Indian J Pediatr (August 2018) 85(8):651–657
DOI 10.1007/s12098-017-2462-6
REVIEW ARTICLE
Tools in Asthma Evaluation and Management: When and How
to Use Them?
Anna Mulholland 1 & Alana Ainsworth 1 & Naveen Pillarisetti 1,2
Received: 7 May 2017 / Accepted: 24 August 2017 / Published online: 15 November 2017
# Dr. K C Chaudhuri Foundation 2017
Abstract The goals of asthma management are accurate di-
agnosis, prompt initiation of treatment and monitoring of dis-
ease progression to limit potential morbidity and mortality.
While the diagnosis and management is largely based on his-
tory taking and clinical examination, there are an increasing
number of tools available that could be used to aid diagnosis,
define phenotypes, monitor progress and assess response to
treatment. Tools such as the Asthma Predictive Index could
help in making predictions about the possibility of asthma in
childhood based on certain clinical parameters in pre-
schoolers. Lung function measurements such as peak expira-
tory flow, spirometry, bronchodilator responsiveness, and
bronchial provocation tests help establish airway obstruction
and variability over time. Tools such as asthma questionnaires,
lung function measurements and markers of airway inflamma-
tion could be used in combination with clinical assessments to
assess ongoing asthma control. Recent advances in digital
technology, which open up new frontiers in asthma manage-
ment, need to be evaluated and embraced if proven to be of
value. This review summarises the role of currently available
tools in asthma diagnosis and management. While many of
the tools are readily available in resource rich settings,
it becomes more challenging when working in resource
poor settings. A rational approach to the use of these
tools is recommended.
* Naveen Pillarisetti
naveenp@adhb.govt.nz
1
Pediatric Respiratory Medicine, Starship Children’s Hospital,
Park Road, Grafton, Auckland 1023, New Zealand
2
Department of Pediatrics, Child and Youth Health,
University of Auckland, Auckland, New Zealand
Keywords Asthma . Wheeze . Management . Evaluation .
Childhood . Preschool
Introduction
Asthma is a common childhood condition characterised by
symptoms and signs of variable airflow limitation, such as
wheeze, breathlessness and cough, and is associated with
chronic airway inflammation and hyper responsiveness. The
diagnosis is often made clinically after a careful history and
examination, but this may not always be straightforward es-
pecially in pre-schoolers. Defining the phenotype of asthma in
childhood could have important implications for predicting
the course of the disease into adulthood as longitudinal studies
suggest [1, 2].
Poor management of asthma can lead to sub-optimal symp-
tom control, poor quality of life, ongoing morbidity and po-
tential mortality. It is well known that excessive steroid ther-
apy in asthma can affect growth and cause adrenal suppres-
sion. A recent review of asthma deaths showed that the ma-
jority of deaths are preventable with better management [3].
Hence, there is a need for prompt diagnosis and appropriate
monitoring of asthma. This article aims to describe the tools
that are useful in the evaluation and management of asthma in
childhood or wheeze in preschool children.
Tools Used in the Evaluation of Asthma
There are no specific diagnostic tests for asthma, but tools can
be used to support a diagnosis and describe the phenotype.
Tools include: lung function tests such as spirometry, bron-
chodilator responsiveness, bronchial provocation testing;
markers of airway inflammation; allergy testing and the
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Asthma Predictive Index. These tools have varying predictive
values, sensitivities and specificities that depend on the pre-
test probability for the individual.
History, Examination, Asthma Predictive Index
The most important tool in asthma evaluation is a thorough
clinical assessment. Key features in the history include the
presence and pattern of respiratory symptoms along with their
triggers and effect on daily life. Information about past and
current use of inhalers, the frequency of use and their effec-
tiveness should be evaluated. Clinical examination in the non-
acute situation is often normal but is important to identify
features such as chest hyperinflation and deformity that may
suggest ongoing severe airway obstruction. Failure to thrive,
chronic wet cough and digital clubbing may suggest an alter-
native diagnosis. The majority of asthma cases can be diag-
nosed through clinical assessment.
Making a diagnosis of asthma is more difficult in preschool
children. Epidemiological studies have shown that the cumu-
lative prevalence of wheeze by six years of age is almost 50%,
but most pre-schoolers who wheeze do not go on to develop
asthma [4]. The well validated Asthma Predictive Index (API)
is used to predict asthma in childhood for preschool children
with recurrent wheeze [5]. The most widely used original
stringent API (Table 1), has positive and negative predictive
values of 48% and 92% respectively for an asthma diagnosis
at six years. The Global initiative for asthma (GINA) guide-
line recommends its use to assist decision-making regarding
inhaled corticosteroid (ICS) use in preschool children [6].
Lung Function
Airflow limitation is demonstrated on spirometry by a reduced
FEV1, a reduced FEV1/FVC ratio and concavity of the expi-
ratory flow volume loop [7]. Demonstrating variability over
time is pivotal for a diagnosis of asthma to differentiate it from
other diseases that also show obstructive patterns. Variability
can be demonstrated by diurnal differences in forced expira-
tory volume in one second (FEV1) or peak expiratory flow
(PEF) or by an obstructive pattern that emerges when symp-
tomatic. Bronchodilator responsiveness (BDR) indicating re-
versibility (i.e. an improvement in baseline FEV1 of 12% or
Table 1 The Asthma Predictive
Index [5] Stringent API: More than 3 episodes of wheezing per year during the first 3 years of life and 1 major or 2 minor criteria
Loose API: Fewer than 3 episodes of wheezing per year and 1 major or 2 minor criteria
Major Criteria
