PEN-Plus Clinical Tools and Programmatic Standards

PEN-PLUS CLINICAL TOOLS AND PROGRAMMATIC STANDARDS

Disclaimer: This booklet is a selection of high value tools from the PEN-Plus Resource Library developed by the NCDI Poverty Network. The Resource Library is an online repository of tools to help to support initial implementation of PEN-Plus. All tools included in this booklet have received input and validation from the PEN-Plus Expert Groups (Sickle Cell Disease, Diabetes, and Cardiac) and are aimed to support frontline PEN-Plus providers. The online Resource Library will continue to incorporate edits. These tools are consistent with vetted PEN-Plus training tools, but where applicable, providers should defer to national treatment guidelines.

See link below for full PEN-Plus Resource Library including an electronic version of this booklet https://drive.google.com/drive/folders/1_x8QHVAD0QVKt1cVGsxdePtMTY8I_tZW We welcome comments on this toolkit and will incorporate them in the next version. Please send any comments or questions to the following addresses; ewroe@bwh.harvard.edu; kdomingues@bwh. harvard.edu; colinpfaff5@gmail.com Version 1. April 2024

Table of Contents Section 1: PEN-Plus Essential programmatic standards

1

1.1 PEN-Plus: Essential Programmatic Standards

2

1.2 Programmatic Standards Checklist

7 13

1.3 Indicators for programmatic standards

Section 2:Tools for cardiac disease

14

2.1 Protocol For Heart Failure

15

2.2 Pediatric Protocol For Heart Failure

16

2.3 Warfarin dose adjustment chart

16

Section 3: Tools for diabetes

17

3.1 Pen-Plus Working Definition Of T1D Diagnosis

18

3.2 Insulin Regimen Options 3.3 How To Adjust Insulin Doses Based On Home Glucometer Readings

19 20

3.4 Using correction scales (mmol/L)

21

3.5 Using correction scales (mg/dL)

22 23 24 25

3.6 Diabetic Ketoacidosis (DKA) Algorithm - Adults 3.7 Diabetic Ketoacidosis (DKA) Algorithm - Children 3.8 DKA Monitoring Chart

Section 4: Tools for Sickle Cell Disease

26

4.1 Screening for SCD using rapid tests

27

4.2 Sickle Cell Disease: Prevention Protocol 4.3 Hydroxyurea (HU) Protocol

28 29

4.4 Hydroxyurea dose chart for use in sickle cell disease

30

4.5 Blood Transfusion (Emergency simple) 4.6 Pain Management Protocol

31 31

4.7 Acute Complications Protocol

32

Section 5: Tools for Respiratory Disease

33

5.1 Asthma Out-Patient Management Chart

34

5.2 Asthma Exacerbation Management Chart

35

5.3 COPD Out-Patient Management Chart

36 37 38

5.4 COPD Exacerbation Management Chart 5.5 How to make a bottle spacer

SECTION 1

PEN-PLUS ESSENTIAL PROGRAMMATIC STANDARDS

PEN-Plus Essential programmatic standards

1.1 PEN-Plus: Essential Programmatic Standards Introduction What is PEN-Plus?

PEN-Plus complements the World Health Organization’s (WHO) Package for Essential NCDs (PEN).

Whereas WHO PEN focuses on primary care for common chronic NCDs, PEN-Plus focuses on care at the secondary level for more severe conditions, including type 1 diabetes (T1D), sickle cell disease (SCD), and rheumatic and congenital heart disease. PEN-Plus is a clinical model that provides high-quality longitudinal care for people living with severe and chronic NCDs. It is an integrated strategy that focuses on developing teams of nurses, clinical officers, other mid-level providers, and often general medical officers working at first-level hospitals, such as district hospitals. These expert NCD teams focus on diagnosis and care for chronic NCDs that may require services beyond primary care, focusing on caring for patients at the hospital level as well as supporting primary care systems through mentorship and referrals.

Who is this document for?

This document is for anyone leading, implementing, funding, advising on, or advocating for PEN-Plus clinics. It is meant to aid clinic and program planning, budgeting, and operations by providing a crisp definition of PEN-Plus clinical care, including the diagnostic, treatment, and patient support services available. With a clear definition of these services, stakedholders can extrapolate additional parts of the program, such as lists of essential medications and equipment, training needs, and healthcareprovider competencies.

How was this document created?

The PEN-Plus Essential Programmatic Standards are drawn from years of experience implementing PENPlus across 14 countries. The first version of the document was drafted based on models of care in these countries and informed by multiple sources: •

Clinical experts, ministries of health, healthcare providers, and other partners with PEN-Plus experience;

•

Clinical Expert Groups in T1D, SCD, and cardiac care through the PEN-Plus Partnership, composed of clinical specialists and other providers across the NCDI Poverty Network;

•

Clinical outcomes data from early PEN-Plus clinics in Rwanda, Malawi, Liberia, and Haiti; and

•

PEN-Plus training packages, which were refined with input from the above sources over several years.

How should this document be used?

This document can be used as a reference document both for planning a PEN-Plus program and for assessing and refining existing PEN-Plus clinics. A few pointers: •

In defining different diagnostic and treatment services, this document assumes on-site availability and functionality at the PEN-Plus clinic, unless otherwise indicated.

•

“Availability” also assumes that key components—including durables, consumables, and staff skills and competencies—that are required to make services possible are available as well.

•

This will be a living document that will change and adapt as PEN-Plus systems strengthen and higher levels of care and standards are achieved.

2

Diagnosis & Treatment Standards Condition Area (conditions that are part of PEN-Plus across the lifespan)

Essential Part of Package vs. Adapted to Context

Type 1 diabetes

Essential

Cardiac: congenital heart disease, rheumatic heart disease, heart failure

Essential

Sickle cell disease

Essential (unless not present from an epidemiologic perspective)

Severe asthma

Adapted to context

Chronic liver conditions

Adapted to context

Chronic kidney conditions

Adapted to context

Other*

Adapted to context

*Other conditions that might be part of these categories—such as insulin-dependent type 2 diabetes, other types of heart conditions, other hemoglobinopathies, and epilepsy—can all be part of the package, depending on the context.

Cross-cutting Standards Diagnosis • • • • •

Basic physical exam and vital signs equipment: stethoscopes, pulse oximetry probes (both pediatric and adult), blood pressure cuffs, thermometers, weighing scales, MUAC tape Full blood count Urinalysis

Chest x-ray

Blood electrolytes, liver function, kidney function

Treatment and Support Outpatient • Patients with conditions in the PEN-Plus package are diagnosed and cared for across the lifespan, with no age limits to enrollment, treatment, or access to PEN-Plus resources • • • • • •

Trained PEN-Plus clinical providers are consistently available in the clinic

Patients are given appointment dates and tracked to ensure longitudinal follow-ups

Inpatient • Treatment of NCD emergencies with diagnosis and management • •

Identification of new cases of people admitted with severe NCDs Education, discharge planning, and referrals to PEN-Plus

Social support mechanisms are in place to avoid catastrophic costs—such as consultation fees, medications, lab testing, and transport fees—for patients who need that support Patients are enrolled in medical insurance, if available

Social support systems are also in place to identify and address specific vulnerabilities, such as food insecurity and school fees

The longitudinal data system tracks patient appointments and individual medical records with data elements required for reporting on core and clinical indicators

Other

• • • • 3

Case finding is incorporated into inpatient settings, outpatient clinics, other specialized clinics, and—where appropriate—community settings Peer-support opportunities are available to people living with PEN-Plus conditions

Contextualized referral procedures are available for complex cases and those requiring specialist assistance, such as surgical options for cardiac patients; exchange transfusions, bone marrow transplant, and hip replacement for patients with sickle cell disease; and gastroscopy and banding for patients with liver disease Linkage with other services at the facility as needed, including mental health and palliative care

PEN-Plus Essential programmatic standards

Type 1 Diabetes Diagnosis and Treatment Standards Diagnosis • • •

Fingerstick blood glucose; hemoglobin A1C

The facility is equipped to diagnose diabetic ketoacidosis (DKA) with blood glucose and urine dipstick with ketones Optimal: blood electrolytes, kidney function

Treatment and Support Outpatient • • • • • • •

Insulin regimens using basal bolus with long-acting insulin (e.g., NPH or glargine) and rapid mealtime insulin

Inpatient •

Treatment of DKA with

· IV fluids (normal saline and/or Ringer’s lactate);

Home glucometers, lancets, and test strips available free of charge (quantity: 3 checks per day or 90 per month)

· Short-acting insulin;

Check A1C every 3 to 6 months

· Potassium replacement (IV preferred); and

Behavioral counseling on diabetes self-management; availability of diabetes educator Adolescent- and young-adult-specific counseling and therapy

Screening and management for complications including diabetic ulcers, retinopathy, neuropathy, and proteinuria

· Monitoring for fluids, fluid sequestration, and urine output.

