Hi everyone- as Respiratory Nurse Specialist I am receiving lots of queries regarding respiratory physio & what constitutes an AGP. I have read latest CPS guidance. The confusion seems to be around induction of sputum & whether manual airway clearance techniques, ACBT, flutter devices etc are AGPs. Our community physio services are also seeing increase in referrals from pts recovering from COVID -19 who have been advised to refer for lung strengthening exercises by GPs. Would welcome thoughts & comments from my colleagues out in the wider respiratory community. Thank you :)
As with all Covid-19 advice - please note the date of this response.
The short answer is YES - I would classify all those activities as AGP and recomend people where a FIT tested FFP3 mask. If not fit tested against the 5+ manoeuvres it is not effective to just pop on the mask.
Flutter-yes ACBT -yes, manual tech -yes
For reference for those whom haven't seen it. CSP AGP guidance- open access https://www.csp.org.uk/system/files/documents/2020-04/Government%20and%20CSP%20guidance%20on%20Aerosol%20Generating%20Procedures.pdf
Despite no specific guidance locally my advice has been for sputum sample and Peak Flow should all be considered AGP so should be done independently by the patient at home, remotely supervised via video or if absolutely indicated have to be supervised in person considered as AGP - so PPE.
And the first question being do I need this test let alone witness this test?
I am in South West so the population I have seen with Covid-19 is very small so this advice is based on talking and reading. So my answer is a little sign posting and pragmatic thinking rather than reflective clinical experience.
Some principles to always promote for chest clearance
- Hydration. ( with very occasional exception of fluid restriction. e.g Heart failure)
- Sitting out, sitting out - regular change of position.
- Active patient lead chest clearance ACBT over manual tech.
- Mobility is fantastic for chest clearance
These are activities people need to fit into their routine as part of active Covid management and in recovery.
Unable to manage secretions with the above first line suggestions is a sign of acute pneumonia and if for escalation it would be highly probable these should be treated in hospital not the community setting. Its should be considered than inability to manage secretions and not escalate to hospital is a compromise is care.
My message is spread the message of good basic care far and wide and manual technique and assisted modality needs to be considered in the content of the patient if not for transfer to the acute trust and for palliative, ceiling of care are these interventions inline with the patients wishes - they are active care.
This is an excellent patient facing resource and one I would certainly endorse, produced by Lancashire Teaching Trust https://covidpatientsupport.lthtr.nhs.uk/
It huge ! and with the breath that is covered much more than chest clearance, I would ensure that you sign post you patient to chapters, set home-work of focused areas and check in with them as they progress though the course. Some people will need more or less guidance. The personalisation will offer much better engagement and support as questions pop up along the way.
Re chest clearance is covered three techs
- Deep breathing
- Breath sacking
- Postural Drainage
ABCT Active Cycle of breathing
Those with Long term conditions with a productive nature or infective exacerbations are likely know ACBT- active cycle of breathing. If they know these techniques I would advise they do what they know well before adding other exercises on. This will be taught in many hospitals. with the basics of hydration and posture for this to be effective.
For the final days of palliative care secretion management is likely to include pharmacology- Hyoscine hydrobromide
'Lung strengthening' - not a term I use
In COPD evidence is emerging re inspiratory muscle training but not peer reviewed - yet I dont think and no evidence in Covid
People will undoubtably benefit from
- Muscle strength training
- Aerobic activity
I would promote this to be done by following the physical health section of the https://covidpatientsupport.lthtr.nhs.uk/ This broken in activities in lying/sitting and standing.
NB- consider if anyone has had an MI during their hospitalisation or have very high risk factors and consider measures to reduce risk CV instability and question do they require further consideration for suitability of exercise. Talking to cardiac rehab and PR rehab teams on a case-by-case basis can be really helpful.
Personalised care to ensure some activity for all I would advocate as the best advice for chest clearance and lung strengething. Reduces PE risk too. Seemingly of significance in covid-19
Blimey that wouldn't fit in a tweet would it!
Regarding risk from recovering COVID19 patients and AGP, I found this podcast on the virology science very useful about how long the risk of infection lasts
I would welcome views on this as it seems reassuring when thinking about rehabilitation of survivors?
Stay well everyone