This transcript was automatically generated using speech recognition technology and may differ from the original audio. In citing or otherwise referring to the contents of this podcast, please ensure that you are quoting the recorded audio rather than this transcript.

Gavin: Special

episode of The Lancet Voice. I'm Gavin 

Jessamy: and I'm Desi Mee. 

Gavin: So far, we've done quick fire COVID 19 episodes on misinformation, on personal protective equipment, on older people and on pregnancy. Today, we're looking at the current advice and information out there for people with asthma during this pandemic.

And there's not a huge amount about, is there, Jasmu, which is why it's important for us to clarify it, I think. 

Jessamy: Yeah, exactly. Asthma is a heterogeneous group of airway diseases that affects, an enormous amount of young to, to middle aged and old people. And because it's a respiratory disease, there is obviously anxiety about how this might be interplaying with COVID 19.

But at the moment, we don't have that much evidence on whether this is a risk factor. 

Gavin: Yeah, again, it's one of those things that as we've always been saying with throughout these COVID 19 podcasts, we're still very much playing catch up with the disease and the effects it has on everyone.

Jessamy: Exactly. These things normally take years and years to try and untangle the interplay between a disease that might affect the lungs and then a virus that may also be on top of that. And so at the moment the advice is not necessarily based on a huge amount of actual research. It's based on a kind of precautionary approach.

And that is that mainly that those patients with severe asthma should be particularly cautious. And so those patients with severe asthma are those ones that maybe have to be admitted several times a year to hospital for extra help when they have an asthma attack, or they may have to take different types of medications that Make that immune system change slightly in the U.

K. We've had this shielding approach, so the government has sent out 1. 5 million letters to people who it has deemed as very high risk and people with severe asthma are included in that. And Professor Hilary Pinnock, who we speak to, outlines that a little bit further. 

Hillary: My name is Hilary Pinnock.

I am by background a general practitioner. And I work one day a week in a primary care practice in Whitstable, Kent. I am also the Professor of Primary Care Respiratory Medicine at the University of Edinburgh, where I am a Principal Investigator with the Asthma UK Centre for Applied Research.

Jessamy: And that seems particularly topical at the moment given that there are so many people who live with asthma in the country who are also concerned about COVID 19. Absolutely, 

Hillary: And indeed if there was ever a time when people with asthma needed an action plan it has to be now because people are having to make decisions, we're all making decisions about our health but people with asthma are taking asthma related decisions, and if an action plan isn't Which is really just a reminder on what to do if something happens is absolutely crucial.

I'm one of the most important messages here is that supported self management and an action plan and knowing what to do if is crucial for patients. 

Jessamy: Exactly. Perhaps we could start just talking about the evidence or lack of the kind of interaction between asthma and COVID 19. Okay there isn't 

Hillary: really very much evidence.

I had a look at some of the recent systematic reviews which are coming out from the early work that's been done in China. And asthma doesn't actually appear as one of the risk factors here. Now, what we don't know, of course, is whether that's because it isn't a risk factor or whether it just wasn't looked at in the analysis.

COPD chronic obstructive pulmonary disease, is very high on the list and hypertension and heart disease. But asthma just isn't mentioned either positively or negatively. It would seem that it's not a major risk factor for either catching coronavirus. It doesn't seem to increase the risk of catching it.

And the recent meta analyses don't suggest it's a major risk factor for most patients. And there's the big caveat, because there is a subgroup of people with asthma who have very severe disease and they are definitely at risk of major problems. 

Jessamy: And of course, intuitively from a clinical point of view, because it's COVID 19 is a respiratory condition, patients present with this viral pneumonia, you, we assume or feel that asthma should somehow be in the mix there.

Yeah. What's your opinion about that? 

Hillary: Absolutely, because we know that some, one of the commonest triggers for an asthma attack is a respiratory viral infection. So it is in there, absolutely in terms of triggering an asthma attack. But it doesn't seem to have come out at this stage. And I just add that as a caveat at this stage, it's not come out in any of the systematic reviews that I've seen.

yet. 

Jessamy: Of course, it's such a fast moving field that it's always that at the evidence so far suggests. But in terms of kind of patients who may get COVID 19, again, the evidence so far suggests that they don't get any worse. 

