A stepped treatment algorithm for chronic respiratory disease using budesonide-formoterol in a rural healthcare setting in Vietnam

Abstract

Inhaled budesonide-formoterol (BF) used as-needed is effective in preventing exacerbations in patients with mild to moderate asthma. It is unclear if a similar approach can be used for chronic obstructive respiratory diseases (CRD), irrespective of the label of asthma or COPD. We aimed to assess the feasibility of a pragmatic intervention that entails a stepped algorithm using BF (dry powder inhaler, 160µg /4.5µg per dose) for patients presenting with CRD to three rural district hospitals in Hanoi, Vietnam.

We recruited patients with spirometric airflow obstruction and/or symptoms consistent with asthma. The algorithm consisted of three steps: 1. as-needed BF for symptoms, 2. maintenance plus as-needed BF, and 3. referral to a higher-level healthcare facility. All participants started at step 1, with escalation to the next step at review visits if there had been an exacerbation or inadequate symptom control. Patients were followed for 12 months.

We enrolled 315 participants. During the follow-up period, 140 (44.4%) had ≥ 1 episodes of acute respiratory symptoms requiring a visit to clinic or hospital; 105 (33%) were diagnosed with an exacerbation. We observed that 200 (63.5%) were still using the recommended BF 12 months after enrolment. The mean and median number of doses/day was 1.4 (SD 1.1) doses and 1.0 (IQR 0.6 – 2.0) doses, respectively. The proportion of patients taking more than 4 doses/day was 3.5%.

This novel therapeutic algorithm is feasible for patients with CRD in a rural healthcare setting in Vietnam. Further studies are required to establish the effectiveness, safety and cost-effectiveness of similar approaches in different settings.