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 Table of Contents  
EDITORIAL
Year : 2021  |  Volume : 1  |  Issue : 1  |  Page : 2-4

How do we manage chronic respiratory diseases during this pandemic?


Department of Pulmonary Medicine, DM Wayanad Institute of Medical Sciences, Wayanad, Kerala, India

Date of Submission19-Oct-2020
Date of Decision19-Oct-2020
Date of Acceptance24-Oct-2020
Date of Web Publication28-Jan-2021

Correspondence Address:
Dr. Ravindran Chetambath
Navaneeth, Sarovaram Road, Kozhikode - 673 020, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jalh.jalh_6_20

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How to cite this article:
Chetambath R, Kumar J. How do we manage chronic respiratory diseases during this pandemic?. J Adv Lung Health 2021;1:2-4

How to cite this URL:
Chetambath R, Kumar J. How do we manage chronic respiratory diseases during this pandemic?. J Adv Lung Health [serial online] 2021 [cited 2021 Feb 24];1:2-4. Available from: http://www.jalh.com/text.asp?2021/1/1/2/308272



The COVID-19 pandemic is unlike anything that we have ever witnessed. In fact, the clock would have to be wound back more than a hundred years to witness a pandemic of this magnitude. As we begin to come to terms with the fact that we might have to live longer than anticipated with this virus, it would be pertinent to address certain issues that might be bothering patients with chronic respiratory illnesses such as asthma and chronic obstructive pulmonary disease (COPD).[1] These cohorts of patients have been living with weakened and hyperresponsive airways and hence would be understandably wary of the SARS-CoV-2 virus which is known to wreak havoc primarily in the respiratory system. Since health advisory nowadays is primarily tailored to address COVID-19, there are certain issues and trepidations that need to be allayed among this subset of patients. While controlling the pandemic effectively, adequate care should be given to chronic respiratory diseases to minimize the potential “collateral damage” to patients from suboptimal management.

The global initiative on asthma (GINA), in their recently updated guidelines, decided to address the issue of noncompliance to maintenance therapy among asthmatics by advocating the use of long-acting bronchodilators with a fast onset of action in combination with inhaled corticosteroids. Backed by the “SYGMA” trial, this revision was welcomed by respiratory physicians, who were of the opinion that this modification was long overdue. However, with the emergence of the COVID-19 pandemic, many apprehensions were voiced by the public and social media regarding the vulnerability of people on oral or inhaled steroid to the virus.[2] GINA has stood by their decision and taken significant efforts to reiterate the safety and necessity of steroids among asthmatics. Hence, these medications should be adhered to by all asthmatics. Nowadays, since social distancing and staying at home are the norm, it would be prudent for asthmatics to have a written asthma action plan. This plan should address common issues likely to be faced by them and measures to be taken. Adherence to this plan along with the regular monitoring of their peak flow rates should enable them to manage most of the issues they face and hence minimize health-care visits. General precautionary measures such as avoidance of triggers, allergens, and cigarette smoke should also be followed as always.

COPD patients are at an increased risk of acquiring severe infections due to COVID-19. Hence, adherence to general measures such as social distancing, hand hygiene, and the use of face mask is mandatory. Inhalers and other oral medications should be continued, even if they contain corticosteroids. A certain amount of stockpiling of medications and essential supplies can also be resorted to minimize the need to step outside of their houses. The use of oxygen concentrators, portable noninvasive ventilators, and nebulizers should be continued if needed.

Patients using home nebulizers should do so with utmost caution. Nebulization, being an aerosol-generating procedure, can transmit the infection to caregivers and other persons living in close proximity. Thus, they should be done in isolation, in a room with open windows preferably with a table fan directed outward to dissipate any aerosols generated to the atmosphere. Regular sterilization of the equipment and other surfaces in this room should also be done to curtail the risk of infections and transmission through fomites.

COVID-19 directly affects patients with interstitial lung disease (ILD) in multiple ways, given their natural course leading to poor outcomes. This includes restricted access to various components of the diagnostic process, uncertainties, and apprehensions in the use of common medications, limited ability to monitor the disease severity, and timely identification of medication adverse effects. The median time in diagnosis from symptom onset is likely to worsen with reduced access to diagnostic tests during the COVID-19 pandemic.[3],[4] It is important that this delay in diagnosis and management should be minimized while also avoiding nonessential contact with the health-care system. Decisions to conduct more invasive tests such as bronchoscopy or surgical lung biopsy are more difficult in the context of the COVID-19 pandemic given the infection control concerns. These tests should be performed if there is a reasonable likelihood that the results will directly influence urgent management decisions. At the same time, immunosuppressed patients did not appear to be at higher risk of severe illness during past coronavirus outbreaks including severe acute respiratory syndrome in 2002 and Middle-East respiratory syndrome in 2013.[5] Patients with ILD who develop a new fever or mild change in respiratory symptoms should have a lower threshold than the general population. Telemedicine facility may be employed to determine whether an emergency room visit is necessary. Urgent medical attention should be sought for patients with ILD who have more than mild symptoms or with objectively worsened respiratory status.

