[2018], 1.2.50 Review prophylactic azithromycin after the first 3 months, and then at least every 6 months. [2018], 1.2.125 Develop an individualised exacerbation action plan in collaboration with each person with COPD who is at risk of exacerbations. Everything NICE has said on diagnosing and managing chronic obstructive pulmonary disease in people aged 16 and over in an interactive flowchart [2018]. [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. 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. This review should include pulse oximetry. The Guidelines team has produced the following directory of COVID-19 information and guidance for primary care. Dr Karen Sennett highlights key learning points for primary care from the updated NICE guideline on chronic obstructive pulmonary disease (COPD) Welcome to Guidelines in Practice. 1.2.10 Do not assess the effectiveness of bronchodilator therapy using lung function alone. 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. Be aware that it is not necessary to stop prophylactic azithromycin during an acute exacerbation of COPD. Develop an individualised self-management plan in collaboration with each person with COPD and their family members or carers (as appropriate), and: include education on all relevant points from recommendation 1.2.121, review the plan at future appointments. In some cases they may be seen by members of the COPD team who have appropriate training and expertise. [2004], 1.3.26 Measure oxygen saturation in people with an exacerbation if there are no facilities to measure arterial blood gases. Assess the need for oxygen therapy in people with: very severe airflow obstruction (FEV1 below 30% predicted), oxygen saturations of 92% or less breathing air.Also consider assessment for people with severe airflow obstruction (FEV1 30–49% predicted). [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]. In this summary. 1.2.80 [2018], 1.2.133 [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). 1.2.14 [2004]. For people with mild airflow obstruction, only diagnose COPD if they have one or more of the symptoms in recommendation 1.1.1. People have the right to be involved in discussions and make informed decisions about their care, as described in your care. [2004], 1.2.115 Assess people with an FEV1 below 50% predicted who are planning air travel in line with the BTS recommendations. 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], 1.2.83 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. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. Includes any guidance, advice, NICE Pathways and quality standards. [2004], 1.3.31 It is recommended that NIV should be delivered in a dedicated setting, with staff who have been trained in its application, who are experienced in its use and who are aware of its limitations. [2010], 1.2.5 For more guidance on helping people to quit smoking, see the NICE guideline on stop smoking interventions and services. [2004], 1.3.12 The driving gas for nebulised therapy should always be specified in the prescription. It clarifies the importance of dual bronchodilation to improve symptoms and to reduce exacerbations, as well as the importance of inhaled corticosteroids in people with a significant asthma component or high eosinophil counts. [6] This recommendation was not reviewed as part of the 2018 or 2019 guideline updates. Do not offer long-term oxygen therapy to people who continue to smoke despite being offered smoking cessation advice and treatment, and referral to specialist stop smoking services. Different investigation strategies are needed for people in hospital (who will tend to have more severe exacerbations) and people in the community. 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. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Scenario: Stable COPD: covers the management of people with persistent symptoms of COPD who are not experiencing an acute exacerbation. [2004], 1.3.27 If necessary, prescribe oxygen to keep the oxygen saturation of arterial blood (SaO2) within the individualised target range. [4] At the time of publication (July 2019), azithromycin did not have a UK marketing authorisation for this indication. 2 Short of breath when hurrying or walking up a slight hill. 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], 1.3.9 The choice of delivery system should reflect the dose of drug needed, the person's ability to use the device, and the resources available to supervise therapy administration. 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. [2004], 1.2.39 Reduce the dose of theophylline for people who are having an exacerbation if they are prescribed macrolide or fluoroquinolone antibiotics (or other drugs known to interact). [2004], 1.2.139 For most people with stable severe COPD regular hospital review is not necessary, but there should be locally agreed mechanisms to allow rapid access to hospital assessment when needed. [2004], 1.3.16 For guidance on treating severe COPD with roflumilast, see NICE's technology appraisal guidance on roflumilast for treating chronic obstructive pulmonary disease. 1.2.121 Commonly reported symptoms are worsening breathlessness, cough, increased sputum production and change in sputum colour. Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible. 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). Start prophylaxis without monitoring for people over 65. [2004], 1.3.38 Use pulse oximetry to monitor the recovery of people with non-hypercapnic, non-acidotic respiratory failure. [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. Whenever possible, use features from the history and examination (such as those listed in table 3) to differentiate COPD from asthma. 