Considerations for asthma management and viral transmission in the era of COVID-19

Background: As the global COVID-19 pandemic has unfolded, there has been much debate surrounding the optimal management of patients with asthma who are at risk of or contract COVID-19, whether asthma and steroids are risk factors for severe COVID-19, and how transmissible the virus is among children. Objective: The objective of this study is to provide allergists and other clinicians with pearls pertaining to the management of patients with asthma in the setting of the COVID-19 pandemic and to provide some information regarding the risk of transmission among the pediatric population. Methods: Utilizing the case of one of our own patients with asthma who developed COVID-19 as context, we review the recent literature discussing the risk of COVID-19 in patients with asthma, the management of asthma medications in the time of the pandemic, and the risk of viral transmission. Results: Despite initial reports that asthma was a risk factor for developing severe COVID-19, subsequent investigation has shown that this is likely not true. Additionally, the use of systemic or inhaled glucocorticoids does not appear to increase the risk of severe COVID-19, but there is no evidence guiding the use of biologic therapy. There is conflicting evidence regarding the ability of children to transmit the virus. Conclusion: We provide pearls that asthma does not appear to be associated with an increased risk of COVID-19 and continued use of inhaled corticosteroids appears to be safe. While there is no evidence guiding the use of biologic therapies, a recent position paper suggests that they should be continued unless a patient contracts COVID-19, at which point they should be held until clinical recovery occurs.

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Asthma and COVID-19: Emphasis on Adequate Asthma Control

Canadian Respiratory Journal ◽

10.1155/2021/9621572 ◽

2021 ◽

Vol 2021 ◽

pp. 1-12

Author(s):

David D. Nassoro ◽

Leodegard Mujwahuzi ◽

Issakwisa Habakkuk Mwakyula ◽

Mwajabu K. Possi ◽

Sylvester L. Lyantagaye

Keyword(s):

Asthma Control ◽

Seasonal Influenza ◽

Inhaled Corticosteroids ◽

Asthma Management ◽

Cell Mediated Immunity ◽

Level Of Evidence ◽

Increased Risk ◽

Wide Availability ◽

The Relationship ◽

Increased Susceptibility

Asthmatics are at an increased risk of developing exacerbations after being infected by respiratory viruses such as influenza virus, parainfluenza virus, and human and severe acute respiratory syndrome coronaviruses (SARS-CoV). Asthma, especially when poorly controlled, is an independent risk factor for developing pneumonia. A subset of asthmatics can have significant defects in their innate, humoral, and cell-mediated immunity arms, which may explain the increased susceptibility to infections. Adequate asthma control is associated with a significant decrease in episodes of exacerbation. Because of their wide availability and potency to promote adequate asthma control, glucocorticoids, especially inhaled ones, are the cornerstone of asthma management. The current COVID-19 pandemic affects millions of people worldwide and possesses mortality several times that of seasonal influenza; therefore, it is necessary to revisit this subject. The pathogenesis of SARS-CoV-2, the virus that causes COVID-19, can potentiate the development of acute asthmatic exacerbation with the potential to worsen the state of chronic airway inflammation. The relationship is evident from several studies that show asthmatics experiencing a more adverse clinical course of SARS-CoV-2 infection than nonasthmatics. Recent studies show that dexamethasone, a potent glucocorticoid, and other inhaled corticosteroids significantly reduce morbidity and mortality among hospitalized COVID-19 patients. Hence, while we are waiting for more studies with higher level of evidence that further narrate the association between COVID-19 and asthma, we advise clinicians to try to achieve adequate disease control in asthmatics as it may reduce incidences and severity of exacerbations especially from SARS-CoV-2 infection.

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Clinical utility of fractional exhaled nitric oxide in severe asthma management

European Respiratory Journal ◽

10.1183/13993003.01633-2019 ◽

2020 ◽

Vol 55 (3) ◽

pp. 1901633 ◽

Cited By ~ 11

Author(s):

Andrew Menzies-Gow ◽

Adel H. Mansur ◽

Christopher E. Brightling

Keyword(s):

Nitric Oxide ◽

Severe Asthma ◽

Inhaled Corticosteroids ◽

Healthcare Providers ◽

Asthma Management ◽

Cost Effective ◽

Chronic Inflammatory Disease ◽

Initial Diagnosis ◽

Increased Risk ◽

The Usa

Asthma is a chronic inflammatory disease of the airways, affecting over 350 million people worldwide and placing a significant burden on healthcare providers and wider society. Approximately 5–10% of asthma patients are diagnosed with severe asthma and typically are associated with increased risk of hospitalisation from exacerbations, increased morbidity, mortality and higher asthma-associated healthcare costs. Nitric oxide (NO) is an important regulator of immune responses and is a product of inflammation in the airways that is over-produced in asthma. Fractional exhaled NO (FeNO) is predominantly used as a predictor of response to inhaled corticosteroids (ICSs), to monitor adherence and as a diagnostic tool in ICS-naïve patients. In the UK, the National Institute for Health and Care Excellence (NICE) guidelines recommend the use of FeNO for the initial diagnosis of patients with suspected asthma. In the USA, American Thoracic Society (ATS) guidelines recommend FeNO as part of the initial diagnosis of asthma and for monitoring of airway inflammation. FeNO has also been shown to be a predictive factor for asthma exacerbations, with higher levels being associated with a greater number of exacerbations. In addition, higher levels of FeNO have been shown to be associated with a decline in lung function. FeNO testing is a cost-effective procedure and has been shown to improve patient management when combined with standard assessment methods. Recent evidence suggests that FeNO may also be useful as a surrogate biomarker for the assessment and management of severe asthma and to predict responsiveness to some biological therapies.

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Withdrawal of inhaled corticosteroids versus continuation of triple therapy in patients with COPD in real life: observational comparative effectiveness study

Respiratory Research ◽

10.1186/s12931-021-01615-0 ◽

2021 ◽

Vol 22 (1) ◽

Author(s):

Helgo Magnussen ◽

◽

Sarah Lucas ◽

Therese Lapperre ◽

Jennifer K. Quint ◽

...

Keyword(s):

Primary Care ◽

Triple Therapy ◽

Comparative Effectiveness ◽

Inhaled Corticosteroids ◽

Blood Eosinophil ◽

Research Database ◽

Effectiveness Study ◽

Increased Risk ◽

Comparative Effectiveness Study ◽

Oral Corticosteroids

Abstract Background Inhaled corticosteroids (ICS) are indicated for prevention of exacerbations in patients with COPD, but they are frequently overprescribed. ICS withdrawal has been recommended by international guidelines in order to prevent side effects in patients in whom ICS are not indicated. Method Observational comparative effectiveness study aimed to evaluate the effect of ICS withdrawal versus continuation of triple therapy (TT) in COPD patients in primary care. Data were obtained from the Optimum Patient Care Research Database (OPCRD) in the UK. Results A total of 1046 patients who withdrew ICS were matched 1:4 by time on TT to 4184 patients who continued with TT. Up to 76.1% of the total population had 0 or 1 exacerbation the previous year. After controlling for confounders, patients who discontinued ICS did not have an increased risk of moderate or severe exacerbations (adjusted HR: 1.04, 95% confidence interval (CI) 0.94–1.15; p = 0.441). However, rates of exacerbations managed in primary care (incidence rate ratio (IRR) 1.33, 95% CI 1.10–1.60; p = 0.003) or in hospital (IRR 1.72, 95% CI 1.03–2.86; p = 0.036) were higher in the cessation group. Unsuccessful ICS withdrawal was significantly and independently associated with more frequent courses of oral corticosteroids the previous year and with a blood eosinophil count ≥ 300 cells/μL. Conclusions In this primary care population of patients with COPD, composed mostly of infrequent exacerbators, discontinuation of ICS from TT was not associated with an increased risk of exacerbation; however, the subgroup of patients with more frequent courses of oral corticosteroids and high blood eosinophil counts should not be withdrawn from ICS. Trial registration European Network of Centres for Pharmacoepidemiology and Pharmacovigilance (EUPAS30851).

