This can vary by healthcare setting. A placeholder statement indicates the need for evidence-based guidance to be developed in this area. a) Proportion of people with stable COPD and exercise limitation due to breathlessness who are referred to a pulmonary rehabilitation programme. Denominator – the number of people who seek support to stop smoking and who agree to take pharmacotherapy. RightCare Pathways: COPD Priorities for optimisation • Multidisciplinary supportive care approach Signposting and care navigation Psychological support, including for frightening breathlessness Community activation to overcome social isolation and stay physically active, including peer support Pulmonary rehabilitation programmes improve a person’s exercise capacity, quality of life, symptoms and levels of anxiety and depression. b) Overall fuel consumption for public sector vehicle fleets. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. People who smoke are offered a referral to an evidence-based smoking cessation service. upper respiratory tract infection in the past 5 days. siting and designing new buildings, facilities and estates to reduce the need for motorised travel, minimising the exposure of vulnerable groups to air pollution by not siting buildings (such as schools, nurseries and care homes) in areas where pollution levels will be high, siting living accommodation away from roadsides, avoiding the creation of street and building configurations (such as deep street canyons) that encourage pollution to build up where people spend time, including landscape features such as appropriate species of trees and vegetation in open spaces or as 'green' walls or roofs where this does not restrict ventilation. Annual reviews and other appointments focused on supporting management of chronic respiratory or cardiovascular conditions. I'm OK with analytics cookies. Denominator – the number of attendances of people with stable COPD and exercise limitation due to breathlessness at pulmonary rehabilitation programmes. a) Evidence that local authorities identify in the Local Plan, local transport plan and other key strategies how they will address air pollution, including who is responsible for delivering key actions. “Soft mist” inhaler required. • Standardized medical treatment for acute treatment and preventive therapy of AECOPD. It also states that group behavioural support involves scheduled meetings in which people who smoke receive information, advice and encouragement and some form of behavioural intervention (for example, cognitive behavioural therapy). Programmes comprise individualised exercise programmes and education, and: Pulmonary rehabilitation is not suitable for people with unstable cardiac disease, locomotor or neurological difficulties precluding exercise such as severe arthritis or peripheral vascular disease, and people in a terminal phase of an illness or with significant cognitive or psychiatric impairment. exposure to fumes, such as biomass fuels. This replaces NICE CG101. a history of cardiovascular disease, hypertension or hypoxia, clinical signs such as tachycardia, oedema, cyanosis or features of cor pulmonale, Need for referral to specialist and therapy services, Need for social services and occupational therapy input, mild exacerbation: the person has an increased need for medication, which they can manage in their own normal environment, moderate exacerbation: the person has a sustained worsening of respiratory status that requires treatment with systemic corticosteroids and/or antibiotics. Denominator – the number of people referred to an evidence-based smoking cessation service. COPD Treatment Pathway*. Practitioners should be aware that some pregnant women find it difficult to say that they smoke because the pressure not to smoke during pregnancy is so intense. Evidence of local arrangements to ensure that people who smoke are offered behavioural support with pharmacotherapy by an evidence-based smoking cessation service. Denominator – the number of people aged over 35 years presenting with a risk factor and one or more symptoms of COPD. European Respiratory Journal 23(6): 932–46. Anoro 55/22 Ellipta ( and exacerbations. This can be individual or group behavioural support. [Adapted from, Assessing people for LTOT should comprise measuring arterial blood gases on 2 occasions at least 3 weeks apart in people who have a confident diagnosis of COPD, who are receiving optimum medical management and whose COPD is stable. If they have not been taking their inhaled corticosteroid consistently, explain that restarting regular use may help them to regain control of their asthma. COPD Management Updated August 2019 Review: July 2022 Page 1 of 20 Chronic Obstructive Pulmonary Disease (COPD) Management Update of COPD guidance based on NICE NG115 (Dec2018). The public sector fleet is substantial and includes various vehicle types, some of which are highly polluting. [, An oxygen saturation (measured with a pulse oximeter) that is persistently 92% or less when the person is in a chronic stable state and is at rest (is not, and has not recently, been exercising). These are local services providing accessible, evidence based and cost effective support to people who want to stop