Dr Toni Hazell discusses the recommendations from NICE about managing COVID-19 symptoms in the community, including cough, fever, breathlessness, and delirium

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Dr Toni Hazell

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Read this article to learn more about:

  • the role of the NICE rapid guideline in managing symptoms of COVID-19 in the community
  • approaches and options for managing symptoms such as cough, fever, and breathlessness
  • potential long-term complications of COVID-19.

Implementation actions for STPs and ICSs

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The COVID-19 pandemic has caused rapid change in the NHS, an organisation not known for the speed at which it embraces new ways of working; a global pandemic is a very persuasive driver for speedy adaptation. In primary care, we now have video consultations, the ability to attach documents to text messages, and empty waiting rooms while we deal with most things over the phone. NICE has reacted with similar speed, turning around a guideline on managing COVID-19 symptoms within a couple of months of the start of the pandemic.1 The end of life aspects of this guidance are covered elsewhere, as are specific issues related to patients with chronic respiratory diseases, so this article will look at the management of symptoms of COVID-19 in the community.

The role of NICE Guideline 163

In the words of ex-NICE chair Professor David Haslam, NICE produces ‘guidelines and not tramlines’.2 We are expected to take guidelines fully into account, but it is not mandatory to apply any of their recommendations, and they do not replace our obligation to make a patient-centred decision that takes a person’s needs, preferences, and values into account.

It is important that we keep an open mind and continue to think laterally when patients present—not everyone will have COVID-19, even if they have symptoms that are suggestive of it. We should also be aware that some patients with COVID-19 will deteriorate quickly; thus, safety netting is important, possibly even more so than usual. When we are managing patients by phone or video call, body language is harder to pick up, and so the words used are key. For elderly patients or those with co-morbidities, a pre-emptive discussion about ceilings of care and advanced care planning is useful. If that is a subject that you are not used to introducing, consider reading up on it so that you are prepared,3,4 or discussing the subject with a colleague who has more experience in this area.

Managing symptoms of COVID-19

Cough

There will be many patients who have symptoms suggestive of COVID-19 (but may of course have rhinovirus, flu, or another upper respiratory tract infection) and are well enough to stay at home, but who still phone you for advice on managing their symptoms. They can now access a test online,5 and should follow government advice to self-isolate for 7 days from the start of symptoms, with household contacts self-isolating for 14 days.6

Any experienced GP will know that the general public often underestimates how long a cough will go on; in every ‘cough and cold’ season, it is common to get phone calls from patients who are surprised that their cough has lasted for over a week. Patients can be directed to official government advice saying that the cough may last for ‘several weeks’ and that a persistent cough doesn’t mean that they need to continue self-isolating for more than 7 days.6

First-line management is with home remedies such as honey, and only if the cough is very distressing should we consider options like codeine linctus (see Table 1). This can be prescribed, but bearing in mind NHS England guidance on the prescription of over-the-counter medicines, we should be asking most patients who need it to buy it over the counter.7 Patients with a particularly severe cough can use morphine sulfate, but it is sensible to reassess such patients to check for another cause of cough because the use of morphine for a cough is unusual outside of palliation.8

Table 1: Treatments for managing cough in adults aged 18 years and over1
TreatmentDosage

Notes: See BNF and MHRA advice for appropriate use and dosing in specific populations.

All doses are for oral administration.

© NICE 2020. COVID-19 rapid guideline: managing symptoms (including at the end of life) in the community. Available from: www.nice.org.uk/guidance/ng163 All rights reserved. Subject to Notice of rights. NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication. See www.nice.org.uk/re-using-our-content/uk-open-content-licence for further details.

Initial management: use simple non-drug measures, for example taking honey

A teaspoon of honey

First choice, only if cough is distressing: codeine linctus (15 mg/5 ml) or codeine phosphate tablets (15 mg, 30 mg)

15 mg to 30 mg every 4 hours as required, up to 4 doses in 24 hours

If necessary, increase dose to a maximum of 30 mg to 60 mg 4 times a day (maximum 240 mg in 24 hours)

Second choice, only if cough is distressing: morphine sulfate oral solution (10 mg/ 5 ml)

2.5 mg to 5 mg when required every 4 hours

Increase up to 5 mg to 10 mg every 4 hours as required

If the patient is already taking regular morphine increase the regular dose by a third

 

Special considerations

Seek specialist advice for patients under 18 years old

Consider addiction potential of codeine linctus, codeine phosphate and morphine sulfate. Issue as an ‘acute’ prescription with a limited supply. Advise the patient of the risks of constipation and consider prescribing a regular stimulant laxative

