|Year : 2016 | Volume
| Issue : 1 | Page : 22-26
Pattern of respiratory diseases among patients seen at the emergency unit of a tertiary health facility in South-West Nigeria
BO Adeniyi1, OS Ilesanmi2, SO Fadare1, AO Akinyugha3, GE Erhabor4
1 Department of Medicine, Respiratory Unit, Federal Medical Centre, Owo, Ondo State, Nigeria
2 Department of Community Medicine, Federal Medical Centre, Owo, Ondo State, Nigeria
3 Department of Family Medicine, Federal Medical Centre, Owo, Ondo State, Nigeria
4 Department of Internal Medicine, Respiratory Unit, Obafemi Awolowo University, Ile-Ife, Nigeria
|Date of Web Publication||8-Sep-2016|
B O Adeniyi
Department of Internal Medicine, Respiratory Unit, Federal Medical Centre, Owo, Ondo State
Source of Support: None, Conflict of Interest: None
Background: Respiratory diseases constitute a large percentage of the medical conditions requiring hospital presentation. The burden of respiratory diseases presenting as emergencies need to be understood.
Objective: This study aimed at reviewing the pattern of respiratory diseases in the emergency unit of Federal Medical Centre, Owo.
Methods: The records of 914 patients seen with respiratory diseases from January 2007 to December 2012 were reviewed. Data were analyzed using SPSS version 21. Descriptive statistics were done. Chi-square test was used to compare other sociodemographic characteristics and disease-related variables by gender. Level of statistical significant was 5%.
Results: The mean age of respondents was 46.5 ± 20 years, 54.9% were 40 years and above. Males were 57.9%, 24% presented as acute conditions, 10.4% were Human immunodeficiency virus, HIV-positive. Death occurred in 7.1% within 24 h of admission. Median length of stay was 1.9 ± 1.4 days. Complicated pulmonary tuberculosis (PTB) was diagnosed in 35.1% of the patients followed by pneumonias (26.9%) and acute severe asthma (18.4%). The mean age of male patient was 48.5 ± 20.4 years while female was 43.8 ± 18.9 years, males are significantly older than females P < 0.001. Patients with HIV were younger with mean age 35.9 ± 10.4 years compared with HIV-negative patients, 47.8 ± 20.3 years P < 0.001. More females (13.8%) were HIV-positive compared to males (7.9%), P = 0.004.
Conclusion: Complicated PTB and the pneumonias were the leading causes of respiratory emergency in our environment. Not all respiratory cases seen at the emergency were acute condition. Standard precaution should be ensured as every one out of ten patients seen were HIV-positive. Disparities exist in the pattern of respiratory disease across gender.
Keywords: Emergencies, HIV, pneumonia, respiratory diseases, tuberculosis
|How to cite this article:|
Adeniyi B O, Ilesanmi O S, Fadare S O, Akinyugha A O, Erhabor G E. Pattern of respiratory diseases among patients seen at the emergency unit of a tertiary health facility in South-West Nigeria. Niger J Health Sci 2016;16:22-6
|How to cite this URL:|
Adeniyi B O, Ilesanmi O S, Fadare S O, Akinyugha A O, Erhabor G E. Pattern of respiratory diseases among patients seen at the emergency unit of a tertiary health facility in South-West Nigeria. Niger J Health Sci [serial online] 2016 [cited 2018 May 22];16:22-6. Available from: http://www.chs-journal.com/text.asp?2016/16/1/22/190031
| Introduction|| |
Respiratory diseases constitute a large percentage of the medical conditions seen at the emergency department.  The common causes of respiratory emergencies include pneumonias, acute severe asthma, acute exacerbation of chronic obstructive pulmonary diseases (COPD), TB, lung cancers, and acute respiratory distress syndromes from other causes.  In Nigeria, as in many African countries, communicable diseases continue to take their toll on the populace, however, with increasing smoking prevalence, rapid urbanization with its attending air pollution and exposure to biomass fuels from various sources, the noncommunicable respiratory diseases are gradually adding to the disease burden in this region. 
