Dr Kevin Gruffydd-Jones highlights common themes and important considerations from NICE COVID-19 rapid guidelines on severe asthma, pneumonia, and COPD

Dr Kevin Gruffydd-Jones

Dr Kevin Gruffydd-Jones

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Read this article to learn more about:

  • minimising COVID-19 risk in patient communications and consultations
  • assessing disease symptoms and severity
  • helping patients manage symptoms, medications, and wellbeing.

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NICE has produced a series of ‘rapid’ guidelines to help clinicians deal with the challenge of managing patients with medical problems in a COVID-19 era. This article focuses on three rapid guidelines, published in April 2020, on:

  • community-based care of patients with chronic obstructive pulmonary disease (COPD)1
  • severe asthma2
  • managing suspected or confirmed pneumonia in adults in the community.3

Communicating with patients and minimising risk

A common theme in the rapid guidelines is how to minimise face-to-face contact with patients to minimise the risk of COVID-19 transmission (see Box 1). In the acute situation it can be difficult to differentiate between worsening symptoms (such as cough or shortness of breath), which might be due to COVID-19 and/or due to the patient’s pre-existing condition of asthma/COPD.

Box 1: Communicating with patients and reducing risk1–­3

  • Offer telephone or video consultations whenever possible
  • Cut non-essential face-to-face appointments or follow up
  • Contact patients via text message, telephone, or email where appropriate/possible
  • Use electronic rather than paper prescriptions
  • Use different methods to deliver medicines to patients, e.g. pharmacy deliveries, postal service, NHS volunteer responders, or drive through pick-up points
  • Where face-to-face contact is considered necessary, minimise patient time in the waiting area by:
    • appropriate scheduling of appointments
    • having separate entrance and exit points, where possible
    • encouraging patients not to arrive at the surgery too early and texting or calling them when you are ready to see them, e.g. so they can wait outside the surgery in their car
  • If patients have known or suspected COVID-19 infection, follow UK government guidance on infection prevention and control4 including the use of PPE, patient transfers, decontaminating reusable equipment etc.

The British Medical Journal (BMJ) has produced an excellent guide to carrying out assessment of acute respiratory symptoms in the current situation in primary care.5 Where the likelihood of COVID-19 infection is low, the patient can be managed according to disease-specific guidelines, which can often involve self-management at home. However, diagnostic doubt may remain and patients may need to be reviewed face-to-face via local or surgery-based ‘hot clinics’ (clinics or surgery areas designated for assessing patients with suspected COVID-19).6

Another general point is to be aware of the effects of COVID-19 containment measures on mental health wellbeing and to signpost patients to charities such as the British Lung Foundation (www.blf.org.uk) and Asthma UK (www.asthma.org.uk); these two patient-centred charities have now amalgamated and offer a wealth of advice for patients with respiratory problems, including advice during the COVID-19 pandemic, action plans, and videos of inhaler technique. Guidance for the public on mental health and wellbeing during the current pandemic is available from Public Health England.7

Community-based care of patients with COPD1

In general, NICE Guideline (NG) 1681 advises remote consultation for people with COPD. Routine spirometry and oxygen assessments should be delayed and routine prescriptions given for no more than 30 days, in order to preserve supply chains. It is important to be alert for symptoms of anxiety or depression, which may have been exacerbated by fear about COVID-19 or social distancing/isolation.1

Patients at very high risk

Some patients with severe COPD are at very high risk of severe illness from COVID-19—advise them (or their families/carers) to follow UK government advice on shielding.1,8 In addition, NICE recommends that these patients should be encouraged to develop advance care plans.1

There have been different definitions from the governments of the four nations in the UK about what constitutes ‘severe COPD’.1,9–11 NICE states that severe airflow obstruction is defined as having a forced expiratory volume in 1 second (FEV1) less than 50% predicted, but severity of airflow obstruction does not necessarily correlate with severity of disease or degree of risk alone. Other factors associated with a worse prognosis include:1

  • past history of hospital admission
  • the need for long-term oxygen therapy (LTOT) or non-invasive ventilation (NIV)
  • ‘limiting breathlessness’
  • the presence of frailty and multimorbidity.

