NICE guideline [NG115]Published: 05 December 2018 Last updated: 26 July 2019
My name is Fernando Florido and I am a GP in the United Kingdom. In this podcast I go through the NICE Guideline: Chronic obstructive pulmonary disease in over 16s: diagnosis and management (NG115 guideline), updated on 26th July 2019.
This podcast will be saved on a website.
There is also a YouTube video on this subject and other NICE guidance. You can access the channel here:
https://www.youtube.com/channel/UClrwFDI15W5uH3uRGuzoovw
NICE Guideline NG115 can be found here:
https://www.nice.org.uk/guidance/NG115
Other links referred to in this episode:
· guideline on antimicrobial prescribing for acute exacerbations of COPD
· visual summary covering non-pharmacological management and use of inhaled therapies
· MRC breathlessness scale 1959
· visual summary covering non-pharmacological management and use of inhaled therapies
· asthmatic features/features suggesting steroid responsiveness
· MHRA safety advice on Respimat and Handihaler inhalers
· amantadine, oseltamivir and zanamivir for the treatment of influenza
· NICE interventional procedures guidance on lung volume reduction surgery, endobronchial valves
· British Thoracic Society recommendations
· NICE guideline on antimicrobial prescribing for acute exacerbations of COPD
· recommendations on systemic corticosteroids
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Thank you for downloading and welcome. This podcast is intended for healthcare professionals and it brings you medical information about clinical guidelines by the National Institute for Clinical Excellence or NICE from a Primary Care perspective. My name is Fernando Florido and I am a GP in the United Kingdom.
In this episode I am going to tell you about the NICE guidelines on Chronic obstructive pulmonary disease in over 16s: diagnosis and management (this is the NG115 guideline). These guidelines were last updated in July 2019. NICE checked this guideline in January 2022 and it was decided that it did not need to be updated at that time.
In this episode I am going to summarise the main body of the guideline. You may be aware that many clinicians and formularies now rely on the management recommendations produced by the Global initiative for obstructive lung disease, also known as GOLD, which some say are more easily applied in practice than the NICE recommendations. The NICE recommendations do not contradict the GOLD report, but there are some who say that they are much more concise in their approach. Considering that the PDF document of this NICE guideline is 72 pages long, that is quite a statement. However, stay tuned because I intend to create another episode in future on the GOLD guidelines.
I have also uploaded YouTube videos on this subject and other NICE guidance. A link to access the YouTube channel can be found in the episode description.
As ever, all information is correct at the time of recording and all views and opinions are my own. I hope that you enjoy this episode.
Right, this guideline covers diagnosing and managing chronic obstructive pulmonary disease or COPD (which includes emphysema and chronic bronchitis) in people aged 16 and older. 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.
NICE has also produced a guideline on antimicrobial prescribing for acute exacerbations of COPD and a visual summary covering non-pharmacological management and use of inhaled therapies. I will put the links to these two in the episode description.
The diagnosis of COPD is suspected on the basis of symptoms and signs and is supported by spirometry.
We will 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:
· exertional breathlessness
· chronic cough
· regular sputum production
· frequent winter 'bronchitis'
· or wheeze.
One of the primary symptoms of COPD is breathlessness. 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. I will put the link to this table in the episode description. The scale goes from 1 to 5 where 1 means minimal breathlessness and 5 disabling breathlessness.
So, In the MRC dyspnoea scale
Grade 1
Means that the person is not troubled by breathlessness except on strenuous exercise
Grade 2
Means that the person is short of breath when hurrying or walking up a slight hill
Grade 3
Is when the person walks slower than contemporaries on level ground because of breathlessness, or has to stop for breath when walking at own pace
Grade 4
Is when the person needs to stop for breath after walking about 100 metres or after a few minutes on level ground
And Grade 5
Is when the person is too breathless to leave the house, or is breathless when dressing or undressing
We need to perform spirometry:
· at diagnosis
· to reconsider the diagnosis, for people who show an exceptionally good response to treatment
· to monitor disease progression.
