What's new at this update
NICE updates COVID-19 rapid guideline
The UK’s National Institute for Health and Care Excellence (NICE) has updated its COVID-19 rapid guideline to include new recommendations on non-invasive respiratory support. NICE recommends offering continuous positive airway pressure (CPAP) to patients with hypoxaemia that is not responding to supplemental oxygen, provided that 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.
NICE has also updated its existing recommendations on the use of heparins. The guideline now recommends a standard prophylactic dose of a low molecular weight heparin in patients who require low-flow or high-flow oxygen, CPAP, non-invasive ventilation, or invasive mechanical ventilation, and who do not have an increased bleeding risk. A treatment dose may be considered in those who require low-flow oxygen and who do not have an increased bleeding risk (conditional recommendation). Intermediate or treatment doses are recommended only as part of a clinical trial in those receiving high-flow oxygen, CPAP, non-invasive ventilation, or invasive mechanical ventilation.
See the Treatment algorithm section for more information.
[Figure caption and citation for the preceding image starts]: Number of COVID-19 cases reported weekly by WHO Region, and global deaths, as of 12 September 2021World Health Organization [Citation ends].
Original source of updateexternal link opens in a new window
Summary
Definition
History and exam
Other diagnostic factors
- fatigue
- myalgia or arthralgia
- sputum production/expectoration
- chest tightness
- gastrointestinal symptoms
- sore throat
- headache
- dizziness
- neurological symptoms
- ocular symptoms
- rhinorrhoea/nasal congestion
- audio-vestibular symptoms
- chest pain
- cutaneous symptoms
- lower urinary tract symptoms
- haemoptysis
- bronchial breath sounds
- tachypnoea
- tachycardia
- cyanosis
- crackles/rales on auscultation
Risk factors
- contact with probable or confirmed case
- residence/work/travel in location with high risk of transmission
- older age
- male sex
- ethnicity
- residence in a long-term care facility
- presence of comorbidities
- obesity
- cardiovascular disease
- diabetes
- chronic respiratory disease
- chronic kidney disease
- pregnancy
- smoking
- malignancy
- cerebrovascular disease
- solid organ or blood stem cell transplant
- Down's syndrome or learning disability
- haemoglobin disorders
- hypertension
- dementia
- immunosuppression
- HIV infection
- substance use disorders
- children with certain underlying conditions
- chronic liver disease
- vitamin D deficiency
- proton-pump inhibitor use
- autoimmune disease
- Parkinson's disease
- physical inactivity
- dyslipidaemia
- surgery
- blood groups A and B
- gut dysbiosis
- environmental factors
Diagnostic investigations
1st investigations to order
- real-time reverse transcription polymerase chain reaction (RT-PCR)
- pulse oximetry
- ABG
- FBC
- comprehensive metabolic panel
- thyroid function tests
- blood glucose level
- coagulation screen
- cardiac biomarkers
- serum C-reactive protein
- serum erythrocyte sedimentation rate
- serum lactate dehydrogenase
- serum interleukin-6 level
- serum procalcitonin
- serum ferritin level
- serum amyloid A level
- serum creatine kinase and myoglobin
- blood and sputum cultures
- chest x-ray
Emerging tests
- reverse transcription loop-mediated isothermal amplification (RT-LAMP)
- lung ultrasound
- calprotectin
Treatment algorithm
Contributors
Expert advisers
Nicholas J. Beeching, MA, BM BCh, FRCP, FRACP, FFTM RCPS (Glasg), FESCMID, DCH, DTM&H
Consultant and Emeritus Professor of Tropical and Infectious Diseases
Royal Liverpool University Hospital and Liverpool School of Tropical Medicine
Liverpool
UK
Disclosures
NJB is partially supported by the National Institute of Health Research Health Protection Unit (NIHR HPRU) in Emerging and Zoonotic Infections at University of Liverpool in partnership with Public Health England (PHE), in collaboration with Liverpool School of Tropical Medicine. He is affiliated with Liverpool School of Tropical Medicine. The views expressed are those of the author and not necessarily those of the NHS, the NIHR, the Department of Health, or PHE.
