What are the guidelines for managing cough and congestion symptoms in COVID-19?

Guidelines for Managing COVID-19 Cough and Congestion Symptoms

For patients with COVID-19, honey (for patients over 1 year old) is recommended as first-line treatment for cough, followed by short-term use of codeine linctus, codeine phosphate tablets, or morphine sulfate oral solution for distressing cough, while guaifenesin can be used to loosen phlegm and thin bronchial secretions to make coughs more productive. 1, 2

Management of Cough

First-line approaches:

• Encourage patients to avoid lying on their back as this makes coughing ineffective 1
• Recommend honey for patients aged over 1 year 1
• Consider guaifenesin to help loosen phlegm and thin bronchial secretions 2

For distressing cough:

• Consider short-term use of one of the following:
  • Codeine linctus
  • Codeine phosphate tablets
  • Morphine sulfate oral solution 1

Cautions with cough suppressants:

• Dextromethorphan should not be used in patients taking monoamine oxidase inhibitors (MAOIs) 3
• Avoid dextromethorphan in patients with chronic cough associated with smoking, asthma, or emphysema 3
• Discontinue if cough persists beyond 7 days, returns, or occurs with fever, rash, or persistent headache 3

Management of Congestion

• Ensure adequate hydration - advise patients to drink fluids regularly (no more than 2 liters per day) 1
• Position patients appropriately to facilitate drainage of secretions
• Use closed tracheal suction systems when available for hospitalized patients requiring airway management 1

Management of Breathlessness

Techniques to help manage breathlessness:

• Controlled breathing techniques:

  • Positioning
  • Pursed-lip breathing (inhale through nose for several seconds, then exhale slowly through pursed lips for 4-6 seconds)
  • Breathing exercises
  • Coordinated breathing training 1

• Body positioning:

  • Relaxing and dropping shoulders to reduce hunched posture
  • Sitting upright to increase peak ventilation
  • Leaning forward with arms bracing a chair or knees with upper body supported 1

Fever Management

• Be aware that fever typically peaks around five days after exposure 1
• Use paracetamol for fever and associated symptoms
• Continue antipyretics only while symptoms persist
• Paracetamol is preferred over NSAIDs for COVID-19 patients until more evidence is available 1

Special Considerations for Severe Cases

Oxygen Therapy:

• Start supplemental oxygen when SpO2 falls below 92%, with strong recommendation for initiating when SpO2 is below 90% 4
• Maintain SpO2 between 90-96% to prevent oxygen toxicity 4

For patients requiring hospitalization:

• Monitor airway carefully in intubated patients
• Use heat and moisture exchange (HME) filter between catheter mount and circuit 1
• Ensure proper cuff inflation (20-30 cmH2O) to minimize air leaks 1
• Use closed suction systems to prevent aerosolization 1, 4

Care Planning

• Discuss risks, benefits, and possible outcomes of treatment options with patients and their families 1
• Establish treatment escalation plans early, as COVID-19 patients may deteriorate rapidly 1
• For patients with pre-existing advanced comorbidities, check for advance care plans or decisions to refuse treatment 1

Common Pitfalls to Avoid

• Do not use antipyretics with the sole aim of reducing body temperature 1
• Avoid auscultation of the chest when wearing airborne precaution PPE as it risks contamination 1
• Do not delay appropriate escalation of care if symptoms worsen, as COVID-19 can progress rapidly 1, 5
• Be aware that over-the-counter medicines used for common cold and flu symptoms can safely treat the same symptoms in COVID-19 6

Remember that older patients or those with comorbidities, frailty, impaired immunity, or reduced ability to cough and clear secretions are at higher risk of developing severe pneumonia, which could lead to respiratory failure 1.