Clinical Interventions Following Escalations from a Continuous Respiratory Monitoring Service in Patients With Chronic Obstructive Pulmonary Disease.

Background: Continuous respiratory monitoring can support integrated care for chronic obstructive pulmonary disease (COPD) patients, by coupling them with remote clinical personnel who triage patients in coordination with their health care providers. When deploying such services, there remains uncertainty surrounding outcomes when at-risk patients are proactively identified and escalated for provider evaluation. This study presents findings from a service deployed in a real-world COPD cohort by analyzing the clinical interventions made during in-person and telehealth pulmonary outpatient visits following remote escalations. Methods: A single-center, retrospective, observational study of real-world COPD patients at a multi-site pulmonary practice was conducted. Patients who were enrolled in a continuous respiratory monitoring service for at least one year and were seen by a provider within seven days of an escalation by the service (N=168) were included. To evaluate the potential impact of these escalations on provider and patient burden, medical charts from outpatient visits were manually reviewed and grouped into six categories based on the clinical action(s) taken by the provider. Results: A total of 245 outpatient visits occurred from 168 patients within seven days of escalation. Of the 245 visits, 206 (84.1%) resulted in clinical intervention and 163 (66.5%) resulted in treatment consistent with acute exacerbations of COPD (AECOPDs). 1.6% of the outpatient visits resulted in referral to the emergency room. Conclusion: Provider encounters occurring following the escalation of a patient from a continuous respiratory monitoring service consistently resulted in that provider administering a treatment to the escalated patient.

Use of Remote Cardiorespiratory Monitoring is Associated with a Reduction in Hospitalizations for Subjects with COPD.

Background: Chronic obstructive pulmonary disease (COPD) is prevalent and results in high healthcare resource utilization. The largest impact on health status and proportion of healthcare costs in COPD are related to hospitalizations for acute exacerbations. Accordingly, the Centers for Medicare & Medicaid Services have advocated for remote patient monitoring (RPM) to aid in chronic disease management. However, there has been a lack of evidence for the effectiveness of RPM in reducing the need for unplanned hospitalizations for patients with COPD. Methods: This pre/post study was a retrospective analysis of unplanned hospitalizations in a cohort of COPD subjects started on RPM at a large, outpatient pulmonary practice. The study included all subjects with at least one unplanned, all-cause hospitalization or emergency room visit in the prior year, who had elected to enroll in an RPM service for assistance with clinical management. Additional inclusion criteria included being on RPM for at least 12 months and a patient of the practice for at least two years (12 months pre- and post-initiation of RPM). Results: The study included 126 subjects. RPM was associated with a significantly lower rate of unplanned hospitalizations per patient per year (1.09 ± 0.07 versus 0.38 ± 0.06, P<0.001). Conclusion: Unplanned, all-cause hospitalization rates were lower in subjects started on RPM for COPD when compared to their prior year. These results support the potential of RPM to improve the long-term management of COPD.

Early identification and treatment of COPD exacerbation using remote respiratory monitoring.

Remote patient monitoring (RPM) is increasingly more accessible and accurate. The optimal utilization of RPM requires medical conditions which have predictive physiologic changes and effective outpatient therapies. Respiratory rate elevation has been shown to be predictive of impending chronic obstructive pulmonary disease (COPD) exacerbation and treatment often focuses on home-based medical therapies. In this case, we report the successful treatment of a patient with an exacerbation of COPD based on pre-identification via respiratory RPM.

Post-acute care management of a patient with COVID-19 using remote cardiorespiratory monitoring.

Hospital discharge planning can be complex and hospital space is often limited. Patients, including those with COVID-19, can have prolonged symptoms after discharge and often require ongoing monitoring. Furthermore, prolonging hospital stays primarily for monitoring can expose patients to iatrogenic and infectious risks. The patient's overall condition and their home support system factor into the decisions of when and where to discharge patients. Innovations in remote patient monitoring (RPM) now allow for more options in the discharge process. This case report presents a patient with severe COVID-19 pneumonia where RPM was used at discharge to improve home monitoring and clinical follow-up. Additional experience with RPM is necessary to refine its role in post-acute care monitoring.

Early Identification of COVID-19 Infection Using Remote Cardiorespiratory Monitoring: Three Case Reports.

BACKGROUND: The adoption of remote patient monitoring (RPM) in routine medical care requires increased understanding of the physiologic changes accompanying disease development and the proactive interventions that will improve outcomes. OBJECTIVE: The aim of this study is to present three case reports that highlight the capability of RPM to enable early identification of viral infection with COVID-19 in patients with chronic respiratory disease. METHODS: Patients at a large pulmonary practice who were enrolled in a respiratory RPM program and who had contracted COVID-19 were identified. The RPM system (Spire Health) contains three components: (1) Health Tags (Spire Health), undergarment waistband-adhered physiologic monitors that include a respiratory rate sensor; (2) an app on a smartphone; and (3) a web dashboard for use by respiratory therapists. The physiologic data of 9 patients with COVID out of 1000 patients who were enrolled for monitoring were retrospectively reviewed, and 3 instances were identified where the RPM system had notified clinicians of physiologic deviation due to the viral infection. RESULTS: Physiologic deviations from respective patient baselines occurred during infection onset and, although the infection manifested differently in each case, were identified by the RPM system. In the first case, the patient was symptomatic; in the second case, the patient was presymptomatic; and in the third case, the patient varied from asymptomatic to mildly symptomatic. CONCLUSIONS: RPM systems intended for long-term use and that use patient-specific baselines can highlight physiologic changes early in the course of acute disease, such as COVID-19 infection. These cases demonstrate opportunities for earlier diagnosis, treatment, and isolation. This study supports the need for further research into how RPM can be effectively integrated into clinical practice.

Heterogeneity in combined pulmonary fibrosis and emphysema.

BACKGROUND: Combined pulmonary fibrosis and emphysema (CPFE) is a unique disorder described in several case series of upper lobe emphysema associated with lower lobe fibrosis. Patients with this entity have relatively preserved lung volumes and spirometry but marked reductions in diffusing capacity on pulmonary function testing. Smoking appears to be the predominant risk factor for this disorder. Usual interstitial pneumonia has been the most common histological pattern of interstitial lung disease described on biopsy in the literature. OBJECTIVES: To characterize the clinical, imaging and pathological features of a cohort of patients with CPFE. METHODS: Retrospective review of electronic medical record data, radiological imaging, and available lung biopsy specimens for a series of 10 patients with CPFE at the Providence VA Medical Center, Providence, R.I., USA. RESULTS: We describe a series of 10 patients with CPFE. All had severe reductions in diffusing capacity out of proportion to their lung volumes and spirometry. All had predominantly upper lobe emphysema on computed tomography; 8/10 had lower lobe subpleural reticular abnormalities and honeycombing, while 2 had lower lobe ground glass changes on imaging. These 2 patients demonstrated a pattern of interstitial lung disease on biopsy characterized by intra-alveolar macrophage accumulation in association with marked alveolar septal fibrosis, consistent with a variant form of desquamative interstitial pneumonia with extensive fibrosis. CONCLUSIONS: The imaging findings and pathology in patients with CPFE are heterogeneous.