Pediatric Annals

EDITORIAL 

Asthma- A Pediatrician's Experience

Milton I Levine, MD

Abstract

Having suffered from asthma until a few years ago when I started on beclamethosone aerosol once daily, I can speak and write with considerable authority on the subject.

I had hay fever for years, particularly during my days at medical school and internships as well. I started practicing in the fall when the ragweed season was over. One day a doctor from whom I rented my office asked me to spend an evening with him at his club. I accepted his friendly offer and met him on the appointed evening. We had an excellent meal and afterward went upstairs, stripped, and entered a steam room where we sat for at least 20 minutes, hot and perspiring profusely. Then we rose, went through a door and jumped into a pool of very cold water.

I hit the water and suddenly was unable to breathe. I splashed my way to the side of the pool and struggled out. I didn't know what happened, it happened so quickly. Breathing with great difficulty, I dressed and with gasping breaths thanked my host for the evening and drove home. By the time I reached home, I had diagnosed my case as a sudden and severe asthmatic attack - a physical allergic reaction caused by a sudden shock to my sensitized bronchial tissue.

And so, from that time on, I was subjected to attacks of asthma and became very much interested in the subject. Í read articles and books on the condition and learned that even as early as 1190 A.D. the great physician Maimonides, wrote a "Treatise on Asthma" in which he not only mentioned that the condition was known by ancient man, but noted that asthma occurred in succeeding generations. I also learned that Gladstone suffered from asthma and treated himself by inhaling stramonium smoke.

I wanted to learn more about asthma so I joined the staff of a pediatrie asthma clinic in New York City conducted by one of the outstanding allergists of that day. We skin-tested the children, gave them routine injections of what we felt were offending proteins and used drugs such as ephedrine and aminophyllin by mouth, and epinephrine by injection when necessary.

Skin testing for allergy was originated in 1915 by a pediatrician, Dr. Oscar M. Schloss. Dr. Schloss later became Professor of Pediatrics at Cornell University Medical College, and it was while Dr. Schloss was Professor that Dr. Brett Rattner established in his department one of the first children's allergy clinics.

I personally did not continue in the field of child allergy but closely followed the advances in the area and later became Director of the Pediatrie Pulmonary Clinic of New York Hospital. There 1 was able to examine and treat numerous pulmonary conditions including a fairly large number of severely asthmatic children.

During all these years much has been learned about the basic mechanism of asthma and great advances have been made in treatment, although a cure has not as yet been attained.

The mechanism? It is now held that in a potentially allergic person some foreign protein, whether by inhalation or bacterial or viral contact enters the mucosa and acts on the plasma cells just within the lining, causing them to form IgE molecules (reagins). These, in turn, leave the plasma cells and attach themselves to the surface membrane of mast cells or circulating basophils. Now that the person is sensitized to the particular protein, the next time he or she meets with it, the sensitized mast cells or basophils release histamine, and this causes a bodily defense mechanism which unfortunately is overreactive. The bronchial tree…

Having suffered from asthma until a few years ago when I started on beclamethosone aerosol once daily, I can speak and write with considerable authority on the subject.

I had hay fever for years, particularly during my days at medical school and internships as well. I started practicing in the fall when the ragweed season was over. One day a doctor from whom I rented my office asked me to spend an evening with him at his club. I accepted his friendly offer and met him on the appointed evening. We had an excellent meal and afterward went upstairs, stripped, and entered a steam room where we sat for at least 20 minutes, hot and perspiring profusely. Then we rose, went through a door and jumped into a pool of very cold water.

I hit the water and suddenly was unable to breathe. I splashed my way to the side of the pool and struggled out. I didn't know what happened, it happened so quickly. Breathing with great difficulty, I dressed and with gasping breaths thanked my host for the evening and drove home. By the time I reached home, I had diagnosed my case as a sudden and severe asthmatic attack - a physical allergic reaction caused by a sudden shock to my sensitized bronchial tissue.

