A Summary of Outpatient Recommendations for COVID-19 Patients and Providers December 9, 2021

Richard A. Robbins MD¹

Stephen A. Klotz MD²

¹Phoenix Pulmonary and Critical Care Research and Education Foundation, Gilbert, AZ USA

²Division of Infectious Disease, Department of Medicine, University of Arizona College of Medicine, Tucson, AZ USA

We thought a follow-up to our original brief review of COVID-19 in February, 2020 might be useful. As we write this in early December 2021, we again caution that this area is rapidly changing and what is true today will likely be outdated tomorrow. We again borrowed heavily from the Centers for Disease Control (CDC)  CDC website and the NIH website which have extensive discussions over numerous pages covering COVID-19. Our hope is to condense those recommendations. We do not discuss inpatient care in any detail.

COVID-19 Variants

The initial steps of coronavirus infection involve the specific binding of the coronavirus spike (S) protein to the cellular entry receptors which are normally on a cell. These include human aminopeptidase N (APN; HCoV-229E), angiotensin-converting enzyme 2 (ACE2; HCoV-NL63, SARS-CoV and SARS-CoV-2) and dipeptidyl peptidase 4 (DPP4; MERS-CoV).

All viruses, but especially simple single-stranded RNA viruses like COVID-19, constantly change through mutation resulting in new variants (1). The variants vary in severity and infectivity. The CDC, World Health Organization (WHO), and other public health organizations monitor COVID-19 for emergence of new variants. Some variants emerge and disappear while others persist.

The Delta variant causes more infections and spreads faster than the original SARS-CoV-2 strain of the virus that cause COVID-19 (2). Delta is currently the predominant variant of the virus in the United States causing over 99% of infections (2). On November 24, 2021, a new variant of SARS-CoV-2, B.1.1.529, was reported to the World Health Organization (WHO). This new variant was first detected in specimens collected on November 11, 2021 in Botswana and on November 14, 2021 in South Africa. On November 26, 2021, WHO named the B.1.1.529 Omicron and classified it as a variant of concern because of the number of mutations on the spike protein. As of this yesterday morning (12/8/21), the first Omicron case was reported in Arizona (2). Omicron is also present in California, Utah and Colorado and probably several other states since there is a lag between the presence of the virus and detection.

Early reports have suggested the Omicron variant might cause milder disease more often in children, raising hopes that the variant might be less severe than some of its predecessors (3). Dr. Müge Çevik, an infectious-disease specialist at the University of St Andrews, UK cautions, “Everyone is trying to find some data that could guide us but it’s very difficult at the moment.”

Symptoms

People with COVID-19 have had a wide range of symptoms reported – from none to severe illness (2). Symptoms may appear 2-14 days after exposure to the virus. Symptoms of flu and COVID-19 may be very similar and it may be hard to tell the difference between them based on symptoms alone. Testing may be needed to help confirm a diagnosis. COVID-19 seems to spread more easily than flu and causes more serious illnesses in some people. It can also take longer before people show symptoms and people can be contagious for longer. Despite mild symptoms, people infected with COVID-19 can still infect others.

Testing

Two types of viral tests are used: nucleic acid amplification tests and antigen tests (2). A viral test checks specimens from the nose or mouth by first reverse transcribing the RNA to DNA and then amplifying the DNA by polymerase chain reaction. COVID-19 antigen tests are designed for the rapid diagnosis of active infection primarily by detecting the nucleocapsid protein antigen of the SARS-CoV-2 virus. People who develop symptoms or have come into close contact with someone with COVID-19 should be tested 5–7 days after their last exposure or immediately if symptoms develop.

Prevention

The CDC recommends several steps for prevention of COVID-19 (2).

1. Get Vaccinated. COVID-19 vaccines are protective against COVID-19, especially severe disease and death. Boosters should be administered as soon as possible.
2. Wear a mask. Everyone 2 years or older who is not fully vaccinated should wear a mask in indoor public places. In general, masks are unnecessary in outdoor settings.
3. However, in areas with high numbers of COVID-19 cases, consideration should be given to wearing a mask in crowded outdoor settings and for activities with close contact with others who are not fully vaccinated.
4. Stay 6 feet away from others. Whenever possible, people should stay 6 feet away from others especially those who are sick. If possible, patients should be advised to maintain 6 feet between sick family members.
5. Avoid crowds and poorly ventilated spaces. Crowded places like restaurants, bars, fitness centers, or movie theaters are high risk areas for spread of COVID-19. Indoor spaces that do not offer fresh air from the outdoors should be avoided.
6. Test to prevent spread to others. Testing provides information about the risk of spreading COVID-19. Over-the-counter self-tests can be used at home or anywhere, are easy to use, and produce rapid results.
7. Wash Hands Often. Hands should be washed often with soap and water after the patient blows their nose, coughs, sneezes, or is exposed to any public place.
8. Clean and disinfect. High touch surfaces should be cleaned and disinfected regularly or as needed. This includes tables, doorknobs, light switches, countertops, handles, desks, phones, keyboards, toilets, faucets, and sinks.

Specific Groups

Any immunocompromised group or group living in close contact is at increased risk for COVID-19 infection and complications of the infection (2). This includes asthma, pregnancy, the elderly (>65 years), nearly all chronic diseases and jails or prisons.

Holidays

With Holiday gatherings here, many are concerned about COVID-19 especially with an unvaccinated relative or guest. First, the CDC recommends they get vaccinated (2). Second follow the recommendations under prevention above.

COVID-19 Patients

Patients with COVID-19, should follow the steps under prevention above (2). In addition, they stay home for 10 days after symptoms appear except to get medical care. Patients should be advised to drink fluids, take over-the-counter medications for symptomatic relief, and go to the emergency room or a physician’s office if needed, but call ahead. They should tell their close contacts that they may have been exposed to COVID-19.

COVID-19 Exposure

Patients should quarantine if you have been in close contact (within 6 feet of someone for a cumulative total of 15 minutes or more over a 24-hour period) with someone who has COVID-19, unless they are fully vaccinated (2). People who are fully vaccinated do not need to quarantine after contact with someone who had COVID-19 unless they have symptoms.

Travel

At this time patients should delay travel by bus, train, plane or ship unless fully vaccinated.

Treatment

The NIH has convened a COVID-19 Treatment Guidelines Panel (4). They recommend*:

1. COVID-19 vaccination for everyone who is eligible according to the Advisory Committee on Immunization Practices (AI).
2. Using one of the following anti-SARS-CoV-2 monoclonal antibodies (as post-exposure prophylaxis (PEP) for people who are at high risk of progressing to severe COVID-19:
   • Bamlanivimab 700 mg plus etesevimab 1,400 mg administered as an intravenous (IV) infusion (BIII).
   • Casirivimab 600 mg plus imdevimab 600 mg administered as subcutaneous injections (AI) or an IV infusion (BIII).
3. Do not use hydroxychloroquine for SARS-CoV-2 PEP (AI).
4. Do not use of other drugs for SARS-CoV-2 PEP, except in a clinical trial (AIII).
5. Do not use any drugs for SARS-CoV-2 pre-exposure prophylaxis, except in a clinical trial (AIII).

*Rating of Recommendations: A = Strong; B = Moderate; C = Optional Rating of Evidence: I = One or more randomized trials without major limitations; IIa = Other randomized trials or subgroup analyses of randomized trials; IIb = Nonrandomized trials or observational cohort studies; III = Expert opinion

References

1. Yang H, Rao Z. Structural biology of SARS-CoV-2 and implications for therapeutic development. Nat Rev Microbiol. 2021 Nov;19(11):685-700. [CrossRef] [PubMed]
2. CDC. COVID-19. Available at: https://www.cdc.gov/coronavirus/2019-ncov/index.html (accessed 12-6-21).
3. Callaway E, Ledford H. How bad is Omicron? What scientists know so far. Nature. 2021 Dec 2. [CrossRef] [PubMed]
4. NIH. COVID-19 Treatment Guidelines. October 27, 2021. Available at: https://www.covid19treatmentguidelines.nih.gov/ (accessed 12/6/21).

Cite as: Robbins RA, Klotz SA. A Summary of Outpatient Recommendations for COVID-19 Patients and Providers December 9, 2021. Southwest J Pulm Crit Care. 2021;23(6):151-5. doi: https://doi.org/10.13175/swjpcc066-21 PDF 

Alveolopleural Fistula In COVID-19 Treated with Bronchoscopic Occlusion with a Swan-Ganz Catheter

Nathaniel Hitt DO¹

Aleksey Tagintsev DO¹

Douglas Summerfield MD¹

Evan Schmitz MD² 

¹MercyOne North Iowa Medical Center, Des Moines, IA USA

²Airod Medical, Gainesville, FL USA

Abstract

Pneumothorax and pneumomediastinum are known complications of COVID-19 patients. They have been documented to occur both with and without mechanical ventilation. There are several reports of cases further complicated by alveolopleural or bronchopleural fistulas. However, there are no studies and only a few case reports on the treatment options used for alveolopleural fistulas in COVID-19 patients. To our knowledge, there is only one report of bronchoscopic treatment with endobronchial valves in a COVID-19 patient. We present the case of a 63-year-old male with COVID-19, pneumothorax, and an alveolopleural fistula that was successfully sealed using bronchoscopic occlusion with a Swan-Ganz catheter.

Abbreviation List

• COVID-19: Severe acute respiratory distress syndrome coronavirus-2
• PAL: Persistent air leak
• APF: Alveolopleural fistula
• PaO2: Partial pressure of arterial oxygen
• FiO2: Fraction of inspired oxygen

Background

Pneumothorax complicates 1% of COVID-19 hospital admissions and the risk increases with mechanical ventilation (1). There have been several reports of pneumothoraces in COVID-19 complicated by persistent air leaks (PAL) and alveolopleural fistulas (APFs) (1-3). APFs are a communication between the pulmonary parenchyma of the alveoli and the pleural cavity. The most common cause is lung reduction surgery, but it can also be present following spontaneous pneumothorax.  Less commonly it can be caused by pulmonary infection. Clinically, APFs present as a PAL on chest tube drainage with a PAL defined as a duration greater than 5 days. Complications include pleural infection and ventilation/perfusion mismatch with a loss of positive end expiratory pressure.  APFs in non-COVID patients have been associated with an increased duration of chest tube, prolonged hospital stay, and increased morbidity a drainage and mortality. Treatments in non-COVID patients have ranged from insertion of additional thoracostomy tubes, surgical intervention, and bronchoscopic intervention (2). There is one reported case of an APF in COVID-19 successfully treated with endobronchial valves (3). Here we present the case of an APF in COVID-19 treated with bronchoscopic occlusion with a Swan-Ganz catheter.

