The results of the first studies and that observed in recent months in Spanish hospitals indicate that patients suffering from a chronic obstructive pulmonary disease (COPD) are at risk of being infected by the SARS-CoV-2 coronavirus similar to that of the general population. However, those who get to enter the hospitals because of COVID-19, the disease that causes this microorganism, have a worse prognosis than the average. Research confirms that in the most severe cases, the coronavirus triggers what is called a cytokine storm in the body. These proteins, also called cytokines, help fight infection, but when too many are activated, the immune system ends up attacking the body and causing an uncontrolled inflammatory process that can be fatal.
More details of this phenomenon remain to be understood and understood in patients with COVID-19, but clinical observations suggest that when the immune response does not control the virus – for example, in the case of older people with a weakened immune system– It spreads more efficiently and damages the lungs. It causes hyper inflammation of such organs that would be associated with acute respiratory failure syndrome or adult respiratory distress syndrome (ARDS), described as the main cause of COVID-19 mortality.
Previous respiratory diseases: a risk factor?
Paradoxically, people with chronic respiratory diseases are not being particularly affected by the new virus that has turned the world upside down. The data available so far show that the most frequent comorbidities (the presence of coexisting or additional diseases in relation to the initial diagnosis) in those hospitalized with COVID-19 are high blood pressure, cardiovascular disease, diabetes and smoking. Because individuals with chronic respiratory ailments – especially asthma and COPD – they are more susceptible to viral infections, they were considered a potentially more vulnerable group to SARS-CoV-2 infection. But experts say that “as of today there is no data that has confirmed this suspicion.”
In a recent online seminar organized by the Spanish Society of Primary Care Physicians (SEMERGEN), José Tomás Gómez Sáenz, coordinator of the Working Group of this, stated that patients with respiratory diseases “do not fare particularly badly with this new disease ” Why? “Perhaps they have protected themselves more from the beginning for fear of getting it, or perhaps their treatments work. No clear explanation has yet been found. ” The data collected in Spain indicates that the percentage of people with COPD admitted by COVID-19 is not higher in relative terms than that of the general population. In the largest series published to date, of 1590 cases analyzed, only twenty-four – 1.5% – had COPD, and none had asthma.
What has been proven is that, as expected, having chronic obstructive pulmonary disease is a bad thing when the coronavirus enters the equation: “In general, those affected have a worse prognosis, and their mortality rate is higher,” he says. Marina Blanco, coordinator of the Asthma Area of the Spanish Society of Pneumology and Thoracic Surgery (SEPAR). For his part, Leovigildo Ginel, secretary of the SEMERGEN Respiratory Working Group, clarifies that “patients with chronic respiratory ailments do not have a higher risk of becoming infected with the SARS-CoV-2 virus, and the way in which the COVID-19 in them does not differ from that of the rest of the population. The important thing is that such chronic diseases are well controlled; In this sense, the main recommendation is that patients comply correctly with their usual treatments ”.
In addition, Dr. Ginel recommends, both asthmatics and those with COPD, “use pressurized cartridge inhalers with inhalation chamber, instead of nebulizers, since the latter produce aerosols in the environment that increase the chances of contagion by SARS-CoV-2”. If they experience an acute worsening of their symptoms, they should use rescue medication (short-acting bronchodilators) together with the specific measures for each disease.
Dr. Blanco has observed in an in vitro study that corticosteroids commonly inhaled by COPD patients decrease the viral replication of SARS-CoV-2. “The results will have to be confirmed, but this could explain why there is a lower percentage of COVID-19 cases among these people than in the rest of the population. “There is another theory that explains this phenomenon,” he adds, “but it affects a minority of patients and cannot be extrapolated. Some people with COPD take azithromycin three days a week. ” It is an antibiotic that is being used to stop COVID-19, so there could be a relationship.
What does seem very clear is that the disease caused by the new coronavirus that emerged in China in late 2019 is more likely to be serious in COPD patients and smokers. Both have an increased number of angiotensin-converting enzyme 2 (ACE-2) receptors in bronchial epithelial cells of the lower respiratory tract, the door that opens SARS-CoV-2 to penetrate cells where it replicates. According to Dr. Blanco, “this may explain the fact that in COPD patients the disease is more dangerous. “What we don’t know is whether bronchodilator-based treatments or corticosteroid inhalation can modulate the expression of these receptors.”
The respiratory comorbidities of COVID-19
When two or more diseases coincide in one person, we speak of comorbidity. Sometimes these ailments interact and worsen the evolution of each other. Julio Ancochea, head of the Pneumology Service at the University Hospital of La Princesa (Madrid), tells VERY that in his center and in the case of COVID-19 they put the emphasis on these comorbidities: cardiovascular diseases, hypertension and diabetes; and not so much in asthma and COPD, “which are minorities.”
As he says, “we have reviewed a study published in The Lancet Respiratory Medicine that analyzed whether these respiratory ailments and their treatments were risk factors in patients from China, Taiwan, Hong Kong, Canada … The conclusion is that, within comorbidities, COPD and asthma are very little present ”. Why? Ancochea explains it to us based on these three factors:
Underdiagnosis: “In Spain, these diseases are little diagnosed. And in China even less. If the disease is not previously registered in a person, it is not recorded. “
Immune response: “Some specialists have the theory that patients suffering from asthma and COPD have a particular immune response to SARS-CoV-2. However, it is a fact that has not yet been proven. ”
Treatments: “Many people with strong asthma and COPD symptoms inhale corticosteroids, often associated with bronchodilators. To what extent do these inhaled corticosteroids exert an anti-inflammatory effect that can inhibit virus replication and the inflammatory phase with cytokine production? It is not at all clear, but it is a hypothesis that a few researchers maintain. “