Rhinitis, Sinusitis, and Asthma

Abstract

Asthma and sinusitis are both described in ancient medical literature. The word asthma is a derivation from the ancient Greek, aazein, meaning “gasping” or “panting.” (Homer, Iliad, book 15. The term “asthma” was used to describe Hector’s state: “He saw Hector lying on the ground with his comrades gathered round him, gasping for breath.”) Similar descriptions exist in medicinal remedies recorded from ancient Egypt, and it is from ancient Egypt that some of the first references to the potential shared pathophysiology of asthma and rhinitis/sinus disease originate. Interestingly, peppermint vapor and other herbs (and paraphernalia for its delivery) were used to treat both rhinitis/sinusitis and asthma. Perhaps the first documented connection between asthma and the sinuses dates to approximately 1000 bc with medicinal “Peppermint buckets” being found in Egyptian tombs. It is thought that this remedy was prescribed for treating upper and lower airway maladies. (Ebers, George, 1873–1874, “Ebers Papyrus” describing treatment for asthma using heated herbal preparations found on Egyptian papyrus describing the treatment of various maladies.)

Appendices

Appendix

Inpatient Aspirin (ASA) (NSAID) Desensitization Policy Indications

• 1. Aspirin (ASA) desensitization is indicated for patients who have aspirin-exacerbated respiratory disease (AERD)

  • (a) Demonstrate suboptimal control of their asthma and/or rhinosinusitis with ICS and leukotriene-modifying drugs (LTMDs).

  • (b) Have required multiple polypectomies for nasal polyp control.

  • (c) Require ASA for another medical indication, such as those who require antiplatelet therapy with aspirin or anti-inflammatory therapy with other Cox-1 inhibitors.

• 2. This procedure is limited to patients who have been identified as having AERD after experiencing a respiratory reaction to aspirin or any of the nonsteroidal anti-inflammatory drugs (NSAIDs) that inhibit cyclooxygenase-1. Aspirin desensitization may be possible for individuals without AERD, but with histories of cutaneous reactions to aspirin or other NSAIDs. However, cutaneous ASA/NSAID reactors are a heterogeneous group of patients and may require different desensitization protocols not addressed in this paper.

Policy

• 1. Physicians specifically trained in desensitization protocols, such as board certified allergists/immunologists, can safely direct aspirin desensitization in the appropriate medical setting with the appropriate support staff.

• 2. General requirements for aspirin desensitization

  • (a) Aspirin desensitization should be performed in a facility able to provide advanced ­cardiac care, ventilator support, and frequent or constant observation by qualified personnel. The level of monitoring will be dependent upon the degree of ASA sensitivity and general medical health of the patient and ultimately determined by the supervising ­physician at the time of the admission request.

  • (b) The supervising physician must be immediately available and should be present at the bedside at the time of the first challenge and through any reaction.

    • –The first reaction is almost always the most severe and is unpredictable.

    • –If the first reaction has been managed without physician intervention, then subsequent challenges may proceed without the supervising physician being physically present.

• 3. Inpatient aspirin desensitization may be considered when the following conditions exist:

  • (a) A physician experienced in assessing and treating patients with acute severe asthma exacerbations is immediately available for patient evaluation and treatment.

  • (b) There is sufficient staff so that at least one experienced staff member as outlined above is readily available to care and assess the individual patient being desensitized for the full course of the desensitization. At times, the supervising physician may require that a staff member be constantly assigned to monitor a patient undergoing ASA desensitization. Again, this is at the discretion of the supervising physician.

  • (c) Medically qualified personnel experienced in assessing and treating patients with acute severe asthma exacerbations are available to monitor the patient. Depending on the specific licensing criteria and the scope of practice, limitations in particular state this could include Registered Nurses, Nurse Practitioners, Physicians’ Assistants, Respiratory Therapists, and/or other personnel.

  • (d) Equipment is immediately available for continuous respiratory and cardiovascular monitoring, pulse oximetry, spirometry, and cardiopulmonary resuscitation.

• 4. Inpatient desensitization should always be used in patients with the following risk factors.

  • (a) Beta-blocker use.

  • (b) Recent myocardial infarction.

  • (c) Any other underlying medical condition or drug treatment regimen that would make the management of severe asthma or anaphylactoid reaction difficult.

  • (d) Severe asthma.

  • (e) History of severe or life-threatening ASA/NSAID reaction.

• 5. Oral aspirin challenge:

  • (a) Discuss the risks and benefits of the procedure with the patient and document the discussion in the medical record. Advise the patient that the procedure generally takes 2 days to complete. Obtain written informed consent.

  • (b) Begin early in the morning. Establish intravenous access.

