VERSION 2.0 DIAGNOSIS · COPD . chronic obstructive pulmonary disease . COX . ... Aaron SD,...

VERSION 2.0

DIAGNOSIS Adults

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ABBREVIATIONS

CFC chlorofluorocarbon

COPD chronic obstructive pulmonary disease

COX cyclo-oxygenase

DXA dual-energy X-ray absorptiometry

ED emergency department

EIB exercise-induced bronchoconstriction

FEV1 forced expiratory volume over one second FEV6 forced expiratory volume over six seconds FSANZ Food Standards Australia and New Zealand FVC forced vital capacity

GORD gastro-oesophageal reflux disease

HFA formulated with hydrofluroalkane propellant

ICS inhaled corticosteroid

ICU intensive care unit

IgE Immunoglobulin E IL interleukin

IU international units

IV intravenous

LABA long-acting beta2-adrenergic receptor agonist

LAMA long-acting muscarinic antagonist

LTRA leukotriene receptor antagonist

MBS Medical Benefits Scheme

NHMRC National Health and Medical Research Council

NIPPV non-invasive positive pressure ventilation

NSAIDs nonsteroidal anti-inflammatory drugs

OCS oral corticosteroids

OSA obstructive sleep apnoea

PaCO carbon dioxide partial pressure on blood gas

analysis

PaO oxygen partial pressure on blood gas analysis

PBS Pharmaceutical Benefits Scheme

PEF peak expiratory flow

pMDI pressurised metered-dose inhaler or 'puffer'

PPE personal protective equipment

SABA short-acting beta2 -adrenergic receptor agonist

SAMA short-acting muscarinic antagonist

SaO2 oxygen saturation

SpO2 peripheral capillary oxygen saturation measured

by pulse oximetry

TGA Therapeutic Goods Administration

RECOMMENDED CITATION

National Asthma Council Australia. Australian Asthma Handbook, Version 2.0. National Asthma Council Australia, Melbourne, 2019.

Available from: http://www.asthmahandbook.org.au

ISSN 2203-4722

© National Asthma Council Australia Ltd, 2019

SPONSORS

National Asthma Council Australia would like to acknowledge the support of the sponsors of Version 2.0 of the Australian Asthma Handbook:

• Boehringer Ingelheim Australia

• Novartis Australia

NATIONAL ASTHMA COUNCIL AUSTRALIA

ABN 61 058 044 634

Suite 104, Level 1 153-161 Park Street South Melbourne VIC 3205 Australia

Tel: 03 9929 4333

Fax: 03 9929 4300

Email: [email protected]

Website: nationalasthma.org.au

DISCLAIMER

The Australian Asthma Handbook has been compiled by the National Asthma Council Australia for use by general practitioners, pharmacists, asthma educators, nurses and other health professionals and healthcare students. The information and treatment protocols contained in the Australian Asthma Handbook are based on current evidence and medical knowledge and practice as at the date of publication and to the best of our knowledge. Although reasonable care has been taken in the preparation of the Australian Asthma Handbook, the National Asthma Council Australia makes no representation or warranty as to the accuracy, completeness, currency or reliability of its contents.

The information and treatment protocols contained in the Australian Asthma Handbook are intended as a general guide only and are not intended to avoid the necessity for the individual examination and assessment of appropriate courses of treatment on a case-by-case basis. To the maximum extent permitted by law, acknowledging that provisions of the Australia Consumer Law may have application and cannot be excluded, the National Asthma Council Australia, and its employees, directors, officers, agents and affiliates exclude liability (including but not limited to liability for any loss, damage or personal injury resulting from negligence) which may arise from use of the Australian Asthma Handbook or from treating asthma according to the guidelines therein.

http://www.asthmahandbook.org.au/

mailto:[email protected]

HOME > DIAGNOSIS > ADULTS

Overview

A clinical definition of asthma in adults

Asthma is defined clinically as the combination of variable respiratory symptoms (e.g. wheeze, shortness of breath, cough and chesttightness) and excessive variation in lung function.

See: A working definition of asthma

There is no single reliable test ('gold standard') and there are no standardised diagnostic criteria for asthma.

The diagnosis of asthma is based on:

historyphysical examinationconsidering other diagnosesdocumenting variable airflow limitation.

In some patients, observing a response to treatment may help confirm the diagnosis, but lack of response to bronchodilators or to inhaledcorticosteroids does not rule out asthma.

Figure. Steps in the diagnosis of asthma in adults

Please view and print this figure separately: http://www.asthmahandbook.org.au/figure/show/4

The guidance in this section generally also applies to older adolescents.

In this section

Initial investigations

History, physical examination and lung function testing in the investigation of asthma-like symptoms in adults and adolescents

http://www.asthmahandbook.org.au/diagnosis/adults/initial-investigations

Alternative diagnoses

Considering alternative diagnoses in adults and adolescents

http://www.asthmahandbook.org.au/diagnosis/adults/alternative-diagnoses

Making the diagnosis

Considerations and criteria for the diagnosis of asthma in adults and adolescents

http://www.asthmahandbook.org.au/diagnosis/adults/making-a-diagnosis

Starting treatment

Reviewing the response to treatment to help confirm the diagnosis in adults and adolescents

http://www.asthmahandbook.org.au/diagnosis/adults/starting-treatment

Further investigations

When to consider further investigations, including tests of airway hyperresponsiveness or airway inflammation, allergy tests andimaging, in the investigation of asthma symptoms in adults and adolescents

http://www.asthmahandbook.org.au/diagnosis/adults/further-investigations


asthmahandbook.org.auAustralian Asthma Handbook v2.0 asset ID: 4

VARIABLE RESPIRATORY SYMPTOMS THAT SUGGEST ASTHMA

HISTORY AND PHYSICAL EXAMINATION

Table. Findings that increase or decrease the probability of asthma in adults

Supports asthma diagnosis?

SPIROMETRYFEV1 before and 10-15 mins after bronchodilator

Reversible airflow limitation? (FEV1 increase ≥200 mL and ≥12% from baseline)

Expiratory airflow limitation? (FEV1/FVC < lower limit of normal for age)

asthmaStart asthma treatment and review response

INVESTIGATIONS FOR SPECIFIC ALTERNATIVE DIAGNOSIS

Alternative diagnosis confirmed?

FURTHER INVESTIGATIONSTests as indicated

Consider bronchial provocation test

Supports asthma diagnosis?

ALTERNATIVE DIAGNOSIS

CONSIDER REFERRAL

NO NO

YES

NO

YES YES

NO YES

HOME > DIAGNOSIS > ADULTS > INITIAL INVESTIGATIONS

In this section

History

Taking a history to investigate asthma-like symptoms in adults and adolescents

http://www.asthmahandbook.org.au/diagnosis/adults/initial-investigations/history

Physical examination

Performing a physical examination to investigate asthma-like symptoms in adults and adolescents

http://www.asthmahandbook.org.au/diagnosis/adults/initial-investigations/physical-examination

Lung function

Assessing lung function to investigate asthma-like symptoms in adults and adolescents

http://www.asthmahandbook.org.au/diagnosis/adults/initial-investigations/lung-function

HOME > DIAGNOSIS > ADULTS > INITIAL INVESTIGATIONS > HISTORY

Recommendations

Consider asthma in adults with (any of):

episodic breathlessnesswheezingchest tightnesscough.

Ask about:

current symptoms (both daytime and night-time)pattern of symptoms (e.g. course over day, week or year)precipitating or aggravating factors (e.g. exercise, viral infections, ingested substances, allergens)relieving factors (e.g. medicines)impact on work and lifestylehome and work environmentsmoking history (tobacco or cannabis, exposure to other people’s smoke)past history of allergies including atopic dermatitis (eczema) or allergic rhinitis (‘hay fever’)family history of asthma and allergies.

When respiratory symptoms are not typical, do not rule out the possibility of asthma without doing spirometry, because symptoms ofasthma vary widely from person to person.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).


Consensus


Last reviewed version 2.0


Consensus


HOME > DIAGNOSIS > ADULTS > INITIAL INVESTIGATIONS > PHYSICAL EXAMINATION

Recommendations

Perform a physical examination, including chest auscultation and inspection of upper respiratory tract for signs of allergic rhinitis.

Do not rule out the possibility of asthma without doing spirometry, because physical examination may be normal when symptoms areabsent and this does not exclude a diagnosis of asthma.

More information

Significance of findings on physical examination

Wheeze suggests asthma but does not prove the diagnosis. Widespread wheeze on auscultation of the chest during symptoms increasesthe probability that the patient has asthma, but this may also occur in patients with COPD, viral or bacterial respiratory infection,

tracheomalacia or inhaled foreign body. Obese people who do not have asthma may also report wheezing.1

High-pitched stridor is commonly mistaken for wheezing in people with upper airway dysfunction.2 However, careful auscultation will

reveal that the sound is localised to the upper airway (not peripheral airway expiratory wheezing).2

Crackles on chest auscultation indicate an alternate or concurrent diagnosis.

References

Aaron SD, Vandemheen KL, Boulet LP, et al. Overdiagnosis of asthma in obese and nonobese adults. CMAJ. 2008; 179: 1121-1131.Available from: http://www.cmaj.ca/content/179/11/1121.full

1.

Morris MJ, Christopher KL. Diagnostic criteria for the classification of vocal cord dysfunction. Chest. 2010; 138: 1213-23. Availablefrom: https://journal.chestnet.org/article/S0012-3692(10)60600-9/fulltext

2.


Consensus



Consensus


HOME > DIAGNOSIS > ADULTS > INITIAL INVESTIGATIONS > LUNG FUNCTION

Recommendations

Perform or arrange spirometry for every patient with suspected asthma.

Note: If reliable equipment and appropriately trained staff are available, spirometry can be performed in primary care. If not, refer to an appropriateprovider such as an accredited respiratory function laboratory.

Measure bronchodilator reversibility by performing spirometry before and after administration of a rapid-onset beta2 agonistbronchodilator (e.g. 4 puffs of salbutamol 100 microg/actuation via pressurised metered-dose inhaler and spacer).

Notes

Airflow limitation is defined as reversible (i.e. bronchodilator response is clinically important) if FEV1 increases by ≥200 mL and ≥12%.

Failure to demonstrate reversible airflow limitation after bronchodilator (‘bronchodilator reversibility’) does not exclude asthma, and its presencedoes not prove asthma – the pattern of symptoms and other clinical features must also be considered.



Record the ratio of FEV1 to FVC (FEV1/FVC). Before making the diagnosis of asthma, confirm that FEV1/FVC is reduced (less than thelower limit of normal for age) at a time when FEV1 is lower than predicted.

Note: If the spirometer does not provide lower limit of normal for age, use the follow age-based cut-points to indicate expiratory airflow limitation inadults and older adolescents:

less than 0.85 (up to 19 years)less than 0.80 (20–39 years)less than 0.75 (40–59 years)less than 0.70 (60 years and older).


Consensus



Consensus




Consensus

Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference to thefollowing source(s):

National Heart Lung and Blood Institute (NHLBI) National Asthma Education and Prevention Program, 20071

Johns and Pierce, 20112

Quanjer et al. 20123

If a patient shows some improvement in FEV1 after bronchodilator, but does not meet criteria for reversible airflowlimitation, consider other investigations. If necessary, repeat spirometry after a treatment trial of 4–6 weeks with regular low-doseinhaled corticosteroid plus short-acting beta2 agonist as needed, to see if there is a significant improvement in symptoms and lungfunction.

Note: Airflow limitation can be transient (e.g. when recorded during a severe acute infection of the respiratory tract) and does not necessarily meanthat the person has chronic asthma. Ideally, airflow limitation should be confirmed when the patient does not have a respiratory tract infection.

Hand-held lung function-measuring devices (designed to measure FEV1 and/or FEV6, but not FVC) can be used in COPD case-findingand may also be useful in asthma case-finding, but must not be relied on either for ruling out asthma or when making a definitivediagnosis of asthma, because there is not enough evidence and validated protocols have not been developed.

Do not use peak flow meters in place of spirometry for diagnosing asthma.

More information

Spirometry in diagnosis and monitoring

Spirometry is the best lung function test for diagnosing asthma and for measuring lung function when assessing asthma control.Spirometry can:

detect airflow limitation

measure the degree of airflow limitation compared with predicted normal airflow (or with personal best)demonstrate whether airflow limitation is reversible.

