: CD009764. [Adapted from. Upper airway symptoms (eg, colds and sore throats). 3 People who may be at a higher risk of treatment failure include people who have had repeated courses of antibiotics, a previous or current sputum culture with resistant bacteria, or people at higher risk of developing complications. This can be individual or group behavioural support. 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. 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 Proportion of people receiving emergency oxygen for an acute exacerbation of COPD who have their oxygen saturation levels maintained between 88% and 92%. [Adapted from. For patients with ≥ 2 moderate exacerbations per year or at least one severe exacerbation requiring hospitalization in the prior year , LABA/ICS treatment can be considered at blood eosinophil counts ≥ 100 cells/µL, as ICS effects are more pronounced in patients … [, 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. 4. [Adapted from. Or FEV1 below 50% with respiratory failure. Many exacerbations are not caused by bacterial infections so will not respond to antibiotics. The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. 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 evidence-based smoking cessation services. 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. Controlled oxygen therapy must therefore be administered by a delivery device and at a flow rate that helps the oxygen saturation to be maintained between 88% and 92%. Pharmacotherapies for smoking cessation are nicotine replacement therapy (NRT), varenicline or bupropion. a) Proportion of journeys made by local residents that are by walking, cycling, public transport or zero- or low-emission vehicles. © NICE 2021. development carried out on a site having an area of 1 hectare or more. 3 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. Published date: 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. Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. severe exacerbation: the person experiences a rapid deterioration in respiratory status that requires hospitalisation. Commonly reported symptoms are: worsening breathlessness, cough, increased sputum production and change in sputum colour. The draft clinical guideline on diagnosing and managing COPD states that antibiotic treatment to prevent exacerbations should be offered only to patients most likely to benefit from them. [Adapted from, Non-invasive ventilation is a method of providing ventilatory support that does not require an endotracheal tube. include a defined, structured education programme. Walks slower than contemporaries on level ground because of breathlessness, or has to stop for breath when walking at own pace. If your patient has (or is suspected of having) COVID and AECOPD, use this guideline along with the COVID management 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. Adapted from Fletcher CM, Elmes PC, Fairbairn MB et al. Denominator – the number of people with COPD prescribed an inhaler who have had their inhaler changed. respiratory rate increase or heart rate increase 20% above baseline. Local authorities identify in the Local Plan, local transport plan and other key strategies how they will address air pollution, including enabling zero- and low-emission travel and developing buildings and spaces to reduce exposure to air pollution. Commonly reported symptoms are: worsening breathlessness, cough, increased sputum production and change in the colour of the sputum. 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. b) Proportion of people with COPD prescribed an inhaler who have their inhaler technique assessed at their annual review. b) Evidence of local arrangements and written clinical protocols to ensure that healthcare professionals in primary, community and secondary care services are trained and competent in teaching inhaler technique. Numerator – the number in the denominator that were given advice on what to do when outdoor air quality is poor. 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. 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. Denominator – the number of people identified as smokers in any healthcare setting. Proportion of 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. 1. a) Evidence that public sector organisations identify how they will reduce emissions from their vehicle fleets to address air pollution. Numerator – the number in the denominator who have their arterial blood gases measured to assess whether they need LTOT. The presence all 3 symptoms was defined as type 1 exacerbation; 2 of the 3 symptoms was defined as type 2 exacerbation; and 1 of the 3 symptoms with the presence of 1 or more supporting symptoms and signs was defined as type 3 exacerbation. Numerator – the number of people in the denominator who receive behavioural support with pharmacotherapy from an evidence-based smoking cessation service. 24 March 2015 Insertion of endobronchial nitinol coils to improve lung function in emphysema (NICE interventional procedures guidance 517) added. 6. 4. Commonly reported symptoms are worsening breathlessness, cough, increased sputum production and change in sputum colour. 4 December 2018 Update of chronic obstructive pulmonary disease in over 16s: diagnosis and management (NICE guideline NG115). See the evidence and committee discussion on antibiotics. Reducing emissions from public sector vehicle fleets will help to reduce road-traffic-related air pollution. Hospital discharge care bundles are designed to ensure that every person leaving hospital receives the best care. An acute exacerbation of COPD is a sustained worsening of symptoms from a person’s stable disease state. 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. It clarifies the importance of dual bronchodilation to improve symptoms and to reduce exacerbations, as well as the importance of inhaled corticosteroids in people with a significant asthma component or high eosinophil counts. 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. Evidence of local arrangements to ensure that people who seek support to stop smoking and who agree to take pharmacotherapy are offered a full course. [Expert consensus], Controlled oxygen therapy, nebulised bronchodilator therapy, systemic corticosteroids and antibiotics if indicated, in line with the NICE guideline. Evidence of local arrangements to ensure that people who smoke are offered a referral to 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. 2 If a person is receiving antibiotic prophylaxis, treatment should be with an antibiotic from a different class. Smoking cessation services provide the most effective route to stopping smoking, but many people who smoke do not use these services when they try to stop. A summary of further considerations relating to pharmacotherapy is provided in quality statement 4. 27 February 2019 Air pollution: outdoor air quality and health (NICE quality standard 181) added. Assessing proposals to minimise and mitigate road-traffic-related air pollution will help to ensure they are robust and evidence based. Proportion of people who smoke who are referred to an evidence-based smoking cessation service. This guideline includes recommendations on: treatment; reassessment; referral and seeking specialist advice; choice of antibiotic; Who is it for? 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. Austin MA, Wills KE, Blizzard L, et al. 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. 1.2.1 When prescribing an antibiotic for an acute exacerbation of COPD, follow table 1 for adults aged 18 years and over. Numerator – the number in the denominator who have non-invasive ventilation. For guidance on assessing the need for hospital referral, see NICE guideline: Chronic obstructive pulmonary disease in over 16s (see Useful resources). 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. 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. Evidence of local arrangements and written clinical protocols to ensure that people with stable COPD and exercise limitation due to breathlessness are referred to a pulmonary rehabilitation programme. 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. 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. Spirometry should be performed by a healthcare professional who has had appropriate training and who has up-to-date skills. It recommends changes to usual practice to maximise the safety of … Local planning authorities assess proposals to minimise and mitigate road-traffic-related air pollution in planning applications for major developments. People with COPD need to use their inhaler correctly to receive the optimal treatment dose. In the context of primary care settings, this would involve evidence-based, opportunistic advice offered to people who smoke about the options and support available to help them stop smoking. 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. Advice may include referral to an evidence-based smoking cessation service. Post-bronchodilator spirometry is used to identify abnormalities in lung volumes and air flow. 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. There are several elements of ongoing care that an adult with COPD should start before discharge from hospital, which can improve their outcome. [, 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. some people at risk of exacerbations may have antibiotics to keep at home as part of their exacerbation action plan (see the recommendations on choice of antibiotic).See the NICE guideline on COPD in over 16s. 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. LTOT is used to treat people with stable COPD who have developed daytime hypoxaemia. 9 November 2015 Structure revised, and summarised recommendations replaced with full recommendations. (1959) The significance of respiratory symptoms and the diagnosis of chronic bronchitis in a working population. Wedzicha JA, Calverley PMA, Albert RK, Anzueto A, Criner GJ, Hurst JR, et al. NICE has published an updated COPD guideline which makes recommendations on inhaled triple therapy, and oral corticosteroids for managing exacerbations. 6, 500 mg three times a day (see BNF for dosage in severe infections), 960 mg twice a day (see BNF for dosage in severe infections), 4.5 g three times a day (see BNF for dosage in severe infections), Consult local microbiologist; guided by susceptibilities. Periods of poor air quality are associated with adverse health effects, including asthma attacks, reduced lung function, and increased mortality and admissions to hospital. Acute exacerbations of chronic obstructive pulmonary disease. Commonly reported symptoms include: Increased breathlessness. 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. b) Evidence of a local framework for assessing proposals to minimise and mitigate road-traffic-related air pollution in planning applications for major developments. 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%. a) Proportion of people who are asked if they smoke by their healthcare practitioner. d) Proportion of people with COPD prescribed an inhaler who have their inhaler technique assessed after an acute exacerbation. Denominator – the number of people aged over 35 years presenting with a risk factor and one or more symptoms of COPD. 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. 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. This can vary by healthcare setting. They emphasise the key interventions in the management pathway, including details of settings for care and treatment. 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. 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. It covers stable COPD and exacerbations. Health effects may occur when air pollution is moderate (4 to 6), high (7 to 9) or very high (10). 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. NICE does recommend that, when using triple therapy for breathlessness, there should be a review after 3 months to check efficacy, but in … PCRS and other organisations advised that this omission would render the guideline out of date on 1.2.1 When prescribing an antibiotic for an acute exacerbation of COPD, follow table 1 for adults aged 18 years and over. the risk of antimicrobial resistance with repeated courses of antibiotics. 1987, in the Annals of Internal Medicine, occupational exposure to harmful fumes, dust or chemicals. Who receive a full course the optimal treatment dose because advice on how to stop smoking who. For other recommendations on inhaled triple therapy, and summarised recommendations replaced with recommendations.: worsening breathlessness, or has to stop emphasise the key interventions in the denominator who have inhaler. Identify key actions to mitigate the impact of charges on specific groups should be sensitive to the issue smoking. 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