Chronic obstructive pulmonary disease Management of chronic obstructive pulmonary disease in adults in primary and secondary care Clinical Guideline 12 February 2004
Developed by the National Collaborating Centre forChronic Conditions
Clinical Guideline 12 Chronic obstructive pulmonary disease Management of chronic obstructive pulmonary disease in adults in primary and secondary care Issue date: February 2004
This document, which contains the Institute's full guidance on the management of chronicobstructive pulmonary disease in adults, is available from the NICE website(www.nice.org.uk/CG012NICEguideline).
An abridged version of this guidance (a 'quick reference guide') is also available from the NICEwebsite (www.nice.org.uk/CG012quickrefguide). Printed copies of the quick reference guide canbe obtained from the NHS Response Line: telephone 0870 1555 455 and quote reference numberN0462.
Information for the Public is available from the NICE website or from the NHS Response Line(quote reference number N0463 for a version in English and N0464 for a version in English andWelsh).
The quick reference guide for this guideline has been distributed to the following:
• Respiratory nurse specialists in England and
• NHS trust chief executives in England and Wales
• Clinical governance leads in England and Wales
• Senior pharmacists and pharmaceutical advisors
• Medical and nursing directors in England and
• Senior health visitors, practice nurses and
• NHS trust, PCT and LHB libraries in England and
• Strategic health authority chief executives in
• Consultants in occupational health medicine in
• Directors of directorates of health and social
• Consultants in rehabilitation medicine in
• Chief Executive of the NHS in England
• Consultants in respiratory medicine in England
• Consultants in elderly care in England and
• Clinical directors for physiotherapy in England
• Chief Medical, Nursing and Pharmaceutical
• Directorate nurse managers for occupational
• Medical Director & Head of NHS Quality - Welsh
• Directorate nurse managers for rehabilitation in
• Representative bodies for health services,
professional organisations and statutory bodies
• Directorate nurse managers for respiratory
This guidance is written in the following context: This guidance represents the view of the Institute, which was arrived at after careful consideration of the evidence available. Health professionals are expected to take it fully into account when exercising their clinical judgement. The guidance does not, however, override the individual responsibility of health professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer. National Institute for Clinical Excellence
MidCity Place71 High HolbornLondon WC1V 6NA
ISBN: 1-84257-542-2Published by the National Institute for Clinical ExcellenceFebruary 2004
Copyright National Institute for Clinical Excellence, February 2004. All rights reserved. This material may be freelyreproduced for educational and not-for-profit purposes within the NHS. No reproduction by or for commercialorganisations is allowed without the express written permission of the National Institute for Clinical Excellence. Contents Working definition of chronic obstructive pulmonary disease Key priorities for implementation Guidance Diagnosing COPD Symptoms Spirometry Further investigations Reversibility testing Assessment of severity Identification of early disease Referral for specialist advice Managing stable COPD Smoking cessation Inhaled bronchodilator therapy Theophylline Corticosteroids Combination therapy Delivery systems used to treat patients with stable COPD Non-invasive ventilation Management of pulmonary hypertension and cor pulmonale 1.2.10 Pulmonary rehabilitation 1.2.11 Vaccination and anti-viral therapy 1.2.12 Lung surgery 1.2.13 Alpha-1 antitrypsin replacement therapy 1.2.14 Mucolytic therapy 1.2.15 Anti-oxidant therapy 1.2.16 Anti-tussive therapy 1.2.17 Prophylactic antibiotic therapy 1.2.18 Multidisciplinary management 1.2.19 Fitness for general surgery 1.2.20 Follow up of patients with COPD Management of exacerbations of COPD Definition of an exacerbation Assessment of need for hospital treatment Investigation of an exacerbation Hospital-at-home and assisted-discharge schemes Pharmacological management Oxygen therapy during exacerbations of COPD Non-invasive ventilation and COPD exacerbations Invasive ventilation and intensive care Respiratory physiotherapy and exacerbations 1.3.10 Monitoring recovery from an exacerbation 1.3.11 Discharge planning Notes on the scope of the guidance Implementation in the NHS In general Research recommendations Full guideline Related NICE guidance Review date Appendix A: Appendix B: Appendix C: Appendix D:
Technical detail on the criteria for audit
Appendix E:
NICE Guideline – Chronic obstructive pulmonary disease
Working definition of chronic obstructive pulmonary disease
Chronic obstructive pulmonary disease (COPD) is characterised byairflow obstruction. The airflow obstruction is usually progressive,not fully reversible and does not change markedly over severalmonths. The disease is predominantly caused by smoking.
• Airflow obstruction is defined as a reduced FEV1 (forced expiratory
volume in 1 second) and a reduced FEV1/FVC ratio (where FVC isforced vital capacity), such that FEV1 is less than 80% predictedand FEV1/FVC is less than 0.7.
• The airflow obstruction is due to a combination of airway and
• The damage is the result of chronic inflammation that differs from
that seen in asthma and which is usually the result of tobaccosmoke.
• Significant airflow obstruction may be present before the
• COPD produces symptoms, disability and impaired quality of life
which may respond to pharmacological and other therapies thathave limited or no impact on the airflow obstruction.
• COPD is now the preferred term for the conditions in patients
with airflow obstruction who were previously diagnosed as havingchronic bronchitis or emphysema.
• Other factors, particularly occupational exposures, may also
contribute to the development of COPD.
There is no single diagnostic test for COPD. Making a diagnosis relieson clinical judgement based on a combination of history, physicalexamination and confirmation of the presence of airflow obstructionusing spirometry.
NICE Guideline – Chronic obstructive pulmonary disease
Key priorities for implementation
The following recommendations have been identified as prioritiesfor implementation. Diagnose COPD
• A diagnosis of COPD should be considered in patients over the
age of 35 who have a risk factor (generally smoking) and whopresent with exertional breathlessness, chronic cough, regularsputum production, frequent winter ‘bronchitis’ or wheeze. Thepresence of airflow obstruction should be confirmed byperforming spirometry.
• All health professionals managing patients with COPD should
have access to spirometry and be competent in the interpretationof the results.
Stop smoking
• Encouraging patients with COPD to stop smoking is one of the
most important components of their management. All COPDpatients still smoking, regardless of age, should be encouraged tostop, and offered help to do so, at every opportunity. Effective inhaled therapy
• Long-acting inhaled bronchodilators (beta2-agonists and/or
anticholinergics) should be used to control symptoms and improveexercise capacity in patients who continue to experience problemsdespite the use of short-acting drugs.
• Inhaled corticosteroids should be added to long-acting
bronchodilators to decrease exacerbation frequency in patientswith an FEV1 less than or equal to 50% predicted who have hadtwo or more exacerbations requiring treatment with antibiotics ororal corticosteroids in a 12-month period. Pulmonary rehabilitation for all who need it
• Pulmonary rehabilitation should be made available to all
NICE Guideline – Chronic obstructive pulmonary disease
Use non-invasive ventilation
• Non-invasive ventilation (NIV) should be used as the treatment of
choice for persistent hypercapnic ventilatory failure duringexacerbations not responding to medical therapy. It should bedelivered by staff trained in its application, experienced in its useand aware of its limitations.
• When patients are started on NIV, there should be a clear plan
covering what to do in the event of deterioration and ceilings oftherapy should be agreed. Manage exacerbations
• The frequency of exacerbations should be reduced by appropriate
use of inhaled corticosteroids and bronchodilators, andvaccinations.
• The impact of exacerbations should be minimised by:
– giving self-management advice on responding promptly to the
– starting appropriate treatment with oral corticosteroids and/or
– use of non-invasive ventilation when indicated– use of hospital-at-home or assisted-discharge schemes. Multidisciplinary working
• COPD care should be delivered by a multidisciplinary team.
NICE Guideline – Chronic obstructive pulmonary disease
The following guidance is evidence based. The grading scheme usedfor the recommendations (A, B, C, D, NICE or HSC) is described inAppendix A; a summary of the evidence on which the guidance isbased is provided in the full guideline (see Section 5).
