April 8, 2020

Successful management of COVID-19 using telemedicine, and the role of imaging in asymptomatic or suspected COVID-19

By Denise Baez

NEW YORK -- April 8, 2020 -- Today’s DG Alert covers managing patients with coronavirus disease 2019 (COVID-19) virtually, and the role of imaging in asymptomatic individuals or patients with suspected COVID-19 and mild clinical symptoms.

Researchers have developed and used a multidisciplinary self-managed, home quarantine method that was effective in controlling the source of COVID-19 infection and was useful in alleviating the shortage of medical resources. 

Published in Telemedicine and e-Health, Li Yan, Tongji Hospital, Wuhan, China, and colleagues describe how they successfully treated 2 cases of COVID-19 -- 1 mild and 1 severe case -- using an online/offline multidisciplinary quarantine observation form, online monitoring, and strict compliance with quarantine measures. The mild case was able to be treated entirely at home, while the severe case ultimately required hospitalisation.

The 2 patients described and reported their symptoms online using a quarantine observation form at least 2 times per day. The quarantine team created a WeChat group to ease communication. Nursing experts provided guidance on quarantine and disinfection and oversaw patients' diets and sleep schedule. Rehabilitation experts developed a feasible rehabilitation plan, and psychotherapists encouraged patients to stay optimistic. Importantly, the quarantined patients were not alone, as they had regular contact with the quarantine team, aimed at increasing their confidence in recovery and enhancing self-management capabilities. If continuous deterioration in conditions, such as persistent fever and diarrhoea or reduction in mental state score, was observed, the quarantined individual was urged to seek medical attention to prevent delayed treatment.

The first case was a male emergency room physician aged 32 years with no underlying health conditions. The patient presented with cough and rhinorrhoea on January 15 and developed dyspnoea, soreness, lack of strength, and fever on January 19. He received oral oseltamivir, arbidol, and avelox as per the physician's instructions and was rested and quarantined at home. From January 19 to 20, the patient had persistent fever with chest tightness, dyspnoea, soreness, lack of strength, and diarrhoea, and his SpO2 was 95% to 97%. His symptoms gradually improved after the use of the multidisciplinary self-quarantine method and his CT results indicated significant absorption of lesions in the lung. The patient's throat swab samples tested negative for COVID-19 nucleic acid on February 20 and 21.

The second case was also a male emergency room physician, aged 31 years, with no underlying health issues. The patient developed persistent fever of unknown cause on January 5 and his CT results revealed blurry patchy shadows in the lower right lobe of the lung. He developed persistent fever with chest tightness and dyspnoea during the first 3 days of home quarantine and was advised to stay in the emergency quarantine ward for symptomatic treatment during his follow-up visit and was subsequently hospitalised for treatment after 3 days due to worsening symptoms. He was given alternating non-invasive mechanical ventilation and high-flow oxygen therapy. The patient’s conditions began to improve on day 25 after onset, and his CT results indicated significant absorption of lesions in the lung. The patient’s throat swab samples were consecutively tested negative for COVID-19 nucleic acid and fever was not detected for 17 days. The patient was eventually transferred to the general quarantine ward.

“This model is applicable to the current novel coronavirus [pandemic] and can actively promote the management of suspected or confirmed mild cases, monitoring of critical cases, and self-management of discharged patients,” the authors wrote. “The application of this new management model is worthy of being promoted in our specialised treatment facilities and in countries with severe epidemics.”

A multinational consensus statement on the role of chest imaging in the management of patients with COVID-19 was jointly published in the journals Radiology and Chest, endorsed by the Radiological Society of North America and the American College of Chest Physicians.

The statement represents the collective opinions and perspectives of thoracic radiology, pulmonology, intensive care, emergency medicine, laboratory medicine and infection control experts practicing in 10 countries, representative of the highest burden of COVID-19 worldwide.

The consensus statement suggests that imaging is not routinely indicated in asymptomatic individuals or patients with suspected COVID-19 and mild clinical symptoms. Use of chest imaging is indicated in patients with COVID-19 who have worsening respiratory status. Imaging is also indicated for patients with moderate to severe features of COVID-19 regardless of COVID-19 test results.

In a resource-constrained environment (lack of personal protection equipment or availability of COVID-19 testing), imaging is indicated for medical triage of patients with suspected COVID-19 who present with moderate to severe clinical features and a high pre-test probability of disease.

The panel also found that CT is appropriate in patients with functional impairment and/or hypoxemia after recovery from COVID-19. When there is known community transmission, evidence of COVID-19 has been incidentally found on CT scans. In these cases, patients should have COVID-19 testing using reverse-transcription polymerase chain reaction.

The authors noted that the consensus statement represents opinion at a moment in time within a highly dynamic environment where the status of regional epidemics and the availability of critical resources to combat those epidemics vary daily. Recommendations may undergo refinement as the situation evolves.

SOURCE: Telemedicine and e-Health and Radiology
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