NICE guidelines on interstitial lung disease and COVID-19: a summary

  • National Institute for Health and Care Excellence

  • curated by Dawn O'Shea
  • Clinical Guidance Summaries
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NICE has published rapid guidance on the management of patients with interstitial lung disease (ILD) during the COVID-19 pandemic. Here, Univadis provides a summary of the key recommendations.

General recommendations

  • Communicate patients/families/carers, and support their mental well-being.
  • Provide advice on shielding and protecting.
  • Minimise face-to-face contact.
  • If a face-to-face appointment is needed, screen patient by phone on the day of the appointment and again on arrival (including temperature check).
  • Patients should attend appointments with no more than one other person.
  • Minimise time in the waiting area.

Assessing symptoms

  • Patients taking immunomodulators may have atypical presentations of COVID‑19, e.g., patients taking corticosteroids may not develop a fever.
  • Some adverse effects caused by antifibrotic drugs and immunosuppressants may be mistaken for symptoms of COVID‑19, e.g., diarrhoea, fatigue and loss of appetite.
  • Symptoms of COVID‑19 can be similar to the symptoms of the underlying condition.
  • ILD and COVID‑19 are associated with increased risk for coagulopathy.

New referrals

  • Hold the first outpatient appointment by telephone/video. Only offer face-to-face appointment if the benefits outweigh the risks.
  • Use blood tests and pulmonary function tests from the last six weeks or computed tomography scan from the last 12 months to guide treatment decisions.
  • If these test results are unavailable and are necessary to guide urgent care, refer patient for testing/scan.

Diagnosing interstitial lung disease

  • Only carry out bronchoscopy and pulmonary function tests if the results are urgently needed.
  • If supervised spirometry is not possible, consider home spirometry.
  • Consider community blood monitoring services.

Starting and continuing treatment

  • When deciding whether to start or continue an immunosuppressant, consider the following:
    • Is the patient's condition stable?
    • Is there a treatment with a better risk profile?
    • Is monitoring and review feasible?
    • Would it be safer to delay starting the treatment?
    • Does the patient need to continue the treatment?
    • Are there changes to dose or route of administration that could reduce hospital attendance?
    • Can the patient tolerate a reduced dose?
    • If the patient has rapidly progressive interstitial lung disease, is intravenous therapy an option?
  • Advise patients on immunosuppressives and antifibrotics to continue treatment as prescribed.
  • For patients responding to immunosuppressant but are unable to attend for blood monitoring, consider prednisolone alone.
  • Offer the lowest dose of prednisolone possible or the last dose that controlled symptoms.

Oxygen assessment

  • Decide whether to carry out or defer an assessment for ambulatory or long-term oxygen therapy.
  • Carry out oxygen assessments in the patient's home if possible.
  • Continue to offer pulmonary rehabilitation if available.
  • If remote pulmonary rehabilitation is unavailable, consider the British Thoracic Society pulmonary rehabilitation resource pack.
  • When face-to-face pulmonary rehabilitation becomes available, discuss the risks and benefits of attendance with the patient.

Lung transplantation

  • Continue to refer for lung transplant assessment as usual.

Patients with known or suspected COVID-19

  • Follow COVID-19 infection prevention and control guidance.
  • If COVID‑19 is later diagnosed in a patient not isolated from admission or presentation, follow guidance on management of exposed health care workers and patients in hospital settings.
  • Follow guidance on investigation and initial clinical management of possible cases of COVID-19.
  • If a patient is diagnosed with COVID‑19 pneumonia and shows radiological changes, follow the British Thoracic Society's guidance on respiratory follow-up of the patients.

Continuing and stopping treatment

  • Before deciding to stop or adjust treatment, contact the patient's specialist team for advice.
  • Continue antifibrotics if blood monitoring parameters are in an acceptable range and there is no other reason to stop.
  • Consider pausing immunosuppressants if COVID‑19 is confirmed.
  • The half-life of some medicines means that the immunosuppressive effects continue for some time after stopping treatment.
  • Maintain oral prednisolone in patients diagnosed with COVID‑19.
  • Some patients on long-term oral prednisolone may be at risk of adrenal crisis and may need a higher dose if diagnosed with COVID‑19.
  • Stop or adjust doses of medicines for interstitial lung disease if the patient develops acute kidney injury or deranged liver function tests because of COVID‑19.