RHINITIS AND ASTHMA: UNITED AIRWAY DISEASE Dr. İ.Kıvılcım Oğuzülgen Gazi University School of...

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 Unpublished dataDinmezel S et al.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)


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.


Allergic Rhinitis and Asthma Have Similar Trends in Prevalence


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)

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


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)


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.


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









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


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


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.


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 (- )


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)


19751975 19901990

n:1370 (20-44 yr)

Plaschke P et al. Am J Respir Crit Care Med 2000;162:920–924


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


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)


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

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)



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




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...

RHINITIS AND ASTHMA: UNITED AIRWAY DISEASE Dr. İ.Kıvılcım Oğuzülgen Gazi University School of...

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