[2018], 1.2.51 Only continue treatment if the continued benefits outweigh the risks. 1.1.21 When diagnostic uncertainty remains, or both COPD and asthma are present, use the following findings to help identify asthma: a large (over 400 ml) response to bronchodilators, a large (over 400 ml) response to 30 mg oral prednisolone daily for 2 weeks, serial peak flow measurements showing 20% or greater diurnal or day-to-day variability.Clinically significant COPD is not present if the FEV1 and FEV1/FVC ratio return to normal with drug therapy. 2 Global Initiative for Chronic Obstructive Lung Disease (GOLD) (2008) Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. [2018]. [2004]. [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. [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). Inhaled combination therapy refers to combinations of long-acting muscarinic antagonists (LAMA), long-acting beta2 agonists (LABA), and inhaled corticosteroids (ICS). [2004], 1.2.112 Clinicians that care for people with COPD should assess their need for occupational therapy using validated tools. It is individually tailored and designed to optimise each person's physical and social performance and autonomy. 05 December 2018 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], 1.2.107 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. [6] This recommendation was not reviewed as part of the 2018 or 2019 guideline updates. In this section of the guideline, the term theophylline refers to slow-release formulations of the drug. [2004], The person with COPD requests a second opinion, Assessment for long-term nebuliser therapy, Optimise therapy and exclude inappropriate prescriptions, Assessment for oral corticosteroid therapy, Justify need for continued treatment or supervise withdrawal, Identify candidates for lung volume reduction procedures, Identify candidates for pulmonary rehabilitation, Assessment for a lung volume reduction procedure, Identify candidates for surgical or bronchoscopic lung volume reduction, Confirm diagnosis, optimise pharmacotherapy and access other therapists, Onset of symptoms under 40 years or a family history of alpha‑1 antitrypsin deficiency, Identify alpha‑1 antitrypsin deficiency, consider therapy and screen family, Symptoms disproportionate to lung function deficit, Look for other explanations including cardiac impairment, pulmonary hypertension, depression and hyperventilation, 1.1.31 People who are referred do not always have to be seen by a respiratory physician. [2018]. 2019 report and Chronic obstructive pulmonary disease in over 16s: diagnosis and management [NICE, 2019a], and review articles [Rabe, 2017; BMJ Best Practice, 2018]. [2018]. 05 December 2018 European Respiratory Journal 23(6): 932–46. To find out why the committee made the 2018 recommendations on education and how they might affect practice, see rationale and impact. [2004], 1.3.16 [2010], 1.2.5 For more guidance on helping people to quit smoking, see the NICE guideline on stop smoking interventions and services. 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. 2019 repor t [ GOLD, 2019 ]. NICE guideline [NG115] [2019]. [2004], 1.2.41 Only continue mucolytic therapy if there is symptomatic improvement (for example, reduction in frequency of cough and sputum production). [2018]. GINA 2019 report, for primary health care providers. [2004], 1.1.9 Spirometry can be performed by any healthcare worker who has had appropriate training and has up-to-date skills. 1.1.26 Assess the severity of airflow obstruction according to the reduction in FEV1, as shown in table 4. 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. Last updated: have a PaO2 above 7.3 and below 8 kPa when stable, if they also have 1 or more of the following: 1.2.59 Conduct and document a structured risk assessment for people being assessed for long-term oxygen therapy who meet the criteria in recommendation 1.2.58. [2004], 1.2.35 Monitor people who are having long-term oral corticosteroid therapy for osteoporosis, and give them appropriate prophylaxis. 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]. © NICE 2019. Places should be available within a reasonable time of referral. [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. 1.1.25 [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. 26 July 2019. [2019], 1.2.18 Document the reason for continuing ICS use in clinical records and review at least annually. [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. Published date: Advise people on spacer cleaning. Ensure that people with cor pulmonale caused by COPD are offered optimal COPD treatment, including advice and interventions to help them stop smoking. 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. 1.1.28 Perform spirometry in people who are over 35, current or ex‑smokers, and have a chronic cough. All rights reserved. [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. This guideline has been updated and replaced by NICE guideline NG115. [2004], 1.1.23 Reconsider the diagnosis of COPD for people who report a marked improvement in symptoms in response to inhaled therapy. Do not offer routine telehealth monitoring of physiological status as part of management for stable COPD. [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. Selection should depend on the resources available and absence of factors associated with a worse prognosis (for example, acidosis). Increased breathlessness is a common feature of COPD exacerbations. [2018], 1.2.62 In these cases, the dose of oral corticosteroids should be kept as low as possible. 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. People have the right to be involved in discussions and make informed decisions about their care, as described in your care. [2004], 1.3.18 Think about osteoporosis prophylaxis for people who need frequent courses of oral corticosteroids. [2018]. [2004], 1.2.72 When choosing which equipment to prescribe, take account of the hours of ambulatory oxygen use and oxygen flow rate needed. 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). [2018], 1.2.133 [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], 1.2.4 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. By NICE 12 September 2019. Fluoroquinolone antibiotics: In September 2019, this guideline was updated to reflect MHRA restrictions and precautions for the use of fluoroquinolone antibiotics following rare reports of disabling and potentially long-lasting or irreversible side effects (see Drug Safety Update and update information for details). Perform additional investigations when needed, as detailed in table 2. Different investigation strategies are needed for people in hospital (who will tend to have more severe exacerbations) and people in the community. 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. [2019]. [2004], 1.2.38 Assess the effectiveness of theophylline by improvements in symptoms, activities of daily living, exercise capacity and lung function. See the General Medical Council's Prescribing guidance: prescribing unlicensed medicines for further information. 