Clinical standards for the diagnosis and management of asthma in low- and middle-income countries
METHODS: A panel of 52 experts in the field of asthma in LMICs participated in a two-stage Delphi process to establish and reach a consensus on the clinical standards.
RESULTS: Eighteen clinical standards were defined: Standard 1, Every individual with symptoms and signs compatible with asthma should undergo a clinical assessment; Standard 2, In individuals (>6 years) with a clinical assessment supportive of a diagnosis of asthma, a hand-held spirometry measurement should be used to confirm variable expiratory airflow limitation by demonstrating an acute response to a bronchodilator; Standard 3, Pre- and post-bronchodilator spirometry should be performed in individuals (>6 years) to support diagnosis before treatment is commenced if there is diagnostic uncertainty; Standard 4, Individuals with an acute exacerbation of asthma and clinical signs of hypoxaemia or increased work of breathing should be given supplementary oxygen to maintain saturation at 94–98%; Standard 5, Inhaled short-acting beta-2 agonists (SABAs) should be used as an emergency reliever in individuals with asthma via an appropriate spacer device for metered-dose inhalers; Standard 6, Short-course oral corticosteroids should be administered in appropriate doses to individuals having moderate to severe acute asthma exacerbations (minimum 3–5 days); Standard 7, Individuals having a severe asthma exacerbation should receive emergency care, including oxygen therapy, systemic corticosteroids, inhaled bronchodilators (e.g., salbutamol with or without ipratropium bromide) and a single dose of intravenous magnesium sulphate should be considered; Standard 8, All individuals with asthma should receive education about asthma and a personalised action plan; Standard 9, Inhaled medications (excluding dry-powder devices) should be administered via an appropriate spacer device in both adults and children. Children aged 0–3 years will require the spacer to be coupled to a face mask; Standard 10, Children aged <5 years with asthma should receive a SABA as-needed at step 1 and an inhaled corticosteroid (ICS) to cover periods of wheezing due to respiratory viral infections, and SABA as-needed and daily ICS from step 2 upwards; Standard 11, Children aged 6–11 years with asthma should receive an ICS taken whenever an inhaled SABA is used; Standard 12, All adolescents aged 12–18 years and adults with asthma should receive a combination inhaler (ICS and rapid onset of action long-acting beta-agonist [LABA] such as budesonide-formoterol), where available, to be used either as-needed (for mild asthma) or as both maintenance and reliever therapy, for moderate to severe asthma; Standard 13, Inhaled SABA alone for the management of patients aged >12 years is not recommended as it is associated with increased risk of morbidity and mortality. It should only be used where there is no access to ICS.
The following standards (14–18) are for settings where there is no access to inhaled medicines. Standard 14, Patients without access to corticosteroids should be provided with a single short course of emergency oral prednisolone; Standard 15, Oral SABA for symptomatic relief should be used only if no inhaled SABA is available. Adjust to the individual’s lowest beneficial dose to minimise adverse effects; Standard 16, Oral leukotriene receptor antagonists (LTRA) can be used as a preventive medication and is preferable to the use of long-term oral systemic corticosteroids; Standard 17, In exceptional circumstances, when there is a high risk of mortality from exacerbations, low-dose oral prednisolone daily or on alternate days may be considered on a case-by-case basis; Standard 18. Oral theophylline should be restricted for use in situations where it is the only bronchodilator treatment option available.
CONCLUSION: These first consensus-based clinical standards for asthma management in LMICs are intended to help clinicians provide the most effective care for people in resource-limited settings.
