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Management of the Asthmatic Attack in Childhood
MANAGEMENT OF THE ASTHMATIC ATTACK IN CHILDHOOD BRET RATNER,
M.D. #
CAN a child die during an attack of asthma? May such a death result from faulty treatment? These are questions always posed when asthma is the subject of discussion. Because of the anxiety and fear engendered in the parent and child by an attack of asthma, this syndrome appears in the forefront of emergency practice, and the symptomatic therapy of the asthmatic attack is therefore of great interest to the physician. First, I should like to emphasize the fact that amongst the most serious errors I encounter are overmedication and a bad choice of drugs.
CHOICE OF DRUGSl
Adrenalin (Epinephrine).-A child should never be given an injection of adrenalin of more than 2 or 3 minims. It should be given subcutaneously or intradermally and never intravenously or intramuscularly. There is no objection to the repetition of the same small dose at intervals of twenty to thirty minutes. Effect of Large Doses.-If the aim is to produce relief of bronchiolar spasm, small amounts produce the desired effect. Large amounts only tend to cause a further bronchiolar constriction. The other deleterious effects of large doses (0.5 to 1.0 cc.) are (a) the enhancement of apprehension, (b) acceleration of pulse, (c) rise in blood pressure, (d) pounding headache, (e) cardiac syncope, (f) pallor. The result to the patient is the superimposition of a greater feeling of disaster than he is already experiencing from the asthma, and an increase in pulmonary vascular congestion. Adrenalin in Oil.-The use of adrenalin in oil has been advocated to allay the bad effects of large doses and for prolonged action. 1 see no need for such a therapeutic agent in children. Adrenalin is not a drug that can be used for a long-range effect. It either works promptly or not at all. It is only effective in the alkaline pH of the blood but a short time, for it retains its potency only in an acid pH. An additional fact to be borne in mind is that an oleoma may result fr0Il! the injection of this combination, which oil tumor may have to o Clinical Professor of Pediatrics, New York University College of Medicine; Director of Pediatrics, Sea View Hospital for Tuberculosis, New York; Associate Attending Physician, Children's Medical Division, Bellevue Hospital, New York; Consultant Pediatrician, French Hospital, New York. 537
538
BRET RATNER
be excised because it has a tendency to continue to destroy tissue and grow larger. Adrenalin (1:100) Inhalation.-If the premise, that the action of adrenalin is immediate, is correct, then one or two series of inhalations should be sufficient for relief of an attack of asthma. In my experience, when a patient is given an inhalation outfit he tends to use it excessively. I have therefore come to regard this procedure as a dangerous one and forbid its use for the following reasons: 1. Epinephrine is a habit-forming drug and inhalation is probably the most habit-forming type of therapy because the simpl~city of administration tempts the patient to reach for it at the slightest provocation. I do not use the term "habit-forming" in the same sense that we speak of addiction to morphine, but rather to imply that, since a patient does get relief in certain acute seizures, he is tempted to administer it to himself for its stimulating effect when it may not be altogether necessary. It gives the patient a "lift." I recently had a child of twelve who was so dependent upon it that she inhaled adrenalin every night before retiring for fear that she might otherwise suffocate. It took four months to rid her of the habit. She now states that at times she really misses the exciting stimulus it gave her. 2. Since there is no control of dosage an unusually large amount may be absorbed, and the consequences may be serious. Benson and Perlman21 of Portland, Oregon, recently reviewed a series of more than a thousand chronic asthmatic cases and reported that death occurred seven to eight times more frequently amongst those who used adrenalin inhalation. Eplledrine.-What has been said relative to the action and overdosage of epinephrine holds for ephedrine as well, though to a lesser degree. It must be remembered, however, that thoughtless and excessive use of ephedrine in nose drops may result in the absorption of large amounts. Ephedrine sulfate should be prescribed for a given attack and only several doses be advised. Nose drops should also be prescribed in small amounts and limitation put upon their use. Syrup of Ipecac-Its Use in Refractory Asthma.