3 Management

3.1 In the community

Care planning


In the community, consider the risks and benefits of face-to-face and remote care for each person. Where the risks of face-to-face care outweigh the benefits, remote care can be optimised by:


When possible, discuss the risks, benefits and possible likely outcomes of the treatment options with people with COVID-19, and their families and carers. Use decision support tools (where available). [23 March 2021]


Put treatment escalation plans in place in the community after sensitively discussing treatment expectations and care goals with people with COVID-19, and their families and carers. [23 March 2021]


People with COVID-19 may deteriorate rapidly. If it is agreed that the next step is:

  • a move to secondary care, ensure that they and their families understand how to access this with the urgency needed

  • other community-based support (whether virtual wards, hospital-at-home services or palliative care), ensure that they and their families understand how to access these services, both in and out of hours. [23 March 2021]

Managing cough


Encourage people with cough to avoid lying on their backs, if possible, because this may make coughing less effective. [23 March 2021]


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. [23 March 2021]

Managing fever


Advise people with COVID-19 and fever to drink fluids regularly to avoid dehydration. Support their families and carers to help when appropriate. Communicate that fluid intake needs can be higher than usual because of fever. [23 March 2021]


Advise people to take paracetamol or ibuprofen if they have fever and other symptoms that antipyretics would help treat. Tell them to continue only while both the symptoms of fever and the other symptoms are present (see the Central Alerting System: ibuprofen and coronavirus [COVID-19] for further details of ibuprofen including dosage). [23 March 2021]

Managing breathlessness


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. [23 March 2021]


If hypoxia is the likely cause of breathlessness:

  • consider a trial of oxygen therapy

  • discuss with the person, their family or carer, possible transfer to and evaluation in secondary care. [23 March 2021]


Be aware that breathlessness with or without hypoxia often causes anxiety, which can then increase breathlessness further. [23 March 2021]

Managing anxiety, delirium and agitation


Address reversible causes of anxiety by:

  • exploring the person's concerns and anxieties

  • explaining to people providing care how they can help. [23 March 2021]

Managing medicines

3.2 In hospital

Deciding when to escalate treatment


Base decisions about escalating treatment within the hospital on the likelihood of a person's recovery. Take into account their treatment expectations, goals of care and the likelihood that they will recover to an outcome that is acceptable to them. [23 March 2021]


Discuss treatment escalation with a multidisciplinary team of medical and allied health professional colleagues (such as from critical care, respiratory medicine, geriatric medicine and palliative care) when there is uncertainty about treatment escalation decisions. [23 March 2021]


Document referral to and advice from critical care services and respiratory support units in a standard format. When telephone advice from critical care or respiratory support units is appropriate, this should still be documented in a standard format (see an example referral form). [23 March 2021]

Escalating and de-escalating treatment


Before escalating respiratory or other organ support, identify agreed treatment goals with the person (if possible), and their family and carers, or an independent mental capacity advocate (if appropriate). Start all advanced respiratory support or organ support with a clear plan of how it will address the diagnosis and lead to agreed treatment goals (outcomes). Ensure this includes management plans for when there is further deterioration or no response to treatment. [23 March 2021, amended 2 September 2021]


Do not continue respiratory or other organ support if it is considered that it will no longer result in the desired overall goals (outcomes). Record the decision and the discussion with the person (if possible), and their family and carers, or an independent mental capacity advocate (if appropriate). [23 March 2021, amended 2 September 2021]

Delivering services in critical care and respiratory support units

Non-invasive respiratory support

Early treatment escalation planning for non-invasive respiratory support


For information on deciding when to escalate and de-escalate treatment for people who need non-invasive respiratory support, see the section on deciding when to escalate treatment and the section on escalating and de-escalating treatment. Also, consider factors such as:

  • how much supplemental oxygen is needed to reach target oxygen saturation

  • the person's overall clinical trajectory

  • the person's effort of breathing (inspiratory effort and respiratory rate)

  • how well the person has tolerated treatments so far

  • treatment preferences after discussion with the person, and their family and carers (when appropriate). [2 September 2021]


Optimise pharmacological and non-pharmacological management strategies in people who need non-invasive respiratory support. [2 September 2021, amended 10 March 2022]


Consider awake prone positioning for people in hospital with COVID-19 who are not intubated and have higher oxygen needs. Discuss this with the person to reach a shared decision on whether to try the position. [10 March 2023]


When trying awake prone positioning, factors to consider may include:

  • whether the person has any contraindications to prone positioning (for example, communication difficulties that affect their ability to try the position, respiratory distress, potential need for invasive ventilation, untreated pneumothorax, or recent abdominal, thoracic, facial, pelvic or spinal injury)

  • availability of support from healthcare professionals with skills and experience in prone positioning

  • allowing a suitable duration to measure response to prone positioning (for example, by monitoring oxygen saturation, need for supplemental oxygen, respiratory rate, sensation of breathlessness)

  • ensuring regular review and continuous monitoring (for example, oxygen saturation level)

  • how well the person can tolerate prone positioning and the importance of breaks

  • stopping prone positioning if it causes excessive discomfort (including pressure damage, or pins and needles or numbness in the upper limbs), or there is worsening hypoxia or excessive breathlessness.

    The Intensive Care Society has produced information on conscious prone positioning for people with COVID-19.

    Follow relevant national guidance on communication, providing information (including in different formats and languages) and shared decision making, for example, NICE's guideline on shared decision making. [10 March 2023]

For a short explanation of why the panel made these recommendations, see the rationale section on early escalation treatment planning for non-invasive respiratory support.

Full details of the evidence and the panel's discussion are in:

Delivering non-invasive respiratory support


Consider continuous positive airway pressure (CPAP) for people with COVID-19 when they have hypoxaemia that is not responding to supplemental oxygen with a fraction of inspired oxygen of 0.4 (40%) or more and either:


For people with COVID-19 having CPAP, ensure:


Staff caring for people with COVID-19 having CPAP should have appropriate skills and competencies and provide appropriate monitoring. For further information on standards of care and provision of services, see the Faculty of Intensive Care Medicine and Intensive Care Society guidelines on the provision of intensive care services, the British Thoracic Society and Intensive Care Society guidance on development and implementation of respiratory support units and the Paediatric Intensive Care Society guidance on the management of critically ill children. [2 September 2021, amended 10 March 2022]


Consider using HFNO for people when:

  • they cannot tolerate CPAP but need humidified oxygen at high-flow rates

  • maximal conventional oxygen is not maintaining their target oxygen saturations and:

    • they do not need immediate invasive mechanical ventilation or escalation to invasive mechanical ventilation is not suitable and

    • CPAP is not suitable

  • they need:

    • a break from CPAP (such as at mealtimes, for skin and pressure area relief, or for mouth care)

    • humidified oxygen or nebulisers (or both)

    • weaning from CPAP. [2 September 2021, amended 10 March 2022]

For a short explanation of why the panel made these recommendations, see the rationale section on delivering non-invasive respiratory support.

Full details of the evidence and the panel's discussion are in: