International expert consensus on the management of allergic rhinitis (AR) aggravated by air pollutants: Impact of air pollution on patients with AR: Current knowledge and future strategies

Allergic rhinitis affects the quality of life of millions of people worldwide. Air pollution not only causes morbidity, but nearly 3 million people per year die from unhealthy indoor air exposure. Furthermore, allergic rhinitis and air pollution interact. This report summarizes the discussion of an International Expert Consensus on the management of allergic rhinitis aggravated by air pollution. The report begins with a review of indoor and outdoor air pollutants followed by epidemiologic evidence showing the impact of air pollution and climate change on the upper airway and allergic rhinitis. Mechanisms, particularly oxidative stress, potentially explaining the interactions between air pollution and allergic rhinitis are discussed. Treatment for the management of allergic rhinitis aggravated by air pollution primarily involves treating allergic rhinitis by guidelines and reducing exposure to pollutants. Fexofenadine a non-sedating oral antihistamine improves AR symptoms aggravated by air pollution. However, more efficacy studies on other pharmacological therapy of coexisting AR and air pollution are currently lacking.

A technique to measure the ability of the human nose to warm and humidify air

To assess the ability of the nose to warm and humidify inhaled air, we developed a nasopharyngeal probe and measured the temperature and humidity of air exiting the nasal cavity. We delivered cold, dry air (19-1 degrees C, <10% relative humidity) or hot, humid air (37 degrees C, >90% relative humidity) to the nose via a nasal mask at flow rates of 5, 10, and 20 l/min. We used a water gradient across the nose (water content in nasopharynx minus water content of delivered air) to assess nasal function. We studied the characteristics of nasal air conditioning in 22 asymptomatic, seasonally allergic subjects (out of their allergy season) and 11 nonallergic normal subjects. Inhalation of hot, humid air at increasingly higher flow rates had little effect on both the relative humidity and the temperature of air in the nasopharynx. In both groups, increasing the flow of cold, dry air lowered both the temperature and the water content of the inspired air measured in the nasopharynx, although the relative humidity remained at 100%. Water gradient values obtained during cold dry air challenges on separate days showed reproducibility in both allergic and nonallergic subjects. After exposure to cold, dry air, the water gradient was significantly lower in allergic than in nonallergic subjects (1,430 +/- 45 vs. 1,718 +/- 141 mg; P = 0.02), suggesting an impairment in their ability to warm and humidify inhaled air.

