C laudia Saad M agalhaes M achado
T h e treatm en t o f allerg ic rh in itis im p ro v es th e reco v ery
fro m asth m a an d u p p er resp irato ry in fectio n s
Respiratory Allergy, Hospital das Clinicas, Faculdade de
Medicina de Ribeirao Preto - Sao Paulo,
Brazil
F o rty-six a sth m a tic ch ild re n w ith re p e a te d re sp ira to ry in fe ctio n s p re se n te d sym p to m s o f a lle rg ic rh in itis. A ll p a tie n ts w e re tre a te d lo ca lly fo r a lle rg ic rh in itis e ith e r w ith d iso d iu m cro m o g lyca te o r b e clo m e th a so n e d ip ro p io n a te . A fte r six m o n th s o f tre a tm e n t, 9 5 % o f th e ch ild re n sh o w e d im p ro ve m e n t o f a lle rg ic rh in itis a n d 8 4 % im p ro ve m e n t o f b ro n ch ia l a sth m a , a s w e ll a s fe w e r in fe ctio n s. W e co n clu d e d th a t a lle rg ic rh in itis p la ys a n im p o rta n t ro le in fa cilita tin g in fe ctio n s o f th e u p p e r re sp ira to ry tra ct, a n d a p o ssib le a sso cia tio n o f rh in itis, vira l in fe ctio n s a n d b ro n ch ia l a sth m a is d iscu sse d .
U N IT E R M S : A sth m a in ch ild re n . A lle rg ic rh in itis a n d a sth m a . A sth m a a n d re sp ira to ry in fe ctio n .
IN T R O D U C T IO N
W
e h a v e lo n g n o te d a s tro n g re la tio n s h ip b e tw e e n th e p re s e n c e o f a lle rg ic rh in itis a n d th e s ig n s a n d s y m p to m s o f b ro n c h ia l a s th m a . In d e e d , T u ft a n d M u lle r(2 1 ) h a d p o in te d o u t th is a s s o c ia tio n in1 9 7 0 , e m p h a s iz in g th a t a th ird o r m o re o f a ll c h ild re n w ith a lle rg ic rh in itis w o u ld d e v e lo p a s th m a if le ft u n tre a te d . T h e s e a u th o rs a d d e d th a t a d e ta ile d e x a m in a tio n o f th e h is to ry o f s o m e a d o le s c e n ts o r y o u n g a d u lt p a tie n ts d e m o n s tra te d th a t th e o n s e t o f p e re n n ia l rh in itis p re c e d e d b y m a n y m o n th s o r e v e n y e a rs th e b e g in n in g o f b ro n c h ia l a s th m a a tta c k s .
A ddress for correspondence: W illy Sarti
D epartam ento de C lfnica M edica
Faculdade de M edicina de R ibeirao Preto R ibeirao Preto - SP - Brasil - C EP 14049-900
In a d d itio n to th e p re s e n c e o f a lle rg ic rh in itis in a s th m a tic c h ild re n , w e h a v e o b s e rv e d a n a s s o c ia tio n o f a s th m a w ith re c u rre n t b a c te ria l in fe c tio n s u c h a s o titis m e d ia in s m a ll c h ild re n a n d w ith to n s illitis a n d s in u s itis in o ld e r c h ild re n , th e s e in fe c tio u s e p is o d e s b e in g a s s o c ia te d w ith th e o n s e t o f a s th m a a tta c k s . S im ila r o b s e rv a tio n s w e re re p o rte d b y M c In to s h e t a I.(1 3 ). In a d d itio n , th e c o n trib u tio n o f v ira l in fe c tio n s to th e p a th o g e n e s is o f a irw a y h y p e rre a c tiv ity h a s b e e n re p o rte d s in c e th e s ix tie s (1 ,2 ,4 ,5 ,7 ,8 ,1 0 ,1 1 ,1 3 ,1 4 ,1 5 ). R e g a rd le s s o f th e m e c h a n is m s th a t d e te rm in e th e s e a s s o c ia tio n s , th e a b o v e c o n s id e ra tio n s s u g g e s t th a t a lle rg ic rh in itis m a y b e a c o n d itio n fa c ilita tin g th e o n s e t o f th e s e in fe c tio n s , w h ic h in tu rn w o u ld le a d to th e in s ta lla tio n o f b ro n c h ia l h y p e rre a c tiv ity . T h u s , th e tre a tm e n t o f a lle rg ic rh in itis m a y b e a w a y o f p re v e n tin g o r d e c re a s in g th e fre q u e n c y o f re s p ira to ry in fe c tio n s , th e p o s s ib le s tim u lu s re s p o n s ib le fo r th e fre q u e n t a tta c k s o f b ro n c h ia l a s th m a . O n th e b a s is o f th is ra tio n a le , w e h a v e b e e n s u c c e s s fu lly e m p lo y in g lo c a l tre a tm e n t o f a lle rg ic rh in itis fo r s e v e ra l y e a rs fo r c h ild re n a n d y o u n g a d u lts a s th e s in g le c o n tin u o u s tre a tm e n t b e tw e e n a tta c k s .
