Clinical processes and considerations for diagnosing ... · including initial investigations,...

Clinical processes and considerations for diagnosing asthma in children, including initial investigations, differential diagnosis and further investigations

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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

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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

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HOME > DIAGNOSIS > CHILDREN

Diagnosing asthma in children

Overview

A clinical definition of asthma in children

Asthma is defined clinically as the combination of variable respiratory symptoms (e.g. wheeze, shortness of breath, cough

and chest tightness) and excessive variation in lung function, i.e. variation in expiratory airflow that is greater than that

seen in healthy children (‘variable airflow limitation’).

See: A working definition of asthma

There is no single reliable test (‘gold standard’) and there are no standardised diagnostic criteria for asthma.

The clinical diagnosis of asthma in children involves the consideration of:

• history of recurrent or persistent wheeze

• presence of allergies or family history of asthma and allergies

• absence of physical findings that suggest an alternative diagnosis

• tests that support the diagnosis (e.g. spirometry in children able to perform the test)

• a consistent clinical response to an inhaled bronchodilator or preventer.

Figure: Steps in the diagnosis of asthma in children

Please view and print this figure separately: https://www.asthmahandbook.org.au/figure/show/17

It can be difficult to diagnose asthma with certainty in children aged 0–5 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

3

HOME > DIAGNOSIS > CHILDREN > INITIAL INVESTIGATIONS

Investigating asthma-like symptoms in children

In this section

History and physical examination

Lung function

4

HOME > DIAGNOSIS > CHILDREN > INITIAL INVESTIGATIONS > HISTORY AND PHYSICAL EXAMINATION

Taking a history and performing a physical examination to

investigate asthma-like symptoms in children

Recommendations

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:

• If possible, see the child during a bout of ‘wheezing’.

• Ask parents to make an audio or video recording of noisy breathing (e.g. on phone).

• Show parents a video of true wheezing and ask them whether signs match their child.

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 child’s 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.

Conduct a general physical examination, including:

• height and weight compared with normal range for age

• inspection of chest for deformity

How this recommendation was developed

ConsensusBased on clinical experience and expert opinion (informed by evidence, where available).

s


Consensus

Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference

to the following source(s):

• Brand et al. 20081

• Global Initiative for Asthma (GINA), 20092

• Weinberger and Abu-Hasan, 20073

s


Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

s

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.

Table. Findings that require investigations in children

Finding Notes

Persistent cough that is not associated with

wheeze/breathlessness or systemic disease

Unlikely to be due to asthma

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

rhinitis, enlarged tonsils and adenoids or nasal polyps)

Specialist assessment should be considered

Crepitations on chest auscultation that do not clear on

coughing

Suggest a serious lower respiratory tract condition

such as pneumonia, atelectasis, bronchiectasis

Unilateral wheeze Suggests inhaled foreign body

Systemic symptoms (e.g. fever, weight loss, failure to

thrive)

Suggest an alternative systemic disorder

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)

Persistent voice abnormality Suggests upper airway disorder

Finger clubbing Suggests cystic fibrosis, bronchiectasis

Chronic (>4 weeks) wet or productive cough Suggests cystic fibrosis, bronchiectasis, chronic

bronchitis, recurrent aspiration, immune

abnormality, ciliary dyskinesia


Consensus


s

6

Finding Notes

Focal (localised) lung signs Suggests pneumonia

Nasal polyps in child under 5 years old Suggests cystic fibrosis

Severe chest deformity Harrison’s Sulcus and Pectus Carinatum can be due

to uncontrolled asthma, but severe deformity

suggests an alternative diagnosis

Obvious breathing difficulty, especially at rest or at

night


Recurrent pneumonia Specialist assessment should be considered

Asset ID: 59

More information

Definition of wheeze

Wheeze is defined as a continuous, high-pitched sound coming from the chest during expiration.1, 2

It 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).

Inspiratory sounds (e.g. rattling or stridor) should not be described as ‘wheeze’.3

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

Significance of wheeze in children 0–5 years

Approximately one in three children has at least one episode of wheezing before their third birthday,1

and almost half of

all children have at least one episode of wheezing by age 6 years.1


Consensus



• Weinberger and Abu-Hasan, 20073

• Gibson et al. 2010 4

s

7

Wheezing is the most common symptom associated with asthma in children aged 5 years and under.2

Among 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 1–5 years is usually associated with viral upper respiratory tract infections, which recur

frequently in this age group.1, 2

Many 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

Asthma versus wheezing disorder in children 0–5 years

Although many individuals later diagnosed with asthma first show respiratory symptoms by the age of 5 years,1

it is

difficult to make the diagnosis of ‘asthma’ with a high degree of certainty in a baby or preschool child.

