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Asthma Through the Years

A brief history of asthma
morbidity, cultural context and
management in the United States
The Historical Perspective
How the lay public has viewed it
How the medical profession has
managed it (or not managed it)
Why this perspective should be
important to us
Bronchial Asthma- 1908-1940
Expiratory dyspnoea, pulmonary emphysema with dry bronchial
catarrh.dependent upon a neurosis of the respiratory system which
can be regarded mainly as a spasm of the muscles of respirationor
perhaps a neurosis of the of secretion of the mucous membrane of the
organs 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; and
also 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.
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

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 bronchitisimmediately
assumes an asthmatic character....In the intervals of
freedom they are often somewhat short of breath
and frequently have chronic nasal catarrh and
adenoids.

Recommended Prophylaxis
Removal of adenoid vegetations
careful treatment of nasal and bronchial catarrhs
and eczema
strengthening and hardening of the system
outdoor exercise, prolonged sojourn in the country
or mountains, removal from large cities, curtailing
animal food, avoidance of overfeeding, abundant
supply of vegetables and fruit.
gymnastics of the lung


Recommended Treatment-
1908
Sedation (chloral hydrate, codeine or
morphine)
Potassium iodide or sodium iodide
administered by mouth 5X day
ammonium bromaticawith warm
vapors may be triedin cases which
terminate tardily
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 4
th
-grade classmate, the best cure for asthma is to
move to a dry climate.
If you cant move, the second best thing is a.

The dog, not
the girl!
One place where you might find
both the dry air and the dog.
Evolving Pharmacological
Treatment- 1908-1958
Anticholinergics
Anticholinergics (belladonna alkaloids- scopolamine,
atropine, etc) given as plant extracts, usually by
inhalation, sometimes by injection. Oslers Principles
and Practice of Medicine (1914): may be given in
the form of solution or used as cigarettesExcellent
cigarettes are now manufactured.one form benefits
one patient, one form another
For children, Elliots Asthma Powder appeared some
in the first quarter of the century.
Note: Ipratropium was not introduced until the
1980s.
Methyl Xanthines
Osler (1914) recommended coffee
Cecils 1940 Textbook of Medicine mentions
the use of aminophylline 0.25gm in 10cc
water, injected intravenously.
By 1950, various oral theophylline products
were in wide use. While side effects were
widely recognized, it is unlikely that fatal ones
were recognized. Preparations varied greatly
in strength, and often were named similarly.
Adrenergics
Adrenaline injections first reported successful in acute attacks in the
Lancet- 1910.
Cecils 1947 textbook recommends either injections of 0.25cc of 1:1000
solution every half hour, or inhalation of a 1:100 solution. Long-acting
susphrine for injection was available by 1960.
By the mid 50s, metered dose epinephrine and isoproterenol
appeared.
Significant adverse affects identified, including a well-studied epidemic
of 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.
My introduction to the effect of
endogenous epinephrine on acute
asthma, December 21
st
, 1958.
Corticosteroids
Oral steroids anecdotally reported
effective in refractory cases in the early
50s, by 1970 were in wide use for both
treatment and prevention. This
continued well into the 80s. Steroids
were regarded as dangerous but
necessary.
Note: A 1975 British Thoracic Society
report clearly documented the effect of
inhaled steroid in controlling asthma.

A 1975 British Thoracic Society report
clearly documented the effect of inhaled
steroid in controlling asthma. Adoption
was VERY slow in the US. Use was
minimal well into the 80s.
Standard of Care
Intermittent or continuous theophylline, with regular monitoring
of levels.
Attacks treated with SQ epinephrine followed by susphrine,
with adjustment of theophylline levels as necessary.
Oral steroids, usually a one-week taper for severe
exacerbations, with continuous use for severe asthmatics.
Pediatricians avoided steroids as long as possible, often
withholding 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.
The State of the Art, 1981-85
Case presentation:
Sarah Louise Irons
SLI
Managed first by her father, later his partners, finally by a
board-certified allergist-pulmonologist.
First wheezing before age 2, treated with continuous oral
theophylline, SQ epinephrine for acute attacks, usually 2-3
doses followed by susphrine and a good emesis in the car on
the 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.

My Eye-Opener
An invitation from the AAFP in late 1985 to present a mainstage
lecture 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 mom
and dad (and Sarah).
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
This history may help us
better understand:
Why many see asthma as a
sign of weakness or frailty
Why people say they never
had asthma as children, just
asthmatic bronchitis
How slowly we adopt
therapies proven effective
why physicians often under-
prescribe oral steroid



Why patients and physicians
are so concerned about the
possible side effects of
inhaled steroids
How those concerns are
used effectively by
pharmaceutical companies
Why sometimes a doctor has
to take care of his or her
own family, AMA advice or
not.

The End