It should be performed by well-trained operators with well-maintained and calibrated equipment.4, 5

Before performing spirometry, check if the person has any contraindications (e.g. myocardial infarction, angina, aneurysm, recentsurgery, suspected pulmonary embolism, suspected pneumothorax, fractured ribs). Advise them to stop if they become dizzy.

Clearly explain and physically demonstrate correct spirometry technique: 2

Sit upright with legs uncrossed and feet flat on the floor and do not lean forward.Breathe in rapidly until lungs feel absolutely full. (Coaching is essential to do this properly.)Do not pause for more than 1 second.Place mouthpiece in mouth and close lips to form a tight seal.Blast air out as hard and fast as possible and for as long as possible, until the lungs are completely empty or you are unable to blowout any longer.Remove mouthpiece.

Repeat the test until you obtain three acceptable tests and these meet repeatability criteria.

Acceptability of test

A test is acceptable if all the following apply:


Consensus



Consensus



Consensus


Go to: National Asthma Council Australia's spirometry technique video, Performing spirometry in primary care

forced expiration started immediately after full inspirationexpiration started rapidlymaximal expiratory effort was maintained throughout the test, with no stopsthe patient did not cough during the testthe patient did not stop early (before 6 seconds for adults and children over 10 years, or before 3 seconds for children under 10years).

Record the highest FEV1 and FVC result from the three acceptable tests, even if they come from separate blows.2

Repeatability criteria

Repeatability criteria for a set of acceptable tests are met if both of the following apply:4

the difference between the highest and second-highest values for FEV1 is less than 150 mL

the difference between the highest and second-highest values for FVC is less than 150 mL.

For most people, it is not practical to make more than eight attempts to meet acceptability and repeatability criteria.2

Testing bronchodilator response (reversibility of airflow limitation)

Repeat spirometry 10-15 minutes after giving 4 separate puffs of salbutamol (100 microg/actuation) via a pressurised metered-dose

inhaler and spacer.2 (For patients who have reported unacceptable side-effects with 400 microg, 2 puffs can be used.)

For adults and adolescents, record a clinically important bronchodilator response if FEV1 increases by ≥ 200 mL and ≥ 12%.2

For children, record a clinically important bronchodilator response if FEV1 increases by

≥ 12%.2


Roles of other lung function tests in diagnosing asthma in adults

Peak expiratory flow meters in asthma diagnosisOccasional measurement of peak expiratory flow rate using a peak flow meter is not as reliable as spirometry in the diagnosis of asthma

and should not be used as a substitute.6

However, peak expiratory flow monitoring can be used to support the diagnosis of asthma in some patients (e.g. as one of severalinvestigations in the assessment of suspected work-related asthma).

When using peak expiratory flow rate to measure lung function in diagnostic investigation, greater than 10% diurnal variation in peak

expiratory flow rate with twice-daily readings (averaged for one week) suggests a diagnosis of asthma:7

Hand-held lung function measuring devices

Small hand-held devices that measure FEV1 and/or FEV6 could be useful in primary care case-finding to detect patients who need full

investigation for COPD.6 However, there is not enough evidence to recommend their use in asthma diagnosis at present.6

Other lung function tests used in further investigation

Tests of airway hyperresponsiveness, lung volume tests and diffusing capacity tests may have roles within further investigation ofrespiratory symptoms in some patients.


Definition of variable expiratory airflow limitation

Most of the tests for variable expiratory airflow limitation are based on showing variability in FEV1. While reduced FEV1 may be seen

with many other lung diseases (or due to poor spirometric technique), a reduced ratio of FEV1 to FVC indicates airflow

limitation.8 Normal FEV1/FVC values derived from population studies vary,1, 3 but are usually greater than:1

0.85 in people aged up to 19 years0.80 in people aged 20–39 years0.75 in people aged 40–59 years0.70 in people aged 60–80 years.

In children, it is less useful to define expiratory airflow limitation according to a specific cut-off for FEV1/FVC ratio, because normal

values in children change considerably with age.3

Go to: National Asthma Council Australia’s Spirometry Resources

Some spirometers provide predicted normal values specific to age group. If these are available, a FEV1/FVC ratio less than the lower

limit of normal (i.e. less than the 5th percentile of normal population) indicates airflow limitation.

Variable expiratory airflow limitation (beyond the range seen in healthy populations) can be documented if any of the following arerecorded:

a clinically important increase in FEV1 (change in FEV1 of at least 200 mL and 12% from baseline for adults, or at least 12% from

baseline for children) 10–15 minutes after administration of bronchodilatorclinically important variation in lung function (at least 20% change in FEV1) when measured repeatedly over time (e.g. spirometry on

separate visits)a clinically important reduction in lung function (decrease in FEV1 of at least 200 mL and 12% from baseline on spirometry, or

decrease in peak expiratory flow rate by at least 20%) after exercise (formal laboratory-based exercise challenge testing usesdifferent criteria for exercise-induced bronchoconstriction)a clinically important increase in lung function (at least 200 mL and 12% from baseline) after a trial of 4 or more weeks of treatmentwith an inhaled corticosteroidclinically important variation in peak expiratory flow (diurnal variability of more than 10%)a clinically important reduction in lung function (15–20%, depending on the test) during a test for airway hyperresponsiveness(exercise challenge test or bronchial provocation test) measured by a respiratory function laboratory.

Notes

Patients referred to a respiratory function laboratory may be asked not to take certain medicines within a few hours to days before a spirometry visit.

A clinically important increase or decrease in lung function is defined as a change in FEV1 of at least 200 mL and 12% from baseline for adults, or at

least 12% from baseline for children, or a change in peak expiratory flow rate of at least 20% on the same meter.5, 8 A clinically important increase inFVC after administering bronchodilator may also indicate reversible airflow limitation, but FVC is a less reliable measure in primary care because FVCmay vary due to factors such as variation in inspiratory volume or expiratory time.

The finding of ‘normal’ lung function during symptoms reduces the probability that a patient has asthma, but a clinically important improvement inresponse to bronchodilator or inhaled corticosteroid can occur in patients whose baseline value is within the predicted normal range.

The greater the variation in lung function, the more certain is the diagnosis of asthma. However, people with longstanding asthma may develop fixedairflow limitation.

Reversibility in airflow limitation may not be detected if the person is already taking a long-acting beta2 agonist or inhaled corticosteroid.

Airflow limitation can be transient and does not necessarily mean that the person has asthma (e.g. when recorded during a severe acute infection of therespiratory tract). Ideally, airflow limitation should be confirmed when the patient does not have a respiratory tract infection. Reduction in lungfunction during a respiratory tract infection with improvement in lung function after its resolution, commonly occurs in people with asthma, but canalso be seen in patients with COPD or in healthy people without either asthma or COPD.9,10

References

National Heart Lung and Blood Institute (NHLBI) National Asthma Education and Prevention Program. Expert Panel Report 3:guidelines for the diagnosis and management of asthma. Full report 2007. US Department of Health and Human Services NationalInstitutes of Health, Bethesda, 2007. Available from: http://www.nhlbi.nih.gov/health-pro/guidelines/current/asthma-guidelines/full-report

1.

Johns DP, Pierce R. Pocket guide to spirometry. 3rd edn. McGraw Hill, North Ryde, 2011.2. Quanjer PH, Stanojevic S, Cole TJ, et al. Multi-ethnic reference values for spirometry for the 3-95-yr age range: the global lungfunction 2012 equations. Eur Respir J. 2012; 40: 1324-43. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22743675

3.

Miller MR, Hankinson J, Brusasco V, et al. Standardisation of spirometry. Eur Respir J. 2005; 26: 319-338. Available from:http://erj.ersjournals.com/content/26/2/319

4.

Levy ML, Quanjer PH, Booker R, et al. Diagnostic Spirometry in Primary Care: Proposed standards for general practice compliantwith American Thoracic Society and European Respiratory Society recommendations. Prim Care Respir J. 2009; 18: 130-147.Available from: http://www.ncbi.nlm.nih.gov/pubmed/19684995

5.

National Asthma Council Australia. Asthma and lung function tests. An information paper for health professionals. National AsthmaCouncil Australia, Melbourne, 2012. Available from: http://www.nationalasthma.org.au/publication/asthma-lung-function-tests-hp

6.

Chong J, Haran C, Chauhan BF, Asher I. Intermittent inhaled corticosteroid therapy versus placebo for persistent asthma inchildren and adults. Cochrane Database Syst Rev. 2015; : Cd011032. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26197430

7.

Pellegrino R, Viegi G, Brusasco V, et al. Interpretative strategies for lung function tests. Eur Respir J. 2005; 26: 948-968. Availablefrom: http://erj.ersjournals.com/content/26/5/948

8.

Collier AM, Pimmel RL, Hasselblad V, et al. Spirometric changes in normal children with upper respiratory infections. Am Rev RespirDis. 1978; 117: 47-53. Available from: http://www.ncbi.nlm.nih.gov/pubmed/619724

9.

Melbye H, Kongerud J, Vorland L. Reversible airflow limitation in adults with respiratory infection. Eur Respir J. 1994; 7: 1239-1245.10.

Go to: National Asthma Council Australia’s Spirometry ResourcesGo to: National Asthma Council Australia and Woolcock Institute Peak Flow Chart

Available from: http://www.ncbi.nlm.nih.gov/pubmed/7925901

HOME > DIAGNOSIS > ADULTS > ALTERNATIVE DIAGNOSES

Recommendations

Consider other possible causes of respiratory symptoms, including:

poor cardiopulmonary fitnessother respiratory conditions (e.g. bronchiectasis, chronic obstructive pulmonary disease, hyperventilation/dysfunctionalbreathing, inhaled foreign body, large airway stenosis, pleural effusion, pulmonary fibrosis, rhinitis/rhinosinusitis, upper airwaydysfunction)cardiovascular disease (e.g. chronic heart failure, pulmonary hypertension)comorbid conditions (e.g. obesity, gastro-oesophageal reflux)lung cancer.


Asthma is more likely to explain the symptoms if any of

these apply

Asthma is less likely to explain the symptoms if any of

these apply

More than one of these symptoms:

wheeze

breathlessness

chest tightness

cough

Symptoms recurrent or seasonal

Symptoms worse at night or in the early morning

History of allergies (e.g. allergic rhinitis, atopic dermatitis)

Symptoms obviously triggered by exercise, cold air,

irritants, medicines (e.g. aspirin or beta blockers),

allergies, viral infections, laughter

Family history of asthma or allergies

Symptoms began in childhood

Widespread wheeze audible on chest auscultation

FEV1 or PEF lower than predicted, without other

explanation

Eosinophilia or raised blood IgE level, without other

explanation

Symptoms rapidly relieved by a SABA bronchodilator

Dizziness, light-headedness, peripheral tingling

Isolated cough with no other respiratory symptoms

Chronic sputum production

No abnormalities on physical examination of chest when

symptomatic (over several visits)

Change in voice

Symptoms only present during upper respiratory tract

infections

Heavy smoker (now or in past)

Cardiovascular disease

Normal spirometry or PEF when symptomatic (despite

repeated tests)

Adapted from:

Respiratory Expert Group, Therapeutic Guidelines Limited. Therapeutic Guidelines: Respiratory, Version 4. Therapeutic GuidelinesLimited, Melbourne, 2009.

British Thoracic Society (BTS) Scottish Intercollegiate Guidelines Network (SIGN). British Guideline on the Management of Asthma. Anational clinical guideline. BTS/SIGN, Edinburgh; 2012. Available from: https://www.brit-thoracic.org.uk/guidelines-and-quality-standards/asthma-guideline/.

Asset ID: 2

Consider the possibility of upper airway dysfunction when FEV1/FVC ratio on spirometry is normal or when symptoms ofbreathlessness or wheeze do not improve after taking short acting beta2 agonist.

Investigate cough thoroughly if there are findings that might indicate a serious alternative or comorbid diagnosis.

If expiratory airflow limitation is not completely reversible, consider the possibility of COPD as an alternative diagnosis or of asthma–COPD overlap, especially in smokers and ex-smokers over 35 years old and in people over 65 years old.

Consider the possibility of adult-onset asthma in people with dyspnoea, wheeze or cough, even if they have no previous diagnosis ofasthma.


ConsensusBased on clinical experience and expert opinion (informed by evidence, where available).


