Acute Bronchopulmonary Diseases in Rural Children (Clinical-Epidemiological Features and Effectiveness of Stage-Based Treatment)

The study is dedicated to a comprehensive investigation of acute bronchopulmonary diseases in rural children residing in rural districts of the Omsk Region. The work examines the clinical-epidemiological features of pneumonia and acute bronchitis in children living in rural conditions, taking into account the stage-based nature of medical care provision—from feldsher-obstetric points to regional children's clinical hospitals. Special attention is given to the relationship between morbidity and mortality indicators and the medical-organizational and social factors determining the accessibility of qualified pediatric care in rural areas. The effectiveness of diagnosis and treatment at various stages of medical care provision has been investigated, and organizational and methodological approaches to improving care have been developed, including non-invasive therapy technologies adapted for conditions of rural healthcare facilities. The pathogenic mechanisms of hypoxia-mediated metabolic disorders associated with acute disruption of purine metabolism and activation of lipoperoxidation have also been studied, and methods for their correction in severe forms of the disease have been developed.

Relevance of the Problem. Respiratory diseases in children occupy the first place in the structure of morbidity and the third place in the structure of infant mortality [41, 67, 90, 91, 264]. They are classified as so-called 'manageable,' i.e., preventable, causes of child mortality [22, 23, 177, 202]. Reducing mortality from respiratory diseases is the most realistic reserve for reducing overall child mortality [94,95,115,176]. Of particular interest in this regard are acute diseases of the lower respiratory tract, which have a more severe, complicated course in the structure of acute respiratory pathology [41,330].

Optimizing pulmonological care for children is impossible without detailed epidemiological studies and associated organizational decisions, without improving approaches to diagnosis and therapy of these diseases [78, 108, 160,326]. The organization of diagnostic and therapeutic care for children with acute respiratory pathology has been identified by the WHO as a priority task [92,243,438].

Recent decades have been characterized by significant progress in studying the etiology [17,41,45, 50, 184, 211,223,288, 302,307,382,402,449, 483, 497, 500] and epidemiology [15, 18, 41, 43, 61,73, 133, 179, 183, 239, 295, 306] of acute bronchopulmonary diseases (ABPD) in children. Diagnostic criteria have been developed [15, 45, 57, 76, 211, 223, 289], and a clinical classification has been adopted [125]. Approaches to etiotropic and pathogenetic therapy of ABPD have been unified [45, 148, 154, 172,211,223].

A new direction in studying this pathology is the investigation of epidemiological and clinical features of ABPD in children in various living conditions: high altitude [27, 135], hot climate [154, 315], ecological unfavorable conditions [80]. The effectiveness of medical care for children with ABPD in a pediatric district in a polyclinic has been studied [61, 77, 280]. Knowledge of these features allows for a differentiated approach in organizing medical care for children with ABPD depending on the zone of residence or medical service.

For Russia, where a significant portion of the child population lives in rural areas, a comprehensive study of this pathology in rural children is relevant, where consistently higher overall mortality and, primarily, mortality from respiratory diseases is registered [22,46,165,199,443].

Distinguishing features of the organization of medical services in rural areas, compared to urban areas, include its stage-based nature: (feldsher-obstetric point (FAP), district hospital (DH) or medical ambulatory care (MAC), central district hospital (CDH), regional children's clinical hospital (RCCH)) and the necessity of transporting a sick child over long distances to receive qualified care [165, 254, 279]. Provision with pediatricians in rural areas is worse than in cities [58, 59]. The district-based principle of serving children, inherent to cities, exists in rural areas only in district centers and large villages with district hospitals (MAC) where a pediatrician is available. In villages with FAPs, medical observation of children is conducted by a feldsher, and in villages with DH(MAC) - most often by a general practitioner. There are more socially maladapted families in rural areas, with higher morbidity and mortality among their children, which is well-known [9, 19,20, 103, 140, 178,208,245,270,294].

Improving medical care for rural children with ABPD is impossible without comprehensive study of the features of this pathology in rural areas, including epidemiology and clinical manifestations [78,91, 108,326].

The study of morbidity from acute respiratory pathology in urban and rural settings in a comparative aspect was conducted in isolated works and only from the perspective of studying the influence of the unfavorable ecological situation in industrial cities, when rural children constituted the comparison group as living in relatively more favorable ecological conditions [43, 120, 183, 210, 321]. In this case, the aforementioned medical-organizational and social factors were not taken into account, which inevitably affect epidemiological indicators and features of the clinical course of the disease.

