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Remote management of covid-19 using home pulse oximetry and virtual ward support

BMJ 2021; 372 doi: https://doi.org/10.1136/bmj.n677 (Published 25 March 2021) Cite this as: BMJ 2021;372:n677

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  1. Trisha Greenhalgh, professor1,
  2. Matthew Knight, consultant respiratory physician2 3,
  3. Matt Inada-Kim, consultant acute physician4 5,
  4. Naomi J Fulop, professor6,
  5. Jonathan Leach, general practitioner7,
  6. Cecilia Vindrola-Padros, postdoctoral researcher6
  1. 1Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
  2. 2West Hertfordshire Hospitals NHS Trust, Hertfordshire, UK
  3. 3West Hertfordshire Respiratory Service—Central London Community Healthcare, Hertfordshire, UK
  4. 4Hampshire Hospitals NHS Foundation Trust, Hampshire, UK
  5. 5NHS England, London, UK
  6. 6Department of Applied Health Research, University College London, London, UK
  7. 7Royal College of General Practitioners, London, UK
  1. Correspondence to T Greenhalgh trish.greenhalgh{at}phc.ox.ac.uk

What you need to know

  • Pulse oximeters used at home can detect hypoxia associated with acute covid-19

  • Home oximetry requires clinical support, such as regular phone contact from a health professional in a virtual ward setting

  • More research is needed to understand the safety and effectiveness of home oximetry and to optimise service models and referral pathways

Oxygen levels in covid-19

Low blood oxygen—technically, hypoxaemia but usually referred to as hypoxia—can be defined as a measured oxygen saturation below 94% in the absence (or below 88% in the presence) of chronic lung disease.1 In most patients who die of acute covid-19, the initial illness advances insidiously, sometimes with “silent hypoxia” (hypoxia without clinically perceptible symptoms of dyspnoea23), leading to pneumonia followed by acute respiratory distress syndrome, usually in week 2.4 The underlying pathology in covid-19 related hypoxia is probably a ventilation-perfusion mismatch,5 caused by a combination of intrapulmonary shunting, loss of lung perfusion regulation, intravascular microthrombi, and reduced lung compliance leading to alveolar collapse.267

Many patients hospitalised with acute covid-19 have severe hypoxia.478 Hypoxia, silent hypoxia, and the need for supplementary oxygen are all independent predictors of worse outcomes in covid-19.8910111213141516 Novel prognostic tools such as the 4C score have shown the importance of identifying hypoxia early,917 and there are physiological reasons for managing the complication promptly and actively.118

For all these reasons, UK guidelines recommend that assessment and monitoring of breathless, unwell, or high risk patients with suspected covid-19 should include pulse oximetry.1920 Guidance published in January 2021 by the World Health Organization includes a provisional recommendation for “use of pulse oximetry monitoring at home as part of a package of care, including patient and provider education and appropriate follow-up.”21

Pulse oximeters: practicalities and cautions

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