ARTP COVID19 Update - 18th March 2020

18 March 2020

The COVID19 infection has changed from “containment” to “delay” phase and the likely “crisis phase” is expected to peak in June 2020 (timing currently approximate). ARTP members are continuing to be asked about lung function testing and other respiratory diagnostics/therapies. We are being asked for further advice from hospitals, community, patients and staff. ARTP have reviewed the initial guidance and are updating content to help ARTP membership consider solutions to some of the problems posed.

All NHS organisations are developing and modifying their own contingency plans together which no doubt most lung function services will follow; however, we are outlining specific guidance based on expert opinion, prepared after review and consultation. These recommendations and suggestions may further change over time as the virus impact hits the UK further.

The guidance covers the following key points;

Who and when should you test?
How should you test them?
What should departments do in the event of escalated COVID19?

You can also view other information which may be of help here:

Use of acute NIV in patients hospitalised with suspected or confirmed COVID-19 infection. Technical information from the British Thoracic Society - https://www.brit-thoracic.org.uk/media/455095/advice-on-acute-niv-technical-aspects-final-16-march-2020.pdf

Critical Care Preparation and management of Critical Care Patients: https://icmanaesthesiacovid-19.org/critical-care

Area	Issue	Delay Phase Advice	Crisis Phase Advice
Who to test?	Is the test routine or urgent?	Decrease numbers attending the department and primary care (e.g. postpone non-urgent tests, use “virtual options” for CPAP review patients, remote monitoring of CPAP & NIV if possible; review of machine SD cards if remote monitoring unavailable) Urgent includes; inpatient cancer, preoperative patients for urgent surgery where lung function or CPET is essential. Avoid airway challenge testing, which actively induces cough.	Emergency only in hospital. Cancellation of all non-urgent in primary and secondary care. (e.g. cancer, pre-operative)
	Does the patient have COVID19 symptoms?	Contact patients by phone the day before their appointment to confirm symptoms & contact with COVID19. Non-urgent patients should not attend. Dismiss any patient attending with COVID symptoms and advise to self-quarantine using NHS 111 advice line only if they deteriorate.	Assume all patients and staff infected with COVID19. Urgent patients may already have COVID19 and will need testing for urgent clinical reasons only (e.g. pre-operative testing for urgent surgery).
Which tests?	Which tests should be offered?	Spirometry, gas transfer, lung volumes, FeNO, blood gases, CPET, other urgent procedures in exceptional cases.	Blood gases (ABG, CBG), spot-check oximetry and exceptionally spirometry.
How to test?	What infection control measures should be taken?	Additional hand sanitiser to be available to patients in waiting areas. Patients to sit >1 metre apart where possible. All patients and staff to use hand gel prior to entering and on leaving any clinical room/area. Routine Lung Function infection control measures should suffice (filters, wiping down contact parts with appropriate wipes e.g. alcohol/Clinell wipes between patients, etc.) Immunocompromised patients (e.g. BMT patients) that must be tested should be tested as first patient of the day. Patients with long-term conditions that require monitoring with lung function testing (e.g. CF) must be considered on a case by case basis.	Routine Lung Function infection control measures should suffice with PPE as directed by hospital infection control team. Most respiratory diagnostics will cease.
	Extra infection control measures	All staff to wash hands appropriately whenever arriving or leaving the department and between patients. Wipe down equipment and surrounding areas after each patient and clean down department at the end of each day. Provide patients with tissues to cough in to. Patient to dispose in an appropriate clinical waste bin. Personal protective equipment to be deployed as directed by your hospital infection control team.	All staff to wash hands appropriately whenever arriving or leaving the department and between patients. Wipe down equipment and surrounding areas after each patient and clean down department at the end of each day. Personal protective equipment to be deployed as directed by your hospital infection control team.
How to deploy staff? (Secondary care)	Senior Bands (6-8)	Can be used to deliver specialist services (NIV, oxygen, blood gases – supporting respiratory wards and HDU/ITU facilities)	Can be used to deliver specialist services (NIV, oxygen, blood gases – supporting respiratory wards and HDU/ITU facilities)
	Bands (2-5)	To deliver reduced routine service in accordance with usual standards. May be redeployed contacting patients at home to perform virtual CPAP reviews, etc.	Can be redeployed contacting patients at home to perform virtual CPAP reviews, etc. May be trained to support ward staff performing routine observations/care.
How to deploy staff? (Primary care)	GPs, Specialist respiratory nurses, practice nurses	To deliver appropriate services in accordance with the PHE/NHSE Guidance.	To deliver appropriate services in accordance with PHE/NHSE and Trust Guidance.

Contributors:

Professor Brendan Cooper, Consultant Clinical Scientist, University Hospitals Birmingham NHS Trust
Dr James Hull, Consultant Physician, Royal Brompton and Harefield Hospital NHS Trust
Julie Lloyd, Service Lead/Clinical Scientist, University Hospitals Birmingham NHS Trust
Peter Moxon, Service Lead, The Royal Wolverhampton NHS Trust
Dr Adrian Kendrick, Consultant Clinical Scientist, University Hospitals Bristol NHS Trust
Carol Stonham MBE, PCRS Executive Chair
BTS/ARTP Strategy Group
Dr Martin Allen, Consultant Physician, University Hospitals of North Midlands

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