Diagnosis of asthma in adolescents and adults
- Christopher H Fanta, MD
Christopher H Fanta, MD
- Professor of Medicine
- Harvard Medical School
- Section Editors
- Peter J Barnes, DM, DSc, FRCP, FRS
Peter J Barnes, DM, DSc, FRCP, FRS
- Editor-in-Chief — Pulmonary and Critical Care Medicine
- Section Editor — Asthma
- Professor of Medicine
- National Heart and Lung Institute, Imperial College, London
- Bruce S Bochner, MD
Bruce S Bochner, MD
- Editor-in-Chief — Allergy and Immunology
- Section Editor — Adult Allergy; Asthma
- Samuel M Feinberg Professor of Medicine
- Northwestern University Feinberg School of Medicine
The "classic" signs and symptoms of asthma are intermittent dyspnea, cough, and wheezing. Although typical of asthma, these symptoms are nonspecific, making it sometimes difficult to distinguish asthma from other respiratory diseases. The definitive diagnosis of asthma requires the history or presence of respiratory symptoms consistent with asthma, combined with the demonstration of variable expiratory airflow obstruction [1,2].
Tools used in the diagnosis of asthma include history, physical examination, pulmonary function testing, and other laboratory evaluations. This topic review describes these tools, followed by several specific strategies for making the diagnosis of asthma in adolescents and adults.
The diagnosis of asthma in children and older adults and an overview of asthma management are discussed separately. (See "Asthma in children younger than 12 years: Initial evaluation and diagnosis" and "Diagnosis and management of asthma in older adults" and "An overview of asthma management".)
While asthma is readily recognized in its classic presentation, with intermittent cough, wheeze, and shortness of breath brought on by characteristic triggers and relieved by bronchodilating medications, it is difficult to provide a definition that distinguishes asthma from similar and overlapping conditions. In the absence of a definitive laboratory test or biomarker, asthma has defied precise definition, one acceptable to all disciplines (including clinicians, physiologists, and pathologists). Clinically, its symptoms are non-specific. Physiologically, asthma is characterized by bronchial hyperresponsiveness, the tendency of airways to narrow excessively in response to a variety of stimuli that provoke little or no bronchoconstriction in persons without airway disease, but bronchial hyperresponsiveness is not unique to asthma. Pathologically, asthma may be described broadly as "a chronic inflammatory disorder of the airways" . However, this description omits the characteristic waxing and waning of airflow obstruction in asthma and fails to distinguish asthma from other inflammatory airways disorders, such as chronic bronchitis or bronchiolitis.
A more precise definition combines the central roles of inflammation and bronchial hyperresponsiveness with the characteristic clinical symptoms. Towards this end, asthma has been defined by the Expert Panel 3 of the National Asthma Education and Prevention Program as "a common chronic disorder of the airways that is complex and characterized by variable and recurring symptoms, airflow obstruction, bronchial hyperresponsiveness, and an underlying inflammation. The interaction of these features of asthma determines the clinical manifestations and severity of asthma and the response to treatment" . This definition is descriptive of key features of the disease, but it lacks utility for patients and clinicians.
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- CLINICAL FEATURES
- Physical findings
- Pulmonary function testing
- - Spirometry
- - Bronchodilator response
- - Bronchoprovocation testing
- - Peak expiratory flow
- - Exhaled nitric oxide
- Blood tests
- Tests for allergy
- Initial spirometry shows airflow limitation
- Initial spirometry is normal
- - Serial measurements of lung function over time
- - Bronchoprovocation
- Diagnosis based on history and clinical course
- DIFFERENTIAL DIAGNOSIS
- Conditions causing similar symptoms
- Conditions producing obstructive patterns on spirometry
- Co-existent conditions
- INDICATIONS FOR REFERRAL
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS