Impact of allergic rhinitis on asthma: effects on bronchodilation testing

Comorbid allergy and rhinitis and patient-related outcomes in asthma and COPD: a cross-sectional study

Introduction

The study aimed to compare prevalence of comorbid allergic manifestations and rhinitis, allergy testing and associations with patient-related outcomes in patients with asthma and COPD.

Methods

Cross-sectional study of randomly selected Swedish patients with a doctor's diagnosis of asthma (n = 1291) or COPD (n = 1329). Self-completion questionnaires from 2014 provided data on demographics, rhinitis, allergic symptoms at exposure to pollen or furry pets, exacerbations, self-assessed severity of disease and scores from the Asthma Control Test (ACT) and the COPD Assessment Test (CAT), and records were reviewed for allergy tests.

Results

Allergic manifestations were more common in asthma (75%) compared with COPD (38%). Rhinitis was reported in 70% of asthma and 58% of COPD patients. Allergy tests had been performed during the previous decade in 28% of patients with asthma and in 8% of patients with COPD.In patients with asthma; comorbid allergy and rhinitis were both independently associated with increased risk for poor asthma symptom control (ACT < 20) (OR [95% CI] 1.41 [1.05 to 1.87] and 2.13 [1.60 to 2.83]), exacerbations (1.58 [1.15 to 2.17] and 1.38 [1.02 to 1.86]), and self-assessed moderate/severe disease (1.64 [1.22 to 2.18] and 1.75 [1.33 to 2.30]). In patients with COPD, comorbid allergy and rhinitis were both independently associated with increased risk for low health status (CAT ≥ 10) (OR [95% CI] 1.46 [1.20 to 1.95] and 2.59 [1.97 to 3.41]) respectively, with exacerbations during the previous six months (1.91 [1.49 to 2.45] and 1.57 [1.23 to 2.01]), and with self-assessed moderate/severe disease (1.70 [1.31 to 2.22] and 2.13 [1.66 to 2.74]).

Conclusion

Allergic manifestations and rhinitis are more common in asthma than COPD but associated with worse outcomes in both diseases. This highlights the importance of examining and treating comorbid allergy and rhinitis, not only in asthma but also in COPD.

House dust mites-driven allergic rhinitis: could its natural history be modified?

INTRODUCTION

Allergic rhinitis (AR) is the most common IgE-mediated disease. House dust mites (HDMs)-sensitization is the main cause of AR. HDM-driven AR is characterized by a typical natural history consisting of possible progression to asthma. Allergen Immunotherapy (AIT) is, at present, a unique treatment to modify the natural history of allergic diseases. Tablets AIT (TAIT) represents a new era in AIT. There is evidence that TAIT could prevent asthma in AR patients.

AREAS COVERED

The literature search methodology was based on the articles cited by PubMed from 1980 to 2020. AIT's rationale is to restore an immunological and, consequently, clinical tolerance toward the causal allergen. The progression from rhinitis to asthma may be influenced by a relevant risk factor, such as the persistent type 2 inflammation of airways. HDMs are perennial allergens and allergen exposure is the condicio sine qua non to maintain inflammation. AIT could modify the progression toward asthma restoring physiologic immune response to the causal allergen and consequently dampening type 2 inflammation.

EXPERT OPINION

Patients with HDM-driven AR are susceptible to develop asthma over time. Many studies explored this topic. Cross-sectional and longitudinal studies identified some markers which predict the risk of developing asthma. They include bronchial airflow limitation, bronchial hyperresponsiveness, type 2 inflammation, and rhinitis duration. TAIT could block this progression by acting on this vicious circle. Future studies should explore this issue using adequate methodology.

