Subclinical lower airways correlates of chronic allergic and non-allergic rhinitis.

The upper and lower airways behave as a physiological and pathophysiological unit. Subclinical lower airways abnormalities have been described in patients with rhinitis without asthma. These are expressed as bronchial hyperreactivity, abnormalities in lung function and bronchial inflammation, likely as a result of the same phenomenon with systemic inflammatory impact that reaches both the nose and the lungs, which for unknown reasons does not always have a full clinical expression. Patients with rhinitis are at increased risk of developing asthma; therefore, most authors suggest a careful clinical evaluation and monitoring of these patients, especially if symptoms related to inflammation in the lower airways are observed. Although current treatments, such as H1-antihistamines, intranasal steroids and allergen immunotherapy, are quite effective for the management of rhinitis, it is difficult to prove their capacity to prevent asthma among subjects with rhinitis. Evidence showing that the treatment of rhinitis has a favourable impact on indicators of bronchial hyperreactivity and inflammation among subjects that have no symptoms of asthma is more frequently described. In this review, we address the frequency and characteristics of lower airway abnormalities in subjects with rhinitis, both in paediatric and adult populations, their likely predictive value for the development of asthma and the possibilities for therapeutic intervention that could modify the risk of subjects with rhinitis towards presenting asthma.

Mecanismos de la conexión nariz-pulmón / Mechanisms of nose-lung connection

La vía respiratoria, de la nariz al pulmón, actúa como un sincicio anátomo -funcional con su correlato fisiopatológico. Desde tiempos remotos los autores estudiaron los mecanismos de conexión entre la vía respiratoria superior e inferior que pudiera explicar la elevada coincidencia en la prevalencia de sus respectivas patologías. Algunos de esos mecanismos no se han podido demostrar fehacientemente y las investigaciones muestran resultados contradictorios. Otros responden a determinados fenotipos como el de la relación entre rinitis y asma alérgicas, el modelo más estudiado, en el que un fenómeno inflamatorio mediado a través del torrente circulatorio es el más aceptado. No obstante los fenotipos de enfermedad respiratoria no alérgica y el de la patología mediada por IgE local en nariz y bronquios, no tienen una conexión absolutamente resuelta por las investigaciones. En esta revisión discutiremos los distintos mecanismos de interacción nariz pulmón que por sus características anatómicas, fisiológicas y fisiopatológicas avalan la hipótesis de "una vía aérea única, una única enfermedad" aceptada en la actualidad por la mayoría de los autores. (AU)

The airway, from the nose to the lung, may be accepted as an anatomo-functional unit with its physiopathological correlate. From a long time ago the authors studied the mechanisms of connection between the upper and lower airway that could explain the high coincidence in the prevalence of their respective pathologies. Some of these mechanisms have not been proven conclusively and the research shows contradictory results. Others respond to certain phenotypes such as the relationship between rhinitis and allergic asthma, the most studied model, in which an inflammatory phenomenon mediated through the bloodstream is the most accepted. However the knowledge of phenotypes of non-allergic respiratory disease and the pathology mediated by local IgE in the nose and bronchi, they do not have a connection mechanisms completely determined by the investigations. In this review we will discuss the different mechanisms of nasal lung interaction that support its anatomical, physiological and pathophysiological characteristics responsible for "one airway, one disease" currently accepted by most authors. (AU)

Relación entre sensibilización alérgica por pruebas cutáneas y grados clínicos de rinitis / Relationship between allergic sensitization by skin test and severity of rhinitis

