Rules of thumb in Pulmonary

Content

Background
Rules of thumb
Conclusion
Further readings

Author's details

Dr.Khashau Eleburuike
MBBS (Ilorin) MSc. Global Health Karolinska Institute.
Resident doctor in family medicine in Northen Sweden.

Reviewer's details

Dr. Jafaru Momodu
MBBS, FWACP Pulmonology
National Hospital Abuja. Introduction

Rules of thumb in Pulmonary

Background

Respiratory diseases remain a significant cause of morbidity and mortality in sub-Saharan Africa, with tuberculosis, pneumonia, asthma, chronic obstructive pulmonary disease (COPD), and other respiratory infections being prevalent. Access to healthcare, diagnostic tools, and medications can be limited in this region, necessitating the use of practical “rules of thumb” to guide clinical decision-making. These are simple yet effective strategies that healthcare providers can use when managing respiratory diseases under resource-limited settings.

Keywords: Respiratory diseases in resource-limited settings, asthma, pneumonia, tuberculosis, COPD, HIV.

Rules of thumb

1. Comprehensive Clinical Assessment

Conduct thorough history-taking and physical examinations to identify common respiratory conditions such as tuberculosis (TB), asthma, chronic obstructive pulmonary disease (COPD), and respiratory infections. Pay attention to risk factors like smoking, biomass fuel exposure, and HIV status.

2. Utilize Basic Diagnostic Tools

Rely on readily available diagnostic tools such as chest X-rays, sputum analysis, and simple spirometry. When advanced diagnostics are unavailable, clinical judgment and basic tools become crucial

3. Suspect Tuberculosis (TB) in Chronic Cough

Rule of Thumb

Any patient presenting with a cough lasting more than two weeks, especially if accompanied by weight loss, fever, night sweats, or haemoptysis, should be evaluated for tuberculosis.

Guideline

The WHO recommends that sputum smear microscopy, GeneXpert rapidly diagnoses for mycobacterium tuberculosis and detect resistance to Rifampicin, or culture be performed where possible. In resource-limited settings, starting empirical anti-TB therapy may be necessary while awaiting diagnostic results.

4. Prioritize Pneumonia in Children Under Five

Rule of Thumb

Any child presenting with fever, fast breathing, and chest indrawing should be suspected of having pneumonia and started on antibiotics without delay.

Guideline

The Integrated Management of Childhood Illness (IMCI) by WHO/UNICEF recommends classifying pneumonia based on symptoms and severity. Oral amoxicillin is typically first-line for outpatient management, and severe cases should be referred for hospital care with oxygen therapy if needed.

5. Assess for HIV in Chronic Respiratory Symptoms

Rule of Thumb

In areas with a high HIV prevalence, any adult presenting with recurrent respiratory infections, chronic cough, or unexplained weight loss should be screened for HIV.

Guideline

All patients with suspected or confirmed HIV should be started on antiretroviral therapy (ART) according to local HIV management guidelines. Co-infections such as pneumocystis pneumonia (PCP) or TB should also be investigated.

6. Treat Acute Exacerbations of Asthma and COPD Aggressively

Rule of Thumb

For asthma or COPD exacerbations, provide bronchodilators (inhaled beta-agonists like salbutamol) immediately, and add short-term systemic (oral or parenteral) corticosteroids (within 5-7 days) for moderate to severe cases.

Guideline

The Global Initiative for Asthma (GINA) and the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines suggest inhaled corticosteroids (ICS) for long-term asthma control and bronchodilators for COPD. In severe exacerbations, supplemental oxygen, antibiotics, and corticosteroids may be required.

7. Prioritize Oxygen Therapy in Hypoxic Patients

Rule of Thumb

Any patient with respiratory distress and signs of hypoxia (cyanosis, altered consciousness, fast breathing) should be given supplemental oxygen, if available.

Guideline

Oxygen therapy should be targeted to maintain oxygen saturation above 92% in most patients except COPD patients whose saturation may be <90%. In settings without pulse oximetry, clinical signs such as cyanosis or laboured breathing can guide oxygen use.

8. Consider Environmental Factors in Respiratory Diseases

Rule of Thumb

Given the high exposure to biomass fuel smoke, poor ventilation, and dust in some parts of sub-Saharan Africa, environmental factors should always be considered in the management of chronic respiratory diseases.

Guideline

Encourage the use of cleaner cooking methods, improved ventilation, and reducing indoor air pollution to mitigate environmental contributors to respiratory illness.

9. Vaccinate to Prevent Respiratory Infections

Rule of Thumb

Vaccination against common respiratory pathogens, including Streptococcus pneumoniae, Haemophilus influenzae type B, and influenza, should be prioritized in children and at-risk populations like tuberculous, diabetes mellitus, heart diseases, asthma and COPD patients.

Guideline

The WHO Expanded Program on Immunization (EPI) recommends routine childhood vaccination against pneumococcus, H. influenzae, and influenza. Annual influenza vaccination should be considered for high-risk groups such as healthcare workers and those with chronic diseases.

Use Antibiotics Judiciously in Suspected Respiratory Infections

Rule of Thumb

For respiratory tract infections like acute bronchitis or viral upper respiratory infections, antibiotics are often not needed and should be avoided unless there is evidence of bacterial infection. The evidence of bacterial infection could be suspected in a patient who has a high white blood cell count or C-reactive protein (CRP) > 50. High CRP could also be found in Covid-19 or influenza patients.

Guideline

WHO and local guidelines recommend antibiotics for bacterial infections like pneumonia or in high-risk patients, but emphasize antimicrobial stewardship to prevent resistance.

11. Assess Nutritional Status in Respiratory Disease Patients

Rule of Thumb

Malnutrition is a major complicating factor in respiratory diseases, especially in children, COPD and TB patients. Always assess and address nutritional status.

Guideline

Nutritional support is critical in the management of patients with chronic respiratory conditions. For children, the IMCI guidelines recommend therapeutic feeding for those with severe acute malnutrition.

12. Provide Health Education on Smoking and Air Quality

Rule of Thumb

Smoking cessation and education on reducing exposure to air pollution are key preventive strategies for chronic respiratory diseases.

Guideline

Smoking cessation programs should be integrated into healthcare services, and efforts to improve air quality through community education and policy advocacy should be prioritized.

Summary of Guidelines

WHO TB Guidelines:

Focus on early diagnosis and treatment initiation, particularly in high-risk populations (e.g., people living with HIV).

IMCI (Integrated Management of Childhood Illness):

Classifies respiratory illness in children and provides guidance for treatment based on severity.

GINA and GOLD Guidelines:

Standardize management of asthma and COPD, promoting the use of inhaled therapies, corticosteroids, and lifestyle modifications.

WHO Expanded Program on Immunization (EPI):

Promotes vaccination against key respiratory pathogens in children and at-risk populations.

Conclusion

In resource-limited settings, these rules of thumb help guide clinical decision-making when advanced diagnostics and therapeutics may not be available, and integrating local and international guidelines improves outcomes in respiratory care. Task-Shifting and Training: of primary healthcare providers and community health workers in recognizing and managing common respiratory conditions. This extends the reach of respiratory care to underserved areas.

Follow-Up and Continuity of Care: Ensure regular follow-up for patients with chronic respiratory conditions to monitor treatment adherence and disease progression. Use community health workers for home visits and follow-up reminders.

Community Engagement and Education: Engage communities in respiratory health promotion. Use culturally appropriate materials and methods to educate about the prevention and management of respiratory diseases.

Holistic and Culturally Sensitive Care: Provide care that respects local cultural beliefs and practices. Engage with patients and their families to address any cultural concerns and ensure that care plans are acceptable and adhered to.

By adhering to these principles, healthcare providers can deliver effective, resource-appropriate, and culturally sensitive respiratory care in Sub-Saharan Africa, improving patient outcomes and reducing the burden of respiratory diseases.

Content

Author's details

Reviewer's details

Rules of thumb in Pulmonary

Are you a Medical Doctor?