Managing asthma in a pandemic

The current Covid-19 pandemic provides new challenges in managing chronic diseases for both patients and healthcare professionals (HCPs). These are illnesses which require dedicated time for education, review, and management. This can be challenging in normal circumstances. However, in a public health emergency, these challenges are magnified greatly.

This article will discuss aspects of managing asthma in the current pandemic. Before addressing how management has changed, we must establish a groundwork regarding how asthma should be managed in times of normality.

Asthma is an easily treatable chronic disease but relies on a high level of knowledge both from the patient and HCPs. Management of asthma is based on several key areas. These are patient education and knowledge, reduction and best possible control of triggers, regular review and monitoring of symptoms and pharmacologic therapy. In order to implement these key areas, there must be clear goals in place. These goals can be broken down into firstly achieving good asthma control and secondly, minimising ongoing risk surrounding future exacerbations, lung function or adverse effects of pharmacologic therapy.

Many symptoms associated with poorly controlled asthma will overlap with symptoms of Covid-19. Achieving the goals of care and implementing the key areas of management will prove more challenging now than ever before.

Dr Haris Al-Sayyed

Patient education
Patient education is arguably the most important aspect of asthma management. The goal of patient education is to educate patients to become an active partner in their ongoing care. In times of calm, patient education is predominately achieved through consultations with their general practitioner (GP) or specialist. In addition, patients would typically be informed regarding additional online resources available, including the Asthma Society of Ireland. With Covid-19, online resources have and will represent the most significant medium of patient education.

It is crucial that Asthma Action Plans are devised for each patient, and that the patient understands what to do for the relevant zone of severity.

This is more important now than ever to minimise contact between patients and doctors. It is necessary that Asthma Action Plans are tailored to each patient based on the severity of their disease. What is even more crucial now, is the importance of highlighting to patients that certain symptoms which may reflect an asthma exacerbation may also reflect infection with Covid-19. A new cough or shortness of breath may represent features of both illnesses. Given the current Health Protection Surveillance Centre (HPSC) guidelines and possible need for in-person review in practice, it is advisable to tell such patients to phone their GP should they become concerned about an exacerbation of their symptoms, which may require testing for Covid-19.

In comparison to the general population, asthmatics are not at an increased risk of contracting Covid-19. However, those with underlying conditions which may affect respiratory function, have a higher risk of acquiring more severe symptoms and complications arising from contracting Covid-19. As such, the Health Service Executive (HSE) has advised that those above the age of 70 years old, or those who are medically vulnerable should ‘cocoon’.

The term medically vulnerable includes patients with severe asthma.

Cocooning involves staying at home and avoiding contact with others, including members of your own household where possible. A clear roadmap is now in place to outline how the current restrictions will be eased over the coming months. The Asthma Society of Ireland has set out clear criteria for what defines severe asthma. In brief, it is defined as asthma requiring treatment with high-dose inhaled corticosteroids, plus a second controller, and/or systemic corticosteroids to prevent poor control or asthma which remains uncontrolled despite the above.

Control of triggers
Advice surrounding avoidance and control of triggers of asthma will remain largely unchanged during the Covid-19 pandemic. It remains a key aspect of successful asthma management and assists in promoting patient engagement in self-care. Simple questions regarding smoke exposure, dust or mould exposure or occupational exposure can help unmask potential causes for frequent exacerbations and poor control. What has changed is the advice regarding avoiding potential infection leading to a respiratory tract illness. The basic tenets of infection control remain the same, including regular handwashing, avoidance of people who are unwell and ensuring good cough/sneeze hygiene. However, as per the Government and medical guidelines, increasingly stricter precautions must be followed regarding physical distancing for mild to moderate asthma patients and cocooning for severe asthmatics.

Monitoring for changes in symptoms
A significant challenge arises when monitoring for changes in symptoms of asthma in this period. Usually, if a patient feels that their asthma is poorly controlled or they are developing an exacerbation, they will contact their GP and may need to attend the surgery for assessment. Covid-19 presents new practical and logistical challenges in this regard. If a patient reports a mild worsening of symptoms, it may be sufficient to increase the frequency of their inhalers or to escalate inhalers entirely. However, considering the overlap between symptoms of poor asthma control and exacerbation with Covid-19, remote testing should be organised. If it is felt that a patient requires a review in practice, precautions must be taken and a differential of Covid-19 must be considered, particularly the presence of a new fever.

