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Contents included in this summary

Contents not included in this summary

  • Managing stable COPD
    • Multidisciplinary management
      • Respiratory nurse specialists
      • Physiotherapy
      • Identifying and managing anxiety and depression
      • Nutritional factors
      • Palliative care
      • Assessment for occupational therapy
      • Social services
      • Advice on travel
      • Advice on diving
  • Managing exacerbations of COPD
    • People referred to hospital
    • Hospital-at-home and assisted-discharge schemes
    • Pharmacological management
    • Oxygen therapy during exacerbations of COPD
    • Non-invasive ventilation (NIV) and COPD exacerbations
    • Invasive ventilation and intensive care
    • Respiratory physiotherapy and exacerbations
    • Monitoring recovery from an exacerbation
    • Discharge planning

Diagnosing COPD 

  • The diagnosis of chronic obstructive pulmonary disease (COPD) depends on thinking of it as a cause of breathlessness or cough. The diagnosis is suspected on the basis of symptoms and signs, and is supported by spirometry 

Symptoms

  • Suspect a diagnosis of COPD in people over 35 who have a risk factor (generally smoking or a history of smoking) and who present with 1 or more of the following symptoms:
    • exertional breathlessness
    • chronic cough
    • regular sputum production
    • frequent winter ‘bronchitis’
    • wheeze
  • When thinking about a diagnosis of COPD, ask the person if they have:
    • weight loss
    • reduced exercise tolerance
    • waking at night with breathlessness
    • ankle swelling
    • fatigue
    • occupational hazards
    • chest pain
    • haemoptysis (coughing up blood)

      these last two symptoms are uncommon in COPD and raise the possibility of alternative diagnoses
  • One of the primary symptoms of COPD is breathlessness. The Medical Research Council (MRC) dyspnoea scale (see table 1) should be used to grade the breathlessness according to the level of exertion required to elicit it
Table 1: MRC dyspnoea scale

Grade 

Degree of breathlessness related to activities 

1

Not troubled by breathlessness except on strenuous exercise

2

Short of breath when hurrying or walking up a slight hill

3

Walks slower than contemporaries on level ground because of breathlessness, or has to stop for breath when walking at own pace

4

Stops for breath after walking about 100 metres or after a few minutes on level ground

5

Too breathless to leave the house, or breathless when dressing or undressing

Adapted from Fletcher CM, Elmes PC, Fairbairn MB et al. (1959) The significance of respiratory symptoms and the diagnosis of chronic bronchitis in a working population. British Medical Journal 2: 257–266.

Spirometry

  • Perform spirometry:
    • at diagnosis
    • to reconsider the diagnosis, for people who show an exceptionally good response to treatment 
    • to monitor disease progression (amended 2018)
  • Measure post-bronchodilator spirometry to confirm the diagnosis of COPD
  • Think about alternative diagnoses or investigations for older people who have an FEV1/FVC ratio below 0.7 but do not have typical symptoms of COPD
  • Think about a diagnosis of COPD in younger people who have symptoms of COPD, even when their FEV1/FVC ratio is above 0.7
  • All healthcare professionals who care for people with COPD should have access to spirometry and be competent in interpreting the results
  • Spirometry can be performed by any healthcare worker who has had appropriate training and has up-to-date skills
  • Spirometry services should be supported by quality-control processes
  • It is recommended that Global Lung Function Initiative GLI 2012 reference values are used, but it is recognised that these values are not applicable for all ethnic groups (amended 2018)

Incidental findings on chest X-rays or CT scans (2018)

  • Consider primary care respiratory review and spirometry (see Spirometry) for people with emphysema or signs of chronic airways disease on a chest X-ray or CT scan
  • If the person is a current smoker, their spirometry results are normal and they have no symptoms or signs of respiratory disease:
    • offer smoking cessation advice and treatment, and referral to specialist stop smoking services (see the NICE guideline on stop smoking interventions and services)
    • warn them that they are at higher risk of lung disease
    • advise them to return if they develop respiratory symptoms
    • be aware that the presence of emphysema on a CT scan is an independent risk factor for lung cancer
  • If the person is not a current smoker, their spirometry is normal and they have no symptoms or signs of respiratory disease:
    • ask them if they have a personal or family history of lung or liver disease and consider alternative diagnoses, such as alpha-1 antitrypsin deficiency
    • reassure them that their emphysema or chronic airways disease is unlikely to get worse
    • advise them to return if they develop respiratory symptoms
    • be aware that the presence of emphysema on a CT scan is an independent risk factor for lung cancer

Further investigations

  • At the time of their initial diagnostic evaluation, in addition to spirometry all patients should have:
    • a chest radiograph to exclude other pathologies
    • a full blood count to identify anaemia or polycythaemia
    • body mass index (BMI) calculated
  • Perform additional investigations when needed, as detailed in Table 2
Table 2: Additional investigations
InvestigationRole