‘Limiting breathlessness’ is not defined in NG168 but would equate to a Medical Research Council (MRC) Dyspnoea Scale12 score of 3 or above.13 Also ‘the presence’ of multimorbidity is vague and would incorporate the majority of patients with COPD.

The author recommends that the following would constitute patients with COPD who are at ‘high risk’, for the purpose of a practice register:

  • past history of hospital admission for COPD
  • two or more severe exacerbations needing oral steroids/antibiotics in the last year
  • patient is on LTOT or NIV
  • presence of frailty and/or significant multimorbidity (e.g. heart failure, diabetes).

Special considerations for people with COPD during the COVID-19 pandemic

Patients with COPD are increased risk of severe illness from COVID-19. There are a number of important factors to consider because of this increased risk, outlined below.

Inhaled corticosteroid therapy

Patients should be encouraged to continue their inhaled corticosteroid (ICS) therapy. There is no evidence that treatment with ICS increases the risk associated with COVID-19 infection. The increased risk of pneumonia with high-dose ICS is outweighed by the risk of destabilising COPD control if the ICS is withdrawn.1

Self-management plan

Review the patient’s self-management plan. Patients should not be offered ‘just in case’ antibiotics or oral steroids unless they have had an exacerbation in the previous year. Provide strict instructions about when to use the medications, not to use them for symptoms of COVID-19 (dry cough, fever, myalgia, loss of taste/smell), and to inform their usual doctor/nurse when they have started the medications.1,13

Smoking cessation

Smoking cessation advice should be reinforced to reduce the risk of poor outcomes from COVID-19 infection and to reduce the risk of COPD exacerbations.1

Exercise

Patients should be encouraged to exercise. The British Thoracic Society has an excellent resource pack on home exercise and also offers advice on managing respiratory problems during the COVID-19 pandemic.1,14,15

Infection control

Home nebulisers can continue to be used. Equipment, including inhalers and spacers, should be washed regularly using washing-up liquid or according to the manufacturer’s instructions1 and left to air dry.

Patients with severe asthma2

NICE Guideline 166, NICE’sCOVID-19 rapid guideline: severe asthma,2 has been mainly written from a secondary-care perspective. In the guideline, NICE uses the European Respiratory Society and American Thoracic Society definition of ‘severe asthma’:2

  • asthma that requires treatment with high-dose inhaled corticosteroids plus a second controller (and/or systemic corticosteroids) to prevent it from becoming “uncontrolled”, or which remains “uncontrolled” despite this therapy.’

In practice this means patients on ICS budesonide 800 mcg (or equivalent) plus long-acting beta2 - agonist (LABA) or montelukast or tiotropium (or on regular oral steroids). Patients with severe asthma represent 3.8% of the asthma population16 and should be advised to follow UK government advice on shielding.2,8 Practices may want to add them to a ‘high risk’ register, with proactive review.

In addition to the general measures on remote consultation, prescribing no more than 30 days’ treatment at a time, and equipment care outlined above, the guideline2 emphasises that patients on biologic therapy and/or ICS/maintenance oral steroids should continue their treatment. There is no evidence that taking ICS increases the risk of COVID-19 infection and stopping maintenance treatment may increase the risk of an exacerbation. This advice applies also to those with COVID-19, or suspected of having it, to ensure that their asthma remains as stable as possible.

In practice, the key elements of asthma review can be carried out by remote consultation:

  • assess control using a validated symptom questionnaire such as the Royal College of Physicians’ ‘3 questions’17 or Asthma Control Test (ACT)18,19
  • adjust treatment according to the British asthma guideline:19 stepping-down treatment during the COVID-19 pandemic is not advisable because of the risk of exacerbation2
  • review inhaler technique: this can be carried out directly via video link or patients can be directed to inhaler technique videos such as those on the Asthma UK website (www.asthma.org.uk/advice/inhaler-videos/)
  • review the patient’s asthma action plan.

