Professional Documents
Culture Documents
March 2014
March 2014
First word
Respiratory diseases have been reported to cause immense health burdens worldwide; each
year about 4 million people die prematurely from chronic respiratory diseases.
In recent decades, modern medicine has advanced the length and quality of life in most
health and the effort needed to care for the ill and dying affects national productivity. Poor
health along with lack of education and lack of an enabling political structure are the major
impediments to a countrys development.
In the past, focus has been on communicable diseases with a thrust on tuberculosis. However, there has been an increasing awareness on the importance of the non-communicable
The incidence of lung cancer has been on the increase and the aetiology may differ between
the developing and the more developed countries. However, the role of occupational lung
diseases cannot be overemphasised. The increasing use of biomass fuel and smoking also
has a tremendous role to play.
Co-Editors
Dr Evans Amukoye,
KEMRI, Centre for Respiratory Disease
Research, Nairobi
Email: amukoye@gmail.com
and
Prof. Gregory Erhabor,
Consultant Chest Physician, OAU
Teaching Hospital, Ile-Ife, Nigeria
Email: gregerhabor7@yahoo.com
Consulting Editor
Prof Stephen Gordon
Head, Department of Clinical Sciences
Professor of Respiratory Medicine,
Liverpool School of Tropical Medicine, UK
Email: sbgordon@liverpool.ac.uk
Editorial Board
Tuberculosis
Dr Jeremiah Chakaya, Kenya
Prof Keertan Dedha, South Africa
Contents
,,
2 News/Notes
4 Report
Respiratory diseases in the world. Realities of today opportunities for tomorrow
The Forum of International Respiratory Societies
14 Review Article
Advances in the treatment of severe asthma
F Gandia and S Rouatbi
18 Review Article
Pneumonia
Prof Stephen Gordon, UK
Paediatrics
Prof Lisa Obimbo, Kenya
Dr Regina Oladokun, Nigeria
Asthma
Prof Elvis Irusen
Dr Joe Aluoch, Kenya
Managing Editor
Penny Lang
Email: penny@fsg.co.uk
Publisher
Bryan Pearson
24 Original Article
The Asthma Control Test and its relationship with lung function parameters
J Jumbo, B O Adeniyi, P O Ikuabe, and G E Erhabor
28 Original Article
Knowledge, awareness, and practice of the use of peak flow meters by physicians
in the management of asthma in children
A A Raheem, R O Soremekun, and O F Adeniyi
33 Case Report
Foreign body aspiration and tuberculosis: possible misdiagnosis
R C Ideh, U Egere, D B Garba, and T Corrah
Correspondence to:
African Journal of Respiratory
Medicine
FSG Communications Ltd, Vine
House Fair Green,
Reach, Cambridge CB25 0JD, UK.
www.fsg.co.uk
E-mail: editor@fsg.co.uk
Report
Foreword
Introduction
Report
die prematurely from chronic respiratory disease.5
Infants and young children are particularly susceptible.
Nine million children under 5 years of age die annually,
and lung diseases are the most common causes for these
deaths. Pneumonia is the worlds leading killer of young
children.6 Asthma is the most common chronic disease,
affecting about 14% of children globally and rising.7
Chronic obstructive pulmonary disease (COPD) is the
fourth leading cause of death worldwide, and the numbers are growing.8 The most common lethal cancer in the
world is lung cancer, which kills more than 1.4 million
people each year (2008 statistics),9 and the numbers are
kill 250,000 to 500,000 people and costs 71 to 167 billion
US dollars annually.10
Respiratory infections ranks number one as the greatest single contributor to the overall burden of disease in
the world, as measured in disability-adjusted life-years
lost (DALY), which estimate the amount of active and
productive life lost due to a condition.*
No organ is more vital and no organ is more vulnerable than the lung. Being unable to breathe is one of
the most distressing feelings one can have. The lungs
are the largest internal organ in the body, and the only
internal organ that is exposed constantly to the external
environment. Everyone who breathes is vulnerable to the
infectious and toxic agents in the air. While respiratory
disease causes death in all regions of the globe and in
all social classes, certain people are more vulnerable to
environmental exposures than others are.
In recent decades, modern medicine has advanced the
length and quality of life in most countries, although
changing life styles and infections, such as with human
lenges. At the same time, increasing health care costs
effort needed to care for the ill and dying affects national
productivity. It has become abundantly clear that the
economic development of countries is tightly linked to
the health of its citizens. Poor health, both individual
and public, along with lack of education and lack of an
countrys development and the roots of poverty. Poor
,
in part related to inadequate access to quality health
care. Even more distressing is the enormous suffering
that living with illness causes. Those who are most disadvantaged suffer most due to poor health. With this
awareness, the United Nations convened a high-level
meeting on noncommunicable diseases to develop a
global plan for their prevention and control.11 The Forum
DALY is composed of two measures, years of life lost (YLL), which
ears lived with disability (YLD), to take into account the
Disability-Adjusted Life Years (DALY) is
Five respiratory conditions account for the greatest burden to society: 1. chronic obstructive pulmonary disease
(COPD), 2. asthma, 3. acute respiratory infections, 4.
tuberculosis, and 5. lung cancer.
Report
COPD, to avoid misdiagnosis, and to evaluate the severthe main medicines that help these patients. Long-term
treatment with inhaled corticosteroids added to longacting bronchodilators can help patients with frequent
Avoiding other precipitating factors and air pollution
is important. Persons with low levels of oxygen in their
blood may require supplemental oxygen. Maintaining
lead to a lack of activity and subsequent deconditioning.
Therefore, exercise-based pulmonary rehabilitation is important for most people with COPD. Treating coexisting
2. Asthma
and
it has been increasing during the past three decades in
both developed and developing countries. Although it
strikes all ages, races, and ethnicities, wide variation exists in different countries and in different groups within
the same country. It is the most common chronic disease
1
countries. In these settings, under-diagnosis and undertreatment are common, and effective medicines may not
be available or affordable. The burden of asthma is also
greater in urban settings. It is one of the most frequent
reason for preventable hospital admissions among chil6
Report
Control or elimination
Research is critical to understand better the origins of
asthma, the causes of exacerbations, and the reasons
for its rising worldwide prevalence. The International
Study of Asthma and Allergies in Childhood (ISAAC)
has provided insights into the disease and facilitated
standardized research on asthma in children that has
of asthma and allergies worldwide.23
The Global Initiative for Asthma (GINA) has developed an evidence-based strategy for the management
of asthma. Dissemination and implementation of this
strategy will improve asthma control. Making inhaled
corticosteroids, bronchodilators, and spacer devices
widely available at an affordable price and educating
people with asthma about the disease and its management are key steps to improve outcomes for people with
asthma. Policy-makers should develop and apply effective means of quality-assurance within health services
for respiratory diseases at all levels. Strategies to reduce
indoor air pollution, smoke exposure, and respiratory
infections will enhance asthma control.
increases the risk of pneumonia caused by this organism twenty-fold.25 Pneumonia can also lead to chronic
respiratory disease, such as bronchiectasis.
can spread rapidly within communities across the globe.
5 to 15% of the population and severe illness in three to
10
In 2003, the severe acute respiratory
syndrome (SARS), caused by a previously unrecognized
coronavirus, rapidly spread throughout the world. Its
lethality mobilized international efforts that rapidly
Treatment
Most bacterial respiratory infections are treatable with
antibiotics and most viral infections are self-limited.
Yet, millions of people die of pneumonia. The failure to
prevent these deaths largely results from lack of access
to health care or the inability of the health care system
to care for these individuals.
The most effective way to manage these diseases is
through standard case management. Case management
planning, facilitation, care coordination, evaluation, and
advocacy for options and services to meet an individuals
and familys comprehensive health needs through communication and available resources to promote quality
cost-effective outcomes.27
For childhood pneumonia this involves a standard
approach to diagnosis and treatment as has been well
of Childhood Illness program. The contribution of case
services developed in Malawi in collaboration with
The Union. In this resource-limited country, adopting a
standardized case management program, training health
workers, and developing the infrastructure to implement
the program steadily improved the outcome for children
under 5 years of age with pneumonia.28 The cornerstone
of pneumonia management is appropriate diagnosis and
use of antibiotics.
Report
Control or elimination
Antibiotics have made most bacterial pneumonia easily curable. As with other diseases in which the causes
are known and cures are available, the key efforts must
be in improving the availability and delivery of quality health care and medicine. Diagnosis must be made
earlier, which entails more awareness in the community.
Better diagnostic tests include more effective sampling
procedures and better methods for rapid laboratory
detection of the infectious agents or microbial molecules
in sputum, blood, and urine.
Improved diagnosis enables targeted therapy. More intelligent use of antibiotics will decrease the huge problem
of antimicrobial drug resistance. Misuse of antibiotics
leads to the emergence and selection of resistant bacteria. Physicians worldwide now face situations where
infected patients cannot be treated adequately because
the responsible bacterium is totally resistant to available
antibiotics. Three strategic areas of intervention include:
(a) prudent use of available antibiotics, giving them only
when they are needed, with the correct diagnosis and
in the correct dosage, dose intervals, and duration; (b)
hygienic precautions to control of transmission of resistant strains between persons, including hand hygiene,
screening for carriage of resistant strains, and isolation
of positive patients, and (c) research and development of
effective antibiotics with new mechanisms of action [29].
