COVID-19 rapid guideline: managing COVID-19

In the community, consider the risks and benefits of face-to-face and remote care for each person. Where the risks of face-to-face care outweigh the benefits, remote care can be optimised by:

• offering telephone or video consultations (see BMJ guidance on Covid-19: a remote assessment in primary care for a useful guide, including a visual summary for remote consultation)

• cutting non-essential face-to-face follow‑up

• using electronic prescriptions rather than paper

• using different methods to deliver medicines to people, for example, pharmacy deliveries, postal services and NHS volunteers, or introducing drive-through pick-up points for medicines. [23 March 2021]

When possible, discuss the risks, benefits and possible likely outcomes of the treatment options with people with COVID-19, and their families and carers. Use decision support tools (where available). [23 March 2021]

Put treatment escalation plans in place in the community after sensitively discussing treatment expectations and care goals with people with COVID-19, and their families and carers. [23 March 2021]

People with COVID-19 may deteriorate rapidly. If it is agreed that the next step is:

• a move to secondary care, ensure that they and their families understand how to access this with the urgency needed

• other community-based support (whether virtual wards, hospital-at-home services or palliative care), ensure that they and their families understand how to access these services, both in and out of hours. [23 March 2021]

Encourage people with cough to avoid lying on their backs, if possible, because this may make coughing less effective. [23 March 2021]

Be aware that older people 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. [23 March 2021]

For guidance on managing acute cough, see NICE's guideline on cough (acute): antimicrobial prescribing. [30 November 2023]

Advise people with COVID-19 and fever to drink fluids regularly to avoid dehydration. Support their families and carers to help when appropriate. Communicate that fluid intake needs can be higher than usual because of fever. [23 March 2021]

Advise people to take paracetamol or ibuprofen if they have fever and other symptoms that antipyretics would help treat. Tell them to continue only while both the symptoms of fever and the other symptoms are present (see the Central Alerting System: ibuprofen and coronavirus [COVID-19] for further details of ibuprofen including dosage). [23 March 2021]

Identify and treat reversible causes of breathlessness, for example, pulmonary oedema, pulmonary embolism, chronic obstructive pulmonary disorder and asthma. [23 March 2021]

For further information on identifying and managing pulmonary embolism, see NICE's guideline on venous thromboembolic diseases: diagnosis, management and thrombophilia testing.

When significant medical pathology has been excluded or further investigation is inappropriate, the following may help to manage breathlessness as part of supportive care:

• keeping the room cool

• encouraging relaxation and breathing techniques, and changing body positioning

• encouraging people who are self-isolating alone to improve air circulation by opening a window or door. [23 March 2021]

If hypoxia is the likely cause of breathlessness:

• consider a trial of oxygen therapy

• discuss with the person, their family or carer, possible transfer to and evaluation in secondary care. [23 March 2021]

Be aware that breathlessness with or without hypoxia often causes anxiety, which can then increase breathlessness further. [23 March 2021]

Assess reversible causes of delirium. See NICE's guideline on delirium: prevention, diagnosis and management in hospital and long-term care. [23 March 2021]

Address reversible causes of anxiety by:

• exploring the person's concerns and anxieties

• explaining to people providing care how they can help. [23 March 2021]

When supporting people with symptoms of COVID-19 who are having care in the community delivered by social care, follow NICE's guideline on managing medicines for adults receiving social care in the community. This includes processes for ordering and supplying medicines, and transporting, storing and disposing of medicines. [23 March 2021]

When prescribing, handling, administering and disposing of medicines in care homes and hospices, follow NICE's guideline on managing medicines in care homes. [23 March 2021]

Base decisions about escalating treatment within the hospital on the likelihood of a person's recovery. Take into account their treatment expectations, goals of care and the likelihood that they will recover to an outcome that is acceptable to them. [23 March 2021]

Ensure healthcare professionals have access to resources to support discussions about treatment plans (see, for example, decision making for escalation of treatment and referring for critical care support, and an example decision support form). [23 March 2021]

Discuss treatment escalation with a multidisciplinary team of medical and allied health professional colleagues (such as from critical care, respiratory medicine, geriatric medicine and palliative care) when there is uncertainty about treatment escalation decisions. [23 March 2021]

Document referral to and advice from critical care services and respiratory support units in a standard format. When telephone advice from critical care or respiratory support units is appropriate, this should still be documented in a standard format (see an example referral form). [23 March 2021]

Before escalating respiratory or other organ support, identify agreed treatment goals with the person (if possible), and their family and carers, or an independent mental capacity advocate (if appropriate). Start all advanced respiratory support or organ support with a clear plan of how it will address the diagnosis and lead to agreed treatment goals (outcomes). Ensure this includes management plans for when there is further deterioration or no response to treatment. [23 March 2021, amended 2 September 2021]

Do not continue respiratory or other organ support if it is considered that it will no longer result in the desired overall goals (outcomes). Record the decision and the discussion with the person (if possible), and their family and carers, or an independent mental capacity advocate (if appropriate). [23 March 2021, amended 2 September 2021]

Trusts should review:

• their strategy on management for people who are deteriorating and

• use of the track-and-trigger system (NEWS2 has been endorsed by NHS England).
  
