Asthma Management Handbook

History and physical examination for a wheezing child aged 1–5 years

Recommendations

Confirm that the breathing sounds described by parents/carers as ‘wheezing’ are actually wheeze:

  • If possible, see the child during a bout of ‘wheezing’.
  • Ask parents/carers to make an audio or video recording of noisy breathing (e.g. on phone).
  • Show parents/carers a video of true wheezing and ask them whether signs match their child.
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):

  • Brand et al. 20081
  • Global Initiative for Asthma (GINA), 20092
  • Weinberger and Abu-Hasan, 20073

Last reviewed version 2.0

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, joins in play with other children
  • home environment (e.g. exposure to smoke, pets)
  • allergies, including atopic dermatitis (eczema) and allergic rhinitis (‘hay fever’)
  • family history of asthma and allergies.
How this recommendation was developed

Consensus

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

Last reviewed version 2.0

Conduct a general physical examination, including:

  • height and weight compared with normal range for age
  • inspection of chest for deformity
  • inspection of upper airway for signs of allergic rhinitis (e.g. swollen turbinates, transverse nasal crease, mouth breathing, darkness and swelling under eyes caused by sinus congestion) or polyps
  • auscultation of chest
  • inspection of fingers for clubbing (requires investigation)
  • skin inspection for atopic dermatitis (eczema).

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

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

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), with particular reference to the following source(s):

  • Weinberger and Abu-Hasan, 20073
  • Gibson et al. 2010 4

More information

Definition of wheeze

Wheeze is defined as a high-pitched sound coming from the chest during inspiration or expiration.1 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

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'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.

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

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Significance of wheeze in children 1–5 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

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

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Relationship of allergies to asthma

Asthma can be atopic or non-atopic. Atopic asthma, characterised by eosinophilic airway inflammation associated with sensitisation to aeroallergens (positive skin prick test or specific immunoglobulin E on serology) is the more common form in children.6

The links between asthma and atopy are unclear.7 Many children with asthma are also atopic and have eczema, hay fever, or food allergies, but not all children with atopy develop asthma.7

Eczema and allergic rhinitis are risk factors for developing asthma.8, 9, 10, 11, 12, 13 Parental atopy has been identified as a risk factor for asthma in several studies, but the strength of the association differs between populations.14

A family history of atopy or asthma, or a personal history of atopy are generally considered to increase the probability that wheezing in children is due to asthma.

The association between allergic rhinitis and asthma may reflect the common allergic causes of both conditions, rather than a causal link.13 However, few studies have examined interactions between genes and environment for asthma and for atopy in the same population, and there is not consistent evidence that similar gene–environment interactions are common to asthma and atopy.7

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Wheezing phenotypes in preschool children

Longitudinal population-based cohort studies1516 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
Tucson Children’s Respiratory Study † ‡ Transient wheeze

Wheezing commences before the age of 3 years and disappear by age 6 years

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

Not associated with hypersensitivity to airborne allergens

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 never/infrequent wheeze phenotype

Late-onset wheeze

Wheezing mainly begins after age 3.5 years

Strongly associated with atopy (especially house mite, cat 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

# 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

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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.17

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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; 120: 855-864. Available from: http://pediatrics.aappublications.org/content/120/4/855.full
  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: https://www.mja.com.au/journal/2010/192/5/cicada-cough-children-and-adults-diagnosis-and-assessment-australian-cough
  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. Comberiati P, Di Cicco ME, D'Elios S, Peroni DG. How much asthma is atopic in children? Front Pediatr. 2017; 5: 122. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5445121/
  7. Turner S. Gene-environment interactions-what can these tell us about the relationship between asthma and allergy? Front Pediatr. 2017; 5: 118. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28589116
  8. van der Hulst AE, Klip H, Brand PL. Risk of developing asthma in young children with atopic eczema: a systematic review. J Allergy Clin Immunol. 2007; 120: 565-9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/17655920
  9. Pallasaho P, Juusela M, Lindqvist A et al. Allergic rhinoconjunctivitis doubles the risk for incident asthma – results from a population study in Helsinki, Finland. Respir Med. 2011; 105: 1449-56. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21600752
  10. Rochat MK, Illi S, Ege MJ et al. Allergic rhinitis as a predictor for wheezing onset in school-aged children. J Allergy Clin Immunology. 2010; 126: 1170-5.e2. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21051078
  11. van den Nieuwenhof L, Schermer T, Bosch Y et al. Is physician-diagnosed allergic rhinitis a risk factor for the development of asthma? Allergy. 2010; 65: 1049-55. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20132162
  12. Morais-Almeida M, Gaspar A, Pires G et al. Risk factors for asthma symptoms at school age: an 8-year prospective study. Allergy Asthma Proc. 2007; 28: 183-9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/17479602
  13. Shaaban R, Zureik M, Soussan D et al. Rhinitis and onset of asthma: a longitudinal population-based study. Lancet. 2008; 372: 1047-57. Available from: https://www.ncbi.nlm.nih.gov/pubmed/18805333
  14. Bjerg A, Hedman L, Perzanowski MS et al. Family history of asthma and atopy: in-depth analyses of the impact on asthma and wheeze in 7- to 8-year-old children. Pediatrics. 2007; 120: 741-8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/17908760
  15. 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
  16. 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: http://thorax.bmj.com/content/63/11/974.long
  17. 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: http://www.ncbi.nlm.nih.gov/pubmed/22704537