Implementation of COPD Case Finding and Self-Management Action Plans in Low and Middle Income Countries

点击翻译按钮获取中文摘要

Chronic Obstructive Pulmonary Disease (COPD) is a long-term lung disease resulting when a susceptible individual is exposed to sufficient environmental stimulus (typically cigarette smoke, and/or biomass fuel smoke). More than 90% of COPD-related deaths occur in LMICs, and over the next 15 years COPD is expected to be the leading cause of death globally. LMICs face unique challenges in managing COPD including deficient primary care systems which present challenges with diagnosis and management, especially at the time of exacerbation. Formal diagnosis requires specialised testing with a breathing test (spirometry), which is often limited to urban health centres, while the vast burden of people affected with COPD may live in rural areas. Similarly, treatment options for COPD remain limited where lack of diagnostic testing delays diagnoses and health providers are inexperienced with treating COPD and COPD exacerbations. For the benefit of global health, a revolution in the diagnosis and management of COPD in LMIC is an urgent priority.In response to the challenges of diagnosing COPD and a renewed global effort to confront tuberculosis, the WHO developed the Practical Approach to Lung Health (PAL). While efforts have been made to improve the diagnosis and differentiation of respiratory illnesses in LMICs, effective community screening with subsequent management strategies have not been successful. Thus, despite these efforts, chronic management of COPD remains limited among LMICs. A key aim of COPD management is to prevent exacerbations. For future efforts to be successful, they need to be combined with robust case finding mechanisms (to better target scarce spirometry resources) as well as effective treatment strategies which are simple and easily applied in resource-limited community health-care settings.Community-based case finding and self-management are usual care for patients with COPD in developed settings. While a number of COPD pre-screening questionnaires have been developed, many of these are too cumbersome in the number and type of questions assessed to be successfully implemented in LMIC, and they have been developed for tobacco-associated (not biomass) COPD. Simple questionnaires, with a limited number of items, have recently proved successful among populations in the United States. The Lung Function Questionnaire, which assesses five items (age, smoking history, wheeze, dyspnoea and phlegm) has a high predictive value for diagnosing COPD when applied in a US based sample. We plan to assess implementation of a modified, locally relevant Lung Function Questionnaire in three LMICs. Efforts to simplify COPD management have similarly shown success. Action Plans support people with known COPD to recognise and react appropriately to an exacerbation of their symptoms by making changes to their medication including starting courses of antibiotics or steroids with additional salbutamol. COPD Action Plans for self-management currently implemented in both Europe and the US have been shown to decrease the impact of exacerbations on quality of life, increase appropriate use of treatments and hasten recovery time. Action Plans empower people living with COPD to better manage their own lungs, in collaboration with local health-care practitioners. We plan to assess the implementation of case finding with modified Action Plans for COPD management in three LMIC.Thus, this study aims to modify and assess the usefulness of a currently utilised COPD case finding questionnaire and COPD Action Plans to allow for simple, low-cost models of care which can be generalised across LMICs. We intend to study patients with COPD in Peru, Nepal and Uganda, thereby allowing for inclusion of three distinct middle income and low-income regions. We believe the study will lead to validated and cost-effective diagnosis and treatment packages which can be implemented by national ministries of health and non-governmental organisations globally.