For guidance on assessing the need for hospital referral, see NICE guideline: Chronic obstructive pulmonary disease in over 16s (see Useful resources). The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. To assess cardiac status if cardiac disease or pulmonary hypertension are suspected because of: 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, Night-time waking with breathlessness and/or wheeze, Significant diurnal to day-to-day variability of symptoms, 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 lung volume reduction procedures, 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, Factors to consider when deciding where to treat the person, Significant comorbidity (particularly cardiac disease and insulin-dependent diabetes), 200 mg on first day, then 100 mg once a day for 5-day course in total (see, Use alternative first choice (from a different class), Levofloxacin (with specialist advice if co-amoxiclav or co-trimoxazole cannot be used; consider safety issues, Consult local microbiologist; guided by susceptibilities, A general classification of the severity of an acute exacerbation (provided in. A summary of further considerations relating to pharmacotherapy is provided in quality statement 4. Numerator – the number of people in the denominator who are asked if they smoke by their healthcare practitioner. Denominator – the number of children, young people and adults with chronic respiratory or cardiovascular conditions attending a routine health appointment. Denominator – the number of people with stable COPD and a persistent resting stable oxygen saturation level of 92% or less. e) Evidence that local authorities identify key actions to address air pollution and monitor progress against them. COPD should be suspected in people aged over 35 years, who have a risk factor and symptoms including exertional breathlessness, chronic/recurrent cough, or regular sputum production. LTOT is used to treat people with stable COPD who have developed daytime hypoxaemia. See the evidence and committee discussion on choice of antibiotic and antibiotic course length. Acute Exacerbation of Chronic Obstructive Pulmonary Disease (AECOPD) N.B. [Adapted from, Acute acidotic hypercapnic respiratory failure results from an inability of the respiratory system to provide sufficient alveolar ventilation to maintain a normal arterial PCO2 and blood pH level. b) Overall fuel consumption for public sector vehicle fleets. There is evidence that people who smoke are receptive to smoking cessation advice in all healthcare settings. Evidence of local arrangements to ensure that people who smoke are offered a referral to an evidence-based smoking cessation service. More than 3 million people died of COPD in 2012 accounting for 6% of all deaths globally. Scenario: End-stage COPD: covers the management of people with COPD that is very severe, unresponsive to usual medical treatment, and associated with … People who smoke are more likely to stop smoking if they are offered a combination of interventions, with combined behavioural support and pharmacotherapy the most likely to be successful. People admitted to hospital for an acute exacerbation of chronic obstructive pulmonary disease (COPD) start a pulmonary rehabilitation programme within 4 weeks of discharge. Denominator – the number of people with COPD prescribed an inhaler who have had an acute exacerbation. Health professionals Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. Co-existent hypoxaemia is usually mild and easily corrected. All rights reserved. b) Evidence that public sector organisations require commissioned transport or fleet services to reduce emissions from their vehicle fleets to address air pollution. NICE has produced resources to help implement its guidance on: NICE has written information for the public on each of the following topics. These include, but are not limited to, doctors, nurses, midwives, pharmacists, dentists, opticians and allied health professionals. 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. Malaise. 11 June 2019 Bronchoscopic thermal vapour ablation for upper-lobe emphysema (NICE interventional procedures guidance 652) added to. More severe degrees of acidosis, such as pH <7.25, have been used as a threshold for considering provision of invasive mechanical ventilation. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer. [, Non-invasive ventilation should be given once it is recognised that a person is not responding to 1 hour of optimal medical therapy. 2. Providing advice to children, young people and adults with chronic respiratory or cardiovascular conditions (and their families or carers, if appropriate) at routine health appointments will support self-management, improve their awareness of how to protect themselves when outdoor air quality is poor and prevent their condition escalating. 