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

Classification of symptom patterns in children

The pattern and severity of symptoms in a child with asthma or wheezing disorder is a guide to initial treatment.

Table. Definitions of asthma patterns in children aged 0–5 years not taking regular preventer

Category Pattern and intensity of symptoms (when not taking regular

treatment)

Infrequent intermittent asthma Symptom-free for at least 6 weeks at a time (flare-ups up to

once every 6 weeks on average but no symptoms between

flare-ups)

Frequent intermittent asthma Flare-ups more than once every 6 weeks on average but no

symptoms between flare-ups

Persistent asthma Mild At least one of:

• Daytime symptoms†

more than once per week but not

every day

• Night-time symptoms†

more than twice per month but not

every week

Moderate Any of:


daily


more than once per week

8


treatment)

• Symptoms sometimes restrict activity or sleep

Severe Any of:


continual


frequent

• 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 of other 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


treatment)

Infrequent intermittent asthma † Symptom-free for at least 6 weeks at a time (flare-ups up to


flare-ups)



Persistent asthma Mild FEV1 ≥80% predicted and at least one of:

• Daytime symptoms‡


every day

• Night-time symptoms‡


every week

Moderate Any of:

• FEV1 <80% predicted‡


daily



9


treatment)


Severe Any of:

• FEV1 ≤60% predicted‡


continual


frequent



† 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.




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.

Short-term and long-term wheezing patterns in children: 0–5 years

Patterns of childhood wheezing over the short termClassifying a child’s current pattern of symptoms can be useful for making immediate management decisions. The

following descriptions of wheezing patterns apply to the pattern of symptoms in children aged 0–5 years and are

sometimes used in clinical trials:

Episodic (viral) wheeze: episodes of wheezing (e.g. for a few days when child has a viral cold), but no wheezing between

episodes.1, 2

Multiple-trigger wheeze: episodes of wheezing from time to time, with cough and wheeze between episodes when child

does not have a viral cold (e.g. when the child cries, plays or laughs).1, 2

However, these patterns are not stable over time and have limited use in predicting whether or not a wheezing preschool

child will have asthma by primary school age.6, 7

An individual child is likely to show a different pattern within one year.6

Patterns of childhood wheezing over the long term

Longitudinal population-based cohort studies8, 9

of preschool children with wheezing have identified various long-term

patterns (wheezing phenotypes).1

Table. Systems for retrospectively classifying the duration of childhood wheeze

Classification

system/source

Phenotypes

identified

Description

Transient wheeze Wheezing commences before the age of 3 years and disappear

by age 6 years

10

Classification

system/source

Phenotypes

identified

Description

Tucson Children’s

Respiratory Study †

‡

Persistent wheeze Wheezing continues until up to or after age 6 years

Late-onset wheeze Wheezing starts after age 3 years.

Avon Longitudinal

Study of Parents

and Children §

Transient early

wheeze

Wheezing mainly occurs before 18 months, then mainly

disappears by age 3.5 years

Not associated with hypersensitivity to airborne allergens

Prolonged early

wheeze

Wheezing occurs mainly between age 6 months and 4.5 years,

then mainly disappears before child’s 6th birthday


Associated with a higher risk of airway hyperresponsiveness

and reduced lung function at age 8–9 years, compared with

never/infrequent wheeze phenotype

Intermediate-onset

wheeze

Wheezing begins sometime after age 18 months and before

3.5 years.

Strongly associated with atopy (especially house mite, cat

allergen), higher risk of airway hyperresponsiveness and

reduced lung function at age 8–9 years, compared with


Late-onset wheeze Wheezing mainly begins after age 3.5 years


allergen, grass pollen)

Persistent wheeze Wheezing mainly begins after 6 months and continues through

to primary school

Strongly associated with atopy

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

'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.

• Over-reliance on these devices could result in over- or under-treatment.

Cough and asthma in children

Relationship of cough to asthma in children

• Misdiagnosis of nonspecific cough as asthma can result in overtreatment in children.

