Not a single kind of human activity can do without mistakes, and this fully applies to healing. However, the specificity of medical activity, its direct relationship with human health and human life prompts doctors to closely and self-critically analyze diagnostic errors.
Naturally, they are possible in all areas of medicine, including respiratory diseases. In the diagnosis of bronchial asthma in adult patients, errors reach 22.4%. Bronchial asthma, as noted by academician of RAMS A.G. Chuchalin is common, but diagnosed poorly.
Often, the diagnosis of asthma in childhood presents significant difficulties and requires differentiation with a fairly wide range of diseases.
Despite the manifest nature, bronchial asthma is characterized by a variety of clinical and functional manifestations related to the age of the sick child, the course of the disease, a possible combination with other bronchopulmonary diseases, and not only with them.
Even in the first domestic monograph on bronchial asthma in children, S.G. Zvyagintseva (1958) wrote about the need to differentiate bronchial asthma from pneumonia and acute bronchitis, diphtheria croup, and foreign bodies of the respiratory tract.
According to the materials “Bronchial asthma. Global Strategy ”(1996), alternative diagnoses for childhood bronchial asthma are cystic fibrosis, primary ciliary dyskinesia, primary immunodeficiency, congenital malformations of the respiratory system and cardiovascular system, foreign body aspiration.
The many years of experience in the Pulmonology Clinic of the Research Institute of Pediatrics and Pediatric Surgery of the Ministry of Health of the Russian Federation made it possible to identify and group typical errors that arise in the diagnosis of bronchial asthma in children.
Analysis of the development and course of the disease, comparison of diagnoses at admission to the clinic and at the time of discharge made it possible to notice diagnostic errors in 5.2% of cases. This indicator is undoubtedly underestimated, because patients, as a rule, were admitted to the clinic after repeated consultations in specialized pulmonological and allergological centers and departments. According to the advisory department of the Institute, errors in the diagnosis of asthma in children are much more common – more than 60% of cases. In this case, there was both a hypodiagnosis and an overdiagnosis of bronchial asthma.
Almost half of the patients were admitted to the clinic with a diagnosis of bronchitis, which often replaces the diagnosis of true bronchial asthma. Sometimes, even with fairly typical clinical symptoms in children, the concept of obstructive bronchitis is inappropriately applied. However, episodes of bronchial obstruction in children with acute respiratory viral infection are often the first manifestations of asthma.
In everyday pediatric practice, the diagnosis of asthmatic bronchitis is widely used, even in cases of typical asthma, including in older children. It should be emphasized that asthmatic bronchitis is a variant of asthma inherent in young children, in which vasosecretory disorders prevail. Substitution of the diagnosis of a dangerous disease – “bronchial asthma” with a softened “asthmatic bronchitis” calms the parents of a sick child and disorientates the doctor himself. In addition, the use of another concept often leads to late diagnosis and lack of timely treatment. Therapists use the term “asthmatic or asthmoid bronchitis” is also objectionable. According to the academician of RAMS A.G. Chuchalina, these terms are applicable only for deontological reasons.
Often the diagnosis of bronchial asthma is replaced by the concept of “allergic bronchitis.” However, unlike bronchial asthma, allergic bronchitis is not accompanied by asthma attacks and wheezing.
Difficulties and errors arise in the differential diagnosis of bronchial asthma and chronic pneumonia in children, according to our observations, in 20% of cases. Persistent physical changes in the lungs with chronic pneumonia are usually the cause. Doctors consider stable moist rales as a manifestation of a chronic infectious and inflammatory process. It does not take into account that wet chrine in the lungs can be caused by allergic inflammation, which is currently considered the main mechanism for the development of bronchial asthma.
In connection with the erroneous diagnosis of patients, they are sometimes subjected to bronchological examination, which may entail further diagnostic and therapeutic errors. This is due to the fact that in patients with bronchial asthma when filling the bronchial tree with a contrast agent as a result of the hypotension of the bronchi, their dilatation is possible, which is reversible, but it is mistaken for true bronchiectasis.