ConsensusBased on clinical experience and expert opinion (informed by evidence, where available), with particular reference to thefollowing source(s):

Benninger et al. 2011 1

Deckert and Deckert, 2010 2

Weinberger and Abu-Hasan, 2007 3

Morris and Christopher, 2010 4

Kenn and Balkissoon, 2011 5



Gibson et al. 2010 6



Abramson et al. 2012 7



More information

Upper airway dysfunction

Upper airway dysfunction is intermittent, abnormal adduction of the vocal cords during respiration, resulting in variable upper airway

obstruction. It often mimics asthma1, 2 and is commonly misdiagnosed as asthma.3, 4 It can cause severe acute episodes of dyspnoea

that occur either unpredictably or due to exercise.3 Inspiratory stridor associated with vocal cord dysfunction is often described as

‘wheezing’,3 but symptoms do not respond to asthma treatment.2, 5

Upper airway dysfunction can coexist with asthma.1 People with asthma who also have upper airway dysfunction experience moresymptoms than those with asthma alone and this can result in over-treatment if vocal cord dysfunction is not identified and managed

appropriately.1

Upper airway dysfunction probably has multiple causes.1 In some people it is probably due to hyperresponsiveness of the larynx in

response to intrinsic and extrinsic triggers.1, 8 Triggers can include exercise, psychological conditions, airborne irritants, rhinosinusitis,

gastro-esophageal reflux disease, and medicines.2, 4

Upper airway dysfunction should be considered when spirometry shows normal FEV1/FVC ratio in a patient with suspected asthma4 or

symptoms do not respond to short-acting beta2 agonist reliever. The shape of the maximal respiratory flow loop obtained by spirometry

may suggest the diagnosis.3 Direct observation of the vocal cords is the best method to confirm the diagnosis of upper airway

dysfunction.1

Asthma–COPD overlap

Distinguishing between typical allergic asthma (childhood-onset allergic asthma) and typical COPD (emphysema in a heavy smoker) is

straightforward.9 However, it can be difficult to distinguish COPD from asthma in adults who have features of both conditions.10,

11These people are described as having asthma–COPD overlap.10, 9, 12

Asthma–COPD overlap is not a single, well-defined disease entity, but includes a range of airway disease phenotypes with different

causal mechanisms.10, 13 Features of both asthma and COPD have been described in:12, 14, 15, 16

people with current asthma (allergic or non-allergic) who have had significant exposure to tobacco smokepeople with longstanding asthma or late-onset asthma who have become persistently short of breath over timepeople significant smoking history and symptoms consistent with COPD who also have a history of childhood asthmapeople who present in middle age or later with shortness of breath, with a history of childhood asthma but no or few symptoms inbetween, and little smoking history.

Figure. Development of asthma, COPD and asthma–COPD overlap


People with asthma–COPD overlap often have poor disease outcomes, including:10, 1718, 19, 20

high need for healthcare servicesworse quality of life, more wheezing, dyspnoea, cough and sputum production, and more frequent and severe respiratoryexacerbations and hospitalisations, than people with COPD or asthma aloneworse lung function demonstrated by spirometry than those with COPD alone, despite lower average exposure to tobacco smoke.

Features of asthma, COPD and asthma–COPD overlap

If several features of both asthma and COPD are present and neither condition is strongly favoured, respiratory disease should bemanaged according to recommendations for asthma–COPD overlap.

Table. Features that, when present, favour asthma or COPD

Clinical feature (if

measured/relevant)

Asthma more likely COPD more likely

Age of onset Before 20 After 40


measured/relevant)


Pattern of symptoms Variation in respiratory symptoms:

changes over minutes, hours or days

worse at night or early morning

triggered by exercise, emotions,

airborne pollutants or allergens

Persistence of respiratory symptoms

despite treatment

Symptoms every day, including

exertional dyspnoea

History of chronic cough and sputum

unrelated to specific triggers, before

onset of dyspnoea

Lung function Expiratory airflow limitation* is

variable#

Lung function normal between

symptoms

Expiratory airflow limitation* is

persistent†

Lung function abnormal between

symptoms

History Previous diagnosis of asthma

Family history of asthma and allergies§

(allergic rhinitis or eczema)

Previous diagnosis of COPD, chronic

bronchitis or emphysema

Heavy exposure to tobacco smoke or

biomass fuels

Long-term disease trajectory Seasonal or yearly variation in

symptoms

Improvements (spontaneously or in

response to medication) last for weeks

Slowly worsens over years

Relief in response to medication is

limited and short term

Chest X-ray Normal Severe hyperinflation‡

Features that, when present, increase the probability of either typical asthma or typical COPD. None of these features is essential tomake the diagnosis of asthma or COPD, with the exception of persistent airflow limitation for making the diagnosis of COPD.

* Expiratory airflow limitation: indicated by a reduced ratio of forced expiratory volume in one second (FEV1) to forced vital capacity

(FVC) on spirometry (FEV1/FVC less than the lower limit of normal (i.e. less than the 5th percentile of normal population). Typical

FEV1/FVC values derived from population studies are > 0.75 in people aged 40–59 years and > 0.70 in people aged 60–80 years.

# Variable expiratory airflow limitation: variation beyond the range seen in healthy populations. It is indicated in adults by any of thefollowing:

a clinically important increase in FEV1 (change in FEV1 of at least 200 mL and 12% from baseline) 10–15 minutes after

administration of bronchodilatorclinically important variation in lung function (at least 20% change in FEV1) when measured repeatedly over time (e.g. spirometry

on separate visits)a clinically important increase in lung function (at least 200 mL and 12% from baseline) after ≥ 4 weeks’ treatment trial with anICSclinically important variation in peak expiratory flow (diurnal variability of more than 10%, calculated over 1–2 weeks as theaverage of daily amplitude per cent mean)a clinically important reduction in lung function (decrease in FEV1 of at least 200 mL and 12% from baseline on spirometry, or

decrease in peak expiratory flow rate by at least 20%) after exercise (formal laboratory-based exercise challenge testing usesdifferent criteria for exercise-induced bronchoconstriction)a clinically important reduction in lung function (15–20%, depending on the test) during a test for airway hyperresponsiveness(exercise challenge test or bronchial provocation test) measured by a respiratory function laboratory.

The greater the variations, or the more occasions excess variation is seen, the more confidently the diagnosis of variable expiratoryairflow limitation consistent with asthma can be made.

† Persistent expiratory airflow limitation is indicated by reduced post-bronchodilator FEV1/FVC*

§ Lack of history of atopy does not exclude non-allergic asthma.

‡ Chest X-ray may be normal in a patient with COPD

Adapted from

Global Initiative for Asthma, Global Initiative for Obstructive Lung Disease. Diagnosis and initial treatment of asthma, COPD andasthma-COPD overlap. Updated April 2017. Global Initiative for Asthma and Global Initiative for Obstructive Lung Disease; 2017.Available from: http://ginasthma.org/gina-reports

Asset ID: 104

Table. Spirometry findings in asthma, COPD and asthma–COPD overlap

Finding Consistent with

Asthma COPD Asthma–COPD

overlap

Normal FEV1 /FVC before of after

bronchodilator

Yes No No *

Abnormal lung function

(post-bronchodilator reduced FEV1/FVC and FEV1

< lower limit of normal)

Yes # Yes Yes

Airflow limitation with greater

bronchodilator reversibility than in healthy

population

(post-bronchodilator FEV1 increase ≥ 12% and

200mL from baseline)

Yes ‡ Yes Yes

Marked bronchodilator reversibility

(FEV1 increase ≥ 12% and 400mL from baseline)

Yes Possible but unusual†

Possible §

FEV1/FVC: ratio of forced expiratory volume in one second (FEV1) to forced vital capacity (FVC), either before or after

bronchodilator

* Normal FEV1/FVC is not consistent with COPD unless there is other evidence of chronic non-reversible expiratory airflow

limitation.

# This finding is consistent with asthma that is poorly controlled or measured during a flare-up, or can be seen in some patients withlongstanding asthma.

‡ The greater the variation, and the more times variation is seen, the more likely the diagnosis of asthma. However, some patientswith longstanding asthma may develop persistent airflow limitation.

† Marked reversibility strongly favours asthma and is generally inconsistent with COPD, but does not rule out asthma–COPDoverlap.

§ This finding may be seen in patients with asthma–COPD overlap, or occasionally in COPD, especially when FEV1 is low.

Sources


Woodruff P, van den Berge M, Boucher R et al. ATS-NHLBI Asthma COPD Overlap (ACO) Workshop Report. Am J Respir Crit Care Med

2017; 196:375-381. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28636425

Asset ID: 103

Treatment for patients with asthma–COPD overlap

Inhaled corticosteroid treatment at low–moderate doses is essential to reduce the risk of potentially life-threatening flare-ups, even if

asthma symptoms appear mild or infrequent.10, 21

Most patients also need treatment with a long-acting bronchodilator (either long-acting beta2 agonist or long-acting muscarinic

antagonist) in addition to an inhaled corticosteroid. Long-acting beta2 agonists and long-acting muscarinic antagonists should not be

used by people with asthma or asthma–COPD overlap unless they are also taking an inhaled corticosteroid (either in combination orseparately).

Table. Long-acting bronchodilators for asthma–COPD overlap

Class Dosing

frequency

Agent Brand name

ICS–LABA

combinations

Once daily Fluticasone furoate + vilanterol Breo Ellipta 100/25 microg†

Do not prescribe

200/25 microg

formulation#

Twice daily Budesonide + formoterol Symbicort Rapihaler

Symbicort Turbuhaler

Twice daily Fluticasone propionate + formoterol Flutiform

Twice daily Fluticasone propionate + salmeterol Fluticasone and Salmeterol

Cipla

Seretide Accuhaler

Seretide MDI

LABAs* Once daily Indacaterol Onbrez Breezhaler

Twice daily Formoterol Oxis

Foradile

Twice daily Salmeterol Serevent Accuhaler

LAMAs* Once daily Glycopyrronium Seebri Breezhaler

Once daily Tiotropium Spiriva

Spiriva Respimat

Once daily Umeclidinium Incruse Ellipta‡

Twice daily Aclidinium Bretaris Genuair

Class Dosing

frequency

Agent Brand name

LABA–LAMA

combinations*

Once daily Indacaterol + glycopyrronium Ultibro Breezhaler

Once daily Olodaterol + tiotropium Spiolto Respimat

Once daily Vilanterol + umeclidinium Anoro Ellipta‡

Twice daily Formoterol + aclidinium Brimica Genuair

* Ensure that patient is also using regular long-term ICS. LABAs and LAMAs should not be used by people with asthma or asthma–COPD overlap unless they are also taking an ICS, in combination or separately)

Advise patients/carers that inhalers should be stored below 30°C and should not be left in cars.

† The inhaler must be discarded 1 month after opening the package and removing device from tray. When first opened, patientsshould write the discard date on the label in the space provided. If stored in the refrigerator, inhaler should be taken out and allowedto return to room temperature for at least an hour before use.

‡ The inhaler must be discarded 6 weeks after opening the package and removing device from tray. When first opened, patientsshould write the discard date on the label in the space provided. If stored in the refrigerator, inhaler should be taken out and allowedto return to room temperature for at least an hour before use.

# Only the 100/25 microg dose of fluticasone furoate/vilanterol is TGA-approved for treatment of COPD. The higher dose (200/25microg) is not TGA-approved for the treatment of COPD, so it should not be used in people with asthma–COPD overlap.

High doses of ICS (alone or in combination) are not recommended in patients with COPD and should therefore be used with cautionin patients with asthma-COPD overlap, because of the risk of pneumonia.

Refer to PBS status before prescribing.


Asset ID: 105

Management should also include smoking cessation, treatment of comorbid conditions, physical activity, pulmonary rehabilitation,

vaccinations, self-management (including a regularly updated action plan) and regular follow-up.10

Respiratory tract infections should be monitored carefully because people with asthma–COPD overlap have high morbidity rates and

because ICS treatment is associated with increased risk of non-fatal pneumonia in people with COPD.22 Most of the available evidenceis from patients treated with fluticasone propionate, particularly at higher doses. Increased pneumonia rates have also been observed instudies of patients with COPD using fluticasone furoate/vilanterol. The higher dose of fluticasone furoate/vilanterol (Breo Ellipta200/25 microg) is not approved for patients with COPD, so it should also not be used in patients with asthma–COPD overlap.

Specialist referral should be considered for patients with atypical symptoms or symptoms that suggest an alternative diagnosis,persistent symptoms or flare-ups despite treatment, or complex comorbidities.

For information on diagnosis and management of COPD, refer to the COPD-X Concise Guide for Primary Care.23


Cough and asthma in adults

When no other asthma symptoms are present, chronic cough (present for more than 8 weeks) is unlikely to indicate asthma.

Chronic cough may be due to asthma if:6

cough is episodiccough with exercise is associated with other symptoms that suggest airflow limitation (expiratory wheeze or breathlessness)

Go to: Asthma action plansGo to: COPD action plans

Go to: National Asthma Council Australia's Asthma–COPD overlap information paper

Go to: Lung Foundation Australia's COPD-X Concise Guide for Primary Care

spirometry confirms reversible airflow limitation.

If cough is due to asthma, it should respond to treatment with an inhaled corticosteroid preventer taken regularly and reliever as

needed).6

Findings that suggest a serious alternative or comorbid diagnosis that requires further investigation include:6

haemoptysissmoker with > 20 pack–year smoking historysmoker aged over 45 years with a new cough, altered cough, or cough with voice disturbanceprominent dyspnoea, especially at rest or at nightsubstantial sputum productionhoarsenessfeverweight losscomplicated gastro-oesophageal reflux diseaseswallowing disorders with choking or vomitingrecurrent pneumoniaabnormal clinical respiratory examination.


















Go to: Australian Cough Guidelines








≥ 12%.26


References

Benninger C, Parsons JP, Mastronarde JG. Vocal cord dysfunction and asthma. Curr Opin Pulm Med. 2011; 17: 45-49. Availablefrom: http://www.ncbi.nlm.nih.gov/pubmed/21330824

1.

Deckert J, Deckert L. Vocal cord dysfunction. Am Fam Physician. 2010; 81: 156-159. Available from: http://www.aafp.org/afp/2010/0115/p156.html

2.

Weinberger M, Abu-Hasan M. Pseudo-asthma: when cough, wheezing, and dyspnea are not asthma. Pediatrics. 2007; 120: 855-864.Available from: http://pediatrics.aappublications.org/content/120/4/855.full

3.

Morris MJ, Christopher KL. Diagnostic criteria for the classification of vocal cord dysfunction. Chest. 2010; 138: 1213-23. Availablefrom: https://journal.chestnet.org/article/S0012-3692(10)60600-9/fulltext

4.

Kenn K, Balkissoon R. Vocal cord dysfunction: what do we know?. Eur Respir J. 2011; 37: 194-200. Available from:http://erj.ersjournals.com/content/37/1/194.long

5.

Gibson PG, Chang AB, Glasgow NJ, et al. CICADA: cough in children and adults: diagnosis and assessment. Australian coughguidelines summary statement. Med J Aust. 2010; 192: 265-271. Available from: https://www.mja.com.au/journal/2010/192/5/cicada-cough-children-and-adults-diagnosis-and-assessment-australian-cough

6.

Abramson MJ, Crockett AJ, Dabscheck E, et al. The COPD-X Plan: Australian and New Zealand guidelines for the management of chronicobstructive pulmonary disease. Version 2.34. The Australian Lung Foundation and The Thoracic Society of Australia and NewZealand, 2012. Available from: http://www.copdx.org.au/

7.

Gimenez LM, Zafra H. Vocal cord dysfunction: an update. Ann Allergy Asthma Immunol. 2011; 106: 267-274. Available from:http://www.ncbi.nlm.nih.gov/pubmed/21457874

8.

Knorr, B, Matz, J, Bernstein, JA, et al. Montelukast for chronic asthma in 6- to 14-year-old children: a randomized, double-blind trial.Pediatric Montelukast Study Group. JAMA. 1998; 279: 1181-1186. Available from: https://www.ncbi.nlm.nih.gov/pubmed/9555757

9.

Zeiger, RS, Szefler, SJ, Phillips, BR, et al. Response profiles to fluticasone and montelukast in mild-to-moderate persistent childhoodasthma. J Allergy Clin Immunol. 2006; 117: 45-52. Available from: https://www.ncbi.nlm.nih.gov/pubmed/16387583

10.

Becker, A, Swern, A, Tozzi, C A, et al. Montelukast in asthmatic patients 6 years-14 years old with an FEV1 > 75%. Curr Med Res Opin.2004; 20: 1651-1659. Available from: https://www.ncbi.nlm.nih.gov/pubmed/15462699

11.

Gibson PG, Simpson JS. The overlap syndrome of asthma and COPD: what are its features and how important is it?. Thorax. 2009;64: 728-735. Available from: http://thorax.bmj.com/content/64/8/728.full

12.

Stempel, D. A., Szefler, S. J., Pedersen, S., et al. Safety of adding salmeterol to fluticasone propionate in children with asthma. N Engl JMed. 2016; 375: 840-9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27579634

13.

McDonald VM, Higgins I, Gibson PG. Managing older patients with coexistent asthma and chronic obstructive pulmonary disease.Drugs Aging. 2013; 30: 1-17. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23229768

14.

Reed CE. Asthma in the elderly: diagnosis and management. J Allergy Clin Immunol. 2010; 126: 681-7; quiz 688-9. Available from:http://www.ncbi.nlm.nih.gov/pubmed/20673985

15.

Rabinovitch, N., Mauger, D. T., Reisdorph, N., et al. Predictors of asthma control and lung function responsiveness to step 3 therapyin children with uncontrolled asthma. J Allergy Clin Immunol. 2014; 133: 350-6. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/pmid/24084071/

16.

Lemanske RF, Mauger DT, Sorkness CA, et al. Step-up therapy for children with uncontrolled asthma receiving inhaledcorticosteroids. N Engl J Med. 2010; 362: 975-985. Available from: http://www.nejm.org/doi/full/10.1056/NEJMoa1001278#t=article

17.

Papadopoulos, N. G., Philip, G., Giezek, H., et al. The efficacy of montelukast during the allergy season in pediatric patients withpersistent asthma and seasonal aeroallergen sensitivity. J Asthma. 2009; 46: 413-20. Available from: https://www.ncbi.nlm.nih.gov/pubmed/19484680

18.

Carroll, W. D., Jones, P. W., Boit, P., et al. Childhood evaluation of salmeterol tolerance–a double-blind randomized controlled trial.Pediatr Allergy Immunol. 2010; 21: 336-44. Available from: https://www.ncbi.nlm.nih.gov/pubmed/19725893

19.

Fogel, R. B., Rosario, N., Aristizabal, G., et al. Effect of montelukast or salmeterol added to inhaled fluticasone on exercise-inducedbronchoconstriction in children. Ann Allergy Asthma Immunol. 2010; 104: 511-7. Available from: https://www.ncbi.nlm.nih.gov

20.


/pubmed/20568384Adler, A., Uziel, Y., Mei-Zahav, M., Horowitz, I.. Formoterol induces tolerance to the bronchodilating effect of Salbutamol followingmethacholine-provocation test in asthmatic children. Pulm Pharmacol Ther. 2006; 19: 281-5. Available from:https://www.ncbi.nlm.nih.gov/pubmed/16169761

21.

Pharmaceutical Benefits Scheme,. Post-market review. PBS medicines used to treat asthma in children. Report to PBAC. Final Report.2017.

22.

Akashi K, Mezawa H, Tabata Y, et al. Optimal step-down approach for pediatric asthma controlled by salmeterol/fluticasone: Arandomized, controlled trial (OSCAR study). Allergol Int. 2016; 65: 306-11. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27155753

23.


24.


25.

Johns DP, Pierce R. Pocket guide to spirometry. 3rd edn. McGraw Hill, North Ryde, 2011.26.

HOME > DIAGNOSIS > ADULTS > MAKING THE DIAGNOSIS

Recommendations

Consider features that increase or decrease the probability of asthma.



these apply


these apply


wheeze

breathlessness

chest tightness

cough











explanation


explanation







Change in voice


infections




repeated tests)

Adapted from:



Asset ID: 2

Make a diagnosis of asthma if all of the following apply:

The person has a history of variable symptoms (especially cough, chest tightness, wheeze and shortness of breath).Expiratory airflow limitation has been demonstrated (FEV1/FVC less than lower limit of normal for age).Expiratory airflow limitation has been shown to be variable.There are no findings that suggest an alternative diagnosis.

Note: If the spirometer does not provide lower limit of normal for age, use the follow age-based cut-points to indicate expiratory airflow limitation inadults and older adolescents:

less than 0.85 (up to 19 years)less than 0.80 (20–39 years)less than 0.75 (40–59 years)less than 0.70 (60 years and older).



If a patient’s asthma has been diagnosed elsewhere (e.g. in a new patient reporting the diagnosis of asthma), try to confirm thediagnosis – whether or not the person has current symptoms, and whether or not the person is taking asthma medicines.

More information












Respiratory Expert Group, Therapeutic Guidelines Limited, 2009 1

British Thoracic Society, 2012 2










Notes



least 12% from baseline for children, or a change in peak expiratory flow rate of at least 20% on the same meter.6, 3 A clinically important increase inFVC after administering bronchodilator may also indicate reversible airflow limitation, but FVC is a less reliable measure in primary care because FVCmay vary due to factors such as variation in inspiratory volume or expiratory time.






























≥ 12%.10


Making the clinical diagnosis of asthma in adults and adolescents

The clinical diagnosis of asthma is based on the probability that the symptoms are due to asthma rather than another cause, and on the

magnitude of deviation from the level of lung function and the variation in lung function that is seen in a healthy population (i.e.

demonstrating variable airflow limitation).



these apply


these apply


wheeze

breathlessness

chest tightness

cough














Change in voice


infections




repeated tests)



these apply


these apply



explanation


explanation


Adapted from:



Asset ID: 2

Although untreated asthma is usually characterised by airway hyperresponsiveness and airway inflammation (eosinophilic and/orneutrophilic), these features are not essential for making the diagnosis of asthma in clinical practice.

The evidence for asthma must be documented at the time of diagnosis, because characteristic clinical, physiological and pathologicalfeatures may improve spontaneously or with treatment, and because fixed (irreversible or incompletely reversible) airflow limitationmay develop over time. It is often difficult to confirm the diagnosis of asthma after a patient has been started on preventer treatment.


References

Respiratory Expert Group, Therapeutic Guidelines Limited. Therapeutic Guidelines: Respiratory, Version 4. Therapeutic GuidelinesLimited, West Melbourne, 2009.

1.

British Thoracic Society (BTS), Scottish Intercollegiate Guidelines Network (SIGN). British Guideline on the Management of Asthma. Anational clinical guideline. BTS, SIGN, Edinburgh, 2012. Available from: https://www.brit-thoracic.org.uk/guidelines-and-quality-standards/asthma-guideline/

2.


3.


4.

Quanjer PH, Stanojevic S, Cole TJ, et al. Multi-ethnic reference values for spirometry for the 3-95-yr age range: the global lungfunction 2012 equations. Eur Respir J. 2012; 40: 1324-43. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22743675

5.


6.

Collier AM, Pimmel RL, Hasselblad V, et al. Spirometric changes in normal children with upper respiratory infections. Am Rev RespirDis. 1978; 117: 47-53. Available from: http://www.ncbi.nlm.nih.gov/pubmed/619724

7.

Melbye H, Kongerud J, Vorland L. Reversible airflow limitation in adults with respiratory infection. Eur Respir J. 1994; 7: 1239-1245.Available from: http://www.ncbi.nlm.nih.gov/pubmed/7925901

8.


9.

Johns DP, Pierce R. Pocket guide to spirometry. 3rd edn. McGraw Hill, North Ryde, 2011.10.

HOME > DIAGNOSIS > ADULTS > STARTING TREATMENT

Recommendations

After making the diagnosis of asthma, begin treatment for 4–6 weeks with either of the following:

short-acting beta2 agonist taken as neededregular treatment with an inhaled corticosteroid (plus short-acting beta2 agonist taken as needed).

Table. Initial treatment choices (adults and adolescents not already using a preventer)

Clinical situation Suggested starting regimen † Alternative options and notes

Symptoms less than twice per month

and no flare-up that required oral

corticosteroids within previous 12

months

SABA as needed

Symptoms twice per month or more Regular ICS starting at a low dose

(plus SABA as needed)

Montelukast‡

Cromones§

Waking due to asthma symptoms at

least once during the past month

Regular ICS starting at a low dose


If patient also has frequent daytime

symptoms consider either of:

medium- to high-dose ICS (plus

SABA as needed)

(private prescription)

combination low-dose

ICS/LABA#

Oral corticosteroids required for an

asthma flare-up within the last 12

months (even if symptoms infrequent,

e.g. less than twice per month on

average)



History of artificial ventilation or

admission to an intensive care unit due

to acute asthma (even if symptoms

infrequent, e.g. less than twice per

month on average)



Monitor frequently

Clinical situation Suggested starting regimen † Alternative options and notes

Patient not currently taking a

preventer whose symptoms are severely

uncontrolled or very troublesome

Regular ICS (plus SABA as needed)

For very uncontrolled asthma at

presentation (e.g. frequent night

waking, low lung function), consider

(either of):

high-dose ICS (then down-titrate

when symptoms improve)

a short course of oral

corticosteroids in addition to ICS

Consider (private prescription)

combination ICS/LABA#

† When prescribing inhaled asthma medicines, take into account the person’s preferences, ability to use the device, and cost issues.

§ Requires multiple daily doses and daily maintenance of inhaler.

‡ PBS status as at March 2019: Montelukast treatment is not subsidised by the PBS for people aged 15 years or over. Special

Authority is available for Department of Veteran’s Affairs gold card holders or white card holders with approval for asthmatreatments.

# PBS status as at March 2019: ICS/LABA combination therapy as first-line preventer treatment is not subsidised by the PBS, exceptfor patients with frequent symptoms while taking oral corticosteroids.

Asset ID: 32

Arrange to check response to treatment after 4–6 weeks. Depending on the severity of initial symptoms, consider also monitoringprogress and clinical signs during the treatment trial.

Table. Steps for conducting a treatment trial

Document baseline lung function.1.

Document baseline asthma control using a validated standardised tool such as the Asthma Score.2.

Discuss treatment goals and potential adverse effects with the person.3.

Run treatment trial for agreed period (e.g. 4–8 weeks, depending on the treatment and clinical circumstances, including

urgency).

4.

At an agreed interval, measure asthma control and lung function again and document any adverse effects.5.

If asthma control has not improved despite correct inhaler technique and good adherence, resume previous treatment

and consider referral for specialist consultation.

6.

Asset ID: 36

Note: Although response to initial asthma treatment supports the diagnosis of asthma, respiratory symptoms and low lung function may improvespontaneously (e.g. if they were due to a respiratory infection). Conversely, lack of response to treatment does not necessarily rule out asthma.



See: Asthma Score (Asthma Control Test)


Also consider a treatment trial if asthma is strongly suspected but spirometry before and after bronchodilator does not demonstrateclinically important reversible airflow limitation (change in FEV1 of at least 200 mL and 12% from baseline) and other investigationshave not confirmed variable airflow limitation.



If there is no clear response to initial treatment, after confirming correct inhaler technique and good adherence, consider furtherinvestigations or referral to confirm or exclude the diagnosis of asthma.

Table. Conditions that can be confused with asthma in adults and adolescents

Conditions characterised by cough

Pertussis (whooping cough)

Gastro-oesophageal reflux

Rhinosinusitis/upper airway cough syndrome

Adverse effect of medicines (e.g. ACE inhibitors)

Bronchiectasis

Chronic obstructive pulmonary disease

Pulmonary fibrosis

Large airway stenosis

Habit-cough syndrome

Inhaled foreign body

Conditions characterised by wheezing

Respiratory infections

COPD

Upper airway dysfunction

Conditions characterised by difficulty breathing

Breathlessness on exertion due poor cardiopulmonary fitness

Hyperventilation

Anxiety




Conditions characterised by cough

Chronic heart failure

Pulmonary hypertension

Lung cancer

Sources

Therapeutic Guidelines Limited. Therapeutic Guidelines: respiratory. Version 4. West Melbourne: Therapeutic Guidelines Limited;2009.

Weinberger M, Abu-Hasan M. Pseudo-asthma: when cough, wheezing, and dyspnea are not asthma. Pediatrics 2007; 120: 855-64.Available from: http://pediatrics.aappublications.org/content/120/4/855

Asset ID: 83

More information















Notes



least 12% from baseline for children, or a change in peak expiratory flow rate of at least 20% on the same meter.4, 1 A clinically important increase in



FVC after administering bronchodilator may also indicate reversible airflow limitation, but FVC is a less reliable measure in primary care because FVCmay vary due to factors such as variation in inspiratory volume or expiratory time.






























≥ 12%.8


Confirming the diagnosis of asthma in adults and adolescents

A prior diagnosis of asthma reported by a patient should be corroborated by documentation of how the diagnosis was confirmed at thetime, or by current evidence.

Reports from around the world show that 25–35% of people with a diagnosis of asthma in primary care may not actually have

asthma.9, 10, 11, 12 Wheezing and other respiratory symptoms do not always mean a person has asthma. Airflow limitationdemonstrated on spirometry can be transient and does not necessarily mean that the person has asthma (e.g. when recorded during asevere acute viral infection of the respiratory tract). Ideally, airflow limitation should be confirmed when the patient does not have arespiratory tract infection.

Once a person is already taking regular treatment with a preventer, it may be more difficult to confirm the diagnosis because variabilityin lung function often decreases with treatment.

Table. Confirming the diagnosis of asthma in a person using preventer treatment

Please view and print this figure separately: http://www.asthmahandbook.org.au/table/show/9

Correct use of inhaler devices

Checking and correcting inhaler technique is essential to effective asthma management.

Most patients with asthma or COPD do not use their inhalers properly,13, 14,15, 15, 16 and most have not had their technique checked orcorrected by a health professional.

Incorrect inhaler technique when using maintenance treatments increases the risk of severe flare-ups and hospitalisation for people

with asthma or COPD.13, 14, 17, 18, 19, 20

Poor asthma symptom control is often due to incorrect inhaler technique.21, 22

Incorrect inhaler technique when using inhaled corticosteroids increases the risk of local side effects like dysphonia and oral thrush.

The steps for using an inhaler device correctly differ between brands. Checklists of correct steps for each inhaler type and how-tovideos are available from the National Asthma Council website.


References


1.


2.

Quanjer PH, Stanojevic S, Cole TJ, et al. Multi-ethnic reference values for spirometry for the 3-95-yr age range: the global lungfunction 2012 equations. Eur Respir J. 2012; 40: 1324-43. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22743675

3.


4.

Collier AM, Pimmel RL, Hasselblad V, et al. Spirometric changes in normal children with upper respiratory infections. Am Rev Respir5.


Go to: National Asthma Council Australia's Using your inhaler webpage for information, patient resources and videos on inhalertechniqueGo to: National Asthma Council Australia's information paper for health professionals on Inhaler technique for people with asthma orCOPDGo to: NPS MedicineWise information on Inhaler devices for respiratory medicines

Dis. 1978; 117: 47-53. Available from: http://www.ncbi.nlm.nih.gov/pubmed/619724Melbye H, Kongerud J, Vorland L. Reversible airflow limitation in adults with respiratory infection. Eur Respir J. 1994; 7: 1239-1245.Available from: http://www.ncbi.nlm.nih.gov/pubmed/7925901

6.


7.

Johns DP, Pierce R. Pocket guide to spirometry. 3rd edn. McGraw Hill, North Ryde, 2011.8. Lucas AE, Smeenk FW, Smeele IJ, van Schayck CP. Overtreatment with inhaled corticosteroids and diagnostic problems in primarycare patients, an exploratory study. Fam Pract. 2008; 25: 86-91. Available from: http://fampra.oxfordjournals.org/content/25/2/86.full

9.

Luks VP, Vandemheen KL, Aaron SD. Confirmation of asthma in an era of overdiagnosis. Eur Respir J. 2010; 36: 255-260. Availablefrom: http://erj.ersjournals.com/content/36/2/255.full

10.

Marklund B, Tunsäter A, Bengtsson C. How often is the diagnosis bronchial asthma correct?. Fam Pract. 1999; 16: 112-116.Available from: http://fampra.oxfordjournals.org/content/16/2/112.full

11.

Nathan, A. M., de Bruyne, J., Khalid, F., Arumugam, K.. Caesarean section and asthma in Malaysian children: a case-control study.Asian Pac J Allergy Immunol. 2012; 30: 204-8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/23156850

12.

The Inhaler Error Steering Committee,, Price, D., Bosnic-Anticevich, S., et al. Inhaler competence in asthma: common errors,barriers to use and recommended solutions. Respir Med. 2013; 107: 37-46. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23098685

13.

Bjermer, L.. The importance of continuity in inhaler device choice for asthma and chronic obstructive pulmonary disease.Respiration; international review of thoracic diseases. 2014; 88: 346-52. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25195762

14.

Basheti, I A, Armour, C L, Bosnic-Anticevich, S Z, Reddel, H K. Evaluation of a novel educational strategy, including inhaler-basedreminder labels, to improve asthma inhaler technique. Patient Educ Couns. 2008; 72: 26-33. Available from:http://www.ncbi.nlm.nih.gov/pubmed/18314294

15.

Bosnic-Anticevich, S. Z., Sinha, H., So, S., Reddel, H. K.. Metered-dose inhaler technique: the effect of two educational interventionsdelivered in community pharmacy over time. The Journal of asthma : official journal of the Association for the Care of Asthma. 2010; 47:251-6. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20394511

16.

Melani AS, Bonavia M, Cilenti V, et al. Inhaler mishandling remains common in real life and is associated with reduced diseasecontrol. Respir Med. 2011; 105: 930-8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21367593

17.

Levy ML, Dekhuijzen PN, Barnes PJ, et al. Inhaler technique: facts and fantasies. A view from the Aerosol Drug ManagementImprovement Team (ADMIT). NPJ Prim Care Respir Med. 2016; 26: 16017. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27098045

18.

Haughney, J., Price, D., Barnes, N. C., et al. Choosing inhaler devices for people with asthma: current knowledge and outstandingresearch needs. Respiratory medicine. 2010; 104: 1237-45. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20472415

19.

Giraud, V., Roche, N.. Misuse of corticosteroid metered-dose inhaler is associated with decreased asthma stability. The Europeanrespiratory journal. 2002; 19: 246-51. Available from: https://www.ncbi.nlm.nih.gov/pubmed/11866004

20.

Harnett, C. M., Hunt, E. B., Bowen, B. R., et al. A study to assess inhaler technique and its potential impact on asthma control inpatients attending an asthma clinic. J Asthma. 2014; 51: 440-5.

21.

Hardwell, A., Barber, V., Hargadon, T., et al. Technique training does not improve the ability of most patients to use pressurisedmetered-dose inhalers (pMDIs). Prim Care Respir J. 2011; 20: 92-6. Available from: http://www.nature.com/articles/pcrj201088

22.

HOME > DIAGNOSIS > ADULTS > FURTHER INVESTIGATIONS

In this section

Considerations for investigations

General considerations for further investigations in adults and adolescents

http://www.asthmahandbook.org.au/diagnosis/adults/further-investigations/general-considerations

Airway hyperresponsiveness tests

The role of airway hyperresponsiveness tests in the investigation of asthma-like symptoms in adults and adolescents

http://www.asthmahandbook.org.au/diagnosis/adults/further-investigations/airway-hyperresponsiveness-tests

Airway inflammation tests

The role of airway inflammation tests in the investigation of asthma-like symptoms in adults and adolescents

http://www.asthmahandbook.org.au/diagnosis/adults/further-investigations/airway-inflammation-tests

Allergy tests

The role of allergy tests in the investigation of asthma-like symptoms in adults and adolescents

http://www.asthmahandbook.org.au/diagnosis/adults/further-investigations/allergy-tests

Imaging

The role of imaging in the investigation of asthma-like symptoms in adults and adolescents

http://www.asthmahandbook.org.au/diagnosis/adults/further-investigations/imaging

HOME > DIAGNOSIS > ADULTS > FURTHER INVESTIGATIONS > CONSIDERATIONS FOR INVESTIGATIONS

Recommendations

Consider arranging further investigations and referral to appropriate specialists if the diagnosis cannot be made with confidence fromclinical features, spirometry and response to treatment.

Consider investigation for conditions that may affect or mimic asthma symptoms (e.g. coronary heart disease, obstructive sleepapnoea, gastro-oesophageal reflux disease or aspirin-exacerbated respiratory disease).

