[Translated article] Spanish Asthma Management Guidelines (GEMA) v.5.1. Highlights and Controversies.

In this fifth phase of development, the contents of the Spanish Asthma Management Guidelines (GEMA), which include versions 5.0 and 5.1, have undergone a thorough review. The aim here is to set the main changes in context. These could be summarized as follows: DIAGNOSIS: new FENO cut-off and severity classification based on treatment needed to maintain control; INTERMITTENT ASTHMA: a more restrictive concept and treatment extended to include a glucocorticoid/adrenergic combination as needed; MILD ASTHMA: glucocorticoid/adrenergic therapy as needed as an alternative in case of low therapeutic adherence to conventional fixed-dose steroids; SEVERE ASTHMA: readjustment of phenotypes, incorporation of triple therapy in a single inhaler, and criteria for selection of a biologic in severe uncontrolled asthma; OTHERS: specific scoring in childhood asthma, incorporation of certain organizational aspects (care circuits, asthma units, telemedicine), new sections on COVID-19 and nasal polyposis.

Spanish Asthma Management Guidelines (GEMA) v.5.1. Highlights and Controversies

In this fifth phase of development, the contents of the Spanish Asthma Management Guidelines (GEMA), which include versions 5.0 and 5.1, have undergone a thorough review. The aim here is to set the main changes in context. These could be summarized as follows: DIAGNOSIS: new FENO cut-off and severity classification based on treatment needed to maintain control;INTERMITTENT ASTHMA: a more restrictive concept and treatment extended to include a glucocorticoid/adrenergic combination as needed;MILD ASTHMA: glucocorticoid/adrenergic therapy as needed as an alternative in case of low therapeutic adherence to conventional fixed-dose steroids;SEVERE ASTHMA: readjustment of phenotypes, incorporation of triple therapy in a single inhaler, and criteria for selection of a biologic in severe uncontrolled asthma;OTHERS: specific scoring in childhood asthma, incorporation of certain organizational aspects (care circuits, asthma units, telemedicine), new sections on COVID-19 and nasal polyposis. Resumen La quinta fase de la Guía Española para el Manejo del Asma (GEMA) que incluye las versiones 5.0 y 5.1, ha efectuado una profunda revisión de su contenido. El presente texto tiene como objetivo contextualizar los principales cambios. Estos se podrían resumir en: DIAGNÓSTICO: nuevo punto de corte de FENO y clasificación de gravedad basada en el tratamiento necesario para mantener el control;ASMA INTERMITENTE: concepto más restrictivo y tratamiento ampliado a combinación de glucocorticoide/adrenérgico a demanda;ASMA LEVE: tratamiento con glucocorticoide/adrenérgico a demanda como alternativa si baja adhesión terapéutica a esteroide fijo clásico;ASMA GRAVE: reajuste de los fenotipos, incorporación de la triple terapia en un solo inhalador y criterios para la selección del fármaco biológico en asma grave no controlada;OTROS: puntualizaciones concretas en asma infantil, incorporación de determinados aspectos organizativos (flujos entre niveles asistenciales, unidades de asma, telemedicina), nuevas secciones de COVID-19 y de poliposis nasal.

Gustatory and olfactory dysfunctions in hospitalised patients with COVID-19 pneumonia: a prospective study.

IMPORTANCE: Identifying undetected clinical signs is imperative in the prevention of SARS-CoV-2. OBJECTIVE: To establish the prevalence of clinical gustatory and olfactory dysfunctions in patients with COVID-19 pneumonia. Clinical outcomes and recovery rates associated with gustatory and olfactory dysfunctions were also assessed. DESIGN: A prospective study was performed in 80 patients admitted to Hospital Clínic of Barcelona (Spain) for COVID-19 pneumonia. Patients were re-evaluated in the ward daily until discharge. Gustatory and olfactory dysfunction symptoms were retrospectively collected from emergency room (ER) charts after first assessments. Follow-up was performed in telemedicine consultation. SETTING: The single-centre study was performed in a hospitalisation ward at a university hospital. PARTICIPANTS: Consecutive patients meeting hospitalisation criteria for COVID-19 pneumonia were eligible. Study exclusion criteria were patients who could not speak, had previous gustatory and olfactory dysfunctions or whose PCR tests for SARS-CoV-19 were negative. INTERVENTIONS: Systematic assessment of gustatory and olfactory symptoms with standardised questions. OUTCOMES: Prevalence of gustatory and olfactory dysfunctions in patients with COVID-19 pneumonia. RESULTS: Of the 80 study subjects, 62.5% were male and the median age was 57 years. Half of the cohort (n=40) presented with comorbidities. The prevalence of chemosensitive disorder was 73.8% (n=59) (95% CI: 63.8 to 83.8), although self-reported symptoms were recorded in only 26.3% (n=21) of patients in the ER. Gustatory and olfactory dysfunctions were observed in 58.8% (n=47) and 55% (n=44) of cases, respectively. They were also the first symptoms in 25% (n=20) of patients. Anosmia was associated with ageusia, OR: 7, 95% CI: 2.3 to 21.8, p=0.001). No differences in clinical outcomes were observed when patients with and without gustatory and olfactory dysfunctions were compared. Recovery rates were 20% (n=10) and 85% (n=42) at days 7 and 45, respectively. CONCLUSION: The prevalence of gustatory and olfactory dysfunctions in COVID-19 pneumonia was much higher than in self-report. Presence of gustatory and olfactory dysfunctions was not a predictor of clinical outcomes.

Spanish Asthma Management Guidelines (GEMA) VERSION 5.1. Highlights and Controversies. / Guía española para el manejo del asma (GEMA) versión 5.1. Aspectos destacados y controversias.

In this fifth phase of development, the contents of the Spanish Asthma Management Guidelines (GEMA), which include versions 5.0 and 5.1, have undergone a thorough review. The aim here is to set the main changes in context. These could be summarized as follows: DIAGNOSIS: new FENO cut-off and severity classification based on treatment needed to maintain control; INTERMITTENT ASTHMA: a more restrictive concept and treatment extended to include a glucocorticoid/adrenergic combination as needed; MILD ASTHMA: glucocorticoid/adrenergic therapy as needed as an alternative in case of low therapeutic adherence to conventional fixed-dose steroids; SEVERE ASTHMA: readjustment of phenotypes, incorporation of triple therapy in a single inhaler, and criteria for selection of a biologic in severe uncontrolled asthma; OTHERS: specific scoring in childhood asthma, incorporation of certain organizational aspects (care circuits, asthma units, telemedicine), new sections on COVID-19 and nasal polyposis.

Self-reported Taste and Smell Disorders in Patients with COVID-19: Distinct Features in China.

Last December 2019, a cluster of viral pneumonia cases identified as coronavirus disease 2019 (COVID-19) was reported in Wuhan, China. We aimed to explore the frequencies of nasal symptoms in patients with COVID-19, including loss of smell and taste, as well as their presentation as the first symptom of the disease and their association with the severity of COVID-19. In this retrospective study, 1206 laboratory-confirmed COVID-19 patients were included and followed up by telephone one month after discharged from Tongji Hospital, Wuhan. Demographic data, laboratory values, comorbidities, symptoms, and numerical rating scale scores (0-10) of nasal symptoms were extracted from the hospital medical records, and confirmed or reevaluated by the telephone follow-up. From patients (n=1172) completing follow-up, 199 (17%) subjects had severe COVID-19 and 342 (29.2%) reported nasal symptoms. 20.6% COVID-19 patients had loss of taste (median score=6), while 11.4% had loss of smell (median score=5). Loss of taste scores, but not loss of smell scores, were significantly increased in severe vs. non-severe COVID-19 patients. Interleukin (IL)-6 and lactose dehydrogenase (LDH) serum levels were positively correlated with loss of taste scores. About 80% of COVID-19 patients recovered from smell and taste dysfunction in 2 weeks. In this cohort, only 1 out of 10 hospital admitted patients had loss of smell while 1 out of 5 reported loss of taste which was associated to severity of COVID-19. Most patients recovered smell and taste dysfunctions in 2 weeks.

