|Year : 2022 | Volume
| Issue : 2 | Page : 50-55
Prevalence of coexistent allergic rhinitis in schoolchildren with bronchial asthma and its association with asthma control
Aruna Shanmuganathan1, Kumaran Gopalakrishnan2, Nisha Ganga2
1 Department of Pulmonary Medicine, Karpaga Vinayaga Institute of Medical Sciences, Maduranthakam, Tamil Nadu, India
2 Department of Pulmonary Medicine, Chettinad Hospital and Research Institute, Chengalpattu, Tamil Nadu, India
|Date of Submission||18-Apr-2022|
|Date of Decision||07-Jun-2022|
|Date of Acceptance||21-Jun-2022|
|Date of Web Publication||23-Dec-2022|
Dr. Aruna Shanmuganathan
Department of Pulmonary Medicine, Karpaga Vinayaga Institute of Medical Sciences, Maduranthagam, Chengalpattu - 603 308, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Introduction: Bronchial asthma (BA) is a common chronic respiratory disease in children with a wide variation in global prevalence due to differences in environmental and genetic factors as well as differences in diagnostic criteria. Allergic rhinitis (AR) is one of the major risk factors associated with childhood asthma, with coexistent AR reported in 60%–70% of children with asthma in India. According to the one airway hypothesis, with evidence from epidemiological and clinical studies, the upper and lower airways share the same pathophysiological changes. This similarity results in inflammatory changes in either airway to have an effect on each other. Very few Indian studies have reported on increasing prevalence of childhood BA. Hence, it is essential to diagnose and treat concomitant AR in patients with BA to achieve good asthma control. Aim: To study the prevalence of coexistent AR in schoolchildren with BA and its association with asthma control. Materials and Methods: This prospective cross-sectional study was done during 3 months period from June to August 2018 in five randomly selected schools from a semi-urban area. A total of 1417 students of both genders belonging to 8–14 years of age were included. Demographic details were noted and spirometry was done. BA was diagnosed and control of asthma was assessed based on the Global Initiative for Asthma guidelines. Children diagnosed with BA were administered AR and its Impact on Asthma (ARIA) questionnaire to determine the prevalence and severity of AR. Data were analyzed using SPSS Version-20 and the severity of ARIA was correlated with asthma control using Pearson's correlation test. Results: The prevalence of BA among 1417 schoolchildren was 5.86% and majority of the asthmatic children were not well controlled (95%). 97.5% of children with BA had coexistent AR. There was a significant (P < 0.001) correlation between the severity of AR with asthma control. Conclusions: Our study showed a high prevalence of coexistent AR in children with BA. Children with greater severity of AR were found to have poor asthma control.
Keywords: Allergic rhinitis, Allergic Rhinitis and its Impact on Asthma guidelines, bronchial asthma, coexistence, Global Initiative for Asthma guidelines, schoolchildren, spirometry
|How to cite this article:|
Shanmuganathan A, Gopalakrishnan K, Ganga N. Prevalence of coexistent allergic rhinitis in schoolchildren with bronchial asthma and its association with asthma control. J Assoc Pulmonologist Tamilnadu 2022;5:50-5
|How to cite this URL:|
Shanmuganathan A, Gopalakrishnan K, Ganga N. Prevalence of coexistent allergic rhinitis in schoolchildren with bronchial asthma and its association with asthma control. J Assoc Pulmonologist Tamilnadu [serial online] 2022 [cited 2023 May 29];5:50-5. Available from: https://www.japt.in//text.asp?2022/5/2/50/365086
| Introduction|| |
Bronchial asthma (BA) is one of the most common chronic respiratory diseases in childhood, with wide variations in global prevalence of 4.5%–29%., According to the WHO, over 80% of asthma-related deaths occur in low- and lower-middle-income countries., According to studies conducted across various regions in India, the prevalence of childhood asthma ranges between 4% and 19% and there was a huge difference in the prevalence of asthma in children. The prevalence of childhood asthma has continued to increase in the last 10 years.,,,,,,,, BA is characterized by chronic airway inflammation with variable expiratory airflow limitation and clinically presenting with symptoms of wheeze, shortness of breath, chest tightness, and cough. In 2006, the Global Initiative for Asthma (GINA) included disease control levels as a tool to assess therapeutic goals in asthma and stressed the need for achieving good control. The risk factors for BA in children include family history of BA, recurrent respiratory viral infections, atopy, allergic rhinitis (AR), and environmental triggers.,
AR is one of the common upper respiratory illness in children with a prevalence of 10%–25% in India. It is characterized by one or more symptoms, including sneezing, itching, nasal congestion, and rhinorrhea. This significantly affects the quality of life in childhood. AR may be seasonal or perennial, and the common triggers include house dust mite, animal dander, pollen, and other environmental allergens. The concept of “One Airway, One Disease” hypothesis states that pathological conditions in the upper airway may predispose to lower airway disease conditions., Studies have shown that allergen sensitization of the upper airway may lead to lower airway hyperreactivity and may predispose to the development of BA., The correlation between AR and BA has been elucidated in many studies.,,,,,, AR has emerged in the last few decades as a significant risk factor of BA and has shown to be associated with persistent airway hyperreactivity and poor outcomes in adult asthma.,,, It is thus essential for the early diagnosis and the management of AR in children with BA to achieve optimum asthma control. Although there are several studies on the coexistence of AR with asthma and vice versa in adults, similar studies in children are few, especially in India. Hence, the present study was undertaken to assess the prevalence of coexisting AR in children with BA and to determine its association with asthma control.
| Materials and Methods|| |
This was a prospective cross-sectional school-based study done after obtaining the approval from the Institutional Human Ethics Committee (Proposal No: 109/IHEC/03-18) and informed consent from the parent and assent from the participating child. The study was conducted for a period of 3 months from June 2018 to August 2018. Five schools were randomly selected in a semi-urban area, and due permission from school authorities was obtained before starting the study. The study details were provided in the participant information sheet in English and local language.
The students belonging to the age group of 8–14 years of both genders were included in the study.
Children with obstructive airway diseases other than BA, severe upper respiratory tract infection, and acute respiratory illness and/or children who are unable to perform an acceptable pulmonary function test (PFT) and underlying cardiac conditions were excluded.
A total of 1417 children were screened and selected after fulfilling the inclusion and exclusion criteria. Under circumstances, when children were not able to provide satisfactory detail in the questionnaire, parental assistance was obtained. Their demographic details and body mass index (BMI) were noted, and spirometry was done using digital portable spirometry machine (Model-SPIROLAB III). The diagnosis of BA was established based on PFT-spirometric parameters and GINA 2017 guidelines. Children diagnosed with BA were then administered with AR and its Impact on Asthma (ARIA) questionnaire to assess the presence and severity of AR. The control of BA was assessed based on the GINA (2017) Questionnaire and categorized as Well controlled, partly controlled, and uncontrolled. The severity of AR was based on ARIA guidelines assessed by total four symptom score method and grouped into mild intermittent, mild persistent, moderate/severe, and severe persistent.
The data analysis was done using Statistical Package for the Social Sciences version 20 software for Windows (SPSS Inc., Chicago, IL, USA). Pearson's correlation test was used to assess the strength of relationship between the asthma control and severity of AR.
| Results|| |
The demographic characteristics of the 1417 schoolchildren screened are shown in [Table 1], the mean age was 12.1 ± 1.45 standard deviation (SD) years, with a slight female preponderance, and majority of the children had a normal BMI. Out of 1417 schoolchildren, 83 students were diagnosed with BA [Table 2], with a prevalence of 5.86%. The demographic characteristics of the asthmatic children are shown in [Table 2]. Children with BA had mean age of 12.4 ± 1.37 SD years with a slight female preponderance, and the BMI of the asthmatic children showed that the majority had a normal BMI followed by underweight. Out of the 83 children diagnosed with BA, 81 had AR. The control of BA assessed based on the GINA guidelines in the 83 children with BA is shown in [Table 3]. Majority of the children had partly controlled (64%) followed by uncontrolled (31%) and only 5% of the children had well-controlled asthma [Table 4]. Out of the 81 children who had coexistence AR and BA with a prevalence of 97.5%, the severity of AR as assessed by ARIA scoring is shown in [Table 4]; majority of the children had moderate-to-severe ARIA score. The Pearson's correlation test to assess the association of ARIA score and asthma control is shown in [Table 5]; there was a positive correlation between the ARIA score and asthma control score which was statistically significant (P < 0.001).
|Table 1: Age, sex, and body mass index of the total number of children (n=1417)|
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|Table 2: Age, sex, and body mass index of the children diagnosed with bronchial asthma (n=83)|
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|Table 3: Age, sex, and body mass index of the children diagnosed with coexistent allergic rhinitis with bronchial asthma (n=81)|
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|Table 5: Severity of the children diagnosed with allergic rhinitis (n=81)|
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Total number of children with BA and coexistence AR is 81 with mean ARIA score of 2.89. There was a moderate positive correlation between the two variables, R = 0.396 [Table 6], and found to be statistically significant, P < 0.001.