Managing suspected or confirmed pneumonia in adults in the community3

NICE has withdrawn its guideline on diagnosing and managing pneumonia in adults (Clinical Guideline 191)20 during the COVID-19 pandemic. The guideline has been replaced by COVID-19 rapid guidelines on managing suspected or confirmed pneumonia in adults in the community3 and antibiotics for pneumonia in adults in hospital,21 until further notice.

NICE Guideline 165 states that a diagnosis of community-acquired pneumonia should be considered if the patient has a:3

  • temperature above 38°C
  • respiratory rate >20 breaths/minute
  • heart rate >100 beats/minute
  • new-onset confusion.

Assessment

It can be very difficult to differentiate viral pneumonia (including COVID-19) from bacterial pneumonia, especially remotely. Initial remote assessment will be directed towards assessing the severity of symptoms and the need for hospital admission. The BMJ article on remote assessment for COVID-19 (mentioned earlier),5 includes a very useful algorithm summarising this assessment process, which is available from NICE.22

Viral versus bacterial pneumonia

The distinction between viral-induced (COVID-19) and bacterial pneumonia becomes important if a patient is being treated in the community and the use of antibiotics is being considered.

Table 1 shows the features which can help differentiate between COVID-19 viral pneumonia and bacterial-induced pneumonia.

Table 1: Features to help distinguish COVID-19 viral pneumonia from bacterial pneumonia3
COVID-19 viral pneumonia is more likely if the patient:Bacterial pneumonia is more likely if the patient:
  • Presents with 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 e.g. in the workplace or household
  • Becomes rapidly unwell after only a few days of symptoms
  • Does not have typical COVID-19 symptoms
  • Has pleuritic chest pain
  • Has purulent sputum

The clinician may feel that face-to-face assessment is necessary, especially where diagnostic doubt remains or additional tools of severity assessment may be needed, such as pulse oximetry. If this is the case, full COVID-19 infection control should take place, including the use of personal protective equipment (PPE). Box 2 shows NICE’s recommendations for assessing severity.

Box 2: Features of severe disease of suspected community-acquired pneumonia3

  • 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

The decision to admit to hospital will depend on these features and also:3

  • if pulse oximetry is available, oxygen saturations <92% (<88% if the patient has COPD) indicate a need for admission
  • the wishes of the patient: these may depend on advance care planning decisions, and discussion with the patient of the benefits and risks of hospital admission
  • level of social and NHS support in the community
  • the patient’s co-morbidities.

The use of CRB65 score is not recommended as it requires face-to-face assessment and has not been validated in people with COVID-19.3

Managing pneumonia in the community

NICE Guideline 165 refers to the NICE COVID-19 rapid guideline on managing symptoms (including at the end of life) in the community (NG163)23 for recommendations on the management of breathlessness in pneumonia. Recommendations about management of other symptoms of COVID-19 are shown in Table 2. 

Table 2: Managing non-end-of-life symptoms in COVID-19 infection23
SymptomAdvice

Cough

Avoid lying on back

A teaspoon of honey (or could use a honey-based linctus)

Codeine linctus if aged >18 years

Breathlessness

Minimise anxiety

Breathing exercises (e.g. pursed lips breathing)

Ensure adequate ventilation in room

Fever

Regular fluids

Use paracetamol or NSAID. If NSAID, take the lowest effective dose for the shortest period needed to control symptoms

Anxiety

Ascertain specific concerns and signpost to mental health support if required

NSAID=non-steroidal anti-inflammatory drug

Antibiotic prescribing

Antibiotics should be offered if:3

  • the likely cause is bacterial
  • it is uncertain whether the cause is bacterial or viral and symptoms are more ‘concerning’
  • the patient is at high risk of complications because of co-morbid conditions such as frailty, immunosuppression, or significant heart or lung disease.

