Croup is one of the most common symptoms of asthma. In mild asthma, the croup is only at the end of the breath. As the severity of the disease increases, the croup continues throughout the exhalation. In more severe asthma attacks, croup may also be present during inspiration. In very severe asthma attacks, croup may be absent due to severe airflow limitation associated with airway narrowing and respiratory muscle fatigue. When the site of obstruction is mainly in the small airways, asthma may be without croup. Therefore, croup is not a basis for the diagnosis of asthma. Further, croup may be associated with other causes of airway obstruction, such as fibrosis and heart failure. Patients with vocal cord dysfunction may have predominantly inspiratory monophonic wheezing (unlike the polyphonic croup of asthma), which is best heard in the cervical laryngeal region. Monophonic wheezing may also be heard in patients with bronchial tenderness and tracheal tenderness. In exercise-induced asthma, croup may be present after exercise, and croup may be present at night in patients with nocturnal asthma. Cough may be the only symptom of asthma, especially in exercise-induced asthma or nocturnal asthma. Typically, the cough is dry and non-episodic. Children with nocturnal asthma usually cough at night and early in the morning. There may be chest tightness or chest pain, with or without other asthma symptoms, especially exercise-induced or nocturnal asthma. Other nonspecific symptoms in infants or children may be recurrent bronchitis, capillary bronchitis, or pneumonia; persistent cough after a cold. Most children with chronic or recurrent bronchitis have asthma. The most common disease in children with recurrent pneumonia is asthma. Exercise-induced bronchospasm The clinical findings in patients with exercise-induced bronchospasm are typical of asthma but only associated with exercise. Typical symptoms include cough, croup, shortness of breath, chest pain, or chest tightness. Some patients may also present with a sore throat or gastrointestinal distress. Initially, airway dilation may occur during exercise. If exercise lasts longer than about 10 minutes, bronchoconstriction ensues, producing asthma symptoms. If the duration of exercise is shortened, symptoms may persist for 5-10 minutes after the exercise ends. High-intensity exercise levels can lead to high-intensity asthma attacks, and running can produce more symptoms than walking. Patients exercising are seen to have asthma symptoms associated with seasonal changes or changes in ambient temperature and moderation. Other triggers may be pollutants or upper respiratory tract infections. Dry, cold air is more likely to cause obstruction than hot, humid air. Therefore, athletes are better tolerated in sports such as swimming. Athletes in better physical condition may be less likely to observe typical asthma symptoms and may only have reduced endurance. However, patients may have typical obstructive symptoms, a sensation of choking during exercise, and inhaled croup or wheezing, which are evidence for assessing vocal cord dysfunction. Extra-pulmonary manifestations Atopic reactive or allergic rhinitis, such as conjunctival congestion and inflammation, dark circles under the eyes, transverse nasal folds due to frequent rubbing from allergic rhinitis, and lavender nasal mucosa from allergic rhinitis may manifest in patients without acute exacerbations. There may be erythema or hypertrophy of the turbinates. There may be polyps. Skin examination may show signs of atopic dermatitis, eczema, or other allergic skin disorders. Pestle finger is not a feature of asthma, but may be a feature of other diseases, and diseases such as cystic fibrosis need to be ruled out. Nocturnal symptoms Most patients with asthma have nocturnal symptoms once or twice a month. Some patients have symptoms only at night, with normal lung function during the day. This is partly due to hyperresponsiveness to circadian airflow. Children with nocturnal asthma usually cough at night and in the early morning.