gathered from https://www.asthmahandbook.org.au/ -v2.0
Checking Whether Current Symptoms Are Due to Asthma
Recommendations
Thorough History
Take a detailed history of respiratory symptoms :
Start from before the diagnosis of asthma was made.
For children, start from birth.
Ask about :
Symptoms :
Types and descriptions (e.g., wheeze, breathlessness, chest tightness, cough).
Factors that worsen or improve asthma :
Triggers such as exercise, cold air, irritants, medicines (e.g., aspirin, beta-blockers), allergens, viral infections, and laughter.
Medical history :
Previous respiratory conditions, history of allergies (e.g., allergic rhinitis, atopic dermatitis), family history of asthma or allergies.
Medications :
Current and past medications, including over-the-counter and complementary medicines.
Confirming Diagnosis
For patients with a typical pattern of respiratory symptoms :
Review documentation of demonstrated variable expiratory airflow limitation :
Check previous spirometry results showing variability in FEV1.
Identify and investigate any signs and symptoms that could suggest an alternative diagnosis :
Consider differential diagnoses such as COPD, heart disease, pulmonary hypertension, etc.
Likelihood of Asthma
Asthma More Likely
Criteria Details Symptoms More than one of wheeze, breathlessness, chest tightness, cough Symptom Pattern Recurrent or seasonal, worse at night or early morning History of Allergies Allergic rhinitis, atopic dermatitis Triggers Exercise, cold air, irritants, medicines (aspirin, beta-blockers), allergies, viral infections, laughter Family History Asthma or allergies Onset Symptoms began in childhood Physical Exam Widespread wheeze audible on chest auscultation Spirometry FEV1 or PEF lower than predicted without other explanation Blood Tests Eosinophilia or raised blood IgE level without other explanation Response to Treatment Symptoms rapidly relieved by a SABA bronchodilator
Asthma Less Likely
Criteria Details Symptoms Dizziness, light-headedness, peripheral tingling, isolated cough with no other respiratory symptoms Chronic Sputum Production Persistent mucus production Physical Exam No abnormalities on chest examination when symptomatic (over several visits) Voice Change in voice Symptom Pattern Symptoms only present during upper respiratory tract infections Smoking History Heavy smoker (current or past) Cardiovascular Disease History of heart conditions Spirometry Normal spirometry or PEF when symptomatic (despite repeated tests)
Differential Diagnoses or Comorbidities
Dyspnoea Prominent
Criteria Possible Diagnoses Obesity and inactivity Deconditioning Respiratory Diseases COPD, Alpha-1 antitrypsin deficiency, Interstitial lung disease, Bronchiolitis obliterans, Lung cancer Cardiovascular Diseases Heart disease, Pulmonary hypertension Airway Conditions Central airway stenosis, Tracheobronchomalacia, Tracheal stricture Other Pulmonary embolism
Cough Prominent
Criteria Possible Diagnoses Upper airway dysfunction Upper airway cough syndrome Adverse Drug Reaction ACE inhibitors, beta-blockers Respiratory Diseases Bronchiolitis obliterans, Lung cancer, Herpetic tracheobronchitis Airway Conditions Tracheal stricture
Chronic Sputum Production
Criteria Possible Diagnoses Respiratory Diseases COPD, Bronchiectasis, Allergic bronchopulmonary aspergillosis, Cystic fibrosis
History of Exposure to Tobacco Smoke/Biomass Fuels
Criteria Possible Diagnoses Respiratory Diseases COPD, Lung cancer
Dizziness or Lightheadedness
Criteria Possible Diagnoses Breathing Patterns Dysfunctional breathing/hyperventilation syndrome Heart Conditions Tachyarrhythmias
Sudden-Onset Symptoms
Criteria Possible Diagnoses Respiratory Conditions Vocal cord dysfunction (paradoxical vocal cord movement), Pulmonary embolism Psychological Conditions Panic attacks with hyperventilation
Irritative Triggers, Tightness in Upper Chest/Neck, Dysphonia
Criteria Possible Diagnoses Respiratory Conditions Vocal cord dysfunction (paradoxical vocal cord movement)
Symptoms Triggered by Food or Posture
Criteria Possible Diagnoses Gastrointestinal Conditions Symptomatic gastro-oesophageal reflux disease
Night Waking
Criteria Possible Diagnoses Sleep Disorders Obstructive sleep apnoea Gastrointestinal Conditions Symptomatic gastro-oesophageal reflux disease Heart Conditions Heart failure
Chest Crackles
Criteria Possible Diagnoses Respiratory Diseases Bronchiectasis, Interstitial lung disease, Hypersensitivity pneumonitis Heart Conditions Heart failure
Respiratory Symptoms with Sinusitis and/or Nasal Polyposis
Criteria Possible Diagnoses Respiratory Conditions Eosinophilic granulomatosis with polyangiitis (Churg–Strauss syndrome), Aspirin-exacerbated respiratory disease
Respiratory Symptoms with Gastrointestinal Symptoms
Criteria Possible Diagnoses Genetic Disorders Cystic fibrosis Blood Conditions Hypereosinophilic syndrome
Onset Related to Menstrual Cycle
Criteria Possible Diagnoses Respiratory Conditions Premenstrual (catamenial) asthma
Eosinophilia
Criteria Possible Diagnoses Respiratory Diseases Chronic eosinophilic pneumonia, Eosinophilic granulomatosis with polyangiitis (Churg–Strauss syndrome), Hypereosinophilic syndrome, Hypersensitivity pneumonia Infections Parasitic infection
Additional Notes
Topic Details Upper airway dysfunction Often mimics asthma, can cause severe acute dyspnoea, confirmed by direct observation of vocal cords Chronic cough Chronic cough (lasting >8 weeks) without other asthma symptoms unlikely to indicate asthma; may be due to protracted bacterial bronchitis, post-viral cough, or pollutants
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.
Respiratory Expert Group, Therapeutic Guidelines Limited. Therapeutic Guidelines: Respiratory, Version 4. Therapeutic Guidelines Limited, Melbourne, 2009.
Israel E, Reddel HK. Severe and difficult-to-treat asthma in adults. N Engl J Med. 2017; 377: 965-976.
Chung KF, Wenzel SE, Brozek JL, et al. International ERS/ATS guidelines on definition, evaluation, and treatment of severe asthma. Eur Respir J. 2014; 43: 343-73.
Maltby S, Gibson P, Mattes J, McDonald V. How to treat severe asthma. Part 1. Diagnosis. Australian Doctor 2016; September.
Papi A, Brightling C, Pedersen SE, Reddel HK. Asthma. Lancet. 2018; 391: 783-800.
FitzGerald JM, Lemiere C, Lougheed MD, et al. Recognition and management of severe asthma: a Canadian Thoracic Society position statement. Can J Respir Crit Care Med. 2017; 1: 199-221.
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