Last reviewed: 26 Jun 2021
Last updated: 26 May 2021
23 Apr 2021

International guidelines update recommendations for patients with acute exacerbation of COPD during the COVID-19 pandemic

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) has released the 2021 version of its report on the diagnosis and management of COPD.

New recommendations on management of acute exacerbations in light of the ongoing COVID-19 pandemic include the following.

  • Arrange a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) polymerase chain reaction test if a patient with COPD presents with new or worsening respiratory symptoms, fever, and/or any other symptoms that could be COVID-19 related, even if these are mild. In practice, it may be difficult to differentiate between COVID-19 infection and an acute exacerbation of COPD clinically.

  • During periods of high prevalence of COVID-19 in the community, only use spirometry if it will definitively inform or change a patient’s urgent or essential management.

  • Use systemic corticosteroids according to the usual indications for acute COPD exacerbation whether or not there is evidence of SARS-COV-2 infection.

    • There is no evidence that this approach modifies the patient’s susceptibility to SARS-CoV-2 infection or worsens outcomes.

  • Treat with antibiotics as per usual indications for acute COPD exacerbations whether or not there is evidence of SARS-COV-2 infection.

    • This is particularly important because patients with COPD who also have COVID-19 frequently develop bacterial or fungal co-infections.

During the COVID-19 pandemic, seek advice from a respiratory specialist and consult local guidelines before using a nebuliser. There are currently differences of opinion between organisations in different countries on whether use of a nebuliser is an aerosol-generating procedure.

  • GOLD recommends minimal use of nebulisers, advising that inhalers should ideally be used for drug delivery instead. GOLD acknowledges that nebulisers may be needed in critically ill patients with COVID-19 receiving ventilatory support. GOLD recommends using a mesh nebuliser (to keep the circuit intact and prevent virus transmission) if absolutely necessary to do so (e.g., in ventilated patients).

  • However, nebulisers are not considered to represent a significant infectious risk for COVID-19 according to Public Health England and the UK National Institute for Health and Care Excellence.[90][91] 

For more detailed information on COVID-19 see our topic  Coronavirus disease 2019 (COVID-19). external link opens in a new window

See Diagnosis: recommendations

See Management: approach

Original source of updateexternal link opens in a new window

Summary

Definition

History and exam

Key diagnostic factors

  • dyspnoea
  • cough
  • increased sputum purulence and volume
  • wheeze
  • chest tightness/chest pain
  • tachypnoea
  • tachycardia
  • risk factors
  • cor pulmonale

Other diagnostic factors

  • signs of respiratory failure
  • fever
  • gastro-oesophageal reflux and/or swallowing dysfunction

Risk factors

  • bacterial infection
  • gastro-oesophageal reflux and/or swallowing dysfunction
  • viral infection
  • pollutants
  • atypical bacterial infection
  • change in weather

Diagnostic investigations

1st investigations to order

  • arterial blood gas (in hospital)
  • pulse oximetry (in hospital and in the community)
  • ECG (in hospital and in the community if available)
  • FBC with platelets (in hospital)
  • urea, electrolytes, and creatinine (in hospital)
  • CRP (in hospital)
  • CXR (in hospital)
  • sputum microscopy, culture, and Gram stain (in hospital)
  • vitamin D (in hospital or in the community)

Investigations to consider

  • blood cultures
  • respiratory virus diagnostics
  • cardiac troponin
  • serum theophylline level
  • pro-brain natriuretic peptide (BNP)
  • CT scan of chest
  • spirometry

Emerging tests

  • procalcitonin
  • point-of-care CRP

Treatment algorithm

Contributors

Expert advisers

Jonathan Bennett, MD

Honorary Professor of Respiratory Sciences

University of Leicester

Respiratory Consultant

Glenfield Hospital

Leicester

UK

Biography

JB is Chair of the British Thoracic Society.

Disclosures

JB declares that he has no competing interests.

Richard Russell,

Specialty Registrar in Respiratory Medicine

Glenfield Hospital

Leicester

UK

Disclosures

RJR received sponsorship from AstraZeneca to attend a conference, May 2018 (covering travel, accommodation, and conference fee).

Acknowledgements,

BMJ Best Practice would like to gratefully acknowledge the previous team of expert contributors, whose work has been retained in parts of the content:

Carolyn L. Rochester MD

Associate Professor

Yale University School of Medicine

New Haven

VA Connecticut Healthcare System

West Haven

CT

Richard A. Martinello MD

Associate Professor

Yale University School of Medicine

New Haven

Veterans Health Administration

Office of Public Health

West Haven

CT

Disclosures

CLR serves on the COPD scientific advisory board for GlaxoSmithKline Pharmaceuticals but has no competing interests pertaining to this publication. RAM declares that he has no competing interests.

Peer reviewers

Carlos Echevarria,

Consultant Respiratory Physician

Royal Victoria Infirmary

Newcastle upon Tyne

UK

Disclosures

CE declares that he has no competing interests.

Editors

Emma Quigley,

Section Editor, BMJ Best Practice

Disclosures

EQ declares that she has no competing interests.

Tannaz Aliabadi-Oglesby,

Lead Section Editor, BMJ Best Practice

Disclosures

TAO declares that she has no competing interests.

Julie Costello,

Comorbidities Editor, BMJ Best Practice

Disclosures

JC declares that she has no competing interests.

Adam Mitchell,

Drug Editor, BMJ Best Practice

Disclosures

AM declares that he has no competing interests.

