United Airway Research Articles

Efficacy of Biologics in NSAID-ERD: United Airways From the Nose to the Bronchi

Efficacy of Biologics in NSAID-ERD: United Airways From the Nose to the Bronchi

Efficacy of Biologics in NSAID-ERD: United Airways From the Nose to the Bronchi

Nonsteroidal anti-inflammatory drug (NSAID)-exacerbated respiratory disease (NSAID-ERD), the clinical triad of chronic rhinosinusitis with nasal polyps (CRSwNP), asthma, and respiratory reactions to cyclooxygenase 1 inhibitors, is often challenging to manage, with many patients failing first-line therapies for CRSwNP and asthma. There are now 6 biologic medications approved for asthma and/or severe CRSwNP: omalizumab, mepolizumab, reslizumab, benralizumab, dupilumab, and tezepelumab. With the availability of respiratory biologic treatment for both asthma and CRSwNP, clinicians now have a multitude of additional management options for patients with NSAID-ERD. Herein, we review the currently available clinical trial and real-world evidence for biologic efficacy and safety in patients with NSAID-ERD, discuss the mechanisms of biologic therapy specific to NSAID-ERD, and review evidence regarding the use of biologic therapy versus endoscopic sinus surgery for CRSwNP in patients with NSAID-ERD. We propose a management approach for choosing biologic therapy or endoscopic sinus surgery paired with aspirin therapy after desensitization for patients with NSAID-ERD.

Endotyping Chronic Respiratory Diseases: T2 Inflammation in the United Airways Model.

Over the past 15 years, the paradigm of viewing the upper and lower airways as a unified system has progressively shifted the approach to chronic respiratory diseases (CRDs). As the global prevalence of CRDs continues to increase, it becomes evident that acknowledging the presence of airway pathology as an integrated entity could profoundly impact healthcare resource allocation and guide the implementation of pharmacological and rehabilitation strategies. In the era of precision medicine, endotyping has emerged as another novel approach to CRDs, whereby pathologies are categorized into distinct subtypes based on specific molecular mechanisms. This has contributed to the growing acknowledgment of a group of conditions that, in both the upper and lower airways, share a common type 2 (T2) inflammatory signature. These diverse pathologies, ranging from allergic rhinitis to severe asthma, frequently coexist and share diagnostic and prognostic biomarkers, as well as therapeutic strategies targeting common molecular pathways. Thus, T2 inflammation may serve as a unifying endotypic trait for the upper and lower airways, reinforcing the practical significance of the united airways model. This review aims to summarize the literature on the role of T2 inflammation in major CRDs, emphasizing the value of common biomarkers and integrated treatment strategies targeting shared molecular mechanisms.

Co-Occurrence of Equine Asthma and Pharyngeal Lymphoid Hyperplasia in Pleasure Horses

With the increasing awareness of the “united airway disease” theory, more horses, not only sport horses but also pleasure horses, undergo detailed examinations of the respiratory tract. Using endoscopy, equine asthma (EA) is most commonly diagnosed in the lower airway, while pharyngeal lymphoid hyperplasia (PLH) is common in the upper airway. Grading EA as mild–moderate (MEA) and severe (SEA), this study aims to compare the co-occurrence and investigate the possible relationship between the clinical symptoms and endoscopic signs of MEA/SEA and PLH in pleasure horses. In this retrospective study, 80 out of 93 pleasure horses suspected of EA were enrolled and underwent a standardized protocol for a complete airway examination, including resting endoscopy with mucus accumulation assessment and cytology. The obtained results were scored and analyzed. In the studied pleasure horses, PLH co-occurred more frequently in horses with EA than without (p < 0.0001) and more in horses with SEA than with MEA (p = 0.025). However, when EA and PLH co-occurred, the severity of the clinical symptoms of EA did not increase (p > 0.05). In both EA and PLH, the amount of tracheal and nasopharyngeal mucus increased with the severity of the disease; however, it was positively correlated (ρ = 0.33; p = 0.02) only in SEA horses. In conclusion, it is likely that EA is often accompanied by PLH; however, PLH did not play a role in increasing the severity of EA’s clinical symptoms. The role of the severity of accumulated mucus in the lower and upper airways when EA/PLH co-occur requires further research to confirm the morphological and functional unity of the respiratory tract, aligning with the concept of “united airways disease”.

Causal associations between pediatric asthma and united airways disease: a two-sample Mendelian randomization analysis.

Prior observational research has indicated a potential link between pediatric asthma and united airways disease (UAD). However, these findings could be subject to confounding factors and reverse causation. Therefore, our study utilizes Mendelian randomization (MR) method to further investigate the causal relationship between pediatric asthma and UAD. We conducted a comprehensive two-sample Mendelian randomization (MR) analysis to investigate the association between pediatric asthma and seven groups of UAD, including chronic sinusitis, chronic rhinitis, nasopharyngitis and pharyngitis, chronic diseases of tonsils and adenoids, chronic laryngitis and laryngotracheitis, chronic bronchitis, bronchiectasis, chronic obstructive pulmonary disease (COPD). The present study employed a range of methods for two-sample MR analysis, including inverse variance weighted (IVW), MR-Egger regression, Simple mode, weighted median, and weighted models. The conclusion of the MR analysis primarily relies on the IVW results, while other analytical methods are utilized as supplementary evidence to ensure result robustness in this MR analysis. And sensitivity analyses were conducted, including heterogeneity test, horizontal pleiotropy test, MR-PRESSO test, and leave-one-out analysis to validate the results. The results of the MR analysis indicate significant causal effects of pediatric asthma on chronic rhinitis, nasopharyngitis and pharyngitis (IVW: OR = 1.15, 95%CI: 1.05-1.26, p-value = 0.003), chronic diseases of tonsils and adenoids (IVW: OR = 1.07, 95%CI: 1.00-1.15, p-value = 0.038), chronic bronchitis (IVW: OR = 1.51, 95%CI: 1.42-1.62, p-value <0.001), bronchiectasis (IVW: OR = 1.51, 95%CI: (1.30-1.75), p-value <0.001), and COPD (IVW: OR = 1.43, 95%CI: 1.34-1.51, p-value <0.001). However, no significant causal association was observed between pediatric asthma and chronic sinusitis (IVW: OR = 1.00, 95%CI: 1.00-1.00, p-value = 0.085), chronic laryngitis and laryngotracheitis (IVW: OR = 1.05, 95%CI: 0.90-1.21, p-value = 0.558). Our findings support a potential causal relationship between pediatric asthma and UAD, suggesting that pediatric asthma may be a potential risk factor for various UAD.

Airways Type-2 Related Disorders: Multiorgan, Systemic or Syndemic Disease?

Chronic rhinosinusitis (CRS) has recently undergone a significant paradigm shift, moving from a phenotypical classification towards an "endotype-based" definition that places more emphasis on clinical and therapeutic aspects. Similar to other airway diseases, like asthma, most cases of CRS in developed countries exhibit a dysregulated type-2 immune response and related cytokines. Consequently, the traditional distinction between upper and lower airways has been replaced by a "united airway" perspective. Additionally, type-2 related disorders extend beyond respiratory boundaries, encompassing conditions beyond the airways, such as atopic dermatitis. This necessitates a multidisciplinary approach. Moreover, consideration of possible systemic implications is crucial, particularly in relation to sleep-related breathing diseases like Obstructive Sleep Apnoea Syndrome (OSAS) and the alteration of systemic inflammatory mediators such as nitric oxide. The trends in epidemiological, economic, and social burden are progressively increasing worldwide, indicating syndemic characteristics. In light of these insights, this narrative review aims to present the latest evidence on respiratory type-2 related disorders, with a specific focus on CRS while promoting a comprehensive perspective on the "united airways". It also introduces a novel concept: viewing these conditions as a multiorgan, systemic, and syndemic disease.

Allergy/Atopic March and United Airway Disease: What We Know and What We Need to Know?

Abstract “Allergy/atopic march” refers to a typical sequence in which the allergic or atopic features appear at a certain age, and may or may not persist thereafter. In general, atopic dermatitis or atopic eczema occurs first, which progresses to immunoglobulin-E-mediated food allergy, asthma, and then allergic rhinitis (AR). However, this sequence may not be conspicuous in many cases. AR is an independent risk factor for asthma; in fact, AR often precedes that of asthma. United airway disease (allergic rhino-bronchitis) means the coexistence of AR and asthma. This has been shown in clinical and experimental studies, which suggest a similar immune pathology between the upper and lower airways in allergic subjects. In children with asthma, coexistent AR leads to an increased risk of asthma exacerbation leading to hospitalization and/or emergency visits as well as increased health-care cost. Treatment of AR in asthmatic children results in a lowered risk of asthma-related hospitalizations and emergency visits, and improved quality of life. In this article, we have discussed the current evidence for the clinically relevant effects that allergic conditions (from food allergies to atopic march, united airways disease, and AR) can have on children with asthma along with the future of allergic diagnosis (precision allergy molecular diagnosis) and allergen immunotherapy.