  • (c) Prior to dosing, measure FEV1 and perform clinical assessment to determine baseline.

  • (d) Start with aspirin 20.25 mg by mouth, followed by 40.5, 81, 162.5, and 325 mg at 90-min intervals. (Since many practitioners have no access to anything but commercially available forms of ASA, the dosing is based on using 81 mg ASA tablets and using pill cutter to obtain the lower doses. While almost no one reacts to 20.25 mg, an occasional reaction occurs to 40.5 mg.)

  • (e) Measure FEV1 and perform clinical assessment at least every 90 min and/or with any symptoms. Based on individual patient characteristics, the dosing interval may be extended to 3 h. A lower respiratory tract reaction is defined as a 15% decrease in the FEV1 from baseline FEV1. Record any change in baseline naso-ocular symptoms.

  • (f) Reactions will likely occur with one of the early doses, usually 81 mg. If it does, treat the reaction with the appropriate medication(s) described below.

  • (g) When the patient is completely stabilized after a reaction, but not less than 3 h after the last dose, the provoking dose can be repeated.

  • (h) When the provoking dose is tolerated, dose escalation may continue.

  • (i) Persistent greater than 15% decrease in FEV1, with or without other associated symptoms lasting greater than 3 h despite therapy, is an indication to discontinue the desensitization process for the day.

  • (j) If a second day of desensitization is needed, start the day by repeating the last tolerated dose.

  • (k) Continue the desensitization procedure, as indicated above, until the goal of 325 mg of ASA is tolerated. Most individuals will take 2 days to complete the desensitization procedure.

• 6. Adverse reaction treatment policy:

  • (a) For isolated pulmonary symptoms, have an albuterol meter dose inhaler with a spacer tube (inhale up to five breaths) or a hand-held nebulizer with albuterol already prepared ready to deliver. Aspirin reactions can persist for several hours. Repeat the treatment, as necessary.

  • (b) For laryngeal symptoms, use racemic epinephrine in a hand-held nebulizer.

  • (c) For laryngeal edema with hypotension, use intramuscular epinephrine.

  • (d) For isolated hypotension, use intramuscular epinephrine.

  • (e) For ocular and/or nasal reactions, use oral antihistamines.

  • (f) Refer to Anaphylaxis Practice Parameter for specific medication guidance and additional anaphylaxis management recommendations.

Physician Orders for Aspirin Desensitization

q Oral Aspirin Challenge Protocol

• Establish intravenous access.

  • May use intradermal lidocaine 1% solution 0.1 mL or EMLA (lidocaine 2.5%, prilocaine 2.5%) cream 5 g PRN for IV starts.

• Measure FEV1 and perform clinical assessment to determine baseline.

• Start with aspirin 20.25 mg by mouth, followed by 40.5, 81, 162.5, and 325 mg at 90-min intervals.

• Measure FEV1 and perform clinical assessment at least every 90 min and/or with any symptoms. Based on individual patient characteristics, the dosing interval may be extended to 3 h. A lower respiratory tract reaction is defined as a 15% decrease in the FEV1 from baseline FEV1.

  • Record any change in baseline naso-ocular symptoms.

• Reactions will likely occur with one of the early doses, usually 81 mg. If it does, treat the reaction with the appropriate medication(s) described below.

• When the patient is completely stabilized after a reaction, but not less than 3 h after the last dose, the provoking dose can be repeated.

• When the provoking dose is tolerated, dose escalation may continue.

• Persistent greater than 15% decrease in FEV1, with or without other associated symptoms lasting greater than 3 h despite therapy, is an indication to discontinue the desensitization process for the day.

• If a second day of desensitization is needed, start the day by repeating the last tolerated dose.

• Continue the desensitization procedure, as indicated above, until the goal of 325 mg of ASA is tolerated. Most individuals will not take 2 days to complete the desensitization procedure.

• Other: ________________________________________________________________

Adverse Reaction Treatment Protocols

• For isolated pulmonary symptoms, have an albuterol meter dose inhaler with a spacer tube (inhale up to five breaths) or a hand held nebulizer with albuterol ________already prepared ready to deliver q _______ PRN.

• For laryngeal symptoms, use racemic epinephrine _______ in a hand held nebulizer q ______ × ______ doses.

• For laryngeal edema with hypotension, use intramuscular epinephrine _______ q ______ × ______ doses.

• For isolated hypotension, use intramuscular epinephrine _________ q ______ × ______ doses.

• For ocular and/or nasal reactions, use oral pseudoephedrine 60 mg and/or diphenhydramine 50 mg q 6 h as directed ___________________________

• Other: ________________________________________________________________

Physician’s Signature Date Time