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Asthma in patients admitted to emergency department for COVID-19: prevalence and risk of hospitalization

Dear Editor,

Current literature suggests that the prevalence of asthma among COVID-19 patients is similar to global one and that asthma does not appear to increase the risk of developing severe COVID-19. [1,2,3,4,5,6,7,8] Published data come from studies on patients admitted to hospital for COVID-19, whereas little or no evidence are available on the setting of emergency department (ED).

Aims of our study were to assess in consecutive adult patients admitted to emergency room for COVID-19:

  1. 1.

    The prevalence of asthma;

  2. 2.

    The relationship between history of asthma and risk of hospitalization.

This study was approved by the institutional review board of our hospital, the Fondazione Policlinico Universitario Agostino Gemelli—IRCCS, Rome, Italy.

We retrospectively reviewed the electronic health records of all patients with age ≥ 18 years, symptoms compatible with COVID-19, and evidence of SARS-CoV2 infection using a molecular nasopharyngeal swab performed during admission to ED of our hospital. There were two enrollment periods: between March and May 2020 and between October and December 2020.

We consecutively reviewed the medical records of 816 patients. After the exclusion of 82 due to incomplete data, 734 patients were available for the present study.

Their demographic and clinical characteristics are listed in Table 1.

Table 1 Demographic and clinical and laboratory characteristics of patients admitted to Emergency Department for COVID-19

We reported data as percentages for categorical variables and as mean (standard deviation) for continuous variables. We compared categorical variables by the χ2 test or the Fisher exact test, and continuous variables by the independent t-test or the non-parametric Mann–Whitney U test. We performed the statistical analysis using IBM SPSS 20 software (IBM Corp., Armonk, NY, USA). P values of < 0.05 was considered statistically significant.

Among 734 newly diagnosed COVID-19 patients, we identified 18 subjects with a history of asthma (2.5%), a much lower prevalence than expected. According to a 2020 national report on the epidemiological impact of chronic diseases in general practice, asthma has a national prevalence of 9.1%, and a local prevalence (Lazio) of 8.8% [9]

A total of 579 out of 734 were hospitalized (78.9%): 6/18 (33.3%) in the group with history of asthma with respect to 573/716 (80%) in the one without asthma. The difference resulted to be statistically significant (P < 0.00001).

None of the 12 patients with asthma and COVID-19 discharged at home were readmitted to the ED of our hospital in the following month.

Our data agree with the current literature suggesting that asthma is not a risk factor for COVID-19. Furthermore, our results are extremely similar to the only other data on Italian epidemiology by Caminati et al. In 2000 COVID-19 patients admitted to 5 hospitals in the Northern Italy, the authors found a prevalence of asthma of 2.1%. [10] As mentioned above, to the best of our knowledge, the present study is the only one performed on an ED population, more representative of the entire clinical severity spectrum of symptomatic SARS-CoV2 infection.

Some physiopathological considerations can help to explain this “asthma paradox” in COVID-19.

As is well known, there are two main steps affecting the entry of SARS-CoV-2 into host cells: the angiotensin converting enzyme 2 (ACE-2) receptor and the Transmembrane Serine Protease 2 (TMPRSS-2), the first binding and the second priming the viral spike protein. [11] Asthma patients have no overexpression in the ACE-2 gene in either sputum or lung resection specimens compared to healthy subjects, suggesting that asthma is not at increased risk of SARS-CoV2 infection. [12, 13] The use of inhaled corticosteroids (ICS), which are the mainstay of asthma treatment, is associated in a dose-dependent manner with reduced expression of ACE-2 and TMPRSS-2 mRNA. [12] In addition, the polarization of the inflammatory response toward an overexpression of T helper (Th) 2 cytokines, typical of at least a subgroup of asthmatic patients, may counteract the typical Th1 response in COVID-19, thus reducing the risk of complications due to the pro-inflammatory Th1-cytokines, IL-6 among others [14].

Our study has some intrinsic limitations: retrospectivity, lack of a control group, inability to better characterize the asthmatic pattern due to the ED setting, the small number of patients with asthma not allowing to explore other outcomes.

However, the present study suggests that, in patients admitted to ED with new diagnosis of COVID-19, a history of asthma is not common and, if present, it should not be considered per se as an indication for hospitalization.

