Over the past few decades we are witnessing a steady increase of the prevalence of allergic diseases. Nowadays, this group of diseases constitutes a significant economic burden for the healthcare system of developed countries, both in the terms of direct treatment costs and social costs associated with absenteeism and disability pensions. Studies indicate that this might be associated with unfavourable influence of the environment and faulty behaviour leading to change of life- style, both leading to the development of allergies. This paper presents health hazards associated with these diseases in the context of public health and most frequently quoted causes of increasing incidence of atopic diseases. The authors present a short analysis of the key epidemiological studies of the last decades. The increasing incidence of asthma, allergic rhinitis and anaphylaxis is analysed, with special emphasis on drug reactions. Data originate from studies performed in many letcountries worldwide and refer to both adults and children. In the Midspan family study carried out in Scotland, a threefold increase in the prevalence of asthma and pollinosis has been noted over a period of twenty years of observation. Similar results were obtained in a study of schoolchildren in Sydney, where a fourfold increase in the incidence of asthma and pollinosis was noticed. A twofold increase in the incidence of these diseases has been notices in Israel in the '90 and a similar trend was observed in China. An additional finding of the Chinese study was that the prevalence of asthma was higher in highly urbanized areas. There was a correlation between the risk of asthma and some everyday activities (e. g.: the use of gas ovens for cooking, high humidity in living areas, the use of pillows made of synthetic fabrics). On the other hand, the use of cotton bedclothes and high intake of fruits and vegetables had a protective effect.
Asthma is characterized by the development of reversible airway obstruction and the decline of pulmonary function test. Determination of baseline ventilatory parameters i.e. forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1) with airway obstruction reversibility test using spirometry play essential role in the diagnosing and monitoring asthma. Peak expiratory flow (PEF) in monitoring of asthma course is also recommended, but this parameter is less sensitive than FEV1. The fundamental feature of asthma is bronchial hyperreactivity. The term bronchial hyperreactivity indicates a degree of responsiveness greater than that observed in nonasthmatic subjects with normal spirometry. Bronchial hyperreactivity can be defined using inhaling provocative test with bronchospastic substances (histamine, methacholine, 5-AMP). In children very useful bronchospastic stimulus is exercise which is characterized by very great specificity but very low sensitivity. Treatment of asthma results not only in clinical course improvement, but also in increase in ventilatory parameters which allow us to determine clinical stadium of asthma. In asthmatic patients with bronchial remodeling an increase in ventilatory parameters is not observed. Bronchial remodeling results irreversible airway obstruction and is typical in patients suffering from severe asthma. In this kind of asthma is characterized by negative result of airway obstruction reversibility test and sometimes by low value of PEF. Bronchial hyperreactivity is very useful in diagnosing process. Its value is connected with bronchial allergic inflammation and with pulmonary function tests. Treatment of asthma although improves clinical course of the disease and ventilatory parameter has no influence on bronchial hyperreactivity.
It’s being discussed which parameters should be considered most relevant in asthma and asthma treatment monitoring, so called end-points. So far spirometric values, syptom presence (eg., night awakenings, night or day-time dyspnea) and rescue- medication-need were the most commonly used end-points in asthma. They do not, however monitor all aspects of the disease. Therefore monitoring of inflammatory and QoL parameters should be added. Authors present a wide panel of possible end-points, divided into several groups of parameters: inflammatory (blood/sputum ECP, sputum eosinophilia, eNO), bronchial reactivity (PC20, PD20), spirometric parameters (FEV1, PEF), QoL (hospitalization rate, rate and magnitude of exacerbations). In the paper it is also demonstrated, that QoL monitoring seems to gain an increasing interest of clinicians as far as asthma controlling is concerned. It is well documented that life quality correlates with several other parameters as well as it is crucial for patients compliance and good patient-doctor relations. Many clinical trials showing the accuracy and correlations of different asthma-control-parameters are further analyzed. Also data are presented to show the necessity of combining various end-points to obtain a more accurate clinical evaluation that is especially stressed by GINA 2006 and is also crucial for accurate treatment adjustment. In conclusion authors suggest that optimal asthma monitoring requires monitoring of at least one parameter of each presented group and further that research is needed to obtain accurate asthma-monitoring-strategy.
The authors presented characteristic features of mild persistent asthma, the method of diagnosing and optimal treatment of this disease. The Global Initiative for Asthma (GINA) quidelines describe mild, persistent asthma as having asthma symptoms more than weekly, but less than daily, nocturnal symptoms more than twice monthly, but less than weekly, with normal lung function (FEV1 or PEF‡80%) between asthma episodes. Patients suffering from mild, persistent asthma constitute a major portion of asthmatics. They rarely attend their physician because of symptoms of asthma, although sometimes they experience very severe attacks of dyspnoea. Some studies revealed that it is difficult to diagnose mild asthma because ventilatory parameters are normal, and bronchial reversibility test is negative. Studies based on examination of induced sputum and bronchial biopsies proved that markers of inflammation and airway remodeling airway are related to severity of disease. In mild asthma these consequences of long-term inflammation are very often as in moderate asthma. Most large studies which have studied the influence of inhaled corticosteroids waron mild asthma, revealed that this therapy is very effective. The first published was the OPTIMA trial. In this study two groups of asthmatic were selected to evaluate the efficacy of budesonide alone compared with combination budesonide and formoterol for 1 year. The rate of severe asthma exacerbationis per patient per year, and days with any asthma symptoms, poorly controlled asthma days and night with nocturnal symptoms were markedly reduced. The second study evaluating inhaled corticosteroids was START trial, which examined the effects of early intervention with budesonide in new-onset persistent mild asthma. Severe asthma exacerbations which required an emergency room visits or hospitalization in budesonide group were significantly reduced. The mast recently published study reported that it may be possible for patients with mild persistent asthma to be treated with intermittent courses of inhaled or oral corticosteroids. This conclusion was given despite the fact that the regular use of inhaled budesonide was better than intermittent.
Asthma is a serious global health problem, because people of all ages are affected by this illness. It was show that a one in three child has at least one episode of wheezing prior to there third birthday. That is why GINA report and other guidelines for diagnosis and treatment of wheezing in children were issued. One of them is PRACTALL consensus report as a guideline for clinical practice in Europe and in North America. In this report four different pattern of recurrent wheeze in paediatric population have been proposed: transient, nonatopic, persistent asthma and severe intermittent asthma. PRACTALL report underlying that age and triggers can be used to define different phenotypes. According to ERS TASK FORCE (2008) episodic and multiple trigger wheezes are recognized. Episodic wheeze is defined as wheeze in discrete episodes child being well between episodes. This phenotype is usually associated with viral respiratory tract infection. Among multiple triggers are different allergens, viruses, tobacco smoke. The PRACTALL report states that age is one of the strongest determinants of asthma phenotype in childhood and it is important to design diagnostic and management strategies based on age. In infants (0-2 years old) persistent symptoms is a major indicator of severity, in preschool children (3-5 years old) the asthma phenotypes are established basing the persistent wheeze during last year. If symptoms disappear between episodes of viral infections, doprowaviral asthma is the most appropriate diagnosis. In children with skin prick tests or in vitro test are positive the allergen-induced asthma should be recognized because atopy is a strong risk factor for asthma. In some children phenotype non-allergic asthma can be identified. An important risk factor for new-onset asthma in early adult life is pre-existing allergic rhinitis. Also bronchial hyperresponsiveness in non-asthmatic children at age 6 years showed increased risk asthma by 11 years.
Bronchial asthma is one of the most frequent pulmonary diseases of the childhood. Albeit its diagnosis is mostly based on history and few simply laboratory test, still asthma seems to be underdiagnosed virtually in every population. To make matters worse, asthma treatment is often far from perfection. Asthma control in children is often not assessed. This situation happens despite of country or region for many reasons. Asthma is often treated by GP and several specialists (pediatricians, pulmonary physicians and allergists). Some of them have relatively small experience in treating children, though they have many successes in adults. Current asthma treatment guidelines in most cases are just small parts of an adult consensus. Sometimes, even children guidelines are derived from CRTs done in adults’ asthmatics. To help all physicians to treat childhood asthma, the PRACTALL consensus group have been formed few years ago. Recently, “Allergy” publish PRACTALL (an acronym taken from PRACTical ALLergy), an EBM guidelines focused on child asthma diagnosis and therapy. The document was prepared by allergists and pediatricians from Europe and the USA. This is the first worldwide children asthma consensus. Some aspects of new guidelines are really a breakthrough in asthma diagnosis and therapy in children, especially in babies 0-4 years old. This review is an approach to summarize major aspects of PRACTALL.
This review assesses the evidence regarding the use asthma-treatment with combination long-acting β2-agonist (LAβA) and inhaled corticosteroid (ICS). The first line-treatment in asthma is inhaled corticosteroid. The integral part of asthma management is β2-agonist, which present the strongest bronchodilators. Currently, two long-acting β2-agonist – salmeterol and formoterol are widely available. Recently several clinical studies have proved that LAβAs in combination with ICS are effective and safe option in asthma management. GINA guidelines recommend the addition of LAβAs to a low and medium dose ICS, when low doses of ICS do not allow to achieve control of asthma symptoms. From some clinical trials we have knowledge that LAβAs given in combination with ICS demonstrate that addition LAβAs is more beneficial in control asthma symptoms than doubling dose of ICS. Asthma is a chronic inflammatory disease of the airways with their hyperresponsiveness. The clinical course of asthma is usually different in different patients and even in the same subject. In normal clinical practice, a maintenance dose of ICS appropriate to the severity of the patient’s asthma of either combination of ICS and LAβA is administered twice daily, and a separate β2-agonist (SAβA – short acting β2-agonist) is used as needed to relieve asthma symptoms. Recently a new model of combination of ICS budesonide and LAβA (formoterol) in one inhaler has been proposed. This model is called SMART (Single Maintenance and Reliever Therapy). In this treatment concept combination budesonide/formoterol in one inhaler is used for both maintenance and as-needed therapy for symptoms relief, without a separate rescue medication. Several clinical trials have shown that SMART method reduced the risk of severe exacerbations and was well tolerated. This method has a beneficial role in patients who remain symptomatic despite treatment with combination maintenance therapy.
Clinically, two types of the sensitivity to aspirin (ASA) are distinguished: bronchospastic and urticaria/ angioedema. Bronchospastic type of ASA sensitivity occurs in patients with asthma and it is called ASA- asthma. In these patients the symptoms of ASA- sensitivity are: dyspnoea and extrabronchial symptoms i.e. watery rhinorrhoea, conjunctivitis and lacrimation, flushing of the face, neck and chest. Dramatic oedema of the larynx, fall in blood pressure and even death have been described as well. ASA- induced urticaria/ angioedema is called ASA- urticaria and this type sensitivity concerns mainly patients with chronic or recurrent urticaria and angioedema. ASA- asthma and ASA- urticaria occur in patients of any age, but it especially concerns women between 30 and 50 years of age (70% of examined patients). In some patients with ASA- sensitivity atopy is stated. The typical feature of ASA- asthma are nasal and paranasal polyps, which are recurrent and persistent. They are presented in 80% asthmatics sensitive to ASA. Nasal mucosa of ASA- asthmatics is inflamed with T- lymphocytes, eosinophils, mast cells and macrophages. The majority of proinflammatory cells elicit expression mRNA for IL- 5. Bronchial mucosa is also inflamed with eosinophils, which are the rich source of leukotriene C4, which probably takes part in the pathomechanism of sensitivity to ASA. The clinical course of ASAasthma is usually severe, but using inhaled corticosteroids and long- acting β2-agonist control asthma may be achieved. It was reported, that majority of nonsteroidal anti- inflammatory drugs (NSAID’s) elicited dyspnoea in patients with ASA- asthma and skin eruption in ASA- urticaria patients. The above mentioned symptoms are produced by indomethacin, mefenamic acid, flufenamic acid, ibuprofen, phenylbutazone, naproxen, diflunisal and zomepirac. On the other hand, paracetamol, chloroquine, benzydamine, salicylic acid and dextropropoxyphene are well- tolerated by patients with ASA- asthma. Detection of sensitivity to ASA and other NSAID’s is based mainly on the anamnesis and oral challenge with administration of increasing ASA doses at 24 hours intervals. Sometimes, nasal and inhaling tests with ASA lysine are performed. These test are more safely, but less sensitive. In provocative test only ASA is recommended. In patients with ASA- asthma and ASA- urticaria, ASA desensitization may be induced by administering increasing doses of ASA every 24 hours until a good tolerance of 600 mg is obtained. There is hypothesis, that pathomechanism of the ASA- asthma and ASA- urticaria is related cyclooxygenase inhibition – an enzyme, which is involved in prostaglandins, prostacycline and thromboxane synthesis.
Asthma, allergic rhinitis and idiosyncrasy to aspirin stand for an increasing epidemiologic. In Poland an epidemiological study has been carried out in 11 centres, showing the occurrence of asthma at 5.4% of general population, for allergic rhinitis and idiosyncrasy – 8.5% and 0.5%, respectively. Some publications suggest more often presentation of idiosyncrasy in atopic patients. Taking under consideration high and increasing occurrence of allergy and massive use of non-steroid anti inflammatory drugs, their coincidence is quite important and we decided to investigate it. In a retrospective analysis of patients diagnosed at the Department of Internal Medicine and Allergology, Wrocław Medical University, we determined a group of 1 557 patients suffering from at least of one of these conditions. Asthma has been recognized in 1 015 patients (65%), allergic rhinitis and aspirin idiosyncrasy in 495 (32%) and 363 (23%), respectively. Coincidence of asthma and allergic rhinitis has been reported in 255 patients, and coincidence of asthma or rhinitis and idiosyncrasy – in 3% and 6%, respectively. We conclude that asthma and allergic rhinitis coexist very frequently, confirming a mutual pathophysiologic background and the concept of united airways disease. Further, idiosyncrasy appears 10 times more often in allergic patients than in general population.
