Concomitant Disease management of Asthma
Allergic Rhinitis:
Definition: Rhinitis is characterized by inflammation of the lining of the nose. Clinical diagnosis is made on the basis of recognizing a symptom complex of two or more of the following:
- Nasal blockage - Nasal discharge - Sneezing - Nasal itching
Classification:
1) Intermittent Rhinitis :
Acute form of rhinitis persists from few hours to maximum 14 days.
a) Viral (Common cold): The common viral cold is probably the most common form of acute rhinitis. It presents along with myalgia and sore throat, resolves within 10 days to 2 weeks.
b) Allergen induced: Induced by direct contact with domestic pets (cat) or sudden exposure to mite containing dust or pollen.
2) Persistent Rhinitis:
Symptom complex of rhinitis, persistent for more than 14 days, usually through out a specific season (Seasonal) or round the year (Perennial).
a) Allergic Rhinitis: Associated with allergen specific IgE and eosinophils in the nasal mucosa, usually associated with allergic conjunctivitis, sensitive to multiple stimuli.
b) Vasomotor Rhinitis: Hyperreactive noses with nasal congestion without allergic sensitization to nonspecific stimuli such as: smoke, air pollution or odors. These patients lack associated conjunctivitis.
c) Non-allergic Rhinitis with eosinophilia syndrome (NARES): Eosinophils are found in nasal secretions as in allergic rhinitis, but the patient does not have allergies. The same observation is frequently made in asthma; there may be abundant eosinophils in the bronchial secretions even though the patient does not have allergies (eosinophillic bronchitis or cough variant asthma).
d) Rhinitis medicamentosa: An intermittent rhinitis, may become persistent, with rebound swelling due to frequent doses of decongestant sprays/drops.
e) Pregnancy associated Rhinitis
f) Pseudo pregnancy Rhinitis (Oral pill associated)
g) Hypothyroidism associated Rhinitis
h) Gustatory rhinitis: Rhinorrhea occurring during and after meals, usually seen in patients over age 60. Patients may suspect food allergy; but in these patients, skin tests for allergic foods are negative.
Link between rhinitis and asthma:
Recent study in Bangladesh, (NAPS, 1999), reveals that as much as 42-58% of asthmatics have concomitant allergic rhinitis, the figure may be much more higher in fact. There are several other studies in Indian Subcontinent and Western World showing the link between asthma and allergic rhinitis and advocating that, “by treating rhinitis we can improve lung function in asthmatics.” Disorders involving the nasal passages or the sinus cavities frequently accompany the symptoms of asthma. There is a substantial overlap between patients with asthma, rhinitis and nasal polyposis. Up to 50-80% of patients with asthma have rhinitis symptoms, whereas 10% to 15% of patients with perennial rhinitis have asthmatic symptoms. In patients with rhinitis, bronchoprovocation test with methacholine is often positive, which suggests concomitant presence of asthma. Although they have no overt history or manifestations of asthma.
Nasal polyps associated with rhinitis and asthma are seen primarily in patients who are over age 40. It suggests that nasal polyps are probably a manifestation, not of allergy, but of the underlying eosinophilic hypertrophic sinusitis that accompanies severe asthma and rhinitis. The only medications capable of shrinking polyps are topical and systemic corticosteroids. There appear to be a high incidence of radiographic sinus abnormalities in patients with asthma, perhaps over 50%.
Diagnosis:
Allergic status of an individual is determined by the allergy history and allergy skin testing, not by examination of the nose alone. Anterior nasal polyps may be visible using a nasal speculum. Rhinoscopy using flexible or rigid endoscopes permits thorough examination of the nasal passages. A person with allergic rhinitis may have a red mucosa resulting from complications due to the following: Viral infections , Smoking , Decongestant spray abuse . A pale, edematous mucosa may also be seen in nonallergic rhinitis with eosinophils (NARES).
Investigations:
Circulating eosinophil count may be elevated in allergic rhinitis or asthma, but this is nonspecific. A smear of nasal secretions or nasal scraping typically shows polymorphonuclear leukocytes in infectious rhinitis. Eosinophils may predominate in allergic rhinitis, NARES and asthma. Skin tests for allergy may be positive.
