Rosana Câmara Agondi

Aerobic training decreases bronchial hyperresponsiveness and systemic inflammation in patients with moderate or severe asthma: a randomised controlled trial

Background The benefits of aerobic training for the main features of asthma, such as bronchial hyperresponsiveness (BHR) and inflammation, are poorly understood. We investigated the effects of aerobic training on BHR (primary outcome), serum inflammatory cytokines (secondary outcome), clinical control and asthma quality of life (Asthma Quality of Life Questionnaire (AQLQ)) (tertiary outcomes). Methods Fifty-eight patients were randomly assigned to either the control group (CG) or the aerobic training group (TG). Patients in the CG (educational programme+breathing exercises (sham)) and the TG (same as the CG+aerobic training) were followed for 3 months. BHR, serum cytokine, clinical control, AQLQ, induced sputum and fractional exhaled nitric oxide (FeNO) were evaluated before and after the intervention. Results After 12 weeks, 43 patients (21 CG/22 TG) completed the study and were analysed. The TG improved in BHR by 1 doubling dose (dd) (95% CI 0.3 to 1.7 dd), and they experienced reduced interleukin 6 (IL-6) and monocyte chemoattractant protein 1 (MCP-1) and improved AQLQ and asthma exacerbation (p<0.05). No effects were seen for IL-5, IL-8, IL-10, sputum cellularity, FeNO or Asthma Control Questionnaire 7 (ACQ-7; p>0.05). A within-group difference was found in the ACQ-6 for patients with non-well-controlled asthma and in sputum eosinophil and FeNO in patients in the TG who had worse airway inflammation. Conclusions Aerobic training reduced BHR and serum proinflammatory cytokines and improved quality of life and asthma exacerbation in patients with moderate or severe asthma. These results suggest that adding exercise as an adjunct therapy to pharmacological treatment could improve the main features of asthma. Trial registration number NCT02033122.

Comorbidities in Severe Asthma: Frequency of Rhinitis, Nasal Polyposis, Gastroesophageal Reflux Disease, Vocal Cord Dysfunction and Bronchiectasis

OBJECTIVES Severe asthma is found in approximately 10% of patients with asthma. Some factors associated with worse asthma control include rhinitis, gastroesophageal reflux disease, vocal cord dysfunction (VCD), nasal polyposis and bronchiectasis. Therefore, we evaluated the prevalence of these illnesses in patients with severe asthma. METHODS We conducted a retrospective analysis of data obtained from electronic medical records of patients with severe asthma between January 2006 and June 2008. Symptoms of rhinitis and gastroesophageal reflux disease were evaluated as well as intolerance to nonsteroidal anti-inflammatory drugs. We evaluated the results of esophagogastroduodenoscopy, videolaryngoscopy and CT scans of the chest in order to confirm gastroesophageal reflux disease, nasal polyposis, vocal cord dysfunction and bronchiectasis. RESULTS We evaluated 245 patients. Rhinitis symptoms were present in 224 patients (91.4%); 18 (7.3%) had intolerance to nonsteroidal anti-inflammatory drugs, and 8 (3.3%) had nasal polyposis. Symptoms of gastroesophageal reflux disease were reported for 173 (70.6%) patients, although the diagnosis of gastroesophageal reflux disease was confirmed based on esophagogastroduodenoscopy or laryngoscopy findings in just 58 (33.6%) patients. Vocal cord dysfunction was suspected in 16 (6.5%) and confirmed through laryngoscopy in 4 (1.6%). The patient records provided CT scans of the chest for 105 patients, and 26 (24.8%) showed bronchiectasis. DISCUSSION Rhinitis and gastroesophageal reflux disease were the most common comorbidities observed, in addition to bronchiectasis. Therefore, in patients with severe asthma, associated diseases should be investigated as the cause of respiratory symptoms and uncontrolled asthma.

Allergic asthma in patients with common variable immunodeficiency

To cite this article: Agondi RC, Barros MT, Rizzo LV, Kalil J, Giavina‐Bianchi P. Allergic asthma in patients with common variable immunodeficiency. Allergy 2010; 65: 510–515.

Administration of anti-IgE to a Churg-Strauss syndrome patient.

Background: Treatment of the Churg-Strauss syndrome (CCS) remains a challenge. Many patients relapse after achieving remission, and a substantial proportion of them present adverse drug reactions with relevant morbidity. In most patients, severe asthma and upper respiratory symptoms persist, requiring continuous therapy. The aim of the present study is to describe a patient with CSS who was administered anti-IgE. Case Report: A 46-year-old male patient with CSS followed up for 17 years is described. Upon treatment, CSS showed remission but asthma failed to improve despite high-dose inhaled corticosteroids, long-acting β2-agonists and several courses of systemic steroids. In order to better control asthma, anti-IgE was administered. Following omalizumab administration, asthma symptoms (according to clinical features and lung function tests) and eosinophilia improved. Conclusions: Anti-IgE offers the potential not only to decrease asthma activity but also to reduce the risk of morbidity that can result from currently available treatment options. Whether it can also affect the activity of other CSS components is an open question. As far as we know, there are no published reports about the prescription of omalizumab to patients with CSS and with non-allergic asthma. Anti-IgE improved our patient’s asthma and decreased the eosinophil blood count but did not worsen the outcome of CSS. However, large and long-term studies are necessary before a more widespread utilization of anti-IgE in CSS patients can be implemented.

United airway disease: current perspectives

Upper and lower airways are considered a unified morphological and functional unit, and the connection existing between them has been observed for many years, both in health and in disease. There is strong epidemiologic, pathophysiologic, and clinical evidence supporting an integrated view of rhinitis and asthma: united airway disease in the present review. The term “united airway disease” is opportune, because rhinitis and asthma are chronic inflammatory diseases of the upper and lower airways, which can be induced by allergic or nonallergic reproducible mechanisms, and present several phenotypes. Management of rhinitis and asthma must be jointly carried out, leading to better control of both diseases, and the lessons of the Allergic Rhinitis and Its Impact on Asthma initiative cannot be forgotten.

Omalizumab and Churg-Strauss syndrome

Jean-Louis Paquay, MD Giuseppe Carbutti, MD Etienne Beaudouin, MD Denise Anne Moneret-Vautrin, MD Gisèle Kanny, MD, PhD From EA 3999 ‘‘Allergy Diseases: Diagnosis & Therapeutics,’’ Department of Internal Medicine, Clinical Immunology and Allergology, University Hospital of Nancy, Nancy, France; and the Department of Internal Medicine and Intensive Care, Clinic of South Luxemburg, Arlon, Belgium. E-mail: frederic.hasdenteufel@wanadoo.fr. Disclosure of potential conflict of interest: The authors have declared that they have no conflict of interest.

Esophageal Candidiasis—An Adverse Effect of Inhaled Corticosteroids Therapy

Over the last few decades, inhaled corticosteroids (ICs) became the cornerstone in the treatment of persistent asthma. Their use improved asthma control, decreased mortality and also minimized adverse reactions associated with systemic steroid. Esophageal candidiasis is a rare complication resulting from the use of ICs. Although, in recent years, as their prescriptions has increased, more cases have been reported, especially in Japan. Listed are 4 case reports regarding esophageal candidiasis in asthmatic patients associated with inhaled budesonide administration. In the cases reported herein, the use of a different device of dry powder budesonide might have favored esophageal drug deposition and Candida infection. Patients denied using systemic corticosteroids in the previous 6 months. Furthermore, none of the patients presented Diabetes mellitus, malignant disease, HIV infection, or other immunosuppressive conditions. We conclude that patients treated with high doses of ICs are at higher risk of developing esophageal candidiasis. These patients should undergo upper gastrointestinal endoscopy whenever they present symptoms. Nevertheless, we must keep in mind that infection might also be asymptomatic and esophageal candidiasis prevalence may be higher than that reported thus far.

