rhinitis and asthma: united airway disease dr. İ.kıvılcım oğuzülgen gazi university school of...
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RHINITIS AND ASTHMA: UNITED AIRWAY DISEASERHINITIS AND ASTHMA: UNITED AIRWAY DISEASE
Dr. İ.Kıvılcım Oğuzülgen
Gazi University School of Medicine, Department of Pulmonary Medicine
Ankara, Turkey
EPIDEMIOLOGICAL OUTCOMESEPIDEMIOLOGICAL OUTCOMES
ασθμα
Asthma in historyAsthma in history
... A disease, emphasizing the wheezing, the dry, often non productive cough, and the inability to sleep in a prone position. The disease called ortopnoia is also called asthma ..... ....They eagerly go into the open air, since no house sufficieth for their respiration.........cough incessant and laborious, expectoration small, thin, cold, resembling the efflorescence of foam........if these symptoms increase, they sometimes produce suffocation......
81-131 ADAretaeus of Cappadocia
Aretaeus of Cappadocia described asthma with care, attributing it to thick and viscid phlegm caused by coldness and humidity suffered by the patient.
Aretaeus of Cappadocia (81 131) De Causis et Signis Acutorum etDiuturnorum Morborum, Liber Primus (Of the Causes and Signs of Acute and Morbid Disease)Oxford, 1723
The prevalance of asthma in world
The prevalance of asthma in world
9.5-18.9
7.2
12
2.7
2.9 4 4 4
6.9
7.1
3.4 5.8 – 6.7
10.5
GINA, updated 2004.
The prevalance of asthma in TurkeyThe prevalance of asthma in Turkey
5.9-7.3
5.6-7.6 7.1-8.9
5.5-7.9
9.5-11.2
5.9-7.3
8.1-10.8
8.2-11.0
5.7-7.78.5-11.0
9.6-8.1
Kurt E et al. PARTFAIT study. Unpublished dataDinmezel S et al. Allergy Asthma Proc 2005; 26:403-409
Kalyoncu AF et al. Allergol Immunopathol 2001; 29:264-271
5.8-7.42.2-2.59.4
Rhinitis in historyRhinitis in history
About the beginning or middle of the June every year....
... a sensation of heat and fulness is experienced in the eyes...
... to this succeeds irritation of the nose producing sneezing
To the sneezing are added a further sensation of thightness of the chest, a difficulty of breathing
Med Chir Trans 1819; 10: 161
Dr. John Bostock
The prevalance of rhinitis in worldThe prevalance of rhinitis in world 10
14.9 – 29
22.7
13.3 4.1 10.6
4.4 – 14.2
10.2 – 21.1
14 19-23.4
6.6
4.5
ARIA Workshop Report. J Allergy Clin Immunol 2001;108: S153-S161.
The prevalance of rhinitis in TurkeyThe prevalance of rhinitis in Turkey
12.2-16.1
12.9-17.8 13.1-18.5
13.3-17.5
17.5-22.9
5.9-7.3
13.4-18.4
15.2-20.3
10.7-16.413.6-19.4
15.7-20.6
Kurt E et al. PARTFAIT study. Unpublished dataDinmezel S et al. Allergy Asthma Proc 2005; 26:403-409
Kalyoncu AF et al. Allergol Immunopathol 2001; 29:264-271
12.2-17.812.7-14.527.7
Allergic Rhinitis
Epidemiologic Links between Allergic Rhinitis and Asthma
Allergic Rhinitis and Asthma Have Similar Prevalence Patterns (ISAAC)
Epidemiologic Links between Allergic Rhinitis and Asthma
Allergic Rhinitis and Asthma Have Similar Prevalence Patterns (ISAAC)
ISAAC Steering Committee Lancet 1998;351:1225–1232.
UKAustralia
CanadaBrazil
USASouth Africa
GermanyFrance
ArgentinaAlgeria
ChinaRussia
0 5 10 15 20 25 30 35 40
% prevalence
UKAustralia
CanadaBrazil
USASouth Africa
GermanyFrance
ArgentinaAlgeria
ChinaRussia
0 5 10 15 20 25 30 35 40
% prevalence
Asthma
3.5
3.0
2.5
2.0
1.5
1.0
0.5
0
% o
f m
en
% o
f m
enAsthma Allergic Rhinitis
9
8
7
6
5
4
3
2
1
01960 1970 1980 1990 2000
Year
1960 1970 1980 1990 2000
Year
Latvala J et al. 2005;3301186–1187.
Epidemiologic Links between Allergic Rhinitis and Asthma
Allergic Rhinitis and Asthma Have Similar Trends in Prevalence
Epidemiologic Links between Allergic Rhinitis and Asthma
Allergic Rhinitis and Asthma Have Similar Trends in Prevalence
First published papers in PubMed about the relation between rhinitis and asthmaFirst published papers in PubMed about the relation between rhinitis and asthma
RANDOLPH TG, ROLLINS JP. Adrenocorticotropic hormone
(ACTH) its effect in bronchial asthma and ragweed hay
fever.
