J Med. 1995; 332:
133-138. Available from: http://www.nejm.org/doi/full/10.1056/NEJM199501193320301#t=article
4. Morgan WJ, Stern DA, Sherrill DL, et al. Outcome of asthma and wheezing in the first 6 years of life: follow-up
through adolescence. Am J Respir Crit Care Med. 2005; 172: 1253-8. Available from:
http://ajrccm.atsjournals.org/content/172/10/1253.long
5. Henderson J, Granell R, Heron J, et al. Associations of wheezing phenotypes in the first 6 years of life with atopy, lung
function and airway responsiveness in mid-childhood. Thorax. 2008; 63: 974-980. Available from:
http://thorax.bmj.com/content/63/11/974.long
6. Castro-Rodriguez JA. The Asthma Predictive Index: a very useful tool for predicting asthma in young children. J
Allergy Clin Immunol. 2010; 126: 212-216. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20624655
48
7. Weinberger M, Abu-Hasan M. Pseudo-asthma: when cough, wheezing, and dyspnea are not asthma. Pediatrics. 2007;
120: 855-864. Available from: http://pediatrics.aappublications.org/content/120/4/855.full
8. Schultz A, Devadason SG, Savenije OE, et al. The transient value of classifying preschool wheeze into episodic viral
wheeze and multiple trigger wheeze. Acta Paediatr. 2010; 99: 56-60. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/19764920
9. Savenije OE, Kerkhof M, Koppelman GH, Postma DS. Predicting who will have asthma at school age among preschool
children. J Allergy Clin Immunol. 2012; 130: 325-331. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/22704537
10. Basheti IA, Armour CL, Bosnic-Anticevich SZ, Reddel HK. Evaluation of a novel educational strategy, including
inhaler-based reminder labels, to improve asthma inhaler technique. Patient Educ Couns. 2008; 72: 26-33. Available
from: http://www.ncbi.nlm.nih.gov/pubmed/18314294
11. Bosnic-Anticevich, S. Z., Sinha, H., So, S., Reddel, H. K.. Metered-dose inhaler technique: the effect of two educational
interventions delivered in community pharmacy over time. The Journal of asthma : official journal of the Association for
the Care of Asthma. 2010; 47: 251-6. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20394511
12. Price, D., Bosnic-Anticevich, S., Briggs, A., et al. Inhaler competence in asthma: common errors, barriers to use and
recommended solutions. Respiratory medicine. 2013; 107: 37-46. Available from:
https://www.ncbi.nlm.nih.gov/pubmed/23098685
13. Capanoglu, M., Dibek Misirlioglu, E., Toyran, M., et al. Evaluation of inhaler technique, adherence to therapy and their
effect on disease control among children with asthma using metered dose or dry powder inhalers. The Journal of
asthma : official journal of the Association for the Care of Asthma. 2015; 52: 838-45. Available from:
https://www.ncbi.nlm.nih.gov/pubmed/20394511
14. Lavorini, F., Magnan, A., Dubus, J. C., et al. Effect of incorrect use of dry powder inhalers on management of patients
with asthma and COPD. Respiratory medicine. 2008; 102: 593-604. Available from:
https://www.ncbi.nlm.nih.gov/pubmed/18083019
15. Federman, A. D., Wolf, M. S., Sofianou, A., et al. Self-management behaviors in older adults with asthma: associations
with health literacy. Journal of the American Geriatrics Society. 2014; 62: 872-9. Available from:
https://www.ncbi.nlm.nih.gov/pubmed/24779482
16. Crane, M. A., Jenkins, C. R., Goeman, D. P., Douglass, J. A.. Inhaler device technique can be improved in older adults
through tailored education: findings from a randomised controlled trial. NPJ primary care respiratory medicine. 2014;
24: 14034. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25188403
17. Melani AS, Bonavia M, Cilenti V, et al. Inhaler mishandling remains common in real life and is associated with reduced
disease control. Respir Med. 2011; 105: 930-8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21367593
18. National Asthma Council Australia. Inhaler technique for people with asthma or COPD. National Asthma Council
Australia, Melbourne, 2016. Available from: https://www.nationalasthma.org.au/living-with-
asthma/resources/health-professionals/information-paper/hp-inhaler-technique-for-people-with-asthma-or-copd
19. Bjermer, L.. The importance of continuity in inhaler device choice for asthma and chronic obstructive pulmonary
disease. Respiration; international review of thoracic diseases. 2014; 88: 346-52. Available from:
https://www.ncbi.nlm.nih.gov/pubmed/25195762
20. Haughney, J., Price, D., Barnes, N. C., et al. Choosing inhaler devices for people with asthma: current knowledge and
outstanding research needs. Respiratory medicine. 2010; 104: 1237-45. Available from:
