Chronic Obstructive Pulmonary Disease Exacerbations of Copd Treatments Only Delivered in Hospital

Exacerbations of COPD: treatments only
delivered in hospital
NICE Pathways bring together everything NICE says on a topic in an interactive

flowchart. NICE Pathways are interactive and designed to be used online.
They are updated regularly as new NICE guidance is published. To view the latest
version of this NICE Pathway see:
http://pathways.nice.org.uk/pathways/chronic-obstructive-pulmonary-disease
NICE Pathway last updated: 30 January 2020
This document contains a single flowchart and uses numbering to link the boxes to the
associated recommendations.
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© NICE 2020. All rights reserved. Subject to Notice of rights.
Exacerbations of COPD: treatments only delivered in hospital NICE Pathways
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Exacerbations of COPD: treatments only deliv
delivered
ered in hospital NICE Pathways
1 Person aged 16 or over with an exacerbation of COPD requiring

hospitalisation
No additional information
2 Intravenous theophylline
Only use intravenous theophylline as an adjunct to the exacerbation management if there is an

inadequate response to nebulised bronchodilators.
Take care should be taken when using intravenous theophylline, because of its interactions with
other drugs and potential toxicity if the person has been taking oral theophylline.
Monitor theophylline levels within 24 hours of starting treatment, and as frequently as indicated
by the clinical circumstances after this.
3 Invasive ventilation
Treat hospitalised exacerbations of COPD on intensive care units, including invasive ventilation
when this is thought to be necessary.
When assessing suitability for intubation and ventilation during exacerbations, think about
functional status, BMI, need for oxygen when stable, comorbidities and previous admissions to
intensive care units, in addition to age and FEV1. Neither age nor FEV1 should be used in
isolation when assessing suitability.
Consider NIV for people who are slow to wean from invasive ventilation.
NICE has published medtech innovation briefings on
PulmoVista 500 for monitoring ventilation in critical care

Video laryngoscopes to help intubation in people with difficult airways.
Quality standards
The following quality statement is relevant to this part of the interactive flowchart.
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Chronic obstructive pulmonary disease in adults
7. Non-invasive ventilation
4 Non-invasive ventilation and doxapram
Refer people who are adequately treated but have chronic hypercapnic respiratory failure and
have needed assisted ventilation (whether invasive or non-invasive) during an exacerbation, or
who are hypercapnic or acidotic on LTOT to a specialist centre for consideration of long-term
NIV.
Use NIV as the treatment of choice for persistent hypercapnic ventilatory failure during
exacerbations despite optimal medical therapy.
It is recommended that NIV should be delivered in a dedicated setting, with staff who have been
trained in its application, who are experienced in its use and who are aware of its limitations.
When people are started on NIV, there should be a clear plan covering what to do in the event
of deterioration, and ceilings of therapy should be agreed.
It is recommended that doxapram is used only when NIV is either unavailable or inappropriate.
Quality standards
6. Emergency oxygen during an exacerbation
5 Monitoring
Monitor people's recovery by regular clinical assessment of their symptoms and observation of
their functional capacity.
Use pulse oximetry to monitor the recovery of people with non-hypercapnic, non-acidotic
respiratory failure.
Use intermittent arterial blood gas measurements to monitor the recovery of people with
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respiratory failure who are hypercapnic or acidotic, until they are stable.
Do not routinely perform daily monitoring of PEF or FEV1 to monitor recovery from an
exacerbation, because the magnitude of changes is small compared with the variability of the
measurement.
Nasal Alar SpO2 sensor
NICE has published a medtech innovation briefing on Nasal Alar SpO2 sensor for monitoring
oxygen saturation by pulse oximetry.
6 Discharge
Measure spirometry in all people before discharge.
Re-establish people on their optimal maintenance bronchodilator therapy before discharge.
People who have had an episode of respiratory failure should have satisfactory oximetry or
arterial blood gas results before discharge.
Assess all aspects of the routine care that patients receive (including appropriateness and risk
of side effects) before discharge.
Give people (or home carers) appropriate information to enable them to fully understand the
correct use of medications, including oxygen, before discharge.
Make arrangements for follow-up and home care (such as visiting nurse, oxygen delivery or
referral for other support) before discharge.
The person, their family and their physician should be confident that they can manage
successfully before they are discharged. A formal activities of daily living assessment may be
helpful when there is still doubt.
For information about reducing the risk of death and ill health associated with living in a cold
home, see NICE's recommendations on excess winter deaths and illnesses associated with
cold homes. See also NICE's recommendations on home care for older people.
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Quality standards
2. Inhaler technique
7 Pulmonary rehabilitation
See Chronic obstructive pulmonary disease/Managing COPD /Pulmonary rehabilitation
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Glossary
Acute exacerbations of COPD
(a sustained worsening of the person's symptoms from their usual stable state which is beyond
normal day-to-day variations, and is acute in onset: commonly reported symptoms are
worsening breathlessness, cough, increased sputum production and change in sputum colour)
COPD exacerbation
Exacerbation of COPD
Exacerbations of COPD
Exacerbation
Exacerbations
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Acute exacerbation of COPD
Asthmatic features/features suggesting steroid responsiveness
(this includes any previous, secure diagnosis of asthma or of atopy, a higher blood eosinophil
count, substantial variation in FEV1 over time [at least 400 ml] or substantial diurnal variation in
peak expiratory flow [at least 20%])
ASA
American Society of Anesthesiologists
ATS
American Thoracic Society
BODE
body mass index, airflow obstruction, dyspnoea and exercise capacity
BTS
British Thoracic Society
CAT
COPD assessment test
CEN
Comité Européen de Normalisation (European Committee for Standardisation)
COPD
chronic obstructive pulmonary disease
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cor pulmonale
(in the context of this guidance, the term 'cor pulmonale' has been adopted to define a clinical
condition that is identified and managed on the basis of clinical features; this clinical syndrome
of cor pulmonale includes patients who have right heart failure secondary to lung disease and
those in whom the primary pathology is retention of salt and water, leading to the development
of peripheral oedema)
ECG
electrocardiogram
ERS
European Respiratory Society
FEV1
forced expiratory volume in 1 second
FVC
forced vital capacity
GOLD
global initiative for chronic obstructive lung disease
ICS
inhaled corticosteroid
LABA
long-acting beta2 agonist
LAMA
long-acting muscarinic antagonist
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LTOT
long-term oxygen therapy
Mild or no hypoxaemia
(people who are not taking long-term oxygen therapy and who have a mean PaO2 greater than
7.3 kPa)
MRC
Medical Research Council
MHRA
Medicines and Healthcare Products Regulatory Agency
NIV
non-invasive ventilation
NRT
nicotine replacement therapy
PaO2
partial pressure of oxygen in arterial blood
PaCO2
partial pressure of carbon dioxide in arterial blood
PEF
peak expiratory flow
SABA
short-acting beta2 agonist
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SAMA
short-acting muscarinic antagonist
SaO2
oxygen saturation of arterial blood
Theophylline
(here, the term theophylline refers to slow-release formulations of the drug)
TLCO
carbon monoxide lung transfer factor
Sources
Chronic obstructive pulmonary disease in over 16s: diagnosis and management (2018 updated
2019) NICE guideline NG115
Your responsibility
Guidelines
The recommendations in this guideline represent the view of NICE, arrived at after careful
consideration of the evidence available. When exercising their judgement, professionals and
practitioners are expected to take this guideline fully into account, alongside the individual
needs, preferences and values of their patients or the people using their service. 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.
Local commissioners and providers of healthcare have a responsibility to enable the guideline
to be applied when individual professionals and people using services wish to use it. 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
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advance equality of opportunity and to reduce health inequalities. Nothing in this guideline
should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable

health and care system and should assess and reduce the environmental impact of
implementing NICE recommendations wherever possible.
Technology appraisals
The recommendations in this interactive flowchart represent the view of NICE, arrived at after
careful consideration of the evidence available. When exercising their judgement, health
professionals are expected to take these recommendations fully into account, alongside the
individual needs, preferences and values of their patients. The application of the
recommendations in this interactive flowchart is at the discretion of health professionals and
their individual patients and do not override the responsibility of healthcare professionals to
make decisions appropriate to the circumstances of the individual patient, in consultation with
the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable
the recommendations to be applied when individual health professionals and their patients wish
to use it, in accordance with the NHS Constitution. They should do so 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.

Medical technologies guidance, diagnostics guidance and interventional procedures

guidance
The recommendations in this interactive flowchart represent the view of NICE, arrived at after
careful consideration of the evidence available. When exercising their judgement, healthcare
professionals are expected to take these recommendations fully into account. However, the
interactive flowchart does not override the individual responsibility of healthcare professionals to
make decisions appropriate to the circumstances of the individual patient, in consultation with
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the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in

their local context, in light of their duties to have due regard to the need to eliminate unlawful
discrimination, advance equality of opportunity, and foster good relations. Nothing in this
interactive flowchart should be interpreted in a way that would be inconsistent with compliance
with those duties.

Chronic obstructiv

Chronic Obstructive Pulmonary Disease Exacerbations of Copd Treatments Only Delivered in Hospital

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Exacerbations of COPD: treatments only

NICE Pathways bring together everything NICE says on a topic in an interactive

1 Person aged 16 or over with an exacerbation of COPD requiring

Only use intravenous theophylline as an adjunct to the exacerbation management if there is an

NICE has published medtech innovation briefings on

PulmoVista 500 for monitoring ventilation in critical care

Chronic obstructive pulmonary disease in adults

4 Non-invasive ventilation and doxapram

Chronic obstructive pulmonary disease in adults

6. Emergency oxygen during an exacerbation

Nasal Alar SpO2 sensor

Measure spirometry in all people before discharge.

Re-establish people on their optimal maintenance bronchodilator therapy before discharge.

Chronic obstructive pulmonary disease in adults

See Chronic obstructive pulmonary disease/Managing COPD /Pulmonary rehabilitation

Acute exacerbations of COPD

Acute exacerbation of COPD

Asthmatic features/features suggesting steroid responsiveness

American Society of Anesthesiologists

American Thoracic Society

body mass index, airflow obstruction, dyspnoea and exercise capacity

British Thoracic Society

COPD assessment test

Comité Européen de Normalisation (European Committee for Standardisation)

chronic obstructive pulmonary disease

European Respiratory Society

forced expiratory volume in 1 second

forced vital capacity

global initiative for chronic obstructive lung disease

long-acting beta2 agonist

long-acting muscarinic antagonist

long-term oxygen therapy

Medical Research Council

Medicines and Healthcare Products Regulatory Agency

nicotine replacement therapy

partial pressure of oxygen in arterial blood

partial pressure of carbon dioxide in arterial blood

peak expiratory flow

short-acting beta2 agonist

short-acting muscarinic antagonist

oxygen saturation of arterial blood

(here, the term theophylline refers to slow-release formulations of the drug)

carbon monoxide lung transfer factor

Commissioners and providers have a responsibility to promote an environmentally sustainable

Commissioners and providers have a responsibility to promote an environmentally sustainable

Medical technologies guidance, diagnostics guidance and interventional procedures

the patient and/or guardian or carer.

Commissioners and/or providers have a responsibility to implement the recommendations, in

Commissioners and providers have a responsibility to promote an environmentally sustainable

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