Expert: Marc Rubin, RPh Asthma Educator - 1/24/2009

Question
Hi, recently my 15-1/2 year old daughter started having a dry/hacking cough, went to the doctor who said she was fine just buy Robitussin, cough drops, etc. About 5 days later it started getting worse, to the point where she was coughing & hacking so much is was violent, she looked like she was choking, had difficulties breathing, etc.  Brought her back into the same doctor (her pediatrician) who now hear a wheeze when she breathed then she asked me if she ever wheezed before.  I said yes when she was 7 she had a real dry/hacking cough, not as bad as this time so her doctor at the time put her on albuteral for 2 weeks and then she was fine.  After which her current doctor said she had asthma and prescribed 2 inhalers, 1 being albuteral & I can't remember the other but it's only used in the morning & at night.  Since this diagnoses (Wednesday 11/21/09) my daughter has had 2 more violent coughing attacks where she had to use the albuteral to stop it.

I am just curious as to what sort of testing is generally done with diagnosing asthma?  I had always heard that chest x-rays were involved but in this case nothing other than when I asked her doctor how she determined that she had asthma and her exact words were "because she's wheeze more than 1 time."  Sounded a little funny to me but I'm not a medical professional.

Thank you for your time in answering my question.

Answer
Hi Patricia,

To begin with ANY diagnosis is approached by following a S.O.A.P. work-up. It begins with:

CC: (Chief complaint) the reason for the visit.

Then the SOAP is done..
S: (Subjective) a patient verbal history of the symptom onset, duration, associated issues (food, dust, day/night, etc.) What the patient has found,or not found to be helpful. In asthma, family history of asthma is significant, skin disorders like psoriasis, runny nose (rhinitis), general allergy tendencies.

O: (Objective) this is the testing phase to get real numbers and digging deeper. On an initial work-up, the practitioner should at least do a peak-flow meter test which is repeated ~ 15 minutes after giving a dose of albuterol. If the improvement is greater than 15%, it indicates a "reversible" airway constriction. But this may also be seen with acute bronchitis. A blood test would be done: CBC w/differential..a complete blood count which also shows variations in the different types of white blood cells. In allergic conditions, like asthma, eosinophils are increased...not so in bronchitis. If there appears a strong indication of asthma, then another, much more accurate and specific breathing test is done: spirometry. Chest X-rays are not of value here. For diagnosing pneumonia, yes, but not asthma.

A: (Assessment) by reviewing the subjective and objective information, a short list of likely diagnosis is achieved, including the probability of one specific one.

P: (Plan) if there is not one clear-cut diagnosis, then a list is created, with the most serious malady at the top (usually cancer), then the least life threatening at the bottom. This reduces the risk of overlooking something dangerous that has similar presentation. From this, tests are run to narrow down to the correct diagnosis.

IF the diagnosis appears obvious, then the next step is prescribing treatment and lifestyle changes (if necessary) to address the problem. The treatment approach should follow established medical guidelines which provide a protocol based upon a number of factors. In the case of asthma, the latest guidelines were issued in November of 2007: NHLBI Expert Panel Report#3 ( http://www.nhlbi.nih.gov/guidelines/index.htm ) These guidelines also establish procedures for monitoring patient progress.

Your suspicions appear well grounded. I'd get a second opinion from an allergist. You can locate a local specialist at.. (http://www.aaaai.org/physref/). Be sure to check to see from the list which are covered by your insurance plan.

NEVER doubt your gut feelings...you've done an excellent parenting job.

Sincerely,

Marc