We will measure post-bronchodilator spirometry to confirm the diagnosis of COPD. An FEV1/FVC ratio below 0.7 is typical in COPD
We will also think about alternative diagnoses or investigations for older people who have an FEV1/FVC ratio below 0.7 but do not have typical symptoms of COPD.
And we will think about a diagnosis of COPD in younger people who have typical symptoms of COPD, even when their FEV1/FVC ratio is above 0.7.
We will consider primary care respiratory review and spirometry for people with emphysema or signs of chronic airways disease on a chest X-ray or CT scan.
If the person is a current smoker, their spirometry results are normal and they have no symptoms or signs of respiratory disease:
· we will offer smoking cessation advice and treatment
· we will warn them that they are at higher risk of lung disease
· we will advise them to return if they develop respiratory symptoms
· So all this is if the person is a smoker. However
If the person is not a current smoker, their spirometry is normal and they have no symptoms or signs of respiratory disease:
· We will 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
· We will reassure them that their emphysema or chronic airways disease is unlikely to get worse but
· We will advise them to return if they develop respiratory symptoms
For both situations, smokers and non-smokers, we need to be aware that the presence of emphysema on a CT scan is an independent risk factor for lung cancer.
in addition to spirometry all patients should have:
· a chest X-ray to exclude other pathologies
· a full blood count to identify anaemia or polycythaemia
· their body mass index (BMI) calculated.
· So these three investigations should always be carried out but
We will perform additional investigations when needed, and these investigations will be
Sputum culture
if sputum is purulent
Serial home peak flow measurements
To exclude asthma if diagnostic doubt remains
ECG and serum natriuretic peptides
To assess cardiac status if cardiac disease or pulmonary hypertension are suspected because of:
· a history of cardiovascular disease, hypertension or hypoxia or
· clinical signs such as tachycardia, oedema, cyanosis or features of cor pulmonale
Echocardiogram
To assess cardiac status if cardiac disease or pulmonary hypertension are suspected
CT scan of the thorax
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 and
To assess suitability for lung volume reduction procedures
Serum alpha-1 antitrypsin
To assess for deficiency if there is early onset, minimal smoking history or family history
Transfer factor for carbon monoxide (TLCO)
To investigate symptoms that seem disproportionate to the spirometric impairment and
To assess suitability for lung volume reduction procedures
For most people, routine spirometric reversibility testing is not necessary as part of the diagnostic. 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
· response to long-term therapy is not predicted by acute reversibility testing.
Untreated COPD and asthma are frequently distinguishable on the basis of history (and examination) in people presenting for the first time. Whenever possible, we will use features from the history and examination to differentiate COPD from asthma.
These six Clinical features differentiating COPD and asthma are as follows
For example
COPD
Asthma
1- being a smoker or ex-smoker
Is a feature in almost all COPD patients
Whereas it is only possible in asthma
2- Symptoms under age 35
are Rare in COPD
Whereas they appear often in asthma
3- Chronic productive cough
Is common in COPD
But uncommon in asthma
4- Breathlessness
Is persistent and progressive in COPD
Whereas it is variable in asthma
5- Night time waking with breathlessness and/or wheeze
Is uncommon in COPD
Whereas it is common in asthma
6- Significant diurnal or day-to-day variability of symptoms
Is uncommon in COPD
Whereas it is common in asthma
For more information on diagnosing asthma you can refer to the NICE guideline on asthma and I will put a link to this in the episode description.
In addition to these six features, we can use the regular observation of symptoms or spirometry or peak flow readings to help differentiate COPD from asthma.
And when diagnostic uncertainty remains, or we suspect that both COPD and asthma are present, we will use the following findings to help identify asthma:
1. a response to bronchodilators or to 30 mg oral prednisolone daily for 2 weeks of over 400 ml in the FEV1.
2. Or serial peak flow measurements showing 20% or greater diurnal or day-to-day variability.
In addition, we will conclude that clinically significant COPD is not present if the FEV1 and FEV1/FVC ratio return to normal with drug therapy and we will reconsider the diagnosis of COPD for people who report a marked improvement in symptoms in response to inhaled therapy.
If diagnostic uncertainty remains, we will think about referral for more detailed investigations, including imaging and measurement of transfer factor for carbon monoxide (TLCO).