• Cough can indicate the possibility of a serious underlying illness and warrant further assessment and investigations.4

Table. Red flags for cough in children

Wet or productive cough lasting more than 4 weeks

Obvious difficulty breathing, especially at rest or at night

Systemic symptoms: fever, failure to thrive or poor growth velocity

Feeding difficulties (including choking or vomiting)

Recurrent pneumonia

Inspiratory stridor (other than during acute tracheobronchitis)

Abnormalities on respiratory examination

Abnormal findings on chest X-ray

‘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

Go to: National Asthma Council Australia's Asthma and wheezing in the first years of life information paper

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.10

A 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 cough is most likely:4

• due to protracted bacterial bronchitis (resolves with 2–6 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 preventers such as montelukast, cromones or

inhaled corticosteroids.

• Children attending day care or preschool can have a succession of viral infections that merge into each other,11

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).4

Alternative diagnoses in children

Other conditions characterised by wheezing, breathlessness or cough can be confused with asthma. These include:

• protracted bacterial bronchitis4, 12

• habit-cough syndrome4

• upper airway dysfunction.3

Table. Conditions that can be confused with asthma in children

Conditions characterised by cough

Pertussis (whooping cough)

Cystic fibrosis

Airway abnormalities (e.g. tracheomalacia, bronchomalacia)

Protracted bacterial bronchitis in young children

Habit-cough syndrome

Conditions characterised by wheezing

Upper airway dysfunction

Go to: Australian Cough Guidelines

13


Inhaled foreign body causing partial airway obstruction

Tracheomalacia

Conditions characterised by difficulty breathing

Hyperventilation

Anxiety

Breathlessness on exertion due to poor cardiopulmonary fitness

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

Table. Findings that increase or decrease the probability of asthma in children

Asthma more likely Asthma less likely

More than one of:

• wheeze

• difficulty breathing

• feeling of tightness in the chest

• cough

Any of:

• symptoms only occur when child has a cold, but

not between colds

• isolated cough in the absence of wheeze or

difficulty breathing

• history of moist cough

• dizziness, light-headedness or peripheral

tingling

• repeatedly normal physical examination of

chest when symptomatic

• normal spirometry when symptomatic (children

old enough to perform spirometry)

• no response to a trial of asthma treatment

• clinical features that suggest an alternative

diagnosis

AND

Any of:

• symptoms recur frequently

• symptoms worse at night and in the early

morning

• symptoms triggered by exercise, exposure to

pets, cold air, damp air, emotions, laughing

• symptoms occur when child doesn’t have a cold

• history of allergies (e.g. allergic rhinitis, atopic

dermatitis)

• family history of allergies

• family history of asthma

• widespread wheeze heard on auscultation

• symptoms respond to treatment trial of

reliever, with or without a preventer

• lung function measured by spirometry increases

in response to rapid-acting bronchodilator

14



in response to a treatment trial with inhaled

corticosteroid (where indicated)

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. Available from: 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

Relationship of allergies to asthma

A history of other atopic conditions (e.g. eczema and rhinitis) increases the probability of asthma in wheezing children.13

A family history of asthma or allergies in a first-degree relative is a risk factor for atopy and asthma in

children.13, 2

Maternal atopy is most strongly associated with childhood onset of asthma and for recurrent wheezing that

persists throughout childhood.13

Diagnostic difficulties when investigating asthma-like symptoms in adolescents

Asthma is commonly misdiagnosed in young people presenting with exercise-related symptoms or cough.14

Conditions

associated with dyspnoea include hyperventilation, anxiety, and poor cardiopulmonary fitness.3

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

Confidentiality issues for adolescents

Adolescents’ concerns about confidentiality prevent them using health care services, especially if substance use is likely to

be raised. Adolescents are more likely to disclose information about health risk behaviours, and are more likely to return

for review, if they know that confidential information will not be revealed to their parents or others.16

When adolescents are accompanied by parents or carers, health care providers should consider seeing the adolescent

alone for part of each consultation.16

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


See: Allergies and asthma

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 include poor 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;


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:


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:


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:


10. van Asperen PP. Cough and asthma. Paediatr Resp Rev. 2006; 7: 26-30. Available from:


11. Bush A. Diagnosis of asthma in children under five. Prim Care Respir J. 2007; 16: 7-15. Available from:


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.


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:


16. The Royal Australasian College of Physicians Joint Adolescent Health Committee. Confidential Health Care for

Adolescents and Young People (12–24 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

See: Investigation and management of exercise-induced bronchoconstriction

16

HOME > DIAGNOSIS > CHILDREN > INITIAL INVESTIGATIONS > LUNG FUNCTION

Assessing lung function in children 6 years and over

Recommendations

In children able to perform spirometry, measure bronchodilator reversibility by performing spirometry before and after

giving inhaled rapid-onset beta2 agonist bronchodilator (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 4–5 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 that airflow limitation is reversible and supports the diagnosis of asthma. In children with

asthma, it is also predictive of a good lung function response to inhaled corticosteroids.1

However, an absent response to

bronchodilators does not exclude asthma.1


Consensus


s


Consensus


s

Go to: National Asthma Council Australia’s Spirometry Resources

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 a few weeks before challenge

testing, because these could invalidate the result.

