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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The new coronavirus &#40;SARS-CoV-2&#41;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> is characterized by high contagiousness&#58; this has forced to implement existing strategies or to conceive new approaches toward the management of chronic diseases in order to limit the spread of the virus among healthcare workers&#44; patients and their caregivers&#46; In this context&#44; individuals affected by severe asthma have represented a challenge for the health care system during the lockdown phase of the SARS-CoV-2 pandemic&#46; First&#44; it is commonly accepted that these patients could be at greater risk for more severe disease if infected with SARS-CoV-2&#59; therefore&#44; as strongly encouraged by the Global Initiative for Asthma document that has issued frequently asked questions &#40;<a href="https://ginasthma.org/about-us/faqs/">https&#58;&#47;&#47;ginasthma&#46;org&#47;about-us&#47;faqs&#47;</a>&#41; about asthma management in the context of COVID-19&#44; all measures should be applied to limit the risk of infection&#46; Second&#44; an individual suffering from the most severe forms of asthma who experiences acute exacerbation may&#44; to some extent&#44; mimic the onset of COVID-19 disease&#46; Indeed&#44; early observations indicate that the clinical spectrum of COVID-19 disease can be very heterogeneous&#44; perhaps related to the infectious dose and the viral load of SARS-CoV-2 within the first weeks of disease onset&#59; cough and dyspnea may overlap&#44; challenging the diagnosis at least in the first phases&#44; and therefore delaying the appropriate therapeutic strategies&#46; Taken together&#44; these considerations force clinicians&#44; and mostly those who daily cope with severe asthma and severe asthmatics&#44; to adopt novel&#44; and not rarely never experienced before&#44; strategies and pathways to continue treating patients without increasing the risk of contagious&#46; Pandemics are unanticipated&#44; and the time has come to put together skills and experiences&#44; and to make the best out of the clinical activities that centers of excellence for asthma around the world have proposed&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">In our perspective&#44; the current emergency situation has accelerated the application in real life contexts of techniques of home monitoring and teleconsulting&#44; aiming to minimize the risk of exposure to positive COVID-19 patients related to in-person healthcare visits in hospital facilities&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Most of the outpatient visits have been transformed into &#8220;virtual visits&#8221; in which the patient is followed by means of electronic tools&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Telemedicine has proven to be particularly useful in the management of patients with chronic diseases such as asthma who need continuous monitoring&#46; Romano et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> showed that the use of this approach in persistent asthma is associated to reduction in symptoms and improvement in quality of life&#46; Another study comparing telemedicine with face-to-face visits showed equal disease control suggesting that telemedicine can be considered a valid alternative&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The question is whether severe asthmatics under biological treatment are also candidates for distance monitoring&#46; No doubt that this is applicable when symptoms are under control&#44; and patients can be regularly followed by phone calls of electronic diaries&#46; In other words&#44; in the context of severe asthma virtual patient encounters become efficient for delivering clinical services within a risk-stratified context&#46; On the other hand&#44; when the disease is out of control&#44; symptoms are not crystal-clear&#44; the suspect of drug-related side effects is concrete&#44; or patients want to arbitrarily stop the biologic drug&#44; face-to-face-interactions are mandatory&#46; This scenario requires deep thinking on how to design dedicated areas in outpatient clinics at the hospitals or ambulatory services for severe asthma&#44; since agreements on how to prioritize service shut down and patient care are scarce and mostly reflect regional epidemic and local decisions&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Prior to describing potential measures or promising decisions&#44; it should be clear that such measures would be for emergency purposes only&#44; such as at the present time&#44; with the hope that the contingency planning will eventually have an end&#46; Most of the suggestions below are appropriate for the greatest level of social distancing and quarantine&#44; such as that during a lockdown state&#44; but obviously may vary according to the evolving conditions&#46; In the hope of a return to normality&#44; some of the clinical decisions at social or institutional levels may even last&#44; if deemed necessary and cost-effective&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">We envision a condition in which patients already under biologic drugs are advised to continue the administration of medications&#46; There is no scientific reason why severe asthmatics should stop their medications&#46; With the aim to reduce contacts and to avoid any withdrawal of biological treatment&#44; patients supported programs &#40;PSP&#41; should be implemented and home delivery of medications activated&#46; The PSP often offers a nurse support and a training to patients and&#47;or caregivers on the subcutaneous injection technique of administration&#46; This is particularly important for older patients&#44; since it has been demonstrated that biologics are safe and commonly used in this population&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> The PSPs were born before the outbreak&#44; but this is a unique opportunity to implement them&#44; in that&#44; they are becoming a resource for the health care system&#44; preserving patients from visiting the hospital when the clinical conditions do not necessarily require it&#46; A re-organization of the public health system that involves local pharmacies able to deliver the drug&#44; community nurses qualified to administer the drug at home&#44; health-care