Guideline Copd

Guideline Summary NGC-7907
Guideline Title
Chronic obstructive pulmonary disease. Management of chronic obstructive pulmonary disease in adults in primary
and secondary care.
Bibliographic Source(s)
National Clinical Guideline Centre for Acute and Chronic Conditions. Chronic obstructive pulmonary disease. Management
of chronic obstructive pulmonary disease in adults in primary and secondary care. London (UK): National Institute for
HealthandClinicalExcellence(NICE)2010Jun.61p.(Clinicalguidelineno.101).
Guideline Status
This is the current release of the guideline.
This guideline updates a previous version: National Collaborating Centre for Chronic Conditions. Chronic obstructive
pulmonary disease. National clinical guideline on management of chronic obstructive pulmonary disease in adults in
primary and secondary care. Thorax 2004 Feb;59 Suppl 1:1-232. [491 references]
Scope
Disease/Condition(s)
Chronic obstructive pulmonary disease (COPD) characterized by airflow obstruction, including chronic bronchitis and
emphysema
Guideline Category
Diagnosis
Evaluation
Management
Treatment
Clinical Specialty
Critical Care
Emergency Medicine
Family Practice
Geriatrics
Internal Medicine
Nursing
Physical Medicine and Rehabilitation
Pulmonary Medicine
Thoracic Surgery
Intended Users
Advanced Practice Nurses
Allied Health Personnel
Dietitians
Health Care Providers
Hospitals
Nurses
Occupational Therapists
Patients
Dietitians
Health Care Providers
Hospitals
Nurses
Occupational Therapists
Patients
Physical Therapists
Physician Assistants
Physicians
Public Health Departments
Respiratory Care Practitioners
Students
Guideline Objective(s)
Toofferbestpracticeadviceontheidentificationandcareofpatientswithchronicobstructivepulmonarydisease
(COPD)
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Todefinethesymptoms,signs,andinvestigationsrequiredtoestablishadiagnosisofCOPD
Todefinethefactorsthatarenecessarytoassessitsseverity,provideprognosticinformation,andguidebest
management
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Togiveguidanceonthepharmacologicalandnon-pharmacological treatment of patients with stable COPD, and on

the management of exacerbations
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Todiscusstheinterfacewithsurgeryandintensivetherapyunits(ITU)
Update Aim
The aim of the National Collaborating Centre for Acute and Chronic Conditions (NCC-ACC) is to provide a user-friendly,
clinical, evidence-based guideline for the National Health Service (NHS) in England and Wales that:
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OffersbestclinicaladviceforthemanagementandtreatmentofCOPDinadultsinprimaryandsecondarycare
Isbasedonbestpublishedclinicalandeconomicsevidence,alongsideexpertinterpretation
Takesintoaccountpatientchoiceandinformeddecision-making
DefinesthemajorcomponentsofNHScareprovisionforCOPD
Detailsareasofuncertaintyorcontroversyrequiringfurtherresearch
Providesachoiceofguidelineversionsfordifferentaudiences
Target Population
Adults who have a clinical working diagnosis of chronic obstructive pulmonary disease (COPD)
Interventions and Practices Considered
Diagnosis
1.Identificationofsignsandsymptomsandriskfactorsforchronicobstructivepulmonarydisease(COPD)
2.Spirometry(Note:reversibilitytestingnotroutinelyrecommended)
3.Furtherinvestigations,asneeded,includingchestradiograph,fullbloodcount,bodymassindex,alpha -1
antitrypsin measurement, serial domiciliary peak flow measurement, transfer factor for carbon monoxide (T LCO),
computed tomography (CT) scan of the thorax, electrocardiogram, echocardiogram, pulse oximetry, sputum culture
4.Identificationofearlydiseasetofacilitateinterventionstoslowdiseaseprogression
5.Assessmentofseverityofairflowobstruction
6.Referralforspecialistadvice
Management of Stable COPD
1.Smoking cessation (nicotine replacement therapy, varenicline, or bupropion combined with an appropriate support
programme)
2. Short-acting and long-acting bronchodilator therapy, including beta -agonists and/or muscarinic antagonists
2
3.Oraltheophylline
4.Inhaledandoralcorticosteroidtherapy
5.Combinationtherapy
6.Drugdeliverysystems,includinginhalers,spacers,andnebulisers
7.Mucolytictherapy
8.Nonpharmacologicalinterventions,includingpulmonaryrehabilitation,lifestyleadviceandeducationinselfmanagement techniques
9.Managementofanxietyanddepression
10.
Nutritionalfactors
11.
Oxygentherapy(long-term oxygen therapy [LTOT], ambulatory oxygen therapy, and short-burst oxygen therapy)
12.
Noninvasiveventilation
13.
Managementofpulmonaryhypertensionandcorpulmonale
7.Mucolytictherapy
8.Nonpharmacologicalinterventions,includingpulmonaryrehabilitation,lifestyleadviceandeducationinselfmanagement techniques
9.Managementofanxietyanddepression
10.
Nutritionalfactors
11.
Oxygentherapy(long-term oxygen therapy [LTOT], ambulatory oxygen therapy, and short-burst oxygen therapy)
12.
Noninvasiveventilation
13.
Managementofpulmonaryhypertensionandcorpulmonale
14.
Pneumococcalvaccination,influenzavaccination,andantiviraltherapy
15.
Surgeryreferral(bullectomy,lungvolumereduction,lungtransplant)
16.
Deliveryofcarebymultidisciplinaryteam
17.
Follow-up
18.
Palliativecare
19.
Assessmentforoccupationaltherapy
20.
Referralforassessmentbysocialservices
21.
Adviceontravelordiving
22.
Education
Note: The following interventions are not recommended:
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Angiotensin-converting enzyme inhibitors, calcium channel blockers, alpha-blockers, or digoxin in the treatment of cor pulmonale
Alpha-1 antitrypsin replacement therapy in the management of patients with alpha-1 antitrypsin deficiency
Treatmentwithalpha-tocopherol and beta-carotene supplements
AntitussivetherapyinthemanagementofstableCOPD
ProphylacticantibiotictherapyinthemanagementofstableCOPD
Management of COPD Exacerbations

1.Assessmentofneedforhospitaltreatment
2.Investigationsofexacerbation(e.g.,chestradiograph,arterialbloodgas,electrocardiogram,fullbloodcount,
theophylline level, sputum sample for microscopy and culture, blood cultures, pulse oximetry)
3.Considerationofhospital-at-home and assisted discharge schemes
4.Pharmacologicalmanagement,includinginhaledbronchodilators,deliverysystemsforinhaledtherapy,systemic
corticosteroids, antibiotics, theophylline, respiratory stimulants
5.Oxygentherapy
6.Noninvasiveventilation
7.Invasiveventilationandintensivecare
8.Respiratoryphysiotherapy
9.Monitoringrecoveryanddischargeplanning
Major Outcomes Considered
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Signsandsymptoms
Activitiesofdailyliving
Lungfunction,asmeasuredbyforcedexpiratoryvolumein1second(FEV 1), forced vital capacity (FVC), and peak

expiratory flow
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Arterialoxygensaturation
Exercisecapacity/tolerance
Qualityoflife
Hospitalisation
Numberordurationofexacerbations
Morbidity
Mortality
Costmeasures,includingcosteffectiveness
Qualityadjustedlifeyear
Methodology
Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence
Note from the National Guideline Clearinghouse (NGC): This guideline was developed by the National Clinical Guideline
Centre for Acute and Chronic Conditions (NCGC-ACC) on behalf of the National Institute for Health and Clinical Excellence
(NICE). See the "Availability of Companion Documents" field for the full version of this guidance.
Searching for the Evidence
Hand-searches of Published Literature (Primary Sources)

Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence
Searching for the Evidence
The Information Scientist developed a search strategy for each question. Key words for the search were identified by the
Guideline Development Group (GDG). A separate health economic search strategy was developed looking for economic
studies in chronic obstructive pulmonary disease (COPD). Papers that were published in peer-reviewed journals (including
e-publications ahead print where identified) were considered as evidence by the GDG. Conference paper abstracts and
non-English language papers were excluded from the searches. Where it was deemed appropriate and where there was
lack of evidence in the literature on an area of clinical importance, the GDG decided to initiate a 'call for evidence' asking
all registered stakeholders to submit any relevant unpublished evidence. Where this occurred this is detailed within the
guideline write-up.
Each clinical question dictated the appropriate study design that was prioritised in the search strategy but the strategy
was not limited solely to these study types. The research fellow or health economist identified relevant titles and
abstracts for each clinical question from the search results and full papers were obtained. Exclusion lists were generated
for each question together with the rationale for the exclusion. The exclusion lists were presented to the GDG. See
appendices I and J in the full version of the actual guideline for review protocols and literature search details.
Literature Search
Limited details of the searches with regard to databases and constraints applied can be found in Appendix A of the
original guideline document (full version). In general, no formal contact was made with authors of identified studies, but
occasionally it was necessary to contact authors for clarification of specific points. Additional contemporary articles were
identified by the Guideline Development Group on an ad hoc basis. Stakeholder evidence identified via a process
established by the National Institute for Clinical Excellence was incorporated where appropriate. Both were assessed for
inclusion by the same criteria as evidence provided by the electronic searches.
Searches were re-run at the end of the guideline development process, thus including evidence published up to the end of
May 2003. Studies recommended by stakeholders or Guideline Development Group members that were published after this
date were not considered for inclusion. This time-point should be the starting point for searching for new evidence for
future updates to this guideline.
Re-run Evidence
Literature searches were repeated for all of the evidence based questions at the end of the GDG development process
allowing any relevant papers published up until 20th August 2009 to be considered. Future guideline updates will consider
evidence published after this cut-off date. Further updates will take place in concordance with the specifications outlined
in the NICE guidelines manual.
Literature Search for Economic Evidence
Priority areas for new health economics modelling were agreed by the GDG after the formation of the clinical questions
and consideration of available health economic evidence. The Health Economist performed supplemental literature
searches to obtain additional data for modelling. Assumptions, data and structures of the models were explained to and
agreed by the GDG members during meetings, and they commented on subsequent revisions. See appendix M in the full
version of the guideline for details of the modelling undertaken for the guideline.
Number of Source Documents
Not stated
Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence
Hierarchy of Evidence
Ia: Evidence from systematic reviews or meta-analysis of randomized controlled trials
Ib: Evidence from at least one randomized controlled trial
IIa: Evidence from at least one controlled study without randomization
IIb: Evidence from at least one other type of quasi-experimental study
III: Evidence from non-experimental descriptive studies, such as comparative studies, correlation studies, and casecontrol studies
IV: Evidence from expert committee reports or opinions and/or clinical experience of respected authorities
DS: Evidence from diagnostic studies
NICE: Evidence from National Institute for Health and Clinical Excellence (NICE) guidelines or Health Technology
Appraisal program
HSC: Evidence from Health Service Circulars
Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence
Methods Used to Analyze the Evidence

