19-05-2025
Managing Comorbid Chronic Lung Disease With Allergies
Michael A. Bernstein, MD, can't contain his curiosity when he hears the common claim: This is the worst allergy season ever . 'I feel like the current season is always said to be 'the worst' for allergies, but it's difficult to know how bad any season is until it's actually over,' said Bernstein, a pulmonologist at Stamford Health, Stamford, Connecticut. What's easier to acknowledge, however, is the number of patients requiring treatment for seasonal allergies, including those with chronic lung disease, continues to escalate.
As more patients experience greater allergy symptom severity with each calendar year, Bernstein and other physicians are often establishing appropriate care planning for patients in real time. While there's a certain level of unpredictability to accept with allergies, there's also evidence that defines effective strategies based on each patient's symptom portfolio, age, chronic lung conditions, and the time of year. Many of the protocols used by today's specialists are born out of a better understanding of why seasonal allergies are on the rise and how environmental clues can assist patients.
New Sense of Seasons
Numerous factors are increasing the rate of allergy diagnoses. Among them is a heightened awareness about outdoor and indoor aeroallergens — airborne substances such as pollen from grass, weeds, trees, and plants; fungi and mold spores; dust mites; animal dander; and insect debris that can trigger a cascade of hay fever–related symptoms. But the lead cause of more allergies today is primarily the effect of global climate change, most notably changes in seasonal variation and increased production of pollen. According to the US National Oceanic and Atmospheric Administration (NOAA), the earth's average surface temperature has become consistently warmer since the late 19th century, with 2023 ranking as the warmest year (by a wide margin) since global temperature records began in 1850. The 10 individual warmest years have all occurred since 2014, per the NOAA.
'Because of climate change, the winter season is now shorter,' explained Bernstein. 'When you're robbing days from winter, you're adding days to spring. Whereas allergy season previously started toward the end of April or the beginning of May, we're now seeing it begin early in April or even March. The season now starts further back.'
It is estimated that the typical allergy season is 13 days longer than it once was, said Purvi S. Parikh, MD, an allergist at New York University Langone Health, New York City. 'We have fewer 'frost-free' days today as well, and these are the types of days when pollen can form.'
Compounding the issue is an increase in carbon dioxide levels, which allows for more efficient photosynthesis, leading to more pollen.
'The pollen itself is becoming more allergenic, meaning its structure is evolving to be more likely to cause allergies,' said Parikh, who also pointed to basic human genetics and other circumstances as associated allergy culprits.
'You only need one parent with allergies to increase your risk [of eventually developing allergies], along with lack of exposure to good bacteria and microorganisms that protect us from being allergic,' she said. 'An increase in urban living away from farmland has also done a disservice to our immune systems because urbanization exposes us more to carbon emissions and ozone that worsen with climate change. And the foods that we eat with pesticides or that are processed can also disrupt our internal microbiome and immune systems.'
Consequences for Chronic Lung Disease
Despite the potential for allergy symptoms to mimic various chronic lung conditions, allergy symptoms can likely be identified temporally.
'Ultimately, it's that their clinical symptoms worsen episodically during times when you know the pollen count is high,' said David Beuther, MD, PhD, professor of medicine at National Jewish Health, Denver. 'In addition to their chronic condition, we're also seeing rhinitis — it's itching, sneezing, watery eyes, nasal drainage, congestion — and sometimes, this puts them at risk for worsening lung problems or sinus infections. There's that clinical timing of symptoms that are big clues.'
Beuther estimates that asthma is most likely to occur in conjunction with allergies, followed by chronic obstructive pulmonary disease (COPD), 'because asthma is typically more chronic year-round,' said Beuther. 'For a subset of patients, allergens in the environment are a trigger for their asthma to worsen. But independent of that, patients who have sinus issues caused by allergies can actually lead to their asthma becoming uncontrolled, or not well controlled, when those conditions are most active.'
Inflammation within the nasal passages caused by allergies can lead to enhanced inflammation of the airways and worsen asthma. Additionally, persistent coughing can cause an irritation of the airway, and nerves that become irritated can cause bronchial spasms when they're triggered. 'But there are also asthma patients who say they have no response to allergens,' Beuther said. 'So there's variability. Inflammation caused by seasonal allergies can also disrupt the normal mucosal barrier that serves as the immune system's 'first line of defense,' leaving patients at increased risk of developing upper respiratory tract infections, which are a major driver of asthma and COPD exacerbations.'
As a heterogeneous disease, COPD can mimic allergy symptoms or be exacerbated during allergy season, making it difficult to decipher the cause of symptoms. 'I see many COPD patients who experience worse symptoms when their nasal passages are congested, or they're sneezing or coughing,' said Beuther. 'You may see some patients who say their COPD is worse seasonally, similar to those with asthma. That's important to know.'
Patients with cystic fibrosis, however, are less likely to experience seasonal allergy aggravation of the condition. 'I don't know that we spend a lot of time worrying about allergies with these patients,' said Beuther. 'But what we more often see is that cystic fibrosis affects the nasal passages and the sinuses so much from the disease alone that the allergy issue is not felt to be that much more.'
According to Sobia Farooq, MD, a pulmonologist at Cleveland Clinic, Cleveland, mild to moderate warning signs of an allergy exacerbating a chronic lung condition include increased coughing, especially at night or early morning; chest tightness or discomfort; increased nasal congestion; sneezing; postnasal drip that triggers wheezing; noticeable drop in peak flow readings; and more frequent use of a rescue inhaler.
