Spirometry is useful for the diagnosis, management and monitoring of
chronic respiratory conditions in children, especially asthma. As severe
acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can be transmitted
via aerosol generation, coughing or sneezing [1], spirometry can
pose a risk for transmission of the virus as the procedure requires
generation of high minute ventilation and flow, and for the patient to
be in close contact with the technician and equipment. We have tried to
extrapolate information from adult guidelines on spirometry during the
COVID-19 pandemic.
As the pandemic evolves over time, prevalence can be
classified to be in the pandemic phase, post-peak phase or post-pandemic
phase, with high, low or controlled community prevalence, respectively.
This can be determined by the local health authorities. Level 1 safety
recommendations are suggested for those places in the pandemic phase,
Level 2 in the post-peak phase, and Level 3 in the post-pandemic phase
[2].
Indication for spirometry: During the
pandemic phase and post-peak phase, clinicians should restrict referrals
for spirometry to those patients who require it urgently or when it is
essential for their diagnosis [3]. A pediatrician can teleconsult the
patient and determine the need for spirometry, to reduce the number of
visits of a child to the hospital. One should; however, not perform
spirometry on patients with a clinical suspicion of COVID-19,
influenza-like illness (ILI) or severe acute respiratory infections
(SARI) [4]. In children who test positive for COVID-19 infection, all
pulmonary function tests (PFTs) should be deferred for at least 30 days
post-infection, as viral shedding can occur even after 10 days.
Guidelines for performing spirometry: The
following are the Level 1 safety precautions one must follow while
performing a spirometry in children during the pandemic phase. Similar
precautions are advised for Level 2 in post-peak phase as it might be
difficult to determine pre-test probability of infection in children.
• Screening: The clinician or technician
performing the test, the child and the caregiver, should all be
screened prior to entering the PFT room. A proposed triage
questionnaire is available in the European Respiratory Society
statement [2]. Patients who screen positive should not undergo
spirometry.
• Infrastructure: Under ideal
conditions, negative pressure rooms or HEPA filtration systems with
UV germicidal lamps are recommended. However, this may not be
available in most centres. Hence, at least a separate enclosed room
with adequate ventilation should be designated for performing
spirometry [2]. Waiting areas should be re-organized to ensure
patients are not in contact with those who are febrile. Thorough
cleaning and ventilation of both the room and equipment needs to be
performed between each test [5]. The number of air exchanges between
procedures need to be determined by each facility to ensure removal
of 99.0-99.9% of airborne microorganisms calculated as per CDC
guidelines [6]. Only one caregiver, who must wear a face mask and
follow hand hygiene procedures, should be allowed into the room [5].
• Staff: The person performing the
spirometry in the pandemic and post-peak phases should wear full
personal protective equipment (PPE) which includes a fit tested N95
mask, eye goggles or face shield, apron and disposable gloves [7].
Strict hand hygiene protocols must be followed by both the operator
and the patient.
• Equipment: Equipment should be cleaned
and disinfected by wiping down all surfaces that the patient comes
in contact within a 2-metre radius, using a hospital grade antiviral
disinfectant such as 70% isopropyl alcohol (IPA). Recalibration of
the equipment after decontamination is suggested [2]. Single use
bacterial and viral in-line filters of high specification are
required to be used. The ideal filter is one with minimum proven
efficiency for high expiratory flow of 600 to 700 L/min [8]. Replace
all consumables to single use or disposable ones, wherever possible.
Appointments need to be staggered with a gap of 45-60
minutes, taking into consideration the time required for donning and
doffing of PPE by the clinician/technician between each patient,
post-test cleaning of the room and equipment, and recalibration of the
spirometer [5].
All these safety recommendations for performing
spirometry must be maintained till the local public health authorities
can confirm that the community spread is controlled and the district is
in the post-pandemic phase. More specific guidelines for performing lung
function tests in children will need to be formulated by global
organizations as the pandemic evolves.
1. Anderson EL, Turnham P, Griffin JR, Clarke CC.
Consideration of the aerosol transmission for COVID-19 and Public
Health. Risk Anal. 2020;40:902-07.
2. European Respiratory Society. Recommendation from
ERS Group 9.1 (Respiratory function technologists/scientists): Lung
function testing during COVID 19 pandemic and beyond. Available from:
https://ers.app. box.com/s/zs1uu88wy51monr0ewd990itoz4tsn2h.
Accessed July 18, 2020.
3. American Thoracic Society. Pulmonary Function
Laboratories: Advice regarding COVID-19. 2020. Available from:
https://www.thoracic.org/professionals/clinical-resources/disease-related-resources/pulmonary-function-laboratories.php.
Accessed July 18, 2020.
4. Global Initiative for Asthma. Global Strategy for
Asthma Management and Prevention, Updated 2020. Available from:https://ginasthma.org/wp-content/uploads/2020/04/GINA-2020-full-report_-final-_wms.pdf.
Accessed July 18, 2020.
5. Canadian Thoracic Society. Resumption of pulmonary
function testing during the post-peak phase of the COVID-19 pandemic: A
position statement from the Canadian Thoracic Society and the Canadian
Society of Respiratory therapists. Available from:
https://cts-sct.ca/wp-content/uploads/2020/07/CTS_CSRT_COVID_
PFT_Final-July12_2020.pdf. Accessed July 17, 2020.
6. Centers for Disease Control and Prevention (CDC).
Guidelines for Environmental Infection Control in Health-Care
Facilities: Recommendations of CDC and the Healthcare Infection Control
Practices Advisory Committee (HICPAC), Update 2019. Available from:
https://www.cdc.gov/infectioncontrol/pdf/guidelines/
environmental-guidelines-P.pdf. Accessed July 26, 2020.
7. American Academy of Allergy Asthma and Immunology.
Spirometry during COVID-19. Available from:
https://www.aaaai.org/ask-the-expert/spirometry. Accessed July 17,
2020.
8. Unstead M, Stearn MD, Cramer D, Chadwick MV,
Wilson R. An audit into the efficacy of single use bacterial/viral
filters for the prevention of equipment contamination during lung
function assessment. Respir Med. 2006;100:946-50.
