Estudos sobre comorbidades de vias aéreas superiores em associação à asma grave

Abstract

Introduction: Severe asthma is a complex heterogeneous disease that can be complicated by several comorbidities, especially those related to the upper airways, such as chronic rhinosinusitis and allergic rhinitis, which play a key role in the management of these patients, considering the concept of a 'Unified Airway'. The aim of this study was to evaluate upper airway comorbidities (UAC) in patients in the ProAR cohort and their association with asthma control. Methods: The evaluation of the first visit of the cohort, between 2013 and 2015, of the aeroallergic sensitization profile; and evaluation of a sample of patients at the second visit of the cohort, between March⁄2018 and February⁄2020, of UAC. In both studies, clinical and laboratory evaluations and complementary asthma tests were performed. In the prospective study, otorhinolaryngological evaluation, questionnaires to evaluate CRS and other comorbidities of UA, in addition to nasopharyngolaryngoscopy video, were added. Results: A narrative review of the literature was conducted to identify the main asthma-related comorbidities of AV and their control, as well as to systematize an otorhinolaryngological evaluation of these comorbidities in asthmatic patients. The main ones were: Allergic Rhinitis, CRS, AERD, GERD, CVD and OSAHS; The systematization was presented through clinical cases and multiple-choice questions. The results of the first visit of the cohort involved 1066 participants, with a higher prevalence of aeroallergic sensitization in individuals with asthma, compared to those with chronic rhinitis alone (70.4% vs 47%, p=0.000), high sensitization to mites, cockroaches, animal dander, grasses and fungi in the presence of asthma, which is also associated with polysensitization, in addition to a sensitization profile different from that observed in individuals with chronic rhinitis alone. In the study referring to the second visit of the cohort, 428 patients with asthma were evaluated, 76.2% of those with mild asthma had CRS, and 60.8% with moderate to severe asthma. The diagnosis of CRS, regardless of asthma severity, was associated with poor asthma control (GINA and ACQ-6), asthma exacerbation and poorer asthma quality of life in more than 50% of these patients; GERD symptoms and daytime sleepiness were also highly prevalent in the presence of CRS. Nasal polyposis has been shown to be a marker of moderate to severe asthma, and the diagnosis of AERD was exclusive to this group. Conclusions: Comorbidities of UA are common in patients with asthma, regardless of their severity. Aeroallergic sensitization differs from chronic rhinitis alone in comparison with its association with asthma, endorsing the hypothesis that allergic rhinitis presents a different phenotype when associated with asthma. CRS is also commonly associated with asthma, contributing to its poor control. Adequate investigation and treatment of upper airways comorbidities in asthmatic patients is recommended, especially in those in whom there is partial or no asthma control, and a systematized evaluation of these comorbidities facilitates the clinical care trajectory of these patients.