1.1.7 Refer people with an acute exacerbation of COPD to hospital if they have any symptoms or signs suggesting a more serious illness or condition (for example, cardiorespiratory failure or sepsis) and in line with the NICE guideline on COPD in over 16s. All rights reserved. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. A summary of prescribing recommendations from NICE guidance NICE Bites February 2019: No. European Respiratory Journal 23(6): 932–46. 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. Health professionals Acute exacerbations of chronic obstructive pulmonary disease. b) Annual and hourly mean concentrations for nitrogen dioxide (NO, c) Annual and daily mean concentrations for particulate matter of 10 micrometres or less in diameter (PM, d) Annual mean concentration for fine particulate matter of 2.5 micrometres or less in diameter (PM. The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. Increased dyspnoea. c) Proportion of people with COPD prescribed an inhaler who have their inhaler technique assessed after a change in treatment. 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. Proportion of people discharged from hospital after an acute exacerbation of COPD who start a pulmonary rehabilitation programme within 4 weeks of discharge. NICE guidance and other sources used to create this interactive flowchart. Healthcare practitioners should be sensitive to the issue of smoking in young people. People aged over 35 years who present with a risk factor and one or more symptoms of chronic obstructive pulmonary disease (COPD) have post-bronchodilator spirometry. Identifying their approach to air pollution in the Local Plan, local transport plan and other key strategies will provide a clear framework for joined-up local action. d) Proportion of people with COPD prescribed an inhaler who have their inhaler technique assessed after an acute exacerbation. It recommends changes to usual practice to maximise the safety of … 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. Advice should include how to minimise exposure to outdoor air pollution and manage any related symptoms such as: The Daily Air Quality Index describes air pollution on a scale of 1 to 10 and is divided into 4 bands from low to very high. c) Evidence that local authorities identify in the Local Plan, local transport plan and other key strategies how they will encourage and enable travel by zero- and low-emission vehicles. : CD009764. PCRS and other organisations advised that this omission would render the guideline out of date on 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. Denominator – the number of referrals of people with stable COPD and exercise limitation due to breathlessness to pulmonary rehabilitation programmes. b) Proportion of people with COPD prescribed an inhaler who have their inhaler technique assessed at their annual review. the person becomes systemically very unwell. [, The absence of any of the features of a recent acute exacerbation, such as worsening breathlessness, cough, increased sputum production and change in colour of sputum. 2017, in the Cochrane Library, Anthonisen et al. 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. 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. Programmes should be available within a reasonable time from referral. 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. Bronchodilator therapy is usually delivered using a hand-held inhaler device. Proportion of people who receive behavioural support with pharmacotherapy from an evidence-based smoking cessation service. 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. [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. Review the person's history, paying particular attention to compliance with medication, and details … Numerator – the number of people in the denominator who are assessed for carbon monoxide levels 4 weeks after the quit date. Evidence-based smoking cessation services should target minority ethnic and socioeconomically disadvantaged communities in the local population; it is important to ensure that services are easily accessible by people from these groups and that they are encouraged to use them. Denominator – the number of people who seek support to stop smoking and who agree to take pharmacotherapy. (2004) Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper. See the NICE guideline on COPD in over 16s for other recommendations on preventing and managing an acute exacerbation of COPD, including self-management. It is important that people who smoke who receive pharmacotherapy receive a full course, which will vary depending on the individual smoker. Proportion of people who seek support to stop smoking and who agree to take pharmacotherapy who receive a full course. are at least 6 weeks in duration and include a minimum of twice-weekly supervised sessions, include supervised, individually tailored and prescribed, progressive exercise training including both aerobic and resistance training. Annual reviews and other appointments focused on supporting management of chronic respiratory or cardiovascular conditions. 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. 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. Published date: Proportion of planning applications for major developments granted permission with conditions or obligations to minimise and mitigate road-traffic-related air pollution. [Adapted from, Non-invasive ventilation is a method of providing ventilatory support that does not require an endotracheal tube. Includes cycling and walking; travel by zero- and low-emission vehicles such as electric cars, buses, bikes and pedal cycles; and car sharing schemes or clubs. 1.2.1 When prescribing an antibiotic for an acute exacerbation of COPD, follow table 1 for adults aged 18 years and over. This can be individual or group behavioural support. People with stable chronic obstructive pulmonary disease (COPD) and exercise limitation due to breathlessness are referred to a pulmonary rehabilitation programme. Denominator – the number of people identified as smokers in any healthcare setting. 