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State of the art review
Respiratory follow-up of patients with COVID-19 pneumonia
  1. Peter M George1,2,
  2. Shaney L Barratt3,4,
  3. Robin Condliffe5,
  4. Sujal R Desai6,
  5. Anand Devaraj6,
  6. Ian Forrest7,
  7. Michael A Gibbons8,
  8. Nicholas Hart9,
  9. R Gisli Jenkins10,
  10. Danny F McAuley11,
  11. Brijesh V Patel12,
  12. Erica Thwaite13,
  13. Lisa G Spencer13
  1. 1 Interstitial Lung Disease Unit, Royal Brompton and Harefield NHS Foundation Trust, London, UK
  2. 2 National Heart and Lung Institute, Imperial College London, London, United Kingdom
  3. 3 Department of Respiratory Medicine, North Bristol NHS Trust, Bristol, UK
  4. 4 University of Bristol School of Clinical Science, Bristol, UK
  5. 5 Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK
  6. 6 Department of Radiology, Royal Brompton and Harefield NHS Foundation Trust, London, UK
  7. 7 Department of Respiratory Medicine, Royal Victoria Infirmary, Newcastle upon Tyne, UK
  8. 8 Department of Respiratory Medicine, Royal Devon & Exeter NHS Foundation Trust, Exeter, UK
  9. 9 Lane Fox Respiratory Service, Guy’s & St Thomas’ NHS Foundation Trust, London, UK
  10. 10 Centre for Respiratory Research, University of Nottingham, Nottingham, UK
  11. 11 Intensive Care Unit, Queen"s University Belfast, Belfast, UK
  12. 12 Department of Anaesthetics, Pain Medicine & Intensive Care, Imperial College London, London, UK
  13. 13 Aintree University Hospitals NHS Foundation Trust, Liverpool, UK
  1. Correspondence to Dr Peter M George, Interstitial Lung Disease Unit, Royal Brompton and Harefield NHS Foundation Trust, London, UK; p.george{at}rbht.nhs.uk; Dr Lisa G Spencer; lisa.spencer{at}liverpoolft.nhs.uk

Abstract

The COVID-19 pandemic has led to an unprecedented surge in hospitalised patients with viral pneumonia. The most severely affected patients are older men, individuals of black and Asian minority ethnicity and those with comorbidities. COVID-19 is also associated with an increased risk of hypercoagulability and venous thromboembolism. The overwhelming majority of patients admitted to hospital have respiratory failure and while most are managed on general wards, a sizeable proportion require intensive care support. The long-term complications of COVID-19 pneumonia are starting to emerge but data from previous coronavirus outbreaks such as severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) suggest that some patients will experience long-term respiratory complications of the infection. With the pattern of thoracic imaging abnormalities and growing clinical experience, it is envisaged that interstitial lung disease and pulmonary vascular disease are likely to be the most important respiratory complications. There is a need for a unified pathway for the respiratory follow-up of patients with COVID-19 balancing the delivery of high-quality clinical care with stretched National Health Service (NHS) resources. In this guidance document, we provide a suggested structure for the respiratory follow-up of patients with clinicoradiological confirmation of COVID-19 pneumonia. We define two separate algorithms integrating disease severity, likelihood of long-term respiratory complications and functional capacity on discharge. To mitigate NHS pressures, virtual solutions have been embedded within the pathway as has safety netting of patients whose clinical trajectory deviates from the pathway. For all patients, we suggest a holistic package of care to address breathlessness, anxiety, oxygen requirement, palliative care and rehabilitation.

  • pneumonia
  • interstitial fibrosis
  • pulmonary embolism
  • viral infection

This article is made freely available for use in accordance with BMJ’s website terms and conditions for the duration of the covid-19 pandemic or until otherwise determined by BMJ. You may use, download and print the article for any lawful, non-commercial purpose (including text and data mining) provided that all copyright notices and trade marks are retained.

https://bmj.com/coronavirus/usage

https://doi.org/10.1136/thoraxjnl-2020-215314

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    Footnotes

    • Twitter @DrPeteGeorge, @GibboILD, @NickHartThorax

    • PMG and LGS contributed equally.

    • Contributors PMG and LGS wrote the first draft. All authors contributed to the literature search, writing of the manuscript and approval of the final version.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests PMG reports grants, personal fees and non-financial support from Boehringer Ingelheim, personal fees and non-financial support from Roche Pharmaceuticals, personal fees from Teva, outside the submitted work. SLB reports personal fees from Boehringer Ingelheim, outside the submitted work. RC reports he has received honoraria for advisory boards and lecturing from Bayer pharmaceuticals. SRD reports personal fees from Boehringer Ingelheim, personal fees from GSK, outside the submitted work. AD reports personal fees from Boehringer Ingelheim, personal fees from GSK, personal fees from Galapagos, personal fees from Galecto Biotech, outside the submitted work. IF reports personal fees from Boehringer Ingelheim, from Roche Ltd, outside the submitted work. MAG has nothing to disclose. NH reports unrestricted grants from Philips and Resmed outside the area of work commented on here with the funds held and managed by Guy’s & St Thomas’ NHS Foundation Trust; financial support from Philips for development of the MYOTRACE technology that has patent approved in Europe and US outside the area of work commented on here; personal fees for lecturing from Philips-Respironics, Philips, Resmed, Fisher-Paykel outside the area of work commented on here; NH is on the Pulmonary Research Advisory Board for Philips outside the area of work commented on here with the funds for this role held by Guy’s & St Thomas’ NHS Foundation Trust. GJ reports grants from Astra Zeneca, grants from Biogen, personal fees from Boehringer Ingelheim, personal fees from Daewoong, personal fees from Galapagos, grants from Galecto, grants from GlaxoSmithKline, personal fees from Heptares, non-financial support from NuMedii, grants and personal fees from Pliant, personal fees from Promedior, non-financial support from Redx, personal fees from Roche, other from Action for Pulmonary Fibrosis, outside the submitted work. Outside the submitted work, DFM reports personal fees from consultancy for GlaxoSmithKline, Boehringer Ingelheim and Bayer, Outside the submitted work, his institution has received funds from grants from the UK NIHR, Wellcome Trust and others. In addition, DFM is one of the four named inventors on a patent US8962032 covering the use of sialic acid-bearing nanoparticles as anti-inflammatory agents issued to his institution, The Queen’s University of Belfast http://www.google.com/patents/US8962032. This has no direct impact on the contents of the manuscript. BP reports personal fees from GSK, grants from Mermaid Care A/C, grants from ESICM, grants from Royal Brompton & Harefield Charity, grants from European Commission, grants from Academy of Medical Sciences, outside the submitted work. LGS reports personal fees from Roche and Boehringer Ingelheim, other from Roche and Boehringer Ingelheim, other from Boehringer Ingelheim, outside the submitted work.

    • Patient consent for publication Not required.

    • Provenance and peer review Not commissioned; externally peer reviewed.