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NICE 2018 Guideline on management of stable COPD

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NICE 2018 Guideline on management of stable COPD

NICE has released its updated 2018 guidelines on the management of stable COPD. The guideline covers non-pharmacological management and use of inhaled therapies.

Key Recommendations=

Managing stable COPD

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Inhaled therapy

Inhaled corticosteroids (ICS)

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  •  Be aware of, and be prepared to discuss with the person, the risk of side effects (including pneumonia) in people who take inhaled corticosteroids for COPD.

Inhaled combination therapy

  • Inhaled combination therapy refers to combinations of long-acting muscarinic antagonists (LAMA), long-acting beta2 agonists (LABA) and inhaled corticosteroids (ICS).The evidence on triple therapy (LAMA+LABA+ICS) is being reviewed as part of the 2019 update to this guideline. This update is expected to publish in June 2019.
  • Offer LAMA+LABA to people who:1)have spirometrically confirmed COPD and 2) do not have asthmatic features/features suggesting steroid responsiveness and3)remain breathless or have exacerbations despite:
    • having used or been offered treatment for tobacco dependence if they smoke and
    • optimised non-pharmacological management and relevant vaccinations and
    • using a short-acting bronchodilator.
  • Consider LABA+ICS for people who: 1) have spirometrically confirmed COPD and 2)have asthmatic features/features suggesting steroid responsiveness and 3) remain breathless or have exacerbations despite:
    • having used or been offered treatment for tobacco dependence if they smoke and
    • optimised non-pharmacological management and relevant vaccinations and
    • using a short-acting bronchodilator.
  • For people using long-acting bronchodilators outside of recommendations 11 and 12 before this guideline was published (December 2018), explain to them that they can continue with their current treatment until both they and their NHS healthcare professional agree it is appropriate to change.
  • Offer LAMA+LABA+ICS to people with COPD with asthmatic features/features suggesting steroid responsiveness who remain breathless or have exacerbations despite taking LABA+ICS.1)Base the choice of drugs and inhalers on:1)how much they improve symptoms 2)the person’s preferences and ability to use the inhalers3)the drugs’ potential to reduce exacerbations4)their side effects,5)their cost. Minimize the number of inhalers and the number of different types of inhaler used by each person as far as possible.
  • When prescribing long-acting drugs, ensure people receive inhalers they have been trained to use (for example, by specifying the brand and inhaler in prescriptions).

Delivery systems used to treat stable COPD

  • Most people with COPD – whatever their age – can develop adequate inhaler technique if they are given training. However, people with significant cognitive impairment may be unable to use any form of inhaler device. In most people with COPD, however, a pragmatic approach guided by individual patient assessment is needed when choosing a device.
  • Advise people on spacer cleaning. Tell them: a)not to clean the spacer more than monthly, because more frequent cleaning affects their performance (because of a build‑up of static)b)to hand wash using warm water and washing‑up liquid, and allow the spacer to air dry.
Oral mucolytic therapy
  • Do not routinely use mucolytic drugs to prevent exacerbations in people with stable COPD.
Oral prophylactic antibiotic therapy
  • Before starting prophylactic antibiotic therapy in a person with COPD, think about whether respiratory specialist input is needed.
  • Consider azithromycin (usually 250 mg 3 times a week) for people with COPD if they:a) do not smoke and b)have optimised non-pharmacological management and inhaled therapies, relevant vaccinations and (if appropriate) have been referred for pulmonary rehabilitation and c)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.
  • Before offering prophylactic antibiotics, ensure that the person has had:1)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)2)training in airway clearance techniques to optimise sputum clearance (see recommendation 1.2.95)3) a CT scan of the thorax to rule out bronchiectasis and other lung pathologies.
  • Before starting azithromycin, ensure the person has had:1)an electrocardiogram (ECG) to rule out prolonged QT interval and2) baseline liver function tests.
  • When prescribing azithromycin, advise people about the small risk of hearing loss and tinnitus, and tell them to contact a healthcare professional if this occurs.
  • Review prophylactic azithromycin after the first 3 months, and then at least every 6 months.
  • Only continue treatment if the continued benefits outweigh the risks. Be aware that 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, provide a non-macrolide antibiotic to keep at home as part of their exacerbation action plan (see recommendation 1.2.122).
  • Be aware that it is not necessary to stop prophylactic azithromycin during an acute exacerbation of COPD. Oral phosphodiesterase‑4 inhibitors
  • For guidance on treating severe COPD with roflumilast, see NICE’s technology appraisal guidance on roflumilast for treating chronic obstructive pulmonary disease.


Long-term oxygen therapy

21. Consider long-term oxygen therapy[5] for people with COPD 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 PaO2 above 7.3 and below 8 kPa when stable, if they also have 1 or more of the following:
    • secondary polycythaemia
    • peripheral oedema
    • pulmonary hypertension.
  • Conduct and document a structured risk assessment for people being assessed for long-term oxygen therapy who meet the criteria in recommendation 1.2.54. As part of the risk assessment, cover the risks for both the person with COPD and the people who live with them, including:1) the risks of falls from tripping over the equipment2)the risks of burns and fires, and the increased risk of these for people who live in homes where someone smokes (including e‑cigarettes).Base the decision on whether long-term oxygen therapy is suitable on the results of the structured risk assessment.
  • For people who smoke or live with people who smoke, but who meet the other criteria for long-term oxygen therapy, ensure the person who smokes is offered smoking cessation advice and treatment, and referral to specialist stop smoking services (see the NICE guidelines on stop smoking interventions and services and medicines optimisation).
  • Do not offer long-term oxygen therapy to people who continue to smoke despite being offered smoking cessation advice and treatment, and referral to specialist stop smoking services.
  • Advise people who are having long-term oxygen therapy that they should breathe supplemental oxygen for a minimum of 15 hours per day.
  • Do 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 for long-term oxygen therapy.
  • People who are having long-term oxygen therapy should be reviewed at least once per year by healthcare professionals familiar with long-term oxygen therapy. This review should include pulse oximetry.

Ambulatory oxygen therapy

  • Do not offer ambulatory oxygen to manage breathlessness in people with COPD who have mild or no hypoxaemia at rest.
  •  Consider ambulatory oxygen in people with COPD who have exercise desaturation and are shown to have an improvement in exercise capacity with oxygen, and have the motivation to use oxygen.

Short-burst oxygen therapy

  • Do not offer short-burst oxygen therapy to manage breathlessness in people with COPD who have mild or no hypoxaemia at rest.
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