Management of chronic respiratory diseases during viral pandemics: A concise review of guidance and recommendations : Journal of Family Medicine and Primary Care

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Review Article

Management of chronic respiratory diseases during viral pandemics: A concise review of guidance and recommendations

Sharma, Prakhar; Mishra, Mayank; Dua, Ruchi; Saini, Lokesh Kumar; Sindhwani, Girish

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Journal of Family Medicine and Primary Care 11(11):p 6633-6639, November 2022. | DOI: 10.4103/jfmpc.jfmpc_974_21
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Abstract

Introduction

Since respiratory disease patients are at increased risk of contracting the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2),[1] it seems pertinent to be aware of such threats now and in the future. Being a new friend of older guys (SARS and MERS),[2] there is an ocean of fresh literature which might submerge the mind of the common physician when it comes to dealing with our regular patients of respiratory diseases. Hence, at the time of writing, we tried to analyze and consolidate the present information into this paper which shall assist a healthcare professional working at the ground level to confidently choose the right management strategy.

Method

A working group comprising of faculty members of the department of pulmonary medicine at our institute was constituted. Detailed internet search of electronic databases such as PubMed and Google Scholar was done. All relevant documents including guidance, guidelines, reviews, and recommendations were thoroughly analyzed.

Consensus recommendations on each of the issues were formulated based on the level of available evidence. Wherever evidence was insufficient, expert opinion was used to formulate usual practice points (UPPs). The modified Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system was used to classify the quality of available evidence as 1, 2, 3, or UPP [Table 1]. The strength of the recommendation was graded as A or B depending on the level of evidence [Table 1].

T1
Table 1:
Quality of evidence and recommendations

General considerations for the management of patients with respiratory illnesses at home and at the OPD

OPD services and tele consultations

  1. Patients should be advised not to come for routine visits to the outpatient department (OPD) if it can be avoided or postponed.[3]
  2. Home based self-assessment methods should be utilized.
  3. Patients exhibiting flu-like symptoms should be attended to separately (COVID screening OPD) from other patients and spaced out so as to avoid overcrowding.[3]
  4. Pre-appointment for OPD visits should be made to prevent overcrowding.
  5. Option of telemedicine (via video appointments or telephonic conversations) should be explored.[4]
  6. Newer technologies like Bluetooth stethoscopes should be now utilized adequately.[5]

Spirometry

Pulmonary function test (PFT) may pose an extreme risk of COVID-19 transmission due to congregation of patients and potential risk of coughing, droplet and aerosol formation during the procedure. While deciding for PFT, the following points shall be taken into account:

  1. Non-urgent patients should not attend PFT. Urgent includes inpatient cancer and preoperative patients for urgent surgery where lung function or CPET is essential.[67]
  2. Airway challenge tests should be avoided as it actively induces cough.[67]
  3. Protective measures for staff and individuals including the use of personal protective equipment (PPE) and enhanced cleaning of the testing space, such as wiping down surfaces with appropriate cleaners, should be implemented.
  4. There should be a time gap of approximately 45 minutes between each patient for adequate disinfection of instruments and rooms.
  5. Spirometry room should have good air exchange and negative pressure.
  6. If PFT is necessary, a viral filter (single use) should be used.[67]
  7. Surfaces of spirometry instruments and body box should be adequately cleaned between each patient with 1% sodium hypochlorite.[7]

COVID-19 vaccination

  1. Patients suffering from chronic lung diseases can and should receive COVID-19 vaccination.[8]
  2. There are only limited contraindications for vaccination against COVID-19 including anaphylaxis and active COVID 19-infection, etc.[9]
  3. Patients who are treated with rituximab may receive the vaccine.[8]
  4. Patients taking regular systemic steroids or other combinations of oral immunosuppression can be vaccinated.[8]
  5. Patients with asthma who are receiving treatment with biological therapy can take the vaccine. A seven-day interval between the vaccine and asthma biologic is advisable.[8]

Recommendations for disease-specific management of chronic respiratory diseases during the COVID-19 pandemic

COPD and COVID-19

A few single-centre case series and a couple of meta-analyses have shown that patients already suffering from COPD are at a higher risk of countering COVID-19 infection, developing a more severe form of the disease, and hence, have a higher rate of associated mortality.[1011] Thus, it becomes highly essential to protect this subgroup of patients.

How to prevent COPD exacerbation?

  1. Advise patients to continue with their regular medications as advised on the last visit (UPP).
  2. Advise patients who are already on long-term oxygen therapy (LTOT) to have their oxygen cylinders refilled and opt for home delivery (UPP).
  3. Strict advice to not smoke or be exposed to any form of smoke (UPP).
  4. Keep away from others who are sick (UPP).
  5. Avoid crowds or large gatherings (UPP).
  6. Practice regular hand hygiene by washing with warm water and soap for 40 seconds at a time (UPP).
  7. Do not touch your mouth, nose and eyes with unwashed hands (UPP).

