Paediatric Asthma 1: Diagnosing Asthma in
Children, Dr Rahul Chodhari
Speaker Key
RC
IV
Rahul Chodhari
Interviewer
RC
My name is Rahul Chodhari. I’m a paediatrician. The talk today was about
management of wheezing children in a primary care setup.
IV
How can you differentiate between viral induced wheeze and asthma?
RC
Approach to a wheeze in primary care environment is about age at which a
wheezing child presents. So, generally speaking, under five years of age, we would
think more about viral induced wheeze and as school-going children with ongoing
wheezing spectrum is thought more on the line of asthma. Viral induced wheeze can
be triggered by either common viruses and sometimes there are other factors, such as
cold or pollen or smoke. On the other hand, asthma is a chronic respiratory disease,
resulting into an airflow obstruction in the lung, which mostly manifests as night-time
coughing, tightness of the chest, difficulty in breathing and requires a medication to
relieve the airflow obstruction.
IV
How would you diagnose virally induced wheeze and asthma in primary care?
RC
Viral induced wheeze, which is often precipitated by viruses, tends to improve
over a period of time whereas viral induced wheeze, which has got other triggers,
such as cold, smoke or pollens, tend to go towards a diagnosis of asthma. It is not easy
to make the diagnosis in one single consultation and it is a time and a journey, which
makes a difference, in terms of knowing which children will have a chronic asthma.
IV
How could it present?
RC
A common presentation of wheezing disorders in children is with
breathlessness, noisiness of the sounds, poor feeding and in school-going children,
often losing out on school attendance. Families would also report that their children
are not able to do exercise in a way they are able to do when they’re well.
IV
What tests are there in primary care to enable diagnosis?
RC
Diagnosis of viral induced wheeze or in asthma is largely clinical and a key
part of the diagnosis for asthma in a school-going child is to think about is there a
high probability of asthma or a low probability of asthma? Features, which will
suggest that there is a high probability of asthma, include episodes of tightening of
chest, wheezing, coughing at night-time, response to the inhalers, and sometimes poor
growth.
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IV
Are there any common pitfalls in diagnosis to try and avoid?
RC
For primary care setup, it’s worth thinking, asthma is very common so it does
get mislabelled as well but for all practical purposes, a dry cough in a community
environment is rarely because of an asthma. It’s also worth exploring what parents
mean by wheeze; in many studies, it has been found that upper respiratory tract
symptoms are misinterpreted by parents as a wheeze. And clarifying parents’
perception is quite important before labelling a diagnosis of asthma.
IV
Once diagnosed, what should a GP do next?
RC
There’s a pragmatic approach of use of medication and a review. It’s also
worth thinking about what is our aim when we diagnose for the families. So,
pragmatic approach is, if you do start the treatment, such as an inhaled corticosteroid,
it’s good practice to do a review in six–eight weeks’ time, with two possible
outcomes: Either there is a possibility that you may be able to reduce the inhaler dose,
or you may need to keep it same or consider a referral if there is not a significant
improvement. The aim of our treatment is to offer children a good quality of life, such
as excellent school attendance, excellent exercise tolerance and reduction in
symptoms such as night-time coughing.
IV
Are there any important differential diagnoses?
RC
There are many number of diagnoses, but the key ones, which are often underreported, under-looked for, are upper airway problems, such as allergic rhinitis; there
is a good experience suggesting that children with allergic rhinitis symptoms are
regularly offered inhalers, with poor response to it. And it’s important to recognise
that the wheeze is not what families are interpreting, upper airway symptoms and it’s
confirmed on auscultation.
IV
If it’s not asthma, what else could it be?
RC
There are few indicators in clinical diagnosis, which would help to suggest
there’s low probability of asthma with differential diagnosis. For example, symptoms,
which present from birth or a perinatal period usually suggest that this is not due to
asthma and other causes. Or, if you have an episode where you’re having
hyperventilation or tingling and a very poor response to the inhaled medication, it’s
probably due to other causes as well and it’s worth thinking about upper airway
sounds, which are regular after infection or allergic rhinitis symptoms, which are
often treated with asthma medication without much of a good response.
IV
Where can GPs find out more?
RC
There’s quite a lot of information available but the key websites, which can
help are NICE guidance on asthma’s management in children, British Thoracic
Society’s October 2014 update on asthma, and for family resource, Asthma UK is
excellent. GP surgeries are welcome to contact me on 0207 830 2211 or on email:
r.chodhari@nhs.net.
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