Keywords: asthma; chronic respiratory disease; clinical standards; low-income and middle-income countries; non-communicable disease
Document Type: Research Article
Affiliations: 1: Academic Unit of Primary Care, University of Sheffield, Sheffield 2: Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa 3: Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia, International Primary Care Respiratory Group, Edinburgh, Scotland, UK 4: Global Allergy and Airways Patient Platform, Vienna, Austria 5: Hospital Centro Médico, Guatemala City, Guatemala, Mexico, Asociación Latinoamericana de Tórax, Montevideo, Uruguay 6: Department of Medicine, University of Hong Kong, Hong Kong, Asian Pacific Society of Respirology, Hong Kong, China 7: Division of Pulmonary Rehabilitation, Istituti Clinici Scientifici Maugeri, Istituto di Ricovero e Cura a Carattere Scientifico, Tradate, Department of Medicine and Surgery, Respiratory Diseases, University of Insubria, Varese-Como 8: Asociación Latinoamericana de Tórax, Montevideo, Uruguay, Department of Medicine, University of Hong Kong, Hong Kong 9: Servizio di Epidemiologia Clinica delle Malattie Respiratorie, Istituti Clinici Scientifici Maugeri, Tradate, Italy 10: College of Medicine, University of Nigeria, Enugu, Nigeria 11: Affiliation Departamento de Farmacologia y Tóxicologia, Facultad de Medicina, Universidad de Antioquia, Medellín, Colombia 12: Medical Research Council, The Gambia at the London School of Tropical Medicine, The Gambia 13: Hospital Infantil de México Federico Gômez, Mexico D.F, Mexico 14: Department of Primary Care Sciences, University of Zimbabwe, Harare, Zimbabwe 15: Division of Allergy and Clinical Immunology, Chian Mai University, Chiang Mai, Thailand 16: Health Sciences School, Universidad Peruana de Ciencias Aplicadas, Lima, Peru 17: Head Pediatric Respiratory Medicine Department, Clinica Regional del Este, San Francisco, Argentina 18: Paediatrics and Child Health, University of Lusaka, Lusaka, Zambia 19: Department of Respiratory Medicine, JSS Medical College, Mysore, India 20: Department of Pediatrics, Universidad Industrial de Santander, Santander, Colombia 21: College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia 22: Department of Pediatrics, Universidad de Costa Rica, San Jose, Costa Rica 23: Douala General Hospital, University of Douala, Douala, Cameroon 24: Institute of Pneumology M. Nasta, Bucharest, Romania 25: School of Health Systems and Public Health, University of Pretoria, Pretoria, South Africa 26: College of Medicine, Ajman University, Ajman, United Arab Emirates 27: University of Maiduguri Teaching Hospital, Maiduguri 28: Deparment of Medicine, University of Abuja, Abuja 29: Department of Paediatrics, Usmanu Danfodiyo, University Teaching Hospital, Sokoto, Nigeria 30: Deparment of Biological Sciences, Eduardo Mondlane University, Maputo, Mozambique 31: University of Medical Sciences, Porto Alegre, RS, Brazil 32: Department of Paediatrics, University of Ibadan, Ibadan, Nigeria 33: Dragiša Mišovic, Childrens Hsopital for Lung Disease and TB, Belgrade, Serbia 34: Health Sciences, Academic Division, Juarez Autononous, University of Tabasco, Villahermosa, Mexico 35: Department of Medicine, Obafemi Awolowo University Teaching Hospital Complex, Ile-Ife, Nigeria 36: Department of Paediatrics & Child Health & SA MRC Unit on Children & Adolescent Health, Red Cross Childrens Hospital, University of Cape Town, Cape Town, South Africa 37: Department of Pulmonary Diseases, Istanbul University, Cerrahpasa, Turkey 38: State University of Feira de Santana, Feira de Santana, BA, Brazil 39: UBT Higher Education Institution, Prishtina, Kosovo 40: Al-Quds University, Jerusalem, Palestine 41: MJ Rajasthan Hospital, Jaipur, India 42: Paediatrics Unit, Teaching Hospital Peradeniya, Kandy 43: Faculty of Medicine, University of Peradeniya, Kandy, Sri Lanka 44: Shahid Beheshti University of Medical Sciences, Tehran, Iran 45: Medical School, Santander Industrial, Bucaramanga, Colombia 46: Department of Community Medicine, Kasturba Medical College, Mangalore 47: Universudad Espíritu Santo, Samborondón, Ecuador 48: Asociación Latinoamericana de Tórax, Montevideo, Uruguay, Francisco Morroguín University, Guatemala City, Guatemala 49: Faculty of Health Sciences, Catholic University of Salta, Salta, Argentina 50: Department of Allergy and Clinical Immunology, University Hospital Centre “Mother Teresa”, Tirana, Albania 51: Hospital San Angel Inn, Mexico DF, Mexico 52: The University of Yaounde 1, Yaounde, Cameroon 53: Health Concern Initiative, Wakiso, Uganda 54: Shishuka Children’s Speciality Hospital, Bangalore, India 55: The Allergy and Asthma Institute, Islamabad, Pakistan 56: Medecin Faculty, Mustapha Universitary Hospital Algiers, Algeria 57: Centrode Investigación de Enfermedades Alérgicas y Respiratorias SC, Mexico DF, Mexico 58: Pediatrics, All India Institute of Medical Sciences, New Delhi, India 59: Levy Mwanawasa Medical University, School of Public Health and Environmental Sciences, Lusaka, Zambia 60: Federal University of Parana, Curitiba, PA, Brazil 61: Social Medicine, Medical Faculty, University of Prishtina, Prishtina, Kosovo 62: University of Cambridge, Cambridge, Imperial College, London, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK, Department of Paediatrics and Child Health, School of Clinical Medicine, University of KwaZulu Natal, Durban, South Africa 63: Department of Non-communicable Diseases, World Health Organization, Geneva, Switzerland 64: Department of Paediatrics and Child Health, School of Clinical Medicine, University of KwaZulu Natal, Durban, South Africa
Publication date: September 1, 2023
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