Complications:
(i) Otitis media - more common in children
(ii) Sinusitis - more common in adults
Management:
The general goals of therapy for Persistent rhinitis syndrome include: Restoration of nasal patency , Control of nasal secretions, Treatment of complications such as secondary bacterial infection.
In the management of Allergic Rhinitis we can follow the golden rule of Asthma Association:
- Education (Patient education)
- Caution (Identification & avoidance of trigger)
- Medication (Step care management)
Who should receive prolonged treatment for Rhinitis?
Persistent allergic rhinitis, Vasomotor rhinitis and NARES need prolonged treatment. The step care management can be formulated as follows:
Step - I: Mild:(intermittent/acute) symptoms
1. Maintain nasal hygiene: Wash nostril with tap-water/Normal saline, Check nasal patency. Never go to bed with a blocked/watery nose.
2. If not cleared with washing, give decongestant/anti-cholinergic drop 2-3 drops each nostril thrice daily but no more than 3-7 days.
3. Oral antihistamine (preferably Ketotifen or Loratidin) at bed time or 12 hourly.
4. Ocular therapy as per need for concomitant allergic conjunctivitis.
Step: II: Moderate symptoms: (More frequent or not adequately controlled by step -I)
1. Continue treatment of Step-I
2. Add intranasal Cromolyn, 2 drops 3-4 times/day or Intranasal corticosteroid, 50-100 mcg /day per nostril
Step: III Severe (Persistent) symptoms
1. Continue treatment of Step-I
2. Add intranasal corticosteroid, 100-200 mcg/day per nostril
Step: IV Very Severe symptoms
Step: I Plus Step- III Plus Oral prednisolone 20mg/day for 4-5 days, followed by regimen of Step- III
Atopic Dermatitis (Eczema)
Atopic dermatitis (Eczema) is characterized by dryness of skin, intense itching and thickening or lichenification with excoriation, persists at least 6 months or more with waxe and wane characteristics. It mostly involves face in infants, extensor aspects of limbs in toddler and limb flexures in older child and in adult.
Management of atopic dermatitis comprises: i) Avoidance of specific allergens, ii) Oral antihistamines (Ketotifen/Loratidine), iii) Topical steroid.
Recurrent intense itching and rash after taking a particular food e.g. beef, brinjal, duck egg, shrimp etc is known as urticaria. It is actually a separate condition, not included in atopic dermatitis. It may be managed by avoidance of offending foods or by oral Sodium Cromoglycate (Fanil Tab.), 1/2 hour before ingestion of allergic food.
Allergic Conjunctivitis
It is characterized by sudden lacrimation with itchy, red eyes, after exposure to pollen or allergen, usually associated with Rhinitis.
Since conjunctivitis commonly presents with rhinitis, treatment of rhinitis is enough to manage this condition. Antihistamine gives prompt relief. If conjunctivitis recurs frequently (e.g. on daily/weekly basis), instillation of topical cromone drops is helpful. It should be continued for at least 6 months after remission. Topical steroids should be avoided as prolonged use of such medication may lead to cataract or glaucoma.
Pregnancy and Asthma
Asthma during pregnancy follows the rule of one-third, that is, one-third asthmatics become worse, one-third remain same and one-third improve. he exact mechanism behind this is not known. It is common to experience some breathlessness near the end of the pregnancy, this is related to the size of the fetus and the pressure it puts on the diaphragm.
It is dangerous to have untreated asthma during pregnancy, because attacks of asthma may reduce the amount of oxygen available to the baby. Triggers should be controlled meticulously during pregnancy. They can influence the probability of giving birth of a wheezy baby. Active and passive smoking should also be avoided at this time. It increases the chances of wheezing in the newborn. Caesarean section delivery is not a must in an asthmatic mother. The rate of caesareans among women with asthma is no higher than in those without it.
Management of asthma in pregnancy is identical to non-pregnant woman. All asthma medicines have been shown to be absolutely safe for both the mother and the baby. Inhaled route is preferred. Asthma medications may enter breast milk, but the concentration is extremely small and do not have any adverse effect on the baby.
See Also:
Step Care Management of Asthma
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