Bronchial provocation tests of airway hyperresponsiveness include:

• exercise challenge test5

• mannitol challenge test6, 7

• methacholine challenge test.8, 9

Roles of other lung function tests in diagnosing asthma in children

Peak expiratory flow meters in asthma diagnosisVariability in lung function based on serial home measures of peak expiratory flow and FEV1 shows poor concordance

with disease activity in children.1

Using a peak flow meter to measure peak expiratory flow in children does not reliably rule the diagnosis of asthma in or

out.1

Newer tests under investigation

Impulse oscillometry, tests of specific airways resistance, and measurements of residual volume are being investigated for

use in asthma diagnosis and management,10, 11

but their availability is mainly restricted to specialist and research centres.1

References




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:


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

19

HOME > DIAGNOSIS > CHILDREN > ALTERNATIVE DIAGNOSES

Considering alternative diagnoses in children

Recommendations

Consider features that increase or reduce the probability of asthma.



More than one of:

• wheeze



• cough

Any of:


not between colds





tingling







diagnosis

AND

Any of:



morning





dermatitis)











Sources

20






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 cough can result in overtreatment in children.

If cough is a prominent symptom, investigate according to the current Australian Cough Guidelines.

Consider the following alternative diagnoses before making a clinical diagnosis of asthma:

• 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.



Consensus



• British Thoracic Society, Scottish Intercollegiate Guidelines Network, 2012 1

• Respiratory Expert Group Therapeutic Guidelines Limited, 2009 2

s


Adapted from existing guidance

Based on reliable clinical practice guideline(s) or position statement(s):


s






s

21



Cystic fibrosis







Tracheomalacia


Hyperventilation

Anxiety


Source



Asset ID: 11

More information









Noisy breathing is







so wheezing is best



Consensus


s

22





and almost half of



Among people with





airways




have asthma5








treatment)



flare-ups)






every day



every week

Moderate Any of:


daily




23


treatment)

Severe Any of:


continual


frequent











Asset ID: 14



treatment)



flare-ups)






every day



every week

Moderate Any of:



daily




24


treatment)

Severe Any of:



continual


frequent









Asset ID: 15








episodes.4, 5











Classification

system/source

Phenotypes

identified

Description

Tucson Children’s


‡


by age 6 years



25

Classification

system/source

Phenotypes

identified

Description

Avon Longitudinal

Study of Parents

and Children §

Transient early

wheeze




Prolonged early

wheeze







Intermediate-onset

wheeze


3.5 years.









to primary school


Notes


preschool child.


Sources













Asset ID: 10

26


retrospectively.4















Recurrent pneumonia





Source




Asset ID: 13







This diagnosis should be only made in

consultation with a paediatric respiratory physician.








0-5 years


27






giving




6 years and over




Alternative diagnoses in children

Other conditions characterised by wheezing, breathlessness or cough can be confused with asthma. These include:

• protracted bacterial bronchitis3, 14

• habit-cough syndrome3

• upper airway dysfunction.6




Cystic fibrosis







Tracheomalacia


Hyperventilation

Anxiety


Source




28

Asset ID: 11



More than one of:

• wheeze



• cough

Any of:


not between colds





tingling







diagnosis

AND

Any of:



morning





dermatitis)











Sources






Asset ID: 12

Diagnostic difficulties when investigating asthma-like symptoms in adolescents


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

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.1

For adolescents with exercise-related symptoms, common conditions that should be considered in the differential

diagnosis include poor cardiopulmonary fitness, exercise-induced upper airway dysfunction and exercise-induced

hyperventilation.15, 17

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




2. Respiratory Expert Group, Therapeutic Guidelines Limited. Therapeutic Guidelines: Respiratory, Version 4. Therapeutic

Guidelines Limited, West Melbourne, 2009.




























