COVID-19: information for the respiratory community
BTS worked with a range of partners to produce guidance and collate information and resources to support the respiratory community during the COVID-19 pandemic. Please note that the individual guidance documents, some of which may have been more relevant during the peaks of the pandemic, are not being reviewed or updated. This should be considered when referring to the information provided.
Last update 18/01/2022
In May 22, a DHSC independent advisory group report was published defining new patient cohorts eligible for COVID19 treatments. This is for community infection and is about access to neutralising monoclonal antibodies (nMABs) and specific anti-viral drugs available to treat COVID19 via CDMU’s.
A letter was also sent to all trusts asking teams to contact relevant at risk patients. A copy of this letter is available here.
Please be aware there is currently no recommendation that this guidance is intended to offer treatment access to patients with airways disease on steroids e.g. COPD and asthma – see more below.
Most of the access authorised is for patients with diseases and/or treatments which to some extent impair the patient’s own immune system e.g. solid organ cancers, immunodeficiency states. These patients often benefit minimally from vaccination (unable to mount an immune response) making anti-viral and nMABs an important part of their treatment and protection against serious effects of COVID19.
This document also includes a number of other diseases or diagnoses where data (ISARIC and/or QCOVID sources) has suggested poor outcomes for infected patients, e.g. Down’s Syndrome. Other conditions appear to be included due to expert opinion.
The only respiratory patients (aside from thoracic cancers) covered by this report fall under the slightly confusing heading of Immune Mediated Inflammatory Disorders (IMIDs). This group covers some types of Interstitial Lung Disease patients only, on certain types of immunosuppressant drugs.
The IMID section in Figure 1 of the report could be seen as confusing because it mentions patients on prednisolone 10mg or greater do have access to these COVID treatments. This relates only to patients with multisystem inflammatory disorders and not single organ lung disease. These patients are often on multiple drugs or have received long acting treatments like rituximab. As we understand it, evidence showing disrupted immune system function or studies demonstrating a lack of a good response to COVID vaccinations for many respiratory diseases has not yet appeared in the literature. We hope that the advice in this document will be updated as new evidence appears. BTS will be writing to the committee concerned to draw attention to the need to include respiratory conditions in any future guidance.
BTS September 2022
Important: Update on booster vaccinations for severely immunosuppressed people.
21 December 2021
BTS members may be aware that the Joint Committee on Vaccination and Immunisation (JCVI) is in the process of considering its future advice re COVID-19 BOOSTER vaccines. A ‘booster’ is currently defined as a jab given at least 6 months after the usual 2 dose COVID-19 vaccine schedule.
On 1 September the JCVI has provided new advice regarding vaccines in patients with 'severe' immunosuppression. We wish to highlight this to members as it affects respiratory patients and members may need to take action for their patients.
New terminology has been introduced with the latest advice; namely the term “third primary dose of vaccine” has been used. This is not the same as a booster vaccine. The third primary dose of vaccine can be given at least 8 weeks after the ‘usual’ primary course of 2 vaccine doses for COVID-19. The exact timing may be affected by current or planned immunosuppressive therapies (if the patient is on these).
Giving a third primary dose is a separate vaccination strategy for a specific group of people who may not generate a robust immune response following the primary course of 2 vaccine doses. For these people, a third vaccine dose is offered as part of the primary course of vaccination with the aim of topping-up their immune responses. This is distinct from the concept of a booster dose which is a vaccine dose given to people subsequent to the primary course of vaccination to extend the duration of protection provided by the vaccine. Those advised to consider a third primary dose have various forms of 'severe' immunosuppression as defined by JCVI advice.
Please see below for more information and links to updated advice. Many of you will need to take action. All medical specialties may be affected by this new advice as it covers a range of diseases.
Update: JCVI Advice on a third dose primary vaccine published on 1 September 2021
This new advice covers: Third primary doses for those aged ≥ 12 years and over with 'severe' immunosuppression. This advice affects adult and paediatric respiratory teams. The definition of 'severe' immunosuppression is as described in detail by the JCVI here.
Please see link for full details but this will affect some respiratory patients including for example:
- Interstitial lung disease patients on some types and doses of immunosuppression
- Patients with bronchiectasis with immunodeficiency
- Lung transplant recipients
- Some patients with airways disease on certain steroid regimes
What action do I need to take if I am the lead clinician for a patient with 'severe' immunosuppression as per criteria specified by JCVI?
To help identify relevant patients and optimise vaccine use specialists should take responsibility for providing clear advice to relevant patient’s general practitioner about the need for a third primary dose of vaccine and the optimal timing to deliver it.
These patients are not easy to identify in primary care as immunosuppressing drugs are often prescribed by hosital teams. Hospital specialists are being asked to assist in identifying these patients to GPs. GPs however are responsible to ensure the vaccines are offered. We suggest that the patient is copied into the GP letter so that patients are informed of their vaccine eligibility status.
You can create your own GP letters if you wish however it may be helpful to our GP colleagues if a fairly standard letter format is received.
A draft template letter that can be used to send to the GP and patient can be found here.
A Frequently Asked Questions document is available here.
13 September 2021
On 22 July 2022 JCVI announced information on the autumn 2022 booster programme noting that all adults aged 50 years or over be offered a COVID-19 booster vaccine. This is in addition to all those who are already eligible for a booster (whch includes those aged 5 years and above who are in an at-risk group).
BTS has worked with clinical colleagues to specify a definition of poorly controlled asthma which has been incorporated into the Green Book.
Poorly controlled asthma is defined as:
- ≥2 courses of oral corticosteroids in the preceding 24 months OR
- On maintenance oral corticosteroids OR
- ≥1 hospital admission for asthma in the preceding 24 months
*24 months preceding issue of the JCVI guidance (i.e. starting September 2019)
This definition used a timeframe of 24 months to reflect a period prior to shielding/ lockdown measures that started in Spring 2020.
General advice
During the winter it is important that patients are supported to keep their asthma as stable as possible, and patients should be encouraged to:
- Take up all offers of vaccination when offered (COVID, plus booster, and flu).
- Take all inhaled steroids and medications routinely as prescribed.
- Practise good respiratory hygiene.
BTS 11 August 2022
On 3 Sept 2021 the Joint Committee on Vaccination and Immunisation (JCVI) published new advice that affects children aged 12-15 years old and is for the attention of paediatric respiratory teams.
This advice covers which ‘at risk’ 12-15 year old children should be offered a primary COVID-19 vaccine schedule. This update also contains NEW information on the definition of poorly controlled asthma.
Previously, JCVI advised that children with severe neuro-disabilities, Down’s Syndrome, underlying conditions resulting in immunosuppression, profound and multiple learning disabilities (PMLD), severe learning disabilities or who are on the learning disability register, should be offered COVID-19 vaccination. The eligible disease categories for the vaccine have now been widened following analysis of emerging data.
What do I need to do as a result of this new JCVI advice?
Respiratory teams do not need to take any specific action regarding this new advice it is for information only. Primary care is being asked to identify the relevant patients and offer the vaccines. However, it is possible paediatric respiratory teams may need to field queries from GPs or patients/parents over which children may for fill the definition of these ‘at risk’ groups.
Full details can be found here: JCVI statement on COVID-19 vaccination of children aged 12 to 15 years: 3 September 2021 - GOV.UK (www.gov.uk)
Primary COVID-19 vaccination is recommended for children aged 12-15 with chronic respiratory disease which includes but is not an exclusive list: poorly controlled asthma, cystic fibrosis, ciliary dyskinesias and bronchopulmonary dysplasia.
It is recognised that there are a number of less common conditions in children, often due to congenital or metabolic defects, where respiratory infections of any sort can result in severe illness. Clinical judgement would need to be applied in identifying these children, and they should be offered a course of COVID-19 vaccination.
The British Thoracic Society, in collaboration with academic partners, have agreed a consensus view that children (≥12 years) with poorly controlled asthma are at a higher risk of an adverse outcome from COVID-19 if they become infected. Therefore they should be offered vaccination.
Poorly controlled asthma in this context is defined as:
- ≥2 courses of oral corticosteroids in the preceding 24 months OR
- On maintenance oral corticosteroids OR
- ≥1 hospital admission for asthma in the preceding 24 months
A course of COVID-19 vaccination refers to a 2-dose primary schedule unless the individual is severely immunosuppressed when a 3-dose primary schedule is advised in accordance with the latest JCVI advice on third primary vaccine doses (see the Green Book, Chapter 14a).
Current JCVI advice is that children aged 12–15 years with poorly controlled asthma should be offered a course of COVID-19 vaccination.
BTS 10 September 2021
NICE guideline for the management of COVID-19 for children, young people and adults in all care settings.
September 2021
READ MOREBTS and the Intensive Care Society have produced updated guidance on the use of CPAP, HFNO and NIV for patients with acute hypoxaemic respiratory failure associated with COVID-19
This information includes an updated respiratory support pathway. Patients with COVID-19 may be looked after on general wards, Respiratory Support Units (RSUs) or critical care units and this document offers guidance for which patients could be looked after in non-critical care settings and what criteria should be used for escalation to areas with higher acuity treatments.
19 January 2021
Advice on acute sector workforce models during COVID-19, which includes information on RSUs was published by NHSE in December 2020.
The GIRFT Clinical practice guide for improving the management of adult COVID-19 patients in secondary care was published in December 2020.
7/1/2021
BTS is updating the information for respiratory health care professionals in relation to the COVID-19 vaccination programme. Revised information will be available soon.
3 September2021
BTS has endorsed the latest GIRFT publication:
"Clinical practice guide for improving the management of adult COVID-19 patients in secondary care".
14/12/2020
BTS has produced brief guidance for Community Respiratory Services in relation to COVID-19 which is available here.
Last update 30/3/21
During the COVID-19 pandemic it is important to reduce the variation in individual ward/service/organisational practices and try as much as possible to adopt a shared, safe standard for staff looking after ward patients.
SPACES (Sharing Patient Assessments Cuts Exposure for Staff) is a standarised approach to the management of ward care. It is based on the principles of "Maximum patient contact - minimum staff exposure".
SPACES can help keep staff safe and reduce PPE use. It is for everyone working on a ward with suspected or proven COVID-19 cases, and particularly for multi-professional teams.
Last update 6/4/2020
Checked 21/04/2021 - no changes made
Updated BTS/ICS Guidance on respiratory care in patients with acute hypoxaemic respiratory failure associated with COVID-19 is available here.
14/12/20
Guidance from the British Society for Thoracic Imaging is available here. This includes:
National COVID-19 chest imaging database
11 January 2021
BTS has produced the following guidance for follow up of patients with a clinico-radiological diagnosis of COVID-19 pneumonia.
Last updated 6/5/20
Checked 16/4/21 - no changes made
BTS/ICS Guidance on the Respiratory support of patients on medical wards is available here.
Clinical guide for the management of surge during the coronavirus pandemic: rapid learning
ARTP guidance for oxygen utilisation
Last updated 4/1/2021
BTS has produced advice for healthcare professionals treating patients with COPD which is available here.
NICE Rapid Guideline: community based care of patients with COPD
Last update 14/4/2020
Updated BTS Guidance on Venous Thromboembolic Disease in patients with COVID-19 is available here.
Last updated 31/8/2021
BTS has produced advice for healthcare professionals treating patients with asthma which is available here. Please note that this information refers to the NICE Severe Asthma COVID-19 guideline.
Last update 26/11/2020
BTS guidance on the community management of patients receiving Long-Term Ventilation (LTV) during COVID-19 is available here
Updated 25 June 2020
Advice from PHE and HPS is that nebulisation is not a VIRAL droplet generating procedure. The droplets are from the machine (liquid bronchodilator drug particles), not the patient. Nebulisation is not therefore considered a 'viral' aerosol generating procedure.
Last update 23/3/20
BTS has produced information in relation to the supply of inhalers which is available here.
Last update 15/1/2021
Updated recommendations for day case bronchoscopy services during the COVID-19 pandemic have now been produced to cover services during the restoration and recovery COVID-19 endemic phase in the light of higher vaccination rates, and the need to avoid delay in diagnosis of thoracic malignancies - now available here.
Last update 22/4/2022
Updated lung cancer and mesothelioma service guidance during the COVID-19 pandemic: the restoration and recovery COVID-19 endemic phase - available here.
Differentiation of the Cs in lung cancer: Cancer vs. COVID
Guidance from the Lung Cancer CEG on the distinction between lung cancer and COVID-19
Last update 30/11/20
The NICE guideline on Interstitial Lung Disease has been published and is available here.
BTS guidance for managing patients with ILD is available here. This information will be updated regularly.
Shielding people with ILD
BTS has been working with RCP London, Action for Pulmonary Fibrosis, the BLF/AUK Partnership and SarcoidosisUK to ensure that all patients with ILD are given the appropriate advice on shielding in line with recent government information. Please find further information regarding this here.
Last update 15/4/20
Information produced by BTS as part of the OSA Alliance is available here.
Last update 16/12/2020
Latest guidance - 17 September 2020
Guidance on adapted delivery of pulmonary rehabilitation to patients surviving COVID-19
Checklist for COVID-19 recovery programme, for use during exercise, is available here
Guidance for pulmonary rehabilitation - reopening services
Checklist of safety precautions for remotely supervised interventions available here.
It is advised to stop classes to reduce the risk to patients, and to enable staff redeployment to acute community settings. Consider alternative methods of rehab such as online and web‐based resources.
This resource pack is intended to be used as a resource for professionals conducting remote assessments during the COVID-19 pandemic.
The following resource pack has been put together to support pulmonary rehabilitation whilst face to face PR is not possible.
Last update 2/6/21
NICE COVID-19 rapid guideline: managing suspected or confirmed pneumonia in adults in the community
NICE COVID-19 rapid guideline: antibiotics for pneumonia in adults in hospital
Updated 1/5/20
Critical Care Preparation and Management in the COVID-19 Pandemic is now available.
Information for those working in intensive care medicine is available here.
Airway management guidance is available here.
ICS Guidance for Prone Positioning of the conscious COVID patient 2020
BAPEN/BTS/ICS guidance on Route of Nutrition Support in Patients Requiring NIV & CPAP During the COVID-19 Response
Last update 21/5/20
BTS guidance on provision of pleural services during the COVID-19 pandemic is available here. Updated December 2021.
Please see the ARTP guidelines for COVID-19.
ARTP guidance on COVID-19 infection control issues for lung function.
Last update 26/5/20
The following sites provide information specific to Primary Care during the COVID-19 pandemic.
The Primary Care Respiratory Society COVID-19 advice
PCRS Pragmatic guidance for management of asthma and COPD
NHS England COVID-19 Primary Care advice is available here.
Further information is available from the Royal College of General Practitioners.
Last update 30/3/20
Specialty clinical guidance on palliative care is available here.
Last update January 2021
Guidance from Faculty of Occupational Medicine regarding healthcare workers with underlying health issues available here.
The FOM has now published a risk reduction framework for NHS staff at risk of COVID-19 infection.
Last update 1/6/20
With thanks to: Dr Morag Farquhar (University of East Anglia (UEA), Dr Gail Ewing and Professor Gunn Grande (University of Manchester).
Last update 24/3/20
Patients concerned about the risk of infection should be advised to take precautions as outlined by Public Health England.
We have listed information for people with respiratory disease here.