[2004], 1.2.38 Assess the effectiveness of theophylline by improvements in symptoms, activities of daily living, exercise capacity and lung function. Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. 2 Short of breath when hurrying or walking up a slight hill. 3 Walks slower than contemporaries on level ground because of breathlessness, or has to. [2004], 1.3.45 Give people (or home carers) appropriate information to enable them to fully understand the correct use of medications, including oxygen, before discharge. [2004], 1.2.135 It is recommended that lung function should not be the only criterion used to assess people with COPD before surgery. Consider long-term oxygen therapy[5] for people with COPD who do not smoke and who: have a partial pressure of oxygen in arterial blood (PaO2) below 7.3 kPa when stable or. [2018], 1.2.125 Develop an individualised exacerbation action plan in collaboration with each person with COPD who is at risk of exacerbations. Be aware that there are no long-term studies on the use of prophylactic antibiotics in people with COPD. [2004], 1.3.20 This includes any previous, secure diagnosis of asthma or of atopy, a higher blood eosinophil count, substantial variation in FEV1 over time (at least 400 ml) or substantial diurnal variation in peak expiratory flow (at least 20%). [2010], 1.3.28 Pulse oximeters should be available to all healthcare professionals involved in the care of people with exacerbations of COPD, and they should be trained in their use. Most people with COPD – whatever their age – can develop adequate inhaler technique if they are given training. Advise people on spacer cleaning. If the person is not a current smoker, their spirometry is normal and they have no symptoms or signs of respiratory disease: ask them if they have a personal or family history of lung or liver disease and consider alternative diagnoses, such as alpha‑1 antitrypsin deficiency, reassure them that their emphysema or chronic airways disease is unlikely to get worse. [2004], 1.2.9 [2004], 1.2.22 Provide an alternative inhaler if a person cannot use a particular one correctly or it is not suitable for them. [2004], 1.3.23 Take care when using intravenous theophylline, because of its interactions with other drugs and potential toxicity if the person has been taking oral theophylline. NICE COPD guidance for diagnosis, management, and antimicrobial prescribing for acute exacerbations. Consider physiotherapy using positive expiratory pressure devices for selected people with exacerbations of COPD, to help with clearing sputum. [2004], 1.2.85 Advise people of the benefits of pulmonary rehabilitation and the commitment needed to gain these. [2004]. [2004], 1.3.33 Treat hospitalised exacerbations of COPD on intensive care units, including invasive ventilation when this is thought to be necessary. [2018], 1.2.68 [2019]. Included on this page is a collection of key guidance and advice from PHE and the NHS, as well as a list of information for specific groups from a range of professional bodies. [2004]. [2004]. Composite assessment tools such as the ASA scoring system are the best predictors of risk. Publications Guidance. [2004]. Perform additional investigations when needed, as detailed in table 2. Thorax 57(4): 289–304. [2004], 1.3.27 If necessary, prescribe oxygen to keep the oxygen saturation of arterial blood (SaO2) within the individualised target range. [2004]. Definition of a pulmonary hypertension referral centre 13. [2004], 1.3.16 [2018], 1.2.94 [2018], 1.2.132 1 [2] The MHRA has published advice on the risk for people with certain cardiac conditions when taking tiotropium delivered via Respimat or Handihaler (2015). It recommends changes to usual practice to maximise the safety of patients and protect staff from infection during the COVID-19 pandemic. [2004]. It is recommended that GLI 2012 reference values are used, but it is recognised that these values are not applicable for all ethnic groups. [2018]. [2004], 1.3.10 Change people to hand-held inhalers as soon as their condition has stabilised, because this may allow them to be discharged from hospital earlier. It includes sections on the diagnosis and management of stable COPD and the management of exacerbations. If they do, consider including a cognitive behavioural component in their self-management plan to help them manage anxiety and cope with breathlessness. [2018], 1.2.111 Regularly ask people with COPD about their ability to undertake activities of daily living and how breathless these activities make them. Pulmonary rehabilitation is defined as a multidisciplinary programme of care for people with chronic respiratory impairment. [2004], 1.2.83 For pulmonary rehabilitation programmes to be effective, and to improve adherence, they should be held at times that suit people, in buildings that are easy to get to and that have good access for people with disabilities. In the absence of significant contraindications, use oral corticosteroids, in conjunction with other therapies, in all people admitted to hospital with a COPD exacerbation. 