Nasobronchial interaction in allergic rhinitis and asthma

The key to the diagnosis lies in taking a good medical history. This rule especially applies to allergic rhinitis and asthma. Both diseases have in common that they are often underdiagnosedl and lack proper treatment. Allergic rhinitis and asthma frequently occur together. Almost 40 % of the allergic rhinitis patients have lower airways involvement, whereas more than 80 % of the allergic asthma patients have concomitant rhinitis symptoms. The latter percentage gets close to 95 % when a careful nasal history is taken and physical examination is performed. Allergic asthma is characterized by a history of episodes of cough, dyspnea, shortness of breath, chest tightness and wheezing, in combination with variable bronchoconstriction and/or bronchial hyperresponsiveness (BRR). Mucosal inflammation is also considered an important hallmark of asthma6. However, the associations between mucosal inflammation and clinical parameters, such as variable airflow obstruction and BRR, are still controversia. Allergic rhinitis is primarily based on a typical history of sneezing, rhinorrhoea, eye symptoms and nasal obstruction. As in allergic asthma, the atopic status needs to be confirme<f4. In perennial rhinitis, chronic nasal obstruction can sometimes be the only symptom, which makes it difficult to confIrm the diagnosis. The diagnosis of seasonal allergic rhinitis is less disputable, the symptomatology and seasonal occurrence are characteristic and have been well established for many years. The distinction between allergic asthma and rhinitis is sometimes difficult to make since symptom perception is widely variable; lung function can be normal in mild asthmatics and, although BHR is a constant feature of asthma, it is also frequently present in allergic rhinitis

Segmental bronchial provocation induces nasal inflammation in allergic rhinitis patients

Allergic rhinitis and asthma often coexist and share a genetic background. Pathophysiologic connections between the nose and lungs are still not entirely understood. This study was undertaken to compare allergic inflammation and clinical findings in the upper and lower airways after segmental bronchial provocation (SBP) in nonasthmatic allergic rhinitis patients. Eight nonasthmatic, grass pollen-sensitive patients with allergic rhinitis and eight healthy controls were included. Bronchial biopsies and blood samples were taken before (T(0)) and 24 h (T(24)) after SBP. Nasal biopsies were obtained at T(0), 1 h after SBP (T(1)), and T(24). Immunohistochemical staining was performed for eosinophils (BMK13), interleukin (IL)-5, and eotaxin. The number of eosinophils increased in the challenged and unchallenged bronchial mucosa (p < 0.05) and in the blood (p = 0.03) of atopic subjects at T(24). We detected an increase of BMK13-positive and eotaxin-positive cells in the nasal lamina propria and enhanced expression of IL-5 in the nasal epitheliu

Stratification of COPD patients towards personalized medicine:reproduction and formation of clusters

BACKGROUND: The global initiative for chronic obstructive lung disease (GOLD) 2020 emphasizes that there is only a weak correlation between FEV(1), symptoms and impairment of the health status of patients with chronic obstructive pulmonary disease (COPD). Various studies aimed to identify COPD phenotypes by cluster analyses, but behavioral aspects besides smoking were rarely included. METHODS: The aims of the study were to investigate whether (i) clustering analyses are in line with the classification into GOLD ABCD groups; (ii) clustering according to Burgel et al. (Eur Respir J. 36(3):531–9, 2010) can be reproduced in a real-world COPD cohort; and (iii) addition of new behavioral variables alters the clustering outcome. Principal component and hierarchical cluster analyses were applied to real-world clinical data of COPD patients newly referred to secondary care (n = 155). We investigated if the obtained clusters paralleled GOLD ABCD subgroups and determined the impact of adding several variables, including quality of life (QOL), fatigue, satisfaction relationship, air trapping, steps per day and activities of daily living, on clustering. RESULTS: Using the appropriate corresponding variables, we identified clusters that largely reflected the GOLD ABCD groups, but we could not reproduce Burgel’s clinical phenotypes. Adding six new variables resulted in the formation of four new clusters that mainly differed from each other in the following parameters: number of steps per day, activities of daily living and QOL. CONCLUSIONS: We could not reproduce previously identified clinical COPD phenotypes in an independent population of COPD patients. Our findings therefore indicate that COPD phenotypes based on cluster analysis may not be a suitable basis for treatment strategies for individual patients. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s12931-022-02256-7

Systemic Inflammation and Lung Function Impairment in Morbidly Obese Subjects with the Metabolic Syndrome

