Journal of Allergy
Volume 2014, Article ID 898965, 8 pages
http://dx.doi.org/10.1155/2014/898965
Clinical Study
Diagnosis of Asthma in Primary Health Care: A Pilot Study
Karin C. Ringsberg,1,2 Paula Bjrneman,2 Ronny Larsson,3
Elisabeth Wallstrm,3 and Olle Lwhagen2
1
1. Introduction
Bronchial asthma is a common disease worldwide and good
treatment could often be offered [1]. Its prevalence in the adult
population in Sweden is up to 10% [2], being the highest
in the north part and in younger people. The diagnosis is
based on the presence of episodic breathing troubles and
variable and reversible airway obstruction [1, 3]. Most cases
are not difficult to diagnose and treat; however, some patients
respond poorly to asthma treatment despite ongoing asthmalike symptoms. In those cases, other diagnoses must be
considered [415]. Disorders with asthma-like symptoms
mentioned in the literature are dysfunctional breathing [11,
1618], vocal cord dysfunction [19], pseudoasthma [20],
cough variant asthma [8], multiple chemical sensitivity [21],
and airway sensory hyperreactivity (SHR) [22]. In GINA,
the international guidelines for asthma diagnostics and
treatment [1], two disorders with asthma-like symptoms are
mentioned, vocal cord dysfunction (VC) [19] and hyperventilation syndrome (HVS) [7]. As the above conditions
are presented under different names, it is not possible to
know the prevalence. However, Marklund et al. found that
every third asthmatic had been given a wrong diagnosis
[14]. They also found that the older the patients, the greater
the risk of an incorrect diagnosis [14]. Johansson et al. [23]
estimated the prevalence of airway sensory hyperreactivity
to be about 6% in the adult population. These patients often
seek primary care because of asthma-like symptoms and poor
quality of life [5]. Using factor analysis in a general population
sample Bonde et al. [18] identified five groups of breathingrelated disorders, dysfunctional breathing, odour intolerance,
asthma, bronchitis, and a group with mixed symptoms. These
groups should therefore be considered when investigating
patients in the primary care.
In this study, an operational definition of asthma-like
disorder is used, meaning symptoms that most physicians
Journal of Allergy
2.2.2. Skin Prick Test. The skin prick test was performed on
patients who reported a suspected allergy history. A standard
panel of 10 allergen extracts (Soluprick SQ ALK Copenhagen)
was used (two mites, two moulds, birch, mugwort, timothy,
cat, dog, horse).
(1) episodic lower airway symptoms (breathing complaints, wheezing, coughing, phlegm, chest tightness,
or chest pain/pressure) [1],
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Table 1: Age, sex, lung function, and classification of patients.
Group
(I) Asthma
= 12
(II) Asthma-like
= 19
(III) Idiopathic cough
=5
(IV) Nonreversible bronchial
obstructive
=7
PEF variability
mean %
(range)
Age median
(range)
Sex
male/female
44 (3683)
0/12
99 (76123)
6 (013)
24 (852)
47 (1976)
3/16
103 (91122)
2 (08)
10 (719)
50 (3957)
0/5
103 (95107)
3 (07)
11 (215)
59 (1766)
2/5
79 (7386)
4 (011)
11 (516)
(2)
Included
Positive Negative
FEV1 -revers.
n=3
n = 40
PEF-variabil.
n=7
n = 36
Methacholine n = 2
n=8
Asthma
n = 12
43 12 = 31 Nonasthma
n=5
Chron
cough
n=0
COPD
n = 7 Obstructive
n = 43
n = 19 Asthma-like
3. Results
Chronic Idiopathic Cough [27] . Chronic idiopathic cough
included the following:
(1) dominant cough lasting 8 weeks,
(2) FEV1 90% of predicted normal value,
(3) reversibility in FEV1 < 12%,
(4) variability in PEF < 20%.
2.3. Statistics. Within-group comparisons in questionnaire
number 1 (yes/no answers) were analysed using the chisquare test. The statistical analysis focused on the difference
between asthma and asthma-like disorders. For differences
between groups, nonparametric methods were used; for
Journal of Allergy
Table 2: The five most reported symptoms based on questionnaire no. 1. Group IIV.
