How COVID-19 Affects Patients with Asthma

This Guideline Knowledge Check reviews treatment guidelines for COVID-19 in patients with asthma. A 2020 Pulmonology Advisor discusses a recent study on the effects of COVID-19 on asthma. How do the study’s data alter the care of patients with asthma who require admission for COVID-19?

Today’s Guideline Knowledge Check question comes from the desk of Med-Challenger Emergency Medicine Editor-in-Chief, Andrea Eberly, MD, FAAEM.

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Try this COVID-19 asthma patient case question and find out if you’re following the most current guideline.

A 54 year-old female presents to the emergency department with worsening fever, cough, and shortness of breath.

She states that her symptoms began 6 days ago and that she received a positive SARS-CoV-2 test result 2 days ago.

She has never been a smoker, but she has a history of asthma and regularly uses a long-acting beta-agonist inhaler and inhaled corticosteroids.

She has no other comorbidities.

Question:

According to recent findings, how will the presence of asthma most likely impact her COVID-19 course?

Answer Options:

As compared to non-asthmatics, asthmatics present with more hypoxemia and severe radiological findings

Asthmatics and non-asthmatics with SARS-CoV-2 pneumonia are equally likely to require admission

Similar to other respiratory viruses, SARS-CoV-2 is associated with acute asthma exacerbations in patients with a history of asthma

Among admitted patients with SARS-CoV-2 pneumonia, asthma, obesity, diabetes, and cardiovascular disease are the leading comorbidities associated with a poor outcome

See the Answer:

The correct answer is:

Asthmatics and non-asthmatics with SARS-CoV-2 pneumonia are equally likely to require admission.

Key Point:

A recent small, prospective study found that asthmatics are not overrepresented among patients who require hospitalization for severe SARS-CoV-2 pneumonia. More specifically, 6.4% of the general population had a history of asthma, whereas only 5% of all patients requiring admission for SARS-CoV-2 infection had asthma.

Explanation:

A recent, small prospective cohort study in France followed a study group of asthmatics (N = 37 patients) and a matched control group without asthma (N = 75 patients) selected from 768 hospitalized patients with a confirmed diagnosis of COVID-19 pneumonia.

Study Group:

The asthmatics with COVID-19 (study group) were mainly female (70%), non-smokers (85%), and had a median age of 54 years. Nearly 60% had major comorbidities - defined as (1) cardiovascular disease, (2) obesity, (3) being overweight (a separate category), (4) diabetes, (5) renal disease, and (6) hypertension). The most common comorbidities were obesity (36%), hypertension (27%), diabetes (19%), and multiple comorbidities (40%). (Editor’s note: asthma was not considered a comorbidity).

At the time of admission, 30% of asthmatics were on long-acting-beta agonists (LABA) and a high dose of inhaled corticosteroids (ICS).

Their median time from onset of symptoms to admission was 6 days. A total of 50% of patients had an initial peripheral oxygen saturation below 95% while breathing room air and 25% had a respiratory rate above 30/min. A total of 30% were admitted to the intensive care unit with 8% of deaths occurring among those with comorbidities.

Control Group:

As compared to the study group, the matched controls showed a statistically non-significant trend towards being older and male, and having slightly more comorbidities, which may explain at least in part, the better outcomes in the study versus control group.

Pertinent study findings were:

The study group fared slightly better than the control group.
None of the asthmatics presented with an asthma exacerbation.
Mild wheezing was reported at admission in only 16% of asthmatics.
Baseline asthma therapy remained unchanged during the hospitalization of the asthmatic group.
As compared to the asthmatics (study group), the control group had more severe-to-critical radiological findings and a trend towards more severe hypoxemia, more pronounced lymphopenia and worse CRP, D-dimers, LDH, liver transaminases levels.
Worst outcomes were observed in patients with major comorbidities in both the study and control groups.

Bottom Line:

Asthma not a Risk Factor for Severe Disease: From these and other data, the researchers concluded that COVID-19 pneumonia was not associated with asthma exacerbation at admission and at one-month follow-up in patients who were compliant with their asthma treatment. These findings contrasts sharply with the observation that usually, viral respiratory infections, including other types of coronaviruses, are the main causes of asthma exacerbations.

Asthma Down-Regulates SARS-CoV-2 Receptor: The tendency amongst asthmatics towards milder SARS-Co-2 pneumonia may be explained by the fact that the airways cells of patients with respiratory allergy and/or asthma show a lower expression of SARS-CoV-2 cellular receptor angiotensin-converting enzyme-2 (ACE2).

Inhaled Steroids Down-Regulate SARS-CoV-2 Receptor: The researchers furthermore observed that pneumonia tended to also be less severe in the most asthmatics taking higher baseline doses of ICS. Indeed, sputum analysis showed that ACE2 expression levels are significantly lower in asthma patients taking ICS than in those not taking ICS, especially when high doses are administrated.

Reference:

Beurnier A, Jutant E-M, Jevnikar M, et al. Characteristics and outcomes of asthmatic patients with COVID-19 pneumonia who require hospitalisation. Eur Respir J. Published online July 30, 2020. doi:10.1183/13993003.01875-2020

Horby P, Lim WS, Emberson J, et al. Effect of Dexamethasone in Hospitalized Patients with COVID-19: Preliminary Report. medRxiv 2020. 2020.06.22.20137273.

