In a new series examining the challenges and opportunities for healthcare, Sally Williams hears from Dr Jonathan Bennett, Honorary Professor of Respiratory Sciences, University of Leicester, Respiratory Consultant at Glenfield Hospital and Chair of the British Thoracic Society. This is what he said on 26 May 2020.
It has been a difficult week due to a series of events, including a frightening cancer diagnosis for a friend of mine. I, like so many people, have been so immersed in all things COVID-19 and it brought home to me how people continue to experience devastating events unrelated to the pandemic.
When I’m on the admissions unit I still see people with non-COVID problems, like blood clots, asthma flare ups, chronic pulmonary obstructive disorder (COPD) and worsening heart failure. These health problems don’t go away just because the country is in lockdown and we need to keep doing out utmost for these patients.
Older people and COVID-19
Like so many, I’ve also been thinking about the care provided to older people with COVID-19. The numbers of older people are a worry. We had anticipated a reduction in COVID patients, but instead we’ve hit a plateau, and this seems to be due to a cohort of older patients. Nearly half of our current COVID-19 population are aged 80 years and over.
In theory, we shouldn’t be seeing this demographic because they should have been shielding at home for the last nine weeks and shouldn’t have had significant contact with other people. It doesn’t take eight or nine weeks for the virus to incubate – it’s a matter of days from exposure to an infected person. So, logic dictates that they must have contracted the virus via care homes, recent hospital admissions or their carers.
This is reflected in our approach to risk stratification. If an older person comes to the admissions unit from their own home, they are stratified as low risk COVID-19. If they come from a care home, then they are categorised as high risk. The question then becomes what can we offer this patient group?
The numbers of people dying in care homes highlights that we really don’t have clarity on the best way to care for frail elderly people who’ve contracted COVID-19. We can give only limited medical care. Predominantly, the emphasis is on nursing care. We also try to ensure that we aren’t sending someone who is COVID-19 positive back to a care home that doesn’t have proper infection prevention and isolation facilities or enough PPE for staff.
We haven’t had older, frailer patients with COVID-19 in ITU. With increasing age comes increasing frailty and comorbidities, including the risk of hypertension, chronic heart or lung disease. Before a patient is moved to ITU, we must consider the likelihood they’ll survive being artificially fed, or with the interventions necessary to support their heart and kidneys. The short answer is that people my age struggle with two weeks of these interventions, so it’s unlikely therefore that someone in their eighties would survive.
Holding strategies
The way we use ITU has changed with COVID-19. Previously, most respiratory patients who went to ITU with lung conditions would be on ventilation for three to five days. Now, a significant number of COVID-19 patients who go to ITU are put on a ventilator for an average of 14 days. And the virus doesn’t just affect one organ; the heart, lungs and kidneys all struggle, and the muscles start to waste. Amongst the patients who have gone to ITU who have been relatively fit, the mortality rate has been approximately 50%. This compares to an ITU mortality rate of 10-20% pre-COVID-19.
Lots of studies are underway to explore what strategies are proving most effective. These include drug treatments but also what ventilation strategies are best and the effectiveness of ECMO machines (a machine that replaces the function of the heart and lungs) in these patients. Essentially, these are holding strategies, designed to allow the lungs, heart or kidneys time to regain independent function. As we’ve discussed before some of the “normal” rules of care have been thrown into confusion, including how to optimise oxygen delivery to patients.
Holding strategies are our best bet until we have data to support specific treatments. Trials are exploring the repurposing of existing treatments (https://www.bbc.com/news/amp/health-52737169) and the race for a vaccine continues at pace (https://mailchi.mp/cepi/vaccines-against-covid-19-how-are-cepis-programmes-progressing).
Things are also moving on in other ways.
New pathway for bronchoscopy
We are now set up to resume bronchoscopy – a procedure using a small camera that allows us to look inside the lungs and airways. This is an aerosol generating procedure and so creates a risk of spreading the virus from COVID-19 positive patients to staff. We’ve had to redesign our processes to manage this risk. Patients requiring a bronchoscopy are sent a COVID-19 testing kit a few days before they are due to come in. The procedure only goes ahead if they’ve tested negative.
For the first time, the doctor who performs the bronchoscopy uses a respirator – like the one I’m wearing in the photograph. It’s a sealed hood, which means you can’t touch your face. I found it very uncomfortable initially, but I’ve since discovered there’s a way of fitting it more comfortably. In the current environment, there’s no-one around to teach us how to use this type of new equipment.
Cancer clinic changes
Our cancer clinics have been running throughout but we have had to change how we deliver them, offering a mix of face to face and telephone appointments. There’s a great deal of discussion happening about how many cancer deaths might arise due to the impact of COVID-19 and delayed attendance, diagnosis and treatment. However, we haven’t (yet) had the massive backlog of patients waiting to be seen that we’d anticipated.
It’s hard to know how many people have put off contacting their GP with worrying symptoms, or whether GPs are able to assess patients with sufficient rigor over the telephone or online. I do know that we’ve had several patients not turn up for CT scans because they’re scared to come into hospital.
We try to reassure patients that it is safe to come into hospital. It is because we’re working hard to make it that way. We have systems underway to protect patients and staff from the potential of cross-infection with COVID-19. And all of us have a responsibility to get the message out there that the NHS is still working, albeit it a new way, and we are still there for all and not just COVID-19.
As told to Sally Williams
Image: Dr Bennett and colleague wearing respirator hoods to undertake bronchoscopy procedures