The impact of allergic rhinitis on bronchial asthma: What therapy?

Childhood asthma constitutes a significant healthcare burden due to its chronic nature and prevalence, affecting approximately 5–10 % of the pediatric population. Asthma is often heterogeneous and characterized by chronic airway inflammation. It is classified into two main phenotypes based on airway inflammation: T2-high (eosinophilic) and T2-low (neutrophilic/pauci-granulocytic) phenotype. Allergic sensitization is commonly associated with T2-high asthma, involving T helper 2 and innate immunity cells and type 2-associated cytokines, including interleuikin-4 (IL-4), IL-5, and IL-13. Type 2 inflammation is characterized by eosinophilic infiltrate. Asthma and allergic rhinitis share common mechanisms, and their association, known as united airways disease, highlights the close interconnection between upper and lower airways. Effective allergic rhinitis control positively impacts asthma, emphasizing the importance of early identification and personalized therapeutic strategies. One is allergen immunotherapy, a disease-modifying approach demonstrating preventive and therapeutic efficacy in children. However, more research is needed to optimize pediatric allergic rhinitis management.

The United Airways Clinic: roadmap of a patient-centred multidisciplinaryapproach to the complex airways patient: the Sydney model.

Severe asthma is a subset of difficult-to-treat asthma which requires a systematic and multidimensional approach including the need to manage multiple comorbidities that mimic asthma. Multidisciplinary care is becoming the standard for the assessment of such patients. Multidisciplinary team (MDT) clinics are virtually nonexistent in the private space. We developed an MDT clinic to handle needs in the private space and found it was an invaluable tool for assessment, reflective practice and professional development.

The effect of biologics in lung function and quality of life of patients with united airways disease: A systematic review

Increasing evidence supports the united airway disease concept for the management of upper and lower respiratory tract diseases, particularly in patients with asthma and chronic rhinosinusitis with nasal polyps (CRSwNP). However, evidence for a combined approach in asthma and CRSwNP is scarce. In this systematic review, we focused on the role of biologics in the lung function and quality of life in patients with severe asthma and CRSwNP. We conducted a systematic search of 3 electronic databases using 2 search strategies to identify studies published from January 2010 to March 2022. Quality assessment was performed with the Critical Appraisal Skills Programme. Of 1030 studies identified, 48 original studies reporting data of benralizumab (12), dupilumab (14), mepolizumab (10), omalizumab (13), and reslizumab (2) were analyzed. Primary diagnosis was mostly asthma or CRSwNP, with only 15 studies, mainly observational, performed in populations with united airway disease. In total, 18 studies reported data on quality of life (mostly 22-item Sino-Nasal Outcome Test score), 8 on lung function (mostly FEV1), and 22 on both outcomes. Significant FEV1 and 22-item Sino-Nasal Outcome Test score improvements were consistently observed after 24-week treatment, and thereafter, mostly in real-world studies that included variable proportions of patients with asthma/CRSwNP. The use of biologics in patients with severe asthma and CRSwNP was overall associated with significant improvements in lung function and quality of life. However, we observed a high heterogeneity of populations and outcome measurements across studies. Notwithstanding the need of larger studies, our results reinforce the joint management of asthma and CRSwNP as united airway disease in clinical practice.

The need for an integrated approach to rhinitis and asthma

Several evidences support the concept of united airway and its pathophysiological, clinical, and therapeutic implications. The existence of rhinitis can generate greater difficulty in asthma control and higher direct and indirect health care costs, which is not sufficiently recognized by the majority of physicians who often treat them as separate entities. To examine witness evidence of the relationship between rhinitis and asthma that contributes to the integrated approach to both pathologies. A bibliographic search was carried out in the PubMed (Medline), EBSCO, Scielo, and Google Scholar databases using MeSH and DeCS terms related to the clinical and therapeutic relationship between rhinitis and asthma. Finally, 46 references describing the impact of rhinitis on the quality of life of patients with asthma and its therapeutic correlate were included. The treatment of both diseases based on this integrated model is imperative. Both, the endo-phenotypic recognition and the consequent therapeutic approach allow to the concomitant control of asthma and rhinitis and a decrease in their morbidity. Complementary therapeutic measures based on the concept "one airway, one disease" support the good clinical practices necessary to achieve the best therapeutic result.