Comments: Simple protective measures like social distancing and appropriate hygiene have been found to be significantly effective.[12] Meanwhile, preparedness in terms of following a regular treatment plan and keeping stock of medications has been proposed by the Global Initiative for Chronis Obstructive Lung Disease (GOLD) and COPD Foundation as well as the European Lung Foundation[1314]

Should inhaled corticosteroid be continued in stable COPD patients*?

  1. At present, there is no scientific evidence to support that inhaled corticosteroids (ICSs) should be avoided in patients with COPD (already taking ICS based on criteria*) during the COVID-19 epidemic [3A].
  2. If on high-dose ICS, the dose of ICS should be optimized without affecting the stability of disease (UPP).

Comments: A few studies have reported that taking ICS may be beneficial in dealing with respiratory viral infections, specifically those with coronavirus[1516] while some have evidenced toward increased risk of death when coinfected with COVID-19.[17] In view of no definite answer, both GOLD and previously mentioned studies have recommended not to stop ICS in patients who have been already prescribed.[13]

*Indications for using inhaled corticosteroid in COPD: Absolute eosinophil counts >300/mm3; concomitant asthma or major reversibility in PFT; high risk of exacerbations (≥ two moderate exacerbations in the past year or exacerbations requiring admission).[13]

Should inhaled and parenteral corticosteroid be used in COPD exacerbation during the COVID-19 pandemic?

  1. Use of ICS during COPD exacerbation should be based on the indications for use of ICS in COPD [1A].
  2. Metered dose inhalers (MDIs) with spacer (patient-individualized) should be preferred over nebulization [3A].
  3. Systemic corticosteroid should be used in severe COPD exacerbation for a duration of five to seven days [1A].
  4. Oral corticosteroid is preferred over intravenous corticosteroid [1A].

Comments: Short-acting beta (2)-agonists and anticholinergics are the preferred bronchodilators advised for management of bronchospasm in COPD exacerbation.[13] GOLD guidelines for COPD recommend the use of corticosteroids in moderate and severe exacerbations which are associated with or without life-threatening respiratory failure.[13] The decision to use inhaled or oral, or intravenous corticosteroid should be patient-specific and depending on the gastrointestinal access and function.[18]

Should corticosteroid be used in COPD exacerbation with concomitant COVID-19?

  1. Systemic corticosteroid MAY be used [3A].

Comments: Studies from patients having other viral diseases like SARS and H1N1 suggest that systemic corticosteroid may have harmful effects like increased viral replication and prolonged shedding.

The Centers for Disease Control and Prevention (CDC) has recommended that use of systemic corticosteroids be avoided unless required for management of COPD exacerbation and septic shock.[14] The Surviving Sepsis Campaign has given recommendations for use in mechanically ventilated COVID-19 patients with acute respiratory distress syndrome (ARDS).[15] The University of Oxford RECOVERY trial reported that low-dose dexamethasone reduced mortality only among COVID-19 patients requiring invasive mechanical ventilation (IMV) (11.7% absolute reduction) or oxygen supplementation (3.5% absolute reduction).[19]

Whether nebulization, or MDIs with spacer or mask be used in COPD exacerbation during COVID-19 pandemic

  1. MDI with spacer should be preferred over nebulization [3A].
  2. If nebulization is required, it should be done in a designated isolation area with recommended air exchange and caregivers wearing adequate PPE [3A].
  3. Nebulized medications may be administered in mechanically ventilated patients through the use of viral filters [UPP].

Comments: Nebulizers are associated with aerosolization and potentially increase the risk of SARS-CoV-2 transmission and thus should be used only for reversal of acute bronchospasm.[20]

Should any specific precaution be taken while using non-invasive ventilation or HFNO during COPD exacerbation?

  1. Both non-invasive ventilation (NIV) an HFNO can be used with necessary precautions [3A].
  2. Non-vented oronasal face mask or full face mask, or helmet should be preferred over vented mask [3A].
  3. Dual limb tubing is beneficial (if NIV is being provided through a ventilator machine) [UPP].
  4. If providing NIV support via conventional machine (single tubing) and non-vented mask, exhaust system via whisper swivel or expiratory port should be used and viral filter should be placed between interface and the exhaust system [3A].
  5. If HFNO is being used, a face mask shall be placed covering the patient’s nose and mouth [3A].
  6. Healthcare professionals should try to maintain a minimum distance of one meter from the patient and use PPE [3A].