Avoid cough suppressants in chronic bronchitis and bronchiectasis because they can cause sputum retention

Fever

Patients may also phone to ask what to do about fever, particularly those who have read that ibuprofen is dangerous when used in suspected or confirmed COVID-19. This came about because of advice from the French Health Ministry in March 2020 that ibuprofen may exacerbate COVID-19.9 In response to this, and acknowledging the paucity of evidence, the Medicines and Healthcare products Regulatory Agency issued an alert advising against the use of ibuprofen in patients with COVID-19.9 It is now clear that there is no scientific evidence of increased risk of severe COVID-19 through the use of anti-inflammatories,9 and that patients can use either ibuprofen or paracetamol (see Table 2), taking into account the usual contraindications for anti-inflammatory use.10 If they are using ibuprofen or other non-steroidal inflammatory drug (NSAID) acutely, they should continue only while the symptoms of fever and other symptoms are present and take the lowest effective dose for the shortest period needed.1,10

Table 2: Antipyretics for managing fever in adults and children1
TreatmentDosage

Notes: See BNF and MHRA advice for appropriate use and dosing in specific populations.

All doses are for oral administration. Rectal paracetamol, if available, can be used as an alternative.

See the BNF and BNF for children for rectal dosing information.

Continue only while the symptoms of fever and the other symptoms are present.

© NICE 2020. COVID-19 rapid guideline: managing symptoms (including at the end of life) in the community. Available from: www.nice.org.uk/guidance/ng163 All rights reserved. Subject to Notice of rights. NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication. See www.nice.org.uk/re-using-our-content/uk-open-content-licence for further details.

Adults (18 years and over): paracetamol

0.5 g to 1 g every 4 to 6 hours, maximum 4 g per day

Adults (18 years and over): ibuprofen

400 mg three times a day when required

See BNF for dosing and for alternative non-steroidal anti-inflammatory medicines

Children and young people over 1 month and under 18 years: paracetamol or ibuprofen

See the dosing information on the pack or the

BNF for children

Breathlessness

The NICE guidance provides recommendations on how to advise patients with breathlessness, and reminds us that breathlessness can lead to anxiety, which in turn can make breathing worse—a vicious cycle.1 However, it is also important to remember that being short of breath is a red flag that should make us consider whether a patient needs a face-to-face assessment to check their oxygen saturation, or admission to hospital. The Centre for Evidence-Based Medicine advises using the same questions asked by 111 to screen for shortness of breath, as follows:11

  • Are you so breathless that you are unable to speak more than a few words?’
  • ‘Are you breathing harder or faster than usual when doing nothing at all?’
  • ‘Are you so ill that you’ve stopped doing all of your usual daily activities?’

The Roth score, a measure of how far a patient can count without taking a breath, was initially suggested as a means of testing for breathlessness over the phone, but has since been discredited in the remote assessment of patients with possible COVID-19.11 If you are reassured that the patient has been fully assessed and that their breathlessness does not indicate a need for admission or another escalation of care, NICE advises simple measures such as keeping the room cool with an open window or door, breathing techniques, and relaxation.1 A fan should not be used for a patient who is self-isolating because this has the potential to spread infection to others in the household.1 A trial of oxygen therapy may be considered if this is available;1 however, as with the suggestion to use morphine for a cough, the need for oxygen in a patient who does not already use it at home and is not undergoing palliative care may be an indicator that something more serious is going on.

Delirium

We are all familiar with the situation in which an elderly person develops confusion and delirium with an infection that may have relatively mild effects in someone younger, and COVID-19 is no exception. In this situation, it is important to be sure that there is no other underlying disease process by considering possibilities such as urinary retention, hypoxia, or constipation.1 If all of these have been ruled out and it is felt that the patient should not be admitted (either because their symptoms do not warrant it or because they have an advanced care plan that suggests that admission is not appropriate), then NICE recommends a variety of treatment options (see Table 3). These include oral or sublingual lorazepam, or injectable midazolam, haloperidol, or levomepromazine.1 Non-pharmacological measures such as good communication, ensuring familiar surroundings, good lighting, and a clear explanation to the patient are also important.1

Table 3: Treatments for managing anxiety, delirium, and agitation in patients aged 18 years and over1
TreatmentDosage
Higher doses may be needed for symptom relief in patients with COVID-19. Lower doses may be needed because of the patient’s size or frailty.
The doses are based on the BNF and the Palliative care formulary

Notes: At the time of publication (April 2020), midazolam and levomepromazine did not have a UK marketing authorisation for this indication or route of administration (see General Medical Council’s guidance on prescribing unlicensed medicines for further information).