The impact of comorbidities on severe asthma

PURPOSE OF REVIEW

Severe asthma is often associated with numerous comorbidities that complicate disease management and affect patient's outcomes. They contribute to poor disease control and mimic asthma symptoms. Although some comorbidities such as obstructive sleep apnea, bronchiectasis, and chronic obstructive pulmonary disease are generally well recognized, many other may remain undiagnosed but may be detected in an expert specialist setting. The management of comorbidities seems to improve asthma outcomes, and optimizes therapy by avoiding overtreatment. The present review provides recent knowledge regarding the most common comorbidities which are associated with severe asthma.

RECENT FINDINGS

Comorbidities are more prevalent in severe asthma than in mild-to-moderate disease or in the general population. They can be grouped into two large domains: the pulmonary domain and the extrapulmonary domain. Pulmonary comorbidities include upper respiratory tract disorders (obstructive sleep apnea, allergic and nonallergic rhinitis, chronic rhinosinusitis, nasal polyposis) and middle/lower respiratory tract disorders (chronic obstructive pulmonary disease, allergic bronchopulmonary aspergillosis and fungal sensitization, bronchiectasis, dysfunctional breathing). Extrapulmonary comorbidities include anxiety, depression, gastro-esophageal reflux disease, obesity, cardiovascular, and metabolic diseases.

SUMMARY

The identification of comorbidities via multidimensional approach is needed to initiate appropriate multidisciplinary management of patients with severe asthma.

Janus looks both ways: How do the upper and lower airways interact?

Our understanding of the relationship between the upper and lower airways has greatly increased as a consequence of epidemiologic and pharmacologic studies. A consistent body of scientific evidence supports the concept that rhinitis, rhinosinusitis and asthma may be the expression of a common inflammatory process, which manifests at different sites of the respiratory tract, at different times. This paradigm states that allergic reactions may begin at the local mucosa, but tend to propagate along the airway. Central to the allergic diathesis is the eosinophil and its interaction with the airway epithelium. The implications of the interplay between upper and lower airway are not only academic, but also important for diagnostic and therapeutic reasons. Furthermore, there is significant overlap in symptomatology and pathophysiology for childhood sleep disordered breathing (SDB) and asthma. Recent evidence supports an association between these two conditions, but causality has not been demonstrated. Regardless, it is important to recognize the overlap and evaluate for the other condition when one is present. In children with poorly controlled asthma, the presence of SDB may significantly contribute to asthma morbidity and, as such, should be actively excluded. On the other hand, clinical evaluation for asthma should be considered in children with SDB. Future robust longitudinal research is needed to explore the association between upper and lower airway diseases using objective measures in children.

The pragmatic role of FEF25-75 in asymptomatic subjects, allergic rhinitis, asthma, and in military setting

Introduction: The forced expiratory flow between 25% and 75% of forced vital capacity (FEF25-75) is a spirometry parameter that may be useful in many clinical settings. Values <65% of predicted have been defined as abnormal.Areas covered: The current report discusses the clinical value of FEF25-75 in different settingv, namely military medicine, primary care, and specialized clinic. Moreover, the predictive role of FEF25-75 was discussed considering different patients' populations, including patients suffering from allergic rhinitis and/or asthma, as well as normal subjects. The most recent literature concerning the assessment of FEF25-75 in these covered areas was searched.Expert opinion: In clinical practice, impaired values have been defined as a reliable surrogate marker for bronchial airflow limitation associated with early onset of asthma, bronchial hyperresponsiveness, lower airway inflammation, reversibility to bronchodilation testing, allergic sensitization, and uncontrolled asthma. In the military medicine setting, simple spirometry, including FEF25-75, may suggest a series of fruitful information.

