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Epidemiological studies have consistently shown that asthma and rhinitis often co-exist in the same patients. Greisner, et al. reported that among college students in the US, 85.7% of patients with BA had a history of AR. It appears that at least 60% of asthmatics suffer from rhinitis. Furthermore, around 20-30% of patients with allergic rhinitis also have asthma. Patients with non-allergic asthma also commonly present with rhinitis. Non-specific bronchial hyperactivity is more common in patients with rhinitis than in the general population.
In normal subjects, the structure of the airway mucosa of the nose and the bronchi share similarities. The major difference is that in the nose there is a rich vascular supply that accounts for nasal obstruction during the inflammation of rhinitis, whereas, in the bronchi, smooth muscles account for bronchospasm during the inflammation of asthma.
The recent progress achieved in elucidating the cellular and molecular biology of airway disease has clearly documented that inflammation plays a critical role in the pathogenesis of both asthma and rhinitis. The same inflammatory cells (T-cells, eosinophils) and Th2-like cytokines are found in nasal and bronchial biopsies but epithelial shedding is not a common feature of rhinitis. Moreover, remodeling appears to be less extensive in rhinitis.
Quality-of-life studies have strongly suggested a relationship between rhinitis and asthma. It seems that nasal and bronchial symptoms are combined to induce an impaired quality of life in patients suffering from both diseases. (Bousquet J et al., 2001)
EPIDEMIOLOGY OF ASTHMA:
According to WHO estimates, 300 million people suffer from asthma and 255 000 people died of asthma in 2005. Asthma is the most common chronic disease among children. Asthma is not just a public health problem for high income countries: it occurs in all countries regardless of level of development. Over 80% of asthma deaths occur in low and lower-middle income countries. Asthma is under-diagnosed and under-treated, creating a substantial burden to individuals and families and possibly restricting individuals' activities for a lifetime. (WHO 2005)
The National Asthma Education and Prevention Program (NAEPP) define asthma as a chronic inflammatory disorder of the airways in which many cells and cellular elements play a role. In susceptible individuals, inflammation causes recurrent episodes of wheezing, breathlessness, chest tightness, and coughing. These episodes are usually associated with airflow Obstruction that is often reversible either spontaneously or with treatment. The inflammation also causes an increase in bronchial hyper responsiveness (BHR) to a variety of stimuli. (Joseph T.Dipero et al., 2009)
TYPES OF ASTHMA
Nighttime (Nocturnal) Asthma
Health Conditions That May Mimic Asthma
Allergies and asthma often go hand-in-hand. Allergic rhinitis (also called hay fever) is inflammation of the inside lining of the nose and is the single most common chronic allergic disease. In thoseÂ with allergic rhinitis, increased sensitivity (allergy) to a substance causes the body's immune cells to release histamines in response to contact with the allergens. Histamines along with other chemicals lead to allergy symptoms. The most common allergens enter the body through the airway.
With allergic rhinitis, symptoms are constant runny nose, ongoing sneezing, swollen nasal passages, excess mucus, weepy eyes, and a scratchy throat. A cough may result from the constant postnasal drip. Many times asthma symptoms are triggered by allergic rhinitis.
Exercise-induced asthma is a type of asthma triggered by exercise or physical exertion. Many people with asthma experience some degree of symptoms with exercise. However, there are many people without asthma, including Olympic athletes, who develop symptoms only during exercise.
With exercise-induced asthma, airway narrowing peaks five to 20 minutes after exercise begins, making it difficult to catch the breath. Symptoms of an asthma attack with wheezing and coughing occurs.
In the type of asthma called cough-variant asthma, severe coughing with asthmaÂ is the predominant symptom. There can be other causes of cough such as postnasal drip, chronic rhinitis, sinusitis, or gastro esophageal reflux disease (GERD or heartburn). Coughing because of sinusitis with asthma is common.
Asthma is a serious cause of cough that is common today. Cough-variant asthma is vastly under diagnosed and undertreated. Asthma triggers for cough-variant asthma are usually respiratory infections and exercise.
Occupational asthma is a type of asthma that results from workplace triggers. With this type of asthma, it's have difficulty breathing and asthma symptoms just on the days of job. Many people with this type of asthma suffer with runny nose and congestion or eye irritation or have a cough instead of the typical asthma wheezing. Some common jobs that are associated with occupational asthma include animal breeders, farmers, hairdressers, nurses, painters, and woodworkers.
Nighttime (Nocturnal) Asthma
Nighttime asthma, also called nocturnal asthma,Â is a common type of the disease. If you have asthma, the chances of having symptoms are much higher during sleep because asthma is powerfully influenced by the sleep-wake cycle (circadian rhythms). Nighttime asthma symptoms are wheezing, cough, and trouble breathing are common and dangerous, particularly at nighttime.
Studies show that the most deaths related to asthma occur at night. It's thought that this may be because of increased exposure to allergens (asthma triggers), cooling of the airways, reclining position, or even hormone secretions that follow a circadian pattern.Â Sometimes heartburn can cause asthma at night. Sinusitis and asthma are often problems at night, particularly with postnasal drip triggering symptoms such as coughing. Even sleeping causes changes in airway function.
Health Conditions That May Mimic Asthma
A variety of illnesses can cause some of the same symptoms as asthma. For example, cardiac asthma is a form of heart failure in which the symptoms mimic some of the symptoms of regular asthma.
Vocal cord dysfunction is another asthma mimic. Many recent reports have drawn attention to a peculiar syndrome in which an abnormality of the vocal cords causes wheezing that is frequently misdiagnosed as asthma. This is most common in young females who have loud and dramatic episodes of wheezing that do not respond to medications that open the airways.Â (James E. Gerace et al., 2009)
Objective of treatment based on the severity of the disease and the presence of co-morbidities. Drug used for allergic rhinitis are most commonly administered intranasaly or orally. Many drug used in the treatment of allergic rhinitis are available without a medical prescription although there is a large disparity between countries.
Non-sedating H1 oral antihistamines are more preferred than to sedative ones because of their considerably lower incidence of side effects compared to sedating antihistamines. Intranasal corticosteroids are the most effective management of allergic rhinitis, in particular in severe disease or when nasal obstruction predominates. Here blow table given the classification of allergic rhinitis drug and generic name.
Oral H1 antihistamines
Acrivastine , Azelastine , Cetirizine
Desloratadine , Ebastine , Fexofenadine
Levocetirizine , Loratadine , Mizolastine
Chlorpheniramie , Clemastine , Diphenhydramie , Hydroxyzine
Ketotifen , Mequitazine
Cardio toxic , Astemizole , Terfenadine
Azelastine, , Levocabastine , Olopatadine
Beclomethasone , Budesonide , Ciclesonide
Fluticasone , Flunisolide , Mometasone
Local chromones (intranasal, ocular)
Sodium cromoglycate , Nedocromil
Ephedrine , Phenylephrine
Epinephrine , Naphazoline , Oxymethazoline
Phenylephrine , Tetrahydrozoline
Montelukast , Pranlukast , Zafirlukast
Betamethasone, Deflazacort , Dexamethasone
Hydrocortisone , Methylprednisolon,
Prednisolone, Prednisone , Triamcinolone
Figure no: 4 managements of allergic rhinitis
Allergen specific vaccination is the practice of administering gradually increasing quantities of an allergen extract to allergic rhinitis patients to ameliorate the symptoms associated with the subsequent exposure to the causative allergen. The efficacy of injection and sublingual immunotherapy used inhalant allergens to treat allergic rhinitis and asthma is evidence-based. Standardized immunotherapy vaccines which are available for the most common allergens are favored. (Jean Bousquet et al., 2003)
The goal of treatment is to minimize or prevent symptoms with minimal or no side effects and reasonable medication expense. Patients should be able to maintain a normal lifestyle, including participation in outdoor activities and playing with pets as desire. (Joseph T. Dipiro et al 2009)
AIM AND PLAN OF WORK
Bronchial asthma (BA) and allergic rhinitis (AR) are thought to share a common pathogenesis in many patients. There is no published population-based epidemiologic study about allergic diseases in south India.
Analysis of the Co morbidity of Bronchial Asthma and Allergic Rhinitis in pediatric patients attending child care clinic in Tamil Nadu.
PLAN OF WORK:
Performing literature review.
Based on the International Study of Asthma and Allergies in Childhood (ISAAC) questionnaire form was prepared.
Collected clinical and demographic data, a personal and family history of allergic diseases, and data on the duration and severity of asthma and rhinitis. These data were classified according to the criteria of the Global Initiative for Asthma and the Allergic Rhinitis and its Impact on Asthma guidelines.
Seeking approval from the hospital ethical committee.
Enrolling patients based on the study criteria.
REVIEW of LITERATURE
Paulo Augusto Moreira Camargosb et al., 2008 reported that the prevalence of symptoms related to asthma and AR co morbidity was 8.4% (95% CI, 8.09-10.25). Among asthmatic adolescents, symptoms of AR were reported in 46.5% (95% CI, 42.60-52.08%). There is a high prevalence of adolescent asthma and AR co-morbidity in this area of Brazil.
A Navarro et al., 2008 found that a total of 968 subjects were screened and 942 were enrolled in the study. Mean (SD) age was 35.5 (14) years and 63% were female. Of these patients, 89.5% presented with allergic rhinitis. The severity of asthma was classified as intermittent (39%), mild persistent (30%), moderate persistent (27%), and severe persistent (4%). Rhinitis was classified as mild intermittent (24%), moderate/severe intermittent (22%), mild persistent (19%) and moderate/severe persistent (35%). This study reinforces the high prevalence of allergic rhinitis in patients with asthma, which can affect as many as 89.5%.
Kohei Yamauchi et al., 2009 study the Sixty one percent of the patients with adult BA showed symptoms of AR. Among them, 68% of the patients were diagnosed with AR. Among the patients with childhood BA, 68% showed AR symptoms and 60% were diagnosed with AR. On the other hand, 49% of AR patients showed BA symptoms and 35% of them were diagnosed with BA. The symptoms of both BA and AR in the BA and AR patients were frequent in two seasons, March and April, and September and October. In addition, BA and AR symptoms often co-occurred in the patients with BA and AR. The symptoms of both BA and AR co-occurred on both a daily and seasonal basis.
Ashok Shah et al., 2009 in his study In India, allergic rhinitis (AR) is considered to be a trivial disease, despite the fact that symptoms of rhinitis were present in 75% of children and 80% of asthmatic adults. AR adversely affects sleep related Quality Of Life.
Eli O Meltzer et al., 2004 in his to review data supporting the integrated airway hypothesis. Allergic rhinitis, rhinosinusitis, and asthma are common conditions associated with significant morbidity and health care costs. A theory has been developed suggesting that these conditions may be manifestations of an inflammatory process within a continuous airway rather than fully separate diseases. Several recent studies have suggested that allergic rhinitis, rhino sinusitis, and asthma may be manifestations of a common underlying pathology.
Jodi Crystal-Peters et al., 2001 in his summary Asthma was more prevalent in the allergic rhinitis population (10%) than in the general population. In addition, the rate of allergic rhinitis in the asthmatic population (44%) was much higher than the rate of allergic rhinitis in the overall population (11%). On average, patients with both conditions had approximately 30% more asthma prescriptions (10.9) than did those with asthma alone (8.4). Likewise, patients with both conditions also had approximately 31% more allergic rhinitis prescriptions (4.62) than did those with allergic rhinitis alone (3.52).
H Yuksel et al., 2008 reported that Asthma was reported in 14.7% of the children older than 3 years of age while the prevalence of physician-diagnosed asthma was 7.9%. The burden of allergy was 27.1%. Asthma was significantly more common in children with rhinitis (31.5% vs. 11.8%; P < .01; odds ratio [OR], 3.45).
Fanny WS KO et al., 2010 found that over three quarters (463/600; 77%) of patients had experienced allergic rhinitis symptoms in the past 12 months, of whom 96% had a previous diagnosis of allergic rhinitis. Asthmatics without allergic rhinitis symptoms had higher rates of visits to doctors, pharmacy visits, emergency department attendances, and hospitalizations for asthma than those with both conditions
In general Ruby Pawankar et al., 2003 Epidemiological evidences and clinical as well as experimental observations have suggested a link between rhinitis and asthma. This relationship between rhinitis (and sinusitis) and asthma also involve other aspects, such as viral infections and bronchial hyper reactivity. These have been further confirmed by functional and immunological evidences, challenge studies of the nose and the bronchi, and, indirectly, by observing the therapeutic effects of drugs used mainly for rhinitis on the symptoms of asthma. Therefore, the present article is a review of the most relevant experimental results, so far provided, supporting the 'One Airway One Disease' concept, the possible mechanisms involved in this link and emerging therapeutic strategies like leukotriene receptor antagonists.
Teng Nging Tan et al., 2006 identified the cross-sectional prevalence of wheeze, rhinitis and eczema in 7,549 randomly selected Singaporean preschoolers aged 4 to 6 years old is reported in this study. Cumulative and past 12 months ('current') prevalence of wheeze was 27.5% and 16.0%, respectively. 'Asthma' was reported by 11.7%. Current rhinitis prevalence was 25.3% and rhino conjunctivitis, 7.6%.
Omer Kalayc et al., 2008 epidemiologic studies have consistently shown that asthma and rhinitis often coexist in the same patients in every region of the world. The vast majority of patients with asthma have rhinitis, but the prevalence of asthma in rhinitis patients still needs to be assessed. The treatment of the nose does not considerably impact the lower airways, but there have been some compelling data suggesting that new studies with innovative methods need to be started. Specific immunotherapy in patients with allergic rhinitis has a prolonged effect on the development of asthma when stopped.
