57
Vol. 68, No. 1
Acute Appendicitis in Patients Over Age 65 SHIN K. KIM, M.D.,
Surgical Resident, and EARL BELLE SMITH, M.D., F.A.C.S., Director of Surgical Education and Research, St. Francis General Hospital, Pittsburgh, Pennsylvania
A CUTE appendicitis is one of the most common diseases affecting all age groups, although the incidence rates in infancy and the aged are relatively low. The decrease in the morbidity and mortality rates of acute appendicitis is a reflection of major advances in surgical diagnosis and treatment. Acute appendicitis in aged persons produces special problems which have been discussed by various authors. 16. Concomitant cardiovascular and metabolic diseases and the high incidence of other diseases such as malignancy, diverticulitis, etc., increase morbidity-mortality statistics and delay the diagnosis. Delay in seeking medical attention is a contributing factor in the increase in perforation and generalized peritonitis rates. In addition the patients' failure to recognize the seriousness of their symptoms, greater tolerance of pain and discomfort, reluctance to ask for help, the disadvantages of living alone, and the low economic status of the elderly, aggravate the situation. Pathophysiologically, in elderly people, 1) the symptoms and the localization of pain often are not typical; and 2) the inflammation tends to progress rapidly to gangrene and perforation.6 The purpose of this paper is to evaluate the general clinical features, diagnosis and treatment of acute appendicitis in 29 patients over age 65 during 1965 to 1973 at St. Francis General Hospital, Pittsburgh.
acute appendicitis which appeared to be linked with the humidity. In our series of aged patients, no definitive correlation was noted. CLINICAL SYMPTOMS
The most common chief complaint was abdominal pain which was noted in 25(89%) of the 29 patients. It was not always typical right lower quadrant pain. It was rather vague and diffuse or even left lower quadrant or right upper quadrant in some cases. Diarrhea, vomiting, abdominal mass and abdominal distension were noted as chief complaints in the other four patients. Nausea and vomiting were present in 20 patients or 69%. The duration of symptoms, prior to hospital admittance, was from six hours to three weeks. Fifteen patients were evaluated in the hospital within 24 hours, and delayed admittances characterized the aged patients (Table 1). Table 1. DURATION OF SYMPTOMS Duration I Day 2 Days 3 Days 4 Days 5 Days I Week 3 Weeks ?
Number of Patients 15 4 2 1 2 3 1 I
PHYSICAL FINDINGS INCIDENCE
Of the 29 patients, 22(79%) were female and seven were male. The average age was 72.6 and which ranged from 66 to 90 years. Brumer7 reported a seasonal incidence of
Abdominal tenderness was noted in all cases, however, not always over McBurney's point. Rebound tenderness was positive in 15 of 26 patients and in three patients, there was no description available, probably because of
58
JANUARY, 1976
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
the lack of suspicion of an acute intra-abdominal inflammatory process. The average body temperature upon admittance to the hospital was 100.1 F (range from 97.6 to 103.4F). Some studies1 showed the relationship of an elevated temperature and the perforation of the appendix, which was not found in our series. A palpable abdominal mass was noted in eight patients (28%). The average distribution of white blood cell count was 13,343 (range from 7,590 to 21,300). Increased polymorphonuclear cell count was regularly observed1. The body temperature and white blood cell counts are helpful in the diagnosis of acute appendicitis, but a normal figure did not exclude the diagnosis'.
