What is the recommended treatment for allergic rhinitis patients at risk of post-operative bronchospasm?

Management of Allergic Rhinitis Patients at Risk of Post-Operative Bronchospasm

Intranasal corticosteroids are the first-line treatment for allergic rhinitis patients at risk of post-operative bronchospasm, as they effectively control nasal symptoms while reducing airway inflammation that could contribute to bronchospasm. 1, 2

Pre-Operative Management Algorithm

First-Line Therapy

• Intranasal corticosteroids (e.g., fluticasone propionate, mometasone furoate)
  • Start at least 1-2 weeks before surgery if possible
  • Continue through perioperative period
  • Effectively controls all allergic rhinitis symptoms including congestion 1, 3
  • Reduces airway inflammation that may contribute to bronchospasm 4

Second-Line/Adjunctive Therapy

• Oral second-generation antihistamines

  • Particularly effective for sneezing and itching symptoms 1, 5
  • Less sedating than first-generation antihistamines
  • May be used in combination with intranasal steroids for enhanced symptom control 2

• Intranasal antihistamines

  • Option for patients with seasonal, perennial, or episodic allergic rhinitis 1
  • Can be used in combination with intranasal steroids for enhanced efficacy 2

For Inadequate Response to First-Line Therapy

• Combination therapy options:
  • Intranasal corticosteroid + intranasal antihistamine (superior to either alone) 2
  • Consider allergen immunotherapy for long-term management in patients with inadequate response to pharmacologic therapy 1

Treatments to Avoid

• Oral leukotriene receptor antagonists should not be used as primary therapy 1
• Topical or oral decongestants are not recommended as adjunctive treatment 1

Perioperative Management

For Patients Experiencing Bronchospasm

1. First-line treatment: Inhaled bronchodilators 1
2. For persistent life-threatening bronchospasm:
   • Continue inhaled bronchodilators
   • Consider adding IV bronchodilators 1

Additional Considerations

• Environmental controls: Advise avoidance of known allergens when possible 1
• Inferior turbinate reduction: Consider for patients with nasal airway obstruction and enlarged inferior turbinates who have failed medical management 1
• Assess for comorbidities: Document presence of asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media 1

Special Considerations

• Nasally inhaled corticosteroids through a spacer may provide concomitant control of allergic rhinitis and asthma, which could be beneficial in reducing risk of post-operative bronchospasm 4

• For severe symptoms unresponsive to standard therapy:

  • Consider a short course (5-7 days) of oral corticosteroids pre-operatively 2
  • This should be discussed with the anesthesia team to coordinate timing

• Avoid antihistamines in acute bacterial rhinosinusitis as they are not recommended as adjunctive treatment 1

Post-Operative Management

• Continue intranasal corticosteroids post-operatively
• Monitor for at least 6 hours post-procedure for any signs of bronchospasm 1
• For patients with severe reactions, consider ICU monitoring 1

The evidence strongly supports intranasal corticosteroids as the cornerstone of treatment for allergic rhinitis patients at risk of post-operative bronchospasm, with second-generation antihistamines as effective adjunctive therapy. This approach provides optimal control of allergic symptoms while minimizing the risk of respiratory complications during the perioperative period.