-In 1939, I published a study on experimental asthma in the guinea pig. 3 As a result of these studies, I have come to the conclusion that asthmatics may be divided, broadly speaking, into two groups: (1) those suffering from asthma due to a bronchiolar spasm, and (2) those suffering from asthma due to a bronchial obstruction. The classification is not rigid, and one individual may present both types. The bearing that this classification has on the drug therapy of severe asthmatic attacks, and particularly status asthmaticus, is the point of emphasis. In the bronchiolar spasm type, the antigen reaches the bronchioles via the blood stream and adrenalin will work like a charm. We find this type in food-sensitive cases, and it is the one often encountered in
MANAGEMENT OF. ASTHMATIC ATTACKS IN CHILDHOOD
589
early childhood. The same form occurs in serum-sensitive patients following an injection of specific serum, and it is relieved by adrenalin if the shock is not too profound. Let us now turn to the child who is given injection after injection of adrenalin without the slightest relief. Why doesn't adrenalin help? What about the child who has been in a state of status asthmaticus for several days? The answer as I see it is that in such cases it is not the bronchiolar. spasm that is predominantly at play, but an edematous state of the lumina of the bronchi with marked bronchial plugging. This we learned from our guinea pig experiments. When the animals inhaled antigenic dusts, the allergen, coming into direct contact with the lining and vessels of the larger air passages, produced edema and increased secretion, which resulted in obstructive symptoms. On the other hand, in anaphylaxis after intravenous injection the allergen, coming in contact with the smooth muscle of the terminal bronchioles, produces a bronchiolar spasm. The object lesson is evident. If a bronchiolar spasm is the cause of the symptoms, the administration of adrenalin will bring about relief. If no relief ensues from repeated injections of adrenalin, then we must be dealing with an obstructive bronchial asthma due in all probability to some inhalant allergen which has entered the air passages directly. Cease adrenalin administration and order some syrup of ipecac! For infants and young children give % to 1 teaspoonful; if this does not induce emesis, give 2 teaspoonfuls. For older children and young adults, repeated doses may be given until the desired result is produced. Follow the ipecac with lukewarm water to further its effectiveness. If this therapy is effective, the result is brilliant because relief from distress follows quickly upon the release of the plugs. The exphlnation for such therapy is simple. Because of the ease with which very small particles, or even quite large objects gain access to the respiratory tract, and because exudates can accumulate within it, there arises the necessity for freeing the tract from such obstructions and irritants. To this end, Macklin4 points out, three mechanisms have developed: (1) the cough reflex; (2) the action of cilia, and (3) a wave motion said to resemble peristalsis. These three often work together. According to Gunn,5 the cough reflex functions in the upper airway, the cilia act as far down as the finer bronchioles, while "peristaltic" movements evacuate the entire tract, even including the airway terminals. Thus, these activities overlap, the upper part of the airway having all three, the intermediate part two, while the terminals would have only one mechanism for evacuation-namely, that of cCperistaltoid" motion. The peristaltic movements are brought into play only under abnormal conditions, such as the ejection of masses of thick exudate from the respiratory lumina. The cCperistaltic" wave in the bronchial tree is said to resemble the reverse peristaltic wave in
540
BRET RATNER
the digestive tract, and the speed is too rapid to be accounted for by ciliary action. Reinberg6 describes it as "tracheal vomiting," and Bullowa and Gottlieb,7 as "bellows-like." I prefer the former. It is obvious that the ipecac which causes the nausea, retching, and vomiting, and the irritation caused by the presence of the foreign material in the air passages, hasten and increase peristaltoid action. This "'tracheal vomiting" releases the obstruction, which under ordinary circumstances might not be released for days. Opiates.-I shall not dwell on tIle use of opiates, but I should again like to go on record as stating that the use of morphine in asthma is little short of criminal. Besides its inhibitory effect on the respiratory center, it also causes a bronchoconstriction. I can see no reason for its use and believe that most deaths from asthma have been directly or indirectly due to its use. This is supported by the study of Huher and Koessler. 