Review article

Supported by a grant from Zeneca Pharmaceuticals

Clinical evaluation of asthma

James T C Li, MD* and Edward J OConnell, MD

Objective: The purpose of this article is to review the medical history and ing, shortness of breath, chest tight-
physical examination of the asthmatic patient. ness, and cough. What is the evidence
Data Sources: English references identified from relevant articles and book that these, indeed, are the most impor-
chapters, experts, and MEDLINE search, using asthma, physical diagnosis, and tant symptoms of asthma, and how of-
medical history. ten are these symptoms described by
Study Selection: Clinical studies of the medical history or physical examination individuals with asthma? It is very dif-
in subjects with respiratory disease were selected for review. ficult or impossible to offer an accurate
Results: Symptoms such as wheezing, chest tightness and difficulty in taking a answer to this question. However, pub-
deep breath suggest asthma, while symptoms such as gasping, smothering or air lished studies of symptoms of asthma
hunger suggest alternative diagnoses. Symptoms of asthma correlate poorly with can shed some light on this issue and
airway obstruction in one-third to one-half of asthmatic patients. Respiratory signs provide guidance for the differential
such as wheezing, breath sound intensity, forced expiratory time, accessory muscle diagnosis of asthma.
use, respiratory rate and pulsus paradoxus correlate roughly with airway obstruction. In one study, 53 patients with a va-
However, clinicians disagree on the presence or absence of respiratory signs 55% to riety of cardiopulmonary disorders in-
89% of the time. Furthermore, physicians correctly predict pulmonary function cluding asthma were asked to select
based on history and physical examination only about half the time, and correctly descriptions of their sensation of
diagnose asthma based on the clinical examination 63% to 74% of the time. breathlessness from a list of 19 de-
Conclusions: The medical history and physical examination are moderately scriptors.1 Analysis of the responses
effective in diagnosing asthma and estimating its severity. Objective measures of suggested that individuals with asthma
lung function are necessary for the accurate diagnosis of asthma. were more likely to select descriptors
Ann Allergy Asthma Immunol 1996;76:114. such as My breath does not go out all
the way, My chest feels tight, I
INTRODUCTION history and examination of the patient cannot take a deep breath, and My
The clinical evaluation of a new patient with asthma or possible asthma, an ex- breathing requires more concentra-
with asthma or possible asthma begins ample of which is shown in Table 1. tion. Individuals with asthma and in-
with a medical history, proceeds to a Rather, we will show how published dividuals with chronic obstructive pul-
physical examination of the patient, and clinical studies can guide the medical monary disease both selected the
often concludes with selected laboratory history and physical examination in descriptor My breathing requires ef-
studies. A careful and comprehensive asthma. We will point out where evi- fort or My breathing is heavy. On
medical history is essential for the diag- dence is lacking and when reliance on the other hand, individuals with
nosis and management of asthma. clinical judgement alone is required. chronic obstructive pulmonary disease
In this review, we will draw from The four major issues we will address use descriptors such as I am gasping
clinical studies, experiences, and obser- are (1) What are the symptoms of for breath, I cannot get enough air,
vations to provide an evidentiary frame- asthma? (2) How do symptoms of and My breathing requires more
work for the clinical evaluation of asthma correlate with the degree of air- work while individuals with asthma
asthma. This review is not intended as a way obstruction? (3) How accurate is the did not. Similarly, individuals with
comprehensive exposition of the medical physical examination in asthma? and (4) congestive heart failure were more
How good are physicians at diagnosing likely to select descriptors such as I
asthma and estimating its severity? feel that my breath is rapid, I feel
Division of Allergic Diseases and Internal that I am smothering, My breathing
Medicine* and Pediatric Allergy and Immunol- WHAT ARE THE SYMPTOMS is heavy, and I feel a hunger for
ogy, Mayo Clinic and Foundation, Rochester, OF ASTHMA? more air while individuals with
Minnesota. Descriptors asthma did not. Thus, individuals with
Received for publication February 27, 1995.
Accepted for publication in revised form June Most clinicians would agree that the asthma use somewhat different terms
24, 1995. major symptoms of asthma are wheez- to describe their symptoms compared

VOLUME 76, JANUARY, 1996 1

with individuals who have chronic ob-
structive pulmonary disease or conges-
tive heart failure. It is worth pointing
out that wheezing and cough were not
included on the dyspnea questionnaire.
In a similar way, another study an-
alyzed a dyspnea questionnaire con-
sisting of 45 descriptors of breathing
discomfort from 169 patients with car-
diopulmonary disorders.2 Ninety-two
percent of asthmatic patients selected
the descriptor I feel wheezy, 83%
selected I feel short of breath or re-
lated descriptors, and 81% selected
My chest feels tight. The percentage
of affirmative responses to these three
descriptors were 76%, 82%, and 68%,
respectively, for chronic obstructive
pulmonary disease and 28%, 54%, and
41%, respectively, for cardiac disease.
Thus, almost all patients with asthma
include wheezing as one of their symp-
toms compared with about three out of
four patients with chronic obstructive
pulmonary disease and about three out
of ten patients with heart disease. It
may be useful, then, for the physician
to elicit the description of respiratory
symptoms from the patient in order to
form a differential diagnosis. Of
course, a detailed and comprehensive
medical history would include much
more than simply a description of
symptoms, such as associated symp-
toms (eg, chest pain), and triggering or
alleviating factors.
Interestingly, physiologic study of
dyspnea suggests that the descriptor
My breath does not go out all the
way is associated with an increased
functional residual capacity (ie, pul-
monary hyperinflation) rather than air-
way obstruction.35 Deliberate hyper-
ventilation is associated with the
descriptor I feel hunger for more air
or I cannot get enough air which
might be helpful in differentiating
asthma from the hyperventilation syn-
drome.3
Virtually all clinicians will recog-
nize that there is a wide variation in
how patients perceive and describe
their symptoms of asthma. Studies an-
alyzing the ability of individuals with
asthma to detect or describe resistive
loading find significant variation
2 ANNALS OF ALLERGY, ASTHMA, & IMMUNOLOGY
Table 1. The Medical History in Asthma
I. Symptoms
A. Quality
1. Description
a. wheeze, breathlessness, cough, chest tightness, etc.
2. Onset
3. Progression
B. Provoking or triggering factors
1. Exercise
a. timing, duration, severity
b. effect on work, school, recreation
2. Infection
a. frequency, severity
b. response to treatment
3. Allergens
a. season
b. animals, pets
c. occupational
d. risk factors for dust mite exposure
e. related to hobbies, recreation
f. associated rhinoconjunctivitis
g. previous allergy testing
4. Irritant
a. fumes, dust, pollution
b. smoking
c. environmental smoke
5. Cold air
a. exercise in cold air
6. Medications
a. beta-adrenergic blocking agents
b. aspirin and non-steroidal anti-inflammatory drugs
c. medications for co-morbid medical condition
7. Emotional/stress
a. hyperventilation
b. panic attacks
8. Foods
a. sulfites
C. Alleviating factors
1. Rest, avoidance of physical activity
2. Avoidance of allergens, irritants
3. Medications
a. timing and duration (eg, beta-adrenergic agonists, corticosteroids)
b. immunotherapy
II. Assessment of Severity
A. Severity of symptoms
1. Frequency, number of episodes per day or week
2. Duration
3. Description of typical exacerbation
4. Response to treatment
B. Limitations of daily activity
1. Walking, distance, pace
2. Stairs, number of flights
3. Exercise, sports
4. Sleep disturbance, early morning symptoms
5. Daily activity
C. Hospitalizations
1. Number, frequency, length of stay
2. Intubation
3. Intensive care
(continued on next page)
Table 1. Continued among individuals.6 8 A few generali-
D. Emergency visits zations, however, can be made.
1. Number, frequency First, when the perception of exter-
2. Provoking factors nal resistive loading and induced bron-
3. Other unscheduled visits chospasm are compared, there is a
E. Days lost from work or school greater sense of dyspnea with broncho-
1. School or work performance spasm at any given level of resistance.6
F. Medication requirements
This suggests that airway resistance
1. Systemic coriticosteroid use
2. Beta-adrenergic agonist use
alone is not responsible for all asth-
a. number of puffs per day matic symptoms and that other physi-
b. number of canisters per month ologic derangements such as hyperin-
3. Inhaled corticosteroid, nedocromil, cromolyn use, theophylline, ipratropium flation or inflammation may be
4. Changes in medication requirements contributory.
G. Tests Second, psychologic status can af-
1. Previous or home peak flow measurements fect the description of respiratory
2. Previous spirometry symptoms. On one hand, individuals
III. Associated and Co-Morbid Medical Conditions with psychologic profiles of anxiety
A. Rhinitis
and dependency exhibit decreased per-
B. Sinusitis; nasal polyposis
C. Chronic obstructive pulmonary disease
ception of airway obstruction.8 On the
D. Gastroesophageal reflux other hand, respiratory symptoms such
E. Eczema as wheeze and dyspnea are correlated
F. Heart disease with anxiety, anger, and depression in
G. Hypertension patients without respiratory disease.9
H. Glaucoma Third, a study of 21 individuals with
I. Psychiatric disorder asthma showed that 19 subjects re-
IV. Current Medications ported increased inspiratory rather than
A. Asthma medications expiratory difficulty following metha-
B. All other medications
choline bronchoprovocation.5 Physio-
C. Non-prescription medications
D. Alternative medicine therapy
logic correlation suggested that the in-
V. Immunizations crease in inspiratory capacity (ie,
A. Childhood pulmonary hyperinflation) correlated
B. Influenza better with symptoms than the change
C. Pneumococcus in FEV1 (ie, airway obstruction). This
VI. Psychosocial sense of inspiratory dyspnea may be a
A. Residence result of increased inspiratory muscle
1. Slab construction, ventilation elastic loading caused by hyperinfla-
2. Humidity tion. A review of 119 patients experi-
3. Heating, cooling systems
encing acute asthma showed that 71%
4. Carpets, furnishings
5. Pets, hobbies
of patients found breathing air in more
6. Factors for dust mite, cockroach, rodents difficult compared with 19% who
7. Change in residence, previous residencies found breathing out more difficult.10
8. Other household members Interestingly, 78% of doctors surveys
B. Occupation thought that their asthmatic patients
1. Current and previous found expiration more difficult.10
a. building, location Fourth, a study of 28 asthmatic in-
b. daily activity dividuals undergoing allergen bron-
c. exposure to allergen and irritants choprovocation suggests that per-
C. School
ceived breathlessness is closely related
1. Performance
2. Phobia
to the rate of fall in FEV1 rather than
3. Physical education the absolute degree of airway obstruc-
4. Relationship with peers, teachers tion.11 Asthmatic individuals thus de-
D. Hobbies scribed a stronger sense of dyspnea
1. Animals during the rapid fall in FEV1 during the
2. Exposure early asthmatic response and lower de-
3. Hobbies of family members grees of dyspnea during the slower fall
(continued on next page) of FEV1 of the late asthmatic response.