Jares E, Jarvis D, Jassem E, Jenko K, Jiméneracruz Uscanga RD, Johnston SL, Joos G, Jošt M, Julge K, Jung K, Just J, Jutel M, Kaidashev I, Kalayci O, Kalyoncu F, Kapsali J, Kardas P, Karjalainen J, Kasala CA, Katotomichelakis M, Kavaliukaite L, Kazi BS, Keil T, Keith P, Khaitov M, Khaltaev N, Kim Y, Kirenga B, Kleine‐Tebbe J, Klimek L, Koffi N’Goran B, Kompoti E, Kopač P, Koppelman G, KorenJeverica A, Koskinen S, Košnik M, Kostov KV, Kowalski ML, Kralimarkova T, Kramer Vrščaj K, Kraxner H, Kreft S, Kritikos V, Kudlay D, Kuitunen M, Kull I, Kuna P, Kupczyk M, Kvedariene V, Kyriakakou M, Lalek N, Landi M, Lane S, Larenas‐Linnemann D, Lau S, Laune D, Lavrut J, Le L, Lenzenhuber M, Lessa M, Levin M, Li J, Lieberman P, Liotta G, Lipworth B, Liu X, Lobo R, Lodrup Carlsen KC, Lombardi C, Louis R, Loukidis S, Lourenço O, Luna Pech JA, Madjar B, Maggi E, Magnan A, Mahboub B, Mair A, Mais Y, Maitland van der Zee A, Makela M, Makris M, Malling H, Mandajieva M, Manning P, Manousakis M, Maragoudakis P, Marseglia G, Marshall G, Reza Masjedi M, Máspero JF, Matta Campos JJ, Maurer M, Mavale‐Manuel S, Meço C, Melén E, Melioli G, Melo‐Gomes E, Meltzer EO, Menditto E, Menzies‐Gow A, Merk H, Michel J, Micheli Y, Miculinic N, Midão L, Mihaltan F, Mikos N, Milanese M, Milenkovic B, Mitsias D, Moalla B, Moda G, Mogica Martínez MD, Mohammad Y, Moin M, Molimard M, Momas I, Mommers M, Monaco A, Montefort S, Mora D, Morais‐Almeida M, Mösges R, Mostafa B, Mullol J, Münter L, Muraro A, Murray R, Musarra A, Mustakov T, Naclerio R, Nadeau KC, Nadif R, Nakonechna A, Namazova‐Baranova L, Navarro‐Locsin G, Neffen H, Nekam K, Neou A, Nettis E, Neuberger D, Nicod L, Nicola S, Niederberger‐Leppin V, Niedoszytko M, Nieto A, Novellino E, Nunes E, Nyembue D, O’Hehir R, Odjakova C, Ohta K, Okamoto Y, Okubo K, Oliver B, Onorato GL, Pia Orru M, Ouédraogo S, Ouoba K, Paggiaro PL, Pagkalos A, Pajno G, Pala G, Palaniappan S, Pali‐Schöll I, Palkonen S, Palmer S, Panaitescu Bunu C, Panzner P, Papadopoulos NG, Papanikolaou V, Papi A, Paralchev B, Paraskevopoulos G, Park H, Passalacqua G, Patella V, Pavord I, Pawankar R, Pedersen S, Peleve S, Pellegino S, Pereira A, Pérez T, Perna A, Peroni D, Pfaar O, Pham‐Thi N, Pigearias B, Pin I, Piskou K, Pitsios C, Plavec D, Poethig D, Pohl W, Poplas Susic A, Popov TA, Portejoie F, Potter P, Poulsen L, Prados‐Torres A, Prarros F, Price D, Prokopakis E, Puggioni F, Puig‐Domenech E, Puy R, Rabe K, Raciborski F, Ramos J, Recto MT, Reda SM, Regateiro FS, Reider N, Reitsma S, Repka‐Ramirez S, Ridolo E, Rimmer J, Rivero Yeverino D, Angelo Rizzo J, Robalo‐Cordeiro C, Roberts G, Roche N, Rodríguez González M, Rodríguez Zagal E, Rolla G, Rolland C, Roller‐Wirnsberger R, Roman Rodriguez M, Romano A, Romantowski J, Rombaux P, Romualdez J, Rosado‐Pinto J, Rosario N, Rosenwasser L, Rossi O, Rottem M, Rouadi P, Rovina N, Rozman Sinur I, Ruiz M, Ruiz Segura LT, Ryan D, Sagara H, Sakai D, Sakurai D, Saleh W, Salimaki J, Samitas K, Samolinski B, Sánchez Coronel MG, Sanchez‐Borges M, Sanchez‐Lopez J, Sarafoleanu C, Sarquis Serpa F, Sastre‐Dominguez J, Savi E, Sawaf B, Scadding GK, Scheire S, Schmid‐Grendelmeier P, Schuhl JF, Schunemann H, Schvalbová M, Schwarze J, Scichilone N, Senna G, Sepúlveda C, Serrano E, Shields M, Shishkov V, Siafakas N, Simeonov A, FER Simons E, Carlos Sisul J, Sitkauskiene B, Skrindo I, SokličKošak T, Solé D, Sooronbaev T, Soto‐Martinez M, Soto‐Quiros M, Sousa Pinto B, Sova M, Soyka M, Specjalski K, Spranger O, Stamataki S, Stefanaki L, Stellato C, Stelmach R, Strandberg T, Stute P, Subramaniam A, Suppli Ulrik C, Sutherland M, Sylvestre S, Syrigou A, Taborda Barata L, Takovska N, Tan R, Tan F, Tan V, Ping Tang I, Taniguchi M, Tannert L, Tantilipikorn P, Tattersall J, Tesi F, Thijs C, Thomas M, To T, Todo‐Bom A, Togias A, Tomazic P, Tomic‐Spiric V, Toppila‐Salmi S, Toskala E, Triggiani M, Triller N, Triller K, Tsiligianni I, Uberti M, Ulmeanu R, Urbancic J, Urrutia Pereira M, Vachova M, Valdés F, Valenta R, Valentin Rostan M, Valero A, Valiulis A, Vallianatou M, Valovirta E, Van Eerd M, Van Ganse E, Hage M, Vandenplas O, Vasankari T, Vassileva D, Velasco Munoz C, Ventura MT, Vera‐Munoz C, Vicheva D, Vichyanond P, Vidgren P, Viegi G, Vogelmeier C, Von Hertzen L, Vontetsianos T, Vourdas D, Tran Thien Quan V, Wagenmann M, Walker S, Wallace D, Wang DY, Waserman S, Wickman M, Williams S, Williams D, Wilson N, Wong G, Woo K, Wright J, Wroczynski P, Xepapadaki P, Yakovliev P, Yamaguchi M, Yan K, Yeow Yap Y, Yawn B, Yiallouros P, Yorgancioglu A, Yoshihara S, Young I, Yusuf OB, Zaidi A, Zaitoun F, Zar H, Zedda M, Zernotti ME, Zhang L, Zhong N, Zidarn M, Zubrinich C. Cabbage and fermented vegetables: From death rate heterogeneity in countries to candidates for mitigation strategies of severe COVID-19

Large differences in COVID‐19 death rates exist between countries and between regions of the same country. Some very low death rate countries such as Eastern Asia, Central Europe, or the Balkans have a common feature of eating large quantities of fermented foods. Although biases exist when examining ecological studies, fermented vegetables or cabbage have been associated with low death rates in European countries. SARS‐CoV‐2 binds to its receptor, the angiotensin‐converting enzyme 2 (ACE2). As a result of SARS‐CoV‐2 binding, ACE2 downregulation enhances the angiotensin II receptor type 1 (AT₁R) axis associated with oxidative stress. This leads to insulin resistance as well as lung and endothelial damage, two severe outcomes of COVID‐19. The nuclear factor (erythroid‐derived 2)‐like 2 (Nrf2) is the most potent antioxidant in humans and can block in particular the AT₁R axis. Cabbage contains precursors of sulforaphane, the most active natural activator of Nrf2. Fermented vegetables contain many lactobacilli, which are also potent Nrf2 activators. Three examples are: kimchi in Korea, westernized foods, and the slum paradox. It is proposed that fermented cabbage is a proof‐of‐concept of dietary manipulations that may enhance Nrf2‐associated antioxidant effects, helpful in mitigating COVID‐19 severity.

Air pollution and indoor settings

Indoor environments contribute significantly to total human exposure to air pollutants, as people spend most of their time indoors. Household air pollution (HAP) resulting from cooking with polluting ("dirty") fuels, which include coal, kerosene, and biomass (wood, charcoal, crop residues, and animal manure) is a global environmental health problem. Indoor pollutants are gases, particulates, toxins, and microorganisms among others, that can have an impact especially on the health of children and adults through a combination of different mechanisms on oxidative stress and gene activation, epigenetic, cellular, and immunological systems. Air pollution is a major risk factor and contributor to morbidity and mortality from major chronic diseases. Children are significantly affected by the impact of the environment due to biological immaturity, prenatal and postnatal lung development. Poor air quality has been related to an increased prevalence of clinical manifestations of allergic asthma and rhinitis. Health professionals should increase their role in managing the exposure of children and adults to air pollution with better methods of care, prevention, and collective action. Interventions to reduce household pollutants may promote health and can be achieved with education, community, and health professional involvement.

Ipratropium bromide increases the ability of the nose to warm and humidify air

We have developed a method for measuring the temperature and relative humidity of air prior to and after nasal conditioning and used it to study the effect of treatment with ipratropium bromide on the ability of the nose to condition cold, dry air. We performed randomized, double-blind, placebo-controlled, two-way crossover studies and an open study in nonallergic subjects. The subjects were treated with ipratropium bromide (84 microgram) or normal saline solution sprayed into the nasal cavity 15 min before the measurement of nasal conditioning capacity. Cold, dry air was delivered to the nose via a nasal mask, and the temperature and humidity of air were measured before entering and after exiting the nasal cavity. The total water gradient across the nose was calculated and represents nasal conditioning capacity. Ipratropium bromide treatment significantly increased nasal conditioning capacity when compared with saline. Ipratropium bromide led to less reduction in the cold, dry air-induced decrease in the nasal volume (p < 0.05) without affecting the decrease in nasal surface temperature during cold, dry air exposure (p = 0.3). Our data show that ipratropium bromide increases the ability of the nose to condition cold, dry air. Thus, treating rhinitis with ipratropium bromide should not increase the burden for inspired air conditioning on the conducting pulmonary airways.

Intranasal beclomethasone reduces allergen-induced symptoms and superficial mucosal eosinophilia without affecting submucosal inflammation

Previous investigations have suggested that nasal secretions, obtained by lavage or scraping, and the nasal submucosa, sampled by biopsy, are two distinct compartments. We investigated the effect of intranasal corticosteroids on antigen-induced eosinophil influx into both compartments. We performed a double-blind, placebo-controlled study in 15 patients with seasonal allergic rhinitis. Beclomethasone dipropionate, 84 microg twice a day, was delivered to one nostril while the other nostril received placebo for 1 wk. Subjects were then challenged with grass or ragweed extracts on each inferior turbinate. Nasal scrapings from both inferior turbinates were obtained before and 24 h after challenge, and bilateral inferior turbinate biopsies were obtained 24 h after challenge, with the subjects still receiving treatment. Intranasal steroids led to a significant reduction in sneezes and eosinophil influx in nasal secretions without affecting the number of eosinophils in the submucosa. Furthermore, intranasal steroids had no effect on the numbers of submucosal EG2+ (activated eosinophils) or CD25+ (IL-2-receptor-bearing) cells, nor did they decrease the endothelial expression of vascular cell adhesion molecule-1 (VCAM-1). These data show that pretreatment with intranasal steroids successfully inhibited the clinical response to allergen and reduced eosinophils in the superficial compartment of the nasal mucosa, but it had no effect on inflammation in the deeper compartment. This might be related to a different distribution of the active medication and antigen into the nasal mucosa or to a specific effect of the active medication on the epithelium resulting in inhibited migration of eosinophils across this layer.

Medical devices in allergy practice

Medical devices provide people with some health benefits in terms of diagnosis, prevention, treatment, and monitoring of disease processes. Different medical specialties use varieties of medical devices more or less specific for them. Allergology is an interdisciplinary field of medical science and teaches that allergic reactions are of systemic nature but can express themselves at the level of different organs across the life cycle of an individual. Subsequently, medical devices used in allergology could be regarded as: 1) general, servicing the integral diagnostic and management principles and features of allergology, and 2) organ specific, which are shared by organ specific disciplines like pulmonology, otorhinolaryngology, dermatology, and others. The present position paper of the World Allergy Organization (WAO) is meant to be the first integral document providing structured information on medical devices in allergology used in daily routine but also needed for sophisticated diagnostic purposes and modern disease management. It is supposed to contribute to the transformation of the health care system into integrated care pathways for interrelated comorbidities.

Digital tools in allergy and respiratory care

Patient care in the allergy and respiratory fields is advancing rapidly, offering the possibility of the inclusion of a variety of digital tools that aim to improve outcomes of care. Impaired access to several health care facilities during the COVID-19 pandemic has considerably increased the appetite and need for the inclusion of e-health tools amongst end-users. Consequently, a multitude of different e-health tools have been launched worldwide with various registration and access options, and with a wide range of offered benefits. From the perspective of both patients and healthcare providers (HCPs), as well as from a legal and device-related perspective, several features are important for the acceptance, effectiveness,and long-term use of e-health tools. Patients and physicians have different needs and expectations of how digital tools might be of help in the care pathway. There is a need for standardization by defining quality assurance criteria. Therefore, the Upper Airway Diseases Committee of the World Allergy Organization (WAO) has taken the initiative to define and propose criteria for quality, appeal, and applicability of e-health tools in the allergy and respiratory care fields from a patient, clinician, and academic perspective with the ultimate aim to improve patient health and outcomes of care.

Twenty-five years: The fexofenadine clinical experience

Allergic rhinitis (AR) and urticaria affect a sizable portion of the population worldwide, resulting in reduced quality-of-life and productivity and increased healthcare costs. Fexofenadine (FEX) is a non-sedating second-generation H1 antihistamine with pronounced efficacy and a very good safety profile, used for the treatment of allergic diseases. In addition to its antihistaminic properties, FEX also has anti-inflammatory effects. FEX has a wide therapeutic window and is not associated with any sedative effects, even at higher than recommended doses. There is a need for an integrated management system for AR and urticaria which includes safe and effective treatment options. An ideal anti-allergic formulation should provide fast relief of symptoms and long-lasting effect without drowsiness. Data from randomized clinical trials show that FEX meets these criteria and is an effective treatment option with a favourable safety profile, improving the quality of life of patients suffering from AR and urticaria.