allergic rhinitis and asthma - aboutallergy.co.za · gp,lp,wc,ec & eastern fs, most pts with...
TRANSCRIPT
![Page 1: Allergic Rhinitis and asthma - aboutallergy.co.za · GP,LP,WC,EC & eastern FS, most pts with pollen induced rhinitis have persistent rhinitis. Management AR in children often misdiagnosed](https://reader030.vdocuments.us/reader030/viewer/2022041207/5d5f532688c993cc778bd2db/html5/thumbnails/1.jpg)
Dr Lorraine Masotja
ENT
April 2019
Allergic Rhinitis and asthma
![Page 2: Allergic Rhinitis and asthma - aboutallergy.co.za · GP,LP,WC,EC & eastern FS, most pts with pollen induced rhinitis have persistent rhinitis. Management AR in children often misdiagnosed](https://reader030.vdocuments.us/reader030/viewer/2022041207/5d5f532688c993cc778bd2db/html5/thumbnails/2.jpg)
Intro
Rhinitis= Inflammation of the membranes lining the nose
AR - IGE mediated immune response to specific allergens
Affects social life, school/ work performance
![Page 3: Allergic Rhinitis and asthma - aboutallergy.co.za · GP,LP,WC,EC & eastern FS, most pts with pollen induced rhinitis have persistent rhinitis. Management AR in children often misdiagnosed](https://reader030.vdocuments.us/reader030/viewer/2022041207/5d5f532688c993cc778bd2db/html5/thumbnails/3.jpg)
Epidemiology
Worldwide affects 10- 40% of population
20 – 40% in developing countries & incidence is rising ( C Rondon et al)
AR Affects 20-40 million in USA
Prevalence is increasing in relation to increase in all IGE mediated diseases
Currently its the most common atopic dz & one of the leading chronic conditions in children < 18yrsFemale =Male
Age- before age 20. Earlier in children with bilateral family history of AR or other Allergic conditions
Childhood history of food allergy or Eczema
![Page 4: Allergic Rhinitis and asthma - aboutallergy.co.za · GP,LP,WC,EC & eastern FS, most pts with pollen induced rhinitis have persistent rhinitis. Management AR in children often misdiagnosed](https://reader030.vdocuments.us/reader030/viewer/2022041207/5d5f532688c993cc778bd2db/html5/thumbnails/4.jpg)
Risk factors- Frequency increases with age.
+ SPT is a sig. Risk factor.
Higher socioeconomic classes
Polluted areas
+ family H/O allergy
Individual born during pollen season,
Firstborns
Early introduction of foods or formula
Heavy maternal cigarette smoking in 1st yr of life
Exposure to indoor allergens
High serum IGE( >100 before age of 6 yrs)
Recent studies – association between obesity, nutrition & atopy
![Page 5: Allergic Rhinitis and asthma - aboutallergy.co.za · GP,LP,WC,EC & eastern FS, most pts with pollen induced rhinitis have persistent rhinitis. Management AR in children often misdiagnosed](https://reader030.vdocuments.us/reader030/viewer/2022041207/5d5f532688c993cc778bd2db/html5/thumbnails/5.jpg)
![Page 6: Allergic Rhinitis and asthma - aboutallergy.co.za · GP,LP,WC,EC & eastern FS, most pts with pollen induced rhinitis have persistent rhinitis. Management AR in children often misdiagnosed](https://reader030.vdocuments.us/reader030/viewer/2022041207/5d5f532688c993cc778bd2db/html5/thumbnails/6.jpg)
![Page 7: Allergic Rhinitis and asthma - aboutallergy.co.za · GP,LP,WC,EC & eastern FS, most pts with pollen induced rhinitis have persistent rhinitis. Management AR in children often misdiagnosed](https://reader030.vdocuments.us/reader030/viewer/2022041207/5d5f532688c993cc778bd2db/html5/thumbnails/7.jpg)
![Page 8: Allergic Rhinitis and asthma - aboutallergy.co.za · GP,LP,WC,EC & eastern FS, most pts with pollen induced rhinitis have persistent rhinitis. Management AR in children often misdiagnosed](https://reader030.vdocuments.us/reader030/viewer/2022041207/5d5f532688c993cc778bd2db/html5/thumbnails/8.jpg)
Rhinitis
AR
AR
with systemic atopy
Seasonal
perennial
Local AR without systemic atopy
Intermittent
persistent
NAR
Infectious
Occupational (irritant)
Drug induced
Hormonal
Irritant
Food
Emotional
Atrophic
GER
Idiopathic (NARES included)
Etiological classification of rhinitis ( C Rondon et al)
Seasonal AR 10%.Perennial AR 10-20%
![Page 9: Allergic Rhinitis and asthma - aboutallergy.co.za · GP,LP,WC,EC & eastern FS, most pts with pollen induced rhinitis have persistent rhinitis. Management AR in children often misdiagnosed](https://reader030.vdocuments.us/reader030/viewer/2022041207/5d5f532688c993cc778bd2db/html5/thumbnails/9.jpg)
