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Summary for primary care

Chronic Obstructive Pulmonary Disease in Over 16s: Diagnosis and Management

This Guidelines summary covers diagnosis and management of chronic obstructive pulmonary disease or COPD (which includes emphysema and chronic bronchitis) in people aged 16 and older. It aims to help people with COPD to receive a diagnosis earlier so that they can benefit from treatments to reduce symptoms, improve quality of life and keep them healthy for longer

NICE has also produced a guideline on antimicrobial prescribing for acute exacerbations of COPD and a visual summary covering non-pharmacological management and use of inhaled therapies

This guideline should be read in conjunction with NG114.

Diagnosing COPD

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


  • Suspect a diagnosis of COPD in people over 35 who have a risk factor (generally smoking or a history of smoking) and who present with 1 or more of the following symptoms:
    • exertional breathlessness
    • chronic cough
    • regular sputum production
    • frequent winter ‘bronchitis’
    • wheeze.
  • When thinking about a diagnosis of COPD, ask the person if they have:
    • weight loss
    • reduced exercise tolerance
    • waking at night with breathlessness
    • ankle swelling
    • fatigue
    • occupational hazards
    • chest pain
    • haemoptysis (coughing up blood).These last two symptoms are uncommon in COPD and raise the possibility of alternative diagnoses.
  • One of the primary symptoms of COPD is breathlessness. The Medical Research Council (MRC) dyspnoea scale (see Table 1) should be used to grade the breathlessness according to the level of exertion required to elicit it.

Table 1: MRC Dyspnoea Scale

Grade Degree of Breathlessness Related to Activities 
1Not troubled by breathlessness except on strenuous exercise
2Short of breath when hurrying or walking up a slight hill
3Walks slower than contemporaries on level ground because of breathlessness, or has to stop for breath when walking at own pace
4Stops for breath after walking about 100 metres or after a few minutes on level ground
5Too breathless to leave the house, or breathless when dressing or undressing
Adapted from Fletcher CM, Elmes PC, Fairbairn MB et al. (1959) The significance of respiratory symptoms and the diagnosis of chronic bronchitis in a working population. British Medical Journal 2: 257–266.


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

Incidental Findings on Chest X-rays or CT Scans

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

Further Investigations

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

Table 2: Additional Investigations

Sputum cultureTo identify organisms if sputum is persistently present and purulent
Serial home peak flow measurementsTo exclude asthma if diagnostic doubt remains
Electrocardiogram (ECG) and serum natriuretic peptides[A]To assess cardiac status if cardiac disease or pulmonary hypertension are suspected because of:– a history of cardiovascular disease, hypertension or hypoxia or

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

EchocardiogramTo assess cardiac status if cardiac disease or pulmonary hypertension are suspected
CT scan of the thorax

To investigate symptoms that seem disproportionate to the spirometric impairment

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

To investigate abnormalities seen on a chest X‑ray

To assess suitability for lung volume reduction procedures

Serum alpha‑1 antitrypsinTo assess for alpha‑1 antitrypsin deficiency if early onset, minimal smoking history or family history
Transfer factor for carbon monoxide (TLCO)

To investigate symptoms that seem disproportionate to the spirometric impairment

To assess suitability for lung volume reduction procedures

[A] See the NICE guideline on chronic heart failure in adults for recommendations on using serum natriuretic peptides to diagnose heart failure.
  • Offer people with alpha‑1 antitrypsin deficiency a referral to a specialist centre to discuss how to manage their condition.

Reversibility Testing

Table 3: Clinical Features Differentiating COPD and Asthma

Smoker or ex-smokerNearly allPossibly
Symptoms under age 35RareOften
Chronic productive coughCommonUncommon
BreathlessnessPersistent and progressiveVariable
Night-time waking with breathlessness and/or wheezeUncommonCommon
Significant diurnal or day-to-day variability of symptomsUncommonCommon
  • For most people, routine spirometric reversibility testing is not necessary as part of the diagnostic process or to plan initial therapy with bronchodilators or corticosteroids. It may be unhelpful or misleading because:
    • repeated FEV1 measurements can show small spontaneous fluctuations
    • the results of a reversibility test performed on different occasions can be inconsistent and not reproducible
    • over-reliance on a single reversibility test may be misleading unless the change in FEV1 is greater than 400 ml
    • the definition of the magnitude of a significant change is purely arbitrary
    • response to long-term therapy is not predicted by acute reversibility testing
  • Untreated COPD and asthma are frequently distinguishable on the basis of history (and examination) in people presenting for the first time. Whenever possible, use features from the history and examination (such as those listed in Table 3) to differentiate COPD from asthma. For more information on diagnosing asthma, see the NICE guideline on asthma
  • In addition to the features in Table 3, use longitudinal observation of people (with spirometry, peak flow or symptoms) to help differentiate COPD from asthma
  • When diagnostic uncertainty remains, or both COPD and asthma are present, use the following findings to help identify asthma:
    • a large (over 400 ml) response to bronchodilators
    • a large (over 400 ml) response to 30 mg oral prednisolone daily for 2 weeks
    • serial peak flow measurements showing 20% or greater diurnal or day-to-day variabilityClinically significant COPD is not present if the FEV1 and FEV1/FVC ratio return to normal with drug therapy.
  • If diagnostic uncertainty remains, think about referral for more detailed investigations, including imaging and measurement of transfer factor for carbon monoxide (TLCO)
  • Reconsider the diagnosis of COPD for people who report a marked improvement in symptoms in response to inhaled therapy.

Assessing Severity and Using Prognostic Factors

  • COPD is heterogeneous, so no single measure can adequately assess disease severity in an individual. Severity assessment is, nevertheless, important because it has implications for therapy and relates to prognosis. 
  • Do not use a multidimensional index (such as BODE) to assess prognosis in people with stable COPD
  • From diagnosis onwards, when discussing prognosis and treatment decisions with people with stable COPD, think about the following factors that are individually associated with prognosis:
    • FEV1
    • smoking status
    • breathlessness (MRC scale)
    • chronic hypoxia and/or cor pulmonale
    • low BMI
    • severity and frequency of exacerbations
    • hospital admissions
    • symptom burden (for example, COPD Assessment Test [CAT] score)
    • exercise capacity (for example, 6-minute walk test)
    • TLCO
    • whether the person meets the criteria for long-term oxygen therapy and/or home non-invasive ventilation
    • multimorbidity (see the NICE guideline on multimorbidity)
    • frailty.

Assessing and Classifying the Severity of Airflow Obstruction

  • Assess the severity of airflow obstruction according to the reduction in FEV1 as shown in Table 4, below
  • For people with mild airflow obstruction, only diagnose COPD if they have one or more of the symptoms (described in the section, Symptoms).

Table 4: Gradation of Severity of Airflow Obstruction

  NICE Guideline CG12 (2004)ATS/ERS2004[A]GOLD 2008[B]NICE Guideline CG101 (2010)
Post-bronchodilator FEV1/FVC FEV% predicted Severity of airflow obstruction 
 --Post-bronchodilator Post-bronchodilator Post-bronchodilator 
<0.7≥80%-MildStage 1–MildStage 1–Mild
<0.750–79%MildModerateStage 2–ModerateStage 2–Moderate
ModerateSevereStage 3–SevereStage 3–Severe
<0.7<30%Severevery SevereStage 4–Very severe*Stage 4–Very severe*
*Or FEV1 below 50% with respiratory failure.[A] Celli BR, MacNee W, Agusti A et al. (2004) Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper. European Respiratory Journal 23 (6): 932–946.

[B] Global Initiative for Chronic Obstructive Lung Disease (GOLD; 2008) Global strategy for the diagnosis, management and prevention of COPD.

Identifying Early Disease

  • Perform spirometry in people who are over 35, current or ex‑smokers, and have a chronic cough
  • Consider spirometry in people with chronic bronchitis. A significant proportion of these people will go on to develop airflow limitation.

Referral for Specialist Advice

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

Table 5: Reasons for Referral Include

There is diagnostic uncertaintyConfirm diagnosis and optimise therapy
Suspected severe COPDConfirm diagnosis and optimise therapy
The person with COPD requests a second opinionConfirm diagnosis and optimise therapy
Onset of cor pulmonaleConfirm diagnosis and optimise therapy
Assessment for oxygen therapyOptimise therapy and measure blood gases
Assessment for long-term nebuliser therapyOptimise therapy and exclude inappropriate prescriptions
Assessment for oral corticosteroid therapyJustify need for continued treatment or supervise withdrawal
Bullous lung diseaseIdentify candidates for lung volume reduction procedures
A rapid decline in FEV1Encourage early intervention
Assessment for pulmonary rehabilitationIdentify candidates for pulmonary rehabilitation
Assessment for a lung volume reduction procedureIdentify candidates for surgical or bronchoscopic lung volume reduction
Assessment for lung transplantation Identify candidates for surgery
Dysfunctional breathingConfirm diagnosis, optimise pharmacotherapy and access other therapists
Onset of symptoms under 40 years or a family history of alpha-1 antitrypsin deficiencyIdentify alpha-1 antitrypsin deficiency, consider therapy and screen family
Symptoms disproportionate to lung function deficitLook for other explanations including cardiac impairment, pulmonary hypertension, depression and hyperventilation
Frequent infectionsExclude bronchiectasis
HaemoptysisExclude carcinoma of the bronchus

Managing Stable COPD

Managing stable COPD
Chronic Obstructive Pulmonary Disease in Over 16s—Non-pharmacological Management and Use of Inhaled Therapies
  • See above for a visual summary covering non-pharmacological management and use of inhaled therapies.
  • For guidance on the management of multimorbidity, see the NICE guideline on multimorbidity.

Smoking Cessation

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

Inhaled Therapy

Short-acting Beta2 Agonists (SABA) and Short-acting Muscarinic Antagonists (SAMA)

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

Inhaled Corticosteroids (ICS)

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

Inhaled Combination Therapy

  • Inhaled combination therapy refers to combinations of long-acting muscarinic antagonists (LAMA), long-acting beta2 agonists (LABA) and inhaled corticosteroids (ICS).
  • Do not assess the effectiveness of bronchodilator therapy using lung function alone. Include a variety of other measures such as improvement in symptoms, activities of daily living, exercise capacity, and rapidity of symptom relief
  • Offer LAMA+LABA[B] to people who:
    • have spirometrically confirmed COPD and
    • do not have asthmatic features/features suggesting steroid responsiveness and
    • remain breathless or have exacerbations despite:
      • having used or been offered treatment for tobacco dependence if they smoke and
      • optimised non-pharmacological management and relevant vaccinations and
      • using a short-acting bronchodilator
  • Consider LABA+ICS for people who:
    • have spirometrically confirmed COPD and
    • have asthmatic features/features suggesting steroid responsiveness and
    • remain breathless or have exacerbations despite:
      • having used or been offered treatment for tobacco dependence if they smoke and
      • optimised non-pharmacological management and relevant vaccinations and
      • using a short-acting bronchodilator
  • For people who are using long-acting bronchodilators outside of recommendations 1.2.11 and 1.2.12 and whose symptoms are under control, explain to them that they can continue with their current treatment until both they and their NHS healthcare professional agree it is appropriate to change
  • Before starting LAMA+LABA+ICS, conduct a clinical review to ensure that:
    • the person’s non-pharmacological COPD management is optimised and they have used or been offered treatment for tobacco dependence if they smoke
    • acute episodes of worsening symptoms are caused by COPD exacerbations and not by another physical or mental health condition
    • the person’s day-to-day symptoms that are adversely impacting their quality of life are caused by COPD and not by another physical or mental health condition
  • For people with COPD who are taking LABA+ICS, offer LAMA+LABA+ICS if:
    • their day-to-day symptoms continue to adversely impact their quality of life or
    • they have a severe exacerbation (requiring hospitalisation) or
    • they have 2 moderate exacerbations within a year
  • For people with COPD who are taking LAMA+LABA, consider LAMA+LABA+ICS if:
    • they have a severe exacerbation (requiring hospitalisation) or
    • they have 2 moderate exacerbations within a year
  • For people with COPD who are taking LAMA+LABA and whose day-to-day symptoms adversely impact their quality of life:
    • consider a trial of LAMA+LABA+ICS, lasting for 3 months only
    • after 3 months, conduct a clinical review to establish whether or not LAMA+LABA+ICS has improved their symptoms:
      • if symptoms have not improved, stop LAMA+LABA+ICS and switch back to LAMA+LABA
      • if symptoms have improved, continue with LAMA+LABA+ICS
  • Document the reason for continuing ICS use in clinical records and review at least annually
  • Base the choice of drugs and inhalers on: 
    • how much they improve symptoms
    • the person’s preferences and ability to use the inhalers
    • the drugs’ potential to reduce exacerbations
    • their side-effects
    • their cost

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

Delivery Systems Used to Treat Stable COPD

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


  • In most cases bronchodilator therapy is best administered using a hand-held inhaler (including a spacer if appropriate)
  • Provide an alternative inhaler if a person cannot use a particular one correctly or it is not suitable for them
  • Only prescribe inhalers after people have been trained to use them and can demonstrate satisfactory technique
  • People with COPD should have their ability to use an inhaler regularly assessed and corrected if necessary by a healthcare professional competent to do so.


