Remote control: the respiratory annual review in lockdown and beyond
Is it possible to carry out a ‘virtual’ respiratory review or do we need to see patients with asthma or COPD face-to-face to assess control and inhaler technique? And what about newly presenting symptoms? Can a diagnosis be made via phone or video link?
In a previous article we considered how a diabetes annual review could be carried out remotely, via a telephone or video consultation, reflecting on how the COVID-19 pandemic has moved the Digital NHS agenda forward by a decade, with more and more care being managed remotely.1 We have already outlined the general principles that should be borne in mind when engaging in remote consultations so these will not be revisited here, but it would be useful to read through these again if you are not used to carrying out remote reviews.2 In this article, we consider how a virtual respiratory consultation, for asthma or chronic obstructive pulmonary disease (COPD) might be carried out, highlighting the potential opportunities and challenges that remote consultations can offer.
After reading this article you should be able to:
REMOTE DIAGNOSIS – IS IT POSSIBLE?
A question that has been raised several times during the pandemic, both in live webinars and in social media debate, is whether or not it is possible to diagnose asthma or COPD remotely.
Asthma is an inflammatory condition which presents with symptoms such as cough, wheeze, shortness of breath and tight chest, often on a background of a family history of atopic conditions. Symptoms are often diurnal in nature and may also be seasonal. People with asthma will usually be able to identify a trigger for their symptoms such as exercise, temperature change, infections, pollen or house dust mite.3 The diagnosis of asthma is based on the presence of these symptoms plus evidence of variable but reversible airflow obstruction, and spirometry is considered to be the gold standard for demonstrating these parameters.3
In suspected COPD, the diagnosis is made on the basis of symptoms, risk factors and evidence of irreversible airflow obstruction, demonstrated through post-bronchodilator spirometry.4 Symptoms include cough, breathlessness and sputum production, the main risk factor is cigarette smoking and post-bronchodilator spirometry would show an FEV1/FVC ratio of 70% or less with a normal FVC and (usually) a reduced FEV1.
The British Thoracic Society/Scottish Intercollegiate Guidelines Network (BTS/SIGN) asthma guidelines state that an FEV1/FVC ratio less than the lower limit of normal, indicates airflow obstruction, with the FEV1 denoting the severity of obstruction.3 However, the Global Initiative for Obstructive Lung Disease (GOLD) guidelines for COPD4 and the NICE guidelines for COPD5 both state that airflow obstruction should be diagnosed if the FEV1/FVC ratio is less than 70% (or 0.7). The BTS/SIGN guidelines for asthma also state that normal spirometry does not rule out asthma as a diagnosis as the variable nature of the airflow obstruction may mean that someone with asthma may have normal lung function on some days but not on others. Similarly, the GOLD guidelines remind the clinician that readings which are either normal or abnormal, but which do not fit the clinical picture, should be repeated as they cannot be relied upon to make a diagnosis.4 I have stated before that for an ‘objective’ test, there seems to be a lot of leeway in the diagnostic values and parameters and that in every guideline there appears to be the acceptance that the history gives the clinician most of the diagnosis.6
As a result, if a diagnosis of asthma or COPD is suspected, the following approach seems to balance risk and benefit effectively.
Take a robust history as described above. Code as ‘suspected asthma’ and prescribe an inhaled corticosteroid – 400mcg total daily dose for those age 12 years or older, 200mcg total daily dose for those age under 12 years. Under 5s can have a trial of montelukast as first line therapy. Ensure that a bronchodilator is also provided for ‘as required’ use. Record an asthma control test score and provide the patient with a peak flow monitor to note peak flow readings before and during their trial of treatment. Make a firm diagnosis of asthma based on the response to treatment and the lung function tests. This is in line with the BTS/SIGN asthma guidelines.3 It does not meet the planned QOF requirement for spirometric diagnosis of asthma, but this has been postponed as a result of the pandemic.
Once again, history taking is the cornerstone of the diagnosis so a careful review of the symptoms, smoking history or other risk factors should be recorded. Importantly, the absence of any other symptoms which might reduce the likelihood of a straightforward COPD diagnosis, should be noted – e.g. orthopnoea, weight loss, oedema, haemoptysis. If there are any red flags, a full face-to-face review would be indicated. If the patient has a history of slowly increasing breathlessness and productive cough over a number of years, with a background of smoking or other risk factors, and no red flags, a COPD assessment test (CAT) score can be recorded and a trial of a bronchodilator can be initiated with a review planned for 2-4 weeks later. If the patient feels symptomatically better and the CAT test has improved, this supports a diagnosis of COPD, although it is not fully confirmed until the post-bronchodilator spirometry test has been completed and irreversible airflow obstruction has been demonstrated. Until this is possible, though, the patient has been treated and no harm has been done.