And so, from that time on, I was subjected to attacks of asthma and became very much interested in the subject. Í read articles and books on the condition and learned that even as early as 1190 A.D. the great physician Maimonides, wrote a "Treatise on Asthma" in which he not only mentioned that the condition was known by ancient man, but noted that asthma occurred in succeeding generations. I also learned that Gladstone suffered from asthma and treated himself by inhaling stramonium smoke.

I wanted to learn more about asthma so I joined the staff of a pediatrie asthma clinic in New York City conducted by one of the outstanding allergists of that day. We skin-tested the children, gave them routine injections of what we felt were offending proteins and used drugs such as ephedrine and aminophyllin by mouth, and epinephrine by injection when necessary.

Skin testing for allergy was originated in 1915 by a pediatrician, Dr. Oscar M. Schloss. Dr. Schloss later became Professor of Pediatrics at Cornell University Medical College, and it was while Dr. Schloss was Professor that Dr. Brett Rattner established in his department one of the first children's allergy clinics.

I personally did not continue in the field of child allergy but closely followed the advances in the area and later became Director of the Pediatrie Pulmonary Clinic of New York Hospital. There 1 was able to examine and treat numerous pulmonary conditions including a fairly large number of severely asthmatic children.

During all these years much has been learned about the basic mechanism of asthma and great advances have been made in treatment, although a cure has not as yet been attained.

The mechanism? It is now held that in a potentially allergic person some foreign protein, whether by inhalation or bacterial or viral contact enters the mucosa and acts on the plasma cells just within the lining, causing them to form IgE molecules (reagins). These, in turn, leave the plasma cells and attach themselves to the surface membrane of mast cells or circulating basophils. Now that the person is sensitized to the particular protein, the next time he or she meets with it, the sensitized mast cells or basophils release histamine, and this causes a bodily defense mechanism which unfortunately is overreactive. The bronchial tree contracts and the mucosa swells, surrounding the passages - for under normal circumstances the exhaled air flows faster through a narrower tube in an effort to push any foreign objects out. In addition, thick mucus forms in the tubes, another protective mechanism to rid the tubes of foreign irritants. But the body overreacts and causes the sensitized child or adult to have great difficulty breathing, especialty on expiration when the tubes are narrowed and clogged with mucus.

Obviously the treatment should center on achieving bronchodilation and removing mucus from the bronchial tree. In this area there has been gradual improvement in the last 30 or 40 years.

Prevention, until recently, centered on the elimination of the allergens, if possible, and then giving graded injections of the allergen protein extract to build up the body's toleration.

Epinephrine by injection was the standard treatment for acute attacks, although oral aminophylline and theophylline were also used. (I must admit that in the early 30s I smoked stramonium cigarettes in an unsuccessful attempt to relieve one bothersome attack.

Prevention of attacks by ephedrine drops or tablets was prescribed by allergists but was not too effective. Then came a great advance - the discovery that epinephrine 1:100 or isoproterenol 1:200 inhaled from a special glass nebulizer was very effective in relieving the early symptoms of asthma. Later these preparations were provided in metal nebulizers with gas propellants.

Next came the discovery that steroids given orally were remarkably successful in controlling attacks. Many of us were extremely excited by this information and felt that, at last, we had the answer to this difficult problem. But our enthusiasm was short lived for side effects of this therapy were often serious.

Then cromolyn was discovered in England and given by inhalation. It was quite useful in preventing attacks but was not helpful in treating acute asthma.

But even though epinephrine and isoproterenol were effective, if taken too frequently they had a detrimental effect on the heart. So newer drugs were produced which gave a higher degree of safety. Among these were isoetharine (Bronkosol) given by nebulizer, metaproterenol (Alupent) given by liquid or nebulizer, terbutaline (Brethine) given orally, and more recently albuterol (Proventil) used by nebulization.

The latest and most effective approach in the prophylaxis of severe asthmatics is through the inhalation of the nebulized steroid beclomethasone (Vanceril). It is not recommended for treatment of acute attacks but is only for prevention and has been highly successful. This steroid given by nebulization is only slightly absorbed into the system and thus avoids the side effects so commonly seen when steroids are given by mouth. This does not mean that every child or adult should receive steroids by nebulization. It should be reserved only for those cases of chronic asthma when other means of prevention have been found inadequate. To my knowledge it has not been determined just how ' much this therapy affects the adrenal glands. We : advise that it never should be stopped abruptly for ' fear that the adrenal output of steroids might be depressed.

Pediatricians who care for asthmatic patients are often asked by the parents whether the activity of these children should be limited. The answer should definitely be in the negative. One of my daughters followed me genetically and developed asthma. We permitted her to enter fully into all activities with the admonition, "when you're wheezy take it easy. " She became a most active person - an excellent swimmer, mountain climber, and folk dancer.

During my 50 years of practice, I never once hospitalized any of my patients for severe asthmatic attacks, although once I sent a child with intractable asthma to the National Jewish Hospital in Denver where he received oral steroids. This boy is now an adult in excellent health and his asthma is wellcontrolled.

None of my numerous patients with asthma ever developed status asthmaticus - I strongly believe that this should not occur with proper care. I remember a bad experience with one of my clinic patients, a boy who had frequent severe attacks of asthma, all of which we relieved with injections of epinephrine and susphrine. One night during a weekend his mother brought him to the hospital. The boy was having great difficulty breathing. There was a new resident on pur service who had, in a previous residency, special training in child psychology. This resident decided the boy's problem was essentially psychological, keyed by the mothers anxiety. So he decided on a parentectomy and admitted the youngster, placed him in a room by himself and sent the mother home. A few hours later when he went to the room, the child had died. I have had so many experiences with wheezing children and asthmatic children that I could write an anecdotal treatise on the subject.

However, the contributors to this issue of Pediatrie Annals are authorities in the field and bring us upto-date on the subject.

Dr. Jacob Hen, Assistant Clinical Professor of Pediatrics at Yale University, and Director of the Intensive Care Unit at Bridgeport Hospital is the Guest Editor of the symposium. In the first article Dr. Hen presents an overview of the present knowledge on the subject of asthma.

This is followed by a paper on the "Approach to the Wheezing Infant" written by Dr. Bruce G. Nickerson, Pediatrie Pulmonologist and Director of the Pulmonary Function Laboratory of the Children's Hospital at Oakland, California. Here is presented the physiological basis for this symposium, the many possible causes and modern methods of treatment.

The third article on the "Office Evaluation and Management of Pediatrie Asthma" is also presented by Dr. Hen. This is an excellent study of the role of the pediatrician in making a careful diagnosis and in the management of children with asthma. The section devoted to drug therapy is especially valuable and covers drugs for prophylactic use as well as those for active therapy.

The fourth contribution discusses "Status Asthmaticus" and is authored by Dr. Robert G. Zwerdling, Director of Pediatrie Pulmonology of the University of Massachusetts Medical School at Worcester, Massachusetts. This is a clear discussion of the most severe of all asthmatic conditions. Dr. Zwerdling states that at the present time with skillrul medical care there rarely should be a need to hospitalize a child for treatment of asthma. However, he notes that almost 100,000 childem a year are still being admitted with this diagnosis.

The final article on "Asthma Self-Management Programs and Education" is by Dr. Norman J. Lewiston, Associate Professor of Pediatrics at the Stanford School of Medicine, and Chief of Pediatrie Allergy and Pulmonary Diseases at the Children's Hospital of Stanford. Essentially, Dr. Lewiston advises on integrating the reality of asthma into the child's lifestyle, and learning methods to avoid or minimize conditions which cause asthmatic attacks. He emphasizes that most asthmatic children can lead full and active lives. He also discusses the value of camps and residential facilities for individual cases.

10.3928/0090-4481-19860201-05

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