8 Histamine and Histaluinase.-As to histamine and histaminase, I should also like to go on record as stating that not until it is more adequately proved that histamine plays a dominant role in asthma shall I regard its use or the use of its antienzyme, histaminase (Torantil), as of truly significant value. There is still too much mysticism surrounding the histamine concept of allergy, and its soundness is seriously questioned by many. That histanline may be increased in allergy is true, but whether such an increase is in any way related to its causation is questionable. It may merely be an end product of disturbed physiology. Aminophylline.-This drug has undoubted value in the treatment of asthma in childhood. It is more useful in the chronic type of adult asthma and should be given intravenously, or given intramuscularly with 1 or 2 per cent procaine. Its value lies in relieving arteriolar spasm and vascular congestion of the bronchi. So-called Antihistaminic Drugs, Benadryl and Pyribenzamine. -These newer anti-allergic drugs are of great value in relieving nasal symptoms and urticaria, but have been found wanting in the treatment of asthma. They are contraindicated in severe asthma or status asthmaticus because of their marked soporific effect, for which reason they may at times be as deleterious as opiates. Furthermore, the drying effects of these drugs on the already dehydrated mucous membranes of the bronchi would tend to aggravate the obstruction by the thickened secretions which are found in all cases of status asthmaticus. MANAGEMENT OF THE ASTHMATIC ATTACK
1. Give small doses of adrenalin (1: 1000 ), 2 to 3 minims, subcutaneously. Repeat, intracutaneously, if necessary, two or three times at intervals of twenty to thirty minutes. 2. If adrenalin is not effective, give syrup of ipecac by mouth, 1
MANAGEMENT OF ASTHMATIC ATTACKS IN CIllLDHOOD
541
teaspoonful to 1 tablespoonful, depending on the age of the patient and his response. Follow with lukewarm water to produce emesis. S. As adjuvants: ( a ) give the patient an enema; (b) remove patient from the bedroom into another room and prop him up in a chair; (c) be sure patient is well protected, then open windows and if not enough air is circulating in the room turn on an electric fan, directing the current of air on the child; (d) burn asthma powders. Be sure that all persons attending the child assume a cheerful attitude to give the child encouragement. 4. Unmedicated steam inhalation is an important adjuvant. 5. If the attack is severe and prolonged, the ipecac emesis should be followed by: (a) Ten to 15 per cent intravenous glucose by slow drip infusion (300 cc. for young children, and 500 to 1000 cc. for older ones). This is an important procedure, because it allays dehydration, which is usually pronounced, and also reduces edema. ( b) A rectal retention dose of some sedative, such as bromides (10 to 15 grains), phenobarbital (~ grain), chloral (2 to 7 grains), of ether in oil (1 to 2 teaspoonsfuls in 1 to 2. ounces of olive or Mazola oil). The sedative may also be given by mouth in the form of triple bromides (5 to 15 grains), phenobarbital (~ to ~ grain), amytal (~ grain), and/or acetyl salicylic acid (5 to 10 grains). This sedation may. be repeated in two or more hours. (c) Oxygen therapy is soothing and reassuring; but under no circumstances should the patient be put under an oxygen tent, for claustrophobia is very pronounced during severe asthmatic seizures. It is for this reason that a gentle breeze from a fan is also reassuring. 6. The status asthmaticus patient, having relieved himself of the obstructive plug and been soothed by the intravenous infusion of glucose and sedative, usually falls into tranquil sleep. The nurse or parent may be left to watch over the patient (he should not be left unattended), with an order for a repetition of the ipecac and additional ~edation if necessary. After the attack, a salt-free diet should be given, high in carbohydrates. Plenty of liquids, particularly the cola drinks and other sweet beverages, should be prescribed. The salt-free, high carbohydrate, and liquid diet is supportive and increases diuresis, tending to rid the body of the offending allergens. All of these measures can readily be carried out in the home. However, if it is deemed wise under certain circumstances to remove the child to the hospital, there i~ no danger in doing it if the child is well protected. Indeed, sometimes \tvhen children are moved to another room, or while they are being transported to the hospital, the asthma clears up. This would indicate that an environmental factor is involved.