VOLUME 76, JANUARY, 1996 3

Table 1. Continued
E. Education
1. Level of general education
2. Level of asthma education
3. Need for additional asthma education
F. Financial
1. Health insurance
2. Impact on patient and family finances
G. Patient perceptions
1. Concerns, fears, current understanding of medical problem
2. Concerns, fears, current understanding of family or significant others
3. Impact of medical problem on patient, life, family
H. Psychiatric and personality
1. Anxiety, dependence
2. Depression
3. Rebelliousness
4. Marital or family discord
5. Somatization
6. Physical, psychologic, sexual abuse, current or previous
7. Major psychiatric disorder
VII. Family History
A. Asthma
B. Respiratory diseases
C. Allergy, rhinitis, eczema
D. Marital status
E. Marital and family discord
F. Impact of medical problem on family
Collectively, these observations
suggest that wheezing, shortness of
breath, and chest tightness are indeed
important symptoms of asthma. Fur-
thermore, an accurate medical history
should include elicitation of the symp-
tom descriptors, which may be helpful
in differentiating asthma from chronic
obstructive pulmonary disease, con-
gestive heart failure, and hyperventila-
tion. Symptoms of asthma are caused
by pulmonary hyperinflation as well as
airway obstruction, and a high rate of
change in airway obstruction, charac-
teristic of many asthmatic patients,
may result in heightened perception of
breathlessness. Finally, individuals
with anxious and dependent personal-
ity traits may display a decreased sen-
sation of airway obstruction. This lat-
ter finding clearly has important
clinical significance since patients with
asthma who have decreased perception
of airway obstruction or hypoxia are at
risk for fatal and nearly fatal asthma.12
Chronic cough is an important
symptom for many patients with
asthma, although by convention is
not considered a form of dyspnea.
4 ANNALS OF ALLERGY, ASTHMA, & IMMUNOLOGY
Cough may be the primary or sole
presenting symptom of some chil-
dren or adults with asthma.13,14 A re-
view of cough symptoms in 32 chil-
dren with asthma whose primary
symptom was chronic cough showed
that cough was triggered by an upper
respiratory tract infection in 100% of
patients, the cough was exercise-in-
duced in 78%, the cough was noctur-
nal in 72%, and was induced by cold
air in 44% of patients.13
The idea that cough can be the sole
symptom of patients with asthma is
closely linked to the demonstration of
nonspecific bronchial hyperrespon-
siveness in these individuals.14 17 The
definitive diagnosis of the cause of a
chronic cough, however, may take
years to elucidate or may never be
fully understood in individual pa-
tients.18 Recognizing these limitations,
the authors of one study estimated that
the methacholine bronchial challenge
had a negative predictive value of
100% and a positive predictive value
of 74% for chronic cough caused by
asthma.15 In other words, in this study
a negative methacholine challenge ef-
fectively ruled out the presence of
asthma while a positive methacholine
challenge indicated a 74% chance that
the cough was caused by asthma. In
this same study, 14 of 45 or 29% of
patients presenting with chronic cough
were diagnosed as having cough
caused by asthma. Importantly, this
and other studies19,20 show that inter-
pretation of the medical history is not
very effective at predicting the pres-
ence or absence of bronchial hyperre-
sponsiveness. For patients with
chronic cough, a concomitant history
of dyspnea increased the likelihood
that the cough was caused by asthma
by tenfold.15 A history of wheezing,
cough with respiratory tract infection,
and a previous diagnosis of asthma
were not significantly linked to asth-
ma-induced cough in this study.
Cough, therefore, can be an impor-
tant symptom of asthma. Cough in-
duced by respiratory infections, cold
air and exercise, along with nocturnal
cough, may be suggestive of asthma.
Although the presence of dyspnea in
addition to cough is suggestive of
asthma, a previous diagnosis of
asthma, a history of wheezing, the du-
ration of cough, and personal or family
history of allergy are not helpful in
predicting whether or not chronic
cough is caused by asthma.15,17 A long-
term follow-up study of 78 adults who
underwent diagnostic methacholine
challenge suggests that individuals
who had a positive methacholine chal-
lenge were more likely to develop
symptoms of chest tightness, wheez-
ing, and dyspnea.18 Interestingly, de-
velopment of cough was not correlated
with the results of the previous metha-
choline bronchial challenge. These re-
sults together suggest that a careful
medical history will not be sufficient to
establish whether or not asthma is the
major cause of chronic cough for many
patients. The methacholine bronchial
challenge is a useful test for many of
these patients, although close fol-
low-up and assessing the response to
therapy are also very important.
Asthma may cause other symptoms
such as chest pain, particularly in chil-
dren. While most studies suggest that
asthma is an important cause of chest
pain in about 20% of children present-
ing with chest pain, one study demon-
strated exercise-induced airway ob-
struction in 73% of such children.21
Respiratory Questionnaires
Epidemiologic surveys have used re-
spiratory questionnaires to estimate the
prevalence of respiratory symptoms
and to correlate these symptoms with
cardiopulmonary disease states. In one
such survey,22 59% of patients with a
new diagnosis of asthma reported
wheezing compared with 19% of con-
trol patients, and 31% of patients with
a new diagnosis of asthma reported
shortness of breath with wheezing
compared with only 6% of controls. Of
interest, 69% of asthmatic patients re-
ported symptoms of rhinitis compared
with 39% of control patients. These
same data showed that individuals who
reported any wheeze or shortness of
breath with wheezing were seven times
more likely to have asthma compared
with those who did not. Individuals
who reported rhinitis were more than
three times more likely to have asthma
compared with those who did not. A
history of rhinitis may be moderately
useful in the diagnosis of asthma.
