Consensus on the Management of the COPD Patient in the COVID-19 Setting: COPD Forum Working Group

Since the beginning of the COVID-19 SARS-CoV-2 pandemic, numerous papers have been published on strategic planning and the positioning of different medical societies in the prevention and management of chronic obstructive pulmonary disease (COPD).1–6 However, the reality is far from perfect. Although much was learned during the darkest hours of the pandemic, many aspects of the diagnosis, treatment, and follow-up of these patients remain controversial and raise concerns among health professionals.7 Therefore, in order to determine the opinion of COPD experts, we drew up a Delphi-based consensus statement8 on certain issues surrounding disease management during the COVID-19 pandemic. The scientific committee was made up of 19 COPD experts who analyzed scientific evidence in 4 areas: diagnosis, follow-up, treatment, and exacerbations of COPD during the COVID-19 pandemic. This evidence was then discussed in 15 sessions to which 8 practicing pulmonologists were invited. Using the information obtained from these meetings, a 61-item questionnaire (Table 1) was developed and sent to a panel of 106 experienced COPD pulmonologists who were asked to grade them on a Likert scale of 1–9. Statements that scored 1–3 (disagreement, median ≤ 3) or 7–9 (agreement, median ≥ 7) by more than two-thirds of the panelists were considered to have achieved consensus. Statements that were given a score of 4–6 points by more than two-thirds of the panelists were not considered to have achieved consensus. After two consecutive rounds, consensus was reached on 44 statements (72.1%): 40 in agreement (65.6%) and 4 in disagreement (6.6%). Seventeen statements (27.9%) failed to achieve consensus. Table 1 shows the scores and the degree of agreement for each statement. Of the 17 statements on diagnosis, 11 achieved consensus agreement and 2 achieved consensus disagreement. The panelists believed it was important to take necessary precautions to prevent the transmission of the virus, such as the use of PPE, FFP2 masks and face shields, even if the health personnel were vaccinated, and that particular care should be taken in cleaning and disinfecting laboratories and all equipment used. Despite the pandemic situation, the vast majority felt that spirometry was essential for diagnosis and could not be replaced by another method. However, in order to relieve the pressure of care, the panelists agreed that patients with frequent exacerbations should be prioritized, while stable patients could be monitored by recording symptoms and exacerbations. They agreed that the limitations imposed during the pandemic have led to the underdiagnosis or erroneous diagnosis of COPD, and in some cases, treatment has begun without lung function evaluations. Of the 16 statements on follow-up, 11 achieved consensus agreement and the rest did not achieve consensus. Consensus agreement was reached on the usefulness of remote consultations during the pandemic, especially in non-complex COPD patients and frail patients who either could not or would not travel to a health facility. It was also agreed that virtual consultations should include a visual element (not just telephone contact) and that blood oxygen should be measured and the COPD Assessment Test (CAT) administered, as a minimum, during these sessions. Furthermore, remote consultations should be conducted primarily by physicians. Nurses would preferably intervene in mild cases or frail patients who need more continuous follow-up. Even so, it was agreed that in spite of the pandemic, initial consultations should be in-person, as such visits achieve better quality care than remote consultations. Of the 19 statements on COPD treatment, consensus agreement was achieved on 11 and consensus disagreement on 2. It was agreed that the objectives of COPD treatment should be maintained despite the development of SARS-CoV-2 infection, and that the bronchodilator treatment used before the infection should be maintained, continued physical activity prioritized, and access to smoking cessation treatment facilitated. The panelists did not agree that inhaled corticosteroids should be contraindicated in patients with COPD and SARS-CoV-2 infection with a history of pneumonia. The panel also agreed that hospital admission for COVID-19 should be considered a serious exacerbation, that COPD patients admitted for COVID-19 should start a rehabilitation program, and that attending physicians should screen these patients for symptoms of COVID-19-related anxiety, depression, cardiovascular and other comorbidities. Although the degree of consensus was small, participants agreed that antithrombotic prophylaxis should be administered only to COPD patients with COVID-19 who required hospital admission. Finally, 7 of the 9 statements on exacerbations achieved consensus agreement. Panelists agreed that home telemonitoring of exacerbations should be initiated after a severe exacerbation, and should include modified Medical Research Council dyspnea scale results, oxygen saturation data, a physical activity diary, rescue medication use, and sputum color. No consensus was reached on the inclusion of daily peak flow results. The panel agreed that telemonitoring alerts should be managed by skilled nurses, but not that they should be managed by a physician. This Delphi study shows how panelists managed COPD patients during the COVID-19 pandemic. Although certain areas remain controversial, the high degree of agreement highlights some key messages that should be taken into account in recommendations

