Within telehealth there are a number of domains relevant to pulmonary care: telemonitoring, teleassistance, telerehabilitation, teleconsultation and second opinion calls. In the last decade, several ...studies focusing on the effects of various telemanagement programs for patients with chronic obstructive pulmonary disease (COPD) have been published but with contradictory findings. From the literature, the best telemonitoring outcomes come from programs dedicated to aged and very sick patients, frequent exacerbators with multimorbidity and limited community support; programs using third-generation telemonitoring systems providing constant analytical and decisionmaking support (24 h/day, 7 days/week); countries where strong community links are not available; and zones where telemonitoring and rehabilitation can be delivered directly to the patient’s location. In the near future, it is expected that telemedicine will produce changes in work practices, cultural attitudes and organization, which will affect all professional figures involved in the provision of care. The key to optimizing the use of telemonitoring is to correctly identify who the ideal candidates are, at what time they need it, and for how long. The time course of disease progression varies from patient to patient; hence identifying for each patient a ‘correct window’ for initiating telemonitoring could be the correct solution.
In conclusion, as clinicians, we need to identify the specific challenges we face in delivering care, and implement flexible systems that can be customized to individual patients’ requirements and adapted to our diverse healthcare contexts.
In this cross-sectional study, we evaluated skeletal muscle strength and physical performance (1-min sit-to-stand and short physical performance battery tests), dyspnea, fatigue, and single-breath ...counting at discharge from a postacute COVID department, in patients recovering from COVID-19 pneumonia who had no locomotor disability before the infection.Quadriceps and biceps were weak in 86% and 73% of the patients, respectively. Maximal voluntary contraction for quadriceps was 18.9 (6.8) kg and for biceps 15.0 (5.5) kg (i.e., 54% and 69% of the predicted normal value, respectively). The number of chair rises in the 1-min sit-to-stand test was 22.1 (7.3 corresponding to 63% of the predicted normal value), whereas the short physical performance battery score was 7.9 (3.3 corresponding to 74% of the predicted normal value). At the end of the 1-min sit-to-stand test, 24% of the patients showed exercise-induced desaturation. The single-breath counting count was 35.4 (12.3) corresponding to 72% that of healthy controls. Mild-to-moderate dyspnea and fatigue were found during activities of daily living (Borg scale score, median value = 0.5 0-2 and 1 0-2) and after the 1-min sit-to-stand (Borg scale score, median value = 3 2-5 and 1 0-3). Significant correlations were observed between muscle strength and physical performance indices (R = 0.31-0.69).The high prevalence of impairment in skeletal muscle strength and physical performance in hospitalized patients recovering from COVID-19 pneumonia without previous locomotor disabilities suggests the need for rehabilitation programs after discharge.
Progress in management has improved hospital mortality of patients admitted to the intensive care units, but also the prevalence of those patients needing weaning from prolonged mechanical ...ventilation, and of ventilator assisted individuals. The result is a number of difficult clinical and organizational problems for patients, caregivers and health services, as well as high human and financial resources consumption, despite poor long-term outcomes. An effort should be made to improve the management of these patients. This narrative review summarizes the main concepts in this field.
There is great variability in terminology and definitions of prolonged mechanical ventilation.There have been several recent developments in the field of prolonged weaning: ventilatory strategies, use of protocols, early mobilisation and physiotherapy, specialised weaning units.There are few published data on discharge home rates, need of home mechanical ventilation, or long-term survival of these patients.Whether artificial nutritional support improves the outcome for these chronic critically ill patients, is unclear and controversial how these data are reported on the optimal time of initiation of parenteral vs enteral nutrition.There is no consensus on time of tracheostomy or decannulation. Despite several individualized, non-comparative and non-validated decannulation protocols exist, universally accepted protocols are lacking as well as randomised controlled trials on this critical issue. End of life decisions should result from appropriate communication among professionals, patients and surrogates and national legislations should give clear indications.
Present medical training of clinicians and locations like traditional intensive care units do not appear enough to face the dramatic problems posed by these patients. The solutions cannot be reserved to professionals but must involve also families and all other stakeholders. Large multicentric, multinational studies on several aspects of management are needed.
