Senior lecturer in nursing shares her expert view on Covid-19
Lindsay Welch, Senior Lecturer in Nursing at Solent and a frontline nurse, talks to us this National Nurse's Week about how nurses are trained to deal with pandemic situations, and the impact COVID-19 is currently having on patients.
Hi Lindsay, can you tell us how nurses are trained for this kind of pandemic situation, and how the experience of Covid-19 might help to reinforce this training in the future?
Nurses are trained in barrier nursing and infection control, referred to as universal precautions.
It forms a core part of the first year nurse skills session and theory teaching.
Barrier nursing is taught in the Solent University Nursing Skills Lab and students are required to work in PPE (Personal Protective Equipment) and can practice ‘donning’ and ‘doffing’ their PPE in a safe environment.
The principles and practice of infection control in taught in the first year and reiterated through modules such as wound, skin care and complex care planning. Infection control underpins many nursing procedures and is a fundamental skill.
The COVID-19 pandemic has affirmed and highlighted the importance of this teaching and provides a clear example of how and when barrier nursing is appropriate, and provides a safe space at university to hone this skill.
Can you explain the immediate impacts Covid-19 has on patients’ respiratory systems?
In order to understand how the Covid-19 virus effects the respiratory system, a little refresher of anatomy and physiology is required.
The respiratory system starts at our nose, and is considered to be all one airway, containing the same epithelial cell structure, down through the trachea, dividing into the left and right bronchus then sub dividing again and again until the air reaches tiny alveoli sacs. The alveoli sacs facilitate gas exchange – the key part of respiration.
Therefore, in mild COVID we see the upper airways affected; this manifests as a loss of smell and taste, sore throat and mild breathlessness.
In severe cases the lower airways are affected, the alveoli. The virus causes cell death (through a complex chain of infection in immune response), this cell death and inflammation in the lower airways, the place where we exchange our oxygen and expel CO2, is directly affected, therefore hindering the process of gas exchange.
This presents clinically as acute breathlessness, and fever; the fever is the result of the immune system fighting the virus. The breathlessness is due to low oxygen levels or hypoxia. Low oxygen means that our other organs can be damaged, or even stop working if they do not get enough oxygen to enable them to function.
Is there any insight into the long term effects this can, or will, have on respiratory systems?
At the moment there are no long term studies (longitudinal studies) to provide us with a clinical evidence base to answer this question. We can apply learning from similar viral outbreaks, like MERS (Middle Eastern Respiratory Syndrome). However the virus is tending to be more serious in those people with underlying long term conditions and blood pressure problems.
People with pre-existing long term respiratory conditions have been advised to ‘socially shield’; stay completely isolated for 12 weeks. This in itself is challenging for the mental health and wellbeing of people with chronic illness.
Existing primary and community care services are still supporting all people with long term conditions thought video consultations and phone calls.
The British Thoracic Society is collating clinical evidence around rehabilitation of people who have recovered from COVID-19. Respiratory rehabilitation (often delivered by physiotherapists and occupational therapists) will highlight areas of concern and add to the clinical evidence base to enable others to treat the after effects of COVID-19.
These could be fatigue, ongoing breathlessness (due to damage in the lower area of the lung), and anxiety. We are yet to be able to measure any long term lung changes or lasting lung damage.
How do you treat people you can’t artificially ventilate?
As we have discussed the lower airways can be inflamed and damaged by COVID-19 and often when this is very severe we can use artificial ventilation to enable the lungs and the body the rest and fight the virus and the machines can take over.
Artificial ventilation can be invasive, this is the type of ventilation you see on the news. People who require this type of ventilation are very unwell, and have either lost consciousness or have unconsciousness induced because it is better for their body at that time. They are then intubated and the ventilator ensures that their lungs are adequately ventilated at the correct pressure, temperature and volume of gas. In this way the levels of oxygen can also be increased to the lungs to assist the body in distributing oxygen to the cells and organs.
Some people need this extra oxygen, but can remain awake to have support. This is Non-Invasive ventilation (NIV) and is referred to as BiPAP (Bi Positive Airways Pressure) or CPAP (Continuous Positive Airways Pressure). The NIV can have oxygen added to the system, in this way people who are struggling with hypoxia due to COVID-19 can have a tight mask fitted and oxygen forced into their lungs at a set volume and pressure.
In this way the lungs can be assisted with oxygenation and ventilation, whilst they are fighting the virus.