PATHOLOGY
A striking characteristic of acute appendicitis in the aged is the high incidence of perforation 2,5. Eighteen patients (62%) had perforation, manifested by acute perforation in six cases, appendiceal abscess in 10, pelvic abscess in one, and generalized peritonitis in one case. Acutely inflamed or acute gangrenous appendicitis was found in 11 patients or 38% (Table 3). In other series, perforation was found in 68%3 and 61% 1 of cases of appendicitis in patients over 60 years of age. Table 3. PATHOLOGICAL FINDINGS OF 29 PATIENTS WITH ACUTE APPENDICITIS OVER AGE OF 65 Pathology
Number of Cases
Per Cent
11
38
10 1 1
21 34 3.5 3.5
Acutely Inflammed
Table 2. ADMITTING DIAGNOSIS OF 29 PATIENTS OF ACUTE APPENDICITIS OVER AGE OF 65 Diagnosis
Number of Cases
Acute Appendicitis or Append. Abscess 7 Diverticulitis Malignancy Cholecystitis 2 Gastroenteritis Intestinal Obstruction 2 1 Colitis Renal Colic Incarcerated Hemia 1 Urinary Tract Infection 1
15 4 3
or Acute Gangrenous Recent Perforation Append. Abscess Pelvic Abscess
Peritonitis
6
During the same period, autopsies were done on two patients, in whom, acute appendicitis was not suspected or diagnosed prior to their deaths. Perforated appendicitis with peritonitis was confirmed.
1
DIFFERENTIAL DIAGNOSIS
Acute appendicitis or its complications were suspected or diagnosed at the time of hospital admittance in 15 of the 29 patients or 52%. In some instances, appendicitis was not considered as a differential diagnosis until the exploratory laparatomy. Diverticulitis, carcinoma of cecum or colon, and cholecystitis are common in this age group and were
misdiagnosed frequently (Table 2). Coexistent surgical conditions, such as, colorectal cancer with abdominoperineal resection, gall stones, ventral hernia and inguinal hernia were noted in two, three, one, and one patients, respectively. This caused confusion to the clinician in the early diagnosis of acute appendicitis.
HOSPITAL COURSE
Early diagnosis and early operation are essential in the treatment of acute appendicitis, especially in the aged. It diminishes hospital stay and occurrences of complication, as well as mortality2. But poor history, concomitant medical problems, and other features characteristic of the aged, as described heretofore, delay the diagnosis. Four patients had surgery on the same day of admission and 10 on the next day. One patient had surgery 11 days after he was admitted. A tender right lower quadrant mass in three patients diagnosed as an appendiceal abscess responded well to medical or nonoperative treatment and elective surgery was performed later in these cases. One of the features of the aged is prolonged hospital stay. Delayed diagnosis is characterized by an unusually long interval
Vol. 68, No. I
Geriatric Appendicitis
between admittance and operative intervention. Postoperative courses were complicated by high incidences of complications, delayed wound healing, concomitant cardiovascular problems, and other factors. The average hospitalization stay was 19 days and ranged from nine to 40 days. The average postoperative stay was 16.6 days (range 9 days to 34 days). Three patients with appendiceal abscess were treated medically on first admission and one patient was discharged on his 13th hospital day and two on their 19th days. Seven to 10 weeks later, elective appendectomy was performed. The mean length of hospital stay by Hospital Utilization Project8 is compared with our series in Table 4. Table 4. LENGTH OF STAY BY DIAGNOSIS AND SURGICAL PROCEDURE COMPARISON BETWEEN HUP AND SFGH
Age Group
65+ HUP SFGH Single
Acute Appendicitis
Appendectomy
DX Multiple Single DX Multiple
12.3
20-34 HUP 6.0
19.0 19.0 11.6
9.5 5.9
16.6 17.7
8.5
fection, intra-abdominal abscess, intestinal obstruction, hemorrhage, fistula, pulmonary and urinary tract complications have a significant incidence in the post-operative period. In our series, wound infection was noted in nine patients or 31%; cerebral embolism, with paresis in one; and pulmonary embolism and infarct in two (total complication rate: 41%). There was no postoperative mortality. SUMMARY
Acute appendicitis, in patients over 65 was reviewed clinically in 29 cases. The aged patients are characterized by 1) concomitant degenerative, metabolic or neoplastic diseases; 2) delay in seeking medical attention; and 3. Altered pathophysiology. Fourteen patients (48%) were admitted to the hospital two days or more after the symptoms developed. In only 15 cases (52%), was acute appendicitis suspected upon admission. Perforation was present in 18 patients (62%). Difficulty in diagnoses was demonstrated in the time interval between the date of admittance and the date of operation. Also prolonged hospital stay was noted. In spite of a 31% post-operative complication rate, there was no operative mortality.
