The nasal passage of subjects with asthma has a decreased ability to warm and humidify inspired air

Mechanism of Lower Airway Hyperresponsiveness Induced by Allergic Rhinitis

Allergic rhinitis is a global illness that puzzles many researchers. Most patients with allergic rhinitis also have lower airway hyperresponsiveness, and an allergic rhinitis attack can increase lower airway hyperresponsiveness. However, the mechanism of the effect of allergic rhinitis on the lower airways is still unclear. In this paper, the effects of allergic rhinitis on the lower airways are studied in terms of epidemiology, anatomy, pathophysiology, nasal function loss, inflammation drainage, nasobronchial reflex, and whole-body circulatory flow to determine the mechanism involved and provide ideas for future diagnosis, treatment, and experiments.

The mystery of dry indoor air - An overview

"Dry air" is a major and abundant indoor air quality complaint in office-like environments. The causality of perceived "dry air" and associated respiratory effects continues to be debated, despite no clear definition of the complaint, yet, has been provided. The perception of "dry air" is semantically confusing without an associated receptor but mimics a proto-state of sensory irritation like a cooling sensation. "Dry air" may also be confused with another common indoor air quality complaint "stuffy air", which mimics the sense of no fresh air and of nasal congestion. Low indoor air humidity (IAH) was dismissed more than four decades ago as cause of "dry air" complaints, rather indoor pollutants was proposed as possible exacerbating causative agents during the cold season. Many studies, however, have shown adverse effects of low IAH and beneficial effects of elevated IAH. In this literature overview, we try to answer, "What is perceived "dry air" in indoor environments and its associated causalities. Many studies have shown that the perception is caused not only by extended exposure to low IAH, but also simultaneously with and possibly exacerbated by indoor air pollutants that aggravate the protective mucous layer in the airways and the eye tear film. Immanent diseases in the nose and airways in the general population may also contribute to the overall complaint rate and including other risk factors like age of the population, use of medication, and external factors like the local ambient humidity. Low IAH may be the single cause of perceived "dry air" in the elderly population, while certain indoor air pollutants may come into play among susceptible people, in addition to baseline contribution of nasal diseases. Thus, perceived "dry air" intercorrelates with dry eyes and throat, certain indoor air pollutants, ambient humidity, low IAH, and nasal diseases.

[Biologics in Rhinology - Forthcoming Personalized Concepts: the Future Starts Today]

Sinunasale Erkrankungen zählen mit zu den häufigsten chronischen Erkrankungen und führen zu einer erheblichen Störung der Lebensqualität, ein komorbides Asthma ist häufig. Trotz leitliniengerechter Therapie ist anzunehmen, dass mind. 20% der Patienten ihre Erkrankungssymptome nicht adäquat kontrollieren können. Neben den etablierten chirurgischen und konservativen Therapieoptionen finden sich nun vielversprechende Therapieansätze, die bspw. mittels therapeutischer Antikörper mechanistisch gezielt in die Pathophysiologie der Erkrankungen eingreifen können. Die Auswahl der geeigneten Patienten durch geeignete Biomarker und die richtige Therapie zum richtigen Stadium der Erkrankung anbieten zu können, ist das Ziel stratifizierter Medizin und eine wichtige Perspektive für die HNO.Chronic diseases of the nose and the paranasal sinuses are most common, frequently associated with bronchial asthma, and result in substantial reduction of quality of life. Despite optimal treatment according to guidelines, approx. 20 % of the patients will report inadequate control of symptoms. Apart from well established surgical and conservative approaches in therapy new therapeutic antibodies are available that aim specifically pathophysiological targets. The optimal allocation of effective therapy for patients using appropriate biomarkers at the most suitable timepoint is the hallmark of stratified medicine and an important perspective in ENT.

Asthma control and cold weather-related respiratory symptoms

BACKGROUND

In the northern hemisphere people are exposed recurrently to cold air and asthmatics experience more respiratory symptoms. We hypothesized that subjects with poor asthma control are more prone to experience cold weather-related respiratory symptoms than those with good asthma control.