•

Optimal: IV pump

Co-management with a nutritionist, if available

Cardiovascular Diagnosis and Treatment Standards Diagnosis •

Echocardiography*, gel, and a place to perform echocardiography

•

ECG (minimum of single lead)

•

*2D echo minimum, color flow Doppler, image archiving system, cardiac probe (optional capabilities are spectral PW/ CW Doppler)

Electrolytes, kidney function, INR

Treatment and Support Outpatient • • • • • • • • • • • • •

Echocardiography with a trained clinician for initial diagnosis and routine follow-up echo

Inpatient •

Monitoring for atrial fibrillation with ECG

Display and use of the PEN-Plus cardiac failure protocol to guide assignment of diagnostic category and treatment

· IV diuretics, e.g., furosemide; · IV hydralazine or IV labetalol

Treatment of heart conditions with furosemide, ACE inhibitors, betablockers, spironolactone, hydralazine, isosorbide dinitrate, aspirin, calcium channel blockers, and thiazide diuretics

· Heparin; and

Pediatric formulations of furosemide, spironolactone, and propranolol

•

Optimal: Anticoagulation options include low-molecular-weight heparin during pregnancy

•

Treatment with long-term anticoagulation, including warfarin with routine INR monitoring

Secondary prophylaxis for rheumatic heart disease with oral and IM penicillin (and penicillin alternatives for those allergic)

Treatment for heart failure exacerbations, hypertensive emergency or urgency, and other cardiac complications with:

· Medications on the outpatient list

Identification of potential children with congenital heart disease and referral for cardiologist evaluation

Optimal: Access to cardiac surgery for some subset of patients every year

Management of anticoagulation for thromboembolism, including initiation with heparin and transition to outpatient therapy Management of complex cases of hypertension that cannot be managed at the primary care level Capability for remote review of echo images, such as by referral hospital cardiology clinicians, cardiac surgeons, or mentors

Referral pathway for patients who need cardiologist evaluation, including those with rheumatic or congenital heart disease Post-surgical long-term follow-up and management for patients who receive cardiac surgery for rheumatic or congenital heart disease

4

Sickle Cell Disease Diagnosis and Treatment Standards Diagnosis •

Rapid confirmatory testing (SickleScan, HemotypeSC, or Gazelle Hb variant)

•

Optional: sickling test, peripheral smear Per national guidelines: Send out to the lab for advanced confirmatory testing (e.g., Hb electrophoresis, isoelectric focusing (IEF), or high-performance liquid chromatography (HPLC))

•

•

Routine use of on-site testing for people with signs and symptoms of SCD, per the PEN-Plus diagnostic testing algorithm

Treatment and Support Outpatient • •

• •

• • • •

Hydroxyurea treatment (initiated based on on-site testing availability) as per the PEN-Plus protocol

Inpatient •

Treatment of acute events with: ·

Optimal: Pediatric formulation of hydroxyurea Treatment monitoring with complete blood count, Hb Preferable: Liver function tests, kidney function Preventive care with folic acid, antibiotic prophylaxis, vaccination, and malaria prophylaxis as per the PENPlus protocol Pain control, with narcotics available as needed Counseling and education on SCD-related complications, a healthy diet, nutrition, hydration, hygiene, and prevention of acute events Specific care for SCD during pregnancy, including close monitoring, medication changes per protocols, and ensuring the availability of facility-based delivery with referrals when indicated

· ·

·

Emergency blood transfusions; IVF (RL, NS, or DNS);

Pain control, including IV narcotics (e.g., morphine or other opioids), as needed; and IV antibiotics

Respiratory Disease Diagnosis and Treatment Standards Diagnosis •

Chest x-ray and GeneXpert

•

Optimal: Use of spirometry to confirm asthma based on reversibility and/or to identify additional possible causes of respiratory symptoms

•

Consider: Peak flow

Treatment and Support Outpatient • • • • • • • • • 5

Determination of a clear diagnosis of asthma, with other causes excluded (e.g., TB, a cardiac cause, cancer, COPD) Treatment with inhaled beta-agonists (e.g., salbutamol), inhaled corticosteroids, inhaled ipratropium bromide No patients on oral salbutamol

All asthma patients are, at a minimum, on a rescue or short-acting beta-agonist inhaler (SABA) and inhaled corticosteroids (ICS) An inhaler-technique assessment on all patients, with appropriate counseling and teaching on inhaler technique Counseling on identifying and avoiding triggers Availability of spacer device

Treatment of acute illness with oral steroids and antibiotics as needed

Optimal: A written action plan for patients to increase their own steroid dose if their condition worsens

Inpatient •

Treatment of acute exacerbations or illness with:

· · · ·

Oxygen;

Nebulizers;

Steroids, including an IV option; Antibiotics

PEN-Plus Essential programmatic standards

Liver Disease Diagnosis and Treatment Standards Diagnosis •

Liver function tests, electrolytes

•

Abdominal ultrasound

• •

•

Full blood count (platelets)

Optimal: Hepatitis B surface antigen, hepatitis C antibody Optimal: Microscopy of ascitic fluid, serum albumin, and fluid albumin

Treatment and Support Outpatient

Inpatient

•

•

•

Diuretic therapy with furosemide, spironolactone

•

Beta-blocker therapy if the patient is at risk for esophageal varices bleeding

• • • •

Antibiotic prophylaxis for a history of spontaneous bacterial peritonitis

Scheduled or outpatient paracentesis as indicated

•

Paracentesis

•

Optimal: Lactulose therapy for hepatic encephalopathy Optimal: Proton-pump inhibitor therapy and blood transfusion for esophageal bleeding

•

Optimal: Lactulose for hepatic encephalopathy Optimal: Serum electrolytes Optimal: Antiviral treatment for chronic hepatitis B or C infection with routine laboratory monitoring

IV antibiotics for spontaneous bacterial peritonitis

Kidney Disease Diagnosis and Treatment Standards Diagnosis •

Urine dipstick

•

Renal ultrasound

• • •

Creatinine and electrolytes HIV testing Optimal: Urine microscopy

Treatment and Support Outpatient

Inpatient

•

•

•

Diuretic therapy as indicated

•

ACE inhibitors

• • • •

Treatment for hypertension Iron supplementation

Laboratory monitoring for kidney function, electrolytes, and Hb

•

IV diuretics

•

Treatment of urinary obstruction

•

IV antihypertensives Palliative care

Treatment and follow-up for nephrotic syndrome, including steroids

Treatment for symptoms and co-morbidities, including depression, poor nutrition, pain, delirium, and other palliative-care needs

6

1.2 Programmatic Standards Checklist This checklist can be used as a quick guide to determine whether a given PEN-Plus clinic is meeting the programmatic standards and to help identify areas for early action.

Cross Cutting / Health Systems Staffing

Notes

c Nonspecialist providers are consistently available on-site to provide integrated chronic care for severe NCDs (A nonspecialist—or mid-level—provider refers to nurses, clinical officers, or medical officers, depending on the context.)

c Number of providers trained is adequate to meet both the clinic’s volume needs and staffing schedules

c The same health care providers are dedicated to the clinic and are consistently

staffing the clinic week to week (as opposed to all hospital staff rotating through the clinic)

c Clinic staff members have received thorough training in the diagnosis and

management of the prioritized severe, chronic NCDs to care for those patients across the lifespan

Case finding procedures

Notes

c There is a clear linkage from the inpatient setting for people with severe, chronic NCDs to be enrolled directly in the PEN-Plus clinic prior to discharge

c Enrollment into the PEN-Plus program is open to patients of all ages, with conditions

in the PEN-Plus package guiding eligibility, noting that the PEN-Plus conditions often occur in children, adolescents, and young adults, necessitating diagnosis and care across the lifespan

c Staff in outpatient clinics (such as adult and pediatric OPD) have a working

knowledge of the signs and symptoms of severe NCDs and can refer patients to the PEN-Plus clinic for diagnostic workup and enrollment to care

c Community outreach includes education for severe NCDs and, where appropriate, screening and linkage to PEN-Plus care, such as through school programs and community health workers

Appointment structure

Notes

c A dedicated and consistent space enables the clinic to be held on all PEN-Plus clinic days

c There are designated days when the PEN-Plus clinic is held, and all staff and re-

sources are available during those days. (Note: This may be every day of the week.)

c Clinic days are scheduled such that severe or complex conditions have sufficient

clinician time for appointments. (This indicates a need to separate clinical time for severe or complex NCDs from primary care high-volume conditions, such as hypertension.)

c Optimal: There is a mechanism to track upcoming appointments and provide appointment reminders at least once weekly

Social work & social support

c All patients are receiving lab testing and treatment either for free or at minimal cost

for those who can pay (with or without insurance coverage); all those who cannot pay are receiving services without out-of-pocket fees

7

Notes

PEN-Plus Essential programmatic standards

c

The clinic has a mechanism to identify missed visits in a timely manner AND to perform outreach to try to bring people back to care

c

The clinic has a mechanism for assessing each patient’s vulnerability and social support needs

c

The clinic has a social support program for patients who are the most vulnerable and/ or the most at risk of being lost to follow-up. This includes, at minimum, coverage of user and clinical fees for any needed medications or diagnostics and transport fees for patients deemed to need it.