NARES
Perennial nasal symptoms with profound eosinophilia in nasal
secretions with no sign of allergy
Not IR- pts respond nasal corticosteroids
VS
IR
Its usually assoc. With nasal polyps, bronchial hyperreactivity, non allergic
asthma & sleep apnoea
![Page 10: Allergic Rhinitis and asthma - aboutallergy.co.za · GP,LP,WC,EC & eastern FS, most pts with pollen induced rhinitis have persistent rhinitis. Management AR in children often misdiagnosed](https://reader030.vdocuments.us/reader030/viewer/2022041207/5d5f532688c993cc778bd2db/html5/thumbnails/10.jpg)
Classification - based on duration of symptoms& impact on QOL
ARIA supported by WHO
In line with GINA classification of Asthma
Long pollen seasons in GP,LP,WC,EC & eastern FS, most pts with pollen induced rhinitis have persistent rhinitis
![Page 11: Allergic Rhinitis and asthma - aboutallergy.co.za · GP,LP,WC,EC & eastern FS, most pts with pollen induced rhinitis have persistent rhinitis. Management AR in children often misdiagnosed](https://reader030.vdocuments.us/reader030/viewer/2022041207/5d5f532688c993cc778bd2db/html5/thumbnails/11.jpg)
Management
AR in children often misdiagnosed – recurrent colds
When cough is present esp at night, misdiagnosed as “ cough
variant asthma”
Clinician should ask directed questions
Be aware of cormorbidities- asthma, sinusitis, OM, pursue
specific diagnostic tests, often administer therapeutic trials of
anti-inflammatory meds.
QOL may be worse than in Asthmatics
![Page 12: Allergic Rhinitis and asthma - aboutallergy.co.za · GP,LP,WC,EC & eastern FS, most pts with pollen induced rhinitis have persistent rhinitis. Management AR in children often misdiagnosed](https://reader030.vdocuments.us/reader030/viewer/2022041207/5d5f532688c993cc778bd2db/html5/thumbnails/12.jpg)
SYMPTOMS
Nasal Itching
Sneezing
Rhinorrhoea
Nasal blockage (90%)
PND
Repeated throat clearing
Hyposmia
Hyponasal speech
Epistaxis
Red ,itchy eyes, itchy throat and
ears. Cough
20% have symptoms of Asthma
![Page 13: Allergic Rhinitis and asthma - aboutallergy.co.za · GP,LP,WC,EC & eastern FS, most pts with pollen induced rhinitis have persistent rhinitis. Management AR in children often misdiagnosed](https://reader030.vdocuments.us/reader030/viewer/2022041207/5d5f532688c993cc778bd2db/html5/thumbnails/13.jpg)
“ Allergic salute”
![Page 14: Allergic Rhinitis and asthma - aboutallergy.co.za · GP,LP,WC,EC & eastern FS, most pts with pollen induced rhinitis have persistent rhinitis. Management AR in children often misdiagnosed](https://reader030.vdocuments.us/reader030/viewer/2022041207/5d5f532688c993cc778bd2db/html5/thumbnails/14.jpg)
“Allergic nasal crease”
![Page 15: Allergic Rhinitis and asthma - aboutallergy.co.za · GP,LP,WC,EC & eastern FS, most pts with pollen induced rhinitis have persistent rhinitis. Management AR in children often misdiagnosed](https://reader030.vdocuments.us/reader030/viewer/2022041207/5d5f532688c993cc778bd2db/html5/thumbnails/15.jpg)
“ Allergic shiners’
![Page 16: Allergic Rhinitis and asthma - aboutallergy.co.za · GP,LP,WC,EC & eastern FS, most pts with pollen induced rhinitis have persistent rhinitis. Management AR in children often misdiagnosed](https://reader030.vdocuments.us/reader030/viewer/2022041207/5d5f532688c993cc778bd2db/html5/thumbnails/16.jpg)
Dennie- Morgan lines
![Page 17: Allergic Rhinitis and asthma - aboutallergy.co.za · GP,LP,WC,EC & eastern FS, most pts with pollen induced rhinitis have persistent rhinitis. Management AR in children often misdiagnosed](https://reader030.vdocuments.us/reader030/viewer/2022041207/5d5f532688c993cc778bd2db/html5/thumbnails/17.jpg)
Grimacing; twitching & picking the nose-
Mouth breathing
Dental malocclusion,
Patients should be examined for other allergic diseases-
eczema, asthma
![Page 18: Allergic Rhinitis and asthma - aboutallergy.co.za · GP,LP,WC,EC & eastern FS, most pts with pollen induced rhinitis have persistent rhinitis. Management AR in children often misdiagnosed](https://reader030.vdocuments.us/reader030/viewer/2022041207/5d5f532688c993cc778bd2db/html5/thumbnails/18.jpg)
Clear nasal secretions,
Oedematous nasal mm.
