People with asthma and lung conditions are at higher risk for severe illness from COVID-19. While asthma alone may not increase risk of contracting the virus, poorly controlled asthma can lead to worse outcomes. It is important for those with asthma to continue controller medications like inhaled corticosteroids and use oral steroids for exacerbations. Nebulizers should be avoided outside the home due to increased risk of transmission. Symptoms of asthma exacerbation can mimic COVID-19, but fever is more indicative of the virus. Face masks may be difficult for some with severe asthma but provide protection if able to be tolerated.

1. 1

3. By

9. 28 June

12. Coronavirus Disease 2019 Case Surveillance — United States,
January 22–May 30, 2020
 Morbidity and Mortality Weekly Report (MMWR) / June 19, 2020
(Surveillance data reported to CDC through April 2020 indicated that
COVID-19 leads to severe outcomes in older adults and those with
underlying health conditions).

17.  IN USA ,As of May 30, 2020, among COVID-19 cases, the
most common underlying health conditions were:
1. Cardiovascular disease (32%),
2. Diabetes (30%)
3. Chronic lung disease (18%).
 Hospitalizations were six times higher and deaths 12 times higher
among those with reported underlying conditions compared with
with none reported.

19. What should people with a lung condition do now?
https://www.blf.org.uk/support-for-you/coronavirus [Last Assessed 27 March 2020]
Some people, including children, with long-term lung conditions who are at very high
risk of severe illness from coronavirus, are now advised to rigorously follow shielding
measures to keep themselves safe
Severe Asthma, severe Chronic Obstructive Pulmonary Disease (COPD)
Interstitial lung disease, including pulmonary fibrosis and sarcoidosis
Severe bronchiectasis, all types of cystic fibrosis
Lung cancer and mesothelioma, who are having active chemotherapy or radical radiotherapy

21. Are People with asthma at increased risk
of contracting COVID-19?

22.  No. Most studies to date suggest that asthma patients have no greater
risk of acquiring COVID-19 than the general population.
 As community testing for COVID-19 is still limited, it is impossible to say
with any certainty if any groups are more or less likely to contract the
disease.
 Most data on disease prevalence and outcomes come from people
hospitalised with COVID-19.

23.  In the largest studies published to date based on both US data and data
from China, the prevalence of asthma in the COVID-19 population was
below or approximated the expected general population prevalence;
asthma patients were not over-represented.
 At present, there is no evidence suggesting that people with asthma are
any more likely to contract COVID-19 than anyone else.

24.  The Canadian Thoracic Society have issued a position statement that
there does not appear to be an increased risk for PWA to acquire COVID-
19 infection.
 The British Thoracic Society states that it remains unclear whether
asthma is a risk factor for COVID-19 and COVID-19 related complications.
 It is important to remember we are dealing with an evolving pandemic
and new information could change the situation in the future.

25. Are people with asthma at higher risk of
severe illness or death from COVID 19?

27. The American College of Allergy, Asthma & Immunology (ACAAI) released this
statement on March 12, 2020:
“Patients with severe asthma, immunodeficiency, and other chronic
conditions where their immune system may be compromised are most
susceptible to increased morbidity and mortality from viral infections in
general.
We assume similar precautions should be recommended to these individuals
for coronavirus.”

28.  The Centers for Disease Control identify people with moderate-severe
asthma as a group that may be at higher risk for severe illness from
COVID-19.
 Despite warnings that asthmatics were at higher risk for severe illness
from the coronavirus, asthma is showing up in only about five percent
of NewYork State’s fatal COVID-19 cases. (Asthma was under-represented
in those who died from COVID-19).

29.  Asthma does not appear to be a strong risk factor for acquiring
COVID-19. However, poorly controlled asthma may lead to more
serious illness for those who contract COVID-19.

30. Are patients with asthma at risk of having an
exacerbation triggered by SARS-CoV-2
(COVID 19)?

31.  Respiratory viruses, including strains of coronavirus that cause the
common cold (Non-pandemic coronaviruses) , can trigger asthma
exacerbations, and it’s likely that COVID-19 could do the same.

