Odds for poor outcomes increase during hospitalization for both asthma, COVID-19
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Key takeaways:
- Hospital stays nearly doubled for patients with asthma exacerbations and COVID-19 compared with those who did not have COVID-19.
- Risks for invasive ventilation also more than doubled for these patients.
BOSTON — Patients hospitalized with both asthma exacerbations and COVID-19 had worse outcomes than those hospitalized for either of those conditions alone, according to a poster presented at the CHEST Annual Meeting.
Physicians should work with their patients with asthma to ensure they have current COVID-19 vaccinations, Antony Jackson Arumairaj, MD, clinical assistant professor, Metropolitan Hospital Center, New York Medical College, and colleagues wrote.
“Data regarding the impact of COVID-19 infection on the outcomes of asthma exacerbations have been conflicting, with some clinical studies showing a significant reduction in asthma exacerbations while other clinical studies have demonstrated severe outcomes of asthma exacerbations with COVID-19 infection,” Arumairaj told Healio.
These conflicting findings prompted Arumairaj and his colleagues to conduct this study, he continued.
The researchers identified 339,873 adult patients hospitalized with COVID-19 and 32,814 patients hospitalized with asthma exacerbations in the 2020 National Inpatient Sample database.
Specifically, the cohort included 29,363 patients (average age, 56.3 years; 69.9% women) with asthma exacerbations who did not have COVID-19 and 3,451 patients (average age, 54.7 years; 68.2% women) who had both asthma exacerbations and COVID-19.
Both groups primarily were white (51.3% vs. 43.1%), followed by African American (27.8% vs. 26.7%). Also, both groups primarily included patients in the lowest quartile for national income (36.2% vs. 35.4%).
The most common insurance coverage was Medicaid (44.5%) in the group with exacerbations but no COVID-19 and private insurance (41.2%) in the group with exacerbations and COVID-19.
“Although we expected a possibility of severe outcomes in patients with asthma exacerbation from COVID-19 infection, the results showed markedly severe outcomes of longer hospital stay, two times higher need for invasive ventilation and six to seven times higher mortality in patients with asthma exacerbation from COVID-19 infection than those without COVID-19 infection,” Arumairaj said.
The unadjusted odds ratio for hospitalization with simultaneous exacerbation and COVID-19 was 2.13. After adjusting for age, sex, race, national income quartile and infection, the OR was 1.84 (P < .001), indicating the odds for hospitalization for both exacerbations and COVID-19 were higher than the odds for hospitalization with exacerbations alone.
Median lengths of hospitalization included 8 days for patients with both exacerbations and COVID-19 and 4.6 days for those who only had exacerbations (P < .001).
Odds ratios for invasive ventilation among patients with both exacerbations and COVID-19 included 2.27 (unadjusted) and 2.37 (adjusted; P < .001).
Similarly, odds ratios for mortality among patients with both exacerbations and COVID-19 included 5.81 (unadjusted) and 6.68 (P < .001).
Mortality rates included 1.4% for the patients with exacerbations but no COVID-19 and 7.5% for patients with exacerbations and COVID-19 (P < .001).
These findings indicate more severe outcomes for hospitalization, length of stay, need for invasive ventilation and mortality among patients with both asthma exacerbations and COVID-19 compared with those who only had COVID-19, the researchers said.
“These findings were significant and surprising since it has overcome the findings of previous clinical studies that showed that there was a marked reduction in asthma exacerbations,” Arumairaj said.
“The reduction in asthma exacerbations could be explained by the fact that those patients with asthma were able to better self-isolate and thereby prevent the COVID-19 infection,” he continued. “But once the patients had COVID-19 infection, then the asthma exacerbation had particularly severe outcomes.”
The researchers advised physicians to maintain a low threshold for transferring patients with asthma exacerbations and COVID-19 into critical care units for multimodal management and intensive monitoring, in addition to other care.
Physicians should aim for better outpatient management and control of asthma with inhaled bronchodilators and inhaled steroids, Arumairaj said.
“Given the severe outcomes, patients with asthma must be advised and encouraged to be up-to-date with COVID-19 vaccinations to prevent COVID-19 infection resulting in asthma exacerbations,” he continued.
Next, the researchers will adjust these findings based on whether patients were hospitalized in teaching or nonteaching hospitals; whether they were in tertiary, rural or suburban hospitals; the size of these hospitals; and the region where these hospitals were located.
These adjustments may help “determine if any of these factors played a role in the outcome of the findings and served as a confounding factor in the outcome of the study,” Arumairaj said.
Perspective
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It is not surprising that patients with asthma experienced an exacerbation due to SARS-CoV-2 infection; note that the number was less than those with exacerbation due to other etiologies. There also was a proportion where SARS-CoV-2 was found incidentally, and therefore, not felt to be an etiology of the exacerbation, or that could be unclear.
No information about asthma severity was provided in either group. It would be helpful to understand the population; the only information is that the largest proportion of patients were from the lowest income group in both cohorts. This could suggest less access to medication and medical care for asthma prior to the exacerbation. I am concerned about baseline asthma control in this vulnerable population.
It also would be very helpful to understand the characteristics of both asthmatic cohorts admitted that would be available from the database, including the mean age, sex distribution, race, and the ethnicity distribution (which are available, but not specifically outlined in the abstract, likely due to space limitations); the number of exacerbations in the past year; current medications (especially biologics); refill rates (if available); comorbid conditions (as many as available); and the blood eosinophil counts (which should be available from a CBC with differential, a standard test).
I am hoping that some of this information may be available in the poster presentation or would be next steps in the research. Given that asthma is protective in milder forms of asthma, it is not clear if this group with SARS-CoV-2 represents a severe group or those with undertreated asthma compared to the group without SARS-CoV-2 infection.
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