S a o P a u lo M e d ica l Jo u rn a l/R P M 1 1 3 (5 ): 9 6 8 -9 7 2 , 1 9 9 5 S A R T I, W ; G O M E S -M O N T E IR O , L .A . & M A C H A D O , C .S .M . - T h e tre a tm e n t o f a lle rg ic rh in itis
T a b le 1
S ig n s a n d s y m p to m s
m o s t o fte n d e te c te d a t firs t in te rv ie w
in 4 5 a s th m a tic
c h ild re n
H isto ry
P a tie n ts
P h ysica l fin d in g s
P a tie n ts
N o .
(% )N o .
(% )C o ryza
44
96
G a p in g a p p e a ra n ce
27
59
S n e e zin g
42
91
A lte re d n a sa l m u co sa
35
76
N a sa l p ru ritis
36
78
V -sh a p e d p a la te
43
93
N a sa l o b stru cio n
42
91
H yp e rtro p h ic to n sils
34
74
O titis m e d ia
13
28
E n la rg e d ce rvica l lym p h n o d e s
26
56
T o n sillitis
19
41
P n e u m o n ia
23
50
F a m ily h isto ry o f a to p y
32
70
T h e p re s e n t p a p e r re p o rts th e re s u lts o b ta in e d u s in g
th is m e th o d o f tre a tm e n t fo r a g ro u p o f a s th m a tic c h ild re n
in a s y s te m ic , p ro s p e c tiv e s tu d y .
M A T E R IA L A N D M E T H O D S
F o rty -s ix b o y s a n d g irls a g e d 1 y e a r a n d 8 m o n th s to
1 2 y e a rs w e re s tu d ie d p ro s p e c tiv e ly . A ll h a d b e e n
d ia g n o s e d a s h a v in g b ro n c h ia l a s th m a o n th e b a s is o f
s p o ra d ic o r fre q u e n t a tta c k s o f w h e e z in g , c o u g h in g a n d
d y s p n e a re q u irin g b ro n c h o d ila tin g m e d ic a tio n s a n d a t
tim e s e v e n h o s p ita liz a tio n . O th e r c a u s e s o f w h e e z in g s u c h
a s g a s tro e s o p h a g e a l re flu x a n d c y s tic fib ro s is w e re ru le d
o u t b y s p e c ific e x a m in a tio n .
A q u e s tio n n a ire w a s u s e d fo r e a c h p a tie n t to id e n tify
th e s ig n s a n d s y m p to m s o f a s th m a a n d a lle rg ic rh in itis
a n d o th e r a s s o c ia te d m a n ife s ta tio n s s u c h a s to n s illitis , o titis
m e d ia a n d p n e u m o n ia . E a c h p a tie n t w a s th e n s u b m itte d
to a p h y s ic a l e x a m in a tio n . T h e s ig n s a n d s y m p to m s
o b s e rv e d a re lis te d in T a b le 1 .
T h e c h ild re n in c lu d e d in th e s tu d y w e re th o s e w ith a
h is to ry o f b ro n c h ia l a s th m a w h o h a d s u ffe re d a t le a s t th re e
a tta c k s o v e r th e la s t 3 m o n th s a n d w h o e x h ib ite d
s y m p to m s s u c h a s c o u g h in g a n d s lig h t w h e e z in g o r
d y s p n e a b e tw e e n a tta c k s , re q u irin g th e u s e o f
b ro n c h o d ila tin g a g e n ts . A s s o c ia te d s y m p to m s w e re
re c o rd e d o n ly w h e n th e y h a d o c c u rre d a t le a s t th re e tim e s
d u rin g th e la s t y e a r. O f th e 4 6 p a tie n ts e x a m in e d a t firs t
in te rv ie w , 3 8 c o n c lu d e d th e s tu d y , w ith b im o n th ly v is its
u n til th e e n d o f a 6 -m o n th o b s e rv a tio n p e rio d . T h e 8
p a tie n ts w h o d ro p p e d o u t c o u ld n o t b e re a c h e d fo r fu rth e r
c o n ta c t.
