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

慢性阻塞性肺疾病（COPD）是易感个体暴露于足够的环境刺激（通常是香烟烟雾和/或生物质燃料烟雾）时产生的一种长期肺部疾病。90%以上的COPD相关死亡发生在中低收入国家，预计在未来15年，COPD将成为全球主要死亡原因。中低收入国家在管理慢性阻塞性肺病方面面临着独特的挑战，包括缺乏初级保健系统，这给诊断和管理带来了挑战，特别是在病情加重时。正式诊断需要进行呼吸试验（肺活量测定法）的专门检测，这种检测通常仅限于城市卫生中心，而慢性阻塞性肺病患者的巨大负担可能生活在农村地区。同样，慢性阻塞性肺病的治疗选择仍然有限，因为缺乏诊断测试延误了诊断，卫生服务提供者在治疗慢性阻塞性肺病和慢性阻塞性肺病加重方面缺乏经验。为了全球健康的利益，在低收入和中等收入国家COPD的诊断和管理方面进行革命是一项紧迫的优先事项。为了应对诊断慢性阻塞性肺病的挑战和全球抗击结核病的新努力，世卫组织制定了《肺部健康实用方法》（PAL）。虽然为改善中低收入国家呼吸道疾病的诊断和鉴别作出了努力，但有效的社区筛查和随后的管理战略尚未取得成功。因此，尽管做出了这些努力，中低收入国家对慢性阻塞性肺病的慢性管理仍然有限。慢性阻塞性肺病管理的一个关键目标是防止病情恶化。为了使今后的努力取得成功，它们需要与强有力的病例发现机制（以更好地针对稀缺的肺活量测定资源）以及简单且易于在资源有限的社区卫生保健环境中应用的有效治疗战略相结合。在发达国家，以社区为基础的病例发现和自我管理是COPD患者的常规护理。虽然已经开发了许多COPD预筛查问卷，但其中许多问卷在评估问题的数量和类型上过于繁琐，无法在低收入和中等收入国家中成功实施，而且它们是为烟草相关（非生物质）COPD开发的。简单的问卷调查，项目数量有限，最近在美国人群中被证明是成功的。肺功能问卷评估了5个项目（年龄、吸烟史、喘息、呼吸困难和痰），在美国的样本中对诊断COPD具有很高的预测价值。我们计划在三个中低收入国家评估修改后的本地相关肺功能问卷的实施情况。简化COPD管理的努力也同样取得了成功。行动计划支持已知患有慢性阻塞性肺病的人通过改变药物治疗，包括开始抗生素或类固醇疗程并额外使用沙丁胺醇，来识别并适当应对其症状恶化。目前在欧洲和美国实施的慢性阻塞性肺病自我管理行动计划已被证明可以减少病情恶化对生活质量的影响，增加适当使用治疗并加快恢复时间。行动计划使慢性阻塞性肺病患者能够与当地卫生保健从业人员合作，更好地管理自己的肺部。我们计划在三个低收入国家中评估经修改的慢阻肺管理行动计划的病例发现实施情况。因此，本研究旨在修改和评估目前使用的COPD病例调查问卷和COPD行动计划的有用性，以允许在中低收入国家推广的简单，低成本的护理模式。我们打算研究秘鲁、尼泊尔和乌干达的COPD患者，从而纳入三个不同的中等收入和低收入地区。我们相信，这项研究将产生有效的、具有成本效益的诊断和治疗方案，可由全球各国卫生部和非政府组织实施。

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.