Risk of adverse outcomes in patients with underlying respiratory conditions admitted to hospital with COVID-19 a national, multicentre prospective cohort study using the ISARIC WHO Clinical Characterisation Protocol UK

Background Studies of patients admitted to hospital with COVID-19 have found varying mortality outcomes associated with underlying respiratory conditions and inhaled corticosteroid use. Using data from a national, multicentre, prospective cohort, we aimed to characterise people with COVID-19 admitted to hospital with underlying respiratory disease, assess the level of care received, measure in-hospital mortality, and examine the effect of inhaled corticosteroid use. Methods We analysed data from the International Severe Acute Respiratory and emerging Infection Consortium (ISARIC) WHO Clinical Characterisation Protocol UK (CCP-UK) study. All patients admitted to hospital with COVID-19 across England, Scotland, and Wales between Jan 17 and Aug 3, 2020, were eligible for inclusion in this analysis. Patients with asthma, chronic pulmonary disease, or both, were identified and stratified by age (< 16 years, 16-49 years, and >= 50 years). In-hospital mortality was measured by use of multilevel Cox proportional hazards, adjusting for demographics, comorbidities, and medications (inhaled corticosteroids, short-acting I3-agonists [SABAs], and long-acting I3-agonists [LABAs]). Patients with asthma who were taking an inhaled corticosteroid plus LABA plus another maintenance asthma medication were considered to have severe asthma. Findings 75 463 patients from 258 participating health-care facilities were included in this analysis: 860 patients younger than 16 years (74 [8 center dot 6%] with asthma), 8950 patients aged 16-49 years (1867 [20 center dot 9%] with asthma), and 65 653 patients aged 50 years and older (5918 [9 center dot 0%] with asthma, 10 266 [15 center dot 6%] with chronic pulmonary disease, and 2071 [3 center dot 2%] with both asthma and chronic pulmonary disease). Patients with asthma were significantly more likely than those without asthma to receive critical care (patients aged 16-49 years: adjusted odds ratio [OR] 1 center dot 20 [95% CI 1 center dot 05-1 center dot 37]; p=0 center dot 0080; patients aged >= 50 years: adjusted OR 1 center dot 17 [1 center dot 08-1 center dot 27]; p < 0 center dot 0001), and patients aged 50 years and older with chronic pulmonary disease (with or without asthma) were significantly less likely than those without a respiratory condition to receive critical care (adjusted OR 0 center dot 66 [0 center dot 60-0 center dot 72] for those without asthma and 0 center dot 74 [0 center dot 62-0 center dot 87] for those with asthma; p < 0 center dot 0001 for both). In patients aged 16-49 years, only those with severe asthma had a significant increase in mortality compared to those with no asthma (adjusted hazard ratio [HR] 1 center dot 17 [95% CI 0 center dot 73-1 center dot 86] for those on no asthma therapy, 0 center dot 99 [0 center dot 61-1 center dot 58] for those on SABAs only, 0 center dot 94 [0 center dot 62-1 center dot 43] for those on inhaled corticosteroids only, 1 center dot 02 [0 center dot 67-1 center dot 54] for those on inhaled corticosteroids plus LABAs, and 1 center dot 96 [1 center dot 25-3 center dot 08] for those with severe asthma). Among patients aged 50 years and older, those with chronic pulmonary disease had a significantly increased mortality risk, regardless of inhaled corticosteroid use, compared to patients without an underlying respiratory condition (adjusted HR 1 center dot 16 [95% CI 1 center dot 12-1 center dot 22] for those not on inhaled corticosteroids, and 1 center dot 10 [1 center dot 04-1 center dot 16] for those on inhaled corticosteroids; p<0 center dot 0001). Patients aged 50 years and older with severe asthma also had an increased mortality risk compared to those not on asthma therapy (adjusted HR 1 center dot 24 [95% CI 1 center dot 04-1 center dot 49]). In patients aged 50 years and older, inhaled corticosteroid use within 2 weeks of hospital admission was associated with decreased mortality in those with asthma, compared to those without an underlying respiratory condition (adjusted HR 0 center dot 86 [95% CI 0 center dot 80-0 center dot 92]). Interpretation Underlying respiratory conditions are common in patients admitted to hospital with COVID-19. Regardless of the severity of symptoms at admission and comorbidities, patients with asthma were more likely, and those with chronic pulmonary disease less likely, to receive critical care than patients without an underlying respiratory condition. In patients aged 16 years and older, severe asthma was associated with increased mortality compared to non-severe asthma. In patients aged 50 years and older, inhaled corticosteroid use in those with asthma was associated with lower mortality than in patients without an underlying respiratory condition; patients with chronic pulmonary disease had significantly increased mortality compared to those with no underlying respiratory condition, regardless of inhaled corticosteroid use. Our results suggest that the use of inhaled corticosteroids, within 2 weeks of admission, improves survival for patients aged 50 years and older with asthma, but not for those with chronic pulmonary disease.

Automated summary

This study analyzed data from patients admitted to hospital with COVID-19 in England, Scotland, and Wales from January 17 to August 3, 2020. The findings showed that patients with asthma were more likely to receive critical care, while patients with chronic pulmonary disease were less likely. In older patients, inhaled corticosteroid use reduced mortality rates in asthma patients but not in those with chronic pulmonary disease.