COVID-19 and Asthma Guideline Update for Emergency Kidney Imaging - National Radiology Kidney Consensus statement provides new guidance regarding contrast-enhanced emergency imaging of patients with an abnormal renal history

About Guideline Knowledge Checks:

With each update of national clinical practice guidelines, some recommendations change and many remain unchanged. Med-Challenger Guideline Knowledge Checks help you know both what is new and what has stayed the same in the most recent guidelines pertinent to each medical specialty.

About the Author:

Andrea Eberly, MD, FAAEM graduated from the David Geffen Medical School of Los Angeles (UCLA) and completed her residency in Emergency Medicine at the University Medical Center, Tucson, Arizona. After working as an attending physician in Tucson, she followed a recruiting call to the island of Guam, where she served in various roles, including as the director of the emergency department, the EMS Medical Director of Guam, and the Director of the 911 Call System. She has maintained her emergency medicine board certification through three cycles of American Board of Emergency Medicine Board Exams (last in 2014), all three with the help of Med-Challenger.

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The correct answer is:

After resolution of symptoms, observe the asymptomatic patient for at least 6 hours; antihistamines and glucocorticoids do not reliably decrease risk of biphasic anaphylaxis and are not recommended for this purpose.

Key Point:

The AAAAI and ACAAI jointly emphasize that importance of:

1. identifying patients at increased risk for a recurrence of anaphylaxis within 1-72 hours (biphasic anaphylaxis), and secondly

2. understanding that neither antihistamines nor glucocorticoids ameliorate that risk.
They recommend an extended observation period for those at risk for biphasic anaphylaxis, with a suggestion that 6 hours observation of the asymptomatic patient may be sufficient, depending on the patient’s co-morbidities. The threshold for admission should be low in older patients and those with cardiovascular or other chronic disease (increased risk of fatal anaphylaxis also during the recurrence).

Explanation:

The AAAAI and ACAAI endorse a 3-category definition of anaphylaxis from 2006 that captures the full range of anaphylaxis presentations - from milder cases to those that lack classic features such as skin manifestations or hypotension. They state:

Anaphylaxis is likely when 1 of the following 3 categories applies:

a) Assumes rash, but not hypotension; 2 symptoms required: acute onset of an illness (minutes to hours) with involvement of the skin, mucosal tissue, or both with either respiratory involvement or reduced blood pressure and/or associated symptoms of end-organ dysfunction; or

b) Most flexible definition designed to capture milder cases, eg urticaria plus GI symptoms – 2 symptoms required: two or more of the following that occur rapidly after exposure to a likely allergen for the patient, including:

i. involvement of skin-mucosal tissue,
ii. respiratory involvement,
iii. reduced blood pressure or associated symptoms, or
iv. gastrointestinal symptoms; or i. involvement of skin-mucosal tissue,

c) Assumes hypotension, but not rash - 1 symptom required: reduced blood pressure as a result of exposure to a known allergen trigger.

In a patient who falls into one of the above categories for anaphylaxis, epinephrine is the first drug to be given, something that one study found to only occurs in 8% of patients due to the administration of antihistamines and glucocorticoids prior to epinephrine. Studies show that the delay of epinephrine is associated with increased fatality.

Antihistamines and glucocorticoids also do not reliably decrease the risk of biphasic anaphylaxis. It is estimated that at a 5% incidence rate of biphasic anaphylaxis, 72 patients would need to be treated with antihistamine and 161 patients with glucocorticoids, respectively, to possibly prevent one case of biphasic anaphylaxis. However, both agents can be given as secondary treatment to increase patient comfort. This is not to be confused with patients who have an allergic reaction without anaphylaxis, who do not require epinephrine and are routinely treated with antihistamines and glucocorticoids.

Finally, a 1-hour observation period of the ASYMPTOMATIC patient after resolution of anaphylaxis is sufficient in most non-severe cases of anaphylaxis (negative predictive value of 95% for occurrence of biphasic anaphylaxis) as long as the patient also does not have co-morbidities that increase the risk of a fatal outcome.

In patients with either a severe case of anaphylaxis or e.g. cardiovascular or other chronic morbidities, the optimal observation period is unknown. The authors suggest a minimum of a 6-hour observation period of the asymptomatic patient AFTER resolution of anaphylaxis (97.3% negative predictive value for occurrence of biphasic anaphylaxis). This extended observation period has been calculated to be cost-effective, based on an estimate that the extended observation period leads to an estimated 76% reduction in mortality.

Signs of increased risk of biphasic anaphylaxis (requires extended observation:

1. Severe symptoms at presentation (no odds ratio provided)

2 doses of epinephrine are necessary (odds ratio 4.82)

3. cutaneous signs and symptoms (odds ratio 2.54)

4. drug trigger in children (odds ratio 2.35)

5. wide pulse pressure (odds ratio 2.11)

6. unknown trigger (odds ratio 1.63)

How COVID-19 Affects Patients with Asthma – Guideline Knowledge Check

How COVID-19 Affects Patients with Asthma

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