Rhinosinusitis and asthma: the missing link

Transcription

1 Rhinosinusitis and asthma: the missing link Curr Opin Pulm Med January ; 15(1): Anne E. Dixon, MD. Vermont Lung Center at the University of Vermont Ri 王怡人 X

2 Epidemiology 梁 risk factor Allergic Rhinitis Asthma??? Cross-sectional studies: Longitudinal studies: childhood: 42% vs 12.9%, Burgess et al 7 y/o allergic rhinitis *3-fold risk developed asthma Infants atopy with eczema risk developed allergic rhinitis Environmental factors: (O) Smoking + allergic rhinitis *3-fold risk developed asthma, cohort, Polosa et al (X) Obesity : allergic rhinitis(not ) ; asthma( ) The Allergic March : the progression of allergic disease from the nose and sinuses down to the airways of the lung

3 Not known 梁

4 梁 Upper Airway Inflammation Epidemiological studies: suggest rhinitis/earlier eczema predict the development of asthma. (1) upper airway disease experienced by asthmatics is different vs general population Rolla et al: persistent allergic rhinitis & chronic rhinosinusitis associate asthma nasal polyps requires multiple surgeries (2) inflammatory process share common features Eosinophilic inflammation & local IgE production Gene expression: nasal polyposis sinus mucosa vs aspirin sensitive asthma no difference (3) severity: upper parallels lower Ponte et al: 557 pt, severe rhinitis severe asthma Mehta el al: sinus CT score sputum & peripheral blood eosinophils CT scan osteitis

5 梁

6 Lung Function in patients with 江後 allergic rhinitis Allergic rhinitis pt (with/out asthma) have subtle abnormalities in their lower airway Young children with allergic rhinitis prevalence of bronchial hyperreactivity Crimi el al: without obvious physiological abnormalities may have evidence of subtle dysfunction a lack of bronchodilator response to a deep inhalation suggests altered smooth muscle function in the intrathoracic airways

7 Inflammation x/o progressive inflammation (exhaled NO, interleukin-5 ) detectable when comparing four groups of patients: (1) normal controls, (2) patients with allergic rhinitis without bronchial hyperreactivity/asthma, (3) patients with allergic rhinitis and bronchial hyperreactivity(without asthma), (4) patients with allergic rhinitis and asthma.

8 Link between upper and lower 梁 Adults: airway nasal challenge may increase lower airway inflammation Children(Marucci et al): dust mite nasal challenge NO exhaled Previous studies: allergen challenge in asthmatics release eosinophil precursors from bone marrow nasal challenge in a mouse model of allergic rhinitis release eosinophil precursors from bone marrow separate anatomic compartments affected by one systemic disease

9 江 x/o Asthma Control Cross-sectional studies: nasal symptom scores vs asthma symptoms Pt with nasal symptoms appear to experience worse asthma control Prospective cohort study: Pt with rhinitis had increased emergency room visits the severity of rhinitis correlated with the severity of asthma

10 王 Outcomes from Treatment Retrospective: improved Prospective: disappointing Nasal steroid effect on nasal inflammation(levels of eosinophilic cationic protein) effect on systemic inflammation (eosinophil count) no effect on lower airway inflammation (exhaled NO)

11 王 Conclusions Studies published during this last year confirm: rhinitis & sinusitis are very important comorbidities in asthma pt. The temporal sequence of disease and parallel inflammatory pathways involved suggest that they may be progressive manifestations of a common disease process. studies investigating treatment of early disease on the development of asthma are of great interest. Retrospective studies: suggest treatment of chronic upper airway diseased in established asthma can lead to improved asthma outcomes Controlled clinical trials: has not been established