Facts and Fancies in the Management of the Seriously Ill Patient with Bronchial Asthma

1) In order to restore physiologic balance in the sick asthmatic, it is necessary to maintain a therapeutic balance. I have attempted to illustrate the various measures which are necessary to balance this therapeutic seesaw. 2) The therapeutic measures suggested are based largely on personal experiences in the management of 513 patients and have been correlated with extensive laboratory studies with a large variety of protecting drugs, employing a method of human assay (protection studies). 3) With this technique, a method of human assay of the relative value of new and accepted therapeutic agents for the relief of bronchial asthma is possible. This technique has afforded us the opportunity of making these studies under controlled conditions usually not present in the sick patient. A comparative study of the protective abilities of several bronchodilators against the effects of intravenous histamine and mecholyl-induced dyspnea and bronchospasm is presented. The role and limitations of epinephrine, aminophyllin and the antihistaminic preparations based on laboratory and clinical correlation is discussed. 4) The role of sedation with drugs and anesthetic agents is presented. The use of chloral hydrate and sodium bromide, demerol, demerol and scopolamine (a modified form of “twilight sleep”), ether and paraldehyde, and caution about the use of sprays or topical pontocaine and cocaine is discussed. 5) Supportive therapy including the replacement of water, glucose, electrolytes and blood plasma is discussed at length. There should be no standard “intravenous cocktail mixture”. It should be prescribed according to physiologic needs. Interrupted or continuous intravenouses containing aminophyllin may be of great value. Addition of Cytochrome-C, nicotinic acid, vitamin B. Complex or cevitamic acid to the infusion fluid has not proven of striking value. On occasion, relaxation followed the use of alcohol-dextrose solution in place of the saline-dextrose infusions. These effects, however, did not persist with repeated use. 6) The therapeutic use of gases is discussed: oxygen for the relief of anoxia and cyanosis; helium and oxygen mixtures for the relief of respiratory obstruction; positive pressure inhalations of oxygen or helium and oxygen for the management of pulmonary edema; carbon dioxide mixtures as expectorants (“bronchial catharsis”); and aerosols of bronchodilator drugs for the relief of bronchospasm or antibiotic drugs for the control of infection. 7) Considerable emphasis is placed on the value of bronchial evacuation. Evacuation of the bronchi may be accomplished by “bronchial catharsis,” positional drainage, bronchoscopic aspiration and endoscopic lavage. “Bronchial catharsis” in its physiologic sense can be observed with the use of expectorant drugs (e.g., iodides) and syrup of ipecac, Ipecac acts by substituting effective retching for ineffective coughing. 8) The role of infection in bronchial asthma and its management is discussed. Adequate levels of sulfonamides and antibiotics in the sputum, the tracheobronchial tree and the pulmonary tissues should be the primary aim in management. We have been unable to demonstrate any penicillin in the sputum of patients with suppurative lung disease following intramuscular penicillin. On the other hand, we have been able to demonstrate high sputum levels in the same patients following aerosol and endoscopic instillations. In normal subjects, we have also demonstrated adequate penicillin blood levels which persist for a longer period than those following intramuscular injection. These levels were highest when neosynefrin and pantopaque were employed as diluents in place of saline. 9) Paranasal sinus disease is responsible for the reinfection and recurrence of cough and wheezing in patients with bronchial asthma. These patients are more likely to have serious asthma and irreparable sino-bronchitic disease. Treatment should consist of the combined use of antihistaminic preparations and nasal penicillin therapy with the technique of intermittent negative pressure and replacement with penicillin aerosol, with judicious but minimal surgical assistance. 10) The antihistaminics although generally of limited value in the management of the asthmatic subject, may be of considerable value in the following: Orally for the relief of paranasal obstruction (allergy is the dominant factor in the maintenance of chronic paranasal sinus disease in the asthmatic); intravenously to restore the delicate histamine-sympathin balance in the epinephrine refractory state; and for sedative effects in the status state.