Children with chest tightness variant asthma (CTVA) represent an atypical asthma phenotype in which chest tightness may be the predominant or only presenting symptom. According to the Global Initiative for Asthma (GINA) 2025, asthma is a heterogeneous disease characterized by chronic airway inflammation and variable respiratory symptoms, including wheeze, cough, dyspnoea, and chest tightness, accompanied by variable expiratory airflow limitation.1 Although objective demonstration of variable airflow obstruction remains the cornerstone of diagnosis, GINA recognizes that patients with atypical presentations may require additional investigations when spirometry is normal or inconclusive. In such cases, fractional exhaled nitric oxide (FeNO) and blood eosinophil measurements may support the diagnosis of Type 2 airway inflammation, although these biomarkers should not be used in isolation because elevated values may occur in other allergic conditions and normal levels do not exclude asthma. Children with chest tightness variant asthma (CTVA) demonstrate distinct inflammatory and pulmonary function abnormalities compared with healthy children, according to a recent retrospective case-control study published in Frontiers in Pediatrics.2 CTVA is an atypical phenotype of asthma in which chest tightness is the predominant symptom, often occurring in the absence of the classic manifestations of wheezing or persistent cough. This atypical presentation can delay diagnosis, highlighting the need for reliable objective markers to facilitate early recognition and management.2
The study evaluated 39 children diagnosed with CTVA between February 2022 and February 2024 and compared their findings with those of 50 healthy age-matched controls who underwent routine health examinations. All participants were assessed using fractional exhaled nitric oxide (FeNO) measurements and comprehensive pulmonary function testing at the time of diagnosis or physical examination.2
The investigators observed that children with CTVA had significantly elevated FeNO concentrations, indicating increased eosinophilic airway inflammation, a well-recognized feature of allergic asthma. Pulmonary function assessment further demonstrated evidence of impaired airflow, particularly involving the small airways. Compared with healthy controls, children with CTVA showed significantly lower values of the forced expiratory volume in one second to forced vital capacity ratio (FEV₁/FVC), peak expiratory flow (PEF), and maximal expiratory flow at 25%, 50%, and 75% of forced vital capacity (MEF25, MEF50, and MEF75). In contrast, no statistically significant differences were identified in FEV₁, FVC, or maximal mid-expiratory flow (MMEF), suggesting that conventional spirometric parameters may remain normal despite early small-airway dysfunction.2
The study also identified several clinical characteristics that were more prevalent among children with CTVA. These included obesity, sensitization to inhaled allergens, allergic rhinitis, atopic dermatitis, recurrent respiratory tract infections, and a family history of allergic diseases. Univariate logistic regression analysis confirmed that each of these variables was significantly associated with the presence of CTVA, indicating that they may represent important risk factors for the disease.
Overall, the findings suggest that FeNO measurement combined with small-airway function parameters may improve the identification of children with CTVA, particularly when routine spirometry appears normal. However, the authors emphasized that larger prospective studies evaluating the diagnostic accuracy and predictive value of these combined markers are required before they can be recommended as standard diagnostic tools for clinical practice.
References:
1. Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention. 2025 Update.
2. Cao RY, et al. Pulmonary function characteristics and risk factors in children with chest tightness variant asthma. Front Pediatr. 2026;14:1842381. doi:10.3389/fped.2026.1842381.
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