Wheezing and Dyspnea in a 15-Year-Old:
Differentiating New-Onset Asthma from Other
Etiologies
Clinical Scenario
A 15-year-old male presents with a 3-week history of intermittent wheezing, chest
tightness, and dyspnea. Symptoms occur primarily at night and during physical
education class. He has no prior history of respiratory problems. His parents report
he had a "cold" about 4 weeks ago. On examination, he has mild expiratory wheezing
on auscultation. Peak expiratory flow is 75% of predicted.
Differential Diagnosis
Diagnosis Key Features Diagnostic Approach
Episodic symptoms, triggers Spirometry with bronchodilato
New-Onset Asthma (exercise, night), reversible response, peak flow monitoring
airflow obstruction allergy testing
Post-Infectious Airway Onset after viral URI, self-limiting Clinical diagnosis; symptoms re
Hyperreactivity (4-8 weeks) spontaneously
Exercise-Induced Symptoms only with exercise, Exercise challenge test, respons
Bronchoconstriction (EIB) peak 5-10 minutes post-exercise pre-exercise bronchodilator
Inspiratory stridor, throat
Vocal Cord Dysfunction Laryngoscopy during symptom
tightness, normal PEF during
(VCD) volume loops
symptoms, laryngeal findings
, Diagnosis Key Features Diagnostic Approach
Allergic Bronchopulmonary Asthma symptoms, eosinophilia, IgE levels, Aspergillus-specific I
Aspergillosis (ABPA) central bronchiectasis chest imaging
Gastroesophageal Reflux Nocturnal symptoms, cough, Empiric PPI trial, esophageal pH
Disease (GERD) heartburn monitoring
Sudden onset, unilateral findings, Chest X-ray (inspiratory/expirat
Foreign Body Aspiration
history of choking bronchoscopy
Dyspnea on exertion, syncope,
Cardiac Conditions Echocardiogram, cardiac evalua
murmur
1. New-Onset Asthma
Pathophysiology
Asthma is a chronic inflammatory disorder of the airways characterized by:
• Airway inflammation (eosinophils, mast cells, T-lymphocytes)
• Airway hyperresponsiveness to various triggers
• Airway obstruction that is reversible (spontaneously or with treatment)
Clinical Presentation
• Symptoms: Wheezing, dyspnea, chest tightness, cough
• Pattern: Episodic, often worse at night, early morning, or with triggers
• Triggers: Exercise, allergens (pollen, dust mites, pet dander), viral infections, cold air,
irritants
• Physical exam: Expiratory wheezing; may be normal between episodes
Diagnostic Criteria
Differentiating New-Onset Asthma from Other
Etiologies
Clinical Scenario
A 15-year-old male presents with a 3-week history of intermittent wheezing, chest
tightness, and dyspnea. Symptoms occur primarily at night and during physical
education class. He has no prior history of respiratory problems. His parents report
he had a "cold" about 4 weeks ago. On examination, he has mild expiratory wheezing
on auscultation. Peak expiratory flow is 75% of predicted.
Differential Diagnosis
Diagnosis Key Features Diagnostic Approach
Episodic symptoms, triggers Spirometry with bronchodilato
New-Onset Asthma (exercise, night), reversible response, peak flow monitoring
airflow obstruction allergy testing
Post-Infectious Airway Onset after viral URI, self-limiting Clinical diagnosis; symptoms re
Hyperreactivity (4-8 weeks) spontaneously
Exercise-Induced Symptoms only with exercise, Exercise challenge test, respons
Bronchoconstriction (EIB) peak 5-10 minutes post-exercise pre-exercise bronchodilator
Inspiratory stridor, throat
Vocal Cord Dysfunction Laryngoscopy during symptom
tightness, normal PEF during
(VCD) volume loops
symptoms, laryngeal findings
, Diagnosis Key Features Diagnostic Approach
Allergic Bronchopulmonary Asthma symptoms, eosinophilia, IgE levels, Aspergillus-specific I
Aspergillosis (ABPA) central bronchiectasis chest imaging
Gastroesophageal Reflux Nocturnal symptoms, cough, Empiric PPI trial, esophageal pH
Disease (GERD) heartburn monitoring
Sudden onset, unilateral findings, Chest X-ray (inspiratory/expirat
Foreign Body Aspiration
history of choking bronchoscopy
Dyspnea on exertion, syncope,
Cardiac Conditions Echocardiogram, cardiac evalua
murmur
1. New-Onset Asthma
Pathophysiology
Asthma is a chronic inflammatory disorder of the airways characterized by:
• Airway inflammation (eosinophils, mast cells, T-lymphocytes)
• Airway hyperresponsiveness to various triggers
• Airway obstruction that is reversible (spontaneously or with treatment)
Clinical Presentation
• Symptoms: Wheezing, dyspnea, chest tightness, cough
• Pattern: Episodic, often worse at night, early morning, or with triggers
• Triggers: Exercise, allergens (pollen, dust mites, pet dander), viral infections, cold air,
irritants
• Physical exam: Expiratory wheezing; may be normal between episodes
Diagnostic Criteria
