Challenges in diagnosing asthma in children
BMJ 2024; 384 doi: https://doi.org/10.1136/bmj-2023-075924 (Published 13 February 2024) Cite this as: BMJ 2024;384:e075924
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Dear Editor,
I read with interest Dr Chisholm and colleagues article on challenges in diagnosing asthma in children. It exemplifies that a diagnosis remains a conundrum, with guidelines aiding a clinician in categorising a child as having a high or low probability of asthma but having to use a trial treatment usually a bronchodilator and inhaled corticosteroid for several months on and off to ascertain whether it is asthma. In my experience, a trial of treatment may be misinterpreted by many parents and children and so needs to be clearly planned and explained. It is vital the child can use an appropriate spacer device with a metered dose inhalers or if old enough a dry powder device. The parents and child if old enough must have a clear written plan to make their likelihood of following the trial of treatment successful. Follow up from an asthma nurse can be helpful during the trial period.
I also wanted to allude to a very common cause of respiratory symptoms that can masquerade as asthma not mentioned in the article and that is breathing pattern disorders also called dysfunctional breathing. These are usually older children and if not recognised can lead to inappropriate labelling as asthma. The skill in identifying children with asthma lies as always in taking a careful history, listening carefully to the responses and in addition being familiar with symptoms that have a high probability of asthma and those that suggest a differing diagnosis. Examination should include height and weight including trajectories and examination of the nose for rhinitis or polyps in addition to those mentioned in the article.
Reference
Breathing pattern disorders ( dysfunctional breathing ) characteristics and outcomes of children and young people attending a secondary care respiratory clinic.2020. https://onlinelibrary.wiley.com/doi/10.1002/ppul.24791
Competing interests: No competing interests
Re: Challenges in diagnosing asthma in children
Dear Editor,
I read with interest Dr Chisholm and colleagues article on the challenges in diagnosing asthma in children.
They outline clearly the ongoing conundrum of making a definitive diagnosis of asthma by reviewing the differing asthma guidelines.
The collection of symptoms suggestive of asthma, cough, wheeze and difficulty breathing, are cited as being key to diagnosis. I would like to further emphasise these symptoms need to be interrogated thoroughly by clinicians. Consideration needs to given to whether a cough is dry, wet, or brassy; is a wheeze really wheeze “a whistling” noise suggestive of small airway obstruction or is it rattly breathing suggestive of airway secretions; and is it breathing difficulty due to reversible airway obstruction or is it due poor conditioning especially if associated with exercise. Breathing pattern disorders or dysfunctional breathing not mentioned in the article is important to consider as they can masquerade as asthma and lead to inappropriate labelling of symptoms as asthma and unnecessary asthma treatment. (1)
An important aspect of diagnosing asthma is a positive response to treatment with trials on and off treatment usually with a bronchodilator and inhaled corticosteroids (ICS). In my experience, parents, children and adolescenys must be given clear instructions about the trial of treatment and the reasoning behind it. Concerns about ICS are common and should be addressed before the trial of treatment with ICS commences.
Appropriate delivery devices for the child or young person’s age should be used. Spacers in younger children and dry powder devices in older children maybe appropriate but checks on technique and coaching are needed to optimise drug delivery. Advice about rinsing out mouth after taking ICS to limit systemic absorption is important. A written plan of the trial of treatment should be given to parents and patients.
An agreed follow up should be arranged with the same clinician or asthma nurse. This is good for continuity for patients and clinicians. An asthma nurse making contact with patients and families in the first few weeks of a trial of treatment can be extremely useful in making sure the plan is being followed.
I hope these comments compliment a useful article.
Newson TP, Elias A. 2020 ; Breathing Pattern Disorders (Dysfunctional breathing) characteristics and outcomes in children and young people attending a secondary care respiratory clinic. Paediatric Pulmonology https://onlinelibrary.wiley.com/doi/10.1002/ppul.24791
Competing interests: No competing interests