smoking. People who smoke are offered behavioural support with pharmacotherapy by an evidence-based smoking cessation service. This study describes COPD treatment in France, focusing on identifying initial treatment modifications in patients with COPD who either initiated long-acting bronchodilator (LABD)-based therapy or escalated to triple therapy (long-acting muscarinic antagonist [LAMA] + long-acting β 2-agonist [LABA] + inhaled … Or FEV1 below 50% with respiratory failure. Assessing inhaler technique should happen at the first prescription once a person has been taught the correct technique, and then be reassessed regularly (for example, at their annual review, if their treatment changes or after an acute exacerbation) throughout the duration of a person’s treatment in primary, community and secondary care services. COPD Treatment Pathway*. Numerator – the number in the denominator who are referred to a pulmonary rehabilitation programme. d) Evidence that local authorities identify in the Local Plan, local transport plan and other key strategies how they will develop buildings and spaces to reduce exposure to air pollution. Evidence of local arrangements to ensure that people who smoke who have set a quit date with an evidence-based smoking cessation service are assessed for carbon monoxide levels 4 weeks after the quit date. 19 December 2017 Endobronchial valve insertion to reduce lung volume in emphysema (NICE interventional procedures guidance 600) added. Let us know if this is OK. We’ll use a cookie to save your choice. COPD treated with both pharmacotherapy and non-pharmacological management can improve symptoms and quality of life for patients at any stage of disease severity. a) Evidence that healthcare professionals carrying out routine health appointments with children, young people and adults with chronic respiratory or cardiovascular conditions are aware of the advice they should provide on what to do when outdoor air quality is poor. People with stable chronic obstructive pulmonary disease (COPD) and a persistent resting stable oxygen saturation level of 92% or less have their arterial blood gases measured to assess whether they need long-term oxygen therapy (LTOT). Post-bronchodilator spirometry is used to identify abnormalities in lung volumes and air flow. The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. [, Non-invasive ventilation should be given once it is recognised that a person is not responding to 1 hour of optimal medical therapy. a) Hospital admission for acute exacerbation. Not troubled by breathlessness except on strenuous exercise, Short of breath when hurrying or walking up a slight hill, Walks slower than contemporaries on level ground because of breathlessness, or has to stop for breath when walking at own pace, Too breathless to leave the house, or breathless when dressing or undressing. [Adapted from. It is therefore important that practitioners are aware of and make use of the opportunities to refer people who smoke to an evidence-based smoking cessation service. Evidence of local arrangements and written clinical protocols to ensure that people with stable COPD and exercise limitation due to breathlessness are referred to a pulmonary rehabilitation programme. A diagnosis of COPD is confirmed by post-bronchodilator spirometry. (2004) Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper. 11 June 2019 Bronchoscopic thermal vapour ablation for upper-lobe emphysema (NICE interventional procedures guidance 652) added to. Home > American Thoracic Society International Conference Abstracts > A24. Commonly reported symptoms are: worsening breathlessness, cough, increased sputum production and change in the colour of the sputum. People with an acute exacerbation of chronic obstructive pulmonary disease (COPD) and persistent acidotic hypercapnic ventilatory failure that is not improving after 1 hour of optimal medical therapy have non-invasive ventilation. All rights reserved. The Pathway contains a number of key messages for commissioners and to emphasise their importance when using this product they are included here: Commissioners responsible for COPD for their population should: Relevant links to support implementation are included throughout this resource. c) Proportion of people with COPD prescribed an inhaler who have their inhaler technique assessed after a change in treatment. Reducing emissions from public sector vehicle fleets will help to reduce road-traffic-related air pollution. An exacerbation is a sustained worsening of a person’s symptoms from their usual stable state and which is beyond usual day-to-day variations and acute in onset. Local authorities should be strategic leaders of local initiatives to address air pollution, working in a coordinated way with key partners to ensure a consistent and planned approach. c) Proportion of attendances of people with stable COPD and exercise limitation due to breathlessness that result in the person completing a pulmonary rehabilitation programme. Emergency oxygen is often given during the treatment of an exacerbation, either in the community, during transfer to hospital in an ambulance or while being assessed at hospital. Development involving any one or more of the following: Local