|
 
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| COMMENTARY |
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| Year : 2023 | Volume
: 2
| Issue : 2 | Page : 58-61 |
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Tips and pitfalls in the diagnosis and treatment of bronchial asthma
Mohamed Saleh Al-Hajjaj
Clinical Sciences Department, College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
| Date of Submission | 28-Nov-2022 |
| Date of Decision | 19-Jan-2023 |
| Date of Acceptance | 28-Jan-2023 |
| Date of Web Publication | 06-Mar-2023 |
Correspondence Address:
Prof. Mohamed Saleh Al-Hajjaj
Clinical Sciences Department, College of Medicine, University of Sharjah, Sharjah
United Arab Emirates
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/abhs.abhs_63_22
Bronchial asthma (BA) is one of the common presentations in the outpatient clinic. In most cases, diagnosis of BA is straightforward with typical history and pertinent physical examination. However, a significant number of patients who present or referred as BA, yet they lack the classical signs and symptoms of BA. The pattern of symptoms and past history of similar episodes are crucial in the diagnosis. Several diseases can mimic asthma presentation including air hunger, acute bronchopulmonary aspergillosis, and vocal cord dysfunction need to be identified and managed accordingly. Even if BA can be easily managed in most cases, there are several obstacles that can prevent a good asthma control. Compliance with medication, incorrect use of different devices, and steroid phobia may lead to a poor control of BA. A better control of BA can be obtained by additional measures in the treatment plan. These include step-up and step-down method of therapy, offering influenza and pneumococcal vaccines, attention to comorbidities, and utilizing telemedicine for easy approach and follow-up.
Keywords: Acute bronchopulmonary aspergillosis, air hunger, asthma, difficult-to-control, step-down, step-up, steroid phobia, telemedicine, vocal cord dysfunction
How to cite this article:
Al-Hajjaj MS. Tips and pitfalls in the diagnosis and treatment of bronchial asthma. Adv Biomed Health Sci 2023;2:58-61 |
| Background | |  |
Diagnosis of bronchial asthma (BA) can easily be made in most cases based on the typical history and presence of bilateral wheezes [1]. Blood eosinophilia, spirometry, fractional-exhaled nitric oxide (FeNO), and serum immunoglobulin-E (IgE) provide confirmation of clinical diagnosis [2]. In few cases, a methacholine challenge test can be utilized to rule out BA. However, in the regular practice, the diagnosis may remain unclear in some patients, and they are misdiagnosed or wrongly diagnosed as BA. Furthermore, even after a correct diagnosis, there are several obstacles that prevent acceptable asthma control.
BA is not one disease but has several phenotypes. Therefore, personalized medicine in asthma management is important to tailor treatment plans to individual patients based on factors such as symptoms, comorbidities, occupational history, smoking history, and response to previous treatments. This approach aims to improve treatment efficacy and reduce side effects by identifying the specific underlying cause of a patient's asthma and targeting treatment accordingly [3].
In this article, several tips and pitfalls are explained to help the optimal diagnosis and treatment.
| Common Conditions That Can Be Misdiagnosed as Bronchial Asthma | | |
Air hunger
Air hunger (AH) is a condition that commonly occur in young females and is characterized by difficulty in taking a good inspiration. A typical patient will try hard to take a deep breath and often try to yawn to relief the feeling of “AH” disorder. Other symptoms include hand tremors, sweating, and tachycardia. These patients are usually having stress and an anxiety disorder. When they present to the clinic, many of these patients can be misdiagnosed as having BA and often prescribed bronchodilators. Nevertheless, when the case is reviewed by an asthma specialist, the typical asthma history is not part of the condition and spirometry, chest X-ray and FeNo are usually normal. Most of these patients will have a significant relief with reassurance and anxiety management. Rarely, they need anti-anxiety drugs and/or referral to psychiatry [4].
Cough variant asthma
Cough variant asthma (CVA) is one of the phenotypes of asthma. In CVA, cough is the only presenting symptom of asthma without associated wheeze or dyspnea. Even their spirometry and chest X-ray if performed are usually normal. In the absence of other clear causes of cough, a trial of an inhaled bronchodilator and inhaled corticosteroids will settle the cough confirming the diagnosis of CVA. It is common that this presentation is misdiagnosed with other causes of cough like upper respiratory tract infection.
Patients are managed like regular BA cases as they often require a long-term inhaled therapy [5]. If the diagnosis remains uncertain, then confirmation of bronchial hyperresponsiveness can be made by doing methacholine provocation test [6].
Vocal cord dysfunction
Patients with vocal cord dysfunction usually present with difficulty in breathing and inspiratory stridor that often occurs after exercise mimicking BA. However, spirometry flow volume loop usually shows a blunt or flattened inspiratory phase. A definite diagnosis can be made by laryngoscopy showing a paradoxical vocal cord movement [7]. These patients are preferably managed by a multidisciplinary team including psychology, ENT, neurology, and speech therapy [8].
Acute bronchopulmonary aspergillosis
Acute bronchopulmonary aspergillosis (ABBA) can be misdiagnosed as severe BA because it has similar presentation [9]. However, very high eosinophilic count and very high IgE should alert the treating physician to the possibility of ABBA [10]. Diagnosis is confirmed by computed tomography scan of the chest showing central bronchiectasis and Aspergillus species-specific precipitating antibodies [11].
| Crucial Details That Can Be Overlooked During History Taking | | |
Drug history
Commonly used drugs can be contributing to the severity of asthma symptoms including beta-blockers and nonsteroidal anti-inflammatory drugs. Angiotensin-converting enzyme inhibitors can be the sole cause of refractory cough. Therefore, it is crucial to take detailed drug history from every asthmatic patient [12].