For people for whom the FEV1/FVC ratio is <0.7 we will classify the severity of airflow obstruction according to the reduction in FEV1, and this is
Gradation of severity of airflow obstruction
If
FEV1≥ 80% predicted
It will be Stage 1 – Mild
FEV1 50–79% predicted
It will be Stage 2 – Moderate
FEV1 30–49% predicted
It will be Stage 3 – Severe
FEV1 <30% predicted
It will be Stage 4 – Very severe (or FEV1 below 50% with respiratory failure)
We should perform spirometry in people who are over 35, current or ex‑smokers, and have a chronic cough.
We will consider spirometry in people with chronic bronchitis given that a significant proportion of these people will go on to develop airflow limitation.
We will refer patients for the following reasons:
If There is diagnostic uncertainty or there is severe COPD or cor pulmonale
In order to Confirm the diagnosis and optimise the therapy
We will also refer For Assessment for oxygen therapy long term nebuliser therapy or corticosteroid therapy
In order to Optimise therapy and measure blood gases
If there is Bullous lung disease, For Assessment for a lung volume reduction procedure and For Assessment for lung transplantation
In order to Identify candidates for intervention
We will also refer If there is A rapid decline in FEV1 and for pulmonary rehabilitation and If the Symptoms are disproportionate to the lung function deficit or if there is Dysfunctional breathing
In order to Look for other explanations
Finally we will refer If there is Onset of symptoms under 40 years or a family history of alpha‑1 antitrypsin deficiency
In order to Identify alpha‑1 antitrypsin deficiency
If there are Frequent infections
In order to Exclude bronchiectasis
If there is Haemoptysis
In order to Exclude carcinoma of the bronchus
NICE has produced a visual summary covering non-pharmacological management and use of inhaled therapies and I will put a link to this in the episode description.
Document an up-to-date smoking history, including pack years smoked (which is the number of cigarettes smoked per day, divided by 20 cigarettes in a pack, multiplied by the number of years smoked)
At every opportunity, we will advise and encourage to stop, and offer them help to do so.
So, unless contraindicated, we will offer nicotine replacement therapy, varenicline or bupropion as appropriate to people who want to stop smoking, combined with an appropriate support programme
We need to discuss with the person, the risk of side effects (including pneumonia) of inhaled corticosteroids for COPD and
We will not use oral corticosteroid reversibility tests to identify which people should be prescribed inhaled corticosteroids, because they do not predict response to inhaled corticosteroid therapy.
We will not assess the effectiveness of bronchodilator therapy using lung function alone but we will also include a clinical improvement in symptoms.
We will offer LAMA+LABA to COPD patients who are on a short-acting bronchodilator if
· do not have asthmatic features/features suggesting steroid responsiveness such as previous diagnosis of asthma or of atopy, a higher blood eosinophil count, substantial variation in FEV1 over time ( and of at least 400 ml) or substantial diurnal variation in peak expiratory flow (at least 20%)and
· remain breathless or have exacerbations despite existing management.
We need to be aware of the MHRA safety advice on Respimat and Handihaler inhalerswhich basically refers to taking into account the risk of cardiovascular side effects for patients with conditions that may be affected by the anticholinergic action of tiotropium, including MI, cardiac arrythmia and heart failure. I will put a link to this advice in the episode description.
We will consider LABA+ICS for COPD patients who are on a short-acting bronchodilator if
· they have asthmatic features/features suggesting steroid responsiveness and
· remain breathless or have exacerbations despite existing management.
For people with COPD who are taking LABA+ICS, we will offer triple therapy with 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 is because adding the LAMA has a beneficial effect on symptoms and exacerbations
For people with COPD who are taking LAMA+LABA, consider LAMA+LABA+ICS if:
· they have a severe exacerbation (requiring hospitalisation) or
· they have 2 moderate exacerbations within a year.
· And this is because ICS have a significant impact on exacerbations and not so much on symptoms.
For people with COPD who are taking LAMA+LABA and whose day-to-day symptoms adversely impact their quality of life:
· we will consider a trial of LAMA+LABA+ICS, lasting for 3 months only
· And then:
o if symptoms have not improved, stop LAMA+LABA+ICS and switch back to LAMA+LABA
o if symptoms have improved, continue with LAMA+LABA+ICS.
