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Special considerations for the pregnant woman and senior citizen with airway disease

1998; Elsevier BV; Volume: 101; Issue: 2 Linguagem: Inglês

10.1016/s0091-6749(98)70224-6

1097-6825

Michael Schatz,

Neonatal Respiratory Health Research

Asthma and rhinitis may occur during pregnancy and in senior citizens. Many aspects of the diagnosis and management of these illnesses do not change in these special circumstances. However, a number of diagnostic and therapeutic considerations are unique to these conditions. This article will review those special considerations in the diagnosis and management of airway disease in pregnant women and senior citizens. Managing asthma and rhinitis during pregnancy is unique because the effect of the illness and its treatment on the developing fetus as well as on the mother must be considered. In addition, physiologic changes associated with pregnancy could affect the upper or lower airways. Nasal vascular pooling (resulting from an increased circulating blood volume and possibly enhanced by the vasodilating effect of progesterone) and increased nasal glandular activity occur during pregnancy.1Schatz M, Zeiger RS. Diagnosis and management of rhinitis during pregnancy. Allergy Proc 988;9:545-54.Google Scholar The most important physiologic change affecting the lower airways during pregnancy is the progesterone-mediated physiologic hyperventilation of pregnancy, associated with an increased tidal volume (VT), somewhat increased Po2 (102 to 196 mm Hg), and markedly decreased Pco2 (28 to 30 mm Hg).2Schatz M, Hoffman CP, Zeiger RS, Falkoff R, Macy E, Mellon M. The course and management of asthma and allergic disease during pregnancy. In: Middleton E, Reed CE, Ellis EF, et al. editors. Allergy: principles and practices. 5th ed. St. Louis: Mosby. In press.Google Scholar The rise in free cortisol that occurs with advancing pregnancy could also be relevant to upper or lower airway disease.1Schatz M, Zeiger RS. Diagnosis and management of rhinitis during pregnancy. Allergy Proc 988;9:545-54.Google Scholar, 2Schatz M, Hoffman CP, Zeiger RS, Falkoff R, Macy E, Mellon M. The course and management of asthma and allergic disease during pregnancy. In: Middleton E, Reed CE, Ellis EF, et al. editors. Allergy: principles and practices. 5th ed. St. Louis: Mosby. In press.Google Scholar The developing fetus is totally dependent on the mother for its oxygen supply. Thus, the hypoxia and other blood gas abnormalities associated with exacerbations of maternal asthma could threaten the fetus. Although rhinitis should not directly affect the fetus, severe gestational nasal symptoms could indirectly affect pregnancy adversely through an effect on eating, sleeping, or emotional well-being, or by exacerbating coexistent asthma. A major concern in the management of airway disease during pregnancy are the potential adverse effects of medications on the fetus. Unfortunately, assessing the actual risks of medications during pregnancy may be difficult. Ethical and statistical considerations make it virtually impossible to scientifically prove that a medication is safe during pregnancy. Thus, medication choices during pregnancy must be based on less definitive information, such as animal studies, observational human data, and preferences for topical and older medications.2Schatz M, Hoffman CP, Zeiger RS, Falkoff R, Macy E, Mellon M. The course and management of asthma and allergic disease during pregnancy. In: Middleton E, Reed CE, Ellis EF, et al. editors. Allergy: principles and practices. 5th ed. St. Louis: Mosby. In press.Google Scholar, 3National Asthma Education Program Report of the Working Group on Asthma and Pregnancy management of asthma during pregnancy. NIH publication 93-3279A, Bethesda, Md.:September 1993Google Scholar In general, medications are recommended for use during pregnancy when their potential benefits for the mother and/or fetus outweigh their apparent risks, based on the best information available.2Schatz M, Hoffman CP, Zeiger RS, Falkoff R, Macy E, Mellon M. The course and management of asthma and allergic disease during pregnancy. In: Middleton E, Reed CE, Ellis EF, et al. editors. Allergy: principles and practices. 5th ed. St. Louis: Mosby. In press.Google Scholar, 3National Asthma Education Program Report of the Working Group on Asthma and Pregnancy management of asthma during pregnancy. NIH publication 93-3279A, Bethesda, Md.:September 1993Google Scholar Allergen immunotherapy may be indicated in the management of airway disease in women of childbearing age. Immunotherapy appears to be generally safe during pregnancy,4Metzger WJ Turner E Patterson R. The safety of immunotherapy during pregnancy.J Allergy Clin Immunol. 1978; 61: 268-272Abstract Full Text PDF PubMed Scopus (128) Google Scholar, 5Shaikh WA. A retrospective study on the safety of immunotherapy in pregnancy.Clin Exp Allergy. 1993; 23: 857-860Crossref PubMed Scopus (65) Google Scholar although anaphylaxis caused by immunotherapy occasionally occurs and could be a threat to the fetus. It is generally recommended that allergen immunotherapy be continued during pregnancy by women who are deriving benefit from it, are not prone to systemic reactions, and are at maintenance dosage or at least receiving a substantial dosage.2Schatz M, Hoffman CP, Zeiger RS, Falkoff R, Macy E, Mellon M. The course and management of asthma and allergic disease during pregnancy. In: Middleton E, Reed CE, Ellis EF, et al. editors. Allergy: principles and practices. 