In this section of the guideline, the term theophylline refers to slow-release formulations of the drug. 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. For more information on diagnosing asthma see the NICE guideline on asthma. European Respiratory Journal 23(6): 932–46. , 1.3.13  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). , 1.2.131 Ask people with COPD if they experience breathlessness they find frightening.  The MHRA has published a safety alert around the use of non CE marked nebulisers for COPD. Pulmonary rehabilitation is not suitable for people who are unable to walk, who have unstable angina or who have had a recent myocardial infarction. , 1.3.28 Pulse oximeters should be available to all healthcare professionals involved in the care of people with exacerbations of COPD, and they should be trained in their use. 26 July 2019. For carbocisteine the manufacturer recommends a starting dose of 2250 mg in divided doses, reducing to 1500 mg daily in divided doses when a satisfactory response is … [2004, amended 2018], To identify organisms if sputum is persistently present and purulent, To exclude asthma if diagnostic doubt remains. , 1.1.7 Think about a diagnosis of COPD in younger people who have symptoms of COPD, even when their FEV1/FVC ratio is above 0.7. Comprehensive evidence syntheses, including meta-analyses, were performed to summarise all available evidence relevant to the Task Force's questions. 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. Give people (particularly people discharged from hospital) clear instructions on why, when and how to stop their corticosteroid treatment. The rehabilitation process should incorporate a programme of physical training, disease education, and nutritional, psychological and behavioural intervention. , 1.1.19 Untreated COPD and asthma are frequently distinguishable on the basis of history (and examination) in people presenting for the first time. 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. , 1.2.40 Consider mucolytic drug therapy for people with a chronic cough productive of sputum. , 1.2.64 To ensure everyone eligible for long-term oxygen therapy is identified, pulse oximetry should be available in all healthcare settings.  This recommendation was not reviewed as part of the 2018 or 2019 guideline updates. All rights reserved. , 1.3.11 If a person with COPD is hypercapnic or acidotic the nebuliser should be driven by compressed air rather than oxygen (to avoid worsening hypercapnia). , 1.2.6 For more guidance on varenicline see the NICE technology appraisal guidance on varenicline for smoking cessation. Managing an acute exacerbation of COPD with antibiotics , 1.3.16 , 1.3.22 Only use intravenous theophylline as an adjunct to exacerbation management if there is an inadequate response to nebulised bronchodilators. . , 1.3.20 , 1.2.105 Pay attention to changes in weight in older people, particularly if the change is more than 3 kg. Do not use a multidimensional index (such as BODE) to assess prognosis in people with stable COPD. Places should be available within a reasonable time of referral. , 1.2.118 There are significant differences in the response of people with COPD and asthma to education programmes. , 1.3.33 Treat hospitalised exacerbations of COPD on intensive care units, including invasive ventilation when this is thought to be necessary. By NICE 12 September 2019. , 1.2.139 For most people with stable severe COPD regular hospital review is not necessary, but there should be locally agreed mechanisms to allow rapid access to hospital assessment when needed. , 1.2.125 Develop an individualised exacerbation action plan in collaboration with each person with COPD who is at risk of exacerbations. 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). 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. To find out why the committee made the 2018 recommendation on risk factors for exacerbations and how it might affect practice see rationale and impact. If oxygen therapy is needed, administer it simultaneously by nasal cannulae. NICE has also produced a visual summary covering non-pharmacological management and use of inhaled therapies. Last updated May 2019. Whenever possible, use features from the history and examination (such as those listed in table 3) to differentiate COPD from asthma. , 1.2.18 Document the reason for continuing ICS use in clinical records and review at least annually. Be alert for anxiety and depression in people with COPD. 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. For guidance on managing anxiety, see the NICE guideline on generalised anxiety disorder and panic disorder in adults. . 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. 1.2.26 Advise people to use a spacer with a metered-dose inhaler in the following way: administer the drug by single actuations of the metered-dose inhaler into the spacer, inhaling after each actuation, there should be minimal delay between inhaler actuation and inhalation, normal tidal breathing can be used as it is as effective as single breaths, repeat if a second dose is required. * Or FEV1 below 50% with respiratory failure. . 1.2.130 Encourage people with COPD to respond promptly to exacerbation symptoms by following their action plan, which may include: adjusting their short-acting bronchodilator therapy to treat their symptoms, taking a short course of oral corticosteroids if their increased breathlessness interferes with activities of daily living, adding oral antibiotics if their sputum changes colour and increases in volume or thickness beyond their normal day-to-day variation, telling their healthcare professional. 1.2.12 1 Celli BR, MacNee W (2004) Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper. , 1.3.24 Monitor theophylline levels within 24 hours of starting treatment, and as frequently as indicated by the clinical circumstances after this. , 1.2.85 Advise people of the benefits of pulmonary rehabilitation and the commitment needed to gain these. Inhaled combination therapy refers to combinations of long-acting muscarinic antagonists (LAMA), long-acting beta2 agonists (LABA), and inhaled corticosteroids (ICS). , 1.2.82 , 1.2.57 Assess people for long-term oxygen therapy by measuring arterial blood gases on 2 occasions at least 3 weeks apart in people who have a confident diagnosis of COPD, who are receiving optimum medical management and whose COPD is stable. , 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. The diagnosis is suspected on the basis of symptoms and signs and is supported by spirometry. , 1.2.37 Take particular caution when using theophylline in older people, because of differences in pharmacokinetics, the increased likelihood of comorbidities and the use of other medications. , 1.3.17 For guidance on stopping oral corticosteroid therapy it is recommended that clinicians refer to the BNF. 1.2.77 Advise people on spacer cleaning. , 1.2.22 Provide an alternative inhaler if a person cannot use a particular one correctly or it is not suitable for them. . , 1.3.43 People who have had an episode of respiratory failure should have satisfactory oximetry or arterial blood gas results before discharge. NICE has produced a COVID-19 rapid guideline on community-based care of patients with chronic obstructive pulmonary disease (COPD). 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