Offer people a short course of oral corticosteroids and a short course of oral antibiotics to keep at home as part of their exacerbation action plan if: they have had an exacerbation within the last year, and remain at risk of exacerbations, they understand and are confident about when and how to take these medicines, and the associated benefits and harms, they know to tell their healthcare professional when they have used the medicines, and to ask for replacements. Abstract. [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. 1.2.89 At the respiratory review, refer the person with COPD to a lung volume reduction multidisciplinary team to assess whether lung volume reduction surgery or endobronchial valves are suitable if they have: hyperinflation, assessed by lung function testing with body plethysmography and, emphysema on unenhanced CT chest scan and, optimised treatment for other comorbidities. [2004], 1.3.43 People who have had an episode of respiratory failure should have satisfactory oximetry or arterial blood gas results before discharge. The Guidelines team has produced the following directory of COVID-19 information and guidance for primary care. [2004], 1.2.102 [2004], 1.2.107 When appropriate, use benzodiazepines, tricyclic antidepressants, major tranquillisers and oxygen for breathlessness in people with end-stage COPD that is unresponsive to other medical therapy. For people with COPD who are taking LAMA+LABA and whose day-to-day symptoms adversely impact their quality of life: consider a trial of LAMA+LABA+ICS, lasting for 3 months only. 1.2.11 [2004], 1.3.38 Use pulse oximetry to monitor the recovery of people with non-hypercapnic, non-acidotic respiratory failure. Chronic obstructive pulmonary disease All NICE products on chronic obstructive pulmonary disease. [2018], 1.2.55 Be aware that inappropriate oxygen therapy in people with COPD may cause respiratory depression. 1.2.19 Advise people with COPD that the following factors increase their risk of exacerbations: continued smoking or relapse for ex‑smokers, seasonal variation (winter and spring). [2018]. 1.2.27 [2018]. [2004], 1.2.136 If time permits, optimise the medical management of people with COPD before surgery. [2004], 1.2.84 Pulmonary rehabilitation programmes should include multicomponent, multidisciplinary interventions that are tailored to the individual person's needs. Chronic thromboembolic pulmonary hypertension (group 4) 10.1 Diagnosis 10.2 Therapy 10.2.1 Surgical 10.2.2 Medical 10.2.3 Interventional 11. If people have excessive sputum, they should be taught: how to use positive expiratory pressure devices, active cycle of breathing techniques. [2004, amended 2018], To identify organisms if sputum is persistently present and purulent, To exclude asthma if diagnostic doubt remains. [2004], 1.2.141 Specialists should regularly review people with severe COPD who need interventions such as long-term non-invasive ventilation. As part of the risk assessment, cover the risks for both the person with COPD and the people who live with them, including: the risks of falls from tripping over the equipment, the risks of burns and fires, and the increased risk of these for people who live in homes where someone smokes (including e‑cigarettes).Base the decision on whether long-term oxygen therapy is suitable on the results of the structured risk assessment. [2018], 1.2.129 See recommendations 1.3.13 to 1.3.20 for more guidance on oral corticosteroids. 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. It includes people who have right heart failure secondary to lung disease and people whose primary pathology is salt and water retention, leading to the development of peripheral oedema (swelling). 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. Long-term oxygen therapy (LTOT) [2004]. [2004], 1.2.34 Long-term use of oral corticosteroid therapy in COPD is not normally recommended. 10. Composite assessment tools such as the ASA scoring system are the best predictors of risk. [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. [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). 1.1.26 Assess the severity of airflow obstruction according to the reduction in FEV1, as shown in table 4. To find out why the committee made the 2018 recommendation on risk factors for exacerbations and how it might affect practice see rationale and impact. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. 