Tom E. Fletcher, MBE, PhD, MBChB, MRCP, DTM&H
Senior Clinical Lecturer and Defence Consultant in Infectious Diseases
Royal Liverpool University Hospital and Liverpool School of Tropical Medicine
Liverpool
UK
Disclosures
TEF is a consultant/expert panel member to the World Health Organization, and is funded by the UK Surgeon General, the NHS, and Liverpool School of Tropical Medicine. TEF is partially supported by the National Institute of Health Research Health Protection Unit (NIHR HPRU) in Emerging and Zoonotic Infections at University of Liverpool in partnership with Public Health England (PHE), in collaboration with Liverpool School of Tropical Medicine. He is affiliated with Liverpool School of Tropical Medicine. He has received research grants from the Wellcome Trust, Medical Research Council, and the UK Public Health Rapid Support Team (UK-PHRST). The views expressed are those of the author and not necessarily those of the NHS, the NIHR, the Department of Health, or PHE.
Robert Fowler, MDCM, MS (Epi), FRCP(C)
H. Barrie Fairley Professor of Critical Care
University Health Network and Interdepartmental Division of Critical Care Medicine
Director
Clinical Epidemiology and Health Care Research
Institute of Health Policy, Management and Evaluation
Dalla Lana School of Public Health
University of Toronto
Chief
Tory Trauma Program
Sunnybrook Hospital
Toronto
Canada
Disclosures
RF declares that he has no competing interests.
Peer reviewers
William A. Petri, Jr., MD, PhD
Professor
Division of Infectious Diseases and International Health
University of Virginia
Charlottesville
VA
Disclosures
WAP declares that he has no competing interests.
Xin Zhang, MD, PhD
Attending Physician
The Fifth Medical Center of PLA General Hospital
Clinical Division and Research Center of Infectious Disease
Beijing
China
Disclosures
XZ declares that he has no competing interests.
Ran Nir-Paz, MD
Associate Professor in Medicine
Department of Clinical Microbiology and Infectious Diseases
Hadassah Hebrew University Medical Center
Jerusalem
Israel
Disclosures
RNP has received research grants from US-Israel Binational Science Foundation, Hebrew University, Rosetrees Trust, and SpeeDx. He is chair of the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) Study Group for Mycoplasma and Chlamydia Infections (ESGMAC). RNP is a consultant for and has stocks in eDAS Healthcare. He is also chairperson of the Israeli Society for Infectious Diseases guidelines committee.
Editors
Adam Mitchell,
Section Editor (Infectious Diseases)/Drug Editor, BMJ Best Practice
Disclosures
AM declares that he has no competing interests.
Irene Chiwele,
Lead Section Editor, BMJ Best Practice
Disclosures
IC declares that she has no competing interests.
Julie Costello,
Comorbidities Editor, BMJ Best Practice
Disclosures
JC declares that she has no competing interests.
Expert advisers: comorbidities
Martyn Patel, BMBcH, FRCP, MA
Consultant, Older People's Medicine
Norfolk and Norwich University Hospitals
NHS Foundation Trust
Norwich
UK
Disclosures
MP is a contributor to the Oxford Textbook of Otolaryngology, Oxford University Press, 2021, having written a chapter about mental capacity law, for which he received no fee. MP is the NHS representative on the board for Norwich Institute for Healthy Ageing (unpaid role). MP has spoken at the International Forum on Quality and Safety in Healthcare virtual conference in November 2020, for which he received no fee. MP has accepted speaker fees and/or travel expenses to deliver lectures from: University of East Anglia, Leicester University (speaker fees only); Astellas Pharma Ltd (speaker fees and travel expenses). MP has accepted travel expenses from Newton Europe to present a joint project conducted by his main employer (Norfolk and Norwich University Hospitals NHS Trust) and Newton Europe at the NHS Confederation conference (Manchester 2018).
Andrew Lewington, BSc (Hons), MBBS, MEd, MD, FRCP
Consultant Renal Physician
Honorary Associate Professor
Nephrology Department
Leeds Teaching Hospitals NHS Trust
Leeds
UK
Disclosures
AL is Associate Clinical Director of NIHR Leeds In-Vitro Diagnostics Co-operative, Co-Chair of UK Kidney Research Consortium Renal Clinical Study Group, Member of Kidney Research UK Research Grant Committee, Committee Member of NICE Kidney Injury Clinical Guideline Update 2018-20, Committee Member of NICE Diagnostic Assessment for Point of Care Creatinine Testing 2018-19. AL attended the Acute Dialysis Quality Initiative Meeting in San Diego 2018 (accommodation expenses); AL was a speaker at the AKI & CRRT Conference in San Diego 2019 (travel and accommodation expenses), the AKI Conference in Coventry 2019 (travel expenses), and the NIHR AKI and Sepsis Meeting in Leeds 2019 (no expenses).
