Rhinosinusitis and asthma: the missing link

Exploring the Relationship between Wind Patterns and Hospital Admissions Due to Respiratory Symptoms in Children

Respiratory disorders significantly impact adolescents' health, often resulting in hospital admissions. Meteorological elements such as wind patterns have emerged as potential contributors to respiratory symptoms. However, it remains uncertain whether fluctuations in wind characteristics over extended periods have a tangible impact on respiratory health, particularly in regions characterized by distinct annual wind patterns. Crete is situated in the central-eastern Mediterranean Sea and frequently faces southerly winds carrying Sahara Desert sand from Africa and northerly winds from the Aegean Sea. This retrospective study analyzes long-term wind direction data and their relationship to respiratory symptoms observed in children up to 14 years old admitted at the University Hospital of Heraklion between 2002 and 2010. Symptoms such as headache, dyspnea, dry cough, dizziness, tachypnea, throat ache, and earache were predominantly reported during the presence of southern winds. Fever, productive cough, and chest pain were more frequently reported during northern winds. Cough was the most common symptom regardless of the wind pattern. Southern winds were significantly associated with higher probabilities of productive or non-productive cough, headache, dyspnea, tachypnea, dizziness, earache, and throat ache. Northern winds were related to a higher incidence of productive cough. Rhinitis, asthma, allergies, pharyngitis, and sinusitis were related to southern winds, while bronchiolitis and pneumonia were associated with northern winds. These findings underscore the critical role of local climatic factors, emphasizing their potential impact on exacerbating respiratory conditions in children. Moreover, they point out the need for further research to elucidate the underlying mechanisms and develop targeted interventions for at-risk populations.

Rethinking the relationships between chronic rhinosinusitis and asthma severity

BACKGROUND

Previous authors have endorsed the need for prospective studies on the effect of treatment of chronic rhinosinusitis on asthma outcomes. Although common pathophysiology for asthma and chronic rhinosinusitis (CRS) has been suggested with the unified airway theory, there is limited data to support the claim and our study does not support the theory.

METHODS

This case-control study involved adult patients with a primary diagnosis of asthma in 2019 who were identified from the electronic medical records and divided into those with and without an associated CRS diagnosis. For each asthma encounter, the asthma severity classification, oral corticosteroid (OCS) use and oxygen saturation scores were tabulated and compared between asthma patients with CRS versus control patients after 1:1 matching on age and sex. We determined the association between asthma and chronic rhinosinusitis when evaluating proxies for disease severity: oral corticosteroid use, average oxygen saturation and minimum oxygen saturation. We identified 1321 clinical encounters for asthma associated with CRS and 1321 control encounters for asthma without CRS.

RESULTS

OCS prescription rates at the asthma encounter were not statistically different between the groups (15.3 % and 14.6 %, respectively; p = 0.623). Asthma severity classification was higher in those with CRS versus those without (38.9 % and 25.7 % classified as severe, respectively; p < 0.001). We identified 637 asthma with CRS and 637 matched control patients. There was no significant difference in mean recorded O2 saturations between asthma patients with CRS versus control patients (mean O2 saturations, 97.2 % and 97.3 %, respectively; p = 0.816) nor in minimum oxygen saturation (96.8 % and 97.0 %, respectively; p = 0.115).

CONCLUSION

Among patients with a primary diagnosis of asthma an increasing severity of asthma classification was significantly associated with an associated diagnosis of CRS. In contradistinction, the presence of CRS comorbidity in asthma patients was not associated with increased OCS use for asthma. Similarly, average oxygen saturation and minimum oxygen saturation did not seem differ according to CRS comorbidity. Our study does not support the unified airway theory that suggests a causative relationship between the upper and lower airway.

Reduced forced expiratory flow between 25% and 75% of vital capacity in children with allergic rhinitis without asthmatic symptoms

INTRODUCTION

Allergic rhinitis (AR) and asthma are closely associated in children. Reduced FEF_25%-75% which reflects small airway airflow limitation is frequently observed in asthma. This study aimed to examine the proportion of small airway dysfunction in children with AR and to determine its associated factors.Methods: The medical records of 144 aged 6-18-year children with AR without overt asthmatic symptoms were retrospectively reviewed. Subjects were divided into 2 groups according to the FEF_25%-75% values; normal FEF_25%-75% group (n = 129) and reduced FEF_25%-75% group (n = 15). Clinical data, allergen sensitization profile, exhaled nitric oxide, spirometry, and methacholine provocation test results were compared between the two groups.Results: The mean FEV₁ and FEF_25%-75% values in the reduced FEF_25%-75% group (73.5 ± 9.4%pred and 56.0 ± 7.7%pred, respectively) were significantly lower than in the normal FEF_25%-75% group (87.0 ± 12.5%pred and 99.1 ± 21.4%pred, respectively). The mean disease duration was significantly longer in the reduced FEF_25%-75% group than in the normal FEF_25%-75% group (5.39 ± 1.85 y vs 3.14 ± 1.80 y, p < 0.001). Subjects with positive bronchial hyperresponsiveness (MChPC₂₀<16 mg/mL) were more frequently detected in the reduced FEF_25%-75% group than in the normal FEF_25%-75% group (26.7% vs 8.52%, p = 0.013). Long disease duration and severity of AR were significantly associated with impaired FEF_25%-75% values.Conclusions: Subjects with AR alone may have impaired FEF_25%-75% values which is considered as a marker of early bronchial involvement. Longer disease duration and severity of AR are important risk factors for progressive declines in small airway function. Physicians should be aware of need for the measurement of FEF_25%-75% values for early detection of small airway dysfunction, particularly in children with severe long-lasting allergic rhinitis.

Exosomes Derived hsa-miR-4669 as a Novel Biomarker for Early Predicting the Response of Subcutaneous Immunotherapy in Pediatric Allergic Rhinitis

Purpose

Subcutaneous immunotherapy (SCIT) is an effective treatment for pediatric allergic rhinitis (AR), but its efficacy fluctuates among individuals. This study aims to identify the profile of serum exosomes derived microRNAs (miRNAs) and evaluate their capacities to early predict SCIT efficacy in pediatric AR.

Patients and Methods

High-throughput sequencing was applied to identify the miRNA of serum exosomes in AR children. GO enrichment and KEGG pathway analysis were performed to enrich the biological annotations of target mRNAs of miRNAs. Then we validated differentially expressed miRNAs in two independent cohorts by RT-qPCR. Logistic regression and receiver operating characteristic curve (ROC) were applied to evaluate the abilities of identified miRNAs in predicting the efficacy of SCIT in AR children.

Results

A total of 812 miRNAs were detected in the serum exosomes, including 16 upregulated and 14 downregulated. Differentially expressed genes are enriched in the biological process of developmental process and regulation of cellular process, and gathered in pathways such as the signaling pathways regulating pluripotency of stem cells and the Wnt signaling pathway. In the first validation cohort, hsa-miR-4669 (P=0.009) and hsa-miR-4686 (P=0.032) were significantly downregulated in the effective group than the ineffective group, while hsa-miR-3196 (P=0.015) was upregulated. In the second cohort, hsa-miR-4669 level (P<0.0001) was downregulated in the effective group than the ineffective group. In addition, logistic regression revealed that hsa-miR-4669 level was correlated with the visual analogue scale (r=0.323, P=0.001) and total nasal symptoms score (r=0.269, P =0.007). ROC curve highlighted that hsa-miR-4669 level exhibited a reliable accuracy in predicting SCIT efficacy in pediatric AR (AUC=0.785).

Conclusion

Serum exosomes derived miRNA were associated with the efficacy of SCIT. Serum exosomes derived hsa-miR-4669 might serve as a novel biomarker for early predicting the response of SCIT in AR children.

The GSDMB rs7216389 SNP is associated with chronic rhinosinusitis in a multi-institutional cohort

BACKGROUND

Chronic rhinosinusitis (CRS) is a multifactorial disease with a high co-occurrence with asthma. In this multicohort study, we tested whether single nucleotide polymorphisms (SNPs) associated with childhood asthma and rhinovirus (RV)-associated disease are related to an increased susceptibility to adult CRS in a multicohort retrospective case-control study.

METHODS

Participants at two tertiary academic rhinology centers, University of Arizona (UofA) and University of Pennsylvania (UPenn) were recruited. Cases were defined as those with physician diagnosed CRS (UofA, n = 149; UPenn, n = 250), and healthy controls were those without CRS (UofA, n = 66; UPenn, n = 275). Genomic DNA was screened for the GSDMB rs7216389 SNP and CDHR3 rs6967330 SNP. Gene dosage, or the number of combined risk alleles in a single subject was calculated. Meta-analysis of the association between GSDMB or CDHR3 genotypes and CRS was performed and additive gene dosage effect for each population calculated using p for trend.

RESULTS

A meta-analysis revealed a combined increased risk for CRS in subjects with the GSDMB rs7216389 SNP (odds ratio [OR] 1.40; 95% confidence interval [CI], 1.16-1.76; p = 0.004). Both the UofA (OR 1.73; 95% CI, 1.23-2.43; p = 0.002) and UPenn (OR 1.27; 95% CI, 1.02-1.58; p = 0.035) populations showed a significant positive association between the number of combined risk alleles of GSDMB rs7216389 SNP and CDHR3 rs6967330 SNP and risk for CRS.

CONCLUSION

Carriers of the GSDMB rs7216389 SNP and CDHR3 rs6967330 SNP are at increased susceptibility for CRS. These data suggest that therapeutic approaches to target aberrant responses to RV infection may play a role in the treatment of unified airway disease.

A prospective pilot study on the effects of endoscopic sinus surgery on upper and lower airway performance

Objective

Methods

Results

Conclusions

Precision Medicine for Paediatric Severe Asthma: Current Status and Future Direction

Asthma is a heterogeneous disease, characterised by different phenotypes and endotypes. Precision medicine in asthma refers to the implementation of a targeted therapy for each individual child, based on the identification of treatable traits, including environmental, immunological and genetic factors. Severe asthma in children is associated with increased hospitalisation rates, a lower quality of life, increased healthcare costs and an increased mortality. In the era of new molecular biologics treatments, it is essential to improve deep phenotyping of children with severe asthma in order to deliver the most effective treatment to each individual child. In this review, we discuss the personalised approach to the assessment and management of severe asthma. We explore the indications and use of the currently licensed biologics, as well as the potential of other emerging treatments.

Association of chronic rhinosinusitis with bronchial asthma and its severity: A protocol for systematic review and meta-analysis

BACKGROUND

To explore the association of chronic rhinosinusitis (CRS) with bronchial asthma (BA) as well as its severity.

METHODS

A comprehensive database search will be performed from PubMed, Embase, Cochrane Library, and Web of science for related literatures. Heterogeneity test will be used to assess each outcome indicator. If heterogeneity statistics I2 ≥ 50%, the random effects model will be applied; if I2 < 50%, the fixed effects model will be performed. Sensitivity analysis will be performed in all models. STATA 15.0 software (Stata Corporation, College Station, TX) will be used for statistical analysis. Risk ratio (RR) will be used as the effect size for enumeration data. P < .05 is considered statistically significant.

CONCLUSION

This study will evaluate the association of CRS with the prevalence of BA as well as its severity.

OSF REGISTRATION NUMBER

10.17605/OSF.IO/GCTM9.

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.

CFD Guided Optimization of Nose-to-Lung Aerosol Delivery in Adults: Effects of Inhalation Waveforms and Synchronized Aerosol Delivery

PURPOSE

The objective of this study was to optimize nose-to-lung aerosol delivery in an adult upper airway model using computational fluid dynamics (CFD) simulations in order to guide subsequent human subject aerosol delivery experiments.

METHODS

A CFD model was developed that included a new high-flow nasal cannula (HFNC) and pharmaceutical aerosol delivery unit, nasal cannula interface, and adult upper airway geometry. Aerosol deposition predictions in the system were validated with existing and new experimental results. The validated CFD model was then used to explore aerosol delivery parameters related to synchronizing aerosol generation with inhalation and inhalation flow rate.

RESULTS

The low volume of the new HFNC unit minimized aerosol transit time (0.2 s) and aerosol bolus spread (0.1 s) enabling effective synchronization of aerosol generation with inhalation. For aerosol delivery correctly synchronized with inhalation, a small particle excipient-enhanced growth delivery strategy reduced nasal cannula and nasal depositional losses each by an order of magnitude and enabled ~80% of the nebulized dose to reach the lungs. Surprisingly, nasal deposition was not sensitive to inhalation flow rate due to use of a nasal cannula interface with co-flow inhaled air and the small initial particle size.

CONCLUSIONS

The combination of correct aerosol synchronization and small particle size enabled high efficiency nose-to-lung aerosol delivery in adults, which was not sensitive to inhalation flow rate.

Development of an Inline Dry Powder Inhaler for Oral or Trans-Nasal Aerosol Administration to Children

Background: Dry powder inhalers (DPIs) offer a number of advantages, such as rapid delivery of high-dose inhaled medications; however, DPI use in children is often avoided due to low lung delivery efficiency and difficulty in operating the device. The objective of this study was to develop a high-efficiency inline DPI for administering aerosol therapy to children with the option of using either an oral or trans-nasal approach. Methods: An inline DPI was developed that consisted of hollow inlet and outlet capillaries, a powder chamber, and a nasal or oral interface. A ventilation bag or compressed air was used to actuate the device and simultaneously provide a full deep inspiration consistent with a 5-year-old child. The powder chamber was partially filled with a model spray-dried excipient enhanced growth powder formulation with a mass of 10 mg. Device aerosolization was characterized with cascade impaction, and aerosol transmissions through oral and nasal in vitro models were assessed. Results: Best device performance was achieved when all actuation air passed through the powder chamber (no bypass flow) resulting in an aerosol mean mass median aerodynamic diameter (MMAD) <1.75 μm and a fine particle fraction (<5 μm) ≥90% based on emitted dose. Actuation with the ventilation bag enabled lung delivery efficiency through the nasal and oral interfaces to a tracheal filter of 60% or greater, based on loaded dose. In both oral and nose-to-lung (N2L) administrations, extrathoracic depositional losses were <10%. Conclusion: In conclusion, this study has proposed and initially developed an efficient inline DPI for delivering spray-dried formulations to children using positive pressure operation. Actuation of the device with positive pressure enabled effective N2L aerosol administration with a DPI, which may be beneficial for subjects who are too young to use a mouthpiece or to simultaneously treat the nasal and lung airways of older children.

Managing comorbid conditions in severe asthma

Asthma care has increasingly focused on personalised management for severe asthma, and recognition of the role and importance of comorbid conditions has increased. Severe asthma can be crippling; associated comorbid conditions often play a key role in the significant disease morbidity and frequently contribute to a severe and difficult-to-treat asthma phenotype. Comorbid conditions can be broadly grouped as being either airway-related or airway-unrelated. Airway-related comorbid conditions with the greatest impact are allergic rhinitis, chronic rhinosinusitis, vocal cord dysfunction, lung fungal sensitisation and underlying structural lung disease. The most important airway-unrelated comorbid conditions are obesity, obstructive sleep apnoea, gastro-oesophageal reflux disease and anxiety and depression. A diagnostic and management algorithm for comorbid conditions in severe asthma is outlined. It concentrates initially on the group with common comorbid conditions that can be managed in primary care. If asthma remains troublesome, emphasis can shift to identifying uncommon and more complex factors. The algorithm allows for personalised diagnostic and management pathways to be implemented. Personalised diagnosis and management of comorbid conditions are essential to achieving effective and improved outcomes for patients with severe asthma.

Asthma in the Primary Care Setting

Asthma is one of the commonest respiratory diseases in the United States, affecting approximately 8% of adults. This article reviews the epidemiology, diagnosis, and treatment of asthma, with integration of recommendations from professional societies, with special attention to differential diagnosis. A framework for outpatient management of patients with asthma is presented, including indications for subspecialist referral. With integration of objective diagnostic information, systematic approach through modification of disease triggers and adjustment of controller medications, and patient empowerment to respond to varying symptoms using an asthma action plan, most individuals with asthma are successfully managed in the primary care setting.

Lund-Mackay Computed Tomography Score Is Associated With Obstructive Pulmonary Function Changes in Chronic Cough Patients

BACKGROUND

A remarkable relationship between upper airway conditions and lung diseases has been reported. At the same time, sinonasal findings in chronic cough patients have not been fully examined.

OBJECTIVE

The purpose of this study is to show paranasal sinus findings and lung function in chronic cough patients without asthma and chest X-ray abnormalities.

METHODS

A total of 1412 patients with persistent cough were enrolled in this study. Of these patients, 376 patients were evaluated for further examination, as the patients with asthma and/or chest X-ray abnormality were excluded from the study. Normal control subjects without any chronic respiratory symptoms were also recruited. Pulmonary function was examined by spirometry. A bronchial obstruction reversibility test was applied. The Lund-Mackay computed tomography (CT) score, peripheral blood eosinophil count, and immunoglobulin E concentration in serum samples were examined. The Sino-Nasal Outcome Test was used to determine the severity of clinical symptoms.

RESULTS

The patients with an abnormal soft tissue shadow in the paranasal sinus had significant obstructive lung function. The percent predicted forced expiratory volume in 1 second (FEV_1.0) and the FEV_1.0/forced vital capacity ratio negatively correlated with Lund-Mackay CT scores both before and after bronchodilator inhalation. There was a statistically significant correlation between pulmonary function and eosinophil count.

CONCLUSION

The patients with chronic cough frequently had paranasal sinus abnormalities. The Lund-Mackay CT score may be useful for assessing the condition of the lower airway in chronic cough patients. Upper airway examinations should play a part in the management of chronic cough.

Current healthcare pathways in the treatment of rhinosinusitis in Germany

BACKGROUND

In the outpatient setting in Germany, patients with rhinosinusitis usually present at general practices (GP) or ear, nose, and throat practices (ENT) for initial diagnosis and treatment.

OBJECTIVES

The aim of this study was to analyze the referral patterns of rhinosinusitis patients in GPs and ENT practices in Germany, with respect to existing recommendations.

MATERIAL AND METHODS

The study sample included patients from 940 GP and 106 ENT practices from Disease Analyzer database (IQVIA) who received an acute sinusitis (AS) or chronic sinusitis (CS), or nasal polyp (NP) in 2015.

RESULTS

The total numbers of patients in GP versus ENT practices were 24,648 versus 12,095 (AS), 26,768 versus 19,826 (CS), and 516 versus 1773 patients (NP). Referrals to ENT practices were made by GP in 12.3% (AS), 14.8% (CS), and 40.5% (NP). The percentages of patients in GP versus ENT practices with subsequent hospital admissions were 6.9 versus 3.3% (AS), 6.3 versus 6.5% (CS), and 9.5 versus 13.8% (NP), respectively.

CONCLUSIONS

Although 40% of patients with NP who consult GPs are referred to ENT practices, it remains unclear how the other 60% are being treated. The hospital admission rates of patients with CS as well as of patients with NP were found to be surprisingly low.

New-Onset Asthma in Adults: What Does the Trigger History Tell Us?

BACKGROUND

Adult-onset asthma is an important asthma phenotype and, in contrast to childhood asthma, is often associated with specific triggers of onset. It is unknown whether these triggers correspond with specific phenotypic characteristics or predict a specific asthma outcome.

OBJECTIVE

To compare clinical, functional, and inflammatory characteristics between patients with different triggers of asthma onset, and relate these triggers to asthma outcome.

