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Association of Allergic Rhinitis With Change in Nasal Congestion in New Continuous Positive Airway Pressure Users

Educational Objective
To quantify the association between continuous positive airway pressure (CPAP) initiation and change in nasal congestion in general.
1 Credit CME
Key Points

Question  Is baseline rhinitis status (allergic, nonallergic, or none) associated with change in nasal congestion when continuous positive airway pressure (CPAP) is used?

Findings  In this cohort study of 102 participants with newly diagnosed obstructive sleep apnea, CPAP was associated with improved subjective nasal congestion on average, but less so in participants with baseline allergic rhinitis.

Meaning  Baseline allergic rhinitis may predict which patients are more vulnerable to potential congestive effects of CPAP.


Importance  Nasal congestion occurring after continuous positive airway pressure (CPAP) treatment initiation impairs CPAP adherence. Allergic rhinitis is associated with worsening nasal congestion in patients who are exposed to nonallergic triggers. Use of CPAP presents potential nonallergic triggers (eg, humidity, temperature, pressure, and airflow).

Objective  To compare nasal congestion among CPAP users with allergic rhinitis, nonallergic rhinitis, and no rhinitis. We hypothesize that CPAP patients with baseline allergic rhinitis are more likely to experience a worsening of nasal congestion (or less improvement in nasal congestion) compared with patients with no baseline rhinitis.

Design, Setting, and Participants  This prospective cohort study included consecutive patients newly diagnosed with obstructive sleep apnea in a tertiary sleep center who were using CPAP therapy 3 months after diagnosis. Baseline rhinitis status was assigned as allergic rhinitis, nonallergic rhinitis, or no rhinitis, based on questionnaire responses and past allergy testing. Data were collected from 2004 to 2008 and analyzed from July 2019 to February 2020.

Main Outcomes and Measures  At baseline before CPAP exposure and again 3 months later, subjective nasal congestion was measured with the Nasal Obstruction Symptom Evaluation (NOSE) scale and a visual analog scale (VAS), each scored from 0 to 100 (100 = worst congestion). Changes in nasal congestion were tested over 3 months for the whole cohort, within each rhinitis subgroup (paired t test), and between rhinitis subgroups (multivariate linear regression).

Results  The study cohort comprised 102 participants, of whom 61 (60%) were male and the mean (SD) age was 50 (13). The study included 23 (22.5%) participants with allergic rhinitis, 67 (65.7%) with nonallergic rhinitis, and 12 (11.8%) with no rhinitis. Nasal congestion improved from baseline to 3 months in the whole cohort (mean [SD] NOSE score, 38 [26] to 27 [23], mean [SD] change, −10 [23]; 95% CI, −15 to −6; mean [SD] VAS score, 41 [27] to 32 [28]; mean [SD] change, −10 [26]; 95% CI, [−15 to −4]) and in each rhinitis subgroup. Adjusted improvement in nasal congestion at 3 months was significantly less in the allergic rhinitis subgroup compared with the no rhinitis subgroup (positive difference means less improvement) compared with baseline: NOSE score 14 (95% CI, 1 to 28) and VAS score 15 (95% CI, 0 to 30).

Conclusions and Relevance  Initiation of CPAP was associated with improved subjective nasal congestion, but less improvement in patients with baseline allergic rhinitis. Baseline allergic rhinitis may predict which patients are more vulnerable to potential congestive effects of CPAP.

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Article Information

Accepted for Publication: February 10, 2020.

Corresponding Author: Jonathan R. Skirko, MD, MPH, University of Utah, Division of Otolaryngology—Head & Neck Surgery, 100 N Mario Capecchi Dr, Salt Lake City, UT 84113 (jskirko@gmail.com).

Published Online: April 9, 2020. doi:10.1001/jamaoto.2020.0261

Author Contributions: Drs Skirko and Weaver had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Skirko, Shusterman, Weaver.

Acquisition, analysis, or interpretation of data: Skirko, James, Weaver.

Drafting of the manuscript: Skirko.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Skirko.

Obtained funding: Weaver.

Administrative, technical, or material support: All authors.

Supervision: Weaver.

Conflict of Interest Disclosures: Dr Weaver reported grants from the National Institutes of Health and other support from the Department of Veterans Affairs during the conduct of the study. No other disclosures were reported.

Funding/Support: Supported by grants K23 HL068849 (Weaver), R01 HL084139 (Weaver), and T32 DC000018 (Ernest A. Weymuller, Jr., MD) from the National Institutes of Health, and resources from the VA Puget Sound Health Care System, Seattle, Washington.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The contents of this article do not represent the views of the US Department of Veterans Affairs or US government.

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AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 CME points in the American Board of Surgery’s (ABS) Continuing Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

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