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Overview

The purpose of this guideline is to maximise the safety of adults and children with severe asthma during the COVID-19 pandemic, while protecting staff from infection. It will also enable services to make the best use of NHS resources.

Communicating with patients and minimising risk

  • Communicate with patients, their families and carers, and support their mental wellbeing, signposting to charities (such as the British Thoracic Society, Asthma UK, and the British Lung Foundation) to help alleviate any anxiety and fear they may have about COVID-19
  • Be aware that severe asthma is defined by the European Respiratory Society and American Thoracic Society as asthma that requires treatment with high-dose inhaled corticosteroids (see inhaled corticosteroid doses for NICE’s asthma guideline) plus a second controller (and/or systemic corticosteroids) to prevent it from becoming ‘uncontrolled’, or which remains ‘uncontrolled’ despite this therapy
  • Some patients with severe asthma will have received a letter telling them they are at high risk of severe illness from COVID-19. Tell them, or their parent or carer, to follow the advice on shielding in UK government advice on shielding and protecting people defined on medical grounds as extremely vulnerable to COVID-19
  • Tell all patients, or their parent or carer, to continue taking their regular medicines in line with their personalised asthma action plan. This includes those with COVID-19, or suspected of having it. This is because it’s important that they make sure their asthma is as stable as possible. Ensure their action plan is up to date
  • Minimise face-to-face contact by:
    • offering telephone, video or email consultations whenever possible
    • cutting non-essential face-to-face appointments
    • contacting patients by text message or email
    • using alternative ways to deliver prescriptions and medicines, such as postal services, NHS volunteers, or drive through pick-up points
  • If patients are having a face-to-face appointment, on the day of the appointment first screen them by telephone to make sure they have not developed symptoms of COVID-19
  • Ask patients to attend appointments with no more than 1 family member or carer, or alone if they can, to reduce the risk of contracting or spreading the infection. If the patient is a child, ask that only 1 adult accompanies them
  • Minimise time in the waiting area by:
    • careful scheduling
    • encouraging patients not to arrive early
    • texting patients when you are ready to see them, so that they can wait in their car, for example
  • When patients with known or suspected COVID-19 have been identified, follow appropriate UK government guidance on COVID-19: infection prevention and control. This includes recommendations on using personal protective equipment (PPE), patient transfers, transport and options for outpatient settings

Investigations

Treatment

Patients having biological treatment

  • Tell patients, or their parent or carer, that they should continue treatment because there is no evidence that biological therapies for asthma suppress immunity
  • If the patient usually attends hospital to have biological treatments, think about if they can be trained to self-administer, or could be treated at a community clinic or at home
  • Carry out routine monitoring of biological treatment remotely if possible

Patients starting biological treatment

  • When patients start on a new biological treatment, balance the risks and benefits of treatment, and take into account service modifications
  • Start treatment even if:
    • you’re not able to assess adherence to regular treatment in the usual way
    • a multidisciplinary team discussion is not possible; 2 senior clinicians in the commissioned service, or delegated by the commissioned service, may make the decision to start biological treatment
  • Make sure that:
    • the patient initiation form on Blueteq is completed; for continuation and annual review forms, make sure forms are completed at a future date
    • patient data are added to the registry at the earliest opportunity, after getting patient consent; this can be deferred but, if it is, make arrangements to complete it at a future date
  • Have arrangements in place to enable patient self-administration or homecare for subsequent doses, to reduce the need for patients to come into hospital for treatment. Some homecare medicine delivery services are not accepting new referrals, in which case the department would need to organise this

Corticosteroids

  • Tell patients, or their parent or carer, to continue using inhaled corticosteroids because stopping can increase the risk of asthma exacerbation. Tell them there is no evidence that inhaled corticosteroids increase the risk of getting COVID-19
  • Tell patients on maintenance oral corticosteroids, or their parent or carer, to continue to take them at their prescribed dose because stopping them can be harmful
  • Tell patients, or their parent or carer, that if they develop symptoms and signs of an asthma exacerbation, they should follow their personalised asthma action plan and start a course of oral corticosteroids if clinically indicated

Equipment

  • Tell patients, or their parent or carer, to wash their hands and clean equipment such as face masks, mouth pieces, spacers and peak flow meters regularly using a detergent (for example, washing-up liquid), or to follow the manufacturer’s cleaning instructions
  • Tell patients, or their parent or carer, not to share their inhalers and devices with anyone else
  • Tell patients, or their parent or carer, they can continue to use their nebuliser. This is because the aerosol comes from the fluid in the nebuliser chamber and will not carry virus particles from the patient. Find out more from UK government guidance on COVID-19: infection prevention and control

Modifications to usual care

  • Local policies should address modifying usual care at an organisational level
  • Organise outpatient waiting areas so patients can continue social distancing from other patients and from clinic administrative staff
  • Prescribe enough asthma medicines to meet the patient’s clinical needs for no more than 30 days’ treatment. For inhalers this depends on the type of inhaler and the number of doses in the inhaler. Prescribing larger quantities of asthma medicines puts the supply chain at risk

Want to learn more about this guideline?

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Read the related Guidelines in Practice article

© NICE 2020. COVID-19 rapid guideline: severe asthma. Available from: www.nice.org.uk/guidance/NG166. All rights reserved. Subject to Notice of rights.

NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication.

Published date: 03 April 2020.