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.
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.
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DOI：
10.1016/s2213-2600(21)00013-8
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发表时间：
2021-07
期刊：
影响因子：
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通讯作者：
ISARIC investigators
中科院分区：
文献类型：
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作者：
Bloom CI;Drake TM;Docherty AB;Lipworth BJ;Johnston SL;Nguyen-Van-Tam JS;Carson G;Dunning J;Harrison EM;Baillie JK;Semple MG;Cullinan P;Openshaw PJM;ISARIC investigators
对因COVID-19入院的患者进行的研究发现，不同的死亡率结局与基础呼吸系统疾病和吸入性皮质类固醇使用相关。使用来自全国性、多中心、前瞻性队列的数据，我们的目的是评估因潜在呼吸系统疾病住院的COVID-19患者，评估所接受的护理水平，测量住院死亡率，并检查吸入性皮质类固醇使用的影响。我们分析了国际严重急性呼吸道和新发感染联盟（ISARIC）WHO英国临床特征描述方案（CCP-UK）研究的数据。2020年1月17日至8月3日期间，英格兰、苏格兰和威尔士所有因COVID-19入院的患者都有资格入选本分析。确定哮喘、慢性肺病或两者兼有的患者，并按年龄（<16岁、16-49岁和≥50岁）分层。通过使用多水平考克斯比例风险，调整人口统计学、合并症和药物（吸入性皮质类固醇、短效β受体激动剂[SABA]和长效β受体激动剂[LABA]），测量住院死亡率。接受吸入性皮质类固醇+LABA+另一种维持哮喘药物的哮喘患者被认为患有重度哮喘。来自258家参与医疗保健机构的75463名患者纳入本分析：860例16岁以下患者（74例[8.6%]哮喘），8950例16-49岁患者（1867例[20.9%]哮喘），65653例50岁及以上患者（5918例[9.0%]哮喘，10266例[15.6%]慢性肺病，2071例[3.2%]哮喘和慢性肺病）。哮喘患者比非哮喘患者更容易接受重症监护（16-49岁患者：校正比值比[OR] 1·20 [95% CI 1·05-1·37]; p=0·0080; ≥50岁患者：校正OR 1·17 [1·08-1·27]; p<0·0001），和50岁及以上慢性肺病患者（有或无哮喘）比那些没有呼吸系统疾病的人接受重症监护的可能性要小得多。（无哮喘患者校正OR为0.66 [0.60 - 0.72]，哮喘患者校正OR为0.74 [0.62 - 0.87];两者均为p<0.0001）。在16-49岁的患者中，只有重度哮喘患者的死亡率较无哮喘患者显著增加（未接受哮喘治疗的患者的调整风险比[HR] 1·17 [95%CI 0·73-1·86]，仅接受SABA治疗的患者的调整风险比[HR] 1·17 [95%CI 0·73-1·86]，0·99 [0·61-1·58]，仅吸入皮质类固醇的患者为0·94 [0·62-1·43]，吸入皮质类固醇加LABA的患者为1·02 [0·67-1·54]，重度哮喘患者为1·96 [1·25-3·08]）。在50岁及以上的患者中，与无基础呼吸系统疾病的患者相比，无论是否使用吸入性皮质类固醇，慢性肺病患者的死亡风险均显著增加（未使用吸入性皮质类固醇的患者校正HR为1.16 [95% CI 1.12 - 1.22]，使用吸入性皮质类固醇的患者校正HR为1.10 [1.04 - 1.16]; p<0.0001）。与未接受哮喘治疗的患者相比，50岁及以上重度哮喘患者的死亡风险也增加（校正HR 1.24 [95% CI 1.04 - 1.49]）。在50岁及以上的患者中，与无基础呼吸系统疾病的患者相比，入院后2周内使用吸入性皮质类固醇与哮喘患者死亡率降低相关（校正HR 0·86 [95% CI 0·80−0·92]）。潜在的呼吸系统疾病在因COVID-19入院的患者中很常见。无论入院时症状的严重程度和合并症如何，与无基础呼吸系统疾病的患者相比，哮喘患者更有可能接受重症监护，而慢性肺病患者接受重症监护的可能性较小。在16岁及以上的患者中，与非重度哮喘相比，重度哮喘与死亡率增加相关。在50岁及以上的患者中，哮喘患者使用吸入性皮质类固醇与无基础呼吸系统疾病患者的死亡率较低相关;与无基础呼吸系统疾病患者相比，慢性肺病患者的死亡率显著增加，无论是否使用吸入性皮质类固醇。我们的研究结果表明，在入院后2周内使用吸入性糖皮质激素可提高50岁及以上哮喘患者的生存率，但对慢性肺病患者无效。国家卫生研究所、医学研究理事会、利物浦大学NIHR新发和人畜共患病感染研究单位以及伦敦帝国理工学院呼吸道感染研究单位，与英国公共卫生部合作。
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. 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 β-agonists [SABAs], and long-acting β-agonists [LABAs]). Patients with asthma who were taking an inhaled corticosteroid plus LABA plus another maintenance asthma medication were considered to have severe asthma. 75 463 patients from 258 participating health-care facilities were included in this analysis: 860 patients younger than 16 years (74 [8·6%] with asthma), 8950 patients aged 16–49 years (1867 [20·9%] with asthma), and 65 653 patients aged 50 years and older (5918 [9·0%] with asthma, 10 266 [15·6%] with chronic pulmonary disease, and 2071 [3·2%] 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] 1·20 [95% CI 1·05–1·37]; p=0·0080; patients aged ≥50 years: adjusted OR 1·17 [1·08–1·27]; p<0·0001), 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 0·66 [0·60–0·72] for those without asthma and 0·74 [0·62–0·87] for those with asthma; p<0·0001 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] 1·17 [95% CI 0·73–1·86] for those on no asthma therapy, 0·99 [0·61–1·58] for those on SABAs only, 0·94 [0·62–1·43] for those on inhaled corticosteroids only, 1·02 [0·67–1·54] for those on inhaled corticosteroids plus LABAs, and 1·96 [1·25–3·08] 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 1·16 [95% CI 1·12–1·22] for those not on inhaled corticosteroids, and 1·10 [1·04–1·16] for those on inhaled corticosteroids; p<0·0001). Patients aged 50 years and older with severe asthma also had an increased mortality risk compared to those not on asthma therapy (adjusted HR 1·24 [95% CI 1·04–1·49]). 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 0·86 [95% CI 0·80−0·92]). 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. National Institute for Health Research, Medical Research Council, NIHR Health Protection Research Units in Emerging and Zoonotic Infections at the University of Liverpool and in Respiratory Infections at Imperial College London in partnership with Public Health England.