Sputum culture

To identify organisms if sputum is persistently present and purulent

Serial home peak flow measurements

To exclude asthma if diagnostic doubt remains

Electrocardiogram (ECG) and serum natriuretic peptides[A]

To assess cardiac status if cardiac disease or pulmonary hypertension are suspected because of:

– a history of cardiovascular disease, hypertension or hypoxia or

– clinical signs such as tachycardia, oedema, cyanosis or features of cor pulmonale

Echocardiogram

To assess cardiac status if cardiac disease or pulmonary hypertension are suspected

CT scan of the thorax

To investigate symptoms that seem disproportionate to the spirometric impairment

To investigate signs that may suggest another lung diagnosis (such as fibrosis or bronchiectasis)

To investigate abnormalities seen on a chest X‑ray

To assess suitability for lung volume reduction procedures

Serum alpha‑1 antitrypsin

To assess for alpha‑1 antitrypsin deficiency if early onset, minimal smoking history or family history

Transfer factor for carbon monoxide (TLCO)

To investigate symptoms that seem disproportionate to the spirometric impairment

To assess suitability for lung volume reduction procedures

[A] See the NICE guideline on chronic heart failure in adults for recommendations on using serum natriuretic peptides to diagnose heart failure.

  • Offer people with alpha‑1 antitrypsin deficiency a referral to a specialist centre to discuss how to manage their condition

Reversibility testing

Table 3: Clinical features differentiating COPD and asthma
 COPD Asthma 

Smoker or ex-smoker

Nearly all

Possibly

Symptoms under age 35

Rare

Often

Chronic productive cough

Common

Uncommon

Breathlessness

Persistent and progressive

Variable

Night-time waking with breathlessness and/or wheeze

Uncommon

Common

Significant diurnal or day-to-day variability of symptoms

Uncommon

Common

  • For most people, routine spirometric reversibility testing is not necessary as part of the diagnostic process or to plan initial therapy with bronchodilators or corticosteroids. It may be unhelpful or misleading because:
    • repeated FEV1 measurements can show small spontaneous fluctuations
    • the results of a reversibility test performed on different occasions can be inconsistent and not reproducible
    • over-reliance on a single reversibility test may be misleading unless the change in FEV1 is greater than 400 ml
    • the definition of the magnitude of a significant change is purely arbitrary
    • response to long-term therapy is not predicted by acute reversibility testing.
  • Untreated COPD and asthma are frequently distinguishable on the basis of history (and examination) in people presenting for the first time. Whenever possible, use features from the history and examination (such as those listed in table 3) to differentiate COPD from asthma. For more information on diagnosing asthma, see the NICE guideline on asthma (amended 2018)
  • In addition to the features in table 3, use longitudinal observation of people (with spirometry, peak flow or symptoms) to help differentiate COPD from asthma
  • When diagnostic uncertainty remains, or both COPD and asthma are present, use the following findings to help identify asthma:
    • a large (over 400 ml) response to bronchodilators
    • a large (over 400 ml) response to 30 mg oral prednisolone daily for 2 weeks
    • serial peak flow measurements showing 20% or greater diurnal or day-to-day variability

      Clinically significant COPD is not present if the FEV1 and FEV1/FVC ratio return to normal with drug therapy
  • If diagnostic uncertainty remains, think about referral for more detailed investigations, including imaging and measurement of transfer factor for carbon monoxide (TLCO)
  • Reconsider the diagnosis of COPD for people who report a marked improvement in symptoms in response to inhaled therapy

Assessing severity and using prognostic factors

COPD is heterogeneous, so no single measure can adequately assess disease severity in an individual. Severity assessment is, nevertheless, important because it has implications for therapy and relates to prognosis 

  • Do not use a multidimensional index (such as BODE) to assess prognosis in people with stable COPD (2018)
  • From diagnosis onwards, when discussing prognosis and treatment decisions with people with stable COPD, think about the following factors that are individually associated with prognosis:
    • FEV1
    • smoking status
    • breathlessness (MRC scale)
    • chronic hypoxia and/or cor pulmonale
    • low BMI
    • severity and frequency of exacerbations
    • hospital admissions
    • symptom burden (for example, COPD Assessment Test [CAT] score)
    • exercise capacity (for example, 6-minute walk test)
    • TLCO
    • whether the person meets the criteria for long-term oxygen therapy and/or home non-invasive ventilation
    • multimorbidity (see the NICE guideline on multimorbidity)
    • frailty (amended 2018)

Assessing and classifying the severity of airflow obstruction

  • Assess the severity of airflow obstruction according to the reduction in FEV1 as shown in table 4, below 
  • For people with mild airflow obstruction, only diagnose COPD if they have one or more of the symptoms (described in Symptoms)
Table 4: Gradation of severity of airflow obstruction
    NICE guideline CG12 (2004)  ATS/ERS20041 GOLD 20082 NICE guideline CG101 (2010) 
Post-bronchodilator FEV1/FVC 