1. Asthma in a parent, documented by a physician
2. Eczema in the child, documented by a physician
Indian J Pediatr (August 2018) 85(8):651–657
more) is predictive of asthma in adults [7]. This has been
extrapolated to children, but diagnostic efficacy is not clear
due to limited studies and the lack of guidelines for BDR
interpretation in children. Although BDR is commonly used,
further studies determining appropriate levels of change are
required before it can recommended with confidence.
Spirometry can be performed in preschool children with
trained personnel using standardised techniques [8]. This
helps to overcome difficulties with co-operation, short atten-
tion spans and wide variability between attempts typically
seen in preschool children. The publication of normative data,
such as in the Global Lung Function Initiative, has addressed
the previous issue of a lack of reference data [9]. Pre-schoolers
have lower lung volumes and shorter exhalation times. FEV1
can therefore be similar to forced vital capacity (FVC) [10],
resulting in FEV1/FVC ratios as high as 90%. A ‘normal’ ratio
of 70% may actually be indicative of obstruction in some
preschool children [11]. Alternative measurements such as
FEV0.75 or FEV0.5 may prove to be more useful [12]. A sys-
tematic review of BDR in preschool children concluded there
is currently little evidence to support its use [10]. But a recent
trial published in 2017 showed a significantly larger broncho-
dilator response in preschool children with a diagnosis of
asthma compared with controls [13]. Spirometry and BDR
in preschool children are potential tools to aid diagnosis but
require further research.
Bronchial hyperesponsiveness (BHR) or provocation testing
is a tool used to demonstrate variable airflow limitation,
supporting a diagnosis of asthma. Direct agents include inhaled
methacholine, histamine and mannitol. Methacholine has a neg-
ative predictive value reported at 92%, thus is useful in exclud-
ing a diagnosis of asthma [14]. Positive reactions are often seen
in allergic rhinitis, cystic fibrosis and bronchopulmonary dys-
plasia, giving the test poor specificity [6]. Exercise can be used
as an indirect stimulant and has a higher specificity for asthma
than other methods [15]. Hypertonic saline (4.5%) is also fre-
quently used and has a sensitivity of 47% and specificity of
92% for current wheeze with greater responses seen in
children with atopy [16]. Both hypertonic saline and
exercise induced provocation tests are inexpensive and
relatively easy to perform.
Measuring lung volumes as a tool to identify gas trapping
may be more sensitive at detecting airway obstruction in
Minor Criteria
1. Allergic rhinitis in the child, documented by a physician
2. Wheezing apart from with colds, reported by the parents
3. Peripheral eosinophilia greater than or equal to 4%
Indian J Pediatr (August 2018) 85(8):651–657
asymptomatic children [17]. Specific airway resistance
(sRaw), measured by body plethysmography, has a stronger
association with FEF50% than FEV1 in children. Therefore
sRaw may be a marker of early airway obstruction [18].
There are other methods of lung function testing in pre-
school children that only require passive co-operation. These
are being used with increasing frequency in research and in
clinical settings when available. The interrupter resistance
technique (Rint) has shown a higher baseline level of airway
resistance in young children who wheeze, with some differ-
ences noticeable between wheezing phenotypes [19]. Forced
oscillometry technique (FOT), along with its variant impulse
oscillometry (IOS), are more sensitive in detecting small
changes in lung function compared with spirometry in chil-
dren with controlled vs. uncontrolled asthma [20]. Increased
resistance and decreased reactance has been shown to be pres-
ent in preschool wheezers at baseline [21]. FOT, BDR and
BHR studies have generally shown good correlation with
changes in spirometry, but some studies have not been able
to discriminate between asthmatic patients and controls [21].
Considering the lack of accessibility of FOT in most areas and
the lack of constancy in research, FOT currently cannot be
recommend as a tool in asthma assessment.
Peak Expiratory Flow
Short term monitoring of peak expiratory flow (for example
twice daily for two to four weeks) may be useful in aiding the
diagnosis of asthma by assessing variable expiratory airflow
limitation. A diurnal variation >13% in children is suggestive
of asthma [6].
Biomarkers of Asthma
Fractional exhaled nitric oxide (FeNO) is the most studied
biomarker in asthma. It is non-invasive and easy to obtain
during tidal breathing [22]. Elevated levels reflect eosinophilic
airway inflammation but levels are also raised in atopy, eosin-
ophilic bronchitis and in some respiratory tract infections.
Levels are reduced in cystic fibrosis, primary ciliary dyskine-
sia, and with smoke exposure and steroid use. Values >35 ppm
in school children are considered positive [23]. The American
Thoracic Society guidelines report that eosinophilic inflam-
mation is likely to be present with values >50 ppm, less likely
with values <20 ppb and levels between 20–35 ppm should be
interpreted in clinical context [24]. Reference values for pre-
school children have been published [22].
Higher levels of FeNO are present in children with allergic
asthma compared with non-allergic asthma [25]. Elevated
levels in preschool wheezers is associated with a greater risk
of asthma in childhood, although current research does not
suggest any extra benefit for prediction when compared with
the API [26]. FeNO is a useful additive to clinical information
653
to support a diagnosis and maybe predictive of asthma in
preschool children.
Tests for Atopy
Atopy is an important associate of asthma and is related to
asthma severity [27]. Positive allergy tests in pre-school
wheezers such as skin prick tests and specific IgE to
aeroallergens, egg white or wheat, are associated with an in-
creased likelihood of an asthma diagnosis in childhood [6].
Sensitisation does not mean the allergen is the cause of asthma
and the absence of a positive allergy test does not rule out
asthma.
