San Antonio Uniformed Services Health Education Consortium

Transition to Inhaled Steroids for Asthma

Both Bob Jacobs and Bob Lanier trained and practiced during this period and these comments are our perspectives and experiences. The specialty of Allergy was considered by both internal medicine and pediatric departments at this time as “voodoo” medicine. Bob Jacobs, in 1970, was told by the chairman of the medicine department that Allergy was not considered a part of “real” medicine and he was urged to choose another field (Rheumatology or Pulmonary Medicine). Bob Lanier was treated similarly by the chairman of the pediatric department and urged to consider Neonatology. Fortunately, for us, neither took that advice.  

During the early years of the program, the majority of allergic and asthmatic patients were managed by the pediatric and internal medicine outpatient clinics. The allergy program was understaffed and able to see only the most severe of patients, particularly patients who were on repetitive steroids. Asthma at that time was conceptualized as “bronchospasm sometimes complicated by inflammation”. Particularly for children, residential treatment similar to older TB sanitoriums were developed with the leading one  in Denver at National Jewish Hospital where cross training with military allergists had significant influence on the Allergy program at Wilford Hall. Oral steroids were the mainstay of treatment of severe asthma, the discovery of every other day steroids – a concept developed by parents of the residents – led to less toxic therapy. While aminophylline had been used in cardiac catheterization procedures as early as 1939 to dilate arteries and bronchial tubes, its oral use was fraught with toxic side effects. A less toxic derivative, theophylline was developed leading to a very popular combination medication called Tedral (ephedrine, theophylline, phenobarbital) favored by the program because of the personal experience of some of the staff who personally suffered with asthma. Its ban in 1993 led to a chorus of discontent from lifetime users. Theophylline was titrated at the time “pushing to higher doses until they puke” then reducing slightly. Improvements continued as theophylline became available in time release format. Isoproterenol and even epinephrine itself was used commonly by metered dose inhalers or even spritzers.. Deep breathing using the green IPPB machines configured uniquely for children by pediatrician neonatologist, Robert deLemos, at Wilford Hall. Every pediatric resident was trained to “field strip and reassemble these machines”. Isuprel drips and aminophylline drips were common for pediatricians and internists without much participation by the Allergy division on in-patients. Severe status asthmaticus was handled at that time by the anesthesia department where intubation and maintenance were done before release back to the floor.  However, when over the counter inhalers became available in Mexico in the early 1970s at an incredibly low five dollars per unit, groups of parents would drive to Mexico and purchase those inhalers, cheap steroids, and other items to distribute back in this country. The border patrol “looked the other way” and did not question persons with 20-50 inhalers. In 1976, beclomethasone inhalers became available, although the general physician audience resisted them very much. This “steroid phobia” was such a prevailing problem that allergists had trouble using this expensive medication. By 1977 the attacks were reduced in this country and steroid phobia slowly dissolved with resultant decrease in hospitalization for asthma. 

The concept of asthma slowly reversed itself from being a “disease of bronchospasm sometimes associated with inflammation”, to a “disease of inflammation complicated by bronchospasm”. The military allergy program at Wilford Hall championed this concept leading to change in both the military, in general, and the city in particular. This concept of an “eosinophilic inflammation” as the driving cause of severe asthma, as well as, “mixed COPD with asthma” was uncovered in the mid-70s as a result of automatically collecting nasal and sputum secretions in all patients and being read and reported by the staff and fellows. An astonishing percentage of these patients had elevated eosinophils in sputum smears. This discovery led to a study, in which patients were given high-dose prednisone (50 mg daily as a single dose) for 7 days. If 10% reversibility occurred, the study was continued a second week. If further reversibility occurred, the study was continued a 3rd week. Most patients experienced significant reversibility, however, we had no drugs to hold this position and patients relapsed to their former status. This data was presented in either 1979 or 1980 at the Fitzsimons Symposium by Bill Culver. The TB doctors went “berserk”, yelling that this approach would activate TB in large numbers of patients (despite no evidence that this had ever happened). We did not publish this data, and this is one of my greatest disappointments, for 10 years later eosinophilic inflammation was formally recognized as the primary driving force of severe asthma.