5th ed. St. Louis: Mosby. In press.Google Scholar Beginning immunotherapy generally is not recommended during pregnancy because of the unknown potential in the pregnant patient for benefit or systemic reactivity, and because of the usual latency of several months before any substantial clinical benefit from immunotherapy is achieved.2Schatz M, Hoffman CP, Zeiger RS, Falkoff R, Macy E, Mellon M. The course and management of asthma and allergic disease during pregnancy. In: Middleton E, Reed CE, Ellis EF, et al. editors. Allergy: principles and practices. 5th ed. St. Louis: Mosby. In press.Google Scholar The presence of specific IgE is usually most practically and accurately detected by skin tests. However, skin testing is associated with a small risk of systemic allergic reactions. Therefore, selective radioimmunosorbent tests may be chosen over skin testing during pregnancy in previously untested patients in whom specific allergen sensitizations cannot be ascertained by a careful history alone. Asthma may improve, worsen, or remain unchanged during pregnancy.6Juniper EF Newhouse MT. Effect of pregnancy on asthma: a systematic review and meta-analysis.in: Asthma and immunological diseases in pregnancy and early infancy. Marcel Dekker, New York1998: 401-427Google Scholar Although change in the course of asthma during pregnancy in individual women is unpredictable, studies have suggested that women with more severe asthma before pregnancy may be more likely to experience worsening of their asthma during pregnancy than women with milder disease.7Gluck JC Gluck PA. The effects of pregnancy on asthma: a prospective study.Ann Allergy. 1976; 37: 164-168PubMed Google Scholar In addition, experience during a previous pregnancy may be somewhat predictive, because in approximately 60% of women, the course of asthma is similar in successive pregnancies.8Schatz M Harden K Forsythe A Chilingor L Hoffman C Spelling W. The course of asthma duringpregnancy, postpartum and with successive pregnancies: a prospective analysis.J Allergy Clin Immunol. 1988; 81: 509-517Abstract Full Text PDF PubMed Scopus (6) Google Scholar The variable effect of pregnancy on the course of asthma appears to be more than merely random fluctuation in the natural history of the disease, because the changes in asthma severity that women attribute to pregnancy generally revert toward the prepregnancy course of asthma within 3 months postpartum.8Schatz M Harden K Forsythe A Chilingor L Hoffman C Spelling W. The course of asthma duringpregnancy, postpartum and with successive pregnancies: a prospective analysis.J Allergy Clin Immunol. 1988; 81: 509-517Abstract Full Text PDF PubMed Scopus (6) Google Scholar The exact mechanisms involved in the change of course of asthma during pregnancy have not been defined, but a number of gestational physiologic changes have the potential to affect asthma.6Juniper EF Newhouse MT. Effect of pregnancy on asthma: a systematic review and meta-analysis.in: Asthma and immunological diseases in pregnancy and early infancy. Marcel Dekker, New York1998: 401-427Google Scholar It does appear that upper respiratory infections are the most common precipitants of severe gestational asthma. Several observations have been made regarding the course of asthma and the stage of pregnancy. The peak incidence of flares during pregnancy appears to occur between 24 and 36 weeks' gestation, especially in women whose asthma worsens during pregnancy.7Gluck JC Gluck PA. The effects of pregnancy on asthma: a prospective study.Ann Allergy. 1976; 37: 164-168PubMed Google Scholar, 8Schatz M Harden K Forsythe A Chilingor L Hoffman C Spelling W. The course of asthma duringpregnancy, postpartum and with successive pregnancies: a prospective analysis.J Allergy Clin Immunol. 1988; 81: 509-517Abstract Full Text PDF PubMed Scopus (6) Google Scholar In contrast, women with asthma tend to experience fewer symptoms during the last 4 weeks of pregnancy than during any other 4-week gestational period.8Schatz M Harden K Forsythe A Chilingor L Hoffman C Spelling W. The course of asthma duringpregnancy, postpartum and with successive pregnancies: a prospective analysis.J Allergy Clin Immunol. 1988; 81: 509-517Abstract Full Text PDF PubMed Scopus (6) Google Scholar Additionally, troublesome asthma during labor and delivery is extremely rare in prospectively managed asthmatic women.8Schatz M Harden K Forsythe A Chilingor L Hoffman C Spelling W. The course of asthma duringpregnancy, postpartum and with successive pregnancies: a prospective analysis.J Allergy Clin Immunol. 1988; 81: 509-517Abstract Full Text PDF PubMed Scopus (6) Google Scholar Controlled studies comparing the outcome of pregnancy in patients with asthma to outcomes in concurrently followed nonasthmatic women have been recently reviewed.9Schatz M. Asthma and pregnancy.Immunol Allergy Clin North Am. 1996; 16: 893-916Abstract Full Text Full Text PDF Scopus (7) Google Scholar Maternal asthma, especially more severe or uncontrolled asthma, may increase the risk of perinatal complications, such as pre-eclampsia, perinatal mortality, preterm birth, and low-birth-weight infants. Potential mechanisms for the apparent increase in perinatal risks in the pregnancies of asthmatic women include hypoxia and other adverse physiologic consequences of uncontrolled asthma, asthma medications, and/or common pathogenetic factors. The latter could include factors that predispose to bronchial hyperreactivity as well as vascular and uterine muscle hyperreactivity, such as circulating mediators that act on smooth muscle, or autonomic nervous system (ANS) abnormalities. The data supporting these various mechanisms are summarized in Table 1.2Schatz M, Hoffman CP, Zeiger RS, Falkoff R, Macy E, Mellon M. The course and management of asthma and allergic disease during pregnancy. In: Middleton E, Reed CE, Ellis EF, et al. editors. Allergy: principles and practices. 