INTRODUCCIÓN: La rinitis alérgica (RA) es una enfermedad inflamatoria de la mucosa nasal mediada por IgE. Existen controversias en los diferentes estudios acerca de la relación entre la gravedad de los síntomas de RA y la magnitud de la sensibilización medidas por pruebas cutáneas con alergenos. OBJETIVOS: Relacionar la magnitud de sensibilización alérgica con los grados clínicos de la RA. POBLACIÓN Y MÉTODO: Estudio Observacional, analítico y transversal, que incluyó pacientes de ambos sexos, entre 6 y 18 años con diagnóstico de RA. Se clasificaron según el grado clínico establecido por Allergic rhinitis and its impact on asthma (ARIA). La sensibilización alérgica se midió a través de pruebas cutáneas por puntura con aeroalergenos y se determinó su magnitud según: PC1 (número de alérgenos positivos), PC2 (sumatoria de milímetros de pápulas) e Índice de atopía (relación entre PC2/PC1). Se dividieron según la presencia de monosensibilización y/o polisensibilización. ANÁLISIS ESTADÍSTICO: Se realizó estadística descriptiva y analítica utilizando prueba de Wilcoxon Mann Withney y prueba de Kruskal Wallis. Se consideró un valor significativo a una p<0,05. RESULTADOS: Se incluyeron 156 pacientes con una mediana de edad de 11,18 años (5-18,66 años). No se encontró diferencia en los valores de PC1, PC2 ni en el índice de atopía entre los cuatro grados clínicos de rinitis (p=0,3370, p=0,2222 y p=0,8774 respectivamente). Tampoco se observó diferencia en el índice de atopia entre los pacientes monosensibilizados y polisensibilizados (p=0,5493). Al comparar la rinitis según la frecuencia no se encontró diferencia en los valores de PC1, PC2 ni en el índice de atopía entre los grupos intermitente y persistente (p=0,0810; p=0,0587 y p=0,5705). Con respecto a la gravedad de la rinitis no se encontró diferencia en los valores de PC1, PC2 ni en el índice de atopía entre los grupos leve y moderado/grave (p=0,5693; p=0,1653 y p=0,4613). CONCLUSIONES: Las pruebas cutáneas por puntura de lectura inmediata no son un método diagnóstico capaz de diferenciar los grados clínicos de rinitis. (AU)

INTRODUCTION: Allergic rhinitis (RA) is an inflammatory disease of nasal mucosal mediated by IgE. There are controversies in the different studies about the relationship between the severity of RA symptoms and the magnitude of sensitization measured by skin tests with allergens. OBJECTIVE: Relate the magnitude of allergic sensitization to the clinical grades of AR. PATIENTS AND METHODS: In a observational, analytical and crosssectional study, we included patients aged 6 to 18 years with diagnosis of allergic rhinitis (RA). Were classified according to the clinical grade established by Allergic Rhinitis and its Impact on Asthma (ARIA) guide. Allergic sensitization was measured through skin prick test with aeroallergens and their magnitude was determined according to: PC1 (Number of positive allergens), PC2 (sum of millimeters of papules) and index of atopy (relation between PC2/PC1). The patients were divided in two groups according to the presence of monosensitization and/or polysensitization. RESULTS: We included 156 patients with a median age of 11,18 years (5-18,66 years). There were no difference in the values of PC1, PC2 or in the index of atopy between the clinical grades of rhinitis (p=0,337; p=0,2222 and p=0,8774 respectively). There was no difference in the index of atopy between monosensitized and polysensitized patients (p=0,5493). When comparing rhinitis according to the frequency, no difference was found in the values of PC1, PC2 or the index of atopy between the intermittent and persistent groups (p=0,0810; p= 0,0587 and p= 0,5705). Regarding the severity of rhinitis, no difference was found in the values of PC1, PC2 or in the index of atopy between the mild and moderate/severe groups (p=0,5693; p=0,1653 and p= 0,4613). CONCLUSIONS: Skin prick tests with aeroallergens are not a diagnostic method capable of differentiating the clinical grades of rhinitis. (AU)

Impact of rhinitis on lung function in children and adolescents without asthma.

