COVID-19: COPD
Patients with severe chronic obstructive pulmonary disease (COPD) are at greater risk of severe illness than the general population from COVID-19 infection, so it is more important than ever that their COPD is as stable as possible. This Guideline in a Nutshell summarises the latest rapid guidance from NICE
Patients with COPD are at greater risk of severe illness from COVID-19. NICE defines severe airflow obstruction in COPD as FEV1 less than 50% predicted. Other factors associated with a worse prognosis in patients with COPD include:
- Past history of hospital admission
- Need for long-term oxygen therapy or non-invasive ventilation
- Limiting breathlessness
- The presence of frailty and multimorbidity
Patients with COPD are among the groups who have been advised to follow the Government advice on shielding because they are extremely vulnerable to COVID-19.
Minimise face-to-face contact
Face-to-face contact should be minimised, by:
- Offering telephone, video or email consultations whenever possible. See Changing the way we work: virtual consultations now and in the future
- Cutting non-essential face-to-face appointments
- Contacting patients by text message or email
- Using alternative ways to deliver prescriptions such as postal services, NHS volunteers or drive through pick up points.
Face-to-face appointments
If patients are attending for a face-to-face appointment, they should first be screened by phone on the day to make sure they haven’t developed symptoms. If they think they have COVID-19 contact NHS 111 online coronavirus service or call NHS 111. If they are seriously ill they should call 999.
To reduce the risk of contracting or spreading the infection, ask patients to attend alone if possible, or with only one family member or carer. A child should be accompanied with only one adult.
Minimise time in waiting areas by:
- Careful scheduling
- Have separate entrance and exit routes if possible to minimise contact
- Encouraging patients not to arrive early
- Texting patients when you are ready to see them so they can wait in their car, for example.
For patients with known or suspected COVID-19, follow guidance on infection prevention and control
CARE PLANNING
Find out if patients have advance care plans or advance decisions around ceilings of care, including do not attempt cardiopulmonary resuscitation decisions. Encourage patients with more severe COPD who do not have an advance care plan to develop one, using decision support tools when available. Remember that these discussions may need to take place remotely. Document discussions and decisions clearly.
TREATMENT
Advise patients to continue using regular inhaled and oral medicines in line with their individualised COPD self-management plan to ensure their COPD is as stable as possible. Keep their self-management plan up to date and remind them that online video resources on correct inhaler technique are available
Corticosteroids
Patients established on ICS should continue to use them and any planned trials of withdrawal should be delayed. There is some evidence that use of ICS in COPD may increase the risk of pneumonia but this should not be a reason to change treatment in those established on ICS and risk destabilising COPD management.
Self-management for exacerbations
Patients should follow their individual self-management plan if they think they are having an exacerbation, and start a course of oral corticosteroids (OCS) and/or antibiotics if clinically indicated. Patients should be told not to start a short course of OCS or antibiotics for COVID-19 symptoms such as fever, dry cough or myalgia. Do not offer patients with COPD a rescue pack (OCS and/or antibiotics) unless clinically indicated.
Prophylactic antibiotics
Do not routinely start prophylactic antibiotics to reduce risk from COVID-19. Patients already prescribed prophylactic antibiotics should continue to take them as prescribed unless there is a new reason to stop them, e.g. side effects or allergic reaction.
Oxygen
Patient currently receiving long-term oxygen therapy not to adjust their oxygen flow rate unless advised to do so by their healthcare professional. Patients using ambulatory oxygen should not start using it at rest or in their home.
Pulmonary rehabilitation
Recommend online pulmonary rehab resources such as the exercise video from the British Lung Foundation
Airway clearance
Advise patients currently using airway clearance techniques to continue but warn that inducing sputum is a potential aerosol generating procedure and they should perform airway clearance techniques:
- In a well-ventilated room
- Away from other family members if possible, and
- Advise other family members not to enter the room until enough time has passed for aerosols to clear.
Smoking
Strongly advise patients who are still smoking to stop, to reduce the risk of poor outcomes from COVID-19 and their risk of acute exacerbations. Recommend remote support (See NHS Stop smoking services to help you quit) and offer pharmacological support.
Equipment
Patients should wash their hands and clean equipment such as face masks, mouth pieces, spaces and peak flow meters regularly using washing up liquid or follow the manufacturer’s instructions. Patients should be told not to share inhalers with anyone else.
Patients currently using a nebuliser can continue to do so, but do not offer nebulisers unless clinically indicated.
Patients currently using non-invasive ventilation at home should advised that these are potential aerosol generating procedures and they should take appropriate precautions including using equipment in a well ventilated room and away from other family members if possible.
Prescribing
Prescribe enough medication to meet patients’ clinical need for no more than 30 days’ treatment. Prescribing larger quantities puts the supply chain at risk.
Reference
NICE NG168. COVID-19 rapid guideline: community-based care of patients with chronic obstructive pulmonary disease; 9 April 2020
