Practice Rational Testing

Investigating asthma symptoms in primary care

BMJ 2012; 344 doi: http://dx.doi.org/10.1136/bmj.e2734 (Published 25 April 2012) Cite this as: BMJ 2012;344:e2734
  1. Christine Jenkins, thoracic physician1,
  2. Leigh Seccombe, senior respiratory scientist12,
  3. Ron Tomlins, adjunct associate professor3
  1. 1Department of Thoracic Medicine, Concord Hospital, Concord NSW 2139, Australia
  2. 2Australian School of Advanced Medicine, Macquarie University, North Ryde NSW 2109, Australia
  3. 3Discipline of General Practice, Western Clinical School, University of Sydney, Australia
  1. Correspondence to: C Jenkins christine.jenkins{at}sydney.edu.au
  • Accepted 22 March 2012

Even when dyspnoea is accompanied by a history of wheeze, use of spirometry and related tests is needed before making a diagnosis of asthma

Learning points

  • Never assume recurrence of dyspnoea is due to asthma without lung function testing, even when a history of wheeze is present

  • Spirometry with bronchodilator testing is the investigation of choice to diagnose asthma in adults and children >10 years old

  • Consider referral for bronchial provocation testing with a direct agent (such as methacholine) or indirect agent (such as mannitol or hypertonic saline) according to clinical features (such as a suggestive history but normal spirometry) and local resources

  • Longstanding asthma may evolve in adult life into a syndrome of fixed airflow limitation with poor response to short acting β agonists, so diagnostic reversibility is not always present

  • If asthma treatment is poorly effective and spirometry is normal or near normal, pursue other diagnoses and consider referral to a respiratory specialist

A 36 year old man presents with a six to nine month history of exercise related dyspnoea and chest tightness, especially during football training. It does not restrict him badly and does not occur every time he exercises. It usually resolves after about 15 minutes of rest, and he can resume exercising. A friend offered him salbutamol for relief, and it definitely improved his symptoms. He has a history of childhood wheeze with upper respiratory tract infection but never required regular inhalers and seemed to be “cured” by about age 10. There is no family history of asthma. He had hay fever as a teenager, and doesn’t think he has any allergies now. He smoked 10–15 cigarettes a day from age 18 years until age 33. Clinical examination is unremarkable, and his body mass index is in the normal range at 23.4.

What are the likely diagnoses?

Asthma is a common condition, …

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