Diagnosis of Bronchial Asthma

By Vineet Mariyappan
 How to start making a diagnosis of bronchial
asthma?
• The diagnosis of bronchial asthma is not always
straight forward.
• There are no direct laboratory findings, which tells a
person has bronchial asthma.
• Therefore, taking a proper good history and a careful
physical examination may tell if a person has bronchial
asthma or not.
 History
• There are certain hallmark symptoms of asthma,
which include wheeze, chest tightness, breathlessness
and cough. However these symptoms may overlap
with other pulmonary conditions.
• It is particularly important to ask whether these
symptoms are variable or intermittent, nocturnal, or
provoked by certain triggers like cold air, exercise and
allergen exposure.
• A family history of bronchial asthma would be present.
 Clinical Examination
• If the percussion note is hyperresonant, this may
corroborate with acute asthma.
• On auscultation, wheezing can be heard.
FEV1 is normal/reduced and FVC is normal. The ratio itself may be reduced or normal.

Spirometry
• As one knows, spirometry
assesses lung function by
measuring the volume of air
exhaled from a full lung over 6
seconds.
𝐹𝐸𝑉1
• This is measured by .
𝐹𝑉𝐶
• In asthma, obstruction of bronchi
may be present, but values are
often normal in well-controlled
individuals.
 What to do if patients have airflow
obstruction?
• Reversibility testing is done. FEV1 or PEF (Peak
expiratory flow) is recorded before and 20 minutes
after an inhaled short-acting beta-agonist delivered via
nebulizer/atomizer/inhaler. This drug may be
salbutamol or albuterol. (Dose = 2.5 mg)
• If there is at least >400 mL improvement in FEV1 or
60L/min in PEF, it is regarded as diagnostic.
• But remember, that PEF itself has a low sensitivity in
confirming the diagnosis and so useful in monitoring
rather.
What to do if patients do not have airflow
obstruction?
• Exercise testing is done. Here the PEF is
measured at rest and the patient is asked
to exercise (that is to run for 6 minutes).
Then for 30 minutes, PEF would be
recorded every 10 minutes.
• Post-exercise, a fall of 20% is diagnostic.
• Just to know, how can one reverse this
fall? Inhale a 200 mcg
salbutamol/albuterol.
 What to do if patients do not have airflow
obstruction?
• Bronchial challenge testing can be done. One can
assess the extent of hyper-reactivity of the airways.
• Histamine and methacholine are commonly used
stimuli which act directly upon bronchial smooth
muscles and cause bronchoconstriction. The same, if
inhaled, can also cause the same effect.
• To do this, measure baseline FEV1 levels. Administer
the stimulus by nebulizer/inhaler/atomizer. Then
measure the FEV1 level again. (A fall in 20% would be
 What to do if patients do not have airflow
obstruction?
• Now, construct a log dose-response curve. One can
find out the PD20 levels (This is known as the
provocative dose or the dose causing a 20% decrease
in FEV1 in one second).
• Lower PD20 levels indicate greater airways reactivity.
• This test is replaced by a newer mannitol challenge
test, available as a pre-prepared kit. Mannitol, in a
powder form, is inhaled.
What to do if patients do not have airflow
obstruction?
 Or else…
• One can determine by tests of airway inflammation.
This can be done by two methods.
1. Sputum eosinophilia. – A differential count of >2% in
such patients is significant.
2. Exhaled nitric oxide analysis – Now, within the airway,
NO is synthesised by the action of NOS on l-Arginine.
In inflammation, iNOS (inducible NOS) is expressed,
resulting in overproduction of eNO (exhaled nitric
oxide). In asthma, eNO rises > 25ppb [NORMAL: 6-8
ppb]
This is an exhaled nitric oxide
analyser…