Managing Asthma during Coronavirus Disease-2019: An Example for Other Chronic Conditions in Children and Adolescents
2020; Elsevier BV; Volume: 222; Linguagem: Inglês
10.1016/j.jpeds.2020.04.049
ISSN1097-6833
AutoresElissa M. Abrams, Stanley J. Szefler,
Tópico(s)Chronic Obstructive Pulmonary Disease (COPD) Research
ResumoThe novel coronavirus disease-2019 (COVID-19), caused by the pathogen severe acute respiratory syndrome corona virus (SARS-CoV-2), has now spread around the globe with more than 1.8 million individuals affected and more than 110 000 deaths internationally.1Wu D. Wu T. Liu Q. Yang Z. The SARS-CoV-2 outbreak: what we know.Int J Infect Dis. 2020; 94: 44-48Abstract Full Text Full Text PDF PubMed Scopus (804) Google Scholar, 2Johns Hopkins Coronavirus Resource Centerhttps://coronavirus.jhu.edu/map.htmlGoogle Scholar, 3Centers for Disease Control and Prevention (CDC) Morbidity and mortality weekly report - coronavirus disease 2019 in Children.www.cdc.gov/mmwr/volumes/69/wr/mm6914e4.htmGoogle Scholar, 4Our World in Data COVID-19 Statistics.https://ourworldindata.org/coronavirus?fbclid=IwAR0Yxq8A4Qa24Sq2ORmEoW5VkX58cdo48NHROzgFKmu2NToAipLzT3GgilgGoogle Scholar As of April 12, 2020, there are 530 830 cases in the US with more than 20 000 deaths.2Johns Hopkins Coronavirus Resource Centerhttps://coronavirus.jhu.edu/map.htmlGoogle Scholar,3Centers for Disease Control and Prevention (CDC) Morbidity and mortality weekly report - coronavirus disease 2019 in Children.www.cdc.gov/mmwr/volumes/69/wr/mm6914e4.htmGoogle Scholar The Institute for Health Metrics and Evaluation has predicted that this pandemic could exceed current healthcare capacity in the US with a total of 81 114 deaths (95% CI, 38 242-162 106) through August 2020.5Institute for Health Metrics and Evaluation (IHME)Forecasting COVID-19 impact on hospital bed-days, ICU-days, ventilator days and deaths by US state in the next 4 months.http://www.healthdata.org/research-article/forecasting-covid-19-impact-hospital-bed-days-icu-days-ventilator-days-and-deathsGoogle Scholar Asthma is one of the most common chronic diseases of childhood in the US. Data from the US Department of Health and Human Services notes that asthma prevalence increased between 2001 and 2010 and is now at its highest prevalence ever (overall 8.4% in 2010).6Akinbami L.J. Moorman J.E. Bailey C. Zahran H.S. King M. Johnson C.A. et al.Trends in asthma prevalence, health care use, and mortality in the United States, 2001-2010.NCHS Data Brief. 2012; 94: 1-8PubMed Google Scholar In the US, approximately 7 million children have asthma.6Akinbami L.J. Moorman J.E. Bailey C. Zahran H.S. King M. Johnson C.A. et al.Trends in asthma prevalence, health care use, and mortality in the United States, 2001-2010.NCHS Data Brief. 2012; 94: 1-8PubMed Google Scholar The morbidity of asthma in the US is high, and is higher in children than adults. Children missed 10.5 million school days owing to asthma in 2008; there were 6.7 million primary care visits related to asthma and 600 000 asthma-related emergency department visits for children in 2007.7Akinbami L.J. Moorman J.E. Liu X. Asthma prevalence, health care use, and mortality: United States, 2005-2009.Natl Health Stat Report. 2011; 32: 1-14PubMed Google Scholar Multiple guidelines have emerged from international societies on the management of medical care during the COVID-19 pandemic, which include a section on pediatric asthma, including a North American guideline on contingency planning for allergy and immunology clinics during a pandemic and a Canadian Pediatric Society statement on asthma management during the COVID-19 pandemic.8Shaker M.S. Oppenheimer J. Grayson M. Stukus D. Hartog N. Hsieh E. et al.COVID-19: pandemic contingency planning for the allergy and immunology clinic.J Allergy Clin Immunol. 2020; 145: 1082-1123Abstract Full Text Full Text PDF PubMed Scopus (404) Google Scholar,9Abrams E. T'Jong G. Yang C. Canadian Pediatric Society practice point: paediatric asthma and COVID-19.www.cps.ca/en/documents/position/paediatric-asthma-and-covid-19Google Scholar Owing to the high prevalence of asthma in the US, which is at the current epicenter of a global pandemic, the goal of this commentary is to provide an overview of what is known, and what is yet to be learned, about COVID-19 and pediatric asthma. Symptoms of COVID-19 can be similar to those of worsening asthma, or an asthma exacerbation. Dry cough and shortness of breath, commonly seen in asthma, are among the most common presenting symptoms of COVID-19 in case series of children admitted to the hospital in China, as well as in available data from the Centers for Disease Control and Prevention (CDC) in the US.10Zheng F. Liao C. Fan Q.-H. Chen H.-B. Zhao X.-G. Xie Z.-G. et al.Clinical characteristics of children with coronavirus disease 2019 in Hubei, China.Curr Med Sci. 2020; ([Epub ahead of print])Crossref Scopus (286) Google Scholar, 11Sun D. Li H. Lu X.-X. Xiao H. Ren J. Zhang F.-R. et al.Clinical features of severe pediatric patients with coronavirus disease 2019 in Wuhan: a single center's observational study.World J Pediatr. 2020; ([Epub ahead of print])Crossref Scopus (436) Google Scholar, 12Chen N. Zhou M. Dong X. Qu J. Gong F. Han Y. et al.Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study.Lancet. 2020; 395: 507-513Abstract Full Text Full Text PDF PubMed Scopus (14520) Google Scholar Fever, a common presenting symptom of COVID-19, may help to differentiate COVID-19 from an asthma exacerbation, although fever can be present in other virus-triggered asthma exacerbations as well.3Centers for Disease Control and Prevention (CDC) Morbidity and mortality weekly report - coronavirus disease 2019 in Children.www.cdc.gov/mmwr/volumes/69/wr/mm6914e4.htmGoogle Scholar,10Zheng F. Liao C. Fan Q.-H. Chen H.-B. Zhao X.-G. Xie Z.-G. et al.Clinical characteristics of children with coronavirus disease 2019 in Hubei, China.Curr Med Sci. 2020; ([Epub ahead of print])Crossref Scopus (286) Google Scholar, 11Sun D. Li H. Lu X.-X. Xiao H. Ren J. Zhang F.-R. et al.Clinical features of severe pediatric patients with coronavirus disease 2019 in Wuhan: a single center's observational study.World J Pediatr. 2020; ([Epub ahead of print])Crossref Scopus (436) Google Scholar, 12Chen N. Zhou M. Dong X. Qu J. Gong F. Han Y. et al.Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study.Lancet. 2020; 395: 507-513Abstract Full Text Full Text PDF PubMed Scopus (14520) Google Scholar Other less common symptoms of COVID-19, better described in the adult population, may help to differentiate COVID-19 from asthma and include myalgia, confusion headache, pharyngitis, rhinorrhea, loss of sense of smell and taste, diarrhea, nausea, and vomiting.12Chen N. Zhou M. Dong X. Qu J. Gong F. Han Y. et al.Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study.Lancet. 2020; 395: 507-513Abstract Full Text Full Text PDF PubMed Scopus (14520) Google Scholar A travel history, close contact with someone infected with COVID-19, and absence of a prior atopic history in a child also help to differentiate the two. Because there is substantial overlap between the clinical presentation of worsening asthma and COVID-19 and increasing community spread decreases likelihood of known contact with a case, screening for COVID-19 is required if available in any child with asthma who comes to medical attention with worsening cough or shortness of breath.8Shaker M.S. Oppenheimer J. Grayson M. Stukus D. Hartog N. Hsieh E. et al.COVID-19: pandemic contingency planning for the allergy and immunology clinic.J Allergy Clin Immunol. 