Excitingly, home spirometry testing is now a possibility.7 Using a specially developed hand-held spirometer, linked to a smart phone, there is now the potential for clinicians and patients to assess and monitor lung function and optimise treatment for their lung condition from the patient’s own home (See Box 1). This is a significant step forward and opens up new opportunities for remote, ongoing respiratory care.
KEY AREAS TO COVER IN A REMOTE ASTHMA REVIEW
Once the diagnosis of asthma has been made, reviews should be carried out at least once a year, although there is an argument for doing this more frequently.8
When carrying out an asthma review, it is important to consider the aims and objectives of the review. For asthma, we should be aiming for people having few or no symptoms, on the minimum amount of medication thus maximising their risk: benefit ratio.3 People living with asthma should be supported to implement both pharmacological and lifestyle interventions. Thus, in a standard face-to-face review, an assessment should be made of any symptoms, recent exacerbations, use of preventer medication and the need for reliever medication. Inhaler technique should also be checked at each review and lung function may be assessed. In a remote review, particularly if carried out via a video consultation, it is perfectly possible to cover all of these areas.
A simple calculation of medication use can be made before starting the remote asthma review by looking at which preventer they are on, how many puffs per day they have been prescribed and whether they are getting through the number of inhalers anticipated. For example, if the patient is taking a combination inhaler at the rate of 2 puffs bd i.e. 4 puffs in total per day, then a 120-puff inhaler will last one calendar month. It is then just a case of counting how many inhalers were collected in the past year, and that number should be twelve. If they are using less, they may have stepped down to 1 puff bd if their asthma is well controlled. Alternatively, their adherence may be poor. Conversely, if they are using more than 12 inhalers, this may be because they are using the maintenance and reliever therapy (MART) regime and are using extra doses for symptom relief. This is perfectly acceptable as long as they are not using too many additional doses, in which case a full review of their asthma management is needed. For those patients who are using a standard inhaled corticosteroid inhaler with a blue reliever inhaler, the same calculation should be carried out along with an assessment of reliever use. According to the BTS/SIGN guidelines, reliever inhalers should not be needed any more than 3 times a week maximum, which will mean that no more than two relievers are needed per year.3 Checking to see how many relievers have gone out in the past 12 months can help to establish any overuse, and when compared with the number of preventer inhalers going out, can help to inform the clinician as to why so much reliever is needed. This means that the clinician is prepared for these discussions when the consultation starts.
Evaluating the appropriateness of remote consultations in achieving these aims
Of the areas identified as being important as part of the asthma review, all can be addressed in a remote consultation, whether that is carried out by telephone, by video or through a group video consultation.
It is very important to take a non-judgemental approach to the consultation, once the preventer/reliever ratio has been ascertained. Some people will order more than 2 relievers because they have lost one, or because their child has two homes, one with each parent, or because they like to keep one in different places – home, school or work, sports bag etc. Consultations should begin with warm greetings, a general catch up on the patient’s holistic health, especially at this time, before launching into the asthma review and interrogating someone about perceived mismanagement of the condition.
A full and spontaneous discussion of the key areas can be made simply by asking people how their asthma has been lately. My own approach to assessing people’s asthma and their knowledge of how to self-manage, whether face-to-face or remotely, uses a three-question approach, which I refer to as the ‘Key Three’:
1. ‘What does good asthma control feel like to you?’
2. ‘How do you know if your asthma control is sliding?’
3. ‘What do you do if this happens?’
The three key questions can be backed up with more specific questions if needed, based on the RCP 3 questions and the Asthma Control Test (ACT).9,10 These more closed questions can all be included in an informal way during as you chat with the patient:
‘So how have things been with your asthma over the past few weeks?’
‘Would I be right in thinking that you are not waking at night at all, or is that still happening at times? Are you finding your asthma interferes with day-to-day life?’
‘On the basis of what you’ve mentioned during our chat, how often are you needing your blue rescue inhaler?’
This broad but natural approach enables the clinician to identify any reported symptoms, any history of recent exacerbations, as well as the actual use of preventer medication and the need for reliever medication, and more importantly why they are using their reliever.
Inhaler technique should also be checked at each review and this can be done as part of the video consultation, so make sure the patient has their inhaler to hand. People can also be directed towards the Asthma UK inhaler videos,11 which gives both parties the chance to consider other areas of the website, such as the section on personalised asthma action plans. Through the platform used in my own surgery, I can send direct links to websites, specific videos and other resources and I can also include a personalised asthma action plan, built using the information gleaned from our discussion. In many ways, remote consultations offer easier and more convenient ways to share information. Lung function may be assessed using home peak flow monitors and lifestyle interventions such as smoking cessation, dietary advice and discussions about physical activity levels can be carried out remotely.
