The unified immune system: respiratory tract-nasobronchial interaction mechanisms in allergic airway disease

Short-term effects of air pollutants and meteorological factors on outpatients with allergic airway disease in Ningbo, China, 2015-2021

OBJECTIVES

The allergic airway disease, such as allergic rhinitis, chronic rhinosinusitis, asthma, is a general term of a range of inflammatory disorders affecting the upper and lower airways and lung parenchyma. This study aimed to investigate the short-term effects of air pollutants and meteorological factors on AAD-related daily outpatient visits.

STUDY DESIGN

An ecological study.

METHODS

Data on outpatient visits due to AAD (n = 4,554,404) were collected from the platform of the Ningbo Health Information from January 1, 2015 to December 31, 2021. A Quasi-Poisson generalized additive regression model was established to analyze the lag effects of air pollution on daily outpatient visits for AAD. Restricted cubic spline functions were used to explore the potential non-linear relationships between air pollutants and meteorological and daily outpatient visits for AAD.

RESULTS

PM2.5, PM10, SO2, NO2, or CO were associated with daily outpatient visits for AAD, and there was a significant increasing trend in the cumulative lag effects. SO2 had the largest effect at Lag07, with a 25.3% (95% CI: 21.6%-29.0%) increase in AAD for every 10 μg/m3 increase in exposure concentration. Subgroup analysis showed that the 0-18 years old age group had the strongest effects, especially for AR, and all effects were stronger in the cold season.

CONCLUSIONS

Given that patients aged 0-18 are more susceptible to environmental changes, protective measures specifically for children should be taken during dry and cold weather conditions with poor air quality.

Inflammatory and infectious upper respiratory diseases associate with 41 genomic loci and type 2 inflammation

Inflammatory and infectious upper respiratory diseases (ICD-10: J30-J39), such as diseases of the sinonasal tract, pharynx and larynx, are growing health problems yet their genomic similarity is not known. We analyze genome-wide association to eight upper respiratory diseases (61,195 cases) among 260,405 FinnGen participants, meta-analyzing diseases in four groups based on an underlying genetic correlation structure. Aiming to understand which genetic loci contribute to susceptibility to upper respiratory diseases in general and its subtypes, we detect 41 independent genome-wide significant loci, distinguishing impact on sinonasal or pharyngeal diseases, or both. Fine-mapping implicated non-synonymous variants in nine genes, including three linked to immune-related diseases. Phenome-wide analysis implicated asthma and atopic dermatitis at sinonasal disease loci, and inflammatory bowel diseases and other immune-mediated disorders at pharyngeal disease loci. Upper respiratory diseases also genetically correlated with autoimmune diseases such as rheumatoid arthritis, autoimmune hypothyroidism, and psoriasis. Finally, we associated separate gene pathways in sinonasal and pharyngeal diseases that both contribute to type 2 immunological reaction. We show shared heritability among upper respiratory diseases that extends to several immune-mediated diseases with diverse mechanisms, such as type 2 high inflammation.

Multidisciplinary approaches to identifying and managing global airways disease: Expert recommendations based on qualitative discussions

Background

Chronic rhinosinusitis with nasal polyps (CRSwNP) and asthma frequently co-exist and share pathologic features. Taking a "global" treatment approach benefits diagnosis and treatment of both, but care is often siloed by specialty: joined-up clinics are uncommon. Our objectives were to explore expert opinion to give practical suggestions to identify adults needing global airways care; enhance cross-specialty working; and widen knowledge to support diagnosis and management, integrate with existing care pathways, and supplement existing guidelines.

Methods

Sixteen practicing physicians from northern Europe were invited for their national and/or international standing in treating asthma and/or chronic rhinosinusitis. Appreciative Inquiry techniques were used to guide their discussions.

Results

Key themes arising were screening and referral, collaboration on management, awareness and education, and research. Provided are screening criteria and suggestions for specialist referrals, and pointers for physicians to optimize their knowledge of global airways disease. Collaborative working is underscored, and practical suggestions are given for multidisciplinary teamworking within global airways clinics. Research gaps are identified.

Conclusion

This initiative provides practical suggestions for optimizing the care of adults with CRSwNP and asthma. Discussion of the role of allergy and drug exacerbations on these conditions, and care for patients with other global airways diseases were beyond scope; however, we expect some principles of our discussion will likely benefit patients with related conditions. The suggestions bridge asthma and CRSwNP management guidelines, envisioning interdisciplinary, global airway clinics relevant to various clinical settings. They highlight the value of joint screening for early recognition and referral of patients.

Persistent Asthma at School Age: Associated Factors in Preschool Children with Asthma

Most patients with childhood asthma present their first symptoms at preschool age. Identifying modifiable risks and protective factors at an early age may help develop asthma prevention and control strategies. This study aimed to identify factors at preschool age that are associated with persistent asthma at school age. This retrospective observational study included preschool children with asthma from 2015 to 2020 at a university hospital in Southern Thailand. In total, 189 eligible participants (70.9% boys; median age, 7.6 [6.7, 8.5] years) were included. Wheeze characteristics included early transient wheeze, persistent wheeze, and late-onset wheeze that accounted for 55%, 27.5%, and 19.5% of the patients, respectively. Approximately 20% of the participants had persistent asthma. Breastfeeding was a protective factor (odds ratio [OR] 0.4 [0.2, 0.9], p = 0.04). The modifiable risk factors were siblings living in the same household (OR 2.6 [1.1, 6.2], p = 0.02) and residence in an industrial area (OR 3.8 [1.4, 10.5], p = 0.009). Additionally, presence of allergic rhinitis was associated with an increased risk of persistent asthma at school age (OR 3.6 [1.6, 8.2], p = 0.002). Early therapeutic interventions targeting modifiable factors provide a window of opportunity to prevent persistent asthma at school age.

The Utility of Nasal Challenges to Phenotype Asthma Patients

Asthma is a heterogeneous disease in terms of both phenotype and response to therapy. Therefore, there is a great need for clinically applicable tools allowing for improved patient classification, and selection for specific management approaches. Some interventions are highly helpful in selected patients (e.g., allergen immunotherapy or aspirin desensitization), but they are costly and/or difficult to implement. Currently available biomarkers measurable in peripheral blood or exhaled air display many limitations for asthma phenotyping and cannot identify properly the specific triggers of the disease (e.g., aeroallergens or NSAID). The united airway concept illustrates the relevant epidemiological and pathophysiological links between the upper and lower airways. This concept has been largely applied to patient management and treatment, but its diagnostic implications have been less often explored. Of note, a recent document by the European Academy of Allergy and Clinical Immunology proposes the use of nasal allergen challenge to confirm the diagnosis of allergic asthma. Similarly, the nasal challenge with lysine acetylsalicylate (L-ASA) can be used to identify aspirin-sensitive asthma patients. In this review, we will summarize the main features of allergic asthma and aspirin-exacerbated respiratory disease and will discuss the methodology of nasal allergen and L-ASA challenges with a focus on their capacity to phenotype the inflammatory disease affecting both the upper and lower airways.

Pharmacological Benefits of Triphala: A Perspective for Allergic Rhinitis

Allergic rhinitis (AR) is considered a major nasal condition impacting a large number of people around the world, and it is now becoming a global health problem. Because the underlying mechanisms of AR are complex, the development of single-drug treatment might not be enough to treat a wide spectrum of the disease. Although the standard guidelines classify and provide suitable diagnosis and treatment, the vast majority of people with AR are still without any means of controlling it. Moreover, the benefits of AR drugs are sometimes accompanied by undesirable side effects. Thus, it is becoming a significant challenge to find effective therapies with limited undesirable side effects for a majority of patients suffering from uncontrolled AR. Aller-7/NR-A2, a polyherbal formulation, has revealed promising results in patients by reducing nasal symptoms and eosinophil counts without serious adverse effects. Interestingly, three out of seven of the herbals in the Aller-7/NR-A2 formulation are also found in an Ayurvedic polyherbal formulation known as “Triphala,” which is a potential candidate for the treatment of AR. However, there are no current studies that have examined the effects of Triphala on the disease. This review aims to describe the complexity of AR pathophysiology, currently available treatments, and the effects of Triphala on AR in order to help develop it as a promising alternative treatment in the future.

Nasal polyp eosinophilia and FeNO may predict asthma symptoms development after endoscopic sinus surgery in CRS patients without asthma

BACKGROUND

Asthma is a significant comorbidity of eosinophilic chronic rhinosinusitis (CRS). Type2-driven biomarkers such as sinus tissue eosinophilia and fractional nitric oxide (FeNO) may be utilized to detect high risk patients who develop asthma symptoms after endoscopic sinus surgery (ESS) in CRS patients.