Reported wheezing is found in up to
30% of survey populations22 and per-
sistent wheezing is present in about
10% of children.23 Similar studies sug-
gest that dyspnea is present in 5% to
25% of the general population.24 26 A
study of 1,392 male workers using a
standardized respiratory questionnaire
showed that individuals reporting
wheezing or breathlessness, and espe-
cially those with both symptoms, were
more likely to show a low PC20 when
undergoing a methacholine bronchial
challenge. The symptom of chest tight-
ness was not independently correlated
with bronchial hyperresponsiveness.27
Another study showed that wheeze
and attacks of shortness of breath
with wheeze were independently pre-
dictive of asthma.28 Surveys using re-
spiratory questionnaires confirm that
the symptom of wheezing or wheezing
combined with shortness of breath are
highly suggestive of asthma.
VOLUME 76, JANUARY, 1996
HOW DO ASTHMATIC
SYMPTOMS CORRELATE
WITH AIRWAY
OBSTRUCTION?
The preceding review shows that the
symptoms of wheeze, shortness of
breath, chest tightness, and cough are
important in asthma. How well or how
poorly symptoms of asthma correlate
with asthma severity is a different
question entirely. This issue has great
clinical significance since management
decisions in asthma are founded in
large part on the physicians estimate
of the severity of asthma. With few
exceptions, the evidence to date clearly
indicates that asthmatic symptoms cor-
relate poorly with the degree of airway
obstruction for a significant proportion
of asthmatic patients; hence, objective
measurement of airway obstruction is
essential for these individuals.
In one study, 255 individuals with
asthma estimated the severity of symp-
toms of asthma using a visual analog
scale while measurements of peak ex-
piratory flow rate were taken at the
same time.29 Sixty percent of patients
showed no significant correlation be-
tween subjective asthma scores and
peak expiratory flow rate measure-
ments. Study of 82 patients with
asthma undergoing methacholine bron-
chial challenge showed that 15% of
patients were unable to subjectively
detect reverse airway obstruction (50%
predicted or lower).30 A similar study
of asthmatic patients undergoing bron-
choprovocation showed that although
symptoms of breathlessness were sta-
tistically correlated with FEV1 (r 5
.88),31 there was a large variation in the
severity of breathlessness for any par-
ticular degree of airway obstruction.
Study of patients with nocturnal
asthma shows that the increase in air-
way obstruction in the early morning
hours may go undetected in one-third
of patients.32
In another study, 20 children with
asthma were studied over a 16-week
period with symptom scores, peak ex-
piratory flow readings, and measure-
ment of FEV1.33 During asymptomatic
periods, peak expiratory flow rate was
decreased 54% of the time and FEV1
was decreased 36% of the time. When
patients recovering from acute asthma
were studied, pulmonary function was
only between 40% and 50% of pre-
dicted normal values when symptoms
disappeared.34 Collectively, these ob-
servations clearly show that one-third
to one-half of asthmatic patients under-
estimate the severity of asthma when
judged by symptoms alone. Appar-
ently, the perception of asthma cannot
be learned, inasmuch as home record-
ing of peak expiratory flow rates does
not improve the subjective assessment
of asthma severity.35 Nor does the use
of symptom questionnaires improve
the perception of airway obstruction.36
Perhaps one-third to one-half of asth-
matic patients can successfully esti-
mate their degree of airway obstruc-
tion. One study of ten asthmatic
subjects showed that a symptom diary
was superior to daily peak flow moni-
toring in detecting exacerbations of
asthma.37
These findings together are impor-
tant because poor perception of asthma
may be a risk factor for fatal asthma.
Patients with histories of nearly fatal
asthma show reduced chemosensitivity
and blunted perception of dyspnea.12
Psychiatric disease and psychologic
disturbances are also important risk
factors for fatal asthma.38 Such patients
may also have blunted perceptions of
airway obstruction.7
HOW ACCURATE IS THE
PHYSICAL EXAMINATION IN
ASTHMA?
If symptoms of asthma correlate
poorly with airway obstruction in a
significant proportion of asthmatic pa-
tients, is the physical examination an
accurate and inexpensive way to eval-
uate asthma severity? There is a rough
correlation between the presence of
wheezing on physical examination and
the severity of airflow obstruction.39 41
Although loud wheezing is associated
with greater airway obstruction, the
degree of correlation between wheez-
ing and airway obstruction is modest
and there is great variability.39,40 These
and other studies suggest that wheez-
5
ing during inspiration and expiration,
loudness of wheezing and prolonged
duration of wheezing during the respi-
ratory cycle are associated with greater
airway obstruction.39,40,42,43 Wheezing
during forced exhalation apparently
does not correlate with airway obstruc-
tion or bronchial hyperresponsive-
ness.40,44
The stethoscope and human ear to-
gether limit the usefulness of wheezing
as a measure of airway obstruction.
Analysis of recorded lung sounds
shows that there is a good correlation
between the duration of wheezing dur-
ing the breath cycle and the FEV1 (r 5
.89).42,43 Another computer-assisted
lung sound analysis showed that lung
sound mapping correctly classified
about 70% of subjects with a variety of
cardiopulmonary disorders such as in-
terstitial pulmonary fibrosis, chronic
obstructive pulmonary disease, con-
gestive heart failure, and pneumonia.45
Lung sound analysis of asthmatic chil-
dren undergoing bronchoprovocation
showed that wheezing detected by lung
sound analysis was much more sensi-
tive at detecting airway obstruction
than respiratory symptoms or wheez-
ing on auscultation.46 Auscultated
wheezes during bronchoprovocation
are not as sensitive as direct measure-
ment of FEV1, however.47
Since auscultation for wheezing in
the office and hospital setting is gen-
erally confined to auscultation with the
stethoscope, we conclude that there is
only a rough correlation between
wheezing and airway obstruction.
Most clinicians would agree that sig-
nificant airway obstruction can be
present in the absence of wheezing on
examination.