Ann Allergy. 1950 Mar-Apr;8(2):149-62.
CUERVO TRUJILLO C. [Bronchial asthma in children
consecutive to allergic rhinitis.] Rev Colomb Pediatr
Pueric. 1952 Jun;11(5):221-40.
VUKOBRATOVIC S. [The relation between allergic rhinitis
and bronchial asthma and the reaction of sensitized tissue
to histamine.] Med Glas. 1954 Sep;8(9):310-3.
Approximately
60% of the
patients
experience
rhinitis
symptoms before
asthma
symptoms
60-80% of asthmatics have coexisting allerjic
rhinitis,
20% - 38% of patients who have allergic rhinitis
have coexisting asthma.
Braman SS et al.Chest 1987; 1:671-74
Grossman J. CHEST 1997; 111:11S-16S.
Epidemiologic Links between Allergic Rhinitis and AsthmaEpidemiologic Links between Allergic Rhinitis and Asthma
Asthma and rhinitis might be two different manifestations of the same atopic disease?
Asthma and rhinitis might interact each other?
Pedersen PA et al. Allergy 1983; 38:25-29
Leynaert B et al. J Allergy Clin Immunol 2004; 113:86-93
Epidemiologic evidence for the link between rhinitis and asthmaEpidemiologic evidence for the
link between rhinitis and asthma
1. Asthma prevalence is increased in allergic and non-allergic rhinitis
2. Rhinitis is almost always present in asthma
3. Rhinitis may be a risk factor for asthma
4. Non-spesific bronchial hyperresponsiveness is increased in persistent rhinitis
Adopted from ARIA (www.whiar.com)
Epidemiologic evidence for the link between rhinitis and asthmaEpidemiologic evidence for the
link between rhinitis and asthma
1. Asthma prevalence is increased in allergic and non-allergic rhinitis
2. Rhinitis is almost always present in asthma
3. Rhinitis may be a risk factor for asthma
4. Non-spesific bronchial hyperresponsiveness is increased in persistent rhinitis
1. Asthma prevalence is increased in allergic and non-allergic rhinitis
2. Rhinitis is almost always present in asthma
3. Rhinitis may be a risk factor for asthma
4. Non-spesific bronchial hyperresponsiveness is increased in persistent rhinitis
ECRHS Swedish results (n:9325)ECRHS Swedish results (n:9325)
E. Björnsson et al. Eur Respir J 1994; 7,:2146–2153.
Rhinitis (-)Rhinitis (+)
19.5% had asthma related
disease
2.3% had asthma related
disease
OR=10.1 (95% CI 8.4-12.2) p<0.001
Asthma prevalence is increased in allergic and non-allergic rhinitisAsthma prevalence is increased in allergic and non-allergic rhinitis
Rhinitis (-)Rhinitis (+)
Asthma 16.2% Asthma 1.0%
OR=19.9 (95%CI 14.6-27.2)
ECRHS resultsECRHS results
Leynaert B et al.J Allergy Clin Immunol 1999; 104:301-304.
1412 perennial rhinitis and 5198 control
subjects
Asthma prevalence is increased in allergic and non-allergic rhinitisAsthma prevalence is increased in allergic and non-allergic rhinitis
Leynaert B et al.J Allergy Clin Immunol 1999; 104:301-304.
ECRHS results-2 (1412 perennial rhinitis and 5198 control
subjects)
ECRHS results-2 (1412 perennial rhinitis and 5198 control
subjects)
Asthma prevalence is increased in allergic and non-allergic rhinitisAsthma prevalence is increased in allergic and non-allergic rhinitis
Rhinitis (+)
Asthma 7.8%,
Rhinitis (-)
Asthma 0.5%
OR=11.6
(95%CI 6.2-21.9, p=0.001)
Rhinitis (+)
Asthma 19.1%
Rhinitis (-)
Asthma 2.3%
OR=8.1
(95%CI 5.4-12.1, p=0.001)
Nonatopic subjects Atopic subjects
Leynaert B et al. J Allergy Clin Immunol 2004; 113: 86-93
The proportion of of subjects with asthma was 2.0% in subjects without rhinitis and 13.4% in subjects with rhinitis, OR=6.63 (95%CI 5.44-8.08), p<0.001.