4. Tuberculosis
other illnesses. The disease lies dormant because the infection is contained by the bodys immune system, but can
become active at any point in the persons lifetime. Active
disease usually develops slowly so that individuals may
cough and spread the disease without knowing it. With
the ease and frequency of international travel, spread
to other people is easy. No one is safe from tuberculosis
until the world is safe from tuberculosis.
Tuberculosis is a particular problem in children where
are especially susceptible to developing severe or disseminated tuberculosis. Tuberculosis can strain national
health care systems because of the effort and cost needed
for contact tracing and treatment, especially if the tuberculosis bacteria are resistant to the commonly used drugs.
Prevention
In no disease is the phrase treatment is prevention
truer than with tuberculosis. The factors promoting
the spread of infection relate to the chance that an uninfected individual is exposed to persons with infectious
tuberculosis: the more cases in the community, the more
likely it is that an individual will become infected. Factors promoting the development of disease in infected
individuals relate to the function of the immune system.
conditions that affect immunity, such as certain medications and the presence of poorly controlled diabetes
increase the risk of developing active disease.
Comprehensive public health programs that search
out cases and contacts and effectively treat tuberculosis
reduce the presence of the bacteria in society and thus
prevent its spread. Treatment of contacts of patients
with active tuberculosis and those with latent tuberculosis that are at high risk for developing active disease,
tuberculosis.
The current vaccine, Bacille-Calmette-Gurin (BCG),
is largely ineffective for pulmonary tuberculosis, but offers some protection against disseminated tuberculosis.
on developing new vaccines for tuberculosis.
Treatment
Most cases of tuberculosis can be cured if diagnosed
and treat; there are many nuances to its management.
Tuberculosis is best managed by a standardized approach
that is based on evidence derived from clinical trials. The
Vol 9 No 1 March 2014
Report
long duration of therapy (usually 6 months with three
or four drugs in uncomplicated cases) makes adherence
to treatment challenging especially in individuals who
Failure to take the full course of prescribed drugs may
result in relapse with drug-resistant disease, which is
could be infected by that person. For this reason, supervised or directly observed therapy is recommended to
ensure adherence throughout the course of treatment
for tuberculosis.
To complement the standard case management proStop TB Department, the Tuberculosis Coalition for
Technical Assistance developed a document to engage
all providers in the best care for tuberculosis patients
wherever they may be found.32
Control or elimination
Many areas of tuberculosis research are producing enhas generally relied on seeing bacteria microscopically
in the sputum. New diagnostic technologies, such as
GeneXpert MTB/RIF that analyze sputum for mymicroscopic sputum smear examination. In addition,
DNA technology can detect drug resistance. These tools
are becoming available to high prevalence countries
technology and enabling treatment for drug resistance
be used because of drug-resistance, drug-intolerance, or
drug-interactions, treatment must extend much longer.
Treating drug resistant disease costs much more and
the chance for cure is much less. Fortunately, several
new drugs are on the horizon for drug-resistant disease.
Shorter course therapy for both sensitive and resistant
tuberculosis is urgently needed to further reduce the
prevalence of this disease. Shorter duration of therapy
is also needed for latent tuberculosis. A recent study
showed that the treatment with only 12 weekly doses
of medicine, directly observed over three months, was
as good as the current 9 month daily regimen.33 Public
health efforts to reduce the tuberculosis burden include
improved Infection control).4
5. Lung cancer
Report
young but they usually present with advanced disease
and have a poor prognosis. The treatment with chemodrug interactions and toxicity.
Identifying and treating early cancer is a potential
life saving strategy. The national lung cancer screening
trial undertaken in the United States was the largest
(53,454 participants) randomized trial of a single cancerscreening test in the history of US medicine. The study
randomly assigned current and former smokers to plain
chest radiography (control) or low-dose chest computed
tomography (intervention) yearly for three years and
followed them for another 3.5 years. The study showed
tervention group and a 7% reduction in overall mortality.
test result, and 96% of these were false positive meaning
that many people will need additional investigations as
a result of screening and most of these will not derive
is likely to be costly but, as of yet, there have been no
cost effectiveness studies with this technology.
Control or elimination
cancer lies with efforts to decrease smoking by helping
current smokers stop and developing methods to decrease
the number of smokers who start. It is important to limit
smoke exposure in the workplace and home. Legislation
to regulate tobacco use and its promotion, to eliminate
exposure to cigarette smoke in public areas, and to raise
taxes on tobacco products are proven techniques that
decrease tobacco use. These are particularly important
in countries where smoking rates are rising.