Review of Published Meta-Analyses
Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence
Distilling and Synthesizing the Evidence
The evidence from each full paper was distilled into an evidence table and synthesized into an evidence profile and
evidence statements before being presented to the Guideline Development Group (GDG). The results of health economic
modelling undertaken for the guideline were also presented to the GDG. This evidence was then reviewed by the GDG and
used as a basis upon which to formulate recommendations. Evidence tables are available at
http://guidance.nice.org.uk/CG101/EvidenceTables/pdf/English .
Appraising the Evidence
The research fellow or health economist, as appropriate, critically appraised the full papers. In general, no formal contact
was made with authors. However there were ad hoc occasions when this was required in order to clarify specific details.
Critical appraisal checklists were compiled for each full paper.
For non-observational studies, where possible this included meta-analysis of data and synthesis of data into a GRADE
'evidence profile'. The evidence profile shows for each outcome an overall assessment of both the quality of the evidence
as a whole (low, moderate or high), as well as an estimate of the size of effect. For observational and qualitative
studies, a narrative summary (evidence statements) was written summarising the results.
For economic studies, an economic 'evidence profile' was constructed. The economic evidence profile shows, for each
economic study, an assessment of applicability (directly applicable, partially applicable or not applicable) and
methodological quality (minor limitations, potentially serious limitations, very serious limitations) with footnotes
indicating the reasons for the assessment. It also shows incremental costs, incremental outcomes (e.g., QALYs) and the
incremental cost-effectiveness ratio from the primary analysis, as well as information about the assessment of
uncertainty in the analysis. In this guideline results are presented for the comparison specified in the clinical question
irrespective of whether or not the comparison was 'appropriate' in the analysis being reviewed (that is where an
intervention is compared with the next most expensive non-dominated option a clinical strategy is said to 'dominate'
the alternatives when it is both more effective and less costly). Footnotes indicated if a comparison was 'inappropriate' in
the analysis.
A research fellow or health economist, as appropriate, undertook the critical appraisal and data extraction. The evidence
was considered carefully by the GDG for accuracy and completeness.
All procedures are fully compliant with the NICE methodology as detailed in the 'Guideline Development Methods
Information for National Collaborating Centres and Guideline Developers' Manual.
Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations
The National Clinical Guidelines Centre for Acute and Chronic Conditions (NCGC-ACC) was set up in 2009 and is housed
within the Royal College of Physicians (RCP). The NCGC-ACC undertakes commissions received from the National Institute
for Health and Clinical Excellence (NICE).
The technical team met approximately two weeks before each Guideline Development Group (GDG) meeting and
comprised the following members: GDG Chair, GDG Clinical Advisor, Information Scientist, Research Fellow, Health
Economist and Project Manager.
The GDG met monthly and comprised a multi-disciplinary team of health professionals and a person with chronic
obstructive pulmonary disease (COPD), who were supported by the technical team. The GDG membership details including
patient representation and professional groups are detailed in the GDG membership table at the front of this guideline.
Guideline Project Executive (PE) was involved in overseeing all phases of the guideline. It also reviewed the quality of the
guideline and compliance with the Department of Health (DH) remit and NICE scope. The PE comprised of: NCGC-ACC
Clinical Director; NCGC-ACC Operations Director; NICE Commissioning Manager; Technical Team.
At the end of the guideline development process, the GDG met to review and agree the guideline recommendations.
Involvement of people with COPD
The NCGC-ACC was keen to ensure the views and preferences of people with COPD and their carers informed all stages of
the guideline. This was achieved by:
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HavingapersonwithCOPDasapatientrepresentativeontheguidelinedevelopmentgroup(GDG)
ConsultingwiththePatientandPublicInvolvementProgramme(PPIP)housedwithinNICEduringthepredevelopment (scoping) and final validation stages of the guideline.

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Inclusionofpatientgroupsasregisteredstakeholdersfortheguideline.
SecuringpatientorganizationrepresentationfromtheBritishLungFoundationontheguidelinedevelopmentgroup.
Drafting Recommendations
Evidence tables are available at http://guidance.nice.org.uk/CG101/EvidenceTables/pdf/English .
Agreeing Recommendations
The GDG employed formal consensus techniques to:
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Ensurethattherecommendationsreflectedtheevidence-base
Approverecommendationsbasedonlesserevidenceorextrapolationsfromothersituations
Reachconsensusrecommendationswheretheevidencewasinadequate
Debateareasofdisagreementandfinalizerecommendations
Drafting Recommendations
Evidence tables are available at http://guidance.nice.org.uk/CG101/EvidenceTables/pdf/English .
Agreeing Recommendations
The GDG employed formal consensus techniques to:
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Ensurethattherecommendationsreflectedtheevidence-base
Approverecommendationsbasedonlesserevidenceorextrapolationsfromothersituations
Reachconsensusrecommendationswheretheevidencewasinadequate
Debateareasofdisagreementandfinalizerecommendations
The GDG also reached agreement on the following:

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Recommendationsaskeyprioritiesforimplementation
Futureresearchrecommendations
Algorithms
In prioritizing key priorities for implementation, the GDG took into account the following criteria:
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Highclinicalimpact
Highimpactonreducingvariationinpractice
MoreefficientuseofNationalHealthService(NHS)resources
Allowingthepatienttoreachcriticalpointsinthecarepathwaymorequickly
Writing the Guideline

The first draft version of the guideline was drawn up by the technical team in accordance with the decisions of the GDG,
incorporating contributions from individual GDG members in their expert areas and edited for consistency of style and
terminology. The guideline was then submitted for a formal public and stakeholder consultation prior to publication. The
registered stakeholders for this guideline are detailed on the NICE website www.nice.org.uk . Editorial responsibility for
the full guideline rests with the GDG.
Rating Scheme for the Strength of the Recommendations
Not applicable
Cost Analysis
Undertaking New Health Economic Analysis
Priority areas for new health economics modelling were agreed by the Guideline Development Group (GDG) after the
formation of the clinical questions and consideration of available health economic evidence. The Health Economist
performed supplemental literature searches to obtain additional data for modelling. Assumptions, data and structures of
the models were explained to and agreed by the GDG members during meetings, and they commented on subsequent
revisions. See appendix M in the full version of the original guideline for details of the modelling undertaken for the
guideline.
Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation
The guideline was validated through two consultations.
1.Thefirstdraftoftheguideline(thefullguideline,NationalInstituteforClinicalExcellence[NICE]guidelineand
Quick Reference Guide) were consulted with Stakeholders and comments were considered by the Guideline
Development Group (GDG).
2.Thefinalconsultationdraftofthefullguideline,theNICEguidelineandtheInformationforthePublicwere
submitted to stakeholders for final comments.
The final draft was submitted to the Guideline Review Panel for review prior to publication.
Recommendations
Major Recommendations
Unlike the original guideline, recommendations made in this partial update are no longer graded on the strength of
evidence, in keeping with the guidelines manual 2009.
Diagnosing Chronic Obstructive Pulmonary Disease (COPD)
The diagnosis of 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 supported by spirometry.
Symptoms
A diagnosis of COPD should be considered in patients over the age of 35 who have a risk factor (generally smoking) and
who present with one or more of the following symptoms:
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Exertionalbreathlessness
Chroniccough
Regularsputumproduction
Frequentwinter"bronchitis"
The diagnosis of 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 supported by spirometry.
Symptoms
A diagnosis of COPD should be considered in patients over the age of 35 who have a risk factor (generally smoking) and
who present with one or more of the following symptoms:
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Exertionalbreathlessness
Chroniccough
Regularsputumproduction
Frequentwinter"bronchitis"
Wheeze[2004]
Patients in whom a diagnosis of COPD is considered should also be asked about the presence of the following factors:
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Weightloss
Effortintolerance
Wakingatnight
Ankleswelling
Fatigue
Occupationalhazards
Chestpain
Hemoptysis
Note: These last two symptoms are uncommon in COPD and raise the possibility of an alternative diagnosis. [2004]
One of the primary symptoms of COPD is breathlessness. The Medical Research Council (MRC) dyspnea scale (see Table 1
below) should be used to grade the breathlessness according to the level of exertion required to elicit it. [2004]
Table 1. MRC Dyspnea Scale
Grade
Degree of Breathlessness Related to Activities
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
Stops for breath after walking about 100 meters or after a few minutes on level ground
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 2:257-66.
Spirometry
Spirometry should be performed:
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Atthetimeofdiagnosis
Toreconsiderthediagnosisifpatientsshowanexceptionallygoodresponsetotreatment.[2004]
Measure post-bronchodilator spirometry to confirm the diagnosis of COPD. [new 2010]

Consider alternative diagnoses or investigations in:
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OlderpeoplewithouttypicalsymptomsofCOPDwheretheFEV 1/FVC ratio is < 0.7
YoungerpeoplewithsymptomsofCOPDwheretheFEV 1/FVCratiois0.7.[new 2010]
All health professionals involved in the care of people with COPD should have access to spirometry and be competent in
the interpretation of the results. [2004]
Spirometry can be performed by any health-care worker who has undergone appropriate training and who keeps his or her
skills up to date. [2004]
Spirometry services should be supported by quality control processes. [2004]
It is recommended that European Respiratory Society (ERS) 1993 reference values are used but it is recognized that these
values may lead to under-diagnosis in older people and are not applicable in black and Asian populations. [2004]
Further Investigations
At the time of their initial diagnostic evaluation, in addition to spirometry all patients should have:
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Achestradiographtoexcludeotherpathologies
Afullbloodcounttoidentifyanaemiaorpolycythaemia
Bodymassindex(BMI)calculated[2004]
Additional investigations should be performed to aid management in some circumstances (see Table 2 below and in the
original guideline document [full version]). [2004]
Table 2. Additional Investigations
Investigation
Role
Serial domiciliary peak flow

measurements
To exclude asthma if diagnostic doubt remains
Alpha-1 antitrypsin
If early onset, minimal smoking history, or family history
Transfer factor for carbon monoxide

(T L CO)
To investigate symptoms that seem disproportionate to the spirometric impairment
Computed tomography (CT) scan of the

thorax

To investigate abnormalities seen on a chest radiograph
Serial domiciliary peak flow

measurements
To exclude asthma if diagnostic doubt remains
Alpha-1 antitrypsin
If early onset, minimal smoking history, or family history
Transfer factor for carbon monoxide

