COPD and COVID-19

If you’re living with chronic obstructive pulmonary disease (COPD), you likely have questions about how your condition affects your risk for contracting or becoming seriously ill with COVID-19, what complications might occur, and whether your medications could either increase or decrease your risk.

While the Centers for Disease Control and Prevention (CDC) states that people with COPD are at an increased risk from COVID-19, some studies suggest that the risk is not as high as previously thought when looking at COPD alone (without the factors of age and other medical conditions).

We will look at what the studies show to date, what you should know about your medications, the current GOLD guidelines, and discuss a positive effect that COVID-19 precautions have had on COPD exacerbations.

COPD and COVID-19 Risk

When talking about COPD and COVID-19 risk, it’s important to separate the question into two topics:

• Susceptibility: Is someone who has COPD more likely to contract COVID-19 when exposed to SARS-CoV-2, the virus that causes COVID-19?
• Outcomes: Is someone who has COPD and develops COVID-19 more likely to have bad outcomes, such as hospitalization, intensive care admission, the need to be intubated, or death?

Susceptibility

Whether having COPD increases the risk of becoming infected with COVID-19 when exposed is still unclear. People who have COPD have an increased susceptibility to infections in general, and some medications (inhaled corticosteroids) can increase the risk of pneumonia.

A number of factors could impact susceptibility to COVID-19, including:

• Compromised immune systems: People with COPD tend to have blunted immune responses as well as reduced clearance of viruses by cilia in the airways.
• Increased angiotensin 2 receptor levels in lungs: The ACE receptor is what COVID-19 binds to in order to enter cells.
• Side effects from medications: Corticosteroids—either inhaled or oral—can affect immune responses.

Severity/Outcomes

As with susceptibility, having COPD—and the medications for treatment—affects the immune system and airways. It’s well known that people with COPD are at risk for severe outcomes with common cold virus infections, and these viruses—especially rhinoviruses—are a common cause of COPD exacerbations.

Because of this, people with pre-existing COPD are reported to have worse outcomes from COVID-19. Specifically, COPD is associated with increased risk of:

• COVID-19-related hospital admission
• Admission to the intensive care unit (ICU)
• Use of mechanical ventilation
• Death during hospitalization
  

Unknown Risks

At the current time, it’s unknown whether people with COPD (and possibly those using inhaled steroids) are any more or less likely to develop long COVID.

It’s also unknown whether experiencing a serious COVID-19 infection will affect the progression or prognosis of COPD in the future. Fortunately, these questions are being asked by scientists, and information is being gathered.

Complications of COPD and COVID-19

There are special considerations for people with COPD who may have symptoms of COVID-19 or have been diagnosed with COVID-19.

Challenge of Diagnosis

The first challenge and potential complication of living with COPD during this pandemic is the challenge of distinguishing COVID-19 from a COPD exacerbation. Symptoms of the two can be similar, with shortness of breath common to both.

What is most important at this time is that people with COPD who develop new or worsening respiratory symptoms, a fever, or any other suspicious symptoms (such as loss of taste/smell) be tested to see if they have an infection with COVID-19.

Even when examined by a healthcare provider, discriminating between the two can be difficult. Chest X-rays are relatively insensitive early on and with mild disease.

If identified early, this would provide the greatest ability for people to work with their healthcare providers to reduce risk, if possible, and to ensure adequate management.

Prolonged Intubation

People who live with the more advanced stages of COPD are familiar with the concern about ventilatory support. If intubation is required, would there be difficulty removing the tube eventually? According to the Belgian study above, prolonged intubation was more common in people with COPD.

For people without COPD, it was discovered that delaying intubation (if possible) led to better outcomes, and this appears to be the case with COPD as well.

In addition, with COPD it was found that high-flow nasal therapy (HFTN) is preferable to noninvasive ventilation (NIV) when oxygen therapy alone cannot maintain oxygen levels in the blood.

Blood Clots

Unlike influenza, which is primarily a disease that affects the lungs, the ability of COVID-19 to affect blood vessels and clotting was noted fairly early. Instead of being a disease that led to respiratory failure alone, other symptoms were seen, including:

• Associated increased risk of blood clots
• Associated pulmonary embolism
• Associated heart attacks
• Associated strokes

COPD Treatments and COVID-19

If you’re living with COPD, you may wonder whether your medications (especially corticosteroids) could affect your risk of COVID-19. And if you should develop COVID-19, would your treatment differ from someone who does not have COPD?

COPD Treatments During the COVID-19 Pandemic

At the current time, the CDC recommends that people with COPD continue their usual medications, including inhaled corticosteroids if used.

In addition, current GOLD recommendations hold that antibiotics and oral corticosteroids should be used according to indications whether or not a person also has COVID-19.

Since inhaled corticosteroids (ICI) may increase the risk of pneumonia, there was some concern at the beginning of the pandemic that these medications could either predispose to infection or worsen COVID-19 severity if contracted.

In one study early on, it appeared that severity was worse among those treated with ICIs. When looked at more closely, however, this increased severity was likely related to the severity of the underlying COPD.

According to current recommendations, ICIs are only recommended for people who have had a COPD exacerbation in the past year. The severity of a person’s lung disease, rather than the medications they use, appeared to have the most impact on outcomes.

A different study looking specifically at inflammation and factors that may affect COVID-19 severity found that people with COPD who were treated with either inhaled or oral corticosteroids did not have a higher risk of severe COVID-19 infections. (They suspect that ICIs have effects on inflammation and ACE2 receptors that may both increase and reduce susceptibility to severe COVID-19.)

Hospital-based pulmonary rehabilitation has been helpful for some people with COPD, but restrictions related to COVID-19 have led to the temporary closure of some of these practices. Even when available, many people wanted to face the risk of infection posed by leaving home. While home-based programs are less effective, it’s thought that they are “better than nothing” with regard to maintaining disease control when COVID-19 is prevalent in the community.

COVID-19 Treatments in People With COPD

For people with COPD who become infected with COVID-19, currently available treatments such as dexamethasone, blood thinners, and antibodies should be used as they would for people without COPD.

For asymptomatic or mild disease, current protocols should be followed. For moderate symptoms of COVID-19 (or worse), people with COPD should be monitored more often than people without COPD, especially with regard to the need for oxygen therapy.

With severe disease, oxygen, prone positioning, and ventilatory options (high flow oxygen, noninvasive ventilation, and mechanical ventilation) should be used per protocol.

COVID-19 Treatments in People With COPD

It’s recommended for people with COPD who develop moderate or severe COVID-19, that pulmonary rehabilitation should be offered after discharge from the hospital.

So far we’ve talked about concerns related to the COVID-19 pandemic on top of a diagnosis of COPD, but we’re learning there has actually been a silver lining—an unexpected “benefit.”

A significant contributor to illness and hospitalizations, cost, and deaths from COPD has been COPD exacerbations. In turn, a leading cause of these exacerbations is viral infections. Frequent exacerbations not only lead to more deaths from COPD but speed up the progression of lung damage and reduce the quality of life. Many of these infections (unlike COVID-19) are not preventable with vaccines.

A study in Singapore comparing hospitalizations for COPD exacerbations in a pre-pandemic period (January of 2018 through January of 2020) to that during the pandemic (February to July of 2020) found that there was a 50% reduction in COPD exacerbation admissions each month. In addition, a test done to look for a number of respiratory viruses went from being positive 49% of the time to only 11% of the time.

Not only is this a silver lining amidst the pandemic we are still experiencing, but it has important implications for the future. Could simple hygiene measures (such as masks, distancing, hand washing) reduce COPD exacerbations to this degree? In addition, this finding pointed out the role that common viral infections (especially rhinovirus) play in COPD care and could lead to further treatments for these in the future.

How to Stay Safe

Staying safe and healthy with COPD amidst the pandemic requires thought and balance.

CDC recommendations for prevention should be followed, including:

• Frequently washing your hands
• Wearing a mask or respirator
• Staying up-to-date with your COVID-19 vaccines 
• Staying home if you have suspected or confirmed COVID-19
• Avoiding contact with people who have COVID-19

That said, the current GOLD standards for COPD note that these measures should not lead to social isolation and inactivity, which can be detrimental for those with COPD. People with COPD require contact with family and friends (in safe ways) and continued physical activity.

Tips that can make living with COPD easier include:

• Make sure you have at least a 30-day supply of medications
• Make sure you have an adequate supply of oxygen if you use it
• Avoid triggers that you know can make your symptoms worse
• Keep regular appointments with your healthcare provider (via telehealth if possible) to make sure you have the best control possible of your disease
• Stay up-to-date on immunizations such as those for influenza and pneumonia
• Consult reputable sources for up-to-date information concerning COVID-19 and how it is managed

The information in this article is current as of the date listed. As new research becomes available, we’ll update this article. For the latest on COVID-19, visit our coronavirus news page.