AsthmaSummitPresentation Irons

8/12/2019 AsthmaSummitPresentation Irons

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Asthma Through the Years

A brief history of asthma

morbidity, cultural context andmanagement in the United States


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The Historical Perspective How the lay public has viewed it

How the medical profession hasmanaged it (or not managed it)

Why this perspective should beimportant to us


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Bronchial Asthma- 1908-1940 Expiratory dyspnoea, pulmonary emphysema with dry bronchial

catarrh.dependent upon a neurosis of the respiratory system whichcan be regarded mainly as a spasm of the muscles of respirationorperhaps a neurosis of the of secretion of the mucous membrane of theorgans of respiration.

Heredity recognized as important Diagnosis grouped with other neuropathies such as migraine or gout. mostly developed from peripheral irritation, from chronic

nasopharyngeal affections, especially from adenoidal vegetations; andalso from chronic relapsing bronchitis.

Eczema is important, and less so other affections, aschronic

urticaria. Children who are predisposed to asthma are often anemic, nervous

and irritable. Changes of weather and climate, certain odors, fresh colds, and

psychic factors(are)exciting causes.

From Pfaundler and Schlossman, The Diseases of Children, Volume III, 1908.


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1908-1940

Identified signs

Expiratory dyspnoea

Diminished respiratory murmur

Wheezes (sibilant ronchi)

Cough (sets in toward the close of the

attack) Eosinophils observed in sputum


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1908-1940 After weeks and months recurrences frequently take

place. The evil generally lasts for years.

Hay asthma described, attributed to pollens,

especially of grass and grains. Bronchial asthma seen as a distinct entity, in which

every new attack of bronchitisimmediatelyassumes an asthmatic character....In the intervals of

freedom they are often somewhat short of breathand frequently have chronic nasal catarrh andadenoids.


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Recommended Prophylaxis Removal of adenoid vegetations

careful treatment of nasal and bronchial catarrhsand eczema

strengthening and hardening of the system

outdoor exercise, prolonged sojourn in the countryor mountains, removal from large cities, curtailinganimal food, avoidance of overfeeding, abundant

supply of vegetables and fruit. gymnastics of the lung


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Recommended Treatment-

1908 Sedation (chloral hydrate, codeine or

morphine)

Potassium iodide or sodium iodideadministered by mouth 5X day

ammonium bromaticawith warm

vapors may be triedin cases whichterminate tardily


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What Most Lay People

Believed Asthmatics are weak, nervous, and sickly. They

should avoid exercise.

Most asthmatics are allergic to something, with the

exception of those with asthmatic bronchitis. The latter should always be treated with antibiotic, as

well as whatever is required to break the attack.

Aside from Oral Roberts, who was said to have cured

a 4th

-grade classmate, the best cure for asthma is tomove to a dry climate.

If you cant move, the second best thing is a.


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The dog, notthe girl!


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One place where you might find

both the dry air and the dog.


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Evolving PharmacologicalTreatment- 1908-1958

Anticholinergics Anticholinergics (belladonna alkaloids- scopolamine,

atropine, etc) given as plant extracts, usually byinhalation, sometimes by injection. Oslers Principles

and Practice of Medicine (1914): may be given inthe form of solution or used as cigarettesExcellentcigarettes are now manufactured.one form benefitsone patient, one form another

For children, Elliots Asthma Powder appeared somein the first quarter of the century.

Note: Ipratropium was not introduced until the1980s.


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Methyl Xanthines Osler (1914) recommended coffee

Cecils 1940 Textbook of Medicine mentions

the use of aminophylline 0.25gm in 10ccwater, injected intravenously.

By 1950, various oral theophylline productswere in wide use. While side effects werewidely recognized, it is unlikely that fatal oneswere recognized. Preparations varied greatlyin strength, and often were named similarly.


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Adrenergics

Adrenaline injections first reported successful in acute attacks in theLancet-1910.

Cecils 1947 textbook recommends either injections of 0.25cc of 1:1000solution every half hour, or inhalation of a 1:100 solution. Long-actingsusphrine for injection was available by 1960.

By the mid 50s, metered dose epinephrine and isoproterenolappeared.

Significant adverse affects identified, including a well-studied epidemicof asthma deaths in Britain, ultimately linked to a high-potency inhaler,isoproterenol forte, which was withdrawn from the market.

As a result Americas first asthma education program for physicians

was launched in the late 50s. Relatively specific beta-2 adrenergics began to emerge in the late 60s. Possible rebound effect or tachyphylaxis from regular use identified

early, still not fully appreciated by many.


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My introduction to the effect ofendogenous epinephrine on acute

asthma, December 21st, 1958.


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Corticosteroids

Oral steroids anecdotally reportedeffective in refractory cases in the early

50s, by 1970 were in wide use for bothtreatment and prevention. Thiscontinued well into the 80s. Steroidswere regarded as dangerous but

necessary. Note: A 1975 British Thoracic Society

report clearly documented the effect of

inhaled steroid in controlling asthma.


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A 1975 British Thoracic Society reportclearly documented the effect of inhaled

steroid in controlling asthma. Adoptionwas VERY slow in the US. Use wasminimal well into the 80s.


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Standard of Care

Intermittent or continuous theophylline, with regular monitoringof levels.

Attacks treated with SQ epinephrine followed by susphrine,with adjustment of theophylline levels as necessary.

Oral steroids, usually a one-week taper for severeexacerbations, with continuous use for severe asthmatics.Pediatricians avoided steroids as long as possible, oftenwithholding them until hospitalization was required.

Targeted agents such as Cromolyn were just hitting the market,were to later play an important role in our understanding of the

disease process. Home nebulizers for albuterol entered the market in 1980,

changing the sleep cycles of pediatricians everywhere.


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The State of the Art, 1981-85

Case presentation:Sarah Louise Irons


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SLI

Managed first by her father, later his partners, finally by aboard-certified allergist-pulmonologist.

First wheezing before age 2, treated with continuous oraltheophylline, SQ epinephrine for acute attacks, usually 2-3

doses followed by susphrine and a good emesis in the car onthe way home. Theophylline level constantly adjusted to keep close to 15. Oral steroids required with increasing frequency, for longer

periods. Frequent nocturnal awakenings, complaints of insomnia Appearance of new body hair was the last straw for her mom

and dad.


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My Eye-Opener

An invitation from the AAFP in late 1985 to present a mainstagelecture on asthma at their Fall 1986 annual meeting

Extensive literature review, Winter 1986. I learned:

Inhaled albuterol is at least as effective as SQ epinephrine Inhaled steroids are proven effective and have many fewer side effects than

oral steroids and theophylline. There is a relatively new targeted drug called cromolyn that I should learn

more about The airways of asthmatics are probably inflamed whether or not symptoms

are acute. Asthma symptoms are often not blatantly obvious. Asthmatics learn to

compensate for their symptoms.

Sarah Irons asthma management had to be taken over by her momand dad (and Sarah).


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Sarahs New Regimen- 1986

Daily inhaled steroid (2 times daily)

Daily inhaled cromolyn (4 times daily)

PRN albuterol Later, daily inhaled steroid and long-acting

beta-2 adrenergic, with prn albuterol, nasal

cromolyn, new generation antihistamines Not much different from what we all do today


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This history may help usbetter understand:

Why many see asthma as asign of weakness or frailty

Why people say they neverhad asthma as children, justasthmatic bronchitis

How slowly we adopttherapies proven effective

why physicians often under-prescribe oral steroid

Why patients and physiciansare so concerned about thepossible side effects ofinhaled steroids

How those concerns areused effectively bypharmaceutical companies

Why sometimes a doctor hasto take care of his or her

own family, AMA advice ornot.


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The End

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