Key learning points  

  • It can be difficult to distinguish between symptoms of COVID-19 infection and other causes of acute cough and breathlessness
  • Initial assessment should look for ‘red flags’ and the need for immediate hospital referral
  • Further assessment is aimed at determining causality (including the likelihood of COVID-19 infection) and severity of symptoms; video consultations may help with this
  • If face to face assessment is deemed necessary, even if the patient is considered ‘low risk’, full COVID-19 precautions should be taken
  • Remember to safety net and document your advice

Introduction

The advent of the COVID-19 pandemic has resulted in a significant shift towards the use of remote consultation.1,2 This article looks at the management of patients consulting remotely by telephone or e-consult (email or video consultation) in primary care with acute respiratory problems of cough and breathlessness and is based on a recent article on remote consultation and COVID-19,1,2 and a series of NICE rapid guidelines looking at management of COPD, severe asthma and community-acquired pneumonia in a COVID-19 pandemic.3-5

Assessment

The main causes of acute respiratory problems are summarised in Table 1.

Table 1: Causes of acute respiratory symptoms

Causes
Exacerbation of pre-existent respiratory disease (e.g. asthma, COPD)
Viral pneumonia (including COVID-19)
Influenza
Community-acquired bacterial pneumonia
Acute onset of new respiratory problem (e.g. asthma, inhaled foreign body)
Non-respiratory problems (e.g. cardiac problems, pulmonary embolism, anxiety)

Pre-consultation

Ideally the consulting practitioner should have time pre-consultation to establish the past medical history from the medical records and to set up video consultation (see below), if available.1 Practices should have systems in place so that patients who are deemed at high risk can be fast tracked to the duty healthcare professional. This might include ‘high risk’ patients with COPD or asthma or patients who present with chest pain and/or severe breathlessness. 

Initial assessment

Initial assessment should be directed at determining the severity of symptoms and the need for immediate hospital admission. Table 2 indicates red flag features necessitating the need for immediate hospital admission. A brief history should be taken to include the likelihood of possible COVID-19 infection.

Table 2: Red flag features indicating immediate hospital admission1,5

Red flags
Severe shortness of breath at rest or difficulty breathing (e.g. indrawing of intercostal muscles)
Pain or pressure in chest
Cold, clammy mottled skin
New onset confusion
Difficult to rouse
Blue lips or face
Coughing up blood (severity guiding urgency of admission)

History

If immediate hospital referral is not deemed necessary then a more detailed history can be taken to ascertain severity, likely aetiology of the symptoms and especially the likelihood of COVID-19 infection. 

  • Is there pre-existent disease, such as asthma or COPD? If so, are the current symptoms indicative of a flare up or are they different? What treatment has been tried already?
  • Are there features of a new acute problem, such as fever, productive cough, chest pain, risk factors for pulmonary embolism? 
  • Is there a likelihood of COVID-19 infection? Has the patient had recent contact, recent dry cough, fever or changes in taste and/or smell? 

Specific questions about the severity of breathlessness are:1,2

  • How is the breathing today?
  • Are you so breathless that you are unable to speak more than a few words?
  • Are you breathing harder or faster than usual when doing nothing at all?
  • Are you so ill that you’ve stopped doing all of your usual daily activities?

Examination

Video consultation can be useful in determining the appearance of the patient and their degree of breathlessness.2 Some patients will have peak flow meters and this reading compared to usual readings might be helpful (preferably observe the patient via video).2 Some patients and care homes might have access to pulse oximetry, and oxygen saturations of <92% (<88% in COPD patients) indicate a need for hospital admission.5 Patients falling outside of this category should continue to be monitored and considered for admission if there are additional factors (see above), which cause clinical concern.6

Further assessment

In some cases, face-to-face consultation may be deemed necessary.2 If a patient is deemed ‘low risk’ then full COVID-19 precautions, including personal protective equipment (PPE), optimal hand hygiene and frequent surface decontamination, should be taken before and during examination.3,7-9 For current PPE advice, click here.9

Management

Patients should be managed according to disease-specific guidelines. Hospital admission is indicated if there is clinical concern (see above) with a lower threshold for admission if there are adverse psychosocial circumstances, significant comorbidities or previously severe exacerbations. Patients may have advance care plans in place which would determine palliative care in the community rather than active care.1 

Safety-netting advice

There is a significant risk of pneumonia in susceptible patients in the 2 weeks following COVID-19 infection.1 It is vital that patients are given advice about signs of deterioration and who to contact – this advice should be documented.1

Dr Kevin Gruffydd-Jones, GP, Box Surgery, Wiltshire

This project was initiated and funded by Teva Respiratory. Teva have had no influence over content. Topics and content have been selected and written by independent experts.

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