Consider and investigate the possibility of work-related asthma if (any of):

the timing of asthma symptoms is associated with work activities (especially if symptoms improve when the person is away fromthe workplace)the person is exposed to substances known to cause occupational asthmaco-workers have respiratory symptoms.

Note: Do not rule out the possibility of work-related asthma if the person’s occupation is not among those commonly associated with asthmatriggers (e.g. bakers, vehicle spray painters, electronics manufacturing workers who perform soldering, woodworkers, healthcare workers,laboratory animal workers, agriculture workers), because many substances and occupations have been associated with asthma and more are beingidentified continually.

Consider referral in the following circumstances:

if the diagnosis is uncertain (consider referral for diagnostic assessment and further investigation by a respiratory physician orgeneral physician)if signs and symptoms do not respond to a treatment trial (consider further investigations or referral to an appropriate specialist)if work-related asthma is suspected (consider referral to a respiratory physician, occupational physician and/or allergist, orallergist with experience in work-related asthma, if possible. Investigation is complex and involves a very detailed history, detailedlung function testing, site visits and sometimes challenge testing).






Adapted from existing guidanceBased on reliable clinical practice guideline(s) or position statement(s):

Dykewics, 2009 1

Henneberger et al. 2011 2

Hoy et al. 2010 3

Tarlo et al. 2008 4


More information
























≥ 12%.7





Cough and asthma in adults

When no other asthma symptoms are present, chronic cough (present for more than 8 weeks) is unlikely to indicate asthma.

Chronic cough may be due to asthma if:8

cough is episodiccough with exercise is associated with other symptoms that suggest airflow limitation (expiratory wheeze or breathlessness)spirometry confirms reversible airflow limitation.

If cough is due to asthma, it should respond to treatment with an inhaled corticosteroid preventer taken regularly and reliever as

needed).8

Findings that suggest a serious alternative or comorbid diagnosis that requires further investigation include:8

haemoptysissmoker with > 20 pack–year smoking historysmoker aged over 45 years with a new cough, altered cough, or cough with voice disturbanceprominent dyspnoea, especially at rest or at nightsubstantial sputum productionhoarsenessfeverweight losscomplicated gastro-oesophageal reflux diseaseswallowing disorders with choking or vomitingrecurrent pneumoniaabnormal clinical respiratory examination.

Asthma–COPD overlap

Distinguishing between typical allergic asthma (childhood-onset allergic asthma) and typical COPD (emphysema in a heavy smoker) is

straightforward.9 However, it can be difficult to distinguish COPD from asthma in adults who have features of both conditions.10,

11These people are described as having asthma–COPD overlap.10, 9, 12

Asthma–COPD overlap is not a single, well-defined disease entity, but includes a range of airway disease phenotypes with different

causal mechanisms.10, 13 Features of both asthma and COPD have been described in:12, 14, 15, 16

people with current asthma (allergic or non-allergic) who have had significant exposure to tobacco smokepeople with longstanding asthma or late-onset asthma who have become persistently short of breath over timepeople significant smoking history and symptoms consistent with COPD who also have a history of childhood asthmapeople who present in middle age or later with shortness of breath, with a history of childhood asthma but no or few symptoms inbetween, and little smoking history.

Figure. Development of asthma, COPD and asthma–COPD overlap


People with asthma–COPD overlap often have poor disease outcomes, including:10, 1718, 19, 20

high need for healthcare servicesworse quality of life, more wheezing, dyspnoea, cough and sputum production, and more frequent and severe respiratoryexacerbations and hospitalisations, than people with COPD or asthma aloneworse lung function demonstrated by spirometry than those with COPD alone, despite lower average exposure to tobacco smoke.

Features of asthma, COPD and asthma–COPD overlap

If several features of both asthma and COPD are present and neither condition is strongly favoured, respiratory disease should bemanaged according to recommendations for asthma–COPD overlap.

Table. Features that, when present, favour asthma or COPD


measured/relevant)


Go to: Australian Cough Guidelines


measured/relevant)


Age of onset Before 20 After 40

Pattern of symptoms Variation in respiratory symptoms:

changes over minutes, hours or days

worse at night or early morning

triggered by exercise, emotions,

airborne pollutants or allergens

Persistence of respiratory symptoms

despite treatment

Symptoms every day, including

exertional dyspnoea

History of chronic cough and sputum

unrelated to specific triggers, before

onset of dyspnoea

Lung function Expiratory airflow limitation* is

variable#

Lung function normal between

symptoms

Expiratory airflow limitation* is

persistent†

Lung function abnormal between

symptoms

History Previous diagnosis of asthma

Family history of asthma and allergies§

(allergic rhinitis or eczema)

Previous diagnosis of COPD, chronic

bronchitis or emphysema

Heavy exposure to tobacco smoke or

biomass fuels

Long-term disease trajectory Seasonal or yearly variation in

symptoms

Improvements (spontaneously or in

response to medication) last for weeks

Slowly worsens over years

Relief in response to medication is

limited and short term

Chest X-ray Normal Severe hyperinflation‡

Features that, when present, increase the probability of either typical asthma or typical COPD. None of these features is essential tomake the diagnosis of asthma or COPD, with the exception of persistent airflow limitation for making the diagnosis of COPD.

* Expiratory airflow limitation: indicated by a reduced ratio of forced expiratory volume in one second (FEV1) to forced vital capacity

(FVC) on spirometry (FEV1/FVC less than the lower limit of normal (i.e. less than the 5th percentile of normal population). Typical

FEV1/FVC values derived from population studies are > 0.75 in people aged 40–59 years and > 0.70 in people aged 60–80 years.

# Variable expiratory airflow limitation: variation beyond the range seen in healthy populations. It is indicated in adults by any of thefollowing:

a clinically important increase in FEV1 (change in FEV1 of at least 200 mL and 12% from baseline) 10–15 minutes after

administration of bronchodilatorclinically important variation in lung function (at least 20% change in FEV1) when measured repeatedly over time (e.g. spirometry

on separate visits)a clinically important increase in lung function (at least 200 mL and 12% from baseline) after ≥ 4 weeks’ treatment trial with anICSclinically important variation in peak expiratory flow (diurnal variability of more than 10%, calculated over 1–2 weeks as theaverage of daily amplitude per cent mean)a clinically important reduction in lung function (decrease in FEV1 of at least 200 mL and 12% from baseline on spirometry, or

decrease in peak expiratory flow rate by at least 20%) after exercise (formal laboratory-based exercise challenge testing usesdifferent criteria for exercise-induced bronchoconstriction)a clinically important reduction in lung function (15–20%, depending on the test) during a test for airway hyperresponsiveness(exercise challenge test or bronchial provocation test) measured by a respiratory function laboratory.

The greater the variations, or the more occasions excess variation is seen, the more confidently the diagnosis of variable expiratoryairflow limitation consistent with asthma can be made.

† Persistent expiratory airflow limitation is indicated by reduced post-bronchodilator FEV1/FVC*

§ Lack of history of atopy does not exclude non-allergic asthma.

‡ Chest X-ray may be normal in a patient with COPD

Adapted from


Asset ID: 104

Table. Spirometry findings in asthma, COPD and asthma–COPD overlap

Finding Consistent with

Asthma COPD Asthma–COPD

overlap

Normal FEV1 /FVC before of after

bronchodilator

Yes No No *

Abnormal lung function

(post-bronchodilator reduced FEV1/FVC and FEV1

< lower limit of normal)

Yes # Yes Yes

Airflow limitation with greater

bronchodilator reversibility than in healthy

population

(post-bronchodilator FEV1 increase ≥ 12% and

200mL from baseline)

Yes ‡ Yes Yes

Marked bronchodilator reversibility

(FEV1 increase ≥ 12% and 400mL from baseline)

Yes Possible but unusual†

Possible §

FEV1/FVC: ratio of forced expiratory volume in one second (FEV1) to forced vital capacity (FVC), either before or after

bronchodilator

* Normal FEV1/FVC is not consistent with COPD unless there is other evidence of chronic non-reversible expiratory airflow

limitation.

# This finding is consistent with asthma that is poorly controlled or measured during a flare-up, or can be seen in some patients withlongstanding asthma.

‡ The greater the variation, and the more times variation is seen, the more likely the diagnosis of asthma. However, some patientswith longstanding asthma may develop persistent airflow limitation.

† Marked reversibility strongly favours asthma and is generally inconsistent with COPD, but does not rule out asthma–COPDoverlap.

§ This finding may be seen in patients with asthma–COPD overlap, or occasionally in COPD, especially when FEV1 is low.

Sources

Global Initiative for Asthma, Global Initiative for Obstructive Lung Disease. Diagnosis and initial treatment of asthma, COPD andasthma-COPD overlap. Updated April 2017. Global Initiative for Asthma and Global Initiative for Obstructive Lung Disease; 2017.

Available from: http://ginasthma.org/gina-reports

Woodruff P, van den Berge M, Boucher R et al. ATS-NHLBI Asthma COPD Overlap (ACO) Workshop Report. Am J Respir Crit Care Med2017; 196:375-381. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28636425

Asset ID: 103

Treatment for patients with asthma–COPD overlap

Inhaled corticosteroid treatment at low–moderate doses is essential to reduce the risk of potentially life-threatening flare-ups, even if

asthma symptoms appear mild or infrequent.10, 21

Most patients also need treatment with a long-acting bronchodilator (either long-acting beta2 agonist or long-acting muscarinic

antagonist) in addition to an inhaled corticosteroid. Long-acting beta2 agonists and long-acting muscarinic antagonists should not be

used by people with asthma or asthma–COPD overlap unless they are also taking an inhaled corticosteroid (either in combination orseparately).

Table. Long-acting bronchodilators for asthma–COPD overlap

Class Dosing

frequency

Agent Brand name

ICS–LABA

combinations

Once daily Fluticasone furoate + vilanterol Breo Ellipta 100/25 microg†

Do not prescribe

200/25 microg

formulation#

Twice daily Budesonide + formoterol Symbicort Rapihaler

Symbicort Turbuhaler

Twice daily Fluticasone propionate + formoterol Flutiform

Twice daily Fluticasone propionate + salmeterol Fluticasone and Salmeterol

Cipla

Seretide Accuhaler

Seretide MDI

LABAs* Once daily Indacaterol Onbrez Breezhaler

Twice daily Formoterol Oxis

Foradile

Twice daily Salmeterol Serevent Accuhaler

LAMAs* Once daily Glycopyrronium Seebri Breezhaler

Once daily Tiotropium Spiriva

Spiriva Respimat

Once daily Umeclidinium Incruse Ellipta‡

Class Dosing

frequency

Agent Brand name

Twice daily Aclidinium Bretaris Genuair

LABA–LAMA

combinations*

Once daily Indacaterol + glycopyrronium Ultibro Breezhaler

Once daily Olodaterol + tiotropium Spiolto Respimat

Once daily Vilanterol + umeclidinium Anoro Ellipta‡

Twice daily Formoterol + aclidinium Brimica Genuair

* Ensure that patient is also using regular long-term ICS. LABAs and LAMAs should not be used by people with asthma or asthma–COPD overlap unless they are also taking an ICS, in combination or separately)

Advise patients/carers that inhalers should be stored below 30°C and should not be left in cars.

† The inhaler must be discarded 1 month after opening the package and removing device from tray. When first opened, patientsshould write the discard date on the label in the space provided. If stored in the refrigerator, inhaler should be taken out and allowedto return to room temperature for at least an hour before use.

‡ The inhaler must be discarded 6 weeks after opening the package and removing device from tray. When first opened, patientsshould write the discard date on the label in the space provided. If stored in the refrigerator, inhaler should be taken out and allowedto return to room temperature for at least an hour before use.

# Only the 100/25 microg dose of fluticasone furoate/vilanterol is TGA-approved for treatment of COPD. The higher dose (200/25microg) is not TGA-approved for the treatment of COPD, so it should not be used in people with asthma–COPD overlap.

High doses of ICS (alone or in combination) are not recommended in patients with COPD and should therefore be used with cautionin patients with asthma-COPD overlap, because of the risk of pneumonia.

Refer to PBS status before prescribing.