Allergic rhinitis (AR) is the most common allergic disease in the world. Frequently it coexists with other allergic diseases such as asthma, allergic conjunctivitis or allergic dermatitis. It is inflammatory disease with immunological background, and it is caused by IgE-dependent reaction of the nasal mucous membrane to allergen. If time of symptoms duration is taken into account AR can be classified into intermittent or perennial, and severity of symptoms classifies it into mild or moderate/severe. Allergic rhinitis is a disease that depends of many factors. Interactions of environmental and genetic factors are responsible for its development. Environmental factors include airborne outdoor and indoor allergens (pollen, mold spores, house dust mites, animals fur and dander, insects), occupational allergens and atmospheric air pollution. Genetic factors are atopy and particular genetic polymorphisms coexistence. Symptoms of AR are itching, sneezing, clear nasal discharge, nasal congestion and loss of smell ability. Recognition of AR bases on compliance of symptoms and results of skin prick tests or the presence of specific IgE antibodies in blood. Assessment of amount of total IgE is not helpful in diagnostic process, while nasal provocation tests are more useful in scientific researches than clinical practice. Therapeutic process consists of patients education, exposure to allergens reduction, pharmacological treatment and specific immunotherapy. In pharmacological treatment are used systemic or topical antihistamine drugs, systemic or topical glucocorticoids, topical decongestants, pyłmontelukast, cromoglicas, and ipratropium bromide. Specific immunotherapy is indicated in selected groups of patients and it influences natural history of allergic diseases.
The aim of this paper is to review the relationship between the prevalence of atopic disease and exposure to respiratory infection. Mucosal inflammation in asthma is present from the beginning of the disease and is even seen in patients with allergic rhinitis predisposed to asthma. In other hand, a viral infection may be the immediate cause for an asthma exacerbation. Rhinoviruses infections are common and can be transmitted easily, leading to an asthma exacerbation. The peak of the epidemic asthma hospitalisation is synchronized with school return after the summer vacation. Children returning to school after the summer vacation are re-exposed to respiratory viral infections, most commonly rhinoviruses aetiology. The infections of the upper respiratory tract are one of the most common health problems in preschool and school children. Recurrent respiratory tract infections are demanding medical consultation and diagnosis of the causes. These infections have a lot reasons and the risk factors. Therefore it is important to administer antibiotics only in necessary cases. Specific vaccine play role in prevention of the bacterial infections. Immunostimulatory drugs presume to prevent respiratory tract infections.
During the recent years there is a rise in prevalence of asthma and other allergic diseases. Simultaneously the number of overweight patients with increased value of body mass index (BMI) rises. It seems that although pathomechanisms of asthma and obesity are different, there is a common pathogenic link in development of these diseases. The influences of environmental, dietary, genetic and infectious factors are taken under consideration. Most epidemiological surveys confirm connection between overweight, obesity and risk of asthma at children and adults. The influence of high birth weight and higher gains of body mass during the first year of life is frequently highlighted. In contrast the risk of allergic rhinitis and allergic conjunctivitis is in negative correlation with body mass. No relation is observed between obesity and allergic dermatitis prevalence. Adipose tissue as an endocrinous organ produces number of cytokines, hormones, and growth factors. It is a source of proinflammatory factors such as: IL-6, TNF-a, TGF-b, leptin, resistin. Adipocytes produce leptin which level stays in positive correlation with adipose tissue mass. Leptin can exacerbate inflammatory process and probably plays an important role in development of lungs. Higher serum level of leptin is considered as a prognostic factor of asthma evolution. Adiponectin has anti-inflammatory abilities and its level is decreased in obesity. There is a negative correlation between concentration of adiponectin and BMI. Also resistin, aP2 protein, and Chilfemale sex hormones take part in development of asthma in obese patients. Influence of genetic factors is still not well known. Since now there were isolated four chromosomic regions, which had connection with higher susceptibility for both: obesity and asthma. Protective effects have dietary factors such as antioxidants and microelements. Obesity deteriorates course of the asthma, exacerbates its symptoms and coexists with other diseases such as obturative sleep apnoea or oesophageal reflux. In coexistence of obesity and asthma, apart from pharmacological treatment of patients, reduction of body mass should be strongly recommended.
The specific immunotherapy next to the elimination of allergen from patient’s environment is the only causal way of treatment of allergic diseases. It refers to give the patients increasing doses of allergenic vaccination by injectional way or more rarely used non-injectional. Local immunotherapy includes: sublingual immunotherapy – “spit” type and “swallow” type, oral, intranasal, intrabronchial and intraconjunctival immunotherapy. First attempts of using immunotherapy have dated back to the year 1900. Over next hundred years there have been periods of variable interests of this form of treatment. In the nineties of twentieth century an interest of non-injectional form of specific immunotherapy has increased distinctly. Last years research confirms that sublingual immunotherapy can be an alternative to injectional immunotherapy. A necessary condition is using high doses of allergen. SLIT is safe way of treatment and acceptable to patients. Most of observed side effects are connected with immediate exposing mucous membrane to action of allergenic vaccination. Local side effects are usually short-time, they recede spontaneous and doesn’t need to be treated. Vaccinations, which are used in specific immunotherapy, should be standardized by biological tests. Due to it, next series of vaccinations are comparable to the biological model in respect of contents of allergen and power of activity. It is recommended to use maximum four allergens in one vaccination and not to connect seasonal allergens with yearlong ones. Specific immunotherapy can be used seasonal and yearlong, a scheme of yearlong immunotherapy enables giving higher doses of allergenic vaccination and allows to achieve better clinical efficiency. Optimal period of specific immunotherapy isn’t defined ultimately. It is recommended to use immunotherapy not shorter than three to five years.
The number of various diagnostic criteria for atopic eczema that have been carried out world-wide shows how many difficulties and doubts this diagnose still causes. In 1994 one of those criteria were presented by the UK working party’s (Williams et al.). The aim of his study was to examine the validity of the UK diagnostic criteria for atopic dermatitis in children and to compare the results with those of Hanifin and Rajka. One hundred and sixty six children from paediatric out-patient clinic (67 boys and 99 girls) aged 4-15 lat (mean age 10.3) were examined. All of them beside the skin changes had pruritus. They underwent thorough clinical examination and were assessed according to Hanifin and Rajka criteria. The results were then subjected to statistical analysis. Atopic eczema was diagnosed in 108 children, remaining 58 infants suffered from scabies, seborrhoic dermatitis, irritant reactions, psoriasis vulgaris, acne vulgaris and urticaria. All of the examined children had a history of dry skin in the last year. History of involvement of typical skin areas, onset under the age of 2, visible eczema of typical localization and a personal history of asthma or hay fever were noted in 96,3% (104/108), 71.3% (77/108), 67.6% (73/108) and 64.3% (70/108) respectively. All of those features were observed more frequently in comparison with the group of non-atopic children and that fact was statistically significant (p<0.001). In 3/108 examined children the results turned false negative and in 2/58 – false positive. The Williams criteria showed sensitivity and specificity of 97.2% and 96.6% respectively. Conclusions: 1. The UK diagnostic criteria for atopic dermatitis are very useful in paediatrician everyday practice, especially in children over 3 years old. 2. Both features general dry skin and history of skin involvement in typical localization are the most useful in diagnosing atopic eczema in children. 3. In complicated and doubtful cases the age limit of the early onset below 2 might be stretched up to 5 which improves overall diagnostic efficiency.
Asthma is the most frequent chronic respiratory tract disease at children. The rate of its appearance in Poland is 8.6% among children. Its inflammatory basis is a cause that any even non-specific factor inducing inflammatory changes in respiratory tract can lead to asthma exacerbation. Children suspected of asthma or with already established diagnosis are frequent patients of pediatricians and family doctors. But once set diagnosis doesn’t exempt the doctor of vigilance and individual approach to every asthmatic patient. In the article we present a case of a patient with asthma exacerbation that was caused by foreign body set in bronchial tree. History of foreign body aspiration was initially negative. Despite of intensive treatment response to it was inadequate. In addition asymmetry of auscultatory pulmonary signs and characteristics of chest x-ray led to deepening and widening of the diagnosis. The foreign body was found in the bronchial tree and its removal allowed to gain control over asthma and to prevent further forced treatment and prawiits complication. Relapsing course of asthma and its chronic character make doctor lose his or her vigilance. Consecutive exacerbations are treated routinely especially if the response is satisfactory. On the other side, negative history of foreign body aspiration and its heterogeneous and non-specific course causes to misleading diagnoses. Furthermore antiasthmatic treatment can temporary mute the symptoms and suggests asthma the leading cause of the condition. Unrecognized foreign body leads to serious and irreversible repercussions, which are a consequence of leaving it in the organism as well as inappropriate harmful treatment of other overdiagnosed states.