4. Evidence of local arrangements and written clinical protocols to ensure that people receiving emergency oxygen for an acute exacerbation of COPD have their oxygen saturation levels maintained between 88% and 92%. Numerator – the number in the denominator who had their inhaler technique assessed after an acute exacerbation. Review the person's history, paying particular attention to compliance with medication, and details … Denominator – the number of people who smoke who have set a quit date with an evidence-based smoking cessation service. It is therefore important that practitioners are aware of and make use of the opportunities to refer people who smoke to an evidence-based smoking cessation service. d) Evidence that local authorities identify in the Local Plan, local transport plan and other key strategies how they will develop buildings and spaces to reduce exposure to air pollution. Emergency oxygen is often given during the treatment of an exacerbation, either in the community, during transfer to hospital in an ambulance or while being assessed at hospital. 9 November 2015 Structure revised, and summarised recommendations replaced with full recommendations. Evidence of local arrangements and written clinical protocols to ensure that people with COPD admitted to hospital for an acute exacerbation start a pulmonary rehabilitation programme within 4 weeks of discharge. It updates the NICE December 2018 guideline on diagnosing and managing COPD which had omitted recommendations on triple therapy. Antibiotic It covers stable COPD and exacerbations. The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. An exacerbation is a sustained worsening of a person’s symptoms from their usual stable state and which is beyond usual day-to-day variations and acute in onset. Pharmacotherapies for smoking cessation are nicotine replacement therapy (NRT), varenicline or bupropion. Some people with COPD may not be well enough to attend a pulmonary rehabilitation programme within 4 weeks of an acute exacerbation, may not have attended hospital after an acute exacerbation of COPD or may not have been admitted to hospital after their exacerbation of COPD. Public sector organisations can extend their impact by commissioning transport or fleet services from organisations that reduce emissions from their vehicle fleets to address air pollution. a) Evidence of local arrangements and written clinical protocols to ensure that people with COPD who are prescribed an inhaler have their technique assessed at the start of treatment and then regularly during their treatment. Practitioners should be aware that some pregnant women find it difficult to say that they smoke because the pressure not to smoke during pregnancy is so intense. To ensure early diagnosis, spirometry should be done in primary care when a person presents with a risk factor for COPD (which is usually smoking) and one or more symptoms of COPD. [. NICE guidance recommends that young people aged 12–17 who smoke should be offered information, advice and support on how to stop smoking and be encouraged to use local evidence-based smoking cessation services. People with an acute exacerbation of chronic obstructive pulmonary disease (COPD) and persistent acidotic hypercapnic ventilatory failure that is not improving after 1 hour of optimal medical therapy have non-invasive ventilation. For guidance on antibacterial treatment in acute exacerbations of COPD, see Chronic obstructive pulmonary disease, acute exacerbations in Respiratory system infections, antibacterial therapy . Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should. However, the National Institute of Clinical Excellence (NICE) 2018 guidelines recommend against its use in primary care because it is time-intensive and challenging to carry out. Annual reviews and other appointments focused on supporting management of chronic respiratory or cardiovascular conditions. d) Proportion of people with COPD prescribed an inhaler who have their inhaler technique assessed after an acute exacerbation. Advice should be culturally appropriate and accessible to people with additional needs such as physical, sensory or learning disabilities, and to people who do not speak or read English. Evidence of local arrangements to ensure that people who smoke who have set a quit date with an evidence-based smoking cessation service are assessed for carbon monoxide levels 4 weeks after the quit date. Most patients with exacerbation of chronic obstructive pulmonary disease (COPD) require oxygen supplementation during an exacerbation. Evidence of local arrangements and written clinical protocols to ensure that people with stable COPD and a persistent resting stable oxygen saturation level of 92% or less have their arterial blood gases measured to assess whether they need LTOT. 1.2.1 When prescribing an antibiotic for an acute exacerbation of COPD, follow table 1 for adults aged 18 years and over. People who smoke are offered behavioural support with pharmacotherapy by an evidence-based smoking cessation service. Exacerbations of COPD can be associated with the following symptoms: 1. exposure to fumes, such as biomass fuels. 