BACKGROUND: Subclinical spirometric abnormalities may be detected in patients with rhinitis without asthma, proportional to the severity established by ARIA (Allergic Rhinitis and Its Impact on Asthma) guidelines. New criteria of rhinitis classification were recently validated according to the ARIA modified (m-ARIA), which allow the discrimination between moderate to severe grades. The impact of rhinitis on lung function according to frequency and severity is unknown. OBJECTIVES: To investigate subclinical spirometric impairment in children and adolescents with allergic and non-allergic rhinitis without overt symptoms of asthma, according to the frequency and severity criteria of rhinitis classified by m-ARIA. METHODS: An observational cross-sectional study, including children and adolescents aged 5-18 years with allergic and non-allergic rhinitis without asthma. We analysed the functional abnormalities and bronchodilator response with spirometry in relation to the grade of rhinitis established by m-ARIA using an adjusted logistic model. A value of p<0.05 was considered statistically significant. RESULTS: We studied 189 patients; 22.2% showed spirometric abnormalities. Patients with persistent rhinitis had greater impairment of lung function compared to intermittent grade (p=0.026). Lung functional impairment was more frequent in severe and moderate rhinitis than mild grade (p=0.005) and was independent of the atopic status to both frequency (p=0.157) and severity (p=0.538). There was no difference in bronchodilator reversibility between groups (p>0.05). CONCLUSIONS: Impaired lung function was associated with persistence and severity of rhinitis and there was no significant difference between patients with moderate and severe rhinitis. The spirometric abnormality was demonstrated in patients with allergic and non-allergic rhinitis.

Impacto de la frecuencia y la gravedad de la rinitis sobre la función pulmonar en niños y adolescentes sin asma / Impact of frequency and severity of rhinitis on lung function in children and adolescents without asthma

Introducción. Se han observado alteraciones espirométricas en pacientes con rinitis, sin asma, proporcionales al grado clínico de la rinitis establecido por la guía Allergic Rhinitis and its Impact on Asthma (ARIA). Recientemente se ha validado una nueva clasificación de la rinitis como ARIA modificada (ARIAm), que disocia la forma moderada de la grave. Se desconoce el impacto de la rinitis sobre la función pulmonar considerando su frecuencia y gravedad por separado. Objetivos. Determinar las posibles alteraciones de la función pulmonar y su potencial reversibilidad al broncodilatador en niños y adolescentes con rinitis alérgica y no alérgica sin asma, de acuerdo a su frecuencia (intermitente y persistente) y gravedad (leve, moderada y grave) establecida según ARIAm. Población y métodos. Estudio observacional, analítico de corte transversal, que incluyó pacientes de ambos sexos, entre 5 y 18 años, con rinitis alérgica y no alérgica, sin asma. Se realizó espirometría por curva flujo-volumen y se analizó la existencia de anormalidades en la función pulmonar y la respuesta broncodilatadora en relación con el grado de rinitis por ARIAm ajustando un modelo logístico. Se consideró un valor de p<0,05 para establecer significación estadística. Resultados. Se incluyeron 189 pacientes. En 42 (22,2%) se observó al menos un parámetro alterado en la función pulmonar. Los pacientes con rinitis persistente exhibieron mayor afectación de la función pulmonar que los de grado intermitente (p=0,0257). El defecto funcional fue más frecuente en las formas grave y moderada que en el grado leve (p=0,0052) y fue independiente de la condición de atopia (p=0,1574 para frecuencia y p =0,5378 para gravedad). No se encontró diferencia en la reversibilidad al broncodilatador entre los grupos (p=0,1859 y p=0,0575, respectivamente). Conclusiones. La alteración de la función pulmonar se asoció con rinitis persistente. Fue más prevalente en las formas moderada y grave pero no existieron diferencias significativas entre ambas. El defecto funcional se demostró tanto en rinitis alérgica como no alérgica. (AU)

