Revista Clínica Española 223 (2023) 298---309

Revista Clínica
Española
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ORIGINAL ARTICLE

Patients with COPD hospitalized due to COVID-19 in

Spain: a comparison between the first and second wave
M. Gómez-Antúnez a,∗ , A. Muiño-Míguez a , M. Bacete-Cebrián a , M. Rubio-Rivas b ,
J.M. Lebrón Ramos c , S. de Cossío Tejido d , J.J. Peris-García e , J.F. López-Caleya f ,
J.M. Casas-Rojo g , J. Millán Núñez-Cortés a , en nombre del Grupo SEMI-COVID-19
Network1

a
Hospital General Universitario Gregorio Marañón, Madrid, Spain
b
Hospital Universitario de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain
c
Hospital Costa del Sol. Marbella, Málaga, Spain
d
Hospital Universitario 12 de Octubre, Madrid, Spain
e
Hospital Clínico Universitario San Juan, San Juan de Alicante, Alicante, Spain
f
Hospital Universitario de Cabueñes, Gijón, Asturias, Spain
g
Hospital Universitario Infanta Cristina, Parla, Madrid, Spain

Received 10 October 2022; accepted 28 February 2023

Available online 5 April 2023

KEYWORDS Abstract
COPD; Objective: This work aimed to compare the characteristics, progress, and prognosis of patients
COVID-19; with COPD hospitalized due to COVID-19 in Spain in the first wave with those of the second
SARS-CoV-2; wave.
First and second Material and methods: This is an observational study of patients hospitalized in Spain with
wave of infection; a diagnosis of COPD included in the SEMI-COVID-19 registry. The medical history, symptoms,
Prognosis analytical and radiological results, treatment, and progress of patients with COPD hospitalized
in the first wave (from March to June 2020) versus those hospitalized in the second wave (from
July to December 2020) were compared. Factors associated with poor prognosis, defined as all-
cause mortality and a composite endpoint that included mortality, high-flow oxygen therapy,
mechanical ventilation, and ICU admission, were analyzed.
Results: Of the 21,642 patients in the SEMI-COVID-19 Registry, 6.9% were diagnosed with COPD:
1128 (6.8%) in WAVE1 and 374 (7.7%) in WAVE2 (p = 0.04). WAVE2 patients presented less dry
cough, fever and dyspnea, hypoxemia (43% vs 36%, p < 0.05), and radiological condensation (46%
vs 31%, p < 0.05) than WAVE1 patients. Mortality was lower in WAVE2 (35% vs 28.6%, p = 0.01).
In the total sample, mortality and the composite outcome of poor prognosis were lower among
patients who received inhalation therapy.

∗ Corresponding author.
E-mail address: [email protected] (M. Gómez-Antúnez).
1 A full list of the SEMI-COVID-19 Network members can be found in Appendix A.
https://doi.org/10.1016/j.rceng.2023.04.002
2254-8874/© 2023 Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI). All rights reserved.
 Revista Clínica Española 223 (2023) 298---309

Conclusions: Patients with COPD admitted to the hospital due to COVID-19 in the second wave
had less respiratory failure and less radiological involvement as well as a better prognosis.
These patients should receive bronchodilator treatment if there is no contraindication for it.
© 2023 Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI). All rights
reserved.