The first-choice antibiotic is doxycycline 200 mg on day 1, then 100 mg per day for 4 days (i.e. a 5-day course in total); second-choice is amoxicillin 500 mg three times a day for 5 days. Doxycycline is preferred as it has greater activity against Mycoplasma pneumoniae and Staphylococcus aureus which are more likely to be secondary causes in the COVID-19 pandemic.3

Safety netting

If a patient with pneumonia is managed in the community, whether they are taking an antibiotic or not, the guideline recommends that they should be advised to seek help if their symptoms worsen or if they fail to improve ‘as expected’ (for example, improvement in fever after 48 hours of antibiotic treatment).3 The author recommends active review according to individual circumstances, but certainly no later than 48 hours after initiation of treatment.

Summary

Patients with chronic respiratory illnesses, such as asthma and COPD, are at increased risk of severe illness from COVID-19. Primary care clinicians play a key role in managing patients with these respiratory conditions, as well as managing suspected or confirmed pneumonia in adults in the community. The NICE COVID-19 rapid guidelines discussed in this article aim to maximise the safety of patients with respiratory illness during the COVID-19 pandemic, while protecting staff from infection.

Dr Kevin Gruffydd-Jones

GP, Box, Wiltshire

Key points

  • Minimise face-to-face consultations wherever possible using video/telephone consultation
  • Consider proactive review of patients with severe asthma and COPD
  • Remote review of patients with asthma and COPD should include:
    • assessment of symptom and exacerbation history
    • adjustment of treatment
    • review of personalised action plans
    • reinforcement of smoking cessation (where appropriate)
    • discussion of advance care plans in patients with severe COPD
  • Delay stepping down ICS therapy until the COVID-19 pandemic has been controlled
  • Initial assessment of patients with acute respiratory problems should include the severity of their symptoms and need for hospital admission
  • Only use antibiotics for patients with suspected bacterial pneumonia or where there are significant co-morbidities:
    • the first choice antibiotic is doxycycline 200 mg immediately on day 1 and 100 mg once a day for 4 days (5-day course in total)
  • Proactive safety netting review is recommended to reassess severity of symptoms.

COPD=chronic obstructive pulmonary disease; ICS=inhaled corticosteroid

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. 

  • Establish local COVID-19 response groups to help coordinate and interpret national guidance in a local context during the COVID-19 pandemic
  • Assess the local prevalence of COVID-19 and keep all healthcare providers informed of the relative local risk
  • Publish local guidelines for the assessment and management of cases, recognising that previously published algorithms are already out of date (e.g. the need now to add loss of taste and smell to triage questions)
  • Coordinate local provider services with nationally provided ones like the 111 national clinical assessment service
  • Inform all local health and social care providers of changes in guidelines and infection rates regularly
  • Encourage remote assessment, but facilitate safe face-to-face assessment where needed; and establish whether remote assessment will qualify for QOF reviews where face-to-face review is specified (COPD, asthma, rheumatoid arthritis).
STP=sustainability and transformation partnership; ICS=integrated care system; QOF=quality and outcomes framework; COPD=chronic obstructive pulmonary disease

