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Resumption of respiratory outpatient services in the COVID-19 era: Experience from Southern Italy

      COVID-19 pandemic turned the entire health-care system organization upside-down, suspending elective activities and outpatient services. In Italy, we are entering a second phase of the pandemic and several strategies have been developed to “re-open” the country, some businesses, and also health care outpatient activities. This manuscript describes the experience of a Southern Italy Respiratory Unit for safely resuming outpatient respiratory services and preventing COVID-19 transmission.

      Key Words

      Abbreviations: COVID-19 (coronavirus disease 2019), WHO (World Health Organization), HCWs (health-care workers), PFTs (pulmonary function tests), PPE (personal protective equipment)
      Coronavirus disease 2019 (COVID-19) has quickly spread nationwide and has officially designated as a pandemic by World Health Organization.

      WHO. Coronavirus Disease (COVID-2019) Situation Report 2020. Available at:https://www.who.int/emergencies/diseases/novel-coronavirus-2019/events-as-they-happen. Accessed May 17, 2020

      At the beginning of the outbreak, the need to contain transmission caused not only the lock-down of entire nations but also the shut-down of hospitals’ outpatient care.

      WHO. Critical Preparedness, Readiness and Response Actions for COVID-19: Interim Guidance. Available at: https://apps.who.int/iris/handle/10665/331511. Accessed May 17, 2020

      The Sars-CoV-2 infection is mainly transmitted by respiratory droplets
      • Anfinrud P.
      • Stadnytskyi V.
      • Bax C.E.
      • Bax A.
      Visualizing speech-generated oral fluid droplets with laser light scattering.
      and close contact, and both respiratory clinicians and patients are at increased risk for transmission during the outpatient visit and the pulmonary function testing procedures.
      Patients scheduled for an outpatient visit may also suffer from common respiratory symptoms that can mimic or represent undiagnosed cases of COVID-19.
      Planned pulmonary visit and pulmonary function tests were suspended and postponed unless when deemed clinically essential, as recommended by The American Thoracic Society, The Thoracic Society of Australia and New Zealand and The Irish Thoracic Society,

      American Thoracic Society. Pulmonary Function Laboratories: Advice Regarding COVID-19. Available at: https://www.thoracic.org/professionals/clinical-resources/disease-related-resources/pulmonary-function-laboratories.php. Accessed May 17, 2020

      Irish Thoracic Society Guidance on Lung Function Testing: SARS COVID-19. Available at: https://irishthoracicsociety.com/wp-content/uploads/2020/03/ITS-Guideline-on-lung-function-testing-24.03-FINAL.pdf. Accessed May 17, 2020

      TSANZ/ANZSRS. Peak Respiratory Bodies Recommend Suspension of Lung Function Testing. Available at: https://www.anzsrs.org.au/images/anzsrs/peak_respiratory_bodies_recommend_suspension_of_lung_function_testing_002.pdf

      ARTP COVID19 Guidelines. Available at: https://www.artp.org.uk/News/artp-covid19-update-18th-march-2020. Accessed May 17, 2020

      at the beginning of the pandemic.
      In some realities, COVID-19 has rapidly changed the way of providing medical care, with hospitals providing “virtual visits” with remote consultations through video calls using commercially available software, to fill the gap with patients.
      • Hollander J.E.
      • Carr B.G.
      Virtually perfect? Telemedicine for covid-19.
      Nevertheless, the ongoing medical needs of patients with pre-existing chronic respiratory diseases do not disappear during pandemics. Therefore, health care organizations should implement strategies to respond to patients’ needs proactively, while maintaining physical distancing policies, preventing infection transmission, and ensuring the safety of health care workers at the same time.
      In Italy, we are now experiencing a second phase of the pandemic where several efforts to cautiously “re-open” the country has been made, and despite restrictions start to ease, physical distancing is not to an untimely end and we cannot lower the guard. Therefore, a plan to manage the health issues of people with pre-existing chronic lung conditions is essential to prevent an inevitably indirect effect of COVID-19 on these frail patients that could be devastating, increasing deaths and disabilities. Moreover, a respiratory follow-up on patients who have recovered from COVID-19 pneumonia is pivotal in monitoring the possible fibrotic sequela of the disease.
      Task Force of Pulmonary Function TestingClinical Respiratory PhysiologyChinese Association of Chest PhysiciansPulmonary Function Testing Group and R. T. G. C. T. Society
      Expert consensus on pulmonary function testing during the epidemic of Corona Virus Disease 2019.
      Many national/international professional organizations