FEV% predicted 

Severity of airflow obstruction 

 

Post-bronchodilator 

Post-bronchodilator 

Post-bronchodilator

<0.7

≥80%

Mild

Stage 1–Mild

Stage 1–Mild

<0.7

50–79%

Mild

Moderate

Stage 2–Moderate

Stage 2–Moderate

<0.7

30–49%

Moderate

Severe

Stage 3–Severe

Stage 3–Severe

<0.7

<30%

Severe

Very severe

Stage 4–Very severe*

Stage 4–Very severe*

* Or FEV1 below 50% with respiratory failure.
1 Celli BR, MacNee W, Agusti A et al. (2004) Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper. European Respiratory Journal 23 (6): 932–946.
2 Global Initiative for Chronic Obstructive Lung Disease (GOLD; 2008) Global strategy for the diagnosis, management and prevention of COPD.

Identifying early disease

Perform spirometry in people who are over 35, current or ex‑smokers, and have a chronic cough. [2004]

Consider spirometry in people with chronic bronchitis. A significant proportion of these people will go on to develop airflow limitation. [2004]

Referral for specialist advice

  • When clinically indicated, refer people for specialist advice. Referral may be appropriate at all stages of the disease and not solely in the most severely disabled people (see table 5, below)
  • People who are referred do not always have to be seen by a respiratory physician. In some cases they may be seen by members of the COPD team who have appropriate training and expertise
Table 5: Reasons for referral include
Reason Purpose 

There is diagnostic uncertainty

Confirm diagnosis and optimise therapy

Suspected severe COPD

Confirm diagnosis and optimise therapy

The person with COPD requests a second opinion

Confirm diagnosis and optimise therapy

Onset of cor pulmonale

Confirm diagnosis and optimise therapy

Assessment for oxygen therapy

Optimise therapy and measure blood gases

Assessment for long-term nebuliser therapy

Optimise therapy and exclude inappropriate prescriptions

Assessment for oral corticosteroid therapy

Justify need for continued treatment or supervise withdrawal

Bullous lung disease

Identify candidates for lung volume reduction procedures

A rapid decline in FEV1

Encourage early intervention

Assessment for pulmonary rehabilitation

Identify candidates for pulmonary rehabilitation

Assessment for a lung volume reduction procedure

Identify candidates for surgical or bronchoscopic lung volume reduction

Assessment for lung transplantation 

Identify candidates for surgery

Dysfunctional breathing

Confirm diagnosis, optimise pharmacotherapy and access other therapists

Onset of symptoms under 40 years or a family history of alpha-1 antitrypsin deficiency

Identify alpha-1 antitrypsin deficiency, consider therapy and screen family

Symptoms disproportionate to lung function deficit

Look for other explanations including cardiac impairment, pulmonary hypertension, depression and hyperventilation

Frequent infections

Exclude bronchiectasis

Haemoptysis

Exclude carcinoma of the bronchus

Managing stable COPD

NICE COPD non-pharmacological management and use of inhaled therapies

NICE COPD non-pharmacological management and use of inhaled therapies. Download a PDF of this algorithm

  • See above for a visual summary covering non-pharmacological management and use of inhaled therapies
  • For guidance on the management of multimorbidity, see the NICE guideline on multimorbidity(2018)

Smoking cessation

  • Document an up-to-date smoking history, including pack years smoked (number of cigarettes smoked per day, divided by 20, multiplied by the number of years smoked) for everyone with COPD.
  • At every opportunity, advise and encourage every person with COPD who is still smoking (regardless of their age) to stop, and offer them help to do so.
  • Unless contraindicated, offer nicotine replacement therapy, varenicline or bupropion as appropriate to people who want to stop smoking, combined with an appropriate support programme to optimise smoking quit rates for people with COPD. 
  • For more guidance on helping people to quit smoking, see the NICE guideline on stop smoking interventions and services
  • For more guidance on varenicline, see the NICE technology appraisal guidance on varenicline for smoking cessation

Inhaled therapy

Short-acting beta2 agonists (SABA) and short-acting muscarinic antagonists (SAMA)

  • Use short-acting bronchodilators, as necessary, as the initial empirical treatment to relieve breathlessness and exercise limitation

Inhaled corticosteroids (ICS)

  • Do not use oral corticosteroid reversibility tests to identify which people should be prescribed inhaled corticosteroids, because they do not predict response to inhaled corticosteroid therapy
  • Be aware of, and be prepared to discuss with the person, the risk of side effects (including pneumonia) in people who take inhaled corticosteroids for COPD[A](amended 2018)

Inhaled combination therapy

  • Inhaled combination therapy refers to combinations of long-acting muscarinic antagonists (LAMA), long-acting beta2 agonists (LABA) and inhaled corticosteroids (ICS)
  • Do not assess the effectiveness of bronchodilator therapy using lung function alone. Include a variety of other measures such as improvement in symptoms, activities of daily living, exercise capacity, and rapidity of symptom relief
  • Offer LAMA+LABA[B] to people who:
    • have spirometrically confirmed COPD and
    • do not have asthmatic features/features suggesting steroid responsiveness and
    • remain breathless or have exacerbations despite:
      • having used or been offered treatment for tobacco dependence if they smoke and
      • optimised non-pharmacological management and relevant vaccinations and
      • using a short-acting bronchodilator (2018)
  • Consider LABA+ICS for people who:
    • have spirometrically confirmed COPD and
    • have asthmatic features/features suggesting steroid responsiveness and
    • remain breathless or have exacerbations despite:
      • having used or been offered treatment for tobacco dependence if they smoke and
      • optimised non-pharmacological management and relevant vaccinations and
      • using a short-acting bronchodilator (2018)
  • For people using long-acting bronchodilators outside of the recommendations above, and before this guideline was published (December 2018), explain to them that they can continue with their current treatment until both they and their NHS healthcare professional agree it is appropriate to change (2018)
  • Offer LAMA+LABA+ICS[B] to people with COPD with asthmatic features/features suggesting steroid responsiveness who remain breathless or have exacerbations despite taking LABA+ICS (amended 2018)
  • Base the choice of drugs and inhalers on: 
    • how much they improve symptoms
    • the person’s preferences and ability to use the inhalers
    • the drugs’ potential to reduce exacerbations
    • their side-effects
    • their cost

      Minimise the number of inhalers and the number of different types of inhaler used by each person as far as possible (2018)
  • When prescribing long-acting drugs, ensure people receive inhalers they have been trained to use (for example, by specifying the brand and inhaler in prescriptions) (2018)

Delivery systems used to treat stable COPD

Most people with COPD—whatever their age—can develop adequate inhaler technique if they are given training. However, people with significant cognitive impairment may be unable to use any form of inhaler device. In most people with COPD, however, a pragmatic approach guided by individual patient assessment is needed when choosing a device.

Spacers

  • Provide a spacer that is compatible with the person’s metered-dose inhaler
  • Advise people to use a spacer with a metered-dose inhaler in the following way:
    • administer the drug by single actuations of the metered-dose inhaler into the spacer, inhaling after each actuation
    • there should be minimal delay between inhaler actuation and inhalation
    • normal tidal breathing can be used as it is as effective as single breaths
    • repeat if a second dose is required
  • Advise people on spacer cleaning. Tell them:
    • not to clean the spacer more than monthly, because more frequent cleaning affects their performance (because of a build‑up of static)
    • to hand wash using warm water and washing‑up liquid, and allow the spacer to air dry (amended 2018)

Nebulisers

  • Think about nebuliser therapy for people with distressing or disabling breathlessness despite maximal therapy using inhalers
  • Do not prescribe nebulised therapy without an assessment of the person’s and/or carer’s ability to use it
  • Do not continue nebulised therapy without assessing and confirming that 1 or more of the following occurs:
    • a reduction in symptoms
    • an increase in the ability to undertake activities of daily living
    • an increase in exercise capacity
    • an improvement in lung function
  • Use a nebuliser system that is known to be efficient[C]
  • Offer people a choice between a facemask and a mouthpiece to administer their nebulised therapy, unless the drug specifically requires a mouthpiece (for example, anticholinergic drugs)
  • If nebuliser therapy is prescribed, provide the person with equipment, servicing, and ongoing advice and support

Oral therapy

Oral corticosteroids

  • Long-term use of oral corticosteroid therapy in COPD is not normally recommended. Some people with advanced COPD may need long-term oral corticosteroids when these cannot be withdrawn following an exacerbation. In these cases, the dose of oral corticosteroids should be kept as low as possible
  • Monitor people who are having long-term oral corticosteroid therapy for osteoporosis, and give them appropriate prophylaxis. Start prophylaxis without monitoring for people over 65

Oral theophylline

In this section of the guideline, the term theophylline refers to slow-release formulations of the drug

  • Theophylline should only be used after a trial of short-acting bronchodilators and long-acting bronchodilators, or for people who are unable to use inhaled therapy, as plasma levels and interactions need to be monitored
  • Take particular caution when using theophylline in older people, because of differences in pharmacokinetics, the increased likelihood of comorbidities and the use of other medications
  • Assess the effectiveness of theophylline by improvements in symptoms, activities of daily living, exercise capacity and lung function
  • Reduce the dose of theophylline for people who are having an exacerbation if they are prescribed macrolide or fluoroquinolone antibiotics (or other drugs known to interact)