Comparative effectiveness research into strategies
aimed at tobacco reduction, cessation, and public policy
are needed. Research into improving early diagnosis,
understanding genetic and molecular mechanisms that
and genetic predisposition to lung cancer are important.
tant for secondary prevention.
10
Report
Poor indoor air quality is an important contributor to
respiratory disease. About 50% of all households in the
world and 90% of rural households use solid fuels, exposing 23 billion people to noxious smoke.40 The World
38.5 million DALYs per year can be attributed to indoor
smoke. Most disease and death attributable to exposure
to poor indoor air quality occurs in women and children,
especially in low income families.41 Exposure to indoor
smoke used for heating and cooking leads to COPD, lung
cancer and, in children, pneumonia and asthma.42 People
with lung disease are particularly susceptible to the effects of outdoor air pollution. Increased concentrations
hospital admissions and deaths.4345 It is estimated that
poor air quality in Europe leads to an average loss of 8.6
months of life expectancy.46 There is a growing body of
evidence that air pollution affects the unborn child leading to enhanced susceptibility to infection, respiratory,
and cardiovascular disease.47 Children, especially those
with chronic lung disease, are also more susceptible to
the adverse effects of air pollution.48 The environmental
risks are greater in low and middle-income countries
and among the disadvantaged and low socio-economic
sections of society. The respiratory societies of the world
believe that everyone has the right to breathe clean air.46
and we ask lawmakers to enact and enforce clean air
air policies are far reaching. In one large urban area, it
was estimated that complying with current standards
would reduce the annual death toll by 1200 deaths per
year, reduce the hospitalizations for heart and lung
diseases by 600 per year, reduce the cases of chronic
bronchitis in adults by 1,900 per year, reduce the cases
of acute bronchitis in children by 12,100 per year, and
reduce asthma attacks in children and adults by 18,700
per year.49 Greater improvements in air quality would
the past two decades have been shown to be associated
with increases in life expectancy in the USA and improved
respiratory health.46 Legislation and political action on
clean air makes a difference.
Appropriate nutrition and physical activity are critical
for health. Both malnutrition and obesity contribute to
respiratory diseases. Obesity is linked with obstructive
sleep apnea in Western societies and to asthma, heart
disease, and diabetes. Malnutrition is an important risk
factor for childhood pneumonia and severe illness.
Prevention of respiratory disease entails strengthening health care systems, using established guidelines
for health promotion and disease prevention, training
medical personnel, and educating the populace.
Treatment and cure
Once disease occurs, the goal is to lessen its effects and
cure it if possible. Reducing its effects is best accomplished
by early detection, prompt diagnosis, and early, effecVol 9 No 1 March 2014
11
Report
Latin America. The Pan African Thoracic Society has developed similar courses that have operated since 2007. The
Union has many programs for operational research and
management training. Administration is an important
component of the health care system that is often ignored.
The
has sought to improve
respiratory care in Europe by developing a Europeantion in Respiratory Medicine for European Specialists
an authorized post-graduate examination in respiratory
medicine. The American College of Chest Physicians offers
dedicated courses, attended by participants from around
The other main tool to reduce respiratory diseases lies
in research. Public health and clinical research improves
and promotes health for a population by improving health
care systems ability to deal with disease and promote
health and to set improved guidelines and standards
for the care of patients. Basic research aims to uncover
the mechanism of disease and develop newer and better
diagnostic tools or treatments to alleviate or cure diseases.
The investment in respiratory research has paid enormous dividends. People are living longer and healthier,
and we are only on the threshold of even greater advances.
are working hard to uncover the basic processes that go
wrong in disease. The complicated network of cells, signals, and structures is being revealed and used to identify
susceptible individuals, to develop better diagnostic
people and to control disease. The results of clinical trials are distilled into guidelines on to how best to manage an illness. These evidence-base recommendations
can be powerful tools to secure uniform high quality
medical care throughout the world. Respiratory medical
research has been shown to represent a six-fold return
on investment.50 Knowledge created through research
is cross-cultural and enduring.
Summary
12
Recommendations
2.
3.
4.
5.
6.
7.
8.
Report
References
.
2013; Available from: http://www.who.int/respiratory/
asthma/en/.
of COPD. 2013; Available from: http://www.who.int/respiratory/copd/burden/en/index.html.
. Available
from: http://www.who.int/gard/publications/chronic_respiratory_diseases.pdf.
.
2012; Available from: http://www.who.int/tb/publications/
global_report/en/.
S201-7.
Tropical
14: p. 840-848.
25.
26.
