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Pediatric asthma diagnosis should not be based on spirometry only

Published: October 21, 2022

Asthma is the most frequent chronic non-communicable disease in children, but an appropriate diagnosis is sometimes difficult to reach at this age group. Indeed, international guidelines for asthma diagnosis focus strongly on spirometry parameters (presence of an airway obstruction associated to an increase of 12% of the Forced Expiratory Volume in 1 second, FEV1, after bronchodilation test), while clinicians corroborate their diagnostic approach in children mainly by associating different clinical symptoms and patients’ personal medical history.

The aim of the study by Fillard et al., published on The Journal of Allergy and Clinical Immunology: In Practice, was to measure, in real-life settings, the sensitivity (Se) of the spirometry criteria for pediatric asthma diagnosis and that of clinical parameters. The Authors conducted a multicenter retrospective cohort study that included 871 asthmatic children of at least 5 years of age (mean age at diagnosis 9.2 years) from the Pediatric and the Allergy Unit of the University Hospital of Montpellier (France) and from the Immunology and Allergy Pediatric Unit of the University Hospital of Pavia (Italy), who performed a spirometry at the time of the diagnosis. Patients were considered as asthmatic if, after the first consultation, the physician, specialized in childhood respiratory and allergic diseases, concluded the visit by declaring the child affected by asthma, and if they responded to prescribed asthma treatment within 2 follow-up visits. For each patient, they collected demographic information, spirometry results at the time of the diagnosis, asthma severity, clinical symptoms, and presence of comorbidities, including results of skin prick tests to respiratory allergens.  

The primary outcome of their study was to assess the Se of the reversibility criterion proposed by international guidelines of an increase of 12% of FEV1 after bronchodilation test: in their cohort, the reversibility criterion showed a sensitivity of 30.4% in the whole population and of 23.5% in the subgroup of patients with an airway obstruction. Nonetheless, they underlined that the mean improvement in FEV1 after bronchodilation was higher and showed a better Se in patients presenting with more severe forms of asthma. Also, they showed that atopy has a significant impact on asthma severity (92.7% in persistent severe patients, 78.3% in persistent moderate asthma, and 73.4% in mild forms). Considering other endpoints, Fillard et al. evaluated other spirometry parameters suggested in the literature for assessing pediatric asthma and the Se of clinical symptoms as well. They again showed that the best single criterion was a clinical one, i.e., the presence of “dry cough” (Se 90.9%); considering the association of possible criteria, the best option included only clinical criteria, which were either “dry cough, or wheezing or atopy”, or “dry cough, or wheezing or exercise-induced dyspnea” (Se 99.5%). The Authors concluded that the diagnosis of asthma in children could be carried out by general practitioners and pediatricians, without needing, at least initially, to perform spirometry tests, but simply through carefully evaluating the clinical history and the symptoms presented by children.

The Journal of Allergy and Clinical Immunology: In Practice is an official journal of the AAAAI, focusing on practical information for the practicing clinician.

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