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COVID-19: Respiratory & Thoracic Medicine service guide (Devon)

March 2022

Key Update

Diagnostic spirometry in primary care

Due to COVID-19 infection-control concerns, diagnostic spirometry has been paused in primary-care settings.

The South West Respiratory Network have recently released guidance which summarises how to restart spirometry safely and appropriately. It is important to note that this is for diagnostic spirometry and not for routine annual spirometry for COPD which, while previously in QOF, is no longer required. The main emphasis of this document is advice to only perform or request diagnostic spirometry when this is essential to manage your patient.

Further useful guidance has been produced by the Primary Care Respiratory Society on Diagnostic Workup of patients with respiratory symptoms without the need for formal spirometry. You can download it here.

Express Diagnostics are recommencing their diagnostic spirometry service for the Western locality region from 1 October and the CCG are working towards a solution to allow safe diagnostic spirometry in primary-care settings for all cases across North, East and South Devon.

Questions should be directed to Hanna.ellison@nhs.net

Scope

This information provides guidance on the management of Respiratory / Thoracic Medicine patients across Devon during the COVID-19 pandemic. The information is based on National guidance available through the NICE and the British Lung Foundation websites.

Patients with severe respiratory disease without COVID-19 are at risk of coming to more harm by admission and potential exposure to COVID-19.

Admitting patients with COVID-19 for oxygen therapy, even if not for escalation to ITU, is appropriate where it is needed;

  • to relieve symptoms
  • patient wishes for admission
  • hypoxia (SpO2 less than 92% scale 1 or less than 88% scale 2 (hypercapnic respiratory failure; usually COPD) or SaO2 less than or equal to 94% if desaturates on exertion e.g. 40m walk (a sign of moderate-severe pneumonitis). Recommend admission for further assessment/monitoring of patients in whom ITU escalation is appropriate. Follow latest guidance with regards admission thresholds: As of 8/4/20, NICE and NHSE guidance is not fully aligned
  • Be more cautious if symptoms of pneumonitis develop within a week of first symptoms (as patient may be earlier in inflammatory process). Symptomatic deterioration within 2 days suggests a bacterial pneumonia. Be aware that all patients can deteriorate, and safety netting is essential
  • If there is concern about whether patient could have a community acquired pneumonia, give doxycycline or amoxycillin
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Suspected lung cancer
  • Referrals to be made through 2WW and National Optimal Lung Cancer Pathway (NOLCP). Patients with a suspected cancer will be triaged and reviewed in the usual way through these pathways
  • Patients will need to attend for Chest X-ray and some for CT scan
  • Face to face appointments will be booked for those patients who need to be seen. Referrals and results will be reviewed prior to appointment being made and results can be relayed to GP via letter. If possible, the clinician will do so without the need to see the patient in clinic
  • 2WW bronchoscopy / EBUS and thoracoscopy will continue to be carried out in line with 2WW pathway and treatment plan for patients

e-Referral selection:

  • Specialty: 2WW
  • Clinic type: 2WW Lung
  • Service: 2WW Respiratory Medicine - NDHCT - NDDH - RBZ

