Allergy PA at Arizona Asthma and Allergy Institute

Heather O'Connell, PA-C

Improving Patient and Clinician Education on the Unified Airway

One of the practical challenges of the unified airway framework is that patients don't come in thinking about it. A patient presenting to pulmonology with poorly controlled 

 has been living with their lungs as the problem. A patient who has never connected their rhinitis to their wheeze needs someone to make that case — clearly, concisely, and in a way that motivates action. 

For Heather O'Connell, PA-C, MS, physician assistant and certified asthma educator at Arizona Asthma and Allergy Institute in Phoenix, Arizona, and President-Elect of the Association of Physician Assistants in Allergy, Asthma, and Immunology, that patient conversation is one of the most important things that happens in a clinic visit for unified airway disease. 

Association of Pulmonary Advanced Practice Providers (APAPP) National Conference, held June 28-20 in Colorado Springs

"It is a sell to the patient sometimes," she acknowledged — more so when a patient presents to pulmonology without having previously thought about allergies or sinus disease, and less so when a patient in an allergy clinic already has rhinitis symptoms they recognize as burdensome.

Her go-to tool for making the connection real: the work of Gert-Jan Braunstahl, whose 2001 study at Erasmus University Medical Center in Rotterdam demonstrated that nasal allergen challenge in patients with seasonal allergic rhinitis — but without asthma — produced bronchial inflammation not present before the challenge. In the reciprocal experiment, allergen delivered into the bronchus produced nasal inflammation.

 "That can kind of click with a patient who hasn't really gotten it," O'Connell said. "If they're immunologically connected that way — okay, that makes sense."

From there, the clinical approach is structured and outcome-driven. O'Connell described prescribing treatments — including over-the-counter options — as formal recommendations rather than suggestions, then setting a defined window of 6 weeks for the patient to return for objective reassessment: FEV₁, FeNO, and albuterol use frequency. Giving a patient a prescription, even for an intranasal corticosteroid, signals clinical seriousness in a way that a verbal recommendation does not. And measuring outcomes at follow-up gives both patient and provider evidence of whether treating the upper airway is moving the needle on asthma control. "Most of the time it does," she said.

On the question of whether APPs bring particular advantages to this work, O'Connell offered 2 observations. The first is practical: many APPs entered pulmonology or allergy from primary care or general medicine backgrounds, which means they already think beyond single-organ disease. The second is relational: patients frequently describe APPs as approachable and communicative in ways that facilitate the kind of extended education these conversations require. 

"I hear it from patients all the time — I love seeing a PA, I love seeing an NP, because I feel like you understand what I'm saying," she said. Whether that reflects training, time, or something more individual, it translates into clinical utility in a disease that demands patient engagement to manage well.

O’Connell had no relevant disclosures to report.

Braunstahl GJ, Overbeek SE, Kleinjan A, Prins JB, Hoogsteden HC, Fokkens WJ. Nasal allergen provocation induces adhesion molecule expression and tissue eosinophilia in upper and lower airways. 

 2001;107(3):469–476. doi:10.1067/mai.2001.113046

O'Connell H. Treating allergic asthma outside of the airways: the United Airway. Presented at: Association of Pulmonary Advanced Practice Providers Annual Meeting (APAP 2026); Las Vegas, NV

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Heather O'Connell, PA-C, an allergy and asthma PA, describes how she uses clinical research and structured follow-up to shift patient thinking about the nose-lung connection, and why APPs bring a distinct advantage to that conversation.

Collaboration is Key in Treating Asthma in a Unified Airway, With Heather O'Connell, PA-C

The unified airway is not an idea that lives comfortably inside any single specialty. Pulmonologists manage the lungs. ENTs manage the nose and sinuses. Allergists manage immunologic triggers. And because most providers are trained to think within those silos, patients who sit at the intersection — with rhinitis driving 

, or sinusitis complicating airway disease — can fall through the cracks between them. 

That gap is one Heather O'Connell, PA-C, MS, physician assistant and certified asthma educator at Arizona Asthma and Allergy Institute in Phoenix, Arizona, and President-Elect of the Association of Physician Assistants in Allergy, Asthma, and Immunology, addressed directly in her session at the 

"We all siphon off into our own medical specialty and think about the things we're assigned to — but that's just not how the body works," O'Connell said. Closing the gap requires both guideline-level consensus and practical, on-the-ground relationship building within clinical communities.

On the guideline side, the Allergic Rhinitis and its Impact on Asthma (ARIA) initiative — a World Health Organization collaboration — has produced both evidence-based treatment recommendations and explicit calls to action for cross-specialty collaboration in managing unified airway disease.1 The most recent ARIA–EAACI 2024–2025 guidelines continue that work, with updated recommendations on intranasal treatments including a strong recommendation for combining an intranasal antihistamine with an intranasal corticosteroid over monotherapy in patients with moderate-to-severe allergic rhinitis unlikely to respond to a single agent.

 O'Connell noted that while the guidelines exist and are regularly updated, provider awareness of them — particularly among clinicians who encounter these patients at the margins of their specialty — remains inconsistent.

