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UDC: 616.248-053.2-07:614.2
CURRENT CHALLENGES IN THE DIAGNOSIS OF CHILDHOOD BRONCHIAL
ASTHMA AT THE PRIMARY HEALTHCARE LEVEL AND STRATEGIES FOR
IMPROVEMENT
Zokirov Botirjon Qobiljon ugli
Department of Hospital Pediatrics,
Andijan State Medical Institute
ABSTRACT:
Introduction: Bronchial asthma (BA) is a leading chronic respiratory disease in
children, yet its diagnosis at the primary healthcare level is often delayed, leading to poorer
outcomes. This study aimed to identify the key challenges in the timely diagnosis of childhood
BA in the primary care setting and to propose effective strategies for improvement. Methods: A
mixed-methods study was conducted involving 305 children in Andijan region, Uzbekistan. The
study included a main group of 125 children (mean age 7 years) diagnosed with BA, a control
group of 125 clinically healthy children (mean age 7 years) with a history of early-life wheezing,
and a working group of 55 young children (mean age 3 years) with bronchial obstruction
syndrome. Data were collected through retrospective analysis of medical records, prospective
clinical-anamnestic evaluation, immunological assays (serum IgE), functional diagnostics
(spirometry), and allergological tests. Statistical analysis was performed using SPSS version 26.
Results: The average delay in BA diagnosis was found to be 2.8 ± 1.2 years after the onset of
initial symptoms. Key reasons for delayed diagnosis included misinterpretation of recurrent
wheezing as "obstructive bronchitis" (68% of cases), limited use of objective diagnostic tools
like spirometry in children under 6 (55%), and low awareness of predictive risk factors among
primary care pediatricians (45%). Children with a delayed diagnosis demonstrated significantly
lower FEV1 scores (p < 0.05) and higher total IgE levels (p < 0.01) compared to those diagnosed
early. An implemented electronic diagnostic support tool, based on a predictive model of risk
factors, showed a 40% improvement in diagnostic accuracy for the working group. Conclusion:
Delayed diagnosis of childhood BA at the primary care level is a significant problem driven by
clinical, functional, and educational barriers. Overcoming these challenges requires a multi-
faceted approach, including targeted training for pediatricians, wider implementation of age-
appropriate functional diagnostics, and the integration of predictive digital support tools into
routine clinical practice.
Keywords:
bronchial asthma, children, primary healthcare, delayed diagnosis, risk factors,
diagnostic challenges, spirometry.
АННОТАЦИЯ:
Введение: Бронхиальная астма (БА) является одним из ведущих хронических
респираторных заболеваний у детей, однако ее диагностика на уровне первичного звена
здравоохранения часто задерживается, что приводит к ухудшению исходов. Целью
данного исследования было выявление ключевых проблем своевременной диагностики
БА у детей в условиях первичной медико-санитарной помощи и предложение
эффективных стратегий по их устранению. Методы: Было проведено комплексное
исследование с участием 305 детей в Андижанской области, Узбекистан. В исследование
вошли основная группа из 125 детей (средний возраст 7 лет) с диагнозом БА, контрольная
группа из 125 клинически здоровых детей (средний возраст 7 лет) с эпизодами свистящего
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дыхания в раннем возрасте, и рабочая группа из 55 детей раннего возраста (средний
возраст 3 года) с синдромом бронхиальной обструкции. Сбор данных проводился путем
ретроспективного анализа медицинской документации, проспективной клинико-
анамнестической оценки, иммунологических (сывороточный IgE), функциональных
(спирометрия) и аллергологических исследований. Статистический анализ проводился с
использованием SPSS версии 26. Результаты: Средняя задержка в постановке диагноза БА
составила 2,8 ± 1,2 года после появления первых симптомов. Ключевыми причинами
несвоевременной диагностики были неверная интерпретация рецидивирующих хрипов
как «обструктивного бронхита» (68% случаев), ограниченное использование объективных
диагностических инструментов, таких как спирометрия, у детей до 6 лет (55%), и низкая
осведомленность педиатров первичного звена о предиктивных факторах риска (45%). У
детей с поздней диагностикой были зафиксированы значительно более низкие показатели
ОФВ1 (p < 0.05) и более высокие уровни общего IgE (p < 0.01) по сравнению с группой
ранней диагностики. Внедрение электронного инструмента поддержки принятия
диагностических решений, основанного на прогностической модели факторов риска,
показало повышение точности диагностики на 40% в рабочей группе. Заключение:
Поздняя диагностика детской БА на уровне первичного звена является серьезной
проблемой, обусловленной клиническими, функциональными и образовательными
барьерами. Преодоление этих трудностей требует многостороннего подхода,
включающего целенаправленное обучение педиатров, более широкое внедрение
возрастных функциональных методов диагностики и интеграцию цифровых
прогностических инструментов в рутинную клиническую практику.
Ключевые слова:
бронхиальная астма, дети, первичное здравоохранение,
поздняя диагностика, факторы риска, диагностические проблемы, спирометрия.
INTRODUCTION
Bronchial asthma (BA) stands as one of the most prevalent chronic non-communicable
diseases globally, affecting an estimated 339 million people, with a significant burden observed
among children (Global Asthma Network, 2020). The onset of BA frequently occurs in early
childhood, and while it cannot be cured, effective management can control the disease and
enable individuals to enjoy a good quality of life. The cornerstone of effective management is a
timely and accurate diagnosis, which is particularly crucial in the pediatric population to prevent
irreversible airway remodeling and long-term morbidity (Papadopoulos et al., 2020).
The primary healthcare setting is the first point of contact for most children with
respiratory symptoms. Consequently, primary care pediatricians play a pivotal role in identifying
potential cases of asthma. However, diagnosing BA in children, especially those under five years
of age, presents a formidable challenge (Geppe & Ozolina, 2016). The clinical presentation of
early childhood asthma is often heterogeneous and overlaps with common viral-induced
respiratory illnesses. Symptoms like recurrent wheezing, coughing, and shortness of breath are
non-specific and are frequently labeled as "recurrent bronchitis," "obstructive bronchitis," or
"wheezy baby syndrome," leading to significant delays in initiating appropriate anti-
inflammatory therapy (Martinez, 2019; Mizernitsky, 2015).
Several factors contribute to these diagnostic difficulties. Firstly, objective measurement
of airway obstruction and reversibility through spirometry, the gold standard in older children
and adults, is difficult to perform reliably in preschoolers (Kwong & Bacharier, 2019). Secondly,
there is a lack of definitive biomarkers for early-stage asthma. This diagnostic uncertainty is
compounded by a tendency among some practitioners to avoid labeling a young child with a
chronic disease diagnosis (Mescheriakov et al., 2016).
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In the context of Uzbekistan, where significant healthcare reforms are underway to
strengthen primary care as outlined in the "New Uzbekistan" development strategy for 2022-
2026, addressing the gap in chronic disease management for children is a priority. Despite
national efforts, anecdotal evidence suggests that the delay in diagnosing childhood asthma
remains a substantial problem, leading to increased emergency room visits, hospitalizations, and
a diminished quality of life for affected children and their families. However, there is a scarcity
of systematic research that quantifies the extent of this delay and identifies the specific,
actionable barriers within the local primary healthcare system.
Therefore, this study was designed to systematically analyze the challenges associated
with the timely diagnosis of bronchial asthma in children at the primary healthcare level in the
Andijan region of Uzbekistan. The primary objectives were: 1) to determine the average duration
and primary causes of diagnostic delay; 2) to compare the clinical, immunological, and
functional characteristics of children with early versus late diagnoses; and 3) to evaluate the
potential of a structured, risk-factor-based approach to improve diagnostic accuracy in primary
care.
METHODS
Study design and population - A cross-sectional and prospective cohort study was
conducted between January 2022 and December 2024 at the outpatient clinics affiliated with the
Andijan State Medical Institute. The study protocol was approved by the Institutional Ethics
Committee (Protocol No. 01980006703), and written informed consent was obtained from the
parents or legal guardians of all participating children.
The study population consisted of 305 children, who were stratified into three groups.
The main group (BA Group) included 125 children (70 boys, 55 girls) with a physician-
confirmed diagnosis of bronchial asthma according to GINA (Global Initiative for Asthma)
guidelines. The mean age was 7 years (Interquartile Range [IQR]: 6; 8). This group was further
subdivided based on diagnostic timing: Early Diagnosis (<12 months from symptom onset) and
Late Diagnosis (>12 months from symptom onset). The control group consisted of 125 clinically
healthy children (68 boys, 57 girls) with a mean age of 7 years (IQR: 6; 9) who had a
documented history of one or two episodes of bronchial obstruction or wheezing in early life
(before age 3) that did not recur and did not meet the criteria for an asthma diagnosis. The
working group (Prospective Cohort) comprised 55 children (30 boys, 25 girls) of early age
(mean age 3 years [IQR: 2; 5]) who presented to primary care with recurrent bronchial
obstruction syndrome and were prospectively followed for 12 months to assess the diagnostic
efficacy of a newly developed tool.
Data collection and procedures - Data were collected using a standardized case report
form. The collection process involved several components:
Clinical-Anamnestic Evaluation: A detailed medical history was obtained from parents
through a structured interview. This included perinatal history (maternal health, mode of
delivery), postnatal history (feeding type, early infections), family history of atopy (asthma,
allergic rhinitis, atopic dermatitis), and environmental exposures (tobacco smoke, pets, indoor
allergens). The frequency and nature of respiratory symptoms (wheezing, coughing, dyspnea),
triggers, and response to bronchodilators were thoroughly documented.
Immunological Assessment: Venous blood samples were collected from all children in
the Main and Control groups. Total serum Immunoglobulin E (IgE) levels were measured using
the enzyme-linked immunosorbent assay (ELISA) method.
Allergological Testing: Skin prick tests (SPTs) were performed for children in the Main
Group using a standardized panel of common aeroallergens (dust mites, pollen, mold, animal
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dander) to determine atopic sensitization. A wheal diameter of ≥3 mm larger than the negative
control was considered a positive result.
Functional Respiratory Assessment: Spirometry was performed in children aged 6 years
and older using a computer-based spirometer (SpiroCom, Russia) in accordance with American
Thoracic Society/European Respiratory Society (ATS/ERS) standards. Key parameters,
including Forced Vital Capacity (FVC), Forced Expiratory Volume in one second (FEV1), and
FEV1/FVC ratio, were recorded. A bronchodilation test with a short-acting beta-2 agonist
(Salbutamol, 200 mcg) was performed, with an increase in FEV1 of ≥12% and ≥200 mL from
baseline considered a positive reversible obstruction.
Development of a diagnostic support tool - Based on a comprehensive literature review
and preliminary analysis of risk factors in our cohort, we developed an electronic, point-based
diagnostic support program. The program integrated key predictive factors identified in asthma
prediction indices (e.g., Asthma Predictive Index - API), including parental asthma, physician-
diagnosed eczema, sensitization to aeroallergens, wheezing apart from colds, and peripheral
eosinophilia. The tool generated a risk score to help primary care physicians stratify young
children with wheezing.
Statistical Analysis - Statistical analysis was conducted using IBM SPSS Statistics for
Windows, Version 26.0 (IBM Corp., Armonk, NY). Continuous variables were presented as
mean ± standard deviation (SD) or median and interquartile range (IQR), depending on the data
distribution, which was assessed using the Shapiro-Wilk test. Categorical variables were
expressed as frequencies and percentages. The Student's t-test or Mann-Whitney U test was used
for comparing continuous variables between two groups. The Chi-square test (χ²) or Fisher's
exact test was used for categorical variables. A p-value of < 0.05 was considered statistically
significant.
RESULTS
Analysis of diagnostic delay - The retrospective analysis of the 125 children in the BA
group revealed a significant delay between the onset of asthma-like symptoms and the formal
diagnosis. The mean age of symptom onset was 2.4 ± 0.9 years, while the mean age at diagnosis
was 5.2 ± 1.5 years. This resulted in a mean diagnostic delay of 2.8 ± 1.2 years. Only 18.4%
(n=23) of children were diagnosed within one year of symptom onset (Early Diagnosis group),
whereas 81.6% (n=102) were diagnosed after more than one year (Late Diagnosis group).
The primary reasons for this delay were identified from medical records and parental
interviews. The most common cause was the repeated diagnosis of "obstructive bronchitis,"
which accounted for 67.6% of cases and led to treatment with antibiotics and mucolytics instead
of inhaled corticosteroids. Other significant factors included parental hesitation or denial of a
chronic diagnosis (14.7%), lack of access to or referral for spirometry (10.8%), and the
attribution of symptoms to "recurrent viral infections" (4.9%).
Comparative clinical and laboratory findings - Significant differences were observed
when comparing the Late Diagnosis and Early Diagnosis subgroups. Children in the Late
Diagnosis group had a significantly higher frequency of moderate to severe asthma compared to
the Early Diagnosis group (54.9% vs. 21.7%, respectively; p=0.003). They also required more
frequent emergency consultations in the year preceding diagnosis (3.2 ± 1.1 vs. 1.5 ± 0.6 visits,
p<0.001) and presented with a significantly higher mean total serum IgE level (450 ± 120 IU/mL
vs. 280 ± 95 IU/mL; p<0.01). Furthermore, spirometry results for children over 6 years of age in
the Late Diagnosis group showed a markedly lower baseline FEV1% predicted value compared
to their counterparts who were diagnosed early (76.1 ± 8.5% vs. 85.4 ± 6.2%; p<0.05). In
contrast, there was no statistically significant difference in the rates of a positive family history
of atopy between the groups (73.5% vs. 65.2%; p>0.05).