Co-Occurrence of Severe Equine Asthma and Palatal Disorders in Privately Owned Pleasure Horses.

According to the "unified or united airway disease" theory, diseases in the upper and lower airways frequently co-occur because they represent a single morphological and functional unit. Palatal disorders (PDs) and severe equine asthma (SEA) are frequent diseases that, respectively, affect upper and lower equine airways; however, clinical studies focusing on the co-occurrence of PDs and SEA are limited. The present study investigated the prevalence of PDs in horses affected by SEA, and whether prevalence decreased after SEA treatment. Forty-six privately owned horses affected by SEA in exacerbation were included. For each horse, the severity of the asthma clinical signs was assessed using a previously described scoring system, and the co-occurrence of palatal disorders was investigated using overground endoscopy, before and after treatment for SEA. Before treatment (in exacerbation), 67.4% of SEA-affected horses showed evidence of PDs, including 39.1% showing evidence of palatal instability (PI) and 28.3% of dorsal displacement of the soft palate (DDSP). Airway inflammation (neutrophil percentage in the tracheal wash and bronchoalveolar lavage fluid) was worse in horses with co-occurring PDs. After treatment (in remission), no horses showed evidence of PI, while DDSP was diagnosed in 8.7% of horses. These findings suggest that palatal disorders respond to asthma treatment, supporting the hypothesis that both diseases could be manifestation of a common underlying disorder.

Pathobiology of Type 2 Inflammation in Asthma and Nasal Polyposis.

Asthma and nasal polyposis often coexist and are frequently intertwined by tight pathogenic links, mainly consisting of the cellular and molecular pathways underpinning type 2 airway inflammation. The latter is characterized by a structural and functional impairment of the epithelial barrier, associated with the eosinophilic infiltration of both the lower and upper airways, which can be driven by either allergic or non-allergic mechanisms. Type 2 inflammatory changes are predominantly due to the biological actions exerted by interleukins 4 (IL-4), 13 (IL-13), and 5 (IL-5), produced by T helper 2 (Th2) lymphocytes and group 2 innate lymphoid cells (ILC2). In addition to the above cytokines, other proinflammatory mediators involved in the pathobiology of asthma and nasal polyposis include prostaglandin D2 and cysteinyl leukotrienes. Within this context of 'united airway diseases', nasal polyposis encompasses several nosological entities such as chronic rhinosinusitis with nasal polyps (CRSwNP) and aspirin-exacerbated respiratory disease (AERD). Because of the common pathogenic origins of asthma and nasal polyposis, it is not surprising that the more severe forms of both these disorders can be successfully treated by the same biologic drugs, targeting many molecular components (IgE, IL-5 and its receptor, IL-4/IL-13 receptors) of the type 2 inflammatory trait.

Consensus on the management of united airways disease with type 2 inflammation: a multidisciplinary Delphi study

BackgroundScientific evidence on patients with multimorbid type 2 asthma and chronic rhinosinusitis with nasal polyps (CRSwNP) from a united airways disease (UAD) perspective remains scarce, despite the frequent coexistence of these entities. We aimed to generate expert consensus-based recommendations for the management of UAD patients.MethodsUsing a two-round Delphi method, Spanish expert allergists, pulmonologists and otolaryngologists expressed their agreement on 32 statements (52 items) on a 9-point Likert scale, classified as appropriate (median 7–9), uncertain (4–6) or inappropriate (1–3). Consensus was considered when at least two-thirds of the panel scored within the range containing the median.ResultsA panel of 30 experts reached consensus on the appropriateness of 43 out of the 52 (82.7%) items. The usefulness of certain biomarkers (tissue and peripheral blood eosinophil count, serum total IgE, and fraction of exhaled nitric oxide [FeNO]) in the identification and follow-up of type 2 inflammation, and assessment of the response to biologics, were agreed. Some of these biomarkers were also associated with disease severity and/or recurrence after endoscopic sinus surgery (ESS). Consensus was achieved on treatment strategies related to the prescription of anti-IL-4/IL-13 or anti-IgE agents, concomitant treatment with systemic corticosteroids, and combining or switching to biologics with a different mechanism of action, considering a number of UAD clinical scenarios.ConclusionWe provide expert-based recommendations to assist in clinical decision-making for the management of patients with multimorbid type 2 asthma and CRSwNP. Specific clinical trials and real-world studies focusing on the single-entity UAD are required to address controversial items.