5th ed. St. Louis: Mosby. In press.Google Scholar, 9Schatz M. Asthma and pregnancy.Immunol Allergy Clin North Am. 1996; 16: 893-916Abstract Full Text Full Text PDF Scopus (7) Google Scholar, 10Stenius-Aarniala R Piirila P Teramo K. Asthma and pregnancy: a prospective study of 198 pregnancies.Thorx. 1988; 43: 12-18Crossref PubMed Scopus (225) Google Scholar, 11Stenius-Aarniala B Riikonen S Teramo K. Slow-release theophylline in pregnant asthmatics.Chest. 1995; 107: 642-647Crossref PubMed Scopus (81) Google Scholar, 12M Schatz, RS Zeiger, CP Hoffman, KR Harden, A Forsythe, L Chilingor, et al., Perinatal outcomes in the pregnancies of asthmatic women: a prospective controlled analysis, Am J Respir Crit Care Med 151 1170-1174 (195).Google Scholar, 13Greenberger PA Patterson R. The outcome of pregnancy complicated by severe asthma.Allergy Proc. 1988; 9: 539-543Crossref PubMed Scopus (79) Google Scholar, 14Schatz M Zeiger RS Hoffman CP. Intrauterine growth is related to gestational pulmonary function in pregnant asthmatic women.Chest. 1990; 98: 389-392Crossref PubMed Scopus (127) Google Scholar, 15Perlow JH Montgomery D Morgan MA Towers CV Porto M Severity of asthma and perinatal outcome.Am J Obstet Gynecol. 1992; 167: 963-967Abstract Full Text PDF PubMed Scopus (193) Google Scholar, 16Reinisch JM Simon NG Karow WG Gandelman R. Prenatal exposure to prednisone in humans and animals retards intrauterine growth.Science. 1978; 202: 436-438Crossref PubMed Scopus (479) Google Scholar, 17Bertrand JM Riley SP Popkin J Coates AL The long term pulmonary sequelae of prematurity: the role of familial airway hyperreactivity and the respiratory distress syndrome.N Engl J Med. 1985; 312: 742-745Crossref PubMed Scopus (169) Google Scholar It is particularly difficult to differentiate the effects of corticosteroids, used to treat more severe asthma, from the effects of uncontrolled asthma itself or from associated extrapulmonary smooth-muscle hyperreactivity in patients with more severe asthma. Table 1Potential mechanisms of increased adverse perinatal outcomes associated with maternal asthmaHypothetical mechanismOutcomeSupporting dataSeverely uncontrolled asthmaPerinatal mortalitySevere asthma during pregnancy has been associated with perinatal mortality,9Schatz M. Asthma and pregnancy.Immunol Allergy Clin North Am. 1996; 16: 893-916Abstract Full Text Full Text PDF Scopus (7) Google Scholar whereas asthma managed by asthma specialists during pregnancy has not been associated with increased perinatal mortality.10Stenius-Aarniala R Piirila P Teramo K. Asthma and pregnancy: a prospective study of 198 pregnancies.Thorx. 1988; 43: 12-18Crossref PubMed Scopus (225) Google Scholar, 11Stenius-Aarniala B Riikonen S Teramo K. Slow-release theophylline in pregnant asthmatics.Chest. 1995; 107: 642-647Crossref PubMed Scopus (81) Google Scholar, 12M Schatz, RS Zeiger, CP Hoffman, KR Harden, A Forsythe, L Chilingor, et al., Perinatal outcomes in the pregnancies of asthmatic women: a prospective controlled analysis, Am J Respir Crit Care Med 151 1170-1174 (195).Google ScholarModerately uncontrolled asthmaIntrauterine growthInfants of mothers hospitalized during pregnancy for status asthmaticus weighed significantly less than did infants of mothers who did not require emergency therapy for asthma13Greenberger PA Patterson R. The outcome of pregnancy complicated by severe asthma.Allergy Proc. 1988; 9: 539-543Crossref PubMed Scopus (79) Google Scholar; poorer maternal pulmonary function during pregnancy in asthmatic women was associated with an increased risk of intrauterine growth retardation.14Schatz M Zeiger RS Hoffman CP. Intrauterine growth is related to gestational pulmonary function in pregnant asthmatic women.Chest. 1990; 98: 389-392Crossref PubMed Scopus (127) Google ScholarMedicationPre-eclampsiaIncidence of pre-eclampsia increased in asthmatic subjects treated with prednisone in one series,10Stenius-Aarniala R Piirila P Teramo K. Asthma and pregnancy: a prospective study of 198 pregnancies.Thorx. 1988; 43: 12-18Crossref PubMed Scopus (225) Google Scholar theophylline in another.11Stenius-Aarniala B Riikonen S Teramo K. Slow-release theophylline in pregnant asthmatics.Chest. 1995; 107: 642-647Crossref PubMed Scopus (81) Google ScholarMedicationPrematurityIncreased incidence of preterm and low-birth-weight infants in orally corticosteroid-dependent asthmatic subjects compared with non-corticosteroid-treated controls.15Perlow JH Montgomery D Morgan MA Towers CV Porto M Severity of asthma and perinatal outcome.Am J Obstet Gynecol. 1992; 167: 963-967Abstract Full Text PDF PubMed Scopus (193) Google ScholarMedicationIntrauterine growthLower birth weight in infants of mothers treated with prednisone 10 mg daily throughout pregnancy (for pregnancy maintenance) compared to control infants.16Reinisch JM Simon NG Karow WG Gandelman R. Prenatal exposure to prednisone in humans and animals retards intrauterine growth.Science. 