See BNF and MHRA advice for appropriate use and dosing in specific populations.

© NICE 2020. COVID-19 rapid guideline: managing symptoms (including at the end of life) in the community. Available from: www.nice.org.uk/guidance/ng163 All rights reserved. Subject to Notice of rights. NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication. See www.nice.org.uk/re-using-our-content/uk-open-content-licence for further details.

Anxiety or agitation and able to swallow: lorazepam tablets

Lorazepam 0.5 mg to 1 mg 4 times a day as required (maximum 4 mg in 24 hours)

Reduce the dose to 0.25 mg to 0.5 mg in elderly or debilitated patients (maximum 2 mg in 24 hours)

Oral tablets can be used sublingually (off-label use)

Anxiety or agitation and unable to swallow: midazolam injection

Midazolam 2.5 mg to 5 mg subcutaneously every 2 to 4 hours as required

If needed frequently (more than twice daily), a subcutaneous infusion via a syringe driver may be considered (if available) starting with midazolam 10 mg over 24 hours

Reduce dose to 5 mg over 24 hours if estimated glomerular filtration rate is less than 30 ml per minute

Delirium and able to swallow: haloperidol orally

Haloperidol 0.5 mg to 1 mg at night and every 2 hours when required. Increase dose in 0.5-mg to 1-mg increments as required (maximum 10 mg daily, or 5 mg daily in elderly patients)

The same dose of haloperidol may be administered subcutaneously as required rather than orally, or a subcutaneous infusion of 2.5 mg to 10 mg over 24 hours

Consider a higher starting dose (1.5 mg to 3 mg) if the patient is severely distressed or causing immediate danger to others

Consider adding a benzodiazepine such as lorazepam or midazolam if the patient remains agitated (see dosages above)

Delirium and unable to swallow: levomepromazine injection

Levomepromazine 12.5 mg to 25 mg subcutaneously as a starting dose and then hourly as required (use 6.25 mg to 12.5 mg in the elderly)

Maintain with subcutaneous infusion of 50 mg to 200 mg over

24 hours, increased according to response (doses greater than 100 mg over 24 hours should be given under specialist supervision)

Consider midazolam alone or in combination with levomepromazine if the patient also has anxiety (see dosages above)

 

Special considerations

Seek specialist advice for patients under 18 years old

Long-term complications of COVID-19

NICE Guideline 163 does not cover the management of long-term complications of COVID-19; clearly, with such a new disease, there has been little opportunity to gather evidence on its long-term complications and how to manage them. However, evidence from previous viral epidemics that have caused acute respiratory distress syndrome suggests that long-term effects may include muscle weakness,12 lung fibrosis,13,14 and restricted physical capability,12,15 as well as the already recognised psychological harms of admission to intensive care.15

Evidence from other studies on non-COVID respiratory diseases raises the question of whether the COVID-19 cohort will be at increased risk of cardiovascular disease. A 2015 study of over 20,000 patients found that patients hospitalised for pneumonia were at increased risk of cardiovascular disease relative to a control group, even after controlling for risk factors.16 This risk persisted for up to 10 years in one cohort;16 therefore, we should take this possibility seriously, and ensure that attention is paid to risk factor management for patients post COVID-19.

Post-viral fatigue is also being reported, which may need a multidisciplinary approach involving specialists such as physiotherapists and occupational therapists.17 The NHS has published a comprehensive document about COVID-19 aftercare,18 which advises that some patients may need input from specialists in dietetics and speech and language therapy, and a multidisciplinary team approach that includes pulmonary rehabilitation.18 This will of course depend on such services being available and able to cope with demand.

Summary

It is clear that the challenges posed by COVID-19 are just beginning rather than coming to an end. Over the next few months, we will have to continue to triage patients with symptoms of possible COVID-19, care for those who have been diagnosed, potentially deal with a second, larger wave of cases, and manage those with long-term sequelae, as well as answering questions from patients on a wide range of topics, including employment. COVID-19 remains a marathon not a sprint, so make sure that you look after yourself and your colleagues so that we can stay fit enough to help our patients over the months to come.

Dr Toni Hazell

Part-time GP, Greater London

Implementation actions for STPs and ICSs

written by Dr David Jenner, GP, Cullompton, Devon

The following implementation actions are designed to support STPs and ICSs with the challenges involved with implementing new guidance at a system level. Our aim is to help you consider how to deliver improvements to healthcare within the available resources.