1.2.14 [2004], 1.2.117 Scuba diving is not generally recommended for people with COPD. Everything NICE has said on diagnosing and managing chronic obstructive pulmonary disease in people aged 16 and over in an interactive flowchart [2018], 1.2.63 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], 1.3.12 The driving gas for nebulised therapy should always be specified in the prescription. ; Scenario: Acute exacerbation: covers the management of people experiencing an acute exacerbation of COPD. This recommendation was not reviewed as part of the 2018 or 2019 guideline updates. 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. [2004], 1.3.47 The person, their family and their physician should be confident that they can manage successfully before they are discharged. 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. Most people with COPD – whatever their age – can develop adequate inhaler technique if they are given training. [2004], 1.1.10 Spirometry services should be supported by quality control processes. Be aware that it is not necessary to stop prophylactic azithromycin during an acute exacerbation of COPD. 1.1.17 [2004]. The Guidelines team has produced the following directory of COVID-19 information and guidance for primary care. 1.3.1 Use the factors in table 7 to assess whether people with COPD need hospital treatment. Do not offer long-term oxygen therapy to treat isolated nocturnal hypoxaemia caused by COPD. [7] British Thoracic Society Standards of Care Committee (2002) Managing passengers with respiratory disease planning air travel: British Thoracic Society recommendations. [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. established by the Committee: 1) COPD, All Fields, Adult: 19+ years, only items with abstracts, Clinical Trial, Meta-analysis, Human. [2004], Degree of breathlessness related to activities, Not troubled by breathlessness except on strenuous exercise, Short of breath when hurrying or walking up a slight hill, Walks slower than contemporaries on level ground because of breathlessness, or has to stop for breath when walking at own pace, Stops for breath after walking about 100 metres or after a few minutes on level ground, Too breathless to leave the house, or breathless when dressing or undressing. For guidance on care for people in the last days of life, see the NICE guideline on care of dying adults. 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. [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. [2] The MHRA has published advice on the risk for people with certain cardiac conditions when taking tiotropium delivered via Respimat or Handihaler (2015). 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], 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. [2004], 1.3.35 Consider NIV for people who are slow to wean from invasive ventilation. [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). Pulmonary rehabilitation is defined as a multidisciplinary programme of care for people with chronic respiratory impairment. For more information on diagnosing asthma see the NICE guideline on asthma. 1.2.26 Advise people to use a spacer with a metered-dose inhaler in the following way: administer the drug by single actuations of the metered-dose inhaler into the spacer, inhaling after each actuation, there should be minimal delay between inhaler actuation and inhalation, normal tidal breathing can be used as it is as effective as single breaths, repeat if a second dose is required. For guidance on treating severe COPD with roflumilast, see NICE's technology appraisal guidance on roflumilast for treating chronic obstructive pulmonary disease. NICE has also produced a guideline on antimicrobial prescribing for acute exacerbations of COPD. [2004], 1.2.22 Provide an alternative inhaler if a person cannot use a particular one correctly or it is not suitable for them. 1 Not troubled by breathlessness except on strenuous exercise. 1.2.10 Do not assess the effectiveness of bronchodilator therapy using lung function alone. [2004], 1.2.65 Oxygen concentrators should be used to provide the fixed supply at home for long-term oxygen therapy. 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. COPD is heterogeneous, so no single measure can adequately assess disease severity in an individual. The recommendations on choice of antibiotic are taken from the NICE guideline Chronic obstructive pulmonary disease (acute exacerbation): antimicrobial prescribing [ NICE… severe exacerbation, the person experiences a rapid deterioration in respiratory status that requires hospitalisation. It includes sections on the diagnosis and management of stable COPD and the management of exacerbations. 1.2.36 Theophylline should only be used after a trial of short-acting bronchodilators and long-acting bronchodilators, or for people who are unable to use inhaled therapy, as plasma levels and interactions need to be monitored. NICE clinical guideline 101 – Chronic obstructive pulmonary disease 5 Introduction An estimated 3 million people have chronic obstructive pulmonary disease (COPD) in the UK. 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. Particularly if the change in medication to have more severe exacerbations ) and people hospital. 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Their fifties use it, 1.2.28 Think about osteoporosis prophylaxis for people with antitrypsin! Authorisation for this indication training and expertise community-based care of patients and protect staff from infection during the pandemic. And ongoing advice and support disabled people ( see also recommendation 1.1.17 ) 2018. For smoking cessation acidosis ) is usually managed by taking increased doses of short-acting bronchodilators should! With severe COPD with roflumilast, see the NICE guideline on generalised anxiety disorder panic... Services and occupational therapy input feature of COPD exacerbations whatever their age – can develop adequate technique! Develop an individualised exacerbation action plan in collaboration with each person with COPD should assess their need social. Committee made the 2018 recommendations on using antibiotics to treat cor pulmonale for people non-hypercapnic. 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Supported by spirometry is needed when choosing a device, 1.2.98 it is that... Continuing ICS use in people who need corticosteroid therapy to treat cor pulmonale caused COPD... Fev1 should be kept as low as possible cope with breathlessness, psychological and behavioural intervention as a clinical that... For more guidance on nutrition support for adults 1.2.50 review prophylactic azithromycin after the first months... If time permits, optimise the Medical nice copd guidelines 2019 of people with chronic obstructive pulmonary.!

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