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The purpose of this summary is to maximise the safety of patients with chronic obstructive pulmonary disease (COPD) during the COVID-19 pandemic, while protecting staff from infection. It will also enable services to make the best use of NHS resources. For more detailed information, please refer to the full guideline.

Communicating with patients and minimising risk

  • Communicate with patients, their families and carers, and support their mental health and wellbeing to help alleviate any anxiety and fear they may have about COVID-19. Signpost to charities (such as the British Lung Foundation) and support groups (such as NHS Volunteer Responders), and UK government guidance on the mental health and wellbeing aspects of COVID-19
  • Explain to patients with chronic obstructive pulmonary disease (COPD), and their families and carers, that they are at increased risk of severe illness from COVID-19
  • Be aware that the NICE guideline on chronic obstructive pulmonary disease in over 16s defines severe airflow obstruction in patients with COPD as those who have an FEV1 less than 50% of 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
  • Some patients with severe COPD will have received a letter telling them they are at very high risk of severe illness from COVID-19. Tell them, or their families and carers, to follow UK government advice on shielding and protecting people defined on medical grounds as extremely vulnerable from COVID-19
  • Minimise face-to-face contact to reduce the risk of infection by:
    • using telephone, video or email consultations whenever possible
    • cutting non-essential face-to-face appointments
    • contacting patients via text message, telephone or email
    • using electronic prescriptions rather than paper
    • using different methods to deliver prescriptions and medicines to patients, for example pharmacy deliveries, postal services, NHS Volunteer Responders or introducing drive-through pick-up points for medicines
  • If patients are having a face-to-face appointment, on the day of the appointment first screen them by telephone to make sure they have not developed symptoms of COVID-19
  • Tell patients, their families and carers that they should contact NHS 111 online coronavirus service or call NHS 111 if they think they have COVID-19. They should do this as soon as they have symptoms. In an emergency they should call 999 if they are seriously ill

Patients not known to have COVID-19

  • If patients need to attend face-to-face appointments, ask them to go alone if they can, or with no more than 1 family member or carer, to reduce the risk of contracting or spreading infection with COVID-19. They should avoid using public transport if possible
  • Minimise time in the waiting area by:
    • careful scheduling to avoid several patients waiting at the same time
    • separate entrance and exit routes if possible to minimise contact
    • encouraging patients not to arrive early
    • texting or calling patients when you are ready to see them, so that they can wait in their car, for example

Patients known or suspected to have COVID-19

Treatment and care planning

  • Tell all patients to continue taking their regular inhaled and oral medicines in line with their individualised COPD self-management plan to ensure their COPD is as stable as possible. This includes those with COVID-19, or who are suspected of having it. Keep their self-management plan up to date, and remind them that online video resources on correct inhaler technique are available
  • At every interaction with a patient, be alert for new or increased issues with mental health and wellbeing, particularly anxiety and depression
  • 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 advance care plans to develop one. Use decision support tools (when available), and refer to the Mental Capacity Act 2005 for patients who may lack capacity. Bear in mind that these discussions may need to take place remotely (see the recommendation on minimising face-to-face contact, above). Document discussions and decisions clearly and take account of these in planning care

Corticosteroids

  • Explain to patients there is no evidence that treatment with inhaled corticosteroids (ICS) for COPD increases the risk associated with COVID-19
  • Tell patients established on ICS to continue to use them, and delay any planned trials of withdrawal of ICS. While there is some evidence that use of ICS in COPD may increase the overall risk of pneumonia (see the 2014 MHRA drug safety update on inhaled corticosteroids: pneumonia), do not use this risk alone as a reason to change treatment in those established on ICS and risk destabilising COPD management
  • Tell patients on long-term oral corticosteroids that they should continue to take them at their prescribed dose, because stopping them can be harmful. Advise patients to carry a Steroid Treatment Card

Self-management for exacerbations

  • Tell patients that if they think they are having an exacerbation, they should follow their individualised COPD self-management plan and start a course of oral corticosteroids and/or antibiotics if clinically indicated
  • Tell patients not to start a short course of oral corticosteroids and/or antibiotics for symptoms of COVID-19, for example fever, dry cough or myalgia
  • Do not offer patients with COPD a short course of oral corticosteroids and/or antibiotics to keep at home unless clinically indicated, as set out in the NICE guideline on chronic obstructive pulmonary disease in over 16s

Smoking cessation

Pulmonary rehabilitation

Oxygen

  • Advise patients currently receiving long-term oxygen therapy not to adjust their oxygen flow rate, unless advised to by their healthcare professional
  • Advise patients currently receiving ambulatory oxygen not to start using it at rest or in their home

Oral prophylactic antibiotic therapy

  • Do not routinely start prophylactic antibiotics to reduce risk from COVID-19
  • Tell patients already prescribed prophylactic antibiotics to continue taking them as prescribed, unless there is a new reason to stop treatment (for example, side effects or allergic reaction). Advise patients to contact their care team if this happens

Airway clearance

  • Advise patients currently using airway clearance techniques to continue to do so
  • Advise patients that inducing sputum is a potentially infectious aerosol generating procedure, and they should take appropriate precautions such as:
    • performing airway clearance techniques in a well-ventilated room
    • performing airway clearance techniques away from other family members if possible
    • advising other family members not to enter the room until enough time has passed for aerosols to clear

Equipment

  • Tell patients to wash their hands and clean equipment, such as face masks, mouth pieces, spacer devices and peak flow meters, regularly using washing-up liquid or following the manufacturer’s cleaning instructions
  • Tell patients not to share their inhalers and devices with anyone else
  • Tell patients they can continue to use their nebuliser. This is because the aerosol comes from the fluid in the nebuliser chamber and will not carry virus particles from the patient. Find out more from UK government guidance on COVID-19: infection prevention and control
  • Do not offer nebulisers to patients unless clinically indicated (see the NICE guideline on chronic obstructive pulmonary disease in over 16s)
  • Advise patients currently receiving non-invasive ventilation at home that these are potentially infectious aerosol generating procedures, and they should take appropriate precautions such as:
    • using equipment in a well-ventilated room
    • using equipment away from other family members if possible

Modifications to usual care and service delivery

  • When planning changes to usual care, take into account people’s access to digital and online resources, digital literacy and any preference for verbal or written support (for example, digital-only services could lead to inequalities of access for people with limited internet access)
  • Think about how to modify usual care to reduce patient exposure to COVID-19 and make best use of resources (workforce, facilities, equipment), for example:
    • switch respiratory services to telephone or virtual consultations, including routine annual reviews
    • defer routine pulmonary function testing
    • defer oxygen follow-up assessments if possible
  • On a case-by-case basis, carry out or defer assessments to establish if patients are eligible for long-term oxygen therapy (as defined by the NICE guideline on chronic obstructive pulmonary disease in over 16s) or might benefit from non-invasive ventilation at home for nocturnal hypoventilation
  • Prescribe enough COPD medicines to meet the patient’s clinical needs for no more than 30 days. For inhalers this depends on the type of inhaler and the number of doses in the inhaler. Prescribing larger quantities of medicines puts the supply chain at risk

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Read the related Guidelines in Practice article

© NICE 2020. COVID-19 rapid guideline: community-based care of patients with chronic obstructive pulmonary disease (COPD). Available from: www.nice.org.uk/guidance/ng168. All rights reserved. Subject to Notice of rights.

NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication.

Published date: 09 April 2020.