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pseudo asthma

pseudo asthma

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DOI:10.1542/peds.2007-00782007;120;855-864
Pediatrics
Miles Weinberger and Mutasim Abu-Hasan
Pseudo-asthma: When Cough, Wheezing, and Dyspnea Are Not Asthma
 http://www.pediatrics.org/cgi/content/full/120/4/855located on the World Wide Web at:The online version of this article, along with updated information and services, is
rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.Grove Village, Illinois, 60007. Copyright © 2007 by the American Academy of Pediatrics. Alland trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk publication, it has been published continuously since 1948. PEDIATRICS is owned, published,PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
 at UNIV OF CHICAGO on June 1, 2008www.pediatrics.orgDownloaded from 
 
REVIEW ARTICLE
Pseudo-asthma: When Cough, Wheezing, andDyspnea Are Not Asthma
MilesWeinberger,MD,MutasimAbu-Hasan
Pediatric Allergy and Pulmonary Division, Department of Pediatrics, University of Iowa, Iowa City, Iowa
 The authors have indicated they have no financial relationships relevant to this article to disclose.
ABSTRACT
Although asthma is the most common cause of cough, wheeze, and dyspnea inchildren and adults, asthma is often attributed inappropriately to symptoms fromother causes. Cough that is misdiagnosed as asthma can occur with pertussis, cysticfibrosis, primary ciliary dyskinesia, airway abnormalities such as tracheomalaciaand bronchomalacia, chronic purulent or suppurative bronchitis in young chil-dren, and habit-cough syndrome. The respiratory sounds that occur with theupper airway obstruction caused by the various manifestations of the vocal corddysfunction syndrome or the less common exercise-induced laryngomalacia areoften mischaracterized as wheezing and attributed to asthma. The perception ofdyspnea is a prominent symptom of hyperventilation attacks. This can occur inthose with or without asthma, and patients with asthma may not readily distin-guish the perceived dyspnea of a hyperventilation attack from the acute airwayobstruction of asthma. Dyspnea on exertion, in the absence of other symptoms ofasthma or an unequivocal response to albuterol, is most likely a result of othercauses. Most common is the dyspnea associated with normal exercise limitation, but causes of dyspnea on exertion can include other physiologic abnormalitiesincluding exercise-induced vocal cord dysfunction, exercise-induced laryngoma-lacia, exercise-induced hyperventilation, and exercise-induced supraventriculartachycardia. A careful history, attention to the nature of the respiratory soundsthat are present, spirometry, exercise testing, and blood-gas measurement provideuseful data to sort out the various causes and avoid inappropriate treatment ofthese pseudo-asthma clinical manifestations.
www.pediatrics.org/cgi/doi/10.1542/peds.2007-0078doi:10.1542/peds.2007-0078
KeyWords
asthma, cough, wheezing, dyspnea
Accepted for publication May 4, 2007Address correspondence to Miles Weinberger,MD, Department of Pediatrics, University of Iowa Hospital, 200 Hawkins Dr, Iowa City, IA52242. E-mail: miles-weinberger@uiowa.eduPEDIATRICS(ISSNNumbers:Print,0031-4005;Online,1098-4275).Copyright©2007bytheAmericanAcademyofPediatrics
PEDIATRICS Volume 120, Number 4, October 2007
855
 at UNIV OF CHICAGO on June 1, 2008www.pediatrics.orgDownloaded from 
 
C
OUGH, WHEEZING (AND
other respiratory noises),and dyspnea are common respiratory symptomsthat potentially have an extensive differential diagnosis.
1
Because asthma is an exceedingly common disorder,such symptoms are often a result of this recurring andchronic respiratory disorder. Although there is demon-strable underdiagnosis of asthma,
2
the purpose of thisreview is to increase awareness of common and uncom-mon entities that have resulted in inappropriate diag-noses of asthma.
WHATISASTHMA?
Asthma is a disease that is characterized by hyperrespon-siveness of the airways to various stimuli, which resultsin airway obstruction that is reversible either spontane-ously or as a result of treatment. The airway obstructionis from variable components of bronchial smooth musclespasm and inflammation that result in edema of therespiratory mucosa and mucous secretions. Althoughthe diagnosis of asthma is frequently readily apparent,we have encountered several clinical entities that have been misdiagnosed as asthma and consequently treatedinappropriately. In this review we describe these clinicalentities, identify how their clinical presentation is con-fused with asthma, and indicate the diagnostic methodsfor identifying these pseudo-asthma syndromes.
WHENISITNOTASTHMA?
Asthma is diagnosed clinically and is suspected whenthere is cough, wheezing, or dyspnea. However, thesame symptoms may be results of other causes. Al-though for some patients the presenting clinical picturecan readily identify the problem as being somethingother than asthma, there can also be legitimate diagnos-tic uncertainty with others. The distinguishing charac-teristic of asthma is the response to bronchodilator orcorticosteroids when the patient is symptomatic. Forpatients who are old enough to perform a pulmonary-function test, substantial improvement of airway ob-struction from an aerosol bronchodilator or a shortcourse of reasonably high-dose systemic corticosteroid, 2mg/kg twice daily to a maximum of 40 mg twice daily(reduced to once daily in the morning if insomnia orirritability becomes problematic), supports diagnosis ofasthma. Failure to observe substantial improvementwithin 5 to 7 days with complete relief of symptoms andsubstantial improvement in lung function after a maxi-mum of 10 days argues against asthma as the etiology,assuming, of course, that the patient has taken the med-ication.
COUGHTHATISNOTASTHMA
Asthma is the most common cause of chronic or recur-rent inflammatory airway disease and a major cause ofcough. Although there are causes of cough that areunlikely to be confused with asthma, there are severalthat characteristically are confused with asthma and re-sult in overdiagnosis of asthma with consequent inap-propriate treatment.
3
Pertussis, known in the past as the100-day cough, causes a prolonged period of cough, andwe have seen several cases in which the primary carephysician prescribed antiasthmatic medication becausepertussis was not adequately considered. Characteristi-cally spasmodic and associated with posttussive gaggingor emesis, the classical clinical symptoms are often notpresent in an immunized population.
4–6
However, thediagnosis is important to prevent spread to contacts, andpertussis should be suspected for any cough that persistsfor
2 weeks in those with no previous history ofasthma or other causes of chronic cough. Diagnosis ismade most readily by polymerase chain reaction from aproperly collected nasal swab to detect pertussis antigen.
CysticFibrosis
Cystic fibrosis is the second most common chronic in-flammatory airway disease, at least among the whitepopulation. It occurs in
1 in 2500 live births in popu-lations of northern European descent with variablelesser incidence in other ethnic groups and races. Al-though the mechanisms of airway inflammation are dif-ferent in these 2 diseases, both cause airway obstruction,cough, wheezing, and dyspnea. The classical clinical pre-sentation of malabsorption is not always present, andthe severity and progression of the airway disease ishighly variable. There is a variability in the extent towhich the
1500 mutations of the cystic fibrosis trans-membrane regulator gene alters the chloride channeland results in clinical manifestations.
7
Consequently,some people do not present with respiratory symptomsuntil adolescence or even adulthood.
8
Some degree of bronchodilator response may even be present, althoughthe physiology of the airway responsiveness differs fromthat in asthma.
9
Also, asthma can coexist with cysticfibrosis.Cystic fibrosis should be suspected when symptomsand signs of airway inflammatory disease persist despitea short course of high-dose systemic corticosteroid. Thediagnosis of cystic fibrosis is made most reliably by per-forming a sweat chloride measurement using the classi-cal quantitative pilocarpine iontophoresis method. Mostof the various screening methods that assess by theconductivity of sweat are unreliable, because they canhave both false-positive and false-negative results.
10
Forthe test to be valid, duplicate collections of at least 75 mgare required for the filter-paper discs or gauze pads, andduplicate 15-
L samples are sufficient with the Macro-duct collection coil (Wescor, Logan, UT).
11
Measurementof 60 mEq/L chloride with substantial agreement in bothsamples is generally diagnostic of cystic fibrosis. Sweatchloride concentrations of
40 mEq/L are generally re-assuring that cystic fibrosis is not the cause of the pa-tient’s airway inflammatory disease. Levels of 40 to 60
856
WEINBERGER, ABU-HASAN
 at UNIV OF CHICAGO on June 1, 2008www.pediatrics.orgDownloaded from 

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