workers appointed to specifically train and educate patients and their care-givers to self-management&#44; application of digital medicine services to follow stable patients is mandatory&#46; At this stage&#44; lung function assessment should be limited because of the potential for coughing and droplet formation&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">A situation that cannot be underestimated is the potentially tragic consequences of fake news on subjects affected by severe asthma&#46; Since stress&#44; fear and anxiety can trigger asthma attacks&#44; patients should be advised to only rely on scientific sources about COVID-19&#44; and provided with psychological support whenever needed&#46; Some centers for excellence for severe asthma have already incorporated a psychologist in their multidisciplinary team&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In the case of refusal of home administration&#44; or need for face-to-face-visits&#44; appointments at the hospital facilities should always be assured&#44; using a specific operational plan that includes a phone triage to explore the occurrence of respiratory symptoms suggestive of COVID-19 the day before the in-person visit and&#47;or contact with COVID-19 positive subjects&#46; Upon entering the facility&#44; the patient should be instructed to follow rigid protocols to mitigate risk to both medical staff and patients during the ongoing pandemic&#44; including separate waiting areas and pathways&#44; administering specific questions related to health status and measuring body temperature&#46; Proper use of medical masks is mandatory for both patients and health-care workers&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Our experience and current reports<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> support the strategy that&#44; during the COVID-19 pandemic&#44; every effort should be made in patients affected by chronic respiratory diseases at high impact like severe asthma to minimize patient contact with the health-care system&#44; planning specific pathways that allow patients to receive appropriate medical care and to continue the biological therapies administration&#44; preventing the loss of disease control and exacerbations&#46; Whether specific phenotypes of asthma will guide decisions on how to manage the disease in relation to the susceptibility to virus infection is a current object of active research&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Innovative tools&#44; such as telemedicine<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> and digital medicine services&#44; are strongly encouraged&#44; and home-delivering and self-administration of the biological drugs will necessarily become &#40;like it or not&#41; an essential part of the overall clinical management of severe asthma&#46;</p></span>"
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Editorial
Prioritizing care for severe asthma during SARS-CoV-2 pandemic
A. Benfante, N. Scichilone
Corresponding author
nicola.scichilone@unipa.it

Corresponding author.
Dipartimento Universitario di Promozione della Salute, Materno Infantile, Medicina Interna e Specialistica di Eccellenza “G. D’Alessandro” (PROMISE), Division of Respiratory Medicine, “Paolo Giaccone” University Hospital, University of Palermo, Palermo, Italy
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The new coronavirus &#40;SARS-CoV-2&#41;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> is characterized by high contagiousness&#58; this has forced to implement existing strategies or to conceive new approaches toward the management of chronic diseases in order to limit the spread of the virus among healthcare workers&#44; patients and their caregivers&#46; In this context&#44; individuals affected by severe asthma have represented a challenge for the health care system during the lockdown phase of the SARS-CoV-2 pandemic&#46; First&#44; it is commonly accepted that these patients could be at greater risk for more severe disease if infected with SARS-CoV-2&#59; therefore&#44; as strongly encouraged by the Global Initiative for Asthma document that has issued frequently asked questions &#40;<a href="https://ginasthma.org/about-us/faqs/">https&#58;&#47;&#47;ginasthma&#46;org&#47;about-us&#47;faqs&#47;</a>&#41; about asthma management in the context of COVID-19&#44; all measures should be applied to limit the risk of infection&#46; Second&#44; an individual suffering from the most severe forms of asthma who experiences acute exacerbation may&#44; to some extent&#44; mimic the onset of COVID-19 disease&#46; Indeed&#44; early observations indicate that the clinical spectrum of COVID-19 disease can be very heterogeneous&#44; perhaps related to the infectious dose and the viral load of SARS-CoV-2 within the first weeks of disease onset&#59; cough and dyspnea may overlap&#44; challenging the diagnosis at least in the first phases&#44; and therefore delaying the appropriate therapeutic strategies&#46; Taken together&#44; these considerations force clinicians&#44; and mostly those who daily cope with severe asthma and severe asthmatics&#44; to adopt novel&#44; and not rarely never experienced before&#44; strategies and pathways to continue treating patients without increasing the risk of contagious&#46; Pandemics are unanticipated&#44; and the time has come to put together skills and experiences&#44; and to make the best out of the clinical activities that centers of excellence for asthma around the world have proposed&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">In our perspective&#44; the current emergency situation has accelerated the application in real life contexts of techniques of home monitoring and teleconsulting&#44; aiming to minimize the risk of exposure to positive COVID-19 patients related to in-person healthcare visits in hospital facilities&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Most of the outpatient visits have been transformed into &#8220;virtual visits&#8221; in which the patient is followed by means of electronic tools&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Telemedicine has proven to be particularly useful in the management of patients with chronic diseases such as asthma who need continuous monitoring&#46; Romano et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> showed that the use of this approach in persistent asthma is associated to reduction in symptoms and improvement in quality of life&#46; Another study comparing telemedicine with face-to-face visits showed equal disease control suggesting that telemedicine can be considered a valid alternative&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The question is whether severe asthmatics under biological treatment are also candidates for distance monitoring&#46; No doubt that this is applicable when symptoms are under control&#44; and patients can be regularly followed by phone calls of electronic diaries&#46; In other words&#44; in the context of severe asthma virtual patient encounters become efficient for delivering clinical services within a risk-stratified context&#46; On the other hand&#44; when the disease is out of control&#44; symptoms are not crystal-clear&#44; the suspect of drug-related side effects is concrete&#44; or patients want to arbitrarily stop the biologic drug&#44; face-to-face-interactions are mandatory&#46; This scenario requires deep thinking on how to design dedicated areas in outpatient clinics at the hospitals or ambulatory services for severe asthma&#44; since agreements on how to prioritize service shut down and patient care are scarce and mostly reflect regional epidemic and local decisions&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Prior to describing potential measures or promising decisions&#44; it should be clear that such measures would be for emergency purposes only&#44; such as at the present time&#44; with the hope that the contingency planning will eventually have an end&#46; Most of the suggestions below are appropriate for the greatest level of social distancing and quarantine&#44; such as that during a lockdown state&#44; but obviously may vary according to the evolving conditions&#46; In the hope of a return to normality&#44; some of the clinical decisions at social or institutional levels may even last&#44; if deemed necessary and cost-effective&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">We envision a condition in which patients already under biologic drugs are advised to continue the administration of medications&#46; There is no scientific reason why severe asthmatics should stop their medications&#46; With the aim to reduce contacts and to avoid any withdrawal of biological treatment&#44; patients supported programs &#40;PSP&#41; should be implemented and home delivery of medications activated&#46; The PSP often offers a nurse support and a training to patients and&#47;or caregivers on the subcutaneous injection technique of administration&#46; This is particularly important for older patients&#44; since it has been demonstrated that biologics are safe and commonly used in this population&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> The PSPs were born before the outbreak&#44; but this is a unique opportunity to implement them&#44; in that&#44; they are becoming a resource for the health care system&#44; preserving patients from visiting the hospital when the clinical conditions do not necessarily require it&#46; A re-organization of the public health system that involves local pharmacies able to deliver the drug&#44; community nurses qualified to administer the drug at home&#44; health-care workers appointed to specifically train and educate patients and their care-givers to self-management&#44; application of digital medicine services to follow stable patients is mandatory&#46; At this stage&#44; lung function assessment should be limited because of the potential for coughing and droplet formation&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">A situation that cannot be underestimated is the potentially tragic consequences of fake news on subjects affected by severe asthma&#46; Since stress&#44; fear and anxiety can trigger asthma attacks&#44; patients should be advised to only rely on scientific sources about COVID-19&#44; and provided with psychological support whenever needed&#46; Some centers for excellence for severe asthma have already incorporated a psychologist in their multidisciplinary team&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In the case of refusal of home administration&#44; or need for face-to-face-visits&#44; appointments at the hospital facilities should always be assured&#44; using a specific operational plan that includes a phone triage to explore the occurrence of respiratory symptoms suggestive of COVID-19 the day before the in-person visit and&#47;or contact with COVID-19 positive subjects&#46; Upon entering the facility&#44; the patient should be instructed to follow rigid protocols to mitigate risk to both medical staff and patients during the ongoing pandemic&#44; including separate waiting areas and pathways&#44; administering specific questions related to health status and measuring body temperature&#46; Proper use of medical masks is mandatory for both patients and health-care workers&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Our experience and current reports<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> support the strategy that&#44; during the COVID-19 pandemic&#44; every effort should be made in patients affected by chronic respiratory diseases at high impact like severe asthma to minimize patient contact with the health-care system&#44; planning specific pathways that allow patients to receive appropriate medical care and to continue the biological therapies administration&#44; preventing the loss of disease control and exacerbations&#46; Whether specific phenotypes of asthma will guide decisions on how to manage the disease in relation to the susceptibility to virus infection is a current object of active research&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Innovative tools&#44; such as telemedicine<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> and digital medicine services&#44; are strongly encouraged&#44; and home-delivering and self-administration of the biological drugs will necessarily become &#40;like it or not&#41; an essential part of the overall clinical management of severe asthma&#46;</p></span>"
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Article information
ISSN: 25310437
Original language: English
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Pulmonology

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