1.2.14 Before starting prophylactic antibiotic therapy in a person with COPD, think about whether respiratory specialist input is needed. [2018], 1.2.128 At all review appointments, discuss corticosteroid and antibiotic use with people who keep these medicines at home, to check that they still understand how to use them. managing stable COPD (including an algorithm) follow-up of people with COPD. From diagnosis onwards, when discussing prognosis and treatment decisions with people with stable COPD, think about the following factors that are individually associated with prognosis: symptom burden (for example, COPD Assessment Test [CAT] score), exercise capacity (for example, 6‑minute walk test), whether the person meets the criteria for long-term oxygen therapy and/or home non-invasive ventilation. 1.2.46 Consider azithromycin (usually 250 mg 3 times a week) for people with COPD if they: have optimised non-pharmacological management and inhaled therapies, relevant vaccinations and (if appropriate) have been referred for pulmonary rehabilitation and. 1.2.137 [2018], 1.2.61 Before offering prophylactic antibiotics, ensure that the person has had: sputum culture and sensitivity (including tuberculosis culture), to identify other possible causes of persistent or recurrent infection that may need specific treatment (for example, antibiotic-resistant organisms, atypical mycobacteria or Pseudomonas aeruginosa), training in airway clearance techniques to optimise sputum clearance (see recommendation 1.2.99), a CT scan of the thorax to rule out bronchiectasis and other lung pathologies. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. If people have excessive sputum, they should be taught: how to use positive expiratory pressure devices, active cycle of breathing techniques. European Respiratory Journal 23(6): 932–46. [2004], 1.3.30 Use NIV as the treatment of choice for persistent hypercapnic ventilatory failure during exacerbations despite optimal medical therapy. This is usually managed by taking increased doses of short-acting bronchodilators. In common with the global GOLD 2019 guidance PCRS suggests a stepped approach to COPD treatment for patients with predominant breathlessness - starting initially with LAMA (or LABA)alone before stepping up if necessary to a LAMA/LABA combination. Clinical Guidelines Fully Endorsed . [2004, amended 2018], To identify organisms if sputum is persistently present and purulent, To exclude asthma if diagnostic doubt remains. [2004], 1.3.29 Measure arterial blood gases and note the inspired oxygen concentration in all people who arrive at hospital with an exacerbation of COPD. 2019 repor t [ GOLD, 2019 ]. The diagnosis is suspected on the basis of symptoms and signs and is supported by spirometry. [2004], 1.2.140 When people with very severe COPD are reviewed in primary care they should be seen at least twice per year, and specific attention should be paid to the issues listed in table 6. [2018], 1.2.91 For more guidance on lung volume reduction procedures, see the NICE interventional procedures guidance on lung volume reduction surgery, endobronchial valves and endobronchial coils. [2004], 1.3.41 Measure spirometry in all people before discharge. In this guideline 'cor pulmonale' is defined as a clinical condition that is identified and managed on the basis of clinical features. [2010], 1.1.7 Think about a diagnosis of COPD in younger people who have symptoms of COPD, even when their FEV1/FVC ratio is above 0.7. 1.2.124 [2018]. 1.2.93 Consider referral to a specialist multidisciplinary team to assess for lung transplantation for people who: have severe COPD, with FEV1 less than 50% and breathlessness that affects their quality of life despite optimal medical treatment (see recommendations 1.2.11 to 1.2.17) and, have completed pulmonary rehabilitation and, do not have contraindications for transplantation (for example, comorbidities or frailty). [2004]. Selection should depend on the resources available and absence of factors associated with a worse prognosis (for example, acidosis). [2004], 1.2.8 Do not use oral corticosteroid reversibility tests to identify which people should be prescribed inhaled corticosteroids, because they do not predict response to inhaled corticosteroid therapy. [2010], ATS/ERS There are 1.3 million people in the UK with a diagnosis of chronic obstructive pulmonary disease (COPD) and the condition is responsible for considerable morbidity and mortality.1 COPD is also a common cause of hospital admission. To find out why the committee made the 2018 recommendations on incidental findings on chest X‑ray or CT scans and how they might affect practice, see rationale and impact. 