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The very nature of asthmatic attacks is alarming. Waiting for an attack in itself creates anxiety. The unpredictable nature of the condition is also anxiety producing. However, this type of anxiety is not simple and the patient's attitude to it is often ambiguous. Asthmatic patients do not have a specific type of personality but a neurotic and psychosomatic context is common. By psychosomatic we mean reactional behaviour to the disease rather than "psychogenesis" of attacks, although emotional factors are often observed. Asthmatic patients do not live alone. They live in an environment which affects them and which is affected by them: a special psychodynamic relationship is set up, especially in young patients, and not to recognise it would be to ignore part of the patient and of the disease.

A vagal mechanism appears to be involved in the development of exercise-induced asthma (EIA), although previous studies have failed to demonstrate a protective effect of anticholinergic drugs against post-exercise bronchoconstriction. To reassess this hypothesis the effect of a new anticholinergic drug, Oxitropium Bromide (OTB) has been studied in ten subjects with documented EIA. There was no change after inhalation of a placebo. Administration of OTB led to bronchodilatation and totally blocked post-exercise bronchoconstriction in 7 patients, and it did so partly in 2. The response to the drug appeared to depend on pretest respiratory function. Thus, the anticholinergic drug OTB may protect against EIA in most patients, confirming the role of a vagal cholinergic mechanism in EIA.

1. Terfenadine, a histamine H1-receptor antagonist, was studied in 52 patients with stable mild perennial asthma with an allergic basis. 2. After a placebo run-in period, patients were randomly allocated to either terfenadine 120 mg twice daily or placebo. After 2 weeks they were crossed over to the other treatment. Forty-six patients completed the study. 3. Terfenadine was significantly more effective than placebo as measured by peak expiratory flows and by symptom scores. 4. These results suggest that histamine may play a more significant role in asthmatic bronchoconstriction than is currently recognised.

Unlabelled: The respiratory tolerance can limit the use of beta-blocker medication (beta-) currently indicated in numerous clinical situations, both cardiovascular and also neurological and ophthalmological. Blockade of beta adrenergic receptors is without risk in subjects free of bronchial pathology, but may destabilize underlying airflow obstruction; either presenting as or sustaining bronchospasm in an asthmatic, and increasing bronchial obstruction, in patients suffering from chronic airflow obstruction (BPCO). Now BPCO, and in particular asthma, are easily associated with diseases for which beta- are indicated. In addition the notion of cardioselectivity is relative and dose dependent., In Practice: beta- are contraindicated in chronic airflow obstruction with bronchial hyper-reactivity; in other cases, beta- should be used carefully choosing the most cardioselective products at the lowest effective dose. Whatever the route of administration (in particular eye drops), the beta- are reliable to produce the same harmful effects. There should be strict follow up of treatment and a watch kept for signs of a worsening or a provocation of respiratory problems; conversely the occurrence of such symptomatology in a patient with bronchial pathology should call into question the place of beta-. Finally beta- should be avoided in allergic subjects and (a fortiori) in specific immunotherapy where there is a possibility of anaphylactic shock.

The technique of intracavitary aspiration introduced by Monaldi in 1938 in the treatment of tuberculous cavities and then applied by him in the treatment of lung abscesses was forgotten for nearly 30 years. The advent of antibiotics and their success explain its abandonment. It may take an important place again in the treatment of difficult cases, as a last resort, after failure of properly conducted classical medical treatment. A study of 20 hospitalised patients in an intensive care unit presenting with severe pulmonary abscesses demonstrates this point. After recalling the causes, the therapeutic difficulties and the complications of these abscesses, the authors describe the medications, the method of endocavitary drainage and the technical problems posed by its use in patients often artificially ventilated. The absence of any major dangers inherent in using this technique is also discussed. Finally the short (one month) and long term (20 months) results were analysed. Three deaths occurred during the initial period, although largely explained by associated lesions in these patients. The other 17 patients, of whom 11 were followed up for more than six months, had a satisfactory outcome from the respiratory stand-point. The disappearance of all signs of infection was constantly obtained and in only four patients the bullous cavities persisted. The authors conclude by attesting the efficacy of the technique and its low risk often in the most critically ill patients.

The aim of this study was to estimate, in patients with chronic obstructive pulmonary disease (COPD), the maximal strength of the expiratory muscles, its correlation with exercise performance and the effects of a specific physiotherapy. In 38 COPD men, aged 54 +/- 7 years, pulmonary function data, maximal alveolar pressure (Palv, max) developed during forced vital capacity, were measured using a whole-body plethysmograph and the maximal tolerated power (MTP), i.e. the highest power maintained for at least 3 min, was determined by a progressive test on a treadmill. Airway obstruction was severe (FEV1/FVC: 54 +/- 10%), Palv, max was lower than normal (74 +/- 36 vs. 130 +/- 48 hPa in 20 healthy men of the same age; p less than 0.01) and increased with airway resistance values (Raw); mean MTP was low: 115 +/- 30 W and individual values were inversely related to Raw values. Then, two subgroups of 14 patients were chosen at random. One subgroup received an abdominal muscle physiotherapy during 3 weeks. The other subgroup only received usual medical treatment. No modification in any parameter was found in the second subgroup. Specific physiotherapy of abdominal muscles improves significantly both Palv, max (118 +/- 45 hPa) and MTP (171 +/- 38 W; p less than 0.01), without any variation in other respiratory function parameters. We conclude that abdominal muscle weakness is common in COPD patients and can participate in the limitation in exercise performance. Specific physiotherapy increases abdominal muscle strength and seems to improve exercise tolerance by a still unexplained mechanism.