TREATMENT
Appendectomy with drainage was performed in 21 patients or 72%, and five patients had simple appendectomy without drainage. Initial antibiotic treatment and late elective appendectomy were carried out in three patients. It is generally believed that peritoneal drainage is indicated whenever perforation has occurred and the incidence of prolonged ileus and intra-abdominal abscess appears to be lessened3. Also special emphasis is attached to fluid and electrolyte balance and cardiopulmonary care as well as general pre- and post-operative care in the management of acute appendicitis in the aged. MORBIDITY AND MORTALITY
Post-operative mortality in acute appendicitis was reduced markedly because of antibiotics, improved pre- and post-operative care and advances in anesthesia9. Wound in-
59
ACKNOWLEDGMENT Indebtedness is extended to Sister Magdala, Sister Florence, Mrs. DiLeonardo, and other members in the Medical Record Room for their help with the charts and to Mr. Hinkes, Mrs. Bauer and Miss Kappemaros of the Visual Communication Department for their assistance with charts
and slides.
LITERATURE CITED 1. LOE, R. H. Acute Appendicitis in Senior Citizens. Postgrad. Med., 45:179-83, 1969. 2. PEITOKALLIO, P. et al. Acute Appendicitis in the Aged Patients. Study of 300 Cases after the Age of 60. Arch. Surg., 100:140-3, 1970. 3. THORBJARNARSON, B. et al. Acute Appendicitis in Patients Over the Age of Sixty. Surg.
Gynec. Obstet., 125:1277-80, 1967. 4. TALBERT, J. L. et al. Appendicitis-A Reappraisal of an Old Problem. Surg. Clin. N. Amer., 46:1101-12, 1966. 5. CORAN, A. G. et al. Early Perforation in Appendicitis after Age 60. J.A.M.A., 197:745-8, 1966. (Concluded on page 50)
50
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
bination bronchodilator therapy with Marax, Tedral, or Quadrinal, still with dose based upon theophylline content. If the child continues to have several significant attacks per month we will generally attempt: 1) a trial of Cromolyn (Intal), 20 mg by spinhaler t.i.d. or q.i.d. between attacks; or 2) five day course of prednisone at 1 mg/lb up to 60 mg. Children who do not respond to this regimen must be considered as "severe asthmatics." Severe asthmatics must be seen as often as they are still symptomatic. This might mean daily. Generally, they have been managed with: 1) hydration; 2) oral bronchodilator therapy-theophylline in the doses mentioned; 3) metaproterenol p.o. alone or in combination with theophylline; 4) steroids 1 mg/lb daily only as long as is necessary to control symptoms. Then they are switched to alternate day therapy; 5) sub Q epinephrine at home for periods when they are symptomatic in spite of the above measures. Generally, we will give epinephrine: Children between 20-35 lbs 35-60 lbs 60 lbs+
0.1 cc epinephrine 0.2 cc epinephrine 0.3 cc epinephfine
We seldom use more than 0.3 cc epinephrine. We teach parents to use it at home with the insistence that we be called whenever it has been given; and 6) Isoproterenol & Metaproterenol (Alupent) by medihaler one to two sprays every three to four hours pm severe wheezing. If severe patients stabilize, all medications except theophylline and alternate day prednisone are discontinued. We will generally attempt to reduce the steroid dose to 2/3 of the original level. If the patient does not become symptomatic, we will usually try to start cromolyn and further reduce the steroid dose. Most moderate to severe asthmatics will
JANUARY, 1976
be referred for skin testing by a doctor experienced in these procedures. Appropriate environmental controls are instituted and, if indicated, immunotherapy is begun. SUMMARY
The child with asthma poses an interesting and challenging medical problem for the physician. A guide for classifying and managing has been presented. We emphasize that our method is not the only method. However, we do feel that some understanding of the pathophysiology and familiarity with specific treatment modalities is essential in planning an effective therapeutic course for any one child. A structured and continuous approach to the problem encountered by children with asthma and their families will result in a reduction in morbidity. This will be a rewarding experience for the physician and parent alike. LITERATURE CITED
1. SZENTIVANYI, A. The Beta-adrenergic Theory of the Atopic Abnormality in Bronchial Asthma. J. Allergy Clin. Immunol., 42:203, 1968. 2. ROBINSON, L. D. and M. A. Le NOIR. The Immunologic and Neurohumoral Regulation of Bronchial Asthma. J. Natl. Med. Assoc., 66:407, 1974. 3. WEINBERGER, M. M. and E. A. BRONSKY, Evaluation of Oral Bronchodilation Therapy. J. Pediatr. 84:421, 1974. 4. COX, J. S. Disodium cromoglycate; Mode of Action and its Possible Relevance to the Clinical use of the Drug. Br. J. Dis. Chest, 65:189, 1971. 5. JOHNSTONE, D. E. and A. DUTTON. The Value of Hyposensitization Therapy for Bronchial Asthma in Children-a 14 Year Study. J. Pediatr., 42:793, 1968.
