Many people at some point will have a respiratory event and will go to a clinic or urgent care center for evaluation. Typically, what may be found — wheezing sounds on the chest. The doctor will likely prescribe an antibiotic and an inhaler as treatment for a diagnosis of “asthma.” This diagnosis will remain in the chart of this person, perpetuated, and will be shared repeatedly with future providers who will likely accept the diagnosis without ever questioning the source.
Why is this important?
We live in an age of surveillance and qualifications. The government oversees insurance companies, the insurance companies oversee various provider groups they contract with, and the provider groups oversee the individual healthcare providers. In addition, there are organizations that represent consumer groups, those who purchase health insurance for large groups, and all this “reporting of data” goes back to government agencies and is stored on record.
Asthma is part of this surveillance process. There are measures of care in place for those who carry the diagnosis of asthma, and there are rewards for the providers who follow those measures, and also consequences for those who don’t.
This process makes clear how very important it is that the diagnosis of asthma be accurate and only be made and logged into the records when true disease is present.** How is the diagnosis of asthma made?**
Traditionally, providers depended on taking a full verbal history from the patient, and the symptoms and complaints described which point to asthma, would then be confirmed by spirometric studies. Spirometry is a measure of pulmonary function in which a patient blows as hard as he can into a hand-held instrument that measures how much air is expelled from the lungs (vital capacity). The device also measures how quickly the air is expelled by measuring the amount of air expelled in the first second (FEV1). It’s important to note that many other conditions can result in abnormal spirometry readings, so overreliance on this test can result in many patients who do not have asthma, being diagnosed as asthmatics.
Why is spirometry so important?
Spirometry is an objective measure and it therefore can be used in national statistics, which is what national agencies are interested in. There are specific criteria for the results of spirometric studies that are associated with a diagnosis of asthma.
How compelling are spirometry measurements in the diagnosis of asthma?
With this question in mind, a new study is being designed to study the diagnostic rate of error in asthma and also in chronic obstructive pulmonary disease (COPD), which is also measured by spirometry.
At the University of Illinois in Chicago, researchers have designed a study to measure the impact of diagnostic error on outcomes and the use of lung function testing. The ongoing study is called The Reducing Diagnostic Error to Improve Patient Safety in COPD and Asthma (REDEFINE). The study will take three years and will involve participation of 60 primary care providers along with 300 adults. These patients will be divided into those who have a diagnosis of asthma with spirometry confirmation and those with the diagnosis who have not had spirometry testing.
Both groups will be followed for a year, after which the group without the test will undergo a confirmatory spirometry to ensure that the proper diagnosis is confirmed. The data collected will focus on diagnostic error and its effect on asthma outcomes.
Summing up the findings
The most important part of this discussion is to certainly value the patient’s personal history. This information cannot be easily measured by national statistics. Doctors begin to form a “working diagnosis” from the history and symptoms a patient describes, so it continues to be an invaluable tool. Clearly this type of interaction is not one that the government (agencies) can record in large numbers, so it has never been valued as “collectable data” by the government.
The clinician does need to keep these following points in mind:
Asthma is a condition that involves the airways, with inflammation and spasm present that causes narrowing in airway opening. This physical phenomenon results in the “shortness of breath” symptom.
Asthma symptoms are reversible with medication, unlike COPD (which often needs to be ruled out), a disease which can result in permanent, irreversible damage.
Proper, timely treatment can prevent long-term consequences.
Diagnosing other conditions that can present with wheezing and shortness of breath can help to prevent the “incorrect” diagnosis of asthma, which also can help to prevent the complications associated with the wrong respiratory diagnosis.
As a pulmonologist I always remind doctors that, “All that wheezes is not asthma…, and asthma does not always present with wheezing." Use history combined with objective testing to finalize this diagnosis before assigning it to a patient.
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Eli Hendel, M.D. is a board-certified Internist and pulmonary specialist with board certification in Sleep Medicine. He is an Assistant Clinical Professor of Medicine at Keck-University of Southern California School of Medicine, and Qualified Medical Examiner for the State of California Department of Industrial Relations. His areas of expertise in private practice include asthma, COPD, sleep disorders, obstructive sleep apnea, and occupational lung diseases.