A new model of care is urgently needed for follow up of survivors of COVID-19 who had severe acute disease requiring breathing support, a leading respiratory physician says.
Professor Peter Wark, of the John Hunter Hospital in Newcastle, says the COVID-19 pandemic has meant that a large number of Australians have experienced serious pneumonia in a short period of time, and the healthcare system is unprepared to deal with the long term respiratory consequences.
He says there will be thousands of patients who were hospitalised with acute severe COVID-19 who develop chronic breathlessness, of whom about one in five will have impaired lung function.
In a submission to the parliamentary inquiry into long COVID he argues that a standardised plan is needed for review of patients hospitalised with COVID-19, with provision for objective lung function testing and referral pathways to specialist respiratory services.
The respiratory consequences of long COVID-19 will also benefit from objective evidence-based guidelines, such as the living guidelines that have been developed for acute COVID-19, he adds.
In his submission Professor Wark says there should be routine specialist respiratory follow-up at three months after hospital discharge for survivors of COVID-19 who required respiratory or breathing support, either in ICU or with ward-based care.
With large numbers of people likely to develop long COVID, Professor Wark says it is important to have a plan for objective assessment of breathlessness and lung function, to avoid over-investigation and inappropriate interventions.
He advises assessment of breathlessness severity using a validated tool such as the mMRC scale or the Dyspnoea-12 score.
“In those with breathlessness initial assessment should include lung function, that needs to include both spirometry and a measurement of the gas transfer factor (DLCO), in a pulmonary function laboratory. Spirometry alone will not have sufficient sensitivity,” he writes.
Patients found to have interstitial lung disease following COVID-19 should be followed up by a respiratory physician, he adds, where possible assessed in a multidisciplinary interstitial lung disease clinic.
To cope with the large numbers of people expected to have chronic respiratory symptoms after COVID-19, Professor Wark says there is a need to develop education programs and self-management approaches, with escalation from community care to specialist services where needed.
However he notes that there is currently very little evidence to inform the management of people with persistent breathlessness after COVID-19, with only one RCT of a home-based telerehabilitation programme showing some benefit in perceived dyspnoea and exercise tolerance.
While pulmonary rehabilitation could be offered to patients that fit these criteria, a lack of access to programs and lack of MBS items to fund them will be a barrier in the Australian context, he warns.
“Caution should be used in recommending pulmonary rehabilitation programmes in individuals who had milder acute COVID-19 presentations and where there is not objective evidence of impaired exercise tolerance,” he advises.
“Access to these programmes is limited and they still need to meet the needs of patients with chronic lung disease for which they have been established.”
The submission also calls for more education of healthcare workers on long COVID and highlights the need for research into the assessment and management of the condition.
“The understanding of long COVID is rapidly evolving and the evidence base for current guidelines is weak. Long COVID will represent challenges for the Australian health system. It is a disease that will have many features that are unique, but equally will resemble the areas of chronic disease that we are experienced in managing. There is an urgent need to conduct high value clinical research into the assessment and management of long COVID-19. Australia should proactively seek to design, conduct and collaborate in these clinical trials,” he concludes.