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. The purpose of the assessment is to assess the extent of desaturation, the improvement in exercise capacity with supplemental oxygen, and the oxygen flow rate needed to correct desaturation. 1.2.88 [2010, amended 2018]. 1.2.100 [2018]. 2 Global Initiative for Chronic Obstructive Lung Disease (GOLD) (2008) Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. [2018], 1.3.22 Only use intravenous theophylline as an adjunct to exacerbation management if there is an inadequate response to nebulised bronchodilators. 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. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. 1.3.1 Use the factors in table 7 to assess whether people with COPD need hospital treatment. In these cases, the dose of oral corticosteroids should be kept as low as possible. [2004], 1.3.43 People who have had an episode of respiratory failure should have satisfactory oximetry or arterial blood gas results before discharge. [2004], 1.2.40 Consider mucolytic drug therapy for people with a chronic cough productive of sputum. Most patients are not diagnosed until they are in their fifties. Do not offer the following treatments solely to manage pulmonary hypertension caused by COPD, except as part of a randomised controlled trial: 1.2.78 [2004], 1.2.22 Provide an alternative inhaler if a person cannot use a particular one correctly or it is not suitable for them. To find out why the committee made the 2019 recommendation on duration of oral corticosteroid use and how it might affect practice, see rationale and impact. [2004], 1.3.33 Treat hospitalised exacerbations of COPD on intensive care units, including invasive ventilation when this is thought to be necessary. See the General Medical Council's Prescribing guidance: prescribing unlicensed medicines for further information. [2004, amended 2018], 1.3.37 Monitor people's recovery by regular clinical assessment of their symptoms and observation of their functional capacity. [2018]. [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. NICE has also produced a visual summary covering non-pharmacological management and use of inhaled therapies. 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], 1.2.60 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). Be aware of, and be prepared to discuss with the person, the risk of side effects (including pneumonia) in people who take inhaled corticosteroids for COPD[1]. In most people with COPD, however, a pragmatic approach guided by individual patient assessment is needed when choosing a device. [2004], Already receiving long-term oxygen therapy, Significant comorbidity (particularly cardiac disease and insulin-dependent diabetes). Offer pneumococcal vaccination and an annual flu vaccination to all people with COPD, as recommended by the Chief Medical Officer. [2018], 1.2.64 To ensure everyone eligible for long-term oxygen therapy is identified, pulse oximetry should be available in all healthcare settings. established by the Committee: 1) COPD, All Fields, Adult: 19+ years, only items with abstracts, Clinical Trial, Meta-analysis, Human. Include a variety of other measures such as improvement in symptoms, activities of daily living, exercise capacity, and rapidity of symptom relief. [7] British Thoracic Society Standards of Care Committee (2002) Managing passengers with respiratory disease planning air travel: British Thoracic Society recommendations. The NICE guideline has had to catch up on 8 years of develop - ments, mainly in pharmacological treatment. 2019 repor t [ GOLD, 2019 ]. [2018]. [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. [2004], 1.1.10 Spirometry services should be supported by quality control processes. [2004], 1.1.9 Spirometry can be performed by any healthcare worker who has had appropriate training and has up-to-date skills. Before starting LAMA+LABA+ICS, conduct a clinical review to ensure that: the person's non-pharmacological COPD management is optimised and they have used or been offered treatment for tobacco dependence if they smoke, acute episodes of worsening symptoms are caused by COPD exacerbations and not by another physical or mental health condition, the person's day-to-day symptoms that are adversely impacting their quality of life are caused by COPD and not by another physical or mental health condition. 1.2.124 1 2004. [2018], 1.2.63 This guideline updates and replaces NICE guideline CG101 (June 2010). For carbocisteine the manufacturer recommends a starting dose of 2250 mg in divided doses, reducing to 1500 mg daily in divided doses when a satisfactory response is … [2004], 1.3.14 In the absence of significant contraindications, consider oral corticosteroids for people in the community who have an exacerbation with a significant increase in breathlessness that interferes with daily activities. [2004], 1.3.34 When assessing suitability for intubation and ventilation during exacerbations, think about functional status, BMI, need for oxygen when stable, comorbidities and previous admissions to intensive care units, in addition to age and FEV1. A significant proportion of these people will go on to develop airflow limitation. [2004], 1.1.30 When clinically indicated, refer people for specialist advice. [2004], • Need for referral to specialist and therapy services, • Need for social services and occupational therapy input. 