Personal protective equipment (PPE) must be worn when examining any patient presenting with new signs of respiratory tract infection. Effective infection prevention protocol and correct use of PPE is crucial to ensure the safety of healthcare workers and patients during the current crisis. The availability of PPE has proven challenging in both primary and tertiary care settings. It not only creates additional workload burden, but also leads to increased stress and anxiety in the workplace. In each healthcare setting a designated Covid-19 assessment room should be set-up, with strict decontamination of the room following each assessment. The HPSC advises that if possible, a distance of 1 metre should be maintained from the patient and unless clinically indicated, a physical examination should not be performed. However, if a patient is attending for review, it is likely they will require some form of physical examination, especially if concerned about a superimposed bacterial respiratory tract infection. If stethoscopes or ophthalmoscopes are required, they must be disinfected and decontaminated with disinfectant wipes after use, as per the HPSC guidelines.

The introduction of community assessment hubs has helped to offset some of the burden on general practice. Community assessment hubs require a referral from a GP who has assessed the patient over the phone. A patient may be referred for assessment for Covid-19 if they are over 16 years old with a confirmed or presumptive diagnosis of Covid-19 and where their symptoms are progressing, and they require urgent assessment. They may also be referred if they require face-to-face assessment for urgent non- Covid-19-related illnesses in the setting of confirmed or presumptive Covid-19 infection.

Pharmacotherapy
There are various forms of pharmacotherapy available for the treatment of asthma, depending on the severity of the disease. Those with intermittent or mild asthma may be sufficiently treated with an as-required inhaled short-acting beta agonist (SABA), or an as-required SABA in addition to a regular low-dose inhaled glucocorticoids (ICS), or a combination of a low-dose ICS with a long-acting beta agonist (LABA). The Global Initiative for Asthma (GINA) now recommends an as-needed use of a budesonide/formoterol combination inhaler. For moderate asthma, an increased dose of ICS may be warranted in addition to a LABA, or a long-acting muscarinic antagonist (LAMA) for those intolerant to a LABA.

In severe asthma, medium to high doses of ICS are preferred in combination with a LABA. Further treatments including a LAMA, leukotriene modifier or biologic may be needed depending on asthma severity or the trigger. For acute exacerbations, systemic glucocorticoids are often required, in addition to an increased frequency of inhaler use, or an escalation of inhaler dosage or form. This may need to be stepped-down following improvement of symptoms. In addition, nebulised beta-agonists or muscarinic antagonists may be required during exacerbations.

The Covid-19 pandemic has raised questions and created challenges in relation to asthma therapy. Nonetheless, the method in which asthma and exacerbations are treated has remained unchanged. Concerns had been raised at the outset of the virus regarding the safety of ICS or systemic glucocorticoid use. Evidence to date has not shown any increased risk of infection with use of ICS or systemic glucocorticoids. As such, the current advice is to treat asthma and acute exacerbations as they would have been treated prior to this pandemic.

However, what has changed is the use of nebulisers. If Covid-19 infection is suspected or confirmed, caution must be taken when using nebulisers. They must be used alone and in a well-aerated room. The devices must be cleaned thoroughly after each use. The same guideline applies if being used in a healthcare setting. Extra precautions must be taken due to aerosolisation of the virus and nebuliser facemasks must be disposed of after use.

Rescue packs
Concern had been raised about the necessity for rescue packs for asthma patients and possible shortages of medications including antibiotics and steroids. While rescue packs exist, they are only to be used for very select patients and not as part of the routine response to this healthcare emergency. As per the Asthma Society of Ireland, rescue packs are only to be used in patients with the most severe form of asthma.

Additionally, the patient must be able to work very closely with their GP or asthma care team and they must be well versed in the management of their condition. The misuse of rescue packs can result in unintended short- or long-term complications.

Finally, reassurance has been provided by the Irish Pharmacy Union and the HSE regarding the ongoing availability of asthma medications in Ireland.

Evolving means of care
To summarise, in this constantly evolving global pandemic, the fundamentals of asthma management have not changed. Patient education, trigger control, monitoring of symptoms and pharmacotherapy still comprise the backbone of asthma care. The same goals remain in place with the aim of achieving safe asthma control and minimising ongoing risk.

However, the means by which we provide this care and the ways in which patients undertake their treatment have altered significantly, in order to achieve the best possible outcome whilst mitigating risk.

Authors
Dr Haris Al-Sayyed, MRCPI, GP Trainee, HSE South East General Practice Training Scheme — Irish College of General Practitioners (ICGP).
Dr Dermot Nolan, MICGP FRCGP, GP Tramore, ICGP/HSE National Clinical Lead for Asthma.