Asthma Emergency Room Research Articles

Ozone: A trigger for hospital pediatric asthma emergency room visits

A time-series study was carried out in Paris from January 1 to December 31, 1988 with the aim of investigating the association between urban air pollution and daily emergency room visits for asthma in a pediatric hospital. Levels of black smoke, sulfur dioxide, nitrogen dioxide, and ozone were monitored throughout the study area, and meteorological data were collected. Influenza epidemics and pollen periods were identified. Health data were collected from a pediatric hospital emergency room. Case definition of asthma attacks was based on clinical diagnosis. Children were included in the study if: 1) they were 1 to 15 years old; 2) they had doctor-diagnosed asthma and were followed in our asthma outpatient clinic; and 3) they were residents in the Paris region. The relation between daily asthma visit counts and air pollution levels was assessed, using a multiple linear regression model and taking into account temporal variations and autocorrelation in the data. A thousand and twenty visits for asthma were observed during the study period. A positive statistical association was found between daily asthma visits and daily variations of ozone levels (1 day after exposure, relative risk = 1.52 [95% confidence interval: 1. 06-2.19]) after controlling for monthly and weekly variations, influenza epidemics, periods of pollen exposure, and daily mean temperature (2 days' lag). This study underlines the significant role of ozone as a trigger for asthma attacks in children.

960 Cockroach hypersensibility in the pediatric emergency room asthma in a city of the Carribean Colombian area

960 Cockroach hypersensibility in the pediatric emergency room asthma in a city of the Carribean Colombian area

Differences in mortality between patients attending the emergency room services for asthma and chronic obstructive pulmonary disease

Asthma has a more favourable prognosis than chronic obstructive pulmonary disease (COPD), based on studies including few asthmatics and few women with COPD. We assessed differences in mortality between people attending the emergency room for asthma and for COPD in a population-based cohort. We recruited all the men and women, who were residents of Barcelona (Spain) over 14 years of age, who attended emergency room services for an obstructive lung disease during the period 1985–1989. Vital status was followed up to the end of 1995. A total of 15 517 individuals (including 4555 asthmatics and 2194 females with COPD) were studied. Mortality was ascertained using a record linkage with the regional Mortality Registry. Overall, 43·6% people died during the follow-up period. Mortality was higher among individuals with COPD than with asthma, in males and females, for all causes of death, as well as for cancer, cardiovascular and respiratory causes. After adjusting for age, the relative risk (RR) of dying of a male attending for COPD and discharged home was 1·50 (1·29-1·74) in comparison with a male attending for asthma, and 3·06 (2·66-3·51) for a male attending for COPD and admitted into the hospital. Similar figures were found for females. The increased risk for patients with COPD was significantly higher than for asthma in all age groups. Both males and females with asthma have a more favourable prognosis than patients with COPD, for all age groups.

Evaluation of an educational programme for socially deprived asthma patients

The aim of this study was to evaluate the effectiveness of an asthma education programme in moderate and severe asthma patients in a longitudinal, prospective and randomized study with a control group. Fifty-three asthmatic patients were studied, 26 of whom were assigned to the educational group and 27 to the control group. The educational group attended the programme regularly for a period of 6 months. The programme included information about asthma, instruction on the appropriate use of medication and training in the metered dose inhaler (MDI) technique, and information about the identification and control of asthma attacks and the recognition of early signs of exacerbation. The control group was submitted to the routine care provided at the Asthma Clinic, with no formal instruction regarding asthma control. The groups were identical with regard to severity parameters, skills, lung function and quality of life at the beginning of the trial. At the end of the study, the education group showed significant differences when compared with the control group (education/control (mean values)) with respect to: visits to the asthma emergency room over the previous 6 months, 0.7/2 (p=0.03); nocturnal symptoms, 0.3/0.7 (p=0.04); score of symptoms, 1.3/2 (p=0.04). Improvements were also observed in skills and quality of life, knowledge of how to deal with attacks and how to control the environmental triggering factors, 73/35 (<0.05); correct use of the MDI, 8/4 (0.001); understanding of the difference between relief and anti-inflammatory medication, 86/20 (<0.05); and in the global limitation quality of life score, 28/50 (0.02). It is concluded that the educational programme led to a significant improvement in asthma morbidity and that the implantation of educational programmes is possible for special populations when these programmes are adapted to the socioeconomic profile of the patients, with a significant gain in terms of the reduction of symptoms and improved pulmonary function and quality of life of asthmatics.