https://www.ncbi.nlm.nih.gov/pubmed/20472415
21. Giraud, V., Roche, N.. Misuse of corticosteroid metered-dose inhaler is associated with decreased asthma stability.
The European respiratory journal. 2002; 19: 246-51. Available from: https://www.ncbi.nlm.nih.gov/pubmed/11866004
22. Basheti IA, Reddel HK, Armour CL, Bosnic-Anticevich SZ. Improved asthma outcomes with a simple inhaler technique
intervention by community pharmacists. J Allergy Clin Immunol. 2007; 119: 1537-8. Available from:
http://www.jacionline.org/article/S0091-6749(07)00439-3/fulltext
23. Giraud, V., Allaert, F. A., Roche, N.. Inhaler technique and asthma: feasability and acceptability of training by
pharmacists. Respiratory medicine. 2011; 105: 1815-22. Available from:
https://www.ncbi.nlm.nih.gov/pubmed/21802271
24. Basheti, I. A., Reddel, H. K., Armour, C. L., Bosnic-Anticevich, S. Z.. Counseling about turbuhaler technique: needs
assessment and effective strategies for community pharmacists. Respiratory care. 2005; 50: 617-23. Available from:
https://www.ncbi.nlm.nih.gov/pubmed/15871755
25. Lavorini, F.. Inhaled drug delivery in the hands of the patient. Journal of aerosol medicine and pulmonary drug delivery.
2014; 27: 414-8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25238005
26. Newman, S.. Improving inhaler technique, adherence to therapy and the precision of dosing: major challenges for
pulmonary drug delivery. Expert opinion on drug delivery. 2014; 11: 365-78. Available from:
https://www.ncbi.nlm.nih.gov/pubmed/24386924
49
HOME > DIAGNOSIS > CHILDREN > TREATMENT TRIAL > 6 YEARS AND OVER
Table. Initial preventer treatment for children aged 6 years and over
Frequent intermittent asthma Consider a treatment trial with montelukast 5mg once daily; assess
response after 24weeks
Mild persistent asthma Consider a treatment trial with montelukast 5mg once daily; assess
response after 24weeks
Moderate-to-severe persistent Consider a treatment trial with regular inhaled corticosteroid (low
asthma dose); assess response after 4weeks.
Low High
50
Inhaled corticosteroid Daily dose (mcg)
Low High
If cough does not respond to a treatment trial with a preventer, cease treatment instead of increasing the dose.
More information
51
Systemic symptoms: fever, failure to thrive or poor growth velocity
Recurrent pneumonia
Clubbing of fingers
Source
Gibson PG, Chang AB, Glasgow NJ et al.,CICADA: Cough in Children and Adults: Diagnosis and Assessment. Australian
cough guidelines summary statement. Med J Aust, 2010; 192: 265-71. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/20201760
Asset ID: 13
Chronic cough (cough lasting more than 4 weeks)without other features of asthma is unlikely to be due to asthma.1
Cough is a frequent symptom in children with asthma, but may have a different mechanism from other symptoms of
asthma (e.g. wheeze, chest tightness or breathlessness). Children who have recurrent cough, but do not wheeze, are
unlikely to have asthma.2A very small minority of children with recurrent nocturnal cough, but no other asthma
symptoms, may be considered to have a diagnosis of atypical asthma.2 This diagnosis should be only made in consultation
with a paediatric respiratory physician.
In children with no abnormalities detected on physical examination, chest X-ray or spirometry, and no wheezing or
breathlessness, chronic coughis most likely:1
due to protracted bacterial bronchitis (resolves with 26 weeks treatment with antibiotics)1
post-viral (resolves with time)
due to exposure to tobacco smoke and other pollutants.1
Frequency of cough reported by parents correlates poorly with frequency measured using diary cards or by audio
recording monitors.3
0-5 years
Most cases of coughing in preschool children are not due to asthma:
Recurrent cough in preschool children, in the absence of other signs, is most likely due to recurrent viral bronchitis.
