Questions and Answers from the Webinar: COVID-19: The AARC, Telerespiratory, and Educators Weigh In.

Please note, with the unprecedented demands COVID-19 has placed on our profession, the distribution of certificates for the CEU will be slightly delayed.  We apologize for this.  As you can imagine, we are doing our best to be responsive to the needs of the participants, but our first priority has to be responding to the immediate needs of this pandemic.  

We have done our best to post and answer all of the questions posted in the webinar below.  Please note that there are a few questions to Shawna and Sarah that do not have an answer.  We will post the answers as we get them.

Clinical Practice Questions

Q: what are we doing about performing PFT s :Comments below are taken from the Diagnostic section of AARConnect:

A: Infection Prevention Team, we have been (obviously) extra conscientious about hand hygiene and monitoring for staff and patient symptoms. We have also been instructed to wear masks, eye shield and gloves when performing PFTs, given that PFTs can be cough-inducing, i.e. being at higher risk of exposure.

We have also instructed our team to wear masks, eye shields and gloves when performing PFTs. Additional screening has been put into place prior to testing. We are postponing all testing in patients who have been symptomatic (flu-like symptoms) within 21 day prior to the appointment. If a patient comes in symptomatic, we are obtaining a temperature and following our emergency room protocol.

Calling patients prior to testing and asking health screening questions to help determine if they should come in for testing or not.

I have also been hearing many health organizations are looking to halt OP testing of any sort if it is routine or does not have an impact on other treatment or surgical interventions.

Q: For patients who are having a hard time oxygenating, is proning appropriate?

A: There are good article references in the AARConnect “Resources for COVID-19” community if you are an AARC member. Also from what I have been reading using ventilation/oxygenation techniques as you would for any patient would be appropriate.

Q: RT can perform PCR NASOPHRAYNGEAL swap?

A: This would be up to your facility & lab policy.

Q: How many days Do patients is expected to remain intubated?

A:  This will vary from patient to patient due to all the individual variables factoring into the specific case.

Q: Any idea what percentage of infected patients are experiencing respiratory symptoms? 

A: I refer you to the CDC.gov  web page for the most up to date information. I have not seen the statistics presented exactly as you have asked in your question.

Q: should outpatient, routine PFTs be postponed until further notice? 

A: This is unfolding in realtime and would look to your internal organizations plans and following the CDC.gov web site. I have heard of some OP diagnostic centers considering postponing testing unless essential for treatment determination.

Q: Is there a special protocol for COVID-19 patients?

A: The CDC.gov has great information and suggested guidelines. https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html

Q: What is the course of treatment?!? My hospital does not see using NIV or HFNC has producing droplets (which I’ve always disagreed with) and are not following the proper precautions?!? How do we treat these patients when everyone says something different?!?

A: One of our speakers referenced an article from China indicating that NIV was not very effective in treating some of the patients and they also discussed using a “helmet” patient interface with NIV. 

Q: Do these patients need to be in a negative flow environment?

A: CDC says to use airborne infection isolation rooms only when a known COVID-19 infection + aerosol generating procedures 

Q: Still use multi canister mdi’s?

A: What I have seen is that protocols for use of multi-canister mdi are not applicable for patients in isolation.

Q: Still use multi canister inhalers?

A: What I have seen is that protocols for use of multi-canister mdi are not applicable for patients in isolation.

Q: Hand held nebulizer or MDI??? Which is best practice for covid19?

A: Because of the droplet transmission, it is recommended to minimize aerosols that may carry and disperse aerosols. It would be reasonable to consider non-aerosol generating therapeutic inter-change.

Q: What do we know about children and COVID?

A: Refer to CDC.gov, however children have not been affected as much compared  with influenza viruses 

Q: What is the clinical recommendations for treating COVID 19? Are they saying not to use HFNC and NIV?

A: Due to the potential aerosol/droplet dispersion of these modalities, some references discourage their use.

Q: So is the recommendation to not use nebulizers and just use MDI and DPI on these patients?

A: Because of the droplet transmission, it is recommended to minimize aerosols that may carry and disperse aerosols. It would be reasonable to consider non-aerosol generating therapeutic inter-change.

Q: Is it worth using NIV, HFNC, aerosols? Or just going straight to intubation? 

A: Each patient presents a unique situation, the decision to intubate, or not, will depend on a number of factors specific to each patient.  Using evidence based criteria in determining the appropriateness of intubation in any specific situation is recommended. 

Q: How do you stop physicians from ordering unneeded treatments to this population. Bronchodilators does not fix hypoxia.

A: This is certainly a challenge…even when protocols are utilized! If your ordering physician is receptive to seeing information present the treatment guidelines from the CDC.

Q: What is the CXR pattern for viral PNA?

A: The following may be a good resource: https://www.itnonline.com/content/how-does-covid-19-appear-lungs

Q: How to handle the ventilator?

A: Like disinfection the surface & equipment etc.. Look to CDC.gov for guidance and your standard procedures

Q: After intubation how could disinfect the scope, blade,other misc equipment.?

A: Look to CDC.gov for guidance and your standard procedures

Q: Shawna, I know you recommended MDIs and DPIs in place of SVNs. For those that can’t do those and need a SVN would putting an HME (viral/ antibacterial filter on the end of the SVN a good idea to eliminate droplets in the air?

A: Shawna Strickland@Victoria Hodges – I believe the advice is to put the patient in a negative pressure (airborne infection isolation room) during that procedure if possible.

Q: How do we confirmed in the lab test if it is ncov? What kind of point of care testing ? Thank you & please take care.

A: I refer you to CDC.gov the CDC and private labs are ramping up production of testing kits with daily updates. https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html#investigational-therapeutics

Q: Alos niños los está afectando y si esos ninos tenían todas sus vacunas (Translation: Children are affecting them and if those children had all their vaccines)

A: https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html#investigational-therapeutics 

Q: Los pacientes adultos que fueron afectados tenían sus vacunas completas y los que fallecieron las tenían también ,se que no hay vacuna para covide 19pero existe relación en la Morbi mortalidad de esto. (Translation: The adult patients who were affected had their vaccines complete and those who died had them too, I know there is no vaccine for covide 19 but there is a relationship in the Morbi mortality of this)

A: I don’t know that there has been enough evidence reported to date regarding other vaccinations. Underlying chronic conditions has a significant factor affecting the mortality rate in conjunction with the age of the patient. https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html#investigational-therapeutics

Q: Is there a recommendation for facilities whose therapist who care for NICU/pediatric and adult populations? Should therapists be dedicated to one age population?

A: Facility internal resources will likely be the determining factor. 

Q: As i said before I work as home care rt, do you think we can spread it if go from one home to another?

A: https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-home-care.html

Q:  How about using nebulization anti viral – specific for RNA viruses ? What’s your opinion using in-line nebulization of antiviral – RNA like Ribavirin and Zanamivir ? or other Anti-viral – RNA virus

A: I personally have not seen data to support this and refer you to CDC.gov guidelines https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html#investigational-therapeutics

Q: Is there a need to put a patient into a negative pressure room?

A: CDC recommends this when possible https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html#investigational-therapeutics

Q: Covid19 recovery patient do they have recurrent ?

A: I believe I saw a repeat case in China from one of the published studies on CDC.gov.

Q: How about checking IgM and IgG covid 19 ?

A: I believe this testing is pending FDA approval at this time 

 

CDC Questions:

Q: Is there any idea about how widespread this could become in coming weeks/months?

A: https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html#investigational-therapeutics

Q: I heard mix things coming from different source are we verified that if it is airborne and contact ? Or is it strictly airborne?

A: https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html#investigational-therapeutics

Q: How should pregnant RRTs protect themselves while taking care of pt in hospital?

A: CDC is saying we don’t know if pregnant women are more susceptible to the coronovirus

https://www.cdc.gov/coronavirus/2019-ncov/prepare/pregnancy-breastfeeding.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fspecific-groups%2Fpregnancy-faq.html 

Q: Is it known how many days post symptom presentation the inflammatory response peaks?

A: Information is more specific to symptom changes, the CDC has some more information on this here; https://www.cdc.gov/coronavirus/2019-ncov/hcp/disposition-hospitalized-patients.html

Q: How long do these droplet particles last on solid surfaces?

A: CDC indicates the virus may live for hours to possibly days depending on the surface. https://www.cdc.gov/coronavirus/2019-ncov/prepare/cleaning-disinfection.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fcommunity%2Fhome%2Fcleaning-disinfection.html

Q: Is there a time line for how long the virus lasts or at what day it would peak?

A: Repeat, https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html

Q: I might have missed this slide but, the virus supposedly has an incubation period 5-10 days or so, what of the chances of contracting the virus of an asymptomatic host if you don’t wear a mask if you’re not sick?

A: I don’t know if this is known however here is a good link you may find useful; Healthcare FAQ’s: https://www.cdc.gov/coronavirus/2019-ncov/hcp/faq.html

Q: Of the patients that have confirmed with COVID-19, What is the instance of patients needing respiratory support (ie invasive ventilation)?

A: Approximately 20-30% of hospitalized patients with COVID-19 and pneumonia have required intensive care for respiratory support.[2–3] Compared to patients not admitted to an intensive care unit, critically ill patients were older (median age 66 years versus 51 years), and were more likely to have underlying co-morbid conditions (72% versus 37%). [3] Among critically ill patients admitted to an intensive care unit, 11–64% received high-flow oxygen therapy and 47-71% received mechanical ventilation; some hospitalized patients have required advanced organ support with endotracheal intubation and mechanical ventilation (4–42%).[3–4,9] A small proportion have also been supported with extracorporeal membrane oxygenation (ECMO, 3–12%).[3–4,9] Other reported complications include cardiac injury, arrhythmia, septic shock, liver dysfunction, acute kidney injury, and multi-organ failure. Post-mortem biopsies in one patient who died of ARDS reported pulmonary findings of diffuse alveolar damage. [14]; 

https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html

Q: How long are you contagious? How long should we self-quarantine?

A: Resolution of fever, without use of antipyretic medication

Improvement in illness signs and symptoms

Negative results of an FDA Emergency Use Authorized molecular assay for COVID-19 from at least two consecutive sets of paired nasopharyngeal and throat swabs specimens collected ≥24 hours apart* (total of four negative specimens—two nasopharyngeal and two throat). See Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens from Patients Under Investigation (PUIs) for 2019 Novel Coronavirus (2019-nCoV) for specimen collection guidance.

Q: Once a person has it, and gets over it, is there a chance for re-exposure?

A: The immune response to COVID-19 is not yet understood. Patients with MERS-CoV infection are unlikely to be re-infected shortly after they recover, but it is not yet known whether similar immune protection will be observed for patients with COVID-19. https://www.cdc.gov/coronavirus/2019-ncov/hcp/faq.html

Q: I see on tv other countries are using head to toe ppe. Are we safe just using goggles, Updated PPE recommendations for the care of patients with known or suspected COVID-19:

A: Based on local and regional situational analysis of PPE supplies, facemasks are an acceptable alternative when the supply chain of respirators cannot meet the demand.  During this time, available respirators should be prioritized for procedures that are likely to generate respiratory aerosols, which would pose the highest exposure risk to HCP.

• • Facemasks protect the wearer from splashes and sprays.
  • Respirators, which filter inspired air, offer respiratory protection. https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhcp%2Finfection-control.html

Q: Mask, and gown only? What if droplets from treating a COVID-19 patient get on our hair, skin, shoes. Wouldn’t that travel with us to other non-infected patient rooms?

A: We are unsure at this time.  Please continue to visit the CDC. 

Q: Doesn’t humidity diminish the virus?

A: We are unsure at this time.  Please continue to visit the CDC. 

Q: Is there evidence on how the virus will respond as our season temps warm up?

A: Not fully understood at this time continue to follow the CDC.gov page

Q: Is there a way for anyone to learn of having the virus before being diagnosed or having any symptoms?

A: There is testing in development that can be quick test self nasal swab testing. 

Q: My job insists that NIV & HFNC are not droplet 🤔 Because both of these modalities involve very high flows and/or pressures, any potential moisture collected in the circuit or interface can easily be dispersed into the air and onto surfaces. 

A: Perhaps a demonstration would provide better understanding.

Q: I work in long-term care facilities that currently do not have a respiratory protection program and N95 fit testing protocols in place. In the event that we have a resident test positive for COVID-19 how would we be protected if we were unable to transfer the patient out?

A: This is from the CDC.gov

Capacity across the healthcare continuum: Use of N95 or higher-level respirators are recommended for HCP who have been medically cleared, trained, and fit-tested, in the context of a facility’s respiratory protection program

The majority of nursing homes and outpatient clinics, including hemodialysis facilities, do not have respiratory protection programs nor have they fit-tested HCP, hampering implementation of recommendations in the previous version of this guidance. This can lead to unnecessary transfer of patients with known or suspected COVID-19 to another facility (e.g., acute care hospital) for evaluation and care. In areas with community transmission, acute care facilities will be quickly overwhelmed by transfers of patients who have only mild illness and do not require hospitalization.

Many of the recommendations described in this guidance (e.g., triage procedures, source control) should already be part of an infection control program designed to prevent transmission of seasonal respiratory infections. As it will be challenging to distinguish COVID-19 from other respiratory infections, interventions will need to be applied broadly and not limited to patients with confirmed COVID-19.