(T L CO)
Computed tomography (CT) scan of the

thorax

To investigate abnormalities seen on a chest radiograph
To assess suitability for surgery
Electrocardiography (ECG)
To assess cardiac status if features of cor pulmonale
Echocardiogram
To assess cardiac status if features of cor pulmonale
Pulse oximetry
To assess need for oxygen therapy; if cyanosis or cor pulmonale present, or if forced expiratory volume in 1
second (FEV 1 ) < 50% predicted
Sputum culture
To identify organisms if sputum is persistently present and purulent
Patients identified as having alpha-1 antitrypsin deficiency should be offered the opportunity to be referred to a specialist
centre to discuss the clinical management of this condition. [2004]
Reversibility Testing
In most patients, routine spirometric reversibility testing is not necessary as a part of the diagnostic process or to plan
initial therapy with bronchodilators or corticosteroids. It may be unhelpful or misleading because:
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RepeatedFEV 1 measurements can show small spontaneous fluctuations.
Theresultsofareversibilitytestperformedondifferentoccasionscanbeinconsistentandnotreproducible.
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Over-reliance on a single reversibility test may be misleading unless the change in FEV 1 is greater than 400 ml.
Thedefinitionofthemagnitudeofasignificantchangeispurelyarbitrary.
Responsetolong-term therapy is not predicted by acute reversibility testing.[2004]
COPD and asthma are frequently distinguishable on the basis of history (and examination) in untreated patients
presenting for the first time. Features from the history and examination should be used to differentiate COPD from
asthma whenever possible. (See Table 3 below and in the original guideline document [full version] [2004]).
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
Longitudinal observation of patients (whether using spirometry, peak flow, or symptoms) should also be used to help
differentiate COPD from asthma. [2004]
To help resolve cases where diagnostic doubt remains, or both COPD and asthma are present, the following findings
should be used to help identify asthma:
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Alarge(greaterthan400ml)responsetobronchodilators
Alarge(greaterthan400ml)responseto30mgoralprednisolonedailyfor2weeks
Serialpeakflowmeasurementsshowing20%orgreaterdiurnalorday-to-day variability
Clinically significant COPD is not present if the FEV 1 and FEV 1/forced vital capacity (FVC) ratio return to normal with drug
therapy. [2004]
If diagnostic uncertainty remains, referral for more detailed investigations, including imaging and measurement of T LCO,
should be considered. [2004]
If patients report a marked improvement in symptoms in response to inhaled therapy, the diagnosis of COPD should be
reconsidered.
Assessment of Severity and Prognostic Factors
COPD is heterogeneous, so no single measure can give an adequate assessment of the true severity of the disease in an
individual patient. Severity assessment is, nevertheless, important because it has implications for therapy and relates to
prognosis.
Be aware that disability in COPD can be poorly reflected in the FEV 1. A more comprehensive assessment of severity
includes the degree of airflow obstruction and disability, the frequency of exacerbations and the following known
prognostic factors:
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FEV 1
T LCO
Breathlessness(MRCscale)
Healthstatus
Exercisecapacity(forexample,6-minute walk test)
Bodymassindex(BMI)
Partialpressureofoxygeninarterialblood(PaO 2)
Corpulmonale
Calculate the BODE index (BMI, airflow obstruction, dyspnoea and exercise capacity) to assess prognosis where its
component information is currently available. [new 2010]
T LCO
Breathlessness(MRCscale)
Healthstatus
Exercisecapacity(forexample,6-minute walk test)
Bodymassindex(BMI)
Partialpressureofoxygeninarterialblood(PaO 2)
Corpulmonale
Calculate the BODE index (BMI, airflow obstruction, dyspnoea and exercise capacity) to assess prognosis where its
component information is currently available. [new 2010]
Assessment and Classification of Severity of Airflow Obstruction
The severity of airflow obstruction should be assessed according to the reduction in FEV 1 as shown in Table 4. [new
2010]
Table 4. Gradation of Severity of Airflow Obstruction
NICE clinical
American Thoracic Society
Global Initiative for Chronic
guideline 12
(ATS)/ERS 2004
Obstructive Lung Disease (GOLD) 2008
(2004)
NICE clinical guideline

101 (2010)
Postbronchodilator
FEV 1/FVC
FEV 1 %
Postbronchodilator
Postbronchodilator
Postbronchodilator
<0.7
80%
Mild
Stage 1Mild
Stage 1Mild*
<0.7
5079%
Mild
Moderate
Stage 2Moderate
Stage 2Moderate
<0.7
3049%
Moderate
Severe
Stage 3Severe
Stage 3Severe
<0.7
<30%
Severe
Very severe
Stage 4Very severe**
Stage 4Very severe**
Severity of Airflow Obstruction
Predicted
*Symptoms should be present to diagnose COPD in people with mild airflow obstruction (see recommendation Diagnosing COPD, Symptoms
above).
**Or FEV 1 <50% with respiratory failure.
Identification of Early Disease

