Respiratory Medicine

Paediatric Asthma · Wheeze · Cystic Fibrosis · Spirometry · Inhaler Technique · Respiratory Infections · Occupational Lung

Paediatric Asthma

NICE NG80

NICE NG80 — Asthma: Diagnosis, Monitoring and Chronic Asthma Management (updated 2023)

Co-produced with BTS/SIGN guidelines. Probabilistic diagnosis approach — no single test rules in/out asthma in children <5y.

Diagnostic Features (NICE NG80)

WheezeRecurrent (≥3 episodes), polyphonic, expiratory — bilateral
CoughNight-time, early morning, exercise — worse without URTI
BreathlessnessOn exertion, or rest in acute episodes
Chest tightnessMay describe as stomach ache in young children
TriggersCold air, exercise, allergens, viral URTIs, smoke, stress
Response to SABASymptom resolution within 15–20 minutes = strong diagnostic indicator
AtopyEczema, allergic rhinitis, food allergy — personal or FH — increases probability

Objective Tests (>5 years)

Spirometry + bronchodilator reversibility

FEV1/FVC <70% (or below lower limit of normal) = obstructive. Reversibility: ≥12% and ≥200 mL increase in FEV1 after salbutamol = positive.

FeNO (Fractional exhaled NO)

≥35 ppb = high — suggests eosinophilic airway inflammation, predicts ICS response. Useful in diagnostic uncertainty. Not a standalone test.

Peak Flow Variability

Daily diary ≥2 weeks. Variability >20% = significant (best − worst / best × 100). More useful in school-age children.

Skin prick tests / specific IgE

House dust mite, grass pollen, cat, dog — positive = atopic asthma. Guides allergen avoidance and immunotherapy eligibility.

Alternative Diagnoses to Exclude

Viral-induced wheezeToddlers — see Recurrent Wheeze tab
Cystic fibrosisFailure to thrive, steatorrhoea, chronic wet cough
Primary ciliary dyskinesiaSitus inversus, chronic sinusitis, bronchiectasis, male infertility
Tracheomalacia / laryngomalaciaStridor, inspiratory wheeze, worse with feeding/crying
GORDPost-prandial wheeze, regurgitation, nocturnal cough
Foreign body aspirationSudden onset, unilateral wheeze, asymmetric air entry
Cardiac diseaseFailure to thrive, sweating with feeds, cardiomegaly
Vascular ringPersistent stridor + wheeze from birth, worse in prone

Under 5 — Diagnosis is Clinical (NICE NG80)

Spirometry and FeNO are not reliable under 5. Diagnosis is based on clinical features + therapeutic trial of ICS (8 weeks). If good response = supports asthma. If no response = stop ICS and reassess. Document as 'probable asthma' pending review.