1978; 202: 436-438Crossref PubMed Scopus (479) Google ScholarCommon pathogenetic factorsPreterm birthIncreased bronchial hyperreactivity demonstrated in 68% of women delivering preterm infants for no identifiable reasons17Bertrand JM Riley SP Popkin J Coates AL The long term pulmonary sequelae of prematurity: the role of familial airway hyperreactivity and the respiratory distress syndrome.N Engl J Med. 1985; 312: 742-745Crossref PubMed Scopus (169) Google Scholar; increased incidence of preterm births in patients with more severe asthma requiring oral corticosteroids.15Perlow JH Montgomery D Morgan MA Towers CV Porto M Severity of asthma and perinatal outcome.Am J Obstet Gynecol. 1992; 167: 963-967Abstract Full Text PDF PubMed Scopus (193) Google ScholarCommon pathogenetic factorsPre-eclampsiaVascular α-adrenergic hyperreactivity and β-adrenergic hyporeactivity demonstrated in asthmatic subjects2Schatz M, Hoffman CP, Zeiger RS, Falkoff R, Macy E, Mellon M. The course and management of asthma and allergic disease during pregnancy. In: Middleton E, Reed CE, Ellis EF, et al. editors. Allergy: principles and practices. 5th ed. St. Louis: Mosby. In press.Google Scholar; increased pre-eclampsia in patients with more severe asthma requiring corticosteroids.10Stenius-Aarniala R Piirila P Teramo K. Asthma and pregnancy: a prospective study of 198 pregnancies.Thorx. 1988; 43: 12-18Crossref PubMed Scopus (225) Google ScholarFrom Schatz M, Hoffman CP, Zeiger RS, Falkoff R, Macy E, Mellon M. The course and management of asthma and allergic diseases during pregnancy. In: Middleton E, Reed CE, Ellis EF, Adkinson NF, Yunginger JW, Busse WW, editors. Allergy: principles and practices. 5th ed. St. Louis: Mosby (In press). By permission. Open table in a new tab Although the mechanisms responsible for it remain undefined, the absence of increased incidence of adverse fetal and infant outcomes in three prospective studies in which asthma was managed by allergy or pulmonary specialists supports the hypothesis that optimal control of asthma during pregnancy improves perinatal outcome.10Stenius-Aarniala R Piirila P Teramo K. Asthma and pregnancy: a prospective study of 198 pregnancies.Thorx. 1988; 43: 12-18Crossref PubMed Scopus (225) Google Scholar, 11Stenius-Aarniala B Riikonen S Teramo K. Slow-release theophylline in pregnant asthmatics.Chest. 1995; 107: 642-647Crossref PubMed Scopus (81) Google Scholar, 12M Schatz, RS Zeiger, CP Hoffman, KR Harden, A Forsythe, L Chilingor, et al., Perinatal outcomes in the pregnancies of asthmatic women: a prospective controlled analysis, Am J Respir Crit Care Med 151 1170-1174 (195).Google Scholar From Schatz M, Hoffman CP, Zeiger RS, Falkoff R, Macy E, Mellon M. The course and management of asthma and allergic diseases during pregnancy. In: Middleton E, Reed CE, Ellis EF, Adkinson NF, Yunginger JW, Busse WW, editors. Allergy: principles and practices. 5th ed. St. Louis: Mosby (In press). By permission. Most women of childbearing age who complain of wheezing associated with chest tightness, cough, or dyspnea have asthma. The diagnosis of asthma can generally be confirmed by the demonstration of reversible obstructive airway disease on pulmonary function testing. If methacholine testing is required to confirm a diagnosis of asthma, it should be deferred until after childbirth. Important triggering factors for asthma can usually be ascertained from a history. Confirmation of specific IgE during pregnancy is discussed earlier. Several conditions unique to pregnancy must be considered in the differential diagnosis of asthma.18Schatz M Zeiger RS. Allergic diseases.in: 2nd ed. Principles and practice of medical therapy in pregnancy. Appleton &Lange, Norwalk, CT1992: 435Google Scholar Dyspnea of pregnancy may occur in early pregnancy (presumably because of the hyperventilation of pregnancy) or in late pregnancy (presumably because of the effects of the expanding uterus on the diaphragm). Such dyspnea is not associated with cough, wheezing, or airway obstruction. Peripartum cardiomyopathy or tocolytic therapy (i.e., therapy that inhibits uterine contractions) may cause pulmonary edema during pregnancy, which may be associated with wheezing. Additionally, amniotic fluid embolism, which usually presents with acute respiratory distress during labor or delivery, may rarely cause wheezing. Avoidance of triggering factors is an obvious but often underused modality in the management of asthma. Avoidance measures are particularly beneficial during pregnancy because they may improve clinical well-being while reducing the need for pharmacologic intervention. It is especially important for the pregnant asthmatic woman to discontinue smoking during pregnancy because smoking may predispose to increased asthma, bronchitis, or sinusitis, and increase the need for medication; the increased morbidity attributed to smoking may be additive to that conferred by maternal asthma.14Schatz M Zeiger RS Hoffman CP. Intrauterine growth is related to gestational pulmonary function in pregnant asthmatic women.Chest. 1990; 98: 389-392Crossref PubMed Scopus (127) Google Scholar The pharmacologic management of asthma during pregnancy is not substantially different from such management in nonpregnant patients, and the usual goals of therapy (i.e., achieving symptomatic control, preventing acute episodes, optimizing pulmonary function) appear to be beneficial for the fetus and for the mother.6Juniper EF Newhouse MT. Effect of pregnancy on asthma: a systematic review and meta-analysis.in: Asthma and immunological diseases in pregnancy and early infancy. Marcel Dekker, New York1998: 401-427Google Scholar However, data on the use of asthma medications during pregnancy have led to certain specific recommendations for the pharmacologic management of asthma in pregnant women (Table 2).3National Asthma Education Program Report of the Working Group on Asthma and Pregnancy management of asthma during pregnancy. NIH publication 93-3279A, Bethesda, Md.:September 1993Google Scholar Table 2Preferred medications for the management of asthma during pregnancyBronchodilatorsInhaled short-acting β2-agonistTheophyllineTerbutaline if systemic β2-agonist requiredAntiinflammatory AgentsCromolynBeclomethasonePrednisone Open table in a new tab Medications recommended for the outpatient management of mild, moderate, and severe chronic asthma are shown in Table 3.3National Asthma Education Program Report of the Working Group on Asthma and Pregnancy management of asthma during pregnancy. NIH publication 93-3279A, Bethesda, Md.:September 1993Google Scholar, 19Schatz M Zeiger RS. Asthma and allergy during pregnancy.in: 3rd ed. Allergy, clinical immunology and asthma management in infants, children and adults. WB Saunders, Orlando, FL1996: 729Google Scholar Medications generally should be added one by one until adequate control is achieved. Table 3Pharmacologic step therapy of chronic asthma during pregnancyCategoryFrequency/severity of symptomsPulmonary function*(untreated)Step therapyMild<3 Times per week; nocturnal symptoms 80%Inhaled β2-antagonists as neededModerate≥3 Times per week; exacerbations affect sleep or activity60-80%Inhaled cromolyn; substitute inhaled beclomethasone; add oral theophyllineSevereDaily; limited activity; frequent nocturnal symptoms; frequent acute exacerbations<60%Above plus oral corticosteroids (burst for active symptoms, alternate day or daily if necessary)*FEV1 or PEF based on the norm for the patient, which may be standardized norms or personal best. FEV1, forced expiratory volume in 1 second; PEF, peak expiratory flow.From Schatz M, Zeiger RS. Asthma and allergy during pregnancy. In: Bierman CW, Pearlman DS, Schaprio GG, Busse WW, editors. Allergy, asthma, and immunology from infancy to adulthood. 3rd ed. Orlando, FL: WB Saunders, 1996. p. 727-42. By permission. Open table in a new tab Recent data confirm that inhaled corticosteroids reduce the frequency of asthma exacerbations during pregnancy.20Wendel PJ Ramin SM Barnett-Hamm C et al.Asthma treatment in pregnancy: a randomized controlled study.Am J Obstet Gynecol. 1996; 175: 150-154Abstract Full Text Full Text PDF PubMed Scopus (130) Google Scholar, 21Stenius-Aarniala BSM Hedman J Teramo KA. Acute asthma during pregnancy.Thorax. 1996; 51: 411-414Crossref PubMed Scopus (172) Google Scholar Although the data suggest that systemic corticosteroids could increase the risk of preeclampsia,10Stenius-Aarniala R Piirila P Teramo K. Asthma and pregnancy: a prospective study of 198 pregnancies.Thorx. 1988; 43: 12-18Crossref PubMed Scopus (225) Google Scholar reduced intrauterine growth,15Perlow JH Montgomery D Morgan MA Towers CV Porto M Severity of asthma and perinatal outcome.Am J Obstet Gynecol. 1992; 167: 963-967Abstract Full Text PDF PubMed Scopus (193) Google Scholar, 16Reinisch JM Simon NG Karow WG Gandelman R. Prenatal exposure to prednisone in humans and animals retards intrauterine growth.Science. 1978; 202: 436-438Crossref PubMed Scopus (479) Google Scholar or infant prematurity,15Perlow JH Montgomery D Morgan MA Towers CV Porto M Severity of asthma and perinatal outcome.Am J Obstet Gynecol. 1992; 167: 963-967Abstract Full Text PDF PubMed Scopus (193) Google Scholar since severe asthma can be associated with maternal and/or fetal mortality,9Schatz M. Asthma and pregnancy.Immunol Allergy Clin North Am. 1996; 16: 893-916Abstract Full Text Full Text PDF Scopus (7) Google Scholar benefit-risk considerations still favor using systemic corticosteroids when indicated for severe asthma during pregnancy.3National Asthma Education Program Report of the Working Group on Asthma and Pregnancy management of asthma during pregnancy. NIH publication 93-3279A, Bethesda, Md.:September 1993Google Scholar *FEV1 or PEF based on the norm for the patient, which may be standardized norms or personal best. FEV1, forced expiratory volume in 1 second; PEF, peak expiratory flow. From Schatz M, Zeiger RS. Asthma and allergy during pregnancy. In: Bierman CW, Pearlman DS, Schaprio GG, Busse WW, editors. Allergy, asthma, and immunology from infancy to adulthood. 3rd ed. Orlando, FL: WB Saunders, 1996. p. 727-42. By permission. The recommended management of acute asthma during pregnancy is described in Table 4.3National Asthma Education Program Report of the Working Group on Asthma and Pregnancy management of asthma during pregnancy. NIH publication 93-3279A, Bethesda, Md.:September 1993Google Scholar, 19Schatz M Zeiger RS. Asthma and allergy during pregnancy.in: 3rd ed. Allergy, clinical immunology and asthma management in infants, children and adults. WB Saunders, Orlando, FL1996: 729Google Scholar In addition to medications, oxygen (to maintain a Po2 G70 mm Hg or pulse oximetry ≥95%) and intravenous hydration (at least 100 ml/hour initially) are important in the management of acute gestational asthma. Table 4Pharmacologic management of acute asthma during pregnancyNebulized β2-agonist bronchodilatorUp to three doses in first 60 to 90 minutesEvery 1 to 2 hours thereafter until adequate responseNebulized ipratropiumIntravenous methylprednisone (with initial therapy in patients on regular corticosteroids and for those with poor response during the first hour of treatment)1 mg/kg every 6 to 8 hoursTaper as patient improvesConsider intravenous aminophylline in hospitalized patients not responding to the above. If it is to be used:6 mg/kg loading dose0.5 mg/kg per hour initial maintenance dosageAdjust rate to keep theophylline level between 8 to 12 μg/mLConsider subcutaneous terbutaline 0.25 mg if patient not responding to the foregoing therapyFrom Schatz M, Zeiger RS. Asthma and allergy during pregnancy. In: Bierman CW, Pearlman DS, Schapiro GG, Busse WW, editors. Allergy, asthma, and immunology from infancy to adulthood. 