An Approach to the Treatment of Asthma - NCBI

Refer to: Mellon M, Incaudo GI, Kahler S, et al: An approach to the treatment of asthma-University of California, San Diego, School of Medicine, and the University of California Medical Center, San Diego (Specialty Conference). West J Med 128:408-418, May 1978

Specialty Conference Participants MICHAEL MELLON, MD GARY 1. INCAUDO, MD STEPHEN KAHLER, MD. ROBERT N. HAMBURGER, MD WILLIAM L NYHAN, MD, PhD

An Approach to the Treatment of Asthma

From the Department of Pediatrics, University of California, San Diego, School of Medicine and the University of California Medical Center, San Diego.

WILLIAM L. NYHAN, MD, PH D: * The subject of this conference is asthma. We shall illustrate the problem by presenting the case of a patient who had had a long-standing and difficult problem. STEPHEN KAHLER, MD:t The patient was a 15year-old white girl who had had onset of wheezing at the age of three. She had had approximately two episodes of wheezing each year and had never been admitted to hospital or given any medication until, at the age of 8 years, when the family moved to Santee, California, she began to wheeze every day. Treatment was started with tablets containing ephedrine sulfate, theophylline and hydroxyzine hydrochloride (Marax®), and she received 25 to 30 tablets a week. She was missing about 30 days of school a year. She was seen first at University Hospital when she was ten years old. It was clear that her asthma was at least partly allergic in nature. She had other allergic signs and symptoms, including itchy eyes and palate, runny nose and allergic shiners. Her environmental situation in Santee was felt to be quite heavily contributory to her problems. She slept on a wool covered couch in the living room, where there was a shag carpet. She used a feather pillow. The family kept four dogs and four cats, and countless stuffed animals in their home. An attempt was begun at environmental *Professor

and Chairman, Department of Pediatrics.

tChief Resident in Pediatrics. Reprint requests to: Robert N. Hamburger, MD, Division of Pediatric Immunology and Allergy, University of California, San Diego, La Jolla, CA 92093.

408

MAY 1978 * 128 * 5

control, and immunotherapy was started. The Marax tablets were continued. In the following year, decongestants were added. She continued in relatively poor control until the end of 1973, when she missed three months of appointments, and came in to the clinic wheezing quite badly. She was treated with oxytriphylline (Choledyl®) and prednisone. Her condition did not improve. She was admitted to hospital and rapidly deteriorated while receiving aminophylline by injection and hydrocortisone (Solu-Cortef®); an isoproterenol (Isuprel®) infusion was required. Following this admission, treatment was begun with cromolyn sodium by inhalation. Steroids were taken orally every other day. She was readmitted about seven months later and then again a few months later at the end of 1974, when administration of salbutamol was begun. In the spring of 1975 she was admitted twice, about two weeks apart, and after the second admission she was discharged receiving aminophylline and salbutamol orally and beclomethasone dipropionate (Vanceril®) by inhalation. She occasionally used metaproterenol by inhalation. Since then, she has had two more admissions to the hospital while oral administration of prednisone was being tapered. The most recent admission was in March 1977. With the current regimen of Vanceril, salbutamol and theophylline (anhydrous) and glyceryl guaiacolate (guainfenesin) (Quibron®), she has been doing extremely well. She has no longer been receiving orally given steroids; immuno-

TREATMENT OF ASTHMA

therapy has been discontinued, and she has been essentially asymptomatic. She won a trophy in Little League baseball during the summer. Her environment problems, which had a lot to do with her wheezing were only gradually resolved. The dogs stayed in the house for a long time and contributed to her problem. There were also family quarrels and numerous psychosocial problems in the family, some of which have since been resolved. ROBERT N. HAMBURGER, MD: * This discussion is not simply about this little girl who was one of our patients in recent years with a, happier outcome. Her case does point out that the outpatient management of this type of intractable, almost crippling asthma, has changed considerably from what was described above and has become complex enough to be discouraging to general clinicians. We would like to outline an approach, primarily for outpatients with severe, chronic or intractable asthma. With today's patient we utilized many approaches. First, one of our Allergy Physician's Assistant Instructors made home visits and spoke to the family a great number of times, trying to get the patient and family cooperation that we need in this type of illness. In this patient there was a major amount of allergic disease as well as hyperreactivity of the lung that we do not fully understand. The environmental approach was an important aspect of her care. More recently, through self-hypnosis, we have taught her how to relax when she begins to feel the onset of bronchospasm. We and the social worker tried to help the family through some very difficult social situations. Therefore, even though today we are going to emphasize primarily a drug approach to the treatment of asthma, we do not *Professor of Pediatrics, Head, Pediatric Immunology and Allergy Division.

TABLE 2.-The Association of Atopic Disease With IgE of Percent Adult Incidence Allergic Population Diseases

IgE-IUlml Birth to 2 Years

3 years to Adult

750