Asthma Management Handbook

Investigating asthma-like symptoms in adolescents and young adults

Recommendations

Use spirometry to assess lung function objectively and to confirm the diagnosis, even if the person had asthma during childhood.

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):

  • Towns and Asperen, 20091
  • Weinberger and Abu-Hasan, 20072
  • Yeatts et al. 20033

For adolescents with exercise-related symptoms, consider objective tests (e.g. exercise testing, bronchial provocation (challenge) tests) or referral to investigate the possibility of non-asthma causes such as dyspnoea due to poor cardiopulmonary fitness, hyperventilation or upper airway dysfunction.

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 and Scottish Intercollegiate Guidelines Network, 20084
  • Tilles, 20105

Ask about smoking and exposure to other people’s tobacco smoke.

How this recommendation was developed

Consensus

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

In adolescent girls, consider whether asthma symptoms are affected by the menstrual cycle. 

How this recommendation was developed

Consensus

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

More information

Impact of puberty on asthma

In the past, it was thought that children typically 'outgrew' asthma due to maturation of the autonomic and central nervous systems under the effect of sex steroids during puberty.6 However, there is little evidence to support this assumption.6 Puberty does not predict remission of asthma. Almost two-thirds of children with chronic asthma have persistent symptoms throughout puberty.6

Early puberty has been reported to be an independent risk factor for the persistence of asthma into adolescence, and for the severity of asthma in adulthood.6 The mechanism for this association is unclear, and might involve the effects of hormonal changes on reactivity of airways or risk factors that are common to both asthma and early puberty.6

Increased BMI in girls has been associated with both early puberty and increased asthma risk.

Australian data show that more boys than girls experience remission of asthma during adolescence (based on 2007–2008 data):7

  • the prevalence of current asthma is higher for boys than girls among children aged 0–14 years, and higher for women among people aged 15 years and over
  • the prevalence of current asthma in children aged 10–14 years is approximately 12% for boys and 7% for girls
  • the prevalence of current asthma in adolescents and young adults aged 15–24 years is approximately 11% in both sexes.

Asthma can worsen or improve during adolescence; close monitoring is necessary so that medicines can be adjusted to maintain good asthma control at the lowest effective doses. If attempted back-titration of an adolescent’s preventer dose or step-down in the treatment regimen results in worsening of asthma symptoms, this experience can help the person understand why it is necessary to take these medicines regularly. Health professionals can make unsuccessful back-titration an opportunity to reinforce self-management education.

Asthma can occur for the first time during adolescence, more commonly in girls than boys.1 The true prevalence of asthma in adolescents is difficult to estimate because of under- and over-diagnosis.

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Assessment of asthma in adolescents

The majority of adolescents with asthma have normal lung function despite experiencing significant asthma symptoms.8

Lung function may not be a strong predictor of future flare-ups or correlate with current symptoms in adolescents.9

Assessment of asthma in adolescents is usually similar to assessment in adults, taking into account confidentiality and psychosocial factors that are especially important in this age group.

At each visit, it is useful to ask about days absent from school due to asthma.

Table. Definition of levels of recent asthma symptom control in adults and adolescents (regardless of current treatment regimen)

Good control

Partial control

Poor control

All of:

  • Daytime symptoms ≤2 days per week
  • Need for reliever ≤2 days per week
  • No limitation of activities
  • No symptoms during night or on waking

One or two of:

  • Daytime symptoms >2 days per week
  • Need for reliever >2 days per week
  • Any limitation of activities
  • Any symptoms during night or on waking

Three or more of:

  • Daytime symptoms >2 days per week
  • Need for reliever >2 days per week
  • Any limitation of activities
  • Any symptoms during night or on waking

† Not including SABA taken prophylactically before exercise. (Record this separately and take into account when assessing management.)

Note: Recent asthma symptom control is based on symptoms over the previous 4 weeks.