METHODS

Two hundred adults with recently diagnosed (<1 year) asthma were prospectively followed for 5 years. The trigger of asthma onset was patient reported and defined by the question: "What, in your opinion, elicited your asthma?" Asthma remission was defined as no asthma symptoms and no asthma medication use for ≥1 year. Kruskal-Wallis and Fisher's exact test were used to compare categories containing >10 patients.

RESULTS

Ten categories of triggers were identified, of which 5 contained >10 patients. Clinical and inflammatory characteristics and remission rates differed significantly between categories. "New allergic sensitization" (11%) was associated with mild atopic asthma and a relatively young age at onset; "pneumonia" (8%) with previous smoking, low IgE, and the highest remission rates (one third); "upper respiratory symptoms" (22%) with high exhaled NO and eosinophilia; "no trigger identified" (38%) did not show any specific characteristics; and "stressful life event" (7%) with high medication usage, low type 2 markers, and no disease remission.

CONCLUSIONS

Patients with adult-onset asthma can be characterized by the trigger that seemingly incited their asthma. These triggers might represent underlying mechanisms and may be important to phenotype patients and predict disease outcome.

The characteristic of asthma control among nasal diseases population: Results from a cross-sectional study

Asthma affects a large number of patients in China, but comprehensive evaluation of risks associated with poor asthma control in asthmatic patients with nasal diseases was still limited. We conducted this study to provide a comprehensive estimate of asthma control in Chinese asthma patients with combined nasal diseases, to explore the effect of kinds of nasal diseases on the asthma control, and to identify risk factors associated with uncontrolled asthmatic patients with combined nasal diseases. 1756 asthma patients concomitant with nasal diseases aged ≥17 years and representing all regions of mainland China were surveyed. Multivariate logistic regression model with all related demographic characteristics and disease characteristics factors entered was used to identify risk factors associated with uncontrolled asthma. 56.4% of asthmatic patients with combined allergic rhinitis or rhinosinusitis or rhinopolyp remained uncontrolled. Concomitant without allergic rhinitis, younger age, better treatment adherence and higher education level might positively impact asthma control among asthmatic patients with combined nasal diseases. Perennial allergic rhinitis (OR = 1.5, P = 0.021), moderate-severe allergic rhinitis (OR = 2.2, P = 0.001) were all found to significantly increase the risk of uncontrolled asthma among asthma patients with combined allergic rhinitis. The high prevalence of uncontrolled asthma indicates that asthma management among adult Chinese asthmatic patients comorbid with nasal disease is still a challenge. Efforts should be made to raise the awareness of asthma management and to provide sufficient treatment will greatly contribute to improved quality of asthma management. It is possible to minimize the influence of allergic rhinitis on asthma control by improving nasal function, especially for more severe allergic rhinitis and perennial allergic rhinitis.

Acute and chronic rhinosinusitis and allergic rhinitis in relation to comorbidity, ethnicity and environment

Background

This study was conducted to assess the effect of comorbidity, ethnicity, occupation, smoking and place of residence on allergic rhinitis (AR), acute rhinosinusitis (ARS) and chronic rhinosinusitis (CRS).

Methods

A GA²LEN (The Global Allergy and Asthma European Network) screening questionnaire was sent to a random sample of the Dutch population (n = 16700) in three different areas of the Netherlands.

Results

Fifty percent (8347) of the questionnaires sent were returned. A total of 29% respondents (27–31% in different areas) met the criteria for AR, 18% (17–21%) for ARS and 16% (13–18%) for CRS. Risk factors for AR were itchy rash, eczema, adverse response after taking a painkiller, asthma, CRS and ARS. Moreover, the risk of AR was twice as low for full-time housewives/househusbands than for people with jobs. The risk of ARS or CRS was significantly higher in respondents with a doctor’s diagnosis of CRS, AR, itchy rash or smoking. The risk of CRS was also significantly higher in respondents with an adverse response after taking painkillers, active smoking or asthma. Caucasians are generally less likely to have AR or CRS than Latin-Americans, Hindustani and African-Creoles, and more likely to have ARS than Asian, Hindustani, Mediterranean and African-Creoles.

Conclusions

This study found shared and distinct risk factors for AR, ARS and CRS and therefore provides support for the belief that they have shared symptoms but are different diseases with different aetiologies.

Association between Asthma and Chronic Rhinosinusitis Severity in the Context of Asthma Control

Objective Comorbid asthma is associated with decreased quality of life (QOL) in chronic rhinosinusitis (CRS). It is unclear whether this association is independent of the patients' clinical asthma status. We therefore sought to determine if asthma is associated with lower QOL in CRS, independent of asthma control. Study Design Cross-sectional cohort study of 350 patients with CRS. Setting Tertiary academic rhinology clinic. Subjects and Methods In total, 350 participants with CRS were recruited and 28.3% were asthmatic. CRS-specific QOL was measured using the 22-item Sinonasal Outcome Test (SNOT-22). Asthma control was assessed with the Asthma Control Test (ACT). General health-related QOL was assessed with the EuroQoL 5-dimensional general health-related quality of life survey visual analog scale (EQ-5D VAS). Associations were sought between SNOT-22 and EQ-5D VAS (dependent variables) and asthma (independent variable), while controlling for ACT. ACT score for patients with CRS without asthma was set at 25 (indicating completely controlled, asymptomatic asthma). Results Comorbid asthma was associated with SNOT-22 (β = 11.8; 95% confidence interval [CI], 6.2-17.3; P < .001) and EQ-5D VAS (β = -6.2; 95% CI, -11.2 to -1.3; P = .014). After controlling for ACT, asthma was no longer associated with SNOT-22 ( P = .147) or EQ-5D VAS ( P = .994). Instead, ACT score was associated with SNOT-22 (β = -2.1; 95% CI, -3.2 to -1.1; P < .001) and EQ-5D VAS (β = 2.1; 95% CI, 1.1 to 3.0; P < .001). ACT score completely drove the association between asthma and worse QOL. Conclusion Comorbid asthma is not necessarily reflective of decreased QOL in CRS. The association of comorbid asthma with lower QOL in CRS is related to the clinical status (eg, control) of asthma.

Asthma control among adults in Saudi Arabia. Study of determinants

Objectives:

To explore the determinants of uncontrolled asthma in Saudi Arabia.

Methods:

A consecutive series of adult asthma patients attending 3 pulmonary primary care clinics in Riyadh, Saudi Arabia for a scheduled appointment were interviewed. A multiple logistic regression analysis was used.