Asset ID: 105

Management should also include smoking cessation, treatment of comorbid conditions, physical activity, pulmonary rehabilitation,

vaccinations, self-management (including a regularly updated action plan) and regular follow-up.10

Respiratory tract infections should be monitored carefully because people with asthma–COPD overlap have high morbidity rates and

because ICS treatment is associated with increased risk of non-fatal pneumonia in people with COPD.22 Most of the available evidenceis from patients treated with fluticasone propionate, particularly at higher doses. Increased pneumonia rates have also been observed instudies of patients with COPD using fluticasone furoate/vilanterol. The higher dose of fluticasone furoate/vilanterol (Breo Ellipta200/25 microg) is not approved for patients with COPD, so it should also not be used in patients with asthma–COPD overlap.

Specialist referral should be considered for patients with atypical symptoms or symptoms that suggest an alternative diagnosis,persistent symptoms or flare-ups despite treatment, or complex comorbidities.

For information on diagnosis and management of COPD, refer to the COPD-X Concise Guide for Primary Care.23


Other diagnostic tests in adults

For patients with incompletely reversible airflow limitation, a careful history will often clarify which investigation is most appropriate.Lung volume tests and diffusing capacity tests may be helpful to identify emphysema or pulmonary fibrosis. High-resolution computed

Go to: Asthma action plansGo to: COPD action plans

Go to: National Asthma Council Australia's Asthma–COPD overlap information paper

Go to: Lung Foundation Australia's COPD-X Concise Guide for Primary Care

tomography is useful if bronchiectasis is suspected.

References

Dykewics MS. Occupational asthma: Current concepts in pathogenesis, diagnosis, and management. J Allergy Clin Immunol. 2009;123: 519-528. Available from: http://www.jacionline.org/article/S0091-6749(09)00214-0/fulltext

1.

Henneberger PK, Redlich CA, Callahan DB, et al. An official american thoracic society statement: work-exacerbated asthma. Am JRespir Crit Care Med. 2011; 184: 368-78. Available from: http://ajrccm.atsjournals.org/content/184/3/368.long

2.

Hoy RF, Abramson MJ, Sim MR. Work related asthma - diagnosis and management. Aust Fam Physician. 2010; 39: 39-42. Availablefrom: http://www.racgp.org.au/afp/201001/35841

3.

Tarlo SM, Balmes J, Balkissoon R, et al. Diagnosis and management of work-related asthma: American College Of Chest PhysiciansConsensus Statement. Chest. 2008; 134(3 Suppl): 1S-41S. Available from: http://journal.publications.chestnet.org/article.aspx?articleid=1044851

4.


5.


6.

Johns DP, Pierce R. Pocket guide to spirometry. 3rd edn. McGraw Hill, North Ryde, 2011.7. Gibson PG, Chang AB, Glasgow NJ, et al. CICADA: cough in children and adults: diagnosis and assessment. Australian coughguidelines summary statement. Med J Aust. 2010; 192: 265-271. Available from: https://www.mja.com.au/journal/2010/192/5/cicada-cough-children-and-adults-diagnosis-and-assessment-australian-cough

8.

Knorr, B, Matz, J, Bernstein, JA, et al. Montelukast for chronic asthma in 6- to 14-year-old children: a randomized, double-blind trial.Pediatric Montelukast Study Group. JAMA. 1998; 279: 1181-1186. Available from: https://www.ncbi.nlm.nih.gov/pubmed/9555757

9.

Zeiger, RS, Szefler, SJ, Phillips, BR, et al. Response profiles to fluticasone and montelukast in mild-to-moderate persistent childhoodasthma. J Allergy Clin Immunol. 2006; 117: 45-52. Available from: https://www.ncbi.nlm.nih.gov/pubmed/16387583

10.

Becker, A, Swern, A, Tozzi, C A, et al. Montelukast in asthmatic patients 6 years-14 years old with an FEV1 > 75%. Curr Med Res Opin.2004; 20: 1651-1659. Available from: https://www.ncbi.nlm.nih.gov/pubmed/15462699

11.

Gibson PG, Simpson JS. The overlap syndrome of asthma and COPD: what are its features and how important is it?. Thorax. 2009;64: 728-735. Available from: http://thorax.bmj.com/content/64/8/728.full

12.

Stempel, D. A., Szefler, S. J., Pedersen, S., et al. Safety of adding salmeterol to fluticasone propionate in children with asthma. N Engl JMed. 2016; 375: 840-9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27579634

13.

McDonald VM, Higgins I, Gibson PG. Managing older patients with coexistent asthma and chronic obstructive pulmonary disease.Drugs Aging. 2013; 30: 1-17. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23229768

14.

Reed CE. Asthma in the elderly: diagnosis and management. J Allergy Clin Immunol. 2010; 126: 681-7; quiz 688-9. Available from:http://www.ncbi.nlm.nih.gov/pubmed/20673985

15.

Rabinovitch, N., Mauger, D. T., Reisdorph, N., et al. Predictors of asthma control and lung function responsiveness to step 3 therapyin children with uncontrolled asthma. J Allergy Clin Immunol. 2014; 133: 350-6. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/pmid/24084071/

16.

Lemanske RF, Mauger DT, Sorkness CA, et al. Step-up therapy for children with uncontrolled asthma receiving inhaledcorticosteroids. N Engl J Med. 2010; 362: 975-985. Available from: http://www.nejm.org/doi/full/10.1056/NEJMoa1001278#t=article

17.

Papadopoulos, N. G., Philip, G., Giezek, H., et al. The efficacy of montelukast during the allergy season in pediatric patients withpersistent asthma and seasonal aeroallergen sensitivity. J Asthma. 2009; 46: 413-20. Available from: https://www.ncbi.nlm.nih.gov/pubmed/19484680

18.

Carroll, W. D., Jones, P. W., Boit, P., et al. Childhood evaluation of salmeterol tolerance–a double-blind randomized controlled trial.Pediatr Allergy Immunol. 2010; 21: 336-44. Available from: https://www.ncbi.nlm.nih.gov/pubmed/19725893

19.

Fogel, R. B., Rosario, N., Aristizabal, G., et al. Effect of montelukast or salmeterol added to inhaled fluticasone on exercise-inducedbronchoconstriction in children. Ann Allergy Asthma Immunol. 2010; 104: 511-7. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20568384

20.

Adler, A., Uziel, Y., Mei-Zahav, M., Horowitz, I.. Formoterol induces tolerance to the bronchodilating effect of Salbutamol followingmethacholine-provocation test in asthmatic children. Pulm Pharmacol Ther. 2006; 19: 281-5. Available from:https://www.ncbi.nlm.nih.gov/pubmed/16169761

21.

Pharmaceutical Benefits Scheme,. Post-market review. PBS medicines used to treat asthma in children. Report to PBAC. Final Report.2017.

22.

Akashi K, Mezawa H, Tabata Y, et al. Optimal step-down approach for pediatric asthma controlled by salmeterol/fluticasone: Arandomized, controlled trial (OSCAR study). Allergol Int. 2016; 65: 306-11. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27155753

23.

HOME > DIAGNOSIS > ADULTS > FURTHER INVESTIGATIONS > AIRWAY HYPERRESPONSIVENESS TESTS

Recommendations

Consider arranging bronchial provocation (challenge) tests for airway hyperresponsiveness if asthma is suspected but initialspirometry does not demonstrate reversible airflow limitation.

Notes:

If challenge testing is needed, consider referring to a respiratory physician for investigation, or discussing with a respiratory physician beforeselecting which test to order.

Don’t test during a respiratory infection, or initiate inhaled corticosteroid treatment in the few weeks before challenge testing, because these couldinvalidate the result.

Bronchial provocation (challenge) tests should be performed only in accredited respiratory function laboratories.

Note: A list of accredited laboratories is available from the Australian and New Zealand Society of Respiratory Science

Do not routinely order tests for airway hyperresponsiveness (challenge tests) for all patients with suspected asthma. It is notnecessary to demonstrate airway hyperresponsiveness if the patient shows clinical features of asthma and there is a high probabilitythat these are not due to another cause.

More information

Bronchial provocation (challenge) tests in adults and older adolescents

The main roles of bronchial provocation tests of airway hyperresponsiveness (airway hyperreactivity) in adults are to exclude asthma as

the cause of current symptoms, and to confirm the presence of exercise-induced bronchoconstriction.1, 2, 3

Bronchial provocation tests for hyperresponsiveness are performed in accredited lung function testing laboratories. These tests involverepeated spirometry tests.

Bronchial provocation tests of airway hyperresponsiveness include:

direct challenge tests (e.g. methacholine challenge test)3

indirect challenge tests (e.g. exercise challenge test, eucapnic voluntary hyperpnea, hypertonic (4.5%) saline, mannitol challenge

test)4







Challenge tests for exercise-induced bronchoconstriction

Role of challenge testsSelf-reported symptoms are not sensitive enough to detect exercise-induced bronchoconstriction reliably or specific enough to rule out

other conditions, particularly in elite athletes.5, 6, 7 Single office FEV1 readings or peak expiratory flow measurement are not adequate

to demonstrate exercise-induced bronchoconstriction.8

Standardised, objective bronchial provocation (challenge) tests using spirometry are necessary for the investigation of suspectedexercise-induced bronchoconstriction in elite athletes. These tests involve serial spirometry measurements after challenge withexercise (or exercise surrogates e.g. dry powder mannitol, eucapnic voluntary hyperpnoea or hyperventilation, or hyperosmolar

aerosols such as 4.5% saline).5, 8, 9, 10 Severity of exercise-induced bronchoconstriction is assessed by percentage fall in FEV1 after

challenge.8

Challenge testing is mandated by sports governing bodies before the athlete is given permission to use some asthma medicines, and therequired testing protocol varies between specific sports. The latest information is available from the Australian Sports Anti-DopingAuthority (ASADA) and the World Anti-Doping Agency (WADA).

Challenge tests are also used in the investigation of exercise-related symptoms in recreational and non-athletes, when objectivedemonstration of exercise-induced bronchoconstriction is needed to guide management decisions.

Choice of challenge test

There is no single challenge test that will identify all individuals with exercise-induced bronchoconstriction.5 The most appropriate testor tests for an individual depend on clinical and individual factors:

The eucapnic voluntary hyperpnoea test can provoke a severe response.5 For safety reasons, the eucapnic voluntary hyperpnoea

test should only be used in adults who regularly exercise at high intensity (e.g. elite athletes).5 It should not be used in children.When an exercise challenge test is used, inhalation of dry air is recommended to diagnose or exclude exercise-induced

bronchoconstriction because it increases the sensitivity of the test.5

Mannitol challenge can be used as an alternative to exercise provocation testing to investigate suspected exercise-induced

bronchoconstriction, 5, 11, 12 including in children.13, 14

For safety reasons, exercise challenge in dry air should be avoided in patients with FEV1 <70% predicted5

Referral

If challenge testing is needed, consider referring to a respiratory physician for investigation, or discussing with a respiratory physicianbefore selecting which test to order. Do not test during a respiratory infection, or initiate inhaled corticosteroid treatment in the fewweeks before challenge testing, because these could invalidate the result.

A list of accredited respiratory function laboratories is available from the Australian and New Zealand Society of Respiratory Science.

References

Anderson SD. Indirect challenge tests: Airway hyperresponsiveness in asthma: its measurement and clinical significance. Chest.2010; 138(2 Suppl): 25S-30S. Available from: http://journal.publications.chestnet.org/article.aspx?articleid=1086636

1.

Anderson SD. Bronchial challenge tests: usefulness, availability and challenges. Breathe. 2011; 8: 53-60. Available from:http://www.ers-education.org

2.

Cockcroft DW. Direct challenge tests: airway hyperresponsiveness in asthma: its measurement and clinical significance. Chest.2010; 138(2 Suppl): 18S-24S. Available from: http://journal.publications.chestnet.org/article.aspx?articleid=1086632

3.

Anderson SD, Pearlman DS, Rundell KW, et al. Reproducibility of the airway response to an exercise protocol standardized forintensity, duration, and inspired air conditions, in subjects with symptoms suggestive of asthma. Respir Res. 2010; Sept 1: 120.Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2939602/

4.

Weiler JM, Anderson SD, Randolph C, et al. Pathogenesis, prevalence, diagnosis, and management of exercise-inducedbronchoconstriction: a practice parameter. Ann Allergy Asthma Immunol. 2010; 105: S1-47. Available from:http://www.ncbi.nlm.nih.gov/pubmed/21167465

5.