Cough due to viral infection is unresponsive to bronchodilators and preventerssuch as montelukast, cromones or
inhaled corticosteroids.
Children attending day care or preschool can have a succession of viral infections that merge into each other,3giving
the false appearance of chronic cough (cough lasting more than 4 weeks).
In preschool-aged children, cough may be due to asthma when it occurs during episodes of wheezing and breathlessness
or when the child does not have a cold.
6 years and over
Chronic cough may be due to asthma if the cough is episodic and associated with other features of asthma such as
expiratory wheeze, exercise-related breathlessness, or airflow limitation objectively demonstrated by spirometry
(particularly if responsive to a bronchodilator).1
52
Table. Definitions of asthma patterns in children aged 05 years not taking regular preventer
Frequent intermittent asthma Flare-ups more than once every 6 weeks on average but no
symptoms between flare-ups
Daytime symptomsdaily
Night-time symptoms more than once per week
Symptoms sometimes restrict activity or sleep
Daytime symptoms continual
Night-time symptomsfrequent
Flare-ups frequent
Symptoms frequently restrict activity or sleep
Symptoms between flare-ups.A flare-up is defined as a period of worsening asthma symptoms, from mild (e.g.
symptoms that are just outside the normal range of variation for the child, documented when well) to severe (e.g.
events that require urgent action by parents and health professionals to prevent a serious outcome such as
hospitalisation or death from asthma).
Note:Use this table when the diagnosis of asthma can be made with reasonable confidence (e.g. a child with wheezing
accompanied by persistent cough or breathing difficulty, no signs or symptoms that suggest a potentially serious
alternative diagnosis, and the presence ofother factors that increase the probability of asthma such as family history
of allergies or asthma).
Asset ID: 14
Table. Definitions of asthma patterns in children aged 6 years and over not taking regular preventer
53
Category Pattern and intensity of symptoms (when not taking regular
treatment)
Frequent intermittent asthma Flare-ups more than once every 6 weeks on average but no
symptoms between flare-ups
Persistent asthma Mild FEV1 80% predicted and at least one of:
It may not be appropriate to make the diagnosis of asthma in children aged 6 or older who wheeze only during upper
respiratory tract infections. These children can be considered to have episodic (viral) wheeze.
Symptoms between flare-ups.A flare-up is defined as a period of worsening asthma symptoms, from mild (e.g.
symptoms that are just outside the normal range of variation for the child, documented when well) to severe (e.g.
events that require urgent action by parents and health professionals to prevent a serious outcome such as
hospitalisation or death from asthma).
Asset ID: 15
For children already taking regular preventer treatment, adjustments to the treatment regimen are based on finding
the lowest dose of medicines that will maintain good control of symptoms.
54
The majority of patients do not use inhaler devices correctly. Australian research studies have reported that only
approximately 10% of patients use correct technique.4,5
Highrates of incorrect inhaler use among children with asthma and adults with asthma or COPD have been reported,6, 7, 8,
9, 10
evenamong regular users.11Regardless of the type of inhaler device prescribed, patients are unlikely to use inhalers
correctly unless they receive clear instruction, including a physical demonstration,and have their inhaler technique
checked regularly.12
Poor inhaler technique has been associated with worse outcomes in asthma and COPD. It can lead to poor asthma
symptom control and overuse of relievers and preventers.6, 13, 11, 14, 15In patients with asthma or COPD, incorrect
technique is associated with a 50% increased risk of hospitalisation, increased emergency department visits and increased
use of oral corticosteroids due to flare-ups.11
Correcting patients' inhaler technique has been shown to improve asthma control, asthma-related quality of life and lung
function.16, 17
Common errors and problems with inhaler technique
Common errors with manually actuated pressurised metered dose inhalersinclude:12
12
Common errors for dry powder inhalers include:
not keeping the device in the correct position while loading the dose (horizontal for Accuhaler and vertical for
Turbuhaler)
failing to exhale fully before inhaling
failing to inhale completely
inhaling too slowly and weakly
exhaling into the device mouthpiece before or after inhaling
failing to close the inhaler after use
using past the expiry date or when empty.
difficulty manipulating device due to problems with dexterity (e.g. osteoarthritis, stroke, muscle weakness)
inability to seal the lips firmly around the mouthpiece of an inhaler or spacer
inability to generate adequate inspiratory flow for the inhaler type
failure to use a spacer when appropriate
use of incorrect size mask
inappropriate use of a mask with a spacer in older children.
