- Email: [email protected]
COMMISSIONING RESEARCH
312
A doctor confronted with streptococcal disease in an institution may hope to find one of the uncommon foodborne outbreaks, for these are more likely than others to be self-limiting.6 The common person-toperson spread of throat and skin infection is more difficult to control. A survey of the whole institution for cases and carriers, followed by isolation and treatment, plus environmental cleaning, had led to the end of epidemics,’ but these ,procedures are not always successful. Because these measures will disrupt the running of any institution, they may be unacceptable unless severe complications have occurred. Prompt treatment of clinical illness is adequate in schools and homes for normal children suffering no worse than tonsillitis, scarlet fever, or impetigo. More action is demanded when the risk of complications is high, although a high risk is hard to define when the incidence of serious sequelae in the general population is low and unmeasured. Clinical attacks of rheumatic fever and glomerulonephritis, the presence ofa nephritogenic type, and M type 5, which has caused serious institutional outbreaks, indicate increased risks. Hospital patients are clearly an institutional group at high risk. It may be that past social deprivation is a factor in rheumatic fever in penal institutions. Streptococcal typing is a specialised and timeconsuming microbiological technique, but one that should be applied when an outbreak is suspected. Prevention in hospitals has been largely achieved by good hygiene and surveillance, but the record in other institutions gives no grounds for complacency. Full penicillin prophylaxis for all entrants to an institution can be justified when a serious epidemic is in progress, but must leave those so treated still without typespecific immunity. Because there is still uncertainty about the efficacy of control measures, the epidemiology of streptococci in institutions should be further investigated. Outbreaks of both skin sepsis and pharyngitis are sufficiently common and prolonged for a formal trial. Most young people in institutions are not there by choice, so in these we have a special obligation to prevent streptococcal infection. COMMISSIONING RESEARCH IT is now nearly ten years since the Rothschild Reportl drew a distinction between fundamental and applied research and indicated the way in which Government departments should organise their research strategies. There were immediate protests that scientists themselves were quite capable of seeing the social relevance of their work, and that the implications and interactions of each type of research on the other were anyway so great that the distinction was unhelpful. But Rothschild commented that "the country’s needs are not so trivial as to be left to the mercies of a form of Ryder RW, Lawrence DN, Nitzkin JL, Feeley JC, Merson MH. An evaluation of penicillin prophylaxis during an outbreak of food borne streptococcal pharyngitis. Am J Epidemiol 1977; 106: 139-44. 7. Backhouse CI, Cartwright RY. An outbreak of streptococcal skinsepsis ina closedcommunity. Br Med J 1974; ii: 497. 1. The Organisation and Management of Government R and D (Rothschild Report). H.M. Stationery Office, 1971. 6.
scientific roulette, with many more than the conventional 37 numbers on which the ball may land". To meet these needs Government departments commissioning research were to adopt a customer/contractor stance with researchers, appoint Chief Scientists to advise customers what they needed, and be given a proportion of the various Research Councils’ budgets in view of the applied nature of some of their work. Chief Scientists also had a clear obligation to see that the results of research were used in policy formulation. The Department of Health accepted the proposals with alacrity, appointing a Chief Scientist with a Research Committee and a Health Services Research Board to help him, and establishing Research Liaison Groups with professionals and administrators from within the Department, together with advisers from outside it, to commission the research. The Department was awarded a quarter of the M.R.C. budget to commission research from the M.R.C.-to the alarm of those who saw the Council weakened thereby. A team from Brunel University2 has analysed, in a critical and informative way, what has happened since the Rothschild report. They, and others,3 point to the gradual withering and final demise of the Chief Scientist’s Advisory Committees which found they had less and less to say to Research Liaison Groups which were increasingly confident in their own ability to define needs and commission suitable research. Where "client groups" existed within the Department-and they were established early in just those spheres (old age, physical handicap) which had previously been starved of scientific interest-there were ready customers for research. Such a gradual shift of emphasis in Departmental ar. rangements has not made it easier for research contractors to discern clear and consistent policy behind the Department’s commissioning nor to be satisfied that the results of their efforts are used to the best effect. It has, however, enabled the Chief Scientist to attain the powerful position of research manager as well as scientific adviser-judge and advocate in a sphere which is not his own. As the Brunel team point out, many of the Department’s concerns involve issues other than the purely medical: they have strongly behavioural and economic components as well. To achieve useful answers often implies several different approaches to the same question, and it may be hard for a Chief Scientist reared on the strong milk of fundamental science to recognise the value of unfamiliar methodologies needed for multi-faceted applied research. Indeed, as the Research Liaison Groups grew in strength, the Department found itself able to explore areas, such as nursing and general practice, where research methods have yet to be developed. Academic units strong enough to encompass multiple approaches and devise new methods take time to grow and mature, and, while it is perfectly in order for the Department to set high standards and to demand value for its money, high standards are most likely to be achieved in experienced units. And such experience, as the Research Councils very well know, implies good career prospects for those prepared to put their lives to gaining it. Until two years ago there was every indication that the Department, though somewhat uncertain in its own functioning and far from clear in its policy, was at least sensitive to these issues. But now the experience it slowly acquired during ten years of commissioning service related research is to 2.