Case Presentation

The patient was a 63-year-old man diagnosed with COVID-19 who required intubation, mechanical ventilation, and admission to the critical care unit. On hospital day 2 chest x-ray revealed bilateral pneumothoraces requiring chest tube placement. Bilateral PAL was present and on hospital day 10 the patient developed a moderate sized right sided pneumothorax despite the adequately positioned chest tube. The initial thoracostomy tube was replaced with a large bore chest tube with immediate resolution of the pneumothorax. However, a moderate air leak persisted and by hospital day 14, the diagnosis of APF was suspected. Bronchoscopic occlusion using the balloon of a Swan-Ganz catheter was performed.

A Swan-Ganz catheter was inserted through the endotracheal tube and along-side of a bronchoscope. The balloon was sequentially inflated and deflated to occlude each lobe to assess for air leak resolution. The air leak was reduced, but not resolved with occlusion of the right lower lobe and right middle lobe individually. The balloon was inflated just enough to occlude the right bronchus intermedius with near complete resolution of the leak (Figure 1).

Figure 1. Chest radiograph showing Swan-Ganz catheter (yellow arrow) with its cuff inflated in the right bronchus intermedius to seal an alveolopleural fistula.

The patient was observed for ten minutes to ensure tolerability before concluding the procedure. He was kept paralyzed to reduce coughing. After 3 days the air leak resolved, the Swan-Ganz catheter was removed, and the air leak remained sealed. The PaO2:FiO2 ratio improved from 79 to 250. However, despite initial improvement and no air leak the patient's conditioned worsened in the setting of multisystem organ failure. Multisystem organ failure was attributed to a combination of severe acute respiratory distress syndrome, cytokine storm, and septic shock from a urinary tract infection. The patient's family made the decision to withdraw care on day 22.

Discussion

Despite several cases of refractory pneumothorax in COVID-19, the significance and optimal treatment remains unclear (1,3,4). There is one report of two COVID-19 patients treated with thoracoscopy, bleb resection, and pleurectomy(4) and a single report of endobronchial valves (3). Conservative management with prolonged chest tube remains the recommended treatment (2). The American College of Chest Physicians guidelines only recommend bronchoscopic treatment in refractory cases when surgery is not possible (2). This patient was not a surgical candidate due to his instability, endobronchial valves were unavailable at our facility, and at height of the COVID-19 pandemic, transfer to a tertiary care center was not possible. Bronchoscopic occlusion with a balloon catheter has been described previously in a case a of PAL secondary to polymicrobial pneumonia, pulmonary interstitial emphysema, and in a case of necrotic lung complicated by hydropneumothorax (2,5,6). Bronchoscopy in COVID-19 is associated with an increased risk of infection and its use should be limited if possible. In this case, it was determined that with proper personal protective equipment and lack of access to other treatments, bronchoscopic occlusion was the best option.

An 8.0 French Swan-Ganz catheter was selected for its balloon that connects to an integrated stopcock to maintain inflation and for its relative availability. We classified the PAL as an APF after the leak was revealed to be distal to the segmental bronchi. The average time to resolution is reported to be 4-7.5 days (2). The decision to maintain occlusion for 3 days was based on the above average, patient improvement, and the lack of drainage from the occluded lung. The risk of infection, in particular pneumonia and empyema, must be considered when using this technique.  Ideally, an endobronchial valve would have been available to allow a one-way valve to drain secretions (2). Our patient was closely monitored for developing pulmonary infection with daily chest radiography and, following the removal of the Swan-Ganz Catheter, a bacterial sputum culture which was negative.

Conclusion

There are no randomized controlled trials investigating which treatment of PALs is most effective or safe in COVID-19 patients or even in non-COVID-19 patients (2). Furthermore, pneumothorax and persistent air leaks in COVID-19 patients have not been universally shown to increase mortality (1). However, considering the known morbidity and mortality associated with PALs, we suggest it may be reasonable in cases refractory to thoracostomy tube to treat with a Swan-Ganz catheter when otherresources are not available.

Acknowledgement

Peter L. Larsen PhD for editorial and administrative support.

References

1. Martinelli AW, Ingle T, Newman J, et al. COVID-19 and pneumothorax: a multicentre retrospective case series. Eur Respir J. 2020 Nov 19;56(5):2002697. [CrossRef] [PubMed]
2. Sakata KK, Reisenauer JS, Kern RM, Mullon JJ. Persistent air leak - review. Respir Med. 2018 Apr;137:213-218. [CrossRef] [PubMed]
3. Pathak V, Waite J, Chalise SN. Use of endobronchial valve to treat COVID-19 adult respiratory distress syndrome-related alveolopleural fistula. Lung India. 2021 Mar;38(Supplement):S69-S71. [CrossRef] [PubMed]
4. Aiolfi A, Biraghi T, Montisci A, et al. Management of Persistent Pneumothorax With Thoracoscopy and Bleb Resection in COVID-19 Patients. Ann Thorac Surg. 2020 Nov;110(5):e413-e415. [CrossRef] [PubMed]
5. Ellis JH, Sequeira FW, Weber TR, Eigen H, Fitzgerald JF. Balloon catheter occlusion of bronchopleural fistulae. AJR Am J Roentgenol. 1982 Jan;138(1):157-9. [CrossRef] [PubMed]
6. Schmitz ED. A new interventional bronchoscopy technique for the treatment of bronchopleural fistula. Southwest J Pulm Crit Care. 2017;15(4):174-8. [CrossRef]

Cite as: Hitt N, Tagintsev A, Summerfield D, Schmitz E. Alveolopleural Fistula In COVID-19 Treated with Bronchoscopic Occlusion with a Swan-Ganz Catheter. Southwest J Pulm Crit Care. 2021;23(4):100-3. doi: https://doi.org/10.13175/swjpcc026-21 PDF 