How the Discrepancy between Symptoms and Peak Expiratory Flow Rate Influences Evaluation of Asthma Severity

Recent asthma guidelines recommend the assessment of severity levels based on the most severe symptoms and peak expiratory flow rate (PEFR). Discrepancies are frequently encountered in the use of these variables in determining the severity levels of asthmatics. The objective of this study was to determine the difference in asthma severity levels as assessed by either symptoms alone or by PEFR alone, as compared with the assessment by the asthma guidelines. Severity levels that were determined by recent asthma guidelines for 60 asthmatic patients were reassessed, based on symptoms alone and PEFR alone. They were compared for any significant differences to the asthma guidelines. Asthmatics were aged between 15 and 70 (mean 34) years, and 63.8% were females. Severity levels by symptoms alone were different from the guidelines in 27 cases (45%). Of these, 89% showed a tendency toward higher severity levels. Severity levels by PEFR alone were different in only three cases (5%). In both comparisons, differences of severity levels were significant (P<0.0001), but assessment by symptoms alone showed more deviation (x(2) =162.1) than PEFR alone (x(2) =73.1). The study documented significant discrepancies in asthma severity assessed by symptoms alone and PEFR alone, when compared to the recent asthma guidelines. Severity assessed by symptoms alone showed lower levels, and the use of PEFR tended to categorize some asthmatics into a more severe level.

Asthma visits to emergency rooms and soybean unloading in the harbors of Valencia and A Coruña, Spain.

Soybean unloading in the harbor of Barcelona, Spain, has been associated with large increases in the numbers of asthma patients treated in emergency departments between 1981 and 1987. In this study, the association between asthma and soybean unloading in two other Spanish cities, Valencia and A Coruña, was assessed. Asthma admissions were retrospectively identified for the period 1993-1995, and harbor activities were investigated in each location. Two approaches were used to assess the association between asthma and soybean unloading: One used unusual asthma days (days with an unusually high number of emergency room asthma visits) as an effect measure, and the other estimated the relative increase in the daily number of emergency room visits by autoregressive Poisson regression, adjusted for meteorologic variables, seasonality, and influenza incidence. No association between unusual asthma days and soya unloading was observed in either Valencia or A Coruña, except for one particular dock in Valencia. When the association between unloaded products and the daily number of emergency asthma visits was studied, a statistically significant association was observed for unloading of soya husk (relative risk = 1.50, 95% confidence interval 1.16-1.94) and soybeans (relative risk = 1.31, 95% confidence interval 1.08-1.59) in A Coruña. In Valencia, a statistical association was found only for the unloading of soybeans at two particular docks. Although these findings support the notion that asthma outbreaks are not a common hidden condition in most harbors where soybeans are unloaded, the weak associations reported are likely to be causal. Therefore, appropriate control measures should be implemented to avoid soybean dust emissions, particularly in harbors with populations living in the vicinity.

Modelling asthma epidemics on the relationship between air pollution and asthma emergency visits in Barcelona, Spain.

We have investigated different methods of controlling for asthma epidemics in the time series regression of the relationship between air pollution and asthma emergency visits in Barcelona, Spain. The relationship between air pollution and asthma emergency room visits was modelled using autoregressive Poisson models. We examined the effect of using no control by epidemics, and modelling asthma epidemics with a single dummy variable, six dummy variables, and a dummy variable for each epidemic day. Air pollution coefficients increased when controlling asthma epidemics with six dummy variables instead of a single variable. They further increased when autocorrelation was allowed for. Standard errors were relatively unaffected when either the epidemics or the autocorrelation were included in the model. Black smoke, nitrogen dioxide and ozone were statistically significant associated to asthma emergency visits after using six dummy variables to control for asthma epidemics. We have shown that different models, including different confounding variables, give markedly different estimates of the effect of a pollutant on health. Care is needed in the interpretation of such models, and careful reporting so it is clear how the confounding variables have been modelled.

