Protocole National de Prévention et de Prise en Charge de la BPCO au Burundi

Objectives

Burundi’s national protocol on chronic obstructive pulmonary disease (COPD), developed under the Ministry of Public Health and the Fight against AIDS’ National Integrated Programme for Non-Communicable Chronic Diseases, provides a practical framework for preventing, diagnosing and managing COPD throughout the health-system pyramid.[1][2]It addresses COPD as a major cause of disability, exacerbations, mortality and high health expenditure, while recognising that national prevalence is unknown and that tobacco exposure is a principal risk factor.[3][4][5]

• Strengthen health workers’ COPD knowledge at community, health-centre and referral levels; facilitate diagnosis; improve care and complication management; and reduce COPD morbidity and mortality.[2]
• Prevent COPD by reducing tobacco use, second-hand smoke, biomass-smoke exposure, air pollution and occupational exposure to dusts and chemicals.[3][6][7]
• Promote complete and permanent smoking cessation, identified as the only intervention that changes COPD’s natural history, through early information, counselling and cessation support.[7][8]
• Improve patients’ breathlessness, exercise capacity and quality of life, while reducing respiratory-function decline, disability, chronic respiratory failure, exacerbations, hospitalisation and intensive-care needs.[7]
• Support early identification through clinical symptom assessment and spirometry, using post-bronchodilator airflow limitation to confirm persistent obstruction.[9]
• Provide integrated stable-disease and exacerbation care, including bronchodilators, appropriate corticosteroid use, respiratory physiotherapy, vaccination and escalation for severe or unresolved illness.[8][10][5]
• Prevent serious illness and mortality among people with COPD through influenza vaccination, and offer pneumococcal vaccination to older patients and selected younger patients with significant comorbidities.[7]

Implementation

The protocol uses a tiered delivery model spanning community services, health centres, first- and second-referral hospitals, and the national referral hospital, with level-specific responsibilities, medicines, personnel and equipment.[11][12][13][14]Community action combines health education, exposure reduction, follow-up and linkage with facilities; clinical services progressively provide diagnostic confirmation, treatment, referral and management of complicated disease.[15][16][17]Formal programme governance, implementation timelines, reporting systems and institutional accountability arrangements are not specified in the supplied extracts.[2][14]

• Disseminate tobacco-prevention information through media, schools, families, markets, health services, peer educators and other public places, and use home visits for counselling, surveillance, follow-up and referral linkage.[18][7][15]
• Identify tobacco use and biomass exposure routinely at health-centre consultations; advise non-smokers, support smokers to set a quit date, involve relatives where appropriate, prevent relapse and arrange follow-up.[18][8][15]
• Recognise suspected COPD from chronic dyspnoea, cough, sputum production, recurrent lower respiratory infections and exposure history, then undertake clinical assessment and refer for spirometry where required.[9][19][20]
• Confirm persistent airflow limitation by spirometry after bronchodilator administration, using a forced expiratory volume in one second to forced vital capacity ratio below 0.70.[9][21]
• Assess disease across spirometric impairment, symptom burden, exacerbation risk and coexisting conditions rather than relying on forced expiratory volume in one second alone.[21][22]
• Differentiate COPD from asthma, congestive heart failure, bronchiectasis, tuberculosis, obliterative bronchiolitis and diffuse panbronchiolitis using history, examination, imaging, microbiological tests and lung-function findings as relevant.[23][21]
• Classify airflow limitation after bronchodilator use as GOLD 1 when forced expiratory volume in one second is at least 80% predicted, GOLD 2 at 50% to below 80%, GOLD 3 at 30% to below 50%, and GOLD 4 below 30%, where the ratio remains below 0.70.[22]
• Deliver health-centre care through symptom treatment, exposure counselling, oxygen-saturation measurement, referral for pulmonary-function testing and initial management of exacerbations.[15][20]
• Provide first-referral hospitals with responsibility for clinical confirmation, dyspnoea assessment, stage-based treatment and recognition and treatment of exacerbations.[16][13]
• Use second-referral hospitals for spirometry, severity classification, management of exacerbations not improved at lower levels, and collaborative care of chronic respiratory failure with the national referral hospital.[13]
• Use the national referral hospital for arterial blood-gas testing, complicated cases unresolved at lower levels and follow-up of acute respiratory decompensation.[17]
• Manage exacerbations with rapid-acting bronchodilators, systemic corticosteroids when appropriate, antibiotics when clinically indicated, oxygen, rehydration when needed, treatment of precipitating causes, physiotherapy, early mobilisation and smoking-cessation advice.[10][20][16]
• Manage acute respiratory decompensation as a potentially fatal emergency by assessing respiratory, neurological and cardiovascular signs and providing oxygen targeted to saturation of 88% to 92%, bronchodilator treatment, short-course corticosteroids and antibiotics when indicated.[18][24][17]
• Refer or hospitalise patients with immediate danger signs, rapid deterioration, failed initial treatment, diagnostic uncertainty, severe baseline symptoms, frailty, inadequate home support, relevant comorbidities or prior intensive-care admission.[16]
• Equip services according to level with trained nurses and community health mediators, progressively broader multidisciplinary staff, bronchodilators, corticosteroids, antibiotics, vaccines, pulse oximetry, nebulisation, oxygen, spirometry, blood-gas analysis, imaging and laboratory testing.[14][4]
• Evaluate patients after exacerbations at one- to three-month intervals and refer those without clinical improvement; no formal national indicator framework or surveillance methodology is specified.[16]

