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Chronic Obstructive Pulmonary Disease (COPD)

NICE guideline [NG115] Chronic obstructive pulmonary disease in over 16s: diagnosis and management. Last updated: Jul 2019.

Background Information

COPD
  • Common lung condition characterised by persistent respiratory symptoms and airflow obstruction that is typically progressive and not fully reversible.
  • COPD is the umbrella term that includes chronic bronchitis and emphysema, which often coexist:
    • Chronic bronchitis
      • Clinical diagnosis defined by cough and sputum production for at least 3 months per year, for 2 consecutive years
    • Emphysema
      • Pathological diagnosis referring to irreversible enlargement and destruction of airspaces distal to terminal bronchioles

COPD exacerbation / AECOPDAcute exacerbation of COPD  
  • Episodes of acute worsening of COPD symptoms (e.g., increased breathlessness, cough), beyond normal day-to-day variations. 

Age of onset: typically 40-50 y/o [ref]

Prevalence: ~6-7% of adults >40 y/o [ref]

Exogenous (Environmental) 
  • Smoking (Major risk factor) 
    • Cigarette smoking → ~ 90% of cases 
    • Risk also ↑ with pipes, cigars, marijuana & passive smoking
  •  Occupational exposures (~20% of COPD cases overall)
    • Dusts: coal, grains, silica
    • Fumes/chemicals: welding fumes, isocyanates, PAHs  
  • Air pollution (i.e., biomass fuels)
  • Early-life exposures 
    • In utero → maternal smoking
    • Childhood → severe respiratory infections, passive smoke

Endogenous (Host/Intrinsic) 
  • Genetic factors 
    • Alpha-1 antitrypsin deficiency (rare but important cause)
      • Presents in <45 yrs 
      • Affects both smokers & non-smokers 
  • Prematurity → Impaired lung development 
    • Prematurity 
  • Asthma 
    • Independent risk factor for COPD 

  

Red flags for A1AT deficiency–related COPD

  • Younger patients (<45 yrs)

  • Non-smokers or minimal smoking history

  • Family history of early emphysema or liver disease

  • Lower zone/lobe predominant emphysema on imaging

  • COPD plus unexplained liver disease (cirrhosis, hepatitis)

  1. Infections (most common trigger) [Ref]
    • Respiratory viruses (up to 60%)
      • Rhinovirus (most common) 
      • Other: Influenza, RSV, parainfluenza, coronavirus, adenovirus 
    • Bacterial (40-60%)
      • Most frequently; Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis, Pseudomonas aeruginosa
  2. Environmental triggers
    • Air pollution (e.g., particulates, NO2, ozone)
    • Cold weather / winter seasonality
  3. Host factors 
    • Defective mucociliary clearance (smoking damage) 
    • Immune dysfunction → poor pathogen clearance 

  • Chronic cough (often productive, worse in the morning)
  • Dyspnoea 
    • Early → exertional breathlessness 
    • Advanced → breathlessness at rest 
  • Wheezing
  • Nonspecific 
    • Fatigue / Reduced exercise tolerance 
    • Weight loss / Anorexia (advanced, linked to cachexia)

Early / General 
  • Tachypnoea / Tachycardia (due to hypoxaemia)
  • Pursed-lip breathing
  • Prolonged expiratory phase (due to airflow obstruction)
  • Cyanosis (esp. in advanced disease)
Advanced
  • Barrel chest (↑ anteroposterior diameter of chest in emphysema) 
  • Cor pulmonale (raised JVPJugular Venous Pressure , peripheral oedema, hepatomegaly)
  • Cachexia & muscle wasting 

 

COPD itself is not a cause of nail clubbing. If clubbing is present, consider comorbid conditions such as lung cancer, bronchiectasis, or interstitial lung disease, which may coexist with COPD

Examination may be normal. Potential findings may include:
  • Palpation → h yperinflated chest & reduced chest expansion
  • Percussion → h yperresonance 
  • Auscultation 
    • ↓ breath sounds
    • prolonged expiration 
    • Wheeze and/or crackles 
    • Signs of cor pulmonale (loud P2, RV heave) 
 

Symptoms
  • Common 
    • ↑ breathlessness, cough and/or sputum production 
    • change in sputum colour 
  • Other 
    • ↑ wheeze & chest tightness 
    • URTI Upper Respiratory Tract Infection symptoms 
    • Reduced exercise tolerance / increased fatigue 
 

COPD has a variable but generally progressive course, with gradual lung function decline and worsening symptoms over time.