Guidance Diagnosing COPD
The diagnosis of COPD depends on thinking of it as a cause ofbreathlessness or cough. The diagnosis is suspected on the basis ofsymptoms 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 followingsymptoms:
• exertional breathlessness• chronic cough• regular sputum production• frequent winter ‘bronchitis’• wheeze.
Patients in whom a diagnosis of COPD is considered should
also be asked about the presence of the following factors:
• weight loss• effort intolerance• waking at night • ankle swelling• fatigue• occupational hazards• chest pain• haemoptysis.
NB These last two symptoms are uncommon in COPD andraise the possibility of an alternative diagnosis.
One of the primary symptoms of COPD is breathlessness.
The Medical Research Council (MRC) dyspnoea scale (seeTable 1) should be used to grade the breathlessnessaccording to the level of exertion required to elicit it.
NICE Guideline – Chronic obstructive pulmonary disease
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 ofbreathlessness, or has to stop for breath when walking at own pace
Stops for breath after walking about 100 m or after a few minutes onlevel ground
Too breathless to leave the house, or breathless when dressing orundressing
Adapted from Fletcher CM, Elmes PC, Fairbairn MB et al. (1959) The significance ofrespiratory symptoms and the diagnosis of chronic bronchitis in a workingpopulation. British Medical Journal 2:257–66. Spirometry
• at the time of diagnosis• to reconsider the diagnosis, if patients show an
exceptionally good response to treatment.
All health professionals managing patients with COPD
should have access to spirometry and be competent in theinterpretation of the results.
Spirometry can be performed by any healthcare worker
who has undergone appropriate training and who keepshis or her skills up to date.
Spirometry services should be supported by quality control
It is recommended that ERS 1993 reference values* are
used but it is recognised that these values may lead tounder-diagnosis in the elderly and are not applicable inblack and Asian populations.
* Quanjer PH, Tammeling GJ, Cotes JE et al. (1993) Lung volumes and forced
ventilatory flows. Report Working Party Standardization of Lung Function Tests,European Community for Steel and Coal. Official Statement of the EuropeanRespiratory Society. European Respiratory Journal (Suppl) 16:5–40.
NICE Guideline – Chronic obstructive pulmonary disease
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.
Additional investigations should be performed to aid
management in some circumstances (see Table 2).
Patients identified as having alpha-1 antitrypsin deficiency
should be offered the opportunity to be referred to aspecialist centre to discuss the clinical management of thiscondition. Investigation
To exclude asthma if diagnostic doubt remains
If early onset, minimal smoking history or familyhistory
To investigate symptoms that seem disproportionate to
carbon monoxide (TLCO) the spirometric impairment
To investigate symptoms that seem disproportionate tothe spirometric impairment
To investigate abnormalities seen on a chestradiograph
To assess cardiac status if features of cor pulmonale
To assess cardiac status if features of cor pulmonale
To assess need for oxygen therapyIf cyanosis, or cor pulmonale present, or if FEV1 < 50%predicted
To identify organisms if sputum is persistently presentand purulent
NICE Guideline – Chronic obstructive pulmonary disease
Reversibility testing
In most patients, routine spirometric reversibility testing is
not necessary as a part of the diagnostic process or to planinitial therapy with bronchodilators or corticosteroids. Itmay be unhelpful or misleading because:
• repeated FEV1 measurements can show small
• 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 than400 ml
• the definition of the magnitude of a significant change
• response to long-term therapy is not predicted by acute
COPD and asthma are frequently distinguishable on the
basis of history (and examination) in untreated patientspresenting for the first time. Features from the history andexamination (such as those listed in Table 3) should be usedto differentiate COPD from asthma whenever possible.
Longitudinal observation of patients (whether using
spirometry, peak flow or symptoms) should also be used tohelp differentiate COPD from asthma.
Table 3 Clinical features differentiating COPD and asthma
Night time waking with breathlessness and/or
Significant diurnal or day to day variability of
NICE Guideline – Chronic obstructive pulmonary disease
To help resolve cases where diagnostic doubt remains, or
both COPD and asthma are present, the following findingsshould be used to help identify asthma:
• a large (greater than 400 ml) response to
• a large (greater than 400 ml) response to 30 mg oral
• serial peak flow measurements showing 20% or greater
Clinically significant COPD is not present if the FEV1 andFEV1/FVC ratio return to normal with drug therapy.
If diagnostic uncertainty remains, referral for more detailed
investigations, including imaging and measurement ofTLCO, should be considered.
If patients report a marked improvement in symptoms in
response to inhaled therapy, the diagnosis of COPD shouldbe reconsidered. Assessment of severity
COPD is heterogeneous, so no single measure can give an adequateassessment of the true severity of the disease in an individualpatient. Severity assessment is, nevertheless, important because it hasimplications for therapy and relates to prognosis.
Mild airflow obstruction can be associated with significant
disability in patients with COPD. A true assessment ofseverity should include assessment of the degree of airflowobstruction and disability, the frequency of exacerbationsand the following known prognostic factors:
• FEV1• TLCO • breathlessness (MRC scale)• health status• exercise capacity• BMI• partial pressure of oxygen in arterial blood (PaO2)• cor pulmonale.
The severity of airflow obstruction should be assessed
according to the reduction in FEV1 as shown in Table 4.
NICE Guideline – Chronic obstructive pulmonary disease
Table 4 Assessment of severity of airflow obstruction according to FEV1 as apercentage of the predicted value
Severity Identification of early disease
Spirometry should be performed in patients who are over
35, current or ex-smokers, and have a chronic cough.
Spirometry should be considered in patients with chronic
bronchitis. A significant proportion of these will go on todevelop airflow limitation. Referral for specialist advice
It is recommended that referrals for specialist advice are
made when clinically indicated. Referral may beappropriate at all stages of the disease and not solely inthe most severely disabled patients (see Table 5).
Patients who are referred do not always have to be seen by
a respiratory physician. In some cases they may be seen bymembers of the COPD team who have appropriate trainingand expertise. Managing stable COPD Smoking cessation
An up-to-date smoking history, including pack years
smoked (number of cigarettes smoked per day, divided by20, multiplied by the number of years smoked), should bedocumented for everyone with COPD.
All COPD patents still smoking, regardless of age, should be
encouraged to stop, and offered help to do so, at everyopportunity.
Unless contraindicated, bupropion or nicotine replacement
therapy combined with an appropriate support programmeshould be used to optimise smoking quit rates for peoplewith COPD.
NICE Guideline – Chronic obstructive pulmonary disease
Confirm diagnosis, optimisepharmacotherapy and access othertherapists
NICE Guideline – Chronic obstructive pulmonary disease
NICE Technology Appraisal Guidance No 39 (see Section 6)
“If a smoker’s attempt to quit is unsuccessful withtreatment using either NRT or bupropion, the NHS shouldnormally fund no further attempts within 6 months. However, if external factors interfere with a person’s initialattempt to stop smoking, it may be reasonable to try againsooner.”
Inhaled bronchodilator therapy
Short-acting bronchodilators, as necessary, should be the
initial empirical treatment for the relief of breathlessnessand exercise limitation.
The effectiveness of bronchodilator therapy should not be
assessed by lung function alone but should include avariety of other measures such as improvement insymptoms, activities of daily living, exercise capacity, andrapidity of symptom relief.
Patients who remain symptomatic should have their
inhaled treatment intensified to include long-actingbronchodilators or combined therapy with a short-actingbeta2-agonist and a short-acting anticholinergic.
Long-acting bronchodilators should be used in patients
who remain symptomatic despite treatment with short-acting bronchodilators because these drugs appear to haveadditional benefits over combinations of short-actingdrugs.
Long-acting bronchodilators should also be used in patients
who have two or more exacerbations per year.
The choice of drug(s) should take into account the patient’s
response to a trial of the drug, the drug’s side effects,patient preference and cost. Theophylline
In this section of the guideline, the term theophylline is used tomean slow-release formulations of this drug.
Theophylline should only be used after a trial of short-
acting bronchodilators and long-acting bronchodilators, orin patients who are unable to use inhaled therapy, as thereis a need to monitor plasma levels and interactions.
NICE Guideline – Chronic obstructive pulmonary disease
Particular caution needs to be taken with the use of
theophylline in elderly patients because of differences inpharmacokinetics, the increased likelihood of comorbiditiesand the use of other medications.
