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Role of the Allergist-Immunologist and Upper Airway Allergy in Sleep-Disordered Breathing

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Role of the Allergist-Immunologist and Upper Airway Allergy in Sleep-Disordered Breathing AAAAI Work Group Report Role of the Allergist-Immunologist and Upper Airway Allergy in Sleep-Disordered Breathing Dennis Shusterman, MD, MPHa, Fuad M. Baroody, MDb, Timothy Craig, DOc, Samuel Friedlander, MDd, Talal Nsouli, MDe, and Bernard Silverman, MD, MPHf; on behalf of the American Academy of Allergy, Asthma & Immunology’s Rhinitis, Rhinosinusitis and Ocular Allergy Committee Work Group on Rhinitis and Sleep-disordered Breathing San Francisco, Calif; Chicago, Ill; Hershey, Pa; Solon, Ohio; Washington, DC; and Brooklyn, NY BACKGROUND: Sleep-disordered breathing in general and RESULTS: Survey results were returned by 339 of 4881 active obstructive sleep apnea in particular are commonly encountered members (7%). More than two-third of respondents routinely conditions in allergy practice. Physiologically, nasal (or asked about sleep problems, believed that sleep-disordered nasopharyngeal) obstruction from rhinitis, nasal polyposis, or breathing was a problem for at least a “substantial minority” adenotonsillar hypertrophy are credible contributors to snoring (10%-30%) of their adult patients, and believed that medical and nocturnal respiratory obstructive events. Nevertheless, therapy for upper airway inflammatory conditions could existing practice parameters largely relegate the role of the potentially help ameliorate sleep-related complaints. Literature allergist to adjunctive treatment in cases of continuous positive review supported the connection between high-grade nasal airway pressure intolerance. congestion/adenotonsillar hypertrophy and obstructive sleep OBJECTIVES: To survey active American Academy of Allergy, apnea, and at least in the case of pediatric patients, supported the Asthma & Immunology members regarding their perceptions use of anti-inflammatory medication in the initial management and practices concerning sleep-disordered breathing in adult and of obstructive sleep apnea of mild-to-moderate severity. pediatric patients with rhinitis, and to review the medical liter- CONCLUSIONS: Clinical allergy practice and the medical ature concerning this connection to identify therapeutic impli- literature support a proactive role for allergists in the diagnosis cations and research gaps. and management of sleep-disordered breathing. Ó 2016 METHODS: Members of the Work Group on Rhinitis and American Academy of Allergy, Asthma & Immunology (J Allergy Sleep-disordered Breathing composed and distributed a Web- Clin Immunol Pract 2017;5:628-39) based clinically oriented survey to active American Academy of Key words: Adults; Allergic rhinitis; Adenotonsillar hypertrophy; Allergy, Asthma & Immunology members in mid-2015. The Children; CPAP; Epidemiology; Nasal polyposis; Obstructive group, in addition, conducted an English-language literature sleep apnea; Pathophysiology; Sleep-disordered breathing; review using PubMed and other sources. Therapy aUniversity of California San Francisco, San Francisco, Calif Sleep-disordered breathing (SDB) spans a spectrum of diseases bUniversity of Chicago, Chicago, Ill including snoring, upper airways resistance syndrome, obstruc- c Pennsylvania State University, Hershey, Pa tive sleep apnea (OSA), and central sleep apnea. SDB in general dCase Western Reserve University, Solon, Ohio e and OSA in particular are highly prevalent conditions in adult Georgetown University, Washington, DC — — 1,2 fSUNY Downstate Medical Center, Brooklyn, NY and increasingly in pediatric populations. SDB is Conflicts of interest: F. M. Baroody has received consultancy fees from Allergan and frequently found as a comorbid condition in upper airway al- GlaxoSmithKline; is employed by the University of Chicago Medicine; has received lergy, including in patients with rhinitis and rhinosinusitis.2-7 In research support from the National Institutes of Health and Meda; and has received lecture spite of this fact, clinical guidelines from the American Academy fees from Meda. T. Craig is a past Interest Section Leader for the American Academy of Allergy, Asthma & Immunology; an American Lung Association of Pennsylvania Board of Sleep Medicine for the diagnosis and management of OSA Member; a US Hereditary Angioedema Association Advisory Board member; on the relegate the role of the allergist to that of adjunctive support. Alpha-1 Foundation Clinical Research Center Board; has received consultancy fees from Although these guidelines recommend examination for nasal CSL Behring, Dyaz, Shire, Merck, Biocryst, Bellrose, Merck, and Novartis; has received abnormalities (“polyps, [septal] deviation, [nasal] valve abnor- research support from CSL Behring, Shire, Dyax, Pharming, Merck, Genentech, ” GlaxoSmithKline, Grifols, Novartis, Sanofi