METHODS

A population-based cross-sectional study of 1995 adult asthmatics (response rate 40.4%) living in the Northern Finland was conducted using a questionnaire where cold weather-related respiratory symptoms as well as questions related to asthma control were inquired. The Asthma Control Test (ACT) was defined based on five questions (disadvantage and occurrence of asthma symptoms, waking up because of asthma symptoms, use of rescue medication and self-assessment of asthma control during the past 4 weeks), and was divided into quartiles.

RESULTS

Cold weather-related respiratory symptoms were more frequent among asthmatics with poorly controlled asthma (ACT Q1 vs. ACT Q4); adjusted prevalence ratio (PR) for shortness of breath (men 1.47, 95% confidence interval 1.22-1.77; women 1.18, 1.07-1.30), cough (men 1.10, 0.91-1.34; women 1.18, 1.08-1.30), wheezing (men 1.91, 1.31-2.78; women 1.48, 1.17-1.87), phlegm production (men 1.51, 1.06-2.14; women 1.62, 1.27-2.08) and chest pain (men 4.47, 1.89-10.56; women 2.60, 1.64-4.12). The relations between asthma control and symptom occurrence seemed stronger among smokers than never smokers and subjects with body mass index (BMI) below and above 25-30.

CONCLUSIONS

Our study provides new evidence that subjects whose asthma is poorly controlled are more prone to experience cold weather-related respiratory symptoms and even a slight worsening of asthma control increases symptom prevalences.

Sinusitis, Rhinitis, Asthma, and the Single Airway Hypothesis

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

Asthma and allergic rhinitis increase respiratory symptoms in cold weather among young adults

BACKGROUND

The occurrence of cold temperature-related symptoms has not been investigated previously in young adults, although cold weather may provoke severe symptoms leading to activity limitations, and those with pre-existing respiratory conditions may form a susceptible group. We tested the hypothesis that young adults with asthma and allergic rhinitis experience cold-related respiratory symptoms more commonly than young adults in general.

METHODS

A population-based study of 1623 subjects 20-27 years old was conducted with a questionnaire inquiring about cold weather-related respiratory symptoms, doctor-diagnosed asthma and rhinitis, and lifestyle and environmental exposures.

RESULTS

Current asthma increased the risk of all cold weather-related symptoms (shortness of breath adjusted PR 4.53, 95% confidence interval 2.93-6.99, wheezing 10.70, 5.38-21.29, phlegm production 2.51, 1.37-4.62, cough 3.41, 1.97-5.87 and chest pain 2.53, 0.82-7.79). Allergic rhinitis had additional effect especially on shortness of breath (7.16, 5.30-9.67) and wheezing (13.05, 7.75-22.00), some on phlegm production (3.69, 2.49-5.47), but marginal effect on cough and chest pain.

INTERPRETATION

Our study shows that already in young adulthood those with asthma, and especially those with coexisting allergic rhinitis, experience substantially more cold temperature-related respiratory symptoms than healthy young adults. Hence, young adults with a respiratory disease form a susceptible group that needs special care and guidance for coping with cold weather.

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.

Does nasal hair (vibrissae) density affect the risk of developing asthma in patients with seasonal rhinitis?

BACKGROUND

Large particles entering the nose are collected by nasal hair present in the anterior nares. Increased hair density provides an improvement in the filtering efficiency of the nose, while reduced amounts of nasal hair cause a decrease in its efficiency. The amount of nasal hair can vary between individuals, which can make a difference in the filtering efficiency of the nose. Reduced filter function of the nose leads to increased exposure of the airways to allergens. The aim of this study was to determine the effect of nasal hair density on the risk of developing asthma in seasonal rhinitis (SR) patients.

METHODS

A standard questionnaire was filled in, and physical examination and allergy tests were performed in 233 patients. Patients were divided into 3 groups according to the amount of nasal hair [few (few or none), moderate and many]. The association between asthma and nasal hair density was assessed.