METHODS

Thirty-six CRS patients without asthma who agreed to undergo ESS between October 2015 and December 2017 were prospectively observed for 12 months following ESS. They were monitored for the development of typical asthma symptoms including dyspnea, wheezes, and cough which responded to anti-asthma medication. Biomarkers were compared between patients who developed asthma symptoms after ESS (asthma symptoms group) and those who did not (non-asthma group). Biomarker changes following ESS intervention were also evaluated.

RESULTS

Six patients were lost to follow after ESS. Thus, 30 CRS patients [16 with nasal polyps (NPs) proved by surgery] were followed. Seven (23%) newly complained of asthma symptoms during follow-up. Levels of FeNO and the prevalence of eosinophilic NPs (eosinophils ≥ 70/high power fields) were significantly higher in the asthma symptom group than in non-asthma group [50.7 ppb vs 22.4 ppb for FeNO levels, and 100% (n = 3) vs 23% (n = 3) for eosinophilic NP prevalence, both p < 0.05]. Levels of sputum periostin decreased significantly by ESS in the non-asthma group. However, changes of biomarkers after ESS were comparable between the two groups.

CONCLUSIONS

Eosinophils in NPs (≥70/high power fields) and preoperative FeNO may be significant biomarkers for predicting the development of asthma symptoms after ESS.

Nasal nitric oxide in relation to asthma characteristics in a longitudinal asthma cohort study

OBJECTIVE

Cross-sectional studies report relations between low nasal nitric oxide (nNO) and poor asthma control and between low nNO and chronic rhinosinusitis (CRS). In our cohort study, we studied if changes in nNO related to changes in asthma control, symptoms of CRS, or asthma or rhinitis medication.

METHODS

A total of 196 subjects with predominantly mild to moderate asthma, aged 10-35 years, performed nNO measurements at both baseline and follow-up after a median of 43 (range 23-65) months. Asthma control, CRS symptoms, and medication, were questionnaire-assessed at both timepoints. IgE sensitisation against aeroallergens was quantified at baseline.

RESULTS

There was an increase in nNO between baseline and follow-up (764 ± 269 ppb vs. 855 ± 288 ppb, p < 0.001). When adjusted for covariates, a larger increase in nNO was found in subjects sensitised to perennial aeroallergens than those not sensitised (92 (16-167) ppb), as well as in subjects with daily use of inhaled corticosteroids (ICS) at baseline but not at follow-up than those on ICS daily at both timepoints (146 (51-242) ppb). In the same model, subjects using nasal steroids daily at both timepoints had decreased nNO compared with those without such treatment at both timepoints (-185 (-321-(-48)) ppb). No relations between changes in nNO levels and changes in asthma control or symptoms of CRS were found.

CONCLUSION

Longitudinal changes in nNO were not related to changes in asthma control, but were related to changes in asthma or rhinitis medication.

Tonsillectomy does not reduce asthma in children: A longitudinal follow-up study using a national sample cohort

This study aimed to investigate the occurrence of tonsillectomy in asthmatic children using a control group with a comparable frequency of a preoperative history of asthma. Asthmatic children ≤15 years old were collected from the Korean Health Insurance Review and Assessment Service - National Sample Cohort (HIRA-NSC) from 2002 through 2013. In study I, asthmatic children who had undergone a tonsillectomy (n = 2,326) and control I participants (n = 9,304) were selected and matched 1:4 for age, sex, income, and region of residence but not a preoperative history of asthma. In study II, a preoperative history of asthma was additionally matched for between the tonsillectomy (n = 2,280) and the new control II participants (n = 9,120). The margin of equivalence of difference (control-tonsillectomy) for asthma was set at -0.05 to 0.05 per year. In addition, repeated measures ANOVA was performed for tonsillectomy according to yearly changes in asthma, status asthmaticus, and admission. In study I, the preoperative frequencies of asthma, status asthmaticus, and admission were higher in the tonsillectomy group than in the control group (P ≤ 0.001). The frequencies of postoperative asthma, status asthmaticus, and admission were lower in the tonsillectomy group than in the control I group for 3 years. In study II, the frequencies of postoperative 1-, 2-, and 3-year asthma and admission were not lower in the tonsillectomy group than in the control II group. Tonsillectomy did not further reduce the frequency of asthma in patients who underwent this procedure compared to the control group when a preoperative history of asthma history was equally matched between the two groups.

The effects of endoscopic sinus surgery on pulmonary function in chronic rhinosinusitis patients with asthma: a systematic review and meta-analysis

PURPOSE

Evidences showed improvements in clinical asthma outcomes following endoscopic sinus surgery (ESS) in chronic rhinosinusitis (CRS) patients with asthma. However, pulmonary function benefits have remained controversial up to date. The goal of this study was to conduct a systematic review and meta-analysis to investigate the effects of ESS on pulmonary function tests in CRS patients with asthma.

METHODS

Pubmed, Embase and Cochrane Library were searched up to March 2018 to obtain relevant studies. The researches that evaluated the effects of ESS on pulmonary function in CRS patients with asthma and had at least one parameter of pulmonary function tests before and after surgery were included in the study.

RESULTS

A total of 13 studies containing 421 patients satisfied the eligibility after judgment by 2 reviewers. These included three RCTs and ten case series. The heterogeneity in parameters of spirometry and difference in data presented forms across studies along with the lack of standard deviation of some data make it difficult to synthesize results. If data were unavailable for meta-analyses, descriptive statistics were used to report study outcomes. After qualitative and quantitative analysis, the weighted mean change after ESS in forced expiratory flow between 25% and 75% of vital capacity (FEF25-75%) was 0.21 L/s (95% CI 0.12-0.30); eight of ten studies supported that forced expiratory volume at 1 s (FEV1) improved after ESS; five of six studies supported that peak expiratory flow (PEF) improved after ESS. However, strength of evidence is generally low to insufficient.

CONCLUSION

A generally low-quality evidence supports the association between ESS and improvements in FEF25-75%, FEV1 and PEF. A few studies met inclusion criteria for meta-analysis, which indicates the need for more high-quality studies to determine the effect of ESS.

Does allergy explain why some children have severe asthma?

Asthma is a common disease in childhood with a minority of affected children having severe therapy-resistant asthma (STRA). Children with STRA can be differentiated from those with mild-moderate disease by greater allergic sensitization, increased eosinophilic airway inflammation, increased airway remodelling and reduced corticosteroid responsiveness. The aetiology of STRA in children is multifactorial but allergy seems to play a key role. Many children with asthma have coexisting allergic disease, and severe rhinitis seems to be an important driver of STRA in children. Allergies to foods, moulds, pollen and pets have also been associated with severe asthma exacerbations. Identifying allergens that are driving asthma symptoms in children with STRA may provide additional strategies for improving their disease control. Avoidance strategies may be possible. Additional monoclonal antibody therapy with Omalizumab or Mepolizumab may be helpful in children with clinically important polysensitization.

Upper and lower airway remodelling mechanisms in asthma, allergic rhinitis and chronic rhinosinusitis: The one airway concept revisited

Allergic rhinitis (AR), chronic rhinosinusitis (CRS) and asthma often co-exist. The one airway model proposes that disease mechanisms occurring in the upper airway may mirror lower airway events. Airway remodelling is the term used to describe tissue structural changes that occur in a disease setting and reflect the dynamic process of tissue restructuring during wound repair. Remodelling has been long identified in the lower airways in asthma and is characterized by epithelial shedding, goblet cell hyperplasia, basement membrane thickening, subepithelial fibrosis, airway smooth muscle hyperplasia and increased angiogenesis. The concept of upper airway remodelling has only recently been introduced, and data so far are limited and often conflicting, an indication that more detailed studies are needed. Whilst remodelling changes in AR are limited, CRS phenotypes demonstrate epithelial hyperplasia, increased matrix deposition and degradation along with accumulation of plasma proteins. Despite extensive research over the past years, the precise cellular and molecular mechanisms involved in airway remodelling remain incompletely defined. This review describes our current rather limited understanding of airway remodelling processes in AR, CRS and asthma and presents mechanisms both shared and distinct between the upper and lower airways. Delineation of shared and disease-specific pathogenic mechanisms of remodelling between the sinonasal system and the lung may guide the rational design of more effective therapeutic strategies targeting upper and lower airways concomitantly and improving the health of individuals with inflammatory airway diseases.

