Introduction
Rates of COVID-19 infections and deaths have varied geographically and temporally since the beginning of the pandemic.1 Considerable research activities have been carried out to understand the immune response triggered on severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections. To some extent, identifying the drivers of severe and fatal COVID-19 have been understood. Autopsies of deceased patients with COVID-19 have revealed very little active viral infection and substantial accumulation of activated immune cells, suggesting that organ failure is unlikely to result from extensive viral-induced tissue damage but is instead caused by an overactivated immune system or vascular damage.2 Hence, multiple efforts were made to establish empirical treatments to prevent COVID-19 symptoms progression, especially among high-risk population.3 Before the advent of effective antivirals, reducing the activity of the immune system in patients with COVID-19 was one of the first lines of treatment to prevent the development of the severe form of the disease, in which corticosteroids (CS) offered a promising perspective, whereas evidence for budesonide is predominantly encouraging. Even now, this approach is mainly applied where expensive antivirals are not balanced by health and economic benefits such as in lower-risk groups or in developing countries.4
The Czech Republic and Slovakia were among the countries mostly affected by COVID-19.
Asthma is a chronic disease of the airways that is caused by inflammation of the airways, which leads to bronchial hyper-reactivity, variable bronchial obstruction and episodes of acute dyspnoea, cough, chest tightness and wheezing. Asthma therapy is based on the anti-inflammatory effect of preventive drugs controlling the airway inflammation and relieving bronchodilators which alleviate the symptoms.5–8 The most effective anti-inflammatory drugs for the treatment of asthma are currently inhaled CS (ICS), whose effectiveness has been demonstrated in a number of studies and novel monoclonal antibodies indicated for most severe patients who require phenotype-specific therapy because of frequent exacerbation and uncontrolled disease despite maximal therapy. ICS therapy alone or in combination with long-acting beta2-agonists and if needed with other anti-asthma drugs as leukotriene inhibitors are effective in controlling asthma symptoms in nearly 90% of patients with asthma.
Patients with asthma were initially considered to be at risk of developing severe COVID-19.9 Predisposition to morbidity and mortality from COVID-19 was, however, shown to be less straight-forward.10 A consideration that ICS may confer some degree of protection against SARS-CoV-2 infection and the development of severe disease is justified. Evidence suggests that ICS may be beneficial in viral infections, specifically those due to COVID-19.11 Other studies have also suggested that ICS reduced cytokines interleukin (IL)-6 and IL-8 responsible for inflammation.12 13 The routine use of ICS was suggested as an explanation to observed under-representation of chronic obstructive pulmonary disease (COPD) and asthma among patients with COVID-19.14 Recently, the inhaled budesonide was shown in a phase II clinical trial set-up to reduce the likelihood of needing urgent medical care and reduced time to recovery after early COVID-19.15
In management of asthma, all patients (older ≥12 years) should be treated with ICS-containing controller treatment to reduce risk of serious exacerbations and to control symptoms.5 The critical role of patients’ correct use of inhalation aerosol delivery devices has been well acknowledged yet recently shown to pose a persisting challenge.16–22 It was shown that a patient’s adherence to medication delivered via an inhalation device can be as low as 10%—greatly due to various inhalation systems in use and frequent need for combination therapy.18 There are three main types of inhalers: pressurised metered dose inhaler (pMDI), dry powder inhaler (DPI) and soft mist inhaler. These inhalers differ in the way they are manually operated and, in the inhalation, manoeuvre technique.16 21
Vytrisalova et al suggested a Five-Steps Assessment tool, which uses five simple steps to determine the adherence to an inhaled medication application technique (A-AppIT). This method is currently being used as an easy-to-use clinical tool for fast and effective evaluation of correctness of inhalation technique.18 We hypothesise that impaired inhalation not only affects the treatment of underlying asthma but is also associated with increased severity of COVID-19.