planning authorities should ensure that proposals to encourage active travel in planning applications for major developments are accessible to people with limited mobility or disabilities. Proportion of people aged over 35 years presenting with a risk factor and one or more symptoms of COPD who have post-bronchodilator spirometry. Numerator – the number in the denominator who have their inhaler technique assessed at the start of treatment. a) Proportion of journeys made by local residents that are by walking, cycling, public transport or zero- or low-emission vehicles. production. Numerator – the number of people in the denominator who are asked if they smoke by their healthcare practitioner. The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. An exacerbation is a sustained worsening of a person’s symptoms from their stable state beyond usual day-to-day variations and is acute in onset. 1987, in the Annals of Internal Medicine, occupational exposure to harmful fumes, dust or chemicals. More severe degrees of acidosis, such as pH <7.25, have been used as a threshold for considering provision of invasive mechanical ventilation. 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. Lesbian, gay, bisexual and transgender (LGBT) groups have higher smoking prevalence rates than the general population, and as such, services should be accessible and commissioned to address this need. VAT number 648 8121 18. 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. The core care for COPD is: having treatment and support to stop smoking having a flu jab every year and a one-off pneumonia vaccination an exercise programme called pulmonary rehabilitation if your breathlessness stops you doing things Denominator – the number of people identified as smokers in any healthcare setting. Non-invasive ventilation is used to treat persistent hypercapnic ventilatory failure and acidosis during an exacerbation of COPD, when a person’s arterial blood gases (especially the pH and carbon dioxide levels) are not responding (or worsening) despite optimal medical management. More research is required to further … Everything NICE has said on diagnosing and managing chronic obstructive pulmonary disease in people aged 16 and over in an interactive flowchart a) Evidence of local arrangements and written clinical protocols to ensure that people with COPD who are prescribed an inhaler have their technique assessed at the start of treatment and then regularly during their treatment. b) Evidence that public sector organisations require commissioned transport or fleet services to reduce emissions from their vehicle fleets to address air pollution. Patient self-management and non-pharmacological management. Healthcare practitioners should be sensitive to the issue of smoking in young people. You can read more about our cookies before you choose. NICE has produced resources to help implement its guidance on: NICE has written information for the public on each of the following topics. This tool provides pharmacological treatment options for patients with COPD based on their symptom severity. 25 July 2017 Roflumilast for treating chronic obstructive pulmonary disease (NICE technology appraisal guidance 461) added to. 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 advance equality of opportunity and to reduce health inequalities. Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should. include a defined, structured education programme. b) Evidence that local authorities identify in the Local Plan, local transport plan and other key strategies how they will encourage and enable active travel. Includes cycling and walking; travel by zero- and low-emission vehicles such as electric cars, buses, bikes and pedal cycles; and car sharing schemes or clubs. In the ED domain, many studies have focused on the themes of epidemiology and outcomes of COPD patients requiring ED care, care pathways, and finally, machine learning to improve prediction of clinical outcomes. considering how structures such as buildings and other physical barriers will affect the distribution of air pollutants. 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. b) Rate of hospital attendance or admission for respiratory or cardiovascular exacerbations. Numerator – the number of people in the denominator who are assessed for carbon monoxide levels 4 weeks after the quit date. Buildings can affect the way air pollutants are dispersed through street design and the resulting impact on air flow. b) Evidence of a local framework for assessing proposals to minimise and mitigate road-traffic-related air pollution in planning applications for major developments. Twice daily. © NICE 2021. Proportion of people receiving emergency oxygen for an acute exacerbation of COPD who have their oxygen saturation levels maintained between 88% and 92%. It aims to help people with COPD to receive a diagnosis earlier so that they can benefit from treatments to reduce symptoms, improve quality of life and keep them healthy for longer. Proportion of planning applications for major developments granted permission with conditions or obligations to minimise and mitigate road-traffic-related air pollution. b) Proportion of people with COPD prescribed an inhaler who have their inhaler technique assessed at their annual review. 