Optimizing respiratory management in resource-limited settings

Rebecca Inglis, Emmanuel Ayebale, Marcus J Schultz, Rebecca Inglis, Emmanuel Ayebale, Marcus J Schultz

Abstract

Purpose of review: This review focuses on the emerging body of literature regarding the management of acute respiratory failure in low- and middle-income countries (LMICs). The aim is to abstract management principles that are of relevance across a variety of settings where resources are severely limited.

Recent findings: Mechanical ventilation is an expensive intervention associated with considerable mortality and a high rate of iatrogenic complications in many LMICs. Recent case series report crude mortality rates for ventilated patients of between 36 and 72%. Measures to avert the need for invasive mechanical ventilation in LMICs are showing promise: bubble continuous positive airway pressure has been demonstrated to decrease mortality in children with acute respiratory failure and trials suggest that noninvasive ventilation can be conducted safely in settings where resources are low.

Summary: The management of patients with acute respiratory failure in LMICs should focus on avoiding intubation where possible, improving the safety of mechanical ventilation and expediting weaning. Future directions should involve the development and trialing of robust and context-appropriate respiratory support technology.

Figures

Box 1
Box 1
no caption available
FIGURE 1
FIGURE 1
Proposed interventions to improve outcomes in patients with acute respiratory failure in low-income and middle-income countries. ∗Evidence-based interventions; ^Authors’ opinions only, with further research required.
FIGURE 2
FIGURE 2
Proposed order of priority for respiratory support interventions.

References

    1. GBD 2015 Healthcare Access and Quality Collaborators Healthcare Access and Quality Index based on mortality from causes amenable to personal healthcare in 195 countries and territories, 1990–2015: a novel analysis from the Global Burden of Disease Study 2015. Lancet 2017; 390:231–266.
    1. Kruk ME, Gage AD, Arsenault C, et al. The Lancet Global Health Commission High-quality health systems in the sustainable development goals era: time for a revolution. Lancet Glob Health 2018; 6:e1196–e1252.

    2. The report highlights the fact that poor-quality care is common and a systems wide approach is required to improve health outcomes worldwide.

    1. Mandelzweig K, Leligdowicz A, Murthy S, et al. Noninvasive ventilation in children and adults in low- and low-middle income countries: a systematic review and meta-analysis. J Crit Care 2018; 47:310–319.

    2. The meta-analysis provides the most comprehensive view to date of the use of noninvasive ventilation in low- and middle-income countries (LMICs).

    1. Franca SA, Junior CT, Hovnanian ALD, et al. The epidemiology of acute respiratory failure in hospitalized patients: a Brazilian prospective cohort study. J Crit Care 2011; 26:e1–e8.
    1. Azevedo LCP, Park M, Salluh JIF, et al. Clinical outcomes of patients requiring ventilatory support in Brazilian intensive care units: a multicenter, prospective, cohort study. Crit Care 2013; 17:R63.
    1. Prin M, Itaye T, Clark S, et al. Critical care in a tertiary hospital in Malawi. World J Surg 2016; 40:2635–2642.
    1. Khatib KI, Dixit SB, Joshi MM. Factors determining outcomes in adult patient undergoing mechanical ventilation: a ‘ real-world’ retrospective study in an Indian Intensive Care Unit. Int J Crit Illn Inj Sci 2018; 8:9–16.
    1. Mehta AB, Syeda SN, Wiener RS, Walkey AJ. Epidemiological trends in invasive mechanical ventilation in the United States: a population-based study. J Crit Care 2015; 30:1217–1221.
    1. Intensive Care National Audit and Research Centre Key statistics from the case mix programme. 2017; Available from: . [Accessed 20 September 2018].
    1. La JG, Madotto F, Bellani G, et al. Geo-economic variations in epidemiology, patterns of care, and outcomes in patients with acute respiratory distress syndrome: insights from the LUNG SAFE prospective cohort study. Lancet Respir Med 2017; 5:627–638.

    2. A prospective cohort of patients with acute respiratory distress syndrome (ARDS) which demonstrated a strong association between a country's economic status and ARDS survival.