A. B. Taegtmeyer et al reported that overall, 950 (76.4%) patients had A + AR and 294 (23.6%) Aâˆ’AR. Patients with A+AR were generally younger (42.2 Â±16.2 vs. 49.8 Â± 19.3 years, p<0.0001), used less ICS (24.8% vs. 11.2% were on an ICSâˆ’free regime, p < 0.001) than patients with Aâˆ’AR while LTRA usage was similar in both groups (45.9% vs. 47.6%). Asthma was uncontrolled in 53% of A+AR and 57.1% of Aâˆ’AR patients, respectively (p = 0.003). Allergic rhinitis was intermittent in 64.0% and persistent in 36.0% of the patients.
This study was carried out in multicenter (kavin hospital, balaji child care hospital and vignesh child care centre) duration between Junes to December 2010 at bhavani, erode district, Tamil nadu, south India
Below 18 year old
Both inpatients and outpatients
Both allergic rhinitis and asthma patients
Above 18 yrs old
Asthma and allergic rhinitis co morbidity with other disease
The patients were requested to answer a questionnaire of following question: patients were asked "Do you suffer with a blocked nose/stuffy nose/catarrh/sneezing/runny nose/itchy eyes/ears/roof of mouth?"; "Do you suffer with asthma (wheezing/tight chest/cough/shortness of breath)?'; "In the last month, have you suffered with any of these symptoms even when taking your regular medicine? Waking in the night because of asthma, Shortness of breath , Wheezing, Tight chest, Cough, A blocked nose, Stuffy nose, Catarrh, Sneezing ,Runny nose, Itchy eyes , Itchy ears , Itchy roof of mouth";
Core questionnaire Wheezing
"Have you ever had wheezing or whistling in the chest at any time in the past?"; "Have you had wheezing or whistling in the chest in the last 12 months?";"How many attacks of wheezing have you had in the last 12 months?";"In the last 12 months, how often, on average, has your sleep been disturbed due to wheezing?";"In the last 12 months, has wheezing ever been severe enough to limit your speech to only one or two words at a time between breaths?";"Have you ever had asthma?"; " In the last 12 months, has your chest sounded wheezy during or after exercise?";"In the last 12 months, have you had a dry cough at night, apart from a cough associated with a cold or a chest infection?"; "Check which time of year your child has the most difficulty breathing (cough, wheeze, chest tightness)."; "Family history of Asthma?"; "How often are breathing problems, coughing or wheezing Occurring during the DAY?"; "How often are breathing problems, coughing or wheezing Occurring during the NIGHT?"; "Does physical activity cause breathing problems, coughing or Wheezing?"; "How often is an inhaler or nebulizer used to treat these Problems?";
Core questionnaire Allergic Rhinitis
All questions are about problems which occur when you DO NOT have a cold or the flu.
"Have you ever had a problem with sneezing, or a runny, or a blocked nose when you DID NOT have a cold or the flu?"; "In the past 12 months, have you had a problem with sneezing, or a runny, or a blocked nose when you DID NOT have a cold or the flu?"; "In the past 12 months, has this nose problem been accompanied by itchy-watery eyes?"; " In which of the past 12 months did this nose problem occur?"; "In the past 12 months, how much did this nose problem interfere with your daily activities?"; "Have you ever had hay fever?";
In the patients with childhood asthma and allergic rhinitis, the mothers or adult attendants answered the questions if the patients seemed unable to understand the questionnaire.
Linguistic Validation of International Study of Asthma and Allergies in Childhood(ISAAC)
The Tamil version of International Study of Asthma and Allergies in Childhood(ISAAC) was validated according to procedures of linguistic validation developed by the Mapi Research Institute (Lyon, France) (Acquadro et al., 2004., WHO 2005) and culturally adapted for use with people in India. Accordingly the instrument was forward translated by two medical qualified personnel and the Tamil version-1 was back translated to English by two non medical personnel. After adopting the changes found in conceptual definition, Tamil version -2 was prepared. This version -2 was subjected to cognitive debriefing process where 10 diabetic patients were administered with the questionnaire and taken the acceptability of each items. The same was give to a medical personnel for checking the medical terms and conceptual definition. After compiling all the changes to the final version it was used for the study. (Figure 5) outlines the various components of the linguistic validation process which were undertaken for each questionnaire in Tamil language
English Instrumentâ†“ Phaseâ†“ Actionâ†“ Tamil Instrumentâ†“
Figure 5: Linguistic validation methodology used to develop each questionnaire