542
BRET RATNER
Once the attack is relieved, I am sure we will all agree that the offending substances underlying the disease should be ferreted out. In conclusion, I should like to comment that if the child is breathing forcefully during the attack and is not cyanosed, the doctor has little to fear. The harder the patient breathes the better. If a child is cyanosed and his breathing is shallow or is apneic, the situation is dangerous. If the sounds on auscultation are clear, loud and resonant, with sibilant and sonorous rales, the asthma is of no serious consequence. If auscultation, on the other hand, discloses feeble sounds and there are moist rales, the seriousness is real. If the rales break through after coughing, it is indicative of moderate bronchial plugging. A rise in body temperature may occur in the asthma of childhood; do not be misled and change the diagnosis to pneumonia. However, it is equally important to diagnose pneumonia if it is present, even in the presence of asthma, for only in this situation should sulfonamides or antibiotics or aerosol penicillin be used. Fluoroscopy or x-ray is an important aid in the differential diagnosis of superimposed pneumonia. The keynote, therefore, of the treatment of the asthmatic attack (probably with the exception of the emesis produced by ipecac) is gentleness of therapy, with the aim to correct the physiologic disturbance encountered.
REFERENCES 1. Ratner, B.: Allergy in Childhood. V. Choice of Drugs in the Treatment of the Asthmatic Attack. New York State J. Med., 42:2029, 1942. 2. Benson, P. L. and Perlman, F.: Paper Read at the Annual Meeting of the American Academy of Allergy, Hotel Pennsylvania, New York, November, 1946. 3. Ratner, B.: Experimental Asthma. Am. J. Dis. Child., 58:699, 1939. 4. Macklin, C. C.:· Musculature of Bronchi and Lungs. Physiol. Rev., 9: 1, 1929. 5. Gunn, J. A.: Action of Expectorants. Brit. M. J., 2:972, 1927. 6. Reinberg, S. A.: Roentgen-ray Studies on Physiology and Pathology of Tracheo-bronchial Tree. Brit. J. Radiol., 30:451, 1925. 7. Bullowa, J. G. M. and Gottlieb, C.: Experimental Studies in Bronchial Function. Laryngoscope, 32:284, 1922. 8. Huber, H. L. and Koessler, K. K.: The Pathology of Bronchial Asthma. Arch. Int. Med., 30:689, 1922,.
M.D. #
CAN a child die during an attack of asthma? May such a death result from faulty treatment? These are questions always posed when asthma is the subject of discussion. Because of the anxiety and fear engendered in the parent and child by an attack of asthma, this syndrome appears in the forefront of emergency practice, and the symptomatic therapy of the asthmatic attack is therefore of great interest to the physician. First, I should like to emphasize the fact that amongst the most serious errors I encounter are overmedication and a bad choice of drugs.
CHOICE OF DRUGSl
Adrenalin (Epinephrine).-A child should never be given an injection of adrenalin of more than 2 or 3 minims. It should be given subcutaneously or intradermally and never intravenously or intramuscularly. There is no objection to the repetition of the same small dose at intervals of twenty to thirty minutes. Effect of Large Doses.-If the aim is to produce relief of bronchiolar spasm, small amounts produce the desired effect. Large amounts only tend to cause a further bronchiolar constriction. The other deleterious effects of large doses (0.5 to 1.0 cc.) are (a) the enhancement of apprehension, (b) acceleration of pulse, (c) rise in blood pressure, (d) pounding headache, (e) cardiac syncope, (f) pallor. The result to the patient is the superimposition of a greater feeling of disaster than he is already experiencing from the asthma, and an increase in pulmonary vascular congestion. Adrenalin in Oil.-The use of adrenalin in oil has been advocated to allay the bad effects of large doses and for prolonged action. 1 see no need for such a therapeutic agent in children. Adrenalin is not a drug that can be used for a long-range effect. It either works promptly or not at all. It is only effective in the alkaline pH of the blood but a short time, for it retains its potency only in an acid pH. An additional fact to be borne in mind is that an oleoma may result fr0Il! the injection of this combination, which oil tumor may have to o Clinical Professor of Pediatrics, New York University College of Medicine; Director of Pediatrics, Sea View Hospital for Tuberculosis, New York; Associate Attending Physician, Children's Medical Division, Bellevue Hospital, New York; Consultant Pediatrician, French Hospital, New York. 537
538
BRET RATNER
