Box 1-1. nostic flowchart for clinical practice — presentation Patient with respiratory ‘symptoms (Box 1-2) ‘Are the symptoms typical of asthma? Detailed historylexamination for asthma History/examination supports ‘asthma diagnosis? Further bigfory and tests for |___— no alternatiy@siagnoses (Box 1-3) Cina urgency, and other, Atternifve diagnosis confirmed? Perform spirometry/PEF with reversibility test (Box 1-2) Results support asthma diagnosis? Répbat on another gsation or arrange other | ves tests (Box 1-2) ‘Confirms asthma diagnosis? |— xo Empiric treatment with ves No Yes ICS and pen SABA (Box 3-4) vaidetsl opie Consider trial of treatment for Diagnostic testing within most likely diagnosis, or refer 1-3 months (Box 1-4) for further investigations Treat for ASTHMA 1 for alternative diagnosis 19S: inhaled concasteroige; PEF: peak expiratory ow (highest of tee readings). When measuring PEF, use the same meter each tie as the value may vaty by upto 20% between different meter; pin: 35-needed: SABA: short acting beta agonist. Bronchadliatorrevetsibity may be last curing severe exacerbations of viral infections, and in long-standing asthma, i bronchodilator reversibly not found at intial presentation, the next step depends on the avallbity of tests andthe clinical urgency of need for treatment, See Box 1-4for Aiagnosis of asthma in patients already taking controler treatment. 18 1 Defnition, description and diagnosis of asthmaBox 1.2. Diagnostic criteria for asthma in adults, adolescents, and children 6-11 years Asthma is a heterogeneous disease, usually characterized by chronic airway inflammation. Itis defined by the history of respiratory symptoms such as wheeze, shortness of breath, chest tightness and cough that vary over time and in intensity, together with variable expiratory airflow limitation, DIAGNOSTIC FEATURE CRITERIA FOR MAKING THE DIAGNOSIS OF ASTHMA 1. History of variable respiratory symptoms Wheeze, shortness of breath, chest ‘© Generally more than one type of respiratory symptom. tightness and cough (in adutts, isolated cough is seldom due to asthma) Descriptors may vary between cultures and | symptoms occur variably aver time and vary in intensity by age, e.g. children may be described as, having heavy breathing ‘+ Symptoms are often worse at night or on waking ‘+ Symptoms are often triggered by exercise, laughter, allergens, cold air ‘+ Symptoms often appear or worsen with Viral infections 2. Confirmed variable expiratory airflow limitation Documented excessive variability inlung | The greater the variations, or theimiore occasions excess variation is function* (one or more of the tests below) | seen, the more confident tha-diagnosis AND documented expiratory airflow Ata time when FEV, is réduiced, confirm that FEV,/FVC is reduced (itis limitation* usually >0.75-0.80 inadutts, >0.80 in children®) Positive bronchodilator (BD) reversibly | Adus: increase if FEV, of >12% and >200 mL from baseline, 10-18 test” (more likely to be positive if BD minutes after 260-400 meg albuterol or equivalent (greater confidence it medication is withheld before test: SABA | increase is =18% and >400 mL). 24 hours, LABA 215 hours) Children. increase in FEV, of >12% predicted Excessive variability in twice-daily PEF | Adutaverage daily diurnal PEF variability >10%™ over 2 weeks" Chidren: average daily diurnal PEF variabilty >13%™ Significant increase in lung function after; Adults: increase in FEV, by >12% and >200 mL (or PEF* by >20%) from 4 weeks of antiinflammatory treatment <\) baseline atter 4 weeks of treatment, outside respiratory infections Positive exercise challenge test” Adutts. fallin FEV, of >10% and >200 mL from baseline Chilorer: fallin FEV, of 12% predicted, or PEF >15% Posttive bronchial challenge teat Fall in FEV; from baseline of 220% with standard doses of methacholine (usually only performed in adults) or histamine, or 215% with standardized hyperventilation, hypertonic. saline or mannitol challenge Excessive variation in ling function Adutts: variation in FEV, of >12% and >200 mL between visits, outside of between visits” (less reliable) respiratory infections Children: vatiation in FEV, of >12% in FEV, or »15% in PEF* between visits (may include respiratory infections) {D: bronchodilator (short acting SABA or rapid-acting LABA); FEV: foroed expiratory volume in 1 second: LABA: long-acting beta- agonist PEF: peak expiratory flow (highest of thre readings); SABA: short acting beta agonist. See Box 1-4for diagnos inpatients already taking controller treatment "These tests can be repeated duting symptoms or inthe early morning. "Daily dlurnal PEF variability & caloulated from tice daiy PEF as ({éays highest minus day's lowest mean of day’ highest and lomest), and averaged over one week. 'For PEF. use the same meter each time, 35, PEF may vary by up to 20% between diferent meters. BD reveisibilty may be lest during severe exacerbations of vital infections.” and alow limitation may become pets stent overtime If bronchodilator reversibility not present at intial presentation, the next step depends on the avaabilty of ether ‘tests and the uigency ofthe need for treatment In a situation of elnical urgency, asthma treatment may be commenced and diagnostic testing arranged thin the next fen weeks (Box 1-4, p22), but other condtions that ean mimie asthma (Box 1-3) should be considereg, and the diagnos of asthma confirmed as s00n as possible 1. Definition, description and diagnosis of asthma 19