Telemedicine, according to its first nomenclature reconciliation by the World Health Organization, was defined as “the delivery of health care services, where distance is a critical factor, by all health care professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of health care providers, all in the interests of advancing the health of individuals and their communities”.3

More recently, from a more operational perspective, telemedicine has been seen as the “distribution of health services in conditions where distance is a critical factor, by health care providers that use information and communication technologies to exchange information useful for diagnosis where a doctor is able to perform diagnosis at distance”4, having the potential of mediating patients’ contact with specialised care consultants.5 Although a broader concept of telehealth has been argued,4,6,7 for the purposes of this paper, ‘telemedicine’ and ‘telehealth’ are used interchangeably. There are core elements in telemedicine that must always be respected7:

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  its purpose of providing clinical support;

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  its intention to overcome geography issues, connecting patients to healthcare professionals in different locations;

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  its practice including the use of information and communication technologies;

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  its goal of improving health outcomes.

In Portugal, telehealth has been perceived as a core part of digital transformation strategies in health by addressing geographic inequalities and improving access to healthcare, thus improving the health system's effectiveness and efficiency.6 Indeed, good outcomes and promising local and regional strategies have been reported in our country.8,9

Furthermore, general standards for the legal practice of teleconsultations in Portugal have been established,10 including: respecting the doctor-patient relationship, ultimately not to be replaced by teleconsultations; ensuring the independence of physicians, who shall follow this practice when a good clinical overview of the patients’ condition is deemed possible; and ensuring that the physician has quality, complete, and sufficient information through teleconsultation to make a medical decision. In addition, a governmental guidance was released in 2015, focusing on teleconsultations between different healthcare institutions, with the objective of improving access to a specialised healthcare team even across long distances. That guidance falls outside the scope of this document as it applies to forms of doctor-doctor interaction where clinical cases of patients are discussed.

Teleconsultations make it possible to assess, diagnose, and treat patients remotely. These take place using one of two main approaches: remote patient–doctor contact while the patient remains at home; or the patient going to a local clinic or hospital, where other healthcare providers mediate the contact with a consultant physician. The latter is indicated in clinical conditions in which a clinical and/or biometric physical evaluation is required. Both approaches encompass several advantages,6,18–21 such as:

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  increasing access to specialists regardless of their national distribution;

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  improving articulation between different physicians and levels of care of the health system, namely by facilitating the communication between hospital physicians and general practitioners;

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  gains in care effectiveness, coupled with gains in comfort, time, and travel costs for patients;

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  supporting long-term home management of specific chronic health conditions;

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  reducing infections associated with healthcare services due to less crowded waiting rooms.

With regard to minimising infectious risks, critical during the pandemic of COVID-19, telehealth was established in a systematic review as very appropriate for reducing disease transmission and overall morbidity and mortality.22 It has been argued that the pandemic led to the development of more “sophisticated” telemedicine, by simplifying processes and reducing unnecessary complexity,23 although consensus practices remain to be established.24

Examples of good outcomes of telemedicine have been published, namely in Chronic Obstructive Pulmonary Disease – COPD.25 However, teleconsultations are not suitable for all patients and for all clinical situations.26 From a technological perspective, it is important to ensure adequate technical infrastructures (phone, computer, internet connection, as appropriate)27 and carefully keep in mind that “technology should always be adapted to the patient and not the reverse”.25 The transition to teleconsultation, with its related bureaucratic processes, at least at the beginning, does not seem to minimize consultation time. From a clinical perspective, some conditions are not adequately managed by teleconsultation,26–28 and some objectives of consultation may not be achieved with this modality.27 Finally, only clinicians duly trained in teleconsultation should perform it,29 and practices shall be standardised, compliant, and regulated.28

Video consultations have shown some advantages over audio (telephone) consultations,26 such as more personal contact between health professionals and patients,26,30,31 although strong evidence of their effectiveness is still lacking.24 These consultations are generally suitable for:

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  younger patients (< 65 years), with good digital literacy in the technological solution used;

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  follow-up consultations for clinically stable patients where a full physical exam is not expected to be necessary (as video consultations allow some parts of a physical examination to be performed). First consultations and consultations due to new symptoms should only be considered in very specific and well-defined clinical circumstances;

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  situations where the video is the preferred method for both clinician and patient.

On the other hand, telephone (audio) consultations tend to be shorter and have a more restricted patient disclosure of health problems than face-to-face consultations.30 These consultations may generally be appropriate for:

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  older patients (≥ 65 years) and/or those with poor digital skills in complex technological solutions;

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  settings where complex video call setup and/or technical infrastructures for video consultation are unattainable;

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  consultations aimed at addressing simple health concerns by the patient or the physician;

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  follow-up of clinically stable patients in which a physical examination is not necessary;

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  situations in which a teleconsultation is deemed appropriate by both clinician and patient, and telephone is their preferred method.

Finally, there are specific situations that should exclude the possibility of a teleconsultation,27,28 such as:

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  presence of acute respiratory symptoms;

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  new complications of underlying diseases;

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  consultations where severe prognostic circumstances are expected to be addressed;

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  or consultations where decompensation of underlying diseases cannot be correctly established.

From a general perspective, we find that it is important to highlight some essential principles for the correct implementation of teleconsultation in respiratory diseases – Table 1.

Main eligibility criteria are common to the different respiratory diseases.36 The particularities regarding specific diseases will be described below.

Inclusion Criteria

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  Adults (≥ 18 years) with a diagnosis of respiratory disease, with a suspected or diagnosed sleep-disordered breathing, or referred for smoking cessation;

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  Verbal or written consent to perform the teleconsultation;

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  Availability and familiarity with a suitable device - phone, mobile phone, tablet or computer;

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  Patients already followed by the department.

Exclusion Criteria

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  Current exacerbation or clinical instability requiring urgent physical examination;

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  Physical or cognitive impairment that makes the teleconsultation unfeasible.

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  First consultations for smoking cessation and sleep-disordered breathing may be suitable, as described below.

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  Follow-up consultations and hospital discharge follow-up consultations should be considered, respecting individual plans of care for each patient according to the disease and clinical condition. Renewal of therapy plans for medication and oxygen or ventilation therapies is a clear indication for teleconsultation.

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  An unscheduled consultation shall be considered if there is a need by the patient to have an additional consultation related to his/her condition. In this case, there should be an assessment of the situation through teleconsultation, and, if it is not possible to adequately resolve the problems, a face-to-face consultation should be proposed and scheduled.

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  Another potential use of teleconsultation is as initial screening of acute situations for chronic respiratory patients in home care, to better decide between a home visit or a face-to-face consultation in the hospital.

Guidance regarding respiratory tele-rehabilitation, given its own specificities, falls outside the scope of this document and will be described elsewhere.

In this document, we discriminate the disease-specific criteria for each of the follow-up consultations in the different respiratory diseases.

However, the preparatory steps apply to all of them, and are described below.

These recommendations only apply to follow-up consultations.

1. Guidance steps

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  Asthma Control Test (ACT) / Control of Allergic Rhinitis and Asthma Test (CARAT)

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  Peak expiratory flow meter, if applicable

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  Pulse oximeter, if available

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  Inhalers to explain inhaler technique (if video consultations) or pre-recorded videos on specific inhalers

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  Electronic prescription system

These recommendations apply to follow-up teleconsultations in patients diagnosed with lung cancer who have undergone previous curative surgery and do not require additional treatment beyond adjuvant therapy.

There are, however, some anecdotal lung cancer cases that can be considered after a long course of stability without treatment requirement, although that orientation should be validated by an accurate evaluation and decision from the multidisciplinary team meeting.

Apart from lung cancer, incidental pulmonary nodules follow-up requires serial chest CT evaluation and is guided by algorithms, posing a particular indication for teleconsultations.

1. Guidance steps

Follow-up teleconsultations may be considered for patients with suspected or diagnosed Nocturnal Hypoventilation Syndrome. This also applies to neuromuscular patients, depending on the speed of disease progression and clinical judgement.

Patients who require previous evaluation to start non-invasive ventilatory support are not suitable for teleconsultation. Also, patients of high complexity (e.g. Amyotrophic Lateral Sclerosis) or highly ventilator-dependent may require a face-to-face assessment, a home visit, or a scheduled hospital admission.

Considering the potential role of the caregiver, physical or cognitive impairment should not be regarded as exclusion criteria for teleconsultation.

1. Guidance steps

Interstitial Lung Diseases (ILDs) encompass a range of distinct diseases with substantial differences in their underlying pathophysiological mechanisms, therapeutic approach, and prognosis.

Regardless of ILD, all consultations during the diagnostic approach should be done face-to-face until the diagnosis is fully established at the Multidisciplinary Team meeting. Thereafter, diseases such as sarcoidosis or some smoking-related disorders (e.g. respiratory bronchiolitis associated with ILD), which often have a stable clinical course and do not need any significant therapeutic intervention, are much more suitable for teleconsultation. In contrast, in all other ILDs that require complex therapeutic interventions, such as immunosuppressants and antifibrotic agents, or have a more unstable clinical course with risk of progression, patients need to be assessed in person. Therefore, the modality of the consultation will depend on the nature of the disease and the particularities of the drugs prescribed.

1. Guidance steps