Healthcare assessments have traditionally been undertaken during face-to-face clinical interactions. Social distancing requirements introduced to prevent community transmission of COVID-19 have resulted in much broader use of virtual care models. This document provides guidance about broader virtual basic respiratory assessment for patients with acute and chronic respiratory condition.
NSW Health and the NSW Agency for Clinical Innovation provide support for clinicians to transition to telehealth models of care. Each local health district has a telehealth manager or lead who can be contacted for help or advice.
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A rapid review of evidence on validated tools to assess respiratory illness via telehealth in published and grey literature was undertaken by the COVID-19 Critical Intelligence Unit on 15 April 2020. Google and PubMed were searched using the following terms:
Criteria for assessing evidence included: credibility of authors, inclusion of papers in high quality journals, availability of systematic reviews and evidence of validated tools.
Availability of evidence was limited; finding mainly prospective cohort and observational studies for telemedicine assessment, real time testing and accuracy of self-monitoring and clinical outcome patient surveys. No validated tools or studies were found for assessing dyspnoea by telephone or online video consultations, for remote monitoring of respiratory rate or for evidence of the accuracy of smartphone technology for measurement of oxygen saturation.
A further rapid evidence review was released on 2 June 2020 using Google and Twitter search terms:
The PubMed search cited evidence that whilst conducting physical examinations remotely by telehealth is recognised to be a challenge in clinical practice, there is evidence that telehealth assessments and monitoring can be carried out for a variety of respiratory illnesses. A systematic review found that forced expiratory volume, assessed daily by using a spirometer, was the most common modality of remote respiratory assessment in people with COPD.1 Other measurements included resting respiratory rate, respiratory sounds and end-tidal carbon dioxide level.
There are no validated tests for assessing breathlessness in acute primary care settings and insufficient published literature was found which provided detailed clinical guidance and instructions (a ‘how-to’) for conducting virtual respiratory assessments via telehealth. This resource gap has been acknowledged in other research.2,3 Some experts advise that screening include a questionnaire as part of the care delivery system.4
There is emerging evidence of increased usage of mobile technology to collect and send medical and healthcare data to an app, device or service including:
Australian and NSW Government sites were used to identify relevant policies that support the Guide.
A working group consisting of primary and acute care clinical and telehealth experts supported the development of the document. Consultation was sought from the Virtual Care, Primary Care, Community Health and Respiratory Communities of Practice prior to finalisation.
The guide is for clinicians undertaking basic or extended adult virtual respiratory assessment including:
Refer to inclusion criteria for patients who can appropriately receive care according to this guidance.
This guide supports virtual assessment of respiratory function. However, many patients will have comorbidities which need to be considered in the context of the respiratory assessment. A concurrent general assessment is necessary to place components of the respiratory assessment into context e.g. a raised heart rate in the context of marked anxiety.
A healthcare professional should assess whether virtual respiratory assessment is appropriate on an individual case by case basis.
General assessment should begin with a rapid assessment: Is the patient very sick or not so sick? Does the patient seem distressed?
The primary focus should be on any change in symptoms and placing the symptoms and clinical findings into the context of the patient’s medical history with the overall assessment, using open ended questions.
Whilst the guide to undertaking virtual respiratory assessment has been developed to assist clinicians to undertake basic respiratory assessment, where possible it should be read in partnership with other policy documents addressing clinical care of people with COVID-19, virtual care and infection control (Appendix 1).
The following criteria are adapted from the Delivering pulmonary rehabilitation via telehealth during COVID-19 guidance developed by the ACI Respiratory Network.5
A self-reported respiratory questionnaire suitable for assessing the patient’s perception of health-related quality of life (HRQL) can be used to help determine inclusion and exclusion criteria, as well as acting as a component of the rapid assessment.
The COPD Assessment TestTM (CAT) is a patient-reported questionnaire that can quantify the impact of COPD on the patient’s health.6 A recent systematic review confirmed that the CAT provides reliable measurement of health status for COPD and is responsive to change with treatment and exacerbations.7 Since 2013 the CAT has been incorporated as the preferred measure of symptomatic impact of COPD into clinical assessment schemes.
COPD Questionnaires are not validated for use in assessing acute viral respiratory illness, however the CAT does provide a helpful guide regarding HRQL when undertaken with COPD patients as part of the rapid virtual assessment (see Section 8 for rapid assessment process, and Appendices 3 and Appendices 4 for CAT questions and scoring).
Refer to the Recognition and management of patients who are deteriorating policy directive (PD2020_018) for further information.8
Red flag symptoms can indicate that the patient needs urgent medical assessment.8 It is important to consider within the context of the wider history, that many patients with chronic respiratory conditions, may have signs and symptoms which fall outside red flag parameters at rest, and therefore escalation pathways may not be appropriate.
Paediatric population groups are not within scope of this guide and palliative care and end of life care is not detailed in this document. Breathlessness at end of life is extremely common and assessment should be considered in association with end of life care planning.
