Usefulness of the subjective cold hyperresponsiveness scale as evaluated by cold dry air provocation

Application of a Cold Dry Air Provocation Test in Pediatric Patients with Asthma

Asthma is a chronic inflammatory airway disease characterized by reversible airway obstruction and airway hyperreactivity. We proposed a cold dry air (CDA) provocation test and investigated its application in pediatric patients with asthma. We enrolled 72 children and adolescents older than 5 years who presented to our hospital with chronic cough, shortness of breath, and wheezing. We analyzed the results of allergy, pulmonary function, methacholine provocation, and CDA provocation tests. The FEV1 change 5 min after the provocation was recorded as CDA5 dFEV1; that after 15 min was recorded as CDA15 dFEV1. PT10 was the provocation time causing a 10% decrease in FEV1; a decrease of >10% in dFEV1 was considered a positive CDA test. Among the 72 subjects, 51 were diagnosed with asthma. A positive CDA test in patients with asthma correlated with non-eosinophilic asthma. In patients with asthma, sputum eosinophils and eosinophil cationic protein (ECP) levels of the patients with a positive CDA test were significantly lower than those of patients with a negative test. CDA5 dFEV1 correlated with PC20 and total immunoglobulin E. CDA15 dFEV1 correlated with PC20, sputum eosinophils, and ECP. PT10 became shorter as the peripheral blood eosinophil, FVC, FEV1, FEV1/FVC, and FEF25-75 decreased. The CDA provocation test showed airway hyperreactivity to non-specific stimuli, a high correlation with non-eosinophilic asthma, and the possibility of assessing asthma severity via PT10.

Qualitative identification and characterisation of self-reported symptoms arising in humans during experimental exposure to cold air

Background: Exposure to cold air is associated with increased morbidity and mortality in the general population. It is difficult to study the effects of whole-body exposure to cold air under controlled conditions in real life. Objectives: The aim of this study was to (1) explore and describe the experience of symptoms in humans during experimental and controlled exposures to cold air, by using controlled environmental chamber exposures and qualitative methodology, and to (2) categorise the symptoms. Method: The study used a randomised, double blind design, in which 34 subjects undertook rest and moderate-intensity exercise in an environmental chamber set to two or three different temperatures (0, −10, and −17°C) on separate occasions. During the chamber exposures, subjects were interviewed. Qualitative content analysis was selected as the method of analysis. Findings: Subjects reported 50 distinct symptoms during the exposures. The symptoms were grouped into ten sub-categories and two major categories; airway versus whole-body symptoms. Conclusion: We have identified a broad range of symptoms in humans undertaking rest and moderate-intensity exercise at sub-zero temperatures. The symptoms and their categories may well be used to more extensively and quantitatively map cold-induced morbidity.

Nasal hyperreactivity in rhinitis: A diagnostic and therapeutic challenge

Although nasal hyperreactivity (NHR) is a common feature in patients suffering from allergic and nonallergic rhinitis, it is widely neglected during history taking, underdiagnosed in the majority of patients with rhinitis and rhinosinusitis, not considered as an outcome parameter in clinical trials on novel treatments for rhinitis and rhinosinusitis, and no target for routine treatment. In contrast to the simple nature of diagnosing NHR by a history of nasal symptoms induced by nonspecific exogenous and/or endogenous triggers, quantification is hardly performed in routine clinic given the lack of a simple tool for its diagnosis. So far, limited efforts have been invested into gaining better insight in the underlying pathophysiology of NHR, helping us to explain why some patients with inflammation develop NHR and others not. Of note, environmental and microbial factors have been reported to influence NHR, contributing to the complex nature of understanding the development of NHR. As a consequence of the neglect of NHR as a key clinical feature of rhinitis and chronic rhinosinusitis (CRS), patients with NHR might be suboptimally controlled and/or dissatisfied with current treatment. We here aim to provide a comprehensive overview of current knowledge on the pathophysiology, and the available tools to diagnose and treat NHR.

Nasal provocation test using allergen extract versus cold dry air provocation test: which and when?

BACKGROUND

Nasal provocation tests (NPTs) are useful for evaluation of patients with allergic rhinitis. The cold dry air (CDA) provocation test is useful for evaluation of patients with nonspecific nasal hyperreactivity (NHR). This study aimed to determine whether the NPT or CDA provocation would be more useful for patients with different clinical pictures.

METHODS

We evaluated changes in nasal symptoms (visual analog scale [VAS]) and acoustic parameters after NPT or CDA provocation in healthy volunteers (group A, n = 27), patients with allergic rhinitis (group B, n = 20), and subjects with nonallergic rhinitis (group C, n = 26). According to their subjective cold hyperresponsiveness (SCH), we compared changes in VAS and acoustic parameters after each protocol. The correlation between results of the skin-prick test (SPT) and changes in VAS after each protocol was analyzed. Finally, we performed an analysis of correlation between NPT and CDA provocation.