Comorbid "treatable traits" in difficult asthma: Current evidence and clinical evaluation

The care of patients with difficult-to-control asthma ("difficult asthma") is challenging and costly. Despite high-intensity asthma treatment, these patients experience poor asthma control and face the greatest risk of asthma morbidity and mortality. Poor asthma control is often driven by severe asthma biology, which has appropriately been the focus of intense research and phenotype-driven therapies. However, it is increasingly apparent that extra-pulmonary comorbidities also contribute substantially to poor asthma control and a heightened disease burden. These comorbidities have been proposed as "treatable traits" in chronic airways disease, adding impetus to their evaluation and management in difficult asthma. In this review, eight major asthma-related comorbidities are discussed: rhinitis, chronic rhinosinusitis, gastroesophageal reflux, obstructive sleep apnoea, vocal cord dysfunction, obesity, dysfunctional breathing and anxiety/depression. We describe the prevalence, impact and treatment effects of these comorbidities in the difficult asthma population, emphasizing gaps in the current literature. We examine the associations between individual comorbidities and highlight the potential for comorbidity clusters to exert combined effects on asthma outcomes. We conclude by outlining a pragmatic clinical approach to assess comorbidities in difficult asthma.

Allergic rhinitis phenotypes based on bronchial hyperreactivity to methacholine

BACKGROUND

Allergic rhinitis (AR) and asthma may be associated, bronchial hyperreactivity (BHR) is quite common in AR patients. Methacholine (MCH) is a stimulus able to elicit BHR, as many other ones. Phenotyping AR is an up-to-date issue.

OBJECTIVE

The aim of this study was to evaluate whether MCH bronchial challenge is able to differentiate patients with AR.

METHODS

A total of 298 patients (277 males, mean age 28.9 years), suffering from AR were evaluated. Sensitization, rhinitis duration, values for bronchial function (forced vital capacity [FVC], forced expiratory volume [FEV]1, forced expiratory flow [FEF]25-75, and FEV1/FVC ratio), MCH bronchial challenge, visual analog scale (VAS) for nasal and bronchial symptoms perception, and fractioned exhaled nitric oxide (FeNO) were evaluated.

RESULTS

BHR-positive patients (22.8%) had significantly more frequent mite allergy (p = 0.025), longer AR duration (p < 0.001), lower FEV1 (p = 0.003), FEV1/FVC (p < 0.001), FEF25-75 (p < 0.001), higher (p < 0.001), and higher VAS values for both nasal and bronchial symptoms (p < 0.001 for both) in comparison with BHR-negative patients. FeNO can be considered a good predictor for BHR in AR patients (area under the curve, 0.90) with 27.0 ppb as cutoff.

CONCLUSIONS

The present study demonstrates that BHR to MCH could define two distinct phenotypes in AR patients. It could be clinically relevant as BHR-positive patients have initial impairment of lung function, impaired FeNO values, and worsening of respiratory symptoms perception.

Increased body mass index and bronchial impairment in allergic rhinitis

BACKGROUND

Several studies have outlined a possible relationship between an increased body mass index (BMI) and respiratory allergic diseases, such as asthma and allergic rhinitis (AR). The aim of this study was to analyze the relationship among BMI, spirometry, bronchial hyperreactivity (BHR), and fractional concentration of exhaled nitric oxide (FeNO) in a cohort of AR patients.

METHODS

The study included 155 patients with persistent AR alone and 155 healthy controls. All subjects were evaluated performing skin-prick test, spirometry, bronchoprovocation test with methacholine, and FeNO measurement.

RESULTS

BMI values were significantly higher in AR patients than in control subjects (p = 0.038). Overweight/obese AR patients had more altered functional and inflammatory parameters than normal weight patients. BMI > 25 is a risk factor for (i) early bronchial airflow limitation (odds ratio [OR], 3.81), (ii) high FeNO values (OR, 1.96), and BHR (OR, 3.29).

CONCLUSIONS

The present study may suggest that BMI assessment should be routinely considered in AR patients for assessing risk for early bronchial impairment, such as suggesting possible evolution to asthma.

May T1 diabetes mellitus protect from asthma?