Kogan M, Korman N, Kenkel M. Government’s commissioning of research: A case study. Department of Government, Brunel University, 1980. 3. McLachlan G, ed. Five years after: a review of health care research and management after Rothschild. Oxford: Oxford University Press for Nuffield Provincial Hospital Trust, 1978.
313 be dissipated; the Medical Research Council is to have back that proportion of the money it lost under Rothschild and promises, in return, to become more interested in health service matters. To what possible end? If the internal (and recently much trimmed) mechanisms of the Department have found it difficult to relate commissioned research to a clear statement of policy, how can the M.R.C. do any better? And where, within it, are those able to judge the scientific value of the "disciplined enquiry"4 suited to health services research rather than the more well-tried and exacting methods of fundamental science? Nobody outside the Chief Scientist’s office has any clear idea why this apparently backward step is to be taken; the least that the Chief Scientist, and the Department, can do is to make the reasons explicit. Only then can the Health Services Research Units, who have at present to be content with little more than rumour, judge whether it is their own performance or the Department’s failure to translate their research findings into policy that is at fault.
ACUTE SEVERE ASTHMA ACUTE
severe
asthma remains
a
common
and lethal
disease5 with recommended therapies including sub-
adrenaline, inhaled (3-stimulants, intravenous aminophylline, and intravenous hydrocortisone up to 2 g daily. Theoretically, oral or parenteral compounds might be expected to work better than inhaled ones in a severe acute atcutaneous
tack of asthma but in four studies6-9 ir.travenous salbutamol was no more effective than inhaled salbutamol. Intravenous aminophylline has been reported more effective and faster acting than a lowish dose of intravenous salbutamol l° Mitenko and Ogilvie 11recommended a loading dose of 5’66 mg/kg aminophylline followed by infusion of 0’ 9 mg/kg, but such regimens dangerous. Hendeles and convulsions and cardiac arrhymsuch as side-effects, Serious other occur before can thias, symptom of toxicity such as any
Weinberger 12 reckon
nausea or
headache.13
single "safe" dosage regimen for intravenous aminophylline can be proposed because theophylline clearance varies greatly between patients; 14 saturable pathways may be affected by dietary methy[xanthines,l 5,16 and further reduction in theophylline clearance may result from liver disease 17 No
4. Cronbach LJ, Suppes P, eds. Research for tomorrow’s schools: disciplined enquiry for education. New York: MacMillan, 1969. 5. Editorial. Management of acute severe asthma. Br Med J 1978; i: 873. 6. Spiro SG, Johnson AJ, May CS, Paterson JW. Effect of intravenous injection of salabutamol and asthma. Br J Clin Pharmacol 1975; 2: 495-501. 7. Hetzel MR, Clark TJH. Comparison of intravenous and aerosol salbutamol. Br Med J 1976; ii: 919. 8. Lawford P, Jones BJM, Milledge JS. Comparison of intravenous and nebulized salbutamol initial treatment of severe asthma. Br Med J 1978; i: 84. 9. Nogrady SO, Hartley JPR, Seaton A. Metabolic effects of intravenous salbutamol in the course of acute severe asthma. Thorax 1977; 32: 559-62. 10. Evans WV, Monie RDH, Crimmins J, Seaton A. Aminophylline, salbutamol and combined intravenous infusions in acute severe asthma. Br J Dis Chest 1980; 74: 385-89. 11. Mitenko PA, Ogilvie RI. Rational intravenous dose of theophylline. N Engl J Med 1973; 289: 600-03. 12. Hendeles L, Weinberger MM, Poisoning patients with intravenous theophylline. Am J Hosp Pharm 1980; 37: 49-50. 13. Zwillich CW, Sutton FD, Neff TA, Cohn WM, Mathay RA, Weinberger MM. Theophylline-Induced seizures in adults. Correlation with serum concentration. Ann Intern Med 1975; 82: 784-87. 