The diagnosis of asthma is “under-diagnosed” rather than “over-diagnosed” in all countries in the world, especially for atypical asthma (such as cough variant asthma CVA), which is often misdiagnosed and missed, resulting in unreasonable use of antibiotics. This increases the unnecessary suffering of children and the economic burden of parents. Therefore, clinicians should pay due attention to the diagnosis of atypical asthma (e.g., hypersecretory/pneumonic asthma). Fan Hui, Department of Pediatrics, The First Affiliated Hospital of Henan College of Traditional Chinese Medicine 2. History: Pneumonia is a pathogenic infection with acute onset, which can be cured by reasonable and effective antibiotic treatment without history of recurrence. Asthma is caused by chronic allergic inflammation of the airways after stimulation by allergens (e.g., dust mites, pollen, etc.) and can be recurrent. Symptoms: Clinical manifestations of pneumonia. (1) Fever: It is important to emphasize that children with infectious pneumonia are theoretically febrile, unless they are severely malnourished and in extremely poor health; asthma is a metabolic inflammation (inflammation) and is usually not febrile. (2) Cough: In pneumonia, the cough is present both day and night with pus sputum; in asthma, the cough is more common in the morning and at bedtime, and it is repeatedly and persistently paroxysmal when exercising or after inhaling cold air, etc. Because of the chronic inflammation of the airways and the daily inhalation of allergens, even if the asthma does not attack, the child may have a dry cough or an itchy throat and rub the air to “scratch” it. Even if you do not have an asthma attack, you may have a dry cough or an itchy throat, rubbing the air against the “tickle” and making a “clearingthroatsound”, often coughing up white foamy sputum. (3) shortness of breath: children with pneumonia have shortness of breath and dyspnea because their lesions involve the alveoli, gas exchange is blocked and oxygen inhalation is affected, and the body’s compensatory respiration is accelerated (the number of breaths per unit of time increases); in asthma, the airway smooth muscle spasms, the lumen is narrowed, there is difficulty in expiration, the expiratory phase is prolonged, so the number of breaths per unit of time does not increase much. Only difficulty in expiration and no shortness of breath. (4) Toxic symptoms: Pneumonia with severe infection can appear systemic toxic symptoms, pale, cold extremities, etc.; asthma in severe cases, the general condition is still good, and no hypoxia/toxic symptoms. Signs: In pneumonia, small and medium-sized vesicular sounds can be heard on auscultation in both lungs, which often take more than 1 week to subside. In typical asthma, there may be significant croup in both lungs. In atypical asthma, besides cough variant asthma (CVA), there is also hypersecretory/pneumonia type asthma which is also atypical. It is characterized by the absence of croup in both lungs, but small and medium-sized vesicular sounds can be heard, which is due to the hyperplasia of mucosal glandular cells and excessive mucus production, which accumulates in the airway cavity and emits vesicular sounds when airflow passes through during breathing. This is often mistaken for “pneumonia” because of the presence of blistering sounds in both lungs. It is important to be aware of this and to differentiate. Laboratory tests: In children with pneumonia, the total leukocyte count is usually high (10×109/L to 12×109/L or more), and the classification count shows elevated neutrophils (>0170). In children with asthma, the total leukocyte count is in the normal range, and neutrophils are not elevated, while eosinophils are often elevated, and the eosinophil cationic protein (ECP) released by them is also elevated, and IgE may also be elevated. Chest x-ray: X-ray chest radiographs of children with pneumonia often show diffuse dotted and blurred shadows in both lung fields, and compensatory emphysema is seen. In children with asthma, most chest radiographs only show thickened lung texture and hyperinflation. However, it should be noted that if the child has hypersecretory/pneumonia type asthma (with blistering sounds on auscultation), it may also show small or dotted shadows in the medial to middle bands. In typical asthma, there is often no punctate shadow on the chest radiograph. Diagnosis: The diagnosis of pneumonia is generally based on the presence of clinical fever, cough, shortness of breath, dyspnea, blistering sounds in both lungs, elevated blood leukocyte count, neutrophilia and dotted shadows in both lungs on chest X-ray. The diagnosis of typical asthma is not difficult either. The diagnosis can be made with the absence of clinical fever, prolonged cough, white foamy sputum, wheezing and croup. “Pneumonia is often misdiagnosed as pneumonia. Pulmonary function tests and allergen skin tests can help confirm the diagnosis. Treatment: Children with pneumonia need to be treated with effective antibiotics. It can be cured after 10 to 14 d. Asthma is a non-infectious inflammatory disease, so the use of antibiotics is actually ineffective, even if the longer term (more than 2-4 weeks) is still ineffective, at this time should be considered asthma, it is a metaplasia (allergic) reactive inflammation, the choice of glucocorticoids is currently the most effective anti-inflammatory drugs, inhaled glucocorticoids is the first line of control drugs. Inhaled glucocorticosteroids are the first line of control. Aerosol + inhalation therapy with aerosol cans are commonly used. Inhaled glucocorticosteroids can be administered by nebulization in emergency cases. Inhalation therapy can directly exert local anti-inflammatory effects, with fast onset of action, low dosage, high efficacy and low side effects, which is worth promoting. The children with pneumonia were cured by reasonable antibiotic treatment and no recurrence. According to the treatment principle of GINA program, the majority of children with asthma can obtain complete/good clinical control after long-term, persistent, standardized and individualized treatment for about 3 years. At present, the diagnostic criteria for atypical asthma (including cough variant asthma and pneumonic asthma/hypersecretory asthma) have not been established, but pneumonic asthma is often mistaken for “pneumonia” in clinical practice. In order to improve the correct diagnosis of pneumonic asthma, we may refer to the diagnostic criteria for cough variant asthma developed in the “Childhood Asthma Prevention and Control Routine” in China, and then combine them with the clinical diagnostic basis for hypersecretory/pneumonic asthma proposed by domestic scholars. Considering that it can also be applied to primary care institutions, the following bases were proposed from the clinical point of view: (1) intermittent recurrent episodes of cough for ≥4 weeks, good in the early morning and at night, aggravated after exercise; (2) fair general condition, no clinical signs of infection and toxic symptoms; (3) small and medium-sized alveolar sounds in the lungs; (4) “pneumonia-like” X-ray chest radiograph ” manifestation; (5) longer-term antibiotic use is ineffective; (6) effective to glucocorticoids/bronchodilators; (7) personal/family history of allergic disease.