Go to: National Asthma Council Australia'sUsing your inhalerwebpagefor information, patient resources and videos
on inhaler technique
55
Go to: National Asthma Council Australia's information paper for health professionals onInhaler technique for people
with asthma or COPD
Go to: NPSMedicineWise information onInhaler devices for respiratory medicines
References
1. Gibson PG, Chang AB, Glasgow NJ, et al. CICADA: cough in children and adults: diagnosis and assessment. Australian
cough guidelines summary statement. Med J Aust. 2010; 192: 265-271. Available from:
http://www.lungfoundation.com.au/professional-resources/guidelines/cough-guidelines
2. van Asperen PP. Cough and asthma. Paediatr Resp Rev. 2006; 7: 26-30. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/16473813
3. Bush A. Diagnosis of asthma in children under five. Prim Care Respir J. 2007; 16: 7-15. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/17297521
4. Basheti IA, Armour CL, Bosnic-Anticevich SZ, Reddel HK. Evaluation of a novel educational strategy, including
inhaler-based reminder labels, to improve asthma inhaler technique. Patient Educ Couns. 2008; 72: 26-33. Available
from: http://www.ncbi.nlm.nih.gov/pubmed/18314294
5. Bosnic-Anticevich, S. Z., Sinha, H., So, S., Reddel, H. K.. Metered-dose inhaler technique: the effect of two educational
interventions delivered in community pharmacy over time. The Journal of asthma : official journal of the Association for
the Care of Asthma. 2010; 47: 251-6. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20394511
6. Price, D., Bosnic-Anticevich, S., Briggs, A., et al. Inhaler competence in asthma: common errors, barriers to use and
recommended solutions. Respiratory medicine. 2013; 107: 37-46. Available from:
https://www.ncbi.nlm.nih.gov/pubmed/23098685
7. Capanoglu, M., Dibek Misirlioglu, E., Toyran, M., et al. Evaluation of inhaler technique, adherence to therapy and their
effect on disease control among children with asthma using metered dose or dry powder inhalers. The Journal of
asthma : official journal of the Association for the Care of Asthma. 2015; 52: 838-45. Available from:
https://www.ncbi.nlm.nih.gov/pubmed/20394511
8. Lavorini, F., Magnan, A., Dubus, J. C., et al. Effect of incorrect use of dry powder inhalers on management of patients
with asthma and COPD. Respiratory medicine. 2008; 102: 593-604. Available from:
https://www.ncbi.nlm.nih.gov/pubmed/18083019
9. Federman, A. D., Wolf, M. S., Sofianou, A., et al. Self-management behaviors in older adults with asthma: associations
with health literacy. Journal of the American Geriatrics Society. 2014; 62: 872-9. Available from:
https://www.ncbi.nlm.nih.gov/pubmed/24779482
10. Crane, M. A., Jenkins, C. R., Goeman, D. P., Douglass, J. A.. Inhaler device technique can be improved in older adults
through tailored education: findings from a randomised controlled trial. NPJ primary care respiratory medicine. 2014;
24: 14034. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25188403
11. Melani AS, Bonavia M, Cilenti V, et al. Inhaler mishandling remains common in real life and is associated with reduced
disease control. Respir Med. 2011; 105: 930-8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21367593
12. National Asthma Council Australia. Inhaler technique for people with asthma or COPD. National Asthma Council
Australia, Melbourne, 2016. Available from: https://www.nationalasthma.org.au/living-with-
asthma/resources/health-professionals/information-paper/hp-inhaler-technique-for-people-with-asthma-or-copd
13. Bjermer, L.. The importance of continuity in inhaler device choice for asthma and chronic obstructive pulmonary
disease. Respiration; international review of thoracic diseases. 2014; 88: 346-52. Available from:
https://www.ncbi.nlm.nih.gov/pubmed/25195762
14. Haughney, J., Price, D., Barnes, N. C., et al. Choosing inhaler devices for people with asthma: current knowledge and
outstanding research needs. Respiratory medicine. 2010; 104: 1237-45. Available from:
