EDUCATIONAL BACKGROUND

• MD. Faculty of Medicine, Airlangga University – Surabaya (1998)

• Paediatrician. Faculty of Medicine, Airlangga University – Surabaya (2009)

PHOTO
LATEST POSITION
• Medical Staff at RS Saiful Anwar – Malang
• Lecturer at Faculty of Medicine, Brawijaya University

Ery Olivianto
RSU. Dr. Saiful Anwar
RECOGNIZING
UNITED AIRWAY PROBLEMS
IN LONGTERM MANAGEMENT OF ASTHMA

Ery Olivianto, Sp.A(K)

 13-14 year age group

Asher MI, et al., 2006 3

SOCIO-ECONOMIC ASTHMA-RELATED COSTS
• OUTPATIENT VISITS
• EMERGENCY VISITS
• HOSPITALIZATIONS
DIAGNOSIS
DIRECT COSTS
•
• MEDICATIONS

• PRODUCTIVITY LOSS
• WORKING DAY LOSS

INDIRECT COSTS • SCHOOL DAY LOSS

• IMPAIRMENT OF QUALITY OF LIFE

• LIMITATION OF PHISICAL ACTIVITY AND STUDY
PERFORMANCE
PSYCHOLOGICAL EFFECT
INTANGIBLE COSTS •

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Ferrante G & La Grutta S. Front Pediatr 2018
EPIDEMIOLOGIC EVIDENCE

• Over 80% of asthmatics have rhinitis, and 10–40% of patients with

rhinitis have asthma
• ∼30% of patients with only AR who do not have asthma present
hyperresponsiveness to methacholine or histamine
• the development of asthma was tripled in rhinitis patients compared
to those without rhinitis

“one airway, one disease”

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Giavina –Bianchi, et al., 2018
 The relationships at the individual level of symptoms of asthma, rhino-conjunctivitis, and
eczema for each age group in ISAAC Phase One and Phase Three
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Asher MI, et al., 2012
Asthma clinical control in adults with rhinitis

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Ohta K, et al., Allergy 2011
 When to start asthma controller ?

Differrential diagnosis has been excluded

Non pharmacologic treatment (avoidance) has been performed

Asthma comorbidities, such as Allergic Rhinitis , rhinosinusitis or GER has

been treated

Persistent asthma symptoms (mild, moderate severe)

UNITED AIRWAY DISEASE:
PATHOPHYSIOLOGICAL EVIDENCE
• Upper and lower respiratory systems have similarities in histology,
physiology, and pathophysiology
• Also, there are similarities in inflammation response between allergic
rhinitis and asthma
• Mechanism :
– Nasal functional impairment
– Inflammation
– Neural reflexes

Vujnovic SD & Domuz A, 20018 ; Kanda A, et al., 2019 9

Giavina –Bianchi, et al., 2018 10
UNITED AIRWAY DISEASE:

ALLERGIC RHINITIS
• Classic symptoms of nasal itching, sneezing, rhinorrhea, and nasal
obstruction.
• Ears or eyes itching, snoring, frequent sore throat, cough, headache
• Comorbidities: atopic dermatitis, sleep-disordered breathing,
conjunctivitis, rhinosinusitis, otitis media, asthma, and emotional
problems
• Often underdiagnosed and overlooked by patients and physicians.

Giavina –Bianchi, et al., 2018 11

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ALLERGIC RHINITIS

Symptom duration

Intermitten Symptoms present less than 4 days per week or for

less than 4 consecutive weeks

Persistent Symptoms present more than 4 days/week and for

more than 4 consecutive weeks

Severity
Mild have no impairment in sleep and are able to
perform normal activities (including work or school)

Moderate-Severe significantly affect sleep or activities of daily living,

and/or if they are considered bothersome
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ALLERGIC RHINITIS:
DIAGNOSIS
• Evaluation : head, eyes, ears, nose, throat
• Tests:
– skin test
– allergen specific Ig E
– serum IgE
• Imaging : not needed, unless sinusistis is suspected.
• Spirometri
• Rhinoscopy
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ALLERGIC RHINITIS:
MANAGEMENT
• Allergen avoidance
• Medication
– Oral
• 2nd generation antihistamines (cetirizine, loratadine, desloratadine)
• Leukotriene receptor antagonist (montelukast)
– Intranasal
• Intranasal antihistamines
• Intranasal corticosteroids (intranasal mometasone, fluticasone, triamcinolone)
• Intranasal decongestant (oxymethazoline, ipratropium)
• Intranasal mast cell stabilizer (chromolyn sodium)
• Alergen specific immunotherapy

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UNITED AIRWAY DISEASE:

CHRONIC RHINOSINUSITIS
• ECRS (eosinophilic) and Non-ECRS
• loss of smell, long-term nasal congestion, thick mucus production,
and intermittent acute exacerbation of secondary bacterial
infections.
• The quality of life is severely impaired
• Risk factors: Allergic and non-allergic rhinitis, anatomic obstruction
of osteomeatal complex, immunologic disorders

Shah SA, et al., 2016 17

CHRONIC RHINOSINUSITIS
Inflammation of the nose and the paranasal sinuses
Characterised by two or more symptoms, one of which should be:
− nasal blockage/obstruction/congestion
or ± facial pain/pressure,
± cough
− nasal discharge (anterior/posterior nasal drip)
And
• Endoscopic signs of:
− nasal polyps, and/or
− mucopurulent discharge primarily from middle meatus
and/or
− oedema/mucosal obstruction primarily in middle meatus
or
• CT changes:
− mucosal changes within the ostiomeatal complex and/or sinuses

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high-density mucosal inflammation of Mucosal thickening of both sphenoid sinuses
both maxillary sinuses, with subsequent
occlusion of both OMC.

Coronal CT scans of paranasal sinus of a 10-year-old asthmatic girl.

Abdel-Khalik K, et al., 2003 19
CHRONIC RHINOSINUSITIS
DIAGNOSIS
• Blood work and cultures, patient with suppurative complication or toxic-
appearing
• Although CT scan is more recommended, the cost and radiation dose
issues have to be considered in children with sinus disease.
• Plain sinus x-ray has limited usefulness for the diagnosis of rhinosinusitis
due to underestimation of bony and soft tissue pathology.
• Nasal endoscopy
• However, the diagnosis of rhinosinusitis in children should be made
clinically

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CHRONIC RHINOSINUSITIS
MANAGEMENT
• Antibiotics
• Saline irrigation
• Intranasal Steroids
• Decongestant
• Antihistamines
• Immunotherapy

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• Medications treating nasal symptoms will also improve asthma
control and reduce hiperresponsiveness in children with
concomitant asthma and allergic rhinitis.
• Measures of allergens avoidance should be based on clinical history
and result of allergy testing.
• Pharmacologic treatment of allergic rhinitis in children includes
antihistamines, saline irrigation and intranasal steroids.

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Limitiation of these medication.
• Beside age limit approval from 2 years and above, compliance to
intranasal medication is lack in children, as 25% patients found intranasal
spray and drops unacceptable.
• Cetirizine and desloratadine have approval only for children and infants
aged six months and older, and first generation antihistamines are not
recommended.
• Nasal decongestant might be useful for patients with nasal blockage, but
are not effective for other nasal symptoms such as rhinorrhea and
sneezing.

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 Take Home Message
• In children with asthma, search AR
• In children with AR, search asthma
• Treatment of concurrent AR or rhinosinusitis will benefit
asthma control and improve quality of life of children with
asthma.
• Treat both .... !

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