RESULTS

Asthma was detected in 75 patients (32.2%), and of these, 45 (60%) also had pollen asthma. The rate of asthma was 44.7, 26.2 and 16.7% in the few, moderate and many groups, respectively (p = 0.002). Few nasal hairs significantly increased the risk of developing asthma [odds ratio (95% confidence interval): few, reference; moderate, 0.41 (0.21-0.78); many, 0.19 (0.06-0.55); p = 0.002].

CONCLUSION

Our findings suggest that the amount of nasal hair providing a nose filtration function has a protective effect on the risk of developing asthma in SR patients. To the best of our knowledge, this is the first report on this subject in the literature.

Greater nasal nitric oxide output during inhalation: effects on air temperature and water content

The nose conditions the temperature and humidity of nasal air, and the nasal mucosal vasculature supplies heat and water for these processes. We hypothesize that nitric oxide (NO) modulates these processes through vasoactive effects on nasal mucosal vasculature. We measured the temperature, humidity and NO concentrations of nasal air during inhalation and exhalation across the nose and calculated net heat, water and NO output before (controls, n=7) and after inhibition of NO synthase by topical l-NAME (N=5) in healthy humans. We found that calculated NO output across the nasal passages is approximately three-fold greater during inhalation (503+/-105 nL/min) compared with exhalation (162+/-56 nL/min). Moreover, topical administration of l-NAME decreased nasal air temperature and humidity conditioning and NO output, but these effects were limited to inhalation. We conclude that nasal NO output is greater during inhalation than exhalation in humans. Our findings also support a role of nasal NO in temperature and humidity conditioning of nasal air.

Evidence-based recommendations regarding the differential diagnosis and assessment of nasal congestion: using the new GRADE system

Nasal congestion is an important symptom in nasal pathology and can be defined as an objective restriction of nasal cavity airflow because of mucosal pathology and/or increased mucus secretion (excluding anatomical variants). Using the new Grading Recommendations Assessment, Development and Evaluation system, evidence-based recommendations are made that will encompass different clinical questions regarding diagnostic modalities of nasal congestion: (i) their usefulness in assessment of presence and severity of congestion; (ii) their usefulness in assessment of etiological pathology responsible for congestion; and (iii) their usefulness in follow up and treatment effectiveness evaluation of nasal congestion.

Upper airways reactions to cold air

Cold air-induced rhinitis is a common complaint of individuals with chronic allergic or nonallergic rhinitis and those with no chronic nasal disease. It is characterized by rhinorrhea, nasal congestion, and nasal burning that appear within minutes of exposure to cold air and dissipate soon after exposure is terminated. The symptoms of cold-air rhinitis are reproduced experimentally with nasal cold-air provocation. This procedure has shown that nasal mast cell activation and sensory nerve stimulation are associated with the development of nasal symptoms. Sensory nerve activation generates a cholinergic reflex that leads to rhinorrhea; therefore, anticholinergic agents are highly effective in treating cold-air rhinitis. Experimental data suggest that individuals with nasal cold-air sensitivity may have reduced ability to compensate for the water loss that occurs during exposure to cold air. Therefore, the symptoms of cold air-induced rhinitis may reflect the activation of compensatory mechanisms to restore mucosal homeostasis.

Nasal conditioning after endonasal surgery in chronic rhinosinusitis with nasal polyps

BACKGROUND

Endoscopic sinus surgery (ESS) is a frequently performed operation for chronic rhinosinusitis (CRS). The aim of this study was to investigate nasal conditioning after ESS with/without septoplasty and turbinoplasty in patients with CRS with nasal polyps and to determine its relation to nasal patency and geometry.

METHODS

Twenty-one patients were enrolled into this study. Nasal conditioning, AAR, and acoustic rhinometry were measured before and 4-8 months after endonasal surgery.

RESULTS

The temperature and humidity gradient across the nose increased significantly after operation. High nasal volumes and patency were positively correlated with elevated nasal conditioning. No correlation between preoperative and postoperative changes in nasal geometry and nasal airflow with changes in conditioning values was found.