In hospitalized patients recovering from the SARS-coronavirus-2 disease 19 (COVID-19), high prevalence of muscle weakness and physical performance impairment has been observed.
The aim of this study ...was to evaluate the effectiveness of pulmonary rehabilitation in these subjects in a real-life setting.
Retrospective data analysis of patients recovering from COVID-19, including those requiring assisted ventilation or oxygen therapy, consecutively admitted to an in-patient pulmonary rehabilitation program between April 1 and August 15, 2020. Short Physical Performance Battery (SPPB: primary outcome), Barthel Index (BI), and six-min walking distance were assessed as outcome measures.
Data of 140 patients were analyzed. After rehabilitation, patients showed improvements in SPPB {from: (median IQR) 0.5 (0-7) to 7 (4-10), p < 0.001} and BI (from 55 30-90 to 95 65-100, p < 0.001), as well as in other assessed outcome measures. The proportion of patients unable at admission to stand, rise from a chair and walk was significantly reduced (p < 0.00).
Pulmonary rehabilitation is possible and effective in patients recovering from COVID-19. Our findings may be useful to guide clinicians taking care of patients surviving COVID-19 infection.
Due to the exponential growth of the number of subjects affected by coronavirus disease 2019 (COVID-19), the entire Italian health care system had to respond promptly and in a very short time with ...the need of semi-intensive and intensive care units. Moreover, trained dedicated COVID-19 teams consisting of physicians were coming from different specialties (intensivists or pneumologists and infectiologists), while respiratory therapists and nurses have been recruited to work on and on without rest. However, due to still limited and evolving knowledge of COVID-19, there are few recommendations concerning the need in respiratory rehabilitation and physiotherapy interventions. The presentation of this paper is the result of a consensus promoted by the Italian societies of respiratory health care professionals who contacted pulmonologists directly involved in the treatment and rehabilitation of COVID-19. The aim was to formulate the more proper and common suggestions to be applied in different hospital settings in offering rehabilitative programs and physiotherapy workforce planning for COVID-19 patients. Two main areas of intervention were identified: organization and treatment, which are described in this paper to face the emergency.
There is evidence of short- and long-term impairment of physical performance in patients with COVID-19 infection, but a verification of measures of physical impairment in this condition is lacking. ...We reviewed the measures used to assess physical performance in these patients. Secondary targets were measures of exercise or daily life activities induced symptoms.
Medline, CINAHL, and Pedro databases were searched from January 2020 to February 2021 for articles in the English language. Two investigators independently conducted the search, screened all titles and/or abstracts based on the inclusion criteria and independently scored the studies. The quality of the studies was evaluated by two reviewers according to the NIH quality assessment tool for observational cohort and cross-sectional studies. Discrepancies were resolved through consensus.
Out of 156 potentially relevant articles, 31 observational studies (8 cross-sectional), 1 randomized controlled trial, and 1 protocol were included. The quality of most of the 31 evaluable studies was judged as low (11 studies) or fair (14 studies). Sample sizes of the studies ranged from 14 to 20,889 patients. among the 28 reported measures, Barthel Index (42.4% of studies), Six-Minute Walking Distance Test (36.4%), Short Physical Performance Battery (21.2%) and 1-Minute Sit-to-Stand (12.1%) were the most used. Fifteen% and 36% of studies reported exercise induced desaturation and dyspnoea when performing the assessments, respectively. Other exercise induced symptoms were fatigue and pain. Studies reported wide ranges of impairment in physical performance as compared to “reference” values (range of mean or median reported values vs “reference values”: 11–77 vs 100 points for Barthel Index; 11–22 vs 22–37 repetitions/min for 1m-STS; 0.5–7.9 vs 11.4 ± 1.3 points for SPPB; and 45–223 vs 380–782 m for 6MWT respectively).
This review found that a wide variety of functional status tests have been used, making comparisons difficult between studies. These measures show impairment in physical performance in COVID-19 patients. However, the quality of most of the studies was judged as low or fair.