14. Craven V, Everard ML. Protracted bacterial bronchitis: reinventing an old disease. Arch Dis Child. 2013; 98: 72-76.


15. Towns SJ, van Asperen PP. Diagnosis and management of asthma in adolescents. Clin Respir J. 2009; 3: 69-76.


See: Investigation and management of exercise-induced bronchoconstriction

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:


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

Making a provisional diagnosis in children

Recommendations

A provisional diagnosis of asthma can be made if the child has (all of):

• wheezing accompanied by breathing difficulty or cough

• other features that increase the probability of asthma such as a history of allergic rhinitis, atopic dermatitis or a

strong family history of asthma and allergies

• no signs or symptoms that suggest a serious alternative diagnosis

• clinically important response to bronchodilator demonstrated on spirometry performed before and after short-

acting beta2 agonist (if child is able to perform spirometry).

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%.

If spirometry does not demonstrate a clinically important response to bronchodilator, the test can be repeated when the child has

symptoms.



More than one of:

• wheeze



• cough

Any of:


not between colds





tingling







diagnosis

AND

Any of:



morning





dermatitis)




32









Sources






Asset ID: 12




Cystic fibrosis







Tracheomalacia


Hyperventilation

Anxiety


Source



Asset ID: 11

Table. Findings that require investigations in children

33

Finding Notes

Persistent cough that is not associated with

wheeze/breathlessness or systemic disease

Unlikely to be due to asthma

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

rhinitis, enlarged tonsils and adenoids or nasal polyps)


Crepitations on chest auscultation that do not clear on

coughing

Suggest a serious lower respiratory tract condition

such as pneumonia, atelectasis, bronchiectasis

Unilateral wheeze Suggests inhaled foreign body

Systemic symptoms (e.g. fever, weight loss, failure to

thrive)

Suggest an alternative systemic disorder

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)

Persistent voice abnormality Suggests upper airway disorder

Finger clubbing Suggests cystic fibrosis, bronchiectasis

Chronic (>4 weeks) wet or productive cough Suggests cystic fibrosis, bronchiectasis, chronic

bronchitis, recurrent aspiration, immune

abnormality, ciliary dyskinesia

Focal (localised) lung signs Suggests pneumonia

Nasal polyps in child under 5 years old Suggests cystic fibrosis

Severe chest deformity Harrison’s Sulcus and Pectus Carinatum can be due

to uncontrolled asthma, but severe deformity

suggests an alternative diagnosis

Obvious breathing difficulty, especially at rest or at

night


Recurrent pneumonia Specialist assessment should be considered

34

Asset ID: 59

Make an initial assessment of the pattern of asthma (infrequent intermittent, frequent intermittent, or persistent).



treatment)



flare-ups)






every day



every week

Moderate Any of:


daily




Severe Any of:


continual


frequent










Consensus


s

35



Asset ID: 14



treatment)



flare-ups)






every day



every week

Moderate Any of:



daily




Severe Any of:



continual


frequent









Asset ID: 15

36

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 4–5 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 that airflow limitation is reversible and supports the diagnosis of asthma. In children with

asthma, it is also predictive of a good lung function response to inhaled corticosteroids.1

However, an absent response to

bronchodilators does not exclude asthma.1




















out.1



Consensus


s

Go to: National Asthma Council Australia’s Spirometry Resources

37




References




2. Johns DP, Pierce R. Pocket guide to spirometry. 3rd edn. McGraw Hill, North Ryde, 2011.
























38

HOME > DIAGNOSIS > CHILDREN > TREATMENT TRIAL

Conducting a treatment trial to confirm the diagnosis in children

In this section

0–5 years

Conducting a treatment trial to confirm the diagnosis in children 0–5 years

https://www.asthmahandbook.org.au/diagnosis/children/treatment-trial/0-5-years

6 years and over

Conducting a treatment trial to confirm the diagnosis in children 6 years and over

https://www.asthmahandbook.org.au/diagnosis/children/treatment-trial/6-years-and-over

39

HOME > DIAGNOSIS > CHILDREN > TREATMENT TRIAL > 0–5 YEARS

Conducting a treatment trial to confirm the diagnosis in children 0

–5 years

Recommendations

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 2–4 puffs (200–400 mcg) when child wheezes, and repeat if wheezing does not stop or recurs.

• Ask parents to watch closely for whether child’s breathing becomes normal (i.e. child stops showing signs of

increased work of breathing) and report effects.

For children aged 6–12 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.

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.


Consensus


s


Consensus


s


Consensus



• Brand et al. 2008 1

s


Consensus




s

40

For children aged 12 months and over with a provisional diagnosis of asthma, consider a trial of preventer treatment 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.

