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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