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chapter 10
Chronic Respiratory Disease
10.1 The Burden of Chronic Respiratory Disease in Rural Rwanda
The main forms of chronic respiratory disease (CRD) in Rwanda are
asthma, chronic obstructive pulmonary disease (COPD), and bronchiec-
tasis. Chronic care clinics in three Rwandan districts support more than
500 patients with CRD, most of whom are followed at the health center
level, mostly for asthma. Prior to treatment, these patients complained
of being limited in their ability to carry out farming or other chores that
are vital to a successful rural existence. Acute exacerbations of asthma
are also a significant cause of hospitalization and can be fatal. There is
no data available regarding population prevalence of CRD in rural Rwanda.
More generally, there is relatively little data on the prevalence of CRD in sub-Saharan Africa, and almost all of this data is regarding asthma in urban centers.1-4 Studies have found that rural areas on the continent probably have a lower prevalence of asthma (around 4% in school-aged children) than cities do (around 10% in the same population).5 Despite wide discussion of the so-called hygiene hypothesis, the reason for this difference is unknown.6 There is some evidence that asthma in rural areas is actually associated with malnutrition.7 10.1.1 The Impact of Biomass Fuels and Tuberculosis on Chronic Respiratory Disease Although in much of the world, tobacco is the main risk factor for CRD, tobacco use in rural Rwanda is low both in prevalence and intensity. The 2005 Demographic Health Survey found that only about 7% of the adult population smoked cigarettes.8 In order to prevent an epidemic of tobacco use, Rwanda has become a party to the Framework Convention on Tobacco Control, and is in the process of passing a ban on smoking in public places.8 Pulmonary tuberculosis (even after treatment), and exposure to par-ticulates from biomass fuels such as wood-burning stoves are probably much more significant risk factors for CRD in Rwanda than tobacco.9,10 In rural Rwanda, as in other areas of sub-Saharan Africa, nearly 90% of cooking is done with biomass fuels, and women and children may spend up to 7 hours a day exposed to the smoke. Rwanda has moved to dis-seminate improved cooking stoves in the entire country.
258 • chronic care integration for endemic non-communicable diseases 10.2 Integration of Chronic Respiratory Disease Management
at Health-Center Level
Many resources exist for sub-Saharan African countries seeking to improve services for chronic respiratory disease at the health-center level.11-16 These resources include practice guidelines from the Global Initiative for Asthma and the Global Initiative for Chronic Obstructive Lung Disease.17,18 The International Union Against Tuberculosis and Lung Disease (IUATLD) has prepared guidelines and training materials for asthma management in resource-poor settings.19 The IUATLD has also established an asthma drug facility that provides inhaled corticoste-roids at lower cost than what is often available on the market in many countries.20,21 The Stop TB department in the World Health Organiza-tion (WHO) has incorporated a program called the Practical Approach to Lung Health (PAL) as part of its strategy to improve case-finding for pulmonary tuberculosis.22 This chapter adapts existing approaches to CRD care integration to the Rwandan setting. There are a couple of aspects of this strategy that are unique. First, the evaluation of severe CRD takes place within a chronic care system capable of basic echocardiography. This probably avoids some misdiagnosis. Second, a network of chronic care community health workers is available to support adherence in advanced cases. 