Download Asthma Consult Checklist – New Diagnosis

Explanatory notes:

  1. Such as wheeze, shortness of breath, cough and chest tightness.4
  2. Including any of episodic breathlessness, wheezing, chest tightness and cough.5
  3. Including chest auscultation and inspection of the upper respiratory tract for signs of allergic rhinitis.6 Physical examination in children should also asses height and weight, and for the presence of chest deformity and eczema.7
  4. Forced expiratory volume in 1 second (FEV1) should be assessed 10–15 minutes after a bronchodilator. Reversible airflow limitation is defined as an FEV1 increase ≥200mL and ≥12% from baseline. Expiratory airflow limitation is defined as FEV1/forced vital capacity (FVC) less than the lower limit of normal for age.2
  5. For recommendations on starting treatment, see the Australian Asthma Handbook including Steps in the diagnosis of asthma in adults,2 Steps in the diagnosis of asthma in children aged 1–5 years,3 Steps in the diagnosis of asthma in children aged 6 years and over,3 Initial treatment choices (adults and adolescents not already using a preventer),8 Classification of asthma and indications for initiating preventer treatment in children aged 6–11,9 and Classification of preschool wheeze and indications for initiating preventer treatment in children aged 1 –5 years.10
  6. Most children aged ≥6 years can reliably perform spirometry.9
  7. Treat with a short-acting beta2 agonist reliever as needed, or a regular preventer (and reliever as needed) according to Australian-approved indications. Assess response after 4–6 weeks and review before prescribing long-term. Discontinue if ineffective. Repeat the treatment trial if effect on symptoms is unclear.9
  8. Consider a short-acting beta2 agonist reliever as needed if wheezing is associated with increased work of breathing. Administer 2–4 puffs (200–400µg) of salbutamol via a spacer and mask to observe response to treatment if a child is wheezing during the appointment, otherwise show parents how to administer salbutamol and ask them to trial it over 1–2 days when wheezing next occurs. A preventer can be trialled in children who already have a provisional diagnosis of asthma, which is defined as all of the following: Wheezing with breathing difficulty or cough, other features increasing probability of asthma (such as history of allergic rhinitis), no signs or symptoms to suggest a serious alternative diagnosis, and clinically important response to a bronchodilator using spirometry.10
  9. Including poor cardiopulmonary fitness, other respiratory conditions, cardiovascular disease, lung cancer or comorbid conditions (such as obesity).11
  10. Including airway hyperresponsiveness tests, airway inflammation tests, allergy tests or imaging.12
  11. Consider referral if diagnosis is uncertain, signs and symptoms don’t respond to a treatment trial or if work-related asthma is suspected.13
  12. Don’t assume cough is due to asthma in the absence of wheezing or breathlessness. Alternative diagnoses include congenital conditions (such as structural airway problems), infections (such as bronchiolitis or chronic rhinosinusitis) or acquired conditions (such as inhaled foreign body).14
  13. Including skin-prick testing for common aeroallergens (for children with recurrent wheezing if it will guide management), bronchial challenge testing or chest X-ray (for unusual respiratory symptoms or localised wheezing).15

Key Australian Asthma Handbook resources:

  • Figure: Steps in the diagnosis of asthma in adults.2
  • Figure: Steps in the diagnosis of asthma in children aged 1–5 years.3
  • Figure: Steps in the diagnosis of asthma in children aged 6 years and over.3
  • Table: Classification of asthma and indications for initiating preventer treatment in children aged 6–11.9
  • Table: Classification of preschool wheeze and indications for initiating preventer treatment in children aged 1–5 10
  • Table: Conditions that can be confused with asthma in children.16
  • Table: Findings that increase or decrease the probability of asthma in adults.11
  • Table: Findings that increase or decrease the probability of asthma in children.9
  • Table: Findings that require investigation in children.17