Table. Initial preventer treatment for children aged 0–5 years

Age Pattern of symptoms Management options and notes *

0–12 months Intermittent asthma

or

Viral-induced wheeze

Regular preventer treatment is not recommended

Multiple-trigger wheeze Refer for specialist assessment or obtain specialist

advice before prescribing

1–2 years Intermittent asthma

or



Persistent asthma

or

Multiple-trigger wheeze

Consider a treatment trial with sodium

cromoglycate 10 mg three times daily and review

response in 2–4 weeks†

Consider a treatment trial of low-dose inhaled

corticosteroids only if wheezing symptoms are

disrupting child’s sleeping or play; review response

in 4 weeks

2–5 years Infrequent intermittent asthma

or



Frequent intermittent asthma

or

Mild persistent asthma

or

Episodic (viral) wheeze with

frequent symptoms

or

Multiple-trigger wheeze

Consider regular treatment with montelukast 4 mg

once daily and review response in 2–4 weeks

If symptoms do not respond, consider regular

treatment with a low dose of an inhaled

corticosteroid and review response in 4 weeks

Moderate–severe persistent

asthma

41

Age Pattern of symptoms Management options and notes *

or

Moderate–severe multiple-

trigger wheeze

Consider regular treatment with a low dose of an

inhaled corticosteroid and review response in 4

weeks

• Advise parents about potential adverse psychiatric effects of montelukast

* 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.

Repeat the treatment trial if the effect on symptoms is unclear.

Explain to parents that:

• 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).


Consensus


s


Consensus


s




• Global Initiative for Asthma (GINA), 2009 2

s


Consensus




• Martinez et al. 1995 3

• Morgan et al. 2005 4

• Henderson et al. 2008 5

• Castro-Rodriguez, 2010 6

s

42

More information









Noisy breathing is







so wheezing is best




Asthma versus wheezing disorder in children 0–5 years

Although many individuals later diagnosed with asthma first show respiratory symptoms by the age of 5 years,1

it is

difficult to make the diagnosis of ‘asthma’ with a high degree of certainty in a baby or preschool child.

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





treatment)



flare-ups)






every day



every week

43


treatment)

Moderate Any of:


daily




Severe Any of:


continual


frequent











Asset ID: 14



treatment)



flare-ups)






every day



every week

Moderate Any of:

44


treatment)



daily




Severe Any of:



continual


frequent









Asset ID: 15








episodes.1, 2











45

Classification

system/source

Phenotypes

identified

Description

Tucson Children’s


‡


by age 6 years



Avon Longitudinal

Study of Parents

and Children §

Transient early

wheeze




Prolonged early

wheeze







Intermediate-onset

wheeze


3.5 years.









to primary school


Notes


preschool child.


Sources







46







Asset ID: 10


retrospectively.1








and almost half of



Among people with





airways




have asthma2




Correct use of inhaler devices

The majority of patients do not use inhaler devices correctly. Australian research studies have reported that only

approximately 10% of patients use correct technique.10, 11

High rates of incorrect inhaler use among children with asthma and adults with asthma or COPD have been reported,12,

13, 14, 15, 16 even among regular users.

17 Regardless 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, 21

In 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

function.22, 23

Common errors and problems with inhaler technique

Common errors with manually actuated pressurised metered dose inhalers include:18

• failing to shake the inhaler before actuating

• holding the inhaler in wrong position

• failing to exhale fully before actuating the inhaler

• actuating the inhaler too early or during exhalation (the medicine may be seen escaping from the top of the inhaler)


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.

Common errors for dry powder inhalers include:18

• 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.

Other common problems include:

• 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.

How to improve patients’ inhaler technique

Patients’ inhaler technique can be improved by brief education, including a physical demonstration, from a health

professional or other person trained in correct technique.18

The best way to train patients to use their inhalers correctly is

one-to-one training by a healthcare professional (e.g. nurse, pharmacist, GP, specialist), that involves both verbal

instruction and physical demonstration.24, 12, 25, 26

Patients do not learn to use their inhalers properly just by reading the

manufacturer's leaflet.25

An effective method is to assess the individual's technique by comparing with a checklist specific

to the type of inhaler, and then, after training in correct technique, to provide written instructions about errors (e.g. a

sticker attached to the device).10, 23

The National Asthma Council information paper on inhaler technique includes checklists for correct technique with all

common inhaler types used in asthma or COPD.