PALABRAS CLAVE Pacientes con EPOC hospitalizados por COVID-19 en España: comparación entre la
COPD; primera y la segunda ola
COVID-19;
Resumen
SARS-CoV-2;
Objetivo: Comparar las características, evolución y pronóstico de los pacientes con EPOC hos-
Primera y segunda ola
pitalizados por COVID-19 en España en la primera ola con los de la segunda ola.
de infección;
Material y métodos: Estudio observacional de los pacientes hospitalizados en territorio español
Prognosis
con diagnóstico de EPOC incluidos en el registro SEMI-COVID-19.
Se compararon los antecedentes, la clínica, resultados analíticos y radiológicos, tratamiento
y evolución de los pacientes con EPOC hospitalizados en la primera ola (desde marzo hasta
junio 2020) frente a los hospitalizados en la segunda ola (desde julio hasta diciembre 2020). Se
analizaron los factores de mal pronóstico, definidos como mortalidad por todas las causas y un
evento combinado que incluía mortalidad, oxigenoterapia con alto flujo, ventilación mecánica
e ingreso en UCI.
Resultados: De 21,642 pacientes del Registro SEMI COVID-19, están diagnosticados de EPOC el
6,9%, 1128 (6,8%) en la OLA1 y 374 (7,7%) en la OLA2 (p = 0,04). Los pacientes de la OLA2
presentan menos tos seca, fiebre y disnea, hipoxemia (43% vs 36%, p < 0,05) y condensación
radiológica (46% vs 31%, p < 0,05) que los de la OLA1. La mortalidad es menor en la OLA2 (35%
vs 28,6%, p = 0,01). En el global de pacientes la mortalidad y la variable combinada de mal
pronóstico fue menor entre los pacientes que recibieron tratamiento inhalador.
Conclusiones: Los pacientes con EPOC con ingreso hospitalario por COVID-19 en la segunda ola
presentan menos insuficiencia respiratoria y menos afectación radiológica, con mejor pronós-
tico. Estos pacientes deben recibir tratamiento broncodilatador si no hay contraindicación para
el mismo.
© 2023 Elsevier España, S.L.U. y Sociedad Española de Medicina Interna (SEMI). Todos los
derechos reservados.

Introduction that the management and prognosis of patients with COPD

and COVID-19 would improve in the second wave.
SARS-CoV-2 infection started in China at the end of 2019 This work aims to compare the characteristics, progress,
and then spread to the rest of the world, with a progressive and prognosis of patients with COPD hospitalized due to
increase in the number of cases reported. The peak of infec- COVID-19 in the first and second waves.
tions in Europe occurred in April 2020, with a decline until
June. This is referred to as the first wave because in July
2020, another progressive increase in cases started, giving Materials and methods
rise to the second wave.1
It was expected that a significant part of patients hos- Observational study
pitalized due to COVID-19 in the first wave would have
been patients with COPD. However, it was observed that Data were collected from patients included in the SEMI-
there were fewer than expected, as different registries have COVID-19 registry, a retrospective cohort which included
shown. A total of 7.7% of patients in the SEMI-COVID-19 consecutive patients hospitalized in Spain from March 2020
registry2 had COPD compared to 5.4% in a series from the with confirmed SARS-CoV-2 infection who were discharged
New York area.3 after hospitalization or who died. The registry inclusion cri-
In the works published on the first wave, patients with teria were: a) patient age ≥18 years; b) confirmed COVID-19
COPD hospitalized due to COVID-19 had more severe disease, diagnosis; c) index hospitalization in a Spanish hospital par-
a worse prognosis, and a mortality rate of up to 40%.4---6 ticipating in the registry; d) hospital discharge or in-hospital
After the experience and large amount of scientific death. COVID-19 disease was confirmed through a positive
research generated after the first wave, it is to be expected result on a real-time polymerase chain reaction (RT-PCR)

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test of a nasopharyngeal or sputum sample or a positive possible to obtain it in writing due to biosafety issues or
result on serological tests and a clinically compatible pre- because the patient was already discharged from the hos-
sentation. The description, characteristics, and baseline pital, verbal informed consent was requested and recorded
results of the SEMI-COVID-19 registry can be consulted in on the medical record.
the work published by Casas-Rojo et al.2
Patients diagnosed with COPD were selected from the
SEMI-COVID-19 registry without needing to have a confirma- Results
tory spirometry. Patients hospitalized from March to June
2020 were considered to belong to the first wave (WAVE1) Of a total of 21,642 patients in the SEMI-COVID-19 Registry,
and those hospitalized from July to December 2020 were 1502 patients (6.9%) had been diagnosed with COPD. Of
considered to belong to the second wave (WAVE2). them, 1128 (6.8%) corresponded to WAVE1 and 374 (7.7%)
The variables selected for the analysis were demographic to WAVE2. The proportion of patients with COPD hospital-
variables; medical history; comorbidities; chronic treat- ized due to COVID-19 was significantly greater in WAVE2
ment; signs and symptoms of patients upon admission; (p < 0.05).
analytical data; radiological findings; treatment received Eighty-two percent of patients in the first wave and 88%
upon admission; radiological progress; ventilatory support: of patients in the second wave were men. Thirty-six percent
high-flow nasal cannula (HFNC) oxygen therapy, noninvasive of patients in WAVE1 and 46% of patients in WAVE2 were older
mechanical ventilation (NIMV), or invasive mechanical ven- than 80 years (Table 1).
tilation (IMV); admission to the ICU; and death. The clinical presentation of patients with COPD contin-
The medical history, symptoms, analytical and radiologi- ued to mainly be dyspnea, fever, and dry cough, but in the
cal results, treatment, and clinical progress of patients with second wave, patients presented with significantly less dry
COPD hospitalized in the first wave were compared to those cough, fever, and dyspnea (p < 0.05). Differences were found
hospitalized in the second wave. Factors associated with in hypoxemia, with 43% of patients in WAVE1 and 36% of
poor prognosis, defined as all-cause mortality and a compo- patients in WAVE2 presenting with SatO2 <92% (p < 0.05).
site variable that included mortality; need for HFNC oxygen Patients in WAVE2 presented with more kidney failure (42%
therapy, NIMV, or IMV; or ICU admission were analyzed. vs 50%, p < 0.05) and less radiological condensation (46% vs
The calculations for the descriptive analysis were per- 31%, p < 0.05) than those in WAVE1 (Table 1). Symptoms
formed using the EXCEL computer program using the differed somewhat in women, who presented with more
dynamic tables tool and the advanced data analysis fea- nonspecific symptoms such as arthromyalgia (27% vs 21%,
ture. Qualitative variables were expressed as absolute p < 0.05), headache (13% vs 5%, p < 0.05), and absence of
frequency (n) and percentage (%). Quantitative variables fever or low-grade fever (59% vs 47%, p < 0.05).
were expressed as medians, interquartile range, and range There were differences in the treatments used in both
with a 95% confidence interval. The Student’s t-test was waves. In WAVE2, lopinavir/ritonavir, hydroxychloroquine,
used. Statistical significance was defined as p < 0.05. A logis- and chloroquine were not used; 15% of patients received
tic regression analysis was performed using the R statistical remdesivir (1% in WAVE1); and 88% of patients received
program to control for confounding bias. To do so, WAVE1 treatment with systemic glucocorticoids, compared to 51%
was treated as the cause or independent variable, mortality in the first wave. Fewer antibiotics were used (82% vs 91%)
and the composite variable as the dependent variable, and and a lower rate of polypharmacy was observed in patients
respiratory failure and radiological involvement as possible in WAVE2.
confounding factors because they were found to be associ- The overall mortality rate in patients with COPD was
ated with mortality. The regression coefficients obtained on 33.4%: 35% in WAVE1 and 28.6% in WAVE2. Mortality declined
two different models were compared and when the magni- in the second wave, with the decline being greater than what
tude of the change in OR was close to or greater than 10%, occurred in the total population of patients with COVID-19
it was considered that there was confounding bias. (Fig. 1). Mortality was greater in men with COPD than in
women (35.2% vs 24.5%, p < 0.001) and declined in WAVE2,
with the decline being greater in women: 26.1% vs 17.4%.
Ethical considerations The probability of death in those older than 80 years is
significantly greater than in the rest of patients (p < 0.05).
Personal data were processed in strict compliance with Nearly all comorbidities increased mortality, but only HT
Law 14/2007, of July 3, on Biomedical Research; Regula- (WAVE1: 38.4% vs WAVE2: 29.3%, p = 0.005) and obesity
tion (EU) 2016/679 of the European Parliament and of the (40.4% vs 27.9%, p = 0.018) significantly increased mortality
Council, of 27 April 2016, on the protection of natural per- between waves.
sons with regard to the processing of personal data and on In all patients with COPD, the presence of dyspnea is an
the free movement of such data, and repealing Directive indicator of poor prognosis (49% vs 30%, p < 0.05) and mor-
95/46/EC (General Data Protection Regulation); and Organic tality (37.3% vs 23.2%, p < 0.05). On the contrary, patients
Law 3/2018, of December 5, on the Protection of Personal who had anosmia (mortality 11.5% vs 34.2%, p < 0.05), ageu-
Data and Guarantee of Digital Rights. The SEMI-COVID-19 sia (mortality 14.8% vs 34%, p < 0.05), or arthromyalgias
Registry was approved for the first time by the Provincial (mortality 27% vs 35.2%, p < 0.05) had a better prognosis.
Research Ethics Committee of Málaga (Spain), following the Patients with SatO2 < 92%, creatinine >1.2 mg/dL, or
recommendation of the Spanish Agency of Medicines and bilateral lung lesions on radiologic tests had greater mor-
Health Products (AEMPS, for its initials in Spanish). Informed tality and a worse prognosis (Table 2). No differences were
consent was requested from all patients. When it was not found between waves in levels of procalcitonin or D-dimer.