T re a tm e n t b e tw e e n a s th m a a tta c k s w a s s tric tly fo r
a lle rg ic rh in itis . T h irty -tw o o f th e 3 8 p a tie n ts re c e iv e d 2 %
d is o d iu m c ro m o g ly c a te in m e th y l c e llu lo s e a s n o s e d ro p s
3 -4 tim e s a d a y , a n d th e re m a in in g 6 re c e iv e d
b e c lo m e th a s o n e d ip ro p io n a te n a s a l s p ra y , o n e p u ff (5 0 j.lg )
in e a c h n o s tril 3 tim e s d a ily . A ll c h ild re n u s e d B -a d re n e rg ic
a g e n ts o r a m in o p h y llin e , o r b o th , d u rin g th e a tta c k s a n d
u s e d a n a n tih is ta m in e d ru g d u rin g th e firs t 2 0 o r 3 0 n ig h ts .
T h e p a re n ts w e re in s tru c te d to a v o id e x p o s u re o f th e ir
c h ild re n to m a jo r in h a la n t a lle rg e n s .
O n th e o c c a s io n o f th e b im o n th ly v is its , th e s e v e rity
o f th e a s th m a a n d rh in itis m a n ife s ta tio n s w e re re c o rd e d ,
a s w e ll a s th e n e e d fo r b ro n c h o d ila tin g a g e n ts a n d th e
a m o u n ts u s e d , p lu s th e o c c u rre n c e o f c o m p lic a tio n s s u c h
a s to n s illitis , o titis , s in u s itis a n d p n e u m o n ia .
T a b le 2
P re s e n c e o f rh in itis
o r a s th m a a s th e p re c e d in g
m a n ife s ta tio n
in 4 6 a s th m a tic
c h ild re n
N o .
(% )R h in itis a s th e p re ce d in g m a n ife sta tio n
1 6
3 5
A sth m a a s th e p re ce d in g m a n ife sta tio n
3
6
R h in itis a n d a sth m a b e g in n in g to g e th e r
2 3
5 0
U n kn o w n
4
9
S A R T I, W .; G O M E S -M O N T E IR O , L .A . & M A C H A D O , C .S .M . - T h e tre a tm e n t o f a lle rg ic rh in itis im p ro ve s th e re co ve ry fro m a sth m a a n d u p p e r re sp ira to ry in fe ctio n s
Patients
w ere
considered
to have im proved
w hen,
during the last 3 m onths of the 6-m onth observation
period,
they only show ed
slight and occasional
m anifestations
of
asthm a
or even
absence
of sym ptom s
and
no use
of
bronchodilators,
and discrete
or absent rhinitis sym ptom s.
Each
patients
served
as his/her
ow n
control
by
com parison
of his/her
clinical
picture
before
and after
treatm ent.
B ecause
of the
effective
results
obtained
previously
w ith this type of treatm ent,
w e felt ethically
bound
not to use a control
group of patients
on placebo.
R E S U L T S
H istory
and physical
exam ination
data obtained
at
first interview
show ed
that all of the asthm atic
children
studied
had perennial
allergic
rhinitis,
the m ost com m on
sym ptom
being coryza
(96% ), follow ed
by nasal itching,
sneezing
and nasal obstruction.
A cute bacterial
infections
such as acute otitis m edia
w ere reported
in 28% of cases
and tonsillitis
in 39%
of cases.
Seventy
percent
of the
children
had
a fam ily
history
of
atopy.
Physical
exam ination
revealed
the presence
of V -shaped
palate in
93%
of the
patients
and
gaping
appearance
in 59% .
H ypertrophied
tonsils
w ere evident
in 74% , alteration
of
the nasal
m ucosa
in 76% ,
and enlarged
lym ph
nodes
in
the cervical
region
in 56% (Table
1).
R hinitis
preceded
asthm a
in 35%
of cases
and
occurred
sim ultaneously
w ith asthm a
in 50% (Table 2).
Seven
of
11 patients
subm itted
to X -rays
presented
hypertrophied
adenoids.
Table 3 show s that 8 children
abandoned
treatm ent.
O f the 38 children
that com pleted
the 6-m onth
period
of
treatm ent,
92% show ed
im provem ent
of allergic
rhinitis
and
84%
im provem ent
of bronchial
asthm a.
D uring
treatm ent,
only 2 children
had tonsillitis,
1 had sinusitis
and none had pneum onia
or acute otitis m edia.
D IS C U S S IO N
The results
obtained
for the 46 asthm atic
children
studied show ed that they invariably
had perennial
allergic
rhinitis.
