Respiratory Medicine (1995) 89, 35-39 Knowledge of asthma and its management in newly qualified doctors in Accra, Ghana I. F. A. HESSE Department of Medicine, University of Ghana Medical School, PO Box 4236, Accra, Ghana This study assessed first-year doctors’ (House Officers) knowledge of asthma at the Korle-Bu Teaching Hospital. Seventy-two out of 80 doctors answered 32 questions on various aspects of asthma. Many of these doctors managed between one to three asthmatics per week. Few, however, did so by acceptable standards. In assessing the severity of asthma, 88% looked for cyanosis, 69% looked for pulsus paradoxicus and 63% looked for a fast pulse rate. Only 63% considered the measurement of peak expiratory flow useful. Ninety-four per cent used intravenous aminophylline, 82% intravenous hydrocortisone and 14% oxygen as the drug of choice for acute severe asthma. In moderate forms of acute asthma, 54% used salbutamol inhaler or intravenous aminophylline, 28% oxygen, 15% steroid inhaler and 14% oral prednisolone. Nebulized bronchodilators are not well known for use in either severe or moderate asthma and only 19-21% of doctors had prescribed their use. In chronic asthma, 55565% of respondents prescribed bronchodilators compared to 19-35% who gave anti-inflammatory drugs. These results reveal insufficient knowledge of the pathophysiology of asthma, the use of standard drugs in asthma therapy and international guidelines for the management of asthma. The results also show that the pragmatic constraints which exist in developing countries preclude the adoption of international guidelines without local modification. Introduction morbidity of asthma in developing countries in par- Asthma is now recognized to be due to chronic ticular, education of health personnel and even of inflammation of the airways. There is evidence of patients on principles of the management of asthma inflammation even in patients with mild forms of the is essential (8). This need has, indeed, been empha- disease (1). This current view of the pathophysiology sized in the international guidelines for assessment of the disease has altered the traditional methods and treatment of asthma (2). of management. Internationally, the rationale of In Ghana, bronchial asthma is well known and management is primarily to reduce inflammation. commonly encountered in clinical practice. However, Anti-inflammatory drugs are generally preferred to very little systematic work has been done to establish bronchodilators in modern practice (2). its prevalence and the level of mortality. It is also The disease still has a significant morbidity and important to determine the level of knowledge of mortality which may increase worldwide despite the practising doctors in Ghana of the disease and its availability of potent drugs. Among the major factors management. The present study focuses on recently which contribute to the morbidity and mortality of qualified doctors who, presumably, have current asthma are under-diagnosis and under-treatment by knowledge of the management of asthma from recent medical personnel and patients (3-5). Factors related medical school training. A reason for choosing this to the availability of health care are also major group is that House Officers are first-in-line for the contributors (6,7). In Third World countries where management of emergencies including asthma. Man- hospital facilities are inadequate and where current agement problems are more likely to be associated information about management may not be readily with this group. available, morbidity and mortality are expected to be even higher. Lack of knowledge of the pathophysiol- Methods ogy of asthma has also contributed to the morbidity and mortality of the disease. To reduce mortality and Seventy-two out of 80 House Officers (aged 25-32 years) at the Korle-Bu Teaching Hospital (KBTH) in Received 1 October 1993 and accepted in revised form 25 March Accra participated in this study. KBTH is the pri- 1994. mary referral centre in Ghana. It has a bed capacity 0954-61 I1/95/010035+05 $08.0010 c 1995 W. B. Saunders Company Ltd 36 I. I; A. Hesse of 1700, and is the main hospital for training students Table 1 Drugs which House Officers would use in the from the University of Ghana Medical School. management of acute asthmatic attack House Officers involved in this study had worked in the KBTH for up to 12 months after graduation from No. (“36) of House Officers medical school. They included doctors trained at the Moderate Severe University of Ghana Medical School, the School of asthma asthma Medical Sciences, Kumasi and a number from schools outside Ghana. Salbutamol inhaler 39 (54) 17 (24) Each respondent answered 32 questions on various Aminophylline injection 39 (54) 68 (94) aspects of asthma, including its management. Some Fran01 tablets 26 (36) 5 (7) of the questions demanded multiple responses to Oxygen 20 (28) 53 (74) Hydrocortisone injection 12 (17) 59 (82) determine degree of knowledge. The areas surveyed Nebulized bronchodilators 15 (21) 21 (29) included Aminophylline tablets 9 (13) 1 (1) 1. experience with the management of asthma; Steroid inhaler 11 (15) 6 (8) 2. assessingt he severity of asthma; Prednisolone tablets 10 (14) 18 (25) 3. choice of drugs for managing acute and chronic Adrenaline injection (1:lOOO) 8 (11) 17 (24) Salbutamol tablets asthma; 7 (10) 2 (3) Salbutamol injection 4 (6) 8 (11) 4. knowledge of the effectiveness of drugs commonly Others 3 (4) 6 (8) used; 5. the use of analgesics, sedatives and tranquillizers for asthma; Table 2 Drugs which House Officers would use in the 6. knowledge of nebulized bronchodilators. maintenance treatment of chronic asthma The results were analysed and expressed as num- bers or percentages of those who responded. No. (%) of House Officers Results Salbutamol tablets 47 (65) Salbutamol inhaler 46 (64) EXPERIENCE WITH THE MANAGEMENT OF ASTHMA Fran01 39 (55) During the 3 month study, 51% of House Officers Ketotifen 25 (35) Prednisolone 21 (29) managed one to three asthmatics a month, 25% Aminophylline tablets 16 (22) between one to three per week and 24% had no Steroid inhaler 14 (19) experience of the management of asthma. Of those Others 16 (22) who had managed patients with asthma, 82% were satisfied with the results of their management, 11% were not sure and 7% were unhappy. severe acute asthma. House Officers seldom used oxygen for mild-to-moderate acute asthma, and not ASSESSING THEI SEVERITY OF ASTHMA all used it for severe asthma. In assessingt he severity of asthma, 88% of House If the patient failed to improve after initial man- Officers looked for cyanosis, 69% for pulsus para- agement, 46% of House Officers referred them to a doxicus, 63% for a rapid pulse rate, 60% for difficulty specialist, 33% increased the dose of the first-line in talking, eating and walking, 36% for the degree of drug, 14% continued management as before and 8% anxiety of the patient, 25% for the intensity of wheeze added steroids if these were not used initially. Ten per and 57% elicited history regarding the duration of the cent of respondents did not know what to do next for attack. Only 63% indicated they used peak expiration such patients. flow to determine the severity of asthma. DRUGS USED FOR THE CONTINUING MANAGEMENT OF DRUGS USED FOR MANAGING ACUTE ASTHMA ASTHMA The results are summarized in Table 1. Bronchodi- The choice of drugs for the continuing manage- lators were the most popular drugs used for both ment of asthma is shown in Table 2. Bronchodilators mild-to-moderate and severe asthma; 36% would were again more popular than anti-inflammatory even consider prescribing Franol, a drug which 63% agents. As many as 44% of House Officers continued knew contained ephedrine and theophylline, and only with bronchodilators for patients whose asthma 43% knew contained phenobarbitone. Steroids, espe- attacks became more frequent, while 21% were not cially by inhalation, were least popular, except for sure what to do for such individuals. Doctors’ knowledge of asthma in Accra 37 Table 3 House Officers’ choice of drugs for acute asthma require expensive equipment, and 54% indicated that which they considered to be most effective with minimal only piped oxygen was required. This is compared to side-effects 40% who knew about the availability of nebulized No. (“VI) of House Officers /I-adrenergic agonists at KBTH. INTRAVENOUS ADMINISTRATION OF AMINOPHYLLINE Hydrocortisone injection 29 (40) Prednisolone tablets With regard to the intravenous administration of 5 (7) Aminophylline injection 41 (66) aminophylline, the survey revealed the following: (i) Salbutamol inhaler 19 (26) 24% of House Officers did not know the loading dose Fran01 tablets 4 (6) of aminophylline; (ii) 44% gave this drug at the Salbutamol tablets 5 (7) dosage of 5 mg kg- ’ body weight; (iii) 76% gave an Adrenaline (1: 1000) injection 9 (12) initial dose of 250 mg in an adult; and (iv) 32% did Aminophylline tablets 0 (0) Steroid inhaler 6 not know the recommended duration for injection of (8) Nebulized salbutamol 26 (36) the loading dose - 3% injected the loading dose over Salbutamol injection 1 (1) 5 min, 56% over 10 min and 10% did so over 20 min. Theophylline injection 3 (4) Thirty-three per cent of those surveyed reduced the loading dose of aminophylline for patients with renal failure, 19% for chronic alcoholics, 15% for smokers, DRUGS CONSIDERED MOST EFFECTIVE AND WITH 60% for patients with impairment of liver function MINIMAL SIDE-EFFECTS and 33% for patients on oral xanthines. Approxi- These are shown in Table 3. Aminophylline (iv) mately half the number of House Officers (55%) did was considered the drug of choice followed by hydro- not know when to modify the loading dose of cortisone (iv), nebulized salbutamol and salbutamol aminophylline. inhaler. Although 44% of House Officers knew that steroid inhalers were available in Ghana, only 8% THE PEAK FLOW METER considered them to be effective and to have only Thirty-three per cent of House Officers indicated minimal side-effects. Ninety-two per cent knew of the they did not know about the peak flow meter and 7% availability of salbutamol inhaler in Ghana but only thought it was expensive. Only 10% did not regard it 26% indicated that it was effective and safe. In as necessary for managing asthma. contrast, 90% of those who used nebulized salbuta- mol considered it effective and safe, compared with 67% of those who used aminophylline (iv). Discussion With reference to the international guidelines for USE OF ANALGESICS, SEDATIVES AND TRANQUILLIZERS the management of asthma (2), this survey reveals FOR MANAGING ACUTE ASTHMA that only 25% of House Officers surveyed managed Forty-six per cent of House Officers did not give asthma patients properly. Fifty per cent have insufB- any form of analgesic, sedative or tranquillizer for cient knowledge of asthma, and 25% have little or no the management of acute and severe asthma. Twenty- knowledge of managing the disease. This is disturb- three per cent gave diazepam and 11% phenobarbi- ing and probably contributes to the high morbidity tone. Eighteen per cent were not certain whether to and mortality of the disease in Ghana. It also reveals use these drugs or not. One person indicated recourse possible deficiencies in the basic medical training to pethidine and another to chlorpromazine for the programme that must be addressed. treatment of severe asthma. The drugs named were The initial assessment of the severity of asthma is administered for various reasons including allevia- crucial to proper and adequate management of the tion of anxiety, direct treatment of asthma, induction disease and to its future course. It is worrying there- of sleep and relaxation of the patient. Twenty-eight fore that many House Officers did not know the early per cent of those who gave such drugs did not symptoms and signs important for the proper assess- indicate the rationale for their use. ment of the severity of the disease. Most would wait for gross and late signs, such as pulsus paradoxicus NEBULIZATION OF BRONCHODILATORS or cyanosis, and some would not even recognize such Seventy-one per cent of House Officers indicated signs. Few knew about assessing the severity of the that nebulization of P-adrenergic agonists was effec- disease by peak expiratory flow equipment. This is tive in the treatment of asthma, 28% did not know not surprising, as this inexpensive equipment is not what this was, 69% thought nebulization did not readily available in Ghana. This is therefore one of 38 I. F. A. Hesse the major contributory factors to the poor manage- Stepcare or stepwise approach to the therapeutic ment of the disease. management of asthma is recommended in the inter- Based on the pathophysiology of the disease, national guidelines (2). Fortunately, many House corticosteroids are introduced early in the treatment Officers follow this practice and would either increase of acute asthma, especially in those refractory to the dosage of drug used or refer difficult cases to a bronchodilators or with severe forms of the disease specialist. This is good practice and should still be (2,9). From this study, most House Officers for emphasized in the educational programme of medical instance, reserved hydrocortisone (iv) for critical schools in the Third World in particular. emergencies. They also preferred hydrocortisone (iv) Although the mainstay of modern maintenance to prednisolone tablets, suggesting they did not know management of chronic asthma is with anti- prednisolone was as effective as hydrocortisone for inflammatory agents, particularly inhaled agents, most cases of acute asthma, which is well established only a minority of House Officers used such treat- (2,lO). It is indicative of the lack of knowledge ment. Several factors may explain this. The first is of the pathophysiology of the disease that many again the lack of knowledge of the pathophysiology House Officers preferred bronchodilators to steroids. of the disease, another reason is that anti- Another reason for this could be that House Officers inflammatory agents known to be available in Ghana were not aware that the effects of steroids manifest at by the House Officers were also the ones they least 4 h and sometimes days after administration indicated were not effective or safe. Due to their (9-11). Certainly, this would explain why many did inexperience, the House Officers were probably not not describe steroid inhalers. It is also possible that aware of the beneficial effects of the early introduc- House Officers do not prefer steroids as they are not tion of inhaled corticosteroids (12). Inhaled cortico- aware that the short term use of systemic steroids is steroids were not well known by the House Officers, without significant long term side-effects. while other prophylactic agents, such as sodium Use of aminophylline for managing acute asthma cromoglycate and nedocromil sodium, were thought is still controversial. Indeed, its use within the first 4 h not to be available in Ghana. The relatively higher of treatment in hospital has not been recommended cost of inhaled prophylactic agents compared with (2). Among House Officers, however, aminophylline oral bronchodilators was also contributory