Onset and remission of allergic rhinitis and asthma and the relationship with atopic sensitization and smoking

The role of atopy in Maltese patients with chronic rhinitis

The global prevalence of allergic rhinitis has been on the increase and recent clinical experience in Malta has shown a similar trend. The aim of this study was to investigate the role of atopy in 415 patients presenting with rhinitis of at least 3 months duration, and to identify the common allergens responsible. Presenting clinical features, past and family history of seasonal allergic symptoms, exposure to cigarette smoking, pet ownership and occupation were analysed. All patients were skin tested for common allergens. Fifty-five per cent of patients were atopic, the main allergens responsible being house dust mite, cat dander and grass pollen. Rhinorrhoea and sneezing were significantly more common in atopic patients, who were more likely to have a past history and family history of seasonal asthma, eczema or rhinoconjunctivitis. Skin test-negative patients with idiopathic rhinitis were mostly females and tended to present a decade later. Differentiation between atopic and idiopathic chronic rhinitis may be helpful in the clinical setting in order to help predict response to treatment.

Assessing individual employee risk factors for occupational asthma in primary aluminium smelting

AIMS

To assess the significance of individual risk factors in the development of occupational asthma of aluminium smelting (OAAS).

METHODS

A matched case-control study nested in a cohort of 545 workers employed in areas with moderate to high levels of smelting dust and fume. The cohort comprised those who had their first pre-employment medical examination between 1 July 1982 and 1 July 1995; follow up was until 31 December 2000. Forty five cases diagnosed with OAAS and four controls per case were matched for the same year of pre-employment and age within +/-5 years. The pre-employment medical questionnaires were examined, blinded as to case-control status, and information obtained on demographics and details of allergic symptoms, respiratory risk factors, respiratory symptoms, and spirometry. Data from the subsequent medical notes yielded subsequent history of hay fever, family history of asthma, full work history, date of termination or diagnosis, and tobacco smoking history at the end-point.

RESULTS

There was a significant positive association between hay fever diagnosed either at or during employment and OAAS (adjusted OR 3.58, 95% CI 1.57 to 8.21). A higher forced expiratory ratio (FEV1/FVC%) at employment reduced the risk of developing OAAS (adjusted OR 0.93, 95% CI 0.88 to 0.99). The risk of OAAS was more than three times higher in individuals with an FER of 70.0-74.9% than in individuals with an FER > or =80.0% (adjusted OR 3.46, 95% CI 1.01 to 11.89).

CONCLUSIONS

Individuals with hay fever may be more susceptible to occupational asthma when exposed to airborne irritants in aluminium smelting. The pathological basis may be reduced nasal filtration and increased bronchial hyperresponsiveness.

Bronchial hyperreactivity and spirometric impairment in polysensitized patients with allergic rhinitis

BACKGROUND: We previously demonstrated in a group of patients with perennial allergic rhinitis alone impairment of spirometric parameters and high percentage of subjects with bronchial hyperreactivity (BHR). The present study aimed at evaluating a group of polysensitized subjects suffering from allergic rhinitis alone to investigate the presence of spirometric impairment and BHR during the pollen season. METHODS: One hundred rhinitics sensitized both to pollen and perennial allergens were evaluated during the pollen season. Spirometry and methacholine bronchial challenge were performed. RESULTS: Six rhinitics showed impaired values of FEV1 without referred symptoms of asthma. FEF 25-75 values were impaired in 28 rhinitics. Sixty-six patients showed positive methacholine bronchial challenge. FEF 25-75 values were impaired only in BHR positive patients (p < 0.001). A significant difference was observed both for FEV1 (p < 0.05) and FEF 25-75 (p < 0.001) considering BHR severity. CONCLUSIONS: This study evidences that an impairment of spirometric parameters may be observed in polysensitized patients with allergic rhinitis alone during the pollen season. A high percentage of these patients had BHR. A close relationship between upper and lower airways is confirmed.

