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

Treating asthma without evaluating the nose and sinuses is like managing half a disease. That was the central message of a session at Association of Pulmonary Advanced Practice Providers (APAPP) National Conference, held June 28-20 in Colorado Springs 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.1

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.1,2 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.2 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.2,3

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 had no relevant disclosures to report.

References

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

2. Brożek JL, Bousquet J, Agache I, et al. Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines — 2016 revision. J Allergy Clin Immunol. 2017;140(4):950–958.

3. Tay TR, Hew M. Comorbid "treatable traits" in difficult asthma: current evidence and clinical evaluation. Allergy. 2018;73(7):1369–1382.