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


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

Oral Therapy

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

Oral Theophylline

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

Oral Mucolytic Therapy

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

Oral Anti-oxidant Therapy

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

Oral Anti-tussive Therapy

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

Oral Prophylactic Antibiotic Therapy

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

Oral Phosphodiesterase-4 Inhibitors

For guidance on treating severe COPD with roflumilast, see NICE’s technology appraisal guidance on roflumilast for treating chronic obstructive pulmonary disease.


  • Please refer to the full guideline for recommendations on oxygen therapy, including long-term, ambulatory, and short-burst oxygen therapy, and non-invasive ventilation. 

Managing Pulmonary Hypertension and Cor Pulmonale

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

Diagnosing Pulmonary Hypertension and Cor Pulmonale

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

Treating Pulmonary Hypertension

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

Treating Cor Pulmonale

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

Pulmonary Rehabilitation

  • Pulmonary rehabilitation is defined as a multidisciplinary programme of care for people with chronic respiratory impairment. It is individually tailored and designed to optimise each person’s physical and social performance and autonomy
  • Make pulmonary rehabilitation available to all appropriate people with COPD, including people who have had a recent hospitalisation for an acute exacerbation
  • Offer pulmonary rehabilitation to all people who view themselves as functionally disabled by COPD (usually Medical Research Council [MRC] grade 3 and above). Pulmonary rehabilitation is not suitable for people who are unable to walk, who have unstable angina or who have had a recent myocardial infarction
  • For pulmonary rehabilitation programmes to be effective, and to improve adherence, they should be held at times that suit people, in buildings that are easy to get to and that have good access for people with disabilities. Places should be available within a reasonable time of referral
  • Pulmonary rehabilitation programmes should include multicomponent, multidisciplinary interventions that are tailored to the individual person’s needs. The rehabilitation process should incorporate a programme of physical training, disease education, and nutritional, psychological and behavioural intervention
  • Advise people of the benefits of pulmonary rehabilitation and the commitment needed to gain these.

Vaccination and Anti-viral Therapy

Lung Surgery and Lung Volume Reduction Procedures
  • Please refer to the full guideline for recommendations on lung surgery and lung volume reduction procedures, alpha-1 antitrypsin replacement therapy, and multidisciplinary management.

Follow-up of People with COPD

Table 6: Summary of Follow-up of People With COPD in Primary Care

 Mild/Moderate/Severe (Stages 1 to 3) Very Severe (Stage 4)
Frequency At least annualAt least twice per year
Clinical assessment

Smoking status and motivation to quit

Adequacy of symptom control:

– breathlessness

– exercise tolerance

– estimated exacerbation frequency

Need for pulmonary rehabilitation 

Presence of complications

Effects of each drug treatment

Inhaler technique

Need for referral to specialist and therapy services

Smoking status and motivation to quit

Adequacy of symptom control:

– breathlessness

– exercise tolerance

– estimated exacerbation frequency

Presence of cor pulmonale

Need for long-term oxygen therapy

Person with COPD’s nutritional state

Presence of depression

Effects of each drug treatment

Inhaler technique

Need for social services and occupational therapy input

Need for referral to specialist and therapy services

Need for pulmonary rehabilitation

Measurements to make

FEV1 and FVC

Calculate BMI

MRC dyspnoea score

FEV1 and FVC

Calculate BMI

MRC dyspnoea score


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

Managing Exacerbations of COPD

Definition of an Exacerbation

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

Assessing the Need for Hospital Treatment

  • Use the factors in Table 7 (below) to assess whether people with COPD need hospital treatment.

Table 7: Factors to Consider When Deciding Where to Treat the Person with COPD

FactorTreat at HomeTreat in Hospital 
Able to cope at homeYesNo
General conditionGoodPoor/deteriorating
Level of activityGoodPoor/confined to bed
Worsening peripheral oedemaNoYes
Level of consciousnessnormalimpared
Already receiving long-term oxygen therapyNoYes
Social circumstancesGoodLiving alone/not coping
Acute confusionNoYes
Rapid rate of onsetNoYes
Significant comorbidity (particularly cardiac disease and insulin-dependent diabetes)NoYes
SaO2 <90%NoYes
Changes on chest radiographNopresent
Arterial pH level≥7.35≥7.35
Arterial PaO2≥7 kPa≥7 kPa

Investigating an Exacerbation

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

Primary Care

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


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

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

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

[D] At the time of publication (July 2019), azithromycin did not have a UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council’s Prescribing guidance: prescribing unlicensed medicines for further information.