Long-term repeatability of the skin prick test is high when supported by history or allergen-sensitivity tests: a prospective clinical study

BACKGROUND

Long-term reproducibility of the skin-prick test (SPT) has been questioned. The aim of the study was to investigate the clinical relevance of SPT changes.

METHODS

SPT to 10 common inhalation allergens was performed annually from 1999 to 2001 in 25 nonsensitized and 21 sensitized subjects. An SPT was positive when > or =3 mm, and repeatable if either persistently positive or negative. Clinical sensitivity to birch pollen was used as model for inhalation allergy, and was investigated at inclusion and at study termination by challenge tests, intradermal test, titrated SPT and IgE measurements. Birch pollen symptoms were confirmed in diaries.

RESULTS

The repeatability of a positive SPT was 67%, increasing significantly to 100% when supported by the history. When not supported by history, the presence of specific IgE was significantly associated with a repeatable SPT. Allergen sensitivity was significantly lower in subjects loosing SPT positivity. The repeatability of a negative test was 95%, decreasing significantly to 87% by the presence of other sensitization. Development of a positive SPT was clinically relevant. Elevation of SPT cut-off point did not enhance repeatability.

CONCLUSION

SPT changes are clinically relevant. Further studies using other allergens are needed. Long-term repeatability of SPT is high in the presence of a supportive history.

Effects of asthma on cell components in peripheral blood among smokers and non-smokers

BACKGROUND

Eosinophils play a central role in asthma, but the interplay of the effects of smoking, eosinophils and asthma remains unclear.

OBJECTIVE

The primary objective of our study was to investigate the extent to which smoking modifies the effect of asthma on circulating eosinophils, CD4+ and CD8+ T cell counts.

METHODS

Data were collected semiannually between 1987 and 1994 from HIV-negative participants in the Multicenter AIDS Cohort Study. Asthma was defined by a questionnaire at baseline as a self-report of diagnosed asthma. A total of 1420 blood samples from 197 asthmatics and 15 822 from 1997 non-asthmatics were collected.

RESULTS

Eosinophil levels were higher in asthmatics (28% of asthmatics had eosinophils >/=4% and 16% of non-asthmatics) regardless of smoking history, but smoking modified the association between eosinophils and asthma. Namely, the odds ratios for eosinophils being >/=4% in asthmatics to non-asthmatics decreased from 2.7 (95% CI: 2.0, 3.6) in never, to 2.1 (1.4, 3.1) in former, and to 1.5 (0.9, 2.3) in current smokers. Cross-sectional and longitudinal analyses coherently showed that smoking increased eosinophils in non-asthmatics, but the converse was true for asthmatics. In contrast, no differences in peripheral blood T cell counts between asthmatics and non-asthmatics were observed.

CONCLUSION

Under the established link between increased eosinophils and asthma, these data indicate that smoking modified this relationship. This finding suggests that smoking plays a different immunological role in asthmatics and non-asthmatics.

Links between rhinitis and asthma

There is compelling evidence of a close relationship between the upper and lower airways in asthma and rhinitis. Rhinitis is present in the majority of patients with asthma, and a significant minority of patients with rhinitis have concomitant asthma. Similarities between the two conditions occur in the nature of the inflammation present in the target tissues. A common initiating step in the inflammatory process of allergic airways disease is the presence of immunoglobulin E providing an adaptor molecule between the offending allergen and inflammatory cell activation and mediator release. Differences in the two conditions arise largely from the structural differences between the nose and the lungs. In an asthmatic, concomitant allergic rhinitis increases healthcare costs and further impairs quality of life. The presence of rhinitis should always be investigated in children and young adults with asthma. Subjects with allergic rhinitis have an increased risk of developing asthma and may form a suitable population for secondary intervention to interrupt the 'allergic march'.

Rhinoconjunctivitis, bronchial responsiveness, and atopy as determinants for incident non-work-related asthma symptoms in apprentices exposed to high-molecular-weight allergens

OBJECTIVE

The aim of this study was to explore the role of rhinoconjunctivitis (RC), taking into account atopy and the level of bronchial responsiveness to methacholine, on the incidence of respiratory symptoms and in the development and/or worsening of asthma.

METHODS

We examined data from a prospective study in 769 students starting exposure to high-molecular-weight occupational allergens and who were serially followed for up to 44 months.

RESULTS

The presence of RC symptoms at baseline was significantly associated with an increased risk of developing shortness of breath and wheezing in atopic subjects regardless of PC20 level and in subjects with a PC20 <or= 32 mg/ml regardless of atopic status. RC symptoms were significantly associated with the development of exercise-induced respiratory symptoms. Multivariate analyses indicated that having a measurable PC20 was significantly associated with the incidence of all respiratory symptoms studied, whereas baseline seasonal RC was associated only with incident exercise-induced respiratory symptoms; atopy played a minimal role, and only through an interaction with seasonal RC.

CONCLUSION

Of the three potential factors for the development of respiratory symptoms that we considered, i.e. RC symptoms, having a measurable PC20 and atopy, having a measurable PC20 is the most significant one.

Cigarette smoking among asthmatic adults presenting to 64 emergency departments

STUDY OBJECTIVES

The emergency department (ED) is an important focal point for asthmatic individuals with uncontrolled illness. Anecdotally, many adults presenting to the ED with acute asthma are active cigarette smokers. The present study determined the prevalence of cigarette smoking among adults presenting to the ED with acute asthma and identified the factors associated with current smoking status.

DESIGN

A prospective cohort study conducted as part of the Multicenter Airway Research Collaboration.

PATIENTS

A structured interview was performed in 1,847 patients, ages 18 to 54 years, who presented to the ED with acute asthma.

SETTING

Sixty-four EDs in 21 US states and 4 Canadian provinces.

RESULTS

Thirty-five percent of the enrolled asthmatic patients were current smokers with a median of 10 pack-years (interquartile range, 4 to 20 pack-years), while 23% were former smokers, and 42% were never-smokers. Current smokers comprised 33% of asthmatic patients aged 18 to 29 years, 40% for ages 30 to 39 years, and 33% for ages 40 to 54 (p < 0.001). In a multivariate analysis, the factors independently associated with current smoking status (p < 0.05) were as follows: age 30 to 39 years; white race/ethnicity; non-high school graduate; lower household income; lack of private insurance; no recent inhaled steroid usage; and no history of systemic steroid usage. Although 50% of current smokers admitted that smoking worsens their asthma symptoms, only 4% stated that smoking was responsible for their current exacerbation.

CONCLUSIONS

Although cigarette smoke is generally recognized as a respiratory irritant, cigarette smoking is common among adults presenting to the ED with acute asthma. The ED visit may provide an opportunity for patients to be targeted for smoking cessation efforts.

Rhinitis is associated with increased systolic blood pressure in men: a population-based study

An association between impaired lower respiratory function and cardiovascular risk factors, such as hypertension, is often reported but it is unknown whether there is a relationship between upper airway disorders and cardiovascular risk factors, despite evidence that upper and lower respiratory tract disorders are closely linked. Our objective was to assess whether rhinitis is associated with arterial blood pressure and hypertension. In a population-based study of 330 adults aged 28-56 years, as part of the European Community Respiratory Health Survey, rhinitis was assessed by means of a questionnaire, and cardiovascular data were obtained using a questionnaire and by measuring blood pressure. Systolic blood pressure (SBP) was higher in men with rhinitis than in men without rhinitis (130.6 +/- 12.7 mm Hg versus 123.5 +/- 13.9 mm Hg; p = 0.002), and it was still the case after adjustment for cardiovascular and respiratory confounding factors. Hypertension was more frequent in men with rhinitis than in men without rhinitis, even after multivariate adjustment (odds ratio = 2.6, 95% confidence interval = [1.14-5.91]). The observation of SBP levels according to whether men have no rhinitis, seasonal rhinitis, or perennial rhinitis was compatible with a dose-response relationship (p for trend = 0.02). In conclusion, rhinitis is strongly associated with SBP and hypertension in men. Blood pressure should be regularly checked in men with rhinitis.

The effect of treatment of allergic rhinitis on asthma morbidity, including emergency department visits

PURPOSE OF REVIEW

It has been hypothesized that asthma and allergic rhinitis are both manifestations of a single inflammatory process present throughout the airway and that control of the inflammatory response associated with allergic rhinitis may help to reduce inflammation throughout the airway and improve control of asthma. Although previous evidence has documented that therapy directed at allergic rhinitis can improve asthma symptoms and bronchial responsiveness, until recently, there was no evidence that the use of medication targeted at the upper airway can also reduce utilization of acute health care services due to asthma.

RECENT FINDINGS

We identified studies published between August 2001 and July 2002 that examined the therapeutic link between allergic rhinitis and asthma. In particular, we concentrated on investigations that evaluated whether, among patients diagnosed with allergic rhinitis and asthma, treatment of the former resulted in significantly fewer asthma-related emergency department visits or inpatient hospitalizations. Two such studies were identified. Using observational study designs, both investigations established that among a population with asthma and allergic rhinitis, treatment for allergic rhinitis was associated with a decrease in the risk of subsequent asthma-related events by one-third to one-half compared with persons who did not receive treatment for this disorder.

SUMMARY

Effective management of allergic rhinitis with nasal steroids and possibly oral antihistamines reduces utilization of acute health care services due to asthma among persons with co-existent asthma.

Asymptomatic skin sensitization to birch predicts later development of birch pollen allergy in adults: a 3-year follow-up study

BACKGROUND

The skin prick test is the allergologic test of choice, but asymptomatic skin sensitization to aeroallergens is common. However, no data in the literature describe the clinical phenotype of asymptomatic sensitized adults.

OBJECTIVE

The purposes of this investigation were to provide a clinical characterization of skin test-positive subjects without symptoms and to ascertain the predictive values of common allergologic tests.

METHODS

Asymptomatic adults with positive skin prick test results for birch (n = 15), nonatopic control subjects (n = 25), and birch pollen-allergic patients (n = 6) were followed through use of daily diary cards during 3 consecutive birch pollen seasons. At inclusion and at the 3-year follow-up visit, conjunctival and nasal challenges, intradermal late-phase reaction evaluation, and measurement of specific IgE were performed.

RESULTS

Asymptomatic sensitized subjects defined a clinically significant phenotype between nonatopic and allergic subjects in terms of specific IgE levels and susceptibility to conjunctival provocation testing. Sixty percent (n = 9) of the asymptomatic sensitized subjects developed clinical allergy. This was associated with an initial birch skin prick test weal diameter of > or =4 mm, a positive conjunctival provocation test result, and specific IgE of > or =CAP class 2, as well as with the presence of other allergies. Specific IgE of > or =CAP class 2 was 87.5% predictive for allergy development, whereas a negative conjunctival provocation test result was 100% negatively predictive. Nasal provocation testing possessed no additional prognostic information. No changes in clinical phenotype were seen in nonatopic or birch-allergic subjects.

CONCLUSION

Asymptomatic skin sensitization is a risk factor for later allergy development. At risk is any subject with target organ sensitivity, an elevated specific IgE level, and/or a skin prick test weal diameter of >4 mm.

Rhinitis increase the risk for adult-onset asthma--a Swedish population-based case-control study (MAP-study)

The aim of the study was to examine certain predictors, especially non-infectious rhinitis, and the risk for adult-onset asthma. A nested case-control study of adult-onset asthma was performed in a random sample from the general population (n = 15,813), aged 21 to 51 years. Cases for the study included subjects reporting physician-diagnosed asthma (n = 235) and controls (n = 2044) were randomly selected from the whole population sample. The case-control sample was investigated with a comprehensive respiratory questionnaire. Odds ratios were calculated stratified for sex, year of diagnosis and birth-year. Adult-onset physician-diagnosed asthma was associated with occurrence of non-infectious rhinitis before asthma onset (OR = 5.4, 95% CI 4.0-7.2), especially among smoking non-atopics (OR = 9.1, 95% CI 5.3-15.4). Smoking before asthma onset increased the risk for asthma (OR = 1.5, 95% CI 1.1-2.1). In conclusion, this population-based case-control study indicate that non-infectious rhinitis and current smoking, especially among non-atopics, are associated with increased risk for adult-onset asthma.

