Could routine spirometry suggest sensitisation in the military medicine setting?

INTRODUCTION: Providing evidence of sensitisation is the formal requirement for allergy diagnosis. The aim of this study was to evaluate whether spirometry may be able to predict sensitisation in a representative cohort of Italian Navy military personnel. METHODS: 2043 (1875 men, 168 women, mean age 28.35±11.6 years) Italian Navy military personnel were enrolled into this study. Spirometry and skin prick testing were performed to predict sensitisation. RESULTS: Sensitisation, assessed by skin prick test, was documented in 658 (32.2%) subjects. Impaired forced expiratory flow at the 25% and 75% of the pulmonary volume (FEF25-75) as demonstrated on spirometry was detected in 82 subjects, of whom 69 were sensitised (P<0.0001). Impaired FEF25-75 was significantly associated with sensitisation (OR 7.43; 95% CI 4.04 to 14.66; P<0.0001). DISCUSSION: The findings of this study suggest that impaired FEF25-75 may predict sensitisation in this cohort of Italian Navy personnel. This outcome is relevant in the military medical setting, as it could allow early identification of subjects with subclinical asthma.

Fractional Exhaled Nitric Oxide: A Potential Biomarker in Allergic Rhinitis?

BACKGROUND: The fractional concentration of exhaled nitric oxide (FeNO) is a surrogate biomarker for Th2-dependent bronchial inflammation. The present study investigated whether FeNO may characterize allergic rhinitis (AR) patients. METHODS: A total of 553 AR patients (497 males, mean age 28.8 years) were evaluated. Those patients with a high FeNO underwent a 2-year follow-up. RESULTS: Increased FeNO was associated with a significantly longer AR duration, impaired lung function, more severe symptoms, and more frequent bronchial hyperresponsiveness (BHR). At follow-up, 22 out of 82 patients (26.8%) with high FeNO levels (>50 ppb) developed asthma. CONCLUSIONS: AR patients may frequently have high FeNO values, exceeding 50 ppb. This might be associated with an initial impaired lung function, BHR, a perceived worsening of respiratory symptoms, and potential progression to asthma.

Exhaled nitric oxide may predict bronchial hyperreactivity in patients with allergic rhinitis.

BACKGROUND: Nowadays it is possible to assess airway inflammation by measuring the fractional concentration of exhaled nitric oxide (FeNO) during an office visit and there is international consensus on the testing methodology. The aim of this study was to evaluate whether FeNO measurement may be a predictor of bronchial hyperreactivity (BHR) in patients with allergic rhinitis (AR). METHODS: Two hundred eleven patients (196 males, median age 28.5 years) suffering from persistent AR were evaluated. Values for bronchial function (FVC, FEV(1), and FEF(25-75)), bronchial provocation tests (methacholine), exhaled nitric oxide (FeNO), a visual analogue scale for nasal and bronchial symptoms, and sensitization were assessed. RESULTS: A strong and inverse correlation between FeNO levels and BHR severity was found (r = -0.58). FeNO was a predictive factor for BHR, and 37 ppb was found to be the best cutoff (area under the curve 0.90) to define the presence of BHR in patients with AR. CONCLUSIONS: This study highlights the relevance of FeNO as a possible predictive marker for BHR in AR patients and underlines the close link between upper and lower airways. Thus, FeNO measurement could be a useful screening tool in identifying subjects with rhinitis at risk of developing asthma.

The Practical Role of FEF25-75 in Young Patients with Allergic Rhinitis.

Allergic rhinitis (AR) is a relevant risk factor asthma as it may frequently precede asthma onset. There is evidence that lung function may be early impaired in AR patients. In this regard, the forced expiratory flow at 25%-75% of vital capacity (FEF25-75) could be a reliable marker of bronchial impairment in AR. Therefore, the present study investigated the practical role of FEF25-75 in young people with AR. The parameters included history, body mass index (BMI), lung function, bronchial hyperresponsiveness (BHR), and fractional exhaled nitric oxide (FeNO). This cross-sectional study included 759 patients (74 females and 685 males, mean age of 29.2 years) suffering from AR. The study demonstrated a significant association between low FEF25-75 values and BMI (OR 0.80), FEV1 (OR 1.29), FEV1/FVC (OR 1.71), and BHR (OR 0.11). Stratifying the patients on the basis of the presence (or absence) of BHR, sensitization to house dust mites (OR 1.81), AR duration (OR 1.08), FEF25-75 (OR 0.94), and FeNO (OR 1.08) were associated with BHR. Stratifying patients based on high FeNO values (>50 ppb), BHR was associated with high FeNO (OR 39). In conclusion, the present study showed that FEF25-75 was associated with low FEV1 and FEV1/FVC and BHR in AR patients. Therefore, spirometry should be considered in the long-term workup of patients with allergic rhinitis as impaired FEF25-75 might suggest an initial progression toward asthma.

Relationship between bronchial hyperreactivity and bronchodilation in patients with allergic rhinitis.

BACKGROUND: Allergic rhinitis (AR) may be considered a risk factor for the onset of asthma. Recently, it has been reported that forced expiratory flow between 25% and 75% of vital capacity (FEF(25%-75%)) may predict a positive response to bronchodilation test in asthmatic children. Moreover, bronchial hyperreactivity (BHR) is frequently detected in AR patients. OBJECTIVE: To evaluate the possible relationship between the response to bronchodilation test and methacholine challenge, also considering the FEF(25%-75%) values in a large group of patients with persistent allergic rhinitis. METHODS: Three hundred sixty-five consecutive AR patients were evaluated. Clinical examination, spirometry, methacholine bronchial challenge, and bronchodilation test were performed in all patients. RESULTS: Two hundred forty-one patients (66%) had "positive" results for bronchodilation test; FEF(25%-75%) was abnormal in 78 patients (21.4%), and 76 patients (20.8%) had severe BHR. An FEF(25%-75%) cutoff value of less than 58.5% of predicted may optimally (AUC 0.97) discriminate patients with both severe BHR and reversibility. CONCLUSION: This study confirms previous studies and increases the strength of the role of FEF(25%-75%) as a marker of early bronchial involvement in patients suffering from persistent allergic rhinitis. Moreover, an FEF(25%-75%) value less than 58.5% of predicted may suggest the co-existence of severe BHR and reversibility.

Bronchial hyperreactivity in patients with allergic rhinitis: forced expiratory flow between 25 and 75% of vital capacity might be a predictive factor.

Allergic rhinitis (AR) is considered a strong risk factor for the onset of asthma. Bronchial hyperreactivity (BHR) may be present in patients with AR. Forced expiratory flow between 25 and 75% of vital capacity (FEF(25-75)) may be impaired in AR patients. The aim of this study was to evaluate the presence of BHR in a large group of patients with AR and whether FEF(25-75) might be related to BHR. Four thousand seven hundred eighty-one patients with AR were enrolled. Clinical examination, skin-prick test, spirometry, and methacholine challenge were performed in all patients. Fourteen percent of patients had severe BHR and 25.3% had mild BHR. Patients with low FEF(25-75) values (such as ≤65% of predicted) had severe BHR more frequently than patients with normal FEF(25-75) values (p < 0.001). In addition, low FEF(25-75) values constitute a relevant predictive factor (OR = 12.9) for severe BHR. This study shows that a relevant percentage of AR patients had BHR, and impaired FEF(25-75) values might predict it. Therefore, BHR should be suspected in AR patients with low FEF(25-75) values.

Clinical assessment of nasal decongestion test by VAS in adolescents.

Nasal airflow, as measured by rhinomanometry, is frequently impaired in allergic rhinitis (AR). The decongestion test evaluates whether the application of an intranasal vasoconstrictor drug increases nasal airflow. The aim of this study was to verify the suitability of the use of the visual analogue scales (VAS) as a surrogate for rhinomanometry in the decongestion test assessment in adolescents with atopic rhinitis. Forty adolescents [16 males and 24 females, mean age 15 (s.d. 2) yr] with AR were studied. Nasal symptoms, VAS, rhinomanometry, and nasal decongestion test were assessed in all patients. A significant association was observed between VAS and nasal airflow after performing the decongestion test (Spearman's r is -51.7%, p < 0.001). The associated sensitivity and specificity were 84.8 (95% confidence interval, CI 68.1-94.8) and 85.7 (95% CI 42.2-97.6), respectively. The corresponding area under the receiver operating characteristic (ROC) curve of 0.83 (95% CI 0.67-0.93) indicated a good discriminating ability for the decongestion measured on the VAS scale. In conclusion, the use of VAS appears as clinically relevant, in that it allows, with a fair reliability, to perform the decongestion test in the absence of rhinomanometry.

The pragmatic role of FEF25-75 in asymptomatic subjects, allergic rhinitis, asthma, and in military setting.

Introduction: The forced expiratory flow between 25% and 75% of forced vital capacity (FEF25-75) is a spirometry parameter that may be useful in many clinical settings. Values <65% of predicted have been defined as abnormal.Areas covered: The current report discusses the clinical value of FEF25-75 in different settingv, namely military medicine, primary care, and specialized clinic. Moreover, the predictive role of FEF25-75 was discussed considering different patients' populations, including patients suffering from allergic rhinitis and/or asthma, as well as normal subjects. The most recent literature concerning the assessment of FEF25-75 in these covered areas was searched.Expert opinion: In clinical practice, impaired values have been defined as a reliable surrogate marker for bronchial airflow limitation associated with early onset of asthma, bronchial hyperresponsiveness, lower airway inflammation, reversibility to bronchodilation testing, allergic sensitization, and uncontrolled asthma. In the military medicine setting, simple spirometry, including FEF25-75, may suggest a series of fruitful information.

Persistent allergic rhinitis includes different pathophysiologic types.

BACKGROUND: Allergy rhinitis is typically classified as seasonal allergy rhinitis (SAR) and perennial allergy rhinitis (PAR). More recently, the Allergic Rhinitis and its Impact on Asthma document proposed the intermittent (ITR) and persistent forms (PER). However, it has been previously reported that each single allergen may induce different clinical and pathophysiologic features. OBJECTIVE: The aim of the study was to test the hypothesis that the type of causal allergen might characterize pathophysiologic differences in a cohort of patients with PER. METHODS: Three hundred nineteen patients, sailors of the Italian Navy, with moderate-severe PER were prospectively and consecutively evaluated with clinical evaluation, skin prick test, rhinomanometry, and nasal decongestion test. RESULTS: Patients with pollen allergy showed significantly more severe symptoms, lower nasal airflow, and higher response to decongestion test than patients with allergy to perennial allergens (P < .0001). CONCLUSION: This study provides evidence that patients with PER may show different pathophysiologic patterns depending on the type of causal allergen.

Relationship between rhinitis duration and worsening of nasal function.

BACKGROUND: While it is well known that asthma is characterized by airway remodeling, few studies instead have investigated this issue in patients with allergic rhinitis (AR). OBJECTIVE: The aim of the study was to evaluate nasal function, ie, nasal airflow, in a cohort of patients with persistent AR (PER). METHODS: One hundred patients, 50 with short-term and 50 with long-term PER, were prospectively and consecutively evaluated, clinically evaluated by visit, skin prick test, and rhinomanometry. RESULTS: Nasal airflow values were significantly lower (median flow: 348 mL/sec) in patients with long-term rhinitis (median duration nine years) as compared to patients with short-term (median duration one year) rhinitis (median flow: 466 mL/sec) (P < 0.0001). CONCLUSION: This study provides the first evidence that patients with PER may show a progressive worsening of nasal airflow depending on the duration of the disorder.

Relationship between severity of rhinitis symptoms and nasal airflow.

BACKGROUND: Allergic rhinitis (AR) is characterized by inflammatory events that lead to the onset of typical nasal symptoms, including itching, sneezing, rhinorrhea and obstruction. OBJECTIVE: The aim of the study was to evaluate the relationship between nasal airflow and severity of nasal symptoms, in a cohort of patients with PER METHODS: 312 patients with PER were prospectively and consecutively evaluated performing clinical evaluation and rhinomanometry. RESULTS: Significant relationship exists between severity of all nasal symptoms and degree of nasal airflow limitation (p < 0.001). CONCLUSION: This study provides the first evidence that patients with PER show close relationship between severity of nasal symptoms and nasal airflow impairment.

FEF25-75 and Asthma in Clinical Practice.

No Abstract.

Nasal decongestion test in allergic rhinitis: definition of responder.

BACKGROUND: Nasal airflow, as measured by rhinomanometry, is frequently impaired in allergic rhinitis (AR). The decongestion test evaluates whether the application of an intranasal vasoconstrictor drug increases nasal airflow. OBJECTIVE: The aim of this study was to define the characteristics of decongestion test responders. METHODS: 123 subjects (112 males and 11 females, mean age 22.9+/-5.7 years) with AR were studied. Nasal eosinophils, rhinomanometry, and decongestion test were assessed in all subjects. RESULTS: The optimal cut-off for % variation of nasal airflow and nasal eosinophils >5 was = 34.4, with sensibility = 82.7% (95%CI 73.7-89.6) and specificity = 80% (95%CI 59.3-93.1). CONCLUSIONS: The clinical relevance of this study is that non-responders may have a likely moderate-severe allergic inflammation that should be adequately evaluated and treated.

