Allergic rhinitis and asthma: How important is the link?,☆☆,

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Abstract

Dysfunction of the upper and lower airways frequently coexist, and they appear to share key elements of pathogenesis. Data from epidemiologic studies indicate that nasal symptoms are experienced by as many as 78% of patients with asthma and that asthma is experienced by as many as 38% of patients with allergic rhinitis. Studies also have identified a temporal relation between the onset of rhinitis and asthma, with rhinitis frequently preceding the development of asthma. Patients with allergic rhinitis and no clinical evidence of asthma commonly exhibit nonspecific bronchial hyperresponsiveness. The observation that management of allergic rhinitis also relieves symptoms of asthma has heightened interest in the link between these diseases. Intranasal corticosteroids can prevent increases in nonspecific bronchial reactivity and asthma symptoms associated with seasonal pollen exposure. Similarly, among patients with perennial rhinitis, daily asthma symptoms, exercise-induced bronchospasm, and bronchial responsiveness to methacholine are reduced after administration of intranasal corticosteroids. Antihistamines, with or without decongestants, reduce seasonal rhinitis symptoms, asthma symptoms, and objective measurements of pulmonary function among patients with rhinitis and asthma. The mechanisms that connect upper and lower airway dysfunction are under investigation. They include a nasal-bronchial reflex, mouth breathing caused by nasal obstruction, and pulmonary aspiration of nasal contents. Nasal allergen challenge results in increases in lower airway reactivity within 30 minutes, suggesting a neural reflex. Improvements in asthma associated with increased nasal breathing may be the result of superior humidification, warming of inspired air, and decreased inhalation of airborne allergens. Postnasal drainage of inflammatory cells during sleep also may affect lower airway responsiveness. A link between allergic rhinitis and asthma is evident from epidemiologic, pathophysiologic, and clinical studies. Future research, however, is needed to determine whether nasal therapy can alter the natural history of asthma. (J Allergy Clin Immunol 1997; 99:S781-6.)

Section snippets

Epidemiologic studies: coexistence or cause-and-effect?

A large number of cross-sectional studies have demonstrated that rhinitis and asthma commonly occur together. Nasal symptoms have been reported among 28% to 78% of patients with asthma,1, 2, 3 compared with approximately 20% of the general population.4 Similarly, as many as 19% to 38% of patients with allergic rhinitis may have asthma,1, 3 much more than the 3% to 5% prevalence among the general population.5 In a survey of 6563 residents, new diagnoses of probable allergic rhinitis or asthma

Clinical trials: The effects of nasal therapy on asthma

In anecdotal experience, physicians have often noted improvements in asthma after successful treatment of rhinitis. Until recently, however, few controlled clinical trials have been attempted to measure this effect. Since the mid 1980s, several investigators have begun to evaluate carefully the impact of rhinitis therapy on asthma symptoms, pulmonary function, and airway responsiveness.

Laboratory research: Exploring the mechanisms

Although there is compelling evidence that allergic rhinitis may influence the clinical course of asthma, the mechanisms connecting upper and lower airway dysfunction are poorly understood. A variety of theories have been proposed to explain the apparent relation between nasal disease and asthma. These theories include (1) the existence of a nasal-bronchial reflex, (2) mouth breathing caused by nasal obstruction, and (3) pulmonary aspiration of nasal contents.

Summary and future directions

Epidemiologic surveys have shown that allergic rhinitis and asthma commonly coexist and that an important minority of patients with nasal allergy demonstrate nonspecific bronchial hyperresponsiveness in the absence of overt asthma. A limited number of studies suggest that allergic rhinitis is a risk factor for asthma and that asymptomatic bronchial hyperresponsiveness may influence this process. Among patients who have both rhinitis and asthma, intranasal corticosteroids and antihistamines,

References (55)

  • JA Grant et al.

    Cetirizine in patients with seasonal allergic rhinitis and concomitant asthma: prospective, randomized, placebo-controlled trial

    J Allergy Clin Immunol

    (1995)
  • JH Hoehne et al.

    Where is the allergic reaction in ragweed asthma?

    J Allergy Clin Immunol

    (1971)
  • MJ Schumacher et al.

    Pulmonary response to nasal-challenge testing of atopic subjects with stable asthma

    J Allergy Clin Immunol

    (1986)
  • J Corren et al.

    Changes in bronchial responsiveness following nasal provocation with allergen

    J Allergy Clin Immunol

    (1992)
  • MP Griffin et al.

    Airway cooling in asthmatic and nonasthmatic subjects during nasal and oral breathing

    J Allergy Clin Immunol

    (1982)
  • EJ Huxley et al.

    Pharyngeal aspiration in normal adults and patients with depressed consciousness

    Am J Med

    (1978)
  • PG Bardin et al.

    Absence of pulmonary aspiration of sinus contents in patients with asthma and sinusitis

    J Allergy Clin Immunol

    (1990)
  • H. Blair

    Natural history of childhood asthma: 20-year follow-up

    Arch Dis Child

    (1977)
  • JM. Smith

    Epidemiology and natural history of asthma, allergic rhinitis and atopic dermatitis (eczema)

  • PA Pedersen et al.

    Asthma and allergic rhinitis in the same patients

    Allergy

    (1983)
  • GA. Settipane

    Allergic rhinitis: update

    Otolaryngol Head Neck Surg

    (1986)
  • PP Van Arsdel et al.

    Frequency and hereditability of asthma and allergic rhinitis in college students

    Acta Genet

    (1959)
  • CJ Maternowski et al.

    The prevalence of ragweed pollinosis in foreign and native students at a midwestern university and its implications concerning methods for determining inheritance of atopy

    J Allergy

    (1962)
  • RJ Settipane et al.

    Long-term risk factors for developing asthma and allergic rhinitis: a 23-year follow-up study of college students

    Allergy Proc

    (1994)
  • EH Ramsdale et al.

    Asymptomatic bronchial hyperresponsiveness in rhinitis

    J Allergy Clin Immunol

    (1985)
  • L Prieto et al.

    Airway responsiveness to methacholine and risk of asthma in patients with allergic rhinitis

    Ann Allergy

    (1994)
  • JW Henriksen et al.

    Effect of an intranasally administered corticosteroid (budesonide) on nasal obstruction, mouth breathing and asthma

    Am Rev Respir Dis

    (1984)
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