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NICE 2018 Guideline for managing pulmonary hypertension and cor pulmonale

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NICE 2018 Guideline for managing pulmonary hypertension and cor pulmonale

NICE has released its updated 2018 guidelines on management of pulmonary hypertension and cor pulmonale. 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 edema.

Key Recommendations-

Treating pulmonary hypertension

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  1. Do not offer the following treatments solely to manage pulmonary hypertension caused by COPD, except as part of a randomised controlled trial:
  • bosentan
  • losartan
  • nifedipine
  • nitric oxide
  • pentoxifylline
  • phosphodiesterase‑5 inhibitors
  • statins.

Treating cor pulmonale

  1. Ensure that people with cor pulmonale caused by COPD are offered optimal COPD treatment, including advice and interventions to help them stop smoking. For people who need treatment for hypoxia, see the section on long-term oxygen therapy.
  2. Do not use the following to treat cor pulmonale caused by COPD:
  • alpha-blockers
  • angiotensin-converting enzyme inhibitors
  • calcium channel blockers
  • digoxin (unless there is atrial fibrillation).

Pulmonary rehabilitation

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Pulmonary rehabilitation is defined as a multidisciplinary programme of care for people with chronic respiratory impairment. It is individually tailored and designed to optimise each person’s physical and social performance and autonomy.

  1. Make pulmonary rehabilitation available to all appropriate people with COPD (see recommendation 1.2.78), including people who have had a recent hospitalisation for an acute exacerbation.

Lung surgery and lung volume reduction procedures

  1. Offer a respiratory review to assess whether a lung volume reduction procedure is a possibility for people with COPD when they complete pulmonary rehabilitation and at other subsequent reviews, if all of the following apply:
  • they 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 1.2.14)
  • they do not smoke
  • they can complete a 6‑minute walk distance of at least 140 m (if limited by breathlessness).

2.At the respiratory review, refer the person with COPD to a lung volume reduction multidisciplinary team to assess whether lung volume reduction surgery or endobronchial valves are suitable if they have:

  • hyperinflation, assessed by lung function testing with body plethysmography and
  • emphysema on unenhanced CT chest scan and
  • optimised treatment for other comorbidities.

3.Only offer endobronchial coils as part of a clinical trial and after assessment by a lung volume reduction multidisciplinary team.

4. For more guidance on lung volume reduction procedures, see the NICE interventional procedures guidance on lung volume reduction surgery, endobronchial valves and endobronchial coils.

5. Refer people with COPD for an assessment for bullectomy if they are breathless and a CT scan shows a bulla occupying at least one third of the hemithorax.

6. 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 1.2.14) and
  • do not smoke and
  • have completed pulmonary rehabilitation and
  • do not have contraindications for transplantation (for example, comorbidities or frailty).

7.Do not use previous lung volume reduction procedures as a reason not to refer a person for assessment for lung transplantation.

  1. If people have excessive sputum, they should be taught:
  • how to use positive expiratory pressure devices
  • active cycle of breathing techniques.

Identifying and managing anxiety and depression

44. Be alert for anxiety and depression in people with COPD. Consider whether people have anxiety or depression, particularly if they:

  • have severe breathlessness
  • are hypoxic
  • have been seen at or admitted to a hospital with an exacerbation of COPD.

45. For guidance on managing anxiety, see the NICE guideline on generalised anxiety disorder and panic disorder in adults.

Palliative care

  1. For standards and measures on palliative care, see the NICE quality standard on end of life care for adults.
  2. For guidance on care for people in the last days of life, see the NICE guideline on care of dying adults.
  3. At diagnosis and at each review appointment, offer people with COPD and their family members or carers (as appropriate):written information about their condition,opportunities for discussion with a healthcare professional who has experience in caring for people with COPD.
  4. Ensure the information provided is:available on an ongoing basis,relevant to the stage of the person’s condition,tailored to the person’s needs.
  5. At minimum, the information should cover:
  • an explanation of COPD and its symptoms
  • advice on quitting smoking (if relevant) and how this will help with the person’s COPD
  • advice on avoiding passive smoke exposure
  • managing breathlessness
  • physical activity and pulmonary rehabilitation
  • medicines, including inhaler technique and the importance of adherence
  • vaccinations
  • identifying and managing exacerbations
  • details of local and national organisations and online resources that can provide more information and support
  • how COPD will affect other long-term conditions that are common in people with COPD (for example, hypertension, heart disease, anxiety, depression and musculoskeletal problems).

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