World Asthma Day Summary

On the day after World Asthma Day, May 3, 2022, we scanned the globe to find a statement that best sums up the current state of affairs regarding Asthma.

Kudos to tbe U.S National Institute of Environmental Health NIH Statement on World Asthma Day 2022: Toward Improved Asthma Care

Good enough of summary that we want to publish this in its entirety.

Asthma is a serious lung disease; causes chest tightness, wheezing, and coughing; can often be controlled with proper treatment.

Today (May 3, 2022) on World Asthma Day, the National Institutes of Health reaffirms its commitment to biomedical research aimed at preventing the onset of asthma, understanding its underlying causes, and improving the treatment of it. This chronic airway disease, which is characterized by periodic worsening of inflammation that can make it hard to breathe, affects more than 25 million people in the United States, including more than 5 million children. Left untreated, it can be life-threatening.

While scientists have made substantial progress in understanding asthma diagnosis, management, and treatment, therapies to permanently improve breathing for those who suffer from asthma remain elusive. Researchers around the globe are working steadily toward this goal while they seek to better understand and find new ways to manage the disease. They also are continuing research on the underlying causes of disparities in the incidence, care, and prevention of the disease. On the heels of recently updated management and treatment guidelines, researchers anticipate a brighter future for people living with asthma.

Three NIH institutes primarily support and conduct studies on asthma — the National Heart, Lung, and Blood Institute (NHLBI); the National Institute of Allergy and Infectious Diseases (NIAID); and the National Institute of Environmental Health Sciences (NIEHS). Other NIH Institutes and Centers also support and conduct asthma research. NIH scientists and grantees made important advances in understanding, treating, and managing asthma in 2021, which are briefly highlighted as follows:

Asthma and COVID-19

An NHLBI-funded study showed that during the pandemic, asthma attacks, also known as asthma exacerbations, significantly decreased in a large group of children and adolescents, compared to the year before the pandemic. The study also found that telehealth visits among these patients increased dramatically during this time. The study included nearly 4,000 participants aged 5-17 years with a prior diagnosis of asthma. Researchers believe a better understanding of the factors that contributed to these improved outcomes could lead to better asthma control in all children and adolescents, as researchers noted no racial or ethnic differences in health outcomes in this population.

A NIAID-funded study found that asthma does not increase the risk of becoming infected with SARS-CoV-2, the virus that causes COVID-19. This finding came from a six-month household survey of more than 4,000 children and adults conducted between May 2020 and February 2021.

Asthma Disparities

Researchers have known for decades that social determinants of health – conditions like housing, neighborhood, education, income, and healthcare access – can affect the quality of life and asthma-related health outcomes of people living with the disease. NIH scientists are now reporting new advances in understanding the relationship between social determinants of health and asthma.

Black and Hispanic children who live in low-income urban environments in the United States are at particularly high risk for asthma attacks. These children tend to be underrepresented in large trials of new biologic therapies for asthma.

In a recent NIAID-supported clinical trial, the monoclonal antibody mepolizumab decreased asthma attacks by 27% in Black and Hispanic children and adolescents who have a form of severe asthma, are prone to asthma attacks, and live in low-income urban neighborhoods.

In one study, NHLBI-funded investigators demonstrated the importance of housing interventions in improving the health of children with asthma. Poor quality housing is associated with a high level of asthma triggers – including mold, cockroach, mouse, and dust mite allergens – that can pose a health threat to children with asthma. The study showed the feasibility of using targeted interventions – including better pest management, improved ventilation, and moisture reduction – to achieve healthy housing. It showed that such interventions can result in reduced symptoms and hospitalizations due to asthma.

Environmental Exposures and Asthma

Researchers have known for years that asthma can be triggered by substances in the indoor and outdoor environment. New research shows that exposure to some asthma triggers might even occur before birth.

In an NIH-supported study that included grant support from NIEHS and the NHLBI, researchers reported that prenatal exposure to tiny air pollution particles significantly increased the risk for developing asthma in children. The study, which analyzed data from two different study cohorts, focused on a group of mothers and their children, mostly Black or Hispanic, in the Boston area who lived near major roadways with heavy traffic. It found that more than 18% of the children who were exposed to high levels of these so-called ultrafine particles in the womb developed asthma in their preschool years, compared to 7% of children overall in the United States.