10.2.1 Initial Evaluation for Chronic Respiratory Disease at Health-Center Level Resource-poor settings face several challenges in the diagnosis and management of CRD. Dyspnea and chronic cough are at once very com-mon and very non-specific complaints. Tuberculosis and other infec-tious diseases, as well as heart failure, anemia, and parasitic infections, may all cause symptoms that mimic the presentation of asthma (short-ness of breath, cough, or wheezing). Even after other causes have been excluded, confirming chronic respiratory pathology can be difficult. Asthma is an intermittent disease, and patients may not have symptoms at the time of presentation to the clinic. Even in developed countries, asthma is a clinical diagnosis, though spirometry is helpful when avail-able. Somatization and anxiety are common in settings such as post-genocide Rwanda, and often feature shortness of breath.23 Furthermore, diagnostic tools such as spirometry are often unavailable, and simpler methods such as peak flow measurement are prone to high rates of error. In our model, most chronic respiratory disease management will take place at the level of the health center integrated chronic care clinic. These clinics also see patients with a variety of chronic illnesses with relatively simple treatment algorithms, such as most cases of hyperten-sion, epilepsy, non-insulin dependent diabetes, tuberculosis, and HIV. chapter 10 chronic respiratory disease • 259 oach adopted at PIH-supported sites for the initial diagnosis and management of chronic respiratory complaints that present to acute care clinics at health centers. PROTOCOL 10.1 Initial Management of Chronic Cough or Shortness of Breath
at Health Center Acute Care Clinics
Respiratory rate 1. Position (sit upright/leaning forward) ≥ 30/min AND wheezing
2. If wheezing, give salbutamol 2–4 sprays every OR patient acutely short of breath
15 min by metered dose inhaler with spacer Chronic cough OR
OR not able to walk unaided OR fever ≥ 39
shortness of breath 3. If known heart disease and uncomfortable Child: Respiratory rate > normal range
lying down, give furosemide (refer to acute for age (see Appendix E),
decompensated heart failure protocol) cyanosis, OR
4. Refer urgently to district hospital 1. Treat with antibiotics (Adult dosing: doxycycline
100 mg 2x/day x 14 days OR amoxicillin 500 mg
3x/day x 14 days. Pediatric dosing: amoxicillin
30 mg/kg/dose 3x/day x 10 days OR erythromycin
12.5 mg/kg/dose 3x/day x 3 days) 2. If wheezing, salbutamol inhaler 3. Have return in 1–2 weeks Cause of dyspnea 2. Obtain sputum smear x 3 orthopnea, known Refer to district hospital NCD clinic for heart condition, confirmation of suspected heart failure 1. Check hemoglobin if available 2. Start elemental iron, Adults: 60 mg 2x/day,
pallor, post-partum Children ≤ 40 kg: 2–3 mg/kg 1x/day
or other history of 3. Albendazole 400 mg x 1 dose (adult or child) OR Mebendazole (adults and children
≥ 1 year) 100 mg 2x/day x 3 days Refer to health center integrated worsened by climate chonic care clinic for probable change or exercise asthma or COPD (see Protocol 10.2)
260 • chronic care integration for endemic non-communicable diseases 10.2.2 Identification and Treatment of Emergency ConditionsClinicians must first determine whether the patient is in acute respira-tory distress (see o stabilize these patients with available tools: patient positioning, a beta-agonist and steroids if there are signs of bronchospasm, and furosemide if heart failure is suspected. We also recommend that all patients receive a dose of antibiotics until infection has been ruled out. It is preferable to use an agent that does not have anti-tuberculous activity, such as doxycycline, ampicillin, erythromycin, or trimethoprim-sulfamethoxazole (TMP-SMX), in case sputum smears are necessary to rule out tuberculosis. Once stabilized, all patients in respiratory distress should be referred urgently to the district-hospital level for inpatient admission.
TABLE 10.1 Evaluation of Asthma Attack Severity (Adapted from IUATLD Guidelines)19
Mild asthma
Moderate asthma Severe asthma
Imminent
respiratory
Very fast (≥30 Very fast (≥30 Pulse (ranges apply Peak expiratory flow ≤ 50% or ≤ 100 (PEF) after salbutamol (% of patient's best PEF or predicted PEF , 10.2.3 Exclusion of Causes Other Than Asthma and COPDIn the rural health center clinic, lack of diagnostic tools and high preva-lence of infectious respiratory disease necessitate exclusion of other diseases before making the diagnosis of COPD or asthma. For the most part, this can be done by taking a careful history of symptoms. Cer-tain symptoms should prompt further testing. outlines the common causes of chronic respiratory symptoms (lasting more than 3 weeks) seen at our clinics.