Hillary: No, there's no evidence that they're getting any worse except as I say for the, there is a group of patients who are extreme risk of very severe asthma and we can probably come to those in a minute, the very high risk group.

But for most people, it would seem that it's it may trigger asthma and perhaps that's where the coming back to the action plan that is where it's important because people with asthma may find it triggers their asthma, but if they've got an action plan, they should be able to manage the asthma aspect of it.

Jessamy: Yeah, absolutely. So just going back to this very high risk group who are they and how do they identify themselves? They 

Hillary: should have been contacted. They are on the on the public health lists and have been, should have been contacted. Basically, they're 1. 5, they're in the 1. 5 million.

Absolutely that they are the ones who are being advised to shield themselves and they are people who are on steroid preventers, but also an add on treatment, an additional controller medication, a long acting beta ragonist, or teleglast, or teatropium they would be people who are having either continuous oral steroids, though they are not very frequent in primary care populations but if they are, they would be a significant risk or who having frequent episodes requiring steroids, so that might be four or more a year.

So that's one definition. The other is if they've been admitted to hospital in the past 12 months, or if they've ever been admitted to an intensive care unit for their asthma. We know that the major predictors of having another attack or another severe attack are having had one before. So that's why those groups are being identified.

Jessamy: So those are the patients that should be particularly careful during this time. 

Hillary: Absolutely. And the the ASME UK have been in discussion with Public Health England and have agreed, I think, that there are one or two other. Drugs that come into this, the biologics, for example people on very high doses of inhaled steroids or who are taking azithromycin as treatment.

Now, these are very specialist treatments. These people should be under severe asthma chemics, specialist care and should know who they are, but they are being added to the at risk group. 

Jessamy: And so what about those patients who perhaps have a milder form of asthma? That doesn't normally affect them too much, but are, equally concerned during this time and the sort of action plan that they should be having in place.

Okay, the 

Hillary: first thing is they should be looking at their regular maintenance treatment. The guidelines suggest that more than two, so three or more doses of a reliever inhaler in a week suggest you should be on a preventer treatment. So that's actually quite a low threshold and I know most of us can think of patients who take more than that.

But that is the threshold we're being given and I think that should be applied very very religiously at the moment. It's important for taking regular reliever medication. Your asthma is not well controlled and you need a preventer and more than ever at this point in time. So taking regular preventer medication is absolutely critical.

The other thing is to know what to do if things do start to deteriorate. And that's, of course, where an action plan comes in. And now, action plans tell you, first of all, how to recognize that you're getting worse. Increased use of a reliever, feeling increasingly breathless, increasingly wheezy.

got a peak flow meter at home, you would see it fall in your peak flow and these indicators suggest that your asthma is getting worse. Now in adults, there is a very good study that's been done in the UK from Tim Harrison and the group in Nottingham who showed that people in adults, people could increase quadruple their dose of inhaled steroids at the onset of the attack.

Now, this happened in a group of pragmatically selected patients, so they weren't all adhering well in the first place. But if you get in quick with your increased inhaled steroids, that reduces the risk of needing oral steroids. It doesn't mean you won't need them, but it does reduce the risk. And I would certainly suggest that's something that people could build into their action plan, certainly for adults.

And then, of course, if things continue to get worse some people with asthma will have a rescue course of steroids to take at home. Others would want to contact their GP to discuss that. 

Jessamy: And on that kind of issue, the relationship that patients might have with their GP during this very difficult time where there's a sort of lack of resources and clinicians attending to not see patients, but perhaps speak to them over the phone.

How should those interactions, be going at what stage should patients and clinicians 

Hillary: be contacting each other? Phone first. All, practices are not are expecting everybody to phone first so that we can screen and indeed tomorrow I will be spending all day sitting in my practice making phone calls and of course in the stay and age video calls, which enables us to actually see people.

