European Respiratory Society guidelines for the diagnosis of asthma in adults

Abstract

Although asthma is very common affecting 5–10% of the population, the diagnosis of asthma in adults remains a challenge in the real world that results in both over- and under-diagnosis. A task force (TF) was set up by the European Respiratory Society to systematically review the literature on the diagnostic accuracy of tests used to diagnose asthma in adult patients and provide recommendation for clinical practice.The TF defined eight PICO (Population, Index, Comparator, and Outcome) questions that were assessed using the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach, The TF utilised the outcomes to develop an evidenced-based diagnostic algorithm, with recommendations for a pragmatic guideline for everyday practice that was directed by real-life patient experiences.The TF support the initial use of spirometry followed, and if airway obstruction is present, by bronchodilator reversibility testing. If initial spirometry fails to show obstruction, further tests should be performed in the following order: FeNO, PEF variability or in secondary care, bronchial challenge. We present the thresholds for each test that are compatible with a diagnosis of asthma in the presence of current symptoms.The TF reinforce the priority to undertake spirometry and recognise the value of measuring blood eosinophils and serum IgE to phenotype the patient. Measuring gas trapping by body plethysmography in patients with preserved FEV1/FVC ratio deserves further attention. The TF draw attention on the difficulty of making a correct diagnosis in patients already receiving inhaled corticosteroids, the comorbidities that may obscure the diagnosis, the importance of phenotyping, and the necessity to consider the patient experience in the diagnostic process.

Common conditions that mimic asthma

“…4 For patients with a high or moderate probability of asthma, obtain good quality spirometry, usually starting with bronchodilator responsiveness (spirometry before and 15 minutes after inhalation of bronchodilator, usually 4 puffs of salbutamol). 4,7 However, its sensitivity is low; in a community population, including patients already on asthma preventer treatment, only 21% of patients ultimately confirmed as having asthma had significant bronchodilator responsiveness at initial testing. 3 Spirometric testing should therefore be carried out when it is most likely to yield a diagnosis, for example, when the patient is symptomatic, and after withholding reliever medications.…”

“…Confirmation of variable expiratory airflow limitation is needed 4 . For patients with a high or moderate probability of asthma, obtain good quality spirometry, usually starting with bronchodilator responsiveness (spirometry before and 15 minutes after inhalation of bronchodilator, usually 4 puffs of salbutamol) 4,7 . However, its sensitivity is low; in a community population, including patients already on asthma preventer treatment, only 21% of patients ultimately confirmed as having asthma had significant bronchodilator responsiveness at initial testing 3 …”

Eosinophilic Asthma, Phenotypes-Endotypes and Current Biomarkers of Choice

“…The Global Initiative for Asthma (GINA) defines asthma as “a heterogeneous disease, usually characterized by chronic airway inflammation with a severe global impact on quality of life, mortality, economy, and health care utilization” [ 1 , 2 ]. Although asthma affects 1–18% of the population, its diagnosis remains a challenge in everyday clinical practice [ 3 ], leading to both over- and under-diagnosis, particularly in the elderly and in low- and middle-income countries [ 3 , 4 , 5 ]. Nowadays, the diagnostic algorithm is mainly based on GINA recommendations and differs in cases of patients already receiving controller treatment [ 6 ].…”

What is the added value of FeNO as T2 biomarker?

“…The global strategy for asthma management and prevention (GINA) guidelines ( 19 ) do not currently find a role for this biomarker in diagnostic algorithms. Recently, the European Respiratory Society (ERS) Guidelines for the Diagnosis of Asthma in Adults ( 20 ) also recommended measuring FeNO in patients suspected of asthma, when the diagnosis could not be established with initial spirometry and bronchodilator reversibility testing. Louis et al propose a cutoff value of 40 ppb.…”