Discussion
The current COVID19 pandemic increased telemedicine’s need to monitor patients with chronic diseases like CF at home, to prevent contamination and disseminate COVID 1910. Although telehealth has been utilized previously in medicine in limited contexts, the onset of the COVID19 pandemic has prompted health systems worldwide to move into comprehensive telehealth monitoring.
One of the most significant achievements of our telephone visit program was the early detection of pulmonary exacerbations and infections and the corresponding antibiotic administration. As already known, surveillance for the development of pulmonary exacerbations is a fundamental component of chronic CF management. Early recognition and treatment of these episodes have an essential impact on the long-term decline in lung function, quality of life, and life expectancy11. We also identified patients who needed acute care and/or immediate admission to the hospital through telephone visits5,7.
Forced expiratory volume in 1 sec (FEV1) and the rate of FEV1 decline are significant markers of progressive lung disease and important predictors of mortality in CF patients12. The decline in lung function is typical of almost all patients with CF, and the rate of decline is variable with a mean value of -3.89±4% / year9,13. Interestingly there was an increase in FEV1 after the lockdown period, compared to the period before the COVID19 pandemic. This may be explained by the fact that our patients had fewer chest infections, probably because of the low spread of viral infections due to the lockdown measures and the fact that CF patients have always paid close attention to infection control and social distancing3. Home isolation with a low incidence of viral infections, less activeness, and more ultra-processed food eating may also explain the weight gain compared to the period before the COVID 19 pandemic.
Cystic fibrosis is a progressive disease with respiratory complications such as polyps, heamoptysis, pneumothorax, and non-pulmonary complications such as DIOS and CFRD. Close monitoring of the patients, early detection, and appropriate management of these complications is vital and was a success of the telephone monitoring project.
Physiotherapy is an essential component of care among the CF population, including airway clearance, exercise, and long-term sequels of musculoskeletal issues14. Due to social distancing measures, most families with CF patients have stopped performing physiotherapy with a physiotherapist as expected.
On the other hand, our patients were encouraged to follow shelf physiotherapy programs and physical exercise to maintain their physical fitness. Physical exercise forms an essential part of standard care for people with cystic fibrosis as it has multiple beneficial effects1. It contributes to maintaining pulmonary function, especially by improving airway clearance, delays the onset of osteoporosis, improves glycaemic control in CFRD, and decreases anxiety and depression15. Evidence indicates additional beneficial effects of exercise on muscle mass and function, body composition, and cardiorespiratory health16,17. Furthermore, exercise— aerobic or a combination of aerobic and strength—could help improve or mitigate the annual decline of forced expiratory volume in the first second and/ or peak functional capacity (VO2peak)17,18. The growing evidence indicates that exercise in patients with CF is an essential therapeutic tool in reducing morbidity and mortality rates and should be considered part of the standard of care19,20,21.
In the coronavirus outbreak and lockdown measures that were established, gyms have been closed, and team sports activities have been halted. Whereas a significant percentage of our CF population had made physical exercise part of its everyday life, during the lockdown days, they could not perform an exercise with appropriate prescription and monitoring, and thus they had to adapt to the new reality and change both the type and the frequency of exercise. Considering the importance of physical exercise for children and adolescents with CF, we need to encourage them to participate in alternative types of exercise programs to maintain their fitness even during the quarantine. An exercise program should be recommended and guided by a CF physiotherapy specialist and should include strength and endurance, balance and flexibility, following the principles of both ACSM22and EACPR23for exercise training.
Examples of alternative types of exercise during quarantine include aerobic exercise performed using ergometers, short walk/running movements inside the house, jumping, or skipping rope. Active videogames could also be used as a complement for their physical exercise program24.
Adherence to chronic therapies for patients with CF is a challenging problem, as poor adherence leads to negative health consequences25, Telephone contacts improved our patients’ awareness about the importance of adherence.
Our telephone visit program during the pandemic had beneficial health effects on our CF population. The application of more sophisticated tools (home spirometry, serial 24-hour SaO2 measurements, daily calorie measurements, etc.) might have further improved our patients’ individual needs and applied more precision medicine treatments. This must undoubtedly be a future goal. However, our results show that even a simple telephone visit program, which is a cheap and easily applicable solution, could have significant beneficial health effects in children with chronic diseases.