3rd ed. Orlando, FL: WB Saunders. 1996. p. 727-42. By permission. Open table in a new tab Additional information about the management of acute gestational asthma has been recently presented elsewhere.9Schatz M. Asthma and pregnancy.Immunol Allergy Clin North Am. 1996; 16: 893-916Abstract Full Text Full Text PDF Scopus (7) Google Scholar From Schatz M, Zeiger RS. Asthma and allergy during pregnancy. In: Bierman CW, Pearlman DS, Schapiro GG, Busse WW, editors. Allergy, asthma, and immunology from infancy to adulthood. 3rd ed. Orlando, FL: WB Saunders. 1996. p. 727-42. By permission. Substantial symptoms of rhinitis have been reported in approximately 30% of pregnant women.22Mabry RL. Rhinitis of pregnancy.South Med J. 1986; 79: 965-971Crossref PubMed Scopus (120) Google Scholar Essentially, any of the recognized forms of rhinitis may occur during pregnancy, but the most common types appear to be allergic rhinitis, bacterial rhinosinusitis, rhinitis medicamentosa, and vasomotor rhinitis.1Schatz M, Zeiger RS. Diagnosis and management of rhinitis during pregnancy. Allergy Proc 988;9:545-54.Google Scholar Many women notice some increase in nasal congestion associated with nasal dryness and epistaxis during pregnancy. These symptoms are apparently caused by the previously mentioned nasal vascular pooling. In some women, this nasal congestion becomes very troublesome and requires treatment; such vasomotor rhinitis usually improves postpartum. Few data exist on the clinical effect of pregnancy on rhinitis or the effect of rhinitis on pregnancy. As mentioned earlier, it seems unlikely that gestational rhinitis would have any direct adverse effect on the course of pregnancy, but severe rhinitis could indirectly affect pregnancy adversely. The etiology of rhinitis during pregnancy can usually be determined from the history, physical examination, and nasal cytology.1Schatz M, Zeiger RS. Diagnosis and management of rhinitis during pregnancy. Allergy Proc 988;9:545-54.Google Scholar The use of blood tests to confirm the presence of specific IgE has been discussed previously. Because the classic symptoms and signs of sinusitis were absent in nearly one half of the pregnant women with proven sinusitis in one study,23Sorri M Hartikainen-Sorri AL Karja J. Rhinitis during pregnancy.Rhinology. 1980; 18: 83-86PubMed Google Scholar clinical findings and a high index of suspicion may be supplemented by other diagnostic procedures. The use of A-mode ultrasonography is limited by the occurrence of false-negative and false-positive results.1Schatz M, Zeiger RS. Diagnosis and management of rhinitis during pregnancy. Allergy Proc 988;9:545-54.Google Scholar Because the radiation exposure associated with sinus radiographs is small and is reduced by abdominal or pelvic shielding,2Schatz M, Hoffman CP, Zeiger RS, Falkoff R, Macy E, Mellon M. The course and management of asthma and allergic disease during pregnancy. In: Middleton E, Reed CE, Ellis EF, et al. editors. Allergy: principles and practices. 5th ed. St. Louis: Mosby. In press.Google Scholar sinus radiographs may be used during pregnancy when necessary to confirm or establish the diagnosis of sinusitis, especially if the patient is not responding adequately to treatment. Diagnostic sinus irrigations may be necessary during pregnancy in patients with abnormal sinus radiographs who are not responding to therapy. Medication choices are based on available data regarding the use of antihistamines and decongestants during pregnancy, data on the gestational use of asthma medications (i.e., cromolyn, inhaled corticosteroids) that have been adapted for topical intranasal use, and the relative efficacy of the various medications for specific rhinitis syndromes.2Schatz M, Hoffman CP, Zeiger RS, Falkoff R, Macy E, Mellon M. The course and management of asthma and allergic disease during pregnancy. In: Middleton E, Reed CE, Ellis EF, et al. editors. Allergy: principles and practices. 5th ed. St. Louis: Mosby. In press.Google Scholar A recent detailed review of gestational antihistamine data24Schatz M Petilli D. Antihistamines and pregnancy.Ann Allergy Asthma Immunol. 1997; 78: 157-159Abstract Full Text PDF PubMed Scopus (73) Google Scholar concluded that chlorpheniramine should be considered the antihistamine of choice during pregnancy. If chlorpheniramine proves ineffective or is poorly tolerated, tripelennamine was suggested. Newer second-generation antihistamines would generally be reserved for patients who clearly need an antihistamine but who are experiencing intolerable side effects from chlorpheniramine or tripelennamine; ideally, these second-generation antihistamines would be used only after the first trimester. The optimal specific second-generation antihistamine to use is less clear.24Schatz M Petilli D. Antihistamines and pregnancy.Ann Allergy Asthma Immunol. 