Asthma in children during the COVID-19 pandemic: lessons from lockdown and future directions for management
Authors: Atul Gupta, Andrew Bush, Prasad Nagakumar
Journal: The Lancet Respiratory Medicine (2020)

Shamefully, children still die from asthma,1Levy ML The national review of asthma deaths: what did we learn and what needs to change?.Breathe. 2015; 11: 14-24Crossref PubMed Scopus (112) Google Scholar and UK asthma outcomes are among the worst in Europe.2Wolfe I Thompson M Gill P et al.Health services for children in western Europe.Lancet. 2013; 381: 1224-1234Summary Full Text Full Text PDF PubMed Scopus (208) Google Scholar COVID-19 has wreaked havoc across the globe, and the world is having to re-evaluate almost every aspect of the daily living we took for granted in 2019. What has COVID-19 taught us about asthma in children? What are the implications for asthma management in children and for the asthma community as lockdowns are eased? COVID-19 is generally a mild disease in children compared with adults, and although a few children get a severe respiratory or systemic disease, most do not need intensive care.3Docherty AB Harrison EM Green CA et al.Features of 20 133 UK patients in hospital with COVID-19 using the ISARIC WHO Clinical Characterisation Protocol: prospective observational cohort study.BMJ. 2020; 369m1985Crossref PubMed Scopus (2080) Google Scholar As a respiratory virus, we might expect severe acute respiratory syndrome coronavirus 2, which causes COVID-19, to increase asthma attacks; however, Kenyon and colleagues4Kenyon CC Hill DA Henrickson SE Bryant-Stephens TC Zorc JJ Initial effects of the COVID-19 pandemic on pediatric asthma emergency department utilization.J Allergy Clin Immunol Pract. 2020; (published online June 6.)DOI:10.1016/j.jaip.2020.05.045Summary Full Text Full Text PDF PubMed Scopus (115) Google Scholar reported a 76% drop in emergency visits for asthma of all severities during the COVID-19 pandemic, a similar drop to our own UK experience. Substantial falls have also been noted in visits for non-asthma respiratory and endocrine diagnoses and for trauma. This decrease in emergency visits is unlikely to be accounted for simply by parents managing mild attacks at home, but the causes for what is clearly a relevant change are uncertain. Reasons could include lockdown preventing transmission of conventional respiratory viruses, such as rhinovirus and respiratory syncytial virus, and reduced exposure to outdoor allergens. Another factor could be the striking reductions in atmospheric pollution,5Ierodiakonou D Zanobetti A Coull BA et al.Ambient air pollution, lung function, and airway responsiveness in asthmatic children.J Allergy Clin Immunol. 2016; 137: 390-399Summary Full Text Full Text PDF PubMed Scopus (122) Google Scholar a well established factor in asthma attacks.6Künzli N Kaiser R Medina S et al.Public-health impact of outdoor and traffic-related air pollution: a European assessment.Lancet. 2000; 356: 795-801Summary Full Text Full Text PDF PubMed Scopus (1444) Google Scholar It is also possible that parental supervision of asthma drugs, leading to better adherence, is a factor.7Kaye L Theye B Smeenk I Gondalia R Barrett MA Stempel DA Changes in medication adherence among patients with asthma and COPD during the COVID-19 pandemic.J Allergy Clin Immunol Pract. 2020; (published online May 3.)DOI:10.1016/j.jaip.2020.04.053Summary Full Text Full Text PDF PubMed Scopus (136) Google Scholar Research is needed to identify the contributing factors and to underpin future measures. The societal challenge is that these huge reductions in asthma attacks have been achieved not with expensive new drugs but by behavioural changes. Can we maintain these post COVID-19? At the very least, we need to challenge ourselves about being more rigorous in preventing transmission of respiratory viruses. Before the COVID-19 pandemic and lockdowns around the world, most parents will have dosed their offspring with paracetamol and left them shedding respiratory viruses in the childcare facility. Do we need to be more ready to keep our children at home and stay off work, irrespective of whether they have asthma? More evidence is needed to study the wider implications of this behaviour for the child and family. There is also a need for sustained efforts to reduce air pollution globally. During the COVID-19 pandemic, not only has the frequency of asthma attacks changed but also asthma management has been transformed, with virtually all routine checks in secondary and tertiary care being done remotely. This adjustment to practice has been facilitated by advances in home monitoring of lung function, which can be directly observed by a physiologist from the hospital. Home self-administration of biologicals can also be directly observed by mobile telephone. Remote consultation clearly has many advantages that will be important going forward, including minimising cross-infection risk, which is likely to be a long-term issue, and reducing disruption to normal life. However, there are frequently safeguarding concerns in children with severe asthma8Nagakumar P Gambir N Sanghani N et al.Role of a prolonged inpatient admission when evaluating children with problematic severe asthma.Eur Respir J. 2018; 511701061Crossref PubMed Scopus (11) Google Scholar that are difficult to assess remotely. Moreover, occasions will arise when a face-to-face consultation is needed, typically to do advanced tests such as histamine challenge or skin prick. But the future default should be remote consultation, not face-to-face meetings. Up to now, we have had to improvise, but telemedicine has gained huge momentum during the COVID-19 pandemic, and now we need to make ambitious plans. Preventable asthma deaths are still happening, and major factors include underuse of inhaled corticosteroids, overuse of short-acting β2 agonists, and above all, an asthma attack being treated as an isolated event instead of a red flag predictive of high future risk.9Levy ML Fleming L Warner JO Bush A Paediatric asthma care in the UK: fragmented and fatally fallible.Br J Gen Pract. 2019; 69: 405-406Crossref PubMed Scopus (23) Google Scholar, 10Pavord ID Beasley R Agusti A et al.After asthma: redefining airways diseases.Lancet. 2018; 391: 350-400Summary Full Text Full Text PDF PubMed Scopus (725) Google Scholar The imperative is to design remote monitoring systems not only to optimise distance outpatient consultations but also to improve outcomes. Routine outpatient monitoring includes height, weight, spirometry, exhaled nitric oxide (in some cases), and physical examination including chest auscultation; all these measurements can be done at home. We have the technology for electronic stethoscopes on mobile telephones. Electronic dose counters for inhalers are also available, which could be used to identify underuse of inhaled corticosteroids and overuse of short-acting β2 agonists with remote Bluetooth technology. Our mobile telephones record where we have shopped and where we have dined, and they could potentially be used to record any unscheduled health visits, mandating an asthma review, with the permission of the family. We would need to devise an alert system so that contact is immediately made if agreed thresholds were met. Remote collection of this information for all children with more than trivial asthma, combined with individual and societal behavioural change, could potentially reduce asthma attacks and improve outcomes. The challenge is to improve clinical practice post COVID-19, not default to the past. We declare no competing interests. AB is funded by the Asthma UK Centre for applied research. COVID-19 heralds a new era for chronic diseases in primary careOn March 23, 2020, the UK Government enforced a country-wide lockdown in response to the COVID-19 pandemic to limit transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Although spread of the virus has been reduced, the lockdown has created new challenges for primary care practitioners who manage patients with chronic respiratory diseases (CRDs). However, there have also been opportunities for innovation, especially in terms of digital and remote working, and these solutions could be maintained and developed further to improve primary health-care services as we recover from the pandemic. Full-Text PDF