CONCLUSION

Patients with CRS with nasal polyps seem to profit from ESS with/without septoplasty and turbinoplasty because nasal conditioning is improved postoperatively. Properly performed ESS has its importance within the variety of nasal surgical procedures ensuring improved nasal function.

Nasobronchial interaction mechanisms in allergic airways disease

PURPOSE OF REVIEW

During the past few decades, the incidence of sensitization to inhaled allergens as well as allergic airways disease has grown steadily. Genetic and environmental factors are recognized as etiologic factors in the development of allergic airway disease, with allergic rhinitis often preceding the development of asthma. Allergic rhinitis is considered a risk factor for the development of asthma, and almost all allergic asthmatic patients have rhinitis. Insight into the risk factors responsible for allergic airways disease and the interaction between the involved organs results in a better diagnostic and therapeutic approach in global airway allergy syndrome.

RECENT FINDINGS

Recent studies have shown that local tissue factors, such as microbial stimuli and systemic inflammatory mechanisms, play a role in the clinical expression of the allergic airway syndrome. In addition, impaired nasal function affects the lower airways of asthmatic patients via different pathways. To date, most human and animal data point towards a systemic pathway linking the upper and lower airways, involving both bloodstream and bone marrow. Recent clinical trials and current guidelines underline the importance of an integrated treatment strategy involving both ends of the respiratory tract.

SUMMARY

This review provides an overview of recent epidemiological and immunopathologic evidence concerning the link between upper and lower airways in allergic disease and its therapeutic implications.

The impact of septorhinoplasty and anterior turbinoplasty on nasal conditioning

BACKGROUND

Septorhinoplasty and turbinoplasty is a frequently performed operation in facial plastic surgery. The aim of this study was to investigate nasal conditioning after septorhinoplasty and inferior turbinoplasty in patients with internal and external nasal deformities and hypertrophy of the inferior turbinates and to determine its relation to nasal patency.

METHODS

Ten patients and 10 volunteers as controls were enrolled into this study. Measurement of nasal conditioning and active anterior rhinomanometry were performed before and 4-6 months after functional-esthetic septorhinoplasty and inferior turbinoplasty.

RESULTS

Nasal airflow was significantly higher postoperatively than preoperatively. The preoperative nasal temperature (TEMP) and heat increase (HI) was lower in the patients compared with the controls. The postoperative TEMP, HI, total water content, and water gradient were significantly higher than the preoperative values.

CONCLUSION

Based on this relatively small series, functional-esthetic septorhinoplasty in combination with inferior turbinoplasty may be associated with improved nasal conditioning.

Familial aggregation of nasal conditioning capacity

In our previous studies on nasal conditioning, we observed a large variability among individuals to condition inspired air. Although we previously investigated various physiological parameters (age, sex, nasal mucosal temperature, heart rate, blood pressure, and nasal volume) that might underlie these differences, we have been unable to explain this variability. Many proteins and molecules, which are under genetic control and could affect nasal conditioning, are involved in water transport,. In this study, we hypothesized that familial factors may contribute to the differences in nasal conditioning capacity (NCC). We performed a prospective study of 47 sibling pairs. Cold dry air was delivered to the nose, and the total water gradient (TWG) was calculated to determine the NCC. We found a highly significant intraclass correlation of 0.53 (P < 0.0001) between sibling pairs for the TWG. These results suggest that there is a familial basis for nasal conditioning and a large enough genetic component to search for genes explaining the observed correlation.

The connection between allergic rhinitis and bronchial asthma

PURPOSE OF REVIEW

The relationship between allergic rhinitis and asthma has intrigued practicing physicians since the turn of the century. Investigations during the past two decades have led to an increased understanding of this relationship.