References

  1. National Asthma Council Australia. Australian Asthma Handbook. Available at: asthmahandbook.org.au. Accessed March 2020.
  2. National Asthma Council Australia. Australian Asthma Handbook. Diagnosing asthma in adults. Available at: https://www. org.au/diagnosis/adults. Accessed March 2020.
  3. National Asthma Council Australia. Australian Asthma Handbook. Diagnosing asthma in children. Available at: https://www. org.au/diagnosis/children. Accessed March 2020.
  4. National Asthma Council Australia. Australian Asthma Handbook. Definitions and commonly used terms. Available at: https:// asthmahandbook.org.au/resources/definitions. Accessed March 2020.
  5. National Asthma Council Australia. Australian Asthma Handbook. Taking a history to investigate asthma-like symptoms in adults. Available at: https://www.asthmahandbook.org.au/diagnosis/adults/initial-investigations/history. Accessed March 2020.
  6. National Asthma Council Australia. Australian Asthma Handbook. Performing a physical examination to investigate asthma-like symptoms in adults. Available at: https://www.asthmahandbook.org.au/diagnosis/adults/initial-investigations/ physical-examination. Accessed March 2020.
  7. National Asthma Council Australia. Australian Asthma Handbook. History and physical examination for a wheezing child aged 6 years or over. Available at: https://www.asthmahandbook.org.au/diagnosis/children/6-years-and-over/history-and-physical-examination. Accessed March 2020.
  8. National Asthma Council Australia. Australian Asthma Handbook. General considerations when prescribing regular preventer treatment for adults. Available at: https://www.asthmahandbook.org.au/management/adults/initial-treatment/ preventers/general-considerations. Accessed March 2020.
  9. National Asthma Council Australia. Australian Asthma Handbook. Provisional diagnosis and treatment trial for asthma in a child aged 6 years and over. Available at: https://www.asthmahandbook.org.au/diagnosis/children/6-years-and-over/ provisional-diagnosis. Accessed March 2020.
  10. National Asthma Council Australia. Australian Asthma Handbook. Treatment trial for preschool wheeze. Available at: https:// asthmahandbook.org.au/diagnosis/children/1-5-years/treatment-trial-for-preschool-wheeze. Accessed March 2020.
  11. National Asthma Council Australia. Australian Asthma Handbook. Considering alternative diagnoses in adults. Available at: https://www.asthmahandbook.org.au/diagnosis/adults/alternative-diagnoses. Accessed March 2020.
  12. National Asthma Council Australia. Australian Asthma Handbook. Considering further investigations in adults. Available at: https://www.asthmahandbook.org.au/diagnosis/adults/further-investigations. Accessed March 2020.
  13. National Asthma Council Australia. Australian Asthma Handbook. General considerations for further investigations in adults.  Available at: https://www.asthmahandbook.org.au/diagnosis/adults/further-investigations/general-considerations.Accessed March 2020.
  14. National Asthma Council Australia. Australian Asthma Handbook. Differential diagnosis for asthma-like symptoms in children aged 6 years and over. Available at: https://www.asthmahandbook.org.au/diagnosis/children/6-years-and-over/ differential-diagnosis-for-asthma-like-symptoms. Accessed March 2020.
  15. National Asthma Council Australia. Australian Asthma Handbook. Further investigations for wheezing in children aged 6 years and over. Available at: https://www.asthmahandbook.org.au/diagnosis/children/6-years-and-over/further-investigations. Accessed March 2020.
  16. National Asthma Council Australia. Australian Asthma Handbook. Differential diagnosis for wheezing in children aged 1–5 years. Available at: https://www.asthmahandbook.org.au/diagnosis/children/1-5-years/alternative-diagnoses. Accessed March 2020.
  17. National Asthma Council Australia. Australian Asthma Handbook. History and physical examination for a wheezing child aged 1–5 years. Available at: https://www.asthmahandbook.org.au/diagnosis/children/1-5-years/history-and-physical-examination. Accessed March 2020.