· We will Minimise the number of inhalers and the number of different types of inhaler used by each person as far as possible, using combination inhalers if necessary
We will say that
In most cases bronchodilator therapy is best administered using a hand-held inhaler (including a spacer if appropriate). And we will only prescribe inhalers after people can demonstrate satisfactory inhaler technique
We will provide a spacer that is compatible with the inhaler advising that
· They should administer the drug by single actuations of the metered-dose inhaler into the spacer, inhaling after each actuation
· And ensuring that there should be minimal delay between inhaler actuation and inhalation and being aware that
· normal tidal breathing can be used as it is as effective as single breaths
In respect of spacer cleaning, we will advise:
· 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.
We will think about nebuliser therapy for people with distressing or disabling breathlessness despite maximal therapy using inhalers.
And we will not continue it unless there is an objective or subjective improvement.
We will 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).
We will say that the long-term use of oral corticosteroid therapy in COPD is not normally recommended. Some people with advanced COPD may need long-term oral corticosteroids when these cannot be withdrawn following an exacerbation. In these cases, the dose of oral corticosteroids should be kept as low as possible.
And we will monitor people who are having long-term oral corticosteroid therapy for osteoporosis, and give them appropriate prophylaxis. Prophylaxis should be started without monitoring for people over 65.
We will say that
slow-release 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.
We will 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.
And we will 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).
We will consider it for people with a chronic cough productive of sputum. And we will only continue it if there is symptomatic improvement. However, we will not routinely use mucolytic drugs to prevent exacerbations in people with stable COPD.
We will consider azithromycin (usually 250 mg 3 times a week) for people with COPD if they:
· do not smoke and
· have optimised management and
· continue to have either:
o frequent exacerbations with sputum production (typically 4 or more per year)
o prolonged exacerbations with sputum production or
o exacerbations resulting in hospitalisation.
Before offering prophylactic antibiotics, we need to 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)
· also training in airway clearance techniques to optimise sputum clearance
· and a CT scan of the thorax to rule out bronchiectasis and other lung pathologies.
In addition, before starting azithromycin, we need to ensure the person has had:
· an electrocardiogram (ECG) to rule out prolonged QT interval and
· baseline liver function tests.
When prescribing azithromycin, we will advise people about the small risk of hearing loss and tinnitus, and tell them to contact a healthcare professional if this occurs.
We will review prophylactic azithromycin after the first 3 months, and then at least every 6 months and
We will only continue treatment if the continued benefits outweigh the risks. This is because there are no long-term studies on the use of prophylactic antibiotics in people with COPD.
For people who are taking prophylactic azithromycin and are still at risk of exacerbations, we will provide a non-macrolide antibiotic to keep at home as part of their exacerbation action plan, telling the patient that it is not necessary to stop prophylactic azithromycin during an acute exacerbation of COPD.
We will say that for treating severe COPD with roflumilast, there is separate NICE guidance which is really outside the scope of this podcast. However, if you are interested, I will put the link to this guidance in the episode description.
We need to be aware that inappropriate oxygen therapy in people with COPD may cause respiratory depression.
We need to assess the need for oxygen therapy in people with:
· very severe airflow obstruction (FEV1 below 30% predicted)
· cyanosis
· polycythaemia
· peripheral oedema
· a raised jugular venous pressure
· oxygen saturations of 92% or less on air.
And we will also consider it for people with severe airflow obstruction (FEV1 30–49% predicted).
We will make the assessment by measuring arterial blood gases on 2 occasions at least 3 weeks apart and we will consider long-term oxygen therapy for people who do not smoke and who:
· have a partial pressure of oxygen in arterial blood (PaO2) below 7.3 kPa when stable or
· have a partial pressure of oxygen in arterial blood (PaO2) between 7.3 and 8 kPa when stable, if they also have 1 or more of the following:
o secondary polycythaemia
o peripheral oedema and / or
o pulmonary hypertension.
We will also conduct and document a structured risk assessment for people being assessed for long-term oxygen therapy. As part of the risk assessment, we will consider:
· 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).