Adapted from:

Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. GINA, 2012. Available from: http://www.ginasthma.org/

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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.1 Conditions associated with dyspnoea include hyperventilation, anxiety, and poor cardiopulmonary fitness.2

Both denial and overplay of symptoms has been observed among adolescents.1 Adolescents with new or re-emerging asthma symptoms may deny their symptoms.1 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.3

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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.10

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.15

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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Psychosocial factors affecting adolescent health

Adolescence is a time of rapid growth and physical, cognitive, emotional and social development. An adolescent’s age is not a reliable indicator of maturity in each of these areas.11

Mental health disorders (e.g. depression, anxiety, eating disorders) are common and clinically important among young people.11 A significant proportion of adult mental health problems emerge during adolescence.11

Adolescence is also a time when people can begin risky behaviours (e.g. smoking, poor eating habits, physical inactivity, and drug and alcohol use), which can continue into adulthood.11, 12 Although smoking rates among adolescents and young people are declining,13 approximately 6% of adolescents aged 15–17 years smoke, and 4% smoke at least daily.14 Smoking rates are higher among Aboriginal and Torres Strait Islander young people, young people living in rural and remote communities, and young people of lower socioeconomic status.1513

Adolescents with chronic disease show higher rates of health risk behaviours than healthy adolescents.1116 Some risk behaviours are based on incorrect health beliefs (e.g. the myth that smoking cannabis is good for asthma).

Risk-taking behaviour – as well as poor understanding of their health condition – may contribute to the higher rate of food-induced fatal anaphylaxis among adolescents and young adults, compared with other age groups.17

Depression, risk behaviours and poor adherence to medicines are interrelated.18 Adolescents with asthma who adhere poorly to asthma treatment and hide their asthma are more likely to start smoking than other adolescents with asthma.19 Among adolescent boys, those with lower quality of life are most likely to start smoking.19

Adolescents often wish to discuss their health concerns with health professionals but are reluctant to discuss sensitive issues unless asked directly and confidentially.11

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Physiological and psychological changes

Stress, anxiety and extreme emotions

Some patients report asthma flare-ups and asthma symptoms in response to stress and extreme emotions.2021

Adolescents with asthma may experience breathlessness in response to stress (without changes in lung function or other asthma symptoms).22

Laughter

Laughing is a common trigger for wheeze in infants. In children, the presence of respiratory symptoms that are triggered by laughter increases the probability of symptoms being due to asthma.

Hormonal changes

Asthma may worsen during the premenstrual phase in up to 40% of women, possibly due to a reduced response to corticosteroids and bronchodilators.23 However, this rarely causes severe flare-ups.23

Perimenstrual worsening asthma may be relatively common among women with severe or poorly controlled asthma, and may share risk factors with aspirin-exacerbated respiratory disease.24

Asthma control worsens during pregnancy in about one third of women with asthma.25 During pregnancy, approximately 6% of women with asthma are hospitalised with a severe asthma flare-up.2627

Sexual activity

Sexual activity may trigger asthma symptoms possibly due to physical exertion (exercise-induced bronchoconstriction), heightened emotion, or a combination of these factors. Exposure to dust mite allergens in bedding may also be a trigger for people who are sensitised.

People with asthma may experience limitation to sexual activity due to asthma or be concerned about the effect of their asthma on their sex life.2829 However, patients are unlikely to mention concerns about sexual activity to their doctor.29

Practical information for patients about sex and asthma is available from Asthma Australia.

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Resources for health professionals working with adolescents
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References