https://www.ncbi.nlm.nih.gov/pubmed/20472415
15. Giraud, V., Roche, N.. Misuse of corticosteroid metered-dose inhaler is associated with decreased asthma stability.
The European respiratory journal. 2002; 19: 246-51. Available from: https://www.ncbi.nlm.nih.gov/pubmed/11866004
16. Basheti IA, Reddel HK, Armour CL, Bosnic-Anticevich SZ. Improved asthma outcomes with a simple inhaler technique
intervention by community pharmacists. J Allergy Clin Immunol. 2007; 119: 1537-8. Available from:
http://www.jacionline.org/article/S0091-6749(07)00439-3/fulltext
17. Giraud, V., Allaert, F. A., Roche, N.. Inhaler technique and asthma: feasability and acceptability of training by
pharmacists. Respiratory medicine. 2011; 105: 1815-22. Available from:
https://www.ncbi.nlm.nih.gov/pubmed/21802271
18. Basheti, I. A., Reddel, H. K., Armour, C. L., Bosnic-Anticevich, S. Z.. Counseling about turbuhaler technique: needs
assessment and effective strategies for community pharmacists. Respiratory care. 2005; 50: 617-23. Available from:
https://www.ncbi.nlm.nih.gov/pubmed/15871755
19. Lavorini, F.. Inhaled drug delivery in the hands of the patient. Journal of aerosol medicine and pulmonary drug delivery.
2014; 27: 414-8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25238005
20. Newman, S.. Improving inhaler technique, adherence to therapy and the precision of dosing: major challenges for
pulmonary drug delivery. Expert opinion on drug delivery. 2014; 11: 365-78. Available from:
https://www.ncbi.nlm.nih.gov/pubmed/24386924
56
57
HOME > DIAGNOSIS > CHILDREN > FURTHER INVESTIGATIONS
Consider allergy tests for children with recurrent wheezing when the results might guide you in (either of):
assessing the prognosis (e.g. in preschool children, the presence of allergies increases the probability that the child
will have asthma at primary school age)
managing symptoms (e.g. advising parents about management if avoidable allergic triggers are identified).
Note: Allergy tests are not mandatory in the diagnostic investigation of asthma in children.
If the diagnosis is uncertain, consider arranging bronchial provocation (challenge) testing or cardiopulmonary exercise
testing to exclude asthma.
Arrange chest X-ray if the child has unusual respiratory symptoms or if wheezing is localised. Routine chest X-ray is not
otherwise recommended in the investigation of asthma symptoms in children.
Measurement of exhaled nitric oxide is not recommended as a diagnostic test for asthma in routine clinical practice.
Brand et al.20081
Dweiket al. 20112
Routine microbiological investigations are not recommended in the investigation of symptoms that suggest asthma in
preschool children.
58
Brand et al.20081
Offer referral to a specialist for further assessment and investigation if the diagnosis is unclear or if a serious condition
cannot be ruled out.
More information
Go to: Australasian Society of Clinical Immunology and Allergy Skin Prick Testing Working Party'sSkin prick testing for
the diagnosis of allergic disease. A manual for practitioners
59
Challenge tests are performed in accredited lung function testing laboratories. These tests are usually difficult to perform
in children under 8 years of age because they involve repeated spirometry tests.
If challenge testing is needed, consider referring to a paediatric respiratory physician for investigation, or discussing with
a paediatric respiratory physician before selecting which test to order.
Do not test during a respiratory infection, or initiate inhaled corticosteroid treatment afew weeks before challenge
testing, because these could invalidate the result.
Bronchial provocation tests of airway hyperresponsiveness include:
A chest X-ray will neither establish nor rule out a diagnosis of asthma.1
Exhaled nitric oxide testing
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The exhaled nitric oxide test is not currently available as a standard clinical test and is mainly a research tool at present.
Exhaled nitric oxide can be measured in unsedated children from the age of 34 years.3Standardised reference values are
available for children aged 4 years and older.1
The use of induced sputum test in the investigation of wheezing syndromes in preschool children has not been studied.1
Sputum induction is feasible in most school-aged children, but it is technically demanding and time consuming, and at
present remains a research tool.3
White cell count
Blood eosinophilia in children aged 05 is a poor predictor of later asthma when used alone.