1.2.74 Refer people who are adequately treated but have chronic hypercapnic respiratory failure and have needed assisted ventilation (whether invasive or non-invasive) during an exacerbation, or who are hypercapnic or acidotic on long-term oxygen therapy, to a specialist centre for consideration of long-term non-invasive ventilation. [2004], 1.2.72 When choosing which equipment to prescribe, take account of the hours of ambulatory oxygen use and oxygen flow rate needed. Be aware that it is not necessary to stop prophylactic azithromycin during an acute exacerbation of COPD. In this session, Dr Nick Hopkinson will provide an overview of the NICE guideline on COPD in over 16s, which was updated earlier this year. [2004], 1.3.18 Think about osteoporosis prophylaxis for people who need frequent courses of oral corticosteroids. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. 1.2.1 For guidance on the management of multimorbidity, see the NICE guideline on multimorbidity. [2004], 1.2.108 People with end-stage COPD and their family members or carers (as appropriate) should have access to the full range of services offered by multidisciplinary palliative care teams, including admission to hospices. Suspect a diagnosis of COPD in people over 35 who have a risk factor (generally smoking or a history of smoking) and who present with 1 or more of the following symptoms: 1.1.2 When thinking about a diagnosis of COPD, ask the person if they have: haemoptysis (coughing up blood).These last 2 symptoms are uncommon in COPD and raise the possibility of alternative diagnoses. [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. Comprehensive evidence syntheses, including meta-analyses, were performed to summarise all available evidence relevant to the Task Force's questions. [2004]. Include a variety of other measures such as improvement in symptoms, activities of daily living, exercise capacity, and rapidity of symptom relief. [2004], 1.2.45 Last updated: 1.2.10 Do not assess the effectiveness of bronchodilator therapy using lung function alone. 1.3.2 For people who have their exacerbation managed in primary care: sending sputum samples for culture is not recommended in routine practice, pulse oximetry is of value if there are clinical features of a severe exacerbation. [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 guideline. [2018]. To assess cardiac status if cardiac disease or pulmonary hypertension are suspected because of: • a history of cardiovascular disease, hypertension or hypoxia or, • clinical signs such as tachycardia, oedema, cyanosis or features of cor pulmonale, To assess cardiac status if cardiac disease or pulmonary hypertension are suspected, To investigate symptoms that seem disproportionate to the spirometric impairment, To investigate signs that may suggest another lung diagnosis (such as fibrosis or bronchiectasis), To investigate abnormalities seen on a chest X-ray, To assess suitability for lung volume reduction procedures, To assess for alpha-1 antitrypsin deficiency if early onset, minimal smoking history or family history, Transfer factor for carbon monoxide (TLCO). 1 [2004], 1.2.76 It is recommended that the diagnosis of cor pulmonale is made clinically and that this process should involve excluding other causes of peripheral oedema (swelling). This is usually managed by taking increased doses of short-acting bronchodilators. (1959) The significance of respiratory symptoms and the diagnosis of chronic bronchitis in a working population. [2004]. 1.1.28 Perform spirometry in people who are over 35, current or ex‑smokers, and have a chronic cough. Scenario: Stable COPD: covers the management of people with persistent symptoms of COPD who are not experiencing an acute exacerbation. 1.2.56 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. It aims to help people with COPD to receive a diagnosis earlier so that they can benefit from treatments to reduce symptoms, improve quality of life and keep them healthy for longer. 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. [2004]. [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. References: NICE COPD guidance NG115 December 2018 and July 2019, NG114 & NICE QS10 February 2016 update Camden, Haringey and Islington Stable COPD Treatment Guidelines v10.1 Updated February 2020; Review date: October 2022 Produced by the Camden, Haringey and Islington Responsible Respiratory Prescribing Group [2004]. [2018], 1.2.79 Oedema associated with cor pulmonale can usually be controlled symptomatically with diuretic therapy. [2004]. [2004, amended 2018], 1.2.138 Review people with COPD at least once per year and more frequently if indicated, and cover the issues listed in table 6. [2004], 1.3.12 The driving gas for nebulised therapy should always be specified in the prescription. The recommendations on choice of antibiotic are taken from the NICE guideline Chronic obstructive pulmonary disease (acute exacerbation): antimicrobial prescribing [ NICE… RELEASE DATE: December 5, 2018 with update July 2019. [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. Do not offer ambulatory oxygen to manage breathlessness in people with COPD who have mild or no hypoxaemia at rest. 