What is the management for patients status post (s/p) respiratory failure secondary to influenza or Covid-19, including follow-up pulmonary function tests (PFTs) and chest X-rays (CXRs)?

Management of Patients Status Post Respiratory Failure from Influenza or COVID-19

Patients who have recovered from respiratory failure due to influenza or COVID-19 require structured follow-up with clinical reassessment, chest X-ray at 6 weeks if symptoms persist, and pulmonary function testing reserved for those with ongoing respiratory symptoms or radiographic abnormalities suggesting fibrotic complications. 1, 2

Immediate Post-Discharge Management

Clinical Reassessment Timing

• All patients with significant complications or worsening of underlying disease should have clinical review within 24 hours of discharge 1
• Patients with two or more unstable clinical factors (temperature >37.8°C, heart rate >100/min, respiratory rate >24/min, systolic blood pressure <90 mmHg, oxygen saturation <90%) should remain hospitalized 1
• Most patients with uncomplicated viral infections without pneumonia do not require routine follow-up 1

High-Risk Populations Requiring Closer Monitoring

• Elderly patients (>65 years) and immunocompromised individuals warrant more frequent follow-up 1
• Patients with worsening of pre-existing comorbid conditions should be managed according to best practice for that condition with increased surveillance 1
• Those who experienced bilateral lung infiltrates, required ICU admission, or had ARDS need structured respiratory follow-up 2

Follow-Up Chest X-Ray Recommendations

Indications for Repeat Chest X-Ray

• Obtain repeat chest X-ray at 6 weeks for patients with persistent respiratory symptoms or signs 1
• This is especially important for those at higher risk of underlying malignancy 1
• Chest X-ray is NOT routinely recommended for all flu-positive or COVID-19 patients without persistent symptoms 1

When to Obtain Earlier Imaging

• Patients not progressing satisfactorily should have full clinical reassessment and repeat chest radiograph before the 6-week mark 1
• Worsening symptoms such as increasing shortness of breath require prompt evaluation with imaging 1

Pulmonary Function Testing (PFT) Recommendations

Patient Selection for PFTs

• Respiratory follow-up of patients who recovered from COVID-19 pneumonia is crucial for monitoring possible fibrotic complications that could reduce pulmonary function 3
• PFTs should be limited to selected cases only, not performed routinely on all recovered patients 3
• Consider PFTs for patients with:
  • Persistent respiratory symptoms beyond typical recovery period (>7 days for influenza) 1
  • Radiographic abnormalities suggesting interstitial lung disease 2
  • Functional impairment on discharge 2
  • Severe pneumonia requiring prolonged mechanical ventilation 2

Timing of PFTs

• International societies including the ATS, ERS, and BTS recommend postponing PFTs unless deemed clinically essential 3
• When indicated, PFTs should be performed after acute infection has resolved and patient is no longer infectious 3
• For COVID-19 patients, consider timing based on viral clearance and clinical stability 3

Safety Precautions for PFT Performance

• All testing personnel must wear appropriate PPE including surgical mask or N95 respirator, eye protection, disposable gloves, and gown 4
• Patients should be screened for COVID-19 symptoms before appointment and upon arrival 4
• Temperature screening with threshold >37.5°C should be performed at facility entrance 4
• Maintain 6 feet physical distancing in waiting areas 4
• Schedule one examination at a time to prevent crowding 4
• All surfaces and equipment must be thoroughly cleaned between each patient 4
• Allow minimum of 5 minutes between patients for cleaning and air exchange 4

Monitoring Parameters During Follow-Up

Clinical Assessment

• Monitor temperature, respiratory rate, pulse, blood pressure, mental status, and oxygen saturation at each visit 1, 5
• Assess for persistent symptoms including cough, malaise, fatigue, and breathlessness 1
• Evaluate functional capacity and ability to perform activities of daily living 2

Red Flags Requiring Urgent Evaluation

• Increasing shortness of breath 1
• Fever lasting >4 days 1
• Focal chest signs or bilateral chest signs 1
• Dyspnea or tachypnea (respiratory rate >30/min) 1
• Oxygen saturation <90% 1, 5
• Altered mental status 5

Anticipated Long-Term Respiratory Complications

COVID-19-Specific Considerations

• Interstitial lung disease and pulmonary vascular disease are likely to be the most important respiratory complications 2
• Data from previous coronavirus outbreaks (SARS and MERS) suggest some patients will experience long-term respiratory complications 2
• Organizing pneumonia following COVID-19 pneumonia may require systemic glucocorticoid treatment 6
• Patients should be followed at least three weeks after diagnosis to recognize early lung damage 6

Risk Stratification for Complications

• Older men, individuals of Black and Asian minority ethnicity, and those with comorbidities are at higher risk 2
• Patients who required mechanical ventilation or ICU admission have increased risk of long-term sequelae 2
• Those with bilateral thoracic imaging abnormalities warrant closer surveillance 2

Holistic Care Package

Comprehensive Management Approach

• Address breathlessness, anxiety, oxygen requirement, palliative care needs, and rehabilitation 2
• Virtual solutions can be embedded within the pathway to mitigate healthcare system pressures 2
• Safety netting should be in place for patients whose clinical trajectory deviates from expected recovery 2

Common Pitfalls to Avoid

• Not arranging appropriate follow-up for high-risk patients or those with complications 1
• Overlooking the need for repeat chest X-ray in patients with persistent respiratory symptoms 1
• Not providing patients with clear information about their illness, medications, and follow-up arrangements at discharge 1
• Performing routine PFTs on all recovered patients rather than selecting based on clinical indication 3
• Delaying evaluation of worsening symptoms after initial improvement 1