Poor prognostic factors 
  • Severe airflow limitation (low FEV1)
  • High symptom burden (e.g., high MRC dyspnoea scale / CAT scores, poor 6-min walk test)
  • Chronic hypoxia / cor pulmonale 
  • Low BMI, muscle wasting, cachexia 
  • Frequent / Severe exacerbations
  • Current smoking 
  • Multimorbidity and frailty 

Systemic 
  • Muscle wasting & cachexia  
  • Psychological: depression & anxiety (very common) 

Respiratory 
  • ↑ Risk of respiratory infections (esp. pneumonia)
  • Pneumothorax → due to rupture of bullae (present in emphysema)
  • Respiratory failure

Cardiovascular / Haematological 
  • Cor pulmonale
  • Secondary polycythaemia → compensatory ↑ RBCs due to chronic hypoxia

Oncological 
  • ↑ Lung cancer risk

COPD severity is classified based on post-bronchodilator FEV1:
 
Staging Post-bronchodilator FEV1 (% of predicted)
Stage 1 (mild) ≥80 %
Stage 2 (moderate) 50-79 %
Stage 3 (severe) 30-49 %
Stage 4 (very severe) <30 %

Guidelines

NICE recommends suspecting COPD in:
  • >35 y/o with a risk factor for COPD (e.g. significant smoking history), and
  • Present with ≥1 of the following:
    • Exertional dyspnoea
    • Chronic cough
    • Regular sputum production
    • Frequent winter ‘bronchitis’
    • Wheeze

Confirmatory test:  post-bronchodilator spirometry demonstrating FEV1/FVC <0.7

Standard work-up for all suspected COPD cases:
  • Chest X-ray (to exclude other pathologies)
  • FBC (to identify anaemia or polycythaemia)
  • Measure BMI

Consider serum alpha-1 antitrypsin, sputum cultures, DLCODiffusion lung capacity for carbon monoxide, and CT thorax on a case-by-case basis

NICE provided this table to help differentiate between COPD and asthma based on clinical features:
 
Clinical feature / factor 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

 When there is diagnostic uncertainty, or both COPD and asthma are present, NICE recommend using the following findings to help identify asthma:
  • Large response (FEV1 improvement >400 mL) to bronchodilators
  • Large response (FEV improvement >400 mL) to oral prednisolone for 2 weeks
  • ≥20% diurnal or day-to-day variability in serial peak flow measurements

 

Note that in real life, it is very common for COPD and asthma to co-exist, known as Asthma-COPD Overlap Syndrome (ACOS). However, in exams one would be expected to be able to differentiate between COPD and asthma.

Hospital admission is indicated in:
  • Severe breathlessness
  • Cyanosis
  • Arterial pH <7 kPa / Arterial PaO2 <7 kPa / SaO2 <90%
  • Worsening peripheral oedema
  • ↓ Level of consciousness
  • Already receiving LTOT
  • Significant comorbidity (esp. cardiac disease and insulin-dependent diabetes)

Patients who do not need to be admitted can be treated as outpatients.
 

Offer all the following:
  • ↑ Frequency or dose of the reliever inhaler (short-acting bronchodilator)
  • Oral prednisolone 30mg for 5 days

Do not routinely give antibiotics, only offer if there are signs of infective COPD exacerbation
  • Purulent sputum, or
  • Increase in sputum volume, or
  • Increase in sputum thickness

  • Oxygen therapy
    • Standard initial SpO2 target / device → 88-92% via venturi mask 
      • Exception: critical illness (e.g. shocked, cardiac arrest) → 94-98% via NRMNon-rebreather (reservoir) mask 
  • Short-acting bronchodilator
    • 1st line: SABAShort-acting beta-2 agonist (e.g. salbutamol)
    • If ineffective: add SAMAShort-acting muscarinic antagonist (e.g. ipratropium)
  • Oral prednisolone 30mg for 5 days

Do not routinely give antibiotics, only offer if there are signs of infective COPD exacerbation
  • Purulent sputum, or
  • Increase in sputum volume, or
  • Increase in sputum thickness

1st line: oral antibiotics
  • Amoxicillin, or
  • Doxycycline, or
  • Clarithromycin 

  • Theophylline
  • Non-invasive ventilation indicated if respiratory acidosis (pH <7.35) despite optimal medical therapy
  • Doxapram - only indicated if non-invasive ventilation is not suitable
 

Patients with a recent exacerbation (≥1 in the last year) who remain at risk are prescribed a 'rescue pack' to enable self-management of future exacerbations at home. 