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. PRIOR VERSION (S): NICE guideline CG101 June 2010, 2004. [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. For people who are taking prophylactic azithromycin and are still at risk of exacerbations, provide a non-macrolide antibiotic to keep at home as part of their exacerbation action plan (see recommendation 1.2.126). NICE Bites is a monthly prescribing bulletin published by North West Medicines Information centre which summarises key recommendations from NICE guidance. [2018], 1.2.133 Most people with COPD – whatever their age – can develop adequate inhaler technique if they are given training. In most people with COPD, however, a pragmatic approach guided by individual patient assessment is needed when choosing a device. [2004, amended 2018], 1.3.37 Monitor people's recovery by regular clinical assessment of their symptoms and observation of their functional capacity. Some people with advanced COPD may need long-term oral corticosteroids when these cannot be withdrawn following an exacerbation. [2018], 1.2.50 Review prophylactic azithromycin after the first 3 months, and then at least every 6 months. [2018], 1.2.20 [2004]. [2004], 1.2.9 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. The change in these symptoms often necessitates a change in medication. Clinical guideline [CG101] Published date: 23 June 2010. 2019 report and Chronic obstructive pulmonary disease in over 16s: diagnosis and management [NICE, 2019a], and review articles [Rabe, 2017; BMJ Best Practice, 2018]. Base the choice of drugs and inhalers on: the person's preferences and ability to use the inhalers, the drugs' potential to reduce exacerbations, their cost.Minimise the number of inhalers and the number of different types of inhaler used by each person as far as possible. 1.2.126 [2018]. [2004], 1.3.13 [2004], 1.3.32 When people are started on NIV there should be a clear plan covering what to do in the event of deterioration, and ceilings of therapy should be agreed. For guidance on treating severe COPD with roflumilast, see NICE's technology appraisal guidance on roflumilast for treating chronic obstructive pulmonary disease. British Medical Journal 2: 257–66. Commonly reported symptoms are worsening breathlessness, cough, increased sputum production and change in sputum colour. Publications Includes any guidance, advice, NICE Pathways and quality standards. NICE clinical guideline 101 – Chronic obstructive pulmonary disease 5 Introduction An estimated 3 million people have chronic obstructive pulmonary disease (COPD) in the UK. [2004], 1.2.29 Do not prescribe nebulised therapy without an assessment of the person's and/or carer's ability to use it. [2010], 1.2.5 For more guidance on helping people to quit smoking, see the NICE guideline on stop smoking interventions and services. For people who are using long-acting bronchodilators outside of recommendations 1.2.11 and 1.2.12 and whose symptoms are under control, explain to them that they can continue with their current treatment until both they and their NHS healthcare professional agree it is appropriate to change. The diagnosis is suspected on the basis of symptoms and signs and is supported by spirometry. 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. 1.2.137 [2018], 1.2.122 Be aware of the obligation to provide accessible information as detailed in the NHS Accessible Information Standard. [2004], 1.3.15 Encourage people who need corticosteroid therapy to present early to get maximum benefits. [2018]. A general classification of the severity of an acute exacerbation (Oba Y et al. Published products on … [2018]. Be aware that there are no long-term studies on the use of prophylactic antibiotics in people with COPD. [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. Subject to Notice of rights. NICE has produced a COVID-19 rapid guideline on community-based care of patients with chronic obstructive pulmonary disease (COPD). Whenever possible, use features from the history and examination (such as those listed in table 3) to differentiate COPD from asthma. [2004], 1.2.57 Assess people for long-term oxygen therapy by measuring arterial blood gases on 2 occasions at least 3 weeks apart in people who have a confident diagnosis of COPD, who are receiving optimum medical management and whose COPD is stable. However, investigations may sometimes be useful in ensuring appropriate treatment is given. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian. Key COVID-19 guidance for primary care. ... 2019 guidelines by the National Institute for Health and Care Excellence (NICE) on antimicrobial prescribing guidance for managing common infections. [2004], 1.2.106 When appropriate, use opioids to relieve breathlessness in people with end-stage COPD that is unresponsive to other medical therapy. remain breathless or have exacerbations despite: having used or been offered treatment for tobacco dependence if they smoke and, optimised non-pharmacological management and relevant vaccinations and, using a short-acting bronchodilator. [2018]. [2004], 1.2.71 Small light-weight cylinders, oxygen-conserving devices and portable liquid oxygen systems should be available for people with COPD. A significant proportion of these people will go on to develop airflow limitation. [2010, amended 2018]. In some cases they may be seen by members of the COPD team who have appropriate training and expertise. [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. [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. [2004]. [2004], 1.3.20 [2004], 1.2.25 Provide a spacer that is compatible with the person's metered-dose inhaler. 1.2.16 For people with COPD who are taking LAMA+LABA, consider LAMA+LABA+ICS if: 1.2.17 [2004, amended 2018], 1.1.12 [2004], 1.1.29 Consider spirometry in people with chronic bronchitis. 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. By NICE 12 September 2019. [3] The MHRA has published a safety alert around the use of non CE marked nebulisers for COPD. We found no new evidence that affects the recommendations in this guideline. [2010], 1.1.6 Think about alternative diagnoses or investigations for older people who have an FEV1/FVC ratio below 0.7 but do not have typical symptoms of COPD. Do not use the following to treat cor pulmonale caused by COPD: digoxin (unless there is atrial fibrillation). [2004], 1.2.87 For guidance on preventing and treating flu, see the NICE technology appraisals on oseltamivir, amantadine (review) and zanamivir for the prophylaxis of influenza and amantadine, oseltamivir and zanamivir for the treatment of influenza. [2018]. Offer LAMA+LABA[2] to people who: do not have asthmatic features/features suggesting steroid responsiveness and. 26 July 2019. 1.2.14 [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. Do not use previous lung volume reduction procedures as a reason not to refer a person for assessment for lung transplantation. [2004, amended 2018], 1.1.5 Measure post-bronchodilator spirometry to confirm the diagnosis of COPD. It is individually tailored and designed to optimise each person's physical and social performance and autonomy. In this guideline 'cor pulmonale' is defined as a clinical condition that is identified and managed on the basis of clinical features. Everything NICE has said on diagnosing and managing chronic obstructive pulmonary disease in people aged 16 and over in an interactive flowchart [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]. [2018]. 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. [2004]. continue to have 1 or more of the following, particularly if they have significant daily sputum production: frequent (typically 4 or more per year) exacerbations with sputum production, prolonged exacerbations with sputum production, exacerbations resulting in hospitalisation. [2004]. 1.2.67 [2004, amended 2018], 1.2.101 For guidance on diagnosing and managing depression, see the NICE guideline on depression in adults with a chronic physical health problem. The NICE guideline has had to catch up on 8 years of develop - ments, mainly in pharmacological treatment. 1.2.12 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. managing exacerbations of COPD. [2004], 1.1.23 Reconsider the diagnosis of COPD for people who report a marked improvement in symptoms in response to inhaled therapy. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties. [2004], 1.2.98 It is recommended that the multidisciplinary COPD team includes respiratory nurse specialists. 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. [2010], 1.2.43 Treatment with alpha-tocopherol and beta-carotene supplements, alone or in combination, is not recommended. 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%). [2004], 1.2.118 There are significant differences in the response of people with COPD and asthma to education programmes. Pulmonary hypertension with unclear and/or multifactorial mechanisms (group 5) 12. 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