Red flags include:
Referral pathway or presentation to ED is recommended in patients where red flags are identified
Refer to resource list for setting up telehealth in Appendix 2.
Refer to the ACI telehealth patient information sheet – Preparing for a virtual appointment
Patients should be asked specific questions regarding:
Additional patient history and observation measures can be made including:
The rapid evidence review found that there is no evidence to suggest that measuring a patient’s respiratory rate over the phone gives an accurate reading, and experts do not use such tests. The Roth Score is a tool in phone assessments for quantifying level of breathlessness, which is assumed to correlate to the level of hypoxia. It combines the maximal count reached and the time taken (starting from 1 to 30) during a single exhalation. However, predicting patient’s hypoxia over the phone using the Roth Score does not provide an accurate assessment and may lead to false reassurance.11
It is possible to measure respiratory rate via a good video connection. Video also allows a more detailed assessment and may prevent the need for an in-person visit.3 There is no current evidence that smartphone technology is accurate for the clinical measurement of oxygen saturation,8 but evidence is still emerging. It is possible to purchase a home pulse oximeter for home use.
Spirometry is the most commonly performed test for assessing respiratory function and is recognized as a valuable tool for identifying and managing chronic obstructive pulmonary disease (COPD), asthma and other disorders affecting the respiratory system.12 Spirometry use is dependent on the accuracy of the spirometer and the competence and knowledge of the operator in performing the test and interpreting the results. However, multiple studies of spirometry in primary care settings 13 have shown poor achievement of adherence to quality criteria, including a lack of knowledge and skill in spirometry performance, access to spirometry training and ongoing support, inability to maintain competency due to infrequent testing and insufficient maintenance and quality control (QC) of spirometers.
In the context of asthma, patient peak flow monitoring could also be undertaken via telehealth.
Adapted from COVID-19 - Guidance for community based health services including home visits
There are many pieces of equipment that are shared and allocated to patients (via community equipment Loan Pools). Provided equipment can be appropriately cleaned and disinfected between use, items can be reused.
If loan equipment is being used, it is the responsibility of the Local Health District equipment pool manager to ensure that any equipment provided for loan is clean and includes cleaning instructions as per the manufacturer guidelines. If in doubt, check with the individual organisation’s Infection Control team.
The device, casing and accessories must be cleaned appropriately before being given to the patient or family member, and after they have been returned.
Hand hygiene must be performed prior to and after touching or handling the device by the patient, health worker and any family member of the patient. When not in use, loan equipment must be stored securely and appropriately.
To clean mobile phones and tablets, unplug all cables and turn off. Using a 70% isopropyl alcohol wipe or Clorox disinfecting wipes, gently wipe the hard, nonporous surfaces of the tablet, such as the display, keyboard, or other exterior surfaces. Don’t use bleach (or cleaners containing hydrogen peroxide), window cleaners, household cleaners, compressed air, aerosol sprays, solvents, ammonia, or abrasives to clean.
Avoid getting moisture in any opening and don’t submerge the tablet in any cleaning agents.
Headsets need to be either cleaned or the shared components must be changed. Items such as these should be cleaned in between use with a detergent/ disinfectant - if this is not possible then they should be dedicated to a single person for use.
Adapted from Covid-19: Remote assessment in the Primary Care9
In good lighting:
Interpret self-monitored results with caution and in the context of your wider assessment.
The COPD Assessment TestTM (CAT) is a patientreported questionnaire that can quantify the impact of COPD on the patient’s health and quality of life.6
The CAT is not validated for use in assessing acute viral respiratory illness, however the following questions may provide a helpful guide when undertaken with COPD patients as part of the virtual rapid assessment (see Section 8).
See an electronic version of the CAT which includes automatic calculation.
Quantifies impact of COPD symptoms on patients’ overall health and quality of life.
The CAT is one component in clinical decision making, along with other considerations such as history of previous exacerbations and airflow limitation.
For all people with chronic respiratory conditions, smoking cessation, preventative care (e.g. annual flu/pneumococcal vaccinations) and reduced exposure to exacerbating risk factors are mainstays of management.
CAT scores may also worsen where a patient has stopped or is not taking their treatment effectively. Check inhaler technique as well as adherence to treatment. Where rapid disease progression is suspected, referral for specialist opinion may be required.
CAT Scores are calculated according to severity scale from COPD Assessment Test (CAT)
Patient Instructions for Borg Dyspnoea Scale
This is a scale that asks you to rate the difficulty of your breathing. It starts at number 0 where your breathing is causing you no difficulty at all and progresses through to number 10 where your breathing difficulty is maximal. How much difficulty is your breathing causing you right now?
Freecall 1800 654 301 or www.lungfoundation.com.au
Virtual Care Community of Practice: Respiratory Assessment Working Group
Communities of Practice:
Dr Nigel Lyons, Deputy Secretary, Health System Strategy and Planning
Clinicians undertaking basic or extended adult virtual respiratory assessment including: