The NICE guideline on COPD marks a significant step forward in providing effective care for patients with this chronic condition, says Dr David Halpin


The last British guidelines on the management of COPD were published by the British Thoracic Society in 1997, although the recommendations were agreed some time before this.

These consensus based guidelines did much to improve the management of patients with COPD. They contained several key messages, particularly about the importance of spirometry in making a diagnosis, and they introduced the concept of the COPD escalator whereby treatment was increased according to the decline in the patient’s FEV1.

Around the same time, guidelines on the management of COPD were published by the American Thoracic Society 1 and the European Respiratory Society 2 and, subsequently, by the Global Initiative for Chronic Obstructive Lung Disease.3

Since these guidelines were published there have been some significant advances in the management of COPD, both pharmacological, such as the use of long-acting bronchodilators, and non-pharmacological, such as the development of hospital-at-home schemes and the use of non-invasive ventilation for the treatment of ventilatory failure during exacerbations.

It has also become clear that not all patients follow the same, unidirectional pattern of decline suggested by the escalator and that some patients are severely disabled with only minimal FEV1 impairment while others have severe airflow limitation and few symptoms. As a consequence of these facts it became clear that the guidelines needed to be updated, and that any update would need to use an evidence-based approach.

The BTS was about to begin work on an update when the Department of Health and the Welsh Assembly announced in August 2001 that they had instructed the National Institute for Clinical Excellence to prepare clinical guidelines for the NHS in England and Wales for the prevention, diagnosis, management and treatment of COPD. The guidelines were published in February 2004.

The Department of Health and the Welsh Assembly instruction recognised the fact COPD is important because it is common and disabling. Many doctors and health service managers remain unaware that COPD is the fifth most common cause of death in the UK. It accounts for around one in 10 of all general practice consultations in the over-60s and is one of the principal causes of emergency hospitalisation.

Its symptoms are distressing and it significantly restricts even the most simple of activities such as washing or dressing. There is widespread under-provision of care and marked geographical variation in the care that is available. For all these reasons, the NICE guideline is very welcome.


Development of the guideline was delegated to the independent National Collaborating Centre for Chronic Conditions (NCC-CC) based at the Royal College of Physicians in London. In line with the instruction, a broad scope was agreed in consultation with stakeholders, and the clinical questions to form the basis of the evidence review were agreed.

As part of the NCC-CC’s guideline development methodology a small technical team consisting of chairperson, clinical lead, systematic reviewer, health economist and project manager undertook literature searches, critical appraisal and the drafting of the evidence statements. The draft recommendations were formulated at monthly meetings of the guideline development group, which was multiprofessional and included two patient representatives. The final recommendations were agreed after extensive consultation.

Despite an exhaustive review of the evidence many of the recommendations were finally categorised as grade D. There were several reasons for this: some recommendations were based on secondary sources, such as other guidelines; other recommendations were based on extrapolations of the evidence.

As might be expected, there was a good body of evidence for the newer pharmacological interventions but there was also grade I evidence for some of the non-pharmacological interventions such as pulmonary rehabilitation or non-invasive ventilation.


The guideline makes nearly 200 specific recommendations in three broad areas: diagnosis and assessment, management of stable disease and management of exacerbations.

The guideline also proposes a new definition of COPD which has evolved from the previous British Thoracic Society and Global Initiative for Chronic Obstructive Lung Disease definitions (Box 1, below).

Box 1: Definition of COPD
Chronic obstructive pulmonary disease (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
  • Airflow obstruction is defined as a reduced FEV1 (forced expiratory volume in 1 second) and a reduced FEV1/FVC ratio (where FVC is forced vital capacity), such that FEV1 is less than 80% predicted and FEV1/FVC is less than 0.7
  • The airflow obstruction is due to a combination of airway and parenchymal damage
  • The damage is the result of chronic inflammation that differs from that seen in asthma and which is usually the result of tobacco smoke
  • Significant airflow obstruction may be present before the individual is aware of it
  • COPD produces symptoms, disability and impaired quality of life which may respond to pharmacological and other therapies that have 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 having chronic bronchitis or emphysema
  • Other factors, particularly occupational exposures, may also contribute to the development of COPD

Figure 1 (below) gives the grading scheme and hierarchy of evidence.

Figure 1: Grading scheme and hierarchy of evidence
Reproduced from Chronic obstructive pulmonary disease. Management of chronic obstructive pulmonary disease in adults in primary and secondary care by kind permission of the National Institute for Clinical Excellence


In terms of diagnosis, the biggest change is the recognition that in most cases the diagnosis of COPD can be made on the basis of a good history with confirmation of the presence of airflow limitation by spirometry.

Unlike the previous BTS guidelines, the NICE guideline does not recommend routine assessment of the change in FEV1 in response to a single dose of an inhaled bronchodilator or a short course of oral or inhaled corticosteroids. It is thought by some that the results of a single ‘reversibility test’ can categorically distinguish COPD from asthma and that the results of such a measurement can be used to predict the long-term response to therapy.

We concluded that the results of such a test could not be relied upon and were potentially misleading because the changes in FEV1 following a single dose of a bronchodilator are normally distributed 4 and any cut off used to distinguish asthma and COPD is therefore entirely arbitrary.

Furthermore, if the measurement is repeated on several occasions,5 different results may be obtained, and depending on the agent used to produce the change in FEV1 (e.g. salbutamol from an MDI, nebulised salbutamol or oral corticosteroids) different responses may be produced. 6 The recommendations on making a diagnosis are summarised in Figure 2, below.

Figure 2: Algorithm for the diagnosis of COPD
Reproduced from Chronic obstructive pulmonary disease. Management of chronic obstructive pulmonary disease in adults in primary and secondary care by kind permission of the National Institute for Clinical Excellence

Management of stable COPD

In its recommendations on the management of stable disease the guideline has moved away from the linear approach to a patient/ symptom centred multi-disciplinary approach. This is emphasised in the algorithm (Figure 3, below).

Figure 3: Algorithm for the management of stable COPD
Reproduced from Chronic obstructive pulmonary disease. Management of chronic obstructive pulmonary disease in adults in primary and secondary care by kind permission of the National Institute for Clinical Excellence

Unlike previous guidelines, the NICE guideline reflects the importance of assessing anxiety and depression and monitoring the patient’s weight as well as making positive recommendations about the role of mucolytic therapy.

The guideline also clarifies the role of inhaled corticosteroids and recommends using long-acting bronchodilators in patients who remain symptomatic despite using short-acting drugs.

Finally, the guideline makes very positive recommendations about the importance of pulmonary rehabilitation in the management of stable disease.

Management of exacerbations

The importance of exacerbations, both for patients and the health service is recognised and recommendations are made about strategies to prevent exacerbations and to manage them effectively. An operational definition of an exacerbation is proposed and it is hoped that this will aid future research in this area.

New ways of caring for patients with exacerbations which reduce the duration of stay or prevent hospital admissions are recommended as effective alternatives to hospitalisation, and non-invasive ventilation is recommended as the treatment of choice for patients requiring ventilatory support during exacerbations.

The algorithm summarising these recommendations includes the recommendation on factors to consider when deciding whether a patient needs to be admitted to hospital or can be managed at home (Figure 4, below).

Figure 4: Algorithm for the management of exacerbations of COPD
Reproduced from Chronic obstructive pulmonary disease. Management of chronic obstructive pulmonary disease in adults in primary and secondary care by kind permission of the National Institute for Clinical Excellence


NICE asked the guideline development group to identify key priorities for implementation.These were to be areas where it was felt that recommendations were likely to have the biggest impact on the management of COPD. Seven key priorities which each encompassed a number of recommendations were agreed by the developers (Box 2, below).