Home-Based Physiological Monitoring of Patients with COVID-19

Akshay Warrier

Akshay Sood, MD, MPH

Division of Pulmonary, Critical Care and Sleep Medicine

Department of Internal Medicine

University of New Mexico School of Medicine

Albuquerque, NM USA

Abstract

The COVID-19 pandemic has necessitated the rise of telehealth modalities to relieve the incredible stress the pandemic has placed on the healthcare system. This rise has seen the emergence of new software, applications, and hardware for home-based physiological monitoring, leading to the promise of innovative predictive and therapeutic practices. This article is a literature-based review of the most promising technologies and advances regarding home-based physiological monitoring of patients with COVID-19. We conclude that the applications currently on the market, while helping stem the flow of patients to the hospital during the pandemic, require additional evidence related to improvement in patient outcomes. However, new devices and technology are a promising and successful venture into home-based monitoring with clinical implications reaching far into the future.

Abbreviations

• ARDS: Acute Respiratory Distress Syndrome
• CGM: Continuous Glucose Monitoring
• COVID-19: Coronavirus disease 2019
• EKG: Electrocardiogram
• FDA: Food and Drug Administration
• HIPAA: Health Insurance Portability and Accountability Act
• HR: Heart Rate
• HRV: Heart Rate Variability
• PP: Prone Positioning
• PPE: Personal Protective Equipment
• RHR: Resting Heart Rate
• RIP: Respiratory Inductive Plethysmograph
• SpO2: Peripheral Capillary Oxygen Saturation

Introduction

The severe acute respiratory syndrome coronavirus 2 (SARS-COV-2), which causes the novel coronavirus disease 2019 (COVID-19) infection, has been ravaging the globe. The number of infected cases worldwide has risen to 213 million and deaths beyond 4.4 million by August 2021 (1). Furthermore, healthcare workers are at nearly 12 times higher risk of becoming infected than the general community (2), exposing the dire need for a stronger "telemedicine" infrastructure for home-based patient care (1,3,4,5). Such a system not only needs to provide preventative information to users but also allow them to self-diagnose (using home-based testing kits) and self-triage (using real-time algorithms), thus telling patients when to seek emergency care (2). For the less severe cases, the "hospital-at-home" structure can provide acute care at low cost with coordinated telemedicine visits and necessary at-home treatment. For the hospitalized patients, this system allows an earlier discharge to receive post-illness care at home (2). This, in turn, decreases the burden on the hospitals during the pandemic.

Telemedicine, and the technology to support it, has been available for decades but had not become mainstream in the pre-pandemic era due to funding and licensing complications. The technology generally consists of three main functional units: general provision of information, provider-patient synchronous and asynchronous interactions, and remote monitoring (2). Virtual video-chat technologies and basic remote live monitoring algorithms and software were all ready to be used but had not been previously integrated into a fully functioning home-based health care system (5). However, as the pandemic began to spread, the focus on these specific technologies increased and recently have been implemented into several developing home-based systems. Most current remote monitoring programs have a few key features: scaled asynchronous entry, education and information videos/reports, standardized patient reports, real-time monitoring and modifications by a central platform, and enabled patient requests for feedback and assistance (2). "Digital personal protective equipment" or "digital PPE" such as wearable vital monitors, smart applications, and various other forms of medical monitoring have emerged so that COVID-19 monitoring can happen in real-time and assistance or advice can be algorithmically provided to patients.

Evolution of Smart Applications (Apps) for Home-based Monitoring

The foundation for remote monitoring during the pandemic has been provided by novel applications on smartphones (i.e., smart apps) and websites, and other innovative technologies and software hitting the App and Google Play stores, creating a unique opportunity in telemedicine for COVID-19 (7).

1. Application (App) Characteristics

Ideally, a developed application should be able to provide the following services: 1) symptom screening, 2) live updates and information about COVID-19, such as local test availability, 3) contact tracing and mapping of COVID-19 cases, 4) remote monitoring and patient surveillance, and 5) online chat/video consultation with a provider in a secure bidirectional network (6). In addition, the app characteristics should help ensure a streamlined and efficient system using a HIPAA verified data collection service for patients to use and allow big data capabilities for infection epidemiology (7).

2. Current App Developments

One of the earliest apps developed in Wuhan, China, using the popular WeChat platform, established bidirectional communication between a multidisciplinary medical team and quarantined patients through an eCounseling system. Using this app to triage patients, preliminary results show that continuous monitoring of changing symptoms helps in two ways: 1) reduces overcrowding in emergency rooms (ER); and 2) notifies those too afraid to present to the ER if their condition is critical enough to do so (8). 

Subsequently, the Cleveland Clinic at Cleveland, USA, put forth an app-based system for real-time monitoring of symptoms, facilitating physician advice and joint decision making, home-based physiological monitoring, and planning for advance directives and related discussions (9). The program used their MyChart Care Companion app, which focused on patient engagement to self-input symptoms and physiological signs (9). Although this app is an excellent first step towards remote patient monitoring, it does not provide patients with technology or equipment for home-based monitoring. Instead, it is an intermediary platform between the provider and the patient.

The GetWellLoop program at the University of Minnesota at Minneapolis, USA, implemented many of the same protocols, such as virtual triaging based on a combination of reported symptoms, conditions, and vital signs, and provision of immediate provider assistance, as needed. In addition, through the use of a smartphone app and basic bidirectional chat software, the program has quickly put in place an adequate but still limited roadmap for patient monitoring (10).