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Higher Omega-3 Index Is Associated with Better Asthma Control and Lower Medication Dose: A Cross-Sectional Study

Nutrients ◽

10.3390/nu12010074 ◽

2019 ◽

Vol 12 (1) ◽

pp. 74 ◽

Cited By ~ 2

Author(s):

Isobel Stoodley ◽

Manohar Garg ◽

Hayley Scott ◽

Lesley Macdonald-Wicks ◽

Bronwyn Berthon ◽

...

Keyword(s):

Fatty Acids ◽

Asthma Control ◽

Inhaled Corticosteroids ◽

Asthma Management ◽

Airway Disease ◽

Cross Sectional Study ◽

Erythrocyte Membranes ◽

Omega 3 ◽

Asthma Control Questionnaire ◽

Cross Sectional

Asthma is a chronic inflammatory airway disease, associated with systemic inflammation. Omega-3 polyunsaturated fatty acids (n-3 PUFA) have established anti-inflammatory effects, thus having potential as an adjunct therapy in asthma. This study aimed to compare erythrocyte n-3 PUFA in adults with (n = 255) and without (n = 137) asthma and determine the relationship between erythrocyte n-3 PUFA and clinical asthma outcomes. Subjects had blood collected, lung function measured and Juniper Asthma Control Questionnaire (ACQ) score calculated. Fatty acids were measured in erythrocyte membranes by gas chromatography, and the omega-3 index (O3I) was calculated (% eicosapentaenoic acid + % docosahexaenoic acid). O3I was similar in subjects with and without asthma (p = 0.089). A higher O3I was observed in subjects with controlled or partially controlled asthma (ACQ < 1.5) compared to subjects with uncontrolled asthma (ACQ ≥ 1.5) (6.0% (5.4–7.2) versus 5.6% (4.6–6.4) p = 0.033). Subjects with a high O3I (≥8%) had a lower maintenance dose of inhaled corticosteroids (ICS) compared to those with a low O3I (<8%) (1000 μg (400–1000) versus 1000 μg (500–2000) p = 0.019). This study demonstrates that a higher O3I is associated with better asthma control and with lower ICS dose, suggesting that a higher erythrocyte n-3 PUFA level may have a role in asthma management.

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The Role of Obesity in Motor Vehicle Injuries and Fatalities in the Pediatric Population: A Systematic Review

Journal of Intensive Care Medicine ◽

10.1177/0885066621992738 ◽

2021 ◽

pp. 088506662199273

Author(s):

Zana Alattar ◽

Shelby Hoebee ◽

Eyal Ron ◽

Paul Kang ◽

Eric vanSonnenberg

Keyword(s):