  • Disseminate this guidance to all primary and community providers
  • Consider establishing a web portal with all relevant COVID-19 guidance in one place to serve as quick reference material for both patients and clinicians
  • Signpost primary care clinicians to auto-consultation software that includes the recommended screening questions for assessing COVID-19 patients remotely
  • Encourage primary care clinicians to actively safety net after consultations, as COVID-19 patients can deteriorate rapidly after initially mild symptoms
  • Ensure both patients and clinicians are aware of how and where they can access COVID-19 testing.

STP=sustainability and transformation partnership; ICS=integrated care system

Guidelines Learningcpd logo

After reading this article, ‘Test and reflect’ on your updated knowledge with our multiple-choice questions. We estimate that this activity will take you 30 minutes—worth 0.5 CPD credits.

References

  1. NICE. COVID-19 rapid guideline: managing symptoms (including at the end of life) in the community. NICE Guideline 163. NICE, 2020. Available at: www.nice.org.uk/ng163
  2. NICE. David Haslam: getting the guidance right. www.nice.org.uk/news/feature/david-haslam-getting-the-guidance-right (accessed 30 June 2020).
  3. Mullick A, Martin J, Sallnow L. An introduction to advance care planning in practice. BMJ 2013; 347: f6064.
  4. Harding M. Advance care planning. patient.info/doctor/advance-care-planning (accessed 30 June 2020).
  5. NHS. Get a free NHS test today to check if you have coronavirus now. www.nhs.uk/conditions/coronavirus-covid-19/testing-and-tracing/ask-for-a-test-to-check-if-you-have-coronavirus/ (accessed 30 June 2020).
  6. Public Health England. Stay at home: guidance for households with possible or confirmed coronavirus (COVID-19) infection. www.gov.uk/government/publications/covid-19-stay-at-home-guidance/stay-at-home-guidance-for-households-with-possible-coronavirus-covid-19-infection (accessed 30 June 2020).
  7. NHS England. Conditions for which over the counter items should not routinely be prescribed in primary care: Guidance for CCGs. London: NHS England, 2018. Available at: www.england.nhs.uk/wp-content/uploads/2018/03/otc-guidance-for-ccgs.pdf
  8. British National Formulary. Morphine. bnf.nice.org.uk/drug/morphine.html#indicationsAndDoses (accessed 30 June 2020).
  9. NICE. COVID-19 rapid evidence summary: acute use of non-steroidal anti-inflammatory drugs (NSAIDs) for people with or at risk of COVID-19. NICE Evidence Summary 23. NICE, 2020. Available at: www.nice.org.uk/es23
  10. HM Government. Commission on Human Medicines advice on ibuprofen and coronavirus (COVID-19). www.gov.uk/government/news/commission-on-human-medicines-advice-on-ibuprofen-and-coronavirus-covid-19 (accessed 30 June 2020).
  11. Greenhalgh T. Question: should the Roth score be used in the remote assessment of patients with possible COVID-19? Answer: No. www.cebm.net/covid-19/roth-score-not-recommended-to-assess-breathlessness-over-the-phone/ (accessed 30 June 2020).
  12. Bein T, Weber-Carstens S, Apfelbacher C. Long-term outcome after the acute respiratory distress syndrome: different from general critical illness? Curr Opin Crit Care 2018; 24 (1): 35–40.
  13. Burnham E, Janssen W, Riches D et al. The fibroproliferative response in acute respiratory distress syndrome: mechanisms and clinical significance. Eur Respir J 2014; 43 (1): 276–285.
  14. Spagnolo P, Balestro E, Aliberti S et al. Pulmonary fibrosis secondary to COVID-19: a call to arms? Lancet Respir Med 2020. Epub ahead of print. Available at: doi.org/10.1016/S2213-2600(20)30222-8
  15. Niittyvuopio M, Liisanantti J, Pikkupeura J et al. Factors associated with impaired physical functioning and mental health in working-age patients attending a post-intensive care follow-up clinic three months after hospital discharge. Anaesth Intensive Care 2019; 47 (2): 160–168.
  16. Corrales-Medina V, Alvarez K, Weissfield L et al. Association between hospitalization for pneumonia and subsequent risk of cardiovascular disease. JAMA 2015; 313 (3): 264–274.
  17. Royal College of Occupational Therapists. Recovering from COVID-19: post viral-fatigue and conserving energy. www.rcot.co.uk/recovering-covid-19-post-viral-fatigue-and-conserving-energy (accessed 30 June 2020).
  18. NHS. After-care needs of inpatients recovering from COVID-19. London: NHS, 2020. www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/06/C0388-after-care-needs-of-inpatients-recovering-from-covid-19-5-june-2020-1.pdf