GPs should have lower threshold for chest X-ray referrals in former COVID-19 patients

GPs should have a lower threshold than usual for chest X-ray referrals for patients who have previously been infected with COVID-19, respiratory experts have said.

(Photo: gorodenkoff/Getty Images)
(Photo: gorodenkoff/Getty Images)

Speaking in a MIMS Learning Live webinar this week, Dr Philip Ind, a respiratory consultant at Imperial College Healthcare NHS Trust in west London, said that despite the many unknowns about the virus patients' respiratory functions should continue to improve during their recovery.

'So they shouldn't be getting worse, it should be getting better and abrupt deterioration needs full assessment,' he said. 'I think radiology will be important here. So I think GP should have a lower threshold than usual for a chest X-ray.'

Wiltshire GP Dr Kevin Gruffyd-Jones, who has an interest in respiratory care and was also taking part in the live webinar, said that persistent symptoms such as cough or shortness of breath six weeks post-infection should also prompt GPs to refer patients for an X-ray.

'We can't assume that symptoms are post-COVID and purely due to COVID,' he added, pointing out that patients could have other serious underlying conditions that had gone unnoticed due to their coronavirus symptoms.

Huge spectrum of problems

Dr Ind said that the coronavirus had produced a 'huge spectrum' of problems in patients. 'I've seen some of the worst acute induced lung fibrosis I've ever seen [in] people who've been ventilated for COVID-19. And yet there are other people who within two or three weeks will be back to normal - and they really will be back to normal,' he said.

'Guidelines say that a lot of people will be back to normal at six weeks,' Dr Ind added. 'I don't think we know what's going to happen to these severe lung fibrosis. People with acute respiratory distress syndrome go on improving for a little bit over a year, but we don't know to what extent that's going to be true of COVID-19 or indeed what [the] effect of steroids administration, high dose steroid at the time, will be.

'Some of these lung complications will lead to bronchiectasis or its equivalent so [patients] will be, I think, susceptible to recurrent bacterial infection.'

Dr Ind also highlighted that a large number of patients had experienced pulmonary embolism (PE), making COVID-19 'completely different from ordinary viral pneumonia'. He said the embolisms were often picked up 'by accident' through CT scans to assess lung function, rather than there having been any clinical signs or suspicion that they had occurred.

He cautioned that GPs should also be alert to a possible recurrence of thromboembolism in patients experiencing any rapid deterioration.

'Again we don't know the long-term sequelae of that, so heart failure comes into the differential of increasing breathlessness and the chest X-ray is pretty good at picking up early heart failure,' Dr Ind added.

Post-COVID-19 fatigue

Post-COVID-19 fatigue could also become 'an emerging clinical problem', Dr Ind suggested. 'We don't really have the data yet, but it may be that GPs will get rather expert in managing this,' he said.

Dr Gruffyd-Jones added that it could potentially take up to six months for a person to recover from tiredness if they have had a serious infection. However he warned that GPs should first rule out depression or another physical reason as the cause of fatigue before assuming it was a post-COVID-19 complication. He added that mindfulness and wellbeing websites could be useful resources for these patients.

Both doctors said they believed that rehabilitation would play a key role in supporting patients experiencing ongoing symptoms including fatigue or malaise.

'The COPD data show just how effective rehabilitation can be,' Dr Ind said. 'It's used by cardiologists for heart failure. It's a very impressive intervention, it's very cheap and it's something that I think we should be using in a lot of our patients.'

Mental health issues could also be common in patients, which could range from depression, to 'full blown post traumatic stress', Dr Ind added. 'So, I think there's a lot to think about when you're seeing these patients, apart from just their respiratory function,' he said.

MIMS Learning Live Digital

Drs Ind and Gruffyd-Jones were speaking in a live webinar on caring for patients with chronic respiratory disease during the COVID-19 pandemic, part of an online programme for MIMS Learning Live Digital this week.

This webinar, along with five new pre-recorded presentations covering CV risk in patients with type 2 diabetes, healthy pregnancies, cardiology, food allergy and cancer care, are available to watch on MIMS Learning at any time here.

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