Asthma Management Handbook

Differential diagnosis for wheezing in children aged 1–5 years

Recommendations

Consider features that increase or reduce the probability of asthma.

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
  • lung function measured by spirometry increases 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.

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How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference to the following source(s):

  • British Thoracic Society, Scottish Intercollegiate Guidelines Network, 2012 1
  • Respiratory Expert Group Therapeutic Guidelines Limited, 2009 2

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

How this recommendation was developed

Adapted from existing guidance

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

  • Gibson et al. 2010 3

Consider alternative diagnoses and comorbidities, including:

  • congenital conditions, e.g. structural airway problems (e.g. tracheomalacia, bronchopulmonary dysplasia, malformation causing narrowing of intrathoracic airways, vascular ring anomaly compressing bronchus, trachea-oesophageal fistula), cystic fibrosis, immune deficiency, primary ciliary dyskinesia, congenital heart disease
  • infective conditions, e.g. bronchiolitis (infants < 12 months), laryngotracheobronchitis (croup), chronic rhinosinusitis, recurrent respiratory tract infections, chronic suppurative lung disease (consider protracted bacterial bronchitis or bronchiectasis as a cause)
  • acquired conditions, e.g. inhaled foreign body, gastro-oesophageal reflux, recurrent aspiration, tumour or pulmonary oedema.

Table. Conditions that can be confused with asthma in children

Conditions characterised by cough

Pertussis (whooping cough)

Post-viral cough

Cystic fibrosis

Airway abnormalities (e.g. tracheobronchomalacia)

Protracted bacterial bronchitis in young children

Habit-cough syndrome

Conditions characterised by wheezing

Upper airway dysfunction

Inhaled foreign body causing partial airway obstruction

Tracheobronchomalacia

Conditions characterised by difficulty breathing

Hyperventilation

Anxiety

Breathlessness on exertion due to poor cardiopulmonary fitness

Upper airway dysfunction

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

Last reviewed version 2.0

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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

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

Specialist assessment should be considered

Recurrent pneumonia

Specialist assessment should be considered

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How this recommendation was developed

Consensus

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

Last reviewed version 2.0

More information

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.3

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

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Chronic cough (cough lasting more than 4 weeks) without other features of asthma is unlikely to be due to asthma.3

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.4 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.4  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:3

  • due to protracted bacterial bronchitis (resolves with 2–6 weeks’ treatment with antibiotics)3
  • post-viral (resolves with time)
  • due to exposure to tobacco smoke and other pollutants.3

Frequency of cough reported by parents correlates poorly with frequency measured using diary cards or by audio recording monitors.5

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,5 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).3

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Alternative diagnoses in children

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

  • protracted bacterial bronchitis36
  • habit-cough syndrome3
  • upper airway dysfunction.7

Table. Conditions that can be confused with asthma in children

Conditions characterised by cough

Pertussis (whooping cough)

Post-viral cough

Cystic fibrosis

Airway abnormalities (e.g. tracheobronchomalacia)

Protracted bacterial bronchitis in young children

Habit-cough syndrome

Conditions characterised by wheezing

Upper airway dysfunction

Inhaled foreign body causing partial airway obstruction

Tracheobronchomalacia

Conditions characterised by difficulty breathing

Hyperventilation

Anxiety

Breathlessness on exertion due to poor cardiopulmonary fitness

Upper airway dysfunction

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

Last reviewed version 2.0

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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
  • lung function measured by spirometry increases 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.

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References

  1. 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/
  2. Respiratory Expert Group, Therapeutic Guidelines Limited. Therapeutic Guidelines: Respiratory, Version 4. Therapeutic Guidelines Limited, West Melbourne, 2009.
  3. 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: https://www.mja.com.au/journal/2010/192/5/cicada-cough-children-and-adults-diagnosis-and-assessment-australian-cough
  4. van Asperen PP. Cough and asthma. Paediatr Resp Rev. 2006; 7: 26-30. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16473813
  5. Bush A. Diagnosis of asthma in children under five. Prim Care Respir J. 2007; 16: 7-15. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17297521
  6. 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
  7. Weinberger M, Abu-Hasan M. Pseudo-asthma: when cough, wheezing, and dyspnea are not asthma. Pediatrics. 2007; 120: 855-864. Available from: http://pediatrics.aappublications.org/content/120/4/855.full