The effectiveness of the treatment with theophylline
should be assessed by improvements in symptoms, activitiesof daily living, exercise capacity and lung function.
The dose of theophylline prescribed should be reduced at
the time of an exacerbation if macrolide or fluroquinoloneantibiotics (or other drugs known to interact) areprescribed. Corticosteroids
None of the inhaled corticosteroids currently available are licensedfor use alone in the treatment of COPD. The followingrecommendations therefore include usage outside licensedindications, and prescribers need to remember that responsibility forsuch prescribing lies with them.
Oral corticosteroid reversibility tests do not predict
response to inhaled corticosteroid therapy and should notbe used to identify which patients should be prescribedinhaled corticosteroids.
Inhaled corticosteroids should be prescribed for patients
with an FEV1 less than or equal to 50% predicted, who arehaving two or more exacerbations requiring treatmentwith antibiotics or oral corticosteroids in a 12-monthperiod. The aim of treatment is to reduce exacerbationrates and slow the decline in health status and not toimprove lung function per se.
Clinicians should be aware of the potential risk of
developing osteoporosis and other side effects in patientstreated with high-dose inhaled corticosteroids (especially inthe presence of other risk factors), and should discuss therisk with patients.
Maintenance use of oral corticosteroid therapy in COPD is
not normally recommended. Some patients with advancedCOPD may require maintenance oral corticosteroids whenthese cannot be withdrawn following an exacerbation. In
NICE Guideline – Chronic obstructive pulmonary disease
these cases, the dose of oral corticosteroids should be keptas low as possible.
Patients treated with long-term oral corticosteroid therapy
should be monitored for the development of osteoporosisand given appropriate prophylaxis. Patients over the age of65 should be started on prophylactic treatment, withoutmonitoring. Combination therapy
If patients remain symptomatic on monotherapy, their
treatment should be intensified by combining therapiesfrom different drug classes. Effective combinations include:
• beta2-agonist and anticholinergic• beta2-agonist and theophylline• anticholinergic and theophylline• long-acting beta2-agonist and inhaled corticosteroid.
The clinical effectiveness of combined treatments can be
assessed by improvements in symptoms, activities of dailyliving, exercise capacity and lung function. Combinationtreatment should be discontinued if there is no benefitafter 4 weeks. Delivery systems used to treat patients with stable COPD
Most patients – whatever their age – are able to acquire andmaintain adequate inhaler technique given adequate instruction. The exception to this is that those with significant cognitiveimpairment (as a guideline, those with a Hodkinson AbbreviatedMental Test Score of 4 or less) are unable to use any form of inhalerdevice. In most patients, however, a pragmatic approach guided byindividual patient assessment is needed in choosing a device.
In most cases bronchodilator therapy is best administered
using a hand-held inhaler device (including a spacer deviceif appropriate).
If the patient is unable to use a particular device
satisfactorily, it is not suitable for him or her and analternative should be found.
Inhalers should be prescribed only after patients have
received training in the use of the device and havedemonstrated satisfactory technique.
NICE Guideline – Chronic obstructive pulmonary disease
Patients should have their ability to use an inhaler device
regularly assessed by a competent healthcare professionaland, if necessary, should be re-taught the correcttechnique.
To ensure optimum efficacy for each patient with COPD,
the dose of medication should be titrated according toindividual clinical response.
The spacer should be compatible with the patient’s
It is recommended that spacers are used in the following
• The drug is administered by repeated single actuations
of the metered dose inhaler into the spacer, with eachfollowed by inhalation.
• There should be minimal delay between inhaler
• Tidal breathing can be used as it is as effective as single
Spacers should be cleaned no more than monthly as more
frequent cleaning affects their performance (due to buildup of static). They should be cleaned with water andwashing-up liquid and allowed to air dry. The mouthpieceshould be wiped clean of detergent before use.
Patients with distressing or disabling breathlessness despite
maximal therapy using inhalers should be considered fornebuliser therapy.
1.2.6.10 Nebulised therapy should not continue to be prescribed
without assessing and confirming that one or more of thefollowing occurs:
• a reduction in symptoms• an increase in the ability to undertake activities of daily
• an increase in exercise capacity• an improvement in lung function.
1.2.6.11 Nebulised therapy should not be prescribed without an
assessment of the patient’s and/or carer’s ability to use it.
NICE Guideline – Chronic obstructive pulmonary disease
1.2.6.12 A nebuliser system that is known to be efficient should be
used. Once available, Comité Europeen de Normalisation(European Committee for Standardisation, CEN) datashould be used to assess efficiency.
1.2.6.13 Patients should be offered a choice between a facemask
and a mouthpiece to administer their nebulised therapy,unless the drug specifically requires a mouthpiece (forexample, anticholinergic drugs).
1.2.6.14 If nebuliser therapy is prescribed, the patient should be
provided with equipment, servicing, advice and support.
Clinicians should be aware that inappropriate oxygen
therapy in people with COPD may cause respiratorydepression.
LTOT is indicated in patients with COPD who have a PaO2
less than 7.3 kPa when stable or a PaO2 greater than 7.3and less than 8 kPa when stable and one of: secondarypolycythaemia, nocturnal hypoxaemia (oxygen saturationof arterial blood [SaO2] less than 90% for more than 30%of time), peripheral oedema or pulmonary hypertension.
To get the benefits of LTOT patients should breathe
supplemental oxygen for at least 15 hours per day. Greaterbenefits are seen in patients receiving oxygen for 20 hoursper day.
The need for oxygen therapy should be assessed in:
• all patients with severe airflow obstruction (FEV1 less
• patients with cyanosis • patients with polycythaemia• patients with peripheral oedema • patients with a raised jugular venous pressure • patients with oxygen saturations less than or equal to
Assessment should also be considered in patients withmoderate airflow obstruction (FEV1 30–49% predicted).
NICE Guideline – Chronic obstructive pulmonary disease
To ensure all patients eligible for long-term oxygen therapy
(LTOT) are identified, pulse oximetry should be available inall healthcare settings.
The assessment of patients for LTOT should comprise the
measurement of arterial blood gasses on two occasions atleast 3 weeks apart in patients who have a confidentdiagnosis of COPD, who are receiving optimum medicalmanagement and whose COPD is stable.
Patients receiving LTOT should be reviewed at least once
per year by practitioners familiar with LTOT and this reviewshould include pulse oximetry.
Oxygen concentrators should be used to provide the fixed
supply at home for long-term oxygen therapy.
Patients should be warned about the risks of fire and
explosion if they continue to smoke when prescribedoxygen.
1.2.7.10 People who are already on LTOT who wish to continue
with oxygen therapy outside the home, and who areprepared to use it, should have ambulatory oxygenprescribed.
1.2.7.11 Ambulatory oxygen therapy should be considered in
patients who have exercise desaturation, are shown tohave an improvement in exercise capacity and/or dyspnoeawith oxygen, and have the motivation to use oxygen.
1.2.7.12 Ambulatory oxygen therapy is not recommended in COPD
if PaO2 is greater than 7.3 kPa and there is no exercisedesaturation.
1.2.7.13 Ambulatory oxygen therapy should only be prescribed after
an appropriate assessment has been performed by aspecialist. The purpose of the assessment is to assess theextent of desaturation, and the improvement in exercisecapacity with supplemental oxygen, and the oxygen flowrate required to correct desaturation, aiming to keep theSaO2 above 90%.
1.2.7.14 Small light-weight cylinders, oxygen-conserving devices and
portable liquid oxygen systems should be available for thetreatment of patients with COPD.
NICE Guideline – Chronic obstructive pulmonary disease
Table 6 Appropriate equipment for ambulatory oxygen therapy
Equipment
For a duration of use of less than 90 minutes
For a duration of use less than 4 hours but
1.2.7.15 A choice about the nature of equipment prescribed should
take account of the hours of ambulatory oxygen userequired by the patient and the oxygen flow rate required(see Table 6).
1.2.7.16 Short-burst oxygen therapy should only be considered for
episodes of severe breathlessness in patients with COPDnot relieved by other treatments.
