A survey of asthma mortality in patients between ages 35 and 64 in the Greater London hospitals in 1971

We have examined the death certificates from all patients aged 35-64 years who were recorded as dying from asthma in Greater London Council hospitals in 1971. Of the 47 death certificates studied, nine suggested that the primary cause of death was not asthma. From the remaining 38 deaths we have obtained 36 case records and found that 15 deaths occurred outside hospital and another two patients died in hospital having been admitted in a stable state. We have examined the remaining 19 case records to find out the circumstances of death in patients with asthma who die in hospital. We have been unable to exclude the possibility that many of the deaths in hospital were avoidable. Assessment of severity in most patients was incomplete, as judged by a retrospective analysis of case records, and many of the patients would be regarded as having had insufficient treatment. Four patients did not receive corticosteroids and in a further three the dose given was small. No physiological assessment of airflow obstruction was made in over half the patients. A comparison with 19 survivors of an admission to hospital with asthma did not provide enough information to account for the deaths. The survivors were in hospital for a shorter period of time, were slightly less ill, and were given comparable treatment regimens. Both groups of patients were inadequately assessed, and sedatives were given to approximately 70% of all subjects studied. The deaths in hospital usually occurred suddenly in the early morning in general medical wards.

Myopathy in severe asthma

Myopathy complicating the therapy of severe asthma has been recently described in several case reports. Twenty-five consecutive patients admitted to the intensive care unit (ICU) at this hospital for mechanical ventilation for severe asthma were studied for the incidence of creatine kinase (CK) enzyme rise and for the development of clinical myopathy. Pharmacologic therapy was standardized, every patient receiving corticosteroids and aminophylline intravenously and salbutamol both nebulized and intravenously. Twenty-two patients received muscle relaxant therapy with vecuronium. In 19 of 25 (76%) of patients there was elevation of CK levels to a median of 1,575 U/L (range, 66 to 7,430) occurring 3.6 +/- 1.5 days after admission. In nine patients there was clinically detectable myopathy. The presence of either myopathy or CK enzyme rise was associated with a significant prolongation of ventilation time. Arterial blood gas measurements on admission to the ICU revealed a pH (mean +/- SD) of 7.07 +/- 0.21, a PaCO2 of 87.2 +/- 32.7, and a PaO2 (with a high FIO2) of 129 +/- 97 mm Hg; however, no correlation was found between the severity of initial metabolic disturbance and the subsequent development of myopathy. There was no association between the type of corticosteroid administered and the subsequent development of myopathy. Patients with myopathy had received a significantly higher total dose of vecuronium when compared with those who did not develop myopathy (p < 0.001, Kruskal Wallis test). We have therefore found a surprisingly high incidence of CK enzyme rise and myopathy in this group of mechanically ventilated patients with severe asthma.(ABSTRACT TRUNCATED AT 250 WORDS)

Randomized trial of nasal synchronized intermittent mandatory ventilation compared with continuous positive airway pressure after extubation of very low birth weight infants

OBJECTIVE

To determine whether noninvasive, nasal synchronized intermittent mandatory ventilation (nSIMV) improves the likelihood that very low birth weight infants will be successfully extubated.

METHODS

Infants of <1251-g birth weight who were due to be extubated before 6 weeks of age were eligible once they were receiving <35% oxygen and were on a ventilator rate of <18 breaths per minute (bpm). Extubation was performed following intravenous loading with aminophylline, after a successful trial of 12 hours of endotracheal synchronized intermittent mandatory ventilation at a rate of 8. Infants were randomized to either nasal continuous positive airway pressure (nCPAP) at 6 cm H(2)O or nSIMV after extubation. nSIMV was commenced at a rate of 12 bpm with pressure on the ventilator set to achieve a delivered pressure of at least 12 cm H(2)O and a peak end expiratory pressure of 6 cm H(2)O. Continuous recording for diagnosis of apnea was performed for 72 hours after extubation. Objective criteria for failure of extubation were as follows: a PaCO(2) >70; FIO(2) >0.7; or severe recurrent apnea (>2 apneas requiring intermittent positive-pressure ventilation in 24 hours or >6 apneas >20 seconds per day). The study ended after 72 hours postextubation or when infants satisfied failure criteria. A sample size of 54 was determined by power analysis.