An NIEHS clinical study will assess how environmental factors affect disease progression in non-smoking adults who have moderate or severe asthma. The study will focus on the microbiological and genetic factors associated with atopic asthma, also known as allergic asthma, which is triggered by pollen, dust mites, and other allergens. A better understanding of this data might lead to improved treatments for people with this type of asthma, researchers say.

Climate Change and Asthma

Studies have shown that climate change can increase air pollutants such as ground-level ozone, fine particulates, wildfire smoke, and dust, and that these pollutants can exacerbate asthma. Climate change can also affect the production, distribution, and severity of airborne allergens.

NIEHS, NHLBI, and other NIH institutes and centers are leading the NIH Climate Change and Health Initiative. This is a cross-cutting NIH effort to reduce health threats such as asthma that can develop or worsen because of climate change. The initiative will look at these threats across the lifespan and find ways to build health resilience in individuals, communities, and nations around the world. A strategic framework for the Initiative will help guide NIH investments in this area.

An NIEHS-funded study provides examples of how extreme weather events can affect asthma outcomes. For example, as heat waves and droughts become more frequent and prolonged, the risk of large wildfires will likely increase, resulting in poor air quality that makes it more difficult to control asthma. Other climate-change events can lead to longer and more intense pollen seasons, while mold and dampness in homes may cause asthma to develop or worsen preexisting cases.

About the National Institute of Allergy and Infectious Diseases (NIAID): NIAID conducts and supports research—at NIH, throughout the United States, and worldwide—to study the causes of infectious and immune-mediated diseases, and to develop better means of preventing, diagnosing and treating these illnesses. News releases, fact sheets and other NIAID-related materials are available on the NIAID website.

About the National Heart, Lung, and Blood Institute (NHLBI): NHLBI is the global leader in conducting and supporting research in heart, lung, and blood diseases and sleep disorders that advances scientific knowledge, improves public health, and saves lives. For more information, visit For additional information about NHLBI’s asthma resources, visit

About the National Institute of Environmental Health Sciences (NIEHS): NIEHS supports research to understand the effects of the environment on human health and is part of the National Institutes of Health. For more information on NIEHS or environmental health topics, visit

About the National Institutes of Health (NIH): NIH, the nation’s medical research agency, includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. NIH is the primary federal agency conducting and supporting basic, clinical, and translational medical research, and is investigating the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit

Asthma and COVID-19 Update Study on Risk

Asthma does not appear to increase the risk or influence its severity, according to University study

Whats new

Rutgers researchers say further study is needed but those with the chronic respiratory disease don’t appear to be at a higher risk of getting extremely ill or dying from coronavirus.“Older age and conditions such as heart disease, high blood pressure, chronic obstructive pulmonary disease, diabetes and obesity are reported risk factors for the development and progression of COVID-19,” said Reynold A. Panettieri Jr., a pulmonary critical care physician and director of the Rutgers Institute for Translational Medicine and Science and co-author of a paper published in the Journal of Allergy and Clinical Immunology.

“However, people with asthma — even those with diminished lung function who are being treated to manage asthmatic inflammation — seem to be no worse affected by SARS-CoV-2 than a non-asthmatic person. There is limited data as to why this is the case — if it is physiological or a result of the treatment to manage the inflammation.”

Children and young adults with asthma suffer mainly from allergic inflammation, while older adults who experience the same type of airway inflammation can also suffer from eosinophilic asthma — a more severe form. In these cases, people experience abnormally high levels of a type of white blood cell that helps the body fight infection, which can cause inflammation in the airways, sinuses, nasal passages and lower respiratory tract, potentially making them more at risk for a serious case of COVID-19.

Further Study Needed

Panettieri discusses what we know about asthma and inflammation and the important questions that still need to be answered.

How might awareness of SARS-CoV-2 affect the health of people with asthma?
Since the news has focused our attention on the effects of COVID-19 on people in vulnerable populations, those with asthma may become hyper-vigilant about personal hygiene and social distancing. Social distancing could improve asthma control since people who are self-quarantined are also not as exposed to seasonal triggers that include allergens or respiratory viruses. There is also evidence that people are being more attentive to taking their asthma medication during the pandemic, which can contribute to overall health.

What effect might inhaled steroids have on COVID-19 outcomes?
Inhaled corticosteroids, which are commonly used to protect against asthma attacks, also may reduce the virus’s ability to establish an infection. However, studies have shown that steroids may decrease the body’s immune response and worsen the inflammatory response. Steroids also have been shown to delay the clearing of the SARS and MERS virus — similar to SARS-CoV-2 — from the respiratory tract and thus may worsen COVID-19 outcomes. Future studies should address whether inhaled steroids in patients with asthma or allergies increase or decrease the risks of SARS-CoV-2 infection, and whether these effects are different depending on the steroid type.

In what way does age play a role in how asthma patients react to exposure to the virus?
A person’s susceptibility to and severity of COVID-19 infection increases with age. However, since asthma sufferers tend to be younger than those with reported high-risk conditions, age-adjusted studies could help us better understand if age is a factor in explaining why asthma patients may not be at greater risk for infection.

Children and young adults with asthma suffer mainly from allergic inflammation, while older adults who experience the same type of airway inflammation can also suffer from eosinophilic asthma — a more severe form. In these cases, people experience abnormally high levels of a type of white blood cell that helps the body fight infection, which can cause inflammation in the airways, sinuses, nasal passages and lower respiratory tract, potentially making them more at risk for a serious case of COVID-19.

In addition, an enzyme attached to the cell membranes in the lungs, arteries, heart, kidney and intestines that has been shown to be an entry point for SARS-CoV-2 into cells is increased in response to the virus. This enzyme is also thought to be beneficial in clearing other respiratory viruses, especially in children. How this enzyme affects the ability of SARS-CoV-2 to infect people with asthma is still unclear.

How might conditions in addition to asthma affect a person’s risk of infection?
Asthma tends to be associated with far fewer other conditions than chronic obstructive pulmonary disease or cardiovascular disease. If SARS-CoV-2 is a disease that causes dysfunction in the cells that line blood vessels throughout the body, then diabetes, heart disease, obesity and other diseases associated with this condition may make people more susceptible to the virus than those who are asthmatic.

Important to know

However, older people with asthma who also have high blood pressure, diabetes or heart disease may have similar instances of COVID-19 as non-asthmatics with those conditions.

COVID-19 Clues -Shortness of breath is a critical differentiator from other common illnesses

Interesting News Asthmatics

Harvard Medical School is reporting a couple of days ago on their news its news website, that “What can we learn from people with coronavirus who seek care at outpatient clinics?

NOTE from WAF: We salute Harvard Medical School for the sharing of this research and all of those on the front line. If your an Asthmatic and you experience any of these symptoms including severe shortness of breathe call someone right away. 

Since the early days of the COVID-19 pandemic, scientific literature and news reports have dedicated much attention to two groups of patients—those who develop critical disease and require intensive care and those who have silent or minimally symptomatic infections. This article is part of Harvard Medical School’s continuing coverage of medicine, biomedical research, medical education and policy related to the SARS-CoV-2 pandemic and the disease COVID-19.

Such accounts have mostly overlooked another large and important category of patients—those with symptoms concerning enough to seek care, yet not serious enough to need hospital treatment.

Now, a new analysis by researchers at Harvard Medical School and Harvard-affiliated Cambridge Health Alliance offers insights into this in-between category based on data collected from people presenting at an outpatient COVID-19 clinic in Greater Boston.

The team’s observations, published April 20 in the journal Mayo Clinic Proceedings, are based on data from more than 1,000 patients who visited the clinic for respiratory illness since COVID-19 was declared a pandemic in March.

The findings offer a compilation of clues that can help clinicians distinguish between patients with COVID-19 infections and those with other conditions that may mimic COVID-19 symptoms.

Such clues are critical because early triage and rapid decision-making remain essential even now that testing is becoming more widely available than it was in the early days of the pandemic, the research team said. Testing remains far from universal, and even when available, tests still may have a turnaround time of one to three days. Additionally, some rapid point-of-care tests that have emerged on the market have not been entirely reliable and have caused false-negative readings.

“Early recognition and proper triage are especially important given that in the first days of infection, people infected with SARS-CoV-2 may experience symptoms indistinguishable from a variety of other acute viral and bacterial infections,” said study lead author Pieter Cohen, an associate professor of medicine at Harvard Medical School and a physician at Cambridge Health Alliance. “Even when point-of-care diagnostic tests are available, given the potential for false-negative results, understanding the early natural history of COVID-19 and good old-fashioned clinical skills will remain indispensable for proper care.”

