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<h5 class="section-title" id="d3988791e2311">Background</h5>
<p id="d3988791e2313">Studies of patients admitted to hospital with COVID-19 have
found varying mortality
outcomes associated with underlying respiratory conditions and inhaled corticosteroid
use. Using data from a national, multicentre, prospective cohort, we aimed to characterise
people with COVID-19 admitted to hospital with underlying respiratory disease, assess
the level of care received, measure in-hospital mortality, and examine the effect
of inhaled corticosteroid use.
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<h5 class="section-title" id="d3988791e2316">Methods</h5>
<p id="d3988791e2318">We analysed data from the International Severe Acute Respiratory
and emerging Infection
Consortium (ISARIC) WHO Clinical Characterisation Protocol UK (CCP-UK) study. All
patients admitted to hospital with COVID-19 across England, Scotland, and Wales between
Jan 17 and Aug 3, 2020, were eligible for inclusion in this analysis. Patients with
asthma, chronic pulmonary disease, or both, were identified and stratified by age
(<16 years, 16–49 years, and ≥50 years). In-hospital mortality was measured by
use
of multilevel Cox proportional hazards, adjusting for demographics, comorbidities,
and medications (inhaled corticosteroids, short-acting β-agonists [SABAs], and long-acting
β-agonists [LABAs]). Patients with asthma who were taking an inhaled corticosteroid
plus LABA plus another maintenance asthma medication were considered to have severe
asthma.
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<h5 class="section-title" id="d3988791e2321">Findings</h5>
<p id="d3988791e2323">75 463 patients from 258 participating health-care facilities
were included in this
analysis: 860 patients younger than 16 years (74 [8·6%] with asthma), 8950 patients
aged 16–49 years (1867 [20·9%] with asthma), and 65 653 patients aged 50 years and
older (5918 [9·0%] with asthma, 10 266 [15·6%] with chronic pulmonary disease, and
2071 [3·2%] with both asthma and chronic pulmonary disease). Patients with asthma
were significantly more likely than those without asthma to receive critical care
(patients aged 16–49 years: adjusted odds ratio [OR] 1·20 [95% CI 1·05–1·37]; p=0·0080;
patients aged ≥50 years: adjusted OR 1·17 [1·08–1·27]; p<0·0001), and patients
aged
50 years and older with chronic pulmonary disease (with or without asthma) were significantly
less likely than those without a respiratory condition to receive critical care (adjusted
OR 0·66 [0·60–0·72] for those without asthma and 0·74 [0·62–0·87] for those with asthma;
p<0·0001 for both). In patients aged 16–49 years, only those with severe asthma
had
a significant increase in mortality compared to those with no asthma (adjusted hazard
ratio [HR] 1·17 [95% CI 0·73–1·86] for those on no asthma therapy, 0·99 [0·61–1·58]
for those on SABAs only, 0·94 [0·62–1·43] for those on inhaled corticosteroids only,
1·02 [0·67–1·54] for those on inhaled corticosteroids plus LABAs, and 1·96 [1·25–3·08]
for those with severe asthma). Among patients aged 50 years and older, those with
chronic pulmonary disease had a significantly increased mortality risk, regardless
of inhaled corticosteroid use, compared to patients without an underlying respiratory
condition (adjusted HR 1·16 [95% CI 1·12–1·22] for those not on inhaled corticosteroids,
and 1·10 [1·04–1·16] for those on inhaled corticosteroids; p<0·0001). Patients
aged
50 years and older with severe asthma also had an increased mortality risk compared
to those not on asthma therapy (adjusted HR 1·24 [95% CI 1·04–1·49]). In patients
aged 50 years and older, inhaled corticosteroid use within 2 weeks of hospital admission
was associated with decreased mortality in those with asthma, compared to those without
an underlying respiratory condition (adjusted HR 0·86 [95% CI 0·80−0·92]).
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<h5 class="section-title" id="d3988791e2326">Interpretation</h5>
<p id="d3988791e2328">Underlying respiratory conditions are common in patients admitted
to hospital with
COVID-19. Regardless of the severity of symptoms at admission and comorbidities, patients
with asthma were more likely, and those with chronic pulmonary disease less likely,
to receive critical care than patients without an underlying respiratory condition.
In patients aged 16 years and older, severe asthma was associated with increased mortality
compared to non-severe asthma. In patients aged 50 years and older, inhaled corticosteroid
use in those with asthma was associated with lower mortality than in patients without
an underlying respiratory condition; patients with chronic pulmonary disease had significantly
increased mortality compared to those with no underlying respiratory condition, regardless
of inhaled corticosteroid use. Our results suggest that the use of inhaled corticosteroids,
within 2 weeks of admission, improves survival for patients aged 50 years and older
with asthma, but not for those with chronic pulmonary disease.
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<h5 class="section-title" id="d3988791e2331">Funding</h5>
<p id="d3988791e2333">National Institute for Health Research, Medical Research Council,
NIHR Health Protection
Research Units in Emerging and Zoonotic Infections at the University of Liverpool
and in Respiratory Infections at Imperial College London in partnership with Public
Health England.
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