Symptoms

1.1.1.

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. [2004]

1.1.2.

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 2 symptoms are uncommon in COPD and raise the possibility of alternative diagnoses. [2004]

1.1.3.

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. [2004]

Table 1

MRC dyspnoea scale.

Spirometry

1.1.4.

Perform spirometry:

• at diagnosis
• to reconsider the diagnosis, for people who show an exceptionally good response to treatment
• to monitor disease progression. [2004, amended 2018]

1.1.5.

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

1.1.6.

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. [2010]

1.1.7.

Think about a diagnosis of COPD in younger people who have symptoms of COPD, even when their FEV1/FVC ratio is above 0.7. [2010]

1.1.8.

All healthcare professionals who care for people with COPD should have access to spirometry and be competent in interpreting the results. [2004]

1.1.9.

Spirometry can be performed by any healthcare worker who has had appropriate training and has up-to-date skills. [2004]

1.1.10.

Spirometry services should be supported by quality control processes. [2004]

1.1.11.

It is recommended that GLI 2012 reference values are used, but it is recognised that these values are not applicable for all ethnic groups. [2004, amended 2018]

Incidental findings on chest X-ray or CT scans

1.1.12.

Consider primary care respiratory review and spirometry (see recommendations 1.1.1 to 1.1.11) for people with emphysema or signs of chronic airways disease on a chest X-ray or CT scan. [2018]

1.1.13.

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. [2018]

1.1.14.

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. [2018]

Further investigations

1.1.15.

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. [2004]

1.1.16.

Perform additional investigations when needed, as detailed in table 2. [2004, amended 2018]

Table 2

Additional investigations.

1.1.17.

Offer people with alpha 1 antitrypsin deficiency a referral to a specialist centre to discuss how to manage their condition. [2004]

Reversibility testing

1.1.18.

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. [2004]

1.1.19.

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. [2004, amended 2018]

Table 3

Clinical features differentiating COPD and asthma.

1.1.20.

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. [2004]

1.1.21.

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 variability.

Clinically significant COPD is not present if the FEV1 and FEV1/FVC ratio return to normal with drug therapy. [2004]

1.1.22.

If diagnostic uncertainty remains, think about referral for more detailed investigations, including imaging and measurement of transfer factor for carbon monoxide (TLCO). [2004]

1.1.23.

Reconsider the diagnosis of COPD for people who report a marked improvement in symptoms in response to inhaled therapy. [2004]

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.

1.1.24.

Do not use a multidimensional index (such as BODE) to assess prognosis in people with stable COPD. [2018]

1.1.25.

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 noninvasive ventilation
• multimorbidity
• frailty. [2010, amended 2018]

Assessing and classifying the severity of airflow obstruction

1.1.26.

Assess the severity of airflow obstruction according to the reduction in FEV1, as shown in table 4. [2010]

1.1.27.

For people with mild airflow obstruction, only diagnose COPD if they have one or more of the symptoms in recommendation 1.1.1. [2010]

Table 4

Gradation of severity of airflflow obstruction.

Identifying early disease

1.1.28.

Perform spirometry in people who are over 35, current or ex-smokers, and have a chronic cough. [2004]

1.1.29.

Consider spirometry in people with chronic bronchitis. A significant proportion of these people will go on to develop airflow limitation. [2004]

Referral for specialist advice

1.1.30.

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). [2004]

Table 5

Reasons for referral include.

1.1.31.

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. [2004]

Smoking cessation

1.2.2.

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. [2004]

1.2.3.

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. [2004]

1.2.4.

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. [2010]

1.2.5.

For more guidance on helping people to quit smoking, see the NICE guideline on stop smoking interventions and services. [2010]

1.2.6.

For more guidance on varenicline see the NICE technology appraisal guidance on varenicline for smoking cessation. [2010]

Inhaled therapy

Oral therapy

Oxygen

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).

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.

1.2.81.

Make pulmonary rehabilitation available to all appropriate people with COPD (see recommendation 1.2.82), including people who have had a recent hospitalisation for an acute exacerbation. [2010]

1.2.82.

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. [2004]

1.2.83.

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. [2004]

1.2.84.

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. [2004]

1.2.85.

Advise people of the benefits of pulmonary rehabilitation and the commitment needed to gain these. [2004]

Vaccination and anti-viral therapy

1.2.86.

Offer pneumococcal vaccination and an annual flu vaccination to all people with COPD, as recommended by the Chief Medical Officer. [2004]

1.2.87.

For guidance on preventing and treating flu, see the NICE technology appraisals on oseltamivir, amantadine (review) and zanamivir for the prophylaxis of influenza and amantadine, oseltamivir and zanamivir for the treatment of influenza. [2004]

Lung surgery and lung volume reduction procedures

1.2.88.

Offer a respiratory review to assess whether a lung volume reduction procedure is a possibility for people with COPD when they complete pulmonary rehabilitation and at other subsequent reviews, if all of the following apply:

• they have severe COPD, with FEV1 less than 50% and breathlessness that affects their quality of life despite optimal medical treatment (see recommendations 1.2.11 to 1.2.17)
• they do not smoke
• they can complete a 6-minute walk distance of at least 140 m (if limited by breathlessness). [2018]

1.2.89.

At the respiratory review, refer the person with COPD to a lung volume reduction multidisciplinary team to assess whether lung volume reduction surgery or endobronchial valves are suitable if they have:

• hyperinflation, assessed by lung function testing with body plethysmography and
• emphysema on unenhanced CT chest scan and
• optimised treatment for other comorbidities. [2018]

1.2.90.

Only offer endobronchial coils as part of a clinical trial and after assessment by a lung volume reduction multidisciplinary team. [2018]

1.2.91.

For more guidance on lung volume reduction procedures, see the NICE interventional procedures guidance on lung volume reduction surgery, endobronchial valves and endobronchial coils. [2018]

1.2.92.

Refer people with COPD for an assessment for bullectomy if they are breathless and a CT scan shows a bulla occupying at least one third of the hemithorax. [2018]

1.2.93.

Consider referral to a specialist multidisciplinary team to assess for lung transplantation for people who:

• have severe COPD, with FEV1 less than 50% and breathlessness that affects their quality of life despite optimal medical treatment (see recommendations 1.2.11 to 1.2.17) and
• do not smoke and
• have completed pulmonary rehabilitation and
• do not have contraindications for transplantation (for example, comorbidities or frailty). [2018]

1.2.94.

Do not use previous lung volume reduction procedures as a reason not to refer a person for assessment for lung transplantation. [2018]

Alpha-1 antitrypsin replacement therapy

1.2.95.

Alpha-1 antitrypsin replacement therapy is not recommended for people with alpha-1 antitrypsin deficiency (see also recommendation 1.1.17). [2004]

Multidisciplinary management

1.2.96.

COPD care should be delivered by a multidisciplinary team. [2004]

1.2.97.

When defining the activity of the multidisciplinary team, think about the following functions:

• assessment (including performing spirometry, assessing which delivery systems to use for inhaled therapy, the need for aids for daily living and assessing the need for oxygen)
• care and treatment, including:

  -

  pulmonary rehabilitation

  -

  identifying and managing anxiety and depression

• -

  advising people on relaxation techniques

  -

  dietary issues

  -

  exercise

  -

  social security benefits and travel

  -

  hospital-at-home/early discharge schemes

  -

  non-invasive ventilation and palliative care

• advising people on self-management strategies
• identifying and monitoring people at high risk of exacerbations and undertaking activities to avoid emergency admissions
• education for people with COPD, their carers, and for healthcare professionals. [2004]

Fitness for general surgery

1.2.134.

The ultimate clinical decision about whether or not to proceed with surgery should rest with a consultant anaesthetist and consultant surgeon, taking account of comorbidities, functional status and the need for the surgery. [2004]

1.2.135.

It is recommended that lung function should not be the only criterion used to assess people with COPD before surgery. Composite assessment tools such as the ASA scoring system are the best predictors of risk. [2004]

1.2.136.

If time permits, optimise the medical management of people with COPD before surgery. This might include a course of pulmonary rehabilitation. [2004]

Follow-up of people with COPD

1.2.137.

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). [2004, amended 2018]

1.2.138.

Review people with COPD at least once per year and more frequently if indicated, and cover the issues listed in table 6. [2004]

1.2.139.

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. [2004]

1.2.140.

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. [2004]

1.2.141.