14. Hendeles L, Weinberger MM, Bighley L. Disposition of theophylline following a single intravenous aminophylline infusion. Am Rev Resp Dis 1978; 118: 97-103. 15. Lesko LJ. Dose-dependent elimination kinetics oftheophylline. Clin Pharmacokinetics 1979; 4: 449-59. 16. Monks TJ, Caldwell J, Smith RL. Influence of methylxanthine containing foods on theophylline metabolism and kinetics. Clin Pharmacol Ther 1979; 26: 513-24. 17. Piafsky KM, Sitar DS, Rangno RE, Ogilvie RI. Theophylline disposition in patients with hepatic cirrhosis. N Engl J Med 1977; 296: 1495-97. 18. Vicuna N, McNay JL, Ludden TH, Schwertner H. Impaired theophylline clearance in patients with cor pulmonale. Br J Clin Pharmacol 1979; 7: 33-37.
and heart failure Therapy also has to aim at the narrow windOW19 between bronchodilation and toxicity (8-20 mg/1). Nevertheless, intravenous aminophylline continues to be used very widely. McFadden and his group20 have reported a comparison of intravenous aminophylline, subcutaneous adrenaline, and inhaled isoprenaline in 48 patients with acute severe asthma. Aminophylline was given according to the Mitenko and Ogilvie regimen, but with greatly reduced doses (less than half) in patients who had previously received oral theophyllines; adrenaline 0’ 3 mg was given subcutaneously three times in the first hour; and isoprenaline 2 -5mg was given three times in one hour via a hand-held nebuliser. Before treatment there was no significant difference between the groups in forced expiratory volume in one second (FEV 1). After one hour bronchodilation was significantly greater in the adrenaline and isoprenaline groups than in the aminophylline group (AFEV0-761, 0-791, and 0-231, respectively). Serum theophylline concentrations were in the therapeutic range (mean 16.22 mg/1) and previous oral theophylline did,not seem to influence the rate of response in the isoprenaline and adrenaline groups. McFadden and coworkers report also that the maximum bronchodilator effect was attained more rapidly with adrenaline and isoprenaline than with aminophylline. Deaths from acute severe asthma can occur before medical advice is sought, after the primary care treatment, or in hospital. Ideally, patients should record their peak expiratory flow rate (PEFR) regularly in the same way that a diabetic patient monitors urinary glucose,21 adjusting therapy accordingly.22 In fact, such routine measurement of PEFR has not been much encouraged by doctors. One useful sign that asthma is getting out of control is a doubling of the number of aerosol puffs required over 48-72 hours:23 this indicates a need for medical advice either at primary care level or at a specialist centre.24 What about therapy during transfer of an acutely ill patient? In view of the possible hazards of intravenous aminophylline, perhaps after a slow intravenous injection of 200 mg hydrocortisone the patient should be given a subcutaneous or intramuscular injection ofa selective (32 stimulant (e.g., terbutaline 0-5mg or salbutamol 0’ 5 mg). If this cannot be done then the patient should be advised to take two puffs of pressurised aerosol P2 stimulant (or its equivalent as dry powder capsule) every 5 minutes during transfer to hospital or until symptoms are relieved. In moderately severe asthma managed in hospital, high-dose aerosol therapy has proved safe and effective.26 On the patient’s arrival in hospital treatment should be by inhaled 2 stimulant in the recommended nebuliser dose, plus hydrocortisone 200 mg intravenously every 6 hours. In those who are severely ill or in whom the PEFR has not increased after an hour’s treatment, intravenous aminophylline may be given in a dose of 5-66 mg/kg over 20-30 minutes followed by 19.
