Eur Respir J 2019… 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], 1.2.33 If nebuliser therapy is prescribed, provide the person with equipment, servicing, and ongoing advice and support. [2018]. Inhaled combination therapy refers to combinations of long-acting muscarinic antagonists (LAMA), long-acting beta2 agonists (LABA), and inhaled corticosteroids (ICS). 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. Consider LABA+ICS for people who: have asthmatic features/features suggesting steroid responsiveness and, 1.2.13 [2004, amended 2018], 1.2.28 Think about nebuliser therapy for people with distressing or disabling breathlessness despite maximal therapy using inhalers. 1.2.58 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 1.2.124 1.2.75 Suspect a diagnosis of cor pulmonale for people with: a loud pulmonary second heart sound. Most patients are not diagnosed until they are in their fifties. To find out why the committee made the 2018 recommendations on lung volume reduction procedures, bullectomy and lung transplantation and how they might affect practice, see rationale and impact. ; Scenario: Acute exacerbation: covers the management of people experiencing an acute exacerbation of COPD. [2019], 1.3.17 For guidance on stopping oral corticosteroid therapy it is recommended that clinicians refer to the BNF. Chronic obstructive pulmonary disease in over 16s: Diagnosis and management1RELEASE DATE: December 5, 2018 with update July 2019 PRIOR VERSION(S): NICE guideline CG101 June 2010, 2004 FUNDING SOURCE: Department of Health and Social Care, United Kingdom TARGET POPULATION: Patients age 16 and older with Chronic Obstructive Pulmonary Disease (COPD) GUIDELINE TITLE: … GINA cannot [2004], 1.3.43 People who have had an episode of respiratory failure should have satisfactory oximetry or arterial blood gas results before discharge. 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. Everything NICE has said on diagnosing and managing chronic obstructive pulmonary disease in people aged 16 and over in an interactive flowchart 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. [2004], 1.2.38 Assess the effectiveness of theophylline by improvements in symptoms, activities of daily living, exercise capacity and lung function. [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. A general classification of the severity of an acute exacerbation (Oba Y et al. Commonly reported symptoms are worsening breathlessness, cough, increased sputum production and change in sputum colour. 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. British Medical Journal 2: 257–66. [2004], 1.2.109 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. [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. 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. 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], 1.2.76 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). 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. By NICE 12 September 2019. 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. 1.3.8 Both nebulisers and hand-held inhalers can be used to administer inhaled therapy during exacerbations of COPD. [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). 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], 1.3.19 Make people aware of the optimum duration of treatment and the adverse effects of prolonged therapy. [2004], 1.2.40 Consider mucolytic drug therapy for people with a chronic cough productive of sputum. [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. COPD care should be delivered by a multidisciplinary team. 115 Chronic obstructive pulmonary disease 115; 2018 Definition of terms COPD chronic obstructive pulmonary disease FEV1 forced expiratory volume in 1 second FVC forced vital capacity ICS inhaled corticosteroids LABA long-acting beta2 agonists [2004], 1.3.24 Monitor theophylline levels within 24 hours of starting treatment, and as frequently as indicated by the clinical circumstances after this. * See the NICE guideline on chronic heart failure in adults for recommendations on using serum natriuretic peptides to diagnose heart failure. 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], 1.2.34 Long-term use of oral corticosteroid therapy in COPD is not normally recommended. See the General Medical Council's Prescribing guidance: prescribing unlicensed medicines for further information. [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. [2018]. [2004], Already receiving long-term oxygen therapy, Significant comorbidity (particularly cardiac disease and insulin-dependent diabetes). [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. People who are having long-term oxygen therapy should be reviewed at least once per year by healthcare professionals familiar with long-term oxygen therapy. Pulmonary rehabilitation is defined as a multidisciplinary programme of care for people with chronic respiratory impairment. NICE guideline [NG115] [2018], 1.2.61 [2018]. [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]. This guideline updates and replaces NICE guideline CG101 (June 2010). [2004, amended 2018], 1.1.12 It is recommended that GLI 2012 reference values are used, but it is recognised that these values are not applicable for all ethnic groups. The NICE guideline has had to catch up on 8 years of develop - ments, mainly in pharmacological treatment. [2004], 1.2.72 When choosing which equipment to prescribe, take account of the hours of ambulatory oxygen use and oxygen flow rate needed. 