2020; 145: 1082-1123Abstract Full Text Full Text PDF PubMed Scopus (404) Google Scholar,13Rasmussen S.A. Thompson L.A. Coronavirus disease 2019 and children: what pediatric health care clinicians need to know.JAMA Pediatr. 2020; ([Epub ahead of print])Crossref Scopus (66) Google Scholar There is a theoretical risk that infection with COVID-19 in a child with asthma may increase the risk of pneumonia or acute respiratory disease.14CDC. Coronavirus disease (COVID-19): people who are at high risk.www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/asthma.htmlDate: 2019Google Scholar As a result, the CDC lists moderate to severe asthma as a risk factor for COVID-19 morbidity and mortality.14CDC. Coronavirus disease (COVID-19): people who are at high risk.www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/asthma.htmlDate: 2019Google Scholar However, to date the literature is ambiguous on whether preexisting asthma increases the risk of either COVID-19 infection, or morbidity/mortality owing to COVID-19, in children. The evidence on COVID-19 risk factors derives largely from the adult population. Four case series, all from Wuhan, China, of adults admitted to hospital with COVID-19 did not list asthma as an underlying preexisting condition in any of those patients.12Chen N. Zhou M. Dong X. Qu J. Gong F. Han Y. et al.Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study.Lancet. 2020; 395: 507-513Abstract Full Text Full Text PDF PubMed Scopus (14520) Google Scholar,15Huang C. Wang Y. Li X. Ren L. Zhao J. Hu Y. et al.Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China.Lancet. 2020; 395: 497-506Abstract Full Text Full Text PDF PubMed Scopus (33292) Google Scholar, 16Zhang J.-J. Dong X. Cao Y.-Y. Yuan Y.-D. Yang Y.-B. Yan Y.-Q. et al.Clinical characteristics of 140 patients infected with SARS-CoV-2 in Wuhan, China.Allergy. 2020; ([Epub ahead of print])Crossref Scopus (2586) Google Scholar, 17Wang D. Hu B. Hu C. Zhu F. Liu X. Zhang J. et al.Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China.JAMA. 2020; ([Epub ahead of print])Crossref Scopus (16387) Google Scholar In a large case series of 1099 adult patients from 552 hospitals in 30 provinces in China, asthma was not listed as a preexisting condition in any of the patients described.18Guan W.-J. Ni Z.-Y. Hu Y. Liang W.-H. Ou C.-Q. He J.-X. et al.Clinical characteristics of coronavirus disease 2019 in China.N Engl J Med. 2020; ([Epub ahead of print])Crossref Google Scholar In contrast, recent data released from the CDC of US hospitalizations in March 2020 notes that 27.3% of adults 18-49 years of age who were hospitalized with COVID-19 had a history of asthma.3Centers for Disease Control and Prevention (CDC) Morbidity and mortality weekly report - coronavirus disease 2019 in Children.www.cdc.gov/mmwr/volumes/69/wr/mm6914e4.htmGoogle Scholar In adults aged 50-64 years of age hospitalized for COVID-19 asthma was present in 13.2% and in those 65 years or older asthma was present in 12.9%.3Centers for Disease Control and Prevention (CDC) Morbidity and mortality weekly report - coronavirus disease 2019 in Children.www.cdc.gov/mmwr/volumes/69/wr/mm6914e4.htmGoogle Scholar,19AAAAI. Asthma and COVID-19 update.https://contentsharing.net/actions/email_web_version.cfm?recipient_id=3712797199&message_id=18453579&user_id=AAAAI&group_id=0&jobid=47601295Google Scholar As a result, the American Academy of Allergy, Asthma & Immunology notes that "those with asthma in the 18-49 year old age range may be at increased risk of hospitalization owing to COVID-19."19AAAAI. Asthma and COVID-19 update.https://contentsharing.net/actions/email_web_version.cfm?recipient_id=3712797199&message_id=18453579&user_id=AAAAI&group_id=0&jobid=47601295Google Scholar Although there is a paucity of literature on pediatric risk factors, the case series to date from Wuhan on hospitalized pediatric cases do not list asthma as a preexisting risk factor for morbidity or mortality.10Zheng F. Liao C. Fan Q.