Another serious concern is the development of fibrosis following COVID-19. This manifestation is almost similar to diffuse interstitial fibrosis, and the long-term effect on the lung is not predictable. Researchers are advising antifibrotic drugs for post-COVID fibrosis to arrest the fibrotic process. It is to be proved beyond doubt whether this fibrosis is transient and reversible or develop into a full-blown fibrotic ILD as time progresses.

Patients with latent tuberculosis (TB) and established disease have an increased risk of the SARS-CoV-2 infection and predisposition toward developing severe COVID-19 pneumonia.[6],[7] The diagnosis of new TB cases has seen a dramatic drop since the onset of this pandemic. The COVID-19 pandemic has made significant restrictions on direct assessments and movement of people due to national lockdown and infection control strategies. Monitoring of the disease remains an issue in the era of social distancing and self-isolation. There is a delay in health-seeking behavior, which will adversely affect the prognosis of a disease such as TB. Supply of medicines for TB patients could prove difficult, due to the short supply of the medications as well as re-stocking medications by patients at home. The program has put in place several strategies such as the utilization of the outreach services to reach patients with TB and the postal delivery of TB medications.[8] More recently, directions were issued for supply of TB medications from the outpatient setting to last for 1 month and in exceptional circumstances for 2 months. This is to reduce the need for patients to attend clinics and therefore reduce the risk of transmitting the disease.

Most people have made the erroneous assumption that hospitals are breeding grounds for the SARS-CoV-2 virus. While it is advised to refrain from unnecessary health-care visits, patients with medical emergencies should not delay them either. This is important in view of the frequent exacerbations expected in COPD or ILD patients. Severe exacerbations fall under the category of severe acute respiratory infections (SARIs) and may mimic a COVID-19 episode. Any patient presenting with SARI during this pandemic is considered COVID pneumonia unless otherwise proved. Hence, it becomes mandatory to rule out SARS-CoV-2 infection before being admitted along with other respiratory patients. Physicians and other health-care providers attending the patient also should observe adequate personal precautions till a diagnosis is confirmed. It is important for any hospital not to deplete the number of health-care providers in its cadre.

This pandemic, being a respiratory illness, has generated a certain amount of anxiety among patients with chronic respiratory diseases. Timely medical care in a hospitalized setting is mandatory for such patients. Most hospitals have systems in place to triage patients and avoid COVID-19 suspects from coming in contact with other patients.

There are, however, certain changes that may be viewed as a silver lining of the COVID-19 pandemic. The reductions in the levels of air pollution and an increase in the amount time spent indoors are some of these. Most respiratory physicians have attributed these changes as the reason behind most of their patients doing reasonably well during these troubled times. The COVID-19 pandemic, while devastating, has created a remarkable opportunity to health-care system, community, and countries to excel in collaboration and partnership, sharing knowledge, and experiences which are essential to control the pandemic, at the same time, reduce the mortality and morbidity among patients having existing chronic respiratory diseases.[9] Let's hope that this trend continues even after we see the end of this pandemic and that day arrives sooner than later.



 
  References Top

1.
Li X, Xu S, Yu M, Wang K, Tao Y, Zhou Y, et al. Risk factors for severity and mortality in adult COVID-19 inpatients in Wuhan. J Allergy Clin Immunol 2020;146:110-8.  Back to cited text no. 1
    
2.
Halpin DM, Faner R, Sibila O, Badia JR, Agusti A. Do chronic respiratory diseases or their treatment affect the risk of SARS-CoV-2 infection? Lancet Respir Med 2020;8:436-38.  Back to cited text no. 2
    
3.
Hoyer N, Prior TS, Bendstrup E, Wilcke T, Shaker SB. Risk factors for diagnostic delay in idiopathic pulmonary fibrosis. Respir Res 2019;20:103.  Back to cited text no. 3
    
4.
Lamas DJ, Kawut SM, Bagiella E, Philip N, Arcasoy SM, Lederer DJ, et al. Delayed access and survival in idiopathic pulmonary fibrosis: A cohort study. Am J Respir Crit Care Med 2011;184:842-7.  Back to cited text no. 4
    
5.
D'Antiga L. Coronaviruses and immunosuppressed patients: The facts during the third epidemic. Liver Transpl 2020;26:832-4.  Back to cited text no. 5
    
6.
Guan WJ. Liang WH. Zhao Y, Liang HR, Chen ZS, Li YM, et al. Comorbidity, and its impact on 1590 patients with Covid-19 in China: a nationwide analysis. Eur Respir J 2020;55:2000547.  Back to cited text no. 6
    
7.
Chen Y, Wang Y, Fleming J, Yu Y, Gu Y, Liu C, et al. Active or latent tuberculosis increases susceptibility to COVID19 and disease severity. medRxiv 2020;Preprint available online. doi: 10.1101/2020.03.10.20033795].  Back to cited text no. 7
    
8.
Government of India. Ministry of Health and Family Welfare (MOHFW) Accredited Social Health Activist. Available from: https://nhm.gov.in/index1.php?lang=1& level=1& sublinkid=150& lid=226. [Last accessed on 2020 Oct 03].  Back to cited text no. 8
    
9.
Khairat S, Meng C, Xu Y, Edson B, Gianforcaro R. Interpreting COVID-19 and virtual care trends: cohort study. JMIR Public Health Surveill 2020;6:e18811.  Back to cited text no. 9
    




 

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