| Discussion|| |
There are wide variations in the estimated prevalence rates of BA in children due to differences in diagnostic modalities, study methodologies, and environmental conditions, and also, wide variation is seen geographically. Our study showed a prevalence of BA -5.86% in 1417 schoolchildren screened for BA in the age group of 8–14 years. This is comparable to the prevalence rates reported in a few South Indian studies in schoolchildren.,, However, higher rates between 10.1% and 13.1% are reported in studies in Northern India. The ISAAC study across several European countries also report higher prevalence rates ranging from 4.1% to 27.8%.,,, Higher rates of BA prevalence (15%–20%) are also seen in Western countries, Australia, and the UK. In general, India as compared to other countries has lower prevalence rates. This may be due to differences in genetic susceptibility, hygiene hypothesis, and environmental and lifestyle factors, since asthma is a heterogeneous disease with multiple factors contributing to its etiopathology.
The incidence and prevalence rates of BA differ by sex at different time periods of lifespan, especially around major reproductive events, suggesting a role for sex hormones. Prepubertal boys have shown to have a higher incidence of asthma than girls of the same age, though this trend reverses after puberty. Our study showed a slight female preponderance of BA in children in the age group of 8–14 years. The study by Shah also showed slight female preponderance similar to our study in childhood asthma. However, a South Indian study by Naik and Ravikumar. showed slight male preponderance as also studies by Bhalla et al. and Pal et al.
Obesity has been shown to not only be a risk factor for development of asthma in children, but its coexistence leads to poor control of asthma. In our study, majority of children (61.5%) had a normal BMI and only 7.2% were obese. In a study by Lang, about 23%–27% of new asthma cases are directly attributable to obesity. An Indian study also showed that children who are obese are more likely to develop severe asthma than those who are not obese. Hence, obesity is a modifiable risk factor which can adversely affect asthma outcomes in children.
Asthma control has been shown to be less than satisfactory in less than 30% of children. This is due to a multitude of factors such as under diagnosis, under treatment, and coexisting comorbidities such as AR, obesity, and environmental factors. In our study, asthma control was assessed using the GINA guideline level of control assessment based on which asthma control was classified as well-controlled, partly controlled, and uncontrolled asthma. We found that 64% of children had partly controlled and 31% had uncontrolled asthma. A European study on asthma control using GINA and Child-Asthma Control Test in children by Koolen et al. showed that 51% had uncontrolled asthma. A similar study by Shaw et al. noted that 68% had uncontrolled asthma. Recent Indian data show that more than 50% of children had severe uncontrolled asthma. Although guidelines for asthma management and medications are available, a significant number of children still have less than optimal control leading to absenteeism, hospitalizations, and poorer long-term outcomes.
AR is the most common of atopic disorders, often beginning in childhood and making it one of the most common chronic diseases in children. It is characterized by symptoms of rhinorrhea, sneezing, nasal obstruction and itching, and postnasal drip. It is also one of the most important risk factors associated with childhood asthma and an often unrecognized and under-treated chronic upper airway disease.,, The prevalence of AR in children according to the ISAAC study is estimated to be around 40% worldwide and is increasing over the last decade., An Indian study showed a prevalence of 11.3% in children age 6–7 years and 24.4% in children aged 13–14 years.
The recent concept of the united or “One Airway, One Disease” is based on the similar morphologic, physiologic, and functional characteristics of upper and lower airways. According to the single airway hypothesis, an integrated approach to diagnosis and management of both upper and lower airway diseases is associated with better outcomes as studies reveal a strong link between disorders occurring in the upper and lower airways.,,, The close association between wheeze and sneeze is highlighted in the study by Simons. The ARIA guidelines published in 2001 proposed a standardized assessment guideline for diagnosis and management of AR and BA. Hence, it is of utmost importance for early diagnosis and management of AR to achieve good asthma control.