1.1 Managing an acute exacerbation of COPD with antibiotics, acute exacerbation of chronic obstructive pulmonary disease. N Engl J Med 2002; 346:988. only change the antibiotic according to susceptibility results if bacteria are resistant and symptoms are not already improving (using a narrow-spectrum antibiotic wherever possible). 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. Many exacerbations are not caused by bacterial infections so will not respond to antibiotics. 4 February 2016 Update of chronic obstructive pulmonary disease in adults (NICE quality standard 10) added. ; guided by susceptibilities when available), Levofloxacin (with specialist advice if co-amoxiclav or co-trimoxazole cannot be used; consider safety issues5), First-choice intravenous antibiotic (if unable to take oral antibiotics or severely unwell; cannot take oral medicines (to explore locally available options for giving intravenous antibiotics at home or in the community, rather than in hospital, where appropriate). 3 Hospitalization for COPD exacerbations is common and impacts patients’ disease trajectory, and mortality, with fewer than half of patients hospitalized for exacerbation surviving 5 years. 1.1.4 If an antibiotic is given, give advice: about possible adverse effects of the antibiotic, particularly diarrhoea, that symptoms may not be fully resolved when the antibiotic course has been completed, symptoms worsen rapidly or significantly or, symptoms do not start to improve within 2–3 days (or other agreed time) or. Numerator – the number in the denominator that result in the person completing a pulmonary rehabilitation programme. Pharmacotherapy interventions act as an aid to help people to stop smoking, and it is important that people who seek support to stop smoking receive the full course of their chosen pharmacotherapy to increase the chances of success. a) Hospital admission for acute exacerbation. People with chronic obstructive pulmonary disease (COPD) who are prescribed an inhaler have their inhaler technique assessed when starting treatment and then regularly during treatment. c) Proportion of attendances of people with stable COPD and exercise limitation due to breathlessness that result in the person completing a pulmonary rehabilitation programme. Due to recent practice … Denominator – the number of people aged over 35 years presenting with a risk factor and one or more symptoms of COPD. Reducing emissions from public sector vehicle fleets will help to reduce road-traffic-related air pollution. e) Evidence that local authorities identify key actions to address air pollution and monitor progress against them. 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. 1,2, First-choice oral antibiotics (empirical treatment or guided by most recent sputum culture and susceptibilities), 500 mg three times a day for 5 days (see BNF for dosage in severe infections), 200 mg on first day, then 100 mg once a day for 5‑day course in total (see BNF for dosage in severe infections), Second-choice oral antibiotics (no improvement in symptoms on first choice taken for at least 2 to 3 days; guided by susceptibilities when available), Use alternative first choice (from a different class), Alternative choice oral antibiotics (if person at higher risk of treatment failure Celli BR, MacNee W, Agusti A et al. 2 If a person is receiving antibiotic prophylaxis, treatment should be with an antibiotic from a different class. Not troubled by breathlessness except on strenuous exercise. This therapy is offered weekly for at least the first 4 weeks of a quit attempt (that is, for 4 weeks following the quit date). 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. siting and designing new buildings, facilities and estates to reduce the need for motorised travel, minimising the exposure of vulnerable groups to air pollution by not siting buildings (such as schools, nurseries and care homes) in areas where pollution levels will be high, siting living accommodation away from roadsides, avoiding the creation of street and building configurations (such as deep street canyons) that encourage pollution to build up where people spend time, including landscape features such as appropriate species of trees and vegetation in open spaces or as 'green' walls or roofs where this does not restrict ventilation. Children, young people and adults with chronic respiratory or cardiovascular conditions are given advice at routine health appointments on what to do when outdoor air quality is poor. In the context of secondary care settings, advice may involve the practitioner providing people who smoke with information and referring them to an evidence-based smoking cessation service. Increased cough. More severe degrees of acidosis, such as pH <7.25, have been used as a threshold for considering provision of invasive mechanical ventilation. Effect of high flow oxygen on mortality in chronic obstructive pulmonary disease patients in prehospital setting: randomised controlled trial. Children and young people aged 5 to 16 to contact a healthcare professional for a review if their asthma control deteriorates. For guidance on assessing the need for hospital referral, see NICE guideline: Chronic obstructive pulmonary disease in over 16s (see Useful resources). A placeholder statement indicates the need for evidence-based guidance to be developed in this area. COPD: overview of updated NICE guidance The guidance addresses many current clinically relevant issues in the diagnosis and management 
o of patients with COPD but acknowledges that evidence is still lacking or unclear in some areas, leading to recommendations for research Scenario: End-stage COPD: covers the management of people with COPD that is very severe, unresponsive to usual medical treatment, and associated with … (1959) The significance of respiratory symptoms and the diagnosis of chronic bronchitis in a working population. Elderly people, or people with learning disabilities, physical disabilities or cognitive impairment may experience difficulties learning and retaining the adequate inhaler technique to ensure that they get the optimal treatment dose. 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. NICE guideline NG115, NICE's guideline on chronic obstructive pulmonary disease, British Thoracic Society. NICE has published a Technology Appraisal Guidance (TAG) recommending roflumilast for use within NHS England as an add-on option to treat adults with severe chronic obstructive pulmonary disease (COPD) who continue to experience exacerbations despite triple inhaled therapy. Starting a pulmonary rehabilitation programme within 4 weeks of hospital discharge after an acute exacerbation reduces the short-term risk of hospital readmission, and improves the quality of life and the short-term exercise capacity of people with COPD. Stoller JK. There is currently a lack of evidence-based guidance about the details that should be included in these care bundles. 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. Recommendations. A guidance on managing exacerbations is expected by Dec 2018. The exacerbations of copd path for the chronic obstructive pulmonary disease pathway. 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. b) Evidence of a local framework for assessing proposals to minimise and mitigate road-traffic-related air pollution in planning applications for major developments. People who smoke are offered a referral to an evidence-based smoking cessation service. Pharmacotherapies for smoking cessation are nicotine replacement therapy (NRT), varenicline or bupropion. During an exacerbation, people with COPD may experience a worsening of gas exchange in the lungs, which can lead to low blood oxygen levels. 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. 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. [Expert opinion]. People admitted to hospital for an acute exacerbation of chronic obstructive pulmonary disease (COPD) start a pulmonary rehabilitation programme within 4 weeks of discharge. This statement is linked to statement 2, because advice on how to stop may include a referral to an evidence-based smoking cessation service. The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. An acute exacerbation of COPD is a sustained worsening of symptoms from a person’s stable disease state. the risk of antimicrobial resistance with repeated courses of antibiotics. 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. b) Evidence that local authorities identify in the Local Plan, local transport plan and other key strategies how they will encourage and enable active travel. Warnings include: stopping treatment at first signs of a serious adverse reaction (such as tendonitis), prescribing with special caution in people over 60 years and avoiding coadministration with a corticosteroid (March 2019). Prevention of COPD exacerbations: an ERS/ATS guideline. 05 December 2018, an acute exacerbation of chronic obstructive pulmonary disease (COPD) is a sustained worsening of symptoms from a person's stable state, a range of factors (including viral infections and smoking) can trigger an exacerbation, many exacerbations (including some severe exacerbations) are not caused by bacterial infections so will not respond to antibiotics. A placeholder statement is an area of care that has been prioritised by the Quality Standards Advisory Committee but for which no source guidance is currently available. [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. Denominator – the number of people with COPD prescribed an inhaler who have had an acute exacerbation. Numerator – the number of people in the denominator who receive a full course of pharmacotherapy. Spirometry should be performed by a healthcare professional who has had appropriate training and who has up-to-date skills. NICE has produced a COVID-19 rapid guideline on community-based care of patients with chronic obstructive pulmonary disease (COPD). It is therefore important that healthcare practitioners proactively ask people if they smoke, and offer advice on how to stop. It updates the NICE December 2018 guideline on diagnosing and managing COPD which had omitted recommendations on triple therapy. Medical Research Council dyspnoea scale of breathlessness grade 3 and above. Healthcare practitioners should be sensitive to the issue of smoking in young people. Numerator – the number in the denominator who had their inhaler technique assessed after a change in treatment. See the evidence and committee discussion on antibiotics. The NICE COPD update committee chair said the benefits of prophylactic antibiotics should be balanced against the potential for resistance. This site uses cookies, some may have been set already. [, Non-invasive ventilation should be given once it is recognised that a person is not responding to 1 hour of optimal medical therapy. Wedzicha JA, Calverley PMA, Albert RK, Anzueto A, Criner GJ, Hurst JR, et al. 1. See the evidence and committee discussion on choice of antibiotic and antibiotic course length. 3 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. 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. A full course for NRT is at least 8 weeks, for varenicline it is at least 12 weeks and for bupropion it is at least 8 weeks. 3. Numerator – the number in the denominator who have their arterial blood gases measured to assess whether they need LTOT. 6 Review intravenous antibiotics by 48 hours and consider stepping down to oral antibiotics where possible. Numerator – the number in the denominator whose last inhaler annual review was no longer than 12 months since the previous one or since inhaler initiation. 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, Too breathless to leave the house, or breathless when dressing or undressing. Acute exacerbations of COPD can be triggered by a range of factors including respiratory tract infections (most commonly rhinovirus), smoking, and environmental pollutants. 4. 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