The impact of allergic rhinitis on asthma

1
The impact of allergic rhinitis on asthma
Gert-Jan Braunstahl Pulmonary medicine, EMCR,
Rotterdam
2
ARIA

• Objectives
• Update knowledge of AR
• Recognise AR as global health problem
• Asthma and AR commonly occur together
• Evidence-based approach to diagnosis and
  treatment
• Management of allergic airways disease

Bousquet et al, J Allergy Clin Immunol 2001
3
Why do we have a nose?
4
Functional relationship
5
Macroscopic view
6
Microscopic view
7
Airway inflammation
8
Pathogenesis allergic airway disease
9
Association rhinitis/sinusitisand asthma
10
Epidemiology

• 80-95 of asthmatic patients have rhinitis.
• 76 asthmatic patients reported presence of
  rhinitis before onset asthma.
• Asthma presence associated with duration and
  severity of rhinitis.

Leynaert, J Allergy Clin Immunol 2004
11
Causal relationship
rhinitis
Disease severity
asthma
time
Togias, Allergy 1999
12
Questions

• What is the relationship between allergic
  rhinitis and asthma?
• Is there any interaction between upper and lower
  airways?
• What are the mechanisms that may play a role in
  nasobronchial cross-talk?

13
Questions

• What is the relationship between allergic
  rhinitis and asthma?
• Is there any interaction between upper and lower
  airways?
• What are the mechanisms that may play a role in
  nasobronchial cross-talk?

14
Worldwide prevalence
15
Prevalence asthma and rhinitis in NL
Non-allergic
Allergic no symptoms
10
68
8
Asthma Rhinitis
16
Nasal inflammation in asthma
16
12
EG2 cells per field
8
4
plt0.001
plt0.001
0
AR
ANR
HC
Gaga M. et al, Clin Exp Allergy 2000
17
Nasal inflammation and BHR
Ciprandi G. et al, Int Arch Allergy Immunol 2004
18
Lower airway involvement in atopic patients
19
Bronchial remodeling in asthma and rhinitis
type I collagen
type III collagen
fibronectin
25
25
25
20
20
20
15
15
15
basement membrane thickness (µm)
10
10
10
5
5
5
0
0
0
controls
rhinitis
asthma
controls
rhinitis
asthma
controls
rhinitis
asthma
Chakir et al, Lab Invest 1996
20

• Nasal and bronchial mucosa in asthma and rhinitis

Courtesy of Jean Bousquet
21
Summary

• Mucosal inflammation is present in the entire
  airway of patients with allergic rhinitis and/or
  asthma.
• Upper airway inflammation is associated with
  bronchial hyperresponsiveness
• Lower airway remodeling is present in asthmatic,
  but also in allergic rhinitis patients.

22
Questions

• What is the relationship between allergic
  rhinitis and asthma?
• Is there any interaction between upper and lower
  airways?
• What are the mechanisms that may play a role in
  nasobronchial cross-talk?

23
NP in allergic rhinitis influence on lower
airways
24
Symptoms (VAS)
25
Airway function
26
Allergic inflammation
27
Bronchial inflammation after NP
28
SBP in allergic rhinitis influence on upper
airways
29
Methods
30
Nasal inflammation after SBP
31
Nasal inflammation after SBP MBP Lamina propria
Cell/mm2

before
after
Braunstahl GJ et al, AJRCCM, 2000
32
Nasal inflammation after SBP MCTC Lamina propria

Cell/mm2
Nose
200

150
100
50
0
before
after
Chymase (C) and Tryptase (T) 400x
Braunstahl GJ et al, AJRCCM, 2001
33
Summary

• The interaction between nose and lung in allergic
  airways disease is a bi-directional process

34
Questions

• What is the relationship between allergic
  rhinitis and asthma?
• Is there any interaction between upper and lower
  airways?
• What are the mechanisms that may play a role in
  nasobronchial cross-talk?

35
Nasal vs. oral ventilation effect of cold air
inhalation
McLane, J. Appl. Physiol. 2000
36
Pulmonary aspiration? Radio-active markers
37
Naso-bronchial reflex?effect of intranasal
methacholine
Littell et al, Am Rev Respir Dis, 1990
38
Systemic interaction?effect of NP on IL-5 plasma
p lt 0.001
Beeh et al, Clin Exp Allergy, 2003
39
Systemic interaction?effect of SBP on IL-5 and
eosinophils
40
Summary
41
Take home messages

• Allergic rhinitis often precedes asthma.
• Allergic rhinitis and asthma characterized by
  global airway inflammation.
• There is a bi-directional influence between upper
  and lower airways.
• The systemic pathway plays an important role in
  the interaction between nose and lung