Cross-Cutting Equipment (all of these items are consistently and reliably available)

c

Full blood count

c

Basic physical exam and vital signs equipment, including stethoscopes, pulse oximetry probes (both pediatric and adult), blood pressure cuffs, and thermometers

c c c

Urinalysis

Notes

Optimal: Chest X-ray Blood electrolyte, liver function, and kidney function tests

Data Systems

c

The clinic has a longitudinal data system—such as a patient file or electronic medical record system—that allows clinical and other staff to track patients in place and over time

c

Data collected routinely for each patient visit include PEN-Plus standardized data elements (“phase 0 data elements”)

c

Data systems allow for quarterly aggregation of “core indicators” with a reasonable degree of effort by staff

c

Clinic staff can obtain longitudinal cohort data, clinical outcomes data, and other patient-level metrics through a manual chart review or digital data extraction

c

The PEN-Plus team works with staff trained in data collection, quality, and aggregation

c

The clinic’s data system can produce any nationally or regionally mandated indicators— such as ministry of health indicators for health management information systems—for severe NCDs

Notes

Diabetes All must be consistently available

c c c c c

Glucometer, test strips, and lancing devices

c c c

Insulin syringes

Notes

A1C testing Urine dipstick for ketones and protein Long acting insulin Short- or rapid-acting insulin

Inpatient therapy for DKA with IV fluids, insulin, and potassium replacement Glucose solution for hypoglycemic emergencies

Patients with T1D are all receiving

c

Long-acting insulin and short-acting insulin (and not mixed insulin)

c

Home glucometers with strips for 3 checks per day (2 bottles/month)

Notes

8

c c

Syringes for home use, 1 for each day (30 / month)

c c c c c c c c

Print logbook for home glucose monitoring

Lancing devices (disposable is 1 per test, or 90 per month; pen-type lancet is 1 per week, or 4 per month) Safe, cool storage for insulin at home (e.g., clay pot) Needle disposal plan (e.g., safety boxes) Home treatment plan for hypoglycemia (e.g., candy, sugar cubes, fruit) A1C testing every 3 to 6 months Individualized behavioral, diet, and self-management counseling Adolescent- and young-adult-specific counseling and therapy, where applicable Screening for complications—including diabetic ulcers, retinopathy, neuropathy, and proteinuria—with appropriate management or referral

Cardiovascular All must be consistently available

c c c c c c c c c c

Functional echo machine and gel

c c c

Pediatric formulations of diuretics and beta blockers

An image storage system that can transmit echo images for review Functional ECG machine (single lead is acceptable) Ability to measure accurate weight Pediatric BP cuff and pediatric 02 sat probes INR monitoring Heart failure medications, including the choice of an ACE inhibitor or a beta-blocker Antihypertensives, including HCTZ and calcium channel blockers Diuretics, including furosemide and spironolactone Additional cardiac medications for specific uses, including hydralazine, isosorbide, and methyldopa Anticoagulation therapy with warfarin Penicillin therapy for secondary prophylaxis of rheumatic heart disease (e.g., oral penicillin, benzathine penicillin), and an alternative for people allergic to penicillin)

Patients with cardiac diagnoses are all receiving, as applicable

9

Notes

c c c

Annual echocardiography monitoring

c c

Heart failure: home management with diuretics, ACE-inhibitors, beta blockers

c c

Referrals for cardiologist evaluation for children with possible congenital heart disease

Treatment and monitoring per the PEN-Plus cardiac failure protocol For patients with rheumatic heart disease: antibiotic prophylaxis, rate control as needed, anticoagulation as needed Education and individualized counseling for behavior, disease management, danger signs, etc.

Referrals for evaluation for cardiac surgery for patients with rheumatic heart disease and children with congenital heart disease

Notes

PEN-Plus Essential programmatic standards

Sickle Cell Disease All must be consistently available

c c c c c c c c c c

Rapid confirmatory tests (SickleScan, Hemotype SC, or Gazelle) Complete blood count, Hb Hydroxyurea Folic acid Penicillin Antimalarial prophylaxis per guidelines Pain control with oral and IV narcotics Blood transfusions for emergencies IV fluids for acute complications IV antibiotics for acute infectious complications

Patients with SCD are all receiving

c c c c c c c c c c

Notes

Notes

Hydroxyurea (unless there is a contraindication) Treatment and monitoring per the PEN-Plus hydroxyurea protocol Treatment monitoring with Hb at minimum Optimal: Treatment monitoring with complete blood count Optimal: Monitoring of kidney function and liver function tests Folic acid Penicillin prophylaxis for those under 5 years or otherwise eligible Analgesics as needed Antimalarial prophylaxis per national guidelines Health education and counseling

Essential Standards Checklist: Optional Conditions Respiratory All must be consistently available

c c c c c

Short-acting beta-agonist inhalers (SABA), such as salbutamol

c c c c c

TB diagnostics (e.g., GeneXpert)

Notes

Inhaled corticosteroids (ICS) Optimal: Anticholinergic inhalers (ipratropium bromide) Spacer devices Optimal: Combined long-acting beta agonist (LABA) inhalers with inhaled corticosteroids (ICS) Functional chest x-ray machine Nebulizer machine with medications Oral and IV steroids Optimal: Spirometry

10

Patients with asthma are all receiving

c

A clear diagnosis of asthma, with other causes—such as TB, cancer, COPD, or a heart condition—excluded

c c c c

Optimal: Spirometry use to support diagnosis

c c c c

TB screening and ruling out as applicable

Notes

Short-acting beta-agonist inhalers (SABA) Inhaled corticosteroids (ICS) Optimal: Combination of long-acting beta agonists (LABA) with inhaled corticosteroids (ICS) Appropriate counseling and teaching on inhaler technique Counseling on identifying and avoiding triggers Optimal: A written action plan for patients to increase their own steroid dose if their condition worsens

Liver All must be consistently available

c c c c c c c c c c c

Liver function tests Full blood count (platelets) Abdominal ultrasound Hepatitis B surface antigen tests Optimal: Hepatitis C antibody tests Optimal: Microscopy of ascitic fluid, serum albumin, and fluid albumin Equipment and supplies for paracentesis Diuretic therapy with furosemide, spironolactone Antibiotics for secondary prophylaxis of spontaneous bacterial peritonitis Beta blockers for patients at risk for esophageal varices bleeding Optimal: Lactulose for hepatic encephalopathy, serum electrolytes for diuretic monitoring, and antiviral treatment for chronic hepatitis B or C infection

Patients with liver disease are all receiving, as applicable

11

Notes

c

Regular evaluation for symptoms and signs of decompensated liver disease (including ascites, encephalopathy, and esophageal varices)

c c c

Antibiotics for secondary prophylaxis of spontaneous bacterial peritonitis

c c

Diuretic therapy as indicated, with electrolyte monitoring

c

Evaluation and secondary prevention of potential etiologies for liver disease (e.g., viral hepatitis, alcoholic hepatitis, steatotic liver disease)

Beta blockers for patients at risk for esophageal varices bleeding Paracentesis when indicated, including scheduled or outpatient paracentesis in clinic

Optimal: Annual measurement and estimation of fibrosis through non-invasive tests (i.e., APRI score)

Notes

PEN-Plus Essential programmatic standards

Kidney Conditions All must be consistently available

c c c c c c c c c

Creatinine and urea testing Urine dipstick Prednisone Palliative care Renal ultrasound Oral and IV diuretics Oral and IV antihypertensive medications Iron supplementation Optimal: Urine microscopy

Patients with kidney conditions are all receiving

c c c c

Notes

Notes

Diuretic therapy ACE-inhibitors if eligible Iron supplementation Laboratory monitoring for creatinine, urea, electrolytes, and Hb

12

1.3 Indicators for programmatic standards* *Note: These indicators focus on process and are designed to help identify key gaps in the programmatic standards. The standardized indicators for clinical outcomes and targets are defined elsewhere.

Category

Indicator

Target

Social Support

% of patients assessed for vulnerability or at risk of interruption to care

100%

% of patients receiving social support

–

# of days with insulin (of any kind) stockout in last year

0

# of days with furosemide stockout in last year

0

# of days with hydroxyurea stockout in last year

0

# of days with glucometer or test strip stockout in last year

0

# of days with sickle cell testing stockout in last year

0

% people with T1D on basal bolus insulin (not pre-mixed insulin)

100%

% people with T1D with home glucometer

100%

% people with T1D with an A1C checked within the last 6 months

100%

% of patients with an echo in the last year

100%

Supply Chain

Type 1 Diabetes

Cardiac Conditions

% of patients with rheumatic heart disease on secondary prophylaxis

—

% of patients with cardiomyopathy on beta blocker and ACE-I

—

% of patients on warfarin with an INR checked in the last 3 months

100%

% of people with SCD on hydroxyurea (among those who do not have a contraindication)

100%

% of under-5 children with SCD on penicillin prophylaxis

100%

% of people with SCD on folic acid

100%

Chronic Respiratory Disease

% of patients with asthma who have a rescue beta-agonist inhaler

100%

% of patients with asthma on oral salbutamol

0%

% of eligible patients on inhaled corticosteroid

100%

Liver

% of patients tested for hepatitis B virus

100%

% of patients with cirrhosis and at risk for variceal bleed who are on prophylaxis for esophageal varices

100%

% of eligible patients on ACE-I

100%

% of patients with chronic kidney disease with kidney function and electrolytes checked in last 6 months

100%

Sickle Cell Disease

Kidney

13

% of patients with suspected congenital or rheumatic heart disease — referred for surgical evaluation

SECTION 2

TOOLS FOR CARDIAC DISEASE

Tools For Cardiac Disease

2.1 Protocol For Heart Failure PROTOCOL FOR HEART FAILURE DIAGNOSIS AND MANAGEMENT Signs or symptoms of heart failure?

Non-cardiomyopathy medications: !"# $ %&'()"*+",&-.+/*0()%&-)"#12/

Check medical records for previous echo

YES

Follow protocol according to diagnosis

NO

Treat as cardiomyopathy & refer for echo

NO

Ultrasound available?

YES

Reduced left ventricular systolic function

YES

Cardiomyopathy

ASA 100mg daily Penicillin V 250mg twice daily or Penicillin IM inj Furosemide (contraindication: Cr >2.3) Hydrochlorothiazide (HCTZ) (contraindication: Cr >2.3) Amlodipine: 2.5-10 mg po od (goal BP <140/90 mmHg) Nifedipine: 20-80 mg po od (goal BP <140/90 mmHg) 1) Furosemide if hypervolemic 2) ACEi (titrate to goal dose) 3) Beta-blocker (titrate to goal dose) 4) if max ACEi and BP not low: add spironolactone 5) Investigate & treat causes of cardiomyopathy 6) If peripartum: add ASA 81 mg od

NO NO

Mitral valve abnormality (2/3) - Thick / calcified mitral leaflets - Elbow shaped anterior leaflet - Fixed posterior leaflet

YES

Rheumatic mitral stenosis

1) Furosemide if hypervolemic 2) Beta blocker (goal HR 60-80 bpm) 3) Penicillin (secondary prophylaxis) 4) Cardiologist consultation

NO

Blood pressure ≥180/110 mmHg or history of hypertension

YES

Hypertensive heart disease

NO YES

Loud murmur

Other valvular or congenital

NO

Dilated right ventricle

YES

Isolated right heart failure

1) Furosemide and/or HCTZ if hypervolemic 2) BP control: goal sBP <140 mmHg 1) Cardiologist consultation 2) Furosemide if hypervolemic 3) BP control 4) Consider penicillin for secondary prophylaxis if mitral valve thickening and calcification is present 1) Furosemide 2) Treat lung disease (asthma/COPD, TB) if present

NO

Pericardial effusion

YES

Pericardial disease

NO

Heart failure unlikely (normal echo)

*Note that combined diagnoses are possible and can be made in consultation with an expert *Family planning should be considered in all cases of heart failure affecting women of childbearing age

Cardiomyopathy medications

Starting dose

Goal dose

Contraindication

Beta-blocker: atenolol Beta-blocker: carvedilol Beta-blocker: metoprolol CR Beta-blocker: bisoprolol

12.5 mg od 6.25 mg BID 12.5 mg BID 2.5 mg od

25 mg BID 25-50 mg BID 50-100 mg BID 10 mg od

Heart rate <55, low doses in pregnancy (should not use atenolol in pregnancy)

ACE inhibitor: captopril ACE inhibitor: lisinopril ACE inhibitor: enalapril ACE inhibitor: ramipril

12.5 mg TID 5 mg od 2.5 mg BID 2.5 mg od

50 mg TID 20-40 mg od 20 mg BID 10 mg od

Cr >2.3, sBP <100, pregnancy

Angiotensin receptor blockers: candesartan Angiotensin receptor blockers: valsartan

8 mg OD 20-40 mg BID

32 mg OD 160 mg BID

Cr >2.3, sBP <100, pregnancy

Spironolactone

12.5 mg daily

25 mg daily

Cr >2.3 or K >5.5, pregnancy

Hydralazine

25 mg TID

75 mg TID

sBP <100 mmHg

40 mg TID

sBP <100 mmHg or headache

Isosorbide dinitrate (ISDN)

15

Consider other diagnoses

1) Refer for pericardiocentesis if tamponade (low BP, tachycardic, IVC dilated) 2) Treat the cause (TB, HIV, cancer)

10 mg TID

Tools For Cardiac Disease

2.2 Pediatric Protocol For Heart Failure PEDIATRIC PROTOCOL FOR HEART FAILURE DIAGNOSIS AND MANAGEMENT

Pathologic murmur, signs & symptoms of heart failure, or cyanosis?

YES

YES

Follow previous plan.

If any concerns, call cardiologist

Previous cardiologist plan?

NO

Perform echo

Reduced left ventricular contraction

1. Suspected cardiomyopathy; treat according to general protocolusing pediatric medication dosages 2. Furosemide if hypervolemic

Mitral regurgitation present (>2 cm jet)

1. Suspicious for rheumatic heart disease 2. Furosemide if hypervolemic 3. Start oral penicillin if available

Dilated right ventricle and atrium Pericardial effusion

Refer to cardiologist or review via telemedicine

1. Suspect congenital heart disease 1. Treat for TB unless obvious other cause 2. Refer for pericardiocentesis if tamponade

Starting dose of furosemide: 1mg/kg IV 12 hourly or 1mg/kg oral 12 hourly.

Discuss dose increases with cardiologist or pediatrician

2.3 Warfarin dose adjustment chart INR

Action

Greater than 5.0 or complaints of bleeding.

•

Hospitalize for warfarin adjustment.

Above goal (INR raised by more than 2.0 above goal)

• •

Stop warfarin for 2 days.

Decrease warfarin dose by 1 mg daily.

Above goal (INR raised by less than 2.0 above goal)

• •

Evaluate for changes in medications or diet.

Decrease warfarin dose by 0.5 – 1 mg daily.

At goal

•

Continue current warfarin dose.

Below goal

• • •

Evaluate for changes in medications or diet.

Assess for non-adherence.

Increase warfarin dose by 0.5 – 1 mg daily.

•

Hospitalize for warfarin adjustment and possibly subcutaneous low molecular weight heparin Assess for non-adherence and discuss with the patient’s community health worker.

Below 1.5

•

16

SECTION 3

TOOLS FOR DIABETES

Tools For Diabetes

3.1 Pen-Plus Working Definition Of T1D Diagnosis PEN-PLUS WORKING DEFINITION OF T1D DIAGNOSIS TYPE 1 DIABETES: Treat and document as T1D

Age 1 – 25* years

Age 25 - 45* years

possible TYPE 1 DIABETES:

TYPE 2 DIABETES: Treat and document as T2D

Consider other type of diabetes

Ever produced ketones?

Obese?

Yes No

*Age ranges can be adjusted based on local epidemiology

Age > 45* years

New onset in pregnancy None of above but signs suggest T1D: low BMI, weight loss, polyuria, polydipsia, and/or history of long-term insulin requirement Consider family history of T1D or T2D as supporting evidence. If this does not help and person does not meet any of the considerations so far, proceed to possible T1D diagnosis.

Treat as T1D and monitor closely.

Continue to evaluate for definitive diagnosis.

Supplementary lab testing if available

Does not require insulin therapy or new onset with no ketosis Clinical evidence suggests T1D (ketosis; weight loss; dehydration; low BMI)

Age <1 year

18

NPH: 2 times daily Regular: 3 times daily with correction dose based on pre-meal glucose

Assumes eating at the same time each day and the same amount of carbohydrates

Reasonable starting regimen for most patients

Cons

Patient considerations Consider if hyperglycemia in evening and is consistently checking glucose at lunch

Challenging with clients who are at work or school during the day

Assumes consuming consistent meals with consistent carbohydrates

Requires a greater number of test strips

Assumes consuming THREE consistent meals with consistent carbohydrates

Simple, closer to physiologic insulin requirements

Requires glucose checking prior to meals

Reduced risk of hypoglycaemia, can reduce hyperglycemia by accounting for pre-meal glucose

1-2 per day (30 – 60 per month)

*Using as a proxy to indicate that the patient is able to give an injection at lunch ** If moving from 2 times a day to 3 times a day, add short acting dose that most closely matches the meal they are having *** long-action means once a day injection will cover metabolic needs for entire day. Preferred Network regimen.

Easy to start with

Pros

2 per day (60 per months)

Requires checking glucose before all meals AND basic numeracy (understanding/ reading numbers).

Consider if glucose is variable and patient has demonstrated competency with previous regimens

Assumes consuming THREE consistent meals with consistent carbohydrates

Requires a greater number of test strips

Not preferred

Preferred if glargine is available ***

1-2 per day (30 – 60 per month)

Use 50/50 rule Glargine 50% total dose once daily Regular – 50% of total dose – split into 2 or 3 doses

Glargine: 25 units daily Regular: 4 units 3 times daily

Best regimen if can afford

Glargine: 25 units daily

Glargine: 1 time daily

Will have persistent hyperglycemia from not giving insulin for carbohydrates consumed -May be more expensive

Reduced injections

or short-term during periods where focusing on diabetes may be a challenge (ie teenager)

Consider during periods of food insecurity

Will have persistent hyperglycemia from not giving insulin for carbohydrates consumed

Reduced injections

1-2 per day (30 – 60 per month)

NPH: 15 AM, 10 PM

Glargine: 1 time daily NPH: 2 times only daily Regular: 2-3 times daily

OPTIMAL / PREFERRED

Requires glucose checking prior May be more expento meals sive

Reduced risk of hypoglycaemia, can reduce hyperglycemia by accounting for pre-meal glucose

3 per day (90 per month)

Correction dose based on chart Checking glucose before breakfast, lunch and dinner and giving an additional dose of insulin, based on scale on chart

Use 50/50 rule ** NPH – 50% of total dose – split into half in morning; half in evening Regular – 50% of total dose – split into three

Correction dose based on chart Checking glucose before breakfast and dinner and giving an additional dose of insulin, based on scale on chart

Use rule of thirds 2/3 daily dose in morning (2/3 NPH; 1/3 regular) 1/3 daily dose in evening (2/3 NPH; 1/3 regular)

1-2 per day (30 – 60 per month)

NPH: 15 AM, 10 PM Regular: 3 times daily before meals

NPH: 15 AM, 10 PM Regular: 4 units 3 times daily

NPH: 15 AM, 10 PM Regular: 2 times daily before meals

Assumes 3 meals per day

Assumes 3 meals per day

1. Can understand numbers (what is a high, low, sugar) 2. Knows numbers on syringe 3. 90 strips per month

NPH: 2 times daily Regular: 3 times daily with fixed doses

Optimal

NPH: 15 AM, 10 PM Regular: 4 units 2 times daily

1. Can understand numbers (what is a high, low, sugar) 2. Knows numbers on syringe 3. 60 strips per month

NPH: 2 times daily Regular: 2 times daily with correction dose (based on pre meal glucose)

NPH: 2 times daily Regular: 2 times daily with fixed dose

If consistently checking BG at lunch* and there is hyperglycemia in the evening

Preferred

Reasonable Starting Regimen

Minimum # test strips/ day

Example

Insulin Regimen

Move patients to a better regimen – even if A1C in range. Aim is to prevent hypoglycemia

Consider during periods where focusing on diabetes may be a challenge (ie teenager) as long as no food insecurity

High risk of hypoglycemia if reduced meal size or inconsistent meals

Reduced injections but maintains meal coverage

Mixed Insulin (70/30) 20 AM, 15 PM

Mixed Insulin (70/30): 2 times daily

Not preferred

Tools For Diabetes

3.2 Insulin Regimen Options

Tools For Diabetes

3.3 How To Adjust Insulin Doses Based On Home Glucometer Readings CHART OF INSULIN ADJUSTMENT BASED ON HOME GLUCOMETER READINGS 1. Does the client have any concerns or patterns with their blood glucose values they would like to talk about?