A review of these apps in the context of other more universal apps (Table 1) reveals that despite many desired features in disparate apps, comprehensive software has yet to be developed so far for the general public.

However, the quick implementation of these apps during the pandemic was crucial for stemming the flow of patients into hospitals and in bidirectional home-based disease management in real-time and learning about the emerging disease from the front lines (9). These smart apps will continue to play a significant role in the medical system, greatly assisting, though perhaps not yet replacing, traditional home assessments and telemedicine visits. They offer a window into a secure, well-organized database and communication system as a focal point of remote care to streamline traditional modalities by avoiding significant parts of preliminary assessments and paperwork.  

Developments in Home-based Physiological Monitoring

As efforts for vaccination and curative measures continue, research on remote physiologic monitoring has increased (Table 2).

Powerful bioanalytical software coupled with innovative technologies and smart applications offers a pragmatic solution. Realizing the potential of these technologies, the U.S. Food and Drug Administration (FDA) has established a streamlined process for the research and use of home-monitoring devices through various medical platforms (11).

A. Cardiac Monitoring

SARS-COV-2 virus can cause myocarditis, acute coronary syndromes, and arrhythmias, while medications can prolong the corrected QT interval (QTc). Therefore, electrocardiographic (EKG) monitoring, which can help detect tachycardias, conduction defects, and other arrhythmias, and changes of myocardial injury (12), is critical to COVID-19 management (13). Remote single-lead EKG monitoring is considered less accurate than 12-lead telemetry, which is the gold standard. However, several companies now offer mobile solutions for real-time EKG monitoring. After a trial with COVID-19 patients, the FDA cleared one such device, a four-lead MCOT PATCH mobile cardiac telemetry path system for outpatient EKG monitoring (14). Another such device called KardiaMobile 6L by AliveCor offers a real-time QTc measurement service from remote EKG tracings (14). Apple Watches 4 and 5 also have certain EKG monitoring capabilities, modified for diagnostic purposes (15). Beyond EKG monitoring, heart rate (HR), resting heart rate (RHR), and heart rate variability (HRV) biometrics have the greatest predictive capacity (15). These devices illustrate the future of remote monitoring by tracking early heart damage or providing useful warning signs of cardiac status or recovery trajectories (16).

B. Respiratory Rate Monitoring

COVID-19 commonly presents as a lower-respiratory tract infection, necessitating respiratory rate monitoring (17, 18). Due to the relative consistency of an individual's resting respiratory rate, changes can be detected remotely (specifically greater than 27 breaths per minute) (17).  Home-based methods for monitoring respiratory rate utilize one of two techniques: 1) respiratory inductive plethysmograph (RIP), which uses belts to measure relative changes in circumference around the abdomen and ribcage, and 2) optoelectronic plethysmography, which uses cameras to map the topography of the torso using local markers. However, new technology has emerged, such as a wearable sensor around the size of a Band-Aid, which remotely monitors local chest wall strain and transmits information to a device through Bluetooth to health care providers (19).

C. Pulse Oximetry

Pulse oximeters, though traditionally used to measure the oxygen saturation of the peripheral blood (SpO2), can also measure heart rate.  Monitoring SpO2 is critical to managing the subset of asymptomatic or paucisymptomatic COVID-19 patients with severe hypoxemia (often referred to as "silent hypoxia"). There are generally two categories of pulse oximeters. The traditional method uses light transmission through cutaneous tissue (finger or earlobe). Varying in size, traditional pocket oximeters approved for clinical use can range in cost from 20-50 US dollars. The other major categories of oximeters use reflected light measured by apps that utilize smartphone hardware and software, like the Nellcor SpO2 forehead monitor (20).

An initiative at Cleveland University Hospitals promotes using a disposable wireless finger sensor for home-based SpO2 monitoring (21). Emerging as a costly but highly competitive alternative to others in its field is the Nonin Connect 3230 Bluetooth Smart Pulse Oximeter, which offers smartphone compatibility and alert generation linked with clinician databases, for unexpected SpO2 measurements below 94% (22). Differing branded alternatives have also quickly emerged on the market, providing a cheap and quick reading, albeit with significant and varying inaccuracies, which can be useful in especially urgent contexts.

D. Temperature Tracking

COVID-19 often presents with mild to moderate fever, making body temperature an important metric to track (23). Temperature monitoring has become standard at entry points to buildings to identify and triage those infected (24). In a home-based monitoring setting, fever can be a key warning sign of both the onset of COVID-19 as well as disease trajectory (25). Elevated body temperature is correlated with mortality - the mortality rate being more than 40% higher among those with a maximum body temperature over 40.0^° C than those with a lower temperature and increasing for every 0.5^° C elevation (26).

There are several modalities for temperature monitoring, the most common of which are electronic thermometers (placed into the mouth, rectum, or armpit); plastic strip surface thermometers which change color to indicate the temperature (limited by their low accuracy); electronic ear thermometers (commonly used but maybe less accurate due to external ear canal blockage); and non-contact forehead infrared thermometers (27). Wearable technology may be effective for frequently measuring and transmitting temperature information. HEATthermo is one such technology that can reliably measure body surface temperature and heart rate every 10 seconds with good reliability (28). The Taiwanese company iWEECARE has come out with the product Temp Pal. The device is the world's smallest thermometer that offers a 36-hour battery life. It sends secure body temperature data to an app and cloud dashboard through Bluetooth for centralized big data tracking (29). These apps and monitoring platforms make it easy for medical professionals to monitor patients and for the latter to seek advice on treatment from the former, using algorithm-based alert messages (30).