Spirometry should be performed in patients who are over 35, current or ex-smokers, and have a chronic cough. [2004]
Spirometry should be considered in patients with chronic bronchitis. A significant proportion of these will go on to develop
airflow limitation. [2004]
Referral for Specialist Advice
It is recommended that referrals for specialist advice are made when clinically indicated. Referral may be appropriate at
all stages of the disease and not solely in the most severely disabled patients. (See Table 5 below and in the original
guideline document [full version]). [2004]
Table 5. Reasons for Referral Include
Reason
Purpose
There is diagnostic uncertainty
Confirm diagnosis and optimise therapy
Suspected severe COPD
The patient requests a second opinion
Onset of cor pulmonale
Assessment for oxygen therapy
Optimise therapy and measure blood gases
Assessment for long-term nebuliser therapy
Optimise therapy and exclude in appropriate prescriptions
Assessment for oral corticosteroid therapy
Justify need for long-term treatment or supervise withdrawal
Bullous lung disease
Identify candidates for surgery
A rapid decline in FEV 1
Encourage early intervention
Assessment for pulmonary rehabilitation
Identify candidates for pulmonary rehabilitation
Assessment for lung volume reduction surgery
Assessment for lung transplantation
Dysfunctional breathing
Confirm diagnosis, optimise pharmacotherapy and access other therapists
Onset of symptoms under 40 years or a family history of alpha-1 Identify alpha-1 antitrypsin deficiency, consider therapy and screen family
antitrypsin deficiency
Uncertain diagnosis
Make a diagnosis
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
Patients 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. [2004]
Managing Stable COPD
Smoking Cessation
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), should be documented for everyone with COPD. [2004]
All COPD patents still smoking, regardless of age, should be encouraged to stop, and offered help to do so, at every
opportunity. [2004]
Unless contraindicated, offer nicotine replacement therapy (NRT), varenicline or bupropion, as appropriate, to people who
are planning to stop smoking combined with an appropriate support programme to optimise smoking quit rates for people
with COPD (See also the NGC summary of the NICE guideline, Smoking cessation services in primary care, pharmacies,
local authorities and workplaces, particularly for manual working groups, pregnant women and hard to reach communities
(NICE public health guidance 10). [2010]
The following two recommendations are from the NGC summary of the NICE guideline, Varenicline for smoking cessation
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), should be documented for everyone with COPD. [2004]
All COPD patents still smoking, regardless of age, should be encouraged to stop, and offered help to do so, at every
opportunity. [2004]
Unless contraindicated, offer nicotine replacement therapy (NRT), varenicline or bupropion, as appropriate, to people who
are planning to stop smoking combined with an appropriate support programme to optimise smoking quit rates for people
with COPD (See also the NGC summary of the NICE guideline, Smoking cessation services in primary care, pharmacies,
local authorities and workplaces, particularly for manual working groups, pregnant women and hard to reach communities
(NICE public health guidance 10). [2010]
The following two recommendations are from the NGC summary of the NICE guideline, Varenicline for smoking cessation
(NICE technology appraisal guidance 123).
Varenicline is recommended within its licensed indications as an option for smokers who have expressed a desire to quit
smoking. [2007]
Varenicline should normally be prescribed only as part of a programme of behavioural support. [2007]
Inhaled Therapy
Short-acting Beta 2-Agonists (SABAs) and Short-acting Muscarinic Antagonists (SAMAs)
Short-acting bronchodilators, as necessary, should be the initial empirical treatment for the relief of breathlessness and
exercise limitation. [2004]
Inhaled Corticosteroids
Oral corticosteroid reversibility tests do not predict response to inhaled corticosteroid therapy and should not be used to
identify which patients should be prescribed inhaled corticosteroids. [2004]
Be aware of the potential risk of developing side effects (including non-fatal pneumonia) in people with COPD treated
with inhaled corticosteroids and be prepared to discuss with patients. [new 2010]
Inhaled Combination Therapy
This section provides recommendations on the sequence of inhaled therapies for people with stable COPD. These
recommendations are also given in diagram form in algorithm 2a (see appendix C in the full version of the original
guideline).
The effectiveness of bronchodilator therapy should not be assessed by lung function alone but should include a variety of
other measures such as improvement in symptoms, activities of daily living, exercise capacity, and rapidity of symptom
relief. [2004]
Offer once-daily long-acting muscarinic antagonist (LAMA) in preference to four-times-daily short-acting muscarinic
antagonist (SAMA) to people with stable COPD who remain breathless or have exacerbations despite using short-acting
bronchodilators as required, and in whom a decision has been made to commence regular maintenance bronchodilator
therapy with a muscarinic antagonist (The British national formulary states that a SAMA should be discontinued when a
LAMA is started). [new 2010]
In people with stable COPD who remain breathless or have exacerbations despite using short-acting bronchodilators as
required, offer the following as maintenance therapy:
IfFEV 150%predicted:eitherlong-acting beta 2-agonist (LABA) or LAMA
IfFEV 1 <50% predicted: either LABA with an inhaled corticosteroid (ICS) in a combination inhaler, or LAMA. [new
2010]
l
l
InpeoplewithstableCOPDandanFEV150%whoremainbreathlessorhaveexacerbationsdespitemaintenance
therapy with a LABA:
l
ConsiderLABA+ICSinacombinationinhaler
ConsiderLAMAinadditiontoLABAwhereICSisdeclinedornottolerated.[new 2010]
Offer LAMA in addition to LABA+ICS to people with COPD who remain breathless or have exacerbations despite taking
LABA+ICS, irrespective of their FEV 1. [new 2010]
Consider LABA+ICS in a combination inhaler in addition to LAMA for people with stable COPD who remain breathless or
have exacerbations despite maintenance therapy with LAMA irrespective of their FEV 1. [new 2010]
The choice of drug(s) should take into account the person's symptomatic response and preference, and the drug's
potential to reduce exacerbations, its side effects and cost. [2010]
Delivery Systems Used to Treat Patients with Stable COPD
Most patients whatever their age are able to acquire and maintain adequate inhaler technique given adequate
instruction. The exception to this is that those with significant cognitive impairment (as a guideline, those with a
Hodkinson Abbreviated Mental Test Score of 4 or less) are unable to use any form of inhaler device. In most patients,
however, a pragmatic approach guided by individual patient assessment is needed in choosing a device.
Inhalers
In most cases bronchodilator therapy is best administered using a hand-held inhaler device (including a spacer device if
appropriate). [2004]
If the patient is unable to use a particular device satisfactorily, it is not suitable for him or her, and an alternative should
be found. [2004]
Inhalers should be prescribed only after patients have received training in the use of the device and have demonstrated
satisfactory technique. [2004]
Patients should have their ability to use an inhaler device regularly assessed by a competent healthcare professional and,
if necessary, should be re-taught the correct technique. [2004]
Spacers
The spacer should be compatible with the patient's metered-dose inhaler. [2004]
It is recommended that spacers are used in the following way:
Thedrugisadministeredbyrepeatedsingleactuationsofthemetereddoseinhalerintothespacer,witheach
followed by inhalation.
l
Thereshouldbeminimaldelaybetweeninhaleractuationandinhalation.
Tidalbreathingcanbeusedasitisaseffectiveassinglebreaths.[2004]
Spacers should be cleaned no more than monthly, as more frequent cleaning affects their performance (because of a
Spacers
The spacer should be compatible with the patient's metered-dose inhaler. [2004]
It is recommended that spacers are used in the following way:
Thedrugisadministeredbyrepeatedsingleactuationsofthemetereddoseinhalerintothespacer,witheach
followed by inhalation.
l
Thereshouldbeminimaldelaybetweeninhaleractuationandinhalation.
Tidalbreathingcanbeusedasitisaseffectiveassinglebreaths.[2004]
Spacers should be cleaned no more than monthly, as more frequent cleaning affects their performance (because of a
build-up of static). They should be cleaned with water and washing-up liquid and allowed to air dry. The mouthpiece
should be wiped clean of detergent before use. [2004]
Nebulisers
Patients with distressing or disabling breathlessness despite maximal therapy using inhalers should be considered for
nebuliser therapy. [2004]
Nebulised therapy should not continue to be prescribed without assessing and confirming that one or more of the
following occurs:
l
Areductioninsymptoms
Anincreaseintheabilitytoundertakeactivitiesofdailyliving
Anincreaseinexercisecapacity
Animprovementinlungfunction.[2004]
Nebulised therapy should not be prescribed without an assessment of the patient's and/or carer's ability to use it.
[2004]
Anebulisersystemthatisknowntobeefficientshouldbeused.Onceavailable,ComitEuropendeNormalisation
(European Committee for Standardisation, CEN) data should be used to assess efficiency. [2004]
Patients should be offered a choice between a facemask and a mouthpiece to administer their nebulised therapy, unless
the drug specifically requires a mouthpiece (for example, anticholinergic drugs). [2004]
If nebuliser therapy is prescribed, the patient should be provided with equipment, servicing, advice, and support. [2004]
Oral Therapy
Oral Corticosteroids
Maintenance use of oral corticosteroid therapy in COPD is not normally recommended. Some patients with advanced COPD
may require maintenance 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. [2004]
Patients treated with long-term oral corticosteroid therapy should be monitored for the development of osteoporosis and
given appropriate prophylaxis. Patients over the age of 65 should be started on prophylactic treatment, without
monitoring. [2004]
Oral Theophylline
In this section of the guideline, the term theophylline is used to mean slow-release formulations of this drug.
Theophylline should only be used after a trial of short-acting bronchodilators and long-acting bronchodilators, or in
patients who are unable to use inhaled therapy, as there is a need to monitor plasma levels and interactions. [2004]
Particular caution needs to be taken with the use of theophylline in older people because of differences in
pharmacokinetics, the increased likelihood of comorbidities, and the use of other medications. [2004]
The effectiveness of the treatment with theophylline should be assessed by improvements in symptoms, activities of
daily living, exercise capacity, and lung function. [2004]
The dose of theophylline prescribed should be reduced at the time of an exacerbation if macrolide or fluoroquinolone
antibiotics (or other drugs known to interact) are prescribed. [2004]
Oral Mucolytic Therapy
Mucolytic drug therapy should be considered in patients with a chronic cough productive of sputum. [2004]
Mucolytic therapy should be continued if there is symptomatic improvement (for example, reduction in frequency of cough
and sputum production). [2004]
Do not routinely use mucolytic drugs to prevent exacerbations in people with stable COPD. [new 2010]
Oral Anti-oxidant Therapy
Treatment with alpha-tocopherol and beta-carotene supplements, alone or in combination, is not recommended. [2004]
Anti-tussive Therapy
Anti-tussive therapy should not be used in the management of stable COPD. [2004]
Oral Prophylactic Antibiotic Therapy
There is insufficient evidence to recommend prophylactic antibiotic therapy in the management of stable COPD. [2004]
Combined Oral and Inhaled Therapy
If patients remain symptomatic on monotherapy, their treatment should be intensified by combining therapies from
different drug classes. Effective combinations include:
l
Beta 2-agonist and theophylline
Anticholinergicandtheophylline.[2004]
Oxygen
Long-term Oxygen Therapy (LTOT)
Clinicians should be aware that inappropriate oxygen therapy in people with COPD may cause respiratory depression.
[2004]
LTOT is indicated in patients with COPD who have a PaO 2 less than 7.3 kPa when stable or a PaO 2 greater than 7.3 and
less than 8 kPa when stable and one of: secondary polycythaemia, nocturnal hypoxaemia (oxygen saturation of arterial
blood [SaO 2] less than 90% for more than 30% of time), peripheral oedema, or pulmonary hypertension. [2004]
Beta 2-agonist and theophylline
Anticholinergicandtheophylline.[2004]
Oxygen
Long-term Oxygen Therapy (LTOT)
Clinicians should be aware that inappropriate oxygen therapy in people with COPD may cause respiratory depression.
[2004]
LTOT is indicated in patients with COPD who have a PaO 2 less than 7.3 kPa when stable or a PaO 2 greater than 7.3 and
less than 8 kPa when stable and one of: secondary polycythaemia, nocturnal hypoxaemia (oxygen saturation of arterial
blood [SaO 2] less than 90% for more than 30% of time), peripheral oedema, or pulmonary hypertension. [2004]
To get the benefits of LTOT patients should breathe supplemental oxygen for at least 15 hours per day. Greater benefits
are seen in patients receiving oxygen for 20 hours per day. [2004]
The need for oxygen therapy should be assessed in:
l
Allpatientswithsevereairflowobstruction(FEV 1 less than 30% predicted)
Patientswithcyanosis
Patientswithpolycythaemia
Patientswithperipheraloedema
Patientswitharaisedjugularvenouspressure
Patientswithoxygensaturationslessthanorequalto92%breathingair
Assessment should also be considered in patients with severe airflow obstruction (FEV 1 30-49% predicted). [2004]
To ensure all patients eligible for LTOT are identified, pulse oximetry should be available in all health-care settings.
[2004]
The assessment of patients for LTOT should comprise the measurement of arterial blood gasses on two occasions at
least 3 weeks apart in patients who have a confident diagnosis of COPD, who are receiving optimum medical
management, and whose COPD is stable. [2004]
Patients receiving LTOT should be reviewed at least once per year by practitioners familiar with LTOT, and this review
should include pulse oximetry. [2004]
Oxygen concentrators should be used to provide the fixed supply at home for long-term oxygen therapy. [2004]
Patients should be warned about the risks of fire and explosion if they continue to smoke when prescribed oxygen.
[2004]
Ambulatory Oxygen Therapy
People who are already on LTOT who wish to continue with oxygen therapy outside the home, and who are prepared to
use it, should have ambulatory oxygen prescribed. [2004]
Ambulatory oxygen therapy should be considered in patients who have exercise desaturation, are shown to have an
improvement in exercise capacity and/or dyspnoea with oxygen, and have the motivation to use oxygen. [2004]
Ambulatory oxygen therapy is not recommended in COPD if PaO 2 is greater than 7.3 kPa and there is no exercise
desaturation. [2004]
Ambulatory oxygen therapy should only be prescribed 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 required to correct desaturation. [2004]
Small light-weight cylinders, oxygen-conserving devices, and portable liquid oxygen systems should be available for the
treatment of patients with COPD. [2004]
A choice about the nature of equipment prescribed should take account of the hours of ambulatory oxygen use required by
the patient and the oxygen flow rate required. [2004]
Short-burst Oxygen Therapy
Short-burst oxygen therapy should only be considered for episodes of severe breathlessness in patients with COPD not
relieved by other treatments. [2004]
Short-burst oxygen therapy should only continue to be prescribed if an improvement in breathlessness following therapy
has been documented. [2004]
When indicated, short-burst oxygen should be provided from cylinders. [2004]
Noninvasive Ventilation (NIV)
Adequately treated patients with chronic hypercapnic respiratory failure who have required assisted ventilation (whether
invasive or noninvasive) during an exacerbation or who are hypercapnic or acidotic on LTOT should be referred to a
specialist centre for consideration of long-term NIV. [2004]
Management of Pulmonary Hypertension and Cor Pulmonale
In the context of this guideline, the term 'cor pulmonale' has been adopted to define a clinical condition that is identified
and managed on the basis of clinical features. This clinical syndrome of cor pulmonale includes patients who have right
heart failure secondary to lung disease and those in whom the primary pathology is retention of salt and water, leading
to the development of peripheral oedema.
Diagnosis of Pulmonary Hypertension and Cor Pulmonale
A diagnosis of cor pulmonale should be considered if patients have:
l
Peripheraloedema
Araisedvenouspressure
Asystolicparasternalheave
Aloudpulmonarysecondheartsound[2004]
It is recommended that the diagnosis of cor pulmonale is made clinically and that this process should involve excluding
other causes of peripheral oedema. [2004]
Treatment of Cor Pulmonale
Patients presenting with cor pulmonale should be assessed for the need for long-term oxygen therapy. [2004]
Oedema associated with cor pulmonale can usually be controlled symptomatically with diuretic therapy. [2004]
Araisedvenouspressure
Asystolicparasternalheave
Aloudpulmonarysecondheartsound[2004]
It is recommended that the diagnosis of cor pulmonale is made clinically and that this process should involve excluding
other causes of peripheral oedema. [2004]
Treatment of Cor Pulmonale
Patients presenting with cor pulmonale should be assessed for the need for long-term oxygen therapy. [2004]
Oedema associated with cor pulmonale can usually be controlled symptomatically with diuretic therapy. [2004]
The following are not recommended for the treatment of cor pulmonale:
l
Angiotensin-converting enzyme inhibitors
Calciumchannelblockers
Alpha-blockers
Digoxin(unlessthereisatrialfibrillation)[2004]
Pulmonary Rehabilitation
Pulmonary rehabilitation is defined as a multidisciplinary programme of care for patients with chronic respiratory
impairment that is individually tailored and designed to optimise each patient's physical and social performance and
autonomy.
Pulmonary rehabilitation should be made available to all appropriate patients with COPD including those who have had a
recent hospitalisation for an acute exacerbation. [new 2010]
Pulmonary rehabilitation should be offered to all patients who consider themselves functionally disabled by COPD (usually
MRC grade 3 and above). Pulmonary rehabilitation is not suitable for patients who are unable to walk, who have unstable
angina, or who have had a recent myocardial infarction. [2004]
For pulmonary rehabilitation programmes to be effective, and to improve concordance, they should be held at times that
suit patients and in buildings that are easy for patients to get to and have good access for people with disabilities.
Places should be available within a reasonable time of referral. [2004]
Pulmonary rehabilitation programmes should include multicomponent, multidisciplinary interventions, which are tailored to
the individual patient's needs. The rehabilitation process should incorporate a programme of physical training, disease
education, and nutritional, psychological, and behavioural intervention. [2004]
Patients should be made aware of the benefits of pulmonary rehabilitation and the commitment required to gain these.
[2004]
Vaccination and Antiviral Therapy
Pneumococcal vaccination and an annual influenza vaccination should be offered to all patients with COPD as
recommended by the Chief Medical Officer (See also the NGC summaries of the NICE guidelines, Oseltamivir, amantadine
[review] and zanamivir for the prophylaxis of influenza [NICE technology appraisal guidance 158] and Amantadine,
oseltamivir and zanamivir for the treatment of influenza [NICE technology appraisal guidance 168]). [2004]
Lung Surgery
Patients who are breathless and have a single large bulla on a computed tomography (CT) scan and an FEV 1 less than
50% predicted should be referred for consideration of bullectomy. [2004]
Patients with severe COPD who remain breathless with marked restrictions of their activities of daily living, despite
maximal medical therapy (including rehabilitation), should be referred for consideration of lung volume reduction surgery
if they meet all of the following criteria:
l
FEV 1 more than 20% predicted
PaCO 2 less than 7.3 kPa
Upperlobepredominantemphysema
T LCO more than 20% predicted [2004]
Patients with severe COPD who remain breathless with marked restrictions of their activities of daily living despite
maximal medical therapy should be considered for referral for assessment for lung transplantation, bearing in mind
comorbidities and local surgical protocols. Considerations include:
l
Age
FEV 1
PaCO 2
HomogeneouslydistributedemphysemaonCTscan
Elevatedpulmonaryarterypressureswithprogressivedeterioration[2004]
Alpha-1 Antitrypsin Replacement Therapy