YES

Address their concerns

NO

2a. Evaluate most recent 2-4 weeks of logbook or glucometer history for patterns of hypoglycemia.

Address any hypoglycemia, even if infrequent, prior to addressing hyperglycemia

2b. Ask client about symptoms of hypoglycemia in the past 2-4 weeks and typical time of day they occur, including overnight (i.e convulsions, eating at night, night sweats)

No Hypoglycemia

Skip to step 3

Hypoglycemia present

2c. If hypoglycemia is infrequent, can client explain why it happened? (ie skipped a meal, had extra activity)

YES

No clear explanation and hypoglycemia occuring in a pattern

Pattern

AM glucose < 4.4 mmol/L (80 mg/dL)

Pre-Lunch glucose < 4.4 mmol/L (80 mg/dL)

Counsel on hypoglycemia prevention Assess for and address any food insecurity

Decrease PM NPH (Lente) insulin 10-20%

Decrease AM Regular (Actrapid) insulin 10-20%

Pre-Dinner glucose < 4.4 mmol/L (80 mg/dL)

Decrease lunchtime Regular (Actrapid) or AM NPH (Lente) 10-20%

Overnight glucose < 5.6 mmol/L (100 mg/dL)

Decrease PM NPH (Lente) 10-20%

Bedtime glucose <?4.4 mmol/L (80 mg/dL)

Decrease PM Regular (Actrapid) 10-20%

3a. Evaluate most recent 2-4 weeks of logbook or glucometer history for patterns of hyperglycemia 3b. Ask client about symptoms of hyperglycemia in the past 2-4 weeks and typical times of day they occur, including overnight (i.e. nocturia) YES

Is the client missing or skipping injections?

NO

How is the client storing insulin? Is there a chance the insulin went bad? (highs mostly at the end of the month, or exposure to heat)

Ask why? Work with client on plan to increase frequency Assess for and address any food insecurity

YES

Give new insulin Educate about storage of insulin

YES

Educate on rotating injection sites

NO

Assess injections sites. Is there lipohypertrophy or infection?

NO

Ask client to demonstrate how they draw up and administer insulin.

Is it correct? Can they differentiate between both of their insulins?

If they mix insulin, are they mixing correctly? (both vials cloudy means insulin not mixed correctly)

NO

Educate on proper administration of insulin

NO

Any changes in diet or activity? Are these changes modifiable?

YES

Educate on improving diet and physical activity

YES

Address illness, consider temporary increase in insulin

NO/NOT MODIFIABLE

Has the client been sick recently? Any recent hormonal changes? (ie menstruation)

Patterns

If AM glucose > 10 mmol/L (180 mg/dL)

Pre-Lunch glucose > 10 mmol/L (180 mg/dL)

Increase PM NPH (Lente) insulin 10-20%

Increase AM Regular (Actrapid) insulin 10-20%

Pre-Dinner glucose > 10 mmol/L (180 mg/dL)

Add regular insulin at lunch (start with same dose as PM) or

Bedtime glucose > 10 mmol/L (180 mg/dL)

Increase PM Regular (Actrapid) 10-20%

Overnight glucose > 10 mmol/L (180 mg/dL)

increase AM NPH (Lente) insulin 10-20%

If no symptoms of overnight hypoglycemia, increase PM NPH (Lente) 10-20%

When ever insulin dose is changed, explain to the patient why the dose was changed, so that they understand what the glucose numbers mean

20

3.4 Using Correction Scales (mmol/L) Another option for patients to improve management of glucose is to use correction scales These can be introduced after the patient is already used to taking fixed doses of insulin It assumes that there are 2 or 3 test strips available each day. It requires the patient to have some knowledge of numbers. If using twice daily regimen – the glucose is checked before each meal (breakfast, dinner). The short acting dose for those meals is increased by adding the amount shown in the scale, based on the glucose result.

If using three times daily regimen (basal bolus) – the glucose is checked before each meal (breakfast, lunch, dinner). The short acting dose for those meals is increased by adding the amount shown in the scale, based on the glucose result One can not use the same correction scale for every patient. This is because every patient responds to insulin differently. You need to choose from 1 of 4 correction scales to give to your patient You choose the scale by calculating the total daily dose of insulin given in 24 hours E.g. add up the short acting and long acting insulin given in the day Scale (mmol/L) based on Total daily dose (TDD) (do not need to adjust further for weight) If TDD < 10 – no correction scale needed Use this scale if Total daily dose of insulin is 10-19 Units per day (Correction factor 1:7) If Pre meal glucose is..

Then add this amount to the usual insulin dose

<15

No correction

15-21.9

1U

22 and above

2U

Use this scale if Total daily dose of insulin is 20-29 Units per day (Correction factor 1:5) If Pre meal glucose is..

Then add this amount to the usual insulin dose

<17

No correction

17-26.9

2U

27 and above

4U

Use this scale if Total daily dose of insulin is 30-49 Units per day (Correction factor 1:2.5) If Pre meal glucose is..

Then add this amount to the usual insulin dose <12 No correction 12-16.9 2U 17-21.9 4U 22 and above 6U Use this scale if Total daily dose of insulin is > 50 Units per day (Correction factor 1:2)

21

If Pre meal glucose is..

Then add this amount to the usual insulin dose

<11

No correction

11-14.9

2U

15-18.9

4U

19-22.9

6U

23 and above

8U

Tools For Diabetes

3.5 Using Correction Scales (mg/dL) Another option for patients to improve management of glucose is to use correction scales. These can be introduced after the patient is already used to taking fixed doses of insulin. It assumes that there are 2 or 3 test strips available each day. It requires the patient to have some knowledge of numbers. If using twice daily regimen – the glucose is checked before each meal (breakfast, dinner). The short acting dose for those meals is increased by adding the amount shown in the scale, based on the glucose result. If using three times daily regimen (basal bolus) – the glucose is checked before each meal (breakfast, lunch, dinner). The short acting dose for those meals is increased by adding the amount shown in the scale, based on the glucose result.

One can not use the same correction scale for every patient. This is because every patient responds to insulin differently. You need to choose from 1 of 4 correction scales to give to your patient You choose the scale by calculating the total daily dose of insulin given in 24 hours E.g. add up the short acting and long acting insulin given in the day Scale (mg/dL) based on Total daily dose (TDD) (do not need to adjust further for weight) If TDD < 10 – no correction scale needed Use this scale if Total daily dose of insulin is 10 - 19 Units per day (Correction factor 1: 120; Target 130-280) If Pre meal glucose is..

Then add this amount to the usual insulin dose

<250

No correction

250-399

1U

> 400

2U

Use this scale if Total daily dose of insulin is 20 - 29 Units per day (Correction factor 1: 75. Target 125-275) If Pre meal glucose is..

Then add this amount to the usual insulin dose

<275

No correction

275-424

2U

> 425

4U

Use this scale if Total daily dose of insulin is 30-49 Units per day (Correction factor 1:45 Target 125-220) If Pre meal glucose is..

Then add this amount to the usual insulin dose

<215

No correction

215-304

2U

305-394

4U

>395

6U

Use this scale if Total daily dose of insulin is >50 Units per day (Correction factor 1: 30 Target 120-180) If Pre meal glucose is..

Then add this amount to the usual insulin dose

<180

No correction

180-239

2U

240-299

4U

300-359

6U

360-419

8U

>420

10 U

22

3.6 Diabetic Ketoacidosis (DKA) Algorithm - Adults (> 15 years) 1. Emergency Room: Initial Management

5. Potassium replacement

1.

2.

3.

4.

5.

Potassium replacement is needed for every patient: 1. Check K level if possible. (If K < 3.5, delay insulin) 2. If no lab – do ECG. (Low K on ECG Flattening of the T wave, widening of the QT interval, and the appearance of U waves; High K - Tall, peaked, symmetrical, T waves and shortening of the QT interval) 3. If no lab – start replacing K after patient passes urine.

4. Add 20 mmol (10 mls of a 15% KCl) to each litre of fluid in first 4 hours (except the first litre/or boluses). Then 40 mmol to each litre after 4 hours.

5. Monitor K 6-hourly.

6. If IV potassium is not available, give oral slow K, one tab 6 hrly or fruit juice / bananas.

7. If no IV potassium, give insulin at a slower rate. (subcut 0,1U/kg 3 hourly or IV 0.05U/ kg per hour)

Assess if in shock Assess Level of consciousness (GCS) Weight Lab essential :Blood glucose; urine ketones; malaria, Hb; Lab preferable : urea and electrolytes, FBC.

2. Correction of shock 1.

2.

3.

Give O2 Two large IV cannula If systolic BP<90 then give 500ml of Normal Saline (NS) over 10 to 15min. Repeat bolus until systolic BP>90.

Most require 500 – 1000ml.

3. Correction of dehydration 1.

2.

3.

4.

5.

6.

7.

8.

6. Treatment of infection If infection is suspected (common), treat with broadspectrum antibiotics. E.g. ceftriaxone

7. Monitoring of management

4. Insulin

1.

1.

2.

2.

3.

4.

5.

6.

7.

8.

