Pediatric Annals

EDITORIAL 

A Pediatrician's View

Milton I Levine, MD

Abstract

Asthma has probably been one of the earliest afflictions of the human being. The Ebers papyrus, discovered in 1873, contained a discussion of asthma and its treatment during the middle of the 16th century BC. We read of it in the writings of the great physician, Galen, who died in 200 AD and in the works of Hippocrates. Maimonides published a treatise on asthma in 1 190 AD.

The treatment of asthma has always proved difficult and numerous attempts have been made to relieve it. It is noted that William Gladstone, England's prime minister in 1868, sat at his desk inhaling the fumes of burning dry stramonium leaves to relieve his difficult asthmatic breathing.

Like all medical students, I read and learned about asthma, with the narrowing of the bronchial tubes and the exudation of thick mucus adding to the obstruction of air. We took histories and examined patients suffering from the condition. We knew it was an allergic response to some specific protein, usually inhaled, such as dog or cat dander, feathers, wool, dust, or even viral and bacterial protein. We learned how to skin test the patients with extracts and how to judge the dermal reactions. I had a deep respect for allergies, for during my years my years as a medical student I suffered from hay fever each year during the ragweed season.

And then, as I mentioned in this column a few years ago, I suddenly developed asthma. I use the word "suddenly" for it occurred while I was being treated to a Turkish bath by a friend. We sat nude in a steam room until we were perspiring profusely, then opened a door and plunged into a pool of cold water. I hit the water and immediately was unable to breathe. I struggled with great difficulty to the side, pulled myself out and soon realized that I was suffering from asthma - a sudden and severe physical allergic reaction.

This was in the early 1930s when treatment for the condition was limited to epinephrine by injection, and a new drug ephedrine brought from China in 1924 where, derived from a desert plant, it had been used for thousands of years. So I received epinephrine subcutaneously and ephedrine orally and was completely tested intradermally. Once I tried stramonium cigarettes, which could be purchased at the pharmacy, but they only made my cough more severe.

Through the years I have watched the advances in the treatment of asthma closely and have felt a great empathy for the children under my care who suffered from this condition. It is interesting to follow the advances in asthma therapy in the years that followed. There was the use of aminophylline and theophylline, each given orally to relieve bronchospasm. Then there was the adrenaline nebulizer, a glass container with a hard propelled rubber bulb, which could be used by older children and provided temporary relief. Later came isoproterenol (Isuprel®) with action similar to aminophylline, but that could be given sublingually and would temporarily relieve bronchospasm.

The rapid advances in the prophylactic and therapeutic care of the asthmatic child will be remembered by most present-day pediatricians. The use of cromolyn powder as an inhalant was administered prophylactically but not for treatment. This was followed by the use of ß2-agonists, such as albuterol (Proventil®, Ventolín®) and terbutahne (Brethine®, Bricanyl®), and finally by the corticosteroids, first given orally and later provided for inhalation in pressure tubes - beclomethasone (\&nceril®). The steroids, given orally, are effective in treating severe asthmatic cases but must be carefully regulated because of side effects. Beclomethasone used as an inhalant…

Asthma has probably been one of the earliest afflictions of the human being. The Ebers papyrus, discovered in 1873, contained a discussion of asthma and its treatment during the middle of the 16th century BC. We read of it in the writings of the great physician, Galen, who died in 200 AD and in the works of Hippocrates. Maimonides published a treatise on asthma in 1 190 AD.

The treatment of asthma has always proved difficult and numerous attempts have been made to relieve it. It is noted that William Gladstone, England's prime minister in 1868, sat at his desk inhaling the fumes of burning dry stramonium leaves to relieve his difficult asthmatic breathing.

Like all medical students, I read and learned about asthma, with the narrowing of the bronchial tubes and the exudation of thick mucus adding to the obstruction of air. We took histories and examined patients suffering from the condition. We knew it was an allergic response to some specific protein, usually inhaled, such as dog or cat dander, feathers, wool, dust, or even viral and bacterial protein. We learned how to skin test the patients with extracts and how to judge the dermal reactions. I had a deep respect for allergies, for during my years my years as a medical student I suffered from hay fever each year during the ragweed season.