Globally, the burden of respiratory emergencies also continues to rise. In Sub-Saharan Africa with over-stretched health facilities, the challenge is equally great. It is projected that respiratory conditions such as COPD will constitute one of the highest causes of mortality in the nearest future.  Asthma is projected to increase from 300 to 400 million by the year 2025. 
Most of the patients in Africa tend to present first at the emergency department  hence there is the need to adequately equip the existing facilities in preparation for the expected rise in morbidity and mortality from these conditions.
Few studies , have taken a look at the pattern of respiratory emergencies in Nigeria. However, in view of the changing epidemiology of diseases and rapid urbanization, there is the need to study the current state of presentation in the emergency department. Hence, we set out to analyze the pattern of respiratory emergencies in our hospital with a view to documenting the top causes of emergency respiratory presentations and to identify possible reasons for the observed pattern.
| Materials and Methods|| |
A review of the records of 914 patients seen with respiratory diseases (which include disorders that affect the respiratory system and included airway diseases such as Asthma, COPD, infectious diseases such as pneumonia, tuberculosis, and tumors affecting the lungs such as lung cancers etc.,) from January 2007 to December 2012 at the emergency unit of the Federal Medical Centre, Owo was done. A structured pro formal was used to extract the following variables age, sex, presentation, HIV status, outcome of care, whether or not the patient was discharged against medical advice, admission status, time patient was seen, and diagnosis from the hospital records. Data were analyzed using IBM SPSS Statistics for Windows, Version 21.0. Descriptive statistics were presented using frequency tables and bar chart, age and length of stay (LOS) were summarized as mean and standard deviation. Chi-square test was used to compare the following variables age group, HIV status, presentation, outcome of care, admission status, and diagnosis with gender and diagnosis with period patients were seen. Level of statistical significance was set at P = 0.05.
This was obtained from the Ethical Committee of the Federal Medical Centre, Owo. Reference FMC/OW/380/VOL.XX/61.
| Results|| |
Respiratory diseases were reported by 914 patients of the 16815 patients seen at the emergency unit of the hospital from January 2007 to December 2012.
[Table 1] shows the characteristics of the patients seen at the emergency unit of FMC, Owo January 2007-December 2012. The mean age of respondents was 46.5 ± 20 years. In all, 502 (54.9%) were 40 years and above. Males were 529 (57.9%) while females were 385 (42.1%). Only 219 (24%) presented as acute conditions, 95 (10.4%) were HIV-positive. Death occurred in 65 (7.1%) within 24 h of stay in the emergency. More patients, 539 (59%), were seen during the raining season.
|Table 1: Characteristics of patients seen at the emergency unit of FMC Owo, 2007-2012|
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Age of the patients in smaller groups is shown in [Figure 1]. Age group 30-39 years had 194 (21.2%) patients. The group with the minimum number of patient was age <20 with 48 (5%) patients. The mean age of male patients was 48.5 ± 20.4 years while for female was 43.8 ± 18.9 years. The difference in age is statistically significant P < 0.001.
[Table 2] shows the diagnosis, mean age and standard deviation of the patients. Complicated pulmonary tuberculosis (PTB) was diagnosed in 321 (35.1%) of the patients followed by pneumonias 246 (26.9%) and acute severe asthma 168 (18.4%). Only a few patients 10 (1.1%) had lung cancer. Patients with acute exacerbation of COPD had a mean age of 70.3 ± 12.1 years while PTB and acute severe asthma patients were 42.5 ± 16.5 years and 39.6 ± 17.8 years respectively P < 0.001. Patients with HIV were younger with a mean age of 35.9 ± 10.4 years compared to HIV-negative patients with 47.8 ± 20.3 years P < 0.001.
Pattern of presentation according to month of the year is shown in [Figure 2]. The highest number was seen in January 100 (10.9%) while the minimum showed up in December 58(6.3%). Other months were as shown in the figure.
[Figure 3] shows the number of patients with chest diseases seen at the emergency unit of FMC, Owo during the study period. 190 (20.8%) were seen in 2008 while the minimum number of patients 113 (12.4%) were seen in 2012. Other years were as shown in the figure.
As shown in [Table 3] patients with acute severe asthma had the minimum number LOS 1.53 ± 0.96 days while PTB patients had mean LOS of 2.15 ± 1.53 days. Although differences were observed in the LOS in the emergency department, the differences observed were not statistically significant, P = 0.106. Mortality within the first 24 h was 7.1% [Figure 4].
|Table 3: Diagnosis and median length of stay (LOS) of patients with chest diseases seen at the emergency of FMC, Owo 2007-2012|
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The characteristics of respondents by gender are as shown in [Table 4]. Among male respondents, 316 (59.7%) were 40 years and above while less than half 186 (48.3%) of female patients were in the same age category, males are significantly older than females P = 0.01. As regards HIV status, 53 (13.8%) female were positive compared to 42 (7.9%) males. The higher number of females being HIV-positive was statistically significant, P = 0.004. More female 78 (20.3%) presented with acute severe asthma compared to 90 (17.0) male. Acute exacerbation of COPD was the cause of presentation in 66 (12.9%) males compared to 14 (3.6%) females, this difference is statistically significant P = 0.01.
As shown in [Table 5] more patients were seen from April to October. In all 56 (68.3%) of patients with acute exacerbation of COPD were seen from April to October. The differences observed in the period patients were seen were not statistically significant.
| Discussion|| |
Our findings revealed that respiratory diseases accounted for approximately 5.4% of presentations at the emergency unit with 24% of them presenting in acute conditions. This is comparable to the findings in Italy and Brazil 5.0% and 5.9%, respectively. , This is, however, lower than 9.3% seen in Uyo and 9.8% in the USA and the 10.8% by Desalu et al., in Ido. ,,
Furthermore, our study found that complicated PTB was the most common respiratory condition necessitating presentation to the emergency unit with 35.1%, followed by pneumonias, 26.9%, acute severe asthma with 18.4%, and then COPD with 9.0%. Some of the observed complications of TB include respiratory failure, superimposed bacterial infection and sepsis.
This pattern is similar to the findings by Umoh et al., in Uyo which showed that PTB (66.8%) and pneumonia (24.9%) were the two leading causes of presentations for admission.  However, in Ido-Ekiti, which is in the same geographic region as our hospital Desalu et al. reported a slightly different order with pneumonia coming ahead of PTB (34.5% vs. 29.4%), followed by acute asthma (24.5%), and acute exacerbation of COPD (10.3%).  Although the Ido-Ekiti study documented pneumonia as the commonest respiratory emergency, it is possible that some of the tuberculosis presented with superimposed bacterial infection.
The findings in this present study were different from the ones found in the UK and in Brazil where chronic noncommunicable respiratory diseases  and upper respiratory tract infections (URTIs) were the most common respiratory diseases seen in the emergency unit respectively.  The higher prevalence of smoking may account for the former. More than half of all the deaths from lung disease in Europe, and, at least, one-quarter of all respiratory hospital admissions are due to diseases caused by smoking.  The high prevalence of patients with URTIs in Brazil was due to the influenza A (H1N1) pandemic that occurred there during the study period. 
In terms of patients' characteristics, this present study found a male: female ratio of 1.4:1. Findings in other studies ranged from 1.2 to 3.5:1. ,,
Our results also show that more females were HIV-positive (13.8% vs. 7.9%). This may be attributed to the higher risk of women contracting the virus during unprotected sex when compared to their male counterparts.  It is interesting to note that 95 of the cases (10.4%), were HIV positive seen more among patients with tuberculosis. This represents one in every ten patients seen. Although it is not routine in our hospital to screen all patients presenting at the emergency department for HIV, this high level was recorded among those who had indications for screening. This underscores the need for universal precautions whenever patients are being attended to in the emergency department regardless of the cause of presentation.
The mean age of the male patients in this study was 48.5 ± 20.4 years while that of the females was 43.8 ± 18.9 years. From our study, this difference was statistically significant.
This study also revealed that 54.9% of the patients were aged 40 years and above. This is similar to the findings in Ido where 64.1% of the patients were 40 years and above. This may be attributable to comorbid medical conditions and possible increase susceptibility to illnesses including respiratory infections with increasing age. 
From this study, we observed that more patients were seen during the rainy season (April-October) - 59% than during the dry season (November-March) - 41%. This finding in this study, though not statistically significant, is similar to that of Sachdeva in India who reported more TB-related admissions in April-June (56.4%) in comparison to January-March (43.6%). 
Desalu in his study in 2011 also reported that asthma and pulmonary TB were higher in the wet season but found that the number of patients with acute exacerbation of COPD and pneumonia were significantly higher in the dry season.  It is generally known that there is increase susceptibility to respiratory tract infections during the wet seasons particularly viral infections which could then increase the likelihood of a superimposed bacterial infection. It is, however, pertinent to note that in recent times, there have been changes in weather conditions which are possibly due to climate change engendered by the depleting ozone layer, this has made the previous clear - cut delineation between dry and wet seasons to be less distinct. In addition, presentation to the hospital in our environment is usually a function of the economic power of the patients, accessibility of the health facility and the general health-seeing behavior of the people.
The mortality within 24 h of presentation was found to be 7.1% from this study. This is similar to what was recorded by the study in Ido where the mortality within 24 h was found to be 7.4%.  Our result is higher than the findings in Brazil with a mortality of 2.7%.  This may be due to late presentation to the hospital by many of the patients in this part of the world and also to the availability of better healthcare facilities when compared to the latter.
Poor, missing, and incomplete documentations were some of the limitations we observed in carrying out this study. Due to inadequately equipped emergency department with diagnostic facilities, some rarer respiratory conditions might have been missed out. However, this audit is a good starting point in documenting the pattern of respiratory emergencies in our environment.
| Conclusion|| |
This study showed that respiratory diseases constitute a high burden in our environment. Of special note is the contribution by complicated tuberculosis, pneumonias, acute severe asthma, and acute exacerbation of COPD. It is hoped that this study will form a framework for larger studies in this regard. There is urgent need to adequately equip hospitals in Nigeria to handle common acute respiratory emergencies in other reduce morbidity and mortalities from these diseases.
We wish to acknowledge the nursing and record staff of the Internal Medicine Department of the Federal Medical Centre, Owo for their support while the data gathering was on.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Hubbard R. The burden of lung disease. Thorax 2006;61:557-8.
Masoli M, Fabian D, Holt S, Beasley R; Global Initiative for Asthma (GINA) Program. The global burden of asthma: Executive summary of the GINA Dissemination Committee report. Allergy 2004;59:469-78.
Hanewinckel R, Jongman HP, Wallis LA, Mulligan TM. Emergency medicine in Paarl, South Africa: A cross-sectional descriptive study. Int J Emerg Med 2010;3:143-50.
Umoh VA, Otu A, Okpa H, Effa E. The pattern of respiratory disease morbidity and mortality in a tertiary hospital in southern-eastern Nigeria. Pulm Med 2013;2013:581973.
Desalu OO, Ojo OO, Busari OA, Fadeyi A. Pattern of respiratory diseases seen among adults in an emergency room in a resource-poor nation health facility. Pan Afr Med J 2011;9:24.
Tramuto F, Cusimano R, Cerame G, Vultaggio M, Calamusa G, Maida CM, et al.
Urban air pollution and emergency room admissions for respiratory symptoms: A case-crossover study in Palermo, Italy. Environ Health 2011;10:31.
Valença LM, Restivo PC, Nunes MS. Seasonal variations in emergency room visits for asthma attacks in Gama, Brazil. J Bras Pneumol 2006;32:284-9.
Gonçalves BD, Cavalini LT, Valente JG. Epidemiological monitoring of tuberculosis in a general teaching hospital. J Bras Pneumol 2010;36:347-55.
Sachdeva R, Sachdeva S, Gupta KB. Pattern and outcome of patients discharged from chest ward of a university hospital. Med J DY Patil Univ 2013;6:240-4. Available from: http://www.mjdrdypu.org/text.asp?2013/6/3/240/114642
. [Last accessed on 2014 Oct 10; Last cited on 2014 Sep 17].
World Health Organization (WHO). Strategy for Prevention and Control of Chronic Respiratory Diseases. Geneva: WHO/MNC/CRA/02; 2002. p. 1-13.
Desalu OO. Seasonal variation in hospitalisation for respiratory diseases in the tropical rain forest of South Western Nigeria. Niger Postgrad Med J 2011;18:39-43.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]