A practical approach to managing asthma and rhinitis

The young woman who has attended for her asthma review in the above clinical scenario¹ is obviously experiencing sub-optimal asthma control as indicated by her nocturnal and exertional symptoms.²

As is the case when any patient attends for review, the Royal College of Physicians' Three Questions³ or a validated questionnaire such as the Asthma Control Test⁴ should be used to assess accurately the current level of asthma control.⁵ In this instance¹ the patient is poorly controlled and the clinician has to ascertain the reasons for this. We are told that she has good inhaler technique, is complying with her prescribed medication, and there has been no change in her circumstances. Therefore, other environmental influences, co-morbidities, or diagnoses must be sought.

Important questions include the time of year she is presenting, and her occupation. Although we are told there has been no change in her circumstances, occupational rhinitis and asthma can develop even when an individual has been working in the same environment for some time. Accurate and early recognition of occupational rhinitis is useful in the prevention and early diagnosis of occupational asthma, since nasal symptoms often precede the development of chest symptoms.² New hobbies may pose a similar risk as occupational rhinitis. It is therefore important to ask detailed questions regarding current employment and activities and whether or not symptoms are better on days away from work.⁶

However, it is more likely that this young woman has undiagnosed or untreated seasonal allergic rhinitis which is contributing to her poor asthma control, particularly given the family history of hay fever and her occasional sneezing in the summer months.

Identifying allergens

A detailed and accurate history is critical to the proper diagnosis of allergic rhinitis and its successful treatment (see Table 1). A physical examination should focus on the nose and eyes (see Table 2) as well as the chest (if there is co-morbid asthma). The patient should be asked about exposure to common aeroallergens such as pollens, spores and moulds, animal dander (cat, dog, horse), weeds, and house dust mite. Exposure to pollens, moulds and weeds is likely to cause seasonal symptoms, whereas pet dander and house dust mite may cause perennial symptoms. Successful allergen avoidance advice depends on:

• Accurate identification of the allergen causing the symptoms

• Patient education and practical advice about allergen avoidance

• Regular follow-up with reinforcement

Table 1 Taking a history from a patient with asthma and suspected rhinitis

Table 2 Examination of a patient with asthma and suspected rhinitis

A detailed history and examination is generally sufficient to confirm the diagnosis in primary care. However, in some instances skin prick testing (SPT) may confirm the clinical suspicion of an allergy and enable appropriate allergen avoidance advice to be given.

Skin prick testing

Skin prick testing (SPT) to aeroallergens can be performed in general practice by a trained healthcare professional and the results are available within 15 minutes (see Table 3).

Table 3 A guide to skin prick testing in primary care

The results of SPT must always be correlated with the patient's history. SPTs are highly sensitive (they detect low levels of sensitisation to allergens) and therefore a positive response to a particular allergen does not necessarily mean the allergen is the cause of the patient's symptoms. However, a positive SPT with a corroborating history means that allergen avoidance advice can be confidently given to the patient. For inhaled allergens, a good correlation exists between the results of SPT levels of specific IgE and bronchial or nasal challenge.

Referral for specialist advice

Referral for more extensive investigation and management should be considered if symptoms do not respond to conventional treatment, if the morbidity associated with allergic rhinitis is considerable (i.e. leading to poor sleep, worsening of asthma symptoms, poor concentration, loss of time from work or education), or if examination findings warrant (e.g. large nasal polyps, nasal septum deviation).

Reducing the burden of disease

Despite evidence that co-morbid rhinitis is associated with clinically important worsening in asthma control which results in substantial increases in health care utilisation including emergency room attendance, hospitalisation, primary care consultation and treatments for asthma,^1,7 many patients tolerate symptoms.

In primary care we have the opportunity to improve morbidity by managing both allergic rhinitis and asthma proactively (see Table 4 for some practical strategies). We should be able to identify patients with both conditions, identify and review people with seasonal rhinitis (such as the young woman in the clinical scenario¹) before the start of the season, and offer a holistic approach to treatment and management.

Table 4 Strategies for proactive management of people with seasonal rhinitis and asthma