The Journal of Pediatrics
Volume 152, Issue 5 , Page 733, May 2008

50 years ago in The Journal of Pediatrics:

Management of bronchial asthma in children

Department of Paediatrics, Prince of Wales Hospital, Shatin, Hong Kong

Article Outline

 

Unger L, Wolf AA, Johnson JH, Unger DL. J Pediatr 1958;52:539-46

In the 1940s, “bronchial asthma” was equated with an allergic condition. Unger et al emphasized that a delay in allergy surveys, including skin tests, was apt to be followed by chronic asthma with emphysema and chest deformation. Consequently, skin tests should be conducted in all cases of “bronchial asthma.” Following strict precautions and protocols, the skin tests performed in their institute included all possible inhalant materials and foods. The results guided subsequent asthma management. The standard therapy for bronchial asthma in the 1940s included specific, symptomatic, and preventive measures. Specific therapy included avoidance of causative allergens, including inhalant materials and foods, with or without hyposensitization. Hyposensitization involved repeated injections of increasing amounts of extracts of important unavoidable allergens given over extended periods.

Symptomatic therapy consisted mainly of subcutaneous injections of epinephrine or rectal aminophylline. Corticosteroids were thought to temporarily eliminate the asthmatic symptoms as they occurred, without curing asthma. Preventive therapy was instituted when allergic parents planned for pregnancy. Home environment adjustments, careful new food trials, occupational planning, and allergy surveys were thought to be effective in preventing the onset of severe asthma in children.

The definition and management of asthma have evolved substantially over the past 50 years with increasing knowledge of its pathophysiologic changes. Currently, asthma is classified as a chronic hyperresponsive inflammatory disorder,1 and it is no longer termed “bronchial asthma.”

Asthma is a clinical diagnosis,2 and various investigations can help confirm the diagnosis. These include measurements of lung function (especially reversibility and variability), airway hyperresponsiveness,3 airway inflammation (eg, sputum eosinophils or neutrophils,4 exhaled NO,5 or CO6), and allergic status by skin testing and specific IgE. Skin tests with all possible inhalant materials and foods are no longer in favor.

Avoiding the risk factors that cause asthma symptoms is advised. Asthma medications include stepwise “controller” medications (with glucocorticosteroids as the cornerstone7) and “reliever” medications. Inhalation agents are preferred. Specific immunotherapy, such as hyposensitization or anti-IgE, should be considered only after the patient fails to respond to strict environmental avoidance and pharmacologic intervention, such as inhaled steroids.8, 9 Bronchodilators10 and systemic glucocorticosteroid11 are used for acute exacerbations. Epinephrine injections are reserved only for anaphylaxis or angioedema.

Over the past 50 years, asthma has increasingly become a major cause of chronic morbidity and mortality. It is hoped that continued advances in treatment can someday bring asthma under control.

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References 

  1. Busse WW, Lemanske RF. Asthma. N Engl J Med. 2001;344:350–362
  2. Levy ML, Fletcher M, Price DB, Hausen T, Halbert RJ, Yawn BP. International Primary Care Respiratory Group Guidelines: diagnosis of respiratory diseases in primary care. Prim Care Respir J. 2006;15:20–34
  3. Cockcroft DW, Murdock KY, Berscheid BA, Gore BP. Sensitivity and specificity of histamine PC20 determination in a random selection of young college students. J Allergy Clin Immunol. 1992;89(1 Pt 1):23–30
  4. Pizzichini MM, Papov TA, Efthimiadis A, Hussack P, Evans S, Pizzichini E, et al. Spontaneous and induced sputum to measure indices of airway inflammation in asthma. Am J Respir Crit Care Med. 1996;154(4 Pt 1):866–869
  5. Kharitonov S, Alving K, Barnes PJ. Exhaled and nasal nitric oxide measurements: recommendations (The European Respiratory Society Task Force). Eur Respir J. 1997;10:1683–1693
  6. Horvath I, Barnes PJ. Exhaled monoxides in asymptomatic atopic subjects. Clin Exp Allergy. 1999;29:1276–1280
  7. Juniper EF, Kline PF, Vanzieleghem MA, Ramsdale EH, O'Byrne P, Hargreave FE. Effect of long-term treatment with an inhaled corticosteroid on airway responsiveness and clinical asthma in nonsteroid-dependent asthmatics. Am Rev Respir Dis. 1990;142:832–836
  8. Abramson MJ, Puy RM, Weiner JM. Allergen immunotherapy for asthma. Cochrane Database Syst Rev. 2003;CD001186
  9. Bousquet J, Lockey R, Malling HJ. Allergen immunotherapy: therapeutic vaccines for allergic diseases. Ann Allergy Asthma Immunol. 1998;81(5 Pt 1):401–405
  10. Reisner C, Kotch A, Dworkin G. Continuous versus frequent intermittent nebulization of albuterol in acute asthma: a randomized, prospective study. Ann Allergy Asthma Immunol. 1995;75:41–47
  11. Manser R, Reid D, Abramson M. Corticosteroids for acute severe asthma in hospitalized patients. Cochrane Database Syst Rev. 2000;2:

PII: S0022-3476(07)01131-6

doi:10.1016/j.jpeds.2007.11.029

The Journal of Pediatrics
Volume 152, Issue 5 , Page 733, May 2008

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