COVID-19 NICE Guidance - patients with interstitial lung disease

The purpose of this guidance is to maximise the safety of adults with interstitial lung disease, including idiopathic pulmonary fibrosis, and pulmonary sarcoidosis during the COVID-19 pandemic.

1. Communicating with patients and minimising risk

• Communicate with patients, their families and carers, and support their mental wellbeing to help alleviate any anxiety they may have about COVID-19. Signpost them to relevant support groups/charities
• Many patients with interstitial lung disease will have received a letter telling them they are at high risk of severe illness from COVID-19
• Discuss with patients who have been advised to shield whether the benefit of them attending services outweighs the risks
• Advise patients that if they think they have COVID-19 they should use the NHS 111 online coronavirus service or in an emergency, dial 999
• Minimise face-to-face contact
• Advise patients to keep a list of medicines they take, their conditions and any allergies as well as a copy of recent clinic appointment to give to healthcare staff if they need treatment for COVID-19
• Find out if people have advance care plans or advance decisions to refuse treatment
• Consider asking local specialist palliative care teams for advice if needed

2. Assessing symptoms of interstitial lung disease and COVID-19

• Be aware that patients taking drugs that affect the immune response may have atypical presentations of COVID-19
• Be aware that some adverse effects caused by antifibrotic drugs and immunosuppressants may be mistaken for symptoms of COVID-19
• Be aware that symptoms of COVID-19 can be similar to the symptoms of the patient’s underlying condition
• Be aware that both interstitial lung disease and COVID-19 are associated with increased risk of coagulopathy

3. New referrals to interstitial lung disease specialist services

• Hold the first outpatient appointment by telephone or video consultation
• If blood test results from the last six weeks are available from the referral team or GP, use them to guide treatment decisions
• If pulmonary function test results from the last six months are available and the patient’s clinical condition has not altered considerably, use them to guide diagnosis and treatment decisions
• If a CT scan from the last 12 months is available and the patient’s clinical condition has not altered considerably, use it to guide diagnoses and treatment decisions

4. Interstitial lung disease investigations

• Only carry out bronchoscopy and pulmonary function tests if the patient urgently needs them and if the results will have a direct impact on their care
• If supervised spirometry is not possible, consider using home spirometry to get measurements
• Consider alternatives to patients attending hospital for blood monitoring when on antifibrotic drugs or immunosuppressants

5. Management of patients not known to have COVID-19

• If patients have to attend a face-to-face appointment, on the day of the appointment first screen them by telephone and then again on arrival at the outpatient setting to make sure they have not developed symptoms of COVID-19
• Ask patients to help reduce the risk of contracting or spreading COVID-19
• Check patient’s temperature when they arrive, ideally before they enter the reception area
• Minimise time in the waiting area
• When deciding whether to start or continue an immunosuppressant, discuss the risks and benefits with the patient
• Advise patients on immunosuppressive therapy to continue to take their treatment as prescribed to minimise the risk for their condition worsening
• For patients who have been advised to shield, making blood monitoring difficult, assess whether it is safe to increase the time between blood tests for drug monitoring if their clinical condition is stable on treatment
• Discuss with the patient the risks and benefits of being on an immunosuppressant with blood monitoring requirements
• Offer the lowest dose of prednisolone possible
• Offer antifibrotic therapy as required
• Oxygen assessment: decide whether to carry out or defer an assessment for ambulatory or long-term oxygen therapy
• Continue to offer pulmonary rehabilitation services to patients if available
• If remote pulmonary rehabilitation services are not available locally, discuss the risks and benefits of attending face-to-face services with the patient

6. Management of patients known or suspected to have COVID-19

• When patients with symptoms of COVID-19 have been identified, follow UK Government guidance
• If COVID-19 is later diagnosed in a patient not isolated from admission or presentation, follow UK Government guidance
• If a patient has any signs or symptoms of a possible serious illness, assess and treat the illness in line with usual care
• If other possible diagnoses have been discounted and COVID-19 is suspected, follow UK Government guidance
• If a patient is diagnosed with COVID-19 pneumonia and shows consistent radiological changes, follow UK Government guidance

7. Supplying medicines

• Plan how to manage any disruption to normal routes for supplying medicines, such as homecare medicine delivery services
• Prescribe enough medicines to meet the patient’s clinical needs