23

Give 1l NS stat Then give 1l NS over 1 hr Then give 1l NS over 2 hrs Then give 1l NS over 4hrs Then remaining litres to be given within the first 24 hours to make total of 8 litres in first 24 hours The average fluid deficit in an adult presenting with DKA is 5-10 litres Reassess cardiovascular status at 12 hours; further fluid may be required. Check for fluid overload Be more cautious in fluid replacement in young people aged 18-25 years, elderly, pregnant, heart or renal failure

Start short-acting insulin at 0.1U/kg intravenous every 1 hour. This can be with infusion pump, or by bolus given every 1 hour.** If unable to give insulin every 1 hour, use subcutaneous insulin 0,1U/kg every 2 hours.

Once the blood glucose is <14 mmol/l, (252 mg/dL) add dextrose to the saline (add 100 ml 50% dextrose to every litre of saline, or use 5% dextrose saline). If only D5W available. Then run NS and D5W on 2 separate IV lines. Do not only give D5W. Once the blood glucose is <14 mmol/l, (252 mg/dL), consider decreasing insulin to 0.05U/kg.

Aim for a glucose reduction of 3 mmol/l per hour (90mg/dL).

Once glucose is < 9 mmol/L (162mg/dL), use 10% dextrose saline (add 50ml of 50% dextrose ampule to 500 ml of 5% dextrose saline).

If glucose is falling less than 3 mmol/l per hour, check that insulin is being given correctly, on time. Increase insulin by 1U per dose every hour until glucose drops by 3 mmol/l per hour. **If severe DKA and infusion pump available – give shortacting insulin at 0.1U/kg every 1 hour. Mix 50 IU Regular insulin in 500ml NS. Infuse at 1 ml/kg/hr. (50 kg adult should receive 50 ml/ hr)

3.

4.

5.

Monitor hourly; heart rate, BP, respiratory rate,GCS, glucose Monitor urine ketones in every sample of urine.

Record fluid intake, insulin therapy and urine out put. Catheterise if necessary.

Minimum urine output ≥ 0.5 ml/kg/hr Repeat electrolytes every 6 hours If unconscious, consider naso-gastric tube to prevent aspiration

8. Transition to usual insulin regimen 1.

2.

Once awake, hungry, eating, drinking sips of water change to normal insulin regimen e.g twice or three times daily subcut insulin. Start at next meal. (If using IV insulin, overlap IV insulin infusion with first subcut dose by 30 min) Do not use urine ketones to decide when to change, as they may stay in urine for 12-24 hours

Tools For Diabetes

3.7 Diabetic Ketoacidosis (DKA) Algorithm - Children (< 15 years) 1. Initial Emergency Management

5. Potassium replacement

1.

Potassium replacement is needed for every patient: 1. Check K level if possible. (If K < 3.5, delay insulin) 2. If no lab – do ECG. (Low K on ECG - Flattening of the T wave, widening of the QT interval, and the appearance of U waves; High K - Tall, peaked, symmetrical, T waves and shortening of the QT interval) 3. If no lab – start replacing K after patient passes urine.

4. Add 20 mmol (10 mls of a 15% KCl) to each litre of fluid in first 4 hours (except the first litre/or boluses). Then 40 mmol to each litre after 4 hours.

5. Monitor K 6-hourly.

6. If IV potassium is not available, give oral slow K, one tab 6 hrly or fruit juice / bananas.

7. If no IV potassium, give insulin at a slower rate. (subcut 0,1U/kg 3 hourly or IV 0.05U/kg per hour)

2.

3.

4.

5.

Assess if in shock (cap refill, HR) / severity of dehydration (mucous membrane skin turgor) . If uncertain about this, assume 10% dehydration in significant DKA Assess Level of consciousness (GCS) Weight Lab essential: blood glucose; urine ketones; malaria, Hb. Lab preferable: urea and electrolytes, FBC.

2. Correction of shock 1.

2.

3.

4.

Give O2 2 x large IV cannula. (or use intra-osseous ).

Give repeat boluses of IV normal saline - 20ml/kg until perfusion improves Make sure that the child is adequately resuscitated –good perfusion - before proceeding to the following steps. Use cap refill and HR

6. Treatment of infection 3. Correction of dehydration 1.

2.

Rehydrate the child with normal saline(NS) (or Ringers Lactate RL). Use the table below to calculate fluid replacement to give over 48 hours.

Reassess clinical hydration regularly, using capillary refill, heart rate, mucous membranes Weight

mL/kg/hr

<10 kg

6.5

10 – 20 kg

6

20.1 – 40 kg

5

>40 kg

4 (max 250 mL/hr)

4. Insulin 1.

2.

3.

4.

5.

6.

Start insulin after circulation stable - at least 1 hour after IV fluids Give subcutaneous insulin 0.1U/kg every 2 hours. Eg for 30 kg child give 3U subcut every 2 hours * In children < 5 yrs give lower rate of insulin (0.05 U/kg every 2 hours) Once the blood glucose is <15 mmol/l, (270mg/dL) use 5% dextrose saline (add 100 ml 50% dextrose to 1 litre saline). If only D5W available. Then run NS and D5W on 2 separate IV lines. Do not only give D5W. Aim for a glucose reduction of 5 mmol/l per hour (90mg/ dL). A more rapid decline may cause cerebral injury). If glucose drops rapidly, or once glucose is < 9 mmol/L (162mg/dL), use 10% dextrose saline (add 50ml of 50% dextrose ampule to 500 ml of 5% dextrose saline). If glucose continues to fall rapidly, decrease the rate of insulin delivery by 25% (e.g from 8U to 6U) *If severe DKA and infusion pump available – give shortacting insulin at 0.1U/kg every 1 hour. Mix 50 IU Regular insulin in 500ml NS. Infuse at 1 ml/kg/hr. (14 kg child should receive 14 ml/ hr)

If infection is suspected (common),treat with broad-spectrum antibiotics. E.g. ceftriaxone

7. Monitoring of management 1.

2.

3.

4.

5.

Monitor hourly; heart rate, BP, respiratory rate, GCS, glucose Monitor urine ketones in every sample of urine.

Record fluid intake, insulin therapy and urine out put. Catheterise if necessary. Minimum urine output ≥ 0.5 ml/kg/hr Repeat electrolytes every 6 hours If unconscious, consider naso-gastric tube to prevent aspiration

8. Transition to usual insulin regimen 1.

2.

Once awake, hungry, eating, drinking sips of water, change to normal insulin regimen e.g twice or three times daily subcut insulin. Start at next meal. (If using IV insulin, overlap IV insulin infusion with first subcut dose by 30 min) Do not use urine ketones to decide when to transition. as they may stay in urine for 12-24 hours

9. Cerebral injury 1.

2.

3.

4.

5.

6.

Rapidly rising intra-cranial pressure may cause a change in neurological state (restlessness, irritability, increased drowsiness or seizures), If suspected, exclude hypoglycaemia Reduce rate of fluid by one- third.

Give mannitol 0.5-1 g/kg IV over 20 min and repeat if no response in 30 min to 2 hours.

Elevate head of the bed.

Obtain cranial CT scan if possible 24

25

06 00

05 00

03 00

02 00

01 00

00 00

23 00

22 00

21 00

20 00

19 00

18 00

17 00

16 00

15 00

14 00

13 00

12 00

11 00

10 00

09 00

08 00

07 00

Time

GCS

Blood Pressure

Heart rate

Respiratory rate

Glucose

Insulin given

IV fluids given

Date:

Age:

Weight:

Hospital ID:

Name:

3.8 DKA Monitoring Chart

K+ added to fluids

Urine put

out-

Urine ketones

SECTION 4

TOOLS FOR SICKLE CELL DISEASE

Tools For Sickle Cell Disease

4.1 Screening For SCD Using Rapid Tests HOW TO USE RAPID TESTS* FOR SCD DIAGNOSIS *For PEN-Plus clinics this refers to SickleScan, HemotypeSC, or Gazelle < 35 years old

YES

Anemia (Hb < 8.5) If needs urgent transfusion – keep a sample in lab for later sickle cell testing

YES

Sickle cell screening test previously positive YES

If transfused and no blood sample pre-transfusion available

Perform rapid confirmatory test if not yet done

Any hallmark signs or complications?

History of multiple/recurrent transfusion Physical signs: bossing of skull, dactylitis, AVN History suggesting multiple pain crises Family history of known SCD or sibling death Anemia with jaundice (even if Malaria is positive) Stroke in a child Septic arthritis, cellulitis, osteomyelitis NO

Other OBVIOUS or confirmed reason for anemia ruled out* *Including pregnancy, HIV if > 14 years

If meets criteria for testing and/or high suspicion for SCD, enroll in care and start preventive therapy with folic acid, immunizations.

Proceed with rapid confirmatory test 3 months after transfusion.

NO

YES

(skip directly to testing)

YES

If no sample pre-transfusion is available

RAPID TEST FOR SICKLE CELL (Sickle SCAN, Hemotype SC, Gazelle) If already transfused- go to lab and test cross matching sample POSITIVE

1.

2.

3.

27

Enroll in care, start hydroxyurea*, test all siblings. *Pursue advanced confirmatory testing only if required by national guidelines.

Note hydroxyurea can be started with the positive rapid test alone.

