, 1.2.94 It may be unhelpful or misleading because: repeated FEV1 measurements can show small spontaneous fluctuations, the results of a reversibility test performed on different occasions can be inconsistent and not reproducible, over-reliance on a single reversibility test may be misleading unless the change in FEV1 is greater than 400 ml, the definition of the magnitude of a significant change is purely arbitrary, response to long-term therapy is not predicted by acute reversibility testing. NICE guideline [NG115] . It is individually tailored and designed to optimise each person's physical and social performance and autonomy. 1.2.11  British Thoracic Society Standards of Care Committee (2002) Managing passengers with respiratory disease planning air travel: British Thoracic Society recommendations. NICE Bites is a monthly prescribing bulletin published by North West Medicines Information centre which summarises key recommendations from NICE guidance. , 1.1.8 All healthcare professionals who care for people with COPD should have access to spirometry and be competent in interpreting the results. 1.1.17 , • Need for referral to specialist and therapy services, • Need for social services and occupational therapy input. 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. The diagnosis of an exacerbation is made clinically and does not depend on the results of investigations. Published date: [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. 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. , 1.2.133 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. , 1.2.61 1.2.58 1.2.99 GINA cannot 1.1.14 Perform additional investigations when needed, as detailed in table 2. , 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. In this summary.  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). , 1.2.38 Assess the effectiveness of theophylline by improvements in symptoms, activities of daily living, exercise capacity and lung function. Base the choice of drugs and inhalers on: the person's preferences and ability to use the inhalers, the drugs' potential to reduce exacerbations, their cost.Minimise the number of inhalers and the number of different types of inhaler used by each person as far as possible. 1.2.14 Since 2010, the management of COPD has changed dra- , 1.2.62 [2004, amended 2018]. By NICE 12 September 2019. Offer LAMA+LABA to people who: do not have asthmatic features/features suggesting steroid responsiveness and. 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%). The prescriber should follow relevant professional guidance, taking full responsibility for the decision.  At the time of publication (July 2019), azithromycin did not have a UK marketing authorisation for this indication. FUNDING SOURCE: Department of Health and Social Care, United Kingdom. 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. [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. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. In this section of the guideline, the term theophylline refers to slow-release formulations of the drug. . 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. . 2019 repor t [ GOLD, 2019 ]. For people who are taking prophylactic azithromycin and are still at risk of exacerbations, provide a non-macrolide antibiotic to keep at home as part of their exacerbation action plan (see recommendation 1.2.126). , 1.2.132 , 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. 2004. stop for breath when walking at own pace. Published products on … , 1.2.72 When choosing which equipment to prescribe, take account of the hours of ambulatory oxygen use and oxygen flow rate needed. Consider whether people have anxiety or depression, particularly if they: have been seen at or admitted to a hospital with an exacerbation of COPD. , 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. after 3 months, conduct a clinical review to establish whether or not LAMA+LABA+ICS has improved their symptoms: if symptoms have not improved, stop LAMA+LABA+ICS and switch back to LAMA+LABA, if symptoms have improved, continue with LAMA+LABA+ICS. 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. , 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. 1.2.137 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. , 1.2.5 For more guidance on helping people to quit smoking, see the NICE guideline on stop smoking interventions and services.  This recommendation was not reviewed as part of the 2018 or 2019 guideline updates. Clinicians should be aware that pulse oximetry gives no information about the PaCO2 or pH. Eur Respir J 2019… Before starting azithromycin, ensure the person has had: an electrocardiogram (ECG) to rule out prolonged QT interval and, 1.2.49 When prescribing azithromycin, advise people about the small risk of hearing loss and tinnitus, and tell them to contact a healthcare professional if this occurs. Managing an acute exacerbation of COPD with antibiotics , 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). , 1.3.12 The driving gas for nebulised therapy should always be specified in the prescription. The Guidelines team has produced the following directory of COVID-19 information and guidance for primary care. It aims to help people with COPD to receive a diagnosis earlier so that they can benefit from treatments to reduce symptoms, improve quality of life and keep them healthy for longer. , 1.3.33 Treat hospitalised exacerbations of COPD on intensive care units, including invasive ventilation when this is thought to be necessary. It is recommended that GLI 2012 reference values are used, but it is recognised that these values are not applicable for all ethnic groups. Consider ambulatory oxygen in people with COPD who have exercise desaturation and are shown to have an improvement in exercise capacity with oxygen, and have the motivation to use oxygen. . 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. This is usually managed by taking increased doses of short-acting bronchodilators. Commonly reported symptoms are worsening breathlessness, cough, increased sputum production and change in sputum colour. , 1.2.64 To ensure everyone eligible for long-term oxygen therapy is identified, pulse oximetry should be available in all healthcare settings. 1.2.47 , 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. 