chapter 10 chronic respiratory disease • 261 TABLE 10.2 Causes of Chronic Dyspnea or Chronic Cough (≥ 3 Weeks)
Evaluate for
Episodic wheezing Progressively worsening dyspnea Large volume of purulent sputum Fever, acute dyspnea, productive cough Pulmonary tuberculosis Cough, hemoptysis, fevers, night sweats, weight loss Congestive heart failure Edema, orthopnea, rales Pulmonary hypertension and right Edema, ascites Gastrointestinal Gastroesophageal reflux disease Symptoms of reflux, heartburn Conjunctival pallor, measure hemoglobin Ear, nose, throat Allergic or non-allergic rhinitis Nasal congestion, itchy/watery eyes Postnasal drip, headache, rhinorrhea Dyspnea and chest tightness in social situations, palpitations, sweating, tingling in arms or fingers Usually non-productive cough shortly after starting the medication, though can occur at any time For obvious public health reasons, tuberculosis should be the first diagnosis to consider in all patients presenting with chronic respira-tory symptoms. Other infections such as pneumonia are also common causes. HIV is the major risk factor for tuberculosis in Rwanda, and all patients presenting with respiratory symptoms should have a test for HIV unless one has been administered within the past year. Patients who have recently been tested should be retested if they have a chronic cough (greater than 3 weeks) plus fever, significant weight loss, hemop-tysis or night sweats. These patients as well as those with HIV and respi-ratory symptoms should be treated empirically for a bacterial pneumo-nia with an antibiotic that does not have anti-tuberculous activity, such as doxycycline, erythromycin, TMP-SMX, or amoxicillin.
Patients may also have concomitant asthma and/or bronchospasm as a result of infection. These patients should also be given a short-acting beta agonist inhaler. Patients should return within 2–3 days to ensure that they are improving. If they have not improved, sputum smears should be performed to rule out active tuberculosis. The patient should be referred at this point to a district hospital for a chest x-ray. Patients with active tuberculosis in Rwanda are referred to the integrated chronic care clinic at health center for treatment.24 Patients without signs of an infectious process should be evaluated for signs of other etiologies of chronic respiratory symptoms, such as heart failure and anemia. 262 • chronic care integration for endemic non-communicable diseases Patients with typical signs and symptoms of asthma or COPD should be referred to the health center integrated chronic care clinic for diagnostic confirmation and initiation of treatment.
10.3 Diagnosis and Initial Management of Chronic Respiratory
Disease in Health Center Integrated Chronic Care Clinics
All patients referred to the health center chronic care clinic for chronic respiratory symptoms should first be evaluated for signs of respiratory decompensation and treated appropriately (see ).
Patients who are not in acute respiratory distress should next have a complete history taken and be given a physical examination. The exam should aim to confirm the diagnosis and to classify patients by disease severnative diagnosis, including anxiety/hyperventilation, among patients without classic sympt). Patients in whom the diagnosis is uncertain may be given a bronchodilator and instructed to return in sev-eral weeks or a month to determine whether the intervention is helpful or not. Practitioners must instruct patients in the correct use of inhalers and directly observe patients' inhaler technique at each visit to ensure that the medication is being properly delivered to the lungs. Some pa-tients who are not responding may in fact be using the inhaler incorrect-ly. If available, spacers (usually made from plastic water bottles) should be given to each patient who is using any kind of inhaler.
chapter 10 chronic respiratory disease • 263 PROTOCOL 10.2 Initial Management of Asthma or COPD at Integrated Chronic Care Clinics
1. Position (sit upright/leaning forward) Patient referred to 1. Patient acutely 2. Give salbutamol 2–4 sprays every 15 min by short of breath and wheezing OR
metered dose inhaler using a spacer chronic care clinic 2. RR ≥ 30 bpm if adult OR
3. If has productive cough OR fever, give dose of
(CCC) for suspected > normal range for doxycycline 100 mg OR amoxicillin 500 mg (adult
asthma OR COPD
dosing OR if child, give amoxicillin 30 mg/kg OR
erythromycin 12.5 mg/kg) 4. Give dose of prednisolone 2 mg/ kg (max 60 mg) 5. Refer urgently to district hospital Complete history and physical exam, including peak flow measurement 1. Consider alternative diagnosis, including 2. May give trial of salbutamol abnormal peak flow 3. Follow up in health center CCC OR wheezing on
2 weeks–2 months for reassessment 1. Start appropriate asthma treatment (see Table 10.6) and
give inhaler teaching 2. Albendazole 400 mg x 1 dose (adult or child) OR Mebendazole
(adults and children ≥ 1 year) 100 (see Table 10.4)
asthma OR
mg 2x/day x 3 days 3. Obtain sputum smear x 3 4. Refer to district hospital NCD clinic for CXR, echocardiography and higher-level evaluation 1. Start appropriate asthma treatment (see Table 10.6 ) and give inhaler teaching
2. Albendazole 400 mg x 1 dose (adult or child) OR Mebendazole (adults and
children ≥ 1 year) 100 mg 2x/day x 3 days if not treated within the last year 3. Education about avoidance of triggers 4. Follow-up in health center CCC 2 weeks 5. Obtain CXR within next 6 months TABLE 10.3 Common Signs and Symptoms of Asthma
Symptoms are intermittentSymptoms triggered by changes in weather, exposure to dust, exhaust, exercise or cooking smokeDyspneaWheezingCough Chest tightnessReduced PEF in setting of symptoms, 20% improvement with bronchodilators 264 • chronic care integration for endemic non-communicable diseases Patients for whom the diagnosis of asthma is likely should be classified according to disease sevacter-ized mainly by functional limitation, assessing the severity of a patient's asthma via symptoms can be very useful, especially in determining an initial medication regimen. At subsequent visits, an assessment should be made of how well the patient's symptoms are controlled on the cur-rent regimen. Our clinic uses questions based on the asthma control test ).25 The assessment should help determine whether the patient needs therapy increased, decreased, or maintained at the same level. All patients should have a chest x-ray performed within the first 3–4 months of diagnosis to rule out any structural cause of dyspnea (such as scarring, bronchiectasis, foreign body aspiration, or anatomic abnormalities). TABLE 10.4 Classification of Asthma Severity at Initial Visit26
Components of severity
≤ 2 days/week ≥ 2 days/week Daily Nighttime awakenings Salbutamol use for ≤ 2 days/week ≥ 2 days/week Daily Interference with Exacerbations requiring 0–1/year ≥ 2 exacerbations in 6 months requiring oral oral systemic cortico- systemic corticosteroids, OR ≥ 4 wheezing
steroids (prednisolone) episodes/year lasting ≥ 1 day AND risk factors
for persistent asthma Consider severity and interval since last exacerbation. Frequency and severity may fluctuate over time. Exacerbations of any severity may occur in patients in any severity category. chapter 10 chronic respiratory disease • 265 TABLE 10.5 Asthma Control Test25
Maximum score is 25 (points are 1–5 in order as below)
≤ 19 means asthma may not be well controlled
In the past 4 weeks, how much of the time did
your asthma keep you from getting as much done
at work, school, or home?
A little of the time During the past 4 weeks, how often have you had
More than once a day shortness of breath?
3–6 times a week Once or twice a week During the past 4 weeks, how often did your
4 or more nights a week asthma symptoms (wheezing, coughing,
shortness of breath, chest tightness or pain)
2 or 3 nights a week wake you up at night or earlier than usual in
the morning?
During the past 4 weeks, how often have you
3 or more times per day used your rescue inhaler (salbutamol)?
1 or 2 times per day 2 or 3 times per week Once a week or less How would you rate your asthma control during
Not controlled at all the past 4 weeks?
Poorly controlled Somewhat controlled Completely controlled Our approach does not ask clinicians to differentiate between COPD and asthma. To do so would likely be impractical in the rural Rwandan chronic care clinic. Risk factors for COPD in our setting are not well understood. Tobacco smoking, the main cause of COPD in industrial-ized regions, is relatively rare in Rwanda and, when present, is rarely of an intensity or duration likely to cause COPD. Possible causes of COPD, such as repeated exposure to cooking smoke, are hard to quantify. While spirometry may be available at some district hospital clinics, results are both effort-dependent and potentially misleading. Furthermore, we assert that the same simplified strategy can successfully manage both conditions in our setting. With the exception of long-acting beta agonists 266 • chronic care integration for endemic non-communicable diseases and anticholinergics, both of which are not readily available in settings such as rural Rwanda, the treatment of these two conditions is similar. As with asthma, patients with suspected COPD should be referred to social work for assessment of indoor air pollution and possible cooking stove improvement.
10.3.1 Step Therapy for Asthma or COPD at Health Centers
Once disease severity has been established, patients should be started
on the appropriate therapy (see ). We have
adapted the step therapy model promoted by the Global Initiative for
Asthma (GINA) to the Rwandan setting using the following principles:
• Patient education: All patients should receive education about
avoidance of triggers, as well as education on the use of the inhaler pumps. Ability to correctly use inhalers should be confirmed by whomever is instructing the patient, and confirmed again at each appointment, particularly if symptoms are not controlled. Where possible, patients should be given spacers (made from plastic water bottles) to be used with their inhalers.
