Treating Allergic Asthma During the Emergence of COVID-19

Transcript: Thomas Casale, MD: Geoff, you mentioned COVID-19 [coronavirus disease 2019], and a lot of patients with COVID-19 clearly have problems with shortness of breath. How do you tell the difference? If you have a patient with bad asthma and they call you and say, “You know, I’m getting a lot of shortness of breath,” how do you discriminate that from COVID-19 or other conditions that can cause similar symptoms?

Geoffrey L. Chupp, MD: I think that this is real challenge for us as clinicians. In places where they have adequate testing capabilities and patients can be quickly evaluated and you can rule in or out COVID-19, then we’re going to have a very low threshold to test these patients, because there’s so much overlap in symptomology. The key thing is that patients may have COVID-19 and have asthmalike symptoms or have a mild flare that’s suggestive of bronchitis or upper respiratory infection. As long as that illness stays relatively mild, it’s OK for those patients to stay at home and take their usual medications and get through the illness, without any major complications. I think the key is to follow them closely, even remotely, and make sure that they understand that if things are worsening, they need to contact us, and we need to make some decision about whether they need to be hospitalized or not.

Thomas Casale, MD: It’s a follow-up to that. We’re a little bit off the topic of T2 [type 2]—high, T2-low asthma now. One of the questions that comes up is about, for example, New York City now, where you have a lot of people with bad asthma, and you’re there in New Jersey, right? If a patient calls you with bad asthma, are you changing who you recommend to go in to the hospital to seek emergency care, because you’re afraid that they might be exposed to COVID-19?

Geoffrey L. Chupp, MD: Well, I think we have to keep our standard approach. We do everything we can to keep our asthmatics out of the hospital, normally. That really doesn’t change, and we have to be cautious about patients having problems at home and actually telling us they won’t go to the hospital, even though they should. We have to reassure them that it’s safe to do that, if they’re really in distress. I do think we probably lowered our threshold to initiate systemic steroids for flares a little bit. I don’t know; I’d like to hear what the other panelists think about that, because we don’t want patients to progress into a flare. Other than that, I think our current algorithm of treating asthma exacerbations is about the same.

Michael E. Wechsler, MD, MMSc: What I’ve been recommending for my patients with asthma in the era of COVID-19—I get asked all the time “Should I stop my corticosteroids? Should I change my inhalers? What should I be doing?” I’ve been telling people to just continue their current maintenance therapy, and in the event that they have worsening symptoms, it can be challenging, as Geoff said, to tease out the differences between asthma-related symptoms and other viral-related symptoms. I still think that we need to treat the asthma. People should continue to use their inhaled corticosteroids.

One thing that I have been changing in my practice a little bit is that with patients who are used to using nebulizers and who may be at risk of having COVID-19, I’ve been cautioning them about using their nebulizers in rooms where other people who may not be infected might be, because the nebulizer can propel the aerosolized droplets a bit more easily than a metered-dose inhaler. For people who can use a metered-dose inhaler, I’ve been recommending that.

Thomas Casale, MD: That’s a good point. What I’ve heard from a friend of mine, who’s a paramedic here, is that they’re not doing any nebulizer treatments in the ambulance themselves. If they feel that a patient needs it, they want to make sure they’re in an open environment so that they don’t have a problem with that.

Transcript Edited for Clarity