In its latest report, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) Science Committee discusses the management of patients with COPD during the COVID-19 pandemic. The committee addresses some key questions such as whether modifications of COPD therapy are required and how to recognise and differentiate COVID-19 from COPD. Treatment and management strategies are also discussed.

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The COVID-19 pandemic has created unprecedented challenges for the world, especially the healthcare system. Apart from causing increased deaths and global distress, the pandemic has hindered the routine management and diagnosis of chronic conditions such as COPD. The pandemic has caused shortage of medicines and reductions in physician consultations. There is also difficulty in performing spirometry, and limitations in traditional pulmonary rehabilitation and homecare programs.

COVID-19 has raised questions as to whether modifications of COPD therapy are required to better manage the patients. There are also questions regarding recognising and differentiating COVID-19 from COPD given the similarity of the symptoms.

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) Science Committee in its latest report discusses the strategies for the management of patients with COPD during the COVID-19 pandemic.

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Risk of infection with SARS-CoV-2

As per current evidence, COPD patients do not seem to be at a greatly increased risk of infection for SARS-CoV-2, which may be due to the effect of protective strategies. However, COPD patients may be at an increased risk of hospitalisation for COVID-19 and may be at increased risk of developing severe disease and death.

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Investigations

Testing for SARS-CoV-2 infection

COPD patients with respiratory symptoms, fever, or other symptoms suggesting SARS-CoV-2 infection, even if mild, need to be tested for COVID-19. There have also been reports of false-negative RT-PCR tests in patients with computed tomographic (CT) scan findings of COVID-19, but who were eventually tested positive with serial sampling. The panel suggests antibody testing to support clinical assessment in patients who present late.

The panel encourages testing for other causes of respiratory illness in addition to testing for SARS-CoV-2. Repeat testing should be performed in patients with suspected recurrence or relapse of COVID-19.

Spirometry and pulmonary function testing

There is a risk of COVID-19 transmission during spirometry and pulmonary function testing as a result of coughing and droplet formation during the tests. Spirometry should hence be restricted to patients requiring urgent or essential tests for the diagnosis of COPD and/or to assess lung function status for interventional procedures or surgery. Also, whenever possible, RT-PCR test for SARS-CoV-2 should be performed, and the results should be available before performing the test. In cases with a positive RT-PCR test, spirometry and pulmonary function testing should be delayed until the test is negative.

Bronchoscopy

Diagnostic and therapeutic bronchoscopy may be required in some COPD patients during the COVID-19 pandemic. However, elective bronchoscopy should be delayed until patients have a negative PCR test. In urgent cases in which COVID-19 infection status is unknown, all cases should be managed as if positive. Use of a disposable bronchoscope is suggested.

Radiology

Chest radiography is indicated in patients with COPD who have moderate-to-severe symptoms of COVID-19 and for those with evidence of worsening respiratory status. Chest radiography can be useful for excluding or confirming alternative diagnoses (e.g., lobar pneumonia, pneumothorax, or pleural effusion). Point-of-care lung ultrasound can also be used to detect the pulmonary manifestations of COVID-19.

With regards to the use of CT scans in COVID-19, there are no special considerations for patients with COPD. In circumstances with limited access to CT scans, chest radiography may be preferred unless features of respiratory worsening warrant the use of CT scans.

There have been reports of increased occurrence of deep venous thrombosis and pulmonary thromboembolism in patients with COVID-19, hence, if pulmonary embolism is suspected, chest CT angiography should be performed.

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Differentiating COVID-19 infection from the daily symptoms of COPD

A key challenge during the pandemic is differentiating the symptoms of COVID-19 from the frequent symptoms of COPD.

COVID-19 is associated with the prodrome of milder symptoms, but rapid deterioration in lung function may occur. The prodrome of milder symptoms is worrisome in COPD patients with diminished lung reserve and the lack of recognition of the prodromal symptoms may delay early diagnosis.

As per the panel, a high index of suspicion for COVID-19 needs to be maintained in patients with COPD who present with symptoms of an exacerbation, especially if accompanied by fever, impaired taste or smell, or gastrointestinal complaints.

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Maintenance pharmacological treatment for COPD during the COVID-19 pandemic

Alteration of maintenance COPD pharmacological treatment to reduce the risk of developing COVID-19 is not suggested.

Patients should continue the use of long-acting bronchodilators, roflumilast, or macrolides to manage COPD as there are no studies which explored the clinical outcomes or risk of SARS-COV-2 infection with the use of these COPD medicines.

Use of nebulisers

Aerosol therapy increases droplet generation and risk of disease transmission; hence, pressurised metered-dose inhalers, dry powder inhalers, and soft mist inhalers are suggested for drug delivery instead of nebulisers.

Nebulisers may be needed in patients who are critically ill with COVID-19 receiving ventilatory support. It is important to keep the circuit intact and prevent the transmission of the virus in such patients. Using a mesh nebuliser in patients who are ventilated allows for the addition of medication without requiring the circuit to be broken for aerosol drug delivery.

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Treatment of COVID-19 in patients with COPD

As per the panel, patients with COPD and COVID-19 should be treated with the same standard of care treatments as other patients with COVID-19. Furthermore, there are no known drug interactions between remdesivir and inhaled COPD treatments.

The panel suggests the inclusion of patients with COPD in randomised controlled trials of COVID-19 treatments, with subgroup analyses of their outcomes presented.

Systemic corticosteroids should be used in COPD exacerbations according to the usual indications whether or not there is evidence of a SARS-CoV-2 infection, as there is no evidence that this approach modifies the susceptibility to a SARS-CoV-2 infection or worsens outcomes.

Antibiotics should be used in COPD exacerbations according to the usual indications whether or not there is evidence of a SARS-CoV-2 infection, particularly as patients with COPD who develop COVID-19 are reported, to more frequently develop bacterial or fungal coinfections.

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Ventilatory support for patients with COPD and COVID-19 pneumonia

COVID-19 patients who need ventilatory support have a high risk of mortality. COPD has been reported to increase the risk of respiratory failure and ICU admissions in some but not all studies.

Noninvasive ventilation (NIV) can be used for the treatment of hypercapnic respiratory in patients with COPD and COVID-19 pneumonia, but it is associated with worsening lung injury as a result of high transpulmonary pressures and ventricular tachycardias (VT).

Patients on high-flow nasal therapy (HFNT) or NIV should be monitored closely for worsening, and early intubation and invasive mechanical ventilation (IMV) with adoption of a protective lung strategy, similar to that used in other forms of acute respiratory distress syndrome (ARDS), should be considered. A PaO2/FiO2 ratio <150 mmHg may be a useful indicator for NIV failure and increased risk of mortality.

The indications in COVID-19 are similar to the indications for other causes of ARDS, and extracorporeal membrane oxygenation is suggested only after other strategies fail to achieve goals of oxygenation or ventilation.