• Rescue medications:
Short-acting beta-agonist—For all patients with asthma, salbuta-mol should be used as a rescue therapy to control crisis symptoms. Patients should be educated that this medication helps to stop an attack. While oral or injectable salbutamol is widely available, we do not recommend its use. Systemic use of beta-agonists can cause dangerous rises in heart rate and blood pressure due to their non-selective effects. The effect of inhaled salbutamol is relatively limited to the airways without much systemic absorption.
Oral steroids—For patients in the midst of an acute, severe attack, or for patients with persistent uncontrolled symptoms, a prednisolone burst can be given. We recommend a short burst (0.5 mg/kg twice a day for adults or 2 mg/kg once a day for children < 30 kg for 5 days) as a trial. If this fails to control symptoms or if symptoms rebound, a longer steroid taper (7–14 days) may be given. • Controller medications:
For all patients with persistent symptoms (mild, moderate, or se-vere), treatment should include medications to reduce the frequency of attacks. Patients should be educated that these medications need to be taken on a daily basis for effective prevention. Patients using steroid inhalers should be instructed to rinse their mouths out with water after each use, since the medication can land in their mouths and sometimes lead to thrush.
chapter 10 chronic respiratory disease • 267 Inhaled steroids—An inhaled steroid such as beclomethasone should be the first controller medication added. The dose of beclomethasone depends on the severity of the patient's symptAminophylline—Aminophylline is widely available and can be used as a second-line medication in adults if symptoms are not controlled with inhaled corticosteroids.27,28 However, if taken at high doses, aminophylline can have toxic effects (particularly nausea, headache, low blood pressure, and seizures). Doses less than 10 mg/kg/day in adults are generally well tolerated.29 Aminophylline also interacts with many common medications (particularly cimetidine, flucon-azole, erythromycin, and ritonavir), and the dose should be reduced if there is potential for drug-drug interaction. Oral aminophylline should not be used for acute exacerbations. Aminophylline should not be used in pregnancy.30 We also do not use aminophylline in children. In the future, other, safer agents may help to replace aminophylline as the second-line agent of choice for asthma and COPD.
Long-acting beta-agonists—Long-acting preparations of beta-agonist drugs can help prevent and control asthma symptoms when taken on a daily basis. Currently, these medications are not available in Rwanda, but they may be an option in the future.
• Medication adjustment: As a patient's symptoms stabilize, monitor-
ing on the current regimen should continue for about 3–6 months. If symptoms remain stable, the therapy can be reduced. The protocol will depend in part on how severe symptoms were initially. Some-times patients will need controller therapy for a few years or even for the rest of their lives. Others may have symptoms only in the set-ting of a respiratory infection. Some cases will not fit neatly into the protocol. In such cases, providers should use their best judgments, provided these are based on the underlying principles for managing asthma. If uncertainty persists, the patient should be seen in consul-tation with a doctor.
• Level of care and frequency of visits: Patients with severe disease
should be evaluated at the district hospital NCD clinic and receive an extensive work-up for alternative diagnoses, such as tuberculosis or heart failure. Patients with mild or moderate symptoms will be man-aged at the health center NCD clinic. Follow-up interval should also depend on symptom severity.
• Adjunctive medications:
Anti-helminthics—Although likely not a common cause of asthma symptoms, parasitemia (especially Strongyloides stercoralis) can cause wheezing and other respiratory symptoms. Treatment is both inexpensive and effective. Therefore, we recommend treating 268 • chronic care integration for endemic non-communicable diseases all newly diagnosed patients with albendazole 400 mg x 1 dose or Mebendazole 100 mg 2x/day for 3 days, if they have not already been treated for parasites within the last year.
Acid-controllers—Gastroesophogeal reflux disease (GERD) can oc-casionally cause or exacerbate asthma symptoms. If patients report symptoms of GERD, the clinician may consider a trial of an H2-block-er (cimetidine, ranitidine) or a proton pump inhibitor (omeprazole). If after 2–4 weeks symptoms have improved, the clinician should consider continuing the medication long term. Patients should also be instructed on ways to reduce GERD, such as making sure to stay upright 30–60 minutes after meals, not eating before going to bed, and sleeping with the head and torso propped up.