Specialists should regularly review people with severe COPD who need interventions such as long-term non-invasive ventilation. [2004]

Table 6

Summary of follow-up of people with COPD in primary care.

Definition of an exacerbation

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

Assessing the need for hospital treatment

1.3.1.

Use the factors in table 7 to assess whether people with COPD need hospital treatment. [2004]

Table 7

Factors to consider when deciding where to treat the person with COPD.

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.

Hospital-at-home and assisted-discharge schemes

1.3.4.

Hospital-at-home and assisted-discharge schemes are safe and effective and should be used as an alternative way of caring for people with exacerbations of COPD who would otherwise need to be admitted or stay in hospital. [2004]

1.3.5.

The multiprofessional team that operates these schemes should include allied health professionals with experience in managing COPD, and may include nurses, physiotherapists, occupational therapists and other health workers. [2004]

1.3.6.

There are currently insufficient data to make firm recommendations about which people with COPD with an exacerbation are most suitable for hospital-at-home or early discharge. Selection should depend on the resources available and absence of factors associated with a worse prognosis (for example, acidosis). [2004]

1.3.7.

Include people’s preferences about treatment at home or in hospital in decision-making. [2004]

Pharmacological management

Increased breathlessness is a common feature of COPD exacerbations. This is usually managed by taking increased doses of short-acting bronchodilators.

Oxygen therapy during exacerbations of COPD

1.3.26.

Measure oxygen saturation in people with an exacerbation if there are no facilities to measure arterial blood gases. [2004]

1.3.27.

If necessary, prescribe oxygen to keep the oxygen saturation of arterial blood (SaO₂) within the individualised target range. [2010]

1.3.28.

Pulse oximeters should be available to all healthcare professionals involved in the care of people with exacerbations of COPD, and they should be trained in their use. Clinicians should be aware that pulse oximetry gives no information about the PaCO₂ or pH. [2004]

1.3.29.

Measure arterial blood gases and note the inspired oxygen concentration in all people who arrive at hospital with an exacerbation of COPD. Repeat arterial blood gas measurements regularly, according to the response to treatment. [2004]

Non-invasive ventilation (NIV) and COPD exacerbations

1.3.30.

Use NIV as the treatment of choice for persistent hypercapnic ventilatory failure during exacerbations despite optimal medical therapy. [2004]

1.3.31.

It is recommended that NIV should be delivered in a dedicated setting, with staff who have been trained in its application, who are experienced in its use and who are aware of its limitations. [2004]

1.3.32.

When people are started on NIV there should be a clear plan covering what to do in the event of deterioration, and ceilings of therapy should be agreed. [2004]

Invasive ventilation and intensive care

1.3.33.

Treat hospitalised exacerbations of COPD on intensive care units, including invasive ventilation when this is thought to be necessary. [2004]

1.3.34.

When assessing suitability for intubation and ventilation during exacerbations, think about functional status, BMI, need for oxygen when stable, comorbidities and previous admissions to intensive care units, in addition to age and FEV1. Neither age nor FEV1 should be used in isolation when assessing suitability. [2004]

1.3.35.

Consider NIV for people who are slow to wean from invasive ventilation. [2004]

Respiratory physiotherapy and exacerbations

1.3.36.

Consider physiotherapy using positive expiratory pressure devices for selected people with exacerbations of COPD, to help with clearing sputum. [2004, amended 2018]

Monitoring recovery from an exacerbation

1.3.37.

Monitor people’s recovery by regular clinical assessment of their symptoms and observation of their functional capacity. [2004]

1.3.38.

Use pulse oximetry to monitor the recovery of people with non-hypercapnic, non-acidotic respiratory failure. [2004]

1.3.39.

Use intermittent arterial blood gas measurements to monitor the recovery of people with respiratory failure who are hypercapnic or acidotic, until they are stable. [2004]

1.3.40.

Do not routinely perform daily monitoring of peak expiratory flow (PEF) or FEV1 to monitor recovery from an exacerbation, because the magnitude of changes is small compared with the variability of the measurement. [2004]

Discharge planning

1.3.41.

Measure spirometry in all people before discharge. [2004]

1.3.42.

Re-establish people on their optimal maintenance bronchodilator therapy before discharge. [2004]

1.3.43.

People who have had an episode of respiratory failure should have satisfactory oximetry or arterial blood gas results before discharge. [2004]

1.3.44.