Inhaler technique must be rechecked and training must be repeated regularly to help children and adults maintain correct

technique.22, 12, 13

References








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:







Go to: National Asthma Council Australia's Using your inhaler webpage for information, patient resources and videos

on inhaler technique

Go to: National Asthma Council Australia's information paper for health professionals on Inhaler technique for people

with asthma or COPD

Go to: NPS MedicineWise information on Inhaler devices for respiratory medicines

48









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


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:


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:


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:


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:


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:


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:


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:


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:


49

HOME > DIAGNOSIS > CHILDREN > TREATMENT TRIAL > 6 YEARS AND OVER

Conducting a treatment trial to confirm the diagnosis in children 6

years and over

Recommendations

Trial treatment according to pattern of symptoms.

Table. Initial preventer treatment for children aged 6 years and over

Pattern of symptoms * Management options and notes †

Infrequent intermittent asthma ‡ Regular preventer treatment is not recommended

Frequent intermittent asthma Consider a treatment trial with montelukast 5 mg once daily; assess

response after 2–4 weeks

A cromone (sodium cromoglycate or nedocromil) can be trialled as

an alternative§

Mild persistent asthma Consider a treatment trial with montelukast 5 mg once daily; assess

response after 2–4 weeks

If inadequate response after checking adherence, consider

treatment trial with inhaled corticosteroid (low dose)

A cromone (sodium cromoglycate or nedocromil) can be trialled as

an alternative§

Moderate-to-severe persistent

asthma

Consider a treatment trial with regular inhaled corticosteroid (low

dose); assess response after 4 weeks.

• Advise parents about potential adverse psychiatric effects of montelukast

* Pattern of symptoms when not taking regular preventer treatment

† In addition to use of rapid-onset inhaled beta2 agonist when child experiences difficulty breathing

‡ Also applies to children who wheeze only during upper respiratory tract infections and do not have a diagnosis of

asthma

§ E.g. sodium cromoglycate 5 mg/actuation; 10 mg (two inhalations) three times daily, then 10 mg twice daily when

stable. Note: Cromone inhaler device mouthpieces require daily washing to avoid blocking

Asset ID: 16

Table. Definitions of ICS dose levels in children

Inhaled corticosteroid Daily dose (mcg)

Low High

50

Inhaled corticosteroid Daily dose (mcg)

Low High

Beclometasone dipropionate † 100–200 >200 (up to 400)

Budesonide 200–400 >400 (up to 800)

Ciclesonide ‡ 80–160 >160 (up to 320)

Fluticasone propionate 100–200 >200 (up to 500)

† Dose equivalents for Qvar (TGA-registered CFC-free formulation of beclometasone dipropionate)

‡ Ciclesonide is registered by the TGA for use in children aged 6 and over

Source

van Asperen PP, Mellis CM, Sly PD, Robertson C. The role of corticosteroids in the management of childhood asthma. The

Thoracic Society of Australia and New Zealand, 2010. Available from:

http://www.thoracic.org.au/clinical-documents/area?command=record&id=14

Asset ID: 21

If cough does not respond to a treatment trial with a preventer, cease treatment instead of increasing the dose.

Repeat the treatment trial if the effect on symptoms is unclear.

More information









Consensus


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Consensus


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Consensus


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51



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This diagnosis should be only made in consultation

with a paediatric respiratory physician.








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every week

Moderate Any of:


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treatment)

53


treatment)



flare-ups)






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every week

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daily




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Asset ID: 15



Correct use of inhaler devices

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

High rates of incorrect inhaler use among children with asthma and adults with asthma or COPD have been reported,6, 7, 8,

9, 10 even among regular users.

11 Regardless 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, 15

In 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 inhalers include:12

• failing to shake the inhaler before actuating

• holding the inhaler in wrong position

• failing to exhale fully before actuating the inhaler

• actuating the inhaler too early or during exhalation (the medicine may be seen escaping from the top of the inhaler)

• 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.

Common errors for dry powder inhalers include:12

• 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.

Other common problems include:

• 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.

How to improve patients’ inhaler technique

Patients’ inhaler technique can be improved by brief education, including a physical demonstration, from a health

professional or other person trained in correct technique.12

The best way to train patients to use their inhalers correctly is

one-to-one training by a healthcare professional (e.g. nurse, pharmacist, GP, specialist), that involves both verbal

instruction and physical demonstration.18, 6, 19, 20

Patients do not learn to use their inhalers properly just by reading the

manufacturer's leaflet.19

An effective method is to assess the individual's technique by comparing with a checklist specific

to the type of inhaler, and then, after training in correct technique, to provide written instructions about errors (e.g. a

sticker attached to the device).4, 17

The National Asthma Council information paper on inhaler technique includes checklists for correct technique with all

common inhaler types used in asthma or COPD.