27.
28.
A study
41.
42.
43.
44.
.
Available from: http://www.who.int/mediacentre/factsheets/
fs206/en.
International Study of Asthma and Allergies in Childhood.
Available from: http://isaac.auckland.ac.nz/
World Lung Foundation,
.
2010, New York: World Lung Foundation.
Scott, J.A., et al.,
Lancet, 2000. 355(9211):
p. 1225-30.
Centers for Disease Control and Prevention. Available from:
http://www.cdc.gov/sars.
Case Management Society of America Standards of Practice for
Case Management. 2010.
Enarson, P.M., et al.,
p. 341-50.
. 2010;
Available from: http://www.euro.who.int/__data/assets/
24.
23.
. 2007.
Erratum
13
Review Article
Introduction
1
For
2
1
1.
asthma
6
6
Review Article
Asthma has an
Anti-IgE: omalizumab
11
14
2
16
Biological agents
IL-4 and IL-13 inhibitors: altrakincept and pitrakinra
15
Review Article
-
Conclusion
-
21
22
References
24
Lancet
Inhibition of chemokines
Am J Crit Care Med
Eur Respir J
26
Respir Med
Allergy
S Afr
Med J
Eur Respir Rev
High-altitude treatment
Chest
16
Review Article
Am J Respir Crit Care Med
N Engl J Med
N Engl J Med
Engl J Med
. Thorax
Lancet
Indian
N Engl J Med
Lancet
Bron
Eur Respir J
About us
The Paediatric and Adult African Spirometry (PAAS) project is a research venture set up to address the lack of
Our Aim
Who to contact
before the 31st of May 2014:
17
Review Article
Introduction
Study design
This was a pilot survey conducted in two parts: part 1,
a household survey to assess the perceptions of asthma
and part 2, a survey of patients with asthma to assess
the level of asthma control in developing countries. Five
G A Nadeau, I Samji, and R D Walters, GlaxoSmithKline,
Medical Affairs, Uxbridge, UK;
S F R Godwin, J Lucas, and M Moodley,
Ipsos Healthcare, London, UK.
Correspondence to: Gilbert A Nadeau,
Medical Affairs Director,
GSK Respiratory Centre of Excellence.
Email: gilbert.a.nadeau@gsk.com
18
Review Article
sures for the three African cities and was complemented
by questions on education and occupation for Dakar. A
combination of education and occupation was used for
Dhaka, whereas income was used in Phnom Penh for
assessment of socioeconomic class.
Part 2. Asthma survey
cian diagnosis in the last 12 months or breathing problems/symptoms suggestive of asthma were asked to
participate in the asthma survey. Asthmatic adults and
parents/guardians of children with asthma living within
the households from the above described survey were
then interviewed with regard to their own asthma or the
asthma of children under their care.
The aim was to recruit 300 people with asthma in each
-
Dakar
Dhaka
Lusaka
Nairobi
Phnom Penh
1618
1913
1194
1355
3668
472
733
50
112
2386
1146
1180
1144
1243
1282
n=302
47.5
(189)
35.5
64.5
n=300
35.6
(180)
53
47
n=301
30
(<191)
58
42
n=300
27
(<187)
58
42
n=302
30
(187)
60
40
169
70
152
53
159
62
163
63
141
49
15
17
24
18
20
22
13
28/41
19
23
34/34
23
22
19
36
Number of completed
surveys (n)
Results
% Households in SEC
A
AB
B
C
C1/C2
D
DE
E
High
Medium
Low
19
Review Article
Asthmatic subjects in our survey were asked to report
repeated asthma exacerbations requiring hospitalisations
in the previous year. The majority of subjects reported
at least 1 exacerbation requiring hospitalisation in the
previous year (between 48% and 82% of responders per
city) and an average hospitalisation rate of between 4.6
and 10.7 per year (see Table 5). The majority of patients
from all cities surveyed stayed for <1 day in hospital and
received tablets as treatment for exacerbations. Aligned
not having inhaled or nebuliser therapy (see Table 5).
Frequently used asthma treatments
Based on reports from asthmatics, large numbers of
patients did not use or even possess an inhaler, whereas
oral bronchodilators were used very commonly and appeared to prevail in most cities (see Table 6).