This
association
suggests
an im portant
role of
allergic
rhinitis
both
in the triggering
and evolution
of
bronchial asthm a. N asal obstruction
is of itself an im portant
contributing
factor by inducing
buccal respiration
and thus
preventing
the patients
from utilizing
the filtration
and air
conditioning
system s
of the nose(21).
A t the sam e tim e,
chronic inflam m ation
of the nasopharyngeal
m ucosa leads
to anatom ical
and functional
changes,
thus low ering
both
the specific and nonspecific
defense
ability and leading to
a higher
susceptibility
to infection.
This
statem ent
is
suppprted
by high frequency
of hypertrophied
tonsils and
of cervical adenopathy
detected
in these patients.
It should
be pointed
out here that the the present
data agrees
w ith
those obtained
by Tuft and M uller(21),
w ho reported
that
one third of the asthm atic
children
studied
by them
had
allergic rhinitis
before
the onset of asthm .
Thus, the role
of allergic
rhinitis
m ay be to facilitate
viral infection
of
the respiratory
tract through
the nasal
route.
A m ong
the
possibly
deteriorated
specific
defense
m echanism s
m ay
be the local production
of secretory
IgA at the nasal m ucosa
level, an antibody
responsible
for, am ong other functions,
the fight against viral infections.
Low secretory
IgA levels
have
been
detected
in patients
w ith
allergic
rhinitis,
T a b le 3
E ffe c t o f 6 m o n th s o f lo c a l tre a tm e n t o f rh in itis o n th e s y m p to m s o f 3 8 a s th m a tic c h ild re n
P a tie n ts T re a tm e n t
D is o d iu m c h ro m o g ly c a te
B e c lo m e th a s o n e d ip rq p io n a te
T o ta l .
s a o P a u lo M e d ic a l J o u rn a V R P M 1 1 3 (5 ): 9 6 8 -9 7 2 , 1 9 9 5
32
6
38
R h in itis . A s th m a
Im p ro v e d U n c h a n g e d Im p ro v e d U n c h a n g e d
3 0 2 2 6 6
6 0 6 0
3 6 (9 5 % ) 2 (5 % ) 3 2 (8 4 % ) 6 (1 6 % )
suggesting
a local
and transitory
deficiency
of this
immunoglobulin
(3,18,19).
Viral infections of the respiratory tract have been held
responsible
for the onset of bronchial
hyperreactivity
by
many investigators
(10,13), and several mechanisms
have
been suggested
for this phenomenon.
In addition, chronic
inflammation
of the nasal mucosa and superimposed
acute
infections
such as tonsillitis,
otitis media and sinusitis may
stimulate
in
a nonspecific
manner
the
so-called
rhinosinobronchial
reflex (17). Indeed, several reports have
shown that patients
with allergic rhinitis but no bronchial
asthma
present
increased
bronchial
responsiveness
after
challenge
with cholinergic
drugs (6,12,16,20).
In should
be emphasized
that in the present
study,
even though the treatment
had been strictly limited to the
nasal
mucosa,
improvement
occurred
in 84%
of the
asthmatic
children.
In addition,
the symptoms
of rhinitis
improved
in 92%
of the children
and the infectious
episodes
were almost
totally
abolished.
With respect
to
the patients treated with intranasal
beclomethasone
spray,
it may be argued that the treatment
of rhinitis had effect
on the improvement
of bronchial
asthma because
part of
the drug may have reached the bronchial
tree and exerted
a direct therapeutic
effect there. However,
Harris et al. (9)
demonstrated
that intranasal spray of beclomethasone
does
not reach the bronchial
tree .
._ .On this basis, we may conclude
that the repair of the
nasal mucosa through treatment
restores the local defense
capacity
as well as the functional
capacity
of the nose,
thus providing
effective control of infections
of the upper
respiratory
tract and consequently
of the manifestations
of bronchial
asthma.
Finally, the present results support the su'ggestion that
allergic rhinitis plays an important
role in the onset and
development
of bronchial
asthma.
ACKNOWLEDGEMENTS
This study was financed by grant 301042 from CNPq
(Brazilian
National
Research
Council).
'
RESUMO
M ateriais e M etodos: Q uarenta e seis crianyas asm aticas com repetidas infecy6es respiratorias apresentaram sintom as de rinite alergica. T odos os pacientes foram tratados localizadam ente da rinite alergica isolada com crom oglicato de disodio e dipropionato de beclom etasona. R esultados: A pos seis m eses de tratam ento, 95% das crianyas m ostraram m elhora da rinite alE ~rgicae 84% m elhora de bronquite asm atica, bem com o de infecy6es m enores. C onclusao: C onclui-se que a rinite alergica desem penha im portante papel na facilitayao de infecy6es do trato respiratorio superior, e a posslvel associayao entre rinite, infecy6es virais e bronquite asm atica e discutida.