RECENT FINDINGS

A growing body of evidence clearly demonstrates that patients with allergic rhinitis, in the absence of asthma, have distinct abnormalities of lower airway function, including alterations in physiology, histology and biochemistry. In addition, epidemiologic surveys have consistently shown allergic rhinitis as an independent risk factor for developing asthma, and that preexisting abnormalities in lung function may predispose to lower airway disease development. Clinical trials show that specific allergen immunotherapy for children and adults with seasonal allergic rhinitis reduces the risk of developing asthma. In patients with established asthma and concomitant allergic rhinitis, several medications have significant effects upon the upper and lower airways, including intranasal corticosteroids, oral antihistamines, and leukotriene receptor antagonists.

SUMMARY

Our understanding of the natural history of allergic rhinitis could lead to improvements in early intervention, potentially preventing the progression of allergic rhinitis to asthma. Aggressive treatment of rhinitis in patients with concomitant asthma may enhance asthma outcomes and quality of life for all patients with these chronic diseases.

Influence of passive humidification on nasal conditioning

BACKGROUND

Passive humidifiers (PH) have been beneficial to upper and lower airway humidity, especially in patients who are in a long-time ventilated intensive care unit. The goal of this pilot study was to provide nasal conditioning data and measure the benefit of a nasal PH to spontaneously breathing, conscious subjects.

METHODS

Eleven healthy volunteers had to wear a PH for 1 hour, which was introduced into both nasal vestibules. The PH had a heat and moisture restoring body of polyurethane foam with an open-pore structure. Before and after application of the nasal PH, nasal conditioning was measured and nasal symptoms were assessed by the participants.

RESULTS

Ten minutes after removal of the PH a significant increase was observed for the scores for nasal patency and nasal humidity.

CONCLUSION

We hypothesize that the nasal PH could provide a valuable contribution to the supportive therapy of diseases that accompany nasal mucosal dryness.

Combined mediator blockade or topical steroid for treating the unified allergic airway

BACKGROUND

Asthma and allergic rhinitis are manifestations of a single unified allergic airway, for which the best treatment is uncertain.

OBJECTIVE

To compare the anti-inflammatory efficacy in the unified allergic airway of combined oral mediator antagonism and combined topical steroid.

METHODS

Subjects with asthma and perennial allergic rhinitis entered a randomized double blind crossover study comparing montelukast 10 mg and cetirizine 10 mg to extra-fine inhaled beclomethasone 400 mcg/day and intranasal beclomethasone 200 mcg/day, each taken once daily for 2 months, after 2-week placebo washouts. Measurements were made after each washout and randomized treatment, comprising: methacholine PC20, exhaled and nasal nitric oxide, blood eosinophils and eosinophilic cationic protein, symptoms, lung and nasal function tests.

RESULTS

Seventeen patients completed per protocol. For PC20 and exhaled nitric oxide, only combined topical steroid produced improvements (P < 0.005) from placebo baseline. Combined steroid was superior by a 0.93 (95% CI 0.14-0.93, P < 0.05) doubling dilution difference for PC20 and a 0.99 (95% CI 0.9-15.1, P < 0.01) doubling difference for exhaled nitric oxide. Both treatments attenuated eosinophils and eosinophilic cationic protein, and reduced nasal symptoms (P < 0.05). Only steroid improved nasal nitric oxide (P=0.05) and asthma symptoms (P < 0.05). Neither treatment affected lung or nasal function tests.

CONCLUSION

Combined topical steroid and combined mediator antagonism both attenuated systemic inflammation in the unified allergic airway, but only the former reduced bronchial and nasal inflammatory markers. The relevance of this to exacerbations and airway remodelling needs to be defined.

Nasal symptoms, airway obstruction and disease severity in chronic obstructive pulmonary disease

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is characterized by inflammation of the lung in association with airflow obstruction. There is increasing evidence of upper airway involvement in COPD and we have reported that this nasal inflammation is proportional to that in the lung. Given recognized relationships between lower airway inflammation and spirometric indices such as the Forced Expiratory Volume in one second (FEV(1)), we hypothesized that there may be a relationship between nasal obstruction and FEV(1) in COPD. We also sought to investigate relationships between nasal symptoms and nasal patency in COPD.

METHODS

We assessed the nasal and pulmonary airways, using acoustic rhinometry and spirometry respectively, in 51 patients with COPD.