This guidance is applicable to all U.S. healthcare settings. This guidance is not intended for non-healthcare settings (e.g., schools) OR for persons outside of healthcare settings. For recommendations regarding clinical management, air or ground medical transport, or laboratory settings, refer to the main CDC COVID-19 website.

Q: If your family member gets sick, can you come to work?

A: There is not a simple answer to your question here is a link that can provide you more information. One of the recommendations is to speak with your organizations Occupational Health group for further guidance. 

https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html

Q: Is the current recommendation is to wear the N95 mask for all confirmed COVID-19 patients?

A: This is from the CDC.gov – 

Capacity across the healthcare continuum: Use of N95 or higher-level respirators are recommended for HCP who have been medically cleared, trained, and fit-tested, in the context of a facility’s respiratory protection program

The majority of nursing homes and outpatient clinics, including hemodialysis facilities, do not have respiratory protection programs nor have they fit-tested HCP, hampering implementation of recommendations in the previous version of this guidance. This can lead to unnecessary transfer of patients with known or suspected COVID-19 to another facility (e.g., acute care hospital) for evaluation and care. In areas with community transmission, acute care facilities will be quickly overwhelmed by transfers of patients who have only mild illness and do not require hospitalization.

Many of the recommendations described in this guidance (e.g., triage procedures, source control) should already be part of an infection control program designed to prevent transmission of seasonal respiratory infections. As it will be challenging to distinguish COVID-19 from other respiratory infections, interventions will need to be applied broadly and not limited to patients with confirmed COVID-19.

This guidance is applicable to all U.S. healthcare settings. This guidance is not intended for non-healthcare settings (e.g., schools) OR for persons outside of healthcare settings. For recommendations regarding clinical management, air or ground medical transport, or laboratory settings, refer to the main CDC COVID-19 website.

Q: As a home care provider our employees come into contact with people in their homes and in our offices. We have no idea their exposure risks. what precautions should our staff be taking?

A: Not a simple answer however the CDC has home care guidelines you can access. https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-home-care.html

Q: I’m over the age of 60 and being told I shouldn’t even leave my house. Thoughts on working in a hospital where it may happen that I’m giving to undiagnosed covid 19 patients.

A: Not a simple answer suggest speaking with your hospital’s Occupational Health group for further guidance. 

Q: Do you recommend we stay in surgical masks while in the hospital, and then step up to N95s when caring for patients in strict isolation?

A: I don’t believe the CDC is suggesting that we wear surgical masks while in the hospital as a precautionary measure. They do have clinical guidelines for PPE that you can find at: https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhcp%2Finfection-control.html

Q: In addition to COPD, are our patients with pectus excavatum also considered high risk? Also, there is an abundance of information out saying that it is droplet and an equal amount stating airborn. What is the official transmission/isolation for this virus? I have also seen a couple articles recommending intubate patients be placed prone, is this being considered best practice?

A: Droplet is the accepted transmission occurrence. https://www.cdc.gov/coronavirus/2019-ncov/hcp/caring-for-patients.html

Proning may be required if clinically indicated however I don’t know that this has been established as best practice.

Q: In CF clinic they didn’t do PFT for my daughter due to her being positive for flu so I don’t think they would for COVID no reason its diagnostic from what we were told.? Her respiratory illness we were told to take extra precautions in crowds stay home as much as possible, so anyone with pulmonary issues I would think that would be the same?

A: As currently recommended,  anyone with compromise is advised to self-isolate to avoid potential infection.

Q: What is the actual treatment for this?

A: Not a simple answer, I will defer to the CDC guidelines for mgt. https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html

Q: Should therapist that work full-time in the hospital setting stay away from contingent jobs in the LTAC setting?

A: Might be best answered by the Occupational Health at your LTAC.

Q: I work as a RRT in LTC with most patients being in the range of 60 plus. We are allowing no visitors unless its terminal illness. Anything you think we could do or look for to help out?

A: This is a common mitigation protocol used across the nation. Stay in the know with CDC 

Q: Based off of the incubation period for the virus, can you please clarify again why those who are not infected have no need to wear masks unless you’re caring for a pt with covid-19? What if the host is asymptomatic?

A: I defer to CDC however it is likely most of us will be exposed to this virus as we are to influenza etc. Most people will have non to mild symptoms unless you are in the high risk groups.

Conference/CRCE Questions

Q: Does one need to be a member to access these AARC resources? Free to Non-members?