Discussion
56
37
37
53
32
39
27
40
42
44
27
19
32
22
23
68
24
42
38
14
Table 2. Perception of asthma control, weekly symptoms, and inhaler use by patients
from different cities
Review Article
Parameter
Dakar
(n=302)
Dhaka
(n=300)
Lusaka
(n=301)
Nairobi
(n=300)
Phnom Penh
(n=302)
22
78
(48; 30)
27
73
(38; 35)
15
85
(39; 46)
19
81
(40; 41)
15
85
(36; 49)
20 (80)
14 (86)
14 (86)
29 (71)
25 (75)
3 (6)
22 (78)
29 (71)
15 (85)
24 (76)
18 (82)
5 (95)
4 (96)
16 (84)
23 (77)
17 (83)
23 (77)
16 (84)
19 (81)
0 (100)
19 (81)
16 (84)
9 (91)
11 (89)
5 (95)
38 (62)
28 (72)
29 (71)
21 (79)
23 (77)
23 (77)
22 (78)
10 (90)
7 (93)
23 (77)
25 (75)
12 (88)
8 (92)
30 (70)
18 (82)
5 (95)
5 (95)
32 (68)
23 (78)
17 (83)
Socioeconomic class (SEC) was based on the Living Standards Measures for the three African cities and was complemented by questions on education and occupation for Dakar. A combination of education and occupation was used for Dhaka,
whereas income was used in Phnom Penh for assessment of socioeconomic class.
Table 3 Asthma control and influence of age and socio-economic class (SEC) in patients from different cities.
Parameter
Dakar
Dhaka
28
28
18
26
15
16
38
12
17
15
22
27
15
19
15
therapy. The relatively limited use of inhaled medicause of inhaled medication and with asthma in general.
It could also result from the limited availability of inhaled medication. These observations suggest that care
may be improved by implementing simple educational
programmes aimed at increasing the understanding
of asthma for both the general population and asthma
patients. In addition, healthcare workers should be kept
informed of international and local guidelines and of the
role of inhaled controller medications.
Our study has limitations. The interviewers were
asked to move on to another household if they were
Vol 9 No 2 March 2014
cities surveyed, however, suggests that our observations are valid at least for urban settings. We also used
standardised questionnaires developed and translated
for this study during face to face interviews rather than
telephone interviews, which increases the validity of our
observations. Identifying asthmatic subjects in a survey
usually from a more severe consulting population. Reversibility testing is impractical during a cross-sectional
study because of the transient nature of the disease and
sure and ethically complicated. Asthmatics in our survey
African Journal of Respiratory Medicine
21
Review Article
Parameter
Dakar
Dhaka
Lusaka
Nairobi
(n=302)
77
(n=299)
48
(n=301)
80
(n=300)
82
(n=297)
61
(n=232)
10.7 (25.16)
(n=144)
5.1 (11.8)
(n=240)
4.24 (4.3)
(n=245)
4.6 (4.9)
(n=180)
6.2 (8.0)
90
2
8
0
62
15
11
11
78
12
6
4
68
14
10
8
64
15
14
6
% patients receiving:
Tablets
Inhaler
Nebuliser
Oxygen
Other
42
21
15
16
32
63
46
27
31
4
88
15
10
5
3
74
39
12
17
23
81
46
32
11
9
Frequency of hospitalisation
in last 12 months (mean (SD))
Phnom Penh
5.8
6.3
8.5
5.9
7.7
6.5
6.9
7.8
7.8
7.3
Table 5 Acute exacerbation-associated hospitalisation and treatments in patients from different cities
Dakar
Dhaka
Lusaka
Nairobi
Phnom Penh
Nebuliser
Salbutamol tablet/
inhaler/syrup
Ventolin syrup
Ventolin
Ventolin syrup
Oxygen
Ventolin tablet/
inhaler/syrup
Ventolin tablet
Salbutamol tablet
Ventolin and
salbutamol tablets
Ventolin inhaler
Aminophylline
injection
Adrenaline
Aminophylline
tablet 4/10
Doctor
prescribed
Ventolin Evohaler
inhaler 7/10
Seretide inhaler 4/10
Salbutamol
tablet 7/10
Seretide 4/10
Table 6 Top three treatments used generally or prescribed by doctors for moderate asthmatics as standard of
care in different cities.
were self-reported as having a physician diagnosis of
asthma in the last 12 months or symptoms suggestive
of asthma in the same period. Although not perfect, this
approach is consistent with major international surveys
including the International Study of Asthma and Allergies
in Childhood (ISAAC) and the European Community
Respiratory Health Survey (ECRHS). It is possible that
more representative of the general population and that
those from the secondary search strategy would be more
severe cases. A sensitivity analysis comparing the ACT
scores in these two groups did not support this hypothesis. The mean age in our surveys was higher than that
based on the search methodology.