A composite of exhaled LTB4 , LXA4 , FeNO, and FEV1 as an "asthma classification ratio" characterizes childhood asthma

BACKGROUND

Aberrant generation of eicosanoids is associated with asthma, but the evidence remains incomplete and its potential utility as biomarkers is unclear. Major eicosanoids in exhaled breath condensates (EBCs) were assessed as candidate markers for childhood asthma.

METHODS

Ten exhaled eicosanoid species was evaluated using ELISA in the discovery phase, followed by prediction model-building and validation phases.

RESULTS

Exhaled LTB₄ , LTE₄ , PGE_2, and LXA₄ showed significant difference between asthmatics (N = 60) and controls (N = 20). For validation, an expanded study population consisting of 626 subjects with asthma and 161 healthy controls was partitioned into a training subset to establish a prediction model and a test sample subset for validation. Receiver operating characteristic (ROC) analyses of the training subset revealed the level of exhaled LTB₄ to be the most discriminative among all parameters, including FeNO, and a composite of exhaled LTB₄ , LXA₄ , together with FeNO and FEV₁ , distinguishing asthma with high sensitivity and specificity. Further, the Youden index (J) indicated the cut point value of 0.598 for this composite of markers as having the strongest discriminatory ability (sensitivity = 85.2% and specificity = 83.6%). The predictive algorithm as "asthma classification ratio" was further validated in an independent test sample with sensitivity and specificity being 84.4% and 84.8%, respectively.

CONCLUSIONS

In a pediatric study population in Taiwan, the levels of exhaled LTB₄ , LTE₄ , LXA_4, and PGE₂ in asthmatic children were significantly different from those of healthy controls, and the combination of exhaled LTB₄ and LXA₄ , together with FeNO and FEV₁ , best characterized childhood asthma.

Airway Diseases Education and Expertise (ADEX ) in Pediatrics: Adaptation for Clinical Practice in India

JUSTIFICATION

Asthma and allergic rhinitis together are part of the concept of one airway, one disease or united airway disease. The management of allergic airway diseases should address this united concept and manage the issue by educating the patients and their parents and health care providers, along with environmental control measures, pharmacotherapy and immunotherapy. Here, we present recommendations from the module of Airway Diseases Education and Expertise (ADEX) that focused on allergic rhinitis, asthma and sleep disorder breathing as a single entity or Allergic Airway Disease.

PROCESS

A working committee was formed by the collaboration of Pediatric Allergy Association of India (PAAI) and Indian Academy of Pediatrics (IAP) Allergy and Applied Immunology chapter to develop a training module on united airway disease.

OBJECTIVE

To increase awareness, understanding and acceptance of the concept of United Airway disease and to educate the primary health care providers for children and public health officials, in the management of united airway diseases.

RECOMMENDATIONS

Recommendations for diagnosis, management and follow-up of Allergic airway disease are presented in this document. A better compliance by linking education of child, parent, grandparents and other health care providers, and scientific progress by collaboration between practitioners, academicians, researchers and pharmaceutical companies is suggested.

Mouth breathing, another risk factor for asthma: the Nagahama Study

BACKGROUND

Allergic rhinitis, a known risk factor for asthma onset, often accompanies mouth breathing. Mouth breathing may bypass the protective function of the nose and is anecdotally considered to increase asthma morbidity. However, there is no epidemiological evidence that mouth breathing is independently associated with asthma morbidity and sensitization to allergens. In this study, we aimed to clarify the association between mouth breathing and asthma morbidity and allergic/eosinophilic inflammation, while considering the effect of allergic rhinitis.

METHODS

This community-based cohort study, the Nagahama Study, contained a self-reporting questionnaire on mouth breathing and medical history, blood tests, and pulmonary function testing. We enrolled 9804 general citizens of Nagahama City in the Shiga Prefecture, Japan.

RESULTS

Mouth breathing was reported by 17% of the population and was independently associated with asthma morbidity. The odds ratio for asthma morbidity was 1.85 (95% CI, 1.27-2.62) and 2.20 (95% CI, 1.72-2.80) in subjects with mouth breathing alone and allergic rhinitis alone, which additively increased to 4.09 (95% CI, 3.01-5.52) when mouth breathing and allergic rhinitis coexisted. Mouth breathing in nonasthmatics was a risk for house dust mite sensitization, higher blood eosinophil counts, and lower pulmonary function after adjusting for allergic rhinitis.

CONCLUSION

Mouth breathing may increase asthma morbidity, potentially through increased sensitization to inhaled allergens, which highlights the risk of mouth-bypass breathing in the 'one airway, one disease' concept. The risk of mouth breathing should be well recognized in subjects with allergic rhinitis and in the general population.

Comorbidities of asthma and the unified airway

BACKGROUND

Asthma is a comorbid condition that may be seen by otolaryngic allergists when treating their patients with allergic rhinitis (AR). Often asthma is overlooked when aggressive treatment could prevent the development or progression of early disease.

METHODS

This article is a retrospective review of the current literature on asthma as a comorbidity of the unified airway. The unified airway and asthma are clearly defined. The epidemiology, morbidity, mortality, pathophysiologic mechanisms, and the chronicity of asthma are reviewed.

RESULTS

The otolaryngic allergist will become familiar the unified airway concept and the close relationships between AR, chronic rhinosinusitis, and asthma.

CONCLUSION

Otolaryngologists should be aware of the unified airway in order to most effectively treat their patients with AR. Knowledge of the close relationships between asthma and AR will help prevent progression of disease, identify early asthma, and improve the outcomes and quality of life for our patients.

Exhaled particles as markers of small airway inflammation in subjects with asthma

Exhaled breath contains suspended particles of respiratory tract lining fluid from the small airways. The particles are formed when closed airways open during inhalation. We have developed a method called Particles in Exhaled air (PExA^® ) to measure and sample these particles in the exhaled aerosol. Here, we use the PExA^® method to study the effects of birch pollen exposure on the small airways of individuals with asthma and birch pollen allergy. We hypothesized that birch pollen-induced inflammation could change the concentrations of surfactant protein A and albumin in the respiratory tract lining fluid of the small airways and influence the amount of exhaled particles. The amount of exhaled particles was reduced after birch pollen exposure in subjects with asthma and birch pollen allergy, but no significant effect on the concentrations of surfactant protein A and albumin in exhaled particles was found. The reduction in the number of exhaled particles may be due to inflammation in the small airways, which would reduce their diameter and potentially reduce the number of small airways that open and close during inhalation and exhalation.

Bronchoabsorption; a novel bronchoscopic technique to improve biomarker sampling of the airway

Background

Current techniques used to obtain lung samples have significant limitations and do not provide reproducible biomarkers of inflammation. We have developed a novel technique that allows multiple sampling methods from the same area (or multiple areas) of the lung under direct bronchoscopic vision. It allows collection of mucosal lining fluid and bronchial brushing from the same site; biopsy samples may also be taken. The novel technique takes the same time as standard procedures and can be conducted safely.

Methods

Eight healthy smokers aged 40–65 years were included in this study. An absorptive filter paper was applied to the bronchial mucosa under direct vision using standard bronchoscopic techniques. Further samples were obtained from the same site using bronchial brushings. Bronchoalveolar lavage (BAL) was obtained using standard techniques. Chemokine (C-C Motif) Ligand 20 (CCL20), CCL4, CCL5, Chemokine (C-X-C Motif) Ligand 1 (CXCL1), CXCL8, CXCL9, CXCL10, CXCL11, Interleukin 1 beta (IL-1β), IL-6, Vascular endothelial growth factor (VEGF), Matrix metalloproteinase 8 (MMP-8) and MMP-9 were measured in exudate and BAL. mRNA was collected from the bronchial brushings for gene expression analysis.

Results

A greater than 10 fold concentration of all the biomarkers was detected in lung exudate in comparison to BAL. High yield of good quality RNA with RNA integrity numbers (RIN) between 7.6 and 9.3 were extracted from the bronchial brushings. The subset of genes measured were reproducible across the samples and corresponded to the inflammatory markers measured in exudate and BAL.

Conclusions

The bronchoabsorption technique as described offers the ability to sample lung fluid direct from the site of interest without the dilution effects caused by BAL. Using this method we were able to successfully measure the concentrations of biomarkers present in the lungs as well as collect high yield mRNA samples for gene expression analysis from the same site. This technique demonstrates superior sensitivity to standard BAL for the measurement of biomarkers of inflammation. It could replace BAL as the method of choice for these measurements. This method provides a systems biology approach to studying the inflammatory markers of respiratory disease progression.

