Diagnosing asthma in children represents an important clinical challenge. There is no single gold standard test to confirm the diagnosis. Consequently, both over-, and under-diagnosis of asthma are frequent in children.A Task Force (TF) supported by the European Respiratory Society has developed these evidence-based clinical practice guidelines for the diagnosis of asthma in children aged 5–16 years using nine PICO (Population, Intervention, Comparator and Outcome) questions. The TF conducted systematic literature searches for all PICO questions and screened the outputs from these, including relevant full text articles. All TF members approved the final decision for inclusion of research papers. The TF assessed the quality of the evidence using the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach.The TF then developed a diagnostic algorithm based on the critical appraisal of the PICO questions, preferences expressed by lay members and test availability. Proposed cut-offs were determined based on the best available evidence. The TF formulated recommendations using the GRADE Evidence to Decision framework.Based on the critical appraisal of the evidence and the Evidence to Decision Framework the TF recommends spirometry, bronchodilator reversibility testing and FeNO as first line diagnostic tests in children under investigation for asthma. The TF recommends against diagnosing asthma in children based on clinical history alone or following a single abnormal objective test. Finally, this guideline also proposes a set of research priorities to improve asthma diagnosis in children in the future.
IntroductionThere are few data on the usefulness of different tests to diagnose asthma in children.AimWe assessed the contribution of a detailed history and a variety of diagnostic tests for diagnosing asthma in children.MethodsWe studied children aged 6–16 years referred consecutively for evaluation of suspected asthma to two pulmonary outpatient clinics. Symptoms were assessed by parental questionnaire. The clinical evaluation included skin-prick tests, measurement of exhaled nitric oxide fraction (FeNO), spirometry, bronchodilator reversibility and bronchial provocation tests (BPT) by exercise, methacholine and mannitol. Asthma was diagnosed by the physicians at the end of the visit. We assessed diagnostic accuracy of symptoms and tests by calculating sensitivity, specificity, positive and negative predictive values and area under the curve (AUC).ResultsOf the 111 participants, 80 (72%) were diagnosed with asthma. The combined sensitivity and specificity was highest for reported frequent wheeze (more than three attacks per year) (sensitivity 0.44, specificity 0.90), awakening due to wheeze (0.41, 0.90) and wheeze triggered by pollen (0.46, 0.83) or by pets (0.29, 0.99). Of the diagnostic tests, the AUC was highest for FeNO measurement (0.80) and BPT by methacholine (0.81) or exercise (0.74), and lowest for forced expiratory volume in 1 s (FEV1) (0.62) and FEV1/forced vital capacity ratio (0.66), assessed by spirometry.ConclusionThis study suggests that specific questions about triggers and severity of wheeze, measurement of FeNO and BPT by methacholine or exercise contribute more to the diagnosis of asthma in school-aged children than spirometry, bronchodilator reversibility and skin-prick tests.
IntroductionDiagnosing asthma in children remains a challenge because respiratory symptoms are not specific and vary over time.AimIn a real-life observational study, we assessed the diagnostic accuracy of respiratory symptoms, objective tests, and two paediatric diagnostic algorithms proposed by GINA and NICE to diagnose asthma in school-aged children.MethodsWe studied children aged 5–17 years referred consecutively for evaluation of suspected asthma to pulmonary outpatient clinics. Symptoms were assessed by parental questionnaire. The investigations included specific IgE measurement or skin prick tests, measurement of fractional exhaled nitric oxide, spirometry, body plethysmography, and bronchodilator reversibility. Asthma was diagnosed by paediatric pulmonologists based on all available data. We assessed diagnostic accuracy of symptoms, tests, and diagnostic algorithms by calculating sensitivity, specificity, positive and negative predictive values, and area under the curve (AUC).ResultsAmong 514 participants, 357(70%) were diagnosed with asthma. The combined sensitivity and specificity (sensitivity/specificity) was highest for any wheeze (0.75/0.65), dyspnoea (0.56/0.76), and wheeze triggered by colds (0.58/0.78) or by exercise (0.55/0.74). Of the diagnostic tests, the AUC was highest for specific total resistance (sRtot) (0.73) and lowest for the residual volume (RV) total lung capacity (TLC) ratio (0.56). The NICE algorithm had a sensitivity of 0.69 and specificity of 0.67, whereas the GINA algorithm had a sensitivity of 0.42 and specificity of 0.90.ConclusionThis study confirms the limited usefulness of single tests as well as existing algorithms for the diagnosis of asthma. It highlights the need for new and more appropriate evidence-based guidance.
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