[2004], 1.2.141 Specialists should regularly review people with severe COPD who need interventions such as long-term non-invasive ventilation. 1.2.99 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. 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. Pulmonary hypertension with unclear and/or multifactorial mechanisms (group 5) 12. 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. People who are not taking long-term oxygen and who have a mean PaO2 greater than 7.3k Pa. [1] The Medicines and Healthcare Products Regulatory Agency (MHRA) has published advice on the risk of psychological and behavioural side effects associated with inhaled corticosteroids (2010). NICE has produced a COVID-19 rapid guideline on community-based care of patients with chronic obstructive pulmonary disease (COPD ). [2004], 1.3.25 It is recommended that doxapram is used only when non-invasive ventilation is either unavailable or inappropriate. [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. [2004]. [2004], 1.2.116 Warn people with bullous disease that they are at a theoretically increased risk of a pneumothorax during air travel. 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. Be aware that it is not necessary to stop prophylactic azithromycin during an acute exacerbation of COPD. Abstract. 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], 1.2.104 For guidance on nutrition support, see the NICE guideline on nutrition support for adults. Different investigation strategies are needed for people in hospital (who will tend to have more severe exacerbations) and people in the community. 1.2.12 [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. [2004]. FUNDING SOURCE: Department of Health and Social Care, United Kingdom. [2004], 1.2.96 European Respiratory Journal 23(6): 932–46. 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. [2018]. [2004], 1.3.27 If necessary, prescribe oxygen to keep the oxygen saturation of arterial blood (SaO2) within the individualised target range. Include a variety of other measures such as improvement in symptoms, activities of daily living, exercise capacity, and rapidity of symptom relief. Informed consent should be obtained and documented. 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. [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]. [2018], 1.2.92 Refer people with COPD for an assessment for bullectomy if they are breathless and a CT scan shows a bulla occupying at least one third of the hemithorax. 1.2.120 Ensure the information provided is: relevant to the stage of the person's condition. This guideline updates and replaces NICE guideline CG101 (June 2010). NICE has also produced a visual summary covering non-pharmacological management and use of inhaled therapies. Offer people with alpha 1 antitrypsin deficiency a referral to a specialist centre to discuss how to manage their condition. Do not use previous lung volume reduction procedures as a reason not to refer a person for assessment for lung transplantation. [2004], 1.3.33 Treat hospitalised exacerbations of COPD on intensive care units, including invasive ventilation when this is thought to be necessary. [2004], 1.1.10 Spirometry services should be supported by quality control processes. 1.2.137 Offer 30 mg oral prednisolone daily for 5 days. [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. [2004], 1.2.29 Do not prescribe nebulised therapy without an assessment of the person's and/or carer's ability to use it. 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. Be alert for anxiety and depression in people with COPD. Do not offer short-burst oxygen therapy to manage breathlessness in people with COPD who have mild or no hypoxaemia at rest. 26 July 2019. [2004, amended 2018], 1.1.12 [2004, amended 2018], 1.3.37 Monitor people's recovery by regular clinical assessment of their symptoms and observation of their functional capacity. Increased breathlessness is a common feature of COPD exacerbations. 1.3.3 [6] This recommendation was not reviewed as part of the 2018 or 2019 guideline updates. The NICE guideline has had to catch up on 8 years of develop - ments, mainly in pharmacological treatment. [2018]. 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. For guidance on managing anxiety, see the NICE guideline on generalised anxiety disorder and panic disorder in adults. [2019]. 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. 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). [2004], 1.3.44 Assess all aspects of the routine care that people receive (including appropriateness and risk of side effects) before discharge. NICE Bites No 115, February 2019, includes one topic: chronic obstructive pulmonary disease (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. 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. Managing an acute exacerbation of COPD with antibiotics In this section of the guideline, the term theophylline refers to slow-release formulations of the drug. 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). 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. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Referral may be appropriate at all stages of the disease and not solely in the most severely disabled people (see table 5). 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). [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. [2004], 1.3.41 Measure spirometry in all people before discharge. © NICE 2019. Do not use a multidimensional index (such as BODE) to assess prognosis in people with stable COPD. [2004]. 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 [2004], 1.2.41 Only continue mucolytic therapy if there is symptomatic improvement (for example, reduction in frequency of cough and sputum production). [2004, amended 2018], To identify organisms if sputum is persistently present and purulent, To exclude asthma if diagnostic doubt remains. * Or FEV1 below 50% with respiratory failure. [2004], 1.2.33 If nebuliser therapy is prescribed, provide the person with equipment, servicing, and ongoing advice and support. Some people with advanced COPD may need long-term oral corticosteroids when these cannot be withdrawn following an exacerbation. The Guidelines team has produced the following directory of COVID-19 information and guidance for primary care. [2004], 1.2.42 Do not routinely use mucolytic drugs to prevent exacerbations in people with stable COPD. [2018]. The recommendations on choice of antibiotic are taken from the NICE guideline Chronic obstructive pulmonary disease (acute exacerbation): antimicrobial prescribing [ NICE… It recommends changes to usual practice to maximise the safety of patients and protect staff from infection during the COVID-19 pandemic. However, people with significant cognitive impairment may be unable to use any form of inhaler device. 1.1.17 1.3.21 For guidance on using antibiotics to treat COPD exacerbations, see the NICE guideline on antimicrobial prescribing for acute exacerbations of COPD. 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], 1.2.71 Small light-weight cylinders, oxygen-conserving devices and portable liquid oxygen systems should be available 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. 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. When prescribing long-acting drugs, ensure people receive inhalers they have been trained to use (for example, by specifying the brand and inhaler in prescriptions). Advise people who are having long-term oxygen therapy that they should breathe supplemental oxygen for a minimum of 15 hours per day. [2018], 1.2.53 All rights reserved. 05 December 2018 [2004], 1.2.118 There are significant differences in the response of people with COPD and asthma to education programmes. [2004, amended 2018], 1.1.5 Measure post-bronchodilator spirometry to confirm the diagnosis of COPD. In this summary. NICE has produced a COVID-19 rapid guideline on community-based care of patients with chronic obstructive pulmonary disease (COPD). It is recommended that GLI 2012 reference values are used, but it is recognised that these values are not applicable for all ethnic groups. 2019 repor t [ GOLD, 2019 ]. [2018], 1.3.22 Only use intravenous theophylline as an adjunct to exacerbation management if there is an inadequate response to nebulised bronchodilators. This review should include pulse oximetry. 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]. About 900,000 have diagnosed COPD and an estimated 2 million people have COPD which remains undiagnosed1. March 2019. [2004], 1.1.3 One of the primary symptoms of COPD is breathlessness. [2018]. 1.2.126 [2018]. Commonly reported symptoms are worsening breathlessness, cough, increased sputum production and change in sputum colour. In the absence of significant contraindications, use oral corticosteroids, in conjunction with other therapies, in all people admitted to hospital with a COPD exacerbation. Offer pulmonary rehabilitation to all people who view themselves as functionally disabled by COPD (usually Medical Research Council [MRC] grade 3 and above). 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. [2004]. 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. 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 Do not offer ambulatory oxygen to manage breathlessness in people with COPD who have mild or no hypoxaemia at rest. [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. See the General Medical Council's Prescribing guidance: prescribing unlicensed medicines for further information. A summary of prescribing recommendations from NICE guidance NICE Bites February 2019: No. [2004], 1.3.47 The person, their family and their physician should be confident that they can manage successfully before they are discharged. 1.2.81 Make pulmonary rehabilitation available to all appropriate people with COPD (see recommendation 1.2.82), including people who have had a recent hospitalisation for an acute exacerbation. 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. [2004], 1.3.7 Include people's preferences about treatment at home or in hospital in decision-making. A formal activities of daily living assessment may be helpful when there is still doubt. [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. 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