The respiratory signs of breath
sound intensity and forced expiratory
time have both been correlated with
airway obstruction. Examination of
183 patients referred to a pulmonary
function laboratory showed that breath
sound intensity correlated with mea-
surements of FEV1.48 Other studies of
physical findings in chronic obstruc-
tive pulmonary disease support the ob-
servation that reduced intensity of
breath sounds is associated with air-
6 ANNALS OF ALLERGY, ASTHMA, & IMMUNOLOGY
way obstruction.49 51 Decreased breath
sound intensity presumably is caused
by a combination of decreased acoustic
transmission through the lung and
chest wall combined with decreased
inspired and expired lung volumes and
flow rates.
The forced expiratory time is mea-
sured by instructing the subject to in-
hale maximally and then exhale force-
fully through a completed forced vital
capacity maneuver. The examiner
times the exhalation maneuver and
records a forced expiratory time. Com-
parison of forced expiratory time and
FEV1 shows that a prolonged forced
expiratory time of six seconds or
longer is associated with increased air-
way obstruction.52,53 As a test for ob-
structive airway disease, the forced ex-
piratory time has a sensitivity of 74%
to 92% and a specificity of 43% to
75%.52,53
Individuals with chronic obstructive
pulmonary disease and emphysema
may exhibit a constellation of physical
findings that is somewhat different
from asthma. Increased resonance to
percussion, excavation of the supracla-
vicular fossa, tracheal tug, and acces-
sory muscle activity correlate signifi-
cantly with airway obstruction in
patients with chronic obstructive lung
disease.49,50,54,56 As described above,
the forced expiratory time and breath
sound intensity correlate reasonably
well with objective measures of air-
flow obstruction.49,51 A study of 31 pa-
tients with chronic obstructive pulmo-
nary disease showed that of patients
with severe obstruction (FEV1 one liter
or less), 100% used accessory muscles,
70% had wheezing, 62% had dimin-
ished breath sounds, and 44% had in-
creased resonance to percussion.57 In
contrast, among patients with milder
obstruction (FEV1 . 1.1 L) approxi-
mately 39% showed accessory muscle
use, 30% had wheezing, 21% had di-
minished breath sounds, and 14% had
increased resonance to percussion.57 In
asthmatic children, severe airway ob-
struction correlates with accessory
muscle use, although prolonged expi-
ration and wheezing predicted airway
obstruction poorly.58
The presence of pulsus paradoxus is
associated with severe obstructive lung
disease including asthma.59,60 A study
of 93 patients with asthma showed that
a pulsus paradoxus was associated
with a peak expiratory flow rate of
33% of predicted values on average.59
Similarly, the respiratory rate corre-
lates modestly (r 5 .42) with peak
expiratory flow rates in patients with
acute asthma.61
Auscultation at the mouth or trachea
shows that wheezing may be transmit-
ted much better through the airways
than across the chest wall.62 Wheez-
ing over the neck, particularly when
predominantly inspiratory, suggests
stridor and upper airway obstruction,
rather than asthma.63
In summary, the presence of wheez-
ing, the duration of wheezing as a pro-
portion of the breath cycle, inspiratory
and expiratory wheezing, and the loud-
ness of wheezing all correlate roughly
with airway obstruction. The intensity
of breath sounds and the forced expi-
ratory time both correlate reasonably
well with airway obstruction. Both
pulsus paradoxus and a rapid respira-
tory rate are associated with severe
airway obstruction. Despite the statis-
tically significant correlation of these
respiratory signs with airflow obstruc-
tion, it is nevertheless very difficult for
clinicians to estimate airway obstruc-
tion accurately based on the physical
examination alone. One reason for this
is the correlation of physical signs with
measures of airflow obstruction is not
always close enough to be clinically
important. Another important reason is
the wide observer variability of skill in
the physical examination of the chest.
One study of interobserver variabil-
ity in eliciting physical signs in exam-
ination of the chest showed that a
group of four physicians agreed with
the presence or absence of a physical
sign only 55% of the time.64 Fortu-
nately, the presence or absence of
wheezing seemed somewhat more re-
liable than other respiratory signs since
physicians were in complete agree-
ment 63% of the time. In a separate
study of intraobserver and interob-
server variability, there was disagree-
ment about physical findings of the
chest 11% to 26% of the time.65 Fur-
ther, medical students demonstrated
better self-consistency than pulmonary
specialists. Rhonchi (low pitched
wheezes)66 and wheezes64 66 seem
more reliably detected than other respi-
ratory signs. These studies suggest that
physicians agree on the presence or
absence of physical signs of the respi-
ratory system 55% to 89% of the
time.57,64 66
Although physicians are moderately
successful in eliciting respiratory
signs, there is considerable disagree-
ment among observers when the same
patients are examined, and even signif-
icant variation when a single observer
examines the same patient on multiple
occasions. Nevertheless, most clini-
cians would agree that the pulmonary
examination is important for patients
with asthma or possible asthma. For
example, the presence of wheezing
would suggest clinically important air-
way obstruction, although the absence
of wheezing would not rule it out.
In one clinical study, investigators
trained actresses to simulate a new pa-
tient with asthma.67 The chest was not
examined in 61% of 74 consultations.
We suggest that all new patients with
asthma or possible asthma should un-
dergo a careful examination of the chest
and lungs. Although there is no direct
evidence to indicate that physical exam-
ination of the chest results in improved
patient outcomes, clinicians should be
aware of the benefits and limitations of
the pulmonary examination.
HOW GOOD ARE PHYSICIANS
AT DIAGNOSING ASTHMA AND
ESTIMATING ITS SEVERITY?
While it may be useful or interesting to
understand the clinical implications of
symptoms of asthma and to appreciate
the limitations of the pulmonary exam-
ination, physicians reach clinical im-
pressions based on the complete med-
ical history and physical examination.
There has been some study of the di-
agnostic usefulness of the medical his-
tory in patients with asthma. One study
prospectively evaluated 85 patients
with dyspnea and found a diagnostic
VOLUME 76, JANUARY, 1996
accuracy of 66% based on the medical
history, physical examination, and
chest radiograph.68 These patients were
seen at a subspecialty clinic and were
evaluated by board certified pulmo-
nologists. A similar study based in a
general internal medicine clinic
showed that internists were able to di-
agnose patients with dyspnea correctly
74% of the time.69
Study of the medical history in
chronic obstructive pulmonary disease
suggests that independent predictors of
obstructive airway disease from the
clinical examination were patient re-
ported wheezing, auscultated wheez-
ing, number of years the patient had
smoked cigarettes, forced expiratory
time, and peak expiratory flow rate.70
A similar study suggested that a previ-
ous diagnosis of chronic obstructive
pulmonary disease, 70 pack year
smoking history, and diminished
breath sounds on examination sug-
gested the diagnosis of chronic ob-
structive pulmonary disease.71,72 A
study of patients admitted to the hos-
pital for dyspnea showed that the re-
ferring physicians diagnoses were
correct only 66% of the time.73
A study of 162 patients with pos-
sible work related asthma suggests
that the type and timing of respira-
tory symptoms was modestly useful
in differentiating occupational
asthma from asthma that was not
work related.74 For example, symp-
toms at work were reported by 91%
of patients with occupational asthma
and 86% of patients without occupa-
tional asthma. Improvement of
symptoms on weekends or on holi-
days were reported by 77% and 88%,
respectively, of patients with occupa-
tional asthma and 56% and 76%, re-
spectively, by patients without occu-
pational asthma. The investigators
estimate that the predictive value of
a history suggesting occupational
asthma was 63%. These findings are
consistent with the observation that
occupational asthma may be cor-
rectly diagnosed only 12% of the
time.75
Physicians are only moderately
successful in predicting the results of
pulmonary function studies in pa-
tients with asthma or other respira-
tory diseases. One study of hospital-
ized asthmatic patients showed that
physicians were able to estimate the
peak expiratory flow rate to within
20% of the measured value only 44%
of the time based on physical exam-
ination alone. The correlation coeffi-
cient was 0.66.76 In a similar study,
physicians referring patients for pul-
monary function tests were asked to
predict the nature of the ventilatory
defect (eg, obstructive, restrictive,
normal) and estimate the severity of
the abnormality.77 Physicians cor-
rectly predicted airway obstruction in
81% of cases. On the other hand,
61% of the tests gave a result that the
physicians predicted as being un-
likely, and physicians were unable to
predict reversibility of airflow ob-
struction in patients with obstructive
lung disease. Similar conclusions
were reached in a study of 71 chil-
dren presenting to an emergency
room with acute asthma.78 Based on
the medical history and physical ex-
amination, physicians were moder-
ately successful in predicting FEV1
(correlation coefficient 0.47). On the
other hand, the addition of spirome-
try results in a pulmonary medicine
continuity clinic altered the clinical
management plan in only 5% of pa-
tients.79 Patients with severe lung
dysfunction or deteriorating clinical
status benefited most from spirome-
try.
Physicians are also only moder-
ately successful in predicting non-
specific bronchial hyperresponsive-
ness. In a study of 34 patients
evaluated for unexplained wheezing,
the clinical history was only moder-
ately successful in predicting the re-
sults of a methacholine bronchial
challenge.80 A previous diagnosis of
asthma predicted bronchial hyperre-
activity 62% of the time; a history of
past wheezing, 35% of the time; and
expiratory wheezing on examination,
43% of the time. A separate study of
51 patients with possible asthma and
normal spirometry showed that phy-
sicians were able to predict the re-
7
sults of a methacholine challenge test
successfully only 39% of the time.81
When chest physicians were asked to
predict the result of a histamine bron-
chial challenge in a group of patients
with possible asthma, there was no
correlation at all between physician pre-
dictions (based on a medical history and
physical examination) and bronchial
hyperresponsiveness.19 Another study
showed that patient responses on a med-
ical history questionnaire could not pre-
dict bronchial responses to histamine.20
These studies together support the
notion that the medical history and
physical examination are useful and
moderately successful in diagnosing
asthma and estimating its severity.
Chest specialists and internists can be
expected to diagnose asthma correctly
about two-thirds or three-quarters of
the time. At the same time, these pub-
lished observations highlight the limi-
tations of the clinical evaluation of
asthma, even by specialists. Measures
of lung function, in particular spirom-
etry with response to bronchodilator,
are needed to confirm a diagnosis of
asthma.
These limitations become apparent
in studies of undiagnosed asthma. A
survey of 14,127 patients showed that
physician-diagnosed asthma was re-
ported by 6.1% of patients, but that
undiagnosed asthma that was active
within the previous year was reported
by 3.3% of patients.82 This suggests
that one-third of asthmatic patients
have not been properly diagnosed. An-
other report suggests that 17% of pa-
tients with unexplained dyspnea may
have asthma.83 A study of 179 children
who reported at least one episode of
wheezing showed that only 21 children
had been diagnosed with asthma,84 in-
cluding 11 of 31 children who experi-
enced more than 12 episodes of wheez-
ing per year. When these latter
children were treated for asthma,
school absenteeism fell tenfold. Chil-
dren with asthma whose symptoms
were a chronic cough rather than
wheezing often remained undiagnosed
for years.85 Review of 72 physician-
referred adult patients with dyspnea
unexplained by initial history, physical
8 ANNALS OF ALLERGY, ASTHMA, & IMMUNOLOGY
examination, chest radiograph, and
spirometry demonstrated that 17% had
undiagnosed asthma83; hence, asthma
is commonly unrecognized in both
adults and children.