E. Glucose Monitoring

Patients with pre-existing diabetes are uniquely vulnerable to SARS-CoV-2 infection and its associated morbidity and mortality. The virus' inflammatory surge (dubbed "cytokine storm") can result in insulin resistance and new-onset diabetes mellitus and its complications. The systemic hyperglycemia can lead to greater viral replication in vivo coupled with a suppressed immune response (31). Continuous glucose monitoring may therefore be helpful in those infected. Recent developments in the field of Continuous Glucose Monitoring (CGM) devices offer a pragmatic solution. Low cost and small wearable devices, like Freestyle Libre, Dexcom, Medtronic, and Eversense, offer a variety of functions, like audio and visual alerts, automatic insulin injections, data confidentiality and integration, strong smartphone and app compatibility, blind data collection for big data studies, and bidirectional clinician interaction (32).

F. Adapting Existing Wearable Biometric Technology

The most logical response to the need for home-based monitoring involves repurposing existing wearable technology to generate useful multimodal biometric data. One-fifth of Americans currently wear some smartwatch or activity tracker, and most of them can give baseline resting heart rate, sleep data, and activity data (33). Duke University investigated the role of an app that tracks smartwatches and fitness trackers in mapping and diagnosing the disease (34,35) through their DETECT program. Recently, new research with larger population input has come to light due to collaborative studies from Stanford, Fitbit, and Scripps, among others, corroborating the use of smartwatches as a predictive tool for disease (15). A recent study of 30,529 people using Fitbit, Apple Health Kit, and Google Fit data showed that individuals' changes in physiological metrics (like HRV, respiratory rate, temperature, oxygen saturation, blood pressure, cardiac output, etc.) tracked by these devices could significantly improve the detection of COVID-19 days before symptoms (33). In a retrospective study sponsored by Stanford University, researchers determined that 63% of COVID-19 cases could have been detected before symptom onset in real-time (36), using smartwatches to generate resting heart rate (RHR) difference data based on standardized values and using anomalies in "heart rate over steps" data (36). Other studies have also bolstered the use of RHR data to detect COVID-19 with smartwatches (37).

G. Emerging Multimodal Biometric Technologies

As the necessity for home-based monitoring grows, wearable multimodal monitoring technologies are being developed. One of the most promising wearable devices is the Oura ring, an aesthetic piece of jewelry that tracks multimodal data. Its use with Smart apps is being investigated (38,39). Northwestern University has invented a wireless sensor, the size of a postage stamp, that rests on the suprasternal notch to monitor cough intensity and patterns, chest wall movements, and vital signs (40,41). Mayo Clinic has started its own project, offering an albeit bulkier device yielding multimodal data, including patient self-reporting of symptoms, lung function (spirometry), and vital signs including oxygen saturation (42,5). Two powerful technology companies, Lenovo and Motorola, have joined efforts to begin certification of their Vital Moto Mod product for multimodal monitoring of vital signs, though not in a continuous or wearable fashion (43). A Chinese company KoKo LLC has agreed to distribute the Belun Technology's system (including the popular Belun ring) for monitoring vital signs. The device, called BLR-1000, uses a SIM (subscriber identification module) card and a HIPAA (Health Insurance Portability and Accountability Act) secured cloud-based system with secure protocols for data transmission to clinicians through a centralized platform (44).

More innovative research is coming in continuous respiratory rate monitoring through the modulation of radio waves and Wi-Fi signals caused by respiration-related thoracic movements, as well as smart garments and mattress pressure sensors (10), combined with cloud-based analytics. Moreover, technologies are being disseminated even as they are developed: Oakland University, California, USA, started handing out skin temperature tracking devices (BioButtons) to its students; employees in Plano, Texas, and football players at the University of Tennessee are already using proximity detectors; Kinexon from Munich is distributing SafeZone proximity trackers to many companies; and GlaxoSmithKline began manufacturing a virus tracking system with Microshare (45).

Although the devices listed above may greatly facilitate home-based physiological monitoring, physical interaction with the provider is still necessary and reassuring for patients. A recent 2020 survey of SWJPCC readership showed that despite the reduced need for documentation, greater overall efficiency, and decreased virus exposure with remote monitoring, patients valued interpersonal interactions associated with physical visits (63). Of course, considerations must be taken into account of those without easy access to technology and the Internet and those requiring additional services such as translation, interpretation, and further testing. Thus, although televisits may have increased out of necessity during the pandemic, they will likely decrease post-pandemic. However, the developed platforms may positively affect harder-to-reach communities if supplemented with the necessary resources, long after the pandemic abates (64).

Promising Home-based Lung Monitoring, Diagnosis, and Treatment Modailities

Lung ultrasound, useful in the point-of-care diagnosis and management of patients with acute respiratory failure, may be helpful in the diagnosis and management of COVID-19 pneumonia (46-49, 62). However, the lack of robust evidence and the need for technology and training renders this option currently not feasible for use in the home setting (62).

Patients at risk for atelectasis use an incentive spirometer to encourage deep, slow breaths (50,51). Although useful for atelectasis, there is little role for incentive spirometry in the treatment of COVID-19. Used in the investigation of asthma, peak expiratory flow rate measures the speed of exhalation (52,53), but its role in the home-based monitoring of COVID-19 is not known. Patients with COVID-19 pneumonia with hypoxia managed at home can be encouraged to use electronically timed treatments of prone-positioning (PP) sessions (54,55).