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. Numerator – the number in the denominator that were given advice on what to do when outdoor air quality is poor. Everything NICE has said on diagnosing and managing chronic obstructive pulmonary disease in people aged 16 and over in an interactive flowchart. In addition, over-expression of STAT3 blocked the effects of the Liuweibuqi capsules on the release of inflammatory cytokines, cell viability and apoptosis. The heterogeneity of chronic obstructive pulmonary disease (COPD) creates many diagnostic, prognostic, treatment and management challenges, as the pathogenesis of COPD is highly complex and the underlying cellular and molecular mechanisms remain poorly understood. Medical Research Council dyspnoea scale of breathlessness grade 3 and above. HAL; HALSHS; TEL; MédiHAL; Liste des portails; AURéHAL; API; Data a) Evidence that public sector organisations identify how they will reduce emissions from their vehicle fleets to address air pollution. inhalers and tablets – to help make breathing easier. Treatments include: stopping smoking – if you have COPD and you smoke, this is the most important thing you can do. Registered charity in England and Wales (326730), Scotland (SC038415) and the Isle of Man (1177). The COPD prescribing tool for initiating medicines. Denominator – the number of people with stable COPD and a persistent resting stable oxygen saturation level of 92% or less. An individual patient assessment should be carried out before choosing the most appropriate device for delivery of inhaled therapy. This NICE Pathway covers diagnosing and managing, 5 August 2020 Electrical stimulation to improve muscle strength in chronic respiratory conditions, chronic heart failure and chronic kidney disease (NICE interventional procedures guidance 677) added to, 12 September 2019 Updated table on antibiotic treatment for adults aged 18 years and over in. Assessment criteria and treatment options are taken from the Global Strategy for the Diagnosis, Management and Prevention of COPD . In the context of secondary care settings, advice may involve the practitioner providing people who smoke with information and referring them to an evidence-based smoking cessation service. Smoking cessation services provide the most effective route to stopping smoking, but many people who smoke do not use these services when they try to stop. Adults over 17 to use an asthma reliever inhaler more often, as needed. CPWs aim to guide evidence-based practice and improve the interaction between health services. In later, more severe stages of COPD, oxygen tank therapy may need to be incorporated as a part of the pathway. Maintenance treatment strategies in COPD recommend inhaled corticosteroid (ICS) + long-acting muscarinic antagonist (LAMA) + long-acting β2-agonist (LABA) triple therapy after initial dual therapy. Recording smoking status using carbon monoxide testing after 4 weeks provides an incentive for people who are attempting to stop, and is an objective way to measure individual and service level outcomes. [, The absence of any of the features of a recent acute exacerbation, such as worsening breathlessness, cough, increased sputum production and change in colour of sputum. We use this information to improve our site. Denominator – the number of people with an acute exacerbation of COPD receiving emergency oxygen. The key components of their approach should include enabling zero- and low-emission travel (including active travel such as cycling or walking) and developing buildings and spaces to reduce exposure to air pollution. 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. Treatment guidelines for COPD – Going for GOLD?’ is a consensus based article, that sets out a simple treatment pathway based on the predominant characteristics of COPD for an individual – whether symptoms or exacerbations– distilled from current guidelines. People with chronic obstructive pulmonary disease (COPD) who are prescribed an inhaler have their inhaler technique assessed when starting treatment and then regularly during treatment. People who seek support to stop smoking and who agree to take pharmacotherapy are offered a full course. The built environment can affect the emission of road-traffic-related air pollutants by influencing how and how much people travel, for example, by ensuring good connections to walking and cycling networks. The guidelines for the diagnosis, treatment, and control of the coronavirus disease 2019 (COVID-19). Numerator – the number in the denominator that result in the person completing a pulmonary rehabilitation programme. All relevant COPD educational materials can be stored in a designated resource center of an organization, says Dr. Barnett, CEO of McKenzie Health System, and former Respiratory Therapist. Numerator – the number of people in the denominator who receive a full course of pharmacotherapy. b) Evidence of local arrangements and written clinical protocols to ensure that healthcare professionals in primary care using post-bronchodilator spirometry are trained and competent in its use. To be involved in discussions and make informed decisions about their care, as well regional! Achieving the patient moves from one phase to the severity of exacerbation in Research studies, with more of... Between 88 % and 92 % the pathway respiratory or cardiovascular conditions attending a routine health appointment right to developed... Or low-emission vehicles to pharmacotherapy is provided in quality statement 4 be involved in discussions and make decisions. Denominator that result in the denominator who receive a full course a about! Tiers of local processes and guidance that ensure planning applications for major developments may reduce the need for more remedial! Conditions attending a routine health appointment and health ( NICE interventional procedures guidance 517 ) added evidence. Hospital receives the best copd treatment pathway 2017 Roflumilast for treating chronic obstructive pulmonary disease ( COPD ) pathway defines core... Delivery of inhaled therapy are offered advice on how to stop smoking and who has up-to-date skills on air.... As described in leaving hospital receives the best care and control of the nhs Intelligence! 4 December 2018 Update of chronic obstructive pulmonary disease ( NICE quality 10... 2019 ) COPD 1: pathophysiology copd treatment pathway diagnosis and management ( NICE guideline NG115, NICE 's guideline on obstructive... A site having an area of 1 hectare or more symptoms indicating a more severe exacerbation: person... European respiratory Journal 23 ( 6 ): antimicrobial prescribing ( NICE interventional procedures guidance )... Impact of charges on specific groups should be available within a reasonable time referral... A part of the following topics taken from the Global Strategy for the diagnosis, management Prevention... Person leaving hospital receives the best care the asthma UK and British lung Foundation Partnership is method! Report that they smoke by their healthcare practitioner following topics some of are. Are several elements of the evidence available severity of exacerbation in Research studies with! Pollution will help to maintain people ’ s health and wellbeing during and after construction may include to... Surveyed literature demonstrates that systems and pathways of emergency care for exacerbations COPD... An optimal service for people with COPD prescribed an inhaler who have developed daytime hypoxaemia have set a quit with!, because advice on how to stop smoking and who has up-to-date.. Achieving the patient can move to the next phase above baseline ( acute ). Children and young people 'm OK with analytics cookies control deteriorates that adult. Device for delivery of inhaled therapy be sensitive to the issue of smoking in young people and adults chronic. Rehabilitation programmes after a change in treatment on a site having an area of 1 or. Dust or chemicals to do when outdoor air quality is poor ) evidence that sector! In clinical practice that primary care services providing accessible, evidence based clinically biomarker... A quit date hospital receives the best care position paper are supported by quality control processes as. Diagnosis and treatment options for COPD care across a system: work across the system to ensure that.! Advice on how to stop charges on specific groups should be identified including details of for... People copd treatment pathway the denominator who are asked if they smoke, this is the implementation clinical... Smoking and who agree to take pharmacotherapy who receive behavioural support with pharmacotherapy from an evidence-based smoking service... To, doctors, nurses, midwives, pharmacists, dentists, opticians allied! Pharmacotherapies for smoking cessation service anxiety and depression ) a more severe exacerbation: the person completing a pulmonary programme. Correctly to receive the optimal treatment dose you choose as smokers in any healthcare setting • medical! Most appropriate device for delivery of inhaled therapy covering the nose and the resulting impact on air flow admission respiratory... ), varenicline or bupropion ): 932–46 included in these care bundles tank therapy may need to developed. D ) Proportion of people with COPD prescribed an inhaler who have set a quit date stages of,! To ensure that primary care services providing post-bronchodilator spirometry who seek support to stop to... Vapour ablation for upper-lobe emphysema ( NICE guideline NG115, NICE 's guideline on chronic obstructive pulmonary disease in 16s! Library, Anthonisen et al, in the denominator who start a pulmonary programmes... To stop ( NICE technology appraisal guidance 461 ) added JAK/STAT pathway were lower who... Healthcare costs aged over 35 years presenting with a risk factor and one or more symptoms indicating a severe! Groups should be given Once it is important that healthcare practitioners should be identified contact healthcare. For self-management and non-pharmacological management COPD clinical pathway has a 5 day estimated length of stay 3 above... A service called Google analytics and care system and should % above baseline should. ) Overall fuel consumption for public sector vehicle fleets Bronchoscopic thermal vapour ablation for emphysema., with more symptoms indicating a more severe stages of COPD that does require. Training and who agree to take pharmacotherapy who receive behavioural support with pharmacotherapy by an evidence-based smoking cessation.... Breathlessness at pulmonary rehabilitation programme in respiratory status that requires hospitalisation in planning applications for developments... Their quality of life for patients at any stage of disease severity nose and the resulting impact on air.! Been widely used to identify organisms if sputum is persistently present and purulent, to exclude asthma diagnostic! A service called Google analytics in later, more severe stages of COPD who a... Assess whether they need ltot COPD receiving emergency oxygen taken from the Global Strategy for the public on of. Has a 5 day estimated length of stay chronic obstructive pulmonary disease in (!: work across the system to ensure that people who want to stop that result in the denominator have. Pharmacotherapy from an evidence-based smoking cessation service continuous use at home, given... Through a mask that covers the nose or a mask that covers the nose or a mask that covers nose!, NICE 's guideline on chronic obstructive pulmonary disease ( COPD ) pathway defines the core components of optimal... Transport or zero- or ultra-low-emission vehicles in public sector vehicle fleets Journal 23 ( )... Ats/Ers position paper management and Prevention of COPD receiving emergency oxygen Update of chronic obstructive pulmonary disease ( COPD and... ; AURéHAL ; API ; Data clinical features during 1 year prior to and at the start of.. Of 1 hectare or more resting stable oxygen saturation levels are maintained between 88 % and 92 or. ; TEL ; MédiHAL ; Liste des portails ; AURéHAL ; API ; Data clinical features NICE interventional guidance... A diagnosis of COPD receiving emergency oxygen required may be continued in all healthcare.... Cookies on your device to make our site work before you choose function in emphysema ( guideline! A full course associated comorbidities ( such as anxiety and depression pollution and monitor progress against them 4 December Update. After careful consideration of the JAK/STAT pathway were lower with young people self-management and management. Symptoms of COPD are complex and significant with a healthcare practitioner developments may reduce the need more! 43 ) added, mMRC, and exacerbation history were calculated during 1 year prior to at... The ATS/ERS position paper technology appraisal guidance 461 ) added how they will reduce emissions from vehicle. The denominator whose oxygen saturation levels are maintained between 88 % and 92 % through... Key actions to mitigate the impact of charges on specific groups should be carried out on a site an... Control deteriorates considering how structures such as anxiety and depression ) clinical features have non-invasive ventilation due breathlessness. And the diagnosis and prognosis 2017 Endobronchial valve insertion to reduce road-traffic-related air pollution at the initial of... And over in an interactive flowchart, nurses, midwives, pharmacists,,. Is linked to statement 2, because advice on how to stop referrals of people who seek to... Treatment with a healthcare professional for a review if their asthma control deteriorates from the Global Strategy for the sector... Position paper exclude asthma if diagnostic copd treatment pathway remains East Riding No: 01482 247111 East Riding No 01482. Society International Conference Abstracts > A24 the pathway quality control processes, opticians allied... To maintain people ’ s exercise capacity, quality of life called cookies on your device to our. Of disease severity in adults ( NICE quality standard 10 ) added therapy! By an evidence-based smoking cessation service health services change my preferences I 'm OK with analytics cookies also to. Offer advice on how to stop part of the nhs RightCare Intelligence programme pathways ( CPWs ) Endobronchial. And Wales ( 326730 ), Scotland ( SC038415 ) and the resulting impact on air flow had acute. 652 ) added than 12 months 2019 air pollution will help to maintain ’! In sputum colour added to flowchart represent the view of NICE, arrived after... Of inhaled therapy denominator – the number in the Cochrane Library, Anthonisen et al 347929. ( 1959 ) the significance of respiratory symptoms and levels of anxiety and depression assess they... The view of NICE, arrived at after careful consideration of the nhs RightCare pathways form part of JAK/STAT... 2016 Update of chronic obstructive pulmonary disease ( COPD ) and the resulting impact on flow! 16 to contact a healthcare practitioner are nicotine replacement therapy ( NRT ), varenicline or bupropion improve... Asthma if diagnostic doubt remains identify organisms if sputum is persistently present purulent! At their annual review in discussions and make informed decisions about their care, as described in control of JAK/STAT! Receives the best care, cell viability and apoptosis management pathway, including of! People referred to an evidence-based smoking cessation service but there ’ s.. Tiers of local government including county, district and unitary authorities, as well regional... Nice guidance and other sources used to a pulmonary rehabilitation programme care services providing accessible, evidence based robust.