Mucosa look pale &blue-gray
Swollen turbinates
Allergic Conjunctivitis-Conjuctival oedema, itching, tearing, hyperaemia
![Page 19: Allergic Rhinitis and asthma - aboutallergy.co.za · GP,LP,WC,EC & eastern FS, most pts with pollen induced rhinitis have persistent rhinitis. Management AR in children often misdiagnosed](https://reader030.vdocuments.us/reader030/viewer/2022041207/5d5f532688c993cc778bd2db/html5/thumbnails/19.jpg)
Diagnostic tests
SPT
children younger than 1yr may not display + rxn
Child with seasonal allergic dz may not have + test until two
seasons of exposure
Allergy testing should be guided by the history and prevalent
aeroallergens in the area
Inhalant allergy - dust mite, animal dander & weed, grass
tree pollen
Geographic distribution is NB
![Page 20: Allergic Rhinitis and asthma - aboutallergy.co.za · GP,LP,WC,EC & eastern FS, most pts with pollen induced rhinitis have persistent rhinitis. Management AR in children often misdiagnosed](https://reader030.vdocuments.us/reader030/viewer/2022041207/5d5f532688c993cc778bd2db/html5/thumbnails/20.jpg)
In vitro tests Total IGE NOT useful Lab. Confirmation of presence of IGE abs
Helpful to convince family
The ImmunoCAP is sensitive and specific blood test
Should be based on history & exposure
Phadiotop may be used for screening
Nasal secretions & sputum for eosinophil - non specific
The ultimate standard for diagnosis remains a combination of
1. positive history
2. presence of specific IGE antibodies
3.demonstration that symptoms are a result of IGE-
mediated inflammation
![Page 21: Allergic Rhinitis and asthma - aboutallergy.co.za · GP,LP,WC,EC & eastern FS, most pts with pollen induced rhinitis have persistent rhinitis. Management AR in children often misdiagnosed](https://reader030.vdocuments.us/reader030/viewer/2022041207/5d5f532688c993cc778bd2db/html5/thumbnails/21.jpg)
![Page 22: Allergic Rhinitis and asthma - aboutallergy.co.za · GP,LP,WC,EC & eastern FS, most pts with pollen induced rhinitis have persistent rhinitis. Management AR in children often misdiagnosed](https://reader030.vdocuments.us/reader030/viewer/2022041207/5d5f532688c993cc778bd2db/html5/thumbnails/22.jpg)
Management Patient education
• Environmental control
![Page 23: Allergic Rhinitis and asthma - aboutallergy.co.za · GP,LP,WC,EC & eastern FS, most pts with pollen induced rhinitis have persistent rhinitis. Management AR in children often misdiagnosed](https://reader030.vdocuments.us/reader030/viewer/2022041207/5d5f532688c993cc778bd2db/html5/thumbnails/23.jpg)
Intranasal steroids
Most potent anti-infla. Meds for management of AR
First line for pts with moderate-severe & persistent AR
Also have effect on ocular symptoms
MOA: vasoconstriction & reduction of edema, suppression of cytokine production & inhibition of inflammatory cell influx
Proper instruction is essential
Work best if taken regularly daily or prophylactically in anticipation of pollen season
Rapid onset of action – 12-24hrs, may be effective when used intermittently
Safe for long term use
Relieve symptoms of nasal pruritis, rhinorrhea, sneezing & congestion
Some pts experience nasal dryness and epistaxis
![Page 24: Allergic Rhinitis and asthma - aboutallergy.co.za · GP,LP,WC,EC & eastern FS, most pts with pollen induced rhinitis have persistent rhinitis. Management AR in children often misdiagnosed](https://reader030.vdocuments.us/reader030/viewer/2022041207/5d5f532688c993cc778bd2db/html5/thumbnails/24.jpg)
