Desktop Helper No.11 - Remote Respiratory Consultations - online

Remote respiratory consultation is any consultation without physical contact between the HCP and the patient, for example via videocall, telephone or web-based devices. It may also include consultations where patients are in a separate room and communication is via a telephone or intercom for viral infection control.

Telephone consultations have been a common feature of primary care (typically not reimbursed), usually accompanied by face to face later, the use of video-consultation was previously rare but has accelerated during the COVID-19 pandemic.

Primary care relies on developing close, continuous relationships with patients, using talk, eye contact and touch; where the way the patient behaves, walks and coughs drives the diagnosis. These and “doorknob”/ secondary agenda moments can be hard to replicate remotely. In addition to patient choice, sustainability may be a challenge.

HCPs report online consultation fatigue and cognitive stress as well as a loss of connection, satisfaction and identity when the rituals of face to face contacts are lost.1 But remote consultations reduce travel, improving the carbon footprint.

Use remote respiratory consultations for:

• Routine reviews
• Medication review, including polypharmacy
• Inhaler technique training and evaluation (single or group)
• Triage of known patient with new onset breathlessness
• Education and support (individual or group)
• Pulmonary rehabilitation (individual or group)

Routine management & review

This is the best opportunity for remote consultations, with appropriate preparation by both HCPs and patients. However, consider the following: (2-5)

Suggests remote consultation:

• Patient preference eg neutral location
• Their comfort with technology, e.g. apps for monitoring; note-taking; record-keeping
• Access to smartphone or webcam
• Travel or parking difficulties, financial issues
• Value of involving family living apart from patient
• Opportunity to gain insight into home situation
• Has equipment for observations: O2 saturation, temperature, blood pressure, peak flow
• Where face to face puts individual at risk

Suggests face to face:

• Preference for the traditional approach
• Complex needs
• Hearing or sight problems
• Low digital literacy
• No access to internet
• Low trust for accuracy, safety or confidentiality of remote consultation
• Lack of privacy at home

Be conscious of how the community might perceive any variation in approach between patients. Avoid increasing inequity for those who cannot use or afford apps or other home-based technology.

Multidisciplinary consultations

Patients with multiple comorbidities may benefit from a joint remote consultation with their primary HCP and other specialists. However, be mindful that speaking with several people at the same time remotely can be overwhelming. Check understanding during the call, or in a follow-up call.

Telephone triage (6,7)

This can be used to decide which patients need face to face contact. However, there is currently limited evidence on value beyond infection control. If a patient reports any red flag symptoms during a remote consultation, conduct a usual urgent review either face to face or via video, or direct them to emergency care. (8)

Assessment of exacerbations

If a patient is already under the care of a community respiratory service and is well-known to you, assessment of new onset breathlessness and decisions about the diagnosis, whether to escalate treatment and action may be possible remotely even using the telephone alone. Provide self-management tips; check these are understood.

Diagnosis 

IPCRG colleagues advise remote consultations for diagnosis are only appropriate when the need for infection control is paramount. They may be sufficient to assess probability of diagnosis and inform a trial of treatment alongside mitigation of any risk factors. (9) Video offers the closest match to a face-to-face consultation that employs looking and listening. Include a structured clinical assessment with a focus on meticulous history taking. If the patient has a peak flow meter, diaries can be useful. Questionnaires may help. Defer referral for additional testing such as spirometry (if this is available safely), chest X-ray or computed tomography but follow up later if circumstances allow. Asthma is a variable disease therefore several consultations will probably be needed to confirm the diagnosis and perhaps with more than one HCP if additional tests are needed. Communicate this to the patient in terms of probability, explaining the diagnosis has been reached by their clinical team who ‘suspect that’ it is, for example, asthma. Help your patient navigate to approved information and ensure they are clear what to do if their symptoms do not improve or worsen. Be sure to spend time on your patient’s understanding of the situation.

Group consultations

Effective group and supportive consultations can be carried out remotely and offer the opportunity to gain from several experts in one session. They may help the patient feel in the epicentre of care, and also give them confidence to ask more questions. This may spark support between the patients themselves, facilitated and guided by the HCP.

(some could be done by trained receptionist/administration)

• Am I aware of this patient’s needs?
• Can I access their medical history?
• Do I know the patient’s goals?
• What is their physical, smoking and mental health status?
• Do they have access to a phone, smartphone, tablet orcomputer?
• Should I be expecting any questionnaire results or peak flow diary?
• Do they have access to respiratory function testingequipment?
• Can they use it correctly?
• Do I need to see them – if so, is a video-consultation possible?
• Is the family/home condition supportive?

• Vital signs – temperature, pulse and respiratory rate - https://www.youtube.com/watch?v=Y-CWTqKiIhQ
• Peak flow test – https://www.asthma.org.uk/advice/manage-your-asthma/peak-flow/
• 1 minute Sit to stand
• Inhaler technique – https://www.asthma.org.uk/advice/inhaler-videos/
• Pulse oximetry – https://www.youtube.com/watch?v=Y-CWTqKiIhQ
• Breathlessness questionnaires
  • MRC Breathlessness Scale - www.pcrs-uk.org/mrc-dyspnoea-scale
  • Modified MRC - https://academic.oup.com/occmed/article/67/6/496/4095219
• COPD questionnaires
  • COPD Assessment Test - https://www.catestonline.org/
  • Clinical COPD Questionnaire (CCQ) - www.ccq.nl
• Asthma questionnaires
  • Asthma Control Test - https://www.asthmacontroltest.com
  • CARAT - https://core.ac.uk/download/pdf/62692897.pdf
  • RCP 3 questions - https://cks.nice.org.uk/topics/asthma/management/follow-up/#the-royal-co...
• See IPCRG guide to tools here: Asthma control tools: Users' guide and Guide to COPD wellness assessment tools 

*Links are to some open source videos and instructions – note none were designed specifically for remote consultations