The end of the 20th century has witnessed a rapid progress in the understanding of the etiology of bonchial asthma. Development of various protocols for the treatment of bronchial asthma have been effective for the prevention and treatment of bronchial asthma. However, progress of infant diagnosis has been slow, which is contrary to the concept of early intervention. Furthermore, precise observaion of the severity and frequency of attack is necessary in order to create a detailed drug protocol guideline; however, blind testing of drugs according to the patients' symptoms is difficult in infants. Objective clinical experimentation is essential for the production of an effective drug and treatment protocol.
Here, I present my experiences in the diagnosis and treatment of bronchial asthma in the latter one third of the 20th century.

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Glucocorticosteroids are very effective to treat inflammatory disorders. However, wide range of side effects would be seen, if patients received the drug systemically for long period. Therefore, topical steroids such as inhaler, nasal spray, ointment were developed for allergic diseases to reduce its side effect. In this review, the current insights on the mechanisms of action of steroids are discussed, especially focused on bronchial asthma.

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[in Japanese]

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[in Japanese]

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Although it is well known that childhood asthma tends to be in remission during adolescence, the mechanism for this remains unclear. Considering the features of childhood bronchial hyperresponsiveness (BHR), we discussed the relationship between BHR and the remission of asthma in adolescence. It has been reported that aging has an effect on BHR in children, and most reports suggest a decrease in BHR with aging. Thus, the decrease of BHR plays a role in remission of asthma during adolescence. However, BHR in asthmatics is significantly higher than that in normal controls, and the discrepancy between BHR and the symptoms of asthma become very noticeable during this period. Long-term follow-up studies have reported the relationship between the degree of BHR and the degree of asthma symptoms in children, and the relationship between the result of first challenge at infantile period and the result of second challenge at adolescent period. Furthermore, there is no significant difference between the individual result of first challenge and second challenge in patients with non-remission, although a small improvement is seen in patients with remission. These results suggest that the degree of BHR does not so change in individuals during childhood.
Considering the mechanism of asthma remission during adolescence, the decrease of BHR may have an effect. However, the discrepancy between BHR and asthma symptoms during this period and the persistence of the degree in BHR in individuals should be discussed further. It is important to evaluate the mechanism of asthma remission in adolescence, and further studies in this field are expected.

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Background: To identify causative allergens in patients with allergic disease, we have to evaluate overall symptoms and clinical data including in vitro and in vivo tests. Recently, a new glass microfiber histamine release test (HRT) has been clinically available.
Objectives: To evaluate usefulness and limit of HRT for determining allergen, we mainly compare the results of HRT and those of specific serum IgE (CAP-RAST^® (Pharmacia)) in allergic children.
Method: We measured HRT and CAP-RAST^® in 286 children, who were treated at our department as having bronchial asthma, atopic dermatitis or others.
Results: The positive rates of HRT and CAP-RAST^® were 22%, 52% in inhalant allergens, and 10%, 39% in food allergens, respectively. That is, the positive rate of HRT is lower than that of CAP-RAST^®, especially in egg white and mite at young age-group. This might suggest a necessity in reassessment of the level of cut off point of HRT in young-age group. Furthermore, it was demonstrated that the positive rates of HRT in food allergens were lower than those in inhalant allergens. Frequency in positive HRT was significantly higher in patients who treated with more than four kinds of drugs than those who treated with less than three kinds of drugs. Since patients who need many kinds of drugs to control their symptoms may have severe disease, the results suggest that HRT may reflect severity of allergic diseases.
Conclusion: HRT is considered to be one of useful in vitro tests to determine causative allergen. The data of HRT might predict clinical severity of allergic disorders. However, there is a limit that HRT has lower sensitivity than CAP-RAST^® has at young age-group in some allergens.

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The relationship between development of atopic dermatitis and IgE antibodies specific to egg white and cow's milk in sera of cord blood and peripheral blood of infants was studied. Fourteen out of 23 infants who had had high levels (≥0.07IU/ml) of cord blood IgE antibodies to egg white and 6 out of 28 infants who had had low levels (<0.07IU/ml) of cord blood IgE antibodies to egg white had high levels (≥0.35UA/ml) of serum IgE antibodies to egg white at 10-months of age, which is significantly different (p=0.0098). Nine out of 23 infants who had had high levels (≥0.07IU/ml) of cord blood IgE antibodies to egg white and 2 out of 28 infants who had had low levels (<0.07IU/ml) of cord blood IgE antibodies to egg white developed atopic dermatitis, which is significantly different (p=0.015). On the other hand, only one out of 23 infants who had had high levels (≥0.07IU/ml) of cord blood IgE antibodies to cow's milk had high levels (≥0.35UA/ml) of serum IgE antibodies to cow's milk at 10-months of age. No relationship was found between cord blood IgE antibodies to cow's milk and development of atopic dermatitis in early infancy. Increase in IgE specific to egg white and development of atopic dermatitis in early infancy is predictable by the existence of egg white-specific IgE antibodies in cord blood.

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Respiratory syncytial Virus (RSV) infection is the major cause of bronchiolitis in infants and also it is the most important respiratory tract pathogen of early childhood. We experienced 166 RSV positive cases, and about 10% of them, 19 cases had recurrent RSV infections. We examined the clinical features of these 19 chirdren with bronchial asthma who had recurrent RSV infections. Ashma severity score according to the criteria of the Japanese Research Group for Pediatric Allergy, worsened after recurrent RSV infections. In first RSV infection, six cases had first episode of wheeze and all of them was diagnosed as ashma after first RSV infection. RSV infection is supposed to be act as the trigger factor and also worsening factor of bronchial ashma, but on the other hand RSV infection does not seem to affect IgE production.

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We examined 339 episodes of atelectasis with acute asthma attack for recent 12 years retrospectively. Aletectasis with acute asthma occurred more frequently in girls (4.1%) than in boys (2.6%), and in age group between 4 and 6 years-old (7.2%) than in age group between 0 and 3 years-old (3.2%) and over 7years-old (2.1%), . The right middle lobe was involved in 68.8% of all episodes, left upper lobe in 13.7% (lingula in 11.5%), right upper lobe in 11.2%, respectively. Recurrent episodes were more frequenly recorded in asthmatic children (42.4%) than in whom with only acute peumonia (12.5%). Atelectasis persist for longer than 1 year in 4 episodes.
Inflammation signs tended to be lower in severe attack than in cases without asthma. It indicated that atelectasis in non-asthmatic cases were asscociated with respiratory tract infection. Duration of atelectasis with the severe attack was significantly shorter and the recurrence rate of it got higher than cases with mild attack and without asthma attack.
Furthermore, we consider that atelectasis is important when we diagnose it as “bronchial asthma”.

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