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Impact of COVID‐19 on pediatric pulmonology healthcare practice

Abstract Introduction Coronavirus 2019 (COVID‐19) is typically spread by droplets and has had a remarkable effect on pediatric pulmonology healthcare practice. Here, we aimed to evaluate the effect of the COVID‐19 pandemic on the clinical follow‐up and hospital visits of patients followed up at a pediatric pulmonology unit at a tertiary care center. Methods This study was an observational descriptive study performed at a tertiary care center pediatric pulmonology unit between January 2019 and December 2020. We analyzed the outpatient visits, laboratory procedures which including pulmonary function tests (PFTs), diffusion capacity assessment, plethysmography, and lung clearance index (LCI), high‐speed video microscopy, gastric aspirate sampling, and Flexible fiberoptic bronchoscopy (FFB) during clinical follow‐up, and hospitalization numbers of patients with chronic lung diseases during the COVID‐19 pandemic and compared them with the previous year before the pandemic started. Results In 2020, compared with 2019, outpatient visits decreased by 42.2%; from 8324 patients to 4804 patients and other laboratory procedures decreased after the pandemic started; PFTs including spirometry by 87.2%; from 2990 to 380 tests, diffusion capacity assessment from 172 to 55 tests, plethysmography from 172 to 53 and LCI from 70 to 9 tests, also high‐speed video microscopy analyses by 64.3% from 300 to 107 patients, and gastric aspirate sampling by 75.5% from 42 to 9 patients. FFB procedures also decreased by 59.1%, from 142 to 58 patients, and only 15 were after the first reported case of COVID‐19 in our country, and they were all for urgent indications. None of these patients was positive pretesting for COVID‐19 who underwent the FFB. There was no significant decrease in patients' hospitalization due to pulmonary exacerbation in cystic fibrosis, interstitial lung disease, and primary ciliary dyskinesia.


| Study design
This study was an observational descriptive study performed at a tertiary care children's hospital's pediatric pulmonology unit between January 2019 and December 2020. Our centre is a reference centre in our country, and we follow up children between 0 and 18 years mainly with cystic fibrosis (CF), primary ciliary dyskinesia (PCD), interstitial lung diseases (ILD), recurrent pneumonia, pleural effusion, tracheostomy, non-CF bronchiectasis, sleep disorders, difficult-totreat asthma and immune deficiency. Annual outpatient visits, laboratory procedures including pulmonary function tests, diffusion capacity assessment, plethysmography, and lung clearance index (LCI), high-speed video microscopy, gastric aspirate sampling, and FFB during clinical follow-up were recorded for the comparison of 2019 and 2020. Pulmonary function testing is routinely used to assess lung disease in children and adolescents, they can help physicians in the decision-making process. 9 High-speed video microscopy of ciliary beat frequency and pattern is used for the diagnosis of PCD using the nasal brushing method. 10 Flexible bronchoscopy is a procedure enabling visualization, sampling, and treatment of the airways of children. 11 Gastric aspirate sampling is used in the differential diagnosis of tuberculosis in patients who may not be able to expectorate respiratory secretions.
Hospitalization numbers of patients and acute pulmonary exacerbations (APEx) of patients with chronic lung diseases, CF, ILD, and PCD were also recorded and the results were compared with the previous year.
Patients with CF who had at least four of any of the following were considered as having APEx: change in sputum; new or increased haemoptysis; increased cough; increased dyspnea; malaise, fatigue or lethargy; temperature above 38°C; anorexia or weight loss; sinus pain or tenderness, change in sinus discharge; change in physical examination of the chest; decrease in pulmonary function 10% by baseline, or radiographic changes indicative of pulmonary infection. 12 Patients with ILD who had at least two or more of the following criteria were considered as having APEx: increase in respiratory rate 20% from baseline, an increase in the development of dyspnea, newly developing or increased abnormalities on chest imaging, onset/increase in oxygen demand to attain the individual baseline saturation, need for an additional level of ventilator support, decrease in spirometry (10% from baseline for vital capacity), and reduced exercise tolerance. 13 Three or more of the following definitions must be present with PCD to be considered as APEx: increased cough, change in sputum volume and/or colour, increased shortness of breath perceived by the patient or parent, the decision to start or change antibiotic treatment because of perceived pulmonary symptoms, malaise, tiredness, fatigue or lethargy, new or increased haemoptysis and temperature more than 38°C. 14

| Statistical analysis
The SPSS V. 22.0 (IBM Corp.) software was used for statistical analyses. Patient outpatient visits, hospitalization, and laboratory procedures are presented as numbers and percentages of the total. We compared the results with the year before the pandemic and during the COVID-19 outbreak.     Early in the pandemic, for our patient group with chronic lung disease, the National Institute for Health and Care Excellence recommended minimizing face-to-face contact by pausing unnecessary outpatient checkups. 15,16 Later, many professional societies published recommendations for precautions during pediatric pulmonology procedures. [17][18][19] Similarly, in this study, we saw that our In pediatric pulmonology practice, PFTs are routinely used to assess lung disease in children and adolescents, which can help physicians in the decision-making process. 9 They are usually used to diagnose pulmonary exacerbations during the follow-up of chronic lung diseases. 10 The American Thoracic Society (ATS) raised concerns about PFTs "as a potential avenue for COVID-19 transmission due to the congregation of patients with lung disease and because of the potential for coughing and droplet formation". 22 The ATS recommended that PFTs be limited only to immediate treatment decisions, and PPE for HCWs should be discussed with local infection control teams. As these recommendations were taken into account, F I G U R E 2 The numbers of pulmonary function tests during both years. DLCO, diffusion capacity assessment; LCI, lung clearance index [Color figure can be viewed at wileyonlinelibrary.com] there was a significant decrease in PFTs in the pandemic year compared with previous years, including spirometry, in our clinic. In addition, all our staff wore PPE while performing PFTs, and none was infected with COVID-19.

| Evaluation of therapeutic procedures
Microbiologic diagnoses of diseases depend on the detection of microorganisms in respiratory samples. Regular comprehensive microbiologic evaluations of sputum samples taken from the lower respiratory tract are significant. From some patients who may not be able to expectorate respiratory secretions, samples can be collected using gastric aspirate and induced sputum or bronchoalveolar lavage. 11 During the pandemic, gastric aspiration may be preferred over induced sputum because it emits less aerosol. 18 Also, the use of nebulisers should be avoided to decrease the risk of disseminating COVID-19 unless an airborne infection isolation room is available. 23 Our use of gastric aspirate and nebuliser notably reduced in the pandemic year.
Bronchoscopy is an essential and safe method to diagnose and treat airway and lung problems in infants and children. 11  infection. In all patients with negative results, the procedure is performed using PPE, including a face shield, gown, gloves, and N-95 respirators or powered air-purifying respirators. 24 Fifteen patients underwent FFB at our clinic after the first reported case of COVID-19 in our country, and they were all for emergencies.