In conclusion, this study has shown that asthma control,
as assessed by ACT scores, frequency of symptoms, and
the very high rate of exacerbations requiring hospitalisa22
Review Article
Parameter
Dakar
(n=1152)
Dhaka
(n=1167)
Lusaka
(n=1145)
Nairobi
(n=1247)
Phnom Penh
(n=1266)
a
Households ratings for understanding of asthma (%)
1
2
3
4
5
10
14
22
25
29
20
14
18
13
35
21
17
20
20
21
17
16
19
17
31
26
26
16
23
10
Mean rating
3.5
3.3
3.0
3.3
2.6
22
30
43
35
35
18
29
26
16
29
63
44
62
31
53
35
25
40
10
42
44
21
41
45
43
81
79
58
54
62
74
47
54
48
36
c
c
c
c
leads to asthma
Rating scale 1 to 5: with 1 = very little understanding and 5 = very good understanding.
Expressed as percentage of responders who agree, rather than those that were aware of this perception.
c
Expressed as percentage of total asthmatics surveyed in Dakar (n= 302).
a
b
Table 7 Asthma understanding and treatment-associated attitudes and social stigma in different cities
Acknowledgements
7.
8.
9.
10.
11.
12.
13.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
23
Original Article
Abstract
Introduction
Original Article
200 ml, 20 minutes after inhalation of 400 microgram
of -agonist (salbutamol))17 were included.In addition,
only those without an acute exacerbation of asthma in
the preceding 4 weeks were included in the sample.
All asthma patients who had co-morbid conditions
such as hypertensive heart failure and chronic obstructive
pulmonary disease (COPD), patients with acute severe
were excluded. A Medical Research Council (MRC)
questionnaire was used to record socio-demographic
data obtained were summarised.
Asthma control was assessed by self-reported asthma
tionnaire that assesses interference with activity, shortness of breath, nocturnal symptoms, rescue medication
use, and self-rating of asthma control. Each item is scored
using a 15 scale and then scores are totalled (total score
525). A score of 20 or higher was found to be the most
-
10
Frequency (n=65)
Percentage
Age (years)
<21
2130
3140
4150
51 and above
8
25
14
12
6
12.3%
38.5%
21.5%
18.5%
9.2%
Educational status
Primary
Secondary
Post-secondary
9
16
40
13.8%
24.6%
61.6%
Gender
Male
Female
27
38
41.5%
58.5%
Occupation
Civil servant
Traders
Schooling
Artisan
Farming
Unemployed
23
6
28
2
3
3
35.4%
9.2%
43.1%
3.1%
4.6%
4.6%
BMI (kg/metre2)
<18
1825
>25
19
26
20
29.2%
40.0%
30.8%
Results
Variables
PEF (L/min)
FEV1 (L)
FVC (L)
FEV1/FVC (%)
Pre-bronchodilator Post-bronchodilator
(Mean SD)
(Mean SD)
286.00107.00
1.970.87
2.671.02
75.2210.80
348114
2.320.95
2.870.97
7911.0
Reversibility
FEV1(%)
20.1311.26
Reversibility
PEF (%)
22.7310.51
FEV1
predicted (%)
75.025.7
82.024.3
25
Original Article
pared with 5 (12%)
controlled group
that used controller
medications. The
difference was sta-
Original Article
responsiveness has been reported to be more common
among females than males in general population surveys.26 However, this phenomenon needs to be further
evaluated in other socio-cultural setting, and stimulates
further work in ACT in diverse communities.
This study showed that only 26% of the respondents
than others reported in the work of Marks et al,27 who
found that 36% of adult asthmatics with daily symptoms
and 41% with symptoms on most days were taking
controller medication.
References
1.
2.
3.
4.
6.
7.
8.
done by Green R J28 in South Africa who found that asthmatics on controller medications achieved better control.
Also evaluated in this study was the relationship between ACT scores and lung function parameters. There
was a poor correlation between ACT scores and lung
10.
Conclusion
Acknowledgements
9.
11.
12.
13.
14.
15.
16.
17.
18.
27
Original Article
Introduction
Abstract
asthma monitoring and in determining the severity of
symptoms. Against the background of reported unand prescription for home use, and the paucity of such
data in developing countries, this study was carried
out to assess the knowledge, awareness, and practice
of children with asthma.
The work was a prospective cross-sectional study
involving 67 doctors working in the paediatric departments of two government hospitals in Lagos State, Nigeria. The number of doctors varied as not all responded to
the number of doctors that responded to the particular
issue/question addressed. The survey was conducted
with a self-administered structured questionnaire. Infrequency of prescription, and constraints in prescribing
28
to show it to the researcher and were also unable to adequately demonstrate the correct use of the meter. Only
58% and 63% of practitioners in the public and private
Original Article
In Nigeria, among 68 tertiary hospitals only 38% have a
9
10
Results
This work was a prospective cross-sectional study involving 67 doctors working in two government hospitals in
Lagos State, Nigeria. Of the 67 doctors, 43 worked at the
paediatric department of the Lagos University Teaching
children with asthma than doctors in LUTH.
the management of childhood diseases. The number of
doctors varied as not all responded to all the questions.
doctors that responded to the particular issue/question
addressed.