S A R T I, W .; G O M E S -M O N T E IR O , L.A . &M A C H A D O , C .S .M . - T he treatm ent of allergic rhinitis
im proves the recovery from asthm a and upper respiratory infections
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1 1 . L IT T L E , J.W .; H A L L , W .J.; D O U G L A S , R .G .; M U D H O L K A R , G .S .; S P E E R , D .M . &P A T E L , K . - A irw a y
h y p e rre a c itiv ity a n d p e rip h e ra l a irw a y d isfu n c tio n in in flu e n z a A in fe c tio n . A m R e v R e sp D is 1 1 8 :2 9 5 -3 0 3 , 1 9 7 8 . 1 2 . M A D O N IN I, E .; B R IA T IC O - V A N G O S A , G .; P A P P A C O D A , A .; M A C C A G N I, G .; C A R D A N I, A . &
S A P O R O T I, F . - S e a so n a l in c re a se o f b ro n c h ia l re a c tiv ity in a lle rg ic rh in itis.
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A lle rg y C lin Im m u n o I7 9 :3 5 8 -3 6 3 , 1 9 8 7 . 1 3 . M c IN T O S H , K .; E L L IS , E .F .; H O F F M A N , L .S .; L Y B A S S ,T .G .; E L L E R , 1 .J. & F U L G IN IT I, V .A . - T h e a sso c ia tio n o f v ira l a n d b a c te ria l re sp ira to ry in fe c tio n s w ith e x a c e rb a tio n s o f w h e e z in g in y o u n g a sth m a tic c h ild re n .
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P e d ia tr 8 2 :5 7 8 -5 9 0 , 1 9 7 3 .1 4 .0 U L L E T E , J.1 . & R E E D , C .E . - In c re a se d re sp o n se o f a sth m a tic su b je c ts to m e th a c h o lin e a fte r in flu e n z a v a c c in e .
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A lle rg y 3 6 :5 5 8 -5 6 3 , 1 9 6 5 .1 5 . Q U A R L E S v a n U F F O R D , W .J. & S A B E L B E R G , P .J. -A sia tic in flu e n z a in a lle rg ic p a tie n ts w ith b ro n c h ia l a sth m a . In A rc h A lle rg y 1 5 : 1 8 9 -1 9 2 , 1 9 5 9 .
1 6 . R A M S D A L E , E .H .; M O R R IS , M .M .; R O B E R T S , R S . &
H A R G R E A V E , F .E . - A sy m p to m a tic b ro n c h ia l h y p e r-re sp o n siv e n e ss in rh in itis.
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A lle rg y C lin Im m u n o I7 5 :5 7 3 -5 7 7 , 1 9 8 5 .-1 7 . S E T T IP A N E , G .A . - R h in o sin o b ro n c h ia l re fle x . In : S e ttip a n e G A , e d . C u rre n t tre a tm e n t o f a m b u la to ry a sth m a . P ro v id e n c e : N E R A lle rg y P ro c e e d in g s, 1 9 8 6 , p p . 6 -1 0 .' 1 8 . T A Y L O R , B .; N O R M A N , A .P .; O R G E L , H .A .; S T O K E S ,
e .R .; T U R N E R , M .W . & S O O T H IL L , J.F . - P a th o g e n e sis o f in fa n tile a to p y . L a n c e t 2 : 1 1 1 -1 1 3 , 1 9 7 3 .
1 9 . T A Y L O R , C .E . & T O M , G .L . - Im m u n o g lo b u lin c o n c e n tra tio n s in n a so p h a ry n g e a l se c re tio n s. A rc h D is C h ild 5 9 :4 8 -5 3 , 1 9 8 4 .
2 0 . T O W N L E Y , G .; R Y O , U .Y .; K O L O T K IN , B .M . & K A N G , B . - B ro n c h ia l se n sitiv ity to m e th a c h o lin e in c u rre n t a n d fo rm e r a sth m a tic a n d a lle rg ic rh in itis p a tie n ts a n d c o n tro l su b je c ts.
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A lle rg y C lin Im m u n o l 5 6 :4 2 9 -4 4 2 , 1 9 7 5 . 2 1 . T U F T , L . & M U E L L E R , H .L . - In : T U F T , L .; M U E L L E R ,L . e d s. A lle rg y in c h ild re n . P h ila d e lp h ia : W B S a u n d e rs, 1 9 7 0 .
