Diagnosing and assessing COPD - NICE Pathways · Diagnosing and assessing COPD ... version of this NICE Pathway see: ... (see clinical features differentiating COPD and asthma

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.

Chronic obstructivChronic obstructive pulmonary diseasee pulmonary disease© NICE 2018. All rights reserved. Subject to Notice of rights.

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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.



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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:



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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




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.



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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]).



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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.


If the BMI is abnormal (high or low), or changing over time, the patient should be referredfor dietetic advice.



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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




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.



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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


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



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http://pathways.nice.org.uk/pathways/chronic-obstructive-pulmonary-disease/managing-exacerbations-of-copd

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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



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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.



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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



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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



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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



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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



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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



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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.



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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.




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.



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Documents

Diagnosing and assessing COPD - NICE Pathways · Diagnosing and assessing COPD ... version of this NICE Pathway see: ... (see clinical features differentiating COPD and asthma