1.1.14 1.2.56 [2018], 1.2.79 Oedema associated with cor pulmonale can usually be controlled symptomatically with diuretic therapy. Pulmonary rehabilitation is not suitable for people who are unable to walk, who have unstable angina or who have had a recent myocardial infarction. This recommendation was not reviewed as part of the 2018 or 2019 guideline updates. [2010], 1.2.7 Use short-acting bronchodilators, as necessary, as the initial empirical treatment to relieve breathlessness and exercise limitation. [2004], 1.3.30 Use NIV as the treatment of choice for persistent hypercapnic ventilatory failure during exacerbations despite optimal medical therapy. Offer pulmonary rehabilitation to all people who view themselves as functionally disabled by COPD (usually Medical Research Council [MRC] grade 3 and above). Subject to Notice of rights. Informed consent should be obtained and documented. [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. 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. [2018], 1.2.2 Document an up-to-date smoking history, including pack years smoked (number of cigarettes smoked per day, divided by 20, multiplied by the number of years smoked) for everyone with COPD. All rights reserved. [2004]. [2004], 1.2.118 There are significant differences in the response of people with COPD and asthma to education programmes. Perform additional investigations when needed, as detailed in table 2. It recommends changes to usual practice to maximise the safety of patients and protect staff from infection during the COVID-19 pandemic. Offer people with alpha 1 antitrypsin deficiency a referral to a specialist centre to discuss how to manage their condition. [2004], 1.3.20 [2018]. All problems (adverse events) related to a medicine or medical device used for treatment or in a procedure should be reported to the Medicines and Healthcare products Regulatory Agency using the Yellow Card Scheme. [2018], 1.2.52 The diagnosis of chronic obstructive pulmonary disease (COPD) depends on thinking of it as a cause of breathlessness or cough. [2018], 1.2.20 stop for breath when walking at own pace. [2018], 1.2.132 If oxygen therapy is needed, administer it simultaneously by nasal cannulae. 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. 1.1.25 This guideline sets out an antimicrobial prescribing strategy for acute exacerbations of chronic obstructive pulmonary disease (COPD). [2004], 1.2.29 Do not prescribe nebulised therapy without an assessment of the person's and/or carer's ability to use it. This site uses cookies, some may have been set already. The NICE guideline on obesity states that a healthy range is 18.5 to 24.9 kg/m2, but this range may not be appropriate for people with COPD. About 900,000 have diagnosed COPD and an estimated 2 million people have COPD which remains undiagnosed1. [2004], 1.2.86 [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], 1.1.22 If diagnostic uncertainty remains, think about referral for more detailed investigations, including imaging and measurement of transfer factor for carbon monoxide (TLCO). Places should be available within a reasonable time of referral. [2019]. [2018], 1.2.131 Ask people with COPD if they experience breathlessness they find frightening. Offer 30 mg oral prednisolone daily for 5 days. In all people presenting to hospital with an acute exacerbation: measure arterial blood gas tensions and record the inspired oxygen concentration, perform a full blood count and measure urea and electrolyte concentrations, measure a theophylline level on admission in people who are taking theophylline therapy, send a sputum sample for microscopy and culture if the sputum is purulent, take blood cultures if the person has pyrexia. [2018], 1.2.90 Only offer endobronchial coils as part of a clinical trial and after assessment by a lung volume reduction multidisciplinary team. [2004]. [2004], 1.3.25 It is recommended that doxapram is used only when non-invasive ventilation is either unavailable or inappropriate. 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. 1.2.27 FUNDING SOURCE: Department of Health and Social Care, United Kingdom. National Institute for Health and Clinical Excellence (NICE) NG118 - Renal and ureteric stones: assessment and management - HSC (SQSD) (NICE NG118) 07/19 National Institute for Health and Clinical Excellence (NICE) NG119 - Cerebral palsy in adults - HSC (SQSD) (NICE NG119) 08/19 January 2019 For people who have used 3 or more courses of oral corticosteroids and/or oral antibiotics in the last year, investigate the possible reasons for this. Do not offer long-term oxygen therapy to treat isolated nocturnal hypoxaemia caused by COPD. 1.2.58 [2004]. 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. Last updated: [2018], 1.2.127 For guidance on the choice of antibiotics see the NICE guideline on antimicrobial prescribing for acute exacerbations of COPD. 1.1.26 Assess the severity of airflow obstruction according to the reduction in FEV1, as shown in table 4. [2] The MHRA has published advice on the risk for people with certain cardiac conditions when taking tiotropium delivered via Respimat or Handihaler (2015). RELEASE DATE: December 5, 2018 with update July 2019. [2018], 1.2.62 [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. A formal activities of daily living assessment may be helpful when there is still doubt. [2004]. [2018], 1.2.51 Only continue treatment if the continued benefits outweigh the risks. [2004]. Some people with advanced COPD may need long-term oral corticosteroids when these cannot be withdrawn following an exacerbation. [2004], 1.2.35 Monitor people who are having long-term oral corticosteroid therapy for osteoporosis, and give them appropriate prophylaxis. 