Management of Allergic Diseases During COVID-19 Outbreak.

PURPOSE OF REVIEW: The coronavirus disease 2019 (COVID-19) has challenged healthcare system capacities and safety for health care workers, reshaping doctor-patient interaction favoring e-Health or telemedicine. The pandemic situation may make difficult to prioritize patients with allergies diseases (AD), face-to-face evaluation, and moreover concern about the possible COVID-19 diagnosis, since COVID-19 shared many symptoms in common with AD. Being COVID-19 a novel disease, everyone is susceptible; there are some advances on vaccine and specific treatment. We evaluate existing literature on allergic diseases (AD): allergic rhinitis, asthma, food allergy, drug allergy, and skin allergy, and potential underlying mechanisms for any interrelationship between AD and COVID-19. RECENT FINDINGS: There is inconclusive and controversial evidence of the association between AD and the risk of adverse clinical outcomes of COVID-19. AD patients should minimize hospital and face-to-face visits, and those who have used biologics and allergen immunotherapy should continue the treatment. It is essential to wear personal protective equipment for the protection of health care workers. Social distancing, rational use of facemasks, eye protection, and hand disinfection for health care workers and patients deserve further attention and promotion. Teleconsultation during COVID-19 times for AD patients is very encouraging and telemedicine platform can provide a reliable service in patient care.

Subjective evaluation of smell and taste dysfunction in patients with mild COVID-19 in Spain.

BACKGROUND: Has been described the loss of smell and taste as onset symptoms in SARS-CoV-2. The objective of this study was to investigate the prevalence in Spain. METHODS: Prospective study of COVID-19 confirmed patients through RT-PCR in Spain. Patients completed olfactory and gustatory questionnaires. RESULTS: A total of 1043 patients with mild COVID-19 disease. The mean age was 39 ±â€¯12 years. 826 patients (79.2%) described smell disorder, 662 (63.4%) as a total loss and 164 (15.7%) partial. 718 patients (68.8%) noticed some grade of taste dysfunction. There was a significant association between both disorders (p < 0.001). The olfactory dysfunction was the first symptom in 17.1%. The sQOD-NS scores were significantly lower in patients with a total loss compare to normosmic or hyposmic individuals (p = 0.001). Female were significantly more affected by olfactory and gustatory dysfunctions (p < 0.001). The early olfactory recover in 462 clinically cured patients was 315 (68.2%), during the first 4 weeks. CONCLUSION: The sudden onset smell and/or taste dysfunction should be considered highly suspicious for COVID-19 infection.

ANTECEDENTES Y OBJETIVO: En la infección por SARS-CoV-2 la pérdida repentina del olfato y/o gusto han sido descritas como síntomas iniciales. El objetivo principal de este estudio es conocer la prevalencia de estos síntomas en España. MATERIALES Y MÉTODOS: Estudio prospectivo de pacientes con COVID-19 confirmado mediante RT-PCR en España. Se utilizaron los cuestionarios traducidos y validados. RESULTADOS: Un total de 1043 pacientes COVID-19 leve. Edad media de 39 ±â€¯12 años. 826 pacientes (79,2%) refirieron algún grado de alteración del olfato, 662 (63,4%) pérdida total y 164 (15,7%) parcial. 718 pacientes (68,8%) notaron alteración del gusto. Hubo una asociación significativa entre ambos trastornos (p < 0,001). La disfunción olfatoria fue el síntoma inicial en el 17,1%. Las puntuaciones del sQOD-NS fueron significativamente menores en pacientes con una alteración total. Ambas alteraciones fueron proporcionalmente mayores en las mujeres (p < 0,001). De 462 pacientes clínicamente curados 315 (68,2%) recuperaron el olfato dentro de las primeras 4 semanas. CONCLUSIONES: La alteración repentina del olfato y el gusto debería ser reconocida como un síntoma de alarma de posible infección por COVID-19.