Systematic Review ◽

Risk Factor ◽

Motor Vehicle ◽

Pediatric Population ◽

Extremity Injury ◽

Obese Children ◽

Patients Âgés ◽

Vehicle Accidents ◽

Increased Risk ◽

Extremity Injuries

Purpose: A systematic review done to evaluate obesity as a risk factor for injuries and mortality in motor vehicle accidents (MVAs) in the pediatric population, as there has not been a systematic review done in over 10 years. This study aims to update the literature regarding obesity as a risk factor for injuries in MVAs in the pediatric population. Materials and Methods: A systematic review was conducted according to the PRISMA guidelines with strict inclusion and exclusion criteria, resulting in the use of 3 total articles to analyze obesity as a risk factor for overall injury and mortality in the pediatric population. Results: Zaveri et al demonstrated a statistically significant, but weak, decrease in the odds of extremity injury in overweight patients ages 2 to 17 years old (odds ratio [OR] = 0.6, 95% confidence interval [CI] = 0.4-1.0, P ≤ 0.05). On the other hand, Pollack et al and Haricharan et al found an increase in extremity injury in the obese population, in ages 9 to 15 years (OR = 2.54, 95% CI = 1.15-5.59, P ≤ 0.05), and 10 to 17 years (Age 10-13: OR = 6.06, 95% CI = 2.23-16.44, P ≤ 0.05, Age 14-17 OR = 1.44, 95% CI = 1.04-2.00, P ≤ 0.05), respectively. Haricharan et al also found an increase in thoracic injuries in obese children, ages 2 to 13 and increased risk of head/face/neck injury in obese children ages 2 to 5 (OR = 3.67, 95% CI = 1.03-13.08, P ≤ 0.05), but a decreased risk of head injury in obese children ages 14 to 17 (OR = 0.33, 95% CI = 0.18-0.60, P ≤ 0.05). Conclusions: There are sparse data that are conflicting, regarding the effect of obesity on extremity injuries in the pediatric population. Obesity is not protective against thoracic, head, or abdominal injuries. However, it was found to be a risk factor for trunk injuries in ages 2 to 13, as well as head/face/neck injuries for ages 2 to 5. Since the literature is so sparse, further research is warranted in these areas.

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A snapshot of general practitioner attitudes, levels of confidence and self-reported paediatric asthma management practice

Australian Journal of Primary Health ◽

10.1071/py11009 ◽

2011 ◽

Vol 17 (3) ◽

pp. 288 ◽

Cited By ~ 5

Author(s):

Jessica A. Roydhouse ◽

Smita Shah ◽

Brett G. Toelle ◽

Susan M. Sawyer ◽

Craig M. Mellis ◽

...

Keyword(s):

General Practitioners ◽

Management Practices ◽

Inhaled Corticosteroids ◽

Management Practice ◽

Controlled Trial ◽

Asthma Management ◽

Convenience Sample ◽

Paediatric Asthma ◽

Baseline Questionnaire ◽

Practitioner Attitudes

The prevalence of asthma in Australia is high. Previous findings have suggested that asthma management, particularly in primary care, remains suboptimal and recent government initiatives to improve asthma management and encourage the use of written asthma action plans (WAAPs) in general practice have been implemented. We aimed to assess the attitudes, confidence and self-reported paediatric asthma management practices of a convenience sample of Australian general practitioners (GPs). A baseline questionnaire was administered to GPs as part of a randomised controlled trial. General practitioners (GPs) were recruited from two areas of greater metropolitan Sydney, NSW between 2006 and 2008. Invitations were sent to an estimated 1200 potentially eligible GPs. Of 150 (12.5%) GPs that enrolled, 122 (10.2%) completed the baseline questionnaire. Though 89% were aware of the Australian National Asthma Guidelines, less than 40% were familiar with guideline recommendations. While 85.2% had positive attitudes towards WAAPs, only 45.1% reported providing them frequently. For children with frequent symptoms, 90% agreed they should prescribe daily, inhaled corticosteroids (ICS), and 83% reported currently prescribing ICS to such patients. These findings indicate gaps between GP attitudes and behaviours and highlights opportunities for interventions to improve paediatric asthma management.

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Abstract 3047: What Are the Effects of Nonsteroidal Anti-Inflammatory Drugs on Post-Cardiothoracic Surgery Outcomes?

Circulation ◽

10.1161/circ.116.suppl_16.ii_682-d ◽

2007 ◽

Vol 116 (suppl_16) ◽

Author(s):

Richard T Ruffin ◽

Jeffrey Kluger ◽

Stephanie M Wills ◽

C M White ◽

Craig I Coleman

Keyword(s):