Jenne JW, Wyze E, Rood FS, MacDonald FM. Pharmacokinetics oftheophylline. Application to adjustment of the clinical dose of aminophylline. Clin Pharmacol Ther 1972 13: 349-60.
20.
Rossing TH, Fanta CH, Goldstein DH, Snapper JR, McFadden ER, Jr. Emergency therapy of asthma: Comparison of the acute effects of parenteral and inhaled sympathomimetics and infused aminophylline. Am Rev Resp Dis 1980; 122: 365-71. 21. Seaton A. Asthma-contrasts in care. Thorax 1978; 33: 1-2. 22. Prior JG, Cochrane GM. Home monitoring of peak expiratory flow rate using miniWright peak flow meter in diagnosis of asthma. J RoySoc Med 1980; 73: 731-33.
23. Cochrane GM. Bronchodilators. Practitioner 1979; 223: 489-98. 24. Crompton GK, Grant IWB, Bloomfield P. Edinburgh emergency asthma admission service: Report on 10 years’ experience. Br Med J 1979; ii; 1199-1201. 25. Pang LM, Rodriguez-Martinez F, Davis WJ, Mellins RB. Terbutaline in the treatment of status asthmatics. Chest 1977; 72: 469-73. 26. Cayton RM, WebberB, PatersonJW, ClarkTJH. A comparisonof salbutamol givenby pressure-packed aerosol or nebulization in acute asthma. BrJ Dis Chest 1978; 72: 222-24.
A doctor confronted with streptococcal disease in an institution may hope to find one of the uncommon foodborne outbreaks, for these are more likely than others to be self-limiting.6 The common person-toperson spread of throat and skin infection is more difficult to control. A survey of the whole institution for cases and carriers, followed by isolation and treatment, plus environmental cleaning, had led to the end of epidemics,’ but these ,procedures are not always successful. Because these measures will disrupt the running of any institution, they may be unacceptable unless severe complications have occurred. Prompt treatment of clinical illness is adequate in schools and homes for normal children suffering no worse than tonsillitis, scarlet fever, or impetigo. More action is demanded when the risk of complications is high, although a high risk is hard to define when the incidence of serious sequelae in the general population is low and unmeasured. Clinical attacks of rheumatic fever and glomerulonephritis, the presence ofa nephritogenic type, and M type 5, which has caused serious institutional outbreaks, indicate increased risks. Hospital patients are clearly an institutional group at high risk. It may be that past social deprivation is a factor in rheumatic fever in penal institutions. Streptococcal typing is a specialised and timeconsuming microbiological technique, but one that should be applied when an outbreak is suspected. Prevention in hospitals has been largely achieved by good hygiene and surveillance, but the record in other institutions gives no grounds for complacency. Full penicillin prophylaxis for all entrants to an institution can be justified when a serious epidemic is in progress, but must leave those so treated still without typespecific immunity. Because there is still uncertainty about the efficacy of control measures, the epidemiology of streptococci in institutions should be further investigated. Outbreaks of both skin sepsis and pharyngitis are sufficiently common and prolonged for a formal trial. Most young people in institutions are not there by choice, so in these we have a special obligation to prevent streptococcal infection. COMMISSIONING RESEARCH IT is now nearly ten years since the Rothschild Reportl drew a distinction between fundamental and applied research and indicated the way in which Government departments should organise their research strategies. There were immediate protests that scientists themselves were quite capable of seeing the social relevance of their work, and that the implications and interactions of each type of research on the other were anyway so great that the distinction was unhelpful. But Rothschild commented that "the country’s needs are not so trivial as to be left to the mercies of a form of Ryder RW, Lawrence DN, Nitzkin JL, Feeley JC, Merson MH. An evaluation of penicillin prophylaxis during an outbreak of food borne streptococcal pharyngitis. Am J Epidemiol 1977; 106: 139-44. 7. Backhouse CI, Cartwright RY. An outbreak of streptococcal skinsepsis ina closedcommunity. Br Med J 1974; ii: 497. 1. The Organisation and Management of Government R and D (Rothschild Report). H.M. Stationery Office, 1971. 6.