[Subjective evaluation of smell and taste dysfunction in patients with mild COVID-19 in Spain]. / Evaluación subjetiva de las alteraciones del olfato y del gusto en pacientes con afectación leve por COVID-19 en España.

BACKGROUND: Has been described the loss of smell and taste as onset symptoms in SARS-CoV-2. The objective of this study was to investigate the prevalence in Spain. METHODS: Prospective study of COVID-19 confirmed patients through RT-PCR in Spain. Patients completed olfactory and gustatory questionnaires. RESULTS: A total of 1043 patients with mild COVID-19 disease. The mean age was 39±12 years. 826 patients (79.2%) described smell disorder, 662 (63.4%) as a total loss and 164 (15.7%) partial. 718 patients (68.8%) noticed some grade of taste dysfunction. There was a significant association between both disorders (p<.001). The olfactory dysfunction was the first symptom in 17.1%. The sQOD-NS scores were significantly lower in patients with a total loss compare to normosmic or hyposmic individuals (p=.001). Female were significantly more affected by olfactory and gustatory dysfunctions (p<.001). The early olfactory recover in 462 clinically cured patients was 315 (68.2%), during the first 4 weeks. CONCLUSION: The sudden onset smell and/or taste dysfunction should be considered highly suspicious for COVID-19 infection.

Olfactory Dysfunction in a Mexican Population Outside of COVID-19 Pandemic: Prevalence and Associated Factors (the OLFAMEX Study).

PURPOSE OF REVIEW: To study the prevalence of olfactory loss and its associated factors in a Mexican population a cross-sectional analytical study based on a population interviewed about health, epidemiologic aspects, and sense of smell (tested with four scents: rose, banana, perfume, and gas) was conducted to evaluate olfactory detection, memory, and identification. Levels of sense of smell perception were determined when the participants detected, recognized, or identified all (normosmia), 1-3 (hyposmia), or none (anosmia) of the odorants. Associated factors of olfactory dysfunction were identified by multivariate analysis (odds ratio, 95%CI). RECENT FINDINGS: Olfactory dysfunction is a prevalent disorder affecting up to 20% of the general population. In addition to viral infection, including COVID-19, a number of other causes and factors may also be involved. 1,956 surveys were conducted and 1,921 were analyzed. Most of the participants (62.1%) were women. The general prevalence of olfactory dysfunction, regarding detection, was 7.2% (7.1% hyposmia, 0.1% anosmia). Age-related olfactory deterioration was observed in both sexes from the 5th decade of life (OR 2.74, p = 0.0050). Women showed better olfactory identification (OR 0.73, p = 0.0010). Obesity (OR 1.97, p = 0.0070), low educational level, bad/very bad self-perceived olfactory function (OR 2.74, p = 0.0050), olfactory loss for less than one week (OR 1.35, p = 0.0030), exposure to toxics/irritants (OR 1.31, p = 0.0030), active smoking (OR 1.58, p < 0.0010), and type 2 diabetes mellitus (OR 2.68, 95%CI 1.74-4.10, p < 0.0001) were identified as factors associated with olfactory dysfunction. These results in a Mexican population suggest better olfactory identification (verbalization) in females. Age was a determining factor in the olfactory deterioration process and obesity and diabetes mellitus were also associated with olfactory disorders. Finally, these findings reinforce the differential diagnosis with other potential causes of sense of smell loss, during the COVID-19 outbreak.

Translation and validation of the short version of the Questionnaire of Olfactory Disorders-Negative Statements to Spanish.

INTRODUCTION: There are more than 400 million of native Spanish speakers around the world, being the second most spoken language in regard to the number of native speakers. For this reason, a valid questionnaire to access the olfaction of our patients is necessary. MATERIAL AND METHODS: Validation and cross-cultural adaptation of the svQOD-NS questionnaire to the Spanish language. Internal consistency of svQOD-NS measured with Cronbach α. RESULTS: 40 patients met the inclusion criteria. 41 ± 153 (range 21-82), and 32 (80%) were female. 20 patients (57,1%) were male and 15 (42,9%) were female. There was a normal distribution among patients included according to the Shapiro-Wilk test (p = 0.175). Internal consistency of svQOD-NS measured with Cronbach α was 0.861. The intraclass correlation coefficient was 0.849 (confidence interval [CI] 95%: 0.766-0.911). CONCLUSION: The Spanish Language is the second most spoken language with regard to the number of native speakers and the svQOD-NS translation represents a valid option for the Spanish-speaking medical community, from which a large number of patients can benefit.

Timing, Complications, and Safety of Tracheotomy in Critically Ill Patients With COVID-19.

IMPORTANCE: The current coronavirus disease 2019 (COVID-19) pandemic has led to unprecedented needs for invasive ventilation, with 10% to 15% of intubated patients subsequently requiring tracheotomy. OBJECTIVE: To assess the complications, safety, and timing of tracheotomy performed for critically ill patients with COVID-19. DESIGN, SETTING, AND PARTICIPANTS: This prospective cohort study assessed consecutive patients admitted to the intensive care unit (ICU) who had COVID-19 that required tracheotomy. Patients were recruited from March 16 to April 10, 2020, at a tertiary referral center. EXPOSURES: A surgical tracheotomy was performed for all patients following recommended criteria for use of personal protective equipment (PPE). MAIN OUTCOMES AND MEASURES: The number of subthyroid operations, the tracheal entrance protocol, and use of PPE. Infections among the surgeons were monitored weekly by reverse-transcriptase polymerase chain reaction of nasopharyngeal swab samples. Short-term complications, weaning, and the association of timing of tracheotomy (early [≤10 days] vs late [>10 days]) with total required days of invasive ventilation were assessed. RESULTS: A total of 50 patients (mean [SD] age, 63.8 [9.2] years; 33 [66%] male) participated in the study. All tracheotomies were performed at the bedside. The median time from intubation to tracheotomy was 9 days (interquartile range, 2-24 days). A subthyroid approach was completed for 46 patients (92%), and the tracheal protocol was adequately achieved for 40 patients (80%). Adequate PPE was used, with no infection among surgeons identified 4 weeks after the last tracheotomy. Postoperative complications were rare, with minor bleeding (in 6 patients [12%]) being the most common complication. The successful weaning rate was higher in the early tracheotomy group than in the late tracheotomy group (adjusted hazard ratio, 2.55; 95% CI, 0.96-6.75), but the difference was not statistically significant. There was less time of invasive mechanical ventilatory support with early tracheotomy compared with late tracheotomy (mean [SD], 18 [5.4] vs 22.3 [5.7] days). The reduction of invasive ventilatory support was achieved at the expense of the pretracheotomy period. CONCLUSIONS AND RELEVANCE: In this cohort study, with the use of a standardized protocol aimed at minimizing COVID-19 risks, bedside open tracheotomy was a safe procedure for patients and surgeons, with minimal complications. Timing of tracheotomy may be important in reducing time of invasive mechanical ventilation, with potential implications to intensive care unit availability during the COVID-19 pandemic.

Chemosensory dysfunction in COVID-19 out-patients.