Air Pollution and Emergency Room Visits for Asthma in Santa Clara County, California

During the winters of 1986-1987 through 1991-1992, rainfall throughout much of Northern California was subnormal, resulting in intermittent accumulation of air pollution, much of which was attributable to residential wood combustion (RWC). This investigation examined whether there was a relationship between ambient air pollution in Santa Clara County, California and emergency room visits for asthma during the winters of 1988-1989 through 1991-1992. Emergency room (ER) records from three acute-care hospitals were abstracted to compile daily visits for asthma and a control diagnosis (gastroenteritis) for 3-month periods during each winter. Air monitoring data included daily coefficient of haze (COH) and every-other-day particulate matter with aerodynamic diameter equal to or less than 10 microns (PM10, 24-hr average), as well as hourly nitrogen dioxide and ozone concentrations. Daily COH measurements were used to predict values for missing days of PM10 to develop a complete PM10 time series. Daily data were also obtained for temperature, precipitation, and relative humidity. In time-series analyses using Poisson regression, consistent relationships were found between ER visits for asthma and PM10. Same-day nitrogen dioxide concentrations were also associated with asthma ER visits, while ozone was not. Because there was a significant interaction between PM10 and minimum temperature in this data set, estimates of relative risks (RRs) for PM10-associated asthma ER visits were temperature-dependent. A 60 micrograms/m3 change in PM10 (2-day lag) corresponded to RRs of 1.43 (95% CI = 1.18-1.69) at 20 degrees F, representing the low end of the temperature distribution, 1.27 (95% CI = 1.13-1.42) at 30 degrees F, and 1.11 (95% CI = 1.03-1.19) at 41 degrees F, the mean of the observed minimum temperature. ER visits for gastroenteritis were not significantly associated with any pollutant variable. Several sensitivity analyses, including the use of robust regressions and of nonparametric methods for fitting time trends and temperature effects in the data, supported these findings. These results demonstrate an association between ambient wintertime PM10 and exacerbations of asthma in an area where one of the principal sources of PM10 is RWC.

AIR POLLUTION AND ASTHMA EMERGENCY ROOM VISITS IN RENO, NEVADA

The association between air pollution and the daily number of emergency room (ER) visits for asthma was assessed in Reno, Nevada, for the period 1992-1994. All three hospitals in the region were included. There was a total of 1593 ER visits for asthma during this period of time. The air pollution variables were collected from seven monitoring stations, including particulate matter (PM-10), ozone (O3), and carbon monoxide (CO). Levels of pollution were moderately elevated (the average concentrations of PM-10, CO, and O3 3 were 38.0 g/m, 4.55 ppm, and 51.0 ppb, respectively). Weighted least-squares (WLS) regression and autoregressive integrated moving average (ARIMA) time-series analyses were applied and compared. After adjusting for such factors as day of the week, seasonal variation, and weather, both modeling methods showed that the daily 1-h maximum O3 concentration was a significant predictor of asthma ER visits, although ARIMA increased the magnitude of the estimated response after controlling the autocorrelated errors. Total asthma visits were found to increase 33.7% (95% CI; range 6.0-61.5%) for each 100 ppb increase in the O3 level. No association of the concentration of other measured pollutants with daily asthma ER visits was found. The results provide evidence that O3 pollution concentrations even below the federal standard may have an adverse effect on the respiratory health of susceptible persons. Further research will be conducted, examining the effects of ambient air pollution concentrations on other respiratory diseases in Reno.

Preventing asthma epidemics due to soybeans by dust-control measures.

The inhalation of soybean dust released during the unloading of soybeans into a silo caused outbreaks of asthma in Barcelona, Spain. This study was designed to determine morbidity due to asthma and serum IgE reactivity before and after the installation of filters in the silo. We measured soybean-allergen concentrations in 136 samples of air collected for 9 months before and 24 months after the installation of filters. We compared the number of days on which there was an unexpected increase in emergency room visits for asthma, the number of days on which the number of emergency room visits for asthma in one four-hour period was so high that it was unlikely to be due to chance, and the mean daily number of emergency room and intensive care unit admissions for asthma for a total of 60 months before and after filter installation. Serum IgE antibodies against soybean allergens were measured in 38 patients before and after filter installation. The concentration of airborne soybean allergens on days when soybeans were unloaded decreased from 324 to 25 U per cubic meter after the installation of filters (P < 0.001). The number of days on which there was an unusually large number of visits to the hospital for asthma and the number of days on which asthma was epidemic both decreased significantly (both P < 0.001), from 29 to 6 and from 18 to 0, respectively. The mean daily number of emergency room and intensive care unit admissions for asthma on days when soybeans were unloaded decreased from 8.3 to 5.4 and from 0.26 to 0.01, respectively (both P < 0.001). The mean serum IgE antibody concentrations in the 38 patients studied decreased from 2 Pharmacia reference units per milliliter to 1 (P < 0.001). Installing filters on silos to prevent airborne dissemination of allergenic soybean dust eliminates outbreaks of asthma caused by inhalation of the dust, thus supporting the idea that the avoidance of allergens helps prevent asthma.