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Acknowledgements

Below are listed all members of the GEMELLI AGAINST COVID study group: Abbate Valeria, Acampora Nicola, Addolorato Giovanni, Agostini Fabiana, Ainora Maria Elena, Akacha Karim, Amato Elena, Andreani Francesca, Andriollo Gloria, Annetta Maria Giuseppina, Annicchiarico Brigida Eleonora, Antonelli Mariangela, Antonucci Gabriele, Anzellotti Gian Marco, Armuzzi Alessandro, Baldi Fabiana, Barattucci Ilaria, Barillaro Christian, Barone Fabiana, Bellantone Rocco Domenico Alfonso, Bellieni Andrea, Bello Giuseppe, Benicchi Andrea, Benvenuto Francesca, Berardini Ludovica, Berloco Filippo, Bernabei Roberto, Bianchi Antonio, Biasucci Daniele Guerino, Biasucci Luigi Marzio, Bibbò Stefano, Bini Alessandra, Bisanti Alessandra, Biscetti Federico, Bocci Maria Grazia, Bonadia Nicola, Bongiovanni Filippo, Borghetti Alberto, Bosco Giulia, Bosello Silvia, Bove Vincenzo, Bramato Giulia, Brandi Vincenzo, Bruni Teresa, Bruno Carmine, Bruno Dario, Bungaro Maria Chiara, Buonomo Alessandro, Burzo Livia, Calabrese Angelo, Calvello Maria Rosaria, Cambieri Andrea, Cambise Chiara, Cammà Giulia, Candelli Marcello, Canistro Gennaro, Cantanale Antonello, Capalbo Gennaro, Capaldi Lorenzo, Capone Emanuele, Capristo Esmeralda, Carbone Luigi, Cardone Silvia, Carelli Simone, Carfì Angelo, Carnicelli Annamaria, Caruso Cristiano, Casciaro Francesco Antonio, Catalano Lucio, Cauda Roberto, Cecchini Andrea Leonardo, Cerrito Lucia, Cesarano Melania, Chiarito Annalisa, Cianci Rossella, Cicetti Marta, Cicchinelli Sara, Ciccullo Arturo, Ciciarello Francesca, Cingolani Antonella, Cipriani Maria Camilla, Consalvo Maria Ludovica, Coppola Gaetano, Corbo Giuseppe Maria, Corsello Andrea, Costante Federico, Costanzi Matteo, Covino Marcello, Crupi Davide, Cutuli Salvatore Lucio, D'Addio Stefano, D'Alessandro Alessia, D'alfonso Maria Elena, D'Angelo Emanuela, D'Aversa Francesca, Damiano Fernando, De Berardinis Gian Maria, De Cunzo Tommaso, de Gaetano Donati Katleen, De Luca Giulio, De Matteis Giuseppe, De Pascale Gennaro, De Santis Paolo, De Siena Martina, De Vito Francesco, Del Gatto Valeria, Del Giacomo Paola, Del Zompo Fabio, Dell'Anna Antonio Maria, Della Polla Davide, Di Gialleonardo Luca, Di Giambenedetto Simona, Di Luca Roberta, Di Maurizio Luca, Di Muro Mariangela, Dusina Alex, Eleuteri Davide, Esperide Alessandra, Facheci Daniele, Faliero Domenico, Falsiroli Cinzia, Fantoni Massimo, Fedele Annalaura, Feliciani Daniela, Ferrante Cristina, Ferrone Giuliano, Festa Rossano, Fiore Maria Chiara, Flex Andrea, Forte Evelina, Franceschi Francesco, Francesconi Alessandra, Franza Laura, Funaro Barbara, Fuorlo Mariella, Fusco Domenico, Gabrielli Maurizio, Gaetani Eleonora, Galletta Claudia, Gallo Antonella, Gambassi Giovanni, Garcovich Matteo, Gasbarrini Antonio, Gasparrini Irene, Gelli Silvia, Giampietro Antonella, Gigante Laura, Giuliano Gabriele, Giuliano Giorgia, Giupponi Bianca, Gremese Elisa, Grieco Domenico Luca, Guerrera Manuel, Guglielmi Valeria, Guidone Caterina, Gullì Antonio, Iaconelli Amerigo, Iafrati Aurora, Ianiro Gianluca, Iaquinta Angela, Impagnatiello Michele, Inchingolo Riccardo, Intini Enrica, Iorio Raffaele, Izzi Immacolata Maria, Jovanovic Tamara, Kadhim Cristina, La Macchia Rosa, La Milia Daniele Ignazio, Landi Francesco, Landi Giovanni, Landi Rosario, Landolfi Raffaele, Leo Massimo, Leone Paolo Maria, Levantesi Laura, Liguori Antonio, Liperoti Rosa, Lizzio Marco Maria, Lo Monaco Maria Rita, Locantore Pietro, Lombardi Francesco, Lombardi Gianmarco, Lopetuso Loris, Loria Valentina, Losito Angela Raffaella, Lucia Mothanje Barbara Patricia, Macagno Francesco, Macerola Noemi, Maggi Giampaolo, Maiuro Giuseppe, Mancarella Francesco, Mangiola Francesca, Manno Alberto, Marchesini Debora, Maresca Gian Marco, Marrone Giuseppe, Martis