10. [2004]. 1.2.130 Encourage people with COPD to respond promptly to exacerbation symptoms by following their action plan, which may include: adjusting their short-acting bronchodilator therapy to treat their symptoms, taking a short course of oral corticosteroids if their increased breathlessness interferes with activities of daily living, adding oral antibiotics if their sputum changes colour and increases in volume or thickness beyond their normal day-to-day variation, telling their healthcare professional. An exacerbation is a sustained worsening of the patient's symptoms from their usual stable state which is beyond normal day-to-day variations, and is acute in onset. To find out why the committee made the recommendations on assessing severity and using prognostic factors and how it might affect practice, see rationale and impact. To find out why the committee made the 2018 recommendations on ambulatory oxygen and short-burst oxygen therapy, and how they might affect practice, see rationale and impact. The NICE guideline on obesity states that a healthy range is 18.5 to 24.9 kg/m 2, but this range may not be appropriate for people with COPD. [2004], 1.3.18 Think about osteoporosis prophylaxis for people who need frequent courses of oral corticosteroids. Do not offer short-burst oxygen therapy to manage breathlessness in people with COPD who have mild or no hypoxaemia at rest. Dr Hopkinson will discuss the five fundamentals of COPD care: offer treatment and support to stop smoking [2004], 1.1.19 Untreated COPD and asthma are frequently distinguishable on the basis of history (and examination) in people presenting for the first time. 2019 report and Chronic obstructive pulmonary disease in over 16s: diagnosis and management [NICE, 2019a], and expert opinion in review articles [Gentry, 2017; BMJ Best Practice, 2018]. [2004]. For guidance on care for people in the last days of life, see the NICE guideline on care of dying adults. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties. 1.3.8 Both nebulisers and hand-held inhalers can be used to administer inhaled therapy during exacerbations of COPD. NICE has also produced a visual summary covering non-pharmacological management and use of inhaled therapies. The Guidelines team has produced the following directory of COVID-19 information and guidance for primary care. Key COVID-19 guidance for primary care. [2018], 1.2.60 For people who smoke or live with people who smoke, but who meet the other criteria for long-term oxygen therapy, ensure the person who smokes is offered smoking cessation advice and treatment, and referral to specialist stop smoking services (see the NICE guidelines on stop smoking interventions and services and medicines optimisation). To find out why the committee made the 2018 recommendations on prophylactic oral antibiotic therapy and how they might affect practice, see rationale and impact. Before starting azithromycin, ensure the person has had: an electrocardiogram (ECG) to rule out prolonged QT interval and, 1.2.49 When prescribing azithromycin, advise people about the small risk of hearing loss and tinnitus, and tell them to contact a healthcare professional if this occurs. 1.2.16 For people with COPD who are taking LAMA+LABA, consider LAMA+LABA+ICS if: 1.2.17 [2018], 1.2.55 Be aware that inappropriate oxygen therapy in people with COPD may cause respiratory depression. 1.1.1 [2004, amended 2018]. Be aware that it is not necessary to stop prophylactic azithromycin during an acute exacerbation of COPD. [2018], 1.2.131 Ask people with COPD if they experience breathlessness they find frightening. 1.2.95 Alpha‑1 antitrypsin replacement therapy is not recommended for people with alpha‑1 antitrypsin deficiency (see also recommendation 1.1.17). [2004]. [2004], 1.2.4 Unless contraindicated, offer nicotine replacement therapy, varenicline or bupropion as appropriate to people who want to stop smoking, combined with an appropriate support programme to optimise smoking quit rates for people with COPD. In this summary. At minimum, the information should cover: advice on quitting smoking (if relevant) and how this will help with the person's COPD, advice on avoiding passive smoke exposure, physical activity and pulmonary rehabilitation, medicines, including inhaler technique and the importance of adherence, details of local and national organisations and online resources that can provide more information and support, how COPD will affect other long-term conditions that are common in people with COPD (for example hypertension, heart disease, anxiety, depression and musculoskeletal problems). This document provides clinical recommendations for treatment of chronic obstructive pulmonary disease (COPD) exacerbations. 