Are Patients with COPD More Vulnerable to COVID-19?
The Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease (COPD) Science Committee recently released a report on COVID-19 and COPD. The committee does a great job of providing timely, consensus-based recommendations for all things COPD. The new report is a long, comprehensive document. Our goal here will be to highlight a few areas of interest and provide a summary.
COPD is a chronic airway disease characterized by hypoxia, hypercapnia, and destruction of lung tissue. Given that COVID-19 is predominantly a respiratory disease that causes hypoxia and acute respiratory distress syndrome, there is concern that persons with COPD will be particularly vulnerable. The GOLD report concludes that data for patients with COPD being at increased risk for contracting COVID-19 are mixed, but they’re confident that COPD is a risk factor for adverse outcomes with infection.
Face coverings are recommended, as they are for everyone, with the caveat that some data show that N95 masks can lead to elevated CO2 levels in patients with COPD in certain scenarios. Face shields and looser covers, such as surgical masks, should be fine.
With respect to treatment, the report could best be summarized as saying “do everything you normally would” — meaning that if a given therapy is indicated for COPD in the absence of COVID-19, it should still be used now. While the authors note that data are limited, inhaled corticosteroids (ICS), long-acting bronchodilators (LABAs), roflumilast, or chronic macrolides should be prescribed according to guidelines. As is the case with asthma, avoiding loss of symptom control and acute exacerbations is key to limiting unnecessary exposures to the healthcare system.
Participation in “center-based” pulmonary rehabilitation proves the exception. The authors recommend against this owing to risk for exposure and suggest home-based programs or an exercise prescription. This is in keeping with good common sense, but clinicians should expect this to affect disease outcomes. Pulmonary rehabilitation has been shown to reduce exacerbations and improve quality of life and symptom control. Physical activity must still be stressed at every opportunity.
I was interested to see them discuss the prospect of shielding or sheltering in place. This involves isolating individuals at higher risk for morbidity or mortality from COVID-19 infection. The United Kingdom has recommended isolation or shielding for patients with COPD with an FEV1 < 50%, a Modified Medical Research Council Dyspnea Scale (mMRC) score ≥ 3, a history of hospitalization for an exacerbation, or requirement for long term oxygen or noninvasive ventilation. The GOLD report cites a modeling study to support efficacy for this strategy, and for those with severe COPD who can afford to stay at home and have all daily necessities brought to them, this seems advisable. Obviously, this won’t be an option for all people in all places. Before reading this GOLD report, I’d been advising some of my patients with COPD to avoid work and stay at home when possible.
The indications for remdesivir and dexamethasone for patients with COVID-19 continue to evolve. However, if a patient with COPD otherwise meets the threshold to receive these drugs, they should be given. There are no known interactions between remdesivir and inhaled COPD therapies.
In summary, this GOLD report reads like most other COVID-19 guidelines. There’s simply not enough data to suggest we should do anything different for COPD than we normally would. COVID-19 poses unique challenges to treating patients with COPD, but these are self-evident and don’t require a review of the literature. As we gain experience and the pandemic persists, I suspect we’ll see more data on virtual care, home lung testing, and other forms of remote monitoring. We’re also likely to see more progress and research on home-based pulmonary rehabilitation programs. This isn’t a bad thing.
Authored by Aaron B. Holley, MD, is an associate professor of medicine at Uniformed Services University and program director of pulmonary and critical care medicine at Walter Reed National Military Medical Center. He covers a wide range of topics in pulmonary, critical care, and sleep medicine.