guidelines recommended by the British Thoracic Society and others.' In the section on immediate treatment for acute severe asthma an intravenous bronchodilator and intravenous aminophylline are recommended. There was no mention of inquiry as to whether the patient is already receiving oral theophylline preparations. In our department we would not instigate such treatment without estimating the plasma concentration of theophylline because of the possibility of inducing convulsions and dysrhythmias. I believe that this is an important point that cannot be too strongly emphasised. D G McGEEHAN North Staffordshire Royal Infirmary, Stoke-on-Trent ST4 7LN

I British Thoracic Society, Research Unit of the Royal Collegc of Physicians of London, King's Fund Centre, National Asthma Campaign. Guidelines for management of asthma in adults. 2. Acute severe asthma. BA1I 1990;301:797-800. (6 October.)

AUTHOR'S REPLY,-Mr D G McGeehan raises a very important point and makes it more strongly than the guidelines do. The guidelines do state, however, that "A 132 agonist is preferred [to intravenous aminophylline] if the patient is already taking oral theophylline." Most chest doctors would advise that when intravenous bronchodilators are indicated an intravenous bolus of aminophylline should not be given to patients already receiving oral theophylline if intravenous 32 agonists are available, or unless the plasma concentration of theophylline has been estimated. Nevertheless, in moribund asthmatic patients intravenous bronchodilator and steroid treatment may be life saving. In this case, when it may be impossible to determine whether or not the patient is receiving oral theophylline and the only intravenous bronchodilator to hand may be aminophylline it would probably be unwise to withhold aminophylline (250 mg over 30 minutes). B D W HARRISON British Thoracic Society, London NW1 4LB

SIR,-The guidelines for managing asthma issued by the British Thoracic Society, research unit of the Royal College of Physicians of London, King's Fund Centre, and National Asthma Campaign again recommend active intervention,'2 but I do not believe that this is always the best treatment. At a celebration of our tutor's 80th birthday recently, we remembered that we had been taught that asthma seldom killed. As a registrar in old Charing Cross Hospital my neighbour usually treated severe asthma with a large dose of phenobarbitone and found the patient better in the morning; the textbooks commonly recommend morphine. In 1929 Young and Beaumont wrote "During a severe attack the aspect of the patient may be so alarming that a fatal issue may seem imminent, yet death very rarely occurs"'; and in 1950 Brooks wrote "It is doubtful whether death has ever been caused by uncomplicated asthma."4 This was my experience too. After a single injection ofaminophylline children admitted to the calm of a ward usually settled to a sleep of exhaustion with the help of promethazine and woke much improved. As the years passed it became increasingly difficult to protect them from fuss, drips, radiography, inhalers, and measurements of blood gas tensions and peak flow. Drugs improved, but the results changed little and it seemed that the advice to Bo-peep, leave them alone and they will come home, was being forgotten. Just as for tears, tics, and tantrums, the frequency and severity of asthma can be relieved by relaxation and exacerbated by undue attention or

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anxiety. Suitably reinforced, the initial trigger of cat, mite, or mould may transfer to apprehension of an attack or to apprehension generally. As they matured most children lost this fear, and often their asthma, though some became the clergyman who fled the pulpit if the puffer was missing, the traveller relapsing as he neared a station where he was once affected, or the house doctor wheezing as his chief approached. Children with intractable asthma often responded permanently to a month or so of tree climbing and "catch up" schooling, which widened their horizons beyond high rise flats and television. The hospitals where this was possible have closed as better drugs have appeared, but the effect should not be forgotten. Mild asthma, which might be only an occasional nuisance, may become a considerable handicap if the child's concern and the parents' anxieties are focused on it too early by diaries and frequent respiratory measurements. Are there still enough conservative pockets to mount a comparison of treatment by diversion and reassurance with that by drugs and close monitoring? T H HUGHES-DAVIES

Fordingbridge, Hampshire SP6 2EJ I British Thoracic Society, Research Unit of the Royal College of Physicians of London, King's Fund Centre, National Asthma Campaign. Guidelines for the management of asthma in adults. 1. Chronic persistent pain. BMJ7 1990;301:651-4.

(29 September.) 2 British 'rhoracic Society, Research Unit of the Royal College of

Physicians of London, King's Fund Centre, National Asthma Campaign. Guidelines for the management of asthma in adults. 2. Acute severe asthma. BMJ 1990;301:797-800. (6 October.) 3 Price FW, ed. A textbook for the practice of medicine. 3rd ed. Oxford: Oxford University Press, 1929. 4 Conybeare J, ed. Textbook of medicine. 9th ed. Edinburgh: Livingstone, 1950.

Adrenaline and nocturnal asthma SIR,-The basic structure of the paper by Dr J F J Morrison and colleagues is questionable.' The patients were woken at 4 am in the disturbing environment of a hospital, and many of them had their antiasthma drugs withdrawn. What faith can be placed in the baseline levels of adrenaline and peak expiratory flow rate recorded under these conditions? Was any attempt made to establish the normal profile of plasma adrenaline and peak flow rate in these subjects, and did these values- differ from those obtained in the study? By the author's own admission for up to a quarter of the time there was no diurnal variation in the patients' peak flow rates in the two weeks preceding the study. Considering the small number of subjects studied, this introduces another important source of error. Were there true relative falls in peak flow rate at night in enough of the subjects?

aspergillus infection of 19% (15 proved cases from 81 patients), whereas those undergoing bone marrow transplantation on the same ward but in protective isolation had no fungal infections,2 which confirms the value of isolation. There were, however, two unusual presentations of aspergillus infections in which mass lesions were thought to be due to relapsed leukaemia and antifungal treatment was delayed. The first patient was a 47 year old man who had been treated with conventional chemotherapy and autologous bone marrow transplantation for T cell acute lymphoblastic lymphoma. Six months later he relapsed and received further chemotherapy. A routine bone marrow examination on day 14 of the treatment showed residual disease. One week later he developed a right homonymous hemianopia, and computed tomography showed a mass lesion in the left temporoparietal region. This was initially thought to be a leukaemic deposit, and he was not treated with amphotericin until four days later when a fever failed to respond to antibiotics. Despite this he deteriorated rapidly and died. Necropsy showed an aspergillus abscess. The second patient was a 62 year old man treated with conventional chemotherapy for common acute lymphoblastic lymphoma. Bone marrow examination on day 14 showed residual leukaemia. At this time he developed hyperglycaemia secondary to the steroids, and changes on chest radiography suggested a right sided pneumonic process. Two days later he had no fever but he developed a left submandibular swelling, which was thought to represent recurrent leukaemia and to reflect the poor systemic response. His general condition rapidly deteriorated and he died before a needle biopsy of the mass could be done. Necropsy showed the mass to be due to aspergillus infection. These two cases underline the point made by Dr Dewhurst and colleagues that aspergillus infection is an important problem in immunocompromised patients. Our two cases taken together with their first case clearly show that mass lesions can be wrongly attributed to the underlying disease. We recommend that immediate intravenous amphotericin is considered in immunocompromised patients with mass lesion while a diagnostic procedure is being arranged. P W COLLINS S M KELSEY C DE LORD A C NEWLAND

Royal London Hospital, London E I 1BB 1 Dewhurst AG, Cooper MJ, Khan SM, Pallett AP, Dathan JRE. Invasive aspergillosis in immunocompromised patients: potential hazard of building work. BMJ 1990;301:802-4. (6 October.) 2 Kelsey SM, Newland AC, van der Walt J, Doran H. Pulmonary aspergillosis in patients with leukaemia. J Clin Pathol 1990;43:783.

A S EASTON

London SE5 8EH I Morrison JFJ, Teale C, Pearson SB, et al. Adrenaline and nocturnal asthma. BMJ 1990;301:473-6. (8 September.)

Invasive aspergillosis in immunosuppressed patients SIR,-Dr A G Dewhurst and colleagues highlight the risk of aspergillus infection in immunocompromised patients during local building work.' We noted a similar increase in fungal infections in our haematology unit during recent renovations near our ward. During the building work patients who were severely neutropenic after intensive chemotherapy for haematological malignancies had a rate of

SIR,-Dr A G Dewhurst and colleagues highlight the problems posed by invasive fungal infections in immunocompromised patients. ' A recent outbreak of invasive aspergillosis in our haematology unit emphasises the relation of such outbreaks to building works; difficulties of proving the diagnosis before death; and the poor response to treatment when infection is established. Our experience suggests a possible role for prophylaxis with itraconazole. A review of the admissions to our unit between December 1989 and May 1990 showed that of 20 patients who had prolonged severe neutropenia, three had confirmed and two had suspected invasive aspergillosis despite reverse barrier nursing in cubicles fitted with high efficiency particulate air filtration systems2 and early use of systemic amphoteracin.' All five patients died, one of whom had been treated with itraconazole but not until 15 days after she had developed a fever.

BMJ VOLUME 301

3 NOVEMBER 1990

Invasive aspergillosis in immunosuppressed patients.

guidelines recommended by the British Thoracic Society and others.' In the section on immediate treatment for acute severe asthma an intravenous bronc...
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