Asthma is a chronic inflammatory disease of the airways in the lungs of children and adults.
The patient usually complains of shortness of breath, chest tightness and coughing with wheezing.
Goals of treatment are effective symptom control with minimal or no exacerbations, minimal or no nocturnal and daytime symptoms, no limitations on activities, minimal or no need for reliever treatment, and minimal adverse effects of medication.

Differential Diagnosis

Difficult Diagnostic Groups

  • May require specialist referral

Children ≤5 years old

  • Episodic wheezing & coughing are common in children especially ages <3 years
  • Diagnosis is based primarily on clinical judgment, evaluation of symptoms & physical findings
  • There are symptoms highly suggestive of asthma
    • Wheezing more than once a month
    • Nocturnal cough not associated with a viral infection
    • Wheeze that do not vary seasonally
    • Presence of symptoms after 3 years old
  • Trial of treatment with short-acting bronchodilators & inhaled glucocorticosteroids may help confirm the diagnosis in this age group
  • Please refer to the Asthma Management Chart in the latest edition of MIMS Pediatrics


  • Pregnant asthmatics should be treated the same way as nonpregnant adults w/ exacerbations


  • Wheezing, breathlessness, & cough are sometimes cardiac in etiology
    • Thorough history & physical exam, together with electrocardiogram (ECG) & chest x-ray may help distinguish a cardiac pathology
  • COPD should be differentiated from asthma by trial of treatment with bronchodilators &/or inhaled glucocorticosteroids

Occupational Asthma

  • Asthma acquired in the workplace & is usually caused by inhalant chemicals (eg isocyanates, platinum salts, complex plant & animal biological products)
  • Diagnosis is successfully confirmed w/ lung function measurement, particularly serial measurement of PEF at work & away from work, & specific bronchial provocation testing

Seasonal Asthma

  • May occur intermittently with the patient being entirely asymptomatic between seasons or may occur as a seasonal worsening of symptoms in an asthmatic patient

Cough Variant Asthma

  • Has the principal symptom of chronic cough frequently during the night
  • Documentation of variability in lung function or of airway hyperresponsiveness & search for sputum eosinophilia are important for possible diagnosis

Patients on Controller Treatment

  • For patients currently taking controller treatments but have not been previously documented, confirming the diagnosis is based on the following:
    • Presence of variable respiratory symptoms with variable airflow limitation confirms asthma
    • For patients with variable respiratory symptoms without variable airflow limitation, BD reversibility test should be repeated after withholding bronchodilator treatments
      • May indicate that controller treatment may need to be reassessed
    •  Few respiratory symptoms, no variable airflow limitation, & normal lung function: withholding the BD treatment before repeating BD reversibility test
      •  If patient develops symptoms & lung function worsens after withdrawal of treatments, diagnosis is confirmed
      •  If there is absence of symptoms & lung function remains the same after withdrawal of treatment, cessation of controller treatments may be done
    •  Presence of dyspnea with fixed airflow limitation may indicate the need to reassess treatment regimen & further management

Specialist Referral is Recommended in the Following:

  • Patient had life-threatening asthma exacerbation
  • Atypical clinical findings, eg clubbing, crackles, cyanosis, heart failure (HF), stridor, hemoptysis; & children with abnormal voice or cry, dysphagia, focal signs in the chest, inspiratory stridor
  • Excessive vomiting or possetting in children
  • Persistent cough &/or sputum production; & children with persistent productive cough despite proper inhaler technique & good treatment adherence
  • Persistent SOB (not episodic & without associated wheeze)
  • Spirometry or PEF findings do not indicate asthma & requires additional testing (skin allergy testing, provocative challenge test)
  • Symptoms present from birth or perinatal lung problem & has family history of unusual chest disease
  • Unilateral or fixed wheeze
  • Weight loss
  • Patient is not responding to therapy after 3-6 months, needs step >4 care, or being considered for immunotherapy

Differential Diagnosis

  • Failure to respond to asthma treatment should prompt search for an alternative or additional diagnosis
  • Asthma symptoms are nonspecific & are shared with other diseases
    • Aspiration
    • Bronchiectasis
    • Cardiac disease
    • Vocal cord dysfunction
    • CF
    • COPD
    • Foreign body
    • Pulmonary emboli
    • Hyperventilation syndrome & panic attacks
    • Interstitial lung disease
    • Tumor: laryngeal, lung, tracheal
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Stephen Padilla, 21 Nov 2018
Use of triple therapy consisting of a long acting muscarinic antagonist (LAMA), long acting β agonist (LABA) and inhaled corticosteroid (ICS) leads to a reduced rate of moderate or severe exacerbations of chronic obstructive pulmonary disease (COPD) and better lung function and health-related quality of life compared with dual therapy (ICS and LABA or LAMA and LABA) or LAMA monotherapy, according to the results of a meta-analysis.