What People With Asthma Should Know About COVID-19

S. Cindy Xi, MD, an allergist and immunologist at Keck Medicine of USC, answers some common questions about asthma and the coronavirus, and tells how to protect yourself and stay healthy.

The coronavirus’ ability to wreak havoc in the lungs is raising a lot of concerns and questions from my asthma patients. They already know how it feels to have trouble breathing. Now they are wondering what risks they face amid this pandemic.

Some worry that their asthma inhalers could increase their risk of COVID-19 infection. Others are asking if nebulizers are safe and if they can use expired inhalers.

Here are answers to some of the common questions I’m hearing as an allergist.

Do people with asthma face a higher risk of severe illness if they get COVID-19?

There’s a lot we still don’t know about COVID-19 and how it affects asthma patients.

Based on the data we have so far, asthma does not appear to increase the risk of acquiring COVID-19. However, the Centers for Disease Control and Prevention (CDC) does list “chronic lung disease or moderate to severe asthma” under groups at higher risk for severe illness if they get COVID-19.

It’s important to understand what “severe illness” means.

One complication from COVID-19 is acute respiratory distress syndrome (ARDS), a severe lung disease that results from damage to the alveoli, the air sacs of the lungs. When COVID-19 patients require ventilators, it’s often for acute respiratory distress syndrome. We don’t know very much about the risk factors for developing acute respiratory distress syndrome or how to treat the specific type of inflammation that drives this condition, but there is no evidence that asthma is a risk factor for developing acute respiratory distress syndrome if infected with COVID-19.

In contrast to acute respiratory distress syndrome, asthma is a chronic condition that we know a lot about. It is characterized by airway inflammation, mucous production and airway spasm. Respiratory viruses, including strains of coronavirus that cause the common cold, can trigger asthma symptoms, and it’s likely that COVID-19 could do the same. Even though asthma is also an inflammatory condition, in contrast to acute respiratory distress syndrome, we have very effective treatments for asthma.

What should I do to protect myself?

Get your asthma under control and maintain that control. I cannot stress that enough. That means staying on your usual medications.

At the first onset of respiratory symptoms, asthma patients should follow their individualized asthma action plan and contact their health care provider to see if additional treatments are necessary to prevent symptoms from worsening.

Can I keep using steroid medications?

A few patients have told me they stopped their inhaled corticosteroid medication, because they were concerned that the steroids would suppress their immune systems. That’s exactly what asthma doctors don’t want to hear.

Asthma controller therapies reduce the frequency and severity of everyday asthma symptoms, as well as asthma attacks. Stopping asthma controllers can increase the likelihood of a severe asthma attack when exposed to a trigger, such as a virus or allergen. An asthma attack, even if unrelated to COVID-19, may result in an emergency room visit, which can then increase risk of exposure to COVID-19.

For patients with COVID-19, the messages about corticosteroids can be confusing. In SARS and MERS, as well as emerging studies on COVID-19, corticosteroids have not been shown to have a survival benefit. The World Health Organization and the CDC recommend that corticosteroids not be used routinely to treat viral pneumonia or ARDS due to COVID-19.

However, if a patient has an asthma attack, regardless of whether the trigger is COVID-19, corticosteroids are usually effective and should be used.

Are nebulizers okay to use at home?

Sometimes patients have difficulty using handheld inhalers and instead use nebulizers, which turn liquid medicine into a mist. Particularly when the patient is experiencing severe asthma symptoms, nebulizers can be more effective at delivering medication slowly into the airways.

The current concern about nebulizers is that if they are used by a patient with a respiratory infection, the nebulizer could aerosolize droplets containing virus, allowing the virus to stay in the air longer. Hospitals and other facilities are being advised to reduce their use of nebulizers to reduce spread of the new coronavirus.

If an asthma patient finds that nebulized therapy is more effective than inhalers, the nebulizer should be used in a room that is isolated from other household members.

What can I do if my pharmacy runs out of albuterol rescue inhalers?

Some parts of the country are experiencing shortages of albuterol inhalers, in part because hospitals are using them more for COVID-19 patients. (To help with the demand, the FDA approved a generic version of Proventil HFA, a commonly used albuterol inhaler.) If the pharmacy is out of stock, patients have some options:

• Albuterol handheld inhalers are marketed under various names, and not all are in short supply. It’s worth asking the pharmacist if another formulation is available.
• Nebulized albuterol is widely available and may be an alternative if the user takes the recommended precautions.
• Check with mail order or other local pharmacies.
• Ask your physician whether other rescue inhalers, such as levalbuterol or ipratropium, would be appropriate. Your physician may also suggest other alternatives.
• If necessary, patients can use albuterol that has expired. In general, medications are thought to be safe one year after their expiration date, but they are not guaranteed to have the same potency.

What else should I do to stay healthy?

Asthma care is individualized, and I recommend that asthma patients check in with their health care providers to make sure they are using daily controller medications correctly and have a plan in place in case asthma symptoms worsen. Keep a 30-day supply of your usual medications, but don’t stockpile medications, which can lead to shortages.

At this point, most people are aware of the CDC’s recommendations on how to protect yourself, including social isolation, hand hygiene and disinfecting surfaces. I would add one more — pay attention to your mental health, too.

When I asked one patient whether she had experienced asthma symptoms recently, her response was that she was hyperventilating at times just sitting and watching the news. She knew it was time to turn off the TV.

It’s a stressful time. Getting good sleep and being kind to yourself and others is more important than ever.

Editor’s Note: This article was originally published in The Conversation on April 9, 2020.

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