Box 2: Key priorities
Diagnose COPD
  • 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 exertional breathlessness, chronic cough, regular sputum production, frequent winter ‘bronchitis’ or wheeze
  • The presence of airflow obstruction should be confirmed by performing spirometry. All health professionals managing patients with COPD should have access to spirometry and be competent in the interpretation of results
Stop smoking
  • Encouraging patients with COPD to stop smoking is one of the most important components of their management.All COPD patients still smoking, regardless of age, should be encouraged to stop, 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 improve exercise capacity in patients who continue to experience problems despite the use of short-acting drugs
  • Inhaled corticosteroids should be added to long-acting bronchodilators to decrease exacerbation frequency in patients with an FEV1 less than or equal to 50% predicted who have had two or more exacerbations requiring treatment with antibiotics or oral corticosteroids in a 12-month period
Pulmonary rehabilitation for all who need it
  • Pulmonary rehabilitation should be made available to all appropriate patients with COPD
Use non-invasive ventilation
  • Non-invasive ventilation (NIV) should be used as the treatment of choice for persistent hypercapnic ventilatory failure during exacerbations not responding to medical therapy. It should be delivered by staff trained in its application, experienced in its use and 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 of therapy should be agreed
Manage exacerbations
  • The frequency of exacerbations should be reduced by appropriate use of inhaled corticosteroids and bronchodilators, and vaccinations
  • The impact of exacerbations should be minimised by:
    • giving self-management advice on responding promptly to the symptoms of an exacerbation
    • starting appropriate treatment with oral corticosteroids and/or antibiotics
    • 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


Many patients with COPD have received poor treatment over the past 30 years. Fortunately, clinicians are now taking more interest in the disease and want to deliver effective care. The 1997 British Thoracic Society guidelines were a first step towards this and the NICE guideline marks a further significant step forward.

Unlike the recent BTS/SIGN asthma guidelines, which largely recommend management strategies that are already in widespread use, this COPD guideline makes many recommendations about management that will lead to changes in practice and which will, we hope, improve the quality of life of patients with COPD.

Four versions of the guideline have been published: the full guideline; a short form containing only the recommendations, available on the NICE website; a quick reference guide, which has been sent to all relevant clinicians and managers in the NHS; and a version for patients, which is published in English and Welsh. Copies of the patient version are available from the NHS Response Line, 0800 1555 455.

Chronic obstructive pulmonary disease. Management of chronic obstructive pulmonary disease in adults in primary and secondary care. Clinical Guideline No 12 is published as a supplement to Thorax (Thorax 2004; 59(Suppl 1): 1-232) and a version can also be downloaded from the NICE website:


  1. Standards for the diagnosis and care of patients with chronic obstructive pulmonary disease. American Thoracic Society. Am J Respir Crit Care Med 1995; 152(5 Pt 2): S77-121.
  2. Siafakas NM,Vermeire P, Pride NB et al. Optimal assessment and management of chronic obstructive pulmonary disease (COPD). The European Respiratory Society Task Force. Eur Respir J 1995; 8(8): 1398-420.
  3. Pauwels RA, Buist AS, Calverley PM et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. NHLBI/WHO Global Initiative for Chronic Obstructive Lung Disease (GOLD) Workshop summary. Am J Respir Crit Care Med 2001; 163(5): 1256-76.
  4. Anthonisen NR, Wright EC. Bronchodilator response in chronic obstructive pulmonary disease. Am Rev Respir Dis 1986; 133(5): 814-9.
  5. Calverley PM, Burge PS, Spencer S, Anderson JA, Jones PW. Bronchodilator reversibility testing in chronic obstructive pulmonary disease. Thorax 2003; 58(8): 659-64.
  6. Nisar M,Walshaw M, Earis JE et al. Assessment of reversibility of airway obstruction in patients with chronic obstructive airways disease.Thorax 1990; 45(3): 190-4.

Guidelines in Practice, April 2004, Volume 7(4)
© 2004 MGP Ltd
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