BACKGROUND

Type 1 diabetes mellitus (T1DM) may be associated with allergy. It was previously reported that >20% of children with T1DM had allergic rhinitis (AR), but none was asthmatic. This finding was surprising as allergic rhinitis is frequently associated with asthma and asthma prevalence is about 10% of the general paediatric population. Thus, it was hypothesized that T1DM could protect from asthma.

OBJECTIVES

The aim of this preliminary study was to evaluate the pulmonary function and the response to bronchodilation testing in children, suffering from T1DM with associated AR, comparing them with a control group of children with AR alone.

METHODS

Twenty children with T1DM and AR were compared with 59 children with AR alone; spirometry and bronchodilation testing were performed in all patients.

RESULTS

There were no statistically significant differences in both "at baseline" and after bronchodilation testing about FVC, FEV1, and FEF25-75 values. However, changes in "post-bronchodilator" values of FEF25-75 (ΔFEF25-75) were significantly higher in children with AR alone than in children with T1DM and AR (p=0.04).

CONCLUSIONS

This preliminary study could sustain the hypothesis that T1DM in children suffering also from AR might exert a protective effect of preventing the possible evolution in asthma.

High exhaled nitric oxide levels may predict bronchial reversibility in allergic children with asthma or rhinitis

BACKGROUND

Allergic asthma and rhinitis may be associated. Airway inflammation is shared by both disorders. The measure of the fractional concentration of exhaled nitric oxide (FeNO) may be considered as a surrogate marker for airway inflammation, mainly in allergic patients. Reversibility to bronchodilation (BD) testing is a functional characteristic of asthma.

OBJECTIVE

The aim of this study was to evaluate whether FeNO may predict reversibility to BD in a pediatric cohort of allergic subjects with asthma (180) or rhinitis (150).

METHODS

Lung function (including forced expiratory volume at the first second (FEV(1)), forced volume capacity (FVC), forced expiratory flow at 25-75% of volume capacity (FEF (25-75))), FeNO measurement, and BD testing were performed in all children.

RESULTS

Lung function, FeNO, and sensitization type were significantly different in the two groups. A strong correlation was found between FeNO and ΔFEV(1) after BD. Two main predictors of reversibility were FeNO values >34 ppb [Odds RatioAdj (ORAdj) = 1.9] and sensitization to perennial allergens (ORAdj = 1.7).

CONCLUSIONS

This study provided evidence that FeNO was strongly related with the response to BD testing and could predict bronchial reversibility in children with allergic rhinitis or asthma. Therefore, a simple FeNO measurement could suggest relevant information about bronchial reversibility.

The united allergic airway: connections between allergic rhinitis, asthma, and chronic sinusitis

BACKGROUND

The united allergic airway is a theory that connects allergic rhinitis (AR), chronic rhinosinusitis, and asthma, in which seemingly disparate diseases, instead of being thought of separately, are instead viewed as arising from a common atopic entity.

OBJECTIVE

This article describes patients with such diseases; explores ideas suggesting a unified pathogenesis; elucidates the various treatment modalities available, emphasizing nasal corticosteroids and antihistamines; and provides an update of the literature.

METHODS

A literature review was conducted.

CONCLUSION

The aggregation of research suggests that AR, asthma, and chronic rhinosinusitis are linked by the united allergic airway, a notion that encompasses commonalities in pathophysiology, epidemiology, and treatment.

Nasal disease and asthma

The nose plays a primary role within the airways, working as a filter and air-conditioner, together with other important functions. Thus, it is not surprising that nasal diseases are associated with several other comorbidities, including both upper and lower airways, such as bronchial hyperresponsiveness (BHR) and asthma. Several studies have investigated the relationship existing between the upper and the lower airways and new insights are rising. Nevertheless, some uncertainties still remain, mainly because nasal disorders are quite heterogeneous, overlapping (i.e. rhinitis-rhinosinusitis-sinusitis, acute or chronic, allergic or non-allergic) and difficult to diagnose, so that, frequently, many studies don’t differentiate between the various conditions. For this reason, the purpose of this review is to systematically analyze present epidemiological, pathophysiological and clinical data on the relationship between nasal diseases and asthma, splitting up three main conditions: allergic rhinitis, chronic rhinosinusitis and nasal polyposis.

Spirometric abnormalities in patients with allergic rhinitis: Indicator of an "asthma march"?

BACKGROUND

Allergic rhinitis (AR) may precede and promote the onset of asthma. However, few studies addressed this issue mainly concerning bronchial physiological parameters. The aim of this study was to assess forced expiratory flow at 25-75% (FEF(25-75)), forced expiratory volume at 1 second (FEV(1)), and response to bronchodilation test in a large group of AR patients.

METHODS

Sixteen hundred five adult AR patients were evaluated. Clinical examination, assessment of nasal obstruction perception by visual analog scale, spirometry, and bronchodilation test were performed in all patients.

RESULTS

There were 8.4% of patients with abnormal FEV(1) values, 24.7% had impaired FEF(25-75), and 66.1% had reversibility with bronchodilation. A trend of spirometric impairment seems to exist in these patients. Age, gender, and duration of rhinitis may be risk factors for these findings. Different grades of bronchial impairment seem to exist.

CONCLUSION

This study highlights the close link between upper and lower airways and suggests the possible existence of a progression from AR toward asthma, such as an "asthma march." Therefore, asthma should be suspected and carefully investigated in AR patients.

Relationship between bronchial hyperreactivity and bronchodilation in patients with allergic rhinitis

BACKGROUND

Allergic rhinitis (AR) may be considered a risk factor for the onset of asthma. Recently, it has been reported that forced expiratory flow between 25% and 75% of vital capacity (FEF(25%-75%)) may predict a positive response to bronchodilation test in asthmatic children. Moreover, bronchial hyperreactivity (BHR) is frequently detected in AR patients.

OBJECTIVE

To evaluate the possible relationship between the response to bronchodilation test and methacholine challenge, also considering the FEF(25%-75%) values in a large group of patients with persistent allergic rhinitis.

METHODS

Three hundred sixty-five consecutive AR patients were evaluated. Clinical examination, spirometry, methacholine bronchial challenge, and bronchodilation test were performed in all patients.

RESULTS

Two hundred forty-one patients (66%) had "positive" results for bronchodilation test; FEF(25%-75%) was abnormal in 78 patients (21.4%), and 76 patients (20.8%) had severe BHR. An FEF(25%-75%) cutoff value of less than 58.5% of predicted may optimally (AUC 0.97) discriminate patients with both severe BHR and reversibility.

CONCLUSION

This study confirms previous studies and increases the strength of the role of FEF(25%-75%) as a marker of early bronchial involvement in patients suffering from persistent allergic rhinitis. Moreover, an FEF(25%-75%) value less than 58.5% of predicted may suggest the co-existence of severe BHR and reversibility.

Bronchodilation test in patients with allergic rhinitis

BACKGROUND

Allergic rhinitis (AR) may be considered a risk factor for the onset of asthma. Recently, it has been reported that forced expiratory flow between 25% and 75% of vital capacity (FEF₂₅₋₇₅) may predict a positive response to bronchodilation test in asthmatic children. The aim of this study was to evaluate a large group of adult AR patients to investigate the frequency of response to bronchodilation test and FEF₂₅₋₇₅ values.

METHODS

One thousand four hundred and sixty-nine consecutive patients suffering from persistent AR were evaluated. Clinical examination, spirometry, and bronchodilation test were performed in all patients.

RESULTS

In this study, 62.9% of patients had reversibility to bronchodilation test and 17.8% had impaired FEF₂₅₋₇₅ values (≤ 65% of predicted). Impaired FEF₂₅₋₇₅ values associated with longer rhinitis duration may predict reversibility to bronchodilation test (OR = 11.3; P < 0.001). In addition, a FEF₂₅₋₇₅ cutoff value ≤ 71% of predicted may already discriminate patients with reversibility.