CONCLUDING COMMENTS
Physicians should recognize the limi-
tations of the medical history and
physical examination even when con-
ducted by an expert. An unbiased de-
scription of symptoms of asthma may
be more effectively elicited through
open-ended questions such as Please
describe your symptoms, rather than
directed questions such as Do you
have wheezing or shortness of breath?
To a limited extent, symptom descrip-
tors such as wheezing and chest tight-
ness may suggest asthma, although a
full medical history should include
triggering and alleviating factors, re-
sponse to treatment, and associated
symptoms.
Physical examination of the chest,
especially for the presence and quality
of wheezing has moderate predictive
value in diagnosing asthma and esti-
mating the degree of airway obstruc-
tion. Additional respiratory signs such
as breath sound intensity and forced
expiratory time may be useful. Physi-
cians should be familiar with the phys-
ical signs of other causes of dyspnea
such as chronic obstructive pulmonary
disease, congestive heart failure, hy-
perventilation, and foreign body aspi-
ration.
A detailed medical history and phys-
ical examination of the patient with
possible asthma leads to the correct
diagnosis about three quarters of the
time, even by asthma specialists. Be-
cause it is impossible to identify mis-
diagnosed patients prospectively, addi-
tional studies such as peak expiratory
flow rate measurements, spirometry, or
the methacholine bronchial challenge
are needed. Furthermore, even when
asthma is diagnosed correctly, both pa-
tients and physicians are only moder-
ately successful in estimating the de-
gree of airway obstruction.
The National Asthma Education
Program recommends that all pa-
tients suspected of having asthma
should have office spirometry per-
formed, at minimum, for initial as-
sessment.86 We support this recom-
mendation. Some asthma experts
suggest that the peak expiratory flow
rate can substitute for measurement
of FEV1 for patients with asthma.
Indeed, there is ample evidence to
show that the peak expiratory flow
rate and FEV1 are closely correlated
in asthma.87,88 These studies also
show that there is a significant vari-
ation in peak expiratory flow rate for
a given measurement of FEV1, typi-
cally in the range of 620%.86 Fur-
ther, the peak expiratory flow rate is
often misleading when chronic ob-
structive pulmonary disease or re-
strictive lung disease is present.
Measurement of the peak expiratory
flow rate with a peak flow meter is less
expensive than measurement of FEV1
with spirometry; however, misdiagno-
sis of asthma and underestimating se-
verity of asthma are costly as well.
Further studies are needed to deter-
mine whether measurement of pulmo-
nary function actually results in inter-
vention that improves symptoms, lung
function, frequency of hospitalizations,
or days missed from work or school.
Further studies may elucidate the rela-
tive advantages of peak flow measure-
ment and spirometry.
We recommend that physicians car-
ing for patients with asthma continue
to develop their interviewing and phys-
ical examination skills. At the same
time, the best care of the asthmatic
patient includes spirometry at the time
of initial diagnosis and monitoring of
pulmonary function through periodic
spirometry and peak expiratory flow
rate measurements.
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CME Examination
Identification N 016-001
Questions 120, Li JTC and EJ OConnell. 1996;76:114.
CME Test Questions
1. Which of the following chest
symptoms is most closely as-
sociated with congestive heart
failure?
A. My breath does not go out
all the way.
B. I cannot take a deep breath.
C. I feel wheezy.
D. I feel that I am smothering.
E. I cannot take a deep breath.
2. What percentage of patients
with chronic obstructive pul-
monary disease admit to
wheezing?
A. 100%
B. 75%
C. 50%
D. 25%
E. 0%
3. Which of the following state-
ments about the symptom of
inspiratory dyspnea is true?
A. Associated with increased
PEFR
B. Associated with decreased
RV/TLC ratio
C. Rarely described during a
positive methacholine
bronchial challenge
D. Rarely reported by patients
experiencing acute asthma
E. Reported by the majority of
patients experiencing acute
asthma
4. Which of the following state-
ments about chest pain in chil-
dren is true?
A. About 20% of chest pain in
children is caused by
asthma.
VOLUME 76, JANUARY, 1996
acute bronchial asthma. Ann Emerg
Med 1982;11:64 9.
88. Connolly CK, Chan NS. Relationship
between different measurements of re-
spiratory function in asthma. Respira-
tion 1987;52:2233.
B. Only 5% of chest pain in
children is caused by
asthma.
C. Chest pain is rarely de-
scribed in exercise-induced
asthma.
D. Chest tightness is rarely de-
scribed in exercise-induced
asthma.
E. Lipid screening is recom-
mended.
5. The prevalence of wheezing in
the general population is about
A. 5% or less
B. 10% to 25%
C. 50% to 65%
D. 75% to 90%
E. Prevalence studies of
wheezing have not been
conducted
6. Which of the following is as-
sociated with nearly fatal
asthma?
A. Wheezing
B. Use of home peak flow di-
ary
C. Increased use of inhaled
nedocromil
D. Increased use of inhaled
corticosteroids
E. Reduced chemosensitivity
to hypoxia
7. Which of the following char-
acteristics about wheezing is
associated with increased air-
way obstruction?
A. Wheezing during exercise
B. Low pitched wheezing
C. Low intensity wheezing
D. Wheezing during inspira-
tion and expiration
E. Wheezing with forced ex-
halation
Request for reprints should be addressed to:
James T C Li, MD
Mayo Clinic & Foundation
200 First St, SW
Rochester, MN 55905
8. Which of the following lung
sounds are called continuous
adventitious sounds?
A. Expiratory wheezes
B. Inspiratory rales
C. Expiratory rales
D. Fine crackles
E. Coarse crackles
9. As a test of airway obstruc-
tion, a prolonged forced expi-
ratory time has a sensitivity of
about
A. 5% or less
B. 10% to 25%
C. 50% to 65%
D. 75% to 90%
E. 99%
10. Which of the following signs
is associated with obstructive
lung disease?