Background: Subclinical spirometric abnormalities have been observed in patients with rhinitis without asthma, proportional to the clinical grade established by Allergic Rhinitis and Its Impact on Asthma (ARIA) guideline. Recently has been validated a new criteria of rhinitis classification designed as ARIA modified (ARIAm), which allow to discrimination moderate to severe grades. Rhinitis impact on lung function according to frequency and severity considering separately is unknown. Objectives: To investigate possible subclinical alterations in lung function and bronchodilator reversibility in children and adolescents with allergic and nonallergic rhinitis without asthma, according to the frequency and severity criteria of rhinitis classified by ARIAm. Methods: In an observational cross sectional study we included children and adolescents aged 5 to 18 years with symptoms of allergic and nonallergic rhinitis without asthma. Spirometry was performed by flow-volume curve and we analyzed the abnormalities in respiratory function and bronchodilator response in relation to clinical grade of rhinitis by ARIAm using an adjusted logistic model. A p value <0.05 was considered statistically significant. Results: We studied 189 patients; 42 (22.2%) had some spirometric abnormalities. Patients with persistent rhinitis had greater impairment of lung function compared to intermittently grade (p = 0.0257). The functional defect was more frequent in rhinitis severe and moderate than mild grade (p = 0.0052) and was independent of atopy status both frequency (p = 0.1574) and severity (p=0.5378). There was no difference in bronchodilator reversibility between groups (p = 0.1859 and p = 0.0575 respectively). Conclusion: Impaired lung function was associated with persistent rhinitis. It was more prevalent in moderate and severe rhinitis, but there wasn't a significant difference between them. The functional defect was demonstrated in both allergic and nonallergic rhinitis.(AU)

Evaluación del conocimiento de los padres de la técnica de aerosolterapia con aerocámara / Evaluation of parental knowledge of the aerosol technique with holding chamber

Introducción. Los episodios de tos, disnea y sibilancias son causa frecuente de consulta pediátrica. Su tratamiento de elección es la administración de fármacos a través de la aerosolterapia. El éxito de esta estrategia depende de la correcta aplicación de la técnica inhalatoria. Objetivo. Evaluar el conocimiento de padres de niños con patología obstructiva recurrente de la vía aérea en el uso de la aerosolterapia con aerocámara. Población y métodos. Estudio transversal, observacional, descriptivo. Se incluyeron aleatoriamente padres de niños menores de 6 años con tos, disnea y/o sibilancias con antecedentes de uso de aerocámara en la consulta al Servicio de Pediatría y/o de Alergia e Inmunología. Se evaluó el conocimiento en el empleo del inhalador mediante observación de la técnica. Resultados. Se incluyeron 114 niños, 51% masculino, con una edad promedio de 29,23 meses (DE=18,30). La persona a cargo de realizar la aerosolterapia tenía una media de edad de 32,28 años (DE=5,29); la mayoría de los responsables evaluados fueron madres (92,98%), con nivel de educación superior (71,05%). La forma de aprendizaje de la técnica fue demostrativa visual en 62 casos (54,4%), y el principal instructor de la misma fue el pediatra. Se demostró que 68 (72%) padres no realizaban en forma correcta la técnica y se encontró asociación entre edad del paciente y la correcta realización de la aerosolterapia (r=0,21; p=0,03). Conclusión. La mayoría de los padres realizan la aerosolterapia de forma incorrecta y la edad del niño influye en la técnica de la terapia inhalatoria.(AU)

Introduction. Symptoms of cough, dyspnea and wheezing are common cause for medical consultation. Their treatment is the administration of drugs through the aerosol. The success of this strategy depends on the correct application of inhalation technique. Objective. To evaluate the knowledge of parents of children with recurrent obstructive airway disease in the use of aerosol therapy with valved holding chamber. Population and Methods. Cross-sectional, observational, descriptive study. Randomly included parents of children under six years with cough, dyspnea and / or wheezing with a background of use in the office holding chamber of Pediatric and / or of Allergy and Immunology section of an Hospital. We evaluated the knowledge about the inhaler technique by medical observation. Results. We included 114 children, 51% male, with an average age of 29.23 months (SD=18.30). The median age o the caregiver responsible for conducting the aerosol therapy was 32.28 years (SD=5.29); the majority of evaluated makers were mothers (92.98%) with higher education level (71.05%). The most frequent way for learning was the visual demonstration technique in 62 cases (54.4%), and the main instructor was the pediatrician. Sixty-eight (72%) of parents did not perform properly the inhalation technique and a positive association was found between patient age and the proper realization of the aerosol (r=0.21; P=0.03). Conclusion. Most parents perform incorrectly aerosol therapy with valved holding chamber and the child's age influences the inhalation technique.(AU)