COVID-19 rapid guideline: Managing Cough and Breathlessness in COVID-19

The National Institute for Health and Care Excellence (NICE) Guidance

Managing cough

Recommendations

· Encourage patient with cough to avoid lying on their backs, if possible, because this may make coughing less effective.

· 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.

· Use simple measures first, including advising people over 1 year with cough to take honey.
The dose is 1 teaspoon of honey.

· Consider short-term use of codeine linctus, codeine phosphate tablets or morphine sulfate oral solution in people 18 years and over to suppress coughing if it is distressing.

· Avoid cough suppressants in chronic bronchitis and bronchiectasis because they can cause sputum retention.

Treatments for managing cough in adults aged 18 years and over

Treatment	Dosage
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:

All doses are for oral administration.
Consider addiction potential of codeine linctus, codeine phosphate and morphine sulfate. Advise the person of the risks of constipation and consider prescribing a regular stimulant laxative.

Available Brand

Managing breathlessness

Recommendations
Identify and treat reversible causes of breathlessness, for example, pulmonary oedema, pulmonary embolism, chronic obstructive pulmonary disorder and asthma.

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.

If hypoxia is the likely cause of breathlessness:

consider a trial of oxygen therapy.
discuss with the person, their family for possible transfer to and evaluation in hospital.

Breathlessness with or without hypoxia often causes anxiety, which can then increase breathlessness further.

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 4-6 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 a person regain a sense of control and improve respiratory muscle strength.