Alpha-1 antitrypsin replacement therapy is not recommended for patients with alpha-1 antitrypsin deficiency. [2004]
Multidisciplinary Management
Many of these activities may be undertaken in the clinic or in the practice as part of routine care by the practitioner
seeing the patient but in certain circumstances the patient may need to be referred to a specialist department, for
example, physiotherapy. Multidisciplinary working means breaking down historic demarcation of roles because many of the
activities in managing COPD can be undertaken by individuals from different professional backgrounds. Competencies are
more important than professional boundaries.
COPD care should be delivered by a multidisciplinary team. [2004]
The following functions should be considered when defining the activity of the multidisciplinary team:
Assessingpatients(includingperformingspirometryandassessingtheneedforoxygen,theneedforaidsfordaily
living, and the appropriateness of delivery systems for inhaled therapy)
l
Careandtreatmentofpatients(includingnoninvasiveventilation,pulmonaryrehabilitation,hospital-at-home/early
discharge schemes, providing palliative care, identifying and managing anxiety and depression, advising patients on
relaxation techniques, dietary issues, exercise, social security benefits, and travel)
l
Advisingpatientsonself-management strategies
more important than professional boundaries.

The following functions should be considered when defining the activity of the multidisciplinary team:
Assessingpatients(includingperformingspirometryandassessingtheneedforoxygen,theneedforaidsfordaily
living, and the appropriateness of delivery systems for inhaled therapy)
l
Careandtreatmentofpatients(includingnoninvasiveventilation,pulmonaryrehabilitation,hospital-at-home/early
discharge schemes, providing palliative care, identifying and managing anxiety and depression, advising patients on
relaxation techniques, dietary issues, exercise, social security benefits, and travel)
l
Advisingpatientsonself-management strategies
Identifying and monitoring patients at high risk of exacerbations and undertaking activities which aim to avoid
emergency admissions
l
Advisingpatientsonexercise
Educationofpatientsandotherhealthprofessionals[2004]
Respiratory Nurse Specialists

It is recommended that respiratory nurse specialists form part of the multidisciplinary COPD team. [2004]
Physiotherapy
If patients have excessive sputum, they should be taught:
l
TheuseofPositiveExpiratoryPressuremasks
Activecycleofbreathingtechniques[2004]
Identifying and Managing Anxiety and Depression

Health-care professionals should be alert to the presence of depression in patients with COPD. The presence of anxiety
and depression should be considered in patients:
l
Whoarehypoxic
Whohaveseveredyspnoea
WhohavebeenseenatoradmittedtoahospitalwithanexacerbationofCOPD
Refer to the NGC summary of the NICE guideline, Depression in adults with a chronic physical health problem (NICE
clinical guideline 91), which updates the recommendations on the treatment of depression in patients with COPD.
Nutritional Factors
BMI should be calculated in patients with COPD:
l
ThenormalrangeforBMIis20tolessthan25.
IftheBMIisabnormal(highorlow)orchangingovertime,thepatientshouldbereferredfordieteticadvice.
IftheBMIislow,patientsshouldalsobegivennutritionalsupplementstoincreasetheirtotalcalorificintake,and
be encouraged to take exercise to augment the effects of nutritional supplementation.
l
Refer to Nutrition support in adults
(NICE clinical guideline 32). [2004]
In older patients, attention should also be paid to changes in weight, particularly if the change is more than 3 kg. [2004]
Palliative Care
Opioids should be used when appropriate to palliate breathlessness in patients with end-stage COPD which is
unresponsive to other medical therapy. [2004]
Benzodiazepines, tricyclic antidepressants, major tranquillisers, and oxygen should also be used when appropriate for
breathlessness in patients with end-stage COPD unresponsive to other medical therapy. [2004]
Patients with end-stage COPD and their family and carers should have access to the full range of services offered by
multidisciplinary palliative care teams, including admission to hospices. [2004]
Assessment for Occupational Therapy
Patients should be regularly asked about their ability to undertake activities of daily living and how breathless they
become when doing these. [2004]
Clinicians involved in the care of patients with COPD should assess their need for occupational therapy using validated
tools. [2004]
Social Services
Patients disabled by COPD should be considered for referral for assessment by a social services department. [2004]
Advice on Travel
All patients on LTOT planning air travel should be assessed in line with the British Thoracic Society (BTS)
recommendations (Managing passengers with respiratory disease planning air travel: British Thoracic Society
recommendations [2002] Thorax 57(4):289-304). [2004]
All patients with an FEV 1 less than 50% predicted who are planning air travel should be assessed in line with the BTS
recommendations. [2004]
All patients known to have bullous disease should be warned that they are at a theoretically increased risk of developing
a pneumothorax during air travel. [2004]
Advice on Diving
Scuba diving is not recommended for patients with COPD. Advise people with queries to seek specialist advice. [2004]
Education
There are significant differences in the response of patients with COPD and asthma to education programmes.
Programmes designed for asthma should not be used in COPD. [2004]
Specific educational packages should be developed for patients with COPD.
SuggestedtopicsforinclusionarelistedinAppendixCoftheoriginalguidelinedocument(seesection5fordetails
in the full version of the guideline).
l
Thepackagesshouldtakeaccountofthedifferentneedsofpatientsatdifferentstagesoftheirdisease.[2004]
Patients with moderate and severe COPD should be made aware of the technique of NIV. Its benefits and limitations
Scuba diving is not recommended for patients with COPD. Advise people with queries to seek specialist advice. [2004]
Education
There are significant differences in the response of patients with COPD and asthma to education programmes.
Programmes designed for asthma should not be used in COPD. [2004]
Specific educational packages should be developed for patients with COPD.
SuggestedtopicsforinclusionarelistedinAppendixCoftheoriginalguidelinedocument(seesection5fordetails
in the full version of the guideline).
l
Thepackagesshouldtakeaccountofthedifferentneedsofpatientsatdifferentstagesoftheirdisease.[2004]
Patients with moderate and severe COPD should be made aware of the technique of NIV. Its benefits and limitations
should be explained so that, if it is ever necessary in the future, they will be aware of these issues. [2004]
Self-management
Patients at risk of having an exacerbation of COPD should be given self-management advice that encourages them to
respond promptly to the symptoms of an exacerbation. [2004]
Patients should be encouraged to respond promptly to the symptoms of an exacerbation by:
Startingoralcorticosteroidtherapyiftheirincreasedbreathlessnessinterfereswithactivitiesofdailyliving(unless
contraindicated)
l
Startingantibiotictherapyiftheirsputumispurulent
Adjustingtheirbronchodilatortherapytocontroltheirsymptoms[2004]
Patients at risk of having an exacerbation of COPD should be given a course of antibiotic and corticosteroid tablets to
keep at home for use as part of a self-management strategy. [2004]
The appropriate use of these tablets should be monitored. [2004]
Patients given self-management plans should be advised to contact a health-care professional if they do not improve.
[2004]
Fitness for General Surgery
The ultimate clinical decision about whether or not to proceed with surgery should rest with a consultant anaesthetist and
consultant surgeon taking account of the presence of comorbidities, the functional status of the patient, and the
necessity of the surgery. [2004]
It is recommended that lung function should not be the only criterion used to assess patients with COPD before surgery.
Composite assessment tools such as the American Society of Anesthesiologists (ASA) scoring system are the best
predictors of risk. [2004]
If time permits, the medical management of the patient should be optimised prior to surgery, and this might include
undertaking a course of pulmonary rehabilitation. [2004]
Follow-up of Patients with COPD
Follow-up of all patients with COPD should include:
l
HighlightingthediagnosisofCOPDinthecaserecordandrecordingthisusingReadcodesonacomputerdatabase
Recordingthevaluesofspirometrictestsperformedatdiagnosis(bothabsoluteandpercentpredicted)
Offeringsmokingcessationadvice
Recordingtheopportunisticmeasurementofspirometricparameters(alossof500mlormoreover5yearswill
select out those patients with rapidly progressing disease who may need specialist referral and investigation) [2004]
l
Patients with COPD should be reviewed at least once per year, or more frequently if indicated, and the review should
cover the issues listed below in Table 6.
Table 6: Summary of Follow-up of Patients with COPD in Primary Care
Mild/Moderate/Severe (Stages 1 to 3)
Very Severe (Stage 4)
At Least Annual
At Least Twice per Year
Frequency
Clinical Assessments
Measurements to Make
Smokingstatus&desiretoquit
Smokingstatus&desiretoquit
Adequacyofsymptomcontrol
Adequacyofsymptomcontrol
Breathlessness
Breathlessness
Exercisetolerance
Exercisetolerance
Estimatedexacerbationfrequency
Estimatedexacerbationfrequency
Presenceofcomplications
Presenceofcorpulmonale
Effectsofeachdrugtreatment
Needforlong-term oxygen therapy
Inhalertechnique
Patient'snutritionalstate
Needforreferraltospecialistandtherapyservices
Presenceofdepression
Needforpulmonaryrehabilitation
Effectsofeachdrugtreatment
Inhalertechnique
NeedforSocialServices&OccupationalTherapyinput
Needforreferraltospecialistandtherapyservices
Needforpulmonaryrehabilitation
FEV 1 & FVC
FEV 1 & FVC
CalculateBMI
CalculateBMI
MRCdyspnoeascore
MRCdyspnoeascore
SaO 2
For most patients with stable severe disease, regular hospital review is not necessary, but there should be locally agreed
mechanisms to allow rapid access to hospital assessment when necessary. [2004]
When patients with severe COPD are reviewed in primary care, they should be seen at least twice a year, and specific
Measurements to Make
FEV 1 & FVC
FEV 1 & FVC
CalculateBMI
CalculateBMI
MRCdyspnoeascore
MRCdyspnoeascore
SaO 2
For most patients with stable severe disease, regular hospital review is not necessary, but there should be locally agreed
mechanisms to allow rapid access to hospital assessment when necessary. [2004]
When patients with severe COPD are reviewed in primary care, they should be seen at least twice a year, and specific
attention should be paid to the issues listed above in Table 6. [2004]
Patients with severe disease requiring interventions such as long-term noninvasive ventilation should be reviewed
regularly by specialists. [2004]
Management of Exacerbations of COPD
The exacerbation section of this guideline was outside the scope of the 2010 update. However, the GDG was aware that
some recommendations in the 'Oxygen therapy during exacerbations of COPD' section (section 1.3.6 in the original
guideline) of the guideline were out of date, and these have been removed. Readers should refer to local protocols.
Deleted recommendations can be found in appendix K of the full guideline.
Definition of an Exacerbation
An exacerbation is a sustained worsening of the patient's symptoms from their usual stable state which is beyond normal
day-to-day variations, and is acute in onset. 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.
Assessment of Need for Hospital Treatment
Factors that should be used to assess the need to treat patients in hospital are listed in Table 7 of the original guideline
document. [2004]
Table 7. Factors to Consider When Deciding Where to Treat the Patient
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 LTOT
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
SaO 2 <90%
No
Yes
Changes on chest radiograph
No
Present
Arterial pH level
7.35
<7.35
Arterial PaO 2
7kPa
<7 kPa
Investigation of an Exacerbation
The diagnosis of an exacerbation is made clinically and does not depend on the results of investigations; however, in
certain situations, investigations may assist in ensuring appropriate treatment is given. Different investigation strategies
are required for patients managed in hospital (who will tend to have more severe exacerbations) and those managed in
the community.
Primary Care
In patients with an exacerbation managed in primary care:
l
Sendingsputumsamplesforcultureisnotrecommendedinroutinepractice
Pulseoximetryisofvalueifthereareclinicalfeaturesofasevereexacerbation.[2004]
Patients Referred to a Hospital

In all patients with an exacerbation referred to hospital:
l
Achestradiographshouldbeobtained
Arterialbloodgastensionsshouldbemeasuredandtheinspiredoxygenconcentrationrecorded
Anelectrocardiogram(ECG)shouldberecorded(toexcludecomorbidities)
Afullbloodcountshouldbeperformed,andureaandelectrolyteconcentrationsshouldbemeasured
Atheophyllinelevelshouldbemeasuredinpatientsontheophyllinetherapyatadmission
Ifsputumispurulent,asampleshouldbesentformicroscopyandculture
Bloodculturesshouldbetakenifthepatientispyrexial[2004]
Hospital-at-home and Assisted Discharge Schemes

Hospital-at-home and assisted discharge schemes are safe and effective and should be used as an alternative way of
managing patients with exacerbations of COPD who would otherwise need to be admitted or stay in hospital. [2004]
The multi-professional team required to operate these schemes should include allied health professionals with experience
in managing patients with COPD, and may include nurses, physiotherapists, occupational therapists, and generic health
workers. [2004]
There are currently insufficient data to make firm recommendations about which patients with an exacerbation are most
suitable for hospital-at-home or early discharge. Patient selection should depend on the resources available and absence
of factors associated with a worse prognosis (e.g., acidosis). [2004]
Bloodculturesshouldbetakenifthepatientispyrexial[2004]
Hospital-at-home and Assisted Discharge Schemes

Hospital-at-home and assisted discharge schemes are safe and effective and should be used as an alternative way of
managing patients with exacerbations of COPD who would otherwise need to be admitted or stay in hospital. [2004]
The multi-professional team required to operate these schemes should include allied health professionals with experience
in managing patients with COPD, and may include nurses, physiotherapists, occupational therapists, and generic health
workers. [2004]
There are currently insufficient data to make firm recommendations about which patients with an exacerbation are most
suitable for hospital-at-home or early discharge. Patient selection should depend on the resources available and absence
of factors associated with a worse prognosis (e.g., acidosis). [2004]
Patient's preferences about treatment at home or in hospital should be considered. [2004]
Pharmacological Management
Increased breathlessness is a common feature of an exacerbation of COPD. This is usually managed by taking increased
doses of short-acting bronchodilators.
Delivery Systems for Inhaled Therapy During Exacerbations
Both nebulisers and hand-held inhalers can be used to administer inhaled therapy during exacerbations of COPD. [2004]
The choice of delivery system should reflect the dose of drug required, the ability of the patient to use the device, and
the resources available to supervise the administration of the therapy. [2004]
Patients should be changed to hand-held inhalers as soon as their condition has stabilised because this may permit
earlier discharge from hospital. [2004]
If a patient is hypercapnic or acidotic the nebuliser should be driven by compressed air, not oxygen (to avoid worsening
hypercapnia). If oxygen therapy is needed, it should be administered simultaneously by nasal cannulae. [2004]
The driving gas for nebulised therapy should always be specified in the prescription. [2004]
Systemic Corticosteroids
In the absence of significant contraindications, oral corticosteroids should be used, in conjunction with other therapies, in
all patients admitted to hospital with an exacerbation of COPD. [2004]
In the absence of significant contraindications, oral corticosteroids should be considered in patients managed in the
community who have an exacerbation with a significant increase in breathlessness which interferes with daily activities.
[2004]
Patients requiring corticosteroid therapy should be encouraged to present early to get maximum benefits (see
Recommendations 122-126 in the original guideline document [full version]). [2004]
Prednisolone 30 mg orally should be prescribed for 7 to 14 days. [2004]
It is recommended that a course of corticosteroid treatment should not be longer than 14 days as there is no advantage
in prolonged therapy. [2004]
For guidance on stopping oral corticosteroid therapy it is recommended that clinicians refer to the British National
Formulary section 6.3.2. [2004]
Osteoporosis prophylaxis should be considered in patients requiring frequent courses of oral corticosteroids. [2004]
Patients should be made aware of the optimum duration of treatment and the adverse effects of prolonged therapy.
[2004]
Patients, particularly those discharged from hospital, should be given clear instructions about why, when, and how to stop
their corticosteroid treatment. [2004]
Antibiotics
Antibiotics should be used to treat exacerbations of COPD associated with a history of more purulent sputum. [2004]
Patients with exacerbations without more purulent sputum do not need antibiotic therapy unless there is consolidation on
a chest radiograph or clinical signs of pneumonia. [2004]
Initial empirical treatment should be an aminopenicillin, a macrolide, or a tetracycline. When initiating empirical antibiotic
treatment, prescribers should always take account of any guidance issued by their local microbiologists. [2004]
When sputum has been sent for culture, the appropriateness of antibiotic treatment should be checked against laboratory
culture and sensitivities when they become available. [2004]
Theophylline and Other Methylxanthines
Intravenous theophylline should only be used as an adjunct to the management of exacerbations of COPD if there is an
inadequate response to nebulised bronchodilators. [2004]
Care should be taken when using intravenous theophylline because of interactions with other drugs and potential toxicity
if the patient has been on oral theophylline. [2004]
Theophylline levels should be monitored within 24 hours of starting treatment and subsequently as frequently as
indicated by the clinical circumstances. [2004]
Respiratory Stimulants
It is recommended that doxapram is used only when noninvasive ventilation is either unavailable or considered
inappropriate. [2004]
Oxygen Therapy during Exacerbations of COPD
The exacerbation section of this guideline was outside the scope of the 2010 update. However the GDG was aware that
some recommendations in this section of the guideline were out of date, and these have been removed. Readers should
refer to local protocols. Deleted recommendations can be found in appendix K of the full guideline.
The oxygen saturation should be measured in patients with an exacerbation of COPD, if there are no facilities to measure
arterial blood gases. [2004]
If necessary, oxygen should be given to keep the SaO 2 within the individualized target range. [2004, amended 2010]
Pulse oximeters should be available to all health-care professionals managing patients with exacerbations of COPD, and
they should be trained in their use. Clinicians should be aware that pulse oximetry gives no information about the PCO 2
or pH. [2004]
When the patient arrives at hospital, arterial blood gases should be measured and the inspired oxygen concentration
noted in all patients with an exacerbation of COPD. Arterial blood gas measurements should be repeated regularly,
The exacerbation section of this guideline was outside the scope of the 2010 update. However the GDG was aware that
some recommendations in this section of the guideline were out of date, and these have been removed. Readers should
refer to local protocols. Deleted recommendations can be found in appendix K of the full guideline.
The oxygen saturation should be measured in patients with an exacerbation of COPD, if there are no facilities to measure
arterial blood gases. [2004]
If necessary, oxygen should be given to keep the SaO 2 within the individualized target range. [2004, amended 2010]
Pulse oximeters should be available to all health-care professionals managing patients with exacerbations of COPD, and
they should be trained in their use. Clinicians should be aware that pulse oximetry gives no information about the PCO 2
or pH. [2004]
When the patient arrives at hospital, arterial blood gases should be measured and the inspired oxygen concentration
noted in all patients with an exacerbation of COPD. Arterial blood gas measurements should be repeated regularly,
according to the response to treatment. [2004]
Noninvasive Ventilation (NIV) and COPD Exacerbations
NIV should be used as the treatment of choice for persistent hypercapnic ventilatory failure during exacerbations despite
optimal medical therapy. [2004]
It is recommended that NIV should be delivered in a dedicated setting with staff who have been trained in its application,
who are experienced in its use, and who are aware of its limitations. [2004]
When patients are started on NIV, there should be a clear plan covering what to do in the event of deterioration and
ceilings of therapy should be agreed. [2004]
Invasive Ventilation and Intensive Care
Patients with exacerbations of COPD should receive treatment on intensive care units, including invasive ventilation when
this is thought to be necessary. [2004]
During exacerbations of COPD, functional status, BMI, requirement for oxygen when stable, comorbidities, and previous
admissions to intensive care units should be considered, in addition to age and FEV 1, when assessing suitability for
intubation and ventilation. Neither age nor FEV 1 should be used in isolation when assessing suitability. [2004]
NIV should be considered for patients who are slow to wean from invasive ventilation. [2004]
Respiratory Physiotherapy and Exacerbations
Physiotherapy using positive expiratory pressure masks should be considered for selected patients with exacerbations of
COPD, to help with clearing sputum. [2004]
Monitoring Recovery from an Exacerbation
Patients' recovery should be monitored by regular clinical assessment of their symptoms and observation of their
functional capacity. [2004]
Pulse oximetry should be used to monitor the recovery of patients with nonhypercapnic, nonacidotic respiratory failure.
[2004]
Intermittent arterial blood gas measurements should be used to monitor the recovery of patients with respiratory failure
who are hypercapnic or acidotic, until they are stable. [2004]
Daily monitoring of peak expiratory flow (PEF) or FEV 1 should not be performed routinely to monitor recovery from an
exacerbation because the magnitude of changes is small compared with the variability of the measurement. [2004]
Discharge Planning
Spirometry should be measured in all patients before discharge. [2004]
Patients should be reestablished on their optimal maintenance bronchodilator therapy before discharge. [2004]
Patients who have had an episode of respiratory failure should have satisfactory oximetry or arterial blood gas results
before discharge. [2004]
All aspects of the routine care that patients receive (including appropriateness and risk of side effects) should be
assessed before discharge. [2004]
Patients (or home carers) should be given appropriate information to enable them to fully understand the correct use of
medications, including oxygen, before discharge. [2004]
Arrangements for follow-up and home care (e.g., visiting nurse, oxygen delivery, referral for other support) should be
made before discharge. [2004]
Before the patient is discharged, the patient, family and physician should be confident that he or she can manage
successfully. When there is remaining doubt a formal activities of daily living assessment may be helpful. [2004]
Clinical Algorithm(s)
The following clinical algorithms are provided in the appendices of the original guideline document:
l
DiagnosingCOPD
ManagementofstableCOPD
Useofinhaledtherapies
ManagementofexacerbationsofCOPD
Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations
The type of supporting evidence is not specifically stated for each recommendation.
Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits
If adopted, these guideline recommendations should lead to better standards of care and thus better outcomes from
chronic obstructive pulmonary disease.
Type of Evidence Supporting the Recommendations

The type of supporting evidence is not specifically stated for each recommendation.
Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits
If adopted, these guideline recommendations should lead to better standards of care and thus better outcomes from
chronic obstructive pulmonary disease.
Potential Harms
Adverse effects of therapies
Qualifying Statements
Qualifying Statements
ThisguidancerepresentstheviewofNationalInstituteforHealthandClinicalExcellence(NICE),whichwasarrived
at after careful consideration of the evidence available. Healthcare professionals are expected to take it fully into
account when exercising their clinical judgment. However, the guidance does not override the individual responsibility of
healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation
with the patient and/or guardian or carer, and informed by the summary of product characteristics of any drugs they are
considering.
l
Whileeveryefforthasbeenmadetoensuretheaccuracyoftheinformationcontainedwithinthispublication,the
publisher can give no guarantee for information about drug dosage and application thereof contained in this book. In
every individual case the respective user must check current indications and accuracy by consulting other pharmaceutical
literature and following the guidelines laid down by the manufacturers of specific products and the relevant authorities
in the country in which they are practising.
l
Healthcareprovidersneedtouseclinicaljudgement,knowledgeandexpertisewhendecidingwhetheritis
appropriate to apply guidelines. The recommendations cited here are a guide and may not be appropriate for use in all
situations. The decision to adopt any of the recommendations cited here must be made by the practitioner in light of
individual patient circumstances, the wishes of the patient, clinical expertise and resources.
l
Implementation of the Guideline

Description of Implementation Strategy
National Institute for Clinical Excellence (NICE) has developed tools to help organisations implement this guidance (see
http://guidance.nice.org.uk/CG101 ).
Key Priorities for Implementation
The following recommendations have been identified as priorities for implementation. (Note that the order of the key
priorities given here is arbitrary and does not reflect their relative importance. The reader should refer to the original
recommendations for further detail.)
Diagnose COPD
Adiagnosisofchronicobstructivepulmonarydisease(COPD)shouldbeconsideredinpatientsovertheageof35
who have a risk factor (generally smoking) and who present with exertional breathlessness, chronic cough, regular
sputum production, frequent winter "bronchitis" or wheeze. [2004]
l
Thepresenceofairflowobstructionshouldbeconfirmedbyperformingpost-bronchodilator* spirometry. All health

professionalsinvolvedinthecareofpeoplewithCOPDshouldhaveaccesstospirometryandbecompetentinthe
interpretation of the results. [2004] [*added 2010]
l
Stop Smoking
Encouraging patients with COPD to stop smoking is one of the most important components of their management. All
COPD patients still smoking, regardless of age, should be encouraged to stop, and offered help to do so, at every
opportunity. [2004]
Promote Effective Inhaled Therapy
InpeoplewithstableCOPDwhoremainbreathlessorhaveexacerbationsdespiteuseofshort-acting bronchodilators
asrequired,offerthefollowingasmaintenancetherapy:
l
IfFEV 150%predicted:eitherlong-acting beta 2-agonist (LABA) or long-acting muscarinic antagonist (LAMA)
IfFEV 1 <50% predicted: either LABA with an inhaled corticosteroid (ICS) in a combination inhaler, or LAMA. [new
2010]
l
OfferLAMAinadditiontoLABA+ICStopeoplewithCOPDwhoremainbreathlessorhaveexacerbationsdespite
taking LABA+ICS, irrespective of their FEV 1. [new 2010]
l
Provide Pulmonary Rehabilitation for All Who Need It

Pulmonary rehabilitation should be made available to all appropriate people with COPD including those who have had a
recent hospitalisation for an acute exacerbation. [new 2010]
Use Non-invasive Ventilation
Non-invasive ventilation (NIV) should be used as the treatment of choice for persistent hypercapnic ventilatory
failure during exacerbations not responding to medical therapy. It should be delivered by staff trained in its application,
experienced in its use and aware of its limitations.
l
WhenpatientsarestartedonNIV,thereshouldbeaclearplancoveringwhattodointheeventofdeteriorationand
l
Manage Exacerbations
Thefrequencyofexacerbationsshouldbereducedbyappropriateuseofinhaledcorticosteroidsandbronchodilators,
and vaccinations. [2004]
l
Use Non-invasive Ventilation

Non-invasive ventilation (NIV) should be used as the treatment of choice for persistent hypercapnic ventilatory
failure during exacerbations not responding to medical therapy. It should be delivered by staff trained in its application,
experienced in its use and aware of its limitations.
l
WhenpatientsarestartedonNIV,thereshouldbeaclearplancoveringwhattodointheeventofdeteriorationand
l
Manage Exacerbations
Thefrequencyofexacerbationsshouldbereducedbyappropriateuseofinhaledcorticosteroidsandbronchodilators,
and vaccinations. [2004]
l
Theimpactofexacerbationsshouldbeminimisedby:
l
Givingself-management advice on responding promptly to the symptoms of an exacerbation
Startingappropriatetreatmentwithoralsteroidsand/orantibiotics
Useofnon-invasive ventilation when indicated
Useofhospital-at-home or assisted-discharge schemes [2004]
Ensure Multidisciplinary Working

Implementation Tools
Audit Criteria/Indicators
Clinical Algorithm
Foreign Language Translations
Patient Resources
Quick Reference Guides/Physician Guides
Resources
Slide Presentation
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.
Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
End of Life Care
Living with Illness
IOM Domain
Effectiveness
Patient-centeredness
Safety
Identifying Information and Availability

