Asthma Management In Times Of COVID-19: Expert Guidelines To Stay Safe

According to the WHO, Asthma is a major non-communicable disease characterised by recurrent attacks of breathlessness and wheezing, which vary in severity and frequency from person to person. Strongest risk factors are a combination of genetic predisposition with environmental exposure to inhaled substances and particles that may provoke allergic reactions or irritate the airways.

In India, as many as 37 million people suffer from asthma, according to the Global Burden Disease Report. This contributes to only 11.1% of the global asthma burden. But, India accounts for 42% of global asthma deaths. While currently there is no evidence of increased infection rates in those with asthma, taking extra precautionary measures is important in for prevention and controlling asthma.

Dr Randeep Guleria, Director of AIIMS, elaborates on the multiple precautionary measures that asthmatics should take during the Covid-19 outbreak.

"This is a crucial time for people who have chronic respiratory diseases, including asthma. They have to be careful about social distancing, hand washing, wearing a mask and going out," he said.

Inhalers for asthmatics: Do's & Don'ts

Inhalers are the primary medicine for asthma and an asthma patient must always have an inhaler. Inhaled corticosteroids are the medicines that help in keeping inflammation in airways under control. "Asthma patients must continue to take their medications regularly," says Dr Guleria while adding that patients should take their inhalers as prescribed by their doctor.

Patients need not increase their dosage for extra precaution from Covid-19. "If patients experience an increase in symptoms, they must consult their doctor and have an asthma action plan in place. Patients should not increase medication in fear of Covid-19," Dr Guleria suggests.

When asked if an inhaler can become infected with coronavirus, he said that it is possible if one is not careful in using it. "Before using an inhaler, the patient must wash their hands properly and use it in a proper manner. Patients should keep the inhalers clean, as it is usually advised with each inhaling device," Dr Guleria says.

He also added that asthma patients must be careful about not sharing inhalers. "I have a few patients who have reported using inhalers of a family member in times when they couldn't find their own. This should be avoided in times of Covid-19 because a person can be asymptomatic carriers of the infection. Sharing inhalers can increase risk of catching the infection," he explains.

Dr Guleria says that there is no need to replace your current inhaler with a new one. However, special attention needs to be paid to hygiene and cleanliness for the inhaler.

Management of symptoms

There are two kinds of inhalers: Controllers (Works over a period of time to reduce airway inflammation and prevent asthma symptoms) and Rescuers/Relievers (immediately relieves asthma symptoms when they occur).

Whenever a patient experiences an increase in symptoms, they can take an additional puff of rescue inhalers as prescribed by the doctor. "But if a patient finds the need to use rescue inhaler significantly, and still does not get relief from breathlessness, consultation from physician is required. The doctor will tell if there's a need to change medication or start with a new medicine for better asthma control and relief from breathlessness," says Dr Guleria.

"Patients have to be careful about triggers like sudden exposure change in temperature and sudden exposure to dust, fumes, etc. Many asthmatics experience cough at night, which could be related to acid reflux; or carpets in the bedroom, or dust below the bed. All these triggers need to be eliminated", suggests Dr Guleria. Some people have cough variant asthma, in which the main symptom is cough. These patients can get relief by taking inhalers. "If a patient does not find relief with inhaler, then consulting a doctor is needed," he says.

Telemedicine vs personal visit to the doctor: What to do when?

In the current times, it is advised that people with chronic respiratory infections must avoid places where it is possible to catch an infection. Telemedicine is thus advisable as far as possible. "If a physical examination by a doctor is required, then schedule an appointment and be careful in terms of social distancing, hand washing and the time of the appointment," Dr Guleria says while asserting that when it comes to asthma, a lot can be done through online consultation.

When visiting a doctor, patients should be careful of the following:

• Take an appointment and reach at the required time slot to get away with any waiting in queues.
• Wear a mask properly. Make sure the mask fits you comfortably and you don't have to touch it repetitively.
• Keep a hand sanitiser and keep sanitising your hands.
• Avoid touching face, nose and mouth when outside. Carry rescue inhaler.

Asthma action plan: How to monitor the condition at home

According to Dr Guleria, having an asthma action plan is going to become more important in this era of Covid-19. It empowers the patient with the confidence and ability to manage asthma without visiting or consulting a doctor.

"Doctors should educate patients about a plan to monitor the symptoms, have a scoring system where patients can know when to increase inhaler dosage. An action plan which helps in better control of asthma needs to be put in place," says the doctor.

The action plan should include:

• Preventive measures
• Proper inhaler technique
• Iteration of medicines on worsening or improving of symptoms
• Having an action plan can considerably reduce hospital visits of asthma patients.

Monitoring asthma with Peak flow meter

A peak flow meter is a portable and simple device which measures how well your lungs are able to expel air. Patients need to blow a quick blast of air through a mouthpiece on one end. The meter measures the force of air in litres per minute and gives a reading on built-in numbers scale. "Some peak flow meters also have a coloured coding. There are three colour ranges in red, orange and green. Reading in green zone is not a cause of worry. An orange zone reading suggests you need to increase medication and a red zone suggests that you need to consult your doctor," Dr Guleria explains while adding that peak flow meter is a simple way of monitoring your condition objectively.

Doctors use peak flow meters more for patients who have moderate to severe asthma as compared to ones who have intermittent or mild asthma. The device is not very expensive and is popular among younger asthma patients. Parents and kids find it reassuring that their peak expiratory flow rate (PEFR) is in green zone and has a good value.

Keeping a record of the readings and the day-to-day fluctuations is important. Lot of fluctuations or diurnal variation in the readings is indicative of the fact that one's asthma is not in good control. "If there's a trend that one's peak flow rate is coming down over a period of time, it is indicative that your asthma control is worsening," says Dr Guleria and suggests asthmatics to maintain a chart of their peak flow ratings on a daily basis.

Managing stress and anxiety

Dr Guleria says that anxiety is an important asthma trigger and is not highlighted as one. He shares an anecdote, "Many years ago, I had an asthmatic child who gave all her final exams from the emergency. She would have a panic attack before the exam day and would land up at the emergency the night before." Anxiety is an important asthma trigger and is not stressed upon as much. "We need to put in measures to reassure asthmatics, develop plans to help them de-stress. Studies have found that yoga and meditation are helpful in terms of breathing and de-stressing," Dr Guleria suggested.

Is Covid-19 more severe in patients with chronic respiratory illnesses?

"Chronic respiratory illnesses are a risk factor for causing more severe Covid-19 infection.

Smoking is also a risk factor as it causes an impairment in the defence mechanism of lungs. Looking at the data so far, asthma per se, has not emerged to cause very severe Covid-19 infection," Dr Guleria added. "However, it is still early to claim this as the number of asthmatics documented with Covid-19 have not been that large."

Pollution, asthma and Covid-19

With the improvement in air quality, there has been a decrease in the number of people who have had respiratory problems, reported Dr Guleria. "Documenting how much of this is because of good air quality can be difficulty because there's also a nationwide lockdown. Having said that, patients have found breathing much more comfortably nowadays as compared to earlier times," he stressed. If the economy opens up and there is a rise in air pollution in the upcoming winter months (as it has been the case since the past few years), will Covid-19 increase complications for people with chronic respiratory diseases? "It is my worry that these people are going to face difficulty in this case. Not only are they going to face consequences of high levels of air pollution, they will also be at risk of Covid-19. There is thus a need for developing good strategies for asthma management in order to protect these vulnerable individuals.