Question: A patient asked about Budesonide by nebulization to treat COVID-19. Is there information about this, or is it all anecdotal?

Answer:  There has been a study from the Severe Asthma Research Program (SARP) investigators demonstrating reduced ACE2 and TMPRSS2 mRNA expression in sputum from severe asthmatics on ICS (with a modest dose response) (Am J Respir Crit Care Med. 2020 Jul 1; 202(1): 83-90.). Caution is that this study depends on mRNA and not protein expression, and has not been repeated. A review of the literature done before the SARP study was published found no compelling data for or against the use of ICS in COVID-19 (Eur Respir J. 2020 May; 55(5): 2001009.). So this is not necessarily anecdotal (although the use of nebulization would be), but there are no clear data to support the use of budesonide to treat COVID-19. There are several clinical trials ongoing looking at the use of inhaled budesonide with or without LABA (with or without additional therapies) in COVID-19 (NCT04416399, NCT04331470, NCT04355637, NCT04331054, and NCT04193878), so, hopefully, we will soon know the outcome of ICS therapy as a treatment for COVID-19.

Of course caution must be taken when considering nebulization for an individual actively infected with SARS-CoV-2.

Question: We are getting requests from asthma patients to write a letter to their employer on their behalf stating that they should work from home due to coronavirus risks.  CDC update from June 25, 2020 says "mixed evidence" with regard to asthma and COVID-19.  How should we respond to these patients' requests?  Is there a liability issue if we don't write the letter and later a patient contracts COVID-19 and has significant morbidity from infection?

Answer: With regards to the liability issue, some states have instituted protections (see https://www.nga.org/coronavirus/#states); you may also want to check with your malpractice carrier. A response to patients should include the statement that the majority of evidence does not support that asthma is a risk factor for disease transmission or severity so just having asthma is not a reason to remain at home.  On the other hand, if a patient has poorly controlled asthma and is often coughing, then they may put their fellow employees at risk and should remain at home until their asthma is under better control.  None of the asthma specialty societies are recommending routine letters like this. Decisions about such letters should be made in the context of community spread and details about the patient's workplace.

Question: We are already receiving calls from teachers with asthma and parents of students with asthma requesting letters allowing them to opt out of returning to classroom this fall. I suspect we will get swamped with these requests next month. I understand that there is not much evidence suggesting that patients with asthma are in a higher risk group for COVID-19 infections. Would the Academy be able to offer some general guidelines regarding addressing these requests, so allergists can be on the same page in responding to these requests?

Answer: As we have stated previously, there are no data suggesting that asthma is a risk factor for becoming infected with SARS-CoV-2; and there are no data to suggest that, if infected, asthma patients have a more severe course of COVID-19 disease. Further, there are no data that suggest SARS-CoV-2 exacerbates asthma. As such, the task force members do not see a reason that asthma would be a reason to avoid school. However, the task force does not and cannot provide specific guidance to clinicians and practices in this regard. Therefore, it is the responsibility of the individual practitioner/practice to determine their policies and how they will respond to these requests.

Question: At this point (mid-June), can we go back to checking peak flow rates and performing spirometry in the office or not? What about spirometry?

Answer: There are currently no guidelines for when to resume the performance of in-office spirometry, other than consensus opinion. As the AAAAI COVID-19 Task Force has said before, the situation with COVID-19 is fluid, and practices need to make decisions on what is best for their individual practice and staff based on the local community conditions with respect to incidence of infections and asymptomatic patients, and with findings and recommendations from CDC and other appropriate entities in mind.

The American Thoracic Society states: “Concern has been raised that pulmonary function testing could represent a potential avenue for COVID 19 transmission due to the congregation of patients with lung disease and because of the potential for coughing and droplet formation surrounding pulmonary function testing procedures. We recognize that most patients are screened for symptoms and travel before entry into our health care systems, but it is more difficult to screen and assess pulmonary patients who are more likely to have respiratory symptoms unrelated to COVID 19. There remain many unknowns about the possibility of transmission in this setting and the data are in evolution; however, the risks of transmission may be significant, and likely vary based on the prevalence of the virus in the community and the age, severity of lung disease and presence of immunosuppression.” (1)

While CDC guidelines indicate that forced exhalation is not a risk for infection transmission, we know that singing in the absence of facial protection and social distancing is (2). As performing peak flow can trigger coughing in a patient, who would not be wearing a mask, this too is a potential risk for infection transmission.

Decisions regarding the conduct of pulmonary function tests need to balance the potential risks against the need for assessment of lung function to make treatment decisions. If a practice decides to resume spirometry, consider the following:

  • Concern for staff and patient safety is paramount, so proper use and availability of PPE is important. Ideally, due primarily to concern over exposure from an asymptomatic patient who might cough into the room, staff should be in full PPE, including a gown, gloves, N95 respirator and face shield.
  • Be sure to use filters that are capable of blocking virus passage into the spirometer.
  • Even when utilizing filters, the patient may pull the device out of their mouth and start coughing, increasing the risk of spreading potentially infected aerosolized particles.
  • If in office albuterol treatments are necessary, use an MDI with spacer. Ideally, the patient will bring their own MDI to the office; if not you must dispense one, but you cannot reuse MDIs due to potential risk of infection spread.

1) American Thoracic Society (ATS). Advice Regarding COVID 19 For Pulmonary Function Laboratories https://www.thoracic.org/professionals/clinical-resources/disease-related-resources/pulmonary-function-laboratories.php

2) The Center for Disease Control and Prevention (CDC). Morbidity and Mortality Weekly Report. May 15, 2020. https://www.cdc.gov/mmwr/volumes/69/wr/mm6919e6.htm?s_cid=mm6919e6_w

Question: I have patients with asthma, COPD, and rhinitis who find it difficult to breathe through face masks. In addition to limiting time away from home, what recommendations are there about material or types of face masks? I was reading bandanas may be the best material given breathability. What is the best mask for our patients in terms of protection and breathability?

Answer: The CDC and medical organizations’ websites all mention that social distancing, hand washing, and avoiding crowds as well as sick persons, are important measures to staying healthy, and that a face mask is not a substitute for these measures. There is no endorsement of a “best mask” for patients with chronic lung diseases. Cloth masks are recommended for non-healthcare personnel. Fabric selection must balance sufficient capacity to trap viral particles with comfort. Recommended fabrics include cotton blends, 100% cotton T-shirt fabric and sheets/pillowcases with high thread counts. Two layers of fabric or one layer of fabric plus a filter layer are most commonly recommended. Too many layers will result in a mask that makes breathing difficult. Make sure that you cannot see daylight through the mask. If someone is having trouble breathing, they should probably avoid wearing a mask, as this could paradoxically lead to worsening of their respiratory status. The CDC recommends wearing a bandana, which may be the most comfortable approach for persons with lung conditions since it is not constricting. It is important to keep in mind that the purpose of the mask is to reduce transmission of viral particles to other persons.

Question: We are getting a large number of requests for letters from our asthmatic patients for work from home continuation excuses.  As we learn more about COVID19 we are seeing that asthma has not been a major risk factor for contracting COVID19 and/or developing severe COVID19 disease related complications.  Does the AAAAI have advice on how to handle these requests?

Answer: The AAAAI stands behind their earlier comments about asthma and risk for COVID-19 or severe COVID-19.  Each individual patient is just that, an individual patient.  The AAAAI feels that this is a practitioner's decision on how and when to provide support to their patients, and therefore will not provide a template letter for membership to use.

Question: I have always obtained pre/post injection peak flows for asthmatic patients on controller medications. Should this practice be abandoned?

Answer: Based on the potential for aerosol generation with peak flow meters conducted in the office, we recommend a peak flow meter be provided to the patient for them to use at home before coming to the office, as well as on a regular basis to establish their personal best. We would not recommend performing peak flows or spirometry in the office.

Question: Can anyone offer any advice on administration of Dupixent to a patient who was recently diagnosed with COVID-19 but has been fever free for a week and feeling better?  Is there a timeline or a test that helps me to assess the safety of reintroducing this biologic?

Answer: There are two issues here. One is regarding administering anti-IL4Ra in someone with (or recently convalesced from) COVID-19. The answer there is we have no data, but there is no reason to suspect that anti-IL4Ra (or any of the commonly used biologics in AI) will have any untoward effects. From that standpoint, it is fine to administer.

The second question is when someone with COVID-19 can return to society. There are two options per the CDC:

  1. If not tested, then need to be fever free for 72h, other symptoms must have improved, and it has to be AT LEAST 7 days since symptoms first appeared.
  2. If tested, then it requires 2 negative tests 24 hours apart, with improvement in symptoms, and no fever.

Based on the history listed, the patient probably falls into group 1, and is okay to return to society. As mentioned, there is no reason not to administer the biologic (anti-IL4Ra) in this patient.

Question: What do you recommend regarding starting patients on Xolair?  I have a few refractory urticaria patients who may need to start in the next few weeks. I'm concerned over having to keep them for 2 hour observation times for 3 visits per the official recommendations.  In light of the 2017 Lieberman article which suggested that most cases of reaction happening within 60 min and typically on patients with prior history of anaphylaxis, could a modified strategy be adopted?  

Answer: At this time the Academy has not changed its recommendations on waiting times for new Xolair starts.  Following the current recommendations should not add a significant burden to a practice that is still providing biologic injections. Of course, adequate screening, proper PPE, physical spacing and hand and room hygiene are vitally important.

Question: Our large multispecialty group has transitioned all patients with upper respiratory tract symptoms to an outdoor triage and treatment strategy.  Many of those patients are coughing and wheezing from asthma.  Because of concerns about nebulizer treatments and lack of sufficient PPE, would treating these patients with Albuterol HFA and spacers be an alternative? There is also concern about a shortage of albuterol MDI. Are there recommendations for reusing spacers and albuterol MDI in a clinic setting to administer this medication, and if so, how to sufficiently clean and sanitize spacers so that they can be reused?

Answer: Using albuterol by MDI and a spacer is an appropriate means for administering a bronchodilator during this pandemic. It also does not appear to have the risk of aerosolizing virus that is seen with nebulized solutions.

There are limited studies on the use of shared MDIs which have been published in the recent literature: 

These articles examine the risk of cross contamination for patients. A few hospitals have used such protocols for cost-savings, but results are dependent on strict adherence to disinfecting protocol. Even with strict protocols, the risk of contamination of the MDI and the spacer, while low, is real. In addition, there are no studies on viral cross contamination and transmission.  As a result, the use of common MDIs cannot be recommended based on the current data.

Question: I am confused by the statement that asthma is not a risk factor for COVID 19 because the CDC has many TV ads which clearly state that asthma is a risk factor.

Answer: Here is what the CDC states on their website: People with moderate to severe asthma may be at higher risk of getting very sick from COVID-19. COVID-19 can affect your respiratory tract (nose, throat, lungs), cause an asthma attack, and possibly lead to pneumonia and acute respiratory disease. However, data from China and Seattle show that the prevalence of asthma among those hospitalized for COVID-19 was less (China) or the same (Seattle) as the prevalence in the general population, suggesting that asthma was not a risk factor for severe disease with COVID-19. The CDC statement is useful in suggesting that patients with asthma must make sure they are medication compliant and following their action plans. The key word in their statement is “may.”

Recently, the CDC did release data for the month of March looking at patients hospitalized for COVID-19 in the US. From these data, it appears that asthma may be over-represented in younger adults (18-49 year olds; it was 12 out of 44 subjects, or 27%) who are hospitalized with COVID-19. However, the data appear similar to what has been seen with influenza in terms of the prevalence of asthma in hospitalized younger adults with COVID-19. New York state data show that fewer hospitalized patients with asthma had died from COVID-19 than would be predicted from the prevalence of asthma. A recent retrospective chart review of a single health center published in JACI IP would suggest that having asthma led to increased intubation time for those hospitalized with COVID. Given these somewhat contradicting data, the important message at this time is to tell your asthma patients to get and keep their asthma under control.

If you are interested in additional information, consider these references:

Guan W, et al. Clinical characteristics of coronavirus disease 2019 in China. NEJM. DOI: 10.1056/NEJMoa2002032

Arentz M, et al. Characteristics and outcomes of 21 critically ill patients with COVID-19 in Washington state. JAMA. doi:10.1001/jama.2020.4326

CDC. Preliminary estimates of the prevalence of selected underlying health conditions among patients with coronavirus disease 2019 - United States, February 12-March 28, 2020. MMWR. March 31, 2020. Vol 69. pp. 1-5.