Asthma prevalence is increased in allergic and non-allergic rhinitisAsthma prevalence is increased in allergic and non-allergic rhinitis
ECRHS results (31 centers)ECRHS results (31 centers)
Spain Italy France Benelux UK Scandinavia US
20
18
16
14
12
10
8
6
4
2
0
% with asthma
Rhinitis (+)
Rhinitis (-)
Epidemiologic evidence for the link between rhinitis and asthma
Epidemiologic evidence for the link between rhinitis and asthma
1. Asthma prevalence is increased in allergic and non-allergic rhinitis
2. Rhinitis is almost always present in asthma
3. Rhinitis may be a risk factor for asthma
4. Non-spesific bronchial hyperresponsiveness is increased in persistent rhinitis
1. Asthma prevalence is increased in allergic and non-allergic rhinitis
2. Rhinitis is almost always present in asthma
3. Rhinitis may be a risk factor for asthma
4. Non-spesific bronchial hyperresponsiveness is increased in persistent rhinitis
Data from Finnish Twin Cohort (n:11540)Data from Finnish Twin Cohort (n:11540)
Huovinen E et al. Chest 1999;115;928-936
Rhinitis is almost always present in asthmaRhinitis is almost always present in asthma
2%28%
34%
36% Later
Concomitant
Prior
None
5%
29%
39%
27%Later
Concomitant
Prior
None
Hay fever (men) Hay fever (women)
Hay fever in 219 subjects with incident asthma
19751975 19901990
The Copenhagen Allergy StudyThe Copenhagen Allergy Study
0%
20%
40%
60%
80%
100%
Polen Animal Mite
Had no AR
Developed AR duringthe follow- up
Had AR at baseline
Linneberg A et al. Allergy 2002; 57: 1048-1052
19901990 19981998
Patients who developed allergic asthma during the follow-up
Rhinitis is almost always present in asthmaRhinitis is almost always present in asthma
ISAYA 2005 (n:17666)ISAYA 2005 (n:17666)
Reported allergic rhinitis prevalence is
18.7%.
The prevalence of allergic rhinitis in
subjects reporting asthma was about
60%.
Bugiani M et al. Allergy 2005: 60: 165–170
Rhinitis is almost always present in asthmaRhinitis is almost always present in asthma
Data from asthmatic children aged
3-16 years (n:369)
Data from asthmatic children aged
3-16 years (n:369)68.8% (254) of asthmatics (87.9% of allergic asthmatics) were diagnosed with allergic rhinitis.
Retrospective evaluation of their file records showed that only 23.8% and 57.7% of this group had received a diagnosis of allergic rhinitis and treatments for allergic rhinitis, respectively.
Kocabas CN et al. Pediatr Pulmonol. 2005; 40:235–240.
Rhinitis is almost always present in asthmaRhinitis is almost always present in asthma
Epidemiologic evidence for the link between rhinitis and asthmaEpidemiologic evidence for the
link between rhinitis and asthma
1. Asthma prevalence is increased in allergic and non-allergic rhinitis
2. Rhinitis is almost always present in asthma
3. Rhinitis may be a risk factor for asthma
4. Non-spesific bronchial hyperresponsiveness is increased in persistent rhinitis
1. Asthma prevalence is increased in allergic and non-allergic rhinitis
2. Rhinitis is almost always present in asthma
3. Rhinitis may be a risk factor for asthma
4. Non-spesific bronchial hyperresponsiveness is increased in persistent rhinitis
Settipane RJ et al. Allergy Proc 1994;15:21–25.
12
10
8
6
4
2
0
% of patients who developed
asthma
10.5
Allergic rhinitis
at baseline(n=162)
3.6
No allergic rhinitisat baseline
(n=528)
p<0.002
Rhinitis may be a risk factor for asthmaRhinitis may be a risk factor for asthma
23-years follow-up study23-years follow-up study
Wright AL et al. Pediatrics 1994; 94: 895-901
n:747
42% had allergic rhinitis /
58% was non-rhinitic
0
10
20
30
40
50
Physician
diagnosis of
asthma (%)
AR (+) AR (- )
AR (+)
AR (- )
Rhinitis may be a risk factor for asthmaRhinitis may be a risk factor for asthma
BirthBirth 6 years6 years
Data from Finnish Twin CohortData from Finnish Twin Cohort
Huovinen E et al. Chest 1999; 115;928-936
Hay fever significantly icreased the risk of asthma !
