Evidence check
A rapid review outlining the available evidence on a discrete topic or question. Evidence includes grey and peer review literature. View all Evidence Checks by date of publication.
Archive Immunosuppression and COVID-19
Added: 30 Apr 2020
Updated: 19 May 2020
What is the evidence for the risk and management of people with immunosuppression and COVID-19?
- A systematic review showed that people with immunosuppression showed favourable disease course when compared to the general population. Cancer patients experienced more severe COVID-19 infections but did not necessarily have a poor prognosis. The review is subject to bias due to the limited number of included papers and small sample size.
- Additional small case series suggest that patients with immunosuppression generally have similar risk profiles to the general population in terms of COVID-19 outcomes and severity, however patients with cancer have been shown in some studies to have more severe disease. Results for transplant patients regarding disease severity varies and is based on small numbers.
- People with cancer provide the majority of the evidence on immunosuppression during COVID- 19. Expert opinion varies on whether cancer patients with a diagnosis of COVID-19 should continue cancer treatment. However there is agreement that decisions should be based on balancing risks and benefits of treatment in the context of the pandemic and infection control principles.
- A systematic review showed that there is no definitive evidence that specific cytotoxic drugs, low-dose methotrexate for autoimmune disease, NSAIDs, Janus kinase (JAK) kinase inhibitors or anti-TNFα agents are contraindicated in people with COVID-19.
- The National Institute for Health and Care Excellence (NICE) recommends continuing systemic anticancer treatment only if it is needed for urgent control of the cancer, and if possible, defer treatment until the patient has at least one negative test for COVID-19.
- NICE have also released guidance on children and young people who are immunocompromised with COVID-19.
Archive NIPPV and requirements
Added: 11 May 2020
Updated: 14 May 2020
Has the increasing use of NIPPV to manage suspected or confirmed COVID-19 patients led to any additional guidance regarding the physical requirements and engineering services (e.g. negative pressure rooms or where positive pressure rooms vent to)?
- In negative pressure rooms, consider using NIV therapy for patients with hypoxaemia associated with COVID-19, ensuring it is used with caution and strict attention is paid to staff safety.
- In single rooms or shared ward spaces with a cohort of confirmed COVID-19 patients only, consider using NIV therapy for patients with hypoxaemia associated with COVID-19, ensuring it is used with caution and strict attention is paid to staff safety.
- In shared wards or emergency department cubicles, do not use NIV therapy for patients with hypoxaemia associated with COVID-19.
- During inter-hospital patient transfer and/or retrieval, do not use NIV therapy for patients with hypoxaemia associated with COVID-19.
- In patients with COVID-19 who are deteriorating, consider endotracheal intubation and invasive mechanical ventilation. In patients with COVID-19 for whom NIV is appropriate for an alternate clinical presentation (e.g. concomitant chronic obstructive pulmonary disease with type 2 respiratory failure and hypercapnoea), ensure airborne and other infection control precautions are optimised.
- In adults with COVID-19 on high-level respiratory support, monitor for worsening respiratory status. If worsening occurs, undertake early in the disease course endotracheal intubation in a controlled setting. Patients can deteriorate rapidly 5-10 days after symptom onset.
Archive Pulmonary rehabilitation and COVID-19
Added: 7 May 2020
Updated: 12 May 2020
What is the guidance for the provision of pulmonary rehabilitation for people recovering from COVID-19?
- A small quasi-randomised trial of elderly patients with COVID-19 showed respiratory rehabilitation can improve respiratory function, quality of life and anxiety.
- Recommendations from international researchers for physiotherapy in acute hospital settings cover post COVID-19 mobilisation, exercise and rehabilitation interventions. They recommend early rehabilitation after the acute phase of acute respiratory distress syndrome, which is of particular value to those admitted to intensive care unit (ICU) to limit the severity of ICU-acquired weakness and promote rapid functional recovery.
- Expert opinion suggests pulmonary rehabilitation could relieve the symptoms of dyspnoea, anxiety and depression, and eventually improve physical function and quality of life.
- One article lists a range of common practices used in respiratory physiotherapy that are not recommended in with patients with COVID-19 in the acute phase including diaphragmatic breathing, pursed lips breathing, manual mobilisation or stretching of the rib cage, respiratory muscle training, exercise training and mobilisation during clinical instability. Other guidance suggests early mobilisation and physical exercises to improve respiratory and diaphragmatic muscle strength and promote recovery.
