Table 2.
Clinical evaluation and management of asthma comorbidities
| Comorbidity | Clinical Clues | Suggested Evaluation | Recommended Intervention | Anticipated asthma benefit |
|---|---|---|---|---|
| Allergic Rhinitis | Nasal symptoms | SPT or sIgE | INCS ± oral/nasal antihistamines, montelukast, nasal saline | Uncertain, possible fewer exacerbations |
| CRSwNP | Chronic congestion, sinus pressure, cough | Nasal examination, sinus CT, rhinoscopy; Aspirin sensitivity In children: sweat test, ciliary bx/PCD genetics |
Oral/intranasal steroids, antihistamines, nasal saline, antibiotics, sinus surgery; Aspirin desensitization; anti-IgE, anti-IL-5, IntiIL-4r therapy | Improved symptoms, FEV1, exacerbations |
| Obesity | Elevated BMI | BMI, Metabolic syndrome | Diet, exercise program; bariatric surgery (adult) | Improved QOL, asthma control, FEV1 |
| ILO; | Stridor, discrete episodes, hyperventilation | Laryngoscopy with provocation; | Speech Pathology, stimulus avoidance, inhaled anticholinergics*; psychopharmacologic therapy, if indicated | Improved symptoms |
| Dysfunctional breathing | hyperventilation, sighing, asynchronous thoraco-abdominal breathing | SEBQ/Nijmegen Questionnaire | Breathing retraining | Improved symptoms, QOL |
| OSA | Snoring Daytime somnolence | PSG | Adenotonsillectomy (children) CPAP | Improved exacerbations, symptoms, QOL |
| GERD | Heartburn, regurgitation, chest pain, cough | GI endoscopy, impedence/pH probe | Gastric acid suppression, fundoplication | Slight improved FEV1 and rescue medication use |
| Anxiety/depression | mood/behavioral cues | Screening tools (i.e., GAD7, PHQ9, HADS); psychology referral | CBT, psychopharmacologic therapy | Possible improved symptoms, QOL |
| Vitamin D deficiency | 25 OH Vitamin D level (<30 ng/ml) | Vitamin D supplementation | Possible improved exacerbation rate in adults achieving normal Vitamin D levels | |
| ABPA/M | Uncontrolled asthma, bronchitis, mucus plugs | Skin test/sIgE to fungus, total IgE, aspergillus precipitins or sIgG**; CXR; chest CT | Systemic corticosteroids + antifungal agent; alternative: omalizumab | Symptoms, lung function |
| Smoking/SHS | History, observed odor of smoke | History, urinary cotinine | Smoking cessation counseling, medical management | Symptoms, lung function, exacerbations |
| COPD | Dyspnea, chronic cough, sputum production | History, pre-and post spirometry | Smoking cessation; Asthma pharmacotherapy; LAMA-LABA-ICS therapy | Symptoms, lung function, exacerbations |
CRSsNP, chronic rhinosinusitis without nasal polyps; CRSwNP, chronic rhinosinusitis with nasal polyps; ILO, inducible laryngeal obstruction; OSA, obstructive sleep apnea; GERD, gastroesophageal reflux; ABPA/M. allergic bronchopulmonary aspergillosis/mycosis; SHS (secondhand smoke); PSG, polysomnography; sIgE, specific Immunoglobulin E; CT, computed tomography; CPAP, continuous positive airway pressure; CBT, cognitive behavioral therapy; FEV1, forced exhalatory volume in one second; QOL, quality of life; GAD7, General Anxiety Disorder-7; PHQ9, Patient Health Questionnaire-9; HADS, Hospital Anxiety and Depression Scale; ICS, inhaled corticosteroids:*anecdotal evidence; ** ABPA diagnostic criteria: (1) predisposing asthma or CF, (2) Aspergillus skin test reactivity or detectable serum IgE to Aspergillus fumigatus, (3) total serum IgE >1000 IU/ml (lower levels acceptable if patient meets all other criteria), (4) at least two of the following: Precipitating antibodies or increased Aspergillus species IgG level; chest radiographic infiltrates; Total eosinophil count >500 cells/microL in glucocorticoid-naïve patients (may be historical).