• Key priority• Criterion• Exception
1. 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 they must be competent in the interpretation of the results.
  1. percentage of smokers over the age of 35 consulting with a chronic cough and/or breathlessness who have had spirometry performed
  2. percentage of patients with a diagnosis of COPD who have had spirometry performed
Inability to perform spirometry, for example because of facial paralysis
2. 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.
Percentage of patients with COPD who are current smokers recorded in the general practice records as having been offered smoking cessation advice and or therapy
3. Effective inhaled therapy
Long-acting inhaled bronchodilators should be used in people with COPD who remain symptomatic (e.g. breathlessness or exacerbations) despite the use of short-acting drugs. A long-acting beta2 agonist or a long-acting muscarinic antagonist should be used in people with COPD and FEV1 > 50% predicted who continue to experience problems despite the use of short-acting drugs. Either a long-acting beta2 agonist and inhaled corticosteroid in a combination inhaler, or a long-acting muscarinic antagonist should be used in patients with an FEV1 < 50% predicted who continue to experience problems despite the use of short-acting drugs. Additional treatment with a long-acting muscarinic antagonist should be used in people with COPD who remain symptomatic despite taking a long-acting beta-agonist and inhaled steroid in a combination inhaler, irrespective of their FEV1.
Appropriateness of inhaled steroid therapyPatient choice
4. Pulmonary rehabilitation for all who need it
Pulmonary rehabilitation should be offered to all patients who consider themselves functionally disabled by COPD. Pulmonary rehabilitation programmes must meet clinical needs in terms of access, location and availability.
Percentage of patients with COPD who have undergone pulmonary rehabilitationPatient choice
5. Use non-invasive ventilation
Non-invasive ventilation (NIV) is the treatment of choice for persistent hypercapnic respiratory failure during exacerbations after optimal 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.
Percentage of patients presenting with acute hypercapnic respiratory failure who have received non-invasive ventilationPatient choice
6. 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 steroids and or antibiotics
  • use of non-invasive ventilation when indicated
  • use of hospital-at-home or assisted-discharge schemes
Frequency and appropriateness of oral steroid and antibiotic therapyPatient choice

From: 9, Audit criteria

Cover of Chronic Obstructive Pulmonary Disease
Chronic Obstructive Pulmonary Disease: Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care [Internet].
NICE Clinical Guidelines, No. 101.
National Clinical Guideline Centre (UK).
Copyright © 2010, National Clinical Guideline Centre - Acute and Chronic Conditions.

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