Globally, an estimated 60%–70% of children with asthma have concomitant AR. Our study showed that 97.5% of children with BA had coexistent AR which is significantly higher than the global average as well as other Indian studies. Indian studies show that 58.8%–80% of children with asthma had AR as a major comorbidity. The ARIA classifies AR based on the duration of symptoms into intermittent and persistent and based on the severity into mild and moderate-severe. Our study showed 29% of children had mild AR while 35% and 36% had moderate and severe AR, respectively. The India ARIA Asia Pacific Workshop Report on AR and comorbid asthma showed that nasal symptoms occurred in 28%–78% of children with asthma while 17%–38% of patients with AR had coexistent asthma. It was also observed that AR was associated with significant effects on quality of life, sleep disturbances, and absenteeism.
The impact of AR on asthma control in adults has shown that the coexistence and severity of AR is associated with higher morbidity and poorer quality of life. However, studies in children on the impact of concomitant AR with asthma are limited, especially in India. Our study showed a positive correlation which was statistically significant between the ARIA scores and the asthma control scores, implying that poor control of underlying AR was associated with less optimal asthma control. Similar to our study, a Dutch study by de Groot et al. showed that in 76.2% of asthmatic children with coexisting AR, their Asthma Control Questionnaire scores were significantly lower as compared to the children without AR. Padilla et al. in a Peruvian study also concluded a positive correlation between AR and inadequate asthma control, similar to our study. However, a French study demonstrated that 58% of asthmatic children had concomitant AR and no association with asthma severity was found. The frequent coexistence of exacerbations of upper and lower airway diseases was demonstrated in a Japanese study implying a link between both diseases. Data from India are scarce with a recent Indian multicenter study using the Coexistence of AR and Asthma questionnaire survey, showing a 65.24% prevalence of concomitant AR in adult asthmatics, though similar data in children are few.
Hence, the early diagnosis and treatment of coexisting AR in children with BA are essential to achieve better outcomes in both conditions. Studies have shown that treatment of concomitant AR with anti-histamines and/intranasal corticosteroids might improve the morbidity and quality of life scores in children with asthma.,,, A holistic approach to identify the risk factors especially AR, in children with asthma, is necessary to achieve optimum asthma control and improve the quality of life. Randomized controlled trials on the impact of treatment of coexistent AR in children with asthma are the need of the hour, especially in India.
| Conclusion|| |
There is a high prevalence of concomitant AR in school-going children with BA. Children with greater severity of AR were found to have poor asthma control. Hence, the early diagnosis of concomitant AR and its optimum management is essential to improve the quality of life, reduce school absenteeism, and prevent long-term complications in children with asthma.
Financial support and sponsorship was given by Indian Council of Medical Research under Short Term Studentship 2018 Program.
Financial support and sponsorship
Financial support and sponsorship was given by Indian Council of Medical Research under Short Term Studentship 2018 Program.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Narayana PP, Prasanna MP, Guruprasad AM. Prevalence of asthma in school children in rural India. Ann Thorac Med 2010;5:118-9.
] [Full text]
Serebrisky D, Wiznia A. Pediatric asthma: A global epidemic. Ann Glob Health 2019;85:6.
Pal R, Dahal S, Pal S. Prevalence of bronchial asthma in Indian children. Indian J Community Med 2009;34:310-6.
] [Full text]
Jain A, Vinod Bhat H, Acharya D. Prevalence of bronchial asthma in rural Indian children: A cross sectional study from South India. Indian J Pediatr 2010;77:31-5.
Kumar GS, Roy G, Subitha L, Sahu SK. Prevalence of bronchial asthma and its associated factors among school children in urban Puducherry, India. J Nat Sci Biol Med 2014;5:59-62.
Behl RK, Kashyap S, Sarkar M. Prevalence of bronchial asthma in school children of 6-13 years of age in Shimla city. Indian J Chest Dis Allied Sci 2010;52:145-8.
Chhabra SK, Gupta CK, Chhabra P, Rajpal S. Prevalence of bronchial asthma in schoolchildren in Delhi. J Asthma 1998;35:291-6.
Qureshi UA, Bilques S, Ul Haq I, Khan MS, Qurieshi MA, Qureshi UA. Epidemiology of bronchial asthma in school children (10-16 years) in Srinagar. Lung India 2016;33:167-73.
] [Full text]
Naik PB, Ravikumar P. Study of prevalence of bronchial asthma in school children of 6-12 years of age in rural schools of Tumakuru district. Indian J Allergy Immunol 2017;31:56-60.
Kroegel C. Global initiative for asthma management and prevention-GINA 2006. Pneumologie 2007;61:295-304.
Mejias SG, Ramphul K. Prevalence and associated risk factors of bronchial asthma in children in Santo Domingo, Dominican Republic. Cureus 2018;10:e2211.
Chandrika D. Allergic rhinitis in India: An overview. Int J Otorhinolaryngol Head Neck Surg 2017;3:1-6.
Skoner DP. Allergic rhinitis: Definition, epidemiology, pathophysiology, detection, and diagnosis. J Allergy Clin Immunol 2001;108:S2-8.
Grossman J. One airway, one disease. Chest 1997;111:11S-6S.
Corren J. Allergic rhinitis and asthma: How important is the link? J Allergy Clin Immunol 1997;99:S781-6.
Chang CC. Sinusitis, rhinitis, asthma, and the single airway hypothesis. In: Diseases of Sinuses. New York, NY: Springer; 2014. p. 173-94.
Jeffery PK, Haahtela T. Allergic rhinitis and asthma: Inflammation in a one-airway condition. BMC Pulm Med 2006;6 Suppl 1:S5.
Shah A, Pawankar R. Allergic rhinitis and co-morbid asthma: Perspective from India – ARIA Asia-Pacific Workshop report. Asian Pac J Allergy Immunol 2009;27:71-7.
Padilla J, Uceda M, Ziegler O, Lindo F, Herrera-Pérez E, Huicho L. Association between allergic rhinitis and asthma control in Peruvian school children: A cross-sectional study. Biomed Res Int 2013;2013:861213.
Bergeron C, Hamid Q. Relationship between asthma and rhinitis: Epidemiologic, pathophysiologic, and therapeutic aspects. Allergy Asthma Clin Immunol 2005;1:81-7.
Kumar AP, Vinayaka HS, Premkumar P. A clinical study of the prevalence and impact of allergic rhinitis in children with asthma. Indian J Child Health 2017;4:367-9.
Pearce N, Aït-Khaled N, Beasley R, Mallol J, Keil U, Mitchell E, et al.
Worldwide trends in the prevalence of asthma symptoms: Phase III of the International Study of Asthma and Allergies in Childhood (ISAAC). Thorax 2007;62:758-66.
GBD 2016 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990-2016: A systematic analysis for the Global Burden of Disease Study 2016. Lancet 2017;390:1211-59.
Worldwide variation in prevalence of symptoms of asthma, allergic rhinoconjunctivitis, and atopic eczema: ISAAC. The International Study of Asthma and Allergies in Childhood (ISAAC) Steering Committee. Lancet 1998;351:1225-32.
Worldwide variations in the prevalence of asthma symptoms: The International Study of Asthma and Allergies in Childhood (ISAAC). Eur Respir J 1998;12:315-35.
Eder W, Ege MJ, von Mutius E. The asthma epidemic. N Engl J Med 2006;355:2226-35.
Pearce N, Douwes J. The global epidemiology of asthma in children. Int J Tuberc Lung Dis 2006;10:125-32.
Dharmage SC, Perret JL, Custovic A. Epidemiology of asthma in children and adults. Front Pediatr 2019;7:246.
Shah R, Newcomb DC. Sex bias in asthma prevalence and pathogenesis. Front Immunol 2018;9:2997.
Naik PB, Ravikumar P. Study of prevalence of bronchial asthma in school children of 6–12 years of age in rural schools of Tumakuru district. Indian J Allergy Asthma Immunol 2017;31:56-60. [Full text]
Bhalla K, Nehra D, Nanda S, Verma R, Gupta A, Mehra S. Prevalence of bronchial asthma and its associated risk factors in school-going adolescents in Tier-III North Indian City. J Family Med Prim Care 2018;7:1452-7.
] [Full text]
Mohanan S, Tapp H, McWilliams A, Dulin M. Obesity and asthma: Pathophysiology and implications for diagnosis and management in primary care. Exp Biol Med (Maywood) 2014;239:1531-40.
Lang JE. Obesity, nutrition, and asthma in children. Pediatr Allergy Immunol Pulmonol 2012;25:64-75.
Ramasamy AK, Gupta N, Kumar R. Impact of obesity on bronchial asthma in Indian population. Lung India 2014;31:121-6.
] [Full text]
Ferrante G, La Grutta S. Reasons for inadequate asthma control in children: An important contribution from the “French 6 Cities Study”. Multidiscip Respir Med 2012;7:23.
Koolen BB, Pijnenburg MW, Brackel HJ, Landstra AM, van den Berg NJ, Merkus PJ, et al.
Comparing Global Initiative for Asthma (GINA) criteria with the Childhood Asthma Control Test (C-ACT) and Asthma Control Test (ACT). Eur Respir J 2011;38:561-6.
Shaw DE, Berry MA, Thomas M, Green RH, Brightling CE, Wardlaw AJ, et al.
The use of exhaled nitric oxide to guide asthma management: A randomized controlled trial. Am J Respir Crit Care Med 2007;176:231-7.
Bousquet J, Khaltaev N, Cruz AA, Denburg J, Fokkens WJ, Togias A, et al.
Allergic Rhinitis and its Impact on Asthma (ARIA) 2008 update (in collaboration with the World Health Organization, GA (2) LEN and AllerGen). Allergy 2008;63 Suppl 86:8-160.
Guerra S, Sherrill DL, Martinez FD, Barbee RA. Rhinitis as an independent risk factor for adult-onset asthma. J Allergy Clin Immunol 2002;109:419-25.
Shaaban R, Zureik M, Soussan D, Neukirch C, Heinrich J, Sunyer J, et al.
Rhinitis and onset of asthma: A longitudinal population-based study. Lancet 2008;372:1049-57.
Strachan D, Sibbald B, Weiland S, Aït-Khaled N, Anabwani G, Anderson HR, et al.
Worldwide variations in prevalence of symptoms of allergic rhinoconjunctivitis in children: The International Study of Asthma and Allergies in Childhood (ISAAC). Pediatr Allergy Immunol 1997;8:161-76.
Bousquet J, Van Cauwenberge P, Khaltaev N, Aria Workshop Group, World Health Organization. Allergic rhinitis and its impact on asthma. J Allergy Clin Immunol 2001;108:S147-334.
Singh S, Sharma BB, Salvi S, Chhatwal J, Jain KC, Kumar L, et al.
Allergic rhinitis, rhinoconjunctivitis, and eczema: Prevalence and associated factors in children. Clin Respir J 2018;12:547-56.
Simons FE. Allergic rhinobronchitis: The asthma-allergic rhinitis link. J Allergy Clin Immunol 1999;104:534-40.
Everhart RS, Kopel SJ, Esteban CA, McQuaid EL, Klein R, McCue CE, et al.
Allergic rhinitis quality of life in urban children with asthma. Ann Allergy Asthma Immunol 2014;112:365-70.e1.
Jaggi V, Dalal A, Ramesh BR, Tikkiwal S, Chaudhry A, Kothari N, et al.
Coexistence of allergic rhinitis and asthma in Indian patients: The CARAS survey. Lung India 2019;36:411-6.
] [Full text]
Demoly P, Calderon MA, Casale T, Scadding G, Annesi-Maesano I, Braun JJ, et al.
Assessment of disease control in allergic rhinitis. Clin Transl Allergy 2013;3:7.
Mir E, Panjabi C, Shah A. Impact of allergic rhinitis in school going children. Asia Pac Allergy 2012;2:93-100.
de Groot EP, Nijkamp A, Duiverman EJ, Brand PL. Allergic rhinitis is associated with poor asthma control in children with asthma. Thorax 2012;67:582-7.
Hamouda S, Karila C, Connault T, Scheinmann P, de Blic J. Allergic rhinitis in children with asthma: A questionnaire-based study. Clin Exp Allergy 2008;38:761-6.
Xia S, Zhu Z, Guan WJ, Xie YQ, An JY, Peng T, et al.
Correlation between upper and lower airway inflammations in patients with combined allergic rhinitis and asthma syndrome: A comparison of patients initially presenting with allergic rhinitis and those initially presenting with asthma. Exp Ther Med 2018;15:1761-7.
Simons FE. Is antihistamine (H1-receptor antagonist) therapy useful in clinical asthma? Clin Exp Allergy 1999;29 Suppl 3:98-104.
Pasquali M, Baiardini I, Rogkakou A, Riccio AM, Gamalero C, Descalzi D, et al.
Levocetirizine in persistent allergic rhinitis and asthma: Effects on symptoms, quality of life and inflammatory parameters. Clin Exp Allergy 2006;36:1161-7.
Henriksen JM, Wenzel A. Effect of an intranasally administered corticosteroid (budesonide) on nasal obstruction, mouth breathing, and asthma. Am Rev Respir Dis 1984;130:1014-8.
Corren J, Adinoff AD, Buchmeier AD, Irvin CG. Nasal beclomethasone prevents the seasonal increase in bronchial responsiveness in patients with allergic rhinitis and asthma. J Allergy Clin Immunol 1992;90:250-6.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]