Allergies and irritants
When taking the history from an asthmatic patient a specific inquiry of home or work-related allergens and irritants are to be explored. Some young patients will hide the presence of domestic animals or pets at home fearing that their physician will advise parents to relocate their pet outside their home. This risk if not tackled may be the main reason for having uncontrolled asthma. Finding a high titer of specific allergy test to animals like cats and dogs will be a convincing tool for such patients to address the cause of their asthma symptoms and contribute to a better control [13].
Comorbidities
Comorbidities can be a significant factor in the difficulty of controlling asthma. The association of allergic rhinitis (AR) and BA was shown in a study by Luthra et al.[14] In their patients with AR, 59.03% have BA, whereas in the BA group 78.20% had AR. Therefore, it is important to explore the symptoms and signs of AR as patients with severe symptoms to BA may ignore the less problematic symptoms of AR. Managing AR by prescribing the appropriate treatment or referring the patient to the ear, nose, and throat (ENT) clinic will result in a better control of BA.
Vitamin D deficiency and obesity are other contributing factors to severity of BA. Both obesity and vitamin D deficiency are very common in the Gulf Cooperation Council countries. Association of both has been shown in several studies and addressing these two comorbidities will lead to a better control of BA [15],[16].
Other comorbidities including heart failure, liver and kidney diseases should be identified and proper management should be offered.
Smoking and bronchial asthma
Patients with BA usually do not smoke as it is an irritant and can induce their asthma symptoms. If a heavy smoker patient who is >40-year-old presented with asthma-like symptoms, chronic obstructive pulmonary disease (COPD) should be considered. Spirometry and other supporting diagnostic tools are to be followed to be able to offer the right management. Asthma, COPD overlap is another possibility that needs to be addressed by finding common features of both diseases in spirometry and blood tests. Addressing this specific phenotype will lead to a better control of respiratory symptoms [17].
Asthma control
Home use of peak flow meter (PFM) can be a very helpful tool for both patients and the treating physician for a clear management plan leading to a better asthma control. Furthermore, use of PFM has been shown to improve patient's compliance and improves the physician's assessment, follow up and therapeutic interventions [18].
| Treatment Of Bronchial Asthma | | |
Steroid phobia
Social media has substantiated fear from steroids in some patients leading to reluctance in accepting to take even the inhaled steroids or early withdrawal of the treatment [18],[19]. Trust of the treating physician and clear explanation of the extent of the steroids side effects will lead to a better acceptance and compliance with the treatment plan. Furthermore, asthma educational programs directed to the public is a useful tool to clear misconceptions and lead to a better understanding of BA and its management [19],[20],[21].
Correct use of inhalers and poor technique
Different devices with different method of correct use are an obstacle to many patients especially for children and elderly patients [21]. Instructions on the right method of using the inhaler device is to be obtained from the enclosed leaflet within the device container. Written and/or video clips can be shared with patients to minimize the poor technique and improve the drug administration. Limiting the prescription to one device type and using combined formulas in one device will reduce the errors in inhalation technique. Utilizing smartphone applications that shows step-by-step methods of use will be a useful tool [22].
Adherence and compliance with treatment
Misunderstanding of the nature of the inflammatory reaction in BA is the main reason of patients interrupting or holding the treatment and only using a reliever to respond to their symptoms [23]. A full explanation by the physician and clarification of the prophylactic nature of the steroid inhaler helps to avoid incompliance.
A clear treatment plan and follow up fixed appointments leads to a better adherence with treatment regimen [24]. Opedun et al. found that incorrect use of asthma medication may lead to poor compliance as patients do not find a beneficial effect of the treatment [25]. Innovative methods to improve compliance include e-monitoring and digital counter of dose consumption [26],[27].
Step-down and step-up method
Most BA management guidelines emphasize the step-down and step-up chart for dealing with persistent asthma type [28]. Because of the nature of BA pathophysiology and variable response to different environmental circumstances, one form of treatment may not be suitable for an extended period. Frequent revision of the treatment plan is to be made on at least 3 monthly bases. Patients should be involved in the management plan and need to be well informed about the nature of their illness and the need to adjust the treatment either up or down depending on set criteria including symptoms, asthma control test, and pulmonary function tests [29],[30].
Vaccines
One of the common triggers of BA exacerbation is upper respiratory tract viral infections. Influenza vaccine has been shown to be effective in reducing the influenza-triggered asthma attacks [31]. Likewise pneumococcal vaccine has been shown to reduce pneumonia and acute exacerbations in asthmatic patients [32]. As part of the comprehensive management of asthmatic patients, these vaccines should be an integral part of the management plan to reduce all possible factors that can lead to deterioration of the asthma control.
Telemedicine
The COVID-19 pandemic has expanded the rule of distant e-medicine practice which has proved to be effective in a better control of BA particularly in patients who are unable to regularly attend to the clinics for face-to-face encounter [33]. This method of communications can be well utilized to maintain patient compliance and respond to any change in the patient medical condition without the burden and delay in attending the clinic. A better compliance of patients with the given plan of therapy and hence an improved control of BA is one of the gains of telemedicine practice provided the rules and regulation of the practice are followed [34].
| Conclusion | | |
BA is a common and heterogeneous disease with different presentations and variable response to treatment. It is crucial to take a through history and emphasize on parts of the history that may give clues for all risk factors and possible obstacle for optimal control. It is important to apply the personalized medicine approach as each patient may need a different method in diagnosis, management, and prevention.
Financial support and sponsorship
Not applicable.
Conflict of Interests
Al-Hajjaj MS is an editorial member of the Advances in Biomedical and Health Sciences Journal. No conflict of interests declared.
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