NICE 2018 Guideline on diagnosis of COPD
NICE has released its updated 2018 guidelines on diagnosis of Chronic obstructive pulmonary disease in over 16s.COPD is a common, preventable and treatable disease that is characterized by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar abnormalities, usually caused by significant exposure to noxious particles or gases.
Following are the major recommendations for Diagnosing COPD:
The diagnosis of chronic obstructive pulmonary disease (COPD) depends on thinking of it as a cause of breathlessness or cough. The diagnosis is suspected on the basis of symptoms and signs and is supported by spirometry.
1. Perform spirometry:
- at diagnosis
- to reconsider the diagnosis, for people who show an exceptionally good response to treatment
- to monitor disease progression.
Incidental findings on chest X‑rays or CT scans
2. Consider primary care respiratory review and spirometry for people with emphysema or signs of chronic airways disease on a chest X‑ray or CT scan.
3. If the person is a current smoker, their spirometry results are normal and they have no symptoms or signs of respiratory disease:
- offer smoking cessation advice and treatment, and referral to specialist stop smoking services (see the NICE guideline on stop smoking interventions and services)
- warn them that they are at higher risk of lung disease
- advise them to return if they develop respiratory symptoms
- be aware that the presence of emphysema on a CT scan is an independent risk factor for lung cancer.
4. If the person is not a current smoker, their spirometry is normal and they have no symptoms or signs of respiratory disease:
- ask them if they have a personal or family history of lung or liver disease and consider alternative diagnoses, such as alpha‑1 antitrypsin deficiency
- reassure them that their emphysema or chronic airways disease is unlikely to get worse
- advise them to return if they develop respiratory symptoms
- be aware that the presence of emphysema on a CT scan is an independent risk factor for lung cancer.
Further investigations
5. Perform additional investigations when needed, as detailed in table 2.
Table 2 Additional investigations
| Investigation | Role |
| Sputum culture | To identify organisms if sputum is persistently present and purulent |
| Serial home peak flow measurements | To exclude asthma if diagnostic doubt remains |
| Electrocardiogram (ECG) and serum natriuretic peptides* | To assess cardiac status if cardiac disease or pulmonary hypertension are suspected because of: • a history of cardiovascular disease, hypertension or hypoxia or • clinical signs such as tachycardia, oedema, cyanosis or features of cor pulmonale |
| Echocardiogram | To assess cardiac status if cardiac disease or pulmonary hypertension are suspected |
| CT scan of the thorax | To investigate symptoms that seem disproportionate to the spirometric impairment To investigate signs that may suggest another lung diagnosis (such as fibrosis or bronchiectasis) To investigate abnormalities seen on a chest X‑ray To assess suitability for lung volume reduction procedures |
| Serum alpha‑1 antitrypsin | To assess for alpha‑1 antitrypsin deficiency if early onset, minimal smoking history or family history |
| Transfer factor for carbon monoxide (TLCO) | To investigate symptoms that seem disproportionate to the spirometric impairment To assess suitability for lung volume reduction procedures |
| * See the NICE guideline on chronic heart failure in adults for recommendations on using serum natriuretic peptides to diagnose heart failure | |
Reversibility testing
6. Untreated COPD and asthma are frequently distinguishable on the basis of history (and examination) in people presenting for the first time. Whenever possible, use features from the history and examination (such as those listed in table 3) to differentiate COPD from asthma. For more information on diagnosing asthma, see the NICE guideline on asthma.
Table 3 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 |
| Breathlessness | Persistent and progressive | Variable |
| Night-time waking with breathlessness and/or wheeze | Uncommon | Commn |
| Significant diurnal or day-to-day variability of symptoms | Uncommon | Common |
Assessing severity and using prognostic factors
COPD is heterogeneous, so no single measure can adequately assess disease severity in an individual. Severity assessment is, nevertheless, important because it has implications for therapy and relates to prognosis.
7. Do not use a multidimensional index (such as BODE) to assess prognosis in people with stable COPD.
8. From diagnosis onwards, when discussing prognosis and treatment decisions with people with stable COPD, think about the following factors that are individually associated with prognosis:
- FEV1
- smoking status
- breathlessness (MRC scale)
- chronic hypoxia and/or cor pulmonale
- low BMI
- severity and frequency of exacerbations
- hospital admissions
- symptom burden (for example, COPD Assessment Test [CAT] score)
- exercise capacity (for example, 6‑minute walk test)
- TLCO
- whether the person meets the criteria for long-term oxygen therapy and/or home non-invasive ventilation
- multimorbidity
- frailty.
Table 4 Gradation of the severity of airflow obstruction
| NICE guideline CG12 | ATS/ERS | GOLD 2008 | NICE guideline CG101 | ||
| Post-bronchodilator FEV1/FVC | FEV1 % predicted | Severity of airflow obstruction | |||
| - | - | Post-bronchodilator | Post-bronchodilator | Post-bronchodilator | |
| <0.7 | ≥80% | - | Mild | Stage 1 – Mild | Stage 1 – Mild |
| <0.7 | 50–79% | Mild | Moderate | Stage 2 – Moderate | Stage 2 – Moderate |
| <0.7 | 30–49% | Moderate | Severe | Stage 3 – Severe | Stage 3 – Severe |
| <0.7 | <30% | Severe | Very severe | Stage 4 – Very severe* | Stage 4 – Very severe* |
| * Or FEV1 below 50% with respiratory failure. 1 Celli BR, MacNee W, Agusti A et al. 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 Global Initiative for Chronic Obstructive Lung Disease (GOLD; 2008) Global strategy for the diagnosis, management and prevention of COPD | |||||
Table 5 Reasons for referral include
| Reason | Purpose |
| There is diagnostic uncertainty | Confirm diagnosis and optimise therapy |
| Suspected severe COPD | Confirm diagnosis and optimise therapy |
| The person with COPD 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 continued treatment or supervise withdrawal |
| Bullous lung disease | Identify candidates for lung volume reduction procedures |
| A rapid decline in FEV1 | Encourage early intervention |
| Assessment for pulmonary rehabilitation | Identify candidates for pulmonary rehabilitation |
| Assessment for a lung volume reduction procedure | Identify candidates for surgical or bronchoscopic lung volume reduction |
| Assessment for lung transplantation | Identify candidates for surgery |
| Dysfunctional breathing | Confirm 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 |
| 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 |
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