Overview
Exposure to cold air caused by a series of allergy-like symptoms or diseases, such as rhinitis, asthma, urticaria, etc. can be manifested as nasal congestion, runny nose, sneezing, shortness of breath or wheezing; skin urticaria or hives; itchy eyes, tearing, etc. etiology is still not clear, the respiratory symptoms may be related to cold air-induced airway hyperreactivity, first of all, should be avoided, the medication has glucocorticosteroids, antihistamine, leukotriene Glucocorticoids, antihistamines, leukotriene modulators, etc.
Definition
Cold air allergy refers to a series of symptoms or diseases that resemble allergic reactions, such as idiopathic rhinitis, allergic rhinitis (also known as allergic rhinitis), asthma, cold urticaria, and allergic conjunctivitis, caused by exposure to the natural environment, or to cold air created by machines such as air conditioners.
Strictly speaking, cold air allergy is not an allergy in the traditional sense.
Clinical symptoms include nasal symptoms, such as nasal congestion, runny nose, sneezing; respiratory symptoms, such as shortness of breath or even wheezing; skin symptoms, such as windsickness and/or angioedema with itching; and eye symptoms, such as itchy eyes and tearing.
Both idiopathic rhinitis and allergic rhinitis have symptoms such as nasal congestion, runny nose, sneezing and nasal itching, but the allergen test of the former is negative. This reactive state of the nasal mucosa to cold air may be termed nonspecific nasal hyperreactivity.
Morbidity
There are no exact epidemiologic statistics on this disease.
Some studies have shown the prevalence of cold urticaria to be about 0.05%, i.e., 1 in 10,000 people have cold urticaria. It is highly prevalent in countries with cold temperatures and is most common in young people [1-3].
Causes
Causes
The exact etiology and pathogenesis of cold air-induced allergic symptoms in the body are not known.
Respiratory symptoms may be related to cold air-induced airway hyperresponsiveness.
The basic pathogenesis involves the activation of various inflammatory cells centered on mast cells triggered by physical factors, and the release of chemical mediators with inflammatory activity, including histamine and leukotrienes, which cause vasodilation and increased permeability, smooth muscle contraction, and increased glandular secretion, resulting in a series of localized or systemic allergic symptoms in the skin, mucous membranes, and respiratory tract.
High risk factors
Allergic and immunocompromised individuals are at high risk [4-5].
Symptoms
The clinical symptoms caused by this disease may occur within minutes after exposure to cold air, last for hours to days, and resolve with treatment or on their own, but may recur after re-exposure to cold air.
Main Symptoms
Nasal symptoms
Nasal congestion, watery runny nose, sneezing, itchy nose.
Physical examination reveals pale edema of the nasal mucosa and a large amount of clear nasal discharge.
Upper airway symptoms
Wheezing, i.e. increased respiratory rate;
Shortness of breath, i.e., rapid, uneven breathing;
Dyspnea, i.e. self-consciousness of not being able to breathe;
Paroxysmal cough, which may be accompanied by coughing up sputum.
Skin symptoms
There may be reddening of the skin and urticaria, which may be manifested as windburn and/or angioedema with itching.
Eye symptoms
There may be itching of the eyes, tearing and conjunctival congestion.
Other symptoms
In severe cases of allergy, there may be edema of the lips, soft palate, base of the tongue, and larynx, and life-threatening breath-holding due to mechanical obstruction of the respiratory tract [3,6-8].
Medical care
Department of Medicine
Allergology/Rhinology
For allergic symptoms such as nasal congestion, itchy nose, itchy eyes, etc., consult the Department of Allergy/Rhinology.
Respiratory Medicine
For symptoms such as shortness of breath, wheezing, irritating cough, etc., consult the Department of Respiratory Medicine.
Dermatology
Consult the Dermatology Department for symptoms such as urticaria, wheezing, itchy skin.
Emergency Medicine
In case of emergency such as severe edema of the mouth, lips and tongue, respiratory distress, shock, etc., it is recommended to go to the emergency room or call 120 emergency immediately.
Preparation
Preparing for your visit: registration, information preparation, common problems
Tips for medical treatment
Avoid taking any medication that may mask your symptoms, such as anti-allergy medication or cough suppressants, to avoid affecting the doctor’s judgment of your condition.
