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Childhood asthma overdiagnosed, warn respiratory doctors

Inhalers often dispensed for no good reason; it’s trivialising serious condition, they suggest

Caroline White

Wednesday, 06 April 2016

Doctors are overdiagnosing asthma, with inhalers frequently dispensed for no good reason, to the point that they have “almost become a fashion accessory,” argue two leading respiratory doctors in a leading article* published online in the Archives of Disease in Childhood.

In the past, asthma was undoubtedly underdiagnosed, but the evidence now is that the pendulum has swung too far in the opposite direction, insist Professor Andrew Bush and Dr Louise Fleming of Imperial College and Royal Brompton & Harefield NHS Foundation Trust in the journal.

It matters, not only because of the cost of inhalers, but also because of their side effects, which are more likely to occur in patients who are prescribed an inappropriate dose, they say.

“Inhaled corticosteroids, when properly used, dramatically improve quality of life and reduce the risk of asthma attacks and mortality,” they write.

But there are potential side effects associated with their use, they point out. These include growth suppression and the dampening down of immune cell activity in the airways and consequent heightened risk of respiratory infections.

“There is also evidence that systemic absorption of [inhaled corticosteroids] depends not just on the prescribed dose, but is greater if the dose is inappropriately high for the degree of airway inflammation,” they caution.

Key to diagnosing asthma correctly is a detailed knowledge of normal respiratory symptoms in healthy children, they say.

But as the National Review of Asthma deaths shows, children who have asthma still die because of failures in basic management, including not taking inhalers that they really need.

“We propose that one contributing factor is that the diagnosis of asthma has been trivialised and inhalers dispensed for no good reason, and have become almost a fashion accessory,” they write.

The result is, the fact that asthma is fatal if not correctly managed, is being overlooked, they warn.

All too often, the hallmark symptom of asthma—wheeze—is used imprecisely by both parents and healthcare professionals. More objective evidence, such as the results of simple breathing tests, is required before a diagnosis is made, they suggest.

“Is there any other chronic disease in the world in which children are committed to potentially hazardous, long-term therapy without every effort being made objectively to document the diagnosis?” they ask.

They outline various approaches to aid correct diagnosis, including simple breathing tests and the need to remember that many children outgrow asthma symptoms. Treatment shouldn’t simply be stepped up if the child fails to respond, because there’s a chance the diagnosis might not be right in the first place, they point out.

Dr Maureen Baker, who chairs the Royal College of GPs, moved to reassure parents and children by insisting that most cases were appropriately managed.

“Inhalers, like any other medication, come with risks and GPs would never prescribe them unless they think it is in the best interests of the patient in front of them,” she said.

But she pointed out: “Diagnosing and treating asthma is incredibly difficult in young children as some common symptoms are similar to those of other illnesses, and there is no single test that can definitively diagnose asthma.”

Dr Samantha Walker, Director of Research and Policy at charity Asthma UK, added: “It’s astonishing in the 21st century that there isn’t a test your child can take to tell if they definitely have asthma. Asthma isn’t one condition but many, with different causes and triggered by different things at different ages. Asthma symptoms also change throughout someone’s life or even week by week and day by day.

“This complexity means that it is both over and underdiagnosed, in children and in adults, so people don’t get the care they need to manage their asthma effectively. As a result, a child is admitted to hospital every 20 minutes because of an asthma attack and asthma attacks still kill the equivalent of a classroom of children every year in the UK. We urgently need more investment in asthma research to get to a definitive test to ensure people get the right diagnosis.”

* Bush A, Fleming L. Is asthma overdiagnosed? Archives of Disease in Childhood, 2016; archdischild-2015-309053 DOI: 10.1136/archdischild-2015-309053

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