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Asthma - Initial Diagnosis

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Overview

Initial diagnosis focuses on history and physical exam findings, spirometry, and exclusion of other diagnoses. Key symptoms for the diagnosis include: (note that, in patients over 5 years of age, spirometry is essential to establish the diagnosis and that none of these symptoms, even wheezing, are necessary for a diagnosis of asthma).
  • Wheezing
  • History of:
    • Cough, particularly at night
    • Recurrent wheeze
    • Recurrent difficulty in breathing
    • Recurrent chest tightness
  • Symptoms occur or worsen in the presence of:
    • Exercise
    • Viral infection
    • Inhalant allergens (e.g., animals with fur or hair, house-dust mites, mold, pollen)
    • Irritants (tobacco or wood smoke, airborne chemicals)
    • Changes in weather
    • Strong emotional expression (laughing or crying hard)
    • Stress
    • Menstrual cycles
  • Symptoms occur or worsen at night, awakening the patient

Diagnostic Criteria

There are three general criteria for the diagnosis of asthma, including:
  1. symptoms of recurrent airway obstruction or airway hyperresponsiveness,
  2. symptoms are at least partially reversible, and
  3. alternative diagnoses have been excluded.

These criteria are determined by a detailed history and physical and spirometry testing. Spirometry, required by criterion 2, cannot be reliably performed in children who are younger than 5 years of age. Younger children should be given a provisional diagnosis of asthma and treated appropriately, but the diagnosis should be frequently reassessed to avoid prolonged, unnecessary treatment in a child who doesn't really have asthma.

Pearls And Alerts

Cough variant asthma, relatively common in young children, involves cough that is responsive to asthma therapy but no wheezing. See Cough variant asthma for more detail.

For infants and children too young for spirometry, the diagnosis of asthma can be challenging. Wheezing can be treated without labeling the child as having asthma until they get older and the diagnosis becomes more certain. See Asthma in young children (< 5 years) for more information.

Practice Guidelines

National Asthma Education and Prevention Program Expert Panel.
Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma - Summary Report 2007.
National Institutes of Health: National Heart, Lung, and Blood Institute; (2007) http://www.nhlbi.nih.gov/guidelines/asthma/asthsumm.htm. Accessed on 3/31/08.

National Heart Lung Blood Institute.
Expert Guidelines for the Diagnosis and Management of Asthma.
NIH; (2007) http://www.nhlbi.nih.gov/guidelines/asthma/.

Differential Diagnosis

Symptoms of asthma do not necessarily mean a diagnosis of asthma. Wheezing, especially, may occur due to other conditions. The following differential diagnosis is from the NHLBI Guidelines. [National: 2007]
  • Upper airway disease
  • Allergic rhinitis and sinusitis
  • Obstructions involving large airways
  • Foreign body in trachea or bronchus
  • Vocal cord dysfunction (VCD)
  • Vascular rings or laryngeal webs
  • Laryngotracheomalacia, tracheal stenosis, or bronchostenosis
  • Enlarged lymph nodes or tumor
  • Obstructions involving small airways
  • Viral bronchiolitis
  • Cystic fibrosis
  • Bronchopulmonary dysplasia
  • Heart disease
  • Other causes
    • Recurrent cough, not due to asthma
    • Aspiration from swallowing mechanism dysfunction or gastroesophageal reflux
If wheezing does not respond to treatment with medications to reverse airflow obstruction, additional studies may be needed to identify other causes (e.g., additional pulmonary function studies looking for restrictive defects, referral for broncho-provocation if there is still a strong clinical suspicion of asthma, or chest imaging).

History And Examination

For a list of key questions in the diagnosis of asthma, click Questions for initial history in children with asthma (2007 NHLBI Guidelines) (PDF Document 57 KB)

Family History

History of asthma, allergy, sinusitis, rhinitis, eczema, or nasal polyps.

Pregnancy/Perinatal History

Premature delivery and subsequent respiratory complications may be relevant.

Medical History

Current symptoms, including cough, wheezing, shortness of breath, chest tightness, sputum production.

Pattern of symptoms, including perennial, seasonal, or both, continual, episodic, or both, onset, duration, frequency, diurnal variations, especially nocturnal and on awakening.

Precipitating and/or aggravating factors, including symptoms of comorbid conditions such as reflux, viral exposures, allergens, home characteristics, etc.

Development of disease and treatment, including age at onset, progression of disease, present management and response, including plans for managing exacerbations, frequency of using short-acting beta2-agonist (SABA, oral corticosteroid use).

History of exacerbations, including usual prodromal signs and symptoms, rapidity of onset, duration, frequency, severity (need for urgent or emergent care, hospitalization, intensive care unit (ICU) admission), life-threatening exacerbations, number and severity of exacerbations in the past year, usual patterns and management (what works?).

Social and Family History

Social history, including daycare and school, that may interfere with adherence; social support/social networks.

Impact of asthma on patient and family, including episodes of unscheduled care (emergency department (ED), urgent care, hospitalization), number of days missed from school/work; limitation of activity, especially sports and strenuous work; history of nocturnal awakening; effect on growth, development, behavior, school or work performance, and lifestyle; impact on family routines, activities, or dynamics; and economic impact.

