NICE issues new guidance on asthma, pneumonia and end-of-life care in the community

NICE has issued new rapid guidance on caring for patients in the community with severe asthma and adults with suspected or confirmed pneumonia.

Asthma
Patients with severe asthma are at high risk of severe illness from COVID-19. Understanding who these patients are is critical to ensuring they and their families and carers are aware of how best to shield themselves. The NICE guidance reaffirms that patients with severe asthma are those requiring high dose ICS plus a second controller (and/or systemic corticosteroids) to maintain control of their symptoms or whose asthma remains uncontrolled despite this therapy. 

Most people with severe asthma will have already received their shielding letter and already know who they are. Our members have had enquiries from people with asthma who think they are classified severe because they have inhalers containing BDP equivalents above 1000mcg. A key part of the NICE statement is that ‘severe’ is people who are uncontrolled or can’t be controlled on high dose ICS. 

When supporting these people, consider:

1. Are they controlled or uncontrolled? If uncontrolled is it definitely asthma causing the symptoms (consider whether other comorbid conditions may be contributing)
2. Was the step up to above BDP equivalent 1000mcg daily justified when it happened and did the step up align with guidance or exceed this? Have they been reviewed subsequently with a view to stepping back down?
3. Are they using the inhaler, including their spacer if applicable, effectively and as prescribed such that they are receiving this high dose?
4. Has anything changed since the last review, for example, have they stopped smoking, has their device been changed without their having received support to use the new device correctly?

The guidance also stipulates that all patients with asthma, including those with or suspected of having COVID-19, should be advised to continue taking their prescribed medications in line with their personal action plan if they have one. There is no evidence that ICS increase the risk of getting COVID-19 and stopping ICS or maintenance oral corticosteroids can be harmful. Patients who develop symptoms of an asthma attack should follow their personalised asthma action plan. PCRS have published pragmatic guidance on managing patients presenting with respiratory symptoms in the community.

Pneumonia
For patients with suspected or confirmed pneumonia the challenges are first to differentiate between viral COVID-19 pneumonia and bacterial pneumonia and then to determine which patients should be referred for hospital-based care. COVID-19 viral pneumonia is more likely if the patient has a history of typical COVID-19 symptoms for about a week, severe muscle pain, loss of smell (and/or taste), breathlessness without pleuritic pain and a history of exposure to the virus. NICE guidance for the management of these patients is that if COVID-19 is the likely cause and symptoms are mild, antibiotics should not be given. Bacterial pneumonia is more likely if the patient has become rapidly unwell after a few days of symptoms, have no history typical of COVID-19 infection and has pleuritic pain and purulent sputum. The guidance from NICE for these patients, antibiotics (doxycycline first choice, amoxicillin as alternative and avoidance of antibiotic combinations) are appropriate. All patients should be advised to seek medical help without delay if their symptoms worsen. The decision about hospital admission should be made based on the severity of symptoms and the patients wishes and care plans as would be the usual recommendation for these patients. 

You can access the PCRS dedicated COVID-19 webpage for the latest information advice and helpful links.