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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: characterised by chronic respiratory symptoms caused by not fully reversible airlow limitation

COPD encompasses both chronic bronchitis and emphysema which often occur simultaneously:
  • 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 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 to suspect 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, 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 (>400 mL) to bronchodilators
  • Large response (>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 exepcted 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 that 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 to maintain 88-92% oxygen saturation with a venturi mask
    • Exception is the patient is critically ill (e.g. shocked, cardiac arrest)
  • Short-acting bronchodilator
    • 1st line: SABAShort-acting beta-2 agonist (e.g. salbutamol)
    • If ineffective: add SAMAShort-acting muscarinic antagonist (e.g. ipratropium)
    • If moderate to severe exacerbation, use nebuliser driven by air (not oxygen)
  • 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

  • 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

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 
  • SAMA should be avoided in glaucoma, BPHBenign prostate hypertrophy and bladder obstruction (due to risk of worsening from the anti-cholinergic effects) 

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 2 antimuscarinic inhalers together (i.e. SAMA and LAMA). 

Such that in step 2 without steroid responsiveness where LABA and LAMA will be added, make sure the reliever inhaler is a SABA, but not SAMA. 

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

All the following medications should only be initiated by a specialist.
 

Oral theophylline should only be used if:

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

Oral roflumilast (PDE4 inhibitor) should only be 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
  • ≥4 exacerbations with sputum production / exacerbations resulting in hospitalisation / prolonged exacerbations with sputum production

Consider LTOT if:
  • Patient stopped smoking (or do not smoke), and 
  • One of the following
    • PaO2 <7.3 kPa
    • PaO2 7.3-8.0 + 1 of the 3Ps (secondary polycythaemia, peripheral oedema, pulmonary hypertension)

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

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 distance 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 appreciate the various possible procedures and aim, instead of learning the exact indications.

References

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