1.2.7.17 Short-burst oxygen therapy should only continue to be
prescribed if an improvement in breathlessness followingtherapy has been documented.
1.2.7.18 When indicated, short-burst oxygen should be provided
Non-invasive ventilation
Adequately treated patients with chronic hypercapnic
ventilatory failure who have required assisted ventilation(whether invasive or non-invasive) during an exacerbationor who are hypercapnic or acidotic on LTOT should bereferred to a specialist centre for consideration of long-term NIV. Management of pulmonary hypertension and cor pulmonale
Diagnosis of pulmonary hypertension and cor pulmonale
In the context of this guideline, the term ‘cor pulmonale’ has beenadopted to define a clinical condition that is identified and managedon the basis of clinical features. This clinical syndrome of cor
NICE Guideline – Chronic obstructive pulmonary disease
pulmonale includes patients who have right heart failure secondaryto lung disease and those in whom the primary pathology isretention of salt and water, leading to the development ofperipheral oedema.
A diagnosis of cor pulmonale should be considered if
• peripheral oedema• 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 involveexcluding other causes of peripheral oedema.
Patients presenting with cor pulmonale should be assessed
for the need for long-term oxygen therapy.
Oedema associated with cor pulmonale can usually be
controlled symptomatically with diuretic therapy.
The following are not recommended for the treatment of
• angiotensin-converting enzyme inhibitors• calcium channel blockers• alpha-blockers• digoxin (unless there is atrial fibrillation). 1.2.10 Pulmonary rehabilitation
Pulmonary rehabilitation is defined as a multidisciplinary programmeof care for patients with chronic respiratory impairment that isindividually tailored and designed to optimise the individual’sphysical and social performance and autonomy.
1.2.10.1 Pulmonary rehabilitation should be made available to all
1.2.10.2 Pulmonary rehabilitation should be offered to all patients
who consider themselves functionally disabled by COPD(usually MRC grade 3 and above). Pulmonary rehabilitationis not suitable for patients who are unable to walk, haveunstable angina or who have had a recent myocardialinfarction.
NICE Guideline – Chronic obstructive pulmonary disease
1.2.10.3 For pulmonary rehabilitation programmes to be effective,
and to improve concordance, they should be held at timesthat suit patients, and in buildings that are easy forpatients to get to and have good access for people withdisabilities. Places should be available within a reasonabletime of referral.
1.2.10.4 Pulmonary rehabilitation programmes should include multi-
component, multidisciplinary interventions, which aretailored to the individual patient’s needs. The rehabilitationprocess should incorporate a programme of physicaltraining, disease education, nutritional, psychological andbehavioural intervention.
1.2.10.5 Patients should be made aware of the benefits of
pulmonary rehabilitation and the commitment required togain these. 1.2.11 Vaccination and anti-viral therapy
1.2.11.1 Pneumococcal vaccination and an annual influenza
vaccination should be offered to all patients with COPD asrecommended by the Chief Medical Officer.
1.2.11.2 NICE Technology Appraisal Guidance No. 58 (see Section 6)
“Within their licensed indications, zanamivir andoseltamivir are recommended for the treatment of at-riskadults who present with influenza-like illness and who canstart therapy within 48 hours of the onset of symptoms.”
The technology appraisal also notes that zanamivir shouldbe used with caution in people with COPD because of riskof bronchospasm. If people with COPD are prescribedzanamivir they should be made aware of the risks and havea fast-acting bronchodilator available. 1.2.12 Lung surgery
1.2.12.1 Patients who are breathless, and have a single large bulla
on a CT scan and an FEV1 less than 50% predicted shouldbe referred for consideration of bullectomy.
1.2.12.2 Patients with severe COPD who remain breathless with
marked restrictions of their activities of daily living, despitemaximal medical therapy (including rehabilitation), should
NICE Guideline – Chronic obstructive pulmonary disease
be referred for consideration of lung volume reductionsurgery if they meet all of the following criteria:
• FEV1 more than 20% predicted • PaCO2 less than 7.3 kPa • upper lobe predominant emphysema • TLCO more than 20% predicted.
1.2.12.3 Patients with severe COPD who remain breathless with
marked restrictions of their activities of daily living despitemaximal medical therapy should be considered for referralfor assessment for lung transplantation, bearing in mindcomorbidities and local surgical protocols. Considerationsinclude:
• age• FEV1• PaCO2• homogeneously distributed emphysema on CT scan • elevated pulmonary artery pressures with progressive
1.2.13 Alpha-1 antitrypsin replacement therapy
1.2.13.1 Alpha-1 antitrypsin replacement therapy is not
recommended in the management of patients with alpha-1antitrypsin deficiency (see also recommendation 1.1.3.3). 1.2.14 Mucolytic therapy
1.2.14.1 Mucolytic drug therapy should be considered in patients
with a chronic cough productive of sputum.
1.2.14.2 Mucolytic therapy should be continued if there is
symptomatic improvement (for example, reduction infrequency of cough and sputum production). 1.2.15 Anti-oxidant therapy
1.2.15.1 Treatment with alpha-tocopherol and beta-carotene
supplements, alone or in combination, is notrecommended. 1.2.16 Anti-tussive therapy
1.2.16.1 Anti-tussive therapy should not be used in the
NICE Guideline – Chronic obstructive pulmonary disease
1.2.17 Prophylactic antibiotic therapy
1.2.17.1 There is insufficient evidence to recommend prophylactic
antibiotic therapy in the management of stable COPD. 1.2.18 Multidisciplinary management
Multidisciplinary working is breaking down historic demarcation ofroles and many of the activities in managing COPD can beundertaken by individuals from different professional backgrounds. Many of these activities may be undertaken in the clinic or in thepractice as part of routine care by the practitioner seeing the patientbut in certain circumstances it may be necessary for the patient to bereferred to a specialist department, such as physiotherapy.
1.2.18.1 COPD care should be delivered by a multidisciplinary team.
1.2.18.2 The following functions should be considered when
defining the activity of the multidisciplinary team:
• assessing patients (including performing spirometry,
assessing the need for oxygen, the need for aids for dailyliving and the appropriateness of delivery systems forinhaled therapy)
• managing patients (including non-invasive ventilation,
pulmonary rehabilitation, hospital-at-home/early-discharge schemes, providing palliative care, identifyingand managing anxiety and depression, advising patientson relaxation techniques, dietary issues, exercise, socialsecurity benefits and travel)
• advising patients on self-management strategies• identifying and monitoring patients at high risk of
exacerbations and undertaking activities which aim toavoid emergency admissions
• advising patients on exercise• education of patients and other health professionals.
1.2.18.3 It is recommended that respiratory nurse specialists form
part of the multidisciplinary COPD team.
1.2.18.4 If patients have excessive sputum, they should be taught:
• the use of positive expiratory pressure masks
• active cycle of breathing techniques.
NICE Guideline – Chronic obstructive pulmonary disease
Identifying and managing anxiety and depression
1.2.18.5 Healthcare professionals should be alert to the presence of
depression in patients with COPD. The presence of anxietyand depression should be considered in patients:
• who are hypoxic (SaO2 less than 92%)• who have severe dyspnoea• who have been seen at or admitted to a hospital with an
1.2.18.6 The presence of anxiety and depression in patients with
COPD can be identified using validated assessment tools.
1.2.18.7 Patients found to be depressed or anxious should be
treated with conventional pharmacotherapy.
1.2.18.8 For antidepressant treatment to be successful, it needs to
be supplemented by spending time with the patientexplaining why depression needs to be treated alongsidethe physical disorder.
1.2.18.9 BMI should be calculated in patients with COPD (see
• The normal range for BMI is 20 to less than 25. • If the BMI is abnormal (high or low), or changing over
time, the patient should be referred for dietetic advice.
• If the BMI is low, patients should also be given
nutritional supplements to increase their total calorificintake, and be encouraged to take exercise to augmentthe effects of nutritional supplementation.
The NICE guideline Nutritional support in adults: oralsupplements, enteral and parenteral feeding, can bereferred to when it is available (scheduled for publicationin December 2005).