For people who smoke or live with people who smoke, we will ensure the person who smokes is offered advice and support to stop. However, we will not offer long-term oxygen therapy to people who continue to smoke despite these efforts.
We should advise people who are having long-term oxygen therapy that they should use it for a minimum of 15 hours per day.
We will not offer long-term oxygen therapy to treat isolated nocturnal hypoxaemia caused by COPD.
Oxygen concentrators should be used to provide the fixed supply at home.
People on long-term oxygen therapy should be reviewed at least once per year
We will consider ambulatory oxygen in COPD if there is exercise desaturation and are shown to improve with oxygen
We will prescribe ambulatory oxygen to people who are already on long-term oxygen therapy, who wish to continue oxygen therapy outside the home, but we will only prescribe it after an assessment by a specialist. 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.
We will use small light-weight cylinders, oxygen-conserving devices and portable liquid oxygen systems depending on the hours of ambulatory oxygen use and oxygen flow rate needed.
We will not offer Short-burst oxygen therapy to manage breathlessness in people with COPD who have mild or no hypoxaemia at rest.
We will say that In this guideline ‘cor pulmonale’ is defined as a clinical condition that is identified and managed on the basis of clinical features. 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.
We will suspect a diagnosis of cor pulmonale for people with:
· peripheral oedema
· a raised venous pressure
· a systolic parasternal heave and
· a loud pulmonary second heart sound.
And it is recommended that the diagnosis of cor pulmonale is made clinically.
We will not offer solely to manage pulmonary hypertension caused by COPD, any the following treatments:
· bosentan, losartan, nifedipine
· nitric oxide, pentoxifylline
· phosphodiesterase-5 inhibitors
· statins.
caused by COPD we will ensure that patients are offered optimal COPD treatment, including stop smoking and oxygen therapy if there is hypoxia
Oedema associated with cor pulmonale can usually be controlled symptomatically with diuretic therapy.
We will not use any of the following to treat cor pulmonale caused by COPD:
· alpha-blockers
· angiotensin-converting enzyme inhibitors
· calcium channel blockers or
· digoxin (unless there is atrial fibrillation).
We will offer pulmonary rehabilitation to all people who view themselves as functionally disabled by COPD (usually Medical Research Council [MRC] grade 3 and above), including people who have had a recent hospitalisation for an acute exacerbation. Pulmonary rehabilitation is not suitable for people who are unable to walk, who have unstable angina or who have had a recent myocardial infarction.
The rehabilitation process should incorporate a programme of physical training, disease education, and nutritional, psychological and behavioural intervention.
We will offer pneumococcal vaccination and an annual flu vaccination to all people with COPD.
There is separate guidance on preventing and treating flu using antivirals, and I will put the links to this guidance in the podcast description.
But being such a specialised area, I will not say much about this. Only that it applies only to the most severe forms of COPD, that it can involve lung volume reduction surgery, bullectomy, endobronchial valves and coils and lung transplantation and that careful investigations including imaging of the lungs will be required for this. I will put links to this specific guidance in the episode description.
We will also say that Alpha‑1 antitrypsin replacement therapy is not recommended in Alpha‑1 antitrypsin deficiency
We will say that COPD care should be delivered by a multidisciplinary team including:
We need to develop an individualised self-management plan in collaboration with each person with COPD and their family members or carers (as appropriate), including an individualised exacerbation action plan. We will also 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.
There is separate NICE guidance on the choice of antibiotics and I will put the link to this in the episode description. In summary the choice of antibiotics will be:
· as first line amoxicillin, doxycycline or clarithromycin.
· As second line if the first line antibiotic has failed, we will use an alternative first choice, preferably from a different class
· Finally an Alternative choice antibiotic if person at higher risk of treatment failure would be co-amoxiclav, cotrimoxazole and levofloxacine
For people who have used 3 or more courses of oral corticosteroids and/or oral antibiotics in the last year, we should investigate the possible reasons for this.
There is also separate guidance on the recommendations on systemic corticosteroids for more guidance on oral corticosteroids and the link will also be in the podcast description.
We will 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.
· apart from offering the usual advice and treatment we will record the opportunistic measurement of spirometric parameters and if there is a loss of 500 ml or more over 5 years, this will show rapidly progressing disease and may need referral to specialist treatment and investigation.
· We will review people with mild to severe COPD (stages 1 to 3) at least once per year and those with very severe COPD (or stage 4) should be seen at least twice per year in primary care
· A review should include:
o Smoking status and advice,
o symptoms and complications including cor pulmonale
o response to treatment, including inhaler technique, pulmonary rehabilitation and long-term oxygen therapy
o and measure FEV1 and FVC, BMI and the MRC dyspnoea score. We should also check oxygen saturation in patients with very severe COPD
We will define an exacerbation as a sustained worsening of the patient's symptoms which is beyond normal day-to-day variations. The change in these symptoms often necessitates a change in medication.
· a mild exacerbation requires increasing their medication in their own normal environment
· a moderate exacerbation, requires treatment with systemic corticosteroids and/or antibiotics
· a severe exacerbation, requires hospitalisation.
According to the patient’s symptoms and social circumstances as well as objective measurements. In particular significant changes on a chest x-ray and an oxygen saturation of less than 90% is likely to indicate the need for hospital treatment, as well as arterial blood gases showing a PH less than 7.35 or the partial pressure of oxygen in arterial blood is less than 7 kilopascals
sending sputum samples for culture is not recommended routinely for people who have their exacerbation managed in primary care but pulse oximetry can be of value
· a chest X-ray
· arterial blood gases
· an ECG
· a full blood count and urea and electrolyte
· a theophylline level for people taking theophylline
· a sputum culture if the sputum is purulent
· and blood cultures if there is a fever
Hospital-at-home and assisted-discharge schemes are safe and can also be used as an alternative
We can use both nebulisers and inhalers but we will change people to inhalers as soon as their condition has stabilised, because this may allow them to be discharged from hospital earlier.
If a person with COPD is hypercapnic or acidotic the nebuliser should be driven by compressed air rather than oxygen to avoid worsening hypercapnia. If oxygen therapy is needed, we should administer it simultaneously by nasal cannulae.
In the absence of significant contraindications, we will use oral corticosteroids, to people having an exacerbation, offering 30 mg of oral prednisolone daily for 5 days and we will think about osteoporosis prophylaxis for people who need frequent courses of oral corticosteroids.
For guidance on using antibiotics to treat COPD exacerbations, there is separate guidance and I will put the link in the episode description. It is basically:
· amoxicillin, doxycycline or clarithromycin as first line.
· As second line if the first line antibiotics has failed, we will use an alternative first choice, preferably from a different class
· Alternative choice oral antibiotics (if person at higher risk of treatment failure would be co-amoxiclav, cotrimoxazole and levofloxacine
We will only use intravenous theophylline with careful monitoring as an adjunct to exacerbation management if there is an inadequate response to nebulised bronchodilators.
Respiratory stimulants such as doxapram should be used only when non-invasive ventilation is either unavailable or inappropriate.
We will measure oxygen saturation if there are no facilities to measure arterial blood gases and if necessary, prescribe oxygen to keep the oxygen saturation of arterial blood within the individualised target range.
Pulse oximetry gives no information about the partial pressure of CO2 in arterial blood 2 or pH so we will measure arterial blood gases in all people who arrive at hospital with an exacerbation of COPD.
We will use Non-Invasive Ventilation as the treatment of choice for persistent hypercapnic ventilatory failure during exacerbations despite optimal medical therapy.
We will treat hospitalised exacerbations of COPD on intensive care units, including invasive ventilation when this is thought to be necessary.
We will also consider physiotherapy using positive expiratory pressure devices for selected people with exacerbations of COPD, to help with clearing sputum.
We will do regular clinical assessments, use pulse oximetry and for people who are hypercapnic or acidotic , we will measure intermittent arterial blood gases until they are stable.
We will not, however, routinely perform daily monitoring of peak expiratory flow or FEV1 because the magnitude of changes is small compared with the variability of the measurement.
We have come to the end of this episode. I hope that you have enjoyed it and I hope that you will join me in the next one. Thank you for listening and goodbye.