CONCLUSIONS

This study highlights that about two-thirds of patients with persistent AR may be considered at risk of becoming asthmatic. This finding should be adequately considered as a precocious spirometry may allow the early detection of patients prone to develop asthma and consequently to treat them.

Impact of allergic rhinitis on bronchi: an 8-year follow-up study

BACKGROUND

Allergic rhinitis is considered a strong risk factor for the onset of asthma. However, few studies addressed this issue from a functional point of view. The aim of this study was to follow up a group of patients with allergic rhinitis to investigate the onset of possible spirometric abnormalities and/or bronchial hyperreactivity (BHR).

METHODS

Eighty-nine patients with moderate-severe persistent allergic rhinitis were prospectively and consecutively evaluated; 940 controls were also included in the study. Clinical examination, skin-prick test, spirometry, and methacholine challenge were performed in all patients every 2 years for 8 years.

RESULTS

The number of patients with forced expiratory flow at 25 and 75% of pulmonary volume of <70% of predicted significantly increased during the observation time. At baseline, no subjects had BHR; whereas 34 patients had BHR after 8 years. Sensitization to mites, birch, and Parietaria as well as rhinitis duration are risk factors for these changes.

CONCLUSION

This study highlights the close link between upper and lower airways and suggests that spirometry should be performed in patients with allergic rhinitis.

The role of inhaled and/or nasal corticosteroids on the bronchodilator response

PURPOSE

To compare the profiles of the bronchodilator response (BDR) among children with asthma and/or allergic rhinitis (AR) and to determine whether BDR in these children is reduced by treatment with inhaled and/or nasal corticosteroid.

METHODS

Sixty-eight children with asthma (mean age, 10.9 years), 45 children with comorbid asthma and AR (mean age, 10.5 years), and 44 children with AR alone (mean age, 10.2 years) were investigated. After a 2-week baseline period, all children were treated with inhaled fluticasone propionate (either 100 or 250 µg b.i.d., tailored to asthma severity) or nasal fluticasone propionate (one spray b.i.d. in each nostril) or both, according to the condition. Before and 2 weeks after starting treatment, all children were evaluated with spirometry and bronchodilator testing. BDR was calculated as a percent change from the forced expiratory volume in 1 second (FEV(1)) at baseline.

RESULTS

The mean BDR was 10.3% [95% confidence interval (CI) 8.3-12.4%] in children with asthma, 9.0% (95% CI 7.3-10.9%) in subjects with asthma and AR, and 5.0% (95% CI 4.1-5.9%) in children with AR alone (P<0.001). After treatment, the mean BDR was reduced to 5.2% (95% CI 4.2-6.3%) (P<0.001) in children with asthma and to 4.5% (95% CI 3.5-5.5%) (P<0.001) in children with asthma and AR. However, children with rhinitis showed no significant change in BDR after treatment, with the mean value being 4.7% (95% CI 3.7-5.8%) (P=0.597).

CONCLUSION

The findings of this study imply that an elevated BDR in children with AR cannot be attributed to nasal inflammation alone and highlights the close relationship between the upper and lower airways.

The link between allergic rhinitis and asthma: the united airways disease

Rhinitis and asthma are often associated and the two disorders interact at various levels. Rhinitis typically precedes the development of asthma and can contribute to unsatisfactory asthma control. The presence and type of asthma is influenced by sensitization, and the duration and severity of allergic rhinitis. Nasal symptoms, airflow and markers of inflammation directly correlate with lower airway involvement. Local tissue factors, such as microbial stimuli and systemic inflammatory mechanisms, play a role in the clinical expression of the allergic airway syndrome. There is increasing evidence that suggests a major involvement of airway epithelial cells in the pathogenesis of both asthma and allergic rhinitis. Even in patients with rhinitis who do not have asthma, subclinical changes in the lower airways and inflammatory mediators can be detected. The pathogenic role of paranasal sinus infections in respiratory allergy has been better elucidated but there remains a need for further research. Treatment of established rhinitis may affect asthma control and could have some impact on airway obstruction, but a direct effect of rhinitis therapy on lower airway inflammation remains to be clearly established.

