Misperception of airway obstruction — often resulting in undertreatment or overtreatment, especially with reliever medications — was common, although often overlooked, in patients with asthma across all age groups and associated with a host of lifestyle, demographic, and clinical variables, according to study results published in the Journal of Allergy and Clinical Immunology.

Airway obstruction during acute asthma exacerbations results in dyspneic sensations in affected patients, but disordered perception of this phenomenon can lead to treatment delays and avoidable fatalities in patients who under-perceive objective obstruction, and excessive therapies and iatrogenic medication effects in people who have heightened perception. Investigators sought to assess evidence of symptom misperception in the literature, with a focus on identification and management of individuals on whom this has an impact.

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A systematic literature review regarding perception of objective airway function in asthmatics was conducted using the OVID, PubMed, Adisearch/Odyssey, and Embase databases. English language human randomized controlled trials or cross-sectional, longitudinal, or observational studies carried out between 1990 and 2018 were eligible for inclusion. No restrictions were imposed relating to gender, age, or race/ethnicity.

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There were 139 relevant studies included in the analysis, with 125 conducted in adult populations (n=10,918) and 14 that examined pediatric patients (n=898). A total of 88 articles utilized the Borg scale (at 20% reduction of forced expiratory volume in 1 second) to evaluate dyspnea and perception of obstruction, while 39 used a visual analogue scale and 5 employed a Likert scale. Bronchial challenge effects were assessed in 86 of the studies considered.

Distorted perception of airway obstruction was common in patients with asthma regardless of age, following either induced bronchoconstriction or bronchodilation, or other airway resistance changes. Alterations in perception were associated with a variety of demographic, lifestyle, and clinical factors, including smoking, disease severity, ethnicity, gender, medication, aging, and psychological variables of anxiety (P <.01) and catastrophizing (P <.05). Also, inflammation in the airway was correlated with poor perception and a history of severe asthma exacerbations or near-mortality secondary to asthma. In addition, individuals with milder asthma tended to be more aware of bronchoconstriction than individuals with more severe disease.

During the review, the researchers identified several knowledge gaps in the literature as well, involving the possible variation of patient perception over time and the influence of an individual’s perception on relief medication use.

“Identifying patients with these differences in perception of airway obstruction should become a priority in the management of asthma and other obstructive airways diseases,” concluded the investigators. They recommended that future research involve longitudinal studies to assess treatment effects on perception and the impact of misperception on relief medication use.

Disclosures: Literature search and medical writing support were provided 20 by in Science Communications, SpringerNature, Tattenhall, United Kingdom and funded by AstraZeneca, Cambridge, United Kingdom.

Please see original article for conflict of interest declarations.


Barnes PJ, Szefler SJ, Reddel HK, Chipps BE. Symptoms and perception of airway obstruction in asthmatic patients: Clinical implications for use of reliever medications. J Allergy Clin Immunol. 2019;S0091-6749(19):30941-30948.