NG165 - COVID-19 rapid guideline: managing suspected or confirmed pneumonia in adults in the community
The rapid guideline on managing suspected or confirmed pneumonia in adults in the community recommends that GPs use the Medical Research Council’s dyspnoea scale or the Centre for Evidence Based Medicine’s review of ways of assessing dyspnoea by telephone or video in order to assess breathlessness remotely. NICE does not recommend the use of the ROTH tool.
The following signs and symptoms should be used to help make decisions about hospital admission:
- 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.
GPs should not use the CRB65 tool, which is recommended in NICE’s standard guideline on pneumonia diagnosis and management, because it requires BP measurement, which may not be possible if GPs are consulting remotely and also risks cross contamination.
Where pulse oximetry is available oxygen saturation levels below 92% (or below 88% in people with COPD) indicate seriously ill patients. NICE also says that the NEWS2 tool for predicting risk of clinical deterioration ‘may be useful’. However it says face-to-face appointments should not be arranged solely for this purpose.
The guidance says that as COVID-19 becomes more prevalent pneumonia is more likely to be caused by the virus than bacteria. As a result, GPs should only offer antibiotics if bacteria are the likely cause, if it is unclear whether the cause is bacterial or viral and symptoms are ‘more concerning’, or if the patient is at high risk of developing complications.
The guidance says COVID-19 viral pneumonia is more likely if the patient:
- presents with a history of 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, such as a household or workplace contact.
NICE also says that clinicians need to assess the benefits, risks and disadvantages of hospital admission in patients who become unwell. They should also take into account ‘service delivery issues and local NHS resources during the COVID-19 pandemic’. It also recommends that GPs find out about whether patients have any care plans or advance decisions to refuse treatment in place.
When considering hospital admission, patients should be told of the benefits, including access to improved diagnostic testing and respiratory support, but also the risks and disadvantages, including spreading or catching COVID-19 and loss of contact with their family.
Patients should be advised to seek further advice if their symptoms don’t improve or worsen rapidly.