Trial registration

NHS Health Research Authority (13/LO/0256).

The effect of exercise on exhaled nitric oxide depends on allergic rhinoconjunctivitis in children

OBJECTIVE

Fractional exhaled nitric oxide (FENO) and exercise testing are widely used for the evaluation of pediatric asthma. The evidence relating to the effects of strenuous exercise on FENO in children is conflicting. Little information is available on the association between exercise and FENO in relation to allergic rhinoconjunctivitis (AR). We aimed to investigate the effects of AR on children's FENO in response to a standardized treadmill exercise test.

METHODS

A total of 124 children with current asthma and 124 non-asthmatic children aged 8-16 years were studied. FENO was measured at baseline, at 1 and 30 min after an exercise challenge test using the single breath technique with EcoMedics Exhalyzer. A structured parental interview, spirometry, serum allergen-specific IgE and skin prick tests were performed.

RESULTS

Baseline FENO was higher in both asthmatics and non-asthmatics with AR than without AR (both p < 0.001). The FENO time trend was dependent on AR (p = 0.039), irrespective of asthma (p = 0.876). In children with AR, FENO had declined at 1 min by a mean of 6.1 ppb with a 95% confidence level of 5.1-7.5 ppb; at 30 min, the reduction was 2.8 (2.5-3.3) ppb. In children without AR, at 1 min the decline in FENO was 2.7 (2.1-3.5) ppb and by 30 min post-exercise it was 1.6 (1.3-2.0) ppb.

CONCLUSIONS

The impact of exercise on FENO was dependent on the allergic phenotype, regardless of asthma status. FENO decreased immediately after exercise, and did not return to baseline level within 30 min.

Establishing IMMULITE® 2000 cut-off values for serum allergen-specific immunoglobulin and exploring their relationship to exhaled nitric oxide

Aim

Paediatric cut-off values for serum allergen-specific IgE (sIgE) using the Siemens IMMULITE® 2000 system to diagnose allergic rhinoconjunctivitis have not been established. We aimed to determine cut-off levels for sIgE for 10 common inhalant allergens and to study the relationship between sIgE, total IgE and fractional exhaled nitric oxide (FE_NO).

Methods

We enrolled 243 schoolchildren, including 164 with allergic rhinoconjunctivitis. Parental interviews, skin prick tests, sIgE, total IgE, FE_NO measurements, spirometry and exercise tests were performed.

Results

Cut-off values with the best combined sensitivity and specificity were above the detection limit of the assay for seven of the ten allergens (0.23–1.1 kU/L). The overall accuracy of the IMMULITE® in detecting allergic rhinoconjunctivitis was good. sIgE was superior to total IgE and FE_NO in predicting allergic rhinoconjunctivitis to timothy, birch, mugwort, cat, dog and house dust mite. FE_NO was elevated in children with allergic rhinoconjunctivitis, irrespective of asthma.

Conclusion

Cut-off values for sIgE were dependent on the allergic phenotype and were above the IMMULITE® detection limit for seven of ten inhalant allergens. Consequently, using the detection limit for sIgE as the decision point would result in over-diagnosing allergic rhinoconjunctivitis. When measuring elevated FE_NO in children, allergic rhinoconjunctivitis should be suspected.

Allergic sensitization to perennial allergens in adults and children sensitized to Japanese cedar or Japanese cypress pollen in Japan

In Japan, seasonal allergic rhinitis in the spring due to exposure to Japanese cedar or Japanese cypress pollen is common. However, the allergic profile for perennial allergens in spring pollinosis remains unclear. Therefore, in this study, we investigated the allergic profiles of 652 patients with rhinitis. Total serum IgE, serum-specific IgE, and blood eosinophil counts were measured. Allergic sensitization, determined by the serum allergen-specific IgE level, did not always correspond with the patient's symptoms. Only 27% of patients with allergic symptoms in response to spring pollens were sensitized to these allergens alone; 31% of patients were also sensitized to perennial allergens, even without symptoms due to perennial allergens. Total serum IgE and eosinophil cell counts were significantly elevated in patients sensitized to perennial allergens and spring pollens, as compared to patients sensitized only to spring pollens. Most children sensitized to spring pollen (84%) were sensitized to perennial allergens, at a higher rate than adults (49%). Patients sensitized to spring pollens are likely to be latently sensitized to perennial allergens. This is especially true for children and should be monitored closely. Improvement in seasonal allergic conditions, including latent perennial allergy, is important to prevent symptoms that could advance to asthma.

Improvement in asthma control and inflammation in children undergoing adenotonsillectomy

BACKGROUND

Observational studies suggest that asthma control improves after adenotonsillectomy, but longitudinal studies that correlate the effect of the procedure on the levels of biomarkers associated with airway inflammation are limited.

METHODS

We conducted a longitudinal, observational study on pediatric patients, both with and without asthma, undergoing adenotonsillectomy. Asthma control test (ACT) scores and chitinase activity in the circulation were measured at time of surgery and at 6-mo follow-up.

RESULTS

Sixty-six children with asthma and 64 control subjects were enrolled. Mean ACT scores improved by three points (P < 0.001) after 6 mo. 85% of children with poorly controlled asthma demonstrated an increase in ACT score of at least three points or a decrease in emergency department/urgent care visits, oral corticosteroid courses, or rescue short acting bronchodilator usage. Chitinase activity decreased significantly in asthmatics who improved (P < 0.01). Higher chitinase activity levels at baseline were associated with improved asthma control following surgery (P < 0.01).

CONCLUSION

In children with high preoperative circulating chitinase activity levels, asthma control and healthcare utilization were significantly improved after adenotonsillecotmy. Chitinase activity decreased after surgery in children with improved control. This suggests that adenotonsillectomy modulates chitinase activity, affecting airway inflammation and improving airway disease.

Sinusitis, Rhinitis, Asthma, and the Single Airway Hypothesis

The one airway, one disease hypothesis proposes that the upper and lower airways share the same physiology and histomorphology. Epidemiological clinical studies support a link between rhinosinusitis and asthma. The relationship can occur in both directions, with nasal allergen challenge leading to inflammatory changes in the lower airway and bronchoprovocation studies of the lower airway leading to inflammatory changes in the upper airway. In addition, both similarities and differences exist in the pathogenesis of nasal polyps and asthma. The mechanism for the connection between the upper and lower airways is a matter of great debate. It has been proposed that inflammatory changes in the lower airway may lead to systemic inflammatory effects that play a role in increased bronchial hyperresponsiveness. Similarly, lower airway inflammatory changes may affect nasal airway patency via systemic effects. Moreover, nasopharyngeal-bronchial reflexes may play a non-immunologic role in the interaction between the lower and upper airways. An example of the connection between the upper and lower airways is found in aspirin-exacerbated respiratory disease whereby leukotrienes play a role in the pathology of chronic rhinosinusitis with polyps and asthma. It is also been observed that the treatment of asthma is hindered by untreated rhinosinusitis.

Prevalence and clinical relevance of allergic rhinitis in patients with classic asthma and cough variant asthma

BACKGROUND

A clinically relevant relationship between classic asthma and allergic rhinitis has been reported. However, the possible link between cough variant asthma (CVA) and allergic rhinitis remains unknown.

OBJECTIVES

To clarify the prevalence and clinical relevance of perennial allergic rhinitis or seasonal allergic rhinitis in CVA patients compared to classic asthma patients.

METHODS

We retrospectively studied adult patients with classic asthma (n = 190) and those with CVA (n = 83). The prevalence of perennial allergic rhinitis or seasonal allergic rhinitis and associations of concomitant perennial or seasonal allergic rhinitis with asthma severity, forced expiratory volume in 1 s (% predicted), fractional exhaled nitric oxide (FeNO) levels, and eosinophil proportions in sputum and blood were analyzed in the two groups.

RESULTS

The prevalence of perennial allergic rhinitis and/or seasonal allergic rhinitis was significantly higher in classic asthma patients than in CVA patients (all p < 0.05). Concomitant perennial allergic rhinitis was associated with higher FeNO levels and eosinophil proportions in sputum and blood in classic asthma patients (p = 0.035, p = 0.036, and p = 0.008, respectively) and with higher asthma severity, FeNO levels, and sputum eosinophil proportions in CVA patients (p = 0.031, p = 0.007, and p = 0.010, respectively). Concomitant seasonal allergic rhinitis was only associated with higher sputum eosinophil proportions in CVA patients with active rhinitis symptoms during the sensitized pollen season (p = 0.025).

CONCLUSIONS

Perennial allergic rhinitis may be relevant for CVA patients as well as classic asthma patients by consistently augmenting eosinophilic lower airway inflammation.

Pediatric allergic rhinitis and asthma: can the march be halted?

The strong epidemiologic and pathophysiologic link between allergic rhinitis (AR) and asthma has led to the concept of 'united airways disease' or 'respiratory allergy', implying that allergy, in its widest sense, underlies this clinical syndrome. Progression from AR to asthma is frequent and part of the 'atopic march'. Since pediatric immune responses are more adaptable and therefore may be more amenable to treatment, interventions at early childhood are characterized by a higher chance to affect the natural history of respiratory allergy. Although current treatments are quite effective in alleviating respiratory allergy symptoms, it has proven much more difficult to confirm any influence on the progression of the disease. Much more promising is the field of specific allergen immunotherapy, where current evidence, although not yet of ideal robustness, points towards a disease-modifying effect. In addition, newer or emerging, possibly more effective or more targeted interventions are promising in the preventive sense.

One airway: Biomarkers of protection from upper and lower airway injury after World Trade Center exposure

BACKGROUND

Firefighters exposed to World Trade Center (WTC) dust have developed chronic rhinosinusitis (CRS) and abnormal forced expiratory volume in 1 s (FEV1). Overlapping but distinct immune responses may be responsible for the clinical manifestations of upper and lower airway injury. We investigated whether a panel of inflammatory cytokines, either associated or not associated with WTC-LI, can predict future chronic rhinosinusitis disease and its severity.

METHODS

Serum obtained within six months of 9/11/2001 from 179 WTC exposed firefighters presenting for subspecialty evaluation prior to 3/2008 was assayed for 39 cytokines. The main outcomes were medically managed CRS (N = 62) and more severe CRS cases requiring sinus surgery (N = 14). We tested biomarker-CRS severity association using ordinal logistic regression analysis.

RESULTS

Increasing serum IL-6, IL-8, GRO and neutrophil concentration reduced the risk of CRS progression. Conversely, increasing TNF-α increased the risk of progression. In a multivariable model adjusted for exposure intensity, increasing IL-6, TNF-α and neutrophil concentration remained significant predictors of progression. Elevated IL-6 levels and neutrophil counts also reduced the risk of abnormal FEV1 but in contrast to CRS, increased TNF-α did not increase the risk of abnormal FEV1.

CONCLUSIONS

Our study demonstrates both independent and overlapping biomarker associations with upper and lower respiratory injury, and suggests that the innate immune response may play a protective role against CRS and abnormal lung function in those with WTC exposure.

Does allergic rhinitis make a difference to the respiratory resistance and reactance of asthma?

BACKGROUND

Concomitant allergic rhinitis (AR) in asthmatic patients can contribute to increased asthma exacerbations and poorer symptom control. A recent study indicated that impulse oscillometry is a more sensitive measure of change in airway function than spirometry, but this has not been used to compare asthmatic patients with or without AR.

OBJECTIVE

We used impulse oscillometry (Mostgraph-01) to examine the impact of AR on asthma.

METHODS

Impulse oscillometry and spirometry were assessed in 50 patients with asthma only and 95 patients with asthma and AR.

RESULTS

Mean age in the asthma only group was significantly higher than in the asthma with AR group. Therefore, analysis of covariance adjusted for age was used to compare between these two groups. Percentage of mean forced expiratory volume in 1 s (FEV1), respiratory resistance at 5 Hz (R5) minus respiratory resistance at 20 Hz (R20), and resonant frequency (Fres) in the asthma with AR group were significantly less severe than in the asthma only group. Parameters of resistance and reactance were correlated with age and body mass index only in the asthma with AR group but not in the asthma only group. Correlations were observed between rate of change of maximum mid-expiratory flow and impulse oscillometry values of R5 and Fres in the asthma only group, but not between the rate of change of FEV1 and impulse oscillometry values.

CONCLUSION

Asthma with AR was associated with higher lung function and better values of resistance and reactance than asthma only.

Genetics of chronic rhinosinusitis: state of the field and directions forward

The cause of chronic rhinosinusitis (CRS) remains unclear. Study of the genetic susceptibility to CRS might be a valuable strategy to understand the pathogenesis of this burdensome disorder. The purpose of this review is to critically evaluate the current literature regarding the genetics of CRS in a comprehensive fashion. The most promising findings from candidate gene studies include the cystic fibrosis transmembrane conductance regulator gene (CFTR), as well as genes involved in antigen presentation, innate and adaptive immune responses, tissue remodeling, and arachidonic acid metabolism. We also review the few hypothesis-independent genetic studies of CRS (ie, linkage analysis and pooling-based genome-wide association studies). Interpretation of the current literature is limited by challenges with study design, sparse replication, few functional correlates of associated polymorphisms, and inadequate examination of linkage disequilibrium or expression quantitative trait loci for reported associations. Given the relationship of CRS to other airway disorders with well-characterized genetic components (eg, asthma), study of the genetics of CRS deserves increased attention and investment, including the organization of large, detailed, and collaborative studies to advance knowledge of the mechanisms that underlie this disorder.

Effect of nebulized beclomethasone on airway inflammation and clinical status of children with allergic asthma and rhinitis: a randomized, double-blind, placebo-controlled study

We aimed to evaluate the therapeutic effect of nebulized beclomethasone dipropionate (nBDP) on both allergic asthma and rhinitis. In a randomized, double-blind, placebo-controlled study, 40 children (mean age 10.7 ± 2.1 years) with allergic asthma and rhinitis received either nBDP (daily dose of 800 µg, administered twice daily) or placebo for 4 weeks (with a face mask), after a 2-week run-in period of clinical assessment. Nasal and oral fractional exhaled nitric oxide (FeNO) measurements together with pulmonary function tests, nasal and oral exhaled breath condensate (EBC) collection for pH and interleukin-5 (IL-5) measurements as well as nasal and bronchial symptom scores were obtained at baseline and after 4-week treatment. A significant improvement in oral FeNO, oral and nasal EBC IL-5 and nasal EBC pH was observed in the nBDP group when comparing the values with baseline, together with an improvement in symptom score of the visual analogue scale, nasal obstruction, sneezing, rhinorrhea, breathing difficulty, cough, wheezing and sleep disturbance (nBDP end treatment vs. baseline, Wilcoxon signed-rank test). nBDP was more effective than placebo (ANCOVA test) in improving [difference Δ = response after treatment at the last visit (active or placebo) - value at baseline] nasal pH, oral IL-5, oral FeNO, forced expiratory volume in 1 s, forced expiratory volume in 1 s/forced vital capacity, peek expiratory flow, visual analogue scale, breathing difficulty, cough, wheezing and sleep disturbance scores. No differences were observed between the nBDP and the placebo group for symptom score of rhinitis. nBDP is a useful treatment for airway inflammation and clinical status in children with concomitant allergic asthma and rhinitis.

Nasal mucosa temperature as a marker of disease in children with allergic rhinitis

BACKGROUND

Allergic rhinitis (AR) is a symptomatic disorder of the nose induced after allergen exposure by an IgE-mediated inflammation of the nasal mucosa. This study was designed to investigate the role of nasal mucosa temperature in AR.

METHODS

We investigated the relationship between eosinophilic infiltration, nasal obstruction, and nasal mucosa temperature in 35 children with rhinitis aged 6-12 years.

RESULTS

A significant relationship was shown between nasal temperature values and eosinophil infiltration at nasal cytology (p < 0.01). Nasal temperature was also significantly associated with nasal obstruction, assessed in terms of nasal volume (Vol [2-5 cm]; p < 0.05) and minimum cross-sectional area (p < 0.01). No significant correlation emerged between the degree of nasal obstruction and presence of eosinophils at nasal cytology (p > 0.05).

CONCLUSION

These results suggest a relationship between nasal temperature and nasal mucosa inflammation and obstruction.

The interest of FEF(25-75) in evaluating bronchial hyperresponsiveness with the methacholine test

BACKGROUND

Bronchial hyperresponsiveness is the pathogenic basis of asthma, and measurement of its intensity is investigated using the methacholine provocation test, which not only and particularly evaluates the reduction in FEV1 (PD20) but also takes forced mid-expiratory flow or FEF(25-75) (PD40) into account. The present study aims to evaluate the usefulness of both parameters.

