Læknablaðið - 15.12.1986, Blaðsíða 49

LÆKNABLAÐIÐ
353
til sjúkdómsgreiningar þar sem blóð er tekið úr
sjúklingum, granulocytar einangraðir og merktir með
Indium áður en þeim er sprautað aftur í sjúklinginn.
Síðan er hægt að sjá með gammamyndavél hvert
granulocytarnir fara og þá hvort einhvers staðar er
óeðlileg upphleðsla sem bendir á graftarsýkingu.
Á seinustu átta mánuðum hafa verið gerð 12
hvítfrumuskönn á Landspítalanum, í tveimur tilfellum í
leit að skýringu á hita, þrisvar til að staðfesta eða
útiloka graftarkýli (absess) í kviðarholi, fjórum sinnum
til að meta liða- eða beinaprótesu m.t.t. sýkingar og
þrisvar til að meta virkni Crohn’s sjúkdóms. 1 átta
tilvikum sáust merki graftarsýkingar og í fimm tilvikum
staðfestist þetta síðar í aðgerð. Tveir af þessum átta
reyndust vera með þarmabólgu (Crohn’s og volvulus) og
einn var með fistil i magál sem sást á skanninu. Af þeim
fjórum rannsóknum sem ekki sýndu merki bólgu
reyndist einn sj. hafa endocarditis, annar CMV
lungnabólgu, þriðji Crohn’s sjúkdóm í remissio og ekki
er ljóst hvað olli hita hjá þeim fjórða en hann er hitalaus
á gigtarlyfjum. Þetta sýnir að hvítfrumuskann er
hjálplegt við greiningu á sýkingum í kviðarholi og
stoðkerfi. Nokkrar sjúkasögur verða raktar nánar.
THE MANAGEMENT OF CHRONIC SEVERE
ASTHMA
Prof. M. Turner-Warwick. Cardiothoracic Institute,
London.
There are several important types of chronic asthma to
identify. Many patients have varying airflow limitation
but with a substantial additional irreversible
component, presumably reflecting permanent damage
to airways. The extent of the irreversible component is
important to establish because on the one hand it is
crucial to adjust medication so that optimal airflow is
maintained. On the other hand it is useless to continue
to use large doses of sometimes dangerous drugs because
peak-flow measurements are abnormally low when such
medication is evidently failing to open the airways
further.
The best way of establishing the optimal peak-flow (or
spirographic) measurements is often to give planned
course of oral corticosteroids (often around 40 to 60 mg
of prednisolone daily) and continue over at least three
weeks. It is our practice to do full lung-function test
before and afterwards because in some patients
peak-flow measurements may remain unaltered but
because the vital capacity improves and the patient
breathes at a lower lung volume he may be considerably
more comfortable. Response to such treatment may be
slow and as an empirical rule treatment over about three
weeks will probably identify the majority of those who
may be improved. It is vital to explain to the patient at
the outset that if no improvement is measured
corticosteroids will be withdrawn. Otherwise many
patients are left on corticosteroids because of subjective
improvement and exposed unnecessarily to the dangers
of prolonged oral steroid therapy.
Other patients have chronic asthma showing highly
unstable peak-flow trace. Rapid improvement can be
obtained using bronchodilators but stability cannot be
obtained. Many of these patients are not improved by
corticosteroids and again this failure of medication
should be identified. Attempts at stabilization using
regular aerosolized beta-agonists, oral theophylline
and/or aerosolized corticosteroids have sometimes been
successful. However some patients are refractory to all
these forms of medication. Why a group of patients
cannot be stabilized with bronchodilators when they are
so responsive when bronchoconstricted is one of the
major problems in chronic asthma requiring an answer.
Patients with chronic disease have to adapt if they are to
maintain any semblance of normal life. This often
means that they learn to ignore quite serious symptoms,
because it has happened so often before. Analyses of
causes of mortality in asthma have repeatedly shown
that some deaths have resulted from patients
underestimating the severity of their asthma. Rather
than apportioning blame it is crucial for doctors to
recognize how understandable it is for the patient to
underplay their symptoms and through this
understanding persuade the patients to monitor their
asthma objectively more carefully if in doubt.
Patients are also frequently accused of being
non-compliant when they fail to take various forms of
medication regularly, serveral times day, year in and
year out. Frequent medication over prolonged periods is
virtually impossible to remember unless some effect
from drug omission is immediately apparent (eg insulin
in a diabetic). More recent understanding and
recognition of this fact has led to more effort being put
into the development of medication which can be taken
twice or even once daily. Such developments should not
be regarded as an »optional extra« of minor
importance. These developments are vital if optimal
treatment is to be given to patients on a realistic basis
over long periods of time. The search for long-acting
bronchodilators or more convenient methods of
effective prevention of asthma are both urgently
needed. Many patients can be maintained as
conveniently on twice-daily regimen of aerosolized
corticosteroids as four-times-a-day regimen. Others can
achieve twice-daily system using higher dose
beclomethasone diproprionate. Budesonide may also be
used in the same way.
Clearly there are some patients who can only be
maintained under reasonable control on oral steroids.
The minimum dose to achieve optimal objective control
can often be titrated quite finely and the patients taught
to adjust their dose both upwards and downwards
according to their changing pattern of asthma.
Arbitrary courses or doses of steroids do not seem to be
appropriate in the management of chronic severe
asthma.
There has been much recent interest in various forms of
corticosteroid-resistant asthma. It is apparent that many
different patterns of asthma may fail to respond to
steroids and alternative medication will depend on the
type. Where there is irreversible airflow obstruction no
medication will improve the situation. Where the
pattern is of unstable asthma regular oral theophyllines
may help. Where the pattern is of severe morning
dipping modifications of night-time medication,
including long-acting bronchodilators, long-acting
betaagonists and or theophylline may improve control.
Better identification of the patterns of chronic severe
asthma leads to better use of existing drugs as well as
better understanding of the problem by both patient and