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Table 1 Characteristics of patients with COPD hospitalized due to COVID-19. Comparison between WAVE1 and WAVE2.
Total (1502) WAVE1 (1128) WAVE2 (374) p WAVE1 vs WAVE2
Men 84% 82% 88% p < 0.01
>80 years 39% 36% 46%
HT 70% 69% 72% NS
Dyslipidemia 54% 54% 54% NS
AF 23% 24% 22% NS
Obesity 28% 28% 30% NS
Dry cough 45% 48% 36% p< 0.05
Fever 50% 52% 44% p< 0.05
Dyspnea 72% 74% 66% p< 0.05
SatO2 < 92% 41% 43% 36% p< 0.05
Kidney failure 44% 42% 50% p< 0.05
Radiological condensation 43% 46% 31% p< 0.05
Prone positioning 11% 12% 6% NS
HFNC oxygen therapy 13% 12% 14% NS
NIMV 11% 11% 10% NS
IMV 6% 6% 7% NS
ICU 8% 8% 10% NS
Mortality 33.4% 35% 28.6% p< 0.05
HT: hypertension. AF: atrial fibrillation. SatO2 : pulse oxymetry oxygen saturation. Renal failure: creatinine >1.2 mg/dL. HFNC: high-flow
nasal cannula oxygen therapy. NIMV: non-invasive mechanical ventilation. IMV: invasive mechanical ventilation. ICU: intensive care unit.

Figure 1 Mortality in total admissions due to COID-19, mortality in patients with and without COPD and decline in mortality in
WAVE1 and WAVE2.

No differences in mortality were found among patients patients who did not use them. Patients treated with sys-
with chronic habitual use of inhaled corticosteroids, inhaled temic glucocorticoids had greater overall mortality (47.1%
beta-adrenergics, and inhaled anticholinergics compared to vs 32.2%, p < 0.001) and a worse prognosis on the combined

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Table 2 Indicators of a poor prognosis in patients with COPD hospitalized due to COVID-19.
Total Mortality Mortality p WAVE1 vs Poor Poor Poor p WAVE1 vs
mortality WAVE1 WAVE2 WAVE2 overall prognosis prognosis WAVE2
prognosis WAVE1 WAVE2
33% 35% 28.6% 44% 46% 38%
Confusion 52% 54% 47% p<0.05 62% 64% 57% p < 0.05
Tachypnea 46% 47% 40% p<0.05 59% 60% 53% p < 0.05
Sat02* <92% 45% 46% 43% p<0.05 59% 60% 55% p < 0.05
Creatinine 44% 46% 39% p<0.05 53% 56% 47% p < 0.05
>1.2 mg/dL
Bilateral 44% 46% 36% p<0.05 54% 57% 42% p < 0.05
condensation on
X-ray**
Bilateral interstitial 39% 40% 34% p < 0.05 52% 54% 48% p < 0.05
pattern on X-ray**
* SatO2 : pulse oxymetry oxygen saturation.
** X-ray: chest X-ray.