It is of interest to study morbidity not only in rural areas as a whole but also in different rural districts differing in levels of socio-economic development and state of medical services, since the aforementioned differences in individual districts may substantially differ [279]. It is also logical to assume the existence of a dependence between morbidity and place of residence from the perspective of the level of medical service in a rural settlement (FAP, DH or MAC, CDH), its distance from the regional and district center, and its location relative to transportation arteries, since all this collectively determines the accessibility of qualified care. The latter not only affects the incidence and, consequently, morbidity, but can also be directly related to an epidemiological indicator such as mortality, since it inevitably influences the timeliness of providing emergency care to a sick child.

Higher mortality from ABPD in rural areas is associated with a more frequent occurrence of complicated courses of these diseases [43, 211]. Complications of ABPD are mainly determined by the effect of hypoxia on the body as the most important triggering mechanism of metabolic disorders in severe courses of ABPD in children [38,99, 148,211,223,319].

Therefore, to improve the quality of treatment of these diseases in rural children, it is also relevant to further improve diagnostic and therapeutic approaches in severe and complicated courses of ABPD, including methods of pathogenetic therapy aimed at correcting hypoxia-mediated metabolic disorders.

In this regard, fundamentally new approaches to understanding the pathogenesis of metabolic disorders in hypoxia, associated with acute disruption of purine metabolism (ADPM) and concomitant activation of lipoperoxidation processes [138], are of interest. The latter, as is known, is the triggering link of cell apoptosis and, consequently, organism death as a whole [223,255,273, 534].

The aim of the study is to assess the quality of medical care provided to children with acute bronchopulmonary diseases in rural conditions and to develop the main directions for optimizing their diagnosis and treatment at stages of medical care provision.

Research Objectives.

1. Based on surveying rural pediatricians, to assess the level of their theoretical knowledge on issues of diagnosis and therapy of acute bronchopulmonary diseases and to establish the main objective factors determining it.

2. Based on expert review of primary medical documentation, to assess the effectiveness of established diagnostic and therapeutic approaches for acute diseases of the lower respiratory tract in children at stages of rural healthcare provision.

3. To investigate the clinical features of the course of acute diseases of the lower respiratory tract in rural children as a whole and in villages with different levels of medical service in particular.

4. Based on verified data, to study the features of morbidity based on healthcare utilization, mortality from this pathology in rural children, and the relationship between these indicators and medical-organizational and social factors.

5. To develop and implement organizational and methodological methods for optimizing diagnosis and treatment of acute bronchopulmonary diseases at stages of medical care provision in rural conditions.

6. To develop forms of implementing non-invasive technologies for treating acute diseases of the lower respiratory tract in ambulatory and inpatient conditions, adapted for rural healthcare facilities of different levels, using oral antibacterial therapy and modern inhalation techniques, and to assess their clinical and pharmacoeconomic effectiveness.

7. To develop methods for clinical prediction of toxic-hypoxic cerebral complications of acute bronchopulmonary diseases in children and an algorithm for their prophylactic and emergency treatment at stages of rural healthcare provision.

8. Based on the study of hypoxia-mediated and interrelated acute disruption of purine metabolism and lipoperoxidation of cell membranes, to develop methods for improving diagnosis and treatment of metabolic disorders in severe forms of acute bronchopulmonary diseases in children.

9. To assess the effectiveness of implementing a comprehensive regional-scale program for improving medical care for children with acute bronchopulmonary pathology living in rural areas.

Scientific Novelty. For the first time, based on expert review of primary medical documentation with verification of diagnoses, morbidity based on referrals to healthcare facilities (HCF) and mortality from acute diseases of the lower respiratory tract in rural children compared with urban children have been studied, and the relationship between these indicators and social and medical-organizational features of rural districts has been examined. It has been shown that lower morbidity from pneumonia and bronchitis in rural children is associated with undercounting of non-severe forms of the disease due to the population of children over 3 years old living in villages outside the district pediatric service zone, rather than ecological differences between rural and urban areas. It has been proven that higher mortality from respiratory diseases among rural children is also registered due to the population of children from villages outside the district pediatric service zone.

