We would like to thank Dr. Kessel and Dr. Toubi for their comments. They first asserted that sensitization to perennial or to seasonal allergens cannot be considered as one group in relation to bronchodilation test results. Although the percentage of patients with positive response to bronchodilators was higher in the perennial when compared with the seasonal allergic rhinitis group, an important message of our study is that also patients with seasonal allergic rhinitis may have reversible bronchoconstriction. We fully agree with their second comment, not addressed in our study, i.e. that a proven connection between the severity of allergic rhinitis and bronchial impairment could be an important issue in defining patients with high risk of developing asthma. However, as recently reported (1), when evaluating reversibility to bronchodilation, allergic rhinitis severity should probably be scored using nasal airflow limitation rather than using the ARIA classification (mild, moderate and severe), as Dr. Kessel and Dr. Toubi suggested. The third issue is related to the positive effect of nasal treatment on lung function in children with allergic rhinitis, also shown by the results of the study performed by Dr. Kessel and Dr. Toubi (2). Their findings further support the concept of a tight connection between nasal inflammation and airflow limitation of hyperreactivity (3). This link has also been highlighted by the American Guidelines on rhinitis when state that a reduced FEF25-75 may be considered a marker of early bronchial pathology in patients with allergic rhinitis (4). Interestingly, the up-dated ARIA document, addressing the association between allergic rhinitis and asthma (5), suggests that FEV1 may not be sensitive enough to detect small airways obstruction in some rhinitis patients, quoting two recent papers on FEF25-75, in which this parameter was identified as predictor of early bronchial involvement in this patient population (6, 7).

To further evaluate this possibility, we conducted a preliminary analysis in adolescents with allergic rhinitis to define a cut-off value of FEV1 for identifying overt impaired FEF25-75 values (such as ≤65% of predicted). This cross-sectional study included 120 subjects (71 men, mean age 15.2 years) with AR but no current or past asthma symptoms. Twenty-eight patients (23%) showed FEF25-75 values ≤65%. By Receiver Operator Curve (ROC) analysis, we were able to show that a FEV1 of 83% was the optimal cut-off value to discriminate patients with FEF25-75 ≤ 65% from those with FEF25-75 > 65% (Fig. 1). The associated sensitivity and specificity were 96.4% (95% CI 93.1–99.7) and 88% (95% CI 82.2–93.8), respectively. The positive and negative predictive values were 71.1% and 98.8%. The corresponding area under the ROC curve of 0.92 (95% CI 0.85–0.96) indicated a good discriminating ability (Fig. 1). Therefore, FEV1 value still in the lower part of the adult normal range (8) could be associated in adolescents with allergic rhinitis with severe reduction of forced expiratory flows.


Figure 1.  Discrimination ability of the chosen cut-off of 83% for the FEV1 values in patients with FEF25-75 ≤ 65% and FEF25-75 > 65%.

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  2. References
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    Ciprandi G, Pistorio A, Tosca MA, Cirillo I, Marseglia GL. Relationship between responses to nasal decongestion testing and to bronchodilation testing in patients with allergic rhinitis alone. Eur J Inflamm 2009;7:153160.
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    Kessel A, Halloub H, Bamberger E, Kugelman A, Toubi E. Abnormal spirometry in children with persistent allergic rhinitis due to mite sensitization: the benefit of nasal corticosteroids. Pediatr Allergy Immunol 2008;19:6162.
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    Sale R, Silvestri M, Battistini E, Defilippi AC, Sabatini F, Pecora S et al. Nasal inflammation and bronchial reactivity to methacholine in atopic children with respiratory symptoms. Allergy 2003;58:11711175.
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    Bousquet J, Khaltaev N, Cruz AA, Denburg J, Fokkens WJ, Togias A et al. Allergic Rhinitis and its Impact on Asthma (ARIA) 2008 Update (in collaboration with the World Health Organization, GA2LEN and AllerGen). Allergy 2008;63(Suppl. 86):8160.
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    Cirillo I, Klersy C, Marseglia GL, Vizzaccaro A, Pallestrini E, Tosca MA et al. Role of FEF25-75 as predictor of bronchial hyperreactivity in allergic patients. Ann Allergy Asthma 2006;96:692700.
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    Ciprandi G, Cirillo I, Klersy C, Marseglia GL, Vizzaccaro A, Pallestrini E et al. Role of FEF25-75 as an early marker of bronchial impairment in patients with seasonal allergic rhinitis. Am J Rhinol 2006;20:641647.
  • 8
    Global strategy for asthma management and prevention, updated 2009. Available at: Accessed January 2010.