632

Clearly the Council has a long row to hoe beforeit need worry about the detailed implementation of itsnew and ambitious plans.

RESPIRATORY ACIDOSISIN BRONCHIAL ASTHMA

MEASURES applied in acute bronchial asthma includeadministration of sympathomimetic agents, intravenousaminophylline, and adrenal steroids, removal of secretionsfrom the airways by means of bronchoscopy or tracheo-stomy, and application of assisted respiration. Blumenthalet al. 1 suggested that in some instances the correction ofrespiratory acidosis may be important, and now Mithoeferet awl. report 6 cases in which this measure produced reliefafter standard treatment (short of suction and assistedrespiration) had failed. All 6 patients had severe unremit-ting bronchospasm and were shown by blood-gas analysisand pH measurements to have associated respiratoryacidosis. Relief was obtained only when the pH wasrestored to near-normal values by intravenous administra-tion of sodium bicarbonate. In chronic obstructive air-

ways disease acidosis may stimulate respiration, andcorrection of acidosis lead to a fall in ventilation 4; but inthe asthmatic subjects of Mithoefer et al.-even in thosewith associated chronic respiratory disease-the decisiveresponse was a distinct diminution in airways resistanceand the net effect an increase in alveolar ventilation anda fall in arterial carbon-dioxide tension.

Acidosis has been shown to lessen, by a direct hydrogen-ion effect,5 both contractile and relaxation 2 responses toadrenaline; and Blumenthal et al.1 thought that therelief from bronchospasm which they noted in suitableasthmatic cases treated by the intravenous administrationof an alkalinising solution (sodium lactate) resulted fromthe elimination of this action. Experimental work, how-ever, has cast doubt on the significance of this acidoticdepression of the adrenaline response,5 and Mithoefer et al.do not believe that there is as yet a convincing rationalefor the striking therapeutic results they obtained.They recommend that, when patients with status

asthmaticus have failed to respond to standard treatment,the arterial C02 level and the pH should be measured and,if significant respiratory acidosis is revealed, 90 mEq. ofsodium bicarbonate (100 ml. of 0-3 M solution) beadministered intravenously over a five-minute period.The measurements should then be repeated and furtherdoses of 44-90 mEq. given at five to ten minute intervalsuntil the pH has returned to a near-normal value or untilthe clinical condition has improved. So far, they have hadno experience of the procedure in children. They pointout that, since renal loss of chloride is part of the com-pensatory mechanism for respiratory acidosis,’ metabolicalkalosis associated with hypochloraemia may occur whenthe carbon-dioxide tension is lowered,8 and administrationof chloride may be indicated. Potassium depletion mayalso demand correction.9 9

1. Blumenthal, J. S., Brown, E. B., Campbell, G. S. Ann. Allergy, 1956,14, 506.

2. Blumenthal, J. S., Blumenthal, M. N., Brown, E. B., Campbell, G. S.,Prasad, A. Dis. Chest, 1961, 39, 516.

3. Mithoefer, J. C., Runser, R. H., Karetzky, M. S. New Engl. J. Med.1965, 272, 1200.

4. Luchsinger, P. C. Ann. N.Y. Acad. Sci. 1961, 92, 743.5. Tenney, S. M. Am. J. Physiol. 1956, 187, 341.6. Tenney, S. M. Anesthesiology, 1960, 21, 674.7. Polak, A., Haynie, G. D., Hays, R. M., Schwartz, W. B. J. clin. Invest.

1961, 40, 1223.8. Schwartz, W. B., Hays, R. M., Polak, A., Haynie, G. D. ibid. p. 1238.9. Refsum, H. E. Scand. J. clin Lab. Invest. 1962, 14, 545.

NO HELP FOR THE SMOKER

SCANT success from antismoking clinics and campaignsseems to be taken for granted, and indeed failure of

persuasion alone was predictable. In combating an irra-tional craving, appeals to reason are unlikely to meet withmuch response. Effective and legitimate means of rein-forcing them have, however, still to be found.

Lobeline has been said to be helpful in the first cigarette-free days in reducing symptoms of withdrawal and sotiding the smoker over the shock of abstention. ButScott et al.1 could find no evidence of this benefit. Thecase recently made out for the drug by Golledge 2

however, establishes nothing so well as the extraordinarydifficulty of establishing anything in an antismokingclinic. Golledge set out to conduct a double-blind trial oflobeline as an aid to stopping smoking. He was runninghis clinic single-handed and only 36 smokers were invitedto attend: only 32 came, and only 27 persevered with thecourse of four weekly meetings. At these meetings,films, charts, and posters were displayed. Each smokerwas given a supply of white tablets containing eitherlobeline or a placebo preparation, and each was asked torecord the number of tablets he took and the number of

cigarettes he smoked each day. Of 15 subjects takinglobeline, 11 had stopped smoking after twenty-eight days,compared with 6 of 12 taking the placebo. The differenceis not signicant and the figures are small. They were,nevertheless, arrived at only with difficulty.What, for instance, in the treatment of nicotine addic-

tion, constitutes success ? The man who cuts his dailyconsumption of cigarettes from sixty to six must be felt tohave achieved something; but he has not regained hisindependence. How, in any analysis of results, should hefigure ? " Percentage reduction in cigarette consump-tion " is a measure which perhaps conveys more than itought.

Golledge also had difficulty with lackadaisical attendersat his clinic. Where the subject’s will and inclination areso much at variance, consistency can hardly be expected.Golledge lost trace of 10 of his 32 subjects before the trialwas complete; after extended inquiry only 5 were subse-quently found. 9 of the 10 proved to have been taking theplacebo, and this Golledge liked to feel was significantsince, in general, lack of interest complements lack ofsuccess.

Once a trial or course of treatment is over, however,there is nothing to induce either those who have managedto stop smoking or those who have failed to contact theclinic for follow-up. The assessment of success in the

longer run must be difficult and frustrating. Golledge, inhis trial of lobeline, did not attempt it; and, indeed, in thetesting of a drug intended only to facilitate withdrawal,follow-up is hardly relevant. But withdrawal, howeverpainlessly achieved, is itself a waste of time if it has to berepeated too often.

Sooner or later someone will want to know whetherantismoking propaganda is having any real success.

How he is to be answered is not yet apparent. The

campaign of persuasion seems perfectly to reconcile

doing nothing and doing everything about the establisheddangers of cigarette-smoking. A Government in twominds about the wisdom of reducing cigarette sales couldhave lighted on no more obscure or unexceptionablecompromise.1. Scott, G. W., Cox, A. G. C., Maclean, K. S., Price, T. M. L.,

Southwell, N. Lancet, 1962, i, 54.2. Golledge, A. H. Med. Offr, 1965, 117, 59.