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Children with exercise-induced respiratory symptoms may get conflicting diagnoses

Pediatric Pulmonology
Reuters Health - 24/11/2020 - Children referred to outpatient clinics for exercise-induced respiratory symptoms often get a diagnosis that differs from the one they received from their primary care provider, a Swiss study suggests.

Researchers examined data on a cohort of 214 children up to 16 years old who were referred from primary care to specialists for exercise-induced respiratory symptoms. Overall, the final diagnosis after outpatient clinic consultations differed from the original diagnosis in primary care in 115 (54%) of the cases.

"Exercise-induced respiratory symptoms can have different underlying causes, and the distinction is often not easy, because signs and symptoms overlap," said senior study author Dr. Claudia Kuehni of the Institute for Social and Preventive Medicine at the University of Bern in Switzerland.

Several problems can co-exist in the same child, such as asthma and dysfunctional breathing, Dr. Kuehni said by email.

"A definite diagnosis often needs several visits to a doctor, and sometimes specialized investigations, or repeated tests, such as repeated lung function tests," Dr. Kuehni said. "A clinical history alone is often misleading."

Children in the study were 12 years old on average and ranged in age from 2 to 17 years.

More than half (59%) were referred to specialists with a diagnosis of asthma in primary care. Another 12 children (6%) were referred for dysfunctional breathing, and 74 (35%) were referred to specialists without a formal diagnosis from their primary care provider.

After specialist visits, the most common final diagnosis was asthma (54%). Other common final diagnoses included extrathoracic dysfunctional breathing (16%), thoracic dysfunctional breathing (10%), asthma plus dysfunctional breathing (11%), insufficient fitness level (5%), and chronic cough (3%).

The final diagnosis matched the initial diagnosis in primary care most often for children with asthma plus dysfunctional breathing (70%), and least often for children with thoracic dysfunctional breathing (32%).

Prior to referral to specialists, 65% of children were on inhaled corticosteroids or other asthma therapies. After specialist consultations, these medications were almost exclusively prescribed to asthma patients with or without dysfunctional breathing.

One limitation of the study is the lack of standardization among clinics in diagnostic evaluations and diagnosis descriptions, the study team notes in Pediatric Pulmonology. Use of cardiopulmonary exercise testing also was limited, and certain invasive tests, such as flexible laryngoscopy that might be needed to make a differentiated diagnosis, were lacking, they add.

"The ability to accurately and confidently diagnose the etiology underlying exercise induced symptoms varies widely among clinicians and depends on the clinician's experience and interest in this specific field," said Dr. Jason Lang, an associate professor of pediatrics at Duke Children's Hospital & Health Center and Duke University School of Medicine in Durham, North Carolina.

"In this study, the final diagnosis from the specialist, even following additional testing, still often was only 'suspected' and not necessarily a confirmed diagnosis," Dr. Lang, who wasn't involved in the study, said by email. "This is due to the fact that the field of exercise-induced symptoms in children is relatively understudied and in great need of systematic research."

SOURCE: https://bit.ly/2J9d8Ds Pediatric Pulmonology, online October 20, 2020.

By Lisa Rapaport


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