Since the beginning of the COVID-19 SARS-CoV-2 pandemic, numerous papers have been published on strategic planning and the positioning of different medical societies in the prevention and management of chronic obstructive pulmonary disease (COPD). [1][2][3][4][5][6] However, the reality is far from perfect. Although much was learned during the darkest hours of the pandemic, many aspects of the diagnosis, treatment, and follow-up of these patients remain controversial and raise concerns among health professionals. 7 Therefore, in order to determine the opinion of COPD experts, we drew up a Delphi-based consensus statement 8 on certain issues surrounding disease management during the COVID-19 pandemic.
The scientific committee was made up of 19 COPD experts who analyzed scientific evidence in 4 areas: diagnosis, follow-up, treatment, and exacerbations of COPD during the COVID-19 pandemic. This evidence was then discussed in 15 sessions to which 8 practicing pulmonologists were invited. Using the information obtained from these meetings, a 61-item questionnaire (Table 1) was developed and sent to a panel of 106 experienced COPD pulmonologists who were asked to grade them on a Likert scale of 1-9. Statements that scored 1-3 (disagreement, median ≤ 3) or 7-9 (agreement, median ≥ 7) by more than two-thirds of the panelists were considered to have achieved consensus. Statements that were given a score of 4-6 points by more than two-thirds of the panelists were not considered to have achieved consensus.
After two consecutive rounds, consensus was reached on 44 statements (72.1%): 40 in agreement (65.6%) and 4 in disagreement (6.6%). Seventeen statements (27.9%) failed to achieve consensus. Table 1 shows the scores and the degree of agreement for each statement.
Of the 17 statements on diagnosis, 11 achieved consensus agreement and 2 achieved consensus disagreement. The panelists believed it was important to take necessary precautions to prevent the transmission of the virus, such as the use of PPE, FFP2 masks and face shields, even if the health personnel were vaccinated, and that particular care should be taken in cleaning and disinfecting laboratories and all equipment used. Despite the pandemic situation, the vast majority felt that spirometry was essential for diagnosis and could not be replaced by another method. However, in order to relieve the pressure of care, the panelists agreed that patients with frequent exacerbations should be prioritized, while stable patients could be monitored by recording symptoms and exacerbations. They agreed that the limitations imposed during the pandemic have led to the underdiagnosis or erroneous diagnosis of COPD, and in some cases, treatment has begun without lung function evaluations.
Of the 16 statements on follow-up, 11 achieved consensus agreement and the rest did not achieve consensus. Consensus agreement was reached on the usefulness of remote consultations during the pandemic, especially in non-complex COPD patients and frail patients who either could not or would not travel to a health facility. It was also agreed that virtual consultations should include a visual element (not just telephone contact) and that blood oxygen should be measured and the COPD Assessment Test (CAT) administered, as a minimum, during these sessions. Furthermore, remote consultations should be conducted primarily by physicians. Nurses would preferably intervene in mild cases or frail patients who need more continuous follow-up. Even so, it was agreed that in spite of the pandemic, initial consultations should be in-person, as such visits achieve better quality care than remote consultations.
Of the 19 statements on COPD treatment, consensus agreement was achieved on 11 and consensus disagreement on 2. It was agreed that the objectives of COPD treatment should be maintained despite the development of SARS-CoV-2 infection, and that the bronchodilator treatment used before the infection should be maintained, continued physical activity prioritized, and access to smoking cessation treatment facilitated. The panelists did not agree that inhaled corticosteroids should be contraindicated in patients with COPD and SARS-CoV-2 infection with a history of pneumonia. The panel also agreed that hospital admission for COVID-19 should be considered a serious exacerbation, that COPD patients admitted for COVID-19 should start a rehabilitation program, and that attending physicians should screen these patients for symptoms of COVID-19-related anxiety, depression, cardiovascular and other comorbidities. Although the degree of consensus was small, participants agreed that antithrombotic prophylaxis should be administered only to COPD patients with COVID-19 who required hospital admission. Finally, 7 of the 9 statements on exacerbations achieved consensus agreement. Panelists agreed that home telemonitoring of exacerbations should be initiated after a severe exacerbation, and should include modified Medical Research Council dyspnea scale results, oxygen saturation data, a physical activity diary, rescue medication use, and sputum color. No consensus was reached on the inclusion of daily peak flow results. The panel agreed that telemonitoring alerts should be managed by skilled nurses, but not that they should be managed by a physician.
This Delphi study shows how panelists managed COPD patients during the COVID-19 pandemic. Although certain areas remain controversial, the high degree of agreement highlights some key messages that should be taken into account in recommendations

