Prominent elevation of the ST segment by convulsion.

A few thousand patients die of asthma each year in the United States, and Dr. Sears fears that an explanation may be found in his discovery that some patients with relatively mild asthma appear to suffer deterioration when they use 3-adrenergic aerosols routinely. Nevertheless, it is evident that many millions of patients use routine @-adrenergicaerosol therapy, and there is good reason to believe that as a result they enjoy a comfortable life. I feel that there is a logical inconsistency in the extension of Sears's claims: he implies that patients with chronic, variable asthmaare harmed by using standard daily doses of f3-adrenergic therapy, but their resultant lapse into acute asthma can be safely managed by giving far greater doses of these same drugs. It is possible that the apparent harm of routine therapy is only of significance in a subgroup of patients such as those who use fenoterol. The established dogma of using routine @3-agonist aerosol therapy is supported by the bulk ofthe literature and by a vast experience)'3 Before aerosol steroids were introduced in the 1960s, children with asthma relied principally upon sympathomimetic aerosols. With few exceptions, it appears that these children not only did well, but they “¿ grew out― of their asthma. In the era of aerosol steroids, there is still enough documented experience to suggest that long-term @3agonist aerosol therapy given alone is beneficial in children and younger adults.°'@ The vision of deaths that Dr. Sears relates to the continuing daily use of @-agonists appears to be a mirage; most deaths occur in poorly compliant, psychologically disturbed, or economically disadvantaged patients with brittle asthma who fail to use their medications appropriately.9b0 Fortunately, there is an important point that both sides can agree upon: without doubt, all drugs can be dangerous if used in excess. Thus, if a patient uses “¿ excessive― doses of a @3-adrenergic aerosol, there is a risk of an adverse outcome. The critical issue lies in the definition of “¿ excessive―; all parties might agree that this means “¿ more than is symptomatically necessary.― Two problems face us, however: (1) Do all symptoms (eg, wheezing on forced exhalation as well aswheezingon effort) deservetreatment?(2) How shouldwe interpret the term “¿ p.r.n.―? If I hear an asthmaticwheeze,but he does not report dyspnea on effort (perhaps because he makes no effort), I tend to advise treatment with @3-adrenergic aerosol several times a day. Dr. Sears presumably would tend not to treat such a patient, unless the individual started exercising and became aware of dyspnea.Thus, Dr. Searsadvocates@3-adrenergic aerosolsonly for airway obstruction that becomes symptomatic under special circumstances, whereas I favor treatment for all patients who present any evidence of reversible asthmatic bronchoconstriction. The division between the Sears camp and traditionalists such as myself may depend on inappropriately loose terminology; and our differences may be partially resolved if we could correlate the need to treat clinical disease with the presence, as Sears' suggests, of objective quantified measures of disordered physiology: If we could establish a rational set ofcntena for defining “¿ p.r.n. :â€w̃e might find that our different approachesare really very similar. Thus, it is probable that those asthmatic patients for whom I choose to not prescribe routine @-agonistsare similar to those of Dr. Sears, whereas those for whom he does end up having to treat with routine daily “¿ p.r.n.― @3-agonist therapy are similar to those whom I treat with twoto four-limes-a-day therapy. There is an intermediate group for whom the establishment of an appropriate therapeutic regimen is a challenge for each of us. However, it is now important for the two apparently opposed views on asthma therapy to define a mutually acceptable approach to n-agonist dosing that covers the majority of patients with asthma—leavingro@@m for disagreement on the remaining few. Irwin Ziment, M.D., FC.C.P, Department of Medicine, Olive View Medical Center, Sylinar, California