RESULTS

Mean birth weight (831 standard deviation [SD]: 193 g) and gestation (26.3 SD: 1.8 weeks) did not differ between groups. Mean age at extubation was 7.6 (SD: 9.7) days, range 1 to 40 days. The nSIMV group had a lower incidence of failed extubation 4/27 compared with the continuous positive airway pressure group, 12/27. This was attributable to both a decreased incidence of apnea and a decreased incidence of hypercarbia. There was no increase in the incidence of abdominal distension or feeding intolerance.

DISCUSSION

nSIMV is effective in preventing extubation failure in very low birth weight infants in the first 72 hours after extubation. Noninvasive ventilation may have other roles in the care of the very low birth weight infant.

Single-dose slow-release aminophylline at night prevents nocturnal asthma

Twelve asthmatic patients with nocturnal wheezing were given a single nocturnal oral dose of slow-release aminophylline or matched placebo in a double-blind crossover trial. A dose of slow-release aminophylline (mean 683 mg; 10.4 mg/kg) gave a therapeutic plasma-theophylline concentration 10 h later (mean 10.9 mg/l). This was not associated with any adverse effects. Mean peak expiratory flow on waking was significantly greater with aminophylline (332 +/- 31 l/min) than placebo (283 +/- 32 l/min), whereas evening values did not differ. There was a significant difference between morning and evening peak flow on placebo (mean 22%) but not on aminophylline (5%), indicating abolition of the morning fall in peak flow. This was not at the expense of response to beta-agonists, since the response to inhaled salbutamol was the same for both treatments. The use of extra metered doses of inhaled beta-agonist during the night was significantly less with aminophylline, and there was a subjective improvement in nocturnal symptoms in all patients. Slow-release aminophylline in adequate dosage appears to be the most effective treatment yet demonstrated for nocturnal asthma.

Theophylline kinetics in acute pulmonary edema

Nine patients with acute cardiogenic pulmonary edema were given theophylline intravenously, and its disposition was observed over the next 24 hr. Compared to that in 19 normal subjects, these patients had prolonged plasma half-lifes (mean, 22.9 from 6.7 hr) and decreased plasma clearances of theophylline (mean, 0.041 from 0.062 L [kg-1] hr-1). The intersubject variation in these parameters was 20-fold in patients with pulmonary edema and 4-fold in normal subjects. Since the peak plasma concentrations attained and the apparent volumes of distribution were not different in the two groups, a suitable initial dose can be calculated. A loading dose of 4.5 to 5 mg/kg theophylline (6 mg/kg aminophylline) given over 20 min appears safe. Because of the great variability in the plasma clearance of this drug in patients with heart failure, plasma concentrations and toxicity would be unpredictable after repeated doses or constant infusions.

Bronchodilator effects of terbutaline and aminophylline alone and in combination in asthmatic patients

In 17 patients with moderate to severe asthma, we compared acute bronchodilator effects of the following drugs or drug combinations using a double-blind crossover design: terbutaline, 5; aminophyline 400; terbutaline, 5, plus aminophyline, 400; terbutaline, 2.5; aminophylline, 200; terbutaline, 2.5, plus aminophyline, 200 mg; and placebo. The higher doses of terbutaline and aminophylline alone produced comparable bronchodilation and similarly frequent adverse side effects; low doses of each drug also had comparable effects. The high-dose combination produced significantly (P less than 0.05) greater bronchodilatation than either drug alone. The low dose combination had bronchodilator effects comparable to those produced by the higher dose of either drug alone. These findings suggest therapeutic advantages in combining high doses of theophylline and an oral beta adrenergic agonist (terbutaline) in asthma not well controlled on high doses of either drug alone and in combining these drugs in lower doses in patients experiencing intolerable side effects from a high dose of either drug.

Asthma treatment in pregnancy: a randomized controlled study

OBJECTIVE

Our purpose was to study the effect of inhaled corticosteroids on asthma exacerbations in pregnancy.

STUDY DESIGN

We prospectively studied 84 pregnant women with 105 asthma exacerbations. Women were hospitalized if the forced expiratory volume in 1 second was < 70% after sequential bronchodilator therapy. They were randomly assigned to receive either intravenous aminophylline and inhaled beta 2-adrenergic receptor agonist or intravenous methylprednisolone and a beta 2-adrenergic receptor agonist. At discharge women were randomly assigned to receive either inhaled beclomethasone, beta 2-adrenergic receptor agonist, and an oral corticosteroid taper or a beta 2-adrenergic receptor agonist and a corticosteroid taper.

RESULTS

Sixty-five (62%) of 105 women with exacerbation required hospitalization. Aminophylline did not shorten response time or decrease hospital stay. Readmission rate was decreased by 55% in women given inhaled beclomethasone (33% vs 12%, p < 0.05, odds ratio 3.63, 95% confidence interval 1.01 to 13.08). Pregnancy-induced hypertension and cesarean delivery were increased over those of the general population.

CONCLUSIONS

Intravenous aminophylline offers no therapeutic advantages. Continuous inhaled corticosteroids reduced the need for subsequent admissions.

Nonlinear theophylline elimination

Elimination kinetics of theophylline and its major metabolites were investigated in 14 healthy adults in single-dose studies and in a multiple-plateau study. The plasma concentrations of theophylline and the metabolites 3-methylxanthine (3-MX), 1-methyluric acid (1 MU), and 1,3-dimethyluric acid (13-MU) were monitored to about 0.020 mg/l and became convex descending at concentrations below 1 mg/l after single theophylline doses. Renal clearance values of 3-MX, 1-MU, and 13-MU were 12.0 +/- 1.3 l/hr, 22.5 +/-1.5 l/hr, and 22.6 +/- 1.6 l/hr. Metabolite formation of the three metabolites followed Michaelis-Menten kinetics and became capacity limited within the therapeutic range of theophylline. The apparent Michaelis-Menten parameters for each metabolite formation step were obtained by computer fitting. For the formation of 3-MX. 1-MU, and 13-MU, the approximate mean maximal rate of formation of metabolite (Vmax) values were 5 mg/hr, 13 mg/hr, and 34 mg/hr and the apparent concentration of theophylline at which metabolite formation rate is half of Vmax values were 2.7 mg/l, 9.3 mg/l, and 14.2 mg/l. The elimination of each of the metabolites was rate limited by the elimination of theophylline. Concomitant measurement of theophylline urinary excretion rate showed the renal clearance of the drug to be highly dependent on urine flow. The initial renal clearance, elevated due to diuresis, and the distribution phase tended to counterbalance the saturable metabolic formation clearance after a single therapeutic dose. Therefore, plasma theophylline concentration decayed roughly in a log-linear fashion and the convex-descending curve, characterized by capacity-limited elimination kinetics, was observed only at lower concentrations.

Involvement of adenosine 3',5'-monophosphate in the activation of tyrosine hydroxylase elicited by drugs

Immediately after the injection of reserpine (16 micromoles per kilogram, intraperitoneally), aminophylline (200 micromoles per kilogram, intraperitoneally), and carbamylcholine (8.2 micromoles per kilogram, intraperitoneally), the concentration of adenosine 3',5'-monophosphate in adrenal medulla of rats is increased severalfold. The three drugs also cause a delayed increase of medullary tyrosine hydroxylase activity. Our results are consistent with the view that an increase of medullary adenosine 3',5'-monophosphate concentration is involved in the drug-induced increase of tyrosine hydroxylase activity in adrenal medulla. Experiments with tyramine (130 micromoles per kilogram, intraperitoneally) suggest that the increase of tyrosine hydroxylase activity and of adenosine 3',5'-monophosphate concentrations is independent of an increase in adrenal catecholamine turnover rate.

Emergency room of treatment of asthma. Relationships among therapeutic combinations, severity of obstruction and time course of response

In an effort to determine the optimal emergency therapy for acute episodes of asthma, we randomly, assigned 102 acute ill patients to 60 minutes of treatment with inhaled isoproterenol alone, isoproterenol plus intravenous aminophylline or isoproterenol plus a single oral dose of an elixir of theophylline. Patients requiring treatment beyond this time were given an injectable sympathomimetic agent in addition. The combination of isoproterenol and a methylxanthine was not found to be better than isoproterenol alone, and the route of administration of methylxanthine was not an important determinant of either the serum theophylline level or the therapeutic response. A major variable that influenced the duration of therapy needed to produce a remission was the severity of the obstruction at presentation. Persons whose initial 1-second forced expiratory volumes were less than 30 percent of predicted and who did not improve 35 percent or more to at least 40 percent of predicted at the end of 60 minutes of intense treatment were those who ultimately required prolonged emergency room therapy and/or hospital admission for control of their symptoms. Thus, simple objective assessment of the degree of impairment at presentation coupled with the response to initial treatment will serve to identify early a high-risk group of asthmatic patients in whom the usual emergency room therapeutic modalities will often prove ineffective.

Theophylline prescribing, serum concentrations, and toxicity

Slow-release theophylline preparations have been prescribed increasingly at the Brompton Hospital, and a serum theophylline assay is requested about once for every ten prescriptions. In a period of eighteen months 1913 such assays were performed, and their influence on management was assessed by retrospective analysis in two groups--113 outpatients on stable dosage with no recent exacerbations of disease; and 28 inpatients and outpatients with concentrations exceeding 25 mg/l. In those with stable treatment, there was only a loose relation between dose and serum theophylline level. High serum levels were associated with abnormal liver function, diuretic use, and duplicate prescribing. When serum theophylline levels were reported high, dosage was always reduced, whereas a low serum theophylline prompted dosage increase in only one-third of patients. Of the patients with very high serum theophylline concentrations (over 25 mg/l), 18 had been receiving oral theophylline and 10 aminophylline by infusion. 3 had seizures, of whom 2 died, and 1 patient was resuscitated after cardiac arrest. Unsuspected theophylline toxicity may be responsible for considerable hidden morbidity.

Treatment of acute asthma. Is combination therapy with sympathomimetics and methylxanthines indicated?

The role of bronchodilator regimens combining a sympathomimetic and a methylxanthine in the treatment of acute exacerbations of asthma remains controversial. This report describes the outcome of 157 emergency room visits for asthma in which patients were randomly assigned to single-drug therapy with intravenous aminophylline, subcutaneous epinephrine, or inhaled isoproterenol or to one of three regimens combining a sympathomimetic and a methylxanthine. The increase in one-second forced expiratory volume after one hour of treatment with the two-drug combinations (0.79 +/- 0.07 liter) was significantly greater than for epinephrine alone (0.57 +/- 0.08 liter; p less than 0.05) but did not differ significantly from that occurring with therapy with isoproterenol alone (0.72 +/- 0.09 liter; p = NS). This disparity reflects the greater bronchodilation effected by isoproterenol as a single agent than by epinephrine, in the dosing schedules and routes of administration chosen. Among patients presenting with severe airflow obstruction (one-second forced expiratory volume 35 percent or less of normal), the bronchodilator response to isoproterenol alone was 0.88 +/- 0.14 liter versus 0.51 +/- 0.11 for epinephrine alone (p less than 0.05). It is concluded that the observed benefit derived from use of combination therapy depends on the dosage and potency of the particular sympathomimetic to which a methylxanthine is added, and on the severity of the airflow obstruction at presentation.

Magnesium bolus or infusion fails to improve expiratory flow in acute asthma exacerbations

HYPOTHESIS

Intravenous magnesium sulfate improves objective measures of expiratory flow in patients with acute severe exacerbations of asthma.

DESIGN

Randomized, double-blind, placebo-controlled trial.

SETTING

Urban emergency department.

PARTICIPANTS

Forty-eight asthmatic patients aged 18 to 60 years with initial peak expiratory flow rate (PEFR) < 200 L/min who failed to double their initial PEFR after two standardized albuterol treatments.

INTERVENTIONS

Subjects were randomized to three groups: a loading dose of magnesium sulfate, 2 g IV over 20 min followed by 2 g/h over 4 h (infusion), magnesium sulfate, 2 g over 20 min followed by placebo infusion (bolus), or placebo loading dose and infusion (placebo). All subjects received standardized aminophylline and steroid therapy.

MEASUREMENTS

The PEFR and FEV1 were measured at the start of the loading dose, and 20, 50, 80, 140, 200, and 260 min later using a water-displacement spirometer. Changes from baseline were compared by one-way analysis of variance for repeated measures.

RESULTS

Magnesium sulfate administration did not at any time significantly improve either FEV1 (F = 0.036, p = 0.96) or PEFR (F = 0.51, p = 0.61). This study had the power to detect a PEFR difference of 26 L/min and a FEV1 difference of 0.19 L between groups (beta = 0.20, alpha = 0.05 two-tailed significance).

CONCLUSION

Use of IV magnesium sulfate in addition to standard therapy does not provide clinically meaningful improvement of objective measures of expiratory flow in patients with moderate to severe asthma exacerbations.

Three-dimensional nonfluoroscopic mapping and ablation of inappropriate sinus tachycardia. Procedural strategies and long-term outcome

OBJECTIVES

We conducted this study to assess long-term results of three-dimensional (3-D) mapping-guided radiofrequency ablation (RFA) of inappropriate sinus tachycardia (IST). Change in activation after the administration of esmolol was also assessed and compared to the shift documented with successful sinus node (SN) modification.

BACKGROUND

The long-term results after RFA of IST have been reported to vary between 27% and 66%.

METHODS

Thirty-nine patients (35 women, mean age 31 +/- 9 years) with debilitating IST were included in the study. The area around the earliest site of activation recorded using the 3-D mapping system was targeted for ablation. The shift in the earliest activation site after administration of esmolol was compared with the shift after RFA.

RESULTS

The heart rate at rest and in drug-free state ranged between 95 and 125 beats/min (mean 99 +/- 14 beats/min). Sinus node was successfully modified in all patients. Following ablation, the mean heart rate dropped to 72 +/- 8 beats/min, p < 0.01. The extent of the 3-D shift in caudal activation along the crista terminalis was more pronounced after RFA than during esmolol administration (23 +/- 11 mm vs. 7 +/- 5 mm, respectively, p < 0.05). No patient required pacemaker implantation after a mean follow-up time of 32 +/- 9 months; 21% of patients experienced recurrence of IST and were successfully re-ablated.

CONCLUSIONS

Three-dimensional electroanatomical mapping seems to facilitate and improve the ablation results of IST. The difference in caudal shift seen after esmolol administration and following SN modification suggests that adrenergic hypersensitivity is not the only mechanism responsible for the inappropriate behavior of the SN.

Aminophylline for acute exacerbations of chronic obstructive pulmonary disease. A controlled trial

STUDY OBJECTIVE

To determine the efficacy of intravenous aminophylline in the treatment of patients hospitalized for exacerbation of chronic obstructive pulmonary disease.

DESIGN

Randomized, double-blind, placebo-controlled trial during the first 72 hours of hospitalization.

PATIENTS

Thirty patients admitted from the emergency room or walk-in clinic with the primary diagnosis of an exacerbation of chronic obstructive pulmonary disease. Twenty-eight patients completed the study; 2 patients, 1 receiving placebo and 1 receiving aminophylline, were removed from the study because of respiratory failure requiring mechanical ventilation.

INTERVENTIONS

PATIENTS received either intravenous aminophylline or placebo, in addition to nebulized, inhaled 0.3 mL of a 5% solution every 6 hours; methylprednisolone, 0.5 mg/kg body weight every 6 hours intravenously; ampicillin, 500 mg orally every 6 hours (tetracycline or trimethoprim-sulfamethoxazole were substituted in penicillin-allergic patients); and supplemental oxygen as needed. Aminophylline infusion rates were adjusted by an unblinded investigator to achieve theophylline levels of 72 to 83 mumol/L. Changes were also made in placebo infusion rates to maintain the double-blind design.

MEASUREMENTS AND MAIN RESULTS

The forced expiratory volume in one second (FEV1) and forced vital capacity (FVC) before and after metaproterenol inhalation were measured twice daily by a blinded investigator, who also administered a verbal dyspnea index with a scale of 1 to 10 and questioned patients regarding possible side effects of treatment (tremor, palpitations, nausea, or vomiting). Arterial blood gas measurements at 72 hours were compared with those obtained on admission. Significant improvements in FEV1 and FVC measured before and after metaproterenol treatment and in dyspnea occurred over time in both treatment groups (p less than 0.05 for all measurements). However, there were no significant differences between the placebo and aminophylline groups in any of the spirometric measurements or the dyspnea indices (p greater than 0.5 in all five analyses). The mean increases (+/- SE) in Po2 of 1.9 (+/- 0.5) kPa with placebo and 1.7 (+/- 0.7) kPa with aminophylline and the mean decreases in PCO2 of 0.5 (+/- 0.4) kPa with placebo and 1.2 (+/- 0.4) kPa with aminophylline were not significantly different (p greater than 0.6 for PO2, p greater than 0.2 for PCO2).(ABSTRACT TRUNCATED AT 400 WORDS)

Effect of aminophylline on urinary excretion of epinephrine and norepinephrine in man

The excretion of catecholamines and the changes in plasma concentration of free fatty acids during aminophylline administration were explored. The relationships between cardiac arrhythmia, cardiac rate, and change in blood pressure under the conditions of these experiments were defined. Eighteen experiments were performed on eight volunteers. Blood pressures and heart rates before and during aminophylline infusion were recorded at frequent intervals, and urine and blood were collected during the control and infusion periods and in some subjects after the infusion. Loading with ethanol, glucose, or placebo before administration of aminophylline was used.

These studies demonstrated that intravenous infusion of aminophylline increases the urinary excretion of epinephrine and norepinephrine in man, the rate of excretion of epinephrine being greater than that of norepinephrine. This increase was accompanied by an increase in the concentration of free fatty acids in the plasma.

Highly crosslinked, PEG-containing copolymers for sustained solute delivery

Novel ionizable polymer networks were prepared from oligo(ethylene glycol) (OEG) multiacrylates and acrylic acid (AA) employing bulk radical photopolymerization techniques. The properties of these materials exhibited a complex dependence on the network structure and composition, and the materials were therefore used in the design of controlled release devices with precisely controlled properties. The release kinetics of model solute proxyphylline exhibited a strong compositional dependence, with measured diffusion coefficients varying over several orders of magnitude, depending on the polymer network structure and the pH of the release medium. Varying the OEG chain length provided a means of coarsely adjusting the proxyphylline release rate, while varying the AA content and the pH offered a more precise measure of control.

Control of systemic capillary leak syndrome with aminophylline and terbutaline

PURPOSE

Patients with systemic capillary leak syndrome have a characteristic triad of hypotension, hemoconcentration, and monoclonal gammopathy. They have frequent and severe attacks of hemoconcentration and hypotension accompanied by marked plasma shifts. The exact role of this monoclonal protein is unknown, but it probably leads, in some way, to an increase in capillary permeability. Despite efforts to resuscitate the patients during an acute attack, the syndrome is often fatal. Some success has been obtained in preventing the attacks with the beta-adrenergic-stimulating agent terbutaline. The purpose of this study was to determine the effectiveness of aminophylline and terbutaline in the treatment of systemic capillary leak syndrome.

METHODS

Over a decade, three patients with systemic capillary leak syndrome presented at our institution. All three patients were treated with terbutaline and aminophylline. Prednisone was used during the course of treatment in each of the three patients.

RESULTS

In contrast to previous reports of partial or temporary control of episodes, all three patients are alive with almost complete resolution of their recurrent attacks and have been able to return to their normal lifestyles.

CONCLUSION

The regimen of terbutaline and aminophylline effectively prevents the attacks of hypotension and hemoconcentration that occur in systemic capillary leak syndrome. The role of prednisone is not clear. Until more is known about the pathophysiology of the disorder, treatment must remain empiric and supportive.

Need for intravenous hydrocortisone in addition to oral prednisolone in patients admitted to hospital with severe asthma without ventilatory failure

52 severely ill asthmatic patients requiring acute admission to hospital entered a double-blind placebo-controlled trial to determine whether intravenous hydrocortisone given in addition to high-dose oral prednisolone and standard bronchodilator therapy accelerated recovery. Patients who had been given parenteral steroids before admission, by comparison with those who had not received such treatment, had been deteriorating for a shorter period before admission, had received more injected or nebulised bronchodilator therapy, and had higher admission peak flows. As judged by peak flow measurements 24 h after admission, parenteral steroids had no effect on the outcome, irrespective of whether they were given before or after (ie, intravenous hydrocortisone) admission. There is no evidence for the continued use of intravenous hydrocortisone in addition to oral prednisolone and bronchodilator therapy in patients admitted to hospital with severe asthma without ventilatory failure.

Bronchoalveolar lavage. Its safety in subjects with mild asthma

It has been suggested that fiberoptic bronchoscopy may induce life-threatening bronchospasm in persons with asthma. The safety of bronchoscopy and bronchoalveolar lavage (BAL) with bilateral installation of 300 ml of saline solution was assessed prospectively in ten adults with mild asthma as a part of a study of the lower respiratory tract in bronchospastic disease. Asthmatic subjects had pretreatment with intravenous aminophylline prior to bronchoscopy. Pulmonary function tests were performed prior to and immediately after the procedure, and values were compared to results in 12 normal adults undergoing bronchoscopy with BAL. One subject had mild bronchospasm (the third subject) before BAL could be performed. There were no major complications in the remaining asthmatic or normal subjects. Mean forced expiratory volume in one second (FEV1) did not change significantly in either group, and the mid-flow rate at 50 percent of vital capacity (Vmax 50%) decreased significantly only in normal subjects (p = 0.002). Moreover, none of the nine asthmatic subjects completing bronchoscopy with BAL had clinically significant bronchospasm. These results suggest that elective fiberoptic bronchoscopy and BAL can be performed safely in subjects with mild asthma.