Respiratory exercise program for elderly individuals with asthma

INTRODUCTION: Asthma in older adults is frequently underdiagnosed, as reflected by approximately 60% of asthma deaths occurring in people older than age 65. OBJECTIVE: The present study evaluates the effects of a respiratory exercise program tailored for elderly individuals with asthma. We are not aware of any other reports examining breathing exercises in this population. METHODS: Fourteen patients concluded the 16-week respiratory exercise program. All the patients were evaluated with regard to lung function, respiratory muscle strength, aerobic capacity, quality of life and clinical presentation. RESULTS: After 16 weeks of this open-trial intervention, significant increases in maximum inspiratory pressure and maximum expiratory pressure (27.6% and 20.54%, respectively) were demonstrated. Considerable improvement in quality of life was also observed. The clinical evaluations and daily recorded-symptoms diary also indicated significant improvements and fewer respiratory symptoms. A month after the exercises were discontinued, however, detraining was observed. DISCUSSION: In conclusion, a respiratory exercise program increased muscle strength and was associated with a positive effect on patient health and quality of life. Therefore, a respiratory training program could be included in the therapeutic approach in older adults with asthma.

Intranasal Corticosteroid Administration Reduces Nonspecific Bronchial Hyperresponsiveness and Improves Asthma Symptoms

Introduction. Rhinitis and asthma are currently recognized as manifestations of a single syndrome, the chronic allergic respiratory syndrome. Nearly all individuals with asthma have rhinitis, and severe rhinitis has been associated with worse outcomes in asthma patients. Intranasal treatment has been reported to be beneficial for the lower airways. Methods. This was a randomized, double-blind, placebo-controlled study. The objective was to evaluate the effects that treatment with intranasal beclomethasone dipropionate (BDP; 400 μ g/d) has on nasal and bronchial symptoms, as well as on lung function test results and bronchial responsiveness to histamine in patients with allergic rhinitis and asthma. We evaluated 33 patients, divided into two groups: treatment (n = 17); and placebo (n = 16). Over the course of the 125-day study period, each patient reported daily rhinitis and asthma symptoms, as well as the need for additional medication. All patients were submitted to spirometry and histamine challenge at baseline and at each subsequent evaluation (on days 50 and 75). Results. In comparison with the patients in the placebo group, those in the BDP treatment group presented significantly fewer nasal symptoms on day 50 and fewer asthma symptoms on day 75 (p < 0.01 for both); required rescue medications less often; and presented a significantly lower degree of bronchial responsiveness to histamine on day 75 (p < 0.01). Conclusion. In this study, intranasal BDP was effective in treating rhinitis as well as asthma. The benefits for the lower airways were observed only after prolonged treatment and might be better evaluated through nonspecific bronchial challenge.

One year administration of anti-IgE to a patient with Churg-Strauss syndrome.

At present, our patient has been treated with anti-IgE for 1 year. He has well controlled asthma, maintains low eosinophil blood count and has not presented increased CSS clinical activity ( table 1 ). The literature shows some evidence that antileukotriene drugs could be associated with CSS, triggering it. A similar discussion emerges with the use of anti-IgE and we agree with the authors that large and long-term studies are necessary before widespread utilization of omalizumab in patients with asthma and Churg-Strauss syndrome. The case reported by Bargagli and Rottoli and the authors’ comments are very appropriate [1] . Although the immunopathogenesis of Churg-Strauss syndrome (CSS) is still poorly known, it is difficult to conjecture that it can be induced or amplified by anti-IgE effects. Our study strengthens this idea, since anti-IgE has improved asthma, decreased eosinophil blood count and has not increased CSS clinical activity [2] . We believe that the current CSS case and the one described earlier [3] are actually due to steroid tapering rather than to anti-IgE use. Published online: January 18, 2008