key: cord-0960962-5rgkasmz
authors: Saunders, Matthew J.; Haynes, Jeffrey M.; McCormack, Meredith C.; Stanojevic, Sanja; Kaminsky, David A.
title: How Local SARS-CoV-2 Prevalence Shapes Pulmonary Function Testing Laboratory Protocols and Practices During the COVID-19 Pandemic
date: 2021-05-15
journal: Chest
DOI: 10.1016/j.chest.2021.05.011
sha: 8d2ebf211efe3b3b72311429579853a3ec06d30e
doc_id: 960962
cord_uid: 5rgkasmz

nan

In March, 2020, the World Health Organization declared coronavirus disease 19 (COVID-19) a global pandemic. 1 Initially, hospitals canceled numerous elective and outpatient medical services, including non-urgent pulmonary function tests (PFTs). 2 Gradually these services were resumed in accordance with national guidelines. 3 Organizations including the American Thoracic Society (ATS) and others have since published recommendations regarding provision of respiratory services in the era of COVID-19. 4, 5 We aimed to evaluate which practices were being most widely adopted by PFT laboratories across the United States and to examine how community COVID-19 prevalence shaped those practices.

In August of 2020 we invited all members of the ATS PFT Laboratory Registry to complete an online survey, and we asked the American Association for Respiratory Care (AARC) to post an invitation to members of the AARC Diagnostics Section. The questionnaire collected information on how PFT laboratories were responding to the COVID-19 pandemic: demographics, including local COVID-19 prevalence according to the CDC coronavirus map. 6 ; clinical utility and aerosolgenerating potential (AGP) of specific PFT's; infection prevention; patient screening protocols; and laboratory functional status. We assessed associations by contingency analysis, with Chisquare p-value <0.05 indicating statistical significance (JMP Pro 15, SAS Institute, Inc.). The study did not require IRB review since it was considered a quality-related investigation.

Respondents completed the survey between August 17 th -October 31 st , 2020. From the ATS Registry, the response rate was 41%. Most of the 132 respondents indicated their clinical role as laboratory manager (48.8%), or PFT technology staff (35.1%). The majority of laboratories were in community and academic hospitals. Most laboratories were small (63%) and medium (31%) sized (size indicated in Table 1 ). Most academic laboratories were medium or large, J o u r n a l P r e -p r o o f whereas community, private, and other laboratories were primarily small (P<0.01). Fifty-one percent of laboratories were located in low COVID-19 prevalence areas, 28% in mediumprevalence areas, and 21% in high-prevalence areas. The results of the survey categorized by local prevalence of COVID-19 are highlighted in Table 1 .

Respondents indicated that they thought spirometry and diffusing capacity of the lung for carbon monoxide (DLCO) had the highest utility for patient care (Figure 1 ). The majority of laboratories (82%) reported that most PFTs were considered by their institution to be high AGP ( Figure 1 ), with no differences between types of laboratories (p=0.34). Several respondents commented that they were working to convince their administration that PFTs should be considered high AGP.

With respect to personal protective equipment (PPE), 98% of laboratories required that staff wear a facemask during PFTs, and that patients wear one except during testing. There were no differences between the use of N95 respirators and local COVID-19 prevalence (p=0.22), with 84% of laboratories using N95s for at least some procedures. In addition to masks, 95% of laboratories utilized eye protection, 85% used gloves, and 70% used protective gowns during PFT.

All laboratories disinfected surfaces and equipment in PFT rooms between patients, and 83% provided time for air exchange, with a mean (SD) duration of 31(28) minutes. Almost all laboratories (92%) reported using in-line antimicrobial filters in PFT equipment. Additionally, 95% of laboratories implemented waiting room precautions such as physical distancing, maskwearing policies, and hand hygiene. We found that high-efficiency particulate air (HEPA) filters and negative pressure systems were used to similar extents (37% and 36%, respectively), both J o u r n a l P r e -p r o o f being more common than UV sanitization (17%). No significant variation was observed among room and equipment disinfection protocols based on local prevalence of COVID-19.

Screening for symptoms of COVID-19 and temperature checks prior to PFT appointments were implemented at rates of 99% and 96%, respectively. Testing for SARS-CoV-2 by polymerase chain reaction (PCR) was adopted by 54% of laboratories, of which 58% required patients to have a negative test result within 5 days of their appointment. We also found that implementation of PCR testing differed significantly between high-prevalence areas (74%) and low-or medium-prevalence areas (51% and 39%, respectively) (P=0.02). For patients with a positive COVID-19 diagnosis, 41% of laboratories required a period of at least 14 days symptom-free prior to testing, and 43% required a period of at least 30 days. Only 9% of laboratories indicated wait times of 10 days or less.

Pulmonary services had largely been restored by the close of the survey, with 71% of laboratories reporting as fully operational, 28% partially operational, and 1% fully closed. Many respondents commented that testing volume was markedly reduced due to cleaning protocols required to maintain a safe testing environment. The number of laboratories conducting various tests during the survey period is illustrated in Figure 2 . It is noteworthy that only 70% of laboratories were conducting spirometry, which suggests that concern over the high AGP of spirometry was influencing laboratories not to perform it despite its high clinical utility.

Our survey has demonstrated that PFT laboratories have acted in accordance with ATS or ERS Implementation of some practices varied depending on local prevalence while others did not.

For example, PCR testing was more likely to be adopted in high-prevalence areas in comparison to low-or medium-prevalence areas, while N95 respirator usage among laboratories was relatively uniform. Some more resource-intensive measures were utilized to a lesser degree independent of prevalence. Despite all of these challenges, nearly three-quarters of laboratories in our sample were fully operational. We acknowledge important limitations to these results, which include small sample size, estimated to be <5% of all PFT laboratories, the timing of the survey, incomplete responses for Figure 2 data, and that non-operational laboratories or those following less stringent protective measures may not have responded.

Nevertheless, these results demonstrate the resilience and adaptability necessary to cope with the ever-changing demands of safely providing respiratory care during the COVID-19 pandemic. 

speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-oncovid

Addressing Reduced Laboratory-Based Pulmonary Function Testing During a Pandemic

Re-opening Facilities to Provide Non-emergent Non-COVID-19 Healthcare

Restoring Pulmonary and Sleep Services as the COVID-19 Pandemic Lessens: From an Association of Pulmonary, Critical Care, and Sleep Division Directors and

1 Statement on lung function during COVID-19

Aerosol generation during spirometry

Airborne particulate concentrations during and after pulmonary function testing

Supported by Vermont Lung Center, University of Vermont Larner College of Medicine, which had no specific role in the development of the study or the manuscript.