Management of COPD (NICE Guideline)

Summary of NICE guidance on COPD treatment.

Download a pdf version of the above chart.

1. DIAGNOSIS AND ASSESSMENT

  • Consider diagnosis of COPD if: age >35 years, smoker/ex-smoker, no asthma symptoms and presenting with any of the below:
    – exertional breathlessness
    – chronic cough
    – regular sputum production
    – frequent winter 'bronchitis'
    – wheeze
    • Confirm presence and degree of airflow obstruction with post-bronchodilator spirometry (see Table 1)
    • Perform chest X-ray, FBC and calculate BMI
    • Also consider:
      – Level of disability (eg, breathlessness [use MRC dyspnoea scale], exercise limitation, frequency of exacerbations)
      – Other prognostic factors (eg, BMI, health status, PaO2, cor pulmonale)
      • Calculate BODE Index** if information available
      • Consider CT scan or TLCO* testing if symptoms disproportionate to spirometric impairment
      KEY:
      * TLCO = carbon monoxide lung transfer factor
      ** BODE Index comprises measures of BMI, airflow obstruction, dyspnoea and exercise tolerance
      Table 1: Severity of airflow obstruction where post-bronchodilator FEV1/FVC <0.7
      Severity of airflow obstruction Stage 1:
      Mild
      Stage 2:
      Moderate
      Stage 3:
      Severe
      Stage 4:
      Very severe
      FEV1 (% predicted) ≥80 + symptoms 50–79 39–49 < 50 + respiratory failure or < 30

      2. MANAGEMENT OF STABLE DISEASE

      INHALED TREATMENT

      Refer to the treatment algorithm at the top of this page.

      • Choose a drug based on patient's symptomatic response and preference, side-effects of drug and potential to reduce exacerbations and cost
      • Do not use oral corticosteroid reversibility tests to identify patients who will benefit from inhaled corticosteroids
      • Be aware of potential side-effects (including non-fatal pneumonia) of inhaled corticosteroids and be prepared to discuss with patients
      • Assess effectiveness in terms of: lung function, symptoms, daily activities, exercise capacity, speed of symptom relief (short-acting bronchodilators only)
      • Consider nebuliser if distressing or disabling breathlessness despite maximal inhaled therapy; continue use only if condition improves

      ORAL TREATMENT

      • Long-term oral corticosteroid treatment – consider only if no other practical way of managing frequent exacerbations and/or severe breathlessness; keep dose as low as possible. Monitor patients for osteoporosis and prescribe appropriate prophylaxis; if >65 years, start prophylaxis without monitoring
      • Theophylline – consider if inhaled therapy cannot be used or if patient still symptomatic after trials of short-acting and long-acting bronchodilators (can be added to these). Assess effectiveness as for inhaled therapy; monitor plasma levels and interactions
      • Mucolytics – consider if chronic productive cough; continue use only if symptoms improve (do not use routinely to prevent exacerbations)

      OXYGEN THERAPY

      • Assess need for long-term oxygen therapy (LTOT) in patients with FEV1 <30% predicted, cyanosis, polycythaemia, peripheral oedema, raised JVP or O2 saturations ≤92% breathing air
      • Offer LTOT to patients with PaO2 < 7.3kpa when stable or > 7.3kPa and < 8kpa when stable plus a secondary condition (eg, peripheral oedema, pulmonary hypertension, polycythaemia, nocturnal hypoxaemia)
      • Following specialist assessment, offer ambulatory oxygen to patients on LTOT who are motivated to use it, have PaO2 ≤7.3kPa and exercise desaturation, and oxygen improves exercise capacity and/or breathlessness
      • Advise patient to use for ≥15 hours/day and warn of fire/explosion risk
      • Consider short-burst oxygen therapy only for episodes of severe breathlessness not relieved by other treatments; continue only if effective

      Note:

      • Exclude clinically significant COPD if FEV1 and FEV1/FVC normalise on drug therapy
      • Consider asthma if >400ml FEV1 response to bronchodilators/oral corticosteroids and significant daily fluctuations in peak flow

      3. INITIAL MANAGEMENT OF EXACERBATIONS

      • Increase frequency of bronchodilator use and consider use of a nebuliser
      • Prescribe oral antibiotics if sputum is purulent or clinical signs of pneumonia
      • Offer prednisolone 30mg daily for 7–14 days
      • Decide whether to manage at home or in hospital, taking into account clinical and social factors

      SELF MANAGEMENT

      Provide patients at risk of exacerbation with a course of antibiotics and corticosteroids to keep at home and encourage patients to respond to an exacerbation by:

      • starting oral corticosteroid if breathlessness increases sufficiently to interfere with daily activities
      • starting antibiotics if sputum is purulent
      • adjusting bronchodilator therapy to control symptoms

      4. FOLLOW-UP

      • Review patients with mild or moderate COPD at least yearly and those with very severe COPD at least twice yearly
      Additional supportive measures
      • Smoking cessation:
        – Provide encouragement and assistance to all patients at every opportunity
        – Offer nicotine replacement therapy, varenicline or bupropion
        • Offer pulmonary rehabilitation to all appropriate patients, including those with a recent hospitalisation for an acute exacerbation, and to those who consider themselves to be functionally disabled by COPD
        • Use non-invasive ventilation for persistent hypercapnic ventilatory failure during exacerbations unresponsive to drug therapy
        • Offer annual influenza and pneumococcal vaccinations to all patients
        • Identify and treat anxiety and depression
        • Address obesity or poor nutrition
        • Consider referral for physiotherapy, dietetic advice, occupational therapy, social services and multidisciplinary palliative care as appropriate
        Specialist referral
        • Diagnostic uncertainty
        • Suspected severe COPD
        • Onset of cor pulmonale
        • Assessment for O2 therapy, long-term nebuliser therapy or oral corticosteroid therapy
        • Rapid decline in FEV1
        • Assessment for pulmonary rehabilitation
        • Assessment for surgical options
        • Dysfunctional breathing
        • Onset of symptoms < 40 years or a family history of alpha-1 antitrypsin deficiency
        • Symptoms disproportionate to lung function deficit
        • Frequent infections
        • Haemoptysis
        • Bullous lung disease

        Adapted from: NICE Clinical Guideline 101 (June 2010) - Chronic obstructive pulmonary disease: Management of chronic obstructive pulmonary disease in adults in primary and secondary care.


        KEYWORDS: LABA | LAMA | ICS | Beta2 agonist | Anticholinergic | Antimuscarinic | Muscarinic | Antagonist | Bronchodilator | Corticosteroid | Inhaled COPD therapy


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