asthma
ASTHMA
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 and coughing are common in children especially ages <3 years
  • Diagnosis is based primarily on clinical judgment, evaluation of symptoms and physical findings
  • There are symptoms highly suggestive of asthma
    • Recurrent wheezing
    • 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 and inhaled glucocorticosteroids may help confirm the diagnosis in this age group
  • Please see Asthma disease management chart in the latest edition of MIMS Pediatrics for further information

Pregnancy

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

Elderly

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

Occupational Asthma

  • Asthma acquired in the workplace and is usually caused by inhalant chemicals (eg isocyanates, platinum salts, complex plant and animal biological products)
  • Diagnosis is successfully confirmed with lung function measurement, particularly serial measurement of PEF at work and away from work, and 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 and 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, and normal lung function: Withholding the BD treatment before repeating BD reversibility test
      •  If patient develops symptoms and lung function worsens after withdrawal of treatments, diagnosis is confirmed
      •  If there is absence of symptoms and 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 and further management

Differential Diagnosis

  • When symptoms are not typical with asthma and lung function does not support asthma, consider other diagnosis
  • Failure to respond to asthma treatment should prompt search for an alternative or additional diagnosis
  • Asthma symptoms are nonspecific and are shared with other diseases
    • Aspiration
    • Bronchiectasis
    • Cardiac disease
    • Vocal cord dysfunction
    • CF
    • COPD
    • Foreign body
    • Pulmonary embolism
    • Hyperventilation syndrome and panic attacks
    • Interstitial lung disease
    • Tumor: laryngeal, lung, tracheal
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