scientific roulette, with many more than the conventional 37 numbers on which the ball may land". To meet these needs Government departments commissioning research were to adopt a customer/contractor stance with researchers, appoint Chief Scientists to advise customers what they needed, and be given a proportion of the various Research Councils’ budgets in view of the applied nature of some of their work. Chief Scientists also had a clear obligation to see that the results of research were used in policy formulation. The Department of Health accepted the proposals with alacrity, appointing a Chief Scientist with a Research Committee and a Health Services Research Board to help him, and establishing Research Liaison Groups with professionals and administrators from within the Department, together with advisers from outside it, to commission the research. The Department was awarded a quarter of the M.R.C. budget to commission research from the M.R.C.-to the alarm of those who saw the Council weakened thereby. A team from Brunel University2 has analysed, in a critical and informative way, what has happened since the Rothschild report. They, and others,3 point to the gradual withering and final demise of the Chief Scientist’s Advisory Committees which found they had less and less to say to Research Liaison Groups which were increasingly confident in their own ability to define needs and commission suitable research. Where "client groups" existed within the Department-and they were established early in just those spheres (old age, physical handicap) which had previously been starved of scientific interest-there were ready customers for research. Such a gradual shift of emphasis in Departmental ar. rangements has not made it easier for research contractors to discern clear and consistent policy behind the Department’s commissioning nor to be satisfied that the results of their efforts are used to the best effect. It has, however, enabled the Chief Scientist to attain the powerful position of research manager as well as scientific adviser-judge and advocate in a sphere which is not his own. As the Brunel team point out, many of the Department’s concerns involve issues other than the purely medical: they have strongly behavioural and economic components as well. To achieve useful answers often implies several different approaches to the same question, and it may be hard for a Chief Scientist reared on the strong milk of fundamental science to recognise the value of unfamiliar methodologies needed for multi-faceted applied research. Indeed, as the Research Liaison Groups grew in strength, the Department found itself able to explore areas, such as nursing and general practice, where research methods have yet to be developed. Academic units strong enough to encompass multiple approaches and devise new methods take time to grow and mature, and, while it is perfectly in order for the Department to set high standards and to demand value for its money, high standards are most likely to be achieved in experienced units. And such experience, as the Research Councils very well know, implies good career prospects for those prepared to put their lives to gaining it. Until two years ago there was every indication that the Department, though somewhat uncertain in its own functioning and far from clear in its policy, was at least sensitive to these issues. But now the experience it slowly acquired during ten years of commissioning service related research is to 2.
Kogan M, Korman N, Kenkel M. Government’s commissioning of research: A case study. Department of Government, Brunel University, 1980. 3. McLachlan G, ed. Five years after: a review of health care research and management after Rothschild. Oxford: Oxford University Press for Nuffield Provincial Hospital Trust, 1978.
313 be dissipated; the Medical Research Council is to have back that proportion of the money it lost under Rothschild and promises, in return, to become more interested in health service matters. To what possible end? If the internal (and recently much trimmed) mechanisms of the Department have found it difficult to relate commissioned research to a clear statement of policy, how can the M.R.C. do any better? And where, within it, are those able to judge the scientific value of the "disciplined enquiry"4 suited to health services research rather than the more well-tried and exacting methods of fundamental science? Nobody outside the Chief Scientist’s office has any clear idea why this apparently backward step is to be taken; the least that the Chief Scientist, and the Department, can do is to make the reasons explicit. Only then can the Health Services Research Units, who have at present to be content with little more than rumour, judge whether it is their own performance or the Department’s failure to translate their research findings into policy that is at fault.