Bhatraju PK, et al. Covid-19 in critically ill patients in the Seattle region - case series. NEJM. DOI: 10.1056/NEJMoa2004500

Chen N, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet 2020;395:507-13.

Zhang JJ, et al. Clinical characteristics of 140 patients infected with SARS-CoV-2 in Wuhan, China. Allergy. 2020 Feb 19. doi: 10.1111/all.14238. [Epub ahead of print]

Dong Y, Mo X, Hu Y, et al. Epidemiological characteristics of 2143 pediatric patients with 2019 coronavirus disease in China. Pediatrics. 2020; doi: 10.1542/peds.2020-0702

CDC. Hospitalization rates and characteristics of patients hospitalized with laboratory-confirmed coronavirus disease 2019 – COVID-NET, 14 states, March 1-30, 2020. MMWR. April 8, 2020. Vol 69. pp. 1-7.

Asthma Is Absent Among Top Covid-19 Risk Factors, Early Data Shows https://www.nytimes.com/2020/04/16/health/coronavirus-asthma-risk.html

Mahdavinia M, et al. Asthma prolongs intubation in COVID-19. J Allergy Immuno Pract. In press. 2020.

Question:  Which of the approved disinfectants SARS-CoV-2 are less likely to trigger asthma symptoms?

Answer: The response to any specific product will vary based on multiple factors including the manner in which it is used, proximity to use, time since use, and size of space in which it is used. Individual factors related to the inherent severity of each asthmatic’s own level of control at any given time may also influence product choice. As such, a comprehensive review of each product is not feasible. However, this does raise an important point regarding the proactive role allergists can play in helping our patients through basic messaging:

  • Any aerosolized product can potentially trigger asthma symptoms
  • Given the heterogeneity in asthma, each individual can be guided to use their own personal history to understand the types of products or exposures that have caused symptoms in the past, and avoid accordingly
  • Anyone with asthma should continue all prescribed controller medications and start rescue treatment if symptoms occur because it is more important than ever to try to maintain good asthma control

The EPA provides recommendations for using disinfectants in a household with family members who have asthma or other chronic respiratory diseases.

Question: Should we be concerned about giving oral corticosteroids to patients with asthma attacks due to COVID-19?

Answer: The use of systemic corticosteroids for treatment of COVID-19 lung disease in individuals without asthma is not recommended. There are no data at this time that would support changing standard asthma therapeutic measures, including systemic corticosteroids, in individuals with asthma and a COVID-19 infection. Patients with asthma should continue to take their controller medications and not stop them, even if they have symptoms of COVID-19. Also, the studies showing a potentially worse outcome with systemic steroids were in hospitalized COVID-19 patients who received the steroids as a treatment for the viral illness and not for another disease.

Patients with asthma need to continue to take their controller medications and keep their asthma under control because the risk here is that they stop the medications, have an asthma flare, then have to go to the emergency department because they have respiratory symptoms in an area with known community spread of COVID-19, and then they get COVID-19 from being in the emergency department—all of which could have been avoided by keeping their asthma under control in the first place.

Question: To the best of our knowledge, it is advised to use short term step-up therapy in asthmatic patients during viral infections. Regarding the epidemiology of COVID-19, do you advise this strategy for asthmatic patients who are compromised with COVID-19 or not?

Answer: The management of asthma exacerbations in individuals with COVID19 is the same as with any other virally induced asthma exacerbation. At this time, there has been no data to suggest that COVID-19 is causing asthma exacerbations (similarly to what was seen with other pandemic coronaviruses, like SARS). As such, there does not seem to be a strong rationale to step-up therapy in a patient with otherwise controlled asthma. However, if their asthma becomes uncontrolled, then it would be prudent to step-up therapy.

Question: We are currently in the process of establishing protocols for screening potential COVID-19 patients in our practice. We currently have several hundred asthmatics in our practice. The typical symptoms for COVID-19 of cough, shortness of breath, and fever could be very similar to an asthmatic having a viral induced exacerbation. Would peak flow meters help? What if no peak flow meter available? Would there be a significant downside of giving oral corticosteroids or high dose inhaled corticosteroids to a known asthmatic patient who also has COVID-19? 

Answer: The current continually updated recommendations for COVID-19 screening and management are available at the CDC website: https://www.cdc.gov/coronavirus/2019-ncov/hcp/index.html.

