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Evaluation of clinically and physiologically atypical asthma: If it doesn't wheeze it may still be asthma
Dorit Ater1,2, Israel Amirav3, Matan Attias1
1a Pediatric Pulmonary Unit , Department of pediatrics, Wolfson Medical Centre , Holon , Israel.
Insights
Many children with asthma symptoms do not wheeze during testing. Adding oxygen saturation and respiratory rate measurements to bronchial challenge testing (BCT) improves asthma diagnosis sensitivity in young children.
Area of Science:
- Pediatric Pulmonology
- Respiratory Medicine
- Diagnostic Testing
Background:
- Asthma diagnosis in children can be challenging, particularly when wheezing is absent.
- Physician-documented wheeze is a common indicator, but not all children with asthma-like symptoms exhibit this sign.
- Bronchial challenge testing (BCT) is used to assess airway hyperresponsiveness.
Purpose of the Study:
- To determine if children without physician-documented wheeze wheeze during BCT.
- To evaluate if O2Sat and respiratory rate measurements enhance BCT sensitivity.
Main Methods:
- Seven hundred and twenty-four children suspected of having asthma underwent BCT.
- Positive BCT was defined by provocation concentration (PC) causing a 20% decrease in FEV1 (PC20), a 50% increase in respiratory rate (PC_RR), or a 5% decrease in oxygen saturation (PC_O2-Sat).
- Children were categorized into two groups: those unable to perform spirometry (Group A) and those able to perform spirometry (Group B).
Main Results:
- 507 BCTs were positive. 17.6% of positive tests were in Group A (n=89) and 82.4% in Group B (n=418).
- Children without physician-documented wheeze were more likely to have a positive BCT without wheezing (65.5%) compared to those with wheeze (41.0%).
- In Group A, incorporating PC_RR and PC_O2-Sat increased BCT sensitivity by 23.6%.
Conclusions:
- A significant number of children do not wheeze during BCT, even with positive results.
- Relying solely on wheezing may lead to under-diagnosis of asthma in children.
- Adding respiratory rate and oxygen saturation measurements to BCT significantly improves diagnostic sensitivity, especially in younger children.
Objective:
Children with asthma-like symptoms may not clinically wheeze. The objectives of this study were to evaluate if children, without physician-documented wheeze, wheeze during bronchial-challenge-testing (BCT), and if measurements of O2Sat and respiratory rate during BCT improve the BCT sensitivity?
Methods:
Seven hundred and twenty-four children, who were referred for suspicion of asthma, performed a BCT. Positive BCT was determined by the provocation concentration (PC) which resulted in a 20% decrease in FEV1 (PC20), (in those who were able to perform spirometry, group B), or (in those unable to perform spirometry, group A) a 50% increase in respiratory rate (PCRR), or a 5% decrease in oxygen-saturation (PCO2-Sat) or appearance of wheezing (PCwheeze).
Results:
Five hundred and seven BCTs were positive: group A n = 89 age, median (IQR), 3 (2.5-3.7) years (17.6%), were unable to perform spirometry, and group B n = 418 age 10.7 (6.8-15.6) years (82.4%), were able to perform spirometry. Children, without physician-documented wheeze in the total population (groups A plus B), were more likely (65.5%) to have a positive BCT without wheeze compared with those with physician-documented wheeze (41.0%, P < 0.001). In group A, adding PCRR and PCO2-Sat increased BCT sensitivity by 23.6%.
Conclusions:
Many children in both groups did not wheeze despite reaching BCT endpoints. Children without physician-documented wheeze tended not to wheeze at BCT. This may result in clinical under-diagnosis of asthma if depending on the presence of wheeze. In young children, adding PCRR and PCO2-Sat substantially increases BCT sensitivity and may improve asthma diagnosis.