And then, as I mentioned in this column a few years ago, I suddenly developed asthma. I use the word "suddenly" for it occurred while I was being treated to a Turkish bath by a friend. We sat nude in a steam room until we were perspiring profusely, then opened a door and plunged into a pool of cold water. I hit the water and immediately was unable to breathe. I struggled with great difficulty to the side, pulled myself out and soon realized that I was suffering from asthma - a sudden and severe physical allergic reaction.

This was in the early 1930s when treatment for the condition was limited to epinephrine by injection, and a new drug ephedrine brought from China in 1924 where, derived from a desert plant, it had been used for thousands of years. So I received epinephrine subcutaneously and ephedrine orally and was completely tested intradermally. Once I tried stramonium cigarettes, which could be purchased at the pharmacy, but they only made my cough more severe.

Through the years I have watched the advances in the treatment of asthma closely and have felt a great empathy for the children under my care who suffered from this condition. It is interesting to follow the advances in asthma therapy in the years that followed. There was the use of aminophylline and theophylline, each given orally to relieve bronchospasm. Then there was the adrenaline nebulizer, a glass container with a hard propelled rubber bulb, which could be used by older children and provided temporary relief. Later came isoproterenol (Isuprel®) with action similar to aminophylline, but that could be given sublingually and would temporarily relieve bronchospasm.

The rapid advances in the prophylactic and therapeutic care of the asthmatic child will be remembered by most present-day pediatricians. The use of cromolyn powder as an inhalant was administered prophylactically but not for treatment. This was followed by the use of ß2-agonists, such as albuterol (Proventil®, Ventolín®) and terbutahne (Brethine®, Bricanyl®), and finally by the corticosteroids, first given orally and later provided for inhalation in pressure tubes - beclomethasone (\&nceril®). The steroids, given orally, are effective in treating severe asthmatic cases but must be carefully regulated because of side effects. Beclomethasone used as an inhalant is extremely effective in controlling moderate asthma; it is only very slightly absorbed into the system. There are no side effects. As to my own asthma, I have been on daily doses of beclomethasone by aerosol inhalation for the past few years and have had no attacks of asthma since I started using this steroid.

In examining the child with asthma, a good history is often indicative of the etiology. There is an occasional exception. One of my patients, a beautiful little girl, was brought in one day with a history of wheezing of 2 days duration. She had been followed since birth and had no previous history or signs of allergic bronchitis or asthma. She had been visiting a 12-year'old cousin in the country over the weekend when the wheezing respirations first appeared. She had visited there before without any problems. But this time there had been one severely upsetting experience. She was with the cousin when the 12 year old had her first menstrual period and there was blood and excitement. This was surely asthma of emotional origin. But, as was my practice in pulmonary cases, I conducted a fluoroscopy and shockingly found a large mediastinal mass pressing on the trachea. Subsequent studies tragically proved it to be a lymphosarcoma.

During 50 years of my pediatrie practice, only one child under my care died of asthma. He was a clinic patient who would have severe attacks, which we always controlled with injections of epinephhne and Sus-Phrine®, a long-acting form of epinephrine. But every so often the anxious parents would rush the child to the hospital for injections to control the attack.

One Monday I returned to the hospital and was told that this 11 -year-old boy had died two nights before. The story I received was outrageous. The assistant resident saw the boy and his parents that Saturday evening and decided that the child's attacks were of emotional origin. What the boy needed, he said, was a "parentectomy. " So he admitted the asthmatic boy to the hospital, had him placed in a room by himself where he could not seek sympathy, and the boy died in status asthmaticus. All this occurred before the advent of steroid therapy.

Today, with the metered-dose inhalers using the ß2-agonists( such as albuterol, terbutaline, and fenoterol (Berotec®), most asthma in children 3 years of age and older can be controlled. Fbr those who do not respond adequately to therapy with the ß2-agonists, the use of corticosteroide may be advised; these also may be given by means of an inhaler. But how does one give young children the metered-dose drugs by inhalation? These may be provided adequately and effectively by means of holding chambers for aerosol drugs, as described by Dr Thomas F. Plaut in this present symposium.

