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Original Investigation
April 9, 2020

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

Author Affiliations
  • 1Division of Otolaryngology–Head & Neck Surgery, Department of Surgery, University of Utah, Salt Lake City
  • 2Comparative Effectiveness, Cost and Outcomes Research Center, University of Washington, Seattle
  • 3Division of Occupational and Environmental Medicine, Department of Medicine, University of California, San Francisco
  • 4Department of Otolaryngology–Head and Neck Surgery, University of Washington, Seattle
  • 5Surgery Service, Seattle VA Medical Center, Seattle, Washington
JAMA Otolaryngol Head Neck Surg. Published online April 9, 2020. doi:10.1001/jamaoto.2020.0261
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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