Atrial Fibrillation ◽

Cardiothoracic Surgery ◽

Red Blood Cell Transfusion ◽

Beta Blockade ◽

Randomized Controlled ◽

Conflicting Evidence ◽

Increased Risk ◽

Inflammatory Drugs ◽

Surgery Outcomes ◽

Anti Inflammatory

Background: Two previous studies evaluating nonsteroidal anti-inflammatory drug (NSAID) use following cardiothoracic surgery (CTS) demonstrated conflicting evidence regarding their ability to reduce the incidence of postoperative atrial fibrillation (POAF). Moreover, neither study examined negative cardiovascular outcomes such as stroke and myocardial infarction (MI). Since a recent study evaluating paracoxib/valdecoxib following CTS demonstrated an increased risk of cardiovascular events, we sought to evaluate whether NSAIDs could reduce the incidence of POAF without increasing patients’ risk of stroke or MI. Methods: Patients (n=555) undergoing CTS from the randomized, controlled Atrial Fibrillation Suppression Trials (AFISTs) I, II and III were evaluated in this nested study. Demographic, surgical and medication use characteristics were prospectively collected as part of the AFIST trials. Endpoints included POAF, stroke, MI and the need for red blood cell transfusion. Multivariable logistic regression was used to calculate odds ratios with 95% confidence intervals. Results: The population was 67.8 ± 8.6 years old, 77.1% male, 14.6% underwent valve surgery, 6.1% had prior AF, 12.6% had heart failure and 84.0% and 44.1% received postoperative beta-blockade and prophylactic amiodarone. In total, 127 (22.9%) patients received a NSAID postoperatively. NSAID use was associated with reductions in the odds of POAF and the need for RBC transfusions. (Table ) No elevation in the odds of developing stroke or MI was observed. Conclusions: NSAIDs decreased the odds of developing POAF and the need for RBC transfusions without significantly increasing MI or stroke. Table. Effect of Nonsteroidal Anti-Inflammatory Drugs on Postoperative Outcomes

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The study of severe asthma in Latin America and Spain (1994-2004): characteristics of patients hospitalized with acute severe asthma

Jornal Brasileiro de Pneumologia ◽

10.1590/s1806-37132009000700004 ◽

2009 ◽

Vol 35 (7) ◽

pp. 635-644 ◽

Cited By ~ 11

Author(s):

Gustavo Javier Rodrigo ◽

Vicente Plaza ◽

Jesús Bellido-Casado ◽

Hugo Neffen ◽

María Teresa Bazús ◽

...

Keyword(s):

Latin America ◽

Severe Asthma ◽

Latin American ◽

Inhaled Corticosteroids ◽

Pulmonary Function Tests ◽

Tertiary Care ◽

Asthma Management ◽

Case Series ◽

Acute Severe Asthma ◽

The Mean

OBJECTIVE: Studies assessing the characteristics and management of patients hospitalized with asthma have been limited to a small number of facilities and have evaluated short time periods. The present study evaluated long-term changes among hospitalized asthma patients at a large number of facilities. METHODS: This was a retrospective, hospital-based observational case series, designated the Study of Severe Asthma in Latin America and Spain, which was conducted in Spain and in eight Latin-American countries. We reviewed the hospital records of 3,038 patients (age range, 15-69 years) hospitalized with acute severe asthma at one of nineteen tertiary-care hospitals in 1994, 1999 and 2004. RESULTS: Over time, the use of inhaled corticosteroids and long-acting β2 agonists increased significantly, whereas the use of theophylline as a controller medication decreased. The utilization of pulmonary function tests also increased. There was a significant reduction in the mean hospital stay (8.5 days, 7.4 days and 7.1 days in 1994, 1999 and 2004, respectively, p = 0.0001) and a significant increase in the mean of the lowest arterial pH at hospital admission. In contrast, there was a significant decrease in the proportion of cases in which PEF was determined in the emergency room (48.6% in 1994 vs. 43.5% in 2004, p = 0.0001). We found the quality of asthma management and care to be generally better in Spain than in Latin America. CONCLUSIONS: Although there have been certain improvements in the management of asthma between severe exacerbations and during hospitalization, asthma management remains suboptimal in Spain and, especially, in Latin America.

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Asthma Management at Discharge from the Emergency Department: A Descriptive Study

Canadian Respiratory Journal ◽

10.1155/2005/565862 ◽

2005 ◽

Vol 12 (4) ◽

pp. 219-222 ◽

Cited By ~ 4

Author(s):

Pascale Gervais ◽

Isabelle Larouche ◽

Lucie Blais ◽

Anne Fillion ◽

Marie-France Beauchesne

Keyword(s):

Emergency Department ◽

Inhaled Corticosteroids ◽

Tertiary Care ◽

Airflow Obstruction ◽

Asthma Management ◽

Descriptive Study ◽

Management Plan ◽

Oral Corticosteroids ◽

Tertiary Care Hospitals

BACKGROUND: The management of asthma remains suboptimal despite the publication of Canadian asthma guidelines in 1999.OBJECTIVES AND METHODS: A descriptive study was conducted to estimate the proportion of patients admitted to the emergency department (ED) for an asthma exacerbation who received a management plan at discharge that was in accordance with seven criteria stated in the Canadian asthma guidelines. The present study took place in two tertiary care hospitals in Montreal, Quebec.RESULTS: A total of 37 patients were enrolled. Three (8%) patients received a management plan at discharge that was in accordance with all seven criteria. Inhaled corticosteroids and oral corticosteroids were prescribed at discharge for 29 (78%) and 35 (95%) patients, respectively. Minimal asthma education was provided for 29 (78%) patients and a medical follow-up was recommended to 22 (60%) patients. Airflow obstruction was evaluated at discharge for only 20 (54%) patients.CONCLUSION: Overall, asthma management at discharge from the ED was generally not in accordance with the 1999 Canadian asthma guidelines. A standardized management plan should be implemented in the ED to improve the care of patients with asthma exacerbations.

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Managing asthma in pregnancy

Breathe ◽

10.1183/20734735.007915 ◽

2015 ◽

Vol 11 (4) ◽

pp. 258-267 ◽

Cited By ~ 19

Author(s):

Vanessa E. Murphy

Keyword(s):

Pregnant Women ◽

Inhaled Corticosteroids ◽

Action Plan ◽

Asthma Management ◽

Perinatal Outcomes ◽

List Type ◽

Night Time ◽

Exacerbation Rate ◽

Common Chronic Disease ◽

In Pregnancy

Asthma is a common comorbidity during pregnancy and its prevalence is increasing in the community. Exacerbations are a major clinical problem during pregnancy with up to 45% of women needing to seek medical help, resulting in poor outcomes for mothers and their babies, including low birth weight and preterm delivery. The goals of effective asthma management in pregnancy are to maintain the best possible asthma control and prevent exacerbations. This is achieved by aiming to prevent day- and night-time symptoms, and maintain lung function and normal activity. In addition, maintaining fetal oxygenation is an important consideration in pregnancy. Guidelines recommend providing asthma advice and review prior to conception, and managing asthma actively during pregnancy, with regular 4-weekly review, provision of a written action plan, use of preventer medications as indicated for other adults with asthma, and management of comorbid conditions such as rhinitis.Improvements have been made in recent years in emergency department management of asthma in pregnancy, and multidisciplinary approaches are being proposed to optimise both asthma outcomes and perinatal outcomes. One strategy that has demonstrated success in reducing exacerbations in pregnancy is treatment adjustment using a marker of eosinophilic lung inflammation, the exhaled nitric oxide fraction (FeNO). The use of an algorithm that adjusted inhaled corticosteroids (ICS) according toFeNOand added long-acting β-agonists when symptoms remained uncontrolled resulted in fewer exacerbations, more women on ICS but at lower mean doses, and improved infant respiratory health at 12 months of age. Further evidence is needed to determine whether this strategy can also improve perinatal outcomes and be successfully translated into clinical practice.Key pointsAsthma is the most common chronic disease to affect pregnant women.Exacerbations occur in up to 45% of pregnant women with asthma.Asthma should be managed during pregnancy as for other adults.Treatment adjustment using a marker of airway inflammation reduces the exacerbation rate in pregnancy.Educational aimsTo identify the goals of and steps associated with effective asthma management in pregnancy.To understand the maternal and perinatal risks associated with asthma during pregnancy.To describe a management strategy that has been shown to reduce exacerbations in pregnant women with asthma.

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