Importance of allergic rhinitis management in achieving asthma control: ARIA update

Asthma continues to be a major burden for the health and healthcare of people worldwide. The recent updates of the Global Initiative for Asthma and the National Heart, Lung and Blood Institute asthma guidelines stress the need for achieving and monitoring asthma 'control', emphasizing the importance of identifying, assessing and treating comorbid conditions. Allergic rhinitis (AR) is a major comorbid condition in people with asthma and is related to inflammation of the upper portions of the airway. Recognizing and treating AR has been shown to improve asthma control, specifically by decreasing rates of asthma attacks or asthma exacerbations. In 2008, updated Allergic Rhinitis in Asthma (ARIA) guidelines were published. The updated version of the guidelines has a familiar look, with classification systems and care algorithms that are similar to those presented in other asthma guidelines. The new ARIA guidelines make one major change that should affect the care of adults and children with asthma: everyone with asthma should be assessed for AR. In addition, AR should be considered a risk factor for asthma, and all children and adults with AR, especially persistent AR, should be assessed for asthma, including testing lung function for reversible obstruction whenever feasible. Treatment for AR follows a similar format to that for asthma, including symptom management, treatment of chronic inflammation, identification and management of triggers, including allergens, and ongoing education for self-management. Pharmacotherapies that address both asthma and AR include corticosteroids (intranasal and inhaled), leukotriene receptor antagonists, immunomodulation or immunotherapy. Too often, pharmacotherapy is not supplemented by the necessary education and evaluation related to allergen, trigger identification and management.

Lower airways may also be affected in asymptomatic patients with recent onset of allergic rhinitis

OBJECTIVES/HYPOTHESIS

It is well known that there is a close association between allergic rhinitis (AR) and asthma, and AR is a strong risk factor for the onset of asthma. AR duration is significantly associated with a possible bronchial involvement. The aim of this study was to investigate the presence of possible spirometric abnormalities and bronchial hyperreactivity (BHR) in a large group of patients with recent onset of AR.

STUDY DESIGN

Observational cross-sectional study.

METHODS

A total of 1,539 AR patients were consecutively evaluated. Clinical examination, skin prick test, spirometry, and methacholine challenge were performed on all patients.

RESULTS

: There were 362 (23%) patients with FEF(25-75) values <70% of predicted. The methacholine challenge was positive in 74.43% of patients, and 72.22% of the population presented a polysensitization. At multivariable analysis, an FEV(1) value lower than 92% of predicted, as well as increasing severity of BHR and polysensitization appeared to be independent predictors of a reduced FEF(25-75) value.

CONCLUSIONS

This study shows that reduced FEF(25-75) values may be present in some patients with recent onset of AR. FEV(1) <92%, severity of BHR, and polysensitization may be considered risk factor for this phenomenon.

Impact of allergic rhinitis on asthma in children: effects on bronchodilation test

BACKGROUND

Relevant relationship exists between upper and lower airways. Bronchial obstruction is a paramount feature of asthma and its reversibility is considered a diagnostic step for asthma diagnosis.

OBJECTIVE

This study aimed at evaluating a large group of children with allergic rhinitis alone for investigating the degree of brochodilation and possible factors related to it.

METHODS

Two hundred patients with allergic rhinitis and 150 normal subjects were consecutively evaluated. Clinical examination, skin prick test, spirometry, and bronchodilation test were performed in all patients.

RESULTS

Rhinitics showed a significant FEV(1) increase after bronchodilation test (P < 0.0001) in comparison both to basal values and to controls' levels. More than 20% of rhinitics had reversibility (> or =12% basal levels). Patients with reversibility had lower FEV(1) levels, longer rhinitis duration, and perennial allergy.