In children aged over 5 years, the presence of eosinophilia ( 4%) increases the probability that wheeze is due to asthma.3
Blood eosinophil testing is a component of the Asthma Predictive Index.15 However, this test is not routinely
recommended because the Asthma Predictive Index has only limited clinical value in predicting whether a wheezing
preschool child will have asthma at school age.1, 16
Invasive tests
Airway wall biopsy and bronchoalveolar lavage are invasive investigations. These should only be used in unusual cases,
and must be performed in specialised centres.1
References
1. Brand PL, Baraldi E, Bisgaard H, et al. Definition, assessment and treatment of wheezing disorders in preschool
children: an evidence-based approach. Eur Respir J. 2008; 32: 1096-1110. Available from:
http://erj.ersjournals.com/content/32/4/1096.full
2. Dweik RA, Boggs PB, Erzurum SC, et al. An Official ATS Clinical Practice Guideline: Interpretation of Exhaled Nitric
Oxide Levels (FeNO) for Clinical Applications. Am J Respir Crit Care Med. 2011; 184: 602-615. Available from:
http://ajrccm.atsjournals.org/content/184/5/602.long
3. British Thoracic Society (BTS), Scottish Intercollegiate Guidelines Network (SIGN). British Guideline on the
Management of Asthma. A national clinical guideline. BTS, SIGN, Edinburgh, 2012. Available from: https://www.brit-
thoracic.org.uk/guidelines-and-quality-standards/asthma-guideline/
4. Global Initiative for Asthma (GINA). Global strategy for the diagnosis and management of asthma in children 5 years and
younger. GINA, 2009. Available from: http://www.ginasthma.org/
5. Australasian Society of Clinical Immunology and Allergy (ASCIA), Skin Prick Testing Working Party. Skin prick testing
for the diagnosis of allergic disease: A manual for practitioners. ASCIA, Sydney, 2013. Available from:
http://www.allergy.org.au/health-professionals/papers/skin-prick-testing
6. Anderson SD. Bronchial challenge tests: usefulness, availability and challenges. Breathe. 2011; 8: 53-60. Available
from: http://www.ers-education.org
7. Cockcroft DW. Direct challenge tests: airway hyperresponsiveness in asthma: its measurement and clinical
significance. Chest. 2010; 138(2 Suppl): 18S-24S. Available from:
http://journal.publications.chestnet.org/article.aspx?articleid=1086632
8. Anderson SD, Pearlman DS, Rundell KW, et al. Reproducibility of the airway response to an exercise protocol
standardized for intensity, duration, and inspired air conditions, in subjects with symptoms suggestive of asthma.
Respir Res. 2010; Sept 1: 120. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2939602/
9. Barben J, Roberts M, Chew N, et al. Repeatability of bronchial responsiveness to mannitol dry powder in children with
asthma. Pediatr Pulmonol. 2003; 36: 490-4. Available from: http://www.ncbi.nlm.nih.gov/pubmed/14618640
10. Kersten ET, Driessen JM, van der Berg JD, Thio BJ. Mannitol and exercise challenge tests in asthmatic children.
Pediatr Pulmonol. 2009; 44: 655-661. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19499571
11. Liem JJ, Kozyrskyj AL, Cockroft DW, Becker AB. Diagnosing asthma in children: what is the role for methacholine
bronchoprovocation testing?. Pediatr Pulmonol. 2008; 43: 481-9. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/18383334
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12. Carlsten C, Dimich-Ward H, Ferguson A, et al. Airway hyperresponsiveness to methacholine in 7-year-old children:
sensitivity and specificity for pediatric allergist-diagnosed asthma. Pediatr Pulmonol. 2011; 46: 175-178. Available
from: http://www.ncbi.nlm.nih.gov/pubmed/20963839
13. Child F. The measurement of airways resistance using the interrupter technique (Rint). Paediatr Respir Rev. 2005; 6:
273-7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16298310
14. Oostveen E, MacLeod D, Lorino H, et al. The forced oscillation technique in clinical practice: methodology,
recommendations and future developments. Eur Respir J Supplement. 2003; 22: 1026-41. Available from:
http://erj.ersjournals.com/content/22/6/1026.long
15. Castro-Rodriguez JA. The Asthma Predictive Index: a very useful tool for predicting asthma in young children. J
Allergy Clin Immunol. 2010; 126: 212-216. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20624655
16. Savenije OE, Kerkhof M, Koppelman GH, Postma DS. Predicting who will have asthma at school age among preschool
children. J Allergy Clin Immunol. 2012; 130: 325-331. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/22704537
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