Reliability of a Monitoring System for Respiratory Emergency Room Admissions

A respiratory emergency room admissions monitoring system (RERAMS) was set up in Barcelona between 1985–1989, in order to investigate asthma epidemics in the city. Information on emergency room admissions for asthma and chronic obstructive pulmonary disease (COPD) was recorded daily from the four main hospitals of the city. The present study aims at assessing the reliability and coverage of this monitoring system. Identification of asthma and COPD emergencies was repeated by a reference observer, following the same protocol to extract data as that used by the register. To assess the coverage of the monitoring system, information was collected over 28 randomly selected days, from the emergency room clinical records for the seven additional hospitals in the city with five or more daily emergencies. Identification of asthma emergencies was highly reliable (kappa value, k = 0.81) as was the discrimination between asthma and COPD diagnoses (k = 0.91). Reliability for emergencies classified as COPD was lower, but still good (k = 0.65). The monitoring system covered 76 and 78% of all Barcelona asthma and COPD emergency room admissions, respectively. Emergency room admissions from our monitoring system did not differ in terms of social and demographic characteristics from emergencies recorded at the other hospitals. We conclude that the monitoring system for the Barcelona respiratory emergency room admissions was highly reliable, which suggests that, when adequately collected, information from clinical records of respiratory emergencies could be used for environmental epidemiological purposes.

Particulate Air Pollution and Hospital Emergency Room Visits for Asthma in Seattle

Recent studies have associated short-term exposure to respirable particulate matter (PM10) exposure with peak flow decrements, increased symptoms of respiratory irritation, increased use of asthma medications, and increased hospitalization for asthma. Increased mortality from chronic respiratory disease has also been reported. To help confirm whether PM10 exposure is a risk factor for the exacerbation of asthma, we compiled daily records of asthma emergency room visits from eight hospitals in the Seattle area. In Poisson regressions controlling for weather, season, time trends, age, hospital, and day of the week, the daily counts of emergency room visits for persons under age 65 were significantly associated with PM10 exposure on the previous day. The mean of the previous 4 days' PM10 was a better predictor (p < 0.005). The relative risk for a 30 micrograms/m3 increase in PM10 was 1.12 (95% confidence interval 1.20 to 1.04). Daily PM10 concentrations never exceeded 70% of the current ambient air quality standards during the period. The consistency of investigations of the health effects of PM10 suggest that increased attention should be given to the control of particulate matter air pollution.

Reliability of a monitoring system for respiratory emergency room admissions

A respiratory emergency room admissions monitoring system (RERAMS) was set up in Barcelona between 1985-1989, in order to investigate asthma epidemics in the city. Information on emergency room admissions for asthma and chronic obstructive pulmonary disease (COPD) was recorded daily from the four main hospitals of the city. The present study aims at assessing the reliability and coverage of this monitoring system. Identification of asthma and COPD emergencies was repeated by a reference observer, following the same protocol to extract data as that used by the register. To assess the coverage of the monitoring system, information was collected over 28 randomly selected days, from the emergency room clinical records for the seven additional hospitals in the city with five or more daily emergencies. Identification of asthma emergencies was highly reliable (kappa value, kappa = 0.81) as was the discrimination between asthma and COPD diagnoses (kappa = 0.91). Reliability for emergencies classified as COPD was lower, but still good (kappa = 0.65). The monitoring system covered 76 and 78% of all Barcelona asthma and COPD emergency room admissions, respectively. Emergency room admissions from our monitoring system did not differ in terms of social and demographic characteristics from emergencies recorded at the other hospitals. We conclude that the monitoring system for the Barcelona respiratory emergency room admissions was highly reliable, which suggests that, when adequately collected, information from clinical records of respiratory emergencies could be used for environmental epidemiological purposes.

Relation of measures of asthma severity and response to treatment to outcome in acute severe asthma.

It would be helpful if patients with asthma who require admission to hospital for an acute attack could be identified. The relation between the severity of an attack of asthma as determined by admission assessment and the eventual outcome was studied in 52 asthmatic patients aged 14 to 44 years and admitted to an asthma emergency room. The patient's history, including medication and previous admissions to hospital, was recorded and a clinical assessment, including a full inspiratory and expiratory flow-volume loop, was performed on four occasions: on admission, at two hours and at 12-18 hours after the start of a standardised treatment, and two weeks later on an outpatient basis. Patients who were discharged and who had an uneventful follow up at the two week assessment were defined as good responders. Patients who had to be admitted to hospital after 12 to 18 hours or were readmitted during the two weeks, or both, were defined as poor responders. Thirty eight patients were good responders and 14 were poor responders (seven admitted at 12 to 18 hours, seven returned to hospital). All four patients with a raised arterial carbon dioxide tension (PaCO2) (> or = 6 kPa) and the three with cyanosis were in the poor responder group, and this group had lower peak expiratory flow (PEF) values (21% v 30% predicted) on admission. There was, however, considerable overlap in PEF between the two groups and no clinical measure was able to distinguish between the good and the poor responders reliably. Poor responders had a history of more chronic systemic steroid administration, regular use of inhaled beta agonists, and asthma related hospital admissions. Nearly all the subjects showing a good response to standardised treatment had a PEF > 75% predicted and an FEV1 > 65% predicted 12 to 18 hours after the start of treatment. Prediction of outcome at admission was not possible in individual patients. A history of poor long term control of asthma, a PEF < 30% of predicted, a PaCO2 > or = 6 kPa, the presence of cyanosis, and lack of early response to treatment indicated a group of asthmatic patients who are less likely to respond to conventional emergency treatment over a short period.

Facilitated referral to asthma specialist reduces relapses in asthma emergency room visits

Facilitated asthma-specialist care delivered by allergists was compared to generalist care on the rate of relapse of asthma emergency room (ER) visits and hospitalizations and on asthma control in a prospective, controlled study of San Diego Kaiser Health Plan members with asthma. Subjects with asthma between the ages of 6 and 59 years presenting for acute ER care for asthma were systematically assigned by alternating, consecutively, the day of their ER visit to receive either (1) facilitated referral to an asthma specialist within the allergy department and concomitant comprehensive ongoing asthma care (intervention group, n = 149) or (2) continued outpatient management from generalist physicians (control group, n = 160). The course of their asthma was evaluated blindly during the subsequent 6 months by review of medical records, initial and follow-up questionnaires, and spirometry. Compared to the control group, the intervention group noted (1) a 75% reduction in the number of, and percent of, subjects with asthma awakenings per night ( p ≤ 0.0001), (2) an almost 50% reduction in asthma ER relapses ( p = 0.017) resulting from a reduction in the frequency of multiple relapses ( p = 0.005), and (3) a greater use of inhaled corticosteroids ( p < 0.00001) and cromolyn ( p = 0.002). Thus, facilitated referral of subjects with asthma to specialists in asthma therapy after acute ER therapy appears to reduce asthma ER relapses and to improve asthma outcome.

378 Asthma emergency room relapse: Risk factors and effect of facilitated allergist referral

378 Asthma emergency room relapse: Risk factors and effect of facilitated allergist referral

The effect of a patient education program on emergency room use for inner-city children with asthma.

An educational program for children with asthma designed to reduce emergency room (ER) use enrolled all eligible children (n = 253 primarily low-income Black) within a health maintenance organization (HMO) who had used the hospital or ER for asthma during the pre-enrollment period and randomized them into two groups. Twenty-four of the experimental group patients had 55 ER visits and 18 of the control patients had 39 ER visits during the first 12 months post-intervention. This program did not achieve its goal.

Epidemiology of emergency room asthma in northern California: Association with IgE antibody to ryegrass pollen

To examine the relationship between allergy and acute attacks of asthma, we have examined adult patients with acute asthma presenting during a defined pollen season. Sera from 59 patients presenting with acute asthma to the David Grant Medical Center emergency room at Travis Air Force Base during the spring “epidemic” of asthma were assayed for IgE antibody (Ab) to five allergens (mite, cat, cockroach, ryegrass pollen, and ragweed) with RAST. Control sera were obtained from 34 patients without asthma and 25 employees. The results demonstrate that 92% of the patients with asthma had >200 units of IgE Ab to ryegrass pollen (~20 ng of IgE Ab per milliliter) compared to 14% of the control subjects (x 2 = 69; p < 0.0001; odds ratio = 69). Some of the grass pollen-allergic patients also had increased levels of IgE Ab to ragweed, but only 25% had >200 units. In contrast, there was no significant difference between subjects with asthma and control subjects in the prevalence of IgE Ab to the three indoor allergens (mite, cockroach, and cat). Twelve percent of the patients with asthma compared to 5% of the control subjects had >200 units of IgE Ab to one of these three (x 2 = 0.98; p > 0.1; odds ratio = 2.5). Dust samples from the homes of 15 of the patients with asthma demonstrated very high levels of grass pollen ( 13 15 houses with >10 μg of allergen per gram of dust), low levels of mite ( 13 15 homes with <2 μg of allergen per gram of dust), and no detectable cockroach allergen. These results demonstrate that the development of IgE Ab to an inhalant allergen (i.e., grass pollen) increased the patients' odds of developing acute asthma during a period of increased exposure.

