Last updated 20th April 2020
Author: Dr Jacqui Bollmann, Independent Consultant Occupational Physician and Force Medical Adviser, South Yorkshire Police
Reviewed by: Prof Paul Cullinan, Honorary Consultant in Respiratory Medicine, Royal Brompton & Harefield NHS Trust and Professor in Occupational and Environmental Respiratory Disease at the National Heart and Lung Institute, Imperial College London
A stratification flow chart for asthma can be found at /sites/0050/uploads/content/documents/stratification-for-asthma.pdf?1587985279
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Respiratory condition
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Vulnerability
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references
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Age |
Elevate to next level over 50 | |
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Asthma Hospital admission in last year Intensive care treatment ever Steroid inhaler plus montelukast Steroid orally daily (prednisolone) Antibiotic orally weekly (azithromycin)
Biological therapy Xolair/Omalizumab Nucala/Mepolizumab Cinqaero/Reslizumab Faseura/Benralizumab
Inhalers Aerivo Spiromax 500/50 1 twice d AirFluSal Forspiro 500/50 1 twice d AirFluSal pMDI 250/25 2 twice d Aloflute mMDI 250/25 2 twice d Alvesco pMDI 160mg 2 twice d Asmanex Twisthaler 400mcg 1 twice d Budelin Novolizer 200mcg 4 twice d Budesonide Easyhaler 400mcg 2 twice d Clenil Modulite pMDI 500ug twice d Combisal pMDI 250/25 2 twice d DuoResp Spiromax 320/9 2 twice d Flixotide Evohaler 250mcg 2 twice d Flutiform MDI 250/10 2 twice d Flutiform K-Haler high Fostair pMDI or NEXThaler 200/6 2 twice d Fusacomb Easyhaler 500/50 1 twice d Kelhale pMDI 400ug twice d Pulmicort Turbohaler 400 mcg 2 twice d Qvar pMDI, Autohaler or Easi-Breathe 100mcg 4 twice d Relvar Ellipta184/22 1 twice d Sereflo pMDI250/25 2 twice d Seretide Accuhaler 500/50 1 twice d Seretide Evohaler 250/25 2 twice d Sirdupla pMDI 250/25 2 twice d Soprobec pMDI250mcg 2 twice d Stalpex Orbicel 500/50 1 twice d Symbicort Turbohaler400/12 2 twice d Tiotropium |
Very high
Moderate to severe asthmatics are deemed to be at high risk - use this as your starting point and stratify depending on dose of medication.
Very high risk includes those using a combination inhaler including a long-acting bronchodilator at a high daily steroid dose
Elevate to next level if smoker/vaper |
https://www.asthma.org.uk/advice/triggers/coronavirus-covid-19/ https://www.blf.org.uk/support-for-you/coronavirus/what-is-social-shielding https://www.lung.org/blog/covid-19-myth-busting https://erj.ersjournals.com/cc/sars-cov-2-and-covid-19 Around 10% of the population have clinician-diagnosed asthma, and around 10% of those who have diagnosed asthma fall into this 'severe asthma' category. This means around 1% of the population have severe asthma, and the current suggested fatality rate for COVID-19 is 0.2% for people under age 40. This adds useful perspective to the likely risk from severe asthma, as this is only one of the possible co-morbidities increasing the risk of death in the under 40s. MUKHERJEE, M., et al, A. 2016. The epidemiology, healthcare and societal burden and costs of asthma in the UK and its member nations: analyses of standalone and linked national databases. BMC Med, 14, 113. YANG, J. F., et al. 2018. Insights into frequent asthma exacerbations from a primary care perspective and the implications of UK National Review of Asthma Deaths recommendations. NPJ Prim Care Respir Med, 28, 35.
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Asthma On blue inhaler/salbutamol/Ventolin plus daily steroid inhaler in lower dose than above Daily combination inhaler on dose lower than above |
High |
Emerging evidence suggests that asthma is not as high a risk as initially thought. These tables may therefore overestimate risk. HALPIN, D. M. G., et al. 2020. Do chronic respiratory diseases or their treatment affect the risk of SARS-CoV-2 infection? Lancet Respir Med. |
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Asthma Two or more courses of oral steroid in last year Blue inhaler/salbutamol/Ventolin more than three times a week recently |
Increased | |
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Asthma On blue inhaler/salbutamol/Ventolin only, less than three times a week use average |
Low | |
| Breathlessness |
MRC Dyspnoea score is a predictor 2 = Increased 3 and above = High or Very high |
https://copdnewstoday.com/2020/03/26/copd-patients-vulnerable-to-severe-covid-19-infections-study-finds/ |
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Bronchiectasis Severe, requiring nebulised treatments or FEV1 <50% MRC breathlessness score 3 or more Two or more exacerbations in past year requiring steroid or antibiotics Regular daily oral steroid Home oxygen therapy Non-invasive home ventilation or BiPAP |
Very high | |
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Bronchiectasis Moderate, MRC 2, none of above criteria |
High | |
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Bronchiectasis Mild, MRC 1, none of above criteria |
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COPD FEV1 <50% GOLD 3 or 4 classification MRC breathlessness score 3 or more Hospital admission for COPD in past Two or more exacerbations in past year requiring steroid or antibiotics Regular daily oral steroid Home oxygen therapy Non-invasive home ventilation or BiPAP |
Very high |
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COPD MRC score 2 and none of above criteria |
High |
https://www.pcrs-uk.org/mrc-dyspnoea-scale https://copdnewstoday.com/2020/03/26/copd-patients-vulnerable-to-severe-covid-19-infections-study-finds/ |
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COPD Mild, MRC score 1, no other criteria above |
Increased |
https://www.pcrs-uk.org/mrc-dyspnoea-scale https://copdnewstoday.com/2020/03/26/copd-patients-vulnerable-to-severe-covid-19-infections-study-finds/ |
| Cystic fibrosis: all | Very high | https://www.blf.org.uk/support-for-you/coronavirus/what-is-social-shielding |
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Interstitial lung disease and pulmonary fibrosis Limited by breathlessness MRC 3 or above Previous hospital admission for condition Two or more exacerbations or flare-ups in past year requiring steroids or antibiotics Regular daily oral steroid Home oxygen therapy FVC <80%, TLco <60% Pulmonary hypertension
Currently taking Azathioprine Cyclosporin Methotrexate Mycophenylate mofetil Nintedanib Pirfenidone Sirolimus Tacrolimus
Intravenous therapy in past six months with Cyclophosphamide Infliximab Rituximab |
Very high |
https://www.blf.org.uk/support-for-you/coronavirus/what-is-social-shielding
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Interstitial lung disease and pulmonary fibrosis MRC breathlessness score 2 and below, none of the above treatments |
High | |
| Lymphangioleiomyomatosis (LAM) | Very high or high | Likely to be at least high once a patient has presented clinically, and may well be advised to shield if at an advanced stage or if substantially immunosuppressed. |
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MRC Dyspnoea Scale 5 too breathless to leave the house, or breathless when dressing/undressing |
Very high | |
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MRC Dyspnoea Scale 4 Stops for breath after walking 100yds or after a few minutes on level ground |
Very high | |
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MRC Dyspnoea Scale 3 Walks slower than most people on the level, stops after a mile or so, or stops after 15 minutes walking at own pace |
Very high or High |
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MRC Dyspnoea Scale 2 Short of breath when hurrying on a level or when walking up a slight hill |
High or increased |
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MRC Dyspnoea Scale 1 Not troubled by breathlessness except on strenuous exercise |
Increased | |
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Other respiratory infection Past TB |
Increased | post-TB lung damage often puts you at a higher risk of picking up chest infections and so you might be at slightly higher risk of having a chest infection if you were infected with COVID-19 |
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Other respiratory infection Current viral infection |
Unclear, may be increased |
https://www.europeanlung.org/en/QA-covid-19 individuals can get Covid19 in the presence of other URTI – no data on whether the effect will be increased |
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Other respiratory infection Past infection, recovered |
Low once well and after 7 days |
https://www.europeanlung.org/en/QA-covid-19 Previous infections do not increase the risk of more severe infections in future unless the previous infections were due to other diseases (such as severe heart or lung conditions, diabetes or conditions or drugs that suppress the immune system) |
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Sarcoidosis Stage III or IV MRC breathlessness score 3 or more Two or more exacerbations or flare-ups in past year requiring steroids or antibiotics Regular daily oral steroid Home oxygen therapy FVC <80%, TLco <60% Pulmonary hypertension Currently taking immunosuppresants |
Very high |
https://www.blf.org.uk/support-for-you/coronavirus/what-is-social-shielding
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Sarcoidosis Stage II bilateral hilar lymphadenopathy and infiltrates In remission for eighteen months |
Increased | |
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Sarcoidosis Stage I bilateral hilar lymphadenopathy In remission for eighteen months Stage 0 (normal CXR) or I (bilateral hilar lymphadenopathy) Never required treatment |
Low | |
| Smoking/Vaping |
Increased Consider elevating to next level of risk |