Oral mucolytic therapy

  • Consider mucolytic drug therapy for people with a chronic cough productive of sputum
  • Only continue mucolytic therapy if there is symptomatic improvement (for example, reduction in frequency of cough and sputum production)
  • Do not routinely use mucolytic drugs to prevent exacerbations in people with stable COPD

Oral anti-oxidant therapy

  • Treatment with alpha-tocopherol and beta-carotene supplements, alone or in combination, is not recommended

Oral anti-tussive therapy

  • Anti-tussive therapy should not be used in the management of stable COPD

Oral prophylactic antibiotic therapy (2018)

  • Before starting prophylactic antibiotic therapy in a person with COPD, think about whether respiratory specialist input is needed
  • Consider azithromycin (usually 250 mg 3 times a week) for people with COPD if they:
    • do not smoke and
    • have optimised non-pharmacological management and inhaled therapies, relevant vaccinations and (if appropriate) have been referred for pulmonary rehabilitation and
    • continue to have 1 or more of the following, particularly if they have significant daily sputum production:
      • frequent (typically 4 or more per year) exacerbations with sputum production 
      • prolonged exacerbations with sputum production
      • exacerbations resulting in hospitalisation[D] 
  • Before offering prophylactic antibiotics, ensure that the person has had: 
    • sputum culture and sensitivity (including tuberculosis culture), to identify other possible causes of persistent or recurrent infection that may need specific treatment (for example, antibiotic-resistant organisms, atypical mycobacteria or Pseudomonas aeruginosa)
    • training in airway clearance techniques to optimise sputum clearance)
    • a CT scan of the thorax to rule out bronchiectasis and other lung pathologies
  • Before starting azithromycin, ensure the person has had:
    • an electrocardiogram (ECG) to rule out prolonged QT interval and
    • baseline liver function tests
  • When prescribing azithromycin, advise people about the small risk of hearing loss and tinnitus, and tell them to contact a healthcare professional if this occurs
  • Review prophylactic azithromycin after the first 3 months, and then at least every 6 months
  • Only continue treatment if the continued benefits outweigh the risks. Be aware that there are no long-term studies on the use of prophylactic antibiotics in people with COPD
  • For people who are taking prophylactic azithromycin and are still at risk of exacerbations, provide a non-macrolide antibiotic to keep at home as part of their exacerbation action plan
  • Be aware that it is not necessary to stop prophylactic azithromycin during an acute exacerbation of COPD

Oral phosphodiesterase-4 inhibitors (2018)

Oxygen

Long-term oxygen therapy 

  • Be aware that inappropriate oxygen therapy in people with COPD may cause respiratory depression
  • Assess the need for oxygen therapy in people with:
    • very severe airflow obstruction (FEV1 below 30% predicted)
    • cyanosis (blue tint to skin)
    • polycythaemia
    • peripheral oedema (swelling)
    • a raised jugular venous pressure
    • oxygen saturations of 92% or less breathing air

      Also consider assessment for people with severe airflow obstruction (FEV1 30–49% predicted)
  • Assess people for long-term oxygen therapy by 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
  • Consider long-term oxygen therapy[E] for people with COPD who do not smoke and who:
    • have a partial pressure of oxygen in arterial blood (PaO2) below 7.3 kPa when stable or
    • have a PaO2 above 7.3 and below 8 kPa when stable, if they also have 1 or more of the following: 
      • secondary polycythaemia
      • peripheral oedema
      • pulmonary hypertension (2018)
  • Conduct and document a structured risk assessment for people being assessed for long-term oxygen therapy who meet the criteria above. As part of the risk assessment, cover the risks for both the person with COPD and the people who live with them, including:
    • the risks of falls from tripping over the equipment
    • the risks of burns and fires, and the increased risk of these for people who live in homes where someone smokes (including e‑cigarettes)

      Base the decision on whether long-term oxygen therapy is suitable on the results of the structured risk assessment (2018)
  • For people who smoke or live with people who smoke, but who meet the other criteria for long-term oxygen therapy, ensure the person who smokes is offered smoking cessation advice and treatment, and referral to specialist stop smoking services (see the NICE guidelines on stop smoking interventions and services and medicines optimisation) (2018)
  • Do not offer long-term oxygen therapy to people who continue to smoke despite being offered smoking cessation advice and treatment, and referral to specialist stop smoking services (2018)
  • Advise people who are having long-term oxygen therapy that they should breathe supplemental oxygen for a minimum of 15 hours per day (2018)
  • Do not offer long-term oxygen therapy to treat isolated nocturnal hypoxaemia caused by COPD (2018)
  • To ensure everyone eligible for long-term oxygen therapy is identified, pulse oximetry should be available in all healthcare settings
  • Oxygen concentrators should be used to provide the fixed supply at home for long-term oxygen therapy
  • People who are having long-term oxygen therapy should be reviewed at least once per year by healthcare professionals familiar with long-term oxygen therapy. This review should include pulse oximetry

Ambulatory oxygen therapy

  • Do not offer ambulatory oxygen to manage breathlessness in people with COPD who have mild or no hypoxaemia at rest (2018)
  • Consider ambulatory oxygen in people with COPD who have exercise desaturation and are shown to have an improvement in exercise capacity with oxygen, and have the motivation to use oxygen (amended 2018)
  • Prescribe ambulatory oxygen to people who are already on long-term oxygen therapy, who wish to continue oxygen therapy outside the home, and who are prepared to use it
  • Only prescribe ambulatory oxygen therapy after an appropriate assessment has been performed by a specialist. The purpose of the assessment is to assess the extent of desaturation, the improvement in exercise capacity with supplemental oxygen, and the oxygen flow rate needed to correct desaturation
  • Small light-weight cylinders, oxygen-conserving devices and portable liquid oxygen systems should be available for people with COPD
  • When choosing which equipment to prescribe, take account of the hours of ambulatory oxygen use and oxygen flow rate needed

Short-burst oxygen therapy

  • Do not offer short-burst oxygen therapy to manage breathlessness in people with COPD who have mild or no hypoxaemia at rest (2018)

Non-invasive ventilation

Refer people who are adequately treated but have chronic hypercapnic respiratory failure and have needed assisted ventilation (whether invasive or non-invasive) during an exacerbation, or who are hypercapnic or acidotic on long-term oxygen therapy, to a specialist centre for consideration of long-term non-invasive ventilation.

Managing pulmonary hypertension and cor pulmonale

In this guideline, ‘cor pulmonale’ is defined as a clinical condition that is identified and managed on the basis of clinical features. It includes people who have right heart failure secondary to lung disease and people whose primary pathology is salt and water retention, leading to the development of peripheral oedema (swelling).

Diagnosing pulmonary hypertension and cor pulmonale

  • Suspect a diagnosis of cor pulmonale for people with:
    • peripheral oedema (swelling)
    • a raised venous pressure
    • a systolic parasternal heave
    • a loud pulmonary second heart sound.
  • It is recommended that the diagnosis of cor pulmonale is made clinically and that this process should involve excluding other causes of peripheral oedema (swelling).

Treating pulmonary hypertension (2018)

  • Do not offer the following treatments solely to manage pulmonary hypertension caused by COPD, except as part of a randomised controlled trial:
    • bosentan
    • losartan
    • nifedipine
    • nitric oxide
    • pentoxifylline
    • phosphodiesterase-5 inhibitors 
    • statins

Treating cor pulmonale (2018)

  • Ensure that people with cor pulmonale caused by COPD are offered optimal COPD treatment, including advice and interventions to help them stop smoking. For people who need treatment for hypoxia, see the section on long-term oxygen therapy
  • Oedema associated with cor pulmonale can usually be controlled symptomatically with diuretic therapy
  • Do not use the following to treat cor pulmonale caused by COPD:
    • alpha-blockers
    • angiotensin-converting enzyme inhibitors
    • calcium channel blockers
    • digoxin (unless there is atrial fibrillation)

Pulmonary rehabilitation

Pulmonary rehabilitation is defined as a multidisciplinary programme of care for people with chronic respiratory impairment. It is individually tailored and designed to optimise each person’s physical and social performance and autonomy.

  • Make pulmonary rehabilitation available to all appropriate people with COPD, including people who have had a recent hospitalisation for an acute exacerbation.
  • Offer pulmonary rehabilitation to all people who view themselves as functionally disabled by COPD (usually Medical Research Council [MRC] 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.
  • For pulmonary rehabilitation programmes to be effective, and to improve adherence, they should be held at times that suit people, in buildings that are easy to get to and that have good access for people with disabilities. Places should be available within a reasonable time of referral.
  • Pulmonary rehabilitation programmes should include multicomponent, multidisciplinary interventions that are tailored to the individual person’s needs. The rehabilitation process should incorporate a programme of physical training, disease education, and nutritional, psychological and behavioural intervention.
  • Advise people of the benefits of pulmonary rehabilitation and the commitment needed to gain these.