Antihistamines—Patients suspected of having asthma should also be asked about symptoms of allergic rhinitis, such as itchy or watery eyes, itchy or runny nose, itchy ears, post-nasal drip, and frequent sneezing or cough without concomitant infection. Although the prev-alence of allergic rhinitis in the Rwandan population is not known, it is common worldwide and has been reported to be common in other African countries, including Nigeria, Zimbabwe, and South Africa.1,31-33 Allergic rhinitis often exacerbates asthma. Treating patients with allergic rhinitis who also have asthma can decrease exacerbation and hospitalization rates by 80%.34 Treatment can be initiated with anti-histamines (chlorpheniramine).
TABLE 10.6 Asthma Step Therapy
Salbutamol Beclomethasone Aminophylline Prednisone (for use only in Step 5: Severe uncontrolled Step 4: Severe persistent Step 3: Moderate persistent Yes Step 2: Mild persistent STEP when poor c
STEP when doing w Step 1: Intermittent
chapter 10 chronic respiratory disease • 269 TABLE 10.7 Asthma Medication Dosing
100 mcg (inhaler)
50 and 250 mcg (inhaler) 100 mg tab
Always use a spacer
1–2 puffs, 3x/day 1500 mcg (3 puffs 2x/d) (max 60 mg) x 5 days.
If no response, can do a taper over 7–14 days.
If new CRD diagnosis, first, rule out TB (smear 1–2 puffs, 3x/day 2 mg/kg once per day x 5 days (max 60 mg).
If no response, can do a taper over 7–14 days.
(1 puff 2x/d)
Low:
REFER TO PHYSICIAN
Very small children should use a metered-dose inhaler with a spacer, or a nebulizer if available.
10.4 Follow-Up Management of Asthma
outlines subsequent management of patients with an
established diagnosis of asthma.
As with other visits, the follow-up visit should first focus on identifying signs of acute respiratory distress and treating accordingly. Next, the clinician should ask the patients about frequency of symp-toms. Questions from the Asthma Control T) can be used. Vital signs, a lung exam, and peak flow measurement should be performed. Using this data, the clinician should consider how well con-trolled the patient's symptoms are and decide whether therapy should be continued, increased, or decreased. 270 • chronic care integration for endemic non-communicable diseases PROTOCOL 10.3 Follow-Up Management of Asthma or COPD
at Health-Center Level
Continue maximum therapy1. 2. Refer to district hospital NCD clinic if child, give
OR
Step up treatment e Table 10.6(se follow up in 2 weeks
fever, give dose of doxycycline
OR
erythromycin 12.5 mg/kg
OR
therapy Table 10.6
Step down continue current Position (sit upright/leaning forward) Give salbutamol 2–4 sprays every 15 min by metered dose inhaler with a spacer If has productive cough 100 mg or amoxicillin 500 mg if adult amoxicillin 30 mg/kg Give dose of prednisolone 2 mg/kg (max 60 mg) Refer urgently to hospital > normal range
OR
e Table 10.5
Appendix
for age if child (se Assess degree of asthma control, compare to last visit breath and wheezing ≥ 30 bpm Continue current therapy, return in 3 months Patient with diagnosis of asthma or chapter 10 chronic respiratory disease • 271 Most patients should improve within 3–6 months of receiving consis-tent, adequate treatment.
Patients whose symptoms are not well controlled may need more inten-sive therapy. Before intensifying treatment, the clinician should make sure that the patient is adherent to the medications and can demon-strate good inhaler technique. If the clinician believes a worsening of symptoms is due to a temporary exacerbating factor (viral infection or exposure to a known allergen), then intensification of controller medica-tions may not be necessary, or can be employed for a short period only. Patients who are still uncontrolled after a trial of maximum therapy should be referred to the district hospital NCD clinic for evaluation by a physician.
Patients who have achieved symptom control after at least 3–6 months of therapy may be eligible for a reduction in therapy intensity. This should be undertaken with care, in stages. Further reductions should be pursued only after a 3–6 month trial at the new level of treatment. If patients worsen on the less intensive treatment, the higher intensity treatment should be resumed and maintained for one to two years be-fore reduction is again attempted.
Patients well controlled on a stable regimen will require less frequent clinic visits. Some patients may only require visits every 6 (or even 12) months.
10.5 Bronchiectasis
Bronchiectasis is abnormal and irreversible dilatation of the airways,
usually due to scarring from previous infection, especially tubercu-
losis, pneumonia, and pertussis, as well as from other infections. HIV
can predispose people to bronchiectasis, most likely from recurrent
infections.35,36 People with bronchiectasis usually have chronic produc-
tive cough, shortness of breath, and recurrent infections. Often they
also have chest pain (usually pleuritic) and hemoptysis. Occasionally
they have wheezing. Diagnosis can be made by CXR, which can reveal
thickened airways or evidence of scarring. CT scans, if available, reveal
dilated and thickened airways. Symptoms of exacerbations include in-
creased sputum production, fever, shortness of breath, and cough. Exac-
erbations should be treated with antibiotics (such as doxycyline) for at
least 7–10 days, sometimes for as long as 14 days. Anti-pseudomonals,
such as ciprofloxacin, may be needed if the patient does not improve. It
may be beneficial to give inhaled steroids on a continuing basis. In some
studies, this approach led to decreased airway inflammation and clinical
improvement.37,38 It is not unreasonable to try inhaled beta-agonists and
272 • chronic care integration for endemic non-communicable diseases continue them if there is symptomatic improvement. Ongoing sputum clearance techniques, such as chest percussion, breathing techniques, and postural drainage, are effective and can be an important means for staving off exacerbations.39 Such interventions can be performed by a patient's family members or by a community health worker, if the patient has one.
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Draft hkctt editorial policy

Editorial Guide on Hong Kong Clinical Terminology Table – Drugs (Medication Terminology Table) [Document Reference No. G52] Version 1.1 January 2015 The Government of the Hong Kong Special Administrative Region Editorial Guide on Hong Kong Clinical Terminology Table – Drugs (Medication Terminology Table)

Sanofi and lilly announce licensing agreement for cialis® (tadalafil) otc

Sanofi and Lilly announce licensing agreement for Cialis® (tadalafil) OTC - Companies anticipate providing over-the-counter (OTC) product to treat erectile dysfunction after expiration of certain patents - PARIS, France, and INDIANAPOLIS, May 28, 2014 — Sanofi (EURONEXT: SAN and NYSE: SNY) and Eli Lilly and Company (NYSE: LLY) today announced an agreement to pursue regulatory approval of nonprescription Cialis (tadalafil). Cialis is currently available by prescription only worldwide for the treatment of men with erectile dysfunction (ED). Under the terms of the agreement, Sanofi acquires the exclusive rights to apply for approval of Cialis OTC in the United States, Europe, Canada and Australia. Sanofi also holds exclusive rights to market Cialis OTC following Sanofi's receipt of all necessary regulatory approvals. If approved, Sanofi anticipates providing Cialis OTC after expiration of certain patents. Terms of the licensing agreement were not disclosed. "This agreement provides us with an opportunity to work with Lilly, a leader in men's health, to transform how this important medicine is offered to millions of men throughout the world," said Vincent Warnery, senior vice president, Global Consumer Healthcare Division, Sanofi. "The opportunity to forge an industry-leading partnership that adds to Sanofi Consumer Healthcare's leading portfolio and successful track record of over-the-counter switches reinforces consumer health care as a major growth platform for Sanofi." "Millions of men worldwide trust Cialis to treat ED. We are pleased to work with Sanofi to pursue a path that could allow more men who suffer from ED to obtain convenient access to a safe and reliable product without a prescription," said David Ricks, senior vice president, Lilly, and president, Lilly Bio-Medicines. "Switching a medicine to over-the-counter is a highly regulated process that is data-driven and scientifically rigorous. Together with Sanofi, we look forward to working closely with regulatory authorities to define the proper actions and necessary precautions to help patients use over-the-counter Cialis appropriately." Cialis was first approved by the European Medicines Agency in 2002, then by the U.S. Food and Drug Administration in 2003, for the treatment of erectile dysfunction. Ultimately, Cialis has received approval in more than 120 countries for indications that vary by country, including erectile dysfunction and erectile dysfunction and the signs and symptoms of benign prostatic hyperplasia (BPH). Cialis reached $2.16 billion USD (€1.58 billion) in worldwide sales in 2013 and has recorded total global sales of more than $14 billion USD (€10.2 billion) since launch. To date, more than 45 million men worldwide have been treated with Cialis. About Cialis Currently only available with a prescription, Cialis is a tablet taken to treat erectile dysfunction (ED), the signs and symptoms of benign prostatic hyperplasia (BPH), and both ED and the