So it is a question of speaking to a GP and sometimes that's all that's needed. We can assess to some degree the severity of somebody's asthma attack just by talking to them and listening to their symptoms. One of the challenges that's been discussed quite a lot is how can you assess people's breathlessness?

when they're not sitting in front of you. And the answer is we have no validated way of doing that remotely. The interesting article about video consultations in the BMJ a couple of weeks ago by Trish Greenhouse, where she has some very pragmatic solutions to some of these assessments. Most clinicians tend to rely on the traditional approach of just talking to people, listening to people, talking and the patient that has to stop every few words is clearly breathless.

It is around listening, ask the patient how breathless they are and listen to the flow of conversation. I certainly would do that routinely. I also then tend to ask patients now and say, I've been listening to the way you're speaking and it sounds as though you're talking quite comfortably. Am I right in thinking this means you're not feeling too breathless at the moment.

So you can actually clarify your assessment by talking to the patients. Other simple things, is there feelings of breathlessness limiting their activities? The patient that's been up and about doing the housework or whatever, is less likely to be severely breathless than the patient who really doesn't want to get out of bed.

Is it changed from yesterday? Is it getting worse? There's been talk about using the MRC Disney score, which of course is validated, but that unfortunately isn't very useful when you're isolating yourself. It asks questions like can you Talk, can you walk up a hill, up an incline, or how far can you walk on the flat and talk to people at the same time?

You can't do these things when you're self isolating. So it does have limited value in the specific 

Jessamy: context that we're in at the moment. It's funny, isn't it? With this sort of increase in telemedicine and tech, which we're using for speaking to patients, we're actually almost having to go back and rely more on our very basic kind of medical training, medical acumen, that really listening sort of common sense approach to these things.

Hillary: Absolutely. And I see there are people have suggested that the Roth score where you count and it takes people to just take, have to take a breath, but there's no validation for that. And I, my, I think most clinicians are coming to the conclusion that it is around using, as you say, our clinical acumen and just listening to people.

Jessamy: And looking forward. What do you think are the interesting areas, the links between COVID 19 and asthma? What do we, there's obviously so much to find out still, but what do we, what are you looking forward to learning or which bits of research would you like to see? 

Hillary: I certainly think there's a lot more to discover about what the risks are in people with asthma.

As I say there's really nothing about this at the moment. So I think over time, we will learn whether people with asthma were more at risk. And I'm talking here about the general population with asthma rather than the high risk group we've already talked about. So I think that's one thing. I think there's also the The impact on people with asthma are being told they're at high risk.

We listen to news bulletins, 24 hours a day, don't we, these days? And we hear about high risk groups, and we hear about the death rate has gone up by so many hundred, but of course they were all elderly or had underlying conditions. And I sometimes wonder what that message does for people who are.

elderly or have an underlying condition. So I think how that messaging gets across is something that would be interesting to learn about. I also think we need it. Hopefully we'll give considerable impetus to the supported self management. We've known for 30 years that supported self management improves outcomes in people with asthma, but it's something we struggle to put into routine clinical care.

And. It's, it is something that I hope will be given some impetus as we realize that the one thing that people with asthma need now is information on what to do if things start to go wrong. Maybe the one other thing I would just mention is the importance of inhaler technique. Yeah, we are getting a lot of people asking for inhalers who perhaps haven't had one for a couple of years don't appear to have seen An asthma specialist or an asthma nurse or a pharmacist to check their inhaler technique for two or three years And we know that inhaler technique is often very poor There are some excellent videos on the asthma UK website for people to look and perhaps we should be directing people to those Because inhalers don't work if you can't use them properly So I would certainly suggest that I would also suggest to colleagues who want to look up information about asthma two website resources.

The British Thoracic Society have got an excellent website with a lot of links and information. And the Primary Care Respiratory Society have also got an excellent summary of the evidence from a primary care perspective. So those are some resources that perhaps some people might like to look at.

Jessamy: That's brilliant, Hilary. Thank 

Hillary: you so much. 

Jessamy: The Lancet did a great asthma commission in 2017 that kind of redefined this as an airways disease and the lack of progress that had happened over the last 10 years. So if you're interested, please access that on our website. 

Gavin: Thank you for listening to another special episode of The Lancet Voice.

Please remember to subscribe wherever you get your podcasts and join us again next time for another special episode on COVID 19. 

This is the transcript.