1.2.3 Review intravenous antibiotics by 48 hours and consider stepping down to oral antibiotics where possible. Chronic Obstructive Pulmonary Disease (COPD) is currently the fourth leading cause of death in the world1 but is projected to be the 3rd leading cause of death by 2020. PCRS and other organisations advised that this omission would render the guideline out of date on 19 December 2017 Endobronchial valve insertion to reduce lung volume in emphysema (NICE interventional procedures guidance 600) added. Development involving any one or more of the following: Local planning authorities should ensure that proposals to encourage active travel in planning applications for major developments are accessible to people with limited mobility or disabilities. 1.1.8 Seek specialist advice for people with an acute exacerbation of COPD if they: have symptoms that are not improving with repeated courses of antibiotics or, have bacteria that are resistant to oral antibiotics or. 3 the NICE guideline on COPD) • previous exacerbation and hospital admission history, and the risk of developing complications • previous sputum culture and susceptibility results • the risk of antimicrobial resistance with repeated courses of antibiotics Give oral antibiotics first line if possible Local authorities should ensure that they assess the impact on vulnerable groups if local charges on certain classes of vehicle in clean air zones are proposed. This NICE Pathway covers diagnosing and managing, 5 August 2020 Electrical stimulation to improve muscle strength in chronic respiratory conditions, chronic heart failure and chronic kidney disease (NICE interventional procedures guidance 677) added to, 12 September 2019 Updated table on antibiotic treatment for adults aged 18 years and over in. By publicising their approach, public sector organisations can encourage organisations in other sectors to take action to reduce emissions from their vehicle fleets. The built environment can affect the emission of road-traffic-related air pollutants by influencing how and how much people travel, for example, by ensuring good connections to walking and cycling networks. Commonly reported symptoms are: worsening breathlessness, cough, increased sputum production and change in the colour of the sputum. (1959) The significance of respiratory symptoms and the diagnosis of chronic bronchitis in a working population. specifying emission standards for private hire and other licensed vehicles. It can also help to maintain people’s health and wellbeing during and after construction. Chronic obstructive pulmonary disease (COPD), projected to be the third leading cause of death by 2020, accounts for 6% of deaths globally. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. 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. 1.2.2 Give oral antibiotics first line if the person can take oral medicines, and the severity of their exacerbation does not require intravenous antibiotics. 8 Table 3 highlights the factors … Clinical practice. a) Evidence of local arrangements and written clinical protocols to ensure that people aged over 35 years presenting with a risk factor and one or more symptoms of COPD have post-bronchodilator spirometry. NICE guideline [NG114] Local planning authorities assess proposals to minimise and mitigate road-traffic-related air pollution in planning applications for major developments. An exacerbation of COPD causes an acute deterioration of respiratory symptoms, particularly increased breathlessness and cough, and increased sputum volume and/or a change in the colour of the sputum. a) Evidence of local processes and guidance that ensure planning applications for major developments include proposals to minimise and mitigate road-traffic-related air pollution. Evidence of local arrangements to ensure that people are asked if they smoke by their healthcare practitioner, and those who smoke are offered advice on how to stop. [, An oxygen saturation (measured with a pulse oximeter) that is persistently 92% or less when the person is in a chronic stable state and is at rest (is not, and has not recently, been exercising). 