Systemic steroids
Should not be used as first line
For severe incapacitating AR after excluding other causes
Short periods- 5-10days
Study in SA- Short term adrenal suppression within 2 weeks
of 1mg betamethasone given daily, which was reversible on
discontinuing therapy
Long term use not recommended
Intraturbinate injections- not recommended
Oral steroids+ Sedating antihistamine are often
abused in treatment of AR
![Page 25: Allergic Rhinitis and asthma - aboutallergy.co.za · GP,LP,WC,EC & eastern FS, most pts with pollen induced rhinitis have persistent rhinitis. Management AR in children often misdiagnosed](https://reader030.vdocuments.us/reader030/viewer/2022041207/5d5f532688c993cc778bd2db/html5/thumbnails/25.jpg)
Antihistamines
2nd generation & new generation antihistamines available in SA
Preferential binding to peripheral H1 receptors with minimal
penetration to the CNS, minimal anticholinergic & -adrenergic
blocking activities.
New gen. Also have anti-inflammatory effects
They act to control the “wet” symptoms of AR- rhinorrhoea, sneezing,
itchy membranes
Less effective for nasal congestion
![Page 26: Allergic Rhinitis and asthma - aboutallergy.co.za · GP,LP,WC,EC & eastern FS, most pts with pollen induced rhinitis have persistent rhinitis. Management AR in children often misdiagnosed](https://reader030.vdocuments.us/reader030/viewer/2022041207/5d5f532688c993cc778bd2db/html5/thumbnails/26.jpg)
Decongestants Produce vasoconstriction
through adrenergic action -> relieve nasal congestion
Topical : if used > 5-7 days may cause rebound congestion after withdrawal of the drug
If used for prolonged periods-> Rhinitis Medicamentosa
ARIA – suggest that they not be used in preschool children
![Page 27: Allergic Rhinitis and asthma - aboutallergy.co.za · GP,LP,WC,EC & eastern FS, most pts with pollen induced rhinitis have persistent rhinitis. Management AR in children often misdiagnosed](https://reader030.vdocuments.us/reader030/viewer/2022041207/5d5f532688c993cc778bd2db/html5/thumbnails/27.jpg)
Saline.
Nasal irrigation- simple non expensive
Improves symptoms and QOL
Reduces medication requirements
Hypertonic & Isotonic saline are of modest benefit in reducing
symptoms & improving QOL. Improvement of mucocilliary
clearance, removal of allergen & inflammatory mediators &
protective effect on nasal mucosa
May improve effect of INCS
![Page 28: Allergic Rhinitis and asthma - aboutallergy.co.za · GP,LP,WC,EC & eastern FS, most pts with pollen induced rhinitis have persistent rhinitis. Management AR in children often misdiagnosed](https://reader030.vdocuments.us/reader030/viewer/2022041207/5d5f532688c993cc778bd2db/html5/thumbnails/28.jpg)
Leukotriene receptor antagonist May be considered in patients
with AR + Asthma- Add on .
Also patients unresponsive or noncompliant with intranasal steroids.
On its own its less effective than intranasal corticosteroids
Beneficial effects also due to anti-inflammatory effect on vascular permeability, eosinophils & mucus production
DOC for Samters triad
Samter's Triad is a chronic condition defined by asthma, sinus inflammation with recurring nasal polyps, and aspirin sensitivity. It's also called aspirin-exacerbated respiratory disease (AERD), or ASA triad.