Tools For Sickle Cell Disease

4.2 Sickle Cell Disease: Prevention Protocol SICKLE CELL DISEASE: PREVENTION PROTOCOL Vaccinations

• • • •

Confirm all routine childhood vaccinations Infants: Pneumococcal Conjugated Vaccine (PCV 13) – (6,10,14 weeks) Children: Pneumococcal polysaccharide vaccine (PPSV-23) at 2 years and booster at 5 years apart (if available) All: pneumococcus, Hib, Hepatitis B, meningococcus (per country schedule / availability)

Antibiotic Prophylaxis

Oral penicillin • Children < 3 years: 125 mg twice a day • Children 3-5 years: 250 mg twice a day • Penicillin allergy: erythromycin or clarithromycin • Children > 5 years: discontinue if received the due pneumococcal vaccine. Do not stop if the child had severe pneumococcal infection, splenectomy, or functional asplenia IM Benzathine monthly if oral penicillin not available

Malaria Prophylaxis

• • •

Insecticide-treated bed nets; add indoor residual spraying where available Prompt diagnosis and treatment Malaria prophylaxis highly recommended if permitted per country guidelines

Folic Acid

•

5 mg once a day

Mebendazole

• •

1-2 years: 200mg every 3 months >2 years: 400mg every 3 months

Growth Monitoring

• • •

Infants: Length in supine position (0-24 month); Head circumference (0-36 month) 1-5 years: mid-upper arm circumference (MUAC) Children and Adolescents: Weight (every visit), Height (annually)

Counseling

•

Seek immediate medical attention for fever (101F, 38C), difficulty in breathing, chest pain, abdominal swelling, sudden weakness, loss of feeling and movement, seizure, painful erection of penis, sudden loss of vision, uncontrollable pain with medication and other signs of dehydration Teach families to own and use a thermometer Basic hygiene: Handwashing with soap after use of the toilet, changing of infants and toddlers, and before eating

• • Screening

(consider referral if unavailable at facility)

• • • •

Eyes: annual fundoscopic examination starting at age 10 years Kidneys: annual creatinine & electrolytes. Add annual proteinuria starting at age 10 years Cardiac: >18 years echocardiogram every 3-5 years Stroke: please see transcranial doppler specific considerations

28

29

5

4

3

1

NOT good clinical response: Consider dose escalation

Discontinue 3 months prior to conception in both males and females Breast milk should be discarded for first 3 hours of taking hydroxyurea

Precautions:

If side effects persist, Do NOT restart hydroxyurea Consult mentor or refer to specialist

Repeat abnormal lab every 2 weeks

Side Effects: Low granulocyte/neutrophil count (AGC/ANC), Hb, platelets Mouth ulceration Skin toxicity: rashes

Every 6 months (recommended): Creatinine, Urea, SGPT/ALT

For 500 mg capsules, calculate weekly dose in number of capsules per week and distribute the required capsules throughout the week

For age > 14 years: Starting dose 15 / mg / kg / day Infants & Children: Starting dose 20 mg / kg / day (age < 14 years) Weigh child every visit and adjust dose!

2 Initiation of hydroxyurea:

Every visit: Essential: Hemoglobin Recommended: FBC

Note: Clinical response may take 3–6 months

Every visit: Monitor for clinical response and side effects, check weight Assess symptoms and medication adherence

*If only Hb is available – and not FBC – initiate at 10 mg/kg/day **Chronic kidney disease: Initiate at 5–10 mg/kg/day

Contraindications to initiation: Absolute Neutrophil Count (ANC) <1,500/ Platelet < 100 000/ Recommended Investigations: Hb<5 g/dL 3. Creatinine** and ALT/SPGT Pregnancy

Essential Investigations 1. Full Blood Count (FBC)* 2. Pregnancy Test

Indications: All patients ≥ 9 months with confirmed sickle cell disease (SS, S/Beta-thalassemia)

HYDROXYUREA (HU) TREATMENT PROTOCOL FOR SICKLE CELL DISEASE

4.3 Hydroxyurea (HU) Protocol

Tools For Sickle Cell Disease

4.4 Hydroxyurea Dose Chart For Use In Sickle Cell Disease Pediatrics. Pediatric dose (9 months to 14 years) – start with 20 mg/kg/day. *for weight 6 to 8 kg • •

If pharmacy is able to safely compound hydroxyurea into syrup, then dispense as per pharmacist instruction If pharmacy is not able to safely compound hydroxyurea into syrup, then mother should take one 500 mg capsule each day and dissolve into 10 ml water (give her 10 ml syringe). She should draw 5 ml to give to the baby on alternate days, and throw 5 ml away. (The solution should not be kept for more than 24 hours).

Number of 500 mg capsules per week

Number of 500 mg capsules per month

6kg - 8kg

20mg/kg/dose

20mg/kg/dose

Weight bands

Mon

Tues

Wed

Thur

2 *(dispense 4) 8 (dispense 16) 5ml

0

5ml

0

5ml

0

5ml

9kg - 12kg

3

12

13kg -16kg

4

16

1

0

1

0

1

0

0

17kg -19kg

5

20

1

1

1

1

1

0

0

20kg - 23kg

6

24

1

1

1

1

1

1

0

24kg - 26kg

7

28

1

1

1

1

1

1

1

27kg - 30kg

8

32

1

1

1

1

1

1

2

31kg - 33kg

9

36

1

1

2

1

1

1

2

34kg - 37kg

10

40

1

2

1

2

1

1

2

38kg - 41kg

11

44

1

2

1

2

1

2

2

42kg - 44kg

12

48

2

2

1

2

1

2

2

45kg - 48kg

13

52

2

2

2

2

1

2

2

49kg - 51kg

14

56

2

2

2

2

2

2

2

1

0

1

0

Fri

1

Sat

0

Sun

1

Adults. Adult dose (>14 years) – start with 15 mg/kg/day. * For adults above 40 kg, consider starting hydroxyurea at 500 mg daily, checking blood results after 2 weeks and then increasing to the dose in this table.

Weight bands

Number of 500 mg capsules per week

Number of 500 mg capsules per month

15mg/kg/dose

15mg/kg/dose

Mon

Tues

Wed

Thur

Fri

Sat

Sun

30kg - 40kg

7

28

1

1

1

1

1

1

1

41kg - 55kg*

10

40

1

2

1

2

1

2

1

56 kg and above*

14

56

2

2

2

2

2

2

2

30

4.5 Blood Transfusion (Emergency Simple) BLOOD TRANSFUSION PROTOCOL FOR SICKLE CELL (EMERGENCY / SIMPLE TOP-UP TRANSFUSION) INDICATIONS FOR EMERGENCY TOP-UP TRANSFUSION:

Pre-Investigations: baseline blood tests • •

Full Blood Count (FBC) Cross match*

* Remember to ask the lab to save a sample if the patient is not confirmed SCD and needs testing to confirm the diagnosis

Transfusion:

Dose for transfusion (10-15 mls/kg of Packed Red Blood cells or 20 mls/kg of whole blood) Monitoring

Post-transfusion

3.6 Pain Management Protocol MILD

MODERATE

SEVERE

Reassurance, hot packs, reposition, massage, distraction (stories, play)​

Treat as mild pain and ADD​

Treat as moderate pain and ADD​

Child: Ibuprofen 10mg/kg PO 8 hrly OR Diclofenac 1mg/kg PO 8 hrly​ Child: Paracetamol 15mg/kg PO 6 ​ hourly​ Adult: Ibuprofen 600 mg PO 6 hrly OR Diclofenac 100 mg stat, then 50 Adult: Paracetamol 1g PO 6 hourly. mg 8 hrly​ Max dose 4g daily.

If in moderate pain add IV/PO tramadol 50 – 100 mg 6 hrly

Infant: Morphine 0.1mg/kg PO 4 hrly​ Child: Morphine 0.2-0.5mg/kg PO 4 hrly ​ Adult: Morphine 10-20mg PO 4 hrly​ If in severe pain consider adding IV/ subcut morphine ​ Adult: 2.5mg – 5mg IV / subcut prn.

Child: 0.1mg/kg IV / subcut prn.

31

Tools For Sickle Cell Disease

4.7 Acute Complications Protocol HISTORY

Recurrent acute pain events

SIGNS & SYMPTOMS:

Fatigue, pallor, shortness of breath, hepatomegaly+/- splenomegaly, chest pain, limb pain, stroke presentation, jaundice

INITIAL ASSESSMENT:

• • • •

Maintain airway Give oxygen if sPO2 <95% Gain IV access & send FBC, X-match, U&ES and malaria RDT/blood film Measure vital signs (including BP, HR, RR, Temp, glucose and oxygen)

MANAGEMENT: Treat the following 4 Key areas: 1.

Rehydration is vital: Give 1 litre IV fluid Normal Saline/Ringer’s lactate over 1 hour (rate depends on hydration status/if hypotensive give rapidly). Encourage oral fluids.

2.

Analgesia within 30 mins: For all patients in pain: Assess the pain Step 1: Mild pain. Child: Paracetamol 15mg/kg PO 6 hourly. Adult: Paracetamol 1g PO 6 hourly. Max dose 4g daily.

Step 2: Moderate pain. In addition to step 1- Child: Ibuprofen 10mg/kg PO 8 hrly OR Diclofenac 1mg/kg PO 8 hrly. Adult: Ibuprofen 600 mg PO 6 hrly OR Diclofenac 100 mg stat, then 50 mg 8 hrly. If in moderate pain add IV/PO tramadol 50 – 100 mg 6 hrly Step 3: Severe pain in addition to step 1+2. Infant: Morphine 0.1mg/kg PO 4 hrly. Child: Morphine 0.2-0.5mg/kg PO 4 hrly.

Adult: Morphine 10-20mg PO 4 hrly If in severe pain consider adding IV/ subcut morphine. Adult: 2.5mg – 5mg IV / subcut prn. Child: 0.1mg/kg IV / subcut prn.

3.

Treat infection: If fever present you must exclude infection (pneumonia/UTI/malaria etc.) as infection common precipitator to an acute crisis (give broad spectrum antibiotic e.g. ceftriaxone / amoxicillin-clavulanic acid)

4.

Transfuse: If patient symptomatic and Hb < 5 or drop ≥ 2g/dl below steady state g TRANSFUSE. If patient stable/no symptoms with Hb > 5 - monitor closely.