A real world study of anti-IgE monoclonal antibody in the treatment of allergic united airway disease

Objective: To investigate the clinical efficacy and safety of anti-IgE monoclonal antibody (omazumab) in the treatment of allergic united airway disease (UAD) in the real-wold. Methods: Retrospective cohort study summarizes the case data of patients with allergic united airway disease who were treated with anti IgE monoclonal antibody (omalizumab) for more than 16 weeks from March 1, 2018 to June 30, 2022 in the Peking University First Hospital.The allergic UAD is defined as allergic asthma combined with allergic rhinitis (AA+AR) or allergic asthma combined with chronic sinusitis with nasal polyps (AA+CRSwNP) or allergic asthma combined with allergic rhinitis and nasal polyps (AA+AR+CRSwNP). The control of asthma was evaluated by asthma control test (ACT), lung function test and fractional exhaled nitric oxide (FeNO). The AR was assessed by total nasal symptom score (TNSS). The CRSwNP was evaluated by nasal visual analogue scale (n-VAS), sino-nasal outcome test-22 (SNOT-22), nasal polyps score (TPS) and Lund-Mackay sinus CT grading system. The global evaluation of omalizumab for the treatment of allergic UADwas performed by Global Evaluation of Treatment Effectiveness(GETE).The drug-related side effects were also recorded. Matched t test and Wilcoxon signed-rank test were used to compare the score changes of IgE monoclonal antibody (omazumab) before and after treatment, and multivariate logistic regression analysis was used to determine the influencing factors of IgE monoclonal antibody (omazumab) response. Results: A total of 117 patients with UAD were enrolled, ranging in age from 19 to 77 years; The median age of patients was 48.7 years; Among them, 60 were male, ranging from 19 to 77 years old, with a median age of 49.9 years; There were 57 females, ranging from 19 to 68 years old, with a median age of 47.2 years. There were 32 cases in AA+AR subgroup, 59 cases in AA+CRSwNP subgroup, and 26 cases in AA+AR+CRSwNP subgroup. The total serum IgE level was 190.5 (103.8,391.3) IU/ml. The treatment course of anti IgE monoclonal antibody was 24 (16, 32) weeks. Compared with pre-treatment, omalizumab increased ACT from 20.0 (19.5,22.0) to 24.0 (23.0,25.0) (Z=-8.537, P<0.001), increased pre-bronchodilator FEV1 from 90.2 (74.8,103.0)% predicted value to 95.4 (83.2,106.0)% predicted value (Z=-5.315,P<0.001), increased FEV1/FVC from 80.20 (66.83,88.38)% to 82.72 (71.26,92.25)% (Z=-4.483,P<0.001), decreased FeNO from(49.1±24.8) ppb to (32.8±24.4) ppb (t=5.235, P<0.001), decreased TNSS from (6.5±2.6)to (2.4±1.9) (t=14.171, P<0.001), decreased n-VAS from (6.8±1.2) to (3.4±2.0)(t=14.448, P<0.001), decreased SNOT-22 from (40.0±7.9) to (21.3±10.2)(t=15.360, P<0.001), decreased TPS from (4.1±0.8) to (2.4±1.0)(t=14.718, P<0.001) and decreased Lund-Mackay CT score from (6.0±1.3) to (3.1±1.6)(t=17.012, P<0.001). The global response rate to omalizumab was 67.5%(79/117). The response rate in AA+AR (90.6%,29/32) was significantly higher than that in AA+CRSwNP (61.0%,36/59) and AA+AR+CRSwNP (53.8%,14/26) subgroups (χ2=11.144,P=0.004). Only 4 patients (3.4%,4/117) had mild side effects. Conclusion: The real-world study showed favorable effectiveness and safety of anti-IgE monoclonal antibody for treatment of allergic UAD. To provide basis for preventing the progress and precise treatment of allergic UAD.