RESULTS

After NPT, group B showed a larger change in VAS for rhinorrhea, sneezing, and itching (p < 0.01). After CDA challenge, the change in VAS for nasal obstruction was larger in group C (p < 0.05). Changes in acoustic parameters were larger in groups B and C after NPT (p < 0.01). After CDA challenge, the SCH(+) group (n = 49) showed a larger decrease of acoustic parameters than the SCH(-) group (n = 24; p < 0.01). Significant correlation was observed between the size of SPT and degree of change in VAS after NPT. No significant correlation was observed between NPT and CDA.

CONCLUSION

CDA could be an adjunct tool for evaluating NHR in patients with self-reported SCH.

Uncontrolled allergic rhinitis and chronic rhinosinusitis: where do we stand today?

State-of-the-art documents like ARIA and EPOS provide clinicians with evidence-based treatment algorithms for allergic rhinitis (AR) and chronic rhinosinusitis (CRS), respectively. The currently available medications can alleviate symptoms associated with AR and RS. In real life, a significant percentage of patients with AR and CRS continue to experience bothersome symptoms despite adequate treatment. This group with so-called severe chronic upper airway disease (SCUAD) represents a therapeutic challenge. The concept of control of disease has only recently been introduced in the field of AR and CRS. In case of poor control of symptoms despite guideline-directed pharmacotherapy, one needs to consider the presence of SCUAD but also treatment-related, diagnosis-related and/or patient-related factors. Treatment-related issues of uncontrolled upper airway disease are linked with the correct choice of treatment and route of administration, symptom-oriented treatment and the evaluation of the need for immunotherapy in allergic patients. The diagnosis of AR and CRS should be reconsidered in case of uncontrolled disease, excluding concomitant anatomic nasal deformities, global airway dysfunction and systemic diseases. Patient-related issues responsible for the lack of control in chronic upper airway inflammation are often but not always linked with adherence to the prescribed medication and education. This review is an initiative taken by the ENT section of the EAACI in conjunction with ARIA and EPOS experts who felt the need to provide a comprehensive overview of the current state of the art of control in upper airway inflammation and stressing the unmet needs in this domain.

Nasal obstruction and rhinorrhea reflect nonspecific nasal hyper-reactivity as evaluated by cold dry air provocation

CONCLUSION

Nasal obstruction, rhinorrhea, and the amount of rhinorrhea that confidently reflect the parasympathetic stimulation can be used to more precisely predict nonspecific nasal hyper-reactivity (NHR).

OBJECTIVE

We aimed to identify factors that confidently reflected the presence and the degree of NHR, measured by cold dry air (CDA) provocation and acoustic rhinometry.

METHODS

A total of 156 patients with allergic or non-allergic rhinitis were classified into three groups according to the decrease of minimal cross-sectional area (MCA) after CDA provocation (group A: n = 40, MCA decrease >60%; group B: n = 29, MCA decrease 30-60%; group C: n = 87, MCA decrease <29%). Symptom scores using the visual analog scale (VAS) were obtained before and after CDA provocation. Changes of VAS were compared between groups. The amount of rhinorrhea was measured after CDA provocation.

RESULTS

VAS scores for nasal obstruction, rhinorrhea, and sneezing were significantly higher in groups A and B than in group C before and after CDA provocation. Change of nasal obstruction and rhinorrhea was significantly larger in group A compared with group B or C. There were also significant differences in the amount of rhinorrhea between groups. All these parameters significantly correlated with the change of MCA values after CDA provocation.

Subjective cold hyper-responsiveness grade reflects age- and duration-related increase of nonspecific nasal hyperreactivity

OBJECTIVE

We evaluated the effect of patients' age and duration of allergic rhinitis on nonspecific nasal hyper-reactivity (NHR) using cold dry air (CDA) provocation.

METHODS

In 156 patients of various ages with allergic rhinitis and different symptom duration, we evaluated the change of symptoms, the subjective cold hyper-responsiveness (SCH) grade, the change of acoustic parameters such as total nasal volume (TNV) and minimal cross-sectional area (MCA), and the amount of rhinorrhea before and after CDA provocation.

RESULTS

Patients in different age or duration groups did not show significant differences in the change of each nasal symptom. SCH grade 2 or 3 was more frequently observed in patients older than 30 years (p=0.018). There was a significant correlation between the age of the patients and the SCH grade (R=0.184, p=0.022). Patients with >10 years of duration reported higher SCH grade (p=0.022). There was a significant correlation between the duration of disease and SCH grade (R=0.284, p<0.001). However, there were no significant differences in the change of TNV and MCA, and the amount of rhinorrhea after CDA provocation between different age and duration groups.

CONCLUSION

SCH grade reflects the age- and duration-related increase of NHR. Further studies to elucidate the pathophysiologic mechanisms are needed in the future.