The study was carried out between July and September, 2012. A convenience sampling technique was used
as all voluntary participants were recruited in the study.
A self-administered, structured questionnaire was
used to collect the data on demographic information
and years of experience in the management of asthma
in children. Other information sought was the presence/
severity of an asthma episode. The majority of the docwas useful in objectively assessing the effectiveness of
caregivers actively involved in managing the asthma
African Journal of Respiratory Medicine
29
Original Article
Knowledge of PFMs
Good
n (%)
Fair
n (%)
Poor
n (%)
Test
2 = 6.911
p = 0.546
the years of experience of the doctor in attending to children with asthma and the frequency of prescription of
doctors with 6 to 10 years experience and all doctors
with more than 15 years experience only prescribed the
Designationa
Years of
b
1620
2125
2 (100.0) 0 (0)
1 (100.0) 0 (0)
0 (0)
0 (0)
Discussion
surveyed doctors in Lagos State. The relatively inex-
Notes:
a
30
Original Article
and management of asthma among the doctors surveyed while only 28.1% of doctors in this study had the instruwas demonstrated in this study. Some 70.3% of the doctors ment in their consulting rooms. Since most of the doctors
78% would use it in assessing the severity of asthma, but rooms nor used it for diagnosis, demonstrating the use
only 16.7% and 20.7% respectively reported regular use of the meter to patients/caregivers would be minimal
if not impossible, hence, the low prescription rate. The
ments and treated more asthma cases than their counlar to reports among health maintenance organisations diagnosis since the instrument was not available in the
where p
clinics. This unfortunately, seems to be the situation in
asthma severity based on measurement of pulmonary many hospitals in Nigeria, as even among 68 surveyed
function.14
tertiary hospitals in Nigeria9
10
This is
review of asthma management in Nigeria, where lack
treatment of asthma.15 However in Johannesburg, South
Africa, 58% of the practitioners in the public sector used in asthma management.16 The experience of the doctors
8
The reasons
those with 5 years experience or less in management
of paediatric asthma. Doctors with more than 5 years
experience with asthma management in paediatrics
asthma
Signs and
symptoms
66 (100%)
0.0
0.0
n (%)
n (%)
n (%)
31
Original Article
n (%)
n (%)
n (%)
Designationa
2 = 8.522,
References
1620
2125
0 (0)
0 (0)
2 (100.0)
1 (100.0)
0 (0)
0 (0)
2
610
1 (9.1)
10 (90.9)
0 (0)
n=65, b n=64
Table 4 Respondents characteristics and the prescription of PFMs for homemonitoring of asthma in children
15
of pictures.
similar reasons though to varying degrees.8 The variation
in the degrees of importance of the reasons may be due
to differences in the study environments.
Though all categories of doctors seem to be aware of
19
Health Policy
2011;
Conclusion
The cost
who.int/home/countries/fact_sheets/nigeria.pdf.
Medscape Reference, 2012.
article/1000997.
Nigeria. Chest
, Shah S,
2000;
Case Report
Abstract
Introduction
Case presentation
33
Case Report
right lower zone. Other systems were essentially normal.
hemithorax, occupying the midzone and some collapse
and consolidation of the right upper lobe (see Figure 1).
An initial diagnosis of pulmonary TB with pleural effusion and a pneumothorax was made at the clinic; the
patient was admitted for investigation and TB treatment
started.
A Mantoux tuberculin skin test was non-reactive and
two sputum samples were negative for acid and alcohol
fast bacilli. An initial thoracocentesis yielded 365 mls of
pus which was sent for microscopy and TB culture and
routine microbiology. Microscopy showed a pleocytosis
with 80% neutrophils and 20% lymphocytes. No AFB
(acid-fast bacilli) was seen, however, Gram-positive
cocci were visible on Gram stain. There was no growth
on the culture.
Management
The patient was initially commenced on intravenous
ceftriaxone and metronidazole. A review of X-rays identi-
The diagnosis was revised to right lung abscess secondary to inhaled foreign body. An attempt to remove the
unsuccessful.
Because of the limited cardiothoracic services available
in our region the patient was transferred to a specialist
centre in Dakar, Senegal where the foreign body, a metal
spring (see Figure 2), was successfully removed by rigid
bronchoscopy.
8, 9
Conclusion
Discussion
Acknowledgement
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