32. In times Of COVID-19, Are inhaled steroids in
asthma OK to use or should you discontinue
them?

35.  “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, ICS 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 virus induced asthma exacerbation.”

36. Should asthma patients change treatment during the COVID-19
pandemic?
 No. Asthma patients should restart or continue their prescribed inhaled
corticosteroid or inhaled corticosteroid steroid plus long-acting beta2-
agonist maintenance therapy to improve disease control and to reduce
the severity of exacerbations, including exacerbations that may be
caused by SARS-CoV-2.

37.  In the current pandemic, the best thing a person with asthma can do is to
get and keep their asthma under control. Stopping a controller medication
will put the person at risk for developing an asthma exacerbation.
 In the current pandemic, treatment of an exacerbation will likely require
going to the emergency department , where the individual has a much
higher risk of being exposed to someone with COVID-19.
 So, in a way, by continuing to keep asthma under control, the person with
asthma is actually reducing their chance of exposure to COVID-19.

38.  People must continue to take their asthma medication as usual during
the pandemic. Keeping asthma symptoms under control is one of the
best methods people with asthma can take to protect themselves.
 According to the ACAAI, there is no evidence that asthma
medications will increase the risk of contracting the virus or worsen
outcomes of COVID-19.

39. Should Oral steroids still be used to treat asthma
exacerbations ?

40.  Regarding prednisone, when used briefly to treat acute asthma exacerbations,
it is expected the drug does not compromise users’ immune systems enough
to increase SARS-CoV-2 infection risk or the development of COVID-19.
 if a patient has an asthma attack, regardless of whether the trigger is COVID-
19, oral corticosteroids are usually effective and should be used.

41.  Many are wondering what should people with asthma do if their controller
medication is a steroid (inhaled or oral). The short answer is continue
taking your controller medications and do not stop them.
 People with asthma are placed on controller medications to keep their
asthma under control.

42. March 25, 2020

43.  People with asthma should continue all of their inhaled medication,
including inhaled corticosteroids, as prescribed by their doctor.
 In acute asthma attacks patients should take a short course of oral
corticosteroids if instructed in their asthma action plan or by their
healthcare provider, to prevent serious consequences.

44.  In rare cases, patients with severe asthma might require long-term
treatment with oral corticosteroids (OCS) on top of their inhaled
medication(s).
 This treatment should be continued in the lowest possible dose in
these patients at risk of severe attacks/exacerbations.

45.  While a patient is being treated for a severe attack, their
maintenance inhaled asthma treatment should be continued (at
home AND in the hospital).
 Patients with allergic rhinitis should continue to take their intranasal
corticosteroids, as prescribed by their clinician.

46.  Biologic therapies should be used in severe asthma patients who
qualify for them, in order to limit the need for OCS as much as
possible.
 Patients who are receiving biological therapies for their asthma should
not stop their biologics as there is no evidence these suppress immunity.

47. PCRS: Who are higher risk Asthma
patients?Targeted system search for patients considered to have higher risk asthma in relation to
COVID-19.
• PCRS advise these patients would benefit from a review of their asthma management,
particularly in their underuse of inhaled corticosteroids (ICS).
 6+ issues of SABA per year (suggesting poor control)
 12+ issues of SABA per year (suggesting very poor control)
 LABA but no corresponding issue of an inhaled corticosteroid (ICS) inhaler
 3+ issues of SABA in last 6 months with no corresponding issue of an inhaled
corticosteroid (ICS) inhaler (review to consider ICS inhaler use)
Primary Care Respiratory Society = PCRS

48. Who are very high risk Severe Asthma
patients?
https://www.blf.org.uk/support-for-you/coronavirus [Last Assessed 27 March 2020]
Asthma patients have been admitted to hospital in the last 12
months or ever been admitted to an intensive care unit for asthma.
OR
 Patients taking any biologic therapy or on maintenance OCS /antibiotic therapy
 Long acting muscarinic antagonist (LAMA)
 Combination Long acting beta agonist (LABA) & high dose inhaled corticosteroid
(ICS)
 high dose ICS & leukotriene receptor antagonist (LTRA)
OCS = oral corticosteroid