Raised blood eosinophil levels >4% in a wheezy preschool
child is associated with a greater likelihood of childhood asth-
ma [28].
Similar to FeNO, positive atopic tests can make a diagnosis
of asthma more likely. They have a role in identifying and
therefore reducing the exposure of allergens where possible.
Increasingly, the role of fungi sensitisation in asthma path-
ophysiology is being discussed. This will be reviewed in a co-
publication as part of this symposium.
Adjuncts to Diagnose Mimics of Asthma
While the diagnosis of asthma can be relatively straightfor-
ward, it is important to consider a variety of other conditions
which can either mimic asthma or be associated with asthma.
The presence of a chronic or recurrent wet cough should raise
the possibility of suppurative lung disease and prompt a work
up including a sweat test, CXR and consideration of a CT
chest. A history of inspiratory airway obstruction, or a mono-
phonic or unilateral wheeze should raise the possibility of a
congenital airway abnormality or a foreign body, and warrant
a bronchoscopic airway evaluation. The flow volume curve
can sometimes point to structural airway abnormalities such as
severe tracheomalacia. A fixed airway obstruction non-
responsive to bronchodilator therapy suggests bronchiolitis
obliterans. The early onset of a wet cough, neonatal respirato-
ry distress syndrome and sino-pulmonary symptoms raise the
possibility of primary ciliary dyskinesia.
Tools for Asthma Management
Once a diagnosis of asthma has been made there are published
management pathways and guidelines which consist of regu-
larly assessing symptom control, future risk and adherence to
treatment. They also guide the stepping up or down the treat-
ments [6, 11]. Tools available to assist in assessing control
include asthma questionnaires, lung function measurements
and biomarkers of airway inflammation. Tools to assist in
654
asthma management also include asthma action plans, phone
apps and medication counters. These tools should be consid-
ered in the context of resource availability.
Asthma Questionnaire’s
GINA have defined asthma ‘control’ as effective management
of disease characteristics including symptoms, nocturnal wak-
ening, reliever use, activity limitation and lung function.
Based on expert opinion they established a scale of three
levels: controlled, partly controlled or uncontrolled asthma
(Table 2) [6]. Several self-administered questionnaires such
as the Asthma Control Questionnaire (ACQ) and the
Asthma Control Test (ACT) have been developed and validat-
ed as tools used to assess asthma control [29, 30]. They are
based on reported symptoms, rescue inhaler use and FEV1.
Both questionnaires have variants available for younger chil-
dren [29, 31], are simple tools that can be used to assess for
controlled asthma and provide a numeric value. However,
they have short recall times and may not represent control
between clinics accurately especially if symptom perception
is poor.
Lung Function
It is suggested that lung function should be monitored on a
regular basis in asthmatic children on treatment [32]. It is
possible for children to be ‘asymptomatic’ but have significant
airflow obstruction on spirometry. These patients have poor
symptom perception and are at an increased risk of serious
asthma events [33]. Many asthmatic children have a normal
FEV1. A reduced FEV1 less than 60% confers double the risk
of an asthma exacerbation within the year [34].
A persistent BDR may indicate poor control and is associ-
ated with a greater risk of progressive decline in lung function
and exacerbations [32]. Exercise testing can be used to assess
the protective effect of medication. Treatment adjusted based
on methacholine BHR showed improvements in FEV1, but
not on symptom free days [35].
Table 2 Assessing asthma
symptom control [6] Asthma symptom control
In the past 4 weeks, has the patient had
Daytime asthma symptoms more than twice per week?
Yes/No
Any night waking due to asthma? Yes /No
Reliever needed for symptoms more than twice per week?
Yes /No
Any activity limitation due to asthma? Yes/No
Indian J Pediatr (August 2018) 85(8):651–657
Rint and FOT have potential to be used in the future for
monitoring, but are currently lacking in evidence.
Lung function should be monitored periodically to identify
children at risk of serious events and possibly to help identify
non-compliance. Monitoring BHR as not proven to be bene-
ficial currently. There is no current guidance given for the
frequency of monitoring.
Peak Expiratory Flow
Peak expiratory flow meters have been used in action plans for
children with asthma. Although they are portable, relatively
inexpensive and can be used in the home setting, they have
limitations. Results are effort dependent, highly variable,
can underestimate the degree of airflow limitation and
when used as part of a symptom diary can be unreliable
[36]. Peak flow meters are generally recommended only
for long term monitoring in patients with severe asthma
or those who have sudden exacerbations and are poor
perceivers of airway obstruction. If using a peak flow
meter the measurements should be performed twice dai-
ly and compared to the personal best result for that
individual patient [37].
Biomarkers
Elevated FeNO in asthmatic patients can reflect poor adher-
ence, poor inhaler technique or ongoing airway inflammation
needing review of current therapy [24]. No levels have been
established to discriminate asthma severity [38]. A Cochrane
review in 2016 showed no difference in hospital admissions,
exacerbation rates, lung function, symptom scores or ICS dose
when using FeNO to assist asthma management [39].
However, there were significant reductions in the number of
exacerbations and the use of oral steroids. Therefore, FeNO
may have a role in assisting treatment decisions in some
patients.
Sputum eosinophil count is a biomarker mainly used
in research. It can be obtained in school children, is
quick and inexpensive. The normal range of less than
Level of asthma symptom control
Well Partly Uncontrolled
controlled controlled
None of these 1–2 of these 3–4 of these
Indian J Pediatr (August 2018) 85(8):651–657 655