MATERIAL AND METHODS

Provocation testing was carried out in 151 patients between 7 and 22 years of age diagnosed with asthma, tracheobronchitis and/or rhinitis, using a short method that allows quantification of the methacholine administered. The subjects were divided into three groups according to the amount of methacholine needed to obtain the mentioned parameters (group 1: ≤1000μg; group 2: 1001-2000μg; group 3: ≥2001μg).

RESULTS

Greater variability was recorded for FEF(25-75) than for FEV1. Paired comparison among the three groups for FEV1 proved significant, in the same way as for FEF(25-75) between groups 2 and 3, and 1 and 3, but not between groups 1 and 2. Calculation was made of the amount of methacholine required to obtain PD20 and PD40 from the same dose. Only the significant differences corresponded to the comparison of group 1 versus the rest, with no differences between the means of the total mean values.

CONCLUSIONS

The utility of PD20 is more evident, considering the variability of PD40; the latter may be useful in patients with rhinitis or tracheobronchitis when PD20 proves scantly demonstrative.

Poor asthma control?--then look up the nose. The importance of co-morbid rhinitis in patients with asthma

Many factors can impair asthma control. One which is frequently overlooked is rhinitis. Asthma patients with significant rhinitis are over four times more likely to have poorly controlled asthma than those without. Over 80% of patients with asthma have rhinitis, which may be allergic or inflammatory/non-allergic. Both types of rhinitis share pathophysiological similarities with eosinophilic asthma, cause bronchial hyper-reactivity, and are predisposing factors for the subsequent development of asthma. Nasal allergen challenge in allergic rhinitis results in inflammation in the bronchi as well as the nose, and the reverse is also true. This article reviews briefly the evidence for the link between asthma and rhinitis, advocates looking for rhinitis when patients present with poorly controlled asthma, and provides guidance for the diagnosis and treatment of rhinitis.

Systemic up-regulation of TLR4 causes lipopolysaccharide-induced augmentation of nasal cytokine release in allergic rhinitis

BACKGROUND

Allergic rhinitis is a systemic disorder, and it is clinically well recognized that it can be aggravated by infection. Activation of the innate immune system constitutes a critical element in the process. Toll-like receptors (TLRs) comprise a part of the innate immune system, and lipopolysaccharide (LPS)-induced activation of TLR4 represents bacterial-induced interactions in various model systems. The present study examines how TLR2 and TLR4 expression is affected by symptomatic allergic rhinitis, and if LPS added upon allergen affects nasal cytokine release.

METHODS

In patients with pollen-induced allergic rhinitis and healthy non-allergic volunteers, nasal lavage (NAL), peripheral blood and bone marrow were sampled before and during the pollen season. TLR2 and TLR4 expression was determined flow cytometrically. Changes in the TLR receptor expression pattern were evaluated by a nasal challenge with allergen followed by LPS, or vice versa. Symptoms along with cells and cytokines in NAL were analyzed.

RESULTS

TLR4 expression increased in leukocytes in NAL, peripheral blood and bone marrow during symptomatic allergic rhinitis. A similar increase was seen for TLR2 in neutrophils in blood. Nasal challenge with allergen followed by LPS augmented the release of IL-4, IL-5, IL-10, IL-13, IFN-γ and TNF-α.

CONCLUSION

A systemic up-regulation of TLR4 in symptomatic allergic rhinitis may explain why LPS preceded by allergen increases nasal cytokine release.

The relationship of rhinitis and asthma, sinusitis, food allergy, and eczema

Epidemiologic, genetic, immunologic, and clinical studies show a close relationship between allergic rhinitis and asthma, food allergy, and atopic dermatitis. Rhinitis and sinusitis often coexist and are commonly referred to with the term rhinosinusitis. These conditions are also linked in the so-called atopic march, which is the sequential appearance of atopic manifestations starting with atopic dermatitis and later followed by food allergy, allergic rhinitis, and asthma. Allergic rhinitis and asthma are now increasingly being approached diagnostically and therapeutically as the one-airway concept.

Novel perspectives in the detection of oral and nasal oxidative stress and inflammation in pediatric united airway diseases

United airway disease (UAD) concept proposed that asthma and rhinitis are both different clinical manifestation of a single inflammatory process. The aim of this study is to assess in upper and lower airways the level of inflammation and oxidative stress and to investigate the relationship between biomarkers in persistent allergic rhinitis (PER) and in concomitant asthma with PER. By a crosssectional study we measured oral and nasal (FENO) and oral and nasal EBC 8-isoprostane, LTB4 and PGE2 in children with PER (n=14) and with PER and concomitant intermittent asthma (IA; n=25), mild persistent asthma (mA; n=28), moderate persistent asthma (MA; n=13) and in Healthy Controls (HCs; n=13). Oral and nasal FENO concentrations were increased in children with PER, IA, mA and MA when compared with HCs. Nasal 8-isoprostane was higher in EBC of children with PER and asthma than in HCs. Oral and nasal LTB4 were higher in EBC of children with PER and mA than in HCs. Oral and nasal PGE2 concentrations were higher in EBC of children with PER than in HCs. Positive correlations between oral and nasal biomarkers were found in IA for LTB4 and PGE2, in mA for FENO, 8-isoprostane, LTB4 and PGE2, and in MA for PGE2. No correlations were observed in children with PER and HCs. Our results suggest that non-invasive markers of inflammation and oxidative stress might be useful to study the relationships between oral and nasal compartments in allergic children with PER and concomitant asthma with the aim of defining the UAD.

Allergic rhinitis and inflammatory airway disease: interactions within the unified airspace

BACKGROUND

Allergic rhinitis (AR), the most common chronic allergic condition in outpatient medicine, is associated with immense health care costs and socioeconomic consequences. AR's impact may be partly from interacting of respiratory conditions via allergic inflammation. This study was designed to review potential interactive mechanisms of AR and associated conditions and consider the relevance of a bidirectional "unified airway" respiratory inflammation model on diagnosis and treatment of inflammatory airway disease.

METHODS

MEDLINE was searched for pathophysiology and pathophysiological and epidemiologic links between AR and diseases of the sinuses, lungs, middle ear, and nasopharynx.

RESULTS

Allergic-related inflammatory responses or neural and systemic processes fostering inflammatory changes distant from initial allergen provocation may link AR and comorbidities. Treating AR may benefit associated respiratory tract comorbidities. Besides improving AR outcomes, treatment inhibiting eosinophil recruitment and migration, normalizing cytokine profiles, and reducing asthma-associated health care use in atopic subjects would likely ameliorate other upper airway diseases such as acute rhinosinusitis, chronic rhinosinusitis (CRS) with nasal polyposis (NP), adenoidal hypertrophy, and otitis media with effusion.

CONCLUSION

Epidemiological concordance of AR with several airway diseases conforms to a bidirectional "unified airway" respiratory inflammation model based on anatomic and histological upper and lower airway connections. Epidemiology and current understanding of inflammatory, humoral, and neural processes make links between AR and disorders including asthma, otitis media, NP, and CRS plausible. Combining AR with associated conditions increases disease burden; worsened associated illness may accompany worsened AR. AR pharmacotherapies include antihistamines, leukotriene antagonists, intranasal corticosteroids, and immunotherapy; treatments attenuating proinflammatory responses may also benefit associated conditions.

Patients with allergic rhinitis and allergic asthma share the same pattern of eosinophil and neutrophil degranulation after allergen challenge

Background

Patients with allergic rhinitis and allergic asthma demonstrate comparable local and systemic eosinophil inflammation, and yet they present with different clinical pictures. Less is even known about the contribution of neutrophil inflammation in allergic diseases. The aim of the study was to examine the propensity and selectivity of granule release from primed systemic eosinophils and neutrophils in allergic rhinitis and allergic asthma after seasonal and experimental allergen exposure. We hypothesize that the dissimilar clinical manifestations are due to diverse eosinophil and neutrophil degranulation.

Methods

Nine birch pollen allergic patients with rhinitis, eight with asthma and four controls were studied during pollen season and after nasal and bronchial allergen challenge. Eosinophils and neutrophils were incubated in vitro with assay buffer and opsonized Sephadex particles for spontaneous and C3b-induced granule protein release. The released amount of eosinophil cationic protein (ECP), eosinophil peroxidase (EPO) and myeloperoxidase (MPO) was measured by specific radioimmunoassay.

Results

C3b-induced degranulation resulted in increased release of ECP and MPO from primed blood eosinophils and neutrophils in both allergic rhinitis and allergic asthma during pollen season and after both nasal and bronchial challenge (p-values 0.008 to 0.043). After bronchial challenge, the ECP release was significantly higher in the rhinitic group compared to the asthmatic group [19.8 vs. 13.2%, (p = 0.010)]. The propensity for EPO release was weak in all challenge models but followed the same pattern in both allergic groups.

Conclusions

Systemically activated eosinophils and neutrophils have similar patterns of degranulation after allergen exposure in allergic rhinitis and allergic asthma. The released amount of ECP, EPO and MPO was similar in all allergen challenge models in both allergic groups. Our results indicate that other mechanisms than the magnitude of eosinophil and neutrophil inflammation or the degranulation pattern of the inflammatory cells determines whether or not an allergic patient develops asthma.

Allergic rhinitis as a predictor for wheezing onset in school-aged children

BACKGROUND

Rhinitis in older children and adults has been shown to be a predictor for adolescent- and adult-onset asthma. These findings suggest an interaction between the upper and lower airways. Whether rhinitis is a predictor for childhood-onset asthma is unknown.

OBJECTIVE

We sought to investigate whether rhinitis in early childhood is an independent predictor for wheezing between the ages of 5 and 13 years in the German Multicentre Allergy Study birth cohort.

METHODS

The German Multicentre Allergy Study cohort initially included 1314 healthy children. They were followed from birth to the age of 13 years with regular questionnaires and interviews. Specific IgE levels were measured at yearly intervals. Airway hyperresponsiveness was assessed at 7 years.

RESULTS

Allergic rhinitis until the age of 5 years was found to be a predictor for developing wheezing between the ages of 5 and 13 years, with an adjusted relative risk of 3.82 (P < .001). This association was not attributable to the type of sensitization, the severity of sensitization, or atopic dermatitis during the first 2 years of life. In this group of children, 41.5% of all new cases of wheezing occurred among children with preceding allergic rhinitis.

CONCLUSIONS

The first manifestation of allergic rhinitis occurs in preschool children in whom it is a predictor for subsequent wheezing onset. Preschool children with rhinitis might thus benefit from early assessment of allergic sensitization to identify the children at high risk of wheezing.

The role of the gut mucosal immunity in the development of tolerance against allergy to food

PURPOSE OF REVIEW

To provide an overview on the role of gut mucosal immunity in the development of tolerance against allergy to food.

RECENT FINDINGS

The gastrointestinal tract, through innate and specific immunologic factors, acts as a defense against ingested antigens. In addition to the mucous membrane integrity and digestion, numerous specific immunologic cells and mediators orchestrate such defensive mechanisms. In case of food antigens, the outcome is usually in favor of tolerance. Defects in that barrier, however, can lead to the development of aberrant immunologic responses, including hypersensitivity reactions.

SUMMARY

The prevailing evidence is that healthy mucosal immunity plus appropriate feeding regimen during early infancy are in favor of food tolerance. However, in addition to genetic predisposition, development of allergy is facilitated by defects in the gut barrier (immune or nonimmune) and the food allergen load.

Experimental and seasonal exposure to birch pollen in allergic rhinitis and allergic asthma with regard to the inflammatory response

BACKGROUND AND AIMS

Seasonal allergy is an interesting model to study the pathophysiological mechanisms involved in allergic inflammation. However, experimental allergen exposure is easier to perform and standardise. The primary aim of this study was to compare the inflammatory responses to high-dose bronchial challenge and natural exposure during birch pollen season. The second aim was to compare the responses of patients with allergic rhinitis and allergic asthma, respectively to both types of allergen exposure.

METHODS

Fifteen birch pollen-allergic patients (seven with asthma and eight with rhinitis) and five healthy individuals were studied during pollen season and after challenge with birch allergen. Symptoms, medication and peak expiratory flow rate (PEFR) were recorded, and blood samples, spirometry and induced sputum were analysed during season and after challenge.

RESULTS

Patients with allergic asthma demonstrated a greater bronchial responsiveness to bronchial provocation with birch allergen than patients with rhinitis (P = 0.04) whereas no difference was found regarding nasal challenge. No significant association was found between the level of responsiveness and the inflammatory response after seasonal exposure. Seasonal exposure was related to a more marked systemic inflammatory blood-eosinophil increase than bronchial challenge [(median) (0.25 vs 0.11 x 109/L, P = 0.03)] and after nasal challenge, respectively [(median) (0.25 vs 0.04 x 109/L, P = 0.003)]. A significant correlation in eosinophil cationic protein in induced sputum was found between the experimental and seasonal exposure (rho = 0.62, P = 0.02).

CONCLUSIONS

Bronchial allergen challenge with inhalation of birch pollen gives a similar inflammatory response in the airway but less systemic inflammation than seasonal exposure in birch pollen allergic patients with asthma and rhinitis.

Relationship between fractional exhaled nitric oxide and nasal nitric oxide in airways disease

BACKGROUND

Invasive techniques show evidence of a unified allergic airway. Nitric oxide is measured noninvasively from the lungs (fractional exhaled nitric oxide [FeNO]) and nose (nasal nitric oxide [nNO]).

OBJECTIVE

To investigate the relationship between FeNO and nNO in different airway conditions.

METHODS

A total of 227 participants were assessed: 41 healthy volunteers (HVs), 33 patients with asthma, 52 patients with allergic rhinitis (AR), 63 with unified airway disease (UAD), and 38 with nasal polyposis (NP). Correlation and multiple linear regression analyses were performed.

RESULTS

Geometric means (95% confidence intervals) for FeNO were as follows: 14.7 (12.4-17.5) ppb for HVs, 29.0 (22.5-37.4) ppb for asthma patients, 23.1 (19.0-28.1) for AR patients, 27.2 (23.0-32.4) for UAD patients, and 28.5 (21.5-37.8) for NP patients. For nNO, the values were as follows: 878.1 (807.0-955.6) ppb for HVs, 674.1 (557.4-815.1) for asthma patients, 853.3 (778.8-934.8) ppb for AR patients, 763.4 (694.1-839.5) for UAD patients, and 388.6 (317.9-474.9) for NP patients. The nNO was lower in the NP group than the other groups (P < .001). The nNO and FeNO were correlated in the AR patients (r = 0.56; P < .0001) and HVs (r = 0.44; P = .004) but not significantly in the other groups. Multiple linear regression of the whole cohort demonstrated that after diagnosis, age, sex, and inhaled corticosteroids were taken into account nNO had a significant association with FeNO (P = .02).

CONCLUSION

Reduced nNO in NP patients is due to ostiomeatal complex obstruction. FeNO is sensitive to suppression by inhaled corticosteroids. The AR and HV groups have no such confounders; hence, correlation is most evident. Exclusion of confounders reveals a correlation between upper and lower airway inflammation with noninvasive techniques.

Upper and lower airway patency are associated in young children

BACKGROUND

Although allergic rhinitis and asthma frequently coexist, the nature of this association is poorly understood. Therefore, we examined whether upper and lower airway patency are associated.

METHODS

We investigated 221 6-year-old children from the Copenhagen Prospective Study on Asthma in Childhood birth cohort, assessing upper airway patency by acoustic rhinometry before and after alpha-agonist, and lower airway patency by spirometry before and after beta2-agonist. Furthermore, we measured blood eosinophil count, nasal eosinophilia, total IgE, and fraction of exhaled nitric oxide. Associations were investigated by generalized linear models.

RESULTS

Decongested nasal airway patency and post-beta2 FEV(1) were significantly associated (P = .007). The association remained significant after adjustments for sex, body size, FVC, and atopic diseases (beta-coefficient 2.85 cm(3); 95% CI, 0.42 to 5.29; P = .02). Baseline values of upper and lower airway patency were also significantly associated (beta-coefficient 0.89 cm(3); 95% CI, 0.26-1.51; P = .01). In addition, blood eosinophil count and nasal eosinophilia were inversely associated with decongested nasal airway patency, beta-coefficient -0.42 cm(3) (95% CI, -0.77 to -0.07; P = .02) and beta-coefficient -0.47 cm(3) (95% CI, -0.89 to -0.05; P = .03), respectively.

CONCLUSIONS

We found a strong and consistent association between upper and lower airway patency. This may be due to a common pathology, as suggested by the inverse association between decongested nasal airway patency, blood eosinophil count, and nasal eosinophilia. Alternatively, the association between upper and lower airway patency might reflect a physiologic background for the common comorbidity.

Interleukin 17 and RANTES levels in induced sputum of patients with allergic rhinitis after a single nasal allergen challenge

BACKGROUND

Interleukin 17 (IL-17) is produced by T(H)17 cells and was recently implicated in the development of the T(H)2 cell response. RANTES (regulated on activation of normal T cells expressed and secreted), among other chemokines, plays a crucial role in chemotaxis of eosinophils into airway mucosa. According to the "united airway" hypothesis, markers of inflammation in allergic diseases are elevated in the upper and lower airways.

OBJECTIVE

To assess the impact of a single nasal allergen challenge on IL-17 and RANTES levels in induced sputum of patients with allergic rhinitis (AR).

METHODS

Eighteen patients with a history of AR due to grass pollen confirmed by positive skin prick test results and 10 control subjects entered the study. Initially, all the patients underwent sputum induction. A single nasal placebo challenge was performed 24 hours later, with repeated sputum induction 24 hours after challenge. After 4 weeks of washout, these procedures were repeated with allergen challenge. Differential cell counts in sputum were determined, and concentrations of IL-17 and RANTES were measured by means of enzyme-linked immunosorbent assay.

RESULTS

Levels of IL-17 and RANTES significantly increased in sputum of patients with AR after allergen (but not placebo) challenge (P = .03 and P = .007, respectively). Postallergen levels of both cytokines in sputum were positively correlated (r = 0.570, P = .02). Allergen challenge led to increased total inflammatory cell (P = .005) and eosinophil (P = .03) counts in induced sputum of patients with AR.

CONCLUSIONS

Nasal allergen challenge induces the enhanced secretion of IL-17 and RANTES in the lower airways of nonasthmatic patients with AR.

Effect of natural seasonal pollen exposure and repeated nasal allergen provocations on elevation of exhaled nitric oxide

BACKGROUND

Exhaled nitric oxide (FENO) is a marker for allergic airway inflammation. We wondered whether in patients with intermittent allergic rhinitis only (i) natural pollen exposure and (ii) artificial pollen exposure by repeated nasal allergen provocations may lead to an elevation of FENO.

METHODS

In two prospective studies, we compared the FENO of nonatopic controls with the FENO of nonasthmatic individuals with mild intermittent rhinitis to tree and/or grass pollen. Study I: 13 atopic individuals and seven controls had measurements of FENO, blood eosinophils and eosinophilic cationic protein (ECP) before, during and after pollen season. Study II: 16 atopic individuals and 12 controls had nasal allergen provocations on four following days out of pollen season, with daily measurements of FENO before, 2 and 6 h after provocation, and determination of blood eosinophils, ECP and FEV1 at baseline, on days 5 and 10-12.

RESULTS

Natural pollen exposure (study I) caused a significant elevation of FENO in allergic individuals. Nasal allergen provocations (study II) did not elicit a statistically significant rise neither of FENO nor of blood eosinophils between baseline and day 5. However, a subgroup of four individuals with a rise of blood eosinophils during nasal allergen provocations showed also a rise of FENO.

CONCLUSIONS

We suppose that in allergic rhinitis a concomitant reaction of the bronchial system is dependent on a strong local inflammation leading to a generalized immune stimulation.

Objective assessments of allergic and nonallergic rhinitis in young children

BACKGROUND

Allergic and nonallergic rhinitis are common childhood disorders.

OBJECTIVE

To study nasal eosinophilia and nasal airway patency in young children with allergic and nonallergic rhinitis to assess the pathology behind such diagnoses.

METHODS

We investigated 255 children at six years of age from the Copenhagen Prospective Study on Asthma in Childhood birth cohort assessing rhinitis history, specific immunoglobulin E relevant to rhinitis symptoms, nasal eosinophilia and nasal airway patency by acoustic rhinometry before and after decongestion. Associations were studied in a multivariate graphical model corrected for gender, height and nasal steroid usage.

RESULTS

Allergic rhinitis was significantly and directly associated with irreversible nasal airway obstruction (reduced decongested nasal airway patency) (P = 0.004), whereas nonallergic rhinitis was not. Both allergic rhinitis (P = 0.000) and nonallergic rhinitis (P = 0.014) were directly and significantly associated with nasal eosinophilia, but this association was stronger for allergic rhinitis.

CONCLUSION

Allergic rhinitis and nonallergic rhinitis are of different pathologies as suggested from their different associations not only to allergy but importantly also to irreversible nasal airway obstruction and eosinophilic inflammation. Allergic rhinitis was significantly associated with nasal eosinophilia and irreversible nasal airway obstruction suggesting chronic inflammation and structural remodeling of the nasal mucosa in children at the age of 6 years. Nonallergic rhinitis exhibited no change in the nasal airway patency, but some nasal mucosal eosinophilia albeit less than children with allergic rhinitis.

Allergic rhinitis in patients with asthma: the Swiss LARA (Link Allergic Rhinitis in Asthma) survey

OBJECTIVE

To determine the characteristics of asthma (A) and allergic rhinitis (AR) among asthma patients in primary care practice.

RESEARCH DESIGN AND METHODS

Primary care physicians, pulmonologists, and allergologists were asked to recruit consecutive asthma patients with or without allergic rhinitis from their daily practice. Cross-sectional data on symptoms, severity, treatment and impact on quality of life of A and AR were recorded and examined using descriptive statistics. Patients with and without AR were then compared.

RESULTS

1244 asthma patients were included by 211 physicians. Asthma was controlled in 19%, partially controlled in 27% and not controlled in 54%. Asthma treatment was generally based on inhaled corticosteroids (ICS) with or without long acting beta 2 agonists (78%). A leukotriene receptor antagonist (LTRA) was used by 46% of the patients. Overall, 950 (76%) asthma patients had AR (A + AR) and 294 (24%) did not (A - AR). Compared to patients with A - AR, A + AR patients were generally younger (mean age +/- standard deviation: 42 +/- 16 vs. 50 +/- 19 years, p < 0.001) and fewer used ICS (75% vs. 88%, p < 0.001). LTRA usage was similar in both groups (46% vs. 48%). Asthma was uncontrolled in 53% of A + AR and 57% of A - AR patients. Allergic rhinitis was treated with a mean of 1.9 specific AR medications: antihistamines (77%), nasal steroids (66%) and/or vasoconstrictors (38%), and/or LTRA (42%). Rhinorrhoea, nasal obstruction, or nasal itching were the most frequently reported AR symptoms and the greatest reported degree of impairment was in daily activities/sports (55%).

CONCLUSIONS

Allergic rhinitis was more common among younger asthma patients, increased the burden of symptoms and the need for additional medication but was associated with improved asthma control. However, most asthma patients remained suboptimally controlled regardl-ess of concomitant AR.

Rhinitis and onset of asthma: a longitudinal population-based study

BACKGROUND

A close relation between asthma and allergic rhinitis has been reported by several epidemiological and clinical studies. However, the nature of this relation remains unclear. We used the follow-up data from the European Community Respiratory Health Survey to investigate the onset of asthma in patients with allergic and non-allergic rhinitis during an 8.8-year period.

METHODS

We did a longitudinal population-based study, which included 29 centres (14 countries) mostly in western Europe. Frequency of asthma was studied in 6461 participants, aged 20-44 years, without asthma at baseline. Incident asthma was defined as reporting ever having had asthma confirmed by a physician between the two surveys. Atopy was defined as a positive skin-prick test to mites, cat, Alternaria, Cladosporium, grass, birch, Parietaria, olive, or ragweed. Participants were classified into four groups at baseline: controls (no atopy, no rhinitis; n=3163), atopy only (atopy, no rhinitis; n=704), non-allergic rhinitis (rhinitis, no atopy; n=1377), and allergic rhinitis (atopy+rhinitis; n=1217). Cox proportional hazards models were used to study asthma onset in the four groups.

FINDINGS

The 8.8-year cumulative incidence of asthma was 2.2% (140 events), and was different in the four groups (1.1% (36), 1.9% (13), 3.1% (42), and 4.0% (49), respectively; p<0.0001). After controlling for country, sex, baseline age, body-mass index, forced expiratory volume in 1 s (FEV(1)), log total IgE, family history of asthma, and smoking, the adjusted relative risk for asthma was 1.63 (95% CI 0.82-3.24) for atopy only, 2.71 (1.64-4.46) for non-allergic rhinitis, and 3.53 (2.11-5.91) for allergic rhinitis. Only allergic rhinitis with sensitisation to mite was associated with increased risk of asthma independently of other allergens (2.79 [1.57-4.96]).

INTERPRETATION

Rhinitis, even in the absence of atopy, is a powerful predictor of adult-onset asthma.