Asthma Management Handbook

History and physical examination for a wheezing child aged 6 years or over

Recommendations

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, 20071
  • Gibson et al. 2010 2

More information

Definition of wheeze

Wheeze is defined as a high-pitched sound coming from the chest during inspiration or expiration.3 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 mechanism3 (e.g. bronchoconstriction or secretions in the airway lumen).

Inspiratory sounds (e.g. rattling or stridor) should not be described as ‘wheeze’.1

Various forms of noisy breathing, including wheezing, are common among babies and preschoolers.3 Noisy breathing is particularly common among infants under 6 months old, but only a small proportion have wheeze.3

Parents and doctors sometimes use the word ‘wheeze’ to mean different things,3, 1 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.3

There are no validated questionnaire-based instruments to identify wheeze in preschoolers,3 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.3

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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.4

The links between asthma and atopy are unclear.5 Many children with asthma are also atopic and have eczema, hay fever, or food allergies, but not all children with atopy develop asthma.5

Eczema and allergic rhinitis are risk factors for developing asthma.6, 7, 8, 9, 10, 11 Parental atopy has been identified as a risk factor for asthma in several studies, but the strength of the association differs between populations.12

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.11 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.5

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Diagnostic difficulties when investigating asthma-like symptoms in adolescents

Asthma is commonly misdiagnosed in young people presenting with exercise-related symptoms or cough.13 Conditions associated with dyspnoea include hyperventilation, anxiety, and poor cardiopulmonary fitness.1

Both denial and overplay of symptoms has been observed among adolescents.13 Adolescents with new or re-emerging asthma symptoms may deny their symptoms.13 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.14

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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.15

When adolescents are accompanied by parents or carers, health care providers should consider seeing the adolescent alone for part of each consultation.15

Health professionals should discuss confidentiality and its limits with adolescents.15 Adolescents are more willing to communicate honestly with healthcare professionals who discuss confidentiality with them.16

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 15.15

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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.17

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.1318

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.

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References

  1. 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
  2. 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
  3. 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
  4. 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/
  5. 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
  6. 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
  7. 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
  8. 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
  9. 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
  10. 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
  11. 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
  12. 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
  13. Towns SJ, van Asperen PP. Diagnosis and management of asthma in adolescents. Clin Respir J. 2009; 3: 69-76. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20298380
  14. 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: http://www.ncbi.nlm.nih.gov/pubmed/12728087
  15. 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/
  16. 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
  17. Schuh, S, Willan, AR, Stephens, D, et al. Can montelukast shorten prednisolone therapy in children with mild to moderate acute asthma? A randomized controlled trial. J Pediatr. 2009; 155: 795-800. Available from: https://www.ncbi.nlm.nih.gov/pubmed/19656525
  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