![Page 29: Allergic Rhinitis and asthma - aboutallergy.co.za · GP,LP,WC,EC & eastern FS, most pts with pollen induced rhinitis have persistent rhinitis. Management AR in children often misdiagnosed](https://reader030.vdocuments.us/reader030/viewer/2022041207/5d5f532688c993cc778bd2db/html5/thumbnails/29.jpg)
Other meds
Mast cell stabilizers e.g. Cromolyn sodium
- May be useful in relieving symptoms, minimal affect on
congestion. Better if taken before allergen exposure. Short
duration of action therefore poor compliance
Anti- cholinergics (Ipratropium bromide.) Reduces volume of
watery secretions. May be used in AR when rhinorrhea is
refractory to other treatment or in blocking reflex mediated
rhinitis ( spicy foods, cold air exposure)
Omalizumab. Monoclonal antibody against IGE. Currently
approved for severe persistent allergic asthma refractory to other
meds. Studies show efficacy in AR But costly.
![Page 30: Allergic Rhinitis and asthma - aboutallergy.co.za · GP,LP,WC,EC & eastern FS, most pts with pollen induced rhinitis have persistent rhinitis. Management AR in children often misdiagnosed](https://reader030.vdocuments.us/reader030/viewer/2022041207/5d5f532688c993cc778bd2db/html5/thumbnails/30.jpg)
Allergen immunotherapy
Specific allergen immunotherapy (SIT) is the only therapy that can change
natural h/o AR, prevent progression of the disease & cure patients if they
are selected carefully
Should be considered in Pts who
-Do not respond to combination of environmental control measures and
medication
-Experience substantial side effects with medication
-Have symptoms for a sig. Portion of the year that require daily treatment
-Prefer long term modulation of their allergic symptoms
Two forms- SCIT, SLIT
Both highly effective for pts with HDM or grass pollen allergies
![Page 31: Allergic Rhinitis and asthma - aboutallergy.co.za · GP,LP,WC,EC & eastern FS, most pts with pollen induced rhinitis have persistent rhinitis. Management AR in children often misdiagnosed](https://reader030.vdocuments.us/reader030/viewer/2022041207/5d5f532688c993cc778bd2db/html5/thumbnails/31.jpg)
Contraindications for Immunotherapy
Polysensitisation to several unrelated allergen groups
Severe / poorly controlled Asthma
Over 60 yrs
Thyrotoxicosis
Coronary vascular dz
Mental disorders
Autoimmune dz
Hypertension
![Page 32: Allergic Rhinitis and asthma - aboutallergy.co.za · GP,LP,WC,EC & eastern FS, most pts with pollen induced rhinitis have persistent rhinitis. Management AR in children often misdiagnosed](https://reader030.vdocuments.us/reader030/viewer/2022041207/5d5f532688c993cc778bd2db/html5/thumbnails/32.jpg)
Algorithm for DX & MX of AR ( SAARWG)
![Page 33: Allergic Rhinitis and asthma - aboutallergy.co.za · GP,LP,WC,EC & eastern FS, most pts with pollen induced rhinitis have persistent rhinitis. Management AR in children often misdiagnosed](https://reader030.vdocuments.us/reader030/viewer/2022041207/5d5f532688c993cc778bd2db/html5/thumbnails/33.jpg)
Sinusitis / Rhinosinusitis
![Page 34: Allergic Rhinitis and asthma - aboutallergy.co.za · GP,LP,WC,EC & eastern FS, most pts with pollen induced rhinitis have persistent rhinitis. Management AR in children often misdiagnosed](https://reader030.vdocuments.us/reader030/viewer/2022041207/5d5f532688c993cc778bd2db/html5/thumbnails/34.jpg)
![Page 35: Allergic Rhinitis and asthma - aboutallergy.co.za · GP,LP,WC,EC & eastern FS, most pts with pollen induced rhinitis have persistent rhinitis. Management AR in children often misdiagnosed](https://reader030.vdocuments.us/reader030/viewer/2022041207/5d5f532688c993cc778bd2db/html5/thumbnails/35.jpg)
![Page 36: Allergic Rhinitis and asthma - aboutallergy.co.za · GP,LP,WC,EC & eastern FS, most pts with pollen induced rhinitis have persistent rhinitis. Management AR in children often misdiagnosed](https://reader030.vdocuments.us/reader030/viewer/2022041207/5d5f532688c993cc778bd2db/html5/thumbnails/36.jpg)
