Provision of holistic care after extreme COVID-19 pneumonia: anticipating scientific want and managing assets

 

The COVID-19 pandemic continues to pose extraordinary challenges for doctors, patients and health services around the world. Many organizations have set up clinical services after COVID-19 in anticipation of considerable stress from multisystem and psychological morbidity. The exponential increase in case numbers at the height of the pandemic required the rapid implementation of follow-up pathways that evolved in response to clinical needs and in the absence of robust COVID-19-specific data by extrapolating post-critical disease evidence and observations during previous coronavirus outbreaks made. As the daily incidence of COVID-19 continues to increase, there is an urgent need to establish adequately resourced, multidisciplinary pathways to COVID-19 based on the assessment of recent shared experiences.

The spectrum of fibrotic lung diseases observed in COVID-19 ranges from fibrosis in connection with the organization of pneumonia to severe acute lung injuries with evolution to widespread fibrotic changes. Early observations suggest that impaired diffusion capacity is the most common lung dysfunction in discharged COVID-19 survivors, followed by restrictive ventilation defects. These observations are consistent with previous outbreaks of SARS and Middle East Respiratory Syndrome (MERS) coronaviruses. In an early follow-up study in patients with SARS, 15 (62%) of 24 patients had CT evidence of pulmonary fibrosis 4-6 weeks after discharge. However, the natural history of COVID-19 pneumonia is not fully understood, and it is premature to label lung changes as an indication of irreversible fibrosis. Indeed, the most common evolutionary pattern observed in early COVID-19 case series was initial progression to a peak followed by radiographic improvement, and long-term data from SARS survivors show the resolution of restrictive lung function defects and the improvement or stability of frosted glass Changes. The effects of pulmonary sequelae could be outweighed by chronic extrapulmonary COVID-19 manifestations. SARS and moderate to severe acute respiratory distress syndrome (ARDS) that require intensive care are associated with adverse physiological and psychological outcomes, with functional limitations likely due to muscle wasting and weakness, as well as impaired health-related quality of life at 6 and 12 months. Preliminary data from COVID-19 survivors indicate a high prevalence of post-traumatic stress disorder (28%), anxiety (42%), and depression (31%) 1 month after hospitalization. The well-described extrapulmonary manifestations of acute COVID-19 have been reported (including venous thromboembolism, kidney failure, liver dysfunction, myocarditis, and delirium) and immediate follow-up is required to identify possible complications such as pulmonary hypertension, chronic kidney disease, heart failure and neurocognitive impairment. To achieve this, however, several hurdles must be overcome. First, the range of clinical consequences has not yet been defined. Designing a clinical service is therefore challenging as appropriate patient-centered outcome measures and follow-up timeframes remain unknown. However, the consequences of severe COVID-19 pneumonia can be comparable to those of critical illness, and we can draw on experience with intensive care programs to select appropriate tools that facilitate the early detection and treatment of consequences after COVID-19 and their Attenuate long-term illnesses. Term implications. Second, the backlog created by the temporary suspension of outpatient services has already drained resources. While recognizing the value of core findings that are well-established in acute respiratory failure research, outcome actions undertaken in a busy clinical service during the COVID-19 pandemic must be pragmatically selected to achieve maximum clinical benefit and at the same time avoiding excessive exposure to both patients and doctors. Staff training, equipment, and clinical room needs and the ability to adhere to infection control precautions must be considered. Third, the potential for aerosolization of respiratory droplets limits various diagnostic and therapeutic resources. Pulmonary function tests will gradually restart, but strict infection control precautions will limit availability, and careful assessment is required as to whether tests are needed to guide patient management. In the meantime, face-to-face rehabilitation programs remain largely suspended. Finally, the involvement of multiple systems and the novelty of the disease requires the integration of multidisciplinary and related health activities into a service that can be tailored to patient needs as our understanding of the COVID-19 consequences evolves. As an inherently multidisciplinary field, the respiratory departments are well placed to make this possible and indeed have been an integral part of acute and follow-up care during the pandemic. However, the ideal surveillance department for post-COVID-19 follow-up care should be the one best suited to receiving and delivering patient-centered multidisciplinary care.Similar to other centers, our post-COVID-19 clinic was developed with no additional funding at the height of the pandemic, so patient selection and the rationalization of clinical evaluations were paramount. Based on the guidelines of the British Thoracic Society, we invite patients with severe COVID-19 pneumonia (defined locally as a requirement for a proportion of inhaled oxygen ≥ 40% or admission to the intensive care unit) to personal appointments 4 to 6 weeks after discharge to participate. A summary of our clinical evaluation can be found in the appendix. All patients will have a chest x-ray and a specific exam will be done for the presence and severity of persistent shortness of breath, cough, difficulty sleeping, tiredness, or pain. Results reported by patients are assessed using validated questionnaires (Modified Medical Research Council Respiratory Distress Scale, Patient Health Questionnaire 9, Generalized Anxiety Disorder Assessment 7, Trauma Screening Questionnaire, Nijmegen Questionnaire, and 6-Point Cognitive Test). In order to be able to objectively assess the impairment of mobility, we use the 4 m walking speed and the 1-minute sit-to-stand tests. These tests require minimal staff training and space in the clinic and are fast, reliable, and validated techniques that closely correlate with traditional measurements of exercise capacity (incremental shuttle and 6-minute walk tests) and allow comparisons to be made with existing data. It is important that they facilitate the identification of the (often asymptomatic) oxygen desaturation and warrant further assessment. Our service is currently inviting survivors of severe COVID-19 pneumonia for a follow-up examination, and we recognize the as yet undefined burden of non-severe COVID-19. There is increasing awareness of people with what is known as long-term COVID, who have symptoms for weeks or months after the acute phase of illness, which is likely to continue to affect both primary and secondary health care providers.

By developing this service, we have strengthened existing relationships in a wide variety of disciplines. Specialized respiratory physiologists carry out functional tests before the medical examination. CT scans for patients with persistent radiological opacity, symptoms, or desaturation (including high resolution CT and pulmonary angiography with or without ventilatory perfusion single photon emission CT) are discussed in the radiology multidisciplinary meeting. There are also ways to refer patients with extrapulmonary disease to appropriate clinical specialties, and those who require ICU admission are screened by the ICU team on the same day. Regular service evaluations are conducted to monitor the usefulness of the selected outcome measures and to allow the service to evolve in response to the patient’s needs.

Despite the devastating effects of COVID-19 on an individual and societal level, we have been given the opportunity to strengthen clinical and academic multidisciplinary relationships and develop a de novo clinical service that is practical, easy to provide, and enables holistic assessment is the physical and psychological consequences of severe COVID-19 pneumonia. Given the continued increase in confirmed cases worldwide, the increasing interest and commitment of funding agencies and health management, and the emergence of long-term data, we are continuing to customize and streamline our service to provide evidence-based post-COVID-19 care.

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We do not declare any competing interests.

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Published: November 13, 2020

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DOI: https://doi.org/10.1016/S2213-2600(20)30529-4

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