ACUTE SEVERE ASTHMA ACUTE
severe
asthma remains
a
common
and lethal
disease5 with recommended therapies including sub-
adrenaline, inhaled (3-stimulants, intravenous aminophylline, and intravenous hydrocortisone up to 2 g daily. Theoretically, oral or parenteral compounds might be expected to work better than inhaled ones in a severe acute atcutaneous
tack of asthma but in four studies6-9 ir.travenous salbutamol was no more effective than inhaled salbutamol. Intravenous aminophylline has been reported more effective and faster acting than a lowish dose of intravenous salbutamol l° Mitenko and Ogilvie 11recommended a loading dose of 5’66 mg/kg aminophylline followed by infusion of 0’ 9 mg/kg, but such regimens dangerous. Hendeles and convulsions and cardiac arrhymsuch as side-effects, Serious other occur before can thias, symptom of toxicity such as any
Weinberger 12 reckon
nausea or
headache.13
single "safe" dosage regimen for intravenous aminophylline can be proposed because theophylline clearance varies greatly between patients; 14 saturable pathways may be affected by dietary methy[xanthines,l 5,16 and further reduction in theophylline clearance may result from liver disease 17 No
4. Cronbach LJ, Suppes P, eds. Research for tomorrow’s schools: disciplined enquiry for education. New York: MacMillan, 1969. 5. Editorial. Management of acute severe asthma. Br Med J 1978; i: 873. 6. Spiro SG, Johnson AJ, May CS, Paterson JW. Effect of intravenous injection of salabutamol and asthma. Br J Clin Pharmacol 1975; 2: 495-501. 7. Hetzel MR, Clark TJH. Comparison of intravenous and aerosol salbutamol. Br Med J 1976; ii: 919. 8. Lawford P, Jones BJM, Milledge JS. Comparison of intravenous and nebulized salbutamol initial treatment of severe asthma. Br Med J 1978; i: 84. 9. Nogrady SO, Hartley JPR, Seaton A. Metabolic effects of intravenous salbutamol in the course of acute severe asthma. Thorax 1977; 32: 559-62. 10. Evans WV, Monie RDH, Crimmins J, Seaton A. Aminophylline, salbutamol and combined intravenous infusions in acute severe asthma. Br J Dis Chest 1980; 74: 385-89. 11. Mitenko PA, Ogilvie RI. Rational intravenous dose of theophylline. N Engl J Med 1973; 289: 600-03. 12. Hendeles L, Weinberger MM, Poisoning patients with intravenous theophylline. Am J Hosp Pharm 1980; 37: 49-50. 13. Zwillich CW, Sutton FD, Neff TA, Cohn WM, Mathay RA, Weinberger MM. Theophylline-Induced seizures in adults. Correlation with serum concentration. Ann Intern Med 1975; 82: 784-87. 14. Hendeles L, Weinberger MM, Bighley L. Disposition of theophylline following a single intravenous aminophylline infusion. Am Rev Resp Dis 1978; 118: 97-103. 15. Lesko LJ. Dose-dependent elimination kinetics oftheophylline. Clin Pharmacokinetics 1979; 4: 449-59. 16. Monks TJ, Caldwell J, Smith RL. Influence of methylxanthine containing foods on theophylline metabolism and kinetics. Clin Pharmacol Ther 1979; 26: 513-24. 17. Piafsky KM, Sitar DS, Rangno RE, Ogilvie RI. Theophylline disposition in patients with hepatic cirrhosis. N Engl J Med 1977; 296: 1495-97. 18. Vicuna N, McNay JL, Ludden TH, Schwertner H. Impaired theophylline clearance in patients with cor pulmonale. Br J Clin Pharmacol 1979; 7: 33-37.