Results:

The proportion of patients with uncontrolled asthma was 68.1% (177/260). Daily tobacco smoking or monthly household income less than 15,000 Saudi Arabian Riyals were associated with a 4.6 (95% confidence interval [CI]=1.3-16.4) and 3.4 (95% CI=1.8-6.6) times increase in the odds of having uncontrolled asthma. Patients with less than a graduate degree (odds ratio [OR]=3.1; 95% CI=1.0-9.5) or patients who were unemployed, disabled, or too ill to work (OR=3.1; 95% CI=1.4-6.9) had poorer asthma control. Having heartburn during the past 4 weeks decreased the odds of asthma control by 2.5 (95% CI=1.3-4.9), and having chronic sinusitis during the past 4 weeks decreased the odds of asthma control by 2.0 (95% CI=1.0-4.0) times. Being female (OR=2.0; 95% CI=1.0-4.0) or ≥35 years of age (OR=2.0; 95% CI=1.0-3.9) was also associated with having uncontrolled asthma.

Conclusion:

Our findings suggest that most respondents had uncontrolled asthma. Less modifiable socio-demographic factors (for example, income, education, occupation, gender, and age) significantly increased the odds of having uncontrolled asthma. However, modifiable risk factors such as tobacco smoking and clinical factors such as heartburn and chronic sinusitis could also be targeted for intervention.

Impact of rhinitis on lung function in children and adolescents without asthma

BACKGROUND

Subclinical spirometric abnormalities may be detected in patients with rhinitis without asthma, proportional to the severity established by ARIA (Allergic Rhinitis and Its Impact on Asthma) guidelines. New criteria of rhinitis classification were recently validated according to the ARIA modified (m-ARIA), which allow the discrimination between moderate to severe grades. The impact of rhinitis on lung function according to frequency and severity is unknown.

OBJECTIVES

To investigate subclinical spirometric impairment in children and adolescents with allergic and non-allergic rhinitis without overt symptoms of asthma, according to the frequency and severity criteria of rhinitis classified by m-ARIA.

METHODS

An observational cross-sectional study, including children and adolescents aged 5-18 years with allergic and non-allergic rhinitis without asthma. We analysed the functional abnormalities and bronchodilator response with spirometry in relation to the grade of rhinitis established by m-ARIA using an adjusted logistic model. A value of p<0.05 was considered statistically significant.

RESULTS

We studied 189 patients; 22.2% showed spirometric abnormalities. Patients with persistent rhinitis had greater impairment of lung function compared to intermittent grade (p=0.026). Lung functional impairment was more frequent in severe and moderate rhinitis than mild grade (p=0.005) and was independent of the atopic status to both frequency (p=0.157) and severity (p=0.538). There was no difference in bronchodilator reversibility between groups (p>0.05).

CONCLUSIONS

Impaired lung function was associated with persistence and severity of rhinitis and there was no significant difference between patients with moderate and severe rhinitis. The spirometric abnormality was demonstrated in patients with allergic and non-allergic rhinitis.

Comparison of Oral Montelukast and Intranasal Fluticasone in Patients with Asthma and Allergic Rhinitis

INTRODUCTION

Even though the links between upper and lower airway had been of interest to clinicians since long back, it has not attracted the attention of the researchers till recent past. But the evidence is still far from conclusive, due to limited number of randomized controlled trials available on subjects with concomitant allergic rhinitis and asthma. This gap in the knowledge is even more conspicuous in Indian population.

AIM

The current study is conducted with an objective of comparing the efficacy and tolerability of intranasal Fluticasone and oral Montelukast in treatment of allergic rhinitis and bronchial asthma.

MATERIALS AND METHODS

The study was a prospective randomized, single blinded, comparative, parallel group study, with two intervention groups conducted in a tertiary teaching hospital in Chennai, Southern India. One hundred and twenty patients diagnosed with concomitant diagnosis of allergic rhinitis and bronchial asthma was randomly allocated to either Fluticasone propionate aqueous nasal spray or oral Montelukast group.

RESULTS

Out of total 120 subjects recruited, 108 subjects were included in the final analysis. The mean reduction in asthma and rhinitis symptom scores and improvement in PEFR was higher for Group A, compared to Group B during all the follow-up periods. No statistically significant difference was observed in proportion of subjects reporting exacerbations in the current study. Both the treatments were well tolerated.

CONCLUSION

Addition of intranasal Fluticasone propionate to Salmeterol plus Fluticasone is beneficial in improving asthma control, allergic rhinitis control and lung functions as compared to oral Montelukast. Thereby the use of intranasal Fluticasone Propionate in comparison to oral Montelukast in control of Allergic Rhinitis is justified as per the significant improvement in outcome measures.

The link between chronic rhinosinusitis and asthma: A questionnaire-based study

Treatments for chronic rhinosinusitis (CRS) and asthma can affect both conditions, based on the united airway concept. This study aimed to evaluate the link between CRS and asthma, based on disease-specific quality of life measures.We performed a prospective cohort study to investigate the correlations between results from CRS- and asthma-specific questionnaires. Thirty-two patients with asthma and CRS were evaluated before and after undergoing nasal surgery at a tertiary medical center.There were significant correlations between the results from the Asthma Control Test (ACT) and the Sino-Nasal Outcome Test-22, as well as between the results of the ACT and Rhinoconjunctivitis Quality of Life Questionnaire, at both the preoperative and 3-month postoperative evaluations (P < 0.01). Moreover, nasal surgery improved the sinonasal symptoms, asthma control, and pulmonary function (P < 0.01).Increasingly severe sinonasal symptoms of CRS were associated with poor asthma control. Therefore, CRS and asthma should be considered and treated as common airway diseases.

Pulmonary function in never-smoker patients with chronic rhinosinusitis

BACKGROUND

A close relationship between upper and lower respiratory tract diseases has been reported. The purpose of this study was to evaluate lung function in patients with chronic rhinosinusitis (CRS) who have never smoked.

METHODS

A total of 208 patients with CRS were enrolled in this study. Of these subjects, 96 patients were ever smokers and 112 patients were never smokers. CRS patients with lower pulmonary diseases including chronic obstructive pulmonary disease (COPD) and asthma were excluded from this study. Age-matched normal control subjects (n = 55) who were never smokers were also recruited. Pulmonary function testing was performed using spirometry. Lund-Mackay computed tomography (CT) score, peripheral blood eosinophil count, and immunoglobulin E (IgE) level in serum samples were examined. Nasal obstruction was evaluated by active anterior rhinomanometry.

RESULTS

CRS patients who were ever smokers have decreased lung function. Never-smoking patients with CRS also showed significant obstructive lung function changes as compared with normal controls. No significant correlation was detected between the clinical parameters (CT score, eosinophil count, IgE level, and nasal resistance) and lung function.

CONCLUSION

Asymptomatic obstructive lung function changes were observed in never-smoking patients with CRS. Our findings suggest that patients with CRS should be followed carefully in order to detect lung diseases.

Rhinosinusitis and asthma: a very long engagement

Upper and lower airways may be considered as a unique entity, interested by coexisting inflammatory processes that share common etiopathogenic mechanisms. Previous studies have strongly demonstrated a relationship between rhinosinusitis and asthma. This has led to the introduction of the concept of “United Airways”, which has also been included in the WHO document Allergic Rhinitis and its Impact on Asthma (ARIA); this concept has important consequences also on the treatment of these disorders. To better summarize the evident connection between upper and lower airway disease we decided to describe it as a multilayered construction, each level pointing out more deeply the relationship between these entities.

Omalizumab for the treatment of inadequately controlled allergic rhinitis: a systematic review and meta-analysis of randomized clinical trials

BACKGROUND

Patients with moderate-to-severe allergic rhinitis who are inadequately controlled despite treatment according to current rhinitis management guidelines have a significant unmet medical need. Such patients have a negative impact on daily functioning and are at risk of developing serious comorbidities, such as asthma and chronic rhinosinusitis.

OBJECTIVE

To assess the efficacy and safety of omalizumab in poorly controlled allergic rhinitis under a meta-analysis framework.

METHODS

MEDLINE and the Cochrane Central Register of Controlled Trials were searched through September 2013. Studies on the efficacy of omalizumab in allergic rhinitis that assessed clinical outcomes were selected. Descriptive and quantitative information was extracted; mean differences and relative risk estimates were synthesized under a fixed or random effects model. Heterogeneity was assessed by using the Q statistic and the I(2) metric. Subgroup analyses were performed for the presence of specific immunotherapy treatment.

RESULTS

Of the 352 citations retrieved, 11 studies of 2870 patients were finally included. A statistically significant reduction in the daily nasal symptom severity score (standardized mean difference -0.67 [95% CI, -1.3 to -0.31]; P < .0001; I(2), 92%) and a statistically significant reduction in daily nasal rescue medication score (-0.22 [95% CI, -0.39 to -0.05; P = .01; I(2), 58%) were observed. There was not a statistically significant difference in the occurrence of any adverse event (relative risk 1.06 [95% CI, 0.94-1.19; I(2), 55%).

CONCLUSIONS

Omalizumab is statistically significantly associated with symptom relief, decreased rescue medication use, and improvement of quality of life in patients with inadequately controlled allergic rhinosinusitis.

Association of adenotonsillectomy with asthma outcomes in children: a longitudinal database analysis

BACKGROUND

Childhood asthma and obstructive sleep apnea (OSA), both disorders of airway inflammation, were associated in recent observational studies. Although childhood OSA is effectively treated by adenotonsillectomy (AT), it remains unclear whether AT also improves childhood asthma. We hypothesized that AT, the first line of therapy for childhood OSA, would be associated with improved asthma outcomes and would reduce the usage of asthma therapies in children.

METHODS AND FINDINGS

Using the 2003-2010 MarketScan database, we identified 13,506 children with asthma in the United States who underwent AT. Asthma outcomes during 1 y preceding AT were compared to those during 1 y following AT. In addition, 27,012 age-, sex-, and geographically matched children with asthma without AT were included to examine asthma outcomes among children without known adenotonsillar tissue morbidity. Primary outcomes included the occurrence of a diagnostic code for acute asthma exacerbation (AAE) or acute status asthmaticus (ASA). Secondary outcomes included temporal changes in asthma medication prescriptions, the frequency of asthma-related emergency room visits (ARERs), and asthma-related hospitalizations (ARHs). Comparing the year following AT to the year prior, AT was associated with significant reductions in AAE (30.2%; 95% CI: 25.6%-34.3%; p<0.0001), ASA (37.9%; 95% CI: 29.2%-45.6%; p<0.0001), ARERs (25.6%; 95% CI: 16.9%-33.3%; p<0.0001), and ARHs (35.8%; 95% CI: 19.6%-48.7%; p = 0.02). Moreover, AT was associated with significant reductions in most asthma prescription refills, including bronchodilators (16.7%; 95% CI: 16.1%-17.3%; p<0.001), inhaled corticosteroids (21.5%; 95% CI: 20.7%-22.3%; p<0.001), leukotriene receptor antagonists (13.4%; 95% CI: 12.9%-14.0%; p<0.001), and systemic corticosteroids (23.7%; 95% CI: 20.9%-26.5%; p<0.001). In contrast, there were no significant reductions in these outcomes in children with asthma who did not undergo AT over an overlapping follow-up period. Limitations of the MarketScan database include lack of information on race and obesity status. Also, the MarketScan database does not include information on children with public health insurance (i.e., Medicaid) or uninsured children.

CONCLUSIONS

In a very large sample of privately insured children, AT was associated with significant improvements in several asthma outcomes. Contingent on validation through prospectively designed clinical trials, this study supports the premise that detection and treatment of adenotonsillar tissue morbidity may serve as an important strategy for improving asthma control. Please see later in the article for the Editors' Summary.

Chronic rhinosinusitis patients have decreased lung function

BACKGROUND

The relationship between upper and lower airway diseases has been reported. However, the pulmonary function of patients with chronic rhinosinusitis (CRS) has not been fully examined.

METHODS

Pulmonary function was measured in 273 patients with CRS and 100 age-matched normal control subjects. No patients with chronic obstructive pulmonary disease (COPD) were included in this study. The patients with CRS were divided into 8 subgroups based on the presence of asthma, sensitization to common inhaled antigens, and nasal polyposis. The relationships between pulmonary function and clinical parameters, including radiographic severity of CRS according to the Lund-Mackay computed tomography (CT) staging system, eosinophil count in the peripheral blood, and serum total immunoglobulin E (IgE) levels, were assessed.

RESULTS

In pulmonary function testing, the CRS patients had affected pulmonary function. The CRS patients without asthma showed latent obstructive pulmonary function changes when compared to normal controls. No significant correlations were observed between pulmonary function and any clinical parameters (Lund-Mackay CT staging score, eosinophil count in the peripheral blood, and serum total IgE levels).

CONCLUSION

CRS patients had significant obstructive lung function changes regardless of the presence of asthma. The patients with CRS who had not been clinically diagnosed as having lower respiratory tract diseases might have had subclinical lower airway diseases. Therefore, clinicians should be aware of pulmonary function and lower lung diseases in patients with CRS.

Pulmonary function in patients with chronic rhinosinusitis and allergic rhinitis

BACKGROUND

A close relationship between upper and lower respiratory tract diseases has been reported. However, little is known about pulmonary function in patients with upper respiratory tract diseases.