25 July 2017 Roflumilast for treating chronic obstructive pulmonary disease (NICE technology appraisal guidance 461) added to. 1987, in the Annals of Internal Medicine, occupational exposure to harmful fumes, dust or chemicals. Not troubled by breathlessness except on strenuous exercise. Periods of poor air quality are associated with adverse health effects, including asthma attacks, reduced lung function, and increased mortality and admissions to hospital. NICE Bites is a monthly prescribing bulletin published by North West Medicines Information centre which summarises key recommendations from NICE guidance. Reduced exercise t… Upper airway symptoms (eg, colds and sore throats). b) Proportion of people with COPD prescribed an inhaler who have their inhaler technique assessed at their annual review. Assessing proposals to minimise and mitigate road-traffic-related air pollution will help to ensure they are robust and evidence based. NICE has produced a COVID-19 rapid guideline on community-based care of patients with chronic obstructive pulmonary disease (COPD). 4 February 2016 Update of chronic obstructive pulmonary disease in adults (NICE quality standard 10) added. In some people, uncontrolled oxygen therapy may reduce the depth and frequency of breathing, leading to a rise in blood carbon dioxide levels and a fall in the blood pH (acidosis). Guidelines for home oxygen use in adults, Royal College of Physicians’ National COPD Audit Programme: pulmonary rehabilitation clinical audit and organisational audit, Royal College of Physicians’ National COPD Audit Programme: pulmonary rehabilitation clinical audit, Royal College of Physicians’ National COPD Audit Programme: Pulmonary rehabilitation clinical audit, British Thoracic Society's guideline on pulmonary rehabilitation in adults, NICE’s guideline on chronic obstructive pulmonary disease, British Thoracic Society. NICE does recommend that, when using triple therapy for breathlessness, there should be a review after 3 months to check efficacy, but in … Due to recent practice … 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. An exacerbation is a sustained worsening of a person’s symptoms from their stable state beyond usual day-to-day variations and is acute in onset. Numerator – the number in the denominator whose oxygen saturation levels are maintained between 88% and 92%. Commonly reported symptoms are: worsening breathlessness, cough, increased sputum production and change in sputum colour. European Respiratory Journal 23(6): 932–46. This can vary by healthcare setting. [Expert consensus], Controlled oxygen therapy, nebulised bronchodilator therapy, systemic corticosteroids and antibiotics if indicated, in line with the NICE guideline. The key components of their approach should include enabling zero- and low-emission travel (including active travel such as cycling or walking) and developing buildings and spaces to reduce exposure to air pollution. The exacerbations of copd path for the chronic obstructive pulmonary disease pathway. NICE guideline NG115, NICE's guideline on chronic obstructive pulmonary disease, British Thoracic Society. People receiving emergency oxygen for an acute exacerbation of chronic obstructive pulmonary disease (COPD) have their oxygen saturation levels maintained between 88% and 92%. Proportion of people who smoke who are referred to an evidence-based smoking cessation service. Avoiding or reducing strenuous activity outside, especially in highly polluted locations such as busy streets, and particularly if experiencing symptoms such as sore eyes, a cough or sore throat. BMJ 2010; 341:c5462. previous antibiotic use, which may have led to resistant bacteria.Send a sputum sample for culture and susceptibility testing if symptoms have not improved following antibiotic treatment and this has not been done already. 1.2.2 Give oral antibiotics first line if the person can take oral medicines, and the severity of their exacerbation does not require intravenous antibiotics. Buildings can affect the way air pollutants are dispersed through street design and the resulting impact on air flow. Restrict use of antibiotics for COPD NICE says BMJ 2018 ; 362;k3016 ... Art. Children and young people aged 5 to 16 to contact a healthcare professional for a review if their asthma control deteriorates. NICE has published new guidance on prescribing antibiotics for acute exacerbations of chronic obstructive pulmonary disease (COPD) . The Global Initiative for Chronic Obstructive Lung Disease (GOLD), a report produced by the National Heart, Lung, and Blood Institute (NHLBI) and the World Health Organization (WHO), defines an … Proportion of people who receive behavioural support with pharmacotherapy from an evidence-based smoking cessation service. Recording smoking status using carbon monoxide testing after 4 weeks provides an incentive for people who are attempting to stop, and is an objective way to measure individual and service level outcomes. Acute exacerbations of chronic obstructive pulmonary disease. a history of cardiovascular disease, hypertension or hypoxia, clinical signs such as tachycardia, oedema, cyanosis or features of cor pulmonale, Need for referral to specialist and therapy services, Need for social services and occupational therapy input, 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. This can be individual or group behavioural support. b) Proportion of referrals of people with stable COPD and exercise limitation due to breathlessness that result in the person attending a pulmonary rehabilitation programme. Medical Research Council dyspnoea scale of breathlessness grade 3 and above. 