Clinical standards for the diagnosis and management of asthma in low- and middle-income countries.

BACKGROUND: The aim of these clinical standards is to aid the diagnosis and management of asthma in low-resource settings in low- and middle-income countries (LMICs).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.

Analysis of the Budget Impact of Fractional Exhaled Nitric Oxide Monitoring in the Management of Childhood Asthma: The Colombian National Health System Perspective.

BACKGROUND: Fractional exhaled nitric oxide (FeNO) testing is a simple, noninvasive approach to assessing airway inflammation with minimal discomfort that provides results within a few minutes. For policy makers, the economic impact of this technology is the main concern, especially in developing countries. We evaluated the budget impact of asthma management using FeNO monitoring in patients aged between 4 and 18 years in Colombia. METHODS: A budget impact analysis was performed to evaluate the potential cost of FeNO monitoring. The analysis was based on a 5-year time horizon and performed from the perspective of the Colombian National Health System. The incremental budget impact was calculated by subtracting the cost of the new treatment, in which FeNO is reimbursed, from the cost of conventional treatment without FeNO (management based on clinical symptoms [with or without spirometry/peak flow] or asthma guidelines [or both] for asthma-related cases). Univariate 1-way sensitivity analyses were performed. RESULTS: In the base case analysis the 5-year costs associated with FeNO and non-FeNO were estimated to be €469 904 130 and €480 485 149, respectively, indicating savings for the Colombian National Health System of €10 581 019 if FeNO is adopted for the routine management of patients with persistent asthma. This result proved to be robust in the univariate 1-way sensitivity analysis. CONCLUSION: FeNO monitoring generated cost savings in emergency settings for infants with persistent asthma. This evidence can be used by decision makers in Colombia to improve clinical practice guidelines and should be replicated to validate the results in other middle-income countries.

Analysis of the Budget Impact of Fractional Exhaled Nitric Oxide Monitoring in the Management of Childhood Asthma: The Colombian National Health System Perspective

Background: Fractional exhaled nitric oxide (FeNO) testing is a simple, noninvasive approach to assessing airway inflammation withminimal discomfort that provides results within a few minutes. For policy makers, the economic impact of this technology is the mainconcern, especially in developing countries. We evaluated the budget impact of asthma management using FeNO monitoring in patientsaged between 4 and 18 years in Colombia.Methods: A budget impact analysis was performed to evaluate the potential cost of FeNO monitoring. The analysis was based on a5-year time horizon and performed from the perspective of the Colombian National Health System. The incremental budget impact wascalculated by subtracting the cost of the new treatment, in which FeNO is reimbursed, from the cost of conventional treatment withoutFeNO (management based on clinical symptoms [with or without spirometry/peak flow] or asthma guidelines [or both] for asthma-relatedcases). Univariate 1-way sensitivity analyses were performed.Results: In the base case analysis the 5-year costs associated with FeNO and non-FeNO were estimated to be €469 904 130 and€480 485 149, respectively, indicating savings for the Colombian National Health System of €10 581 019 if FeNO is adopted for theroutine management of patients with persistent asthma. This result proved to be robust in the univariate 1-way sensitivity analysis.Conclusion: FeNO monitoring generated cost savings in emergency settings for infants with persistent asthma. This evidence can be used bydecision makers in Colombia to improve clinical practice guidelines and should be replicated to validate the results in other middle-income countries (AU)

Antecedentes: El óxido nítrico en aire exhalado es una medición simple y no invasiva de la inflamación de las vías respiratorias cuyosresultados están disponibles en pocos minutos. Para los responsables de la formulación de políticas sanitarias, la principal preocupaciónes el impacto económico que implica la adaptación de esta tecnología, muy especialmente en los países en desarrollo. Este estudiotiene como objetivo evaluar el impacto presupuestario, en el sistema Nacional de Salud de Colombia, del manejo del asma mediante lamonitorización de óxido nítrico exhalado en pacientes entre 4 y 18 años.Métodos: Se realizó un análisis de impacto presupuestario para evaluar el posible impacto financiero derivado de la implementación de lamonitorización óxido nítrico exhalado fraccionado en el asma. El análisis consideró un horizonte temporal de 5 años y la perspectiva delSistema Nacional de Salud de Colombia. El impacto presupuestario incremental se calculó restando el coste del nuevo tratamiento, en elque se reembolsa el FeNO, del coste del tratamiento convencional sin FeNO (manejo basado en síntomas clínicos (con o sin espirometría /flujo máximo) o guías de asma (o ambos), para los relacionados con el asma). Se realizaron análisis de sensibilidad univariantes de una vía.Resultados: En el análisis del caso base, los costos a 5 años asociados a FeNO y no FeNO se estimaron en 469.904.130 € y 480.485.149 €respectivamente, lo que indica un ahorro para la Salud Nacional de Colombia de 10.581.019 € si se adopta la monitorización de FeNOen el manejo rutinario de pacientes con asma persistente. La solidez de este resultado fue confirmada en el análisis de sensibilidadunivariante, unidireccional.Conclusión: El óxido nítrico exhalado fraccionado ahorró costos en los entornos de emergencia en población pediátrica con asma persistente.Esta evidencia puede ser utilizada por los tomadores de decisiones en nuestro país para mejorar las guías de práctica clínic