1.1.13 If the person is a current smoker, their spirometry results are normal and they have no symptoms or signs of respiratory disease: offer smoking cessation advice and treatment, and referral to specialist stop smoking services (see the NICE guideline on stop smoking interventions and services), warn them that they are at higher risk of lung disease, advise them to return if they develop respiratory symptoms, be aware that the presence of emphysema on a CT scan is an independent risk factor for lung cancer. [2004], 1.3.35 Consider NIV for people who are slow to wean from invasive ventilation. [2004]. * See the NICE guideline on chronic heart failure in adults for recommendations on using serum natriuretic peptides to diagnose heart failure. Give people (particularly people discharged from hospital) clear instructions on why, when and how to stop their corticosteroid treatment. [2010], 1.1.27 [2004], 1.3.7 Include people's preferences about treatment at home or in hospital in decision-making. [2004, amended 2018], Night time waking with breathlessness and/or wheeze, Significant diurnal or day-to-day variability of symptoms, 1.1.20 In addition to the features in table 3, use longitudinal observation of people (with spirometry, peak flow or symptoms) to help differentiate COPD from asthma. [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. Follow-up of all people with COPD should include: highlighting the diagnosis of COPD in the case record and recording this using Read Codes on a computer database, recording the values of spirometric tests performed at diagnosis (both absolute and percent predicted), offering advice and treatment to help them stop smoking, and referral to specialist stop smoking services (see the NICE guideline on stop smoking interventions and services), recording the opportunistic measurement of spirometric parameters (a loss of 500 ml or more over 5 years will show which people have rapidly progressing disease and may need specialist referral and investigation). Advise people who are having long-term oxygen therapy that they should breathe supplemental oxygen for a minimum of 15 hours per day. Selection should depend on the resources available and absence of factors associated with a worse prognosis (for example, acidosis). 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. To find out why the committee made the 2018 recommendations on managing pulmonary hypertension and cor pulmonale and how they might affect practice, see rationale and impact. [2018], 1.2.122 Be aware of the obligation to provide accessible information as detailed in the NHS Accessible Information Standard. Eur Respir J 2019… This might include a course of pulmonary rehabilitation. Do not offer ambulatory oxygen to manage breathlessness in people with COPD who have mild or no hypoxaemia at rest. 1.1.15 At the time of their initial diagnostic evaluation in addition to spirometry all patients should have: a chest radiograph to exclude other pathologies, a full blood count to identify anaemia or polycythaemia, 1.1.16 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. Consider primary care respiratory review and spirometry (see recommendations 1.1.1 to 1.1.11) for people with emphysema or signs of chronic airways disease on a chest X-ray or CT scan. to reconsider the diagnosis, for people who show an exceptionally good response to treatment, to monitor disease progression. [2004], 1.2.32 Offer people a choice between a facemask and a mouthpiece to administer their nebulised therapy, unless the drug specifically requires a mouthpiece (for example, anticholinergic drugs). managing exacerbations of COPD. 3 Walks slower than contemporaries on level ground because of breathlessness, or has to. GINA cannot PRIOR VERSION (S): NICE guideline CG101 June 2010, 2004. Do not offer routine telehealth monitoring of physiological status as part of management for stable COPD. NICE clinical guideline 101 – Chronic obstructive pulmonary disease 5 Introduction An estimated 3 million people have chronic obstructive pulmonary disease (COPD) in the UK. Do not offer short-burst oxygen therapy to manage breathlessness in people with COPD who have mild or no hypoxaemia at rest. The diagnosis is suspected on the basis of symptoms and signs and is supported by spirometry. The rehabilitation process should incorporate a programme of physical training, disease education, and nutritional, psychological and behavioural intervention. [2004], 1.3.18 Think about osteoporosis prophylaxis for people who need frequent courses of oral corticosteroids. Since 2010, the management of COPD has changed dra- Inhaled combination therapy refers to combinations of long-acting muscarinic antagonists (LAMA), long-acting beta2 agonists (LABA), and inhaled corticosteroids (ICS). [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. 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. Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding. [2004], 1.2.136 If time permits, optimise the medical management of people with COPD before surgery. [2004], 1.2.96 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. Or ex‑smokers, and prevention of chronic obstructive pulmonary disease ( COPD ) on! 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