Previous edito July 96 Considerations in asthma and concomitant
upper airway symptoms
(September 1996 Editorial) Professeur Philippe Godard
(partial) translation : | Français/French |  :-)

Bronchial asthma has been defined as an inflammatory disorder of the airways. However upper airways are often forgotten either by the clinicians when they care asthmatics or the designers of clinical trials. Nose and sinus are a part of the airways and their role appear to be important in the pathophysiology of asthma; the treatment of rhinitis and sinusitis has to be included in the recommendations.

Epidemiology:
According to M. Kaliner (1), the prevalence of asthma, allergic rhinitis and chronic sinusitis in the United States is 9-12, 20 and 32 millions respectively.

In the data base of the expert system which has been validated (2), 431 patients of the 729 asthmatic patients (59%) had rhinitis.
15 to 25% of patients with rhinitis have bronchial asthma. The risk factors for a patient with rhinitis to have asthma are not well known; however it has been shown that perannual allergens (3), high IgE level (3), a family history of asthma and pollution could be important factors.

Clinical considerations:
It has been clearly shown that quality of life can be impaired in rhinitic patients (4). Moreover in severe rhinitis this impairment can be as high as in asthmatic patients. Prospective studies are required.
The symptoms of rhinitis (sneezing, itching, stuffiness and rhinorrhea) are well known; however their sensitivity as compared to rhinoscopy abnormalities need to be checked.
The analysis of the data base of the expert system gave interesting results. The number of asthmatic patients with rhinitis was higher in patient with atopy than in non atopic patients. The severity of asthma was lower in patients with rhinitis as compared to patients without any symptoms of rhinitis.
In exercice-induced asthma, it has been recommanded to cure rhinitis in order to diminish symptoms.
The specificity of anosmia and polyposis is not well known; these symptoms could be linked to aspirin intolerance.

Frequency of nasal polyps in various conditions

Settipane GA. Nasal polyps - Immunol Allergy N Am 1987; 7:105

The relationship between sinusitis and asthma is also very interesting to study. Sinusitis is more common in persons with allergies than in control subjects. Medical management of sinusitis results in significant improvement in asthma (5).
In severe corticodependent asthmatics, sinusitis severity as assessed by clinical and scanner symptoms was correlated to FEV1 (the best FEV1, the more severe sinusitis! r=0.74 - n= 31 - personnal unpublished data).

Treatment:
At least from the quality of life point of view, the treatment of rhinitis is important. M. Aubier demonstrated that nasal inhaled steroids are able to decrease bronchial hyperreactivity (6).
Anti leukotrienes could be interesting.
The treatment of sinusitis appears to be more difficult and could require nebulisation, antibiotic or surgery.

References
1- Kaliner M., Lemanske R. Rhinitis and asthma. JAMA 1992; 268: 2807-29.
2- Rédier H, Daurés JP, Michel C, Proudhon H, Vervloet D, Charpin D, Marsac J, Dusser D, Brambilla C, Wallaert B, Kopferschmitt MC, Pauli G, Taytard A, Cogis O, Michel FB, Godard P. Assessment of the severity of asthma by an expert system: Description and evaluation - Am J Respir Crit Care Med 1995;151:345-352.
3- De Lovinfosse S., Charpin D., Magnan A., Vervloët D. Relations entre rhinites et asthmes allergiques. Rev. Mal. Resp. 1995; 12:79-85.
4- Bousquet J., Bullinger M., Fayol C., Marquis P., Valentin B., Burtin B. assessment of quality of life in patients with perennial allergic rhinitis with the french version of the SF-36 health status questionnaire. J. Allergy Clin Immunol. 1994; 94: 182-188.
5- Rachelefsky GS, Kats RM, Siegel SC. Chronic sinus disease with associated reactive airway disease in children. J. Allergy Clin Immunol 1984; 73:526.
6- Aubier M, Levy J, Clerici C, Neukirch F, Herman D. Different Effects of Nasal and Bronchial Glucocorticosteroid Administration on Bronchial Hyperresponsiveness in Patients with Allergic Rhinitis - American Review of Respiratory Disease 1992;146:122-126.

Other references:
Bisgaard H, Gronborg H, Mygind N, Dahl R, Lindqvist N, Venge P. Allergen-Induced Increase of Eosinophil Cationic Protein in Nasal Lavage Fluid - Effect of the Glucocorticoid Budesonide. - J Allerg Clin Immunol 1990;85:891-895.

Boulet LP, Turcotte H, Lampron N, Laviolette M. Influence of natural antigenic exposure on bronchoalveolar lavage in subjects with pollen-induced rhinitis. - J. Allergy Clin. Immunol 1990;86:19-25.

Bousquet J, Chanez P, Michel FB. Pathophysiology and Treatment of Seasonal Allergic Rhinitis - Respiratory Medicine 1990;84:11-17.

Brogden RN, Mctavish D. Budesonide - An Updated Review of Its Pharmacological Properties, and Therapeutic Efficacy in Asthma and Rhinitis - Drugs 1992;44:375-407.

Demoly P, Crampette L, Mondain M, Campbell AM, Lequeux N, Enander I, Schwartz LB, Guerrier B, Michel FB, Bousquet J. Assessment of inflammation in noninfectious chronic maxillary sinusitis - Journal of Allergy and Clinical Immunology 1994;94:95-108.

Godfrey RWA. The Nose and the Lower Airways - Lancet 1994;343:991-992.

Hamilos DL, Leung DYM, Wood RE, Meyers A, Stephens JK, Barkans J, Meng Q, Cunningham L, Bean DK, Kay AB, Hamid Q. Chronic Hyperplastic Sinusitis - Association of Tissue Eosinophilia with Messenger RNA Expression of Granulocyte-Macrophage Colony-Stimulating Factor and Interleukin-3 - Journal of Allergy and Clinical Immunology 1993;92:39-48.

Knapp HR. Reduced Allergen-Induced Nasal Congestion and Leukotriene Synthesis with an Orally Active 5-Lipoxygenase Inhibitor - N. Engl. J. Med 1990;323:1745-1748.

Pipkorn U, Proud D, Lichtenstein LM, Schleimer RP, Peters SP, Adkinson NF, Norman PS, Nacleirio RM. Effect of short term systemic glucocorticosteroid treatment on human nasal mediator release after antigen challenge. - J. Clin. Invest 1987;80:957-961.

Slavin RG. Chronic sinusitis - Immunology and Allergy Clinics of North America 1996;16:35.

Slavin RG. Medical Management of Nasal Polyps and Sinusitis - Journal of Allergy and Clinical Immunology 1991;88:141-146.

Stechschulte DJ. Leukotrienes in Asthma and Allergic Rhinitis - N. Engl. J. Med 1990;323:1769-1770.

Thomas KE, Greenwood L, Murrant N, Cook J, Devalia JL, Davies RJ. The Effects of Topical Fluticasone Propionate on Allergen-Induced Immediate Nasal Airways Response and Eosinophil Activation - Preliminary Results - Respiratory Medicine 1990;84:33-35.

Vignola AM, Crampette L, Mondain M, Sauvere G, Czarlewski W, Bousquet J, Campbell AM. Inhibitory activity of loratadine and descarboethoxyloratadine on expression of ICAM-1 and HLA-DR by nasal epithelial cells - Allergy 1995;50:200-203.

Remarques, conseils et suggestions sont les bienvenus; ils seront publiés dans le courrier des lecteurs. Ecrivez au Professeur Philippe Godard ou à la liste de diffusion Asma-L

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Date de création: August 1996- Dernière mise à jour: 22/07/98
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