Aventis, Boehringer Ingelheim, and Bio- malities, turbinate hypertrophy ), medical treatment for rhinitis cryst; has received lecture fees from CSL Behring, Dyax, Shire, and Grifols; and is is recommended only in the context of intolerance to (or inef- coinvestigator for Asthmanet, National Heart, Lung, and Blood Institute. S. Friedlander fectiveness of) continuous positive airway pressure (CPAP) due has received lecture fees from Teva and Merck. The rest of the authors declare that they to high-grade nasal congestion.8 fl have no relevant con icts of interest. The perspective of allergists, however, appears to place more Received for publication September 23, 2016; accepted for publication October 3, “ ” 2016. upstream emphasis on upper airway allergic conditions. Available online December 5, 2016. Numerous studies link nasal congestion (airflow obstruction; a Corresponding author: Dennis Shusterman, MD, MPH, Upper Airway Biology cardinal manifestation of rhinitis) with mouth breathing, snor- Laboratory, University of California, San Francisco, 1301 So. 46th St, Bldg 112, ing, and in susceptible individuals, OSA.9-13 Furthermore, in Richmond, CA 94804. E-mail: [email protected]. 2213-2198 pediatric populations, adenotonsillar hypertrophy (ATH), a Ó 2016 American Academy of Allergy, Asthma & Immunology frequent accompaniment to atopy, also adversely affects upper http://dx.doi.org/10.1016/j.jaip.2016.10.007 airway function and is linked to OSA, independent of rhinitis 628 J ALLERGY CLIN IMMUNOL PRACT SHUSTERMAN ET AL 629 VOLUME 5, NUMBER 3 TABLE I. Survey results: Practice characteristics of 339 Abbreviations used responding AAAAI-member allergists/immunologists AAAAI- American Academy of Allergy, Asthma & Immunology Characteristic n (%) ADHD- Attention deficit/hyperactivity disorder AHI- Apnea-hypopnea index Country of residence AR- Allergic rhinitis United States 289 (86) ATH- Adenotonsillar hypertrophy Canada 14 (4) CPAP- Continuous positive airway pressure Other 33 (10) NAR- Nonallergic rhinitis Age group treated OSA- Obstructive sleep apnea þ OSAS- Obstructive sleep apnea syndrome Adult pediatric 277 (82) QOL- Quality of life Adult only 32 (9) SDB- Sleep-disordered breathing Pediatric only 30 (9) Routinely query SDB symptoms? Yes 241 (72) 14-19 status. SDB in children can have profound behavioral con- No 96 (28) fi sequences, including daytime somnolence and attention de cit/ Use hardcopy screening tools? hyperactivity disorder (ADHD), making its early recognition and Yes 48 (14) 20-22 effective treatment imperative. These links between allergy Epworth 36 (10) and SDB highlight the possibility that primary treatment for STOP-BANG 2 (1) upper airway allergic conditions may help alleviate SDB symp- Other 1 (3) toms by addressing underlying physiologic abnormalities. No 289 (86) Because allergists may have a unique perspective on SDB, and because important research and practice questions may not be STOP-BANG, Snore, Tired, Observed (apnea), high blood Pressure, Body mass widely articulated, the Rhinitis, Rhinosinusitis and Ocular index, Age, Neck circumference, and Gender. Allergy Committee of the American Academy of Allergy, Asthma & Immunology (AAAAI) undertook, through its Work Group OSA and ATH, 60% used anti-inflammatory medication as initial on Rhinitis and Sleep-disordered Breathing, to (1) survey the therapy, although most managed cases in collaboration with an AAAAI membership regarding members’ experience, attitudes, otolaryngologist (Table III). Overall, 71% of respondents believed and clinical practice regarding SDB in adult and pediatric pa- that allergy medication improved sleep quality in at least a “sub- tients with rhinitis and (2) review the published literature on stantial minority” (10%-30%) of their patients; a smaller per- rhinitis, rhinosinusitis, and ATH and its link to SDB. The centage (44%) believed that immunotherapy was helpful in this objective of this project was to serve as an evidence-based regard. Finally, 73% believed that medical therapy improved resource for providers as they choose among diagnostic and CPAP tolerance in at least a subset of patients with rhinitis management options, as well as to help prioritize future research (Table IV). The attitudes and practices reflected in this limited needs on the basis of identified literature gaps. sample of respondents reflect a more active emphasis on the role of the allergist in SDB than do published sleep guidelines. AAAAI MEMBERSHIP SURVEY A 16-item questionnaire was drafted by the work group and in mid-2015 was distributed electronically to 4881 AAAAI mem- LITERATURE REVIEW bers. The questionnaire asked respondents to indicate their The literature review began with an English-language scope-of-practice (adult, pediatric, or both), and, depending on PubMed search ((“obstructive sleep apnea” OR “sleep-disor-
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