variable (57% vs 43%, p < 0.001) than those who did not use study. However, in this series, the proportion of patients with
them. COPD increased significantly in the second wave compared
Among all patients, those who received inhaled therapy to the first.2---4
had lower mortality (35.8% vs 27.3%, p < 0.05) and a lower Previous works have described that patients with COPD
percentage on the composite poor prognosis variable (46% vs who are hospitalized due to SARS-CoV-2 infection are pre-
39%, p < 0.05). Patients who received beta-adrenergics had dominantly men; are older adults; have high comorbidity;
lower mortality (23% vs 33%, p < 0.05). Those who received have symptoms which consist of an increase in dyspnea and
ipratropium (30% vs 44%, p < 0.05; 35% vs 44%, p < 0.05, expectoration with fever or low-grade fever; and present
respectively) had a better prognosis on the combined vari- with hypoxemia, tachypnea, and confusional syndrome upon
able (Fig. 2). admission.4
Patients who did not receive any antibiotics had a This work found that patients in the second wave con-
lower mortality rate (25% vs 33%, p < 0.05) and a bet- tinued to mainly be older men. These patients in the
ter prognosis (35% vs 44%, p < 0.05) than the mean. second wave presented with fewer symptoms, less respira-
Comparing other treatments received during hospital- tory failure, and less condensation on radiological tests. This
ization (angiotensin-converting enzyme (ACE) inhibitors, suggests that patients in WAVE2 arrived to the hospital ear-
angiotensin II receptor blockers (ARB), statins, acetylsal- lier, with less advanced disease, and in better condition than
icylic acid (ASA), low-molecular-weight heparin (LMWH)), in WAVE1. This could have been influenced by the general
there were no differences in mortality or the composite poor population’s better knowledge on the disease and its symp-
prognosis variable except for LMWH at full anticoagulation toms and consequently, patients may have consulted sooner;
doses, which was associated with a poor prognosis (55% vs an improvement in diagnostics, with an earlier diagnosis and
44%, p < 0.05). a diagnosis in milder phases; less collapse of the healthcare
On the regression analysis, WAVE1 was treated as the system; and a change in virologic pattern given that in the
main independent variable and mortality and the composite second wave, the mean viral load value was lower and the
poor prognosis variable as the dependent variable. Respi- highest levels were detected among younger patients, which
ratory failure and radiological involvement were treated as could be explained by a lower level of viral inoculation as
possible confounding factors. If respiratory failure and radi- a consequence of the use of masks, social distancing, and
ological involvement are analyzed separately, there is no restrictions on gatherings.1---9
sufficiently strong statistical evidence that these factors are As previous publications have described, age continues to
responsible for the differences in mortality and poor prog- be one of the main prognostic factors in SARS-CoV-2 infec-
nosis between waves. On the contrary, when the two factors tion in patients with COPD.
are analyzed jointly, there are differences (Table 3). Although mortality decreased in the second wave, the
mortality rate in patients with COPD is nearly double that of
Discussion the population without COPD. In addition to this, the older
age of patients with COPD than the rest of the hospitalized
population and the high comorbidity of patients with COPD,
According to other published works, the percentage of
especially cardiovascular disease, diabetes, and obesity, are
patients with COPD hospitalized due to COVID-19 is lower
clear factors of a poor prognosis in COVID-19. In this work,
than the overall prevalence of the disease in the popula-
the comorbidity of patients with COPD continues to be very
tion. In the previously reported SEMI-COVID-19 registry, the
high, with no differences between the two waves, as has
prevalence of COPD in the first wave was 7.6% and the preva-
been reported in other publications.4,10,11
lence in this study is 6.9%, a variation that may be due to the
inclusion of more cases following publication of the initial

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Figure 2 Patients with COPD admitted to the hospital due to COVID-19 in the first and second wave. Mortality and poor prognosis
according to the received inhaled treatment during hospital admission.

Table 3 Characteristics of patients with COPD hospitalized due to COVID-19. Logistic regression study.
Results for mortality

Crude OR (95% CI) Adjusted OR (95% CI) Magnitude difference

SatO2 * <92% 1.34 (1.04---1.74) 1.28 (0.99---1.86) 4.80%
Bilateral condensation on X-ray** 1.34 (1.04---1.74) 1.26 (0.98---1.64) 6.10%
SatO2 * <92% + Bilateral condensation on X-ray** 1.34 (1.04---1.74) 1.21 (0.93---1.58) 9.80%

Results for the composite poor prognosis variable

Crude OR (95% CI) Adjusted OR (95% CI) Magnitude difference

SatO2 * <92% 1.39 (1.1---1.78) 1.33 (1.04---1.7) 4.80%
Bilateral condensation on X-ray** 1.39 (1.1---1.78) 1.33 (1.04---1.69) 5.10%
SatO2 * <92% + Bilateral condensation on X-ray** 1.39 (1.1---1.78) 1.28 (0.99---1.64) 8.70%
OR: odds ratio.
* SatO : pulse oxymetry oxygen saturation.
2
** X-ray: chest X-ray.

The better prognosis in women is notable, with a greater bination of lesser respiratory failure and lesser radiologic
decline in mortality in the second wave than in men with involvement----would be behind the lower mortality rate
COPD. One of the hypotheses that could explain this differ- and better prognosis observed in WAVE2. Other works have
ence due to sex is based on the role of sex in the genetic suggested that the pattern of inflammation in the second
and hormonal regulation of immune responses and in the wave----measured through biomarkers such as LDH, ferritin,
different ACE2 activity between men and women; men with CRP, IL-6, and D-dimer----was lower. This was not able to
hypertension and heart failure tend to have a higher level be confirmed in this series, in which no differences were
of ACE2 serum activity compared to women.12,13 found in the lymphocytes or d-dimer figures between the
There was a lower mortality and better prognosis in waves.15
WAVE2. In a work comparing mortality in the two waves Contou et al. described less of a need for invasive
in Japan, mortality was also lower in the second wave, mechanical ventilation in the second wave of patients hos-
even when stratified by age and severity upon admis- pitalized in the ICU, but did not find any differences in
sion. The authors linked this to a shorter period of time mortality. Other authors have also reported greater use of
between disease onset and admission and that the patients non-invasive mechanical ventilation in the second wave. In
had milder disease upon admission.14 After the regres- this study, no differences were found between waves in the
sion analysis in this series, it was also observed that the need for high-flow oxygen therapy, non-invasive or invasive
patients’ better clinical situation----reflected in the com- mechanical ventilation, or ICU admission.16

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One of the factors that contributed to the improvement Conflicts of interest

