Gilbert A. Friday

Asthma and bacterial sinusitis in children

Signs, symptoms, and radiographic abnormalities of sinusitis are frequent in children with asthma; it is not known whether sinus inflammation is associated with bacterial infection or other mechanisms. Eight asthmatic patients with exacerbation of asthma despite bronchodilator therapy were studied after maxillary sinusitis was confirmed by radiographs. All had cough, wheezing, nasal stuffiness, rhinorrhea and were afebrile. Four patients had headaches, and two had facial pain. Maxillary sinus aspirates were obtained, and bacterial cultures were positive in five: Branhamella catarrhalis (2), nontypeable Hemophilus influenzae (2), Streptococcus pneumoniae (1). Nose and throat cultures did not correlate with sinus cultures. All patients received bronchodilators, and four of eight patients received steroids. All were treated for 14 to 28 days with antibiotics during which seven of the eight patients improved clinically including all with positive sinus cultures. Asthma-symptoms diary scores were kept by five; all demonstrated improvement. Pulmonary-function tests improved in five of seven patients after the antibiotic and asthma therapy including the four patients with positive cultures. Sinus radiographs cleared in three, improved in three, and were unchanged in two patients after antibiotic therapy.

Profile of Children Requiring Emergency Treatment for Asthma

BACKGROUND Emergency department care for asthma is expensive and continuity of care is often inefficient. Identification of patients-at-risk for emergency treatment is required in order to intervene before visits to the emergency department. OBJECTIVE To identify the antecedent factors in patients requiring emergency department treatment for wheezing and to determine the level of care before emergency visits. METHODS A prospective survey of patients treated for wheezing in the emergency department of an academic childrens hospital from January 1, 1994 to December 31, 1994. Data were compiled from a data from completed from the information obtained from the medical record, phone calls and letters. RESULTS During 1994, 1474 patients were treated for asthma and accounted for 1870 visits to the emergency department. Thirty-six percent of the total number of visits were made by 16% of the patients who made repeat visits. Two-thirds of the patients were 5 years of younger. Over 190 patients had been hospitalized for wheezing during the preceding 12-month period. Forty-four percent of the patients were referred to the emergency department by primary care physicians and 6.7% were referred by asthma specialists, either allergists or pulmonologists. The major predisposing factor was a family history of asthma in 70%. Beta agonists were the medications most frequently used prior to the emergency visits. Inhaled corticosteroids were used daily by 16% of the patients and oral corticosteroids were used daily by 7% of the patients. CONCLUSION Thirty-six percent of the visits were due to 16% of patients who were seen repeatedly in the emergency department for wheezing and a number of patients (192) had been admitted previously for wheezing. These findings suggest that there is a subset of patients who are known to have recurrent wheezing, but lack adequate management to avoid expensive hospital services. Very few of these patients were followed by asthma specialists and there was a marked underuse of anti-inflammatory drugs. This study characterized a subset of patients-at-risk for requiring emergency treatment for wheezing. There is a need to institute aggressive interventions to improve the quality of care and prevent costly emergency department visits.

Morbidity and mortality of asthma

Morbidity and mortality of asthma has been on the upswing since the 1960s, as marked by increased hospitalizations with asthma since the early 1980s. This has not been explained adequately. The possibility of change in the natural history or increased exposure to environmental irritant chemicals or allergens has been suggested by some. There probably has been better recognition and diagnosis of asthma by distinguishing it from bronchitis, recurrent croup, and bronchiolitis in children. Despite evidence to suggest that this is the case, there are still some missing factors. The increase in asthma mortality is more understandable when one considers the fact the management of asthma has changed greatly in the past two decades. The use of corticosteroids orally, parenterally, and by inhalation has been a double-edged sword. There is no doubt that many asthmatics have a much improved sense of well-being and have lived more normal lives due to the use of corticosteroids. The inability of some patients, parents, or physicians to perceive impending respiratory difficulty, however, may result in underuse of drugs, including corticosteroids, leading to increased mortality. Other factors have led to increased mortality from asthma in recent years, and they include arrhythmias with combinations of theophylline, beta-agonists, and hypoxia. The psychological factors attendant to adolescence and psychological problems are probably quite important in the recent upsurge in asthma deaths in the 15- to 25-year age group. Many deaths are occurring outside of the hospital environment and may be largely preventable. There must be increased awareness by the patient, the family, and the physician. In view of the increased hospitalizations, the total number of deaths is not increasing at an alarming rate, yet it is necessary to make all of us who care for asthmatics aware and take corrective action as soon as we are aware of an asthmatic with respiratory problems.

Cromolyn therapy for severe asthma in children.

Cromolyn sodium is a new antiasthmatic drug which exerts its action by interfering with the release of the mediators of immediate hypersensitivity reactions from the sensitized mast cells lining the bronchial tree. In a double-blind crossover trial, 36 children with chronic intractable asthma, 23 of whom were corticosteroid dependent, inhaled cromolyn sodium or a placebo four times per day for two 4 week periods. Although clinical improvement with cromolyn therapy was not statistically superior to the placebo, 36 patients noted subjective improvement from the cromolyn sodium and entered a 12 month open-end clinical trial. Twenty-six patients completed this second study; 19 of them showed clinical improvement. Of the 18 steroid-dependent patients who completed 12 months of cromolyn sodium therapy, 7 discontinued corticosteroids, 10 decreased their dosage, and one patient increased his corticosteroid requirement. Even though cromolyn sodium is not always clinically efficacious, it should be considered in the management of intractable asthma in children.

Childhood Antecedents of Allergic Sensitization in Young British Adults

One hundred and twenty-one allergic children with moderate to severe perennial asthma were randomly assigned to receive subcutaneous injections of either a mixture of up to seven aeroallergen extracts or a placebo. All went through an initial period ofobservation and stabilization during which time the children and parents were instructed in the management of asthma and environmental control and were seen every 2 to 3 weeks for medication adjustments. Eligible children were without furry pets and in equal numbers from an inner city population, largely black, and a suburban population, largely white. The children were between 5 and 12 years of age. Daily symptom scores as well as peak flow readings