be excised because it has a tendency to continue to destroy tissue and grow larger. Adrenalin (1:100) Inhalation.-If the premise, that the action of adrenalin is immediate, is correct, then one or two series of inhalations should be sufficient for relief of an attack of asthma. In my experience, when a patient is given an inhalation outfit he tends to use it excessively. I have therefore come to regard this procedure as a dangerous one and forbid its use for the following reasons: 1. Epinephrine is a habit-forming drug and inhalation is probably the most habit-forming type of therapy because the simpl~city of administration tempts the patient to reach for it at the slightest provocation. I do not use the term "habit-forming" in the same sense that we speak of addiction to morphine, but rather to imply that, since a patient does get relief in certain acute seizures, he is tempted to administer it to himself for its stimulating effect when it may not be altogether necessary. It gives the patient a "lift." I recently had a child of twelve who was so dependent upon it that she inhaled adrenalin every night before retiring for fear that she might otherwise suffocate. It took four months to rid her of the habit. She now states that at times she really misses the exciting stimulus it gave her. 2. Since there is no control of dosage an unusually large amount may be absorbed, and the consequences may be serious. Benson and Perlman21 of Portland, Oregon, recently reviewed a series of more than a thousand chronic asthmatic cases and reported that death occurred seven to eight times more frequently amongst those who used adrenalin inhalation. Eplledrine.-What has been said relative to the action and overdosage of epinephrine holds for ephedrine as well, though to a lesser degree. It must be remembered, however, that thoughtless and excessive use of ephedrine in nose drops may result in the absorption of large amounts. Ephedrine sulfate should be prescribed for a given attack and only several doses be advised. Nose drops should also be prescribed in small amounts and limitation put upon their use. Syrup of Ipecac-Its Use in Refractory Asthma.-In 1939, I published a study on experimental asthma in the guinea pig. 3 As a result of these studies, I have come to the conclusion that asthmatics may be divided, broadly speaking, into two groups: (1) those suffering from asthma due to a bronchiolar spasm, and (2) those suffering from asthma due to a bronchial obstruction. The classification is not rigid, and one individual may present both types. The bearing that this classification has on the drug therapy of severe asthmatic attacks, and particularly status asthmaticus, is the point of emphasis. In the bronchiolar spasm type, the antigen reaches the bronchioles via the blood stream and adrenalin will work like a charm. We find this type in food-sensitive cases, and it is the one often encountered in
MANAGEMENT OF. ASTHMATIC ATTACKS IN CHILDHOOD
589
early childhood. The same form occurs in serum-sensitive patients following an injection of specific serum, and it is relieved by adrenalin if the shock is not too profound. Let us now turn to the child who is given injection after injection of adrenalin without the slightest relief. Why doesn't adrenalin help? What about the child who has been in a state of status asthmaticus for several days? The answer as I see it is that in such cases it is not the bronchiolar. spasm that is predominantly at play, but an edematous state of the lumina of the bronchi with marked bronchial plugging. This we learned from our guinea pig experiments. When the animals inhaled antigenic dusts, the allergen, coming into direct contact with the lining and vessels of the larger air passages, produced edema and increased secretion, which resulted in obstructive symptoms. On the other hand, in anaphylaxis after intravenous injection the allergen, coming in contact with the smooth muscle of the terminal bronchioles, produces a bronchiolar spasm. The object lesson is evident. If a bronchiolar spasm is the cause of the symptoms, the administration of adrenalin will bring about relief. If no relief ensues from repeated injections of adrenalin, then we must be dealing with an obstructive bronchial asthma due in all probability to some inhalant allergen which has entered the air passages directly. Cease adrenalin administration and order some syrup of ipecac! For infants and young children give % to 1 teaspoonful; if this does not induce emesis, give 2 teaspoonfuls. For older children and young adults, repeated doses may be given until the desired result is produced. Follow the ipecac