Clinical Asthma Symptoms

The classic symptoms of asthma include intermittent, reversible episodes of airflow obstruction manifested by cough, wheezing, chest tightness, and dyspnea (Table 10). When the clinical situation permits, a detailed history (Table 11) should be taken that includes the following: (l) family and personal history of atopic disease; (2) age of onset of asthma, frequency and severity of attacks; (3) times (including seasons) and places of occurrence of asthmatic attacks; (4) known provocative stimuli and any previous correlating skin-test reactions; (5) the severity of the disease as reflected in the wheezing episodes per day, the number of missed school or work days per year, whether sleep is interrupted, the necessity for emergency room visits, and the number of hospitalizations for asthma; and (6) previous pharmacological or immunological therapy and its efficacy.

Early symptoms often include a vague, heavy feeling of tightness in the chest, and, in the allergic patient, there may be associated rhinitis and conjunctivitis. The patient may experience coughing, wheezing, and dyspnea. Although the cough (if present) is initially nonproductive, it may progress to expectoration of a viscous, mucoid, or purulent and discolored sputum. There appears to be a subgroup of asthmatics whose asthma is characterized solely by cough without overt wheezing, the "cough variant of asthma." (Just as all that wheezes is not asthma, all that is asthma does not necessarily wheeze.) If this syndrome is suspected, patient's airways should be examined by spirometry before and after bronchodilator inhalation or after receiving a methacholine inhalation challenge.

Patients who appear to have allergic asthma, as demonstrated by seasonal exacerbations or clearly recognized allergen-related triggering events, may be sensitive to pollens, dust mite, animal dander, mold spores, occupational dusts, or insects. Less frequently, children may also be allergic to certain foods. If the offending allergen can be identified from the patient's history and avoided, further workup may not be necessary. However, the fact that atopic patients may be allergic to many allergens or may react to such small amounts of crude allergens (i.e., dust mite) indicates that the association is not clear-cut. Moreover, allergic asthmatics may respond to many nonallergic conditions (such as cigarette smoke, noxious fumes, upper respiratory tract infections, or weather conditions) by wheezing.

All patients should be asked if they can take aspirin or NSAIDs without ill effects, and this line of inquiry is even more important in patients with sinusitis or nasal polyps. Occupational asthma should be suspected if patient worsens early each week and then improves during the course of the week, or if asthma is worse during the week as com-

Table 10

Asthma Diagnosis: Episodic Symptoms of Airflow Obstruction (Determine Frequency)


Shortness of breath (with or without exercise)

Chest tightness (below sternum)

Cough (throat vs chest, quantity and quality of sputum)

Nocturnal awakenings

Morning vs evening symptoms

Emergency room visits


Table 11

Initial History (Determine Days/Week/Month for Each)

Do you wheeze? Shortness of breath?

Tightness in the chest (inability to take a full breath)? Exercise? Need pretreatment with bronchodilator? Cough? Throat vs chest, sputum quality/quantity? Use of bronchodilator? Nocturnal awakenings

Peak flow meter use; average, best and worst reading? Emergency room visits, hospitalizations?

pared to weekends or during travel. It may be necessary to have the patient use a peak flow meter at work during the course of a week to help determine what exacerbates the disease, or to conduct a bronchial challenge with materials to which the patient is exposed at work.

Chest X-rays should be repeated every 3-5 yr, and a yearly complete blood count is a reasonable precaution in most patients. Some subjects worsen reliably with every upper respiratory infection, and it may be necessary to treat them prophylactically with antibiotics and/or CCSs to prevent these exacerbations.

Many subjects are unaware of their chest disability and benefit from frequent peak flow readings (Table 12). We routinely provide a peak flow meter to all asthmatics and request that readings are taken twice a day, in the morning and at night. These readings are an invaluable adjunct to the management of most asthmatics.

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