Anti-IL-4,13 strategy in management of comormid patients in the regional register of severe bronchial asthma

BACKGROUND: T2 inflammation underlies bronchial asthma and inflammatory nasal diseases, supporting the concept of a united airway disease. Dupilumab, by blocking interleukin-4 and -13 receptors, can improve the clinical and functional parameters and life quality of comorbid patients with T2 diseases. AIM: To evaluate efficacy of anti-IL4R,13 therapy in patients with severe asthma with chronic inflammatory nasal diseases in real clinical practice. MATERIALS AND METHODS: The study of dupilumab efficacy was conducted by comparing related populations based on a regional register of patients with severe asthma and concomitant chronic inflammatory nasal diseases. Asthma control achievement and decrease in the rate of patients with uncontrolled asthma were assessed as primary endpoint. The need for bronchodilators and systemic glucocorticosteroids, number of asthma exacerbations, emergency calls and hospitalizations, AQLQ scores, level of peripheral blood eosinophils, and respiratory function were also assessed. Nasal symptoms were assessed using SNOT-22 and VAS. A subgroup analysis of ACT scores was performed depending on chronic inflammatory nasal disease phenotypes. RESULTS: Within 12 months of dupilumab therapy, ACT increased from 11 (Q1Q3: 713) to 20 (Q1Q3: 1824) points (p 0.001). The rate of patients with partially and fully controlled asthma increased from 0 to 57.9% (p 0.001). The need for bronchodilators decreased from 17.5 doses per week (Q1Q3: 5.824.5) to 1.0 (Q1Q3: 0.02.2) (p 0.001). Before the dupilumab therapy, 68.5% of the patients took systemic corticosteroids and, after 12 months, 10.5% of patients (p 0.001). The number of asthma exacerbations decreased from 2.191.83 (95% CI 1.283.11) to 0.220.55 (0.050.49) (p 0.001) and hospitalizations from 1.001.27 (95% CI 0.371.63) to 0.170.51 (95% CI 0.090.42) (p 0.001). AQLQ scores increased from 2.91 (Q1Q3: 2.433.86) to 5.89 points (Q1Q3: 4.706.58) (p 0.001). The volume of forced exhalation in 1 sec increased from 55.38%16.66% (95% CI 47.1063.67) to 81.5%19.14% (95% CI 71.9891.02) (p 0.001). SNOT-22 scores decreased from 4729 (95% CI 3461) to 2518 (95% CI 1734) points (p 0.001) and the VAS score from 72 (95% CI 68) to 42 (95% CI 35) (p 0.001). CONCLUSIONS: Dupilumab improved asthma and nasal symptoms control, improved quality of life and respiratory function, and reduce asthma exacerbations and hospitalizations. Patients with severe asthma and comorbid allergic rhinitis and chronic rhinosinusitis with polyps responded better to dupilumab therapy than patients with chronic rhinosinusitis without polyps.

