Bronchial asthma (hereinafter referred to as asthma) is the most common chronic respiratory disease in children. Although great progress has been made in the diagnosis and treatment of pediatric asthma in China, about 30% of urban children’s asthma has not been diagnosed in time. Early diagnosis, standardized management and early intervention are important means to improve the control level and prognosis of childhood asthma.
Asthma, as defined in the 2016 Consensus, is a heterogeneous disease characterized by chronic airway inflammation and airway hyperresponsiveness, with recurrent wheezing, cough, shortness of breath, and chest tightness as the main clinical manifestations, often at night and/or in the early hours of the morning. The specific manifestation and severity of respiratory symptoms vary with time and are often accompanied by reversible restriction of expiratory flow and obstructive ventilatory dysfunction.
It is not difficult to see that the diagnosis of childhood asthma relies primarily on clinical manifestations and evidence of reversible airflow restriction, excluding other diseases that may cause the associated symptoms. This is an exclusive diagnosis, which is relatively difficult to diagnose and often requires doctors to have rich clinical experience. However, for general doctors, we can still find some clues of asthma through the following clinical symptoms.
There are many diseases that cause wheezing, but how do you identify asthma from the many that cause wheezing?
The main indicators are the frequency and severity of asthma attacks:
Generally, it refers to the cumulative frequency of wheezing ≥4 times in the past year (some doctors recommend ≥3 times) or the average frequency of wheezing ≥2 times per year in the past 2-3 years;
At least 1 of them required emergency room/oxygen/systemic glucocorticoids/hospitalization for a wheezing attack.
These can be used as important reference basis for asthma diagnosis. And it is this wheezing that is effective with bronchodilators (aerosolized or oral) or anti-asthmatic medications, and that is characteristic of relapse after discontinuation.
Secondly, whether there is wheezing or calculating the number of wheezing is not up to the parents to decide, acute attack of asthma should have typical wheezing signs, we can be counted as a wheezing attack.
Lung wheezing sound recorded by different hospitals and physicians with maximum value of the same signs, because the parents the vague cognition of breathing, and even some parents will physiological respiration as breathing, so parents sometimes unable to provide accurate information, clinical doctors should learn self judgment, the description of the parents alone, may be the cause of misdiagnosis or missed diagnosis, Must be combined with an evaluation by a professional physician.
Coughing is one of the common symptoms of the respiratory system. Persistent cough for more than 4 weeks, although not accompanied by wheezing, should also be considered as one of the symptoms of asthma if it often occurs or worsens at night and/or early in the morning, does not show signs of infection clinically, or does not respond to antibiotic treatment for a long time.
Clinically, we call it cough variant asthma, which is a special type of asthma. The pathogenesis is consistent with typical asthma, with simple cough as the main symptom.
This cough is characterized by:
Can be aggravated after strenuous exercise, but no dyspnea and wheezing, generally no phlegm, no fever;
It is often induced by respiratory irritants such as smoke, cold air and laughter.
There are obvious seasonal, winter and spring season frequently, often inducement such as cold air inhalation, excessive fatigue, mental tension and so on;
General cough and phlegm – reducing drugs and antibiotics are ineffective for several weeks;
Specific tests for asthma are often positive.
Cough-variant asthma is a manifestation of early asthma and should be treated according to asthma norms. Without appropriate treatment, about half of patients will develop typical asthma. According to clinical data, about 80% of children with cough variant asthma will develop into typical asthma 3 years later if not treated in time.
The diagnosis of asthma requires asking the medical history of the child and making the diagnosis in combination with the medical history. By more than 80% of childhood asthma and allergies, doctors should ask for details of children with medical history, if exist in children with atopic dermatitis, family history of asthma, and/or allergic rhinitis, eczema, inhaled or food into the variable should be the source of allergy and other serious allergies and first-degree relatives has some allergic diseases, all of these asthma risk factors contribute to the diagnosis of the disease.
Although medical history may sometimes be a negative result, and even the latest childhood asthma guidelines do not include these indicators in the diagnosis, a positive personal and family history of allergy or allergen testing is still extremely valuable in the diagnosis of asthma. It is worth noting that obesity and traffic-related pollution may also be risk factors for asthma and wheezing in children.
Pulmonary function examination is an important means to diagnose asthma, and also an important basis to evaluate the control level and severity of asthma. The objective evidence of reversible restriction of expiratory airflow can be found through the examination of lung function, which is conducive to improving the accuracy of diagnosis.
The Global Initiative for Asthma (GINA) emphasizes that all school-age children (typically 5 years and older who can complete a required pulmonary function test) should be tested and followed up regularly before asthma is diagnosed and control treatment begins.
Lung function is not necessary to diagnose asthma, but it is important to monitor asthma. Because the whole process of standardized diagnosis and treatment of asthma is long, for clinical symptoms and signs have suggested asthma, pulmonary ventilation function examination should still be carried out as far as possible to obtain objective evidence of variable airflow limitation, and reduce misdiagnosis and missed diagnosis.
Given the nonspecific nature of asthma symptoms, which may in many cases lead to wheezing, the differential diagnosis is particularly important.
Clinically, for children ≥ 3 years old with repeated wheezing, it is relatively easy to make accurate judgment of asthma according to the diagnostic criteria of asthma and start the initial treatment.
For infants and young children, especially children less than 1 year old, it is necessary to be very careful in the diagnosis of asthma and must be differentiated from other asthmatic diseases. For these children, it is recommended to carry out relevant evaluation in specialized hospitals and doctors.
In clinical practice, when it is impossible to make an accurate judgment based on the available information, we can also conduct an overall evaluation based on the reaction after treatment and drug withdrawal through experimental treatment for 2-3 months. If “treatment is effective and the drug is discontinued,” the diagnosis of asthma is also supported.
The treatment goal of asthma is to achieve and maintain asthma control, and the standardized control treatment needs to continue for a long time, even for some children for several years. Therefore, the first step in initiating treatment is to give appropriate diagnosis, so that the children can be treated effectively in the future.