(Kim and Smith, from page 59)
6. BERMAN, P. M. et al. The Aging Gut-Diseases of the Esophagus, Small Intestine, and Appendix. Geriatrics, 27:84-90, 1972. 7. BRUMER, M. Appendicitis-Seasonal Incidence and Post-operative Wound Infection. Brit. J. Surg., 57:93-99, Feb 1970. 8. Length of Stay in H.U.P. Hospitals 1973. Published by Hospital Utilization Project, Pittsburgh, Pennsylvania. 9. KAZARIAN, K. K. et al. Decreasing Mortality and Increasing Morbidity from Acute Appendicitis. Amer. J. Surg., 119:681-5, 1970.
SEE ALSO 1. HOWIE, J. G. R. The Place of Appendicectomy in the Treatment of Young Adult Patients with Possible Appendicitis. Lancet, 1:1365-7, 1968. 2. GROSFELD, J. L. et al. Prevention of Wound Infection in Perforated Appendicitis: Experience with Delayed Primary Wound Closure. Ann. Surg., 168:891-5, 1968. 3. HOWIE, J. G.: Death from Appendicitis and Appendicectomy-an Epidemiological Survey. Lancet, 2:1334-7, Oct 1966.
Vol. 68, No. 1
Acute Appendicitis in Patients Over Age 65 SHIN K. KIM, M.D.,
Surgical Resident, and EARL BELLE SMITH, M.D., F.A.C.S., Director of Surgical Education and Research, St. Francis General Hospital, Pittsburgh, Pennsylvania
A CUTE appendicitis is one of the most common diseases affecting all age groups, although the incidence rates in infancy and the aged are relatively low. The decrease in the morbidity and mortality rates of acute appendicitis is a reflection of major advances in surgical diagnosis and treatment. Acute appendicitis in aged persons produces special problems which have been discussed by various authors. 16. Concomitant cardiovascular and metabolic diseases and the high incidence of other diseases such as malignancy, diverticulitis, etc., increase morbidity-mortality statistics and delay the diagnosis. Delay in seeking medical attention is a contributing factor in the increase in perforation and generalized peritonitis rates. In addition the patients' failure to recognize the seriousness of their symptoms, greater tolerance of pain and discomfort, reluctance to ask for help, the disadvantages of living alone, and the low economic status of the elderly, aggravate the situation. Pathophysiologically, in elderly people, 1) the symptoms and the localization of pain often are not typical; and 2) the inflammation tends to progress rapidly to gangrene and perforation.6 The purpose of this paper is to evaluate the general clinical features, diagnosis and treatment of acute appendicitis in 29 patients over age 65 during 1965 to 1973 at St. Francis General Hospital, Pittsburgh.
acute appendicitis which appeared to be linked with the humidity. In our series of aged patients, no definitive correlation was noted. CLINICAL SYMPTOMS
The most common chief complaint was abdominal pain which was noted in 25(89%) of the 29 patients. It was not always typical right lower quadrant pain. It was rather vague and diffuse or even left lower quadrant or right upper quadrant in some cases. Diarrhea, vomiting, abdominal mass and abdominal distension were noted as chief complaints in the other four patients. Nausea and vomiting were present in 20 patients or 69%. The duration of symptoms, prior to hospital admittance, was from six hours to three weeks. Fifteen patients were evaluated in the hospital within 24 hours, and delayed admittances characterized the aged patients (Table 1). Table 1. DURATION OF SYMPTOMS Duration I Day 2 Days 3 Days 4 Days 5 Days I Week 3 Weeks ?
Number of Patients 15 4 2 1 2 3 1 I
PHYSICAL FINDINGS INCIDENCE
Of the 29 patients, 22(79%) were female and seven were male. The average age was 72.6 and which ranged from 66 to 90 years. Brumer7 reported a seasonal incidence of
Abdominal tenderness was noted in all cases, however, not always over McBurney's point. Rebound tenderness was positive in 15 of 26 patients and in three patients, there was no description available, probably because of
58
JANUARY, 1976
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
the lack of suspicion of an acute intra-abdominal inflammatory process. The average body temperature upon admittance to the hospital was 100.1 F (range from 97.6 to 103.4F). Some studies1 showed the relationship of an elevated temperature and the perforation of the appendix, which was not found in our series. A palpable abdominal mass was noted in eight patients (28%). The average distribution of white blood cell count was 13,343 (range from 7,590 to 21,300). Increased polymorphonuclear cell count was regularly observed1. The body temperature and white blood cell counts are helpful in the diagnosis of acute appendicitis, but a normal figure did not exclude the diagnosis'.
PATHOLOGY
A striking characteristic of acute appendicitis in the aged is the high incidence of perforation 2,5. Eighteen patients (62%) had perforation, manifested by acute perforation in six cases, appendiceal abscess in 10, pelvic abscess in one, and generalized peritonitis in one case. Acutely inflamed or acute gangrenous appendicitis was found in 11 patients or 38% (Table 3). In other series, perforation was found in 68%3 and 61% 1 of cases of appendicitis in patients over 60 years of age. Table 3. PATHOLOGICAL FINDINGS OF 29 PATIENTS WITH ACUTE APPENDICITIS OVER AGE OF 65 Pathology
Number of Cases
Per Cent
11
38
10 1 1
21 34 3.5 3.5
Acutely Inflammed
Table 2. ADMITTING DIAGNOSIS OF 29 PATIENTS OF ACUTE APPENDICITIS OVER AGE OF 65 Diagnosis
Number of Cases
Acute Appendicitis or Append. Abscess 7 Diverticulitis Malignancy Cholecystitis 2 Gastroenteritis Intestinal Obstruction 2 1 Colitis Renal Colic Incarcerated Hemia 1 Urinary Tract Infection 1
15 4 3
or Acute Gangrenous Recent Perforation Append. Abscess Pelvic Abscess
Peritonitis
6
During the same period, autopsies were done on two patients, in whom, acute appendicitis was not suspected or diagnosed prior to their deaths. Perforated appendicitis with peritonitis was confirmed.
1
DIFFERENTIAL DIAGNOSIS
Acute appendicitis or its complications were suspected or diagnosed at the time of hospital admittance in 15 of the 29 patients or 52%. In some instances, appendicitis was not considered as a differential diagnosis until the exploratory laparatomy. Diverticulitis, carcinoma of cecum or colon, and cholecystitis are common in this age group and were
misdiagnosed frequently (Table 2). Coexistent surgical conditions, such as, colorectal cancer with abdominoperineal resection, gall stones, ventral hernia and inguinal hernia were noted in two, three, one, and one patients, respectively. This caused confusion to the clinician in the early diagnosis of acute appendicitis.
HOSPITAL COURSE
Early diagnosis and early operation are essential in the treatment of acute appendicitis, especially in the aged. It diminishes hospital stay and occurrences of complication, as well as mortality2. But poor history, concomitant medical problems, and other features characteristic of the aged, as described heretofore, delay the diagnosis. Four patients had surgery on the same day of admission and 10 on the next day. One patient had surgery 11 days after he was admitted. A tender right lower quadrant mass in three patients diagnosed as an appendiceal abscess responded well to medical or nonoperative treatment and elective surgery was performed later in these cases. One of the features of the aged is prolonged hospital stay. Delayed diagnosis is characterized by an unusually long interval
Vol. 68, No. I
Geriatric Appendicitis
between admittance and operative intervention. Postoperative courses were complicated by high incidences of complications, delayed wound healing, concomitant cardiovascular problems, and other factors. The average hospitalization stay was 19 days and ranged from nine to 40 days. The average postoperative stay was 16.6 days (range 9 days to 34 days). Three patients with appendiceal abscess were treated medically on first admission and one patient was discharged on his 13th hospital day and two on their 19th days. Seven to 10 weeks later, elective appendectomy was performed. The mean length of hospital stay by Hospital Utilization Project8 is compared with our series in Table 4. Table 4. LENGTH OF STAY BY DIAGNOSIS AND SURGICAL PROCEDURE COMPARISON BETWEEN HUP AND SFGH
Age Group
65+ HUP SFGH Single
Acute Appendicitis
Appendectomy
DX Multiple Single DX Multiple
12.3
20-34 HUP 6.0
19.0 19.0 11.6
9.5 5.9
16.6 17.7
8.5
fection, intra-abdominal abscess, intestinal obstruction, hemorrhage, fistula, pulmonary and urinary tract complications have a significant incidence in the post-operative period. In our series, wound infection was noted in nine patients or 31%; cerebral embolism, with paresis in one; and pulmonary embolism and infarct in two (total complication rate: 41%). There was no postoperative mortality. SUMMARY
Acute appendicitis, in patients over 65 was reviewed clinically in 29 cases. The aged patients are characterized by 1) concomitant degenerative, metabolic or neoplastic diseases; 2) delay in seeking medical attention; and 3. Altered pathophysiology. Fourteen patients (48%) were admitted to the hospital two days or more after the symptoms developed. In only 15 cases (52%), was acute appendicitis suspected upon admission. Perforation was present in 18 patients (62%). Difficulty in diagnoses was demonstrated in the time interval between the date of admittance and the date of operation. Also prolonged hospital stay was noted. In spite of a 31% post-operative complication rate, there was no operative mortality.
TREATMENT
Appendectomy with drainage was performed in 21 patients or 72%, and five patients had simple appendectomy without drainage. Initial antibiotic treatment and late elective appendectomy were carried out in three patients. It is generally believed that peritoneal drainage is indicated whenever perforation has occurred and the incidence of prolonged ileus and intra-abdominal abscess appears to be lessened3. Also special emphasis is attached to fluid and electrolyte balance and cardiopulmonary care as well as general pre- and post-operative care in the management of acute appendicitis in the aged. MORBIDITY AND MORTALITY
Post-operative mortality in acute appendicitis was reduced markedly because of antibiotics, improved pre- and post-operative care and advances in anesthesia9. Wound in-
59
ACKNOWLEDGMENT Indebtedness is extended to Sister Magdala, Sister Florence, Mrs. DiLeonardo, and other members in the Medical Record Room for their help with the charts and to Mr. Hinkes, Mrs. Bauer and Miss Kappemaros of the Visual Communication Department for their assistance with charts
and slides.
LITERATURE CITED 1. LOE, R. H. Acute Appendicitis in Senior Citizens. Postgrad. Med., 45:179-83, 1969. 2. PEITOKALLIO, P. et al. Acute Appendicitis in the Aged Patients. Study of 300 Cases after the Age of 60. Arch. Surg., 100:140-3, 1970. 3. THORBJARNARSON, B. et al. Acute Appendicitis in Patients Over the Age of Sixty. Surg.
Gynec. Obstet., 125:1277-80, 1967. 4. TALBERT, J. L. et al. Appendicitis-A Reappraisal of an Old Problem. Surg. Clin. N. Amer., 46:1101-12, 1966. 5. CORAN, A. G. et al. Early Perforation in Appendicitis after Age 60. J.A.M.A., 197:745-8, 1966. (Concluded on page 50)
50
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
bination bronchodilator therapy with Marax, Tedral, or Quadrinal, still with dose based upon theophylline content. If the child continues to have several significant attacks per month we will generally attempt: 1) a trial of Cromolyn (Intal), 20 mg by spinhaler t.i.d. or q.i.d. between attacks; or 2) five day course of prednisone at 1 mg/lb up to 60 mg. Children who do not respond to this regimen must be considered as "severe asthmatics." Severe asthmatics must be seen as often as they are still symptomatic. This might mean daily. Generally, they have been managed with: 1) hydration; 2) oral bronchodilator therapy-theophylline in the doses mentioned; 3) metaproterenol p.o. alone or in combination with theophylline; 4) steroids 1 mg/lb daily only as long as is necessary to control symptoms. Then they are switched to alternate day therapy; 5) sub Q epinephrine at home for periods when they are symptomatic in spite of the above measures. Generally, we will give epinephrine: Children between 20-35 lbs 35-60 lbs 60 lbs+
0.1 cc epinephrine 0.2 cc epinephrine 0.3 cc epinephfine
We seldom use more than 0.3 cc epinephrine. We teach parents to use it at home with the insistence that we be called whenever it has been given; and 6) Isoproterenol & Metaproterenol (Alupent) by medihaler one to two sprays every three to four hours pm severe wheezing. If severe patients stabilize, all medications except theophylline and alternate day prednisone are discontinued. We will generally attempt to reduce the steroid dose to 2/3 of the original level. If the patient does not become symptomatic, we will usually try to start cromolyn and further reduce the steroid dose. Most moderate to severe asthmatics will
JANUARY, 1976
be referred for skin testing by a doctor experienced in these procedures. Appropriate environmental controls are instituted and, if indicated, immunotherapy is begun. SUMMARY
The child with asthma poses an interesting and challenging medical problem for the physician. A guide for classifying and managing has been presented. We emphasize that our method is not the only method. However, we do feel that some understanding of the pathophysiology and familiarity with specific treatment modalities is essential in planning an effective therapeutic course for any one child. A structured and continuous approach to the problem encountered by children with asthma and their families will result in a reduction in morbidity. This will be a rewarding experience for the physician and parent alike. LITERATURE CITED
1. SZENTIVANYI, A. The Beta-adrenergic Theory of the Atopic Abnormality in Bronchial Asthma. J. Allergy Clin. Immunol., 42:203, 1968. 2. ROBINSON, L. D. and M. A. Le NOIR. The Immunologic and Neurohumoral Regulation of Bronchial Asthma. J. Natl. Med. Assoc., 66:407, 1974. 3. WEINBERGER, M. M. and E. A. BRONSKY, Evaluation of Oral Bronchodilation Therapy. J. Pediatr. 84:421, 1974. 4. COX, J. S. Disodium cromoglycate; Mode of Action and its Possible Relevance to the Clinical use of the Drug. Br. J. Dis. Chest, 65:189, 1971. 5. JOHNSTONE, D. E. and A. DUTTON. The Value of Hyposensitization Therapy for Bronchial Asthma in Children-a 14 Year Study. J. Pediatr., 42:793, 1968.
(Kim and Smith, from page 59)
6. BERMAN, P. M. et al. The Aging Gut-Diseases of the Esophagus, Small Intestine, and Appendix. Geriatrics, 27:84-90, 1972. 7. BRUMER, M. Appendicitis-Seasonal Incidence and Post-operative Wound Infection. Brit. J. Surg., 57:93-99, Feb 1970. 8. Length of Stay in H.U.P. Hospitals 1973. Published by Hospital Utilization Project, Pittsburgh, Pennsylvania. 9. KAZARIAN, K. K. et al. Decreasing Mortality and Increasing Morbidity from Acute Appendicitis. Amer. J. Surg., 119:681-5, 1970.
SEE ALSO 1. HOWIE, J. G. R. The Place of Appendicectomy in the Treatment of Young Adult Patients with Possible Appendicitis. Lancet, 1:1365-7, 1968. 2. GROSFELD, J. L. et al. Prevention of Wound Infection in Perforated Appendicitis: Experience with Delayed Primary Wound Closure. Ann. Surg., 168:891-5, 1968. 3. HOWIE, J. G.: Death from Appendicitis and Appendicectomy-an Epidemiological Survey. Lancet, 2:1334-7, Oct 1966.