Subjects Subjects at risk
Cases Incidence of asthma 1976-1990
IRR (95%CI)
Hay fever 1975
No 4554 86 1.9 1.0
Yes 301 25 8.3 4.3 (2.8-6.6)
Hay fever 1975
No 5487 107 2.0 1.0
Yes 355 43 12.1 6.0 (4.2-8.3)
Rhinitis may be a risk factor for asthmaRhinitis may be a risk factor for asthma
19751975 19901990
n:1370 (20-44 yr)
Plaschke P et al. Am J Respir Crit Care Med 2000;162:920–924
Rhinitis may be a risk factor for asthmaRhinitis may be a risk factor for asthma
A.Rhinitis (-)
A.Rhinitis (+)
13.1% 1.6%
19901990 19931993
had new onset of asthmaOR= 4.9 (95% CI 2.3-10.4)
Data from ECRHS stage IIIData from ECRHS stage III
Guerra S et al. J Allergy Clin Immunol 2002; 109: 419-425
Tucson Epidemiologic Study of Obstructive Lung DiseaseTucson Epidemiologic Study of Obstructive Lung Disease
173
Incident asthmatic patients
2177
Subjects without asthma
Subjects who reported the presence of rhinitis before the onset of asthma
76.3% 43.8%p<0.001
Rhinitis had a strong predictive value for the onset of asthma (OR=3.81; 95%CI 2.50-5.79) irrespective of whether subjects had positive or negative skin test responses
Rhinitis may be a risk factor for asthmaRhinitis may be a risk factor for asthma
19721972 19921992
Data from ECRHS (n:10210, 31 centers)Data from ECRHS (n:10210, 31 centers)
The risk of asthma was strongly associated with rhinitis in all centers (combined OR=7.03; 95% CI 6.25-7.91, p<0.001)
Leynaert B et al. J Allergy Clin Immunol 2004; 113: 86-93)
Rhinitis may be a risk factor for asthmaRhinitis may be a risk factor for asthma
BarcelonaGaldakoAlbacete
OviedoHuelvo
PaviaTurin
VeronaBordeauxGrenoble
MontpellierParis
Antwerp-SouthAntwerp-City
GroningenBergen-op-Zoom
GeleenDublin
CambridgeIpswichNorwich
ReykjavikBergen
GöteborgUmea
UppsalaWellington
ChristchurchHawkes-Bay
MelbournePortland
Combined
0.5 1 2 5 10
Epidemiologic evidence for the link between rhinitis and asthmaEpidemiologic evidence for the
link between rhinitis and asthma
1. Asthma prevalence is increased in allergic and non-allergic rhinitis
2. Rhinitis is almost always present in asthma
3. Rhinitis may be a risk factor for asthma
4. Non-spesific bronchial hyperresponsiveness is increased in persistent rhinitis
1. Asthma prevalence is increased in allergic and non-allergic rhinitis
2. Rhinitis is almost always present in asthma
3. Rhinitis may be a risk factor for asthma
4. Non-spesific bronchial hyperresponsiveness is increased in persistent rhinitis
Madonini E et al. J Allergy Clin Immunol. 1987; 79:358-63.
Seasonal increase of bronchial reactivity in allergic rhinitisSeasonal increase of bronchial reactivity in allergic rhinitis
27 patients with hay fever without a history of asthma had inhalation challenge test:
11% (n:3)
48.1% (n:13)
Non-spesific bronchial hyperresponsiveness is increased in persistent rhinitisNon-spesific bronchial hyperresponsiveness is increased in persistent rhinitis
BPT (+)
During pollen season
Out of pollen season
Among Non-asthmatic subjects
Rhinitis (+) BHR 22.5%
Without rhinitis BHR 7.5%
OR=3.6 (95% CI 3.0-4.3)
Leynaert B et al. J Allergy Clin Immunol 1999; 104:301-304.
ECRHS results (1412 perennial rhinitis and 5198 control subjects)
ECRHS results (1412 perennial rhinitis and 5198 control subjects)
Non-spesific bronchial hyperresponsiveness is increased in persistent rhinitisNon-spesific bronchial hyperresponsiveness is increased in persistent rhinitis
Rhinitis (+)
BHR 11.6%,
Rhinitis (-)
BHR 6.6%
(OR=1.5, 95%CI 1.0-2.2,
p=0.001)
Rhinitis (+)
BHR 26.7%
Rhinitis (-)
BHR 10.0%
(OR= 3.3, 95%CI 2.6-
4.2,p=0.001)
Leynaert B et al. J Allergy Clin Immunol 1999; 104:301-304.
Nonatopic subjects Atopic subjects
Non-spesific bronchial hyperresponsiveness is increased in persistent rhinitisNon-spesific bronchial hyperresponsiveness is increased in persistent rhinitis
ECRHS results (1412 perennial rhinitis and 5198 control subjects)
ECRHS results (1412 perennial rhinitis and 5198 control subjects)
Nasal obstruction leading to mouth breathing, causing impaired warming and humidification of the inspired air and increased deposition of inhaled allergens in lower airways;
Nasal–bronchial reflex;
Aspiration of nasal secretions;
Increased bronchial hyperresponsiveness.
Possible pathophysiological mechanisms
for the associationbetween rhinitis and asthma
Possible pathophysiological mechanisms
for the associationbetween rhinitis and asthma
Epidemiological data show that there is a strong link between rhinitis and asthma...