Asthma (NICE Guidance 166)
  • Severe asthma is defined by the European Respiratory Society and American Thoracic Society as asthma that requires;
  • Corticosteroids
    • continue using inhaled corticosteroids because stopping can increase the risk of asthma exacerbation. There is no evidence that inhaled corticosteroids increase the risk of getting COVID-19
    • patients on maintenance oral corticosteroids should continue to take them at their prescribed dose because stopping them can be harmful
    • if patients develop symptoms and signs of an asthma exacerbation, they should follow their personalised asthma action plan and start a course of oral corticosteroids if clinically indicated
  • Patients having biological treatment
    • patients should continue treatment because there is no evidence that biological therapies for asthma suppress immunity
    • if the patient usually attends hospital to have biological treatments, the Respiratory team will consider if this can be safely provided in the community or at home
    • routine monitoring of biological treatment should be carried out remotely if possible
  • Equipment
    • patients, or their parent or carer, should wash their hands and clean equipment such as face masks, mouth pieces, spacers and peak flow meters regularly using a detergent (for example, washing-up liquid), or to follow the manufacturer's cleaning instructions
    • patients, or their parent or carer, should not share their inhalers and devices with anyone else
    • patients, or their parent or carer, can continue to use their nebuliser. This is because the aerosol comes from the fluid in the nebuliser chamber and will not carry virus particles from the patient
COPD (NICE Guidance 168)
  • Corticosteroids
    • there is no evidence that treatment with inhaled corticosteroids (ICS) for COPD increases the risk associated with COVID-19
    • patients established on ICS should continue to use them and delay any planned trials of withdrawal of ICS. (While there is some evidence that use of ICS in COPD may increase the overall risk of pneumonia (see the 2014 MHRA drug safety update on inhaled corticosteroids: pneumonia), do not use this risk alone as a reason to change treatment in those established on ICS and risk destabilising COPD management)
    • patients on long-term oral corticosteroids should continue to take them at their prescribed dose, because stopping them can be harmful. Advise patients to carry a Steroid Treatment Card
  • Self-management for exacerbations
    • If patients think they are having an exacerbation, they should follow their individualised COPD self-management plan and start a course of oral corticosteroids and/or antibiotics if clinically indicated
    • Note, patients should not start a short course of oral corticosteroids and/or antibiotics for symptoms of COVID-19, for example fever, dry cough or myalgia
    • Do not offer patients with COPD a short course of oral corticosteroids and/or antibiotics to keep at home unless clinically indicated, as set out in the NICE guideline on chronic obstructive pulmonary disease in over 16s
  • Oral prophylactic antibiotic therapy
    • Do not routinely start prophylactic antibiotics to reduce risk from COVID-19
    • patients already prescribed prophylactic antibiotics should continue taking them as prescribed, unless there is a new reason to stop treatment (for example, side effects or allergic reaction). Advise patients to seek medical advice if this happens
  • Oxygen
    • Patients currently receiving long-term oxygen therapy should not adjust their oxygen flow rate, unless advised to by their healthcare professional
    • Patients currently receiving ambulatory oxygen should not to start using it at rest or in their home
  • Smoking cessation
    • Strongly encourage patients with COPD who are still smoking to stop, to reduce the risk of poor outcomes from COVID-19 and their risk of acute exacerbations
  • Pulmonary rehabilitation
  • Airway clearance
    • Patients currently using airway clearance techniques should continue to do so
    • Advise patients that inducing sputum is a potentially infectious aerosol generating procedure, and they should take appropriate precautions such as:
      • performing airway clearance techniques in a well-ventilated room
      • performing airway clearance techniques away from other family members if possible
      • advising other family members not to enter the room until enough time has passed for aerosols to clear
  • Equipment
    • patients, or their parent or carer, should wash their hands and clean equipment, such as face masks, mouth pieces, spacer devices and peak flow meters, regularly using washing-up liquid or following the manufacturer's cleaning instructions
    • patients, or their parent or carer, should not to share their inhalers and devices with anyone else
    • patients, or their parent or carer, should continue to use their nebuliser. This is because the aerosol comes from the fluid in the nebuliser chamber and will not carry virus particles from the patient
    • Do not offer nebulisers to patients unless clinically indicated (see the NICE guideline on chronic obstructive pulmonary disease in over 16s)
    • Advise patients currently receiving non-invasive ventilation at home that these are potentially infectious aerosol generating procedures, and they should take appropriate precautions such as:
      • using equipment in a well-ventilated room
      • using equipment away from other family members if possible
Bronchiectasis
  • patients may have respiratory symptoms in common with COVID-19
  • patients should not assume symptoms are due to COVID-19
  • Patients in this group should be prescribed a rescue course of antibiotics to keep at home
  • Choice of antibiotics should be based on known sensitivities of bacteria previously grown in sputum, antibiotics which have worked clinically in that patient, or doxycycline or amoxicillin as a default
  • It is important that such patients can start antibiotics promptly to reduce the chances of deterioration and admission to hospital. Where social isolation/shielding permits, it would still be useful to send in sputum samples on such patients
  • While treatment of COVID-19 is currently supportive, prompt treatment of bacterial infection saves lives
Interstitial Lung Disease (NICE guideline [NG177])
  • Consider ceiling of care. Many patients who have established pulmonary fibrosis, of any cause, will not do well with intubation and mechanical ventilation. Patients are likely to become hypoxic very quickly as they will not have much reserve. They will have often had advance care planning as part of their specialist care
  • Further specific guidance can be found at: NICE guideline [NG177
Oxygen Saturations in Chronic Lung Disease
  • If baseline O2 pulse oximetry saturations are available, the below can be used as a guide to the severity of deterioration e.g. COPD, interstitial lung disease:
    • Mild deterioration would be defined as up to 2% below their baseline
    • Moderate deterioration would be defined as between 3-4% below their baseline
    • Severe deterioration would be defined as 5% or more below their baseline
  • If on Long Term Oxygen Therapy (LTOT); discuss ceiling of care and consider admission if O2 sats less than 88% on their standard dose of LTOT
Community Acquired Pneumonia (NICE Guidance 165)
  • Where physical examination and other ways of making an objective diagnosis are not possible, the clinical diagnosis of community-acquired pneumonia of any cause in an adult can be informed by other clinical signs or symptoms such as:
    • temperature above 38°C
    • respiratory rate above 20 breaths per minute
    • heart rate above 100 beats per minute
    • new confusion
  • It is difficult to determine whether pneumonia has a COVID‑19 viral cause or a bacterial cause (either primary or secondary to COVID‑19) in primary care, particularly during remote consultations. However, as COVID‑19 becomes more prevalent in the community, patients presenting with pneumonia symptoms are more likely to have a COVID‑19 viral pneumonia than a community-acquired bacterial pneumonia
  • COVID‑19 viral pneumonia may be more likely if the patient:
    • presents with a history of typical COVID‑19 symptoms for about a week
    • has severe muscle pain (myalgia)
    • has loss of sense of smell (anosmia)
    • is breathless but has no pleuritic pain
  • has a history of exposure to known or suspected COVID‑19, such as a household or workplace contact.
  • A bacterial cause of pneumonia may be more likely if the patient:
    • becomes rapidly unwell after only a few days of symptoms
    • does not have a history of typical COVID‑19 symptoms
    • has pleuritic pain
    • has purulent sputum
  • Management
Obstructive Sleep Apnoea
  • Most patients will have normal lungs but require CPAP overnight to correct daytime sleepiness. This does not affect their gas exchange and they should be managed as for other patients with no pre-existing lung disease
  • We are advising patients on home CPAP to bring during inpatient admissions and to use it whilst in hospital to reduce the risk of infection – regardless of COVID status. If they need CPAP for other indications e.g. hypoxia secondary to COVID this will be discussed with them in hospital
Tuberculosis
  • Please refer as normal
  • Symptoms of COVID-19 can be similar to those of TB, with fever, cough and shortness of breath in common to both. But there is usually a difference in the speed that the symptoms start. COVID-19 symptoms are likely to be of more recent onset. Ask about contact with someone known to have either TB or COVID-19
  • Devon is in a fortunate situation of having low background rates of TB, but many of those diagnosed with TB in recent years had no known exposure. Less than 50% were of non-UK origin. Where social isolation/shielding permits, it is important to send in sputum samples for AFB is there is any clinical concern of TB
Cystic Fibrosis
  • Patients should continue with all their usual self-care arrangements including, for example:
  • patients, their families and carers should wash their hands and clean equipment such as face masks and mouth pieces used for nebulised therapies, or face masks used for non-invasive ventilation, by regularly using washing-up liquid or following the manufacturer's cleaning instructions
  • prescribe usual quantities of medicines to meet the patient's clinical needs, normally 30 days' supply. Prescribing larger quantities of medicines puts the supply chain at risk
  • patients, their families and carers should follow the advice they have previously been given about what to do if they have an exacerbation, including taking rescue medication and contacting their cystic fibrosis team
  • patients with cystic fibrosis may be at greater risk of rapid deterioration if they contract COVID-19 and closer monitoring is advised

