Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2024 Apr 17:9:205.
doi: 10.12688/wellcomeopenres.21041.1. eCollection 2024.

Causes, outcomes and diagnosis of acute breathlessness hospital admissions in Malawi: protocol for a multicentre prospective cohort study

Stephen A Spencer  1   2   3 , Florence Malowa  2 , David McCarty  3   4 , Elizabeth Joekes  1 , Jacob Phulusa  2 , Beatrice Chinoko  2 , Sylvester Kaimba  2 , Lucy Keyala  2 , Peter Mandala  2 , Mercy Mkandawire  2 , Matthew Mlongoti  2 , Bright Mnesa  2 , Albert Mukatipa  2 , Rhona Mijumbi  1   2 , Mulinda Nyirenda  3   4 , Hendry R Sawe  5 , Marc Henrion  1   2 , Daniel X Augustine  6 , David Oxborough  7 , Eve Worrall  1 , Felix Limbani  2 , Paul Dark  8 , Stephen B Gordon  2   3 , Jamie Rylance  1 , Ben Morton  1 ; Collaborators
Affiliations

Causes, outcomes and diagnosis of acute breathlessness hospital admissions in Malawi: protocol for a multicentre prospective cohort study

Stephen A Spencer et al. Wellcome Open Res. .

Abstract

Background: Hospital admission due to breathlessness carries a significant burden to patients and healthcare systems, particularly impacting people in low-income countries. Prompt appropriate treatment is vital to improve outcomes, but this relies on accurate diagnostic tests which are of limited availability in resource-constrained settings. We will provide an accurate description of acute breathlessness presentations in a multicentre prospective cohort study in Malawi, a low resource setting in Southern Africa, and explore approaches to strengthen diagnostic capacity.

Objectives: Primary objective: Delineate between causes of breathlessness among adults admitted to hospital in Malawi and report disease prevalence. Secondary objectives : Determine patient outcomes, including mortality and hospital readmission 90 days after admission; determine the diagnostic accuracy of biomarkers to differentiate between heart failure and respiratory infections (such as pneumonia) including brain natriuretic peptides, procalcitonin and C-reactive protein.

Methods: This is a prospective longitudinal cohort study of adults (≥18 years) admitted to hospital with breathlessness across two hospitals: 1) Queen Elizabeth Central Hospital, Blantyre, Malawi; 2) Chiradzulu District Hospital, Chiradzulu, Malawi. Patients will be consecutively recruited within 24 hours of emergency presentation and followed-up until 90 days from hospital admission. We will conduct enhanced diagnostic tests with robust quality assurance and quality control to determine estimates of disease pathology. Diagnostic case definitions were selected following a systematic literature search.

Discussion: This study will provide detailed epidemiological description of adult hospital admissions due to breathlessness in low-income settings, which is currently poorly understood. We will delineate between causes using established case definitions and conduct nested diagnostic evaluation. The results have the potential to facilitate development of interventions targeted to strengthen diagnostic capacity, enable prompt and appropriate treatment, and ultimately improve both patient care and outcomes.

Keywords: Breathlessness; emergency care; hospital care; low-resource settings; respiratory distress; sub-Saharan Africa.

Plain language summary

Background: People admitted to hospital with symptoms of breathlessness are often severely ill and need quick, accurate assessment to facilitate timely initiation of appropriate treatments. In low resource settings, such as Malawi, limited access to diagnostic equipment impedes patient assessment. Failure to identify and treat the underlying diagnosis may lead to preventable death.

Aims: This cohort study aims to delineate between common, treatable causes of breathlessness among adult patients admitted to hospital in Malawi and measure survival. We will also evaluate the performance of blood markers to diagnose and differentiate between conditions. The results will help us develop context-appropriate diagnostic and treatment algorithms based on resources available in the health system Methods in brief: We will recruit adult patients who present to hospital with breathlessness in a central national referral hospital (Queen Elizabeth Central Hospital, Blantyre), and a district hospital (Chiradzulu District Hospital, Chiradzulu). We will conduct enhanced diagnostic tests to determine causes of breathlessness against internationally accepted diagnostic guidelines. Patients will be followed up throughout their hospital admission and after discharge, until 90 days.

Interpretation: This study aligns with World Health Assembly resolutions on ‘Strengthening diagnostics capacity’ and on ‘Integrated emergency, critical and operative care for universal health coverage and protection from health emergencies’. The results of this study will have the potential to facilitate development of interventions targeted to strengthen diagnostic capacity, enable prompt and appropriate treatment, and ultimately improve care and outcomes for acutely unwell patients.

PubMed Disclaimer

Conflict of interest statement

No competing interests were disclosed.

Figures

Figure 1.
Figure 1.. Participant flow through study investigations.
BNP: brain natriuretic peptide; CXR: chest x-ray; CRP: C-reactive protein; Hb: haemoglobin; HbA1c: glycated haemoglobin; HIV: human immunodeficiency virus; NT-proBNP: N-terminal pro-brain natriuretic peptide; PCT: procalcitonin; Tb: tuberculosis; urine LAM: urine lipoarabinomannan. *Index tests
Figure 2.
Figure 2.. Sample size impact on precision of prevalence estimate.
See this image and copyright information in PMC

References

    1. Kelly AM, Keijzers G, Klim S, et al. : An observational study of dyspnea in emergency departments: The Asia, Australia, and New Zealand Dyspnea in Emergency Departments Study (AANZDEM). Acad Emerg Med. 2017;24(3):328–36. 10.1111/acem.13118 - DOI - PubMed
    1. Bellani G, Laffey JG, Pham T, et al. : Epidemiology, patterns of care, and mortality for patients with acute respiratory distress syndrome in intensive care units in 50 countries. JAMA. 2016;315(8):788–800. 10.1001/jama.2016.0291 - DOI - PubMed
    1. The Seventy-sixth world health assembly: strengthening diagnostics capacity.Geneva, Switzerland: World Health Assembly,2023. Reference Source
    1. Fleming KA, Horton S, Wilson ML, et al. : The Lancet commission on diagnostics: transforming access to diagnostics. Lancet. 2021;398(10315):1997–2050. 10.1016/S0140-6736(21)00673-5 - DOI - PMC - PubMed
    1. Mandelzweig K, Leligdowicz A, Murthy S, et al. : Non-invasive ventilation in children and adults in low- and low-middle income countries: a systematic review and meta-analysis. J Crit Care. 2018;47:310–9. 10.1016/j.jcrc.2018.01.007 - DOI - PubMed

LinkOut - more resources