At this time, management of virally-induced asthma exacerbations from COVID-19, or any other respiratory virus, remain the same.

The current critically important COVID-19 mitigation measures for patients with asthma, and everyone else, to adhere to are:

  1. social distancing
  2. frequent hand washing
  3. keeping one's hands out of one's face

There are no data on whether SARS-CoV-2 (COVID-19 virus) causes asthma exacerbations. In fact, in the available published data from China it appears that asthma is under-represented in the hospitalized COVID-19 patients, which may suggest protection rather than risk (but take this statement with a large grain of salt). Nonetheless, other coronaviruses can exacerbate asthma (and asthma is over-represented in MERS-CoV infections), so it is plausible that SARS-CoV-2 will cause asthma exacerbations; however, reported data and anecdotal reports from acute care facilities thus far would suggest that SARS-CoV-2 is not causing significant numbers of asthma exacerbations. Having said that, as mentioned above, the treatment of an asthma exacerbation, regardless of etiology, is the same—so if you would normally increase inhaled steroids or add systemic steroids, you should do the same even if the patient has COVID-19.

Question: Multiple patients being treated for asthma with various biologics (Dupixent, Nucala, Xolair) are asking if they should stop biologics in light of possible COVID-19 infection.

Answer: Although not clear if COVID-19 triggers asthma exacerbations, it is clear that many respiratory viruses, including rhinoviruses, and influenza, are triggers for asthma exacerbations, all currently prescribed effective anti-asthma therapy, including all FDA approved anti-asthma biologics, should be continued in patients with asthma. Frequent hand washing, keeping the hands out of the face, and social isolation are also essential factors in helping to mitigate COVID-19 spread. 

Again, it is not known how the IL4, 5, 13, and IgE systems operate in COVID-19 disease. It is more important to keep asthma under control, and if a biologic is required for that control, then it should be continued. As mentioned, in all other respiratory virus infections that associate with asthma exacerbations, the recommendation is to continue the biologic, so again, that would be the advice for COVID-19.

Question: Has there been any guidance issued around the management of asthma exacerbations that might occur with concomitant COVID infection? Is it treatment as usual with the COVID exposure precautions? Is there a contraindication to use of systemic steroids due to increased risk of worsening or nebulized products due to environmental exposure?

Chronic lung diseases including asthma have been mentioned as risk factors for COVID19. Some communications mention severe asthma but without a citation. Are patients who are receiving asthma biologics at any increased risk for a severe respiratory response from COVID? Would management change if they happened to contract COVID and have a concomitant asthma exacerbation? Are there specialty considerations for pediatric patients on biologics?

Answer: There are limited data to support the belief that asthma is a risk factor for COVID-19. The Chinese data actually showed a lower incidence of infection in asthmatics, and in the Seattle data the incidence in the infected population was the same as that of the general population. However, while CDC surveillance data suggest that asthma may be a risk factor for hospitalization from COVID-19 in 18-49 year olds, recent New York State data show that fewer hospitalized patients with asthma had died from COVID-19 than would be predicted from the prevalence of asthma. Systemic steroids are not recommended for the treatment of COVID-19, because it has not been noted to be effective and can increase the duration of viral shedding. The CDC says to avoid steroids in COVID-19, unless needed for another condition. Asthma would be that condition. Steroids are not contraindicated, even systemic steroids, when used to treat asthma.

We know that viral infections can cause asthma exacerbations, so it is important to continue to manage your asthma patients according to the guidelines, and asthma exacerbations according to the guidelines.  As we approach the spring allergy season, and with viral upper respiratory infections and weather changes still prevalent, we should focus on asthma control to keep our patients well and out of emergency rooms and urgent care, where the risk for infection with COVID-19 is much higher. This would be a good time to ensure that all of your asthma patients are up to date on medications and treatment plans.  Keep them at home and well. This is especially important for severe asthma.

There is no evidence that the biologics we use in asthma have any adverse effect on COVID-19 cases, and it would be important to continue them based on the need for asthma control, in both pediatric and adult patients.

 

Some answers have been updated to reflect changing circumstances and information since the individuals submitting the questions were originally provided with a response. While we’re working on keeping answers updated as best we can, information continues to evolve rapidly. Please email us at practicematters@aaaai.org with concerns or additional questions.