A: There is some information on the AARC web site that does not require membership however you would be best served by becoming one to access all the resources available from the AARC, CRCE’s, access to the AARConnect communities and much much more. (not a paid endorsement for the AARC just an RT that believes in what they offer).  

Q: Will this be archived, and if so, when and how to access?

A: We have recorded the webinar event for you available here: https://event.webinarjam.com/go/replay/1/oyl7rawtntqt0

Q: Dr Shawna, Will we have the chance to listen the full Webinar again or you planned to publish it via AARC websites ?

A: We have recorded the webinar event for you!  Replay video: https://event.webinarjam.com/go/replay/1/oyl7rawtntqt0

 

Emergency Changes Make Me Uncertain How to Best do My Job Safely

Q: How are pulmonary rehab facilities functioning? We have closed, are you calling the patients at home to screen? Screen on arrival to PR?

A: Suggest checking with AACVPR for recommendations. 

Q: I work as home care rt what is the other extra precaution i need to tak?

A: Here is the CDC link for home care providers: https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-home-care.html

Q: How can we use telemed in the home care world right now?

A: rtNOW has software available now that can be utilized by home care companies that can send a link via text or email to a patient in the home if they have a smart device or computer with camera. If you want more info email: connect@rtnow.net

Q: Anyone in the cardiac/pulmonary rehab world cancelling rehab? Our patients are the most high risk.

A: Yes seeing this in many OP settings not just PR programs

Q: What about programs such as pulmonary rehab?

A: Starting to see OP programs being postponed, telerespiratory follow in the home is a potential to stay in touch and help support them in their home environment. Not reimbursable (as of 2020-03-16) however clinically beneficial.

Q: We can’t use telehealth because we actually have to deliver equipment to the patients and set up equipment in our office. We want to protect ourselves and our workers.

A: Can be useful for follow up especially for high tech respiratory equipment being able to visualize the equipment for troubleshooting is a plus.

Q: What things have you done to use telerespiratory service scenarios?

A: rtNOW has used telerespiratory to assess patients RCAT’s, set up NIV, follow up on NIV adjustments to therapy, troubleshoot equipment alarms, just-in-time education for staff and patients as well as remote patient monitoring (RPM)

Q: It seems clear that telerespiratory is a great option. But how can RT programs be covered if they’re not approved already? how can a telerespiratory program provide without RT component?

A: rtNOW’s experience has been that organizations see the benefits of not having to transfer patients out, decreasing re-admissions from SNF’s, maximizing resources and in case of COVID-19 putting the RT remotely where the pt is: home/isolation etc. It also can be used to support our argument for reimbursement with CMS. (CONNECT ACT)

Q: No one is talking about protecting ourselves from the asymptomatic. Don’t you think telerespiratory would be a great way to teach the public how to safely wear masks?

A: Yes, it could!  It could also be used for screening pt’s helping to identify the need for seeking testing or medical treatment in a facility.

AARC questions

Q: How to raise the quality of service for COVID-19: patients ??

A: Continue to follow real time updates from reliable sources, CDC, NIH 

Q: What about incorporating more student RT workers?

A: I am sure this will be addressed at the local level. My comment is that because an RT student can’t work independently it increased the PPE supplies being used when they are already in short supply 

Q: Do you think the AARC will post clinical practice guidelines ?

A: Shawna Strickland @Robyn Mustachccio – CPGs take an awful lot of time to develop. Right now, we’re focused on making sure all literature is getting to members as quickly as possible. There will likely be CPGs at some point, probably a joint effort from multiple organizations.

 

COVID-19 Clinical Presentation and Treatment

Q: Does bronchospasm present in the symptoms of Covid 19 pneumonia?

A: Likely not different that any other viral infection that can cause bronchial irritability/spasm.

Q: Does Covid19 really produce fibrosis in the lungs which is not reversible?

A: Not seeing this in the literature.  

Q: How’s everyone treating these patients????? What’s happening first?!! Hypoxia? Hypercarbia?

A: Appears hypoxia respiratory failure and these patients are requiring high FiO2’s and PEEP.

New Case Studies Added to the Website

A couple of weeks ago we asked our rtNOW agents to give us some examples of calls they have had.  It was exciting to hear agents come out with story after story of how rtNOW helped staff and patients at hospitals and in nursing homes.  Particularly exciting to us were the transfers avoided, and how well our agents interacted with remote staff members as part of the team.

Here is a compilation video of some real-world case stories in which our telerespiratory therapists saved the day.