ROLE OF ROUTINE CHEST ROENTEGENOGRAM IN CLINICAL EVALUATION OF ACUTE ASTHMA IN CHILDREN

We prospectively studied the role of routine chest roentgenogram(CXR) in the clinical assessment of the child presenting to the emergency room(ER) for acute asthma and it's effect on the decision to start antibiotic therapy(AT). One hundred seventy seven(177) consecutive acute asthma patients (age 3-14 years) evaluated in our ER were included. History, physical examination, CBC, urinalysis, and peak expiratory flow rate were first obtained. Based on these findings the pediatric house officer in the ER made a clinical diagnosis and a decision concerning AT use. The CXR was evaluated and result recorded. This was followed by revaluation of AT. CXR was read as positive in 23 patients by ER physician (17 pneumonia, 5 atelectasis, 1 mucus plug). CXRs were subsequently examined independently by 2 pediatric radiologists. They confirmed 5 pneumonias, 3 atelectasis. They also found 4 additional pneumonia in CXR's read as negative by the housestaff. Prior to CXR, ER physicians planned to start AT in 4 patients because of clinical pneumonia but after CXR, 8 additional patients were given AT because of CXR findings (7 pneumonia, 1 atelectasis) and 1 patient with clinical pneumonia was not given AT because of negative CXR. In conclusion, 8/12 (67%) of abnormal CXR confirmed by radiologists, (5 pneumonia, 3 atelectasis) were correctly interpreted in ER. CXR was often misinterpreted and led to overtreatment with AT in ER setting.

Seasonal asthma in northern California: Allergic causes and efficacy of immunotherapy

Inland areas of northern California have an intense grass pollination in the spring of each year. This is accompanied by a stirking rise in the incidence of asthma. We documented this relationship and designed a trial to test the efficacy of immunotherapy for grass-pollen asthma. Aeroallergen counts were performed on the roof of the allergy clinic of David Grant Medical Center from January 1981 to December 1984 by a gravity collector. These counts were compared to counts done on a Rotorod at a nearby hospital from July 1982 to September 1984. Climatologic factors were also tabulated. Visits for asthma and rhinitis to our emergency room and asthma admissions to our hospital were counted for the 4-year period. A randomized, double-blinded, placebo-controlled trial of immunotherapy with grass-pollen extract was performed from November 1984 to June 1985. Two groups of clinically and immunologically well-matched subjects were started on an accelerated preseasonal trial of immunotherapy. One group received a standardized grass extract, and the other group did not. Both groups received other extracts of aeroallergens to which they were skin test positive that occur locally in the spring and summer. This was done because of our dissatisfaction with a histamine placebo used in a previous pilot study. Symptom medication scores (SMS) and immunologic parameters were followed. For the 4-year period, grass-pollen count (GPC) correlated strongly with asthma emergency room visits (r = 0.90; p < 0.001) and for rhinitis (r = 0.92; p < 0.001). Asthma admissions also correlated strongly with GPC (r = 0.72; p < 0.001). Other aeroallergens either did not correlate significantly or occurred in such small numbers that they could not be seriously considered. Rotorod counts supported these conclusions with the exceptions of some Basidiomycetes. Climatologic factors demonstrated no relationship to the incidence of asthma. Asthma SMS were lower in the grass-treated group, p < 0.05. Rhinitis SMS were also lower but did not reach significance, p = 0.11. RGGI sIgE did not rise significantly in the grass-treated group but did in the placebo-treated group. RGGI sIgG rose in both groups, although to significantly higher levels in the grass-treated group, p < 0.001. The asthma SMS were inversely related to increasing RGGI cumulative dose, p < 0.10. Linear regression analysis of the dose-response scattergram suggests that a cumulative dose of approximately 90 μg of RGGI may be desirable. At the end of the study, eight of nine of the grass-treated and seven of nine of the placebo-treated subjects believed they were treated with grass extract. In summary, we have presented evidence that grass pollen causes a significant yearly outbreak of allergic asthma in northern California. We have also presented evidence that this asthma can be effectively treated with immunotherapy with a standardized, potent grass-pollen extract in carefully selected patients.