Ilaria, Martone Anna Maria, Marzetti Emanuele, Mattana Chiara, Matteo Maria Valeria, Maviglia Riccardo, Mazzarella Ada, Memoli Carmen, Miele Luca, Migneco Alessio, Mignini Irene, Milani Alessandro, Milardi Domenico, Montalto Massimo, Montemurro Giuliano, Monti Flavia, Montini Luca, Morena Tony Christian, Morra Vincenzina, Moschese Davide, Murace Celeste Ambra, Murdolo Martina, Murri Rita, Napoli Marco, Nardella Elisabetta, Natalello Gerlando, Natalini Daniele, Navarra Simone Maria, Nesci Antonio, Nicoletti Alberto, Nicoletti Rocco, Nicoletti Tommaso Filippo, Nicolò Rebecca, Nicoletti Rocco, Nicolotti Nicola, Nista Enrico Celestino, Nuzzo Eugenia, Oggiano Marco, Ojetti Veronica, Pagano Francesco Cosimo, Paiano Gianfranco, Pais Cristina, Paolillo Federico, Pallavicini Federico, Palombo Andrea, Papa Alfredo, Papanice Domenico, Papparella Luigi Giovanni, Paratore Mattia, Parrinello Giuseppe, Pasciuto Giuliana, Pasculli Pierpaolo, Pecorini Giovanni, Perniola Simone, Pero Erika, Petricca Luca, Petrucci Martina, Picarelli Chiara, Piccioni Andrea, Piccolo Annalisa, Piervincenzi Edoardo, Pignataro Giulia, Pignataro Raffaele, Pintaudi Gabriele, Pisapia Luca, Pizzoferrato Marco, Pizzolante Fabrizio, Pola Roberto, Policola Caterina, Pompili Maurizio, Pontecorvi Flavia, Pontecorvi Valerio, Ponziani Francesca, Popolla Valentina, Porceddu Enrica, Porfidia Angelo, Porro Lucia Maria, Potenza Annalisa, Pozzana Francesca, Privitera Giuseppe, Pugliese Daniela, Pulcini Gabriele, Racco Simona, Raffaelli Francesca, Ramunno Vittoria, Rapaccini Gian Ludovico, Richeldi Luca, Rinninella Emanuele, Rocchi Sara, Romanò Bruno, Romano Stefano, Rosa Federico, Rossi Laura, Rossi Raimondo, Rossini Enrica, Rota Elisabetta, Rovedi Fabiana, Rubino Carlotta, Rumi Gabriele, Russo Andrea, Russo Andrea, Sabia Luca, Salerno Andrea, Salini Sara, Salvatore Lucia, Samori Dehara, Sandroni Claudio, Sanguinetti Maurizio, Santarelli Luca, Santini Paolo, Santolamazza Danilo, Santoliquido Angelo, Santopaolo Francesco, Santoro Michele Cosimo, Sardeo Francesco, Sarnari Caterina, Saviano Angela, Saviano Luisa, Scaldaferri Franco, Scarascia Roberta, Schepis Tommaso, Schiavello Francesca, Scoppettuolo Giancarlo, Sedda Davide, Sessa Flaminio, Sestito Luisa, Settanni Carlo, Siciliano Matteo, Siciliano Valentina, Sicuranza Rossella, Simeoni Benedetta, Simonetti Jacopo, Smargiassi Andrea, Soave Paolo Maurizio, Sonnino Chiara, Staiti Domenico, Stella Claudia, Stella Leonardo, Stival Eleonora, Taddei Eleonora, Talerico Rossella, Tamburello Elio, Tamburrini Enrica, Tanzarella Eloisa Sofia, Tarascio Elena, Tarli Claudia, Tersali Alessandra, Tilli Pietro, Timpano Jacopo, Torelli Enrico, Torrini Flavia, Tosato Matteo, Tosoni Alberto, Tricoli Luca, Tritto Marcello, Tumbarello Mario, Tummolo Anita Maria, Vallecoccia Maria Sole, Valletta Federico, Varone Francesco, Vassalli Francesco, Ventura Giulio, Verardi Lucrezia, Vetrone Lorenzo, Vetrugno Giuseppe, Visconti Elena, Visconti Felicia, Viviani Andrea, Zaccaria Raffaella, Zaccone Carmelina, Zelano Lorenzo, Zileri Dal Verme Lorenzo, Zuccalà Giuseppe.

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Correspondence to Maurizio Gabrielli.

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The ethics committee of our hospital waived written informed consent due to the retrospective nature of the study, assessing only clinical data without exposing patients to any potential risk.

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Gabrielli, M., Pignataro, G., Candelli, M. et al. Asthma in patients admitted to emergency department for COVID-19: prevalence and risk of hospitalization. Intern Emerg Med (2021). https://doi.org/10.1007/s11739-021-02868-9

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Keywords

  • Asthma
  • COVID-19
  • SARS-CoV2
  • Emergency department