  See NICE's guideline on acutely ill adults in hospital for recommendations on identifying patients whose clinical condition is deteriorating or is at risk of deterioration and the Royal College of Physician's information on the place of NEWS2 in managing patients with COVID-19. [23 March 2021, amended 2 September 2021]

For information on deciding when to escalate and de-escalate treatment for people who need non-invasive respiratory support, see the section on deciding when to escalate treatment and the section on escalating and de-escalating treatment. Also, consider factors such as:

• how much supplemental oxygen is needed to reach target oxygen saturation

• the person's overall clinical trajectory

• the person's effort of breathing (inspiratory effort and respiratory rate)

• how well the person has tolerated treatments so far

• treatment preferences after discussion with the person, and their family and carers (when appropriate). [2 September 2021]

Optimise pharmacological and non-pharmacological management strategies in people who need non-invasive respiratory support. [2 September 2021, amended 10 March 2022]

Consider awake prone positioning for people in hospital with COVID-19 who are not intubated and have higher oxygen needs. Discuss this with the person to reach a shared decision on whether to try the position. [10 March 2023]

When trying awake prone positioning, factors to consider may include:

• whether the person has any contraindications to prone positioning (for example, communication difficulties that affect their ability to try the position, respiratory distress, potential need for invasive ventilation, untreated pneumothorax, or recent abdominal, thoracic, facial, pelvic or spinal injury)

• availability of support from healthcare professionals with skills and experience in prone positioning

• allowing a suitable duration to measure response to prone positioning (for example, by monitoring oxygen saturation, need for supplemental oxygen, respiratory rate, sensation of breathlessness)

• ensuring regular review and continuous monitoring (for example, oxygen saturation level)

• how well the person can tolerate prone positioning and the importance of breaks

• stopping prone positioning if it causes excessive discomfort (including pressure damage, or pins and needles or numbness in the upper limbs), or there is worsening hypoxia or excessive breathlessness.
  
  The Intensive Care Society has produced information on conscious prone positioning for people with COVID-19.
  
  Follow relevant national guidance on communication, providing information (including in different formats and languages) and shared decision making, for example, NICE's guideline on shared decision making. [10 March 2023]

Do not routinely offer high-flow nasal oxygen (HFNO) as the main form of respiratory support for people with COVID-19 and respiratory failure in whom escalation to invasive mechanical ventilation would be appropriate. [10 March 2023]

See recommendation 3.2.16 on when to consider HFNO.

Consider continuous positive airway pressure (CPAP) for people with COVID-19 when they have hypoxaemia that is not responding to supplemental oxygen with a fraction of inspired oxygen of 0.4 (40%) or more and either:

• escalation to invasive mechanical ventilation would be an option but it is not immediately needed or

• it is agreed that respiratory support should not be escalated beyond CPAP.
  
  In June 2021, the Medicines and Healthcare products Regulatory Agency (MHRA) issued a National Patient Safety Alert for Philips ventilator, CPAP and bilevel positive airway pressure devices because of a potential for harm from inhaled particles and volatile organic compounds. This applies to all devices manufactured before 26 April 2021. [2 September 2021, amended 10 March 2022]

For people with COVID-19 having CPAP, ensure:

• there is access to critical care providers for advice, review and prompt escalation of treatment if needed

• regular review by an appropriate senior clinician (such as every 12 hours) and more frequent review if needed, in line with the British Thoracic Society guidance on respiratory support units and the Faculty of Intensive Care Medicine guidelines on the provision of intensive care services

• regular assessment and management of symptoms alongside non-invasive respiratory support. [2 September 2021, amended 10 March 2022]

Staff caring for people with COVID-19 having CPAP should have appropriate skills and competencies and provide appropriate monitoring. For further information on standards of care and provision of services, see the Faculty of Intensive Care Medicine and Intensive Care Society guidelines on the provision of intensive care services, the British Thoracic Society and Intensive Care Society guidance on development and implementation of respiratory support units and the Paediatric Intensive Care Society guidance on the management of critically ill children. [2 September 2021, amended 10 March 2022]

Consider using HFNO for people when:

• they cannot tolerate CPAP but need humidified oxygen at high-flow rates

• maximal conventional oxygen is not maintaining their target oxygen saturations and:

  • they do not need immediate invasive mechanical ventilation or escalation to invasive mechanical ventilation is not suitable and

  • CPAP is not suitable

• they need:

  • a break from CPAP (such as at mealtimes, for skin and pressure area relief, or for mouth care)

  • humidified oxygen or nebulisers (or both)

  • weaning from CPAP. [2 September 2021, amended 10 March 2022]