Leeds Breathlessness Pathway for GPs during Covid-19

Leeds Breathlessness Pathway

Updated September 2021

Please find attached the revised Leeds Breathlessness Pathway (Covid-19), which includes updated guidance on use of oral steroids in COPD / asthma and advice regarding reviewing high risk patients and use of pulse oximeters – guidance for patients is attached.

Managing stable COPD and asthma patients over the phone

Updated March 2021

Dr Katherine Hickman, Respiratory Lead for West Yorkshire and Harrogate,  Primary Care Lead for the National Asthma and COPD Audit Programme (NACAP) and Vice-Chair PCRS has produced a video about managing stable COPD and asthma patients over the phone.

Use of oral steroids

Can I use OCS in a more severe asthma attack if I think it is possible Covid-19 is triggering it?

The current advice from GINA, GOLD, BTS is that corticosteroids – inhaled and oral should continue to be used as normal, as they are not aware of “any scientific evidence to support that inhaled (or oral) corticosteroids should be avoided in patients with COPD during the Covid-19 epidemic.”, and in asthma – they should only be used where there is a clear indication for them, to be used.

We should continue to treat exacerbations of asthma and COPD in the normal way, whether Covid-19 negative or positive. We need to make it clear that they are only used to treat exacerbations, and not Covid-19

https://ginasthma.org/recommendations-for-inhaled-asthma-controller-medications/

https://goldcopd.org/gold-covid-19-guidance/

http://www.brit-thoracic.org.uk/document-library/quality-improvement/covid-19/bts-advice-for-community-respiratory-services-in-relation-to-covid19/

There is no evidence to suggest appropriate use of OCS in asthma attacks will cause a worse outcome if Covid-19 or if similar viruses are suspected to be the trigger.  A Cochrane review, www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD011801.pub2/full, found evidence for short or long courses or dosing was poor and they were unable to conclude what was best. Therefore, the important factor is to stop the OCS once symptoms improve so they receive the minimum amount necessary and to have clear follow up and review pathways when someone exacerbates.

The risk of inadequately treating an asthma exacerbation is highly likely to be worse than the risk from Covid-19 in most people with asthma. Current evidence supports up to quadrupling inhaled steroids from standard doses until symptoms improve in adults. Evidence does not support increasing ICS in children in asthma to improve asthma attack outcomes.

We have had some helpful advice from Ian Clifton, Consultant in Respiratory Medicine at Leeds Teaching Hospitals NHS Trust, to aid clinicians in management of patients with asthma.

‘’My thoughts around this for asthma would be to treat asthma exactly the same as we would do normally and use steroids where indicated.  I think the tricky area is here where the patient is breathless and it does not feel like their normal asthma – this could well be Covid-19 pneumonia. Things that might help here:

  • Crackles rather than wheeze on examination – appreciate that this is likely not to be possible due to lack of face-to-face, but it is something we have noticed in hospital so far.
  • Peak flow normal, but very breathless

If we feel this is asthma then treat it with steroids. If we feel that this is Covid-19 disease in someone with asthma then I don’t think they should get steroids unless there is evidence of bronchospasm’’

In asthma there really is no evidence for antibiotics (in fact good evidence of no benefit in the non-Covid-19 context) unless there is evidence of pneumonia.

This guidance may be updated at any time. To ensure the most up-to-date guidance is used it must be accessed directly from the CCG website and not saved or printed. Any guidance saved or printed will only be valid on the day it was taken off the website.