Adenoid hypertrophy
![Page 37: Allergic Rhinitis and asthma - aboutallergy.co.za · GP,LP,WC,EC & eastern FS, most pts with pollen induced rhinitis have persistent rhinitis. Management AR in children often misdiagnosed](https://reader030.vdocuments.us/reader030/viewer/2022041207/5d5f532688c993cc778bd2db/html5/thumbnails/37.jpg)
![Page 38: Allergic Rhinitis and asthma - aboutallergy.co.za · GP,LP,WC,EC & eastern FS, most pts with pollen induced rhinitis have persistent rhinitis. Management AR in children often misdiagnosed](https://reader030.vdocuments.us/reader030/viewer/2022041207/5d5f532688c993cc778bd2db/html5/thumbnails/38.jpg)
AR and ASTHMA
AR and Asthma frequently coexist
Asthma occur in 15-35% of pts with AR
Nasal symptoms resent in approx 75 % of pts with asthma
AR may aggravate asthma
![Page 39: Allergic Rhinitis and asthma - aboutallergy.co.za · GP,LP,WC,EC & eastern FS, most pts with pollen induced rhinitis have persistent rhinitis. Management AR in children often misdiagnosed](https://reader030.vdocuments.us/reader030/viewer/2022041207/5d5f532688c993cc778bd2db/html5/thumbnails/39.jpg)
United airway Upper & lower airways are
considered a unified
morphological and functional unit
The upper and lower respiratory
tracts form a continuum, allowing
passage of air into and out the
lung and sharing many anatomical
and histological properties
They share common structures
like ciliary epithelium, BM, lamina
propria, glands, goblet cells
forming the so called united
airway
![Page 40: Allergic Rhinitis and asthma - aboutallergy.co.za · GP,LP,WC,EC & eastern FS, most pts with pollen induced rhinitis have persistent rhinitis. Management AR in children often misdiagnosed](https://reader030.vdocuments.us/reader030/viewer/2022041207/5d5f532688c993cc778bd2db/html5/thumbnails/40.jpg)
![Page 41: Allergic Rhinitis and asthma - aboutallergy.co.za · GP,LP,WC,EC & eastern FS, most pts with pollen induced rhinitis have persistent rhinitis. Management AR in children often misdiagnosed](https://reader030.vdocuments.us/reader030/viewer/2022041207/5d5f532688c993cc778bd2db/html5/thumbnails/41.jpg)
Upper airway is the first target for allergens and for
physical and chemical environmental stimuli. Therefore
tend to be affected first by allergic airway dz.
If the intensity of the disease is low, the upper airway may
be the only part affected
![Page 42: Allergic Rhinitis and asthma - aboutallergy.co.za · GP,LP,WC,EC & eastern FS, most pts with pollen induced rhinitis have persistent rhinitis. Management AR in children often misdiagnosed](https://reader030.vdocuments.us/reader030/viewer/2022041207/5d5f532688c993cc778bd2db/html5/thumbnails/42.jpg)
Rhinitis and asthma are chronic inflammatory diseases of the upper and lower airways
Mx of rhinitis and asthma must be together leading to better control of both diseases
AR is risk factor in developing asthma
Over 80% of asthmatics have AR.
And 10-40% pts with AR have asthma
“one airway, one disease”
Pts with perennial AR have greater bronchial reactivity than those with seasonal rhinitis
![Page 43: Allergic Rhinitis and asthma - aboutallergy.co.za · GP,LP,WC,EC & eastern FS, most pts with pollen induced rhinitis have persistent rhinitis. Management AR in children often misdiagnosed](https://reader030.vdocuments.us/reader030/viewer/2022041207/5d5f532688c993cc778bd2db/html5/thumbnails/43.jpg)
Rx of rhinitis can be beneficial to lower airway
Reduces symptoms, emergency room visits and
hospitalization and severity of attacks
![Page 44: Allergic Rhinitis and asthma - aboutallergy.co.za · GP,LP,WC,EC & eastern FS, most pts with pollen induced rhinitis have persistent rhinitis. Management AR in children often misdiagnosed](https://reader030.vdocuments.us/reader030/viewer/2022041207/5d5f532688c993cc778bd2db/html5/thumbnails/44.jpg)
UNITED AIRWAY
asthmaAllergic rhinitis
with asthmaAR