Please wear clothes that are easy to put on and take off, so as to facilitate blood sampling or skin examination.
Imaging tests may be required. Please inform your doctor if you are pregnant or planning to become pregnant.
Preparation Checklist
Symptom list
Pay special attention to the time of onset of symptoms and special manifestations.
Is there nasal congestion, runny nose, what color and nature of the nasal mucus?
Is there sneezing, itchy nose, itchy eyes, watery eyes?
Is there coughing, breath-holding?
Is there any itchy skin?
List of medical history
Was there any exposure to cold air before the onset of the illness?
Are you allergic to drugs, food, pollen, etc.?
Any family history of asthma, allergic rhinitis, etc.?
Checklist
Test results in the past six months, which can be brought to the doctor’s office
Laboratory tests: blood test, C-reactive protein, specific IgE test, nasal secretion cytometry, etc.
Imaging tests: sinus CT, lung CT, etc.
Allergen test, lung function test, etc.
List of medications used
Medication since the onset of the disease, which can be carried to the doctor.
Such as anti-inflammatory drugs, anti-allergy drugs, cough suppressants, topical skin medications, etc.
Diagnosis
Diagnostic basis
Medical history
Relevant medical history may assist the doctor in making a diagnosis, such as the presence of the following conditions
A clear history of cold air exposure prior to the onset of clinical symptoms.
A personal or family history of allergies, such as eczema, allergic rhinitis, and food and drug allergies
Clinical manifestations
Symptoms.
Nasal congestion, watery runny nose, sneezing, itchy nose, etc.
Sudden onset of wheezing, breath-holding, shortness of breath, paroxysmal cough, etc.
Pinkish-red windburn and/or angioedema on the skin with itching.
Itchy eyes and tearing.
Physical signs
Nasal mucosa is pale and edematous with visible clear discharge.
Scattered or widespread rales in the lungs may be audible in asthmatic patients, which may disappear in severe cases.
In urticaria, there may be skin surface wheals and angioedema.
In allergic conjunctivitis, conjunctival congestion may be seen.
Laboratory Tests
Hematology
Routine blood tests
Elevated eosinophils may be present in some patients.
Leukocytes may be elevated in those with combined inflammatory conditions.
Serum immunologic tests
Serum specific IgE test can be used to identify whether the patient has clear allergens. IgE may be elevated in allergic rhinitis and allergic asthma, but is usually normal in idiopathic rhinitis, while idiopathic symptoms caused by cold air irritation will not find elevated specific IgE.
Biochemical routine
Fasting is required before blood sampling.
Generally nonspecific, some patients may have electrolyte disturbances.
Arterial blood gas analysis
This test can be used to determine the severity of hypoxia in asthmatics.
In severe asthma, the partial pressure of oxygen decreases and the partial pressure of carbon dioxide increases, manifesting as acidosis.
The radial artery is usually chosen, and pressure is applied to the eye of the needle for 5~10 minutes after blood is drawn.
Nasal secretion examination
A smear of the patient’s nasal secretions is taken, which may be uncomfortable.
Normally, nasal secretions contain only a few epithelial cells and lymphocytes. During an episode of metrorrhagia, eosinophilia may be seen in the nasal secretions, and basophils or mast cells may also be detected.
Sputum examination
Sputum examination can measure the concentration of eosinophils in the sputum, which can help the doctor to determine whether you are allergic or not.
It is recommended to rinse the mouth with water after waking up and to keep the first sputum, place it in a clean and dry container and send the specimen to the hospital as soon as possible.
Allergen testing
A skin prick test or blood test can be done.
A positive test proves that the patient is allergic to the specific allergen being tested, and the type and degree of allergy are usually recorded in the results.
Allergen testing needs to be done in a place where resuscitation is available.
Nasal endoscopy
Nasal endoscopy is performed to observe the structures of the nasal mucosa, septum and turbinates, as well as the character of the nasal secretions.
It mostly shows mucosal edema and clear nasal secretion.
Other Nasal Specialty Tests
Nasal ventilation function test: such as nasal resistance test, nasal acoustic reflex test.
Dry cold air nasal excitation test, which can assist in the diagnosis of atopic rhinitis due to cold air allergy.
