Diagnosis in children with exercise-induced respiratory symptoms: a multi-centre study

Objective Exercise-induced respiratory symptoms (EIS) are common in childhood and reflect different diseases that can be difficult to diagnose. In children referred to respiratory outpatient clinics for EIS, we compared the diagnosis proposed by the referring primary care physician with the final diagnosis from the outpatient clinic and described diagnostic tests performed and treatment prescribed after the diagnostic evaluation. Design Observational study nested in the Swiss Paediatric Airway Cohort (SPAC), which includes respiratory outpatients aged 0-16 years. Patients We included children with EIS as main reason for referral. Information about diagnostic investigations, final diagnosis, and treatment prescribed came from outpatient records. Results 214 were referred for EIS (mean age 12 years, 99 (46%) female). The final diagnosis was asthma in 115 (54%), extrathoracic dysfunctional breathing (DB) in 35 (16%), thoracic DB in 22 (10%), asthma plus DB in 23 (11%), insufficient fitness in 10 (5%), chronic cough in 6 (3%), and other diagnoses in 3 (1%). Final diagnosis differed from referral diagnosis in 115 (54%). Spirometry, body plethysmography and measurements of exhaled nitric oxide were performed in almost all; exercise-challenge tests in a third. 91% of the children with a final diagnosis of asthma were prescribed inhaled medication and 50% of children with DB were referred to physiotherapy. Conclusions Diagnosis given at the outpatient clinic often differed from the diagnosis suspected by the referring physician. Diagnostic evaluation, management and follow-up were inconsistent between clinics and diagnostic groups, highlighting the need for diagnostic guidelines in children seen for EIS. Mandatory statements for Archives of Disease in Childhood What is already known on this topic (2-3 statements of max 25 words) Exercise-induced symptoms are common in childhood but not easy to diagnose because different diagnoses share similar clinical presentations Only few studies focused on children with exercise-induced symptoms and all have included selected groups of patients with difficult-to-diagnose problems What this study adds (2-3 statements of max 25 words) Exercise-induced respiratory symptoms was the main reason for referral in one fifth of the children referred to paediatric respiratory outpatient clinics. Dysfunctional breathing is an under-recognised diagnosis; it was frequently diagnosed in the outpatient clinic (in 37%) but rarely suspected by the referring physician (6%) Diagnostic evaluation, management, and follow-up were inconsistent between clinics highlighting the need for diagnostic guidelines in children seen for EIS.