Although the upper and lower airways have distinct functions and are managed by different specialists, they also share many characteristics. Problems of the nose and sinuses can impact on the lungs, and vice versa. This ERS Monograph presents an up-to-date overview of the subject area, starting with chapters covering basic anatomy, imaging and practical clinical examination. Other chapters focus on associations with cystic fibrosis, infections, asthma, COPD, non-cystic fibrosis bronchiectasis, primary ciliary dyskinesia and air pollution. The “united airways” are discussed in terms of the impact of optimal upper airways treatment on lower airways disorders and current guidelines to aid all physicians, especially ENT and chest specialists, in clinical practice.
- ERS Monograph
- Page 1AbstractMina Gaga, 7th Respiratory Medicine Dept and Asthma Center, Athens Chest Hospital, 152 Mesogion Avenue, Athens 11527, Greece. E-mail: minagaga@yahoo.com
The upper and lower airways form part of the respiratory system, conducting air in and out of the gas-exchanging units of the lungs. They share not only this function but also many histological characteristics and immune mechanisms, and many diseases affect both the upper and lower airways. However, the nose and lungs also have distinct functions and, importantly, they are managed by different physicians. Because of the frequent coexistence of disease all along the respiratory tract, as is the case with upper and lower respiratory tract infections or with asthma and rhinitis, it is important to be aware of the similarities between the two systems and the impact they have on each other.
Cite as: Papaioannou AI, Bostantzoglou C, Kontogianni C, et al. Upper and lower airways: the same tissue? In: Bachert C, Bourdin A, Chanez P, eds. The Nose and Sinuses in Respiratory Disorders (ERS Monograph). Sheffield, European Respiratory Society, 2017; pp. 1–11 [https://doi.org/10.1183/2312508X.10009316].
- Page 12AbstractAlain Didier, Pôle des Voies Respiratoires, Hôpital Larrey, 24 chemin de Pouvourville, 31054 Toulouse, France. E-mail: didier.a@chu-toulouse.fr
Epidemiological and clinical studies show the high frequency of clear associations between upper and lower airways disorders. Chronic inflammatory processes that affect the upper airways can participate in the worsening of bronchopulmonary disease and contribute to impaired QoL. Thus, physicians that manage respiratory diseases need to evaluate common rhinological problems. In daily practice, examination of the nose mainly relies on meticulous questioning followed by a complete clinical examination of the upper respiratory tract. Practitioners can perform anterior rhinoscopy using a frontal lamp and a speculum or an otoscope (with a nasal adapter) before and after vaporisation of a topical vasoconstrictor. This first step may be followed, if necessary, by flexible or rigid nasal endoscopy that requires specialised instrumentation and medical experience. Other examinations, such as rhinomanometry, nasal cytology, mucociliary function or an olfactory examination, are conducted less frequently, and depend on the data obtained during questioning of the patient and subsequent examinations.
Cite as: Guilleminault L, de Bonnecaze G, Serrano E, et al. How to explore the nose in respiratory disorders in 2017: a one-stop clinic? In: Bachert C, Bourdin A, Chanez P, eds. The Nose and Sinuses in Respiratory Disorders (ERS Monograph). Sheffield, European Respiratory Society, 2017; pp. 12–31 [https://doi.org/10.1183/2312508X.10009416].
- Page 32AbstractFrançois Laurent, Centre de Recherche Cardio-thoracique de Bordeaux, INSERM, U1045, Université Bordeaux Segalen, 146 rue Léo Saignat, 33076 Bordeaux Cedex, France. E-mail: francois.laurent@chu-bordeaux.fr
Present-day imaging of the nose and paranasal sinuses is mainly done by slice-based imaging modalities such as CT, cone beam CT and MRI, which have much higher performance than conventional plain films. Although CT has the highest spatial resolution, MRI provides the best contrast analysis and tissue characterisation. Cone beam imaging has the advantage of imaging dental structures and paranasal sinuses together with a lower irradiation burden than CT. Here, we describe the imaging modalities, normal results and variants, and imaging features of inflammatory diseases of the nose and sinuses. The particular aspects of imaging the paranasal sinuses in CF are addressed.
Cite as: Dournes G, Laurent F. Imaging the nose and sinuses in respiratory disorders. In: Bachert C, Bourdin A, Chanez P, eds. The Nose and Sinuses in Respiratory Disorders (ERS Monograph). Sheffield, European Respiratory Society, 2017; pp. 32–47 [https://doi.org/10.1183/2312508X.10009516].