Urgent referrals will be triaged at point of referral and decision made regarding booking an appointment.

Advice and guidance will be given to GP's if this is felt appropriate at the time of referral to prevent any delay in patient's treatment.

New routine referrals are being clinically triaged and seen according to clinical need but there are longer delays due to the backlog of referrals.

Please ensure that a practice-based system is in place to check daily for returning referrals with A&G.

Prior to making a routine referral, please ensure that any appropriate Policy or CRG has been reviewed and that all the suggested investigations and management options have been considered.

Existing new and follow-up routine appointments have been cancelled and changed to telephone / video consultation where appropriate.

Northern Devon Healthcare NHS Trust
Royal Devon & Exeter NHS Foundation Trust
  • via switchboard: 01392 411611
University Hospitals Plymouth NHS Trust - respiratory guidance for use only during COVID-19
Torbay & South Devon NHS Foundation Trust
  • via switchboard: 0300 456 8000 (local rate) or 01803 614567

Advice and Guidance will continue to be given through referrals via e-RS.

High risk patients will be contacted via letter regarding steps they need to take to protect themselves during the pandemic.

Any patient with concerns is advised to contact their GP in the first instance. Advice can be sought in the various methods below:

Northern Devon Healthcare NHS Trust
Royal Devon & Exeter NHS Foundation Trust
  • via switchboard: 01392 411611
University Hospitals Plymouth NHS Trust - respiratory guidance for use only during COVID-19
Torbay & South Devon NHS Foundation Trust
  • via switchboard: 0300 456 8000 (local rate) or 01803 614567

Direct patients to gov.uk website for latest advice re social distancing and isolation

Northern Devon Healthcare NHS Trust
Royal Devon & Exeter NHS Foundation Trust
  • via switchboard: 01392 411611
University Hospitals Plymouth NHS Trust - respiratory guidance for use only during COVID-19
Torbay & South Devon NHS Foundation Trust
  • via switchboard: 0300 456 8000 (local rate) or 01803 614567

Pathway Group

This guideline has been signed off on behalf of the NHS Devon Clinical Commissioning Group

Publication date: May 2020

Date updated: March 2022

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