Rundell KW, Im J, Mayers LB, et al. Self-reported symptoms and exercise-induced asthma in the elite athlete. Med Sci Sports Exerc.2001; 33: 208-13. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11224807

6.

Holzer K, Anderson SD, Douglass J. Exercise in elite summer athletes: Challenges for diagnosis. J Allergy Clin Immunol. 2002; 110:374-80. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12209082

7.

Go to: Australian Sports Anti-Doping AuthorityGo to: World Anti-Doping Agency

Go to: Australian and New Zealand Society of Respiratory Science

Parsons JP, Hallstrand TS, Mastronarde JG, et al. An official American Thoracic Society clinical practice guideline: exercise-inducedbronchoconstriction. Am J Respir Crit Care Med. 2013; 187: 1016-27. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23634861

8.

Fitch KD, Sue-Chu M, Anderson SD, et al. Asthma and the elite athlete: Summary of the International Olympic Committee'sConsensus Conference, Lausanne, Switzerland, January 22-24, 2008. J Allergy Clin Immunol. 2008; 122: 254-260. Available from:http://www.ncbi.nlm.nih.gov/pubmed/18678340

9.

Anderson SD, Kippelen P. Assessment and prevention of exercise-induced bronchoconstriction. Br J Sports Med. 2012; 46: 391-6.Available from: http://www.ncbi.nlm.nih.gov/pubmed/22247297

10.

Brannan JD, Koskela H, Anderson SD, Chew N. Responsiveness to mannitol in asthmatic subjects with exercise- andhyperventilation-induced asthma. Am J Respir Crit Care Med. 1998; 158: 1120-6. Available from: http://www.atsjournals.org/doi/full/10.1164/ajrccm.158.4.9802087

11.

Holzer K, Anderson SD, Chan HK, Douglass J. Mannitol as a challenge test to identify exercise-induced bronchoconstriction in eliteathletes. Am J Respir Crit Care Med. 2003; 167: 534-7. Available from: http://www.atsjournals.org/doi/full/10.1164/rccm.200208-916OC

12.

Kersten ET, Driessen JM, van der Berg JD, Thio BJ. Mannitol and exercise challenge tests in asthmatic children. Pediatr Pulmonol.2009; 44: 655-661. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19499571

13.

Barben J, Kuehni CE, Strippoli MP, et al. Mannitol dry powder challenge in comparison with exercise testing in children. PediatrPulmonol. 2011; 46: 842-8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21465681

14.

HOME > DIAGNOSIS > ADULTS > FURTHER INVESTIGATIONS > AIRWAY INFLAMMATION TESTS

Recommendations

Do not routinely order induced sputum eosinophil count for all patients with suspected asthma. It is not necessary to demonstrateairway inflammation if the patient shows clinical features of asthma and there is a low probability that these are due to another cause.

Measurement of exhaled nitric oxide is not recommended as a diagnostic test for asthma in routine clinical practice.

More information

Induced sputum test for eosinophilia in adults and adolescents

Patients with untreated asthma usually have airway inflammation (eosinophilic and/or neutrophilic), but testing for this is not essentialfor making the diagnosis of asthma in clinical practice. Some types of asthma are not associated with eosinophilic airway inflammation.

The induced sputum test is not a standard microbiology test. It is provided by specialised laboratories.

Peripheral blood eosinophil count in adults and adolescents

White cell differential count on a peripheral blood sample is not currently recommended routinely in the investigation and managementof asthma.

Two studies in severe asthma found that blood eosinophils correlated modestly with sputum eosinophil counts.2, 3 In severe asthma,

higher blood eosinophil counts are associated with greater risk of poor symptom control and more frequent exacerbations.4 In patientswith severe asthma, peripheral blood eosinophil count is important for predicting response to monoclonal antibody therapy and is arequirement for eligibility for some therapies.


Exhaled nitric oxide (NO) testing in adults and adolescents

Measurement of the fraction of exhaled nitric oxide is not routinely used in Australian clinical practice, but is often used by respiratoryphysicians, severe asthma clinics and clinical asthma trials in both primary and secondary care to provide additional information aboutasthma phenotype that may help to inform treatment decisions.

The exhaled nitric oxide test is easy for patients to perform.

Roles in diagnostic investigation




Consensus

Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference to thefollowing source(s):

Dweik et al. 20111

See: Monoclonal antibody therapy

In patients with symptoms that suggest asthma (e.g. wheeze, shortness of breath, variable cough), the finding of increased exhaled nitric

oxide provides supportive evidence for an asthma diagnosis, but is not conclusive for several reasons:1

Some types of asthma (i.e. asthma without eosinophilic airway inflammation) are not associated with increased exhaled nitric oxide.

Patients treated with inhaled corticosteroids may have a normal exhaled nitric oxide level.

Exhaled nitric oxide may be elevated in other conditions (e.g. eosinophilic bronchitis, acute viral infection).Exhaled nitric oxide may suppressed by other factors (cigarette smoke).

The predictive value of exhaled nitric oxide as a diagnostic test for asthma is higher than for peak expiratory flow and spirometry, and

similar to that of bronchial challenge tests.1

Increased exhaled nitric oxide fraction not accurate as a single surrogate marker for airway eosinophilia in patients with asthma.5

There are several inflammatory phenotypes in asthma: eosinophilic, neutrophilic, mixed, and asthma with sputum cell counts withinnormal range (‘paucigranulocytic’). The exhaled nitric oxide fraction is commonly, but not always, associated with eosinophilic airway

inflammation, but not with neutrophilic or paucigranulocytic asthma.5

Role in clinical management of asthma

In people with a clinical diagnosis of asthma, the exhaled nitric oxide test is useful for identifying those with asthma who are likely toexperience a short-term symptomatic response to inhaled corticosteroids. However, there is no evidence at present that it is safe (withregard to risk of exacerbations) to withhold inhaled corticosteroids if exhaled nitric oxide is not elevated.

There is evidence from several studies in children with a diagnosis of asthma that exhaled nitric oxide can be used to adjust the dose ofinhaled corticosteroids, leading to a reduction in exacerbation risk compared with guidelines-based adjustment, though not an

improvement in symptom control.6 However, in adults, there was no significant difference in exacerbation risk with FeNO-based

treatment adjustment compared with guidelines-based adjustment.7


Impulse oscillometry in adults and adolescents

Impulse oscillometry is a noninvasive and rapid technique for measuring pulmonary function. Unlike spirometry, the test is easy to doand requires only passive cooperation by the patient, so it is suitable for small children. It is not used routinely in clinical practice, but iscurrently available in some tertiary referral centres.

Low-frequency impulse oscillometry (resistance at 5 Hz) measurements taken before and after administration of a bronchodilator

correlate with spirometry (FEV1) in people with asthma and without asthma.8 Impulse oscillometry may be useful in identifying patients

with asthma, and might possibly identify obstruction in the peripheral airways.9

This test is not used routinely in clinical practice because diagnostic cut-points are not well established yet.9 Australian normal values

for adults without asthma have been developed.10

References

Dweik RA, Boggs PB, Erzurum SC, et al. An Official ATS Clinical Practice Guideline: Interpretation of Exhaled Nitric Oxide Levels(FeNO) for Clinical Applications. Am J Respir Crit Care Med. 2011; 184: 602-615. Available from: http://ajrccm.atsjournals.org/content/184/5/602.long

1.

Fowler SJ, Tavernier G, Niven R. High blood eosinophil counts predict sputum eosinophilia in patients with severe asthma. J AllergyClin Immunol. 2015; 135: 822-4.e2. Available from: https://www.jacionline.org/article/S0091-6749(14)01370-0/abstract/

2.

ten Brinke A, Zwinderman AH, Sterk PJ et al. Factors associated with persistent airflow limitation in severe asthma. Am J Respir CritCare Med. 2001; 164: 744-8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/11549526/

3.

Fahy JV. Type 2 inflammation in asthma–present in most, absent in many. Nat Rev Immunol. 2015; 15: 57-65. Available from:https://www.ncbi.nlm.nih.gov/pubmed/25534623/

4.

Korevaar DA, Westerhof GA, Wang J et al. Diagnostic accuracy of minimally invasive markers for detection of airway eosinophiliain asthma: a systematic review and meta-analysis. Lancet Respir Med. 2015; 3: 290-300. Available from:https://www.ncbi.nlm.nih.gov/pubmed/25801413/

5.

Petsky HL, Kew KM, Chang AB. Exhaled nitric oxide levels to guide treatment for children with asthma. Cochrane Database Syst. Rev2016; Issue 11: CD011439. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27825189/

6.

Petsky HL, Kew KM, Turner C, Chang AB. Exhaled nitric oxide levels to guide treatment for adults with asthma. Cochrane DatabaseSyst. Rev 2016; 9: CD011440. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27580628/

7.

Nair A, Ward J, Lipworth BJ. Comparison of bronchodilator response in patients with asthma and healthy subjects using spirometryand oscillometry. Ann Allergy Asthma Immunol. 2011; 107: 317-322. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21962091

8.

Galant SP, Nickerson B. Lung function measurement in the assessment of childhood asthma: recent important developments. Curr9.

Opin Allergy Clin Immunol. 2010; 10: 149-154. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20035221Newbury W, Crockett A, Newbury J. A pilot study to evaluate Australian predictive equations for the impulse oscillometry system.Respirology. 2008; 13: 1070-1075. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18699802

10.

HOME > DIAGNOSIS > ADULTS > FURTHER INVESTIGATIONS > ALLERGY TESTS

Recommendations

Consider allergy testing as part of diagnostic investigations if you suspect allergic triggers, or to guide management.

To investigate allergies in a person with severe or unstable asthma, or a history of anaphylaxis, refer to a specialist allergist forinvestigation to minimise risk.

If allergy testing is needed, refer to an appropriate provider for skin prick testing for common aeroallergens.

Notes

If staff are trained in the skin prick test procedure and its interpretation, skin prick testing can be performed in primary care. If not, refer to anappropriate provider.

When performing skin prick testing, follow Australasian Society of Clinical Immunology and Allergy (ASCIA) guidance: Skin prick testing for thediagnosis of allergic disease. A manual for practitioners

Blood test (immunoassay for allergen-specific immunoglobulin E) can be used if skin prick testing is (any of):

unavailableimpractical (e.g. a patient who is unable to cooperate with test procedure, a patient taking antihistamines when these cannot bewithdrawn, or a patient taking tricyclic antidepressants or pizotifen)contraindicated (e.g. patients with severe dermatographism, extensive skin rash, or those at risk of anaphylaxis including patientswith occupational asthma due to latex sensitivity).




Adapted from existing guidance

Based on reliable clinical practice guideline(s) or position statement(s):

Australasian Society of Clinical Immunology and Allergy, 20131









More information

Allergy tests in diagnostic investigation in adults and adolescents

Not all asthma is allergic, so negative allergy tests cannot exclude asthma. The probability that respiratory symptoms are due to allergicasthma is increased if a person has a history of allergy, or a family history of allergic rhinitis or atopic dermatitis.

The Australasian Society of Clinical Immunology (ASCIA) recommends skin prick testing as the first-choice method for investigating

allergies in a person with asthma.1 ASCIA cautions that non-specialist practices should not perform skin prick testing in patients with

persistent severe or unstable asthma due to potential adverse effects.1

References

Australasian Society of Clinical Immunology and Allergy (ASCIA), Skin Prick Testing Working Party. Skin prick testing for the diagnosisof allergic disease: A manual for practitioners. ASCIA, Sydney, 2013. Available from: http://www.allergy.org.au/health-professionals/papers/skin-prick-testing

1.

See: Allergies and asthma

HOME > DIAGNOSIS > ADULTS > FURTHER INVESTIGATIONS > IMAGING

Recommendations

Consider arranging chest X-ray if there are respiratory symptoms that are not explained by asthma or as otherwise indicated toinvestigate the possibility of other conditions (e.g. pneumonia, cancer).

Do not routinely order chest X-ray in all patients with suspected asthma, because it is not a diagnostic test for ruling asthma in or out.

More information

Other diagnostic tests in adults

For patients with incompletely reversible airflow limitation, a careful history will often clarify which investigation is most appropriate.Lung volume tests and diffusing capacity tests may be helpful to identify emphysema or pulmonary fibrosis. High-resolution computedtomography is useful if bronchiectasis is suspected.





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