Monitoring & Evaluation

Monitoring is primarily clinical and embedded in diagnosis, severity assessment, follow-up and referral rather than in a programme-wide performance framework. The protocol does not specify national indicators, routine reporting channels, surveillance architecture, evaluation schedules or formal accountability mechanisms.[2][15][13]

• Use post-bronchodilator spirometry to confirm persistent airflow obstruction, defined by a forced expiratory volume in one second to forced vital capacity ratio below 0.70.[9][21]
• Classify airflow limitation using Global Initiative for Chronic Obstructive Lung Disease stages: mild at a forced expiratory volume in one second of at least 80% predicted, moderate at 50% to below 80%, severe at 30% to below 50%, and very severe below 30%, after confirming obstruction.[22]
• Assess chronic obstructive pulmonary disease across spirometric impairment, current symptom burden, exacerbation risk and coexisting conditions, rather than relying on forced expiratory volume in one second alone to represent symptoms or health status.[21][22]
• Apply the modified Medical Research Council dyspnoea scale to assess breathlessness, ranging from grade 0 for breathlessness only with strenuous exertion to grade 4 for breathlessness that prevents leaving home or occurs while dressing.[25]
• Monitor suspected cases through clinical history, examination, respiratory rate, oxygen saturation, bronchodilator response and referral for spirometry, including reversibility testing.[20]
• Define significant bronchodilator reversibility as an increase in forced expiratory volume in one second of more than 200 millilitres and more than 12% from baseline; define complete reversibility as normalisation of the forced expiratory volume in one second to forced vital capacity ratio above 0.7.[20]
• Evaluate patients treated for an exacerbation at intervals of one to three months and refer those without clinical improvement.[16]
• Undertake community follow-up, surveillance and assessment of adherence to advice during home visits, with linkage to health facilities where needed.[15]
• Monitor acute respiratory decompensation using respiratory, neurological and cardiovascular signs, including increased work of breathing, inability to speak, drowsiness or confusion, hypotension and peripheral oedema.[17]
• Assess eligibility for long-term oxygen therapy through two room-air arterial blood-gas measurements taken at least three weeks apart, alongside assessment for signs of tissue hypoxia.[26]

Costing & Financing

No quantified budget, programme costing, allocation, financing mechanism, funding source, resource-mobilisation plan, funding gap or economic assumption is provided. However, the protocol identifies substantial service-resource requirements and recognises chronic obstructive pulmonary disease as a cause of high health expenditure and wider economic loss.[4][5][27]

• Identify shortages of diagnostic and complication-management equipment and of medicines as operational constraints affecting diagnosis and treatment.[3][2]
• Provide personnel, medicines and equipment across the health-service pyramid, from health centres to national referral hospitals, although no quantities or associated financial values are specified.[14][4]
• Equip higher-level facilities with oxygen sources, spirometry, arterial blood-gas analysis, radiography or computed tomography, laboratory testing and expanded clinical treatment options.[14][4]
• Recognise that long-term oxygen therapy, although clinically indicated for chronic respiratory failure in specified circumstances, is beyond the reach of resource-limited countries and that chronic respiratory failure care remains inaccessible in Burundi.[8][27]
• Make nicotine-replacement products available at a subsidised price to support smoking cessation, without specifying the subsidy amount, financing source or eligibility arrangements.[7][8]
• Recognise economic effects including high healthcare expenditure, premature loss of economically active people and broader consequences for national economic health, without quantified estimates.[5][27]