Fear of flight: behavior therapy versus a systems approach

Systematic desensitization is re-examined as a treatment for flight fear from the perspective of family-systems theory. The problem of the person who avoids flight is considered first from the viewpoint of behavior therapy, and behavioral treatment is briefly described. This problem is next described in terms of the patients's to society, family, and the therapist. From this perspective, the flight-avoidant person is seen to be an "identified patient"-someone defined as ill by the system in which he or she is enmeshed. The problem is then redefined, not as flight fear, but as the pressure to fly, and implications for treatment are discussed.

Beclomethasone dipropionate

Experience with beclomethasone dipropionate during the past 5 years has confirmed and extended the original observation that it is an effective, topically active corticosteroid of great value in treating asthma. Most steroid-dependent asthmatic patients can be successfully controlled with the drug, at least most of the time, and the therapeutic effect is dose dependent. Although high doses may be associated with some adrenal suppression such doses do not cause systemic symptoms, and side effects are of little consequence. It is important that patients treated with steroid aerosols continue to receive other effective therapeutic agents, notably adrenergic drugs, particularly by aerosol, and theophylline compounds; that they learn how to inhale the aerosol properly; and, most important, that they promptly start taking oral steroids when they experience an exacerbation of asthma.

Comparison of oral aminophylline and aerosol metaproterenol in asthma

The bronchodilator efficacy of oral aminophylline and aerosol metaproterenol was compared in 18 asthmatic patients in a stable clinical condition. Treatment consisted of four regimens in a double-blind random sequence on four different days after withholding bronchodilators: (1) the administration of aminophylline tablets, 0.4 to 0.6 g, orally, (2) 3 puffs of aerosol metaproterenol administered in a sequential manner, (3) a combination of both, (4) placebos. Both oral aminophylline and aerosol metaproterenol produced significant bronchodilatation measured by forced expiratory volume in 1 second (FEV1). After the administration of aerosol metaproterenol, there was a more prompt and larger improvement in FEV1 than after the administration of aminophylline (p less than 0.01). The combined therapy produced a response which was larger, but not significantly, than the effect of metaproterenol. Side effects were frequent after the administration of aminophylline but absent after aerosol metaproterenol. The advantages of the aerosol adrenergic agonists are the prompt onset of action and efficacy, small dosage preferentially delivered to the bronchial tree and lack of side effects.

Blood Doping: An Update

In brief: Blood doping-the process of withdrawing an athlete's blood, holding it 9 to 12 weeks until hemoglobin levels return to normal, and reintroducing it into the body immediately before an important contest-is a controversial Procedure, and its ethicality and legality are debated throughout the sports world. This review of the literature concludes that although five early studies did not provide sufficient objective evidence to support its use, the majority of 13 new studies support the physiological rationale and efficacy of the use of blood doping to increase endurance capacity.

Life-threatening asthma

I review my experience with life-threatening asthma, defined as hypercapnia, need for intubation, or death, at a large municipal hospital during a ten-year period. Such severe illness is rare among asthmatics and predicting its occurrence is difficult. Eighty patients had 111 admissions for life-threatening asthma; 773 patients were hospitalized for asthma 851 times during the study period. Only 15% of these 773 patients had experienced severe asthma previously and the duration of asthma and frequency of hospitalization was similar to that of the other patients admitted for asthma. Follow-up study of the survivors of life-threatening asthma has revealed a very high rate of recurrence. More than 35% had a recurrence in one to ten years, and those who had three to four episodes had a recurrence rate of 45% and 60%, respectively. Although life-threatening asthma is rare, unpredictable, and occurs only after many years of symptomatic illness, once it does occur there is a real risk of recurrence. Patients who have experienced such a severe episode of asthma require continuing careful supervision and management.

