What is the management for upper reactive airway disease?

Management of Upper Reactive Airway Disease

Initial Diagnostic Approach

For patients presenting with upper reactive airway disease, clinicians should make a clinical diagnosis based on history and physical examination showing nasal congestion, runny nose, itchy nose, or sneezing, along with findings such as clear rhinorrhea, pale nasal mucosa, and red watery eyes. 1

• Assess for comorbid conditions including asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media, as these frequently coexist and affect treatment outcomes 1
• Do not routinely perform sinonasal imaging in patients with symptoms consistent with upper airway disease 1
• Consider allergy testing (skin or blood IgE) only when patients fail empiric treatment, diagnosis is uncertain, or specific allergen identification is needed to target therapy 1

First-Line Pharmacologic Treatment

For Allergic Rhinitis Component

Intranasal corticosteroids are the strongest recommendation for patients whose symptoms affect quality of life, as they are the most consistently effective treatment. 1

• Prescribe intranasal steroids (e.g., fluticasone propionate) as primary therapy for allergic rhinitis affecting quality of life 1
• Recommend oral second-generation/less sedating antihistamines specifically for patients with primary complaints of sneezing and itching 1
• Consider intranasal antihistamines as an option for seasonal, perennial, or episodic allergic rhinitis 1
• Do NOT offer oral leukotriene receptor antagonists as primary therapy 1

For Upper Airway Cough Syndrome (UACS)

First-generation antihistamines combined with decongestants are the preferred initial treatment for UACS, not intranasal corticosteroids. 1, 2

• Start dexbrompheniramine maleate 6 mg twice daily or azatadine maleate 1 mg twice daily combined with sustained-release pseudoephedrine sulfate 120 mg twice daily 1, 2
• Alternative first-generation options include brompheniramine 12 mg twice daily, chlorpheniramine 4 mg four times daily, or diphenhydramine 25-50 mg four times daily 2
• Initiate with once-daily bedtime dosing for several days before advancing to twice-daily dosing to minimize sedation 2
• Expect improvement within days to 2 weeks of starting treatment 2

Important distinction: First-generation antihistamines work primarily through anticholinergic properties rather than antihistamine effects for UACS, making them more effective than newer antihistamines for non-histamine-mediated upper airway disease 1, 2

Sequential Treatment Algorithm

Step 1: Initial Empiric Therapy

• For allergic rhinitis: Begin intranasal corticosteroids 1
• For UACS: Begin first-generation antihistamine/decongestant combination 1, 2
• Continue treatment for at least 1 month for upper airway symptoms with prominent postnasal drip 1

Step 2: After Cough Resolution (UACS-specific)

• Once cough disappears with initial combination therapy, transition to intranasal corticosteroids 3
• Continue intranasal corticosteroids for 3 months after cough resolution to prevent recurrence 3
• Do NOT discontinue intranasal corticosteroids prematurely—the 3-month continuation is critical 3

Step 3: Inadequate Response to Monotherapy

• Offer combination pharmacologic therapy when single-agent treatment fails 1
• Consider combining intranasal corticosteroid with intranasal antihistamine for moderate to severe symptoms 4
• Avoid using intranasal corticosteroids as monotherapy initially for UACS—they should follow or accompany antihistamine/decongestant combination 3

Step 4: Refractory Cases

• Offer or refer for immunotherapy (sublingual or subcutaneous) when pharmacologic therapy with or without environmental controls provides inadequate symptom response 1
• Consider inferior turbinate reduction for patients with nasal airway obstruction and enlarged inferior turbinates who have failed medical management 1

Treatment of Coexisting Asthma

When upper airway disease coexists with asthma, treating the upper airway inflammation improves both nasal and pulmonary symptoms. 1, 5

• Ensure asthma is well-controlled before initiating immunotherapy, as uncontrolled asthma is an absolute contraindication 1
• Use inhaled corticosteroids as the most consistently effective long-term control medication for persistent asthma 1
• Recognize that treatment of allergic rhinitis with intranasal steroids, cromolyn, antihistamines, and decongestants will also improve pulmonary symptoms of allergic asthma 5
• Consider leukotriene modifiers as pretreatment for patients with aspirin-exacerbated respiratory disease preparing for aspirin desensitization 1

Environmental Controls

• Advise avoidance of known allergens or environmental controls (removal of pets, air filtration systems, bed covers, acaricides) when identified allergens correlate with clinical symptoms 1
• Note that complete allergen avoidance is usually not possible, so pharmacologic therapy remains essential 1

Critical Pitfalls to Avoid

Do NOT use topical nasal decongestants (e.g., oxymetazoline) for more than 5 days, as prolonged use causes rhinitis medicamentosa with rebound nasal edema and congestion. 1, 4

• Avoid first-generation antihistamines when possible in children due to sedation, performance impairment, and anticholinergic effects that may impact school performance 4
• Do not confuse intranasal corticosteroids with nasal decongestants—decongestants are for short-term acute use only (5 days), not maintenance 3
• Monitor for paradoxical bronchospasm with inhaled corticosteroids, which requires immediate discontinuation and alternative therapy 6
• Exercise caution with first-generation antihistamines in older adults due to increased sensitivity, and avoid in patients with glaucoma, symptomatic prostatic hypertrophy, or cognitive impairment 2
• Monitor blood pressure when using combination products with decongestants, particularly in hypertensive patients 2

Special Populations

• Do NOT initiate immunotherapy in pregnant patients, though continuation of maintenance immunotherapy is safe 1
• Patients unable to tolerate injectable epinephrine should not receive immunotherapy due to anaphylaxis risk 1
• Consider acupuncture as an option for patients interested in nonpharmacologic therapy 1