- Page 48AbstractDaniel L. Hamilos, Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, 55 Fruit Street, Bulfinch-422, Boston, MA 02114, USA. E-mail: dhamilos@mgh.harvard.edu
CF is an autosomal recessive disorder caused by mutations in the CFTR gene leading to reduced or defective CFTR protein expression and improper salt balance and thick tenacious secretions. There is an increased prevalence of CFTR mutations in children and adults with CRS who otherwise do not meet diagnostic criteria for CF and who usually have a normal sweat chloride level. Reduced function of CFTR in CF patients negatively impacts sino-nasal mucociliary clearance due to an increase in the viscosity of sino-nasal epithelial lining fluid, and is associated with reduced airway surface liquid pH, increased baseline nasal potential difference and reduced nasal nitric oxide. Reduced nasal airway surface liquid pH has been causally linked to reduced airway innate immunity by virtue of a detrimental effect on the function of antimicrobial proteins. Newborns with CF already manifest the physiological abnormalities of reduced CFTR function. This chapter provides an overview of sino-nasal involvement in CF patients, in terms of genetics, immunology, pathology and clinical presentation, and discusses management strategies and treatment outcomes.
Cite as: Hamilos DL. Nasal and sinus problems in cystic fibrosis patients. In: Bachert C, Bourdin A, Chanez P, eds. The Nose and Sinuses in Respiratory Disorders (ERS Monograph). Sheffield, European Respiratory Society, 2017; pp. 48–66 [https://doi.org/10.1183/2312508X.10009616].
- Page 67AbstractNikolaos G. Papadopoulos, Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Royal Manchester Children's Hospital, Oxford Road, Manchester, M13 9WL, UK. E-mail: nikolaos.papadopoulos@manchester.ac.uk
Respiratory viral infections and potentially bacterial infection/re-activation precipitate the vast majority of exacerbations of chronic respiratory disorders, such as asthma and COPD. The most commonly identified virus, human rhinovirus (hRV), mainly infects the upper respiratory epithelium causing mild symptoms associated with the common cold. Studies have demonstrated that, after nasal inoculation, hRV can infect bronchial epithelium, providing a mechanism by which hRV might trigger lower respiratory tract symptoms. The underlying mechanisms that ultimately lead to an exacerbation seem to be the result of various factors associated with the virus strain itself, the epigenetic and immunological patient profile (host antiviral defence), and the underlying disease status, as well as the sequence of immune and inflammatory responses induced after infection. The epithelium plays a pivotal role in viral adhesion and replication, while defective epithelial, innate and adaptive immune responses have been shown mainly in asthmatic subjects, more so in the presence of atopy. Exacerbations have long been associated with enhanced bacterial growth from respiratory cultures, and relationships between the nasopharyngeal/lung microbiome, acute infection and exacerbation, although still controversial, may provide novel targets for therapeutic interventions in the context of “united airways diseases”.
Cite as: Xepapadaki P, Megremis S, Kitsioulis NA, et al. Infections in the nose and exacerbations of chronic respiratory disorders. In: Bachert C, Bourdin A, Chanez P, eds. The Nose and Sinuses in Respiratory Disorders (ERS Monograph). Sheffield, European Respiratory Society, 2017; pp. 67–86 [https://doi.org/10.1183/2312508X.10009916].
- Page 87AbstractWytske J. Fokkens, Dept of Otorhinolaryngology, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands. E-mail: w.j.fokkens@amc.nl
Asthma patients, especially those with severe asthma, often have CRS with nasal polyps (CRSwNP). In particular, patients with late-onset asthma, high periostin levels and eosinophilia often have CRSwNP. Insufficient control of the upper airways results in insufficient control of asthma and vice versa. In severe uncontrolled asthma in particular, the upper airways are often difficult to control. For this reason, it is important that people treating the lower airways, especially for severe asthma, are also experts on the upper airways. CRS has a significant impact on the QoL of the patient, comparable to congestive heart failure and COPD. The pathophysiology of CRS is complex, and includes local, systemic, microbial, environmental, genetic and iatrogenic factors. Severe CRSwNP, mostly with asthma, especially in Europe and the USA, has a type 2 inflammation with IgE, eosinophils and Th2 cytokines, such as IL-5 and IL-4/IL-13. The development of biological therapies has progressed rapidly in recent years and they have been shown to be effective in CRSwNP, as in asthma. Endoscopic sinus surgery has been shown to improve the lower airways and reduce medication use for asthma, and may even prevent asthma from developing.
Cite as: Fokkens WJ, Hellings PW. Nasal polyposis and asthma: the otorhinolaryngologist's view. In: Bachert C, Bourdin A, Chanez P, eds. The Nose and Sinuses in Respiratory Disorders (ERS Monograph). Sheffield, European Respiratory Society, 2017; pp. 87–104 [https://doi.org/10.1183/2312508X.10010016].
- Page 105AbstractAkke-Nynke van der Meer, Dept of Respiratory Medicine, Medical Center Leeuwarden, Henri Dunantweg 2, 8934 AD Leeuwarden, The Netherlands. E-mail: AkkeNynke.van.der.Meer@znb.nl
There is increasing epidemiological evidence linking asthma and CRS, with an even stronger relationship for specific phenotypes, i.e. eosinophilic asthma and CRS with nasal polyps (CRSwNP). Asthma patients with concomitant nasal polyposis have more severe disease with reduced asthma control, increased airway obstruction and more extensive eosinophilic inflammation. Different pathways are presumed to lead to this eosinophilic airway inflammation in asthma, whether or not IgE-dependent. Staphylococcal enterotoxin might be the link in the underlying pathophysiology of severe adult-onset nonatopic eosinophilic asthma and nasal polyposis. Patients with uncontrolled, in particular eosinophilic, asthma should be screened for possible CRSwNP in collaboration with an ENT specialist, since various treatment options for nasal polyposis have the potential to improve asthma control. Here, we review the relationship between asthma and nasal polyposis from a chest physician's perspective. Data on epidemiology, pathophysiology, impact on asthma control and clinical assessment are discussed. Finally, treatment options and their effect on asthma outcomes are described.
Cite as: van der Meer A-N, ten Brinke A. Nasal polyposis and asthma: the chest physician's view. In: Bachert C, Bourdin A, Chanez P, eds. The Nose and Sinuses in Respiratory Disorders (ERS Monograph). Sheffield, European Respiratory Society, 2017; pp. 105–121 [https://doi.org/10.1183/2312508X.10010116].
- Page 122AbstractClaus Bachert, Upper Airways Research Laboratory, Ghent University, De Pintelaan 185, 9000 Ghent, Belgium. E-mail: claus.bachert@ugent.be
Nasal polyposis and late-onset asthma are mainly characterised by a Th2 immune response, which, although mostly nonallergic, involves increased IgE levels. IgE antibodies found in these patients are predominantly antibodies to Staphylococcus aureus enterotoxins, but not inhalant allergens; their expression indicates more severe upper and lower airways disease and airway comorbidity. S. aureus is a frequent coloniser of nasal polyps, but has also been shown to reside intramucosally, even intracellularly, and releases secreted proteins which have been demonstrated in the mucosa and correlate with type 2 cytokine production. Apart from enterotoxins, known for their superantigen activity, other secreted proteins such as serine protease-like proteins have been identified as allergens. The secreted proteins are able to bias the immune response to type 2 inflammation, which results in severe impairment of the epithelial barrier and innate immune functions, which consequently eases the survival of S. aureus. A better understanding of the role of this microorganism in airways disease is highly warranted.
Cite as: Bachert C, Zhang N, Krysko O, et al. Nasal polyposis and asthma: a mechanistic paradigm focusing on Staphylococcus aureus. In: Bachert C, Bourdin A, Chanez P, eds. The Nose and Sinuses in Respiratory Disorders (ERS Monograph). Sheffield, European Respiratory Society, 2017; pp. 122–137 [https://doi.org/10.1183/2312508X.10010216].
- Page 138AbstractJohn R. Hurst, UCL Respiratory, Royal Free Campus, University College London, Rowland Hill Street, London, NW3 2PF, UK. E-mail: j.hurst@ucl.ac.uk
COPD is associated with nasal symptoms, inflammation and airway narrowing which persists after smoking cessation. This is not recognised in current COPD guidelines. Nasal symptoms and inflammation are increased at exacerbation, and there is some evidence that the magnitude of the inflammatory responses in the upper and lower airways is similar. Nasal symptoms, which associate with inflammation, cause impairment to QoL and may predispose to increased risk of upper airway viral infection. Potential mechanisms of interaction include loss of the air-conditioning function of the nose, unified airway inflammatory cell “homing”, sino-bronchial reflexes and post-nasal drip. The upper airway does not appear to be an adequate surrogate for studying the lower airway in COPD. While symptoms cause QoL impairment and therefore warrant treatment of themselves, whether nasal treatment can improve lower airway outcomes has been inadequately researched and specific intervention on nasal inflammation in COPD poorly studied. This remains a major evidence gap. This chapter considers the evidence for sino-nasal involvement in COPD.
Cite as: Hurst JR, Huerta Garcia A. The nose and sinuses in COPD. In: Bachert C, Bourdin A, Chanez P, eds. The Nose and Sinuses in Respiratory Disorders (ERS Monograph). Sheffield, European Respiratory Society, 2017; pp. 138–147 [https://doi.org/10.1183/2312508X.10010316].