BACKGROUND: Since the outbreak in China due to coronavirus disease 2019 (COVID-19) various studies have been published describing olfactory and gustatory dysfunction (OGD). OBJECTIVE: The aim was to investigate the frequency and severity of OGD in SARS-CoV-2 (+) out-patients compared to controls with common cold/flu like symptoms and two negative RT-PCR. METHODS: A multicenter cross-sectional study on SARS-CoV-2-positive out-patients (n = 197) and controls (n = 107) from five Spanish Hospitals. Severity of OGD was categorized by visual analogue scale (VAS). Frequency and severity of the chemosensory impairment were analyzed. RESULTS: The frequencies of smell (70.1%) and taste loss (65%) were significantly higher among COVID-19 subjects than in the controls (20.6% and 19.6%, respectively). Simultaneous OGD was more frequent in the COVID-19 group (61.9% vs 10.3%) and they scored higher in VAS for severity of OGD than controls. In the COVID-19 group, OGD was predominant in young subjects 46.5 ± 14.5 and females (63.5%). Subjects with severe loss of smell were younger (42.7 years old vs 45.5 years old), and recovered later (median = 7, IQR = 5.5 vs median = 4, IQR = 3) than those with mild loss of smell. Subjects with severe loss of taste, recovered later in days (median = 7, IQR = 6 vs median = 2, IQR = 2), compared to those with mild loss. CONCLUSION: OGD is a prevalent symptom in COVID-19 subjects with significant differences compared to controls. It was predominant in young and females subjects. Stratified analysis by the severity of OGD showed that more than 60% of COVID-19 subjects presented a severe OGD who took a longer time to recover compared to those with mild symptoms.

The Loss of Smell and Taste in the COVID-19 Outbreak: a Tale of Many Countries.

PURPOSE OF REVIEW: Olfactory dysfunction in upper airway viral infections (common cold, acute rhinosinusitis) is common (> 60%). During the COVID-19 outbreak, frequency of sensory disorders (smell and/or taste) in affected patients has shown a high variability from 5 to 98%, depending on the methodology, country, and study. RECENT FINDINGS: A sudden, severe, isolated loss of smell and/or taste, in the absence of other upper airway inflammatory diseases (allergic rhinitis, chronic rhinosinusitis, nasal polyposis), should alert individuals and physicians on being potentially affected by COVID-19. The evaluation of smell/taste disorders with a visual analogue scale or an individual olfactory or gustatory test, at the hospital or by telemedicine, to prevent contamination might facilitate an early detection of infected patients and reduce the transmission of SARS-CoV-2. During the COVID-19 outbreak, patients with sudden loss of smell should initiate social distancing and home isolation measures and be tested for SARS-CoV-2 diagnostic test when available. Olfactory training is recommended when smell does not come back after 1 month but can be started earlier.

Ethyl alcohol threshold test: a fast, reliable and affordable olfactory Assessment tool for COVID-19 patients.

OBJECTIVE: COVID-19 patients may present mild symptoms. The identification of paucisymptomatic patients is paramount in order to interrupt the transmission chain of the virus. Olfactory loss could be one of those early symptoms which might help in the diagnosis of COVID-19 patients. In this study, we aim to develop and validate a fast, inexpensive, reliable and easy-to-perform olfactory test for the screening of suspected COVID-19 patients. STUDY DESIGN: Phase I was a case-control study and Phase II a transversal descriptive study. SUBJECTS AND METHODS: Olfaction was assessed with the ethyl alcohol threshold test and symptoms with visual analogue scales. The study was designed in two phases: In Phase I, we compared confirmed COVID-19 patients and healthy controls. In Phase II, patients with suspected COVID-19 infection referred for testing were studied. RESULTS: 275 participants were included in Phase I, 135 in Phase II. The ROC curve showed an AUC of 0.749 in Phase I, 0.737 in Phase II. The cutoff value which offered the highest amount of correctly classified patients was ≥ 2 (10% alcohol) for all age intervals. The odds ratio was 8.19 in Phase I, 6.56 in Phase II with a 75% sensitivity. When cases report normal sense of smell (VAS < 4), it misdiagnoses 57.89% of patients detected by the alcohol threshold test. CONCLUSION: The olfactory loss assessed with the alcohol threshold test has shown high sensitivity and odds ratio in both patients with confirmed COVID-19 illness and participants with suspected SARS-CoV-2 infection.