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Overview

  • The purpose of this guideline is to provide recommendations for managing COVID‑19 symptoms for patients in the community, including at the end of life. It also includes recommendations about managing medicines for these patients, and protecting staff from infection
  • This Guidelines summary only covers recommendations for primary care. Please see the full guideline for complete recommendations on:
    • end-of-life treatments for managing breathlessness for patients aged 18 years and over
    • treatments for managing anxiety, delirium and agitation in patients aged 18 years and over
    • prescribing anticipatory medicines for patients with COVID-19
    • infection prevention and control measures for healthcare workers

View this summary online at guidelines.co.uk/455280.article

Communicating with patients and minimising risk

  • For patients with COVID‑19 symptoms explain:
    • that the key symptoms are cough, fever, breathlessness, anxiety, delirium and agitation but they may also have fatigue, muscle aches and headache
    • that they and people caring for them should follow the UK guidance on self-isolation and the UK guidance on protecting vulnerable people
    • that if the symptoms are mild they are likely to feel much better in a week
    • who to contact if their symptoms get worse, for example NHS 111 online
  • Communicate with patients and support their mental wellbeing, signposting to charities and support groups where available, to help alleviate any anxiety and fear they may have about COVID‑19
  • Minimise face-to-face contact by:

Treatment and care planning

  • When possible, discuss the risks, benefits and possible likely outcomes of the treatment options with patients with COVID‑19, and their families and carers, so that they can express their preferences about their treatment and escalation plans. Use decision support tools (when available). Bear in mind that these discussions may need to take place remotely
  • Put treatment escalation plans in place because patients with COVID‑19 may deteriorate rapidly and need urgent hospital admission
  • For patients with pre-existing advanced comorbidities, find out if they have advance care plans or advance decisions to refuse treatment, including do not attempt resuscitation decisions. Document this clearly and take account of these in planning care
  • For patients who are being considered for admission to critical care in line with the NICE COVID-19 rapid guideline on critical care in adults bear in mind that this may need to happen urgently

General advice for managing COVID-19 symptoms

  • When managing COVID‑19 symptoms, take into account:
    • that not all patients will have COVID‑19
    • the patient’s underlying health conditions, severity of the acute illness and if they are taking multiple medicines, and the effect of COVID-19 on medicines. For example, supratherapeutic anticoagulation has been reported during the COVID-19 pandemic in some patients taking vitamin K antagonists such as warfarin (see the MHRA advice on warfarin and other anticoagulants—monitoring of patients during the COVID-19 pandemic)
    • that older patients with comorbidities, such as chronic obstructive pulmonary disease (COPD), asthma, hypertension, cardiovascular disease and diabetes, may have a higher risk of deteriorating and need monitoring or more intensive management, including hospital admission
    • that patients with severe symptoms of COVID‑19 may deteriorate rapidly and need urgent hospital admission (see the NICE COVID-19 rapid guideline on managing suspected or confirmed pneumonia in adults in the community)
  • When managing key symptoms of COVID‑19 in the last hours and days of life, follow the relevant parts of NICE guideline on care of dying adults in the last days of life. This includes pharmacological interventions and anticipatory prescribing. Note that symptoms can change, and patients can deteriorate rapidly in a few hours or less

Managing cough

  • Be aware 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. This could lead to respiratory failure and death
  • If possible, encourage patients with cough to avoid lying on their back because this makes coughing ineffective
  • Use simple measures first, including getting patients with cough to take honey (for patients aged over 1 year). See Table 1 for treatments for managing cough
  • For patients with COVID-19 consider short-term use of codeine linctus, codeine phosphate tablets or morphine sulfate oral solution to suppress coughing if it is distressing

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

TreatmentDosage

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

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

All doses are for oral administration

Consider addiction potential of codeine linctus, codeine phosphate and morphine sulfate. Issue as an ‘acute’ prescription with a limited supply. Advise the person 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

Seek specialist advice for patients under 18 years old

Managing fever

Table 2: Antipyretics for managing fever in adults and children

TreatmentDosage

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

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. Please see the BNF and BNF for children for rectal dosing information

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

Managing breathlessness

  • Be aware that severe breathlessness often causes anxiety, which can then increase breathlessness further
  • As part of supportive care the following may help to manage breathlessness:
    • keeping the room cool
    • encouraging relaxation and breathing techniques and changing body positioning (see Table 3 for techniques to help manage breathlessness)
    • encouraging patients who are self-isolating alone, to improve air circulation by opening a window or door (do not use a fan because this can spread infection)
    • when oxygen is available, consider a trial of oxygen therapy and assess whether breathlessness improves

Table 3: Techniques to help manage breathlessness

Controlled breathing techniques include positioning, pursed-lip breathing, breathing exercises and coordinated breathing training

In pursed-lip breathing, people inhale through their nose for several seconds with their mouth closed, then exhale slowly through pursed lips for 4 to 6 seconds. This can help to relieve the perception of breathlessness during exercise or when it is triggered

Relaxing and dropping the shoulders reduces the ‘hunched’ posture that comes with anxiety

Sitting upright increases peak ventilation and reduces airway obstruction

Leaning forward with arms bracing a chair or knees and the upper body supported has been shown to improve ventilatory capacity

Breathing retraining aims to help the person regain a sense of control and improve respiratory muscle strength. Physiotherapists and clinical nurse specialists can help patients learn how to do this (bearing in mind that this support may need to be done remotely).

Managing anxiety, delirium and agitation

  • Address reversible causes of anxiety, delirium and agitation first by:
    • exploring the patient’s concerns and anxieties
    • ensuring effective communication and orientation (for example explaining where the person is, who they are, and what your role is)
    • ensuring adequate lighting
    • explaining to those providing care how they can help
  • Treat reversible causes of anxiety or delirium, with or without agitation, for example hypoxia, urinary retention and constipation
  • Consider trying a benzodiazepine to manage anxiety or agitation (see Table 6 in the full guideline for treatments for managing anxiety, delirium and agitation)

Managing medicines for patients 

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© 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.

Published date: 03 April 2020.

Last updated: 13 October 2020.