NICE publishes rapid guidance on managing COVID-19 in primary care

New guidance on symptom management in patients with suspected and confirmed COVID-19 in the community, along with specific advice on managing those with pneumonia, have been published by NICE. GPonline highlights the key points.

NICE advises on managing breathlessness (Photo: BSIP/UIG/Getty Images)
NICE advises on managing breathlessness (Photo: BSIP/UIG/Getty Images)

Two additional guidelines on managing patients with severe asthma and those with rheumatological disorders in the community during the coronavirus outbreak have also been published.

The guidelines are part of a series of 'rapid guidance' that NICE is developing in response to the coronavirus pandemic. The recommendations are based on evidence and expert opinion, NICE said, and will be reviewed and updated as knowledge develops during the outbreak.

Managing symptoms

In particular, NICE said the recommendations in its guidance on managing symptoms, including at the end of life, will be regularly updated.

The guideline advises GPs that older patients or those with comorbidities, frailty, impaired immunity or a reduced ability to cough and clear secretions are more likely to develop severe pneumonia.

Adults with a cough should be advised to use non-drug measures, such as a teaspoon of honey, to manage symptoms. However, if the cough is distressing, GPs could consider prescribing short-term codeine linctus or codeine phosphate tablets firstline. Morphine sulphate oral solution could be considered as a second choice.

Patients with fever should be advised to use paracetamol as opposed to an NSAID, the guidance says. It says that patients are most likely to experience fever five days after exposure to the infection.

Patients experiencing breathlessness should be advised to keep the room cool, open windows to improve air circulation and NICE also sets out a series of breathing techniques that could help patients manage their symptoms.

If oxygen is available, clinicians could consider a trial of oxygen therapy to assess if breathlessness improves.

NICE advises GPs to consider an opioid and benzodiazepine combination for patients with COVID-19 at the end of life and who have moderate to severe breathlessness and are distressed.

Usual guidance around taking into account waste, medicine shortages and lack of administration equipment are advised when GPs are prescribing and supplying anticipatory medicines at the end of life. However, the guidance says that if fewer health and care staff are available, GPs may need to prescribe subcutaneous, rectal or long-acting formulations for carers or family members to administer.

Pneumonia

The rapid guideline on managing suspected or confirmed pneumonia in adults in the community  recommends that GPs use the Medical Research Council's dyspnoea scale or the Centre for Evidence Based Medicine's review of ways of assessing dyspnoea by telephone or video in order to assess breathlessness remotely. NICE does not recommend the use of the ROTH tool.

The following signs and symptoms should be used to help make decisions about hospital admission:

  • severe shortness of breath at rest or difficulty breathing
  • coughing up blood
  • blue lips or face
  • feeling cold and clammy with pale or mottled skin
  • collapse or fainting (syncope)
  • new confusion
  • becoming difficult to rouse
  • little or no urine output.

GPs should not use the CRB65 tool, which is recommended in NICE's standard guideline on pneumonia diagnosis and management, because it requires BP measurement, which may not be possible if GPs are consulting remotely and also risks cross contamination.

Where pulse oximetry is available oxygen saturation levels below 92% (or below 88% in people with COPD) indicate seriously ill patients. NICE also says that the NEWS2 tool for predicting risk of clinical deterioration 'may be useful'. However it says face-to-face appointments should not be arranged solely for this purpose.

Antibiotics

The guidance says that as COVID-19 becomes more prevalent pneumonia is more likely to be caused by the virus than bacteria. As a result, GPs should only offer antibiotics if bacteria are the likely cause, if it is unclear whether the cause is bacterial or viral and symptoms are 'more concerning', or if the patient is at high risk of developing complications.

The guidance says COVID-19 viral pneumonia is more likely if the patient:

  • presents with a history of typical COVID-19 symptoms for about a week
  • has severe muscle pain (myalgia)
  • has loss of sense of smell (anosmia)
  • is breathless but has no pleuritic pain
  • has a history of exposure to known or suspected COVID-19, such as a household or workplace contact.

Hospital admission

NICE also says that clinicians need to assess the benefits, risks and disadvantages of hospital admission in patients who become unwell. They should also take into account 'service delivery issues and local NHS resources during the COVID-19 pandemic'. It also recommends that GPs find out about whether patients have any care plans or advance decisions to refuse treatment in place.

When considering hospital admission, patients should be told of the benefits, including access to improved diagnostic testing and respiratory support, but also the risks and disadvantages, including spreading or catching COVID-19 and loss of contact with their family.

Patients should be advised to seek further advice if their symptoms don't improve or worsen rapidly.

Patients with severe asthma

The COVID-19 rapid guideline on severe asthma says that all patients should continue to take their medication in line with their asthma action plan, including those who have confirmed or suspected COVID-19.

If a patient needs to be seen they should be screened via telephone to assess whether they have symptoms of COVID-19 ahead of the appointment. GPs should follow guidance on infection prevention and control when seeing patients.

GPs should only prescribe asthma medications to meet the patient's clinical needs and for no more than 30 days, otherwise the supply chain for medication could be put at risk, the guidance says

Pulmonary function tests should only be carried out for urgent cases and if the results will have a direct impact on how the patient is treated, the guidance says, because the tests have the potential to spread the virus.

Patients should also be advised to regularly clean all of their equipment using a detergent, such as washing up liquid, and not to share their devices with anyone else. If patients are using a nebuliser, they can continue to use this because this does not carry virus particles from the patient to anyone else.

GPs should also signpost patients to charities, such as Asthma UK and the British Lung Foundation, if they have any anxieties about COVID-19 and they should be advised to follow advice about social distancing and shielding if they fall into this group.

Rheumatological disorders

GPs should be aware that patients having immunosuppressant treatments may have atypical presentations of COVID-19, according to NICE's rapid guideline on rheumatological autoimmune, inflammatory and metabolic bone disorders.

The guidance highlights the examples of patients taking prednisolone who may not develop a fever, and those taking interleukin-6 inhibitors may not develop a rise in C-reactive protein.

NICE recommends that patients should contact their rheumatology team about any issues related to their medicines, or if their condition worsens. They should also be advised to follow advice about social distancing and shielding if they fall into this group.

NICE said future guidelines that will form part of the rapid COVID-19 recommendations were likely to cover COPD, cystic fibrosis and people receiving immunotherapy.

Links to guidance

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