Overall, then, it is entirely possible to work with the person with asthma remotely and carry out a thorough review in a relaxed, informal and personalised way. For many people with asthma the option of having a remote review will be very welcome and more in keeping with the 21st Century online living, such as banking and shopping.
KEY AREAS TO COVER IN A REMOTE COPD REVIEW
Just as with asthma, it should be possible to complete the key aspects of a COPD review in a remote consultation. The COPD Assessment Test (CAT) can be a good place to start to find out about symptoms and how COPD is impacting on day to day life.12 COPD questionnaires can be sent via the remote consultation platform in many cases, and it is important not to underestimate how tech-savvy older people are becoming, not least because of the pandemic.
Once symptoms have been evaluated, current medication should be reviewed to ensure that symptoms and exacerbation risk are used to inform the most appropriate medication for the patient, based on either GOLD guidance or NICE.4,5 Pre-pandemic there were extensive discussions about the role of inhaled corticosteroids (ICS) in COPD and many people living with COPD were having their ICS-containing inhalers reviewed. Research has demonstrated that they are useful for reducing exacerbations, but that the risk: benefit ratio should be considered carefully for each individual.13 Both GOLD and NICE describe the circumstances in which an ICS should be prescribed in COPD and suggest that people who have been on an ICS-containing inhaler for years, possibly inappropriately, should have a review to debate whether to stop the ICS component.4,5 Nonetheless, the advice during the pandemic is not to step down. However, stepping up should be considered if people are suffering from increased symptoms or exacerbations. As a simple rule of thumb, their inhaled medication can be increased as follows:
*LABA – long acting B2 agonist
**LAMA – long acting muscarinic antagonist
As always with inhaled therapy, consideration should be given to the device as well as the drugs. The Asthma UK inhaler videos cover treatments for COPD as well as asthma, so people with COPD should be encouraged to view the video for their device on this website. In a video consultation, the GPN can demonstrate the device and technique and once the medication has been prescribed, the patient’s technique can also be observed via video link.
Smoking status should be reviewed as this may have changed during the period of lockdown – some people may have started smoking again, current smokers may have increased their intake, and some people will have used this opportunity to stop smoking. For those people who need help with smoking cessation, the National Centre for Smoking Cessation and Training has produced guidance on virtual smoking cessation support to implement in practice.14
People should be reminded about the importance of flu and pneumonia jabs and should be reassured that all infection control measures will be put in place for vaccinations to be given safely. If a second wave of coronavirus hits, reducing the burden that flu puts on the NHS will be another way to protect the NHS and save lives. Healthcare professionals should consider their own role in this by ensuring that they too have their flu jab in order to protect the NHS and save lives.
Pulmonary rehabilitation is an important part of COPD management, but at the moment, classes cannot take place face-to-face. However, virtual group sessions are possible and may also help to support people who are feeling isolated by the pandemic and who may be shielding if they have severe COPD. GPNs may like to think about how they might introduce group video meetings for people with long term conditions such as COPD to meet the physical and emotional needs of these patients.
Lung function tests offer little benefit for people who have a firm and accurate diagnosis of COPD and so the requirement for an FEV1 measurement has been removed from the Quality Outcomes Framework.15 Significant changes in lung function are likely to be accompanied by meaningful changes in symptoms so routine monitoring of lung function is not needed in a standard COPD review, and is certainly not necessary in the current pandemic. A far better use of time would be to listen to the patient’s story during the review, note any changes in the CAT score and tailor the review to the individual’s needs.
Pulse oximetry may be useful, however, as gradual reductions in oxygen saturations (SATs) may occur over time, and which could be missed if SATs are not measured. In COVID-19, asymptomatic hypoxia has been noted to be associated with poorer outcomes.16 There has been an increase in the numbers of people buying or accessing home pulse oximeters and this may help people to self-manage more effectively, although there are some concerns as to whether the quality of some personal meters is reliable enough. Overall, though, they can be seen as an adjunct to monitoring symptom changes in managing COPD.
IDENTIFYING RESPIRATORY PATIENTS WHO CAN BE REVIEWED REMOTELY
As well as the annual review, earlier reviews at 3 or 6 months can easily be carried out remotely, especially if the relevant monitoring equipment is available to the patient. Those with more severe COPD should be reviewed more often than annually, and a quarterly remote review may be easier for both the patient and the clinician, especially if it is a video consultation where the patient can be observed for breathlessness, skin colour and oedema. Remote reviews could also take place following initiation of a new inhaler treatment or chest clearance device to check for evidence of benefit. Remote consultations are also ideal for people who find it hard to get into the surgery because they are housebound or work away. Some people will still prefer face-to-face once lockdown restrictions have been lifted, however, but people should be encouraged to consider whether telephone, video or even group video consultations would work better for them for at least some of their contacts with the surgery in the long term.
IMPLEMENTING GOOD QUALITY, HOLISTIC RESPIRATORY CARE
Examples of how remote consultations might work are given here.
Case study 1
Tim is a 32-year-old electrician who has had asthma for 22 years and is treated with budesonide 400mcg daily. He has been laid off from work since lockdown and his face-to-face asthma review appointment had to be cancelled. He was offered a remote review instead. His best peak flow reading in the past 2 years was 500l/min. He reported that during lockdown he had been exercising much more than he normally would and had rediscovered his rowing machine, bought 2 years ago and hardly ever used. However, he had noticed that he developed a wheeze and cough towards the end of his exercise session, which persisted for half an hour or so after stopping the exercise. He had checked his PEFR and had noticed that it dropped gradually during this time, reaching a low of 300l/min, but rising again after taking 2-4 puffs of his reliever inhaler. The GPN noted this story and carried out an asthma control test10 before recommending a step up in his asthma treatment to a low dose ICS/LABA. She showed him some inhalers and he had a look at the Asthma UK website before making his choice. The nurse prescribed the selected inhaler, reiterated how to take it and discussed an appropriate asthma management plan with Tim. She reviewed him a week later to see how he was getting on, and again 2 weeks later when he said that his symptoms had completely resolved. She checked his technique again via the video consultation and he showed her his PEFR diary, which showed that he now had a new best PEFR of 560l/min.
Case study 2
Gordon, age 73, has had COPD since he was 65. He is treated with a LAMA but described being increasingly breathless over the past 8 weeks. After a thorough video assessment for co-morbidities, and after assessing his current inhaler technique, the GPN prescribed a dual bronchodilator for Gordon, via the same device he was already using for his LAMA. Gordon admitted that, having given up smoking earlier this year, he had started again just last month. He was happy to discuss his options for smoking cessation therapy and support with the nurse and was now having two-weekly remote review to get him back on the road to quitting.
Remote consultations offer Tim and George the opportunity to discuss how they are feeling physically and emotionally as the impact of the pandemic and lockdown may lead to poor health behaviours with regard to diet, activity levels, smoking and alcohol intake – all of which may impact on respiratory health. A useful source of support may be via patient support websites or apps, to help them feel connected to people who may be in the same boat.
Face-to-face consultations in the future should include a full review of inhaler technique, including assessment of inspiratory flow rate to ensure this is correct for the device being used. For the moment, however, there is a great deal that can be done to keep people living with respiratory conditions such as asthma and COPD as well as possible both physically and psychologically, until normal service is resumed.
The key areas that should be covered in a respiratory review can also be addressed in a virtual consultation. Remote consultations offer a real opportunity to support respiratory patients who are unable to visit the surgery, both as a result of the pandemic and in the future. For many people, including clinicians, being thrust into the new world of remote consultations has opened up new opportunities to work differently and more efficiently in the future.
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3. BTS/SIGN 2019 British Guideline on the Management of Asthma https://www.brit-thoracic.org.uk/quality-improvement/guidelines/asthma/
4. Global Initiative for Chronic Obstructive Lung Disease (2019) Global Strategy for the diagnosis, management and prevention ofChronic Obstructive Pulmonary Disease – 2020 report Available from https://goldcopd.org/wp-content/uploads/2019/11/GOLD-2020-REPORT-ver1.0wms.pdf
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11. Asthma UK. How to use your inhaler; 2019 https://www.asthma.org.uk/advice/inhaler-videos/
12. Jones PW, Harding G, Berry P, et al. Development and first validation of the COPD Assessment Test. Eur Respir J 2009;34:648–654.
13. Tashkin DP, Strange C. Inhaled corticosteroids for chronic obstructive pulmonary disease: what is their role in therapy? Int J Chron Obstruct Pulmon Dis 2018;3:2587–2601. https://doi.org/10.2147/COPD.S172240
14. National Centre for Smoking Cessation and Training. Remote consultation guidance; 2020 https://www.ncsct.co.uk/publication_Remote_consultations.php
15. Primary Care Respiratory Society. GP contract introduces key respiratory QOF changes; 2019 https://www.pcrs-uk.org/news/gp-contract-introduces-key-respiratory-qof-changes
16. Ferenchick GS, Ferenchick HRB. Silent Hypoxemia' and Other Curious Clinical Observations in COVID-19; 2020 https://www.medscape.com/viewarticle/928803
RGN MSc MA QN
Nurse Practitioner Mann Cottage Surgery, Moreton in Marsh
Policy Forum member,
Primary Care Respiratory Society
Asthma Lead, Association of Respiratory Nurse Specialists
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