METHODS

Pulmonary function was measured in: 68 patients with chronic rhinosinusitis without nasal polyps, 135 patients with chronic rhinosinusitis with nasal polyps, 89 patients with allergic rhinitis and 100 normal control subjects. The relationships between pulmonary function and clinical parameters were assessed. These parameters included radiographic severity of chronic rhinosinusitis, serum total immunoglobulin E levels, concentrations of cytokines in nasal secretions and exhaled nitric oxide levels.

RESULTS

The pulmonary function of patients with chronic rhinosinusitis was significantly affected. The level of interleukin-5 in nasal secretions was significantly correlated with pulmonary function in patients with chronic rhinosinusitis.

CONCLUSION

The findings indicated latent obstructive lung function changes in chronic rhinosinusitis patients. The cytokines in nasal secretions might be related to obstructive lung function changes in chronic rhinosinusitis.

Lung functions of Japanese patients with chronic rhinosinusitis who underwent endoscopic sinus surgery

BACKGROUND

Chronic rhinosinusitis (CRS), which is clinically classified into CRS without nasal polyps (CRSsNP) and CRS with nasal polyps (CRSwNP), shows considerable geographic differences and heterogeneity. Eosinophilic (E) CRS with nasal polyps (ECRSwNP) has a higher degree of disease severity and higher frequency of comorbid asthma. Epidemiologic studies in different ethnic populations have improved understanding of the pathophysiology of the disease. Here we report the clinical characteristics of Japanese patients with medically refractory CRS undergoing endoscopic sinus surgery (ESS).

METHODS

We recruited a total of 210 CRS patients and assessed them by nasal endoscopy, the Lund-Mackay score using computed tomography (CT), peripheral eosinophilia and smoking status. We also examined the comorbidity of asthma, effects of age and lung functions in the patients.

RESULTS

In this study, 13% of CRSwNP patients and 20% of CRSwNP patients with peripheral blood eosinophilia exhibited obstructive lung dysfunction (FEV1/FVC <70%) despite the absence of an asthma diagnosis. Among elderly nonsmoker patients (≥ 60 years) who had never been diagnosed with asthma, 50% of CRSwNP patients with peripheral blood eosinophilia showed decreased FEV1/FVC <70%.

CONCLUSIONS

Our findings suggest that asthma is under-diagnosed in CRS patients who undergo ESS, especially the elderly. Although the association between CRS and asthma has been recognized, increased attention to the comorbidity of obstructive airway diseases such as asthma is still needed for management of medically refractory CRS.

Comorbidity profile of chronic rhinosinusitis: a population-based study

OBJECTIVES/HYPOTHESIS

This study aimed to explore the prevalence of a broad spectrum of comorbid medical conditions among patients with chronic rhinosinusitis (CRS), using a population-based dataset.

STUDY DESIGN

A cross-sectional study.

METHODS

In total, 5,734 CRS subjects and 17,202 comparison subjects were included in this study. Separate conditional logistic regression analyses were performed to calculate the odds ratio (OR) for each of 39 medical comorbidities between subjects with and without CRS.

RESULTS

For 27 of the 39 study comorbidities, results showed that subjects with CRS had a statistically significantly higher OR than subjects without CRS after adjusting for sociodemographic characteristics. Ranks of the top five comorbid relationships from the strongest ORs to the lowest were as follows: asthma (OR=3.09), chronic pulmonary disease (OR=3.04), weight loss (OR=2.58), obesity (OR=2.50), and migraines (OR=2.30).

CONCLUSION

Our results indicate that subjects with CRS have an increased prevalence of various comorbidities.

LEVEL OF EVIDENCE

3b.

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.

Impact of asthma education meeting on asthma control level assessed by asthma control test

Background

The asthma control test (ACT) is a reliable tool to measure the level of asthma control. In our research, we aimed to investigate the effect of participation in an asthma awareness session on the patient's perception of current asthma control as evaluated by ACT in relation to quality of life (QoL) in an adult population.

Methods

An observational study in subjects who were diagnosed as suffering with persistent asthma was performed. All asthmatic patients who were followed up in healthcare centers around the city were invited to the study. Patients who consented were informed about the study and then skin prick tests, pulmonary function tests, and blood analyses were performed. In addition, a self-administered generic QoL questionnaire (SF-36) was completed. Finally, the patients were invited to attend the asthma awareness session, and pre-post educational ACT assessments were evaluated.

Results

Overall asthma control was less than optimal in almost half of the study group. ACT level changed in 70.5% of the patients. The change in asthma control by using ACT was prominent in the ACT-deteriorated group than the ACT-improved group (-3.8 ± 2.7 and 2.1 ± 1.3, respectively; P = 0.001). Regarding comorbidities, the ACT-deteriorated group had the highest prevalence of rhinitis (P = 0.04). The impairment in QoL was similar between the groups and the physical domains of SF-36 were correlated with the ACT scores. The correlation between education level and asthma control was found to be significant after the training session (r = 0.353, P = 0.04).

Conclusion

Education in asthma is an essential strategy not only to achieve awareness of asthma control level as assessed by ACT, but also for the reliability of QoL measurement.

Differences in airway inflammation according to atopic status in patients with chronic rhinitis

Background

Chronic rhinitis is a heterogeneous group of diseases that cause nasal inflammation. And the nose may be a window into the lung in the concept of "one airway one disease."

Objective

This study was conducted to evaluate differences between the different forms of chronic rhinitis in terms of lower airway inflammation.

Methods

Patients that attended the allergy clinic and presented with moderate/severe persistent rhinitis symptoms for more than 1 year were enrolled. The patients with chronic rhinitis were classified into two groups (house dust mites [HDM]-sensitive allergic rhinitis [AR] or non-allergic rhinitis [NAR]) according to the presence of atopy, and additionally according to nasal polyposis and airway hyperresponsiveness, respectively. Medical records were reviewed and the mRNA expression levels of IL-5, IFN-γ, TGF-β1, IL-17A, and IL-25 were evaluated in induced sputum samples in each group.

Results

Induced sputum samples of 53 patients were evaluated. Patients with NAR were significantly older than patients with HDM-sensitive AR (p < 0.05). Nasal polyposis was more prevalent in NAR patients than in HDM-sensitive AR patients (10.2% vs. 62.5%, p < 0.001). The expression levels of IL-17A mRNA were higher in NAR patients, regardless of the presence of airway hyperresponsiveness (p = 0.005).

Conclusion

These results suggest that patients with different forms of chronic rhinitis could have different inflammatory environments in their lower airway and NAR patients might have bronchial inflammation related to the elevated levels of IL-17A compared to HDM-sensitive AR patients.

Pathophysiology, favoring factors, and associated disorders in otorhinosinusology

The pathogenesis of rhinosinusitis (RS) is related to inflammation, caused by infections in the acute form of the disease but also by other agents in the chronic forms. Cytology allows to evaluate the defensive components, such as hair cells and muciparous cells, while the presence in the nasal mucosa of eosinophils, mast cells, bacteria and/or fungal hyphae, or spores indicates the nasal pathology. The anatomic and physiologic characteristics of the otorhinosinusal system account for the frequent concomitant involvement of the different components. The pivotal pathophysiologic sites are the ostiomeatal complex, the spheno-ethmoidal recess, and the Eustachian tube. The latter is the link with acute otitis media (AOM), which is the most common disease in infants and children and has major medical, social, and economic effects. Moreover, because of the strict relationship between upper and lower airways, nasal sinus disease may contribute to asthma and sinusitis may be considered as an independent factor associated with frequent severe asthma exacerbations. Concerning the role of allergy, the available data do not permit to attribute a central role to atopy in sinusitis and thus allergy testing should not be a routine procedure, while an allergologic evaluation may be indicated in children with OM, especially when they have concomitant rhinitis.

Recent developments in United airways disease

The nose and lung are both part of the respiratory tract. Often the diseases affecting the nose and/or the bronchi are treated separately. However, in recent years, numerous studies have highlighted the fact that the respiratory system is a single entity and the concept of "united airway disease" has become more and more important. The unity of the respiratory tract is confirmed both from a morphological and from a functional point of view. Nevertheless, this concept is also confirmed for the respiratory immune system, innervation and vascularization interesting all along the tract, from the nose to the bronchioles. When treating rhinitis, it is often necessary to assess the presence of asthma. Patients with sinusitis should be evaluated for a possible concomitant asthma. Conversely, patients with asthma should always be evaluated for possible nasal disease. The medications that treat nasal diseases appear to be useful in improving control of asthma and in reducing bronchial hyperresponsiveness as well. Physicians should always keep these notions in mind, and evaluate and treat respiratory diseases taking into account the unity of the respiratory tract.

Association between severity of asthma and degree of chronic rhinosinusitis

BACKGROUND

There is a clinical association between asthma and chronic rhinosinusitis (CRS). This study was designed to determine whether severity of coexistent asthma affects the clinical presentation of CRS.

METHODS

Cross-sectional analysis was performed of prospectively collected data in 187 patients with CRS who were evaluated in a large, tertiary academic nasal and sinus center. Patients were stratified into three groups based on asthma status using National Institutes of Health criteria: (1) nonasthmatic, (2) intermittent/mild asthma, (3) or moderate/severe asthma.

RESULTS

Mean Lund-Mackay scores were 9.7, 11.6, and 15.6, respectively. ANOVA testing with post-hoc Tukey analysis revealed that Lund-MacKay scores were significantly greater in group 3 than either group 1 (p < 0.05) or group 2 (p < 0.01). The prevalence of allergic sensitization was 72.4, 82.8, and 100% in groups 1, 2, and 3, respectively (p = 0.03). The prevalence of nasal polyposis was 31.4% in group 1, 48.3% in group 2, and 94.4% in group 3 (p < 0.0001). No differences were observed regarding demographic factors or the incidence of the triad of aspirin sensitivity, asthma, and nasal polyposis among those with different severities of asthma.

CONCLUSION

Increasing severity of asthma is associated with advancing radiological severity of CRS and a greater prevalence of allergic sensitization and nasal polyposis. This large adult series shows that asthma severity may have a significant correlation with the presentation of CRS. This study adds to the growing support for the unified airway theory.

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.

The role of non-clinicians in a goal setting model for the management of allergic rhinitis in community pharmacy settings

OBJECTIVE

To test the relative effects of a clinician versus non-clinician delivered goal setting intervention to assist patients presenting with Intermittent Allergic Rhinitis (IAR) in community pharmacies.

METHODS

A 10-day mixed-method, parallel group repeated measures study was conducted in Sydney. Clinicians (pharmacists) and non-clinicians (pharmacy assistants) recruited patients suffering IAR. Intervention group pharmacy staff delivered a brief structured goal setting intervention to support IAR patient self-management whilst the control group delivered standard care.

RESULTS

One hundred and fifty participants (N=77 intervention; N=73 control) were recruited at 20 community pharmacies. Both groups significantly improved on all outcome measures when assisted by either clinicians or non-clinicians. The intervention group patients supported by non-clinicians made significant improvements in self-efficacy and quality of life compared to the control group supported by non-clinicians. Strategies devised to control IAR triggers reflected practical actions whereas adherence and dose information strategies addressed IAR symptoms. Adherence did not impact significantly on self-reported symptom severity.

CONCLUSION

Both clinicians and non-clinicians can deliver this service. There is a need for a detailed and practical approach to assist patients towards a goal-directed and autonomous management of IAR.

PRACTICE IMPLICATIONS

With training non-clinicians can support patients with IAR, reducing the time constraints and workload for clinicians.

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.

Paediatric asthma in North Africa: the Asthma Insights and Reality in the Maghreb (AIRMAG) study

BACKGROUND

Bronchial asthma is the most frequent chronic childhood disease and can have a marked impact on educational development, activities and quality of life. The AIRMAG survey provides an opportunity to assess asthma and its impact in children in North Africa.

OBJECTIVE

To describe the prevalence, burden and management of asthma in children in the Maghreb.

METHODS

A general population sample was generated using a stratified sampling method based on randomly-generated lists of telephone numbers. The target sample consisted of 10,000 households in each country, which were contacted by telephone. A structured interview was proposed. Two screening questions were asked to identify subjects with asthma. Children who met these criteria were then questioned in more detail about their asthma.

RESULTS

Of 30,350 households contacted, 1090 subjects with asthma were identified, of whom 248 were aged under sixteen and interviewed by proxy. The prevalence of paediatric asthma ranged from 3.5% in Tunisia to 4.4% in Morocco. 22.8% of children were rated as severe persistent and 30.9% as intermittent. Asthma control was adequate in 7.6% of children and unacceptable in 46.2%. Control was best in Tunisia and worst in Morocco. 12.2% had been hospitalised for their asthma in the previous year and 32.9% had needed to attend an emergency department. Short-acting beta-agonists were used by 52.8% of children and prophylactic inhaled corticosteroids (alone or in association with long-acting beta-agonists) by 27.0%.

CONCLUSIONS

Asthma has a major impact on the lives of children with asthma in the Maghreb. This could be improved by offering more appropriate care as recommended in the GINA guidelines.