The National Institute for Health and Care Excellence (NICE) has issued a further set of rapid COVID-19 guidelines.
The latest guidance covered severe asthma, pneumonia, rheumatological disorders, and symptom management in the community, including end of life care.
Managing Symptoms in the Community: NICE guideline NG163
The guideline provided advice to health professionals on the management of cough, fever, breathlessness, and anxiety, delirium, and agitation in those with COVID-19.
Clinicians should be aware that severe breathlessness can cause anxiety and that this can make breathlessness worse.
Patients should be advised to first treat a mild cough with simple measures and should also avoid lying on their back as this can make it harder to clear the lungs by coughing.
In cases of severe cough, codeine linctus, codeine phosphate tablets, or morphine sulfate oral solution could be considered for short-term use.
The guideline for people with severe asthma said that patients should continue to take their treatment as prescribed and only attend essential appointments.
They should also attend appointments alone wherever possible.
People with severe asthma should be advised to regularly clean equipment such as face masks and mouthpieces, and avoid sharing inhalers and devices with others.
Pneumonia in Adults: NICE guideline NG165
Clinicians should be aware that with the increasing prevalence of COVID-19, pneumonia is more likely to be caused by the virus than by bacteria.
Patients should not be prescribed an antibiotic for treatment or prevention of pneumonia in cases where COVID-19 is likely to be the cause and where symptoms are mild.
People should seek medical help without delay if their symptoms do not improve or if their symptoms worsen rapidly, whether they have been given an antibiotic or not.
When possible, clinicians should discuss with patients and carers the risks, benefits, and possible likely outcomes of treatment options.
Patients with COVID-19 should not suddenly stop taking their medication but should seek advice on which medicines to continue and which to temporarily stop, the updated guidance said.
In cases where their condition worsens, patients should contact their rheumatology team about any rheumatological medicines issues or contact NHS 111 for advice on COVID-19.
Healthcare professionals should use NHS England’s COVID-19 clinical guide when deciding what treatments are appropriate.
The guideline advised that treatment should be avoided where evidence suggests little to no benefit.
In cases where an alternative treatment is available, radiotherapy should be deferred, if clinically appropriate.
If radiotherapy treatment is unavoidable, the shortest safe form of treatment should be used.
Changing treatment schedules or interrupting treatment should be discussed with patients, their families, and carers.
Clinicians were advised to consider both the severity of the disease and the post-transplant risks of COVID-19 when deciding on treatment plans.
Autologous transplants and allogeneic transplants should be deferred in most cases until the risks associated with the COVID-19 pandemic have passed.
Treatment decisions should be made on an individual basis by a multidisciplinary team, and the reasons recorded.
Treatment decisions should be communicated to patients, their families, and carers, with support given to their mental wellbeing.
NICE began issuing rapid COVID-19 guidelines in March and published an update in early April. These were:
All patients admitted to hospital should be assessed for frailty irrespective of COVID-19 status.
Risks and benefits and likely outcomes should be discussed with patients, carers or advocates, and families using decision support tools (where available) so that they can make informed decisions about their treatment wherever possible.
For patients with confirmed COVID-19, decisions about critical care admission should be made on the basis of medical benefit and should take into account the likelihood that the person will recover to an outcome that is acceptable to them and within a period of time consistent with the diagnosis.
NICE later updated this guidance following concerns from patient groups that assessments for frailty using the Clinical Frailty Scale (CFS) score could put people with learning disabilities, autism, and other stable long-term disabilities at a disadvantage when decisions were made about admission to critical care during a time of intense pressure on the NHS.
Where decisions need to be made about prioritising patients for treatment, these need to take into account the level of immunosuppression associated with individual treatments and cancer types, and any other patient-specific risk factors. They should also balance the risk from cancer not being treated optimally versus the risk of becoming seriously ill if they contract COVID-19 because of immunosuppression.
Where changes need to be made to usual care because of system pressures, consideration should be given to delivering treatment in different and less immunosuppressive regimens, different locations, or via another route of administration.
Patients with suspected COVID-19 should be assessed to see whether dialysis could be delayed until their COVID-19 status is known.
NICE also recommends that outpatient transport services should get patients to their dialysis as scheduled to avoid their condition deteriorating.
It should also be ensured that appropriate transport services are available by finding out what current transport providers are prepared to provide, and whether there are alternative providers if the current providers will not transport patients infected with COVID-19.
NICE said the main priorities in its guidelines were the safety of patients, protecting health professionals from infection, and making the best use of NHS resources.
Further guidelines are expected to cover COPD, cystic fibrosis, and dermatological conditions in people receiving immunotherapy.