Lung function tests
Play a key role in diagnosing asthma, grading the severity of the condition and assessing the effectiveness of treatment.
They include ventilation function test, bronchial provocation test, bronchodilator test, peak expiratory flow rate (PEF) and its variability measurement.
Ventilation Tests
Asthma exacerbation is characterized by obstructive ventilatory dysfunction with normal or decreased forceful lung volume (FVC).
Exertional expiratory volume in 1 second (FEV1), FEV1 as a percentage of predicted value (FEV1%), 1-second rate (FEV1/ FVC%), maximal mid-expiratory flow rate (MMFR), and maximal expiratory flow rate (PEF) were decreased.
FEV1/ FVC% <70% or FEV1% <80% were used as the most important indicators and degree of airflow limitation.
Bronchial provocation test
Used to determine airway responsiveness. If the decrease is ≥20%, the result is positive and suggests the presence of airway hyperresponsiveness.
It is suitable for patients with non-asthmatic exacerbations and FEV1 above 70% of the normal expected value.
Bronchodilator test
Used to determine airway reversibility.
A positive test is determined by an increase in FEV1 of ≥12% from the premedication level and an absolute increase of ≥200 mL; an increase in PEF of 60 L/min from the pre-treatment level, or an increase of ≥20%.
Measurement of PEF and its variability
If the diurnal PEF fluctuation rate was ≥20%, it suggested the presence of reversible airway changes.
Cold irritation test of the skin
A cold irritation test is also performed in patients with cold urticaria. By exposing the skin to a cold object and then removing the stimulus, itching and/or an accompanying burning sensation usually occurs in the affected area.
Imaging
CT of the sinuses to determine if there are any abnormalities in the structure of the nasal passages and if sinusitis is present.
CT of the lungs to determine the presence of infection, hyperinflation of the lungs, and the presence of bronchial lesions.
Differential diagnosis
Acute sinusitis
Similarity: both may have nasal congestion and runny nose.
Differences: acute sinusitis onset of cold air exposure history, as well as sneezing, nasal itching and other allergic symptoms, nasal discharge is mostly yellow pus, and can be accompanied by headache, sinus CT can be seen in the sinus cavity liquid plane or soft tissue density shadow.
Chronic obstructive pulmonary disease (COPD)
Similarities: shortness of breath, wheezing and other symptoms can occur.
Differences: COPD patients mostly have a history of long-term smoking or exposure to harmful gases, and the bronchial provocation test and diastolic test are negative.
Urticarial vasculitis
Similarities: Both may present with skin tingling or edematous erythema.
Differences: Urticarial vasculitis usually lasts for more than 24 hours, may be accompanied by burning pain, fever, arthralgia, etc., and hyperpigmentation after the lesions subside. Laboratory results show elevated blood sedimentation and decreased complement [2-3,6].
Treatment
Treatment objective: to relieve clinical symptoms and improve quality of life.
Treatment principle: after determining that a series of clinical symptoms are induced by exposure to cold air, the first step is to reduce or avoid exposure to cold air, and those with more severe allergic symptoms, such as laryngeal edema, anaphylactic shock, anaphylactic asthma attack, and other life-threatening symptoms, need to be immediately resuscitated.
Rescue measures include:
Intramuscular injection of epinephrine.
Rapid establishment of intravenous access and early administration of glucocorticoids such as dexamethasone.
Oxygen intake to keep the airway open.
Rapid replacement of blood volume.
For obvious bronchospasm, give aminophylline plus 5% dextrose injection followed by sedation.
Those with severe laryngeal edema should be tracheotomized as appropriate.
Treatment of nasal allergic symptoms
Oral antihistamines or nasal spray antihistamines, such as cetirizine, loratadine, azelastine nasal spray.
Nasal spray glucocorticoid preparations, such as budesonide, mometasone furoate, etc. Oral glucocorticoids such as methylprednisolone in severe cases.
Decongestants, such as ephedrine, hydroxymetazoline nasal drops, etc., but such drugs need to strictly control the time of use, generally no more than 7 ~ 10 days, otherwise easy to cause drug rhinitis, making nasal congestion more serious.
Anticholinergics, such as ipratropium bromide aerosol.
Mast cell stabilizers, such as sodium cromoglycate nasal drops, or oral Nidocrom.
Biologics: anti-IgE antibodies, such as omalizumab.
Leukotriene receptor antagonists, such as montelukast.
Surgery may be considered for recurrent severe allergic rhinitis or idiopathic rhinitis, provided that the indications for surgery are strictly followed and the appropriate surgical procedure is selected according to the patient’s anatomy, severity of the disease and comorbidities.
Treatment of asthma
Bronchodilator drugs: β2 agonists such as salbutamol, theophyllines such as doxophylline, anticholinergic drugs such as ipratropium bromide.
Drugs to reduce airway inflammatory response: e.g. glucocorticoid prednisone, leukotriene modulator montelukast sodium, mast cell cell membrane stabilizer cromoglycate sodium, antihistamine loratadine, etc.
Biological agents: such as omalizumab, etc.
Treatment of urticaria
In some patients, the hives may subside on their own after detaching from the allergen.
When the skin itching is heavy, you can choose glycerine lotion to stop itching or hormonal ointment such as mometasone furoate for external use.
Oral antihistamines, such as cetirizine, loratadine and so on.
Treatment of allergic conjunctivitis
Antihistamines orally or topically, e.g., emetine fumarate eye drops.
Mast cell stabilizers: such as sodium cromoglycate eye drops.
Non-steroidal anti-inflammatory drugs: e.g. Pranoprofen eye drops can relieve eye symptoms such as itching, conjunctival congestion and tearing.
Vasoconstrictors: can reduce conjunctival congestion, but should not be used for a long time.
Glucocorticoids, such as dexamethasone eye drops, etc.
Artificial tears: can lubricate the ocular surface and relieve patients’ symptoms [6-11].
Prognosis
Cure.
Relatively mild allergic symptoms are usually cured or controlled with symptomatic treatment, but can recur after re-exposure to cold air.
Nasal symptoms, ocular symptoms, and skin urticaria are often significantly improved by symptomatic treatment.
The prognosis of asthma varies from person to person and is closely related to the treatment program. With standardized treatment, the clinical control rate can reach 80% in adults and 95% in children.
Harmful
Recurrent episodes of rhinitis can affect the sense of smell, nasal ventilation, and the patient’s quality of life.
Recurrent asthma attacks can affect cardiopulmonary function.
Urticaria is characterized by recurrent episodes of large, itchy skin bumps, which can negatively affect the patient’s body and mind.
Allergic reactions can cause suffocation or life-threatening anaphylactic shock when the airway is severely affected.
Daily
Daily Management
Dietary management
Recommend a low-fat, high-quality protein, light, easy-to-digest food diet, maintain balanced nutrition, and eat more foods rich in vitamins and fiber, such as a variety of vegetables and fruits.
Avoid contact with allergenic foods for those with a clear allergy spectrum.
Life Management
Maintain adequate sleep and moderate exercise to improve immunity.
Wear a mask when going out in cold weather, pay attention to keep warm and avoid direct contact with air vents of air-conditioning and other refrigeration equipment.
Pay attention to maintaining the humidity and temperature of indoor air and improve air quality.
Those who are prone to allergic conjunctivitis should try not to wear contact lenses.
Psychological support
After correctly recognizing the disease, fully understand the clinical symptoms that may occur throughout the body and the corresponding treatment.
Maintain a relaxed mood and avoid emotional stress and excitement when allergic symptoms occur.
Disease monitoring
Monitor the relief of symptoms such as rhinitis, asthma, urticaria, conjunctivitis, etc., and use medication as prescribed by the doctor.
If the condition worsens, consult a doctor.
Follow-up
Follow the doctor’s instructions for regular checkups.
During the period of allergy recovery or remission, serum IgE level can be monitored regularly to monitor whether the body is still in allergic state, and asthma patients can have their lung function checked regularly to assess the degree of disease control and the effect of treatment.
Prevention
It is recommended that patients with high risk factors or allergy-prone body should avoid direct contact with cold air.
If necessary, medication can be given in advance under the guidance of a doctor to prevent the onset of clinical symptoms.
Under the guidance of a doctor, conscious cold tolerance training can be carried out in general, within the acceptable range, gradually improve the tolerance to cold, which is helpful in preventing and alleviating the attacks.