Management of COPD (NICE Guideline)

Summary of NICE guidance on COPD treatment.

1. DIAGNOSIS AND ASSESSMENT

  • Consider diagnosis of COPD if: age >35 years, smoker/ex-smoker, no asthma symptoms and presenting with any of the below:
    – exertional breathlessness
    – chronic cough
    – regular sputum production
    – frequent winter 'bronchitis'
    – wheeze
    • Confirm presence and degree of airflow obstruction with post-bronchodilator spirometry (see Table 1)
    • Perform chest X-ray, FBC and calculate BMI
    • Also consider:
      – Level of disability (eg, breathlessness [use MRC dyspnoea scale], exercise limitation, frequency of exacerbations)
      – Other prognostic factors (eg, health status, PaO2, cor pulmonale)
      – Sputum culture; serial home peak flow measurements (to exclude asthma); ECG, serum natriuretic peptides and echocardiogram (if cardiac disease or pulmonary hypertension suspected); serum alpha-1 anti-trypsin (if deficiency suspected)
      – CT scan or TLCO (carbon monoxide lung transfer factor) testing if symptoms disproportionate to spirometric impairment
    Table 1: Severity of airflow obstruction where post-bronchodilator FEV1/FVC <0.7
    Severity of airflow obstruction Stage 1:
    Mild
    Stage 2:
    Moderate
    Stage 3:
    Severe
    Stage 4:
    Very severe
    FEV1 (% predicted) ≥80 + symptoms 50–79 39–49 < 50 + respiratory failure or < 30

    2. MANAGEMENT OF STABLE DISEASE

    INHALED TREATMENT

    Refer to the treatment algorithm at the top of this page.

    • Choose a drug based on symptomatic response, patient's preference and ability to use device, side-effects and potential to reduce exacerbations, and cost
    • Ensure patients receive devices they have been trained to use, eg by prescribing inhalers by brand
    • Assess effectiveness in terms of: lung function, symptoms, daily activities, exercise capacity and speed of symptom relief (short-acting bronchodilators only)
    • Consider nebuliser if distressing or disabling breathlessness despite maximal inhaled therapy; continue use only if condition improves
    • Do not use oral corticosteroid reversibility tests to identify patients who will benefit from inhaled corticosteroids

    ORAL TREATMENT

    • Long-term oral corticosteroids – recommended only when these cannot be withdrawn in patients with advanced COPD following an exacerbation; keep dose as low as possible. Monitor patients for osteoporosis and prescribe appropriate prophylaxis; if >65 years, start prophylaxis without monitoring
    • Theophylline – consider if inhaled therapy cannot be used or if patient still symptomatic after trials of short-acting and long-acting bronchodilators (can be added to these). Assess effectiveness as for inhaled therapy; monitor plasma levels and interactions
    • Mucolytics – consider if chronic productive cough; continue use only if symptoms improve (do not use routinely to prevent exacerbations)
    • Prophylactic azithromycin - consider in patients who do not smoke but continue to have frequent or prolonged exacerbations with sputum production, or exacerbations resulting in hospitalisation, despite optimised inhaled therapy (before offering, ensure patient has had sputum culture, training in airway clearance techniques, thorax CT, ECG and LFTs); review after 3 months then every 6 months. Continue during exacerbations.
    • Roflumilast - see nice.org.uk/guidance/ta461

    OXYGEN THERAPY

    • Assess need for long-term oxygen therapy (LTOT) in patients with FEV1 <30% predicted, cyanosis, polycythaemia, peripheral oedema, raised JVP or O2 saturations ≤92% breathing air
    • Offer LTOT to patients with PaO2 < 7.3kPa when stable, or > 7.3kPa and < 8kpa when stable plus a secondary condition (eg, peripheral oedema, pulmonary hypertension, secondary polycythaemia) if they have stopped smoking
    • Following specialist assessment, offer ambulatory oxygen to patients on LTOT who are motivated to use it, have moderate to severe hypoxaemia at rest and exercise desaturation, and oxygen improves exercise capacity
    • Advise patient to use for ≥15 hours/day and warn of fire/explosion risk
    • Do not offer short-burst oxygen therapy to manage breathlessness in people with mild or no hypoxaemia at rest

    Note:

    • Exclude clinically significant COPD if FEV1 and FEV1/FVC normalise on drug therapy
    • Consider asthma if >400ml FEV1 response to bronchodilators/oral corticosteroids and significant daily fluctuations in peak flow

    3. MANAGEMENT OF EXACERBATIONS

    INITIAL MANAGEMENT

    • Increase frequency of short-acting bronchodilator use and consider use of a nebuliser
    • Consider prescribing prednisolone 30mg daily for 5 days if breathlessness increases sufficiently to interfere with daily activities
    • Consider prescribing antibiotics taking into account symptom severity, need for hospitalisation, previous exacerbations and culture results and risk of complications (see MIMS Antibiotic Treatments table)

    SELF MANAGEMENT

    Provide patients at risk of exacerbation with a short course of antibiotics (see MIMS Antibiotic Treatments tableand corticosteroids to keep at home and encourage patients to respond to an exacerbation by:

    • adjusting short-acting bronchodilator therapy to control symptoms
    • starting oral corticosteroid if breathlessness increases sufficiently to interfere with daily activities
    • starting oral antibiotics if sputum changes colour and increases in volume or thickness

    4. FOLLOW-UP

    • Review patients with mild or moderate COPD at least yearly and those with very severe COPD at least twice yearly
    Additional supportive measures
    • Develop an individualised self-management plan in collaboration with the patient
    • Smoking cessation:
      – Provide encouragement and assistance to all patients at every opportunity
      – Offer nicotine replacement therapy, varenicline or bupropion
      • Offer pulmonary rehabilitation to all appropriate patients, including those with a recent hospitalisation for an acute exacerbation, and to those who consider themselves to be functionally disabled by COPD
      • Use non-invasive ventilation for persistent hypercapnic ventilatory failure during exacerbations unresponsive to drug therapy
      • Offer annual influenza and pneumococcal vaccinations to all patients
      • Identify and treat anxiety and depression
      • Address obesity and poor nutrition
      • Consider referral for physiotherapy, dietetic advice, occupational therapy, cognitive behavioural therapy, social services and multidisciplinary palliative care as appropriate
      Specialist referral
      • Diagnostic uncertainty
      • Suspected severe COPD
      • Onset of cor pulmonale
      • Assessment for O2 therapy, long-term nebuliser therapy or oral corticosteroid therapy
      • Rapid decline in FEV1
      • Assessment for pulmonary rehabilitation
      • Assessment for surgical options
      • Dysfunctional breathing
      • Onset of symptoms < 40 years or a family history of alpha-1 antitrypsin deficiency
      • Symptoms disproportionate to lung function deficit
      • Frequent infections
      • Haemoptysis
      • Bullous lung disease

      Unlicensed use.

      Adapted from: NICE Clinical Guideline 115 (December 2018; updated July 2019) - Chronic obstructive pulmonary disease in over 16s: diagnosis and management.


      KEYWORDS: LABA | LAMA | ICS | Beta2 agonist | Anticholinergic | Antimuscarinic | Muscarinic | Antagonist | Bronchodilator | Corticosteroid | Inhaled COPD therapy


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