[Bronchial obstruction in asthmatic patients is underestimated by general practice physicians]

Many asthmatics have few or no symptoms despite severe obstruction of the airways. Physicians confronted with this phenomenon may therefore underrate the severity of the asthma and treatment may be insufficient. We studied the capacity of a group of general practitioners to assess the bronchial obstruction of patients presenting with varying degrees of symptoms and obstruction.

Ten asthmatics were initially examined by a pneumologist. The patients were classified as: normal (N; no dyspnoea, no wheeze, normal spirometry; n = 2); abnormal (A; dyspnoea and whistling, bronchial obstruction; n = 4); falsely normal (FN; mild or no dyspnoea and no wheeze, bronchial obstruction; n = 4). Ten randomly selected general practitioners, ignoring the protocol and aim of the study, examined 6 patients, 2 from each category. They then had to choose from a list of antiasthma treatments, those that would be appropriate for each patient, and assess on a visual analog scale (VAS) the degree of respiratory tract obstruction at the time of examination. Finally, questions on their knowledge and approach to asthma were asked.

The VAS assessments (mm) were of 15.6, 65.2 and 11.0 in the FN, A and N patients, corresponding to a maximum expiratory volume per second of 52, 51 and 98% of the predicted values. Dyspnoea and wheeze were mentioned by each physician as criteria for respiratory tract obstruction. Although they also mentioned the laboured breathing, none noted the signs of thoracic distension, present in the falsely normal patients. None used the paradoxical pulse (inspiratory drop in systolic pressure) and/or spirometric measurements; nobody had noted that dyspnoea and wheeze can be lacking despite substantial obstruction of the airways. Five had prescribed beta 2 agonists alone, without corticosteroid therapy in falsely normal patients.

General practitioners may underrate the severity of asthma, despite substantial obstruction of the respiratory tract, if there are few symptoms and hence under-treat falsely normal patients.