We observed in the clinic several patients previously operated on for chronic pneumonia, the diagnosis of which was erroneous. Surgery only exacerbated the severity of asthma.
One of the options for diagnostic errors in children with bronchial asthma is cystic fibrosis. Sometimes doctors take asthma for malformations of the bronchopulmonary system, in particular for Williams-Campbell syndrome (“ballooning” bronchiectasis syndrome), the main clinical manifestation of which is expiratory dyspnea. However, unlike the suffocation paroxysms characteristic of bronchial asthma, dyspnea in Williams-Campbell syndrome is permanent, patients have a rapidly forming pulmonary heart, there is a thickening of the nail phalanges of the fingers (“drumsticks”), and there are no manifestations of atonic diathesis.
Hypodiagnosis of bronchial asthma, but in our opinion, is due to the fact that anamnestic information characteristic of allergic diseases, indications of aggravated heredity, the manifestations of drug and food allergies in a child are not taken into account, the course of the disease, in particular, severe bronchial obstruction a syndrome that is eliminated with the help of bronchodilators. Not always doctors use the necessary methods of specific allergological diagnostics – staging skin samples with non-bacterial allergens, determining the level of general specific IgE.
Other diseases, which are characterized by a syndrome of bronchial obstruction, are sometimes hidden under the mask of asthma. So, it can simulate foreign bodies in the respiratory tract. In 8% of sick young children observed for bronchial asthma, foreign bodies were the true cause of dyspnea.
We observed three children in whom a foreign body (seeds, seeds of apples) was in the bronchi for 3-6 months, and all this time the children received bronchodilator therapy. The clinic noted the absence of typical asthmatic attacks, changes in the intensity of shortness of breath and cough with a change in body position, and X-ray data were taken into account, indicating areas of hypoventilation of the lungs, as well as the lack of effect of bronchodilator therapy. All this served as the basis for diagnostic bronchoscopy, which revealed a foreign body in the trachea or bronchi. Removal of foreign bodies led to a complete recovery.
Among diseases similar to bronchial asthma, various lesions of the larynx and tracheo-bronchial tree, in particular epiglotitis, bronchial papilloma, are described.
Various vascular abnormalities, squeezing the airways, cause bronchial obstruction and often mistakenly qualify as bronchial asthma. It can be simulated by tuberculosis, as well as bronchial tumors, shortness of breath of neurogenic and psychogenic origin. These pseudo-asthmatic attacks are possible in patients with neurosis and mental illness.
Similar conditions, as shown by our observations, may be in children. With respiratory neurosis, children complain of a feeling of “lack” of air, the inability to take a deep breath. Breathing periodically becomes rapid, forced, that is, the clinical manifestations of hyperventilation syndrome were expressed. Unlike bronchial asthma, patients do not have obstructive disorders, characteristic physical changes in the lungs, and bronchodilators do not bring relief. Respiratory neurosis sometimes develops as a trace reaction after previous respiratory diseases.
Despite the fact that overdiagnosis of bronchial asthma is much less common than underdiagnosis, establishing the correct diagnosis is extremely important for the life and health of patients. Based on the new information technologies conducted jointly with the medical center (supervisor – Professor B.A. Kobrinsky) research of our institute with the participation of specialists from the Institute for System Analysis of the Russian Academy of Sciences (director – academician S.V. Emelyanov) a computer expert system for diagnosing asthma in children was developed . The expert system is based on the STEPCLASS tool environment. The system operates on the basis of a personal computer.
Anamnestic data and the most characteristic clinical, functional and laboratory signs inherent in bronchial asthma and other diseases with which it is most often necessary to differentiate are entered into the database. In total, the database contains information on 13 diseases and 96 of their characteristic signs.
Assessment of the quality of decisions of the expert system was carried out by comparing the diagnosis of specialists and the diagnosis obtained by interacting with the system. Studies have shown that in 87% of cases, the diagnoses obtained as a result of the expert system coincided with the diagnoses made by clinicians.
Pediatricians’ knowledge of the characteristics of the course of bronchial asthma, modern methods for its diagnosis will contribute to its early recognition and the appointment of adequate therapy.