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, Critical Care, and Sleep 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 familiar to most clinicians, these symptoms are nonspecific, making it sometimes difficult to distinguish asthma from other respiratory diseases. The diagnosis of asthma requires the history or presence of respiratory symptoms consistent with asthma, combined with the demonstration of variable expiratory airflow obstruction.
The tools used to diagnose 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 information herein is consistent with "The National Asthma Education and Prevention Program (NAEPP): Expert Panel Report 3, Guidelines for the Diagnosis and Management of Asthma -- Full Report 2007" .
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".)
Asthma has defied a precise definition acceptable to all disciplines. Part of the problem relates to the lack of specificity of the symptoms. 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 useful definition would combine the central roles of inflammation and bronchial hyperresponsiveness with the characteristic clinical symptoms. As an example, asthma may be defined 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 .
The latter definition of asthma has features that overlap with the description of chronic obstructive pulmonary disease (COPD). Besides historic features (eg, onset in middle age and older, history of cigarette smoking), the characteristic that best distinguishes COPD from asthma is the degree of reversibility of airflow obstruction. In most instances the airflow obstruction of asthma is largely or completely reversible, while that of COPD is irreversible or incompletely reversible. (See 'Differential diagnosis' below and "Chronic obstructive pulmonary disease: Definition, clinical manifestations, diagnosis, and staging", section on 'Definitions'.)
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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