Her recommendation to APPs navigating these gaps: meet the people in your institution who see different pulmonary conditions, who read chest imaging, who manage rhinitis and nasal polyps. A thoughtful ENT referral for a patient with severe asthma and suspected NERD can be the pivot point in a patient's care — but only if the referral happens. That kind of collaboration, she noted, develops not through guidelines alone but through the kind of cross-specialty networking that conferences like APAP make possible. "The first step is knowledge — knowledge that this is in fact one airway, one organ system," she said.

O’Connell has no disclosures to report.

Sousa-Pinto B, Vieira RJ, Bousquet J, et al. Allergic Rhinitis and Its Impact on Asthma (ARIA)–EAACI guidelines — 2024–2025 revision: Part I — guidelines on intranasal treatments. 

O'Connell H. Treating allergic asthma outside of the airways: the United Airway. Presented at: Association of Pulmonary Advanced Practice Providers Annual Meeting (APAP 2026); Las Vegas, NV.

O'Connell, an allergy and asthma PA, says the united airway concept has direct implications for how providers from different specialties recognize, refer, and communicate with one another about the same patient.


The United Airway in Practice: Rhinitis, Nasal Polyps, and NERD Are Drivers of Asthma Burden

 without evaluating the nose and sinuses is like managing half a disease. That was the central message of a session at 

 delivered by Heather O'Connell, PA-C, MS, Physician Assistant and Certified Asthma Educator at Arizona Asthma and Allergy Institute in Phoenix, Arizona, and President-Elect of the Association of Physician Assistants in Allergy, Asthma, and Immunology.

O'Connell's talk was built around the unified airway concept — the principle that the nose, sinuses, and lungs constitute a single functional organ unit rather than separate anatomical territories managed by different specialties. Under this framework, allergic rhinitis and asthma are not 2 distinct diseases but different manifestations of the same underlying inflammatory process expressed at opposite ends of the airway.

 The session focused on 3 upper airway conditions that are frequently present in asthma patients, often underrecognized, and meaningfully modifiable: allergic rhinitis, chronic sinusitis with and without nasal polyps, and NSAID-exacerbated respiratory disease (NERD).

On allergic rhinitis, O'Connell emphasized its role not just as a comorbidity but as a risk factor for asthma development and a driver of exacerbations. She cited a 2018 study published in the 

Journal of Allergy and Clinical Immunology

 demonstrating that rhinitis was the most prevalent risk factor for 30-day readmission following an asthma hospitalization — outranking obesity, hypertension, tobacco use, and diabetes.

 She also discussed data showing that fractional exhaled nitric oxide (FeNO) levels in children with allergic rhinitis may function as a marker of subclinical T2 inflammation predictive of asthma development: in one trial she reviewed, children with allergic rhinitis and a FeNO greater than 35 were the only subgroup who went on to develop asthma. Allergy immunotherapy was highlighted as an intervention with both preventive and therapeutic implications — with some studies in seasonal allergic rhinitis showing up to 75% reduction in asthma exacerbations, approaching the efficacy seen with biologic therapy.

Shifting to chronic sinusitis, O'Connell reframed the relevant clinical question from whether a patient has nasal polyps to whether their disease is T2-high or T2-low, with distinct biomarker profiles and treatment implications for each. She noted that chronic sinusitis is substantially more prevalent in patients with severe asthma, and that prevalence scales with asthma severity — making it both a comorbidity to manage and a potential signal of underlying disease burden. Biologic therapies approved for both T2-high chronic sinusitis with nasal polyps and T2-high asthma were discussed as an area of clinical overlap. She also recommended a practical screening step that is often overlooked: obtaining a CT scan of the sinuses in patients who have been hospitalized for an asthma exacerbation.

The third condition, NERD — formerly described as Samter's triad of asthma, chronic sinusitis with nasal polyps, and sensitivity to COX-1 inhibitors — was presented as a frequently missed diagnosis because its classic presentation is increasingly uncommon in clinical practice. The disease typically evolves over years: patients may present first with rhinitis, develop nasal polyps years later, and then develop asthma approximately 2 years after polyp onset. Because NSAID use has declined broadly, many patients have simply not yet been exposed to a COX-1 inhibitor, meaning the classic aspirin or ibuprofen reaction may never have occurred at the time of presentation. O'Connell urged APPs to proactively ask patients with severe asthma and nasal polyps whether any recent exacerbation was preceded by NSAID use, as the temporal connection is often not made by patients spontaneously. She also noted that alcohol intolerance is present in approximately 75–85% of patients with NERD — making it a useful screening question — and that viral upper respiratory infections represent the most common exacerbation trigger in this population, not NSAIDs.

"Allergic rhinitis and asthma are not 2 separate diseases, but rather one single unique disease entity with just different manifestations on opposite ends of the airway," O'Connell said.

O’Connell H. Treating Allergic Asthma Outside of the Airways. Presented at: APAPP 2026 National Conference, June 18-20; Las Vegas, Nevada.

Brożek JL, Bousquet J, Agache I, et al. Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines — 2016 revision. 

Tay TR, Hew M. Comorbid "treatable traits" in difficult asthma: current evidence and clinical evaluation. 

Heather O'Connell, PA-C, makes the case that missing rhinitis, nasal polyps, or NSAID sensitivity is costing patients exacerbations and hospitalizations.


Heather O'Connell, PA-C

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