The adequacy of inhalation of aerosol from canister nebulizers

Thirty patients hospitalized with asthma who had been taking aerosol bronchodilators from canister nebulizers were evaluated for their aerosol inhalation technique. Fourteen patients (47 percent) used an incorrect technique. The most frequent mistake was to inhale first, then to actuate the canister and breathhold. These patients were taught the correct technique. Some learned it easily but others had difficulty. With a teaching aid, incorporating a horn which is actuated by inspiration, all 14 patients learned to inhale the aerosol correctly. When retested five of the 10 patients had reverted to the old incorrect technique and required another lesson. Physicians who prescribe aerosol medication from a canister nebulizer should evaluate each patient for the aerosol inhalation technique. Those who inhale incorrectly should be taught repeatedly until they learn the correct technique and retain it. The teaching aid, utilizing an audio signal, is helpful in this training.

Bronchial response to oral versus aerosol metaproterenol in asthma

We tested the relative efficacy of bronchodilators delivered in aerosol and in oral form in 17 patients with asthma in a double-blind randomized sequence. Treatment consisted of a 20-mg tablet of metaproterenol sulfate, five puffs of metaproterenol aerosol (0.65 mg in each puff for a total of 3.25 mg) administered 20 minutes apart between puffs, a combination of both, and placebos. Bronchodilator response measured by forced expiratory volume in 1 second (FEV1) was significantly greater on the aerosol and the combined regimen than on the oral and placebo regimen. The combined regimen produced a greater bronchodilator response than the aerosol alone, but the difference was not significant. Side effects were frequent after oral medication but absent after the aerosol. Sequential inhalation of aerosol is the preferred route of administration of adrenergic bronchodilator drugs in asthma.

The effect of sequential inhalations of metaproterenol aerosol in asthma

In 19 asthmatic patients, three inhalations of metaproterenol (0.65 mg per puff) followed by placebo at 10 and 20 min were compared with one inhalation of the drug every 10 min for the same total of three doses. Metaproterenol 0.65 mg produced just as much increase of 1-sec forced expiratory volume (FEV1) as did the much larger dose (1.95 mg), but each subsequent inhalation of the drug produced further, significant increase of FEV1 suggesting better penetration of the bronchidilator aerosol after some bronchodilation had been achieved. After completion of treatment, the FEV1 was significantly higher when the drug was given sequentially rather than all at once. These data have important implications with respect to the utilization of bronchodilator aerosols in the treatment of asthma and indicate the unsuitability of sequential inhalation for study of dose response of these agents.

Evaluation of the severity of asthma: patients versus physicians

It is clear that accurate assessment of the severity of asthma requires a measurement of airway obstruction, such as peak expiratory flow rate. In this study, physicians were quite inaccurate in estimating the peak expiratory flow rate by examining patients, whereas the patients themselves were far more accurate in guessing the measurement. In addition, they were able to tell whether the peak expiratory flow rate was better, the same or worse from day to day. Patients' symptoms are important indices of the severity of airway obstruction which should be exploited in management.

Response to corticosteroids in chronic bronchitis

Corticosteroid drugs are often employed in the treatment of patients with chronic bronchitis. Although some patients respond favorably to such therapy, the characteristics of such patients are not known. Twenty-four patients with chronic bronchitis were treated with prednisone 30 mg daily or placebo for one week each in a double-blind crossover study. The following were monitored before and after each treatment period: physical examination, symptoms, peripheral blood eosinophil count, sputum cell exmination, forced vital capacity (FVC), before and after isoproterenol aerosol. Seven of 24 patients had an FEV1 increase greater than 30% of the control value on prednisone but not on placebo. Blood eosinophil count was elevated (greater than or equal to 350/mm(3)) in 7 patients; 2 of these 7 improved on steroid. Sputum cell examination revealed preponderance of eosinophils in 1, and occasional clumps of eosinophils in 8. Seven of these 9 responded to steroid. Sputum but not blood eosinophilia is a good predictor of a favorable response to steroid therapy.