The Guest Editor for this issue of Pediatrie Annals is Dr Jacob Hen, Jr, Associate Clinical Professor of Pediatrics at Yale University School of Medicine. The first paper discusses the "Management of Acute Severe Asthma" and is contributed by Drs Bernie McWilliams, H. William Kelly, and Shirley Murphy, all of the Department of Pediatrics at the University of New Mexico School of Medicine, Albuquerque. This interesting and important article answers a number of fundamental questions, such as how to test the severity of an asthmatic attack-, which is preferable, an aerosolized ß2-agonist or epinephrine by injection; is theophylline of value in treating an acute asthma attack when a ß2-agonist is already being used; and how frequently can a ß-agonist be used? Hospital ization with the use of ICU therapy is also covered.

The second article deals with "Sinusitis and Its Relationship to Asthma." It has been written by Dr Alien D. Adinoff, Assistant Clinical Professor of Pediatrics at the University of Colorado, Denver, and by Dr Nancy P. Cummings, Assistant Clinical Professor of Medicine at Stanford University, Stanford, California. This article brings out that, on the basis of numerous studies, no beneficial results of sinus surgery for asthma have been uniformly found. Evidence is presented, however, that treatment of nasal or sinus disease is often beneficial in controlling asthma.

The next contribution is titled "What is Wheezy Bronchitis?" This is discussed by Dr Norman J. Lewiston, Associate Professor of Pediatrics at the Stanford University School of Medicine, Palo Alto, California. As Dr Lewiston explains, the term "wheezy bronchitis" refers to v ira !-associated wheezing. The pathology of the condition is described and a differentiation is presented between children who wheeze only with infection and those who wheeze from other causes. Methods of treatment are also discussed.

The next article deals with a subject of importance to all practicing pediatricians, "Gaining Control of the Allergic Child's Environment." It is presented by Dr James P. Kemp, Chief of the Division of Allergy and Immunology, Children's Hospital, and Clinical Professor of Pediatrics, Division of Allergy and Immunology, University of California, San Diego; and by Dr Eli O. Meltzer, also Clinical Professor of Pediatrics from the same university. Here, the authors carefully present the environmental factors that influence allergic conditions, including wind, humidity, and changes in temperature and barometric pressure. Outdoor and indoor air pollution are also considered, followed by an excellent discussion of methods to control the environment to minimize or completely remove the offending allergens and making the environment as optimal as possible for the patient.

The following article, "Use of Steroids in Pediatrie Asthma," is contributed by Dr Manon Brenner. Dr Brenner is Associate Professor of Pediatrics Clinical Services at the National Jewish Center for Immunology and Respiratory Medicine, Denver, Colorado. As Dr Brenner points out, pediatricians are often reluctant to resort to steroid therapy for fear of side effects and the development of steroid dependency. However, neither of those fears are accurate. When used correctly steroids can be, if they are necessary, of the greatest value, for they are most effective in inhibiting nearly every aspect of the inflammatory response. Their value in status asthmaticus is emphasized, and the best method of administration is described.

The indications for using oral steroids is first presented. However, the prevention of adrenal insufficiency and other side effects must always be considered and minimized as much as possible. Dr Brenner next discusses the great value of inhaled steroids, emphasizing their effectiveness and lack of systemic adverse effects. He recommends the use of inhaled ß-adrenergic substances for mild asthma, but notes that, if necessary, the safety and efficiency of inhaled steroids has been demonstrated.

The next article discusses "Death Due to Asthma in Children" and is written by Dr Noia J. Attaway and Dr Robert C. Strunk from the Division of Pulmonary Medicine and Allergy/Immunology, St. Louis Children's Hospital and the !Department of Pediatrics at the Washington University School of Medicine. In this age of modern asthma therapy, death from this condition should be extremely rare. But, as the authors point out, patients at times place themselves at high risk for dying because of inadequate care or by their behavior. This article directs the identification of the high-risk child and the special care, psychologically as well as physically, needed for these children.

The final article, mentioned earlier, is most valuable when the use of inhalation therapy is required for young children. It concerns "Holding Chambers for Aerosol Drugs" and has been contributed by Dr Thomas F. Flaut. Dr Flaut is a pediatrie allergist in Amherst, Massachusetts, and the author of the book, Children with Asthma: A Manual for Parents. This valuable paper is short, clearly descriptive, and well illustrated. Obviously, young children usually have great difficulty taking inhalation therapy using metered-dose inhalers. In this article, Dr Flaut presents various holding chambers and their capability for use by the pediatrie patient.

10.3928/0090-4481-19891201-05

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