  1. 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
  2. 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
  3. 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
  4. British Thoracic Society (BTS) Scottish Intercollegiate Guidelines Network (SIGN). British Guideline on the Management of Asthma. Quick Reference Guide. Revised May 2011. BTS, SIGN, Edinburgh, 2008.
  5. 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
  6. Patton GC, Viner R. Pubertal transitions in health. Lancet. 2007; 369: 1130-1139. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17398312
  7. Australian Centre for Asthma Monitoring. Asthma in Australia 2011: with a focus chapter on chronic obstructive pulmonary disease. Asthma series no. 4. Cat. no ACM 22. Australian Institute of Health and Welfare, Canberra, 2011. Available from: http://www.aihw.gov.au/publication-detail/?id=10737420159
  8. van Dalen C, Harding E, Parkin J, et al. Suitability of forced expiratory volume in 1 second/forced vital capacity vs percentage of predicted forced expiratory volume in 1 second for the classification of asthma severity in adolescents. Arch Pediatr Adolesc Med. 2008; 162: 1169-74. Available from: http://archpedi.jamanetwork.com/article.aspx?articleid=380549
  9. Gruchalla RS, Sampson HA, Matsui E, et al. Asthma morbidity among inner-city adolescents receiving guidelines-based therapy: role of predictors in the setting of high adherence. J Allergy Clin Immunol. 2009; 124: 213-21, 221.e1. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2757267/
  10. 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/
  11. 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
  12. Sawyer SM, Afifi RA, Bearinger LH, et al. Adolescence: a foundation for future health. Lancet. 2012; 379: 1630-1640. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22538178
  13. Australian Institute of Health and Welfare. Australia’s health 2010. no. 12 Cat. no. AUS 122. Australian Institute of Health and Welfare, Canberra, 2010. Available from: http://www.aihw.gov.au/publication-detail/?id=6442468376
  14. Australian Bureau of Statistics. 4364.0.55.003 - Australian Health Survey: Updated Results, 2011-2012. Australian Bureau of Statistics, Canberra, 2013. Available from: http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/E3E02505DCAF230CCA257B82001794EB?opendocument
  15. Australian Bureau of Statistics. The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples, Oct 2010. Cat. no. 4704.0. Australian Bureau of Statistics, Canberra, 2011. Available from: http://www.abs.gov.au/AUSSTATS/abs@.nsf/lookup/4704.0Chapter755Oct+2010#currentdailysmokers
  16. Suris JC, Michaud PA, Akre C, Sawyer SM. Health risk behaviors in adolescents with chronic conditions. Pediatrics. 2008; 122: e1113-8. Available from: http://pediatrics.aappublications.org/content/122/5/e1113.long
  17. Australasian Society of Clinical Immunology and Allergy (ASCIA). ASCIA health professional information paper. Nutritional management of food allergy. ASCIA, Sydney, 2013. Available from: http://www.allergy.org.au/health-professionals/hp-information/asthma-and-allergy/nutritional-management-of-food-allergy
  18. Bender BG. Risk taking, depression, adherence, and symptom control in adolescents and young adults with asthma. Am J Respir Crit Care Med. 2006; 173: 953-7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16424441
  19. Van De Ven MO, Engels RC, Sawyer SM. Asthma-specific predictors of smoking onset in adolescents with asthma: a longitudinal study. J Pediatr Psychol. 2009; 34: 118-28. Available from: http://jpepsy.oxfordjournals.org/content/34/2/118.long
  20. Busse WW. The brain and asthma: what are the linkages?. Chem Immunol Allergy. 2012; 98: 14-31. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22767055
  21. Theoharides TC, Enakuaa S, Sismanopoulos N, et al. Contribution of stress to asthma worsening through mast cell activation. Ann Allergy Asthma Immunol. 2012; 109: 14-9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22727152
  22. Rietveld S, van Beest I, Everaerd W. Stress-induced breathlessness in asthma. Psychol Med. 1999; 29: 1359-66. Available from: http://www.ncbi.nlm.nih.gov/pubmed/10616941
  23. Boulet LP. Influence of comorbid conditions on asthma. Eur Respir J. 2009; 33: 897-906. Available from: http://erj.ersjournals.com/content/33/4/897.long
  24. Rao CK, Moore CG, Bleecker E, et al. Characteristics of perimenstrual asthma and its relation to asthma severity and control: data from the Severe Asthma Research Program. Chest. 2013; 143: 984-92. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23632943
  25. Murphy VE, Gibson PG. Asthma in pregnancy. Clin Chest Med. 2011; 32: 93-110. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21277452
  26. Murphy VE, Clifton VL, Gibson PG. Asthma exacerbations during pregnancy: incidence and association with adverse pregnancy outcomes. Thorax. 2006; 61: 169-76. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2104591/
  27. Ali Z, Ulrik CS. Incidence and risk factors for exacerbations of asthma during pregnancy. J Asthma Allergy. 2013; 6: 53-60. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3650884/
  28. Meyer IH, Sternfels P, Fagan JK, Ford JG. Asthma-related limitations in sexual functioning: an important but neglected area of quality of life. Am J Public Health. 2002; 92: 770-2. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1447159/
  29. Kaptein AA, van Klink RC, de Kok F, et al. Sexuality in patients with asthma and COPD. Respir Med. 2008; 102: 198-204. Available from: http://www.resmedjournal.com/article/S0954-6111(07)00400-3/fulltext