A An nt ti i--t tu ub be er rc cu ul lo os si is s m me ed di ic ca at ti io on n a an nd d t th he e l li iv ve er r: : d da an ng ge er rs s a an nd d r re ec co om mm me en nd da at ti io on ns s i in n m ma an na ag ge em me en nt t We suggest a protocol for using liver function tests to monitor for liver damage, and give recommendations on what action to take when these become abnormal.

Two deaths after sudden severe asthma attacks in young people are reported from a clinic set up to identify and manage "at risk" patients. These deaths occurred despite frequent visits at which recommendations made by previous studies were implemented. The risk factors and management of such episodes have been reviewed. Precautions taken proved inadequate due to the severe, abrupt nature of the attacks, failure of the patients' immediate treatment, and delay in reaching hospital. Consideration should be given to the self-administration of subcutaneous adrenaline or specific beta-agonists, the provision of a detailed medical card, and free access to the nearest hospital in such cases.

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Subcutaneous adrenaline and terbutaline have been compared in a double blind study of 20 patients with acute severe asthma presenting to an accident and emergency department. Ten patients received adrenaline 05 mg (0 5 ml) and 10 terbutaline 05 mg (05 ml) subcutaneously. Further treatment with nebulised salbutamol (5 mg), hydrocortisone (200 mg), and aminophylline (0-9 mg/kg/hour) was started 15 minutes later. All patients reported a reduction in chest tightness within three minutes of receiving both adrenaline and terbutaline and reported no adverse effects. Mean baseline values of peak expiratory flow (PEF) and forced expiratory volume in one second (FEV1) did not differ significantly between the adrenaline group (130 1 min-' and 0-83 1) and the terbutaline group (111I min-' and 0 63 1). After administration of adrenaline PEF had increased by 21% and FEV, by 40% five minutes after the injection, and by 35% and 64% at 15 minutes. Terbutaline caused a 23% increase in PEF and a 37% increase in FEV, at five minutes, and a 40% and 58% increase at 15 minutes. There was no significant difference in PEF, FEV,, heart rate, blood pressure, or pulsus paradoxus between the two groups at any time. Continuous electrocardiographic recording showed no abnormalities in either group. Thus in this study subcutaneous adrenaline (0 5 mg) and terbutaline (0 5 mg) produced effective rapid bronchodilatation without serious side effects.About 1500 patients continue to die from asthma each year in England and Wales,' despite self referral to hospital and intensive conventional treatment. Many factors are responsible for this, but one major problem is that severe attacks may start abruptly, often late at night or in the early morning.2"5 Our study was stimulated by the death of two young asthmatic women6 who were known to be "at risk" and for whom we had taken every precaution. Both had had abrupt attacks of asthma, developing within minutes and not responding to pressurised aerosol bronchodilators. Both died despite urgent hospital admission.There are few reports267 supporting the use of self administration of parenteral adrenaline or selective 2 adrenergic drugs in acute asthmatic attacks. Adrenaline appears to have lost favour8 because of the fear of adverse effects such as tachycardia, ventricular ectopic beats, hypertension, pulmonary oedema, tremor, sweating, and headaches, and even death." A closer look at these reports shows that most do not cite the original papers and most of the adverse effects quoted stem from early observations of adrenaline in status

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