RESULTS

The presence of chronic nasal symptoms in COPD was associated with reduced nasal patency (6.04 cm(2) symptoms vs. 9.55 cm(2) no symptoms, at the second minimum cross-sectional area, P = 0.049). Nasal patency in COPD was inversely proportional to pulmonary airflow obstruction, and therefore to COPD disease severity (e.g. FEV(1)% predicted vs. second minimum cross-sectional area, r = 0.36, P = 0.009).

CONCLUSIONS

The degree of nasal airway obstruction in COPD reflects the impairment to pulmonary airflow, and is greater in the presence of chronic nasal symptoms. This study provides further evidence of pan-airway involvement in COPD.

Persistent allergic rhinitis and indoor air quality perception--an experimental approach

In order to compare patterns of indoor air perception, including perceptions of temperature, air movement, indoor air quality (IAQ), mental concentration, and comfort, 33 subjects either with persistent allergic rhinitis or controls were exposed to different temperatures and constant relative humidity in an experimental office environment. Results were obtained by means of a self-administered visual analogue scale, analyzed using mean score comparisons and principal component analysis. At 14 degrees C, the rhinitis group reported higher scores for sensations of air dryness than controls. At 18 degrees C, in the rhinitis group, there was a correlation between dry, stagnant air, and difficult mental concentration. This group also correlated heat, dry air, and poor IAQ, in contrast to the control group, which correlated comfort, easy mental concentration, and freshness. At 22 degrees C, the rhinitis group correlated heat, dryness, stagnant air, and overall discomfort. This group also correlated non-dry air, freshness, and comfort, whereas the control group correlated heat, humidity, good indoor air, freshness, and comfort. This study suggests that the rhinitis group perceives indoor temperatures of 14 degrees C as dryer than controls do, and that at 18 and 22 degrees C this group positively correlates different adverse perceptions of IAQ. By means of a self-administered questionnaire in an experimental condition, the present study compares subjective patterns of indoor air perception from individuals with respiratory allergy (allergic rhinitis) to control individuals. It reports different patterns of perception of indoor air quality (IAQ) between the two groups, suggesting that allergic individuals could have different IAQ perception.

Stronger nasal responsiveness to cold air in individuals with rhinitis and asthma, compared with rhinitis alone

BACKGROUND

We have previously proposed that, compared with rhinitis alone, the constellation of upper and lower airway allergic disease is a manifestation of a more severe form of a syndrome affecting the entire airway. If this is correct, not only the lower, but also the upper airways of patients with asthma and rhinitis should demonstrate more abnormalities compared with patients with rhinitis alone, including higher sensitivity to irritant factors. Objective To test the hypothesis that, a previously well-studied natural nasal stimulus, cold, dry air (CDA), produces a stronger response in subjects with allergic rhinitis (AR) and asthma compared with subjects with AR alone.

METHODS

We performed nasal provocation with CDA on 24 individuals with asthma and rhinitis and 17 with rhinitis alone. Prior to and after the challenge, nasal symptoms were recorded using visual analogue scales and nasal lavages were performed to determine histamine and lysozyme levels.

RESULTS

The two groups reacted differently to CDA: after the challenge, patients with rhinitis and asthma reported significantly higher scores for nasal congestion, rhinorrhea and lacrimation. Also in this group, significant increases in histamine and in lysozyme levels in nasal lavage fluids were induced by CDA. In subjects with rhinitis alone, CDA failed to increase histamine or lysozyme levels above baseline. The CDA-induced change from baseline in histamine was significantly higher in the patients with rhinitis and asthma, compared with the rhinitis-only group.

CONCLUSION

Patients with AR and asthma have stronger nasal responsiveness to CDA compared with patients with rhinitis alone. This observation is consistent with the notion that compared with rhinitis alone, the presence of asthma and rhinitis signifies a higher degree of functional abnormality of the entire airway.

Nasal conditioning in perennial allergic rhinitis after nasal allergen challenge

BACKGROUND

Antigen challenge in seasonal allergic rhinitis is considered to be associated with an increased ability of the nose to condition inspired air. In contrast, little is known about air conditioning after antigen challenge in perennial allergic rhinitis (PAR).

