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I thought it would be easy: basic guidelines for hospital management of asthma. How wrong I was.
Constructing clinical guidelines is one of the tasks I’ve taken on for my year in Oshakati Hospital as a RCPCH/VSO paediatric fellow. Not wanting to be just another Oshilumbo who breezes in expecting the locals to do as I say, I set about trying to introduce my colleagues to evidence based medicine. Current journals and textbooks are hopelessly scarce but the Internet is accessible, and Namibia, classified by the World Bank as a lower middle income nation, qualifies for free online access to many journals.
So, I bravely said, don’t just do what I say, demand evidence (thereby asking them to do as I say). That was the first catch—there is very little evidence for a whole host of conditions one sees here; I’m still trying to work out how best to treat Onyalai, (a bleeding disorder that claims a child every month or so). Furthermore, evidence that does exist often has little relevance: not giving antibiotics for a sore throat may make sense in the UK, but after you’ve seen three cases of rheumatic heart disease that morning and the family are about to travel 50 miles back to their village—believe me, you too would over treat with antibiotics.
But asthma, that’s got to be easier; so much research, so many consensus statements, so many professionally designed guidelines.
The current in-house management for acute attacks relies on small doses of nebulised salbutamol with regular adrenaline. Metered dose inhalers are occasionally used for maintenance therapy when stocks of oral salbutamol run out but inhaled steroids are not used or even available (despite being on the Essential Drug List). Preventative therapy relies on theophylline and long courses of daily prednisolone.
I set out to encourage the use of standardised regular doses of nebulised salbutamol in preference to adrenaline for acute attacks. However, a Medline search I demonstrated to my colleagues to find randomised controlled trials revealed surprisingly few in favour of salbutamol, and fewer still for the dose I was recommending. It has been quite an experience to try to find trials to support practices that I regard as commonplace. Often the evidence is not there, how then can I advocate a change, or know that “my way” is indeed better?
Trials for outpatient maintenance therapy were a little more forthcoming. I could show inhaled salbutamol (and steroids) definitely work, and a few nice papers showing the effectiveness of homemade spacer devices. So having ascertained that salbutamol inhalers were in stock I considered it my duty to drink as much fizzy pop as was needed to keep the department in steady supply of plastic bottle spacers. It didn’t take too long before I was stumped again; the inhalers were just cartridge refills without the plastic delivery casing. Just how does that help? Surely the cost saving is minimal, and now we have several hundred unusable inhaler refills. Not to be defeated I modified my plastic bottle so that the cartridge can be pressed directly into a small hole, delivering a pleasing mist of beta2 agonist which a few well trained children have dutifully inhaled “fudha, fudha!” (breathe, breathe!).
To date, my efforts have yielded little reward; most parents patiently watch, then puzzlingly ask if they can now have some proper medicine and leave without their plastic bottle. A paediatric nurse mother demonstrated to me that her child’s inhaler worked much better when used in a “breath freshener” fashion than with the silly bottle thing.
So maybe there’s a compromise to be reached, maintenance therapy for any chronic condition is notoriously difficult to manage and sustain anywhere, never mind in rural communities in Africa where, for many, fine tuned health is an unattainable luxury.
I’m starting to comprehend the questions that must be asked of every trial and intervention: Is this relevant to my target population? And is this acceptable by my target population?
I’m prescribing oral salbutamol occasionally, the patients are happier and the clinic sister is satisfied that my consultation times are approaching those of my colleagues (3 to 5 minutes maximum). Theophylline remains the mainstay of background control but at least prednisolone courses are shorter. I still battle on with my inhalers and spacers and they’ve even let me include them in the new guidelines. Maybe not as many children are leaving with spacers as I’d like, but at least now that I’m drinking less fizzy pop my teeth stand a chance.