Phlegm
Heavy breathing
Chest pressure/pain
Cough
Wheezing
Group I
= 12
Group II
= 19
Group III
=5
Group IV
=7
12 (100%)
9 (75%)
9 (75%)
2 (16%)
6 (50%)
18 (95%)
16 (84%)
9 (47%)
12 (63%)
7 (37%)
4 (80%)
0 (0%)
0 (0%)
5 (100%)
0 (0%)
7 (100%)
4 (58%)
2 (29%)
3 (29%)
3 (43%)
Group I
= 12
Median (range)
Group II
= 19
Median (range)
Group III
=5
Median (range)
Group IV
=7
Median (range)
1.0 (14)
2.0 (15)
2.0 (15)
1.0 (1-2)
2.0 (15)
2.0 (15)
2.0 (15)
2.0 (15)
2.0 (15)
5.0 (15)
1.0 (13)
1.0 (14)
2.0 (15)
2.0 (15)
2.0 (15)
2.0 (14)
1.0 (14)
2.0 (15)
2.0 (15)
2.0 (14)
1.0 (14)
2.0 (15)
2.0 (15)
1.0 (14)
3.0 (15)
2.0 (15)
2.0(15)
2.0 (15)
2.0 (15)
3.0 (25)
2.0 (15)
2.0 (14)
2.0 (15)
2.0 (15)
2.0 (15)
2.0 (15)
1.0 (14)
2.5 (15)
3.0 (15)
2.5 (15)
1.0 (1-1)
1.0 (14)
1.0 (15)
1.0 (1-2)
1.0 (14)
2.0 (14)
1.0 (1-2)
1.0 (1-2)
1.0 (14)
5.0 (15)
1.0 (14)
1.0 (15)
2.0 (15)
1.0 (14)
1.0 (14)
3.0 (24)
1.0 (1-1)
2.0 (15)
2.0 (13)
2.0 (14)
1.0 (1-1)
2.0 (15)
3.0 (25)
1.0 (1-1)
2.0 (13)
2.0 (15)
1.0 (14)
1.0 (14)
2.0 (15)
3.0 (25)
2.0 (14)
1.0 (1-2)
2.0 (15)
2.0 (14)
2.0 (15)
2.0 (13)
2.0 (13)
2.0 (14)
2.5 (13)
2.0 (15)
Journal of Allergy
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Table 4: Subsets of symptoms scored in questionnaire no. 2.
Group I
= 12
Median (range)
2.0 (15)
2.0 (15)
2.0 (15)
1.0 (14)
2.0 (15)
4. Discussion
Most patients with respiratory complaints in Sweden are first
visiting the primary health care, which has good access to
practical and reliable diagnostic methods. The number of new
Group II
= 19
Median (range)
1.0 (15)
2.0 (15)
2.0 (15)
2.0 (15)
2.0 (15)
Group III
=5
Median (range)
1.0 (15)
1.0 (15)
2.0 (15)
1.0 (15)
2.0 (15)
Group IV
=7
Median (range)
1.0 (15)
2.0 (15)
2.0 (15)
1.0 (14)
2.0 (15)
Journal of Allergy
Table 5: Most reported symptom-inducing trigger factors based on questionnaire no. 1.
Trigger factor
Walking up hills/stairs
Cold air
Mental stress
Tobacco smoke
Flowers
Perfume
Exhaust gases
Group I
= 12
(%)
10 (83)
7 (58)
3 (25)
3 (25)
3 (25)
3 (25)
3 (25)
Group II
= 19
(%)
10 (53)
8 (42)
4 (21)
7 (37)
4 (21)
0 (0)
3 (16)
Group III
=5
(%)
2 (40)
3 (60)
1 (20)
1 (20)
0 (0)
0 (0)
0 (0)
Group IV
=7
(%)
6 (86)
4 (57)
4 (57)
4 (57)
5 (71)
5 (71)
2 (29)
Group I
= 12
Median (range)
1.0 (15)
1.5 (14)
2.5 (15)
2.0 (15)
2.0 (14)
2.0 (15)
1.0 (14)
Group II
= 19
Median (range)
1.0 (14)
1.0 (14)
2.0 (14)
2.0 (14)
2.0 (13)
2.0 (15)
1.0 (13)
Group III
=5
Median (range)
1.0 (1-2)
1.0 (13)
1.0 (1-1)
1.0 (13)
1.0 (1-1)
2.0 (14)
1.0 (1-1)
Group IV
=7
Median (range)
1.5 (14)
1.5 (14)
3.0 (25)
3.0 (25)
3.0 (15)
3.5 (25)
2.0 (15)
= 0.05.
5. Conclusions
In conclusion, this study shows that asthma-like symptoms
with or without reversible bronchial obstruction are equally
common in patients seeking primary health care. The similarities in symptoms and trigger factors support the hypothesis
that asthma and nonobstructive asthma-like disorders are
integrated in the same asthma syndrome, which might
include different mechanisms, not only bronchial obstruction.
Ethical Approval
All diagnostic tests were included in the clinical routine at the
centre. This pilot study is included in a larger planned study
whose design was approved by the local ethical committee
(reference no. 615-11). The rules of the Helsinki Declaration
Journal of Allergy
Conflict of Interests
The authors declare that there is no conflict of interests
regarding the publication of this paper.
[15]
[16]
Acknowledgment
The authors would like to thank Inger Winberg at the Asthma
and Allergy Centre, Sahlgrenska University Hospital, for
performing the methacholine tests.
[17]
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