Vaccination and anti-viral therapy

Lung surgery and lung volume reduction procedures

  • Offer a respiratory review to assess whether a lung volume reduction procedure is a possibility for people with COPD when they complete pulmonary rehabilitation and at other subsequent reviews, if all of the following apply:
    • they have severe COPD, with FEV1 less than 50% and breathlessness that affects their quality of life despite optimal medical treatment 
    • they do not smoke
    • they can complete a 6‑minute walk distance of at least 140 m (if limited by breathlessness) (2018)
  • At the respiratory review, refer the person with COPD to a lung volume reduction multidisciplinary team to assess whether lung volume reduction surgery or endobronchial valves are suitable if they have:
    • hyperinflation, assessed by lung function testing with body plethysmography and
    • emphysema on unenhanced CT chest scan and
    • optimised treatment for other comorbidities (2018)
  • Only offer endobronchial coils as part of a clinical trial and after assessment by a lung volume reduction multidisciplinary team (2018)
  • For more guidance on lung volume reduction procedures, see the NICE interventional procedures guidance on lung volume reduction surgery, endobronchial valves and endobronchial coils(2018)
  • Refer people with COPD for an assessment for bullectomy if they are breathless and a CT scan shows a bulla occupying at least one third of the hemithorax (2018)
  • Consider referral to a specialist multidisciplinary team to assess for lung transplantation for people who:
    • have severe COPD, with FEV1 less than 50% and breathlessness that affects their quality of life despite optimal medical treatment and
    • do not smoke and
    • have completed pulmonary rehabilitation and
    • do not have contraindications for transplantation (for example, comorbidities or frailty)(2018)
  • Do not use previous lung volume reduction procedures as a reason not to refer a person for assessment for lung transplantation (2018)

Alpha‑1 antitrypsin replacement therapy

Alpha‑1 antitrypsin replacement therapy is not recommended for people with alpha‑1 antitrypsin deficiency

Multidisciplinary management

  • COPD care should be delivered by a multidisciplinary team

Education

  • There are significant differences in the response of people with COPD and asthma to education programmes. Programmes designed for asthma should not be used in COPD
  • At diagnosis and at each review appointment, offer people with COPD and their family members or carers (as appropriate):
    • written information about their condition 
    • opportunities for discussion with a healthcare professional who has experience in caring for people with COPD (2018)
  • Ensure the information provided is:
    • available on an ongoing basis
    • relevant to the stage of the person’s condition
    • tailored to the person’s needs (2018)
  • At minimum, the information should cover:
    • an explanation of COPD and its symptoms
    • advice on quitting smoking (if relevant) and how this will help with the person’s COPD 
    • advice on avoiding passive smoke exposure 
    • managing breathlessness 
    • physical activity and pulmonary rehabilitation
    • medicines, including inhaler technique and the importance of adherence
    • vaccinations
    • identifying and managing exacerbations
    • details of local and national organisations and online resources that can provide more information and support
    • how COPD will affect other long-term conditions that are common in people with COPD (for example, hypertension, heart disease, anxiety, depression and musculoskeletal problems) (2018)
  • Advise people with COPD that the following factors increase their risk of exacerbations:
    • continued smoking or relapse for ex‑smokers
    • exposure to passive smoke
    • viral or bacterial infection
    • indoor and outdoor air pollution
    • lack of physical activity
    • seasonal variation (winter and spring) (2018)

Self-management (2018)

  • Develop an individualised self-management plan in collaboration with each person with COPD and their family members or carers (as appropriate), and:
    • include education on all relevant points from Education
    • review the plan at future appointments
  • Develop an individualised exacerbation action plan in collaboration with each person with COPD who is at risk of exacerbations
  • Offer people a short course of oral corticosteroids and a short course of oral 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 and are confident about when and how to take these medicines, and the associated benefits and harms
    • they know to tell their healthcare professional when they have used the medicines, and to ask for replacements
  • For guidance on the choice of antibiotics, see the NICE guideline on antimicrobial prescribing for acute exacerbations of COPD
  • At all review appointments, discuss corticosteroid and antibiotic use with people who keep these medicines at home, to check that they still understand how to use them. For people who have used 3 or more courses of oral corticosteroids and/or oral antibiotics in the last year, investigate the possible reasons for this
  • See full guideline for more guidance on oral corticosteroids
  • Encourage people with COPD to respond promptly to exacerbation symptoms by following their action plan, which may include:
    • adjusting their short-acting bronchodilator therapy to treat their symptoms
    • taking a short course of oral corticosteroids if their increased breathlessness interferes with activities of daily living 
    • adding oral antibiotics if their sputum changes colour and increases in volume or thickness beyond their normal day-to-day variation
    • telling their healthcare professional
  • Ask people with COPD if they experience breathlessness they find frightening. If they do, consider including a cognitive behavioural component in their self-management plan to help them manage anxiety and cope with breathlessness
  • For people at risk of hospitalisation, explain to them and their family members or carers (as appropriate) what to expect if this happens (including non-invasive ventilation and discussions on future treatment preferences, ceilings of care and resuscitation)

Telehealth monitoring (2018)

  • Do not offer routine telehealth monitoring of physiological status as part of management for stable COPD

Follow-up of people with COPD

Table 6: Summary of follow up of people with COPD in primary care
 Mild/moderate/severe (stages 1 to 3) Very severe (stage 4) 

Frequency 

At least annual

At least twice per year

Clinical assessment

Smoking status and motivation to quit

Adequacy of symptom control:

– breathlessness

– exercise tolerance

– estimated exacerbation frequency

Need for pulmonary rehabilitation 

Presence of complications

Effects of each drug treatment

Inhaler technique

Need for referral to specialist and therapy services

Smoking status and motivation to quit

Adequacy of symptom control:

– breathlessness

– exercise tolerance

– estimated exacerbation frequency

Presence of cor pulmonale

Need for long-term oxygen therapy

Person with COPD’s nutritional state

Presence of depression

Effects of each drug treatment

Inhaler technique

Need for social services and occupational therapy input

Need for referral to specialist and therapy services

Need for pulmonary rehabilitation

Measurements to make

FEV1 and FVC

Calculate BMI

MRC dyspnoea score

FEV1 and FVC

Calculate BMI

MRC dyspnoea score

SaO2

  • Follow-up of all people with COPD should include:
    • highlighting the diagnosis of COPD in the case record and recording this using Read Codes on a computer database
    • recording the values of spirometric tests performed at diagnosis (both absolute and percent predicted)
    • offering advice and treatment to help them stop smoking, and referral to specialist stop smoking services (see the NICE guideline on stop smoking interventions and services)
    • recording the opportunistic measurement of spirometric parameters (a loss of 500 ml or more over 5 years will show which people have rapidly progressing disease and may need specialist referral and investigation) (amended 2018)
  • Review people with COPD at least once per year and more frequently if indicated, and cover the issues listed in table 6
  • For most people with stable severe COPD, regular hospital review is not necessary, but there should be locally agreed mechanisms to allow rapid access to hospital assessment when needed
  • When people with very severe COPD are reviewed in primary care, they should be seen at least twice per year, and specific attention should be paid to the issues listed in table 5
  • Specialists should regularly review people with severe COPD who need interventions such as long-term non-invasive ventilation

Managing exacerbations of COPD

Definition of an exacerbation

A sustained acute-onset worsening of the person’s symptoms from their usual stable state, which goes beyond their normal day-to-day variations. Commonly reported symptoms are worsening breathlessness, cough, increased sputum production and change in sputum colour. The change in these symptoms often necessitates a change in medication 

Assessing the need for hospital treatment

Table 7: Factors to consider when deciding where to treat the person with COPD
Factor Treat at home Treat in hospital 

Able to cope at home

Yes

No

Breathlessness

Mild

Severe

General condition

Good

Poor/deteriorating

Level of activity

Good

Poor/confined to bed

Cyanosis

No

Yes

Worsening peripheral oedema

No

Yes

Level of consciousness

Normal

Impaired

Already receiving long-term oxygen therapy

No

Yes

Social circumstances

Good

Living alone/not coping

Acute confusion

No

Yes

Rapid rate of onset

No

Yes

Significant comorbidity (particularly cardiac disease and insulin-dependent diabetes)

No

Yes

SaO2 <90%

No

Yes

Changes on chest radiograph

No

Present

Arterial pH level

≥7.35

<7.35

Arterial PaO2

≥7 kPa

<7 kPa

  • Use the factors in table 7 (above) to assess whether people with COPD need hospital treatment

Investigating an exacerbation

The diagnosis of an exacerbation is made clinically and does not depend on the results of investigations. However, investigations may sometimes be useful in ensuring appropriate treatment is given. Different investigation strategies are needed for people in hospital (who will tend to have more severe exacerbations) and people in the community 

Primary care

  • For people who have their exacerbation managed in primary care:
    • sending sputum samples for culture is not recommended in routine practice
    • pulse oximetry is of value if there are clinical features of a severe exacerbation

Terms used in this guideline

Asthmatic features/features suggesting steroid responsiveness 

This includes any previous, secure diagnosis of asthma or of atopy, a higher blood eosinophil count, substantial variation in FEV1 over time (at least 400 ml) or substantial diurnal variation in peak expiratory flow (at least 20%) 

Mild or no hypoxaemia

People who are not taking long-term oxygen therapy and who have a mean PaO2 greater than 7.3 kPa

[A] The Medicines and Healthcare products Regulatory Agency (MHRA) has published advice on the risk of psychological and behavioural side-effects associated with inhaled corticosteroids (2010).

[B] The MHRA has published advice on the risk for people with certain cardiac conditions when taking tiotropium delivered via Respimat or HandiHaler (2015).

[C] The MHRA has published a safety alert around the use of non-CE marked nebulisers for COPD.

[D] At the time of publication (December 2018), azithromycin did not have a UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council’s Prescribing guidance: prescribing unlicensed medicines for further information.
[E] The MHRA has published an alert on the risk of death and severe harm from failure to obtain and continue flow from oxygen cylinders (2018)

© NICE 2018. Chronic obstructive pulmonary disease in over 16s: diagnosis and management Available from: www.nice.org.uk/guidance/NG115 All rights reserved. Subject to Notice of rights

NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication