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

Aeroallergen sensitization patterns among patients with chronic rhinitis with or without concomitant asthma

OBJECTIVES

The aim of this study was to explore the differences in the pattern of allergen sensitization in CR individuals without or with asthma, according to asthma severity.

METHODS

A total of 1066 adults were evaluated. Asthma and chronic⁄allergic rhinits were identified by specialists, questionnaries and skin-prick test. The phenotypic characterization was avaliable from skin-prick test to an aeroallergen extended panel, total IgE and pulmonary function. Using questionnaires and clinical evaluation, participants were classified into the groups: chronic rhinitis alone (CRA) and chronic rhinitis + asthma, the latter subdivided into CR + mild asthma (CRMA) and CR + moderate to severe asthma (CRMSA). Aerollergen sensitization was defined by a positive prick test to one or more allergens associated with nasal symptoms and/or asthma. The association between CR and asthma was evaluated by multivariable logistic regression. The evidence of effect modification of pattern of sensitization in CR on the association with asthma severity and outcomes was examined by introducing interactions terms in the logistic regression models adjusting for confounders.

RESULTS

Frequency of sensitization to aeroallergens was higher in association with asthma in comparison to CRA (CRMA 70.4%; CRMSA 65.0%; CRA 47.0%; p = 0.000). Similarly, the presence of asthma was associated to aeroallergen multiple sensitization (51.5%) (OR = 2.10, 95% CI 1.27-3.50). Additionally, the sensitization to mites, cockroaches, animal epithelium, grasses, and molds, were higher in asthma (56.8%, 24.3%, 12%, 7.13% and 10.3%, respectively). Sensitization to Alternaria alternata, Cladosporium herbarum and dog epithelium was exclusive in asthma groups. A concomitant asthma diagnosis was directly associated with a positive allergen sensitization at least one allergen (62.7%, OR = 2.45, 95% CI 1.80-3.34) and polissensitization (51.5%, OR = 2.10, 95% CI 1.27-3.50).

CONCLUSION

Asthma is associated with multiple allergen sensitization among patients with CR. Some unique profiles of aeroallergen sensitization were observed in patients with CR and asthma. Nevertheless, no difference was found in the sensitization in relation to asthma severity, which suggest atopy is not the main underlying mechanism for asthma severity among patients with CR.

LEVEL OF EVIDENCE

Level 3.

Rationale and Design of a Panel Study Investigating Six Health Effects of Airborne Pollen: The EPOCHAL Study

Background: While airborne pollen is widely recognized as a seasonal cause of sneezing and itchy eyes, its effects on pulmonary function, cardiovascular health, sleep quality, and cognitive performance are less well-established. It is likely that the public health impact of pollen may increase in the future due to a higher population prevalence of pollen sensitization as well as earlier, longer, and more intense pollen seasons, trends attributed to climate change. The effects of pollen on health outcomes have previously been studied through cross-sectional design or at two time points, namely preceding and within the period of pollen exposure. We are not aware of any observational study in adults that has analyzed the dose-response relationship between daily ambient pollen concentration and cardiovascular, pulmonary, cognitive, sleep, or quality of life outcomes. Many studies have relied on self-reported pollen allergy status rather than objectively confirming pollen sensitization. In addition, many studies lacked statistical power due to small sample sizes or were highly restrictive with their inclusion criteria, making the findings less transferable to the "real world." Methods: The EPOCHAL study is an observational panel study which aims to relate ambient pollen concentration to six specific health domains: (1) pulmonary function and inflammation; (2) cardiovascular outcomes (blood pressure and heart rate variability); (3) cognitive performance; (4) sleep; (5) health-related quality of life (HRQoL); and (6) allergic rhinitis symptom severity. Our goal is to enroll 400 individuals with diverse allergen sensitization profiles. The six health domains will be assessed while ambient exposure to pollen of different plants naturally varies. Health data will be collected through six home nurse visits (at approximately weekly intervals) as well as 10 days of independent tracking of blood pressure, sleep, cognitive performance, HRQoL, and symptom severity by participants. Through repeated health assessments, we aim to uncover and characterize dose-response relationships between exposure to different species of pollen and numerous acute health effects, considering (non-)linearity, thresholds, plateaus and slopes. Conclusion: A gain of knowledge in pollen-health outcome relationships is critical to inform future public health policies and will ultimately lead toward better symptom forecasts and improved personalized prevention and treatment.

Risk Factors and Comorbidities Associated With the Allergic Rhinitis Phenotype in Children According to the ARIA Classification

Purpose

Data are lacking on the association between the allergic rhinitis (AR) phenotype and sensitization to specific allergens or bronchial hyperresponsiveness (BHR) in children. We here investigated risk factors and comorbidities, including sensitization to specific allergens and BHR, for the AR phenotype by AR and its Impact on Asthma (ARIA) classification in a general population-based birth cohort study.

Methods

We enrolled 606 children aged 7 years from the Panel Study of Korean Children. The AR phenotype was assigned in accordance with the ARIA classification in children. Skin prick tests and Provocholine provocation test were performed. Risk factors and comorbidities for AR phenotypes were then analyzed.

Results

The prevalence of mild and moderate to severe AR in our study cohort was 37.2% and 8.8%, respectively. Recent use of analgesics or antipyretics and current cat ownership were associated with the risk of mild persistent AR. Sensitizations to Dermatophagoides Pteronyssinus (Der p), Japanese hop and cat were associated with moderate to severe persistent AR. Children with moderate to severe AR had a higher risk of current asthma and BHR compared to mild AR cases (adjusted odds ratio [aOR], 5.26; 95% confidence interval [CI], 1.77–15.62). Moderate to severe AR with allergic sensitization was associated with the highest risk of BHR (aOR, 11.77; 95% CI, 3.40–40.74).

Conclusions

Moderate to severe-persistent AR is more closely related to respiratory comorbidities and sensitizations than mild AR. Stratifying the AR phenotype by ARIA classification may assist in disease management.

Subclinical lower airways correlates of chronic allergic and non-allergic rhinitis

The upper and lower airways behave as a physiological and pathophysiological unit. Subclinical lower airways abnormalities have been described in patients with rhinitis without asthma. These are expressed as bronchial hyperreactivity, abnormalities in lung function and bronchial inflammation, likely as a result of the same phenomenon with systemic inflammatory impact that reaches both the nose and the lungs, which for unknown reasons does not always have a full clinical expression. Patients with rhinitis are at increased risk of developing asthma; therefore, most authors suggest a careful clinical evaluation and monitoring of these patients, especially if symptoms related to inflammation in the lower airways are observed. Although current treatments, such as H1-antihistamines, intranasal steroids and allergen immunotherapy, are quite effective for the management of rhinitis, it is difficult to prove their capacity to prevent asthma among subjects with rhinitis. Evidence showing that the treatment of rhinitis has a favourable impact on indicators of bronchial hyperreactivity and inflammation among subjects that have no symptoms of asthma is more frequently described. In this review, we address the frequency and characteristics of lower airway abnormalities in subjects with rhinitis, both in paediatric and adult populations, their likely predictive value for the development of asthma and the possibilities for therapeutic intervention that could modify the risk of subjects with rhinitis towards presenting asthma.

Lower airway inflammation and hyperresponsiveness in non-asthmatic patients with non-allergic rhinitis

BACKGROUND

Potential associations between non-allergic rhinitis (NAR) and asthma have been verified epidemiologically, but these associations remain not very clear. It is necessary to further explore the possible implication of lower airway abnormities in NAR patients but without asthma. This study aims to determine lower airway hyperresponsiveness (AHR), inflammation and lung function in non-asthmatic patients with NAR.

METHODS

We recruited 262 non-asthmatic patients with NAR, 377 with AR and 264 healthy subjects. All subjects were non-smokers who underwent meticulous history taking, nasal examination, allergen skin prick test (SPT), blood routine test, measurement of fractional exhaled nitric oxide (FeNO), methacholine bronchial challenge test and induced sputum eosinophil count, in this order.

RESULTS

Compared with healthy subjects, non-asthmatic patients with NAR yielded markedly lower FEV1/FVC, maximal mid-expiratory flow (MMEF), mid-expiratory flow when 50% of FVC has been expired (MEF50%) and mid-expiratory flow when 75% of FVC has been expired (MEF25%) (P<0.05). Differences in spirometry between group AR and NAR were unremarkable (P>0.05). Patients with NAR yielded higher rate of AHR and higher FeNO levels than healthy subjects but lower than those with AR. The proportion of lower airways disorders (sputum eosinophilia, high FeNO levels or AHR) was highest in group AR (70.8%), followed by NAR (53.4%) and healthy subjects (24.2%) (P<0.01). However, sputum eosinophils in NAR patients were not higher compared with healthy subjects (P>0.05). Sputum eosinophils and FeNO had significant correlation with positive AHR and MMEF in group AR but not in NAR.

CONCLUSIONS

Non-asthmatic patients with NAR harbor lower AHR, small airways dysfunction and inflammation, despite being less significant than those with AR. This offers clues to unravel the link between NAR and asthma.

Association and management of eosinophilic inflammation in upper and lower airways

This review discussed the contribution of eosinophilic upper airway inflammation includes allergic rhinitis (AR) and chronic rhinosinusitis (CRS) to the pathophysiology and course of asthma, the representative counterpart in the lower airway. The presence of concomitant AR can affect the severity of asthma in patients who have both diseases; however, it is still debatable whether the presence of asthma affects the severity of AR. Hypersensitivity, obstruction and/or inflammation in the lower airway can be detected in patients with AR without awareness or diagnosis of asthma, and AR is known as a risk factor for the new onset of wheeze and asthma both in children and adults. Allergen immunotherapy, pharmacotherapy and surgery for AR can contribute to asthma control; however, a clear preventive effect on the new onset of asthma has been demonstrated only for immunotherapy. Pathological similarities such as epithelial shedding are also seen between asthma and CRS, especially eosinophilic CRS. Abnormal sinus findings on computed tomography are seen in the majority of asthmatic patients, and asthmatic patients with CRS show a significant impairment in Quality of Life (QOL) and pulmonary function as compared to those without CRS. Conversely, lower airway inflammation and dysfunction are seen in non-asthmatic patients with CRS. Treatments for CRS that include pharmacotherapy such as anti-leukotrienes, surgery, and aspirin desensitization show a beneficial effect on concomitant asthma. Acting as a gatekeeper of the united airways, the control of inflammation in the nose is crucial for improvement of the QOL of patients with co-existing AR/CRS and asthma.

Bronchial hyperresponsiveness in pediatric rhinitis patients: the difference between allergic and nonallergic rhinitis

BACKGROUND

Numerous studies have examined the relationship of bronchial hyperresponsiveness (BHR) to asthma or allergic rhinitis (AR). However, little is known regarding the association between BHR and nonallergic rhinitis (NAR). This study investigated the prevalence and risk factors of BHR in pediatric patients with rhinitis and analyzed the difference between patients with AR and those with NAR.

METHODS

A total of 227 subjects with rhinitis aged 6-15 years underwent a parental survey and laboratory tests, including skin-prick test and methacholine challenge test. Outcome variables were analyzed in relation to BHR.

RESULTS

The prevalence of BHR was 55.7 and 25.5% in patients with AR and those with NAR, respectively. The persistency of rhinitis, blood eosinophil count, and baseline lung function were significantly associated with BHR in patients with AR, whereas individual or familial medical history, environmental factors, the serum immunoglobulin E level, the number of sensitized allergens, and the wheal size ratio of allergen to histamine did not affect the BHR rate. In multivariate analysis, the persistency of rhinitis was the only significant predictor of BHR in AR patients. However, persistent rhinitis symptoms did not increase the risk of BHR in NAR patients.

CONCLUSION

BHR occurs over two times more frequently in children with AR than in those with NAR. In addition, persistent nasal inflammation appears to increase the risk of BHR only in the presence of atopy.

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.

Upper airway inflammation exacerbates bronchial hyperreactivity in mouse models of rhinosinusitis and allergic asthma

BACKGROUND

Recent studies have suggested that upper airway inflammation has a strong impact on lower airway diseases. The purpose of this study was to assess whether nasal inflammation could exacerbate allergic asthma in a mouse model.

METHODS

Mice were assigned to 4 groups: control (Cont), either rhinosinusitis (R) or allergic asthma (A) alone, and both rhinosinusitis and allergic asthma (R&A). Mice underwent induction of nasal inflammation (R and R&A) or sham surgery (Cont and A) on day 1. Mice in the A and R&A groups were sensitized to ovalbumin on days 1, 7, and 14, followed by aerosol challenge on days 18 to 20, whereas in the Cont and R groups only saline was administered. All mice were assessed for airway hyperresponsiveness (AHR) and were euthanized on day 21. The sera, bronchoalveolar lavage fluids (BALFs), and nasal and lung tissues were collected for further analyses.

RESULTS

Histology findings confirmed upper and lower airway inflammation in experimental mice. Significantly increased AHR and total serum immunoglobulin E (IgE) were observed in the R&A group when compared with those of the Cont, R, and A groups. Responses to IgG2a induction were also found in sera and BALFs from mice with rhinosinusitis (R and R&A). Higher levels of interleukin 4 (IL-4) and IL-13, and increased eosinophilic inflammation were detected in BALFs and lung tissues from the experimental groups when compared with those from the Cont group.

CONCLUSION

Our results confirm that upper airway inflammation could exacerbate allergic asthma, and provide support to the concept of "one airway, one disease.

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.

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.

Early bronchial involvement in children with allergic rhinitis

BACKGROUND

Allergic rhinitis (AR) may be frequently associated with asthma or precede it. Bronchial involvement in AR is usually detected by spirometry. Forced expiratory volume in 1 second (FEV(1)) is considered a reliable parameter for asthma diagnosis. However, forced expiratory flow at 25-75% (FEF(25-75)) could be considered a possible marker of early bronchial involvement in AR; indeed, it has been proposed that FEF(25-75) values <70% of predicted may predict this evolution. The aim of this study was to evaluate a large cohort of children with AR to define an FEV(1) value corresponding to impaired FEF(25-75) values.

METHODS

Eight hundred fifty AR children (555 boys; median age, 10 years) were studied. Spirometry and skin-prick test were performed in all of them. Descriptive statistic and multivariate analysis were considered.

RESULTS

Three-hundred (35.3%) patients had FEF(25-75) values <70% of predicted. Still, normal FEV(1) values were associated with overt impaired FEF(25-75) values and the cutoff value was 83%.

CONCLUSION

Spirometry should be adequately interpreted in AR patients; indeed, an FEV(1) cutoff value of 83% detects with good efficiency AR children with early bronchial impairment.

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.

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.