1.2.18.10 In older patients, attention should also be paid to changes
in weight, particularly if the change is more than 3 kg.
1.2.18.11 Opioids should be used when appropriate to palliate
breathlessness in patients with end-stage COPD which isunresponsive to other medical therapy.
NICE Guideline – Chronic obstructive pulmonary disease
1.2.18.12 Benzodiazepines, tricyclic antidepressants, major
tranquillisers and oxygen should also be used whenappropriate for breathlessness in patients with end-stageCOPD unresponsive to other medical therapy.
1.2.18.13 Patients with end-stage COPD and their family and carers
should have access to the full range of services offered bymultidisciplinary palliative care teams, including admissionto hospices.
1.2.18.14 Patients should be regularly asked about their ability to
undertake activities of daily living and how breathless theybecome when doing these.
1.2.18.15 Clinicians managing patients with COPD should assess their
need for occupational therapy using validated tools.
1.2.18.16 Patients disabled by COPD should be considered for referral
for assessment by a social services department.
1.2.18.17 All patients on LTOT planning air travel should be assessed
in line with the BTS recommendations*.
1.2.18.18 All patients with an FEV1 less than 50% predicted who are
planning air travel should be assessed in line with the BTSrecommendations.
1.2.18.19 All patients known to have bullous disease should be
warned that they are at a theoretically increased risk ofdeveloping a pneumothorax during air travel.
1.2.18.20 Scuba diving is not recommended for patients with COPD.
1.2.18.21 There are significant differences in the response of patients
with COPD and asthma to education programmes. Programmes designed for asthma should not be used inCOPD.
* Managing passengers with respiratory disease planning air travel: British
Thoracic Society recommendations (2002) Thorax 57(4):289–304.
NICE Guideline – Chronic obstructive pulmonary disease
1.2.18.22 Specific educational packages should be developed for
• Suggested topics for inclusion are listed in Appendix C of
the full guideline (see Section 5 for details of the fullguideline).
• The packages should take account of the different needs
of patients at different stages of their disease.
1.2.18.23 Patients with moderate and severe COPD should be made
aware of the technique of NIV. Its benefits and limitationsshould be explained so that, if it is ever necessary in thefuture, they will be aware of these issues (see Section1.3.7).
1.2.18.24 Patients at risk of having an exacerbation of COPD should
be given self-management advice that encourages them torespond promptly to the symptoms of an exacerbation.
1.2.18.25 Patients should be encouraged to respond promptly to the
• starting oral corticosteroid therapy if their increased
breathlessness interferes with activities of daily living(unless contraindicated)
• starting antibiotic therapy if their sputum is purulent• adjusting their bronchodilator therapy to control their
1.2.18.26 Patients at risk of having an exacerbation of COPD should
be given a course of antibiotic and corticosteroid tablets tokeep at home for use as part of a self-managementstrategy (see recommendation 1.3.5.9).
1.2.18.27 The appropriate use of these tablets should be monitored.
1.2.18.28 Patients given self-management plans should be advised to
contact a healthcare professional if they do not improve. 1.2.19 Fitness for general surgery
1.2.19.1 The ultimate clinical decision about whether or not to
proceed with surgery should rest with a consultantanaesthetist and consultant surgeon taking account of thepresence of comorbidities, the functional status of thepatient and the necessity of the surgery.
NICE Guideline – Chronic obstructive pulmonary disease
1.2.19.2 It is recommended that lung function should not be the
only criterion used to assess patients with COPD beforesurgery. Composite assessment tools such as the ASAscoring system are the best predictors of risk.
1.2.19.3 If time permits, the medical management of the patient
should be optimised prior to surgery and this might includeundertaking a course of pulmonary rehabilitation. 1.2.20 Follow up of patients with COPD
1.2.20.1 Follow up of all patients with COPD should include:
• highlighting the diagnosis of COPD in the case record
and recording this using Read codes on a computerdatabase
• recording the values of spirometric tests performed at
diagnosis (both absolute and percent predicted)
• offering smoking cessation advice• recording the opportunistic measurement of spirometric
parameters (a loss of 500 ml or more over 5 years willselect out those patients with rapidly progressing diseasewho may need specialist referral and investigation).
1.2.20.2 Patients with mild or moderate COPD should be reviewed
at least once per year, or more frequently if indicated, andthe review should cover the issues listed in Table 7.
1.2.20.3 For most patients with stable severe disease regular
hospital review is not necessary, but there should be locallyagreed mechanisms to allow rapid access to hospitalassessment when necessary.
1.2.20.4 When patients with severe COPD are reviewed in primary
care, they should be seen at least twice a year, and specificattention should be paid to the issues listed in Table 7.
1.2.20.5 Patients with severe disease requiring interventions such as
long-term non-invasive ventilation should be reviewedregularly by specialists.
NICE Guideline – Chronic obstructive pulmonary disease
Table 7 Summary of follow up of patients with COPD in primary care
Mild/Moderate Frequency At least annual At least twice per year
• Need for referral to specialist • Presence of depression
• Inhaler technique• Need for social services and
Management of exacerbations of COPD Definition of an exacerbation
An exacerbation is a sustained worsening of the patient’s symptomsfrom their usual stable state which is beyond normal day-to-dayvariations, and is acute in onset. Commonly reported symptoms areworsening breathlessness, cough, increased sputum production andchange in sputum colour. The change in these symptoms oftennecessitates a change in medication. 1.3.2 Assessment of need for hospital treatment
Factors that should be used to assess the need to treat
patients in hospital are listed in Table 8.
NICE Guideline – Chronic obstructive pulmonary disease
Table 8 Factors to consider when deciding where to treat the patient
Treat at home Treat in hospital
cardiac disease and insulin-dependentdiabetes)
Investigation of an exacerbation
The diagnosis of an exacerbation is made clinically and does notdepend on the results of investigations; however, in certainsituations, investigations may assist in ensuring appropriatetreatment is given. Different investigation strategies are required forpatients managed in hospital (who will tend to have more severeexacerbations) and those managed in the community.
NICE Guideline – Chronic obstructive pulmonary disease
In patients with an exacerbation managed in primary care:
• sending sputum samples for culture is not recommended
• pulse oximetry is of value if there are clinical features of
In all patients with an exacerbation referred to hospital:
• a chest radiograph should be obtained• arterial blood gas tensions should be measured and the
• an ECG should be recorded (to exclude comorbidities)• a full blood count should be performed and urea and
electrolyte concentrations should be measured
• a theophylline level should be measured in patients on
• if sputum is purulent, a sample should be sent for
• blood cultures should be taken if the patient is pyrexial
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 ofmanaging patients with exacerbations of COPD who wouldotherwise need to be admitted or stay in hospital.
The multi-professional team required to operate these
schemes should include allied heath professionals withexperience in managing patients with COPD, and mayinclude nurses, physiotherapists, occupational therapistsand generic health workers.
There are currently insufficient data to make firm
recommendations about which patients with anexacerbation are most suitable for hospital at home orearly discharge. Patient selection should depend on theresources available and absence of factors associated with aworse prognosis, such as acidosis.
Patient’s preferences about treatment at home or in
NICE Guideline – Chronic obstructive pulmonary disease
Pharmacological management
Increased breathlessness is a common feature of an exacerbation ofCOPD. This is usually managed by taking increased doses of short-acting bronchodilators and these drugs may be given using differentdelivery systems.
Delivery systems for inhaled therapy during exacerbations
Both nebulisers and hand-held inhalers can be used to
administer inhaled therapy during exacerbations of COPD.
The choice of delivery system should reflect the dose of
drug required, the ability of the patient to use the deviceand the resources available to supervise the administrationof the therapy.
Patients should be changed to hand-held inhalers as soon
as their condition has stabilised because this may permitearlier discharge from hospital.
If a patient is hypercapnic or acidotic the nebuliser should
be driven by compressed air, not oxygen (to avoidworsening hypercapnia). If oxygen therapy is needed itshould be administered simultaneously by nasal cannulae.
The driving gas for nebulised therapy should always be
In the absence of significant contraindications, oral
corticosteroids should be used, in conjunction with othertherapies, in all patients admitted to hospital with anexacerbation of COPD.
