The critical role of clinical history in accurate asthma diagnosis

A thorough understanding of a patient’s clinical history is key to obtaining an accurate diagnosis of asthma in primary care.^[1]

While objective tests are valuable, a detailed history remains the cornerstone of distinguishing asthma from other respiratory conditions, ensuring appropriate management and reducing misdiagnosis.^[2]

This article provides important insights into how a patients’ clinical history plays a pivotal role in accurate asthma diagnosis.

After reading this article you can:

• gain an understanding around the importance of clinical history
• consider how clinical history can help differentiate between asthma and other conditions
• apply key questions and techniques to gather a more accurate history.

The significance of clinical history in asthma diagnosis

Asthma is a heterogeneous disease with varying underlying factors that influence both susceptibility and disease progression.^[3] NICE guidelines recommend establishing a diagnosis based on a suggestive clinical history supported by objective testing.^[2]

Key historical features include:^[4]

• episodic breathlessness
• wheezing
• chest tightness
• cough – often worse at night or early in the mornings.

The key to accurate diagnosis

Research indicates that a detailed history can differentiate asthma from other respiratory conditions such as COPD.^[5] For example, the pattern of symptom fluctuation and triggers can be distinctive. Patients with asthma often report symptoms that vary throughout the day and are linked to specific exposures or activities, these can include:^[4]

• cold air
• exercise
• allergens
• high levels of air pollution.

Objective tests like spirometry are essential however, evidence suggests there are significant misdiagnosis of respiratory disease. In contrast, a good clinical history can guide the clinician toward appropriate testing and management.^[6] Given the change in recently updated asthma guidelines, testing includes eosinophil count and FeNO before spirometry testing.^[2]

Personal clinical experience

In my practice, I have encountered numerous cases where initial spirometry was inconclusive, yet a meticulous history revealed classic asthma symptoms. For instance, a patient presenting with an intermittent cough or wheeze, worsened by cold weather and exercise, responded remarkably well to inhaled corticosteroids (ICS). This reinforced my belief that understanding the patient’s narrative is invaluable.

I also recall a complex case where a patients symptoms mimicked asthma but were actually vocal cord dysfunction. A thorough history of symptom triggers, coupled with flexible laryngoscopy, clarified the diagnosis. This experience underscored the importance of listening carefully and probing beyond initial impressions. Although consultations are often time limited, it is perfectly acceptable to schedule follow-up appointments for further assessment. A definitive asthma diagnosis does not need to be made during the initial appointment, here’s my advice for making the most out of your consultation.

Structuring consultations using a model like OLDCART ensures a thorough approach to clinical history taking. This framework addresses key elements such as onset, location, duration, characteristics, alleviating and aggravating factors, timing, and severity.

Key takeaways

A detailed clinical history is the foundation of an accurate asthma diagnosis. Recognising symptom patterns, triggers, and variability guides appropriate testing and management. Personal clinical experience highlights the importance of listening probing beyond initial impressions.

Ultimately, dedicating time to gather a comprehensive history can greatly increase diagnostic confidence, can help improve patient outcomes, and reduces the risk of misdiagnosis in primary care.

[1] Asthma guidelines in practice. available at: https://www.pcrs-uk.org/sites/default/files/Asthma%20GuidlinesFINAL_AOP.pdf

[2] Asthma: diagnosis, monitoring and chronic asthma management (BTS, NICE, SIGN) available at: https://www.nice.org.uk/guidance/ng245/resources/asthma-diagnosis-monitoring-and-chronic-asthma-management-bts-nice-sign-pdf-66143958279109

[3] Fuhlbrigge A, Sharma S. Unravelling the heterogeneity of asthma. J of Allergy and Clin Immunology. 2025; 41-50. Available at: https://www.nhs.uk/conditions/asthma/

[4] Asthma. Available at: https://www.nhs.uk/conditions/asthma/

[5] Diagnostic criteria in asthma and COPD. Available at: https://practicenurse.co.uk/modules/respiratory-disease/diagnostic-criteria-in-asthma-and-copd

[6] Spirometry commissioning guidance. Available at: https://www.england.nhs.uk/wp-content/uploads/2020/03/spirometry-commissioning-guidance.pdf