2% has been standardised in children but not preschool
children [40]. Elevated levels were shown to predict the
failure of ICS therapy wean in a cohort study in chil-
dren with stable asthma [41]. A randomised controlled
trial showed a small reduction in exacerbation rate and
symptom free days when sputum eosinophil count was
incorporated in to monitoring of children with severe
asthma, but this did not reach significance [42]. In con-
trast to adults, where high levels predict response to
high dose ICS, children with difficult asthma to respond
to high dose ICS even if their levels are low [43].
Sputum eosinophil monitoring could be a useful addi-
tion to asthma monitoring to guide treatment, but there
is insufficient evidence to currently support its routine
use.
Exhaled breath condensate (EBC) reflects changes in com-
position of respiratory fluid lining the airways. It is easy, in-
expensive and obtained in tidal breathing but is used mainly in
research studies. Properties measured include pH,
concentration of 8-isoprostane, interferon gamma, IL-4 and
hydrogen peroxide. These can be associated with allergic asth-
ma and acute exacerbations. There is no gold standard method
of determining values which can be influenced by technical
issues. A systematic review on its use in childhood asthma
concluded that there is insufficient clinical data to recommend
its use currently, however it holds promise [44].
Asthma Action Plans
Asthma action plans can be regarded as tools that may help
improve asthma control but the evidence is conflicting.
Although at least one study has shown a clear benefit of pro-
viding an individualised asthma action plan to patients, the
majority have not been able to demonstrate a benefit in
addition to asthma education and regular follow-up care.
Despite this they are still considered an important asthma
management tool and continue to be recommended for all
asthma patients [6].