- Page 148AbstractJohanna Raidt, University Hospital Muenster, General Pediatrics, Albert-Schweitzer-Campus 1, Building A1, 48149 Muenster, Germany. E-mail: Johanna.raidt@ukmuenster.de
CRS is a common disease often associated with different medical disorders, including rare mucopurulent respiratory disorders such as CF, non-CF bronchiectasis and PCD. CRS is present in the majority of patients with non-CF bronchiectasis. Individuals with non-CF bronchiectasis and CRS suffer from more severe lung disease than individuals with non-CF bronchiectasis alone. PCD patients show persistent rhinitis from birth and CRS as a hallmark symptom from adulthood. CRS may be accompanied by nasal polyps, especially in PCD subjects. Therapeutic approaches in CRS are focused on conservative management, mainly nasal (saline) irrigation. Topical corticosteroids should be considered if nasal polyps are present. In PCD, however, the benefit of topical corticosteroids is controversial due to a potentially increased risk of infection. Sino-nasal surgery should be performed with caution.
Cite as: Raidt J, Werner C. Chronic rhinosinusitis in non-cystic fibrosis bronchiectasis and primary ciliary dyskinesia. In: Bachert C, Bourdin A, Chanez P, eds. The Nose and Sinuses in Respiratory Disorders (ERS Monograph). Sheffield, European Respiratory Society, 2017; pp. 148–161 [https://doi.org/10.1183/2312508X.10010416].
- Page 162AbstractDenis Charpin, Pneumonology Unit, Hôpital de la Timone, 264 rue Saint-Pierre, 13385 Marseille Cedex 05, France. E-mail: denis-andre.charpin@ap-hm.fr
In vitro animal and human studies have assessed experimentally the effects of air pollution, demonstrating that it acts as an adjuvant for nasal allergic reaction and increases specific IgE levels. The mechanisms of the adverse effects of air pollutants include innate and adaptive immune responses, oxidative stress and gene–environment interactions. Although positive results have been obtained in small studies, large clinical trials are necessary to demonstrate the benefits of antioxidant and anti-inflammatory interventions, especially in subjects with specific genetic risks. Epidemiological surveys have shown that viral infection is a major triggering factor in asthma and, to a lesser extent, in COPD exacerbations. More generally, atopy seems to be a disease modifier in the relationship between air pollution and asthma. Indoor pollution such as moulds, mouldy odours, passive smoking and occupational exposure to high-molecular-mass agents (e.g. phthalates) are risk factors for rhinitis, as well as for asthma.
Cite as: Charpin D, Caillaud DM. Air pollution and the nose in chronic respiratory disorders. In: Bachert C, Bourdin A, Chanez P, eds. The Nose and Sinuses in Respiratory Disorders (ERS Monograph). Sheffield, European Respiratory Society, 2017; pp. 162–176 [https://doi.org/10.1183/2312508X.10010516].
- Page 177AbstractPeter W. Hellings, Dept of Otorhinolaryngology, Head and Neck Surgery, University Hospitals Leuven, Kapucijnenvoer 33, 3000 Leuven, Belgium. E-mail: Peter.hellings@kuleuven.be
Despite historical studies showing the high prevalence of rhinitis and rhinosinusitis in asthma and COPD, and the impact of diagnostic and therapeutic neglect of rhinitis and rhinosinusitis on bronchial symptoms in these patients, routine clinical experience shows that a significant portion of asthma and COPD patients are deprived of proper care for upper airways disease. Rhinitis is considered a major risk factor for asthma, with growing evidence that timely treatment for allergic rhinitis might prevent the development of asthma. In addition, early-stage treatment for CRS has been shown to be associated with a lower prevalence of asthma. Undoubtedly, a significant portion of patients with asthma and COPD benefit from optimal medical and/or surgical treatment of the upper airways. The future challenge will be to predict who might benefit from referral to an ENT specialist to optimise the upper airways treatment, taking into account preventative, predictive and personalised care in the approach.
Cite as: Doulaptsi M, Steelant B, Hellings PW. Treating the nose for controlling the lung: a vanishing story? In: Bachert C, Bourdin A, Chanez P, eds. The Nose and Sinuses in Respiratory Disorders (ERS Monograph). Sheffield, European Respiratory Society, 2017; pp. 177–192 [https://doi.org/10.1183/2312508X.10010616].
- Page 193AbstractGlenis K. Scadding, RNTNE Hospital, University College London NHS Trust, 330 Gray's Inn Road, London, WC1X 8DA, UK. E-mail: g.scadding@ucl.ac.uk
Although some guidelines note the united airways concept, only one provides useful information to aid the practising clinician in diagnosing and treating the patient with combined disease. There is one QoL document for rhinitis and asthma, but, as yet, none published for rhinosinusitis and asthma. This lack of an approach to all of a subject's symptoms may hinder concordance and could predispose to adverse events if medication is prescribed from two sources. A proposal is made regarding future treatment for united airways patients.
Cite as: Scadding GK, Scadding GW. United airways paradigm in guidelines and clinical practice. In: Bachert C, Bourdin A, Chanez P, eds. The Nose and Sinuses in Respiratory Disorders (ERS Monograph). Sheffield, European Respiratory Society, 2017; pp. 193–208 [https://doi.org/10.1183/2312508X.10010716].