CONCLUSION

This study highlights the close link between upper and lower airways and the relevance of performing bronchodilation test in patients with allergic rhinitis and these characteristics.

Asthma control test and peak expiratory flow rate: independent pediatric asthma management tools

BACKGROUND

Management of asthma reflects the complexity of the pathogenesis. According to current National Heart Lung Blood Institute (NHLBI) guidelines, asthma control can be assessed using the validated asthma control test, measures of airway function, and overall assessment of risk and quality of life. We hypothesized that the asthma control test and measures of airway function are independent tools in asthma management. We also studied whether the presence of nasal symptoms is correlated to these measures.

METHODS

Serial visits (n = 45) to a pediatric respiratory clinic in an underserved area of San Diego County with a predominantly Hispanic population were reviewed. Patients were included if they were able to perform airway function tests and had more than one provider visit. Patients with other major diseases were excluded. We determined whether uncontrolled asthmatics, defined as an Asthma Control test (ACT) score of 19 or less, had lower % predicted peak expiratory flow Measurements as a group compared to those with higher scores. In addition, the individual ACT and airway function results were analyzed. Patients with and without nasal symptoms at the time of presentation were sub-analyzed to determine differences in ACT and peak flow measurements.

RESULTS

Based on n = 45 physician visits, the mean ACT score was 21 +/- 3.3 (range 12-25) and the mean peak expiratory flow rate (PEFR) was 87.4% +/- 11 (range 65-109%). Patients with ACT scores < or = to 19 or lower (< or = 90%) PEFRs were determined not to have more nasal symptoms. The measures of ACT and peak expiratory flow were independent and not correlated.

CONCLUSIONS

Our study indicates that ACT and PEFR are distinct parameters used to manage patients in a pediatric outreach asthma clinic.

Management of patients with allergic rhinitis and asthma: literature review

Allergic rhinitis (AR) and asthma are disorders of the airway characterized by inflammation of the respiratory mucosa. The presence of one disorder increases the likelihood that the other will also occur. As they are mechanistically intertwined, one can exacerbate the other when both conditions are present. In addition, comorbid AR and asthma have an additive impact on patients' health-related quality of life. The Allergic Rhinitis and its Impact on Asthma (ARIA) recommendations suggest that asthma patients should be evaluated for AR, and all AR patients should undergo tests for asthma. They also suggest that ideally, a combined strategy should be used to treat the upper and lower airway diseases. While treatment for AR includes antihistamines, intranasal glucocorticosteroids, antileukotrienes, and specific immunotherapy, data suggest that these treatment approaches may also improve asthma outcomes. This article reviews current clinical approaches to the diagnosis and management of patients with comorbid AR and asthma.

Relationship between Responses to Bronchodilation Testing and to Nasal Decongestion Testing in Patients with Allergic Rhinitis Alone

A remarkable relationship exists between upper and lower airways. Bronchial obstruction is a paramount feature of asthma as well as nasal obstruction of allergic rhinitis (AR). This study aims to evaluate the response to both bronchodilation and decongestion testing and their relationships in a large group of patients with moderate-severe persistent AR alone. Two hundred eleven patients with moderate-severe persistent AR were prospectively and consecutively evaluated. Clinical examination, skin prick test, spirometry, bronchodilation test, rhinomanometry, and decongestion test were performed on all patients. Seventeen subjects (8%) did not respond to any of the tests, 55 subjects (26.1%) were responders only to the decongestion test, 31 (14.7%) only to the bronchodilation test, and 108 subjects (51.2%) responded to both these tests. Longer AR duration was significantly associated with positive response to both tests (p<0.01). In conclusion, this study provides the first evidence that patients with moderate-severe persistent AR may frequently show reversibility to both bronchodilation and decongestion tests.