and heart failure Therapy also has to aim at the narrow windOW19 between bronchodilation and toxicity (8-20 mg/1). Nevertheless, intravenous aminophylline continues to be used very widely. McFadden and his group20 have reported a comparison of intravenous aminophylline, subcutaneous adrenaline, and inhaled isoprenaline in 48 patients with acute severe asthma. Aminophylline was given according to the Mitenko and Ogilvie regimen, but with greatly reduced doses (less than half) in patients who had previously received oral theophyllines; adrenaline 0’ 3 mg was given subcutaneously three times in the first hour; and isoprenaline 2 -5mg was given three times in one hour via a hand-held nebuliser. Before treatment there was no significant difference between the groups in forced expiratory volume in one second (FEV 1). After one hour bronchodilation was significantly greater in the adrenaline and isoprenaline groups than in the aminophylline group (AFEV0-761, 0-791, and 0-231, respectively). Serum theophylline concentrations were in the therapeutic range (mean 16.22 mg/1) and previous oral theophylline did,not seem to influence the rate of response in the isoprenaline and adrenaline groups. McFadden and coworkers report also that the maximum bronchodilator effect was attained more rapidly with adrenaline and isoprenaline than with aminophylline. Deaths from acute severe asthma can occur before medical advice is sought, after the primary care treatment, or in hospital. Ideally, patients should record their peak expiratory flow rate (PEFR) regularly in the same way that a diabetic patient monitors urinary glucose,21 adjusting therapy accordingly.22 In fact, such routine measurement of PEFR has not been much encouraged by doctors. One useful sign that asthma is getting out of control is a doubling of the number of aerosol puffs required over 48-72 hours:23 this indicates a need for medical advice either at primary care level or at a specialist centre.24 What about therapy during transfer of an acutely ill patient? In view of the possible hazards of intravenous aminophylline, perhaps after a slow intravenous injection of 200 mg hydrocortisone the patient should be given a subcutaneous or intramuscular injection ofa selective (32 stimulant (e.g., terbutaline 0-5mg or salbutamol 0’ 5 mg). If this cannot be done then the patient should be advised to take two puffs of pressurised aerosol P2 stimulant (or its equivalent as dry powder capsule) every 5 minutes during transfer to hospital or until symptoms are relieved. In moderately severe asthma managed in hospital, high-dose aerosol therapy has proved safe and effective.26 On the patient’s arrival in hospital treatment should be by inhaled 2 stimulant in the recommended nebuliser dose, plus hydrocortisone 200 mg intravenously every 6 hours. In those who are severely ill or in whom the PEFR has not increased after an hour’s treatment, intravenous aminophylline may be given in a dose of 5-66 mg/kg over 20-30 minutes followed by 19.
Jenne JW, Wyze E, Rood FS, MacDonald FM. Pharmacokinetics oftheophylline. Application to adjustment of the clinical dose of aminophylline. Clin Pharmacol Ther 1972 13: 349-60.
20.
Rossing TH, Fanta CH, Goldstein DH, Snapper JR, McFadden ER, Jr. Emergency therapy of asthma: Comparison of the acute effects of parenteral and inhaled sympathomimetics and infused aminophylline. Am Rev Resp Dis 1980; 122: 365-71. 21. Seaton A. Asthma-contrasts in care. Thorax 1978; 33: 1-2. 22. Prior JG, Cochrane GM. Home monitoring of peak expiratory flow rate using miniWright peak flow meter in diagnosis of asthma. J RoySoc Med 1980; 73: 731-33.
23. Cochrane GM. Bronchodilators. Practitioner 1979; 223: 489-98. 24. Crompton GK, Grant IWB, Bloomfield P. Edinburgh emergency asthma admission service: Report on 10 years’ experience. Br Med J 1979; ii; 1199-1201. 25. Pang LM, Rodriguez-Martinez F, Davis WJ, Mellins RB. Terbutaline in the treatment of status asthmatics. Chest 1977; 72: 469-73. 26. Cayton RM, WebberB, PatersonJW, ClarkTJH. A comparisonof salbutamol givenby pressure-packed aerosol or nebulization in acute asthma. BrJ Dis Chest 1978; 72: 222-24.