-H. Chen H.-B. Zhao X.-G. Xie Z.-G. et al.Clinical characteristics of children with coronavirus disease 2019 in Hubei, China.Curr Med Sci. 2020; ([Epub ahead of print])Crossref Scopus (286) Google Scholar,11Sun D. Li H. Lu X.-X. Xiao H. Ren J. Zhang F.-R. et al.Clinical features of severe pediatric patients with coronavirus disease 2019 in Wuhan: a single center's observational study.World J Pediatr. 2020; ([Epub ahead of print])Crossref Scopus (436) Google Scholar It is further reassuring that children seem to be at a lesser risk of COVID-19 morbidity and mortality than the adult population in general, although severe infection still can occur.13Rasmussen S.A. Thompson L.A. Coronavirus disease 2019 and children: what pediatric health care clinicians need to know.JAMA Pediatr. 2020; ([Epub ahead of print])Crossref Scopus (66) Google Scholar,20Tagarro A. Epalza C. Santos M. Sanz-Santaeufemia F.J. Otheo E. Moraleda C. et al.Screening and severity of coronavirus disease 2019 (COVID-19) in children in Madrid, Spain.JAMA Pediatr. 2020; ([Epub ahead of print])Crossref PubMed Scopus (340) Google Scholar The CDC morbidity and mortality report notes that among the 149 082 reported US cases of COVID-19 for which age is known, only 2572 (1.7%) occurred in children 18 years of age and younger.3Centers for Disease Control and Prevention (CDC) Morbidity and mortality weekly report - coronavirus disease 2019 in Children.www.cdc.gov/mmwr/volumes/69/wr/mm6914e4.htmGoogle Scholar Although among the patients with information on underlying conditions, 23% had at least 1 underlying condition such as asthma, only 5.7% of children infected with COVID-19 required hospitalization (compared with 10% of adults aged 18-64 years) and only 3 deaths were reported in children (<1% of pediatric cases). In a case series from China of 72 000 cases, approximately 1% were children aged 0-18 years of age with only 1 death reported in the adolescent population (and none in children under 10 years of age).13Rasmussen S.A. Thompson L.A. Coronavirus disease 2019 and children: what pediatric health care clinicians need to know.JAMA Pediatr. 2020; ([Epub ahead of print])Crossref Scopus (66) Google Scholar,21Wu Z. McGoogan J.M. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72314 cases from the Chinese Center for Disease Control and Prevention.JAMA. 2020; ([Epub ahead of print])Crossref Scopus (12778) Google Scholar Another risk in children with asthma is that infection with COVID-19 could trigger a viral-induced asthma exacerbation. There is minimal literature on this risk from COVID-19, but there are data on the risk of asthma exacerbations triggered from other coronavirus infections, with mixed findings. SARS, owing to human coronaviruses HCoV-229E and HCoV-OC43, did not cause an increase in asthma exacerbations in children during the 2002 epidemic, or induce bronchial hyperreactivity or eosinophilic inflammation.22Van Bever H.P. Chng S.Y. Goh D.Y. Childhood severe acute respiratory syndrome, coronavirus infections and asthma.Pediatr Allergy Immunol. 2004; 15: 206-209Crossref PubMed Scopus (47) Google Scholar In fact, paradoxically, asthma exacerbations actually decreased during that time, which was attributed to improvements in hygiene measures related to the epidemic.22Van Bever H.P. Chng S.Y. Goh D.Y. Childhood severe acute respiratory syndrome, coronavirus infections and asthma.Pediatr Allergy Immunol. 