Assess all aspects of the routine care that people receive (including appropriateness and risk of side effects) before discharge. [2004]

1.3.45.

Give people (or home carers) appropriate information to enable them to fully understand the correct use of medications, including oxygen, before discharge. [2004]

1.3.46.

Make arrangements for follow-up and home care (such as visiting nurse, oxygen delivery or referral for other support) before discharge. [2004]

1.3.47.

The person, their family and their physician should be confident that they can manage successfully before they are discharged. A formal activities of daily living assessment may be helpful when there is still doubt. [2004]

Asthmatic features/features suggesting steroid responsiveness

This includes any previous, secure diagnosis of asthma or of atopy, a higher blood eosinophil count, substantial variation in FEV1 over time (at least 400 ml) or substantial diurnal variation in peak expiratory flow (at least 20%).

Exacerbation

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

A general classification of the severity of an acute exacerbation (Oba Y et al. [2017]) is:

• mild exacerbation, the person has an increased need for medication, which they can manage in their own normal environment
• moderate exacerbation, the person has a sustained worsening of respiratory status that requires treatment with systemic corticosteroids and/or antibiotics
• severe exacerbation, the person experiences a rapid deterioration in respiratory status that requires hospitalisation.

Mild or no hypoxaemia

People who are not taking long-term oxygen and who have a mean PaO₂ greater than 7.3k Pa.

1. Pulmonary rehabilitation during hospital admission

In people with COPD, does pulmonary rehabilitation during hospital admission for exacerbation and/or in the early recovery period (within 1 month of an exacerbation) improve quality of life and reduce hospitalisations and exacerbations compared with a later (defined as after 1 month) pulmonary rehabilitation programme, and in which groups is it most clinically and cost effective?

2. Multidimensional assessment of outcomes

How can the individual factors associated with COPD prognosis (collected from a range of sources including primary care, imaging and pulmonary rehabilitation results) be combined into a multidimensional analysis that provides accurate and useful information on prognosis?

3. Inhaled therapies for people with COPD and asthma

What is the clinical and cost effectiveness of inhaled therapies (bronchodilators and/or inhaled corticosteroids) in people with both stable COPD and asthma?

4. Inhaled corticosteroid responsiveness

What features predict inhaled corticosteroid responsiveness most accurately in people with COPD?

5. Prophylactic antibiotics for preventing exacerbations

Which subgroups of people with stable COPD who are at high risk of exacerbations are most likely to benefit from prophylactic antibiotics?

Diagnosing COPD

What are the characteristics of people diagnosed with COPD as a result of an incidental finding of emphysema on a CT scan, compared with those diagnosed with symptoms?

Prophylactic antibiotics for preventing exacerbations

What is the long-term clinical and cost effectiveness of prophylactic antibiotics for people with stable COPD who are at high risk of exacerbations?

What is the comparative effectiveness of different antibiotics, doses and regimens of prophylactic antibiotics for people with stable COPD who are at high risk of exacerbations?

What is the comparative effectiveness of seasonal versus continuous prophylactic antibiotics for people with stable COPD who are at high risk of exacerbations?

Pulmonary hypertension

What are the most clinical and cost-effective treatments for pulmonary hypertension in people with COPD?

Mucolytic therapy

In people with COPD, does mucolytic drug therapy prevent exacerbations in comparison with placebo and other therapies?

Why the committee made the recommendations

The evidence showed that CT scans and chest X-rays are accurate tests for identifying people who would test positive for COPD using spirometry, including people without symptoms. However, some of the CT and chest X-ray techniques used in the studies are not routinely used in UK clinical practice. This limited how applicable the evidence was to the NHS, so the committee was unable to make a wider recommendation on using CT scans and chest X-rays for diagnosing COPD. The committee therefore made recommendations on what to do if a CT scan or X-ray that was performed for another reason showed signs of emphysema or chronic airways disease.

There was no evidence on what to do for people who have emphysema or signs of chronic airways disease on a CT scan or chest X-ray, but who have no symptoms. Because of this, the committee made consensus recommendations based on their experience and on current practice in the NHS. The committee also made a research recommendation to find out more about the characteristics of this group, to try to determine whether they differ in ways that might mean standard COPD treatment has to be modified for them.

The committee also reviewed evidence on using pulse oximetry or high-sensitivity C-reactive protein (hs-CRP) for diagnosing COPD. They did not recommend these because:

• pulse oximetry is normally used to measure the severity of COPD rather than to diagnose it, and there are other possible causes of low oxygen saturation
• elevated hs-CRP levels are not specifically linked to COPD, and could be caused by other conditions
• the evidence showed that they were not effective diagnostic tests.

The committee amended the ‘Additional investigations℉ table, based on their knowledge and experience, to more accurately reflect good practice.

How the recommendations might affect practice

As the recommendation only covers CT scans or chest X-rays taken for other purposes, there would be no additional costs from these tests. The recommendation to consider spirometry and GP respiratory review and the amendments to the ‘Additional investigations’ table all reflect current practice. There may be a small number of additional referrals for spirometry, but this is expected to have a minimal resource impact.

Full details of the evidence and the committee’s discussion are in evidence review D: Diagnosing COPD and predicting outcomes.

Return to recommendations

Why the committee made the recommendations

The committee recommended against using multidimensional indices, such as BODE, because they were:

• unable to classify people reliably into high- and low-risk groups better than FEV1 alone or
• no better at predicting outcomes than FEV1 alone or
• time-consuming and consisted of components that would not be routinely available in primary care.

However, the committee recognised the need for an effective prognostic tool that did not have these problems, so they made a research recommendation to address this.

The committee used their knowledge and experience to list factors associated with prognosis. In the absence of a single prognostic tool, thinking about these factors can help guide discussions, and help people with COPD to understand how their condition is likely to progress and decide which treatments are right for them.

How the recommendations might affect practice

The BODE index is not used routinely in the NHS and no alternative indices have been recommended, so there should be minimal impact on practice.

Full details of the evidence and the committee’s discussion are in evidence review D: Diagnosing COPD and predicting outcomes.

Return to recommendations

Why the committee made the recommendations

How the recommendations might affect practice

The recommendation on LAMA+LABA dual therapy is likely to increase the number of people with COPD who are having this treatment. The higher cost of dual therapy compared with monotherapy may result in a significant resource impact, but cost savings are also likely from a reduction in treatments needed for exacerbations (including hospitalisation).

Using LABA+ICS for people with features of asthma/features suggesting steroid responsiveness is in line with current practice.

The recommendations may result in an increase in the number of people who are prescribed triple therapy and an increase in the number of people who need treatment for pneumonia, although this may be mitigated by the relatively widespread current use of triple therapy. However, the criteria for who should be offered triple therapy and the recommendation for a trial period should limit the impact of both of these changes.

Triple therapy regimens have a higher cost than dual long-acting bronchodilator regimens. However, this cost is likely to be at least partially offset by savings from reduced numbers of exacerbations and better management of symptoms for people switching to triple therapy.

It is already routine in practice to have a clinical review before starting triple therapy. The recommendation on clinical review may increase the scope of this review. However, any costs incurred from this should be offset by savings from more optimal management of symptoms in people with COPD, which should be associated with fewer primary care and/or hospital visits.

The recommendation on how to choose drugs and inhalers covers factors that prescribers routinely consider, so is not a change in practice. However, minimising the number and type of inhaler devices and avoiding unnecessary within-class switching may produce cost savings through lower upfront spending and better symptom control.

Full details of the evidence and the committee’s discussion are in evidence review F: Inhaled therapies and evidence review I: Inhaled triple therapy.

Return to recommendations

Why the committee made the recommendations

The evidence showed that prophylactic antibiotics reduce the risk of people having an exacerbation and the number of exacerbations per year in people with COPD and sputum production. However, prescribing these to large numbers of people with COPD could increase levels of antibiotic resistance. Problems with adherence may make this worse, as people are not taking the antibiotics to help with any current symptoms and (for azithromycin) have to remember to take it 3 times a week. In addition, the longest follow-up in the trials was 12 months, so there is no evidence on the long-term effects of prophylactic antibiotics. With this in mind, the committee made recommendations for the people who would benefit the most from prophylactic antibiotics, and whose exacerbations were not being managed well by other treatments.

The committee recommended azithromycin because this antibiotic had the most evidence of effectiveness (based on the numbers of trials and study participants). The recommended dosage is taken from the trials the committee reviewed.

People taking prophylactic azithromycin may also keep antibiotics at home as part of their exacerbation action plan (see recommendation 1.2.126). This should be a different class of antibiotic to ensure that it is effective when they need it, as the person may develop resistance to azithromycin.

The committee recommended strict criteria for using and reviewing prophylactic antibiotics, to ensure that:

• the risk of antibiotic resistance is minimised, both for the person taking them and for society
• people only take them if it is safe to do so
• people do not continue taking them if there is no benefit.

How the recommendations might affect practice

It is likely that these recommendations will increase the number of people taking prophylactic antibiotics. This is unlikely to have a significant resource impact, given the relatively low cost of antibiotics. By reducing exacerbation frequency it is likely to reduce the amount of oral corticosteroids taken by people with COPD.

Full details of the evidence and the committee’s discussion are in evidence review E: Predicting and preventing exacerbations.

Return to recommendations

Why the committee made the recommendations

There is evidence that continuous long-term oxygen therapy improves survival in people with more severe hypoxaemia, but not for people with mild hypoxaemia. The specific thresholds for long-term oxygen therapy are taken from the trials that provided the evidence.

The recommendation that people should use supplemental oxygen for more than 15 hours a day is based on the available evidence. There is also evidence that long-term oxygen therapy was not effective for isolated nocturnal hypoxaemia caused by COPD.

The evidence showed risks of harm from the use of long-term oxygen therapy, in particular burns and fires as a result of smoking while using oxygen and falls from tripping over equipment. Given these risks to the person with COPD and the people they live with, the committee agreed that it is important to conduct a detailed risk assessment before offering this treatment.

The committee decided that there were 2 levels of risk posed by smoking around oxygen and the recommendations they made reflect these differences:

• People with COPD who do not smoke but who live with people who smoke. Using cigarettes near oxygen could cause fires or burns, but this risk is likely to be lower because the person who smokes can keep away from the oxygen. Oxygen therapy may benefit these people if they meet the eligibility criteria and the risk assessment is favourable.
• People with COPD who smoke. They will be smoking in close proximity to the oxygen, and the risks to them, the people they live with and their neighbours outweigh the potential benefits of long-term oxygen therapy.

How the recommendations might affect practice

These recommendations may result in an increase in demand for stop smoking services, but these are known to provide good value for money. Additional time may be needed to conduct risk assessments. As these should prevent people from being given oxygen therapy if they would not benefit or may be harmed by it, it would be an appropriate use of resources and should not lead to an overall increase in resource use. These recommendations may also reduce the cost of managing harms associated with oxygen use, including falls, burns and the wider costs of fires.

Full details of the evidence and the committee’s discussion are in evidence review B: Oxygen therapy in people with stable COPD.

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Why the committee made the recommendations

The evidence for people with mild or no hypoxaemia showed that neither ambulatory oxygen nor short-burst oxygen provide a clinically meaningful improvement in breathlessness.

How the recommendations might affect practice

Reducing the use of ambulatory and short-burst oxygen therapy in people who would not benefit is likely to be cost saving and will allow resources to be invested in effective treatments for breathlessness instead.

Full details of the evidence and the committee’s discussion are in evidence review B: Oxygen therapy in people with stable COPD.

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Why the committee made the recommendations

How the recommendations might affect practice

The recommendations will not change practice, as none of the treatments the committee has recommended against for pulmonary hypertension or cor pulmonale are currently in routine use specifically for these conditions in people with COPD.

Full details of the evidence and the committee’s discussion are in evidence review A: Managing pulmonary hypertension and cor pulmonale.

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Why the committee made the recommendations

The evidence showed that people with severe COPD show improvements in lung function, exercise capacity, quality of life and long-term mortality as a result of lung volume reduction surgery. The criteria for who should be referred for this procedure are based on the criteria used in the trials reviewed by the committee and the committee’s clinical expertise, taking into account current practice in the NHS.

It was not clear from the evidence whether endobronchial coils work better than standard lung volume reduction surgery. In addition, the procedure is relatively new. For these reasons, the committee recommended that it is only offered as part of a clinical trial.

The recommendations on referral for bullectomy and lung transplantation are based on the committee’s knowledge and experience. The lung transplantation referral criteria were adapted from the criteria used for the respiratory review for lung volume reduction surgery. The committee noted that some people are refused lung transplantation because they have had previous lung volume reduction procedures. These people could still benefit from transplantation, so the committee made a recommendation to reflect this.

How the recommendations might affect practice

It is current clinical practice to assess for future treatment plans after pulmonary rehabilitation. However, the criteria for referring people to a multidisciplinary team to assess for lung volume reduction assessment have been broadened, as recommended treatment options now include endobronchial valves. The broadening of criteria will lead to more referrals and improved access to these treatments. This will have an impact on resource use, in particular, as a new group of people for whom lung volume reduction surgery was unsuitable may now be treated with endobronchial valves.

Full details of the evidence and the committee’s discussion are in evidence review G: Referral criteria for lung volume reduction procedures, bullectomy or lung transplantation.

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Why the committee made the recommendation

The factors associated with exacerbations are taken from the evidence available and the committee’s experience. The evidence on physical activity was not reviewed, but as promoting exercise and physical activity is an important part of management for stable COPD the committee agreed to include it. The list only covers the factors that people can avoid or reduce their exposure to. Other factors are also associated with exacerbations (for example, disease-related factors, biomarkers and other medicines), but people cannot avoid these on their own and these factors are addressed in other areas of the guideline.

How the recommendation might affect practice

These recommendations are unlikely to have a significant impact on resources, as the marginal cost of providing advice on exacerbations to people with COPD is very low. An increased emphasis on physical activity may lead to an increase in referrals to pulmonary rehabilitation, which is known to be a highly cost-effective intervention for people with COPD. The recommendations may produce some cost savings by reducing the number of exacerbations people have.

Full details of the evidence and the committee’s discussion are in evidence review E: Predicting and preventing exacerbations.

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Why the committee made the recommendations

Evidence showed that self-management plans improve quality of life and reduce hospital admissions. The committee recommended that self-management plans include:

• patient education, because this was a common component of the self-management plans they examined and because education alone was shown to improve knowledge about COPD
• cognitive behavioural components for people with frightening breathlessness, because there is some evidence that these reduce distress (although they do not help with the symptoms of breathlessness).

The list of topics to be covered in information about COPD is taken from the self-management plans the committee examined and their own clinical and personal experience.

Exacerbation action plans were shown to improve quality of life and reduce hospital admissions for people at risk of exacerbations. Most of the exacerbation action plans that the committee examined provided people with short courses of antibiotics and corticosteroids to use at home to respond to symptoms, and monitoring to make sure they were using those medicines appropriately. Therefore these components were included in the recommendations. The committee also discussed the potential for antibiotic overuse, and stressed the importance of continued monitoring to ensure people are using these medicines appropriately.

Telehealth monitoring does not improve quality of life or reduce hospitalisations for people with COPD, and it leads to higher costs. However, the committee did not want to prevent telehealth monitoring being used for specific reasons that were not covered in the evidence they reviewed, such as short-term monitoring following hospital discharge, so they only recommended against routine telehealth monitoring.

How the recommendations might affect practice

Self-management plans are already in place for some people with COPD. The recommendations may change the content of these plans, and may increase the number of people using a self-management plan. However, self-management plans are highly cost effective and the increased cost of providing them should be offset by cost savings from a reduction in hospitalisations.

The number of people with stable COPD who are having telehealth monitoring should decrease, which is likely to reduce costs.

Full details of the evidence and the committee’s discussion are in evidence review C: Self-management interventions, education and telehealth monitoring.

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Why the committee made the recommendations

There are risks associated with long-term corticosteroid use, so it is important to use the shortest effective treatment duration. Treatment is recommended for 5 days because the evidence showed no benefit from taking corticosteroids for more than 7 days and shorter courses of 5 days are routinely used in clinical practice already. The 2019 review did not look at corticosteroid doses, so the dose from the original 2004 recommendation was retained.

How the recommendations might affect practice

The recommendation may reduce the amount of corticosteroids used in clinical practice, which may result in a cost saving. However, the overall impact is likely to be small because oral corticosteroids are cheap, and because prescribing corticosteroids for 5 days is current practice for many clinicians.

Full details of the evidence and the committee’s discussion are in evidence review J: Length of corticosteroid use during exacerbations.

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