In the absence of significant contraindications, oral
corticosteroids should be considered in patients managedin the community who have an exacerbation with asignificant increase in breathlessness which interferes withdaily activities.
Patients requiring corticosteroid therapy should be
encouraged to present early to get maximum benefits (seerecommendations 1.2.17.24–27).
Prednisolone 30 mg orally should be prescribed for 7 to 14
NICE Guideline – Chronic obstructive pulmonary disease
1.3.5.10 It is recommended that a course of corticosteroid treatment
should not be longer than 14 days as there is no advantagein prolonged therapy.
1.3.5.11 For guidance on stopping oral corticosteroid therapy it is
recommended that clinicians refer to the British NationalFormulary section 6.3.2.
1.3.5.12 Osteoporosis prophylaxis should be considered in patients
requiring frequent courses of oral corticosteroids.
1.3.5.13 Patients should be made aware of the optimum duration
of treatment and the adverse effects of prolonged therapy.
1.3.5.14 Patients, particularly those discharged from hospital, should
be given clear instructions about why, when and how tostop their corticosteroid treatment.
1.3.5.15 Antibiotics should be used to treat exacerbations of COPD
associated with a history of more purulent sputum.
1.3.5.16 Patients with exacerbations without more purulent sputum
do not need antibiotic therapy unless there is consolidationon a chest radiograph or clinical signs of pneumonia.
1.3.5.17 Initial empirical treatment should be an aminopenicillin, a
macrolide, or a tetracycline. When initiating empiricalantibiotic treatment, prescribers should always takeaccount of any guidance issued by their localmicrobiologists.
1.3.5.18 When sputum has been sent for culture, the
appropriateness of antibiotic treatment should be checkedagainst laboratory culture and sensitivities when theybecome available.
1.3.5.19 Intravenous theophylline should only be used as an adjunct
to the management of exacerbations of COPD if there is aninadequate response to nebulised bronchodilators.
1.3.5.20 Care should be taken when using intravenous theophylline
because of interactions with other drugs and potentialtoxicity if the patient has been on oral theophylline.
NICE Guideline – Chronic obstructive pulmonary disease
1.3.5.21 Theophylline levels should be monitored within 24 hours of
starting treatment and subsequently as frequently asindicated by the clinical circumstances.
1.3.5.22 It is recommended that doxapram is used only when
non-invasive ventilation is either unavailable or consideredinappropriate. Oxygen therapy during exacerbations of COPD
The oxygen saturation should be measured in patients with
an exacerbation of COPD, if there are no facilities tomeasure arterial blood gases.
If necessary, oxygen should be given to keep the SaO2
Pulse oximeters should be available to all healthcare
professionals managing patients with exacerbations ofCOPD and they should be trained in their use. Cliniciansshould be aware that pulse oximetry gives no informationabout the PCO2 or pH.
In the interim period while the recommendation on the
availability of oximeters is implemented, oxygen should begiven to all patients with an exacerbation of COPD who arebreathless, if the oxygen saturations are not known.
During the transfer to hospital the following points should
• It is not desirable to exceed an oxygen saturation of
93%. Oxygen therapy should be commenced atapproximately 40% and titrated upwards if saturationfalls below 90% and downwards if the patient becomesdrowsy or if the saturation exceeds 93–94%.
• Patients with known type II respiratory failure need
special care, especially if they require a long ambulancejourney or if they are given oxygen at home for aprolonged period before the ambulance arrives.
When the patient arrives at hospital, arterial blood gases
should be measured and the inspired oxygen concentrationnoted in all patients with an exacerbation of COPD. Arterial blood gas measurements should be repeatedregularly, according to the response to treatment.
NICE Guideline – Chronic obstructive pulmonary disease
The aim of supplemental oxygen therapy in exacerbations
of COPD is to maintain adequate levels of oxygenation(SaO2 greater than 90%), without precipitatingrespiratory acidosis or worsening hypercapnia. Patientswith pH less than 7.35 should be considered for ventilatorysupport. Non-invasive ventilation and COPD exacerbations
NIV should be used as the treatment of choice for
persistent hypercapnic ventilatory failure duringexacerbations despite optimal medical therapy.
It is recommended that NIV should be delivered in a
dedicated setting with staff who have been trained in itsapplication, who are experienced in its use and who areaware of its limitations.
When patients are started on NIV there should be a clear
plan covering what to do in the event of deterioration andceilings of therapy should be agreed. Invasive ventilation and intensive care
Patients with exacerbations of COPD should receive
treatment on intensive care units, including invasiveventilation when this is thought to be necessary.
During exacerbations of COPD, functional status, BMI,
requirement for oxygen when stable, comorbidities andprevious admissions to intensive care units should beconsidered, in addition to age and FEV1, when assessingsuitability for intubation and ventilation. Neither age norFEV1 should be used in isolation when assessing suitability.
NIV should be considered for patients who are slow to
Respiratory physiotherapy and exacerbations
Physiotherapy using positive expiratory pressure masks
should be considered for selected patients withexacerbations of COPD, to help with clearing sputum.
NICE Guideline – Chronic obstructive pulmonary disease
1.3.10 Monitoring recovery from an exacerbation
1.3.10.1 Patients’ recovery should be monitored by regular clinical
assessment of their symptoms and observation of theirfunctional capacity.
1.3.10.2 Pulse oximetry should be used to monitor the recovery of
patients with non-hypercapnic, non-acidotic respiratoryfailure.
1.3.10.3 Intermittent arterial blood gas measurements should be
used to monitor the recovery of patients with respiratoryfailure who are hypercapnic or acidotic, until they arestable.
1.3.10.4 Daily monitoring of PEF or FEV1 should not be performed
routinely to monitor recovery from an exacerbationbecause the magnitude of changes is small compared withthe variability of the measurement. 1.3.11 Discharge planning
1.3.11.1 Spirometry should be measured in all patients before
1.3.11.2 Patients should be re-established on their optimal
maintenance bronchodilator therapy before discharge.
1.3.11.3 Patients who have had an episode of respiratory failure
should have satisfactory oximetry or arterial blood gasresults before discharge.
1.3.11.4 All aspects of the routine care that patients receive
(including appropriateness and risk of side effects) shouldbe assessed before discharge.
1.3.11.5 Patients (or home carers) should be given appropriate
information to enable them to fully understand the correctuse of medications, including oxygen, before discharge.
1.3.11.6 Arrangements for follow-up and home care (such as visiting
nurse, oxygen delivery, referral for other support) shouldbe made before discharge.
1.3.11.7 Before the patient is discharged, the patient, family and
physician should be confident that he or she can managesuccessfully. When there is remaining doubt a formalactivities of daily living assessment may be helpful.
NICE Guideline – Chronic obstructive pulmonary disease
Notes on the scope of the guidance
All NICE guidelines are developed in accordance with a scopedocument that defines what the guideline will and will not cover. The scope of this guideline was established at the start of thedevelopment of this guideline, following a period of consultation; itis available from www.nice.org.uk/article.asp?a=32649
The guideline offers best practice advice on the care of adults whohave a clinical working diagnosis of COPD including chronicbronchitis, emphysema, and chronic airflow limitation/obstruction. The guideline is relevant to primary and secondary healthcareprofessionals who have direct contact with patients with COPD, andmake decisions about their care.
The guideline covers diagnostic criteria and identification of earlydisease. The guideline also makes recommendations on themanagement of stable patients, exacerbations and preventingprogression of the disease.
The guideline does not cover the management of people withasthma, bronchopulmonary dysplasia and bronchiectasis, nor does itcover children. Implementation in the NHS
Local health communities should review their existing practice forthe management of COPD against this guideline as they developtheir Local Delivery Plans. The review should consider the resourcesrequired to implement the recommendations set out in Section 1,the people and processes involved and the timeline over which fullimplementation is envisaged. It is in the interests of patients that theimplementation timeline is as rapid as possible.
Relevant local clinical guidelines, care pathways and protocols shouldbe reviewed in the light of this guidance and revised accordingly.
This guideline should be used in conjunction with the NICEtechnology appraisals listed in Section 6, and with the NationalService Framework for Older People, which is available fromwww.doh.gov.uk/nsf/olderpeople/index.htm
NICE Guideline – Chronic obstructive pulmonary disease
Suggested audit criteria are listed in Appendix D. These can be usedas the basis for local clinical audit, at the discretion of those inpractice. Research recommendations
The following research recommendations have been identified forthis NICE guideline. The Guideline Development Group’s full set ofresearch recommendations is detailed in the full guideline producedby the National Collaborating Centre for Chronic Conditions (seeSection 5).
There is a need for long-term studies on the absolute andcomparative efficacy of: – long-acting bronchodilators– theophylline– mucolytics (including the development of outcome measures)– combination therapies– ambulatory oxygen– alpha-1 antitrypsin replacement therapy.
There is a need for further studies on the efficacy of:– nebulised therapy– non-invasive ventilation– oxygen delivery systems– physiotherapy– pulmonary rehabilitation (in particular its efficacy compared
with pharmacological therapies and its efficacy in patients withmild and severe COPD).
There is a need for further studies on:– the content and efficacy of educational packages for patients
– the content and efficacy of self-management strategies for
Full guideline
The National Institute for Clinical Excellence commissioned thedevelopment of this guidance from the National CollaboratingCentre for Chronic Conditions. The Centre established a Guideline
NICE Guideline – Chronic obstructive pulmonary disease
Development Group, which reviewed the evidence and developedthe recommendations. The full guideline, Chronic ObstructivePulmonary Disease: Management of Chronic Obstructive PulmonaryDisease in Adults in Primary and Secondary Care, is published by theNational Collaborating Centre for Chronic Conditions; it is availableon its website www.rcplondon.ac.uk/college/ceeu/ncccc_index.htmthe NICE website (www.nice.org.uk/CG012fullguideline) and on thewebsite of the National Electronic Library for Health(www.nelh.nhs.uk).
The members of the Guideline Development Group are listed inAppendix B. Information about the independent Guideline ReviewPanel is given in Appendix C.
The booklet The Guideline Development Process – Information forthe Public and the NHS has more information about the Institute’sguideline development process. It is available from the Institute’swebsite and copies can also be ordered by telephoning0870 1555 455 (quote reference N0038). Related NICE guidance
National Institute for Clinical Excellence (2002). Guidance on the useof nicotine replacement therapy (NRT) and bupropion for smokingcessation. NICE Technology Appraisal Guidance No. 39. London:National Institute for Clinical Excellence. Available from:www.nice.org.uk/Docref.asp?d=30617
National Institute for Clinical Excellence (2003). Guidance on the useof zanamivir, oseltamivir and amantadine for the treatment ofinfluenza. NICE Technology Appraisal Guidance No. 58. London:National Institute for Clinical Excellence. Available from:www.nice.org.uk/Docref.asp?d=58060
NICE is in the process of developing the following guidance.
• Depression: the management of depression in primary and
secondary care. Clinical guideline. (Publication expected June2004.)
• Anxiety: management of generalised anxiety disorder and panic
disorder (with or without agoraphobia) in adults in primary,secondary and community care. Clinical guideline. (Publicationexpected June 2004.)
• Nutritional support in adults: oral supplements, enteral and
parenteral feeding. Clinical guideline. (Publication expectedDecember 2005.)
NICE Guideline – Chronic obstructive pulmonary disease
Review date
The process of reviewing the evidence is expected to begin 4 yearsafter the date of issue of this guideline. Reviewing may begin earlierthan 4 years if significant evidence that affects the guidelinerecommendations is identified sooner. The updated guideline will beavailable within 2 years of the start of the review process.
A version of this guideline for patients with COPD and theircarers, and for the public, is available from the NICE website(www.nice.org.uk) or from the NHS response line (0870 1555 455:quote reference number N0463 for an English version and N0464for an English and Welsh version).
A quick reference guide for health professionals is also availablefrom the NICE website (www.nice.org/CG012quickrefguide) orfrom the NHS Response Line (telephone 0870 1555 455; quotereference number N0462)
NICE Guideline – Chronic obstructive pulmonary disease
The grading scheme and hierarchy of evidence used in this guidelineare shown in the table below. Hierarchy of evidence Grading of recommendations Type of evidence Evidence
or meta-analysis of randomisedcontrolled trials
Evidence from at least onerandomised controlled trial
Evidence from at least one othertype of quasi-experimental study
Adapted from Eccles M, Mason J (2001) How to develop cost-conscious guidelines. Health Technology Assessment 5 (16): 1–69.
NICE Guideline – Chronic obstructive pulmonary disease
Appendix B: The Guideline Development Group
Dr David MG Halpin* (Lead and Clinical Advisor) Consultant Physician and Senior Lecturer, Royal Devon & Exeter Hospital Ms Jill Parnham* Senior Health Services Research Fellow in Guideline Development, National Collaborating Centre for Chronic Conditions Dr David Bellamy* General Practitioner, Bournemouth Ms Julie Booker* Respiratory Nurse Specialist, Rotherham General Hospital Professor Peter Calverley* (seconded from the Consensus Reference Group for three meetings) Professor of Respiratory Medicine, University of Liverpool and Aintree Hospital NHS Trust Dr Martin Connolly* Consultant Geriatrician, University of Manchester Dr Rachel Garrod* Senior Lecturer, Kingston University Mr Ashley Green* (deputy for Esther Threlfall) Breathe Easy Assistant Manager, British Lung Foundation Ms Gwen Haylett* Patient Representative Dr Michael ML Morgan* (seconded from the Consensus Reference Group for one meeting) Consultant Physician, University Hospitals of Leicester NHS Trust Ms Karen Reid* Information Scientist, National Collaborating Centre for Chronic Conditions Dr Michael Rudolf* Consultant Physician, Ealing Hospital NHS Trust Ms Katherine Stevens* Research Associate in Health Economics, School of Health and Related Research, University of Sheffield
* Denotes member of both the Guideline Development Group and the Consensus
NICE Guideline – Chronic obstructive pulmonary disease
Ms Esther Threlfall* UK Breathe Easy Manager, British Lung Foundation Ms Jane Scullion* (attended two meetings as deputy for Julie Booker), Respiratory Consultant Nurse, University Hospital of Leicester Ms Teresa Smith (attended five meetings as deputy for Julie Booker), Senior Respiratory Nurse/Chest Clinic Manager, Heatherwood and Wexham Park NHS Trust Ms Elaine Stevenson (attended one meeting as deputy for Julie Booker), Clinical Practitioner Respiratory Care, Southern Derbyshire Acute Hospitals Trust Professor Jadwiga Wedzicha* Professor of Respiratory Medicine, St Bartholomew's and the Royal London School of Medicine
To support the development of this guideline, a Consensus ReferenceGroup was formed. This group used formal consensus techniques inits consideration of clinically important areas where there wasinsufficient evidence or disagreement over the interpretation of theevidence.
Professor Duncan Geddes (Chair) Professor of Respiratory Medicine, Royal Brompton Hospital NHS Trust Ms Alison Bent (attended one meeting as deputy for Mary Hickson) Dietitian, Hammersmith Hospitals NHS Trust Professor Peter Calverley Professor of Respiratory Medicine, University of Liverpool and Aintree Hospital NHS Trust Dr Stephen Connellan Consultant Physician, The Royal Wolverhampton Hospitals NHS Trust Dr Sujal Desai (attended one meeting) Radiologist, King’s College Hospital Dr Gillian Hawksworth Community Pharmacist
* Denotes member of both the Guideline Development Group and the Consensus
NICE Guideline – Chronic obstructive pulmonary disease
Dr Mary Hickson Senior Research Dietician, Hammersmith Hospitals NHS Trust Professor Walter W Holland Emeritus Professor of Public Health Medicine, Visiting Professor, London School of Economics Dr Bill Homes (attended one meeting) Group Medical Director, Nestor Healthcare Group Plc Professor Paul Little Professor of Primary Care Research, University of Southampton Dr Michael ML Morgan Consultant Physician, University Hospitals of Leicester NHS Trust Ms Louise Sewell Pulmonary Rehabilitation Specialist, University Hospitals of Leicester NHS Trust Dr Mangalam Sridhar Consultant Physician, Hammersmith Hospitals NHS Trust Dr Mike Thomas (attended one meeting as deputy for David Bellamy) General Practitioner, Minchinhampton, Gloucestershire Ms Patrician Turner-Lawlor (attended one meeting as deputy for Louise Sewell) Senior Research Occupational Therapist, Cardiff and Vale NHS Trust
NICE Guideline – Chronic obstructive pulmonary disease
The Guideline Review Panel is an independent panel that overseesthe development of the guideline and takes responsibility formonitoring its quality. The Panel includes experts on guidelinemethodology, health professionals and people with experience ofthe issues affecting patients and carers. The members of theGuideline Review Panel were as follows. Dr Bernard Higgins (Chair) Consultant Chest Physician, Freeman Hospital, Newcastle upon Tyne Dr Robert Higgins Consultant in Renal and General Medicine, University Hospitals Coventry and Warwickshire Dr Marcia Kelson Director, Patient Involvement Unit for NICE, London Dr Peter Rutherford Senior Lecturer in Nephrology, Medical Director, University College of Wales College of Medicine Dame Helena Shovelton Chief Executive, British Lung Foundation Fiona Wise Acting Director of Modernisation, Bedfordshire and Hertfordshire Strategic Health Authority Dr John Young Medical Director, Merck Sharp and Dohme
NICE Guideline – Chronic obstructive pulmonary disease
Appendix D: Technical detail on the criteria foraudit
Key priority Criterion: data item Exceptions: interpreting the evidence 1. Diagnose COPD
considered in patients over the age of 35
exertional breathlessness, chronic cough,
presence of airflow obstruction should be Percentage of patientsconfirmed by performing spirometry. All
spirometry and be competent in theinterpretation of the results.
2. Stop smoking
COPD patients still smoking, regardless of general practiceage should be encouraged to stop, and
3. Effective inhaled therapy
improve exercise capacity in patients who had two or more
acting bronchodilators in patients with an corticosteroid therapyFEV1 ≤ 50% predicted who have had twoor more exacerbations requiringtreatment with antibiotics or oralcorticosteroids in a 12-month period inorder to decrease exacerbation frequency.
4. Pulmonary rehabilitation for all who
available to all appropriate patients with
NICE Guideline – Chronic obstructive pulmonary disease
Key priority Criterion: data item Exceptions: interpreting the evidence 5. Use non-invasive ventilation
persistent hypercapnic ventilatory failure
medical therapy. It should be delivered bystaff trained in its application,experienced in its use and aware of itslimitations. When patients are started onNIV there should be a clear managementplan in the event of deterioration andceilings of therapy should be agreed. 6. Manage exacerbations
The frequency of exacerbations should be with exacerbations
vaccinations. The impact of exacerbations
should be minimised by:• giving self-management advice on
responding promptly to the symptomsof an exacerbation
NICE Guideline – Chronic obstructive pulmonary disease
Definition of COPD COPD is characterised by airflow obstruction. The airflow obstruction is usually progressive, not fully reversible and does not change markedly over several months. The disease is predominantly caused by smoking. Think of the diagnosis of COPD for patients who are: • over 35 • smokers or ex-smokers • have any of these symptoms:
– exertional breathlessness– chronic cough– regular sputum production– frequent winter ‘bronchitis’– wheeze
• and have no clinical features of asthma (see table below)
Perform spirometry if COPD seems likely. Abbreviations
• FEV1 < 80% predicted
• And FEV1/FVC < 0.7 Spirometric reversibility testing is not usually necessary aspart of the diagnostic process or to plan initial therapyIf still doubt about diagnosis consider the following pointers: • Asthma may be present if:
– there is a > 400 ml response to bronchodilators– serial peak flow measurements show significant diurnal or
– there is a > 400 ml response to 30 mg prednisolone daily for 2 weeks
• Clinically significant COPD is not present if FEV1 and FEV1/FVC ratio return to normal with drug therapy. • Refer for more detailed investigations if needed (see page 10)
If still in doubt, make a provisional diagnosis and If no doubt, diagnose COPD and start treatment Reassess diagnosis in view of response to treatment Clinical features differentiating COPD and asthma
Night-time waking with breathlessness and/or wheeze
Significant diurnal or day-to-day variability of symptoms Uncommon
NICE Guideline – Chronic obstructive pulmonary disease
Patient w Assess symptoms/problems and manage t
Patients with COPD should have access to the wide ra
Breathlessness and exercise limitation Frequent exacerbations Respirato
Use short-acting bronchodilator as needed
If still symptomatic try combined therapy with
a short-acting beta2-agonist and a short-acting
If still symptomatic use a long-acting bronchodilator
In moderate or severe COPD:
if still symptomatic consider a trial of a combination of a
Stop therapy if inef
long-acting beta2-agonist and inhaled corticosteroid; discontinue if no benefit after 4 weeks
If still symptomatic consider adding theophylline
≤ 50% and two or moreexacerbations in a 12-month period (NB
Offer pulmonary rehabilitation to all patients who
consider themselves functionally disabled (usually MRC
Consider referral for surgery: bullectomy, lung volumereduction, transplantation
Palliative care • Opiates can be used for the palliation of breathlessness in patients with end-stage COPD unresponsive to other medical therapy • Use benzodiazepines, tricyclic antidepressants, major tranquillisers and oxygen when appropriate • Involve multidisciplinary palliative care teams Abbreviations BMI body mass index FEV1 forced expiratory volume in 1 second MRC Medical Research Council LVRS lung volume reduction surgery
NICE Guideline – Chronic obstructive pulmonary disease
with COPD those that are present as described below
ange of skills available from a multidisciplinary team
ory failure Cor pulmonale Abnormal BMI Chronic productive cough Anxiety and depression
NICE Guideline – Chronic obstructive pulmonary disease
Algorithm 3: Managing exacerbations of COPD
Exacerbations of COPD can be associated with increased: • dyspnoea • sputum purulence • sputum volume • cough Initial management • Increase frequency of bronchodilator use – consider giving via a nebuliser • Oral antibiotics if purulent sputum • Prednisolone 30 mg daily for 7–14 days – for all patients with significant increase
in breathlessness, and all patients admitted to hospital, unless contraindicated
Decide where to manage Investigations Investigations
• Sputum culture not normally recommended
• Arterial blood gases (record inspired oxygen
• Pulse oximetry if severe exacerbation
• ECG• Full blood count and urea and electrolytes• Theophylline level if patient on theophylline at
Further management
• Sputum microscopy and culture if purulent
• Establish on optimal therapy• Arrange multidisciplinary assessment if necessary
Further management Factors to consider when deciding where to manage patient
• Give oxygen to keep SaO2 above 90% • Assess need for non-invasive ventilation:
– consider respiratory stimulant if NIV not available
treatment treatment in hospital
• Consider intravenous theophyllines if poor response to
Consider hospital-at-home or assisted-discharge scheme
Before discharge
• Arrange multidisciplinary assessment if necessary
Significant comorbidity(particularly cardiac disease and
Abbreviations LTOT
partial pressure of oxygen in arterial blood
NICE Guideline – Chronic obstructive pulmonary disease
NICE Guideline – Chronic obstructive pulmonary disease
National Institute for Clinical Excellence
High Throughput Multiplexed Cellular Toxicity *Jan Turner, Samantha Murphy, Elaine Adie, Angela Williams, Molly Price-Jones. Amersham Biosciences Limited, Amersham Place, Little Chalfont, Buckinghamshire, HP7 9NA, England., email: jan.turner@uk.amershambiosciences.com. Alamar Blue was obtained from Serotec , UK, cells wereplus the cell count were obtained from each well as a
Central Algoma Family of Schools Pre-Acommodation School Council/Principal Discussion - Minutes March 3, 2011 @ CASS Asima Vezina, Superintendent of CAFS Stephanie Smith, Chair Thessalon School Council Jeff Mitchell, Principal Johnson Tarbutt Cindy Glover, Vice-Chair St. Joseph School Brenda Butler-McTaggert, Principal Arthur Henderson Allison Vecchio, Principal Laird Don Nadeau, Princip