Table 1
Results obtained by the panel of experts after 2 rounds of consultations.

Diagnosis
In a pandemic situation when incidence is high, PCR is required in all patients in whom lung function tests are planned. 8 (4) 16.7 66.7 When incidence is low, the use of PPE, the completion of a quick questionnaire, and the measurement of patient temperature are sufficient for performing lung function tests.
In a pandemic situation, PPE must be used by healthcare personnel involved in lung function testing. 8 (3) 6.0 71.8 During the pandemic, the use of an FFP2 mask and face shield are sufficient safety measures for performing lung function tests. 8 (4) 20.4 68.5 In a pandemic situation, the use of PPE is unnecessary for lung function tests when health personnel are vaccinated. 1 (3) 71.3 11.1 In a pandemic situation, a telephone consultation should be conducted prior to lung function testing to detect possible SARS-CoV-2 infection. 5 (4) 44.5 39.8 In a pandemic situation, the material should be disinfected after each lung function test. 9 (1) 2.6 94.9 Since the beginning of the pandemic, cleaning protocols in lung function laboratories have had to be adapted due to the airborne transmission of SARS-CoV-2.
In a pandemic situation, spirometry is only necessary at the time of diagnosis. Limitations in the performance of lung function tests due to the pandemic have led to an underdiagnosis of COPD. 8 (2) 0.9 85.5 The pandemic situation has led to more mis-diagnoses of COPD, and treatments have been initiated without lung function evaluations.
Spirometry is necessary for the diagnosis of COPD and cannot be replaced by other methods. 9 (1) 0.9 91.5 COPD can be diagnosed in primary care using methods other than spirometry, such as clinical questionnaires or peak flow measurements.
In a pandemic situation, measuring the FEV1/FEV6 index with portable devices is an alternative to conventional spirometry. 7 (2) 13.0 57.4 In a pandemic situation, the alternative to conventional spirometry is telespirometry. 6 (2) 16.7 46.3 In patients with COPD who have had SARS-CoV-2 infection, treatment goals should be reconsidered due to infectious sequelae. 6 (5) 31.5 44.4

Follow-up
The low incidence of SARS-CoV-2 infection in COPD patients has been due to greater compliance with isolation measures. 8 (1) 0.9 88.0 The pandemic situation has increased the prevalence of smoking in the population. 6 (2) 4.6 41.7 In a pandemic situation, access to smoking cessation programs should be offered to COPD patients, as smoking is a risk factor for severe SARS-CoV-2 infection.
In a pandemic situation, short-term smoking interventions are irrelevant as a preventive measure. 2 (4) 70.1 12.0 COPD patients who have had SARS-CoV-2 infection should continue the bronchodilator treatment they were receiving prior to their infection. on the management of these patients during the pandemic, including the importance of safety and protection measures, the use of spirometry in diagnosis, the use of remote visits in addition to, not instead of, in-person visits, the continuity of therapeutic objectives despite viral infection, and the use of home telemonitoring to prevent and control exacerbations.

Funding
This study was funded by Chiesi.

Conflict of interest
MCR has received honoraria from Boehringer Ingelheim, AstraZeneca, Grifols, GlaxoSmithKline, Chiesi, Menarini and Novartis. She declares no real or perceived conflict of interest between these sources and this document.