Every day, we must make decisions that range from simple and risk-free to difficult and risky. Our cognitive sources' limitations, as well as the need for speed, can frequently impair the quality and ...accuracy of our reasoning processes. Indeed, cognitive shortcuts lead us to solutions that are sufficiently satisfying to allow us to make quick decisions. Unfortunately, heuristics frequently misguide us, and we fall victim to biases and systematic distortions of our perceptions and judgments. Because suboptimal diagnostic reasoning processes can have dramatic consequences, the clinical setting is an ideal setting for developing targeted interventions to reduce the rates and magnitude of biases. There are several approaches to bias mitigation, some of which may be impractical. Furthermore, advances in information technology have given us powerful tools for addressing and preventing errors in health care. Recognizing and accepting the role of biases is only the first and unavoidable step toward any effective intervention proposal. As a result, our narrative review aims to present some insights on this contentious topic based on both medical and psychological literature.
The estimated prevalence of ventilator-dependent individuals in Europe is 6.6 per 100 000 people. The increasing number and costs of these complex patients make present health organisations largely ...insufficient to face their needs. As a consequence, their burden lays mostly over families. The need to reduce healthcare costs and to increase safety has prompted the development of tele-monitoring for home ventilatory assistance.A European Respiratory Society Task Force produced a literature research based statement on commonly accepted clinical criteria for indications, follow-up, equipment, facilities, legal and economic issues of tele-monitoring of these patients.Many remote health monitoring systems are available, ensuring safety, feasibility, effectiveness, sustainability and flexibility to face different patients' needs. The legal problems associated with tele-monitoring are still controversial. National and European Union (EU) governments should develop guidelines and ethical, legal, regulatory, technical, administrative standards for remote medicine. The economic advantages, if any, of this new approach must be compared to a "gold standard" of home care that is very variable among different European countries and within each European country.Much more research is needed before considering tele-monitoring a real improvement in the management of these patients.
Noninvasive respiratory support (NIRS) has been diffusely employed outside the intensive care unit (ICU) to face the high request of ventilatory support due to the massive influx of patients with ...acute respiratory failure (ARF) caused by coronavirus-19 disease (COVID-19). We sought to summarize the evidence on clinically relevant outcomes in COVID-19 patients supported by NIV outside the ICU.
We searched PUBMED®, EMBASE®, and the Cochrane Controlled Clinical trials register, along with medRxiv and bioRxiv repositories for pre-prints, for observational studies and randomized controlled trials, from inception to the end of February 2021. Two authors independently selected the investigations according to the following criteria: (1) observational study or randomized clinical trials enrolling ≥ 50 hospitalized patients undergoing NIRS outside the ICU, (2) laboratory-confirmed COVID-19, and (3) at least the intra-hospital mortality reported. Preferred Reporting Items for Systematic reviews and Meta-analysis guidelines were followed. Data extraction was independently performed by two authors to assess: investigation features, demographics and clinical characteristics, treatments employed, NIRS regulations, and clinical outcomes. Methodological index for nonrandomized studies tool was applied to determine the quality of the enrolled studies. The primary outcome was to assess the overall intra-hospital mortality of patients under NIRS outside the ICU. The secondary outcomes included the proportions intra-hospital mortalities of patients who underwent invasive mechanical ventilation following NIRS failure and of those with 'do-not-intubate' (DNI) orders.
Seventeen investigations (14 peer-reviewed and 3 pre-prints) were included with a low risk of bias and a high heterogeneity, for a total of 3377 patients. The overall intra-hospital mortality of patients receiving NIRS outside the ICU was 36% 30-41%. 26% 21-30% of the patients failed NIRS and required intubation, with an intra-hospital mortality rising to 45% 36-54%. 23% 15-32% of the patients received DNI orders with an intra-hospital mortality of 72% 65-78%. Oxygenation on admission was the main source of between-study heterogeneity.
During COVID-19 outbreak, delivering NIRS outside the ICU revealed as a feasible strategy to cope with the massive demand of ventilatory assistance.
PROSPERO, https://www.crd.york.ac.uk/prospero/ , CRD42020224788, December 11, 2020.
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