For the first time, a comprehensive assessment of the quality of medical care for children at various stages of rural healthcare provision for ABPD has been given. It has been established that the lower level of theoretical training of rural ambulatory and polyclinic pediatricians compared to hospital-based specialists in pulmonology issues is associated with poorer organization of their professional retraining process.

Features of the course of pneumonia and acute bronchitis in rural children have been established: a longer period for registering the main clinical symptoms of the disease and higher morbidity from ABPD with toxic-hypoxic complications of cerebral origin compared to urban areas. The relationship of these features with later healthcare utilization, primarily among children from villages outside the district pediatric service zone, has been proven.

A system of organizational and methodological approaches aimed at improving medical care for children with acute diseases of the lower respiratory tract, taking into account the existing stage-based nature of medical care in rural areas, has been developed. A clinical and pharmacoeconomic assessment of the effectiveness of implementing non-invasive methods of ABPD therapy in children, adapted for conditions of various departments of rural HCFs (oral antibacterial therapy, emergency care for bronchoobstructive syndrome (BOS) using modern inhalation techniques, possibility of outpatient treatment of uncomplicated forms of ABPD), has been provided. A method of step-by-step therapy for BOS in children at various stages of rural healthcare provision has been developed.

Diagnostic and therapeutic approaches for severe forms of ABPD, which are more common in rural areas than in cities, have been improved. A method for clinical prediction and prophylactic treatment of toxic-hypoxic cerebral complications of ABPD in rural HCFs of various levels has been developed. Based on fundamentally new approaches to understanding the pathogenesis of metabolic disorders in hypoxia, founded on the relationship between ADPM and activation of lipoperoxidation, new biochemical markers of the severity of ABPD course and disease prognosis have been established. Methods for pharmacologic correction of hypoxia-mediated metabolic disorders in severe forms of ABPD in children, based on specifically targeting purine metabolism, have been developed.

Practical Significance. A regional-level program aimed at improving the quality of diagnosis and treatment of ABPD in rural HCFs has been implemented.

The established relationship between morbidity and mortality from ABPD and social and medical-organizational features of rural districts dictates the necessity of addressing these problems to improve epidemiological indicators for the studied pathology in rural children.

The implementation of modern non-invasive approaches to ABPD treatment, adapted for rural HCFs of different levels (oral antibacterial therapy, step-by-step approach to bronchoobstructive syndrome therapy), has allowed improving the quality of treatment, reducing the level of hospitalization, decreasing the flow of ABPD patients to the RCCH, and reducing overall treatment costs.

The use of a method for clinical prediction and prophylactic treatment of toxic-hypoxic cerebral complications allows for the prevention of such complications in children with ABPD.

Determining the concentration of uric acid in serum blood and its ratio with the content of lipofuscin-like pigment in erythrocyte membranes allows for assessing the severity of metabolic disorders in ABPD and predicting the disease outcome. The use of agents that inhibit the breakdown of purine nucleotides positively affects metabolic processes in respiratory hypoxia in children with severe forms of ABPD and the clinical course of the disease.

Main Propositions for Defense.

The quality of medical care for children with acute bronchopulmonary diseases in rural HCFs lags behind that in urban healthcare facilities, resulting in more frequent diagnostic errors, irrational etiotropic therapy, polypragmasia, and less active implementation of modern non-invasive treatment technologies.

Features of morbidity (based on healthcare utilization) and mortality from ABPD in rural children are associated with social and medical-organizational factors limiting the accessibility of qualified medical care in rural living conditions.

Rural patients have more conditions for developing toxic-hypoxic complications of ABPD, which accounts for higher morbidity from these complications among rural children. Toxic-hypoxic cerebral complications serve as the most frequent cause of fatal outcome in ABPD.

Improving diagnosis and treatment of ABPD in rural children is associated with the need to address issues of improving accessibility of qualified pediatric care, activating the ongoing education of rural pediatricians, differentiated implementation of modern technologies in the diagnostic and therapeutic process at various stages of medical care in rural areas, and optimizing diagnosis and treatment of complicated forms of these diseases.

With the aim of improving medical care for severe forms of ABPD in children, the most important task is optimizing diagnostic and therapeutic approaches to complications caused by the effects of hypoxia and toxemia, primarily affecting the brain. Among new diagnostic and therapeutic approaches for respiratory hypoxia in children with ABPD, methods associated with disruption of purine metabolism and concomitant lipoperoxidation may be used.

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