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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: community-based care of patients with chronic obstructive pulmonary disease (COPD). NICE Guideline 168. NICE, 9 April 2020. Available at: www.nice.org.uk/ng168
  2. NICE. COVID-19 rapid guideline: severe asthma. NICE Guideline 166. NICE, 3 April 2020. Available at: www.nice.org.uk/ng166
  3. NICE. COVID-19 rapid guideline: managing suspected or confirmed pneumonia in adults in the community. NICE Guideline 165. NICE, 3 April 2020; last updated 23 April 2020. Available at: www.nice.org.uk/ng165
  4. Public Health England. COVID-19: infection prevention and control (IPC). www.gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-and-control (accessed 27 May 2020).
  5. Greenhalgh T, Koh G, Josip C. Covid-19: a remote assessment in primary care. BMJ 2020; 368: m1182. doi.org/10.1136/bmj.m1182 (25 March 2020).
  6. BBC News. Coronavirus: Berkshire GPs volunteer in ‘hot clinic’. 10 April 2020. www.bbc.co.uk/news/av/uk-england-berkshire-52229863/coronavirus-berkshire-gps-volunteer-in-hot-clinic (accessed 27 May 2020).
  7. Public Health England. COVID-19: guidance for the public on mental health and wellbeing. www.gov.uk/government/publications/covid-19-guidance-for-the-public-on-mental-health-and-wellbeing (accessed 28 May 2020).
  8. Public Health England. COVID-19: guidance on shielding and protecting people defined on medical grounds as extremely vulnerable. www.gov.uk/government/publications/guidance-on-shielding-and-protecting-extremely-vulnerable-persons-from-covid-19 (accessed 2 June 2020).
  9. Scottish Government. Coronavirus (COVID-19): shielding support and contacts. www.gov.scot/publications/covid-shielding/pages/overview/ (accessed 2 June 2020).
  10. NHS Wales information service. COVID-19 high risk shielded patient list identification methodology. nwis.nhs.wales/coronavirus/coronavirus-content/coronavirus-documents/covid-19-high-risk-shielded-patient-list-identification-methodology/ (accessed 2 June 2020).
  11. Northern Ireland Direct. Guidance on shielding for extremely vulnerable people. www.nidirect.gov.uk/articles/guidance-shielding-extremely-vulnerable-people (accessed 2 June 2020).
  12. Medical Research Council. MRC dyspnoea scale / MRC breathlessness scale. mrc.ukri.org/research/facilities-and-resources-for-researchers/mrc-scales/mrc-dyspnoea-scale-mrc-breathlessness-scale/ (accessed 27 May 2020).
  13. NICE. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. NICE Guideline 115. NICE, 2018. Available at: www.nice.org.uk/ng115
  14. British Thoracic Society. Resource pack for pulmonary rehabilitation. BTS, April 2020. Available at: www.brit-thoracic.org.uk/document-library/quality-improvement/covid-19/resource-pack-for-pulmonary-rehabilitation/
  15. British Thoracic Society website. COVID-19: information for the respiratory community. BTS, last updated 21 April 2020. brit-thoracic.org.uk/about-us/covid-19-information-for-the-respiratory-community (accessed 27 May 2020).
  16. Asthma UK website. What is severe asthma? Asthma UK, last updated March 2020. www.asthma.org.uk/advice/severe-asthma/what-is-severe-asthma/ (accessed 27 May 2020).
  17. Pearson M, Bucknall C, editors. Measuring clinical outcomes in asthma: a patient focused approach. London: Royal College of Physicians, 1999.
  18. QualityMetric Incorporated, GlaxoSmithKline. Asthma control test. Updated January 2018. Available at: www.asthmacontroltest.com (accessed 28 May 2020).
  19. British Thoracic Society, Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma. SIGN 158. BTS/SIGN, 2019. Available at: www.sign.ac.uk/sign-158-british-guideline-on-the-management-of-asthma
  20. NICE. Pneumonia in adults: diagnosis and management. Clinical guideline 191. NICE, 2014; last updated 2019. Withdrawn at the time of writing.
  21. NICE. COVID-19 rapid guideline: antibiotics for pneumonia in adults in hospital. NICE Guideline 173. NICE, 1 May 2020. Available at: www.nice.org.uk/guidance/ng173
  22. NICE. COVID-19 rapid guideline: managing symptoms (including at the end of life) in the community. Tools and resources. Summary version: BMJ visual summary for remote consultations. NICE Guideline 163. NICE, 3 April 2020; last updated 30 April 2020. Available at: www.nice.org.uk/guidance/ng163/resources/bmj-visual-summary-for-remote-consultations-pdf-8713904797
  23. NICE. COVID-19 rapid guideline: managing symptoms (including at the end of life) in the community. NICE Guideline 163. NICE, 3 April 2020; last updated 30 April 2020. Available at: www.nice.org.uk/guidance/ng163