Prophylaxis of Postoperative Deep Vein

notes the substantial benefit many children with moderate to severe chronic asthma derive from the use of steroid aerosols. However, it fails to emphasize the important place that regular use of bronchodilators has in management. It is inferred that if adequate control of asthma is not achieved with regular prophylactic disodium cromoglycate and bronchodilator therapy given early in the course of any acute wheezing attack steroid therapy in one form or another should be used. As about 05 % of children have chronic airways obstruction as a result of asthma' 2 and this is often inadequately controlled with regular disodium cromoglycate and intermittent bronchodilators, steroids appear to be recommended for a large number of children. This is despite the wellknown complications of oral corticosteroids and the lack of information of the long-term effects of topical steroids on the human lung. In fact many children with moderate chronic asthma whose airways obstruction persists despite regular disodium cromoglycate and intermittent bronchodilator therapy will be adequately controlled with regular bronchodilator therapy. The effectiveness of regular oral theophylline in full therapeutic dosage is now well documented.3 While the value of combining one of the newer 3-adrenergic stimulators either orally or by inhalation with regular theophylline is not proved, we have used this combination for many years and have achieved very adequate control in a substantial number of children with rmoderate to severe chronic asthma without any apparent side effects.4 Orciprenaline or salbutamol by inhalation using a hand nebulizer driven by small air compressor pump as described in detail elsewhere5 is particularly valuable both for the control of persisting airways obstruction and for the rapid relief of acute exacerbations. Certainly no child should be started on corticosteroids, either by inhalation or orally, until it has been clearly demonstrated that the combination of regular disodium cromoglycate, oral theophylline, and orciprenaline or salbutamol by inhalation has failed to give adequate control. The criteria for control outlined in your article are adequate, but in older children objective evidence from pulmonary function testing is also of considerable importance. Some parents of children with chronic asthma fail to appreciate the severity of the condition and may report that their child is normal whereas he has substantial persisting airways obstruction. Conversely there are a small number of children, usually from disturbed backgrounds, who on reporting by parents seem to be having a great deal of trouble with their asthma, but this is not supported by objective data. There is a substantial risk of undertreating the former group and overtreating the latter if history alone is the guide to therapy.-I am, etc.,