with lukewarm water to further its effectiveness. If this therapy is effective, the result is brilliant because relief from distress follows quickly upon the release of the plugs. The exphlnation for such therapy is simple. Because of the ease with which very small particles, or even quite large objects gain access to the respiratory tract, and because exudates can accumulate within it, there arises the necessity for freeing the tract from such obstructions and irritants. To this end, Macklin4 points out, three mechanisms have developed: (1) the cough reflex; (2) the action of cilia, and (3) a wave motion said to resemble peristalsis. These three often work together. According to Gunn,5 the cough reflex functions in the upper airway, the cilia act as far down as the finer bronchioles, while "peristaltic" movements evacuate the entire tract, even including the airway terminals. Thus, these activities overlap, the upper part of the airway having all three, the intermediate part two, while the terminals would have only one mechanism for evacuation-namely, that of cCperistaltoid" motion. The peristaltic movements are brought into play only under abnormal conditions, such as the ejection of masses of thick exudate from the respiratory lumina. The cCperistaltic" wave in the bronchial tree is said to resemble the reverse peristaltic wave in
540
BRET RATNER
the digestive tract, and the speed is too rapid to be accounted for by ciliary action. Reinberg6 describes it as "tracheal vomiting," and Bullowa and Gottlieb,7 as "bellows-like." I prefer the former. It is obvious that the ipecac which causes the nausea, retching, and vomiting, and the irritation caused by the presence of the foreign material in the air passages, hasten and increase peristaltoid action. This "'tracheal vomiting" releases the obstruction, which under ordinary circumstances might not be released for days. Opiates.-I shall not dwell on tIle use of opiates, but I should again like to go on record as stating that the use of morphine in asthma is little short of criminal. Besides its inhibitory effect on the respiratory center, it also causes a bronchoconstriction. I can see no reason for its use and believe that most deaths from asthma have been directly or indirectly due to its use. This is supported by the study of Huher and Koessler. 8 Histamine and Histaluinase.-As to histamine and histaminase, I should also like to go on record as stating that not until it is more adequately proved that histamine plays a dominant role in asthma shall I regard its use or the use of its antienzyme, histaminase (Torantil), as of truly significant value. There is still too much mysticism surrounding the histamine concept of allergy, and its soundness is seriously questioned by many. That histanline may be increased in allergy is true, but whether such an increase is in any way related to its causation is questionable. It may merely be an end product of disturbed physiology. Aminophylline.-This drug has undoubted value in the treatment of asthma in childhood. It is more useful in the chronic type of adult asthma and should be given intravenously, or given intramuscularly with 1 or 2 per cent procaine. Its value lies in relieving arteriolar spasm and vascular congestion of the bronchi. So-called Antihistaminic Drugs, Benadryl and Pyribenzamine. -These newer anti-allergic drugs are of great value in relieving nasal symptoms and urticaria, but have been found wanting in the treatment of asthma. They are contraindicated in severe asthma or status asthmaticus because of their marked soporific effect, for which reason they may at times be as deleterious as opiates. Furthermore, the drying effects of these drugs on the already dehydrated mucous membranes of the bronchi would tend to aggravate the obstruction by the thickened secretions which are found in all cases of status asthmaticus. MANAGEMENT OF THE ASTHMATIC ATTACK
1. Give small doses of adrenalin (1: 1000 ), 2 to 3 minims, subcutaneously. Repeat, intracutaneously, if necessary, two or three times at intervals of twenty to thirty minutes. 2. If adrenalin is not effective, give syrup of ipecac by mouth, 1
MANAGEMENT OF ASTHMATIC ATTACKS IN CIllLDHOOD
541