Comprehensive therapy in united airway disease: Evidence Based Case Report

ABSTRACTBackground: The concept of the united airway disease (UAD) recognises the association between allergic inflammation in the upper and lower airways. Patients with asthma and concomitant allergic rhinitis experience more asthma-related primary and secondary care visits. Purpose: To determine the best treatment option in the case of patients with asthma related allergic rhinitis, both in the control of nasal and pulmonary symptoms. Case report: A case case of 45 years old woman with asthma related to allergic rhinitis treated with combination of intranasal steroid and asthma therapy. Clinical question: In adult patient with allergic rhinitis related to asthma, does the combination of intranasal and inhaled steroids give better clinical improvement subjectively and objectively compared to monotherapy? Method: Literature search through two different databases (PubMed and Cochrane Library) and by searching the bibliography of articles to evaluate the outcome of combination therapy and monotherapy for the disease. Result: Two articles were found relevant with the topic fulfilled the requirements and relevant with the formulation or clinical question. Conclusion: Treating the inflammation associated with allergic rhinitis may have a true impact on the control of asthma, while the failure to treat rhinitis may impair asthma control.ABSTRAKLatar belakang: Konsep United Airway Disease (UAD) mengenali adanya hubungan antara inflamasi alergi pada saluran napas atas dan bawah. Pasien asma yang bersamaan dengan rinitis alergi melakukan lebih banyak kunjungan ke perawatan primer dan sekunder terkait asma. Tujuan: Menentukan pilihan pengobatan terbaik pada pasien dengan rinitis alergi terkait asma, baik dalam pengendalian keluhan hidung maupun paru. Laporan kasus: Satu kasus seorang wanita berusia 45 tahun dengan asma yang berhubungan dengan rinitis alergi. Metode: Mengumpulkan jurnal terkait dari dua database yang berbeda (PubMed dan Cochrane Library). Pencarian artikel juga dilakukan dengan mencari pada daftar pustaka artikel untuk mengevaluasi luaran dari terapi kombinasi dan terapi tunggal untuk penyakit ini. Pertanyaan klinis: Apakah terapi kombinasi dengan steroid intranasal dan steroid hirup dapat memberikan perbaikan lebih signifikan secara subjektif maupun objektif dibandingkan dengan terapi tunggal pada pasien dewasa dengan rinitis alergi dan asma? Hasil: Didapatkan dua artikel yang relevan dengan topik, sesuai dengan pertanyaan klinis serta memiliki penilaian kritis yang baik. Kesimpulan: Mengobati peradangan yang terkait dengan rinitis alergi dapat berdampak nyata pada pengendalian asma, sedangkan kegagalan untuk mengobati rinitis dapat mengganggu pengendalian asma.

Allergic Rhinosinusitis and Airway Diseases

The concept of united airway disease interaction, which comprises chronic rhinosinusitis and other lower airway disorders such as asthma, has been recognized for over a decade [...]

Management of United Airway Disease Focused on Patients With Asthma and Chronic Rhinosinusitis With Nasal Polyps: A Systematic Review

The clinical approach to upper and lower respiratory diseases from a joint perspective, known as united airways disease (UAD), is challenging for health care professionals owing to a paucity of specific studies. This study reviews recent scientific evidence on the management of asthma and chronic rhinosinusitis with nasal polyps (CRSwNP) from a UAD perspective. A systematic search of PubMed, Scopus, and Web of Science was conducted for 9 research questions, and studies published from January 2015 to July 2021 were included. Quality assessment was performed with the Critical Appraisal Skills Programme. In total, 32 publications met the inclusion criteria. Control of type 2 inflammation in UAD (reported in 9 studies) was associated with biologic therapies, for which an impact on asthma, CRSwNP, and/or aspirin/nonsteroidal anti-inflammatory drug-exacerbated respiratory disease outcomes was described in 9 studies. However, there was a lack of scientific evidence on clinical and/or biochemical markers associated with response to biologics in patients with UAD. The benefit on corticosteroid reduction in patients receiving biologics was reported in 9 studies. Three publications reported a positive impact of surgery on asthma and/or CRSwNP outcomes, and the effect of biologics on reducing the need of surgery was consistent across 6 studies. Our results underscore an overall scarcity of scientific evidence on the treatment strategies for these frequent coexisting entities from an UAD approach but also identify several research gaps and unmet needs that should be addressed to ensure optimal diagnosis, management, and follow-up of these patients.

The Utility of Nasal Challenges to Phenotype Asthma Patients.

Asthma is a heterogeneous disease in terms of both phenotype and response to therapy. Therefore, there is a great need for clinically applicable tools allowing for improved patient classification, and selection for specific management approaches. Some interventions are highly helpful in selected patients (e.g., allergen immunotherapy or aspirin desensitization), but they are costly and/or difficult to implement. Currently available biomarkers measurable in peripheral blood or exhaled air display many limitations for asthma phenotyping and cannot identify properly the specific triggers of the disease (e.g., aeroallergens or NSAID). The united airway concept illustrates the relevant epidemiological and pathophysiological links between the upper and lower airways. This concept has been largely applied to patient management and treatment, but its diagnostic implications have been less often explored. Of note, a recent document by the European Academy of Allergy and Clinical Immunology proposes the use of nasal allergen challenge to confirm the diagnosis of allergic asthma. Similarly, the nasal challenge with lysine acetylsalicylate (L-ASA) can be used to identify aspirin-sensitive asthma patients. In this review, we will summarize the main features of allergic asthma and aspirin-exacerbated respiratory disease and will discuss the methodology of nasal allergen and L-ASA challenges with a focus on their capacity to phenotype the inflammatory disease affecting both the upper and lower airways.