Comments: Aerosol generation during usage of NIV or HFNO depends primarily on the applied pressure or flow, respectively. Based on current literature, increased infectious aerosol particles dispersion is seen primarily on usage of vented masks in patients with a high load of secretions.[21] Moreover, exposure to exhaled air is substantially low at a distance of one meter or more from the patient.[2223] However, medical personnel working at bedside should strictly adhere to basic infection control measures.

How should bronchial hygiene be managed?

  1. If required, at-home airway clearance should be done by the patient in a well-ventilated designated room, which is not visited by family members, and should have a good air exchange [UPP]
  2. Sputum induction and cough producing procedures are not recommended [UPP].
  3. Use of oscillatory positive expiratory pressure devices (OscPEP), cough assist devices and high-frequency vest is not recommended [3A].

Comments: Sputum induction, use of cough assist devices and OscPEP devices are considered to be aerosol-generating procedures and hence are not recommended in the context of COVID-19.[24]

Should chest physiotherapy* be given or continued?

  1. A senior physiotherapist should be involved in determining the appropriateness of physiotherapy interventions [3A].
  2. Routine physiotherapy interventions should not be done [3A].
  3. Staff should use airborne precautions and patient should be wearing a surgical mask during intervention [3A].

Comments: Physiotherapy may be indicated if patients with COVID-19 present with copious airway secretions that they are unable to clear independently.[25] However, the need for physiotherapy and interventions like airway clearance, patient positioning and rehabilitation for ICU-acquired weakness should be evaluated on a case-by-case basis and interventions applied based on clinical indicators.

*Indications for physiotherapy referral and interventions in COVID suspected or proven patients: Mild symptoms and/or pneumonia with coexisting respiratory or neuromuscular comorbidity and anticipated difficulties with secretion clearance; severe symptoms suggestive of pneumonia or lower respiratory tract infection; patients who are frail or have multiple comorbidities impacting on their Independence, e.g., mobilization, exercise and rehabilitation in ICU patients with significant functional decline and/or (at risk of) ICU-acquired weakness.

Asthma and COVID 19

Although asthma has been cited as a potential risk factor for severe COVID-19, the current literature and data are still limited and do not support the above hypothesis. A few systematic reviews and meta-analyses published recently also support this.[2627] Despite this, it is important to ensure that the asthma is well controlled to prevent any chance of complex prognosis in case of coinfection with COVID-19. General considerations for OPD services, telecommunication and prevention of exacerbation (as mentioned for COPD) should be followed.

How to prevent asthma flare-up?

  1. Patients already diagnosed with asthma should stick to the prescribed asthma working plan [3A].
  2. Patients should try their best to avoid potential triggers [UPP].
  3. Regular handwashing with soap and water or using an alcohol-based hand sanitizer should be advised [UPP].
  4. If someone in the patient’s home is sick, have that person stay away from the rest of the household to reduce the risk of spreading the virus within the home [UPP].

Comments: The CDC states that patients with moderate-to-severe asthma could be at greater risk of more severe disease[28]; however, there is no significant published data to support this determination at this time.

Should inhaled or oral corticosteroid be continued by asthmatic patients?

  1. Inhaled or oral corticosteroids should be continued [3A].
  2. Patients should be instructed to follow their Asthma Action Plan [UPP].

Comments: The Global Initiative for Asthma[29] (GINA) and the American Academy for Asthma, Allergy and Immunology[30] (AAAAI) have clearly indicated that patients should continue to take all of their medications (including corticosteroids). Stopping a controller medication will produce the risk of developing an asthma exacerbation.

Should nasal corticosteroids be continued in allergic rhinitis?

  1. Intranasal corticosteroids can be continued at the recommended dose [3A].
  2. Nasal spray should not be shared with anyone [UPP].
  3. After use, tip should be wiped with tissue paper, which should be disposed-off adequately [UPP].

Comments: Both Allergic Rhinitis and its Impact on Asthma (ARIA) Society and the European Academy of Allergy and Clinical Immunology have given their recommendations to continue use of intranasal corticosteroid in allergic rhinitis.[31] Stopping of nasal steroid may lead to more sneezing and more spreading of the coronavirus. In addition, a single study[32] has shown that ciclesonide suppressed coronavirus replication in cultured cells; however, it would be too early to recommend the observation for clinical use.

Should anti-histamine or leukotriene receptor antagonist (LTRA) or stabilizers be continued in asthma?

  1. Antihistaminic and LTRA should be continued as per the asthma action plan [3A].

Comments: Anti-histamine and LTRA do not suppress immunity and the American Academy of Family Physicians (AAFP)[33] and the GINA[29] have advised patients to continue these medications. Allergic rhinitis is associated with IgE antibody, not IgG and IgM, which is the responsible antibody when fighting the SARS-CoV-2 virus.

Should anti-asthma biologics be continued or initiated in severe asthma?

  1. Anti-asthma biologics should be continued [3A].
  2. The decision to initiate anti-asthma biologics should take into account its risk and benefit and the ability of patients to self-administer [UPP].

Comments: The GINA,[29] AAAAI[30] and the recently published Nation Institute for Health and Care Excellence (NICE) COVID-19 rapid guidelines for severe asthma[34] have recommended to continue and initiate biologic therapies in severe asthma patients who qualify for them.

Should there be any change in management of asthma flare-up during the COVID-19 pandemic?

  1. Management of asthma exacerbation is unchanged [3A].

Comments: The management of asthma exacerbations is unchanged[35] and patients should NOT stop taking their ICS-containing inhalers. The GINA[29] has recommended that during acute asthma attacks, patients may take a short course of oral corticosteroids, if instructed in their asthma action plan to prevent serious consequences.

Whether nebulization or metered dose inhalers with spacer or mask be used in asthma flare-up

  1. Nebulizers should be avoided during acute attacks [3A].
  2. Pressurized MDI (pMDI) via a spacer should be preferred over a nebulizer during severe attacks [3A].

Comments: GINA[29] has recommended to avoid nebulization and to use a pMDI with spacer to prevent risk of aerosolization and transmission of COVID-19. Though the (now dissolved) Public Health England[35] advised that nebulization is not a viral droplet generating procedure and not considered an aerosol generating procedure for COVID-19, data is conflicting and its preferable to avoid it.

Interstitial lung diseases and COVID 19

Although data on the impact of COVID-19 on interstitial lung diseases (ILDs) is limited,[3637] these patients are usually older, have multiple comorbidities and are immunosuppressed due to disease or therapy. Hence, due efforts on part of the physician is required to save the catastrophic effects of COVID-19 on ILD.

Should anti-fibrotic be continued in idiopathic pulmonary fibrosis?

  1. Anti-fibrotic drugs (pirfenidone/nintedanib) can be continued in idiopathic pulmonary fibrosis (IPF)[3A].
  2. If any IPF patient is diagnosed with COVID-19, anti-fibrotic drugs may be continued [3A].

Comments: There are no data to suggest that anti-fibrotic therapies like nintedanib or pirfenidone are associated with increased risk of COVID-19 or more severe disease. Both these drugs have pleiotropic effects; neither is immunosuppressive per se, and so there is no role of discontinuing during viral or bacterial infection.[38] The British Thoracic Society[39] recommends pausing them for four to eight weeks. If an IPF patient develops COVID-19, a decision to pause anti-fibrotic drugs for a short period of time may be taken based on the advice of an ILD specialist.

Should corticosteroids be initiated or continued in ILD?

  1. Where indicated, oral corticosteroids should be prescribed in low dose [3A].

Comments: Higher doses of corticosteroids (>20 mg prednisolone or equivalent dose) should be preferably avoided due to associated poor outcome if concurrent COVID-19 develops in these patients.[39]

Should immunosuppressant be initiated or continued in ILD?

  1. Delay starting if patient is stable and evidence of effectiveness is low [3A].
  2. In patients with progressive disease, it remains reasonable to limit the use of corticosteroids and prioritizing steroid-sparing therapies where possible [3A].
  3. Maintain patients on low doses of immunomodulatory therapy and prioritize steroid-sparing medications over prednisone [3A].
  4. In rapidly progressive ILD cases, intravenous therapy may be initiated on case-to-case basis after discussing risk–benefit ratio with the patient [UPP].

Comments: The pathogenesis of COVID-19 has implications for immunomodulatory as well as anti-fibrotic medications for the underlying disease.[40] Evidence from previous coronavirus infections suggests that corticosteroid treatment may lead to increased along with delayed clearance of viremia, leading to added hospital stay and mortality.[414243]

Conclusion

COVID-19 has significantly affected the entire medical field in ways unimagined. In short, minimal OPD visits, vaccination against COVID-19, use of mask and appropriate hand hygiene practices by patients and healthcare providers will curb the spread and impact of any viral illness including COVID-19.

COPD, asthma and ILD patients should continue their regular medications while efforts should be made by the treating physician to reduce the dose or utilization of corticosteroids and immunosuppressant drugs. We expect that the above-mentioned summary of recommendations would help physicians to achieve this goal without being confused in the huge ocean of literature following the COVID-19 pandemic.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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Keywords:

Asthma; COPD; COVID 19; interstitial lung disease; management; recommendations

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