Rescue pack includes:

  • Oral corticosteroid 
  • Oral antibiotic (as per local guidance)
 

The main COPD interventions that are well established to improve prognosis are 

  • Smoking cessation
  • Pulmonary rehabilitation
  • Long-term oxygen therapy


Note that inhaler therapies are used for symptom control and management, with limited impact on long-term prognosis.

 

  • Smoking cessation – most effective intervention for improving COPD prognosis
  • Pulmonary rehabilitation - offered to those who are functionally disabled by COPD
  • Vaccination
    • One-off pneumococcal vaccination
    • Annual influenza vaccination

Step 1: reliever inhaler with SABA or  SAMA 

Step 2: assess for steroid responsiveness to determine step-up therapy
  • +ve → add LABA + ICS in addition to reliever inhaler in step 1
  • -ve → add LABA + LAMA in addition to reliever inhaler in step 1

Step 3: add triple therapy (LABA + LAMA + ICS) in addition to reliever inhaler

 

NICE recommends using combination inhalers (e.g. LABA + LAMA in a single inhaler instead of having to use 2 separate inhalers) to improve adherence.

Do not combine two antimuscarinic inhalers (i.e., SAMA + LAMA). In patients stepping up to LABA + LAMA (without steroid responsiveness), ensure the reliever inhaler is a SABA, not a SAMA.

Examples of some inhaler drugs:
 
Drug class Drug examples
SABA Salbutamol, terbutaline, albuterol
LABA Formoterol, salmeterol
SAMA Ipratropium, oxitropium
LAMA Tiotropium, glycopyronium, umeclidinium

All of the following are initiated by specialists.
 

Oral theophylline is used if:

  • Unable to use inhalers, or
  • Inhaler therapy was unsuccessful

Oral  roflumilast is used if:
  • Severe disease (FEV1 <50%), and
  • ≥2 exacerbations in the past 12 months despite triple inhaler therapy

Regular oral azithromycin to prevent infective exacerbations can be offered if:
  • Patient stopped smoking, AND
  • Referred for pulmonary rehabilitation + optimised non-pharmacological and inhaler therapies, AND 
  • Has had ≥4 exacerbations with sputum production OR exacerbations resulting in hospitalisation OR prolonged exacerbations with sputum production

Consider LTOT if:
  • Patient stopped smoking (or does not smoke), and 
  • ABGArterial blood gas on 2 occasions at least 3 weeks apart shows:
    • PaO2 <7.3 kPa OR 
    • PaO2 7.3-8.0 PLUS 1 of the 3Ps (secondary polycythaemia, peripheral oedema, pulmonary hypertension)

Duration: If offered, LTOT should be used for at least 15 hours per day

 

Due to risk of fire/burns, active smoking or anticipated repeated contact with fire are contraindications for LTOT

Procedure Indications
Lung volume reduction surgery or endobronchial valves All the following must be met:
  • Severe COPD (FEV1 <50%)
  • Does not smoke
  • Able to complete 6-minute walk for at least 140m
  • Hyperinflation (on body plethysmography)
  • Emphysema (on CT)
  • Optimised treatment for other comorbidities
Surgical bullectomy Considered in patients with large emphysematous bullae (occupying at least 1/3 of the hemithorax)
Lung transplantation All the following must be met:
  • Severe COPD (FEV1 <50%)
  • Does not smoke
  • Completed pulmonary rehabilitation
  • Does not have transplantation contraindications

 

It is more important to understand the different possible procedures and their aims, rather than memorising exact indications.

References

Author: Kon M
Reviewer:
Last edited: 29/07/25