      American Thoracic Society. Pulmonary Function Laboratories: Advice Regarding COVID-19. Available at: https://www.thoracic.org/professionals/clinical-resources/disease-related-resources/pulmonary-function-laboratories.php. Accessed May 17, 2020

      Irish Thoracic Society Guidance on Lung Function Testing: SARS COVID-19. Available at: https://irishthoracicsociety.com/wp-content/uploads/2020/03/ITS-Guideline-on-lung-function-testing-24.03-FINAL.pdf. Accessed May 17, 2020

      TSANZ/ANZSRS. Peak Respiratory Bodies Recommend Suspension of Lung Function Testing. Available at: https://www.anzsrs.org.au/images/anzsrs/peak_respiratory_bodies_recommend_suspension_of_lung_function_testing_002.pdf

      ARTP COVID19 Guidelines. Available at: https://www.artp.org.uk/News/artp-covid19-update-18th-march-2020. Accessed May 17, 2020

      ,
      Task Force of Pulmonary Function TestingClinical Respiratory PhysiologyChinese Association of Chest PhysiciansPulmonary Function Testing Group and R. T. G. C. T. Society
      Expert consensus on pulmonary function testing during the epidemic of Corona Virus Disease 2019.

      TSANZ/ANZSRS. Update on Suspension Of Lung Function Testing. Available at: https://www.anzsrs.org.au/images/Updated_Lung_Function_Testing_Guidelines_-_30th_April_2020.pdf. Accessed May 17, 2020

      AIPO-ITS Le prove di funzionalità respiratoria nell'era della pandemia da COVID-19 - Position Paper. Available at: http://www.aiponet.it/news/speciale-covid-19/2471-le-prove-di-funzionalita-respiratoria-nell-era-della-pandemia-da-covid-19-position-paper-aipo-its.html. Accessed May 17, 2020

      Italian Respiratory Society. SIP-IRS. Esami di funzionalità respiratoria nel contesto COVID-19 Position Paper. Available at: https://irn.sipirs.it/storage/61/Documento-EsamiFunzionalitàRes-Covid_Vers.1_12.05.2020.pdf. Accessed May 17, 2020

      Recommendation from ERS Group 9.1 (Respiratory function technologists/scientists) lung function testing during COVID-19 pandemic and beyond. Available at: https://ers.app.box.com/s/zs1uu88wy51monr0ewd990itoz4tsn2h. Accessed May 17, 2020

      Sociedad Uruguaya de Neumología. Recomendaciones para realizar Estudios Funcionales Respiratorios durante la epidemia causada por el coronavirus SARS–CoV–2 (COVID19). Available at: https://suneumo.org/descargar/adjunto/32-grl8hr-coronavirus-2020-15mar-reco1.pdf. Accessed May 17, 2020

      Sociedade Portuguesa de Pneumologia (SPP). Reabertura de Laboratórios de função Pulmonar. Available at: https://www.sppneumologia.pt/uploads/subcanais_conteudos_ficheiros/adenda-pfr-covid19.pdf. Accessed May 17, 2020

      Sociedade Portuguesa de Pneumologia. Recomendações da SPP para a realização de provas funcionais respiratórias durante o surto COVID-19. Available at:https://www.sppneumologia.pt/uploads/subcanais_conteudos_ficheiros/adenda-pfr-covid19.pdf. Accessed May 17, 2020

      UNMC Nebraska Medicine. Recommendations on performing Pulmonary Function Test (PFT) in PFT lab. Available at: https://www.nebraskamed.com/sites/default/files/documents/covid-19/Guidance-regarding-pulmonary-function-testing-(PFT).pdf?date=05122020. Accessed May 17, 2020

      UNMC Nebraska Medicine. SBAR for performing pulmonary function test in PFT lab. Available at:https://www.nebraskamed.com/sites/default/files/documents/covid-19/Guidance-regarding-pulmonary-function-testing-(PFT).pdf?date=04012020. Accessed May 17, 2020

      have released operational indications on how to plan the re-opening of pulmonary function test laboratories proponing different approaches, but the practical organization still relies on local hospital policies, when available or on practicing physicians.
      We share our experience in planning for a resumption of the outpatient activity at the Respiratory Unit, Policlinico-Vittorio Emanuele, Catania, Italy. We believe that our model takes into account several practical operative problems and propose constructive and easy-to-adopt solutions. Table 1 summarizes the main challenges and identified solutions for restart respiratory outpatient clinics.
      Table 1Problems and possible solutions for resuming respiratory outpatient clinics
      ChallengesIdentified solutions
      Physical distancingOne patient at a specific date/time
      COVID-19 infection controlCOVID-19 risk assessment questionnaire

      Body temperature detection
      HCW protectionPPE + Hand washing
      Airborne/Droplet transmissionHCW sitting in the same direction as the patient during PFTs

      Plexiglas wall between HCW and the patient
      Poorly ventilated roomNatural ventilation + Window exhaust fan
      Contact transmissionCleaning of the equipment and surfaces
      COVID-19 = Coronavirus 2019; HCW = health-care worker; PPE = personal protective equipment; PFTs = pulmonary function tests.
      Patients will be informed telephonically and instructed to come on specific dates and times. At the entrance, an ad hoc trained “outpatient triage nurse” with adequate personal protective equipment (PPE)

      WHO. Infection prevention and control during health care when COVID-19 is suspected. Interim Guidance. Available at: https://www.who.int/publications-detail/infection-prevention-and-control-during-health-care-when-novel-coronavirus-(ncov)-infection-is-suspected-20200125. Accessed May 7, 2020

      will evaluate the patient providing a questionnaire for COVID-19 risk assessment, detecting temperature, and assigning a level of risk (high or low risk).
      High-risk individuals will be referred to the emergency room department for nasopharyngeal swab testing and their outpatient visit rescheduled. This screening is an important aspect to consider since it might also trace under-recognized COVID-19 patients. Patients deemed at low risk will be provided with a surgical mask and an alcohol-based hand rub for hand hygiene and proceed to registration.

      WHO. Infection prevention and control during health care when COVID-19 is suspected. Interim Guidance. Available at: https://www.who.int/publications-detail/infection-prevention-and-control-during-health-care-when-novel-coronavirus-(ncov)-infection-is-suspected-20200125. Accessed May 7, 2020

      Pulmonologist evaluation will be carried out in a room with minimal furnishes, with physicians equipped with PPE, a stethoscope, a portable wireless echography probe for lung ultrasound evaluation, and an oximeter. Equipment will be disinfected with alcohol solutions between use for each patient.

      WHO. Infection prevention and control during health care when COVID-19 is suspected. Interim Guidance. Available at: https://www.who.int/publications-detail/infection-prevention-and-control-during-health-care-when-novel-coronavirus-(ncov)-infection-is-suspected-20200125. Accessed May 7, 2020

      Pulmonary Function Tests will be performed in a room with a minimum presence of furnishings; the patient will be placed near the window with a plexiglass wall between he/she and the operator.
      Task Force of Pulmonary Function TestingClinical Respiratory PhysiologyChinese Association of Chest PhysiciansPulmonary Function Testing Group and R. T. G. C. T. Society
      Expert consensus on pulmonary function testing during the epidemic of Corona Virus Disease 2019.
      The technician will wear PPE

      WHO. Infection prevention and control during health care when COVID-19 is suspected. Interim Guidance. Available at: https://www.who.int/publications-detail/infection-prevention-and-control-during-health-care-when-novel-coronavirus-(ncov)-infection-is-suspected-20200125. Accessed May 7, 2020

      and sit in the same direction as the patient for protection in case of coughing or sneezing in the test area.
      Task Force of Pulmonary Function TestingClinical Respiratory PhysiologyChinese Association of Chest PhysiciansPulmonary Function Testing Group and R. T. G. C. T. Society
      Expert consensus on pulmonary function testing during the epidemic of Corona Virus Disease 2019.
      Pulmonary Function Tests will be performed using disposable nose-clips and in-line antibacterial and viral filters

      TSANZ/ANZSRS. Update on Suspension Of Lung Function Testing. Available at: https://www.anzsrs.org.au/images/Updated_Lung_Function_Testing_Guidelines_-_30th_April_2020.pdf. Accessed May 17, 2020

      that will also serve as disposable mouthpieces, to prevent the transmission of infection from within the circuit. The bronchodilator testing will be performed using patients’ salbutamol inhaler or a disposable aerochamber.
      • Saeed H.
      • Abdelrahim M.E.
      • Rabea H.
      • Salem H.F.
      Evaluation of disposable and traditional accessory devices for use with a pressurized metered-dose inhaler.
      Adequate ventilation of each room will be ensured using natural ventilation and an exhaust fan at the window to boost ventilation and direct airflow.
      • Qian H.
      • Li Y.
      • Seto W.H.
      • Ching P.
      • Ching W.H.
      • Sun H.Q.
      Natural ventilation for reducing airborne infection in hospitals.
      A 3D model of room design is shown in Figure 1.
      After each patient, adequate house-keeping and cleaning of the equipment and surfaces (eg, exam bed, countertop, chair, equipment) with alcoholic solutions will be performed,

      WHO. Infection prevention and control during health care when COVID-19 is suspected. Interim Guidance. Available at: https://www.who.int/publications-detail/infection-prevention-and-control-during-health-care-when-novel-coronavirus-(ncov)-infection-is-suspected-20200125. Accessed May 7, 2020

      as well as safe waste management.
      Pulmonary Function Tests will be performed only in essential cases for diagnosis of current illness, with immunocompromised patients tested first.

      ARTP COVID19 Guidelines. Available at: https://www.artp.org.uk/News/artp-covid19-update-18th-march-2020. Accessed May 17, 2020

      ,

      Italian Respiratory Society. SIP-IRS. Esami di funzionalità respiratoria nel contesto COVID-19 Position Paper. Available at: https://irn.sipirs.it/storage/61/Documento-EsamiFunzionalitàRes-Covid_Vers.1_12.05.2020.pdf. Accessed May 17, 2020

      ,

      Sociedad Uruguaya de Neumología. Recomendaciones para realizar Estudios Funcionales Respiratorios durante la epidemia causada por el coronavirus SARS–CoV–2 (COVID19). Available at: https://suneumo.org/descargar/adjunto/32-grl8hr-coronavirus-2020-15mar-reco1.pdf. Accessed May 17, 2020

      Early afternoon appointments will be scheduled for the most severe chronic respiratory patients. COVID-19 pneumonia recovered patients will be scheduled after at least 30 days of 2 consecutive negative swabs.

      Recommendation from ERS Group 9.1 (Respiratory function technologists/scientists) lung function testing during COVID-19 pandemic and beyond. Available at: https://ers.app.box.com/s/zs1uu88wy51monr0ewd990itoz4tsn2h. Accessed May 17, 2020

      We need to change the way we provided care to patients so far and co-habit with the “silent enemy,” since chronic severe medical conditions still exist despite COVID-19, and we need to take care of them taking urgent and effective actions in continuing to assist chronic respiratory diseases while preventing infection dissemination.
      The proposed approach represents a prudent and easy-to-reproduce plan to restart respiratory outpatient services while dealing with this prolonged health-care emergency. We hope that our experience might provide a practical and useful guide for other respiratory units while resuming their respiratory outpatient activity.

      Acknowledgments

      None.

      References

      1. WHO. Coronavirus Disease (COVID-2019) Situation Report 2020. Available at:https://www.who.int/emergencies/diseases/novel-coronavirus-2019/events-as-they-happen. Accessed May 17, 2020

      2. WHO. Critical Preparedness, Readiness and Response Actions for COVID-19: Interim Guidance. Available at: https://apps.who.int/iris/handle/10665/331511. Accessed May 17, 2020

        • Anfinrud P.
        • Stadnytskyi V.
        • Bax C.E.
        • Bax A.
        Visualizing speech-generated oral fluid droplets with laser light scattering.
        N Engl J Med. 2020; 382: 2061-2063
      3. American Thoracic Society. Pulmonary Function Laboratories: Advice Regarding COVID-19. Available at: https://www.thoracic.org/professionals/clinical-resources/disease-related-resources/pulmonary-function-laboratories.php. Accessed May 17, 2020

      4. Irish Thoracic Society Guidance on Lung Function Testing: SARS COVID-19. Available at: https://irishthoracicsociety.com/wp-content/uploads/2020/03/ITS-Guideline-on-lung-function-testing-24.03-FINAL.pdf. Accessed May 17, 2020

      5. TSANZ/ANZSRS. Peak Respiratory Bodies Recommend Suspension of Lung Function Testing. Available at: https://www.anzsrs.org.au/images/anzsrs/peak_respiratory_bodies_recommend_suspension_of_lung_function_testing_002.pdf

      6. ARTP COVID19 Guidelines. Available at: https://www.artp.org.uk/News/artp-covid19-update-18th-march-2020. Accessed May 17, 2020

        • Hollander J.E.
        • Carr B.G.
        Virtually perfect? Telemedicine for covid-19.
        N Engl J Med. 2020; 18: 1679-1681
        • Task Force of Pulmonary Function Testing
        • Clinical Respiratory Physiology
        • Chinese Association of Chest Physicians
        • Pulmonary Function Testing Group and R. T. G. C. T. Society
        Expert consensus on pulmonary function testing during the epidemic of Corona Virus Disease 2019.
        Zhonghua Jie He He Hu Xi Za Zhi. 2020; 43: E032
      7. TSANZ/ANZSRS. Update on Suspension Of Lung Function Testing. Available at: https://www.anzsrs.org.au/images/Updated_Lung_Function_Testing_Guidelines_-_30th_April_2020.pdf. Accessed May 17, 2020

      8. AIPO-ITS Le prove di funzionalità respiratoria nell'era della pandemia da COVID-19 - Position Paper. Available at: http://www.aiponet.it/news/speciale-covid-19/2471-le-prove-di-funzionalita-respiratoria-nell-era-della-pandemia-da-covid-19-position-paper-aipo-its.html. Accessed May 17, 2020

      9. Italian Respiratory Society. SIP-IRS. Esami di funzionalità respiratoria nel contesto COVID-19 Position Paper. Available at: https://irn.sipirs.it/storage/61/Documento-EsamiFunzionalitàRes-Covid_Vers.1_12.05.2020.pdf. Accessed May 17, 2020

      10. Recommendation from ERS Group 9.1 (Respiratory function technologists/scientists) lung function testing during COVID-19 pandemic and beyond. Available at: https://ers.app.box.com/s/zs1uu88wy51monr0ewd990itoz4tsn2h. Accessed May 17, 2020

      11. Sociedad Uruguaya de Neumología. Recomendaciones para realizar Estudios Funcionales Respiratorios durante la epidemia causada por el coronavirus SARS–CoV–2 (COVID19). Available at: https://suneumo.org/descargar/adjunto/32-grl8hr-coronavirus-2020-15mar-reco1.pdf. Accessed May 17, 2020

      12. Sociedade Portuguesa de Pneumologia (SPP). Reabertura de Laboratórios de função Pulmonar. Available at: https://www.sppneumologia.pt/uploads/subcanais_conteudos_ficheiros/adenda-pfr-covid19.pdf. Accessed May 17, 2020

      13. Sociedade Portuguesa de Pneumologia. Recomendações da SPP para a realização de provas funcionais respiratórias durante o surto COVID-19. Available at:https://www.sppneumologia.pt/uploads/subcanais_conteudos_ficheiros/adenda-pfr-covid19.pdf. Accessed May 17, 2020

      14. UNMC Nebraska Medicine. Recommendations on performing Pulmonary Function Test (PFT) in PFT lab. Available at: https://www.nebraskamed.com/sites/default/files/documents/covid-19/Guidance-regarding-pulmonary-function-testing-(PFT).pdf?date=05122020. Accessed May 17, 2020

      15. UNMC Nebraska Medicine. SBAR for performing pulmonary function test in PFT lab. Available at:https://www.nebraskamed.com/sites/default/files/documents/covid-19/Guidance-regarding-pulmonary-function-testing-(PFT).pdf?date=04012020. Accessed May 17, 2020

      16. WHO. Infection prevention and control during health care when COVID-19 is suspected. Interim Guidance. Available at: https://www.who.int/publications-detail/infection-prevention-and-control-during-health-care-when-novel-coronavirus-(ncov)-infection-is-suspected-20200125. Accessed May 7, 2020

        • Saeed H.
        • Abdelrahim M.E.
        • Rabea H.
        • Salem H.F.
        Evaluation of disposable and traditional accessory devices for use with a pressurized metered-dose inhaler.
        Respir Care. 2020; 3: 320-325
        • Qian H.
        • Li Y.
        • Seto W.H.
        • Ching P.
        • Ching W.H.
        • Sun H.Q.
        Natural ventilation for reducing airborne infection in hospitals.
        Build Environ. 2010; 3: 559-565