Fig. 1 Suggested approach to SYMPTOMS SUGGESTIVE OF

asthma evaluation and ASTHMA
management in children. ACQ
Asthma control questionnaire; Wheeze
Cough
ACT Asthma Control Test;
Shortness of breath
BDR Bronchodilator TOOLS TO EVALUATE ASTHMA
Exercise intolerance
responsiveness; BHR Bronchial
hyperesponsiveness; BTS British Asthma predictive Index (in pre-schoolers)
Thoracic Society; C-ACT
Measure airflow obstruction and variability:
Childhood-Asthma Control Test;
CLINICAL ASSESSMENT PEF
FeNO Fractional exhaled nitric Spirometry
oxide; GINA Global Initiative History BDR, BHR
for Asthma; PEF Peak expiratory Physical examination
flow Rule out asthma mimics
FeNO

Tests for atopy:

Total IgE and specific IgE/ skin test to common aeroallergens and specific
allergens directed by history

Treatment as per guidelines (GINA, BTS)

Asthma action plan

TOOLS FOR MONITORING ASTHMA CONTROL

History and examination

Assessment of adherence to treatments
Consider asthma mimics

Assessment of control using guidelines- e.g., GINA

Follow-up
ACT, C-ACT, ACQ

PEF
Spirometry
FeNO

Ongoing education –including use of digital technology

where available
656
Dose Counters and Smart Inhalers
Poor asthma control is sometimes due to the continued use of
empty inhalers. There are now a number of inhalers available
that have dose counters integrated and can track the amount of
medication that has been used.
Poor asthma control is frequently due to poor adherence to
ICS particularly in adolescents. Smart inhalers have an attached
electronic monitoring device and record the time and date of
use and have reminder alarms. They are Bluetooth enabled and
information can be transmitted to phone apps or websites where
patients, families and clinicians can review their use.
Randomised control trials have shown that smart inhalers in-
crease adherence, reduce the number of oral steroid courses and
reduce hospital admissions in children aged 6–16y [45].
Currently the availability is limited and they are mainly a re-
search tool.
Smart Phones, Asthma Apps and the Internet
There are numerous phone applications developed for asthma,
which have the potential to support self-management. They
provide education, monitor symptoms, create action plans, set
medication reminders and develop early warning software for
asthma triggers. However, their quality can be variable and
there is a current lack of evidence about their use. These tools
are promising but their limitations should be recognised and
more evidence is required before routine use in clinical prac-
tice is supported [46].
There are a number of websites available that can be used
as tools to provide education to children and their families.
They often provide the information in the form of entertain-
ment and can be found on popular children’s TVor game sites.
Conclusions
The diagnosis and management of asthma can be supported
by a variety of tools that have been field tested and validated in
studies from around the world. While there is no substitute for
meticulous history taking, clinical examination and regular
patient follow-up; tools for asthma diagnosis and monitoring
should be considered and utilised depending on the clinical
need and specific resource setting. Simple tools such as the
API, questionnaire’s for asthma control and well accepted
guidelines should provide a framework for management.
The increasing availability of peak flow meters, spirometry
and allergy testing should be used when appropriate. The role
of advanced lung function tests may be limited by availability
or lack of supporting data. The authors recommend a pragmat-
ic and rational use of the available tools for asthma evaluation
and management (Fig. 1).
Indian J Pediatr (August 2018) 85(8):651–657
Contributions AM and AA: Did a review of literature, wrote part of
the manuscript and reviewed the manuscript; NP: Conceptualised the
manuscript, wrote part of the manuscript, reviewed, approved the final
draft of the manuscript and will act as guarantor for the paper. Anna
Mulholland is a clinical and research fellow funded by The Starship
Foundation.
Compliance with Ethical Standards
Conflict of Interest None.
Source of Funding None.
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