49. How can you tell the difference
between an
asthma attack and COVID-19 symptoms ?

50.  "One of the big differences between normal asthma worsening symptoms
and coronavirus is if you've had that fever"
 If you're asthmatic and have a fever, or have come into contact with
who has coronavirus, you should immediately get in touch with your health
care provider,

51.  Two of the main presenting symptoms of COVID-19 are cough & shortness
of breath, but those are also common presentations of worsening asthma.
For this reason, it is crucial to maintain good asthma control.
 COVID-19 also often comes with fever, body aches, loss of taste or smell,
which does help distinguish it from worsening asthma.

55. What should people with asthma do if they hav
symptoms of fever and cough?

56.  Remember that asthma symptoms can flare up for a number of reasons,
like seasonal allergies or an infection.
 You may be experiencing asthma symptoms due to an increased
exposure to indoor triggers, simply because you are spending more time
indoors.
 Respiratory symptoms associated with COVID-19 are very similar to
asthma symptoms, like shortness of breath and cough.

57.  Evolving research indicates that the symptom which differentiates
asthma from COVID-19 is experiencing a “new” fever.
 Fever has been most common of any symptom to date in confirmed cases
cases of COVID-19.
 If you experience a sudden fever in addition to respiratory symptoms, you
should immediately self-isolate and contact your healthcare provider
away for further advice.

58. Should I use my nebuliser or spacer for relief if I am
worried I might have coronavirus and my asthma is
bad?

60.  Nebulisers should, where possible, be avoided for acute attacks due
to the increased risk of disseminating COVID-19 (to other patients
AND to physicians, nurses and other personnel).
 Pressurized metered dose inhaler (pMDI) via a spacer is the
preferred treatment during severe attacks. (Spacers must not be
shared at home).

61.  Nebulizers administered within healthcare facilities were not recommended
by investigators,.
 The agent has been shown to increase the risk of aerosol spread of virus
particles, and therefore, the risk of infection among present healthcare
workers.
 “The recommendation to avoid nebulization applies to all patients, not only
to patients that have confirmed or suspected COVID-19 .

62. Nebulization should be avoided if possible
 Nebulization is an aerosol-generating medical procedure that can
increase the risk of aerosolization of SARS-CoV-2 and infection
transmission.
 A metered-dose inhaler with a valved holding chamber or a drypowder
inhaler (turbuhaler or diskus) is strongly preferred over nebulizers,
particularly in health care settings..

63.  Using salbutamol through a spacer can be as effective as nebulizers
 4-6 puffs from a salbutamol pMDI into a spacer with a patient
taking 2-3 tidal breaths is the same as a 2.5mg nebule of
salbutamol (BTS)

64. Are nebulizers OK to use at home?

65.  Sometimes patients have difficulty using handheld inhalers and
instead use nebulizers,
 If an asthma patient finds that nebulized therapy is more effective
than inhalers, the nebulizer should be used in a room that is isolated
from other household members.

66.  The biggest risk to people with asthma is not treating asthma
symptoms when needed at home.
 This can lead to visits to overcrowded emergency rooms with no
hospital beds.

67. SPIROMETRY DURING COVID-19

68.  Routine spirometry testing should be suspended to reduce the risk
of viral transmission, and if absolutely necessary, adequate infection
control measures should be taken.
1. Spirometry can disseminate viral particles and expose staff and
to risk of infection
2. While community transmission of the virus is occurring in your
region, postpone spirometry and peak flow measurement within
health care facilities unless there is an urgent need.
3. Follow contact and droplet precautions

69.  Nebulizer therapy, spirometry, sputum induction and rhinoscopy—all
considered high-risk exposure.
 The CDC recommends the use of appropriate PPE for any aerosol generating
procedures(AGPs), which includes testing patients (nasal swabs), the use of
nebulizers, peak flow meters, spirometry. Transmission may occur even from
asymptomatic individuals.

70. SMOKING AND COVID-19

72. As a smoker, is my risk of getting the COVID-19 virus higher than that
of a non-smoker?
 there are no peer-reviewed studies that have evaluated the risk of SARS-CoV-2
infection associated with smoking.
 However, tobacco smokers (cigarettes, waterpipes, bidis, cigars, heated tobacco
products) may be more vulnerable to contracting COVID-19, as the act of smoking
involves contact of fingers (and possibly contaminated cigarettes) with the lips,
which increases the possibility of transmission of viruses from hand to mouth.
 Smoking waterpipes, also known as shisha or hookah, often involves the sharing of
mouth pieces and hoses, which could facilitate the transmission of the COVID-19
virus in communal and social settings.
WHO 27 May 2020

79.  Tobacco use may increase the risk of suffering from serious symptoms due
to COVID-19 illness.
 Early research indicates that, compared to non-smokers, having a history
smoking may substantially increase the chance of adverse health
outcomes for COVID-19 patients, including being admitted to intensive
care, requiring mechanical ventilation and suffering severe health
consequences ,

87. Should People With Asthma Wear Face
Coverings or Masks During the COVID-1
Pandemic?

88.  Previously, the CDC and the WHO recommended that people not wear
masks to avoid spreading and getting COVID-19.This was based on
previous concerns that using masks incorrectly could actually spread
the virus more.
 New evidence shows that as many as 25 to 50% of people with COVID-
19 may not show symptoms, which means you can spread the virus
before you know you have it.

100. A face covering may not be best for everyone. According to the CDC,
these people should not wear face coverings:
1. Children under age 2
2. Anyone who has trouble breathing
3. Anyone who is unconscious, unable to help themselves or can’t remove
the mask on their own

101.  if you have a lung condition that makes
you breathless and find wearing a face
covering makes you feel too breathless,
don’t have to wear one.

102.  Some people with asthma may experience discomfort or have trouble
breathing while wearing a face covering.
 “For people with very mild asthma or well-controlled asthma, it’s probably
not going to be an issue”
 “For people who have very severe disease and have frequent
exacerbations, ER visits, hospitalizations, require lots of medications&
frequent symptoms, it might cause more issues for those folks.”

106.  If you have asthma, you may need to be cautious while wearing face
coverings during hot weather .
 Exercise is important for people with asthma. But wearing a mask
while exercising may make it harder to breathe.
 Continue to try to stay active, but avoid situations where you would
need a mask.

111. You must still continue to practice physical distancing even if you
wear a face covering.

116. Who are very high risk Severe COPD
patients?
https://www.blf.org.uk/support-for-you/coronavirus [Last Assessed 27 March 2020]
 Everyone who has severe or very severe airflow obstruction.
o FEV1 is less than 50%, GOLD grade 3 or 4.
 Patients who are limited by breathlessness
o mMRC breathlessness score of 3, 4 or 5.
 Prior emergency admission history
 2 or more exacerbations in the past year
o requiring OCS or antibiotics in GP or hospital setting
 Patients who are on maintenance OCS therapy.
 Patients who have oxygen therapy at home or use non-invasive ventilation (BiPAP)

117. Guidance for your COPD
patients
Global Initiative for Chronic Obstructive Lung Disease
• GOLD recognises people with COPD are amongst the worst affected by COVID-19.
• GOLD strongly encourages people with COPD to follow the advice of the public health teams
in their own countries to try to minimise the chance of becoming infected and on when and
how to seek help if they show symptoms of the infection.
• GOLD is not aware of any scientific evidence to support that inhaled (or oral)
corticosteroids should be avoided in patients with COPD during the COVID-19
epidemic.
• COPD patients should maintain their regular therapy.
• Oxygen therapy should be provided if needed following standard recommendations.
https://goldcopd.org/gold-covid-19-guidance/