August 2020

Respiratory care in the post COVID-19 era. There are reasons for being cheerful.

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COVID-19 and respiratory care

We are just starting to understand how profound the impact of COVID-19 will be on how patients with respiratory problems (such as asthma, COPD and bronchiectasis) are looked after in both hospital and general practice. Similarly, the assessment of symptoms such as cough, wheeze and breathlessness has had to be undertaken from the distance of a phone call or video conference during the lockdown period.

Of course, the COVID-19 outbreak has not circumvented the problems or instability of long-term conditions such as asthma or COPD. Likewise, symptoms such as unexplained cough, breathlessness or wheeze continue to require assessment and for many people seeking advice about such problems, there is an additional factor to consider about whether to come to hospital for a face to face assessment or diagnostic tests such as scans and blood tests. Some testing such as spirometry requires additional care because the procedure generates droplets which can increase the risk of transmission to the healthcare professional supervising the test. This has made these crucial and hitherto routine diagnostic tests a scarce and precious resource.

Whist doctors adapt to new methods of practice, patients must be finding this even more difficult. Many have told me about their anxieties about the risks of coming to a hospital clinic (not just the clinic encounter but also navigating the hospital corridors and public transport). Many patients are also having to shield because their long-term respiratory condition puts them at greater risk from COVID-19. I have been impressed with people’s resilience and ability to deal with shielding and social isolation during the lockdown but also been asked many questions about when and whether it is safe to start to emerge and go back to social and physical activities that have great value to many people and vitally important to long term physical and psychological well-being.

How will we emerge from the crisis and make sure standards of diagnosis and treatment for respiratory problems do not suffer? I think there are grounds for optimism. We are rapidly realising that much can be achieved remotely over the phone or by video link. The most critical elements of respiratory assessment come from the history of symptoms provided by the patient. Initial theories about diagnosis can be arrived at and options for initial investigation discussed remotely. As the prevalence of the COVID-19 subsides, face to face consultation can be undertaken where needed because hospital clinics have rapidly reconfigured to allow social distancing and PPE (including masks for patients) are available. Tests such as spirometry can be undertaken if appropriate precautions and PPE are used.

Risks can never be reduced to zero but have to be weighed against the benefits of undertaking appropriate clinical examination and diagnostic testing. The challenge is to ensure the value of these face to face encounters is maximised. There are many circumstances where initial remote assessment can allow assessment of the urgency of the problem and discussion of options for diagnosis and treatment. In the longer term our learning from the enforced restrictions imposed by COVID-19 might improve the flexibility and quality of the service we offer our patients.