Rhinitis as an independent risk factor for adult-onset asthma

BACKGROUND

For many years, the association between asthma and rhinitis has primarily been attributed to a common allergic background. Recently, it has been suggested that asthma and rhinitis are associated in the absence of atopy. The nature of this association is not well known.

OBJECTIVE

The purpose of this study, which was performed in a large, longitudinal community population, was to determine the extent to which rhinitis is an independent risk factor for adult-onset asthma.

METHODS

We carried out a nested case-control study from the longitudinal cohort of the Tucson Epidemiologic Study of Obstructive Lung Diseases. One hundred seventy-three incident patients with physician-confirmed asthma were compared with 2177 subjects who reported no asthma or shortness of breath with wheezing. Potential risk factors, including the presence of rhinitis, were assessed before the onset of asthma (patients) or before the last completed survey (control subjects).

RESULTS

Rhinitis was a significant risk factor for asthma (crude odds ratio, 4.13; 95% confidence interval, 2.88-5.92). After adjustment for years of follow-up, age, sex, atopic status, smoking status, and presence of chronic obstructive pulmonary disease, the magnitude of the association was reduced but still highly significant (adjusted odds ratio, 3.21; 95% confidence interval, 2.19-4.71). After stratification, rhinitis increased the risk of development of asthma by about 3 times both among atopic and nonatopic patients and by more than 5 times among patients in the highest IgE tertile. Patients with rhinitis with persistent and severe nasal symptoms and a personal history of physician-confirmed sinusitis had an additional increased risk of asthma development.

CONCLUSION

We conclude that rhinitis is a significant risk factor for adult-onset asthma in both atopic and nonatopic subjects. The nature of the association between rhinitis and asthma is open to interpretation.

Effect of passive smoking on respiratory symptoms, bronchial responsiveness, lung function, and total serum IgE in the European Community Respiratory Health Survey: a cross-sectional study

BACKGROUND

Passive smoking is widespread, and environmental tobacco smoke contains many potent respiratory irritants. This analysis aimed to estimate the effect of passive smoking on respiratory symptoms, bronchial responsiveness, lung function, and total serum IgE in the European Community Respiratory Health Survey.

METHODS

This analysis included data from 7882 adults (age 20-48 years) who had never smoked, from 36 centres in 16 countries. Information on passive smoking, respiratory symptoms, asthma, and allergic rhinitis was gathered through a structured interview. Spirometry and methacholine challenge were carried out, and total and specific IgE were measured. The effect of passive smoking was estimated by means of logistic and multiple linear regression for each country and combined across countries by random-effects meta-analysis.

FINDINGS

In 12 of the 36 centres, more than half the participants were regularly involuntarily exposed to tobacco smoke. The prevalence of passive smoking in the workplace varied from 2.5% in Uppsala, Sweden, to 53.8% in Galdakao, Spain. Passive smoking was significantly associated with nocturnal chest tightness (odds ratio 1.28 [95% CI 1.02 to 1.60]), nocturnal breathlessness (1.30 [1.01 to 1.67]), breathlessness after activity (1.25 [1.07 to 1.47]), and increased bronchial responsiveness (effect -0.18 [-0.30 to -.05]). Passive smoking in the workplace was significantly associated with all types of respiratory symptoms and current asthma (odds ratio 1.90 [95% CI 0.90 to 2.88]). No significant association was found between passive smoking and total serum IgE.

INTERPRETATION

Passive smoking is common but the prevalence varies widely between different countries. Passive smoking increased the likelihood of experiencing respiratory symptoms and was associated with increased bronchial responsiveness. Decreasing involuntary exposure to tobacco smoke in the community, especially in workplaces, is likely to improve respiratory health.

[Risk factors for bronchial asthma in patients with rhinitis]

OBJECTIVES

To identify risk factors for bronchial asthma in a large sample of patients with rhinitis.

PATIENTS AND METHODS

One thousand seven hundred sixty patients with rhinitis treated at the respiratory medicine out-patient service of Hospital Universitario Virgen de Rocío in Seville (Spain) in 1997 and 1998 were studied. Six hundred forty-one (36.4%) had isolated rhinitis and 1,119 (63.6%) had rhinitis and bronchial asthma. The following variables were analyzed for both groups: 1) age, 2) sex, 3) clinical diagnosis, 4) age of onset of symptoms, 5) a family history of asthma and/or atopy, 6) housing conditions, 7) smoking, 8) a history of skin allergy, 9) recurrent episodes of respiratory infection with wheezing during early childhood, 10) a diagnosis of nasosinus polyposis, 11) atopy and sensitivity (pollens and/or household allergens), 12) peripheral blood eosinophil count.

RESULTS

The variables that best differentiated the group with rhinitis from the group with both rhinitis and asthma were age, family history of asthma and/or atopy, exposure to household humidity or damp, a history of skin allergy, recurrent episodes of respiratory infection with wheezing in early childhood, atopy, sensitivity to household allergens and peripheral blood eosinophil count. The probability of correctly classifying patients in the appropriate group using this model was 69.7%. Among atopic patients, the best predictive variables were the same, with the exception of household humidity/damp. The probability of correct classification using this model was 69.7%.

CONCLUSIONS

Patients with rhinitis have risk factors for bronchial asthma. As many such patients as possible should be identified so that long-term follow-up can take place and strategies to prevent bronchial asthma can be implemented.

Determinants of cough in young adults participating in the European Community Respiratory Health Survey

Cough is a common symptom that affects a large proportion of the general population. The aim of this investigation was to identify determinants of nocturnal, nonproductive and productive cough in population samples from different countries. In a cross-sectional international population survey, 18,277 subjects (20-48 yrs) from 16 countries answered an interview-led questionnaire. Total and specific immunoglobulin-E was measured and spirometry was performed. Three types of cough were defined: nocturnal, nonproductive and productive cough. The relation of the independent variables to cough was estimated by means of logistic regression for each centre or country and combined across centre or country by random-effects meta-analysis. The median prevalence of nocturnal, nonproductive and productive cough in the different centres was 30.7%, 10.2% and 10.2%, respectively. Nocturnal and nonproductive cough were related to female sex (adjusted odds ratio (OR)=2.08 and 1.27, respectively), while nocturnal and productive cough were related to rhinitis (OR=1.46 and 1.61, respectively). All three types of cough were related to asthma, tobacco smoking, environmental tobacco smoke and obesity. Females are more likely to report nocturnal and nonproductive cough than males. Cough was related to treatable disorders, like asthma and rhinitis, as well as avoidable factors, such as tobacco smoking and environmental tobacco smoke.

The European Community Respiratory Health Survey: what are the main results so far? European Community Respiratory Health Survey II

The European Community Respiratory Health Survey (ECRHS) was the first study to assess the geographical variation in asthma and allergy in adults using the same instruments and definitions. The database of the ECRHS includes information from approximately 140,000 individuals from 22 countries. The aim of this review is to summarize the results of the ECRHS to date. The ECRHS has shown that there are large geographical differences in the prevalence of asthma, atopy and bronchial responsiveness, with high prevalence rates in English speaking countries and low prevalence rates in the Mediterranean region and Eastern Europe. Analyses of risk factors have highlighted the importance of occupational exposure for asthma in adulthood. The association between sensitization to individual allergens and bronchial responsiveness was strongest for indoor allergens (mite and cat). Analysis of treatment practices has confirmed that the treatment of asthma varies widely between countries and that asthma is often undertreated. In conclusion, the European Community Respiratory Health Survey has shown that the prevalence of asthma varies widely. The fact that the geographical pattern is consistent with the distribution of atopy and bronchial responsiveness supports the conclusion that the geographical variations in the prevalence of asthma are true and most likely due to environmental factors.