Complaints and Clinical Findings of Asthma
Primary Symptoms
Asthma presents with four cardinal symptoms that are variable, intermittent, worse at night, and provoked by triggers including exercise 1, 2:
- Wheeze - the most characteristic finding 1
- Shortness of breath 1, 3
- Chest tightness 1, 3
- Cough - variable and intermittent, not continuous 1, 2
The hallmark feature distinguishing asthma from other respiratory conditions is that these symptoms are variable, intermittent, worse at night, and provoked by triggers including exercise 1, 2. This pattern is more diagnostically significant than any individual symptom.
Clinical Signs During Examination
During Acute Episodes/Exacerbations
Wheeze is the cardinal physical finding and should be documented when present 1:
- Diffuse, polyphonic, bilateral wheeze - particularly expiratory 1
- Reduced lung function - decreased peak flow or obstructive pattern on spirometry 1
- Accessory muscle use 4
- Tachycardia - pulse >120 beats/min suggests severe obstruction 4
- Pulsus paradoxus 4
- Decreased breath sounds in severe cases 4
Between Episodes
Outside acute episodes, there may be no objective signs of asthma 1. This is a critical pitfall - normal examination between episodes does not exclude asthma. Patients with chronic asthma may show signs of hyperinflation with or without wheeze 1.
Characteristic Patterns and Triggers
Symptom Triggers
- Exercise - polyphonic wheezing with exercise is highly characteristic 2
- Viral infections 1, 5, 6
- Allergen exposure - pollens, dust, feathered or furry animals 1
- Environmental tobacco smoke 1
- Cold air 7
- Chemicals and irritants 1, 4
- Aspirin/NSAIDs in susceptible patients 1
Temporal Patterns
- Nocturnal worsening - symptoms worse at night 1
- Diurnal variability in airflow 5
- Episodic nature - recurrent episodes rather than continuous symptoms 3, 6
Additional Clinical Information
History Features Supporting Asthma Diagnosis
- Personal or family history of atopy - asthma, eczema, allergic rhinitis 1, 6
- Response to bronchodilators 1
- Previous emergency department visits or hospitalizations 5, 4
Cough Variant Asthma
When cough is the predominant symptom without wheeze, this is referred to as cough variant asthma 1. The cough is nonproductive and responds to asthma treatment but not to antibiotics, expectorants, or antitussives 3.
Critical Pitfalls to Avoid
None of the symptoms are specific for asthma 1. The diagnosis requires corroboration with objective testing where possible 1:
- Normal examination between episodes is common - do not exclude asthma based on normal findings during asymptomatic periods 1
- Continuous productive cough suggests alternative diagnoses - bronchiectasis, COPD, or chronic bronchitis rather than asthma 2
- Recurrent respiratory infections are not characteristic of asthma - consider bronchiectasis, cystic fibrosis, or immunodeficiency instead 2
- Physicians' subjective assessments of airway obstruction are often inaccurate - use objective measures like peak flow or spirometry 4
Severe/Life-Threatening Presentations
Features requiring immediate emergency treatment 8: