Despite the ongoing COVID-19 pandemic, the British Thoracic Society (BTS) persevered with its commitment to showcase the latest respiratory research by moving its originally planned November 2020 Winter BTS Meeting in Westminster to an entirely online platform.
Over 1,800 delegates logged in to the first ever virtual BTS Winter Meeting, which took place between 17th and 19th February 2021. There were a number of thought-provoking symposia, journal clubs and presentations, covering the breadth of subspecialties within respiratory medicine. We will explore a small sampling of the asthma related word that was presented.
As one might expect, COVID-19 featured rather heavily throughout the meeting. It was particularly interesting to hear the audit work looking at the impact of shielding and severity of COVID-19 infection on the UK’s severe asthma population. The data was compiled from telephone interviews with 1,365 severe asthma patients across 14 UK Severe Asthma Registry centres (UKSAR) between June and July 2020.1 It showed 89% of those surveyed complied with shielding advice.1 Unfortunately, 47% of respondents suffered with a deterioration in their mental health as a consequence of shielding and in particular, the female sex and an age below 40 years were characteristics associated with a greater decline in mental health.1 This compares to 35% of the general population whose mental health worsened due to shielding, according to the Office of National Statistics (ONS) Shielding Behavioural Study.2 The obvious implications to all health care providers who look after severe asthma patients would include being more cognisant of their patient’s tendency to experience a decline in mental health, with considerations for onward engagement with health psychologists where warranted. This was also reflected in work done across patients with long term respiratory conditions who experienced significant negative psychosocial consequences also.3
The COVID-19 pandemic has also had a profound impact on the administration and delivery of asthma biologic injection treatments to severe asthma patients. The necessity to facilitate shielding measures and limit patient movement around the country triggered a massive transition from a predominantly outpatient, day-unit based biologic injection administration model to a self-administered, home-care delivered model with monthly asthma nurse telephone calls to patients. As with any large-scale change, the question on the tips of clinician’s tongues was how this impacted patients and their asthma control? Fortunately, 2 abstracts addressed this, both in slightly different ways but ultimately looking for an objective change in asthma control; as determined by patient Asthma Control Questionnaire (ACQ) scores.4,5 Rather reassuringly, neither study indicated a deterioration in asthma control when severe asthma patients were transitioned over to the home-care delivered model of self-administration of biologics and in fact, both studies continued to show the expected improvement in asthma control with this model.4,5 What remains to be determined is the longer-term outcome of this change and also the subjective impact on patient’s experiences with the change. Moreover, patient behaviours with regard to biologic timing of administration and adherence, when offered more control over these expensive treatments, will be important to learn.
The other major theme that was elucidated throughout the various Winter BTS sessions was the surprising environmental impact and carbon footprint of metered dose inhalers (MDIs); the most commonly prescribed being short-acting beta-2 agonists (SABAs). It is well established that SABA overuse is associated with increased mortality, with overuse being defined as 3 or more SABA prescriptions in a year.6 The review of over half a million asthma patient records revealed that SABA overuse was responsible for the emission of approximately 250,000 tonnes of greenhouse gas emission, which was three times as much as our European counterparts.6 To put this into context, the authors also presented that this is the equivalent of driving an average diesel car for about 900 million miles.
A common concern that clinicians have when prescribing inhalers encompasses the patient’s ability to adequately use the inhaler and inhale the medicine into the lower airways. An intriguing study looked at this by measuring the peak inspiratory flow rates (PIFR) of nearly 1,000 patients who attended their GP practice for a routine asthma review.7 They found that 93.7% of patients were able to generate a PIFR suitable to a dry powder inhaler (DPI) but only 70.5% were able to generate the appropriate PIFR for a MDI.7 This was reflected even amongst those who were 71 years or older, with 90.2% exhibiting a PIFR suited to DPIs whereas only 71.0% were suitable for a MDI.7 This further supports the adequacy of using a DPI across a range of patients despite the media based popularisation of MDI inhalers and their theoretical superiority.
With a greater understanding of the impact of COVID-19 on our patients, accompanied by some reassurances of our adaptation to the new care environment and a more illuminated comprehension of the wider environmental impacts of our treatments, we can eagerly look forward to the proposed hybrid of part-virtual and part in-person Winter BTS Meeting in November 2021.
Dr Pujan Patel, consultant in respiratory medicine with expertise in severe asthma, Royal Brompton Hospital, London