1997; 78: 157-159Abstract Full Text PDF PubMed Scopus (73) Google Scholar Cetirizine and loratadine do not cause adverse effects in animals, but there are minimal data on their human effects; although some reassuring human data exist for terfenadine, animal studies have revealed some adverse effects of this drug. Pseudoephedrine is considered the oral decongestant of choice for use during pregnancy.3National Asthma Education Program Report of the Working Group on Asthma and Pregnancy management of asthma during pregnancy. NIH publication 93-3279A, Bethesda, Md.:September 1993Google Scholar However, recent case-control studies have associated first-trimester pseudoephedrine (and other decongestant) use with an increased risk of infant gastroschisis.25Werler MM Mitchell AA Shapiro S. First trimester maternal medication use in relation to gastroschisis.Teratology. 1992; 45: 361-367Crossref PubMed Scopus (169) Google Scholar, 26Torfs CP Katz EA Bateson TF Lam PK Curry CJ. Maternal medications and environmental exposures as risk factors for gastroschisis.Teratology. 1996; 54: 84-92Crossref PubMed Scopus (216) Google Scholar The baseline risk of 1 to 2 per 10,000 births in the general population appears to increase to 2 to 6 in 10,000 births in women receiving pseudoephedrine in the first trimester. Although this potential risk should be disclosed to the patient, and some patients may wish to defer the use of any decongestant until after the first trimester on this basis, the potential benefit of pseudoephedrine may warrant this degree of increased risk in other patients. Cultures of sinus aspirates obtained during pregnancy have shown the most common sinus pathogens to be Haemophilus influenzae and Streptococcus pneumoniae.23Sorri M Hartikainen-Sorri AL Karja J. Rhinitis during pregnancy.Rhinology. 1980; 18: 83-86PubMed Google Scholar Amoxicillin is thus the initial antibiotic of choice in the management of sinusitis during pregnancy in women who are not allergic to penicillin. Erythromycin is recommended for the penicillin-allergic patient with gestational sinusitis, and the addition of sulfisoxazole may be considered in early or midpregnancy if the patient does not respond in 5 to 7 days. Our experience suggests that 3 weeks of therapy is superior to a 10- to 14-day course for preventing the development of recurrent sinusitis during pregnancy. Oxymetazoline nose spray or drops (for <5 days) and pseudoephedrine may also be helpful as adjunctive and symptomatic therapy for gestational bacterial rhinosinusitis. Amoxicillin plus clavulanate, cefaclor, cefuroxime, or possibly erythromycin plus sulfisoxazole (in early or midpregnancy) may be considered for women with unequivocal clinical sinusitis who are not responding to amoxicillin. If improvement does not ensue, sinus radiographs should be obtained, and sinus irrigation may be necessary as both a diagnostic and a therapeutic modality. The diagnosis and management of airway disease in the senior citizen requires special consideration because of the physiologic, psychologic, and psychosocial changes that accompany normal aging.27National Asthma Education Program Working Group Report: considerations for diagnosing and managing asthma in the elderly. NIH publication 96-3662, Bethesda, Md.:February 1996Google Scholar In addition, senior citizens have an increased frequency of concomitant medical conditions that may influence the diagnosis or therapy of asthma or rhinitis. In the elderly, the differential diagnosis of asthma is more likely to include chronic obstructive pulmonary disease (COPD), "cardiac asthma" due to left ventricular failure,28Snashall PD Chung KF. Airway obstruction and bronchial hyperresponsiveness in left ventricular failure and mitral stenosis.Am Rev Respir Dis. 1991; 144: 945-956Crossref PubMed Scopus (85) Google Scholar myocardial ischemia, or pulmonary embolism.27National Asthma Education Program Working Group Report: considerations for diagnosing and managing asthma in the elderly. NIH publication 96-3662, Bethesda, Md.:February 1996Google Scholar Many elderly patients with asthma have a persistent degree of airflow obstruction, even when optimally treated.29Braman SS Kaemmerien JT Davis SM. Asthma in the elderly. A comparison between patients with recently acquired and long-standing diseases.Am Rev Respir Dis. 1991; 143: 336-340Crossref PubMed Scopus (192) Google Scholar, 30Burrows B Barbee RA Cline MG Knudson RJ Lebowitz MD. Characteristics of asthma among elderly adults in a sample of the general population.Chest. 1991; 100: 935-942Crossref PubMed Scopus (220) Google Scholar Differentiating asthma with a component of fixed obstruction from COPD may be particularly challenging. A 2-week trial of oral corticosteroid therapy, monitoring both the subjective and pulmonary-function response, may be necessary to reliably differentiate asthma from COPD.27National Asthma Education Program Working Group Report: considerations for diagnosing and managing asthma in the elderly. NIH publication 96-3662, Bethesda, Md.:February 1996Google Scholar Home peak-flow monitoring can be useful in elderly patients as in other patients, especially in those who are poor perceivers of symptom severity, those who require emergency-department care for exacerbations, or those who have coexistent heart or lung diseases that peak-flow monitoring may help differentiate. However, the usefulness of home monitoring by senior citizens with asthma may be limited by certain effects of the aging process, such as pulmonary physiologic changes or physical or cognitive disabilities.27National Asthma Education Program Working Group Report: considerations for diagnosing and managing asthma in the elderly. NIH publication 96-3662, Bethesda, Md.:February 1996Google Scholar Symptom diaries represent an alternative to home peak-flow monitoring that may be more appropriate for some senior citizens with asthma. Clinical experience and some studies show that the following symptom-diary changes are particularly