The video version of this podcast can be found here: https://youtu.be/VZMKD0bY1G8 The link to the video on COPD diagnosis can be found here:https://youtu.be/o_q8TTra3Ys This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". Please note that the content on this channel reflects my professional interpretation/summary of the guidance and that I am in no way affiliated with, employed by or funded/sponsored by NICE. My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode, I go through the management section of the NICE guideline [NG115] on COPD in adults, always focusing on what is relevant in Primary Care only. I am not giving medical advice; this video is intended for health care professionals; it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.   There is a podcast version of this and other videos that you can access here: Primary Care guidelines podcast:  ·      Apple podcast: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148·      Spotify: https://open.spotify.com/show/2kmGZkt1ssZ9Ei8n8mMaE0?si=9d30d1993449494e·      Amazon Music: https://music.amazon.co.uk/podcasts/0edb5fd8-affb-4c5a-9a6d-6962c1b7f0a1/primary-care-guidelines?ref=dm_sh_NnjF2h4UuQxyX0X3Lb3WQtR5P·      Google Podcast: https://www.google.com/podcasts?feed=aHR0cHM6Ly9mZWVkcy5yZWRjaXJjbGUuY29tLzI1ODdhZDc4LTc3MzAtNDhmNi04OTRlLWYxZjQxNzhlMzdjMw%3D%3D·      Redcircle: https://redcircle.com/shows/2587ad78-7730-48f6-894e-f1f4178e37c3 There is a YouTube version of this and other videos that you can access here: ●       The Practical GP YouTube Channel: https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk  The resources consulted can be found here:Chronic obstructive pulmonary disease in over 16s: diagnosis and management- NICE guideline [NG115]:●      https://www.nice.org.uk/guidance/NG115The visual summary for the treatment of COPD can be found here:●      https://www.nice.org.uk/guidance/ng115/resources/visual-summary-treatment-algorithm-pdf-6604261741The NICE technology appraisals on oseltamivir, amantadine and zanamivir to prevent and treat flu can be found here:●      https://www.nice.org.uk/guidance/ta158 Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] ●       Music provided by Audio Library Plus ●       Watch: https://youtu.be/aBGk6aJM3IU ●       Free Download / Stream: https://alplus.io/halfway-through  TranscriptIf you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description.Hello and welcome, I’m Fernando, a GP in the UK. Today we are going to do an up-to-date review of the NICE guideline on the management of stable COPD in adults, always focusing on what is relevant in Primary Care only. If you wish to know about COPD diagnosis, please see the corresponding episode on this channel. The link is in the episode description. Right, so let’s jump into it.For COPD management, once we have offered smoking cessation advice and support, we will offer inhaled therapy. Let’s have a look at the different types of inhalers. We have:·      Short-acting beta2 agonists or SABAs, like salbutamol·      Short-acting muscarinic antagonists or SAMAs, like ipratropium·      Inhaled corticosteroids (ICS)·      Long-acting muscarinic antagonists or LAMAs and·      Long-acting beta2 agonists or LABAsWhen do we use the different types of inhalers? Well, these are the general rules to follow:·      We will use short-acting bronchodilators, that is, either SABAs or SAMAs, as necessary, to relieve breathlessness and exercise limitation. ·      We will judge the effectiveness of bronchodilator therapy depending on symptom improvement, not just lung function alone. ·      We will not use oral corticosteroid reversibility tests to identify who should be prescribed inhaled corticosteroids, because oral steroids do not predict response to inhaled corticosteroid therapy. ·      We will take into account the risk of side effects (including pneumonia) of inhaled corticosteroids for COPD ·      Inhaled combination therapy refers to combinations of a LAMA, a LABA and inhaled corticosteroids (ICS) and ·      Combination therapy is recommended in confirmed COPD with SOB or exacerbations despite short-acting bronchodilatorsLet’s now look at the different combinations and when to recommend them. We will offer a LAMA+LABA combination if there are no asthmatic features or features suggesting steroid responsiveness. This includes a previous diagnosis of asthma or of atopy, a higher blood eosinophil count, substantial variation of at least 400 ml in FEV1 over time or substantial diurnal variation of at least 20% in peak flow rateOn the other hand, we will consider a LABA+ICS combination if these asthmatic features or features suggesting steroid responsiveness, are present. And let’s stop for a moment to remark that the LAMA + ICS dual combination does not appear as a recommended option. Now, what can be recommended after dual combination therapy is triple combination therapy with a LAMA+LABA+ICS. Triple therapy is recommended if:·      they have a severe exacerbation, that is, requiring hospitalisation or·      they have 2 moderate exacerbations, that is, requiring oral steroids and/or antibiotics, within a year, or if·      they have significant symptoms. However, for those patients on a LAMA+LABA combination, that is, patients without asthmatic features or features suggestive steroid responsiveness, we will:o  first give a trial of LAMA+LABA+ICS for 3 months only and then review:§ if symptoms have not improved, we will revert to the LAMA+LABA combination but§ if symptoms have improved, we will continue with the LAMA+LABA+ICS triple combination NICE has produced a one-page visual summary covering non-pharmacological management and use of inhaled therapies in COPD, which I will review at the end of this episode. Now, let’s focus on inhaled therapy a bit more. What delivery systems can be used to deliver inhaled therapy?·      Although alternatives can be offered, if necessary, in most cases a hand-held inhaler (including a spacer if appropriate) is best. In that case, o  We will give advice on spacer cleaning, telling them:§ Not to clean the spacer more than monthly, washing it warm water and washing-up liquid, and allowing it to air dry.§ This is to avoid build-up of static which can affect its performance. ·      We will consider nebuliser therapy if there are significant symptoms despite maximal inhaler therapy and we will continue only if there is symptomatic improvement. And·      We will offer a choice between a facemask and a mouthpiece, unless the drug specifically requires a mouthpiece (for example, anticholinergic drugs). What oral therapy can be given in COPD? Well:·      Long-term use of oral corticosteroid therapy in COPD is not normally recommended. Some people with advanced COPD may need long-term oral steroids if they cannot be stopped following an exacerbation. In these cases, the dose should be kept as low as possible.o  We will monitor people on long-term oral steroid therapy and give them osteoporosis prophylaxis, if appropriate. However, we will start osteoporosis prophylaxis without the need for monitoring in patients over 65. ·      We will consider mucolytic drug therapy for people with a chronic cough productive of sputum. ·      Oral anti-oxidants and oral anti-tussive therapy are not recommended and·      Before starting prophylactic antibiotics, we should seek specialist input is needed. o  Azithromycin, usually 250 mg 3 times a week can be given if certain conditions are met. Because we will normally by guided by secondary care, I will not go through all these conditions and precautions here.o  For people who are taking prophylactic azithromycin and are still at risk of exacerbations, we can provide a non-macrolide antibiotic to keep at home as part of their exacerbation action plan, explaining that it is not necessary to stop prophylactic azithromycin during an acute exacerbation.In this episode, I will not cover the management of pulmonary hypertension and co pulmonale and the use of:·      Oral phosphodiesterase-4 inhibitors·      Non-invasive ventilation·      Oxygen therapy, either long-term, ambulatory or as short-bursts and·      Oral theophylline, except for saying that we should reduce the dose prescribing drugs that interact with it such as macrolide or fluoroquinolone antibioticsIn terms of self-management, we will develop an individualised self-management plan including an exacerbation action plan if the patient is at risk of exacerbations. For this we will offer them a short course of oral steroids and antibiotics to keep at home as part of their exacerbation action plan if:·      they have had an exacerbation within the last year, and remain at risk of exacerbations·      they understand when and how to take them and·      they inform their healthcare professional when they have used them, and ask for replacementsThere is a separate guidance on the choice of antibiotics for acute COPD exacerbations. I will cover these recommendations in my next video on COPD exacerbation management.For people who have used 3 or more courses of oral corticosteroids and/or oral antibiotics in the last year, we will investigate the possible reasons for this. We will offer pulmonary rehabilitation to those functionally disabled by COPD, usually with an MRC dyspnoea grade 3 and above. Pulmonary rehabilitation is not suitable for people who are unable to walk, who have unstable angina or who have had a recent myocardial infarction. We will offer pneumococcal vaccination and an annual flu vaccination to all people with COPD, There is separate guidance on the use on antivirals to prevent and treat flu, which I will not cover here. I have put the link to it in the episode description. We should consider physiotherapy for people have excessive sputum, so that they can be taught:·      how to use positive expiratory pressure devices·      active cycle of breathing techniques. We will monitor:·      for the development of anxiety and depression and·      Their nutritional state and BMI. Whilst the NICE guideline on obesity states that a healthy BMI is between 18.5 to 24.9 , this may not be appropriate for people with COPD, where it is recommended a BMI between 20 and 25. With that in mind, we will:o  refer for dietetic advice if they have an abnormal BMI ando  for people with a low BMI, we will give nutritional supplements and encourage them to exercise We will regularly ask people with COPD about their ability to undertake daily activities and assess their need for occupational therapy. We will also consider referring people for assessment by social services if they have disabilities caused by COPD. When appropriate, palliative care for end-stage COPD, may include the following treatments for breathlessness that is unresponsive to other therapies:·      Opioids ·      Benzodiazepines·      Tricyclic antidepressants·      Major tranquillisers and ·      Oxygen During follow-up of all people with COPD we should:·      Include smoking cessation·      Record spirometric parameters and a loss of 500 ml or more over 5 years in FEV1 suggests rapidly progressing disease which may need specialist referral and investigation. During the clinical review we will cover the following issues:In mild/moderate/severe COPD (stages 1 to 3) we will:·      Review them at least annually·      We will assess:o  Smoking status o  Symptom including breathlessness, exercise tolerance and exacerbation frequencyo  Need for pulmonary rehabilitationo  Presence of complications ando  Medication, including inhaler technique·      We will measure FEV1, FVC, BMI and MRC dyspnoea scoreIn very severe COPD (stage 4) in addition to this, we will :·      Review them at twice a year·      We will assess:o  The Presence of cor pulmonaleo  The need for long term oxygen therapyo  The nutritional stateo  The presence of depressiono  The need for referral to social services, occupational therapy and for specialist inputAs I mentioned earlier, NICE has produced a one-page visual summary covering non-pharmacological management and use of inhaled therapies. Let’s have a look at it now:So, once we have confirmed the diagnosis of COPDWe will cover the fundamentals of COPD care, that is, we will offer treatment and support to stop smoking, pneumococcal and influenza vaccinations, pulmonary rehabilitation if appropriate, develop a personalised self-management plan and we will also optimise treatment for comorbiditiesAnd we will revisit these plans at every reviewThen we will start inhaled therapies only if, after doing all this, they are needed to relieve breathlessness and exercise limitation, as long as they can demonstrate satisfactory inhaler techniqueAnd we will review the medication and assess inhaler technique and adherence regularly So, we will offer a SABA or a SAMA inhaler to use on demandAnd if the patient still has symptoms or has exacerbations despite treatmentWe will see if there are asthmatic features or features of steroid responsiveness. And let’s remember that these features in this context include any previous secure diagnosis of asthma or atopy, a higher blood eosinophil count, a substantial variation in FEV1 over time , that is, at least 400 ml, or a substantial diurnal variation in peak expiratory flow of at least 20%.So, if these features are not presentWe will offer the combination of a LAMA and a LABA And if despite this, the patient’s symptoms are not adequately controlledWe will consider 3-month trial of triple therapy with a LAMA, a LABA and an ICSBearing in mind the increased risk of side effects of ICS (including pneumonia) and we will document in the clinical records the reason for continuing the ICS treatment.But, if there is no improvement, we will revert to dual therapy with a LAMA + LABAIf the issue with the LAMA LABA combination is that the patient has 1 severe or 2 moderate exacerbations within a yearThen we will also consider triple therapy with a LAMA a LABA and an ICS. This is because ICS have been proven to help reduce exacerbationsOn the other hand, if the patient on a SABA or SAMA has asthmatic features or features suggesting steroid responsivenessThen we will offer treatment with a combination of a LABA and an ICSAnd if the patient continues to have significant symptoms, or has 1 severe or 2 moderate exacerbations within a yearThen we will offer triple therapy with a LABA a LAMA and an ICS And, for all these patients, if symptoms or exacerbations continue to be a problem, we will explore further treatment options, including referral.We have come to the end of this episode. Remember that this is not medical advice and it is only my summary and my interpretation of the guidelines. You must always use your clinical judgement. Thank you for listening and goodbye.

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