- A living guideline for allied health professionals recommends that case prioritisation consider the potential impact on critical outcomes of a patient not receiving immediate rehabilitation.
- Guidance suggests continuing rehabilitation care in the outpatient setting, and at home through ongoing therapy either in-person or via telehealth.
- The American Thoracic Society does not endorse a specific approach to pulmonary rehabilitation during COVID-19. However a patient education factsheet has been published suggesting some ways to continue pulmonary rehabilitation at home. The British Thoracic Society released a resource kit with guidance to support pulmonary rehabilitation remote assessment during COVID-19.
- The Lung Foundation Australia is facilitating an at-home exercise series through the initiative COVID-19 - Maintaining Movement.
Archive Fibrinolysis and PCI for STEMI
Added: 8 May 2020
Updated: 12 May 2020
What is the evidence for fibrinolysis versus primary percutaneous coronary intervention in the treatment of ST-Elevation Myocardial Infarction (STEMI)?
Is there evidence for safety and efficacy of tenecteplase use as fibrinolytic to treat STEMI?
What are the current models of care for treatment of STEMI in COVID-19 and non-COVID-19 patient population during the current pandemic?
Is there evidence for safety and efficacy of tenecteplase use as fibrinolytic to treat STEMI?
What are the current models of care for treatment of STEMI in COVID-19 and non-COVID-19 patient population during the current pandemic?
- It is well established that most patients with acute STEMI benefit from reperfusion therapy.(
- Primary PCI has been shown to achieve better outcomes than fibrinolysis. Better outcomes are achieved when PCI is performed within 90 minutes of first medical contact.
- When timely PCI cannot be performed, fibrinolysis is indicated in STEMI patients whose onset of ischaemic symptoms were within the previous 12 hours.
- Primary PCI may be preferred for some patients even when the procedure cannot be performed in a timely manner. This includes patients at high risk of bleeding and those in cardiogenic shock.
- Fibrinolytic agents include streptokinase, alteplase, reteplase, and tenecteplase. Tenecteplase has a lower rate of non-cerebral bleeding events and is given as a single bolus and is often the preferred agent.
Archive Diabetes care during COVID-19
Added: 4 May 2020
Updated: 7 May 2020
Are there risk stratification approaches to identify diabetes patients that are high, intermediate and low risk during COVID-19?
Which clinical pathways and modalities can support diabetes management and service delivery during COVID-19?
Which clinical pathways and modalities can support diabetes management and service delivery during COVID-19?
- Recent evidence reviews and meta-analysis have shown: o People with diabetes appear to be at increased risk of more severe COVID-19 infection, however the factors that moderate this relationship are unclear. o Self-management tools based on text messages and increased blood glucose monitoring have shown benefits to patients. There are algorithms for triaging care for diabetes patients during COVID-19, which guide the use of delivery options including urgent face-to-face, virtual care and deferral of appointments. There are no validated risk stratification tools to identify high risk patients.
- Expert advice from Australian Diabetes Society, NHS Clinical Networks and Association of British Diabetologists recommend services during COVID-19 should include: o For inpatient services increased staff capacity, provision of remote support, teamwork and facilitation of early discharge. o For outpatient services minimising investigations, utilising virtual clinics and conducting remote consultations. The models outline pathways of care for type 1 and type 2 diabetes and diabetes in pregnancy, according to clinical needs and risk factors.
- Evidence for telehealth application of diabetes in COVID-19 is emerging, including a case study of a new onset of type 1 diabetes via a combination of emails, Zoom and telephone calls during COVID-19. Telehealth has previously been demonstrated to be successful in delivery of diabetes services.
- Specialist guidance around managing diabetic foot clinics and diabetes in pregnancy screening is also available.
Archive Intubation in the emergency department during COVID-19
Added: 1 May 2020
Updated: 7 May 2020
What is the evidence for the safe practice of intubation in the emergency department during the COVID-19 pandemic?
- Australian and New Zealand medical societies and colleges have endorsed a consensus statement from the Safe Airway Society on the principles of airway management and tracheal intubation specific to COVID-19. Guidance currently suggests early intubation and that principles of airway management are the same for patients with mild or asymptomatic disease requiring urgent surgery or critically unwell patients with acute respiratory distress syndrome. The statement suggests negative pressure ventilation rooms with an anteroom are ideal to minimise exposure to aerosol and droplet particles. Where this is not feasible, normal pressure rooms with closed doors are recommended.
- Consensus guidelines from the UK suggest if critical care is expanded to areas outside of the intensive care unit, airway management may take place in rooms with positive pressure with reduced air exchanges. The guidelines suggest this may have implications for transmission risks and there needs to be consideration of what constitutes appropriate personal protective equipment (PPE).
- Expert recommendations are for a rapid sequence induction technique (or a modified version) for emergency intubation. The use of video laryngoscopy is suggested to improve first-attempt success. Video laryngoscopy enables a reduction in the proximity of intubator and patient airway.
- Clinical data on 202 patients on emergency tracheal intubation by anaesthetists from two hospitals in Wuhan China with COVID-19 showed that using rapid sequence induction resulted in first-attempt intubation in 89% of cases and 100% overall.
- Guidance consistently suggests that airway management needs to be performed quickly and the number of healthcare workers at the bedside kept to a minimum, and adherence to airborne precautions, hand hygiene and donning of PPE.
- Most guidance features a recommendation that airway management plans, including backup techniques, are to be agreed upon before starting the procedure.
- The evidence and guidance reflects a range of PPE recommended and used.
Archive Rehabilitation needs of post-acute COVID-19 patients
Added: 4 May 2020
Updated: 7 May 2020
What are the rehabilitation needs of post-acute COVID-19 cohort?
What is the appropriate timing of rehabilitation interventions?
What is the appropriate timing of rehabilitation interventions?
- COVID-19 can affect respiratory, cognitive and motor functioning.
- A small quasi-randomised trial of elderly patients with COVID-19 showed respiratory rehabilitation can improve respiratory function, quality of life and anxiety.
- Recommendations from international researchers for physiotherapy in acute hospital settings cover post COVID-19 mobilisation, exercise and rehabilitation interventions. They recommend early rehabilitation after the acute phase of acute respiratory distress syndrome, which is of particular value to those admitted to ICU to limit the severity of ICU-acquired weakness and promote rapid functional recovery.
- Italian guidelines recommend rehabilitation both in the acute phase, when patient has reached a minimum clinical stability, and in the post-acute phase.
- Even with rehabilitation, Recovery time is variable - depending upon the degree of normocapnic respiratory failure, and the associated physical and emotional dysfunction.
- A living guideline for allied health professionals recommends a case prioritisation process that explicitly considers for each patient, the potential impact of not receiving immediate rehabilitation on critical outcomes (i.e., risk of hospitalisation, extended hospital stay).
- The British Society of Rehabilitation Medicine recommends rehabilitation pathways provided by coordinated networks, starting service provision in intensive care units, followed by an acute rehabilitation programme with the opportunity for further triage into post-acute pathways in the network.
- Tele-rehabilitation tools are available to observe and communicate directly with patients and/or staff already in isolation areas (e.g., use of data-secure cameras, such as iPads and baby monitors). Models for cardiac rehabilitation in COVID-19 have also been described.
Archive Conducting virtual respiratory assessments and monitoring via telehealth
Added: 2 May 2020
What is the current evidence for conducting virtual respiratory assessments and monitoring in adults via telehealth?
- Conducting physical examinations remotely by telehealth is recognised to be a challenge in clinical practice.(1-3) However, there is evidence that telehealth assessments and monitoring can be carried out for a variety of respiratory illness, including chronic obstructive pulmonary disease (COPD), acute exacerbations of COPD (AECOPD), asthma, cystic fibrosis, pulmonary hypertension, interstitial lung disease and most recently, COVID-19.
- A previous Critical Intelligence Unit evidence check reported on a rapid review conducted by the Centre for Evidence-based Medicine (CEBM) at the University of Oxford, which found no validated tests for assessing breathlessness in acute primary care settings. The review identified insufficient evidence for the clinical accuracy of the Roth score test for breathlessness. It also advised against the use of smartphone apps to assess oxygen saturation.(4)
- A systematic review found that forced expiratory volume, assessed daily by using a spirometer, was the most common modality of remote respiratory assessments in people with COPD. Other measurements included resting respiratory rate, respiratory sounds and end-tidal carbon dioxide level. When combined with machine learning algorithms, remote assessments were found to be highly predictive of AECOPD. Daily remote respiratory assessments were found to be feasible and well tolerated in most people with COPD and had consistently high user satisfaction.(5)
Rapid evidence checks are based on a simplified review method and may not be entirely exhaustive, but aim to provide a balanced assessment of what is already known about a specific problem or issue. This brief has not been peer-reviewed and should not be a substitute for individual clinical judgement, nor is it an endorsed position of NSW Health. Evidence checks are archived a year after the date of publication.