Dose for transfusion (10-15 mls/kg of Packed Red Blood cells or 20 mls/kg of whole blood) OBSERVE FOR THE FOLLOWING COMPLICATIONS

Acute chest syndrome

Acute severe haemolysis

(SPO2<95% + Symptoms of respiratory distress, hypoxia, chest pain, new infiltrates on CXR)

or Acute Severe Anemia

• Maintain SPO2 >95% • IV hydration – monitor for fluid overload • Ceftriaxone 1-2g od + erythromycin 500mg 6 hrly FOR 7-10 days • Transfuse to target Hb of 10g/dL (in order to dilute HbS not to treat anemia) • If wheezing give salbutamol 2.5mg nebs QDS • This is life threatening- Admit in a high dependency care unit/ICU

(Hb< 5g/dl, drop of Hb 2g/ dl below the steady state, acute symptomatic) • Transfuse until Hb >5g/ dL (target Hb 7-8 g/dL) 10-15 mls/kg of packed red blood cells or 20 mls/kg of whole blood • Check for fluid overload between transfusions • Treat infections e.g. malaria, UTI if present • Repeat Hb the following day

Acute stroke (sudden hemiparesis/ paralysis, unilateral numbness, ataxia, speech abnormalities, seizure)

• Treatment of seizures • Transfuse to target Hb of 10g/dL (in order to dilute HbS not to treat anemia) • IV hydration • Upon discharge, these patients are high risk for future strokes and can benefit from chronic regular transfusion therapy or hydroxyurea

Priapism: prolonged painful erection unrelated to sexual intercourse Mgt <4hrs: analgesia, anxiolytic agents if indicates, increase fluid intake, encourage micturition, warm bath and walk Mgt > 4hrs: Surgical intervention, IV hydration, analgesics and anxiolytics, Catheterize if unable to micturate, consult urologist/surgeon OR refer the patient

Acute Splenic sequestration (sudden enlargement of spleen, life threatening)

• Immediately transfuse 5 -7.5ml/kg (50% of what we commonly transfuse) over 3-4hrs • Give 20ml/kg normal saline bolus while awaiting blood, repeat bolus if needed • Monitor vital signs (PR, BP, RR, temp, oxygen sat.) at least every 30 mins • Monitor spleen size hourly for 12-24 hours, until reducing in size • Check Hb 2 hours posttransfusion, consider repeat transfusion • Treat underlying cause, where applicable • Therapeutic splenectomy if >2 episodes of sequestration

32

SECTION 5

TOOLS FOR RESPIRATORY DISEASE

Tools For Sickle Cell Disease

5.1 Asthma Out-patient Management Chart ASTHMA: MEDICATION MANAGEMENT Start at step 2

Uncontrolled: step up 1-2 steps

STEP DOWN when doing well

Partly controlled: re-assess non-pharmacological management and inhaler use; consider stepping up

STEP UP when poor control

Well-controlled: consider stepping down after 3 months of stability

Asthma Severity

Controler- Beclomethazone inhaler (200 microgm)*

Reliever Salbutamol

Oral Prednis one

Alternative Formoterol and Budesenide Combined

Step 5

High dose (600 mcg 2 times / day)

1 – 2 puff as needed

Yes

2 puff BD and 1 puff as needed

Step 4

High dose (600 mcg 2 times / day)

1 – 2 puff as needed

No

2 puff BD and 1 puff as needed

Step 3

Medium dose (400 mcg 2 times/ day)

1 – 2 puff as needed

No

1 puff BD and 1 puff as needed

Step 2

Low dose (200 mcg 2 times / day)

1 – 2 puff as needed

No

1 puff as needed

Step 1

Low dose (200 mcg) whenever salbutamol is used

1 – 2 puff as needed (never use alone)

No

1 puff as needed

LEVEL OF ASTHMA SYMPTOM CONTROL Well controlled

Partly controlled

Uncontrolled

None of

1-2

3-4

these

of these

of these

Additional notes on asthma •

All patients with asthma should be on steroid inhalers - never salbutamol (SABA) only.

•

Check inhaler technique each visit. Use spacers when needed.

•

If available – use a combination inhaler of formoterol and corticosteroids (LABA and ICS). Never use formoterol-only inhaler in asthma due to increase in mortality.

•

If atopy (rhinitis, eczema, allergies) add antihistamine tabs.

•

Avoid salbutamol and theophylline tablets in asthma.

•

If no response – obtain chest x-ray to consider alternate diagnosis.

•

Teach patients with higher literacy to adjust their own asthma treatment using a written action plan.

•

•

Self increase dose of inhaled steroids if ·

Control is worse – based on 4 questions

·

Peak flow meter at home, done daily at home, worsens by 20%

Come to hospital if no improvement after increasing step of steroid inhaler

34

5.2 Asthma Exacerbation Management Chart ASTHMA EXACERBATION MANAGEMENT CHART

Step 1: Identify Exacerbation Accessory muscle use SpO2<90% Difficulty speaking Chest tightness

RR>24 Wheezing Difficulty breathing Persistent coughing

Manage as outpatient

NO

Hypoxic?

Respiratory distress?

Altered mental state?

YES

Refer to Emergency Department *Consider MgSO4 2g IV over 10 min

Step 2: Manage exacerbation Salbutamol inhaler: 4-10 puffs every 20 minutes x3 (use spacer if needed) Give prednisone PO 40-60mg immediately If no improvement, refer to Emergency Start prednisone 40-60mg PO OD x5-7 days if persistent symptoms Continue Salbutamol inhaler 1-2 puffs every 1-3 hours as needed Identify trigger Re-assess

35

Tools For Sickle Cell Disease

5.3 COPD Out-patient Management Chart COPD: MEDICATION MANAGEMENT STEP UP

Severity

Exacerbations per year

Treatment

N/A

≥ 2 per year or 1 hospital admit / year

Long acting B agonist e.g. formoterol AND Long acting anti muscarinic AND inhaled corticosteroid if exacerbations persist

Group B

Yes (MMRC 2-4)

0-1 per year

Long acting B agonist e.g. formoterol AND Long acting anti muscarinic

Group A

No (MMRC 0-1)

0-1 per year

Short acting B agonist as needed e.g. salbutamol inhaler or short acting anti-cholinergic as needed e.g. ipratropium inhaler

Group E

Lots of exacerbations

Few exacerbations; severe dyspnoea

STEP DOWN

Dyspnea

(Ask: Do others stop and wait for you on a level ground?)

Few exacerbations; more dyspnoea

MMRC Grading of dyspnoea 0

Not troubled by breathlessness except on strenuous exercise

1

Shortness of breath when hurrying on the level or walking up a slight hill

2

Walks slower than the people of the same age on the level because of breathlessness or has to stop when walking at own pace on the level

3

Stops for breath after walking about 100 m or after a few minutes on the level

4

Too breathless to leave the house or breathless when dressing or undressing

If uncontrolled on maximum dose inhalers: Reinforce non-pharmacologic management Ensure proper inhaler technique or use spacer Consider other diagnoses (TB,Cardiac cancer) *Consider theophylline tab in Group E. Max dose 200 mg/day. Check creat every 12m.

Be aware toxicity

36

5.4 COPD Exacerbation Management Chart COPD EXACERBATION MANAGEMENT CHART

Step 1: Identify Exacerbation

Manage as outpatient

NO

Acute Hypoxia (new SpO2<88%)?

Respiratory distress?

YES

Refer to Emergency Department *Consider MgSO4 2g IV over 10 min

Step 2: Manage exacerbation Salbutamol inhaler: 2 puffs every hour x3, then every 2-4 hours as needed Ipratropium inhaler: 2 puffs every 4-6 hours Prednisone 40mg PO OD x5 days Amoxicillin 1g PO TDS x 7 days AND Azithromycin 500mg PO OD x3 days IF increased cough AND increased sputum production or fever

Obtain Chest X ray after 2nd exacerbation – to consider alternate diagnosis

37

Tools For Sickle Cell Disease

5.5 How To Make A Bottle Spacer To modify a 500ml plastic bottle for use as an effective spacer: 1. Wash the bottle with soap and water and air dry for a minimum of 12 hours to reduce electrostatic charge on the interior plastic.

2. Make a wire mould similar in size and shape to the mouthpiece of the inhaler.

3. Heat the mould and hold in position on the outside of the base of the plastic bottle until the plastic begins to melt (~10 seconds). Rotate the mould 180% and reapply to the bottle until the mould melts through to make a hole.

4. While the bottle is still warm, insert the inhaler into the hole to ensure a tight fit between the inhaler and bottle spacer.

New bottle spacers should be primed initially with 10 puffs of the medicine to reduce electrostatic charge on the walls, which attracts small particles, and thus make more aerosol medicine available for inhalation.

A wire mold is used to melt a hole in the base of the 500 ml bottle, to fit an inhaler

Correct use of a modified 500 ml plastic cold-drink bottle as a spacer

How to use a bottle spacer Use a modified 500ml plastic bottle in a similar way to a conventional spacer.

1. Insert the inhaler into the hole at the base of the bottle spacer.

2. Hold the neck of the bottle spacer in the child’s mouth. For a young child who cannot form a tight seal with the spacer in their mouth, a small commercially available facemask that fits on the open end of the bottle can be applied. Do not use a cup or cut the side of the bottle spacer.

3. Give the child a single puff of the inhaler with the spacer, followed by normal breathing, and repeat until the desired amount of medicine is given, which is frequently 2 puffs, but may be up to 6 puffs for relief of bronchoconstriction.

Reference: The Global Asthma Report 2022. http://globalasthmareport.org/management/spacers.php. Zar HJ, Motala C, Weinberg E. Incorrect use of a homemade spacer for treatment of recurrentwheezing in children--a cause for concern. S Afr Med J. 2005 Jun;95(6):388, 390.

38