Warning signs requiring immediate care include shortness of breath during minimal exertion or while at rest, wheezing that doesn't improve with standard medication, lack of relief when using a rescue inhaler, a persistent drop in peak flow below 50% of personal best, difficulty speaking in full sentences, blue lips or fingernails, and showing signs of fatigue or confusion. 'When seasonal allergies start to worsen chronic respiratory symptoms, early recognition is critical,' said Farooq. There are also patients who are diagnosed with perennial rhinitis defined by yearlong nasal congestion and drainage, which can be linked to external triggers or be experienced unrelated to environmental allergens.
'It depends on the patient,' said Bernstein. 'We know that some patients' chronic lung disease is made worse by allergy triggers. But for some, as their lung disease gets worse than it was earlier in their life, they're going to have more impact by the allergens in the air. We don't see as many people 'growing out' of their allergies anymore — which I'm not really sure if that was ever true.'
Treatment Strategies and Suggestions
Multiple options are available for treating seasonal allergies, as well as routes of administration that offer certain tradeoffs, including intranasal medications, pills or liquids, eye drops, and injections.
'I often recommend 24-hour, non-drowsy antihistamines — particularly those that don't cross the blood-brain barrier, so there's no drowsiness or 'brain fog,'' said Parikh. 'Also, steroid nasal sprays, antihistamine nasal sprays, and eye drops. Start your patients on their controller medications for allergies and asthma as early in the year as possible, as it's easier to target allergies proactively rather than retroactively. If they suffer every year, consider immunotherapy or allergy shots, which actually decrease allergies over time and are the closest thing to a 'cure.''
Farooq also suggests the use of sublingual tablets to help with potentially reducing long-term sensitivity.
Physicians suggest allergy season is not the time to tinker with medications prescribed for chronic lung disease regardless of allergy severity. Instead, take stock of those with confirmed allergies and plan patient referrals to an allergist if they're not already seeing a specialist.
'The first question for patients who have chronic lung disease is to determine if they have seasonal allergies,' said Bernstein. 'Ask if they've previously had symptoms and, if so, what time of year do they happen and what triggers their allergies. If they have seasonal allergies and their breathing is worse during seasonal allergy times, that's not a great time to make major moves with their medications. For most of my patients with chronic lung conditions, April, May, and June tend to be the months when I won't take them off medications. Even if they're doing well, I'll suggest that we get to the end of June and then see how they do when stopping their medication. Because if we stop in the middle of allergy season and they get worse — you won't know if it's the allergy season or if they needed the medication.'
Bernstein also suggests timing routine and follow-up appointments for patients with allergies. 'The worst thing that you can do is try to play catch-up during allergy season,' he said. 'But if you get patients started before the spring, you'll have time to help them prevent the symptoms that they have at their worst time of the year.' Mainstay treatments for Bernstein include corticosteroid nasal sprays. 'Oral antihistamines will also certainly help, but they have side effects such as drowsiness and dry mouth that can become issues for patients. And antihistamines, particularly in older patients who are on other medications, get more complicated to use. If you can avoid that it will help.'
Beyond medications, avoiding exposure to allergens can also reduce symptom severity. 'Allergens tend to be the worst at dawn and dusk,' said Bernstein. 'On the highest allergy days, being inside air-conditioned environments is suggested. Don't have patients taking walks during early evenings unless they're walking inside.' These measures can potentially complicate typical self-care among chronic lung patients, however.
'For many of these patients, the best advice you give them is to exercise, so it's a problem when pollen is thick in the air during the spring or when there's wildfires during the summer because taking a walk outside is not going to be the most beneficial recommendation for their health,' said Bernstein. 'Some patients benefit from walking outside with a mask.'
Parikh also advises that patients change their clothes when at home during high-pollen days and showering to wash off any pollen to decrease exposure. 'Keep windows closed early in the morning for the same reason,' she said.
If such precautions aren't taken, allergy severity can peak. 'Two of the issues for patients with chronic lung disease is they'll get bronchial constriction or tightening or narrowing of the airways in their lungs,' said Bernstein. 'This can manifest in wheezing, and that's directly triggered by the allergens in the air. The other is increased mucus production, where mucus builds up in their airways, and they have to cough it up and clear it out. These are constant struggles for some of these patients, and if they have severe allergies, you're taking what's their normal baseline and making it worse.'
Bernstein also warned that some prescribed medications, such as beta-blockers metoprolol and carvedilol, have been known to worsen allergy symptoms. Conversely, drugs prescribed for rheumatoid arthritis, lupus, and other inflammatory conditions can actually help with allergies. 'Some patients will experience lessened allergy symptoms when they're started on anti-inflammatory medications just as an added bonus to being treated for those conditions,' Bernstein said. 'With COPD, we are increasingly using the medication Dupixent. This can help with allergies regardless of how it treats COPD.' During allergy seasons, physicians can also add bronchodilators or leukotriene receptor antagonists, such as montelukast, suggests Farooq.
Can't Sleep on Symptoms
Poorly controlled allergies can also lead to another general health malady that has a tendency to be overlooked, said Beuther — poor sleep quality due to overnight coughing and congestion. 'It's very clear from the care of our patients that the impact on sleep and quality of life from allergies can make the experience of a chronic lung disease worse,' he said. 'Imagine that you're someone with any chronic lung disease. You're struggling to breathe, you're having cough and mucus from your lungs, you might be on oxygen. And now we're adding a nose that's plugged up and you're not sleeping.'
Allergy symptoms during evening hours can be reduced with steam humidifiers, the use of high-efficiency particulate air filters, and peak flow monitoring with a digital app. Other digital tools or telehealth can also support patients in logging symptom cadence.
Updating action plans with clear steps for managing worsening symptoms will also reduce potential for emergency department visits, said Farooq. 'This type of care coordination between pulmonologists, allergists, and primary care physicians, as well as patient education, all improve outcomes,' she said.
