Management of asthma during the Coronavirus disease 2019 outbreak

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## Position maintenance treatment
No change should affect asthma management with the pursued aimed if gaining and maintaining best asthma control according to validated questionnaires such as ACT or ACQ. ICS, LABA, LAMA, LTRA and other controllers shouldn't be modified during the outbreak. To the best of the current knowledge, ICS do not increase the risk of severe Covid19.
Approved and licensed biologics (omalizumab, mepolizumab, benralizumab) or given in an early access program should be maintained at the same dose and rhythm. These biologics are not immunosuppressive. They should be home-administered by selfinjections or with the help of a nurse in order to avoid unnecessary attendance to healthcare facilities.
Continuous treatment with OCS should also be maintained at the lowest possible dose to achieve the best level of asthma control. It is of utmost importance not to stop it abruptly in order to avoid any risk of adrenal insufficiency-this condition being a risk for potentially severe adverse events.

## Position initiation of biologics
If asthma remains uncontrolled whereas all efforts are maintained and the best standard treatments observed, the initiation of a biologic shouldn't be delayed. It is recalled that biologics are not intending to treat exacerbation and that these treatments are usually started at a reasonable distance from such an episode.

## Position treatment of exacerbations
OCS are the treatment of choice of an asthma exacerbation. Delaying OCS treatment for an exacerbation may have some fatal consequences. If fever is present, and if Covid19 is suspected, OCS should nonetheless be given at the usual dose of 0.5 to 1 mg/kg/d. It seems potentially hazardous and inappropriate to wait the RT-PCR diagnostic testing. A mean duration of five days is kept even in the case of Covid infection. OCS do not belong to the NSAIDs class.
Nebulisation are increasing the risk of viral dissemination deserving standardized droplet cautions (protection glasses, FFP2 mask, non-re-usable coat) for health care givers and relatives. Accordingly, aerosol chambers should be used in first intention whenever possible for administrating SABA and/or SAMA.

## Position prevention
Social distancing and barriers should be strictly followed. Occupational issues should be considered on a case by case basis with the employer and the occupational doctor.
At a glance, all asthma medications should be maintained and kept at the doses required to achieve best asthma control, irrespective of underlying asthma severity, throughout the Covid19 outbreak. These positions have been shared and communicated both by the French Language Respiratory Society (SPLF) and the Haute Autorite de Sante (HAS) .

# Disclosure of interest
The authors declare no competing interest related to the present publication. Dr. Bourdin reports grants, personal fees, non-financial support and other from AstraZeneca, grants, personal fees, nonfinancial support and other from Boeringher Ingelheim , grants, personal fees, non-financial support and other from GlaxoSmithKline, personal fees, non-financial support and other from Novartis, personal fees and non-financial support from Teva, personal fees, non-financial support and other from Regeneron, personal fees, non-financial support and other from Chiesi Farmaceuticals, grants, personal fees, non-financial support and other from Actelion, personal fees from Gilead, non-financial support and other from Roche, other from Nuvaira, from null, outside the submitted work.
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