OBJECTIVE

The aims of this study were to investigate whether antigen challenge in PAR changes nasal air conditioning and to assess the relationship between nasal conditioning and nasal patency and geometry.

METHODS

Nineteen subjects with PAR were enrolled into this study. Measurement of nasal conditioning, active anterior rhinomanometry (AAR), acoustic rhinometry (AR), and clinical symptom evaluation were performed before and after nasal allergen challenge with allergen extracts from house dust mites.

RESULTS

Ten and 20 min after nasal allergen challenge, the total water content of the air measured in the nasopharynx and the water gradient across the nose were significantly higher in the nasal cavity in which the allergen extract was sprayed. The temperature on both sides of the nose increased non-significantly after nasal allergen challenge. No correlation to data obtained by AAR, AR, and clinical symptom evaluation after nasal allergen challenge was found.

CONCLUSION

We suggest that an increase in mucosal humidity due to the allergic provocation might be responsible for the increase in nasal conditioning capacity because no correlation to changes in nasal perimeter and patency was found.

Treatment of nasal inflammation decreases the ability of subjects with asthma to condition inspired air

We previously showed that individuals with seasonal allergy have a reduced ability to condition air, which was improved by nasal inflammation. We also showed that subjects with asthma have a reduced ability to condition air. Because individuals with asthma usually have inflammation in the nose, we hypothesized that treatment with an intranasal steroid would reduce nasal inflammation and further decrease nasal conditioning capacity. We performed a randomized, double blind, placebo-controlled, 2-way crossover study on 20 subjects with asthma comparing the effect of treatment with intranasal budesonide for 2 weeks on nasal conditioning. Treatment with budesonide caused no significant effect on nasal conditioning as compared with placebo. When we evaluated the subgroup of nonsmoking subjects, budesonide caused a significant reduction in nasal conditioning. We speculate that nasal inflammation in nonsmoking individuals with asthma increases the conditioning capacity and reducing it with an intranasal steroid worsens the ability of the nose to condition air. In addition, smoking causes an increase in nasal conditioning capacity by non-steroid-dependent factors. These observations help us understand the pathophysiology of nasal conditioning, but do not negate the positive clinical benefits of budesonide on treating nasal inflammation.

Nasal involvement in allergic asthma

Even since the late 19th century, a relationship has been suspected between upper airway disease and the subsequent development or aggravation of asthma symptoms. To date, it has been generally accepted that pathologic conditions of the upper airways, e.g. allergic rhinitis, chronic sinusitis and nasal polyposis, may influence the lower airways. However, the mechanisms underlying this relationship were, for a long time, poorly understood. Recently, evidence has been accumulating which indicates a systemic connection as one of the responsible mechanisms in nasobronchial crosstalk. In this review, the pathophysiologic and immunologic aspects of the interaction between upper and lower airways will be discussed.

Rhinitis and asthma: evidence for respiratory system integration

The vast majority of patients with asthma have rhinitis, and rhinitis is a major independent risk factor for asthma in cross-sectional and longitudinal studies. The relationships between rhinitis and asthma can be viewed under the concept that the 2 conditions are manifestations of one syndrome, the chronic allergic respiratory syndrome, in 2 parts of the respiratory tract. At the low end of the syndrome's severity spectrum, rhinitis appears to be the sole manifestation, although pathologic abnormalities in the lower airways are already present. At the higher end, rhinitis is worse, and the lower airways disease becomes clinically evident. Once manifested, the 2 conditions track in parallel in terms of severity. This parallel relationship is influenced by many interactions between the nasal and the lower airways: some interactions stem from the fact that the nasal passages play a major homeostatic role by conditioning inhaled air, but perhaps even more important is the bidirectional interaction that results from the systemic inflammation that is produced after local allergic reactions. Successful management of the chronic allergic respiratory syndrome requires an integrated view of the airways and an understanding of their interactions.