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)是一种长期的肺部疾病，当易感个体暴露在足够的环境刺激(通常是香烟烟雾和/或生物质燃料烟雾)中时，就会导致这种疾病。超过90%的COPD相关死亡发生在LMICs中，预计在未来15年内，COPD将成为全球主要的死亡原因。LMICs在管理COPD方面面临着独特的挑战，包括初级保健系统的缺陷，这给诊断和管理带来了挑战，特别是在病情恶化的时候。正式诊断需要通过呼吸测试(肺活量测定)进行专门测试，这通常仅限于城市卫生中心，而受COPD影响的人的巨大负担可能生活在农村地区。同样，COPD的治疗选择仍然有限，因为缺乏诊断检测延迟诊断，而且卫生保健提供者在治疗COPD和COPD恶化方面缺乏经验。为了全球健康的利益，在LMIC中对COPD的诊断和管理进行一场革命是当务之急。为了应对诊断COPD的挑战和全球抗击结核病的新努力，世界卫生组织开发了实用的肺健康方法(PAL)。虽然已经努力改善低收入人群中呼吸系统疾病的诊断和鉴别，但有效的社区筛查和随后的管理策略并不成功。因此，尽管做出了这些努力，慢性阻塞性肺病的慢性治疗在LMICs中仍然有限。慢性阻塞性肺疾病管理的一个关键目标是防止病情恶化。为了未来的努力取得成功，它们需要与强大的病例发现机制相结合(以更好地针对稀缺的肺活量测量资源)以及有效的治疗策略，这些策略简单且容易应用于资源有限的社区卫生保健环境。社区病例发现和自我管理是发达环境中慢性阻塞性肺病患者的常见护理。虽然已经开发了一些慢性阻塞性肺病预筛查问卷，但其中许多在评估的问题数量和类型上过于繁琐，无法在LMIC中成功实施，而且它们是为与烟草相关的(而不是生物质)慢性阻塞性肺病开发的。简单的问卷，项目数量有限，最近在美国民众中被证明是成功的。肺功能问卷评估了五个项目(年龄、吸烟史、喘息、呼吸困难和痰)，在美国样本中应用时，对诊断COPD具有很高的预测价值。我们计划评估修改后的、与当地相关的肺功能问卷在三个LMIC中的实施情况。简化慢性阻塞性肺病管理的努力也同样取得了成功。行动计划支持已知的COPD患者通过改变药物治疗来识别其症状的恶化并做出适当的反应，包括开始使用额外的沙丁胺醇进行抗生素或类固醇疗程。目前在欧洲和美国实施的慢性阻塞性肺疾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，增加适当的治疗使用，并加快康复时间。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者合作，更好地管理自己的肺部。我们计划评估三个LMIC中COPD管理的病例发现和修订行动计划的实施情况。因此，这项研究旨在修改和评估目前使用的COPD病例发现问卷和COPD行动计划的有用性，以允许在LMIC中推广简单、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，从而将三个不同的中等收入和低收入地区包括在内。我们相信，这项研究将产生经过验证的、具有成本效益的一揽子诊断和治疗方案，这些方案可以由各国卫生部和全球非政府组织实施。

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.