Martin Cowie, MD, MSc, FRCP, FRCP (Ed), FESC, FHFA, FACC
Professor of Cardiology
Imperial College London (Royal Brompton Hospital)
London
UK
Disclosures
MC is chair of the European Society of Cardiology Digital Health Committee and a trustee of the Atrial Fibrillation Society. He has previously been a non-executive director of the National Institute for Health and Care Excellence. MC provides consultancy advice to AstraZeneca, Servier, Abbott, Medtronic, Boston Scientific, and Genomics PLC. MC declares that none of these interests is directly related to topics advised on for this project.
Rachael Evans, MBChB, FRCP (UK), PhD
Associate Professor (Clinical)
University of Leicester
Honorary Consultant Respiratory Physician
Glenfield Hospital
Leicester
UK
Disclosures
RAE has been reimbursed for a GSK Advisory Board meeting on Physical Activity and Asthma in November 2016, and three Chiesi Education meetings for GPs on COPD care in 2019. RAE received a travel award for ERS 2017 from Chiesi and participated in the GSK clinical experience programme - respiratory in August 2018. RAE participated in the BTS/SIGN guidelines for asthma update 2016 (no fee).
Gerry Rayman, MD, FRCP
Consultant Physician and Head of Service
Diabetes and Endocrine Centre and the Diabetes Research Unit
Ipswich Hospitals NHS Trust
Ipswich
UK
Disclosures
GR has been paid for advisory board meetings with the following companies: Safoni Aventis, Abbott Diabetes UK, Lilly Diabetes, Bayer. GR has received lecture fees from Safoni Aventis, Abbott Diabetes UK, Lilly Diabetes, Novonordisk, Napp Pharmaceuticals Ltd.
Sotiris Posporelis, MD, MRCPsych
Consultant Liaison Neuropsychiatrist
King’s College Hospital
South London and Maudsley NHS Foundation Trust
Honorary Senior Clinical Lecturer
Institute of Psychiatry, Psychology & Neuroscience
King’s College London
London
UK
Disclosures
SP declares that he has no competing interests.
Acknowledgements,
BMJ Best Practice would like to gratefully acknowledge Dr Matthew Jones for his advice on a section of the stroke comorbidity content.
Matthew Jones, MD, FRCP
Consultant Neurologist
Greater Manchester Neurosciences Centre
Salford Royal Foundation Trust
Honorary Senior Lecturer
University of Manchester
Manchester
UK
Disclosures
AA and MJ declare that they have no competing interests.
Peer reviewers: comorbidities
Martyn Patel, BMBcH, FRCP, MA
Consultant, Older People's Medicine
Norfolk and Norwich University Hospitals
NHS Foundation Trust
Norwich
UK
Disclosures
MP is a contributor to the Oxford Textbook of Otolaryngology, Oxford University Press, 2021, having written a chapter about mental capacity law, for which he received no fee. MP is the NHS representative on the board for Norwich Institute for Healthy Ageing (unpaid role). MP has spoken at the International Forum on Quality and Safety in Healthcare virtual conference in November 2020, for which he received no fee. MP has accepted speaker fees and/or travel expenses to deliver lectures from: University of East Anglia, Leicester University (speaker fees only); Astellas Pharma Ltd (speaker fees and travel expenses). MP has accepted travel expenses from Newton Europe to present a joint project conducted by his main employer (Norfolk and Norwich University Hospitals NHS Trust) and Newton Europe at the NHS Confederation conference (Manchester 2018).
Asangaedem Akpan, MPH, FRCP
Consultant Geriatrician
Liverpool University Hospitals NHS Foundation Trust
Visiting Professor
University of Cumbria
Carlisle
Honorary Clinical Associate Professor
University of Liverpool
Liverpool
UK
Disclosures
AA declares that he has no competing interests.
Use of this content is subject to our disclaimer