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], 1.2.70 Only prescribe ambulatory oxygen therapy after an appropriate assessment has been performed by a specialist. 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. [2004], 1.3.39 Use intermittent arterial blood gas measurements to monitor the recovery of people with respiratory failure who are hypercapnic or acidotic, until they are stable. 1.2.77 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. This might include a course of pulmonary rehabilitation. [2004], 1.2.45 About 900,000 have diagnosed COPD and an estimated 2 million people have COPD which remains undiagnosed1. Pulmonary hypertension with unclear and/or multifactorial mechanisms (group 5) 12. The diagnosis of an exacerbation is made clinically and does not depend on the results of investigations. 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. [2004], 1.2.22 Provide an alternative inhaler if a person cannot use a particular one correctly or it is not suitable for them. NICE guideline [NG115] Publications For people at risk of hospitalisation, explain to them and their family members or carers (as appropriate) what to expect if this happens (including non-invasive ventilation and discussions on future treatment preferences, ceilings of care and resuscitation). [2004]. [2010, amended 2018]. A summary of prescribing recommendations from NICE guidance NICE Bites February 2019: No. 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). This recommendation was not reviewed as part of the 2018 or 2019 guideline updates. [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. 2004. 1.2.126 [2004]. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. [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. [2010], 1.2.6 For more guidance on varenicline see the NICE technology appraisal guidance on varenicline for smoking cessation. [2010], 1.2.7 Use short-acting bronchodilators, as necessary, as the initial empirical treatment to relieve breathlessness and exercise limitation. 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. 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], 1.2.50 Review prophylactic azithromycin after the first 3 months, and then at least every 6 months. 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. 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. [2004]. 1.3.3 [2] The MHRA has published advice on the risk for people with certain cardiac conditions when taking tiotropium delivered via Respimat or Handihaler (2015). In this summary. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties. Clinicians should be aware that pulse oximetry gives no information about the PaCO2 or pH. 1.1.26 Assess the severity of airflow obstruction according to the reduction in FEV1, as shown in table 4. The rehabilitation process should incorporate a programme of physical training, disease education, and nutritional, psychological and behavioural intervention. [2018]. [4] At the time of publication (July 2019), azithromycin did not have a UK marketing authorisation for this indication. [2004, amended 2018], 1.2.69 Prescribe ambulatory oxygen to people who are already on long-term oxygen therapy, who wish to continue oxygen therapy outside the home, and who are prepared to use it. [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. People have the right to be involved in discussions and make informed decisions about their care, as described in your care. This site uses cookies, some may have been set already. 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. Perform additional investigations when needed, as detailed in table 2. © NICE 2019. Thorax 57(4): 289–304. GUIDELINE TITLE: Chronic obstructive pulmonary disease in over 16s: Diagnosis and management 1. [2018], 1.2.90 Only offer endobronchial coils as part of a clinical trial and after assessment by a lung volume reduction multidisciplinary team. [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]. [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. [2004]. [2004], 1.3.20 Dr Hopkinson will discuss the five fundamentals of COPD care: offer treatment and support to stop smoking [2004], 1.2.135 It is recommended that lung function should not be the only criterion used to assess people with COPD before surgery. Selection should depend on the resources available and absence of factors associated with a worse prognosis (for example, acidosis). In most people with COPD, however, a pragmatic approach guided by individual patient assessment is needed when choosing a device. 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. 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 reconsider the diagnosis, for people who show an exceptionally good response to treatment, to monitor disease progression. 2 Global Initiative for Chronic Obstructive Lung Disease (GOLD) (2008) Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Published products on … Clinical Guidelines Fully Endorsed . [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. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. 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], 1.2.71 Small light-weight cylinders, oxygen-conserving devices and portable liquid oxygen systems should be available for people with COPD. [2019]. 1.2.30 Do not continue nebulised therapy without assessing and confirming that 1 or more of the following occurs: an increase in the ability to undertake activities of daily living, 1.2.31 Use a nebuliser system that is known to be efficient[3]. Severity assessment is, nevertheless, important because it has implications for therapy and relates to prognosis. [2004], 1.2.23 Only prescribe inhalers after people have been trained to use them and can demonstrate satisfactory technique. 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. [2018]. 1.2.47 [5] The MHRA has published an alert on the risk of death and severe harm from failure to obtain and continue flow from oxygen cylinders (2018). [2018], 1.2.68 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. This guideline covers diagnosing and managing chronic obstructive pulmonary disease or COPD (which includes emphysema and chronic bronchitis) in people aged 16 and older. The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. The significance of respiratory symptoms and the diagnosis of chronic bronchitis in a working population, visual summary covering non-pharmacological management and use of inhaled therapies, asthmatic features/features suggesting steroid responsiveness, roflumilast for treating chronic obstructive pulmonary disease, oseltamivir, amantadine (review) and zanamivir for the prophylaxis of influenza, amantadine, oseltamivir and zanamivir for the treatment of influenza, depression in adults with a chronic physical health problem, generalised anxiety disorder and panic disorder in adults, antimicrobial prescribing for acute exacerbations of COPD, risk of psychological and behavioural side effects, risk for people with certain cardiac conditions when taking tiotropium delivered via Respimat or Handihaler, Prescribing guidance: prescribing unlicensed medicines, Managing passengers with respiratory disease planning air travel: British Thoracic Society recommendations. For guidance on treating severe COPD with roflumilast, see NICE's technology appraisal guidance on roflumilast for treating chronic obstructive pulmonary disease. [2018]. Offer pneumococcal vaccination and an annual flu vaccination to all people with COPD, as recommended by the Chief Medical Officer. [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). 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. Most people with COPD – whatever their age – can develop adequate inhaler technique if they are given training. Last updated May 2019. 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). 1.2.14 [2018]. [2004], 1.3.15 Encourage people who need corticosteroid therapy to present early to get maximum benefits. [2004], 1.3.12 The driving gas for nebulised therapy should always be specified in the prescription. Referral may be appropriate at all stages of the disease and not solely in the most severely disabled people (see table 5). 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]. Pulmonary Clinical Practice Guidelines - 2019 Year in Review : Stay current with new guidelines and recommendations. European Respiratory Society Guideline on Long-term Home Non-Invasive Ventilation for Management of Chronic Obstructive Pulmonary Disease B. Ergan, S. Oczkowski, B. Rochwerg, et al. [2004]. [2018]. [2018]. This guideline sets out an antimicrobial prescribing strategy for acute exacerbations of chronic obstructive pulmonary disease (COPD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. NICE has also produced a visual summary covering non-pharmacological management and use of inhaled therapies. A significant proportion of these people will go on to develop airflow limitation. [2018], 1.2.63 The Guidelines team has produced the following directory of COVID-19 information and guidance for primary care. Do not offer routine telehealth monitoring of physiological status as part of management for stable COPD. [2004], 1.2.66 [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. [2018], 1.2.125 Develop an individualised exacerbation action plan in collaboration with each person with COPD who is at risk of exacerbations. 1.1.25 2019 repor t [ GOLD, 2019 ]. [2004], 1.3.35 Consider NIV for people who are slow to wean from invasive ventilation. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. [2004], 1.3.33 Treat hospitalised exacerbations of COPD on intensive care units, including invasive ventilation when this is thought to be necessary. 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. 05 December 2018 [2018]. [2018]. NICE clinical guideline 101 – Chronic obstructive pulmonary disease 5 Introduction An estimated 3 million people have chronic obstructive pulmonary disease (COPD) in the UK. 1.2.134 The ultimate clinical decision about whether or not to proceed with surgery should rest with a consultant anaesthetist and consultant surgeon, taking account of comorbidities, functional status and the need for the surgery. In this section of the guideline, the term theophylline refers to slow-release formulations of the drug. [2004]. [2018]. 1.1.14 [2018]. 1.2.15 For people with COPD who are taking LABA+ICS, offer LAMA+LABA+ICS if: their day-to-day symptoms continue to adversely impact their quality of life or, they have a severe exacerbation (requiring hospitalisation) or, they have 2 moderate exacerbations within a year. This document provides clinical recommendations for treatment of chronic obstructive pulmonary disease (COPD) exacerbations. 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. 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. [2018], 1.2.122 Be aware of the obligation to provide accessible information as detailed in the NHS Accessible Information Standard. [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. 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