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Diagnosing and assessing COPDDiagnosing and assessing COPD
NICE Pathways bring together everything NICE says on a topic in an interactiveflowchart. NICE Pathways are interactive and designed to be used online.
They are updated regularly as new NICE guidance is published. To view the latestversion of this NICE Pathway see:
http://pathways.nice.org.uk/pathways/chronic-obstructive-pulmonary-diseaseNICE Pathway last updated: 23 May 2018
This document contains a single flowchart and uses numbering to link the boxes to theassociated recommendations.
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Diagnosing and assessing COPDDiagnosing and assessing COPD NICE Pathways
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1 Person over 16 with suspected or previously diagnosed COPD
No additional information
2 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 following symptoms:
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 and raise the possibility of alternative
diagnoses.
See what NICE has to say on lung and pleural cancers in terms of suspected cancer recognition
and referral.
Breathlessness
One of the primary symptoms of COPD is breathlessness. The Medical Research Council
dyspnoea scale [See page 12] should be used to grade the breathlessness according to the
level of exertion required to elicit it.
Diagnosing and assessing COPDDiagnosing and assessing COPD NICE Pathways
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Patients should be regularly asked about their ability to undertake activities of daily living and
how breathless they become when doing these.
Anxiety and depression
Healthcare professionals should be alert to the presence of depression in patients with COPD.
The presence of anxiety and depression should be considered in patients:
who are hypoxic
who have severe dyspnoea
who have been seen at or admitted to a hospital with an exacerbation of COPD.
See NICE's recommendations on generalised anxiety disorder and care for adults with
depression, which includes recommendations on depression in adults with a chronic physical
health problem.
Quality standards
The following quality statement is relevant to this part of the interactive flowchart.
Chronic obstructive pulmonary disease in adults quality standard
1. Diagnosis with spirometry
3 Spirometry
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 to develop airflow limitation1.
Spirometry should be performed:
at the time of diagnosis
to reconsider the diagnosis, if patients show an exceptionally good response to treatment.
Measure post-bronchodilator spirometry to confirm the diagnosis of COPD.
Consider alternative diagnoses or investigations in:
Diagnosing and assessing COPDDiagnosing and assessing COPD NICE Pathways
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1 Celli BR, MacNee W (2004) Standards for the diagnosis and treatment of patients with COPD: a summary of the
ATS/ERS position paper. European Respiratory Journal 23(6): 932–46.
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older people without typical symptoms of COPD where the FEV1/FVC ratio is < 0.7
younger people with symptoms of COPD where the FEV1/FVC ratio is ≥ 0.7.
It is recommended that ERS 1993 reference values1 are used but it is recognised that these
values may lead to under-diagnosis in older people and are not applicable in black and Asian
populations2.
In most patients routine spirometric reversibility testing is not necessary as a 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 andnot reproducible
over-reliance on a single reversibility test may be misleading unless the change in FEV1 isgreater 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.
NICE has published a medtech innovation briefing on Smart One for measuring lung function.
Quality standards
The following quality statement is relevant to this part of the interactive flowchart.
Chronic obstructive pulmonary disease in adults quality standard
1. Diagnosis with spirometry
4 Additional 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
BMI calculated.
Additional investigations [See page 14] should be performed to aid management in some
circumstances.
Diagnosing and assessing COPDDiagnosing and assessing COPD NICE Pathways
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1 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
European Respiratory Society. European Respiratory Journal (Suppl) 16: 5–40.2 Definitive spirometry reference values are not currently available for all ethnic populations. The GDG was aware
of ongoing research in this area.
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BMI should be calculated in patients with COPD:
the normal range for BMI is 20 to less than 25 (not reviewed as part of the 2010 guidelineupdate; NICE guideline CG43 [2006] on obesity states a healthy range is 18.5 to 24.9 kg/
m2, but this may not be appropriate for people with COPD). In older patients attentionshould also be paid to changes in weight, particularly if the change is more than 3 kg.
Clinicians involved in the care of people with COPD should assess their need for occupational
therapy using validated tools.
5 Severity assessment
Be aware that disability in COPD can be poorly reflected in the FEV1. A more comprehensive
assessment of severity includes the degree of airflow obstruction and disability, the frequency of
exacerbations and the following known prognostic factors:
FEV1
TLCO
breathlessness (MRC scale)
health status
exercise capacity (for example, 6-minute walk test)
BMI
partial pressure of oxygen in arterial blood (PaO2)
cor pulmonale.