Expert advisers: comorbidities

Martyn Patel, BMBcH, FRCP, MA

Consultant, Older People's Medicine

Norfolk and Norwich University Hospitals

NHS Foundation Trust

Norwich

UK

Disclosures

MP has accepted speaker fees and/or travel expenses to deliver lectures from: University of East Anglia, Leicester University (speaker fees only); Astellas Pharma Ltd (speaker fees and travel expenses). MP has accepted travel expenses from Newton Europe to present a joint project conducted by his main employer (Norfolk and Norwich University Hospitals NHS Trust) and Newton Europe at the NHS Confederation conference (Manchester 2018). MP has accepted sponsorship for travel expenses and accommodation costs from Astellas Pharma Ltd to attend the European Geriatric Society Meeting (Lisbon 2016).

Andrew Lewington, BSc (Hons), MBBS, MEd, MD, FRCP

Consultant Renal Physician

Honorary Associate Professor

Nephrology Department

Leeds Teaching Hospitals NHS Trust

Leeds

UK

Disclosures

AL is Associate Clinical Director of NIHR Leeds In-Vitro Diagnostics Co-operative, Co-Chair of UK Kidney Research Consortium Renal Clinical Study Group, Member of Kidney Research UK Research Grant Committee, Committee Member of NICE Kidney Injury Clinical Guideline Update 2018-20, Committee Member of NICE Diagnostic Assessment for Point of Care Creatinine Testing 2018-19. AL attended the Acute Dialysis Quality Initiative Meeting in San Diego 2018 (accommodation expenses); AL was a speaker at the AKI & CRRT Conference in San Diego 2019 (travel and accommodation expenses), the AKI Conference in Coventry 2019 (travel expenses), and the NIHR AKI and Sepsis Meeting in Leeds 2019 (no expenses).

Martin Cowie, MD, MSc, FRCP, FRCP (Ed), FESC, FHFA, FACC

Professor of Cardiology

Imperial College London (Royal Brompton Hospital)

London

UK

Disclosures

MC is a Non-Executive Director of NICE and Chair the Digital Health Committee of the European Society of Cardiology. MC’s university receives support for his research from Abbott, ResMed, Boston Scientific, and Medtronic. MC speaks at educational events and provides consultancy advice to a number of device, diagnostic, and pharmaceutical companies including Novartis, Servier, Bayer, Pfizer, AstraZeneca, Boehringer Ingelheim, Roche Diagnostics, Medtronic, Abbott, ResMed, and Boston Scientific. MC declares that none of these interests is directly related to topics advised on for this project.

Rachael Evans, MBChB, FRCP (UK), PhD

Associate Professor (Clinical)

University of Leicester

Honorary Consultant Respiratory Physician

Glenfield Hospital

Leicester

UK

Disclosures

RAE has been reimbursed for a GSK Advisory Board meeting on Physical Activity and Asthma in November 2016, and three Chiesi Education meetings for GPs on COPD care in 2019. RAE received a travel award for ERS 2017 from Chiesi and participated in the GSK clinical experience programme - respiratory in August 2018. RAE participated in the BTS/SIGN guidelines for asthma update 2016 (no fee).

Gerry Rayman, MD, FRCP

Consultant Physician and Head of Service

Diabetes and Endocrine Centre and the Diabetes Research Unit

Ipswich Hospitals NHS Trust

Ipswich

UK

Disclosures

GR has been paid for advisory board meetings with the following companies: Safoni Aventis, Abbott Diabetes UK, Lilly Diabetes, Bayer. GR has received lecture fees from Safoni Aventis, Abbott Diabetes UK, Lilly Diabetes, Novonordisk, Napp Pharmaceuticals Ltd.

Sotiris Posporelis, MD, MRCPsych

Consultant Liaison Neuropsychiatrist

King’s College Hospital

South London and Maudsley NHS Foundation Trust

Honorary Senior Clinical Lecturer

Institute of Psychiatry, Psychology & Neuroscience

King’s College London

London

UK

Disclosures

SP declares that he has no competing interests.

Hamish McAuley, MBBS, BSc, MRCP

Clinical Research Fellow

Specialist Registrar (ST5)

Department of Respiratory Sciences

University of Leicester

Respiratory Biomedical Research Unit

Glenfield Hospital

Leicester

UK

Disclosures

HM declares that he has no competing interests.

Peer reviewers: comorbidities

Martyn Patel, BMBcH, FRCP, MA

Consultant, Older People's Medicine

Norfolk and Norwich University Hospitals

NHS Foundation Trust

Norwich

UK

Disclosures

MP has accepted speaker fees and/or travel expenses to deliver lectures from: University of East Anglia, Leicester University (speaker fees only); Astellas Pharma Ltd (speaker fees and travel expenses). MP has accepted travel expenses from Newton Europe to present a joint project conducted by his main employer (Norfolk and Norwich University Hospitals NHS Trust) and Newton Europe at the NHS Confederation conference (Manchester 2018). MP has accepted sponsorship for travel expenses and accommodation costs from Astellas Pharma Ltd to attend the European Geriatric Society Meeting (Lisbon 2016).

Simon Conroy, MBChB, FRCP, PhD

Professor of Geriatric Medicine

University of Leicester

Honorary Geriatrician

University Hospitals of Leicester

Leicester

UK

Disclosures

SC declares that he has no competing interests.

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