1.2.10 Do not assess the effectiveness of bronchodilator therapy using lung function alone. Adapted from Fletcher CM, Elmes PC, Fairbairn MB et al. , 1.2.125 Develop an individualised exacerbation action plan in collaboration with each person with COPD who is at risk of exacerbations. . [2010, amended 2018]. 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. . NICE COPD guideline. . 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. .  . 1.1.26 Assess the severity of airflow obstruction according to the reduction in FEV1, as shown in table 4. , 1.2.66 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. Advise people with queries to seek specialist advice. A formal activities of daily living assessment may be helpful when there is still doubt. 2 Short of breath when hurrying or walking up a slight hill. , 1.2.52 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 , 1.2.42 Do not routinely use mucolytic drugs to prevent exacerbations in people with stable COPD. 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. 1.1.24 1.2.124 [2004, amended 2018], 1.1.5 Measure post-bronchodilator spirometry to confirm the diagnosis of 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. , 1.2.34 Long-term use of oral corticosteroid therapy in COPD is not normally recommended. , 1.3.47 The person, their family and their physician should be confident that they can manage successfully before they are discharged. The evidence was appraised using the Grading of Recommendations, Assessment, Development and Evaluation … , 1.1.11 , 1.3.24 Monitor theophylline levels within 24 hours of starting treatment, and as frequently as indicated by the clinical circumstances after this. NICE Bites No 115, February 2019, includes one topic: chronic obstructive pulmonary disease (COPD).  The MHRA has published advice on the risk for people with certain cardiac conditions when taking tiotropium delivered via Respimat or Handihaler (2015). 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. A significant proportion of these people will go on to develop airflow limitation. , 1.2.131 Ask people with COPD if they experience breathlessness they find frightening. , 1.2.24 People with COPD should have their ability to use an inhaler regularly assessed and corrected if necessary by a healthcare professional competent to do so. (1959) The significance of respiratory symptoms and the diagnosis of chronic bronchitis in a working population. British Medical Journal 2: 257–66. Pulmonary rehabilitation is defined as a multidisciplinary programme of care for people with chronic respiratory impairment. A summary of prescribing recommendations from NICE guidance NICE Bites February 2019: No. Abstract. 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). NICE guideline [NG115] 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: … 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. . 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 , 1.3.13 1.2.97 When defining the activity of the multidisciplinary team, think about the following functions: assessment (including performing spirometry, assessing which delivery systems to use for inhaled therapy, the need for aids for daily living and assessing the need for oxygen), identifying and managing anxiety and depression, non-invasive ventilation and palliative care, advising people on self-management strategies, identifying and monitoring people at high risk of exacerbations and undertaking activities to avoid emergency admissions, education for people with COPD, their carers, and for healthcare professionals. 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). 1.2.56 If they do, consider including a cognitive behavioural component in their self-management plan to help them manage anxiety and cope with breathlessness. Pulmonary hypertension with unclear and/or multifactorial mechanisms (group 5) 12. 1.1.1 , 1.2.86 . It does NOT contain all of the information required for managing asthma, for example, about safety of treatments, and it should be used in conjunction with the full GINA 2019 report and with the health professional’s own clinical judgment. 2019 report and Chronic obstructive pulmonary disease in over 16s: diagnosis and management [NICE, 2019a], and review articles [Rabe, 2017; BMJ Best Practice, 2018]. to reconsider the diagnosis, for people who show an exceptionally good response to treatment, to monitor disease progression. , 1.2.53 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. To find out why the committee made the 2018 recommendations on education and how they might affect practice, see rationale and impact. 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. 1.2.120 Ensure the information provided is: relevant to the stage of the person's condition. * Or FEV1 below 50% with respiratory failure. We found no new evidence that affects the recommendations in this guideline. , 1.2.51 Only continue treatment if the continued benefits outweigh the risks. Definition of a pulmonary hypertension referral centre 13. , 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). 1.2.67 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. , 1.2.44 Anti-tussive therapy should not be used in the management of stable COPD. Be aware that it is not necessary to stop prophylactic azithromycin during an acute exacerbation of COPD. Suspect a diagnosis of COPD in people over 35 who have a risk factor (generally smoking or a history of smoking) and who present with 1 or more of the following symptoms: 1.1.2 When thinking about a diagnosis of COPD, ask the person if they have: haemoptysis (coughing up blood).These last 2 symptoms are uncommon in COPD and raise the possibility of alternative diagnoses. 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. Consider long-term oxygen therapy 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. . 10. 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. . 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. Whenever possible, use features from the history and examination (such as those listed in table 3) to differentiate COPD from asthma. 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. Composite assessment tools such as the ASA scoring system are the best predictors of risk. In this guideline 'cor pulmonale' is defined as a clinical condition that is identified and managed on the basis of clinical features. Last updated: Last updated May 2019. 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