Calculate the BODE index to assess prognosis where its component information is currently
available.
Severity of airflow obstruction [See page 12] should be assessed according to the reduction in
FEV1.
6 Differentiating between COPD and asthma
COPD and asthma are frequently distinguishable on the basis of history (and examination) in
untreated patients presenting for the first time. Features from the history and examination
should be used to differentiate COPD from asthma whenever possible (see clinical features
differentiating COPD and asthma [See page 15]).
Diagnosing and assessing COPDDiagnosing and assessing COPD NICE Pathways
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Longitudinal observation of patients (whether using spirometry, peak flow or symptoms) should
also be used to help differentiate COPD from asthma.
To help resolve cases where diagnostic doubt remains, or both COPD and asthma are present,
the following findings should be used to help identify asthma:
a large (> 400 ml) response to bronchodilators
a large (> 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.
If diagnostic uncertainty remains, referral for more detailed investigations, including imaging and
measurement of TLCO, should be considered.
If patients report a marked improvement in symptoms in response to inhaled therapy, the
diagnosis of COPD should be reconsidered.
For further information, see NICE's recommendations on asthma.
7 When to refer
It is recommended that referrals for specialist advice are made when clinically indicated.
Referral may be appropriate at all stages of the disease and not solely in the most severely
disabled patients (see reasons for referral [See page 16]).
Patients 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.
Patients identified as having alpha-1 antitrypsin deficiency should be offered the opportunity to
be referred to a specialist centre to discuss the clinical management of this condition.
BMI should be calculated in patients with COPD:
If the BMI is abnormal (high or low), or changing over time, the patient should be referredfor dietetic advice.
Diagnosing and assessing COPDDiagnosing and assessing COPD NICE Pathways
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Patients disabled by COPD should be considered for referral for assessment by a social
services department.
8 Training and skills
All health professionals involved in the care of people with COPD should have access to
spirometry and be competent in the interpretation of the results.
Spirometry can be performed by any healthcare worker who has undergone appropriate training
and who keeps his or her skills up to date.
Spirometry services should be supported by quality control processes.
Quality standards
The following quality statement is relevant to this part of the interactive flowchart.
Chronic obstructive pulmonary disease in adults quality standard
1. Diagnosis with spirometry
9 Managing co-existing conditions
Alpha-1 antitrypsin deficiency
Alpha-1 antitrypsin replacement therapy is not recommended for patients with alpha-1
antitrypsin deficiency (see also when to refer [See page 9]).
Cor pulmonale
A diagnosis of cor pulmonale should be considered if patients have:
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 involve excluding other causes of peripheral oedema.
Diagnosing and assessing COPDDiagnosing and assessing COPD NICE Pathways
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Patients presenting with cor pulmonale should be assessed for the need for LTOT.
Oedema associated with cor pulmonale can usually be controlled symptomatically with diuretic
therapy.
The following are not recommended for the treatment of cor pulmonale:
angiotensin-converting enzyme inhibitors
calcium channel blockers
alpha-blockers
digoxin (unless there is atrial fibrillation).
Low body mass index
BMI should be calculated in patients with COPD:
If the BMI is low patients should also be given nutritional supplements to increase their totalcalorific intake and be encouraged to take exercise to augment the effects of nutritionalsupplementation.
For information on nutrition support in adults who are malnourished or at risk of malnutrition see
NICE's recommendations on nutrition support in adults.
For information on weight loss see NICE's recommendations on obesity.
Multiple long-term conditions
For further information, see NICE's recommendations on multimorbidity.