2 If a person is receiving antibiotic prophylaxis, treatment should be with an antibiotic from a different class. Stoller JK. Numerator – the number of people in the denominator who receive advice on how to stop. a) Evidence that public sector organisations identify how they will reduce emissions from their vehicle fleets to address air pollution. Local authorities should ensure that strategic plans identify areas where air pollution is highest and, in particular, locations where people who are vulnerable to air pollution may be exposed to high levels of air pollution, such as schools, nurseries, hospitals and care homes, so that targeted approaches can be put in place. a) Proportion of people who are asked if they smoke by their healthcare practitioner. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian. People with COPD and a persistent resting stable oxygen saturation of 92% or less should be assessed for their suitability for LTOT, which can improve survival, pulmonary haemodynamics, polycythaemia and neuropsychological health. An acute exacerbation of COPD is a sustained worsening of symptoms from a person’s stable disease state. 1.1.5 If no antibiotic is given, give advice about: symptoms (such as sputum colour changes and increases in volume or thickness) worsen rapidly or significantly or, symptoms do not start to improve within an agreed time or. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. b) Proportion of people who smoke who receive advice on how to stop. Proportion of people with an exacerbation of COPD and persistent acidotic hypercapnic ventilatory failure that is not improving after 1 hour of optimal medical treatment who have non-invasive ventilation. Denominator – the number of people who have face-to-face contact with a healthcare practitioner. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties. a) Frequency of non-invasive ventilation due to oxygen toxicity. Pathway created: May 2011 Last updated: August 2020. Commonly reported symptoms include: Increased breathlessness. © NICE 2021. Healthcare practitioners should be sensitive to the issue of smoking in young people. [, Pulmonary rehabilitation programmes should be held at times that suit people with COPD and in locations that are easy for people with COPD to get to, and have good access for people with disabilities. 1.1.6 Reassess people with an acute exacerbation of COPD if their symptoms worsen rapidly or significantly at any time, taking account of: other possible diagnoses, such as pneumonia, any symptoms or signs suggesting a more serious illness or condition, such as cardiorespiratory failure or sepsis. If necessary, actions to mitigate the impact of charges on specific groups should be identified. 1.1.2 Consider an antibiotic (see the recommendations on choice of antibiotic) for people with an acute exacerbation of COPD, but only after taking into account: the severity of symptoms, particularly sputum colour changes and increases in volume or thickness beyond the person's normal day-to-day variation, whether they may need to go into hospital for treatment (see the NICE guideline on COPD in over 16s), previous exacerbation and hospital admission history, and the risk of developing complications, previous sputum culture and susceptibility results. Proportion of children, young people and adults with chronic respiratory or cardiovascular conditions attending a routine health appointment that were given advice on what to do when outdoor air quality is poor. Everything NICE has said on diagnosing and managing chronic obstructive pulmonary disease in people aged 16 and over in an interactive flowchart. upper respiratory tract infection in the past 5 days. considering how structures such as buildings and other physical barriers will affect the distribution of air pollutants. [Adapted from, Exercise capacity and physical activity levels are impaired during and after an exacerbation, contributing to skeletal muscle dysfunction, particularly of the lower limbs. COPD Exacerbations: An Official ERS/ATS Clinical Practice Guideline. 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. a) Proportion of people with stable COPD and exercise limitation due to breathlessness who are referred to a pulmonary rehabilitation programme. It is normally combined with pharmacotherapy. 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