Key Highlights From the Canadian Thoracic Society Position Statement on the Optimization of Asthma Management During the Coronavirus Disease 2019 Pandemic

Abstract

This commentary summarizes the Canadian Thoracic Society (CTS) position statement on managing asthma during the coronavirus disease 2019 (COVID-19) pandemic1Licskai C. Yang C.L. Ducharme F.M. et al.Addressing therapeutic questions to help Canadian physicians optimize asthma management for their patients during the COVID-19 pandemic.Can J Respir Crit Care Sleep Med. 2020; 4: 73-76Google Scholar in an easy, frequently asked question (FAQ) format. The full asthma position statement as well as other valuable clinical tools, including links to online self-management tools, can be found at the CTS website.2Canadian Thoracic SocietyCOVID-19: Information for Healthcare Professionals and the Respiratory Community.https://cts-sct/ca/covid-19/Date accessed: June 3, 2020Google Scholar In general, asthma maintenance and exacerbation management should continue according to national and international guidelines during the COVID-19 pandemic; however, treatment decisions should be individualized on the basis of patient characteristics. Optimal asthma control is expected to be the best protection against a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) exacerbation.3Global Initiative for AsthmaGlobal Strategy for Asthma Management and Prevention, 2019.https://ginasthma.org/wp-content/uploads/2019/06/GINA-2019-main-report-June-2019-wms.pdfGoogle Scholar, 4FitzGerald J.M. Lemiere C. Lougheed M.D. et al.Recognition and management of severe asthma: a Canadian Thoracic Society position statement.Can J Respir Crit Care Sleep Med. 2017; 1: 199-221Crossref Scopus (44) Google Scholar, 5Lougheed M.D. Lemiere C. Ducharme F. et al.Canadian Thoracic Society 2012 guideline update: diagnosis and management of asthma in preschoolers, children and adults.Can Respir J. 2012; 19: 127-164Crossref PubMed Scopus (215) Google Scholar, 6Ducharme F.M. Dell S.D. Radhakrishnan D. et al.Diagnosis and management of asthma in preschoolers: a Canadian Thoracic Society and Canadian Pediatric Society position paper.Can Respir J. 2015; 22: 135-143Crossref PubMed Scopus (80) Google Scholar The pandemic is a rapidly evolving situation. Health-care professionals are advised to monitor the national/international society websites, including that of the CTS, for resources and links to asthma action plans and tutorial videos for children and adults on the proper use of inhalers and puffers as well as updates on COVID-19 and lung diseases. A link to recommendations regarding the clinical treatment of patients in the event of a salbutamol metered dose inhaler shortage can also be found on the CTS website.2Canadian Thoracic SocietyCOVID-19: Information for Healthcare Professionals and the Respiratory Community.https://cts-sct/ca/covid-19/Date accessed: June 3, 2020Google Scholar No. Most studies to date suggest that patients with asthma have no greater risk of acquiring COVID-19 than the general population. In the largest studies published to date, with 44,672 patients (China) and 5,700 patients (United States), respectively, the prevalence of asthma in the COVID-19 population was below or approximated the expected general population prevalence; patients with asthma were not overrepresented.7Halpin D.M.G. Faner R. Sibila O. Ramon Badia J. Agusti A. Do chronic respiratory diseases or their treatment affect the risk of SARS-CoV-2 infection?.Lancet Respir Med. 2020; 8: 436-438Abstract Full Text Full Text PDF PubMed Scopus (243) Google Scholar, 8Epidemiology Working Group for NCIP Epidemic Response, Chinese Center for Disease Control and Prevention[The epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (COVID-19) in China].Zhonghua Liu Xing Bing Xue Za Zhi. 2020; 41 ([article in Chinese]): 145-151PubMed Google Scholar, 9Richardson S. Hirsch J.S. Narasimhan M. Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City area.JAMA. 2020; 323: 2052-2059Crossref PubMed Scopus (5348) Google Scholar Probably yes, but there is no direct evidence. Viral respiratory tract infections are a common cause of asthma exacerbations.10Jackson D.J. Johnston S.L. The role of viruses in acute exacerbations of asthma.J Allergy Clin Immunol. 2010; 125: 1178-1187Abstract Full Text Full Text PDF PubMed Scopus (267) Google Scholar Exacerbations requiring ED visits and hospitalizations increase annually at times when viral infections increase, typically week 38 on the calendar.11Johnston N.W. Sears M.R. Asthma exacerbations. 1. Epidemiology.Thorax. 2006; 61: 722-728Crossref PubMed Scopus (212) Google Scholar Nonpandemic coronaviruses have been associated with asthma exacerbations.12Satia I. Cusack R. Greene J.M. O’Byrne P.M. Killian K.J. Johnston N. Prevalence and contribution of respiratory viruses in the community to rates of emergency department visits and hospitalizations with respiratory tract infections, chronic obstructive pulmonary disease and asthma.PLoS One. 2020; 15e0228544Crossref PubMed Scopus (40) Google Scholar,13Zheng X.-Y. Xu Y.-J. Guan W.-J. Lin L.-F. Regional, age and respiratory-secretion-specific prevalence of respiratory viruses associated with asthma exacerbation: a literature review.Arch Virol. 2018; 163: 845-853Crossref PubMed Scopus (101) Google Scholar Possibly yes, but there is no direct evidence to answer this question. The Centers for Disease Control and Prevention identify people with asthma as a group that may be at higher risk for severe illness from COVID-19.14Centers for Disease Control and PreventionCoronavirus Disease 2019: Groups at Higher Risk for Severe Illness. 2020.https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/groups-at-higher-risk.htmlDate accessed: June 2, 2020Google Scholar Although comorbid illness is common in people who are admitted to hospital and in people who die of COVID-19, asthma has not been identified as an independent risk factor for severe illness or death. Regarding severe illness leading to hospitalization, two studies from China, one from Korea, and one from the United States did not find that hospitalized patients with asthma were overrepresented in the COVID-19 populations studied.9Richardson S. Hirsch J.S. Narasimhan M. Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City area.JAMA. 2020; 323: 2052-2059Crossref PubMed Scopus (5348) Google Scholar,15Zhang J-J, Dong X, Cao Y-Y, et al. Clinical characteristics of 140 patients infected with SARS-CoV-2 in Wuhan, China. Allergy. In press. https://doi.org/10.1111/all.14238.Google Scholar, 16Guan W.J. Ni Z.Y. Hu Y. et al.China Medical Treatment Expert Group for Covid-19. Clinical characteristics of coronavirus disease 2019 in China.N Engl J Med. 2020; 382: 1708-1720Crossref PubMed Scopus (17227) Google Scholar, 17Korean Society of Infectious Diseases; Korean Society of Pediatric Infectious DiseasesKorean Society of Epidemiology; Korean Society for Antimicrobial Therapy; Korean Society for Healthcare-associated Infection Control and Prevention; Korea Centers for Disease Control and PreventionReport on the Epidemiological Features of Coronavirus Disease 2019 (COVID-19) Outbreak in the Republic of Korea from January 19 to March 2, 2020.J Korean Med Sci. 2020; 35: e112Crossref PubMed Scopus (236) Google Scholar Regarding the risk of death from COVID-19, the Chinese Centre for Disease Control and Prevention reported a higher than average case-fatality rate for patients with “chronic respiratory disease” but did not evaluate asthma as an independent risk factor.8Epidemiology Working Group for NCIP Epidemic Response, Chinese Center for Disease Control and Prevention[The epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (COVID-19) in China].Zhonghua Liu Xing Bing Xue Za Zhi. 2020; 41 ([article in Chinese]): 145-151PubMed Google Scholar In contrast, a report from Italy reporting 481 deaths and one from China reporting 54 deaths did not identify asthma as a comorbid risk factor.18Palmieri L. Andrianou X. Bella A. et al.COVID-19 Surveillance Group. Characteristics of COVID-19 patients dying in Italy: report based on available data on March 20th, 2020.https://www.epicentro.iss.it/coronavirus/bollettino/Report-COVID-2019_20_marzo_eng.pdfDate accessed: June 2, 2020Google Scholar,19Zhou F. Yu T. Du R. et al.Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study.Lancet. 2020; 395: 1054-1062Abstract Full Text Full Text PDF PubMed Scopus (15780) Google Scholar No. Patients with asthma should restart or continue their prescribed inhaled corticosteroid or inhaled corticosteroid plus long-acting β2-agonist maintenance therapy to improve disease control and to reduce the severity of exacerbations, including exacerbations that may be caused by SARS-CoV-2. So far, yes. There is no evidence of harm caused by using prednisone to treat asthma exacerbations during the pandemic. The brief course of prednisone used to treat acute asthma exacerbation is not expected to compromise the immune system enough to increase chances of acquiring SARS-CoV-2 and/or developing COVID-19. Patients should use prednisone to treat severe asthma exacerbations, whether or not the exacerbation is triggered by SARS-CoV-2. Yes. There is no evidence that inhaled corticosteroids increase the risk of acquiring COVID-19 or that inhaled corticosteroids increase the severity of infection. Most importantly, inhaled corticosteroids are key to maintaining disease control in most patients with asthma, and well-controlled asthma is probably the best protection against a SARS-CoV-2-induced asthma exacerbation. Yes. Biologics are not expected to adversely affect the immune response to viral infection. In fact, omalizumab may protect against virus-induced exacerbations.20Esquivel A. Busse W.W. Calatroni A. et al.Effects of omalizumab on rhinovirus infections, illnesses, and exacerbations of asthma.Am J Respir Crit Care Med. 2017; 196: 985-992Crossref PubMed Scopus (158) Google Scholar Patients should continue using anti-IgE, anti-IL-5, and anti-IL-4/IL-13 monoclonal antibodies during the COVID-19 pandemic because they reduce the frequency of severe asthma exacerbations and, therefore, the likelihood of entering the health-care system. (Note: Anti-IL-4/IL-13 monoclonal antibody therapy is not currently approved in Canada for the management of severe asthma.) No, except for patients who are unable to use a metered dose inhaler with a spacing device or a dry powder device. Nebulizers may increase the risk of aerosol spread of viral particles and the risk of infection for health-care workers and caregivers.21van Doremalen N. Bushmaker T. Morris D.H. et al.Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1.N Engl J Med. 2020; 382: 1564-1567Crossref PubMed Scopus (5627) Google Scholar The recommendation to avoid nebulization applies to all patients, not only to patients who have confirmed or suspected COVID-19. Patients should continue using or switch to metered dose inhalers with spacing devices, or dry powder inhalers, to administer inhaled corticosteroids and short-acting bronchodilators. For patients unable to use a metered dose inhaler with spacing devices, or a dry powder inhaler, nebulizers may be used cautiously in compliance with applicable contact and droplet infection control standards. Yes. Patients with asthma should follow current local, national public, and global health advisories on physical distancing and isolation. Patients should work from home, if possible. If not possible, patients with severe asthma should stay away from work until the World Health Organization or local public health authorities declare that physical distancing is no longer necessary or appropriate work accommodations can be made.