    1. Divatia JV, Amin PR, Ramakrishnan N, et al. Intensive care in India: The Indian Intensive Care Case Mix and Practice Patterns Study. Indian J Crit Care Med 2016; 20:216–225.
    1. Towey RM, Amito J, Mer M. Intensive care medicine in rural sub-Saharan Africa. Anaesthesia 2017; 5:181–189.
    1. Karthikeyan B, Kadhiravan T, Deepanjali S. Case-mix, care processes and outcomes in medically-ill patients receiving mechanical ventilation in a low-resource setting from southern india: a prospective clinical case series. PLoS One 2015; 164:1–16.
    1. World Health Organization Road traffic injuries fact sheet. 2018; Available from: . [Accessed 20 September 2018].
    1. Dewan MC, Rattani A, Gupta S, et al. Estimating the global incidence of traumatic brain injury. J Neurosurg 2018; Published online April 27, 2018; DOI: 10.3171/2017.10.JNS17352.
    1. Bonell A, Azarrafiy R, Thi V, et al. A systematic review and meta-analysis of ventilator-associated pneumonia in adults in Asia: an analysis of national income level on incidence and etiology. Clin Infect Dis 2018; 1–8. doi:10.1093/cid/ciy543 [Epub ahead of print].

    2. A meta-analysis that shows that the rate of ventilator-associated pneumonia is higher in LMIC than high-income countries (HIC).

    1. Phu VD, Nadjm B, Hoang N, et al. Ventilator-associated respiratory infection in a resource-restricted setting: impact and etiology. J Intensive Care 2017; 5:1–9.

    2. A prospective multicenter study in Vietnam showed that ventilator-associated infections are associated with increased patient costs and length of stay.

    1. de Souza Kock K, Maurici R. Respiratory mechanics, ventilator-associated pneumonia and outcomes in intensive care unit. World J Crit Care 2018; 7:24–30.
    1. Leligdowicz A, Bhagwanjee S, Diaz JV, et al. Development of an intensive care unit resource assessment survey for the care of critically ill patients in resource-limited settings. J Crit Care 2017; 38:172–176.

    2. The study developed a survey of available resources to manage critically ill patients in resource-limited settings and gives results from ICUs in nine LMICs.

    1. Haniffa R, De Silva AP, Iddagoda S, et al. A cross-sectional survey of critical care services in Sri Lanka: a lower middle-income country. J Crit Care 2014; 29:764–768.
    1. Baker T, Lugazia E, Eriksen J, et al. Emergency and critical care services in Tanzania: a survey of ten hospitals. BMC Health Serv Res 2013; 13:140.
    1. Dobson M. The right stuff – anaesthetic equipment and techniques that work best in low resource countries. 2017; Oxford: First Edit. MD Publications,

    2. The book is an excellent resource to understand more about equipment challenges and solutions in LMICs.

    1. Sarvestani AS, Sienko KH. Medical device landscape for communicable and noncommunicable diseases in low-income countries. Global Health 2018; 14:65.
    1. Vukoja M, Riviello E, Gavrilovic S, et al. A survey on critical care resources and practices in low- and middle-income countries. Glob Heart 2014; 9:337–342.e5.
    1. Lee A, Sing Y, Cheung L, et al. Are high nurse workload/staffing ratios associated with decreased survival in critically ill patients? Ann Intensive Care 2017; 7:46.

    2. Conducted in an HIC, this cohort study links inadequate staffing levels with poor outcomes for crtically ill patients.

    1. World Health Organization. Integrated management for emergency and essential surgical care (IMEESC) toolkit [Internet]. Available from: [Accessed 20 September 2018]
    1. Vincent J, Marshall JC, Ñamendys-Silva SA, et al. Assessment of the worldwide burden of critical illness: the Intensive Care Over Nations (ICON) audit. Lancet Respir Med 2014; 2:380–386.
    1. Ye Y, Zhu B, Jiang L, et al. A contemporary assessment of acute mechanical ventilation in Beijing: description, costs, and outcomes. Crit Care Med 2017; 45:1160–1167.
    1. Blanch L, François F, Amin P, et al. Triage decisions for ICU admission: report from the Task Force of the World Federation of Societies of Intensive and Critical Care Medicine. J Crit Care 2016; 36:301–305.

    2. Consensus recommendations to ensure optimal and equitable use of critical care resources.

    1. Duke T, Wandi F, Jonathan M, et al. Improved oxygen systems for childhood pneumonia: a multihospital effectiveness study in Papua New Guinea. Lancet 2008; 372:1328–1333.
    1. Ginsburg AS, Van Cleve W, Thompson M, English M. Oxygen and pulse oximetry in childhood pneumonia: a survey of healthcare providers in resource-limited settings. J Trop Pediatr 2012; 58:389–393.
    1. Graham HR, Bakare AA, Gray A, et al. Adoption of paediatric and neonatal pulse oximetry by 12 hospitals in Nigeria: a mixed-methods realist evaluation. BMJ Glob Heal 2018; 3:e000812.

    2. The study gives valuable lessons about how to promote oximetry more effectively and demonstrates an approach that can be extened to other healthcare devices.

    1. O’Driscoll BR, Howard L, Earis J, et al. BTS guideline for oxygen use in adults in healthcare and emergency settings. Thorax 2017; 72:ii1–ii90.
    1. Maitland K, Kiguli S, Opoka RO, et al. Children’ s Oxygen Administration Strategies Trial (COAST): a randomised controlled trial of high flow versus oxygen versus control in African children with severe pneumonia [version 2; referees: 2 approved]. Wellcome Open Res 2018.
    1. Chisti MJ, Mbbs MAS, Frca JHS, et al. Bubble continuous positive airway pressure for children with severe pneumonia and hypoxaemia in Bangladesh: an open, randomised controlled trial. Lancet 2015; 386:1057–1065.

    2. The randomized controlled trial showed a mortality benefit with bubble-continuous positive airway pressure (CPAP).

    1. Kawaza K, Machen HE, Brown J, et al. Efficacy of a low-cost bubble CPAP system in treatment of respiratory distress in a Neonatal Ward in Malawi. PLoS One 2014; 9:e86327.
    1. Wilson PT, Baiden F, Brooks JC, et al. Continuous positive airway pressure for children with undifferentiated respiratory distress in Ghana: an open-label, cluster, crossover trial. Lancet Glob Health 2017; 5:e615–e623.

    2. The trial demonstrated a mortality benefit of bubble-CPAP in the subgroup of patients less than 1 year old.

    1. Ekhaguere OA, Mairami AB, Kirpalani H. Risk and benefits of bubble continuous positive airway pressure for neonatal and childhood respiratory diseases in low- and middle-income countries. Paediatr Respir Rev 2018; 10.1016/j.prrv.2018.04.00410.1016/j.prrv.2018.04.004. [Epub ahead of print; Accessed 20 September 2018].

    2. The review article pools the findings from Refs. [35▪,36,37▪].

    1. Duke T. CPAP: a guide for clinicians in developing countries. Paediatr Int Child Health 2014; 34:3–11.
    1. Wilson PT, Brooks JC, Otupiri E, et al. Aftermath of a clinical trial: evaluating the sustainability of a medical device intervention in Ghana. J Trop Pediatr 2014; 60:33–39.
    1. Rochwerg B, Brochard L, Elliott MW, et al. Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure. Eur Respir J 2017; 50: Available from: 10.1183/13993003.02426-2016. [Accessed 20 September 2018].
    1. Serpa Neto A, Schultz MJ, Festic E. Ventilatory support of patients with sepsis or septic shock in resource-limited settings. Intensive Care Med 2016; 42:100–103.
    1. Jooste R, Roberts F, Mndolo S, et al. Global Capnography Project (GCAP): implementation of capnography in Malawi – an international anaesthesia quality improvement project. Anaesthesia 2018; [Epub ahead of print].

    2. The mixed methods study is the first to explore implementation of capnography in an LMIC.

    1. Gelb AW, Morriss FWW, Johnson FW, Merry AF. World Health Organization-World Federation of Societies of Anaesthesiologists (WHO-WFSA) International Standards for a Safe Practice of Anesthesia. Can J Anesthesiol 2018; 126:2047–2055.

    2. The consensus document provides minimum standards for the safe practice of anesthesia worldwide.

    1. Barwise A, Garcia-arguello L, Dong Y, et al. Checklist for Early Recognition and Treatment of Acute Illness (CERTAIN): evolution of a content management system for point-of-care clinical decision support. BMC Med Inform Decis Mak 2016; 16:127.
    1. Lee JS, Roberts SWP, Götsch K, et al. Caring for critically ill patients in humanitarian settings. Am J Respir Crit Care Med 2018; [Epub ahead of print].

    2. A review article exploring the provision of critical care in a humanitarian context, with some helpful practical advice.

    1. Diamedica (UK) Ltd. Baby CPAP [Internet]. Available from: [Accessed 20 September 2018]
    1. Gradian Health Systems. The Gradian Comprehensive Care Ventilator [Internet]. Available from: [Accessed 20 September 2018]
    1. Douglas TS, Haile DA, Atwine D, et al. Building needs-based healthcare technology competencies across Africa. S Afr J Sci 2017; 113:2017.

    2. The report contains links to the African Biomedical Engineering Consortium website.

    1. Dessap AM. Frugal innovation for critical care. Intensive Care Med 2018; [Epub ahead of print].

    2. A must-read opinion piece that makes the case for frugal innovation in critical care.

Source: PubMed

스폰서 및 공동 작업자

건강 상태

약물 개입

3
구독하다