10 Managing exacerbations
See Chronic obstructive pulmonary disease / Managing exacerbations of COPD
11 Managing stable COPD
See Chronic obstructive pulmonary disease / Managing stable COPD
Diagnosing and assessing COPDDiagnosing and assessing COPD NICE Pathways
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Severity of airflow obstruction
Severity of airflow obstruction
NICE clinical
guideline 12
(2004)
ATS/ERS
20041
GOLD 20082
NICE clinical
guideline 101
(2010)
Post-
bronchodilator
FEV1/FVC
FEV1 %
predicted
Post-
bronchodilator
Post-
bronchodilator
Post-
bronchodilator
< 0.7 ≥ 80% MildStage 1 –
MildStage 1 – Mild3
< 0.7 50–79% Mild ModerateStage 2 –
Moderate
Stage 2 –
Moderate
< 0.7 30–49% Moderate SevereStage 3 –
Severe
Stage 3 –
Severe
< 0.7 < 30% Severe Very severeStage 4 –
Very severe4
Stage 4 – Very
severe
Medical Research Council dyspnoea scale
Grade Degree of breathlessness related to activities
1 Not troubled by breathlessness except on strenuous exercise
Diagnosing and assessing COPDDiagnosing and assessing COPD NICE Pathways
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1 Celli BR, MacNee W (2004) Standards for the diagnosis and treatment of patients with COPD: a summary of the
ATS/ERS position paper. European Respiratory Journal 23(6): 932–46.2 GOLD (2008) Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary
disease.3 Symptoms should be present to diagnose COPD in people with mild airflow obstruction.4 Or FEV1 < 50% with respiratory failure.
Diagnosing and assessing COPDDiagnosing and assessing COPD NICE Pathways
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2 Short of breath when hurrying or walking up a slight hill
3Walks slower than contemporaries on level ground because of breathlessness, or has
to stop for breath when walking at own pace
4Stops for breath after walking about 100 metres or after a few minutes on level
ground
5 Too breathless to leave the house, or breathless when dressing or undressing
Adapted from Fletcher CM, Elmes PC, Fairbairn MB et al. (1959) The significance of
respiratory symptoms and the diagnosis of chronic bronchitis in a working population. British
Medical Journal 2: 257–66.
Additional investigations
Investigation Role
Serial domiciliary peak flow
measurementsTo exclude asthma if diagnostic doubt remains
Alpha-1 antitrypsin If early onset, minimal smoking history or family history
TLCOTo investigate symptoms that seem disproportionate to the
spirometric impairment
CT scan of the thorax
To investigate symptoms that seem disproportionate to the
spirometric impairment
To investigate abnormalities seen on a chest radiograph
To assess suitability for surgery
Diagnosing and assessing COPDDiagnosing and assessing COPD NICE Pathways
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ECG To assess cardiac status if features of cor pulmonale
Echocardiogram To assess cardiac status if features of cor pulmonale
Pulse oximetryTo assess need for oxygen therapy if cyanosis or cor pulmonale
present, or if FEV1 <50% predicted
Sputum cultureTo identify organisms if sputum is persistently present and
purulent
Clinical features differentiating COPD and asthma
COPD Asthma
Smoker or ex-smoker Nearly all Possibly
Symptoms under age 35 Rare Often
Chronic productive cough Common Uncommon
BreathlessnessPersistent and
progressiveVariable
Night time waking with breathlessness and/or wheeze Uncommon Common
Significant diurnal or day-to-day variability to day-to-day
variability of symptomsUncommon Common
Diagnosing and assessing COPDDiagnosing and assessing COPD NICE Pathways
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Reasons for referral
Reason Purpose
There is diagnostic uncertainty Confirm diagnosis and optimise therapy
Suspected severe COPD Confirm diagnosis and optimise therapy
The patient requests a second opinion Confirm diagnosis and optimise therapy
Onset of cor pulmonale Confirm diagnosis and optimise therapy
Assessment for oxygen therapy Optimise therapy and measure blood gases
Assessment for long-term nebuliser
therapy
Optimise therapy and exclude inappropriate
prescriptions
Assessment for oral corticosteroid
therapy
Justify need for long-term treatment or supervise
withdrawal
Bullous lung disease Identify candidates for surgery
A rapid decline in FEV1 Encourage early intervention
Assessment for pulmonary
rehabilitationIdentify candidates for pulmonary rehabilitation
Assessment for lung volume reduction
surgeryIdentify candidates for surgery
Assessment for lung transplantation Identify candidates for surgery
Diagnosing and assessing COPDDiagnosing and assessing COPD NICE Pathways
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Dysfunctional breathingConfirm diagnosis, optimise pharmacotherapy and
access other therapists
Onset of symptoms under 40 years or
a family history of alpha-1 antitrypsin
deficiency
Identify alpha-1 antitrypsin deficiency, consider
therapy and screen family
Uncertain diagnosis Make a diagnosis
Symptoms disproportionate to lung
function deficit
Look for other explanations including cardiac
impairment, pulmonary hypertension, depression
and hyperventilation
Frequent infections Exclude bronchiectasis
Haemoptysis Exclude carcinoma of the bronchus
Glossary
ASA
American Society of Anesthesiologists
ATS
American Thoracic Society
BODE
body mass index, airflow obstruction, dyspnoea and exercise capacity
BTS
British Thoracic Society
Diagnosing and assessing COPDDiagnosing and assessing COPD NICE Pathways
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CEN
Comité Européen de Normalisation (European Committee for Standardisation)
COPD
chronic obstructive pulmonary disease
cor pulmonale
in the context of this guidance, the term 'cor pulmonale' has been adopted to define a clinical
condition that is identified and managed on the basis of clinical features; this clinical syndrome
of cor pulmonale includes patients who have right heart failure secondary to lung disease and
those in whom the primary pathology is retention of salt and water, leading to the development
of peripheral oedema
ECG
electrocardiogram
ERS
European Respiratory Society
FEV1
forced expiratory volume in 1 second
FVC
forced vital capacity
GOLD
global initiative for chronic obstructive lung disease
ICS
inhaled corticosteroid
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LABA
long-acting beta2 agonist
LAMA
long-acting muscarinic antagonist
LTOT
long-term oxygen therapy
MRC
Medical Research Council
NIV
non-invasive ventilation
PaO2
partial pressure of oxygen in arterial blood
PaCO2
partial pressure of carbon dioxide in arterial blood
PEF
peak expiratory flow
SABA
short-acting beta2 agonist
SAMA
short-acting muscarinic antagonist
Diagnosing and assessing COPDDiagnosing and assessing COPD NICE Pathways
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SaO2
oxygen saturation of arterial blood
TLCO
carbon monoxide lung transfer factor
Sources
Chronic obstructive pulmonary disease in over 16s: diagnosis and management (2010) NICE
guideline CG101
Your responsibility
Guidelines
The recommendations in this guideline represent the view of NICE, arrived at after careful
consideration of the evidence available. When exercising their judgement, professionals and
practitioners are expected to take this guideline fully into account, alongside the individual
needs, preferences and values of their patients or the people using their service. It is not
mandatory to apply the recommendations, and the guideline does not override the responsibility
to make decisions appropriate to the circumstances of the individual, in consultation with them
and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline
to be applied when individual professionals and people using services wish to use it. They
should do so in the context of local and national priorities for funding and developing services,
and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to
advance equality of opportunity and to reduce health inequalities. Nothing in this guideline
should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable
health and care system and should assess and reduce the environmental impact of
implementing NICE recommendations wherever possible.
Diagnosing and assessing COPDDiagnosing and assessing COPD NICE Pathways
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Technology appraisals
The recommendations in this interactive flowchart represent the view of NICE, arrived at after
careful consideration of the evidence available. When exercising their judgement, health
professionals are expected to take these recommendations fully into account, alongside the
individual needs, preferences and values of their patients. The application of the
recommendations in this interactive flowchart is at the discretion of health professionals and
their individual patients and do not override the responsibility of healthcare professionals to
make decisions appropriate to the circumstances of the individual patient, in consultation with
the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable
the recommendations to be applied when individual health professionals and their patients wish
to use it, in accordance with the NHS Constitution. They should do so in light of their duties to
have due regard to the need to eliminate unlawful discrimination, to advance equality of
opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable
health and care system and should assess and reduce the environmental impact of
implementing NICE recommendations wherever possible.
Medical technologies guidance, diagnostics guidance and interventional proceduresguidance
The recommendations in this interactive flowchart represent the view of NICE, arrived at after
careful consideration of the evidence available. When exercising their judgement, healthcare
professionals are expected to take these recommendations fully into account. However, the
interactive flowchart does not override the individual responsibility of healthcare professionals to
make decisions appropriate to the circumstances of the individual patient, in consultation with
the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in
their local context, in light of their duties to have due regard to the need to eliminate unlawful
discrimination, advance equality of opportunity, and foster good relations. Nothing in this
interactive flowchart should be interpreted in a way that would be inconsistent with compliance
with those duties.
Diagnosing and assessing COPDDiagnosing and assessing COPD NICE Pathways
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Commissioners and providers have a responsibility to promote an environmentally sustainable
health and care system and should assess and reduce the environmental impact of
implementing NICE recommendations wherever possible.
Diagnosing and assessing COPDDiagnosing and assessing COPD NICE Pathways
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