2004; 15: 206-209Crossref PubMed Scopus (47) Google Scholar However, in contrast, nonepidemic coronaviruses are found commonly in the respiratory tracts of children with an asthma exacerbation and have contributed to bronchial hyper-reactivity and eosinophilic inflammation.23Greenberg S.B. Rhinovirus and coronavirus infections.Semin Respir Crit Care Med. 2007; 28: 182-192Crossref PubMed Scopus (27) Google Scholar, 24Marin J. Jeler-Kacar D. Levstek V. Macek V. Persistence of viruses in upper respiratory tract of children with asthma.J Infect. 2000; 41: 69-72Abstract Full Text PDF PubMed Scopus (56) Google Scholar, 25Thumerelle C. Deschildre A. Bouquillon C. Santos C. Sardet A. Scalbert M. et al.Role of viruses and atypical bacteria in exacerbations of asthma in hospitalized children: a prospective study in the Nord-Pas de Calais region (France).Pediatr Pulmonol. 2003; 35: 75-82Crossref PubMed Scopus (108) Google Scholar, 26Greiff L. Andersson M. Akerlund A. Wollmer P. Svensson C. Alkner U. et al.Microvascular exudative hyperresponsiveness in human coronavirus-induced common cold.Thorax. 1994; 49: 121-127Crossref PubMed Scopus (32) Google Scholar In summary, based on available information to date, it is unclear whether there is a significantly increased risk of COVID-19 morbidity among children with asthma.8Shaker M.S. Oppenheimer J. Grayson M. Stukus D. Hartog N. Hsieh E. et al.COVID-19: pandemic contingency planning for the allergy and immunology clinic.J Allergy Clin Immunol. 2020; 145: 1082-1123Abstract Full Text Full Text PDF PubMed Scopus (404) Google Scholar,9Abrams E. T'Jong G. Yang C. Canadian Pediatric Society practice point: paediatric asthma and COVID-19.www.cps.ca/en/documents/position/paediatric-asthma-and-covid-19Google Scholar It is also unknown whether asthma medications such as high-dose inhaled corticosteroids or asthma biological therapies pose a risk in managing COVID-19 infections. Before any definitive conclusions can be drawn, larger scale data are required from pediatric populations, and from heterogeneous locations that have been impacted by COVID-19. It also remains unclear if COVID-19 increases the risk of asthma exacerbations. As a result, good asthma control is essential as a precautionary measure during this time.8Shaker M.S. Oppenheimer J. Grayson M. Stukus D. Hartog N. Hsieh E. et al.COVID-19: pandemic contingency planning for the allergy and immunology clinic.J Allergy Clin Immunol. 2020; 145: 1082-1123Abstract Full Text Full Text PDF PubMed Scopus (404) Google Scholar,9Abrams E. T'Jong G. Yang C. Canadian Pediatric Society practice point: paediatric asthma and COVID-19.www.cps.ca/en/documents/position/paediatric-asthma-and-covid-19Google Scholar,13Rasmussen S.A. Thompson L.A. Coronavirus disease 2019 and children: what pediatric health care clinicians need to know.JAMA Pediatr. 2020; ([Epub ahead of print])Crossref Scopus (66) Google Scholar,20Tagarro A. Epalza C. Santos M. Sanz-Santaeufemia F.J. Otheo E. Moraleda C. et al.Screening and severity of coronavirus disease 2019 (COVID-19) in children in Madrid, Spain.JAMA Pediatr. 2020; ([Epub ahead of print])Crossref PubMed Scopus (340) Google Scholar In addition to the current burden of COVID-19, the spring season is often a time for asthma exacerbations owing to emergence of seasonal aeroallergens, and other respiratory viruses.27Teach S.J. Gergen P.J. Szefler S.J. Mitchell H.E. Calatroni A. Wildfire J. et al.Seasonal risk factors for asthma exacerbations among inner-city children.J Allergy Clin Immunol. 2015; 135: 1465-1473.e5Abstract Full Text Full Text PDF PubMed Scopus (133) Google Scholar The best way to prevent an exacerbation is consistent proper use of medicines to control asthma, such as inhaled corticosteroids and/or montelukast. As a result, children should remain on their current asthma medications during the COVID-19 outbreak.8Shaker M.S. Oppenheimer J. Grayson M. Stukus D. Hartog N. Hsieh E. et al.COVID-19: pandemic contingency planning for the allergy and immunology clinic.J Allergy Clin Immunol. 2020; 145: 1082-1123Abstract Full Text Full Text PDF PubMed Scopus (404) Google Scholar,9Abrams E. T'Jong G. Yang C. Canadian Pediatric Society practice point: paediatric asthma and COVID-19.www.cps.ca/en/documents/position/paediatric-asthma-and-covid-19Google Scholar This recommendation is supported by multiple international organizations, including the CDC, the Global Initiative for Asthma, and the North American consensus guideline on allergy care during the COVID outbreak.8Shaker M.S. Oppenheimer J. Grayson M. Stukus D. Hartog N. Hsieh E. et al.COVID-19: pandemic contingency planning for the allergy and immunology clinic.J Allergy Clin Immunol. 2020; 145: 1082-1123Abstract Full Text Full Text PDF PubMed Scopus (404) Google Scholar,9Abrams E. T'Jong G. Yang C. Canadian Pediatric Society practice point: paediatric asthma and COVID-19.www.cps.ca/en/documents/position/paediatric-asthma-and-covid-19Google Scholar,28Global Initiative for Asthma Recommendations for inhaled asthma controller medications.https://ginasthma.org/recommendations-for-inhaled-asthma-controller-medications/Google Scholar,29Centers for Disease Control and PreventionPeople with asthma and COVID-19.www.cdc.gov/coronavirus/2019-ncov/specific-groups/asthma.htmlGoogle Scholar It is recommended that children not step down any controller medication during this time unless "this is clearly favorable from an individual standpoint, with careful consideration of the balance between benefit and harm/burden."8Shaker M.S. Oppenheimer J. Grayson M. Stukus D. Hartog N. Hsieh E. et al.COVID-19: pandemic contingency planning for the allergy and immunology clinic.J Allergy Clin Immunol. 2020; 145: 1082-1123Abstract Full Text Full Text PDF PubMed Scopus (404) Google Scholar Other recommendations to maintain asthma control include avoiding known asthma triggers such as aeroallergens, frequent handwashing, physical distancing, and regular review of inhaler technique.9Abrams E. T'Jong G. Yang C. Canadian Pediatric Society practice point: paediatric asthma and COVID-19.www.cps.ca/en/documents/position/paediatric-asthma-and-covid-19Google Scholar,29Centers for Disease Control and PreventionPeople with asthma and COVID-19.www.cdc.gov/coronavirus/2019-ncov/specific-groups/asthma.htmlGoogle Scholar An exacerbation, if it occurred, "could require [children] to enter the healthcare system, which would put them at increased risk of being exposed to SARS-CoV-2 during the current pandemic."8Shaker M.S. Oppenheimer J. Grayson M. Stukus D. Hartog N. Hsieh E. et al.COVID-19: pandemic contingency planning for the allergy and immunology clinic.J Allergy Clin Immunol. 2020; 145: 1082-1123Abstract Full Text Full Text PDF PubMed Scopus (404) Google Scholar Some biologic agents, such as omalizumab (anti-IgE) and mepolizumab (anti-IL5), are approved for use in moderate to severe asthma in adolescents.30Abrams E.M. Becker A.B. Szefler S.J. Current state and future of biologic therapies in the treatment of asthma in children.Pediatr Allergy Immunol Pulmonol. 2018; 31: 119-131Crossref PubMed Scopus (28) Google Scholar The current recommendation for adolescents who are using these medications is to continue their use.8Shaker M.S. Oppenheimer J. Grayson M. Stukus D. Hartog N. Hsieh E. et al.COVID-19: pandemic contingency planning for the allergy and immunology clinic.J Allergy Clin Immunol. 2020; 145: 1082-1123Abstract Full Text Full Text PDF PubMed Scopus (404) Google Scholar There is no current evidence that use of these medications increases the risk of COVID-19 infection or morbidity. If a child is using a nebulized asthma relief medication, this should be switched to a metered dose inhaler or dry powder inhaler (turbuhaler or diskus) under most circumstances8Shaker M.S. Oppenheimer J. Grayson M. Stukus D. Hartog N. Hsieh E. et al.COVID-19: pandemic contingency planning for the allergy and immunology clinic.J Allergy Clin Immunol. 2020; 145: 1082-1123Abstract Full Text Full Text PDF PubMed Scopus (404) Google Scholar,9Abrams E. T'Jong G. Yang C. Canadian Pediatric Society practice point: paediatric asthma and COVID-19.www.cps.ca/en/documents/position/paediatric-asthma-and-covid-19Google Scholar Nebulization increases the risk of viral lower lung deposition.8Shaker M.S. Oppenheimer J. Grayson M. Stukus D. Hartog N. Hsieh E. et al.COVID-19: pandemic contingency planning for the allergy and immunology clinic.J Allergy Clin Immunol. 2020; 145: 1082-1123Abstract Full Text Full Text PDF PubMed Scopus (404) Google Scholar,9Abrams E. T'Jong G. Yang C. Canadian Pediatric Society practice point: paediatric asthma and COVID-19.www.cps.ca/en/documents/position/paediatric-asthma-and-covid-19Google Scholar,31Amirav I. Transmission of Corona Virus by Nebulizer- a serious, underappreciated risk!.CMAJ. 2020; (in press)Crossref PubMed Scopus (51) Google Scholar It also increases the risk of infection transmission owing to both stimulating a cough reflex, as well as generating "a high volume of respiratory aerosols that may be propelled over a longer distance than is involved in a natural dispersion pattern."31Amirav I. Transmission of Corona Virus by Nebulizer- a serious, underappreciated risk!.CMAJ. 2020; (in press)Crossref PubMed Scopus (51) Google Scholar It was poignantly noted in a recent editorial that "there is a possibility that nebulizer therapy in patients with COVID-19 infection can transmit potentially viable coronavirus to susceptible bystander hosts."31Amirav I. Transmission of Corona Virus by Nebulizer- a serious, underappreciated risk!.CMAJ. 2020; (in press)Crossref PubMed Scopus (51) Google Scholar The only possible reasons for a child to use a nebulizer at home during the COVID-19 pandemic are a poor response to a metered dose inhaler/spacer, a child who is either uncooperative or unable to follow the directions required for metered dose inhaler use, or medication shortages (which are discussed in greater detail elsewhere in this article).8Shaker M.S. Oppenheimer J. Grayson M. Stukus D. Hartog N. Hsieh E. et al.COVID-19: pandemic contingency planning for the allergy and immunology clinic.J Allergy Clin Immunol. 2020; 145: 1082-1123Abstract Full Text Full Text PDF PubMed Scopus (404) Google Scholar,9Abrams E. T'Jong G. Yang C. Canadian Pediatric Society practice point: paediatric asthma and COVID-19.www.cps.ca/en/documents/position/paediatric-asthma-and-covid-19Google Scholar,31Amirav I. Transmission of Corona Virus by Nebulizer- a serious, underappreciated risk!.CMAJ. 2020; (in press)Crossref PubMed Scopus (51) Google Scholar The CDC and the World Health Organization have recommended against oral corticosteroid (OCS) use as a treatment for COVID-19.32CDC Coronavirus disease 2019 (COVID-19): clinical care.www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.htmlGoogle Scholar,33World Health Organization Clinical management of severe acute respiratory infection when novel coronavirus (nCoV) infection is suspected. Geneva; 2020.www.who-int.uml.idm.oclc.org/publications-detail/clinical-management-of-severe-acute-respiratory-infection-when-novel-coronavirus-(ncov)-infection-is-suspectedGoogle Scholar This recommendation is based on experience with influenza, SARS-CoV, and Middle East respiratory syndrome coronavirus, where OCS use prolonged viral replication and was associated with prolonged viral clearance, increased complication rates, increased risk of mechanical ventilation, and higher mortality rates.34Arabi Y.M. Mandourah Y. Al-Hameed F. Sindi A.A. Almekhlafi G.A. Hussein M.A. et al.Corticosteroid therapy for critically ill patients with Middle east respiratory syndrome.Am J Respir Crit Care Med. 2018; 197: 757-767Crossref PubMed Scopus (838) Google Scholar, 35Memish Z.A. Perlman S. Van Kerkhove M.D. Zumla A. Middle East respiratory syndrome.Lancet. 2020; 395: 1063-1077Abstract Full Text Full Text PDF PubMed Scopus (306) Google Scholar, 36Zumla A. Hui D.S. Perlman S. Middle East respiratory syndrome.Lancet. 2015; 386: 995-1007Abstract Full Text Full Text PDF PubMed Scopus (857) Google Scholar, 37Russell C.D. Millar J.E. Baillie J.K. Clinical evidence does not support corticosteroid treatment for 2019-nCoV lung injury.Lancet. 2020; 395: 473-475Abstract Full Text Full Text PDF PubMed Scopus (1542) Google Scholar It has been noted that OCS therapy increases the risk of nosocomial infection and secondary infection.38Yuen K.-S. Ye Z.-W. Fung S.-Y. Chan C.-P. Jin D.-Y. SARS-CoV-2 and COVID-19: the most important research questions.Cell Biosci. 2020; 10: 40Crossref PubMed Scopus (413) Google Scholar However, there is a distinction between OCS use as a therapy for COVID-19, and OCS use as a treatment of asthma exacerbations.8Shaker M.S. Oppenheimer J. Grayson M. Stukus D. Hartog N. Hsieh E. et al.COVID-19: pandemic contingency planning for the allergy and immunology clinic.J Allergy Clin Immunol. 2020; 145: 1082-1123Abstract Full Text Full Text PDF PubMed Scopus (404) Google Scholar There is broad consensus that asthma exacerbations should be treated aggressively and in keeping with current guideline recommendations.9Abrams E. T'Jong G. Yang C. Canadian Pediatric Society practice point: paediatric asthma and COVID-19.www.cps.ca/en/documents/position/paediatric-asthma-and-covid-19Google Scholar Multiple national and international organizations such as the Global Initiative for Asthma recommend OCS use as required, and in keeping with the child's asthma action plan, during COVID-19.8Shaker M.S. Oppenheimer J. Grayson M. Stukus D. Hartog N. Hsieh E. et al.COVID-19: pandemic contingency planning for the allergy and immunology clinic.J Allergy Clin Immunol. 2020; 145: 1082-1123Abstract Full Text Full Text PDF PubMed Scopus (404) Google Scholar,9Abrams E. T'Jong G. Yang C. Canadian Pediatric Society practice point: paediatric asthma and COVID-19.www.cps.ca/en/documents/position/paediatric-asthma-and-covid-19Google Scholar,28Global Initiative for Asthma Recommendations for inhaled asthma controller medications.https://ginasthma.org/recommendations-for-inhaled-asthma-controller-medications/Google Scholar The use of nebulized medications are especially discouraged in a healthcare setting, where infection transmission to other vulnerable patients is a risk.9Abrams E. T'Jong G. Yang C. Canadian Pediatric Society practice point: paediatric asthma and COVID-19.www.cps.ca/en/documents/position/paediatric-asthma-and-covid-19Google Scholar,31Amirav I. Transmission of Corona Virus by Nebulizer- a serious, underappreciated risk!.CMAJ. 2020; (in press)Crossref PubMed Scopus (51) Google Scholar If used, proper personal protective equipment is required. It must also be consi
Referência(s)