__Abstract__ __Background__: Obesity and asthma are associated. There is a relationship between lung function impairment and the metabolic syndrome. Whether this relationship also exists in the morbidly obese patients is still unknown. Hypothesis. Low-grade systemic inflammation associated with the metabolic syndrome causes inflammation in the lungs and, hence, lung function impairment. __Methods__: This is cross-sectional study of morbidly obese patients undergoing preoperative screening for bariatric surgery.Metabolic syndrome was assessed according to the revised NCEP-ATP III criteria. Results. A total of 452 patients were included. Patients with the metabolic syndrome ( = 293) had significantly higher blood monocyte (mean 5.3 versus 4.9, = 0.044) and eosinophil percentages (median 1.0 versus 0.8, = 0.002), while the total leukocyte count did not differ between the groups.The FEV1/FVC ratio was significantly lower in patients with the metabolic syndrome (76.7% versus 78.2%, = 0.032). Blood eosinophils were associated with FEV1/FVC ratio (adj. B −0.113, = 0.018). Conclusion. Although the difference in FEV1/FVC ratio between the groups is relatively small, in this cross-sectional study, and its clinical relevancemay be limited, these data indicate that the presence of the metabolic syndrome may influence lung function impairment, through the induction of relative eosinophilia

A meta-analysis of baseline characteristics in trials on mite allergen avoidance in asthmatics: Room for improvement

Background: Evidence regarding the clinical effectiveness of mite allergen avoidance for the treatment of asthma is lacking. In previous meta-analyses on mite allergen control, the baseline data were not discussed in detail. This study updates and extends the existing Cochrane review by Gøtzsche and Johansen (Cochrane Database of Systematic Reviews, 2008, Art. No: CD001187), with a focus on baseline asthma outcomes and allergen exposures. Methods: We used the existing trials in the original Cochrane review and included newly published studies. The baseline data for the mite allergen load from the mattress, the standardized asthma symptom score (ASS), the forced expiratory volume in 1 s percentage of predicted (FEV1 %pred.), and the histamine provocative concentration causing a 20% drop in FEV1 (PC20) were extracted. First, the mean values of the outcomes were calculated. The influence of the mite allergen load was examined with a random-effect meta-regression using the Metafor package in R. Results: Forty-five trials were included; 39 trials reported strategies for concurrent bedroom interventions, and 6 trails reported strategies for air purification. The mite allergen load ranged from 0.44 to 24.83 μg/g dust, with a mean of 9.86 μg/g dust (95% CI 5.66 to 14.05 μg/g dust, I2 = 99.8%). All health outcomes showed considerable heterogeneity (standardized ASS mean: 0.13, 95% CI 0.08 to 0.18, I2 = 99.9%; FEV1 %pred. mean: 85.3%, 95% CI 80.5 to 90.1%, I2 = 95.8%; PC20 mean: 1.69 mg/mL, 95% CI 0.86 to 2.52 mg/mL, I2 = 95.6%). The covariate mite allergen load did not significantly influence health outcomes. Discussion: This meta-analysis shows that mite avoidance studies are characterized by the inclusion of patients with rather mild to moderate asthma and with varying and sometimes negligible levels of allergen exposure. Future studies should focus on patients with severe asthma and increased levels of allergen exposure

Effectiveness of the Air Purification Strategies for the Treatment of Allergic Asthma: A Meta-Analysis

We updated the meta-analysis published by McDonald et al. [Chest 2002;122;1535-1542] by reviewing the effectiveness of air purification for the treatment of home-related allergic asthma (dust mite, dog, cat, and cockroach). We analysed the trials included by McDonald et al. as well as studies published since 2000. Data on asthma symptoms scores (ASS), medication use, forced expiratory volume in 1 s as a percentage of the predicted value (FEV1 %pred), histamine provocative concentration causing a 20% reduction in FEV1 (PC20), Asthma Quality of Life Questionnaire (AQLQ) scores, and fractional exhaled nitric oxide (FeNO) levels were extracted. The effectiveness was examined using metafor (registered in Prospero CRD42019127227). Ten trials including a total of 482 patients (baseline characteristics: mean FEV1 %pred 83.2%, I2 = 96.7%; mean PC20 4.93 mg/mL, I2 = 44.0%; mean AQLQ 4.67 [max. 7], I2 = 93.7%; mean FeNO 36.5 ppb, I2 = 0%) were included. We assessed the mean differences in the AQLQ scores as +0.36 (95% CI 0.10 to 0.62, p = 0.01, n = 302, I2 = 0%) and the FeNO levels as -6.67 ppb (95% CI -10.56 to -2.77, p = 0.0008, n = 304, I2 = 0%). The standardised mean differences in all other health outcomes were not significant (ASS -0.68, p = 0.20; medication use: -0.01, p = 0.94; FEV1 %pred -0.11, p = 0.34; PC20 +0.24, p = 0.53). We found statistically significant mean differences in the AQLQ scores and FeNO levels in patients with predominantly mild to moderate asthma at baseline. A large trial reported great improvement in the subgroup of patients receiving Global Initiative for Asthma step 4 therapy. We recommend that future studies on air purification focus on patients with severe and poorly controlled allergic asthma

Implementing integrated care guidelines in asthma and COPD:It ain’t easy!

Objective: To evaluate the implementation of a guideline-based, integrated, standardised, personal approach in patients with Chronic ObstructivePulmonary Disease (COPD) or Asthma in a real-life situation.Methods: Patients at the outpatient clinic of the department of pulmonary disease were included in a controlled cohort study, comparing the use ofdiagnostic items and ‘Personalised care plans’ (PCPs) in patients with obstructive lung disease before (2013) and after (2015) implementation of apersonalised diagnostic pathway. Results were compared with reference data (2016) from two control hospitals that used the same guidelines butdid not implement this pathway.Results: 100 patients were selected for all three cohorts. After implementing the diagnostic pathway in 2015, 35 % of patients visited attended allpre-planned appointments, whereas 65 % of patients did not: they were diagnosed using usual care. Factors contributing to patients not attendingthe diagnostic care pathway were: the logistical complexity and intensity of the 2-day pathway, patients willingness to participate in a personalisedpathway, and low social economic status or low literacy. After the implementation of the pathway, a significant improvement was seen in thenumber of PCPs (P &lt; 0.001) and the number of diagnostic items registered recorded in the patients’ electronic medical records (P &lt; 0.001).Conclusion: Implementing a standardised diagnostic pathway in a real-life population significantly improved the number of personalised care plans,demonstrating that the implementation of holistic care planning is feasible in this population. Nevertheless, the pathway needs further improvements to maximize the number of patients benefitting from it, including logistical streamlining, removing unnecessary diagnostic tools, andincreasing the focus on low literacy. Additionally, we found that implementing existing guidelines in a real life context is complex. Therefore, it isrequired to prioritize the translation of current guidelines into every-day practice, before expanding existing guidelines and protocol

Mepolizumab add-on therapy in a real world cohort of patients with severe eosinophilic asthma: response rate, effectiveness, and safety

Introduction: Severe eosinophilic asthma is an incapacitating disease. Mepolizumab, a humanized anti-interleukin-5 monoclonal antibody, proved to be effective as an add-on therapy in patients with severe eosinophilic asthma. However, only data from randomized controlled trials are available and real world data are lacking. Methods: A retrospective observational longitudinal study was conducted in a real world cohort of patients with severe eosinophilic asthma treated with mepolizumab. The primary objective was to determine response rate, based on a global evaluation of treatment effectiveness by the treating pulmonologist. Secondary objectives were to assess exacerbation frequency, systemic maintenance glucocorticoid usage, Asthma Control Questionnaire (ACQ), lung function, and adverse events. Results: Seventy-eight patients were included. Treatment with mepolizumab was considered beneficial and was therefore continued in 75.6% of patients 12 months from the initiation of mepolizumab. The most common reason for drop-out was insufficient response. Secondary objectives: 12 months from the initiation of mepolizumab there was a decrease of 3.2 (CI 2.5–4.1; p < 0.001) severe asthma exacerbations per year, a decrease of ACQ of 0.80 points (CI 0.49–1.12; p < 0.001), and an increase of 3.7 (CI 0.3–7.2; p = 0.034) percent of predicted FEV1 compared to baseline. At baseline 51.3% of patients were treated with systemic glucocorticoid maintenance therapy, compared to 15.4% (p < 0.001) of patients 12 months from the initiation of mepolizumab. No serious adverse events considered to be related to mepolizumab were reported. Conclusion: This study confirms that mepolizumab add-on therapy is effective and safe in a real world cohort of patients with severe eosinophilic asthma

House dust mite allergen avoidance strategies for the treatment of allergic asthma:A hypothesis-generating meta-analysis

Background: This study continues the review by Gøtzsche and Johansen (Cochrane Database of Systematic Reviews, 2008, Art. No: CD001187), aiming to systematically generate hypotheses on the effectiveness of (sub)strategies for house dust mite allergen avoidance in the treatment of allergic asthma. Methods: We used the trials previously analysed by Gøtzsche and Johansen and searched recently published studies. Data on asthma symptom scores (ASS), ACQ, number of improved patients, AQLQ-scores, medication use, FEV1%, PC20, and FeNO levels were analysed. The effectiveness of strategies was assessed using Metafor in R. Results: Thirty-five trials involving 2419 patients were included in the final study. The patient-reported outcome number of patients with improved condition following total bedroom control was RR = 3.39 (95% confidence interval: 1.04 to 11.04, P = 0.04). The mean differences in the ASS by nocturnal air purification was −0.7 (95% confidence interval: −1.08 to −0.32, P &lt; 0.001). Other outcomes including partial bedroom control were non-significant or clinically not of importance. Conclusions: Total bedroom control and nocturnal air purification of the breathing zone hypothetically provides clinical benefits in patients with house dust mite-induced allergic asthma. The number of patients with improvements in their condition respectively the asthma symptom score differences showed potential in small subgroups, consisting of single studies. Partial bedroom control is not recommended. Systematic Review Registration: Prospero CRD42022323660.</p