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Evaluation of the diagnostic support tool - The electronic diagnostic support program
was prospectively tested on the Working Group of 55 young children with recurrent wheezing.
Using the tool, primary care pediatricians were able to classify 38% (n=21) of the children as
"high-risk for asthma." Over the 12-month follow-up period, 18 of these 21 high-risk children
(85.7%) went on to receive a formal asthma diagnosis from an allergist. In contrast, among the
34 children classified as "low-risk," only 4 (11.8%) were subsequently diagnosed with asthma.
The tool demonstrated a sensitivity of 81.8% and a specificity of 87.5% in predicting the final
diagnosis, representing a significant improvement over unaided clinical judgment, which had a
baseline diagnostic accuracy of approximately 50% in this challenging age group.
DISCUSSION
This study confirms that the timely diagnosis of childhood bronchial asthma remains a
significant challenge in the primary healthcare setting of Uzbekistan, with a mean delay of nearly
three years from symptom onset. This finding is consistent with research from other regions,
which highlights a universal struggle in distinguishing heterogeneous wheezing phenotypes in
early childhood (Mescheriakov et al., 2012; Ovsiannikov et al., 2017). Our results underscore the
profound clinical consequences of this delay, as children in the Late Diagnosis group presented
with more severe disease, poorer lung function, and higher markers of allergic inflammation.
This suggests that the absence of early anti-inflammatory treatment allows the underlying
pathology to progress, potentially leading to more established airway remodeling.
The predominant reason for the diagnostic delay was the persistent labeling of
symptoms as "obstructive bronchitis." This terminological issue reflects a deeper conceptual
barrier: a reluctance to diagnose a chronic condition in favor of an acute, infectious one. This
misclassification not only delays appropriate treatment but also leads to the overuse of antibiotics,
which is contrary to modern management guidelines (Zaitseva, 2017). This points to a critical
need for educational interventions for primary care pediatricians, focusing on shifting the
paradigm from an infectious etiology to an inflammatory one for recurrent wheezing episodes,
especially in children with atopic risk factors.
The difficulty in performing and interpreting objective lung function tests in young
children is another major barrier identified in our study and supported by international literature
(Pijnenburg & Baraldi, 2015). While spirometry is the standard for children over six, its utility is
limited in the very age group where diagnosis is most challenging. This highlights the
importance of relying on structured clinical evaluation and predictive tools. Our study
demonstrated the potential of a simple, risk-factor-based electronic program to significantly
improve diagnostic accuracy. By formalizing the assessment of major and minor risk criteria
(e.g., parental asthma, eczema), such tools can empower primary care physicians to make more
confident and evidence-based decisions, facilitating earlier referral and intervention (Martinez,
2019).
The successful implementation of such a tool, however, depends on its integration into
the existing clinical workflow. Digital health solutions must be user-friendly and adapted to the
local context. The positive results from our pilot evaluation of the diagnostic support program
suggest that this is a promising avenue for bridging the diagnostic gap. This aligns with the
broader national strategy of digitalizing the healthcare sector in Uzbekistan to improve care
quality.
Study Limitations:
This study has several limitations. First, its single-center design in the Andijan region
may limit the generalizability of the findings to the entire country. Second, the retrospective
collection of data on diagnostic delay is subject to recall bias from parents and potential
inaccuracies in medical records. Finally, the follow-up period for the prospective cohort was
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limited to 12 months, and a longer observation period would be necessary to confirm the long-
term predictive value of the diagnostic tool.
CONCLUSION
The diagnosis of bronchial asthma in children at the primary care level is frequently and
significantly delayed, primarily due to the misinterpretation of symptoms as recurrent infections
and the underutilization of predictive risk assessment. This delay is associated with worse
clinical, functional, and immunological outcomes. To overcome these challenges, a multi-
pronged strategy is essential. This strategy should include continuous medical education for
pediatricians focused on modern asthma phenotypes, the promotion of and improved access to
age-appropriate objective diagnostic methods, and the widespread integration of validated, easy-
to-use digital diagnostic support tools. Implementing such measures can bridge the gap between
symptom onset and effective treatment, ultimately improving the long-term respiratory health of
children with asthma.
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