Underlying COPD in Patients with COVID-19 Presents Challenges

October 14, 2020

Underlying chronic obstructive pulmonary disease in patients infected with COVID-19 present a variety of challenges for health care professionals, including increased risk for poor clinical outcomes and increased risk of spreading the disease.

Patients with underlying chronic obstructive pulmonary disease (COPD) are at greater risk of poor outcomes from the coronavirus disease 2019 (COVID-19) and present many unique challenges to treatment. A new article published in Thorax explores viewpoints from four European countries on best practices for caring for such patients.

An international team of investigators explored questions ranging from whether patients with COPD were more likely to contract SARS-CoV-2 to how end-of-life care should be delivered to patients with COPD and COVID-19.

“During these extraordinary times, caring for patients with COVID-19 and underlying COPD poses particular challenges,” the authors noted in the article, adding that some COPD treatments increase the risk of spreading the virus.

Studies so far suggest COPD is not a risk factor for acquiring the virus, but this risk of death is higher for those who do become infected. Two recent studies found that two-thirds of patients hospitalized with COVID-19 experience persistent pulmonary symptoms weeks after hospital discharge.

Patients with COPD are commonly treated with bronchodilators, non-invasive ventilation (NIV) and antibiotics. Some concerns have been raised about continuing some of these treatment during the pandemic.

While bacterial/fungal coinfections are uncommon, occurring in about 8% of patients with COVID-19, one study found that they were present in half of those who died in hospital from the disease and ventilatory-associated pneumonia was seen in 31%.

“Since it may be difficult to distinguish SARS-CoV-2 infections from a bacterial pneumonia and because patients with COPD are at risk for bacterial (super)infections, we suggest treating hospitalized patients with COPD and COVID-19 and respiratory symptoms with broad-spectrum antibiotics, guided by local/national guidelines for treating pneumonia,” the study authors wrote.

While some studies support the use of bronchodilators via nebulizer to treat patients with COPD and COVID-19, the article authors suggest that research doesn’t adequately address the risk of transmission of the virus during such aerosol-generating procedures.

They recommend long-acting dual bronchodilators via pressurized metered-dose inhalers (pMDI) used with a spacer.

“Nebulised treatment should be reserved for those situations in which pMDI with spacer is not possible, such as patients with severe, life-threatening disease or those unable to use a pMDI,” the article noted.

World Health Organization guidelines for the use of dexamethasone or other corticosteroids has shifted during the pandemic, with recent research from the RECOVERY trial suggesting it improves mortality among those requiring respiratory support. Given that evidence coupled with the benefits of corticosteroids for patients with acute exacerbations of COPD, treating patients with COPD and COVID-19 with corticosteroids is reasonable.

Measures such as using non-vented masks with exhaled air passing a bacterial/viral filter should be used to reduce spread of the virus during NIV, high-flow nasal cannula (HFNC) or CPAP with a high fraction of inspired oxygen (FiO2).

Patients with COPD and COVID-19 also should be provided dietary support, psychological and spiritual support, pulmonary rehabilitation, and screening for emotional and functional limitations.

End-of-life care should include timely advance care planning; management of anxiety, dyspnoea and palliative sedation; and bereavement care for loved ones.

“Knowledge of COVID-19 is rapidly accumulating; therefore, the discussion on how to best treat patients with COPD and COVID-19 should continue and we invite the respiratory community to share best practices online,” the authors concluded.