Sublingual immunotherapy induces spirometric improvement associated with IL-10 production: preliminary reports.

BACKGROUND: Sublingual immunotherapy (SLIT) has been demonstrated to be able of inducing immunologic changes as evidenced by IL-10 production. Forced expiratory flow between 25% and 75% of the vital capacity (FEF(25-75)) may be considered a good marker of early bronchial involvement in patients with pure allergic rhinitis. OBJECTIVE: The aim of this study was to evaluate the possible association of IL-10 production with FEF(25-75) values in patients with perennial allergic rhinitis (PAR) successfully treated with SLIT. METHODS: 19 patients with PAR were studied: 9 successfully assumed SLIT for 3 years, 10 were considered as control. In vitro IL-10 production was evaluated after SLIT. Spirometry and bronchodilation test were performed in all subjects at baseline and after 3 years. RESULTS: After 3 years, FEF(25-75) values significantly (p=0.0131) increased in SLIT group (80.5+/-6.7), whereas they significantly (p=0.0021) decreased in non-treated patients (60.8+/-2.62). In addition, SLIT-induced increase of FEF(25-75) values is significantly associated with IL-10 production (p=0.0025). CONCLUSIONS: This study provides the first evidence that SLIT is capable of improving early bronchial involvement in patients with pure allergic rhinitis and this functional effect may be associated with immunological changes, such as the induction of IL-10 production.

Nasal airflow recovery after decongestion test is associated with bronchial hyperreactivity in patients with allergic rhinitis.

BACKGROUND: The decongestion test involves spraying an intranasal vasoconstrictor drug to evaluate the recovery of nasal airflow. OBJECTIVE: The aim of this study was to assess the relationship between pulmonary function (assessed by spirometry and methacholine challenge) and nasal airflow recovery after a topical vasoconstrictor had been administered in patients with allergic rhinitis (perennial, seasonal, or mixed allergic rhinitis). METHODS: A total of 150 subjects were studied. The total symptom score, sensitization, and pulmonary function were all assessed. All subjects underwent rhinomanometry and the decongestion test. RESULTS: Univariate analysis revealed that nasal symptoms and spirometric parameters (except FEF(25-75) in subjects with seasonal allergic rhinitis) were not. Only bronchial hyperreactivity, assessed by methacholine challenge, proved to be significantly (and independently) associated with outcome (OR 1.45, P = 0.025). CONCLUSIONS: This study provides the first evidence of an association between a positive response to the decongestion test and bronchial hyperreactivity, assessed by methacholine challenge, in patients with allergic rhinitis.

Desloratadine and levocetirizine improve nasal symptoms, airflow, and allergic inflammation in patients with perennial allergic rhinitis: a pilot study.

BACKGROUND: Nasal obstruction is the main symptom in patients with perennial allergic rhinitis. Some new antihistamines have been demonstrated to be capable of improving this symptom. OBJECTIVE: The aim of this pilot study was to evaluate nasal symptoms, nasal airflow, eosinophils, and IL-4 in patients with perennial allergic rhinitis, before and after treatment with two new antihistamines: desloratadine and levocetirizine. METHODS: Thirty patients with perennial allergic rhinitis were evaluated, 26 males and 4 females (mean age 26+/-7.1 years). All of them received either desloratadine (5 mg/daily) or levocetirizine (5 mg/daily) or placebo for 4 weeks. The study was double-blind, parallel-group, placebo-controlled, and randomized. Total symptom score (including: rhinorrhea, nasal itching, sneezing, and nasal obstruction) was assessed before and after treatment. Rhinomanometry and decongestion test, nasal lavage, and nasal scraping were performed in all subjects before and after treatment. Eosinophils were counted by conventional staining; IL-4 was measured by immunoassay of fluids recovered from nasal lavage. RESULTS: Desloratadine and levocetirizine treatment induced significant symptom relief and significant reduction of IL-4. Both antihistamines significantly affected all parameters in comparison with placebo. CONCLUSIONS: This pilot study demonstrates the effectiveness of antihistaminic treatment in: i) relieving nasal symptoms, including obstruction, ii) improving nasal airflow, iii) exerting decongestant activity, iv) reducing eosinophil infiltration, and v) diminishing IL-4 levels.