05 December 2018 [2018]. This site uses cookies, some may have been set already. Whenever possible, use features from the history and examination (such as those listed in table 3) to differentiate COPD from asthma. [2018], 1.2.110 1 Not troubled by breathlessness except on strenuous exercise. [2004]. In some cases they may be seen by members of the COPD team who have appropriate training and expertise. March 2019. Tell them: not to clean the spacer more than monthly, because more frequent cleaning affects their performance (because of a build-up of static), to hand wash using warm water and washing-up liquid, and allow the spacer to air dry. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. For more guidance on providing information to people and discussing their preferences with them, see the NICE guideline on patient experience in adult NHS services. [2004, amended 2018], 1.3.4 Hospital-at-home and assisted-discharge schemes are safe and effective and should be used as an alternative way of caring for people with exacerbations of COPD who would otherwise need to be admitted or stay in hospital. A formal activities of daily living assessment may be helpful when there is still doubt. Offer pulmonary rehabilitation to all people who view themselves as functionally disabled by COPD (usually Medical Research Council [MRC] grade 3 and above). To find out why the committee made the 2018 recommendations on self-management and telehealth monitoring and how they might affect practice, see rationale and impact. 2019 report and Chronic obstructive pulmonary disease in over 16s: diagnosis and management [NICE, 2019a], and review articles [Rabe, 2017; BMJ Best Practice, 2018]. © NICE 2019. 1.2.103 Calculate BMI for people with COPD: the normal range for BMI is 20 to less than 25 kg/m2[6], refer people for dietetic advice if they have a BMI that is abnormal (high or low) or changing over time, for people with a low BMI, give nutritional supplements to increase their total calorific intake and encourage them to exercise to augment the effects of nutritional supplementation. [2004], 1.3.46 Make arrangements for follow-up and home care (such as visiting nurse, oxygen delivery or referral for other support) before discharge. Published date: [2004]. [2004], 1.3.35 Consider NIV for people who are slow to wean from invasive ventilation. [2004], 1.1.22 If diagnostic uncertainty remains, think about referral for more detailed investigations, including imaging and measurement of transfer factor for carbon monoxide (TLCO). RELEASE DATE: December 5, 2018 with update July 2019. [2018]. NICE has also produced a guideline on antimicrobial prescribing for acute exacerbations of COPD. 1.1.24 [2004]. [2004], 1.3.6 There are currently insufficient data to make firm recommendations about which people with COPD with an exacerbation are most suitable for hospital-at-home or early discharge. [2004], 1.3.11 If a person with COPD is hypercapnic or acidotic the nebuliser should be driven by compressed air rather than oxygen (to avoid worsening hypercapnia). The NICE guideline has been long overdue; it conflicts with the most recent 2019 GOLD COPD guidance on prevention, diagnosis and management, which might cause clinicians some confusion as to which guideline to use. The Medical Research Council (MRC) dyspnoea scale (see table 1) should be used to grade the breathlessness according to the level of exertion required to elicit it. [2004], 1.2.114 Assess people who are using long-term oxygen therapy and who are planning air travel in line with the BTS recommendations[7]. [2010], 1.2.6 For more guidance on varenicline see the NICE technology appraisal guidance on varenicline for smoking cessation. 05 December 2018 [2017]) is: mild exacerbation, the person has an increased need for medication, which they can manage in their own normal environment, moderate exacerbation, the person has a sustained worsening of respiratory status that requires treatment with systemic corticosteroids and/or antibiotics. [2018], 1.2.51 Only continue treatment if the continued benefits outweigh the risks. [2004], 1.2.37 Take particular caution when using theophylline in older people, because of differences in pharmacokinetics, the increased likelihood of comorbidities and the use of other medications. Repeat arterial blood gas measurements regularly, according to the response to treatment. The literature included in this 2019 edition of the GOLD Report has been updated to include important literature in COPD research and care that was published from January 2017 to July 2018. Offer a respiratory review to assess whether a lung volume reduction procedure is a possibility for people with COPD when they complete pulmonary rehabilitation and at other subsequent reviews, if all of the following apply: they have severe COPD, with FEV1 less than 50% and breathlessness that affects their quality of life despite optimal medical treatment (see recommendations 1.2.11 to 1.2.17), they can complete a 6‑minute walk distance of at least 140 m (if limited by breathlessness). [2004, amended 2018], 1.1.5 Measure post-bronchodilator spirometry to confirm the diagnosis of COPD. [2004], 1.2.70 Only prescribe ambulatory oxygen therapy after an appropriate assessment has been performed by a specialist. identified as omissions, and NICE has decided to add these as a 2019 update for publication in July 2019.3 A draft guideline covering these two areas was put out to consultation in February. Do not offer routine telehealth monitoring of physiological status as part of management for stable COPD. To find out why the committee made the 2018 recommendations on long-term oxygen therapy and how they might affect practice, see rationale and impact. 1.1.18 For most people, routine spirometric reversibility testing is not necessary as part of the diagnostic process or to plan initial therapy with bronchodilators or corticosteroids. [2019]. Last updated May 2019. ... 2019 guidelines by the National Institute for Health and Care Excellence (NICE) on antimicrobial prescribing guidance for managing common infections. Some people with advanced COPD may need long-term oral corticosteroids when these cannot be withdrawn following an exacerbation. [2018], 1.2.129 See recommendations 1.3.13 to 1.3.20 for more guidance on oral corticosteroids. [2004]. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. This Pocket Guide has been developed from the Global Strategy for the Diagnosis, Management, and Prevention of COPD (2019 Report), which aims to provide a non-biased review of the current evidence for the assessment, diagnosis and treatment of patients with COPD that can aid the clinician. NICE guideline [NG115] Severity assessment is, nevertheless, important because it has implications for therapy and relates to prognosis. At diagnosis and at each review appointment, offer people with COPD and their family members or carers (as appropriate): written information about their condition, opportunities for discussion with a healthcare professional who has experience in caring for people with COPD. [2004], 1.2.98 It is recommended that the multidisciplinary COPD team includes respiratory nurse specialists. Carbocisteine and acetylcysteine are the oral mucolytics licensed for use in people with chronic obstructive pulmonary disease. A post bronchodilator ratio of forced expiratory volume in 1 second to forced vital capacity (FEV1/FVC) of less than 0.7 on spirometry confirms persistent airflow obstruction. Eur Respir J 2019… [2004], 1.2.136 If time permits, optimise the medical management of people with COPD before surgery. COPD is heterogeneous, so no single measure can adequately assess disease severity in an individual. 1.2.97 When defining the activity of the multidisciplinary team, think about the following functions: assessment (including performing spirometry, assessing which delivery systems to use for inhaled therapy, the need for aids for daily living and assessing the need for oxygen), identifying and managing anxiety and depression, non-invasive ventilation and palliative care, advising people on self-management strategies, identifying and monitoring people at high risk of exacerbations and undertaking activities to avoid emergency admissions, education for people with COPD, their carers, and for healthcare professionals. 2019 report , and Chronic obstructive pulmonary disease in over 16s: diagnosis and management [NICE, 2019a], and expert opinion in a review article [Suntharalingam, 2016]. 1.2.27 [2004, amended 2018], 1.2.28 Think about nebuliser therapy for people with distressing or disabling breathlessness despite maximal therapy using inhalers. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease.

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