A nuanced understanding of the typical presentation of COVID-19 in the outpatient setting can also help clinicians determine how often to check back with patients, the researchers added. For example, those who have started developing shortness of breath demand very close monitoring and frequent follow-up to check how the shortness of breath is evolving and whether a patient may be deteriorating and may need to go to the hospital.

According to the report, COVID-19 typically presents with symptoms suggestive of viral infection, often with low-grade fever, cough and fatigue, and, less commonly, with gastrointestinal trouble. Shortness of breath usually emerges a few days after initial symptoms, becomes most pronounced upon exertion and may involve sharp drops in blood oxygen levels.

Chief among the team’s findings:

* Fever is not a reliable indicator. If present, it could manifest only with mild elevations in temperature.
* COVID-19 may begin with various permutations of cough without fever, sore throat, diarrhea, abdominal pain, headache, body aches, back pain and fatigue
* It can also present with severe body aches and exhaustion.
* A reliable early hint is loss of the sense of smell in the first days of disease onset.
* In serious COVID-19, shortness of breath is a critical differentiator from other common illnesses.
* Almost no one, however, develops shortness of breath, a cardinal sign of the illness, in the first day or two of disease onset.
* Shortness of breath can appear four or more days after onset of other symptoms.
* The first days after shortness of breath begins are a critical period that requires close and frequent monitoring of patients by telemedicine visits or in-person exams.
* The most critical variable to monitor is how the shortness of breath changes over time. Oxygen saturation levels can also be a valuable clue. Blood oxygen levels can drop precipitously with exertion, even in previously healthy people.
* A small number of people may never develop shortness of breath, but may have other symptoms that could signal low oxygen levels, including dizziness or falling.
* Anxiety—common among worried patients with viral symptoms suggestive of COVID-19—can also induce shortness of breath.

Distinguishing between anxiety-induced shortness of breath and COVID-19-related shortness of breath is critical. There are several ways to tell the two apart.

Key differentiators include:

Time of onset: Anxiety-induced shortness of breath occurs rapidly, seemingly out of the blue, while COVID-19 shortness of breath tends to develop gradually over a few days.
Patient description of sensation: Patients whose shortness of breath is caused by anxiety often describe the sensation occurring during rest or while trying to fall asleep but does not become more pronounced with daily activities. They often describe a sensation of inability to get enough air into their lungs. By contrast, shortness of breath induced by COVID-19-related drops in oxygen gets worse with physical exertion, including performing simple daily activities like walking, climbing stairs or cleaning.
Anxiety-related shortness of breath does not cause drops in blood oxygen levels

During a clinical exam, a commonly used device, the pulse oximeter, can be valuable in distinguishing between the two. The device measures blood oxygen levels and heart rate in a matter of seconds when clipped onto one’s finger.

Several types of pneumonia—a general term denoting infection in the lungs—can present with striking similarity to COVID-19. For example, COVID-19 respiratory symptoms appear to closely mimic symptoms caused by a condition known as pneumocystis pneumonia, a pulmonary infection predominantly affecting the alveoli, the tiny air sacs lining the surface of the lungs. Both COVID-19 patients and patients with pneumocystis pneumonia experience precipitous drops in oxygen levels with exertion and shortness of breath. However, in the case of pneumocystis pneumonia, the shortness of breath typically develops insidiously over weeks, not within days, as is the case with COVID-19. Here, a careful patient history detailing evolution of symptoms would be critical, the authors said.

Likewise, during the initial days of infection, both the flu and COVID-19 may have identical presentations, but thereafter the course of the two infections diverges. People with uncomplicated flu rarely develop significant shortness of breath. When they do experience trouble breathing, the shortness of breath is mild and remains stable. On the rare occasion of when flu causes a viral pneumonia, patients deteriorate rapidly, within the first two to three days. By contrast, patients with COVID-19 don’t begin to develop shortness of breath until several days after they first become ill.

Study co-investigators include Lara Hall, Janice Johns and Alison Rapaport.

Managing Asthma during COVID-19: An Example for Other Chronic Conditions in Children and Adolescents


The novel coronavirus COVID-19, caused by the pathogen SARS-CoV-2, has now spread around the globe with over 1.8 million individuals affected and over 110,000 deaths internationally.(1, 2, 3, 4) As of April 12, 2020 there are 530,830 cases in the U.S. with over 20,000 deaths(2,3) The Institute for Health Metrics and Evaluation (IHME) has predicted that this pandemic could exceed current healthcare capacity in the United States (US) with a total of 81,114 deaths (95%UI 38,242 to 162,106) through August 2020.(5)

Asthma is one of the most common chronic diseases of childhood in the United States. Data from the U.S. Department of Health and Human Services notes that asthma prevalence increased between 2001 and 2010 and is now at its highest prevalence ever (overall 8.4% in 2010).(6) In the US, approximately 7 million children have asthma.(6) The morbidity of asthma in the US is high, and is higher in children than adults. Children missed 10.5 million school days due to asthma in 2008; there were 6.7 million primary care visits related to asthma and 600,000 asthma-related ED visits for children in 2007.(7)

Multiple guidelines have emerged from international societies on the management of medical care during COVID-19 which include a section on pediatric asthma, including a North American guideline on contingency planning for allergy and immunology clinics during a pandemic and a Canadian Pediatric Society statement on asthma management during COVID-19.(8,9) Due to the high prevalence of asthma in the United States, which is at the current epicenter of a global pandemic, the goal of this commentary is to provide an overview of what is known, and what is yet to be learned, about COVID-19 and pediatric asthma.
Differentiating Asthma from COVID-19

Symptoms of COVID-19 can be similar to those of worsening asthma, or an asthma exacerbation. Dry cough and shortness of breath, commonly seen in asthma, are among the most common presenting symptoms of COVID-19 in case series of children admitted to the hospital in China, as well as in available CDC data in the U.S.(10, 11, 12)

Fever, a common presenting symptom of COVID-19, may help differentiate COVID-19 from an asthma exacerbation, although fever can be present in other virus-triggered asthma exacerbations as well.(3,10, 11, 12) Other less common symptoms of COVID-19, better described in the adult population, may help differentiate COVID-19 from asthma and include myalgia, confusion headache, pharyngitis, rhinorrhea, loss of sense of smell and taste, diarrhea, nausea and vomiting.(12) A travel history, close contact with someone infected with COVID-19, and absence of a prior atopic history in a child also help to differentiate the two.

Since there is substantial overlap between the clinical presentation of worsening asthma and COVID-19 and increasing community spread lessens likelihood of known contact with a case, screening for COVID-19 is required if available in any asthmatic child who comes to medical attention with worsening cough or shortness of breath.(8,13)

The Role of Asthma in COVID-19 Morbidity and Mortality

There is a theoretical risk that infection with COVID-19 in an asthmatic child may increase the risk of pneumonia or acute respiratory disease. (14) As a result, the CDC lists moderate to severe asthma as a risk factor for COVID-19 morbidity and mortality.(14) However, to date the literature is ambiguous on whether pre-existing asthma increases the risk of either COVID-19 infection, or morbidity/mortality due to COVID-19, in children.

The evidence on COVID-19 risk factors derives largely from the adult population. Four case series, all from Wuhan, China, of adults admitted to hospital with COVID-19 did not list asthma as an underlying pre-existing condition in any of those patients.(12,15, 16, 17) In a large case series of 1099 adult patients from 552 hospitals in 30 provinces in China, asthma was not listed as a pre-existing condition in any of the patients described.(18) In contrast, recent data released from the CDC of U.S. hospitalizations in March,2020 notes that 27.3% of adults 18-49 years of age who were hospitalized with COVID-19 had a history of asthma.(3) In adults aged 50-64 years of age hospitalized for COVID-19 asthma was present in 13.2% and in those 65 years or older asthma was present in 12.9%.(3,19) As a result, the American Academy of Allergy, Asthma & Immunology (AAAAI) notes that ‘those with asthma in the 18-49 year old age range may be at increased risk of hospitalization due to COVID-19.’(19)

Although there is a paucity of literature on pediatric risk factors, the case series to date from Wuhan on hospitalized pediatric cases don’t list asthma as a pre-existing risk factor for morbidity or mortality.(10,11) It is further reassuring that children appear to be at lower risk of COVID-19 morbidity and mortality than the adult population in general, although severe infection still can occur.(13,20) The CDC morbidity and mortality report notes that among the 149,082 reported U.S. cases of COVID-19 for which age is known, only 2572 (1.7%) occurred in children 18 years and younger.(3) Although among the patients with information on underlying conditions, 23% had at least one underlying condition such as asthma, only 5.7% of children infected with COVID-19 required hospitalization (compared with 10% of adults aged 18-64 years) and only 3 deaths were reported in children (<1% of pediatric cases). In a case series from China of 72,000 cases, approximately 1% were children aged 0 to 18 years of age with only 1 death reported in the adolescent population (and none in children under the age of 10 years).(13,21)

Another risk in children with asthma is that infection with COVID-19 could trigger a viral-induced asthma exacerbation. There is minimal literature on this risk from COVID-19, but there are data on the risk of asthma exacerbations triggered from other coronavirus infections, with mixed findings. Severe acute respiratory syndrome (SARS), due to human coronaviruses HCoV-229E and HCoV-OC43, did not cause an increase in asthma exacerbations in children during the 2002 epidemic, nor induce bronchial hyperreactivity or eosinophilic inflammation.(22) In fact, paradoxically, asthma exacerbations actually decreased during that time, which was attributed to improvements in hygiene measures related to the epidemic.(22) However, in contrast, non-epidemic coronaviruses are found commonly in the respiratory tracts of children with an asthma exacerbation and have contributed to bronchial hyper-reactivity and eosinophilic inflammation.(23, 24, 25, 26)

In summary, based on available information to date, it is unclear whether there is a significantly increased risk of COVID-19 morbidity among asthmatic children.(8,9) It is also unknown whether asthma medications such as high-dose inhaled corticosteroids or asthma biological therapies pose a risk in managing COVID-19 infections. Before any definitive conclusions can be drawn, larger scale data are required from pediatric populations, and from heterogeneous locations that have been impacted by COVID-19. It also remains unclear if COVID-19 increases the risk of asthma exacerbations. As a result, good asthma control is essential as a precautionary measure during this time.(8,9,13,20)
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Treatment of Asthma During COVID-19

In addition to the current burden of COVID-19, the spring season is often a time for asthma exacerbations due to emergence of seasonal aeroallergens, and other respiratory viruses.(27) The best way to prevent an exacerbation is consistent proper use of medicines to control asthma, such as inhaled corticosteroids and/or montelukast. As a result, children should remain on their current asthma medications during COVID-19.(8,9) This recommendation is supported by multiple international organizations, including the Centers for Disease Control, the Global Initiative for Asthma, and the North American consensus guideline on allergy care during COVID.(8,9,28,29) It is recommended that children not ‘step down’ any controller medication during this time unless ‘this is clearly favorable from an individual standpoint, with careful consideration of the balance between benefit and harm/burden.’(8) Other recommendations to maintain asthma control include avoiding known asthma triggers such as aeroallergens, frequent handwashing, physical distancing, and regular review of inhaler technique.(9,29) An exacerbation, if it occurred, ‘could require [children] to enter the healthcare system, which would put them at increased risk of being exposed to SARS-CoV-2 during the current pandemic.’(8)

Some biologic agents, such as omalizumab (anti-IgE) and mepolizumab (anti-IL5), are approved for use in moderate to severe asthma in adolescents(30) The current recommendation for adolescents who are using these medications is to continue their use.(8) There is no current evidence that use of these medications increases the risk of COVID-19 infection or morbidity.

If a child is using a nebulized asthma relief medication, this should be switched to a metered-dose inhaler (MDI) or dry powder inhaler (turbuhaler or diskus) under most circumstances.(8,9) Nebulization increases the risk of viral lower lung deposition.(8,9,31) It also increases the risk of infection transmission due to both stimulating a cough reflex, as well as generating ‘a high volume of respiratory aerosols that may be propelled over a longer distance than is involved in a natural dispersion pattern.’(31) It was poignantly noted in a recent editorial that ‘there is a possibility that nebulizer therapy in patients with COVID-19 infection can transmit potentially viable coronavirus to susceptible bystander hosts.’(31) The only possible reasons for a child to use a nebulizer at home during the COVID-19 pandemic are a poor response to a MDI/spacer, a child who is either uncooperative or unable to follow the directions required for MDI use, or medication shortages (which are discussed in more detail below).(8,9,31)
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Treatment of Asthma Exacerbations during COVID-19

The CDC and World Health Organization (WHO) have recommended against oral corticosteroid (OCS) use as a treatment for COVID-19.(32,33) This recommendation is based on experience with influenza, SARS-CoV, and Middle East Respiratory Syndrome Coronavirus (MERS-CoV), where OCS use prolonged viral replication and was associated with prolonged viral clearance, increased complication rates, increased risk of mechanical ventilation and higher mortality rates.(34, 35, 36, 37) It has been noted that OCS therapy increases the risk of nosocomial infection and secondary infection.(38) However, there is a distinction between OCS use as a therapy for COVID-19, and OCS use as a treatment of asthma exacerbations.(8) There is broad consensus that asthma exacerbations should be treated aggressively and in keeping with current guideline recommendations.(9) Multiple national and international organizations such as the Global Initiative for Asthma recommend OCS use as required, and in keeping with the child’s asthma action plan, during COVID-19.(8,9,28)

The use of nebulized medications are especially discouraged in a healthcare setting, where infection transmission to other vulnerable patients is a risk.(9,31) If used, proper personal protective equipment (PPE) is required. It must also be considered that nebulized viral droplets can persist in the air for hours.(39)

For any child with asthma who is having progressive or worsening symptoms, COVID-19 screening protocols must be used to help determine their level of risk as well as the need for COVID-19 testing at an appropriate facility.(8)

For children hospitalized with an asthma exacerbation either documented or suspected to be associated with COVID-19 that is progressing, it might be decided to use one of the agents currently being considered in adults, for example, hydroxychloroquine.(40,41) or to seek compassionate release of remdesivir. There is no current data on the safety and efficacy of these agents in children and thus should be discussed in the setting of the hospital policy.(42,43) Although dosage of these medications in adolescents may be similar to adults, the appropriate adjustment for children under 12 years remains to be defined.
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Ongoing Challenges during COVID-19

Medication shortages. There is a growing medication shortage across North America, including asthma medications such as albuterol.(39) In many cases, such as with albuterol, these medications increasingly are being used in confirmed or suspected COVID-19 patients to help with respiratory issues. To help combat the shortage of albuterol specifically, the US Food and Drug Administration (FDA) approved the first generic albuterol inhaler on April 8,2020.(44) If faced with albuterol shortage, other available options include substituting other short acting beta-agonists, using an expired albuterol inhaler, and ensuring good asthma control which reduces the need for reliever medications in general.(9,39) Many of the substitute short acting beta-agonists are dry powder inhalers (diskus or turbuhaler) and as such children often need to be at least 6 years of age to produce enough inspiratory force to use these devices properly.(9,45) For adolescents 12 years and older, another option is ICS-formoterol for both maintenance and relief therapy as supported by the Global Initiative for Asthma 2019 update.(46,47) Nebulized albuterol should only be considered as a last resort, and proper infection prevention protocols need to be followed.(8,9,31) If no other medications are available, epinephrine inhalers might be considered as well, if used prudently.

Virtual visits. With the need for significant healthcare resource reallocation, as well as shortages of PPE, much of the allergy/immunology specialty has converted to largely virtual visits, or visit deferral, during COVID-19.(8) Due to the need for almost exclusively virtual visits at this time, having a peak flow meter in homes may be helpful to diagnose an acute exacerbation at home, by comparing baseline measurements with those during highly symptomatic times. There are several advantages to virtual visits, including access to specialists, removing the transportation barrier required for an in-person visit, allowing those too sick to travel to connect with a healthcare provider, and most importantly in the current context, prevention of infection transmission with in-person visits.(48)

Virtual visits should be prioritized for children who have poorly controlled asthma, have worsening asthma symptoms, or who have required dose escalations of their asthma medications in the past several months’ time.(8) It is recommended that follow-up visits for children with mild-to-moderate or well-controlled asthma be postponed during COVID-19, or converted to virtual visits if time permits.(8) It also is recommended that children of any asthma severity who have been well controlled for the past 6-12 months (no ER visits, <1 OCS dose, <2 exacerbations in the past 6-12 months) have visits deferred or converted to virtual visits (time permitting).(8) For children with moderate to severe asthma exacerbations, an in-person visit likely is necessary but as noted in the joint North American guideline on COVID-19 and allergy contingency planning, ‘If the allergy/ immunology office does not have PPE available, it would be recommended that no patients with a co-potential for an asthma exacerbation and COVID-19 be seen at that office; the patient should instead be seen at another facility capable of COVID-19 isolation which is staffed and equipped to assess and manage asthma.’(8) Recommendations may be adjusted over time, based on the duration of COVID-19 and the time required for physical distancing.

Asthma Clinical Trials. It is currently recommended that entry into any asthma clinical trial be suspended during COVID-19.(8) For asthmatic children already participating in clinical trials, consideration could be given to virtual visits if possible.(8) Procedures that require forced expiratory maneuvers such as spirometry, methacholine challenge or induced sputum samples should be postponed in order to minimize staff risk and potential room contamination. Medication withdrawal as part of research protocols also should be deferred to a later time. Consideration should be given to telephone or telemedicine visits in order to limit exposure to a medical setting.

Impact of Social Determinants of Health on Asthma and COVID-19. There are many social determinants of health that have an impact on pediatric asthma morbidity including caregiver income, physical environment including exposure to second-hand smoke, access to health services, and race/ethnicity.(49, 50, 51) There is likely an interplay between some of these social determinants of health and the impact of COVID-19 on children with asthma. It has been suggested that exposure to second-hand smoke increases COVID-19 morbidity.(52,53) Of those hospitalized in the US for COVID-19, data from the CDC indicates that 33.1% were non-Hispanic black, while they only make up 18% of the catchment area population.(3) A recent editorial notes that low-income families are at higher risk of COVID-19 as low income jobs mostly can’t be performed remotely, often don’t pay sick days, are often not associated with insurance benefits and as a result it may not be possible for these families to afford the steps necessary for physical distancing.(54)

Although the relationships between these variables needs to be further elucidated, it is possible that measures that impact social determinants of health, such as reducing exposure to second-hand smoke or improving healthcare access in low income neighborhoods, may improve prognosis in children with asthma who contract COVID-19. In addition, these families could benefit from counseling on having the appropriate amount of medications available for home during this period of restricted travel. In addition, they should check medications to be sure that none is expired.

Impact of COVID Restrictions. It is possible that children may not be severely affected by SARS-CoV-2 for some undefined reason to date, but they can still be carriers and could transmit virus to vulnerable people, including elderly relatives. Therefore, social distancing has included children, which has necessitated discontinuing school. It remains to be determined what impact this step has on children including those children with asthma. Often parents will discontinue medications in children during the summer months because they are doing well and they are out of school.(55) However, this year is different, because school was discontinued during the spring season, a time of seasonal allergen exacerbation and viral infection. School adds a certain structure to the day and there is some level of administration of asthma medication administration around the school day. Clinicians and parents should observe for potential breakdowns in adherence to controlling medications, especially in families in chaotic circumstances. The impact on education of home schooling, especially in families that lack an organizational structure remains to be seen. Finally, it has been suggested that school closure will increase the risk of childhood obesity, a known risk factor for worsening asthma.(56) Whether this occurs, and how this influences asthma control, also is yet unknown.


In the face of unchartered territory and unprecedented times, there remains much to be learned about the impact of pediatric asthma on the course of SARS-CoV-2 virus infection. Although adult data suggest that asthma is a risk factor for COVID-19 morbidity and mortality such a risk in children is unclear. Differentiating COVID-19 from worsening asthma, or an asthma exacerbation, is challenging. As a result, pediatricians and families have an essential role in ensuring that children with asthma maintain good asthma control during this time. Children and adolescents with asthma should remain on their current asthma medications and practice physical distancing, regular handwashing, and aeroallergen avoidance. Treatment of asthma exacerbations should include oral corticosteroids if required. Nebulized medications are not recommended at this time due to increased risk of viral transmission. Healthcare providers should remain alert for changing policies and recommendations knowledge advances.

WAF would like to thank the following for granting permission


Elissa M. Abrams, MD, MPH?
Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba
Department of Pediatrics, Division of Allergy and Immunology, University of British Columbia
Stanley J. Szefler, MD
The Breathing Institute, Children’s Hospital Colorado and Section of Pediatric Pulmonary and Sleep Medicine, Department of Pediatrics, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO