Asthma control and exacerbation risk following SARS-CoV-2 infection in the post-acute COVID-19 phase: a systematic review.

BACKGROUND

The post-acute respiratory consequences of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in individuals with asthma remain incompletely understood. While early coronavirus disease 2019 (COVID-19) research focused on acute infection severity, less is known about asthma control and exacerbation risk following recovery, particularly beyond the acute phase.

OBJECTIVES

To systematically evaluate asthma control and exacerbation risk following SARS-CoV-2 infection in the post-acute COVID-19 phase among pediatric and adult populations.

METHODS

We conducted a systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines and a prospectively registered PROSPERO protocol (CRD420261290371). PubMed, Embase, CINAHL, Scopus, and Web of Science were searched from 1 January 2020 to 21 January 2026. Observational studies evaluating asthma control or exacerbation outcomes assessed ≥ 4 weeks after confirmed SARS-CoV-2 infection were included. Comparators comprised uninfected asthma controls, within-individual pre–post analyses, or population-level controls. Data were synthesised narratively due to substantial clinical and methodological heterogeneity.

RESULTS

Eleven observational studies involving children and adults with asthma met the eligibility criteria. Evidence regarding post-acute asthma control was heterogeneous. Several studies reported short-term worsening of asthma control following SARS-CoV-2 infection, particularly within the first one to three months, whereas larger longitudinal and registry-based studies generally demonstrated stability or recovery of asthma control over longer follow-up. In contrast, asthma exacerbation risk showed a more consistent pattern, with large population-based studies demonstrating approximately a two- to five-fold increase in post-acute exacerbation risk among individuals hospitalised with COVID-19 (adjusted hazard ratios ranging from 2.78 to 5.12), while risk was lower and more variable among non-hospitalised cases (hazard ratios approximately 1.8–2.1). Findings were more variable and often null among patients with mild infection. No consistent evidence of sustained deterioration in asthma control was observed across longer-term follow-up.

CONCLUSION

Post-acute asthma outcomes following SARS-CoV-2 infection are heterogeneous and appear to vary according to acute COVID-19 severity, follow-up duration, and study design. While transient worsening of asthma control may occur, particularly after more severe infection, the available evidence does not consistently demonstrate sustained deterioration in asthma control. These findings suggest that post-COVID asthma management may benefit from consideration of infection severity, while highlighting the need for high-quality longitudinal research to better define long-term outcomes.