A. Decreased breath sound in-
tensity
B. Tracheal tag
C. Increased resonance to per-
cussion
D. Pulsus paradoxus
E. All of the above
11. When physicians evaluate pa-
tients for unexplained dyspnea
about what percentage of the
time do they reach the correct
diagnosis based on the medi-
cal history and physical exam-
ination?
A. 5% to 15%
B. 25% to 35%
C. 45% to 55%
D. 65% to 75%
E. 95% to 100%
12. Which of the following com-
ponents of the medical history
is an independent predictor of
13
 obstructive lung disease in
adults?
A. Fatigue
B. Exercise intolerance
C. Significant smoking his-
tory
D. Chest pain
E. Family history of emphy-
sema
13. Deliberate hyperventilation is
most likely to produce which
of the following symptoms?
A. I feel hunger for more air.
B. I cannot take a deep breath.
C. My chest feels tight.
D. My breath does not go out
all the way.
E. My breathing requires
more concentration.
14. In children whose primary
symptom is chronic cough,
upper respiratory tract infec-
tions trigger cough in what
percentage of patients?
A. 10% to 20%
B. 30% to 40%
C. 50% to 60%
D. 70% to 80%
E. 90% to 100%
15. When patients recovering
from acute asthma in the hos-
pital are studied, symptoms of
asthma disappear when pul-
monary function is
A. 0% to 10% of predicted
normal values
B. 20% to 30% of predicted
normal values
C. 40% to 50% of predicted
normal values
14
D. 60% to 70% of predicted
normal values
E. 80% to 90% of predicted
normal values
16. Which of the following respi-
ratory signs does not have a
statistically significant associ-
ation with FEV1 or PEFR?
A. Breath sound intensity
B. Forced expiratory time
C. Wheezing
D. Increased resonance to per-
cussion
E. Bibasilar fine crackles
17. All of the following have a
statistically significant corre-
lation with severe airway ob-
struction except
A. Wheezing throughout the
respiratory cycle
B. Forced expiratory time
greater than two seconds
C. Excavation of the supracla-
vicular fossa
D. Pulsus paradoxus
E. Respiratory rate
18. The major finding in pulsus
paradoxus is
A. A drop in systolic blood
pressure of 10 mm or
greater during exhalation
(normal tidal breathing)
B. A drop in systolic blood
pressure of 10 mm or
greater during inspiration
(normal tidal breathing)
C. A drop in systolic blood
pressure of 10 mm or
greater during forced exha-
ANNALS OF ALLERGY, ASTHMA, & IMMUNOLOGY
lation (forced vital capacity
maneuver)
D. A drop in systolic blood
pressure of 5 mm or greater
during inspiration
E. A drop in systolic blood
pressure of 5 mm or greater
during a Valsalva maneu-
ver
19. For adult patients with asthma
or suspected asthma, The Na-
tional Asthma Education Pro-
gram Expert Panel Report rec-
ommends spirometry
A. For all patients, at initial
assessment
B. For patients with moderate
or severe asthma only, at
initial assessment
C. Every three months for pa-
tients with moderate or se-
vere asthma
D. Every six months for pa-
tients with moderate or se-
vere asthma
E. Every six months for pa-
tients with severe asthma
20. For adult patients with known
asthma, the National Asthma
Education Program Expert
Panel Report recommends
strong consideration of home
peak flow monitoring for
A. All patients
B. Patients with moderate and
severe asthma
C. Patients with severe asthma
only
D. Patients taking salmeterol
E. Patients taking nedocromil
Instructions for Category I CME Credit

Certification. As an organization
accredited for continuing medical ed-
ucation, the American College of
Allergy, Asthma, & Immunology
(ACAAI) certifies that when the
CME material is used as directed it
meets the criteria for two hours
credit in Category I of the American
College of Allergy, Asthma, & Im-
munology CME Award and the Phy-
sicians Recognition Award of the
American Medical Association.
Instructions. Category I credit can
be earned by reading the text material,
taking the CME examination and re-
cording the answers on the perforated
answer sheet entitled, Continuing
Medical Education, which can be
found after the examination.
Please record your ACAAI identifi-
cation number and the quiz identifica-
tion number in the spaces and scanning
targets provided on the answer sheet.
Your ACAAI identification number
can be found on your ACAAI mem-
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lege will be assigned an ACAAI iden-
tification number and this should be
left blank on the answer sheet. The
quiz identification number can be
found at the beginning of the CME
examination.
Use a No. 2 or soft lead pencil for
marking the answer sheet. You may
erase but do so completely in order to
prevent computer reading errors. Your
ACAAI identification number and quiz
identification number will be used to
record your credit hours earned on the
CME transcript system. No records of
individual performance will be main-
tained.
Tear out the perforated answer sheet
and print your name and address in the
spaces provided. Return it within one
month after the Annals is received to
the American College of Allergy,
Asthma, & Immunology, 85 West Al-
gonquin Rd, Suite 550, Arlington
Heights, IL 60005. Answers will be
published in the next issue of the An-
nals of Allergy, Asthma, & Immunology.

Answers to CME examinationAnnals of Allergy,

Asthma, & Immunology, December 1995 (Identification
No 015-012) Spector SL. Leukotriene inhibitors and an-
tagonists in asthma. Ann Allergy, Asthma, & Immunol
1995; 75:46374.
1. d 6. e 11. b 16. a
2. c 7. c 12. e 17. c
3. b 8. a 13. d 18. a
4. a 9. d 14. b 19. c
5. e 10. e 15. d 20. b

VOLUME 76, JANUARY, 1996 15