Lung disease: A risk for COVID-19 severity?

Chronic obstructive pulmonary disease (COPD) and interstitial lung disease (ILD) are among respiratory conditions associated with an increased risk of severe COVID-19 outcomes, a recent study showed. However, the impact of respiratory disease on COVID-19 risk may not be as alarming as initially thought.

“Asthma appears not to be associated with a major increased risk of the severity of COVID-19, whereas COPD and ILD are associated with a 50 percent increased risk of severe COVID-19,” noted the authors.

“[However,] the risk of severe COVID-19 in people with common airway diseases is only modestly raised over the risk in people without such diseases,” they added.

Data of 8,256,161 patients aged ≥20 years registered with 1,205 general practices in England on January 24, 2020, were linked with Public Health England’s database of SARS-CoV-2 testing and hospitalizations, intensive care unit (ICU) admissions, and COVID-19 deaths. About 15 percent of patients had respiratory disease, the most common being asthma (13.2 percent).

Hospitalization for COVID-19 occurred in 0.2 percent (n=14,479), <0.1 percent (n=1,542) were admitted to the ICU, and 0.1 percent (n=5,956) died by April 30, 2020. About 26, 18, and 25 percent of hospitalizations, ICU admissions, and deaths occurred in patients with respiratory disease.

After adjustment for demographics, BMI, smoking status, and comorbidities, certain respiratory diseases were tied to an increased risk of hospitalization for COVID-19. These included COPD (hazard ratio [HR], 1.54), bronchiectasis (HR, 1.34), sarcoidosis (HR, 1.36), idiopathic pulmonary fibrosis (IPF; HR, 1.59), extrinsic allergic alveolitis (HR, 1.35), and other ILDs (HR, 1.66). Individuals with asthma also had a higher risk of COVID-19 hospitalization (HR, 1.18), particularly those with severe asthma (on ≥3 asthma-control medications; HR, 1.29). COVID-19 hospitalization risk was increased twofold in individuals with vs without lung cancer (HR, 2.24). [Lancet Respir Med 2021;doi:10.1016/S2213-2600(21)00095-3]

Risk of death from COVID-19 was also elevated among individuals with COPD (HR, 1.54), bronchiectasis (HR, 1.12), sarcoidosis (HR, 1.41), extrinsic allergic alveolitis (HR, 1.56), IPF (HR, 1.47), other ILDs (HR, 2.05), and lung cancer (HR, 1.77) compared with individuals without these conditions. The risks of death remained elevated in a post-hoc analysis that excluded care home residents who were considered frail (eg, HRs, 1.55, 1.54, 1.37, 2.37, and 2.07 for patients with COPD, IPF, sarcoidosis, other ILDs, and lung cancer, respectively).

“[T]here was no evidence that people with asthma were at an increased risk of death (HR, 0.99), even for people with active [or] severe asthma [HRs, 1.05 and 1.08, respectively],” said the authors. “The risk of death in people with lung cancer was 77 percent higher than in the general population,” they added.

There were few incidents of ICU admission overall. The risk appeared slightly elevated in individuals with asthma (HR, 1.08), though more so among those with active (≥1 asthma medication prescription) or severe asthma (HRs, 1.34 and 1.30, respectively).

“Most people who worsen with COVID-19 will not be admitted to ICU because their underlying health state suggests little likelihood of benefit. As such, low rates of ICU admission for people with COPD, ILD, and lung cancer probably reflect the selection process and not the severity of COVID-19,” the authors said.

A post-hoc analysis suggested that individuals with ≥2 inhaled corticosteroid (ICS) prescriptions in the 150 days before the study had an elevated risk for COVID-19 hospitalization (HR, 1.13), ICU admission (HR, 1.63), and death (HR, 1.15) compared with individuals with one or no ICS use. “Whether ICS [use] is associated with an increased risk of severe COVID-19 remains unclear,” the authors said.

Shielding, a practice where patients with diseases or on medications with extremely high risk of severe COVID-19 were asked to stay home and minimize all social contact, did not appear to affect the association between respiratory disease and severe COVID-19.

Variations in outcomes were noted with certain demographics. For instance, risk for COVID-19 hospitalization, ICU admission, and death for people with COPD, but not asthma, varied by ethnicity. Women with COPD or asthma were generally at a higher risk for these outcomes than men. There was also a higher risk of these outcomes in patients with asthma or COPD aged <40 years vs ≥40 years.

Respiratory disease + COVID-19: Any cause for concern?

“People with pre-existing respiratory disease had a modestly increased risk of severe COVID-19 in this representative community cohort,” said the authors, noting that the outcomes were based on respiratory disease presence and not severity.

“[However,] the risk of death from COVID-19 perhaps caused by underlying respiratory disease was far lower than the ordinary risk of death in the 4 months (January–April, 2020) that included the peak of the SARS-CoV-2 epidemic in England,” they pointed out.

“The apparent relative risks of severe COVID-19 arising from chronic respiratory disease are less than those of being male and of having diabetes, and are a small fraction of the ordinary risk of death from any cause,” they continued.

These results suggest that the advice given to patients with respiratory illness at the onset of the pandemic may have generated unnecessary alarm.

“[A]s data continue to emerge, [the assumption that pre-existing respiratory disease would inevitably lead to an increased risk from COVID-19] might need to be revisited, and advice to people with respiratory disease … should perhaps be substantially more reassuring,” the authors said.