Patient's and family's perceptions of disease, including knowledge of asthma and treatment, perception and beliefs regarding use and long-term effects of medications; ability of patient and parents to cope with disease; level of family support and patient's and parents' capacity to recognize severity of an exacerbation; economic resources; and sociocultural beliefs.

Physical Exam

Vital Signs

RR | HR | BP (medications may cause elevation), pulsus paradoxus if asthma symptoms present

Growth Parameters

height and weight (current and patterns of gain) for evidence of other chronic underlying disease (e.g. cystic fibrosis), effect of medications, obesity (which might complicate asthma)

HEENT

evidence of allergy (periorbital swelling, conjunctival injection or edema, nasal discharge, nasal polyps, pale or swollen nasal turbinates, Denny's lines, mouth breathing), sinusitis, otitis media or effusion

Chest

evidence of accessory muscle use (tracheal tugging, intercostals retractions, nostril flaring, increased abdominal movement), sounds of expiratory wheezing with normal breathing or with forced expiration, hyperexpansion of the thorax, hunched shoulders

Skin

evidence of atopy/eczema

Extremities

cyanosis, clubbing (suggests other diagnoses, particularly cystic fibrosis)

Testing

Laboratory Testing

Allergy testing may be helpful to confirm allergies as a trigger, as a cause of related symptoms, or to guide avoidance or immuno-therapy.

Imaging and EEG

Chest x-rays or other imaging may be useful to rule out other diagnoses, such as aspirated foreign body, tracheal ring, pneumonia, or congestive heart failure. Though chest x-ray cannot be relied upon to make or rule out the diagnosis, findings associated with asthma include: hyperaeration, flattened diaphragms, and bronchiolar thickening. Sinus imaging may be helpful if chronic sinusitis is suspected.

Genetic Testing

Although there is a genetic susceptibility to asthma (See Asthma, Causes), specific genetic causes have not been identified and testing is not currently available.

Other Testing

Spirometry - (See Services) should be performed in children 5 and older to assess airflow obstruction and reversibility with treatment. For children younger than 5, see Asthma in young children (< 5 years). In children with asthma, airflow obstruction should be present and it should be reversible within 15-20 min after inhalation of a short acting bronchodilator. Airflow obstruction is measured by comparing the forced expiratory volume in 1 second (FEV1) and the FEV1 to Functional Vital Capacity (FVC) ratio to normal values for age. Reversibility is shown by an increase in FEV1 by 12% or a 200 ml increase. For more information see Asthma spirometry basics (getasthmahelp.org) (PDF Document 219 KB) .

Peak flow measurements - after initial diagnosis, peak flow measurements can be used to monitor response to treatment over time. It is quick, easy, and inexpensive and, with practice, can be sufficiently reliable to guide daily therapy or as an in-office assessment tool (see Ongoing Assessment page).

Subspecialist Collaborations and Other Resources

Pediatric Pulmonology (see Services below for relevant providers)

For further testing or consultation and/or management.

Pulmonary Function Testing (see Services below for relevant providers)

For spirometry if not available in your office. Additional testing may be indicated for some patients, often guided by a pediatric pulmonologist.

Pediatric Allergy (see Services below for relevant providers)

For assessment of allergy contributions to asthma as well as asthma management.

Resources

Practice Guidelines

National Asthma Education and Prevention Program Expert Panel.
Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma - Summary Report 2007.
National Institutes of Health: National Heart, Lung, and Blood Institute; (2007) http://www.nhlbi.nih.gov/guidelines/asthma/asthsumm.htm. Accessed on 3/31/08.

National Heart Lung Blood Institute.
Expert Guidelines for the Diagnosis and Management of Asthma.
NIH; (2007) http://www.nhlbi.nih.gov/guidelines/asthma/.

Tools

Questions for initial history in children with asthma (2007 NHLBI Guidelines) (PDF Document 57 KB)
Asthma history questions for the initial assessment of a patient with asthma. From the 2007 NHLBI Guidelines for Asthma Diagnosis and Management

Services

Pediatric Allergy

See all Pediatric Allergy services providers (7) in our database.

Pediatric Pulmonology

Pediatric Asthma Program, more info...
100 N Mario Capecchi Dr
Salt Lake City, UT 84103
Phone: 801-662-1765
http://intermountainhealthcare.org/xp/public/primary/docsclinics/clinics/asthma.xml

See all Pediatric Pulmonology services providers (5) in our database.

Pulmonary Function Testing

See all Pulmonary Function Testing services providers (38) in our database.

For other services related to this condition, browse our Services categories or search our database.

Helpful Articles

National Asthma Education and Prevention Program Expert Panel.
Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma - Summary Report 2007.
National Institutes of Health: National Heart, Lung, and Blood Institute; (2007) http://www.nhlbi.nih.gov/guidelines/asthma/asthsumm.htm. Accessed on 3/31/08.

Authors

Lead Author: Lynne M Kerr MD, PhD, 3/2008
Reviewing Author: Derek Uchida MD, 3/2008
Content Last Updated: 3/2008

Page Bibliography

National Asthma Education and Prevention Program Expert Panel.
Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma - Summary Report 2007.
National Institutes of Health: National Heart, Lung, and Blood Institute; (2007) http://www.nhlbi.nih.gov/guidelines/asthma/asthsumm.htm. Accessed on 3/31/08.