Asthma Management Handbook

Further investigations for wheezing in children aged 6 years and over

Recommendations

Consider skin prick testing for common aeroallergens for children with recurrent wheezing when the results might guide you in managing symptoms (e.g. advising parents/carers about management if avoidable allergic triggers are identified).

Notes:

Allergy tests are not essential in the diagnostic investigation of asthma in children. The finding of allergic sensitisation on skin-prick testing or specific IgE does not necessarily mean that it is clinically important.

Blood test (immunoassay for allergen-specific immunoglobulin E) can be used if skin prick testing is unavailable, impractical or inappropriate.

How this recommendation was developed

Consensus

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

Last reviewed version 2.0

If the diagnosis is uncertain, consider arranging bronchial provocation (challenge) testing.

How this recommendation was developed

Consensus

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

Last reviewed version 2.0

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.

How this recommendation was developed

Consensus

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

Measurement of exhaled nitric oxide is not recommended as a diagnostic test for asthma in routine clinical practice.

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. 2008 1
  • Dweik et al. 2011 2

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

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. 2008 1

Last reviewed version 2.0

Offer referral to a specialist for further assessment and investigation if the diagnosis is unclear or if a serious condition cannot be ruled out. 

How this recommendation was developed

Consensus

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

More information

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.3

The links between asthma and atopy are unclear.4 Many children with asthma are also atopic and have eczema, hay fever, or food allergies, but not all children with atopy develop asthma.4

Eczema and allergic rhinitis are risk factors for developing asthma.5, 6, 7, 8, 9, 10 Parental atopy has been identified as a risk factor for asthma in several studies, but the strength of the association differs between populations.11

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.10 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.4

Last reviewed version 2.0

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Allergy tests in children

Skin-prick testing

Allergy 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.12 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.12 ASCIA’s manual on skin prick testing lists other risk factors.12

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

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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. 1314

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 test15
  • mannitol challenge test1617
  • methacholine challenge test.18, 19
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Roles of other lung function tests in diagnosing asthma in children

Peak expiratory flow meters in asthma diagnosis

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

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,20, 21 but their availability is mainly restricted to specialist and research centres.

Last reviewed version 2.0

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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.

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Further investigations in children

Microbiological investigation

Microbiological 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

The exhaled nitric oxide test is not currently available as a standard clinical test for the diagnosis of asthma and is mainly a research tool at present. Standardised reference values are available for children aged 4 years and older.1

Induced sputum

The sputum test for airway inflammation is not used in the diagnosis of asthma clinical practice.

White cell count

Blood eosinophil level is a component of the Asthma Predictive Index.22 However, this test is not routinely recommended because the Asthma Predictive Index has limited clinical value in predicting whether a wheezing preschool child will have asthma at school age.1, 23

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

Last reviewed version 2.0

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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. 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: http://ajrccm.atsjournals.org/content/184/5/602.long
  3. 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/
  4. 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
  5. 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
  6. 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
  7. 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
  8. 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
  9. 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
  10. 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
  11. 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
  12. 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
  13. Anderson SD. Bronchial challenge tests: usefulness, availability and challenges. Breathe. 2011; 8: 53-60. Available from: http://www.ers-education.org
  14. 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
  15. 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/
  16. 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
  17. 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
  18. 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: http://www.ncbi.nlm.nih.gov/pubmed/18383334
  19. 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
  20. 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
  21. 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
  22. 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
  23. 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