Apneusis

Two cases of apneustic breathing that had several unusual features, as compared with experimental apneusis, are reported here. Both patients had intact vagal function. Respiratory rhythm showed mainly inspiratory apneusis, with a relatively smooth background rhythm. Frequency and duration of apneusis either decreased or were unaffected by breathing CO2, and increased, in one case, after hyperventilation. Both patients were alert and conscious. One had a long history of narcotic abuse, but had no other neurological or respiratory abnormality. Another had been deaf and mute since an episode of meningitis in childhood and had had apneusis for over 35 years, but suffered no other neurological abnormality. These unusual features suggest that the pathogenic mechanisms for apneusis are not the same in experimental models and patients.

Pulsus paradoxus in asthma

Ninety-three patients with asthma were examined on 308 occasions for systolic fluctuation of blood-pressure during quiet breathing. Pulsus paradoxus (fluctuation of 10 mm Hg or greater) was present on 110 occasions. A pulses paradoxus was associated with greater airflow obstruction (average peak expiratory flow-rate 33.6% of the predicted) than an absent pulsus paradoxus which was associated with a peak expiratory flow-rate of 55.4%. However, pulsus paradoxus was often present in mild obstruction and absent in severe obstruction. In six patients the effect of changing respiratory pattern on systolic fluctuation was studied. Systolic fluctuation was directly related to the inspiratory flow-rate. This is probably one of the major reasons why association of airflow obstruction with pulsus paradoxus is not constant.

Treatment of asthma with triamcinolone acetonide aerosol

Thirty-five steroid-dependent asthmatic patients have been treated with an aerosol of triamcinolone acetonide for periods ranging from 8 to 26 months. Fourteen patients discontinued the oral use of steroids for the first time in from 2 to 19 years and throughout the period of treatment with aerosol, have not required any other steroid medication. Fifteen patients were able to discontinue oral use of steroids but have required one or more short supplemental courses of oral steroid treatment for exacerbations of asthma. Six patients have either continued to require oral steroid therapy, or their symptoms have been incompletely controlled by the aerosol. Steroid aerosols represent an important advance for the treatment of asthma. Small doses which do not suppress adrenal function and do not produce hyperadrenocorticism make it possible for most patients to eliminate or substantially reduce their requirement for oral steroid therapy.

Cardiac response to repeated doses of isoproterenol aerosol

We studied 18 patients with moderate to severe asthma for cardiac response to repeated doses of isoproterenol aerosol. In only 1 patient was there a significant increase in heart rate immediately after inhalation of isoproterenol aerosol, and it lasted only for 1 minute. In 2 patients increased heart rate was either due to breathholding or to the propellant in the aerosol. There was no cumulative effect on heart rate. Arrhythmias did not develop at any time despite repeated doses of aerosol every 5 to 20 minutes. Peak expiratory flow rate increased 5 minutes after the first dose, and it increased even further after repeated doses; at no time did it decrease after repeated doses.

Dose response of patients with asthma to inhaled isoproterenol

In 12 patients with asthma, inhalation of approximately 0.02 mg of isoproternol produced as much increase in peak expiratory flow rate (PEFR) as had a previous inhalation of approximately 0.16 mg of isoproternol at a time when the pre-treatment PEFRwas similar. A group or patients recorded measurements of their PEFR before and after inhalation of varying doses of isoproterenol, ranging from 0 to 0.08 mg. In each patient, only data obtained when control PEFRs were similar were utilized. A maximal effect was noted after inhalation of 0.02 mg of isoproterenol, and no further increase of PEFR was noted after inhalation of larger doses. Inhalation of 0.02 mg or less of isoproterenol produces a maximal effect on PEFR of patients with asthma.

Effects of post-hypnotic suggestions on muscular endurance

This study examined the effects of post-hypnotic suggestions upon maximal endurance capacity, Borg ratings of perceived exertion, and heart rate. Experimental subjects were administered post-hypnotic suggestions to improve or decrease performance, and control subjects were given similar instructions during the awake state. Endurance time could be decreased significantly when the fatigue suggestion was given to experimental subjects, but performance could not be enhanced with the facilitating suggestion. Control subjects showed no significant changes across conditions. The Borg ratings indicated that experimental subjects experienced subjective changes as suggested by the hypnotist. In addition, analysis failed to find any significant differences for the heart-rate data.