The purpose of this guideline (NG166) is to ensure the safety of both adults and children with severe asthma during the COVID-19 pandemic and to enable services to make best use of resources while protecting staff.
NG166 discusses the importance of communicating with patients, their families and carers to support their mental wellbeing during the COVID-19 pandemic. NG166 advises signposting to charities such as the British Thoracic Society, Asthma UK and the British Lung Foundation, all of which have provided advice on COVID-19 to help alleviate any anxieties or concerns that patients might have about the virus. NG166 also stresses to clinicians to reinforce with patients that severe asthma has been defined by the European Respiratory Society as a condition that “requires high dose inhaled corticosteroids plus a second controller(and/or systemic corticosteroids) to prevent it from becoming uncontrolled.” In addition, as noted by NG166, some patients with severe asthma will have received a government letter advising them on shielding. Staff should strongly advise patients or their carers (including those with suspected or confirmed COVID-19) to continue with the regular medicines and to follow personal asthma plans which should be current.
NG166 suggests minimising both face-to-face contact for consultations and non-essential follow-up appointments and that telephone or video consultations should be used instead or making contact with patients via email or text messaging. NG166 advises on the use of alternative routes for patients to obtain medicines such as pharmacy deliveries, postal services, use of NHS volunteers or even drive-through pick-up points for medicines.
In cases where face-to-face consultations are required, NG166 directs staff to contact all patients by telephone on the day of their appointment to screen for COVID-19 symptoms. In addition, NG166 suggests patients attend appointments alone if possible but with no more than one family member or carer to reduce the risk of contracting the virus. Clinic staff are advised to minimise the time patients spend in the waiting area through careful scheduling of appointments, discouraging arriving early and asking them to remain in their cars until they receive a text message that the clinic staff are ready to see them.
Where patients are known or suspected of being infected with COVID-19, NG166 recommends that UK government guidance on infection prevention and control is adhered to since this provides advice on the use of personal protective equipment, patient transfers, transport and options for outpatient settings.
NG166 suggests that bronchoscopy and most pulmonary functions tests should only be performed on urgent cases and if these tests have a direct impact on patient care due to the potential of spreading COVID-19. NG166 directs interested readers to NHS England’s recent clinical guide for managing respiratory patients during the COVID-19 pandemic.
NG166 advises that patients or their carers should continue with biological therapy as there is no evidence that treatment suppresses immunity in asthmatics. In cases where a patient normally attends a hospital to obtain biological treatment, NG166 suggests that clinical teams consider if the patient could be trained to self-administer or treated at a community clinic or even at home. If possible, routine monitoring of biological treatment should be performed remotely.
Patients starting biological therapy
For new patients, NG166 recommends that clinical staff assess the balance of risks and benefits of treatment, taking into account any relevant service modifications. The guideline suggests that treatment with a biological in a new patient can be started even if staff are unable to assess adherence to regular treatment in the normal way and if a multidisciplinary team discussion is not possible. In such instances, NG166 recommends that two senior clinicians in the commissioned service or delegated by the commissioned service can make the decision to start treatment.
When initiating biological treatment in a new patient, NG166 instructs staff to ensure that the patient Blueteq is completed and that continuation and annual review forms are finished at a future date. Patients should also be added to the registry after gaining consent. However, NG166 advises that addition of patient data to the registry can be deferred provided arrangements are made to complete it at a future date.
NG166 suggests that arrangements are in place to enable patient self-administration or through homecare for subsequent doses thereby reducing the need to attend hospital. However, in the current pandemic, NG166 also notes that some homecare services are not accepting new referrals and that responsibility to organise delivery therefore remains with the hospital department.
The advice in NG166 is that patients continue to use inhaled corticosteroids as stopping treatment risks an asthma exacerbation. In addition, patients should be informed that there is no evidence that inhaled corticosteroids increase the risk of getting COVID-19. Similar advice applies to oral corticosteroids but NG166 adds that stopping oral agents can be harmful. Patients are also advised follow their personalised asthma plan in the case of an exacerbation.
NG166 advises that clinical staff inform patients or their carers to continue with nebulisers because the aerosol comes from fluid in the device and will not carry COVID-19 particles from the patient. NG166 directs staff to the government infection and control guidance for further information.
Modification to usual care
In light of the pandemic, clinic staff are requested to modify usual care at an organisational level and in particular, to ensure social distancing is observed in the patient waiting areas. Another practical suggestion in NG166 is to only prescribe sufficient quantities of treatment for 30 days as prescribing greater amounts puts the supply chain at risk.
NG166 is available online and interested readers should check this version for further updates.