Bibliographic Source(s)
National Clinical Guideline Centre for Acute and Chronic Conditions. Chronic obstructive pulmonary disease. Management
of chronic obstructive pulmonary disease in adults in primary and secondary care. London (UK): National Institute for
HealthandClinicalExcellence(NICE)2010Jun.61p.(Clinicalguidelineno.101).
Adaptation
Not applicable: The guideline was not adapted from another source.
Date Released
2004 Feb (revised 2010 Jun)
Guideline Developer(s)
National Clinical Guideline Centre for Acute and Chronic Conditions - National Government Agency [Non-U.S.]
Source(s) of Funding
National Institute for Health and Clinical Excellence (NICE)
Guideline Committee
Guideline Development Group
Composition of Group That Authored the Guideline
2010 Guideline Update Development Group Members: Dr Michael Rudolf (Chair), Respiratory Physician, Ealing Hospital
NHS Trust; Dr John O'Reilly (Clinical Advisor), Consultant in General and Respiratory Medicine, University Hospital Aintree
NHS Trust; Ms Jill Parnham, Operations Director, NCGC; Ms Nicola Sloan, Research Fellow, NCGC until March 2009; Dr
Emily Crowe, Senior Research Fellow, NCGC; Dr Rachel O'Mahony, Senior Research Fellow, NCGC from March 2009; Ms
Katrina Sparrow, Senior Research Fellow, NCGC from January 2010; Ms Kate Lovibond, Health Economist, NCGC; Ms Lina
Gulhane, Senior Information Scientist, NCGC; Dr Celia Pincus, Project Manager, NCGC from January 2010; Mrs Margaret
Guideline Committee
Guideline Development Group
Composition of Group That Authored the Guideline
2010 Guideline Update Development Group Members: Dr Michael Rudolf (Chair), Respiratory Physician, Ealing Hospital
NHS Trust; Dr John O'Reilly (Clinical Advisor), Consultant in General and Respiratory Medicine, University Hospital Aintree
NHS Trust; Ms Jill Parnham, Operations Director, NCGC; Ms Nicola Sloan, Research Fellow, NCGC until March 2009; Dr
Emily Crowe, Senior Research Fellow, NCGC; Dr Rachel O'Mahony, Senior Research Fellow, NCGC from March 2009; Ms
Katrina Sparrow, Senior Research Fellow, NCGC from January 2010; Ms Kate Lovibond, Health Economist, NCGC; Ms Lina
Gulhane, Senior Information Scientist, NCGC; Dr Celia Pincus, Project Manager, NCGC from January 2010; Mrs Margaret
Barnard; Patient/carer member, Secretary of Breathe Easy Neathe Valley; Ms Katherine Leach, Patient/carer member,
Project Manager at British Lung Foundation; Dr Kevin Grufydd-Jones, General Practitioner (specialist in COPD), Principal in
General Practice, Wiltshire; Dr Melvyn Jones, General Practitioner (non COPD specialist), GP Warden Lodge Surgery and
Hon Consultant East and North Hertfordshire PCT, Senior Lecturer UCL; Dr Phyo Myint, Geriatrician, Consultant Physician,
Department for Elderly, Norfolk and Norwich University Hospital; Professor Sally Singh, Head of Cardiac and Pulmonary
Rehabilitation, University Hospitals of Leicester NHS Trust; Professor Wisia Wedzicha, Consultant Respiratory Physician,
Royal Free Hospital, London NHS Trust; Professor Peter Calverley, Consultant Respiratory Physician, University Hospital
Aintree NHS Trust; Ms Karen Heslop, Respiratory Nurse Consultant, Chest Clinic, Royal Victoria Infirmary, Newcastle
(secondary care nurse representative); Ms Christine Loveridge, COPD and Spirometry Clinical Lead, Education for Health
(primary care nurse); Invited expert, Dr David Halpin, Consultant Respiratory Physician, Royal Devon and Exeter NHS
Trust; Deputies, Dr Graham Burns, Respiratory Physician (acted as a deputy for Peter Calverley for one GDG meeting); Ms
Erica Haines, Primary Care Nurse (acted as a deputy for Christine Loveridge for one GDG meeting); Ms Barbara Foggo,
Respiratory Nurse (acted as a deputy for Karen Heslop), Freeman Hospital, Newcastle
Financial Disclosures/Conflicts of Interest
All group members made a formal Declaration of Interests at the start of the guideline development and provided
updates throughout the process. The National Clinical Guideline Centre for Acute and Chronic Conditions (NCGC-ACC) and
the Group Chair monitored these.
Guideline Status
This is the current release of the guideline.
This guideline updates a previous version: National Collaborating Centre for Chronic Conditions. Chronic obstructive
pulmonary disease. National clinical guideline on management of chronic obstructive pulmonary disease in adults in
primary and secondary care. Thorax 2004 Feb;59 Suppl 1:1-232. [491 references]
Guideline Availability
Electronic copies: Available in Portable Document Format (PDF) format from the National Institute for Health and Clinical
Excellence (NICE) Web site .
Availability of Companion Documents
The following are available:
Chronicobstructivepulmonarydisease.Managementofchronicobstructivepulmonarydiseaseinadultsinprimary
and secondary care. Quick reference guide. London (UK): National Institute for Health and Clinical Excellence; 2010 Jun.
20 p. (Clinical guideline; no. 101). Electronic copies: Available in Portable Document Format (PDF) from the National
Institute for Health and Clinical Excellence (NICE) Web site .
l
Chronicobstructivepulmonarydisease.Managementofchronicobstructivepulmonarydiseaseinadultsinprimary
and secondary care. Full guideline. London (UK): National Institute for Health and Clinical Excellence; 2010 Jun. 673 p.
(Clinical guideline; no. 101). Electronic copies: Available in PDF format from the NICE Web site .
l
Chronicobstructivepulmonarydisease.ImplementingNICEguidance.Slideset.London(UK):NationalInstitutefor
Health and Clinical Excellence; 2010 Jul. 17 p. (Clinical guideline; no. 101). Electronic copies: Available in Portable
Document Format (PDF) from the NICE Web site .
l
Chronicobstructivepulmonarydisease(COPD).ImplementingNICEguidance.Auditsupport.London(UK):National
Institute for Health and Clinical Excellence; 2010 Oct. 17 p. (Clinical guideline; no. 101). Electronic copies: Available in
PDF from the NICE Web site .
l
Chronicobstructivepulmonarydisease.ImplementingNICEguidance.Baselineassessmenttool.London(UK):
National Institute for Health and Clinical Excellence; 2010 Sep. (Clinical guideline; no. 101). Electronic copies: Available
in PDF from the NICE Web site .
l
Theguidelinesmanual2007.London(UK):NationalInstituteforHealthandClinicalExcellence2007April.
Electronic copies: Available in PDF from the NICE Web site .
l
Patient Resources
The following is available:
Chronicobstructivepulmonarydisease:UnderstandingNICEguidance.Informationforpeoplewithchronic
obstructive pulmonary disease, their families and carers, and the public. National Institute for Health and Clinical
Excellence (NICE), 2010 Jun. 16 p. Electronic copies: Available from the National Institute for Health and Clinical
Excellence (NICE) Web site . Also available in Welsh from the NICE Web site .
l
Please note: This patient information is intended to provide health professionals with information to share with their patients to help them
better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to
provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to
consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their
personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on
NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it
accurately reflects the original guideline's content.
NGC Status
This NGC summary was completed by ECRI on July 12, 2004. The information was verified by the guideline developer on
better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to
provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to
consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their
personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on
NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it
accurately reflects the original guideline's content.
NGC Status
This NGC summary was completed by ECRI on July 12, 2004. The information was verified by the guideline developer on
November 29, 2004. This summary was updated by ECRI on December 5, 2005 following the U.S. Food and Drug
Administration (FDA) advisory on long-acting beta2-adrenergic agonists (LABA). This summary was updated by ECRI on
November 21, 2006 following the FDA advisory on Tamiflu. This summary was updated by ECRI Institute on November 6,
2007, following the U.S. Food and Drug Administration advisory on Antidepressant drugs. This summary was updated by
ECRI Institute on March 10, 2008 following the U.S. Food and Drug Administration (FDA) advisory on Tamiflu (oseltamivir
phosphate). This summary was updated by ECRI Institute on April 9, 2008 following the U.S. Food and Drug
Administration (FDA) advisory on Relenza (zanamivir). This summary was updated by ECRI Institute on May 1, 2009
following the U.S. Food and Drug Administration advisory on antiepileptic drugs. This summary was updated by ECRI
Institute on July 20, 2009 following the U.S. Food and Drug Administration advisory on Varenicline and Bupropion. The
information was reaffirmed by the guideline developer in March 2008 and updated by ECRI Institute on March 31, 2010.
This NGC summary was updated by ECRI Institute on December 9, 2010. This summary was updated by ECRI Institute on
July 15, 2011 following the U.S. Food and Drug Administration advisory on Chantix (varenicline).
The National Institute for Health and Clinical Excellence (NICE) has granted the National Guideline Clearinghouse (NGC)
permission to include summaries of their clinical guidelines with the intention of disseminating and facilitating the
implementation of that guidance. NICE has not yet verified this content to confirm that it accurately reflects that original
NICE guidance and therefore no guarantees are given by NICE in this regard. All NICE clinical guidelines are prepared in
relation to the National Health Service in England and Wales. NICE has not been involved in the development or
adaptation of NICE guidance for use in any other country. The full versions of all NICE guidance can be found at
www.nice.org.uk .
Copyright Statement
This summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.
Disclaimer
NGC Disclaimer
TheNationalGuidelineClearinghouse(NGC)doesnotdevelop,produce,approve,orendorsetheguidelinesrepresented
on this site.
All guidelines summarized by NGC and hosted on our site are produced under the auspices of medical specialty societies,
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Guidelines represented on the NGC Web site are submitted by guideline developers, and are screened solely to determine
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Guideline Summary NGC-7907

Togiveguidanceonthepharmacologicalandnon-pharmacological treatment of patients with stable COPD, and on

Treatmentwithalpha-tocopherol and beta-carotene supplements

Management of COPD Exacerbations

Lungfunction,asmeasuredbyforcedexpiratoryvolumein1second(FEV 1), forced vital capacity (FVC), and peak

Hand-searches of Published Literature (Primary Sources)

Methods Used to Analyze the Evidence

ConsultingwiththePatientandPublicInvolvementProgramme(PPIP)housedwithinNICEduringthepredevelopment (scoping) and final validation stages of the guideline.

The GDG also reached agreement on the following:

Writing the Guideline

Degree of Breathlessness Related to Activities

Not troubled by breathlessness except on strenuous exercise

Short of breath when hurrying or walking up a slight hill

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

Measure post-bronchodilator spirometry to confirm the diagnosis of COPD. [new 2010]

OlderpeoplewithouttypicalsymptomsofCOPDwheretheFEV 1/FVC ratio is < 0.7

YoungerpeoplewithsymptomsofCOPDwheretheFEV 1/FVCratiois0.7.[new 2010]

Serial domiciliary peak flow

To exclude asthma if diagnostic doubt remains

If early onset, minimal smoking history, or family history

Transfer factor for carbon monoxide

To investigate symptoms that seem disproportionate to the spirometric impairment

Computed tomography (CT) scan of the

To investigate symptoms that seem disproportionate to the spirometric impairment

Serial domiciliary peak flow

To exclude asthma if diagnostic doubt remains

If early onset, minimal smoking history, or family history

Transfer factor for carbon monoxide

To investigate symptoms that seem disproportionate to the spirometric impairment

Computed tomography (CT) scan of the

To investigate symptoms that seem disproportionate to the spirometric impairment

To assess cardiac status if features of cor pulmonale

To assess cardiac status if features of cor pulmonale

To identify organisms if sputum is persistently present and purulent

RepeatedFEV 1 measurements can show small spontaneous fluctuations.

Responsetolong-term therapy is not predicted by acute reversibility testing.[2004]

Symptoms under age 35

Chronic productive cough

Persistent and progressive Variable

Night time waking with breathlessness and/or wheeze

Significant diurnal or day-to-day variability of symptoms Uncommon

Exercisecapacity(forexample,6-minute walk test)

Exercisecapacity(forexample,6-minute walk test)

American Thoracic Society

Global Initiative for Chronic

Obstructive Lung Disease (GOLD) 2008

NICE clinical guideline

Stage 4Very severe**

Stage 4Very severe**

Severity of Airflow Obstruction

Identification of Early Disease

There is diagnostic uncertainty

Confirm diagnosis and optimise therapy

Suspected severe COPD

Confirm diagnosis and optimise therapy

The patient 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 in appropriate prescriptions

Assessment for oral corticosteroid therapy