in patients’ prognosis in the second wave is undoubtedly
the fact that Spain’s healthcare system was better prepared The authors confirm there are no conflicts of interest in the
than in the first wave; more diagnostic tests were performed conduct of this work.
and performed earlier; and there was more experience
with and scientific evidence on treatment. In the second
wave, drugs such as lopinavir/ritonavir or hydroxychloro- Acknowledgments
quine were no longer used whereas remdesivir, tocilizumab
were used; most patients (88% in this series) received sys- We would like to thank the invaluable, generous help of
temic glucocorticoids. There was less polypharmacy in the María Ángeles Bacete Silva in the creation of this work.
second wave and lesser use of antibiotics, which was also
described by Brehm, who additionally reported fewer noso- Appendix A. List of SEMI-COVID-19 Network
comial infections.17
group members
In this work, 46% of patients were in treatment with
inhaled glucocorticoids and, as in the work by Mancia, it was
Coordinator of the SEMI-COVID-19 Registry: José Manuel
not found to influence the prognosis of patients with COPD.18
Casas Rojo.
No differences were found in patients who were in chronic
SEMI-COVID-19 Scientific Committee Members: José
inhalation therapy with beta-adrenergics, tiotropium, or
Manuel Casas Rojo, José Manuel Ramos Rincón, Carlos Lum-
other long-acting anticholinergics either. The protective and
breras Bermejo, Jesús Millán Núñez-Cortés, Juan Miguel
prognostic role in COVID-19 of habitual inhalation therapy
Antón Santos, Ricardo Gómez Huelgas.
in patients with COPD is continuously under review. Indeed,
Members of the SEMI-COVID-19 Group
there are works that do suggest benefits of tiotropium as a
H. Univ. de Bellvitge. L’Hospitalet de Llobregat
protective factor against SARS-CoV-2 infection19 and others
(Barcelona)
in which inhalatory treatment with steroids and tiotropium
are a protective factor against mortality.20 Xavier Corbella, Francesc Formiga Pérez, Narcís Homs,
The improvement in the prognosis of patients who Abelardo Montero, Jose María Mora-Luján, Manuel Rubio-
received treatment with inhaled bronchodilators was Rivas
notable. In patients with exacerbated COPD, beta- H. Costa del Sol. Marbella (Málaga)
adrenergics and short-acting muscarinic antagonists are the Victoria Augustín Bandera, Javier García Alegría, Nicolás
basis of treatment. The fact that there were patients who Jiménez-García, Jairo Luque del Pino, María Dolores
did not receive bronchodilator treatment during hospital- Martín Escalante, Francisco Navarro Romero, Victoria Nuñez
ization may be due to the high rates of contagion among Rodriguez, Julián Olalla Sierra
healthcare personnel attributed to the use of nebulizers dur- H. U. 12 de Octubre. Madrid
ing the first wave. In patients with COPD hospitalized due to Paloma Agudo de Blas, Coral Arévalo Cañas, Blanca Ayuso,
COVID-19, bronchodilator treatment must be administered José Bascuñana Morejón, Samara Campos Escudero, María
unless it is contraindicated. It is recommended to avoid neb- Carnevali Frías, Santiago Cossio Tejido, Borja de Miguel
ulizations and instead provide treatment with pressurized, Campo, Carmen Díaz Pedroche, Raquel Diaz Simon, Ana Gar-
dry powder, or soft mist inhalers with or without a spacer cía Reyne, Laura Ibarra Veganzones, Lucia Jorge Huerta,
device. Antonio Lalueza Blanco, Jaime Laureiro Gonzalo, Jaime
Lora-Tamayo, Carlos Lumbreras Bermejo, Guillermo Mae-
stro de la Calle, Rodrigo Miranda Godoy, Barbara Otero
Perpiña, Diana Paredes Ruiz, Marcos Sánchez Fernández,
Conclusions Javier Tejada Montes
H. U. S. Juan de Alicante (Alicante)
Patients with COPD hospitalized due to COVID-19 are mainly Marisa Asensio Tomás, David Balaz, David Bonet Tur, Ruth
men; older adults; have high comorbidity; and present with Cañizares Navarro, Paloma Chazarra Pérez, Jesús Corbacho
dyspnea, cough, fever or low-grade fever, and respiratory Redondo, Eliana Damonte White, María Escamilla Espínola,
failure. In the second wave, patients presented with less Leticia Espinosa Del Barrio, Pedro Jesús Esteve Atiénzar,
respiratory failure and less radiological involvement. This Carles García Cervera, David Francisco García Núñez, Fran-
better clinical condition, together with lesser healthcare cisco Garrido Navarro, Vicente Giner Galvañ, Angie Gómez
overload and strain on hospitals and the updating of treat- Uranga, Javier Guzmán Martínez, Isidro Hernández Isasi,
ment protocols, may have been behind the lower mortality Lourdes Lajara Villar, Verónica Martínez Sempere, Juan
and better prognosis observed in the second wave. Manuel Núñez Cruz, Sergio Palacios Fernández, Juan Jorge
Patients with COPD hospitalized due to COVID-19 must Peris García, Rafael Piñol Pleguezuelos, Andrea Riaño Pérez,
receive bronchodilator treatment unless it is contraindi- José Miguel Seguí Ripoll, Azucena Sempere Mira, Philip
cated. Wikman-Jorgensen
H. de Cabueñes. Gijón (Asturias)
Ana María Álvarez Suárez, Carlos Delgado Vergés, Rosa
Funding Fernandez-Madera Martínez, Eva Ma Fonseca Aizpuru, Ale-
jandro Gómez Carrasco, Cristina Helguera Amezua, Juan
This research has not received specific grants from agencies Francisco López Caleya, Diego López Martínez, María del Mar
in the public, commercial, or non-profit sectors. Martínez López, Aleida Martínez Zapico, Carmen Olabuenaga

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