teaspoonful to 1 tablespoonful, depending on the age of the patient and his response. Follow with lukewarm water to produce emesis. S. As adjuvants: ( a ) give the patient an enema; (b) remove patient from the bedroom into another room and prop him up in a chair; (c) be sure patient is well protected, then open windows and if not enough air is circulating in the room turn on an electric fan, directing the current of air on the child; (d) burn asthma powders. Be sure that all persons attending the child assume a cheerful attitude to give the child encouragement. 4. Unmedicated steam inhalation is an important adjuvant. 5. If the attack is severe and prolonged, the ipecac emesis should be followed by: (a) Ten to 15 per cent intravenous glucose by slow drip infusion (300 cc. for young children, and 500 to 1000 cc. for older ones). This is an important procedure, because it allays dehydration, which is usually pronounced, and also reduces edema. ( b) A rectal retention dose of some sedative, such as bromides (10 to 15 grains), phenobarbital (~ grain), chloral (2 to 7 grains), of ether in oil (1 to 2 teaspoonsfuls in 1 to 2. ounces of olive or Mazola oil). The sedative may also be given by mouth in the form of triple bromides (5 to 15 grains), phenobarbital (~ to ~ grain), amytal (~ grain), and/or acetyl salicylic acid (5 to 10 grains). This sedation may. be repeated in two or more hours. (c) Oxygen therapy is soothing and reassuring; but under no circumstances should the patient be put under an oxygen tent, for claustrophobia is very pronounced during severe asthmatic seizures. It is for this reason that a gentle breeze from a fan is also reassuring. 6. The status asthmaticus patient, having relieved himself of the obstructive plug and been soothed by the intravenous infusion of glucose and sedative, usually falls into tranquil sleep. The nurse or parent may be left to watch over the patient (he should not be left unattended), with an order for a repetition of the ipecac and additional ~edation if necessary. After the attack, a salt-free diet should be given, high in carbohydrates. Plenty of liquids, particularly the cola drinks and other sweet beverages, should be prescribed. The salt-free, high carbohydrate, and liquid diet is supportive and increases diuresis, tending to rid the body of the offending allergens. All of these measures can readily be carried out in the home. However, if it is deemed wise under certain circumstances to remove the child to the hospital, there i~ no danger in doing it if the child is well protected. Indeed, sometimes \tvhen children are moved to another room, or while they are being transported to the hospital, the asthma clears up. This would indicate that an environmental factor is involved.
542
BRET RATNER
Once the attack is relieved, I am sure we will all agree that the offending substances underlying the disease should be ferreted out. In conclusion, I should like to comment that if the child is breathing forcefully during the attack and is not cyanosed, the doctor has little to fear. The harder the patient breathes the better. If a child is cyanosed and his breathing is shallow or is apneic, the situation is dangerous. If the sounds on auscultation are clear, loud and resonant, with sibilant and sonorous rales, the asthma is of no serious consequence. If auscultation, on the other hand, discloses feeble sounds and there are moist rales, the seriousness is real. If the rales break through after coughing, it is indicative of moderate bronchial plugging. A rise in body temperature may occur in the asthma of childhood; do not be misled and change the diagnosis to pneumonia. However, it is equally important to diagnose pneumonia if it is present, even in the presence of asthma, for only in this situation should sulfonamides or antibiotics or aerosol penicillin be used. Fluoroscopy or x-ray is an important aid in the differential diagnosis of superimposed pneumonia. The keynote, therefore, of the treatment of the asthmatic attack (probably with the exception of the emesis produced by ipecac) is gentleness of therapy, with the aim to correct the physiologic disturbance encountered.
REFERENCES 1. Ratner, B.: Allergy in Childhood. V. Choice of Drugs in the Treatment of the Asthmatic Attack. New York State J. Med., 42:2029, 1942. 2. Benson, P. L. and Perlman, F.: Paper Read at the Annual Meeting of the American Academy of Allergy, Hotel Pennsylvania, New York, November, 1946. 3. Ratner, B.: Experimental Asthma. Am. J. Dis. Child., 58:699, 1939. 4. Macklin, C. C.:· Musculature of Bronchi and Lungs. Physiol. Rev., 9: 1, 1929. 5. Gunn, J. A.: Action of Expectorants. Brit. M. J., 2:972, 1927. 6. Reinberg, S. A.: Roentgen-ray Studies on Physiology and Pathology of Tracheo-bronchial Tree. Brit. J. Radiol., 30:451, 1925. 7. Bullowa, J. G. M. and Gottlieb, C.: Experimental Studies in Bronchial Function. Laryngoscope, 32:284, 1922. 8. Huber, H. L. and Koessler, K. K.: The Pathology of Bronchial Asthma. Arch. Int. Med., 30:689, 1922,.