There still exist other developing investigations into the field of lung testing and early diagnosis. For example, one innovative study delves into machine learning with existing smartphone software and hardware to review breathing sounds. Although not specific to COVID-19 pneumonia, the acoustic technology may help classify subjects with and without pneumonia (56). Another area of investigation is the outpatient use of lung compliance measurements for COVID-19 pneumonia tracking and diagnosis (57, 58). However, the use of lung compliance for this purpose is limited by the normal lung compliance noted in some patients despite severe hypoxemia (58-60).  

Conclusion

COVID-19 has radically shifted the healthcare infrastructure; however, depending on how we utilize this system, it may open more doors than close them. The age of telehealth and telemonitoring, and the necessary implications of interactions with the Internet of things, are sure to raise privacy and security questions. Many of the companies and institutions developing smart apps and technologies above prioritize the safety of medical information. From HIPAA-secured clouds to centralized operating databases and governmentally approved/sponsored applications, patients and their security are paramount. A deep and critical analysis of the role that these apps will hold over our healthcare system is not only important but necessary.

The use of remote home-based monitoring to decrease hospital stay is the new future of the medical system. While these technologies are increasing in number and versatility, they are not empirically improving patient outcomes significantly at this time, mainly due to their novelty. The technology’s usefulness and predicted applicability, however, is undeniable in several areas as they become both more intuitive and multifaceted. Using such technological modalities to target rural, underprivileged, and underserved communities could be the stepping-stone to a universal healthcare system. Furthermore, such devices and continuous data streaming to clinician platforms also offer critical benefits to patients with varying conditions outside COVID-19. This system of remote monitoring has changed the healthcare system permanently and will change patient-physician interaction during the pandemic and post-pandemic.

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Disclosures

No disclosures of any personal or financial support or author involvement with organization(s) with financial interest in the subject matter, or any actual or potential conflict of interest.

Cite as: Warrier A, Sood A. Home-Based Physiological Monitoring of Patients with COVID-19. Southwest J Pulm Crit Care. 2021;23(3):76-88. doi: https://doi.org/10.13175/swjpcc005-21 PDF 

Results of the SWJPCC Telemedicine Questionnaire

Richard A. Robbins, MD

Julene R. Robbins, PhD, NCSP

Phoenix Pulmonary and Critical Care Research and Education Foundation

Gilbert, AZ USA

Abstract

As the COVID-19 crisis puts pressure on outpatient providers to facilitate remote care, some have set aside their skepticism and opened telemedicine clinics as an alternative to the traditional office visit. In these visits, the provider and patient usually are able to visually and verbally interact. However, interactions that require contact such as a physical examination are not possible. We conducted a voluntary, anonymous, on-line survey of the Southwest Journal of Pulmonary and Critical Care (SWJPCC) readership to determine their experience and attitudes toward telemedicine. Of the 84 respondents we surveyed, most were favorable towards telemedicine visits with two-thirds of respondents being very or mostly satisfied with telemedicine. However, some (30%) estimated that over 50% of their time was spent with documentation and a significant portion (55%) noted reduced reimbursement. These data support the Center for Medicare and Medicaid’s (CMS) decision to expand telemedicine beyond the present COVID-19 pandemic.

Introduction

The COVID-19 pandemic has created new challenges for patient care. The risk for severe illness from COVID-19 increases with age (1). Many patients and some providers are elderly and at risk for more severe disease. According to the Centers for Disease Control and Prevention (CDC), the best protection is to limit interactions with other people as much as possible (1).

One potential solution which avoids contraction of COVID-19 by face-to-face exposure is telemedicine. Telemedicine is the remote diagnosis and treatment of patients by means of telecommunications technology usually employing both visual and audio interaction. Telemedicine has been around for some time and its use has increasing (2). However, telemedicine is not without limitations including the obvious concerns of reimbursement, regulatory issues, privacy, the need for access to telemedicine devices (e.g., smartphone, tablet, computer), comfort levels with the technology by both healthcare providers and patients, and cultural acceptance of conducting virtual visits in lieu of in-person visits (3). Furthermore, other fundamental issues such as selection of patients and outcomes are largely unknown.

To discover the experiences with and the attitudes toward telemedicine, we posted an on-line questionnaire and solicited the Southwest Journal of Pulmonary and Critical Care (SWJPCC) readership to fill out the questionnaire The results suggest that telemedicine usage has increased with the COVID-19 pandemic, and despite the short time of implementation, is generally acceptable to providers.

Methods

Questionnaire

A questionnaire was constructed with the goals of determining healthcare providers experience and attitudes towards telemedicine.  An additional goal was to keep the survey brief, since previous experience was that long surveys usually have a poor response. A series of 11 questions was developed (Appendix 1).

Data Collection and Statistical Analysis

Data was collected August 9, 2020 through August 31, 2020. The data was collected on the Southwest Journal of Pulmonary and Critical Care website using Excel.

Results

Demographics

There were 84 respondents. Eighty-one answered yes to offering telemedicine but 3 no’s appeared to have prior experience with telemedicine (Appendix 2). Although we did not question which were physicians, nurse practitioners, physician assistants, etc., the vast majority of respondents to previous SWJPCC surveys have been pulmonary and critical care physicians (4).

Sixty-eight of the eighty-four respondents (81%) did not offer telemedicine before the COVID-19 pandemic. The majority of these 64/84 (76%) offered telemedicine to both new and established patients. Only 20/84 (24%) offered telemedicine to established patients only.

Telemedicine platform

There were 90 responses from the 84 respondents to which telemedicine platform was being used. Some respondents apparently used more than one platform.

Table 1. Telemedicine platforms used.

The most common reason cited for using a platform was that the telemedicine platform was offered with the electronic healthcare record currently in use (30 of 84, 36%). An almost an equal number (29/84, 35%) did not know the basis of choosing the platform and presumably had not been involved in the selection process. Only 4 said the platform was chosen on the basis of reviews.

Connectivity

A major concern of telemedicine has been the ability of some patients and providers to use the technology (3). This would likely be reflected in a low number of patients and providers to establish a connection. The results of the questionnaire suggest connectivity is not a major problem (Figure 1).

Figure 1. Connectivity of telemedicine visits. Number of respondents is on the vertical axis and their responses are on the horizontal axis.

There was no consistent pattern in those who had problems with connections (Appendix 2).

Satisfaction

Two-thirds of the respondents were either very or mostly satisfied with their current telemedicine platform (Figure 2).

Figure 2. Satisfaction with current telemedicine system.

There was no consistent pattern to telemedicine satisfaction although other than only one of the seven respondents who used eVisit (Banner Healthcare system) or the VA system was satisfied (Appendix 3).

Disadvantages of Telemedicine

The five most common disadvantages of telemedicine as viewed by the respondents are listed in Table 2.

Table 2. Most common disadvantages of telemedicine.

No other pattern of responses was discerned other than four noting the obvious lack of vitals and physical exams possible with telemedicine.  The questionnaire also asked specifically about time for documentation and reimbursement because one of the authors (RAR) noted high documentation time and low reimbursement in his practice. Documentation time did tend to be high (Appendix 2). Twenty-five respondents (30%) noted that over half the time of a telemedicine visits was spent in documentation and/or billing. Many respondents (35 out of 84, 42%) did not know the reimbursement for the telemedicine visits compared to a face-to-face office visit. One respondent claimed a higher reimbursement with telemedicine; 21 (25%) claimed reimbursement was about the same; and the remainder (74%) claimed lower reimbursement (Appendix 2).

Advantages of Telemedicine

Some advantages of telemedicine are obvious such as decreased exposure to COVID-19. This was noted by a majority of our respondents (80 out of 84 (95%), Table 3).

Table 3. Advantages of telemedicine. 

Other advantages cited included patient preference (42 respondents, 50%); more efficient time utilization (29 respondents, 35%); provider time savings (25 respondents, 30%); and reduced documentation (22 respondents, 26%). There were 11 other responses but none listed by more than 2 respondents.

Discussion

To our knowledge this is the first survey of healthcare providers providing telemedicine since the beginning of the COVID-19 pandemic. Although the sample-size of respondents is not large, it is adequate when compared to relatively smaller number of pulmonary and critical care providers in the Southwest United States. Most (67%) were satisfied with telemedicine. However, 30% noted high documentation times and 55% decreased reimbursement.

Our study is consistent with previous observations that patients are mostly satisfied with telemedicine[HD1] . Gustke et al. (5) reported an extraordinarily high patient satisfaction rate of 98.3% from a telemedicine center. Review articles and meta-analysis suggest that telemedicine is acceptable to most patients in a variety of circumstances (6,7). However, many studies have methodological deficiencies such as low sample sizes, context, and study designs which limit generalizability (6,7). Studies clearly defining “when” and “for what” telemedicine should be utilized are needed. Data demonstrating outcomes will be necessary but at the present time such data is lacking.

Telemedicine has been around for some time but has never been fully utilized. In 2019, only 12% of pulmonologists were using telemedicine although its use has slowly been increasing over the past 20 years (7). Telemedicine usage appears to have been markedly accelerated by the COVID-19 pandemic (8). According to The Physicians Foundation’s 2018 Survey of America’s Physicians conducted by Merritt Hawkins, approximately 18% of physicians indicated they were using telemedicine to treat patients in 2018 (9). That number had increased to 48% by April, 2020 according to a new survey (10). In this rush to establish telemedicine if and how much training the providers receive is unclear.

In a survey conducted by American Well physicians several reasons were listed for choosing telemedicine including: 1. Improved patient access to care (93%); 2. More efficient use of time (77%); 3. Reduced healthcare costs (71%); 4. High-quality communications with patients (71%); and  5. Enhanced doctor-patient relationship (60%) (7). Almost certainly contributing to the increase in telemedicine usage has been the relaxation of the Centers for Medicare & Medicaid Services (CMS) rules regarding reimbursement for telemedicine (11). CMS is now proposing changes to expand telemedicine permanently (12).

Telemedicine visits may require less efforts on the part of the support staff. For example, no vitals are needed. No show rates might also improve. Once telemedicine established and up and running, it can also reduce the size of office space required per provider in the clinic. This could help compensate for lower reimbursement by reducing overhead expenses.

It seems likely that telemedicine will persist in some form after the COVID-19 pandemic. What is unclear is which patients should be seen and what reimbursement should be provided. For example, doing an office visit to check on CPAP compliance for a patient with sleep-apnea is probably appropriate and can probably be done efficiently by telemedicine. However, a more complex patient and especially one where a physical examination is important, might require a face-to-face office visit. Further investigation is needed to determine both appropriateness and optimal reimbursement for telemedicine rather than a one telemedicine fits all approach.

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Cite as: Robbins RA, Robbins JR. Results of the SWJPCC Telemedicine Questionnaire. Southwest J Pulm Crit Care. 2020;21:66-72. doi: https://doi.org/10.13175/swjpcc049-20 PDF