indicative of poor asthma control27National Asthma Education Program Working Group Report: considerations for diagnosing and managing asthma in the elderly. NIH publication 96-3662, Bethesda, Md.:February 1996Google Scholar: nocturnal or early-morning awakenings with wheeze or cough, increased cough and/or sputum, increased use of inhaled β-agonists, decreased tolerance to exercise or daily activities, and increased intensity of dyspnea. Several nonpharmacologic aspects of asthma management may require modification or special emphasis in the senior citizen with asthma.27National Asthma Education Program Working Group Report: considerations for diagnosing and managing asthma in the elderly. NIH publication 96-3662, Bethesda, Md.:February 1996Google Scholar Because of mental or physical impairments that may accompany aging, elderly patients may require additional education to understand the proper use of medication, especially regarding the use of metered-dose inhalers. Avoiding asthma triggers may more frequently include avoiding certain medications, used for other diseases, that may exacerbate asthma (e.g., β-blockers, nonsteroidal antiinflammatory drugs in aspirin-sensitive subjects) or cough (e.g., angiotensin converting enzyme [ACE] inhibitors). In addition, since respiratory infections are important asthma triggers, influenza and pneumococcal immunizations are strongly recommended for elderly patients with asthma. Therapeutic considerations for the senior citizen with asthma include special considerations with regard to efficacy and side effects. Regarding efficacy, inhaled corticosteroids may be the inhaled anti-inflammatory medications of choice, since nedocromil and cromolyn have been primarily studied in younger, more allergic patients.27National Asthma Education Program Working Group Report: considerations for diagnosing and managing asthma in the elderly. NIH publication 96-3662, Bethesda, Md.:February 1996Google Scholar Moreover, as compared with patients without COPD, patients with mixed asthma and COPD may need more bronchodilators, be more responsive to ipratropium, and be less responsive to anti-inflammatory therapy.24Schatz M Petilli D. Antihistamines and pregnancy.Ann Allergy Asthma Immunol. 1997; 78: 157-159Abstract Full Text PDF PubMed Scopus (73) Google Scholar The side effects of asthma medications that may be more problematic or more frequent in senior citizens with asthma are summarized in Table 5.27National Asthma Education Program Working Group Report: considerations for diagnosing and managing asthma in the elderly. NIH publication 96-3662, Bethesda, Md.:February 1996Google Scholar Allergic rhinitis is an uncommon cause of perennial rhinitis in senior citizens over 65 years of age.31Lund VJ Aaronson DW Bousquet J et al.International consensus report on the diagnosis and management of rhinitis.Allergy. 1994; 49: 21PubMed Google Scholar More commonly, rhinitis in the elderly is due to cholinergic hyperreactivity (associated with profuse watery rhinorrhea, which may be triggered by eating), α-adrenergic hyporeactivity (congestion associated with antihypertensive drug therapy), or sinusitis. Watery rhinorrhea in the elderly commonly responds to intranasal ipratropium.32Mygind N Borum P Anticholinergic treatment of watery rhinorrhea.Am J Rhinol. 1990; 4: 1-5Crossref Scopus (37) Google Scholar Discontinuation of the causative drug would be the ideal treatment of congestion due to an antihypertensive agent, but this is frequently not possible. Although α-adrenergic agonists must be used with caution in hypertensive patients, recent data suggest that pseudoephedrine may not increase the blood pressure in patients with controlled hypertension.33Coates ML Rembold CM Farr BM. Does pseudoephedrine increase blood pressure in patients with controlled hypertension.J Fam Prac. 1995; 45: 22-26Google Scholar Other possible decongestant side effects of concern in the elderly include urinary retention in patients with prostatic hypertrophy, cardiac stimulation, and central nervous system stimulation.31Lund VJ Aaronson DW Bousquet J et al.International consensus report on the diagnosis and management of rhinitis.Allergy. 1994; 49: 21PubMed Google Scholar The anticholinergic effects of first-generation antihistamines may cause bladder disturbances or problems with visual accommodation in senior citizens, and sedation may also be a problem. Second-generation antihistamines, which lack anticholinergic or sedative properties, would generally be preferred.34McCue JD. Safety of antihistamines in the treatment of allergic rhinitis in elderly patients.Arch Fam Med. 1996; 5: 464-468Crossref PubMed Scopus (24) Google Scholar However, terfenadine and astemizole may cause cardiac arrhythmias under certain circumstances,34McCue JD. Safety of antihistamines in the treatment of allergic rhinitis in elderly patients.Arch Fam Med. 1996; 5: 464-468Crossref PubMed Scopus (24) Google Scholar especially with hypokalemia or hypomagnesemia.27National Asthma Education Program Working Group Report: considerations for diagnosing and managing asthma in the elderly. NIH publication 96-3662, Bethesda, Md.:February 1996Google Scholar Elderly patients may also be more likely to be treated with β-blockers, which generally contraindicate immunotherapy. Pregnancy and aging are conditions that may affect the diagnosis and management of asthma and rhinitis. However, knowledge of the interactions between these conditions and diseases of the airways should facilitate safe and effective therapy, even under these special circumstances.