to their was the drug of choice for severe asthma. Two low usage. reasons may be adduced for this. Firstly, it is likely The fact that Fran01 was commonly used under- that most House Officers choose this drug because scores the problem of poor knowledge of asthma and few side-effects are known from its use locally, com- of the drugs available for its management. This drug, pared with observations elsewhere. This observation which is a combination of ephedrine (11 mg), theo- by itself is of research interest, suggesting genetic phylline (120 mg) and phenobarbitone (8 mg), is very differences in response to the drug. Secondly, it is popular with Ghanaian patients, not only because of more readily available, relatively inexpensive and its addictive properties but also because it is very is recommended in the Ghana National Formulary cheap. In most countries the sedative component has (13). been removed but this is not so for Ghana and for Nebulized p-adrenergic agonists which are known many other developing countries. The drug is still to have few side-effects and to be effective in manag- popular with House Officers though nearly all did not ing asthma were used by only a few House Officers. think highly of it. The data clearly showed that the This is because they are not readily available. From danger of sedation in asthma is not recognized by a the survey, House Officers who used them confirmed significant majority. that they were valuable and effective. If this form of The problems raised by the results of this survey treatment was readily available in the hospitals, are considerable. Since these doctors received medical many more House Officers would use it and the education in many parts of the world, the deficiencies management of asthma would improve even where found may be more widespread than this study knowledge of the pathophysiology of the disease is indicated. There is firstly a great need for adequate poor. Asthmatics would benefit greatly, as oxygen is education of newly-qualified doctors on asthma and also included in this method of management. It its management. Here, the international guidelines should be noted that most House Officers surveyed in the management of asthma should be stressed. would not give oxygen in asthma because they did Secondly, teaching hospitals should have the essential not appreciate that there is some level of hypoxia equipment for managing asthma adequately. This even in mild asthma. As many as 25% did not use should help inculcate good practice in House Officers oxygen even for severe asthma. for their future contribution to asthma health Doctors’ knowledge of asthma in Accra 39 education and care. Thirdly, in Third World coun- 5. Speight ANP, Lee DA, Hey EN. Underdiagnosis and tries, where financial resources are scarce, drugs undertreatment of asthma in childhood. BMJ 1983; imported or manufactured for asthma should be 286: 125331258. limited to those which are effective, inexpensive and 6. Spitzer WO, Suissa S, Ernst P et al. The use of P-agonists and the risk of death and near death from have minimal side-effects. Lastly, the wide variation asthma. N Engl J Med 1992; 326: 501-516. in the practices of these doctors indicates a need for 7. Weiss KB, Wagener DK. Changing patterns of asthma guidelines for asthma management in developing mortality - identifying target populations at high risk. countries such as Ghana. These guidelines should JAMA 1990; 264: 1683-1687. take cognizance of local circumstances, such as drug 8. Mayo PH, Richman J, Harris HW. Results of a pro- gram to reduce admissions for adult asthma. Ann Intern availability, cost and any variability in the response Med 1990; 112: 866871. to various drugs. 9. Haskell RJ, Wong BM, Hansen JE. .4 double- blind randomized clinical trial of methylprednisolone in status asthmaticus. Arch Intern Med 1983; 143: References 13241327. Jeffery PK, Wardlaw AJ, Nelson FC, Collins JV, Kay 10. Ratto D, Alfaro C, Sipsey J et al. Are intravenous AB. Bronchial biopsies in asthma: an ultrastructural, corticosteroids required in status asthmaticus? JAMA quantitative study and correlation with hyperreactivity. 1988; 260: 527-529. Am Rev Respir Dis 1989; 140: 17451753. 11. Britton MG, Collins JV, Brown D, Fairhurst NPA, National Heart, Lung and Blood Institute. Interna- Lambert RG. High dose corticosteroids in severe acute tional Consensus Report on Diagnosis and Treatment asthma. BMJ 1976; 2: 73-74. of Asthma. Bethesda, MD: US Department of Health 12. Haahtela T, Jarvineu M, Kava T et al. Comparison of and Human Services, 1992 (NIH publication No. &agonist, terbutaline, an inhaled corticosteroid, 92-3091). budesonide, in newly diagnosed asthma. N Engl J Med Johnson AJ, Nunn AJ, Sommer AR, Stableforth DE, 1991; 325: 388-392. Stewart CJ. Circumstances of death from asthma. BMJ 13. Republic of Ghana Ministry of Health. The Provisional 1984; 288: 1870-1872. Essential Drugs List and National Formulary of Ghana, Sears MR, Rea HH, Rothwell RPF et al. Asthma 1988. mortality: comparison between New Zealand and England. BMJ 1986; 293: 1342-1345.