Conference Coverage

When and how to suspect asthma misdiagnosis


 

REPORTING FROM ACP INTERNAL MEDICINE

If a patient’s asthma symptoms don’t fluctuate over time and in severity, it’s definitely time to entertain the possibility of diagnostic error, Kyle I. Happel, MD, said at the annual meeting of the American College of Physicians.

“Asthma is a disease whose symptoms are caused by variable airflow obstruction. It varies throughout the day, usually, and certainly by the week or by the month. I want you to think about the variability of a patient’s disease symptoms in forming your index of suspicion for this disease,” urged Dr. Happel, of the section of pulmonary, critical care, and allergy/immunology at Louisiana State University Medical Center in New Orleans.

Dr. Kyle I. Happel of the section of pulmonary, critical care, and allergy/immunology at Louisiana State University Medical Center in New Orleans Bruce Jancin/MDedge News

Dr. Kyle I. Happel

Lack of variability in asthma symptoms raises three possibilities: the wrong diagnosis; the presence of severe uncontrolled asthma for so long that it may have morphed into an asthma/chronic obstructive pulmonary disease overlap syndrome; or perhaps the asthma has resolved, which can occur when a patient with childhood-onset asthma moves into adulthood.

These phenomena occur often. In a Canadian multicenter study of more than 700 patients with a history of physician-diagnosed asthma within the past 5 years, current asthma was ruled out in fully 33% of them on the basis of no deterioration of asthma symptoms, no evidence of reversible airway obstruction, and no bronchial hyperresponsiveness after all asthma drugs were tapered off (JAMA. 2017 Jan 17;317[3]:269-79).

Wheezing is the most specific symptom of asthma, although it is not, in fact, terribly specific. In descending order, the next most specific symptoms are breathlessness, chest tightness, and cough.

The top seven diseases that mimic asthma symptoms are chronic obstructive pulmonary disease, rhinosinusitis, heart failure with preserved or reduced ejection fraction, gastroesophageal reflux disease, angina, anxiety, and vocal cord dysfunction syndrome.

Strike two for an asthma diagnosis is a patient’s report that albuterol doesn’t improve the symptoms. That definitely raises questions about the diagnosis.

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