Inhaler technique must be rechecked and training must be repeated regularly to help children and adults maintain correct

technique.16, 6, 7

Go to: National Asthma Council Australia's Using your inhaler webpage for information, patient resources and videos

on inhaler technique

55

References








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


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:


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:


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:


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:


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:


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:


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:


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:


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:


Go to: National Asthma Council Australia's information paper for health professionals on Inhaler technique for people

with asthma or COPD

Go to: NPS MedicineWise information on Inhaler devices for respiratory medicines

56

HOME > DIAGNOSIS > CHILDREN > FURTHER INVESTIGATIONS

Considering further investigations in children

Recommendations

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.

Routine microbiological investigations are not recommended in the investigation of symptoms that suggest asthma in

preschool children.


Consensus


s


Consensus


s


Consensus


s


Consensus




• Dweik et al. 2011 2

s


Consensus



s

58

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

Relationship of allergies to asthma

A history of other atopic conditions (e.g. eczema and rhinitis) increases the probability of asthma in wheezing children.3

A family history of asthma or allergies in a first-degree relative is a risk factor for atopy and asthma in

children.3, 4

Maternal atopy is most strongly associated with childhood onset of asthma and for recurrent wheezing that

persists throughout childhood.3

Allergy tests in children

Skin-prick testingAllergy tests have a very limited role in the clinical investigation of asthma. They may be useful to guide management if

the child is sensitised to aeroallergens that are avoidable (e.g. advise parents against getting a cat if skin-prick testing has

shown that the child is sensitised to cat allergens, or advise parents that there is no need to remove a family pet if the child

is not sensitised).

Skin-prick testing is the recommended test for allergies in children.

Risk factors for anaphylaxis during skin prick testing are thought to include asthma (particularly uncontrolled or unstable

asthma), age less than 6 months, and widespread atopic dermatitis in children.5

As a precaution, the Australasian Society

of Clinical Immunology and Allergy (ASCIA) advises that skin prick testing should be performed only in specialist practices

for children under 2 years and children with severe or unstable asthma.5

ASCIA’s manual on skin prick testing lists other

risk factors.5

Total serum IgE testing

In children aged 0–5 years, total serum immunoglobulin E measurement is a poor predictor of allergies or asthma.1

Specific serum IgE testing

Among children aged 1–4 years attending primary care, those with raised specific IgE for inhaled allergens (e.g. house dust

mite, cat dander) are two-to-three times more likely to have asthma at age 6 than non-sensitised children.1

Sensitisation

to hen’s egg at the age of 1 year (specific IgE) is a strong predictor of allergic sensitisation to inhaled allergens at age 3

years.1








Consensus


s


Go to: Australasian Society of Clinical Immunology and Allergy Skin Prick Testing Working Party's Skin prick testing for

the diagnosis of allergic disease. A manual for practitioners


59















out.3





Cardiopulmonary exercise challenge test

Cardiopulmonary exercise (stress) testing may be appropriate to assess cardiopulmonary fitness and identify respiratory

or cardiac limitation of exercise in children presenting with exercise associated respiratory symptoms such as dyspnoea

or noisy breathing.

Further investigations in children: 0–5 years

In preschool children, further investigations (other than allergy tests) are not necessary and are generally not helpful.1

Investigations in a preschool child may be justified in any of the following circumstances:1

• symptoms are present from birth

• airway obstruction is abnormally severe

• recovery is very slow or incomplete (resulting in prolonged or repeated hospital admission in the first few years of life)

• episodes continue in the absence of a viral infection

• when parents are very anxious.

Further investigations in children

Microbiological investigationMicrobiological investigations are not routinely recommended in children because the result does not alter management

decisions, even though respiratory viruses can be identified.1

However, it may be useful to identify the virus in atypical cases (e.g. children with severe viral infections or Mycoplasma

infections).

Chest X-ray and other imaging technologies

Chest X-ray should be ordered when a child’s symptoms and signs suggest an alternative diagnosis that can be identified

or ruled out by X-ray.

A chest X-ray will neither establish nor rule out a diagnosis of asthma.1

Exhaled nitric oxide testing

60

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 3–4 years.3

Standardised reference values are

available for children aged 4 years and older.1

Specialised investigations in children

Induced sputum The sputum test for airway inflammation is not used in clinical practice.

Higher sputum eosinophil counts are associated with more marked airways obstruction and reversibility, greater asthma

severity and atopy. In children with newly diagnosed mild asthma, sputum eosinophilia is present and declines with

inhaled steroid treatment.3

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 0–5 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




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:







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
















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